Predictive role of CHA 2 DS 2 -VASc score for cardiovascular events and death in patients with arterial hypertension and stable sinus rhythm

Abstract

Background

The CHA₂DS₂-VASc score well stratifies the risk for thromboembolic events in non-valvular atrial fibrillation (NVAF) patients. This score may also predict thromboembolic events in sinus rhythm populations.

Purpose

The purpose of this study was to assess the prognostic role of CHA₂DS₂-VASc in a Caucasian community population of patients with arterial hypertension and sinus rhythm.

Methods

A total of 12,599 arterial hypertension residents not receiving anticoagulation were selected from a community population in Trieste between November 2009 and October 2014: 11,159 sinus rhythm and 1440 NVAF patients. We considered thromboembolic events, cardiovascular hospitalisation and all-cause death in all patients divided according to CHA₂DS₂-VASc.

Results

Sinus rhythm patients were 74 (interquartile range 65–81) years old, 50% were women, 32% with CAD, mean CHA₂DS₂-VASc 3.68 ± 1.47 points, significantly lower than NVAF patients (4.26 ± 1.50, P < 0.001). After 37 months follow-up, an increasing CHA₂DS₂-VASc corresponded to a higher rate of thromboembolic events in sinus rhythm patients, ranging from 0% in patients with a score of 1 or 2 to 2.6% in those with a score of 6 or greater (P < 0.0001). A similar trend was found in the reference NVAF group. At Cox multivariable analysis, CHA₂DS₂-VASc predicted thromboembolic events (hazard ratio (HR) 2.12), cardiovascular hospitalisation (HR 1.55) and all-cause death (HR 1.57). The predictive accuracy of CHA₂DS₂-VASc was similar in sinus rhythm and NVAF patients for thromboembolic events, cardiovascular hospitalisation and all-cause death (area under the curve statistic 0.76 vs. 0.76, 0.68 vs. 0.66, 0.64 vs. 0.64, respectively).

Conclusions

In a community population of Caucasian arterial hypertension patients in sinus rhythm, CHA₂DS₂-VASc rather well stratifies for adverse clinical events at mid-term follow-up with a similar accuracy to NVAF patients. These results might be clinically relevant in this setting of sinus rhythm patients.

Keywords

Atrial fibrillation stroke thomboembolic events arterial hypertension

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References

Authors/Task Force Members Piepoli

Hoes

Agewall

et al.

2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts): developed with the special contribution of the European Association for Cardiovascular Prevention and Rehabilitation (EACPR). Eur J Prev Cardiol 2016; 23: NP1–N96.

Laslett

Alagona

Clark

et al.

The worldwide environment of cardiovascular disease: prevalence, diagnosis, therapy, and policy issues: a report from the American College of Cardiology. J Am Coll Cardiol 2012; 25: S1–S49.

Kearney

PM1

Whelton

Reynolds

et al.

Worldwide prevalence of hypertension: a systematic review. J Hypertens 2004; 22: 11–19.

Chi

Jin

et al.

The association of blood pressure with survival rate and cardiovascular events in Chinese patients with type 2 diabetes. Int J Cardiol 2013; 168: 4514–4515.

Lawes

Vander Hoorn

Rodgers

. International Society of Hypertension Global burden of blood-pressure-related disease, 2001. Lancet 2008; 371: 1513–1518.

Gorgui

Gorshkov

Khan

et al.

Hypertension as a risk factor for ischemic stroke in women. Can J Cardiol 2014; 30: 774–782.

Camm

Lip

De Caterina

et al.

2012 Focused update of the ESC guidelines for the management of atrial fibrillation. An update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012; 33: 2719–2747.

January

Wann

Alpert

et al.

2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64: 2246–2280.

You

Singer

Howard

et al.

Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141: e531S–e575S.

10.

Lip

Nieuwlaat

Pisters

et al.

Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart survey on atrial fibrillation. Chest 2010; 137: 263–272.

11.

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. The task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2016; 37: 2893–2962.

12.

Roger

Lloyd-Jones

et al.

Heart disease and stroke statistics – 2011 update: a report from the American Heart Association. Circulation 2011; 123: e18–e209.

13.

Mitchell

Southern

Galbraith

et al.

APPROACH investigators. Prediction of stroke or TIA in patients without atrial fibrillation using CHADS₂ and CHA₂DS₂-VASc scores. Heart 2014; 100: 1524–1530.

14.

Lip

. Stroke and bleeding risk assessment in atrial fibrillation: when, how, and why? Eur Heart J 2013; 34: 1041–1049.

15.

Melgaard

Gorst-Rasmussen

Lane

et al.

Assessment of the CHA₂DS₂-VASc score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA 2015; 314: 1030–1038.

16.

Wolsk

Lamberts

Hansen

et al.

Thromboembolic risk stratification of patients hospitalised with heart failure in sinus rhythm: a nationwide cohort study. Eur J Heart Fail 2015; 17: 828–836.

17.

Poçi

Hartford

Karlsson

et al.

Role of the CHADS₂ score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation. Chest 2012; 141: 1431–1440.

18.

Welles

Whooley

et al.

The CHADS₂ score predicts ischemic stroke in the absence of atrial fibrillation among subjects with coronary heart disease: data from the Heart and Soul Study. Am Heart J 2011; 162: 555–561.

19.

Podolecki

Lenarczyk

Kowalczyk

et al.

Stroke and death prediction with CHA₂DS₂-VASc score after myocardial infarction in patients without atrial fibrillation. J Cardiovasc Med 2015; 16: 497–502.

20.

Morillas

Pallarés

Fácila

et al.

FAPRES registry investigators. The CHADS₂ score to predict stroke risk in the absence of atrial fibrillation in hypertensive patients aged 65 years or older. Rev Esp Cardiol 2015; 68: 485–491.

21.

De Caterina

Camm

. What is ‘valvular’ atrial fibrillation? A reappraisal. Eur Heart J 2014; 14: 3328–3335.

22.

Lip

GYH

Nieuwlaat

Pisters

et al.

Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation. Chest 2010; 137: 263–272.

23.

Blanche

Dartigues

Jacqmin-Gadda

. Estimating and comparing time-dependent areas under receiver operating characteristic curves for censored event times with competing risks. Stat Med 2013; 32: 5381–5397.

24.

Glotzer

Hellkamp

Lee

et al.

CHA₂DS₂-VAS(C) and CHADS₂ scores predict adverse clinical events in patients with pacemakers and sinus node dysfunction independent of atrial fibrillation. Can J Cardiol 2015; 31: 1004–1011.

25.

Lip

Lin

Chien

et al.

Comparative assessment of published atrial fibrillation stroke risk stratification schemes for predicting stroke, in a non-atrial fibrillation population: the Chin-Shan Community Cohort Study. Int J Cardiol 2013; 168: 414–419.

26.

Wolf

Abbott

Kannel

. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983–988.

27.

National Institute for Health and Care Excellence. Atrial fibrillation: management; Clinical guideline; National Institute for Health and Care Excellence. 18 June 2014. https://www.nice.org.uk/guidance/cg180/resources/atrial-fibrillation-management-35109805981381 (accessed 29 July 2017).

28.

HTH

Campbell

BCV

Meretoja

et al.

VISTA collaborators: pre-stroke CHADS₂ and CHA₂DS₂-VASc scores are useful in stratifying three-month outcomes in patients with and without atrial fibrillation. Cerebrovasc Dis 2013; 36: 273–280.

29.

Lackland

Roccella

Deutsch

et al.

American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; Council on Functional Genomics and Translational Biology. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45: 315–353.

30.

Goto

Bhatt

Röther

et al.

REACH Registry Investigators. Prevalence, clinical profile, and cardiovascular outcomes of atrial fibrillation patients with atherothrombosis. Am Heart J 2008; 156: 855–863.

31.

Ohira

Shahar

Chambless

et al.

Risk factors for ischemic stroke subtypes. The Atherosclerosis Risk in Communities (ARIC) Study. Stroke 2006; 37: 2493–2498.

32.

Chong AY, Freestone B, Lim HS, et al. Plasma von Willebrand factor and soluble E-selectin levels in stable outpatients with systolic heart failure: the Frederiksberg Heart Failure Study. Int J Cardiol 119; 1: 80–82.

33.

Dries

Rosenberg

Waclawiw

et al.

Ejection fraction and risk of thromboembolic events in patients with systolic dysfunction and sinus rhythm: evidence for gender differences in the studies of left ventricular dysfunction trials. J Am Coll Cardiol 1997; 29: 1074–1080.

34.

McClung

Naseer

Saleem

et al.

Circulating endothelial cells are elevated in patients with type 2 diabetes mellitus independently of HbA(1)c. Diabetologia 2005; 48: 345–350.

35.

Akoum N. New perspectives on atrial fibrillation and stroke. Review. Heart 2016; 102: 1788–1792.

36.

Wallmann

Tüller

Wustmann

et al.

EMBRACE Steering Committee and Investigators. Frequent atrial premature beats predict paroxysmal atrial fibrillation in stroke patients: an opportunity for a new diagnostic strategy. Stroke 2007; 38: 2292–2294.

37.

Gladstone

Dorian

Spring

et al.

EMBRACE Steering Committee and Investigators. Atrial premature beats predict atrial fibrillation in cryptogenic stroke: results from the EMBRACE trial. Stroke 2015; 46: 936–941.