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Importance of Risk Reassessment in Patients With Atrial Fibrillation in Guidelines: Assessing Risk as a Dynamic

Ting-Yung Chang¹, Gregory Y H Lip², Shih-Ann Chen¹

¹Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.

The Canadian Journal of Cardiology

|April 30, 2019

Insights

Regularly reassessing stroke and bleeding risk scores, like CHA2DS2-VASc and HAS-BLED, is crucial for atrial fibrillation patients. Dynamic risk scores improve prediction and guide timely oral anticoagulant therapy, enhancing patient care.

Area of Science:

Cardiology and Internal Medicine
Pharmacology and Therapeutics

Background:

Atrial fibrillation (AF) management relies on accurate stroke risk prediction using the CHA2DS2-VASc score.
Patient risk profiles, including CHA2DS2-VASc and bleeding risk scores (e.g., HAS-BLED), are dynamic and can change over time due to aging and comorbidities.

Purpose of the Study:

To evaluate the predictive accuracy of dynamic (follow-up and change in) CHA2DS2-VASc and HAS-BLED scores compared to baseline scores for stroke and major bleeding in AF patients.
To emphasize the importance of regular risk reassessment in AF management.

Main Methods:

Analysis of available data comparing the predictive performance of baseline, follow-up, and change (Δ) in CHA2DS2-VASc and HAS-BLED scores.
Assessment of stroke and major bleeding risks following changes in these scores.

Main Results:

Follow-up and Δ CHA2DS2-VASc scores demonstrated superior prediction of ischemic stroke compared to baseline scores.
Approximately 90% of initially low-risk AF patients develop a Δ CHA2DS2-VASc score of ≥1 before experiencing ischemic stroke.
Follow-up and Δ HAS-BLED scores showed significantly higher accuracy in predicting major bleeding than baseline HAS-BLED scores.

Conclusions:

Dynamic risk assessment using follow-up and Δ CHA2DS2-VASc and HAS-BLED scores offers improved prediction of stroke and bleeding in AF patients.
Increased risks of stroke and bleeding are observed shortly after increases in risk scores, highlighting the need for timely intervention.
Regular reassessment of AF patient risk profiles is essential for appropriate oral anticoagulant therapy initiation and modification of bleeding risk factors.

Read full analysis

Abstract:

The appropriate use of oral anticoagulants (OACs) for prevention of stroke in atrial fibrillation (AF) relies on the convenient and accurate stroke risk-prediction scheme: namely, the CHA₂DS₂-VASc score. As patients with AF would become older and accumulate more comorbidities, their risks-for example, as reflected by the CHA₂DS₂-VASc scores-are not static and could increase over time. The available data demonstrated that follow-up and Δ CHA₂DS₂-VASc scores perform better than the baseline CHA₂DS₂-VASc score in the prediction of ischemic stroke. Approximately 90% of initially low-risk patients would have a Δ CHA₂DS₂-VASc score ≥ 1 before the occurrence of ischemic stroke. Apart from risk of stroke, the risk of bleeding for patients with AF is also highly dynamic. For example, the accuracies of the follow-up or Δ Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol (HAS-BLED) score in the prediction of major bleeding was significantly higher than that of the baseline HAS-BLED score. Most importantly, the risks of stroke and major bleeding were higher within several months after patients had changes (increases) in their stroke- or bleeding-risk scores. Therefore, risk profiles of patients with AF should be reassessed regularly so that OACs could be prescribed in a timely manner once patients are no longer at low risk for stroke, and modifiable risk factors for bleeding could be corrected. More efforts are necessary to incorporate clear and easy-to-follow recommendations about risk reassessment into the guidelines to improve AF patient care.

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