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Multicenter Study
. 2024 Jul 2;26(7):euae178.
doi: 10.1093/europace/euae178.

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 Sterliński  1 , Karina V Bunting  2   3 , Giuseppe Boriani  4 , Serge Boveda  5 , Eduard Guasch  6   7   8   9 , Lluís Mont  7   9   10 , Kim Rajappan  11 , Philipp Sommer  12 , Samir Mehta  13 , Yongzhong Sun  13 , Chris P Gale  14   15   16 , Colinda van Deutekom  17 , Isabelle C Van Gelder  17 , Dipak Kotecha  2   3   18   19 ; STEEER-AF Trial Team
Collaborators, Affiliations
Multicenter Study

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 Sterliński et al. Europace. .

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: Atrial fibrillation; Guideline adherence; Rhythm control; Stroke prevention; Trial.

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Figures

Graphical Abstract
Graphical Abstract
The STEEER-AF trial in the context of the European Society of Cardiology roadmap for cardiovascular education (https://doi.org/10.1093/eurheartj/ehy058).
Figure 1
Figure 1
STEEER-AF trial flowchart. Process and outcomes in the STEEER-AF trial. aMinimization algorithm accounting for country and guideline adherence for stroke prevention and rhythm control at baseline. bClass I and III recommendations on stroke prevention and rhythm control therapy (ESC Guidelines on the management of AF). cProportion of relevant guidelines attained; appropriate use of anticoagulation; integrated AF approach; patient quality of life. dComposite of mortality, stroke, TIA, pulmonary or systolic embolus, acute coronary syndrome/myocardial infarction, heart failure, and major or clinically relevant bleeding plus hospital admissions. AF, atrial fibrillation; ESC, European Society of Cardiology; STEEER-AF, 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.
Figure 2
Figure 2
STEEER-AF deployment. Centres, patients, and healthcare professionals engaging with STEEER-AF across six countries. STEEER-AF, 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.
Figure 3
Figure 3
Global context during initiation of the STEEER-AF trial. Displayed for each country taking part in STEEER-AF are the activation of sites and start of patient recruitment (light grey bar) and randomization of centres after completion of patient recruitment (dark grey bars). Corresponding data for COVID-19 cases are displayed (7-day rolling average of confirmed cases from the World Health Organization COVID-19 dashboard; log scale) for Germany, France, Poland, Italy, Spain, and the UK. The round marker notes the start of refugee migration following the invasion of Ukraine. COVID-19, coronavirus disease 2019; STEEER-AF, 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.
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