Developing AHA ECC recommendation informed by GRADE strong or weak recommendation against therapy or diagnostic or prognostic test

This flowchart depicts what can happen when developing an AHA ECC recommendation informed by a GRADE strong or weak recommendation against therapy or a diagnostic or prognostic test. (“ECC” is the acronym for “Emergency Cardiovascular Care.” “GRADE” is an acronym that stands for “Grading of Recommendations Assessment, Development, and Evaluation.”) This flowchart includes seven boxes. There are two boxes of origin. One is labeled “GRADE strong or weak recommendation against, with low or very low evidence.” Only this box of origin leads to two of the boxes. A dashed arrow labeled “Unlikely” points to the box titled “Convert to AHA ECC Class 1 (Strong) Recommendation if Benefit is [substantially greater than] Risk.” The text description states: “Therapy or test is “recommended or indicated, effective or beneficial, should be done.” This applies to therapies or tests that are considered the standard of care or that should generally be provided or used for the vast majority of patients. The writing group should document the rationale for difference from ILCOR GRADE (for example, is it as a result of patient subset or specific conditions?).” (“ILCOR” is an acronym that stands for “International Liaison Committee on Resuscitation.”) Another dashed arrow labeled “Unlikely” points from the same box of origin to a box titled “Convert to AHA ECC Class 2 A (Moderate) Recommendation If Benefit [is somewhat greater than] Risk.” The text description states: “Therapy or text is “probably recommended, is reasonable, can be useful, effective, or beneficial.” It is appropriate with most patients with some exceptions.” The second box of origin is labeled “GRADE strong or weak recommendation against, with high or moderate evidence.” Both boxes of origin point to the box titled “Convert to AHA ECC Class 2 B (Weak Recommendation If Benefit [is greater to or equal than] Risk.” Its text description states: “Therapy or test “may or might be reasonable or may or might be considered, but other options are acceptable.” The “usefulness or effectiveness is unknown, unclear, or uncertain or will not well established.” The group may cite a subpopulation for whom the therapy or test may be useful.” Note that while both boxes of origin lead to this box, the “GRADE strong or weak recommendation against, with low or very low evidence” has a solid arrow labeled “Maybe” whereas the box of origin for those with “high or moderate evidence” has a dashed arrow labeled “Unlikely.” Only the box of origin titled “GRADE strong or weak recommendation against, with high or moderate evidence” points to the next box. It’s titled “AHA ECC Class 3: No Benefit If Benefit [equals] Risk.” The text description states in bold: “This Class requires L.O.E. A or B (not C or E) studies documenting lack of benefit.” (“L.O.E.” is an acronym that stands for “Level of Evidence.”) The description continues, “If you wish to assign this Class with only L.O.E. C or E evidence, provide rationale in the Guidelines.” Both boxes of origin have solid arrows labeled “Maybe” pointing to the final box, which is titled “AHA ECC Class 3 (Strong): Harm.” The text description states: “Potentially harmful. Writing group has strong concerns regarding harm and strongly recommends against use of therapy or the test. Therapy or the test is associated with excess morbidity or mortality and should not be performed or administered.” This figure is copyright 2015 by the American Heart Association. There is a caption beneath this Figure which reads: “Developing an AHA ECC recommendation that is informed by a GRADE strong or weak recommendation against a therapy or diagnostic or prognostic test.”