Transcript Predictors of Stroke Risk in Atrial Fibrillation

Which tool do you most typically use to
evaluate stroke risk for patients with a fib?
1.
2.
3.
CHADS2 score
CHADS2-VASc
Other
0
0
0
CHADS2 score
CHADS2-VASc
Other
10

Patient
› 56 y/o F
› PMH: A fib, Diastolic HF,
HTN, COPD, GERD,
MDD
› Medications






Coumadin 2mg QD
Lasix 60mg BID
K Cl 20mEq QD
Diltiazem 120mg BID
Spiriva 18mcg QD
Flovent 44mcg/act
1 inhalation BID
 Albuterol Nebulizer
0.083% Q4-6H PRN SOB
 TUMS 500mg TID PRN
 Lexapro 20mg QD
 APAP 650mg Q6H PRN
 Colace 100mg BID
 Bisacodyl 10mg Supp
QD PRN
C.S. began obsessing over her INR value
which was (unstable in her perspective),
ranging from 1.9 to 3.1 over the past 5
months…
 Transitioned to Xarelto

› NH called reported patient refused Xarelto
for past 3 days…
 Concerns w/ SE, especially bleeding
When calculating stroke risk, does diastolic
HF carry as much risk as systolic HF?
Yes
2. No
3. Unsure
1.
0
0
0
Yes
No
Unsure
10

PMH: A fib, CHF, HTN, COPD, GERD, MDD

What is C.S. CHADS2 Score?

What is her CHADS2VASc Score?

Any other risk stratification systems you
use?
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

Retrospective analysis
Centre Hospitalier Regional et Universitaire in Tours
(France) – all patients diagnosed w/ NVAF between
2000 and 2010
Exclusion criteria
› No hx chronic HF or echo LV function N/A
› Valvular dysfunction

Stratified into 4 categories – 1276 patients included
 Severe LV impairment w/ EF <35%
 Moderate LV impairment w/ EF 35-40%
 Mild LV impairment w/ EF 41-49%
 Normal LV Function w/ EF ≥ 50%*
*HFPEF defined as clinical HF w/ EF ≥ 50%

Results
› Comparing HFPEF & HFREF no statistical
differences in stroke, stroke/TE, all-cause
death, or bleeding
Which risk factor is the strongest , most
consistent independent risk factor for stroke?
1. CHF
2. HTN
3. Age > 75 years
4. Diabetes
5. Prior Stroke/TIA
0
0
0
0
0
CHF
HTN
Age > 75
years
Diabetes
Prior
Stroke/TIA
10

Methods
› 7 studies (6 independent cohorts)
› Systematic review using multivariate
regression analysis to identify independent
risk factors for stroke in patients with a fib

Results
›
›
›
›
›
Prior Stroke/TIA (RR 2.5, 95% CI 1.8-3.5)
Increasing Age (RR 1.5 per decade, 95% CI 1.3-1.7)
Hx HTN (RR 2.0, 95% CI 1.6-2.5)
Diabetes Mellitus (RR1.7, 95% CI 1.4-2.0)
HF (RR 1.4, 95% CI 0.8-2.3)
Observed absolute stroke rates for nonanticoagulated patients w/ single independent
risk factors

›
›
›
›
Prior Stroke/TIA: 6-9% per year
Age >75 years: 1.5-3%
Hx HTN: 1.5-3% per year
Diabetes: 2-3.5% per year
What would you recommend for C.S. based solely on
her CHADS₂ Score of 2 & CHADS₂VASc Score of 3?
1. No antithrombotic
therapy
2. ASA 75-325mg QD
3. Oral anticoagulant
0
0
0
No antithrombotic ASA 75-325mg QD Oral anticoagulant
therapy
10
What would you recommend for C.S. based on her
CHADS₂ Score of 2 & CHADS₂VASc Score of 3 and her history?
1. No antithrombotic
therapy
2. ASA 75-325mg QD
3. Oral anticoagulant
0
0
0
No antithrombotic ASA 75-325mg QD Oral anticoagulant
therapy
10
Evidence suggests diastolic heart failure
is as much a risk factor for stroke as
systolic heart failure
 Strongest Independent predictors of
stroke are Hx Stroke/TIA Increasing age,
Hx HTN & Diabetes

THANK- YOU!
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
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Abraham, JoEllyn & Connolly, Stuart. Atrial fibrillation in heart failure: stroke
risk stratification and anticoagulation. Heart Fail Rev 2014, 19:305-313.
Springer Science + Business Media, New York. 21 Jan 2014.
Banerjee, et al. Ejection fraction and outcomes in patients with atrial
fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project.
European Journal of Heart Failure 2012, 14, 295-301. 24 October 2011.
UpToDate: http://www-uptodatecom.proxy.lib.uiowa.edu/contents/image?imageKey=CARD/61615&topicKe
y=CARD%2F1031&source=outline_link&search=atrial+fibrillation%3A+anticao
gulation+to+prevent+thromboembolism&selectedTitle=2%7E150&utdPopup=
tru. Accessed 19 October 2015.