Relationship of Aging and Incident Comorbidities to Stroke Risk in Patients With Atrial Fibrillation

Background When assessing ischemic stroke risk in patients with atrial fibrillation (AF), the CHA₂DS₂-VASc score is calculated based on the baseline risk factors, and the outcomes are determined after a follow-up period. However, the stroke risk in patients with AF does not remain static, and with time, patients get older and accumulate more comorbidities. Objectives This study hypothesized that the “Delta CHA₂DS₂-VASc score,” which reflects the change in score between baseline and follow-up, would be more predictive of ischemic stroke compared with the baseline CHA₂DS₂-VASc score. Methods A total of 31,039 patients with AF who did not receive antiplatelet agents or oral anticoagulants, and who did not have comorbidities of the CHA₂DS₂-VASc score except for age and sex, were studied. The Delta CHA₂DS₂-VASc scores were defined as the differences between the baseline and follow-up CHA₂DS₂-VASc scores. During 171,956 person-years, 4,103 patients experienced ischemic stroke. The accuracies of baseline, follow-up, and Delta CHA₂DS₂-VASc scores in predicting ischemic stroke were analyzed and compared. Results The mean baseline CHA₂DS₂-VASc score was 1.29, which increased to 2.31 during the follow-up, with a mean Delta CHA₂DS₂-VASc score of 1.02. The CHA₂DS₂-VASc score remained unchanged in only 40.8% of patients. Among 4,103 patients who experienced ischemic stroke, 89.4% had a Delta CHA₂DS₂-VASc score ≥1 compared with only 54.6% in patients without ischemic stroke, and 2,643 (64.4%) patients had ≥1 new-onset comorbidity, the most common being hypertension. The Delta CHA₂DS₂-VASc score was a significant predictor of ischemic stroke that performed better than baseline or follow-up CHA₂DS₂-VASc scores, as assessed by the C-index and the net reclassification index. Conclusions In this AF cohort, the authors demonstrated that the CHA₂DS₂-VASc score was not static, and that most patients with AF developed ≥1 new stroke risk factor before presentation with ischemic stroke. The Delta CHA₂DS₂-VASc score, reflecting the change in score between baseline and follow-up, was strongly predictive of ischemic stroke, reflecting how stroke risk in AF is a dynamic process due to increasing age and incident comorbidities.