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© 2025 American Heart Association, Inc.BACKGROUND: – Evidence-based practice relies on clinical guidelines, whose recommendations depend on the quality, relevance, and validity of supporting research. We evaluated the class/strength and level of evidence (LOE) or quality of evidence (QOE) supporting American Heart Association/American Stroke Association and European Stroke Organisation guideline recommendations, and examined temporal changes in LOE. METHODS: – Stroke guidelines from American Heart Association/American Stroke Association (1995–2025) and European Stroke Organisation (2014–2025) were identified through society websites and EMBASE/MEDLINE. Eligible documents contained recommendations with class/strength and LOE/QOE. Consensus statements were excluded. Since 2006, American Heart Association/American Stroke Association has classified LOE as A (multiple or large randomized-controlled trials), B (single trial or observational studies), or C (expert opinion). European Stroke Organisation applies the Grading of Recommendations Assessment, Development, and Evaluation system (high, moderate, low, and very low QOE). RESULTS: – Across 1102 recommendations in 9 current American Heart Association/American Stroke Association stroke guidelines, 156 (14.2%) were supported by LOE A, 559 (50.7%) by LOE B, and 387 (35.1%) by LOE C. Of 407 class I recommendations (ie, should do), and 117 class III recommendations (ie, should not do), 116 (22.1%), 258 (49.2%), and 150 (28.6%) were supported by LOE A, B, and C, respectively. Although the number of recommendations increased across guideline updates (median, 22 [interquartile range, 25th–75th percentiles, 18.0–42.0]), the proportion supported by LOE A declined (median, −4.6% [interquartile range, −7.8 to −0.8]). Across 260 recommendations in 30 European Stroke Organisation guidelines, 19 (7.3%) were supported by high, 62 (23.8%) by moderate, 81 (31.2%) by low, and 98 (37.7%) by very low QOE. Among 90 strong recommendations, 18 (20.0%) were supported by high QOE, and 66.7% of guideline topics had no recommendations supported by high QOE. There was insufficient evidence to make recommendations for 123 (32.7%) clinical questions. CONCLUSIONS: – Due to limited randomized data for many important clinical questions, most stroke guideline recommendations are based on low-to-moderate–quality evidence. These findings emphasize the need to improve the funding, design, and delivery of efficient, patient-focused clinical trials.
Author(s): Brennan SO, Gordon B, Anderson CS, Coutts SB, Dawson J, Hill MD, Lemmens R, Menon BK, Price CI, Aguiar de Sousa D, Thomalla G, Tsivgoulis G, Turc G, Kelly PJ, McCabe JJ
Publication type: Article
Publication status: Published
Journal: Stroke
Year: 2026
Volume: 57
Issue: 2
Pages: 381-390
Print publication date: 01/02/2026
Online publication date: 23/10/2025
Acceptance date: 09/10/2025
ISSN (print): 0039-2499
ISSN (electronic): 1524-4628
Publisher: Wolters Kluwer Health
URL: https://doi.org/10.1161/STROKEAHA.125.053239
DOI: 10.1161/STROKEAHA.125.053239
PubMed id: 41128073
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