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. 2021 May 15;22(1):179.
doi: 10.1186/s12882-021-02384-0.

Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA2DS2-VASc score in hemodialysis patients with non-valvular atrial fibrillation

Anat Bel-Ange  1 , Shani Zilberman Itskovich  2 , Liana Avivi  3 , Kobi Stav  4 , Shai Efrati  2 , Ilia Beberashvili  5
Affiliations

Prior ischemic strokes are non-inferior for predicting future ischemic strokes than CHA2DS2-VASc score in hemodialysis patients with non-valvular atrial fibrillation

Anat Bel-Ange et al. BMC Nephrol. .

Abstract

Background: We tested whether CHA2DS2-VASc and/or HAS-BLED scores better predict ischemic stroke and major bleeding, respectively, than their individual components in maintenance hemodialysis (MHD) patients with atrial fibrillation (AF).

Methods: A retrospective cohort study of a clinical database containing the medical records of 268 MHD patients with non-valvular AF (167 women, mean age 73.4 ± 10.2 years). During the median follow-up of 21.0 (interquartile range, 5.0-44.0) months, 46 (17.2%) ischemic strokes and 24 (9.0%) major bleeding events were reported.

Results: Although CHA2DS2-VASc predicted ischemic stroke risk in the study population (adjusted HR 1.74 with 95% CI 1.23-2.46 for each unit of increase in CHA2DS2-VASc score, and HR of 5.57 with 95% CI 1.88-16.49 for CHA2DS2-VASc score ≥ 6), prior ischemic strokes/transient ischemic attacks (TIAs) were non-inferior in both univariate and multivariate analyses (adjusted HR 8.65 with 95% CI 2.82-26.49). The ROC AUC was larger for the prior ischemic stroke/TIA than for CHA2DS2-VASc. Furthermore, the CHA2DS2-VASc score did not predict future ischemic stroke risks in study participants who did not previously experience ischemic strokes/TIAs (adjusted HR 1.41, 95% CI: 0.84-2.36). The HAS-BLED score and its components did not have predictive abilities in discriminating bleeding risk in the study population.

Conclusions: Previous ischemic strokes are non-inferior for predicting of future ischemic strokes than the complete CHA2DS2-VASc score in MHD patients. CHA2DS2VASc scores are less predictive in MHD patients without histories of CVA/TIA. HAS-BLED scores do not predict major bleeding in MHD patients. These findings should redesign approaches to ischemic stroke risk stratification in MHD patients if future large-scale epidemiological studies confirm them.

Keywords: Bleeding; CHA2DS2-VASc; HAS-BLED; Hemodialysis; Stroke.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of the study
Fig. 2
Fig. 2
Kaplan–Meier curves for cumulative hazard of ischemic stroke in the study population (n = 268, event n = 46) according to CHA2DS2VASc-score stratified as low-, intermediate- and high-risk groups (a), as low and high-risk groups according to the cut-off value obtained from AUC ROC analysis (b) and according to the history of prior ischemic stroke (c)
Fig. 3
Fig. 3
Kaplan–Meier curves for cumulative hazard of ischemic stroke in the study population without chronic anticoagulation (n = 176, event n = 31) according to CHA2DS2VASc-score stratified as low-, intermediate- and high-risk groups (a), as low and high-risk groups according to the cut-off value obtained from AUC ROC analysis (b) and according to the history of prior ischemic stroke (c)
Fig. 4
Fig. 4
Kaplan–Meier curves for cumulative hazard of ischemic stroke in the study population without past history of ischemic stroke (n = 181, event n = 18) according to CHA2DS2VASc-score stratified as low-, intermediate- and high-risk groups (a) and as low and high-risk groups according to the cut-off value obtained from AUC ROC analysis (b)
Fig. 5
Fig. 5
Kaplan–Meier curves for cumulative hazard of major bleeding in the whole study population (n = 268, event n = 24) (a) and in the study population without chronic anticoagulation (n = 176, event n = 15) (b) according to HAS-BLED score stratified as low-, intermediate- and high-risk groups
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