Page 34 - BH-2-3

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

rationale for this recommendation, the guidelines note in statistical language. The development of digital tools that
that population-based studies have shown that the benefits translate medical and statistical language into comparative
of anticoagulation in AF generally outweigh the risks of visual aids allows both patients and physicians to improve
bleeding, even in patients at high bleeding risk. 69 shared decision-making engagement. Fourth, legal mandates
For patients who have prohibitive contraindications worldwide to ensure transparency of health data, such as the
st
to anticoagulation, it is worth noting that in the 21 Century Cures Act in the US, provide patients with access
2023 AHA/ACC/ACCP/HRS guidelines, percutaneous to all results and documentation in the electronic health
left atrial appendage occlusion (pLAAO) implantation of record. While patients may not necessarily understand all
a Watchman device is given a Class IIa recommendation the data required to calculate a certain risk score, access to
in patients with AF with a moderate to high risk of stroke this data opens avenues for such interactions to take place.
(CHA DS -VASc score ≥2) and a contraindication to Patient decision aids, described in the last section of this
2
2
long-term oral anticoagulation due to a non-reversible review, can assist patients in understanding their risks, and
cause. In patients with AF with a moderate to high support the value placed on the fundamental rights of patient
30
risk of stroke and a high risk of major bleeding on oral autonomy and access to personal information in the modern
anticoagulation but without an absolute contraindication health-care system.
to oral anticoagulation, pLAAO is considered a reasonable
alternative to oral anticoagulation, based on patient 6.2. Landscape of available tools
preference, with a Class IIb recommendation. 30 We conducted a search for tools to assist in the decision-
Concerning digital tools, the 2023 AHA/ACC/ACCP/ making process for estimating bleeding or stroke risk
HRS guidelines provide a Class IIb recommendation among patients with AF across the Apple App Store,
for using evidence-based decision aids for guidance in Google Play Store, and web platforms. We found five
stroke reduction therapy treatment decisions to improve major digital tools for estimating bleeding or stroke
decision quality and both patient engagement and risk in AF that are publicly available and free of charge:
satisfaction. The guidelines acknowledge that online the Mayo Clinic Anticoagulation Choice Decision Aid,
30
ATRIA, GARFIELD-AF, and CHA2DS2-VASc calculators the Stroke Prevention in Atrial Fibrillation Risk Tool
are available. However, there has not been a systematic (SPARCtool), the GARFIELD-AF Risk Calculator, the
evaluation of the weaknesses and strengths of each digital ACC AnticoagEvaluator Application, and the CardioSmart
tool in the literature to date. Atrial Fibrillation and Bleeding Risk Calculator (Table 3).
Four out of the five tools allow users to assess both stroke
6. Digital tools for estimating the risk of and bleeding risk among patients with AF, while one
stroke or bleeding specifically focuses on stroke risk estimation. While all five
6.1. The need for digital tools tools are available online, the ACC AnticoagEvaluator app
and the GARFIELD-AF risk calculator are also available
The role of digital tools in estimating stroke or bleeding risk as mobile apps. Among these tools, the ACC offers two:
in AF has become increasingly important for several reasons. the ACC AnticoagEvaluator app, designed for use by
First, in an era of increasing patient care volumes and physicians, and the CardioSmart Atrial Fibrillation and
message volumes, physicians need the capability to quickly Bleeding Risk Calculator, intended for patient use.
estimate patient-specific risks using validated risk scores and
estimate the impact of each treatment option on mitigating Of note, several stroke risk scores exist on general
or augmenting these risks. Findings from large cohort medical calculator websites such as MDCalc and QxMD,
studies are only useful if they can be deployed at the point including CHADS , CHA DS -VASC, ATRIA, and
2
2
2
of care. Second, the development of models that use uneven GARFIELD-AF. 70-73 Bleeding risk scores that exist on general
weights for each variable rather than simple point-based medical calculator websites include HEMORR HAGES,
2
systems necessitates using online calculators, to sum up HAS-BLED, ATRIA, ORBIT, and GARFIELD-AF. 73-77
weights, as seen with GARFIELD-AF. Manual calculation of General medical calculator websites hosting risk scores
these scores is not easy. While scores with greater complexity across different organ systems are beyond the scope of
may increase predictive value, the complexity may serve as this present review. The GARFIELD-AF risk calculator,
a barrier for providers and patients, who may struggle to which is hosted on the domain of the GARFIELD-AF
garner insight in the absence of a computerized interface registry through which the score used by the digital tool
that contextualizes the output. Third, the variables that was developed, qualified for inclusion in this review due
comprise each score are often defined in medical language, to its incorporation of additional visual and comparative
and the outputs associated with each score are often defined features for patient-shared decision-making.

Volume 2 Issue 3 (2024) 11 doi: 10.36922/bh.3068