Durability of cardiology practice guidelines varies with level of evidence

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1. Clinical recommendations based on multiple randomized control trials are the most durable through iterations of guidelines. 

2. Guidelines based on expert opinions are not as durable as those based on randomized control trials. 

Study Rundown: Clinical guidelines have become the hallmark of evidence based medicine and largely define the practice of medicine today. Periodic review of these guidelines often leads to changes in recommended practices and treatment options. This study sought to analyze the durability of Class 1 recommendations published by the American College of Cardiology and the American Heart Association (ACC/AHA). Class 1 recommendations champion that a procedure or treatment should be performed. About 80% of the class 1 recommendations remained unchanged between publications. It was found that recommendations based on multiple randomized control trials (RCT) were less often reversed, downgraded, or omitted in subsequent publications. Recommendations most likely to be reversed or omitted were largely based on single RCTs and nonrandomized studies or consensus opinions.

Previous studies have supported review of guidelines every three to five years, but this may be the first analysis of the validity of guidelines over time. The study’s limitations lie in the restriction of the cohort to ACC/AHA guidelines focused on cardiovascular pathology because other associations may have different periodicity and criteria. The results of this study may help elucidate the often contentious policy that measures the practice of medicine by guidelines.

Click to read the study, published today in JAMA

Relevant Reading: The emergence of clinical practice guidelines

In-Depth [textual analysis]: This study analyzed changes in recommendations from guidelines of 11 conditions published by the ACC/AHA from 1998 to 2013. Two iterations of each guideline was analyzed to elucidate characteristics of durable recommendations. Of the 619 recommendations from the original publications, 80% (CI₉₅, 76.6%-83.1%) were maintained in subsequent publications. Level-of-evidence criteria was obtained for 448 of the recommendations and helped elucidate their associations with propensity to be omitted, downgraded, or reversed. Of Level A recommendations, made from multiples RCTs or meta analyses, 90.5% ( CI₉₅, 83.2%-95.3%) were preserved while only 81.0% (CI₉₅, 74.8%-86.3%) of Level B recommendations, based on single trials or observational studies, were retained. Level C recommendations, “supported by expert opinion”, were retained 73.7% (CI₉₅, 65.8%-80.5%) of the time. The authors found downgrades to be most common in Level B recommendations and omissions most common with Level C recommendations.

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