Pulse lineResearch With Heart Logo

Refining Prediction of Atrial Fibrillation-Related Stroke Using the P-CHADS-VASc Score.

TitleRefining Prediction of Atrial Fibrillation-Related Stroke Using the P-CHADS-VASc Score.
Publication TypeJournal Article
Year of Publication2019
AuthorsMaheshwari A, Norby FL, Roetker NS, Soliman EZ, Koene RJ, Rooney MR, O'Neal WT, Shah AM, Claggett BL, Solomon SD, Alonso A, Gottesman RF, Heckbert SR
Secondary AuthorsChen LYee
JournalCirculation
Volume139
Issue2
Pagination180-191
Date Published2019 01 08
ISSN1524-4539
KeywordsAction Potentials, Aged, Aged, 80 and over, Atrial Fibrillation, Atrial Function, Left, Atrial Remodeling, Brain Ischemia, Decision Support Techniques, Electrocardiography, Female, Heart Atria, Heart Rate, Humans, Incidence, Male, Middle Aged, Predictive Value of Tests, Prognosis, Risk Assessment, Risk Factors, Stroke, United States
Abstract

BACKGROUND: In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs)-prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHADS-VASc score would improve its ability to predict AF-related ischemic stroke.

METHODS: We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement.

RESULTS: Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHADS-VASc variables, and that resulted in meaningful improvement in stroke prediction. The ╬▓ estimate was approximately twice that of the CHADS-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P-CHADS-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively.

CONCLUSIONS: Abnormal P-wave axis-an ECG correlate of left atrial abnormality- improves ischemic stroke prediction in AF. Compared with CHADS-VASc, the P-CHADS-VASc is a better prediction tool for AF-related ischemic stroke.

DOI10.1161/CIRCULATIONAHA.118.035411
Alternate JournalCirculation
PubMed ID30586710
PubMed Central IDPMC6481672
Grant ListHHSN268201100012C / HL / NHLBI NIH HHS / United States
HHSN268201100009I / HL / NHLBI NIH HHS / United States
HHSN268201500003C / HL / NHLBI NIH HHS / United States
N01HC95160 / HL / NHLBI NIH HHS / United States
HHSN268201100010C / HL / NHLBI NIH HHS / United States
N01 HC095167 / HC / NHLBI NIH HHS / United States
N01HC95163 / HL / NHLBI NIH HHS / United States
HHSN268201100008C / HL / NHLBI NIH HHS / United States
UL1 TR001079 / TR / NCATS NIH HHS / United States
HHSN268201100005G / HL / NHLBI NIH HHS / United States
HHSN268201100008I / HL / NHLBI NIH HHS / United States
HHSN268201100007C / HL / NHLBI NIH HHS / United States
N01HC95169 / HL / NHLBI NIH HHS / United States
16EIA26410001 / / American Heart Association-American Stroke Association / United States
HHSN268201100011I / HL / NHLBI NIH HHS / United States
HHSN268201100011C / HL / NHLBI NIH HHS / United States
N01 HC095164 / HC / NHLBI NIH HHS / United States
N01 HC095166 / HC / NHLBI NIH HHS / United States
N01HC95164 / HL / NHLBI NIH HHS / United States
N01 HC095160 / HC / NHLBI NIH HHS / United States
N01HC95162 / HL / NHLBI NIH HHS / United States
N01HC95168 / HL / NHLBI NIH HHS / United States
T32 HL007779 / HL / NHLBI NIH HHS / United States
HHSN268201100006C / HL / NHLBI NIH HHS / United States
HHSN268201100005I / HL / NHLBI NIH HHS / United States
N01HC95165 / HL / NHLBI NIH HHS / United States
N01HC95159 / HL / NHLBI NIH HHS / United States
N01HC95161 / HL / NHLBI NIH HHS / United States
N01 HC095169 / HC / NHLBI NIH HHS / United States
UL1 TR001420 / TR / NCATS NIH HHS / United States
N01 HC095165 / HC / NHLBI NIH HHS / United States
HHSN268201500003I / HL / NHLBI NIH HHS / United States
N01HC95167 / HL / NHLBI NIH HHS / United States
HHSN268201100009C / HL / NHLBI NIH HHS / United States
HHSN268201100005C / HL / NHLBI NIH HHS / United States
N01 HC095168 / HC / NHLBI NIH HHS / United States
HHSN268201100007I / HL / NHLBI NIH HHS / United States
UL1 TR000040 / TR / NCATS NIH HHS / United States
R01 HL141288 / HL / NHLBI NIH HHS / United States
N01HC95166 / HL / NHLBI NIH HHS / United States
N01 HC095162 / HC / NHLBI NIH HHS / United States
R01 HL127659 / HL / NHLBI NIH HHS / United States
N01 HC095159 / HC / NHLBI NIH HHS / United States
R01 HL126637 / HL / NHLBI NIH HHS / United States