What we publish in the American Heart Journal and why

Status report 

In 2006, the Journal received 1521 manuscripts and accepted 19%. Our current mean submission to initial decision time is 29 days. Our mean time from final acceptance to print publication is now 3 months. All accepted papers are uploaded to our website (www.ahjonline.com) as soon as the final proofs are completed, in advance of print publication. A variety of statistics have shown us that most of our readers favor accessing the Journal online rather than through the print subscription.

Overview of current editorial processes 

When a paper is submitted to the Journal, the executive editor assigns it to an associate editor (AE), based on its subject focus. The AE then either sends the paper to ≥2 external peer reviewers or recommends that it be rejected without external peer review. In the latter situation, the paper is forwarded to the editor, who makes an independent assessment. If the editor concurs, the paper is rejected without further review. Approximately 50% of papers submitted to the Journal are rejected without review. Why do we do this? We cannot publish all or even most of what is submitted to us. Triage is therefore necessary, and we feel it is fairest to the authors not to conduct a protracted review process for papers we are not likely to publish; similarly, we feel it is unfair to reviewers to ask them to spend time reviewing papers we are unlikely to publish. Common reasons why papers in this category fail to “make the grade” include inadequate sample size, poor or unclear methodology, lack of a clear incremental contribution relative to work already published, or very poor written presentation. Sometimes there is nothing academically wrong with the paper, but we feel it is more suitable for a subspecialty journal than a general cardiovascular journal such as the American Heart Journal.

For papers that we send for external review, once the reviews are received the responsible AE makes a recommendation to accept, ask for a major or minor revision, or reject. This recommendation is then passed to the editor, who makes the final decision. Sometimes we seek ≥1 additional reviews, especially when there are major disagreements among reviewers or the reviews do not address what we see to be key issues.

External peer review is the core of our editorial process and we work hard to make sure that when we ask for assistance from our outside reviewers we are sending them work of reasonable quality and interest. We should note, however, that outside reviewers provide 2 sets of comments: one for the authors, focused ideally on areas where revision may lead to improvements in the work, and the other for the editors, providing confidential comments regarding the quality, importance, and relevance of the work. It is not uncommon for authors to get a rejection letter from the editor along with reviews of their paper that have seemingly nonfatal criticisms and possibly even considerable praise for the work. The missing link in most of these cases is what the reviewers and AEs provided in private comments to the editors. Some authors have expressed the opinion that this system of confidential critique is unfair and does not allow the authors a fair chance for rebuttal. Our response to this concern has 2 elements. First, the major confidential comments generally pertain to the novelty of the work (or lack thereof) and major structural problems that are not remediable by revision (such as an inappropriate control group or an inadequate sample size or duration of follow-up). Second, we do not accept any reviewer critiques without making our own assessment of the work. If the reviewers do not like the paper but we see some potential, we may seek other reviews or invite the authors to do a major revision or even a de novo submission. Alternatively, reviewers may both be positive about the paper but have failed to notice important structural problems that the AEs and editors feel are too substantial to permit publication.

Special interests of the Journal 

In our 1997 editorial initiating our editorial term, we identified 3 types of studies we wanted to encourage: negative clinical studies, trial design papers, and studies involving the organization of medical care. Much has happened in cardiovascular medicine in the past decade, and a restatement of our interests should serve both the Journal and those who are considering submitting papers to us.

Underpowered and/or adequately powered but unexpectedly negative clinical trials often have significant difficulty getting published. The danger of publication bias is now well recognized. We continue to feel that publication of these data is an important service that we intend to continue. Several caveats apply, however. First, the trial must have been performed with appropriate human subject protections in place, including oversight by an institutional review board. Second, the trial must report clinically relevant outcome events. Trials that report only surrogate end points generally will not be considered acceptable. Third, the trial must demonstrate evidence of reasonable quality including acceptable methods of random treatment allocation, high levels of follow-up, and appropriate methods of outcome ascertainment. All trial manuscripts submitted to the Journal will undergo standard peer review. If found acceptable, most of these papers will be published on our website with only the abstract being published in print. Major considerations for the editors in deciding whether to publish the trial manuscript will be an assessment of whether the trial is ever likely to be included in a meta-analysis and whether it addresses a problem where there are currently no other adequate trials published.

As of 2007, we are broadening this area of interest by extending it to papers describing major subgroups of large, clinically important randomized clinical trials. Although the importance of enrolling women, underrepresented minorities, older patients, and subjects with key comorbidities (such as diabetes and chronic kidney disease) is frequently emphasized during trial design and implementation, trials are almost always only powered for the overall treatment comparison. Thus, all the subgroup comparisons are underpowered.

Our own experiences have taught us how difficult it is to find details on subgroup results from major clinical trials in the literature. We are also well aware that trying to get papers published on such data is an uphill battle. These papers often are felt by reviewers and editors to lack sufficient novelty to be competitive for publication. To create the appearance of novelty, authors may feel obliged to emphasize unusual findings in a subgroup analysis, occasionally placing the subgroup paper in conflict with the parent trial result paper.

In this initiative, we will peer review appropriate candidate manuscripts, looking for trial subgroup reports that address important clinical problems and that may subsequently contribute to a subgroup meta-analysis. We will not require authors to establish novel findings if the data do not support such novelty. Most of these trial subgroup papers will be published on our website with the abstract published in the print journal.

We will continue to publish selected clinical trial design papers in the Journal. Our focus here is on large-scale trials that have some reasonable chance of affecting clinical practice or that demonstrate a novel and noteworthy design feature. Design papers for phase 2 trials, pilot studies, and registries will generally not be competitive for publication; but if the authors can make a strong case for the publication of their work, we are willing to listen.

We are also particularly interested in well-done outcomes studies, including quality improvement, novel markers of risk, and cost-effectiveness. As with clinical trials, negative outcome studies that seem to go against prevailing wisdom often have great difficulty getting published. Failure to get these data into the public domain means that the process of correcting prevailing wisdom may be slowed significantly. To be competitive for publication, such papers will need to demonstrate access to high-quality empirical data (where applicable) and state-of-the-art methods and analysis.

Finally, we are interested in well-done, clinically relevant genetic studies. A separate editorial will address the specific qualities we are looking for in such work. As with the other categories considered above, we do not feel that negative results should be a deterrent to publication in this area. In fact, experience to date suggests that a great many of the genetic association studies that have been published present findings that cannot be replicated in independent samples.

The internet and electronic forms of communication have caused a major disruption for the world of print journals, both in medicine and in other fields. Although everyone is searching for the next form of scientific research communication, we see no evidence that major medical journals are going to be supplanted in the foreseeable future. Rather, the way in which physicians and others interact with these media has changed and is likely to continue to evolve in the coming years. Regardless of which way the data is accessed, however, our goal continues to be to present important and well-done medical research and review papers addressing clinical cardiovascular medicine that will continue to serve the needs of our constituency, practicing physicians, and through them patients with heart disease.