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ABC-AF Scores in AF Patients Without Anticoagulation
Quick Takes
- The ABC-AF scores incorporate NT-proBNP, cardiac troponin T, and GDF-15 in addition to age and clinical history (TIA/stroke for the stroke score, and bleeding for the bleeding score).
- This study validates the ABC-AF (Age, Biomarkers, Clinical History) scores for predicting stroke, bleeding, and death in patients with AF treated with antiplatelet therapy.
- ABC-AF scores outperformed the CHA2DS2-VASc and HAS-BLED scores for stroke, bleeding, and death in patients not on anticoagulation, albeit modestly.
Study Questions:
How do ABC-AF (Age, Biomarkers, Clinical History) scores perform in predicting risk of stroke, bleeding, and death in patients with atrial fibrillation (AF) not on anticoagulation?
Methods:
The authors leveraged completed randomized trials (ACTIVE A and AVERROES) and computed ABC-AF scores in patients with AF specifically enrolled in the antiplatelet arms of these trials (n = 4,305). The ABC-AF scores incorporate N-terminal pro–B-type natriuretic peptide (NT-proBNP), cardiac troponin T, and growth-differentiation factor-15 (GDF-15) in addition to age and prior history of transient ischemic attack (TIA)/stroke for the ABC-AF-stroke score, or history of major bleeding for the ABC-AF-bleeding score. The aforementioned biomarkers were measured in participants with blood samples collected at baseline. The ABC-AF 1-year risks of stroke or systemic embolism, major bleeding, and death were estimated and calibrated, and the scores’ risk discrimination ability compared to the CHA2DS2-VASc and HAS-BLED scores.
Results:
Overall, the incidence (per 100 person-years) of first stroke or systemic embolic events was approximately 3.5%, the incidence of major bleeding was 1.5%, and the incidence of death was 5.4%. The ABC-AF-stroke score was superior to the CHA2DS2-VASc score (0.70, 95% confidence interval [CI], 0.67-0.73 vs. 0.63, 95% CI, 0.60-0.67). The ABC-AF-bleeding score outperformed the HAS-BLED score (C-index of 0.73, 95% CI, 0.69-0.77 vs. 0.60, 95% CI, 0.55-0.65). Findings were similar for death.
Conclusions:
The ABC-AF scores for the assessment of the risks of stroke, major bleeding, and death showed good discrimination in patients with AF not receiving oral anticoagulation, and outperformed the CHA2DS2-VASc and HAS-BLED scores.
Perspective:
The ABC-AF scores were initially derived from patients on anticoagulation enrolled in clinical trials comparing warfarin to direct oral anticoagulants and required validation in patients on other therapies such as antiplatelets, which this study has accomplished. In both groups of patients (on anticoagulation or antiplatelet therapy), the ABC-AF scores outperformed the CHA2DS2-VASc and HAS-BLED scores, albeit modestly, with differences in C-index of 0.05-0.10. Use of CHA2DS2-VASc and HAS-BLED scores is recommended by various guidelines in the management of AF, owing to their ease of calculation and lack of better alternatives.
The ABC-AF scores incorporate biomarkers that have shown to provide additional prognostic information in the prediction of various cardiovascular outcomes and requires measurement of biomarkers that may not be routinely available such as GDF-15 and NT-proBNP. Whether implementation of these biomarker measurements to derive the ABC-AF score would be cost-effective compared to the CHA2DS2-VASc score remains to be seen. The CHA2DS2-VASc and HAS-BLED scores, however, have modest risk discrimination ability, and better scores are needed to refine the selection of patients requiring anticoagulation. The ABC-AF scores are a step in the right direction.
Note that characteristics of AF such as burden, symptomatology, or cardiac structural changes are not included in any of these scores. In the era of precision medicine, big data, and panomics, we can envision using an agnostic, data-driven approach to derive models that would accurately discriminate risk and provide decision support to health care providers in the management of AF.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Biomarkers, Cost-Benefit Analysis, Embolism, Growth Differentiation Factor 15, Hemorrhage, Ischemic Attack, Transient, Natriuretic Peptide, Brain, Platelet Aggregation Inhibitors, Secondary Prevention, Stroke, Troponin T, Warfarin, Vascular Diseases
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