The risk stratification in atrial fibrillation
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SELECTED PAPERS – ATRIAL FIBRILLATION
The risk stratification in atrial fibrillation Domenico Prisco • Caterina Cenci • Elena Silvestri Giacomo Emmi • Tommaso Barnini • Carlo Tamburini
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SIMI 2012
Abstract Atrial fibrillation (AF) is the most common rhythm disorder and represents a major public health problem because it carries an increased risk of arterial thromboembolism and ischemic stroke. Because the absolute benefit of antithrombotic therapy depends on the underlying risk of stroke, an accurate stratification of patients’ risk is needed to choose the appropriate antithrombotic strategy. Over the years, several stroke risk stratification models (RSMs) were developed based on the ‘classic’ risk factors for stroke such as increasing age, hypertension, diabetes mellitus, and left ventricular dysfunction. Among all RSMs, the CHADS2 score is the most popular and used one thanks to its simplicity and endorsement in several widely promulgated practice guidelines. Despite its validation in large datasets and specific population of AF patients, it has many limitations, especially due to the non-inclusion of several proven risk factors for stroke and to the classification of a large number of patients in the intermediate risk category, so creating ambiguity over the most appropriate antithrombotic therapy. Thus, the CHA2DS2-VASc score was introduced and was demonstrated to perform better than the CHADS2, even in a ‘‘real world’’ population of elderly AF patients. Recently, in view of the availability of new oral anticoagulant drugs, that can overcome the limitations of warfarin and allow a more personalized therapy, many efforts D. Prisco C. Cenci E. Silvestri Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy D. Prisco (&) E. Silvestri G. Emmi T. Barnini C. Tamburini SOD Patologia Medica, DAI Biomedicina, AOU Careggi, Largo Brambilla 3, 50134 Florence, Italy e-mail: [email protected]
are being made to identify other possibilities to assess the thromboembolic risk in AF patients. It has been demonstrated that an increase in C-reactive protein and interleukin-6 and the presence of G20210A factor II gene polymorphism and hyper-homocysteinemia are independent risk factors for ischemic complications in AF patients. Even the presence of chronic renal disease and the daily AF burden, registered with implantable monitors, are associated with an increase risk of stroke. Finally, the assessment of thromboembolic risk should go hand in hand with the consideration of the risk of bleeding. For this purpose, it has been recently developed a practical bleeding risk score, the HAS-BLED, which was included in the last ESC guidelines for the risk stratification of AF patients before starting anticoagulant therapy. Keywords Atrial fibrillation Stroke Thromboembolism Bleeding Risk factors
Introduction Atrial fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated electrical activation of the atria with consequent deterioration of a
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