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Zhu Y, Qiu H, Wang Z, Shen G, Li W. Predictive value of systemic immune-inflammatory index combined with CHA2DS2-VASC score for contrast-induced acute kidney injury in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Int Urol Nephrol 2023; 55:2897-2903. [PMID: 37000380 DOI: 10.1007/s11255-023-03571-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/22/2023] [Indexed: 04/01/2023]
Abstract
OBJECTIVE To investigate the value of systemic immune-inflammation index (SII) combined with CHA2DS2-VASC score in predicting the risk of contrast-induced acute kidney injury (CI-AKI) in patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) treatment. METHODS 1531 consecutive patients with ACS and undergoing PCI were recruited from January 2019 to December 2021. All patients were divided into CI-AKI and non-CI-AKI groups according to the pre-procedure and post-procedure creatinine changes, and the baseline data were compared between the two groups. Binary logistic regression analysis was used to investigate the factors influencing CI-AKI in ACS patients after PCI. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive value of SII, CHA2DS2-VASC, and their combined levels on CI-AKI after PCI. RESULTS Patients with high SII and high CHA2DS2-VASC score had a higher incidence of CI-AKI. For SII, the area under the ROC curve (AUC) for predicting CI-AKI was 0.686. The optimal cut-off value was 736.08 with a sensitivity of 66.8% and a specificity of 66.3% [95% confidence interval (CI) 0.662-0.709; P < 0.001]. For CHA2DS2-VASC score, the AUC was 0.795, the optimal cut-off value was 2.50 with a sensitivity of 80.3% and a specificity of 62.7% (95% CI 0.774-0.815; P < 0.001). When combining SII and CHA2DS2-VASC score, the AUC was 0.830, the optimal cut-off value was 0.148 with a diagnostic sensitivity of 76.1% and a specificity of 75.2% (95% CI 0.810-0.849; P < 0.001). The results showed that SII combined with CHA2DS2-VASC score resulted in improved predictive accuracy of CI-AKI. Multifactorial logistic regression analysis showed that albumin level (OR = 0.967, 95% CI 0.936-1.000; P = 0.047), lnSII level (OR = 1.596, 95% CI 1.010-1.905; P < 0.001), and CHA2DS2-VASC score level (OR = 1.425, 95% CI 1.318-1.541; P < 0.001) were independent risk factors for CI-AKI in patients with ACS treated with PCI. CONCLUSION High SII and high CHA2DS2-VASC score are risk factors for the development of CI-AKI, and the combination of the two improves the accuracy of predicting the occurrence of CI-AKI in patients with ACS undergoing PCI.
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Affiliation(s)
- Yinghua Zhu
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China
| | - Hang Qiu
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China
| | - Zhen Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221000, Jiangsu, China
| | - Guoqi Shen
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221000, Jiangsu, China
| | - Wenhua Li
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China.
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, No. 99 Huaihai West Road, Xuzhou, 221000, Jiangsu, China.
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Teodorovich N, Gandelman G, Jonas M, Fabrikant Y, Swissa MS, Shimoni S, George J, Swissa M. The CHA 2DS 2-VAS C Score Predicts Mortality in Patients Undergoing Coronary Angiography. Life (Basel) 2023; 13:2026. [PMID: 37895408 PMCID: PMC10608546 DOI: 10.3390/life13102026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/24/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The CHA2DS2-VASC score is used to predict the risk of thromboembolic complications in patients with atrial fibrillation (AF). We hypothesized that the CHA2DS2-VASC score can be used to predict mortality in patients undergoing coronary angiography. METHODS AND RESULTS This was a prospective study of 990 patients undergoing coronary angiography. The median follow-up was 2294 days. The patients were categorized into two groups according to their CHA2DS2-VASC score: group I had scores <4 and group II had scores ≥4 (527 (53.2%) and 463 (46.8%), respectively). A Kaplan-Meier analysis demonstrated a significant association between the CHA2DS2-VASC score and mortality (69/527 (13.1%) vs. 179/463 (38.7%) for group I vs. group II, respectively, p < 0.0001). The association remained significant in patients with and without AF, reduced and preserved LVEF, normal and reduced kidney function, and with and without ACS (p < 0.009 to p < 0.0001 for all). In the Cox regression model, which combined the CHA2DS2-VASC score, the presence of AF, LVEF, anemia, and renal insufficiency, an elevated CHA2DS2-VASC score of ≥4 was independently associated with higher mortality (HR 2.12, CI 1.29-3.25, p = 0.001). CONCLUSIONS The CHA2DS2VASC score is a simple and reliable mortality predictor in patients undergoing coronary angiography and should be used for the initial screening for such patients.
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Affiliation(s)
- Nicholay Teodorovich
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Gera Gandelman
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Michael Jonas
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Yakov Fabrikant
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Michael Sraia Swissa
- Shari-Zedek Medical Center, and the Hebrew University, Jerusalem 9103102, Israel;
| | - Sara Shimoni
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Jacob George
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
| | - Moshe Swissa
- Kaplan Medical Center, Rehovot and the Hebrew University, Jerusalem 7661041, Israel; (G.G.); (M.J.); (Y.F.); (S.S.); (J.G.); (M.S.)
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Del Rio-Pertuz G, Leelaviwat N, Mekraksakit P, Benjanuwattra J, Nugent K, Ansari MM. Association between elevated CHA2DS2-VASC score and contrast-induced nephropathy among patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Acta Cardiol 2023; 78:922-929. [PMID: 37171278 DOI: 10.1080/00015385.2023.2209406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Promising results with the CHA2DS2-VASc risk score (CVRS) have been reported for the prediction of contrast-induced nephropathy (CIN). The aim of this study is to consolidate all the data available and examine the association between elevated CVRS and the incidence of CIN in patients undergoing percutaneous coronary intervention (PCI). METHODS We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to May 2022. Studies were included if they evaluated the association between a high CVRS and the incidence of CIN in patients undergoing PCI. Data were integrated using the random-effects, generic inverse variance method of DerSimonian and Laird. Prospero registration: CRD42022334065. RESULTS Seven studies from 2016 to 2021 with a total of 7,401 patients were included. In patients undergoing PCI, a high CVRS (≥2: Odds ratio [OR]:2.98, 95% confidence interval [95% CI] 2.25-3.94, p < .01, I2 = 1%, ≥3: OR 4.46, 95% CI 2.27-8.78, p < .01, I2=56% and ≥4: OR:2.75, 95% CI 1.76-4.30, p < .01, I2 = 11%) was significantly associated with an increase incidence for CIN. Subgroup analyses were done in patients with acute coronary syndrome, and association with CIN remained statistically significant (≥2: OR 2.93, 95% CI 2.11-4.07, p < .01, I2=22%and ≥4: OR:2.24, 95% CI 1.36-3.69, p < .01, I2 = 0%,). CONCLUSION In patients undergoing PCI, an elevated CVRS is associated with an increased risk for CIN. More rigorous studies are needed to clarify this association and to identify strategies to reduce CIN.
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Affiliation(s)
- Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Natnicha Leelaviwat
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Poemlarp Mekraksakit
- Department of Internal Medicine, Division of Nephrology, Mayo Clinic, Rochester, MN, USA
| | - Juthipong Benjanuwattra
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Mohammad M Ansari
- Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Liu H, Chen L, Song Y, He Y, Kang R, Liu S, Zhang C. Use of left atrial automated functional myocardial imaging to identify patients with paroxysmal atrial fibrillation at high risk of stroke. Quant Imaging Med Surg 2023; 13:4313-4324. [PMID: 37456314 PMCID: PMC10347334 DOI: 10.21037/qims-22-1142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 03/31/2023] [Indexed: 07/18/2023]
Abstract
Background Left atrial automated functional myocardial imaging (AFILA) is a new software program for analyzing the structure and function of the left atrium (LA). The present study sought to analyze the correlation between the LA function parameters as measured by AFILA echocardiography and the risk of cerebral ischemic stroke (CIS) in patients with non-valvular paroxysmal atrial fibrillation (NVPAF) to explore the diagnostic value of LA strain in patients with congestive heart failure, hypertension, age of ≥75 years (doubled), diabetes mellitus, stroke or transient ischemic attack (TIA) (doubled), age of 65-74 years, and sex category (female) (CHA2DS2-VASc) scores of <2. Methods A total of 205 patients with NVPAF were included in the study and divided into the no-CIS group (154 patients) and the CIS group (51 patients). The baseline clinical data for the 2 groups were analyzed, and routine echocardiography examinations were performed. AFILA was used to evaluate the LA function of all the patients. Results Compared to the no-CIS group, the LA emptying fraction and the LA reservoir strain were decreased, the LA contractile strain (S_CT) was increased, and the S_CT value changed from negative to positive in the CIS group, and the difference between the 2 groups were statistically significant (P<0.001). However, there were no significant differences in the volume at the onset of LA contraction, LA evacuation volume, LA minimum volume, LA maximum volume, and LA conduit strain between the 2 groups. The multifactorial regression analysis showed that age, hypertension, and the S_CT were independently associated risk factors for patients with CIS. After correcting for the clinical factors included in the CHA2DS2-VASc score, the S_CT was shown to predict to NVPAF with stroke [odds ratio (OR): 1.234, 95% confidence interval (CI): 1.101-1.383, P=0.000]. In addition, we included the CHA2DS2-VASc score (instead of age, diabetes, coronary artery disease, and hypertension) in a multiple regression analysis, and found that the S_CT was still significant (OR: 1.252, 95% CI: 1.118-1.402, P=0.000). The difference between the 2 groups in the CHA2DS2-VASc score for the S_CT was statistically significant, especially when the CHA2DS2-VASc score was <2. The S_CT equaled -4.5% was the cut-off value for the presence or absence of CIS in the NVPAF patients, with an area under the curve (AUC) of 0.866, sensitivity of 0.80, and specificity of 0.75 (P<0.0001). Conclusions Comparison with LA volume parameter, measuring LA strain by AFILA provides a better index for the dynamic assessment of impaired LA function in patients with NVPAF combined with CIS, especially in those with a CHA2DS2-VASc score of <2. In addition, a LA S_CT of >-4.5% is a valuable cut-off for patients with NVPAF. The results of the current study may form the basis for a large prospective multicenter interventional study in which patients with impaired LA S_CT are randomized to receive oral anti-coagulant (OAC) therapy or no OAC therapy for the primary prevention of stroke.
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Affiliation(s)
- Hailan Liu
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- Department of Ultrasound, Nanchang First Hospital, Nanchang, China
| | - Lili Chen
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yan Song
- Department of Ultrasound, Nanchang First Hospital, Nanchang, China
| | - Yanlin He
- Department of Ultrasound, Nanchang First Hospital, Nanchang, China
| | - Ruirui Kang
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shengbo Liu
- GE Healthcare Ultrasound Application Specialist, Nanchang, China
| | - Chunquan Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Lessomo FYN, Fan Q, Wang ZQ, Mukuka C. The relationship between leukocyte to albumin ratio and atrial fibrillation severity. BMC Cardiovasc Disord 2023; 23:67. [PMID: 36739380 PMCID: PMC9898847 DOI: 10.1186/s12872-023-03097-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 01/27/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND An increased leukocyte count is a sign of inflammation and has been demonstrated to be a predisposing factor and complication of atrial fibrillation. Similarly, albumin, the major protein in the serum, is also considered an acute phase reactant protein that has osmotic and anti-inflammatory properties, and a low albumin level is a known factor associated with severity in many pathologies, including atrial fibrillation. The neutrophil percentage-to-albumin ratio (NPAR) and other emerging leukocyte counts/albumin ratios have been reliable systemic inflammation-based predictors of mortality and complications in various diseases, but they have not yet been used with atrial fibrillation. This study's aim was to explore whether the leukocyte to albumin ratio could also serve as a useful index in estimating atrial fibrillation severity, including the severity of atrial fibrillation secondary to stroke, to provide a new and more objective tool than the conventional and medical history-based CHA2DS2-VASc score. MATERIALS AND METHODS Data were retrospectively collected from the Wuhan University Zhongnan Hospital database from January 1st to December 31st, 2021. The patients were classified into 2 groups: Group 1-low severity and Group 2- moderate to high severity, and diverse statistical analyses were conducted to evaluate the relationship between the leukocyte-to-albumin ratio and AF severity. RESULTS Only 2329 test subjects met the inclusion criteria. We had 727 test subjects (381 males and 346 females) categorized into the low severity cohort and 1601 test subjects (932 males and 670 females) in the moderate to high severity group. The difference in mean age between the two groups was significant (95% CI [-2.682 to -0.154] p = 0.028), and the difference in the LAR mean rank between the two groups was significant (p = 0.00). The Chi-square test of association yielded the following results: the relationship between the LAR level and category of severity was statistically significant (p = 0.00), and the Mantel‒Haenszel statistic association odds ratio was OR = 0.657. 95% CI OR [0.549-0.787] p = 0.000. The association between sex and atrial fibrillation severity also reached statistical significance. However, sex and LAR were found to be independent factors in atrial fibrillation (Chi-square p value = 0.564). CONCLUSION It has been demonstrated throughout this investigation that the leukocyte to albumin ratio could provide key clues in clinical practice and contribute to thromboembolism risk assessment in the setting of atrial fibrillation.
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Affiliation(s)
- Fabrice Yves Ndjana Lessomo
- grid.413247.70000 0004 1808 0969Cardiovascular Internal Medicine, Cardiology Department, Wuhan University Zhongnan Hospital, Wuhan, China
| | - Qian Fan
- grid.413247.70000 0004 1808 0969Cardiovascular Internal Medicine, Cardiology Department, Wuhan University Zhongnan Hospital, Wuhan, China ,grid.410638.80000 0000 8910 6733 Cardiology Department, The second affiliated hospital of Shandong First Medical University, Shandong, China
| | - Zhi-Quan Wang
- Cardiovascular Internal Medicine, Cardiology Department, Wuhan University Zhongnan Hospital, Wuhan, China.
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Zhang W, Chen Y, Hu LX, Xia JH, Ye XF, Cheng YB, Wang Y, Guo QH, Li Y, Lowres N, Freedman B, Wang JG. Changes in the CHA 2DS 2-VAS C score as a predictor of incident atrial fibrillation in older Chinese individuals: the AF-CATCH study. Eur Heart J Open 2022; 2:oeac046. [PMID: 35983405 PMCID: PMC9380993 DOI: 10.1093/ehjopen/oeac046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 07/04/2022] [Indexed: 02/02/2023]
Abstract
Aims Incidence of atrial fibrillation is highly associated with age and cardiovascular co-morbidities. Given this relationship, we hypothesized that the dynamic changes resulting in an increase in the CHA2DS2-VASC score over time would improve the efficiency of predicting incident atrial fibrillation on repeated screening after a negative test. Methods and results We investigated in an analysis of the AF-CATCH trial [quarterly vs. annual electrocardiogram (ECG) screening for atrial fibrillation in older Chinese individuals] data, the association between the changes in the CHA2DS2-VASC score from baseline to end-of-study visit and the risk of incident atrial fibrillation. Participants without a history of atrial fibrillation and with a sinus rhythm at baseline were randomized to the annual (usual) or quarterly 30 s (intensive) single-lead ECG screening groups. During a median follow-up of 2.1 years in 6806 participants, the incidence rate of atrial fibrillation increased from 4.2 per 1000 person-years in participants with a change in the CHA2DS2-VASC score of 0 to 6.4 and 25.8 per 1000 person-years in participants with a change in the CHA2DS2-VASC score of 1 and ≥2, respectively. A change in the CHA2DS2-VASC score of ≥2 was associated with a significantly elevated risk of incident atrial fibrillation. Conclusions Patients with substantial changes in the CHA2DS2-VASC score were more likely to develop incident atrial fibrillation, and regular re-assessments of cardiovascular risk factors in the elderly are probably worthwhile to improve the detection of atrial fibrillation. Registration URL: http://www.clinicaltrials.gov; Unique identifier: NCT02990741.
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Affiliation(s)
- Wei Zhang
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Yi Chen
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Lei-Xiao Hu
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Jia-Hui Xia
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Xiao-Fei Ye
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Yi-Bang Cheng
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China,National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ying Wang
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Qian-Hui Guo
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China,National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yan Li
- Department of Cardiovascular Medicine, State Key Laboratory of Medical Genomics, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Ruijin 2nd Road 197, Shanghai 200025, China
| | - Nicole Lowres
- Heart Research Institute, Sydney Medical School, Charles Perkins Center, Sydney NSW2006, Australia,Cardiology Department, Concord Hospital, The University of Sydney, Sydney NSW2006, Australia
| | - Ben Freedman
- Heart Research Institute, Sydney Medical School, Charles Perkins Center, Sydney NSW2006, Australia,Cardiology Department, Concord Hospital, The University of Sydney, Sydney NSW2006, Australia
| | - Ji-Guang Wang
- Corresponding author. Tel: +86 21 6437 0045 ext 610911, Fax: +86 21 6466 2193,
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Li J, Wang Z, Zhang B, Zheng D, Lu Y, Li W. Predictive value of combining the level of fibrinogen and CHA2DS2-VASC Score for contrast-induced acute kidney injury in patients with acute coronary syndromes undergoing percutaneous coronary intervention. Int Urol Nephrol 2022; 54:2385-2392. [PMID: 35182313 DOI: 10.1007/s11255-022-03149-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/09/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The present study aimed to investigate the value of preprocedural fibrinogen (FIB) combined with CHA2DS2-VASC scores in the risk prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS). METHOD A total of 934 patients (mean age 63.9 ± 11.5 years, and 32.1% female), who were admitted to our hospital for ACS and underwent PCI, were retrospectively enrolled. The patients were divided into two groups: non-CI-AKI group (n = 787) and CI-AKI group (n = 147). Contrast-induced acute kidney injury was defined as an increase of ≥ 0.5 mg/dL or ≥ 25% serum creatinine within 48-72 h after PCI. Spearman correlation analysis was used to determine the relationship between FIB and CHA2DS2-VASC scores. RESULTS Patients with high baseline FIB levels and high CHA2DS2-VASC scores had higher CI-AKI incidence. On spearman correlation analysis, FIB and CHA2DS2-VASC scores were positively correlated (R = 0.236, P < 0.001). The ROC statistical analysis showed that the combination had 63.3% sensitivity with 72.6% specificity for the development of CI-AKI (area under the curve: 0.727, 95% CI 0.697-0.755, P < 0.001). A total of 934 ACS patients were divided into low-risk group (404 cases), medium-risk group (383 cases) and high-risk group (147 cases) according to the cut-off values of FIB and CHA2DS2-VASC scores. The incidence of CI-AKI was higher in the high-risk group than in the low-risk and medium-risk groups (Log-rank χ2 = 104.505, 56.647. P < 0.001). Multivariate analysis revealed that albumin (OR = 0.913, 95% CI 0.867-0.962), FIB (OR = 1.451, 95% CI 1.185-1.77), CHA2DS2-VASC score (OR = 1.271, 95% CI 1.504-1.78) were the independent risk factors of CI-AKI (p < 0.05). CONCLUSION The preprocedural fibrinogen combined with CHA2DS2-VASC score is independently associated with the risk of CI-AKI in ACS patients treated by PCI.
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Affiliation(s)
- Jing Li
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China
| | - Zhen Wang
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China
| | - BaiXiang Zhang
- Department of Cardiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Di Zheng
- Department of Cardiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Yuan Lu
- Department of Cardiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China
| | - Wenhua Li
- Institute of Cardiovascular Diseases, Xuzhou Medical University, Xuzhou, 221000, China. .,Department of Cardiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221000, Jiangsu, China.
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Chen L, Zhang C, Wang J, Guo L, Wang X, Liu F, Li X, Zhao Y. Left atrial strain measured by 4D Auto LAQ echocardiography is significantly correlated with high risk of thromboembolism in patients with non-valvular atrial fibrillation. Quant Imaging Med Surg 2021; 11:3920-3931. [PMID: 34476178 DOI: 10.21037/qims-20-1381] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/08/2021] [Indexed: 11/06/2022]
Abstract
Background The 4-dimensional automated left atrial quantification (4D Auto LAQ) tool is a new software for analysis of the structure and function of the left atrium (LA). This study aimed to evaluate the relationship between LA strain (LAS) as measured by 4D Auto LAQ echocardiography and thromboembolism risk in patients with non-valvular atrial fibrillation (NVAF). Methods Eight-five patients with NVAF were recruited from the cardiovascular center of our hospital, including 39 patients at high risk and 46 patients at low risk of thromboembolism. The study participants were assessed by routine echocardiography; 4D images were obtained, after which 4D Auto LAQ assessment was performed. Results In the thromboembolism high-risk group, the rates of impaired LA reservoir strain, LA contraction strain, LA reservoir circumferential strain, LA conduit circumferential strain, and LA contraction circumferential strain were found to be significantly higher than in the low-risk group. However, there was no significant difference in volume at onset of LA contraction or LA ejection fraction (LAEF) between the 2 groups. LA contraction circumferential strain was found to be an independent high risk factor for thromboembolism [odds ratio (OR): 2.52; P=0.008]. LA contraction circumferential strain >-4.5% was the cut-off for differentiating between participants with high and low risk of thromboembolism, with an area under the curve (AUC) of 0.95 (P<0.0001), a sensitivity of 0.872, and a specificity of 0.978. Sequential analysis revealed that LA contraction circumferential strain had a high diagnostic efficacy for stroke, as well as a specified accuracy in the diagnosis of hypertension and diabetes in patients aged ≥65 years old. However, it was not found to be effective in the diagnosis of heart failure and vascular diseases. Conclusions LAS is a useful index for the dynamic evaluation of LA function in patients with non-valvular AF, with higher sensitivity and accuracy than LA volume. LA contraction circumferential strain is an independent high risk factor for thromboembolism, and LA contraction circumferential strain >-4.5% is a valuable cut-off to guide the use of anticoagulant therapy in patients with non-valvular AF.
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Affiliation(s)
- Lili Chen
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | - Chunquan Zhang
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | | | - Liangyun Guo
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | - Xiaolin Wang
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | - Fengzhen Liu
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | - Xia Li
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
| | - Yu Zhao
- Department of Ultrasound, Second Affiliated Hospital of Nanchang University, Nanhang, China
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9
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Lee CJY, Toft-Petersen AP, Ozenne B, Phelps M, Olesen JB, Ellinor PT, Gislason G, Lip GYH, Torp-Pedersen C, Gerds TA. Assessing absolute stroke risk in patients with atrial fibrillation using a risk factor-based approach. Eur Heart J Cardiovasc Pharmacother 2020; 7:f3-f10. [PMID: 32531029 DOI: 10.1093/ehjcvp/pvaa063] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/03/2020] [Indexed: 11/14/2022]
Abstract
AIM To assess the risk of stroke and thromboembolism in patients with atrial fibrillation (AF) based on risk factor combinations of the CHA2DS2-VASc score. METHODS AND RESULTS Using nationwide Danish registries, patients with AF were included from 1997 to 2015 in this retrospective observational study. A multiple logistic regression, including interactions of history of stroke with age at AF, calendar year of AF, and the CHA2DS2-VASc score risk factors (congestive heart failure, hypertension, diabetes, vascular disease, and female sex) were used to predict the personalized risks of stroke within 1 year. A total of 147 842 patients with AF were included in the study cohort (median age 76 years, range 20-100 years, 51% females). Within the first year, 6% of the cohort were diagnosed with stroke. The predicted personalized 1-year absolute risk of stroke varied widely within each CHA2DS2-VASc score. To estimate the personalized risk of stroke an online calculator was created, the Calculator of Absolute Stroke Risk (CARS), which allows calculation of all the possible combinations of the CHA2DS2-VASc score (https://hjerteforeningen.shinyapps.io/riskvisrr/). CONCLUSION Calculation of the individual risk using a risk factor-based approach as opposed to using average risk for a particular CHA2DS2-VASc score can improve risk estimates. Furthermore, CARS can assist in the communication of the stroke risk for a more evidence-based shared decision-making of whether to initiate oral anticoagulation therapy.
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Affiliation(s)
- Christina J-Y Lee
- Department of Cardiology and Clinical Research, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, 3400 Hillerød, Denmark.,Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Anne Pernille Toft-Petersen
- Department of Cardiology and Clinical Research, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Brice Ozenne
- Neurobiology Research Unit, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | | | | | - Patrick T Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gunnar Gislason
- The Danish Heart Foundation, Copenhagen, Denmark.,Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | | | - Thomas Alexander Gerds
- The Danish Heart Foundation, Copenhagen, Denmark.,Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
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10
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Abugroun A, Hassan A, Gaznabi S, Ayinde H, Subahi A, Samee M, Shroff A, Klein LW. Modified CHA 2DS 2-VASc score predicts in-hospital mortality and procedural complications in acute coronary syndrome treated with percutaneous coronary intervention. Int J Cardiol Heart Vasc 2020; 28:100532. [PMID: 32455161 PMCID: PMC7235953 DOI: 10.1016/j.ijcha.2020.100532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/20/2020] [Accepted: 05/03/2020] [Indexed: 11/16/2022]
Abstract
Background Current risk prediction models in acute coronary syndrome (ACS) patients undergoing PCI are mathematically complex. This study was undertaken to assess the accuracy of a modified CHA2DS2-VASc score, comprised of easily accessible clinical factors in predicting adverse events. Methods The National Inpatient Sample (NIS) was queried for ACS patients who underwent PCI between 2010 and 2014. We developed a modified CHA2DS2-VASc score for risk prediction in ACS patients. Multivariate mixed effect logistic regression was utilized to study the adjusted risk for adverse outcomes based on the score. The primary outcome evaluated was in-hospital mortality. Secondary outcomes assessed were stroke, respiratory failure, acute kidney injury, all-cause bleeding, pacemaker insertion, vascular complications, length of stay and cost. Results There were 252,443 patients admitted with ACS included. Mean age was 62 ± 12 years. The mean CH3A2DS-VASc score was 1.6 ± 1.6. The in-hospital mortality rate was 2.5%. CH3A2DS-VASc score was highly correlated with increased rate of mortality and all secondary outcomes. ROC curve analysis for association of CH3A2DS-VASc score with mortality demonstrates that area under the curve (AUC) = 0.83 (95%C: 0.82–0.84). Stepwise increases in CH3A2DS-VASc score correlated with incremental risk, and total score was an independent predictor of mortality (adjusted OR: 1.99 (95%CI: 1.96–2.03) p < 0.001) and all secondary outcomes. Conclusion This study supports the applicability of the CH3A2DS-VASc score as an accurate risk prediction model for ACS patients undergoing PCI and could supplant more complicated models for quality assurance.
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Affiliation(s)
- Ashraf Abugroun
- Wayne State University/Detroit Medical Center, Detroit, MI, United States
| | - Abdalla Hassan
- University of Massachusetts Medical School, Worcester, MA, United States
| | - Safwan Gaznabi
- University Hospitals Cleveland Medical Center, Case Western Reserve University, United States
| | | | - Ahmed Subahi
- Wayne State University/Detroit Medical Center, Detroit, MI, United States
| | - Mohammed Samee
- Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Adhir Shroff
- University of Illinois-Chicago, Chicago, IL, United States
| | - Lloyd W Klein
- Wayne State University/Detroit Medical Center, Detroit, MI, United States.,University of California, San Francisco, San Francisco, CA, United States
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11
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Miao C, Ju W, Chen H, Yang G, Zhang F, Gu K, Li M, Wang Z, Liu H, Chen M. Clinical and electrophysiological characteristics predicting the re-ablation outcome for atrial fibrillation patients. J Interv Card Electrophysiol 2019; 59:373-379. [PMID: 31784867 DOI: 10.1007/s10840-019-00666-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/10/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Re-ablation has an important role in the control of recurrent atrial fibrillation (AF) post the first ablation. The present study was to report the outcome of AF re-ablation for patients who recurred after initial ablation, and to characterize the clinical and electrophysiological features predicting recurrence after redo ablation. METHODS From January 2012 to May 2017, patients undergoing re-ablation for AF in our hospital were consecutively enrolled. Clinical and electrophysiological data for the initial and second procedure were collected retrospectively and prospectively, respectively. All patients were followed up for one year and recurrences during the time were reported. RESULTS Totally 259 patients entered into the analysis (age, 58.4 ± 10.5 years; 169 men). At the end of one-year follow-up, 85 patients recurred with atrial arrhythmias (32.8%). In the multivariate analysis, higher CHA2DS2-VASC score (p = 0.023, 95% CI 1.03-1.53) and shorter time to recurrence after the initial ablation (p = 0.001, 95% CI 0.93-0.98) were clinical factors predictive of one-year recurrence after the repeat ablation. The reconnection of the right pulmonary vein (PV) (p = 0.034, 95% CI 0.31-0.96) and the absence of not eliminated non-PV trigger at the second procedure (p = 0.032, 95% CI 1.25-142.80) independently predicted the better re-ablation outcome. CONCLUSIONS About one-third of patients recurred after one year following re-ablation. CHA2DS2-VASC score and time to recurrence after the initial ablation were independent clinical factors predicting recurrence. Also, electrophysiological findings during the repeat ablation (the right PV reconnection and absence of not eliminated non-PV trigger) were associated with better outcome during one year of follow-up.
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Affiliation(s)
- Changqing Miao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.,Department of Cardiology, Jingjiang People's Hospital, Jingjiang, Jiangsu Province, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Zidun Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Hailei Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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12
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Wang Y, Zhao HW, Zhang XJ, Chen BJ, Yu GN, Hou AJ, Luan B. CHA2DS2-VASC score as a preprocedural predictor of contrast-induced nephropathy among patients with chronic total occlusion undergoing percutaneous coronary intervention: a single-center experience. BMC Cardiovasc Disord 2019; 19:74. [PMID: 30922230 PMCID: PMC6440000 DOI: 10.1186/s12872-019-1060-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 03/22/2019] [Indexed: 12/16/2022] Open
Abstract
Background The usefulness of the CHA2DS2-VASC risk score (CVRS) in predicting the occurrence of contrast-induced nephropathy (CIN) among patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) remains unclear. Method A total of 239 patients with CTO who underwent PCI were included in this study. They were divided into 3 groups according to the CVRS: low-risk group (1 point, n = 64), intermediate-risk group (2 points, n = 135), and high-risk group (≥3 points, n = 40). Baseline serum creatinine was determined upon admission before the procedure. The serum creatinine level was monitored for 72 h post-procedure to determine the occurrence of CIN. Results The total incidence of CIN in patients with CTO who underwent PCI was 16.3%. The average CVRS in the CIN group was significantly higher than that in the non-CIN group (3.1 ± 1.2 VS 2.1 ± 1.1, P < 0.001). The incidence of CIN in the high-risk group was 5.6 times higher than that in the low-risk group (37.5% VS 6.3%, P < 0.001). Similar to the Mehran risk score (AUC, 0.754; 95% CI, 0.698–0.810; P < 0.001), the receiver operating characteristic curve analysis showed a good diagnostic value of the CVRS in predicting CIN among patients with CTO who underwent interventional therapy for having CVRS≥3 (sensitivity, 69.2%; specificity, 78.0%; AUC, 0.742; 95% CI, 0.682–0.797; P < 0.001). The multivariate analysis showed that the higher pulse pressure and contrast volume, lower baseline glomerular filtration rate, and CVRS ≥3 were independent predictors of CIN. Conclusions The CVRS can be used as a simple pre-procedural predictor of CIN among patients with CTO undergoing PCI.
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Affiliation(s)
- Yong Wang
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China
| | - Hong-Wei Zhao
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China
| | - Xiao-Jiao Zhang
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China
| | - Bao-Jun Chen
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China
| | - Guo-Ning Yu
- Department of Science and Education, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, Shenyang, China
| | - Ai-Jie Hou
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China.
| | - Bo Luan
- Department of Cardiology, The Peple's Hospital of China Medical University, The Peple's Hospital of Liaoning Province, No. 33, Wenyi road, Shenhe District, Shenyang City, 110016, Liaoning Province, China.
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13
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Winkle RA, Mead RH, Engel G, Kong MH, Patrawala RA. Comparison of CHADS2 and CHA2DS2-VASC anticoagulation recommendations: evaluation in a cohort of atrial fibrillation ablation patients. Europace 2013; 16:195-201. [PMID: 24036378 PMCID: PMC3905705 DOI: 10.1093/europace/eut244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aims Atrial fibrillation (AF) is associated with a high incidence of strokes/thromboembolism. The CHADS2 score assigns points for several clinical variables to identify stroke risk. The CHA2DS2-VASC score uses the same variables but also incorporates age 65 to 74, female gender, and vascular disease in an effort to provide a more refined risk of stroke/thromboembolism. We aimed to examine oral anticoagulation (OAC) recommendations for a cohort of patients undergoing AF ablation depending upon whether thrombo-embolic risk was determined by the CHADS2 or CHA2DS2-VASC score. Methods and results For 1411 patients we compared OAC recommendations for each of these risk stratification schemes to one of the three OAC strategies: (i) NO-OAC, (ii) CONSIDER-OAC, and (iii) DEFINITE-OAC. Compared with the CHADS2 score, the CHA2DS2-VASC score reduced NO-OAC from 40.3 to 21.8% and CONSIDER-OAC from 36.6 to 27.9% while increasing DEFINITE-OAC from 23.0 to 50.2% of patients. Age 65 to 74 and female gender accounted for 95.2% and vascular disease for only 4.8% of recommendations for more aggressive OAC using CHA2DS2-VASC. Most vascular disease occurred in patients with higher CHADS2 scores already recommended for DEFINITE-OAC (P < 0.0001). Reclassifying 30 females of age <65 with a CHA2DS2-VASC score of 1 to the NO-OAC group had minimal effect on the overall recommendations. Conclusion Compared with the CHADS2 score, in our AF ablation population, the CHA2DS2-VASC score markedly increases the number of AF patients for whom OAC is recommended. It will be important to determine by randomized trials if this major paradigm shift to greater use of OAC using the CHA2DS2-VASC scoring improves patient outcomes.
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Affiliation(s)
- Roger A. Winkle
- Corresponding author. Tel: +1 650 617 8100; fax: +1 650 327 2947,
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