4-Item HART Scoring System to Assess for AF Risk After Noncardiac Surgery

Investigators evaluated independent predictors of postoperative AF in noncardiac surgery and assessed the accuracy of a score for risk predication in the clinical setting.

A 4-item screening tool, the HART scoring system, was derived and validated for the screening of postoperative atrial fibrillation (POAF). These findings were published in The American Journal of Cardiology.

Patients (N=2048) attending a preoperative cardiological assessment before noncardiac elective  surgery between 2016 and 2019 at the University Hospital Umberto I-Lancisi-Salesi in Italy were prospectively enrolled in a database. For this study, patient information was retrospectively reviewed for potential predictors of POAF and a screening tool was created. The tool was internally validated using a bootstrapping approach.

Patients were aged mean 71.9±12.2 years, 66% were men, BMI was 23.5±5.4, 75% had hypertension, 11% had thyroid dysfunction, and 21% were at high surgical risk. The most common types of surgical interventions included vascular (26.3%), urology (16.0%), general (14.0%), oral and maxillofacial (10.5%), thoracic (9.0%), hepatic (5.9%), and orthopedic (5.9%), among others.

The patients who developed POAF (n=44) at a median of 3 days after surgery were older (P <.001) and had lower BMI (P =.041), and more had hypertension (P =.005), thyroid disfunction (P =.012), and high surgical risk (P <.001). The highest rate of POAF was observed for vascular surgery (9.0%) and neurosurgery (4.5%).

Predictors of POAF were intermediate or high surgical risk (odds ratio [OR], 18.28; 95% CI, 2.51-33.09; P =.004), hypertension (OR, 3.43; 95% CI, 1.12-9.63; P =.033), thyroid dysfunction (OR, 2.47; 95% CI, 1.22-5.01; P =.012), and age (OR, 1.03; 95% CI, 1.01-1.07 per year; P =.023).

On the basis of these associations, the investigators developed the HART scoring system, in which 1 point is awarded for hypertension (OR, 3.4; 95% CI, 1.1-9.6), 1 point for age 65-74 years (OR, 3.8; 95% CI, 1.2-5.8) or 2 points for age 75 years or older (OR, 6.1; 95% CI, 1.8-13.9), 3 points for intermediate (OR, 9.0; 95% CI, 2.1-18.8) or high (OR, 10.2; 95% CI, 2.7-33.9) surgical risk status, and 1 point for thyroid dysfunction (OR, 2.5; 95% CI, 1.2-5.0).

The event rates among this population were 10.4%, 4.8%, 1.1%, 2.3%, and 0.3% for HART scores of 7, 6, 5, 4, and 3 points, respectively.

A cutoff of 6 or greater was found to have a 70% sensitivity and 72% specificity for detecting risk for POAF (area under the curve [AUC], 0.76) in the derivation cohort and 69% sensitivity and 72% specificity (AUC, 0.72) in the validation analysis.

The findings of this study may not be generalizable, as all patients who developed POAF had received enoxaparin or dalteparin and all but 8 received a non-therapeutic dose. It remains unclear what effect these drugs had on the study findings.

“POAF complicates around 2% of all noncardiac surgery,” the researchers noted. “A 4 items point-based risk score such as the HART score, could be effective in implementing effective POAF screening and improving management.”


Stronati G, Mondelli C, Urbinati A, et al. Derivation and validation of a clinical score for predicting postoperative atrial fibrillation in noncardiac elective surgery (the HART score). Am J Cardiol. Published online February 23, 2022. doi:10.1016/j.amjcard.2022.01.020