Download PDF
Thromb Haemost 2018; 118(12): 2014-2017
DOI: 10.1055/s-0038-1676074
Invited Editorial Focus
Georg Thieme Verlag KG Stuttgart · New York

Optimizing Stroke and Bleeding Risk Assessment in Patients with Atrial Fibrillation: A Balance of Evidence, Practicality and Precision

Marco Proietti
1   Istituto di Ricerche Farmacologiche “Mario Negri” IRCCS, Milan, Italy
2   Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
,
Nebojsa Mujovic
3   School of Medicine, University of Belgrade, Belgrade, Serbia
4   Cardiology Clinic, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
,
Tatjana S. Potpara
3   School of Medicine, University of Belgrade, Belgrade, Serbia
4   Cardiology Clinic, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
› Author Affiliations
Further Information

Publication History

31 October 2018

31 October 2018

Publication Date:
20 November 2018 (online)

Also available at
   Permissions and Reprints

Optimal stroke prevention using oral anticoagulant (OAC) therapy is essential for the management of patients with atrial fibrillation (AF) who are at increased risk of stroke, but decision making on thromboprophylaxis requires evaluation of individual patient's thromboembolic and bleeding risks.[1] Several risk assessment tools have been developed to streamline the evaluation of patients with AF but navigating through the labyrinth of options may be confusing for clinicians.[2]

 

  • References

  • 1 Lip G, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: Past, present and future. Comparing the guidelines and practical decision-making. Thromb Haemost 2017; 117 (07) 1230-1239
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Lip GY. Stroke and bleeding risk assessment in atrial fibrillation: when, how, and why?. Eur Heart J 2013; 34 (14) 1041-1049
    CrossrefPubMedGoogle Scholar
  • 3 Borre ED, Goode A, Raitz G. , et al. Predicting thromboembolic and bleeding event risk in patients with non-valvular atrial fibrillation: a systematic review. Thromb Haemost 2018 118. (12). Doi: 10.1055/s-0038-1675400
    PubMedGoogle Scholar
  • 4 Lopes RD, Crowley MJ, Shah BR. , et al. Stroke Prevention in Atrial Fibrillation. Rockville, MD: Agency for Healthcare Research and Quality (US); 2013. . Report No.: 13-EHC113-EF. AHRQ Comparative Effectiveness Reviews.
    Google Scholar
  • 5 Chen JY, Zhang AD, Lu HY, Guo J, Wang FF, Li ZC. CHADS2 versus CHA2DS2-VASc score in assessing the stroke and thromboembolism risk stratification in patients with atrial fibrillation: a systematic review and meta-analysis. J Geriatr Cardiol 2013; 10 (03) 258-266
    PubMedGoogle Scholar
  • 6 Xiong Q, Chen S, Senoo K, Proietti M, Hong K, Lip GY. The CHADS2 and CHA2DS2-VASc scores for predicting ischemic stroke among East Asian patients with atrial fibrillation: a systemic review and meta-analysis. Int J Cardiol 2015; 195: 237-242
    CrossrefPubMedGoogle Scholar
  • 7 Zhu WG, Xiong QM, Hong K. Meta-analysis of CHADS2 versus CHA2DS2-VASc for predicting stroke and thromboembolism in atrial fibrillation patients independent of anticoagulation. Tex Heart Inst J 2015; 42 (01) 6-15
    PubMedGoogle Scholar
  • 8 Zhu W, Fu L, Ding Y. , et al. Meta-analysis of ATRIA versus CHA2DS2-VASc for predicting stroke and thromboembolism in patients with atrial fibrillation. Int J Cardiol 2017; 227: 436-442
    CrossrefPubMedGoogle Scholar
  • 9 Olesen JB, Torp-Pedersen C, Hansen ML, Lip GY. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study. Thromb Haemost 2012; 107 (06) 1172-1179
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Potpara TS, Polovina MM, Licina MM, Marinkovic JM, Prostran MS, Lip GY. Reliable identification of “truly low” thromboembolic risk in patients initially diagnosed with “lone” atrial fibrillation: the Belgrade atrial fibrillation study. Circ Arrhythm Electrophysiol 2012; 5 (02) 319-326
    CrossrefPubMedGoogle Scholar
  • 11 Lip GYH, Banerjee A, Boriani G. , et al. Antithrombotic therapy for atrial fibrillation: CHEST Guideline and Expert Panel Report. Chest 2018; S0012-3692(18)32244-X
    PubMedGoogle Scholar
  • 12 Lip GY, Laroche C, Popescu MI. , et al. Improved outcomes with European Society of Cardiology guideline-adherent antithrombotic treatment in high-risk patients with atrial fibrillation: a report from the EORP-AF General Pilot Registry. Europace 2015; 17: 1777-1786
    CrossrefPubMedGoogle Scholar
  • 13 Proietti M, Nobili A, Raparelli V, Napoleone L, Mannucci PM, Lip GY. ; REPOSI investigators. Adherence to antithrombotic therapy guidelines improves mortality among elderly patients with atrial fibrillation: insights from the REPOSI study. Clin Res Cardiol 2016; 105 (11) 912-920
    CrossrefPubMedGoogle Scholar
  • 14 Li CH, Liu CJ, Chou AY. , et al. European Society of Cardiology guideline-adherent antithrombotic treatment and risk of mortality in Asian patients with atrial fibrillation. Sci Rep 2016; 6: 30734
    CrossrefPubMedGoogle Scholar
  • 15 Mazurek M, Shantsila E, Lane DA, Wolff A, Proietti M, Lip GYH. Guideline-adherent antithrombotic treatment improves outcomes in patients with atrial fibrillation: insights from the Community-Based Darlington Atrial Fibrillation Registry. Mayo Clin Proc 2017; 92 (08) 1203-1213
    CrossrefPubMedGoogle Scholar
  • 16 Nielsen PB, Larsen TB, Skjøth F, Overvad TF, Lip GY. Stroke and thromboembolic event rates in atrial fibrillation according to different guideline treatment thresholds: a nationwide cohort study. Sci Rep 2016; 6: 27410
    CrossrefPubMedGoogle Scholar
  • 17 Olesen JB, Torp-Pedersen C. Stroke risk in atrial fibrillation: do we anticoagulate CHADS2 or CHA2DS2-VASc ≥1, or higher?. Thromb Haemost 2015; 113 (06) 1165-1169
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Fauchier L, Lecoq C, Clementy N. , et al. Oral anticoagulation and the risk of stroke or death in patients with atrial fibrillation and one additional stroke risk factor: the Loire Valley Atrial Fibrillation Project. Chest 2016; 149 (04) 960-968
    CrossrefPubMedGoogle Scholar
  • 19 Lip GY, Skjøth F, Nielsen PB, Larsen TB. Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score. A comprehensive net clinical benefit analysis for warfarin, aspirin, or no therapy. Thromb Haemost 2015; 114 (04) 826-834
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Potpara TS, Dagres N, Mujović N. , et al. Decision-making in clinical practice: oral anticoagulant therapy in patients with non-valvular atrial fibrillation and a single additional stroke risk factor. Adv Ther 2017; 34 (02) 357-377
    CrossrefPubMedGoogle Scholar
  • 21 Nielsen PB, Lip GY. Adding rigor to stroke rate investigations in patients with atrial fibrillation. Circulation 2017; 135 (03) 220-223
    CrossrefPubMedGoogle Scholar
  • 22 Nielsen PB, Skjøth F, Overvad TF, Larsen TB, Lip GYH. 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?. Circulation 2018; 137 (08) 832-840
    CrossrefPubMedGoogle Scholar
  • 23 Brieger D, Amerena J, Attia J. , et al; NHFA CSANZ Atrial Fibrillation Guideline Working Group. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Diagnosis and Management of Atrial Fibrillation 2018. Heart Lung Circ 2018; 27 (10) 1209-1266
    CrossrefPubMedGoogle Scholar
  • 24 Overvad TF, Potpara TS, Nielsen PB. Stroke risk stratification: CHA2DS2-VA or CHA2DS2-VASc?. Heart Lung Circ 2018; S1443-9506(18)31866-3
    PubMedGoogle Scholar
  • 25 Maheshwari A, Norby FL, Roetker NS, et al. Refining prediction of atrial fibrillation-related stroke using the P2-CHA2DS2-VASc score: The atherosclerosis risk in communities (ARIC) study and multi-ethnic study of atherosclerosis (MESA). Circulation 2018. Doi: 10.1161/CIRCULATIONAHA.118.035411
    PubMed
  • 26 Steensig K, Olesen KKW, Thim T, et al. Should the presence or extent of coronary artery disease be quantified in the CHA2DS2-VASc score in atrial fibrillation? A report from the western Denmark heart registry. Thromb Haemost 2018. Doi: 10.1055/s-0038-1675401
    PubMed
  • 27 Steensig K, Olesen KKW, Thim T. , et al. Coronary artery disease is independent risk factor for stroke among patients with atrial fibrillation. J Am Coll Cardiol 2018; S0735-1097(18)36961-4
    PubMedGoogle Scholar
  • 28 Lip GY, Lane DA. Bleeding risk assessment in atrial fibrillation: observations on the use and misuse of bleeding risk scores. J Thromb Haemost 2016; 14 (09) 1711-1714
    CrossrefPubMedGoogle Scholar
  • 29 Esteve-Pastor MA, Rivera-Caravaca JM, Shantsila A, Roldán V, Lip GYH, Marín F. Assessing bleeding risk in atrial fibrillation patients: comparing a bleeding risk score based only on modifiable bleeding risk factors against the HAS-BLED score. The AMADEUS Trial. Thromb Haemost 2017; 117 (12) 2261-2266
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Guo Y, Zhu H, Chen Y, Lip GYH. Comparing bleeding risk assessment focused on modifiable risk factors only versus validated bleeding risk scores in atrial fibrillation. Am J Med 2018; 131 (02) 185-192
    CrossrefPubMedGoogle Scholar
  • 31 Chao TF, Lip GYH, Lin SL. , et al. Major bleeding and intracranial haemorrhage risk prediction in patients with atrial fibrillation: attention to modifiable bleeding risk factors or use of a bleeding risk stratification score? A nationwide cohort study. Int J Cardiol 2018; 254: 157-161
    CrossrefPubMedGoogle Scholar
  • 32 Chao TF, Lip GYH, Liu CJ. , et al. Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation. J Am Coll Cardiol 2018; 71 (02) 122-132
    CrossrefPubMedGoogle Scholar
  • 33 Chao TF, Lip GYH, Lin YJ. , et al. Incident risk factors and major bleeding in patients with atrial fibrillation treated with oral anticoagulants: a comparison of baseline, follow-up and delta HAS-BLED scores with an approach focused on modifiable bleeding risk factors. Thromb Haemost 2018; 118 (04) 768-777
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Lip GYH. The ABC pathway: an integrated approach to improve AF management. Nat Rev Cardiol 2017; 14 (11) 627-628
    CrossrefPubMedGoogle Scholar