Cardio-Oncology Guidelines and Strength of the Evidence

with 837 references. 1 It is a joint venture with the European Hematology Association, the European Society for Therapeutic Radiology and Oncology, and the International Cardio-Oncology Society.The immense undertaking in reviewing and evaluating the published data by the writing committee members should be highly commended.However, though detailed guidance is given, the vast majority of the recommendations are derived from Level of Evidence (LOE) C (low or very low), derived from expert opinion, case studies, retrospective studies, or registries. 1 Of the total 156 Class 1 recommendations in the current guidelines, only 5 (3%) carry LOE A (data derived from multiple randomized trials or meta-analyses), 33 (21%) carry LOE B (data derived from a single randomized clinical trial or a large nonrandomized trial), and 118 (76%) carry LOE C.Among the 5 Class 1 recommendations with LOE A, 3 are for managing cancer-associated venous thromboembolism, 1 for corrected QT interval monitoring of ribociclib, and 1 for evaluating suspected amyloid light chain cardiac amyloidosis using cardiac magnetic resonance.In addition, all 5 Class 3 recommendations carry LOE C.Although the LOE to support strong recommendations is often not very high in cardiology guidelines because many clinical questions have not been addressed by high-quality randomized controlled clinical trials, a guideline with a vast majority of strong recommendations on the basis of LOE C is not common in general cardiology.Among all 272 recommendations in the current 2022 ESC guidelines on cardio-oncology, 76% are supported by LOE C. In contrast, in a systematic review of all 51 current guideline documents published by the American College of Cardiology (ACC)/American Heart Association (AHA) and ESC between 2008 and 2018, which included 6,329 recommendations, 42% of recommendations in the ACC/AHA guidelines and 55% of recommendations in the ESC guidelines were classified as LOE C (Table 1). 2 The ACC/AHA and ESC publish their guidelines using a similar grading scheme for grading of recommendations and LOE.The goal of guidelines is to set the de facto standard for medical practice and therefore influence clinical decisions about individual patients, practice performance measures, insurance reimbursement, and education programs.3 Clinical guidelines have also been used in the determination of the standard of care in medical malpractice litigation.4 In general, the strength of a recommendation indicates the extent to which the medical community can be confident that adherence to the recommendation will do more good than harm; the quality of evidence indicates the extent to which we can be confident that an estimate of effects is correct.5 The level of implementation of guidelines and adherence to guidelines have been used to measure the performance of clinical practice.Class 1 and Class 3 recommendations in the guidelines are explicit, and they are for and against certain interventions, respectively.They are usually followed in clinical practice.Whereas guideline recommendations are "should" (Class 1) or "should not" (Class 3) directives, ACC/AHA performance measures represent "must do" or "must not do" directives.Performance measures are used as the basis for public reporting