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Ogunbayo GO, Pecha R, Misumida N, et al. Relation of CHA2DS2VASC Score With Hemorrhagic Stroke and Mortality in Patients Undergoing Fibrinolytic Therapy for ST Elevation Myocardial Infarction. Am J Cardiol. 2018 Oct 18. pii: S0002-9149(18)31955-6. doi: 10.1016/j.amjcard.2018.10.003. (Original study)
Abstract

Hemorrhagic stroke (HS) is a feared complication of Fibrinolytic therapy (FT). Risk assessment scores may help in risk stratification to reduce this complication. Patients (admissions) =18 years with a primary diagnosis of ST-elevation myocardial infarction (STEMI) who received systemic thrombolysis were extracted from Nationwide Inpatient Sample database and stratified and compared based on CHA2DS2VASC score 0 to 3, 4 to 6, and 7 to 9 as low, intermediate and high risk, respectively. The primary outcomes of interest were HS and mortality. We performed logistic regression analysis with a composite of HS and mortality as the primary end point. Of the 917,307 admissions with a primary diagnosis of STEMI, 39,579 (4.3%) underwent FT. The median score was 3 (interquartile range 1 to 5). The rate of HS significantly increased in the risk category compared with the low and intermediate groups (0.5% and 0.6% vs 4.1%; p <0.001). Mortality increased with increasing risk category (3.8% vs 10.5% vs 20.7%; p <0.001). Compared with the low-risk group patients in the intermediate (odds ratio 2.11 95% confidence interval [CI] 1.56 to 2.85; p <0.001) and high risk groups (odds ratio 3.47 95% CI 1.68 to 7.2; p <0.001) were more likely to experience the composite end point of HS or inpatient mortality. CHA2DS2VASC score performed better at predicting mortality (area under curve 0.67, 95% CI 0.64 to 0.7; p = 0.014) than HS (area under curve 0.6 95% CI 0.52 to 0.69; p = 0.021). In conclusion, patients with high CHA2DS2VASC score (7 to 9) are at a higher risk of hemorrhagic stroke and death after FT for STEMI. CHA2DS2VASC score performed better at predicting mortality than hemorrhagic stroke in this cohort.

Ratings
Discipline Area Score
Physician 5 / 7
Comments from MORE raters

Physician rater

The methodology of the study weak, likely highly influenced by selection bias (only 4.3% of patients with PCI had fibrinolysis, presumably many patient with risk factor for hemorrhage were referred for primary PCI). Also, the study is forcing a model derived for a different population rather than developing a new model with available large data base.

Physician rater

Retrospective analysis of over 39,000 patients who received thrombolysis for STEMI. The CHA2DS2VASC score categories were associated with increasing risk for hemorrhagic stroke and mortality.

Physician rater

Interesting article highlighting the ability of the CHA2DS2VASC score to predict hemorrhagic stroke in those receiving thrombolytic therapy for ST-elevation MI. This applies only to those who receive fibrinolytic therapy instead of cardiac catheterization and will be mostly of interest to those in cardiology, but would be interesting to hematologists who help manage bleeding complications in patients who recently underwent cardiac intervention.
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