Comparing CHA2DS2-VA and CHA2DS2-VASc scores for stroke risk stratification in patients with atrial fibrillation: a temporal trends analysis from the retrospective Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) cohort

Background

Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHA2DS2-VASc risk score (ie. CHA2DS2-VA).

Methods

The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHA2DS2-VA score was compared with the CHA2DS2-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses.

Findings

We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHA2DS2-VA score was inferior to the CHA2DS2-VASc in the early years (-0.333 (95% CI -0.411 to -0.261) and -0.118 (95% CI -0.137 to -0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (-0.093 (95% CI -0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHA2DS2-VA (0.070 (95% CI 0.048-0.087)). The IDI was non-significant in early years (0.0009 (95% CI -0.0024 to 0.0037)), but over time became statistically significant in favor of the CHA2DS2-VA score (0.0022 (95% CI 0.0001-0.0044)). The Cox models fitted with the CHA2DS2-VA and the CHA2DS2-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHA2DS2-VA score emerged (p-value 0.0002).

Interpretation

In 2007-2008 (when females had higher AF-related stroke risks than males), the CHA2DS2-VASc score outperformed the CHA2DS2-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017-2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHA2DS2-VA score.

Funding

This work was supported by the Aarne Koskelo Foundation, The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.

Ischaemic stroke in women with atrial fibrillation: temporal trends and clinical implications

BACKGROUND AND AIMS

Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex.

METHODS

The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed.

RESULTS

Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007-08, female sex was independently associated with a 20%-30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate.

CONCLUSIONS

The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF.

Another possible determinant for ischemic stroke with nonvalvular atrial fibrillation other than conventional oral anticoagulant treatment: The relationship between whole blood viscosity and stroke☆

OBJECTIVES

Patients with nonvalvular atrial fibrillation (NVAF) still experience ischemic stroke despite recommended medications and this could be the consequence of increased whole blood viscosity (WBV). We evaluated the predictive value of WBV for stroke in patients with NVFA despite receiving oral anticoagulant (OAC) therapy.

METHODS

One thousand and forty-three NVAF patients on OAC medication were followed up for median 36.13 ± 18.31 months. WBV was calculated according to the validated de Simone's formula.

RESULTS

WBV was significantly higher in stroke group when compared to non-stroke group at both low shear rate (LSR) and high shear rate (HSR). Multiple regression analysis demonstrated an independent association between WBV and stroke when adjusted for other risk factors.

CONCLUSIONS

WBV appears to be a profitable predictor of ischemic stroke in patients with NVAF receiving OAC.

Stroke and Systemic Thromboembolism according to CHA2DS2-VASc Score in Contemporary Korean Patients with Atrial Fibrillation

PURPOSE

The incidence of stroke and/or systemic thromboembolism (SSE) has not been properly evaluated in well-anticoagulated atrial fibrillation (AF) patients. This study investigated the incidence of SSE according to CHA₂DS₂-VASc score in contemporary well-anticoagulated Korean AF patients.

MATERIALS AND METHODS

From the prospective multicenter COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation (CODE-AF) registry, we identified 9503 patients with non-valvular AF (mean age, 68±8 years; female 35.5%) enrolled between June 2016 and May 2020 with eligible follow-up visits. Stroke incidence in the CODE-AF registry was compared with that in an oral anticoagulant (OAC)-naïve AF cohort from the Korean National Health Insurance database.

RESULTS

The usage rates of OACs and antiplatelet agents were 73.5% (non-vitamin K OACs, 56.4%; warfarin, 17.1%) and 23.8%, respectively. During a mean follow-up period of 26.3±9.6 months, 163 (0.78 per 100 person-years) patients had SSE. The incidence rate (per 100 person-years) of SSE was 0.77 in the total population, 0.26 in low-risk patients [CHA₂DS₂-VASc score 0 (male) or 1 (female)], and 0.88 in high-risk patients (CHA₂DS₂-VASc score ≥2). Contemporary AF patients had a stroke rate that was about one-fifth the stroke rate reported in a Korean OAC-naïve AF cohort. In this cohort, most risk factors for CHA₂DS₂-VASc score showed significant associations with SSE. Female sex was not associated with an increased risk of stroke/SSE in well-anticoagulated AF patients.

CONCLUSION

Contemporary AF patients have a stroke rate about one-fifth that in OAC-naïve AF patients and exhibit different stroke risk factors.

STUDY REGISTRATION

ClinicalTrials.gov (NCT02786095).

Oral Anticoagulation Use in High-Risk Patients Is Improved by Elimination of False-Positive and Inactive Atrial Fibrillation Cases

BACKGROUND

Multiple registries have reported that >40% of high-risk atrial fibrillation patients are not taking oral anticoagulants. The purpose of our study was to determine the presence or absence of active atrial fibrillation and CHA₂DS₂-VASc (Congestive heart failure, Hypertension, Age ≥75 y, Diabetes mellitus, prior Stroke [or transient ischemic attack or thromboembolism], Vascular disease, Age 65-74 y, Sex category) risk factors to accurately identify high-risk atrial fibrillation (CHA₂DS₂-VASc ≥2) patients requiring oral anticoagulants and the magnitude of the anticoagulant treatment gap.

METHODS

We retrospectively adjudicated 6514 patients with atrial fibrillation documented by at least one of: billing diagnosis, electronic medical record encounter diagnosis, electronic medical record problem list, or electrocardiogram interpretation.

RESULTS

After review, 4555/6514 (69.9%) had active atrial fibrillation, while 1201 had no documented history of atrial fibrillation and 758 had a history of atrial fibrillation that was no longer active. After removing the 1201 patients without a confirmed atrial fibrillation diagnosis, oral anticoagulant use in high-risk patients increased to 71.1% (P < .0001 compared with 62.9% at baseline). Oral anticoagulant use increased to 79.7% when the 758 inactive atrial fibrillation patients were also eliminated from the analysis (P < .0001 compared with baseline). In the active high-risk atrial fibrillation group, there was no significant difference in the use of oral anticoagulants between men (80.7%) and women (78.8%) with a CHA₂DS₂-VASc ≥2, or in women with a CHA₂DS₂-VASc ≥3 (79.9%).

CONCLUSIONS

Current registries and health system health records with unadjudicated diagnoses over-report the number of high-risk atrial fibrillation patients not taking oral anticoagulants. Expert adjudication identifies a smaller treatment gap than previously described.

Should We Reintroduce Previous Venous Thromboembolism Into Decision-Making for Anticoagulation in Atrial Fibrillation?

BACKGROUND

We aimed to investigate whether history of venous thromboembolism should be considered a prognostic factor for future thromboembolic events in patients with atrial fibrillation.

METHODS

This was a nationwide cohort study of patients with incident atrial fibrillation from 2000-2017, defined and characterized using Danish health registries. Cox regression analyses were used to calculate hazard ratios and 95% confidence intervals for the outcomes ischemic stroke or systemic embolism, and ischemic stroke, systemic embolism, or venous thromboembolism, according to history of venous thromboembolism. Analyses were adjusted for components of the CHA₂DS₂-VASc score and time-varying use of oral anticoagulation.

RESULTS

The study included 246,313 patients with incident atrial fibrillation, of which 6,516 (2.6%) had previous venous thromboembolism. Patients with previous venous thromboembolism carried an overall similar adjusted risk of ischemic stroke or systemic embolism compared with patients without previous venous thromboembolism (reference; hazard ratio 0.99; 95% confidence interval, 0.90-1.09). When analyzing a composite thromboembolic outcome of ischemic stroke, systemic embolism, or venous thromboembolism, patients with previous venous thromboembolism were at high-risk (hazard ratio 1.76; 95% confidence interval, 1.64-1.90). Similar conclusions were drawn when stratifying by venous thromboembolism subtype, and when restricting to patients with low CHA₂DS₂-VASc scores or the non-anticoagulated subset of the study population.

CONCLUSION

Patients with atrial fibrillation and previous venous thromboembolism carried similar risk of ischemic stroke or systemic embolism compared with patients with atrial fibrillation without previous venous thromboembolism. Nonetheless, patients with previous venous thromboembolism remain a high-risk population due to an excess risk of future venous thromboembolism. Patients and physicians should keep this excess thromboembolic risk in mind when weighing the expected risks and benefits of oral anticoagulation in patients with atrial fibrillation.

Thromboembolic Risk in Nonanticoagulated Patients With Atrial Fibrillation and Valvular Heart Disease

OBJECTIVES

This study sought to describe the risk of thromboembolism in nonanticoagulated atrial fibrillation patients with Evaluated Heartvalves, Rheumatic or Artificial (EHRA) Type 2 valvular heart disease (VHD) <65 or 65 to 74 years of age and with 0 or 1 non-sex comorbidity of the CHA₂DS₂-VASc score.

BACKGROUND

A minor, but important, proportion of patients with atrial fibrillation and VHD beyond moderate-to-severe mitral stenosis and/or a mechanical prosthetic valve, so-called EHRA Type 2 VHD, have 0 or 1 coexisting non-sex comorbidities of the CHA₂DS₂-VASc score, and are therefore not strongly recommended oral anticoagulant therapy according to guidelines. Whether these patients are truly low risk of thromboembolism has not been investigated.

METHODS

This was a cohort study of 55,613 patients identified in nationwide Danish registries from 2000 to 2018, of which 1,907 patients had EHRA Type 2 VHD. Risk of thromboembolism after 1 and 5 years of follow-up were calculated.

RESULTS

At 1 year after atrial fibrillation diagnosis, patients with EHRA Type 2 VHD had a risk of thromboembolism between 1.2% and 1.5%, according to age group (<65 or 65 to 74 years of age), and number of non-sex comorbidities of the CHA₂DS₂-VASc score (0 or 1). Interestingly, in patients with EHRA Type 2 VHD <65 years of age with 0 or 1 comorbidity, the risk was 1.5% (95% confidence interval: 0.7% to 2.8%) and 1.5% (95% confidence interval: 0.6% to 3.4%) at 1 year after the atrial fibrillation diagnosis.

CONCLUSIONS

These observations suggest that in atrial fibrillation patients with EHRA Type 2 VHD, who are not currently recommended oral anticoagulant therapy according to guidelines, the risk of thromboembolism may exceed the level above which oral anticoagulation is considered beneficial.

Differences in Thromboembolic Complications Between Paroxysmal and Persistent Atrial Fibrillation Patients Following Electrical Cardioversion (From the ENSURE-AF Study)

It is unclear if patients with paroxysmal atrial fibrillation (AF) and persistent AF have different outcomes following electrical cardioversion (ECV). ENSURE-AF-a multicenter, prospective, randomized, open-label, blinded-endpoint evaluation trial-compared once-daily edoxaban 60 mg with enoxaparin-warfarin in 2,199 subjects undergoing ECV of nonvalvular AF (NCT02072434). Patients received ≥3 weeks of proper anticoagulation or transesophageal echocardiogram before ECV paroxysmal AF was defined as AF with spontaneous conversion of duration of <7 days; persistent AF was defined as AF lasting ≥7 days without spontaneous conversion. Clinical characteristics and outcomes were compared between subjects based on type of AF present at baseline. In total, 415 subjects had paroxysmal AF; 1,777 had persistent AF. Patients with paroxysmal AF were older (65.8 ± 10.3 vs 63.9 ± 10.5, p = 0.001) with more hypertension (82.7% vs 77.2%, p = 0.01) versus persistent AF patients. Congestive heart failure was more common in persistent AF (46.7%) versus paroxysmal AF (31.3%, p <0.0001). CHA₂DS₂-VASc (score >2: 52.0% vs 49.5%, p = 0.4375) and prior myocardial infarction (6.5% vs 6.8%, p = 0.91) did not significantly differ between groups. After ECV, primary endpoint events were numerically higher in paroxysmal AF versus persistent AF (1.5% vs 0.6%, p = 0.0571), approaching statistical significance. Of note, myocardial infarction was observed in paroxysmal AF (n = 4 vs 0), whereas persistent AF was accompanied by stroke (n = 0 vs 5; p <0.05). In conclusion, patients with paroxysmal AF had more frequent major cardiovascular events than patients with persistent AF. Composite event rates were driven mainly by myocardial infarction in patients with paroxysmal AF and by stroke in those with persistent AF. Overall, the absolute number of events was low after ECV under anticoagulation.

Stroke Risk as a Function of Atrial Fibrillation Duration and CHA 2 DS 2 -VASc Score

Background:

Studies of patients with cardiovascular implantable electronic devices show a relationship between atrial fibrillation (AF) duration and stroke risk, although the interaction with CHA 2 DS 2 -VASc score is poorly defined. The objective of this study is to evaluate rates of stroke and systemic embolism (SSE) in patients with cardiovascular implantable electronic devices as a function of both CHA 2 DS 2 -VASc score and AF duration.

Methods:

Data from the Optum electronic health record deidentified database (2007–2017) were linked to the Medtronic CareLink database of cardiovascular implantable electronic devices capable of continuous AF monitoring. An index date was assigned as the later of either 6 months after device implantation or 1 year after electronic health record data availability. CHA 2 DS 2 -VASc score was assessed using electronic health record data before the index date. Maximum daily AF burden (no AF, 6 minutes–23.5 hours, and >23.5 hours) was assessed over the 6 months before the index date. SSE rates were computed after the index date.

Results:

Among 21 768 nonanticoagulated patients with cardiovascular implantable electronic devices (age, 68.6±12.7 years; 63% male), both increasing AF duration ( P <0.001) and increasing CHA 2 DS 2 -VASc score ( P <0.001) were significantly associated with annualized risk of SSE. SSE rates were low in patients with a CHA 2 DS 2 -VASc score of 0 to 1 regardless of device-detected AF duration. However, stroke risk crossed an actionable threshold defined as >1%/y in patients with a CHA 2 DS 2 -VASc score of 2 with >23.5 hours of AF, those with a CHA 2 DS 2 -VASc score of 3 to 4 with >6 minutes of AF, and patients with a CHA 2 DS 2 -VASc score ≥5 even with no AF.

Conclusions:

There is an interaction between AF duration and CHA 2 DS 2 -VASc score that can further risk-stratify patients with AF for SSE and may be useful in guiding anticoagulation therapy.

Identification of Markers Associated With Development of Stroke in "Clinically Low-Risk" Atrial Fibrillation Patients

Background

Stroke and thromboembolic events may still occur in “clinically low‐risk” atrial fibrillation (AF) patients as categorized by CHA₂DS₂‐VASc score. Our aim was to assess the proportion of “clinically low‐risk” patients using a nongender CHA₂DS₂‐VASc (ie, CHA₂DS₂‐VA) score of 0 to 1 among patients who experienced AF‐associated stroke and to identify markers associated with stroke in “clinically low‐risk” patients.

Methods and Results

We retrospectively recruited nonvalvular AF patients who experienced embolic stroke between 2013 and 2016 from 9 institutes in Korea. AF patients with CHA₂DS₂‐VA score of 0 to 1 at the time of stroke were analyzed and compared with “clinically low‐risk” AF patients without stroke. A total of 3033 subjects with AF‐associated stroke were recruited. Of these, 583 patients (19.2%) had CHA₂DS₂‐VA score of 0 to 1. On multivariate analysis, age (≥60 years), N‐terminal pro B‐type natriuretic peptide (≥300 pg/mL), creatinine clearance (<50 mL/min), and left atrial dimension (≥45 mm) were independently associated with stroke. With the combined application of these 4 factors (collectively, ABCD score) to the “clinically low‐risk” patients, the c‐index was 0.858 (95% CI 0.838–0.877; P<0.001).

Conclusions

The present study suggests a new insight into how additional use of markers can further refine stroke risk differentiation among AF patients initially classified as “clinically low‐risk.”

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT03147911.

Age Threshold for Ischemic Stroke Risk in Atrial Fibrillation

Background and Purpose- Although older age is one of the most important risk factor for stroke in atrial fibrillation (AF), the appropriate age threshold (eg, CHA₂DS₂-VASc score [congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65-74 years, female], 1 point for age 65-74 years, 2 points for age ≥75 years) for increased risk is controversial because actual age thresholds may differ between countries and ethnic groups. We investigated the age threshold for ischemic stroke risk among Asian AF patients. Methods- Using National Health Insurance Service database, including 426 650 oral anticoagulant-naive nonvalvular AF patients from 2005 to 2015, with ≤2 nongender-related CHA₂DS₂-VASc risk scores (CHA₂DS₂-VASc score 0-2 in males, 1-3 in females), we assessed the risk of ischemic stroke in AF patients according to the age. Results- Patients who fulfill the age risk criterion (age, 65-74 years) without other risk factors showed a significantly higher risk of stroke (4.76 per 100 person-years [100PY]; adjusted hazard ratio, 2.25; 95% confidence interval [CI], 2.17-2.36) compared with patients with 1 risk score other than age (1.87/100PY). Patients aged 55 to 59 years with no risk factors showed similar risk of stroke (1.94/100PY; adjusted hazard ratio, 0.95; 95% confidence interval, 0.90-1.00) than patients with 1 risk score (2.06/100PY). Patients aged 65 to 69 years and no other risk factors had similar stroke risk (4.08/100PY; adjusted hazard ratio, 0.93; 95% confidence interval, 0.90-0.97) than patients with 2 nongender-related risk scores (4.42/100PY). Conclusions- Older age is the most important predictor of ischemic stroke in AF, particularly for patients with low to intermediate risk of stroke. These nationwide data suggest lowering the current age threshold (age, ≥65 years) in the CHA₂DS₂-VASc score to age ≥55 years might be appropriate among Asian patients with AF.

Female Sex Is a Risk Modifier Rather Than a Risk Factor for Stroke in Atrial Fibrillation: Should We Use a CHA2DS2-VA Score Rather Than CHA2DS2-VASc?

BACKGROUND

Stroke risk in atrial fibrillation is assessed by using the CHA₂DS₂-VASc score. Sex category (Sc, ie, female sex) confers 1 point on CHA₂DS₂-VASc. We hypothesized that female sex is a stroke risk modifier, rather than an overall risk factor, when added to a CHA₂DS₂-VA (sex-independent thromboembolism risk) score scale.

METHODS

Using 3 nationwide registries, we identified patients with incident nonvalvular atrial fibrillation from January 1, 1997, through December 31, 2015. Patients receiving oral anticoagulant treatment at baseline were excluded, and person-time was censored at the time of treatment initiation (if any). CHA₂DS₂-VA scores were calculated for men and women, and were followed for up to 1 year in the Danish National Patient Registry. The primary outcome was a primary hospital code for ischemic stroke or systemic embolism (thromboembolism). We calculated crude event rates for risk strata as events per 100 person-years. For quantifying absolute risk of stroke, we calculated risks based on the pseudovalue method. Female sex as a prognostic factor was investigated by inclusion as an interaction term on the CHA₂DS₂-VA score to calculate the thromboembolic risk ratio for different score points.

RESULTS

A total of 239 671 patients with atrial fibrillation (48.7% women) contributed to the analyses. The mean ages for women and men were 76.6 years and 70.3 years, respectively; the mean CHA₂DS₂-VA scores were 2.7 for women and 2.3 for men. The overall 1-year thromboembolic rate per 100 person-years for women was 7.3 and 5.7 for men. The 1-year absolute risk of thromboembolism was 0.5% among men and women with a CHA₂DS₂-VA score of 0 and increased up to >7% among very comorbid patients (score >5). The risk ratio (male as reference) across points >1 indicated that women exhibit a higher stroke risk. The interaction was statistically significant (P<0.001).

CONCLUSIONS

Female sex is a risk modifier for stroke in patients with atrial fibrillation. Initial decisions on oral anticoagulant treatment could be guided by a CHA₂DS₂-VA score (ie, excluding the sex category criterion), but the Sc risk component modifies and accentuates stroke risk in women who would have been eligible for oral anticoagulant treatment on the basis of ≥2 additional stroke risk factors.

The safety of NOACs in atrial fibrillation patient subgroups: A narrative review

AIM

Four non-vitamin K oral anticoagulants (NOACs) have been evaluated in clinical trials for the prevention of stroke in patients with atrial fibrillation (AF). Although each of the NOACs have been shown to be at least non-inferior to warfarin for efficacy and safety outcomes, controversy remains over the relative safety of each NOAC inpatient subgroups. This narrative review provides an overview of phase III data on NOAC trials for the prevention of stroke in AF, with a focus on reporting the safety of each agent in key patient subgroups based on age, gender, accumulated risk factors, and primary or secondary prevention of stroke.

METHODS

A comprehensive literature search was completed and, where data permit, analyses of phase III trials of the NOACs are presented for each patient subgroup.

RESULTS

Analyses of key safety outcomes from NOAC trials were completed using primary trial data, including major bleeding and all-cause mortality. The safety of NOACs was generally consistent and favourable compared with warfarin according to patient age, gender, previous history of stroke, and the presence of risk factors for stroke.

CONCLUSIONS

The safety of the NOACs compared with warfarin was generally favourable across different patient subgroups, including those perceived to be at "high risk" for adverse outcomes. However, certain NOACs may be preferable to warfarin in some subgroups, based on indirect analyses.

Changes in oral anticoagulation for elective cardioversion: results from a European cardioversion registry

Aims

In patients with atrial fibrillation (AF) pharmacological or electrical cardioversion may be performed to restore sinus rhythm. The procedure is associated with an increased risk of thromboembolic events, which can be significantly reduced by adequate anticoagulation (OAC). Our aim was to create a partly prospective, partly retrospective cardioversion registry, particularly focusing on OAC strategies in different European countries, and on emerging choice of OAC over time.

Methods

From September 2014 to October 2015, cardioversions due to AF performed in six European city hospitals in five European countries (Hungary: Budapest-1 and -2; Italy: Bari and Pisa; France: Amiens; Spain: Madrid; and Lithuania: Kaunas) were recorded in the registry.

Results

A total of 1101 patients (retrospective/prospective: 679/422, male/female: 742/359, mean age: 67.3 years ± 11.2) were registered. Most of the cardioversions were electrical (97%). Oral anticoagulants were administered in 87% of the patient, the usage of non-VKA oral anticoagulants (NOACs) vs Vitamin K antagonists (VKA) was 31.5% vs 68.5%, respectively. Seventy seven percent of the patients were given oral anticoagulants more than 3 weeks prior to the procedure, and 86% more than 4 weeks after the procedure. When using VKA, international normalized ratio (INR) at cardioversion was above 2.0 in 76% of the cases. A decline in VKA usage (P = 0.033) in elective cardioversion over approximately 1 year was observed. During the observation period, there was an increase in apixaban (P < 0.001), a slight increase in rivaroxaban (P = 0.028) and no changes in dabigatran (P = 0.34) usage for elective cardioversion. There were differences in use of OAC between the countries: Spain used most VKA (89%), while France used least VKA (39%, P < 0.001).

Conclusion

According to current AF guidelines, NOACs are adequate alternatives to VKA for thromboembolic prevention in AF patients undergoing elective cardioversion. Our results indicate that NOAC use is increasing and there is a significant decrease in VKA use.

Viewpoint: Stroke Prevention in Recent Guidelines for the Management of Patients with Atrial Fibrillation: An Appraisal

Formal guidelines play an important role in disseminating the best available evidence knowledge and are expected to provide simple and practical recommendations for the most optimal management of patients with various conditions. Such guidelines have important implications for many disease states, which thereby could be more professionally managed in everyday clinical practice by clinicians with divergent educational backgrounds, and also more easily implemented in wards or outpatient clinics, eliminating inequalities in health care management. In this brief Viewpoint we provide an appraisal on the recommendations pertinent to the prevention of atrial fibrillation-related stroke or systemic thromboembolism, as provided in recently published guidelines for the management of this arrhythmia.

CHA 2 DS 2 -VASc Score (Congestive Heart Failure, Hypertension, Age ≥75 [Doubled], Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack [Doubled], Vascular Disease, Age 65–74, Female) for Stroke in Asian Patients With Atrial Fibrillation

Background and Purpose—

The CHA 2 DS 2 -VASc stroke score (congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65–74, female) is used in most guidelines for risk stratification in atrial fibrillation (AF), but most data for this score have been derived in Western populations. Ethnic differences in stroke risk may be present. Our objective was to investigate risk factors for stroke in AF and application of the CHA 2 DS 2 -VASc score in an Asian AF population from Korea.

Methods—

A total of 5855 oral anticoagulant–naive nonvalvular AF patients aged ≥20 years were enrolled from Korea National Health Insurance Service Sample cohort from 2002 to 2008 and were followed up until December 2013.

Results—

The incidence rates (per 100 person-years) of ischemic stroke were 3.32 in the total population, being 0.23 in low-risk (CHA 2 DS 2 -VASc score 0 [male] or 1 [female]) and 4.59 in high-risk patients (CHA 2 DS 2 -VASc ≥2). Incidence rates of ischemic stroke or the composite thromboembolism end point showed a clear increase with increasing CHA 2 DS 2 -VASc score. On multivariable analysis, significant associations between CHA 2 DS 2 -VASc risk factors and ischemic stroke were observed; however, the significance of vascular disease or diabetes mellitus was attenuated after multivariate adjustment, and female sex (hazard ratio, 0.73; 95% confidence interval, 0.64–0.84) had a lower risk of ischemic stroke than males. Patients who were categorized as low risk consistently had an event rate <1% per year.

Conclusions—

The performance of CHA 2 DS 2 -VASc score in Asians is comparable with that in Western populations. The score shows good performance in defining the truly-low-risk AF patients for stroke/thromboembolism.