Utility of HAS-BLED and CHA(2)DS(2)-VASc Scores Among Patients With Atrial Fibrillation and Imaging Evidence of Cerebral Amyloid Angiopathy

• Authors: Robert Ward, Mayo Clinic, Rochester; Shiva Ponamgi, Mayo Clinic Health System, Austin; Christopher DeSimone, Mayo Clinic, Rochester; Stephen English, Emory University; David O Hodge, Mayo Clinic, Jacksonville; Joshua P Slusser, Mayo Clinic, Rochester; Jonathan Graff-Radford, Mayo Clinic Rochester; Alejandro A Rabinstein, Mayo Clinic, Rochester; Sameul J Asirvatham, Mayo Clinic, Rochester; David Holmes, Mayo Clinic, Rochester
• Journal Title: MAYO CLINIC PROCEEDINGS
• Volume: Volume 95, Number 10
• Publisher: ELSEVIER SCIENCE INC | 2020-10-01, Pages 2090-2098
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.mayocp.2020.03.034
• Subjects: Health Sciences, General
• Keywords: Science & Technology; Life Sciences & Biomedicine; Medicine, General & Internal; General & Internal Medicine; MEDICAL-RECORDS-LINKAGE; INTRACRANIAL HEMORRHAGE; INTRACEREBRAL HEMORRHAGE; RISK STRATIFICATION; ISCHEMIC-STROKE; BLEEDING RISK; EPIDEMIOLOGY; ANTICOAGULATION; VALIDATION; MICROBLEEDS

Abstract

Objective: To determine the utility of the HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, Drugs/alcohol concomitantly) and CHA2DS2-VASc (Congestive heart failure, Hypertension, Age, Diabetes, previous Stroke/transient ischemic attack–VAScular disease) scores among patients on anticoagulation (AC) therapy for atrial fibrillation (AF) who have evidence of cerebral amyloid angiopathy (CAA). Patients and Methods: Patients older than 55 years with a diagnosis of AF who had a nontraumatic intracerebral hemorrhage (ICH) while on AC therapy between 1995 and 2016 were identified using the Rochester Epidemiology Project Database. Medical records were reviewed, including imaging of the brain, to identify baseline characteristics, AC use, and outcomes. Results: A total of 65 patients were identified (mean age, 81.3 years); 35 (53.8%) had evidence of possible/probable CAA. Mean HAS-BLED score in the CAA group was significantly lower (2.1) than that of the non-CAA group (2.9; P<.001). Mortality after ICH, adjusted for HAS-BLED scores, was not significantly different among patients with and without CAA. Sixteen patients restarted on AC therapy after ICH; CHA2DS2-VASc scores were no different between this group and those who were not restarted. Among patients with CAA, the overall rate of ICH recurrence was 8.6% over 93.5 person-years of follow-up. Among patients with CAA, the rate of ICH recurrence was 3.2 per 100 patient-years, higher than their HAS-BLED scores would predict (1.9 bleeds/100 patient-years). Conclusion: HAS-BLED scores were lower in patients who had evidence of CAA compared with those without, suggesting underestimation of ICH risk in patients with CAA. CHA2DS2-VASc scores did not affect resumption of AC therapy. ICH recurrence was higher in patients with CAA than their HAS-BLED scores predicted. Current risk assessment scoring systems do not accurately account for CAA in patients with AF on AC.