STEEER-AF: An International Implementation Trial Demonstrating the Impact of Targeted Education on Guideline Adherence and Patient Outcomes in Atrial Fibrillation Care
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EP LAB DIGEST. 2025;25(12):21.
Interview by Jodie Elrod
In this interview, EP Lab Digest speaks with Dipak Kotecha, MDChB, PhD, PCAP, MSc, FRCP, FESC, FHEA, to discuss his recent work entitled “Education of Healthcare Professionals to Improve Guideline Adherence in Atrial Fibrillation: The STEEER-AF Cluster-Randomized Clinical Trial.”1 Professor Kotecha discusses how the STEEER-AF trial findings demonstrated that structured, theory-based education for healthcare professionals can meaningfully improve guideline adherence, particularly for rhythm control, and lead to better patient outcomes through enhanced stroke prevention. He also shares practical insights for clinicians seeking to strengthen atrial fibrillation (AF) management and integrate evidence-based strategies within their own practice. Professor Kotecha is a Professor of Cardiology at the University of Birmingham and Consultant Cardiologist at University Hospitals Birmingham, UK.
Can you briefly walk us through the design of the STEEER-AF trial and what made it unique compared to previous implementation studies in AF care?
Although much attention is given to arrhythmia and AF itself, the implementation aspect is often less considered—yet it is the factor that most directly influences patient care. Clinical trials have provided important insights into AF management; however, without effective implementation, the benefits of these findings may not reach patients. The primary objective of the STEEER-AF initiative was to objectively examine how implementation occurs in practice, with particular focus on stroke prevention and rhythm control. The patient population in this setting is typically multimorbid and clinically complex.
In addition, the study aimed to determine whether providing education to healthcare professionals—including physicians, nurses, and allied health staff who care for these patients—could improve the quality of care delivered. Specifically, the objective was to assess whether targeted education on stroke prevention, rhythm control, and integrated care influences clinical management.
STEEER-AF was the first randomized trial sponsored by the European Society of Cardiology (ESC). The program was developed using an educational framework and delivered through an online platform focused on stroke prevention, rhythm control, and integrated patient care, emphasizing patient engagement in treatment and education.
Furthermore, the intervention involved expert learners from each participating country, and all educational content was delivered in the local language. The study was conducted across 6 European countries, with expert trainers in each location to guide participants through the learning process and facilitate reflection and planning for future clinical application. Overall, it was a substantial collaborative effort, encompassing 70 centers across the 6 countries. The study was entirely investigator initiated.
A total of 1732 patients were consented and recruited at baseline, and were representative of routine clinical practice at the participating centers. Objective algorithms were developed to assess adherence to clinical guidelines, using the 2016 and 2020 ESC recommendations as the reference standards. This is the first time that has ever been done. Adherence is usually assessed by clinician report; in this study, adherence was determined objectively based on predefined criteria.
After this baseline assessment of adherence in individual patients, each center was randomized in a cluster design to either the intervention or control group. Centers assigned to the control arm continued their usual educational activities, such as seminars, meetings, or in-service training. Centers in the intervention arm received the same standard education, in addition to the structured training program developed by the ESC and the European Heart Rhythm Association. The educational intervention was modest in scope, consisting of an average of 9 hours of learning per participant delivered over 16 weeks.
The primary follow-up occurred 6 to 9 months after each center was randomized, with guideline adherence re-assessed in each individual patient for class I (‘must do’) and class III (‘must not do’) recommendations. No significant change was observed in stroke prevention, where use of anticoagulation therapy was already 90%. In contrast, adherence to rhythm control recommendations—initially achieved in only 1 in 5 patients—increased by 51% following the educational intervention. Thus, providing targeted education to clinical staff was associated with improved delivery of guideline-based care where this was suboptimal, leading to patient management aligning better with recommended clinical practice. The main findings have been published in Nature Medicine.
Clinical outcome follow-up data were presented at a late-breaking session at the ESC Congress in Madrid on September 1, 2025, pending full publication. At 18 months after randomization (average 2 years after patient enrolment), follow-up data were available for 94% of participants. Among patients who were fully adherent to stroke prevention guidelines, the risk of experiencing adverse events (a composite of death, stroke/transient ischemic attack, pulmonary/systemic embolus, acute coronary syndrome, and heart failure hospitalization) was lower by 33% compared to non-adherent patients, with divergence between groups occurring early in follow-up. These findings indicate that adherence to stroke prevention recommendations was associated with a markedly improved prognosis.
No similar association was observed for rhythm control, although it is already recognized that rhythm control therapy is primarily aimed at improving symptoms rather than prognosis, as highlighted in the 2024 ESC Guidelines on AF. There are, of course, exceptions—such as patients with heart failure or where fast heart rhythms cause heart pump failure—in whom a prognostic benefit would be expected.
The clinical outcome findings were exploratory and not a primary objective of the trial, and the study was not powered to detect statistically significant differences. Nevertheless, the findings suggest that patients may derive benefit when their care is aligned to guideline, with the lower event rate driven primarily by fewer hospital admissions.
Overall, STEEER-AF demonstrates that, when assessed objectively, guideline adherence remains suboptimal—particularly for rhythm control—but can be improved substantially through brief educational interventions for healthcare staff. In stroke prevention, patients who were guideline adherent experienced markedly better clinical outcomes. This complex international implementation trial illustrates what can be achieved through the collaborative efforts of thousands of patients and their healthcare staff across multiple countries.
What components of this program were most effective, and how can similar strategies be implemented in EP labs to enhance guideline adherence?
It is important to recognize that this was a trial of a combined intervention. The aim was not only to engage participants, but also to facilitate meaningful changes in clinical practice at each center, which is why the program was intentionally multifaceted. Although the educational intervention was directed toward healthcare professionals, the trial incorporated several components beyond online education. Prior experience has shown that online information alone tends to produce only short-term effects; therefore, this program was designed to include multiple educational elements. An educational theory framework and expert input guided the development of the intervention to maximize its effectiveness. Because it was structured as an integrated program, it is not possible to determine which individual components were most valuable. Nonetheless, despite its simplicity—averaging about 9 hours of participation per learner—the intervention achieved a substantive impact.
Given the international scope of the study, what lessons can be drawn for global EP practices?
Education for healthcare professionals should be approached with the same level of attention as hospital safety initiatives. It is often overlooked that clinicians are expected to absorb large amounts of information, yet the AF guideline represents only one of many they must integrate into daily practice. Simply disseminating information is insufficient; we must actively identify the components most likely to influence clinical impact and focus educational efforts accordingly. Although excellent educational programs for healthcare professionals exist worldwide, many lack structure and specificity. The key is to target those elements that most directly improve patient management and outcomes. Together with patient empowerment, patient education, and joint decision-making, these approaches can start to make an impact on the increasing burden that AF presents.
Disclosure: Prof Kotecha reports grants from the National Institute for Health Research (NIHR CDF-2015-08-074 RATE-AF; NIHR130280 DaRe2THINK; NIHR132974 D2T-NeuroVascular; NIHR203326 Biomedical Research Centre), the British Heart Foundation (PG/17/55/33087, AA/18/2/34218 and FS/CDRF/21/21032), the 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 programme, UK Dept. for Business, Energy & Industrial Strategy Regulators Pioneer Fund, the Cook & Wolstenholme Charitable Trust, Protherics Medicines Development, and the European Society of Cardiology supported by educational grants from Boehringer Ingelheim/BMS-Pfizer Alliance/Bayer/Daiichi Sankyo/Boston Scientific, the NIHR/University of Oxford Biomedical Research Centre and British Heart Foundation/University of Birmingham Accelerator Award (STEEER-AF).
References
- Kotecha D, Bunting KV, Mehta S, et al. Education of healthcare professionals to improve guideline adherence in atrial fibrillation: the STEEER-AF cluster-randomized clinical trial. Nat Med. 2025;31(8):2647-2654. doi:10.1038/s41591-025-03751-2
- Sterlinski M, Bunting KV, Boriani G, et al. 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. Europace. 2024;26(7):euae178. doi:10.1093/europace/euae178
- Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. doi:10.1093/eurheartj/ehae176
