Prospective multicentric validation of a novel prediction model for paroxysmal atrial fibrillation

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Abstract

Background

The early recognition of paroxysmal atrial fibrillation (pAF) is a major clinical challenge for preventing thromboembolic events. In this prospective and multicentric study we evaluated prediction scores for the presence of pAF, calculated from non-invasive medical history and echocardiographic parameters, in patients with unknown AF status.

Methods

The 12-parameter score with parameters age, LA diameter, aortic root diameter, LV,ESD, TDI Aʹ, heart frequency, sleep apnea, hyperlipidemia, type II diabetes, smoker, ß-blocker, catheter ablation, and the 4-parameter score with parameters age, LA diameter, aortic root diameter and TDI A’ were tested. Presence of pAF was verified by continuous electrocardiogram (ECG) monitoring for up to 21 days in 305 patients.

Results

The 12-parameter score correctly predicted pAF in all 34 patients, in which pAF was newly detected by ECG monitoring. The 12- and 4-parameter scores showed sensitivities of 100% and 82% (95%-CI 65%, 93%), specificities of 75% (95%-CI 70%, 80%) and 67% (95%-CI 61%, 73%), and areas under the receiver operating characteristic (ROC) curves of 0.84 (95%-CI 0.80, 0.88) and 0.81 (95%-CI 0.74, 0.87). Furthermore, properties of AF episodes and durations of ECG monitoring necessary to detect pAF were analysed.

Conclusions

The prediction scores adequately detected pAF using variables readily available during routine cardiac assessment and echocardiography. The model scores, denoted as ECHO-AF scores, represent simple, highly sensitive and non-invasive tools for detecting pAF that can be easily implemented in the clinical practice and might serve as screening test to initiate further diagnostic investigations for validating the presence of pAF.

Graphic abstract

Prospective validation of a novel prediction model for paroxysmal atrial fibrillation based on echocardiography and medical history parameters by long-term Holter ECG

Electronic supplementary material

The online version of this article (10.1007/s00392-020-01773-z) contains supplementary material, which is available to authorized users.

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Most cited references 26

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Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation

Marco V. Perez, Kenneth Mahaffey, Haley K Hedlin … (2019)

Optical sensors on wearable devices can detect irregular pulses. The ability of a smartwatch application (app) to identify atrial fibrillation during typical use is unknown.

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Cryptogenic stroke and underlying atrial fibrillation.

Tommaso Sanna, Hans-Christoph Diener, Rod Passman … (2014)

Current guidelines recommend at least 24 hours of electrocardiographic (ECG) monitoring after an ischemic stroke to rule out atrial fibrillation. However, the most effective duration and type of monitoring have not been established, and the cause of ischemic stroke remains uncertain despite a complete diagnostic evaluation in 20 to 40% of cases (cryptogenic stroke). Detection of atrial fibrillation after cryptogenic stroke has therapeutic implications. We conducted a randomized, controlled study of 441 patients to assess whether long-term monitoring with an insertable cardiac monitor (ICM) is more effective than conventional follow-up (control) for detecting atrial fibrillation in patients with cryptogenic stroke. Patients 40 years of age or older with no evidence of atrial fibrillation during at least 24 hours of ECG monitoring underwent randomization within 90 days after the index event. The primary end point was the time to first detection of atrial fibrillation (lasting >30 seconds) within 6 months. Among the secondary end points was the time to first detection of atrial fibrillation within 12 months. Data were analyzed according to the intention-to-treat principle. By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ICM group (19 patients) versus 1.4% of patients in the control group (3 patients) (hazard ratio, 6.4; 95% confidence interval [CI], 1.9 to 21.7; P<0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ICM group (29 patients) versus 2.0% of patients in the control group (4 patients) (hazard ratio, 7.3; 95% CI, 2.6 to 20.8; P<0.001). ECG monitoring with an ICM was superior to conventional follow-up for detecting atrial fibrillation after cryptogenic stroke. (Funded by Medtronic; CRYSTAL AF ClinicalTrials.gov number, NCT00924638.).

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Atrial fibrillation in patients with cryptogenic stroke.

David J Gladstone, Melanie Spring, Paul Dorian … (2014)

Atrial fibrillation is a leading preventable cause of recurrent stroke for which early detection and treatment are critical. However, paroxysmal atrial fibrillation is often asymptomatic and likely to go undetected and untreated in the routine care of patients with ischemic stroke or transient ischemic attack (TIA). We randomly assigned 572 patients 55 years of age or older, without known atrial fibrillation, who had had a cryptogenic ischemic stroke or TIA within the previous 6 months (cause undetermined after standard tests, including 24-hour electrocardiography [ECG]), to undergo additional noninvasive ambulatory ECG monitoring with either a 30-day event-triggered recorder (intervention group) or a conventional 24-hour monitor (control group). The primary outcome was newly detected atrial fibrillation lasting 30 seconds or longer within 90 days after randomization. Secondary outcomes included episodes of atrial fibrillation lasting 2.5 minutes or longer and anticoagulation status at 90 days. Atrial fibrillation lasting 30 seconds or longer was detected in 45 of 280 patients (16.1%) in the intervention group, as compared with 9 of 277 (3.2%) in the control group (absolute difference, 12.9 percentage points; 95% confidence interval [CI], 8.0 to 17.6; P<0.001; number needed to screen, 8). Atrial fibrillation lasting 2.5 minutes or longer was present in 28 of 284 patients (9.9%) in the intervention group, as compared with 7 of 277 (2.5%) in the control group (absolute difference, 7.4 percentage points; 95% CI, 3.4 to 11.3; P<0.001). By 90 days, oral anticoagulant therapy had been prescribed for more patients in the intervention group than in the control group (52 of 280 patients [18.6%] vs. 31 of 279 [11.1%]; absolute difference, 7.5 percentage points; 95% CI, 1.6 to 13.3; P=0.01). Among patients with a recent cryptogenic stroke or TIA who were 55 years of age or older, paroxysmal atrial fibrillation was common. Noninvasive ambulatory ECG monitoring for a target of 30 days significantly improved the detection of atrial fibrillation by a factor of more than five and nearly doubled the rate of anticoagulant treatment, as compared with the standard practice of short-duration ECG monitoring. (Funded by the Canadian Stroke Network and others; EMBRACE ClinicalTrials.gov number, NCT00846924.).

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Author and article information

Contributors

Constanze Schmidt:

ORCID: http://orcid.org/0000-0001-5897-237X

Constanze.Schmidt@med.uni-heidelberg.de

Journal

Journal ID (nlm-ta): Clin Res Cardiol

Journal ID (iso-abbrev): Clin Res Cardiol

Title: Clinical Research in Cardiology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 1861-0684

ISSN (Electronic): 1861-0692

Publication date (Electronic): 19 November 2020

Publication date PMC-release: 19 November 2020

Publication date (Print): 2021

Volume: 110

Issue: 6

Pages: 868-876

Affiliations

[1 ]GRID grid.7700.0, ISNI 0000 0001 2190 4373, Department of Cardiology, University Hospital Heidelberg, , University of Heidelberg, ; Im Neuenheimer Feld 410, 69120 Heidelberg, Germany

[2 ]GRID grid.7700.0, ISNI 0000 0001 2190 4373, DZHK (German Center for Cardiovascular Research), Partner Site Heidelberg/Mannheim, , University of Heidelberg, ; Im Neuenheimer Feld 410, 69120 Heidelberg, Germany

[3 ]Kardiologen Am Brückenkopf, Cardiology Practice, Brückenkopfstraße 1/2, 69120 Heidelberg, Germany

[4 ]GRID grid.411339.d, ISNI 0000 0000 8517 9062, Clinic and Policlinic for Cardiology, , University Hospital Leipzig, ; Liebigstraße 18, 04103 Leipzig, Germany

[5 ]GRID grid.411984.1, ISNI 0000 0001 0482 5331, Clinic for Cardiology and Pneumology, , University Medicine Göttingen, ; 37099 Göttingen, Germany

[6 ]Department of Internal Medicine, GPR Klinikum Rüsselsheim, August-Bebel-Straße 59, 65428 Rüsselsheim am Main, Germany

[7 ]GRID grid.484013.a, Digital Health Center, , Berlin Institute of Health (BIH) and Charité, ; Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany

[8 ]GRID grid.7497.d, ISNI 0000 0004 0492 0584, Division of Theoretical Bioinformatics, , German Cancer Research Center (DKFZ), ; Im Neuenheimer Feld 267, 69120 Heidelberg, Germany

Author information

Constanze Schmidt http://orcid.org/0000-0001-5897-237X

Article

Publisher ID: 1773

DOI: 10.1007/s00392-020-01773-z

PMC ID: 8166666

PubMed ID: 33211156

SO-VID: a184fefd-1115-4976-8fd7-4a931176707a

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 15 August 2020

Date accepted : 27 October 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100010447, Deutsches Zentrum für Herz-Kreislaufforschung;

Award ID: Excellence Grant

Award ID: Postdoc Startup Grant

Award Recipient : Constanze Schmidt Felix Wiedmann

Funded by: FundRef http://dx.doi.org/10.13039/501100005971, Deutsche Herzstiftung;

Award ID: F/15/18

Award ID: F/41/15

Award ID: F/03/19

Award Recipient : Constanze Schmidt Felix Wiedmann

Funded by: FundRef http://dx.doi.org/10.13039/501100001659, Deutsche Forschungsgemeinschaft;

Award ID: SCHM 3358/1-1

Award ID: TH 1120/7-1

Award Recipient : Constanze Schmidt Dierk Thomas

Funded by: FundRef http://dx.doi.org/10.13039/501100003042, Else Kröner-Fresenius-Stiftung;

Award ID: 2019_A106

Award Recipient : Constanze Schmidt

Funded by: FundRef http://dx.doi.org/10.13039/501100002347, Bundesministerium für Bildung und Forschung;

Award ID: Heidelberg Center for Human Bioinformatics

Award Recipient : Stefan M. Kallenberger

Funded by: Medizinische Fakultät Heidelberg der Universität Heidelberg (9149)

Open Access :

Open Access funding enabled and organized by Projekt DEAL.

Custom metadata

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: paroxysmal atrial fibrillation,atrial fibrillation detection,af prediction model,echo-af scores,stroke prevention,systems medicine

Data availability:

ScienceOpen disciplines: Cardiovascular Medicine

Keywords: paroxysmal atrial fibrillation, atrial fibrillation detection, af prediction model, echo-af scores, stroke prevention, systems medicine

Prospective multicentric validation of a novel prediction model for paroxysmal atrial fibrillation

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Abstract

Background

Methods

Results

Conclusions

Graphic abstract

Electronic supplementary material

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Cardiovascular Innovations and Applications

Most cited references 26

Large-Scale Assessment of a Smartwatch to Identify Atrial Fibrillation

Cryptogenic stroke and underlying atrial fibrillation.

Atrial fibrillation in patients with cryptogenic stroke.

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