Improving risk prediction for death, stroke and bleeding in Asian patients with atrial fibrillation

Abstract

Background The objectives of this study were to compare the GARFIELD Refitted model and CHA2DS2‐VASc/HAS‐BLED risk scores with the new model from the COOL‐AF registry for all‐cause death, ischaemic stroke/systemic embolism (SSE) and major bleeding in Asian patients with atrial fibrillation (AF). Methods Patients with non‐valvular AF in the nationwide COOL‐AF registry were studied. Patients were enrolled from 27 hospitals in Thailand during 2014–2017. Main outcomes were all‐cause mortality, SSE and major bleeding. Predictive models of the three outcomes were developed from the variables in the multivariable Cox‐proportional Hazard model. Predictive values of the models were evaluated by C‐statistics, calibration plots and decision curve analysis (DCA). The new COOL‐AF models were compared with the GARFIELD Refitted models and CHA2DS2‐VASc model for all‐cause mortality, SSE/HAS‐BLED model for major bleeding. Results A total of 3405 patients were enrolled. The C‐statistics for the COOL‐AF models were 0.727 (0.712–0.742), 0.708 (0.693–0.724) and 0.706 (0.690–0.721) for all‐cause mortality, SSE and major bleeding, respectively. Calibration plots showed good agreement between predicted probability the observed outcomes for the COOL‐AF models with a calibration slope of 0.94–0.99. The predictive ability remains preserved after the internal validation with bootstraps and optimism (bias) correction. The COOL‐AF predictive models tended to be superior to the GARFIELD Refitted, CHA2DS2‐VASc and HAS‐BLED models. Conclusion The COOL‐AF predictive models for all‐cause mortality, SSE and major bleeding in Asian patients with AF had a good predictive ability. The COOL‐AF model for all‐cause mortality was superior to the GARFIELD Refitted and CHA2DS2‐VASc model.

Secondary prevention after intracerebral haemorrhage

“…Such risk seems higher in the first year and is due to the disease itself as well as to the discontinuation of antithrombotic therapy after index ICH. 15,16 2.2 | Risk of ICH recurrence…”

“…Concomitant AF indeed doubles ischaemic stroke risk in these patients as compared with general population. Such risk seems higher in the first year and is due to the disease itself as well as to the discontinuation of antithrombotic therapy after index ICH 15,16 …”

Predicting the Absolute Risk of Ischemic Stroke in Asian Patients with Atrial Fibrillation: Comparing the COOL-AF Risk Score with CARS/mCARS Models for Absolute Risk and the CHA2DS2-VASc Score

“…The CHA 2 DS 2 -VASc score was designed for simplicity and for population-level assessments [ 6 ], and it has been recommended in major practice guidelines [ 2 , 3 , 4 ]. Although the CHA 2 DS 2 -VASc score was developed using data from a Western population [ 6 ], it has been well-validated in Asian populations [ 12 , 17 ]. CHA 2 DS 2 -VASc scores help identify patients with a very low risk of ischemic stroke and who should not be treated with OACs, while all other patients with intermediate–high risks for ischemic strokes should be treated with OACs.…”

“…More recently, the Calculator of Absolute Risk of Stroke (CARS) [ 10 ] and the modified CARS (mCARS) [ 11 ] were proposed for individual-level absolute risk assessments with and without OACs, but these has not been well-validated among Asian populations with AF. In contrast, the COOL-AF risk scores for SSE, bleeding, and death, which are based on multivariate weighted models, were derived and validated in an Asian AF population from Thailand [ 12 ].…”

External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry

“…Recently, 3 new predictive risk models to identify patients with AF at high risk of death for any causes, major bleeding, and TEs have been proposed from the COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio [INR] Level in Patients With Nonvalvular Atrial Fibrillation in Thailand) study. 11 In these patients, the COOL-AF scores showed more improved performances than the CHA 2 DS 2 -VASc and HAS-BLED scores and have been proposed as possible Asian-specific risk scores for all-cause mortality, major bleeding, and TEs. 11 These risk scores require external validation in other Asian and non-Asian cohorts.…”