Appraisal of the 2024 revision of the level of evidence grading system in European Society of Cardiology Guidelines

The European Society of Cardiology (ESC) introduced evidence-based clinical practice guidelines in the field of cardiovascular medicine more than 30 years ago.1,2 European Society of Cardiology Guidelines have proved invaluable to inform healthcare providers and patients with the goal of improving cardiovascular care and advancing implementation of established therapies. Since publication of its first guideline in 19941 on the prevention of coronary heart disease, the ESC has continuously refined its processes related to guidelines, including the creation of a dedicated Clinical Practice Guidelines (CPG) Office in 2001, publication of a strict Declaration of Interest policy, and, more recently, the inclusion of patient representatives. Of note, ESC Guidelines are typically developed by dedicated task forces with all recommendations required to obtain at least 75% of task force member votes. Documents undergo an intensive review process (on average 3 rounds generating an average of more than 3000 reviewer comments) involving experts and representatives from ESC National Cardiac Societies. As the systematic evaluation of existing evidence is the very basis for any new guideline recommendation, the ESC has recognized the importance of involving clinical methodology experts who are included as representatives in the Clinical Practice Guidelines Committee and in every ESC Guideline Task Force, highlighting the ESC’s commitment to methodological rigour.