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Randomized Controlled Trial
. 2022 Aug 16;11(16):e024916.
doi: 10.1161/JAHA.121.024916. Epub 2022 Aug 5.

DR-FLASH Score Is Useful for Identifying Patients With Persistent Atrial Fibrillation Who Require Extensive Catheter Ablation Procedures

Taiki Sato  1 , Yohei Sotomi  1 , Shungo Hikoso  1 , Daisaku Nakatani  1 , Hiroya Mizuno  1 , Katsuki Okada  1   2 , Tomoharu Dohi  1 , Tetsuhisa Kitamura  3 , Akihiro Sunaga  1 , Hirota Kida  1 , Bolrathanak Oeun  1 , Yasuyuki Egami  4 , Tetsuya Watanabe  5   6 , Hitoshi Minamiguchi  1   7 , Miwa Miyoshi  8 , Nobuaki Tanaka  9 , Takafumi Oka  1   9 , Masato Okada  9 , Takashi Kanda  10 , Yasuhiro Matsuda  10 , Masato Kawasaki  5 , Masaharu Masuda  10 , Koichi Inoue  9   11 , Yasushi Sakata  1 ; Osaka Cardio Vascular Conference (OCVC)‐Arrhythmia Investigators *
Collaborators, Affiliations
Randomized Controlled Trial

DR-FLASH Score Is Useful for Identifying Patients With Persistent Atrial Fibrillation Who Require Extensive Catheter Ablation Procedures

Taiki Sato et al. J Am Heart Assoc. .

Abstract

Background Modification of arrhythmogenic substrates with extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation (PVI-plus) can theoretically reduce the recurrence of atrial fibrillation. The DR-FLASH score (score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension) is reportedly useful for identifying patients with arrhythmogenic substrates. We hypothesized that, in patients with persistent atrial fibrillation, the DR-FLASH score can be used to classify patients into those who require PVI-plus and those for whom a PVI-only strategy is sufficient. Methods and Results This study is a post hoc subanalysis of the a multicenter, randomized controlled, noninferiority trial investigating efficacy and safety of pulmonary vein isolation alone for recurrence prevention compared with extensive ablation in patients with persistent atrial fibrillation (EARNEST-PVI trial). This analysis focuses on the relationship between DR-FLASH score and the efficacy of different ablation strategies. We divided the population into 2 groups based on a DR-FLASH score of 3 points. A total of 469 patients were analyzed. Among those with a DR-FLASH score >3 (N=279), the event rate of atrial arrhythmia recurrence was significantly lower in the PVI-plus arm than in the PVI-only arm (hazard ratio [HR], 0.45 [95% CI, 0.28-0.72]; P<0.001). In contrast, among patients with a DR-FLASH score ≤3 (N=217), no differences were observed in the event rate of atrial arrhythmia recurrence between the PVI-only arm and the PVI-plus arm (HR, 1.08 [95% CI, 0.61-1.89]; P=0.795). There was significant interaction between patients with a DR-FLASH score >3 and DR-FLASH score ≤3 (P value for interaction=0.020). Conclusions The DR-FLASH score is a useful tool for deciding the catheter ablation strategy for patients with persistent atrial fibrillation. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT03514693.

Keywords: DR‐FLASH score; catheter ablation; persistent atrial fibrillation; stratification.

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Figures

Figure 1
Figure 1. Patient tree.
PVI‐alone indicates pulmonary vein isolation only; and PVI‐plus, extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation. EARNEST‐PVI trial indicates a multicenter, randomized controlled, noninferiority trial investigating efficacy and safety of pulmonary vein isolation alone for recurrence prevention compared with extensive ablation in patients with persistent atrial fibrillation.
Figure 2
Figure 2. Kaplan‐Meier analysis with a log‐rank test for the primary end point in patients with a DR‐FLASH score >3 (left panel) and DR‐FLASH score ≤3 (right panel).
PVI‐alone indicates pulmonary vein isolation only; and PVI‐plus, extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation; DR‐FLASH, score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension.
Figure 3
Figure 3. Hazard ratio (HR) for the primary end point using a Cox proportional hazards model.
DR‐FLASH indicates score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension; PVI‐alone, pulmonary vein isolation only; and PVI‐plus, extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation.
Figure 4
Figure 4. Recurrence rate of atrial fibrillation, atrial flutter, and atrial tachycardia, according to procedures in patients with a DR‐FLASH score >3 (top panel) and DR‐FLASH score ≤3 (bottom panel).
Error bars showed SEs. ABL indicates ablation; CFAE, complex fractional atrial electrogram; DR‐FLASH score, score based on the presence of diabetes, renal dysfunction, persistent form of AF, left atrial diameter >45 mm, aged >65 years, female sex, and hypertension; PVI, pulmonary vein isolation; PVI‐alone, PVI only; and PVI‐plus, extensive ablation comprising linear and/or CFAE ablation in addition to PVI. *P<0.01 indicated significance level calculated with the Bonferroni method.
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