Implications of stroke and bleeding risk scores and comorbidities on episode-based bundled payments for patients with nonvalvular atrial fibrillation

2017 ◽  
Vol 34 (2) ◽  
pp. 275-284 ◽  
Author(s):  
Scott Kaatz ◽  
Craig I. Coleman ◽  
Brahim Bookhart ◽  
François Laliberté ◽  
Winnie W. Nelson ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation ◽  
Bundled Payments

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.

CHA2DS2-VASc and HAS-BLED risk scores and real-world oral anticoagulant prescribing decisions in atrial fibrillation

2021 ◽  
Author(s):  
Megan Besford ◽  
Thomas P Leahy ◽  
Cormac Sammon ◽  
Maria Ulvestad ◽  
Robert Carroll ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Oral Anticoagulant ◽  
Bleeding Risk ◽  
Treatment Decisions ◽  
Conditional Inference ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation ◽  
Conditional Inference Trees ◽  
The Individual

Background: Guidelines indicate that oral anticoagulant (OAC) treatment decisions in atrial fibrillation should be based on a balanced consideration of thromboembolic and bleeding risk. Materials & methods: A retrospective cohort of nonvalvular atrial fibrillation patients were identified. Univariate logistic regression and conditional inference trees were used to quantify the importance of the CHA2DS2-VASc and modified HAS-BLED scores and their individual components on OAC treatment decisions. Results: The individual components of these risk scores provided more distinguishability between treated and untreated patients than the risk scores themselves, with bleeding risk factors strongly associated with nontreatment. Conclusion: While individual components of risk scores drive OAC treatment decisions according to guidelines, the relationship between bleeding risk factors and nontreatment warrants further consideration.

Comparison of Bleeding Risk Scores in Patients With Nonvalvular Atrial Fibrillation Starting Direct Oral Anticoagulants

2017 ◽  
Vol 70 (10) ◽  
pp. 878-880
Author(s):  
César Caro Martínez ◽  
José Manuel Andreu Cayuelas ◽  
Pedro José Flores Blanco ◽  
Mariano Valdés ◽  
José Luis Bailén Lorenzo ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Nonvalvular Atrial Fibrillation

Abstract 12541: Features and Causes of Death of Patients With Atrial Fibrillation Seen in French Hospitals in 2012

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Laurent Fauchier ◽  
Adeline Samson ◽  
Gwendoline Chaize ◽  
Anne-Françoise Gaudin ◽  
Alexandre Vainchtock ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Real Life ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Systematic Analysis ◽  
Disease States ◽  
Previous Diagnosis ◽  
Cause Of Deaths ◽  
Cv Disease ◽  
Causes Of Deaths

Introduction/Hypothesis: Atrial fibrillation (AF) has been associated with worse clinical outcomes in many cardiovascular (CV) disease states. There is a lack of data on real world specific causes of deaths in AF patients. The objective of this study was to provide features and causes of deaths of patients with AF seen in French hospitals. Methods: This French cohort study was based on the national hospitalization database (PMSI) covering hospital care for the entire population. All discharged dead patients in 2012 with a previous diagnosis of AF were identified. Cause of death was defined as the principal diagnosis of the last hospitalization stay. Thromboembolic risk scores (HAS-BLED, HEMORR2HAGES and ATRIA) and bleeding risk scores (CHADS2 and CHA2DS2-VASc) calculations were based on a 5-year look-back period of medical history. Results: In 2012, 533,044 AF patients were identified through the PMSI; among them 50,165 (9.4%) died in French hospitals. Deceased patients were older than patients discharged alive (82.3±9.3 vs. 78.0±11.4; p<0.001). They more often suffered from hypertension (73% vs. 70%), diabetes (27% vs. 24%), renal failure (39% vs. 23%), cancer (30% vs. 19%) and, liver failure (9% vs. 5%) (p<0.001 in all cases). Mean stroke and bleeding risk scores were significantly higher for dead patients: CHADS2 was 2.7±1.3 vs. 2.3±1.3 (p<0.001), CHA2DS2-VASc was 4.6±1.6 vs. 4.0±1.8 (p<0.001), HAS-BLED was 2.6±1.1 vs. 2.2±1.1 (p<0.001), HEMORR2HAGES was 3.0±1.4 vs. 2.3±1.5 (p<0.001) and ATRIA was 4.4±2.4 vs. 3.3±2.4 (p<0.001). Cardiovascular (CV)-related deaths represented 34% of all deaths, including heart failures (15.0%), strokes (8.5%), hemorrhages (1.4%) and, TIA/Systemic embolism (1.3%) (cf. Table1). Conclusions: In this systematic analysis of a real-life contemporary AF population, about 10% of deaths were related to stroke/TIA/SE. Despite CV events were a major cause of deaths; a greater part of deaths was related to non-CV causes.

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.

scholarly journals GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

BMJ Open ◽  
2019 ◽  
Vol 9 (11) ◽  
pp. e033283 ◽  
Author(s):  
Frederik Dalgaard ◽  
Karen Pieper ◽  
Freek Verheugt ◽  
A John Camm ◽  
Keith AA Fox ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Major Bleeding ◽  
Risk Model ◽  
Oral Anticoagulants ◽  
External Validation ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Secondary Outcome

ObjectivesTo externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.DesignRetrospective cohort study.SettingDanish nationwide registries.Participants90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.Primary and secondary outcome measuresExternal validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.ResultsOf the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66–83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).ConclusionIn a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

scholarly journals Rivaroxaban Versus Warfarin for Management of Obese African Americans With Non-Valvular Atrial Fibrillation or Venous Thromboembolism: A Retrospective Cohort Analysis

2020 ◽  
Vol 26 ◽  
pp. 107602962095491
Author(s):  
Olivia S. Costa ◽  
Jan Beyer-Westendorf ◽  
Veronica Ashton ◽  
Dejan Milentijevic ◽  
Kenneth Todd Moore ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Venous Thromboembolism ◽  
African Americans ◽  
Major Bleeding ◽  
Cox Regression ◽  
Cohort Analysis ◽  
Bleeding Risk ◽  
Nonvalvular Atrial Fibrillation ◽  
Thrombotic Risk ◽  
Hazard Ratios

African Americans (AAs) and obese individuals have increased thrombotic risk. This study evaluated the effectiveness and safety of rivaroxaban versus warfarin in obese, AAs with nonvalvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). Optum® De-Identified Electronic Health Record (EHR) data was used to perform separate propensity-score matched analyses of adult, oral anticoagulant (OAC)-naïve AAs with NVAF or acute VTE, respectively; who had a body mass index≥30kg/m2 and ≥12-months EHR activity with ≥1-encounter before OAC initiation. Cox regression was performed and reported as hazard ratios (HRs) with 95% confidence intervals (CIs). For the NVAF analysis, 1,969 rivaroxaban- and 1,969 warfarin-users were matched. Rivaroxaban was not associated with a difference in stroke/systemic embolism versus warfarin (HR = 0.88, 95%CI = 0.60-1.28), but less major bleeding (HR = 0.68, 95%CI = 0.50-0.94) was observed. Among 683 rivaroxaban-users with VTE, 1:1 matched to warfarin-users, rivaroxaban did not alter recurrent VTE (HR = 1.36, 95%CI = 0.79-2.34) or major bleeding (HR = 0.80, 95%CI = 0.37-1.71) risk versus warfarin at 6-months (similar findings observed at 3- and 12-months). Rivaroxaban appeared to be associated with similar thrombotic, and similar or lower major bleeding risk versus warfarin in these obese, AA cohorts.

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