The predictive role of CHA2DS2–VASc score between venous thromboembolism and ischemic stroke: a large-scale cohort study

Angiotensin Receptor-neprilysin Inhibitor Versus Renin-angiotensin System Inhibitor for Dementia Risk in Patients With Heart Failure

ABSTRACT

The authors report the impact of angiotensin receptor-neprilysin inhibitor (ARNI) versus renin-angiotensin system inhibitor (RASI) on the management and outcomes in dementia among heart failure (HF) patients as obtained from the real-life nationwide registry. In this study, HF patients between January 1, 2017 and December 31, 2019 were divided into 2 groups, including subjects receiving RASI and ARNI. The incidence rate of dementia was calculated with the unit of 1000 person-years. Cox proportional hazard model was applied for the examination of the hazard ratio, and also presented with 95% confidence interval. Between 2017 and 2019, RASI and ARNI cohorts contain 18,154 subjects. After adjusting with age, sex, comorbidities, and medications, ARNI cohort had a lower risk of dementia (adjusted hazard ratio = 0.83; 95% confidence interval = 0.72, 0.95) than RASI cohort. The authors concluded that use of ARNI was associated with a lower risk of new-onset dementia in patients with HF.

Cholangitis in patients with atrial fibrillation: A retrospective cohort study in Taiwan

The purpose of this study is to investigate whether atrial fibrillation (AF) and cholangitis is associated.This is a propensity-matched retrospective cohort report from the Taiwan National Health Insurance Research Database. We included patients who had AF but didn't have cholangitis, and matched controls between January 1, 2000 and December 31, 2012. The AF cohort comprised 114,572 patients and the comparison cohort comprised 114,572 subjects. All participants were followed up until developing cholangitis, death, or December 31, 2013, whichever came first. The cox model was used to calculate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for comparing the risk of cholangitis in the AF cohort and non-AF cohort.The incidence of cholangitis was higher in patients with AF than in those without AF [4.2 and 2.54 per 1000 person-years; adjusted HR (95%CI), 1.92 (1.54, 2.41)]. Comparing to subjects without AF, patients with AF had higher risk of cholangitis in the subgroup of ≥65 years (adjusted HR = 1.76, 95%CI = 1.40-2.21), female (adjusted HR = 2.51, 95%CI = 1.74-3.63), male (adjusted HR = 1.60, 95%CI = 1.19-2.14), without comorbidities (adjusted HR = 1.79, 95%CI = 1.23-2.61), and with comorbidities (adjusted HR = 1.85, 95%CI = 1.73-1.99).AF is associated with a higher incidence of cholangitis. The need of further investigations is mandatory because of the inherent limitations of observational study.

HAT2CH2 Score Predicts Systemic Thromboembolic Events in Elderly After Cardiac Electronic Device Implantation

Background: The HAT₂CH₂ score has been evaluated for predicting new onset atrial fibrillation, but never for adverse systemic thromboembolic events (STE) in elderly. We aimed to evaluate the HAT₂CH₂ score and comparing to atrial high rate episodes (AHRE) ≥24 h for predicting STE in older patients with cardiac implantable electronic devices (CIED) implantation.

Methods: We retrospective enrolled 219 consecutive patients ≥ 65 years of age undergoing CIED implantation. The primary endpoint was subsequent STE. For all patients in the cohort, the CHA₂DS₂-VASc, C₂HEST, mC₂HEST, HAVOC, HAT₂CH₂ scores and AHRE ≥ 24 h were determined. AHRE was defined as > 175 bpm lasting ≥ 30 s. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent risk of STE.

Results: The median patient age was 77 years, and 61.2% of the cohort was male. During follow-up (median, 35 months), 16 STE occurred (incidence rate, 2.51/100 patient-years; 95% CI, 1.65–5.48). Multiple Cox regression analysis showed that the HAT₂CH₂ score (HR, 3.405; 95% CI, 2.272–5.104; p < 0.001) was an independent predictor for STE. The optimal HAT₂CH₂ score cutoff value was 3, with the highest Youden index (AUC, 0.907; 95% CI, 0.853–0.962; p < 0.001). The STE rate increased with increasing HAT₂CH₂ score (p < 0.001).

Conclusions: This study is the first to show the prognostic value of the HAT₂CH₂ score for STE occurrence in older patients with CIEDs.

The HAT2CH2 score predicts neurologic events in patients with cardiac implantable electronic devices without atrial fibrillation

BACKGROUND

The HAT₂CH₂ score has been evaluated for predicting new-onset atrial fibrillation (AF) in several clinical conditions but never for adverse neurologic events. We aimed to evaluate the HAT₂CH₂ score for predicting neurologic events in patients with cardiac implantable electronic devices (CIED).

METHODS AND RESULTS

We retrospectively reviewed 470 consecutive patients who had CIED without a history of AF. The primary endpoint was a neurologic event, i.e. ischemic stroke or transient ischemic attack. Multivariate Cox regression analysis with time-dependent covariates was used to determine variables associated with independent factors of neurologic events. Patients' median age was 76 years, and 58.7% were male. During follow-up (median 29 months), 21 neurologic events occurred (incidence rate 1.85/100 patient-years, 95% CI 1.03-3.83). Multivariable Cox regression analysis revealed that the HAT₂CH₂ score (HR 3.397, 95% CI 2.357-4.895, p < 0.001) was an independent predictor for neurologic events. Optimal HAT₂CH₂ score cut-off value was 3, with highest Youden index (AUC, 0.923; 95% CI, 0.886-0.959; p < 0.001). The rate of neurologic events increased significantly with increasing HAT₂CH₂ score (p < 0.001).

CONCLUSIONS

The HAT₂CH₂ score can predict the occurrence of neurologic events in patients with CIED with no history of AF. Further study of the utility of the HAT₂CH₂ score for the assessment of neurologic event risk and the selection of anti-thrombotic therapy in patients with CIED without prior AF is warranted.

Risk Factors of Arterial Events in Patients with Venous Thromboembolism: A Systematic Review and Meta-Analysis

BACKGROUND

 If recent studies suggested that arterial ischemic events in patients with venous thromboembolism (VTE) are more frequent than in the general population without VTE, whether patients with VTE have different risk factors of arterial events than classic known cardiovascular risk factors remain undefined. Through this systematic review and meta-analysis, we aimed to identify risk factors of arterial ischemic events in patients with VTE.

METHODS

 We searched PubMed, EMBASE, and Cochrane databases to identify cohort studies published between January 1, 2000, and December 31, 2020, reporting risk factors of arterials ischemic events in patients with VTE. Random-effect models meta-analysis served to get the pooled hazard ratio (HR) and 95% confidence interval (CI) of each risk factor identified.

RESULTS

 We screened 1,467 records of which 18 were finally included in systematic review and 10 in meta-analyses. Adjusted HR for 9 factors were included in meta-analysis. Male gender (HR: 1.38; 95% CI: 1.28-1.49), diabetes (HR: 1.65; 95% CI: 1.28-2.12), hypertension (HR: 1.38; 95% CI: 1.04-1.84), previous atherothrombotic event (HR: 3.22; 95% CI: 1.12-9.23), chronic kidney disease (HR: 1.41; 95% CI: 1.05-1.88), cancer (HR: 1.72; 95% CI: 1.41-2.09), and unprovoked VTE (HR: 1.88; 95% CI: 1.37-2.57) were the identified risk factors of arterial events in VTE population after meta-analysis.

CONCLUSION

 Risk factors of arterial events in patients with VTE include usual cardiovascular risk factors and other risk factors that are related to VTE such as cancer and unprovoked VTE.

Frequency and incidence of arterial events in patients with venous thromboembolism compared to the general population: A systematic review and meta-analysis of cohort studies

BACKGROUND

Recent literature hypothesized that patients with venous thromboembolism (VTE) are at increased risk of developing arterial ischemic events than general population without VTE. However, data summarizing the epidemiology of arterial events among VTE population compared to the general population are lacking.

METHODS

We conducted a systematic review and meta-analysis from current literature. PubMed, EMBASE, and Cochrane databases were searched between Jan 1, 2000, and December 31, 2020. Eligible studies were observational cohort studies published in English on arterial ischemic events in patients with VTE. Pooled effect size estimates and their 95% confidence intervals were obtained through random-effect models meta-analysis.

RESULTS

Twenty-eight observational studies enrolling 352,014 patients were identified and included. The pooled frequency of all arterial events was 6.1% (95% CI: 3.7-9.1) in patients with VTE and was significantly higher than the pooled frequency of 5.0% (95% CI: 3.1-7.2) found in controls, with a pooled risk ratio (RR) of 1.20 (95% CI: 1.01-1.44; p = 0.0422). The pooled incidence of all arterial events in patients with VTE was 11.3‰ per patient-year (95% CI: 4.6-18.0), and was significantly higher than the 9.2‰ per patient-year (95% CI: 2.0-16.4) obtained in controls (Incidence rate ratio, IRR: 1.32; 95% CI: 1.08-1.61; p = 0.0103). The pooled frequency and pooled incidence of arterial events were also higher in patients with unprovoked VTE than in patients with provoked VTE (RR: 2.12; 95% CI: 1.38-3.24; p = 0.0042; and IRR: 2.26, 95% CI: 1.45-3.49; p = 0.0032).

CONCLUSION

The frequency and incidence of arterial events in patients with VTE are considerably higher than in the general population, without VTE. Further studies are urgently needed to understand these differences and reduce the burden related to these diseases.

FUNDING

None.

A novel risk model to predict first-ever ischemic stroke in heart failure with reduced ejection fraction

Patients with heart failure are at increased risk for ischemic stroke. We aim to develop a more accurate stroke risk prediction tools identify high-risk patients with heart failure with reduced ejection fraction (HFrEF). Patient data were extracted retrospectively from the electronic medical database between January 2009 and February 2019. Univariate and multivariate Cox regression analysis were performed to identify independent predictors, which were utilized to construct a nomogram for predicting ischemic stroke. AUROC analysis was used to compare the prognostic value between the new risk score and CHADS₂/CHA₂DS₂-VASc scores. In 6087 patients with HFrEF, the risk of first-ever ischemic stroke was 5.8% events/pts-years (n=468) during 8007.2 person-years follow-up. A nomogram constructed by integrating 6 variables, including age, atrial fibrillation (AF), deep vein thrombosis (DVT), d-dimer, anticoagulant use and spontaneous echocardiographic contrast (SEC)/left ventricular thrombus (LVT), exhibited a greater area under the curve of 0.727, 0.728 and 0.714 than that by CHADS₂ score (0.515, 0.522 and 0.540), and by CHA₂DS₂-VASc score (0.547, 0.553 and 0.562) for predicting first-ever ischemic stroke at hospitalization, 30-day and 6-month follow-up (all p<0.001). This novel stroke risk score performed better than existing CHADS₂/ CHA₂DS₂-VASc scores and showed improvement in predicting first-ever ischemic stroke in HFrEF patients.

Comparison of CHA2DS2-VASc and C2HEST scores for predicting the incidence of atrial fibrillation among patients with end-stage renal disease

PURPOSE

The authors have studied assessment of CHA2DS2-VASc score versus C2HEST score in atrial fibrillation risk prediction in end-stage renal disease patients.

METHODS

The authors conducted this study by Longitudinal Health Insurance Database 2000. The authors totally enrolled 4,601 end-stage renal disease patients. The predictive capability of atrial fibrillation by using CHA2DS2-VASc and C2HEST score was estimated by area under the receiver operating characteristic curve (AUROC).

RESULTS

The AUROC for CHA2DS2-VASc score in predicting atrial fibrillation events was 0.5786, and AUROC for C2HEST score for atrial fibrillation prediction was 0.5983.

CONCLUSION

Both scores yield almost identical AUROC values implying no difference in predictive power. Further work is warranted to verify the prognostic value of the current scores.

Prediction of acute coronary syndrome, ischemic stroke, and mortality in patients with heart failure: a comparison of CHA2DS2-VASc and AHEAD scores

PURPOSE

To compare the predictive capacity of the CHA₂DS₂-VASc and AHEAD scores in predicting acute coronary syndrome (ACS), ischemic stroke (IS), and mortality in patients with heart failure (HF).

METHODS

A total of 404,635 patients hospitalized for HF between 2000 and 2011 were recruited from a large national database in Taiwan. The predictive value of both scores was evaluated by analysis of the area under the receiver operating characteristic curve (AUROC), and the difference in their discriminative capacity was assessed using the DeLong test.

RESULTS

The AUROC for the CHA₂DS₂-VASc score was significantly higher than that for the AHEAD score in predicting ACS and IS: 0.53 (95% CI = 0.53-0.54) versus 0.51 (95% CI = 0.51-0.52) for ACS, and 0.57 (95% CI = 0.56-0.57) versus 0.52 (95% CI = 0.51-0.52) for IS, respectively (all DeLong tests p < 0.001). By contrast, for mortality risk, the AUROC was significantly lower for the CHA₂DS₂-VASc score (0.56, 95% CI = 0.55-0.56) than the AHEAD score (0.60, 95% CI = 0.59-0.60; DeLong test p < 0.001).

CONCLUSIONS

The ability of the CHA₂DS₂-VASc score to predict macrovascular complications (ACS and IS) in HF patients was higher than that of AHEAD.

Atrial fibrillation, an obscured cause of pulmonary embolism can be revealed by adding to Wells criteria

Among the various clinical scoring methods used for the prediagnosis of pulmonary embolism (PE), Wells criteria is the most common. It relies on the findings and story of deep venous thrombosis (DVT), PE and malignancy. It is known that atrial fibrillation (AF) is a risk factor for PE like as DVT or malignancy. We aimed to evaluate the possibility of diagnosing more patients with PE by including AF in the Wells criteria. This prospective study included 250 patients admitted to the emergency department with PE findings. Wells scoring and Wells scoring with AF were performed for each patient. Out of 250 patients, 165 patients were diagnosed as PE. Wells score was >4 in 61.8% of patients with PE and 28.2% of patients without PE. Out of false negative 63 patients with PE, 21 of them had AF. According to Wells scoring with AF the score of 148 (89.7%) patients with PE diagnosis was ≥3, whereas the score of 45 (52.9%) patients without PE was ≥3. AF was detected in 15.8% of patients with PE. The sensitivity of Wells score with AF was significantly higher than that of the Wells score (p<0.001). As a result, when AF, which is one of an important PE cause such as DVT and malignancy, was added to the Wells criteria, an additional correct PE estimate was obtained in 46 patients. We recommend using Wells score with AF since prediagnosing more PE is more valuable than having some false negative PE predictions.

Comparison of CHA2DS2-VASc and AHEAD scores for the prediction of incident dementia in patients hospitalized for heart failure: a nationwide cohort study

This study explores the use of the CHA₂DS₂-VASc and the AHEAD scores to predict incident dementia in patients with heart failure (HF) who need hospitalization. We used a large national database to study 387,595 adult patients hospitalized for HF from Taiwan. This registration cohort was followed to document the cumulative incidence of dementia. The area under the curve of receiver operating characteristics (AUROC) was used to evaluate the discriminative ability of CHA₂DS₂-VASc and AHEAD scores in predicting dementia, whereas the DeLong test was used to examine the difference between the predictive capacity. A higher CHA₂DS₂-VASc and AHEAD scores appear to be more strongly associated with a higher incidence of dementia. The AUROC for CHA₂DS₂-VASc score in predicting dementia (0.61, 95% CI = 0.60-0.61) is significantly higher than the AHEAD score (0.55, 95% CI = 0.54-0.55) (DeLong test p < 0.001). A significantly higher ability, by AUROC, of CHA₂DS₂-VASc score to predict new-onset dementia in patients hospitalized for HF is found.