Age Threshold for Increased Stroke Risk Among Patients With Atrial Fibrillation

et al. 2017

JAHA

101

BackgroundPatients with liver cirrhosis have been excluded from randomized clinical trials of oral anticoagulation therapy for stroke prevention in atrial fibrillation. We hypothesized that patients with liver cirrhosis would have a positive net clinical benefit for oral anticoagulation when used for stroke prevention in atrial fibrillation.Methods and ResultsThis study used the National Health Insurance Research Database in Taiwan. Among 289 559 atrial fibrillation patients aged ≥20 years, there were 10 336 with liver cirrhosis, and 9056 of them having a CHA 2 DS 2‐VASc score ≥2 were divided into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin. Patients with liver cirrhosis had a higher risk of ischemic stroke (hazard ratio=1.10, P=0.046) and intracranial hemorrhage (hazard ratio=1.20, P=0.043) compared with those without. Among patients with liver cirrhosis, patients taking antiplatelet therapy had a similar risk of ischemic stroke (hazard ratio=1.02, 95%CI=0.88‐1.18) compared to those without antithrombotic therapies, but the risk was significantly lowered among warfarin users (hazard ratio=0.76, 95%CI=0.58‐0.99). For intracranial hemorrhage, there were no significant differences between those untreated and those taking antiplatelet therapy or warfarin. The use of warfarin was associated with a positive net clinical benefit compared with being untreated or receiving only antiplatelet therapy.ConclusionsFor atrial fibrillation patients with liver cirrhosis in the current analysis of an observational study, warfarin use was associated with a lower risk of ischemic stroke and a positive net clinical benefit compared with nontreatment, and thus, thromboprophylaxis should be considered for such patients.

Section: Methodsmentioning

confidence: 91%

Liver Cirrhosis in Patients With Atrial Fibrillation: Would Oral Anticoagulation Have a Net Clinical Benefit for Stroke Prevention?

Kuo

et al. 2017

JAHA

101

“…4,7,[9][10][11][12] This study used the well-validated National Health Insurance Research Database (NHIRD) released by the Taiwan National Health Research Institutes. The National Health Insurance system is a mandatory universal health insurance program that offers comprehensive medical care coverage to all Taiwanese residents.…”

Section: Methods Databasementioning

confidence: 99%

“…6 However, the age threshold for an increased risk of ischemic stroke for Asians may be lower than that of Caucasians. 7 For Asian AF patients with a CHA 2 DS 2 -VASc score of 0 (males) or 1 (females) aged between 50 and 64 years, the annual risk of ischemic stroke was ≈1.78%, 7 which exceeds the threshold for the initiation of OACs; 1.7%/y), especially if non-vitamin K antagonist OACs (NOACs) are used (0.9%/y). 8 However, whether resetting the age threshold at 50 years could refine current clinical stroke risk stratification for Asian AF patients is unknown.…”

mentioning

confidence: 99%

Validation of a Modified CHA ₂ DS ₂ -VASc Score for Stroke Risk Stratification in Asian Patients With Atrial Fibrillation

Lip

et al. 2016

Stroke

Self Cite

A trial fibrillation (AF) confers a 5-fold increased risk of stroke compared with patients without AF. 1 The risk of AF-associated stroke is not homogeneous and depends on patients' age and comorbidities, which have resulted in the development of clinical scores to aid stroke risk stratification and guide the use of oral anticoagulation (OAC) for stroke prevention. Currently, the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) score is recommended by guidelines for stroke risk stratification in AF 2,3 and has been shown to be better than the older CHADS 2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score for stroke risk stratification among Asian AF patients. 4 Because age is an important driver of ischemic stroke for AF patients, 5 the CHA 2 DS 2 -VASc scheme assigns 1 point forBackground and Purpose-The age threshold for an increased stroke risk for patients with atrial fibrillation may be different for Asians and non-Asians. We hypothesized that a modified CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scheme, mCHA 2 DS 2 -VASc, which assigned one point for patients aged 50 to 74 years, may perform better than CHA 2 DS 2 -VASc score for stroke risk stratification in Asians. Methods-This study used the Taiwan National Health Insurance Research Database, which included 224 866 newly diagnosed atrial fibrillation patients. The predictive accuracies of ischemic stroke of CHA 2 DS 2 -VASc and mCHA 2 DS 2 -VASc scores were compared among 124 271 patients without antithrombotic therapies. From the whole cohort, 15 948 patients had a CHA 2 DS 2 -VASc score 0 (males) or 1 (females), and 8654 patients had an mCHA 2 DS 2 -VASc score 1 (males) or 2 (females). The latter were categorized into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin, and the risks of ischemic stroke and intracranial hemorrhage (ICH) were compared. Results-During a follow-up of 538 653 person-years, 21 008 patients experienced ischemic stroke. The mCHA 2 DS 2 -VASc performed better than CHA 2 DS 2 -VASc score in predicting ischemic stroke assessed by C indexes and net reclassification index. For 8654 patients having an mCHA 2 DS 2 -VASc score of 1 (males) or 2 (females) because of the resetting of the age threshold, use of warfarin was associated with a 30% lower risk of ischemic stroke and a similar risk of ICH compared with nontreatment. Net clinical benefit analyses also favored the use of warfarin in different weighted models. patients aged between 65 and 74 years and 2 points for those aged ≥75 years. 6 However, the age threshold for an increased risk of ischemic stroke for Asians may be lower than that of Caucasians. Conclusions-In7 For Asian AF patients with a CHA 2 DS 2 -VASc score of 0 (males)...

“…The study protocol of the present study is similar to that of our previous studies 5, 7, 8, 9, 10, 11. This study used Taiwan's National Health Insurance Research Database (NHIRD), released by the Taiwan National Health Research Institutes.…”

Section: Methodsmentioning

confidence: 99%

Is an Oral Anticoagulant Necessary for Young Atrial Fibrillation Patients With a CHA ₂ DS ₂ ‐VASc Score of 1 (Men) or 2 (Women)?

Hung

et al. 2016

JAHA

BackgroundRecent studies demonstrated that oral anticoagulants (OACs) should be considered for patients with atrial fibrillation and 1 risk factor in addition to sex. Because age is an important determinant of ischemic stroke, the strategy for stroke prevention may be different for these patients in different age strata. The aim of this study was to investigate whether OACs should be considered for patients aged 20 to 49 years with atrial fibrillation and a CHA2DS2‐VASc score of 1 (men) or 2 (women).Methods and ResultsUsing the Taiwan National Health Insurance Research Database, 7374 male patients with atrial fibrillation and a CHA2DS2‐VASc score of 1 and 4461 female patients with atrial fibrillation and a CHA2DS2‐VASc score of 2 and all without antithrombotic therapies were identified and stratified into 3 groups by age. The threshold for the initiation of OACs for stroke prevention was set at a stroke rate of 1.7% per year for warfarin and 0.9% per year for non–vitamin K antagonist OACs. Among male patients aged 20 to 49 years with a CHA2DS2‐VASc score of 1, the risk of ischemic stroke was 1.30% per year and ranged from 0.94% per year for those with hypertension to 1.71% for those with congestive heart failure. Among female patients aged 20 to 49 years with a CHA2DS2‐VASc score of 2, the risk of ischemic stroke was 1.40% per year and ranged from 1.11% per year for those with hypertension to 1.67% for those with congestive heart failure.ConclusionsFor atrial fibrillation patients aged 20 to 49 years with 1 risk factor in addition to sex, non–vitamin K antagonist OACs should be considered for stroke prevention to minimize the risk of a potentially fatal or disabling event.