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.     

Does CHA2DS2-VASc Improve Stroke Risk Stratification in Postmenopausal Women with Atrial Fibrillation?

Background

Risk stratification of atrial fibrillation patients with a congestive heart failure (C), hypertension (H), age ≥ 75 (A), diabetes (D), stroke or transient ischemic attack (TIA) (S₂) (CHADS₂) score of <2 remains imprecise, particularly in women. Our objectives were to validate the CHADS₂ and congestive heart failure (C), hypertension (H), age ≥ 75 (A₂), diabetes (D), stroke, TIA or prior thromboembolic disease (S₂)- vascular disease (V), age 65-74 (A), female gender (S) (CHA₂DS₂-VASc) stroke risk scores in a healthy cohort of American women with atrial fibrillation and to determine whether CHA₂DS₂-VASc further risk-stratifies individuals with a CHADS₂ score of <2.

Methods

We identified a cohort of 5981 women with atrial fibrillation not on warfarin at baseline (mean age 65.9 ± 7.2 years) enrolled in the Women's Health Initiative and followed for a median of 11.8 years. Univariate and multivariate proportional hazards analyses were used to examine these 2 risk scores, with main outcome measures being annualized event rates of ischemic stroke or transient ischemic attack stratified by risk score.

Results

Annualized stroke/transient ischemic attack rates ranged from 0.36% to 2.43% with increasing CHADS₂ score (0-4+) (hazard ratio [HR] 1.57; 95% confidence interval [CI], 1.45-1.71 for each 1-point increase) and 0.20%-2.02% with increasing CHA₂DS₂-VASc score (1-6+) (HR 1.50; 95% CI, 1.41-1.60 for each 1-point increase). CHA₂DS₂-VASc had a higher c statistic than CHADS₂: 0.67 (95% CI, 0.65-0.69) versus 0.65 (95% CI, 0.62-0.67), P <.01. For CHADS₂ scores <2, stroke risk almost doubled with every additional CHA₂DS₂-VASc point.

Conclusions

Although both CHADS₂, and CHA₂DS₂-VASc are predictive of stroke risk in postmenopausal women with atrial fibrillation, CHA₂DS₂-VASc further risk-stratifies patients with a CHADS₂ score <2.     

CHADS2, CHA2DS2-VASc,ATRIA, and Essen stroke risk scores in stroke with atrial fibrillation: A nationwide multicenter registry study

The performance of scoring systems for risk stratification in patients with atrial fibrillation (AF) was not validated well in patients with stroke. The purpose of this study was to evaluate whether the risk scoring systems predict vascular outcomes in stroke patients with AF.Data were obtained from a nationwide multicenter registry for acute stroke with AF from January 1, 2013, to December 31, 2015. We investigated the predictive power of the CHADS₂, CHA₂DS₂-VASc, ATRIA, and Essen stroke scores in stroke patients with AF. The subjects were further stratified into groups according to treatment with or without oral anticoagulants (OACs).A total of 3112 stroke with AF subjects were included. The rate of recurrent ischemic stroke and any stroke were not associated with the CHADS₂, CHA₂DS₂-VASc, ATRIA, and Essen stroke risk scores. The risks of death and major adverse cerebrovascular and cardiovascular events (MACEs) increased sequentially with the increase of each risk score in OAC group. (the range of C-index 0.544–0.558 for recurrent ischemic stroke; 0.523–0.537 for any stroke; 0.580–0.597 for death; 0.564–0.583 for MACEs). However, in the group treated with OACs, all risk scores were significantly associated with the risk of MACEs. The C-statistics of the 4 scoring systems were 0.544 to 0.558, 0.523 to 0.537, 0.580 to 0.597, 0.564 to 0.583, respectively, for recurrent ischemic stroke, any stroke, death, and MACEs.The performance of the CHADS₂, CHA₂DS₂-VASc, ATRIA, and Essen stroke risk scores for the prediction of recurrent stroke was unsatisfactory in stroke patients with AF whereas the performance for the prediction of recurrent stroke was not MACEs or death was good. A new risk stratification scheme that is specific for secondary stroke prevention in the AF population is needed.     

The CHADS2 and CHA2DS2-VASc scores predict adverse vascular function,ischemic stroke and cardiovascular death in high-risk patients without atrial fibrillation: Role of incorporating PR prolongation

Objectives

To investigate whether the CHADS₂ and CHA₂DS₂-VASc scores have clinical utility for prediction of adverse vascular function and vascular dysfunction-mediated incident cardiovascular (CV) events among high-risk patients without atrial fibrillation (AF), and the additional value of incorporating PR prolongation to the scores.

Methods

We analyzed 579 high-risk CV outpatients without clinical AF in a prospective cohort for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and CV death. Brachial flow-mediated dilation (FMD) and nitroglycerin-mediated dilatation (NMD), carotid intima-media thickness (IMT) and pulse wave velocity (PWV) were determined.

Results

Baseline CHADS₂ score was associated with lower FMD (Pearson r = −0.16, P < 0.001) and NMD (r = −0.17, P < 0.001), higher carotid IMT (r = 0.30, P < 0.001) and PWV (r = 0.35, P < 0.001; similar for CHA₂DS₂-VASc score: All P < 0.05). After follow-up of 63 ± 11 months, 82 patients (14.2%) developed combined CV endpoint. ROC curve analysis showed that both CHADS₂ and CHA₂DS₂-VASc scores were predictors for ischemic stroke (C-Statistic: CHADS₂ 0.70, P = 0.004; CHA₂DS₂-VASc 0.68, P = 0.010), MI (CHADS₂ 0.63, P = 0.030; CHA₂DS₂-VASc 0.70, P = 0.001), and CV death (CHADS₂ 0.63, P = 0.022; CHA₂DS₂-VASc 0.65, P = 0.011). Higher CHADS₂ score was associated with reduced event-free survival from combined CV endpoints (log-rank = 16.7, P < 0.001) with differences potentiated if stratified by CHA₂DS₂-VASc score (log-rank = 29.2, P < 0.001). Incorporating PR prolongation, the CHA₂DS₂-VASc-PR score achieved the highest C-Statistic for CV death prediction (0.70, P < 0.001) superior to the CHADS₂ score (chi-square: 12.1, P = 0.0005).

Conclusions

The CHADS₂ and CHA₂DS₂-VASc predict vascular dysfunction and cardiovascular events in high-risk CV patients without clinical AF, with further improved performance incorporating PR prolongation.     

R2CHADS2 Score and Thromboembolic Events After Catheter Ablation of Atrial Fibrillation in Comparison With the CHA2DS2-VASc Score

Background

A new risk model, the R₂CHADS₂ (Renal Dysfunction, Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) score, was proposed to be a powerful scoring scheme in predicting stroke or systemic embolism in atrial fibrillation (AF). The goal of the present study is to validate the usefulness of the R₂CHADS₂ score among patients with AF after catheter ablation. We also aimed to compare the accuracy of the CHA₂DS₂-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 y], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 y], Sex [Female]) and R₂CHADS₂ scores for risk stratification of thromboembolic (TE) events after ablation procedures.

Methods

We enrolled a total of 526 patients with AF who underwent catheter ablation. The clinical end point was the occurrence of TE events (ischemic stroke, transient ischemic attack, or other systemic embolisms) during the postablation follow-up.

Results

During a follow-up of 37.5 ± 21.3 months, 14 patients (2.7%) experienced TE events. The R₂CHADS₂ score was an independent predictor of TE events in the multivariate analysis. Patients with an R₂CHADS₂ score of > 2 had a higher event rate compared with those with a score of 0 or 1 (0.5% vs 7.7%). The areas under the receiver operating characteristic (ROC) curves of CHA₂DS₂-VASc and R₂CHADS₂ scores in predicting TE events were 0.832 and 0.872, respectively. The difference between these 2 curves did not reach statistical significance (P = 0.338). In addition, the R₂CHADS₂ score did not improve net stroke risk reclassification over the CHA₂DS₂-VASc score (net reclassification improvement, −0.9%; P = 0.948).

Conclusions

The R₂CHADS₂ and CHA₂DS₂-VASc scores could be used to predict TE events for patients with AF undergoing catheter ablation. The predictive accuracy of both scores were similar in this relatively small cohort undergoing ablation.     

Predictive value of the CHA2DS2-VASc score in atrial fibrillation patients at high risk for stroke despite oral anticoagulation

Introduction and objectives

The risk of stroke in atrial fibrillation is heterogeneous and depends upon underlying clinical conditions included in current risk stratification schemes. Recently, the CHA₂DS₂-VASc score has been included in guidelines to be more inclusive of common stroke risk factors seen in everyday clinical practice, and useful in defining “truly low risk” subjects. We aimed to assess the usefulness of CHA₂DS₂-VASc score to give us an additional prognostic perspective for adverse events and mortality among “real world” anticoagulated patients with atrial fibrillation who are often elderly with many comorbidities.

Methods

Consecutive outpatients with permanent/paroxysmal nonvalvular atrial fibrillation with CHA₂DS₂-VASc≥2 and stabilized oral anticoagulation (international normalized ratio 2.0-3.0) for at least the preceding 6 months were recruited. Patients with CHA₂DS₂-VASc≥2 were selected. Adverse cardiovascular events including stroke, acute coronary syndrome, or heart failure; major bleeds; and mortality were recorded during more than 2.5-year-follow-up.

Results

Of 933 patients (93.5%) assessed, 432 were males, median age 76 (71-81) years. After a follow-up of 946 (782-1068) days, 109 patients (11.7%) had adverse cardiovascular events, 80 patients (8.6%) had major bleeds, 101 patients (10.8%) died, and 230 (24.6%) had major adverse events (composite end-point). Increasing CHA₂DS₂-VASc score by 1 point had a significant impact on the occurrence of cardiovascular events (hazard ratio=1.27; 95% confidence interval, 1.13-1.44; P<.001), mortality (hazard ratio=1.36; 95% confidence interval, 1.19-1.54; P<.001); and major adverse events (hazard ratio=1.23; 95% confidence interval, 1.13-1.34; P<.001). CHA₂DS₂-VASc score was not associated with major bleeding episodes.

Conclusions

Among high risk atrial fibrillation patients on oral anticoagulation, CHA₂DS₂-VASc successfully predicts cardiovascular events and mortality, but not major bleeds.Full English text available from:www.revespcardiol.org     

Hyperuricemia and the risk of ischemic stroke in patients with atrial fibrillation — Could it refine clinical risk stratification in AF?

Background

Although hyperuricemia has been reported to be a risk factor of stroke, the relationship between hyperuricemia and stroke in patients with atrial fibrillation (AF) remains uncertain. The goal of the present study was to investigate whether hyperuricemia could potentially refine clinical risk stratification in AF.

Methods

This study used the “National Health Insurance Research Database” in Taiwan. A total of 7601 AF patients who did not receive antiplatelet agents or oral anticoagulants were identified as the study population. Hyperuricemia was defined as having at least one episode of gout attack necessitating long-term treatment with uric acid-lowering agents. The association between hyperuricemia and ischemic stroke was analyzed.

Results

During the follow up of 3.0 ± 2.7 years, 1116 patients (14.7%) experienced ischemic stroke with an annual rate of around 4.9%. Hyperuricemia significantly predicts stroke, with a hazard ratio (HR) of 1.280 after adjusting for CHA₂DS₂-VASc score and other comorbidities. Among the 376 patients with a CHA₂DS₂VASc score of 0, hyperuricemia can further stratify them into 2 groups with different stroke rates (7.1% versus 1.3%, p = 0.020). The adjusted HR of hyperuricemia in predicting ischemic stroke diminished from 7.491 for patients with a CHA₂DS₂-VASc score of 0 to 1.659 for those with a score of 3, and became insignificant for patients with a score ≥ 4.

Conclusions

Hyperuricemia was a significant risk factor of stroke which could potentially refine the clinical risk stratification in AF. It deserves a prospective trial to investigate whether it would change the current strategy for stroke preventions using oral anticoagulants.     

Study on the predictive ability of emergency CHADS2 score and CHA2DS2-VASc score for coronary artery disease and prognosis in patients with acute ST-segment elevation myocardial infarction

BackgroundAcute ST-segment elevation myocardial infarction (STEMI) has a high morbidity and mortality rate. The congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack (2 points) (CHADS₂) and CHADS₂ score with 2 points assigned for age >75 years-vascular disease (CHA₂DS₂-VASc) scores are widely used for risk stratification management of non-valvular atrial fibrillation stroke and have high prognostic value in cardiovascular disease. This study aims to investigate the predictive value of the emergency CHADS₂ and CHA₂DS₂-VASc score on coronary artery lesions and prognosis in patients with acute STEMI.MethodsA total of 524 patients with STEMI from May 2018 to October 2021 were selected for emergency CHADS₂ and CHA₂DS₂-VASc. Clinical data and laboratory indicators were collected. Patients were evaluated for coronary artery disease (CAD) and prognosis. Logistic regression and the receiver operating characteristic (ROC) curve were used to analyze the data.ResultsIn severe group, CysC levels, CHADS₂, CHA₂DS₂-VASc score and the proportion of diabetes, stroke or transient ischemic attack (TIA), congestive heart failure, smoking history, Killip class ≥2 was higher than that in mild and moderate group. In poor prognosis group, levels of serum creatinine (Crea), CysC, hemoglobin (Hb), CHADS₂, CHA₂DS₂-VASc score and the proportion of hypertension, diabetes, stroke or TIA, congestive heart failure, smoking history, and Killip class ≥2 was higher than that in good prognosis group. Diabetes (OR, 3.678; 95% CI: 2.876–5.872, 0.008), CHADS₂ (OR, 3.829; 95% CI: 2.310–5.832, 0.003) and CHA₂DS₂-VASc score (OR, 4.671; 95% CI: 3.125–6.187, 0.000) were independent risk factors for the severity of CAD (P<0.05). Diabetes (OR, 3.287; 95% CI: 2.231–5.123, 0.012), Killip class ≥2 (OR, 2.212; 95% CI: 1.023–2.987, 0.045), LVEF (OR, 3.110; 95% CI: 2.124–5.031, 0.023), CHADS₂ (OR, 3.228; 95% CI: 2.133–5.886, 0.005) and CHA₂DS₂-VASc score (OR, 3.988; 95% CI: 2.987–5.873, 0.001) were independent risk factors for prognosis of acute STEMI patients. Area under curve (AUC) value of CHA₂DS₂-VASc score in evaluating CAD and prognosis was 0.947, 0.931, higher than that of the CHADS₂ score (0.836, 0.812) (P<0.05).ConclusionsMultiple factors jointly affect the severity and prognosis of CAD in patients with acute STEMI. The CHA₂DS₂-VASc score is better than the CHADS₂ score in predicting the severity of coronary artery lesions and prognosis of patients, providing theoretical support for clinical practice.     

Improving Stroke Risk Stratification in Atrial Fibrillation

Risk factors for stroke and thromboembolism in patients with atrial fibrillation used in current risk stratification schema are derived largely from analyses of clinical trial cohorts, and the available data depend on the comprehensiveness of trial reports and whether specific risk factors were sought. The most commonly used schema is the Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] (CHADS₂) score. Although simple and well validated, some limitations of CHADS₂ this schema are apparent. A more recent approach to risk stratification of patients with nonvalvular atrial fibrillation defines “major (definitive)” risk factors (eg, previous stroke/transient ischemic attack and age ≥ 75 years) and “clinically relevant non-major” risk factors (eg, heart failure, hypertension, diabetes, female gender, age 65-75 years, and atherosclerotic vascular disease). This scheme can be expressed as an acronym, CHA₂DS₂-VASc, denoting Cardiac failure or dysfunction, Hypertension, Age ≥ 75 [Doubled], Diabetes, Stroke [Doubled]-Vascular disease, Age 65-74, and Sex category [Female]), whereby 2 points are assigned for a history of stroke or age 75 years or more and 1 point each is assigned for age 65 to 74 years, a history of hypertension, diabetes, cardiac failure, and vascular disease. Patients with 1 definitive risk factor or a patient with a CHA₂DS₂-VASc score of 1 or more could be considered for oral anticoagulation, but a patient with a CHA₂DS₂-VASc score of 0 is truly low risk and could be managed with no antithrombotic therapy. This would simplify our approach to thromboprophylaxis in patients with atrial fibrillation.     

CHADS2 versus CHA2DS2-VASc score in assessing the stroke and throm-boembolism risk stratification in patients with atrial fibrillation: a systematic review and meta-analysis

Objective To perform a systematic review and meta-analysis of the predictive abilities of CHADS2 and CHA2DS2-VASc in stroke and thromboembolism risk stratification of atrial fibrillation (AF) patients....     

Using the CHA2DS2-VASc Score for Refining Stroke Risk Stratification in ‘Low-Risk’ Asian Patients With Atrial Fibrillation

Background

A new scoring system, the anticoagulation and risk factors in atrial fibrillation (ATRIA) score, was proposed for risk stratification in patients with atrial fibrillation (AF). Whether the ATRIA scheme can adequately identify patients who are at low risk of ischemic stroke remains unknown.

Objectives

The goal of the present study was to compare the performance of ATRIA to that of CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65 to 74, female) scores for stroke prediction.

Methods

This study used the National Health Insurance research database in Taiwan. A total of 186,570 AF patients without antithrombotic therapy were selected as the study cohort. The clinical endpoint was the occurrence of ischemic stroke.

Results

During the follow-up of 3.4 ± 3.7 years, 23,723 patients (12.7%) experienced ischemic stroke. The CHA₂DS₂-VASc score performed better than ATRIA score in predicting ischemic stroke as assessed by c-indexes (0.698 vs. 0.627, respectively; p < 0.0001). The CHA₂DS₂-VASc score also improved the net reclassification index by 11.7% compared with ATRIA score (p < 0.0001). Among 73,242 patients categorized as low-risk on the basis of an ATRIA score of 0 to 5, the CHA₂DS₂-VASc scores ranged from 0 to 7, and annual stroke rates ranged from 1.06% to 13.33% at 1-year follow-up and from 1.15% to 8.00% at 15-year follow-up. The c-index of CHA₂DS₂-VASc score (0.629) was significantly higher than that of the ATRIA score (0.593) in this “low-risk” category (p < 0.0001).

Conclusions

Patients categorized as low-risk by use of the ATRIA score were not necessarily low-risk, and the annual stroke rates can be as high as 2.95% at 1-year follow-up and 2.84% at 15-year follow-up. In contrast, patients with a CHA₂DS₂-VASc score of 0 had a truly low risk of ischemic stroke, with an annual stroke rate of approximately 1%.     

Severity of Hypertension Correlates with Risk of Thromboembolic Stroke

Hypertension plays a significant role in the development of atrial fibrillation (AF) and its complications. The coexistence of the two diseases increases the risk of thromboembolism events. Although CHADS₂ and CHA₂DS₂-VASc scores have been used in the evaluation of the thromboembolism events in AF patients, the different levels of the blood pressure are not appropriately recognized. In this study, the 970 AF patients were divided into three groups according to the severity of hypertension. The CHADS₂ and CHA₂DS₂-VASc scores in the patients of grade 3 hypertension were significantly higher than those of the patients with grade 1 and 2 hypertension, respectively (P < 0.05). Both the CHADS₂ and CHA₂DS₂-VASc scores were positively related to the severity of hypertension (P < 0.001). Our data demonstrated that three grades for hypertensive subjects with AF significantly improved antithrombotic risk stratification in addition to current clinical risk stratification models, such as CHADS₂ and CHA₂DS₂-VASc scores.     

Discontinuing anticoagulation following successful atrial fibrillation ablation in patients with prior strokes

Purpose

This study was conducted to examine the outcomes in patients with prior stroke/transient ischemic attack (CVA/TIA) after atrial fibrillation (AF) ablation and the feasibility of discontinuing oral anticoagulation (OAC).

Methods

This study examined long-term outcomes following AF ablations in 108 patients with a history of prior thromboembolic CVA/TIA. Because of risks of OAC, we frequently discontinue OAC in these patients after successful ablation. These patients understand the risks/benefits of discontinuing OAC and remain on OAC for a longer time following successful AF ablation, compared to our patients without prior CVA/TIA.

Results

Patient age was 66.2?±?9.0 years with an average CHADS₂ score?=?3.0?±?0.9 and CHA₂DS₂-VASc score?=?4.1?±?1.4. Following 1.24 ablations, 71 (65.7 %) patients were AF free 2.8?±?1.6 (median 2.3)?years after their last ablation. OAC was discontinued in 55/71 (77.5 %) patients an average of 7.3 months following the final ablation. These 55 patients had 2.2?±?1.3 (median 1.8)?years of follow-up off of OAC. Kaplan–Meier analysis suggests little AF recurrence >1 year following initial or final ablations, suggesting that 1 year post successful ablation may be the appropriate time to consider discontinuing OAC. Thirty-seven patients had AF postablation, and 32/37 (86.5 %) remained on OAC. One patient with a mechanical valve had a stroke despite OAC. Bleeding occurred in 8.3 % of patients on OAC and 0 % of patients off OAC (P?=?0.027).

Conclusions

Patients with prior CVA/TIAs, who undergo successful AF ablation, have a low incidence of subsequent thromboembolic events. Most patients who appear AF free postablation may be able to discontinue OAC after successful ablation with a low thromboembolic risk and with a reduced bleeding risk.     

CHA2DS2-VASc versus CHADS2 for stroke risk assessment in low-risk patients with atrial fibrillation: a pilot study from a single center of the NCDR-PINNACLE registry

The CHADS₂ score is widely used to assess the risk of stroke in patients with atrial fibrillation (AF). Patients with score of 0 and 1 are considered ‘low risk’ and are often treated with aspirin. In a Danish Study, the CHA₂DS₂-VASc score was shown to identify low and high-risk subgroups among patients with CHADS₂ score of 0 and 1, with annual risk ranging from 0.84 to 8.18 %. This study seeks to assess whether using CHA₂DS₂-VASc score will identify high-risk subset of patients with low CHADS₂ scores in an American population. This pilot study examined data from our cardiology fellowship ambulatory clinics from January 2009 to May 2012 using the NCDR-PINNACLE registry. Each cardiology fellow entered patients’ data using on-line software developed by the American College of Cardiology. Among 2,048 patients followed at our clinics, 478 had AF. Of those, 161 patients had CHADS₂ score of 0 (44 patients) or 1 (117 patients). Calculating the CHA₂DS₂-VASc score in these patients, 12 (7.4 %) had score of 0, 50 (31.1 %) had score of 1, 66(41 %) had score of 2, 31 (19.3 %) had score of 3 and 2 (1.2 %) had score of 4. Using original CHADS₂ recommendation, warfarin would not be strongly recommended in any of these patients. Utilizing the CHA₂DS₂-VASc score, 61.5 % of the 161 patients would have a score of 2 or more signifying increased risk where anticoagulation may be indicated. Compared to CHADS₂, CHA₂DS₂-VASc may more precisely predict the risk of stroke and anticoagulation strategy in low-risk patients with non-valvular AF.     

Comparative assessment of published atrial fibrillation stroke risk stratification schemes for predicting stroke,in a non-atrial fibrillation population: The Chin-Shan Community Cohort Study

Background

In patients at high risk of stroke, such as atrial fibrillation (AF), there has been great interest in developing stroke risk prediction schemes for identifying those at high risk of stroke. Stroke risk prediction schemes have also been developed in non-AF populations, but are limited by lack of simplicity, which is more evident in schemes used in AF populations. We hypothesized that contemporary stroke risk stratification schemes used in assessing AF patients could predict stroke and thromboembolism in a non-AF community population, comparably to that seen in AF populations.

Methods

We tested the CHADS₂ and CHA₂DS₂-VASc schemes, as well as the AF stroke risk stratification schemes from the Framingham study, Rietbrock et al., 2006 ACC/AHA/ESC guidelines, the 8th American College of Cardiology (ACCP) guidelines and NICE, for predicting stroke in a large community cohort of non-AF subjects, the Chin-Shan Community Cohort Study.

Results

The tested schemes had variable classification into low, moderate and high risk strata, with the proportion classified as low risk ranging from 5.4% (Rietbrock et al. to 59.0% (CHADS₂ classical). Rates of stroke also varied in those classified as ‘low risk’ ranging from 1.1% (Rietbrock et al. to 3.5% (Framingham). All common risk schemes had broadly similar c-statistics, ranging from 0.658 (Framingham) to 0.728 (CHADS₂ classical) when assessed as a continuous risk variable for predicting stroke in this population, with clear overlap between the 95% CIs. In an exploratory analysis amongst AF subjects in our population, the c-statistics were broadly similar to those seen in non-AF subjects.

Conclusion

Contemporary stroke risk stratification schema used for AF can also be applied to non-AF populations with a similar (modest) predictive value. Given their simplicity (e.g. CHADS₂ score), these scores could potentially be used for a ‘quick’ evaluation of stroke risk in non-AF populations, in a similar manner to AF populations.     

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.     

Prevalencia de la fibrilación auricular desconocida y la no tratada con anticoagulantes. Estudio AFABE

Introduction and objectives

Atrial fibrillation constitutes a serious public health problem because it can lead to complications. Thus, the management of this arrhythmia must include not only its treatment, but antithrombotic therapy as well. The main goal is to determine the proportion of cases of undiagnosed atrial fibrillation and the proportion of patients not being treated with oral anticoagulants.

Methods

A multicenter, population-based, retrospective, cross-sectional, observational study. In all, 1043 participants over 60 years of age were randomly selected to undergo an electrocardiogram in a prearranged appointment. Demographic data, CHA₂DS₂-VASc and HAS-BLED scores, international normalized ratio results, and reasons for not receiving oral anticoagulant therapy were recorded.

Results

The overall prevalence of atrial fibrillation was 10.9% (95% confidence interval, 9.1%-12.8%), 20.1% of which had not been diagnosed previously. In the group with known atrial fibrillation, 23.5% of those with CHA₂DS₂-VASc≥2 were not receiving oral anticoagulant therapy, and 47.9% had a HAS-BLED score≥3. The odds ratio for not being treated with oral anticoagulation was 2.04 (95% confidence interval, 1.11-3.77) for women, 1.10 (95% confidence interval, 1.05-1.15) for more advanced age at diagnosis, and 8.61 (95% confidence interval 2.38-31.0) for a CHA₂DS₂-VASc score<2. Cognitive impairment (15.2%) was the main reason for not receiving oral anticoagulant therapy.

Conclusions

The prevalence of previously undiagnosed atrial fibrillation in individuals over 60 years of age is 20.1%, and 23.5% of those who have been diagnosed receive no treatment with oral anticoagulants.Full English text available from:www.revespcardiol.org/en     

Albuminuria improves R2CHA2DS2-VASc score in predicting mortality in high cardiovascular risk population

Background and aimsThe CHA₂DS₂-VASc score estimates the risk of cardioembolism in patients with atrial fibrillation (AF). It also predicts vascular events and death in different clinical settings, even in the absence of AF. The R₂CHA₂DS₂-VASc score, obtained by adding the glomerular filtration rate to CHA₂DS₂-VASc, shows a higher prediction ability for new events and all-cause mortality.The present study aims to assess whether the addition of albuminuria to R₂CHA₂DS₂-VASc score further improves its discrimination ability in predicting all-cause mortality in a sample of high cardiovascular risk population.Methods and ResultsProspective, monocentric, observational study, evaluating a subset of 737 subjects consecutively undergoing to coronary angiography at Coronary Unit of Scientific Institute “Casa Sollievo della Sofferenza” from June 2016 to December 2018.The presence of albuminuria was significantly associated with all-cause mortality (p < 0.0001). Any one-point increase of Alb-R₂CHA₂DS₂-VASc score increased mortality of about 1.5-fold (adjusted HR 1.49; 95%CI: 1.37–1.63; p < 0.0001). Considering tertiles of Alb-R₂CHA₂DS₂-VASc, the third tertile showed a 9.5-fold increased risk of mortality (HR 9.52; 95% CI: 5.15–17.60, p < 0.001).Comparing the two scores, the Alb-R₂CHA₂DS₂-VASc score (C-statistic = 0.751; 95%CI: 0.69–0.81) outperformed the R₂-CHA₂DS₂-VASc score (C-statistic = 0.736; 95%CI: 0.68–0.961) in predicting mortality (delta C-statistic = 0.015; 95%CI: 0.001–0.029). The better prediction ability of the Alb-R₂CHA₂DS₂-VASc score was also proven by an IDI of 0.024 (p < 0.0001) and a relative IDI of 24.11% (p < 0.0001), with an NRI = 0.608 (p < 0.00001).ConclusionsThe addition of albuminuria to R₂CHA₂DS₂-VASc significantly and independently predicts the risk of all-cause mortality in a sample of high CV risk patients. Moreover, Alb-R₂CHA₂DS₂-VASc outperforms R₂CHA₂DS₂-VASc.