nach oben

Acta Diabetologica

Erschienen in:

Open Access 23.06.2016 | Original Article

CHA₂DS₂-VASc score is useful in predicting poor 12-month outcomes following myocardial infarction in diabetic patients without atrial fibrillation

verfasst von: Bartosz Hudzik, Janusz Szkodziński, Michal Hawranek, Andrzej Lekston, Lech Poloński, Mariusz Gąsior

Erschienen in: Acta Diabetologica | Ausgabe 5/2016

Abstract

Aims

TIMI risk score and GRACE risk model are widely available and accepted scores for risk assessment in STEMI patients and include predictors of poor outcomes. CHA₂DS₂-VASc is a validated score for predicting embolic/stroke risk in patients with non-valvular atrial fibrillation. Its components contribute to the worse prognosis following myocardial infarction. The advantage of the CHA₂DS₂-VASc score in comparison with other risk scores is that it provides a comprehensive, fast, and simple method for physicians in risk evaluation that requires no calculators or computers. Therefore, we have set out to examine the prognostic significance of CHA₂DS₂-VASc score following STEMI in diabetic patients without AF.

Methods

A total of 472 patients with diabetes mellitus and STEMI undergoing primary PCI were enrolled. Based on the estimated CHA₂DS₂-VASc score, the study population was divided into three groups: group 1 (N = 111) with a moderate CHA₂DS₂-VASc score of 2 or 3; group 2 (N = 257) with a high CHA₂DS₂-VASc score of 4 or 5; and group 3 (N = 104) with a very high CHA₂DS₂-VASc score of 6 or higher.

Results

In diabetic patients with STEMI, the median of CHA₂DS₂-VASc score was 4 (interquartile range 3–5). In-hospital mortality rate was similar across three groups. CHA₂DS₂-VASc score was not a risk factor of in-hospital mortality. ROC analysis revealed good diagnostic value of CHA₂DS₂-VASc score in predicting long-term mortality (AUC 0.62 95 % CI 0.57–0.66 P = 0.0003) and stroke (AUC 0.75 95 % CI 0.71–0.79 P = 0.0003), but no value in predicting long-term myocardial infarction. CHA₂DS₂-VASc score was an independent predictor of 12-month mortality and stroke. One-point increment in CHA₂DS₂-VASc score was associated with an increase in the risk of 12-month death by 24 % and for 12-month stroke by 101 %.

Conclusions

In diabetic patients with STEMI and no previous AF, median CHA₂DS₂-VASc score was high (4 points) and predicted 12-month death and stroke. However, it failed to predict in-hospital death and 12-month MI. CHA₂DS₂-VASc score had a similar discrimination performance in predicting 12-month mortality as TIMI risk score and a better discrimination performance in predicting 12-month stroke than TIMI risk score. Thus, it can serve as an additive tool in identifying high-risk patients that require aggressive management.

Managed by Antonio Secchi.

Introduction

Outcomes following ST-segment elevation myocardial infarction (STEMI) have improved over the past two decades. Nevertheless, survivors of STEMI have an elevated risk of subsequent vascular events, including stroke and 12-month mortality approaches 10 % [1]. Risk stratification following STEMI plays an essential role in managing patients and is recommended prior to discharge by the current guidelines. TIMI risk score and GRACE risk model are widely available and accepted scores for risk assessment and include predictors of poor outcomes which were established in large databases of MI patients [2‐4]. The algorithms aid clinicians in assessing prognosis and may therefore be useful in guiding management. These two models are both fitted for predicting short- and long-term prognosis and assess the risk in a two-step process which includes: (1) stratifying patients at admission based on demographics, physical examination, presenting signs, and initial laboratory and angiographic data, and (2) identifying long-term risk based on the development of post-event complications. These scores were designed to be simple and practical, although they comprise numerous variables.

Evidence suggests that diabetes mellitus (DM) is among the most important risk factors of poor outcome following STEMI. DM is one of the components of the CHA₂DS₂-VASc score. Such a high incidence of thromboembolic events observed in these clinical subsets may be attributable to the DM-related prothrombotic state [5]. Generally, the diagnosis of DM is pivotal to assess cardiovascular risk and to guide therapy and lifestyle modification. Particularly, this topic is especially relevant for those patients who have already experienced a major cardiovascular event [6]. In addition, the presence of coronary artery disease is a prognostic factor in DM complications [7, 8]. Accurate risk assessment together with regular follow-up may result in a lower glycemic burden and a lower rate of vascular complications [9].

CHADS₂ and the more recent CHA₂DS₂-VASc are two validated scores for predicting embolic/stroke risk in patients with non-valvular atrial fibrillation (AF) [10, 11]. They aid us in guiding antithrombotic therapy in AF patients. The individual score components not only predict AF-associated stroke risk but also are linked to the development of AF [12‐14]. The CHADS₂ and CHA₂DS₂-VASc scores have been reported to identify post-STEMI patients at high risk of AF and ischemic stroke [14].

In addition to predicting the risk of stroke/embolic events in AF patients, CHA₂DS₂-VASc score components (i.e., increasing age, hypertension, diabetes mellitus, prior cardiovascular events) are traditional risk factors that are associated with atherosclerosis, coronary artery disease, and contribute to the worse prognosis following myocardial infarction (MI). However, only a few studies have examined the prognostic value of CHA₂DS₂-VASc following MI [15, 16], and no studies have been found to evaluate CHA₂DS₂-VASc among STEMI or diabetic populations exclusively.

The advantage of the CHA₂DS₂-VASc score in comparison with other risk scores is that it provides a comprehensive, fast, and simple method for physicians in risk evaluation that requires no calculators or computers. Therefore, we have set out to examine the prognostic significance of CHA₂DS₂-VASc score following STEMI in diabetic patients. In the interest of averting a possible effect of AF on the outcomes, we have performed the analysis in a population of patients without AF.

Materials and methods

The study conforms to the Declaration of Helsinki. Informed consent for data analysis was obtained from the patients according to the Polish law on patients’ rights regarding data registration. Approval for analyzing recorded data was waived by the local bioethics committee on human research given the retrospective nature of the study. Patients admitted with diagnosis of STEMI, within 12 h from symptom onset were enrolled in the study. Patients with a history of or newly diagnosed AF were excluded. This is a single-center, cross-sectional, retrospective study.

The components of CHA₂DS₂-VASc score include: congestive heart failure (1 point), hypertension (1 point), age >75 years (2 points), diabetes mellitus (1 point), history of stroke (2 points), history of vascular disease (1 point), age >65 years (1 point), and female sex (1 point) [11]. The history of myocardial infarction was regarded as ‘vascular disease’, and the current STEMI was counted as 1 point. As the study investigated only diabetic patients, all patients have received a minimum score of 2 points.

All patients received loading doses of antiplatelet medications (aspirin, clopidogrel) before admission to our hospital (either in the referring hospital or ambulance) according to the guidelines. Diabetes mellitus was defined as: (a) preexisting condition diagnosed before STEMI (patients on insulin, oral glucose-lowering drugs, or on a diet) and (b) newly diagnosed diabetes mellitus based on fasting plasma glucose (FPG) ≥7.0 mmol/L or 2-h plasma glucose ≥11.1 mmol/L during an oral glucose tolerance test (OGTT) [17]. To avoid acute hyperglycemia, FPG was taken into consideration after the third day of hospital stay. For that reason, OGTT was performed on day four of hospital stay or later. STEMI was defined as: (1) ST-segment elevation consistent with MI of at least 2 mm in contiguous precordial leads and/or ST-segment elevation of at least 1 mm in two or more limb leads or new left bundle branch block, and (2) positive cardiac necrosis markers: CK-MB mass (upper limit of normal: 4.9 mg/mL) and/or troponin T (upper limit of normal: 0.014 ng/mL). Patients received 300 mg of acetylsalicylic acid (ASA) loading dose and 600 mg of clopidogrel loading dose, followed by 75 mg of ASA maintenance dose and 75 mg of clopidogrel maintenance dose [18]. Coronary angiography and percutaneous coronary interventions were performed using standard protocols and guidelines. A culprit lesion was described in the presence of an acute occlusion, intraluminal filling defects (or thrombus), ulcerated plaques, dissection, or intraluminal flaps. Successful PCI was defined as a post-procedural residual-diameter stenosis <30 %, with TIMI 3 flow in the infarct-related artery and no procedural complications.

All patients were scheduled for an elective 12-month clinical follow-up. We clinically monitored the patients for cardiovascular events. The major adverse cardiac and cerebrovascular events (MACCEs) included death, rehospitalization for myocardial infarction, and stroke.

Statistical analysis

Quantitative data are presented as means ± standard deviations (SDs) or medians with interquartile ranges (lower and upper quartiles). Qualitative data are presented as frequencies. The Shapiro–Wilk test was used to determine whether random samples came from a normal distribution. The Chi-square test with Yates’ correction was used to compare categorical variables. One-way analysis of variance (ANOVA) and Kruskal–Wallis ANOVA tests were used to compare continuous variables between groups for variables normally and not normally distributed, respectively. In-hospital and one-year survival was estimated with the Kaplan–Meier method and compared with the log-rank test. The relationship between CHA₂DS₂-VASc score and clinical variables was evaluated by Spearman’s rank correlation coefficient. Receiver-operating characteristic (ROC) curves were estimated for CHA₂DS₂-VASc score. ROC analysis was used to determine the cutoff values of CHA₂DS₂-VASc score to predict in-hospital and 12-month mortality, myocardial infarction, and stroke. The effects of the clinical and angiographic variables on the in-hospital and 12-month mortality were assessed using the multivariate Cox proportional hazard regression models with the results expressed as hazard ratios (HRs) and 95 % confidence intervals (CIs). Variables with a significant influence on mortality in univariate analysis were entered into the multivariate model. These included: history of myocardial infarction, left ventricular ejection fraction (per 1 % increment), success of PCI (final TIMI 3 flow) in the culprit vessel, cardiogenic shock, and time form symptom onset (per 1-h increment). Variables with a significant influence on 12-month stroke in univariate analysis were entered into the multivariate model. These included: history of myocardial infarction, anterior myocardial infarction on admission, and left ventricular ejection fraction (per 1 % increment).

A value of P < 0.05 was considered significant.

Results

In diabetic patients with STEMI, the median of CHA₂DS₂-VASc score was 4 (interquartile range 3–5). The number of patients falling in each CHA₂DS₂-VASc score category is depicted in Fig. 1. Baseline clinical characteristics are featured in Table 1. Patients with moderate CHA₂DS₂-VASc score (group 1) were younger and more frequently men. Hypertension and a lower ejection fraction were more prevalent among patients with a high and very high CHA₂DS₂-VASc score (groups 2 and 3). Angiographic data are presented in Table 2. There was a trend toward a worse initial TIMI flow in group 3. Initial TIMI 3 flow was the least prevalent in group 3. Notwithstanding, final TIMI flow was similar in all three groups. ROC analysis demonstrated no value of CHA₂DS₂-VASc score in predicting in-hospital mortality AUC 0,503 (95 % CI 0.463–0.555) P = 0.83. In-hospital mortality rate was similar across three groups (Fig. 2a). CHA₂DS₂-VASc score was not a risk factor of in-hospital mortality (Table 3). During 12-month follow-up, there were 10 deaths (9.0 %) in group 1, 43 deaths (16.7 %) in group 2, and 27 deaths (16.2 %) in group 3 (P = 0.003) (Table 3; Fig. 2b). The rate of non-fatal myocardial infarction was similar across all groups, and the rate of stroke was higher in group 3 (Table 4; Fig. 3a, b). ROC analysis revealed good diagnostic value of CHA₂DS₂-VASc score in predicting 12-month mortality and stroke, but no value in predicting 12-month myocardial infarction (Tables 5, 6; Fig. 4a, b). CHA₂DS₂-VASc score was an independent predictor of 12-month mortality and stroke. One-point increment in CHA₂DS₂-VASc score was associated with an increase in the risk of 12-month death by 24 % and for 12-month stroke by 101 %. CHA₂DS₂-VASc score was positively correlated with age (Spearman R = 0.67 P < 0.0001) and TIMI risk score (Spearman R = 0.40 P < 0.0001), and negatively correlated with ejection fraction (Spearman R = 0.28 P < 0.0001), time to stroke during follow-up (Spearman R = −0.13 P = 0.003), and time to death during follow-up (Spearman R = −0.15 P = 0.001).

Table 1

Patients’ baseline and clinical characteristics

	Group 1 N = 111	Group 2 N = 257	Group 3 N = 104	P
Age, years (mean ± SD)	57 ± 8^†	64 ± 8^†	73 ± 6^†	0.0001
Sex, men, N (%)	106 (95.5 %)	150 (58.4 %)	15 (14.4 %)	0.0001
Systemic hypertension, N (%)	41 (36.9 %)	198 (77.0 %)	100 (96.1 %)	0.0001
Anterior myocardial infarction, N (%)	34 (30.6 %)	89 (34.6 %)	36 (34.6 %)	0.7
Prior myocardial infarction, N (%)	34 (30.6 %)	78 (30.5 %)	32 (30.8 %)	0.9
Time from symptom onset, hours [median (interquartile range)]	5.0 (3.0–7.0)	4.5 (3.0–7.0)	4.5 (3.0–7.5)	0.3
Cardiogenic shock, N (%)	15 (13.5 %)	33 (12.8 %)	16 (15.4 %)	0.8
LVEF, (%) [median (interquartile range)]	50 (41–55)*	40 (35–46)*	40 (35–45)*	0.0001
Hospital stay, days [median (interquartile range)]	8 (6–11)	9 (6–12)	8 (6–12)	0.09
TIMI risk score	3 (2–4)^§	3 (2–5)^§	4 (3–6)^§	<0.0001
HbA1c (%) [median (interquartile range)]	7.6 (7.0–8.0)	7.6 (6.9–8.0)	7.5 (6.9–8.2)	0.9
Admission glycemia (mmol/l) [median (interquartile range)]	8.1 (7.0–11.4)	7.8 (6.8–10.2)	8.0 (6.2–10.3)	0.2
Fasting plasma glucose (mmol/L) [median (interquartile range)]	6.7 (5.3–7.8)	6.8 (5.8–7.9)	6.6 (5.2–8.3)	0.6
In-hospital death, N (%)	17 (15.3 %)	30 (11.7 %)	17 (16.3 %)	0.4

SD standard deviation, LVEF left ventricular ejection fraction

* Group 1 versus group 2 P < 0.001, group 1 versus group 3 P < 0.001, and group 2 versus group 3 P = 0.7

^†Group 1 versus group 2 P < 0.0001, group 1 versus group 3 P < 0.0001, and group 2 versus group 3 P < 0.0001

^§Group 1 versus group 2 P = 0.01, group 1 versus group 3 P < 0.0001, and group 2 versus group 3 P < 0.0001

Table 2

Angiographic findings

	Group 1 N = 111	Group 2 N = 257	Group 3 N = 104	P
Multivessel CAD, N (%)	49 (44.1 %)	117 (45.5 %)	47 (45.2 %)	0.6
Initial TIMI flow, N (%)
0	63 (56.8 %)	150 (58.6 %)	56 (53.8 %)	0.08
1	18 (16.2 %)	46 (17.9 %)	18 (17.3 %)
2	14 (12.6 %)	35 (13.7 %)	25 (24.0 %)
3	16 (14.4 %)	26 (10.1 %)	5 (4.8 %)
Initial TIMI 3 flow, N (%)	16 (14.4 %)	26 (10.1 %)	5 (4.8 %)	0.05
Final TIMI flow, N (%)
0	5 (4.5 %)	17 (6.6 %)	8 (7.1 %)	0.8
1	1 (0.9 %)	3 (1.2 %)	2 (1.9 %)
2	11 (10.0 %)	19 (7.4 %)	9 (8.7 %)
3	94 (84.6 %)	218 (85.1 %)	85 (81.3 %)
Final TIMI 3 flow, N (%)	94 (84.6 %)	218 (85.1 %)	85 (81.3 %)	0.7

Table 3

Predictors of in-hospital and 12-month mortality

In-hospital mortality
	Unadjusted			Adjusted
	HR	95 % CI	P	HR	95 % CI	P
CHA₂DS₂-VASc score (per one-point increment)	0.99	0.81–1.21	0.9	–	–	–

Twelve-month mortality
	Unadjusted			Adjusted*
	HR	95 % CI	P	HR	95 % CI	P
CHA₂DS₂-VASc score (per one-point increment)	1.31	1.11–1.54	0.001	1.24	1.06–1.45	0.008

Twelve-month myocardial infarction
	Unadjusted			Adjusted
	HR	95 % CI	P	HR	95 % CI	P
CHA₂DS₂-VASc score (per one-point increment)	0.78	0.52–1.16	0.22	–	–	–

Twelve-month stroke
	Unadjusted			Adjusted**
	HR	95 % CI	P	HR	95 % CI	P
CHA₂DS₂-VASc score (per one-point increment)	1.81	1.18–2.79	0.006	2.01	1.25–3.23	0.004

HR hazard ratio, CI confidence interval

* Adjusted for: history of myocardial infarction, left ventricular ejection fraction (per 1 % increment), successful percutaneous coronary intervention (final TIMI 3 flow) in the culprit vessel, cardiogenic shock, time form symptom onset (per 1-h increment), platelet distribution width (per 1fL increment), and platelet count (per 10⁴/mm³ increment)

** Adjusted for: history of myocardial infarction, left ventricular ejection fraction (per 1 % increment), anterior myocardial infarction during index hospitalization

Table 4

12-month follow-up

	Group 1 N = 111	Group 2 N = 257	Group 3 N = 104	P
All-cause mortality, N (%)	10 (9.0 %)	43 (16.7 %)	27 (16.2 %)	0.003
Non-fatal myocardial infarction, N (%)	5 (4.5 %)	9 (3.5 %)	3 (2.9 %)	0.7
Stroke, N (%)	0 (0 %)	3 (1.1 %)	7 (6.7 %)	0.004

Table 5

Receiver-operating characteristics curves identifying the discrimination thresholds of CHA₂DS₂-VASc score for predicting 12-month mortality, non-fatal myocardial infarction, and stroke

	Cut off	AUC	95 % CI	Sensitivity (%)	Specificity (%)	PPV (%)	NPV (%)	P
All-cause mortality	>4	0.62	0.57–0.66	62	56	23	88	0.0003
Myocardial infarction		0.58	0.45–0.62					0.3
Stroke	>4	0.75	0.71–0.79	91	54	5	99	0.0003

Table 6

Comparison of the receiver-operating characteristics curves identifying the discrimination thresholds of CHA₂DS₂-VASc score and TIMI risk score for long-term hospital mortality and stroke

	Cut off	AUC	95 % CI
Twelve-month mortality
CHA₂DS₂-VASc score	>4	0.67	0.63–0.71
TIMI risk score	>4	0.60	0.56–0.65
Difference between areas CHA₂DS₂-VASc score and TIMI risk score		0.06
95 % CI		−0.03–0.15
P		0.18
Twelve-month stroke
CHA₂DS₂-VASc score	>4	0.75	0.71–0.79
TIMI risk score	>4	0.52	0.48–0.57
Difference between areas CHA₂DS₂-VASc score and TIMI risk score		0.22
95 % CI		0.06–0.38
P		0.006

Discussion

In the current study, we have set out to investigate the utility of CHA₂DS₂-VASc score in predicting poor outcomes in patients with diabetes mellitus and STEMI. In particular, we have sought to determine whether CHA₂DS₂-VASc score commonly used for prediction of thromboembolic events in AF patients can be used as a risk assessment tool in STEMI patients without AF.

There are several major findings of the study. First and foremost, CHA₂DS₂-VASc score was high across the entire study population with a median of 4 points. Second, it had no influence on the in-hospital mortality. The third major finding was that CHA₂DS₂-VASc score, both unadjusted and adjusted for potential cofounders, correlated with 12-month stroke and all-cause mortality, but it had no influence on 12-month myocardial infarction. CHA₂DS₂-VASc score showed similar predictive value with respect to 12-month mortality as TIMI risk score. More importantly, it demonstrated a better predictive value with respect to 12-month stroke than TIMI risk score. And finally, CHA₂DS₂-VASc score showed a negative correlation with the time to subsequent stroke or death during follow-up.

CHADS₂ score was developed to identify AF patients at risk for stroke or thromboembolic event and thus to guide anticoagulation therapy [10]. However, patients with an intermediate risk (CHADS₂ score 1) presented a challenge in everyday practice because some of them were at low–intermediate risk and others were at high–intermediate risk. Consequently, CHA₂DS₂-VASc score was introduced to improve predictive value for thromboembolic events in patients at low and intermediate risk [11]. The utility of the score goes beyond the benefits of risk stratification for thromboembolic events. Apiyasawat et al. [19] reported it to be an independent prognostic marker of mortality following hospitalization for AF. All elements of the CHA₂DS₂-VASc score are essential risk factors in cardiovascular disease. Hypertension, diabetes mellitus, and congestive heart failure were all found to be predictors of poor outcomes following acute MI [20].

As pointed out in the introduction to this paper, there is little published reports on the utility of CHA₂DS₂-VASc score in risk stratification following acute MI. Poci et al. [21] analyzed 2335 patients with acute coronary syndromes and reported that CHADS₂ score was associated with long-term mortality (HR 1.38 95 % CI 1.28–1.48 P < 0.0001) and stroke (HR 1.46 95 % CI 1.27–1.68 P < 0.0001). Kim et al. [15] performed a retrospective analysis of 15,681 patients with acute MI who were enrolled in the Korean Working Group in Acute Myocardial Infarction (KORMI) registry. They reported that CHA₂DS₂-VASc score was associated with long-term cardiac events (MI, all-cause death) (HR 1.384 P < 0.0001). Interestingly, they found that CHA₂DS₂-VASc score was a more important predictor in STEMI patients (HR 1.455 P < 0.0001) than in NSTEMI patients (HR 1.298 P = 0.048). Piccini et al. [22] proposed a modified R-CHA₂DS₂-VASc score by adding renal function parameters (glomerular filtration rate and urea), performance of a revascularization procedure, and history of atrial fibrillation. Based on that modified R-CHA₂DS₂-VASc score, a study showed a good calibration and high discriminative performance of that score in the prediction of post-discharge ischemic stroke and all-cause mortality [23]. Recently, Podolecki et al. [16] studied 2980 patients with acute coronary syndromes and no AF and reported that an increment of one point in the CHA₂DS₂-VASc score was independently associated with a 41 % increase in stroke risk and a 23 % increase in mortality rate (P < 0.001 for both). Our results agree with the aforementioned studies. We found that one-point increment in CHA₂DS₂-VASc score was associated with an increase in the risk of 12-month death by 24 % and for 12-month stroke by 101 %. The present study validates prior findings and refines their estimates among patients with diabetes mellitus. In addition, we demonstrated that the score was negatively correlated with the time to stroke and the time to death during follow-up. Furthermore, we demonstrated that CHA₂DS₂-VASc score yielded a moderately high negative predictive value (NPV) of 88 % for identifying patients at low risk of 12-month death and a high NPV of 99 % for identifying patients at low risk for 12-month stroke. Similar observations were made by Melgaard et al. [24] in a population of patients with heart failure and no AF.

CHA₂DS₂-VASc score comprises a cluster of common cardiovascular risk factors associated with thromboembolism. It is possible it may identify underlying conditions that may lead to AF, stroke, or death during follow-up. It is reported to predict incident AF in patients without preexisting AF [25‐27]. More importantly, CHA₂DS₂-VASc score is recognized to be related to mortality and ischemic stroke in patients without AF and stroke [28, 29], heart failure [24], acute coronary syndromes [25], undergoing CABG [30]. Interestingly, Podolecki et al. analyzing patients with acute coronary syndromes failed to show any discrimination performance of CHA₂DS₂-VASc score in predicting incident MI during follow-up [16]. This finding is in agreement with our observations. Moreover, cerebral atherosclerosis is reported to be more common in patients with higher CHADS₂ score. Kim et al. [31] demonstrated that patients with higher CHADS₂ score had more carotid (both extra- and intracranial) stenosis. This finding may, in turn, result in an elevated risk of atherothrombotic stroke even in the absence of AF.

Overall, CHA₂DS₂-VASc score seems to be a well-known, simple tool that (1) comprises clusters of conditions that are associated with poor outcomes, (2) may increase the risk of incident AF in patients without preexisting AF leading to thromboembolic stroke, and (3) may be associated with a more extensive atherosclerosis leading to atherothrombotic stroke. All of the aforementioned mechanisms indicate the role of CHA₂DS₂-VASc score in predicting an increased morbidity and mortality. Taken together, these findings further support the potential role of CHA₂DS₂-VASc score in identifying high-risk patients that may require more aggressive management strategies.

Strengths and limitations

We investigated a real-life population of diabetic patients with STEMI in which we did not exclude patients with severe comorbidities, including cardiogenic shock. These comorbidities may have predisposed some of the patients to a greater risk of stroke. Single-center design has also its shortcomings. We cannot exclude that some of the patients have had undiagnosed AF, as vascular disease (acute MI in this instance) is associated with a higher AF prevalence. Moreover, we lack data on the development of AF during follow-up, which may have resulted in the increased risk of stroke. In any way, we were able to demonstrate the role of CHA₂DS₂-VASc score in identifying patients at risk of increased 12-month mortality and stroke regardless the underlying mechanisms. Given the relatively low study size, however, these promising results should be verified on much larger cohorts.

Conclusions

Compliance with ethical standards

Funding

None.

Conflict of interest

The authors have no commercial associations or sources of support that might pose a conflict of interests.

Human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Informed consent was obtained from all patients for being included in the study. Informed consent for data analysis was obtained from the patients according to the Polish law on patients’ rights regarding data registration. Approval for analyzing recorded data was waived by the local bioethics committee on human research given the retrospective nature of the study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Unsere Produktempfehlungen

e.Med Interdisziplinär

Kombi-Abonnement

Für Ihren Erfolg in Klinik und Praxis - Die beste Hilfe in Ihrem Arbeitsalltag

Mit e.Med Interdisziplinär erhalten Sie Zugang zu allen CME-Fortbildungen und Fachzeitschriften auf SpringerMedizin.de.

Jetzt testen ¹

e.Med Innere Medizin

Kombi-Abonnement

Mit e.Med Innere Medizin erhalten Sie Zugang zu CME-Fortbildungen des Fachgebietes Innere Medizin, den Premium-Inhalten der internistischen Fachzeitschriften, inklusive einer gedruckten internistischen Zeitschrift Ihrer Wahl.

Jetzt testen ²

e.Med Allgemeinmedizin

Kombi-Abonnement

Mit e.Med Allgemeinmedizin erhalten Sie Zugang zu allen CME-Fortbildungen und Premium-Inhalten der allgemeinmedizinischen Zeitschriften, inklusive einer gedruckten Allgemeinmedizin-Zeitschrift Ihrer Wahl.

Jetzt testen ³

McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ (2011) Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI. Am J Med 124:40–47CrossRefPubMedPubMedCentral

Morrow DA, Antman EM, Parsons L et al (2001) Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA 286:1356–1359CrossRefPubMed

Granger CB, Goldberg RJ, Dabbous O et al (2003) Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med 163:2345–2353CrossRefPubMed

Eagle KA, Lim MJ, Dabbous OH et al (2004) A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA 291:2727–2733CrossRefPubMed

Pomero F, Di Minno MN, Fenoglio L, Gianni M, Ageno W, Dentali F (2015) Is diabetes a hypercoagulable state? A critical appraisal. Acta Diabetol 52:1007–1016CrossRefPubMed

Luzi A, Rizza S, Cardellini M et al (2015) A1c value for diabetes diagnosis in subjects with established cardiovascular disease. Acta Diabetol 52:999–1001CrossRefPubMed

Bergis D, Bergis PM, Hermanns N, Zink K, Haak T (2014) Coronary artery disease as an independent predictor of survival in patients with type 2 diabetes and charcot neuro-osteoarthropathy. Acta Diabetol 51:1041–1048CrossRefPubMed

Bjornstad P, Maahs DM, Rivard CJ et al (2014) Serum uric acid predicts vascular complications in adults with type 1 diabetes: the coronary artery calcification in type 1 diabetes study. Acta Diabetol 51:783–791CrossRefPubMedPubMedCentral

Anjana RM, Shanthirani CS, Unnikrishnan R et al (2015) Regularity of follow-up, glycemic burden, and risk of microvascular complications in patients with type 2 diabetes: a 9-year follow-up study. Acta Diabetol 52:601–609CrossRefPubMed

10.

Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285:2864–2870CrossRefPubMed

11.

Camm AJ, Kirchhof P, Lip GY et al (2010) Guidelines for the management of atrial fibrillation: the task force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 31:2369–2429CrossRefPubMed

12.

Schnabel RB, Sullivan LM, Levy D et al (2009) Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study. Lancet 373:739–745CrossRefPubMedPubMedCentral

13.

Chamberlain AM, Agarwal SK, Folsom AR et al (2011) A clinical risk score for atrial fibrillation in a biracial prospective cohort (from the Atherosclerosis Risk in Communities [ARIC] study). Am J Cardiol 107:85–91CrossRefPubMedPubMedCentral

14.

Lau KK, Chan PH, Yiu KH et al (2014) Roles of the CHADS2 and CHA2DS2-VASc scores in post-myocardial infarction patients: risk of new occurrence of atrial fibrillation and ischemic stroke. Cardiol J. 21:474–483CrossRefPubMed

15.

Kim KH, Kim W, Hwang SH, Kang WY, Cho SC, Jeong MH (2015) The CHA2DS2VASc score can be used to stratify the prognosis of acute myocardial infarction patients irrespective of presence of atrial fibrillation. J Cardiol 65:121–127CrossRefPubMed

16.

Podolecki T, Lenarczyk R, Kowalczyk J et al (2015) Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation. J Cardiovasc Med (Hagerstown). 16:497–502CrossRef

17.

Ryden L, Standl E, Bartnik M et al (2007) Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The task force on diabetes and cardiovascular diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 28:88–136CrossRefPubMed

18.

Silber S, Albertsson P, Aviles FF et al (2005) Guidelines for percutaneous coronary interventions. The task force for percutaneous coronary interventions of the European Society of Cardiology. Eur Heart J 26:804–847CrossRefPubMed

19.

Apiyasawat S, Tangcharoen T, Wisaratapong T, Yamwong S, Wiboonpolprasert S, Sritara P (2015) CHA(2)DS(2)-VASc scores predict mortality after hospitalization for atrial fibrillation. Int J Cardiol 185:293–296CrossRefPubMed

20.

Gustafsson F, Kober L, Torp-Pedersen C, Hildebrandt P, Ottesen MM, Sonne B, Carlsen J (1998) Long-term prognosis after acute myocardial infarction in patients with a history of arterial hypertension. TRACE study group. Eur Heart J 19:588–594CrossRefPubMed

21.

Poci D, Hartford M, Karlsson T, Herlitz J, Edvardsson N, Caidahl K (2012) Role of the CHADS2 score in acute coronary syndromes: risk of subsequent death or stroke in patients with and without atrial fibrillation. Chest 141:1431–1440CrossRefPubMed

22.

Piccini JP, Stevens SR, Chang Y et al (2013) Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2)CHADS(2) index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) study cohorts. Circulation 127:224–232CrossRefPubMed

23.

Barra S, Almeida I, Caetano F et al (2013) Stroke prediction with an adjusted R-CHA2DS2VASc score in a cohort of patients with a Myocardial Infarction. Thromb Res 132:293–299CrossRefPubMed

24.

Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY (2015) Assessment of the CHA2DS2-VASc score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA 314:1030–1038CrossRefPubMed

25.

Mitchell LB, Southern DA, Galbraith D, Ghali WA, Knudtson M, Wilton SB (2014) Prediction of stroke or TIA in patients without atrial fibrillation using CHADS2 and CHA2DS2-VASc scores. Heart 100:1524–1530CrossRefPubMed

26.

Seo WK, Kang SH, Jung JM, Choi JY, Oh K (2016) Novel composite score to predict atrial fibrillation in acute stroke patients: AF predicting score in acute stroke. Int J Cardiol 209:184–189CrossRefPubMed

27.

Saliba W, Gronich N, Barnett-Griness O, Rennert G (2016) Usefulness of CHADS and CHADS-VASc scores in the prediction of new-onset atrial fibrillation: a population-based study. Am J Med. doi:10.1016/j.amjmed.2016.02.029 PubMed

28.

Ntaios G, Lip GY, Makaritsis K et al (2013) CHADS(2), CHA(2)S(2)DS(2)-VASc, and long-term stroke outcome in patients without atrial fibrillation. Neurology 80:1009–1017CrossRefPubMed

29.

Saliba W, Gronich N, Barnett-Griness O, Rennert G (2016) The role of CHADS and CHA DS -VASc scores in the prediction of stroke in individuals without atrial fibrillation: a population-based study. J Thromb Haemost 14:1155–1162CrossRefPubMed

30.

Verdejo HBP, Zalaquett R, Heuete I, Corbalan R (2015) CHA2DS2-VASc score predicts the occurrence of perioperative stroke in CABG patients without post-operative atrial fibrillation. Circulation 132:A18978

31.

Kim YD, Cha MJ, Kim J et al (2011) Increases in cerebral atherosclerosis according to CHADS2 scores in patients with stroke with nonvalvular atrial fibrillation. Stroke 42:930–934CrossRefPubMed

Titel: CHA2DS2-VASc score is useful in predicting poor 12-month outcomes following myocardial infarction in diabetic patients without atrial fibrillation
verfasst von: Bartosz Hudzik
Janusz Szkodziński
Michal Hawranek
Andrzej Lekston
Lech Poloński
Mariusz Gąsior
Publikationsdatum: 23.06.2016
Verlag: Springer Milan
Erschienen in: Acta Diabetologica / Ausgabe 5/2016
Print ISSN: 0940-5429
Elektronische ISSN: 1432-5233
DOI: https://doi.org/10.1007/s00592-016-0877-6

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

^{Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag}

Kostenlos registrieren

Neu im Fachgebiet Innere Medizin

Echinokokkose medikamentös behandeln oder operieren?

06.05.2024 DCK 2024 Kongressbericht

Die Therapie von Echinokokkosen sollte immer in spezialisierten Zentren erfolgen. Eine symptomlose Echinokokkose kann – egal ob von Hunde- oder Fuchsbandwurm ausgelöst – konservativ erfolgen. Wenn eine Op. nötig ist, kann es sinnvoll sein, vorher Zysten zu leeren und zu desinfizieren.

Aquatherapie bei Fibromyalgie wirksamer als Trockenübungen

03.05.2024 Fibromyalgiesyndrom Nachrichten

Bewegungs-, Dehnungs- und Entspannungsübungen im Wasser lindern die Beschwerden von Patientinnen mit Fibromyalgie besser als das Üben auf trockenem Land. Das geht aus einer spanisch-brasilianischen Vergleichsstudie hervor.

Wo hapert es noch bei der Umsetzung der POMGAT-Leitlinie?

03.05.2024 DCK 2024 Kongressbericht

Seit November 2023 gibt es evidenzbasierte Empfehlungen zum perioperativen Management bei gastrointestinalen Tumoren (POMGAT) auf S3-Niveau. Vieles wird schon entsprechend der Empfehlungen durchgeführt. Wo es im Alltag noch hapert, zeigt eine Umfrage in einem Klinikverbund.

VHF-Ablation nützt wohl nur bei reduzierter Auswurfleistung

02.05.2024 Ablationstherapie Nachrichten

Ob die Katheterablation von Vorhofflimmern bei Patienten mit Herzinsuffizienz die Komplikationsraten senkt, scheint davon abzuhängen, ob die Auswurfleistung erhalten ist oder nicht. Das legen die Ergebnisse einer Metaanalyse nahe.

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Live-Webinar "Chronische Unterbauch- und Viszeralschmerzen in der Praxis managen"

Springer Medizin

Abstract

Aims

Methods

Results

Conclusions

Introduction

Materials and methods

Statistical analysis

Results

Discussion

Strengths and limitations

Conclusions

Compliance with ethical standards

Funding

Conflict of interest

Human and animal rights

Informed consent

Unsere Produktempfehlungen

e.Med Interdisziplinär

e.Med Innere Medizin

e.Med Allgemeinmedizin

Weitere Artikel der Ausgabe 5/2016

Real-world therapeutic benefits of patients on insulin glargine versus NPH insulin

History of mild hypoglycaemia does not affect the prevalence of diabetes-related distress in people with diabetes

A case of type 1 diabetes mellitus with which localized insulin allergy was markedly alleviated by switching to insulin glulisine

Reply to Letter to the Editor “Polypharmacy in elderly people with diabetes admitted to hospital”

Effectiveness of insulin glargine in type 2 diabetes mellitus patients failing glycaemic control with premixed insulin: Adriatic countries data meta-analysis

A dizygotic twin pregnancy in a MODY 3-affected woman

Leitlinien kompakt für die Innere Medizin

Neu im Fachgebiet Innere Medizin

Echinokokkose medikamentös behandeln oder operieren?

Aquatherapie bei Fibromyalgie wirksamer als Trockenübungen

Wo hapert es noch bei der Umsetzung der POMGAT-Leitlinie?

VHF-Ablation nützt wohl nur bei reduzierter Auswurfleistung

Update Innere Medizin