LVS-HARMED risk score for incident heart failure in patients with atrial fibrillation who present to the emergency department: Data from a world-wide registry

BACKGROUND: Heart failure (HF) is a common complication to atrial fibrillation (AF), leading to rehospitalization and death. Early identification of patients with AF at risk for HF might improve outcomes. We aimed to derive a score to predict 1-year risk of new-onset HF after an emergency department (ED) visit with AF. METHODS AND RESULTS: The RE-LY AF (Randomized Evaluation of Long-Term Anticoagulant Therapy) registry enrolled patients with AF presenting to an ED in 47 countries, and followed them for a year. The end point was HF hospitalization and/or HF death. Among 15 400 ED patients, 9765 had no prior HF (mean age, 64.9±14.9 years). Within 1 year, new-onset HF developed in 6.8% of patients, of whom 21% died of HF. Independent predictors of HF included left ventricular hypertrophy (odds ratio [OR], 1.47; 95% CI, 1.19–1.82), valvular heart disease (OR, 1.55; 95% CI, 1.18–2.04), smoking (OR, 1.42; 95% CI, 1.12–1.78), height (OR, 0.93; 95% CI, 0.90–0.95 per 3 cm), age (OR, 1.11; 95% CI, 1.07–1.15 per 5 years), rheumatic heart disease (OR, 1.77, 95% CI, 1.24–2.51), prior myocardial infarction (OR, 1.85; 95% CI, 1.45–2.36), remaining in AF at ED discharge (OR, 1.86; 95% CI, 1.46–2.36), and diabetes (OR, 1.33; 95% CI, 1.09–1.64). A continuous risk prediction score (LVS-HARMED [left ventricular, valvular heart disease, smoking or other tobacco use, height, age, rheumatic heart disease, myocardial infarction, emergency department discharge rhythm, and diabetes]) had good discrimination (C statistic, 0.735; 95% CI, 0.716–0.755). Validation was conducted internally using bootstrapping (optimism-corrected C statistic, 0.705) and externally (C statistic, 0.699). The 1-year incidence of HF hospitalization and/or HF death across quartile groups of the score was 1.1%, 4.5%, 6.9%, and 14.4%, respectively. LVS-HARMED also predicted incident stroke (C statistic, 0.753; 95% CI, 0.728–0.778). CONCLUSIONS: The LVS-HARMED score predicts new-onset HF after an ED visit for AF. Preventative strategies should be considered in patients with high LVS-HARMED HF risk.