CHA2DS2-VASc scores predict mortality after hospitalization for atrial fibrillation

doi:10.1016/j.ijcard.2015.03.180

International Journal of Cardiology

Volume 185, 15 April 2015, Pages 293-296

https://doi.org/10.1016/j.ijcard.2015.03.180 Get rights and content

Abstract

Objective

The outcome of patients hospitalized for atrial fibrillation (AF) is relatively poor. We sought to determine the mortality rate and predictors of mortality following hospitalization for AF and to evaluate whether the CHA₂DS₂-VASc score was a predictor of mortality.

Methods

We examined the national database of Thailand residents who registered for government provided health insurance in 2005 and reviewed patient records from 2005 to 2010 to determine all-cause mortality. A total of 8981 patients (mean age, 65 years; 42% male) were admitted to the hospital with a diagnosis of AF. Data on demographics and comorbidities were retrieved from the database. The CHA₂DS₂-VASc score was calculated for each patient.

Results

The hospitalization rate for AF was 15.5 per 100,000 person-years. The two most common comorbidities were hypertension (N = 1638, 18.2%) and diabetes (N = 1349, 15.0%). The average CHA₂DS₂-VASc score for all patients was 1.8. By the 72-month follow-up (average 46 months), 3948 patients (44.0%) had died. The CHA₂DS₂-VASc score was directly related to the mortality rate (P log-rank < 0.0001). Multivariate analysis showed that a CHA₂DS₂-VASc score ≥ 6 (hazard ratio [HR] 2.2, 95% confidence interval [CI], 1.4–3.7, P = 0.002) and the presence of chronic kidney disease (HR 2.0, 95% CI 1.7–2.4, P < 0.0001) were the strongest predictors of death.

Conclusion

The outcome after hospitalization for AF is relatively poor. The CHA₂DS₂-VASc score is an independent prognostic marker of poor outcomes following hospitalization for AF.

Introduction

Atrial fibrillation (AF) has reached epidemic proportions. Over the past 2 decades, the incidence of AF has risen by more than 10% and is projected to increase 2.5-fold by the year 2050 [1], [2]. AF is a known independent risk factor for stroke and heart failure. According to data from the Framingham study, AF was associated with a 1.5- to 1.9-fold mortality risk after adjusting for other related cardiovascular conditions [3].

The number of AF hospitalizations has been steadily increasing in several countries. Data from national databases in the United States [4], Denmark [5], and Scotland [6] all revealed at least a 2-fold increase in hospitalization for AF over the past 2 decades. Although several studies have shown improved outcomes in patients admitted with AF [5], [6], a large community-based cohort found that over the past 2 decades, the mortality rates for patients with newly diagnosed AF have not changed significantly [7].

One of the core aspects of AF management is the prevention of thromboembolism. The CHA₂DS₂-VASc score (congestive heart failure; hypertension; age ≥ 75 years [doubled]; diabetes; previous stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 75 years; and sex category) is currently the recommended tool for assessing the risk for thromboembolism among non-valvular AF patients [8], [9]. The scores were also shown to be related to cardiovascular hospitalization, stroke recurrence, and mortality in different population groups [10], [11], [12].

In this present study, we evaluated the mortality rate and associated risk factors following hospitalization for AF in Thailand. We hypothesized that the CHA₂DS₂-VASc score would predict mortality after AF hospitalization.

Section snippets

Data source

In Thailand, 3 major health benefits are offered to citizens: the civil servant medical benefit scheme (CSMBS), compulsory social security scheme (SSS), and universal health coverage (UHC). Government officers and their families are eligible for CSMBS, while non-government employees and their families are eligible for SSS. Those who do not enroll in CSMBS or SSS are eligible for UHC. The data collected from citizens enrolled in CSMBS and UHC are monitored by the Ministry of Public Health and

Results

The incidence of hospitalization for AF among the total population, UHC insurers, and the CSMBS insurers was 15.5, 15.4 and 26.4 per 100,000 person-years, respectively. Only 14 patients (0.2%) had a prior history of AF (Table 1). The two most common comorbidities were hypertension (N = 1638, 18.2%) and diabetes (N = 1349, 15.0%). Rheumatic heart disease was present in 628 patients (7.0%). The average CHA₂DS₂-VASc score for all patients was 1.8. Patients stayed in the hospital for an average of 3

Discussion

In this large national database of 8981 patients hospitalized for AF, the mortality rates after the index hospitalization were 18%, 32%, and 44% at 1 year, 3 years, and at the end of the follow-up (46 months), respectively. By utilizing the CHA₂DS₂-VASc scoring system, the mortality rate was shown to be independently and directly correlated with the scores. The risk of dying increased approximately 1.5-fold in the patients with CHA₂DS₂-VASc 2–5 and 2-fold in those with scores ≥ 6.

The mortality rate

Conclusion

Mortality after hospitalization for AF is relatively high. The CHA₂DS₂-VASc score is a strong and independent predictor of death after hospitalization for AF.

Funding

This work was supported by the Thai Society of Atherosclerosis [101/2554], the project of Higher Education Research Promotion and National Research University Development, Office of the Higher Education Commission, Ministry of Education, Thailand [2554], and Pfizer International Co. Ltd [WS2040857]. The authors had full access to the data and take full responsibility for its integrity. All authors have read and approved the final manuscript.

Conflict of interest

None declared.

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Risk stratification of patients with atrial fibrillation in the emergency department
2020, American Journal of Emergency Medicine
Citation Excerpt :
In the study of both outcomes, the CHA2DS2-VASc score consistently performed the worst, which could be explained by the fact that its design was to predict stroke risk rather than composite adverse events or mortality. However, there have been several studies proposing the use of the CHA2DS2-VASc score to predict mortality and other adverse events apart from stroke or thromboembolism [35,36]. In the study by Larsen, it was found that at 5-year follow-up, the c-index of the CHA2DS2-VASc score for predicting mortality was 0.63 (95% CI = 0.59–0.67) [37], similar to that of our study findings for 90-day mortality.
Early and accurate risk stratification of patients with atrial fibrillation (AF) in the emergency department (ED) could aid the physician in determining a timely treatment strategy appropriate to the severity of disease. We conducted a retrospective review of 243 adult patients who presented to a tertiary ED with AF in 2017. Primary outcome studied was 30-day adverse event (a composite outcome of repeat visit to the ED, cardiovascular complications, and all-cause mortality).
Secondary outcome studied was 90-day all-cause mortality. We compared the performance of the RED-AF, AFTER and CHA2DS2-VASc score by plotting receiver operating characteristic (ROC) curves and estimating the areas under curves (AUC), and assessed the potential to further improve the tools with their incorporation of new variables.
Existing scoring tools had poor predictive value for 30-day adverse events, with the RED-AF score performing comparatively better, followed by the AFTER and CHA2DS2-VASc score. All scores performed collectively better to predict 90-day mortality, with the AFTER score performing the best, followed by the RED-AF and CHA2DS2-VASc score. By incorporating heart rate at initial presentation to the ED as a variable into the AFTER Score, we generated a Modified AFTER Score with superior predictive performance above existing scores for 90-day mortality.
Existing scores collectively performed poorly to predict 30-day adverse outcomes, but the AFTER and Modified AFTER score showed good predictive value for 90-day mortality. Further studies should be done to validate their use in guiding clinician’s disposition of patients with AF in the ED.
CHA<inf>2</inf>DS<inf>2</inf>-VASc Score and In-Hospital Mortality in Critically Ill Patients With New-Onset Atrial Fibrillation
2020, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Among those patients who underwent cardiac resynchronization therapy, the CHA2DS2-VASc score also predicted hospitalization for heart failure and death.23 Furthermore, the CHA2DS2-VASc score was also predictive of hospitalization as well as mortality after hospitalization in large cohorts of patients with AF.21,31 In contrast, this study suggests that the CHA2DS2-VASc score by itself may not be a reliable prognostic marker of in-hospital mortality in critically ill patients with NOAF.
To examine the role of the CHA₂DS₂-VASc (Congestive heart failure; Hypertension; Age ≥75 years [doubled]; Diabetes; previous Stroke, transient ischemic attack, or thromboembolism [doubled]; Vascular disease; Age 65-75 years; and Sex category) score as a prognostic marker of in-hospital mortality in critically ill patients who develop new-onset atrial fibrillation (NOAF).
Retrospective analyses.
A single-center study in a tertiary care academic medical center.
The study comprised all adult patients with NOAF admitted to noncardiac intensive care units (ICUs) at a tertiary care academic institution between January 2009 and March 2016.
None.
The authors retrospectively reviewed electronic medical records of all adult patients admitted to noncardiac ICUs at a tertiary care academic institution between January 2009 and March 2016. Patients with NOAF were identified and their CHA₂DS₂-VASc score was calculated. The authors evaluated the association of CHA₂DS₂-VASc score and its individual components with in-hospital mortality in these patients. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%-1.8%) patients developed NOAF during the study period. The in-hospital mortality rate in patients included in the analysis was 14.3%. There was no association between in-hospital mortality and CHA₂DS₂VASc score. However, the likelihood of in-hospital death was 1.56  times greater for patients having atrial fibrillation and concomitant vascular disease (95% CI 1.003-2.429; p = 0.049).
New-onset atrial fibrillation is common in critically ill patients and is associated with high in-hospital mortality. The authors found that the CHA₂DS₂-VASc score itself is not a reliable prognostic marker of in-hospital mortality in these patients. However, the presence of vascular disease in patients with NOAF may increase the mortality associated with this disease.
Relation of CHA<inf>2</inf>DS<inf>2</inf>VASC Score With Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction
2019, American Journal of Cardiology
Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) ≥18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA₂DS₂VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA₂DS₂VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA₂DS₂VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA₂DS₂VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.
Hospital-level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011
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Citation Excerpt :
Second, the CHA2DS2-VASc score was published 2010 as a prediction tool for annual risk for thromboembolic disease and need for oral anticoagulation and incorporated into guidelines for management of AF/AFL in 2014. Although not originally intended as a risk stratification tool to assess need for hospitalization, other studies have demonstrated the association of elevated CHA2DS2-VASc score with increased likelihood of hospitalization and mortality [45,46]. By defining low-risk patients as those with CHA2DS2-VASc score of 0, we are excluding female patients, which may limit the generalizability of this secondary analysis.
Outpatient management of atrial fibrillation can be a safe alternative to inpatient admission after emergency department (ED) visits. We aim to describe trends and predictors of hospital admission for atrial fibrillation and determine the variation in admission among US hospitals.
We analyzed ED visits and hospital admissions for adult patients with a principal diagnosis of atrial fibrillation or atrial flutter in the Nationwide Emergency Department Sample 2006 to 2011. We identified patient and hospital characteristics associated with admission using hierarchical multivariate logistic regression. We analyzed admission rates overall and for patients at low risk of thromboembolic complications (CHA₂DS₂-VASc score 0). We compared hospital-level variance with residual variance to estimate the intraclass correlation in models with and without hospital characteristics.
From 2006 to 2011, annual ED visits for atrial fibrillation and atrial flutter increased by 30.9% and admission rates decreased from 69.7% to 67.4% (P= .02). Admission was associated with setting (metropolitan teaching vs nonmetropolitan, odds ratio = 1.93 [1.62-2.29]) and region (Northeast vs West, odds ratio = 2.09 [1.67-2.60]). Among patients with 0 CHA₂DS₂-VASc score, the national average admission rate was 46.4%. The intraclass correlation was 20.7% adjusting for patient characteristics and hospital clustering, and 19.2% after additionally adjusting for hospital variables.
From 2006 to 2011, ED visits for atrial fibrillation in the United States increased by almost a third, with a minimal change in ED admission rates. One-fifth of variation in admission rates is due to hospital site and not explained by hospital characteristics. Hospital-specific practice patterns may identify opportunities to increase outpatient management.
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CHA2DS2-VASc scores predict mortality after hospitalization for atrial fibrillation

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Data source

Results

Discussion

Conclusion

Funding

Conflict of interest

Int. J. Cardiol.

Int. J. Cardiol.

J. Am. Coll. Cardiol.

Am. J. Cardiol.

Int. J. Cardiol.

Am. J. Cardiol.

Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence

Circulation

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

CHA₂DS₂-VASc scores predict mortality after hospitalization for atrial fibrillation