Adverse cardiovascular outcomes in atrial fibrillation: Validation of the new 2MACE risk score

Simple scores to predict 1-year mortality in atrial fibrillation

BACKGROUND

Traditional scores as CHADS2 and CHA2DS2-Vasc are suitable for predicting stroke and systemic embolism in patients with atrial fibrillation (AF) and have shown to be also associated with mortality. Other more complex scores have been recommended for survival prediction. The purpose of our analysis was to test the performance of different clinical scores in predicting 1-year mortality in AF patients.

MATERIAL AND METHODS

CHADS2 and CHA2DS2-Vasc scores were calculated for AF patients of the BLITZ-AF register and compared to R2-CHADS2, R2-CHA2DS2-Vasc and CHA2DS2VASc-RAF scores in predicting 1-year survival. Scores including renal function were calculated both with glomerular filtration rate (GFR) and creatinine clearance.

RESULTS

One-year vital status (1960 alive and 199 dead) was available in 2159 patients. Receiver-operating characteristic curves displayed an association of each score to all-cause mortality, with R2(ClCrea)-CHADS2 being the best [area under the curve (AUC) 0.734]. Differences among the AUCs of the eight scores were not so evident, and a significant difference was found only between R2(ClCrea)-CHADS2 and CHADS2, CHA2DS2VASc, (ClCrea)-CHA2DS2-VASC-RAF.All the scores showed a similar performance for cardiovascular (CV) mortality, with CHA2DS2VASc-RAF being the best (AUC 0.757), with a significant difference with respect to CHADS2, CHA2DS2VASc, and (ClCrea)CHA2DS2Vasc-RAF.

CONCLUSIONS

More complex scores, even if with better statistical performance, do not show a clinically relevant higher capability to discriminate alive or dead patients at 12 months. The classical and well known CHA2DS2VASc score, which is routinely used all around the world, has a high sensitivity in predicting all-cause mortality (AUC 0.695; Sensit. 80.4%) and CV mortality (AUC 0.691; Sensit. 80.0%).

GRAPHICAL ABSTRACT

http://links.lww.com/JCM/A632.

Validating the predictive ability of the 2MACE score for major adverse cardiovascular events in patients with atrial fibrillation: results from phase II/III of the GLORIA-AF registry

The 2MACE score was specifically developed as a risk-stratification tool in atrial fibrillation (AF) to predict cardiovascular outcomes. We evaluated the predictive ability of the 2MACE score in the GLORIA-AF registry. All eligible patients from phase II/III of the prospective global GLORIA-AF registry were included. Major adverse cardiac events (MACEs) were defined as the composite outcome of stroke, myocardial infarction and cardiovascular death. Cox proportional hazards were used to examine the relationship between the 2MACE score and study outcomes. Predictive capability of the 2MACE score was investigated using receiver-operating characteristic curves. A total of 25,696 patients were included (mean age 71 years, female 44.9%). Over 3 years, 1583 MACEs were recorded. Patients who had MACE were older, with more cardiovascular risk factors and were less likely to be managed using a rhythm-control strategy. The median 2MACE score in the MACE and non-MACE groups were 2 (IQR 1-3) and 1 (IQR 0-2), respectively (p < 0.001). The 2MACE score was positively associated with an increase in the risk of MACE, with a score of ≥ 2 providing the best combination of sensitivity (69.6%) and specificity (51.6%), HR 2.47 (95% CI, 2.21-2.77). The 2MACE score had modest predictive performance for MACE in patients with AF (AUC 0.655 (95% CI, 0.641-0.669)). Our analysis in this prospective global registry demonstrates that the 2MACE score can adequately predict the risk of MACE (defined as myocardial infarction, CV death and stroke) in patients with AF. Clinical trial registration: http://www.clinicaltrials.gov . Unique identifiers: NCT01468701, NCT01671007 and NCT01937377.

Use of P wave indices to evaluate efficacy of catheter ablation and atrial fibrillation recurrence: a systematic review and meta-analysis

BACKGROUND

To investigate the changes of P wave indices in atrial fibrillation (AF) patients after catheter ablation and the association between P wave indices and AF recurrence.

METHODS

PubMed, Embase, and Cochrane Database were searched through September 15th 2021 for studies on the association between P wave indices and AF with catheter ablation. Heterogeneity was estimated using the I² statistic, the random effects model was used to calculate the pooled results, and summary receiver operating characteristic curve (SROC) was used to evaluate the predictive value.

RESULTS

Among included fourteen studies with 1674 AF patients, we found significantly decreased P wave dispersion (P_dis) (mean difference [MD]: - 6.5 ms, 95% confidence interval [95% CI]: - 11.81 to - 1.18, P = 0.02) after cryoballoon ablation (CBA) or radiofrequency ablation (RFA), and maximum P wave (P_max) (MD: - 8.57 ms, 95% CI: - 17.03 to - 0.10, P = 0.05) after RFA only, but increased minimum P wave (P_min) (MD: 3.43 ms, 95% CI: 1.07 to 5.79, P < 0.01) after CBA only. P_dis measured before ablation was remarkably higher (MD: 5.79 ms, 95% CI: 2.23 to 9.36, P < 0.01) in patients with recurrence than without; meanwhile, P_max was higher measured both before and after ablation (MD: 6.49 ms, 95% CI: 2.30 to 10.69, P < 0.01 and MD: 11.2 ms, 95% CI: 2.88 to 19.52, P < 0.01). Furthermore, SROC analysis showed acceptable predictive efficiencies of P_dis (AUC = 0.776) and P_max (AUC = 0.759) for AF recurrence.

CONCLUSION

P_dis was significantly decreased after AF catheter ablation. Higher P_dis and P_max may have predictive values for AF recurrence.

Comparing Atrial-Fibrillation Validated Rapid Scoring Systems in the Long-Term Mortality Prediction in Patients Referred for Elective Coronary Angiography: A Subanalysis of the Białystok Coronary Project

Rapid scoring systems validated in patients with atrial fibrillation (AF) may be useful beyond their original purpose. Our aim was to assess the utility of CHA2DS2-VASc, HAS−BLED, and 2MACE scores in predicting long-term mortality in the population of the Białystok Coronary Project, including AF patients. The initial study population consisted of 7409 consecutive patients admitted for elective coronary angiography between 2007 and 2016. The study endpoint was all-cause mortality, which occurred in 1244 (16.8%) patients during the follow-up, ranging from 1283 to 3059 days (median 2029 days). We noticed substantially increased all-cause mortality in patients with higher values of all compared scores. The accuracy of the scores in predicting all-cause mortality was also assessed using the receiver operator characteristic (ROC) curves. The greatest predictive value for mortality was recorded for the CHA2DS2-VASc score in the overall study population (area under curve [AUC] = 0.665; 95% confidence interval [95%CI] 0.645−0.681). We observed that the 2MACE score (AUC = 0.656; 95%CI 0.619−0.681), but not the HAS−BLED score, had similar predictive value to the CHA2DS2-VASc score for all-cause mortality in the overall study population. In AF patients, all scores did not differ in all-cause mortality prediction. Additionally, we found that study participants with CHA2DS2-VASc score ≥3 vs. <3 had a 3-fold increased risk of long-term all-cause mortality (odds ratio 3.05; 95%CI 2.6−3.6). Our study indicates that clinical scores initially validated in AF patients may be useful for predicting mortality in a broader population (e.g., in patients referred for elective coronary angiography). According to our findings, all compared scores have a moderate predictive value. However, in our study, the CHA2DS2-VASc and 2MACE scores outperformed the HAS−BLED score in terms of the long-term all-cause mortality prediction.

Renal function and outcome of patients with non-valvular atrial fibrillation

AIMS

Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs).

METHODS AND RESULTS

This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325).

CONCLUSIONS

Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs.

Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-analysis of 4,200,000 patients

AIM

Prevalence of chronic obstructive pulmonary disease (COPD) in atrial fibrillation (AF) patients is unclear, and its association with adverse outcomes is often overlooked. Our aim was to estimate the prevalence of COPD, its impact on clinical management and outcomes in patients with AF, and the impact of beta-blockers (BBs) on outcomes in patients with COPD.

METHODS AND RESULTS

A systematic review and meta-analysis was conducted according to international guidelines. All studies reporting the prevalence of COPD in AF patients were included. Data on comorbidities, BBs and oral anticoagulant prescription, and outcomes (all-cause death, cardiovascular (CV) death, ischaemic stroke, major bleeding) were compared according to COPD and BB status. Among 46 studies, pooled prevalence of COPD was 13% [95% confidence intervals (CI) 10-16%, 95% prediction interval 2-47%]. COPD was associated with higher prevalence of comorbidities, higher CHA2DS2-VASc score and lower BB prescription [odds ratio (OR) 0.77, 95% CI 0.61-0.98]. COPD was associated with higher risk of all-cause death (OR 2.22, 95% CI 1.93-2.55), CV death (OR 1.84, 95% CI 1.39-2.43), and major bleeding (OR 1.45, 95% CI 1.17-1.80); no significant differences in outcomes were observed according to BB use in AF patients with COPD.

CONCLUSION

COPD is common in AF, being found in 13% of patients, and is associated with increased burden of comorbidities, differential management, and worse outcomes, with more than a two-fold higher risk of all-cause death and increased risk of CV death and major bleeding. Therapy with BBs does not increase the risk of adverse outcomes in patients with AF and COPD.

Comparative Analysis of Risk Stratification Scores in Atrial Fibrillation

BACKGROUND

Atrial Fibrillation (AF) has become a major global health concern and is associated with an increased risk of poor outcomes. Identifying risk factors in patients with AF can be challenging, given the high burden of comorbidities in these patients. Risk stratification schemes appear to facilitate accurate prediction of outcomes and assist therapeutic management decisions.

OBJECTIVE

To summarize current evidence on risk stratification scores for patients with AF.

RESULTS

Traditional risk models rely heavily on demographics and comorbidities, while newer tools have been gradually focusing on novel biomarkers and diagnostic imaging to facilitate more personalized risk assessment. Several studies have been conducted to compare existing risk schemes and identify specific patient populations in which the prognostic ability of each scheme excels. However, current guidelines do not appear to encourage the implementation of risk models in clinical practice, as they have not incorporated new ones in their recommendations for the management of patients with AF for almost a decade.

CONCLUSION

Further work is warranted to analyze new reliable risk stratification schemes and optimally implement them into routine clinical life.

The Atrial fibrillation Better Care (ABC) pathway and cardiac complications in atrial fibrillation: a potential sex-based difference. The ATHERO-AF study

BACKGROUND

An integrated care approach is recommended to optimize management of patients with atrial fibrillation (AF). The impact of the Atrial fibrillation Better Care (ABC) pathway on major adverse cardiac events (MACE), which are the main causes of death in AF, has not been explored.

MATERIAL AND METHODS

We investigated the association between ABC compliance and MACE incidence in 1157 (2690 patient-years) nonvalvular AF patients from the ATHERO-AF study. A subgroup analysis by sex and high cardiovascular risk patients as defined by a 2MACE score ≥3 was performed.

RESULTS

Overall, 428 (37%) patients composed the ABC-compliant group. During a median follow up of 23 (IQR 12-37) months, 64 MACE occurred (2.38%/year). Kaplan Meier curve analysis showed a higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (log-rank test p=0.006). The risk of MACE increased by the number of non-fulfilled ABC criteria. On multivariable Cox proportional hazard regression analysis, the ABC non-compliance was associated with an increased risk of MACE (Hazard ratio (HR) 2.244, 95% Confidence Interval (95%CI) 1.129-4.462). Men were more likely to have suboptimal anticoagulation control (group A), while uncontrolled symptoms were more frequent in women. The association between non-ABC and MACE was more evident in men than women (HR 3.647, 95%CI 1.294-10.277) and in patients with 2MACE score ≥3 (HR 1.728, 95%CI 1.209-2.472).

CONCLUSION

An integrated care ABC approach is associated with a reduced risk of MACE in the AF population, especially in men and in patients at high risk of MACE.

A novel prognostic tool to predict mortality in patients with atrial fibrillation: The BASIC-AF risk score

BACKGROUND

This study sought to develop and validate a risk score to predict mortality in patients with atrial fibrillation (AF) after a hospitalization for cardiac reasons.

METHODS

The new risk score was derived from a prospective cohort of hospitalized patients with concurrent AF. The outcome measures were all-cause and cardiovascular mortality. Random forest was used for variable selection. A risk points model with predictor variables was developed by weighted Cox regression coefficients and was internally validated by bootstrapping.

RESULTS

In total, 1130 patients with AF were included. During a median follow-up of 2 years, 346 (30.6%) patients died and 250 patients had a cardiovascular cause of death. N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin-T were the most important predictors of mortality, followed by indexed left atrial volume, history and type of heart failure, age, history of diabetes mellitus, and intraventricular conduction delay, all forming the BASIC-AF risk score (Biomarkers, Age, ultraSound, Intraventricular conduction delay, and Clinical history). The score had good discrimination for all-cause (c-index = 0.85 and 95% CI 0.82-0.88) and cardiovascular death (c-index = 0.84 and 95% CI 0.81-0.87). The predicted probability of mortality varied more than 50-fold across deciles and adjusted well to observed mortality rates. A decision curve analysis revealed a significant net benefit of using the BASIC-AF risk score to predict the risk of death, when compared with other existing risk schemes.

CONCLUSIONS

We developed and internally validated a well-performing novel risk score for predicting death in patients with AF. The BASIC-AF risk score included routinely assessed parameters, selected through machine-learning algorithms, and may assist in tailored risk stratification and management of these patients.

Pilot Study on the Role of Circulating miRNAs for the Improvement of the Predictive Ability of the 2MACE Score in Patients with Atrial Fibrillation

Background. Atrial fibrillation (AF) increases the risk for stroke but also for non-stroke major adverse cardiovascular events (MACE). The 2MACE score was recently proposed to predict these events. Since the interest of microRNAs (miRNAs) in cardiovascular diseases is increasing, we aimed to investigate whether miRNA levels may improve the predictive performance of the 2MACE score. Methods. We included consecutive AF patients stable on vitamin K antagonist therapy. Blood samples were drawn at baseline and plasma expression of miRNAs was assessed. During a median of 7.6 (interquartile range (IQR) 5.4–8.0) years, the occurrence of any MACE (nonfatal myocardial infarction/cardiac revascularization and cardiovascular death) was recorded. Results. We conducted a miRNA expression analysis in plasma from 19 patients with and without cardiovascular events. The miRNAs selected (miR-22-3p, miR-107, and miR-146a-5p) were later measured in 166 patients (47% male, median age 77 (IQR 70–81) years) and all were associated with a higher risk of MACE. The addition of miR-107 and miR-146a-5p to the 2MACE score significantly increased the predictive performance (c-indexes: 0.759 vs. 0.694, p = 0.004), and the model with three miRNAs also improved the predictive performance compared to the original score (c-indexes: 0.762 vs. 0.694, p = 0.012). 2MACE models with the addition of miRNAs presented higher net benefit and potential clinical usefulness. Conclusions. Higher miR-22-3p andmiR-107 and lower miR-146a-5p levels were associated with a higher risk of MACE. The addition of these miRNAs to the 2MACE score significantly increased the predictive performance for MACE, which may aid to some extent in the decision-making process about risk stratification in AF.

Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events

Atrial fibrillation (AF) is strongly linked to chronic kidney disease (CKD) and both of these conditions contribute to poor cardiovascular outcomes. We evaluated the impact of renal failure on major adverse cardiovascular events (MACE) in AF, and predictive value of the 2MACE score in this post-hoc analysis of the AMADEUS trial. The primary endpoint was MACE (composite of myocardial infarction, cardiac revascularisation and cardiovascular mortality). Secondary endpoints included the composite of stroke, major bleeding and non-cardiovascular mortality, and each of the specific outcomes separately. Of the 4,554 patients, 1,526 (33.5%) were females and the median age was 71 (IQR 64 to 77) years. There were 3,838 (84.3%) non-CKD and 716 (15.7%) CKD patients. The incidence of cardiovascular and non-cardiovascular mortality were 1.41% and 2.44% per 100 patient-years, respectively. There was no significant difference in crude study endpoints between the groups. Multivariable regression analysis found no association between CKD and MACE (HR 1.03 [95% CI, 0.45 to 2.34]). The c-index of the 2MACE score for MACE was 0.65 (95% CI, 0.59 to 0.71, p <0.001). In the presence of CKD, each additional point of the 2MACE score contributed to a greater risk of MACE (HR 3.17 [95% CI, 1.28 to 7.85] vs 1.48 [95% CI, 1.17 to 1.87] in the non-CKD group). In conclusion, the 2MACE score may be a useful tool for clinical risk stratification of high-risk AF patients with CKD and those at high MACE risk could be targeted for more intensive cardiovascular prevention strategies. The presence of CKD was not found to be independently associated with MACE in AF patients.

Association of metabolic syndrome with non-thromboembolic adverse cardiac outcomes in patients with atrial fibrillation

Aims

Evidence suggests an excess risk of non-thromboembolic major adverse cardiac events (MACE) associated with atrial fibrillation (AF), particularly in individuals free of overt coronary artery disease (CAD). Metabolic syndrome (MetS) increases cardiovascular risk in the general population, but less is known how it influences outcomes in AF patients. We aimed to assess whether MetS affects the risk of MACE in AF patients without overt CAD.

Methods and results

This prospective, observational study enrolled 843 AF patients (mean-age, 62.5 ± 12.1 years, 38.6% female) without overt CAD. Metabolic syndrome was defined according to the National Cholesterol Education Program. The 5-year composite MACE included myocardial infarction (MI), coronary revascularization, and cardiac death. Metabolic syndrome was present in 302 (35.8%) patients. At 5-year follow-up, 118 (14.0%) patients experienced MACE (2.80%/year). Metabolic syndrome conferred a multivariable adjusted hazard ratio (aHR) of 1.98 for MACE [95% confidence interval (CI), 1.23-3.16; P = 0.004], and for individual outcomes: MI (aHR, 2.00; 95% CI, 1.69-5.11; P < 0.001), revascularization (aHR, 2.33; 95% CI, 1.40-3.87; P = 0.001), and cardiac death (aHR, 2.59; 95% CI, 1.25-5.33; P = 0.011). Following the propensity score (PS)-adjustment for MetS, the association between MetS and MACE (PS-aHR, 1.87; 95% CI, 1.21-3.01; P = 0.012), MI (PS-aHR, 1.72; 95% CI, 1.54-5.00; P = 0.008), revascularization (PS-aHR, 2.18; 95% CI, 1.69-3.11; P = 0.015), and cardiac death (PS-aHR, 2.27; 95% CI, 1.14-5.11; P = 0.023) remained significant.

Conclusion

Metabolic syndrome is common in AF patients without overt CAD, and confers an independent, increased risk of MACE, including MI, coronary revascularization, and cardiac death. Given its prognostic implications, prevention and treatment of MetS may reduce the burden of non-thromboembolic complications in AF.

Tailored Practical Management of Patients With Atrial Fibrillation: A Risk Factor-Based Approach

The management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization).

Association between clinical risk scores and mortality in atrial fibrillation: Systematic review and network meta-regression of 669,000 patients

Aims

Many clinical scores for risk stratification in patients with atrial fibrillation have been proposed, and some have been useful in predicting all-cause mortality. We aim to analyse the relationship between clinical risk score and all-cause death occurrence in atrial fibrillation patients.

Methods

We performed a systematic search in PubMed and Scopus from inception to 22 July 2017. We considered the following scores: ATRIA-Stroke, ATRIA-Bleeding, CHADS2, CHA2DS2-VASc, HAS-BLED, HATCH and ORBIT. Papers reporting data about scores and all-cause death rates were considered.

Results

Fifty studies and 71 scores groups were included in the analysis, with 669,217 patients. Data on ATRIA-Bleeding, CHADS2, CHA2DS2-VASc and HAS-BLED were available. All the scores were significantly associated with an increased risk for all-cause death. All the scores showed modest predictive ability at five years (c-indexes (95% confidence interval) CHADS2: 0.64 (0.63–0.65), CHA2DS2-VASc: 0.62 (0.61–0.64), HAS-BLED: 0.62 (0.58–0.66)). Network meta-regression found no significant differences in predictive ability. CHA2DS2-VASc score had consistently high negative predictive value (≥94%) at one, three and five years of follow-up; conversely it showed the highest probability of being the best performing score (63% at one year, 60% at three years, 68% at five years).

Conclusion

In atrial fibrillation patients, contemporary clinical risk scores are associated with an increased risk of all-cause death. Use of these scores for death prediction in atrial fibrillation patients could be considered as part of holistic clinical assessment. The CHA2DS2-VASc score had consistently high negative predictive value during follow-up and the highest probability of being the best performing clinical score.