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	Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings.

To the Editor: Without commenting on the review of clinical practice guidelines in cardiovascular disease by Dr Tricoci and colleagues,¹ we take issue with the corresponding Editorial by Drs Shaneyfelt and Centor² regarding such guidelines in general. The Editorial endorsed a major assumption—also promoted as a tenet of evidence-based medicine—that data based on the highest level of evidence provide an unequivocal path to improved patient care.

The Editorial considered the substantial proportion of recommendations based on results from nonrandomized studies to represent a failure of the process of developing guidelines. Similarly, the finding that many topics involve conflicting evidence was considered disconcerting. These issues were attributed mainly to the influence of specialty societies and to financial conflicts of interest. Conspicuously absent from the Editorial, however, was any mention of problems with hierarchies of evidence themselves.^3-4

The structure of RCTs minimizes bias because of differences in participants' susceptibility to the outcome, . . . [Full Text of this Article]

John Concato, MD, MS, MPH
john.concato@yale.edu
VA Clinical Epidemiology Research Center
VA Connecticut Healthcare System
West Haven

Ralph I. Horwitz, MD
Stanford University School of Medicine
Palo Alto, California

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