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

rate should the patient receive treatment with DOACs, platelet count, white blood cell count, mean platelet
treatment with warfarin, or no treatment. The score was volume, red cell distribution width, mean corpuscular
developed using prospective data from the international hemoglobin concentration, and mean platelet volume) and
GARFIELD-AF registry and validated using data from the basic metabolic panel (sodium, potassium, bicarbonate,
the Outcome Registry for Better Informed Treatment of calcium, glucose, and creatinine), The resultant IMRS
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AF (ORBIT-AF) trial. GARFIELD-AF showed better score estimates risk using different models for males and
predictive value compared to CHA DS -VASc for stroke or females. It demonstrated that among patients within the
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systemic embolism. A major limitation of GARFIELD-AF stratum of a traditional CHA DS -VASc score of 2, there
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is that the weights for each variable are not readily available, was a four-fold separation between those with a high IMRS
so they cannot easily be calculated from memory, unlike score and those with a low IMRS score. To date, the IMRS
more commonly used scores such as CHA DS -VASc. score has not been validated in patients with AF outside
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As the aforementioned scores improved risk the Intermountain Health-care dataset.
stratification in moderate-risk patients, there was a need While the addition of increasing numbers of laboratory-
to improve the prediction of stroke in low-risk patients. In based biomarkers may improve the predictive accuracy of
2019, the ABCD score was introduced as a means of refining the score, as indicated by superior c-statistics, this may
the risk stratification of low-risk patients who had a non- not necessarily translate into a net clinical benefit in real-
gender CHA DS -VASc (i.e., CHA DS -VA) score of 0 or world practice due to the corresponding offset in simplicity
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1. The ABCD score includes age (≥60 years), NT‐proBNP and practicality for clinical decision-making. In a study
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≥300 pg/mL, creatinine clearance <50 mL/min, and left examining the addition of ≥2 biomarkers compared to one
atrial dimension (≥45 mm). The score was developed biomarker to the CHA DS -VASc and HAS-BLED scores
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in Korea by a retrospective review of patients with non- in real-world patients with AF on warfarin, the predictive
valvular AF who experienced cardioembolic stroke, with a ability of CHA DS -VASC for ischemic stroke was not
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control group of patients with AF who did not experience significantly increased, whereas the predictive ability of
cardioembolic stroke, matched with a nearest-neighbor HAS-BLED for major bleeding was only slightly increased.
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approach. The ABCD score for estimating the risk of All things considered, the CHA DS -VASc score remains
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stroke in patients with AF should not be confused with the the most validated among the scores for estimating stroke
ABCD2 score commonly used to estimate the risk of stroke risk in AF, with 82 validation studies. This is followed by
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in patients with TIA. 41 the CHADS2 score, with 46 validation studies; the ATRIA
In addition to ABCD, two other scores were published score, with 11 validation studies; the AFI score, with seven
in 2019: the Anticoagulation-specific Stroke (ACTS) score validation studies; the GARFIELD-AF score, with four
and the Intermountain Mortality Risk Score (IMRS). It validation studies; the SPAF score, with five validation
was noted that for patients with a CHA DS -VASc score studies; the Framingham score, with six validation studies;
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of ≥2, anticoagulation was recommended, but provided and the ABC score, with five validation studies. 8
little guidance on choosing between warfarin and DOACs.
Therefore, ACTS was designed to refine the estimation 3. Estimation of stroke risk in patients with
of stroke risk by the type of anticoagulant used, focusing AF using non-discrete predictors
on those at high risk for stroke. It was developed using Findings derived from electrocardiographic and
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health claims data from MarketScan and validated with echocardiographic data, including non-discrete features,
data from Optum Clinformatics. Variables in ACTS have been observed to predict outcomes in patients
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incorporate prescribed pharmacotherapy, including with AF. In fact, left atrial abnormality, as defined
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anticoagulants, antiplatelet medications, beta-blockers, by abnormal P wave morphology, and paroxysmal
anti-diabetics, antihyperlipidemic, and antiarrhythmic supraventricular tachycardia have both been associated
(type II and type III) medications. However, ACTS did with the development of ischemic stroke, consistent with
not show improved discrimination compared to simpler the paradigm that the presence of the left atrial substrate
models such as CHA DS -VASc. 42
2 2 itself predicts stroke independent of the presence of
The IMRS score was developed by investigators at AF. 49,50 In a study examining different types of P-wave
Intermountain Medical Center by combining their abnormalities — prolonged P-wave duration, abnormal
previously established IMRS, which assesses mortality P-wave axis, advanced interatrial block, and abnormal
and morbidity using laboratory markers across various P-wave terminal force in lead V1 — an abnormal P-wave
diseases, with the CHA DS -VASc score. 43-45 The IMRS uses axis was identified as the only P-wave index associated
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components from the complete blood count (hematocrit, with increased ischemic stroke risk independent of the
Volume 2 Issue 3 (2024) 5 doi: 10.36922/bh.3068