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.