Arrhythmias and Conduction Disturbances
Association of CHADS2, CHA2DS2-VASc, and R2CHADS2 Scores With Left Atrial Dysfunction in Patients With Coronary Heart Disease (from the Heart and Soul Study)

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The predictive ability of the CHADS2 index to stratify stroke risk may be mechanistically linked to severity of left atrial (LA) dysfunction. This study investigated the association between the CHADS2 score and LA function. We performed resting transthoracic echocardiography in 970 patients with stable coronary heart disease and normal ejection fraction and calculated baseline LA functional index (LAFI) using a validated formula: (LA emptying fraction × left ventricular outflow tract velocity time integral)/LA end-systolic volume indexed to body surface area. We performed regression analyses to evaluate the association between risk scores and LAFI. Among 970 subjects, mean CHADS2 was 1.7 ± 1.2. Mean LAFI decreased across tertiles of CHADS2 (42.8 ± 18.1, 37.8 ± 19.1, 36.7 ± 19.4, p <0.001). After adjustment for age, sex, race, systolic blood pressure, hyperlipidemia, myocardial infarction, revascularization, body mass index, smoking, and alcohol use, high CHADS2 remained associated with the lowest quartile of LAFI (odds ratio 2.34, p = 0.001). In multivariable analysis of component co-morbidities, heart failure, age, and creatinine clearance <60 ml/min were strongly associated with LA dysfunction. For every point increase in CHADS2, the LAFI decreased by 4.0%. Secondary analyses using CHA2DS2-VASc and R2CHADS2 scores replicated these results. Findings were consistent when excluding patients with baseline atrial fibrillation. In conclusion, CHADS2, CHA2DS2-VASc, and R2CHADS2 scores are associated with LA dysfunction, even in patients without baseline atrial fibrillation. These findings merit further study to determine the role of LA dysfunction in cardioembolic stroke and the value of LAFI for risk stratification.

Section snippets

Methods

The Heart and Soul Study is a prospective cohort study of psychosocial factors and health outcomes in patients with coronary heart disease (CHD). Details regarding recruitment methods and study design have been previously published.12 From September 2000 to December 2002, 1,024 outpatient subjects were recruited from 2 Department of Veterans Affairs medical centers (San Francisco Veterans Affairs Medical Center and the Veterans Affairs Palo Alto Health Care System), a university medical center

Results

The cohort consisted of 970 subjects (180 women). Baseline characteristics across tertiles of CHADS2 are listed in Table 1. The mean (±SD) CHADS2 score was 1.7 ± 1.2; 464 (48%) had scores of 0 to 1, 407 (42%) had scores of 2 to 3, and 99 (10%) had scores of 4 to 6. There was no significant difference in sex, race, or AF prevalence across tertiles of CHADS2. Compared with those with low (0 to 1) CHADS2 scores, subjects with intermediate (2 to 3) and high (≥4) scores were more likely to have

Discussion

In a cohort of 970 predominantly male outpatients with stable CHD, we found that higher CHADS2 scores were associated with LA dysfunction as measured by the LAFI. Higher CHADS2 predicts lower LAFI independent of age, sex, smoking, or alcohol use. This association was replicated when employing CHA2DS2-VASc and R2CHADS2 indices.

There are several potential explanations for these observations. The overall correlation between stroke risk and LA dysfunction likely reflects the known association

Disclosures

The authors have no conflicts of interest to disclose.

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    Dr. Turakhia is supported by a Grant CDA09027-1 from the Veterans Health Services Research & Development Career Development Award, a Grant 09SDG2250647 from the American Heart Association National Scientist Development Grant, and a Grant IIR 09-092 from the VA Health Services and Development MERIT Award. The content and opinions expressed are solely the responsibility of the authors and do not necessarily represent the views or policies of the Department of Veterans Affairs.

    See page 1171 for disclosure information.

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