Implications of the CHA(2)DS(2)-VASc and HAS-BLED Scores for thromboprophylaxis in atrial fibrillation

There is increasing recognition of the value of oral anticoagulation for stroke prevention in atrial fibrillation, as well as the availability of new oral anticoagulants that overcome the limitations of warfarin, implying that even more atrial fibrillation patients will be using oral anticoagulation, with the role of aspirin being less defined. Thus, we need a paradigm shift so that stroke risk assessment can be simplified in the identification of those patients who are truly at low risk (ie, CHA₂DS₂-VASc [Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category] score = 0) who could be treated with no antithrombotic therapy, and all others (ie, CHA₂DS₂-VASc score ≥1), would be considered for oral anticoagulation. A simple bleeding risk assessment can clearly help guide office management here. The new HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile International Normalized Ratio, Elderly, Drugs/alcohol concomitantly) bleeding risk schema has been proposed as a simple, easy calculation to assess bleeding risk in atrial fibrillation patients, whereby a score of ≥3 indicates “high risk” and some caution and regular review of the patient is needed, following the initiation of antithrombotic therapy, whether with oral anticoagulation or antiplatelet therapy.     

Validation of contemporary stroke and bleeding risk stratification scores in non-anticoagulated Chinese patients with atrial fibrillation

Background

Risk stratification schemes assessing stroke and thromboembolism (stroke/TE) and bleeding relating to atrial fibrillation (AF) have largely been derived and validated in Western populations. We assessed risk factors that constitute scores for assessing stroke/TE (CHADS₂, CHA₂DS₂-VASc) and bleeding (HAS-BLED), and the predictive value of these scores in a large cohort of Chinese patients with AF.

Methods and results

We studied 1034 AF patients (27.1% female, median age 75; 85.6% non-anticoagulated) with mean follow-up of 1.9 years. On multivariate analysis, vascular disease was independently associated with stroke/TE in non-anticoagulated patients (p = 0.04). In patients with a CHADS₂ or CHA₂DS₂-VASc score = 1, the rate of stroke/TE was 2.9% and 0.9% respectively, but in patients at “high risk” (scores ≥ 2), this rate was 4.6% and 4.5%, respectively. The c-statistics for predicting stroke/TE with CHADS₂ and CHA₂DS₂-VASc were 0.58 (p = 0.109) and 0.72 (p < 0.001), respectively. Compared to CHADS₂, the use of CHA₂DS₂-VASc would result in a Net Reclassification Improvement (NRI) of 16.6% (p = 0.009) and an Integrated Discrimination Improvement (IDI) of 1.1% (p = 0.002). Cumulative survival of the patients with a CHA₂DS₂-VASc score ≥ 2 was decreased compared to those with a CHA₂DS₂-VASc score 0–1 (p < 0.001), but the CHADS₂ was not predictive of mortality. There was an increased risk of major bleeding with increasing HAS-BLED score (c-statistic 0.61, 95% CI: 0.51–0.71, p = 0.042).

Conclusions

Vascular disease was a strong independent predictor of stroke/TE in Chinese patients with AF. The CHA₂DS₂-VASc score performed better than CHADS₂ in predicting stroke/TE in this Chinese AF population. Cumulative survival of the patients at high risk with the CHA₂DS₂-VASc score (but not using CHADS₂) was significantly decreased.     

非瓣膜性心房颤动患者的卒中危险因素分析

卒中是非瓣膜性心房颤动(以下简称为房颤)的主要并发症。心力衰竭、高龄、高血压、糖尿病及卒中或短暂性脑缺血发作史与房颤患者卒中的风险相关,此外,临床上其他原因所致的缺血性卒中的危险因素也与房颤患者的卒中风险相关。筛选房颤患者并发卒中的危险因素,并采取有效方法评估其卒中的危险性,无论是对于抗凝治疗预防卒中事件,还是对于减少抗凝治疗引起的出血风险,都具有十分重要的意义。     

Risk stratification of patients with atrial fibrillation: Biomarkers and other future perspectives

Risk stratification of atrial fibrillation (AF) and adequate thromboembolism prophylaxis is the cornerstone of treatment in patients with AF. Current risk stratification schemes such as the CHADS 2 and CHA 2 DS 2 -VASc scores are based on clinical risk factors and suboptimally weight the risk/benefit of anticoagulation. Recently, the potential of biomarkers (troponin and NT-proBNP) in the RE-LY biomarker sub-analysis has been demonstrated. Echocardiography is also being evaluated as a possible approach to improve risk score performance. The authors present an overview on AF risk stratification and discuss future potential developments that may be introduced into our current risk stratification schemes.     

Stroke and dementia risk in patients with and without atrial fibrillation and carotid arterial disease

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Predictors of stroke or systemic embolism in patients with non-valvular atrial fibrillation with CHA2DS2-VASc score of 0

Background

Anticoagulant therapy has been important for stroke prevention in patients with atrial fibrillation (AF). However, it was not recommended due to its relatively higher risk of bleeding than its lower risk of stroke in patients with a CHA₂DS₂-VASc score of 0.

Hypothesis

This study aimed to evaluate the predictors of stroke in AF patients with very low risk of stroke.

Methods

Between 1990 and 2020, 542 patients with non-valvular AF (NVAF) with a CHA₂DS₂-VASc score of 0 followed up for at least 6 months were enrolled. Patients with only being woman as a risk factor were included as a CHA₂DS₂-VASc score of 0 in this study. The primary outcome was stroke or systemic embolism.

Results

The primary outcome rate was 0.78%/year. In Cox hazard model, age of ≥50 years at diagnosis (hazard ratio [HR] 6.710, 95% confidence interval [CI] 1.811–24.860, p = .004), LVEDD of ≥46 mm (HR 4.513, 95% CI 1.038–19.626, p = .045), and non-paroxysmal AF (HR 5.575, 95% CI 1.621–19.175, p = .006) were identified as independent predictors of stroke or systemic embolism. Patients with all three independent predictors had a higher risk of stroke or systemic embolism (4.21%/year), whereas those without did not have a stroke or systemic embolism.

Conclusion

The annual stroke or systemic embolism rate in NVAF patients with CHA₂DS₂-VASc score of 0 was 0.78%/year, and age at AF diagnosis, LVEDD, and non-paroxysmal AF were independent predictors of stroke or systemic embolism in patients considered to have a very low risk of stroke.     

CHADS2评分、心房颤动与卒中风险分层

非瓣膜性心房颤动(nonvalvular atrial fibrillation,NVAF)是最常见的心律失常类型,同时也是缺血性卒中的独立危险因素.华法林能有效降低NVAF患者的缺血性卒中风险,但会大幅增高严重出血风险.目前,多数临床指南均推荐使用CHADS,评分对NVAF患者的卒中风险进行分层以指导抗栓治疗.虽然使...     

Prevalence of risk factors for atrial fibrillation and stroke among 1210 patients with sleep disordered breathing

Aims

This study sought to identify the prevalence of risk factors for atrial fibrillation and stroke in a sleep apnea population.

Methods

Study participants included 1210 consecutive adults who were referred with suspicion of sleep apnea. Statistical analysis was used to determine the relationship between sleep apnea syndrome and risk factors for atrial fibrillation and stroke.

Results

Among 1210 enrolled patients, 65.8% had severe sleep apnea (Apnea/hypopnea Index — AHI > 30), 25.2% had mild to moderate sleep apnea (AHI 5 to 30), and 8.8% had no sleep apnea (AHI < 5). At baseline, the mean apnea–hypopnea index in patients with sleep apnea syndrome was 35. Compared to patients with an AHI < 5, those with an AHI > 30 were older (47.3 ± 11.4 vs. 52.74 ± 12.4, p < 0.001) and had a higher body mass index (BMI) (30.7 ± 7.3 vs. 33.83 ± 10.1, p < 0.001), a higher prevalence of hypertension (38 vs. 16%, p < 0.001), and a higher CHADS₂ (congestive heart failure, hypertension, age, diabetes and prior stroke) score (0.59 ± 0.8 vs. 0.28 ± 0.64, p < 0.001).

Conclusions

Patients with severe sleep apnea have a higher prevalence of risk factors for atrial fibrillation and stroke when compared with subjects without sleep apnea.     

Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: data from a community-based cohort.

AIMS: To estimate the incidence of dementia after the first atrial fibrillation (AF), and its impact on survival in a community-based cohort. METHODS AND RESULTS: Olmsted County, Minnesota adult residents diagnosed with first AF during 1986-2000 were identified, and followed until 2004. The primary outcome was new detection of dementia. Interim stroke was censored in the analyses. Of 2837 subjects (71 +/- 15 years old) diagnosed with first AF and without any evidence of cognitive dysfunction or stroke at the time of AF onset, 299 were diagnosed with dementia during a median follow-up of 4.6 years [interquartile (IQR) range 1.5-7.9 years], and 1638 died. The Kaplan-Meier cumulative rate of dementia was 2.7% at 1 year and 10.5% at 5 years. After adjustment for age and sex, dementia was strongly related to advancing age [hazard ratio (HR)/10 years, 2.8; 95% confidence interval (CI), 2.5-3.2], but did not vary with sex (P = 0.52). The occurrence of post-AF dementia was associated with significantly increased mortality risk (HR 2.9; 95% CI 2.5-3.3), even after adjustment for multiple comorbidities, and did not vary with age (P = 0.75) or sex (P = 0.33). CONCLUSION: Dementia appeared common following the diagnosis of first AF, and was associated with premature death.     

胺碘酮治疗心力衰竭并心房颤动的有效性及安全性

目的:评价胺碘酮对心力衰竭合并心房颤动患者心室率影响,转复窦性心律的可能性.以及治疗的安全性。方法:采用随机、单盲、安慰剂对照方法,运用24 h动态心电图监测胺碘酮治疗组(33例),对照组(31例)的心律、心率。结果:(1)胺碘酮治疗组的心房颤动转复率为33.33%,高于对照组(3.29%).P<0.01;(2)治疗三个月后治疗组平均心室率明显下降(P<0.05);(3)两组间左室射血分数(LVEF)无差异(P>0.05),治疗组QTc延长, 但改为维持量后QTc恢复正常,均无严重副作用。结论:胺碘酮能显著减慢心率并使一部分心力衰竭合并心房颤动患者复律。     

Utility of short-term telemetry heart rhythm monitoring and CHA2DS2-VASc stratification in patients presenting with suspected cerebrovascular accident

BACKGROUNDInpatient telemetry heart rhythm monitoring overuse has been linked to higher healthcare costs. AIMTo evaluate if CHA₂DS₂-VASc score could be used to indicate if a patient admitted with possible cerebrovascular accident (CVA) or transient ischemic attack (TIA) requires inpatient telemetry monitoring. METHODSA total of 257 patients presenting with CVA or TIA and placed on telemetry monitoring were analyzed retrospectively. We investigated the utility of telemetry monitoring to diagnose atrial fibrillation/flutter and the CHA₂DS₂-VASc scoring tool to stratify the risk of having CVA/TIA in these patients.RESULTSIn our study population, 63 (24.5%) of the patients with CVA/TIA and telemetry monitoring were determined to have no ischemic neurologic event. Of the 194 (75.5) patients that had a confirmed CVA/TIA, only 6 (2.3%) had an arrhythmia detected during their inpatient telemetry monitoring period. Individuals with a confirmed CVA/TIA had a statistically significant higher CHA₂DS₂-VASc score compared to individuals without an ischemic event (3.59 vs 2.61, P < 0.001). CONCLUSIONGiven the low percentage of inpatient arrhythmias identified, further research should focus on discretionary use of inpatient telemetry on higher risk patients to diagnose the arrhythmias commonly leading to CVA/TIA. A prospective study assessing event rate of CVA/TIA in patients with higher CHA₂DS₂-VASc score should be performed to validate the CHA₂DS₂-VASc score as a possible risk stratifying tool for patients at risk for CVA/TIA.