Original article

CHA2DS2-VASc in the prediction of early atrial fibrillation relapses after electrical or pharmacological cardioversion Lorenzo Falsettia, Giovanna Viticchib, Nicola Tarquinioc, Mauro Silvestrinib, William Capecic, Andrea Ballonic, Vania Catozzoc, Adelina Gentilec and Francesco Pellegrinic Background In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in the survival rate and incidence of embolic events has been described in patients undergoing rhythm or rate control if the latter is combined with an appropriate anticoagulant therapy. CHA2DS2-VASc is a score that allows clinicians to stratify embolic risk in patients affected by nonvalvular atrial fibrillation. Each item can be involved in triggering and maintaining atrial fibrillation. Thus, we hypothesized that CHA2DS2-VASc may help to predict early recurrences after cardioversion.

the CHA2DS2-VASc score. A logarithmic relationship was the best-fit trend among CHA2DS2-VASc ranks and the predicted probability of sinus rhythm stability in patients undergoing both electrical and pharmacological cardioversion (r2 U 0.98, P < 0.05 for electrical cardioversion; r2 U 0.91, P < 0.05 for pharmacological cardioversion).

Methods A total of 319 consecutive patients, admitted to our emergency department or hemodynamically stable persistent atrial fibrillation, were enrolled and treated with electrical or pharmacological sinus rhythm restoration. Outcome was defined as recurrence of atrial fibrillation 5 days after cardioversion. Predicted probability of sinus rhythm stability was assessed with an ordinal regression model using CHA2DS2-VASc as an independent variable.

J Cardiovasc Med 2014, 15:636–641

Results The model showed a progressive decrease in the predicted probability of sinus rhythm stability after electrical or pharmacological cardioversion along with an increase in

Introduction Atrial fibrillation is the most frequent arrhythmia among patients admitted to internal medicine departments.1 Its natural history is associated with an increased risk of mortality and morbidity for cardioembolic disorder. Particularly, it is related to a five-fold increased risk of stroke occurrence.2 The optimal medical management of atrial fibrillation is still largely based on clinical judgment because of a lack of strong evidences supporting the possible advantage of rate control and anticoagulation over rhythm control approaches in terms of expected improvement in outcome measures such as survival and incidence of embolic events.3,4 In order to assist clinicians in choosing the optimal antithrombotic strategy, current guidelines recommend stratification of affected patients depending on their individual thromboembolic risk.2 The CHA2DS2-VASc scoring system assigns 2 points for a previous history of stroke or transient ischemic attack or for age at least 1558-2027 ß 2014 Italian Federation of Cardiology

Conclusion Our preliminary results suggest that CHA2DS2VASc score could be useful in evaluating the risk of early recurrence of atrial fibrillation after cardioversion. This information may have implications for disease monitoring and treatment strategies in clinical practice.

Keywords: atrial fibrillation, CHA2DS2-VASc, rate control, rhythm restoration a Internal and Sub-Intensive Medicine Department, A.O.U. ‘Ospedali Riuniti’, Ancona, Italy, bDepartment of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy and cDepartment of Internal Medicine, Ospedale ‘S.S. Benvenuti e Rocco’, Osimo (Ancona), Italy

Correspondence to Dr Lorenzo Falsetti, Internal and Sub-Intensive Medicine Department, A.O.U. ‘Ospedali Riuniti’, Via Conca n8 10, Ancona, Italy Tel: +38 071 596 5269; Mobile: þ39 338 7034188; e-mail: [email protected] Received 24 November 2013 Revised 11 April 2014 Accepted 14 April 2014

75 years and 1 point for the 65-year to 74-year bracket, history of hypertension, diabetes, recent episode of cardiac failure, vascular disease [defined as myocardial infarction, complex aortic plaque, and peripheral artery disease (PAD), including prior revascularization, amputation due to PAD, or angiographic evidence of PAD and female sex (Table 1). The same comorbidities included in CHA2DS2-VASc, however, represent some of the risk factors involved in triggering the first episode, and recurrence and maintenance of this arrhythmia.5 In this respect, several studies suggest that chronic heart failure6 and hypertension7 could facilitate atrial electrical and mechanical remodeling. Age, sex,8,9 diabetes,10,11 and atherosclerosis12,13 may also carry an additional risk for atrial remodeling. Atrial remodeling has been strictly related to atrial fibrillation recurrences.14 Based on these data, we speculated that the same predictive model could be used both for the choice of antithrombotic treatment and for the prediction of sinus rhythm maintenance after an electrical or pharmacological cardioversion procedure. DOI:10.2459/JCM.0000000000000139

Copyright © Italian Federation of Cardiology. Unauthorized reproduction of this article is prohibited.

Prediction of early atrial fibrillation relapses Falsetti et al. 637

Table 1

CHA2DS2-VASc score

Risk factor Congestive heart failure/LV dysfunction Hypertension Age  75 Diabetes mellitus Stroke/TIA/thromboembolism Vascular disease Age 65–74 Sex category (female sex) Maximum score

Score 1 1 2 1 2 1 1 1 9

LV, left ventricle; TIA, transient ischemic attack.

Methods We enrolled 319 consecutive patients admitted to our emergency department (ED) for hemodynamically stable and persistent atrial fibrillation, independent of the presence of specific symptoms. On admission, each patient underwent complete clinical history, physical examination, blood analysis evaluating blood cell count, troponin I and thyroid function, 12-lead surface ECG, and echocardiography. Particularly, we evaluated troponin blood levels in all patients to exclude the presence of acute heart failure (AHF) or other acute cardiologic illness. Patients with pulmonary rales or radiologic evidence of pulmonary edema or AHF, a definite diagnosis of acute pulmonary embolism, clinical/electrocardiographic or laboratoristic signs of acute coronary syndrome (ACS), hyperthyroidism, and valvular atrial fibrillation were excluded from further analyses. Patients with a left atrium diameter above 50 mm, as sampled in long-axis echocardiographic projection, were not considered for the higher risk of atrial fibrillation relapse after cardioversion. Moreover, we considered only patients with the first episode of persistent atrial fibrillation. Recurrences were excluded because repeating a direct current shock or a cardioversion could be a potential confounder on data analysis. For a similar reason, we did not include patients with atrial flutter. We also included patients with valvular disorder not related to atrial fibrillation. Because the definition of ‘nonvalvular’ atrial fibrillation is not universally recognized, we decided to include in the study only patients with mild–moderate mitral insufficiency, mild– moderate aortic insufficiency, and mild aortic stenosis. Mitral stenosis, severe insufficiencies and stenoses, and all the rheumatic forms were excluded. Oral anticoagulants and amiodarone (200 mg bid for the first week, and then 200 mg once a day until the restoration attempt) were started 3 weeks before cardioversion. Patients who did not gain optimal anticoagulation levels,2 underwent spontaneous sinus rhythm restoration, experienced immediate relapse of atrial fibrillation after cardioversion, or did not attain sinus rhythm restoration after the procedure (after the second shock for electrical cardioversion, 24 h after the end of intravenous infusion for pharmacological cardioversion) were also excluded from analysis. Patients were selected to perform a pharmacological procedure in case of presence of contraindications

to an electrical sinus rhythm restoration attempt. Patients with contraindications for or at high risk of complications during general anesthesia, history of a chronic alcohol abuse, presence of clinical signs of sub-AHF, very low life expectancy (

CHA2DS2-VASc in the prediction of early atrial fibrillation relapses after electrical or pharmacological cardioversion.

In hemodynamically stable patients, mortality and morbidity related to atrial fibrillation are mainly due to cardioembolic disorder. No difference in ...
322KB Sizes 0 Downloads 3 Views