CHA2DS2-VASc versus CHADS2 for stroke risk assessment in low-risk patients with atrial fibrillation: a pilot study from a single center of the NCDR-PINNACLE registry

SummaryCatheter ablation provides curative treatment for atrial fibrillation (AF). Data on anticoagulation after the procedure are sparse. We investigated real-life antithrombotic treatment after AF ablation and examined its adherence to current recommendations. Eight hundred forty-four patients (age 58 ±10 years) underwent AF ablation. Most patients had a CHADS2 score of 0 (46%) or 1 (45%). Seven-day Holter was performed at three, six and 12 months after ablation. Decision on anticoagulation treatment was made by general practitioners and referring cardiologists in consultation with the patients. At discharge, anticoagulants were prescribed for the vast majority (94–96%) of patients. This percentage remained high at three and six months (80–90%) without differences between stroke risk groups. At 12 months, the use of anticoagulants was mainly influenced by the detection of recurrence; usage exceeded 90% in all stroke risk groups in patients with recurrences. In patients without recurrences, differences between risk groups were significant but small, ranging from 42% (CHADS2=0) to 62% (CHADS2≥2) (p=0.033). In multivariate analysis, the only factor independently associated with oral anticoagulation at 12 months was the detection of recurrences (odds ratio=16.2, p<0.001), whereas the effect of the CHADS2 score was not significant (p=0.080).The effect of all other examined factors was also not significant. Contrary to current recommendations, anticoagulation after AF ablation is hardly guided by the stroke risk profile and remains high even in low-risk patients. The most important factor influencing the use of anticoagulants is the detection of recurrences during follow-up. This results in possible overtreatment of low-risk patients.

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Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA2DS2-VASc Score of 0 (Males) or 1 (Females): Implications for Reassessment of Stroke Risk in Initially ‘Low-Risk’ Patients

Thrombosis and Haemostasis ◽

10.1055/s-0039-1683933 ◽

2019 ◽

Vol 119 (07) ◽

pp. 1162-1170 ◽

Cited By ~ 16

Author(s):

Tze-Fan Chao ◽

Jo-Nan Liao ◽

Ta-Chuan Tuan ◽

Yenn-Jiang Lin ◽

Shih-Lin Chang ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Adverse Events ◽

Ischaemic Stroke ◽

Stroke Risk ◽

Temporal Trends ◽

Low Risk ◽

Stroke Risk Factor ◽

Timing Interval ◽

Risk Patients

Background Oral anticoagulants (OACs) are not recommended for ‘low-risk’ patients with atrial fibrillation (AF). We investigated the incidences of new risk factors developing, and the temporal trends in the CHA2DS2-VASc score in initially ‘low-risk’ AF patients. Second, we propose a reasonable timing interval at which stroke risk should be reassessed for such AF patients. Methods We studied 14,606 AF patients who did not receive anti-platelet agents or OACs with a baseline CHA2DS2-VASc score of 0 (males) or 1 (females). The CHA2DS2-VASc scores of patients were followed up and updated until the occurrence of ischaemic stroke or mortality or 31 December 2011. The associations between the prescription of warfarin and risk of adverse events once patients' scores changed were analysed. Decile values of durations to incident co-morbidities and from the acquirement of new co-morbidities to ischaemic stroke were studied. Results During a mean follow-up of 4 years, 7,079 (48.5%) patients acquired at least one new stroke risk factor component(s) with annual risks of 6.35% for hypertension, 3.68% for age ≥ 65 years, 2.77% for heart failure, 1.99% for diabetes mellitus and 0.33% for vascular diseases. The incidence for CHA2DS2-VASc score increments was 12.1%/year. Initiation of warfarin was associated with a lower risk of adverse events (adjusted hazard ratio, 0.530; 95% confidence interval, 0.371–0.755). Among 6,188 patients who acquired new risk factors, 80% would acquire these co-morbidities after 4.2 months of AF diagnosis. The duration from the acquirement of incident co-morbidities to the occurrence of ischaemic stroke was longer than 4.4 months for 90% of the patients. Conclusion The CHA2DS2-VASc score increases in approximately 12% of initially ‘low-risk’ AF patients each year, and the initiation of warfarin once the score changed was associated with a better prognosis. Three to four months may be a reasonable timing interval at which stroke risk should be reassessed so that OACs could be prescribed in a timely manner for stroke prevention.

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Dynamic Changes of CHA2DS2-VASc Score and the Risk of Ischaemic Stroke in Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study

Thrombosis and Haemostasis ◽

10.1055/s-0038-1651482 ◽

2018 ◽

Vol 118 (07) ◽

pp. 1296-1304 ◽

Cited By ~ 44

Author(s):

Minjae Yoon ◽

Pil-Sung Yang ◽

Eunsun Jang ◽

Hee Yu ◽

Tae-Hoon Kim ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Stroke Risk ◽

Low Risk ◽

Dynamic Changes ◽

Risk Patients ◽

Changes Over Time ◽

Over Time

Background Stroke risk in atrial fibrillation (AF) is often assessed at initial presentation, and risk stratification performed as a ‘one off’. In validation studies of risk prediction, baseline values are often used to ‘predict’ events that occur many years later. Many clinical variables have ‘dynamic’ changes over time, as the patient is followed up. These dynamic changes in risk factors may increase the CHA2DS2-VASc score, stroke risk category and absolute ischaemic stroke rate. Objective This article evaluates the ‘dynamic’ changes of CHA2DS2-VASc variables and its effect on prediction of stroke risk. Patients and Methods From the Korea National Health Insurance Service database, a total of 167,262 oral anticoagulant-naive non-valvular AF patients aged ≥ 18 years old were enrolled between January 1, 2002, and December 31, 2005. These patients were followed up until December 31, 2015. Results At baseline, the proportions of subjects categorized as ‘low’, ‘intermediate’ or ‘high risk’ by CHA2DS2-VASc score were 15.4, 10.6 and 74.0%, respectively. Mean CHA2DS2-VASc score increased annually by 0.14, particularly due to age and hypertension. During follow-up of 10 years, 46.6% of ‘low-risk’ patients and 72.0% of ‘intermediate risk’ patients were re-classified to higher stroke risk categories. Among the original ‘low-risk’ patients, annual ischaemic stroke rates were significantly higher in the re-classified ‘intermediate’ (1.17 per 100 person-years, p < 0.001) or re-classified ‘high-risk’ groups (1.44 per 100 person-years, p = 0.048) than consistently ‘low-risk’ group (0.29 per 100 person-years). The most recent CHA2DS2-VASc score and the score change with the longest follow-up had the best prediction for ischaemic stroke. Conclusion In AF patients, stroke risk as assessed by the CHA2DS2-VASc score is dynamic and changes over time. Rates of ischaemic stroke increased when patients accumulated risk factors, and were re-classified into higher CHA2DS2-VASc score categories. Stroke risk assessment is needed at every patient contact, as accumulation of risk factors with increasing CHA2DS2-VASc score translates to greater stroke risks over time.

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Stroke risk assessment in patients with persistent atrial fibrillation to consider performing pre-cardioversion transesophageal echocardiography

CARDIOVASCULAR THERAPY AND PREVENTION ◽

10.15829/1728-8800-2021-2783 ◽

2021 ◽

Vol 20 (7) ◽

pp. 2783

Author(s):

E. S. Mazur ◽

V. V. Mazur ◽

N. D. Bazhenov ◽

Yu. A. Orlov

Keyword(s):

Atrial Fibrillation ◽

Risk Assessment ◽

Confidence Interval ◽

Transesophageal Echocardiography ◽

Odds Ratio ◽

Left Atrial ◽

Stroke Risk ◽

Left Atrial Appendage ◽

Persistent Atrial Fibrillation ◽

Low Risk

Aim. To study the potential of stroke risk assessment to evaluate the probability of detecting left atrial appendage (LAA) thrombus in patients with persistent atrial fibrillation (AF) to consider performing transesophageal echocardiography (TEE) before cardioversion.Material and methods. TEE before elective cardioversion was performed in 590 patients with persistent AF, of whom 316 (53,6%) had a high stroke risk (valvular AF, hypertrophic cardiomyopathy, CHA2DS2-VASc score >1 in men and >2 in women), and 274 (46,4%) — not high. Adequate anticoagulation at least 3 weeks prior to elective cardioversion was received by 164 (51,9%) patients with a high stroke risk and 151 (55,1%) patients with a low risk. The rest of patients either did not receive adequate anticoagulation or received it for less than 3 weeks.Results. In the group of patients who received anticoagulation at least 3 weeks, LAA thrombus was detected in 23 (14,0%) patients with a high stroke risk and in 8 (5,3%) patients with a low risk (p<0,05). In patients who did not receive adequate anticoagulation or received it for less than 3 weeks, LAA thrombus was identified in 60 (39,5%) patients with a high stroke risk and in 22 (17,9%) patients with a low risk (p<0,005). Thus, a high stroke risk almost 3 times increases the likelihood of LAA thrombus detection in patients who did not receive adequate anticoagulation (odds ratio, 2,99; 95% confidence interval: 1,70-5,26;p<0,001) and in patients receiving adequate anticoagulation (odds ratio, 2,92; 95% confidence interval: 1,26-6,74; p=0,012).Conclusion. In patients with persistent AF with a low stroke risk according to CHA2DS2-VASc score, TEE before sinus rhythm restoration in patients without 3-week anticoagulation should be considered. In patients with a high stroke risk, performing pre-cardioversion TEE is advisable even after adequate anticoagulation.

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Stroke prevention in atrial fibrillation: comparison of recent international guidelines

European Heart Journal Supplements ◽

10.1093/eurheartj/suaa180 ◽

2020 ◽

Vol 22 (Supplement_O) ◽

pp. O53-O60

Author(s):

Tze-Fan Chao ◽

Milan A Nedeljkovic ◽

Gregory Y H Lip ◽

Tatjana S Potpara

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Risk Assessment ◽

Cardiovascular Risk ◽

Stroke Prevention ◽

Stroke Risk ◽

Care Pathway ◽

Symptom Control ◽

Bleeding Risk ◽

Low Risk

Abstract Stroke prevention is one of the cornerstones of management in patients with atrial fibrillation (AF). As part of the ABC (Atrial fibrillation Better Care) pathway (A: Avoid stroke/Anticoagulation; B: Better symptom control; C: Cardiovascular risk and comorbidity optimisation), stroke risk assessment and appropriate thromboprophylaxis is emphasised. Various guidelines have addressed stroke prevention. In this review, we compared the 2017 APHRS, 2018 ACCP, 2019 ACC/AHA/HRS, and 2020 ESC AF guidelines regarding the stroke/bleeding risk assessment and recommendations about the use of OAC. We also aimed to highlight some unique points for each of those guidelines. All four guidelines recommend the use of the CHA2DS2-VASc score for stroke risk assessment, and OAC (preferably NOACs in all NOAC-eligible patients) is recommended for AF patients with a CHA2DS2-VASc score ≥2 (males) or ≥3 (females). Guidelines also emphasize the importance of stroke risk reassessments at periodic intervals (e.g. 4–6 months) to inform treatment decisions (e.g. initiation of OAC in patients no longer at low risk of stroke) and address potentially modifiable bleeding risk factors.

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Less dementia and stroke in low-risk patients with atrial fibrillation taking oral anticoagulation

European Heart Journal ◽

10.1093/eurheartj/ehz304 ◽

2019 ◽

Vol 40 (28) ◽

pp. 2327-2335 ◽

Cited By ~ 21

Author(s):

Leif Friberg ◽

Tommy Andersson ◽

Mårten Rosenqvist

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Lower Risk ◽

Stroke Risk ◽

Low Risk ◽

Clear Indication ◽

Brain Protection ◽

Previous Diagnosis ◽

Diagnosis Of Dementia ◽

Risk Patients

AbstractAimsTo investigate if patients with atrial fibrillation (AF) without clear indication for oral anticoagulant (OAC) due to perceived low stroke risk may benefit from OAC treatment when also dementia and intracerebral bleeding risks are considered.Methods and resultsRetrospective study of cross-matched national registries of all individuals in Sweden with a hospital diagnosis of AF between 2006 and 2014 (n = 456 960). Exclusion was made of patients with a baseline CHA2DS2-VASc score >1, not counting female sex, and of patients with previous diagnosis of dementia or intracranial bleeding. After exclusions, 91 254 patients remained in the study of whom 43% used OAC at baseline. Propensity score matching and falsification endpoints were used. Treatment with OAC was associated with lower risk of dementia after adjustment for death as a competing risk [subhazard ratio (sHR) 0.62 with 95% confidence interval (CI) 0.48–0.81]. Regarding the composite brain protection endpoint, OAC treatment was associated with an overall 12% lower risk (sHR 0.88, CI 0.72–1.00). This apparent benefit was restricted to patients aged >65 years, whereas OAC treatment of patients <60 years of age without risk factors appeared to do more harm than good.ConclusionLow-risk AF patients who take OAC have lower risk of dementia than those who do not use OAC. Patients age >65 years appear to benefit from OAC treatment irrespective of stroke risk score.

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