title: Using the CHA2DS2-VASc score for refining stroke risk stratification in 'low-risk' Asian patients with atrial fibrillation.
abstract: BACKGROUND
  A new scoring system, the anticoagulation and risk factors in atrial fibrillation (ATRIA) score, was proposed for risk stratification in patients with atrial fibrillation (AF). Whether the ATRIA scheme can adequately identify patients who are at low risk of ischemic stroke remains unknown.
  
  
  OBJECTIVE
  The goal of the present study was to compare the performance of ATRIA to that of CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65 to 74, female) scores for stroke prediction.
  
  
  METHODS
  This study used the National Health Insurance research database in Taiwan. A total of 186,570 AF patients without antithrombotic therapy were selected as the study cohort. The clinical endpoint was the occurrence of ischemic stroke.
  
  
  RESULTS
  During the follow-up of 3.4 ± 3.7 years, 23,723 patients (12.7%) experienced ischemic stroke. The CHA2DS2-VASc score performed better than ATRIA score in predicting ischemic stroke as assessed by c-indexes (0.698 vs. 0.627, respectively; p < 0.0001). The CHA2DS2-VASc score also improved the net reclassification index by 11.7% compared with ATRIA score (p < 0.0001). Among 73,242 patients categorized as low-risk on the basis of an ATRIA score of 0 to 5, the CHA2DS2-VASc scores ranged from 0 to 7, and annual stroke rates ranged from 1.06% to 13.33% at 1-year follow-up and from 1.15% to 8.00% at 15-year follow-up. The c-index of CHA2DS2-VASc score (0.629) was significantly higher than that of the ATRIA score (0.593) in this "low-risk" category (p < 0.0001).
  
  
  CONCLUSIONS
  Patients categorized as low-risk by use of the ATRIA score were not necessarily low-risk, and the annual stroke rates can be as high as 2.95% at 1-year follow-up and 2.84% at 15-year follow-up. In contrast, patients with a CHA2DS2-VASc score of 0 had a truly low risk of ischemic stroke, with an annual stroke rate of approximately 1%.
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Tze-Fan
authors.initials: TF
authors.lastname: Chao
authors.affiliation: Division of Hematology and Oncology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Chia-Jen
authors.initials: CJ
authors.lastname: Liu
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Kang-Ling
authors.initials: KL
authors.lastname: Wang
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Yenn-Jiang
authors.initials: YJ
authors.lastname: Lin
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Shih-Lin
authors.initials: SL
authors.lastname: Chang
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Li-Wei
authors.initials: LW
authors.lastname: Lo
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Yu-Feng
authors.initials: YF
authors.lastname: Hu
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
authors.forename: Ta-Chuan
authors.initials: TC
authors.lastname: Tuan
authors.affiliation: Department of Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Tzeng-Ji
authors.initials: TJ
authors.lastname: Chen
authors.affiliation: University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
authors.forename: Gregory Y H
authors.initials: GY
authors.lastname: Lip
authors.affiliation: Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan. Electronic address: epsachen@ms41.hinet.net.
authors.forename: Shih-Ann
authors.initials: SA
authors.lastname: Chen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D044466:Asian People / Q000208:ethnology*; D001281:Atrial Fibrillation / Q000175:diagnosis* / Q000208:ethnology*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance / Q000379:methods*; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000175:diagnosis* / Q000208:ethnology*; D013624:Taiwan / Q000208:ethnology
keywords: ATRIA score; CHA(2)DS(2)-VASc score; atrial fibrillation; ischemic stroke