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.
Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
Can J Cardiol. 2019 May;35(5):611-618. doi: 10.1016/j.cjca.2019.01.018. Epub 2019 Feb 2.
The appropriate use of oral anticoagulants (OACs) for prevention of stroke in atrial fibrillation (AF) relies on the convenient and accurate stroke risk-prediction scheme: namely, the CHADS-VASc score. As patients with AF would become older and accumulate more comorbidities, their risks-for example, as reflected by the CHADS-VASc scores-are not static and could increase over time. The available data demonstrated that follow-up and Δ CHADS-VASc scores perform better than the baseline CHADS-VASc score in the prediction of ischemic stroke. Approximately 90% of initially low-risk patients would have a Δ CHADS-VASc score ≥ 1 before the occurrence of ischemic stroke. Apart from risk of stroke, the risk of bleeding for patients with AF is also highly dynamic. For example, the accuracies of the follow-up or Δ Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile INR, Elderly, Drugs or Alcohol (HAS-BLED) score in the prediction of major bleeding was significantly higher than that of the baseline HAS-BLED score. Most importantly, the risks of stroke and major bleeding were higher within several months after patients had changes (increases) in their stroke- or bleeding-risk scores. Therefore, risk profiles of patients with AF should be reassessed regularly so that OACs could be prescribed in a timely manner once patients are no longer at low risk for stroke, and modifiable risk factors for bleeding could be corrected. More efforts are necessary to incorporate clear and easy-to-follow recommendations about risk reassessment into the guidelines to improve AF patient care.
口服抗凝剂（OACs）在预防心房颤动（AF）中的合理应用依赖于方便且准确的卒中风险预测方案：即 CHADS-VASc 评分。随着 AF 患者年龄的增长和合并症的增多，他们的风险（例如，CHADS-VASc 评分所反映的）并非一成不变，而是可能随时间增加。现有数据表明，与基线 CHADS-VASc 评分相比，随访和ΔCHADS-VASc 评分在预测缺血性卒中有更好的表现。大约 90%的初始低危患者在发生缺血性卒中前ΔCHADS-VASc 评分≥1。除了卒中风险外，AF 患者的出血风险也具有高度动态性。例如，随访或Δ高血压、异常肾功能和肝功能、卒中、出血、INR 不稳定、高龄、药物或酒精（HAS-BLED）评分在预测大出血中的准确性明显高于基线 HAS-BLED 评分。最重要的是，在患者卒中或出血风险评分发生变化（增加）后的几个月内，患者的卒中或出血风险较高。因此，应定期重新评估 AF 患者的风险状况，以便在患者不再处于低卒中风险时及时开具 OACs，并纠正可改变的出血风险因素。需要做出更多努力，将关于风险重新评估的清晰且易于遵循的建议纳入指南中，以改善 AF 患者的护理。
