CHA2DS2-VASc Research Articles

Risk of Stroke and Incident Atrial Fibrillation in Patients in Sinus Rhythm With Nonischemic Dilated Cardiomyopathy

Background: Non-ischemic dilated cardiomyopathy (NIDCM) is associated with an increased risk of atrial fibrillation (AF) and stroke, especially in patients with high CHA2DS2-VASc. We aimed to identify variables associated with incident AF or stroke using left atrial (LA) deformation analysis and its prognostic value added to CHA2DS2-VASc score. Patients with NIDCM and LVEF <50% in sinus rhythm were included between January 2015 and December 2019. LA volume index (LAVI) and atrial strain were used in combination with the CHA2DS2-VAS score to predict ischemic stroke or incident AF. Proportional hazards Cox regression was used to provide hazard ratios (HR). There were 338 patients included. After a median follow-up of 3.6 years, the endpoint occurred in 41 (12.1%) patients. LAVI outperformed other echocardiographic parameters, with significant improvement in risk reclassification compared to CHA2DS2-VASc alone (net reclassification index 0.6, increase in Harrell's C from 0.63 to 0.73, P=0.003) and remained significant after multivariate adjustment. LAVI was associated with both components of the endpoint separately. The best cutoff for LAVI was 44 ml/m2. LAVI ≥44ml/m2 increased the risk of the endpoint among those with CHA2DS2-VASc ≥3 (HR=6.0, 95%CI 2.6-13.5), but not in those with CHA2DS2-VASc <3 (HR=1.2, 95%CI 0.3-4.5). Competing risk analysis did not alter the results. In conclusion, LAVI might be used to assess the risk of incident AF or stroke in NIDCM. Patients with LAVI ≥44 ml/m2 and CHA2DS2-VASc ≥3 could be at high risk of AF and stroke and may benefit from more intensive surveillance.

Rates of Visual Field Progression Before and After the Onset of Atrial Fibrillation.

This case-control study investigated the effect of atrial fibrillation (AF) on the progression of glaucoma. The presence of AF and related microvascular damage were associated with a slightly faster visual field loss in glaucoma patients. To investigate the effect of atrial fibrillation (AF) on glaucoma progression. In this longitudinal case-control study, a total of 144 eyes from 105 patients with primary open angle glaucoma were included. 48 eyes of case developed AF during the follow-up followed for 15.6 years. 96 eyes of control that did not have AF at baseline or during follow-up matched for age, baseline glaucoma severity and follow-up period were followed for an average of 14.7 years. Mixed-effects linear models were used to calculate the difference in the VF MD slopes before and after the AF. CHADS2 and CHA2DS2-VASc scores were used to evaluate the risk of thrombosis event, and related microvascular damage was assessed based on these scores. The rate of VF MD change was -0.20 (-0.42 to 0.02) dB/y before AF and -0.28 (-0.47 to -0.09) dB/y after AF for the patients with AF, and -0.21 (-0.25 to -0.17) dB/y for the control. In the multivariable models, the VF slope difference before and after the onset of AF (-0.10 (-0.14 to -0.05) dB/y, P<0.001), higher CHADS2 score (-0.07 (-0.13 to 0.00) dB/y per 1 unit, P=0.040), and higher CHA2DS2-VASc score (-0.05 (-0.10 to 0.00) dB/y per 1 unit, P=0.039) were associated with faster VF MD loss. The presence of atrial fibrillation and related microvascular damage might accelerate visual field loss. This underscores the need for a comprehensive medical history and management of cardiovascular risk factors to mitigate increase VF loss in glaucoma.

Heart Failure with Preserved Ejection Fraction Correlates with Fibrotic Atrial Myopathy in Patients Undergoing Atrial Fibrillation Ablation.

Background: The incidence of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) is high. Impaired left atrial (LA) function is a major determinant in HFpEF. However, the extent of electrical LA tissue degeneration in HFpEF is unknown. Therefore, we sought to investigate the amount of arrhythmogenic and fibrotic LA tissue degeneration in HFpEF patients presenting for AF ablation. Methods: We prospectively screened consecutive patients presenting for first time AF ablation. The HFA-PEFF score was used to identify HFpEF patients. Bipolar high-density voltage mapping was created in sinus rhythm prior to ablation to evaluate the general LA bipolar voltage and quantify areas of low voltage. LVAs were defined as areas with bipolar voltage < 0.5 mV. Results: In total, 187 patients were prospectively enrolled (age 65 ± 11 years, 45% female, 46% persistent AF, 25% HFpEF) in this study. HFpEF patients were older and had a higher CHA2DS2-VASc score (70 ± 9 vs. 63 ± 11 years and 3.2 ± 1.5 vs. 2.3 ± 1.5, each p < 0.001, respectively). Overall, low-voltage areas (LVAs) were present in 97 patients (52%), whereas 76% of the HFpEF population had LVA, as compared to 44% of patients without HFpEF (p < 0.001). HFpEF was associated with generally decreased LA bipolar voltage (1.09 ± 0.64 vs. 1.83 ± 0.91 mV; p < 0.001) and predictive of the presence of low-voltage areas (76% vs. 44% p < 0.001). The HFA-PEFF score inversely correlated with LA bipolar voltage (=-0.454; p < 0.001). Conclusions: HFpEF closely relates to generally decreased LA bipolar voltage and to the existence of fibrotic and arrhythmogenic LA tissue degeneration.

Correlation between glycated albumin (GA) and CHA2DS2-VASc score in comparison to GRACE score regarding outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention

BackgroundAcute coronary syndrome (ACS) is responsible for one-third of total deaths in people older than 35 years old. Number of prognostic models aims to estimate the future risk of mortality, or the combined risk of all-cause mortality or MI has been developed, such as GRACE score.ObjectiveThe aim of our study is to assess the utility of GA and CHA2DS2-VASc score in predicting outcomes in patients admitted with acute coronary syndromes.Patients and methodsThis study was conducted on 90 patients diagnosed with acute coronary syndrome who were admitted receiving PCI, CHA2DS2-VASc score was calculated on admission, and a serum sample for GA was withdrawn within 24 h from admission.ResultsCombined GA and CHA2DS2-VASc score could significantly predict MACCE with sensitivity 100%, specificity 79%, and diagnostic accuracy 80.9% and significantly predict hospital mortality with sensitivity 100%, specificity 75.3%, and diagnostic accuracy 76.7%; on the other hand, GRACE score can predict MACCE using cutoff point 112.5 with sensitivity 75% and specificity 66%.ConclusionIt was concluded that GA and CHADSVASC score can significantly predict major adverse cardiovascular events, in-hospital mortality, and poor clinical outcomes.

Left Atrial Appendage Occlusion vs Standard of Care After Ischemic Stroke Despite Anticoagulation

Patients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT. To compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT. This cohort study was a propensity score-matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score-matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score. Left atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group). The primary outcome was time to first ischemic stroke. Four hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P < .001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy. In patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke.

Retrieval-Augmented Generation for Extracting CHA2DS2-VASc Risk Factors from Unstructured Clinical Notes in Patients with Atrial Fibrillation.

Assessment of stroke risk in patients with atrial fibrillation (AF) is crucial for guiding anticoagulation therapy. CHA2DS2-VASc is a widely used score for defining this risk, but current assessments rely on manual calculation by clinicians or approximations from structured EHR data elements. Unstructured clinical notes contain rich information that could enhance risk assessment. We developed and validated a Retrieval-Augmented Generation (RAG) approach to extract CHA2DS2-VASc risk factors from unstructured notes in patients with AF. We employed a RAG architecture paired with the large language model, Llama3.1, to extract features relevant to CHA2DS2-VASc scores from unstructured notes. The model was deployed on a random set of 1,000 clinical notes (934 AF patients) from Yale New Haven Health System (YNHHS). To establish a gold standard, 2 clinicians manually reviewed and labeled CHA2DS2-VASc risk factors in a random subset of 200 notes. The CHA2DS2-VASc scores were calculated for each patient using structured data alone and by incorporating risk factors identified with RAG. We assessed performance across risk factors using macro-averaged area under the receiver operating characteristic (AUROC). For external validation, we utilized 100 manually labeled clinical notes from the MIMIC-IV database. The RAG model demonstrated robust performance in extracting risk factors from clinical notes. In the 1000 clinical notes, RAG identified several risk factors more frequently than structured elements, including hypertension (82.4% vs 26.2%), stroke/TIA (62.9% vs 45.5%), vascular disease (83.4% vs 56.6%), and diabetes (84.1% vs 47.2%). In the 200 expert-annotated notes, the RAG approach achieved high performance for various risk factors, with AUROCs ranging from 0.96 to 0.98 for hypertension, diabetes, and age ≥75 years. Incorporating risk factors identified by RAG increased CHA2DS2-VASc scores compared with using structured data alone. An LLM-optimized RAG can accurately extract CHA2DS2-VASc risk factors from unstructured clinical notes in AF patients. This approach can enable computable risk assessment and guide appropriate anticoagulation therapy.

Influencing factors and predictive model for left atrial appendage emptying velocity in nonvalvular AF patients.

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of death and stroke. The left atrial appendage (LAA) plays a crucial role in the development of AF. Reduced left atrial appendage emptying velocity (LAAEV) is an important indicator of nonvalvular AF, associated with thrombosis and recurrence after catheter ablation. This study aims to identify factors influencing LAAEV and construct a predictive model for LAAEV in nonvalvular AF patients. This retrospective cohort study included 1,048 nonvalvular AF patients hospitalized at the Second Hospital of Hebei Medical University from January 1, 2015, to December 31, 2021. Patients underwent transthoracic and transesophageal echocardiography and had complete laboratory data. Statistical analyses included binary logistic regression and multiple linear regression to identify independent predictors of reduced LAAEV and construct a predictive model. Patients were divided into two groups: reduced LAAEV (<40 cm/s) and normal LAAEV (≥40 cm/s). The reduced LAAEV group included 457 patients (43.61%), with significant differences in age, gender, alcohol consumption, heart failure (HF), ischemic stroke, AF type, resting heart rate, CHA2DS2-VASc score, serum creatinine (SCR), serum uric acid (SUA), estimated glomerular filtration rate (eGFR), glycated hemoglobin (HbA1C), β2 macroglobulin (B2M), left atrial diameter (LAD), and left ventricular ejection fraction (LVEF) compared to the normal LAAEV group. Logistic regression analysis identified age (OR 0.974, 95% CI 0.951-0.997, P = 0.028), HF (OR 0.637, 95% CI 0.427-0.949, P = 0.027), AF type [Persistent AF vs. PAF (OR 0.063, 95% CI 0.041-0.095, P = 0) Long-standing Persistent AF vs. PAF (OR 0.077, 95% CI 0.043-0.139, P = 0)], LAD (OR 0.872, 95% CI 0.836-0.91, P < 0.001), and LVEF (OR 1.057, 95% CI 1.027-1.089, P = 0) as independent predictors of reduced LAAEV. Multiple linear regression analysis included age, AF type, LAD, and LVEF in the final predictive model, explaining 43.5% of the variance in LAAEV (adjusted R² = 0.435). Age, HF, type of AF, LAD, and LVEF are independent predictors of reduced LAAEV. The predictive model (LAAEV = 96.567-15.940 × AFtype-1.309 × LAD-0.18 × Age + 37.069 × LVEF) demonstrates good predictive value, aiding in the initial assessment and management of nonvalvular AF patients.

Temporal trends in mortality and causes of death in patients with incident atrial fibrillation: a nationwide register study from 2010 to 2018

ObjectivesAtrial fibrillation (AF) is associated with increased mortality. Previous studies have reported conflicting results in temporal trends of mortality after AF diagnosis. We aim to address this disparity by investigating...

Catheter ablation for atrial fibrillation in patients with prior left atrial appendage occlusion device.

The safety and efficacy of CA for AF and left-sided atrial arrhythmias (AA) in patients with left atrial appendage occlusion (LAAO) devices are lacking. This is a single-center retrospective registry that included all patients with prior LAAO who underwent catheter ablation for AF or left-sided atrial arrhythmia from January 2020-January 2023. The primary outcomes were procedure-related complications, device-related complications, AA recurrence, and stroke. A total of 30 patients with prior LAAO were included in the analysis (mean age 75.1 ± 7.1years old, 50% male, mean CHA2DS2-VASc score 4 ± 1.6, 46.7% paroxysmal AF, 73.3% had prior AF ablation, mean time to ablation 475 ± 365days). 93.3% (n = 28) and 6.6% (n = 2) patients had ablation for AF (46.7% paroxysmal, 36.7% persistent, 10% long-standing persistent) and left-sided atrial tachycardia, respectively. 16.7% (n = 5) patients underwent ablation along the left atrial appendage ostium, and 3.3% (n = 1) underwent Vein of Marshall alcohol ablation. There were 3 (10%) peri-procedural complications (1 access hematoma and two pericardial effusions requiring intervention-none related to left atrial appendage ostium or alcohol ablation). During the mean follow-up of 440 ± 379days, 40% (n = 12) patients had AA recurrence (91.6% AF, 8.3% atrial tachycardia), of which five patients needed repeat ablation, and two patients were readmitted for heart failure. There was no stroke or any device-related complications, including new peri-device leaks or device-related thrombosis in patients who had follow-up imaging studies (n = 11, 36.7%). Catheter ablation for AF (including VoM alcohol ablation) in patients with prior LAAO devices is feasible and safe with favorable outcomes.

Tissue Oedema Following Pulsed Field Ablation Recognized during a Concomitant Left Atrial Appendage Closure Procedure. A Case Report

Abstract Background In patients with non-valvular atrial fibrillation (AF), at high stroke risk and who are ineligible for long-term oral anticoagulation the left atrial appendage closure (LAAC) could be an alternative to anticoagulation. Pulsed field ablation (PFA) is a new nonthermal method for cardiac ablation modality based on high-voltage electrical energy for irreversible electroporation. We first report a case of a concomitant PFA pulmonary vein isolation and LAAC. Case Summary A 74-year-old female patient was referred to our department for pulmonary vein isolation (PVI) for persistent AF (CHA2DS2-VASc Score 5). A concomitant percutaneous LAAC was proposed because of a history of previous cerebellar transient ischemic attack despite continuous oral anticoagulation therapy. PVI was achieved with a pentaspline PFA catheter, LAAC performed with a WATCHMAN FLXTM device (Boston Scientific, Plymouth, MN, USA). After PVI, a swelling of the left atrial ridge was observed, yet a 27 mm LAAC device was successfully implanted. The follow-up transesophageal echo (TEE) after 6 weeks showed complete resolution of the oedema, no device related thrombus but a slight proximal tilting of the LAAC device without leakage could be observed. The 6-month follow-up demonstrated a stable sinus rhythm, no stroke or bleeding events were recorded. Discussion In this case of synchronous PFA-PVI procedure in AF and Watchman FLXTM device implantation, the electroporation created an acute oedema at the ridge level which at the TEE follow-up after 6 weeks was resolved. This resulted in a slightly tilted Watchman device position which was nevertheless stable and showed no leakage.

Spontaneous fluctuation in atrial fibrillation burden and duration in patients with implantable loop monitors.

Most studies of device-detected atrial fibrillation (AF) have recommended indefinite anticoagulation once a patient crosses a particular threshold for AF duration or burden. However, durations and burdens are known to fluctuate over time, but little is known about the magnitude of spontaneous fluctuations and the potential impact on anticoagulation decisions. To quantify spontaneous fluctuations in AF duration and burden in patients with implantable loop recorders (ILRs) METHODS: We reviewed all ILR interrogations for patients with non-permanent AF at our institution from 2018 to 2023. We excluded patients treated with rhythm control. The duration of longest AF episode at each interrogation was classified as<6, 6-24, and>24h, and the AF burden reported at each interrogation was classified as<2%, 2%-11.4%, and>11.4%. Out of 156 patients, the mean age at ILR implant was 70.9±12.5 years, CHA2DS2-VASc score was 4.2±1.8, duration of ILR follow-up was 23.4±11.2 months, and number of ILR interrogations per patient was 18.0±8.9. The duration of longest AF episode at any point during follow-up was<6, 6-24, and>24h in 110, 30, and 16 patients, respectively. Among the 30 patients with a longest AF episode of 6-24h at some point during follow-up, out of 594 total ILR interrogations, only 75 (12%) showed a longest episode of 6-24h. In the remaining 519 interrogations, the longest episode was<6h. In patients with a longest episode of>24h at any point during follow-up (n=16), only 47 out of 320 total ILR interrogations (15%) showed an episode of>24h. When evaluating AF burden, 96, 38, and 22 patients had maximum reported AF burdens of<2%, 2%-11.4%, and>11.4% at any point during ILR follow-up. Among those with a maximum burden of 2%-11.4% at some point during follow-up (n=38), out of 707 ILR interrogations, only 76 (11%) showed a burden of 2%-11.4%. In the remaining 631 interrogations, the burden was<2%. In the 22 patients with a burden>11.4% at some point during follow-up, only 80 out of 480 interrogations (17%) showed a burden of>11.4%. In 65% of interrogations, the burden was<2%. Significant, spontaneous fluctuations in AF burden and duration are common in patients with ILRs. Even in patients with AF episodes of 6-24h or>24h at some point during follow-up, the vast majority of interrogations show episodes of<6h. Similarly, in patients with burdens of 2%-11.4% or>11.4% at some point during follow-up, the vast majority of interrogations show burdens of<2%. More data are needed to determine whether crossing an AF burden or duration threshold once is sufficient to merit lifelong anticoagulation or whether spontaneous fluctuations in AF burden and duration should impact anticoagulation decisions.

Associated Factors and Mortality of Arrhythmia in Emergency Department: A Narrative Review.

Cardiac arrhythmias represent a major concern in the emergency department (ED), particularly given their association with significant morbidity and mortality. This narrative review examines the various factors influencing arrhythmias and their impact on patient outcomes in emergency settings. Managing complex supraventricular and ventricular arrhythmias (VAs) during acute myocardial infarction (AMI) and severe cardiovascular conditions remains challenging, despite advancements in diagnostic and therapeutic techniques. Ventricular arrhythmias frequently forecast worse outcomes during hospital stays and heighten the chances of sudden cardiac death and cardiac arrest, especially within the initial 30 days after a heart attack. The incidence of arrhythmias in ED is increasing due to demographic changes and higher rates of chronic illnesses such as diabetes, hypertension, and chronic kidney disease. These comorbidities, coupled with lifestyle factors such as smoking and alcohol consumption, complicate arrhythmia management, especially among older adults and males. Rapid and precise ECG interpretation in the ED is crucial for identifying specific arrhythmia types and initiating appropriate treatments. Atrial fibrillation (AF), the most prevalent form of rapid heart rhythm originating above the ventricles, notably impacts patient outcomes, particularly in cases of AMIand heart failure. In the ED, managing AFfocuses on preventing strokes with thromboprophylaxis and employing risk assessment tools such as CHA2DS2-VASc and HAS-BLED scores. The analysis highlights how risk factors like hypertension, obesity, obstructive sleep apnea (OSA), and diabetes intricately influence the development and worsening of AF. Optimizing AF treatment outcomes requires a multidisciplinary approach involving cardiologists, emergency physicians, and critical care specialists. Future research should prioritize evaluating the effectiveness of preventive and therapeutic interventions for AF, integrating new risk factors and genetic insights to enhance prediction and management strategies. Understanding the factors contributing to arrhythmias and mortality in the ED underscores the importance of timely and accurate diagnostic and therapeutic measures to improve patient care and outcomes.

Risk of Stroke or Systemic Embolism According to Baseline Frequency and Duration of Subclinical Atrial Fibrillation: Insights From the ARTESiA Trial.

In the ARTESiA trial (Apixaban for the Reduction of Thromboembolism in Patients With Device-Detected Subclinical Atrial Fibrillation), apixaban, compared with aspirin, reduced stroke or systemic embolism in patients with device-detected subclinical atrial fibrillation (SCAF). Clinical guidelines recommend considering SCAF episode duration when deciding whether to prescribe oral anticoagulation for this population. We performed a retrospective cohort study in ARTESiA. Using Cox regression adjusted for CHA2DS2-VASc score and treatment allocation (apixaban or aspirin), we assessed frequency of SCAF episodes and duration of the longest SCAF episode in the 6 months before randomization as predictors of stroke risk and of apixaban treatment effect. Among 3986 patients with complete baseline SCAF data, 703 (17.6%) had no SCAF episode ≥6 minutes in the 6 months before enrollment. Among 3283 patients (82.4%) with ≥1 episode of SCAF ≥6 minutes in the 6 months before enrollment, 2542 (77.4%) had up to 5 episodes, and 741 (22.6%) had ≥6 episodes. The longest episode lasted <1 hour in 1030 patients (31.4%), 1 to <6 hours in 1421 patients (43.3%), and >6 hours in 832 patients (25.3%). Higher baseline SCAF frequency was not associated with increased risk of stroke or systemic embolism: 1.1% for 1 to 5 episodes versus 1.2%/patient-year for ≥6 episodes (adjusted hazard ratio, 0.89 [95% CI, 0.59-1.34]). In an exploratory analysis, patients with previous SCAF but no episode ≥6 minutes in the 6 months before enrollment had a lower risk of stroke or systemic embolism than patients with at least one episode during that period (0.5% versus 1.1%/patient-year; adjusted hazard ratio, 0.48 [95% CI, 0.27-0.85]). The frequency of SCAF did not modify the reduction in stroke or systemic embolism with apixaban (Pinteraction=0.1). The duration of the longest SCAF episode in the 6 months before enrollment was not associated with the risk of stroke or systemic embolism during follow-up (<1 hour: 1.0%/patient-year [reference]; 1-6 hours: 1.2%/patient-year [adjusted hazard ratio, 1.27 (95% CI, 0.85-1.90)]; >6 hours: 1.0%/patient-year [adjusted hazard ratio, 1.02 (95% CI, 0.63-1.66)]). SCAF duration did not modify the reduction in stroke or systemic embolism with apixaban (Ptrend=0.1). In ARTESiA, baseline SCAF frequency and longest episode duration were not associated with risk of stroke or systemic embolism and did not modify the effect of apixaban on reduction of stroke or systemic embolism. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01938248.

Research progress in stroke risk perception assessment tool.

One of the main illnesses in the globe that causes impairment and death in people is stroke. In the globe today, it ranks as the second leading cause of death and the leading cause of death in China. This paper analyses into the critical role of risk perception in developing individual awareness of stroke risk and encouraging proactive preventive health behaviors, essential for effective primary stroke prevention strategies and reduced stroke incidence. It discusses the concept of risk perception, the content and dimensions of global stroke assessment tools, and their application status, aiming to provide insights for their development and intervention research. Risk perception encompasses subjective assessments of stroke likelihood and severity, influenced by personal experiences, knowledge of risk factors, beliefs about prevention effectiveness, and emotional responses. Global stroke assessment tools, like the Framingham Stroke Risk Score and CHA2DS2-VASc Score, evaluate stroke risk based on factors such as age, gender, blood pressure, and cholesterol levels. In order to improve risk perception and proactive health management and lower the burden of strokes, the paper assesses the advantages and disadvantages of these tools and makes recommendations for improving accessibility, customizing interventions, running educational campaigns, promoting multidisciplinary collaboration, and integrating technology. By combining the research tools of stroke risk perception, it is found that the evaluation tools are mostly single-dimensional evaluation tools centered on the two dimensions of onset possibility and susceptibility. Some scholars have developed multi-dimensional evaluation tools, but the evaluation population is relatively limited, and the evaluation system lacks comprehensiveness and systematization.

Edoxaban Antithrombotic Therapy for Atrial Fibrillation and Stable Coronary Artery Disease.

Despite consistent recommendations from clinical guidelines, data from randomized trials on a long-term antithrombotic treatment strategy for patients with atrial fibrillation and stable coronary artery disease are still lacking. We conducted a multicenter, open-label, adjudicator-masked, randomized trial comparing edoxaban monotherapy with dual antithrombotic therapy (edoxaban plus a single antiplatelet agent) in patients with atrial fibrillation and stable coronary artery disease (defined as coronary artery disease previously treated with revascularization or managed medically). The risk of stroke was assessed on the basis of the CHA2DS2-VASc score (scores range from 0 to 9, with higher scores indicating a greater risk of stroke). The primary outcome was a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, and major bleeding or clinically relevant nonmajor bleeding at 12 months. Secondary outcomes included a composite of major ischemic events and the safety outcome of major bleeding or clinically relevant nonmajor bleeding. We assigned 524 patients to the edoxaban monotherapy group and 516 patients to the dual antithrombotic therapy group at 18 sites in South Korea. The mean age of the patients was 72.1 years, 22.9% were women, and the mean CHA2DS2-VASc score was 4.3. At 12 months, a primary-outcome event had occurred in 34 patients (Kaplan-Meier estimate, 6.8%) assigned to edoxaban monotherapy and in 79 patients (16.2%) assigned to dual antithrombotic therapy (hazard ratio, 0.44; 95% confidence interval [CI], 0.30 to 0.65; P<0.001). The cumulative incidence of major ischemic events at 12 months appeared to be similar in the trial groups. Major bleeding or clinically relevant nonmajor bleeding occurred in 23 patients (Kaplan-Meier estimate, 4.7%) in the edoxaban monotherapy group and in 70 patients (14.2%) in the dual antithrombotic therapy group (hazard ratio, 0.34; 95% CI, 0.22 to 0.53). In patients with atrial fibrillation and stable coronary artery disease, edoxaban monotherapy led to a lower risk of a composite of death from any cause, myocardial infarction, stroke, systemic embolism, unplanned urgent revascularization, or major bleeding or clinically relevant nonmajor bleeding at 12 months than dual antithrombotic therapy. (Funded by the CardioVascular Research Foundation and others; EPIC-CAD ClinicalTrials.gov number, NCT03718559.).

O02 SIMULTANEOUS BLOOD PRESSURE AND ATRIAL FIBRILLATION SCREENING IN MAY MEASUREMENT MONTH 2022

Background and objective: May Measurement Month (MMM) is a global campaign aiming to raise awareness of raised blood pressure (BP). In 2022, concurrent screening for BP and atrial fibrillation (AF) was conducted in ten countries, given that hypertension and AF are both major treatable risk factors for stroke. Here, we evaluate AF prevalence and treatment by BP status among opportunistic samples of adults. Methods: In MMM, adults (≥18 years) undergo opportunistic BP screening. In ten participating countries, concurrent AF screening was carried out using OMRON Complete or M7 devices, in addition to three standardized, sitting BP measurements. ‘Known’ AF was defined as having had a previous diagnosis of either AF or irregular heartbeat, or taking oral anticoagulants. To risk-stratify those with AF, we calculated the CHA2DS2-VASc score. Hypertension was defined as a BP ≥140 and/or ≥90 mmHg (average of the second and third readings) and/or taking BP-lowering medication. Results: 80,751 adults (mean age 50.1 years; 58.2% female) underwent BP and AF screening. AF was detected in 1,526 (1.9%), of whom 1,014 (66.4%) had ‘known’ AF. Of those with ‘known’ AF, 214 (21.1%) were taking anticoagulants and 644 (63.5%) were taking neither anticoagulants nor aspirin. AF was detected more commonly among those aged ≥60 than &lt;60 (3.2% vs 1.2%: p&lt;0.001). Hypertension was detected more commonly among those with than without AF (63.6% vs 45.2%; age-sex-adjusted p&lt;0.001). There was a graded association in anticoagulant and aspirin treatment rates according to CHA2DS2-VASc score in participants with ‘known’ AF (Table). Amongst participants with ‘known’ AF, anticoagulant usage was reported by 35.7% of those with a class 1 indication for anticoagulation according to CHA2DS2-VASc score. Conclusions Opportunistic AF screening in the MMM 2022 campaign detected AF in 3.2% of participants aged ≥60, and hypertension was more common in those with AF. Over one third of detected cases were not ‘known’ cases. Only 35.7% of ‘known’ cases with a class 1 indication for anticoagulants were treated.

Incident thrombocytopenia and bleeding risk in elderly patients with atrial fibrillation on direct oral anticoagulants: insights from the ATHEROsclerosis in Atrial Fibrillation study

BackgroundThe bleeding risk of patients with atrial fibrillation (AF) changes over time. Most studies thus far evaluated only the baseline bleeding risk with discordant results. The impact of incident thrombocytopenia during direct oral anticoagulant (DOAC) therapy and its relation to bleeding has not been previously investigated. ObjectivesTo investigate the incidence rate of thrombocytopenia and major bleeding (MB) risk in AF patients on DOACs. MethodsProspective ongoing ATHEROsclerosis in Atrial Fibrillation study including patients with nonvalvular AF on DOACs. Incident thrombocytopenia was defined as a platelet count <150 × 109/L. MB events were recorded at each follow-up visit. Gray estimator for competing risk data was used. Estimates are expressed in terms of subdistributional hazard ratios (sHR) and relative 95% CI for MB. ResultsWe enrolled 957 AF patients treated with DOACs (mean age, 77.3 ± 9.0 years; 49.1% women). During a follow-up (median time to censoring 1330 days; 95% CI, 1246-1443), 139 patients developed thrombocytopenia (3.08 per 100 person-years; 95% CI, 2.27-3.89) with no difference between direct thrombin and factor Xa inhibitors. Overall, 179 bleedings occurred, of which 80 were major (3.17 per 100 person-years; 95% CI, 2.34-3.99). Patients sustaining bleedings were more frequently affected by arterial hypertension, heart failure, anemia and had higher CHA2DS2-VASc and HAS-BLED scores. On multivariable Cox analysis, independent risk factors for MB were incident thrombocytopenia (sHR, 12.77; 95% CI, 8.880-18.360; P < .001), and age (sHR, 1.030 per year; 95% CI, 1.010-1.040; P = .002). ConclusionPatients developing thrombocytopenia have an increased risk of MB. Dynamic evaluation of platelet count during follow-up may provide better prognostic value than baseline assessment only.

Asundexian versus Apixaban in Patients with Atrial Fibrillation.

Stroke prevention with direct-acting oral anticoagulant agents in patients with atrial fibrillation confers a risk of bleeding and limits their use. Asundexian, an activated factor XI (XIa) inhibitor, is an oral anticoagulant that may prevent strokes with less bleeding. In a phase 3, international, double-blind trial, we randomly assigned high-risk patients with atrial fibrillation in a 1:1 ratio to receive asundexian at a dose of 50 mg once daily or standard-dose apixaban. The primary efficacy objective was to determine whether asundexian is at least noninferior to apixaban for the prevention of stroke or systemic embolism. The primary safety objective was to determine whether asundexian is superior to apixaban with respect to major bleeding events. A total of 14,810 randomly assigned patients were included in the intention-to-treat population. The mean (±SD) age of the patients was 73.9±7.7 years, 35.2% were women, 18.6% had chronic kidney disease, 18.2% had a previous stroke or transient ischemic attack, 16.8% had received oral anticoagulants for no more than 6 weeks, and the mean CHA2DS2-VASc score (range, 0 to 9, with higher scores indicating a greater risk of stroke) was 4.3±1.3. The trial was stopped prematurely at the recommendation of the independent data monitoring committee. Stroke or systemic embolism occurred in 98 patients (1.3%) assigned to receive asundexian and in 26 (0.4%) assigned to receive apixaban (hazard ratio, 3.79; 95% confidence interval [CI], 2.46 to 5.83). Major bleeding occurred in 17 patients (0.2%) who received asundexian and in 53 (0.7%) who received apixaban (hazard ratio, 0.32; 95% CI, 0.18 to 0.55). The incidence of any adverse event appeared to be similar in the two groups. Among patients with atrial fibrillation at risk for stroke, treatment with asundexian at a dose of 50 mg once daily was associated with a higher incidence of stroke or systemic embolism than treatment with apixaban in the period before the trial was stopped prematurely. There were fewer major bleeding events with asundexian than with apixaban during this time. (Funded by Bayer; OCEANIC-AF ClinicalTrials.gov number, NCT05643573; EudraCT number, 2022-000758-28.).

The European Society of Cardiology quality indicators in atrial fibrillation in centers of excellence in Spain: the SEC-EXCELENTE FA registry

Introduction and objectivesBy 2022, 9 centers had been accredited by the Spanish Society of Cardiology for the atrial fibrillation (AF) process. Our objective was to evaluate the performance of these centers based on the quality indicators (QIs) proposed by the European Society of Cardiology (ESC) in 2020. MethodsAdults with AF who were attended in the cardiology departments of participating centers during the second week of May 2019 were included in a retrospective registry (n=797, age 72±11 years, 60% male). Key ESC QIs were assessed. ResultsCHA2DS2-VASc, HAS-BLED scores, and serum creatinine levels were documented in 24.9%, 6.1%, and 96.2% of patients, respectively. Anticoagulation was appropriately prescribed in 90.6% of high-risk patients according to the CHA2DS2-VASc score, but was inappropriately prescribed in 57.8% of low-risk patients. Among all patients, 84.1% received high-quality anticoagulation. Inappropriate antiarrhythmic drugs were prescribed in 7.2% of patients with permanent AF, 2.9% of those with structural heart disease, and 0.0% of those with end-stage kidney disease. Catheter ablation was offered to 70% of patients with symptomatic paroxysmal or persistent AF after the failure or intolerance of 1 antiarrhythmic drug. All modifiable risk factors were documented in 59.3% of patients. Rates of all-cause mortality, ischemic stroke or transient ischemic attack, and major bleeding were 8.1, 0.8, and 2.56 per 100 patients/y, respectively. QIs for anticoagulation and outcomes were similar between general cardiology and tertiary referral centers. ConclusionsAlthough accredited centers in Spain demonstrated good performance in many of the ESC QIs for AF, there remains room for improvement. These data could serve as a starting point for enhancing the quality of care in this population.

The CHA2DS2-VASc risk score in patients with Non-ST Elevation myocardial infarction to predict total occlusion in infarct-related arteries

The CHA2DS2-VASc risk score in patients with Non-ST Elevation myocardial infarction to predict total occlusion in infarct-related arteries