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Arterial Thromboembolism in AF With CHA2DS2-VASc 1
Quick Takes
- The CHA2DS2-VASc score provides a reliable, graded estimate of arterial thromboembolic risk for patients with AF.
- No risk factor was present in patients with a CHA2DS2-VASc score of 1; the risk of arterial thromboembolism was similar.
- Clinicians do not need to differentiate various CHA2DS2-VASc 1 subgroups when estimating stroke risk or deciding about anticoagulation therapy.
Study Questions:
What is the incidence of arterial thromboembolism (ATE) in patients with atrial fibrillation (AF) and a single CHA2DS2-VASc risk factor other than female sex?
Methods:
The authors used the Danish National Patient Registry and Danish Prescription Registry to identify patients with AF between 2000–2021 who were not treated with oral anticoagulation. They then identified patients with a CHA2DS2-VASc score of 0, 1, and 2 based on a single risk factor (age, heart failure, hypertension, diabetes, vascular disease) while excluding the female sex characteristic modifier. The primary outcome was ATE (ischemic stroke, embolism of an extremity, or transient cerebral ischemia) and subgroups were compared using Cox regression analysis.
Results:
The study included 26,701 patients with a CHA2DS2-VASc score of 0, 22,915 with a CHA2DS2-VASc score of 1 (1,483 with isolated heart failure, 9,066 with isolated hypertension, 843 with isolated diabetes, 770 with isolated vascular disease, and 10,753 who were age 65-74 years without other comorbidities), and 14,525 patients with a CHA2DS2-VASc score of 2 (age ≥75 years without other comorbidity). With a median 1-year observation time, the cumulative incidence of ATE was 0.6% for a CHA2DS2-VASc score of 0, ranged between 1.4% and 2.3% for patients with a CHA2DS2-VASc score of 1, and 4.4% for patients with a CHA2DS2-VASc score of 2 based only on age ≥75 years. There was no statistically significant difference in the risk of ATE between the subgroups of patients with a CHA2DS2-VASc score of 1 (p = 0.15).
Conclusions:
The authors conclude that patients with AF had an increasing risk of ATE based on the CHA2DS2-VASc score without any difference between subgroups of patients with a CHA2DS2-VASc score of 1.
Perspective:
The CHA2DS2-VASc score has become the default in which most clinicians estimate ATE risk for patients with AF and make determinations about ATE prevention strategies (e.g., anticoagulation therapy, left atrial appendage occlusion). There has been controversy about the need for ATE risk interventions in patients with “intermediate” risk (CHA2DS2-VASc score of 1). Some have suggested that different subgroups of patients with a CHA2DS2-VASc score of 1 may be at higher risk than others based on the specific risk factor present (e.g., heart failure vs. age 65-74 years).
This Danish nationwide cohort analysis of patients who were untreated for ATE prevention did not find a statistically meaningful difference in the ATE risk between the various CHA2DS2-VASc score of 1 cohorts. However, it did find a clinically meaningful difference in ATE risk between CHA2DS2-VASc score of 0, 1, and 2 cohorts. Furthermore, these data provide a reliable estimate of ATE risk in patients with a CHA2DS2-VASc score of 1 to guide decision-making when comparing stroke versus bleeding risk associated with oral anticoagulant use. Finally, clinicians can remain confident that the CHA2DS2-VASc score provides a reasonable graded estimate of ATE risk that can be used to guide ATE prevention decisions (e.g., initiating anticoagulation, implanting left atrial appendage occlusion devices).
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Atrial Fibrillation, Thromboembolism
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