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Published on: July 20, 2022
A prognostic nomogram for event-free survival in patients with atrial fibrillation before cardiac resynchronization
Minsi Cai1, Wei Hua2, Nixiao Zhang1
1Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, No. 167, Beilishi Rd, Xicheng District, Beijing, 100037, China.
Insights
A new nomogram helps identify patients with atrial fibrillation (AF) and heart failure (HF) who are at high risk for mortality and hospitalization after cardiac resynchronization therapy (CRT). This tool aids in early risk stratification for better patient outcomes.
Area of Science:
- Cardiology
- Medical Informatics
Background:
- Atrial fibrillation (AF) is a common comorbidity in heart failure (HF) patients.
- AF is associated with poorer outcomes in patients receiving cardiac resynchronization therapy (CRT).
- A need exists for tools to identify high-risk CRT candidates with AF.
Purpose of the Study:
- To develop and validate a predictive tool for risk stratification in CRT candidates with AF.
- To identify key predictors of mortality and HF readmission in this patient population.
Main Methods:
- A multivariate Cox regression model was used for variable selection in 152 AF patients undergoing CRT.
- A nomogram and scoring system were constructed based on selected predictors.
- Internal validation and calibration were performed using bootstrap methods and sensitivity analysis.
Main Results:
- Five predictors were identified: elevated NT-proBNP, syncope history, pulmonary hypertension, severe tricuspid regurgitation, and elevated TSH.
- The nomogram demonstrated optimal discrimination and calibration (concordance index 0.70).
- Nomogram-derived scores effectively stratified patients into low, intermediate, and high-risk groups for event-free survival.
Conclusions:
- An internally validated nomogram can aid in early risk stratification of CRT candidates with AF.
- This tool may improve clinical decision-making for managing HF patients with AF undergoing CRT.
Background:
Atrial fibrillation (AF), one of the most common comorbidities of heart failure (HF), is associated with worse long-term prognosis in HF patients receiving cardiac resynchronization therapy (CRT). However, there is still no convenient tool to identify CRT candidates with AF who are at high risk of mortality and hospitalization due to HF.
Methods:
We included 152 consecutive patients with AF for CRT in our hospital from January 2009 to July 2019. Multiple imputation was used for missing values. With imputed datasets, a multivariate Cox regression model was performed for variable selection using the backward stepwise method to predict all-cause mortality and HF readmissions. A nomogram and nomogram-based scoring system were constructed from the selected predictors. Then, internal validation and calibration were achieved by the bootstrap method, deriving the corrected concordance index and calibration curves. Sensitivity analysis was also performed to validate our selected predictors.
Results:
Five predictors were incorporated in the nomogram, including N-terminal pro brain natriuretic protein (NT-proBNP) > 1745 pg/mL, history of syncope, previous pulmonary hypertension, moderate or severe tricuspid regurgitation, thyroid-stimulating hormone (TSH) > 4 mIU/L. The concordance index (0.70, 95% CI 0.62-0.77), corrected concordance index (0.67, 95% CI 0.59-0.74) and calibration curve showed optimal discrimination and calibration of the established nomogram. A significant difference in overall event-free survival was recognized by the nomogram-derived scores for patients with high risk (> 50 points), intermediate risk (21-50 points) and low risk (0-20 points) before CRT.
Conclusion:
Our internally validated nomogram may be an applicable tool for the early risk stratification of CRT candidates with AF.
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