Improving risk prediction for death, stroke, and bleeding in Asian patients with atrial fibrillation


The objectives of this study were to compare the GARFIELD Refitted model and CHA2 DS2 -VASc/HAS-BLED risk scores with the new model from the COOL-AF registry for all-cause death, ischemic stroke/systemic embolism (SSE) and major bleeding in Asian patients with atrial fibrillation (AF).


Patients with non-valvular AF in the nationwide COOL-AF registry were studied. Patients were enrolled from 27 hospitals in Thailand during 2014-2017. Main outcomes were all-cause mortality, SSE, and major bleeding. Predictive models of the 3 outcomes were developed from the variables in the multivariable Cox-proportional Hazard model. Predictive values of the models were evaluated by C-statistics, calibration plots, and Decision Curve Analysis (DCA). The new COOL-AF models were compared with the GARFIELD Refitted models and CHA2 DS2 -VASc model for all-cause mortality, SSE/HAS-BLED model for major bleeding.


A total of 3405 patients were enrolled. The C-statistics for the COOL-AF models were 0.727 (0.712-0.742), 0.708 (0.693-0.724), and 0.706 (0.690-0.721) for all-cause mortality, SSE, and major bleeding, respectively. Calibration plots showed good agreement between predicted probability the observed outcomes for the COOL-AF models with a calibration slope of 0.94-0.99. The predictive ability remains preserved after the internal validation with bootstraps and optimism (bias) correction. The COOL-AF predictive models tended to be superior to the GARFIELD Refitted, CHA2 DS2 -VASc and HAS-BLED models.


The COOL-AF predictive models for all-cause mortality, SSE, and major bleeding in Asian patients with AF had a good predictive ability. The COOL-AF model for all-cause mortality was superior to the GARFIELD Refitted and CHA2 DS2 -VASc model.


atrial fibrillation; ischemic stroke; major bleeding; mortality; predictive model.

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