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TABLE 1. Applying Classification of Recommendations and Level of Evidence

“Size of Treatment Effect”

Class I Class IIa Class IIb Class III

Benefit !!! Risk Benefit !! Risk Benefit ! Risk Risk ! Benefit
Procedure/Treatment SHOULD be Additional studies with Additional studies with No additional studies needed
performed/administered focused objectives needed broad objectives needed; Procedure/Treatment should
IT IS REASONABLE to additional registry data NOT be
perform would be helpful performed/administered SINCE
procedure/administer Procedure/Treatment IT IS NOT HELPFUL AND MAY
treatment MAY BE CONSIDERED BE HARMFUL
Level A • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that
Multiple (3–5) procedure or treatment is of treatment or procedure usefulness/efficacy procedure or treatment is
population risk strata useful/effective being useful/effective less well established not useful/effective and
evaluated * • Sufficient evidence from • Some conflicting evidence • Greater conflicting may be harmful
General consistency of multiple randomized trials or from multiple randomized evidence from • Sufficient evidence from
direction and magnitude meta-analyses trials or meta-analyses multiple randomized multiple randomized trials
“Estimate of Certainty (Precision) of Treatment of Effect”

of effect trials or meta- or meta-analyses

analyses

Level B • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that

Limited (2–3) population procedure or treatment is of treatment or procedure usefulness/efficacy procedure or treatment is
risk strata evaluated* useful/effective being useful/effective less well established not useful/effective and
• Limited evidence from single • Some conflicting evidence • Greater conflicting may be harmful
randomized trial or from single randomized evidence from single • Limited evidence from
nonrandomized studies trial or nonrandomized randomized trial or single randomized trial or
studies nonrandomized nonrandomized studies
studies

Level C • Recommendation that • Recommendation in favor • Recommendation’s • Recommendation that

Very limited (1–2) procedure or treatment is of treatment or procedure usefulness/efficacy procedure or treatment is
population risk strata useful/effective being useful/effective less well established not useful/effective and
evaluated * • Only expert opinion, case • Only diverging expert • Only diverging expert may be harmful
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studies, or standard-of-care opinion, case studies, or opinion, case studies, • Only expert opinion, case
standard-of-care or standard-of-care studies, or standard-of-care
Suggested phrases for should is reasonable may/might be considered is not recommended
writing is recommended can be useful/effective/ may/might be reasonable is not indicated
recommendations† is indicated beneficial usefulness/effectiveness should not
is useful/effective/beneficial is probably recommended or is unknown/unclear is not
indicated /uncertain or not useful/effective/beneficial
well established may be harmful
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior
MI, history of heart failure, and prior aspirin use.
†The ACC/AHA Task Force on Practice Guidelines recently provided a list of suggested phrases to use when writing recommendations. All recommendations in the
STEMI guideline have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the
rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase
readers’ comprehension of the guidelines and will allow queries at the individual recommendation level.

fear of potential embarrassment (Level of Evi- that the patient or family member/friend call 9-1-1
dence: C) immediately to access EMS. (Level of Evidence: C)
d. A plan for appropriate recognition and re-
Morbidity and mortality due to STEMI can be reduced
sponse to a potential acute cardiac event that
significantly if patients and bystanders recognize symp-
includes the phone number to access emergency
toms early, activate the EMS system, and thereby shorten
medical services (EMS), generally 9-1-1.15 (Level of the time to definitive treatment. Patients with possible
Evidence: C) symptoms of STEMI should be transported to the hospital
3. Healthcare providers should instruct patients for by ambulance rather than by friends or relatives because
whom nitroglycerin has been prescribed previously to there is a significant association between arrival at the
take ONE nitroglycerin dose sublingually in response emergency department (ED) by ambulance and early
to chest discomfort/pain. If chest discomfort/pain is reperfusion therapy.16 –19 Although the traditional recom-
unimproved or worsening 5 minutes after 1 sublingual mendation is for patients to take 1 nitroglycerin dose
nitroglycerin dose has been taken, it is recommended sublingually, 5 minutes apart, for up to 3 doses before