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Arrhythmias and sudden death
Original research article
Improving CHA2DS2-VASc stratification of non-fatal stroke and mortality risk using the Intermountain Mortality Risk Score among patients with atrial fibrillation
  1. Kevin G Graves1,
  2. Heidi T May1,
  3. Kirk U Knowlton1,
  4. Joseph B Muhlestein1,2,
  5. Victoria Jacobs1,
  6. Donald L Lappé1,2,
  7. Jeffrey L Anderson1,2,
  8. Benjamin D Horne1,3 and
  9. Thomas Jared Bunch1,4
  1. 1 Intermountain Heart Institute, Intermountain Medical Center, Murray, Utah, USA
  2. 2 Cardiology Division, Department of Internal Medicine, University of Utah, Murray, Utah, USA
  3. 3 Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
  4. 4 Department of Internal Medicine, Stanford University, Palo Alto, California, USA
  1. Correspondence to Dr Thomas Jared Bunch; thomas.bunch{at}imail.org

Abstract

Background Oral anticoagulation (OAC) therapy guidelines recommend using CHA2DS2-VASc to determine OAC need in atrial fibrillation (AF). A usable tool, CHA2DS2-VASc is challenged by its predictive ability. Applying components of the complete blood count and basic metabolic profile, the Intermountain Mortality Risk Score (IMRS) has been extensively validated. This study evaluated whether use of IMRS with CHA2DS2-VASc in patients with AF improves prediction.

Methods Patients with AF undergoing cardiac catheterisation (N=10 077) were followed for non-fatal stroke and mortality (mean 5.8±4.1 years, maximum 19 years). CHA2DS2-VASc and IMRS were calculated at baseline. IMRS categories were defined based on previously defined criteria. Cox regression was adjusted for demographic, clinical and treatment variables not included in IMRS or CHA2DS2-VASc.

Results In women (n=4122, mean age 71±12 years), the composite of non-fatal stroke/mortality was stratified (all p-trend <0.001) by CHA2DS2-VASc (1: 12.6%, 2: 22.8%, >2: 48.1%) and IMRS (low: 17.8%, moderate: 40.9%, high risk: 64.5%), as it was for men (n=5955, mean age 68±12 years) by CHA2DS2-VASc (<2: 15.7%, 2: 30.3%, >2: 51.8%) and IMRS (low: 19.0%, moderate: 42.0%, high risk: 65.9%). IMRS stratified stroke/mortality (all p-trend <0.001) in each CHA2DS2-VASc category.

Conclusions Using IMRS jointly with CHA2DS2-VASc in patients with AF improved the prediction of stroke and mortality. For example, in patients at the OAC treatment threshold (CHA2DS2 -VASc = 2), IMRS provided ≈4-fold separation between low and high risk. IMRS provides an enhancing marker for risk in patients with AF that reflects the underlying systemic nature of this disease that may be considered in combination with the CHA2DS2-VASc score.

  • atrial fibrillation
  • stroke
  • risk factors
  • mortality
  • gender

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0

https://doi.org/10.1136/openhrt-2018-000907

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    Footnotes

    • BDH and TJB contributed equally.

    • Contributors BDH and TJB designed the study. KGG, HTM, VJ, BDH and TJB planned the execution of the study. BDH and HTM collected and prepared the data. BDH conducted statistical analyses. KGG, HTM, KUK, JBM, VJ, DLL, JLA, BDH and TJB evaluated and interpreted the results. KGG, VJ, BDH and TJB drafted the manuscript. HTM, KUK, JBM, DLL and JLA revised the paper for important intellectual content.

    • Funding This work was supported by internal institutional funds and the authors had final authority over manuscript content.

    • Competing interests BDH is an inventor of IMRS and other risk scores that are licensed to CareCentra. BDH is PI of grants funded by Intermountain Healthcare's Foundry innovation program, the Intermountain Research and Medical Foundation, CareCentra, AstraZeneca and GlaxoSmithKline for the development and/or implementation of clinical risk scores. The authors have no other potential conflicts of interest to report.

    • Patient consent Not required.

    • Ethics approval This study was approved by the Intermountain Healthcare Institutional Review Board as a minimum-risk study.

    • Provenance and peer review Not commissioned; internally peer reviewed.

    • Data sharing statement No additional data are available.