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Brain & Heart Digital tools for stroke and bleeding risk in AF

CHA DS -VASc score added three additional factors: prevalence of AF is now higher in patients with HFpEF
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female sex, age 65 – 74 years, and history of vascular compared to patients with HFrEF. 32
disease (myocardial infarction, peripheral artery disease, In 2013, data from the Anticoagulation and Risk
or aortic plaque). One point was assigned for the presence Factors in Atrial Fibrillation (ATRIA) score was used to
of each additional factor. Patients with ages ≥75 years were create another scoring system. The ATRIA score was
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given two points. While CHADS had classified 61.9% notable for assigning a different set of point values for age
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of patients into the moderate risk stratum, CHA DS - in primary prevention and secondary patients, giving 6,
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VASc classified only 15.1% of patients into the moderate 5, 3, and 0 points for ≥85, 75 – 84, 65 – 74, and <65 year
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risk stratum. The score was validated using data from olds with no prior stroke, and 9, 7, 7, and 8 points for ≥85,
the Swedish Atrial Fibrillation Cohort Study, a national 75 – 84, 65 – 74, and <65 year olds with a prior stroke.
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cohort study in Denmark, and an administrative claims Moreover, the ATRIA score incorporated markers of renal
database in the US, and demonstrated CHA DS -VASc function associated with increased thromboembolic states,
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to be superior to CHADS2 in predicting “truly low risk including proteinuria and eGFR <45, or end-stage renal
(composite thromboembolism event rate of 0.3% per disease. The score was developed in the ATRIA cohort
year).” 23-25 CHA DS -VASc was then promptly adopted of patients with non-valvular AF and validated using
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by the European Society of Cardiology in their 2010 the ATRIA‐CVRN cohort, both in the California Kaiser
guidelines and the American College of Cardiology (ACC)/ Permanente system. 33,34
American Heart Association (AHA)/American College of
Chest Physicians (ACCP)/Heart Rhythm Society (HRS) in Meanwhile, there has been growing interest in
2014. 26,27 Although other scoring methods have since been incorporating serum biomarkers to refine risk assessment
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introduced CHA DS -VASc remains the most widely used for stroke in AF. In 2016, the ABC (age, biomarkers,
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score for stroke risk estimation in patients with AF. and clinical history) stroke risk score was introduced,
incorporating cardiac biomarkers such as N-terminal
The definition of “C” (congestive HF) in the CHA DS -
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VASc has sparked ongoing debate. Both CHADS and fragment B-type natriuretic peptide (NT-proBNP) and
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high-sensitivity cardiac troponin (hs-cTn). An increasing
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CHA DS -VASc scores were derived at a time before the number of points were assigned based on the levels
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classification of HF into left ventricular ejection fraction of NTproBNP and hs-cTn, measured on a continuous
(LVEF)-based groups — reduced (<40%; HFrEF), mid‐ scale. The score was developed using data from patients
range (40 – 49%; HFmrEF), and preserved (>50%;
HFpEF) — was incorporated in clinical guidelines. with AF in the Apixaban for Reduction in Stroke and
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Other Thromboembolic Events in Atrial Fibrillation
The original study, which proposed the CHADS score, (ARISTOTLE) trial and validated in patients with AF in
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defined “C” as a recent exacerbation of HF without the Stabilization of Atherosclerotic Plaque by Initiation of
specifying an LVEF criterion. In contrast, the original Darapladib Therapy (STABILITY) trial. It demonstrated
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study, which proposed the CHA DS -VASc score, defined an improved c-statistic for predicting stroke and systemic
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“C” as the presence of signs and symptoms of either embolic events compared to CHA DS -VASc. 36,37 The
right (e.g., dependent edema, elevated central venous 2 2
pressure, and hepatomegaly) or left ventricular failure drawback of ABC was the requirement for laboratory
(e.g., pulmonary venous congestion, exertional dyspnea, measurement of biomarkers, in contrast to preceding
rales, cough, fatigue, orthopnea, paroxysmal nocturnal scores, which could be calculated based on clinical
dyspnea, cardiac enlargement, and gallop rhythm) or both, variables readily available in the chart.
confirmed by non-invasive or invasive measurements Recognizing that prior scores were primarily developed
demonstrating objective evidence of cardiac dysfunction. and validated in the era when warfarin was the only
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There was no LVEF criterion. Although not explicitly anticoagulant available to prevent stroke in AF, there was
reported, patients with HFpEF are assumed to be included an increasing need in the late 2010s to develop a score in
because they met study criteria by signs and symptoms of a patient population receiving either warfarin or a direct-
HF without requiring left ventricular systolic failure. The acting anticoagulant (DOAC). In 2017, the GARFIELD-AF
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recent AF guidelines provide limited clarification on this score was introduced and was the first to allow simultaneous
definition. Early research suggested a higher stroke risk estimation of the risk of ischemic stroke, mortality, and
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associated with lower LVEF in patients with AF. However, internal bleeding. In addition to traditional risk factors
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a meta-analysis of 33,773 participants from seven studies (age, sex, and history of stroke) for ischemic stroke, the
found no significant differences in stroke incidence GARFIELD-AF score also considers factors such as
between patients with AF with HFrEF and those with diastolic blood pressure and dementia. Another innovation
HFpEF. Further guidance is needed, particularly as the of GARFIELD-AF was its provision of differences in event
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Volume 2 Issue 3 (2024) 4 doi: 10.36922/bh.3068