Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach The Euro Heart Survey on Atrial Fibrillation
Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach The Euro Heart Survey on Atrial Fibrillation
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DOI：
10.1378/chest.09-1584
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发表时间：
2010-02-01
期刊：
影响因子：
9.6
通讯作者：
Crijns, Harry J. G. M.
中科院分区：
文献类型：
--
作者：
Lip, Gregory Y. H.;Nieuwlaat, Robby;Crijns, Harry J. G. M.
背景：目前用于预测心房颤动(房颤)患者卒中和血栓栓塞症(TE)的临床风险分层方案主要来源于试验队列中确定的危险因素。因此，许多潜在的风险因素没有被纳入。方法：我们将2006年伯明翰/国家健康与临床卓越研究所(NICE)的中风风险分层方案提炼为基于风险因素的方法，方法是重新分类和/或在相关的情况下加入额外的新风险因素。然后将该方案与现有的卒中风险分层方案进行比较，这些方案来自来自欧洲心脏调查的房颤患者(n=1,084)。结果：不同方案之间的风险分类有很大差异。被归类为高危的患者从10.2%的Framingham方案到75.7%的Biramingham 2009方案不等。经典的CHADS(2)(充血性心力衰竭、高血压、年龄和75岁、糖尿病、既往中风/短暂性脑缺血发作)模式将最大比例(61.9%)归入中等风险阶层，而伯明翰2009年的模式将15.1%归入这一类别。伯明翰2009年的方案只将9.2%归类为低风险，而弗雷明翰方案将48.3%归类为低风险。计算的C-统计量表明，所有方案对TE的预测价值不大。伯明翰2009年的模式表现略好于CHADS(2)(C统计，0.606)。然而，那些被伯明翰2009和NICE方案归类为低风险的患者是真正的低风险，没有TE事件的记录，而TE事件发生在1.4%的低风险CHAD受试者中(2)。当被表示为一个评分系统时，伯明翰2009年的方案(CHA(2)DS(2)-VASC缩写)显示TE率随分数的增加而增加(趋势的P值=0.003)。结论：我们基于风险因素方法的新的、简单的卒中风险分层方案提供了比CHADS(2)方案更高的TE的预测价值，低风险受试者的事件发生率较低，并且只将一小部分受试者归入IN(中等风险类别)。这一方案可以改进我们对房颤患者卒中风险分层的方法。《胸腔》2010；137(2)：263-272
Background: Contemporary clinical risk stratification schemata for predicting stroke and thromboembolism (TE) in patients with atrial fibrillation (AF) are largely derived from risk factors identified from trial cohorts. Thus, many potential risk factors have not been included.Methods: We refined the 2006 Birmingham/National Institute for Health and Clinical Excellence (NICE) stroke risk stratification schema into a risk factor-based approach by reclassifying and/or incorporating additional new risk factors where relevant. This schema was then compared with existing stroke risk stratification schema in a real-world cohort of patients with AF (n = 1,084) from the Euro Heart Survey for AF.Results: Risk categorization differed widely between the different schemes compared. Patients classified as high risk ranged from 10.2% with the Framingham schema to 75.7% with the Biramingham 2009 schema. T he classic CHADS(2), (Congestive heart failure, Hypertension, Age > 75, Diabetes, prior Stroke/transient isehemic attack) schema categorized the largest proportion (61.9%) into the intermediate-risk strata, whereas the Birmingham 2009 schema classified 15.1% into this category. The Birmingham 2009 schema classified only 9.2% as low risk, whereas the Framingham scheme categorized 48.3% as low risk. Calculated C-statistics suggested modest predictive value of all schema for TE. The Birmingham 2009 schema fared marginally better (C-statistic, 0.606) than CHADS(2). However, those classified as low risk by the Birmingham 2009 and NICE schema were truly low risk with no TE events recorded, whereas TE events occurred in 1.4% of low-risk CHADS(2) subjects. When expressed as a scoring system, the Birmingham 2009 schema (CHA(2)DS(2)-VASc acronym) showed an increase in TE rate with increasing scores (P value for trend = .003).Conclusion: Our novel, simple stroke risk stratification schema, based on a risk factor approach, provides some improvement in predictive value for TE over the CHADS(2) schema, with low event rates in low-risk subjects and the classification of only a small proportion of subjects into the in(intermediate-risk category. This schema could improve our approach to stroke risk stratification in patients with AF. CHEST 2010; 137(2):263-272