Improvement of HAS-BLED bleeding score predictive capability by changing the definition of renal dysfunction in Japanese atrial fibrillation patients on anticoagulation therapy

Department of Cardiology, Kameda Medical Center, Chiba, Japan
Journal of Cardiology (Impact Factor: 2.78). 05/2014; 64(6). DOI: 10.1016/j.jjcc.2014.03.006
Source: PubMed


Background and purpose:
Severe chronic kidney disease (CKD) is a risk factor for hemorrhagic events in atrial fibrillation (AF) patients on anticoagulation therapy. We postulated that even moderate CKD may be a risk factor for hemorrhage and this recognition would improve predictive capabilities of hemorrhagic risk stratification models in Japanese patients.

Methods and subjects:
In this prospective study, 231 non-valvular AF patients were divided into three groups according to estimated glomerular filtration rate (eGFR) and followed-up for a median of 7.1 years. The clinical endpoint was a major hemorrhagic event (MHE). HAS-BLED score was calculated for the cohort and the predictive capability of the original HAS-BLED score was compared with that in which renal dysfunction was redefined as eGFR<60mL/min/1.73m(2).

Forty-four MHEs occurred during follow-up. Compared to no/mild CKD group (≥60mL/min/1.73m(2)), both moderate (30-59mL/min/1.73m(2)) and severe (<30mL/min/1.73m(2)) CKD groups had higher MHE risks (log rank: both p<0.001). MHE risk of patients with moderate CKD was more than threefold higher than the no/mild CKD group even after adjusting for other risk factors (hazard ratio 3.8, 95% confidence interval 1.7-8.7). The C-statistic in receiver-operating curve analysis was numerically but not significantly superior in modified HAS-BLED score compared to original HAS-BLED score (0.67 and 0.64, respectively; p=0.55). However, using modified HAS-BLED score was associated with significant improvement of net reclassification improvement (0.50, p=0.002) and integrated discrimination improvement (0.033, p=0.043).

Moderate CKD contributes to the risk of future major hemorrhagic events in AF patients. Modification of HAS-BLED score by changing the definition of renal failure markedly improved predictive capability.

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Available from: Yuya Matsue, Nov 27, 2015
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    ABSTRACT: Objective: Anticoagulation therapy with warfarin is recommended for stroke prevention in patients with atrial fibrillation (AF) or atrial flutter (AFL) whose risks for stroke are high. However, previous studies suggest that warfarin is markedly underused. This study aims to investigate the incidence and risk factors of warfarin underutilization in patients with high risk of stroke in Korea. Methods: This was a cross-sectional study using the data of 2009 from National Patients Sample compiled by the Health Insurance Review and Assessment Service. Patients with high risk of thromboembolism were identified with congestive heart failure, hypertension, age ≥75 years, diabetes, and prior stroke (CHADS2) score ≥2. High-risk patients of bleeding were excluded using Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score >4. Warfarin and antithrombotic therapy underutilization were defined and estimated in high-risk patients. Any demographic and clinical factors associated with warfarin and antithrombotic therapy underutilization were explored using a logistic regression model. Results: Of the national patient sample, 15,885 patients were identified with AF or AFL. Among them, a total of 8475 patients who had an admission history, CHADS2 ≥2, and ATRIA score ≤4 were included in the analysis. From the study sample, warfarin underutilization and antithrombotic therapy underutilization were estimated to be 64.0% and 20.4%, respectively. Predictors of warfarin underutilization include female sex, age ≥80 years, lower CHADS2 score, and insurance type (Medical Aid program). Conclusions: A high portion of AF/AFL patients with CHADS2 score ≥2 were undertreated with warfarin. As ischemic stroke is one of the leading causes of death in Korea, a more aggressive approach to prevent stroke in patients with AF/AFL is required.
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