Validation of the CHADS(2) clinical prediction rule to predict ischaemic stroke A systematic review and meta-analysis

HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Republic of Ireland.
Thrombosis and Haemostasis (Impact Factor: 5.76). 07/2011; 106(3):528-38. DOI: 10.1160/TH11-02-0061
Source: PubMed

ABSTRACT The CHADS2 predicts annual risk of ischaemic stroke in non-valvular atrial fibrillation. This systematic review and meta-analysis aims to determine the predictive value of CHADS2. The literature was systematically searched from 2001 to October 2010. Data was pooled and analysed using discrimination and calibration statistical measures, using a random effects model. Eight data sets (n = 2815) were included. The diagnostic accuracy suggested a cut-point of ≥ 1 has higher sensitivity (92%) than specificity (12%) and a cut-point of ≥ 4 has higher specificity (96%) than sensitivity (33%). Lower summary estimates were observed for cut-points ≥ 2 (sensitivity 79%, specificity 42%) and ≥ 3 (specificity 77%, sensitivity 50%). There was insufficient data to analyse cut-points ≥ 5 or ≥ 6. Moderate pooled c statistic values were identified for the classic (0.63, 95% CI 0.52-0.75) and revised (0.60, 95% CI 0.43-0.72) view of stratification of the CHADS2. Calibration analysis indicated no significant difference between the predicted and observed strokes across the three risk strata for the classic or revised view. All results were associated with high heterogeneity, and conclusions should be made cautiously. In conclusion, the pooled c statistic and calibration analysis suggests minimal clinical utility of both the classic and revised view of the CHADS2 in predicting ischaemic stroke across all risk strata. Due to high heterogeneity across studies and low event rates across all risk strata, the results should be interpreted cautiously. Further validation of CHADS2 should perhaps be undertaken, given the methodological differences between many of the available validation studies and the original CHADS2 derivation study.


Available from: Emma Wallace, Dec 19, 2013
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    ABSTRACT: Stroke prevention is central to the management of patients with atrial fibrillation (AF). As effective stroke prophylaxis essentially requires oral anticoagulants, an understanding of the risks and benefits of oral anticoagulant therapy is needed. Although AF increases stroke risk 5-fold, this risk is not homogeneous. Many stroke risk factors also confer an increased risk of bleeding. Various stroke and bleeding risk-stratification schemes have been developed to help inform clinical decision-making. These scores were derived and validated in different study cohorts, ranging from highly selected clinical-trial cohorts to real-world populations. Thus, their performance and classification accuracy vary depending on their derivation cohort(s). In the present review, we provide an overview of currently available stroke and bleeding risk-stratification schemes. We particularly focus on the CHA2DS2-VASc and HAS-BLED schemes, as these are recommended by the latest European guidelines on AF management. Other risk-stratification schemes (eg, CHADS2, R2CHADS2, ATRIA, HEMORR2HAGES, QStroke) and their place in the decision-making are also considered.
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