Guidelines, position papers and critical reviews: differences and similarities

Abstract

In the European Journal of Preventive Cardiology more and more position papers and expert consensus papers are published as well as critical reviews. The same is true for the other journals of the European Society of Cardiology (ESC) family, particularly for the European Heart Journal, where all ESC Guidelines are published. A great number of guidelines, position papers and critical reviews have been issued in other different scientific medical journals around the world as well, particularly during the last decades. When searching PubMed under ‘guidelines’ one can find 221,633 papers with the intensity of publication varying from only four in the year 1960 up to 17,625 in the year 2011. One can find also 91,016 ‘critical reviews’, 11,976 ‘position papers’ and 4287 ‘expert consensus papers’. However, many experts are not quite sure what the differences are between these different types of manuscript. This editorial is aimed at providing a brief insight into their differences and similarities. Although focusing only on publications developed/written by the ESC and its entities such as the European Association for Cardiovascular Prevention and Rehabilitation (EACPR), most of this editorial can be applied to the publications of all other scientific societies in medicine as well. Guidelines are official publications of the ESC which are produced by the task forces supervised, reviewed and approved by the ESC Committee for Practice Guidelines (CPG). ESC entities (Associations, Working Groups, Councils, etc.) do not produce their own guidelines but can produce position papers and expert consensus documents in the name of their entity or group of authors. Guidelines are produced to present all the relevant and best available up-todate evidence on a particular broad clinical issue with the aim to help clinicians in their everyday clinical practice when they have to weigh the benefits and risks of a diagnostic and/or therapeutic procedure. According to this they provide well-balanced information reflecting established evidence-based knowledge on a specific subject and systematically developed recommendations for diagnosis and treatment for practitioners. However, it has to be stressed that applying them in everyday practice always requires careful judgement of individual cases. Considering all this, guidelines are also aimed to be used to develop standards to assess the best clinical practice. The methodological standards for issuing good quality and trustworthy guidelines were well defined more than a decade ago and ESC Guidelines follow the high quality criteria for the development of guidelines which can be found at www.escardio.org/knowledge/ guidelines/rules. Since the guidelines should not only represent the views of one or two specific groups of experts in selected topics, the task forces have to be composed of a diverse expertise to represent the multidisciplinary views and give an objective evaluation of the particular broad subject at hand. The guidelines’ recommendations must be graded according to four different classes (I, IIa, IIb and III) and linked to their levels of evidence (A, B and C), but some guidelines might have in addition also another type of grading such as GRADE (strong or weak recommendation), which could be more suitable for a particular topic and which has the advantage of distinguishing quality of evidence and strength of recommendation. For instance, this latter type of grading was used in the recently published 2012 joint Guidelines on cardiovascular disease prevention in clinical practice, illustrating that strong evidence does not automatically lead to a strong recommendation. Although the implementation of the guidelines’ recommendations should be an integral part of the guidelines’ development process, the adherence to guidelines is often far from optimal due to many barriers which have not substantially changed during the last decade. Some of the ESC Guidelines are produced solely by the ESC and some are produced in partnership with another societies, such as the Guidelines for