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Published on: February 28, 2012
Predictive performance of the CHA2DS2-VASc rule in atrial fibrillation: a systematic review and meta-analysis
S van Doorn1, T P A Debray1, F Kaasenbrood1
1Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
Insights
The CHA2DS2-VASc score for atrial fibrillation stroke risk shows high variability in studies. This heterogeneity in stroke risk prediction could not be fully explained by patient care settings.
Area of Science:
- Cardiology
- Clinical Epidemiology
- Medical Statistics
Background:
- The CHA2DS2-VASc rule is standard for estimating stroke risk in atrial fibrillation (AF) patients.
- Validation studies show conflicting results, necessitating further investigation.
Purpose of the Study:
- To systematically review and meta-analyze studies validating the CHA2DS2-VASc score.
- To assess stroke risk estimates across different CHA2DS2-VASc scores.
- To explore sources of heterogeneity in validation study results.
Main Methods:
- Systematic literature review and random-effects meta-analysis.
- Included 19 external validation studies of CHA2DS2-VASc in non-anticoagulated AF patients.
- Utilized meta-regression and stratification by clinical setting to explore heterogeneity.
Main Results:
- Analysis of over two million person-years revealed significant heterogeneity in stroke risks for CHA2DS2-VASc scores.
- Hospital-recruited patients showed higher stroke risks compared to those from the general population.
- Heterogeneity persisted and was not fully explained by clinical setting or meta-regression.
Conclusions:
- Existing studies validating the CHA2DS2-VASc score exhibit substantial heterogeneity in stroke risk predictions.
- The variability in stroke risk estimates highlights potential limitations in its universal application.
- Further research is needed to understand and address the sources of this heterogeneity.
Abstract:
Essentials The widely recommended CHA2DS2-VASc shows conflicting results in contemporary validation studies. We performed a systematic review and meta-analysis of 19 studies validating CHA2DS2-VASc. There was high heterogeneity in stroke risks for different CHA2DS2-VASc scores. This was not explained by differences between setting of care, or by performing meta-regression.
Summary:
Background The CHA2DS2-VASc decision rule is widely recommended for estimating stroke risk in patients with atrial fibrillation (AF), although validation studies show ambiguous and conflicting results. Objectives To: (i) review existing studies validating CHA2DS2-VASc in AF patients who are not (yet) anticoagulated; (ii) meta-analyze estimates of stroke risk per score; and (iii) explore sources of heterogeneity across the validation studies. Methods We performed a systematic literature review and random effects meta-analysis of studies externally validating CHA2DS2-VASc in AF patients not receiving anticoagulants. To explore between-study heterogeneity in stroke risk, we stratified studies to the clinical setting in which patient enrollment started, and performed meta-regression. Results In total, 19 studies were evaluated, with over two million person-years of follow-up. In studies recruiting AF patients in hospitals, stroke risks for scores of 0, 1 and 2 were 0.4% (approximate 95% prediction interval [PI] 0.2-3.2%), 1.2% (95% PI 0.1-3.8%), and 2.2% (95% PI 0.03-7.8%), respectively. These were consistently higher than those in studies recruiting patients from the open general population, with risks of 0.2% (95% PI 0.0-0.9%), 0.7% (95% PI 0.3-1.2%) and 1.5% (95% PI 0.4-3.3%) for scores of 0, 1, and 2, respectively. Heterogeneity, as reflected by the wide PIs, could not be fully explained by meta-regression. Conclusions Studies validating CHA2DS2-VASc show high heterogeneity in predicted stroke risks for different scores.
