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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Relationship between temporal rhythm-based classification of atrial fibrillation and stroke: real-world vs. clinical
Wern Yew Ding1, José Miguel Rivera-Caravaca1,2, Francisco Marin2
1Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building 6 West Derby Street, L7 8TX, Liverpool, United Kingdom.
Insights
Atrial fibrillation type does not independently predict stroke risk in patients treated with vitamin K antagonists. Anticoagulation decisions should prioritize individual thromboembolic risk profiles over AF classification.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Clinical classification of atrial fibrillation (AF) and its impact on stroke risk is not well-defined.
- This study evaluates AF type's influence on stroke risk in patients on vitamin K antagonist therapy.
- Real-world and clinical trial data were analyzed to assess stroke risk stratification.
Purpose of the Study:
- To determine if atrial fibrillation type influences stroke risk in patients treated with vitamin K antagonists.
- To compare stroke risk prediction using standard CHA2DS2-VASc score versus a modified score including continuous AF.
- To analyze stroke incidence across different AF classifications in real-world and clinical trial settings.
Main Methods:
- Post-hoc analysis of patient data from the Murcia AF Project and AMADEUS trial.
- AF classification based on current international guideline recommendations.
- Ischemic stroke incidence was the primary endpoint, assessed using CHA2DS2-VASc and a modified CHA2DS2-VAS'c' score.
Main Results:
- In clinical trial data, non-paroxysmal AF (non-pAF) showed a higher crude stroke rate compared to paroxysmal AF (pAF).
- Multivariable analysis revealed no independent association between AF type and stroke risk in either real-world or clinical trial cohorts.
- The modified CHA2DS2-VAS'c' score did not significantly improve stroke risk prediction compared to the standard CHA2DS2-VASc score.
Conclusions:
- Atrial fibrillation type is not an independent predictor of stroke risk in patients receiving vitamin K antagonist therapy.
- Current anticoagulation strategies should focus on individual thromboembolic risk assessment rather than AF classification.
- Further research may refine risk stratification models for anticoagulation in AF patients.
Background:
The risk of stroke according to clinical classification of atrial fibrillation (AF) remains poorly defined. Here, we assessed the impact of AF type on stroke risk in vitamin K antagonist-treated patients with AF in 'real-world' and 'clinical trial' cohorts.
Methods:
Post-hoc analysis of patient-level data from the Murcia AF Project and AMADEUS trial. Clinical classification of AF was based on contemporary recommendations from international guidelines. Study endpoint was the incidence rate of ischaemic stroke. Stroke risk was determined using CHA2DS2-VASc score and CARS. A modified CHA2DS2-VAS'c' score that applied one additional point for a 'c' criterion of continuous AF (i.e. non-paroxysmal AF) was calculated.
Results:
We included 5,917 patients: 1,361 (23.0%) real-world and 4,556 (77.0%) clinical trial. Baseline demographics were balanced in the real-world cohort but clinical trial participants with non-pAF (vs. pAF) were older, male-predominant and had more comorbidities. Crude stroke rates were comparable between the groups in real-world patients (IRR 0.72 [95% CI,0.37-1.28], p = 0.259) though clinical trial participants with non-pAF had a significantly higher crude rate of stroke events (IRR 4.66 [95%,CI,2.41-9.48], p < 0.001). Using multivariable analysis, AF type was not independently associated with stroke risk in the real-world (adjusted HR 1.41 [95% CI,0.80-2.50], p = 0.239) and clinical trial (adjusted HR 1.16 [95% CI,0.62-2.20], p = 0.646) cohorts, after accounting for other risk factors. There was no significant improvement in the CHA2DS2-VAS'c' compared to CHA2DS2-VASc score in either cohorts (p > 0.05).
Conclusions:
Overall, our results support the need for anticoagulation based on thromboembolic risk profile rather than AF type.
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