ANTWERP score selects HF patients for AF ablation

The ANTWOORD II study successfully validated the ANTWERP score, which aims to identify patients with heart failure (HF) and atrial fibrillation (AF) who would benefit the most from ablation for AF. According to the authors, the results can be used to standardise shared decision-making in the clinic with regard to AF ablation.

The previously published ANTWOORD I study assessed the ANTWERP score, which predicts left ventricular ejection fraction (LVEF) recovery after ablation in patients with HF and AF, scoring patients who have 1 or more of the following 4 clinical and imaging parameters: known aetiology, wide QRS, severe atrial dilation, and paroxysmal AF [1]. A higher score is related to a greater likelihood of non-recovery, whereas a lower score is linked to a greater likelihood of recovery (AUC 0.93). The current ANTWOORD II study aimed to externally validate these results. The trial included 605 patients with HF and impaired LVEF (<50%) who were referred for AF ablation [2]. The primary endpoint was the number of responders at 1-year follow-up. A response was defined as an LVEF >40% and +10% in case of HF with reduced ejection fraction and an LVEF ≥50% in case of HF with midrange ejection fraction.

“Patients with a low score had a high percentage of LVEF recovery, and patients with a high score had a low percentage of LVEF recovery,” said Dr Marco Bergonti (Cardiocentro Ticino Institute, Switzerland). The corresponding AUC of the ANTWERP score was 0.859 (P<0.001). According to Dr Bergonti, the results were consistent across the LVEF spectrum and geographical regions. “The ANTWERP score identifies patients with HF who benefit the most from AF ablation,” said Dr Bergonti. Patients with a score <3 are estimated to have LVEF recovery in >90% of the cases and should receive early AF ablation. Those with a score >4 have a limited chance of responding (<20%) and physicians should look for alternative strategies to treat these patients. Finally, patients with a score of 3 or 4 have a recovery chance of approximately 50%. Further assessment is needed in these patients to decide which treatment strategy to apply.

1. 1. Bergonti M, et al. Int J Cardiol. 2022;358:45–50.
   2. Bergonti M, et al. Predicting LVEF-recovery after AF ablation in HF patients: The ANTWOORD II study. Late-Breaking Science – Today and Tomorrow, EHRA 2023, 16–18 April, Barcelona, Spain.

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