1. Accuracy of CHADS2, CHA2DS2- VASC and HAS-BLED scores in evaluation of stroke and bleeding risk First author: Alexandra Murar Co-author: Andreia Gherasâm Coordinators: Dr. Monica Dorgo, Prof.Dr. Emilian Caraca Marisiensis 2014

2. Introduction Marisiensis 2014

3. Atrial fibrillation Bleeding risk OAC Ischaemic stroke Age Hypertension pressure Cerebrovascular disease Renal failure Marisiensis 2014

4. Materials and methods  It was performed a retrospective, observational study on 146 patients from the medicine and cardiology departments in our hospital, with a follow up period of 6 months. Data were obtained from medical and computerized records, which were later entered into a statistical analysis software.  From 146 patients 69 were men and 77 women with an average age of 69, regardless of the origin of the demographic and ethnic characteristics. Present comorbidities were hypertension, diabetes, history of stroke, heart failure.  We considered patients with atrial fibrillation of which 131 (89,72%) were on anticoagulants and 15 (10,27%) were not anticoagulated, after which we calculated the CHADS2, CHA2DS2- Vasc and HAS-BLED scores. We divided the stroke risk categories calculated through CHADS2 and CHA2DS2–Vasc scores in low, medium and high. A HAS-BLED score >3, a CHA2DS-Vasc ≥2,and CHADS2 >2 were considered high. Patients were divided into two groups:  Group A with oral anticoagulant therapy  Group B with non-anticoagulant medication Marisiensis 2014

5. Classification according to European Society of Cardiology (ESC) 2010 First diagnosed episode of atrial fibrillation Paroxymal (usualy≤ 48 h) Persistent (>7 days or requires CV) Long-standing Persistent (>1 year) Permanent (accepted) Marisiensis 2014

6. In clinical practice FiACharacteristics Paroxysmal Self-limited recurrent episodes lasting under 7 days Persistent Recurrent episodes lasting more than 7 days to a month Permanent Long episode, it was decided by mutual agreement of the doctor / patient on incidence control (unable to restore sinus rhythm) Marisiensis 2014

7. CHA2DS2-Vasc - Risk factors for stroke and thrombo-embolism “ major” risk factors Previous stroke, TIA, or systemic embolism - 2 points Age > 75 years - 2 points !!! “ non-major” risk factors Heart failure or moderate /severe LV systolic dysfunction (e.g. LV EF < 40%) Hypertension Diabetes mellitus Female sex – 1 point Age 65–74 years - 1 point Vascular disease Marisiensis 2014

9. HAS-BLED bleeding risk score H- Hypertension 1 A - Abnormal renal and liver function (1 point each) 1 or 2 S -Stroke 1 B - Bleeding 1 L - Labile INRs 1 E - Elderly (e.g. age >65 years) 1 D -Drugs or alcohol (1 point each) 1 or 2 Maximum 9 points ‘Hypertension’is defined as systolic blood pressure >160 mmHg. ‘Abnormal kidney function’is defined as the presence of chronic dialysis or renal transplantation or serum creatinine ≥200mmol/L. ‘Abnormal liver function’ is defined as chronic hepatic disease (e.g. cirrhosis) or biochemical evidence of significant hepatic derangement (e.g. bilirubin.2 x upper limit of normal, in association with aspartate aminotransferase/alanine aminotransferase/alkaline phosphatase 3 x upper limit normal, etc.). ‘Bleeding’ refers to previous bleeding history and/or predisposition to bleeding, e.g. bleeding diathesis, anaemia, etc. ‘Labile INRs’ refers to unstable/high INRs or poor time in therapeutic range (e.g. <60%). ‘Drugs/alcohol’ use refers to concomitant use of drugs, such as antiplatelet agents, non-steroidal anti-inflammatory drugs, or alcohol abuse, etc. Marisiensis 2014

10. Inclusion and exclusion criteria Study inclusion criteria were: paroxysmal, persistent either permanent atrial fibrillation regardless of its etiology, at least one electrocardiographic confirmation effective anticoagulation (INR between 2 and 3) Exclusion criteria of the study were: patients with valvular diseases atrial fibrillation secondary hyperthyroidism, acute pericarditis myocarditis, pulmonary disease or after cardiovascular surgery pregnant patients patients whose observation form were not completed patients who refused any kind of treatment Marisiensis 2014

11. Results Statistical analysis of data was performed using the computer program GraphPad Prism 6. t-test and ANOVA were used, the confidence limits was 95% and the statistical estimation of the results was performed according to the decision criteria of statistical tests: p ≥ 0.05 - insignificant differences p <0.05 - significant differences p <0.01 – very significant differences p <0.001 - highly significant differences Subject touched in this study aims to assess the risk of stroke in patients in group A based on CHADS2 scores and CHA2DS2-Vasc also the hemorrhagic strokes frequency based on HAS-BLED score Marisiensis 2014

12. Statistical correlation Confidence interval95% P value < 0.0001 Significantly different? (P < 0.05) yes Marisiensis 2014

13. Confidence interval 95% P value< 0.0001 Significantly different? (P < 0.05) yes Marisiensis 2014

14. Confidence interval 95% P value< 0.0001 Significantly different? (P < 0.05) yes Marisiensis 2014

15. P value < 0,0001

16. Conclusions Patients with AF and a high HAS-BLED score develop a higher clinical benefit from OAC when balancing ischaemic stroke against intracranial bleeding. HAS-BLED score was superior to CHADS2-Vasc in predicting bleeding events which is concordant with the speciality literature. Comparing stroke risk groups using CHADS2 and CHA2DS2-Vasc tools, showed a higher rate of cardioembolic events in medium risk group whilst in CHA2DS2-Vasc group, the rate of stroke was superior in the high risk group. Marisiensis 2014

17. References Camm AJ, Kirchhof P, Lip GY, Schotten U, et al ; Guidelines for the management of atrial fibrillation: the Task Force for the Man-agement of Atrial Fibrillation of the European Society of Cardiology (ESC).Euro-pace2010;12:1360 – 1420. Roldan V, Marin F, Manzano-Fernandez S, Gallego P, Vilchez JA, Valdes M, Vicente V, Lip Gy; The HAS-BLED score has better prediction accuracy for major bleeding than CHADS2 or CHA2DS2-VASc scores in anticoagulated patients with atrial fibrillation;2013;10;62(23):2199-204. [Pubmed: 24055744] Lighezan, Roxana Buzaş;Atrial fibrillation; Assessing the risk of systemic embolism and bleeding ;Romanian Journal of Cardiology; 23;Supplement A; 2013. L. Gherasim, D. Vinereanu; New oral anticoagulants in the treatment of non- valvular atrial fibrillation; Romanian Journal of Cardiology; 23;Supplement A; 2013. E. Apetrei; Atrial fibrillation. Epidemiology. Diagnosis; Romanian Journal of Cardiology; 23;Supplement A; 2013. Marisiensis 2014

18. Singth M, Adigopula S, Patel P, Kiran K. Recent advances in Oral Anticoagulation for Atrial Fibrillation. The Adv Cardiovas Dis 2010; 4(6):395-407. European Heart Rhythm Association et al. 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. 2010; 31:2369–2429. Management of atrial fibrillation. [bmj.b5216] Marisiensis 2014