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To the Editor: Dr Tricoci and colleagues¹ published an analysis indicating that American College of Cardiology/American Heart Association (ACC/AHA) guidelines are largely developed from lower levels of evidence or expert opinion. They concluded that there is a "need to improve the process of writing guidelines and to expand the evidence base from which clinical practice guidelines are derived." Their first conclusion could have been better substantiated by a critical appraisal of the ACC/AHA guideline methods.²

First, the ACC/AHA does not appear to follow Institute of Medicine recommendations to separate the systematic review process from guideline formulation.³ Rather, the same writers appear to perform both processes.

Second, the ACC/AHA uses an overly simplistic, outdated hierarchy of study design (randomized controlled trials [RCTs] at the top) to assess level of evidence. Different types of clinical questions are best answered with different study designs. Moreover, in several recent ACC/AHA guidelines I could find . . . [Full Text of this Article]

Susan L. Norris, MD, MPH, MS
norriss@ohsu.edu
Oregon Health & Science University
Portland

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