Original article
Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation Tomasz Podolecki, Radosław Lenarczyk, Jacek Kowalczyk, Marcin Swierad, Andrzej Swiatkowski, Ewa Jedrzejczyk, Piotr Chodor, Teresa Zielinska and Zbigniew Kalarus Aims The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation. The aim of the study was to assess whether the CHA2DS2-VASc score might be useful to identify patients at a high risk of ischemic stroke and death among individuals after acute myocardial infarction and with no history of atrial fibrillation. Methods We analysed consecutive patients with acute myocardial infarction admitted to our centre between 2003 and 2008. On the basis of the CHA2DS2-VASc score, four groups were distinguished: low-risk (1 point), intermediaterisk (2–3 points), high-risk (4–5 points) and very high-risk (>5 points). Data on long-term follow-up were screened to identify patients who experienced stroke or died during remote observation. Results Out of 2980 registry participants, 333 were excluded because of atrial fibrillation and/or ongoing therapy with oral anticoagulants. Finally, 2647 individuals were included into the analysis. An ischemic stroke occurred in 71 (2.68%) patients, whereas 439 (16.58%) died during a median follow-up of 41.5 months. The risk of stroke and death increased four-fold in the high-risk group
Introduction The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation.1,2 This score is based on a point system in which 2 points are assigned for a history of stroke or transient ischemic attack, or age at least 75, whereas 1 point each is assigned for age 65–74 years, female sex and a history of arterial hypertension, diabetes mellitus, congestive heart failure and vascular disease (myocardial infarction, complex aortic plaque or peripheral artery disease).1 The number of points at least 1 strongly supports the decision of starting anticoagulation therapy in this population and the higher score value is associated with the increasing stroke risk.1 Thanks to the simplicity of its calculation, as it is an additive scale based on clinical data, it has become the common and basic tool in daily practice. Although CHA2DS2-VASc score was validated for nonvalvular atrial fibrillation population, its particular parameters have been also reported to be the independent predictors for stroke and death in the general population, as well as in patients with stable coronary heart disease (CHD).3–7 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
compared with the low-risk group (P < 0.001). Every point in the CHA2DS2-VASc score was independently associated with 41% increase in stroke risk and 23% increase in mortality rate (for both P < 0.001). Conclusion The mortality rate and risk of stroke were strongly associated with the CHA2DS2-VASc scores. Hence, this scoring system could be useful to identify high-risk patients with no history of atrial fibrillation, in whom additional preventive measures might be beneficial to improve the outcome. J Cardiovasc Med 2015, 16:497–502
Keywords: acute myocardial infarction, CHA2DS2-VASc score, mortality, stroke Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Center of Heart Diseases, Zabrze, Poland Correspondence to Tomasz Podolecki, MD, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Center of Heart Diseases, ul. Szpitalna 2, 41-800 Zabrze, Poland Tel: +48 32 3733682; fax: +48 32 3733792; e-mail: [email protected] Received 16 April 2014 Revised 20 October 2014 Accepted 21 October 2014
However, data on a predictive value of the CHA2DS2VASc scale in patients with acute coronary syndrome (ACS) are scarce. Therefore, the aim of the study was to assess whether this risk scale might be also useful to identify patients after acute myocardial infarction (AMI) being at high risk of ischemic stroke and death.
Materials and methods We analysed consecutive AMI-patients admitted to the Silesian Center of Heart Diseases between 2003 and 2008. All of them were involved in the single-centre, prospective registry of AMIs. Coronary angiography and subsequent percutaneous coronary intervention (PCI) were performed, using standard techniques, in all patients. The aim of PCI was to restore TIMI grade 3 flow without remaining residual stenosis of more than 30% in the infarct-related artery (IRA). A single dose of oral aspirin (300–500 mg) and 5000–10 000 U of intravenous heparin were administered before coronary angiography. If necessary, additional boluses of heparin were given to achieve appropriate activated clotting time DOI:10.2459/JCM.0000000000000241
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
498 Journal of Cardiovascular Medicine 2015, Vol 16 No 7
(250–350 s). Patients who received stents were given a loading dose of clopidogrel before PCI. The duration of dual antiplatelet therapy, as well as optimal pharmacotherapy after AMI, was in line with the current recommendations of the cardiac societies.8–10 On the basis of the CHA2DS2-VASc score, four categories of risk were distinguished: low (1 point), intermediate (2–3 points), high (4–5 points) and very high (>5 points). For descriptive purpose, patients with low and intermediate risk were included into Group 1, whereas Group 2 encompassed those with high and very high category of risk.
Data collection The baseline demographic, clinical, laboratory, echocardiographic and angiographic data were obtained from the registry. The remote follow-up (until 30 April 2011) was accomplished on the basis of the data obtained from the insurer, the National Health Fund, which covers over 99% of the treated population. The all-cause and cardiovascular mortality, development of stroke as well as AMI occurrence were assessed during the long-term observation. The diagnosis and type of stroke were established on the basis of the International Classification of Diseases (ICD-10) codes and additionally confirmed by a review of hospital charts obtained from centres admitting patients with stroke. The study methods were revised and approved by the local ethics committee.
Definitions Ischemic stroke was defined as the development of an acute focal neurological deficit with a duration of more than 24 h and with no evidence of bleeding on a computed tomography scan. Renal function was assessed with estimated glomerular filtration rate (GFR) calculated using the simplified Modification of Diet in Renal Disease formula.11 Contrast-induced nephropathy (CIN) was defined as an elevation of serum creatinine by at least 44.2 mmol/l (0.5 mg/dl) or a 25% increase from the baseline value within 48 h after PCI.11 Incomplete revascularization (ICR) was defined as the presence of a total occlusion or more than 70% residual stenosis in any of the major coronary arteries or their major branches at discharge.12 Anaemia was defined using the WHO criteria as a haematocrit value less than 39% (or haemoglobin level
Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation Tomasz Podolecki, Radosław Lenarczyk, Jacek Kowalczyk, Marcin Swierad, Andrzej Swiatkowski, Ewa Jedrzejczyk, Piotr Chodor, Teresa Zielinska and Zbigniew Kalarus Aims The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation. The aim of the study was to assess whether the CHA2DS2-VASc score might be useful to identify patients at a high risk of ischemic stroke and death among individuals after acute myocardial infarction and with no history of atrial fibrillation. Methods We analysed consecutive patients with acute myocardial infarction admitted to our centre between 2003 and 2008. On the basis of the CHA2DS2-VASc score, four groups were distinguished: low-risk (1 point), intermediaterisk (2–3 points), high-risk (4–5 points) and very high-risk (>5 points). Data on long-term follow-up were screened to identify patients who experienced stroke or died during remote observation. Results Out of 2980 registry participants, 333 were excluded because of atrial fibrillation and/or ongoing therapy with oral anticoagulants. Finally, 2647 individuals were included into the analysis. An ischemic stroke occurred in 71 (2.68%) patients, whereas 439 (16.58%) died during a median follow-up of 41.5 months. The risk of stroke and death increased four-fold in the high-risk group
Introduction The CHA2DS2-VASc score is widely used to stratify the risk of stroke in patients with nonvalvular atrial fibrillation.1,2 This score is based on a point system in which 2 points are assigned for a history of stroke or transient ischemic attack, or age at least 75, whereas 1 point each is assigned for age 65–74 years, female sex and a history of arterial hypertension, diabetes mellitus, congestive heart failure and vascular disease (myocardial infarction, complex aortic plaque or peripheral artery disease).1 The number of points at least 1 strongly supports the decision of starting anticoagulation therapy in this population and the higher score value is associated with the increasing stroke risk.1 Thanks to the simplicity of its calculation, as it is an additive scale based on clinical data, it has become the common and basic tool in daily practice. Although CHA2DS2-VASc score was validated for nonvalvular atrial fibrillation population, its particular parameters have been also reported to be the independent predictors for stroke and death in the general population, as well as in patients with stable coronary heart disease (CHD).3–7 1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
compared with the low-risk group (P < 0.001). Every point in the CHA2DS2-VASc score was independently associated with 41% increase in stroke risk and 23% increase in mortality rate (for both P < 0.001). Conclusion The mortality rate and risk of stroke were strongly associated with the CHA2DS2-VASc scores. Hence, this scoring system could be useful to identify high-risk patients with no history of atrial fibrillation, in whom additional preventive measures might be beneficial to improve the outcome. J Cardiovasc Med 2015, 16:497–502
Keywords: acute myocardial infarction, CHA2DS2-VASc score, mortality, stroke Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Center of Heart Diseases, Zabrze, Poland Correspondence to Tomasz Podolecki, MD, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Medical University, Silesian Center of Heart Diseases, ul. Szpitalna 2, 41-800 Zabrze, Poland Tel: +48 32 3733682; fax: +48 32 3733792; e-mail: [email protected] Received 16 April 2014 Revised 20 October 2014 Accepted 21 October 2014
However, data on a predictive value of the CHA2DS2VASc scale in patients with acute coronary syndrome (ACS) are scarce. Therefore, the aim of the study was to assess whether this risk scale might be also useful to identify patients after acute myocardial infarction (AMI) being at high risk of ischemic stroke and death.
Materials and methods We analysed consecutive AMI-patients admitted to the Silesian Center of Heart Diseases between 2003 and 2008. All of them were involved in the single-centre, prospective registry of AMIs. Coronary angiography and subsequent percutaneous coronary intervention (PCI) were performed, using standard techniques, in all patients. The aim of PCI was to restore TIMI grade 3 flow without remaining residual stenosis of more than 30% in the infarct-related artery (IRA). A single dose of oral aspirin (300–500 mg) and 5000–10 000 U of intravenous heparin were administered before coronary angiography. If necessary, additional boluses of heparin were given to achieve appropriate activated clotting time DOI:10.2459/JCM.0000000000000241
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
498 Journal of Cardiovascular Medicine 2015, Vol 16 No 7
(250–350 s). Patients who received stents were given a loading dose of clopidogrel before PCI. The duration of dual antiplatelet therapy, as well as optimal pharmacotherapy after AMI, was in line with the current recommendations of the cardiac societies.8–10 On the basis of the CHA2DS2-VASc score, four categories of risk were distinguished: low (1 point), intermediate (2–3 points), high (4–5 points) and very high (>5 points). For descriptive purpose, patients with low and intermediate risk were included into Group 1, whereas Group 2 encompassed those with high and very high category of risk.
Data collection The baseline demographic, clinical, laboratory, echocardiographic and angiographic data were obtained from the registry. The remote follow-up (until 30 April 2011) was accomplished on the basis of the data obtained from the insurer, the National Health Fund, which covers over 99% of the treated population. The all-cause and cardiovascular mortality, development of stroke as well as AMI occurrence were assessed during the long-term observation. The diagnosis and type of stroke were established on the basis of the International Classification of Diseases (ICD-10) codes and additionally confirmed by a review of hospital charts obtained from centres admitting patients with stroke. The study methods were revised and approved by the local ethics committee.
Definitions Ischemic stroke was defined as the development of an acute focal neurological deficit with a duration of more than 24 h and with no evidence of bleeding on a computed tomography scan. Renal function was assessed with estimated glomerular filtration rate (GFR) calculated using the simplified Modification of Diet in Renal Disease formula.11 Contrast-induced nephropathy (CIN) was defined as an elevation of serum creatinine by at least 44.2 mmol/l (0.5 mg/dl) or a 25% increase from the baseline value within 48 h after PCI.11 Incomplete revascularization (ICR) was defined as the presence of a total occlusion or more than 70% residual stenosis in any of the major coronary arteries or their major branches at discharge.12 Anaemia was defined using the WHO criteria as a haematocrit value less than 39% (or haemoglobin level
