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Same evidence different recommendations: a methodological assessment of transatlantic guidelines for the management
Milan Milojevic1, Miguel Sousa-Uva2, Mateo Marin-Cuartas3
1Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.
Insights
Methodological differences in developing valvular heart disease guidelines by the American College of Cardiology (ACC)/American Heart Association (AHA) and European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) lead to varied recommendations. Standardization is crucial for global practice consistency.
Area of Science:
- Cardiology
- Clinical Practice Guidelines
- Health Policy
Background:
- Transatlantic valvular heart disease guidelines from ACC/AHA and ESC/EACTS exhibit significant methodological variations.
- These discrepancies impact treatment recommendations and potentially global practice patterns.
Purpose of the Study:
- To identify methodological differences in the development of ACC/AHA and ESC/EACTS valvular heart disease guidelines.
- To propose steps for standardizing guideline development processes.
Main Methods:
- Comparative analysis of guideline development methodologies.
- Evaluation benchmarked against Institute of Medicine standards.
Main Results:
- Discrepancies found in committee composition, evidence evaluation, conflict of interest management, and voting processes.
- Both guideline sets deviate from Institute of Medicine standards in literature review and evidence grading.
- Divergent recommendations noted for mitral regurgitation repair and aortic prosthesis selection, including age cut-offs for valve replacement.
Conclusions:
- Methodological variations in guideline development contribute to differing treatment recommendations.
- Standardization of guideline development processes is essential to enhance uniformity, credibility, and healthcare quality globally.
Objectives:
The aim of this study was to identify methodological variations leading to varied recommendations between the American College of Cardiology (ACC)/American Heart Association (AHA) and the European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) valvular heart disease guidelines and to suggest foundational steps towards standardizing guideline development.
Methods:
An in-depth analysis was conducted to evaluate the methodologies used in developing the transatlantic guidelines for managing valvular heart disease. The evaluation was benchmarked against the standards proposed by the Institute of Medicine.
Results:
Substantial discrepancies were noted in the methodologies utilized in development processes, including Writing Committee composition, evidence evaluation, conflict of interest management and voting processes. Furthermore, despite their mutual differences, both methodologies demonstrate notable deviations from the Institute of Medicine standards in several essential areas, including literature review and evidence grading. These dual variances likely influenced divergent treatment recommendations. For example, the ESC/EACTS recommends transcatheter edge-to-edge repair for patients with chronic severe mitral regurgitation ineligible for mitral valve surgery, while the ACC/AHA recommends transcatheter edge-to-edge repair based on anatomy, regardless of surgical risk. ESC/EACTS guidelines recommend a mechanical aortic prosthesis for patients under 60, while ACC/AHA guidelines recommend it for patients under 50. Notably, the ACC/AHA and ESC/EACTS guidelines have differing age cut-offs for surgical over transcatheter aortic valve replacement (<65 and <75 years, respectively).
Conclusions:
Variations in methodologies for developing clinical practice guidelines have resulted in different treatment recommendations that may significantly impact global practice patterns. Standardization of essential processes is vital to increase the uniformity and credibility of clinical practice guidelines, ultimately improving healthcare quality, reducing variability and enhancing trust in modern medicine.
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