Education of healthcare professionals to improve guideline adherence in atrial fibrillation: the STEEER-AF cluster-randomized clinical trial

Competing interests

All principal authors have completed the International Committee of Medical Journal Editors (ICMJE) uniform disclosure form. D.K. declares support for the present manuscript as follows: ESC supported by educational grants from Boehringer Ingelheim/BMS-Pfizer Alliance/Bayer/Daiichi Sankyo/Boston Scientific, the NIHR/University of Oxford Biomedical Research Center and British Heart Foundation (BHF)/University of Birmingham Accelerator Award (STEEER-AF); grants or contracts from the National Institute for Health and Care Research (NIHR; NIHR130280 DaRe2THINK; NIHR132974 D2T-NeuroVascular; NIHR203326 Biomedical Research Center); British Heart Foundation (AA/18/2/34218 and FS/CDRF/21/21032); EU/EFPIA Innovative Medicines Initiative (BigData@Heart 116074); EU Horizon and UKRI (HYPERMARKER 101095480); UK National Health Service—Data for R&D—Subnational Secure Data Environment program (West Midlands); UK Department for Business, Energy and Industrial Strategy Regulators Pioneer Fund; Cook and Wolstenholme Charitable Trust; Bayer; Amomed; Protherics Medicines Development; and consulting fees from Bayer, Amomed, Protherics Medicines Development; monitoring board or advisory board for ESC (Chair of 2024 Atrial Fibrillation Guidelines; no payments). K.V.B. declares grants from the BHF (Career Development Research Fellowship for Nurses and Healthcare Professionals—S/CDRF/21/21032); role in other board, society, committee or advocacy groups as member of the British Society of Echocardiography education committee (no payments); and ESC (Coordinator of 2024 Atrial Fibrillation Guidelines; no payments). P.S. declares grants or contracts from Boston, ImriCor and CVRx and participation on a data safety monitoring board or advisory board for Abbott, Medtronic and Biosense. M.S. declares grants or contracts from Biotronik, HammerMed and Medtronic; consulting fees from Abbott, Biotronik, HammerMed and Medtronic; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Biotronik, Pfizer, Medtronic, Zoll and Novartis; participation on a data safety monitoring board or advisory board for Novartis, Medtronic and Impulse Dynamics; leadership or fiduciary role in other board, society, committee or advocacy group (EHRA Advocacy and Quality Improvement Committee 2022–2024; no payments). L.M. declares research grants paid to his institution from Abbott Medical, Medtronic, Boston Scientific, J&J and Biotronik; consulting fees from Abbott Medical, Medtronic, Boston Scientific and J&J; payment or honoraria for lectures from Abbott Medical, Medtronic, Boston Scientific and J&J; payment for expert testimony and support for attending meetings and/or travel from Abbott Medical, Medtronic and Boston Scientific; participation on a data safety monitoring board or advisory board for Medtronic and Boston Scientific; stock or stock options with Stockholder of Galgo Medical, S.L. E.G. declares grants or contracts from Consejo Superior de Deportes (Spanish Culture and Sports Ministry; reference EXP_75119), Fondo de Investigaciones Sanitarias (FIS)—Instituto de Salud Carlos III (Spanish Ministry of Science, Innovation and Universities; reference PI22/00953) and H2020-MSCA-ITN-2019 program (local PI; grant agreement 860974). S.B. declares consulting fees from Medtronic, Boston Scientific, Microport and Zoll. G.B. declares speakers’ fees from Bayer, Boston, Daiichi Sankyo, Sanofi and Janssen. C.P.G. declares grants or contracts from the Alan Turing Institute, British Heart Foundation, NIHR, Horizon 2020, Abbott Diabetes Bristol-Myers Squibb and ESC; consulting fees from AI Nexus, AstraZeneca, Amgen, Bayer, Bristol-Myers Squibb, Boehrinher Ingleheim, CardioMatics Chiesi, Daiichi Sankyo, GPRI Research B.V., Menarini, Novartis, iRhythm, Organon and The Phoenix Group; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AstraZeneca, Boston Scientific, Menarini, Novartis, Raisio Group, Wondr Medical and Zydus; support for attending meetings and/or travel from Astra Zeneca; participation on a data safety monitoring board or advisory board for the DANBLCOK trial and the TARGET CTCA trial; leadership or fiduciary role in other board, society, committee or advocacy groups (Deputy Editor: EHJ Quality of Care and Clinical Outcomes, NICE Indicator Advisory Committee, Chair ESC Quality Indicator Committee); stock or stock options in CardioMatics; receipt of equipment, materials, drugs, medical writing, gifts or other services from Kosmos device. T.J.R.D.P. declares consulting fees and payment or honoraria for lectures, presentations paid to institutions from Adagio Medical, Volta Medical, Boston Scientific and J&J. I.C.v.G. declares consulting fees from Bayer; participation on a data safety monitoring board or advisory board for the PVI SHAM trial; and leadership or fiduciary role in other board, society, committee or advocacy group (Treasurer EHRA; Chair of 2024 Atrial Fibrillation Guidelines; no payments). All other principal authors have nothing to disclose (S.M., K.R., Y.S. and C.v.D.). All consortium authors have completed the ICMJE uniform disclosure form. T.D. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Biosense for lecture honoraria and Abbott Educational for lecture honoraria; consulting fees from Biotronik, Educational grant to himself; participation on a data safety monitoring board or advisory board from Boston scientific, clinical event committee—studies; leadership or fiduciary role in other board, society, committee or advocacy group (German Cardiology Society, Certification committee; EHRA, National society committee; HRS, Digital Health committee). B.G.-M. declares consulting fees from Biotronik, Medtronic, Boston Sc and Microport; participation on a data safety monitoring board or advisory board for BEAT AF Study and STOP DRUG Study (no payments). M.L. declares consulting fees from Abbott; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Boston Scientific; support for attending meetings and/or travel from Boston Scientific and Microport. A. Mobley declares other financial or nonfinancial interests (role is funded by the Cook and Wolstenholme Charitable Trust and the EU-Horizon and UKRI HYPERMARKER grant 101095480). T.R. declares grants or contracts from the NIHR (senior investigator); leadership or fiduciary role in other board, society, committee or advocacy group for the Stroke Association (trustee until October 2023) and the British and Irish Association of Stroke Physicians (president until December 2021). E.M. declares research grants from Abbott, Biotronik, Boston, Scientific, Medtronic, MicroPort and Zoll; consulting fees from Medtronic, Boston Scientific, Zoll and Abbott; and payment or honoraria from Medtronic, Boston Scientific, Zoll and Abbott. P. Baudinaud declares consulting fees from Medtronic, Abbott and Boston Scientific; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from IMPLICITY; and participation on a data safety monitoring board or advisory board for Medtronic. S.K. declares payment or honoraria (ESC; payment for participation as a trainer). U.R. declares grants or contracts from Bayer (research grant to the institution); consulting fees from Boehringer Ingelheim and Sanofi; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from medpoint, Bayer, Boehringer Ingelheim, BMS / Lilly and Pfizer. M. Proietti declares other financial or nonfinancial interests (Italian national leader of the AFFIRMO project; EU Horizon 899871). S.T. declares grants or contracts (ESC: payment for participation as a trainer); payment or honoraria for lectures from Abbott, Boston Scientific and Astra Zeneca; support for attending meetings and/or travel from Boston Scientific (Congresses: EHRA 2022, EHRA 2023, ESC 2023). P. Buchta declares consulting fees (ESC); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Johnson & Johnso; honorarium for lectures/educational training from Abbott and EP Proctor fee; and support for attending meetings and/or travel (EHRA, EHRA Congress Grant). I.R.L. declares consulting fees from Abbott Medical, Biosense Webster and Boston Scientific; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott Medical, Biosense Webster and Boston Scientific; support for attending meetings and/or travel from Abbott Medical, Biosense Webster and Boston Scientific. D.T. declares honoraria from Abbott and Medtronic. A.S. declares consulting fees from Astra Zeneca, Rhythm AI and Reachora; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott Medical; and support for attending meetings and/or travel from Biosense Webster. O.P. declares consulting fees from BMS Pfizer, Abbott and Zoll Medical; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from BMS Pfizer and Abbott; and leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid from the French Society Cardiology as a board member and EHRA as a member of the NCS committee. C.D.C. declares grants or contracts paid to the institution (research grant from the French Federation of Cardiology); royalties or licenses paid to the institution (license shared with Biosense Webster); honoraria from Biosense Webster, Abbott and Boston Scientific; support for attending meetings and/or travel from Biosense Webster; travel costs from Biosense Webster and Abbott; and patents planned, issued or pending (patent being used by Biosense Webster, payment to institution; two other patents planned). M.D.G. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott and Medtronic. E.G. declares consulting fees from Boston, Medtronic, Microport and Biotronik; support for attending meetings and/or travel from Microport and Boston; participation on a data safety monitoring board or advisory board for Boston; and leadership or fiduciary role in other board, society, committee or advocacy group, unpaid (Vice president groupe de rythmologie et stimulation cardiaque SFC). F.S. declares speaker fees from Abbott, Biosense, Webster, Boston Scientific, Medtronic and Microport; support for attending meetings and/or travel from Abbott, Biosense, Webster, Boston Scientific and Medtronic. C.G. declares consulting fees from Pfizer and Medtronic; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott and Boston Scientific. S.W. declares grants outside the submitted work from Abbott and Boston; consulting fees from Abbott and Boston; speakers bureau from Abbott and Boston (BMS); and participation on a data safety monitoring board or advisory board (BSCI Fellow ship, Abbott EICP). M. Borlich declares consulting fees from Biosense Webster; speakers honoraria from Novartis and Bayer; support for attending meetings and/or travel from Boston Scientific and the Boston Fellowship. A. Metzner declares consulting fees from Medtronic, Biosense Webster and Boston Scientific; payment or honoraria for lectures from Medtronic, Biosense Webster, Boston Scientific, Bayer, Bristol-Myers Squibb, EPD-Philips and Lifetech; support for attending meetings and/or travel from Medtronic, Biosense Webster and Bostin Scientific. H.-H.E. declares grants or contracts from Medtronic and ESC; financial support from Abbot Medical GmbH, Amgen GmbH, Astra Zeneca, Bayer Vital GmbH, Biotronik, Lilly Deutschland GmbH, Boehringer Ingelheim Pharma GmbH & Co. KG, Boston scientific Medizintechnik GmbH, Bristol-Myers Squibb GmbH & Co.KGAA, Daiichi-Sankyo Deutschland GmbH, Medic Plus GmbH, Micro Port GmbH, Medtronic GmbH, Novartis Pharma GmbH, Sanofi–Aventis, Servier Deutschland GmbH, Trommsdorff GmbH & Co. KG and Zoll CMS GmbH; research grant from Medtronic; and payment for presentation from Biotronik. D.D. declares research grants to the institution from CVRx, Roche; consulting fees from Abbott, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol Myer Squibbs, Medtronic, Pfizer and Sanofi; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott, Astra Zeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol Myer Squibbs, CVRx, Medtronic, Pfizer, Sanofi and Zoll; participation on a data safety monitoring board or advisory board from Cardiomatics, Medtronic and Edwards; leadership or fiduciary role in other board, society, committee or advocacy group, unpaid (Chair of the EHRA digital and e-communication committee). P.N. declares grants or contracts from Abbott, Amicus, Cardiac Dimensions, Daiichi, Chiesi, Idorsia, Sanofi and Takeda; consulting fees from Abbott, Amicus, Cardiac Dimensions, Daiichi, Chiesi, Idorsia, Sanofi and Takeda; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott, Amicus, Cardiac Dimensions, Daiichi, Chiesi, Idorsia, Sanofi and Takeda; support for attending meetings and/or travel from Abbott, Amicus, Cardiac Dimensions, Daiichi, Chiesi, Idorsia, Sanofi and Takeda. R.R.T. declares consulting fees from Boston Scientific, Biotronik, Biosense Webster and Abbott Medical; speaker fees from Boston Scientific, Biotronik, Biosense Webster, Abbott Medical and Lifetech; and research grants from Abbott, Biosense Webster and Lifetech. M. Bertini declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Medtronic, Biotronik, Abbott, Microport, Boston,Bayer, Boherningher, Daiichi and Pfizer. S.F. declares grants or contracts (ESC). W.K.G. declares grants or contracts (ESC); payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Biotronik and the ‘Akademia Elektroterapii’ Journal; support for attending meetings and/or travel from Biotronik, Abbott and Medtronic. F.B. declares grants or contracts from Boston Scientific, investigator initiated research—payment to the institution. J.O. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events and support for attending meetings. J.L.M. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott (institution), Milestone Pharmaceuticals (institution), Biotronik (personal) AstraZeneca (institution), Microport (personal) and Zoll (personal); personal support for attending meetings and/or travel from Bayer (personal), Zoll (personal); personal participation on a data safety monitoring board or advisory board from Medtronic and Sanofi. N.R.-G. declares research and teaching grants at the Vall d’Hebron Hospital Arrhythmia Unit; Consulting fees from Abbott, Medtronic, Boston Scientific and Johnson & Johnson; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abbott and Medtronic; payment for expert testimony from Abbott; support for attending meetings and/or travel from Abbott, Medtronic, Boston Scientific and Johnson & Johnson; leadership or fiduciary role in other board, society, committee or advocacy group from the Ritmo Society Accreditation Committee and Spanish Cardiology Society. E.T. declares grants or contracts (speakers’ bureau/ honoraria/research grants; fellowship support from Abbot, Biotronik and Medtronic); consulting fees from Abbott and Biotronik; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events and support for attending meetings and/ or travel and Abbott, Biotronik and Medtronic. F.S.N. declares grants or contracts from the British Heart Foundation (research grant funding), the National Institute for Health Research (research grant funding) and Medical Research Council (research grant funding). M.J.L. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Bisosense-Webster; fees for proctoring cases and lectures; support for attending meetings and/or travel paid to the institution (educational grant to attend conference for Medtronic); unpaid leadership or fiduciary role in other board, society, committee or advocacy group (Member of specialized services device program for NHS England; Monitor new technologies in cardiac rhythm management; Member of NICOR—Cardiac Rhythm—Domain Expert Group). M.F. declares grants or contracts from Barts NIHR (BRC award), Abbott Ltd (SAS AF study), Medtronic Ltd (ORBICA-AF Study), Barts Charity and Minature Robotics for PCI; consulting fees from Abbott, Medtronic, CathVision, Boston Scientific and Arta Health; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Medtronic Ltd, Abbott Ltd, Biosense Webster and Johnson & Johnson; support for attending meetings and/or travel from Abbott, Medtronic and Boston Scientific; patents planned, issued or pending (Rhythm AI Ltd, Echopoint Medical Ltd); leadership or fiduciary role in other board, society, committee or advocacy group (Co-chair EHRA Certification Committee); stock or stock options in Rhythm AI Ltd, Echopoint Medical Ltd. and Epicardio Ltd. H.H. declares grants or contracts from Universities of Hasselt and Antwerp, Abbott, Medtronic, Biotronik, Boston Scientific, Bayer, Boehringer Ingelheim, Daiichi Sankyo and Pfizer-BMS; speakers fees from Bayer, Biotronik, Bristol-Myers Squibb, Daiichi Sankyo, Milestone Pharmaceuticals, Pfizer-BMS alliance, Centrix India, CTI Germany, ESC, Medscape and Springer Healtcare Ltd; unpaid participation on a data safety monitoring board or advisory board (member, DSMB Prestige-AF). W.D. declares research support to the institution from Vifor and Boerhinger; consulting fees paid to him from Aimediq, Bayer, Boehringer Ingelheim, Boston Scientific, Medtronic, Vifor Pharma, Cardiomatics and Icon Clinical research; travel support from Pharmacosmos; participation on a data safety monitoring board or advisory board (Boehringer, IQVIA); leadership or fiduciary role (ESC, councilor of the ESC Board, unpaid), ESC Council on stroke (nucleus member, unpaid); and Society of Cachexia and wasting disorders board member, unpaid. S.P. declares leadership or fiduciary role in other board, society, committee or advocacy group, unpaid (ESC board member, Deputy Editor EHJ, Chair Pan-London cardiogenic Shock Board). H.P. declares payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Abott, Biosense Webster, Biotronik and Medtronic. P.K. declares grants or contracts: EU AFFECT-AF (grant agreement 847770), and MAESTRIA (grant agreement 965286), British Heart Foundation (PG/17/30/32961; PG/20/22/35093; AA/18/2/34218), German Center for Cardiovascular Research supported by the German Ministry of Education and Research (DZHK, grant numbers DZHK FKZ 81 × 2800182, 81Z0710116, and 81Z0710110), German Research Foundation (Ki 509167694), and Leducq Foundation); grants or contracts (P.K. receives research support for basic, translational, and clinical research projects from EU, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Center for Cardiovascular Research, from several drug and device companies active in atrial fibrillation); patents planned, issued or pending (listed as inventor on two issued patents held by University of Hamburg (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783); leadership or fiduciary role in other board, society, committee or advocacy group (board member ESC, Speaker of the Board, AFNET); receipt of equipment, materials, drugs, medical writing, gifts or other services (receives research support for basic, translational, and clinical research projects from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK), and German Center for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies in the past, but not in the last 3 years). A.R.L. declares consulting fees (ARL); speaker, advisory board or consultancy fees and/or research grants from Pfizer, Novartis, Servier, Astra Zeneca, Bristol-Myers Squibb, GSK, Amgen, Takeda, Roche, Janssens-Cilag Ltd, Astellas Pharma, Clinigen Group, Eli Lily, Eisai Ltd, Ferring Pharmaceuticals, Boehringer Ingelheim, Akcea Therapeutics, Myocardial Solutions and iOWNA Health and Heartfelt Technologies Ltd.; participation on a data safety monitoring board or advisory board (ESC STEEER-AF Trial; PROACT Trial DSMB); leadership or fiduciary role in other board, society, committee or advocacy group (chair of ESC Council on Cardio-Oncology); stock or stock options from Myocardial Solutions, Heartfelt Technologies and iOWNA. R.H. declares grants or contracts—institutional payments from Pfizer, Slovak Research and Development Agency; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Boehringer Ingelheim, Organon and Pfizer; support for attending meetings and/or travel (ESC, Pfizer); leadership or fiduciary role in other board (Slovak Heart Rhythm Association, President, unpaid). P.R. declares grants or contracts from the Finnish Foundation for Cardiovascular Research, Payment to Institute for various research projects; Biosense Webster, payment to institute for the MANTRA-VT Trial; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events payments made to him (Biosense Webster; Stereotaxis); participation on a data safety monitoring board or advisory board (ESC STEEER-AF trial, no payment); leadership or fiduciary role in other board, society, committee or advocacy group (ESC Nominating Committee member, UEMS Cardiology Section Treasurer); stock or stock options (Orion Pharma). The other authors declare no competing interests.