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Durability of cardiology guideline recommendations varied over time
A new report demonstrates that the durability of class I cardiology guideline recommendations for procedures and treatments issued by the American College of Cardiology and American Heart Association has varied over time across levels of evidence and individual guidelines.
Mark D. Neuman, MD, MSc, from Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues performed a textual analysis of 11 ACC/AHA guidelines published between 1998 and 2007 and subsequently revised between 2006 and 2013. The guidelines covered atrial fibrillation, perioperative CV evaluation for noncardiac surgical procedures, cardiac pacemakers and antiarrhythmic devices, secondary prevention of CAD, CABG, prevention of CVD in women, HF, PCI, chronic stable angina, unstable angina and non-STEMI, and valvular heart disease.
The researchers compiled all class I recommendations from the first of the two most updated forms of each guideline and identified these recommendations in the very latest revision. Recommendations that were supplanted by less conclusive or contradictory recommendations were categorized as downgraded or reversed. Recommendations for which no corollary could be found in the latest version were categorized as omitted.
Of 619 index recommendations, 495 (80%) were retained in the later guideline version. Fifty-seven (9.2%) recommendations were downgraded or reversed and 67 (10.8%) were omitted.
Across guideline topics, the proportion of recommendations kept intact varied from 15.4% to 94.1% (P<.001). Where data were available on the level of evidence backing a given recommendation, the retention rate was 90.5% for recommendations backed by multiple randomized studies vs. 81% for recommendations backed by one randomized trial or observational data and 73.7% for recommendations based on opinion (P=.001).
Adjustment for guideline-level factors revealed a higher probability of downgrade, reversal or elimination among recommendations based on opinion (OR=3.14; 95% CI, 1.69-5.85) or based on a single trial or observational data (OR=3.49; 95% CI, 1.45-8.41) vs. recommendations backed by multiple trials.
According to the researchers, although the recommendations remained intact overall, the variations based on accrual of evidence and guideline topic may be useful in guiding clinical practice.
“Our findings offer practical insights related to the application of guideline recommendations to clinical care and health policy,” the researchers wrote. “While our results highlight the overall durability of cardiovascular disease guideline recommendations, they also emphasize that particular subsets of recommendations may be more fragile than others as a basis for changes in practice and policy.”
Disclosure: See the study for a full list of the researchers’ relevant financial disclosures.