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. doi: 10.1016/j.hrthm.2015.07.003. Epub 2015 Jul 2.


Background: Left atrial (LA) low-voltage areas (LVAs) are frequently observed in patients with atrial fibrillation (AF) and may predict AF recurrence after catheter ablation.

Objective: The aim of this study was to develop and validate a clinical tool to identify LVAs that are associated with AF recurrence after pulmonary vein isolation (PVI).

Methods: In a cohort of 238 patients, voltage maps were created during LA procedures. LVAs were defined as areas with electrogram amplitudes <0.5 mV. On the basis of regression analysis, predictors of LA substrate were identified. These parameters were used to establish a dedicated risk score (DR-FLASH score, based on diabetes mellitus, renal dysfunction, persistent form of AF, LA diameter >45 mm, age >65 years, female sex, and hypertension). This risk score was then prospectively validated in a multicenter cohort of 180 patients. The association of the score with long-term recurrence of atrial arrhythmias after circumferential PVI was tested in a retrospective cohort of 484 patients.

Results: The DR-FLASH score effectively identified LVA substrate (C statistic = 0.801, P < .001). In the prospective multicenter validation cohort, the predictive value of the DR-FLASH score was confirmed (C statistic = 0.767, P < .001). The probability for the presence of LA substrate increased by a factor of 2.2 (95% confidence interval [CI] 1.6-2.9, P < .001) with each point scored. Furthermore, the risk of AF recurrence after PVI increased by a factor of 1.3 (95% CI 1.1-1.5, P < .001) with every additional point and was almost 2 times higher in patients with a DR-FLASH score >3 (odds ratio 1.7, 95% CI 1.1-2.8, P = .026).

Conclusion: The DR-FLASH score may be useful to identify patients who may require extensive substrate modification instead of PVI alone.

Keywords: Ablation; Atrial fibrillation; Fibrosis; Outcome; Score.

Publication types

  • Comparative Study
  • Multicenter Study
  • Validation Study

MeSH terms

  • Action Potentials
  • Aged
  • Atrial Fibrillation / diagnosis*
  • Atrial Fibrillation / mortality
  • Atrial Fibrillation / surgery*
  • Body Surface Potential Mapping / methods*
  • Brugada Syndrome / diagnosis*
  • Brugada Syndrome / surgery
  • Cardiac Conduction System Disease
  • Catheter Ablation / methods*
  • Catheter Ablation / mortality
  • Cohort Studies
  • Electrophysiologic Techniques, Cardiac
  • Female
  • Follow-Up Studies
  • Heart Atria / physiopathology
  • Humans
  • Kaplan-Meier Estimate
  • Logistic Models
  • Male
  • Middle Aged
  • Predictive Value of Tests
  • ROC Curve
  • Retrospective Studies
  • Risk Assessment
  • Severity of Illness Index
  • Statistics, Nonparametric
  • Survival Rate
  • Treatment Outcome