STROKE RISK PREDICTION IN PATIENTS WITH ATRIAL FIBRILLATION AND RHEUMATIC HEART DISEASE: RESULTS FROM THE RE-LY AF REGISTRY

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Atrial fibrillation (AF) is associated with an increased risk for stroke. Since stroke risk varies according to associated risk factors, scores such as CHA2DS2-VASc are used to assess risk. Patients with AF and rheumatic heart disease (RHD), especially with mitral stenosis, have traditionally been considered to be at very high risk of future stroke, regardless of other factors. However, there are limited data to validate this assumption. The RE-LY AF registry enrolled 15,400 patients with AF from emergency departments across the world and followed them for 1 year. A total of 1,788 (11.6%) patients had RHD. We assessed the one-year risk of stroke in those with and without RHD and evaluated whether the CHA2DS2-VASc score predicted stroke risk in patients both with and without RHD. We also assessed if RHD and moderate-to-severe mitral stenosis were independent risk factors for stroke. Patients with RHD were younger (51.4±15.7 vs. 67.8±13.6 years), predominantly female (66.2% vs. 44.7%), and had a lower CHA2DS2-VASc score (2.1±1.7 vs. 3.7±2.2) as compared to patients without RHD (all p < 0.001). Echocardiographic validation of RHD patients showed that mitral stenosis was the most common valve lesion (69.4% of patients). The average mean transmitral gradient in patients with mitral stenosis was 11.5±6.5 mmHg. Patients with RHD had a higher baseline rate of anticoagulation use (60.5% vs. 45.3%, p < 0.001). Unadjusted annual rates of stroke were 2.8% and 4.1% for patients with and without RHD, respectively. The CHA2DS2-VASc score was predictive for stroke risk in patients with and without RHD (c-statistics: 0.69 and 0.63, respectively). In a multivariate logistic regression model excluding patients with mechanical heart valves, we found that age, gender, prior stroke or transient ischemic attack, congestive heart failure, tobacco and anticoagulation use were significant independent predictors for stroke. Neither RHD (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 0.91-1.97, p=0.13) nor mitral stenosis in particular (adjusted OR 0.96, 95% CI 0.61-1.53, p=0.88) were independently associated with the risk for stroke. The CHA2DS2-VASc score is predictive for stroke risk in AF patients both with and without RHD. In AF patients, moderate-to-severe mitral stenosis is not an independent risk factor for stroke. These data indicate that it is reasonable to use a similar approach to risk stratification in AF patients with and without RHD.