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An Explanation of Recommendation Differences: Illustrations from Recent Atrial Fibrillation Guidelines



    1. New College, University of Oxford, Oxford, UK
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    Corresponding author
    1. Department of Cardiac and Vascular Sciences, St. Georges University of London, London, UK
    • Address for reprints: A. John Camm, M.D., Department of Cardiac and Vascular Sciences, St. Georges University of London, Cranmer Terrace, London SW17 0RE, UK; e-mail:

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  • Funding: None.

  • Conflicts of Interest: C.F. Camm: none.

  • A. John Camm: Chairman of the ESC AF Guideline 2010 and the Update 2012, chairman of the ACC/AHA/ESC Guidelines on Ventricular Arrhythmias and Sudden Cardiac Death, and Supraventricular Arrhythmias. Member and chair of several NICE guidelines.

  • Advisor/speaker: Astra Zeneca, Gilead, Merck, Menarini, Sanofi Aventis, Servier, Xention, Bayer, Boehringer Ingleheim, Bristol Myers Squibb, Daiichi, Pfizer, Boston Scientific, Biotronik, Medtronic, St. Jude Medical, Actelion, GlaxoSmithKline, InfoBionic, Incarda, Johnson and Johnson, Mitsubishi, Novartis, Takeda.


The development of guidelines and their use in all areas of medicine has greatly expanded in recent years. However, despite a shared evidence base, recommendations provided by different professional societies and healthcare authorities often vary considerably. The rapid advances in atrial fibrillation (AF) and the multiplicity of guidelines devoted to AF have made it particularly susceptible to this problem. Many nonmedical aspects are important in the development of guidelines, and without understanding them correct interpretation of guidelines is difficult. Conflicts of interest, the regulatory environment, and local data all influence guidelines. Nuanced wording, resource availability, and strategic purpose add complexity to guideline recommendations. This article reviews major AF guidelines from around the world and discusses aspects which have nothing to do with the scientific evidence base in order to help the practicing physician understand and make better use of differing guideline recommendations.