Exploring Clinical and Echocardiographic Factors in EHRA Type 2 Atrial Fibrillation for Predicting Ischaemic Stroke: A Search for Unrevealed Insights
Keywords:
atrial fibrillation, ischaemic stroke, vvalvular heart disease
Abstract
Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. Valvular heart diseases (VHD), regardless of the arrhythmic problems, increase the risk of thromboembolism, which are even higher in those with associated atrial fibrillation. The EHRA (Evaluated Heartvalves, Rheumatic or Artificial) classification categorised AF patients with significant VHD into type 1 and type 2. Unfortunately, there are currently very limited data on risk prediction in stroke-related valvular AF, particularly in the Asian population.
Aims: To investigate the clinical and echocardiographic risk factors for ischaemic stroke prediction in patients with EHRA type 2 VHD.
Methods: This retrospective study enrolled 695 AF patients with EHRA type 2 VHD. The data were collected from patients' medical records who met the inclusion and exclusion criteria from 2015 until 2020. The primary outcome was ischaemic strokes within observation period.
Results: There were 67 ischaemic stroke events (9,6%) of the total sample. Our analysis found that none of the analysed variables proved to be statistically significant risk factors in predicting the occurrence of ischaemic stroke. The median CHA2DS2-VASc risk prediction in the sample was 3, with an accuracy of AUC 0.502 (CI 95%; 0.429 – 0.576), sensitivity 56.7% and specificity 44.7%.
Conclusion: Based on the parameters analysed in this study, no factor was statistically well-predictive to predict the ischaemic stroke incidence in EHRA type 2 VHD AF. In addition, the CHA2DS2-VAS accuracy was low in this population. Further exploration is needed to build an accurate ischaemic stroke risk prediction for EHRA type 2 VHD.
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References
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18. Hart RG, Eikelboom JW, Brimble KS, McMurtry MS, Ingram AJ. Stroke prevention in atrial fibrillation patients with chronic kidney disease. Canadian Journal of Cardiology. 2013;29(7). doi:10.1016/j.cjca.2013.04.005
19. Gaikwad T, Ghosh K, Shetty S. VKORC1 and CYP2C9 genotype distribution in Asian countries. Thrombosis Research. 2014;134(3):537–44. doi:10.1016/j.thromres.2014.05.028
20. Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients. Thromb Haemost. 2011;106(5):968–77.
21. Suriapranata IM, Tjong WY, Wang T, Utama A, Raharjo SB, Yuniadi Y, et al. Genetic factors associated with patient-specific warfarin dose in ethnic Indonesians. BMC Medical Genetics. 2011;12(1). doi:10.1186/1471-2350-12-80
22. Chan PH, Hai JJ, Chan EW, Li WH, Tse HF, Wong ICK, et al. Use of the SAMe-TT2R2 score to predict good anticoagulation control with warfarin in Chinese patients with atrial fibrillation: Relationship to ischaemic stroke incidence. PLoS One. 2016;11(3):1–9.
23. Hong KS, Kim YK, Bae HJ, Nam HS, Kwon SU, Bang OY, et al. Quality of anticoagulation with warfarin in Korean patients with atrial fibrillation and prior stroke: A multicenter retrospective observational study. J Clin Neurol. 2017;13(3):273–80.
2. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart R. J Am Coll Cardiol. 2019;74(1):104–32.
3. Lip GYH, Collet JP, Caterina R De, Fauchier L, Lane DA, Larsen TB, et al. Antithrombotic therapy in atrial fibrillation associated with valvular heart disease: A joint consensus document from the European Heart Rhythm Association (EHRA) and European Society of Cardiology Working Group on Thrombosis, endorsed by the ESC Working. Europace. 2017;19(11):1757–8.
4. Lip GYH, Jensen M, Melgaard L, Skjøth F, Nielsen PB, Larsen TB. Stroke and bleeding risk scores in patients with atrial fibrillation and valvular heart disease: Evaluating “valvular heart disease” in a nationwide cohort study. Europace. 2019;21(1):33–40.
5. Lip GYH, Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, et al. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: A joint consensus document of the Europ. Europace. 2019;21(2):192–3.
6. Kusumoto FM, Bailey KR, Chaouki AS, Deshmukh AJ, Gautam S, Kim RJ, et al.
Systematic Review for the 2017 AHA/ACC/HRS Guideline for Management of
Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Pract. J Am Coll Cardiol. 2018;72(14):1653–76.
7. Van Den Ham HA, Klungel OH, Singer DE, Leufkens HGM, Van Staa TP. Comparative Performance of ATRIA, CHADS2, and CHA2DS2-VASc Risk Scores Predicting Stroke in Patients With Atrial Fibrillation: Results From a National Primary Care Database. J Am Coll Cardiol. 2015;66(17):1851–9.
8. Jame S, Barnes G. Stroke and thromboembolism prevention in atrial fibrillation. Heart. 2020;106(1):10–7.
9. Doi K, Ogawa H, Ishigami K, Ikeda S, Aono Y, Hamatani Y, et al. Impact of valvular heart disease on mortality, thromboembolic and cardiac events in Japanese patients with atrial fibrillation ― the Fushimi AF registry ―. Circ J. 2020;84(5):714–22.
10. Bisson A, Bodin A, Clementy N, Bernard A, Babuty D, Lip GYH, et al. Stroke, thromboembolism and bleeding in patients with atrial fibrillation according to the Ehra valvular heart disease classification. International Journal of Cardiology. 2018;260:93–8. doi:10.1016/j.ijcard.2018.03.017
11. Winanti R, Raharjo SB, Ariani R, Hanafy DA, Atmadikoesoemah CA, Almazini P. OR41. hypertension and abnormal renal function increased the risk of ischemic stroke in anticoagulated EHRA type-1 valvular atrial fibrillation. European Heart Journal Supplements. 2021;23(Supplement_F). doi:10.1093/eurheartjsupp/suab122.040
12. Vemulapalli S, Hellkamp AS, Jones WS, Piccini JP, Mahaffey KW, Becker RC, et al. Blood pressure control and stroke or bleeding risk in anticoagulated patients with atrial fibrillation: Results from the rocket AF trial. American Heart Journal. 2016;178:74–84. doi:10.1016/j.ahj.2016.05.001
13. Rao MP, Halvorsen S, Wojdyla D, Thomas L, Alexander JH, Hylek EM, et al. Blood pressure control and risk of stroke or systemic embolism in patients with atrial fibrillation: Results from the apixaban for reduction in stroke and other thromboembolic events in atrial fibrillation (ARISTOTLE) trial. J Am Heart Assoc. 2015;4(12):1–8.
14. Sartipy U, Dahlström U, Fu M, Lund LH. Atrial Fibrillation in Heart Failure With Preserved, Mid-Range, and Reduced Ejection Fraction. JACC Hear Fail. 2017;5(8):565–74.
15. Son MK, Park JJ, Lim NK, Kim WH, Choi DJ. Impact of atrial fibrillation in patients with heart failure and reduced, mid-range or preserved ejection fraction. Heart. 2020;106(15):1160–8.
16. Song Z, Xu K, Hu X, Jiang W, Wu S, Qin M, et al. A Study of Cardiogenic Stroke Risk in Non-valvular Atrial Fibrillation Patients. Front Cardiovasc Med. 2020;7(November):1–7.
17. Pokorney SD, Black-Maier E, Hellkamp AS, Friedman DJ, Vemulapalli S, Granger CB, et al. Oral Anticoagulation and Cardiovascular Outcomes in Patients With Atrial Fibrillation and End-Stage Renal Disease. J Am Coll Cardiol. 2020;75(11):1299–308.
18. Hart RG, Eikelboom JW, Brimble KS, McMurtry MS, Ingram AJ. Stroke prevention in atrial fibrillation patients with chronic kidney disease. Canadian Journal of Cardiology. 2013;29(7). doi:10.1016/j.cjca.2013.04.005
19. Gaikwad T, Ghosh K, Shetty S. VKORC1 and CYP2C9 genotype distribution in Asian countries. Thrombosis Research. 2014;134(3):537–44. doi:10.1016/j.thromres.2014.05.028
20. Gallagher AM, Setakis E, Plumb JM, Clemens A, van Staa TP. Risks of stroke and mortality associated with suboptimal anticoagulation in atrial fibrillation patients. Thromb Haemost. 2011;106(5):968–77.
21. Suriapranata IM, Tjong WY, Wang T, Utama A, Raharjo SB, Yuniadi Y, et al. Genetic factors associated with patient-specific warfarin dose in ethnic Indonesians. BMC Medical Genetics. 2011;12(1). doi:10.1186/1471-2350-12-80
22. Chan PH, Hai JJ, Chan EW, Li WH, Tse HF, Wong ICK, et al. Use of the SAMe-TT2R2 score to predict good anticoagulation control with warfarin in Chinese patients with atrial fibrillation: Relationship to ischaemic stroke incidence. PLoS One. 2016;11(3):1–9.
23. Hong KS, Kim YK, Bae HJ, Nam HS, Kwon SU, Bang OY, et al. Quality of anticoagulation with warfarin in Korean patients with atrial fibrillation and prior stroke: A multicenter retrospective observational study. J Clin Neurol. 2017;13(3):273–80.
Published
2024-07-03
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How to Cite
Simbolon, J. P., Raharjo, S., Santoso, A., Liastuti, L., Hermanto, D., Rossimaria, V., Pritazahra, A., Hanafy, D., & Yuniadi, Y. (2024). Exploring Clinical and Echocardiographic Factors in EHRA Type 2 Atrial Fibrillation for Predicting Ischaemic Stroke: A Search for Unrevealed Insights. Indonesian Journal of Cardiology, 44(3), 87-94. https://doi.org/10.30701/ijc.1562
Section
Clinical Research
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