Stroke after coronary artery bypass grafting: Preoperative predictive accuracies of CHADS2 and CHA2DS2VASc stroke risk stratification schemes

Cardiac Surgery Department, General University Hospital of Valencia, Valencia, Spain
The Journal of thoracic and cardiovascular surgery (Impact Factor: 4.17). 12/2012; 144(6):1428–1435. DOI: 10.1016/j.jtcvs.2012.07.053


Neurologic events after coronary artery bypass grafting are an infrequent but devastating complication. This study analyzed the preoperative predictive abilities of the CHADS2 and CHA2DS2VASc stroke scores in patients undergoing isolated coronary artery bypass grafting.

Included in the study were 2910 patients who underwent isolated coronary artery bypass grafting during a 19-year period. CHADS2 and CHA2DS2VASc scores were computed for all patients, and outcomes were evaluated in terms of perioperative stroke and compared with 2 specific models for predicting surgical coronary artery bypass grafting stroke (Northern New England Cardiovascular Disease Study Group and Multicenter Study of Perioperative Ischemia Research Group). Perioperative stroke discrimination was quantified by computing the area under the receiver operating characteristic curve.

Overall, 62 (2.1%) had perioperative strokes. Areas under the curve were 0.71 (95% confidence interval, 0.64-0.78) for CHADS2, 0.72 (95% confidence interval, 0.65-0.79) for CHA2DS2VASc, 0.69 (95% confidence interval, 0.61-0.76) for Northern New England Cardiovascular Disease Study Group, and 0.73 (95% confidence interval, 0.67-0.80) for Multicenter Study of Perioperative Ischemia Research Group scores. Northern New England Cardiovascular Disease Study Group and CHA2DS2VASc scores were better at discriminating patients with particularly low or high risk of stroke.

CHADS2 and CHA2DS2VASc scores predicted perioperative coronary artery bypass grafting strokes with discriminatory abilities similar to those of specific predictive surgical coronary artery bypass grafting stroke models. All schemes tested showed similar limitations in discriminating patients with high postoperative stroke risk, with a high proportion being classified as having intermediate stroke risk.

1 Follower
9 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgical aortic valve replacement (S-AVR) after previous cardiac surgery is expected to be associated with a high rate of adverse events. The aim of this study was to estimate the rate and identify the determinants of postoperative stroke in these patients. This is a multicenter study including 741 patients who underwent S-AVR after previous cardiac surgery. Forty-eight patients (6.5%; after isolated AVR, 6.0%) suffered stroke and 10 of them died during the in-hospital stay (20.8%). At multivariate analysis, women (10.2% vs 4.4%, odds ratio [OR] 2.57, 95% confidence interval [CI] 1.36 to 4.86), emergency procedure (15.1% vs 4.8%, OR 2.63, 95% CI 1.12 to 5.78), perioperative use of intra-aortic balloon pump (22.9% vs 5.3%, OR 2.67, 95% CI 1.15 to 6.19), cardiopulmonary bypass time of >210 minutes (15.7% vs 5.0%, OR 2.31, 95% CI 1.13 to 4.71), blood products transfusion (9.3% vs 0.8%, OR 7.75, 95% CI 1.83 to 32.93), and reexploration for bleeding (24.0% vs 5.2%, OR 4.84, 95% CI 2.18 to 10.77) were independent predictors of postoperative stroke. These findings were confirmed by a regression model including CHA2DS2-VASc score of ≥2, which itself was predictive of stroke (8.2% vs 1.6%, OR 4.52, 95% CI 1.34 to 15.28). Survival at 3 years in patients with postoperative stroke was 51.9%, whereas it was 85.0% in control patients (adjusted analysis: relative risk 2.97 and 1.86 to 4.72, respectively). In conclusion, the risk of postoperative stroke after S-AVR in patients with previous cardiac surgery is high and has an impact on the immediate and late mortality. Excessive bleeding requiring blood transfusion and/or reexploration, prolonged cardiopulmonary bypass time, and use of intra-aortic balloon pump were associated with an extremely high rate of stroke.
    No preview · Article · Aug 2013 · The American journal of cardiology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Vascular events are one of the major causes of death in case of Cushing's syndrome (CS). However, due to the relative low frequency of CS, it is hard to perform a risk assessment for these events. As represented congestive heart failure (C), hypertension (H), age (A), diabetes (D), and stroke (S), the CHADS2 score is now accepted to classify the risk of major adverse cardiovascular events (MACEs) in patients with atrial fibrillation. In this study, participants were enrolled from the National Health Research Institute Database (NHIRD) of Taiwan, and we reviewed 551 patients with their sequential clinically diagnosed CS data between 2002 and 2009 in relation to MACEs risk using CHADS2 score. Good correlation could be identified between the CS and CHADS2 score (AUC = 0.795). Our results show that patients with CS show significantly higher risk of vascular events and the CHADS2 score could be applied for MACEs evaluation. Adequate lifestyle modifications and aggressive cardiovascular risks treatment are suggested for CS patients with higher CHADS2 score.
    Full-text · Article · Jul 2014 · International Journal of Endocrinology
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To determine the accuracy of CHADS2 and CHA2DS2-VASc tools for predicting ischaemic stroke or transient ischaemic attack (TIA) and death in patients without a history of atrial fibrillation or flutter (AF). Methods The study included 20 970 patients without known AF enrolled in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart disease (APPROACH) prospective registry who were discharged after an acute coronary syndrome (ACS) between 2005 and 2011. The outcome measures were incident ischaemic stroke, TIA or death from any cause. Results Over a median follow-up of 4.1 years, 453 patients (2.2%) had a stroke (n=297) or TIA (n=156) and 1903 (9.0%) died. The incidence of stroke or TIA increased with increases in each risk score (p<0.001), with an absolute annual incidence ≥1% with CHADS2 ≥3 or CHA2DS2-VASc ≥4. Both CHADS2 and CHA2DS2-VASc scores had acceptable discrimination performance (C-statistic=0.68 and 0.71, respectively). The mortality rate was also greater in patients with higher CHADS2 and CHA2DS2-VASc scores (p<0.0001). Conclusions In patients with ACS but no AF, the CHADS2 and CHA2DS2-VASc scores predict ischaemic stroke/TIA events with similar accuracy to that observed in historical populations with non-valvular AF, but with lower absolute event rates. Further study of the utility of the CHADS2 and CHA2DS2-VASc scores for the assessment of thromboembolic risk and selection of antithrombotic therapy in patients without AF is warranted.
    No preview · Article · Sep 2014 · Heart (British Cardiac Society)
Show more