cardiology papercut lit review

GARFIELD-AF Risk Score for Mortality Stroke and Bleeding

May 16, 2024

The GARFIELD-AF tool allows a single calculation for mortality, stroke and bleeding and can assist in risk/benefit decision-making.

The GARFIELD-AF(Global Anticoagulant Registry in the FIELD–Atrial Fibrillation) Risk Stratification Tool was derived from prospective data from the GARFIELD-AF registry of 52032 patients over 2 years. The aim was:

To derive and validate a new risk model for predicting mortality, nonhaemorrhagic stroke/SE, and major bleeding up to 2 years after enrolment based on treatment selection.
To include the feature of treatment selection in GARFIELD-AF risk calculator to assist clinicians in applying guideline adherence to anticoagulation decisions for patients with AF

What They did

Comparisons of the performance of the new GARFIELD-AF risk models were made with the CHA2DS2-VASc score and HAS-BLED score. The validity of the risk models was tested externally in patients with AF from an independent US-based registry, the ORBIT-AF registry and Danish nat...

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The GARFIELD-AF tool allows a single calculation for mortality, stroke and bleeding and can assist in risk/benefit decision-making.

To derive and validate a new risk model for predicting mortality, nonhaemorrhagic stroke/SE, and major bleeding up to 2 years after enrolment based on treatment selection.
To include the feature of treatment selection in GARFIELD-AF risk calculator to assist clinicians in applying guideline adherence to anticoagulation decisions for patients with AF

What They did

Patient characteristics included:

Median age 71 years
AF Type:
- New onset AF (44.8%)
- Paroxysmal AF (27.5%)
- Permanent or Persisten AF (27.6%)- Not the patients we would be treating in the emergency department
Emergency Department Patients 10.7%- most patients were hospital patients (58.3%)
Treatment Type
- NOAC + antiplatelet (27.5%)
  - "NOAC use was associated with lower risk of all-cause mortality, non-haemorrhagic stroke/SE, and major bleeding when compared with VKA"
- VKA + anti platelet (39.3%)
- Antiplatelet only (21%)
- None (12.2%)
CHA2DS2-VASc Score Median 3.0
HAS-BLED score median 1.0

What They Found

At 2 years the mortality risks are 3.8 x greater than risks of stroke embolism and major bleeding.

The GARFIELD-AF risk model was superior for the prediction of mortality, non-hemorrhagic stroke, embolism and major bleeding in patients with AF over 2 years.

The predictors of increased mortality , non-haemorrhagic stroke, embolism and major bleeding were found to be:

Age
prior stroke
vascular disease
diabetes
Chronic kidney disease
History of bleeding

The GARFIED-AF tool can be applied to patients with atrial fibrillation who are believed to be at higher risk of stroke.

Let's Look at some Case studies

CASE 1

72 yo female , Weight: 60 kg; BP: 142/86 (treated for hypertension); Pulse: 147 bpm; Early dementia; Renal dysfunction CrCl 50 mL/min (moderate to severe)

This patient scores are:
CHA2DS2-VASc Score of 3 and HAS-BLED score of 2

The GARFIED-AF Score

If we look at this patients 90 day outcomes(below), her mortality without anticoagulation is much higher than her risk of a bleed.

At 2 years her mortality decreases significantly on a NOAC and her bleeding risk, although slightly higher than on no anticoagulants, certainly balances in favour of anticoagulation.

CASE 2

A 61 yo male with weight of 135kg and history of hypertension(controlled) BP of 133/68, pulse rate 157 and no other history.

This patient has a CHA2DS2-VASc Score of 1 and HAS-BLED score of 0

According to the CHA2DS2-VASc, he would be anti coagulated. With a HASBLED Score of 0 his risks of a bleed are Low.

CASE 3

This case is of the same patient as in case 2 above , but with no hypertension history (BP 128/43). The CHA2DS2-VASc is 0. However the patient is in rapid atrial fibrillation.

My question is, would there be any harm in anticoagulation this patient for 30 days, post cardioversion, when he is at the risk of stroke? Here is the GARFIELD-AF result.

It shows that the risk of bleeding in 30 days is lower than the risk of mortality. The risk of mortality is lowest in the NOAC treatment arm.

My Take on This

Although this Tool was not exclusively determined for the emergency department, it looked at all types of AF and at patients that were anti coagulated and that were not.

The benefit of this tool is that it allows us in one calculation to look at the risks of the disease as awell as the risks of the treatment and potentially make batter decisions.

Although it is useful in the lower risk group of patient, it is of even greater use in this patients that have a higher CHA2DS2-VASc score and a high HAS-BLED score, that may see the patient not being anti coagulated. The GARFIELD-AF risk tool may show that the risk of death or stroke is lower in those patients anti coagulated with a DOAC.

Reference

Keith A A. et al. GARFIELD-AF risk score for mortality, stroke, and bleeding within 2 years in patients with atrial fibrillation. Europ Heart Jour - Quality of Care and Clinical Outcomes (2022) 8, 214–227