Elsevier

American Heart Journal

Volume 162, Issue 3, September 2011, Pages 555-561
American Heart Journal

Clinical Investigation
Coronary Artery Disease
The CHADS2 score predicts ischemic stroke in the absence of atrial fibrillation among subjects with coronary heart disease: Data from the Heart and Soul Study

https://doi.org/10.1016/j.ahj.2011.05.023Get rights and content

Background

We sought to evaluate the prognostic performance of the CHADS2 score for prediction of ischemic stroke/transient ischemic attack (TIA) in subjects with coronary heart disease (CHD) without atrial fibrillation (AF).

Methods

In 916 nonanticoagulated outpatients with stable CHD and no AF by baseline electrocardiogram, we calculated CHADS2 scores (congestive heart failure, hypertension, age ≥75 years, diabetes [1 point each], and prior stroke or TIA [2 points]). The primary outcome was time to ischemic stroke or TIA over a mean follow-up of 6.4 ± 2.3 years.

Results

Over 5,821 person-years of follow-up, 40 subjects had an ischemic stroke/TIA (rate 0.69/100 person-years, 95% CI 0.50-0.94). Compared with subjects with low (0-1) CHADS2 scores, those with intermediate (2-3) and high (4-6) CHADS2 scores had an increased rate of stroke/TIA, even after adjustment for age, tobacco, antiplatelet therapy, statins, and angiotensin inhibitors (CHADS2 score 2-3: HR 2.4, 95% CI 1.1-5.3, P = .03; CHADS2 score 4-6: HR 4.0, 95% CI 1.5-10.6, P = .006). Model discrimination (c-statistic = 0.65) was comparable with CHADS2 model fit in published AF-only cohorts.

Conclusions

The CHADS2 score predicts ischemic stroke/TIA in subjects with stable CHD and no baseline AF. The event rate in non-AF subjects with high CHADS2 scores (5-6) was comparable with published rates in AF patients with moderate CHADS2 scores (1-2), a population known to derive benefit from stroke prevention therapies. These findings should inform efforts to determine whether stroke prevention therapies or screening for silent AF may benefit subjects with stable CHD and high CHADS2 scores.

Section snippets

Participants

The Heart and Soul Study is a prospective cohort study designed to investigate psychosocial factors and health outcomes in patients with stable CHD. Details regarding recruitment methods and study design have been published previously.9 In brief, between September 2000 and December 2002, 1,024 outpatients with stable CHD were recruited from 2 Veterans Administration medical centers (Palo Alto and San Francisco), 1 university medical center (University of California, San Francisco), and 9

Results

Of the 916 nonanticoagulated participants with no evidence of baseline AF, the mean CHADS2 score was 1.7 ± 1.2. The CHADS2 score was strongly associated with each of the components used to derive the score (age, CHF, hypertension, diabetes, and stroke/TIA). Compared with participants with low CHADS2 scores (0-1), those with high CHADS2 scores (4-6) also had higher BMIs and were less likely to smoke. They were more likely to have a history of MI, lower left ventricular ejection fractions (LVEF),

Discussion

In 916 patients with CHD who had no known AF at baseline, we found that the CHADS2 score was strongly predictive of ischemic stroke/TIA. Compared with participants with low CHADS2 scores (0-1), those with intermediate CHADS2 scores (2-3) had an over 2-fold increased rate of stroke and those with high CHADS2 scores (4-6) had a 4-fold increased rate of stroke. The event rate in non-AF CHD patients with high CHADS2 scores (5-6) was comparable to the rate in AF patients with moderate CHADS2 scores

Conclusions

In summary, we found that the CHADS2 risk score independently predicts stroke/TIA in patients with CHD who have no known history of AF. The event rate in non-AF CHD patients with high CHADS2 scores (5-6) was comparable to published rates in AF patients with moderate CHADS2 scores (1-2). Because most strokes occur in patients without known AF, the CHADS2 score may have a role in identification of high-risk individuals who may benefit from stroke prevention therapies or screening for silent AF.

Disclosures

None.

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