General Practice Research Database, Medicines and Healthcare Products Regulatory Agency, London, UK.
J Thromb Haemost. 2011 Jan;9(1):39-48. doi: 10.1111/j.1538-7836.2010.04085.x.
Anticoagulation management of patients with atrial fibrillation (AF) should be tailored individually on the basis of ischemic stroke risk. The objective of this study was to compare the predictive ability of 15 published stratification schemes for stroke risk in actual clinical practice in the UK.
AF patients aged ≥ 18 years in the General Practice Research Database, which contains computerized medical records, were included. The c-statistic was estimated to determine the predictive ability for stroke for each scheme. Outcomes included stroke, hospitalizations for stroke, and death resulting from stroke (as recorded on death certificates).
The study cohort included 79,844 AF patients followed for an average of 4 years (average of 2.4 years up to the start of warfarin therapy). All risk schemes had modest discriminatory ability in AF patients, with c-statistics for predicting events ranging from 0.55 to 0.69 for strokes recorded by the general practitioner or in hospital, from 0.56 to 0.69 for stroke hospitalizations, and from 0.56 to 0.78 for death resulting from stroke as reported on death certificates. The proportion of patients assigned to individual risk categories varied widely across the schemes, with the proportion categorized as moderate risk ranging from 12.7% (CHA(2) DS(2)-VASc) to 61.5% (modified CHADS(2)). Low-risk subjects were truly low risk (with annual stroke events < 0.5%) with the modified CHADS(2), National Institute for Health and Clinical Excellence and CHA(2) DS(2) -VASc schemes.
Current published risk schemes have modest predictive value for stroke. A new scheme (CHA(2) DS(2) -VASc) may discriminate those at truly low risk and minimize classification of subjects as intermediate/moderate risk. This approach would simplify our approach to stroke risk stratification and improve decision-making for thromboprophylaxis in patients with AF.
房颤（AF）患者的抗凝管理应根据缺血性卒中风险进行个体化调整。本研究的目的是比较 15 种已发表的风险分层方案在英国实际临床实践中的预测能力。
纳入 General Practice Research Database 中年龄≥18 岁的 AF 患者，该数据库包含计算机化的医疗记录。使用 C 统计量评估每个方案预测卒中风险的能力。结局包括卒中、因卒中住院以及因卒中死亡（记录在死亡证明上）。
研究队列包括 79844 例 AF 患者，平均随访 4 年（平均 2.4 年，直至开始华法林治疗）。所有风险方案在 AF 患者中均具有适度的区分能力，预测事件的 C 统计量范围为 0.55 至 0.69（记录在全科医生或住院记录中的卒中）、0.56 至 0.69（卒中住院）和 0.56 至 0.78（记录在死亡证明上的卒中死亡）。各方案中，患者被分配到不同风险类别的比例差异很大，其中 CHA(2) DS(2)-VASc 方案中中度风险患者比例为 12.7%，而 modified CHADS(2) 方案中比例为 61.5%。改良 CHADS(2)、英国国家卫生与临床优化研究所和 CHA(2) DS(2)-VASc 方案中的低危患者真正低危（年卒中发生率<0.5%）。
目前已发表的风险方案对卒中的预测价值有限。新方案（CHA(2) DS(2)-VASc）可能可以区分真正低危患者，减少将患者分类为中危/高危的比例。这种方法可以简化我们的卒中风险分层方法，并改善 AF 患者的抗栓治疗决策。
