Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA2DS2-VASc Score of 0 (Males) or 1 (Females): Implications for Reassessment of Stroke Risk in Initially ‘Low-Risk’ Patients

Tze-Fan Chao; Jo-Nan Liao; Ta-Chuan Tuan; Yenn-Jiang Lin; Shih-Lin Chang; Li-Wei Lo; Yu-Feng Hu; Fa-Po Chung; Tzeng-Ji Chen; Gregory Y. H. Lip; Shih-Ann Chen

doi:10.1055/s-0039-1683933

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2019; 119(07): 1162-1170
DOI: 10.1055/s-0039-1683933

Stroke, Systemic or Venous Thromboembolism

Georg Thieme Verlag KG Stuttgart · New York

Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA₂DS₂-VASc Score of 0 (Males) or 1 (Females): Implications for Reassessment of Stroke Risk in Initially ‘Low-Risk’ Patients

Tze-Fan Chao

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Jo-Nan Liao

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Ta-Chuan Tuan

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Yenn-Jiang Lin

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Shih-Lin Chang

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Li-Wei Lo

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Yu-Feng Hu

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Fa-Po Chung

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

,

Tzeng-Ji Chen

³Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

,

Gregory Y. H. Lip^*

⁴Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

⁵Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark

,

Shih-Ann Chen^*

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

²Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan

› Institutsangaben

Abstract

Background Oral anticoagulants (OACs) are not recommended for ‘low-risk’ patients with atrial fibrillation (AF). We investigated the incidences of new risk factors developing, and the temporal trends in the CHA₂DS₂-VASc score in initially ‘low-risk’ AF patients. Second, we propose a reasonable timing interval at which stroke risk should be reassessed for such AF patients.

Methods We studied 14,606 AF patients who did not receive anti-platelet agents or OACs with a baseline CHA₂DS₂-VASc score of 0 (males) or 1 (females). The CHA₂DS₂-VASc scores of patients were followed up and updated until the occurrence of ischaemic stroke or mortality or 31 December 2011. The associations between the prescription of warfarin and risk of adverse events once patients' scores changed were analysed. Decile values of durations to incident co-morbidities and from the acquirement of new co-morbidities to ischaemic stroke were studied.

Results During a mean follow-up of 4 years, 7,079 (48.5%) patients acquired at least one new stroke risk factor component(s) with annual risks of 6.35% for hypertension, 3.68% for age ≥ 65 years, 2.77% for heart failure, 1.99% for diabetes mellitus and 0.33% for vascular diseases. The incidence for CHA₂DS₂-VASc score increments was 12.1%/year. Initiation of warfarin was associated with a lower risk of adverse events (adjusted hazard ratio, 0.530; 95% confidence interval, 0.371–0.755). Among 6,188 patients who acquired new risk factors, 80% would acquire these co-morbidities after 4.2 months of AF diagnosis. The duration from the acquirement of incident co-morbidities to the occurrence of ischaemic stroke was longer than 4.4 months for 90% of the patients.

Conclusion The CHA₂DS₂-VASc score increases in approximately 12% of initially ‘low-risk’ AF patients each year, and the initiation of warfarin once the score changed was associated with a better prognosis. Three to four months may be a reasonable timing interval at which stroke risk should be reassessed so that OACs could be prescribed in a timely manner for stroke prevention.

Keywords

atrial fibrillation - CHA₂DS₂-VASc score - ischaemic stroke - reassessment

Volltext

Referenzen

References
1 Chugh SS, Blackshear JL, Shen WK, Hammill SC, Gersh BJ. Epidemiology and natural history of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001; 37 (02) 371-378
2 Chao TF, Liu CJ, Tuan TC. , et al. Lifetime risks, projected numbers, and adverse outcomes in Asian patients with atrial fibrillation: a report from the Taiwan Nationwide AF Cohort Study. Chest 2018; 153 (02) 453-466
3 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
4 January CT, Wann LS, Alpert JS. , et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130 (23) e199-e267
5 Kirchhof P, Benussi S, Kotecha D. , et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
6 Chiang CE, Okumura K, Zhang S. , et al. 2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation. J Arrhythm 2017; 33 (04) 345-367
7 January CT, Wann LS, Calkins H. , et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation 2019; 2019: CIR0000000000000665
8 Lip GYH, Banerjee A, Boriani G. , et al. Antithrombotic therapy for atrial fibrillation: CHEST guideline and expert panel report. Chest 2018; 154 (05) 1121-1201
9 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
10 Chao TF, Chiang CE, Chen TJ, Lip GYH, Chen SA. Reassessment of risk for stroke during follow-up of patients with atrial fibrillation. Ann Intern Med 2019;
11 Chao TF, Lip GY, Liu CJ. , et al. Validation of a modified CHA2DS2-VASc score for stroke risk stratification in Asian patients with atrial fibrillation: a nationwide cohort study. Stroke 2016; 47 (10) 2462-2469
12 Chao TF, Liu CJ, Tuan TC. , et al. Impact on outcomes of changing treatment guideline recommendations for stroke prevention in atrial fibrillation: a nationwide cohort study. Mayo Clin Proc 2016; 91 (05) 567-574
13 Chao TF, Liu CJ, Liao JN. , et al. Use of oral anticoagulants for stroke prevention in patients with atrial fibrillation who have a history of intracranial hemorrhage. Circulation 2016; 133 (16) 1540-1547
14 Chao TF, Liu CJ, Tuan TC. , et al. Rate-control treatment and mortality in atrial fibrillation. Circulation 2015; 132 (17) 1604-1612
15 Chao TF, Wang KL, Liu CJ. , et al. Age threshold for increased stroke risk among patients with atrial fibrillation: a nationwide cohort study from Taiwan. J Am Coll Cardiol 2015; 66 (12) 1339-1347
16 Chao TF, Liu CJ, Wang KL. , et al. Using the CHA2DS2-VASc score for refining stroke risk stratification in ‘low-risk’ Asian patients with atrial fibrillation. J Am Coll Cardiol 2014; 64 (16) 1658-1665
17 Chao TF, Liu CJ, Wang KL. , et al. Should atrial fibrillation patients with 1 additional risk factor of the CHA2DS2-VASc score (beyond sex) receive oral anticoagulation?. J Am Coll Cardiol 2015; 65 (07) 635-642
18 Chao TF, Liu CJ, Lin YJ. , et al. Oral anticoagulation in very elderly patients with atrial fibrillation: a nationwide cohort study. Circulation 2018; 138 (01) 37-47
19 Chao TF, Lip GYH, Lin YJ. , et al. Age threshold for the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with atrial fibrillation: insights into the optimal assessment of age and incident comorbidities. Eur Heart J 2019;
20 Chang CH, Lee YC, Tsai CT. , et al. Continuation of statin therapy and a decreased risk of atrial fibrillation/flutter in patients with and without chronic kidney disease. Atherosclerosis 2014; 232 (01) 224-230
21 European Heart Rhythm A. Heart Rhythm S, Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jr., Jacobs AK, Adams CD, Anderson JL, Antman EM, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Zamorano JL, American College of C, American Heart Association Task Force on Practice G, European Society of Cardiology Committee for Practice G, Writing Committee to Revise the Guidelines for the Management of Patients With Atrial F. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2006; 48: 854-906
22 Cheng CL, Kao YH, Lin SJ, Lee CH, Lai ML. Validation of the National Health Insurance Research Database with ischemic stroke cases in Taiwan. Pharmacoepidemiol Drug Saf 2011; 20 (03) 236-242
23 Hsieh CY, Chen CH, Li CY, Lai ML. Validating the diagnosis of acute ischemic stroke in a National Health Insurance claims database. J Formos Med Assoc 2015; 114 (03) 254-259
24 Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA. , et al. Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients. Thromb Haemost 2017; 117 (07) 1448-1454
25 Raparelli V, Proietti M, Cangemi R, Lip GY, Lane DA, Basili S. Adherence to oral anticoagulant therapy in patients with atrial fibrillation. Focus on non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2017; 117 (02) 209-218