Dynamic Changes of CHA₂DS₂-VASc Score and the Risk of Ischaemic Stroke in Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study

Abstract

Background Stroke risk in atrial fibrillation (AF) is often assessed at initial presentation, and risk stratification performed as a ‘one off’. In validation studies of risk prediction, baseline values are often used to ‘predict’ events that occur many years later. Many clinical variables have ‘dynamic’ changes over time, as the patient is followed up. These dynamic changes in risk factors may increase the CHA₂DS₂-VASc score, stroke risk category and absolute ischaemic stroke rate.

Objective This article evaluates the ‘dynamic’ changes of CHA₂DS₂-VASc variables and its effect on prediction of stroke risk.

Patients and Methods From the Korea National Health Insurance Service database, a total of 167,262 oral anticoagulant-naive non-valvular AF patients aged ≥ 18 years old were enrolled between January 1, 2002, and December 31, 2005. These patients were followed up until December 31, 2015.

Results At baseline, the proportions of subjects categorized as ‘low’, ‘intermediate’ or ‘high risk’ by CHA₂DS₂-VASc score were 15.4, 10.6 and 74.0%, respectively. Mean CHA₂DS₂-VASc score increased annually by 0.14, particularly due to age and hypertension. During follow-up of 10 years, 46.6% of ‘low-risk’ patients and 72.0% of ‘intermediate risk’ patients were re-classified to higher stroke risk categories. Among the original ‘low-risk’ patients, annual ischaemic stroke rates were significantly higher in the re-classified ‘intermediate’ (1.17 per 100 person-years, p < 0.001) or re-classified ‘high-risk’ groups (1.44 per 100 person-years, p = 0.048) than consistently ‘low-risk’ group (0.29 per 100 person-years). The most recent CHA₂DS₂-VASc score and the score change with the longest follow-up had the best prediction for ischaemic stroke.

Conclusion In AF patients, stroke risk as assessed by the CHA₂DS₂-VASc score is dynamic and changes over time. Rates of ischaemic stroke increased when patients accumulated risk factors, and were re-classified into higher CHA₂DS₂-VASc score categories. Stroke risk assessment is needed at every patient contact, as accumulation of risk factors with increasing CHA₂DS₂-VASc score translates to greater stroke risks over time.

Keywords

atrial fibrillation - CHA₂DS₂-VASc score - dynamic - stroke

Note: The review process for this article was fully handled by Christian Weber, Editor-in-Chief.

Note

Minjae Yoon and Pil-Sung Yang contributed equally to the article. Gregory Y. H. Lip and Boyoung Joung are senior co-authors of the article.

Authors' Contributions

M. Yoon and P.S. Yang drafted the manuscript, had full access to all of the data and takes responsibility for the integrity of the data and the accuracy of the data analysis. E. Jang, H.T. Yu, T.H. Kim, J.S. Uhm, J.Y. Kim, H.N. Pak and M.H. Lee contributed to data collection. B. Joung and G.Y.H.L. contributed to data interpretation, critical revision and final approval of the manuscript.

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