Design and deployment of the STEEER-AF trial to evaluate and improve guideline adherence: a cluster-randomized trial by the European Society of Cardiology and European Heart Rhythm Association
Maciej SterlińskiKarina V BuntingGiuseppe BorianiSerge BovédaEduard GuaschLluı́s MontKim RajappanPhilipp SommerSamir MehtaYongzhong SunChris P GaleColinda van DeutekomIsabelle C. Van GelderDipak KotechaYann AllaliAsgher ChampsiThomas DenekeKaitlyn GreeleyBenoît Guy-MoyatMikaël LaredoAlastair MobleyMaximina VenturaMary StanburyTrudie LobbanThompson RobinsonTatjana PotparaÉloi MarijonPascal DefayePierre BaudinaudSimon KochhaeuserUrsula RauchMoritz F. SinnerMarco ProiettiIgor DiembergerVincenzo RussoStanisław TubekPiotr BuchtaPaweł BalsamEusebio García‐IzquierdoIvo Roca‐LuqueMaría José Guerra PalmeroDewi E. ThomasAfzal SohaibMark DaviesOlivier PiotWilliam EscandeChristian de ChillouMaxime De GuillebonFrédéric AnselmeAndréa CianciRodrigue GarciaPhilippe MauryDominique PavinEstelle GandjbakhchFrédéric SacherKarim HasniFabien GarnierCharles GuénanciaNicolas LelloucheStephan WillemsMartin BorlichAndreas MetznerHans-Holger EbertDong‐In ShinDavid DunckerStefan G. SpitzerPeter NordbeckRoland Richard TilzAndrea MazzaCinzia ValzaniaMargherita PadelettiMatteo BertiniGiuseppe BorianiJacopo Francesco ImbertiStefano FumagalliAntonio RapacciuoloMonika Lica GorzynskaAdam GorloMagdalena KostkiewiczGrzegorz SobieszekAndrzej S SkrzyńskiRobert GajdaHanna Wilk-ManowiecJ. BlicharzWiktor K GmińskiTomasz CzerskiFelipe BisbalIgnasi AngueraTeresa LozanoJoaquín OscaJosé Luís MerinoNaiara CalvoJuan Fernández‐ArmentaJuan AcostaNúria Rivas-GándaraMaría del Pilar Cabañas MorenoEmilce TruccoRichard BondRichard AngShawn A A MoraisFu Siong NgMattew G D BatesMichala PedersenDaniel T RaineManish KallaMatthew J. LovellMalcolm FinlayArif Hasan BhuiyanNorman QureshiHein HeidbüchelWolfram DöhnerBernard IungSusanna PriceHelmut PürerfellnerBarbara CasadeiPaulus KirchhofAlex LyonWinston BanyaRóbert HatalaPekka Raatikainen
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Abstract Aims The aim is to describe the rationale, design, delivery, and baseline characteristics of the Stroke prevention and rhythm control Treatment: Evaluation of an Educational programme of the European society of cardiology in a cluster-Randomized trial in patients with Atrial Fibrillation (STEEER-AF) trial. Methods and results STEEER-AF is a pragmatic trial designed to objectively and robustly determine whether guidelines are adhered to in routine practice and evaluate a targeted educational programme for healthcare professionals. Seventy centres were randomized in six countries (France, Germany, Italy, Poland, Spain, and UK; 2022–23). The STEEER-AF centres recruited 1732 patients with a diagnosis of atrial fibrillation (AF), with a mean age of 68.9 years (SD 11.7), CHA2DS2-VASc score of 3.2 (SD 1.8), and 647 (37%) women. Eight hundred and forty-three patients (49%) were in AF at enrolment and 760 (44%) in sinus rhythm. Oral anticoagulant therapy was prescribed in 1543 patients (89%), with the majority receiving direct oral anticoagulants (1378; 89%). Previous cardioversion, antiarrhythmic drug therapy, or ablation was recorded in 836 patients (48.3%). Five hundred fifty-one patients (31.8%) were currently receiving an antiarrhythmic drug, and 446 (25.8%) were scheduled to receive a future cardioversion or ablation. The educational programme engaged 195 healthcare professionals across centres randomized to the intervention group, consisting of bespoke interactive online learning and reinforcement activities, supported by national expert trainers. Conclusion The STEEER-AF trial was successfully deployed across six European countries to investigate guideline adherence in real-world practice and evaluate if a structured educational programme for healthcare professionals can improve patient-level care. Clinical Trial Registration Clinicaltrials.gov, NCT04396418.Keywords:
Guideline
Heart Rhythm
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Atrial fibrillation (AF) in dogs can be managed by electrical cardioversion to sinus rhythm, but early recurrence of AF occurs in some dogs. In humans, the commonly evaluated clinical variables for prediction of early relapse of AF are left atrial size and duration of AF. It is unclear whether the duration of AF affects maintenance of sinus rhythm after cardioversion in dogs with spontaneous AF.That duration of sinus rhythm after cardioversion is related to the chronicity of AF.Forty-one consecutive dogs that had undergone successful transthoracic cardioversion for spontaneous AF were evaluated.The relationship between the duration of documented AF and the duration of sinus rhythm after cardioversion was statistically evaluated using data obtained retrospectively. The effects of structural heart disease and pretreatment with amiodarone were also evaluated.The presence of structural heart disease and the duration of documented AF had significant effects on maintenance of sinus rhythm after cardioversion (P <.001 and P=.022, respectively). The duration of documented AF was inversely related to the duration of sinus rhythm (P=.022) in dogs with and without structural heart disease.Estimates of duration of sinus rhythm based on the duration of documented AF are provided for dogs with and without heart disease allowing prediction of risk for early AF relapse.
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Electrical cardioversion
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To assess factors related to the success of restoration and one-year maintenance of sinus rhythm in chronic (more than 48 h) nonrheumatic atrial fibrillation (AF).One hundred and fifty consecutive patients aged 62+/-9 years with AF lasting 123+/-254 days were evaluated clinically with transthoracic and transesophageal echocardiography before elective direct current cardioversion. Heart chamber dimensions and left ventricular ejection fraction were measured. The presence of left atrial thrombi and spontaneous echocardiographic contrast as well as flow velocities in the left atrial appendage were assessed. The first cardioversion was followed by standardized two-step antiarrhythmic treatment including a second cardioversion, if necessary. Twenty patients (13%) spontaneously reverted to sinus rhythm (S) during anticoagulation preceding cardioversion, 81 (54%) were successfully cardioverted (Y), and in 49 (33%) cardioversion failed initially (N). No differences were noted between the two latter groups. However, S patients had smaller left atria measured in the short and long axes (42+/-4 mm, P=0.05, and 53+/-7 mm, P=0.005, respectively) than both the Y (45+/-4 and 61+/-8 mm) and the N patients (46+/-4 and 61+/-8 mm). One-year follow-up was obtained in 95 patients: 64 (67%) were in sinus rhythm while 31 (33%) had AF. Again, no initial differences predicting the maintenance of sinus rhythm were found.Spontaneous reversion of AF seems more likely with smaller left atria. Echocardiography, including trans-esophageal echocardiography, is unlikely to identify patients in whom attempts to restore and maintain sinus rhythm will fail or succeed.
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The predictive value of plasma atrial natriuretic peptide (ANP) on the cardioversion outcome was evaluated in 46 hospitalized patients with recent-onset atrial fibrillation (AF). Cardioversion was successful in 42 (91%) patients, 7 (15%) of them regained sinus rhythm spontaneously. After 12 months, 14 (33%) cardioverted patients were in chronic AF. There were no differences in plasma ANP levels between groups where cardioversion failed, those who cardioverted but later developed chronic AF or those who remained in sinus rhythm. However, among patients who were on antiarrhythmic therapy, ANP levels obtained after cardioversion were lower in those who later remained in sinus rhythm. We conclude that lower ANP after cardioversion may be associated with increased chances of long-term preservation of sinus rhythm.
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Electrical cardioversion
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Inflammation has been recently implicated in the pathophysiology of atrial fibrillation (AF). The aim of this study was to examine the variation of inflammatory indexes during the first week after successful electrical cardioversion of persistent AF. Successive measurements of white blood cell (WBC) count, C-reactive protein (CRP) and fibrinogen levels were performed in 30 cardioverted patients. At the end of the 7-day follow-up period, AF had recurred in 30% of patients. A significant variance was found in serial measurements of fibrinogen levels in the two groups (non-relapse and relapse, p = 0.005). Fibrinogen levels increased significantly in patients who relapsed into AF, but remained stable in patients who remained in sinus rhythm. In the latter patients, CRP values tended to decrease post-cardioversion, but WBC count was significantly lower (p < 0.001) on the 7th day (6083 ± 1335), compared with baseline values (6648 ± 1395). The variation of inflammatory indices post-cardioversion might have prognostic implications with regard to sinus rhythm maintenance.
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