Bear tracks hypothesis: from atrial fibrillation to atrial fibrosis syndrome in stroke risk assessment

Background: The CHADS-VASC score does not incorporate renal dysfunction in stroke risk assessment in patients with atrial fibrillation and the prevalence of atrial fibrillation, atrial flutter, and cerebrovascular accidents (CVA) in patients with concurrent CHF and CKD is not well investigated. Objective: Evaluate the prevalence of history of stroke, atrial fibrillation, atrial flutter in patients with CHF and CKD. Methods: Data from the single institution Get With The Guidelines- Heart Failure (GWG-HF) cohort of 2938 consecutive inpatients with known GFR was utilized. CHADS-VASC score was calculated from the GWG-HF variables. Chronic kidney disease (CKD) was defined as GFR <60 ml/min. Results: An overwhelming majority (95%) of GWG-HF patients had elevated >1 CHADS-VASC score, which was also significantly more common in patients with CKD (97.6% vs. 91.7% in patients without CKD, p<0.0001). Average CHADS-VASC score was also significantly increased in patients with CKD (4+/-1.3 vs. 3.3+/-1.4, p<0.0001). Furthermore, CKD was associated with increased prevalence of atrial fibrillation and/or flutter (45.6% vs. 35.3%, p<0.0001) and stroke history (17.5% vs. 12.3%, p=0.002). When stroke and TIA histories were removed from the CHADS-VASC score ("CHAD-VASC score"), the remaining variables were strongly predictive of stroke or TIA (14.2% vs. 3.8%, p<0.0001). In multivariate logistic regression analysis, both CHAD-VASC score (OR 2.6, 95%CI 1.3-5.4, p=0.009) and CKD (OR 1.5, 95%CI 1.2-1.8, p=0.001) were associated significantly increased odds of prior stroke or TIA. Conclusions: In patients admitted with heart failure, CKD is associated with increased prevalence of atrial fibrillation or atrial flutter as well as increased prevalence of CVA/TIA. Further prospective studies are warranted to examine whether CKD history should be included in stroke risk assessment in patients with atrial fibrillation or atrial flutter, in conjunction with existing risk assessment frameworks.

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Embolic stroke of undetermined source correlates to atrial fibrosis without atrial fibrillation

Neurology ◽

10.1212/wnl.0000000000007827 ◽

2019 ◽

Vol 93 (4) ◽

pp. e381-e387 ◽

Cited By ~ 14

Author(s):

Karman Tandon ◽

David Tirschwell ◽

W.T. Longstreth ◽

Bryn Smith ◽

Nazem Akoum

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Stroke Risk ◽

Embolic Stroke ◽

Cardioembolic Stroke ◽

Healthy Controls ◽

Atrial Fibrosis ◽

Stroke Risk Factors ◽

Causal Pathway

ObjectiveTo examine the hypothesis that atrial fibrosis and associated atrial cardiopathy may be in the causal pathway of cardioembolic stroke independently of atrial fibrillation (AF) by comparing atrial fibrosis burden between patients with embolic stroke of undetermined source (ESUS), patients with AF, and healthy controls.MethodsWe used late-gadolinium-enhancement MRI to compare atrial fibrosis in 10 patients with ESUS against 10 controls (no stroke, no AF) and 10 patients with AF. Fibrosis was compared between groups, controlling for stroke risk factors.ResultsMean age was 51 ± 15 years, and 43% of participants were female. Patients with ESUS had more atrial fibrosis than controls (16.8 ± 5.7% vs 10.6 ± 5.7%, p = 0.019) and similar fibrosis compared to patients with AF (17.8 ± 4.8%, p = 0.65). Odds ratios of ESUS per quartile of fibrosis were 3.22 (95% CI [CI] 1.11–9.32, p = 0.031, unadjusted) and 3.17 (95% CI 1.05–9.52, p = 0.041, CHA2DVASc score adjusted). Patients with >12% fibrosis had a higher percentage of ESUS (77.8% vs 27.3%, p = 0.02), and patients with >20% fibrosis had the highest proportion of ESUS (4 of 5).ConclusionsPatients with ESUS exhibit similar atrial fibrosis compared to patients with AF and more fibrosis than healthy controls. Fibrosis is associated with ESUS after controlling for stroke risk factors, supporting the hypothesis that fibrosis is in the causal pathway of cardioembolic stroke independently of AF. Prospective studies are needed to assess the role of anticoagulation in primary and secondary stroke prevention in patients with high atrial fibrosis.

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Anticoagulation therapy and the risk of stroke in patients with atrial fibrillation at ‘moderate risk’ [CHADS2 score=1]: Simplifying stroke risk assessment and thromboprophylaxis in real-life clinical practice

Thrombosis and Haemostasis ◽

10.1160/th10-01-0038 ◽

2010 ◽

Vol 103 (04) ◽

pp. 683-685 ◽

Cited By ~ 63

Author(s):

Gregory Lip

Keyword(s):

Atrial Fibrillation ◽

Risk Assessment ◽

Clinical Practice ◽

Stroke Risk ◽

Anticoagulation Therapy ◽

Real Life ◽

Moderate Risk ◽

Chads2 Score

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Stroke risk assessment in atrial fibrillation: risk factors and markers of atrial myopathy

Nature Reviews Cardiology ◽

10.1038/nrcardio.2016.106 ◽

2016 ◽

Vol 13 (9) ◽

pp. 549-559 ◽

Cited By ~ 40

Author(s):

Brandon W. Calenda ◽

Valentin Fuster ◽

Jonathan L. Halperin ◽

Christopher B. Granger

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Risk Assessment ◽

Stroke Risk

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CLINICAL-GENETIC RISKOMETER FOR THE ISCHEMIC STROKE RISK ASSESSMENT IN ATRIAL FIBRILLATION

Russian Journal of Cardiology ◽

10.15829/1560-4071-2015-10-42-45 ◽

2015 ◽

pp. 42

Author(s):

N. V. Aksyutina ◽

V. A. Shulman ◽

S. Yu. Nikulina ◽

B. V. Nazarov ◽

V. N. Maksimov ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Assessment ◽

Ischemic Stroke ◽

Stroke Risk ◽

Clinical Genetic ◽

Ischemic Stroke Risk

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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

Thrombosis and Haemostasis ◽

10.1160/th13-07-0552 ◽

2013 ◽

Vol 110 (11) ◽

pp. 1074-1079 ◽

Cited By ~ 60

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.

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