Adverse cardiovascular outcomes in atrial fibrillation: Validation of the new 2MACE risk score
Introduction
Atrial fibrillation (AF) is an increasingly prevalent cardiac arrhythmia that affects over 33.5 million individuals worldwide [1], [2]. It imposes a significant burden of morbidity and mortality, primarily due to cerebral thromboembolism and heart failure (HF) [3], [4], [5]. Recent evidence indicates that patients with AF, who commonly harbor a constellation of cardiometabolic risk factors, may also have an independent increased risk of atherothrombotic complications, including myocardial infarction (MI). These complications have a critical impact on long-term prognosis [6], [7], [8], [9], [10]. Clinical trials report an annual rate of MI of 0.4% to 2.5% in AF patients [11], translating into a 47% increased risk of MI attributable to AF, as demonstrated in a meta-analysis of 12 studies including 169,306 patients [12]. Higher rates of cardiovascular events (up to 12.5%/year) have been reported in elderly AF patients, and in subjects with a history of vascular disease [13], [14], [15]. Although the rate of cardiovascular events appears to be lower (~ 0.3%/year) in “low-risk” AF patients, including individuals younger than 65 years without comorbidities, AF still confers an independent increased risk of MI and cardiovascular mortality [16], [17].
Recently, the 2MACE risk score (2 points for the Metabolic syndrome and Age ≥ 75 years, 1 point for MI/revascularization, Congestive HF/left-ventricular ejection fraction [LVEF] < 40%, and thrombo-Embolism) has been derived from clinical predictors of atherothrombotic complications in AF patients, and proposed as a tool to help identify patients at risk of major adverse cardiovascular events (MACE), including non-fatal or fatal MI, coronary revascularization and cardiovascular death [18]. Thus far, the score has been developed and validated only in cohorts of unselected elderly AF patients (mean age ~ 73–74 years), presenting with a considerable burden of cardiovascular risk factors and with a history of coronary artery disease (CAD) in ~ 25% of patients [18]. The aim of the present study was to assess whether the 2MACE risk score also accurately predicts the occurrence of MACE during prospective follow-up of AF patients without overt CAD at inclusion.
Section snippets
Study design and inclusion criteria
The study was designed as an observational cohort study recruiting consecutive patients with electrocardiographically documented non-valvular AF, treated either as in- or outpatients at the Department of Cardiology, Clinical Center of Serbia in Belgrade, Serbia. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in a priori approval by the local Ethics Committee. Informed consent was obtained from each patient.
The study flow chart is presented
Baseline characteristics of the study population
The study population comprised of 794 AF patients, free of CAD at baseline. Baseline characteristics are presented in Table 1. The mean age was 62.5 ± 12.1 years (range, 19–90 years) and 61% were male. The most prevalent comorbidities were hypertension (81.5%), mitral valve disease (29.7%, largely manifest as mild-to-moderate mitral regurgitation), diabetes mellitus (18.0%) and CKD (18.9%). Prior stroke/TIA and HF/LVEF < 40% were present in 9.7% and 25.7% of the patients, respectively. The metabolic
Discussion
The 2MACE risk score, featuring components readily assessable in routine clinical practice has been developed to specifically address the risk of atherothrombotic complications and cardiovascular death in the general population of AF patients [18]. The results of the present study demonstrate that the 2MACE score also predicts future MACE, including incident MI, coronary revascularization and cardiovascular death in AF patients free of CAD at baseline. To our knowledge, this the first study to
Conclusions
The results of the present study suggest that the 2MACE risk score could adequately predict future MACE, including the occurrence of the first MI, coronary revascularization and cardiovascular death in a contemporary, real-world cohort of AF patients free of CAD at baseline. Thus, the 2MACE score may offer the opportunity for early identification of patients at risk of serious cardiovascular events (e.g. those with a 2MACE score ≥ 3) who might benefit from interventions to prevent or postpone
Acknowledgments
The authors express their gratitude to the staff of the Department of Cardiology, Clinical Center of Serbia for their help in data acquisition.
Conflict of interest
The authors report no relationships that could be construed as a conflict of interest.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Authors' contributions
MP. DD. AV. M.V. I.M. M.A. M.O. and P.M.S. all significantly contributed to the conception and design of the study, acquisition, analysis and interpretation of data. MP drafted the article, while AJSC and PMS provided critical revision for important intellectual content. All authors approved the final version to be submitted.
References (50)
- et al.
Atrial fibrillation is associated with an increased risk for mortality and heart failure progression in patients with asymptomatic and symptomatic left ventricular systolic dysfunction: a retrospective analysis of the SOLVD trials. Studies of left ventricular dysfunction
J. Am. Coll. Cardiol.
(1998) - et al.
Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study
J. Am. Coll. Cardiol.
(2007) - et al.
Incidence of myocardial infarction and vascular death in elderly patients with atrial fibrillation taking anticoagulants: relation to atherosclerotic risk factors
Chest
(2015) - et al.
Coronary artery diseases in Japanese patients with nonvalvular atrial fibrillation
J. Cardiol.
(2014) - et al.
Atrial fibrillation is associated with an increased risk of myocardial infarction: insights from a meta-analysis
Atherosclerosis
(2016) - et al.
Prognosis of atrial fibrillation in patients with symptomatic peripheral arterial disease: data from the REduction of Atherothrombosis for Continued Health (REACH) Registry
Eur. J. Vasc. Endovasc. Surg.
(2010) - et al.
Acute myocardial infarction in patients with atrial fibrillation with a CHA2DS2-VASc score of 0 or 1: a nationwide cohort study
Heart Rhythm.
(2014) - et al.
Atrial fibrillation without comorbidities: prevalence, incidence and prognosis (from the Framingham Heart Study)
Am. Heart J.
(2016) - et al.
2014 ACC/AHA key data elements and definitions for cardiovascular endpoint events in clinical trials: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (writing committee to develop cardiovascular endpoints data standards)
J. Am. Coll. Cardiol.
(2015) Assessing the performance of the HAS-BLED score: is the C statistic sufficient
Chest
(2011)
Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial–Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial
Lancet
Warfarin treatment and risk of myocardial infarction - a cohort study of patients with atrial fibrillation treated in primary health care
Int. J. Cardiol.
Cardiovascular morbidity and mortality in hypertensive patients with a history of atrial fibrillation: the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study
J. Am. Coll. Cardiol.
Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the atherosclerosis risk in communities (ARIC) study
Am. Heart J.
Role of inflammation and oxidative stress in atrial fibrillation
Heart Rhythm.
Inflammation in atrial fibrillation
J. Am. Coll. Cardiol.
Acute onset human atrial fibrillation is associated with local cardiac platelet activation and endothelial dysfunction
J. Am. Coll. Cardiol.
Impaired flow mediated dilatation as evidence of endothelial dysfunction in chronic atrial fibrillation: relationship to plasma von Willebrand factor and soluble E-selectin levels
Thromb. Res.
Flow-mediated dilation is associated with cardiovascular events in non-valvular atrial fibrillation patients
Int. J. Cardiol.
Effect of atrial fibrillation on atrial thrombogenesis in humans: impact of rate and rhythm
J. Am. Coll. Cardiol.
Supply/demand type 2 myocardial infarction: should we be paying more attention
J. Am. Coll. Cardiol.
Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) study
JAMA
Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 study
Circulation
Heart failure in patients with atrial fibrillation in Europe: a report from the EURObservational Research Programme Pilot survey on Atrial Fibrillation
Eur. J. Heart Fail.
ATrial fibrillation and the risk of myocardial infarction
JAMA Intern. Med.
Cited by (23)
A novel prognostic tool to predict mortality in patients with atrial fibrillation: The BASIC-AF risk score
2021, Hellenic Journal of CardiologyThe Atrial fibrillation Better Care (ABC) pathway and cardiac complications in atrial fibrillation: a potential sex-based difference. The ATHERO-AF study
2021, European Journal of Internal MedicineCitation Excerpt :Second, we investigated if sex may be a risk-modifier in this association [14]. Third, we investigated a subgroup at high risk of MACE, as defined by the 2MACE score [15,16]. This prospective single-center cohort study included AF patients from the ATHERO-AF cohort, and the latter has been previously described [17].
Effects of Atrial Fibrillation and Chronic Kidney Disease on Major Adverse Cardiovascular Events
2020, American Journal of CardiologyCitation Excerpt :Overall, there is limited and conflicting evidence on the effects of CKD on MACE in patients with AF. Polovina et al demonstrated that there was a significantly greater prevalence of CKD among AF patients who suffered a MACE (26.8% vs 17.6% without MACE).19 In a large cohort study involving 77,752 AF patients with or at risk of atherosclerotic disease, the cumulative incidence of MACE at 4 years was 9.9%, occurring at a rate of 2.95 events/100 PYs.20
Atrial fibrillation and ischemic heart disease: beyond stroke prevention
2020, Revista Espanola de Cardiologia SuplementosUsing neural attention networks to detect adverse medical events from electronic health records
2018, Journal of Biomedical InformaticsCitation Excerpt :An Adverse Medical Event (AME), defined as a specific occurrence of one or more clinical problems (e.g., heart attack [1–4], death [5], bleeding [6], drug adverse reaction [7–10] and various clinical major adverse events [11,12]), which is either explicitly (e.g., ischemic events, bleeding events.)