Karolinska Institutet, Department of Medicine Solna, Clinical Pharmacology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
Int J Cardiol. 2013 Dec 10;170(2):208-14. doi: 10.1016/j.ijcard.2013.10.063. Epub 2013 Oct 26.
Earlier validation studies of risk scoring by CHA2DS2VASc for assessments of appropriateness of warfarin treatment in patients with atrial fibrillation have been performed solely with diagnoses recorded in hospital based care, even though many patients to a large extent are managed in primary care.
Cross-sectional registry study of all 43 353 patients with a diagnosis of non-valvular atrial fibrillation recorded in inpatient care, specialist ambulatory care or primary care in the Stockholm County during 2006-2010.
The mean CHA2DS2VASc score was 3.82 (4.67 for women and 3.14 for men). 64% of the entire cohort of patients with atrial fibrillation had the diagnosis in primary care (12% only there). The mean CHA2DS2VASc score of patients with a diagnosis only in inpatient care or specialist ambulatory care increased from 3.63 to 3.83 when comorbidities registered in primary care were added. In 2010 warfarin prescriptions were claimed by 47.2%, and ASA by 41.6% of the entire cohort. 34% of patients with CHA2DS2VASc=1 and 20% with CHA2DS2VASc=0 had warfarin treatment. ASA was more frequently used instead of warfarin among women and elderly patients.
Registry CHA2DS2VASc scores were underestimated without co-morbidity data from primary care. Many individuals with scores 0 and 1 were treated with warfarin, despite poor documentation of clinical benefit. In contrast, warfarin appears to be underused and ASA overused among high risk atrial fibrillation patients. Lack of diagnoses from primary care underestimated CHA2DS2VASc scores and may thereby have overestimated treatment benefits in low-risk patients in earlier studies.
先前对 CHA2DS2VASc 风险评分用于评估房颤患者华法林治疗的适宜性的验证研究仅在基于医院的护理记录的诊断中进行，尽管许多患者在很大程度上在初级保健中进行管理。
这是一项横断面注册研究，纳入了 2006 年至 2010 年期间在斯德哥尔摩县住院护理、专科门诊护理或初级保健中记录的所有 43353 例非瓣膜性房颤患者。
平均 CHA2DS2VASc 评分为 3.82（女性为 4.67，男性为 3.14）。整个房颤患者队列中有 64%的患者在初级保健中诊断（仅 12%在那里）。当将初级保健中记录的合并症纳入后，仅在住院护理或专科门诊护理中诊断的患者的平均 CHA2DS2VASc 评分从 3.63 增加到 3.83。2010 年，整个队列中共有 47.2%的患者开具了华法林处方，41.6%的患者开具了阿司匹林处方。CHA2DS2VASc 评分为 1 的患者中有 34%接受了华法林治疗，评分为 0 的患者中有 20%接受了华法林治疗。女性和老年患者更频繁地使用阿司匹林替代华法林。
如果没有初级保健的合并症数据，登记 CHA2DS2VASc 评分会被低估。尽管临床获益的记录较差，但许多评分 0 和 1 的患者仍接受了华法林治疗。相比之下，在高风险房颤患者中，华法林的应用似乎不足，而阿司匹林的应用过多。缺乏初级保健的诊断会低估 CHA2DS2VASc 评分，并可能高估低风险患者在早期研究中的治疗获益。
