Stratifying Stroke Risk in Atrial Fibrillation: Beyond Clinical Risk Scores.
Stratifying Stroke Risk in Atrial Fibrillation: Beyond Clinical Risk Scores.
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DOI：
10.1161/strokeaha.117.017084
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发表时间：
2017-10
期刊：
影响因子：
8.3
通讯作者：
Kamel H
中科院分区：
文献类型：
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作者：
Yaghi S;Kamel H
2666卒中2017年10月验证研究显示CHADS 2评分的预测能力一般至良好，C统计量范围在0.56至0.82之间。[18]尽管有这些验证研究，但CHADS 2评分的主要局限性已经变得明显，因为它的使用已经变得更加广泛。首先，CHADS 2评分也被证明可以预测AF患者的出血性并发症。19这意味着血栓栓塞事件预测风险高的患者也是出血性并发症预测风险高的患者，这使得抗凝治疗的决策复杂化。更重要的是，在根据CHADS 2评分标记为低风险的患者中，该评分存在显著的实际卒中风险异质性。在CHADS 2评分为0的整个患者组中，年卒中风险范围为0 - 3%。[20]如果分数被用来阻止低分数患者的抗凝治疗，这是有问题的，因为这是经常使用的目的。为了更好地对基于CHADS 2评分被认为是低风险的患者进行风险分层，研究人员设计了CHA 2DS 2-VASc评分。该评分是在CHADS 2评分的基础上，为女性和血管疾病（包括冠心病和外周血管疾病）各增加一分，并将年龄分为3个类别（< 60岁、60-74岁和≥ 75岁），而不是原始CHADS 2评分中的2个类别。[21]在CHADS 2评分为0或1的患者组中，CHA 2DS 2-VASc评分在区分卒中风险方面似乎优于CHADS 2评分。21，22 CHA 2DS 2-VASc评分特别有用，因为被归类为低风险的患者确实似乎卒中风险较低，并且可以安全地在没有抗凝治疗的情况下进行管理。[18]除了CHADS 2和CHA 2DS 2-VASc评分外，还提出了其他几种临床评分。23-26所有这些临床风险预测评分的共同缺点是，它们包括适用于AF和非AF患者的卒中的一般风险因素。很直观，卒中风险随着血管疾病的一般负担而增加。事实上，研究表明，即使在没有AF的患者中，CHADS 2和CHA 2DS 2-VASc评分也可预测卒中风险。27相反，反映左心房或左心耳（LAA）功能障碍的特定生物标志物可能更能预测最有可能通过抗凝治疗预防的卒中类型。
2666 Stroke October 2017 validation studies showed fair-to-good predictive ability of the CHADS2 score, with C statistics ranging between 0.56 and 0.82. 18 Despite these validation studies, major limitations of the CHADS2 score have become apparent because its use has become more widespread. First, the CHADS2 score has also been shown to predict hemorrhagic complications in patients with AF. 19 This means that patients with a high predicted risk of thromboembolic events are also the same patients with a high predicted risk of hemorrhagic complications, which complicates decisions about anticoagulant therapy. More importantly, the score suffers from significant heterogeneity in actual stroke risk in patients labeled as low risk based on their CHADS2 score. In the overall group of patients assigned a CHADS2 score of 0, the annual stroke risk can ranges between 0 and 3%. 20 This is problematic if the score is used to withhold anticoagulant therapy in those with low scores—a purpose for which it is often used. To better risk stratify patients considered to be low risk based on the CHADS2 score, investigators designed the CHA2DS2-VASc score. This score builds on the CHADS2 score by adding an extra point each for female sex and vascular disease (which includes both coronary heart disease and peripheral vascular disease), and dividing age into 3 categories (< 60 years, 60–74 years, and≥ 75 years) instead of the 2 categories in the original CHADS2 score. 21 It seems that the CHA2DS2-VASc score outperforms the CHADS2 score in discriminating stroke risk in the group of patients with a CHADS2 score of 0 or 1. 21, 22 The CHA2DS2-VASc score is especially helpful in that patients classified as low risk truly do seem to be at low risk of stroke and may safely be managed without anticoagulant therapy. 18 In addition to the CHADS2 and CHA2DS2-VASc scores, several other clinical scores have been proposed. 23–26 A shortcoming shared by all of these clinical risk prediction scores is that they include general risk factors for stroke that apply to patients with and without AF. It is intuitive that stroke risk increases with the general burden of vascular disease. In fact, studies have shown that the CHADS2 and CHA2DS2-VASc scores predict stroke risk even in patients without AF. 27 On the contrary, specific biomarkers reflecting dysfunction of the left atrium or left atrial appendage (LAA) may be more predictive of the type of stroke that is most likely amenable to prevention with anticoagulant therapy.