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Identifying patients with atrial fibrillation with a single CHA2DS2-VASC risk factor who are at higher risk of stroke

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Abstract

Aims

Management of patients with a single CHA2DS2-VASc score risk factor is controversial. We attempt to identify the “truly low risk” AF patients who will not benefit from oral anticoagulation (OAC) treatment.

Methods

Retrospective cohort analysis, all incident non-valvular AF (NVAF) cases between 2004 and 2015, and age 21 and older, with up to one thromboembolic risk factor besides sex (CHA2DS2-VASc score of up to 1 for men and up to 2 for women). A “low risk” score was created for these patients using a logistic regression model on the incidence of stroke within 30–2500 days following the NVAF diagnosis.

Results

We identified 15,621 patients. Average age was 53.7 ± 12.3 years, 56.6% male. Mean follow-up was 5.5 years. Significant predictors of ischemic stroke were age 65–74 and diabetes (2 points each), hypertension, vascular disease, and chronic kidney disease stage 2–3 (1 point each). Stroke incidence ranged from 0.8% for score 0 and up to 3.4% for scores ≤ 2. Odds ratio for stroke among patient group with a score ≤ 2 was 4.3 (2.9–6.6) compared with score 0. Our risk score’s area-under-the-curve (AUC) for prediction of stroke was 0.68 (0.65–0.71), compared with 0.60 (0.57–0.62) for the CHAD2S2-VASc score, within this low-risk group.

Conclusion

Patients considered at low or intermediate risk using traditional risk stratification schemes, with ≥ 2 points using this proposed low-risk index (65–74 years old, diabetics or a combination of chronic renal failure and an additional risk factor), had an overall stroke risk that may justify anticoagulation therapy.

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Abbreviations

AF:

Atrial fibrillation

CHA2DS2-VASc:

Congestive heart failure, hypertension, age ≥ 75, diabetes, prior stroke, vascular disease, age 65–74, and female sex category

CHF:

Congestive heart failure

CHS:

Clalit Health Services

CI:

Confidence interval

OR:

Odds ratio

INR:

International normalized ratio

NVAF:

Non-valvular atrial fibrillation

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Funding

The authors are employees of Clalit Health Services and Clalit Health Services Research Institute which received funding from Pfizer Inc. to conduct this study.

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Authors and Affiliations

  1. Cardiology Department, Meir Medical Center, 59 Tshernichovsky St, 44821, Kfar Sava, Israel

    Yoav Arnson

  2. Chief Physician’s Office, Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel

    Yoav Arnson, Adi Berliner Senderey, Moshe Hoshen, Orna Reges, Ran Balicer, Hilmi Alnsasra, Morton Leibowitz, Meytal Avgil Tsadok & Moti Haim

  3. Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel

    Yoav Arnson

  4. Department of Preventive Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA

    Orna Reges

  5. Cardiology Department, Soroka Medical Center, Beer Sheva, Israel

    Hilmi Alnsasra & Moti Haim

  6. Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel

    Ran Balicer, Hilmi Alnsasra & Moti Haim

Authors
  1. Yoav Arnson
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  2. Adi Berliner Senderey
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  3. Moshe Hoshen
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  4. Orna Reges
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  5. Ran Balicer
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  6. Hilmi Alnsasra
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  7. Morton Leibowitz
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  8. Meytal Avgil Tsadok
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  9. Moti Haim
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Corresponding author

Correspondence to Yoav Arnson.

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Ethics approval

The study has been approved by the Clalit health service IRB committee.

Conflict of interest

The authors declare no competing interests.

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Highlights

• Preventive treatment for atrial fibrillation patients with high thromboembolic risk is based on chronic oral anticoagulation treatment.

• The treatment of patients with atrial fibrillation and low to medium thromboembolic risk (CHADS-VASc score of 1) is controversial.

• Within low-risk patients, patients 65–74 years of age and diabetics as a single risk factor are at higher risk for stroke.

• The combination of chronic kidney disease and hypertension or vascular disease increases stroke risk as well.

Supplementary Information

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Supplementary file1 (DOCX 23 KB)

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Arnson, Y., Senderey, A.B., Hoshen, M. et al. Identifying patients with atrial fibrillation with a single CHA2DS2-VASC risk factor who are at higher risk of stroke. Ir J Med Sci 191, 705–711 (2022). https://doi.org/10.1007/s11845-021-02618-y

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  • DOI: https://doi.org/10.1007/s11845-021-02618-y

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