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To the Editor: In their study, Dr Tricoci and colleagues¹ pointed out that less than one-fifth of recommendations advocating a particular procedure or treatment in ACC/AHA practice guidelines were based on level A evidence. However, in using the ACC/AHA evidence grading schema to judge the quality of evidence underpinning guideline recommendations, I believe they have overestimated the strength of this evidence base. For example, under the ACC/AHA schema RCTs or meta-analyses are deemed to be level A evidence (or at worst level B if there is only a single RCT or the RCTs are small) irrespective of study conduct, end points evaluated (surrogate outcomes vs patient-centered outcomes), or the applicability of that RCT to the clinical scenario for which the recommendation is being made.

In a study evaluating the evidence cited in support of cardiovascular treatment recommendations in 9 current national guidelines (from the United States, Canada, and Europe),² my . . . [Full Text of this Article]

Finlay A. McAlister, MD, MSc
finlay.mcalister@ualberta.ca
Division of General Internal Medicine
University of Alberta
Edmonton, Canada

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