J. B. Olesen

The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0–1: A nationwide cohort study

North American and European guidelines on atrial fibrillation (AF) are conflicting regarding the classification of patients at low/intermediate risk of stroke. We aimed to investigate if the CHA2DS2-VASc score improved risk stratification of AF patients with a CHADS2 score of 0-1. Using individual-level-linkage of nationwide Danish registries 1997-2008, we identified patients discharged with AF having a CHADS2 score of 0-1 and not treated with vitamin K antagonist or heparin. In patients with a CHADS2 score of 0, 1, and 0-1, rates of stroke/ thromboembolism were determined according to CHA2DS2-VASc score, and the risk associated with increasing CHA2DS2-VASc score was estimated in Cox regression models adjusted for year of inclusion and antiplatelet therapy. The value of adding the extra CHA2DS2-VASc risk factors to the CHADS2 score was evaluated by c-statistics, Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI). We included 47,576 patients with a CHADS2 score of 0-1, from these 7,536 (15.8%) were CHA2DS2-VASc score=0, 10,062 (21.2%) were CHA2DS2-VASc score=1, 14,310 (30.1%) were CHA2DS2-VASc score=2, 14,188 (29.8%) were CHA2DS2-VASc score=3, and 1,480 (3.1%) were CHA2DS2-VASc score=4. Of the cohort with a CHADS2 score of 0-1, the stroke/thromboembolism rate per 100 person-years increased with increasing CHA2DS2-VASc score (95% confidence interval): 0.84 (0.65-1.08), 1.79 (1.53-2.09), 3.67 (3.34-4.03), 5.75 (5.33-6.21), and 8.18 (6.68-10.02) at one year follow-up with CHA2DS2-VASc scores of 0, 1, 2, 3, and 4, respectively. Patients with a CHADS2 score=0 were not all low risk, with one-year event rates ranging from 0.84 (CHA2DS2-VASc score=0) to 3.2 (CHA2DS2-VASc score=3). Results from Cox regression analyses, NRI, and IDI confirmed the improved predictive ability of the CHA2DS2-VASc score in the AF patients who have a CHADS2 score of 0-1. In conclusion, the CHA2DS2-VASc provides critical information on risk of stroke in AF patients with a CHADS2 score of 0-1 that can aid a decision of using anticoagulation. Even in patients categorised as low risk using a CHADS2 score=0, the CHA2DS2-VASc score significantly improved the predictive value of the CHADS2 score alone and a CHA2DS2-VASc score=0 could clearly identify truly low risk subjects. Use of the CHA2DS2-VASc score would significantly improve classification of AF patients at low and intermediate risk of stroke, compared to the commonly used CHADS2 score.

Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project

Heart failure (HF) increases the risk of stroke and thrombo‐embolism (TE) in non‐valvular atrial fibrillation (NVAF), and is incorporated in stroke risk stratification scores. We aimed to establish the role of ejection fraction (EF) in risk prediction in patients with NVAF and HF.

Risk Factors for Stroke and Thromboembolism in Relation to Age Among Patients With Atrial Fibrillation: The Loire Valley Atrial Fibrillation Project

BACKGROUNDnAccording to the latest European guidelines on the management of nonvalvular atrial fibrillation (NVAF), all patients aged ≥ 65 years should be treated with oral anticoagulation (if not contraindicated). Therefore, stroke risk factors should be investigated exclusively in patients with NVAF aged < 65 years.nnnMETHODSnPatients diagnosed with NVAF in a four-hospital institution between 2000 and 2010 were identified. Event rates of stroke/thromboembolism were calculated according to age category (ie, age < 65, 65-74, and ≥ 75 years). Independent risk factors of stroke and thromboembolism were investigated in univariate and multivariate Cox regression models including patients with NVAF aged < 65 years only. The effect of adding vascular disease to the CHADS(2) (congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke) score was examined by net reclassification improvement (NRI) and integrated discrimination improvement (IDI) models.nnnRESULTSnAmong 6,438 patients with NVAF, 2,002 (31.1%) were aged < 65 years. In patients with no CHADS(2) risk factors who were not treated with anticoagulation (n = 1,035), the stroke/thromboembolic event rate per 100 person-years was 0.23 (95% CI, 0.08-0.72), 2.05 (95% CI, 1.07-3.93), and 3.99 (95% CI, 2.63-6.06) in those aged < 65, 65-74, and ≥ 75 years, respectively. Heart failure, previous stroke, and vascular disease were significantly associated with increased risk of stroke/thromboembolism in both univariate and multivariate analyses, and vascular disease significantly improved the predictive ability of the CHADS(2) score (NRI, 0.40; IDI, 0.031).nnnCONCLUSIONSnPatients with NVAF aged ≥ 65 years have event rates that merit oral anticoagulation. In patients with NVAF aged < 65 years, the risk of stroke/thromboembolism is independently increased by the presence of heart failure, previous stroke, or vascular disease. As proposed in the new CHA(2)DS(2)-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke, vascular disease, age 65-74 years, sex category [female]) score, stroke risk stratification by the CHADS(2) score can be improved by the addition of age 65 to 74 years and vascular disease.

Vascular Disease and Stroke Risk in Atrial Fibrillation: A Nationwide Cohort Study

BACKGROUNDnVascular disease (including myocardial infarction and peripheral artery disease) has been proposed as a less well-validated risk factor for stroke in patients with atrial fibrillation. We investigated whether vascular disease is an independent risk factor of stroke/thromboembolism in atrial fibrillation and whether adding vascular disease improves Congestive heart failure, Hypertension, Age 75 years, Diabetes, previous Stroke (CHADS(2)) risk stratification.nnnMETHODSnBy using nationwide Danish registers, we identified all patients discharged with atrial fibrillation and not treated with vitamin K antagonist or heparin between 1997 and 2008. The rate of stroke/thromboembolism in patients with atrial fibrillation with and without vascular disease was determined, and the risk associated with vascular disease was estimated in Cox regression analyses. The value of adding vascular disease to the CHADS(2) score was evaluated by Net Reclassification Improvement and Integrated Discrimination Improvement.nnnRESULTSnWe included 87,202 patients with non-valvular atrial fibrillation; of these, 15,212 (17.4%) had vascular disease, 11,750 (77.2%) had myocardial infarction, 2503 (16.5%) had peripheral artery disease, and 959 (6.3%) had both. In patients with a CHADS(2) score=0, the rate of stroke/thromboembolism at 1-year follow-up was 2.31 (1.63-3.26) and 1.52 (1.34-1.73) per 100 person-years in patients with and without vascular disease, respectively. Vascular disease increased the risk of stroke/thromboembolism in both univariate (hazard ratio [HR] 1.26; confidence interval [CI], 1.18-1.35) and multivariate (HR, 1.12; CI, 1.05-1.21) analyses. The risk of stroke/thromboembolism associated with peripheral artery disease alone (HR, 1.93; CI, 1.70-2.19) was greater than the risk with myocardial infarction alone (HR, 1.12; CI, 1.04-1.21), and vascular disease significantly improved the predictive ability of the CHADS(2) score (Net Reclassification Improvement 0.032, P<.001).nnnCONCLUSIONSnVascular disease is an independent predictor of stroke/thromboembolism in atrial fibrillation and improves the predictive ability of the CHADS(2) score.

Pattern of atrial fibrillation and risk of outcomes: The Loire Valley Atrial Fibrillation Project

BACKGROUNDnRisk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) is categorised in stroke risk stratification scores. The role of pattern of NVAF in risk prediction is unclear in contemporary real world cohorts.nnnMETHODS AND RESULTSnPatients with NVAF in a four-hospital-institution between 2000 and 2010 were included. Stroke/TE event rates were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent. Risk factors were investigated by Cox regression. Among 7156 NVAF patients, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent patterns of NVAF were included. In non-anticoagulated patients, overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13-1.47). Compared with paroxysmal NVAF, rates of stroke/TE, bleeding and all-cause mortality (p<0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients. In multivariate analyses, previous stroke (hazard ratio, HR 2.58, 95% CI 2.08-3.21), vascular disease (HR 1.34, 1.12-1.61), heart failure (HR 1.20, 1.00-1.44), age ≥ 75 years (HR 2.75, 2.16-3.50) and age 65-74 years (HR 1.60, 1.22-2.09) independently increased stroke/TE risk, but not persistent (HR 1.13, 0.76-1.70) and permanent (HR 1.44, 0.96-2.16) NVAF patterns.nnnCONCLUSIONnIn this large real world NVAF cohort, rates of stroke, TE, death and bleeding differed significantly by patterns of NVAF. However, only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased risk of adverse outcomes in multivariate analyses. Thus, stroke risk is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors, not on arrhythmia pattern.

Comparative safety and effectiveness of rivaroxaban versus VKAs in patients with venous thromboembolism: A Danish nationwide registry-based study

The approval of rivaroxaban has changed the landscape of treatment of venous thromboembolism (VTE). Little is known about the effect of rivaroxaban compared with vitamin K antagonists (VKA), when used in the everyday clinical practice. The aim of this study was to investigate the safety and effectiveness of rivaroxaban compared with VKAs among patients with VTE, using the Danish nationwide registries. All patients diagnosed with VTE and treated with either rivaroxaban or VKAs between 2013 and 2015 were included. A total of 12,318 patients were diagnosed with VTE and treated with VKAs [n=6,907] or rivaroxaban [n=5,411.]. Combined Cox regression analyses showed that the standardised absolute six-month risk of recurrent VTE was 3.03u2009% [95u2009% CI: 2.57u2009% to 3.48u2009%] in the rivaroxaban group and 3.13u2009% [95u2009% CI: 2.70u2009% to 3.56u2009%] in the VKA group (absolute risk difference of -0.11u2009% [95u2009% CI: -0.76u2009% to 0.54u2009%]). The standardised absolute six-months risk of bleeding was 2.28u2009% [95u2009% CI: 1.87u2009% to 2.67u2009%] for patients in the rivaroxaban group and 2.10u2009% [95u2009% CI: 1.78u2009% to 2.43u2009%] in the VKA group (absolute risk difference of 0.18u2009% [95u2009% CI: -0.34u2009% to 0.67]). In conclusion, rivaroxaban was associated with similar risk of recurrent VTE and bleeding compared with VKA.

An epidemic of atrial fibrillation

This editorial refers to ‘Trends in the incidence and prevalence of atrial fibrillation in Iceland and future projections’ by H. Stefansdottir et al. , on page 1110. nnNumerous risk factors pre-dispose to atrial fibrillation (AF), namely, hypertension, heart failure, increasing age, diabetes mellitus, and vascular disease.1 Due to the ageing population and the increasing prevalence of the known risk factors for AF,2 it may be relevant to investigate whether the incidence and prevalence of AF is increasing as well. Indeed, recently Huxley et al .2 reported that more than half of the incident AF cases are due to known cardiovascular risk factors, implying that firstly, the incidence of AF will rise with the increasing prevalence of known risk factors; secondly, that other factors, possibly genetic, may have a greater role in the aetiology of AF; and thirdly, it may be possible to avoid a large proportion of the incident AF cases if the prevalence of the already-known risk factors are reduced.nnStefansdottir et al .3 examined trends in the incidence and prevalence of AF in Iceland among all citizens in the capital, Reykjavik, and both hospital admissions and outpatients AF diagnoses were included. The present study found that the incidence of AF increased significantly in women (by 0.9% per year) but not in men (by 0.1% per year) in the study period, 1991–2008.3 The prevalence of AF was projected to increase from 2.0% in 2008 to 4.3% in 2050 and with the expected increase in population size, this would result in a three-fold increase in the number of patients with AF (from 4495 …

Risk of ischemic stroke, hemorrhagic stroke, bleeding, and death in patients switching from warfarin to dabigatran after an ablation

Successful reperfusion is associated with lower levels of markers of myocardial damage and dysfunction in ST-elevation but not in non-ST-elevation myocardial infarction : insights from the PLATO trialBackground: Carbohydrate antigen 125 (CA125) is a mucin produced by serosal cells in response to mechanical and inflammatory stimuli. CA125 has emerged as prognostic biomarker in heart failure (HF) and correlates with markers of fluid overload, echocardiographic parameters and prognosis in HF patients. In patients with acute coronary syndrome (ACS), elevated CA125 is correlated with a higher risk of in-hospital HF. The relationship between CA125 and long-term prognosis in ACS patients has not previously been assessed. Purpose: The purpose of our study was to investigate if CA125 measured at the time of an acute coronary event is related to cardiac remodeling during the first year of follow-up and long-term risk for HF and death Methods: We measured CA125 in plasma within 24 hours of the acute event in 523 patients with acute myocardial infarction or unstable angina admitted to the Coronary Care Unit. Routine echocardiograms were performed in all participants. The primary outcomes were hospitalization with a diagnosis of heart failure or death during follow-up, identified through data from the Swedish Hospital Discharge Register and the Swedish Cause of Death Register. In a subgroup of 109 patients aged 75 years or above we assessed the relationships between baseline CA125 and echocardiographical parameters of cardiac structure and function at 1 year after the index ACS. Results: The median follow-up period was 27.3 months for incident HF and 39.5 months for mortality. In Cox proportional hazards models we found an adjusted hazard ratio of 1.51 (95% CI 1.08-2.12; p (Less)

The prognostic impact of heart rate in atrial fibrillation

Published on behalf of the European Society of Cardiology. All rights reserved.

Thiazolidinediones decrease risk of atrial fibrillation compared to other antidiabetic treatment

Published on behalf of the European Society of Cardiology. All rights reserved.