Stroke Risk and Treatment in Patients with Atrial Fibrillation and Low CHA ₂ DS ₂ ‐VASc Scores: Findings From the ORBIT‐AF I and II Registries

Abstract

BackgroundCurrent American College of Cardiology/American Heart Association guidelines suggest that for patients with atrial fibrillation who are at low risk for stroke (CHA2DS2VASc=1) (or women with CHA2DS2VASc=2) a variety of treatment strategies may be considered. However, in clinical practice, patterns of treatment in these “low‐risk” patients are not well described. The objective of this analysis is to define thromboembolic event rates and to describe treatment patterns in patients with low‐risk CHA2DS2VASc scores.Methods and ResultsWe compared characteristics, treatment strategies, and outcomes among patients with a CHA2DS2VASc=0, CHA2DS2VASc=1, females with a CHA2DS2VASc=2, and CHA2DS2VASc ≥2 in ORBIT‐AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) I & II. Compared with CHA2DS2VASc ≥2 patients (84.2%), those with a CHA2DS2VASc=0 (60.3%), 1 (69.9%), and females with a CHA2DS2VASc score=2 (72.4%) were significantly less often treated with oral anticoagulation (P<0.0001). Stroke rates were low overall and ranged from 0 per 100 patient‐years in those with CHA2DS2VASc=0, 0.8 (95% confidence interval [CI] [0.5–1.2]) in those with CHA2DS2VASc=1, 0.8 (95% CI [0.4–1.6]) in females with a CHA2DS2VASc score=2, and 1.7 (95% CI [1.6–1.9]) in CHA2DS2VASc ≥2. All‐cause mortality (per 100 patient‐years) was highest in females with a CHA2DS2VASc score=2 (1.4) (95% CI [0.8–2.3]), compared with patients with a CHA2DS2VASc=0 (0.2) (95% CI [0.1–1.0]), and CHA2DS2VASc=1 (1.0) (95% CI [0.7–1.4]), but lower than patients with a CHA2DS2VASc ≥2 (5.7) (95% CI [5.4–6.0]).ConclusionThe majority of CHA2DS2VASc=0‐1 patients are treated with oral anticoagulation. In addition, the absolute risks of death and stroke/transient ischemic attack were low among both male and females CHA2DS2VASc=0‐1 as well as among females with a CHA2DS2VASc score=2.Clinical Trial RegistrationURL:http://www.clinicaltrials.gov. Unique identifier: NCT01701817.

Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant)

“…Patients with paroxysmal AF were shown to suffer from significantly lower frequencies of ischemic heart disease, vascular disease, diabetes mellitus, valvular heart disease and heart failure/left ventricular dysfunction. Our data complements an increasing array of findings generated both prospective and retrospective clinical trials [6–13] that, considered together, continue to shape and improve the risk stratification of patients with AF in terms of the prediction of mortality, stroke and bleeding as well as the optimal timing of anticoagulation therapy.…”

“…There is considerable variability in published results relating to the mortality of AF patients in correlation with CHA 2 DS 2 -VASc score, especially with regards to patient history, drug treatment and clinical status. [6–13] There are several important clinical characteristics that affect the risk of such events, for example, coronary artery disease, heart failure, diabetes mellitus, and hypertension, and this could explain, at least in part, the difference between the results of the present and previous studies. Also, considerable variation exists in the publications about the risk of ischemic stroke in AF patients with CHA 2 DS 2 -VASc score of 1, focused to differences in ischemic stroke versus thromboembolism.…”

“…Although many groups have reported their findings with regards to a number of variables that are associated with outcomes of patients diagnosed with AF (such as bleeding, thrombi or embolisms), fewer reports have looked more specifically at mortality and its causes. [6–13] Because the CHA 2 DS 2 -VASc introduces new variables very useful for the clinical cardiologist, the ESC [4] as well as the ACC/AHA [5] recommended the CHA 2 DS 2 -VASc score in the management of atrial fibrillation in guidelines. The CHA 2 DS 2 -VASc introduces new variables very useful for the clinical cardiologist such as previous myocardial infarction or chronic stable coronary disease in all its clinical manifestation, and peripheral vascular disease, including aortic atherosclerosis, lower extremities arterial disease, and carotid artery disease, and also congestive heart failure, hypertension, diabetes, stroke vascular disease, age, and sex category.…”

“…The CHA 2 DS 2 -VASc introduces new variables very useful for the clinical cardiologist such as previous myocardial infarction or chronic stable coronary disease in all its clinical manifestation, and peripheral vascular disease, including aortic atherosclerosis, lower extremities arterial disease, and carotid artery disease, and also congestive heart failure, hypertension, diabetes, stroke vascular disease, age, and sex category. [6]…”

Anticoagulation in pulmonary arterial hypertension: a decision analysis

“…We estimated women with PAH would have a CHA 2 DS 2 VASc score of two, corresponding to an annual stroke rate of 2.2%, and men would have a score of one and an annual stroke rate of 1.3%. 7,38–47 The effectiveness of AC on the prevention of stroke was also based on the CHA 2 DS 2 VASc scores, with a HR of 0.26 for stroke in women and 0.49 for stroke in men 44–47 (Table 1).…”