Should the Presence or Extent of Coronary Artery Disease be Quantified in the CHA2DS2-VASc Score in Atrial Fibrillation? A Report from the Western Denmark Heart Registry

Abstract

Background Patients with atrial fibrillation (AF) have an increased risk of ischaemic stroke. The risk can be predicted by the CHA2DS2-VASc score, in which the vascular component refers to previous myocardial infarction, peripheral artery disease and aortic plaque, whereas coronary artery disease (CAD) is not included. Objectives This article explores whether CAD per se or extent provides independent prognostic information of future stroke among patients with AF. Materials and Methods Consecutive patients with AF and coronary angiography performed between 2004 and 2012 were included. The endpoint was a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. The risk of ischaemic events was estimated according to the presence and extent of CAD. Incidence rate ratios (IRR) were calculated in reference to patients without CAD and adjusted for parameters included in the CHA2DS2-VASc score and treatment with anti-platelet agents and/or oral anticoagulants. Results Of 96,430 patients undergoing coronary angiography, 12,690 had AF. Among patients with AF, 7,533 (59.4%) had CAD. Mean follow-up was 3 years. While presence of CAD was an independent risk factor for the composite endpoint (adjusted IRR, 1.25; 1.06–1.47), extent of CAD defined as 1-, 2-, 3- or diffuse vessel disease did not add additional independent risk information. Conclusion Presence, but not extent, of CAD was an independent risk factor of the composite thromboembolic endpoint beyond the components already included in the CHA2DS2-VASc score. Consequently, we suggest that significant angiographically proven CAD should be included in the vascular disease criterion in the CHA2DS2-VASc score.

Optimizing Stroke and Bleeding Risk Assessment in Patients with Atrial Fibrillation: A Balance of Evidence, Practicality and Precision

“…In this same issue of Thrombosis Haemostasis, Steensig et al 26 extend their recent report on significant association between the presence of angiographically documented coronary artery disease (CAD) and subsequent thromboembolic events 27 showing that the extent of CAD (i.e. 1-, 2-, 3-vessel or diffuse) did not add additional risk prediction information regarding ischaemic stroke, transient ischaemic attack or systemic embolism among 12,690 AF patients undergoing coronary angiography (with CAD diagnosed in 59.4%) over a 3-year follow-up.…”

Atrial Fibrillation in Older People: Concepts and Controversies

“…In older patients, the presence of multiple comorbidities adds to the complexity of establishing the impact of aging vs. the impact of comorbidities on the development of AF, in isolation. The aging heart offers an ideal environment for AF to flourish in the presence of predisposing “anatomical substrate” abnormalities, due to conditions such as hypertension, ischaemic heart disease, heart failure, valvular disease, and dilated/hypertrophic cardiomyopathy (27, 28). These have been associated with histopathological and atrial chamber abnormalities which result in myocardial fibrosis and atrial dilation, thus increasing the risk of AF (29).…”

The year in cardiology: arrhythmias and pacing

“…20 Risk assessment continues to evolve, with availability of new data showing stroke risks associated with AF patients with hypertrophic cardiomyopathy 21 and imaging-documented significant coronary artery lesions. 22 There has been much interest into use of sophisticated methods such as machine-learning, even predicting incident AF from a simple 12-lead ECG. 23 More complex risk assessment approaches improve AF stroke risk prediction (at least statistically) but need to be balanced against simplicity and practical application.…”