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CLINICAL STATEMENTS AND GUIDELINES

January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e30

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

Yet, despite its extensive use, CHA2DS2-VASc has shown suboptimal performance in selected populations, such as those with renal disease, prompting the creation of other scores. Newer risk scores, such as the ATRIA1,16,17 and GARFIELD-AF3,18 scores, modestly improve risk discrimination (c-index) compared with CHA2DS2-VASc, but their calibration and risk reclassification performance has not been as rigorously evaluated. A recent meta-analysis reported that 19 risk scores, 329 external validations, and 76 risk score updates have been conducted to predict ischemic stroke in patients with AF.19 Potential differences of the most studied risk scores are listed in Table 9. Some potential advantages of other scores, for example, the GARFIELD-AF score, includes mortality and bleeding risk to facilitate discussion with patients in a more comprehensive way. Also, when uncertainty exists, a score such as GARFIELD-AF adds additional variables to consider, such as smoking status, renal disease, and dementia. This guideline does not intend to preclude the future development of more accurate scores for stratifying patients. 2 Clinical decisions surrounding stroke prevention

therapy in patients with AF must balance the risks of ischemic stroke, the risks of bleeding with treatment, net clinical benefit, and patient preferences. The most studied bleeding risk scores (HAS-BLED,5 HEMORR2HAGES,6 and ATRIA7) discriminate poorly between patients with and without bleeding20 (c-index 0.58 to 0.59 in a French nationwide study21). These scores are problematic to use in clinical decision-making because they incorporate several clinical factors that increase the risks of both stroke and bleeding (eg, age, hypertension, renal disease, and previous stroke), which makes it difficult to balance the benefits and risks of anticoagulation because the same risk factors also predict higher risk of stroke. Consideration of factors that specifically indicate a higher risk of bleeding without predicting higher risk of stroke (eg, previous bleeding, anemia, and certain medications) may better inform decision-making about the balance of benefits and harms expected from anticoagulation. Assessment of risk factors specific for bleeding may suggest interventions to reduce bleeding risk, such as discontinuing antiplatelet medications or nonsteroidal anti-inflammatory medications or the use of LAAO devices.10

3 The decision to treat with OACs for stroke pre-

vention in patients with a CHA2DS2-VASc of 1 (CHA2DS2-VASc of 2 in women) may at times require additional discussion with patients as the strength or recommendation is less robust (2a), and often patients might be more reluctant. Also, the 1-point-concept of risk estimation in the subgroup of patients with a CHA2DS2-VASc score of 1 has shown to be simplistic because the magnitude of risk for each factor is heterogeneous and because data have shown a wide range of risk depending on the studied cohort.22 Thus, as part of SDM discussions with patients, other factors, such as AF burden, can be considered when interpreting a stroke risk score.12–14,23 Additional factors, such as degree of hypertension control, can also affect the risk of stroke; in the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, a single elevated BP measurement during the study was associated with a 50% increased risk of stroke.23,24 Additional patientspecific risk factors, such as certain biomarkers (eg, proBNP), LA or left atrial appendage (LAA) function and anatomy, or electrocardiographic features, among others, have been demonstrated to influence stroke risk, yet it is unclear how to incorporate them into clinical practice.12 Antithrombotic treatment with DOACs seems to offer a superior net-benefit with regard to prevention of thromboembolic events and the risk of major bleeding compared with vitamin K antagonists (VKAs). Consideration of these

Table 8.  Three Validated Risk Models for Stroke Risk Factor CHA2DS2-VASc2 ATRIA1 GARFIELD3 Age ≥85 y 6 0.98 Age ≥75 y 2 5 0.59 Age 65-74 y 1 3 0.20 Female sex 1 1 Hypertension 1 1 0.16 Renal disease 1 0.35 Diabetes 1 1 0.21 Current smoking 0.48 Congestive heart failure 1 1 0.23 Previous stroke or TIA 2 2–8* 0.80 Vascular disease 1 0.20 Dementia 0.51 Previous bleeding 0.30 Proteinuria 1 Low risk score 0 0–5 0–0.89 Intermediate risk score 1 6 0.90–1.59 High risk score ≥2 7–15 ≥1.60 C-index (11) 0.63 0.66 - C-index (13) 0.67 - 0.71 *8 points if age <65 y; 4 points if age 65-74 y; 2 points if age 75-84 y; and 3 points if ≥85 y. ATRIA indicates Anticoagulation and Risk Factors in Atrial Fibrillation: anemia, renal disease, elderly (age ≥75 y), any previous bleeding, hypertension; CHA2DS2- VASc, indicates congestive heart failure, hypertension, age ≥75 y (doubled), diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism (doubled), vascular disease, age 65 to 74 y, sex category; GARFIELD-AF, Global Anticoagulant Registry in the Field-Atrial Fibrillation; and TIA, transient ischemic attack.

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