Evaluation of 5 Prognostic Scores for Prediction of Stroke, Thromboembolic and Coronary Events, All-Cause Mortality, and Major Adverse Cardiac Events in Patients With Atrial Fibrillation and Coronary Stenting.

Management of antithrombotic therapy in patients with atrial fibrillation (AF) and coronary stenting remains challenging, and there is a need for efficient tools to predict their risk of different types of cardiovascular events and death. Several scores exist such as the CHA2DS2-VASc score, the Global Registry of Acute Coronary Events (GRACE) score, the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score, the Anatomical and Clinical Syntax II Score and the Reduction of Atherothrombosis for Continued Health score. These 5 scores were investigated in patients with AF with coronary stenting with the aim of determining which was most predictive for stroke/thromboembolic (TE) events, nonlethal coronary events, all-cause mortality, and major adverse cardiac events (MACE). Among 845 patients with AF with coronary stenting seen from 2000 to 2014, 440 (52%) were admitted for acute coronary syndrome and 405 (48%) for elective percutaneous coronary intervention. The rate of cardiovascular complication was at 14.1% per year, and nonlethal coronary events were the most frequent complications with a yearly rate of 6.5%. CHA2DS2-VASc score was the best predictor of stroke/TE events with a c-statistic of 0.604 (95% CI 0.567 to 0.639) and a best cut-off point of 5. SYNTAX score was better to predict nonlethal coronary events and MACE with c-statistics of 0.634 (95% CI 0.598 to 0.669) and 0.612 (95% CI 0.575 to 0.647), respectively, with a best cut-off point of 9. GRACE score appeared to be the best to predict all-cause mortality with a c-statistic of 0.682 (95% CI 0.646 to 0.717) and a best cut-off point of 153. In conclusions, among validated scores, none is currently robust enough to simultaneously predict stroke/TE events, nonlethal coronary events, death, and MACE in patients with AF with stents. The CHA2DS2-VASc score remained the best score to assess stroke/TE risk, as was the SYNTAX score for nonlethal coronary events and MACE, and finally, the GRACE score for all-cause mortality in this study population.

Antithrombotic management in patients with atrial fibrillation undergoing coronary stent implantation: What is the impact of guideline adherence?

AIMS: Patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) and stenting require triple antithrombotic therapy according to current ESC guidelines. The purpose of this study was to assess guideline implementation and predictive factors of the prognosis related to ESC guideline adherence. METHODS AND RESULTS: We enrolled consecutive AF patients referred for PCI with stent from 2011 to 2014. Among 371 patients (72% male; mean age 76 ± 11) followed up for 505 ± 372 days (median 391, interquartile range 550 days), 118 (45%) undergoing elective coronary stenting and 41 (31%) among those with acute coronary syndrome were guideline adherent. Oral anticoagulation (OAC) before hospitalization was the only factor independently associated with guideline adherence (OR, 0.45; 95% CI 0.26-0.77; p=0.003). OAC underuse and antiplatelet therapy (APT) underuse were independently associated with increased risks of death (OR 5.55; 95% CI 2.42-13.47; p<0.0001 and OR 5.56; 95% CI, 2.17-14.65; p=0.0004, respectively) and major adverse cardiac events (MACE) (OR 4.18; 95% CI 2.05-8.79; p<0.0001 and OR 4.81; 95% CI, 2.09-11.18; p=0.0002, respectively). CONCLUSION: Guidelines for antithrombotic therapy in patients with AF who undergo PCI and stent implantation are still poorly followed in clinical practice. OAC and APT underuse were both associated with an increased risk of death and MACE in this population.

Oral Anticoagulation and the Risk of Stroke or Death in Patients With Atrial Fibrillation and One Additional Stroke Risk Factor: The Loire Valley Atrial Fibrillation Project.

BACKGROUND: It remains uncertain whether patients with atrial fibrillation (AF) and a single additional stroke risk factor (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or thromboembolism, vascular disease, age 65-74 years, and sex category [CHA2DS2-VASc] score = 1 in men, 2 in women) should be treated with oral anticoagulation (OAC). We investigated the risk of ischemic stroke, systemic embolism, and death in a community-based cohort of unselected patients with AF with zero to one stroke risk factor based on the CHA2DS2-VASc score. METHODS: Among 8,962 patients with AF seen between 2000 and 2010, 2,177 (24%) had zero or one additional stroke risk factor, of which 53% were prescribed OAC. RESULTS: Over a follow-up of 979 ± 1,158 days, 151 (7%) had a major adverse event (stroke/systemic thromboembolism/death). Prescription of OAC was not associated with a better prognosis for stroke/systemic thromboembolism/death for patients in the "low-risk" category (ie, CHA2DS2-VASc score = 0 for men or 1 for women; adjusted hazard ratio [HR], 0.68; 95% CI, 0.35-1.31; P = .25). OAC use was independently associated with a better prognosis in patients with AF with a single additional stroke risk factor (ie, CHA2DS2-VASc score = 1 in men, 2 in women; adjusted HR, 0.59; 95% CI, 0.40-0.86; P = .007). CONCLUSIONS: Among patients with AF with a single additional stroke risk factor (CHA2DS2-VASc score = 1 in men, 2 in women), OAC use was associated with an improved prognosis for stroke/systemic thromboembolism/death.