Elsevier

International Journal of Cardiology

Volume 249, 15 December 2017, Pages 191-197
International Journal of Cardiology

Adverse cardiovascular outcomes in atrial fibrillation: Validation of the new 2MACE risk score

https://doi.org/10.1016/j.ijcard.2017.09.154Get rights and content

Abstract

Background

In addition to thromboembolism, atrial fibrillation (AF) may also predispose to major adverse cardiovascular events (MACE) attributable to coronary artery disease (CAD), including myocardial infarction (MI). The 2MACE score (2 points - Metabolic syndrome and Age  75 years, 1 point - MI/revascularization, Congestive heart failure/ejection-fraction < 40%, and thrombo-Embolism) was recently proposed to help identify AF patients at risk of MACE. We assessed the predictive validity of the 2MACE score for MACE occurrence in AF patients free of CAD at baseline.

Methods

Non-valvular AF patients (n = 794) without CAD (mean-age, 62.5 ± 12.1 years, metabolic syndrome, 34.0%; heart failure/ejection-fraction < 40%, 25.7%; thromboembolism, 9.7%) were prospectively followed for 5 years, or until MACE (composite of non-fatal/fatal MI, revascularization and cardiovascular death). At inclusion, CAD was excluded by medical history, exercise-stress testing and/or coronary angiography. Also, the 2MACE score was determined.

Results

At follow-up, 112 patients experienced MACE (2.8%/year). The 2MACE score demonstrated adequate discrimination (C-statistic, 0.699; 95% confidence interval [CI], 0.648–0.750; P < 0.001) and calibration (Hosmer-Lemeshow P = 0.79) for MACE. The score was significantly associated with MACE, with the adjusted Hazard Ratio (aHR) of 1.56 (95%CI, 1.35–1.73; P < 0.001). As for individual outcomes, the score predicted MI (n = 46; aHR, 1.49; 95%CI 1.23–1.80), revascularization (n = 32; aHR, 1.41; 95%CI, 1.11–1.80) and cardiovascular death (n = 34; aHR, 1.43; 95%CI, 1.14–1.81), all P < 0.001.

Conclusions

The 2MACE score successfully predicts future MACE, including incident MI, coronary revascularization and cardiovascular death in AF patients free of CAD at baseline. It may have a role in risk-stratification and primary prevention of MACE in AF patients.

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.

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