Yao Xiaoxi, Gersh Bernard J, Sangaralingham Lindsey R, Kent David M, Shah Nilay D, Abraham Neena S, Noseworthy Peter A
Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
Am J Cardiol. 2017 Nov 1;120(9):1549-1556. doi: 10.1016/j.amjcard.2017.07.051. Epub 2017 Jul 31.
The increasing adoption of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF) necessitates a reassessment of bleeding risk scores. Because known risk factors for bleeding are largely the same as for stroke, we hypothesize that stroke risk scores could also be used to identify patients with high bleeding risks. We aimed to compare the performance of 2 stroke risk scores (Congestive Heart failure, hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, and Sex [female] [CHADS-VASc] and Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] [CHADS]) and 3 bleeding risk scores (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile INR, elderly [.65 years], drugs/alcohol concomitantly [1 point each] [HAS-BLED], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT], and AnTicoagulation and Risk factors In Atrial fibrillation [ATRIA]) in predicting major and intracranial bleeding. Using a large US commercial insurance database, we identified 39,539 patients with nonvalvular AF who started NOACs between October 1, 2010 and June 30, 2015. The performance of risk scores was compared using C-statistic and net reclassification improvement (NRI). Over a total of 22,583 person-years, 665 patients (2.94% per year) had major bleeding, including 74 intracranial hemorrhages (0.33% per year). For the prediction of major bleeding, CHADS-VASc had the highest C-statistic both as a continuous score (C-statistic 0.68) and as a categorical score (C-statistic 0.65). For the prediction of intracranial bleeding, CHADS had the highest C-statistic both as a continuous score (C-statistic 0.66) and as a categorical score (C-statistic 0.66). There were no statistically significant differences between scores based on NRI. In conclusion, CHADS-VASc, CHADS, HAS-BLED, ORBIT, and ATRIA had similar, albeit modest, performance in predicting NOAC-associated bleeding in patients with AF. Careful assessment and active management of bleeding risk factors may be warranted in all patients on NOACs who have high stroke risk scores.
在心房颤动（AF）患者中，越来越多地采用非维生素K拮抗剂口服抗凝药（NOACs）预防中风，这就需要重新评估出血风险评分。由于已知的出血风险因素与中风风险因素基本相同，我们推测中风风险评分也可用于识别出血风险高的患者。我们旨在比较两种中风风险评分（充血性心力衰竭、高血压、年龄≥75岁[加倍]、糖尿病、中风[加倍]、血管疾病、年龄65 - 74岁和性别[女性][CHADS - VASc]以及心力衰竭、高血压、年龄、糖尿病、中风[加倍][CHADS]）和三种出血风险评分（高血压、肾/肝功能异常[各1分]、中风、出血史或易感性、INR不稳定、老年人[≥65岁]、同时使用药物/酒精[各1分][HAS - BLED]、心房颤动更好知情治疗结果登记[ORBIT]以及心房颤动抗凝与危险因素[ATRIA]）在预测大出血和颅内出血方面的表现。利用一个大型美国商业保险数据库，我们识别出39539例非瓣膜性AF患者，他们在2010年10月1日至2015年6月30日期间开始使用NOACs。使用C统计量和净重新分类改善（NRI）比较风险评分的表现。在总计22583人年中，665例患者（每年2.94%）发生大出血，其中包括74例颅内出血（每年0.33%）。对于大出血的预测，CHADS - VASc作为连续评分（C统计量0.68）和分类评分（C统计量0.65）时C统计量最高。对于颅内出血的预测，CHADS作为连续评分（C统计量0.66）和分类评分（C统计量0.66）时C统计量最高。基于NRI，各评分之间无统计学显著差异。总之，CHADS - VASc、CHADS、HAS - BLED、ORBIT和ATRIA在预测AF患者NOAC相关出血方面表现相似，尽管效果一般。对于所有中风风险评分高且正在使用NOACs的患者，可能有必要仔细评估并积极管理出血风险因素。
