Prognostic value of GRACE and CHA2DS2-VASc score among patients with atrial fibrillation undergoing percutaneous coronary intervention

AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008–1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020–1.037, p < 0.001) and 1.334 (95% CI 1.107–1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005–1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001–1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.

Key messages:

• In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.
• The GRACE score could also help identify patients at higher risk of stroke and major bleeding.
• Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.

     

The SAMe-TT2R2 score and decision-making between a vitamin K antagonist or a non-vitamin K antagonist oral anticoagulant in patients with atrial fibrillation

Oral anticoagulation therapy is essential in patients with atrial fibrillation and clinicians need guidance on decision-making between the vitamin K antagonists (VKA), e.g. warfarin, or non-vitamin K antagonist oral anticoagulants. Observational studies have shown that patients who receive VKA therapy spend a significant percentage of their time with international normalized ratio values outside of the therapeutic range (time in therapeutic range, TTR <60%.) Recently, a clinical score has been developed with commonly encountered clinical features, the SAMe-TT₂R₂ score, to help decision-making with regard to whether a patient is likely to do well, or not, with a VKA. Those with a SAMe-TT₂R₂ score of 0–1 are likely to do well on a VKA, while those with a SAMe-TT₂R₂ score ≥2 are on probability going to achieve suboptimal TTR. In this article, we provide an overview of the main published retrospective and prospective studies that have validated the SAMe-TT₂R₂ score and its value for decision-making in daily clinical practice.     

Predictive role of CHADS2 and CHA2DS2-VASc scores on stroke and thromboembolism in patients without atrial fibrillation: a meta-analysis

Objective: CHA₂DS₂-VASc is the extension of the CHADS₂ score developed by Birmingham 2009. This risk stratification schema is often used in clinical setting when considering additional risk factors for developing stroke in AF patients. However, its role in the non-AF population is unknown. This study was designed to evaluate the accuracy of the CHADS₂ and the CHA₂DS₂-VASc scoring systems.

Methods: Studies designed for CHADS₂ and CHA₂DS₂-VASc score in stratifying the risks for stroke development in non-AF patients were included.

Results: Among the 114 studies identified, six trials were chosen finally and included for meta-analysis. The pooled diagnostic odds ratio (DOR) for CHADS₂ and CHA₂DS₂-VASc was 2.86 (95% CI =1.83–4.28) and 2.80 (95% CI =1.83–4.28), respectively. CHA₂DS₂-VASc score was of better sensitivity than CHADS₂ score (0.920 vs. 0.768). However, both scores were showed to have inherent heterogeneity and poor specificity.

Conclusions: Though having good diagnostic accuracy, the clinical application of the CHADS₂ and CHA₂DS₂-VASc scores in predicting risk of stroke development in non-AF patients still needs further validation.

• Key message

• The overall diagnostic accuracy of CHADS₂ and CHA₂DS₂-VASc in stroke-risk stratification was good in patients with non-atrial fibrillation.

     

A2DS2评分在预测急性缺血性脑卒中相关性肺炎中的应用

目的 研究急诊病房急性缺血性脑卒中患者卒中相关性肺炎（SAP）的发生率及危险因素,并探讨A2DS2评分对SAP的预测效能。方法 2014年4月至2017年3月连续纳入271例急性缺血性脑卒中患者,将其分为SAP组（n=103）与非SAP组（n=168）,分析SAP的危险因素,并应用受试者工作特征(ROC)曲线分析评价A2DS2评分对SAP的预测作用。 结果 急诊病房中SAP发生率为38.0%,两组年龄、吞咽障碍、美国国立卫生研究院卒中量表评分（NIHSS）、合并症（心房颤动、冠心病和脑卒中）、意识障碍（格拉斯哥昏迷评分<9分）差异均有统计学意义（P<0.05）;Logistic 回归分析显示年龄>75岁、吞咽障碍、高NIHSS评分和意识障碍是SAP发生的危险因素;ROC曲线分析结果显示, A2DS2评分预测SAP的曲线下面积(AUC)为0.928。结论 A2DS2评分能有效预测急诊病房急性缺血性脑卒中患者SAP的发生。     

CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients

Purpose

Prediction of arterial thromboembolic events (ATEs) in relation to supraventricular arrhythmia (SVA) has been poorly investigated in the intensive care unit (ICU). We aimed at evaluating CHADS2 and CHA2DS2-VASc scores to predict SVA-related ATE in the ICU.

Methods

We conducted a prospective observational study including all the patients except those in the postoperative course of cardiac surgery who presented SVA lasting 30 seconds or longer during their ICU stay. We looked for ATE during ICU stay, at the first and sixth month of follow-up after ICU discharge.

Results

During the 15-month study period, 108 (12.8%) of 846 ICU patients experienced SVA with 12 SVA-related ATE occurring 6 days (3; 13) (median, 10%-90% percentiles) after SVA onset. In our SVA patients, CHADS2 score was 2 (0; 5), and CHA2DS2-VASc score 3 (0; 7). Both CHADS2 (odds ratio (OR), 1.6 [1.1; 2.4]; P = .01) and CHA2DS2-VASc scores (OR, 1.4 [1.04; 1.8]; P = .03) were significantly associated with ATE onset. However, the most accurate threshold for predicting ATE was CHADS2 score of 4 or higher. Using a multivariate analysis, only patient's history of stroke was associated with ATE onset (OR, 9.2 [2.4; 35]; P = .001).

Conclusion

CHADS2 and CHA2DS2-VASc scores are predictive of SVA-related thromboembolism in the critically ill patient.     

Atherosclerosis and thromboembolic risk in atrial fibrillation: Focus on peripheral vascular disease

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. It results in a 5-fold increased risk for stroke and thromboembolism and is associated with a high morbidity and mortality. AF shares several risk factors and pathophysiological features with atherosclerosis. Hence AF is often complicated by a variety of other cardiovascular conditions. Indeed, peripheral vascular disease (PVD) is highly prevalent among AF patients and associates with increased mortality. Inclusion of PVD within stroke risk scoring systems such as the CHA₂DS₂-VASc score improves risk stratification of AF patients. Of note, PVD has not been previously well documented nor looked for in observational studies or clinical trials. The aim of this present review article is to provide an overview of the association between atherosclerosis (with particular focus on PVD) and AF as well as its complications.     

Premature atrial complexes in an ischemic stroke population and risk of recurrent stroke: a systematic review

Introduction: Premature atrial complexes (PACs) have been proposed as a possible mediator between normal sinus rhythm and atrial fibrillation (AF). The aim of this study was to summarize the available knowledge of association between PACs and recurrent stroke or transient ischemic attack (TIA) in ischemic stroke patients.

Areas covered: In this systematic review, we investigated the risk of recurrent events in patients who experienced ischemic stroke or TIA. Occurrence of PACs in electrocardiographic monitoring after index stroke/TIA was required. We identified and included three observational cohort studies, investigating in total 1005 patients. The studies reported that a significant burden of PACs occurred in a high proportion of stroke and TIA patients. More PACs were independently associated with an increased risk of recurrent stroke or TIA or the composite of recurrent stroke/TIA or death. Definition of PACs cut-off as well as patient characteristics differed between groups.

Expert Commentary: This review supports an association between higher burden of PACs and recurrent stroke, and stresses the need for studies on PACs in stroke patients. A special awareness of stroke patients with a high PACs load is recommendable particularly for assessing the intensity and duration toward AF progression, and possible future treatment recommendations.     

CHA2DS2-VASc评分在心力衰竭患者血栓栓塞风险预测中的应用

目的分析不同纽约心脏协会（NYHA）心功能分级心力衰竭患者的血栓栓塞风险差异及CHA₂DS₂-VASc评分对于心力衰竭患者血栓栓塞事件的预测价值。 方法回顾性分析4 360例心力衰竭住院患者的CHA₂DS₂-VASc评分，根据心功能的受损状况将其分为NYHA Ⅰ级组（1 180例）、NYHA Ⅱ级组（1 168例）、NYHA Ⅲ级组（1 187例）和NYHA Ⅳ级组（825例）。采用Logistic回归模型分析NYHA心功能分级对心力衰竭患者罹患血栓栓塞疾病风险的影响，NYHA心功能分级与CHA₂DS₂-VASc评分之间的线性相关度用Spearman相关系数表示，采用受试者工作特征（ROC）曲线的曲线下面积（AUC）判定CHA₂DS₂-VASc评分对于心力衰竭患者发生血栓栓塞风险的预测价值。 结果4组患者间年龄（F = 106.490，P<0.001）、女性（H = 79.101，P< 0.001）、年龄亚组（H = 256.557，P<0.001）、高血压（H = 8.092，P = 0.044）、糖尿病（H = 8.060，P = 0.045）、血栓栓塞疾病（H = 41.427，P<0.001）、血管疾病（H = 40.567，P < 0.001）、高脂血症（H = 260.762，P < 0.001）及心房颤动（H = 306.597，P < 0.001）比例的比较，差异均有统计学意义。且与NYHA Ⅰ级组比较，女性比例，NYHA Ⅱ~Ⅳ级组患者中65~74岁与≥ 75岁比例，以及患糖尿病、血栓栓塞疾病、血管疾病、心房颤动比例均显著升高（P均< 0.05）。Logistic回归模型校正危险因素后发现，NYHA Ⅲ级[比值比（OR）=1.500，95%置信区间（CI）（1.126，1.999），P = 0.006]与NYHA Ⅳ级[OR = 1.688，95%CI（1.239，2.300），P = 0.001]均是心力衰竭患者发生血栓栓塞的独立危险因素。心功能级别与CHA₂DS₂-VASc评分两变量之间呈弱相关（r = 0.193，P < 0.001）。ROC曲线分析结果显示CHA₂DS₂-VASc评分[AUC = 0.902，95%CI（0.890，0.915），P < 0.001]对于心力衰竭患者血栓栓塞风险的预测价值较高。 结论心力衰竭患者NYHA心功能分级越高，血栓栓塞风险越高。合并血栓栓塞高危因素时，可采用CHA₂DS₂-VASc评分系统评估栓塞风险的同时给予恰当的抗凝治疗，降低栓塞事件发生率。     

Refinement of CHADS2 and CHA2DS2-VASc scores predict left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation patients

ObjectiveTo investigate the risk factors of left atrial thrombus (LAT)/spontaneous echo contrast (SEC) in patients with nonvalvular atrial fibrillation (AF).MethodsThis retrospective study analysed the data from consecutive patients with nonvalvular AF that underwent transoesophageal echocardiography. Logistic regression analysis was performed to identify risk factors of LAT/SEC. Receiver operating characteristic curve analysis was undertaken compare the new scales with CHADS2 and CHA2DS2-VASc scores.ResultsA total of 558 patients with AF were included in the study. LAT/SEC was detected in 137 (24.6%) patients. The independent risk factors of LAT/SEC beyond CHADS2 or CHA2DS2-VASc scores included non-paroxysmal AF and left atrial diameter >37.5 mm. These two variables were added into the CHADS2 or CHA2DS2-VASc score to build new scales. Areas under the curve for the new scales based on CHADS2 and CHA2DS2-VASc scores were significantly higher than the CHADS2 or CHA2DS2-VASc score both in the overall study cohort and in patients at a high risk of thromboembolism.ConclusionsNon-paroxysmal AF and increased left atrial diameter beyond the CHADS2 or CHA2DS2-VASc score were independent risk factors of LAT/SEC and may help to improve the current risk stratification, especially for patients with nonvalvular AF at a high risk of thromboembolism.     

伴非瓣膜性心房颤动急性缺血性脑卒中合并脑微出血患者发生症状性脑出血危险因素分析

目的 探讨伴非瓣膜性心房颤动的急性缺血性卒中(AIS)患者合并脑微出血(CMBs)时,发生症状性脑出血(sICH)的危险因素.方法 选取自2016年4月至2020年11月于辽宁省人民医院住院治疗的83例伴非瓣膜性心房颤动的AIS患者为研究对象,患者均行头部核磁共振常规序列扫描和头部磁敏感加权成像(SWI)序列检查.根据SWI检查结果,将患者分为无CMBs组(n=27)与CMBs组(n=56).记录并比较两组患者年龄、性别、吸烟史、饮酒史、既往病史(高血压、糖尿病、卒中)、美国国立卫生院神经功能缺损(NIHSS)评分、非瓣膜性心房颤动患者脑卒中危险评分(CHA2DS2-VASc)、出血风险评分(HAS-BLEDS)等临床资料.记录CMBs的患者的严重程度分级、发生CMBs的部位以及抗凝药的种类、剂量、服用时间等,主要终点事件为口服抗凝药90 d内发生sICH,分析CMBs患者口服抗凝剂治疗的安全性.记录本研究纳入患者出血不良事件发生情况.结果 本研究出血事件发生率为16.9％(14/83).其中,小出血10例(12.1％),包括牙龈出血、皮肤瘀斑、痰中带血、便潜血、轻微眼底出血;临床相关非大出血2例(2.4％),包括便血、严重眼底出血;大出血2例(2.4％),为脑出血.2例患者分别于口服抗凝药物后第64天和第82天发生sICH.2例患者的出血部位均与原梗塞部位无关,但出血部位既往均存在CMBs病灶.CMBs组有高血压病病史患者比例高于无CMBs组,差异有统计学意义(P<0.05).多因素分析结果显示,NIHSS评分是伴非瓣膜性心房颤动的AIS合并CMBs患者发生sICH的独立危险因素(OR=0.448,95％可信区间0.150～1.344,P=0.032).结论 伴非瓣膜性心房颤动的AIS患者有较高的CMBs的发生率,高血压病史与CMBs的发生相关.当伴非瓣膜性心房颤动的AIS患者合并CMBs时,NIHSS评分是sICH发生的独立危险因素.     

Efficacy and safety of catheter ablation combined with left atrial appendage occlusion for nonvalvular atrial fibrillation: A systematic review and meta-analysis

Atrial fibrillation (AF) is currently the most prevalent arrhythmia in clinical practice, with stroke being one of its major complications. Combining catheter ablation and percutaneous left atrial appendage occlusion (LAAO) into a “one-stop” intervention could reduce stroke incidence in selected high-risk patients and, at the same time, relieve AF symptoms in a single procedure. This meta-analysis analyzed the efficacy and safety of catheter ablation combined with LAAO for nonvalvular AF. PubMed, EMBASE, and the Cochrane Library were searched from inception to April 2019 to identify relevant citations. Efficacy indexes were procedural success, AF recurrence, stroke/transient ischemic attacks (TIA), and device-related thrombus (DRT). Safety indexes were all-cause death, major hemorrhagic complications, and pericardial effusion/cardiac tamponade. The incidence rate of events (ratio of events to patients) and 95% confidence interval (CI) were calculated as summary results. A forest plot was constructed to present pooled rates. Eighteen studies (two randomized controlled trials and 16 observational studies) were included. The results showed that one-stop intervention has significant efficacy and safety, with procedural success of .98 (95% CI, .97-1.00), AF recurrence of .24 (95% CI, .15-.35), stroke/TIA of .01 (95% CI, .00-.01), DRT of .00 (95% CI, .00-.01), all-cause mortality of .00 (95% CI, .00-.00), cardiac/neurological mortality of .00 (95% CI, .00-.00), major hemorrhagic complications of .01 (95% CI, .00-.02), and pericardial effusion/cardiac tamponade of .01 (95% CI, .00-.01). A single procedure with catheter ablation and LAAO in AF is a feasible strategy with significant efficacy and safety.     

ABCD2评分及ESRS评分对急诊神经内科头晕患者发生缺血性脑卒中的诊断预测价值

目的探讨ABCD2评分及Essen卒中风险评分量表(ESRS)对于急诊神经内科以头晕为主诉患者发生急性缺血性脑卒中的诊断预测价值。方法选取因头晕就诊的患者共260例,分别应用ABCD2量表及ESRS量表进行评分。ABCD2评分分组为低危组(138例,0~3分)、中危组(101例,4~5分)和高危组(21例,6~7分)。ESRS评分分组为低危组(158例,0~2分)、中危组(97例,3~6分)和高危组(5例,7~9分),对所有患者进行头CT和头颅MRI检查。结果共发生急性缺血性脑卒中65例,其中ABCD2评分低危组9例(6.52%),中危组40例(39.60%),高危组16例(76.1%);ESRS评分低危组3例(1.90%),中危组58例(59.79%),高危组4例(80%)。脑卒中组与未发生脑卒中组在年龄、ABCD2评分、ESRS评分、高血压、糖尿病、吸烟史、冠心病史、脑卒中史等方面均有显著差异(P0.01)。多因素Logistic回归分析显示,ABCD2评分、Essen评分、糖尿病史及卒中史是预测急诊神经内科头晕患者发生缺血性脑卒中的独立预测因素。结论ABCD2评分和ESRS评分均可以作为预测急诊神经内科头晕患者发生缺血性脑卒中的独立预测因素。ABCD2评分优于ESRS评分。     

高迁移率族蛋白B1联合改良爱丁堡.斯堪的纳维亚评分评估急性脑梗死静脉溶栓患者预后的价值

目的 探讨血清高迁移率族蛋白Bl(HMGBl)联合改良爱丁堡-斯堪的纳维亚评分(MESSS)评估急性脑梗死(AIS)静脉溶栓患者预后的价值.方法 将:50例AIS患者根据病情程度分为轻度组85例和重度组65例.比较2组治疗前后血清HMGB1、N末端B型利钠肽原(NT-proBNP)、血小板(PLT)、凝血酶原时间(PT...