The Value of the European Society of Cardiology Guidelines for Refining Stroke Risk Stratification in Patients With Atrial Fibrillation Categorized as Low Risk Using the Anticoagulation and Risk Factors in Atrial Fibrillation Stroke Score

CHEST Journal ◽  
2014 ◽  
Vol 146 (5) ◽  
pp. 1337-1346 ◽  
Author(s):  
Gregory Y. H Lip ◽  
Peter Brønnum Nielsen ◽  
Flemming Skjøth ◽  
Deirdre A Lane ◽  
Lars Hvilsted Rasmussen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Risk Stratification ◽  
European Society ◽  
Stroke Risk ◽  
Low Risk ◽  
European Society Of Cardiology

Stroke risk factors and risk stratification in atrial fibrillation

ESC CardioMed ◽  
2018 ◽  
pp. 2182-2185
Author(s):  
Gregory Y. H. Lip
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Decision Making ◽  
Risk Stratification ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Stroke Risk ◽  
Vitamin K Antagonist ◽  
Low Risk ◽  
Good Time

Atrial fibrillation increases the risk of stroke, and the more common and validated risk factors have been used to formulate stroke risk stratification schemes, but the default position is to offer stroke prevention to all patients with atrial fibrillation unless they are shown to be at low risk. The use of the CHA2DS2-VASc score is recommended for stroke risk stratification in guidelines. Decision-making for stroke prevention should apply the simple ‘atrial fibrillation three-step’ patient pathway. Step 1 is to initially identify ‘low-risk’ patients (CHA2DS2-VASc 0 in males, 1 in females) who do not need antithrombotic therapy; step 2 is to offer stroke prevention (i.e. oral anticoagulation) to those with at least one stroke risk factor; step 3 is to decide between a vitamin K antagonist (with good time in therapeutic range at >70%) or a non-vitamin K antagonist oral anticoagulant, using the SAMe-TT2R2 score. This simple streamlined practical approach will help risk stratification and treatment decision-making.

scholarly journals Atrial fibrillation: review of the European Society of Cardiology guidelines and national guidelines 2020

2020 ◽  
pp. 21-29
Author(s):  
Natalia S. Mescherina ◽  
Elena M. Khardikova ◽  
Igor A. Saraev
Keyword(s):  
Atrial Fibrillation ◽  
European Society ◽  
Stroke Risk ◽  
Diagnosis And Treatment ◽  
Russian Society ◽  
Thromboembolic Complications ◽  
National Guidelines ◽  
European Society Of Cardiology ◽  
Risk Symptom

The review presents the key provisions of the recommendations of the Russian society of cardiology and the guidelines of the European society of cardiology for the diagnosis and treatment of atrial fibrillation (AF), updated in 2020. The recommendations clearly state the requirements for atrial fibrillation diagnosis verification, and propose an approach to the formation of a complex characteristic of the disease in four positions, which is designated as 4S-AF (Stroke risk, Symptom severity, Severity of AF burden, Substrate severity). The authors analyzed the strategy "CC To ABC" (Confirm AF, Characterize AF, Treat AF: the ABC pathway) proposed by European experts, the issues of modern terminology and requirements for verifying the diagnosis of AF, complex characteristics of the disease and stratification of the risk of stroke and bleeding, a new ABC approach in the treatment of AF, where A is anticoagulant prevention of thromboembolic complications, B is the control of symptoms of the disease and C is the detection and treatment of comorbid pathology. The General principles that have changed in comparison with the previous versions of guidelines of 2016 on the initiation and tactics of anticoagulant therapy, pharmacological and non-drug cardioversion, catheter ablation in patients with AF, affecting the prognosis and outcomes in patients with AF, are outlined. It is emphasized that the pattern of atrial fibrillation (first diagnosed, paroxysmal, persistent, long-term persistent, permanent) should not determine the indications for anticoagulant prevention. The solution to this issue is determined by the level of risk according to the CHA2DS2-VASc scale. The introduction of the considered methods of diagnosis and treatment of AF into clinical practice will optimize the burden on the health care system and reduce the costs associated with the burden of AF.

Stroke and thromboembolism in atrial fibrillation: A systematic review of stroke risk factors, risk stratification schema and cost effectiveness data

2008 ◽  
Vol 99 (02) ◽  
pp. 295-304 ◽  
Author(s):  
Michael Hughes ◽  
Gregory Y. H. Lip ◽  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Systematic Review ◽  
Cost Effectiveness ◽  
Risk Stratification ◽  
Antithrombotic Therapy ◽  
Stroke Risk ◽  
Patient Characteristics ◽  
Left Ventricular ◽  
Stroke Risk Factors

SummaryThe risk of stroke in atrial fibrillation (AF) needs to be assessed in each patient to determine the clinical and cost-effectiveness of thromboprophylaxis, with the aim of appropriate use of antithrombotic therapy. To achieve this, stroke risk factors in AF populations need to be identified and stroke risk stratification models have been devised on the basis of these risk factors. In this article, we firstly provide a systematic review of studies examining the attributable stroke risk of various clinical, demographic and echocardiographic patient characteristics in AF populations. Secondly, we performed a systematic review of published stroke risk stratification models, in terms of the results of the review of stroke risk factors and their ability to accurately discriminate between different levels of stroke risk. Thirdly, we review the health economic evidence relating to the cost-effectiveness of anticoagulation and antiplatelet therapy as thromboprophylaxis in AF patients. The studies included in the systematic review of stroke risk factors identified history of stroke or TIA, increasing age, hypertension and structural heart disease (left-ventricular dysfunction or hypertrophy) to be good predictors of stroke risk in AF patients. The evidence regarding diabetes mellitus, gender and other patient characteristics was less consistent. Three stroke risk stratification models were identified that were able to discriminate between different categories of stroke risk to at least 95% accuracy. Few models had addressed the cumulative nature of risk factors where a combination of risk factors would confer a greater risk than either factor alone. In patients at high risk of stroke, anticoagulation is cost effective, but not for those with a low risk of stroke. With the evidence available for stroke risk factors and the various alternative stroke risk stratification models, a review of these models in terms of the evidence on which they are devised and their performance in representative AF populations is important. The appropriate administration of thromboprophylaxis in AF patients would need to balance the risks and benefits of antithrombotic therapy with its cost-effectiveness.

Validation of the 2019 European Society of Cardiology risk stratification algorithm for pulmonary embolism in normotensive elderly patients

2021 ◽  
Author(s):  
Jeanne Moor ◽  
Christine Baumgartner ◽  
Marie Méan ◽  
Odile Stalder ◽  
Andreas Limacher ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
European Society ◽  
Risk Groups ◽  
Adverse Outcomes ◽  
Low Risk ◽  
Receiver Operating Curve ◽  
European Society Of Cardiology ◽  
Related Mortality ◽  
Overall Mortality

Background: The 2019 European Society of Cardiology (ESC) guidelines recommend evaluation for right ventricular dysfunction in all normotensive patients with acute pulmonary embolism (PE). We compared the predictive performance of the 2019 and 2014 ESC risk stratification algorithms and the Pulmonary Embolism Severity Index (PESI). Methods: We performed a post-hoc analysis of normotensive patients aged ≥65 years with acute PE from a prospective cohort. The primary outcome was overall mortality; secondary outcomes were PE-related mortality and adverse outcomes (PE-related death, cardiopulmonary resuscitation, intubation, catecholamine use, recurrent venous thromboembolism) at 30 days. We assessed outcomes in intermediate-high, intermediate-low, and low risk groups according to the 2019 and 2014 ESC algorithms and the PESI. Discriminative power was compared using the area under the receiver operating curve (AUC). Results: Among 419 patients, 14 (3.3%) died (7 from PE) and 16 (3.8%) had adverse outcomes within 30 days. The 2019 ESC algorithm classified more patients as intermediate-high risk (45%) than the 2014 ESC algorithm (24%) or PESI (37%), and only 19% as low risk (32% with 2014 ESC or PESI). Discriminatory power for overall mortality was lower with the 2019 ESC algorithm (AUC 63.6%), compared to the 2014 ESC algorithm (AUC 71.5%) or PESI (AUC 75.2%), although the difference did not reach statistical significance (p=0.063). Discrimination for PE-related mortality and adverse outcomes was similar. Conclusions: While categorizing more patients in higher-risk groups, the 2019 ESC algorithm for PE did not improve prediction of short-term outcomes compared to the 2014 ESC algorithm or the PESI.

Incident Co-Morbidities in Patients with Atrial Fibrillation Initially with a CHA2DS2-VASc Score of 0 (Males) or 1 (Females): Implications for Reassessment of Stroke Risk in Initially ‘Low-Risk’ Patients

2019 ◽  
Vol 119 (07) ◽  
pp. 1162-1170 ◽  
Author(s):  
Tze-Fan Chao ◽  
Jo-Nan Liao ◽  
Ta-Chuan Tuan ◽  
Yenn-Jiang Lin ◽  
Shih-Lin Chang ◽  
...  
Keyword(s):  
Risk Factors ◽  
Atrial Fibrillation ◽  
Adverse Events ◽  
Ischaemic Stroke ◽  
Stroke Risk ◽  
Temporal Trends ◽  
Low Risk ◽  
Stroke Risk Factor ◽  
Timing Interval ◽  
Risk Patients

Background Oral anticoagulants (OACs) are not recommended for ‘low-risk’ patients with atrial fibrillation (AF). We investigated the incidences of new risk factors developing, and the temporal trends in the CHA2DS2-VASc score in initially ‘low-risk’ AF patients. Second, we propose a reasonable timing interval at which stroke risk should be reassessed for such AF patients. Methods We studied 14,606 AF patients who did not receive anti-platelet agents or OACs with a baseline CHA2DS2-VASc score of 0 (males) or 1 (females). The CHA2DS2-VASc scores of patients were followed up and updated until the occurrence of ischaemic stroke or mortality or 31 December 2011. The associations between the prescription of warfarin and risk of adverse events once patients' scores changed were analysed. Decile values of durations to incident co-morbidities and from the acquirement of new co-morbidities to ischaemic stroke were studied. Results During a mean follow-up of 4 years, 7,079 (48.5%) patients acquired at least one new stroke risk factor component(s) with annual risks of 6.35% for hypertension, 3.68% for age ≥ 65 years, 2.77% for heart failure, 1.99% for diabetes mellitus and 0.33% for vascular diseases. The incidence for CHA2DS2-VASc score increments was 12.1%/year. Initiation of warfarin was associated with a lower risk of adverse events (adjusted hazard ratio, 0.530; 95% confidence interval, 0.371–0.755). Among 6,188 patients who acquired new risk factors, 80% would acquire these co-morbidities after 4.2 months of AF diagnosis. The duration from the acquirement of incident co-morbidities to the occurrence of ischaemic stroke was longer than 4.4 months for 90% of the patients. Conclusion The CHA2DS2-VASc score increases in approximately 12% of initially ‘low-risk’ AF patients each year, and the initiation of warfarin once the score changed was associated with a better prognosis. Three to four months may be a reasonable timing interval at which stroke risk should be reassessed so that OACs could be prescribed in a timely manner for stroke prevention.

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