Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Oct 26;73(736):e816-e824.
doi: 10.3399/BJGP.2023.0082. Print 2023 Nov.

Optimising prediction of mortality, stroke, and major bleeding for patients with atrial fibrillation: validation of the GARFIELD-AF tool in UK primary care electronic records

Patricia N Apenteng  1 , David Prieto-Merino  2 , Siew Wan Hee  3 , Trudie Ca Lobban  4 , Rishi Caleyachetty  3 , David A Fitzmaurice  3
Affiliations

Optimising prediction of mortality, stroke, and major bleeding for patients with atrial fibrillation: validation of the GARFIELD-AF tool in UK primary care electronic records

Patricia N Apenteng et al. Br J Gen Pract. .

Abstract

Background: The GARFIELD-AF tool is a novel risk tool that simultaneously assesses the risk of all-cause mortality, stroke or systemic embolism, and major bleeding in patients with atrial fibrillation (AF).

Aim: To validate the GARFIELD-AF tool using UK primary care electronic records.

Design and setting: A retrospective cohort study using the Clinical Practice Research Datalink (CPRD) linked with Hospital Episode Statistics data and Office for National Statistics mortality data.

Method: Discrimination was evaluated using the area under the curve (AUC) and calibration was evaluated using calibration-in-the-large regression and calibration plots.

Results: A total of 486 818 patients aged ≥18 years with incident diagnosis of non-valvular AF between 2 January 1998 and 31 July 2020 were included; 50.6% (n = 246 425/486 818) received anticoagulation at diagnosis The GARFIELD- AF models outperformed the CHA2DS2VASc and HAS-BLED scores in discrimination ability of death, stroke, and major bleeding at all the time points. The AUC for events at 1 year for the 2017 models were: death 0.747 (95% confidence interval [CI] = 0.744 to 0.751) versus 0.635 (95% CI = 0.631 to 0.639) for CHA2DS2VASc; stroke 0.666 (95% CI = 0.663 to 0.669) versus 0.625 (95% CI = 0.622 to 0.628) for CHA2DS2VASc; and major bleeding 0.602 (95% CI = 0.598 to 0.606) versus 0.558 (95% CI = 0.554 to 0.562) for HAS- BLED. Calibration between predicted and Kaplan- Meier observed events was inadequate with the GARFIELD-AF models.

Conclusion: The GARFIELD-AF models were superior to the CHA2DS2VASc score for discriminating stroke and death and superior to the HAS-BLED score for discriminating major bleeding. The models consistently underpredicted the level of risk, suggesting that a recalibration is needed to optimise its use in the UK population.

Keywords: all-cause mortality; anticoagulation; atrial fibrillation; bleeding; risk stratification; stroke.

PubMed Disclaimer

Conflict of interest statement

The authors have declared no competing interests.

Figures

Figure 1.
Figure 1.
Flowchart of derivation of CPRD cohort. AF = atrial fibrillation. CPRD = Clinical Practice Research Datalink.
Figure 2.
Figure 2.
Predicted versus Kaplan–Meier risk of the GARFIELD-AF models. f = full. m = month.
Figure 3.
Figure 3.
Calibration plots for death, stroke, and bleeding outcomes by quantiles of predicted risk. KM = Kaplan—Meier.
See this image and copyright information in PMC

References

    1. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: analysis of pooted data from five randomized controlled trials. Arch Intern Med. 1994;154(13):1449–1457. - PubMed
    1. Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373–498. - PubMed
    1. National Institute for Health and Care Excellence Atrial fibrillation: diagnosis and management. NG196. 2021 https://www.nice.org.uk/guidance/ng196 (accessed 5 Oct 2023). - PubMed
    1. NHS Digital Quality and Outcomes Framework, achievement, prevalence and exceptions data 2018–19 [PAS] 2019. https://digital.nhs.uk/data-and-information/publications/statistical/qua... (accessed 5 Oct 2023).
    1. Fox KA, Lucas JE, Pieper KS, et al. Improved risk stratification of patients with atrial fibrillation: an integrated GARFIELD-AF tool for the prediction of mortality, stroke and bleed in patients with and without anticoagulation. BMJ Open. 2017;7(12):e017157. - PMC - PubMed