Priority measures for implementation: an ESC pilot linking guidelines to practice

The European Society of Cardiology (ESC) guidelines are foundational for diagnosing, treating, and managing cardiovascular conditions, emphasizing efficacy through the Class of Recommendation (COR) and Level of Evidence (LOE) system. However, these guidelines do not systematically integrate considerations on economic feasibility and implementation complexity, crucial for decision-making in resource-limited settings. This paper reflects the work and discussion of the ESC Clinical Practice Guidelines Committee to address these gaps and proposes a novel framework that integrates two metrics: the number needed to treat (NNT) at 5 years as a measure of clinical effectiveness and a qualitative assessment of implementation complexity. A three-dimensional grid visualizes these metrics alongside disease prevalence, providing policymakers and healthcare resource planners with a structured tool for prioritizing interventions. The framework is intended as a tool to support the implementation of guideline-based recommendations in specific health system contexts. Using the 2021/23 ESC heart failure guidelines and the focused update as a case study, the pilot framework evaluates pharmacological and device-based therapies with COR I, LOE A, incorporating data from randomized trials underpinning the recommendations. Number needed to treat values are calculated for mortality and hospitalization endpoints, while implementation complexity is assessed through a Delphi process, considering factors such as cost, infrastructure, and patient access. This approach offers a standardized method to compare interventions and their feasibility, bridging to current ESC guidelines. It could be particularly relevant in resource-constrained and high-cost environments, supporting informed decision-making and equitable adoption of evidence-based therapies. While promising, the framework requires further validation, and complexity assessments must be tailored to local contexts. By integrating clinical impact, implementation complexity, and disease prevalence, this proposed framework aims to bridge the gap between the guidelines' focus on treatment efficacy and the practical need for prioritization in implementation and healthcare planning.