CHADS2 and CHA2DS2-VASc scores as bleeding risk indices for patients with atrial fibrillation: the Bleeding with Antithrombotic Therapy Study

Abstract

The CHADS2 and CHA2DS2-VASc scores, that is, ischemic stroke risk indices for patients having atrial fibrillation (AF), may also be useful as bleeding risk indices. Japanese patients with AF, who routinely took oral antithrombotic agents were enrolled from a prospective, multicenter study. The CHADS2 and CHA2DS2-VASc scores were assessed based on information at entry. Scores of 0, 1 and ⩾2 were defined as the low, intermediate and high ischemic risk categories, respectively, for each index. Of 1221 patients, 873 took warfarin, 114 took antiplatelet agents and 234 took both. The annual incidence of ischemic stroke was 0.76% in the low-risk category, 1.46% in the intermediate-risk category and 2.90% in the high-risk category by CHADS2 scores, and 1.44, 0.42 and 2.50%, respectively, by CHA2DS2-VASc scores. The annual incidence of major bleeding in each category was 1.52, 2.19 and 2.25% by CHADS2, and 1.44, 1.69 and 2.24% by CHA2DS2-VASc. After multivariate adjustment, the CHADS2 was associated with ischemia (odds ratio 1.76, 95% confidence interval 1.03-3.38 per 1-category increase) and the CHA2DS2-VASc tended to be associated with ischemia (2.18, 0.89-8.43). On the other hand, associations of the indices with bleeding were weak. In conclusion, bleeding risk increased gradually as the CHADS2 and CHA2DS2-VASc scores increased in Japanese antithrombotic users, although the statistical impact was rather weak compared with their predictive power for ischemic stroke.

Does Dabigatran Increase the Risk of Delayed Hematoma Expansion in a Rat Model of Collagenase-induced Intracerebral Hemorrhage?

“…4 Through many randomized controlled trials, we have learned that the incidence of ICH is substantially lower in patients using NOACs than in those using warfarin. [1][2][3] However, experimental or clinical information about the natural course of NOAC-related ICH is scarce. A detailed analysis of hematoma expansion was not performed in the post hoc analysis of the Randomized Evaluation of Long-term Anticoagulation Therapy trial.…”

“…[1][2][3] Despite its well-established efficacy in embolic stroke prevention, the risk of intracerebral hemorrhage (ICH) is not negligible in warfarin-treated patients. [1][2][3] Warfarin-related ICH differs from spontaneous warfarin-unrelated ICH, in that delayed hematoma expansion is much more frequent in the former. [4][5][6] Recently, novel oral anticoagulants (NOACs), which are equivalent or superior in terms of efficacy and are associated with lower rates of hemorrhagic complications compared with warfarin, have become available for AF patients.…”

“…[4][5][6] Recently, novel oral anticoagulants (NOACs), which are equivalent or superior in terms of efficacy and are associated with lower rates of hemorrhagic complications compared with warfarin, have become available for AF patients. [1][2][3] Despite the better safety profiles of NOACs including a lower frequency of hemorrhagic complications, such as ICH, information regarding the natural history (including delayed hematoma expansion) of NOAC-related ICH has been limited in both clinical and experimental settings. We have been interested in determining whether delayed hematoma expansion observed in patients with warfarinrelated ICH may also be observed in patients with NOAC-related ICH.…”

“…[1][2][3] Oral anticoagulant therapy has been the mainstay of preventive treatment against primary or secondary stroke in AF patients, and until recently, only warfarin, a vitamin K inhibitor, has been the only oral anticoagulant available in our country. [1][2][3] Despite its well-established efficacy in embolic stroke prevention, the risk of intracerebral hemorrhage (ICH) is not negligible in warfarin-treated patients. [1][2][3] Warfarin-related ICH differs from spontaneous warfarin-unrelated ICH, in that delayed hematoma expansion is much more frequent in the former.…”

Stratifying Stroke Risk in Atrial Fibrillation

“…First, the CHADS 2 score has also been shown to predict hemorrhagic complications in patients with AF. 19 This means that patients with a high predicted risk of thromboembolic events are also the same patients with a high predicted risk of hemorrhagic complications, which complicates decisions about anticoagulant therapy. More importantly, the score suffers from significant heterogeneity in actual stroke risk in patients labeled as “low risk” based on their CHADS 2 score.…”