Table 2.
Selected Examples of Downgraded Class I Recommendations From ACC/AHA Clinical Practice Guidelinesa
| Index Guideline | Index Recommendation | Class and LOE |
Revised (Current) Guideline |
Corresponding Revised (Current) Recommendations |
Class and LOE |
|---|---|---|---|---|---|
| 2001: Guidelines for the management of patients with atrial fibrillation18(p1255) | Screening for the presence of thrombus in the left atrium or left atrial appendage by transesophageal echocardiography is an alternative to routine preanticoagulation… for cardioversion of [AF]. | Class I, LOE B | 2006: Guidelines for the management of patients with atrial fibrillation19(pe314) | As an alternative to anticoagulation prior to cardioversion of AF, it is reasonable to perform transesophageal echocardiography in search of thrombus in the left atrium or left atrial appendage. | Class IIa, LOE B |
| 2002: Guideline update on perioperative cardiovascular evaluation for noncardiac surgery20(p19) | Preoperative noninvasive evaluation of LV function: patients with current or poorly controlled HF. (If previous evaluation has documented severe left ventricular dysfunction, repeat preoperative testing may not be necessary.) | Class I, LOE not provided | 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery21(pe437) | Preoperative noninvasive evaluation of LV function: …is reasonable for patients with current or prior HF with worsening dyspnea or other change in clinical status… if not performed within 12 mo. | Class IIa, LOE C |
| 2002: Guideline update for implantation of cardiac pacemakers and antiarrhythmia devices23(p30) | Implantable cardioverter-defibrillator therapy: spontaneous sustained VT in patients without structural heart disease not amenable to other treatments. | Class I, LOE C | 2008: Guidelines for device-based therapy of cardiac rhythm abnormalities22(pe384) | Implantable cardioverter-defibrillators: ICD implantation is reasonable for patients with sustained VT and normal or near -normal ventricular function. | Class IIa, LOE C |
| 2006: Guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease24(p2365) | ACE inhibitors: consider for all other patients [those without left ventricular ejection fraction <40% and those without hypertension, diabetes, or chronic kidney disease]. | Class I, LOE B | 2011: Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease25(p2461) | ACE inhibitors: it is reasonable to use ACE inhibitors in all other patients [those without left ventricular ejection fraction <40% and those without hypertension, diabetes, or chronic kidney disease]. | Class IIa, LOE B |
| 2004: Guideline update for coronary artery bypass graft surgery16(pe407) | CABG is recommended in patients with stable angina who have 2-vessel disease with significant proximal LAD stenosis and either EF less than 0.50 or demonstrable ischemia on noninvasive testing. | Class I, LOE A | 2011: Guideline for coronary artery bypass graft surgery26(pe670) | CABG to improve survival is reasonable in patients with mildmoderate LV systolic dysfunction (EF 35% to 50%) and significant… multivessel CAD or proximal LAD coronary artery stenosis, when viable myocardium is present…. | Class IIa, LOE B |
| 2007: Evidence-based guidelines for cardiovascular disease prevention in women27(p1486) | Lifestyle and pharmacotherapy should be used as indicated in women with diabetes to achieve an HbA1c <7% if this can be accomplished without significant hypoglycemia. | Class I, LOE C | 2011: Evidence-based guidelines for cardiovascular disease prevention in women28(p1253) | Lifestyle and pharmacotherapy can be useful in women with diabetes mellitus to achieve an HbA1c <7% if this can be accomplished without significant hypoglycemia. | Class IIa, LOE B |
| 2005: Guideline update for the diagnosis and management of chronic heart failure in the adult29(pe162) | Coronary arteriography should be performed in patients presenting with HF who have angina or significant ischemia unless the patient is not eligible for revascularization…. | Class I, LOE B | 2013: Guideline for the management of heart failure30(pe259) | When ischemia may be contributing to HF, coronary arteriography is reasonable for patients eligible for revascularization. | Class IIa, LOE C |
| 2005: Guidelines on percutaneous coronary intervention32(pe218) | PCI after successful fibrinolysis: in patients whose anatomy is suitable, PCI should be performed when there is objective evidence of recurrent MI. | Class I, LOE C | 2011: Guideline for percutaneous coronary intervention31(pe599) | PCI is reasonable in patients with STEMI and clinical evidence for fibrinolytic failure or infarct artery reocclusion. | Class IIa, LOE B |
| 2002: Guideline update for the management of patients with chronic stable angina34(p91) | Stress radionuclide imaging or stress echocardiography… [is recommended for follow-up] for patients who have a significant change in clinical status and required a stress imaging procedure on their initial evaluation…. | Class I, LOE C | 2012: Guideline for the diagnosis and management of patients with stable ischemic heart disease33(pe429) | Exercise with nuclear MPI or echocardiography is reasonable in patients with known SIHD who have new or worsening symptoms not consistent with UA and who …previously required imaging with exercise stress…. | Class IIa, LOE B |
| 2002: Guideline update for the management of patients with unstable angina and non–ST-segment myocardial infarction36(p24) | Morphine sulfate intravenously [is recommended] when symptoms are not immediately relieved with nitroglycerin or when acute pulmonary congestion and/or severe agitation is present. | Class I, LOE C | 2007: Guidelines for the management of patients with unstable angina/ non–ST-elevation myocardial infarction35(pe183) | In the absence of contradictions to its use, it is reasonable to administer morphine sulfate intravenously to UA/NSTEMI patients if there is uncontrolled ischemic chest discomfort despite nitroglycerin…. | Class IIa, LOE B |
| 1998: Guidelines for the management of patients with valvular heart disease37(p1957) | Exercise testing in chronic aortic regurgitation: assessment of functional capacity and symptomatic responses in patients with a history of equivocal symptoms. | Class I, LOE not provided | 2006: Guidelines for the management of patients with valvular heart disease38(pe115) | Exercise stress testing for chronic AR is reasonable for assessment of functional capacity and symptomatic response in patients with a history of equivocal symptoms. | Class IIa, LOE B |
Abbreviations: ACC/AHA, American College of Cardiology/American Heart Association; ACE, angiotensin-converting enzyme; AF, atrial fibrillation; AR, aortic regurgitation; CABG, coronary artery bypass graft procedure; CAD, coronary artery disease; EF, ejection fraction; HbA1c, hemoglobin A1c; HF, heart failure; ICD, implantable cardioverter-defibrillator; LAD, left anterior descending artery; LOE, level of evidence; LV, left ventricle; MI, myocardial infarction; MPI, myocardial perfusion imaging; PCI, percutaneous coronary intervention; SIHD, stable ischemic heart disease; STEMI, ST-segment elevation myocardial infarction; UA/NSTEMI, unstable angina/non–ST-segment elevation myocardial infarction; VT, ventricular tachycardia.
a
Recommendations have been edited for length; see eTable 1 in the Supplement for full text.