Heart failure: a weak link in CHA DS -VASc.

AIMS

In atrial fibrillation, stroke risk is assessed by the CHA DS -VASc score. Heart failure is included in CHA DS -VASc, but the rationale is uncertain. Our objective was to test if heart failure is a risk factor for stroke, independent of other risk factors in CHA DS -VASc.

METHODS AND RESULTS

We studied 300 839 patients with atrial fibrillation in the Swedish Patient Register 2005-11. Three definitions of heart failure were used in order to assess the robustness of the results. In the main analysis, heart failure was defined by a hospital discharge diagnosis of heart failure as first or second diagnosis and a filled prescription of a diuretic within 3 months before index + 30 days. The second definition counted first or second discharge diagnoses <1 year before index + 30 days and the third definition any heart failure diagnosis in open or hospital care before index + 30 days. Associations with outcomes were assessed with multivariable Cox analyses. Patients with heart failure were older (80.5 vs. 74.0 years, P < 0.001) and had higher CHA DS -VASc score (4.4 vs. 2.7, P < 0.001). The 1 year incidence of ischaemic stroke without warfarin was 4.4% with heart failure and 3.1% without. Adjustment for the cofactors in CHA DS -VASc eradicated the difference in stroke risk between patients with and without heart failure (hazard ratio 1.01 with 95% confidence interval 0.96-1.05). The area under the receiver operating characteristic curve for CHA DS -VASc was not improved by points for heart failure.

CONCLUSIONS

A clinical diagnosis of heart failure was not an independent risk factor for stroke in patients with atrial fibrillation, which may have implications for anticoagulation management.