Association of CHADS2, CHA2DS2-VASc, and R2CHADS2 scores with left atrial dysfunction in patients with coronary heart disease (from the Heart and Soul study)

The CHA2DS2-VASC Score Predicts Mortality in Patients Undergoing Coronary Angiography

BACKGROUND

The CHA2DS2-VASC score is used to predict the risk of thromboembolic complications in patients with atrial fibrillation (AF). We hypothesized that the CHA2DS2-VASC score can be used to predict mortality in patients undergoing coronary angiography.

METHODS AND RESULTS

This was a prospective study of 990 patients undergoing coronary angiography. The median follow-up was 2294 days. The patients were categorized into two groups according to their CHA2DS2-VASC score: group I had scores <4 and group II had scores ≥4 (527 (53.2%) and 463 (46.8%), respectively). A Kaplan-Meier analysis demonstrated a significant association between the CHA2DS2-VASC score and mortality (69/527 (13.1%) vs. 179/463 (38.7%) for group I vs. group II, respectively, p < 0.0001). The association remained significant in patients with and without AF, reduced and preserved LVEF, normal and reduced kidney function, and with and without ACS (p < 0.009 to p < 0.0001 for all). In the Cox regression model, which combined the CHA2DS2-VASC score, the presence of AF, LVEF, anemia, and renal insufficiency, an elevated CHA2DS2-VASC score of ≥4 was independently associated with higher mortality (HR 2.12, CI 1.29-3.25, p = 0.001).

CONCLUSIONS

The CHA2DS2VASC score is a simple and reliable mortality predictor in patients undergoing coronary angiography and should be used for the initial screening for such patients.

Efficacy of Psycho-Cardiology therapy in patients with acute myocardial infarction complicated with mild anxiety and depression

Objective

To evaluate the efficacy of Psycho-Cardiology therapy among patients with acute myocardial infarction (AMI) complicated with mild anxiety and depression.

Methods

Two hundred and fifty-six patients with AMI who were admitted to the Cardiovascular Department of Chenzhou First People's Hospital from January 2018 to January 2020 were selected as subjects, and randomly divided into the control group (n = 128) and the Psycho-Cardiology treatment group (n = 128). Prior to the intervention, the general clinical data of the enrolled patients, such as gender, age, comorbidities (hypertension, diabetes) and smoking history, were compared, which revealed no statistical differences between the two groups (P > 0.05). The control group was given routine treatments such as reperfusion and secondary prevention of coronary heart disease, while the treatment group was given Psycho-Cardiology intervention in addition to the aforementioned treatments.

Results

No significant differences in PHQ-9 and GAD-7 scores were observed between the control and treatment groups at admission (P > 0.05). After the Psycho-Cardiology treatment, the PHQ-9 and GAD-7 scores of the treatment group decreased significantly. Based on the 1-year post-treatment comparison, the left ventricular ejection fraction was improved more significantly in the Psycho-Cardiology treatment group, showing statistical significance (P < 0.05). The treatment group exhibited statistically significantly low incidences of adverse cardiovascular events, such as recurrent angina pectoris, heart failure, malignant arrhythmia, recurrent myocardial infarction and death (P < 0.05).

Conclusions

Psycho-Cardiology therapy is remarkably efficacious in improving the anxiety, depression, cardiac function and reducing the occurrence of adverse cardiovascular events, which can better improve the long-term prognosis of patients with AMI compared to the traditional treatments.

The CHA2DS2-VASc score as a predictor of high mortality in hospitalized heart failure patients

Aims

Atrial fibrillation (AF) is common in patients with heart failure (HF). CHA₂DS₂‐VASc score was originally employed as a risk assessment tool for stroke in patients with AF; however, it has recently been used to predict not only stroke but also various cardiovascular diseases beyond the original AF field. We aimed to verify the CHA₂DS₂‐VASc score as a risk assessment tool to predict mortality in patients with HF.

Methods and Results

Consecutive 1011 patients admitted for treatment of HF were divided into three groups based on their CHA₂DS₂‐VASc scores: score 1–3 group (n = 317), score 4–6 group (n = 549) and score 7–9 group (n = 145). Of the 1011 HF patients, 387 (38.3%) had AF. We compared patient characteristics among the three groups and prospectively followed for all‐cause mortality. Although left ventricular ejection fraction was similar among all three groups, all‐cause mortality was higher in the score 4–6 group and score 7–9 group than in the score 1–3 group (37.9 and 29.3% vs. 15.1%, log‐rank P < 0.001). In the multivariable Cox proportional hazard analysis, the CHA₂DS₂‐VASc score 7–9 was an independent predictor of all‐cause mortality (all HF patients: hazard ratio (HR) 1.822, P = 0.011; HF patients with AF: HR 1.951, P = 0.031; HF patients without AF: HR 2.215, P = 0.033).

Conclusions

The CHA₂DS₂‐VASc score was an independent predictor of all‐cause mortality in HF patients with or without AF. This comprehensive risk assessment score may help identify HF patients who are at high risk for mortality in HF patient.

Targeted Anticoagulation for Atrial Fibrillation Guided by Continuous Rhythm Assessment With an Insertable Cardiac Monitor: The Rhythm Evaluation for Anticoagulation With Continuous Monitoring (REACT.COM) Pilot Study

INTRODUCTION

Chronic anticoagulation is recommended for patients with AF and additional stroke risk factors, even during long periods of sinus rhythm. Continuous rhythm assessment with an insertable cardiac monitor (ICM) and use of rapid onset novel oral anticoagulants (NOACs) allow for targeted anticoagulation only around an AF episode, potentially reducing bleeding complications without compromising stroke risk.

METHODS

This multicenter, single-arm study enrolled patients on NOAC with nonpermanent AF and CHADS2 score 1 or 2. After a 60-day run-in with no AF episodes ≥ 1 hour, NOACs were discontinued but reinitiated for 30 days following any AF episode ≥ 1 hour diagnosed through daily ICM transmissions. Major endpoints included time on NOAC, stroke, and bleeding.

RESULTS

Among 59 enrollees, 75% were male, age 67 ± 8 years, 76% paroxysmal AF, 69% had prior AF ablation, and mean CHADS2 score 1.3 ± 0.5. Over 466 ± 131 mean days of follow-up there were 24,004 ICM transmissions with a compliance rate of 98.7%. A total of 35 AF episodes ≥ 1 hour occurred in 18 (31%) patients, resulting in a total time on NOAC of 1,472 days. This represents a 94% reduction in the time on NOAC compared to chronic anticoagulation. There were three traumatic bleeds (all on aspirin), three potential transient ischemic attacks (all on aspirin with CHADS2 score of 1), and no strokes or deaths.

CONCLUSIONS

A targeted strategy of ICM-guided intermittent NOAC administration is feasible. A large-scale trial is necessary to evaluate the safety of this approach.

Does the CHA2DS2-Vasc score predict procedural and short-term outcomes in patients undergoing transcatheter aortic valve implantation?

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is associated with periprocedural and postprocedural morbidity and mortality. Currently, there is a paucity of risk stratification models for potential TAVI candidates. We employed the CHA2DS2-Vasc score to quantify the risk of 30-day mortality and morbidity in patients undergoing TAVI.

METHODS AND RESULTS

A retrospective analysis of registry data for consecutive patients undergoing TAVI at 3 tertiary centres in Northwest England between 2008 and 2013. The CHA2DS2-Vasc score and its modification-the R2CHA2DS2-Vasc score, which includes pre-existing renal impairment and pre-existing conduction abnormality (right bundle branch block/left bundle branch block, RBBB/LBBB)-were calculated for all patients. A total of 313 patients with a mean age of 80 (79.1-80.8) years underwent TAVI. The implanted devices were either the CoreValve or the Edwards-SAPIEN prosthesis. The 30-day mortality was 14.3% in those with a CHA2DS2-Vasc score ≥6, whereas it was only 6.2% in those with a score <6 (p=0.04). Using the R2-CHA2DS2-Vasc score, the difference was more pronounced with a 30-day mortality of 22.6% in those patients with an R2-CHA2DS2-Vasc score ≥7 compared to 6.0% in those with a R2-CHA2DS2-Vasc score <7 (p=0.001). In multivariable Cox regression analyses, there was a significant and independent relationship between the CHA2DS2-Vasc score (hazard ratio (HR)= 2.71, (1.01 to 7.31); p<0.05) and the modified R2CHA2DS2-Vasc score (HR=4.27 (1.51 to 12.07); p=0.006) with 30-day mortality.

CONCLUSIONS

Our study demonstrates the potential use of the CHA2DS2-Vasc or the R2CHA2DS2-Vasc score to quantify the risk of mortality in patients undergoing TAVI. This could have significant implications in terms of clinical as well as patients' decision-making.

The CHADS2 Components Are Associated with Stroke-Related In-hospital Mortality in Patients with Atrial Fibrillation

BACKGROUND

The CHADS2 score predicts stroke risk in patients with atrial fibrillation. Although strokes caused by atrial fibrillation carry the highest mortality when compared with other etiologies, it is not known whether the CHADS2 score predicts stroke-related mortality in patients with atrial fibrillation. We hypothesized that higher CHADS2 scores would be associated with higher stroke-related in-hospital mortality.

METHODS

Data were obtained from administrative claims data from all emergency department encounters and hospitalizations at California's nonfederal acute care hospitals between 2008 and 2011. Patients with atrial fibrillation and an admission for acute stroke were identified using appropriate International Classification of Diseases, Ninth Revision (ICD-9), Clinical Modification codes. Age and ICD-9 codes for hypertension, diabetes, congestive heart failure, and prior stroke were used to calculate the CHADS2 score of patients with atrial fibrillation. The primary outcome was in-hospital stroke mortality and the primary predictor was CHADS2 score. A multivariate logistic regression model adjusted for sex and race was used to determine the odds ratio (OR) and 95% confidence interval (CI) for the association between CHADS2 and mortality.

RESULTS

Between January 1, 2008, and December 31, 2011, 25,599 patients with atrial fibrillation were hospitalized with a stroke. The odds of in-hospital mortality was significantly higher with a CHADS2 score of 2 more versus less than 2 (OR, 1.15; 95% CI, 1.08-1.23); however, there was no dose-response association between the CHADS2 score and in-hospital mortality. Among the individual CHADS2 score items, factors associated with increased in-hospital mortality were congestive heart failure (OR, 1.61; 95% CI, 1.53-1.70), age 75 years or older (OR, 1.27; 95% CI, 1.19-1.35), and diabetes (OR, 1.24; 95% CI, 1.14-1.35).

CONCLUSIONS

Unlike prior studies, our studies show that the prestroke CHADS2 score is of limited use in predicting in-hospital mortality in ischemic stroke hospitalizations in patients with atrial fibrillation.

Usefulness of the CHA2DS2VASc score to predict postoperative stroke in patients having cardiac surgery independent of atrial fibrillation

Despite its association with cardioembolic stroke, atrial fibrillation (AF) appears to be inconsistent as a risk factor for postoperative strokes in patients who underwent cardiac surgery. Furthermore, the relation between AF and the CHA2DS2VASc score has not been definitively established with respect to postoperative stroke. We retrospectively analyzed the records of all cardiac surgery performed at our institution between January 2008 and July 2013. Baseline characteristics, operative data, and postoperative outcomes were compared in patients who developed stroke with those who did not. Previously recognized stroke risk factors, including AF, were analyzed along with the CHADS2 and CHA2DS2VASc scores. A total of 3,492 consecutive patients were identified, of which 2,077 (60%) underwent valve surgery, 915 (26%) had coronary artery bypass grafting, 399 (11%) underwent combined coronary artery bypass grafting and valve procedures, and 101 (3%) had other cardiac operations. Postoperative ischemic strokes occurred in 44 patients (1.2%). The development of a stroke was associated with older age (74 ± 12 vs 69 ± 12, p = 0.008), preoperative antiplatelet medication use (38.6% vs 24.5%, p = 0.043), congestive heart failure (37% vs 20%, p = 0.002), and greater CHADS2 (2.48 ± 1.3 vs 1.98 ± 1.1, p = 0.015) and CHA2DS2VASc scores (4.2 ± 1.8 vs 3.4 ± 1.6, p = 0.002). Multivariable analysis demonstrated that the CHA2DS2VASc score was the only independent predictor of postoperative strokes (odds ratio 1.25; 95% confidence interval 1.05 to 1.5, p = 0.014). In conclusion, the CHA2DS2VASc score appears to predict postoperative strokes independent of the presence of AF.

The CHADS2 Score to Predict Stroke Risk in the Absence of Atrial Fibrillation in Hypertensive Patients Aged 65 Years or Older

INTRODUCTION AND OBJECTIVES

The CHADS2 score is a proven, essential tool for estimating cardioembolic risk (mainly stroke) in patients with nonvalvular atrial fibrillation, with the purpose of determining the indication for anticoagulant therapy. In this study we analyzed the use of CHADS2 in hypertensive patients without known atrial fibrillation in a Mediterranean population.

METHODS

The study included 887 hypertensive patients aged 65 years or older without atrial fibrillation or anticoagulant therapy, who attended a medical consultation. Data on the patients' main risk factors, cardiovascular history, and medication were collected, basic laboratory analyses and electrocardiography were performed, and the CHADS2 score (heart failure, hypertension, age ≥ 75 years, diabetes mellitus, and previous stroke or transient ischemic attack) was calculated. A clinical follow-up was carried out, recording hospital admissions for a stroke or transient ischemic attack. The median duration of follow-up was 804 days.

RESULTS

Mean age was 72.5 (SD,5.7) years, 46.6% were men, 27.8% had diabetes, and 8.6% were smokers. During follow-up, 40 patients were hospitalized for a stroke or transient ischemic attack (4.5%). The event-free survival analysis showed significant differences according to the CHADS2 score (log rank test, P < .001). On multivariate analysis, smoking and CHADS2 ≥3 were independent predictors of stroke or transient ischemic attack.

CONCLUSIONS

The CHADS2 may be useful for estimating the risk of stroke or transient ischemic attack in hypertensive patients without known atrial fibrillation.

Left atrial appendage exclusion for atrial fibrillation

Percutaneous left atrial appendage (LAA) closure is being increasingly used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. Several approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. In this article, the published studies on surgical and percutaneous approaches to LAA closure are reviewed, focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management.