A New Scoring System for Evaluating the Risk of Heart Failure Events in Japanese Patients With Atrial Fibrillation

The Cardiovascular Institute, Tokyo, Japan.
The American journal of cardiology (Impact Factor: 3.28). 05/2012; 110(5):678-82. DOI: 10.1016/j.amjcard.2012.04.049
Source: PubMed


Risk stratification for heart failure (HF) in patients with atrial fibrillation (AF) has not been well established. The aim of this study was to identify the predictors of HF events in patients with AF, consequently developing a new risk-scoring system that stratifies the risk for HF events. In this prospective, single hospital-based cohort, all patients who presented from July 2004 to March 2010 were registered (Shinken Database 2004-2009). Follow-up was maintained by being linked to the medical records or by sending study documents of prognosis. Of the 13,228 patients in the Shinken Database 2004-2009, 1,942 patients with AF were identified. Of the patients with AF, HF events (hospitalization or death from HF) occurred in 147 patients (7.6%) during a mean follow-up period of 776 ± 623 days. After identifying the parameters that were independently associated with the incidence of HF events (coexistence of organic heart diseases, anemia [hemoglobin level <11 g/dl], renal dysfunction [estimated glomerular filtration rate <60 ml/min/m(2)], diabetes mellitus, and the use of diuretics), a new scoring system was developed, the H(2)ARDD score (heart diseases = 2 points, anemia = 1 point, renal dysfunction = 1 point, diabetes = 1 point, and diuretic use = 1 point; range 0 to 6 points). This scoring system discriminated the low- and high-risk populations well (incidence in patients scoring 0 and 6 points of 0.2% and 40.8% per patient-year, respectively) and showed high predictive ability (area under the curve 0.840, 95% confidence interval 0.803 to 0.876). In conclusion, the new H(2)ARDD score may help identify the population of patients with AF at high risk for HF events.

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    ABSTRACT: Background A novel risk scoring system (H2ARDD) for estimating the incidence of heart failure (HF) events in atrial fibrillation (AF) has been developed, which represents points assigned for organic heart disease (2 points), anemia (1 point), renal dysfunction (1 point), diabetes (1 point), and diuretic use (1 point). We aimed to clarify whether H2ARDD score is related to cardiopulmonary exercise testing (CPX) parameters in patients with AF. Methods The study population included 344 consecutive patients with AF who underwent CPX as initial screening between June 2004 and March 2012. The association between 4 CPX parameters and the incidence of HF events was analyzed by using multiple linear regression models. Results The peak O2 uptake (peak V̇O2), anaerobic (gas exchange) threshold (AT), and ratio of the increase in V̇O2 to the increase in work rate (ΔV̇O2/ΔWR) were lower and the slope of the increase in ventilation to the increase in CO2 output (V̇E–V̇CO2 slope) was higher in patients with than in those without each H2ARDD score component. Accordingly, the parameters significantly increased or decreased according to H2ARDD score. With the multiple linear regression models, H2ARDD score was independently associated with each CPX parameter even after adjustment for various cofactors. Conclusions H2ARDD score was independently associated with the well-established CPX parameters in patients with AF, suggesting a potential pathophysiological basis for a risk stratification system for predicting HF events in patients with AF.
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    ABSTRACT: Aim: Atrial fibrillation (AF) commonly co-exists with heart failure (HF). The risk factors for and prognostic implications of incident HF development in patients with first-diagnosed AF and structurally normal hearts are poorly defined. In a cohort of patients with first-diagnosed AF and structurally normal hearts on baseline echocardiography, we investigated baseline risk factors for the development of incident HF and tested the hypothesis that incident HF was an independent predictor of adverse outcomes during a mean 10-year follow-up period. Methods and results: This was a registry-based, observational cohort study of 842 patients initially diagnosed between 1992 and 2007 (mean age 51.6 ± 12.4 years), whereby 83 (9.9%) developed HF. The linearized rate of incident HF was 0.97% [95% confidence interval (CI) 0.78-1.19%] per 100 patient-years. Baseline history of hypertension, diabetes mellitus, dilated left atrium, and low-normal LVEF (50-54%) were multivariable predictors of subsequent HF (all P < 0.05). HF development was significantly associated with increased number of hospitalizations, AF progression, any stroke/peripheral thrombo-embolism, ischaemic stroke, cardiovascular death, and all-cause mortality (all P < 0.001). Kaplan-Meier 10-year estimates of survival free of the composite endpoint of AF progression, thrombo-embolism, and mortality were significantly worse for AF patients with incident HF compared with those without HF (68.8%; 95% CI 64.7-72.9 vs. 25.9% 95% CI 15.7-36.1, P < 0.001). Conclusion: Underlying co-morbidities or subtle alterations such as mild left atrial dilatation or low-normal LVEF in the absence of overt underlying heart disease are baseline independent risk factors for incident HF during a long-term follow-up. Incident HF was an independent predictor of adverse outcomes in patients initially diagnosed with first-diagnosed AF and structurally normal hearts. These findings could facilitate the identification of AF patients at increased risk for adverse outcomes within the cohort perceived as being at 'low risk' given a structurally normal heart on echocardiography.
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