Mortality prediction using CHADS2/CHA2DS2-VASc/R2CHADS2 scores in systolic heart failure patients with or without atrial fibrillation

Predictive Value of CHADS2, CHA2DS2-VASc and R2-CHADS2 Scores for Short- and Long-Term Major Adverse Cardiac Events in Non-ST-Segment Elevation Myocardial Infarction

BACKGROUND

Non-ST-elevation myocardial infarction (NSTEMI) carries a poor prognosis, and accurately prognostication has significant clinical importance. In this study, we analyzed the predictive value of the CHADS2, CHA2DS2-VASc, and R2-CHADS2scores for major adverse cardiac events (MACE) following percutaneous coronary intervention (PCI) in patients with NSTEMI using data from a prospective multicenter registry.Methods and Results: The registry included 440 consecutive patients with NSTEMI and coronary artery disease who underwent successful PCI. Patients were clinically followed for up to 3 years or until the occurrence of MACE. MACE was defined as a composite of all-cause death and nonfatal MI. During the follow-up period, 55 patients (12.5%) experienced MACE. Risk analysis of MACE occurrence, adjusted for the multivariable model, demonstrated a significant increase in risk with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores. Kaplan-Meier analysis showed a higher incidence of MACE in patients with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores, both in the short- and long-term periods.

CONCLUSIONS

Patients with NSTEMI and higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores displayed a greater incidence of MACE.

Efficacy of CHA2DS2-VASc scores in predicting chronic kidney disease risk in patients treated in cardiac intensive care units

The CHA2DS2 -VASc score is a vital clinical tool for evaluating thromboembolic risk in patients with atrial fibrillation (AF). This study investigated the efficacy of the CHA2DS2 -VASc score in a cohort of 737 heterogeneous patients (mean age: 63 years) receiving care in cardiac intensive care units (CICUs), with a creatinine-based estimated glomerular filtration rate (eGFR) of ≥60 mL/min/1.73 m2 upon admission and discharge. Incident chronic kidney disease (CKD) was defined as the emergence of a new-onset eGFR<60 mL/min/1.73 m2, accompanied by a decline of >5 mL/min/1.73 m2 compared to that at discharge. The primary endpoint was the incidence of CKD, and the secondary endpoints included all-cause mortality, cardiovascular events, and progression to end-stage kidney disease. In this cohort, 210 (28 %) patients developed CKD. Multivariate analyses revealed that CHA2DS2 -VASc score was a significant independent predictor of incident CKD, regardless of the presence of AF. Integration of CHA2DS2 -VASc scores with eGFR enhanced the predictive accuracy of incident CKD, as evidenced by the improved C-index, net reclassification improvement, and integrated discrimination improvement values (all p < 0.05). Over the 12-month follow-up period, a composite endpoint was observed in 61 patients (8.3 %), with elevated CHA2DS2 -VASc scores being independently associated with this endpoint. In conclusion, CHA2DS2-VASc scores have emerged as robust predictors of both CKD incidence and adverse outcomes. Their inclusion substantially refined the 12-month risk stratification of patients with preserved renal function hospitalized in the CICUs.

Association between R2CHA2DS2-VASc score and three-vessel coronary artery disease in a large population at high cardiovascular risk

Coronary artery disease (CAD), particularly three-vessel coronary disease (3VD), is the main cause of death in industrialized countries. Chronic kidney disease is an independent risk factor for CAD. The CHA2DS2-VASc score shows a good ability to predict CV events in high-risk population independently from atrial fibrillation. The aim of the present study was to evaluate the association between the R2CHA2DS2-VASc score and 3VD in a population of patients at high cardiovascular risk. Monocentric prospective study evaluated 1017 patients undergoing coronary angiography. The R2CHA2DS2-VASc score was obtained by adding 2 points to the CHA2DS2-VASc score in case of eGFR < 60 ml/min/1.73m2. Coronary lesions causing ≥ 50% reduction of a major epicardial vessel diameter were considered significant. Patients were grouped based on R2CHA2DS2-VASc tertiles and according to the severity of CAD: 3VD vs No-3VD. The 3VD group showed significantly higher R2CHA2DS2-VASc score than the No-3VD group (4.20 ± 2.18 vs 3.36 ± 2.06, p < 0.001). The risk of 3VD increased by 21% for every 1-point increase in the score (OR 1.21; 95% CI 1.13-1.28, p < 0.001). The prevalence of 3VD was higher among patients belonging to higher tertiles of R2CHA2DS2-VASc (17.2% vs 26.7% vs 33.6% for first, second, and third tertile respectively, p < 0.001) with a risk more than doubled for the third tertile compared to the first one (OR 2.45; 95% CI 1.71-3.49, p < 0.001). The R2CHA2DS2-VASc score is independently associated with 3VD in patients at high cardiovascular risk. The score could be considered a useful tool for clinicians to identify patients who are at high risk of 3VD.

Clinical Characteristics and Predictors of Long-Term Prognosis of Acute Peripheral Arterial Ischemia Patients Treated Surgically

BACKGROUND

Acute peripheral arterial ischemia is a rapidly developing loss of perfusion, resulting in ischemic clinical manifestations. This study aimed to assess the incidence of cardiovascular mortality in patients with acute peripheral arterial ischemia and either atrial fibrillation (AF) or sinus rhythm (SR).

METHODS

This observational study involved patients with acute peripheral ischemia treated surgically. Patients were followed-up to assess cardiovascular mortality and its predictors.

RESULTS

The study group included 200 patients with acute peripheral arterial ischemia and either AF (n = 67) or SR (n = 133). No cardiovascular mortality differences between the AF and SR groups were observed. AF patients who died of cardiovascular causes had a higher prevalence of peripheral arterial disease (58.3% vs. 31.6%, p = 0.048) and hypercholesterolemia (31.2% vs. 5.3%, p = 0.028) than those who did not die of such causes. Patients with SR who died of cardiovascular causes more frequently had a GFR <60 mL/min/1.73 m² (47.8% vs. 25.0%, p = 0.03) and were older than those with SR who did not die of such causes. The multivariable analysis shows that hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was the predisposing factor for such mortality.

CONCLUSIONS

Cardiovascular mortality of patients with acute ischemia did not differ between patients with AF and SR. Hyperlipidemia reduced the risk of cardiovascular mortality in patients with AF, whereas in patients with SR, an age of ≥75 years was a predisposing factor for such mortality.

One-Year Mortality after Hemodialysis Initiation: The Prognostic Role of the CHA2DS2-VASc Score

BACKGROUND

CKD is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2-VASc is a score used in patients with atrial fibrillation to predict thromboembolic risk; it also appears to be useful to predict mortality risk. The aim of the study was to evaluate CHA2DS2-VASc scores as a tool for predicting one-year mortality after hemodialysis is started and for identifying factors associated with higher mortality.

METHODS

Retrospective analysis of patients who started hemodialysis between January 2014 and December 2019 in Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within one year of hemodialysis initiation. The CHA2DS2-VASc score was calculated at the start of hemodialysis.

RESULTS

Of 856 patients analyzed, their mean age was 68.3 ± 15.5 years and the majority were male (61.1%) and Caucasian (84.5%). Mortality within one-year after starting hemodialysis was 17.8% (n = 152). The CHA2DS2-VASc score was significantly higher (4.4 ± 1.7 vs. 3.5 ± 1.8, p < 0.001) in patients who died and satisfactorily predicted the one-year risk of mortality (AUC 0.646, 95% CI 0.6-0.7, p < 0.001), with a sensitivity of 71.7%, a specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2DS2-VASc ≥3.5 (adjusted HR 2.24 95% CI (1.48-3.37), p < 0.001) and central venous catheter at dialysis initiation (adjusted HR 3.06 95% CI (1.93-4.85)) were significant predictors of one-year mortality.

CONCLUSION

A CHA2DS2-VASc score ≥3.5 and central venous catheter at hemodialysis initiation were predictors of one-year mortality, allowing for risk stratification in hemodialysis patients.

Validation of CHA2DS2 VASc Score Predictability of Stroke and Systemic Embolization in a Middle Eastern Population with AF: The Jordan Atrial Fibrillation (JoFib) Study

Background and Purpose

CHA2DS2-VASc score is one of the most widely used scoring systems to assess the risk of systemic embolization and stroke in patients suffering from atrial fibrillation (Afib); furthermore, it is important in guiding their treatment. This study aimed to evaluate the predictivity of this score in the Jordanian population, build a deeper understanding of patients' demographic and risk factors, and assess the usefulness of anticoagulation as a preventive measure.

Methods

A total of 2020 patients with Afib registered in the Jordanian Atrial Fibrillation (JoFib) registry were enrolled in this study. All patients were followed up for 1 year to assess their susceptibility to develop cerebrovascular accident (CVA) and systemic embolism (SE). The association between CHA2DS2-VASc score and risk of development of stroke or systemic embolization was analyzed based on bivariate and adjusted multivariate analyses. The ROC curve was used to assess the predictivity of the CHA2DS2-VASc score.

Results

The mean age of the study population was 67.8 years; 45.8% were males, and 81.8% were on anticoagulants. And, 71.8% had a CHA2DS2-VASc score of ≥3. During the follow-up period of 1 year; 69 developed new CVA (mean age, 72.8 years), and 9 developed SE. A total of 276 patients died; 18 patients died (6.5% out of all deceased)% from CVA. A moderate predictive power of the CHA2DS2-VASc score was demonstrated through ROC curve analysis with C statistics of 0.689 CI (0.634 to 0.744) for predicting the development of SE or CVA at 1 year.

Conclusion

CHA2DS2-VASc showed a moderate predictivity of stroke, SE, and all-cause mortality at 1 year. The study suggested disregarding gender differences in deciding to initiate anticoagulant therapy.

Optimizing exercise testing‐based risk stratification to predict poor prognosis after acute heart failure

AIMS

The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO₂ ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO₂ and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era.

METHODS AND RESULTS

We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO₂ and HFSS in predicting primary outcomes. The median follow-up period was 3.3 years. The primary outcome occurred in 57 participants. Peak VO₂ outperformed HFSS when predicting 1 year (0.81 vs. 0.61; P = 0.017) and 2 year (0.78 vs. 0.58; P < 0.001) major outcomes. The cutoff peak VO₂ for predicting a 20% risk of a major outcome within 2 years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO₂ , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes.

CONCLUSIONS

Optimizing the cutoff value of peak VO₂ is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.

CHA2DS2-VASc and R2CHA2DS2-VASc scores predict mortality in high cardiovascular risk population

BACKGROUND

The CHA₂ DS₂ -VASc score, widely used to estimate cardioembolic risk in patients with atrial fibrillation (AF), appears to be useful also in predicting vascular adverse events and death in different sets of patients without AF. The R₂ CHA₂ DS₂ -VASc score, which includes renal impairment, allows a better prediction of death and thromboembolism in patients without AF. The aims of our study were to assess, in a large sample of patients at high cardiovascular (CV) risk, (i) the correlation between CHA₂ DS₂ -VASc and R₂ CHA₂ DS₂ -VASc with all-cause mortality, and (ii) to compare the performances of CHA₂ DS₂ -VASc and R₂ CHA₂ DS₂ -VASc in predicting all-cause mortality.

METHODS

In this single-centre prospective observational study, conducted at the Research Hospital 'Casa Sollievo della Sofferenza' between June 2016 and December 2018, 1017 CV patients at high risk of undergoing coronary angiography were enrolled.

RESULTS

CHA₂DS₂-VASc and R₂ CHA₂ DS₂ -VASc scores significantly associated with all-cause mortality. For each one-point increase in CHA₂ DS₂ -VASc or R₂ CHA₂ DS₂ -VASc scores, mortality increased by almost 1.5-fold. The R₂ CHA₂ DS₂ -VASc score (C-statistic = 0.71; 95% CI = 0.65-76) outperformed the CHA₂ DS₂ -VASc score (C-statistic = 0.66; 95% CI = 0.61-0.71) in predicting 4-year mortality (delta C-statistic = 0.05; 95% CI = 0.02-0.07). The better predictive ability of the R-CHA₂ DS₂ -VASc score was also demonstrated by an IDI = 0.027 (95% CI = 0.021-0.034, p < .00001) and a relative IDI = 62.8% (95% CI = 47.9%-81.3%, p < .00001). The R₂ CHA₂ DS₂ -VASc score correctly reclassified the patients with a NRI = 0.715 (95% = 0.544-0.940, p < .00001).

CONCLUSIONS

The CHA₂DS₂-VASc and R₂ CHA₂ DS₂ -VASc scores are useful predictors of all-cause mortality in subjects at high CV risk, with the R₂ CHA₂ DS₂ -VASc score being the best performer.

Prognostic significance of CHADS2 and CHA2DS2-VASc scores to predict unfavorable outcomes in hospitalized patients with COVID-19

Introduction: Owing to the imposed burden of the coronavirus disease 2019 (COVID-19),the need for stratifying the prognosis of patients has never been timelier. Hence, we aimed to ascertain the value of CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (one point for male instead of female) scores to predict unfavorable outcomes in COVID-19 patients. Methods: We enrolled consecutive patients above 18 years of age with confirmed COVID-19,who were admitted between February 16 and November 1, 2020. The primary endpoint of this study was three-month all-cause mortality. The secondary endpoints were considered four major in-hospital clinical features, including acute respiratory distress syndrome, cardiac injury,acute kidney injury, and mechanical ventilation. Results: A total of 1,406 hospitalized COVID-19 patients were studied, among which 301(21.40%) patients died during the follow-up period. Regarding the risk scores, CHADS 2≥1,CHA2DS2-VASc≥2, and CHA2DS2-VASc-M≥2 were significantly associated with mortality. The performance of all risk scores for predicting mortality was satisfactory (area under the curve:0.668, 0.668, and 0.681, respectively). Appraising secondary endpoints, we found that all three risk scores were associated with increased risk of acute respiratory distress syndrome, cardiac injury, acute kidney injury, and mechanical ventilation. Lastly, we revealed that all risk scores were significantly correlated with serum levels of laboratory biomarkers. Conclusion: Our analysis illustrated that the CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-Mscores could aid prognostication of unfavorable outcomes in COVID-19 patients. Therefore,these easily calculable methods could be integrated into the overall therapeutic strategy to guide the COVID-19 management more accurately.

Choice of antithrombotic therapy for patients with atrial fibrillation undergoing carotid angioplasty and stenting: a nationwide population-based study

Nonvalvular atrial fibrillation (NVAF) and carotid stenosis are important risk factors for stroke. Carotid angioplasty and stent placement (CAS) is recommended for patients with symptomatic high-grade carotid stenosis. The optimal medical management for patients with NVAF after CAS remains unclear. We aimed to clarify this issue using real-world data from the Taiwanese National Health Insurance Research Database (NHIRD). In total, 2116 consecutive NVAF patients who received CAS between January 1, 2010, and December 31, 2016, from NHIRD were divided into groups based on post-procedure medication as follows: only antiplatelet agent (OAP, n = 587); only anticoagulation agent (OAC, n = 477); dual antiplatelet agents (DAP, n = 49); and a combination of antiplatelet and anticoagulation agents (CAPAC, n = 304). Mortality, vascular events, and major bleeding episodes were compared after matching with the Charlson comorbidity index and CHA2DS2-VASc score. The CAPAC and the OAC groups had lower mortality rates than the OAP group (P = 0.0219), with no statistical differences in major bleeding, ischemic stroke, or vascular events. Conclusively, OAC therapy after CAS appears suitable for NVAF patients. CAPAC therapy might be considered as initial therapy or when there is concern about vascular events.

Does CHA2DS2-VASc score predict mortality in chronic kidney disease?

Chronic kidney disease (CKD) is a leading cause of morbidity and mortality worldwide. Assessment of cardiovascular (CV) and all-cause mortality in CKD patients is of particular importance. CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes, prior stroke, vascular disease, age 65-74 years, and sex) score was originally formulated to predict the annual thromboembolic risk in patients with nonvalvular atrial fibrillation (AF). The calculation of R2CHADS2 and R2CHA2DS2VASc scores awarded an additional 2 points for CrCl < 60 mL/min and GFR < 60 mL/min/1.73 m². Recent studies have investigated whether CHA2DS2-VASc and R2CHADS ± VASC scores could be used to predict CV or all-cause mortality in patients with CKD. CHA2DS2-VASc score was proven to be a significant predictor of CV and all-cause mortality in CKD patients, and a higher CHA2DS2-VASc score was associated with increased mortality. These findings are quite promising, and they may help physicians to identify high-risk groups in this population.

Using CHADS2, R2CHADS2, CHA2DS2-VASc score for mortality prediction in patients with abnormal low and high ankle-brachial index

Abnormal low and high ankle brachial index (ABI) is regarded as peripheral artery disease (PAD) which has extremely high morbidity and mortality. How to identify high-risk PAD patients with increased mortality is very important to improve the outcome. CHADS₂, R₂CHADS₂, and CHA₂DS₂-VASc score are clinically useful scores to evaluate the annual risk of stroke in patients with atrial fibrillation. However, there was no literature discussing the usefulness of these scores for cardiovascular (CV) and all-cause mortality prediction in the patients with abnormal ABI. This longitudinal study enrolled 195 patients with abnormal low (< 0.9) and high ABI (> 1.3). CHADS₂, R₂CHADS₂, and CHA₂DS₂-VASc score were calculated for each patient. CV and all-cause mortality data were collected for outcome prediction. The median follow-up to mortality was 90 months. After multivariate analysis, CHADS₂, R₂CHADS₂, and CHA₂DS₂-VASc score were significant predictors of CV and all-cause mortality (all P < 0.001). CHA₂DS₂-VASc score had a better additive predictive value than CHADS₂ and R₂CHADS₂ score for CV mortality prediction. R₂CHADS₂ and CHA₂DS₂-VASc score had better additive predictive values than CHADS₂ score for all-cause mortality prediction. In conclusion, our study is the first study to investigate the usefulness of CHADS₂, R₂CHADS₂, and CHA₂DS₂-VASc score for mortality prediction in patients with abnormal ABI. Our study showed all three scores are significant predictors for CV and all-cause mortality although there are some differences between the scores. Therefore, using the three scoring systems may help physicians to identify the high-risk PAD patients with increased mortality.

Prognostic impact of renal dysfunction on embolic stroke of undetermined source-Role beyond CHA2 DS2 -VASc score: Results from Taiwan Stroke Registry

BACKGROUND AND PURPOSE

The CHA₂ DS₂ -VASc score has immense prognostic value in patients with embolic stroke of undetermined source (ESUS). We aimed to determine the usefulness of advanced renal dysfunction and its addition to the CHA₂ DS₂ -VASc score in improving predictive accuracy.

METHODS

In total, 3775 ESUS patients were enrolled from a nationwide hospital-based prospective study. Advanced renal dysfunction was defined as estimated glomerular filtration rate <30 ml/min per 1.73 m² or patients under dialysis. Clinical outcomes included recurrent stroke and 1-year all-cause mortality. Poor functional outcome was defined as a modified Rankin Scale >2 at first-, third-, and sixth-month post-stroke. The renal (R)-CHA₂ DS₂ -VASc score was derived by including advanced renal dysfunction in the CHA₂ DS₂ -VASc score. Risk stratification improvement after including advanced renal dysfunction was assessed using C statistic, integrated discrimination improvement (IDI), and category-free net reclassification index (NRI).

RESULTS

After adjusting for confounding factors and CHA₂ DS₂ -VASc score, advanced renal dysfunction showed significant associations with all-cause mortality (HR: 2.88, 95% CI: 1.92-4.34) and poor functional outcome at third- (OR: 2.69, 95% CI: 1.47-4.94) and sixth-month post-stroke (OR: 2.67, 95% CI: 1.47-4.83). IDI and NRI showed that incorporating advanced renal dysfunction significantly improved risk discrimination over the original CHA₂ DS₂ -VASc score. R-CHA₂ DS₂ -VASc score ≥2 increased risk by 1.94-fold (95% CI: 1.15-3.27) for all-cause mortality, and ≥4 increased risk by 1.62-fold (95% CI: 1.05-2.50) of poor functional outcome at third-month post-stroke and by 1.81-fold (95% CI: 1.19-2.75) at sixth-month post-stroke.

CONCLUSIONS

Advanced renal dysfunction was significantly associated with clinical and functional outcomes in ESUS patients and may improve prognostic impact of the CHA₂ DS₂ -VASc score.

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

BACKGROUND

Heart failure (HF) patients have high risks of thromboembolic events regardless of the category of left ventricular ejection fraction. We sought to assess whether the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, and female sex) and ATRIA (anticoagulation and risk factors in atrial fibrillation) scores could predict clinical outcomes in HF patients with preserved ejection fraction (HFpEF).

METHODS

We performed a retrospective analysis in a multicenter, America-based population of 1766 HFpEF patients who were stratified according to their baseline CHA2DS2-VASc or ATRIA scores. The CHA2DS2-VASc and ATRIA scores were analyzed as a continuous or categorical variable. The outcomes were stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization.

RESULTS

When score was considered as a continuous variable, each point increase in CHA2DS2-VASc was associated with increased risks of stroke (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 1.06-1.41, C-index = 0.62), HF hospitalization (HR 1.08, 95% CI = 1.01-1.17, C-index = 0.59), and any hospitalization (HR 1.06, 95% CI = 1.01-1.11, C-index = 0.57) whereas each point increase in ATRIA was associated with increased risks of stroke (HR 1.11, 95% CI = 1.01-1.21, C-index = 0.62), all-cause death (HR 1.09, 95% CI = 1.05-1.14, C-index = 0.61), cardiovascular death (HR 1.08, 95% CI = 1.02-1.14, C-index = 0.59), HF hospitalization (HR 1.07, 95% CI = 1.03-1.12, C-index = 0.58), and any hospitalization (HR 1.04, 95% CI = 1.01-1.06, C-index = 0.57). When score was regarded as a categorical variable, compared with controls, CHA2DS2-VASc ≥ 4 was associated with increased risks of stroke and hospitalization whereas ATRIA ≥ 8 was associated with increased risks of stroke, death, and hospitalization.

CONCLUSIONS

The CHA2DS2-VASc and ATRIA scores are associated with risks of adverse outcomes in HFpEF patients. However, the predictive abilities of CHA2DS2-VASc and ATRIA are modest, and their clinical utility in HFpEF remains to be determined.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov . Identifier: NCT00094302.

Risk profiling in patients undergoing penile prosthesis implantation

Penile prosthesis implantation is the gold standard of surgical therapy for patients with medication-refractory erectile dysfunction. However, this umbrella definition includes significant heterogeneity and associated risk profiles that should be candidly discussed and addressed perioperatively. Factors associated with operative success and patient satisfaction are often surgery specific; however, risk profiling via patient selection, preoperative optimization, proper device selection, and intraoperative consideration are highly correlated. Some examples of common risk profiles include comorbidity(ies) such as cardiovascular disease, diabetes mellitus, prior abdominal surgery, Peyronie's disease, and psychological risk factors. Similarly, integration of surgeon- and patient-amenable characteristics is key to decreasing risk of infection, complication, and need for revision. Finally, patient risk profiling provides a unique context for proper device selection and evidence-based intraoperative considerations.

Using CHADS2 and CHA2DS2-VASc scores for mortality prediction in patients with chronic kidney disease

Chronic kidney disease (CKD) is a public health issue and is associated with high morbidity and mortality. How to identify the high-risk CKD patients is very important to improve the long-term outcome. CHADS₂ and CHA2DS2-VASc scores are clinically useful scores to evaluate the risk of stroke in patients with atrial fibrillation. However, there was no literature discussing about the usefulness of CHADS₂ and CHA2DS2-VASc scores for cardiovascular (CV) and all-cause mortality prediction in CKD patients. This longitudinal study enrolled 437 patients with CKD. CHADS₂ and CHA2DS2-VASc scores were calculated for each patient. CV and all-cause mortality data were collected for long-term outcome prediction. The median follow-up to mortality was 91 (25th–75th percentile: 59–101) months. There were 66 CV mortality and 165 all-cause mortality. In addition to age and heart rate, CHADS₂ and CHA₂DS₂-VASc scores (both P value < 0.001) were significant predictors of CV and all-cause mortality in the multivariate analysis. Besides, in direct comparison of multivariate model, basic model + CHA₂DS₂-VASc score had a better additive predictive value for all-cause mortality than basic model + CHADS₂ score (P = 0.031). In conclusion, our study showed both of CHADS₂ and CHA₂DS₂-VASc scores were significant predictors for long-term CV and all-cause mortality in CKD patients and CHA₂DS₂-VASc score had a better predictive value than CHADS₂ score for all-cause mortality in direct comparison of multivariate model. Therefore, using CHADS₂ and CHA₂DS₂-VASc scores to screen CKD patients may be helpful in identifying the high-risk group with increased mortality.

The Impact of a Nurse-Led Syncope Clinic: Experience from a single UK tertiary center

Background

Syncope is a leading cause of hospital admission and is associated with significant morbidity and mortality. Our Syncope Clinic commenced in 2014 and we sought to evaluate its impact on outcomes (1‐yr mortality and syncope re‐hospitalization) in patients discharged following syncope admission.

Methods

A single‐center study of all consecutive patients discharged with syncope (ICD‐10 R55) between April 2012 and 2017. Patient demographics, comorbidities, hospital stay, syncope re‐hospitalization, and mortality at one‐year were collected. Those subsequently referred and seen in Syncope Clinic were compared with those who were not and predictors of poor outcome were evaluated.

Results

In total 2950 patients were discharged from hospital with syncope (median age: 73years, 51% male) with 1220 (41%) discharged same‐day; after commencement of Syncope Clinic 231were subsequently reviewed here. Overall mortality was 11%, which was lower in the Syncope Clinic group (3% vs 12%, P < .001). Temporal analysis revealed reduced re‐hospitalization following commencement of Syncope Clinic (2% vs 6%, P = .027). Independent predictors of mortality were increasing age (HR 1.03, 95% CI 1.03‐1.04), AF (HR 1.6, 95% CI 1.2‐2.1), HF (HR 2.2, 95% CI 1.6‐3.0), COPD (HR 1.9, 95% CI 1.4‐2.7), and CHADS₂ score ≥ 1 (HR 1.45, 95% CI 1,12‐1.87). Syncope Clinic attendance was associated with reduced mortality (HR 0.3, 95% CI 0.1‐0.6).

Conclusions

Syncope patients discharged from hospital had reduced 1yr mortality if seen in subsequent Syncope Clinic. Independent predictors of mortality were COPD, HF, AF, and CHADS₂ ≥1. Prospective randomized trials of Syncope Clinics are warranted.

Value of the CHA2 DS2 -VASc score for predicting outcome in patients with heart failure

Aims

Comorbidities are highly prevalent in patients with heart failure (HF) and affect clinical outcome. The CHA₂DS₂‐VASc score is a validated score to estimate assessment of thromboembolic risk in patients with atrial fibrillation.

Methods and results

We evaluated the predictive value of this score on clinical outcome in patients with HF. All patients with a diagnosis of chronic HF at a health maintenance organization were evaluated for the CHA₂DS₂‐VASc score. Patients were followed for cardiac related hospitalizations and death. The cohort included 7106 HF patients. Mean follow‐up was 744 days; the median CHA₂DS₂‐VASc score was 5.0 (range 4.0–6.0). The CHA₂DS₂‐VASc score was a significant predictor of survival and predictive of the combined end point of death and cardiovascular hospitalization. Survival rates were reduced with increasing quintiles of the CHA₂DS₂‐VASc score: 93.6 ± 0.7% vs. 83.0 ± 1.1% vs. 75.7 ± 1.0% vs. 73.0 ± 1.2% vs. 63.3 ± 1.2%, respectively P < 0.001. After adjustment for other significant predictors, increasing CHA₂DS₂‐VASc scores were independently predictive of survival and of the combined end point of death and cardiovascular hospitalization by Cox regression analysis. Analysing the CHA₂DS₂‐VASc score as a continuous parameter by cox regression analysis demonstrated a significant increase with each point increase in the CHA₂DS₂‐VASc score (hazard ratio 1.21, 95% confidence interval 1.17–1.26, P < 0.0001). Cox regression analysis using restricted cubic splines demonstrated an independent continuous increase in mortality with increasing CHA₂DS₂‐VASc score (P < 0.0001 adjusted linear model). The predictive value was present in HF with reduced as well as preserved ejection fraction.

Conclusions

The CHA₂DS₂‐VASc score has a significant impact on outcome in HF patients.

Predicting the Risk of Ischemic Stroke among Patients with Rheumatoid Arthritis Using a Simplified RA-CHADSV Score Based on the CHA2DS2-VASc Score

Background and Objectives: The aim of this retrospective cohort study was to develop a new score (RA-CHADSV) (rheumatoid arthritis - congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack/thromboembolism, and vascular disease), modified from the CHA₂DS₂-VASc score (congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, stroke/transient ischemic attack (doubled), vascular disease, age 65–74 years, and female), in predicting the risk of ischemic stroke in rheumatoid arthritis (RA) patients without atrial fibrillation (AF). Materials and Methods: Using the Taiwan’s National Health Insurance Research Database, 592 patients with RA diagnosed between 2000 and 2002 were identified and followed until first occurrence of ischemic stroke or the last available date in the database. Incidence rate ratios (IRR) of ischemic stroke for the CHA₂DS₂-VASc score were calculated using Poisson regression models. A new prediction score RA-CHADSV was developed using multiple logistic regression analysis with bootstrap validation. Results: The area under the receiver operating characteristic curve of the newly developed RA-CHADSV score and the CHA₂DS₂-VASc score were 0.73 (95% confidence interval (CI) 0.64–0.82) and 0.70 (95% CI 0.61–0.79), respectively. The RA-CHADSV score was significantly associated with a higher ischemic stroke incidence in the patients who scored ≥1 (adjusted IRR 7.39, p < 0.001). Conclusions: A simplified RA-CHADSV score, with comparable efficiency as the CHA₂DS₂-VASc score, but easier to use clinically was developed for predicting the risk of ischemic stroke among non-AF RA patients.

Predicting outcomes in patients with cancer and atrial fibrillation

Background:

The role of cancer-specific factors for ischemic stroke and mortality in patients with cancer and atrial fibrillation (AF) is unknown. We evaluated the utility of a previously validated risk tool for venous thromboembolism (VTE) in cancer outpatients [Khorana score (KS)] in predicting stroke and mortality in cancer patients with AF.

Methods:

We conducted a retrospective cohort study of patients with cancer and AF at the Cleveland Clinic from 2008 to 2014. Outcomes, CHADS2, CHA2DS2-VASc, and KS scores were calculated from date of cancer diagnosis. Prognostic factors were identified with Fine and Gray regression (for stroke) or Cox proportional hazards analysis (for mortality).

Results:

The study population comprised 1181 patients. Genitourinary (19%), lung (18%), and gastrointestinal (13%) were the most frequent cancers. Overall, 67% had CHADS2 ⩾ 2, 57% had an intermediate KS (1–2), and 7% high KS (⩾3). Median follow up was 26.5 months (range 0.03–76). At a median of 8.2 months (range 0–61), 45 patients (3.8%) developed a stroke and 418 (35%) died. In multivariable analysis a high KS (HR 4.5, 95% CI 3.2–6.3, p < 0.001) was associated with a quadruple risk of death and every point increase in CHADS2 score had a 20% increased risk of death (HR 1.19, 95% CI 1.1–1.2, p < 0.001). The addition of KS did not improve risk stratification for ischemic stroke to CHADS2.

Conclusion:

In patients with cancer and AF, CHADS2 and CHA2DS2-VASc but not KS were predictive of ischemic stroke. A high KS represented a unique predictor of mortality beyond traditional risk scores.

Performance of the CHA2DS2-VASc score in predicting new onset atrial fibrillation during hospitalization for community-acquired pneumonia

BACKGROUND

Cardiovascular events are common during hospitalization for community-acquired pneumonia (CAP), with new onset atrial fibrillation (NOAF) being the second most relevant complication. In this study, we aimed to investigate the role of CHA₂DS₂-VASc score in predicting NOAF during hospitalization for CAP.

METHODS

Patients admitted for CAP were prospectively assessed using CHA₂DS₂-VASc. The end-point of the study was the occurrence of any objectively documented episode of NOAF during hospitalization in patients that were in sinus rhythm at hospital admission.

RESULTS

Of 468 patients enrolled (median age 76 years), 48 (10.3%) experienced NOAF during hospitalization. They were older, had more comorbidities, more severe pneumonia, and higher CHA₂DS₂-VASc than those who remained in sinus rhythm (4.4 ± 1.6 vs 3.4 ± 1.9, respectively; p < .0001). There was a direct relationship between CHA₂DS₂-VASc score and risk of NOAF. At ROC curve analysis, a CHA₂DS₂-VASc score > 3 was the most accurate cut-off for prediction of NOAF (AUC 0.653; 95% CI 0.577-0.729; p = .001). In two different multivariable models, each CHA₂DS₂-VASc point increase and a score > 3 both were independently associated with NOAF (HR 1.3; 95% CI 1.09-1.55; p = .003 and 2.3; 95% CI 1.19-4.44; p = .007, respectively).

CONCLUSIONS

CHA₂DS₂-VASc score is an accurate and independent predictor of NOAF in patients with CAP, and a score > 3 features a population at high risk of developing the arrhythmia during hospitalization. This simple and effective tool should be incorporated in the evaluation of patients hospitalized for CAP, with implications ranging from arrhythmic prevention to anticoagulation management.

Relation of CHA2DS2VASC Score With Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA₂DS₂VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA₂DS₂VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA₂DS₂VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA₂DS₂VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.