CHA2DS2–VASc score

Right.

60, 68-year-old CHADS VASC three p- three patients are, are n- I agree, not getting knocked off on antiarrhythmic drugs.

But, um, um, at, at, at the time, um, these were symptomatic patients who we were trying to do rhythm control.

And like you said, we were comparing two rhythm control arms.

Stroke prevention is critical.

For the, the guidelines once again emphasize the use of the CHADS VASC algorithm, which need to be followed in terms of, of reducing stroke.

In one of the cases that we presented here at ESC, the patient had obesity.

And so when a patient is obese, you need to determine what the best optimal treatment for anticoagulation would be.

The next, uh, o- potential, uh, complication that can occur in somebody with obesity is they may have had bariatric surgery, and in that situation, malabsorption can be an issue, so warfarin is indicated.

The other major, uh, areas of difficulty with respect to anticoagulation are people who have renal dysfunction, and that can be a challenge in terms of optimizing therapy to provide, uh, the best balance of stroke prevention as well as bleeding.

Aside from that, most patients by and large are very straightforward, and if they have any of the risk factors of the CHADS VASC score, they should really be an- anticoagulated.

The DOACs have, uh, really changed how we t- uh, treat, uh, stroke, uh, and the risk of bleeding is so much lower than it has ever been, uh, in the past when we used warfarin and other, uh, uh, vitamin K antagonists.

And the question of anticoagulation in patients with AFib who have one risk factor is one of the toughest in EP.

Men with a CHADS-VASc score of 1 or females with a CHADS-VASc 2, they have a pretty low yearly stroke risk.

And of course, the net benefit of anticoagulation turns on stroke risk being at a level that the 60th percent reduction in ischemic stroke is more than the bleeding rate increase with anticoagulants.

Now, I realize that guidelines say treat these patients with anticoagulation.

The NOAA and ARTESIA trials both randomized patients with subclinical AF, that's AF of a couple of hours, to DOAC or placebo or aspirin in the ARTESIA trial.

Both trials found that anticoagulation did indeed lower the stroke risk, but it also increased the major bleeding by similar amounts.

Notably, these trials enrolled patients with a CHADS-VASc of around four, yet stroke rates were about 1% per year.

Now, this leads me to consider two possible patients who could have been in single AF but might have different approaches.

Today is August twenty-eight, twenty twenty-six.

This video is on an NEJM article published today online and also presented at European Society of Cardiology meeting in Munich titled "Anticoagulation for AFib with Intermediate Stroke Risk." There was an accompanying editorial titled "Anticoagulation for AFib with a Single Risk Factor for Stroke." Why does this matter? AFib patients with intermediate CHA2DS2VASc risk live in an anticoagulation gray zone.

What did the investigators do? This single AF randomized one thousand eight hundred and three South Korean patients to direct oral anticoagulant therapy versus no anticoagulation for twenty-four months.

What did they find? The primary composite, point five percent versus one point five percent.

they were a very healthy population.

The CHADS-VASc was basically one, LA size of 39, median, and their burdens were very low.

So the pre-ablation burden was 1.5%, up to 3.5%, and the post-ablation burdens were 0.1, so that their cut-point burden was 0.1.

Whereas I don't really see a lot of patients like that.

The third paper in the atrial fibrillation space, also in the Journal of the American Heart Association, is a Taiwanese nationwide cohort from Huang and colleagues asking whether sodium-glucose cotransporter 2 inhibitors reduce cerebrovascular events after a new diagnosis of atrial fibrillation.

Using national insurance data, they propensity matched about nineteen hundred regular users to nineteen thousand non-users, mean age seventy-two, mean CHA2DS2VASc score just under four.

Baseline use of these drugs was not associated with the primary composite of ischemic stroke, hemorrhagic stroke, or transient ischemic attack, nor with mortality, nor with major adverse cardiovascular events.

A time-dependent analysis did show roughly a thirty percent lower mortality with current exposure, but the authors themselves caution that this is likely residual confounding.

And I would say to all of my friends, if your patient is 90 years old, they have graduated from wearing devices at night.

Okay, performance measures three and four: documentation of stroke risk and use of anticoagulation when indicated, and that seems fine on the surface, right? But I'm getting a lot of CHADS-VASc alerts in my electronic health record because my patient with a score of two who has had no AFib a year out from ablation is no longer taking oral anticoagulation.

They still have a diagnosis of AFib in the chart, but they're not on anticoagulation because we have two trials.

This falls out of the performance measure.