{"id":832,"date":"2015-09-24T14:36:10","date_gmt":"2015-09-24T14:36:10","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=832"},"modified":"2017-08-21T11:34:15","modified_gmt":"2017-08-21T11:34:15","slug":"primary-care-corner-with-geoffrey-modest-md-heart-failure-outcome-and-chads-vasc-risk-score-even-if-not-in-afib-2","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/09\/24\/primary-care-corner-with-geoffrey-modest-md-heart-failure-outcome-and-chads-vasc-risk-score-even-if-not-in-afib-2\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Heart Failure Outcome and CHADS-VASc Risk Score, Even if Not in Afib"},"content":{"rendered":"<p><strong>By Dr. Geoffrey Modest\u00a0<\/strong><\/p>\n<p>The CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc score is perhaps the best metric for predicting thromboembolic complications in patients with atrial fibrillation. This study assessed this tool for a variety of clinical outcomes in patients with\u00a0heart failure, both with and without atrial fibrillation\u00a0(see\u00a0doi:10.1001\/jama.2015.10725).<\/p>\n<p>Details:<\/p>\n<ul>\n<li>Danish registry study of 42,987 patients (all &gt;50yo, mean age 75)\u00a0with incident heart failure (HF), not on anticoagulation, of whom 21.9% had concomitant atrial fibrillation (afib), from 2000-2012<\/li>\n<li>Assessed relation between\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score and ischemic stroke, thromboembolism (TE)\u00a0and death within 1 year of HF diagnosis<\/li>\n<\/ul>\n<p>Results:<\/p>\n<ul>\n<li>Patients without afib, risks of ischemic stroke was 3.1%\u00a0(n=977), TE\u00a0was 9.9% (n=3178), and death was 21.8%\u00a0(n=6956), with stratification by\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score (max=10)\n<ul>\n<li>Ischemic stroke: by\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u200b\u00a0score of 1 through\u00a06, the one year absolute risks were:\n<ul>\n<li>With afib: 4.5%, \u00a03.7%, 3.2%, 4.3%, 5.6%, 8.4%<\/li>\n<li>Without afib: 1.5%, 1.5%, 2.0%, 3.0%,\u00a03.7%, 7%<\/li>\n<\/ul>\n<\/li>\n<li>All-cause death:\n<ul>\n<li>With afib: 19.8%, 19.5%, 26.1%, 35.1%, 37.7%, 45.5%<\/li>\n<li>Without afib: 7.6%, 8.3%, 17.8%, 25.6%, 27.9%, 35.0%<\/li>\n<\/ul>\n<\/li>\n<li>At\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score\u200b&gt;=4, absolute risk of TE was high regardless of presence of afib (e.g. for score of 4, 9.7% and 8.2% for those without and with afib)<\/li>\n<\/ul>\n<\/li>\n<li>The negative predictive value for ischemic stroke at 1 year post HF diagnosis was 92% (91-93%) in those with afib and 91% (88-95%)\u00a0in those without afib<\/li>\n<\/ul>\n<p>So, this study found that those with HF and\u00a0without afib are at high risk of ischemic stroke, TE and death;\u00a0the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score was helpful in stratifying these patients and had a moderately high negative predictive value as determined by 1 year post HF diagnosis; and those with\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score\u200b &gt;=4 had high absolute risk of TE (and even higher in those without afib than those with afib, though it seems that they only excluded those on anticoagulation prior to the HF diagnosis). On subgroup analysis, there was no association between female sex and increased risk of ischemic stroke, in patients both with and without afib (actually, of the individual components of the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score as noted below, female sex was somewhat protective in the group without afib and was not associated with ischemic stroke in those with afib.\u00a0So,\u00a0there seems to\u00a0be differences depending on the individual components of the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score\u200b.)<\/p>\n<p>In general, in patients with afib,\u00a0a stroke risk of &gt;1%\/yr is typically used as the\u00a0cutpoint in identifying benefit from anticoagulation (i.e., tends to outweigh\u00a0risks); in this Danish\u00a0study the risk of\u00a0ischemic stroke in those without afib was approx 1.5%\/yr with\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score&gt;1.\u00a0However, it is important to comment that it\u00a0is not clear what the cutpoint should be in those without afib, though\u00a0there are other\u00a0studies showing that those with\u00a0HF without afib are at increased risk of stroke and TE, and that these clinical events are decreased with warfarin therapy.<\/p>\n<p>One clear concern is that this study does not have data on the LV ejection fraction (EF). Are the ones with terrible EFs the ones who get TE? And, does the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u200b score, which it seems\u00a0would correlate mostly\u00a0with vascular risk, just pick out those with ischemic cardiomyopathy\/low EF\u00a0(i.e., are those with low EFs, who are more likely to have embolic events because of LV clots and\/or stasis, being identified by the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc score, and really just the EF\u00a0itself is important??). \u00a0There are some studies in the literature which suggest that\u00a0those with\u00a0definite HF (recent decompensation requiring hospitalization), that\u00a0HF itself\u00a0was a significant independent risk factor for stroke\/systemic embolism irrespective of LV systolic function, with overall rate of stroke being 1.5-2.4%\/year &#8212;\u00a0perhaps related to the finding in those with HF without afib that\u00a0there are\u00a0higher levels of pro-coagulants and pro-inflammatory factors such as elevated\u00a0b-thromboglobulin, thrombin-antithrombin III complexes, and\u00a0D-dimers\u00a0(see\u00a0Clin\u00a0Ther. 2014; 36: 1135-44)\u200b. \u00a0Other studies have also\u00a0found the\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score predicted\u00a0clinical events\u00a0even in patients without HF: in a 4.1 years\u00a0study of 20,970 patients\u00a0who were discharged with a diagnosis of acute coronary syndrome\u00a0without known afib in a Canadian registry, 453 (2.2%) had a stroke or\u00a0TIA with an annual incidence &gt;=1% in those with\u00a0CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score\u00a0&gt;=4 (e.g.,\u00a0see Heart 2014: 100: 1524-30).<\/p>\n<p>Another concern is that those with HF and\u00a0high\u00a0\u200bCHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc\u00a0score but without afib on initial evaluation\u00a0may actually have intermittent afib leading to the adverse clinical events. For example, identifying those with intermittent afib by an\u00a0event monitor might find those at high risk for TE, allowing for targeted anticoagulant therapy.<\/p>\n<p>So, bottom line: HF is a bad disease with\u00a045-60% 5-yr mortality. This\u00a0Danish study is an observational one, with\u00a0a limited database (not have ejection fraction, or know\u00a0if the patient smoked, or drank alcohol, or&#8230;.). It seems to me that given the high incidence of HF and high mortality, there really should be a randomized control study using anticoagulation vs not in those with HF and no evident afib. And, perhaps as part of this study,\u00a0it\u00a0would also be useful to utilize\u00a0event monitors to identify those with HF and\u00a0intermittent afib to\u00a0see if they might be the patients who really\u00a0benefit from\u00a0anticoagulant therapy.<\/p>\n<p>Here is the CHA<sub>2<\/sub>DS<sub>2<\/sub>-VASc scoring system:<\/p>\n<p><a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/files\/2015\/09\/chart.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-833\" src=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/files\/2015\/09\/chart.jpg\" alt=\"chart\" width=\"762\" height=\"592\" \/><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Heart Failure Outcome and CHADS-VASc Risk Score, Even if Not in Afib [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/09\/24\/primary-care-corner-with-geoffrey-modest-md-heart-failure-outcome-and-chads-vasc-risk-score-even-if-not-in-afib-2\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-832","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/832","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=832"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/832\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=832"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=832"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=832"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}