Electrophysiology And Arrhythmia Scores

DR-FLASH Score Calculator – AF Recurrence After Catheter Ablation

Clinical calculation support · Verify results before clinical use

Clinical Parameters

Enter the patient's pre-ablation characteristics. The score updates automatically when all fields are valid.

—Score / 7

Clinical history

Select the option that best describes the patient before catheter ablation.

Diabetes Mellitus

Established diagnosis of diabetes mellitus.

+1 point

No0 points

Yes+1 point

Atrial Fibrillation Type

Persistent AF is defined as continuous AF sustained beyond 7 days or requiring termination by pharmacological or electrical cardioversion.

+1 point

Paroxysmal AF0 points

Persistent AF+1 point

Sex

One point is assigned for female sex in the original score.

+1 point

Male0 points

Female+1 point

Hypertension

History or established diagnosis of hypertension.

+1 point

No0 points

Yes+1 point

Demographic and echocardiographic parameters

Use measured values from the pre-ablation assessment.

Age

The original criterion is age greater than 65 years (not ≥65 years).

+1 point

Patient age

years

Score 1 point if age is >65 years.

Left Atrial Diameter

Use the anteroposterior left atrial diameter measured by echocardiography.

+1 point

Left atrial diameter

Score 1 point if LA diameter is >45 mm.

Renal Dysfunction

The DR-FLASH definition uses eGFR below 90 mL/min/1.73 m².

+1 point

Estimated glomerular filtration rate (eGFR)

mL/min/1.73 m²

Score 1 point if eGFR is <90 mL/min/1.73 m². This is the score's operational threshold and should not be interpreted as a standalone diagnosis of chronic kidney disease.

—DR-FLASH

Score interpretation

Complete all fields

The score will be displayed after all clinical parameters have been entered.

Clinical and prognostic context Enter the required variables to view the score interpretation.

DR-FLASH is a risk stratification score, not an individualized probability calculator.

About the DR-FLASH Score

The DR-FLASH score was developed to identify left atrial low-voltage areas (LVA), an electro-anatomical marker of atrial remodeling, in patients with atrial fibrillation undergoing catheter ablation. LVA is associated with a more advanced atrial substrate and may be related to less favorable rhythm outcomes after pulmonary vein isolation.

The score comprises seven equally weighted variables: diabetes mellitus, renal dysfunction, persistent AF, left atrial diameter >45 mm, age >65 years, female sex, and hypertension. Each variable contributes one point, giving a total score from 0 to 7.

Score Components

Component	Criterion	Points
Diabetes mellitus	Present	1
Renal dysfunction	eGFR <90 mL/min/1.73 m²	1
Persistent AF	Persistent AF phenotype	1
Left atrial diameter	>45 mm	1
Age	>65 years	1
Female sex	Female	1
Hypertension	Present	1

Evidence-Based Interpretation

Score threshold	Evidence context
≥3 points	Optimal cutoff reported for identifying left atrial low-voltage areas in the original study (sensitivity 76%, specificity 73% in the validation cohort).
>3 points (4–7)	Higher-score group associated with greater AF recurrence after PVI in the original report; OR 1.7 (95% CI 1.1–2.8).
Per 1-point increase	Original study reported approximately 1.3-fold higher risk of AF recurrence after PVI (95% CI 1.1–1.5).

These thresholds describe different study outcomes and should not be conflated. A score of 3 meets the reported LVA cutoff but does not belong to the >3 recurrence subgroup.

Important Limitations

The score was primarily developed to predict left atrial low-voltage substrate, not to provide an absolute percentage probability of AF recurrence.
In the 2018 study, DR-FLASH was not independently associated with late recurrence in the 241-patient BioAF cohort after multivariable adjustment. In the 873-patient Leipzig registry validation cohort, it was independently associated with late recurrence (OR 1.242 per point; 95% CI 1.118–1.381), but discrimination was modest (AUC 0.662).
Early arrhythmia recurrence after ablation was a stronger predictor of later recurrence in the 2018 cohort analysis; it is not a component of DR-FLASH.
The 2022 EARNEST-PVI post hoc analysis evaluated DR-FLASH as a stratifier of ablation strategy in persistent AF; it should not be interpreted as an absolute recurrence-probability validation.
The eGFR threshold of <90 is the score's published operational definition and should not be used alone to diagnose chronic kidney disease.

References

Kosiuk J, Dinov B, Kornej J, et al. (2015). Prospective, multicenter validation of a clinical risk score for left atrial arrhythmogenic substrate based on voltage analysis: DR-FLASH score. Heart Rhythm. 2015;12(11):2207–2212. DOI: 10.1016/j.hrthm.2015.07.003.

Kornej J, Schumacher K, Dinov B, et al. (2018). Prediction of electro-anatomical substrate and arrhythmia recurrences using APPLE, DR-FLASH and MB-LATER scores in patients with atrial fibrillation undergoing catheter ablation. Scientific Reports. 2018;8:12686. DOI: 10.1038/s41598-018-31133-x.

Joglar JA, Chung MK, Armbruster AL, et al. (2023). 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Journal of the American College of Cardiology. 2023. DOI: 10.1016/j.jacc.2023.08.017. Used for AF temporal-pattern terminology.

Sato T, Sotomi Y, Hikoso S, et al. (2022). DR-FLASH Score Is Useful for Identifying Patients With Persistent Atrial Fibrillation Who Require Extensive Catheter Ablation Procedures. Journal of the American Heart Association. 2022;11(16):e024916. DOI: 10.1161/JAHA.121.024916.

Clinical disclaimer: The DR-FLASH score is an adjunctive risk stratification tool and should not be used as the sole basis for treatment decisions, ablation strategy selection, or prediction of an individual patient's outcome. Interpret the result in the context of the patient's clinical profile, AF phenotype, echocardiographic findings, comorbidities, procedural characteristics, and follow-up rhythm monitoring. The score does not replace clinical judgement or guideline-directed care.