Predicting atrial fibrillation recurrence after ablation in patients with heart failure: Validity of the APPLE and CAAP‐AF risk scoring systems

Abstract

Background Compared with medical therapy, catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) improves cardiovascular outcomes. Risk scores (CAAP‐AF and APPLE) have been developed to predict the likelihood of AF recurrence after ablation, have not been validated specifically in patients with AF and HF. Methods We analyzed baseline characteristics, risk scores, and rates of AF recurrence 12 months postablation in a cohort of 230 consecutive patients with AF and HF undergoing PVI in the Duke Center for Atrial Fibrillation registry from 2009‐2013. Results During a follow‐up period of 12 months, 76 of 230 (33%) patients with HF experienced recurrent AF after ablation. The median APPLE and CAAP‐AF scores were 1.5 ([Q1, Q3]: [1.0, 2.0]) and 4.0 ([Q1, Q3]: [3.0, 5.0]), respectively and were not different from those patients with and without recurrent AF. Freedom from AF was not different according to APPLE and CAAP‐AF scores. Discrimination for recurrent AF with the CAAP‐AF score was modest with a C‐statistic of 0.60 (95% CI 0.52‐0.67). Discrimination with the APPLE score was similarly modest, with a C‐statistic of 0.54 (95% CI: 0.47‐0.62). Conclusions Validated predictive risk scores for recurrent AF after catheter ablation exhibit limited predictive ability in cohorts of AF and HF. Additional tools are needed to facilitate risk stratification and patient selection for AF ablation in patients with concomitant HF.

Shifts in gut microbiome and metabolome are associated with risk of recurrent atrial fibrillation

“…5,6 The clinical scoring system, including CAAP-AF, DR-FLASH and APPLE scores, could provide a realistic AF ablation outcome expectation for individual patients. [7][8][9][10][11] However, this scoring system is simple and requires further modifications for increased robustness via substitution of aetiologic factors by surrogate variables.…”

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…Time from diagnosis to ablation is also associated with improved outcomes after ablation. 9,10 Although the likelihood of recurrence of AF is 1 factor that should be considered, it is difficult to predict, 11 and certain patients may derive even greater benefits from catheter ablation, such as in patients with HFrEF, who have been shown to have improved functional status, LV function, and cardiovascular outcomes. 12–14…”

Shifts in gut microbiome and metabolome are associated with risk of recurrent atrial fibrillation

“…Not all AF patients that undergo radiofrequency catheter ablation remain in stable sinus rhythm. The success rates of catheter ablation maintaining sinus rhythm and avoiding a recurrence of AF after ablation are hard to predict and control [5–7]. To date, multiple variables, such as left atrial diameter and N-terminal pro–B-type natriuretic peptide (NT-proBNP), are considered risk factors for the recurrence of AF upon catheter ablation; however, these biomarkers lack specificity, and their predictive powers are barely satisfactory [8, 9].…”

“…To date, multiple variables, such as left atrial diameter and N-terminal pro–B-type natriuretic peptide (NT-proBNP), are considered risk factors for the recurrence of AF upon catheter ablation; however, these biomarkers lack specificity, and their predictive powers are barely satisfactory [8, 9]. The clinical scoring system, including CAAP-AF (coronary artery disease [CAD], age, left atrial size, persistent AF, unsuccessful antiarrhythmics, and female gender), DR-FLASH (diabetes mellitus, abnormal renal function, persistent type of AF, LA diameter > 45 mm, age > 65 years, female gender, and hypertension), and APPLE (age > 65 years, persistent AF, abnormal estimated glomerular filtration rate [eGFR; < 60 ml/min/1.73 m 2 ], as well as LA diameter above 43 mm and ejection fraction below 50%) scores, could provide a realistic AF ablation outcome expectation for individual patients [7, 10–13]. However, this scoring system is simple and requires further modifications for increased robustness via substitution of etiologic factors by surrogate variables.…”