DR-FLASH score for arrhythmogenic left atrial substrate

DR-FLASH score for arrhythmogenic left atrial substrate

DR-FLASH score is based on diabetes mellitus, renal dysfunction, persistent form of AF (atrial fibrillation), LA (left atrial) diameter  above 45 mm, age above 65 years, female sex, and hypertension. It was developed as a clinical  for left atrial arrhythmogenic substrate based on voltage analysis [1]. Left atrial low voltage areas noted in patients with AF may predict recurrence after ablation, hence the need for the score. The probability for the presence of left atrial substrate requiring additional ablation other than the routine pulmonary vein isolation done for AF ablation, increased by a factor of 2.2 with each extra point in the score. Risk of recurrence after pulmonary vein isolation for AF was 2 times higher in those with a DR-FLASH score above 3.

APPLE score is another one which has been developed to predict left atrial low voltage areas. One point each is given for Age above 65 years, Persistent AF, imPaired eGFR below 60 mL/min/1.73 m², Left atrial diameter of 43 mm or more, Ejection fraction less than 50% [2].

MB-LATER score is yet another one for prediction of very late recurrence of atrial fibrillation (AF) occurring more than 12 months after catheter ablation [3]. Parameters assessed in the MB-LATER score were Male, Bundle brunch block, Left atrium ≥47 mm, Type of AF (paroxysmal, persistent or long-standing persistent), and ER-AF = early recurrent AF. Paroxysmal AF was given zero points, 1 point for persistent AF and 2 points for long-standing persistent AF. All other parameters were assigned 1 point each. Maximum points possible was 6. Recurrence of AF within the 3 month blanking period after ablation were classified as the early recurrence of AF.

Kornej J et al compared APPLE, DR-FLASH and MB-LATER scores to predict low voltage areas and arrythmia recurrence in AF patients undergoing first catheter ablation [4]. They calculated APPLE, DR-FLASH scores at baseline and MB-LATER at 3 months after ablation in AF patients undergoing first catheter ablation. Though all scores were significantly associated with recurrences, early recurrent AF was the most powerful predictor of later rhythm outcomes. Hence they concluded that a clinical score useful for prediction of both low voltage areas and rhythm outcomes in AF patients is a clinical unmet need.

References

1. Kosiuk J, Dinov B, Kornej J, Acou WJ, Schönbauer R, Fiedler L, Buchta P, Myrda K, Gąsior M, Poloński L, Kircher S, Arya A, Sommer P, Bollmann A, Hindricks G, Rolf S. Prospective, multicenter validation of a clinical risk score for left atrial arrhythmogenic substrate based on voltage analysis: DR-FLASH score. Heart Rhythm. 2015 Nov;12(11):2207-12.
2. Kornej J, Büttner P, Sommer P, Dagres N, Dinov B, Schumacher K, Bollmann A, Hindricks G. Prediction of electro-anatomical substrate using APPLE score and biomarkers. Europace. 2019 Jan 1;21(1):54-59.
3. Mujović N, Marinković M, Marković N, Shantsila A, Lip GY, Potpara TS. Prediction of very late arrhythmia recurrence after radiofrequency catheter ablation of atrial fibrillation: The MB-LATER clinical score. Sci Rep. 2017 Jan 20;7:40828. 
4. Kornej J, Schumacher K, Dinov B, Kosich F, Sommer P, Arya A, Husser D, Bollmann A, Lip GYH, Hindricks G. Prediction of electro-anatomical substrate and arrhythmia recurrences using APPLE, DR-FLASH and MB-LATER scores in patients with atrial fibrillation undergoing catheter ablation. Sci Rep. 2018 Aug 23;8(1):12686.