Understanding Risk
Professor Dan Atar, MD, FESC
Dept. of Cardiology
Oslo University Hospital
Oslo, Norway
Vice-President of the ESC (2014-16)
The GARFIELD Registry is funded by an unrestricted research grant
from Bayer Pharma AG
www.tri-london.ac.uk
Professor Dan Atar: Disclosures
• Co-author of 2010-2012 ESC Guidelines on
Atrial Fibrillation
• Steering Committee member, National
Coordinator for Norway, and Co-author of
ACTIVE, ARISTOTLE, AVERROES, GARFIELDAF, XANTUS, RE-ALIGN
• Fees, honoraria from Sanofi-Aventis, Merck
(MSD), Boehringer- Ingelheim, Bayer,
BMS/Pfizer, Daiichi-Sankyo, Nycomed-Takeda
European Heart Journal
http://eurheartj.oxfordjournals.org/
A logical sequence to AF management
ESC 2010 AF Guidelines
Adapted from Gage BF
et al. JAMA. 2001;
285:2864-2870.
Courtesy Prof. R. de Caterina
ESC 2010 AF Guidelines
Since 2010, further validation of the
CHA2DS2-VASc score
Lip GY. J Thromb Haemost. 2011;9 Suppl 1:344–351.
Potpara TS, et al. Circ Arrhythm Electrophysiol. 2012;5:319–326.
Olesen JB, et al. Thromb Haemost. 2012;107:1172–1179.
Van Staa TP, et al. J Thromb Haemost. 2011;9:39–48.
Abu-Assi E, et al. Int J Cardiol. 2013;166:205–209.
Recommendations for prevention of thromboembolism in
non-valvular AF - general
Recommendations
Class
The CHA2DS2-VASc score is recommended as a means of
assessing stroke risk in non-valvular AF.
I
Level
A
Camm AJ, et al. Eur Heart J. 2012;33:2719–2747.
Courtesy Prof. R. de Caterina
ESC 2012 AF Guidelines update
CHA2DS2-VASc score
Patients (n=73538)
Stroke and thromboembolism event
rate at 1 year follow-up (%)
0
6369
0.78
1
8203
2.01
2
12771
3.71
3
17371
5.92
4
13887
9.27
5
8942
15.26
6
4244
19.74
7
1420
21.50
8
285
22.38
9
46
23.64
Adapted from Olesen JB, et al. Br Med J. 2011;342:doi: 10.1136/bmj.d124.
The value of the CHA2DS2-VASc score for refining stroke
risk stratification in patients with a CHADS2 score 0-1
Olesen et al Thromb Haemost. 2012 Jun;107(6):1172-9
Proportion of patients free of
stroke/thromboembolism
100%
98%
96%
CHA2DS2-VASc
CHA2DS2-VASc
CHA2DS2-VASc
CHA2DS2-VASc
CHADS2 = 0
94%
92%
=0
=1
=2
=3
0%
0
100
200
300
Days from discharge
In patients with a CHADS2=0, c-statistic was 0.573 (0.539–0.608) and
increased to 0.641 (0.610–0.671) when CHA2DS2-VASc was included.
www.escardio.org/guidelines
European www.tri-london.ac.uk
Heart Journal 2012 - doi:10.1093/eurheartj/ehs253
January CT, et al. Circulation. 2014;129:000-000.
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation:
Executive Summary: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines and the Heart Rhythm Society
Craig T. January, L. Samuel Wann, Joseph S. Alpert, Hugh Calkins, Joseph C. Cleveland, Jr, Joaquin
E. Cigarroa, Jamie B. Conti, Patrick T. Ellinor, Michael D. Ezekowitz, Michael E. Field, Katherine T.
Murray, Ralph L. Sacco, William G. Stevenson, Patrick J. Tchou, Cynthia M. Tracy and Clyde W.
Yancy
Circulation. published online March 28, 2014;
January, CT et al.
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
2014 AHA/ACC/HRS Atrial Fibrillation
Guideline
Copyright © 2014 American
Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
2. Selection of antithrombotic therapy should be based on the risk of thromboembolism irrespective
of whether the AF pattern is paroxysmal, persistent, or permanent (64-67). (Level of Evidence: B)
3. In patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of
The online version of this article, along with updated information and services, is located on the
stroke risk (68-70). (Level of Evidence:
B)Wide Web at:
World
4. For patients withhttp://circ.ahajournals.org/content/early/2014/04/10/CIR.0000000000000040.citation
AF who have mechanical heart valves, warfarin is recommended and the target
international normalized ratio (INR) intensity (2.0 to 3.0 or 2.5 to 3.5) should be based on the type
Data Supplement
(unedited)
at: B)
and location of the
prosthesis (71-73).
(Level of
Evidence:
http://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC1.html
5. For patients withhttp://circ.ahajournals.org/content/suppl/2014/03/24/CIR.0000000000000040.DC2.html
nonvalvular AF with prior stroke, transient ischemic attack (TIA), or a
http://circ.ahajournals.org/content/suppl/2014/04/10/CIR.0000000000000040.DC3.html
CHA2DS2-VASc score of 2 or greater, oral anticoagulants are recommended. Options include:
warfarin (INR 2.0 to 3.0) (68-70) (Level of Evidence: A), dabigatran (74) (Level of Evidence: B),
rivaroxaban (75) (Level of Evidence: B), or apixaban (76). (Level of Evidence: B)
January CT, et al. Circulation. 2014;129:000-000.
6. Among patients treated with warfarin, the INR should be determined at least weekly during
initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is
stable (77-79). (Level of Evidence: A)
What do we know about risk in GARFIELD-AF?
Stroke risk profile: CHADS2 / CHA2DS2-VASc
Stroke risk profile:
CHA2DS2-VASc
Stroke risk profile:
CHADS2
Percentage
Percentage
34.7 33.4
15.7
23.7
19.5
21.9
12.3
10.7
2.2
0
8.8
7.1
6.5
1
2
3
4
5
0.4
6
3.3
0
1
2
3
4
5
6-9
Preliminary first year event rates according
to number of risk factors
No or 1 RF
2 RFs
3 RFs
4 RFs
5 or more RFs
6
5.4
Event rate (%)
5
4
2.8
3
2.2
2
1
1.8
1.5 1.5
0.9 0.9
0.5 0.4
0.8
1
2.1
1.1
0.5
0
Stroke/SE
Major bleed
Death
RF, risk factor (heart failure, LVEF <40%, hypertension, age ≥75, diabetes, previous stroke/TIA/SE,
vascular disease, age 65–74 years, female gender)
Kakkar A, AHA-2012
Poster presentation at ESC
• ‘Truly low-risk’ patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke: 1-year
outcomes from the GARFIELD-AF Registry
Jean-Pierre Bassand et al., for the GARFIELD-AF
Investigators
• Tuesday, 2 September from 14:00–18:00 in the
poster area of the Central Village
Rate of stroke/systemic embolism
according to CHA2DS2-VASc score of
0
0.2%
versus
1-9:
1.1%
Conclusions
• In patients with A-Fib, the estimation of individual
risk of stroke is key before any therapeutic
decision is made
• CHA2DS2-VASc is recommended as the primary
instrument in estimating risk of stroke
(ESC 2012 / AHA+ACC 2014)
• The focus is to identify truly low-risk patients –
these will not need anticoagulation therapy
• All other patients ought to receive
anticoagulation for the indication of “SPAF”
Thank you for your attention
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