Brian F. Gage, MD, MSc; Ambar Andrade, MD
In patients with atrial fibrillation (AF), which risk stratification schemes accurately predict stroke and bleeding?
Registry-based, national cohort study, primarily to validate CHA2DS2-VASc and modified HAS-BLED.
170 291 patients (mean age 76 y, 53% men) who had a diagnosis of nonvalvular AF at any Swedish hospital (admission or visit to hospital outpatient clinic). Exclusion criteria included death within 14 days of index date (date of first AF diagnosis after July 2005) or valvular surgery. 90 490 patients never used warfarin.
Risk stratification schemes for stroke were CHADS2 (congestive heart failure; hypertension; age > 75 y; diabetes; and stroke, transient ischemic attack, or thromboembolism); CHA2DS2-VASc (CHADS2 plus vascular disease, age 65 to 74 y, and sex); ACC/AHA/ESC (American College of Cardiology, American Heart Association, European Society of Cardiology); AFI (AF Investigators); NICE (National Institute for Health and Clinical Excellence); Framingham; and SPAF (Stroke Prevention in AF). Risk stratification schemes for bleeding were modified HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history, age > 65 y, and drugs/alcohol concomitantly) and modified HEMORR2HAGES (hepatic or renal disease, ethanol abuse, malignancy, age > 75 y, reduced platelet count or function, rebleeding risk, hypertension, anemia, fall risk, and stroke).
Thromboembolism outcomes included ischemic stroke. Bleeding outcomes included major bleeding (intracranial bleeding, gastrointestinal bleeding, or anemia secondary to bleeding).
The results for the various stroke risk stratification schemes are shown in the Table. For major bleeding, the c-statistic range (depending on treatment) was 0.57 to 0.66 for the modified HAS-BLED and 0.60 to 0.69 for the modified HEMORR2HAGES risk scheme.
The CHA2DS2-VASc score had 100% sensitivity and 6% specificity for predicting stroke in patients with atrial fibrillation; CHADS2 and Framingham scores had slightly lower sensitivities but higher specificities.
Test characteristics of risk stratification schemes for stroke in patients with atrial fibrillation who never used warfarin (n = 90 490)*
*Scale acronyms defined under “Description of prediction guides”; other abbreviations defined in Glossary. LRs calculated from sensitivities and specificities in article. Cutpoints were low risk vs intermediate or high risk.
Gage BF, Andrade A. Various risk stratification schemes predict ischemic stroke and bleeding in atrial fibrillation. Ann Intern Med. ;157:JC4–13. doi: 10.7326/0003-4819-157-8-201210160-02013
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Published: Ann Intern Med. 2012;157(8):JC4-13.
Cardiology, Neurology, Rhythm Disorders and Devices, Stroke.
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