Validation of a Modified CHA2DS2-VASc Score for Stroke Risk Stratification in Asian Patients With Atrial Fibrillation: A Nationwide Cohort Study.
The age threshold for an increased stroke risk for patients with atrial fibrillation may be different for Asians and non-Asians. We hypothesized that a modified CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female) scheme, mCHA2DS2-VASc, which assigned one point for patients aged 50 to 74 years, may perform better than CHA2DS2-VASc score for stroke risk stratification in Asians.



This study used the Taiwan National Health Insurance Research Database, which included 224 866 newly diagnosed atrial fibrillation patients. The predictive accuracies of ischemic stroke of CHA2DS2-VASc and mCHA2DS2-VASc scores were compared among 124 271 patients without antithrombotic therapies. From the whole cohort, 15 948 patients had a CHA2DS2-VASc score 0 (males) or 1 (females), and 8654 patients had an mCHA2DS2-VASc score 1 (males) or 2 (females). The latter were categorized into 3 groups, that is, no treatment, antiplatelet therapy, and warfarin, and the risks of ischemic stroke and intracranial hemorrhage (ICH) were compared.



During a follow-up of 538 653 person-years, 21 008 patients experienced ischemic stroke. The mCHA2DS2-VASc performed better than CHA2DS2-VASc score in predicting ischemic stroke assessed by C indexes and net reclassification index. For 8654 patients having an mCHA2DS2-VASc score of 1 (males) or 2 (females) because of the resetting of the age threshold, use of warfarin was associated with a 30% lower risk of ischemic stroke and a similar risk of ICH compared with nontreatment. Net clinical benefit analyses also favored the use of warfarin in different weighted models.



In this Asian atrial fibrillation cohort, the mCHA2DS2-VASc score performed better than the CHA2DS2-VASc and would further identify atrial fibrillation patients who may derive a positive net clinical benefit from oral anticoagulation.
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Tze-Fan
TF
Chao
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Gregory Y H
GY
Lip
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Chia-Jen
CJ
Liu
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Ta-Chuan
TC
Tuan
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Su-Jung
SJ
Chen
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Kang-Ling
KL
Wang
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Yenn-Jiang
YJ
Lin
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Shih-Lin
SL
Chang
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Li-Wei
LW
Lo
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Yu-Feng
YF
Hu
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.).
Tzeng-Ji
TJ
Chen
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.). cechiang@vghtpe.gov.tw epsachen@ms41.hinet.net.
Chern-En
CE
Chiang
From the Division of Cardiology, Department of Medicine (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.), Division of Hematology and Oncology, Department of Medicine (C.-J.L.), Division of Infectious Diseases, Department of Medicine (S.-J.C.), Department of Family Medicine (T.-J.C.), General Clinical Research Center (C.-E.C.), and Department of Medical Research and Education (C.-E.C.), Taipei Veterans General Hospital, Taiwan; Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., T.-C.T., K.-L.W., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., C.-E.C., S.-A.C.); University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom (G.Y.H.L.); and Institute of Public Health and School of Medicine, National Yang-Ming University, Taipei, Taiwan (C.-J.L., S.-J.C.). cechiang@vghtpe.gov.tw epsachen@ms41.hinet.net.
Shih-Ann
SA
Chen
D000367:Age Factors; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications*; D002545:Brain Ischemia / Q000188:drug therapy / Q000209:etiology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology*; D013624:Taiwan; D014859:Warfarin / Q000627:therapeutic use
D000925:Anticoagulants; D014859:Warfarin
CHA2DS2-VASc score; age; atrial fibrillation; ischemic stroke; modified CHA2DS2-VASc score