Wide Variation in Reported Rates of Stroke Across Cohorts of Patients With Atrial Fibrillation

Quinn, Gene R.; Severdija, Olivia N.; Chang, Yuchiao; Singer, Daniel E.

doi:10.1161/circulationaha.116.024057

Cited by 89 publications

(46 citation statements)

References 49 publications

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“…Prior studies using the CHA 2 DS 2 VASc stratification tool have produced differing conclusions regarding the role of OAC in patients with an additional risk factor for stroke/systemic embolism 19. Lip and colleagues in a large Danish cohort of patients with AF demonstrated that in untreated patients with 1 additional stroke risk factor (CHA 2 DS 2 VASc=1 [male],=2 [female]), strokes rates increased 3‐fold compared with untreated low‐risk patients (CHA 2 DS 2 VASc=0 [male], =1 [female]) 20.…”

Section: Discussionmentioning

confidence: 99%

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

Jackson

Kim

Fonarow

et al. 2018

JAHA

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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.

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Section: Discussionmentioning

confidence: 99%

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

Jackson

Kim

Fonarow

et al. 2018

JAHA

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“…The AHA/ACC/HRS and ESC guidelines recommend the CHA 2 DS 2 ‐VASc scoring system to guide use of anticoagulants in AF, assuming that CHA 2 DS 2 ‐VASc point scores correspond to fixed absolute risks of ischemic stroke 4, 5, 6. However, our previous work demonstrated wide variation in overall and point score–stratified stroke rates across multiple large AF cohorts, despite similar high study quality using an objective scoring system 10, 28. Of note, the CHA 2 DS 2 ‐VASc point score–specific stroke rates observed in several of these cohorts were too low to support the anticoagulation threshold recommended by the AHA/ACC/HRS and ESC guidelines (CHA 2 DS 2 ‐VASc ≥2, discounting female sex, for the ESC guidelines) 4, 5, 6.…”

Section: Discussionmentioning

confidence: 89%

“…10 We excluded randomized controlled trials, which contribute only a small fraction of follow‐up of AF patients off anticoagulants,10 and we focus exclusively on large observational cohort studies where design and analysis methods are more variable. To this end, we restricted our analyses to studies that included at least 5000 patients.…”

Section: Methodsmentioning

confidence: 99%

“…To support this assumption, the guidelines cite off‐anticoagulant stroke rates from large cohort studies 7, 8, 9. However, our and others’ previous work has shown wide variation in the reported stroke rates from different cohorts of patients with AF 5, 10. Depending upon AF cohort, a CHA 2 DS 2 ‐VASc score of 2 would lead to a positive or a negative expected net clinical benefit, calling into question the general applicability of guideline recommendations.…”

Section: Introductionmentioning

confidence: 99%

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Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk

Quinn

Severdija

Chang

et al. 2018

JAHA

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BackgroundGuidelines for anticoagulation in atrial fibrillation (AF) assume that stroke risk scheme point scores correspond to fixed stroke rates. However, reported stroke rates vary widely across AF cohort studies, including studies from the same country. Reasons for this variation are unclear. This study compares methodologies used to assemble and analyze large AF cohorts worldwide and assesses potential bias in estimating stroke rates.Methods and ResultsFrom a previous systematic review of AF cohorts, we analyzed studies including at least 5000 patients. We assessed methods used to generate rates of ischemic stroke off anticoagulants, according to a structured inventory of database interrogation methods. Nine studies (497 578 total patients) met our criteria. Overall cohort stroke rates ranged from 0.45% to 7.03% per year. In bivariate study‐level analysis, multiple features were associated with higher stroke rates, including AF identified as inpatients versus outpatients (rate ratio 2.60, 95% confidence interval, 1.19, 5.68), and lack of clinical validation of outcome events (rate ratio 4.09, 95% confidence interval, 1.06, 15.70). European studies reported rates more than 4‐fold higher than North American studies. International Classification of Diseases (ICD) coding schemes for outcomes varied widely. Multiple high rate features coexisted in the same studies.ConclusionsAmong AF cohort studies, differences in the composition, method of assembly, determination of clinical features and outcomes, and analytic approach were strongly associated with reported stroke rates. Our study highlights the need for standardized and validated methodologies for AF cohort assembly and analysis to generate accurate stroke rates to better support anticoagulation guidelines for patients with AF.

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“…18 These observations suggest that the sex-related differences in the event risk of AF patients might differ among registry, it was shown that female sex was also a risk factor for stroke in Chinese AF patients. 17 Quinn et al recently reported that the global incidence rates of stroke were The aim of this present study was to assess the characteristics of female AF patients and the effect of female sex on thromboembolism and various clinical events in a cohort of AF patients enrolled in a specific region of Japan.…”

mentioning

confidence: 92%

Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation　― The Fushimi AF Registry ―

Ogawa

Hamatani

Doi

et al. 2017

Circ J

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ies have reported conflicting results. 12, 13 In Japanese patients with AF, the J-RHYTHM registry concluded that female sex was not an independent risk factor for thromboembolic events and that male sex was a risk factor for major bleeding and all-cause death. 14 In addition, they validated that the 'CHA2DS2-VA score', excluding female sex, was performed similarly for risk stratification for thromboembolic events. 15 However, a Taiwanese study indicated that females had a higher rate of ischemic stroke than males among patients with AF who were not taking anticoagulants and aged <65 years. 16 In a Chinese AF A trial fibrillation (AF) is the most common cardiac arrhythmia and increases the risk of ischemic stroke and death. 1,2 Previous studies have indicated sex-related differences in the clinical characteristics and outcomes of AF patients. 3-6 Female sex is considered an increased risk for thromboembolism in patients with AF, albeit with an age-dependency (being relevant at age ≥65 or with other risk factors) and is included in the CHA2DS2-VASc score for stroke risk stratification. 7-10 A recent Swedish study also demonstrated that female AF patients aged ≥75 years are at higher risk of ischemic stroke, 11 but other stud- Background: Female sex is considered a risk factor for thromboembolism in patients with atrial fibrillation (AF), and is included in the risk stratification scheme, CHA2DS2-VASc score. The purpose of the present study was to investigate the clinical outcomes of female Japanese AF patients.

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Wide Variation in Reported Rates of Stroke Across Cohorts of Patients With Atrial Fibrillation

Cited by 89 publications

References 49 publications

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

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

Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk

Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation　― The Fushimi AF Registry ―

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Wide Variation in Reported Rates of Stroke Across Cohorts of Patients With Atrial Fibrillation

Cited by 89 publications

References 49 publications

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

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

Methodologic Differences Across Studies of Patients With Atrial Fibrillation Lead to Varying Estimates of Stroke Risk

Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation ― The Fushimi AF Registry ―

Contact Info

Product

Resources

About

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

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

Sex-Related Differences in the Clinical Events of Patients With Atrial Fibrillation　― The Fushimi AF Registry ―