scholarly journals Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review

2018 ◽  
Vol 118 (12) ◽  
pp. 2171-2187 ◽  
Author(s):  
Ethan Borre ◽  
Adam Goode ◽  
Giselle Raitz ◽  
Bimal Shah ◽  
Angela Lowenstern ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
English Language ◽  
Stroke Risk ◽  
Bleeding Event ◽  
Bleeding Risk ◽  
Patient Characteristics ◽  
Risk Scores ◽  
Prediction Ability ◽  
Thromboembolic Risk ◽  
Strength Of Evidence

Background Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. Aim This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. Methods We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and applicability were extracted. Results Sixty-one studies were relevant to predicting thromboembolic risk and 38 to predicting bleeding risk. Data suggest that CHADS2, CHA2DS2-VASc and the age, biomarkers, and clinical history (ABC) risk scores have the best evidence for predicting thromboembolic risk (moderate strength of evidence for limited prediction ability of each score) and that HAS-BLED has the best evidence for predicting bleeding risk (moderate strength of evidence). Limitations Studies were heterogeneous in methodology and populations of interest, setting, interventions and outcomes analysed. Conclusion CHADS2, CHA2DS2-VASc and ABC scores have the best prediction for stroke events, and HAS-BLED provides the best prediction for bleeding risk. Future studies should define the role of imaging tools and biomarkers in enhancing the accuracy of risk prediction tools. Primary Funding Source Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999)

Abstract 169: The Role Of Clinical Prediction Factors On Anticoagulant Selection In Atrial Fibrillation

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Julie Lauffenburger
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Patient Characteristics ◽  
Treatment Selection ◽  
Risk Scores ◽  
Treatment Benefit ◽  
Risk Treatment

Background: Atrial fibrillation (AF) often benefits from the use of anticoagulants for prevention of stroke or systemic embolism. While novel oral anticoagulants have emerged as possible alternatives to warfarin, it is unknown how treatment selection is determined in practice with clinical guidelines still evolving. This study examined whether and to what extent anticoagulant selection has been driven by clinical predictions of stroke risk (treatment benefit) and bleeding risk (treatment harm) in real-world practice in the US. Methods: A nationwide database of commercial and Medicare Part D supplement claims from 2009-2011 was used to extract a cohort of non-valvular AF patients who were newly-initiating therapy after dabigatran availability in Oct 2010. Patients were excluded if they had claims associated with a reversible AF condition. Risk scores of ischemic stroke (CHADS2 and CHA2DS2-VASc) and bleeding (ATRIA) were used to examine associations with either warfarin or dabigatran use, calculated via claims in the outpatient pharmaceutical, inpatient medical, outpatient, and provider claims files. Baseline demographic and clinical characteristics were also measured as covariates, including concomitant diseases and medications. Multivariable log-binomial regression models assessed the association between each risk score and anticoagulant use, adjusting for the measured covariates. C-statistics were also used to examine the variation in treatment selection explained by inclusion of the risk scores. Results: In total, 37,401 patients were identified with 31% initiating dabigatran. New users of dabigatran were more likely to be younger, male, and have comorbidities. Patients at intermediate stroke risk (CHADS2 or CHA2DS2-VASc =1) were equally likely to receive warfarin and dabigatran (RR, 95% CI: 0.98, 0.93-1.02), while selection for warfarin was significantly associated with high ischemic stroke risk (CHADS2 or CHA2DS2-VASc ≥2) (RR, 95% CI: 0.87, 0.83-0.92). New users of dabigatran were significantly less likely to have high bleeding risk (ATRIA≥5) versus warfarin (RR, 95%: 0.70, 0.66-0.74). The c-statistic of the base model, which included the other measured covariates, was only marginally increased with the addition of any of the risk scores. Conclusions: Despite controlling for other patient characteristics, bleeding risk was strongly associated with the selection of a specific anticoagulant. However, the extent of selection explained by predictions of treatment harm was minimal. Providers appear to base anticoagulant selection on factors other than predictions of treatment benefit, which has implications for studying the anticoagulants’ comparative effectiveness.

Abstract 18538: The ATRIA Stroke Risk Score Predicts Ischemic Stroke Better than CHADS2 and CHA2DS2-VASc in a large Swedish Cohort of Patients with Atrial Fibrillation

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Sara Aspberg ◽  
Yuchiao Chang ◽  
Daniel Singer
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Risk Score ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Cut Points ◽  
Net Clinical Benefit ◽  
Better Than

Introduction: Atrial fibrillation (AF) is a major risk factor for acute ischemic stroke (AIS). Anticoagulation therapy (OAC) effectively prevents AIS, but increases bleeding risk. There is a need for better AIS risk prediction to optimize the anticoagulation decision in AF. The ATRIA stroke risk score (ATRIA) (table) was superior to CHADS2 and CHA2DS2-VASc in two large California community AF cohorts. We now report the performance of the 3 scores in a very large Swedish AF cohort. Methods: The cohort consisted of all Swedish patients hospitalized with a diagnosis of AF from July 1, 2005 to December 31, 2008. Predictor variables and the outcome, AIS, were obtained from inpatient ICD-10 codes. Warfarin use was determined from National Pharmacy Database. Risk scores were assessed via c-index (C) and net reclassification index (NRI). Results: The cohort included 158,370 AF patients off warfarin who contributed 340,332 person-years of follow-up, and 11,823 incident AIS, for an overall AIS rate of 3.47%/yr, higher than the 2%/yr seen in the California cohorts. Using the entire point score, ATRIA had a good C of 0.712 (0.708-0.716), significantly better than CHADS2, 0.694 (0.689-0.698), or CHA2DS2-VASc, 0.697 (0.693-0.702). Using published cut-points for Low/Moderate/High AIS risk, C deteriorated for all scores but ATRIA and CHADS2 were superior to CHA2DS2-VASc. NRI favored ATRIA; 0.16 (0.15-0.18) versus CHADS2; 0.22 (0.21-0.24) versus CHA2DS2-VASc. However, NRI decreased to near-zero when cut-points were altered to better fit the cohort’s stroke rates. Conclusion: Findings in this large Swedish AF cohort validate those in the California AF cohorts, with the ATRIA score predicting stroke risk better than CHADS2 or CHA2DS2-VASc. However, relative performance of the categorical scores varied by population stroke risk. Knowledge about this population risk may be needed to optimize cut-points on the multipoint scores to achieve better net clinical benefit from OAC.

Comparison of the CHADS2, CHA2DS2 -VASc and HAS-BLED scores for the prediction of clinically relevant bleeding in anticoagulated patients with atrial fibrillation: The AMADEUS trial

2013 ◽  
Vol 110 (11) ◽  
pp. 1074-1079 ◽  
Author(s):  
Stavros Apostolakis ◽  
Deirdre A. Lane ◽  
Harry Buller ◽  
Gregory Y. H. Lip
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Assessment ◽  
Risk Score ◽  
Stroke Risk ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Net Reclassification Improvement ◽  
Anticoagulated Patients ◽  
Discriminatory Performance

SummaryMany of the risk factors for stroke in atrial fibrillation (AF) are also important risk factors for bleeding. We tested the hypothesis that the CHADS2 and CHA2DS2-VASc scores (used for stroke risk assessment) could be used to predict serious bleeding, and that these scores would compare well against the HAS-BLED score, which is a specific risk score designed for bleeding risk assessment. From the AMADEUS trial, we focused on the trial’s primary safety outcome for serious bleeding, which was “any clinically relevant bleeding”. The predictive value of HAS-BLED/CHADS2/CHA2DS2-VASc were compared by area under the curve (AUC, a measure of the c-index) and the Net Reclassification Improvement (NRI). Of 2,293 patients on VKA, 251 (11%) experienced at least one episode of “any clinically relevant bleeding” during an average 429 days follow up period. Incidence of “any clinically relevant bleeding” rose with increasing HAS-BLED/CHADS2/CHA2DS2-VASc scores, but was statistically significant only for HAS-BLED (p<0.0001). Only HAS-BLED demonstrated significant discriminatory performance for “any clinically relevant bleeding” (AUC 0.60, p<0.0001). There were significant AUC-differences between HAS-BLED (which had the highest AUC) and both CHADS2 (p<0.001) and CHA2DS2VASc (p=0.001). The HAS-BLED score also demonstrated significant NRI for the outcome of “any clinically relevant bleeding” when compared with CHADS2 (p=0.001) and CHA2DS2-VASc (p=0.04). In conclusion, the HAS-BLED score demonstrated significant discriminatory performance for “any clinically relevant bleeding” in anticoagulated patients with AF, whilst the CHADS2 and CHA2DS2-VASc scores did not. Bleeding risk assessment should be made using a specific bleeding risk score such as HAS-BLED, and the stroke risk scores such as CHADS2 or CHA2DS2-VASc scores should not be used.

scholarly journals Oral anticoagulant therapy in atrial fibrillation older patients with previous bleeding

2020 ◽  
Vol 90 (1) ◽  
Author(s):  
Mario Bo ◽  
Francesco Giannecchini ◽  
Martina Papurello ◽  
Enrico Brunetti
Keyword(s):  
Atrial Fibrillation ◽  
Anticoagulant Therapy ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulant ◽  
Older Patients ◽  
Oral Anticoagulant Therapy ◽  
Unmet Need ◽  
Bleeding Event ◽  
Bleeding Risk ◽  
Risk Scores

Oral anticoagulant therapy (OAT) with direct oral anticoagulant (DOACs) is the established treatment to reduce thromboembolic risk in patients with atrial fibrillation (AF). Bleeding risk scores are useful to identify and correct factors associated with bleeding risk in AF patients on OAT. However, the clinical scenario is more complex in patients with previous bleeding event, and the decision about whether and when starting or re-starting OAT in these patients remains a contentious issue. Major bleeding is associated with a subsequent increase in both short- and long-term mortality, and even minimal bleeding may have prognostic importance because it frequently leads to disruption of antithrombotic therapy. There is an unmet need for guidance on how to manage antithrombotic therapy after bleeding has occurred. While waiting for observational and randomized data to accrue, this paper offers a perspective on managing antithrombotic therapy after bleeding in older patients with AF.

scholarly journals Which scores should use cardiologist to predict outcomes in patients with nonvalvular atrial fibrillation?

2020 ◽  
Vol 29 (4) ◽  
pp. 5-16
Author(s):  
S. Moiseev
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation ◽  
High Bleeding Risk ◽  
Medical University ◽  
Risk Symptom

Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia Management of patients with atrial fibrillation (AF) includes anticoagulation for prevention of stroke and systemic embolism, improvement of AF-related symptoms by rate or rhythm control, and treatment for cardiovascular and other comorbidities. The structured characterization of AF should address four AF-related domains, that is, stroke risk, symptom severity, AF burden (type of AF, number and duration of episodes, etc.), and substrate severity. Various scores, i.e.CHA 2 DS 2 -VASc (stroke risk), HAS-BLED (bleeding risk), EHRA (severity of AF-related symptoms), and 2MACE (risk of cardiovascular events), can be used to estimate the risk of outcomes and for treatment decisions. Noteworthy, bleeding risk assessment using HAS-BLED score focuses attention on modifiable risk factors that should be managed to improve safety of anticoagulation, whereas a high bleeding risk score should not lead to withholding oral anticoagulants. New clini- cal and biomarker-based risk scores were developed. However, their potential advantages over existing scores should be confirmed in clinical studies.

scholarly journals Improvement of the management of anticoagulation in Atrial Fibrillation patients in the emergency and acute medical departments; a service quality improvement report

2021 ◽  
Vol 2 (3) ◽  
pp. 18-24
Author(s):  
Amr Elkammash ◽  
Yosra Taha ◽  
Saleh Kanaan ◽  
Martin Taylor
Keyword(s):  
Atrial Fibrillation ◽  
Quality Improvement ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Junior Doctors ◽  
Improvement Project ◽  
Risk Of Bleeding

Atrial fibrillation (AF) is considered one of the main causes of ischemic stroke. The CHA2DS2VASC score can predict the stroke risk. Proper anticoagulation can significantly reduce such risk. Anticoagulation involves a risk of bleeding, which can be predicted by the HAS-BLED score. The non-documentation of both AF risk scores in the medical notes of patients presenting with acute or paroxysmal AF has alerted our team, for fear of missing administering the proper anticoagulation. A baseline audit showed that the CHA2DS2VASC score was documented in 27% of such patients, while the HAS-BLED score was documented in 5% of them. A quality improvement project was planned and included two PDSA cycles over a period of five months. The first cycle was based on raising the awareness of the junior doctors on risk assessment of AF patients and the importance of anticoagulation prescription. This involved educational posters, emails, and presentations. On the second cycle, the baseline audit showed a 69% improvement (from 27% to 46%) in the rate of CHA2DS2VASC score assessment and a 140% improvement (from 5% to 12%) in the rate of HAS-BLED scoring. However, the rate of anticoagulation prescription remained almost the same in both cycles (55% and 52%). A doctors’ survey showed that they are not quite comfortable prescribing long-term anticoagulation on acute care units because of the inadequate assessment of the bleeding risk, and the associated comorbidities that can disturb the action of the oral anticoagulants. They preferred to refer the patient to a specialised AF clinic for further assessment and prescription. On auditing the patient referral on discharge, it was found that 91% of the patient were seen at the AF clinic in 2 weeks. The remainders were referred to their GP for further assessment and prescription. That seemed to be a safer way of anticoagulation prescription for such patients.

Stroke Risk Scores as Predictors of Severe Outcomes in Atrial Fibrillation

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Andreea Cristina Ivănescu ◽  
Cătălin Adrian Buzea ◽  
Caterina Delcea ◽  
Gheorghe Andrei Dan
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Risk Scores

Abstract 77: Balancing Risks and Benefits of Anticoagulation Therapy in Atrial Fibrillation in Community Practice: Results from the ORBIT-AF Registry

2012 ◽  
Vol 5 (suppl_1) ◽  
Author(s):  
Michael W Cullen ◽  
Sunghee Kim ◽  
Jonathan P Piccini ◽  
Alan S Go ◽  
Gregg C Fonarow ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Community Practice ◽  
Chads2 Score ◽  
Risk Patients ◽  
Study Population ◽  
Risk Treatment ◽  
The Cost

Background Oral anticoagulation (OAC) can reduce stroke risk at the cost of increased bleeding risk in those with atrial fibrillation (AF). Observational data have shown that higher-risk patients with AF most likely to benefit from OAC are less likely to receive OAC at hospital discharge. Methods We used data from ORBIT-AF Registry, a cohort of 9,589 AF patients enrolled among 173 participating outpatient practices. OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using the CHADS2 and ATRIA scores, respectively. Results The study population had a mean age of 73.5 years; 57.8% were men. Overall, 76.4% of patients received OAC. Use of OAC rose with increasing CHADS2 stroke risk, from 67% for CHADS2 <1 to 80% for CHADS2 ≥2 (p<0.0001). OAC use fell slightly with increasing ATRIA bleeding risk, from 77% for ATRIA score ≤3 to 74% with ≥5 (p=0.002 for trend). Among patients with low bleeding risk, rates of OAC increased commensurate with stroke risk (p<0.0001 for interaction; see figure). Higher bleeding risk tended to decrease rates of OAC among patients with a CHADS2 score ≥2 (p=0.13 for interaction). Conclusions In community-based outpatients with AF, use of OAC rose with increasing thromboembolic risk and declined with higher bleeding risk. These findings suggest that the risk-treatment paradox may be less that previously reported. Provision of OAC in community practice appears to appropriately consider patients' stroke and bleeding risks. Further research is required to understand how quality improvement initiatives can further improve stroke prevention.

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