APPLE scoring system may be best predictor of AF recurrence after surgical ablation
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The APPLE scoring system is superior to CHA2DS2‐VASc and CHADS2 in predicting atrial fibrillation recurrence after surgical ablation, data from a retrospective study show.
Recurrence of AF occurs in up to 35% of patients within 1 year of surgery and a scoring system to predict AF recurrence risk after surgical ablation would be of value to physicians, Daniel J. Lauritzen, MD, of the department of cardiothoracic and vascular surgery at Aarhus University Hospital, Denmark, and colleagues wrote in the Journal of Cardiac Surgery.
“Several observational studies have investigated the predictive capabilities of the scoring systems CHA2DS2‐VASc and CHADS2 on AF recurrence,” Lauritzen and colleagues wrote. “These scoring systems were originally invented to predict stroke risk in AF patients. However, these studies include catheter-ablated patients only, and the predictive capabilities of the two scoring systems were found to be moderate. These scoring systems lack important risk factors known to be associated with AF recurrence, such as left atrial diameter and persistent AF.”
Scoring systems
Lauritzen and colleagues analyzed data from 337 patients undergoing concomitant pulmonary vein ablation during cardiac surgery at Aarhus University Hospital between 2004 and 2019. APPLE, CHA2DS2‐VASc and CHADS2 scores were calculated for each patient.
In the APPLE scoring system, 1 point is given for each baseline risk factor: Age greater than 65 years; persistent AF; impaired estimated glomerular filtration rate (< 60 mL/min/1.73 m2); left atrial diameter of 43 mm or more; and left ventricular ejection fraction < 50%. In the CHA2DS2‐VASc scoring system, baseline risk factors are given the following points: LVEF < 40% (1 point), hypertension > 140 mm Hg/90 mm Hg (1 point), age 75 years or older (2 points), diabetes (1 point), previous stroke/transient ischemic attack/thromboembolism (2 points), vascular disease (1 point), age 65 to 74 years (1 point) and female sex (1 point). In the CHADS2 scoring system, baseline risk factors are given the following points: EF less than 40% (1 point), hypertension > 140 mm Hg/90 mm Hg (1 point), age 75 years or older (1 point), diabetes (1 point), previous stroke/TIA/ thromboembolism (2 points).
Predictors of AF recurrence
Researchers assessed the predictive value of the scoring systems on AF recurrence 3 to 12 months after ablation.
Receiver operating characteristic curves showed the superiority of the APPLE scoring system with an area under the curve of 0.69 compared with 0.571 for CHA2DS2‐VASc and 0.569 for CHADS2 (P = .01). Using logistic regression analyses, APPLE and CHA2DS2‐VASc were predictors of AF recurrence between 3 and 12 months after surgical ablation, with an OR of 1.93 for the APPLE scoring system (95% CI, 1.39-2.67; P < .01) and an OR of 1.17 for the CHA2DS2‐VASc scoring system (95% CI, 1.01-1.36; P = .04).
“Certainly, with a sensitivity of 66.7% and a specificity of 69.2% at optimal the cut‐off value of 3, the APPLE cannot stand alone in the clinical decision‐making process,” the researchers wrote. “However, it can be used to help select the right candidates for surgical ablation, choose the most appropriate surgical approach such as a more complete ablation, identify patients who may need more frequent clinical and electrocardiogram controls, as well as guide choices pertaining to anticoagulation therapy. In turn, this could reduce rates of AF recurrences and hospitalization costs.”
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