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Tourountzis T, Lioulios G, Stasini F, Skarlatou Z, Stai S, Christodoulou M, Moysidou E, Ginikopoulou E, Stangou M. Cardiovascular Events and Mortality in Patients on Hemodialysis: The Prognostic Value of the CHA 2DS 2-VASc Score. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:144. [PMID: 38256404 PMCID: PMC10820266 DOI: 10.3390/medicina60010144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Cardiovascular events are the major cause of morbidity and mortality in patients on hemodialysis (HD). Identifying risk factors can help in the effort to reduce cardiovascular risk and improve life expectancy. The objective of this study was to evaluate the ability of the CHA2DS2-VASc score-the risk index of stroke in atrial fibrillation (AF)-to predict strokes, major cardiovascular events, and mortality in patients with end-stage kidney disease. Materials and Methods: The CHA2DS2-VASc and HAS-BLED scores (the bleeding risk from the use of anticoagulation in AF) were calculated in 237 HD patients, 99 women with a median age of 76 (15) years, at the time they commenced HD. The scores' ability to predict long term cardiovascular morbidity and mortality was estimated, both in those with and without AF. Among the exclusion criteria were the change of dialysis method or loss of follow-up, HD due to acute renal failure, and incompliance with medical instructions, thus the sample is not representative of a broader population. Results: The CHA2DS2-VASc score was higher in AF (n = 69) compared to non-AF (n = 168) patients, 5 (2.5) vs. 4 (2), p < 0.0001, respectively. An increased CHA2DS2-VASc score was correlated with cardiovascular events, namely, heart failure (p = 0.007, p = 0.024), stroke (p < 0.0001, p < 0.0001), and risk of all-cause mortality (p < 0.0001, p < 0.0001) in AF and non-AF groups, respectively. The C statistics indicated that the referred score showed modest discrimination in AF and non-AF patients on HD for heart failure, stroke, and all-cause mortality, however for cardiovascular mortality this was found only in the AF group. Conclusions: An increased CHA2DS2-VASc score at the time of HD initiation can predict strokes, heart failure, and all-cause mortality in HD patients independent of the presence of AF. The risk of cardiovascular mortality could only be predicted in patients with AF.
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Affiliation(s)
- Theodoros Tourountzis
- Protypo Dialysis Center, Hemodialysis Unit, 55535 Thessaloniki, Greece; (T.T.); (F.S.); (Z.S.); (E.G.)
| | - Georgios Lioulios
- Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (G.L.); (S.S.); (M.C.); (E.M.)
| | - Fotini Stasini
- Protypo Dialysis Center, Hemodialysis Unit, 55535 Thessaloniki, Greece; (T.T.); (F.S.); (Z.S.); (E.G.)
| | - Zoi Skarlatou
- Protypo Dialysis Center, Hemodialysis Unit, 55535 Thessaloniki, Greece; (T.T.); (F.S.); (Z.S.); (E.G.)
| | - Stamatia Stai
- Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (G.L.); (S.S.); (M.C.); (E.M.)
| | - Michalis Christodoulou
- Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (G.L.); (S.S.); (M.C.); (E.M.)
| | - Eleni Moysidou
- Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (G.L.); (S.S.); (M.C.); (E.M.)
| | - Evdoxia Ginikopoulou
- Protypo Dialysis Center, Hemodialysis Unit, 55535 Thessaloniki, Greece; (T.T.); (F.S.); (Z.S.); (E.G.)
| | - Maria Stangou
- Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (G.L.); (S.S.); (M.C.); (E.M.)
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van der Endt VHW, Milders J, Penning de Vries BBL, Trines SA, Groenwold RHH, Dekkers OM, Trevisan M, Carrero JJ, van Diepen M, Dekker FW, de Jong Y. Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation. Europace 2022; 24:1739-1753. [PMID: 35894866 PMCID: PMC9681133 DOI: 10.1093/europace/euac096] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/24/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS Multiple risk scores to predict ischaemic stroke (IS) in patients with atrial fibrillation (AF) have been developed. This study aims to systematically review these scores, their validations and updates, assess their methodological quality, and calculate pooled estimates of the predictive performance. METHODS AND RESULTS We searched PubMed and Web of Science for studies developing, validating, or updating risk scores for IS in AF patients. Methodological quality was assessed using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). To assess discrimination, pooled c-statistics were calculated using random-effects meta-analysis. We identified 19 scores, which were validated and updated once or more in 70 and 40 studies, respectively, including 329 validations and 76 updates-nearly all on the CHA2DS2-VASc and CHADS2. Pooled c-statistics were calculated among 6 267 728 patients and 359 373 events of IS. For the CHA2DS2-VASc and CHADS2, pooled c-statistics were 0.644 [95% confidence interval (CI) 0.635-0.653] and 0.658 (0.644-0.672), respectively. Better discriminatory abilities were found in the newer risk scores, with the modified-CHADS2 demonstrating the best discrimination [c-statistic 0.715 (0.674-0.754)]. Updates were found for the CHA2DS2-VASc and CHADS2 only, showing improved discrimination. Calibration was reasonable but available for only 17 studies. The PROBAST indicated a risk of methodological bias in all studies. CONCLUSION Nineteen risk scores and 76 updates are available to predict IS in patients with AF. The guideline-endorsed CHA2DS2-VASc shows inferior discriminative abilities compared with newer scores. Additional external validations and data on calibration are required before considering the newer scores in clinical practice. CLINICAL TRIAL REGISTRATION ID CRD4202161247 (PROSPERO).
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Affiliation(s)
| | - Jet Milders
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Bas B L Penning de Vries
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Marco Trevisan
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Juan J Carrero
- Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands
| | - Ype de Jong
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2333 ZA Leiden, The Netherlands,Department of Internal Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
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