Stroke Risk Stratification in a “Real‐World” Elderly Anticoagulated Atrial Fibrillation Population

Stroke Risk Stratification . Introduction: Appropriate stroke risk stratification is essential to ensure suitable tailoring of antithrombotic therapy. The objective of this study was to assess the predictive value of stroke risk classification schemes and to identify patients with atrial fibrillation (AF) who are at substantial risk of stroke despite optimal anticoagulant therapy, in a “real world” consecutive elderly AF cohort. Methods: Six hundred and sixty‐two consecutive AF patients (mean [SD] age 74 [7.7] years; 36.1% female) referred to the Anticoagulation Clinic of the Azienda Ospedaliera Careggi of Florence, Italy, were included and followed‐up for a mean 3.6 ± 2.7 years for the incidence of thromboembolic (TE) events. The ability of the new CHA₂DS₂‐VASc schema to predict TE was compared with other contemporary stroke risk schema (including CHADS₂, NICE 2006, ACC/AHA/ESC 2006, and ACCP 2008), by determining the c‐statistic. Results: Univariate predictors of TE events were female gender (odds ratio 1.9; 95%CI [confidence intervals] 1.01–3.70) and previous stroke/transient ischemic attack (TIA)/TE (OR 5.6; 95%CI 2.70–11.45), although after adjustment only previous stroke/TIA/TE was an independent predictor of TE (OR 5.5; 95%CI 2.68–11.31; P = 0.0001). All stroke risk schema had modest discriminating ability, with c‐statistics ranging from 0.54 (atrial fibrillation investigators [AFI]) to 0.72 (CHA₂DS₂‐VASc). The CHADS₂ and CHA₂DS₂‐VASc schemes having the best c‐statistics (0.717 and 0.724, respectively) with significant discriminating value between risk strata (both P < 0.001). The proportion of patients assigned to individual risk categories varied widely across the schema, with those categorized as “moderate‐risk” ranging from 5.3% (CHA₂DS₂‐VASc) to 49.2% (CHADS₂‐classical). Conclusion: In this “real world” cohort, current published risk schemas have modest predictive ability, with the CHADS₂ and CHA₂DS₂‐VASc schemes having the best predictive value for thromboembolism. Future trials could assess the value of alternative strategies for thromboprophylaxis in high‐risk anticoagulated patients identified by these schemes. (J Cardiovasc Electrophysiol, Vol. 22, pp. 25‐30, January 2011)     

Catheter ablation of atrial fibrillation to reduce stroke risk

Stroke is the most devastating complication of atrial fibrillation (AF), and the latter increases the risk of stroke by almost fivefold. AF elimination by catheter ablation should lower the risk of thromboembolic complications. Several studies support this hypothesis, demonstrating rates of stroke in AF patients similar to non-AF populations after successful catheter ablation. Widespread discontinuation of oral anticoagulation after catheter ablation is currently not supported by scientific data but it may be a viable option for patients with a CHA₂DS₂VASc score of less than 2 and a well-documented stable sinus rhythm.     

The CHADS2 and CHA2DS2–VASc scores predict new occurrence of atrial fibrillation and ischemic stroke

Background

Early identification of individuals who are at risk of developing atrial fibrillation (AF) and ischemic stroke may enable a closer surveillance and thus prompt initiation of oral anticoagulation for stroke prevention.

Objective

This study sought to investigate whether congestive heart failure, hypertension, age?≥?75 years, diabetes, previous stroke (CHADS₂) and CHA₂DS₂–vascular disease, age 65–74 years, sex category (CHA₂DS₂–VASc) scores can predict new-onset AF and/or ischemic stroke in patients presenting with arrhythmic symptoms.

Methods and results

We prospectively followed up 528 patients (68.5?±?10.6 years, male 46.2 %) presented for assessment of arrhythmic symptoms but without any documented arrhythmia, including AF for development of new-onset AF and/or ischemic stroke. Their mean CHADS₂ and CHA₂DS₂–VASc scores on presentation were 1.3?±?1.3 and 2.3?±?1.5, respectively. After 6.1 years, 89 patients (16.8 %, 2.77 per 100 patient-years) had documented AF, and 65 patients (12.3 %, 2.0 per 100 patient-years) suffered stroke. Both the CHADS₂ (C statistic 0.63, 95 % confidence interval (CI) 0.58–0.67, P?2DS₂–VASc (C statistic 0.63, 95 % CI 0.59–0.67, P?2 (C statistic 0.69, 95 % CI 0.65–0.73, P?2DS₂–VASc (C statistic 0.69, 95 % CI 0.65–0.73, P?Conclusion The CHADS₂ and CHA₂DS₂–VASc scores can be used in patients who presented with arrhythmic symptoms to identify those who are at risk with developing new-onset clinical AF and ischemic stroke for close clinical surveillance and early intervention.     

Atrial electromechanical interval can identify patients with paroxysmal atrial fibrillation and is associated with CHADS2 score and peak velocity of left atrial appendage

Electromechanical Interval and Paroxysmal Atrial Fibrillation . Introduction: It is difficult to discriminate patients with and without paroxysmal atrial fibrillation (PAF). The atrial electromechanical interval determined by the transthoracic echocardiogram is demonstrated to be a predictor of new onset AF. The aim of our study was to investigate whether the electromechanical interval is a useful parameter to identify patients with PAF. Methods and Results: A total of 297 patients (PAF group = 103; control group = 194) with mean age of 59.4 ± 12.4 years were enrolled. The electromechanical interval (PA‐PDI) defined as the time interval from the initiation of the P‐wave deflection to the peak of the mitral inflow A wave on the pulse‐wave Doppler imaging was measured for every patient. Patients with PAF had significantly longer PA‐PDI intervals compared with that of patients without it (152.7 ± 13.8 ms vs 133.4 ± 16.8 ms). The area under ROC curve based on the PA‐PDI interval to diagnose PAF was 0.803 (95% confidence interval = 0.755–0.851, P < 0.001). At the cut‐off value of 142 ms, the sensitivity and specificity in identifying PAF were 77.7% and 80.1%, respectively. In the PAF group, the PA‐PDI interval was closely associated with the CHADS₂ score and inversely related with the peak velocity of left atrial appendage. Conclusions: The PA‐PDI interval may be a useful parameter to identify patients with PAF. Further studies are necessary to evaluate the usefulness of PA‐PDI intervals in diagnosing PAF in addition to the current methods and tools. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1325‐1330, December 2011)     

CHA<Subscript>2</Subscript>DS<Subscript>2</Subscript>–VASc score predicts short- and long-term outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis

The CHA₂DS₂–VASc score is a validated tool to assess the thromboembolic risk in patients with atrial fibrillation. Pre-stroke CHA₂DS₂–VASc score may predict outcome in patients with acute ischemic stroke (AIS) without atrial fibrillation. The aim of this study was to investigate if the pre-stroke CHA₂DS₂–VASc score is able to predict short- and long-term outcomes in AIS patients treated with intravenous thrombolysis (IVT). The study group consisted of 256 consecutive patients admitted to the Udine University Hospital with AIS and underwent IVT between January 2015 to March 2017. The pre-stroke CHA₂DS₂–VASc score for each patient was calculated from the collected baseline data. Patients were classified into three groups according to their pre-stroke CHA₂DS₂–VASc score: a score of 0 of 1, a score of 2 or 3 and a score above 3. Primary outcome measures were: rate of favorable outcome at 90-days and at 1-year, and mortality at 90-days and at 1-year. Data on functional outcome and mortality 1 year after stroke were collected in 165 patients (65% of the entire sample). Favorable outcome was defined as a modified Rankin Scale score?≤?2. Compared with the CHA₂DS₂–VASc score 0–1 group, patients with higher CHA₂DS₂–VASc scores had a worse outcome and a higher mortality 3 months and 1 year after stroke. The diagnostic performance of the CHA₂DS₂–VASc score as judged with AUC-ROC was 0.70 (95% CI, 0.64–0.76; p?<?0.001) for favorable outcome at 90-days, 0.78 (95% CI, 0.71–0.85; p?<?0.001) for favorable outcome at 1-year, 0.71 (95% CI 0.61–0.79) for mortality at 90-days, 0.73 (95% CI 0.64–0.80; p?<?0.001) for mortality at 1-year. Pre-stroke CHA₂DS_2–VASc score represents a good predictor for short- and long-term outcomes in AIS patients treated with IVT.     

Advances in Stroke Prevention in Atrial Fibrillation: Enhanced Risk Stratification Combined With the Newer Oral Anticoagulants

Patients with atrial fibrillation (AF) have an increased stroke risk compared with those in sinus rhythm, although the absolute risk for individual patients is modulated by the presence of various additional risk factors. Patient selection for oral anticoagulation for stroke prevention is based on risks of stroke and bleeding. Although CHADS₂ (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack) is the most widely used scheme for evaluating stroke risk in patients with AF, several other stroke risk factors are not included; therefore, many patients' stroke risk may be underestimated, contributing to the underuse of anticoagulants. Furthermore, a substantial proportion of patients are categorized as being at moderate risk (CHADS₂ = 1), and there has been some ambiguity regarding optimum thromboprophylaxis in this group. The refinement of CHADS₂, CHA₂DS₂‐VASc (Congestive heart failure, Hypertension, Age 75 years [2 points], Diabetes mellitus, Stroke or transient ischemic attack [2 points], Vascular disease, Age 65 to 74 years, Sex category [female]), considers additional risk factors. Its main advantage is its ability to identify patients truly at low risk of thromboembolism (CHA₂DS₂‐VASc = 0), who are unlikely to benefit from antithrombotic therapy. For all others, an oral anticoagulant may be the preferred approach, simplifying clinical decision making. Implementation of CHA₂DS₂‐VASc may also result in an increased proportion of patients receiving anticoagulation. The emergence of newer oral anticoagulants that can be given without routine coagulation monitoring, with improved benefit–risk profiles vs vitamin K antagonists, promises to simplify therapy for patients with AF at risk of stroke. This, coupled with advances in stroke risk stratification, is expected to improve patient outcomes and reduce the burden of AF‐related stroke.     

The prevalence of atrial fibrillation in a geographically well-defined population in northern Sweden: implications for anticoagulation prophylaxis

Abstract. Andersson P, Löndahl M, Abdon N‐J, Terent A (Hudiksvall Hospital, Hudiksvall; Lund University, Lund; and Uppsala University, Uppsala; Sweden). The prevalence of atrial fibrillation in a geographically well‐defined population in Northern Sweden: implications for anticoagulation prophylaxis. J Intern Med 2012; 272 : 170–176. Objectives. The aims of this study were to evaluate the community‐based prevalence of atrial fibrillation (AF) in a western society using a geographically well‐defined population in the northern part of Sweden as a reference and to estimate the proportion of patients eligible for oral anticoagulation (OAC) prophylactic therapy according to the stroke risk indices CHADS₂ and CHA₂DS₂‐VASc. Bleeding risk was assessed using the HAS‐BLED score. Design. The study population was recruited from AURICULA, a Swedish national quality register for patients receiving anticoagulation treatment. All patients with the diagnosis AF in the catchment area are registered in AURICULA. Results. Of the 65 532 inhabitants in the catchment area, 1616 were diagnosed with AF (1200 cases were characterized as chronic AF). Thus, the overall prevalence of AF was 2.5%. The prevalence increased with age from 6.3% in patients over 55 years of age to 13.8% in those over 80 years. The prevalence was higher in men than in women in all age groups. Overall, 56.3% and 85.1% of the population were at high risk of stroke (≥2 points) according to CHADS₂ and CHA₂DS₂‐VASc, respectively. In addition, 26.9% had an increased bleeding risk according to HAS‐BLED. Conclusion. Within this large Caucasian population, we identified the highest community‐based prevalence of AF to date. The prevalence was strongly associated with increasing age and male gender. Using CHA₂DS₂‐VASc instead of CHADS₂ widened the indication for OAC prophylactic therapy of AF in this population.     

Thromboembolic risk evaluation in patients with atrial fibrillation using a modified CHADS(2) scoring system

Thromboembolic Risk Stratification in AF. Background : Antithrombotic recommendations for relatively low risk patients with atrial fibrillation (AF) are not well established. Some patients with CHADS₂ score = 0 have a CHA₂DS₂–VASc score of 2, which indicated warfarin therapy in the latter system. We evaluated the thromboembolic risk in AF patients with a CHADS₂ score of 0 or 1. Methods: A total of 695 patients with AF that were followed for ≥ 12 months (median 65.6 months, range 12–138 months), were analyzed retrospectively. The modified CHADS₂ score (MCS) was applied as follows. Each CHADS₂ score group was divided into 2 groups, A and B (i.e., MCS 0A vs 0B, and MCS 1A vs 1B) according to the number of nonmajor risk factors (female gender, chronic kidney disease, coronary artery disease, age 65–74 years). Group A had 0 or 1, and group B had 2 or more nonmajor risk factors. Results: In patients with CHADS₂ score = 1, there were 13 thromboembolic events (0.65%/year) in 343 MCS 1A patients, and 12 thromboembolic events (1.90%/year) in 108 MCS 1B patients. Thromboembolic risk was significantly higher in the MCS 1B compared to the MCS 1A patients (P = 0.006). In 244 patients with CHADS₂ score = 0, the thromboembolic risk of MCS 0B was similar to that of MCS 0A (P = 0.095), and 26 patients had a CHA₂DS₂–VASc score of 2. Conclusion: Patients with MCS 1B had a higher thromboembolic risk than patients with MCS 1A. Antithrombotic strategies for patients with a CHA₂DS₂–VASc score of 2 but a CHADS₂ score of 0 need further investigation. J Cardiovasc Electrophysiol, Vol. 23, pp. 155‐162, February 2012)     

The HAS‐BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta‐analysis

Our objective was to compare the diagnostic accuracy between the HAS‐BLED score and any of HEMORR₂HAGES, ATRIA, CHADS₂, or CHA₂DS₂‐VASc scores in anticoagulated patients with atrial fibrillation. We systematically searched the Cochrane Library, MEDLINE, PubMed, and Embase databases for relevant studies. Data were extracted and analyzed according to predefined clinical endpoints. Eleven studies were identified. Discrimination analysis demonstrates that HAS‐BLED has no significant C‐statistic differences for bleeding risk prediction compared with ATRIA or HEMORR₂HAGES, but it has significant differences compared with CHADS₂ or CHA₂DS₂‐VASc. The significant positive net reclassification improvement and integrated discrimination improvement values also show that HAS‐BLED is superior to that of any of HEMORR₂HAGES, ATRIA, CHADS₂, or CHA₂DS₂‐VASc scores. According to calibration analysis of HAS‐BLED, it overpredicts the risk of bleeding in the low (risk ratio [RR]: 1.16, 95% confidence interval [CI]: 0.63‐2.13, P = 0.64) risk stratification but underpredicts that in the moderate (RR: 0.66, 95% CI: 0.51‐0.86, P = 0.002) and high (RR: 0.88, 95% CI: 0.70‐1.10, P = 0.27) risk stratifications. The HAS‐BLED score not only performs better than the HEMORR₂HAGES and ATRIA bleeding scores, but it also is superior to the CHADS₂ and CHA₂DS₂‐VASc stroke scores for bleeding prediction. The HAS‐BLED score should be the optimal choice to assess major bleeding risk in clinical practice.     

Chronic kidney disease and cardiovascular mortality in patients with atrial fibrillation: European Society of Hypertension project – ESH A Fib

Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m² which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA₂DS₂-VASc score and more CKD than non-CKD patients had CHA₂DS₂-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA₂DS₂VASc and R₂CHA₂DS₂VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA₂DS₂VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R₂CHA₂DS₂VASc score was not associated significantly more with CV mortality than CHA₂DS₂VASc score.     

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.     

TIMI‐AF score and cardiovascular events in vitamin K antagonists‐naïve outpatients with atrial fibrillation

Background

The TIMI‐AF score predicts poor outcomes in patients with atrial fibrillation (AF) and guides selection of anticoagulant therapy by identifying clinical benefit of direct oral anticoagulants (DOACs) or vitamin K antagonists (VKA).

Hypothesis

Our objective was to determine the ability to predict cardiovascular events according to the TIMI‐AF score in a real‐world population.

Methods

Retrospective observational study of VKA‐naïve patients with AF was seen at a cardiology outpatient clinic in Spain between November 2012 and August 2014. We recorded adverse events (myocardial infarction, systemic embolism or stroke, major bleeding, and death).

Results

The study population comprised of 426 patients (50.7% men, mean age, 69 ± 14 years). The TIMI‐AF score identified 372 patients (87.3%) with a low risk, 50 patients (11.7%) with an intermediate risk, and 4 patients (0.9%) with a high risk. After a mean follow‐up of 423.4 ± 200.1 days, 37 patients (9%) experienced an adverse event. Patients with a TIMI‐AF score ≥ 7 had a poorer cardiovascular prognosis (HR, 6.1; 95%CI, 3.2‐11.7; P < 0.001). The area under the ROC curve of TIMI‐AF was 0.755 (95%CI, 0.669‐0.840; P < 0.001), which was greater than that of CHA₂DS₂VASc (0.641; 95%CI, 0.559‐0.724; P = 0.004), HAS‐BLED (0.666; 95%CI, 0.578‐0.755; P < 0.001), and SAMeTT₂R₂ (0.529; 95%CI, 0.422‐0.636; P = 0.565). Similar results were obtained in relation to the net clinical outcome (life‐threatening bleeding, disabling stroke, or all‐cause mortality).

Conclusions

The TIMI‐AF risk score can identify patients who are at greater risk of cardiovascular events and a poor net clinical outcome with a better diagnostic yield than CHA₂DS₂VASc, HAS‐BLED, and SAMeTT₂R₂.     

Low Rate of Atrial Fibrillation Recurrence Verified by Implantable Loop Recorder Monitoring Following a Convergent Epicardial and Endocardial Ablation of Atrial Fibrillation

Implantable Loop Recorder Monitoring Outcomes for the Convergent AF Procedure . Objective: Evaluate long‐term outcomes in patients undergoing the Convergent procedure (CP) for the treatment of atrial fibrillation (AF). Background: The CP provides a multidisciplinary approach, combining endoscopic creation of epicardial linear lesions followed by endocardial mapping and ablation and targets persistent and longstanding persistent AF patients who are at increased risk of heart failure, stroke, and mortality. Methods: Outcomes from a prospective nonrandomized study were recorded for consecutive patients by interrogation of implanted Reveal® monitors. Rhythm status and AF burden were quantified 6–24 months postprocedure, and compared relative to AF type, gender, age, body mass index, left atrial size, left ventricular ejection fraction, and congestive heart failure, hypertension, age >75 years, age between 65 and 74 years, stroke/TIA/TE, vascular disease (previous MI, peripheral arterial disease or aortic plaque), diabetes mellitus, female (CHA₂DS₂VASc). Results: A total of 50 patients were enrolled with 94% having persistent or longstanding persistent AF. There were 2 atrioesophageal fistulas reported. In one patient, the fistula resulted in death at 33 days postprocedure; in the second, the fistula was surgically repaired but patient died 8 months postprocedure from a CVI. After CP, 95% of patients were in sinus rhythm at 6‐month follow‐up; 88% at 12 months; and 87% at 24 months. The median AF burden recorded with Reveal XT monitors was 0.0%, 0.1%, and 0.1% at 6, 12, and 24 months with 81%, 81%, and 87% of patients reporting a burden less than 3%, respectively. Conclusion: Using 24 × 7 continuous loop recording, the CP demonstrated success in treating persistent and longstanding persistent AF patients. Endocardial mapping and catheter ablation with diagnostic confirmation of procedural success complemented the endoscopic creation of epicardial linear lesions in restoring sinus rhythm. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1059‐1066, October 2012)     

A tailored treatment strategy: a modern approach for stroke prevention in patients with atrial fibrillation

The main priority in atrial fibrillation (AF) management is stroke prevention, following which decisions about rate or rhythm control are focused on the patient, being primarily for management of symptoms. Given that AF is commonly associated with various comorbidities, risk factors such as hypertension, heart failure, diabetes mellitus and sleep apnoea should be actively looked for and managed in a holistic approach to AF management. The objective of this review is to provide an overview of modern AF stroke prevention with a focus on tailored treatment strategies. Biomarkers and genetic factors have been proposed to help identify ‘high‐risk’ patients to be targeted for oral anticoagulation, but ultimately their use must be balanced against that of more simple and practical considerations for everyday use. Current guidelines have directed focus on initial identification of ‘truly low‐risk’ patients with AF, that is those patients with a CHA₂DS₂‐VASc [congestive heart failure, hypertension, age ≥75 years (two points), diabetes mellitus, stroke (two points), vascular disease, age 65–74 years, sex category] score of 0 (male) or 1 (female), who do not need any antithrombotic therapy. Subsequently, patients with ≥1 stroke risk factors can be offered effective stroke prevention, that is oral anticoagulation. The SAMe‐TT₂R₂ [sex female, age <60 years, medical history (>2 comorbidities), treatment (interacting drugs), tobacco use (two points), race non‐Caucasian (two points)] score can help physicians make informed decisions on those patients likely to do well on warfarin (SAMe‐TT₂R₂ score 0–2) or those who are likely to have a poor time in therapeutic range (SAMe‐TT₂R₂ score >2). A clinically focused tailored approach to assessment and stroke prevention in AF with the use of the CHA₂DS₂VASc, HAS‐BLED [hypertension, abnormal renal/liver function (one or two points), stroke, bleeding history or predisposition, labile international normalized ratio, elderly (>65 years) drugs/alcohol concomitantly (one or two points)] and SAMeTT₂R₂ scores to evaluate stroke risk, bleeding risk and likelihood of successful warfarin therapy, respectively, is discussed.     

Use of neutrophil‐lymphocyte ratio for risk stratification and relationship with time in therapeutic range in patients with nonvalvular atrial fibrillation: A pilot study

Background

Atrial fibrillation is one of the most common abnormal heart rhythms. Neutrophil‐lymphocyte ratio (NLR) has emerged as a potential marker for the level of inflammation in cardiac disorders.

Hypothesis

NLR might be associated with thrombosis and bleeding risk scores and might predict cardioembolic risk in nonvalvular atrial fibrillation (NVAF) patients within the therapeutic international normalized ratio (INR).

Methods

We enrolled 272 patients taking warfarin for NVAF and classified them into 2 groups: Group A consisted of patients (n = 132) whose time in therapeutic range (TTR) was ≥65%, and Group B comprised patients (n = 139) whose TTR was <65%.

Results

NLR values were higher in group B than in group A (P < 0.0001). Patients classified as high risk according to CHA₂DS₂‐VASc score had significantly higher NLR levels (P = 0.002) than those classified as low and intermediate risk. Furthermore, NLR levels were significantly correlated with CHA₂DS₂‐VASc and HAS‐BLED scores (P < 0.001 and P < 0.0001, respectively). NLR predicted patients within therapeutic INR range (TTR ≥65%) with sensitivity of 81% and specificity of 71% in a receiver operator characteristic curve analysis, using a cutoff value of 2.17. Area under the curve for NLR was 0.81 (P < 0.0001).

Conclusions

To our knowledge, this is the first study showing correlation of NLR with both CHA₂DS₂‐VASc and HAS‐BLED risk scores. NLR might represent a useful marker to identify patients with high risks of stroke and bleeding and may have predictive value in identifying patients within the therapeutic INR range.     

CHA2DS2‐VASc and PESI scores are associated with right ventricular dysfunction on computed tomography pulmonary angiography in patients with acute pulmonary thromboembolism

BackgroundAccurate risk stratification is the most important step in the management of patients with acute pulmonary thromboembolism (PTE). Pulmonary embolism severity index (PESI) is a clinical tool for PTE risk stratification. CHA₂DS₂‐VASc score, a risk assessment tool in patients with atrial fibrillation, is recently considered for acute PTE. The presence of right ventricular (RV) dysfunction in imaging is more efficient in acute PTE risk evaluation.HypothesisThis study aims to evaluate the association between CHA₂DS₂‐VASc and PESI score and each of them with RV dysfunction on computed tomography pulmonary angiography (CTPA).MethodsOne hundred eighteen patients with a definite diagnosis of PTE were entered. The CHA₂DS₂‐VASc and PESI scores were calculated for all of them. RV dysfunction including an increase in RV to left ventricular diameter ratio, interventricular septal bowing, and reflux of contrast medium into the inferior vena cava was examined by CTPA.ResultsPESI and CHA₂DS₂‐VASc scores were significantly associated with RV dysfunction. In addition, different classes of PESI scores were correlated with RV dysfunction. Moreover, this study showed that the CHA₂DS₂‐VASc score and PESI score had a positive correlation. The area under the curve value for the CHA₂DS₂‐VASc score was 0.625 with 61.54% sensitivity and 60.0% specificity for predicting RV dysfunction while for PESI score was 0.635 with 66.7% sensitivity and 60.0% specificity.ConclusionThis study showed that not only CHA₂DS₂‐VASc and PESI scores are positively correlated, but they are both associated with RV dysfunction diagnosed by CTPA. CHA₂DS₂‐VASc and PESI scores are able to predict RV dysfunction.     

Can oral anticoagulants be stopped safely after a successful atrial fibrillation ablation?

Ablations of atrial fibrillation (AF) have become more widely performed, and the strategy about long-term usage of oral anticoagulants (OACs) after catheter ablation is an important issue, especially for patients without obvious evidences of recurrences. The annual rate of thromboembolic (TE) event after catheter ablation was less than 1%. CHADS₂ and CHA₂DS₂-VASc scores could be used to identify patients at the risk of TE events after ablations who should continue OACs regardless of the status of recurrence. Despite the improvement in understanding of AF and advancement of technology in catheter ablation, the long-term successful rates of paroxysmal and non-paroxysmal AF are around 50% and 30%, respectively. Patients with a high CHADS₂ score are at a high risk of recurrence which could continuously occur after the catheter ablation without reaching a plateau. Among the patients with a CHADS₂ score of ≥3, 26.9% of the recurrences happened 2 years post catheter ablation. Compared to the episodes of AF before catheter ablation, the AF episodes after ablation procedures are less symptomatic and shorter in duration. Therefore, it may not be safe to stop OACs for patients with a high risk score since the AF episodes are difficult to be detected after ablation procedures, but remain dangerous. In conclusion, the decision about the long-term strategy of OACs should be based on patients’ baseline clinical risk scores, such as CHADS₂ and CHA₂DS₂-VASc scores, rather than the status of recurrence.     

Relationship of Aging and Incident Comorbidities to Stroke Risk in Patients With Atrial Fibrillation

Background

When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA₂DS₂-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities.