CHADS2 Risk Scores Research Articles

Association between CHADS2, CHA2DS2-VASc, ATRIA, and Essen Stroke Risk Scores and Functional Outcomes in Acute Ischemic Stroke Patients Who Received Endovascular Thrombectomy.

Background: CHADS2, CHA2DS2-VASc, ATRIA, and Essen stroke risk scores are used to estimate thromboembolism risk. We aimed to investigate the association between unfavorable outcomes and stroke risk scores in patients who received endovascular thrombectomy (EVT). Methods: This study was performed using data from a nationwide, multicenter registry to explore the selection criteria for patients who would benefit from reperfusion therapies. We calculated pre-admission CHADS2, CHA2DS2-VASc, ATRIA, and Essen scores for each patient who received EVT and compared the relationship between these scores and 3-month modified Rankin Scale (mRS) records. Results: Among the 404 patients who received EVT, 213 (52.7%) patients had unfavorable outcomes (mRS 3–6). All scores were significantly higher in patients with unfavorable outcomes than in those with favorable outcomes. Multivariable logistic regression analysis indicated that CHADS2 and the ATRIA score were positively correlated with unfavorable outcomes after adjusting for body mass index and variables with p < 0.1 in the univariable analysis (CHADS2 score: odds ratio [OR], 1.484; 95% confidence interval [CI], 1.290–1.950; p = 0.005, ATRIA score, OR, 1.128; 95% CI, 1.041–1.223; p = 0.004). Conclusions: The CHADS2 and ATRIA scores were positively correlated with unfavorable outcomes and could be used to predict unfavorable outcomes in patients who receive EVT.

Association between CHADS2, CHA2DS2-VASc, ATRIA, and Essen Stroke Risk Scores and Unsuccessful Recanalization after Endovascular Thrombectomy in Acute Ischemic Stroke Patients.

Background: The CHADS2, CHA2DS2-VASc, ATRIA, and Essen scores have been developed for predicting vascular outcomes in stroke patients. We investigated the association between these stroke risk scores and unsuccessful recanalization after endovascular thrombectomy (EVT). Methods: From the nationwide multicenter registry (Selection Criteria in Endovascular Thrombectomy and Thrombolytic therapy (SECRET)) (Clinicaltrials.gov NCT02964052), we consecutively included 501 patients who underwent EVT. We identified pre-admission stroke risk scores in each included patient. Results: Among 501 patients who underwent EVT, 410 (81.8%) patients achieved successful recanalization (mTICI ≥ 2b). Adjusting for body mass index and p < 0.1 in univariable analysis revealed the association between all stroke risk scores and unsuccessful recanalization (CHADS2 score: odds ratio (OR) 1.551, 95% confidence interval (CI) 1.198–2.009, p = 0.001; CHA2DS2VASc score: OR 1.269, 95% CI 1.080–1.492, p = 0.004; ATRIA score: OR 1.089, 95% CI 1.011–1.174, p = 0.024; and Essen score: OR 1.469, 95% CI 1.167–1.849, p = 0.001). The CHADS2 score had the highest AUC value and differed significantly only from the Essen score (AUC of CHADS2 score; 0.618, 95% CI 0.554–0.681). Conclusion: All stroke risk scores were associated with unsuccessful recanalization after EVT. Our study suggests that these stroke risk scores could be used to predict recanalization in stroke patients undergoing EVT.

Validation of risk scores for ischaemic stroke in atrial fibrillation across the spectrum of kidney function

Aims The increasing prevalence of ischaemic stroke (IS) can partly be explained by the likewise growing number of patients with chronic kidney disease (CKD). Risk scores have been developed to identify high-risk patients, allowing for personalized anticoagulation therapy. However, predictive performance in CKD is unclear. The aim of this study is to validate six commonly used risk scores for IS in atrial fibrillation (AF) patients across the spectrum of kidney function.Methods and results Overall, 36 004 subjects with newly diagnosed AF from SCREAM (Stockholm CREAtinine Measurements), a healthcare utilization cohort of Stockholm residents, were included. Predictive performance of the AFI, CHADS2, Modified CHADS2, CHA2DS2-VASc, ATRIA, and GARFIELD-AF risk scores was evaluated across three strata of kidney function: normal kidney function [estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2], mild CKD (eGFR 30–60 mL/min/1.73 m2), and advanced CKD (eGFR <30 mL/min/1.73 m2). Predictive performance was assessed by discrimination and calibration. During 1.9 years, 3069 (8.5%) patients suffered an IS. Discrimination was dependent on eGFR: the median c-statistic in normal eGFR was 0.75 (range 0.68–0.78), but decreased to 0.68 (0.58–0.73) and 0.68 (0.55–0.74) for mild and advanced CKD, respectively. Calibration was reasonable and largely independent of eGFR. The Modified CHADS2 score showed good performance across kidney function strata, both for discrimination [c-statistic: 0.78 (95% confidence interval 0.77–0.79), 0.73 (0.71–0.74) and 0.74 (0.69–0.79), respectively] and calibration.Conclusion In the most clinically relevant stages of CKD, predictive performance of the majority of risk scores was poor, increasing the risk of misclassification and thus of over- or undertreatment. The Modified CHADS2 score performed good and consistently across all kidney function strata, and should therefore be preferred for risk estimation in AF patients.

Validation and comparison of six risk scores for post acute myocardial infarction infection

Abstract Background Various risk scores have been proven to predict outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, few of them were validated and compared the difference of the prediction of infection during hospitalization in such patients. Aim We aimed to validate and compare the discriminatory value of different risk scores for predicting infection. Methods Patients who were diagnosed with STEMI treated with PCI were enrolled from January 2010 to May 2018. The six risk scores included the Age, Serum Creatinine (SCr), or Glomerular Filtration Rate, and Ejection Fraction (ACEF or AGEF) score, Canada Acute Coronary Syndrome Risk Score (CACS score), CHADS2 score, Global Registry for Acute Coronary Events (GRACE) score and Mehran score. The primary end point was infection during hospitalization. The secondary endpoint was major adverse clinical events including all cause death, stroke and any bleeding. The prognostic accuracy of the six scores was assessed using the c statistic for discrimination and the Hosmer-Lemeshow test for calibration. Results A total of 2260 eligible patients were enrolled (62.32±12.36 year, 81.3% of males). A significant gradient of risk with respect to infection and in hospital major adverse clinical events (MACE) was observed with increasing all six risk scores. Other than the CHADS2 score (AUC: 0.682; 95% CI, 0.652–0.712), other five risk scores showed the good discrimination for predicting infection, with the GRACE score being the best (AUC: 0.791; 95% CI, 0.765–0.817). In addition, all risk scores showed best calibration for infection, but good calibration for CACS risk score (calibration slope: 0.77, 95% CI: 0.18–1.35) (Figure 1). Furthermore, each score showed a best discrimination for in hospital MACE, with AUCs ranging from 0.761 to 0.786, other than CACS risk score and CHADS2 risk score with AUC of 0.700 and 0.696, respectively. All risk scores showed best calibration for in hospital MACE. Conclusions In patients with STEMI undergoing PCI, these risk scores (ACEF, AGEF, CACS, GRACE and Mehran) showed good discrimination and calibration to predict infection and MACE. The CACS score was recommended for clinical use as its clinical variables were simple and practical. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): National Science Foundation for Young Scientists of China

Authors' reply.

Sir, We thank the authors for their interest in our article[1] and for highlighting the issue of anticoagulation for atrial fibrillation (AF) in children with valvular heart disease (VHD). There is little doubt that AF independently increases the risk of stroke across all age groups, however, the AF-related stroke incidence varies.[2] The presence of concomitant VHD, regardless of the disease type and severity, further amplifies the risk of stroke and thromboembolic events in AF.[23] There are no published studies in pediatric patients, specifically addressing the risk of AF in VHD or the issue of anticoagulation in atrial arrhythmias. An important explanation for the lack of data is that AF is quite rare in the pediatric population, unlike in adults. Therefore, management experience from the adult literature is used as a surrogate and is extrapolated to the pediatric age group. There has been considerable heterogeneity in the definition of valvular and nonvalvular AF, and the definitions have changed with successive editions of major guidelines. A consensus[4] published in 2014 defined nonvalvular AF as AF in the absence of prosthetic mechanical heart valves or hemodynamically significant valve disease, while the term “nonvalvular AF” was no longer used in the recent update.[5] AF evidently leads to an increased risk for thromboembolism in patients with mitral stenosis, but there are limited data for other valvular diseases. There are currently no specific recommendations for thromboembolic prophylaxis in patients with AF and mitral or aortic regurgitation. Recent guidelines reiterate the assessment of stroke risk using the CHA2 DS2-VASc score for patients with nonvalvular AF.[5] Although the data on the use of CHA2 DS2-VASc score for anticoagulation in AF in children are sparse, the risk of stroke with AF in children is very low as per the scoring system. It needs to be highlighted that the CHADS2 risk score was developed for patients with nonvalvular AF, and hence, some studies suggested excluding patients with valve disease, particularly rheumatic mitral valve disease, for risk assessment using the CHADS2 score.[26] Darby et al.[3] recommended the use of systemic anticoagulation in all patients with rheumatic valvular disease with AF, unless there is a contraindication. Nonetheless, the recent guidelines recommend the use of CHA2 DS2-VASc score for deciding anticoagulation therapy in patients with AF and mitral or aortic regurgitation based on post hoc subgroup analyses of large randomized controlled trials.[7] The 2017 European guidelines for the management of VHDs are silent about the use of scoring system when deciding anticoagulation in this population, highlighting the heterogeneity in the recommendations on the issue. The authors mention that novel oral anticoagulants (NOACs) should be considered as an alternative to Vitamin K antagonists (VKAs) in patients with aortic stenosis, aortic regurgitation, and mitral regurgitation presenting with AF (Class IIa, level of evidence B).[8] However, there is a lack of data on the safety and efficacy of NOACs in children. As explained above, the statement in the current guidelines[1] is based on the conflicting evidence available from the studies in the adult population. The use of VKAs is reasonable in children with AF and mitral or aortic regurgitation. However, we agree that the “decision to anticoagulate” should be individualized in children and prospective randomized controlled trials are needed to formulate risk stratification system to guide the use of anticoagulation in this pediatric subset. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgments The authors express thanks to Children's HeartLink Group (Ms. Bistra Zheleva, Ms. Adriana Dobrzycka, and Ms. Veera Rajasekhar), Pediatric Cardiac Society of India, and Dr. Arun Singh, National Advisor, Rashtriya Bal Swasthya Karyakram, Ministry of Health and Family Welfare, Government of India.

Cardiovascular Risk Scores to Predict Perioperative Stroke in Noncardiac Surgery.

Background and Purpose- Perioperative stroke is associated with significant morbidity and mortality. Conventional cardiovascular risk scores have not been compared to predict acute stroke after noncardiac surgery. Methods- Patients undergoing noncardiac surgery between 2009 and 2010 were identified from the US National Surgical Quality Improvement Program (n=540 717). Patients were prospectively followed for 30 days postoperatively for the primary outcome of stroke. Established cardiovascular and perioperative risk scores (CHADS2, CHA2DS2-VASc, Revised Cardiac Risk Index, Mashour et al risk score, Myocardial Infarction or Cardiac Arrest risk score, and National Quality Improvement Project American College of Surgeons surgical risk calculator) were assessed to predict perioperative stroke. Results- Stroke occurred in the perioperative period of 1474 noncardiac surgeries (0.27%). Patients with perioperative stroke were older, more frequently male, had lower body mass index, and were more likely to have undergone vascular surgery or neurosurgery than patients without stroke (P<0.001 for each comparison). All risk prediction models were associated with increased risk of perioperative stroke (C statistic [AUC] range, 0.743-0.836). The Myocardial Infarction or Cardiac Arrest risk score (AUC, 0.833) and American College of Surgeons surgical risk calculator (AUC, 0.836) had the most favorable test characteristics and a greater ability to discriminate perioperative stroke when compared with Revised Cardiac Risk Index, CHADS2, CHA2DS2-VASc, and Mashour risk scores (P for comparison, <0.001; Delong). Risk scores did not provide consistent discriminative ability across surgery types and were least predictive in vascular surgery (AUC range, 0.588-0.672). Conclusions- The Myocardial Infarction or Cardiac Arrest risk score and American College of Surgeons surgical risk calculator surgical risk scores provide excellent risk discrimination for perioperative stroke in most patients undergoing noncardiac surgery. Stroke prediction was less optimal in patients undergoing vascular surgery.

Comparison of Stroke Risk Stratification Scores for Atrial Fibrillation

Several stroke risk stratification scores have been developed to guide clinical decision-making in patients with nonvalvular atrial fibrillation (AF). The aim of this study was to compare the performance of the CHADS2, CHA2DS2-VASc and R2CHADS2 risk scores to predict stroke. This retrospective cohort study was based on electronic medical records from Clalit Health Services (CHS), the largest payer provider healthcare organization in Israel. Data of CHS members with AF diagnosis between 2004 and 2015 were extracted. Demographic and co-morbidity data were used to calculate the 3 risk scores, and the performance of the scores to predict stroke were compared using area under the curve and net reclassification index. Of the 89,213 CHS members with AF, 52.3% were women and median age was 76 years. The proportions of patients at high risk were 66.2%, 86.7%, and 71.1% in the CHADS2, CHA2DS2-VASc, and R2CHADS2, respectively, with stroke incidence rates of 2.91, 2.35, and 2.80 per 100 person-years, respectively. Area under the curves for stroke prediction were 0.61 for both CHADS2 and CHA2DS2-VASc and 0.59 for R2CHADS2. Net reclassification index analysis demonstrated a net improvement of 0.089 in the index when CHA2DS2-VASc was compared with CHADS2 and a net reduction of 0.083 when R2CHADS2 was compared with CHADS2. In conclusion, current stroke stratification scores have comparable but limited ability to predict stroke in patients with AF. Stroke prevention strategies may vary depending on the applied stratification. There is a need for a better stroke risk stratification score for patients with AF.

Efficacy and Safety of Warfarin Experience in a Stroke Polyclinic in Stroke Patients.

Cardioembolic stroke is associated with high morbidity and mortality, with an increased risk of recurrent stroke. Oral anticoagulation is highly effective in reducing the risk of stroke and mortality compared with placebo. Our study aimed to highlight the safety and efficacy of warfarin by analyzing the 20-year follow-up of patients on warfarin therapy. A retrospective observational study was performed with ischemic stroke patients receiving warfarin at our stroke polyclinic between 1992 and 2012. The CHADS2 scoring system was used to assess the annual risk of stroke, and a bleeding risk score termed the HAS-BLED scoring system was calculated to estimate the risk of bleeding. In our study, 394 patients who were receiving warfarin therapy were included. The patients' median age was 66.35±13.602 years. The median follow-up period of the patients was 4.85±3.572 years. During follow-up, 79.9% of the patients revealed no complication on warfarin therapy. Thirty-seven patients had hemorrhagic complications; among these, 33 had systemic complications (including nose bleeding, hematuria, hematochezia) and 4 patients had intracerebral bleeding. The INR value related to hemorrhagic complications was >2.5 in 75.8% of 33 patients having systemic bleeding and in 75% of 4 patients having intracerebral bleeding. The HAS-BLED risk score was >3 in 72.7% of the patients experiencing systemic bleeding complications. Forty-one patients had a recurrent ischemic stroke/TIA during the follow-up. Of this patient group, the INR value at the time of recurrent ischemic stroke was <2 in 41 patients (92.7%), while the CHADS2 risk score was low in this group. Sixty-eight patients were receiving antiplatelet therapy with warfarin. In these groups, 16 patients experienced a complication during the follow-up (bleeding/ischemic), while 10 patients had bleeding complications (systemic and intracerebral). The results suggest that the effectiveness and safety of warfarin depend on maintaining its dose at sufficient levels to keep the patient's INR within the therapeutic range.

5722Correlation of the CHADS2, CHA2DS2-Vasc and ATRIA risk scores with the presence of left atrial appendage thrombus in patients with non-valvular atrial fibrillation

5722Correlation of the CHADS2, CHA2DS2-Vasc and ATRIA risk scores with the presence of left atrial appendage thrombus in patients with non-valvular atrial fibrillation

Relation of red blood cell distribution width with CHADS2 and CHA2DS2-VASc score in Chinese patients with non-valvular atrial fibrillation

BackgroundHigher red cell distribution width (RDW) predicts adverse events in patients with cardiovascular diseases. However, there are limited data regarding the relationship between RDW and thromboembolism risk in the patients with atrial fibrillation (AF). We aimed to investigate the association between RDW and CHADS2, CHA2DS2-VASc scores used for the evaluation of thromboembolic risk in patients with non-valvular atrial fibrillation (AF). MethodsOur study included 99 patients with AF (68 paroxysmal AF; 31 persistent AF). We calculated CHADS2 and CHA2DS2-VASc risk scores for each patient, and we carefully recorded clinical characteristics as well as laboratory and echocardiographic parameters. According to CHADS2 and CHA2DS2-VASc scores, we divided the AF patients into 2 groups (low-intermediate risk and high risk group). Subsequently, we compared the aforementioned parameters between the 2 groups, and we evaluated the relationship between RDW and CHADS2/CHA2DS2-VASc score. Finally, multivariate logistic regression analysis was performed to find independent predictors of high CHADS2, CHA2DS2-VASc scores. ResultsPatients with high CHADS2, CHA2DS2-VASc scores had older age, higher RDW, and creatinine levels, increased left atrial diameter and lower left ventricular ejection fraction, compared to the low CHADS2, CHA2DS2-VASc score group. Multivariate logistic regression analysis showed that RDW was an independent predictor for high CHADS2, CHA2DS2-VASc scores(OR: 2.184 and OR: 5.748; all P<0.05). ConclusionRDW is significantly correlated with CHADS2 and CHA2DS2-VASc score in the patients with AF, while is an independent predictor for high CHADS2 and CHA2DS2-VASc score.

Comparative Performance of ATRIA, CHADS2, and CHA2DS2-VASc Risk Scores Predicting Stroke in Patients With Atrial Fibrillation: Results From a National Primary Care Database

BackgroundPrevious studies report that CHADS2 and CHA2DS2-VASc risk scores have similar discriminating ability (C statistic ∼0.6). Recently a clinically based risk score, the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study risk score, was developed and validated. ObjectivesThis study compared predictive ability of CHA2DS2-VASc and CHADS2 ischemic stroke risk scores with ATRIA stroke risk score and their implications for anticoagulant treatment in patients with atrial fibrillation (AF). MethodsPatients with AF not using warfarin were included from the Clinical Practice Research Datalink database, 1998 to 2012. Patients were followed from AF diagnosis until occurrence of ischemic stroke, prescription of warfarin, death, or the study's end. Independent predictors of ischemic stroke were identified and the c-index and net reclassification improvement were calculated. ResultsA total of 60,594 patients with AF were included. Annualized stroke rate was 2.99%. Event rates for moderate- and high-risk categories for CHA2DS2-VASc were lower than those of the ATRIA and CHADS2. Age and previous stroke most strongly predicted ischemic stroke. C statistics for the full point scores were 0.70 (95% confidence interval [CI]: 0.69 to 0.71) for the ATRIA risk score, 0.68 (95% CI: 0.67 to 0.69) for CHADS2, and 0.68 (95% CI: 0.67 to 0.69) for CHA2DS2-VASc risk score. The net reclassification improvement was 0.23 (95% CI: 0.22 to 0.25) for ATRIA compared with CHA2DS2-VASc. ConclusionsThe ATRIA score performed better in the U.K. Clinical Practice Research Datalink AF cohort. It more accurately identified low-risk patients than the CHA2DS2-VASc score, which assigned these patients to higher-risk categories. Such reclassification of stroke risk could prevent overuse of anticoagulants in very low stroke risk patients with AF.

Cognitive function and left ventricular assist device implantation

Cognitive impairment is frequent in patients with heart failure (HF) and can lead to poor quality of life and increased risk of mortality. The Montreal Cognitive Assessment (MoCA) is a simple screening tool that is sensitive to mild cognitive impairment (MCI) and that has been validated in the settings of neurologic and cardiovascular disease. This study determined the extent of cognitive impairment in patients with HF undergoing evaluation for advanced surgical therapy and evaluated changes in MoCA score with follow-up cognitive assessment at 8 months after left ventricular assist device (LVAD) implantation. As part of routine assessment for LVAD candidacy, 176 patients with advanced HF were administered the MoCA; 56 patients were reevaluated 8 months after LVAD implantation. Patients with MCI, indicated by MoCA score <26 out of 30, made up 67% of the study cohort. MCI was associated with significantly older age, higher CHADS2 (congestive HF, hypertension, age >75 years, diabetes mellitus, prior stroke or transient ischemic attack) risk score, statin use, history of stroke and hypertension, and reduced serum cholesterol levels. In 56 patients who underwent follow-up evaluation after LVAD implantation, total MoCA score and visuospatial, executive, and delayed recall cognitive domains were significantly improved. This study assessed the use of the MoCA in patients with end-stage HF being evaluated for advanced surgical therapy. We found the MoCA to be a rapid, simple, and powerful tool for detecting cognitive impairment in these patients. MCI was highly prevalent in the cohort. Significant improvement in overall MoCA score was noted after LVAD implantation.

Neighborhood deprivation and warfarin, aspirin and statin prescription — A cohort study of men and women treated for atrial fibrillation in Swedish primary care

BackgroundWe aimed to study differences in the prescribing of warfarin, aspirin and statins to patients with atrial fibrillation (AF) in socio-economically diverse neighborhoods. We also aimed to explore the effects of neighborhood deprivation on the relationship between CHADS2 risk score and warfarin prescription. MethodsData were obtained from primary health care records that contained individual clinical data that were linked to national data on neighborhood of residence and a deprivation index for different neighborhoods. Logistic regression was used to estimate the potential neighborhood differences in prescribed warfarin, aspirin and statins, and the association between the CHADS2 score and prescribed warfarin treatment, in neighborhoods with high, middle (referent) and low socio-economic (SES). ResultsAfter adjustment for age, socio-economic factors, co-morbidities and moves to neighborhoods with different SES during follow-up, adults with AF living in high SES neighborhoods were more often prescribed warfarin (men odds ratio (OR) (95% confidence interval (CI): 1.44 (1.27–1.62); and women OR (95% CI): 1.19 (1.05–1.36)) and statins (men OR (95% CI): 1.23 (1.07–1.41); women OR (95% CI): 1.23 (1.05–1.44)) compared to their counterparts residing in middle SES. Prescription of aspirin was lower in men from high SES neighborhoods (OR (95% CI): 0.75 (0.65–0.86)) than in those from middle SES neighborhoods. Higher CHADS2 risk scores were associated with higher warfarin prescription which remained after adjustment for neighborhood SES. ConclusionsThe apparent inequalities in pharmacotherapy seen in the present study call for resource allocation to primary care in neighborhoods with low and middle socio-economic status.

Asymptomatic Atrial Fibrillation After Cryptogenetic Stroke

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence of 1% to 2% in the general population; this increases with age, reaching >8% in subjects over 80 years of age.1,2 The arrhythmia is independently associated with an increased risk of stroke, which is about 5-fold higher in AF-affected patients than in controls.3 AF is considered to be the cause of ischemic stroke in 15% to 17% of cases.3,4 Interestingly, AF-related strokes cause higher mortality and disability than strokes unrelated to AF4,5 and stroke risk is independent of the type of AF (paroxysmal, persistent, or permanent).6,7 The rate of stroke caused by AF can be significantly reduced (by 60% to 70%) by the use of warfarin or novel oral anticoagulants.8,9 Article see p 263 AF is usually symptomatic, causing symptoms, such as palpitations, dyspnea, fatigue, angina, dizziness, and syncope.10 Not rarely, however, the arrhythmia is not perceived at all by the patient and, in this case, is defined as asymptomatic, silent, undetected, occult, or subclinical AF. According to the EURObservational Research Programme–AF (EORP-AF) Pilot General Registry, almost 40% of the AF patients who are seen in daily cardiology practice are completely asymptomatic, and another 30% have only mild symptoms.11 The prevalence of silent AF varies in different clinical settings, ranging from 0% to 31% in postablation patients12,13 to 16% to 25% as incidental finding at standard ECG,2,14 54% to 70% in patients treated with antiarrhythmic drugs, and 15,16 up to 51% to 74% in pacemaker/implantable cardioverter- defibrillator recipients.17,18 Stroke is the leading cause of long-term adult disability and mortality in the developed world. Approximately, 30% to 40% of …

A circulating biomarker risk-prediction model correlates with CHADS-2 risk score in chronic atrial fibrillation

BackgroundInflammation and oxidative stress have been linked to the origin and persistence of atrial fibrillation (AF). CHADS-2 scoring system is a risk stratification schema well validated in prognostication of stroke in AF. We evaluated the association of markers of oxidative stress and inflammation with CHADS-2 scores in chronic AF patients. MethodsCHADS-2 scores were calculated for 64 subjects with chronic AF. Serum markers of inflammation [C-reactive protein (hs-CRP), interleukin-6 (IL-6), interleukin 1β (IL-1β), tumor necrosis factor-α (TNF-α)] and of oxidative stress [derivatives of reactive oxygen metabolites (DROMs) and isoprostanes (IsoPs)] were measured. ResultsTwenty subjects were categorized as 0 (no risk), 24 as 1 (intermediate risk) and 20 as 2 (severe risk) based on their CHADS-2 scores. High sensitivity-CRP (CHADS-2 0=40.0%, 1=70.0%, 2=90.0%; p=0.003) and DROMs (CHADS-2 0=45%, 1=78%, 2=80%; p=0.04) were positively associated with the CHADS-2 risk score. Subjects with intermediate to severe CHADS-2 risk retained significant associations with abnormal hs-CRP (OR: 5.3, 95%CI: 1.1–25.0) and DROMs (adjusted OR: 6.7, 95%CI: 1.2–38.8) after adjusting for gender and hypertension. In a multiple logistic interaction model, there was no significant interaction between hs-CRP and DROMs in their association with CHADS-2 risk categories (p=0.64). A biomarker risk-model, combining hs-CRP and DROMs, correlated well with the CHADS-2 risk categories (r=0.49, p<0.001). ConclusionsA biomarker risk-model using a combination of hs-CRP and DROMs correlates well with CHADS-2 risk scores in chronic AF. Either or both of these markers may add predictive power to future stroke risk prediction models.

Two-year clinical outcome from the Iberian registry patients after left atrial appendage closure

AimsThe aim of this study was to observe the percentage of thromboembolic and haemorrhagic events over a 2-year follow-up in patients with non-valvular atrial fibrillation (NVAF) undergoing closure of the...

Abstract 274: Prevalence of undiagnosed non-valvular atrial fibrillation in the United States

Background: Because atrial fibrillation (AF) is often asymptomatic, clinically silent and therefore undiagnosed, the prevalence of AF is difficult to estimate. In fact, ischemic stroke is often the first clinical sign of AF among previously undiagnosed patients. In this study, we estimated the prevalence of undiagnosed AF using a back-calculation approach that relies on the fact that AF causes stroke but causality generally does not run from stroke to AF. Methods: We first estimated the prevalence of diagnosed non-valvular AF in the elderly (65+) and working age (18-64) U.S. population from a 5% Medicare sample and an OptumInsight commercial claims database from 2004-2010 using validated ICD9 algorithms. To estimate the prevalence of undiagnosed non-valvular AF, our back-calculation methodology used two measured inputs: (i) the number of patients who are diagnosed with new non-valvular AF in the current or subsequent quarter after a stroke; (ii) the probability that patients with non-valvular AF have a stroke, based on CHADS2 risk scores. We confirmed calibration by comparing our prevalence estimates of diagnosed AF with prior Medicare and commercial claims analyses. Results: Between 2005 and 2009, the estimated prevalence of AF gradually increased, reaching 9.9% of the elderly U.S. population and 0.88% of the working aged population by 2009. Among the Medicare AF cases in 2009, 11% of these cases (1.1% out of 9.9%) were undiagnosed; among working aged patients with AF, 8% of cases (0.07% out of 0.88%) were undiagnosed. In addition, a large share of the undiagnosed cases was at high risk of stroke. Among the undiagnosed AF cases for elderly and working age adults, 26% and 37%, respectively have a CHADS2 score of 1, and 68% and 26% have a CHADS2 score of 2+. Conclusions: Among elderly and working adult U.S. populations, a substantial proportion of individuals with undiagnosed AF have moderate to high risk of stroke. Screening for AF could favorably impact the disease burden.

PCV14 - Characterization Of Ischemic Stroke Patients And Second Stroke Rates By Risk Scores

To better understand the ischemic stroke population with respect to atrial fibrillation (AF), oral anticoagulation (OAC) usage, and second stroke rates as a function of baseline CHADS2 and CHA2DS2-VASc risk scores. The population consists of all patients in the Truven Health MarketScan® Commercial and Medicare Supplemental Databases between 01/01/2008 and 12/31/2011 with an index ischemic stroke event and data available ±12 months around the index event. CHADS2 and CHA2DS2-VASc risk scores were derived from diagnosis codes, procedure codes, and prescription drug usage within 12 months prior to the index stroke. A total of 174,318 patients (age 66.6±15.4 years, 54.4% female) were included. Among these, 11.9% had an AF diagnosis and/or antiarrhythmic drug usage within the 12 months prior to their index stroke. AF rates rose from 2.4% to 39.9% as baseline CHADS2 scores increased and from 2.0% to 41.6% with increasing CHA2DS2-VASc scores. Only 9.6% of patients were on OAC in the year prior to their index stroke (3.7% to 27.4% by increasing CHADS2 score; 3.2% to 28.1% by increasing CHA2DS2-VASc score), and 48.9% of patients with AF were on OAC. Just 5.3% had new AF diagnosed within 12 months after their index stroke. The rate of second stroke in the year after the index stroke was 35.0% (29.5% to 39.2% and 29.2% to 39.3% by increasing CHADS2 and CHA2DS2-VASc scores, respectively). Over one-third of all surviving stroke patients experienced second strokes in the year following their first stroke. Given the low rate of newly diagnosed AF, this suggests that undiagnosed AF may be an important contributor to the high recurrent stroke rate. Further study is required to determine if more rigorous post-stroke arrhythmia monitoring can lead to increased AF detection and OAC utilization, thus resulting in a reduction in recurrent stroke.

ASSESSMENT OF STROKE RISK IN ATRIAL FIBRILLATION: PHYSICIAN ESTIMATE VERSUS CHADS2 RISK SCORE: RESULTS FROM ORBIT-AF

Use of oral anticoagulation (OAC) in atrial fibrillation (AF) should be guided by patient stroke risk yet prior studies have found gaps and paradoxical use. We sought to compare physicians' subjective assessment of stroke risk with those derived from the CHADS2 risk scores, and their associations

Alternative CHADS Score Better Assessed A.Fib. Stroke Risk

AMSTERDAM – Use of the CHA2DS2-VASc score markedly improves classification of atrial fibrillation patients who are truly at low risk of stroke, compared with the commonly used CHADS2 score, a German national study found. “We do not feel that a CHADS2 risk score of 0 or 1 is suitable to identify low-risk patients. The CHA2DS2-VASc score provides a more refined risk stratification in low-risk patients,” Michael Näbauer, MD, said at the annual congress of the European Society of Cardiology. Among 795 patients in Germany's AFNET [German Competence Network on Atrial Fibrillation] registry who had a CHA2DS2-VASc score of 0, only 8 correctly categorized patients had a nonprocedurally related stroke, transient ischemic attack (TIA), or thromboembolism during 5 years of follow-up, reported Dr. Näbauer, head of the echocardiographic unit at Ludwig Maximilians University Hospital, Munich. Current American guidelines recom-mend using the CHADS2 score, whereas more recent European Society of Cardiology guidelines advocate the CHA2DS2-VASc scoring system (Eur. Heart J. 2012;33:2719–47). Dr. Näbauer reported that among 8,847 patients with nonvalvular atrial fibrillation participating in the registry, 16.2% were assigned a CHADS2 score of 0 and 31.5% a score of 1, meaning their stroke risk going forward was too low to justify the routine use of prophylactic oral anticoagulation therapy. But of the 403 stroke, TIA, and thromboembolic events that occurred in the nearly 9,000 atrial fibrillation patients during 5 years of follow-up, 36% occurred in patients with a CHADS2 score of 0 or 1. Application of the CHA2DS2-VASc score to the AFNET population resulted in reclassification of 126 of the 145 CHADS2 class 0 or 1 patients who had a stroke, TIA, or thromboembolism to a higher CHA2DS2-VASc category where oral anticoagulation is appropriate. Of the 45 stroke events that occurred among 1,430 patients who were CHADS2 class 0, 12 events occurred in patients who were CHA2DS2-VASc class 2 and 14 in CHA2DS2-VASc class 1, groups in which oral anticoagulation is recommended. Moreover, 4 of the 19 stroke events occurring in the 795 patients who were CHA2DS2-VASc class 0 happened in association with atrial fibrillation ablation or cardioversion procedures, when oral anticoagulation is temporarily discontinued. Another seven stroke events occurred in patients whose true CHA2DS2-VASc score had increased from 0 during follow-up, mainly because of advancing age. So ultimately only 8 of 795 patients correctly classified as CHA2DS2-VASc 0 had a stroke event unrelated to a cardiac procedure during 5 years of follow-up. Session cochair Robert Hatala, MD, PhD, said that the AFNET experience highlights an important clinical lesson: Stroke risk in AF patients is not static. It changes over time, and periodic reassessment is essential. “All of the risk scores are imperfect. It's really very important to relook at your patients and not give them a fixed stamp forever. The risk scores change over time as patients get older, perhaps receive a diagnosis of hypertension, or develop congestive heart failure, maybe with preserved systolic function. So restratify,” urged Dr. Hatala, head of cardiology and director of the arrhythmia and pacing center at Slovak Medical University, Bratislava, Slovakia. Dr. Näbauer and Dr. Hatala reported having no relevant financial conflict.