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

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 486818 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 CHA(2)DS(2)VASc 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 CHA(2)DS(2)VASc; stroke 0.666 (95% CI = 0.663 to 0.669) versus 0.625 (95%CI = 0.622 to 0.628) for CHA(2)DS(2)VASc; 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 CHA(2)DS(2)VASc 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.