Teppo Konsta, Lip Gregory Yoke Hong, Airaksinen Kari Eino Juhani, Halminen Olli, Haukka Jari, Putaala Jukka, Mustonen Pirjo, Linna Miika, Hartikainen Juha, Lehto Mika
Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
Lancet Reg Health Eur. 2024 Jun 10;43:100967. doi: 10.1016/j.lanepe.2024.100967. eCollection 2024 Aug.
Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHADS-VASc risk score (ie. CHADS-VA).
The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHADS-VA score was compared with the CHADS-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses.
We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHADS-VA score was inferior to the CHADS-VASc in the early years (-0.333 (95% CI -0.411 to -0.261) and -0.118 (95% CI -0.137 to -0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (-0.093 (95% CI -0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHADS-VA (0.070 (95% CI 0.048-0.087)). The IDI was non-significant in early years (0.0009 (95% CI -0.0024 to 0.0037)), but over time became statistically significant in favor of the CHADS-VA score (0.0022 (95% CI 0.0001-0.0044)). The Cox models fitted with the CHADS-VA and the CHADS-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHADS-VA score emerged (p-value 0.0002).
In 2007-2008 (when females had higher AF-related stroke risks than males), the CHADS-VASc score outperformed the CHADS-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017-2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHADS-VA score.
This work was supported by the Aarne Koskelo Foundation, The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.
当代数据显示，心房颤动（AF）患者中，女性的缺血性中风风险有所降低。我们评估了非性别CHADS-VASc风险评分（即CHADS-VA）预测价值的时间趋势。
芬兰房颤队列研究（FinACAF）涵盖了2007年至2018年芬兰各级医疗机构中所有新发房颤患者。使用连续和基于类别的净重新分类指数（NRI）、综合判别改善（IDI）、c统计量和决策曲线分析，将CHADS-VA评分与CHADS-VASc评分进行比较。
我们确定了2007年至2018年间144,879例初治抗凝的新发房颤患者（49.�%为女性；平均年龄72.1岁），其中3936例（2.7%）在一年随访期间发生缺血性中风。基于连续和基于类别的NRI，CHADS-VA评分在早期不如CHADS-VASc（分别为-0.333（95%CI -0.411至-0.261）和-0.118（95%CI -0.137至-0.099））。然而，随着时间的推移，差异逐渐减小，到研究期结束时，连续NRI变得不显著（-0.093（95%CI -0.165至0.032）），而基于类别的NRI则转而支持CHADS-VA（0.070（95%CI 0.048 - 0.087））。IDI在早期不显著（0.0009（95%CI -0.0024至0.0037）），但随着时间的推移，在支持CHADS-VA评分方面具有统计学意义（0.0022（95%CI 0.0001至0.0044））。用CHADS-VA和CHADS-VASc评分拟合的Cox模型在研究开始时具有相当的判别能力（p值0.63），但随着时间的推移，出现了有利于CHADS-VA评分的微小差异（p值0.0002）。
在2007 - 2008年（女性房颤相关中风风险高于男性时），CHADS-VASc评分优于CHADS-VA评分，但评分之间的初始差异随着时间的推移而减小。到2017 - 2018年研究期结束时（房颤相关中风的性别差异有限/无差异），CHADS-VA评分略有优势。
这项工作得到了阿尔内·科斯凯洛基金会、芬兰心血管研究基金会、芬兰国家研究基金以及赫尔辛基和新地区医院区研究基金的支持。
