Comparison of the CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA Risk Scores in Predicting Non-Vitamin K Antagonist Oral Anticoagulants-Associated Bleeding in Patients With Atrial Fibrillation

Xiaoxi Yao, Bernard J. Gersh, Lindsey R. Sangaralingham, David M. Kent, Nilay D Shah, Neena Susan Abraham, Peter Noseworthy

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Abstract

The increasing adoption of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF) necessitates a reassessment of bleeding risk scores. Because known risk factors for bleeding are largely the same as for stroke, we hypothesize that stroke risk scores could also be used to identify patients with high bleeding risks. We aimed to compare the performance of 2 stroke risk scores (Congestive Heart failure, hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, and Sex [female] [CHA2DS2-VASc] and Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] [CHADS2]) and 3 bleeding risk scores (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile INR, elderly [.65 years], drugs/alcohol concomitantly [1 point each] [HAS-BLED], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT], and AnTicoagulation and Risk factors In Atrial fibrillation [ATRIA]) in predicting major and intracranial bleeding. Using a large US commercial insurance database, we identified 39,539 patients with nonvalvular AF who started NOACs between October 1, 2010 and June 30, 2015. The performance of risk scores was compared using C-statistic and net reclassification improvement (NRI). Over a total of 22,583 person-years, 665 patients (2.94% per year) had major bleeding, including 74 intracranial hemorrhages (0.33% per year). For the prediction of major bleeding, CHA2DS2-VASc had the highest C-statistic both as a continuous score (C-statistic 0.68) and as a categorical score (C-statistic 0.65). For the prediction of intracranial bleeding, CHADS2 had the highest C-statistic both as a continuous score (C-statistic 0.66) and as a categorical score (C-statistic 0.66). There were no statistically significant differences between scores based on NRI. In conclusion, CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA had similar, albeit modest, performance in predicting NOAC-associated bleeding in patients with AF. Careful assessment and active management of bleeding risk factors may be warranted in all patients on NOACs who have high stroke risk scores.

Original languageEnglish (US)
JournalAmerican Journal of Cardiology
DOIs
StateAccepted/In press - 2017

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Anticoagulants
Atrial Fibrillation
Registries
Hemorrhage
Stroke
Therapeutics
Heart Failure
Hypertension
Renal Hypertension
International Normalized Ratio
Intracranial Hemorrhages
Insurance
Vascular Diseases
Alcohols
Databases
Liver

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

@article{dec4f384a282423990bc13506419afb7,
title = "Comparison of the CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA Risk Scores in Predicting Non-Vitamin K Antagonist Oral Anticoagulants-Associated Bleeding in Patients With Atrial Fibrillation",
abstract = "The increasing adoption of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF) necessitates a reassessment of bleeding risk scores. Because known risk factors for bleeding are largely the same as for stroke, we hypothesize that stroke risk scores could also be used to identify patients with high bleeding risks. We aimed to compare the performance of 2 stroke risk scores (Congestive Heart failure, hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, and Sex [female] [CHA2DS2-VASc] and Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] [CHADS2]) and 3 bleeding risk scores (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile INR, elderly [.65 years], drugs/alcohol concomitantly [1 point each] [HAS-BLED], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT], and AnTicoagulation and Risk factors In Atrial fibrillation [ATRIA]) in predicting major and intracranial bleeding. Using a large US commercial insurance database, we identified 39,539 patients with nonvalvular AF who started NOACs between October 1, 2010 and June 30, 2015. The performance of risk scores was compared using C-statistic and net reclassification improvement (NRI). Over a total of 22,583 person-years, 665 patients (2.94{\%} per year) had major bleeding, including 74 intracranial hemorrhages (0.33{\%} per year). For the prediction of major bleeding, CHA2DS2-VASc had the highest C-statistic both as a continuous score (C-statistic 0.68) and as a categorical score (C-statistic 0.65). For the prediction of intracranial bleeding, CHADS2 had the highest C-statistic both as a continuous score (C-statistic 0.66) and as a categorical score (C-statistic 0.66). There were no statistically significant differences between scores based on NRI. In conclusion, CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA had similar, albeit modest, performance in predicting NOAC-associated bleeding in patients with AF. Careful assessment and active management of bleeding risk factors may be warranted in all patients on NOACs who have high stroke risk scores.",
author = "Xiaoxi Yao and Gersh, {Bernard J.} and Sangaralingham, {Lindsey R.} and Kent, {David M.} and Shah, {Nilay D} and Abraham, {Neena Susan} and Peter Noseworthy",
year = "2017",
doi = "10.1016/j.amjcard.2017.07.051",
language = "English (US)",
journal = "American Journal of Cardiology",
issn = "0002-9149",
publisher = "Elsevier Inc.",

}

TY - JOUR

T1 - Comparison of the CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA Risk Scores in Predicting Non-Vitamin K Antagonist Oral Anticoagulants-Associated Bleeding in Patients With Atrial Fibrillation

AU - Yao, Xiaoxi

AU - Gersh, Bernard J.

AU - Sangaralingham, Lindsey R.

AU - Kent, David M.

AU - Shah, Nilay D

AU - Abraham, Neena Susan

AU - Noseworthy, Peter

PY - 2017

Y1 - 2017

N2 - The increasing adoption of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF) necessitates a reassessment of bleeding risk scores. Because known risk factors for bleeding are largely the same as for stroke, we hypothesize that stroke risk scores could also be used to identify patients with high bleeding risks. We aimed to compare the performance of 2 stroke risk scores (Congestive Heart failure, hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, and Sex [female] [CHA2DS2-VASc] and Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] [CHADS2]) and 3 bleeding risk scores (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile INR, elderly [.65 years], drugs/alcohol concomitantly [1 point each] [HAS-BLED], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT], and AnTicoagulation and Risk factors In Atrial fibrillation [ATRIA]) in predicting major and intracranial bleeding. Using a large US commercial insurance database, we identified 39,539 patients with nonvalvular AF who started NOACs between October 1, 2010 and June 30, 2015. The performance of risk scores was compared using C-statistic and net reclassification improvement (NRI). Over a total of 22,583 person-years, 665 patients (2.94% per year) had major bleeding, including 74 intracranial hemorrhages (0.33% per year). For the prediction of major bleeding, CHA2DS2-VASc had the highest C-statistic both as a continuous score (C-statistic 0.68) and as a categorical score (C-statistic 0.65). For the prediction of intracranial bleeding, CHADS2 had the highest C-statistic both as a continuous score (C-statistic 0.66) and as a categorical score (C-statistic 0.66). There were no statistically significant differences between scores based on NRI. In conclusion, CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA had similar, albeit modest, performance in predicting NOAC-associated bleeding in patients with AF. Careful assessment and active management of bleeding risk factors may be warranted in all patients on NOACs who have high stroke risk scores.

AB - The increasing adoption of non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF) necessitates a reassessment of bleeding risk scores. Because known risk factors for bleeding are largely the same as for stroke, we hypothesize that stroke risk scores could also be used to identify patients with high bleeding risks. We aimed to compare the performance of 2 stroke risk scores (Congestive Heart failure, hypertension, Age ≥75 [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74, and Sex [female] [CHA2DS2-VASc] and Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] [CHADS2]) and 3 bleeding risk scores (hypertension, abnormal renal/liver function [1 point each], stroke, bleeding history or predisposition, labile INR, elderly [.65 years], drugs/alcohol concomitantly [1 point each] [HAS-BLED], Outcomes Registry for Better Informed Treatment of Atrial Fibrillation [ORBIT], and AnTicoagulation and Risk factors In Atrial fibrillation [ATRIA]) in predicting major and intracranial bleeding. Using a large US commercial insurance database, we identified 39,539 patients with nonvalvular AF who started NOACs between October 1, 2010 and June 30, 2015. The performance of risk scores was compared using C-statistic and net reclassification improvement (NRI). Over a total of 22,583 person-years, 665 patients (2.94% per year) had major bleeding, including 74 intracranial hemorrhages (0.33% per year). For the prediction of major bleeding, CHA2DS2-VASc had the highest C-statistic both as a continuous score (C-statistic 0.68) and as a categorical score (C-statistic 0.65). For the prediction of intracranial bleeding, CHADS2 had the highest C-statistic both as a continuous score (C-statistic 0.66) and as a categorical score (C-statistic 0.66). There were no statistically significant differences between scores based on NRI. In conclusion, CHA2DS2-VASc, CHADS2, HAS-BLED, ORBIT, and ATRIA had similar, albeit modest, performance in predicting NOAC-associated bleeding in patients with AF. Careful assessment and active management of bleeding risk factors may be warranted in all patients on NOACs who have high stroke risk scores.

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SN - 0002-9149

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