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Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Atrial fibrillation is fast irregular atrial rhythm whereby the atria discharge electrical current between 300 to 600 times per minute. The origin of the impulses is the pulmonary veins or atria themselves. The atrioventricular node only responds intermittendy to this, which gives the irregular rhythm. It has a large variety of causes. The mainstay of treatment is to treat the underlying cause and to try and revert the heart rhythm back to sinus. This can be done through using either medication, electrical current or ablation. When treating the patient, it is also important to be aware of the complications, the most important being stroke. To prevent this, anticoagulation is required. The CHADS2 score can be used to help the physician decide between aspirin or warfarin as a suitable anticoagulant.
Patient risk assessment: Use of risk calculators
Published in John Edward Boland, David W. M. Muller, Interventional Cardiology and Cardiac Catheterisation, 2019
The CHADS2 score is the original risk calculator for stroke in patients with non-valvular atrial fibrillation. First published in 2001, the CHADS2index identified independent risk factors that were included in pre-existing stroke risk prediction schemes (Atrial Fibrillation Investigators [AFI] or Stroke Prevention and Atrial Fibrillation [SPAF] Investigators), and included factors such as history of previous cerebral ischemia (previous stroke or transient ischaemic attack [TIA]), hypertension, diabetes mellitus, congestive heart failure, and age 75 years or greater.26 The scoring and adjusted stroke risk (%) is shown in Table 12.10, remembering that the stroke rate in this cohort was based on hospitalisation for stroke, which may differ in current practice. While appealingly simple, the CHADS2 score failed to differentiate the truly low-risk population, with the low-risk group having 1.9%–2.8% per year and thus did not aid in differentiating those that did not require anticoagulation well enough.
Supraventricular tachyarrhythmias in the elderly
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Jason T. Jacobson, Sei Iwai, Ali Ahmed, Wilbert S. Aronow
In the CHADS2 score, 1 point is given for CHF, 1 point for hypertension, 1 point for age older than 75 years, 1 point for diabetes, and 2 points for prior stroke or transient ischemic attack (196). The 1-year adjusted risk for stroke in 1733 Medicare beneficiaries with AF and CHF and no contraindications to warfarin was 1.9% for a CHADS2 score of 0, 2.8% for a score of 1, 4.0% for a score of 2, 5.9% for a score of 3, 8.5% for a score of 4, 12.5% for a score of 5, and 18.2% for a score of 6 (196). At 31-month follow-up of 521 patients with AF, a CHADS2 score of 5 or 6 had a 52 times significantly increased risk for stroke than a score of 0 (197). The CHA2DS2-VASc score has largely supplanted the CHADS2 criteria. In this newer system, 1 point is given for age 65–74, 2 points for age 75 and up, 1 point for female sex and 1 point for vascular disease (198). The addition of these factors better defines the low-risk population (199,200). In 441 patients with AF and no contraindications to warfarin, warfarin was used in 8 of 30 patients (27%) with a CHADS2 score of 0, in 82 of 132 patients (62%) with a CHADS2 score of 1, in 121 of 175 patients (70%) with a CHADS2 score of 2, in 72 of 77 patients (94%) with a CHADS2 score of 3, and in 27 of 27 patients (100%) with a CHADS2 of 4 to 6 (201).
Perceptions and knowledge gaps on CHA2DS2-VASc score components: a joint survey of Chinese clinicians and clinical pharmacists
Published in Postgraduate Medicine, 2022
Chi Zhang, Long Shen, Mang-Mang Pan, Ying-Li Zheng, Zhi-Chun Gu, Hou-Wen Lin
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with an estimated prevalence of 2% to 4% in the general population [1]. The most debilitating complication of AF is stroke, and AF increases stroke risk by five-fold, resulting in a high health care cost and public health burden [2]. Anticoagulation, depending on the stroke risk of AF patients, is considered the cornerstone in the management of AF [3]. However, the stroke risk of patients with AF is not homogeneous, and various clinical risk factors have been detected to form the basis for stroke risk stratification schemes [4]. The CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke, or transient ischemic attack (TIA) [doubled]) was the first widely adopted AF stroke risk score, which was proposed and validated in a large cohort of hospitalized AF patients to identify high-risk patients [5]. Subsequently, the CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥ 75 years [doubled], diabetes mellitus, prior stroke or TIA [doubled], vascular disease, age 65–74 years, female) was developed and found to outperform the CHADS2 score in identifying low-risk AF patients [4]. Several subsequent studies also confirmed the CHA2DS2-VASc score over the CHADS2 score for stroke prediction in AF patients [6–8]. Accordingly, current societal guidelines recommend the CHA2DS2-VASc score for stroke risk stratification as the key reference for the management of AF patients [9,10].
Perioperative management of anticoagulation
Published in Hospital Practice, 2020
Goutham Talari, Zachary D. Demertzis, Robert D. Summey, Baljinder Gill, Scott Kaatz
The BRIDGE trial, a double-blind randomized control trial, looked at perioperative bridging in patients with atrial fibrillation where warfarin was interrupted for an elective procedure. Patients had warfarin interrupted 5 days prior to procedure and were randomized to dalteparin or placebo low molecular weight heparin (LMWH) bridging. The aim of the trial was to show LMWH bridging was not effective in preventing thromboembolic events and may be harmful. The primary outcomes were powered to show placebo (no bridging) was non-inferior for arterial thromboembolism and safer than LMWH bridging up to 30 days post-procedure. A total of 1813 patients were enrolled and a no bridging strategy (0.4% of patients) was non-inferior to bridging (0.3% of patients) for arterial thromboembolic events (p = 0.01 for non-inferiority). Major bleeding was significantly less in the non-bridged (1.3% of patients) compared to the bridged group (3.2% of patients, p = 0.005). This study showed that no bridging of anticoagulation was associated with less bleeding without an increase in arterial thromboembolism. Limitations of this study are that the average CHADS2 score was 2.3 and relatively few patients had high CHADS2 scores or underwent major surgery. A further limitation is that CHADS2 was used whereas as CHADS2VA2Sc is the current standard [5].
Use of insertable cardiac monitors for the detection of atrial fibrillation in patients with cryptogenic stroke in the United States is cost-effective
Published in Journal of Medical Economics, 2019
J. Maervoet, N. Bossers, R. P. Borge, S. Thompson Hilpert, A. van Engen, A. Smala
Patients with a history of ischemic stroke are typically prescribed antiplatelet therapy, with the aim of reducing the risk of subsequent stroke. Upon AF detection most will switch to anticoagulants, depending on their individual stroke risk (using the CHADS2 Score, an acronym for congestive heart failure, hypertension, age > 75 years, diabetes mellitus, and prior stroke or transient ischemic attack) and the potential for bleeding as a side effect of anticoagulant therapy. The ultimate decision on the initiation of anticoagulants rests with the clinician, who must weigh the expected benefits and risks associated. Novel oral anticoagulants (NOACs) appear to confer at least a similar clinical benefit to warfarin in reducing the risk of ischemic stroke and systemic embolism and are associated with a lower risk of hemorrhagic stroke compared with warfarin, although have higher acquisition costs24–26.