Prediction models for atrial fibrillation applicable in the community: a systematic review and meta-analysis

Abstract

Aims Atrial fibrillation (AF) is a common arrhythmia associated with an increased stroke risk. The use of multivariable prediction models could result in more efficient primary AF screening by selecting at-risk individuals. We aimed to determine which model may be best suitable for increasing efficiency of future primary AF screening efforts. Methods and results We performed a systematic review on multivariable models derived, validated, and/or augmented for AF prediction in community cohorts using Pubmed, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) through 1 August 2019. We performed meta-analysis of model discrimination with the summary C-statistic as the primary expression of associations using a random effects model. In case of high heterogeneity, we calculated a 95% prediction interval. We used the CHARMS (Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies) checklist for risk of bias assessment. We included 27 studies with a total of 2 978 659 unique participants among 20 cohorts with mean age ranging from 42 to 76 years. We identified 21 risk models used for incident AF risk in community cohorts. Three models showed significant summary discrimination despite high heterogeneity: CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology) [summary C-statistic 0.71; 95% confidence interval (95% CI) 0.66–0.76], FHS-AF (Framingham Heart Study risk score for AF) (summary C-statistic 0.70; 95% CI 0.64–0.76), and CHA2DS2-VASc (summary C-statistic 0.69; 95% CI 0.64–0.74). Of these, CHARGE-AF and FHS-AF had originally been derived for AF incidence prediction. Only CHARGE-AF, which comprises easily obtainable measurements and medical history elements, showed significant summary discrimination among cohorts that had applied a uniform (5-year) risk prediction window. Conclusion CHARGE-AF appeared most suitable for primary screening purposes in terms of performance and applicability in older community cohorts of predominantly European descent.

Clinical Factors Associated with Atrial Fibrillation Detection on Single-Time Point Screening Using a Hand-Held Single-Lead ECG Device

“…Our study indicates that a CHA 2 DS 2 VASc > 0 in males and >1 in females, or its analogue CHA 2 DS 2 VA > 0, can be useful risk stratifiers for detecting unknown AF, since associated with very high sensitivity for AF detection in the whole population. Our study found that female sex is negatively associated with AF detection at screening, a finding not stressed in previous meta-analyses [ 13 , 15 ], but considered in some scores used for predicting incident AF in the community [ 32 ]. The direct implications of this observation is the opportunity to modify CHA 2 DS 2 VASc, for the purpose of AF screening, into a sex neutral score (CHA 2 DS 2 VASc > 0 in males and >1 in females) or a sex-independent score CHA 2 DS 2 VA > 0).…”

“…The lack of benefit found in this study in active screening arm can be explained by the high rate of AF detection that characterizes usual care in The Netherlands, as a result of implemented guidelines for cardiovascular disease management, resulting in a higher baseline prevalence of AF as compared with the SAFE study [ 31 ]. To reduce the complexity of screening initiatives, a series of studies evaluated the possibility of an improved patient targeting, by the selection of candidates with a higher likelihood to have AF detected [ 32 ]. The CHA 2 DS 2 VASc score, even if not developed for this purpose, has been tested in the form of “virtual” CHA 2 DS 2 VASc, both for screen-detected and incident AF [ 32 ].…”

“…To reduce the complexity of screening initiatives, a series of studies evaluated the possibility of an improved patient targeting, by the selection of candidates with a higher likelihood to have AF detected [ 32 ]. The CHA 2 DS 2 VASc score, even if not developed for this purpose, has been tested in the form of “virtual” CHA 2 DS 2 VASc, both for screen-detected and incident AF [ 32 ]. Our study indicates that a CHA 2 DS 2 VASc > 0 in males and >1 in females, or its analogue CHA 2 DS 2 VA > 0, can be useful risk stratifiers for detecting unknown AF, since associated with very high sensitivity for AF detection in the whole population.…”

CHARGE-AF in a national routine primary care electronic health records database in the Netherlands: validation for 5-year risk of atrial fibrillation and implications for patient selection in atrial fibrillation screening

“…It has been validated in various community cohorts 5–10 and appears to be the most viable prediction model for patient selection in future community AF screening. 11 …”

Usefulness of CHADS2, R2CHADS2, and CHA2DS2‐VASc scores for predicting incident atrial fibrillation in heart failure with preserved ejection fraction patients

“…In the general population, prior studies have proposed several risk models that specifically been derived for predicting incident AF such as the Framingham risk score, the Atherosclerosis Risk In Communities Study (ARIC) score, CHADS2, CHA2DS2-VASc, and CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology). 23 A systematic review by Himmelreich et al 23 has summarized all of these 10 risk models (Supporting Information, Figure S3), suggesting that the CHARGE-AF score seems to be the most suitable tool for screening AF in the community. In addition, Himmelreich et al 23 also found that the CHADS2 and CHA2DS2-VASc scores have also been used to predict incident AF in the general population, where the pooled C-indexes for the CHADS2 and CHA2DS2-VASc scores were 0.66 (95% CI: 0.59-0.74), and 0.69 (95% CI: 0.64-0.74), respectively.…”