Publish in this journal
Journal Information
Vol. 68. Issue 6.
Pages 485-491 (June 2015)
Share
Share
Download PDF
More article options
Visits
6689
Vol. 68. Issue 6.
Pages 485-491 (June 2015)
Original article
DOI: 10.1016/j.rec.2014.06.027
Full text access
The CHADS2 Score to Predict Stroke Risk in the Absence of Atrial Fibrillation in Hypertensive Patients Aged 65 Years or Older
La puntuación CHADS2 como predictor de riesgo de ictus en ausencia de fibrilación auricular en pacientes hipertensos de 65 o más años
Visits
6689
Pedro Morillasa,
Corresponding author
pedromorillas68@gmail.com

Corresponding author: Servicio de Cardiología, Hospital General Universitario de Elche, Almazara 11, 03203 Elche, Alicante, Spain.
, Vicente Pallarésb, Lorenzo Fácilac, Jose Luis Llisterrid, María Eugenia Sebastiáne, Manuel Gómeza, Elena Castillaa, Raquel Camarasaa, Miriam Sandina, Antonio García-Honrubiaa, on behalf of the FAPRES registry investigators
a Servicio de Cardiología, Hospital General Universitario de Elche, Elche, Alicante, Spain
b Unidad de Vigilancia de la Salud, Unión de Mutuas, Departamento de Medicina, Universitat Jaume I, Castellón, Spain
c Servicio de Cardiología, Hospital General de Valencia, Valencia, Spain
d Centro de Salud Joaquín Benlloch, Valencia, Spain
e Servicio de Anestesia y Reanimación, Hospital General Universitario de Elche, Elche, Alicante, Spain
This item has received
6689
Visits
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Tables (3)
Table 1. Baseline Characteristics of the Population, Stratified According to CHADS2 Score
Table 2. Comparison Between Patients With and Without a Stroke/Transient Ischemic Attack Over Follow-up
Table 3. Multivariate Analysis. Factors Associated With the Appearance of a Stroke/Transient Ischemic Attack Over Follow-up
Show moreShow less
Abstract
Introduction and objectives

The CHADS2 score is a proven, essential tool for estimating cardioembolic risk (mainly stroke) in patients with nonvalvular atrial fibrillation, with the purpose of determining the indication for anticoagulant therapy. In this study we analyzed the use of CHADS2 in hypertensive patients without known atrial fibrillation in a Mediterranean population.

Methods

The study included 887 hypertensive patients aged 65 years or older without atrial fibrillation or anticoagulant therapy, who attended a medical consultation. Data on the patients’ main risk factors, cardiovascular history, and medication were collected, basic laboratory analyses and electrocardiography were performed, and the CHADS2 score (heart failure, hypertension, age ≥ 75 years, diabetes mellitus, and previous stroke or transient ischemic attack) was calculated. A clinical follow-up was carried out, recording hospital admissions for a stroke or transient ischemic attack. The median duration of follow-up was 804 days.

Results

Mean age was 72.5 (SD,5.7) years, 46.6% were men, 27.8% had diabetes, and 8.6% were smokers. During follow-up, 40 patients were hospitalized for a stroke or transient ischemic attack (4.5%). The event-free survival analysis showed significant differences according to the CHADS2 score (log rank test, P < .001). On multivariate analysis, smoking and CHADS2 ≥3 were independent predictors of stroke or transient ischemic attack.

Conclusions

The CHADS2 may be useful for estimating the risk of stroke or transient ischemic attack in hypertensive patients without known atrial fibrillation.

Keywords:
Systemic arterial hypertension
Stroke
Coagulation
Abbreviations:
TIA
Resumen
Introducción y objetivos

La puntuación CHADS2 es una demostrada herramienta fundamental para identificar el riesgo cardioembólico, fundamentalmente el ictus, de pacientes con fibrilación auricular no valvular, con el propósito de indicar la terapia anticoagulante. El objetivo del presente estudio es analizar la utilidad de dicha puntuación para pacientes hipertensos sin fibrilación auricular conocida en una zona mediterránea.

Métodos

Se incluyó a 887 pacientes hipertensos de edad ≥ 65 años, no anticoagulados y sin fibrilación auricular, que acudieron a la consulta médica. Se recogieron los principales factores de riesgo, la historia cardiovascular, el tratamiento farmacológico, una analítica básica y un electrocardiograma y se calculó la puntuación CHADS2 (insuficiencia cardiaca, hipertensión, edad ≥ 75 años, diabetes mellitus e ictus previo o accidente isquémico transitorio). Se realizó un seguimiento clínico con recogida de los ingresos hospitalarios por ictus o accidente isquémico transitorio. La mediana del seguimiento fue 804 días.

Resultados

La media de edad era 72,5±5,7 años, con el 46,6% de varones, el 27,8% de diabéticos y el 8,6% de fumadores. Durante el seguimiento, 40 pacientes fueron ingresados por ictus o accidente isquémico transitorio (4,5%). El análisis de supervivencia libre de eventos mostró diferencias significativas en función de la puntuación CHADS2 (log rank test, p<0,001). En el análisis multivariable, el tabaquismo y un CHADS2 ≥ 3 fueron predictores independientes de ictus o accidente isquémico transitorio.

Conclusiones

La puntuación CHADS2 puede ser una herramienta útil para identificar el riesgo de ictus o accidente isquémico transitorio de los pacientes hipertensos sin fibrilación auricular conocida.

Palabras clave:
Hipertensión arterial sistémica
Accidente cerebrovascular
Coagulación
Full Text
INTRODUCTION

The CHADS2 score is a clinical predictor of the risk of stroke in patients with nonvalvular atrial fibrillation, used to determine whether anticoagulant or antiplatelet therapy is indicated.1 It is a simple rule that is easy to remember and apply in clinical practice, and it has been validated in several studies.2,3 This has facilitated widespread adoption of CHADS2 and support for its use among major scientific societies in Spain and elsewhere.4–6 The current European guidelines have incorporated additional stroke risk factors in the score to improve identification of patients “at low risk” (CHA2DS2-VASc).7

Despite the proven utility of the CHADS2 score and other risk stratification approaches in patients with nonvalvular atrial fibrillation, most ischemic strokes (85%) occur in individuals without known atrial fibrillation.8 Moreover, epidemiologic studies have shown that hypertension is the most important determinant of stroke risk, and that each component of the CHADS2 score is independently associated with cerebrovascular events in the general population.9 Nonetheless, to our knowledge, there are no studies investigating the utility of this score for estimating the risk of a cerebrovascular event in hypertensive patients without known atrial fibrillation. The aim of this study was to analyze the role of the CHADS2 score to estimate stroke risk in a sample of hypertensive patients aged 65 years or older and in sinus rhythm who attended several centers in a Mediterranean area.

METHODS

The FAPRES registry is an observational, multicenter, epidemiologic study performed in the clinical care setting and designed to acquire information on the prevalence of atrial fibrillation in patients aged 65 years and older with a clinical diagnosis of hypertension, living in the Valencian Community of Spain. Sixty-nine investigators from primary care centers and hospital hypertension units in Alicante, Castellón, and Valencia participated in the study, in percentages consonant with the population density of each of the 3 provinces. A detailed description of the study and definition of the variables has been reported previously.10 A total of 1028 patients were included in the baseline study. The investigators were invited to carry out a 2-year clinical follow-up of these patients, compiling information on the main cardiovascular events. All patients gave informed, written consent for participation, and the study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the Ethics Committee for Clinical Research of Hospital General Universitario de Castellón.

Study Population

The study included all patients recorded in the FAPRES registry who showed sinus rhythm on the baseline echocardiography, were not receiving anticoagulant therapy, and whose medical records showed no history of atrial fibrillation. The patients’ cardiovascular history and risk factors were recorded on a standardized questionnaire. Patients who used some type of tobacco (cigarettes, pipe tobacco, cigars, or smokeless tobacco) in at least the previous month were considered smokers,11 whereas those who had stopped smoking at least 1 year previously were considered former smokers. Patients who actively walked at least 30minutes per day or engaged in some type of sport at least 3 days per week were considered to practice physical exercise.12 We recorded the drug therapy being taken by patients at the time of the medical visit, specifically antihypertensive agents and preventive treatment for cardioembolic stroke (anticoagulant and antiplatelet drugs).

Anthropometric data (weight, height, and waist perimeter) and blood pressure values were recorded at the physical examination. Blood pressure measurement adhered to recommendations from clinical practice guidelines13: blood pressure was measured using calibrated, automated devices with the patient seated and following a 5-minute rest on 2 separate occasions, 2minutes apart. The mean of the 2 values obtained was then calculated. Analytical information was requested from the attending laboratory or obtained from the patients’ medical records when data from the previous 6 months were available. The glomerular filtration rate was calculated using the MDRD (Modification of Diet in Renal Disease Study) formula. The clinical history questionnaire was sent to a CRO (contract research organization) for automatic data processing. The results of electrocardiography study, performed in all patients, were sent by ordinary mail to a reference center, where they were independently analyzed by 2 experienced cardiologists blinded to the patients’ clinical data. The readers evaluated the presence of atrial fibrillation and left ventricular hypertrophy using the Sokolov criteria, Cornell criteria, or ventricular overload. A randomized external audit of 10% of the questionnaires was done to verify the reliability of the data included.

The CHADS2 score was determined in all patients to assess stroke risk (congestive heart failure, hypertension, age ≥ 75 years, and diabetes mellitus, 1 point each, and prior stroke or transient ischemic attack [TIA], 2 points),2 and the patients were divided into 4 groups according to the score: 1, 2, 3, or ≥ 4 points. The patients underwent clinical follow-up with recording of hospitalization for stroke or TIA.

Statistical Analysis

The data compiled in the study are expressed in terms of the central tendency, measures of dispersion, and relative frequencies. Quantitative variables were compared between groups with the Student t test or ANOVA, and categorical variables with the chi-square test. Event-free survival (stroke/TIA) according to the CHADS2 score was calculated with the Kaplan-Meier method. Multivariate logistic regression analysis was used to determine variables independently related to the incidence of cerebrovascular events during follow-up. Logistic regression included all the variables that were significant on univariate analysis, variables with recognized clinical significance, and the CHADS2 score. A receiver operating characteristic (ROC) curve was constructed and the area under the curve was calculated to analyze the validity of the CHADS2 score for estimating the risk of stroke/TIA. Furthermore, a combined variable including CHADS2 and significant variables on multivariate analysis was created, and again, the ROC curve was calculated to predict the risk of stroke/TIA. A P value of less than .05 was considered significant. SPSS version 21 was used for the statistical analyses.

RESULTS

Of the 1028 hypertensive patients included in the baseline FAPRES study, we selected 922 patients without known atrial fibrillation who were not receiving anticoagulant therapy; 887 of them completed follow-up (96.2%) in a median of 804 (723-895) days. The mean age of the population was 72.5 (SD,5.7) years, and 46.6% were men. Relevant background included hypercholesterolemia in 47.8%, diabetes mellitus in 27.8%, and smoking in 8.6%. In addition, 62 patients (7%) had a previous stroke, 31 (3.5%) a diagnosis of heart failure, and 115 (13%) ischemic heart disease.

On calculation of the CHADS2 score, 430 patients (48.5%) were found to have a score of 1, 307 (34.6%) 2, 111 (12.5%) 3, and 39 (4.4%) ≥ 4. The main characteristics of the study population according to CHADS2 score are shown in Table 1. Patients with higher scores were older, had a greater prevalence of risk factors and established cardiovascular disease (in particular, ischemic heart disease and left ventricular hypertrophy), and had been hypertensive for longer than those with lower scores. Plasma high-density lipoprotein cholesterol concentrations and glomerular filtration rates were lowest in the group with the highest CHADS2 score. As to treatment, patients with CHADS2 ≥ 4 were taking angiotensin II receptor blockers, calcium channel blockers, statins, and antiplatelet therapy more frequently than the other patients. There were no differences in the use of angiotensin converting enzyme inhibitors, beta-blockers, or diuretics among the 4 groups.

Table 1.

Baseline Characteristics of the Population, Stratified According to CHADS2 Score

Variable  CHADS2 = 1 (n = 430)  CHADS2 = 2 (n = 307)  CHADS2 = 3 (n = 111)  CHADS2 ≥ 4 (n = 39)  P 
Age, mean (SD), y  69.4 (3.3)  74.8 (6.2)  77.1 (5.3)  75.8 (4.1)  <.001 
Men  188 (43.7)  146 (47.6)  54 (48.6)  25 (64.1)  .088 
Smokers  40 (9.3)  25 (8.1)  9 (8.1)  2 (5.1)  .805 
Diabetes mellitus  146 (47.6)  75 (67.6)  26 (66.7)  <.001 
Hypercholesterolemia  187 (43.5)  150 (48.9)  58 (52.3)  29 (74.4)  .002 
Ischemic heart disease  40 (9.3)  47 (15.3)  19 (17.1)  9 (23.1)  .008 
Heart failure  10 (3.3)  13 (11.7)  8 (20.5)  <.001 
Previous stroke  27 (24.3)  35 (89.7)  <.001 
Physical exercise  186 (43.3)  104 (33.9)  32 (28.8)  16 (41)  .010 
Time since HT onset, mean (SD), y  9.2 (7.2)  11.7 (8.6)  12.8 (7.4)  14.2 (10.4)  <.001 
SAP at visit, mean (SD), mmHg  146.5 (18.3)  147.4 (19.5)  148.9 (18.5)  147.9 (20.6)  .846 
DAP at visit, mean (SD), mmHg  83.1 (10.1)  80.5 (11.3)  77.6 (11)  78.5 (13.9)  <.001 
Waist perimeter, mean (SD), cm  97.3 (11)  99.2 (11.4)  98.2 (11.8)  101.8 (11.7)  .031 
BMI, mean (SD)  29.1 (3.9)  29.5 (4.4)  28.3 (4.4)  29.3 (4)  .073 
Hemoglobin, mean (SD), g/dL  13.7 (1.6)  13.4 (1.8)  13.3 (2.1)  13.2 (2.2)  .041 
Glucose, mean (SD), mg/dL  96.6 (18.3)  116.7 (38.3)  126.6 (38.3)  119.1 (31.5)  <.001 
LDL-C, mean (SD), mg/dL  124.3 (33.2)  117.8 (32.1)  112.8 (37.3)  105.1 (39.1)  <.001 
HDL-C, mean (SD), mg/dL  54.3 (12.1)  51.3 (12.6)  52.4 (14.5)  47.2 (9.8)  .001 
Triglycerides, mean (SD), mg/dL  130.3 (69.7)  126.6 (66.6)  120.6 (50.2)  169.6 (175.6)  .005 
Glomerular filtration, mean (SD), mL/min  78.9 (21.6)  72.8 (22.5)  74.4 (27.3)  68.9 (17.5)  .001 
LVH on ECG*  53 (12.3)  56 (18.2)  23 (20.7)  8 (20.5)  .047 
Statins  96 (22.3)  73 (23.8)  34 (30.6)  22 (56.4)  <.001 
Antiplatelet agents  41 (9.5)  69 (22.5)  40 (36)  27 (69.2)  <.001 

BMI, body mass index; DAP, diastolic arterial pressure; ECG, electrocardiogram; HDL-C, high-density lipoprotein cholesterol; HT, hypertension; LDL-C, low-density lipoprotein cholesterol; LVH, left ventricular hypertrophy; SAP, systolic arterial pressure; SD, standard deviation.

Unless otherwise indicated, the data are expressed as No. (%).

*

Sokolov or Cornell criteria, or ventricular overload.

During follow-up, 40 (4.5%) patients required hospitalization for stroke/TIA, and the incidence was higher in patients with higher CHADS2 scores: 2.8% of CHADS2 1, 4.2% of CHADS2 2, 7.2% of CHADS2 3 and 17.9% of CHADS2 ≥ 4. The Kaplan-Meier curve in Figure 1 indicates poorer outcome in patients with higher CHADS2 scores. Patients with a cerebrovascular event showed a greater prevalence of smoking and previous stroke, and higher CHADS2 scores (2.3 [SD,1.1] vs 1.7 [SD,0.9]; P < .001) than those without this complication, in addition to practicing less physical exercise (Table 2). There were no differences in age or the prevalence of diabetes mellitus or hypercholesterolemia between the populations with and without an event over follow-up. Furthermore, patients who had a stroke/TIA were taking antiplatelet medication more often (35% vs 19.2%; P < .05), whereas there were no differences in the use of antihypertensive treatment or statins between the 2 populations.

Figure 1.

Kaplan-Meier event-free (hospitalization for stroke/transient ischemic attack) survival curve, according to the CHADS2 score.

(0.1MB).
Table 2.

Comparison Between Patients With and Without a Stroke/Transient Ischemic Attack Over Follow-up

Variable  No stroke/TIA (n = 847)  Stroke/TIA (n = 40)  P 
Age, mean (SD), y  72.5 (5.7)  73.2 (5.3)  .271 
Men  392 (46.3)  21 (52.5)  .331 
Smokers  68 (8)  8 (20)  .016 
Diabetes mellitus  235 (27.7)  12 (30)  .439 
Hypercholesterolemia  405 (47.8)  19 (47.5)  .550 
Ischemic heart disease  108 (12.8)  7 (17.5)  .253 
Heart failure  28 (3.3)  3 (7.5)  .160 
Previous stroke  51 (6)  11(27.5)  <.001 
Physical exercise  330 (39)  8 (20)  .01 
Time since HT onset, mean (SD), y  10.7 (8)  11.1 (9.4)  .736 
SAP at visit, mean (SD) mmHg  147.1 (18.9)  146.8 (17.4)  .928 
DAP at visit, mean (SD), mmHg  81.3 (11.1)  81.6 (8)  .896 
Waist perimeter, mean (SD), cm  98.3 (11.3)  98 (12.2)  .843 
BMI, mean (SD)  29.2 (4.2)  28.6 (3.5)  .414 
Hemoglobin, mean (SD), g/dL  13.6 (1.7)  13.2 (2.2)  .279 
Glucose, mean (SD), mg/dL  108.4 (32.4)  106.3 (28.9)  .688 
LDL-C, mean (SD) mg/dL  119.5 (34.1)  124 (32.6)  .421 
HDL-C, mean (SD), mg/dL  52.7 (12.7)  52.5 (12.1)  .929 
Triglycerides, mean (SD), mg/dL  130.3 (75.9)  113.7 (51.4)  .177 
Glomerular filtration, mean (SD), mL/min  75.7 (22.3)  77.1 (30.3)  .703 
LVH on ECG*  136 (16.1)  4 (10)  .215 
CHADS2 score, mean (SD)  1.7 (0.9)  2.3 (1.1)  <.001 
Statins  213 (25.1)  12 (30)  .300 
Antiplatelet agents  163 (19.2)  14 (35)  .017 

BMI, body mass index; DAP, diastolic arterial pressure; ECG, electrocardiogram; HDL-C, high-density lipoprotein cholesterol; HT, hypertension; LDL-C, low-density lipoprotein cholesterol; LVH, left ventricular hypertrophy; SAP, systolic arterial pressure; SD, standard deviation; TIA, transient ischemic attack.

Unless otherwise indicated, the data are expressed as No. (%).

*

Sokolov or Cornell criteria, or ventricular overload.

On multivariate analysis, the factors associated with the incidence of stroke/TIA were smoking and the CHADS2 score, with a higher risk in patients with values of 3 or greater (Table 3). In contrast, physical exercise was associated with a lower risk of stroke/TIA. The area under the ROC curve of the CHADS2 score for the risk of stroke/TIA was 0.64 (95% confidence interval [95%CI], 0.55-0.74; P < .01) (Figure 2A). In the light of these results, we also calculated the ROC curve of the combined score of significant variables in the multivariate analysis (CHADS2 + smoking + sedentary lifestyle) for the risk of stroke/TIA, which yielded an area under the curve of 0.71 (95%CI, 0.62-0.79; P < .001) (Figure 2B).

Table 3.

Multivariate Analysis. Factors Associated With the Appearance of a Stroke/Transient Ischemic Attack Over Follow-up

Variable  Stroke/TIA, OR (95%CI)  P 
Smoking  3.45 (1.50-8.04)  .004 
Exercise  0.39 (0.17-0.88)  .023 
CHADS2 = 2*  1.36 (0.60-3.01)  .469 
CHADS2 = 3*  2.91 (1.12-7.52)  .028 
CHADS2 ≥ 4*  9.40 (3.33-26.49)  < .001 

OR, odds ratio; TIA, transient ischemic attack.

The variables introduced in the model were sex, smoking, hypercholesterolemia, ischemic heart disease, physical exercise, systolic and diastolic arterial pressure, time elapsed since hypertension onset, waist perimeter, glomerular filtration rate, body mass index, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, diuretics, calcium channel blockers, statins, antiplatelet agents, and CHADS2 score.

*

With respect to CHADS2=1.

Figure 2.

ROC curve for predicting the risk of stroke/transient ischemic attack using the CHADS2 score (A) or the combination variable CHADS2 + smoking + sedentary lifestyle (B).

(0.16MB).
DISCUSSION

This is one of the first studies evaluating the prognostic value of the CHADS2 score to estimate the risk of a cerebrovascular event in a cohort of hypertensive patients without known atrial fibrillation from a Mediterranean area. The results show that CHADS2 is a good predictor of stroke/TIA, such that patients with a score of 3 or greater have a higher risk of experiencing a cardiovascular event at mid-term.

Atherosclerotic cardiovascular disease, particularly cerebrovascular disease, is one of the main causes of premature death and disability in industrialized countries.9 The development and progression of atherosclerotic disease is often insidious, and it can manifest in advanced stages without previous warning symptoms. Hence, it is important to establish the risk of stroke and provide adequate medical treatment to reduce the high economic burden placed by these diseases on the health system. In the last few years, use of the CHADS2 score has extended beyond the original scenario of atrial fibrillation,14,15 and it has shown certain advantages over other methods (SCORE or Framingham criteria), such as inclusion of older patients and greater ease of use in daily practice. Henriksson et al applied this score to a large series of stroke survivors included in the Swedish Stroke Registry and reported that the risk of death due to a cerebral event at 5 years showed a progressive, linear increase in parallel with the CHADS2 score, in both patients with atrial fibrillation and those in sinus rhythm.16 These data were recently confirmed in other studies, showing a higher incidence of mortality, recurrent stroke, and cardiovascular events in stroke patients with a CHADS2 score of 2 or greater, regardless of whether they had atrial fibrillation.17,18

The role of CHADS2 has also been investigated in ischemic heart disease. In a study in 916 patients who were not receiving anticoagulants, with stable coronary disease and no atrial fibrillation, patients with an intermediate (2-3) or high (4-6) CHADS2 score had a higher risk of stroke/TIA than those with a low (0-1) score, after adjustment had been made for other risk factors.19 Furthermore, the incidence of stroke in ischemic patients with a score above 5 was comparable to the reported rate in patients with atrial fibrillation and CHADS2 1 or 2, a population known to benefit from stroke prevention therapies, such as anticoagulation.20 The prognostic value of the score has also been demonstrated in patients with an acute coronary syndrome and no atrial fibrillation. High CHADS2 scores at hospital admission were associated with a higher risk of hospitalization due to stroke and greater mortality during follow-up.21 More recently, the CHADS2 score showed an ability to predict stroke in patients who had undergone pacemaker implantation for sinus node disease.22

In the present study, we have extended the ambit in which this score can be used to the field of hypertension, the most important factor determining stroke risk. We found an association between CHADS2 results and the mid-term risk of experiencing a stroke in a sample of hypertensive patients aged 65 years or older. Risk progressively increased in parallel with the CHADS2 value, such that patients with a score of 4 or greater had a 9-fold higher risk of having a cerebrovascular event than those with a score of 1. We believe that these novel findings in this high-risk population may provide valuable support for the use of this straightforward, easily applied predictive scheme in our setting.

Several potential mechanisms may explain the ability of CHADS2 to predict stroke risk in hypertensive patients without atrial fibrillation. First, patients with a higher CHADS2 score can have a greater risk of atrial arrhythmia. A study performed in hospitalized ischemic stroke patients undergoing monitoring showed a higher incidence of episodes of occult atrial fibrillation in those with higher CHADS2 scores.23 Second, the various risk factors comprising CHADS2 may, in themselves, increase the risk of stroke, independently of the cardiac rhythm. In patients with heart failure24 and diabetes mellitus,25 plasma markers of hypercoagulation and endothelial dysfunction are elevated, and these mechanisms are implicated in thrombus formation and stroke in patients with atrial fibrillation.26 Lastly, the various components of the CHADS2 score may directly contribute to left atrial remodeling, a process characterized by atrial dilatation and mechanical dysfunction.27 This may lead to blood stasis and an increased thromboembolic risk regardless of the cardiac rhythm.28 In this line, a recent study in 970 patients with coronary disease reported an association between the CHADS2 score and the functional score, an echocardiographic parameter of left atrial dysfunction, even in patients without atrial fibrillation, opening debate on the role of left atrial dysfunction in cardioembolic stroke.29

Limitations

One of the limitations of this study is selection bias. The patients enrolled spontaneously attended a medical visit; therefore, the study conclusions cannot be extrapolated to other settings. Furthermore, because the events included were obtained from an analysis of hospital admissions, an indeterminate number of TIA patients who did not consult were not detected in the analysis. Stroke and TIA were analyzed in a global manner and no distinction was made among the various causes of these conditions (embolic, atherothrombotic, lacunar, etc.). Finally, the study lacks a second, independent cohort to validate the predictive results obtained in the sample.

CONCLUSIONS

Our findings indicate that the CHADS2 score, a fast, simple, and easy to use tool, may have a role in estimating the risk of a cerebrovascular event in hypertensive patients without known atrial fibrillation. In addition, our data raise the question of whether patients with higher CHADS2 scores might benefit from preventive therapies such as anticoagulation because of their higher risk of silent atrial fibrillation30 or thromboembolic mechanisms independent of the heart rhythm. Studies investigating this possibility could be warranted.

CONFLICT OF INTERESTS

None declared.

Acknowledgements

We thank Lácer Laboratories for their disinterested help with this project and the participating investigators for their invaluable contribution. Without their work and effort, this study would not have been possible.

APPENDIX
FAPRES Registry Investigators

Juan Alberola, Vicente Javier; Maestre Amat, Luis; Mateo Limiñana, Jose Manuel; Monleon Gomez, Jose; Montagud Moncho, Miguel; Guinot Martinez, Enrique; Gamon Pastor, Jose Blas; Salanova Penalba, Alejandro; Sanchis Domenech, Carlos; Pallares Carratala, Vicente; Palacios del Cerro, Antonio; Perez Martinez, Rafael; Baudet Dejean, Chantal; Perez Alonso, Manuel; Facila Rubio, Lorenzo; Sipan Sarrion, Yolanda; Saro Perez, Eugenia; Villaro Gumpert, Juan; Cabrera Ferriols, M. Angeles; Fraile Fraile, Belen; Carbonell Franco, Francisco; Cornejo Mari, Francisco Javier; Barbera Comes, Javier; Quiles Añon, Fernando; Llisterri Caro, Jose Luis; Almenar Cubells, Enrique; Casado Gonzalez, Joaquin; Godoy Rocati, Diego; Martinez Guerola, Carmen; Bonet Garcia, Jorge Alejo; Blazquez Encinar, Julio Cesar; Botella Estrada, Carlos; Saen Alcoy, Montepio; Almarcha Perez, Natividad; Salanova Chilet, Lorena; Torres Ferrando, Miquel; Debon Belda, Manuel; Fluixa Carrascosa, Carlos; Aznar Baset, Lucia; Vivancos Aparicio, Diego; Pineda Cuenca, Manuel; Obarrio Moreno, Alicia; Nuñez Jorge, Carlos; Matoses Nacher, Daniel; Baño Aracil, Manuel; Balanza Garzon, Alicia; Garcia Palomar, Carlos; Peña Forcada, Enrique; Raga Casasus, Jose; Martinez Lahuerta, Juan; Mendizabal Nuñez, Andrea; Santos Alonso, Eufrosina; Corbi Pascual, Miguel; Lillo Sanchez, Antonio; Martorell Adsuara, Vicente; Sanchez Ruiz, Tomas; Ortiz Diaz, Francisco; Llinares Orts, Jose Francisco; Lahoz Ferrer, Julio; Morillas Blasco, Pedro; Pertusa Martinez, Salvador; Manclus Montoya, Carlos; Adria Mico, Jose Manuel; Llaudes Soler, Ricardo; Castillo Castillo, Jesus; Llopis Martinez, Francisco; Ruiz de la Prada Abarzuza, Ignacio; Nebot Rico, Lidia.

References
[1]
G.Y. Lip.
Stroke and bleeding risk assessment in atrial fibrillation: when, how, and why?.
Eur Heart J., 34 (2013), pp. 1041-1049
[2]
B.F. Gage, A.D. Waterman, W. Shannon, M. Boechler, M.W. Rich, M.J. Radford.
Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
JAMA., 285 (2001), pp. 2864-2870
[3]
M. Ruiz Ortíz, E. Romo, D. Mesa, M. Delgado, M. Anguita, A. López, et al.
Predicción de eventos embólicos en pacientes con fibrilación auricular no valvular: evaluación del score CHADS2 en una población mediterránea.
Rev Esp Cardiol., 61 (2008), pp. 29-35
[4]
A.C. Skanes, J.S. Healey, J.A. Cairns, P. Dorian, A.M. Gillis, M.S. McMurtry, et al.
Focused 2012 update of the Canadian Cardiovascular Society atrial fibrillation guidelines: recommendations for stroke prevention and rate/rhythm control.
Can J Cardiol., 28 (2012), pp. 125-136
[5]
J.J. You, D.E. Singer, P.A. Howard, D.A. Lane, M.H. Eckman, M.C. Fang, et al.
Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest., 141 (2012), pp. e531S-e575S
[6]
V. Fuster, L.E. Rydén, D.S. Cannom, H.J. Crijns, A.B. Curtis, K.A. Ellenbogen, et al.
2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
J Am Coll Cardiol., 57 (2011), pp. e101-e198
[7]
A.J. Camm, G.Y. Lip, R. de Caterina, I. Savelieva, D. Atar, S.H. Hohnloser, et al.
2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation.
Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J., 33 (2012), pp. 2719-2747
[8]
V.L. Roger, A.S. Go, D.M. Lloyd-Jones, R.J. Adams, J.D. Berry, T.M. Brown, et al.
Heart disease and stroke statistics—2011 update: a report from the American Heart Association.
Circulation., 123 (2011), pp. e18-e209
[9]
D.T. Lackland, E.J. Roccella, A.F. Deutsch, M. Fornage, M.G. George, G. Howard, et al.
Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association.
[10]
P. Morillas, V. Pallarés, J.L. Llisterri, C. Sanchis, T. Sánchez, L. Fácila, et al.
Prevalencia de fibrilación auricular y uso de fármacos antritrombóticos en el paciente hipertenso > 65 años. El registro FAPRES.
Rev Esp Cardiol., 63 (2010), pp. 943-950
[11]
Guidelines for controlling and monitoring the tobacco epidemic.
World Health Organization, (1998), pp. 76-101
[12]
F. Villar, A. Maiques, C. Brotons, J. Torcal, A. Lorenzo, J. Vilaseca, et al.
Prevención cardiovascular en atención primaria.
Aten Primaria., 28Supl2 (2001), pp. S13-S36
[13]
G. Mancia, R. Fagard, K. Narkiewicz, J. Redón, A. Zanchetti, M. Böhm, et al.
2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).
J Hypertens., 31 (2013), pp. 1281-1357
[14]
P.C. Hsu, T.H. Lin, W.H. Lee, C.Y. Chu, C.A. Chiu, H.H. Lee, et al.
Association between the CHADS2 Score and an ankle-brachial index of <0.9 in patients without atrial fibrillation.
J Atheroscler Thromb., 21 (2014), pp. 322-328
[15]
T. Hoshino, K. Ishizuka, S. Shimizu, S. Uchiyama.
CHADS2 score predicts functional outcome of stroke in patients with a history of coronary artery disease.
J Neurol Sci., 331 (2013), pp. 57-60
[16]
K.M. Henriksson, B. Farahmand, S. Johansson, S. Asberg, A. Terént, N. Edvardsson.
Survival after stroke—the impact of CHADS2 score and atrial fibrillation.
Int J Cardiol., 141 (2010), pp. 18-23
[17]
H.T. Tu, B.C. Campbell, A. Meretoja, L. Churilov, K.R. Lees, G.A. Donnan, et al.
Pre-stroke CHADS2 and CHA2DS2-VASc scores are useful in stratifying three-month outcomes in patients with and without atrial fibrillation.
Cerebrovasc Dis., 36 (2013), pp. 273-280
[18]
G. Ntaios, G.Y. Lip, K. Makaritsis, V. Papavasileiou, A. Vemmou, E. Koroboki, et al.
CHADS2, CHA2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation.
Neurology., 80 (2013), pp. 1009-1017
[19]
C.C. Welles, M.A. Whooley, B. Na, P. Ganz, N.B. Schiller, M.P. Turakhia.
The CHADS2 score predicts ischemic stroke in the absence of atrial fibrillation among subjects with coronary heart disease: data from the Heart and Soul Study.
Am Heart J., 162 (2011), pp. 555-561
[20]
R.G. Hart, O. Benavente, R. McBride, L.A. Pearce.
Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis.
Ann Intern Med., 131 (1999), pp. 492-501
[21]
D. Poçi, M. Hartford, T. Karlsson, J. Herlitz, N. Edvardsson, K. Caidahl.
Role of the CHADS2 score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation.
Chest., 141 (2012), pp. 1431-1440
[22]
J.H. Svendsen, J.C. Nielsen, S. Darkner, G.V. Jensen, L.S. Mortensen, H.R. Andersen, DANPACE Investigators.
CHADS2 and CHA2DS2-VASc score to assess risk of stroke and death in patients paced for sick sinus syndrome.
[23]
J.I. Haft.
Using CHADS2 backwards plus echo criteria to identify stroke patients who have occult intermittent atrial fibrillation.
Am Heart J., 157 (2009), pp. e9
[24]
A.Y. Chong, B. Freestone, J. Patel, H.S. Lim, E. Hughes, A.D. Blann, et al.
Endothelial activation, dysfunction, and damage in congestive heart failure and the relation to brain natriuretic peptide and outcomes.
Am J Cardiol., 97 (2006), pp. 671-675
[25]
J.A. McClung, N. Naseer, M. Saleem, G.P. Rossi, M.B. Weiss, N.G. Abraham, et al.
Circulating endothelial cells are elevated in patients with type 2 diabetes mellitus independently of HbA(1)c.
Diabetologia., 48 (2005), pp. 345-350
[26]
T. Watson, E. Shantsila, G.Y. Lip.
Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited.
Lancet., 373 (2009), pp. 155-166
[27]
G. Casaclang-Verzosa, B.J. Gersh, T.S. Tsang.
Structural and functional remodeling of the left atrium: clinical and therapeutic implications for atrial fibrillation.
J Am Coll Cardiol., 51 (2008), pp. 1-11
[28]
G.G. Blume, C.J. Mcleod, M.E. Barnes, J.B. Seward, P.A. Pellikka, P.M. Bastiansen, et al.
Left atrial function: physiology, assessment, and clinical implications.
Eur J Echocardiogr., 12 (2011), pp. 421-430
[29]
F. Azarbal, C.C. Welles, J.M. Wong, M.A. Whooley, N.B. Schiller, M.P. Turakhia.
Association of CHADS2, CHA2DS2-VASc, and R2CHADS2 scores with left atrial dysfunction in patients with coronary heart disease (from the Heart and Soul Study).
Am J Cardiol., 113 (2014), pp. 1166-1172
[30]
S. Secades-González, M. Martín-Fernández, J.M. De la Hera-Galarza, S. Calleja-Puerta.
Fibrilación auricular en el ictus criptogénico: ¿son necesarias nuevas herramientas para su diagnóstico?.
Rev Esp Cardiol., 67 (2014), pp. 160-161

The FAPRES investigators are listed in the Appendix.

Copyright © 2014. Sociedad Española de Cardiología
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.