Chao Tze-Fan, Liu Chia-Jen, Wang Kang-Ling, Lin Yenn-Jiang, Chang Shih-Lin, Lo Li-Wei, Hu Yu-Feng, Tuan Ta-Chuan, Chung Fa-Po, Liao Jo-Nan, Chen Tzeng-Ji, Lip Gregory Y H, Chen Shih-Ann
Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan.
Heart Rhythm. 2014 Oct;11(10):1752-9. doi: 10.1016/j.hrthm.2014.06.021. Epub 2014 Jun 18.
Renal dysfunction is a significant risk factor for ischemic stroke in atrial fibrillation (AF). However, the incidence of ischemic stroke and how to predict its occurrence among AF patients with end-stage renal disease (ESRD) are unclear.
The purpose of this study was to compare the CHADS2 and CHA2DS2-VASc scores for stroke risk stratification in AF patients with ESRD.
A total of 10,999 AF patients with ESRD undergoing renal replacement therapy who were not receiving oral anticoagulants or antiplatelet agents were identified from Taiwan's National Health Insurance Research Database. The study end-point was occurrence of ischemic stroke.
The median (interquartile) CHADS2 and CHA2DS2-VASc scores for the study cohort were 3 (2-5) and 5 (4-7), respectively. During follow-up, 1217 patients (11.7%) experienced ischemic stroke, with an incidence rate of 6.9 per 100 person-years. In Cox regression models, the CHADS2 and CHA2DS2-VASc scores both were significant predictors of ischemic stroke. C-indexes for CHADS2 and CHA2DS2-VASc were 0.608 and 0.682, respectively (P < .001). CHA2DS2-VASc improved the net reclassification index by 4.8% compared with CHADS2 (P < .0001). Among 1409 patients with a CHADS2 score of 0 or 1, the CHA2DS2-VASc score ranged from 1 to 4, with event rates ranging from 2.1 to 4.7 per 100 person-years.
The CHA2DS2-VASc score was useful in predicting ischemic stroke in AF patients with ESRD undergoing dialysis and was superior to the CHADS2 score. The net clinical benefit balancing stroke reduction against major bleeding with anticoagulation in these high-risk patients remains to be defined.
肾功能不全是心房颤动（AF）患者发生缺血性卒中的重要危险因素。然而，终末期肾病（ESRD）合并AF患者的缺血性卒中发生率及其预测因素尚不清楚。
本研究旨在比较CHADS2和CHA2DS2-VASc评分在ESRD合并AF患者卒中风险分层中的作用。
从台湾国民健康保险研究数据库中识别出10999例接受肾脏替代治疗、未接受口服抗凝药或抗血小板药物的ESRD合并AF患者。研究终点为缺血性卒中的发生。
研究队列的CHADS2和CHA2DS2-VASc评分中位数（四分位间距）分别为3（2-5）和5（4-7）。随访期间，1217例患者（11.7%）发生缺血性卒中，发病率为每100人年6.9例。在Cox回归模型中，CHADS2和CHA2DS2-VASc评分均为缺血性卒中的显著预测因素。CHADS2和CHA2DS2-VASc的C指数分别为0.608和0.682（P < 0.001）。与CHADS2相比，CHA2DS2-VASc使净重新分类指数提高了4.8%（P < 0.0001）。在1409例CHADS2评分为0或1的患者中，CHA2DS2-VASc评分范围为1至4，事件发生率为每100人年2.1至4.7例。
CHA2DS2-VASc评分有助于预测接受透析的ESRD合并AF患者的缺血性卒中，且优于CHADS2评分。在这些高危患者中，抗凝治疗在降低卒中风险与严重出血之间的净临床获益仍有待确定。
