Refining Prediction of Atrial Fibrillation-Related Stroke Using the P-2-CHA(2)DS(2)-VASc Score: ARIC and MESA

• Type of Material: Article
• Authors: Ankit Maheshwari, Hospital of the University of Pennsylvania; Faye L. Norby, University of Minnesota; Nicholas S. Roetker, University of Minnesota; Elsayed Z. Soliman, Wake Forest University; Ryan J. Koene, University of Minnesota; Mary R. Rooney, University of Minnesota; Wesley T. O'Neal, Emory University; Amil M. Shah, Brigham & Women's Hospital; Brian L. Claggett, Brigham & Women's Hospital; Scott D Solomon, Brigham & Women's Hospital; Alvaro Alonso, Emory University; Rebecca F. Gottesman, Johns Hopkins University; Susan R. Heckbert, University of Washington; Lin Y. Chen, University of Minnesota
• Language: English
• Date: 2019-01-08
• Publisher: American Heart Association
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2018 American Heart Association, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1161/CIRCULATIONAHA.118.035411
• Title of Journal or Parent Work: Circulation
• ISSN: 0009-7322
• Volume: 139
• Issue: 2
• Start Page: 180
• End Page: 191
• Grant/Funding Information: LYC is supported by R01HL126637 and R01HL141288.; This research in the Multi-Ethnic Study of Atherosclerosis was supported by contracts HHSN268201500003I, N01-HC-95159, N01-HC-95160, N01-HC-95161, N01-HC-95162, N01-HC-95163, N01-HC-95164, N01-HC-95165, N01-HC-95166, N01-HC-95167, N01-HC-95168 and N01-HC-95169; and grant HL127659 from the National Heart, Lung, and Blood Institute; and by grants UL1-TR-000040, UL1-TR-001079, and UL1-TR-001420 from National Center for Advancing Translational Sciences.; MR is supported by NHLBI T32HL007779.; The Atherosclerosis Risk in Communities Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts (HHSN268201100005C, HHSN268201100006C, HHSN268201100007C, HHSN268201100008C, HHSN268201100009C, HHSN268201100010C, HHSN268201100011C, and HHSN268201100012C).; AA is supported by an American Heart Association grant 16EIA26410001.
• Keywords: P-WAVE DURATION; ADVANCED INTERATRIAL BLOCK; ISCHEMIC-STROKE; stroke; COHORT; STRATIFICATION; atrial fibrillation; ATHEROSCLEROSIS RISK; Cardiovascular System & Cardiology; Peripheral Vascular Disease; Life Sciences & Biomedicine; CARDIOVASCULAR-DISEASE; Cardiac & Cardiovascular Systems; HEART-FAILURE; Science & Technology; ABNORMALITY; CHA(2)DS(2)-VASC SCORE
• Research Categories: Health Sciences, Medicine and Surgery; Health Sciences, Epidemiology

Abstract

Background: In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs) - prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHA2DS2-VASc score would improve its ability to predict AF-related ischemic stroke. Methods: We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement. Results: Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHA2DS2-VASc variables, and that resulted in meaningful improvement in stroke prediction. The β estimate was approximately twice that of the CHA2DS2-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P2-CHA2DS2-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively. Conclusions: Abnormal P-wave axis - an ECG correlate of left atrial abnormality - improves ischemic stroke prediction in AF. Compared with CHA2DS2-VASc, the P2-CHA2DS2-VASc is a better prediction tool for AF-related ischemic stroke.