Does chronic kidney disease improve the predictive value of the CHADS2 and CHA2DS2-VASc stroke stratification risk scores for atrial fibrillation?

Roldán, Vanessa; Marı́n, Francisco; Manzano‐Fernández, Sergio; Fernández, Hermógenes; Gallego, Pilar; Valdés, Mariano; Vicente, Vicente; Lip, Gregory Y.H.

doi:10.1160/th13-01-0054

Cited by 94 publications

(55 citation statements)

References 29 publications

(24 reference statements)

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…2,5,10,12,13,15,17,18,20,21 Different equations were used for estimating the eGFR and classifying patients as having CKD: Cockcroft-Gault formula was used in 5 studies 15,18,20,21,25 collaboration and cystatin C clearance were also used for assessing the safety and efficacy of apixaban and dabigatran at different levels of eGFR. The remaining selected studies for the systematic review did not use any of these, because the diagnosis of CKD was retrieved from codification.…”

Section: Resultsmentioning

confidence: 99%

“…10 In addition, Banerjee et al found that renal impairment and/or eGFR (codified as 3 different categories: <30, 30 to 59, and 60 ml/min) did not increase the risk of ischemic stroke or systemic thromboembolism after adjustment for the CHADS 2 risk factors. Thus, if added to CHADS 2 or CHA 2 DS 2 -VASc risk scores, eGFR did not independently add to the predictive value of any of these.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Meta-Analysis of the Influence of Chronic Kidney Disease on the Risk of Thromboembolism Among Patients With Nonvalvular Atrial Fibrillation

Providência

Marijon

Boveda

et al. 2014

The American Journal of Cardiology

View full text Add to dashboard Cite

Chronic kidney disease (CKD) and atrial fibrillation (AF) frequently coexist. However, the extent to which CKD increases the risk of thromboembolism in patients with nonvalvular AF and the benefits of anticoagulation in this group remain unclear. We addressed the role of CKD in the prediction of thromboembolic events and the impact of anticoagulation using a meta-analysis method. Data sources included MEDLINE, EMBASE, and Cochrane (from inception to January 2014). Three independent reviewers selected studies. Descriptive and quantitative information was extracted from each selected study and a random-effects meta-analysis was performed. Thromboembolic events are one of the most feared complications of atrial fibrillation (AF). 1 Chronic kidney disease (CKD) is relatively prevalent in patients with AF. 2 The extent to which the presence of CKD may increase the risk of thromboembolism in patients with AF has not yet been fully elucidated. Oral anticoagulation is the mainstay of thromboembolic prevention in patients with AF, 3 but data on efficacy and safety in the CKD and dialysis population have been scarce and contradictory. 4,5 Our aim was to systematically evaluate, through a meta-analysis method, the impact of the presence of CKD in patients with AF as regards risk of thromboembolism and the potential benefit of anticoagulation in that setting. MethodsWe performed a search in MEDLINE (by way of Ovid and PubMed), EMBASE, and Cochrane (from inception to January 3, 2014) databases using the following search string: "atrial fibrillation" AND ("renal failure" OR "chronic renal disease" OR "dialysis") AND ("stroke" OR "thromboembolism"). The reference lists of the accessed full-text reports were further researched for sources of potential information relevant to this analysis. The authors of full-text reports and abstracts were contacted by e-mail to retrieve additional information.Only longitudinal studies assessing the occurrence of a composite end point of stroke or systemic embolism (and including transient ischemic attack) during follow-up in patients with AF were considered for inclusion. Both registries and randomized trials were considered eligible for analysis. The methods sections of evaluated studies were reviewed to confirm the suitability and composition of the reported end point. Studies assessing only stroke (either ischemic, hemorrhagic, or a composite of both) and providing no data on systemic embolism were not considered representative of the full spectrum of thromboembolism in AF and were excluded from analysis. Similarly, studies only reporting stroke or systemic embolism in association with myocardial infarction, hospitalization, or death not due to stroke or systemic embolism were not included.

show abstract

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Meta-Analysis of the Influence of Chronic Kidney Disease on the Risk of Thromboembolism Among Patients With Nonvalvular Atrial Fibrillation

Providência

Marijon

Boveda

et al. 2014

The American Journal of Cardiology

View full text Add to dashboard Cite

show abstract

“…17,19,[28][29][30][31] Fourteen studies reported the incidence of a composite outcome (ischemic stroke or systematic embolism) as an outcome of interest and 4 studies only reported the incidence of ischemic stroke. Fourteen studies (77.8%) provided ≥1 adjusted risk estimate, and 11 (78.6%) of them reported an adjusted estimate for CHADS 2 : congestive heart failure, hypertension, age, diabetes mellitus, stroke/transient ischemic attack.…”

Section: Study Characteristicsmentioning

confidence: 99%

Risk of Thromboembolic Events in Atrial Fibrillation With Chronic Kidney Disease

Zeng

Sun

Tang

et al. 2015

Stroke

View full text Add to dashboard Cite

Background and Purpose-Chronic kidney disease may increase the risk for ischemic stroke or systemic embolism in patients with nonvalular atrial fibrillation (AF). We conducted a meta-analysis to summarize all published studies to investigate the link between chronic kidney disease and risk of thromboembolic events in AF. Methods-We performed a literature search using MEDLINE (source PubMed, 1966 and EMBASE (1980 to July 2014) with no restrictions. Pooled effect estimates were obtained by using random-effects meta-analysis. Results-Eighteen studies involving 538 479 patients and 41 719 incident thromboembolic events were identified. From the pooled analysis, AF patients with estimated glomerular filtration rate <60 mL/min compared with those with estimated glomerular filtration rate ≥60 mL/min experienced a significantly increased risk for developing thromboembolic events (relative risk, 1.62 [95% confidence interval, 1.40-1.87; P<0.001]). The annual rate of thromboembolic events increased by 0.41% (95% confidence interval, 0.17%-0.65%) for a 10 mL/min decrease in renal function. Addition of renal impairment to CHADS 2 slightly improved the stroke risk stratification. Conclusions-Impaired renal function is an independent predictor of stroke or systemic embolism in patients with nonvalvular AF. Consideration of renal function may improve stroke risk stratification in patients with AF. (Stroke.

show abstract

“…6 Also, other "real world" studies have shown that adding extra points for "renal impairment" (as with the R2CHADS2 score) did not improve the predictive value of CHA2DS2-VASc. 7- 9 Nonetheless, various attempts to improve prediction of "highrisk" AF subjects using biomarkers have been proposed, but the (very) marginal improvements in c-statistics over clinical-based scores were at the cost of substantially much lower simplicity and applicability for everyday clinical practice.…”

mentioning

confidence: 99%

Modern Management of Atrial Fibrillation Requires Initial Identification of “Low-Risk” Patients Using the CHA<sub>2</sub>DS<sub>2</sub>-VASc Score, and Not Focusing on “High-Risk” Prediction

Lip

Lane

2014

Circ J

View full text Add to dashboard Cite

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp statistics approximately 0.6-0.7), but this depends on the study setting and design. In one of the largest validation cohorts, 5 CHA2DS2-VASc had a c-statistic of 0.850, which outperformed the CHADS2 score (c-statistic 0.722) in predicting "high-risk" patients who developed thromboembolism; importantly, CHA2DS2-VASc was also better than CHADS2 in defining those patients at low-risk of thromboembolism. The other risk score referred to by Ikeda, the R2CHADS2 score, has many limitations that have been well recognised, notwithstanding its initial derivation from a selected trial anticoagulated cohort that did not include the range of stroke risk and excluded those with severe renal impairment. 6 Also, other "real world" studies have shown that adding extra points for "renal impairment" (as with the R2CHADS2 score) did not improve the predictive value of CHA2DS2-VASc. 7-9Nonetheless, various attempts to improve prediction of "highrisk" AF subjects using biomarkers have been proposed, but the (very) marginal improvements in c-statistics over clinical-based scores were at the cost of substantially much lower simplicity and applicability for everyday clinical practice.If Ikeda assumes that "a simple score is better," then classifying patients as "low-risk" using the CHADS2 score is simply putting many AF patients at risk of fatal and devastating strokes. In the Danish nationwide cohort study, based on >17,300 patients with a CHADS2 score=0, stroke rates were as high as 3.2% (with the upper boundary of the 95% CI as high as 6.4%) per year. 10 Would anyone reasonably withhold anticoagulation therapy for a 74-year-old female patient with AF and prior peripheral artery disease? Such a hypothetical patient would have a CHADS2 score=0 ("low risk"), but a CHA2DS2-VASc score=3 (for which anticoagulation is recommended). A comparison of CHA2DS2-VASc, CHADS2 and the van Walraven scores found that only the CHA2DS2-VASc score was a significant predictor of the absence of thromboembolism for a cohort of lone AF patients followed up over 12 years. 11If CHA2DS2-VASc is "very complicated", then Ikeda should be reassured that a recent survey of European clinical practice demonstrated uptake and use of this score in 97.7% of respondents whereas the HAS-BLED score was used by >78% for the assessment of bleeding-risk. 12 The EORP-AF survey found that anticoagulation rates were approx 80%, especially for lthough atrial fibrillation (AF) increases the risk of stroke, this risk is not homogeneous and depends on associated stroke risk factors, which have resulted in clinical scores to aid stroke risk stratification of AF patients. When vitamin K antagonists (VKAs) were the only option for oral anticoagulation, the focus was on the identification of "high risk" patients to be targeted for (inconvenient) VKA treatment. However, the landscape of thromboprophylaxis has changed markedly with the improvements in our understanding of how to use the VKAs ...

show abstract

Does chronic kidney disease improve the predictive value of the CHADS2 and CHA2DS2-VASc stroke stratification risk scores for atrial fibrillation?

Cited by 94 publications

References 29 publications

Meta-Analysis of the Influence of Chronic Kidney Disease on the Risk of Thromboembolism Among Patients With Nonvalvular Atrial Fibrillation

Meta-Analysis of the Influence of Chronic Kidney Disease on the Risk of Thromboembolism Among Patients With Nonvalvular Atrial Fibrillation

Risk of Thromboembolic Events in Atrial Fibrillation With Chronic Kidney Disease

Modern Management of Atrial Fibrillation Requires Initial Identification of “Low-Risk” Patients Using the CHA<sub>2</sub>DS<sub>2</sub>-VASc Score, and Not Focusing on “High-Risk” Prediction

Contact Info

Product

Resources

About