Key result
DR-FLASH score >3 is linked to ~70% higher AF recurrence after PVI.
Why the study?
Left atrial low-voltage areas are frequent in patients with AF and may predict recurrence after catheter ablation, motivating the development and validation of a clinical risk score to identify these substrates.
Does the DR-FLASH clinical risk score accurately identify left atrial low-voltage areas and predict long-term recurrence of atrial arrhythmias in patients with atrial fibrillation undergoing pulmonary vein isolation?
Cohort (n=902)
Yes
Does the DR-FLASH clinical risk score accurately identify left atrial low-voltage areas and predict long-term recurrence of atrial arrhythmias in patients with atrial fibrillation undergoing pulmonary vein isolation?
The DR-FLASH score noninvasively identifies atrial fibrillation patients likely to have left atrial low-voltage substrate and higher recurrence risk after pulmonary vein isolation alone, helping select candidates who may need extensive substrate modification.
Answers are grounded in this paper and cite their sources.
May noninvasively identify AF patients with low-voltage areas at higher PVI recurrence risk; hypothesis-generating for score-guided ablation strategies.
Background Left atrial (LA) low-voltage areas (LVAs) are frequently observed in patients with atrial fibrillation (AF) and may predict AF recurrence after catheter ablation. Objective The aim of this study was to develop and validate a clinical tool to identify LVAs that are associated with AF recurrence after pulmonary vein isolation (PVI). Methods In a cohort of 238 patients, voltage maps were created during LA procedures. LVAs were defined as areas with electrogram amplitudes <0.5 mV. On the basis of regression analysis, predictors of LA substrate were identified. These parameters were used to establish a dedicated risk score (DR-FLASH score, based on diabetes mellitus, renal dysfunction, persistent form of AF, LA diameter >45 mm, age >65 years, female sex, and hypertension). This risk score was then prospectively validated in a multicenter cohort of 180 patients. The association of the score with long-term recurrence of atrial arrhythmias after circumferential PVI was tested in a retrospective cohort of 484 patients. Results The DR-FLASH score effectively identified LVA substrate (C statistic = 0.801, P < .001). In the prospective multicenter validation cohort, the predictive value of the DR-FLASH score was confirmed (C statistic = 0.767, P < .001). The probability for the presence of LA substrate increased by a factor of 2.2 (95% confidence interval [CI] 1.6-2.9, P < .001) with each point scored. Furthermore, the risk of AF recurrence after PVI increased by a factor of 1.3 (95% CI 1.1-1.5, P < .001) with every additional point and was almost 2 times higher in patients with a DR-FLASH score >3 (odds ratio 1.7, 95% CI 1.1-2.8, P = .026). Conclusion The DR-FLASH score may be useful to identify patients who may require extensive substrate modification instead of PVI alone.
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Kosiuk et al. (2015) conducted a cohort in Atrial fibrillation undergoing left atrial procedures / pulmonary vein isolation (n=902). DR-FLASH score (diabetes mellitus, renal dysfunction, persistent AF, LA diameter >45 mm, age >65 years, female sex, hypertension) vs. DR-FLASH score ≤3 or lower score was evaluated on Presence of left atrial low-voltage areas (<0.5 mV) and long-term recurrence of atrial arrhythmias after pulmonary vein isolation (OR 1.7, 95% CI 1.1-2.8, p=0.026). The DR-FLASH score identified left atrial low-voltage areas (C-statistic 0.767, P<.001) and a score >3 predicted higher AF recurrence after PVI (OR 1.7; 95% CI 1.1-2.8; P=0.026).
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