Predicting atrial fibrillation recurrence after ablation in patients with heart failure: Validity of the APPLE and CAAP-AF risk scoring systems.

Abstract

Background

Compared with medical therapy, catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) improves cardiovascular outcomes. Risk scores (CAAP-AF and APPLE) have been developed to predict the likelihood of AF recurrence after ablation, have not been validated specifically in patients with AF and HF.

Methods

We analyzed baseline characteristics, risk scores, and rates of AF recurrence 12 months postablation in a cohort of 230 consecutive patients with AF and HF undergoing PVI in the Duke Center for Atrial Fibrillation registry from 2009-2013.

Results

During a follow-up period of 12 months, 76 of 230 (33%) patients with HF experienced recurrent AF after ablation. The median APPLE and CAAP-AF scores were 1.5 ([Q1, Q3]: [1.0, 2.0]) and 4.0 ([Q1, Q3]: [3.0, 5.0]), respectively and were not different from those patients with and without recurrent AF. Freedom from AF was not different according to APPLE and CAAP-AF scores. Discrimination for recurrent AF with the CAAP-AF score was modest with a C-statistic of 0.60 (95% CI 0.52-0.67). Discrimination with the APPLE score was similarly modest, with a C-statistic of 0.54 (95% CI: 0.47-0.62).

Conclusions

Validated predictive risk scores for recurrent AF after catheter ablation exhibit limited predictive ability in cohorts of AF and HF. Additional tools are needed to facilitate risk stratification and patient selection for AF ablation in patients with concomitant HF.

Department

Description

Provenance

Citation

Published Version (Please cite this version)

10.1111/pace.13805

Publication Info

Black-Maier, Eric, Alice Parish, Benjamin A Steinberg, Cynthia L Green, Zak Loring, Adam S Barnett, Sana M Al-Khatib, Brett D Atwater, et al. (2019). Predicting atrial fibrillation recurrence after ablation in patients with heart failure: Validity of the APPLE and CAAP-AF risk scoring systems. Pacing and clinical electrophysiology : PACE, 42(11). pp. 1440–1447. 10.1111/pace.13805 Retrieved from https://hdl.handle.net/10161/30483.

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.

Scholars@Duke

Parish

Alice Parish

Biostatistician III

Education: Master of Science in Public Health, Biostatistics-  Emory University Rollins School of Public Health.  

Overview: Alice collaborates with researchers and clinicians with the Division of Gastroenterology on many observational studies using data from EHR as well as large national databases such as HCUP, UNOS, and Medicare 5% LDS.  Additionally, Alice collaborates with the Division of Pulmonary on palliative care RCTs and various retrospective studies.  Alice works with the Pharmacy residents on their PGY1 studies.  In the past Alice has had the opportunity to work with investigators in Heart Center and Epicenter.  Alice has experience working with zero inflated count outcomes, among many other statistical methodologies.

Green

Cynthia Lea Green

Associate Professor of Biostatistics & Bioinformatics

Survival Analysis
Longitudinal Data Analysis
Logistic Regression
Missing Data
Clinical Trial Methods
Maximum Likelihood Methods

Loring

Zak Loring

Assistant Professor of Medicine

I am a cardiac electrophysiologist specializing in the treatment of heart rhythm disorders and management of cardiac implantable electronic devices (CIEDs). My research utilizes signal processing of electrocardiographic data and novel analytic techniques to better phenotype patients and identify those for whom interventional electrophysiology procedures may be most beneficial. This includes predicting which patients with left bundle branch block may benefit from early cardiac resynchronization therapy or conduction system pacing. I also analyze population level data to identify patients at high risk for adverse sequelae of rhythm disorders who may benefit from early intervention.

Al-Khatib

Sana Mustapha Al-Khatib

Professor of Medicine

Dr. Sana M. Al-Khatib is a tenured Professor of Medicine at Duke University Medical Center, a board-certified clinical electrophysiologist and an experienced clinical researcher in cardiac arrhythmias.  She is currently the Director of the Fellowship Program at the Duke Clinical Research Institute.  As a graduate of the NIH-funded Clinical Research Training Program, she is one of a few electrophysiologists nationwide with expertise in quantitative research methods. Her clinical expertise is in sudden cardiac death prevention, atrial fibrillation and ventricular arrhythmias, and implantable cardiac devices. Her research expertise lies in the design and conduct of clinical trials, outcomes research, and cost-effectiveness analyses. She is a recipient of a National Heart, Lung and Blood Institute’s R-01 grant titled “Implantable Cardioverter Defibrillator Therapy in Patients with Heart Failure” (2009-2013) and of an American Heart Association Career Development Award (2002-2006). She is a Co-Principal Investigator on an NHLBI-funded T-32 Postdoctoral Training in Cardiovascular Clinical Research and is a co-investigator on several NIH-funded projects. She has more than 350 publications in peer-reviewed journals. She has established several collaborative research efforts both within and outside her institution. The goals of these collaborations are to synergize efforts aimed at improving the survival and quality of life of patients at risk for sudden cardiac death and those with atrial and ventricular arrhythmias through clinical trials and outcomes-based research and to evaluate study design and data analysis in order to improve the quality of research done in these arenas. Dr. Al-Khatib is a Senior Associate Editor for Circulation and is on the Editorial Board for Circulation: Arrhythmia and Electrophysiology, Heart Rhythm, Journal of Cardiovascular Electrophysiology, JACC:EP, the Cardiovascular Digital Health Journal, and the American Heart Journal. Dr. Al-Khatib has served on multiple national committees including the Heart Rhythm Society Board of Trustees (current), the Heart Rhythm Society Finance Committee (current), the Heart Rhythm Society Audit Committee (current), the Heart Rhythm Society Health Policy committee (past), the Heart Rhythm Society Legislative subcommittee (past), and the Heart Rhythm Society Program Planning committee (past). She chaired the 2017 AHA/ACC/HRS Guideline for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. 

Daubert

James Patrick Daubert

Professor of Medicine

Atrial fibrillation ablation.
Cardiac resynchronization therapy.
Implantable defibrillator, including inappropriate shocks.
Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy
Hypertrophic cardiomyopathy.
Long QT syndrome
Sudden cardiac arrest and resuscitation.
Ventricular tachycardia

Frazier

Camille Genise Frazier

Professor of Medicine
Hegland

Donald Dale Hegland

Associate Professor of Medicine
Jackson

Kevin Patrick Jackson

Associate Professor of Medicine

Research interests include:
- optimization of device timing for Cardiac Resynchronzation Therapy (CRT)
- novel cardiac imaging technologies for CRT
- catheter ablation versus anti-arrhythmic drug for treatment of atrial fibrillation.

Jackson

Larry Ronald Jackson

Associate Professor of Medicine

Dr. Jackson is a physician-scientist with clinical expertise in adult clinical cardiac electrophysiology. His research focuses on identifying determinants of racial/ethnic differences in arrhythmia care and the development and implementation of patient-centered interventions aimed at facilitating shared decision-making in populations that have been systemically disadvantaged with abnormal heart rhythm conditions. Dr. Jackson has an advanced degree (MHSc) in clinical and qualitative research methodology and is a member of the Duke Clinical Research Institute. His research skills, obtained during his time at the Duke Clinical Research Institute Research Fellowship, include formal training in large database analysis, clinical trial operations, scientific writing, clinical trial adjudication and statistical analysis. Dr. Jackson’s research funding consists of two career development awards: 1) National Institute of Health/National Heart, Lung, and Blood Institute-K01 focused on racial and ethnic differences in oral anticoagulation use in patients with atrial fibrillation and 2) AHA career development award focused on analyzing racial and ethnic differences in the use of rhythm control strategies in patients with atrial fibrillation.  Dr. Jackson’s long-term, overarching goal as a physician-scientist is to decrease racial and ethnic disparities in arrhythmia care for patients with abnormal heart rhythm conditions.

Koontz

Jason Koontz

Associate Professor of Medicine

Robert Kenneth Lewis

Assistant Professor of Medicine
Pokorney

Sean Pokorney

Assistant Professor of Medicine
Sun

Albert Y. Sun

Associate Professor of Medicine
Thomas

Kevin Lindsey Thomas

Donald F. Fortin, M.D. Distinguished Professor of Cardiology
Bahnson

Tristram Dan Bahnson

Professor of Medicine
Piccini

Jonathan Paul Piccini

Professor of Medicine

Jonathan P. Piccini, MD, MHS, FACC, FAHA, FHRS is a clinical cardiac electrophysiologist and Professor of Medicine and Population Health at Duke University Hospital and the Duke Clinical Research Institute. He is the Director of the Cardiac Electrophysiology section at the Duke Heart Center. His focus is on the care of patients with atrial fibrillation and complex arrhythmias, with particular emphasis on catheter ablation, pacing, and lead extraction. His research interests include the development and evaluation of innovative cardiovascular interventions for the treatment of heart rhythm disorders. He serves on the Board of Trustees of the Heart Rhythm Society, is an Associate Editor at JACC: Clinical Electrophysiology, and is an elected member of the American Society for Clinical Investigation. Dr. Piccini has more than 600 publications in the field of heart rhythm medicine and has been the recipient of several teaching and mentorship awards.


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