GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study.

OBJECTIVES: To externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort. DESIGN: Retrospective cohort study. SETTING: Danish nationwide registries. PARTICIPANTS: 90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year. PRIMARY AND SECONDARY OUTCOME MEASURES: External validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes. RESULTS: Of the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66-83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60). CONCLUSION: In a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding

Clinical and echocardiographic response of apical vs nonapical right ventricular lead position in CRT: A meta‐analysis

BACKGROUND: Traditionally the right ventricular (RV) pacing lead is placed in the RV apex in cardiac resynchronization therapy (CRT). It is not clear whether nonapical placement of the RV lead is associated with a better response to CRT. We aimed to perform a meta-analysis of all randomized controlled trials (RCTs) that compared apical and nonapical RV lead placement in CRT. METHODS: We searched PubMed, EMBASE, Cochrane, Scopus, and relevant references for studies and performed meta-analysis using random effects model. Our main outcome measures were all-cause mortality, composite of death and heart failure hospitalization, improvement in ejection fraction (EF), left ventricle end-diastolic volume (LVEDV), left ventricle end-systolic volume (LVESV), and adverse events. RESULTS: Seven RCTs with a total population of 1641 patients (1199 apical and 492 nonapical) were included in our meta-analysis. There was no difference in all-cause mortality (5% vs 4.3%, odds ratio (OR) = 0.86; 95% confidence interval (CI) 0.45-1.64; =.65; = 11%) and a composite of death and heart failure hospitalization (14.2% vs 12.9%, OR= 0.92; 95% CI: 0.61-1.38; .68; = 0) between apical and nonapical groups. No difference in improvement in EF (Weighted mean difference (WMD)= 0.37; 95% CI: -2.75-3.48; .82; = 68%), change in LVEDV (WMD= 3.67; 95% CI: -4.86-12.20; =.40; = 89%) and LVESV (WMD= -1.20; 95% CI: -4.32-1.91; =.45; = 0) were noted between apical and nonapical groups. Proportion of patients achieving \u3e15% improvement in EF was similar in both groups (OR= 0.85; 95% CI: 0.62-1.16; =.31; = 0). CONCLUSION: In patients with CRT, nonapical RV pacing is not associated with improved clinical and echocardiographic outcomes compared with RV apical pacing