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Stroke risk prediction in patients with atrial fibrillation with and without rheumatic heart disease
Alexander P Benz1, Jeff S Healey1, Ashley Chin2
1Division of Cardiology, Population Health Research Institute, McMaster University, 237 Barton St. E. Hamilton, ON L8L 2X2, Canada.
Insights
Rheumatic heart disease (RHD) patients with atrial fibrillation (AF) have a lower stroke risk than previously assumed. Moderate-to-severe mitral stenosis is not an independent stroke risk factor in AF patients.
Area of Science:
- Cardiology
- Vascular Medicine
- Epidemiology
Background:
- Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), particularly mitral stenosis, are often considered at high risk for stroke.
- This assumption necessitates a re-evaluation of stroke risk factors in contemporary AF populations.
Purpose of the Study:
- To re-evaluate stroke risk factors in a contemporary cohort of AF patients.
- To assess the independent contribution of RHD and mitral stenosis to stroke risk.
Main Methods:
- Analysis of data from 15,400 AF patients in the global RE-LY AF registry across 47 countries.
- 1-year follow-up data collection, with a focus on stroke events.
- Comparison of stroke risk factors and outcomes between patients with and without RHD, including assessment of the CHA2DS2-VASc score performance.
Main Results:
- 11.6% of patients had RHD; they were younger, more likely female, and had lower CHA2DS2-VASc scores than those without RHD.
- Unadjusted 1-year stroke rates were 2.8% for RHD patients and 4.1% for non-RHD patients.
- Mitral stenosis was not independently associated with stroke risk (aOR 1.07, P=0.764), and the CHA2DS2-VASc score showed modest performance in both groups.
Conclusions:
- The CHA2DS2-VASc score demonstrated modest predictive value for stroke in AF patients, irrespective of RHD status.
- Moderate-to-severe mitral stenosis was not identified as an independent risk factor for stroke in this AF cohort.
Aims:
Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), especially mitral stenosis, are assumed to be at high risk of stroke, irrespective of other factors. We aimed to re-evaluate stroke risk factors in a contemporary cohort of AF patients.
Methods And Results:
We analysed data of 15 400 AF patients presenting to an emergency department and who were enrolled in the global RE-LY AF registry, representing 47 countries from all inhabited continents. Follow-up occurred at 1 year after enrolment. A total of 1788 (11.6%) patients had RHD. These patients were younger (51.4±15.7 vs. 67.8±13.6 years), more likely to be female (66.2% vs. 44.7%) and had a lower mean CHA2DS2-VASc score (2.1±1.7 vs. 3.7±2.2) as compared to patients without RHD (all P<0.001). Significant mitral stenosis (average mean transmitral gradient 11.5±6.5 mmHg) was the predominant valve lesion in those with RHD (59.6%). Patients with RHD had a higher baseline rate of anticoagulation use (60.4% vs. 45.2%, P<0.001). Unadjusted stroke rates at 1 year were 2.8% and 4.1% for patients with and without RHD, respectively. The performance of the CHA2DS2-VASc score was modest in both groups [stroke at 1 year, c-statistics 0.69, 95% confidence interval (CI) 0.60-0.78 and 0.63, 95% CI 0.61-0.66, respectively]. In the overall cohort, advanced age, female sex, prior stroke, tobacco use, and non-use of anticoagulation were predictors for stroke (all P<0.05). Mitral stenosis was not associated with stroke risk (adjusted odds ratio 1.07, 95% CI 0.67-1.72, P=0.764).
Conclusion:
The performance of the CHA2DS2-VASc score was modest in AF patients both with and without RHD. In this cohort, moderate-to-severe mitral stenosis was not an independent risk factor for stroke.
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