Applying the CHA2DS2-VASc score to predict the risk of future acute coronary syndrome in patients receiving catheter ablation for atrial fibrillation.
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ABSTRACT:
SUBMITTER: Chou C
PROVIDER: S-EPMC7330062 | biostudies-literature | 2020 Aug
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs)-prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHA2DS2-VASc score would improve its ability to predict AF-related ischemic stroke. METHODS:We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement. RESULTS:Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHA2DS2-VASc variables, and that resulted in meaningful improvement in stroke prediction. The ? estimate was approximately twice that of the CHA2DS2-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P2-CHA2DS2-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively. CONCLUSIONS:Abnormal P-wave axis-an ECG correlate of left atrial abnormality- improves ischemic stroke prediction in AF. Compared with CHA2DS2-VASc, the P2-CHA2DS2-VASc is a better prediction tool for AF-related ischemic stroke.
| S-EPMC6481672 | biostudies-literature
Project description:Background and Purpose- Despite modest predictive ability for ischemic stroke (IS), the CHA2DS2-VASc score is widely used for stroke prediction in atrial fibrillation. Among patients with atrial fibrillation, we aimed to (1) compare the IS or transient ischemic attack (TIA) incidence by CHA2DS2-VASc in blacks and Hispanics versus whites; (2) compare predictive ability of CHA2DS2-VASc score for IS or TIA in blacks and Hispanics versus whites; and (3) determine improvement in predictive ability of CHA2DS2-VASc score from addition of race/ethnicity. Methods- Using data from Optum Clinformatics, a large administrative claims database, we analyzed patients with atrial fibrillation enrolled in commercial and Medicare Advantage health plans from 2009 to 2015. We computed IS or TIA incidence rates, improvement in C statistic, continuous and categorical net reclassification improvement, and relative integrated discrimination improvement from addition of race/ethnicity to CHA2DS2-VASc. Results- A total of 267 419 patients (mean age, 73.1 [SD, 12.3] years; 46.6% women; 84.2% white, 8.5% black, 7.3% Hispanic) were studied. After a mean follow-up of 22 months, there were 6202 IS or TIA events. IS or TIA incidence rates were higher in blacks than Hispanics or whites (1.65, 1.40, and 1.22 cases per 100 person-years, respectively) and increased with higher CHA2DS2-VASc, with no race/ethnicity-based differences ( P for interaction=0.17). The CHA2DS2-VASc and CHA2DS2-VASc+race/ethnicity C statistic (95% CI) were 0.679 (0.670-0.686) and 0.679 (0.671-0.688). The CHA2DS2-VASc C statistic in the 3 groups were comparable. With addition of race/ethnicity, the categorical net reclassification improvement, continuous net reclassification improvement, and relative integrated discrimination improvement were -0.045 (95% CI, -0.067 to -0.025), 0.045 (95% CI, 0.025-0.068), and 0.016 (95% CI, 0.014-0.018). Conclusions- The predictive ability of CHA2DS2-VASc for IS or TIA in atrial fibrillation is comparable among whites, blacks, and Hispanics; hence, it can be used in the latter 2 groups. Addition of race/ethnicity to the CHA2DS2-VASc does not improve its predictive ability.
| S-EPMC6541553 | biostudies-literature
Project description:ImportanceCurrent guidelines support treating atrial fibrillation (AF) and atrial flutter (AFL) as equivalent risk factors for ischemic stroke stratified by CHA2DS2-VASc scores, recommending anticoagulation therapy for patients with a CHA2DS2-VASc score of 2 or higher, but some studies found differences in clinical outcomes.ObjectiveTo investigate differences in clinical outcomes among AF, AFL, and matched control cohorts.Design, setting, and participantsThis nationwide cohort study analyzed data from the Taiwan National Health Insurance Research Database from January 1, 2001, through December 31, 2012. Follow-up and data analysis ended December 31, 2012. A total of 219 416 age- and sex-matched individuals participated in the study. Clinical outcomes were compared after stratification by CHA2DS2-VASc score (possible score range, 0-9; higher scores indicate greater risk of ischemic stroke).Main outcomes and measuresIschemic stroke, heart failure hospitalization, and all-cause mortality among the AF, AFL, and matched control cohorts were analyzed using Cox proportional hazards regression.ResultsThis study comprised 188?811 patients in the AF cohort (mean [SD] age, 73.8 [13.4] years; 104 703 [55.5%] male), 6121 patients in the AFL cohort (mean [SD] age, 67.7 [15.8] years; 3735 [61.0%] male), and 24?484 patients in the matched control cohort (mean [SD] age, 67.3 [15.6] years; 14 940 [61.0%] male). The patients with AF were older, were more predominantly female, and had higher CHA2DS2-VASc scores than the patients with AFL and the control participants. After stratification by CHA2DS2-VASc score, the incidence densities (IDs; events per 100 person-years) of ischemic stroke (AF cohort: ID, 3.08; 95% CI, 3.03-3.13; AFL cohort: ID, 1.45; 95% CI, 1.28-1.62; controls: ID, 0.97; 95% CI, 0.92-1.03), heart failure hospitalization (AF cohort: ID, 3.39; 95% CI, 3.34-3.44; AFL cohort: ID, 1.57; 95% CI, 1.39-1.74; controls: ID, 0.32; 95% CI, 0.29-0.35), and all-cause mortality (AF cohort: ID, 17.8; 95% CI, 17.7-17.9; AFL cohort: ID, 13.9; 95% CI, 13.4-14.4; controls: ID, 4.2; 95% CI, 4.1-4.4) were significantly higher in the AF cohort than in the matched control cohort. For the AFL cohort vs the matched control cohort, the incidences of heart failure hospitalization and all-cause mortality were significantly higher across all levels, but the incidence of ischemic stroke was only significantly higher at CHA2DS2-VASc scores of 5 to 9. For the AF cohort vs the AFL cohort, the incidences of ischemic stroke and heart failure hospitalization were significantly higher at a CHA2DS2-VASc score of 1 or higher, but the incidence of all-cause mortality was significantly higher only at CHA2DS2-VASc scores of 1 to 3.Conclusions and relevanceThis study found different clinical outcomes between patients with AFL and AF and those without AF and AFL. The current recommended level of the CHA2DS2-VASc score in preventing ischemic stroke in patients with AFL should be reevaluated.
| S-EPMC6324304 | biostudies-literature
Project description:OBJECTIVE:The aim of this study was to assess the association between CHA2DS2-VASc score and carotid plaques in patients with non-valvular atrial fibrillation (NVAF). METHODS:We conducted a retrospective study including 3,435 NVAF patients who underwent carotid ultrasound examinations from January 2015 to December 2017.We collected the clinical data on the medical records system. Chi-square trend test was used to analyze trends between the prevalence of carotid plaques with an increasing CHA2DS2-VASc score. Univariate and multivariate logistic regression was also used to assess the association between carotid plaques and CHA2DS2-VASc scores. The area under the receiver operating characteristic (ROC) curve (AUC) was used to determine the optimal cutoff points of different CHA2DS2-VASc scores in NVAF patients. RESULTS:NVAF patients with carotid plaques had higher CHA2DS2-VASc scores compared with patients who did not have carotid plaques (3.01±1.36 vs. 2.55±1.28, P < 0.05). In all participants, male participants and female participants, the prevalence of carotid plaques increased significantly as the CHA2DS2-VASc score increased (P for trend < 0.001). Multivariate logistic regression analysis demonstrated that for each 1-point increase in the CHA2DS2-VASc score, there was an associated 37% increase in the prevalence of carotid plaques. ROC curve analysis revealed that a CHA2DS2-VASc score ? 2 in male patients (sensitivity, 44.67%; specificity, 75.64%; AUC, 0.639) or ? 3 in female patients (sensitivity, 47.24%; specificity, 72.40%; AUC, 0.634) were associated with carotid plaques. CONCLUSION:The prevalence of carotid plaques in patients with NVAF was associated with the CHA2DS2-VASc score.
| S-EPMC6368281 | biostudies-literature
Project description:Exercise intolerance among the clinical symptoms in patients with atrial fibrillation (AF) has usually been masked by their adjusted life style. We sought to assess the role of CHA2DS2-VASc score to predict exercise intolerance in asymptomatic AF patients, and further examine whether the relationship differs by age and gender. Among the 6,275 participants of the prospective Korean registry of the Comparison study of Drugs for symptom control and complication prevention of Atrial Fibrillation (CODE-AF), 1,080 AF patients who underwent exercise treadmill testing were studied. Exercise intolerance was defined as a peak exercise capacity of 7 metabolic equivalents (METs) or less, and the patients were divided into two groups for the analysis: ?7 METs (n?=?131) and >7 METs (n?=?949). Patients with exercise intolerance had a significantly higher CHA2DS2-VASc score than those without (3.1?±?1.3 vs. 2.0?±?1.5, p?<?0.0001). In the multivariate analysis, a higher CHA2DS2-VASc score (OR 1.54, 95% CI 1.31-1.81, p?<?0.0001), corrected QT interval (OR 1.01, 95% CI 1.00-1.02, p?=?0.026), and increased left atrial volume index (OR 1.02, 95% CI 1.01-1.03, p?=?0.001) were found to be independent predictors of exercise intolerance. The impact of the CHA2DS2-VASc score on exercise intolerance was significant only in male patients aged <65 years (OR 3.30, 95% CI 1.76-6.19, p?<?0.0001). The CHA2DS2-VASc score may be a feasible risk assessment tool to predict exercise intolerance, especially in young and middle-aged male patients with asymptomatic AF.
| S-EPMC6303333 | biostudies-literature
Project description:BackgroundThe prevalence of atrial fibrillation in the HIV-infected population is growing, but the ability of the CHA2DS2-VASc score to predict thromboembolic (TE) risk is unknown in this population.SettingWithin the Veterans Affairs HIV Clinical Case Registry, 914 patients had an atrial fibrillation diagnosis between 1997 and 2011 and no previous TE events.MethodsWe compared TE incidence by CHA2DS2-VASc scores and stratified by warfarin use. Using Cox proportional hazards regression with adjustment for competing risks, we modeled associations of CHA2DS2-VASc scores and warfarin use with TE risk.ResultsAt baseline, the distribution of CHA2DS2-VASc scores was 0 (n = 208), 1 (n = 285), and 2+ (n = 421); 34 patients developed 38 TE events during a median of 3.8 years follow-up. Event rates by CHA2DS2-VASc scores of 0, 1, and 2+ were 5.4, 9.3, and 8.1 per 1000 person years, respectively; multivariate-adjusted hazards ratios (HRs) were 1.70 (95% confidence interval: 0.65 to 4.45) for CHA2DS2-VASc score 1 (P = 0.28) and HR = 1.34 (0.51, 3.48) for score 2+ versus 0 (P = 0.55). Baseline warfarin use was associated with increased TE risk, although not statistically significant [HR 2.06 (0.86, 4.93), P = 0.11] with similar results when modeled as time-updated use and duration of use.ConclusionIn this national registry of HIV-infected veterans with atrial fibrillation, CHA2DS2-VASc scores were only weakly associated with TE risk. Furthermore, warfarin did not seem to be effective at preventing TE events. These results should raise concerns about the optimal strategy for TE prevention among HIV-infected persons with atrial fibrillation.
| S-EPMC5646359 | biostudies-literature
Project description:AimsThe GRACE and CHA2DS2-VASc risk score are developed for risk stratification in patients with acute coronary syndrome and AF, respectively. We aimed to assess the predictive performance of the GRACE score and CHA2DS2-VASc score among patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsConsecutive patients with a diagnosis of AF admitted to our hospital for PCI between January 2016 and December 2018 were included and followed up for at least 1 year. The primary endpoint was a composite of major adverse cardiac events (MACEs) including all-cause mortality, repeat revascularization, myocardial infarction, or ischaemic stroke.ResultsA total of 1452 patients were identified. Cox regression demonstrated that the GRACE (HR 1.014, 95% CI 1.008-1.020, p < 0.001) but not the CHA2DS2-VASc score was associated with the risk of MACEs. Both GRACE and CHA2DS2-VASc scores were predictive of all-cause mortality with HR of 1.028 (95% CI 1.020-1.037, p < 0.001) and 1.334 (95% CI 1.107-1.632, p = 0.003). Receiver operating characteristic analyses showed both scores had similar discrimination capacity for all-cause mortality (C-statistic: 0.708 for GRACE vs. 0.661 for CHA2DS2-VASc, p = 0.299). High GRACE score was also significantly associated with increased risk of ischaemic stroke (HR 1.018, 95% CI 1.005-1.031, p = 0.006) and major bleeding (HR 1.012, 95% CI 1.001-1.024, p = 0.039), whereas high CHA2DS2-VASc score was not.ConclusionsHigh GRACE score but not CHA2DS2-VASc score were both associated with an increased risk of MACEs after PCI in patients with AF. The GRACE and CHA2DS2-VASc scores have similar predictive performance for predicting all-cause mortality.Key messages:In patients with AF undergoing PCI, increasing GRACE but not CHA2DS2-VASc scores was independently associated high risk of MACEs.The GRACE score could also help identify patients at higher risk of stroke and major bleeding.Both GRACE and CHA2DS2-VASc scores showed good ability in the prediction of all-cause mortality.
| S-EPMC8604500 | biostudies-literature
Project description:BACKGROUND:Despite progresses in the treatment of the thromboembolic risk related to atrial fibrillation (AF), the management of recurrences remains a challenge. HYPOTHESIS:To assess if congestive heart failure or left ventricular systolic dysfunction (CHA2 DS2 -VASc) score is predictive of early arrhythmia recurrence after AF cardioversion. METHODS:Systematic review and individual patient pooled meta-analysis following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. INCLUSION CRITERIA:observational trials in patients with AF undergoing cardioversion, available data on recurrence of AF and available data on CHA2 DS2 -VASc score. Clinical studies of interest were retrieved by PubMed, Cochrane Library, and Biomed Central. Seven authors were contacted for joining the patient level meta-analysis, and three shared data regarding anthropometric measurements, risk factors, major comorbidities, and CHA2 DS2 -VASc score. The primary outcome was the recurrence of AF after cardioversion in patients free from antiarrhythmic prophylaxis. Univariate and multivariate logistic regression was performed. RESULTS:Overall, we collect data of 2889 patients: 61% were male, 50% with hypertension, 12% with diabetes, and 23% with history of ischemic heart disease. The median CHA2DS2-VASc score was 2.. At the multivariate analysis, chronic kidney disease (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.12-3.27; P = 0.01), peripheral artery disease (OR 1.65; 95% CI 1.23-2.19; P < 0,0001), previous use of beta blockers (OR 1.5; 95% CI 1.19-1.88; P < 0.0001), and CHA2DS2-VASc score > 2 (OR 1.37; 95% CI 1.1-1.68; P = 0.002) were independent predictors of early recurrence of AF. CONCLUSIONS:CHA2DS2-VASc score predicts early recurrence of AF in the first 30 days after electrical or pharmacological cardioversion. Protocol registration PROSPERO (CRD42017075107).
| S-EPMC6712331 | biostudies-other
Project description:Atrial fibrillation (AF) is associated with increased mortality, predictors of which are poorly characterized. We investigated the predictive power of the commonly used CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]), the HAS-BLED score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [age ≥ 65 years], drugs/alcohol concomitantly), and their combination for mortality in AF patients. The PREvention oF thromboembolic events-European Registry in Atrial Fibrillation (PREFER in AF) was a prospective registry including AF patients across seven European countries. We used logistic regression to analyze the relationship between the CHA2DS2-VASc and HAS-BLED scores and outcomes, including mortality, at one year. We evaluated the performance of logistic regression models by discrimination measures (C-index and DeLong test) and calibration measures (Hosmer and Lemeshow goodness-of-fit and integrated discrimination improvement (IDI), with bootstrap techniques for internal validation. In 5209 AF patients with complete information on both scores, average one-year mortality was 3.1%. We found strong gradients between stroke/systemic embolic events (SSE), major bleeding and-specifically-mortality for both CHA2DS2-VASc and HAS-BLED scores, with a similar C-statistic for event prediction. The predictive power of the models with both scores combined, removing overlapping components, was significantly enhanced (p < 0.01) compared to models including either CHA2DS2-VASc or HAS-BLED alone: for mortality, C-statistic: 0.740, compared to 0.707 for CHA2DS2-VASc or 0.646 for HAS-BLED alone. IDI analyses supported the significant improvement for the combined score model compared to separate score models for all outcomes. Both the CHA2DS2-VASc and the HAS-BLED scores predict mortality similarly in patients with AF, and a combination of their components increases prediction significantly. Such combination may be useful for investigational and-possibly-also clinical purposes.
| S-EPMC7764787 | biostudies-literature
Project description:Previous work has suggested that ischemic stroke (IS) may be more likely to occur in individuals with a genetic predisposition. In this study, we investigated the potential association of IS-relevant genetic risk factors with cardioembolic stroke (CES) in atrial fibrillation (AF) patients with low CHA2DS2-VaSc score. Genotyping was performed using the GenomeLab SNPstream genotyping platform for five IS-relevant SNPs (MMP-9 C1562T, ALOX5AP SG13S114A/T, MTHFR 677?C/T, FGB 455?G/A, and eNOS G298A) in 479 AF patients with CES and 580 age and sex-matched AF patients without CES. The multivariate analysis adjusted for potential confounders and demonstrated that FGB 455?G/A was independently associated with increased risk of CES in AF patients and the significance remained after Bonferroni correction in the additive, dominant, and recessive models with ORs of 1.548 (95% CI: 1.251-1.915, P?=?0.001), 1.588 (95% CI: (1.226-2.057, P?=?0.003), and 2.394 (95% CI: 1.357-4.223, P?=?0.015), respectively. Plasma fibrinogen levels were significantly higher in patients with the A allele compared with patients with genotype of GG (3.29?±?0.38?mg/dl vs. 2.87?±?0.18?mg/dl, P?<?0.001). We found for the first time that the A allele of FGB 455?G/A was a risk factor for CES in AF patients, probably by elevating the level of plasma fibrinogen.
| S-EPMC5727505 | biostudies-literature