Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation

Predicting the risk of ischemic stroke in patients with atrial fibrillation using heterogeneous drug-protein-disease network-based deep learning

Current risk assessment models for predicting ischemic stroke (IS) in patients with atrial fibrillation (AF) often fail to account for the effects of medications and the complex interactions between drugs, proteins, and diseases. We developed an interpretable deep learning model, the AF-Biological-IS-Path (ABioSPath), to predict one-year IS risk in AF patients by integrating drug-protein-disease pathways with real-world clinical data. Using a heterogeneous multilayer network, ABioSPath identifies mechanisms of drug actions and the propagation of comorbid diseases. By combining mechanistic pathways with patient-specific characteristics, the model provides individualized IS risk assessments and identifies potential molecular pathways involved. We utilized the electronic health record data from 7859 AF patients, collected between January 2008 and December 2009 across 43 hospitals in Hong Kong. ABioSPath outperformed baseline models in all evaluation metrics, achieving an AUROC of 0.7815 (95% CI: 0.7346-0.8283), a positive predictive value of 0.430, a negative predictive value of 0.870, a sensitivity of 0.500, a specificity of 0.885, an average precision of 0.409, and a Brier score of 0.195. Cohort-level analysis identified key proteins, such as CRP, REN, and PTGS2, within the most common pathways. Individual-level analysis further highlighted the importance of PIK3/Akt and cytokine and chemokine signaling pathways and identified IS risks associated with less-studied drugs like prochlorperazine maleate. ABioSPath offers a robust, data-driven approach for IS risk prediction, requiring only routinely collected clinical data without the need for costly biomarkers. Beyond IS, the model has potential applications in screening risks for other diseases, enhancing patient care, and providing insights for drug development.

A new score with superior stroke risk prediction in atrial fibrillation: entropy-based information gain approaches in a large nationwide cohort

BACKGROUND

Risk scores have been used to assess stroke risk in atrial fibrillation (AF) for reducing ischemic stroke and bleeding risk. Information gain ratio (IGR) is an entropy-based parameter that shows which clinical score is more informative for prediction of the clinical endpoint.

OBJECTIVE

Herein, we aimed to generate and validate a stroke risk score based on the TuRkish Atrial Fibrillation (TRAF) data.

METHODS

We used a split-sample approach to develop and internally validate the new stroke risk score. Based on multivariate logistic regression analysis, we generated CHADS-F in the anticoagulation naïve TRAF cohort (274,631 patients). CHADS-F stands for Cardiac failure (1 point), hypertension (1 point), age (≥ 65-69 = 1 point, ≥ 70-74 = 2 points ≥ 75 = 3 points), diabetes (1 point), stroke (2 points), and older female (1 point) (≥ 65). External validation was performed in the "Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF)" Registry. Informative capacity and accuracy of the CHADS-F score was compared with CHADS2 and CHA2DS2-VASc scores.

RESULTS

In anticoagulation naïve cohort, CHADS-F (IGR for all cohort: 0.7526) outperforms both the CHADS2 (IGR for all cohort: 0.6340) and CHA2DS2-VASc (IGR for all cohort: 0.6969) in terms of the IGR for ischemic stroke and systemic embolism. Receiver operating characteristic curves revealed highest accuracy for the CHADS-F score [area under curve for CHADS-F: 0.743, CHADS2: 0.722, and CHA2DS2-VASc: 0.722]. CHADS-F had good discriminative abilities at predicting clinical endpoints in the GARFIELD-AF registry.

CONCLUSION

The CHADS-F score had higher informative capacity and accuracy than the current CHADS2 and CHA2DS2-VASc scores for predicting stroke and systemic embolism.

A machine learning-based model for predicting paroxysmal and persistent atrial fibrillation based on EHR

BACKGROUND

There is no effective way to accurately predict paroxysmal and persistent atrial fibrillation (AF) subtypes unless electrocardiogram (ECG) observation is obtained. We aim to develop a predictive model using a machine learning algorithm for identification of paroxysmal and persistent AF, and investigate the influencing factors.

METHODS

We collected demographic data, medication use, serological indicators, and baseline cardiac ultrasound data of all included subjects, totaling 50 variables. The diagnosis of AF subtypes is confirmed by ECG observation for at least more than 7 days. Variable selection was performed by spearman correlation analysis, recursive feature elimination, and least absolute shrinkage and selection operator regression. We built a prediction model for AF using three machine learning methods. Finally, the significance of each variable was analyzed by Shapley additive explanations method.

RESULTS

After screening, we found the optimal variable set consisting of 10 variables. The model we built achieved good predictive performance (AUC = 0.870, 95%CI 0.858 to 0.882), and had specificity of 0.851 (95%CI 0.844 to 0.858) and sensitivity of 0.716 (95%CI 0.676 to 0.755). Good predictive performance was stably achieved in different age subgroups and different gender subgroups. LA and NT-proBNP were the two most important variables for predicting paroxysmal and persistent AF in all models, except for the female subgroup aged less than 60 years.

CONCLUSIONS

Our model makes it possible to predict paroxysmal and persistent AF based on baseline data at admission. Early and individualized intervention strategies based on our model may help to improve clinical outcomes in AF patients.

Cross-Cultural Validation of Knowledge About Atrial Fibrillation and Stroke Prevention Questionnaire: A Cross-Sectional Study Among Chinese Patients With Atrial Fibrillation

AIM

To cross-culturally adapt the Knowledge about Atrial Fibrillation and Stroke Prevention Questionnaire (KAFSP-Q) for Chinese AF patients and validate its effectiveness.

DESIGN

Instrument adaptation and cross-sectional validation.

METHODS

The KAFSP-Q was translated into Chinese by using the forward and back translation method. Experts and patients were invited to revise the questionnaire domains and items. The psychometric properties of the Chinese version of the KAFSP-Q were evaluated, that is, its construct validity, discriminant validity, convergent validity, internal consistency and test-retest reliability.

FINDINGS

The Chinese version of the KAFSP-Q consists of 41 items and six domains, namely, bleeding knowledge, AF complications, stroke risk and stroke prevention, stroke symptoms, AF symptoms and general AF knowledge. The Chinese version of the KAFSP-Q demonstrated acceptable content validity (scale-content validity index = 0.859). The exploratory factor analysis revealed six factors, which accounted for 65.725% of the total variance, and the confirmatory factor analysis revealed acceptable fit indices. The convergent validity was poor, because the average variance extracted coefficient of the six domains was lower than 0.500. The square root of the average variance extracted coefficients was higher than the bivariate correlation between the domains, which indicated an acceptable discriminant validity. Meanwhile, the internal consistency and test-retest reliability were satisfactory (Cronbach's α coefficient = 0.973, intraclass correlation coefficient = 0.872).

CONCLUSIONS

The Chinese version of the KAFSP-Q demonstrates acceptable validity and reliability and can be used as a valuable instrument for AF and stroke prevention knowledge evaluation.

IMPACT

In clinical practice, the Chinese version of the KAFSP-Q can be used to help patients increase their disease management knowledge and engage in effective disease management behaviour. Future research is necessary to confirm the psychometric properties of the questionnaire with samples that are highly representative.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Refining Stroke Risk Assessment in Patients with Device-Detected Atrial Fibrillation

Clinical atrial fibrillation (AF) is a well-established major risk factor for stroke and systemic embolism. Pivotal trials have shown that treatment with oral anticoagulation reduces the risk of stroke and systemic embolism in clinical AF with a simultaneous increase in the risk of major bleeding. To help balance the risk of stroke and bleeding in clinical AF, different prediction models including biomarkers and clinical features have been validated. Device-detected AF (DDAF) is also associated with an increased risk of stroke and systemic embolism, but not to the same extent as clinical AF. Two large randomised studies have found significant stroke risk reduction with direct oral anticoagulation in DDAF patients, yet also a significantly increased risk of major bleeding. To date, the question remains how to balance the thromboembolic risk reduction with oral anticoagulation and the increased risk of bleeding in patients with DDAF and to identify the right patients who may benefit from oral anticoagulant treatment.

Systematic evaluation of machine learning models for postoperative surgical site infection prediction

BACKGROUND

Surgical site infections (SSIs) lead to increased mortality and morbidity, as well as increased healthcare costs. Multiple models for the prediction of this serious surgical complication have been developed, with an increasing use of machine learning (ML) tools.

OBJECTIVE

The aim of this systematic review was to assess the performance as well as the methodological quality of validated ML models for the prediction of SSIs.

METHODS

A systematic search in PubMed, Embase and the Cochrane library was performed from inception until July 2023. Exclusion criteria were the absence of reported model validation, SSIs as part of a composite adverse outcome, and pediatric populations. ML performance measures were evaluated, and ML performances were compared to regression-based methods for studies that reported both methods. Risk of bias (ROB) of the studies was assessed using the Prediction model Risk of Bias Assessment Tool.

RESULTS

Of the 4,377 studies screened, 24 were included in this review, describing 85 ML models. Most models were only internally validated (81%). The C-statistic was the most used performance measure (reported in 96% of the studies) and only two studies reported calibration metrics. A total of 116 different predictors were described, of which age, steroid use, sex, diabetes, and smoking were most frequently (100% to 75%) incorporated. Thirteen studies compared ML models to regression-based models and showed a similar performance of both modelling methods. For all included studies, the overall ROB was high or unclear.

CONCLUSIONS

A multitude of ML models for the prediction of SSIs are available, with large variability in performance. However, most models lacked external validation, performance was reported limitedly, and the risk of bias was high. In studies describing both ML models and regression-based models, one modelling method did not outperform the other.

Correlation between thrombocytopenia and adverse outcomes in patients with atrial fibrillation: a systematic review and meta-analysis

Background

Thrombocytopenia is often associated with adverse outcomes in patients with atrial fibrillation. Therefore, we conducted a meta-analysis to comprehensively assess the impact of thrombocytopenia on ischemic stroke/systemic embolism, major bleeding and all-cause mortality in patients with atrial fibrillation.

Methods

Two electronic databases, PubMed and Web of Science, were systematically searched from their inception to December 1, 2023, including the studies on the correlation between atrial fibrillation patients with thrombocytopenia and adverse outcomes. Relevant data was extracted, literature quality was evaluated, meta-analysis was performed by using REVMAN 5.4 software, and the results were reported with odds ratio (OR) of 95% confidence interval (CI).

Results

A total of 12 studies included 73,824 patients with atrial fibrillation (average age: 72.67, males: 42,275, 57.3%), among them, there were 7,673 patients combined with thrombocytopenia. The average follow-up time of these studies was 87 days to 55 months. Compared to no thrombocytopenia, atrial fibrillation patients combined with thrombocytopenia have a significant risk reduction of ischemic stroke/systemic embolism [OR: 0.79, 95% CI: (0.69, 0.91); P < 0.01]. Nevertheless, the risk of both major bleeding [OR: 1.51, 95% CI: (1.20, 1.79), P < 0.01] and all-cause mortality [OR: 1.40, 95% CI: (1.23, 1.61); P < 0.01] is significantly higher in thrombocytopenia group.

Conclusions

Thrombocytopenia has an important impact on the prognosis of patients with atrial fibrillation. Thrombocytopenia is significantly associated with a lower risk of ischemic stroke/systemic embolism but a higher risk of major bleeding and all-cause mortality. Attention to thrombocytopenia and optimization of treatment may be the effective way to improve the prognosis of atrial fibrillation with thrombocytopenia.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO Registration Number: (CRD42023459916).

2024 Guideline for the Primary Prevention of Stroke: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2024 Guideline for the Primary Prevention of Stroke" replaces the 2014 "Guidelines for the Primary Prevention of Stroke." This updated guideline is intended to be a resource for clinicians to use to guide various prevention strategies for individuals with no history of stroke.

METHODS

A comprehensive search for literature published since the 2014 guideline; derived from research involving human participants published in English; and indexed in MEDLINE, PubMed, Cochrane Library, and other selected and relevant databases was conducted between May and November 2023. Other documents on related subject matter previously published by the American Heart Association were also reviewed.

STRUCTURE

Ischemic and hemorrhagic strokes lead to significant disability but, most important, are preventable. The 2024 primary prevention of stroke guideline provides recommendations based on current evidence for strategies to prevent stroke throughout the life span. These recommendations align with the American Heart Association's Life's Essential 8 for optimizing cardiovascular and brain health, in addition to preventing incident stroke. We also have added sex-specific recommendations for screening and prevention of stroke, which are new compared with the 2014 guideline. Many recommendations for similar risk factor prevention were updated, new topics were reviewed, and recommendations were created when supported by sufficient-quality published data.

Predictors of left atrial appendage thrombus in atrial fibrillation patients undergoing cardioversion

BACKGROUND

Atrial fibrillation and atrial flutter represent the most prevalent clinically significant cardiac arrhythmias. While the CHA2DS2-VASc score is commonly used to inform anticoagulation therapy decisions for patients with these conditions, its predictive power is limited. Therefore, we sought to improve risk prediction for left atrial appendage thrombus (LAAT), a known risk factor for stroke in these patients.

METHODS

We developed and validated an explainable machine learning model using the eXtreme Gradient Boosting algorithm with 5 × 5 nested cross-validation. The primary outcome was to predict the probability of LAAT in patients with atrial fibrillation and atrial flutter who underwent transesophageal echocardiogram prior to cardioversion. Our algorithm used 37 demographic, comorbid, and transthoracic echocardiographic variables.

RESULTS

A total of 795 patients were included in our analysis. LAAT was present in 11.3% of the patients. The average age of patients was 63.3 years and 34.7% were women. Patients with LAAT had significantly lower left ventricular ejection fraction (29.9% vs 43.5%; p < 0.001), lower E' lateral velocity (5.7 cm vs. 7.9 cm; p < 0.001) and higher E/A ratio (2.6 vs 1.8; p = 0.002). Our machine learning model achieved a high AUC of 0.79, with a high specificity of 0.82, and modest sensitivity of 0.57. Left ventricular ejection fraction was the most important variable in predicting LAAT. Patients were split into 10 buckets based on the percentile of their predicted probability of having thrombus. The lower the percentile (e.g., 10%), the lower the probability of having thrombus. Using a cutoff point of 0.16 which includes 10.0% of the patients, we can rule out thrombus with 100% confidence.

CONCLUSION

Using machine learning, we refined the predictive power of predicting LAAT and explained the model. These results show promise in providing better guidance for anticoagulation therapy and cardioversion in AF and AFL patients.

Use of Neutrophil-to-Lymphocyte Ratio to Predict In-Hospital Mortality in Patients Admitted with Acute Decompensation of Atrial Fibrillation

Background/Objectives: The prevalence of atrial fibrillation (AF) has been on the rise over the last 20 years. It is considered to be the most common cardiac arrhythmia and is associated with significant morbidity and mortality. The need for in-hospital management of patients having AF is increasing. Acute decompensation of cardiac rhythm is an indication for hospital admission. In the existing literature, several studies on different pathologies have observed that the risk of death was greater for patients with an increased neutrophil-to-lymphocyte ratio (NLR) and suggested that the NLR can be a useful biomarker to predict in-hospital mortality. This study aims to evaluate the link between the neutrophil-to-lymphocyte ratio at admission and death among the patients admitted to the medical ward for the acute manifestation of AF, and to gain a better understanding of how we can predict in-hospital all-cause death based on the NLR for these patients. Methods: A single-center retrospective study in an academic medical clinic was conducted. We analyzed if the NLR at in-hospital admission can be related to in-hospital mortality among the patients admitted for AF at the Medical Ward of Municipal Emergency University Hospital Timisoara between 2015 and 2016. After identifying a total of 1111 patients, we divided them into two groups: in-hospital death patients and surviving patients. We analyzed the NLR in both groups to determine if it is related to in-hospital mortality or not. One patient was excluded because of missing data. Results: Our analysis showed that patients who died during in-hospital admission had a significantly higher NLR compared to those who survived (p < 0.0001, 95% CI (1.54 to 3.48)). The NLR was found to be an independent predictor of in-hospital death among patients with AF, even for the patients with no raised level of blood leukocytes (p < 0.0001, 95% CI (0.6174 to 3.0440)). Additionally, there was a significant correlation between the NLR and the risk of in-hospital death for patients admitted with decompensated AF (p < 0.0001), with an area under the ROC curve of 0.745. Other factors can increase the risk of death for these patients (such as the personal history of stroke, HAS-BLED score, and age). Conclusions: The NLR is a useful biomarker to predict in-hospital mortality in patients with AF and can predict the risk of death with a sensitivity of 72.8% and a specificity of 70.4%. Further studies are needed to determine the clinical utility of the NLR in risk stratification and management of patients with AF.

Current Antithrombotic Treatments for Cardiovascular Diseases: A Comprehensive Review

Antithrombotic therapies (ATT) play a pivotal role in the management of cardiovascular diseases, aiming to prevent ischemic events while maintaining a delicate balance with the patient's bleeding risk. Typically, ATT can be classified into antiplatelet and anticoagulant therapies. Their application spans a broad spectrum of cardiovascular conditions, ranging from ischemic heart disease to atrial fibrillation, encompassing venous thromboembolisms and innovative structural interventional cardiology procedures. The global burden of cardiovascular diseases is steadily increasing, often giving rise to overlapping clinical presentations. Accordingly, the adoption of combined pharmacological approaches becomes imperative, potentially disrupting the delicate equilibrium between ischemic and bleeding risk, thus leading to nuanced pharmacotherapeutic pathways. In this context, contemporary investigations strive to identify a convergence point that optimizes the duration of medical therapy while addressing the need for antithrombotic effects, especially in the context of ischemic heart disease. This review aims to comprehensively revisit the main antithrombotic strategies in cardiovascular diseases, with the intention of enhancing a systematic approach which is key for the effective clinical management of these patients. Also, the review will examine the most impactful studies that have established the groundwork for current scientific evidence, with acknowledgement of special populations. Finally, we will cast a gaze into the future of this dynamic and evolving research field, exploring forthcoming perspectives and advancements.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Real-World Data on the Incidence of Stroke, Myocardial Infarction, and Mortality Among Nonvalvular Atrial Fibrillation Patients in Türkiye: New Oral Anticoagulants-TURKey Study

BACKGROUND

Atrial fibrillation (AF) is strongly associated with an increased risk of ischemic events. Anticoagulation focuses on reducing the risk of embolism. Guideline recommended CHA2DS2-VASc scoring system is most widely used; however, different scoring systems do exist. Thus, we sought to assess the impact of anticoagulant treatment and different scoring systems on the development of stroke, myocardial infarction, and all-cause mortality in patients with nonvalvular AF.

METHODS

The present study was designed as a prospective cohort study. The enrollment of the patients was conducted between August 1, 2015, and January 1, 2016. The follow-up period was defined as the time from enrollment to the end of April 1, 2017, which also provided at least 12 months of prospective follow-up for each patient.

RESULTS

A total of 1807 patients with AF were enrolled. During the follow-up, 2.7% (48) of patients had stroke, 0.8% (14) had myocardial infarction, and 7.5% (136) died. The anticoagulation and risk factors in AF (ATRIA) score had a better accuracy for the prediction of stroke compared to other scoring systems (0.729, 95% CI, 0.708-0.750, P <.05). Patients under low-dose rivaroxaban treatment had significantly worse survival (logrank P <.001). Age, CHA2DS2-VASc score, R2CHADS2 score, ATRIA score, chronic heart failure, prior stroke, and being under low-dose rivaroxaban treatment were independent predictors of clinical endpoint (P <.001).

CONCLUSION

Low-dose rivaroxaban treatment was independently and strongly associated with the combined clinical endpoint. Furthermore, the ATRIA score proved to be a stronger predictor of stroke in the Turkish population.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

External Validation of the HELT-E2S2 Score in Japanese Patients With Nonvalvular Atrial Fibrillation - A Pooled Analysis of the RAFFINE and SAKURA Registries

BACKGROUND

The HELT-E2S2score, which assigns 1 point to Hypertension, Elderly aged 75-84 years, Low body mass index <18.5 kg/m2, and Type of atrial fibrillation (AF: persistent/permanent), and 2 points to Extreme Elderly aged ≥85 years and previous Stroke, has been proposed as a new risk stratification for strokes in Japanese AF patients, but has not yet undergone external validation.

METHODS AND RESULTS

We evaluated the prognostic performance of the HELT-E2S2score for stroke risk stratification using 2 large-scale registries in Japanese AF patients (n=7,020). During 23,241 person-years of follow-up (mean follow-up 1,208±450 days), 287 ischemic stroke events occurred. The C-statistic using the HELT-E2S2score was 0.661 (95% confidence interval [CI], 0.629-0.692), which was numerically higher than with the CHADS2score (0.644, 95% CI 0.613-0.675; P=0.15 vs. HELT-E2S2) or CHA2DS2-VASc score (0.650, 95% CI, 0.619-0.680; P=0.37 vs. HELT-E2S2). In the SAKURA AF Registry, the C-statistic of the HELT-E2S2score was consistently higher than the CHADS2and CHA2DS2-VASc scores across all 3 types of facilities comprising university hospitals, general hospitals, and clinics. However, in the RAFFINE Study, its superiority was only observed in general hospitals.

CONCLUSIONS

The HELT-E2S2score demonstrated potential value for risk stratification, particularly in a super-aged society such as Japan. However, its superiority over the CHADS2or CHA2DS2-VASc scores may vary across different hospital settings.

Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre

Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be 'tailored' in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004-2011 and beyond (years 2012-2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients' sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004-2011 and 2012-2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012-2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.

Copy number variation of gasdermin D gene is associated with atrial fibrillation-related thromboembolic stroke

AIMS

Atrial fibrillation (AF) is one of the major causes of ischaemic stroke. In addition to clinical risk evaluated by the CHA2DS2-VASC score, the impact of genetic factors on the risk of AF-related thromboembolic stroke has been largely unknown. We found several copy number variations (CNVs) in novel genes that were associated with thromboembolic stroke risk in our AF patients by genome-wide approach. Among them, the gasdermin D (GSDMD) gene was related to inflammation. We aimed to test whether GSDMD deletion was associated with AF-related stroke.

METHODS AND RESULTS

A total of 400 patients with documented non-familial AF were selected, of which 100 patients were diagnosed with ischaemic stroke. The baseline characteristics of age, sex, valvular heart disease, coronary artery disease, heart failure, and CHA2DS2-VASc scores were not statistically different between cases and controls. We found that individuals who carried GSDMD homozygous deletion genotype had a higher risk for ischaemic stroke (odds ratio 2.195; 95% confidence interval, 1.24-3.90; P = 0.007), even adjusted by CHA2DS2-VASc scores. We also validated the association of GSDMD with AF stroke in a large Caucasian population (UK Biobank).

CONCLUSION

We found a link between the homozygous deletion of the GSDMD gene and an increased risk of stroke in patients with AF. This may implicate the use of therapy targeting GSDMD in the prevention of ischaemic stroke for AF patients.

A Survey of Saudi General Practitioners on the Use of Thromboprophylaxis Guidelines and Risk Assessment Tools in Atrial Fibrillation

Clinical practice guidelines advise patients with atrial fibrillation who are at risk for stroke to undergo thromboprophylaxis with oral anticoagulants. However, it is noted that guidelines are not always followed. We sought to learn how Saudi Arabian general practitioners (GPs) self-reported using risk assessment tools and atrial fibrillation clinical practice guidelines created by cardiology associations, as well as how GPs felt about the resources that were available. Through the use of a self-administered questionnaire, we carried out a cross-sectional survey. A total of two-hundred GPs participated in the study. The guidelines were frequently used when a clinical decision regarding anticoagulation therapy appeared difficult (n = 57, 28.4%). The most predominant strengths of participants' chosen clinical guidelines were clear recommendations (n = 56, 27.9%), easy-to-follow algorithms (n = 39, 16.9%), detailed recommendations supported by evidence (n = 34, 16.9%), and online availability (n = 27, 13.4%). Many respondents said they used a formal stroke risk assessment tool in addition to their clinical judgment as a GP for most decisions (60%). Most respondents preferred using the CHA2DS2-VASc (n = 106, 52.7%), CHA2DS2-VA (n = 45, 22.4%), CHADS2 (n = 35, 17.4%), and GARFIELD (n = 14, 7.0%). HAS-BLED (n = 100, 49.8%) and HEMORR2HAGES (n = 50, 24.9%) were the most frequently utilized formal tools for assessing the risk of bleeding among GPs. Over half of the participants referred to guidelines when deciding thromboprophylaxis in patients with atrial fibrillation. Additionally, many respondents used formal procedures for assessing the risks of bleeding and stroke in addition to their clinical judgement in their roles as GPs. The guideline was assessed as being extremely helpful overall by GPs who used it to make thromboprophylaxis decisions.

microRNAs as biomarkers of risk of major adverse cardiovascular events in atrial fibrillation

Atrial fibrillation is a complex and multifactorial disease. Although prophylactic anticoagulation has great benefits in avoiding comorbidities, adverse cardiovascular events still occur and thus in recent decades, many resources have been invested in the identification of useful markers in the prevention of the risk of MACE in these patients. As such, microRNAs, that are small non-coding RNAs whose function is to regulate gene expression post-transcriptionally, have a relevant role in the development of MACE. miRNAs, have been investigated for many years as potential non-invasive biomarkers of several diseases. Different studies have shown their utility in the diagnosis and prognosis of cardiovascular diseases. In particular, some studies have associated the presence of certain miRNAs in plasma with the development of MACE in AF. Despite these results, there are still many efforts to be done to allow the clinical use of miRNAs. The lack of standardization concerning the methodology in purifying and detecting miRNAs, still provides contradictory results. miRNAs also have a functional impact in MACE in AF through the dysregulation of immunothrombosis. Indeed, miRNAs may be a link between MACE and inflammation, through the regulation of neutrophil extracellular traps that are a key element in the establishment and evolution of thrombotic events. The use of miRNAs as therapy against thromboinflammatory processes should also be a future approach to avoid the occurrence of MACE in atrial fibrillation.