Incorporating coronary calcification by computed tomography into CHA2DS2-VASc score: impact on cardiovascular outcomes in patients with atrial fibrillation

Tom Kai Ming Wang; Nicholas Chan; Paul C Cremer; Mohamed Kanj; Bryan Baranowski; Walid Saliba; Oussama M Wazni; Wael A Jaber

doi:10.1093/europace/euab032

Incorporating coronary calcification by computed tomography into CHA2DS2-VASc score: impact on cardiovascular outcomes in patients with atrial fibrillation

Europace. 2021 Aug 6;23(8):1211-1218. doi: 10.1093/europace/euab032.

Authors

Tom Kai Ming Wang¹, Nicholas Chan¹, Paul C Cremer¹, Mohamed Kanj², Bryan Baranowski², Walid Saliba², Oussama M Wazni², Wael A Jaber¹

Affiliations

¹ Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, 9500 Euclid Avenue, Main Campus J1-5, Cleveland Clinic, Cleveland,OH 44195, USA.
² Section of Cardiac Electrophysiology and Pacing, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland,OH, USA.

PMID: 33585883
DOI: 10.1093/europace/euab032

Abstract

Aims: CHA2DS2-VASc score is widely utilized for risk stratification and guiding anticoagulation in patients with atrial fibrillation (AF). Cardiac computed tomography (CCT) routinely performed for pulmonary vein isolation (PVI) can also identify coronary artery calcifications (CAC). We evaluated the frequency and outcomes of incorporating CAC into the CHA2DS2-VASc score in AF patients undergoing PVI.

Methods and results: Consecutive patients in a prospective PVI registry during 2014-18 having CCT within 1 year of PVI were studied. Reclassification of CHA2DS2-VASc score and associations between CAC as a binary variable detected on CCT with clinical characteristics, stroke as primary endpoint, death, myocardial infarction, and major adverse cardiovascular events (MACE) were analysed. Amongst 3604 AF patients, 2238 (62.1%) had CAC detected on CCT and was associated with most traditional cardiovascular risk factors. Coronary artery calcification was independently associated with all pre-specified endpoints adjusting for clinical parameters in multivariable analysis. Adjusting for CHA2DS2-VASc score, CAC was associated with stroke (hazards ratio 3.64, 95% confidence interval 1.25-10.6, P = 0.018), death (2.26, 1.29-3.98, P = 0.006), and MACE (2.08, 1.36-3.16, P = 0.001) during 2.8 ± 1.6-year follow-up. Incorporating CAC as a vascular disease parameter of CHA2DS2-VASc score, anticoagulation decision-making would be revised in 723 (20.1%) patients, including an additional 488 (13.5%) patients where anticoagulation would be now indicated.

Conclusion: Coronary artery calcification is prevalent in AF patients undergoing PVI and independently associated stroke, death and MACE even when adjusted for traditional CHA2DS2-VASc score. Adding CAC as vascular component to the CHA2DS2-VASc score requires further research as it potentially modified the anticoagulation management in 20% of our AF cohort.

Keywords: Atrial fibrillation; CHA2DS2-VASc score; Cardiovascular outcome; Computed tomography; Coronary artery calcification; Pulmonary vein isolation.

MeSH terms

Atrial Fibrillation* / diagnosis
Atrial Fibrillation* / diagnostic imaging
Humans
Prospective Studies
Retrospective Studies
Risk Assessment
Risk Factors
Stroke* / epidemiology
Stroke* / etiology
Stroke* / prevention & control
Tomography, X-Ray Computed