Risk Stratification in Atrial Fibrillation

Study Questions:

How does a novel risk score that incorporates biomarkers in addition to clinical variables compare to ones that only utilize clinical variables in predicting mortality in patients with atrial fibrillation (AF) on oral anticoagulant (OAC) therapy?

Methods:

The novel risk score consisting of Age, Biomarkers (e.g., troponin I/T, N-terminal pro–B-type natriuretic peptide [NT-proBNP], growth differentiation factor-15 [GDF-15]), and Clinical history (ABC) was internally and externally validated. The cohort for internal validation was derived from the ARISTOTLE study (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) and for external validation from the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy [dabigatran vs. warfarin]). The novel risk model was compared to one that only utilized clinical variables, and a more conventional risk stratification scheme, namely, CHA2DS2-VASc.

Results:

The novel ABC-death score yielded a c-index of 0.74 in the derivation model and outperformed ones based solely on clinical variables (c-index = 0.68), and CHA2DS2-VASc (c-index = 0.59). Likewise, it also better predicted overall mortality in the validation cohort. A high ABC-death score identified patients who experienced the largest absolute reduction in death while taking apixaban as compared to warfarin.

Conclusions:

The novel ABC-death risk score, consisting of both biomarkers and clinical variables, outperformed models that solely utilized clinical variables.

Perspective:

In patients with AF who are taking OAC therapy, the main causes of death include heart failure and cardiac arrest. In these patients, commonly utilized biomarkers help to identify patients at risk of all-cause and cardiovascular mortality. These biomarkers reflect myocardial injury (troponin) and stress (NT-proBNP), and cellular ageing and inflammation (GDF-15). The prognostic information provided by these biomarkers is incremental to that based on the clinical profile only.


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