The DOI matches its Crossref record; 167 of the 168 references it cites were found in a registry or an index; none of the 11 sources its claims cite is checked for support yet.
Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018
Open accessAbstract
Importance: Clinical decisions are ideally based on evidence generated from multiple randomized controlled trials (RCTs) evaluating clinical outcomes, but historically, few clinical guideline recommendations have been based entirely on this type of evidence. Objective: To determine the class and level of evidence (LOE) supporting current major cardiovascular society guideline recommendations, and changes in LOE over time. Data Sources: Current American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) clinical guideline documents (2008-2018), as identified on cardiovascular society websites, and immediate predecessors to these guideline documents (1999-2014), as referenced in current guideline documents. Study Selection: Comprehensive guideline documents including recommendations organized by class and LOE. Data Extraction and Synthesis: The number of recommendations and the distribution of LOE (A [supported by data from multiple RCTs or a single, large RCT], B [supported by data from observational studies or a single RCT], and C [supported by expert opinion only]) were determined for each guideline document. Main Outcomes and Measures: The proportion of guideline recommendations supported by evidence from multiple RCTs (LOE A). Results: Across 26 current ACC/AHA guidelines (2930 recommendations; median, 121 recommendations per guideline [25th-75th percentiles, 76-155]), 248 recommendations (8.5%) were classified as LOE A, 1465 (50.0%) as LOE B, and 1217 (41.5%) as LOE C. The median proportion of LOE A recommendations was 7.9% (25th-75th percentiles, 0.9%-15.2%). Across 25 current ESC guideline documents (3399 recommendations; median, 130 recommendations per guideline [25th-75th percentiles, 111-154]), 484 recommendations (14.2%) were classified as LOE A, 1053 (31.0%) as LOE B, and 1862 (54.8%) as LOE C. When comparing current guidelines with prior versions, the proportion of recommendations that were LOE A did not increase in either ACC/AHA (median, 9.0% [current] vs 11.7% [prior]) or ESC guidelines (median, 15.1% [current] vs 17.6% [prior]). Conclusions and Relevance: Among recommendations in major cardiovascular society guidelines, only a small percentage were supported by evidence from multiple RCTs or a single, large RCT. This pattern does not appear to have meaningfully improved from 2008 to 2018.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
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“934 (49.6%) as LOE C”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of 1622 class I recommendations, 349 (21.5%) were LOE A.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“ESC guidelines contained 1884 class I and class III recommendations, 402 (21.3%) classified as LOE A”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Across 26 current ACC/AHA guidelines (2930 recommendations; median, 121 recommendations per guideline [25th-75th percentiles, 76-155]), 248 recommendations (8.5%) were classified as LOE A”
- Also stated in: § Results · plain
“Across the 26 current ACC/AHA guidelines, 248 recommendations (8.5%) were classified as LOE A”
- Also stated in: § Discussion · plain
“less than 10% of recommendations from current ACC/AHA guidelines”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Results · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“1217 (41.5%) as LOE C”
- Also stated in: § Results · plain
“1217 (41.5%) as LOE C”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Results · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of 1272 class I recommendations, 180 (14.2%) were classified as LOE A.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Of these recommendations, 207 (12.9%) were supported by LOE A evidence”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The median proportion of LOE A recommendations was 7.9% (25th-75th percentiles, 0.9%-15.2%).”
- Also stated in: § Results · plain
“of which 7.9% (25th-75th percentiles, 0.9%-15.2%)were LOE A”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Results · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“the proportion of recommendations that were LOE B (median, 31.7% [current] vs 33.4% [prior])”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > ESC Guidelines
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“612 (38.2%) by LOE C evidence”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Results
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes
- It may state two separate claims as one. 8
- Probably not a substantial claim. 13
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“or ESC guidelines (median, 15.1% [current] vs 17.6% [prior])”
- Also stated in: § ESC Guidelines · plain
“the median proportion of LOE A recommendations was 15.1% (25th-75th percentiles, 3.7%-26.4%);the median proportion of LOE A recommendations among prior guidelines was 17.6% (25th-75th percentiles, 2.4%-27.6%)”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Also stated in: § ESC Guidelines · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“the proportion of recommendations that were LOE A did not increase in either ACC/AHA (median, 9.0% [current] vs 11.7% [prior])”
- Also stated in: § Changes From Prior to Current Guidelines ACC/AHA Guidelines · plain
“the median proportion of LOE A recommendations was 9.0% (25th-75th percentiles, 4.8%-15.1%);the median proportion of LOE A recommendations in prior guidelines was 11.7% (25th-75th percentiles, 5.8%-17.5%)”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Also stated in: § Changes From Prior to Current Guidelines ACC/AHA Guidelines · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“there was wide variety by subject area-in some guideline documents, more than 33% of recommendations were characterized as LOE A, but others had no LOE A recommendations at all.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
In the paper
“In the intervening years, some of these steps have been taken, [6][7][8]”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Abstract
What the sources say
- Not checked yetcites [6][7][8]
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
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In the paper
“recommendations were abstracted by a single reviewer (A.C.F.) and validated by another reviewer (R.D.L).”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Methods
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Abstraction therefore involved simple reporting of the content of each document and did not require judgment on the part of the abstractors.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Methods
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“exclusion of focused updates, which are usually undertaken when new RCT evidence is generated, may lead to underestimation of the proportion of LOE A recommenda-tions”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Alternatively, standards for LOE A designation may have changed over time.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“however, this limitation should not affect findings regarding changes in LOE over time.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✓ Load-bearing: passes✗ Based: failsProbably not a substantial claim. It may be too vague to check against evidence. The paper may give no reason why it holds.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“First, the evidence supporting major society guideline recommendations is a surrogate for the totality of the evidence in cardiology, rather than a direct measurement.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“this increase in LOE B recommendations could indicate that the proportion of recommendations supported by randomized evidence is increasing”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
In the paper
“At that time, 12% of guideline recommendations were classified as LOE A, including 19% of class I recommendations.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
What the sources say
- Not checked yetcites [5] source
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
In the paper
“in these 6 guideline documents, they found minimal increases in LOE A recommendations compared with LOE B and C.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
What the sources say
- Not checked yetcites [5] source
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The lack of RCT evidence supporting most recommendations in the guidelines was compounded by variability among subspecialties within cardiovascular medicine; some subspecialty guidelines contained almost no LOE A recommendations.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Third, this review describes only evidence supporting cardiology guidelines, rather than across medical and surgical subspecialties”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The quality of evidence supporting each recommendation was not independently assessed”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
In the paper
“Solid RCT evidence delineates treatments and strategies that lead to better patient outcomes, which can then be implemented in clinical practice.106”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
What the sources say
- Not checked yetcites [106] source
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“the high global prevalence of cardiovascular disease suggests that efforts to build a higher-quality cardiovascular medicine evidence base might have a large effect on global health.”
§ Levels of Evidence Supporting American College of Cardiology/American Heart Association and European Society of Cardiology Guidelines, 2008-2018 > Discussion
Strength:hedged· not yet calibratedCausal:conditional· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
The paper relies on this without support.
The ACC/AHA and ESC guidelines are the major cardiovascular society guidelines.
“major cardiovascular society guideline recommendations”
The paper relies on this without support.
The LOE categories are comparable across ACC/AHA and ESC guidelines.
“Although the ESC and ACC/AHA guidelines use similar evidence to generate recommendations”
The paper relies on this without support.
The included guideline documents are representative of the evidence base for cardiovascular medicine.
“Only comprehensive guideline documents were included in this systematic review”
The paper relies on this without support.
The websites used to identify guidelines listed all current guidelines as of February 1, 2019.
“Current ACC/AHA guidelines were identified as those posted on the ACC (https://www.acc.org/guidelines#doctype= Guidelines) and ESC (https://www.escardio.org/Guidelines/ Clinical-Practice-Guidelines) websites as of February 1, 2019.”
The paper relies on this without support.
The prior guideline documents identified are the immediate predecessors covering the same topic.
“Current guidelines were also reviewed to identify references to a previous iteration of the same guideline”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In the citing paper
“First, clinical trials often lack generalizability 4 to complex patients who often fail to qualify for trials.5,6”
From Answering real-world clinical questions using large language model, retrieval-augmented generation, and agentic systems (2025) · cites this paper as [5]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
The same earlier review is assigned two LOE A percentages
MinorThe introduction attributes an 11% LOE A figure to the 2009 ACC/AHA guideline review, while the discussion attributes 12% to that same cited review.
“In a review of the ACC/AHA clinical practice guidelines from 2009, only 11% of recommendations were classified as LOE A. 5”
“In 2009, Tricoci et al 5 analyzed data from ACC/AHA guidelines published from 1984 to 2008.At that time, 12% of guideline recommendations were classified as LOE A”
Citations
Cites
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Metadata
- Authors
- Fanaroff, A. C., Califf, R. M., Windecker, S., Smith, S. C., & Lopes, R. D.
- Affiliations
- Duke University (US)
- University of Bern (CH)
- University of North Carolina at Chapel Hill (US)
- Division of Cardiology and Duke Clinical Research Institute, Duke University, Durham, North Carolina
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2019-03-19
- Volume
- 321
- Issue
- 11
- Pages
- 1069
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC6439920
- OpenAlex
- W2921176698
- Cited by
- 228
- References
- 168
- Citations by year
- 2026: 17 · 2025: 30 · 2024: 30 · 2023: 28 · 2022: 32 · 2021: 30 · 2020: 39 · 2019: 22
- FWCI
- 5.03
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion)
- Funders
- American Heart Association (17FTF33661087)
- Amgen
- Bristol-Myers Squibb
- Eli Lilly and Company
- Pfizer
- GlaxoSmithKline
- Sanofi
- Biogen
- Edwards Lifesciences
- Boston Scientific Corporation
- Cytokinetics
- Genentech
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Health Sciences › Health Professions › General Health Professions › Health Sciences Research and Education
- Social Sciences › Decision Sciences › Statistics, Probability and Uncertainty › Meta-analysis and systematic reviews
- Keywords
- level of evidence, cardiovascular guidelines, ACC/AHA guidelines, ESC guidelines, randomized controlled trials, guideline recommendations, expert opinion, guideline revision, cardiovascular care
- MeSH terms
- American Heart Association, Cardiology, Cardiovascular Diseases, Europe, Societies, Medical, United States, Randomized Controlled Trials as Topic, Practice Guidelines as Topic, Evidence-Based Medicine, Observational Studies as Topic
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