Circulation. 2004;110:2287-2292
Published online before print October 11, 2004, doi: 10.1161/01.CIR.0000145172.55640.93
Published online before print October 11, 2004, doi: 10.1161/01.CIR.0000145172.55640.93
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(Circulation. 2004;110:2287-2292.)
© 2004 American Heart Association, Inc.
Arrhythmia/Electrophysiology |
Selecting Patients With Atrial Fibrillation for Anticoagulation
Stroke Risk Stratification in Patients Taking Aspirin
From the Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Mo (B.F.G.); Departments of Medicine and of Epidemiology and Community Medicine, University of Ottawa, and Ottawa Health Research Institute, Ottawa, Canada (C.v.W.); Biostatistical Consultant, Minot, ND (L.P.); Department of Medicine (Neurology), University of Texas Health Science Center, San Antonio, Tex (R.G.H.); Department of Neurology, Erasmus Medical Center, Rotterdam, the Netherlands (P.J.K.); Department of General Practice, University of Maastricht, Maastricht, the Netherlands (B.S.P.B.); and Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark (P.P.).
Correspondence to Brian F. Gage, MD, MSc, Division of General Medical Sciences, Washington University School of Medicine Campus Box 8005, 660 S Euclid Ave, St. Louis, MO 63110. E-mail bgage{at}im.wustl.edu
Received December 30, 2003; de novo received March 27, 2004; revision received June 30, 2004; accepted August 3, 2004.
Background— The rate of stroke in atrial fibrillation (AF) depends on the presence of comorbid conditions and the use of antithrombotic therapy. Although adjusted-dose warfarin is superior to aspirin for reducing stroke in AF, the absolute risk reduction of warfarin depends on the stroke rate with aspirin. This prospective cohort study tested the predictive accuracy of 5 stroke risk stratification schemes.
Methods and Results— The study pooled individual data from 2580 participants with nonvalvular AF who were prescribed aspirin in a multicenter trial (Atrial Fibrillation, Aspirin, Anticoagulation I study [AFASAK-1], AFASAK-2, European Atrial Fibrillation Trial, Primary Prevention of Arterial Thromboembolism in patients with nonrheumatic Atrial Fibrillation in primary care study, and Stroke Prevention and Atrial Fibrillation [SPAF]-III high risk or SPAF-III low risk). There were 207 ischemic strokes during 4887 patient-years of aspirin therapy. All schemes predicted stroke better than chance, but the number of patients categorized as low and high risk varied substantially. AF patients with prior cerebral ischemia were classified as high risk by all 5 schemes and had 10.8 strokes per 100 patient-years. The CHADS2 scheme (an acronym for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack) successfully identified primary prevention patients who were at high risk of stroke (5.3 strokes per 100 patient-years). In contrast, patients identified as high risk by other schemes had 3.0 to 4.2 strokes per 100 patient-years. Low-risk patients identified by all schemes had 0.5 to 1.4 strokes per 100 patient-years of therapy.
Conclusions— Patients with AF who have high and low rates of stroke when given aspirin can be reliably identified, allowing selection of antithrombotic prophylaxis to be individualized.
Key Words: anticoagulants • aspirin • atrial fibrillation • risk factors • stroke
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