Stroke risk prediction in patients with atrial fibrillation with and without rheumatic heart disease

Abstract

Aims Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), especially mitral stenosis, are assumed to be at high risk of stroke, irrespective of other factors. We aimed to re-evaluate stroke risk factors in a contemporary cohort of AF patients. Methods and results We analysed data of 15 400 AF patients presenting to an emergency department and who were enrolled in the global RE-LY AF registry, representing 47 countries from all inhabited continents. Follow-up occurred at 1 year after enrolment. A total of 1788 (11.6%) patients had RHD. These patients were younger (51.4±15.7 vs. 67.8±13.6 years), more likely to be female (66.2% vs. 44.7%) and had a lower mean CHA2DS2-VASc score (2.1±1.7 vs. 3.7±2.2) as compared to patients without RHD (all P<0.001). Significant mitral stenosis (average mean transmitral gradient 11.5±6.5 mmHg) was the predominant valve lesion in those with RHD (59.6%). Patients with RHD had a higher baseline rate of anticoagulation use (60.4% vs. 45.2%, P<0.001). Unadjusted stroke rates at 1 year were 2.8% and 4.1% for patients with and without RHD, respectively. The performance of the CHA2DS2-VASc score was modest in both groups [stroke at 1 year, c-statistics 0.69, 95% confidence interval (CI) 0.60–0.78 and 0.63, 95% CI 0.61–0.66, respectively]. In the overall cohort, advanced age, female sex, prior stroke, tobacco use, and non-use of anticoagulation were predictors for stroke (all P<0.05). Mitral stenosis was not associated with stroke risk (adjusted odds ratio 1.07, 95% CI 0.67–1.72, P=0.764). Conclusion The performance of the CHA2DS2-VASc score was modest in AF patients both with and without RHD. In this cohort, moderate-to-severe mitral stenosis was not an independent risk factor for stroke.

Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation

“…The majority of the studies validated a risk score in a general predominantly Caucasian AF population, with the exception of studies validating prior or post-surgery ( n = 6), 60–65 in cohorts with a specific secondary disease ( n = 11), 42 , 44 , 66–74 or in cohorts with ethnicity other than predominantly Caucasian ( n = 20). 33 , 34 , 45 , 47 , 53 , 55 , 65 , 71 , 75–87 Discrimination was presented in all studies ( n = 107) and indicated poor (<0.60) to reasonable (0.60–0.80) and in exceptional cases good (>0.80) discrimination; these values are visualized in the forest plots given in Supplementary material online, section ‘Random-effects meta-analysis’ . For the risk scores developed after the publication of the CHA 2 DS 2 -VASc (2010), no discrimination lower than 0.60 was reported in the validation studies.…”

Anticoagulation for rheumatic mitral stenosis, INVICTUS in perspective

“…Progressive increases in left atrial dimensions, in conjunction with atrial inflammation, can lead to the development of AF in patients with rheumatic MS [11][12][13]. Meta-analyses of over 75 000 patients with RHD suggests an AF prevalence rate of upward of 33% with higher rates seen in those with mixed MS and mitral-regurgitation (MR) phenotype [14].…”

“…Many reviews often quote the risk of stroke in patients with AF and RHD to be approximately 18-fold higher than patients without AF-a number that was generated from studies in the 1970s when anticoagulation was used infrequently or incorrectly [13,16]. In a series of recent articles, Karthikeyan et al [12] and Benz et al [13] detail that…”

“…contemporary rates of stroke in patients with AF and rheumatic MS are much lower than have been previously described. In fact, when the global RE-LY registry was interrogated, patients with AF and RHD (n ¼ 1788) had an unadjusted stroke rate at 1-year of 2.8% (compared to 4.1% in those with AF but without RHD) [13]. Compared to previous retrospective studies which suggested yearly stroke rates ranging from 2.4% to 5.2% in patients with rheumatic MS and AF, recent studies indicate that in the era of anticoagulation this is more in the 0.4-4 per 100 patient years range [12,13].…”

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial

“…3 In patients with RHD, AF is associated with increased prevalence of heart failure, stroke, peripheral embolism and death. [4][5][6][7] Especially, about 80% of the strokes in patients with RHD occur in patients with mitral stenosis and AF. 8 Guidelines recommended that surgical ablation for AF could be performed without additional risk of operative mortality or major morbidity, and was recommended at the time of concomitant MV operations to restore sinus rhythm (class I, level A).…”