Should AF Patients With Extra Risk Factor Receive Angicoagulants?
Background Although the CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65 to 74 years, female) score is recommended by both American and European guidelines for stroke risk stratification in atrial fibrillation (AF), the treatment recommendations for a CHA2DS2-VASc score of 1 are less clear.
Objectives This study aimed to investigate the risk of ischemic stroke in patients with a single additional stroke risk factor (i.e., CHA2DS2-VASc score = 1 [males] or 2 [females]) and the impact of different component risk factors.
Methods We used the National Health Insurance Research Database in Taiwan. Among 186,570 AF patients not on antiplatelet or anticoagulant therapy, we evaluated males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2. The clinical endpoint was the occurrence of ischemic stroke.
Results Among 12,935 male AF patients with a CHA2DS2-VASc score of 1, 1,858 patients (14.4%) experienced ischemic stroke during follow-up (5.2 ± 4.3 years), with an annual stroke rate of 2.75%. Ischemic stroke risk ranged from 1.96%/year for men with vascular disease to 3.50%/year for those 65 to 74 years of age. For 7,900 females with AF and a CHA2DS2-VASc score of 2, 14.9% experienced ischemic stroke for an annual stroke rate of 2.55%. Ischemic stroke risk increased from 1.91%/year for women with hypertension to 3.34%/year for those 65 to 74 years of age.
Conclusions Not all risk factors in CHA2DS2-VASc score carry an equal risk, with age 65 to 74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 additional stroke risk factor given their high risk of ischemic stroke.
Atrial fibrillation (AF) is an important risk factor for ischemic stroke, and AF-related stroke has a worse prognosis and higher recurrence rate compared with non–AF-related stroke. In 2010, the CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65 to 74 years, female) score was first proposed to calculate stroke risk for patients with AF. It has now been well validated in several independent cohorts.
In 2012, the European Society of Cardiology (ESC) guidelines recommended using the CHA2DS2-VASc score for stroke risk stratification in AF, followed by the Asia Pacific Heart Rhythm Society, and in 2014 by the American College of Cardiology/American Heart Association (ACC/AHA) AF guidelines as well as the National Institute for Health and Care Excellence guidelines. Nonetheless, the treatment recommendations are not identical in these different guidelines. In the ESC, Asia Pacific Heart Rhythm Society, and National Institute for Health and Care Excellence guidelines, low-risk patients (CHA2DS2-VASc score of 0 for males, 1 for females) are not recommended for any antithrombotic therapy, whereas oral anticoagulant agents (OACs) are advised for male AF patients with a CHA2DS2-VASc score of 1. The 2014 ACC/AHA guideline states that "no antithrombotic therapy, aspirin or an OAC" may be considered for AF patients with a CHA2DS2-VASc score of 1 (class IIb recommendation). Because being female is a risk factor, increasing the CHA2DS2-VASc score by 1 point, does that mean all women in the United States with AF are candidates for OACs?
Abstract and Introduction
Abstract
Background Although the CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65 to 74 years, female) score is recommended by both American and European guidelines for stroke risk stratification in atrial fibrillation (AF), the treatment recommendations for a CHA2DS2-VASc score of 1 are less clear.
Objectives This study aimed to investigate the risk of ischemic stroke in patients with a single additional stroke risk factor (i.e., CHA2DS2-VASc score = 1 [males] or 2 [females]) and the impact of different component risk factors.
Methods We used the National Health Insurance Research Database in Taiwan. Among 186,570 AF patients not on antiplatelet or anticoagulant therapy, we evaluated males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2. The clinical endpoint was the occurrence of ischemic stroke.
Results Among 12,935 male AF patients with a CHA2DS2-VASc score of 1, 1,858 patients (14.4%) experienced ischemic stroke during follow-up (5.2 ± 4.3 years), with an annual stroke rate of 2.75%. Ischemic stroke risk ranged from 1.96%/year for men with vascular disease to 3.50%/year for those 65 to 74 years of age. For 7,900 females with AF and a CHA2DS2-VASc score of 2, 14.9% experienced ischemic stroke for an annual stroke rate of 2.55%. Ischemic stroke risk increased from 1.91%/year for women with hypertension to 3.34%/year for those 65 to 74 years of age.
Conclusions Not all risk factors in CHA2DS2-VASc score carry an equal risk, with age 65 to 74 years associated with the highest stroke rate. Oral anticoagulation should be considered for AF patients with 1 additional stroke risk factor given their high risk of ischemic stroke.
Introduction
Atrial fibrillation (AF) is an important risk factor for ischemic stroke, and AF-related stroke has a worse prognosis and higher recurrence rate compared with non–AF-related stroke. In 2010, the CHA2DS2-VASc (congestive heart failure, hypertension, age 75 years or older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, age 65 to 74 years, female) score was first proposed to calculate stroke risk for patients with AF. It has now been well validated in several independent cohorts.
In 2012, the European Society of Cardiology (ESC) guidelines recommended using the CHA2DS2-VASc score for stroke risk stratification in AF, followed by the Asia Pacific Heart Rhythm Society, and in 2014 by the American College of Cardiology/American Heart Association (ACC/AHA) AF guidelines as well as the National Institute for Health and Care Excellence guidelines. Nonetheless, the treatment recommendations are not identical in these different guidelines. In the ESC, Asia Pacific Heart Rhythm Society, and National Institute for Health and Care Excellence guidelines, low-risk patients (CHA2DS2-VASc score of 0 for males, 1 for females) are not recommended for any antithrombotic therapy, whereas oral anticoagulant agents (OACs) are advised for male AF patients with a CHA2DS2-VASc score of 1. The 2014 ACC/AHA guideline states that "no antithrombotic therapy, aspirin or an OAC" may be considered for AF patients with a CHA2DS2-VASc score of 1 (class IIb recommendation). Because being female is a risk factor, increasing the CHA2DS2-VASc score by 1 point, does that mean all women in the United States with AF are candidates for OACs?
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