Coevolutionary analysis of evidence and recommendations in STEMI clinical practice guidelines: A 33-year...

ST-Segment Elevation Myocardial Infarction (STEMI) is considered the main cause of mortality and morbidity for decades globally. Regularly, cardiology-related medical organizations publish clinical practice guidelines (CPGs) to support healthcare professionals in the diagnosis, management, and prevention of future cardiovascular events. Nevertheless, the level of evidence (LOE) and classification of recommendations (CORs) endorsing STEMI-associated CPGs recommendations have not been systematically appraised.

This meta-research study evaluated and described the CORs and LOE over time for STEMI guidelines endorsed by the American Heart Association (AHA), American College of Cardiology (ACC), and European Society of Cardiology (ESC), from 1990 to 2023.

We initially searched on PubMed and AHA/ACC/ESC electronic repositories to obtain STEMI-related CPGs, published from 1990 to 2023, including their immediate predecessors.

Guidelines related to acute in-hospital STEMI management were included; recommendations related to unstable angina/Non-STEMI were excluded.

Data management was performed by 2 content experts. Recommendations on pharmacological and nonpharmacological interventions (PI and NPI, respectively) were extracted ipsilaterally, further processed and coded based on thematic analysis fundamentals. Recommendation's recordings associated with each recommendation were maintained as the primary guideline publication without team's specialist judgement. Pharmacological-related recommendations were categorized in accordance with the Anatomical Therapeutic Chemical Classification System by the WHO Collaborating Centre for Drug Statistics Methodology. Changes in the proportion and LOE were evaluated longitudinally, using chi-square test (x²). Data visualization included heatmaps, linear plots, and Sankey diagrams.

Twenty-six guidelines (2,139 STEMI-specific recommendations) were evaluated. We observed an overall predominance of recommendations relying on moderate (proportion of 30.1% of LOE-B recommendations) or low (proportion of 28.9% of LOE-C recommendations) quality of evidence over the 33-year span. Only 17.7% of processed recommendations were based on high quality of evidence. Pharmacological interventions were more often LOE-A compared with NPI (21.5% vs 13.8%; P-value < 0.05). Most abstracted PI related to anticoagulants and dual anti-platelet therapies, while the most frequent category of NPI were related to percutaneous coronary interventions and implantable cardiac devices. Two consecutive guidelines comparison revealed that LOE and COR assigned to corresponding recommendation were minimal.

Restriction to only AHA/ACC/ESC guidelines and primary focus on acute in-hospital management recommendations.

STEMI-related recommendations from foremost cardiology societies worldwide have largely relied on moderate/low-quality evidence, with slight changes over time. Novel ways to generate high quality evidence in a more pragmatic and efficient fashion are warranted.

None PROTOCOL REGISTRATION: Open Science Frame under OSF.IO/BRD58.