Selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin.
BACKGROUND
The rate of stroke in atrial fibrillation (AF) depends on the presence of comorbid conditions and the use of antithrombotic therapy. Although adjusted-dose warfarin is superior to aspirin for reducing stroke in AF, the absolute risk reduction of warfarin depends on the stroke rate with aspirin. This prospective cohort study tested the predictive accuracy of 5 stroke risk stratification schemes.


RESULTS
The study pooled individual data from 2580 participants with nonvalvular AF who were prescribed aspirin in a multicenter trial (Atrial Fibrillation, Aspirin, Anticoagulation I study [AFASAK-1], AFASAK-2, European Atrial Fibrillation Trial, Primary Prevention of Arterial Thromboembolism in patients with nonrheumatic Atrial Fibrillation in primary care study, and Stroke Prevention and Atrial Fibrillation [SPAF]-III high risk or SPAF-III low risk). There were 207 ischemic strokes during 4887 patient-years of aspirin therapy. All schemes predicted stroke better than chance, but the number of patients categorized as low and high risk varied substantially. AF patients with prior cerebral ischemia were classified as high risk by all 5 schemes and had 10.8 strokes per 100 patient-years. The CHADS(2) scheme (an acronym for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack) successfully identified primary prevention patients who were at high risk of stroke (5.3 strokes per 100 patient-years). In contrast, patients identified as high risk by other schemes had 3.0 to 4.2 strokes per 100 patient-years. Low-risk patients identified by all schemes had 0.5 to 1.4 strokes per 100 patient-years of therapy.


CONCLUSIONS
Patients with AF who have high and low rates of stroke when given aspirin can be reliably identified, allowing selection of antithrombotic prophylaxis to be individualized.
Gage
Brian F
BF
Division of General Medical Sciences, Washington University School of Medicine Campus Box 8005, 660 S Euclid Ave, St. Louis, MO 63110, USA. bgage@im.wustl.edu
van Walraven
Carl
C
Pearce
Lesly
L
Hart
Robert G
RG
Koudstaal
Peter J
PJ
Boode
B S P
BS
Petersen
Palle
P
D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001241:Aspirin / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy*; D002545:Brain Ischemia / Q000453:epidemiology; D015331:Cohort Studies; D015897:Comorbidity; D003327:Coronary Disease / Q000453:epidemiology; D003920:Diabetes Mellitus / Q000453:epidemiology; D004359:Drug Therapy, Combination; D005060:Europe / Q000453:epidemiology; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D006333:Heart Failure / Q000453:epidemiology; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D020766:Intracranial Embolism / Q000139:chemically induced / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D020521:Stroke / Q000139:chemically induced / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology
D000925:Anticoagulants; D005343:Fibrinolytic Agents; D001241:Aspirin