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Adopting the CHA2DS2-VASc score. Or not.

Oct 22, 2010 13:45 EDT


The first Europe-specific guidance on AF was issued recently. It differs from preexisting guidelines by referring more patients to anticoagulation therapy by assigning higher CHA2DS2-VASc risk scores to women over 65 years and all patients over 75 years and seems to anticipate an era of more anticoagulation agents.

Do you use the CHA2DS2-VASc score? Should US-based physicians pay heed to foreign guidelines?

See:

First Europe-specific guidance on AF

How to calculate the CHA2DS2-VASc score





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Your comments
Adopting the CHA2DS2-VASc score. Or not.
# 1 of 3
October 24, 2010 08:07 (EDT)
Dr. Joel

I totally agree in the sense that the broadening indication for anticoagulation in the CHASDS2-VASC  score is likely secondary to the recent aproval (or near-aproval) of new drugs (eg dabigatran, rivaroxaban).  Various studies have shown the benefits of oral anticoagulation in the previously called intermidiate risk patients (eg CHADS 1 patients), so this new score might protect this group (previously allowed to be treated either with VKA or ASA).   

Being in an european practice i can't really give an opinion about if the US should take into consideration this new score (although it will be clear once the new US guidelines are published), but i'm interesting on hearing your opinion about it.

Thanks!

# 2 of 3
October 24, 2010 11:50 (EDT)
DGH

Identifying Patients at High Risk for Stroke Despite Anticoagulation. A Comparison of Contemporary Stroke Risk Stratification Schemes in an Anticoagulated Atrial Fibrillation Cohort

Gregory Y.H. Lip MD*; Lars Frison PhD; Jonathan L. Halperin MD; and Deirdre A. Lane PhD

From the University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L., D.A.L.), City Hospital, Birmingham, England, UK; AstraZeneca R&D Mölndal (L.F.), Mölndal, Sweden; The Cardiovascular Institute (J.L.H.), Mount Sinai Medical Center, New York, NY.

* To whom correspondence should be addressed. E-mail: g.y.h.lip@bham.ac.uk.

 

Background and Purpose—The risk of stroke in patients with atrial fibrillation (AF) is not homogeneous, and various clinical risk factors have informed the development of stroke risk stratification schemes (RSS). Among anticoagulated cohorts, the emphasis should be on the identification of patients who remain at high risk for stroke despite anticoagulation.

Methods—We investigated predictors of thromboembolism (TE) risk in an anticoagulated AF clinical trial cohort (n=7329 subjects) and tested the predictive value of contemporary RSS in this cohort: CHADS2, Framingham, NICE 2006, American College of Cardiology/American Heart Association/European Society of Cardiology 2006, the 8th American College of Chest Physicians guidelines and the CHA2DS2-VASc schemes.

Results—On multivariate analysis, significant predictors of TE were stroke/TIA (hazard ratio [HR], 2.24; P<0.001), age 75 years or older (HR, 1.77; P=0.0002), coronary artery disease (HR, 1.52; P=0.0047), and smoking (HR, 2.10; P=0.0005), whereas reported alcohol use (HR, 0.70; P=0.02) was protective. Comparison of contemporary RSS demonstrated variable classification of AF patients into risk strata, although c-statistics for TE were broadly similar among the RSS tested and varied between 0.575 (NICE 2006) and 0.647 (CHA2DS2-VASc). CHA2DS2-VASc classified 94.2% as being at high risk, whereas most other RSS categorized two-thirds as being at high risk. Of the 184 TE events, 181 (98.4%) occurred in patients identified as being at high risk by the CHA2DS2-VASc schema. There was a stepwise increase in TE with increasing CHA2DS2-VASc score (Ptrend<0.0001), which had the highest HR (3.75) among the tested schemes. The negative predictive value (ie, the percent categorized as "not high risk" actually being free from TE) for CHA2DS2-VASc was 99.5%.

Conclusion—Coronary artery disease and smoking are additional risk factors for TE in anticoagulated AF patients, whereas alcohol use appears protective. Of the contemporary stroke RSS, the CHA2DS2-VASc scheme correctly identified the greatest proportion of AF patients at high risk, despite the similar predictive ability of most RSS evidenced by the c-statistic.


 
# 3 of 3
May 25, 2011 06:02 (EDT)
DrJHC
It is a reliable scoring system for stroke risk in AF patients, but you should always hold the results up against the HAS BLED score.

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About Dr Seth Bilazarian
Seth Bilazarian MD has been a Clinical and Interventional Cardiologist at Pentucket Medical Associates in Massachusetts since 1993. He is board certified in Internal Medicine, Cardiovascular Medicine, Nuclear Cardiology, Vascular Ultrasound, Interventional Cardiology, and Vascular and Endovascular Medicine.

Dr Bilazarian performs coronary and peripheral interventions at Lahey Clinic and Massachusetts General Hospital. He has been an investigator in the interventional laboratory for new devices including drug-eluting stents, distal protection devices, imaging devices (OCT and InfraRed), and anticoagulant pharmacotherapy.

Dr Bilazarian is an active participant in clinical trials in congestive heart failure, hypertension, coronary disease prevention, prediabetes management, anemia, atrial fibrillation, and anticoagulation/antiplatelet therapies in the outpatient setting. He has authored numerous papers and book chapters in clinical cardiology. He was appointed as a physician advisor to the circulatory device panel of the FDA in 2008.
About this blog
My intent is to create a forum for dialogue on issues pertinent to private practice cardiology around topics such as:

  • Integration of new data and guidelines on inpatient and outpatient practice in clinical and interventional cardiology
  • Practice approaches to the extra clinical issues in dealing with managed care insurers
  • Strategies for navigating the restrictions of pharmacy benefits managers (PBMs) on pharmacologic therapies for our patients
  • Experiences with restrictions on testing and imaging
The video blog (VLOG) will provide an opportunity to share broadly different approaches to the common conundrums we face in caring for patients. My hope is that this forum will provide useful data points for practice outside of tertiary and academic centers and a look inside community hospitals and physician?s practice patterns in the office, starting with mine.