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External Validation of COOL-AF Scores in the Asian Pacific Heart Rhythm Society Atrial Fibrillation Registry
Tommaso Bucci1,2, Alena Shantsila1, Giulio Francesco Romiti1,3
1Liverpool Centre of Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
Insights
The COOL-AF risk scores demonstrated moderate-to-good predictive value for death and bleeding in Asian patients with atrial fibrillation (AF). These scores performed better in Asian populations compared to European populations.
Area of Science:
- Cardiology
- Clinical Risk Stratification
- Atrial Fibrillation Management
Background:
- The COOL-AF risk scores were developed in Thailand to predict death, bleeding, and thromboembolic events (TEs) in patients with atrial fibrillation (AF).
- External validation of these scores is crucial for their broader clinical application.
Purpose of the Study:
- To externally validate the COOL-AF risk scores using data from the Asia-Pacific Heart Rhythm Society (APHRS) registry.
- To compare the performance of COOL-AF scores against established scores like CHA₂DS₂-VASc and HAS-BLED in both APHRS and the European Society of Cardiology-European Heart Rhythm Association (ESC-EHRA) EORP-AF registry.
Main Methods:
- Analysis of 3,628 patients from the APHRS registry and 8,825 patients from the ESC-EHRA EORP-AF registry.
- Utilized Receiver Operating Characteristic (ROC) curves and Cox regression analyses to assess the predictive capabilities of the COOL-AF scores.
- Direct comparison of COOL-AF scores with CHA₂DS₂-VASc and HAS-BLED scores for predicting adverse outcomes.
Main Results:
- In the APHRS cohort, COOL-AF scores showed moderate-to-good predictive value for mortality (AUC: 0.77), major bleeding (AUC: 0.68), and TEs (AUC: 0.61), performing similarly to CHA₂DS₂-VASc and HAS-BLED.
- In the EORP-AF cohort, COOL-AF scores demonstrated modest predictive value for mortality (AUC: 0.68) and major bleeding (AUC: 0.61), which was lower than observed in the APHRS cohort.
- The predictive performance of the COOL-AF score for TEs in the EORP-AF cohort was inferior to that of the CHA₂DS₂-VASc score.
Conclusions:
- The COOL-AF risk scores may serve as a practical tool for identifying Asian patients with AF who are at risk of death and major bleeding.
- The study suggests that COOL-AF scores perform better in Asian populations compared to European populations with AF.
- Further validation and refinement of risk scores tailored to diverse ethnic populations are warranted for optimal AF management.
Background:
The COOL-AF (Cohort of Antithrombotic Use and Optimal International Normalized Ratio Levels in Patients with Atrial Fibrillation) risk scores for death, bleeding, and thromboembolic events (TEs) were derived from the COOL-AF cohort from Thailand and require external validation.
Objectives:
The authors sought to externally validate the COOL-AF scores in the APHRS (Asia-Pacific Heart Rhythm Society) registry and to compare their performance in the ESC-EHRA (European Society of Cardiology-European Heart Rhythm Association) EORP-AF (EURObservational Research Programme in Atrial Fibrillation) General Long-Term Registry.
Methods:
We studied 3,628 APHRS and 8,825 EORP-AF patients. Receiver operating characteristic (ROC) curves and Cox regression analyses were used to test the predictive value of COOL-AF scores and to compared them with the CHA2DS2-VASc and HAS-BLED scores.
Results:
Patients in the EORP-AF were older, had a higher prevalence of male sex, and were at higher thromboembolic and hemorrhagic risk than APHRS patients. After 1 year of follow-up in APHRS and EORP-AF, the following events were recorded: 87 (2.4%) and 435 (4.9%) death for any causes, 37 (1.0%) and 111 (1.3%) major bleeding, and 25 (0.7%) and 109 (1.2%) TEs, respectively. In APHRS, the COOL-AF scores showed moderate-to-good predictive value for all-cause mortality (area under the curve [AUC]: 0.77; 95% CI: 0.71-0.83), major bleeding (AUC: 0.68; 95% CI: 0.60-0.76), and TEs (AUC: 0.61; 95% CI: 0.51-0.71), and were similar to the CHA2DS2-VASc and HAS-BLED scores. In EORP-AF, the predictive value of COOL-AF for all-cause mortality (AUC: 0.68; 95% CI: 0.65-0.70) and major bleeding (AUC: 0.61; 95% CI: 0.60-0.62) was modest and lower than in APHRS. In EORP-AF, the COOL-AF score for TE was inferior to the CHA2DS2-VASc score.
Conclusions:
The COOL-AF risk scores may be an easy tool to identify Asian patients with AF at risk for death and major bleeding and performs better in Asian than in European patients with AF. (Clinical Survey on the Stroke Prevention in Atrial Fibrillation in Asia [AF-Registry]; NCT04807049).
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