应用 P-CHADS-VASc 评分模型细化心房颤动相关卒中的预测。

Refining Prediction of Atrial Fibrillation-Related Stroke Using the P-CHADS-VASc Score.

机构信息

Hospital of the University of Pennsylvania, Philadelphia (A.M.).

University of Minnesota, Minneapolis (F.L.N., N.S.R., R.J.K., M.R.R., L.Y.C.).

出版信息

Circulation. 2019 Jan 8;139(2):180-191. doi: 10.1161/CIRCULATIONAHA.118.035411.

DOI:10.1161/CIRCULATIONAHA.118.035411

PMID:30586710

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6481672/

Abstract

BACKGROUND

In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs)-prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHADS-VASc score would improve its ability to predict AF-related ischemic stroke.

METHODS

We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement.

RESULTS

Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHADS-VASc variables, and that resulted in meaningful improvement in stroke prediction. The β estimate was approximately twice that of the CHADS-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P-CHADS-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively.

CONCLUSIONS

Abnormal P-wave axis-an ECG correlate of left atrial abnormality- improves ischemic stroke prediction in AF. Compared with CHADS-VASc, the P-CHADS-VASc is a better prediction tool for AF-related ischemic stroke.

摘要

背景

在患有心房颤动（AF）的人群中，窦性心律期为通过测量 P 波指数（PWIs）检测促血栓形成的心房重构提供了机会-延长 P 波持续时间、异常 P 波轴、高级房间隔阻滞和 V1 导联的异常 P 波终末力。我们假设将 PWIs 添加到 CHADS-VASc 评分中会提高其预测 AF 相关缺血性卒中的能力。

方法

我们纳入了 ARIC 研究（社区动脉粥样硬化风险研究）中的 2229 名和 MESA（动脉粥样硬化多民族研究）中的 700 名新发 AF 且在 AF 诊断后 1 年内未服用抗凝药物的参与者。PWIs 是从 AF 发生前的研究就诊心电图中获得的。AF 通过研究就诊心电图和医院记录确定。缺血性卒中病例基于医生对医院记录的判断。我们使用 Cox 比例风险模型来估计 PWIs 与缺血性卒中的风险比和 95%置信区间。通过 C 统计量、分类净重新分类改善和相对综合判别改善来评估 1 年卒中预测的改善。

结果

异常 P 波轴是唯一与缺血性卒中风险增加相关的 PWI（风险比，1.84；95%CI，1.33-2.55），独立于 CHADS-VASc 变量，并且对卒中预测有明显改善。β 估计值接近 CHADS-VASc 变量的两倍，因此异常 P 波轴被赋值为 2 分以创建 P-CHADS-VASc 评分。这提高了 ARIC 中的 C 统计量（95%CI）从 0.60（0.51-0.69）到 0.67（0.60-0.75）和 MESA（验证队列）中的 0.68（0.52-0.84）到 0.75（0.60-0.91）。在 ARIC 和 MESA 中，分类净重新分类改善（95%CI）分别为 0.25（0.13-0.39）和 0.51（0.18-0.86），相对综合判别改善（95%CI）分别为 1.19（0.96-1.44）和 0.82（0.36-1.39）。