Validation of a Modified CHA2DS2-VASc Score for Stroke Risk Stratification in Asian Patients With Atrial Fibrillation: A Nationwide Cohort Study

Tze-Fan Chao; Gregory Y H Lip; Chia-Jen Liu; Ta-Chuan Tuan; Su-Jung Chen; Kang-Ling Wang; Yenn-Jiang Lin; Shih-Lin Chang; Li-Wei Lo; Yu-Feng Hu; Tzeng-Ji Chen; Chern-En Chiang; Shih-Ann Chen

doi:10.1161/STROKEAHA.116.013880

Validation of a Modified CHA2DS2-VASc Score for Stroke Risk Stratification in Asian Patients With Atrial Fibrillation: A Nationwide Cohort Study

Stroke. 2016 Oct;47(10):2462-9. doi: 10.1161/STROKEAHA.116.013880. Epub 2016 Sep 13.

Authors

Affiliations

¹ From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
² From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.). cechiang@vghtpe.gov.tw epsachen@ms41.hinet.net.

PMID: 27625386
DOI: 10.1161/STROKEAHA.116.013880

Abstract

Background and purpose: The age threshold for an increased stroke risk for patients with atrial fibrillation may be different for Asians and non-Asians. We hypothesized that a modified CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scheme, mCHA2DS2-VASc, which assigned one point for patients aged 50 to 74 years, may perform better than CHA2DS2-VASc score for stroke risk stratification in Asians.

Methods: This study used the Taiwan National Health Insurance Research Database, which included 224 866 newly diagnosed atrial fibrillation patients. The predictive accuracies of ischemic stroke of CHA2DS2-VASc and mCHA2DS2-VASc scores were compared among 124 271 patients without antithrombotic therapies. From the whole cohort, 15 948 patients had a CHA2DS2-VASc score 0 (males) or 1 (females), and 8654 patients had an mCHA2DS2-VASc score 1 (males) or 2 (females). The latter were categorized into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin, and the risks of ischemic stroke and intracranial hemorrhage (ICH) were compared.

Results: During a follow-up of 538 653 person-years, 21 008 patients experienced ischemic stroke. The mCHA2DS2-VASc performed better than CHA2DS2-VASc score in predicting ischemic stroke assessed by C indexes and net reclassification index. For 8654 patients having an mCHA2DS2-VASc score of 1 (males) or 2 (females) because of the resetting of the age threshold, use of warfarin was associated with a 30% lower risk of ischemic stroke and a similar risk of ICH compared with nontreatment. Net clinical benefit analyses also favored the use of warfarin in different weighted models.

Conclusions: In this Asian atrial fibrillation cohort, the mCHA2DS2-VASc score performed better than the CHA2DS2-VASc and would further identify atrial fibrillation patients who may derive a positive net clinical benefit from oral anticoagulation.

Keywords: CHA2DS2-VASc score; age; atrial fibrillation; ischemic stroke; modified CHA2DS2-VASc score.

Publication types

Validation Study

MeSH terms

Age Factors
Aged
Anticoagulants / therapeutic use
Atrial Fibrillation / complications*
Brain Ischemia / drug therapy
Brain Ischemia / etiology*
Cohort Studies
Female
Humans
Male
Middle Aged
Risk Assessment
Stroke / etiology*
Taiwan
Warfarin / therapeutic use

Substances

Anticoagulants
Warfarin