The role of HATCH score in predicting the success rate of sinus rhythm following electrical cardioversion of atrial fibrillation

Address for correspondence:

Sadık Volkan Emren, MD, Afyonkarahisar State Hospital, Department of Cardiology, Afyonkarahisar, Post code: 03000, Turkey, tel: 9005052644578, e-mail: vemren@hotmail.com

Received: 03.08.2015 Accepted: 10.03.2016 Available as AoP: 01.04.2016 Kardiologia Polska Copyright © Polskie Towarzystwo Kardiologiczne 2016

The role of HATCH score in predicting

the success rate of sinus rhythm following electrical cardioversion of atrial fibrillation

Sadik Volkan Emren

, Ug˘ur Kocabaş

, Hamza Duygu

, Fatih Levent

, Ersin Çag˘ri Şimşek

, Zeynep Yapan Emren

, Selcen Tülüce

1Department of Cardiology, Afyonkarahisar State Hospital, Afyonkarahisar, Turkey

2Department of Cardiology, Katip Celebi University Atatürk Training and Research Hospital, İzmir, Turkey

3Department of Cardiology, Near East University, Nicosia, Cyprus

4Department of Cardiology, Sandıklı State Hospital, Afyonkarahisar, Turkey

A b s t r a c t

Background: The HATCH score predicts the development of persistent and permanent atrial fibrillation (AF) one year after spontaneous or pharmacological conversion to sinus rhythm in patients with AF. However, it remains unknown whether HATCH score predicts short-term success of the procedure at early stages for patients who have undergone electrical cardioversion (EC) for AF.

Aim: The present study evaluated whether HATCH score predicts short-term success of EC in patients with AF.

Methods: The study included patients aged 18 years and over, who had undergone EC due to AF lasting less than 12 months, between December 2011 and October 2013. HATCH score was calculated for all patients. The acronym HATCH stands for Hypertension, Age (above 75 years), Transient ischaemic attack or stroke, Chronic obstructive pulmonary disease, and Heart failure. This scoring system awards two points for heart failure and transient ischaemic attack or stroke and one point for the remaining items.

Results: The study included 227 patients and short-term EC was successful in 163 of the cases. The mean HATCH scores of the patients who had undergone successful or unsuccessful EC were 1.3 ± 1.4 and 2.9 ± 1.4, respectively (p < 0.001). The area of the HATCH score under the curve in receiver operating characteristics analysis was (AUC) 0.792 (95% CI 0.727–0.857, p < 0.001). A HATCH score of two and above yielded 77% sensitivity, 62% specificity, 56% positive predictive value, and 87% negative predictive value in predicting unsuccessful cardioversion.

Conclusions: HATCH score is useful in predicting short-term success of EC at early stages for patients with AF, for whom the use of a rhythm-control strategy is planned.

Key words: HATCH score, cardioversion, atrial fibrillation

Kardiol Pol 2016; 74, 9: 978–984

INTRODUCTION

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia encountered in clinical practice [1]. AF can result in death, stroke, heart failure (HF), a decrease in exercise capacity, left ventricular dysfunction, and a decrease in the

quality of life of the patient [2, 3]. AF is therefore regarded as one of the major public health problems.

The selection of either rate or rhythm control therapies plays an important role together with the treatment of AF, as stated in the latest European Society of Cardiology guidelines

[4]. Even though there are efficient scoring systems for AF for thromboembolism and bleeding, there has not yet been a sim- ple, easy, and applicable scoring system that can be used to predict the success of electrical cardioversion (EC) in patients who had planned rhythm control therapy [5].

De Vos et al. [6] suggested the use of the HATCH scor- ing system in predicting the progression of AF. The acronym HATCH stands for Hypertension, Age (above 75 years), Transient ischaemic attack or stroke, Chronic obstructive pulmonary disease, and Heart failure. The HATCH score predicts the development of AF one year after restoration of sinus rhythm spontaneously or through pharmacological cardioversion [6]. The HATCH score is directly proportional to the persistence of AF over a one-year follow-up period.

However, it is unknown to what extent HATCH score pre- dicts the short-term success of EC performed to restore sinus rhythm. The present study investigated whether the HATCH score predicts short-term success of EC in patients with par- oxysmal and persistent AF.

METHODS

This retrospective consecutive study was designed for patients aged 18 and over, who had undergone EC due to paroxysmal and persistent AF between the dates of October 2011 and November 2013. Paroxysmal AF was defined as AF lasting up to 7 days. Persistent AF was defined as an AF episode lasting longer than 7 days or requiring termination by cardiover- sion. Patients with AF lasting more than 12 months were not evaluated. Also, patients using anti-arrhythmic drugs were not evaluated due to an important difference in the treatment process and the success of cardioversion between pharma- cological and electrical cardioversion.

Transoesophageal echocardiography was performed in patients who had AF more than 48 h before the EC process. EC was not applied to patients who had thrombus in the left atrium (LA) or left atrial appendage (LAA), and these patients were excluded from the study. A total of 351 patients were assessed. Forty-one of these patients had a history of AF lasting more than 12 months, 22 had thrombus in the LA or LAA, but the AF onset of 61 patients was not clearly known. Thus, these patients were excluded from the study, and a total of 227 patients were included in the study.

Electrical cardioversion

After providing patients with detailed information and obtain- ing their written consent for the procedure, EC was performed after 6–8 h of fasting under deep sedation. Heart rhythm, oxygen saturation, and blood pressure were monitored and all equipment necessary for cardiopulmonary resuscitation was made available before the procedure. The device paddles were placed in anterolateral position to deliver a maximum of 200 joules of energy using a biphasic device. EC was not performed in patients with digitalis intoxication, electrolyte

imbalance and those who had not received anticoagulant medications or appropriate sedation.

Patient data was retrieved from hospital records and the patients were then divided into two groups. After EC, the patients were followed with continuous electrocardiographic monitoring until hospital discharge. Those with regular sinus rhythm on electrocardiography at the one-week control were included in the successful cardioversion group whereas the remainder were included in the unsuccessful cardiover- sion group.

Patient age, gender, and past history of hypertension (HT), coronary artery disease (CAD), chronic kidney disease, diabetes, HF, pulmonary disease, valvular heart disease, liver disease, stroke, thyroid disease, and previous drug treatment were all obtained from the hospital records.

The HATCH score [Hypertension (1 point), Age above 75 years (1 point), Transient ischaemic attack or stroke (2 points), Chronic obstructive pulmonary disease (1 point), Heart failure (2 points)], CHA₂DS₂-VASc scores [Heart failure (1 point), Hypertension (1 point), Age (age range 65–75 years

— 1 point), Diabetes (1 point), Vascular disorder (1 point), Age above 75 years (2 points), Stroke (2 points)], and age, presence of Diabetes Mellitus (DM), Hypertension (HT), Chronic Heart Failure (CHF), Ejection Fraction (EF), LA diameter, obesity, Ob- structive Sleep Apnoea Syndrome (OSAS), pulmonary disease, valvular disease, congenital heart disease, hyperthyroidism, and drugs before the procedure (beta-blockers and calcium channel blockers) were all evaluated for their relationship to the short-term success of cardioversion.

Statistical analysis

Statistical analysis was performed using the SPSS (version 15.0, SPSS Inc., Chicago, Illinois) software package. Continu- ous variables were expressed as mean ± standard deviation, and categorical variables were expressed as percentage. The Kolmogorov-Smirnov test was performed to test whether vari- ables were normally distributed. Inter-group differences were evaluated using Student’s t-test for normally distributed con- tinuous variables and using Mann-Whitney U-test for variables that did not show normal distribution. Chi-square tests were used for the comparison of categorical variables. The accuracy of the HATCH and CHA₂DS₂-VASc scores in predicting the short-term success of cardioversion and threshold values were evaluated with the receiver operating characteristics (ROC) curve. Area under curve (AUC) of HATCH and CHA₂DS₂-VASc were compared with the DeLong, DeLong, Clarke-Pearson method using Analyse-it 2.20 statistical software (Leeds, United Kingdom). In order to identify independent factors in predicting unsuccessful EC, multivariate analysis (logistic regression) was applied for variables in univariate analysis with p values < 0.20. Odds ratio (OR) and 95% confidence interval (CI) were calculated with standard methods. Other clinical parameters significant in the univariate analysis were not

evaluated in logistic regression analysis since these variables were included in the HATCH score. A p value < 0.05 was considered statistically significant.

RESULTS

In this study, a total of 227 patients were evaluated. Most of the patients had persistent AF (164, 72%). The mean age of the patients was 60 ± 14 years. 163 of the patients had a short-term successful cardioversion process, whereas 64 had an unsuccessful cardioversion process. 41 (64%) of the patients had an unsuccessful cardioversion immediately (within 5 min), 16 (25%) and 7 (11%) of those had converted the AF within 24 h and 7 days, respectively, after EC. Basic clinical characteristics of the patients can be seen in Table 1. It was observed that elderly age of the patient (p < 0.001), HT

(p < 0.001), CHF (p < 0.001), chronic obstructive pulmonary disease (COPD; p < 0.001), and OSAS (p = 0.031) rate of the unsuccessful cardioversion group was higher compared to the rate of the successful cardioversion group. In addition, we observed that the EF of the unsuccessful group was lower (p < 0.05) and that they more frequently had a dilated LA (≥

40 mm) compared to the other group (p = 0.001). The two groups were comparable in terms of statin, and beta-blockers and calcium channel blocker use (p > 0.05). However, re- nin–angiotensin system blocker use was greater in patients with unsuccessful cardioversion (p < 0.05).

In logistic regression analysis, COPD (OR 14, 95% CI 3–57, p < 0.001), CHF (OR 8.4, 95% CI 2–34.8, p = 0.003), OSAS (OR 6.4, 95% CI 1.3–32.8, p = 0.025), valvular disease (OR 4.8, 95% CI 1.6–14.4, p = 0.005), HATCH score (OR Table 1. Baseline patient characteristics

Parameters Successful cardioversion

(n = 163)

Unsuccessful cardioversion (n = 64)

P

Age [years] 57 ± 14 68 ± 10 < 0.001

Women 61 ( 37%) 23 (36%) 0.655

Obesity (BMI ≥ 30 kg/m²) 40 (25%) 18 (28%) 0.577

AF duration (≤ 2 weeks) 49 (30%) 14 (22%) 0.215

AF duration (2 weeks – 3 months) 51 (31%) 24 (38%) 0.371

AF duration (3–12 months) 63 (39%) 24 (38%) 0.873

Paroxysmal AF 48 (29%) 15 (23%) 0.363

Persistent AF 115 (71%) 49 (77%) 0.363

Diabetes mellitus 36 (22%) 12 (19%) 0.770

Hypertension 68 (42%) 49 (77%) < 0.001

Coronary artery disease 46 (28%) 26 (41%) 0.071

Chronic heart failure 30 (18%) 34 (53%) < 0.001

Chronic obstructive pulmonary disease 12(7%) 19 (30%) < 0.001

Obstructive sleep apnoea syndrome 14 (9%) 12 (20%) 0.031

Valvular disease 23(14%) 14(21%) 0.154

Congenital heart disease 15 (9%) 4 (6%) 0.470

Hyperthyroidism 9 (6%) 4(6%) 0.832

Stroke 6 (4%) 5 (8%) 0.192

Ejection fraction 51 ± 14 46 ± 13 0.005

Ejection fraction (< 50%) 47 (29%) 40 (63%) < 0.001

Left atrial diameter (≥ 40 mm) 71 (44%) 44 (69%) 0.001

Beta-blockers 68 (42%) 34(53%) 0.120

Calcium channel blockers 23 (14%) 12 (19%) 0.384

RAS blockers 57 (35%) 36 (56%) 0.003

Statin 63 (39%) 33 (52%) 0.076

HATCH 1.3 ± 1.4 2.9 ± 1.4 < 0.001

CHA₂DS₂-VASc 1.7 ± 1.5 3.1 ± 1.1 < 0.001

AF — atrial fibrillation, BMI — body mass index, CHA₂DS₂-VASc — Heart failure (1 point), Hypertension (1 point), Age (age range 65–75 years — 1 point), Diabetes (1 point), Vascular disorder (1 point), Age above 75 years (2 points), Stroke (2 points), HATCH — Hypertension, Age (> 75 years), Transient ischaemic attack or stroke (2 points), Chronic obstructive pulmonary disease, Heart failure (2 points); RAS — renin–angiotensin system

2.6, 95% CI 1.6–4.3, p < 0.001), LA diameter (OR 1.2, 95%

CI 1.1–1.3, p = 0.005), EF (OR 1.13, 95% CI 1.07–1.20, p < 0.001) and age (OR 1.06, 95% CI 1.01–1.11, p = 0.010) remained as independent predictors of unsuccessful EC.

CHA₂DS₂-VASc (3.2 ± 1 vs. 1.7 ± 1.5, p < 0.001) and HATCH scores (2.9 ± 1.4 vs. 1.3 ± 1.4, p < 0.001) of patients who had unsuccessful EC were higher com- pared to patients who had successful EC. The area of the HATCH score AUC in the ROC analysis was 0.792 (95% CI 0.727–0.857, p < 0.001), and the AUC of the DS₂-VASc score was 0.781 (95% CI 0.720–0.841, p < 0.001) (Fig. 1).

The AUC of the HATCH score was not different from that of the CHA₂DS₂-VASc score (difference: 0.011-0.028-0.051, p = 0.57). When the HATCH score was two or greater as a threshold, it was found that the EC was unsuccessful, with 77% sensitivity, 62% specificity, 56% positive predictive value, and 87% negative predictive value. When the CHA₂DS₂-VASc score was three or greater as a threshold, EC was unsuccessful with 75% sensitivity, 71% specificity, 51% positive predictive value, and 88% negative predictive value.

DISCUSSION

This is the first study to evaluate HATCH score in predicting the short-term success of EC in patients with AF. According to the results of the current study, patients who underwent unsuccessful EC had significantly higher HATCH scores.

In previous studies, it has been stated that clinical parameters such as antiarrhythmic medication, valvular disease, statin, beta-blocker, and angiotensin converting enzyme/angiotensin receptor blocker (ACE/ARB) use before

cardioversion, LA dilatation, pulmonary disease, cardiomyo- pathy, HT, body weight, duration of AF, and OSAS can be indicative for the success of cardioversion [7–18]. However, in this study only COPD, CHF, OSAS, valvular disease, HATCH score, LA diameter, EF, and age remained as inde- pendent predictors of unsuccessful EC. One of the reasons for these differences is that the use of statin, beta-blocker, and ACE/ARB was below the expectations of guidelines, which might have masked the protective effect of those drugs against AF. The other reason for these differences is that these risk factors were obtained from different stud- ies, and also the onset time of AF, patient characteristics, evaluated clinical parameters, and criteria for EC success varied in these studies. Therefore, it is not possible to reach a firm conclusion about the actual predictive parameters and to determine a clear method for predicting the success of cardioversion. The HATCH score is an easy, simple, and practical scoring system that includes clinical variables that have been separately shown in previous studies to be risk factors for the failure of EC. Hypertension, age, pulmonary disease, HF, and ischaemic cerebrovascular diseases are the clinical parameters constituting the HATCH score. These underlying diseases might cause chronic stretch and atrial dilation, which appear to be important stimuli for chronic atrial structural remodelling (cellular hypertrophy, fibroblast proliferation, and tissue fibrosis) that causes unsuccessful cardioversion and maintenance of AF [19].

In the study by de Vos et al. [6], independent variables that could predict the development of persistent and permanent AF within a follow-up period of one year were evaluated in patients with paroxysmal AF, and they found the HATCH score to be the most significant parameter. A score of 2–4 points was considered to indicate moderate risk, and a HATCH score of five or more points was considered to indicate high risk for the development of persistent AF [6]. The HATCH score was also investigated in other studies for progression of paroxysmal to persistent AF and was found to be useful in the study carried out by Jahangir and Murarka [20] and modestly useful in studies performed by Potpara et al. [21] and Barret et al. [22]. The HATCH score was also evaluated for predicting the recurrence of AF after catheter ablation in studies carried out by Tang et al. [23], in which the score proved not to be useful. Miao et al. [24] and Schmidt et al. [25] demonstrated that with higher HATCH scores, AF recurrences after catheter ablation were more frequent. In the present study, we aimed to investigate the HATCH score in the short-term for predicting the success of cardioversion and found that when a HATCH score was two or more as a threshold, the EC was unsuccessful, with 77% sensitivity, 62% specificity, 56% positive predictive value, and 87% negative predictive value in predicting unsuc- cessful cardioversion. The results of this study revealed that HATCH score was not inferior to the CHA₂DS₂-VASc score.

Despite including similar parameters, the HATCH score has Figure 1. The predictive values of CHA₂DS₂-VASc and HATCH

score determined using receiver operating characteristics (ROC) curve analysis

1.0

0.8

0.6

0.4

0.2

0.00,0 0,2 0,4 0,6 0,8 1,0

Sensitivity

1 - Specificity ROC curve

CHA DS -VASc_{2 2} HATCH

Reference line

Diagonal segments are produced by ties

some differences from the CHA₂DS₂-VASc score. The HATCH score includes older patients (age > 75 years) compared to the CHA₂DS₂-VASc score (age > 65 years). In addition, un- like the CHA₂DS₂-VASc score, the HATCH score gives more importance to HF and COPD. The HATCH score includes COPD whereas the CHA₂DS₂-VASc score does not. Also, in the HATCH score two points are appointed to HF, whereas only one point is appointed to HF in the CHA₂DS₂-VASc score. Heart failure (OR 8.4, 95% CI 2–34.8, p = 0.003) and COPD (OR 14, 95% CI 3–57, p < 0.001) are the two most important variables predicting EC success in this study. Thus, we believe that these two parameters determine the success of HATCH score.

In the current retrospective study, the majority of patients in the study, who had scheduled EC directly before trying pharmacological cardioversion, had persistent AF. This may be due to the cumbersomeness and lower effectiveness of pharmacological cardioversion in patients with persistent AF. To some extent the study shows the real power of EC, without the influence of antiarrhythmic drugs. EC restored sinus rhythm in the vast majority of patients (72%), which is in accordance with earlier studies. The reason for this was that patients who were selected for EC were already expected to respond to the procedure. Despite this selection bias, the HATCH score was significantly different between patients who responded versus those who failed to respond to the cardioversion attempt.

The selection of rhythm-control versus rate-control strate- gies is of particular importance in patients with AF. However, there are no established rules determining which strategy would be more appropriate for each patient. Rhythm versus rate control strategies should be individualised. Therefore, some additional data should be required for the selection of the appropriate means of therapy. In this context, calculation of the HATCH score can be efficiently used to predict patients who would fail to respond to cardioversion attempts. This strategy would reduce the number of patients who would otherwise be redundantly exposed to unsuccessful EC at- tempts. Also, antiarrhythmic therapy can be initiated before EC in patients with high HATCH score, in whom the cardio- version process is likely to be unsuccessful.

Limitations of the study

Before cardioversion, most of the patients were selected based on the physician’s clinical decision and were expected to convert to normal sinus rhythm. Also, most of the patients in this study had persistent AF and had undergone EC directly without pharmacological cardioversion. Therefore, the pos- sibility of selection bias could not be ruled out. Patients who developed AF episodes in the short-term period following EC might have been mistakenly included in the group of patients with successful EC due to lack of continuous electrocardiog- raphy monitoring. In addition, this study only evaluated the

short-term success of cardioversion; long-term AF recurrence rates were not taken into account.

CONCLUSIONS

The HATCH score is higher in patients who fail to respond to cardioversion attempts. Also, HATCH score predicts the suc- cess of EC at early stages. This scoring system can therefore be helpful in patients with AF before deciding on rhythm or rate control strategies.

Acknowledgements

This study was conducted in the Department of Cardiology, Katip Celebi University Atatürk Training and Research Hos- pital, İzmir, Turkey. This paper was already presented at the 30^th Turkish Cardio logy Congress.

Conflict of interest: none declared References

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Cite this article as: Emren SV, Kocabaş U, Duygu H et al. The role of HATCH score in predicting the success rate of sinus rhythm following electrical cardioversion of atrial fibrillation. Kardiol Pol, 2016; 74: 978–984. doi: 10.5603/KP.a2016.0044.

Adres do korespondencji:

Sadık Volkan Emren, MD, Afyonkarahisar State Hospital, Department of Cardiology, Afyonkarahisar, Turkey, Post code: 03000, tel: 9005052644578, e-mail: vemren@hotmail.com

Praca wpłynęła: 03.08.2015 r. Zaakceptowana do druku: 10.03.2016 r. Data publikacji AoP: 01.04.2016 r.

skutecznego powrotu do rytmu zatokowego po kardiowersji elektrycznej z powodu

migotania przedsionków

Sadik Volkan Emren

, Ug˘ur Kocabaş

, Hamza Duygu

, Fatih Levent

, Ersin Çag˘ri Şimşek

, Zeynep Yapan Emren

, Selcen Tülüce

1Department of Cardiology, Afyonkarahisar State Hospital, Afyonkarahisar, Turcja

2Department of Cardiology, Katip Celebi University Atatürk Training and Research Hospital, İzmir, Turcja

3Department of Cardiology, Near East University, Nicosia, Cypr

4Department of Cardiology, Sandıklı State Hospital, Afyonkarahisar, Turcja

S t r e s z c z e n i e

Wstęp: Skala HATCH umożliwia prognozowanie rozwoju przetrwałego i utrwalonego migotania przedsionków (AF) w ciągu roku po samoistnym lub spowodowanym leczeniem powrocie do rytmu zatokowego u chorych z AF. Nie wiadomo jednak, czy wskaźnik HATCH jest przydatny w określaniu prawdopodobieństwa powodzenia zabiegu w perspektywie krótkoterminowej we wczesnym stadium u pacjentów, których poddano kardiowersji elektrycznej (EC) z powodu AF.

Cel: Celem pracy była ocena, czy wskaźnik HATCH umożliwia prognozowanie wczesnego powodzenia EC u chorych z AF.

Metody: Do badania włączono chorych w wieku 18 i starszych, których w okresie od grudnia 2011 r. do października 2013 r.

poddano EC z powodu AF występującego krócej niż 12 miesięcy. U wszystkich chorych obliczono wskaźnik HATCH. Akronim HATCH oznacza Hypertension (nadciśnienie tętnicze), Age (wiek, powyżej 75 lat), Transient ischaemic attack or stroke (przemi- jające niedokrwienie mózgu lub udar mózgu), Chronic obstructive pulmonary disease (przewlekła obturacyjna choroba płuc) i Heart failure (niewydolność serca). W tej skali niewydolność serca i przemijające niedokrwienie mózgu lub udar oznaczają 2 punkty, natomiast obecność każdego z pozostałych elementów — 1 punkt.

Wyniki: W badaniu uczestniczyło 227 chorych. W przypadku 163 z nich odnotowano powodzenie EC we wczesnym okresie po zabiegu. Średnie wartości w skali HATCH u chorych, u których przeprowadzono skuteczną i nieskuteczną EC, wynosiły odpowiednio 1,3 ± 1,4 i 2,9 ± 1,4 (p < 0,001). Pole pod krzywą (AUC) wskaźnika HATCH w analizie krzywych ROC wynosiło 0,792 (95% CI 0,727–0,857; p < 0,001). Wskaźnik HATCH ≥ 2 pozwalał na prognozowanie niepowodzenia kardiowersji, przy czym czułość tego parametru wynosiła 77%, swoistość — 62%, wartość predykcyjna dodatnia — 56%, a wartość predykcyjna ujemna — 87%.

Wnioski: Skala HATCH jest przydatna w prognozowaniu szans powodzenia EC we wczesnym okresie po zabiegu u chorych z AF, u których planuje się zastosowanie strategii kontroli rytmu serca.

Słowa kluczowe: skala HATCH, kardiowersja, migotanie przedsionków

Kardiol Pol 2016; 74, 9: 978–984