Risk Scores for Ischemic Stroke in AF Patients With Kidney Disease

Apr 29, 2021
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Authors:
de Jong Y, Fu EL, van Diepen M, et al.
Citation:
Validation of Risk Scores for Ischemic Stroke in Atrial Fibrillation Across the Spectrum of Kidney Function. Eur Heart J 2021;42:1476-1485.
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • Risk scores did not perform very well in predicting and discriminating risk for ischemic stroke in patients with atrial fibrillation (AF).
  • Risk scores for ischemic stroke may not perform very well for patients with chronic kidney disease and AF.

Study Questions:

How well do common risk scores for ischemic stroke patients with atrial fibrillation (AF) perform across the spectrum of kidney function?

Methods:

The authors used the SCREAM (Stockholm CREAtinine Measurements) cohort of Stockholm residents (n = 36,004). The following stroke risk scores were calculated for each patient: AFI, CHADS2, modified CHADS2, CHA2DS2-VASc, ATRIA, and GARFIELD-AF. The ability of each risk score to predict ischemic stroke was calculated across three strata of kidney function: normal (estimated glomerular filtration rate [eGFR] >60 ml/min/1.73 m2), mild (eGFR 30-60), and advanced (eGFR <30).

Results:

Over 1.9 years of follow-up, 3,069 (8.5%) patients experienced an ischemic stroke. The median c-statistic for normal eGFR was 0.75 (range, 0.68-0.78), decreasing to 0.68 (0.58-0.73) for mild renal dysfunction and 0.68 (0.55-0.74) for advanced renal dysfunction. The modified CHADS2 score showed good performance across renal function strata (c-statistic 0.78, 0.73, and 0.74 for normal, mild, and advanced renal dysfunction, respectively).

Conclusions:

The authors concluded that the performance of most AF-related stroke risk scores was poor across the spectrum of renal function. The authors noted that the modified CHADS2 score performed the best and may be preferred for stroke risk estimation.

Perspective:

While the use of stroke risk scores is quite common (and guideline-recommended) for patients with AF, their ability to predict and discriminate low versus high risk is often moderate, at best. This large population-based cohort study also found that most commonly used AF stroke risk scores had moderate-poor discrimination/prediction. The modified CHADS2 score had the best predictive ability. This uncommonly used score assigns a gradation of points based on age risk (range 1-6) and gives more points for prior stroke (6). It is also well known that the balance between benefits and risk of anticoagulation are less favorable in patients with advanced chronic kidney disease who require dialysis treatment. Although use of the CHA2DS2-VASc is encouraged by various AF guidelines, clinicians should recognize that this (and other) risk scores have important limitations, especially in patients with chronic kidney disease.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Blood Coagulation, Brain Ischemia, Creatinine, Geriatrics, Glomerular Filtration Rate, Kidney Diseases, Kidney Failure, Chronic, Myocardial Ischemia, Renal Dialysis, Renal Insufficiency, Chronic, Risk Assessment, Risk Factors, Secondary Prevention, Stroke, Vascular Diseases


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