Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation

Abstract

Aims Multiple risk scores to predict ischaemic stroke (IS) in patients with atrial fibrillation (AF) have been developed. This study aims to systematically review these scores, their validations and updates, assess their methodological quality, and calculate pooled estimates of the predictive performance. Methods and results We searched PubMed and Web of Science for studies developing, validating, or updating risk scores for IS in AF patients. Methodological quality was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). To assess discrimination, pooled c-statistics were calculated using random-effects meta-analysis. We identified 19 scores, which were validated and updated once or more in 70 and 40 studies, respectively, including 329 validations and 76 updates—nearly all on the CHA2DS2-VASc and CHADS2. Pooled c-statistics were calculated among 6 267 728 patients and 359 373 events of IS. For the CHA2DS2-VASc and CHADS2, pooled c-statistics were 0.644 [95% confidence interval (CI) 0.635–0.653] and 0.658 (0.644–0.672), respectively. Better discriminatory abilities were found in the newer risk scores, with the modified-CHADS2 demonstrating the best discrimination [c-statistic 0.715 (0.674–0.754)]. Updates were found for the CHA2DS2-VASc and CHADS2 only, showing improved discrimination. Calibration was reasonable but available for only 17 studies. The PROBAST indicated a risk of methodological bias in all studies. Conclusion Nineteen risk scores and 76 updates are available to predict IS in patients with AF. The guideline-endorsed CHA2DS2-VASc shows inferior discriminative abilities compared with newer scores. Additional external validations and data on calibration are required before considering the newer scores in clinical practice. Clinical trial registration ID CRD4202161247 (PROSPERO).

microRNAs as biomarkers of risk of major adverse cardiovascular events in atrial fibrillation

“…In addition, a recent meta-analysis, the PROSPERO clinical trial, highlights the permanent interest in refining risk scores to accurately categorize patients with AF. This systematic review of multiple risk scores confirmed a positive trend (which needs to be calibrated and externally validated) of improved risk prediction favorable to the newer scales compared to the more widely used CHADS 2 and CHA 2 DS 2 -VASc ( 12 ). Taken together, these observations support that the identification of biomarkers that are predictors for risk of MACE should be extended to other organs and systems to achieve the best clinical follow-up in patients with AF.…”

The prognostic value of CHA2DS2‐VASc and modified‐CHADS2 scores for cardiovascular events in diabetics and non‐diabetics haemodialysis patients

“…29 Modified-CHADS 2 score demonstrated the best discrimination compared with other scores for predicting ischemic stroke in patients with atrial fibrillation. 5 Moreover, in another study, modified-CHADS 2 score showed good performance across advanced CKD, both for discrimination and calibration, for ischemic stroke risk estimation in atrial fibrillation patients. 12 In the present study, stroke was associated with atrial fibrillation and the presence of central venous catheter.…”

“…Newer scores have optimum predictive abilities, but validations and further studies on calibration are essential to approve this. 5 In CHA 2 DS 2 -VASc score, patients receive 1 or 2 points in each component, with a maximum of 9 points (Table S1). The criteria used are congestive heart failure, arterial hypertension (140/90 mmHg or receiving treatment), age (2 points in over 75 years, 1 point if 65-74 years), DM, previous stroke or transient ischemic attack or thromboembolism (2 points), vascular disease (myocardial infarction, peripheral arterial disease, aortic plaque) and gender (1 point if female).…”

“…A systematic review and meta-analysis of CHA 2 DS 2 -VASc and other scores, which used Prediction model Risk Of Bias ASsessment Tool (PROBAST), showed a risk of methodological bias and were concerns regarding the applicability of the risk score. 5 However, in recent years, use of this score is broadened to predict clinical outcomes in spite of atrial fibrillation. [7][8][9][10] CHA 2 DS 2 -VASc score has weak predictive performance of stroke in dialysis population.…”

“…Although, CHA 2 DS 2 ‐VASc has inferior discriminative abilities contrasted with novel scores, it is suggested by the guidelines and is more widely used. Newer scores have optimum predictive abilities, but validations and further studies on calibration are essential to approve this 5 . In CHA 2 DS 2 ‐VASc score, patients receive 1 or 2 points in each component, with a maximum of 9 points (Table S1).…”