Should the Presence or Extent of Coronary Artery Disease be Quantified in the CHA₂DS₂-VASc Score in Atrial Fibrillation? A Report from the Western Denmark Heart Registry

Abstract

Background Patients with atrial fibrillation (AF) have an increased risk of ischaemic stroke. The risk can be predicted by the CHA₂DS₂-VASc score, in which the vascular component refers to previous myocardial infarction, peripheral artery disease and aortic plaque, whereas coronary artery disease (CAD) is not included.

Objectives This article explores whether CAD per se or extent provides independent prognostic information of future stroke among patients with AF.

Materials and Methods Consecutive patients with AF and coronary angiography performed between 2004 and 2012 were included. The endpoint was a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. The risk of ischaemic events was estimated according to the presence and extent of CAD. Incidence rate ratios (IRR) were calculated in reference to patients without CAD and adjusted for parameters included in the CHA₂DS₂-VASc score and treatment with anti-platelet agents and/or oral anticoagulants.

Results Of 96,430 patients undergoing coronary angiography, 12,690 had AF. Among patients with AF, 7,533 (59.4%) had CAD. Mean follow-up was 3 years. While presence of CAD was an independent risk factor for the composite endpoint (adjusted IRR, 1.25; 1.06–1.47), extent of CAD defined as 1-, 2-, 3- or diffuse vessel disease did not add additional independent risk information.

Conclusion Presence, but not extent, of CAD was an independent risk factor of the composite thromboembolic endpoint beyond the components already included in the CHA₂DS₂-VASc score. Consequently, we suggest that significant angiographically proven CAD should be included in the vascular disease criterion in the CHA₂DS₂-VASc score.

Keywords

prevention - stroke - thromboembolism - coronary artery disease - coronary angiography

^* Kamilla Steensig and Kevin K. W. Olesen are first co-authors.

• References

• 1 Lip G, Freedman B, De Caterina R, Potpara TS. Stroke prevention in atrial fibrillation: Past, present and future. Comparing the guidelines and practical decision-making. Thromb Haemost 2017; 117 (07) 1230-1239
• 2 Lip GYHY, Nieuwlaat R, Pisters R, Lane DAA, Crijns HJGMJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137 (02) 263-272
• 3 Kittelson JM, Steg PG, Halperin JL. , et al; Antithrombotic Trials Leadership and Steering (ATLAS) Group. Bivariate evaluation of thromboembolism and bleeding in clinical trials of anticoagulants in patients with atrial fibrillation. Thromb Haemost 2016; 116 (03) 544-553
• 4 Anandasundaram B, Lane DA, Apostolakis S, Lip GYH. The impact of atherosclerotic vascular disease in predicting a stroke, thromboembolism and mortality in atrial fibrillation patients: a systematic review. J Thromb Haemost 2013; 11 (05) 975-987
• 5 Steensig K, Olesen KKW, Thim T. , et al. Coronary artery disease is independent risk factor for stroke among patients with atrial fibrillation. J Am Coll Cardiol 2018; ; (August): pii: S0735-1097(18)36961-4
• 6 Schmidt M, Maeng M, Madsen M, Sørensen HT, Jensen LO, Jakobsen C-J. The Western Denmark Heart Registry: its influence on cardiovascular patient care. J Am Coll Cardiol 2018; 71 (11) 1259-1272
• 7 Schmidt M, Schmidt SAJ, Sandegaard JL, Ehrenstein V, Pedersen L, Sørensen HT. The Danish National Patient Registry: a review of content, data quality, and research potential. Clin Epidemiol 2015; 7: 449-490
• 8 Johannesdottir SA, Horváth-Puhó E, Ehrenstein V, Schmidt M, Pedersen L, Sørensen HT. Existing data sources for clinical epidemiology: the Danish National Database of Reimbursed Prescriptions. Clin Epidemiol 2012; 4: 303-313
• 9 Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol 2004; 159 (07) 702-706
• 10 Kirchhof P, Benussi S, Kotecha D. , et al; ESC Scientific Document Group. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37 (38) 2893-2962
• 11 January CT, Wann LS, Alpert JS. , et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64 (21) e1-e76
• 12 Olesen KKW, Madsen M, Lip GYH. , et al. Coronary artery disease and risk of adverse cardiac events and stroke. Eur J Clin Invest 2017; 47 (11) 819-828