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CHA2DS2-VASc Score for Identifying Truly Low-Risk Atrial Fibrillation for Stroke: A Korean Nationwide Cohort Study
Tae-Hoon Kim1, Pil-Sung Yang1, Daehoon Kim1
1From the Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea (T.-H.K., P.-S.Y., D.K., H.T.Y., J.-S.U., J.-Y.K., H.-N.P., M.-H.L., B.J.); Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.); and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.).
Insights
The CHA₂DS₂-VASc score effectively identifies low-risk patients with atrial fibrillation, outperforming CHADS₂ and ATRIA scores in predicting ischemic stroke. This helps avoid unnecessary antithrombotic therapy in truly low-risk individuals.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Stroke prevention in nonvalvular atrial fibrillation (AF) is shifting towards identifying low-risk patients who do not require antithrombotic therapy.
- The introduction of non-vitamin K antagonist oral anticoagulants (NOACs) has lowered stroke risk thresholds for treatment initiation.
Purpose of the Study:
- To evaluate the predictive performance of CHADS₂, CHA₂DS₂-VASc, and ATRIA risk stratification schemes in identifying truly low-risk, oral anticoagulant-naive patients with AF in a Korean population.
- To compare the ability of these scores to predict ischemic stroke incidence.
Main Methods:
- A nationwide cohort of 5855 oral anticoagulant-naive nonvalvular AF patients (aged ≥20 years) was analyzed from the Korea National Health Insurance Service-Sample Cohort database (2002-2008).
- Patients were followed until December 2013 to assess ischemic stroke events.
- The predictive accuracy and negative predictive value of CHADS₂, CHA₂DS₂-VASc, and ATRIA scores for stroke were compared.
Main Results:
- At baseline, CHA₂DS₂-VASc categorized 14.7% of patients as low risk, compared to 17.9% for CHADS₂ and 56.0% for ATRIA.
- During follow-up, the incidence of ischemic stroke per 100 person-years in the low-risk categories was 0.26 for CHA₂DS₂-VASc, 0.42 for CHADS₂, and 1.43 for ATRIA.
- CHA₂DS₂-VASc demonstrated the highest sensitivity (98.8%) and negative predictive value (98.8%) for stroke prediction, significantly outperforming CHADS₂ and ATRIA.
Conclusions:
- The CHA₂DS₂-VASc score exhibits superior performance in identifying truly low-risk Asian patients with atrial fibrillation for stroke prevention compared to CHADS₂ and ATRIA scores.
- This suggests that CHA₂DS₂-VASc is a more reliable tool for determining which AF patients can safely forgo antithrombotic therapy.
Background And Purpose:
As the threshold of stroke risk for initiating oral anticoagulants is lowered after the introduction of the nonvitamin K antagonist oral anticoagulants, the focus of stroke prevention in patients with nonvalvular atrial fibrillation has shifted away from predicting high-risk patients toward initially identifying patients with a truly low risk of ischemic stroke, who do not need antithrombotic therapy. We tested the predictive ability of the congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack (doubled; CHADS2), congestive heart failure, hypertension, age ≥75 (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65 to 74, female (CHA2DS2-VASc), and Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) risk stratification schemes in oral anticoagulants naive patients with atrial fibrillation in a Korean nationwide sample cohort.
Methods:
From January 2002 to December 2008, a total of 5855 oral anticoagulant naive patients with nonvalvular atrial fibrillation aged ≥20 years were enrolled from Korea National Health Insurance Service-Sample Cohort database and were followed-up until December 2013.
Results:
At baseline, the proportions categorized as low risk using CHADS2, CHA2DS2-VASc, and ATRIA risk stratification schemes were 1049 (17.9%), 860 (14.7%), and 3280 (56.0%), respectively. During follow-up, the low-risk category using CHADS2, CHA2DS2-VASc, and ATRIA scores was retained in 811 (13.9%), 667 (11.4%), and 2729 (46.6%) patients, respectively. Rates of ischemic stroke (100 person-years) in the low risk categories of CHADS2, CHA2DS2-VASc, and ATRIA scores were 0.42, 0.26, and 1.43, respectively. CHA2DS2-VASc had the best sensitivity (98.8% versus 85.7% in CHADS2 and 74.8% in ATRIA) and negative predictive value (98.8% versus 95.3% for CHADS2 and 93.7% for ATRIA) for the prediction of stroke incidence and was best for the prediction of the absence of ischemic stroke during 5 years of follow-up (odds ratio, 16.4 [95% confidence interval, 8.8-30.8]).
Conclusions:
The CHA2DS2-VASc score shows good performance in defining truly low-risk Asian patients with atrial fibrillation for stroke compared with CHADS2 and ATRIA scores.
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