Formulating a More Comprehensive Stroke-Risk Evaluation Scale

Abstract

Formulating a More Comprehensive Stroke-Risk Evaluation Scale A ll types of atrial fibrillation (AF)-paroxysmal, persistent, and even subclinical-have been associated with stroke. 1-3 In the United States, as many as 6.1 million people have AF and its sequelae. Although AF is observed predominantly in the elderly and its risk increases linearly with age, almost 2% of people younger than 65 years have AF. Atrial fibrillation alone is responsible for more than 750,000 hospitalizations and almost 130,000 deaths each year. Mortality rates associated with AF, including complications such as stroke, have increased in the past few decades. 4 The adverse effects of stroke place a burden not only on individual patients but also on our healthcare system. According to findings in a multinational study, the mean cost of stroke management during the initial hospitalization period was nearly $14,000. 5 Various stroke-risk scores have been developed to identify those at risk and to aid in prevention. The original scoring system extensively used in the U.S., CHADS 2 , was superseded by CHA 2 DS 2-VASc, which incorporates additional risk factors for predicting stroke risk. 6 The latest scoring system, Atria, is even more comprehensive. 7 Table I highlights differences between the 3 scoring systems. Additional factors considered in Atria (Table II) include renal dysfunction (estimated glomerular filtration rate <45 mL/min or end-stage renal disease) and proteinuria. Unlike CHADS 2 and CHA 2 DS 2-VASc, Atria incorporates the finding that history of stroke independently increases the risk of future events. An extended age range for assigning scores (<65, 65-74, 75-84, and >85 yr) accounts for the increase in stroke risk with age. Table III shows the annual rate of stroke incidence with use of different scores. 7 On the basis of C-index and net reclassification improvement (NRI), indices used to compare models and quantify improvements, Atria is relatively more effective than are CHA 2 DS 2-VASc and CHADS 2. For Atria, C=0.708 (range, 0.704-0.713); for CHA 2 DS 2-VASc, C=0.694 (range, 0.690-0.700); and for CHADS 2 , C=0.690 (range, 0.685-0.695). The NRI for Atria was 0.16 (range, 0.14-0.17) in comparison with CHADS 2 , and 0.21 (range, 0.20-0.23) in comparison with CHA 2 DS 2-VASc. Both C-index and NRI indicate improvement in accuracy when Atria is used. 8 The efficacy of Atria notwithstanding, CHA 2 DS 2-VASc is easier to calculate at bedside and remains more popular. Female patients older than 65 years are assigned a CHA 2 DS 2-VASc score of 2 and qualify for anticoagulant therapy, despite their low risk of stroke according to European guidelines. 9 Female patients <65 years of age are scored 1 and are eligible for antiplatelet therapy. Antiplatelet and anticoagulant therapy in an inappropriate patient can cause bleeding, so a stroke score must be specific enough to reveal actual risk without increasing the potential for severe complications. Accordingly, investigators are now considering additional evidence from echocardiography, ...

Predictors and impact of postoperative atrial fibrillation following thoracic surgery: a state‐of‐the‐art review

“…Atrial fibrillation has an estimated prevalence of 9% among adults aged > 65 y and is responsible for 750,000 hospitalisations, 130,000 deaths and $6 billion annually in the USA alone [1][2][3]. In addition to advancing age, risk increases with smoking; alcohol use or abuse; obesity; hypertension; diabetes mellitus; structural heart diseases; myocardial infarction; heart failure; obstructive sleep apnoea; and chronic kidney disease [3].…”