CHA2DS2-VASc and ATRIA Scores and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction

Assessing Stroke and Mortality Risk in Heart Failure: The CHA2DS2-VASc Score's Prognostic Value in Patients With and Without Atrial Fibrillation: A Meta-Analysis

The CHA2DS2-VASc [congestive heart failure, hypertension, age (≥75 years earns 2 points, 65-74 years earns 1 point), diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism (2 points), vascular disease (eg, prior myocardial infarction, peripheral artery disease), and female sex category] score has demonstrated potential as a prognostic indicator for adverse outcomes in patients with heart failure (HF). This systematic review and meta-analysis aimed to assess the predictive accuracy of the CHA2DS2-VASc score in determining the occurrence of stroke and mortality in HF patients. We did a thorough search of electronic databases until December 2023. Included studies examined the correlation between the CHA2DS2-VASc score and the likelihood of stroke or death in patients with HF. The meta-analysis showed a substantial correlation between elevated CHA2DS2-VASc scores and heightened risks of both stroke and mortality in HF patients. Patients with CHA2DS2-VASc scores ≥4 had a greater stroke risk than those with scores <4 (odds ratio, 0.38, 95% confidence interval, 0.33-0.43, P < 0.00001). Similarly, patients with CHA2DS2-VASc scores ≥4 had a higher mortality risk (OR, 0.49, 95% confidence interval, 0.30-0.80, P = 0.05). The CHA2DS2-VASc score is a useful predictive tool for identifying HF patients who are at a high risk of both stroke and mortality. Additional investigation is necessary to confirm these findings and examine the incorporation of the CHA2DS2-VASc score into risk assessment algorithms for tailored patient management.

A nomogram to predict ventricular thrombus in dilated cardiomyopathy patients

BACKGROUND

VT (Ventricular Thrombus) is a serious complication of dilated cardiomyopathy (DCM). Our goal is to develop a nomogram for personalized prediction of incident VT in DCM patients.

METHODS

1267 patients (52.87 ± 11.75 years old, 73.8% male) were analyzed retrospectively from January 01, 2015, to December 31, 2020. A nomogram model for VT risk assessment was established using minimum absolute contraction and selection operator (LASSO) and multivariate logistic regression analysis, and its effectiveness was validated by internal guidance. The model was evaluated by the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA). We compared the performance in predicting VT between nomogram and CHA2DS2, CHA2DS2- VASc or ATRIA by AUC, akaike information criterion (AIC), bayesian information criterion (BIC), net reclassification index (NRI), and integrated discrimination index (IDI).

RESULTS

89 patients (7.02%) experienced VT. Multivariate logistic regression analysis revealed that age, left ventricular ejection fraction (LVEF), uric acid (UA), N-terminal precursor B-type diuretic peptide (NT-proBNP), and D-dimer (DD) were important independent predictors of VT. The nomogram model correctly separates patients with and without VT, with an optimistic C score of 0.92 (95%CI: 0.90-0.94) and good calibration (Hosmer-Lemeshow χ2 = 11.51, P = 0.12). Our model showed improved prediction of VT compared to CHA2DS2, CHA2DS2-VASc or ATRIA (all P < 0.05).

CONCLUSIONS

The novel nomogram demonstrated better than presenting scores and showed an improvement in predicting VT in DCM patients.

Association of CHA2DS2-VASC Score with in-Hospital Cardiovascular Adverse Events in Patients with Acute ST-Segment Elevation Myocardial Infarction

Background

Acute ST-elevation myocardial infarction (STEMI) is a common clinical critical illness, and accurate, reliable, simple, and easy-to-remember tools are needed in clinical practice to quickly identify the risk of this condition in STEMI patients. This study investigates the predictive value of the admission CHA2DS2-VASc score for in-hospital MACE in STEMI patients.

Methods

A total of 210 STEMI patients who visited the Chest Pain Center of the Second People's Hospital of Hefei from December 2019 to December 2021 were retrospectively analyzed. They were divided into MACE and non-MACE groups. The receiver operating characteristic curve (ROC) was used to assess the predictive value of the CHA2DS2-VASc score for MACE events during hospitalization.

Results

The CHA2DS2-VASc score was higher in the MACE group than in the non-MACE group (P < 0.05), and multivariate logistic regression analysis showed that the CHA2DS2-VASc score was an independent risk factor for MACE events during hospitalization in STEMI patients (OR = 1.391, 95%CI 1.044-1.853, P=0.024); ROC curve analysis showed that the area under the curve (AUC) of the CHA2DS2-VASc score was 0.744, the sensitivity was 0.64, the specificity was 0.694, and the optimal cutoff value was 3.5 in predicting the risk of MACE events during hospitalization in STEMI patients. There were no significant differences between the GRACE score (0.744 VS.0.827) and TIMI score (0.744VS.0.745) (P > 0.05).

Conclusion

The CHA2DS2-VASc score can successfully predict the occurrence of in-hospital MACE events in STEMI patients.

Associations of body mass index with mortality in heart failure with preserved ejection fraction patients with ischemic versus non-ischemic etiology

Background

Obesity could paradoxically improve prognosis in patients with heart failure (HF), termed the “obesity paradox.” Whether HF etiology could modify the “obesity paradox” is still controversial. In the present study, we aimed to assess the relationship between obesity and death in patients with heart failure with preserved ejection fraction (HFpEF) with non-ischemic versus ischemic etiologies.

Methods

We analyzed 3,360 HFpEF patients from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. Cox regression models were used to assess the association of obesity assessed by body mass index (BMI) with short-term and long-term death risk.

Results

Overweight and obesity were associated with a lower risk of long-term all-cause death in patients with non-ischemic HFpEF, even in those with class III obesity (adjusted HR: 0.61, 95% CI 0.38–0.97). However, in the ischemic subgroup, as obesity advanced, this paradoxical relationship was gradually attenuated and disappeared in class III obesity (adjusted HR: 0.93, 95% CI 0.56–1.57). Restricted cubic spline analyses confirmed the differential relationship of baseline BMI with risk of long-term death with a BMI higher than 30 kg/m2 in non-ischemic versus ischemic HFpEF. In the short-term follow-up, the beneficial effects of overweight and obesity on survival were consistently observed in all the BMI categories, with the nadirs of all-cause death risk at class III obesity category both in non-ischemic and ischemic subgroups.

Conclusion

“Obesity paradox” was evident both in non-ischemic and ischemic HFpEF during short-term follow-up, even in those with class III obesity. However, the beneficial effect of class III obesity disappeared during long-term follow-up in ischemic HFpEF.

Clinical Trial Registration

[https://clinicaltrials.gov], identifier [NCT00094302].

Usefulness of B-Type Natriuretic Peptide for Predicting the Risk of Stroke in Patients With Heart Failure With Preserved Ejection Fraction

Background B-type natriuretic peptide (BNP) is a well-known biomarker for prognosis in heart failure with patients with preserved ejection fraction. However, the clinical predictive ability of BNP for the risk of stroke in HFpEF is not clear. Methods and Results A total of 799 patients with HFpEF from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial were included. Association of baseline BNP with risk of stroke was assessed using the Cox proportional hazard model. The discriminatory ability of BNP was expressed using the C index. The improvement in 5-year stroke prediction was assessed by C statistic, categorical net reclassification improvement index, and relative integrated discrimination improvement. A total of 34 (4.3%) patients among the 799 patients with HFpEF experienced stroke events over a median of 2.85 years of follow-up. The stroke group showed a higher BNP level than the nonstroke group (375 pg/mL versus 241 pg/mL, respectively; P=0.006). Higher BNP levels were associated with increased risk of stroke after multivariable adjustment (hazard ratio, 3.29 [95% CI, 1.51-7.16]) and had a moderate performance for stroke prediction (C index, 0.67). Adding BNP to CHADS₂/CHA₂DS₂-VASc/R₂CHADS₂ scores improved their predictive value for stroke (CHADS₂: C index, 0.67; BNP+CHADS₂: C index, 0.77; net reclassification improvement, 40.9%; integrated discrimination improvement, 3.0%; CHA₂DS₂-VASc: C index, 0.64; BNP+CHA₂DS₂-VASc: C index, 0.74; net reclassification improvement, 41.4%; integrated discrimination improvement, 2.2%; R₂CHADS₂: C index, 0.70; BNP+R₂CHADS₂: C index, 0.78; net reclassification improvement, 40.9%; integrated discrimination improvement, 3.2%). Conclusions BNP is associated with an increased risk of stroke in patients with HFpEF and may be a valuable biomarker for stroke prediction in HFpEF.

The "Obesity Paradox" in Patients With HFpEF With or Without Comorbid Atrial Fibrillation

Background: Overweight and mildly obese individuals have a lower risk of death than their normal-weight counterparts; this phenomenon is termed "obesity paradox." Whether this "obesity paradox" exists in patients with heart failure (HF) or can be modified by comorbidities is still controversial. Our current study aimed to determine the association of body mass index (BMI) with outcomes with patients with HF with preserved ejection fraction (HFpEF) with or without coexisting atrial fibrillation (AF). Methods: Patients with HFpEF from the Americas in the TOPCAT trial were categorized into the 3 groups: normal weight (18.5-24.9 kg/m²), overweight (25.0-29.9 kg/m²), and obesity (≥30 kg/m²). The Cox proportional-hazards models were used to calculate the adjusted hazard ratios (HRs) and CIs. Results: We identified 1,749 patients with HFpEF, 42.1% of which had baseline AF. In the total population of HFpEF, both overweight (HR = 0.59, 95% CI: 0.42-0.83) and obesity (HR = 0.49, 95% CI: 0.35-0.69) were associated with a reduced risk of all-cause death. Among patients with HFpEF without AF, overweight (HR = 0.51, 95% CI: 0.27-0.95) and obesity (HR = 0.64, 95% CI: 0.43-0.98) were associated with a lower risk of all-cause death. In those with AF, obesity (HR = 0.62, 95% CI: 0.40-0.95) but not overweight (HR = 0.81, 95% CI: 0.54-1.21) was associated with a decreased risk of all-cause death. Conclusions: The "obesity paradox" assessed by BMI exists in patients with HFpEF regardless of comorbid AF. Clinical Trial Registration: https://clinicaltrials.gov, identifier: NCT00094302.

Stroke risk scores to predict hospitalization for acute decompensated heart failure in atrial fibrillation patients

Introduction. Atrial fibrillation (AF) is the most frequent hospitalized arrhythmia. It associates increased risk of death, stroke and heart failure (HF). Stroke risk scores, especially CHA₂DS₂-VASc, have been applied also for populations with different diseases. There is, however, limited data focusing on the ability of these scores to predict HF decompensation.Methods. We conducted a retrospective observational study on a cohort of 204 patients admitted for cardiovascular pathology to the Cardiology Ward of our tertiary University Hospital. We aimed to determine whether the stroke risk scores could predict hospitalisations for acute decompensated HF in AF patients.Results. C-statistics for CHADS₂ and R₂CHADS₂ showed a modest predictive ability for hospitalisation with decompensated HF (CHADS₂: AUC 0.631 p = 0.003; 95%CI 0.560-0.697. R₂CHADS₂: AUC 0.619; 95%CI 0.548-0.686; p = 0.004), a marginal correlation for CHA₂DS_2-VASc (AUC 0.572 95%CI 0.501-0.641 with a p value of only 0.09, while the other scores failed to show a correlation. A CHADS₂ ≥ 2 showed a RR = 2.96, p<0.0001 for decompensated HF compared to a score <2. For R₂CHADS₂ ≥ 2, RR = 2.41, p = 0.001 compared to a score <2. For CHA₂DS_2-VASc ≥ 2 RR = 2.18 p = 0.1, compared to CHA₂DS₂-VASc <2. The correlation coefficients showed a weak correlation for CHADS₂ (r = 0.216; p = 0.001) and even weaker for R₂CHADS₂ (r = 0.197; p = 0.0047 and CHA₂DS₂-VASc (r = 0.14; p = 0.035).Conclusions. Among AF patients, CHADS_2, CHA₂DS₂-VASc and R₂CHADS₂ were associated with the risk of hospitalisation for decompensated HF while ABC and ATRIA failed to show an association. However, predictive accuracy was modest and the clinical utility for this outcome remains to be determined.

C2HEST score predicts clinical outcomes in heart failure with preserved ejection fraction: a secondary analysis of the TOPCAT trial

BACKGROUND

The C₂HEST score has been validated for predicting AF in the general population or post-stroke patients. We aimed to assess whether this risk score could predict incident AF and other clinical outcomes in heart failure with preserved ejection fraction (HFpEF) patients.

METHODS

A total of 2202 HFpEF patients without baseline AF in the TOPCAT trial were stratified by baseline C₂HEST score. Cox proportional hazard model and competing risk regression model was used to explore the relationship between C₂HEST score and outcomes, including incident AF, stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. The discriminative ability of the C₂HEST score for various outcomes was assessed by calculating the area under the curve (AUC).

RESULTS

The incidence rates of incident AF, stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization were 1.79, 0.70, 3.81, 2.42, 15.50, and 3.32 per 100 person-years, respectively. When the C₂HEST score was analyzed as a continuous variable, increased C₂HEST score was associated with increased risk of incident AF (HR 1.50, 95% CI 1.29-1.75), as well as increased risks of all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. The AUC for the C₂HEST score in predicting incident AF (0.694, 95% CI 0.640-0.748) was higher than all-cause death, cardiovascular death, any hospitalization, or HF hospitalization.

CONCLUSIONS

The C₂HEST score could predict the risk of incident AF as well as death and hospitalization with moderately good predictive abilities in patients with HFpEF. Its simplicity may allow the possibility of quick risk assessments in busy clinical settings.

Usefulness of CHADS2, R2CHADS2, and CHA2DS2-VASc scores for predicting incident atrial fibrillation in heart failure with preserved ejection fraction patients

Aims

Coexisting of atrial fibrillation (AF) in patients with heart failure with preserved ejection fraction (HFpEF) could increase the risk of mortality. In this study, we aimed to assess the values of the CHADS2, R2CHADS2, and CHA2DS2‐VASc scores for AF prediction in HFpEF patients.

Methods and results

We performed a retrospective analysis on symptomatic HFpEF patients in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. Associations of the CHADS2, R2CHADS2, and CHA2DS2‐VASc scores with the risk of incident AF in HFpEF patients without baseline AF (n = 2202) were assessed using the multivariable competing risk regression models. The discriminatory performances of these scores were calculated using the C‐index. During a median follow‐up of 3.3 years, the average incidence of AF was 1.80 per 100 patient‐years in HFpEF patients. When score was analysed as a continuous variable, per 1‐point increase in the CHADS2 (hazard ratio [HR] = 1.42, 95% confidence interval [CI]: 1.20–1.68, C‐index: 0.71), R2CHADS2 (HR = 1.25, 95% CI: 1.10–1.42, C‐index: 0.69), or CHA2DS2‐VASc (HR = 1.30, 95% CI: 1.16–1.46, C‐index: 0.70) scores was associated with an increased risk of incident AF. When score was analysed as a categorical variable, patients with CHADS2 ≥ 3 (HR = 2.62, 95% CI: 1.70–4.04), R2CHADS2 ≥ 3 (HR = 2.55, 95% CI: 1.56–4.17), or CHA2DS2‐VASc ≥ 4 (HR = 2.54, 95% CI: 1.59–4.07) had a higher risk of incident AF compared with the corresponding controls.

Conclusions

Our data first suggest that the CHADS2, R2CHADS2, and CHA2DS2‐VASc scores could predict the risk of incident AF in HFpEF patients with modest predictive abilities.