Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?

Chao, Tze Fan; Liu, Chia Jen; Wang, Kang Ling; Lin, Yenn Jiang; Chang, Shih Lin; Lo, Li Wei; Hu, Yu Feng; Tuan, Ta Chuan; Chen, Tzeng Ji; Lip, Gregory Y.H.; Chen, Shih Ann

doi:10.1016/j.jacc.2014.11.046

Cited by 239 publications

(185 citation statements)

References 36 publications

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“…The study protocol of the present study was similar to those of our previous studies 5, 6, 7, 8, 9, 10, 11. From January 1, 2000 to December 31, 2011, a total of 289 559 AF patients aged ≥20 years (10 336 with liver cirrhosis) were identified from the NHIRD.…”

Section: Methodsmentioning

confidence: 91%

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

Kuo

Chao

Liu

et al. 2017

JAHA

101

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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.

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Section: Methodsmentioning

confidence: 91%

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

Kuo

Chao

Liu

et al. 2017

JAHA

101

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“…In contrast, the European guidelines recommend oral anticoagulants among patients with ≥1 stroke risk factors 19. Estimates of baseline untreated stroke risk in this low‐risk population vary in the literature 13, 46, 47. We found that adherence to anticoagulation was not associated with a significant reduction in stroke in patients with CHA 2 DS 2 ‐VASc score 0 or 1, suggesting that the stroke risk is not easily modified in low‐risk patients and that the bleeding risk is nontrivial.…”

Section: Discussionmentioning

confidence: 99%

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Yao

Abraham

Alexander

et al. 2016

JAHA

394

329

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BackgroundIn comparison to warfarin, non–vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.Methods and ResultsWe performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow‐up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA 2 DS 2‐VASc (risk based on the presence of congestive heart failure, hypertension age 65–74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1–3 months: hazard ratio [HR] 1.96, 3–6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA 2 DS 2‐VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA 2 DS 2‐VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA 2 DS 2‐VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.ConclusionsAdherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA 2 DS 2‐VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA 2 DS 2‐VASc score 0 or 1.

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“…Lip and colleagues in a large Danish cohort of patients with AF demonstrated that in untreated patients with 1 additional stroke risk factor (CHA 2 DS 2 VASc=1 [male],=2 [female]), strokes rates increased 3‐fold compared with untreated low‐risk patients (CHA 2 DS 2 VASc=0 [male], =1 [female]) 20. Similarly, Chao and colleagues in a large Taiwanese cohort of patients with AF demonstrated that untreated patients with 1 additional risk factor for stroke derived a benefit from OAC given their increased risk of ischemic stroke 21. Conversely, Friberg and colleagues, in a large Swedish cohort, showed that untreated patients with 1 additional stroke risk factor had lower risk of ischemic stroke than previously reported and that the use of OAC in this group provided no associated benefit 18…”

Section: Discussionmentioning

confidence: 99%

Stroke Risk and Treatment in Patients with Atrial Fibrillation and Low CHA ₂ DS ₂ ‐VASc Scores: Findings From the ORBIT‐AF I and II Registries

Jackson

Kim

Fonarow

et al. 2018

JAHA

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BackgroundCurrent American College of Cardiology/American Heart Association guidelines suggest that for patients with atrial fibrillation who are at low risk for stroke (CHA2DS2VASc=1) (or women with CHA2DS2VASc=2) a variety of treatment strategies may be considered. However, in clinical practice, patterns of treatment in these “low‐risk” patients are not well described. The objective of this analysis is to define thromboembolic event rates and to describe treatment patterns in patients with low‐risk CHA2DS2VASc scores.Methods and ResultsWe compared characteristics, treatment strategies, and outcomes among patients with a CHA2DS2VASc=0, CHA2DS2VASc=1, females with a CHA2DS2VASc=2, and CHA2DS2VASc ≥2 in ORBIT‐AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) I & II. Compared with CHA2DS2VASc ≥2 patients (84.2%), those with a CHA2DS2VASc=0 (60.3%), 1 (69.9%), and females with a CHA2DS2VASc score=2 (72.4%) were significantly less often treated with oral anticoagulation (P<0.0001). Stroke rates were low overall and ranged from 0 per 100 patient‐years in those with CHA2DS2VASc=0, 0.8 (95% confidence interval [CI] [0.5–1.2]) in those with CHA2DS2VASc=1, 0.8 (95% CI [0.4–1.6]) in females with a CHA2DS2VASc score=2, and 1.7 (95% CI [1.6–1.9]) in CHA2DS2VASc ≥2. All‐cause mortality (per 100 patient‐years) was highest in females with a CHA2DS2VASc score=2 (1.4) (95% CI [0.8–2.3]), compared with patients with a CHA2DS2VASc=0 (0.2) (95% CI [0.1–1.0]), and CHA2DS2VASc=1 (1.0) (95% CI [0.7–1.4]), but lower than patients with a CHA2DS2VASc ≥2 (5.7) (95% CI [5.4–6.0]).ConclusionThe majority of CHA2DS2VASc=0‐1 patients are treated with oral anticoagulation. In addition, the absolute risks of death and stroke/transient ischemic attack were low among both male and females CHA2DS2VASc=0‐1 as well as among females with a CHA2DS2VASc score=2.Clinical Trial RegistrationURL:http://www.clinicaltrials.gov. Unique identifier: NCT01701817.

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Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?

Abstract: Not all risk factors in CHA2DS2-VASc score carry an equal risk, with age 65 to 74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 additional stroke risk factor given their high risk of ischemic stroke.

Cited by 239 publications

References 36 publications

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

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

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Stroke Risk and Treatment in Patients with Atrial Fibrillation and Low CHA ₂ DS ₂ ‐VASc Scores: Findings From the ORBIT‐AF I and II Registries

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Should Atrial Fibrillation Patients With 1 Additional Risk Factor of the CHA2DS2-VASc Score (Beyond Sex) Receive Oral Anticoagulation?

Abstract: Not all risk factors in CHA2DS2-VASc score carry an equal risk, with age 65 to 74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 additional stroke risk factor given their high risk of ischemic stroke.

Cited by 239 publications

References 36 publications

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

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

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Stroke Risk and Treatment in Patients with Atrial Fibrillation and Low CHA 2 DS 2 ‐VASc Scores: Findings From the ORBIT‐AF I and II Registries

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Product

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Stroke Risk and Treatment in Patients with Atrial Fibrillation and Low CHA ₂ DS ₂ ‐VASc Scores: Findings From the ORBIT‐AF I and II Registries