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Brief Report
March 2017

Quality of Evidence Underlying the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines on the Management of Atrial Fibrillation

Author Affiliations
  • 1Duke Center for Atrial Fibrillation, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
  • 2Heart and Vascular Center, MetroHealth Medical Center, Cleveland, Ohio
  • 3University of Wisconsin School of Medicine & Public Health, Madison
  • 4Ahmanson–University of California at Los Angeles Cardiomyopathy Center, Ronald Reagan–University of California at Los Angeles Medical Center, Los Angeles
  • 5Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
  • 6Department of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minnesota
  • 7Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Cardiol. 2017;2(3):319-323. doi:10.1001/jamacardio.2016.4936
Key Points

Question  How have the American Heart Association/American College of Cardiology/Heart Rhythm Society clinical practice guidelines on atrial fibrillation changed over time with respect to the distribution of recommendations across classes of recommendations and levels of evidence?

Findings  This review of guideline recommendations found that despite a significant increase in atrial fibrillation research from 2001 to 2014, there was a nonsignificant increase in the use of level B evidence, an insignificant decrease in the use of level C evidence, and the use of level A evidence did not appreciably change. The 2014 guideline was largely supported by level C evidence with few level A recommendations (8.8%); no rate control recommendations were supported by level A evidence.

Meaning  Significant opportunities exist to improve the evidence base on the management of atrial fibrillation, specifically within rate control.

Abstract

Importance  The joint American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) guidelines on the management of atrial fibrillation (AF) are used extensively to guide patient care.

Objective  To describe the evidence base and changes over time in the AHA/ACC/HRS guidelines on AF with respect to the distribution of recommendations across classes of recommendations and levels of evidence.

Data Sources  Data from the AHA/ACC/HRS guidelines on AF from 2001, 2006, 2011, and 2014 were abstracted. A total of 437 recommendations were included.

Data Extraction and Synthesis  The number of recommendations and distribution of classes of recommendation (I, II, and III) and levels of evidence (A, B, and C) were determined for each guideline edition. Changes in recommendation class and level of evidence were analyzed using the 2001 and 2014 guidelines.

Results  From 2001 to 2014, the total number of AF recommendations increased from 95 to 113. Numerically, there was a nonsignificant increase in the use of level of evidence B (30.5% to 39.8%; P = .17) and a nonsignificant decrease in the use of level of evidence C (60.0% to 51.3%; P = .21), with limited changes in the use of level A evidence (8.4% to 8.8%; P = .92). In the 2014 guideline document, 10 of 113 (8.8%) recommendations were supported by level of evidence A, whereas 58 of 113 (51.3%) were supported by level of evidence C. Most recommendations were equally split among class I (49/113; 43.4%) and class IIa/IIb (49/113; 43.4%), with the minority (15/113; 13.3%) assigned as class III. Most class I recommendations were supported by level of evidence C (29/49; 59.2%), whereas only 6 of 49 (12.2%) were supported by level of evidence A. No rate control category recommendations were supported by level of evidence A.

Conclusions and Relevance  Some aspects of the quality of evidence underlying AHA/ACC/HRS AF guidelines have improved over time. However, the use of level of evidence A remains low and has not increased since 2001. These findings highlight the need for focused and pragmatic randomized studies on the clinical management of AF.

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