Author + information
- Received July 30, 2017
- Revision received October 25, 2017
- Accepted October 30, 2017
- Published online January 8, 2018.
- Tze-Fan Chao, MDa,b,
- Gregory Y.H. Lip, MDc,∗∗ (, )
- Chia-Jen Liu, MDd,e,
- Yenn-Jiang Lin, MDa,b,
- Shih-Lin Chang, MDa,b,
- Li-Wei Lo, MDa,b,
- Yu-Feng Hu, MDa,b,
- Ta-Chuan Tuan, MDa,b,
- Jo-Nan Liao, MDa,b,
- Fa-Po Chung, MDa,b,
- Tzeng-Ji Chen, MDf and
- Shih-Ann Chen, MDa,b,∗ ()
- aDivision of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- bInstitute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
- cInstitute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- dDivision of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- eInstitute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan
- fDepartment of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- ↵∗Address for correspondence:
Dr. Shih-Ann Chen, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, Taiwan.
- ↵∗∗Dr. Gregory Y.H. Lip, Institute of Cardiovascular Sciences, University of Birmingham, Dudley Road, Birmingham B18 7QH, United Kingdom.
Background When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA2DS2-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities.
Objectives This study hypothesized that the “Delta CHA2DS2-VASc score,” which reflects the change in score between baseline and follow-up, would be more predictive of ischemic stroke compared with the baseline CHA2DS2-VASc score.
Methods A total of 31,039 patients with AF who did not receive antiplatelet agents or oral anticoagulants, and who did not have comorbidities of the CHA2DS2-VASc score except for age and sex, were studied. The Delta CHA2DS2-VASc scores were defined as the differences between the baseline and follow-up CHA2DS2-VASc scores. During 171,956 person-years, 4,103 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA2DS2-VASc scores in predicting ischemic stroke were analyzed and compared.
Results The mean baseline CHA2DS2-VASc score was 1.29, which increased to 2.31 during the follow-up, with a mean Delta CHA2DS2-VASc score of 1.02. The CHA2DS2-VASc score remained unchanged in only 40.8% of patients. Among 4,103 patients who experienced ischemic stroke, 89.4% had a Delta CHA2DS2-VASc score ≥1 compared with only 54.6% in patients without ischemic stroke, and 2,643 (64.4%) patients had ≥1 new-onset comorbidity, the most common being hypertension. The Delta CHA2DS2-VASc score was a significant predictor of ischemic stroke that performed better than baseline or follow-up CHA2DS2-VASc scores, as assessed by the C-index and the net reclassification index.
Conclusions In this AF cohort, the authors demonstrated that the CHA2DS2-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHA2DS2-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.
This work was supported in part by grants from the Ministry of Science and Technology (MOST 104-2314-B-075-024-MY3), and Taipei Veterans General Hospital (V105B-023), Taipei, Taiwan.
Dr. Lip is a consultant for Bayer/Janssen, Bristol-Myers Squibb/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi-Sankyo; and a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Chao and Lip contributed equally to this work and are joint first authors.
- Received July 30, 2017.
- Revision received October 25, 2017.
- Accepted October 30, 2017.
- 2018 American College of Cardiology Foundation
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