Fibrilación auricular en pacientes con COVID-19. Utilidad de la puntuación CHA2DS2-VASc: un análisis del registro internacional HOPE COVID-19

Introduction and objectivesCoronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2. Atrial fibrillation (AF) is common in acute situations, where it is associated with more complications and higher mortality.MethodsAnalysis of the international HOPE registry (NCT04334291). The objective was to assess the prognostic information of AF in COVID-19 patients. A multivariate analysis and propensity score matching were performed to assess the relationship between AF and mortality. We also evaluated the impact on mortality and embolic events of the CHA₂DS₂-VASc score in these patients.ResultsAmong 6217 patients enrolled in the HOPE registry, 250 had AF (4.5%). AF patients had a higher prevalence of cardiovascular risk factors and comorbidities. After propensity score matching, these differences were attenuated. Despite this, patients with AF had a higher incidence of in-hospital complications such as heart failure (19.3% vs 11.6%, P = .021) and respiratory insufficiency (75.9% vs 62.3%, P = .002), as well as a higher 60-day mortality rate (43.4% vs 30.9%, P = .005). On multivariate analysis, AF was independently associated with higher 60-day mortality (hazard ratio, 1.234; 95%CI, 1.003-1.519). CHA₂DS₂-VASc score acceptably predicts 60-day mortality in COVID-19 patients (area ROC, 0.748; 95%CI, 0.733-0.764), but not its embolic risk (area ROC, 0.411; 95%CI, 0.147-0.675).ConclusionsAF in COVID-19 patients is associated with a higher number of complications and 60-day mortality. The CHA₂DS₂-VASc score may be a good risk marker in COVID patients but does not predict their embolic risk.     

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.     

Riesgo hemorrágico y embólico de los pacientes con fibrilación auricular y cáncer

Introduction and objectivesThe impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF.MethodsThe study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk.ResultsNo association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHA₂DS₂-VASc and HAS-BLED scores showed suboptimal performance to predict embolic and bleeding risk (c-statistic < 0.50), respectively, in nonanticoagulated patients with active cancer. The ratio between the increase in bleeding and the decrease in embolisms with anticoagulation was similar in patients with and without cancer (5.6 vs 7.8; P < .001).ConclusionsCancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA₂DS₂-VASc and HAS-BLED scores to predict embolic and bleeding events, respectively, in nonanticoagulated patients.Full English text available from:www.revespcardiol.org/en     

HAS-BLED and CHA2DS2-VASc Scores as Predictors of Bleeding and Thrombotic Risk After Continuous-Flow Ventricular Assist Device Implantation

BackgroundHAS-BLED and CHA₂DS₂-VASc scores predict bleeding in patients on anticoagulation and thromboembolic (TE) risk in patients with atrial fibrillation, respectively. We hypothesized that these scores would be predictive of bleeding and TE complications following continuous-flow ventricular assist device (CF-VAD) implantation.Methods and ResultsBaseline HAS-BLED and CHA₂DS₂-VASc scores were retrospectively determined for 173 consecutive patients who underwent HeartMate II CF-VAD implantation at a single center from 2005 to 2011. Forty-three patients had bleeding (24.9%) and 22 had TE (12.7%) events over a 290 patient-year follow-up period. The mean ± SD HAS-BLED scores were 2.7 ± 1.0 and 1.9 ± 1.1 (P < .0001) in patients with and without bleeding, respectively. The CHA₂DS₂-VASc scores were 3.6 ± 1.4 and 2.9 ± 1.5 (P = .03) in patients with and without TE events, respectively. A HAS-BLED score of ≥3 was associated with a significantly higher risk of bleeding events compared with a score of <3 (42% vs 15%, respectively; hazard ratio [HR] 3.40, 95% confidence interval [CI] 1.82–6.32; P < .001). A CHA₂DS₂-VASc score of ≥3 was associated with a higher risk of TE events compared with a score of <3 (18% vs 4%, respectively; HR 4.02, 95% CI 1.19–13.6; P = .025).ConclusionsBaseline HAS-BLED and CHA₂DS₂-VASc scores of ≥3 conferred significantly higher risks of bleeding and TE, respectively, following HeartMate II implantation.     

Impact of the CHA2DS2-VASc score on anticoagulation recommendations for atrial fibrillation

BackgroundThe Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke (CHADS₂) score is used to predict the need for oral anticoagulation for stroke prophylaxis in patients with atrial fibrillation. The Congestive heart failure, Hypertension, Age ≥ 75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65-74 years, Sex category (CHA₂DS₂-VASc) schema has been proposed as an improvement. Our objective is to determine how adoption of the CHA₂DS₂-VASc score alters anticoagulation recommendations.MethodsBetween 2004 and 2008, 1664 patients were seen at the University of Virginia Atrial Fibrillation Center. We calculated the CHADS₂ and CHA₂DS₂-VASc scores for each patient. The 2006 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for atrial fibrillation management were used to determine anticoagulation recommendations based on the CHADS₂ score, and the 2010 European Society of Cardiology guidelines were used to determine anticoagulation recommendations based on the CHA₂DS₂-VASc score.ResultsThe average age was 62 ± 13 years, and 34% were women. Average CHADS₂ and CHA₂DS₂-VASc scores were 1.1 ± 1.1 and 1.8 ± 1.5, respectively (P <.0001). The CHADS₂ score classified 33% as requiring oral anticoagulation. The CHA₂DS₂-VASc score classified 53% as requiring oral anticoagulation. For women, 31% had a CHADS₂ score ≥ 2, but 81% had a CHA₂DS₂-VASc score ≥ 2 (P =  .0001). Also, 32% of women with a CHADS₂ score of zero had a CHA₂DS₂-VASc score ≥ 2. For men, 25% had a CHADS₂ score ≥ 2, but 39% had a CHA₂DS₂-VASc score ≥ 2 (P <.0001).ConclusionCompared with the CHADS₂ score, the CHA₂DS₂-VASc score more clearly defines anticoagulation recommendations. Many patients, particularly older women, are redistributed from the low- to high-risk categories.     

The Impact of CHA2DS2-VASc and HAS-BLED Scores on Clinical Outcomes in the Amplatzer Amulet Study

ObjectivesThe aim of this study was to evaluate the impact of CHA₂DS₂-VASc and HAS-BLED scores on ischemic and bleeding events of patients enrolled in the Amplatzer Amulet Observational Study.BackgroundBaseline CHA₂DS₂-VASc and HAS-BLED scores have been validated in atrial fibrillation patients to guide about anticoagulation but not in patients treated by left atrial appendage occlusion (LAAO).MethodsSubjects were stratified according to CHA₂DS₂-VASc and HAS-BLED scores. Clinical outcomes were collected through 2 years and adjudicated by an independent committee.ResultsSubjects were considered at low (n = 156), moderate (n = 715), and high (n = 215) risk for ischemic stroke, corresponding to CHA₂DS₂-VASc scores of <3, 3 to 5, and ≥6, respectively. The annual rates of ischemic stroke were 1.1%, 2.0%, and 3.5%, respectively. When compared with the predicted rate, LAAO reduced the risk of ischemic stroke by 56%, 69%, and 68%. Device-related thrombus occurred in 0.7%, 1.5%, and 3.0% of subjects at low, moderate, and high risk for ischemic stroke, respectively. The HAS-BLED score was ≤3 in 629 subjects and >3 in 456 subjects, respectively. Non-peri-procedural major bleeding was reduced by 11% and 9% compared with predicted rates in the low and high bleeding risk groups, respectively.ConclusionsLAAO with the Amplatzer Amulet reduced the risk of ischemic stroke compared with the predicted rate, with a greater magnitude among patients at high thromboembolic risk without increasing the bleeding risk. (Amplatzer™Amulet™ Post-Market Study [Amulet™PMS]; NCT02447081)     

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.     

Stroke and Bleeding Risk Co-distribution in Real-world Patients with Atrial Fibrillation: The Euro Heart Survey

BackgroundThe choice to recommend antithrombotic therapy to patients with atrial fibrillation should rely on cardioembolic and bleeding risk stratification. Sharing some risk factors, schemes to predict thrombotic and bleeding risk are expected not to be independent, yet the degree of their association has never been clearly quantified.MethodsWe described the cardioembolic (Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack [CHADS₂]/Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack, Vascular disease, Age 65-75, Sex category i.e. females [CHA₂DS₂-VASc]) and bleeding risk (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly [HAS-BLED]) co-distribution among patients of the Euro Heart Survey on atrial fibrillation. We measured the within-patient correlation (Spearman) and concordance between the 2 types of score and score-based risk categorization (low, intermediate, high). The score-based predicted risk co-classification was then related to the observed 1-year stroke and bleeding occurrence.ResultsIn 3920 patients, we found a between-scores correlation of 0.416 (P < .001) between HAS-BLED and CHADS₂, and 0.512 (P < .001) between HAS-BLED and CHA₂DS₂-VASc. In 89% (CHADS₂/HAS-BLED) and 97% (CHA₂DS₂-VASc/HAS-BLED) of patients, the bleeding risk category was equal to or lower than their cardioembolic risk category (P < .001 for symmetry test). A complete concordance between risk categories was found in 39.6% (CHADS₂/HAS-BLED) and 21.7% (CHA₂DS₂-VASc/HAS-BLED) of patients; 4.4% (CHADS₂/HAS-BLED) and 7.7% (CHA₂DS₂-VASc/HAS-BLED) of patients had high cardioembolic risk/low bleeding risk or vice versa. A tendency for an increasing frequency of stroke was observed for increasing bleeding risk within cardioembolic risk categories and vice versa.ConclusionsIn a real-world population with atrial fibrillation, we confirmed that the cardioembolic and bleeding risk classifications are correlated but not exchangeable. It is then worth verifying the advantages of a strategy adopting a combined risk assessment over a strategy relying only on the cardioembolic risk evaluation.     

Prediction of acute-coronary-syndrome using newly-defined R2-CHA2DS2-VASc score among patients with chest pain

BackgroundChest-pain patients with no evidence of acute coronary syndrome might still be at risk for adverse outcomes. Adding renal function to the classic scoring of CHADS and CHA₂DS₂ VASC may improve risk stratification of chest-pain patients discharged from internal medicine wards after acute coronary syndrome (ACS) rule-out.MethodsWe accessed medical records of patients admitted to internal medicine wards during 2010–2016 and discharged following ACS rule-out. A R₂CHA₂DS₂-VASc score model that included higher scores as kidney function deteriorated was calculated and compared to CHADS and CHA₂DS₂ VASC scores. The primary endpoint was the composite of 30-day ACS and mortality. One-year ACS and 1-year mortality were the secondary endpoints. The study included 12,449 patients, stratified into three risk groups according to their R₂CHA₂DS₂-VASc score.ResultsParticipants were stratified into 3 groups according to R₂CHA₂DS₂-VASc score. R₂CHA₂DS₂-VASc score predicted better the composite outcome of ACS and 30-day and 1-year mortality after discharge (OR: 4, 95%, CI 2.3–7, p < 0.01 and OR: 13.3, 95% CI 7.8–22.7, p < 0.01, respectively). Receiver operating characteristic curve analysis showed better risk stratification of the R₂CHA₂DS₂-VASc compared with both CHADS and CHA₂DS₂ VASC score.ConclusionsThe R₂CHA₂DS₂-VASc score is a better predictor of short- and long-term cardiovascular morbidity and mortality after hospital discharge.     

The CHA2DS2-VASc score and Geriatric Multidimensional Assessment tools in elderly patients with persistent atrial fibrillation undergoing electrical cardioversion. A link with arrhythmia relapse?

IntroductionThe CHA₂DS₂-VASc score is widely used for stroke risk stratification in patients with atrial fibrillation (AF). Our endpoints were to evaluate in an old population undergoing electrical cardioversion (ECV) of persistent AF if the CHA₂DS₂-VASc was associated with some of the Geriatric Multidimensional Assessment tools and with the presence of sinus rhythm at the follow-up.MethodsWe enrolled all the consecutive patients admitted in a day-hospital setting aged ≥60 years. The Mini-Mental State Examination (MMSE; neurocognitive function), the 15-item Geriatric Depression Scale (GDS; depressive symptoms) and the Short Physical Performance Battery (SPPB; physical functioning) were administered before ECV.ResultsBetween 2017 and 2019, 134 patients were enrolled (mean age: 77±9 years, range: 60-96; men: 63.4%; EF: 60±12%). Hypertension was the most frequent comorbid condition (82.1%). The CHA₂DS₂-VASc score was 3.8±1.6. Abnormal values of MMSE, GDS and SPPB were observed in 7.9, 19.8 and 22.3% of cases, respectively. There were significant correlations between the CHA₂DS₂-VASc score and the MMSE (p=0.008), the GDS (p<0.001) and the SPPB (p<0.001). Depressive symptoms increased CHA₂DS₂-VASc correlation with SPPB of about 20%. CHA₂DS₂-VASc score was higher in patients with arrhythmia relapse (p=0.048; mean length of follow-up: 195 days). This association persisted even after adjustment for amiodarone therapy.ConclusionsThe CHA₂DS₂-VASc score significantly correlated with neuro-cognitive performance, depressive symptoms and physical functioning. It was also associated with AF relapse. Accordingly, in the elderly, the CHA₂DS₂-VASc could help quantify thrombo-embolic risk, give an indication of frailty status and help to choose between a rate- and a rhythm-control strategy.     

Importance of Risk Reassessment in Patients With Atrial Fibrillation in Guidelines: Assessing Risk as a Dynamic Process

The appropriate use of oral anticoagulants (OACs) for prevention of stroke in atrial fibrillation (AF) relies on the convenient and accurate stroke risk-prediction scheme: namely, the CHA₂DS₂-VASc score. As patients with AF would become older and accumulate more comorbidities, their risks—for example, as reflected by the CHA₂DS₂-VASc scores—are not static and could increase over time. The available data demonstrated that follow-up and Δ CHA₂DS₂-VASc scores perform better than the baseline CHA₂DS₂-VASc score in the prediction of ischemic stroke. Approximately 90% of initially low-risk patients would have a Δ CHA₂DS₂-VASc score ≥ 1 before the occurrence of ischemic stroke. Apart from risk of stroke, the risk of bleeding for patients with AF is also highly dynamic. For example, the accuracies of the follow-up or Δ Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol (HAS-BLED) score in the prediction of major bleeding was significantly higher than that of the baseline HAS-BLED score. Most importantly, the risks of stroke and major bleeding were higher within several months after patients had changes (increases) in their stroke- or bleeding-risk scores. Therefore, risk profiles of patients with AF should be reassessed regularly so that OACs could be prescribed in a timely manner once patients are no longer at low risk for stroke, and modifiable risk factors for bleeding could be corrected. More efforts are necessary to incorporate clear and easy-to-follow recommendations about risk reassessment into the guidelines to improve AF patient care.     

Pacemaker-detected atrial fibrillation burden and risk of ischemic stroke or thromboembolic events—A cohort study

BackgroundAtrial fibrillation (AF) burden might link to increased risk of systemic embolism. Current scoring systems for evaluating stroke risks such as CHA₂DS₂-VASc do not incorporate AF burden partly because of the difficulty to assess these data. Patients with dual-chamber pacemakers implanted have opportunities to acquire incidence and duration of AF.ObjectivesWe aimed to evaluate the AF burden and its association with thromboembolism in patients with dual-chamber pacemakers.MethodsThis retrospective cohort study enrolled patients who underwent dual-chamber pacemaker implantation at our center between October 2003 and May 2017. We excluded patients with prior thromboembolism or receiving anticoagulants. The incidence and duration of pacemaker-detected AF were compared between patients with and without thromboembolic outcomes. Propensity score matching (1:1) was conducted based on clinical characteristics. Multivariate regressions were performed to determine the predictors of thromboembolic outcomes. Survival free from stroke and thromboembolism was assessed using Kaplan–Meier analysis in groups with different AF burden.ResultsAmong the 152 patients enrolled (43.4% women; age 73.2 ± 13.3 years), ten experienced thromboembolic events within a median follow-up of 67 months. Patients with thromboembolisms had higher CHA₂DS₂-VASc scores but not higher AF burden. Higher CHA₂DS₂-VASc score was associated with increased risk for systemic thromboembolism [hazard ratio (HR), 1.87; 95% confidence interval (CI), 1.07–3.24; P = 0.027). In the propensity score-matched cohort with comparable CHA₂DS₂-VASc score, patients with thromboembolism had higher AF burden. Pacemaker-detected AF was associated with increased risk for thromboembolism (propensity-adjusted HR, 9.33; 95% CI, 1.19–72.99; P = 0.033). Experiencing AF episodes lasting >6 min was a predictor of significantly higher risk of future stroke or thromboembolism (propensity-adjusted HR, 6.75; 95% CI, 1.30–35.11; P = 0.023).ConclusionIn patients with dual-chamber pacemakers and comparable CHA₂DS₂-VASc score, pacemaker-detected AF burden is associated with elevated risk for thromboembolism. Further research is needed to clarify how pacemaker-detected AF burden could incorporate with CHA₂DS₂-VASc score variables and help to guide anticoagulation.     

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.     

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.     

Influence of sex on long-term prognosis in patients with atrial fibrillation treated with oral anticoagulants. Results from the prospective,nationwide FANTASIIA study

BackgroundWhile many risk factors for Atrial Fibrillation (AF) have been identified, there are important differences in their relative impact between sexes. The aim of our study was to investigate the influence of sex as a long-term predictor of adverse events in “real world” AF patients treated with direct oral anticoagulants.MethodsThe FANTASIIA registry is a prospective, national and multicentric study including outpatients with anticoagulated AF patients. Baseline characteristics and adverse events at 3 years of follow-up were collected and classified by sex. Cox multivariate analysis was performed to investigate the role of sex in major events and composite outcomes.ResultsA total of 1956 patients were included in the study. 43.9% of them were women, with a mean age of 73.8 ± 9.4 years (women were older 76.5 ± 7.9 vs 71.7 ± 10.1, p<0.001). Women had higher rate of cardiovascular risk factors and higher mean of CHA₂DS₂-VASc (4.4 ± 1.4 vs 3.7 ± 1.6, p<0.001) and HAS-BLED (2.1 ± 1.0 vs 1.9 ± 1.1, p<0.001) than men. After 3 years of follow-up, rates of major events were similar in both groups with limit difference for all-cause mortality (4.4%/year in women vs 5.6%/year in men; p = 0.056). However, all the composite events were more frequent in women. We observed in the non-adjusted adverse events lower rate of all-cause mortality (HR 0.62, 95%CI 0.47–0.81; p<0.001), composite 1 outcomes (HR 0.80, 95%CI 0.65–0.98; p = 0.029) and composite 2 (HR 0.77, 95%CI 0.64–0.94; p = 0.010) in women compared with men. In multivariate Cox regression analysis observed that female sex was an independently protector factor for all-cause mortality and for the composite outcomes 1 and 2.ConclusionsIn this “real world” study of anticoagulated AF patients, women could have a protective role against development of adverse events, mainly on all-cause mortality and combined events.     

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.

Cierre de la orejuela izquierda por ictus pese a la anticoagulación oral (ictus resistente): resultados del registro Amplatzer Cardiac Plug

Introduction and objectivesDespite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment.MethodsWe analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications.ResultsA total of 115 patients (11%) with RS were identified. The CHA₂DS₂-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5 ± 1.5 vs 4.3 ± 1.6; P < .001; 3.9 ± 1.3 vs 3.1 ± 1.2; P < .001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P = .1). With a mean clinical follow-up of 16.2 ± 12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction).ConclusionsPatients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.     

Cierre de orejuela izquierda en pacientes mayores de 85 años: seguridad y eficacia del registro EWOLUTION

Introduction and objectivesElderly patients with atrial fibrillation are at greater risk of both cardioembolic events and major bleeding than younger patients. Left atrial appendage occlusion (LAAO) could be an attractive alternative for these patients, but there are limited data on outcomes with LAAO in patients ≥ 85 years old. The aim of the present study was to assess the safety and efficacy of LAAO in patients ≥ 85 years old.MethodsA total of 1025 patients included in the EWOLUTION registry who underwent LAAO were analyzed and 84 patients ≥ 85 years old were identified and compared with the younger cohort.ResultsPatients ≥ 85 years old had higher estimated stroke and hemorrhagic risks than younger patients (CHA₂DS₂-VASc: 5.2 ± 1.2 vs 4.4 ± 1.6, P < .0001; HAS-BLED: 2.7 ± 1.1 vs 2.3 ± 1.2; P = .003; ≥ 85 years vs < 85 years). Procedural success was high and similar in both groups (98.8% vs 98.5%; P = .99). There were no differences in 7-day device- or procedure-related adverse event rates (2.6% in ≥ 85 years vs 3.1% in < 85 years; P = .80). Despite the higher baseline stroke risk, there was no difference at follow-up between the groups in the annualized stroke rate (0.8/100 patient-years in ≥ 85 years vs 1.3/100 patient-years in < 85 years; P = .649).ConclusionsLAAO in patients ≥ 85 years is safe and effective even though these patients are at high risk for embolic and hemorrhagic events. LAAO may be a reasonable alternative to oral anticoagulation in these patients.