Jul 2026· Open Heart· Vol 13, pp. e004232· 0 citations· 39 references
Medicine
TL;DR
The guideline-endorsed CHA2DS2-VA score showed the lowest discrimination, and patients classified as intermediate-risk using this score had stroke incidence below the treatment threshold, indicating truly low-risk patients in Australia.
Abstract
Background Australian guidelines recommend the CHA2DS2-VA (congestive heart failure, hypertension, age ≥75 years (double weight), diabetes mellitus, previous stroke (double weight), vascular disease, age 65–74 years) score to identify patients with atrial fibrillation (AF) at low stroke risk who should avoid oral anticoagulation. Treatment thresholds were derived from heterogeneous international data, and alternate scores require validation in an Australian population. We evaluated whether existing stroke scores (CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke (double weight)), CHA2DS2-VA, ATRIA (anticoagulation and risk factors in atrial fibrillation) and Modified-CHADS2) accurately identify truly low-risk patients in Australia. Methods We conducted a population-based cohort study using linked data from the New South Wales Admitted Patient Data Collection, the National Death Index and the Pharmaceutical Benefits Scheme databases. Oral anticoagulant-naïve patients with a first hospital admission for AF between July 2003 and January 2021 were included. Patients were followed for ≥12 months and classified into low-risk, intermediate-risk or high-risk categories for each score. ‘Truly low-risk’ was defined as annual ischaemic stroke incidence <0.9%. Predictive accuracy was assessed using the concordance-statistic. Results Among 224 451 eligible patients, 3552 (1.6%) were hospitalised for ischaemic stroke within 12 months. The proportion labelled low-risk ranged from 2.0% (Modified-CHADS2) to 50.9% (ATRIA). Patients assigned low-risk using each score, and intermediate-risk with the CHA2DS2-VA score, met the definition of truly low-risk. Concordance-statistics were modest, with the weakest performing score being the CHA2DS2-VA score (0.61, 95% CI 0.60 to 0.61) and the best performing model being the ATRIA score (0.66, 95% CI 0.66 to 0.67). Conclusions The guideline-endorsed CHA2DS2-VA score showed the lowest discrimination, and patients classified as intermediate-risk using this score had stroke incidence below the treatment threshold. Strong consideration should be given to the development and validation of locally applicable risk tools.
A supervised machine learning algorithm for AF in a Western Pacific population was derived and demonstrated that higher risk was associated with hospitalisation for other cardio-renal diseases and death.
J. Hsu, C. Hayward, Tobin Joseph et al.· Heart, Lung and Circulation· 0 citations
Greater uptake of these therapies and comprehensive risk factor management are needed to mitigate stroke burden in this high-risk group of patients with T2DM and ASCVD.
Z. Arow, Tzipi Hornik-Lurie, R. Hilu et al.· Annales d'Endocrinologie· 0 citations
BACKGROUND
Current U.S. and European guidelines recommend oral anticoagulation as a class IIa indication in patients with atrial fibrillation at intermediate risk for stroke; however, evidence from randomized trials is needed.
METHODS
We conducted a multicenter, open-label, adjudicator-masked superiority trial in South Korea involving patients with atrial fibrillation and an intermediate risk of stroke (a score of 1 in men and 2 in women on the CHA2DS2-VASc scale; range, 0 to 9, with higher scores indicating a greater risk of stroke). Patients were randomly assigned in a 1:1 ratio to receive either direct oral anticoagulant (DOAC) therapy or no anticoagulation. The primary end point was a composite of stroke, systemic embolism, major bleeding, or death from cardiovascular causes at 24 months.
RESULTS
Of 1803 patients who underwent randomization, 902 were assigned to receive DOAC therapy and 901 were assigned to receive no anticoagulant therapy. The mean age of the patients was 60.4 years, and 23.7% were women. At 24 months, a primary end-point event had occurred in 4 patients (cumulative incidence, 0.5%) in the DOAC group and in 13 (cumulative incidence, 1.5%) in the no-anticoagulant group (difference, -1.0 percentage points; 95% confidence interval [CI], -2.0 to -0.1; P = 0.03; hazard ratio, 0.31; 95% CI, 0.10 to 0.94). Stroke occurred in 3 patients (cumulative incidence, 0.3%) in the DOAC group and in 10 (cumulative incidence, 1.1%) in the no-anticoagulant group. The incidence of systemic embolism and major bleeding appeared to be similar in the two trial groups, and no deaths from cardiovascular causes occurred in either group. Serious adverse events occurred in 80 patients (8.9%) in the DOAC group and in 84 (9.3%) in the no-anticoagulant group.
CONCLUSIONS
Among patients with atrial fibrillation at intermediate risk for stroke, DOAC therapy led to a lower risk of stroke, systemic embolism, major bleeding, or death from cardiovascular causes at 24 months than no anticoagulation. (Funded by the Ministry of Health and Welfare, South Korea, and others; SINGLE-AF ClinicalTrials.gov number, NCT04437654.).
Daehoon Kim, Young-soo Lee, J. Shim et al.· New England Journal of Medic...· 0 citations
The CHA2DS2-VALa score significantly improves stroke risk stratification in AF by integrating LA diameter into conventional scoring, as echocardiographic measurement is widely available and reproducible.
Sefa Erdi Ömür, Emin Koyun, G. Genc Tapar et al.· Cardiovascular Electrophysio...· 0 citations
Background Atrial fibrillation (AF) is an important risk factor for ischemic stroke. However, the prognostic impact of acute atrial fibrillation (AAF) at the onset of acute ischemic stroke (AIS) remains unclear. Methods This retrospective study categorized 417 patients with AIS into the AAF (n = 72), other AF (n = 142), and non-AF (n = 203) groups. Multivariate logistic regression analysis of associations with 30-day all-cause mortality and severe early neurological deficit (7-day NIHSS ≥16). Results The AAF group demonstrated significantly worse outcomes than the other AF and non-AF groups. In the multivariable analysis, AAF was identified as an independent risk predictor for severe 7-day neurological deficit [odds ratio (OR): 10.09; 95% CI: 3.87−27.36; P < 0.001] and all-cause mortality within 30 days (OR: 4.11; 95% CI: 2.28−7.43; P < 0.001). Conclusions AAF at the onset of AIS is an independent risk predictor for early neurological deterioration and short-term mortality, establishing it as a crucial prognostic indicator that warrants vigilant management.
G. Duan, Xiaoguang Zhu, Jiangshan Deng et al.· Frontiers in Cardiovascular...· 0 citations
BACKGROUND AND AIMS
Accurate stroke-risk stratification is central to anticoagulation decision-making in patients with atrial fibrillation (AF), but conventional scores may not fully capture risk heterogeneity. We aimed to develop and externally validate an interpretable weighted score using a time-to-event framework.
METHODS
GLORIA-AF Phase II/III data were used to evaluate 17 baseline predictors using LASSO-penalized Cox regression with stability selection; coefficients were converted into integer weights. Performance was assessed using discrimination, calibration, integrated discrimination improvement (IDI), continuous net reclassification improvement (NRI), and decision-curve analysis. External validation was performed in EORP-AF and APHRS-AF registries.
RESULTS
Among 20,517 patients included in the derivation cohort (mean [SD] age, 69.9 [10.3] years; 9,196 women [44.8%]), 487 (2.4%) had stroke, and 17,397 (84.8%) were receiving anticoagulation at baseline. Ten selected predictors formed a 0-23-point score. The derived score achieved a C-index of 0.661 (95% CI, 0.636-0.685), higher than CHA2DS2-VA (0.626; P < 0.001), CHA2DS2-VASc (0.615; P < 0.001), and the unweighted score (P = 0.016), with no significant difference from the full Cox or machine learning models. In external validation (8,309 patients; 147 strokes), the C-index was 0.652 (95% CI, 0.614-0.690) versus 0.616 for CHA2DS2-VA (95%CI, 0.598-0.634; P < 0.001). IDI/NRI, calibration, and decision-curve analyses supported improved risk differentiation, close calibration, and generally greater net benefit than CHA2DS2-VA. The score retained higher discrimination than CHA2DS2-VA among patients without baseline anticoagulation (P < 0.001).
CONCLUSION
The GLORIA-AF Stroke Weighted Risk Score provides risk refinement beyond CHA2DS2-VA while retaining discrimination consistent with more complex models. External validation supports its transportability and potential adjunctive role in guideline-directed thromboembolic risk assessment.