Methodological Quality of Heart Failure Systematic Reviews and Meta-Analyses in the Era of AMSTAR-2 (a Measurement Tool to Assess Systematic Reviews): A Pre-registered Repeat Cross-Sectional Survey

BackgroundSystematic reviews and meta-analyses guide heart failure (HF) practice, yet their methodological quality has been questioned.An AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews) appraisal of HF reviews in 11 high-impact journals during 2009-2019 rated 79 of 81 as critically low confidence.Whether quality has changed in the era of routine protocol registration and PRISMA 2020 is unknown. MethodsIn a pre-registered repeat cross-sectional survey, we replicated that sampling frame for 2021-2025: HF systematic reviews with a meta-analysis of an intervention, in the same 11 journals.Two reviewers independently applied all 16 AMSTAR-2 items to each review; disagreements were resolved by consensus.Item-level compliance (the proportion rated Yes or Partial Yes) and overall confidence were compared with the 2009-2019 figures. ResultsOf 751 records screened, 26 reviews were included (median of eight primary studies).Overall confidence was critically low in 16, low in seven, and moderate in three; none was high.A total of 10 of 26 (38%) reached low confidence or better, versus two of 81 (2%) in 2009-2019.Compliance was higher for an a priori protocol (5% to 88%), the provision of an excluded-studies list (5% to 46%), and the specification of population, intervention, comparison, and outcome (PICO) (65% to 100%).Conversely, accounting for the risk of bias when interpreting results was lower (88% to 35%).Reporting the funding of individual included studies remained rare in both eras (4%).Inter-rater agreement was moderate (kappa = 0.47). ConclusionsThe AMSTAR-2 compliance of high-impact HF systematic reviews was higher in 2021-2025 than in 2009-2019, most markedly for protocol reporting, though most reviews remained critically low.Reviews were less likely to carry risk-of-bias findings into their interpretation; one interpretation is that registration has become routine while substantive appraisal has not.