Stroke Risk Scores as Predictors of Severe Outcomes in Atrial Fibrillation

Introduction: Acute atrial fibrillation or flutter (AFF) is the most common dysrhythmia managed in the emergency department (ED). A key component of managing AFF in the ED is the prevention of stroke. Predictive indices (e.g., CHADS2 , HAS-BLED) should be used to assess each patient’s risk of stroke and bleeding to determine the appropriate anticoagulation therapy. The frequency of use of these predictive indices in the emergency department to determine appropriate anticoagulation therapy remains unclear. This systematic review is designed to examine the use of risk scores in the ED to determine the management of patients presenting to the ED for atrial fibrillation and flutter. Methods: An extensive search of eight electronic databases and grey literature was conducted. Quasi-experimental studies were eligible for inclusion. Studies had to report on the ED management of adult patients presenting with AFF to be included. Two independent reviewers judged the relevance, inclusion, and risk of bias of the studies. Individual and pooled statistics were calculated as odds ratios (OR) with 95% CI using a random effects model and heterogeneity (I2) was reported. Results: From 1,648 citations, 37 studies were included in this review. Heterogeneity was very high, precluding pooling. Only one of the included studies documented the use of CHADS2 scores by attending physicians; while no studies documented the use of HAS-BLED. There was variability in the ED management strategies of AFF. The utilization of rhythm control in the treatment of AFF ranged considerable (OR: 0.04-9.84) in comparison to rate control. Of the 17 studies reporting cardioversion approaches, chemical (9 {53%}) cardioversion was the most common management strategy of AFF. Conclusion: Our results suggests that either few physicians are documenting stroke risk scores in adult patients with AFF, or that research studies assessing ED management of AFF are not reporting scores documented by the attending physicians. Future research needs to examine the use of stroke risk scores to determine the optimal and appropriate care for patients.

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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 ◽

10.1161/circ.130.suppl_2.18538 ◽

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.

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Renal Dysfunction, Stroke Risk Scores (CHADS 2 , CHA 2 DS 2 -VASc, and R 2 CHADS 2 ), and the Risk of Thromboembolic Events After Catheter Ablation of Atrial Fibrillation

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.113.000869 ◽

2013 ◽

Vol 6 (5) ◽

pp. 868-874 ◽

Cited By ~ 36

Author(s):

Jelena Kornej ◽

Gerhard Hindricks ◽

Jedrzej Kosiuk ◽

Arash Arya ◽

Philipp Sommer ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Renal Dysfunction ◽

Stroke Risk ◽

Risk Scores ◽

Thromboembolic Events

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THE CHADS2 SCORE PREDICTS ISCHEMIC STROKE IN CHRONIC HEART FAILURE PATIENTS WITHOUT ATRIAL FIBRILLATION: COMPARISON TO OTHER STROKE RISK SCORES

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(16)31309-2 ◽

2016 ◽

Vol 67 (13) ◽

pp. 1308

Author(s):

Takumi Kondo ◽

Takahisa Yamada ◽

Takashi Morita ◽

Yoshio Furukawa ◽

Shunsuke Tamaki ◽

...

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ischemic Stroke ◽

Chronic Heart Failure ◽

Stroke Risk ◽

Risk Scores ◽

Chads2 Score ◽

Heart Failure Patients

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How Well Do Stroke Risk Scores Predict Hemorrhage in Patients With Atrial Fibrillation?

The American Journal of Cardiology ◽

10.1016/j.amjcard.2016.06.014 ◽

2016 ◽

Vol 118 (5) ◽

pp. 697-699 ◽

Cited By ~ 7

Author(s):

Gene R. Quinn ◽

Daniel E. Singer ◽

Yuchiao Chang ◽

Alan S. Go ◽

Leila H. Borowsky ◽

...

Keyword(s):

Atrial Fibrillation ◽

Stroke Risk ◽

Risk Scores

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Predicting Stroke Risk in Patients with Atrial Fibrillation Using Machine Learning

10.21203/rs.3.rs-209356/v1 ◽

2021 ◽

Author(s):

Seonwoo Jung ◽

Eunjoo Lee ◽

Minji Lee ◽

Sejin Bae ◽

Yeon-Yong Kim ◽

...

Keyword(s):

Machine Learning ◽

Atrial Fibrillation ◽

Stroke Risk ◽

Predictive Performance ◽

Cerebrovascular Diseases ◽

Risk Scores ◽

Health Examination ◽

History Information ◽

Korean National Health Insurance ◽

Deep Learning Model

Abstract Atrial fibrillation (AF) is a well-known risk factor for stroke. Predicting the risk is important to prevent the first attack and re-attack of cerebrovascular diseases by determining the medication. Although several statistical methods have been developed to assess the stroke risk in AF patients, considerable improvement is needed in predictive performance. We propose a machine learning-based approach based on the massive and complex Korean National Health Insurance (KNHIS) data. We extracted 72-dimensional features, including demographics, health examination, and medical history information, of 754,949 patients with AF from KNHIS. Logistic regression was used to determine whether the extracted features had a statistically significant association with stroke occurrence. Then, we constructed the stroke risk prediction model based on a deep neural network. The extracted features were used as input, and the occurrence of stroke after the diagnosis of AF was the output used to train the model. When the proposed deep learning model was applied to 150,989 AF patients, it was confirmed that stroke risk was predicted with high accuracy, sensitivity, and specificity. As part of preventive medicine, this study could help AF patients prepare for stroke prevention based on predicted stoke associated feature and risk scores.

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Abstract 18703: Impact of the 2014 Atrial Fibrillation Guideline on the Proportion of Patients Recommended for Oral Anticoagulation

Circulation ◽

10.1161/circ.130.suppl_2.18703 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Emily C O’Brien ◽

Sunghee Kim ◽

Paul L Hess ◽

James V Freeman ◽

Laine Thomas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Stroke Risk ◽

Treatment Guidelines ◽

Treatment Guideline ◽

Risk Scores ◽

Community Based ◽

Chads2 Score ◽

Number Of Patients ◽

Using Data

Introduction: In 2014, the AHA/ACC/HRS published new atrial fibrillation (AF) treatment guidelines recommending use of a refined stroke risk score and revised threshold for oral anticoagulation (OAC) initiation. Methods: Using data from ORBIT-AF, an ongoing, national, outpatient AF registry conducted at 176 sites, we examined changes in the number of patients qualifying for OAC based on clinical stroke risk scores under 2011 ACCF/AHA/HRS versus 2014 AHA/ACC/HRS guidelines. Patients were considered recommended for OAC under the 2011 guideline with a CHADS2 score >=2 and under the 2014 guideline with a CHA2DS2-VASC score >=2. We reported the fraction of patients treated with OAC (warfarin or dabigatran) among patients qualifying for OAC under each guideline. Results: From 2009 - 2010, 10132 patients were enrolled in ORBIT-AF (median age [IQR] = 75 years [67 - 82]; 42.3% female). The proportion of patients qualifying for OAC increased from 71.8% under the 2011 guideline to 90.8% under the 2014 guideline (Figure). For patients under the age of 65, the proportion qualifying for treatment with OAC increased from 43.1% to 60.6%. Similar increases were observed for patients over the age of 65: 79.1% indicated for OAC under the 2011 guideline, compared with 98.5% under the 2014 guideline. There were 97.7% of women who qualified for OAC under the 2014 guideline, compared with 76.7% under the 2011 guideline. The fraction of indicated patients who were not receiving OAC increased under the 2014 guideline (21.9% vs. 19.9% under the 2011 guideline), with the highest undertreatment rates for patients younger than 65 (25.4%). Conclusions: The 2014 AF treatment guideline substantially increased the proportion of patients who qualified for OAC, with near-universal indication for women and for patients older than 65. Under the 2014 guideline, approximately 22% of the indicated patients in our community-based cohort did not receive OAC.

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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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