Abstract

CHADS2 or CHA2DS2-VASc score is used for prediction of stroke in patients with atrial fibrillation (AF). Recently, CHADS2 score is reported to have prognostic value in acute coronary syndrome without AF. However, clinical validation of CHA2DS2-VASc score for prognostic stratification in coronary heart disease (CHD) without AF remains uncertain. In this study, we evaluate whether CHA2DS2-VASc score could predict clinical outcome in CHD without known AF. SHINANO registry was a prospective, observational, multicenter cohort study, enrolling 1923 consecutive patients with CHD from August 2012 to July 2013. Two hundred nine patients were excluded because of known AF. We calculated CHA2DS2-VASc score in the remaining 1714 patients (mean age 70 ± 11 years, 23% female) without known AF. To assess the clinical validation of CHA2DS2-VASc score, we divided patients into 3 groups according to the tertiles (score 0–2, 3–4, and ≥ 5). The primary endpoint was MACE including death, nonfatal myocardial infarction, and ischemic stroke at 1 year. One-year follow-up was completed in 1632 patients (95.2%). Cumulative incidence of MACE was 139 cases. In Kaplan–Meier analysis, incidence of MACE was significantly higher in patients with CHA2DS2-VASc score ≥ 5 compared to 3–4 and 0–2 (14.6% vs. 6.8% vs. 5.3%, p < 0.001). In multivariate Cox-regression analysis, CHA2DS2-VASc score was an independent predictor for MACE (hazard ratio 1.26, 95% confidence interval 1.15–1.39p < 0.001). This study demonstrated that CHA2DS2-VASc score could provide prognostic information in CHD without known AF.

Abstract

Deaths due to coronary heart disease (CHD) remain high worldwide, despite recent achievements. An effective screening strategy may improve outcomes further if implemented in a high or ‘at risk’ cohort. Asymptomatic CHD in the young maybe underappreciated and applying an effective screening strategy to a young cohort may lead to improved outcomes due to significant socioeconomic impact from the consequences of CHD in this sub-group. A positive family history of CHD, which is known to be associated with an increased risk of future myocardial events, could aid in identifying the ‘at risk’ young cohort. Traditional cardiovascular risk scoring systems are in wide use but lack the sensitivity or specificity required to estimate risk in an individual. Rather their use is limited to predicting population attributable risk. Functional studies such as exercise stress tests are readily available and cost effective but do not have the required sensitivity required to suggest their use as part of a screening protocol. Coronary CT angiography has been demonstrated to have high sensitivity for the detection of CHD and therefore may be suitable for screening purposes but there are concerns regarding radiation exposure. Here we review the evidence for the use of potential screening strategies and the suitability of using such strategies to estimate risk of CHD in a young ‘at risk’ population.