International Journal of Cardiology 172 (2014) e234–e237

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Letter to the Editor

The CHA2DS2-VASc score predicts 320-slice CT-based coronary artery plaques and N 50% stenosis in subjects with chronic and paroxysmal atrial fibrillation Nobusada Funabashi ⁎,1, Masae Uehara 1, Hiroyuki Takaoka, Yoshio Kobayashi Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba 260-8670, Japan.

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Article history: Received 21 October 2013 Accepted 27 December 2013 Available online 8 January 2014 Keywords: CHA2DS2-VASc score 320-slice CT Coronary artery plaques N 50% stenosis Atrial fibrillation

The CHADS2 score is a simple score to evaluate the risk of occurrence of cerebral infarction in subjects with atrial fibrillation (AF) that includes the variables of age (≥75 yrs), hypertension, diabetes mellitus, previous stroke, and heart failure. Furthermore the CHA2DS2-VASc score is a more detailed assessment scheme than the CHADS2 score to further stratify the risk of occurrence of cerebral infarction in subjects with AF considering the following factors; female sex, presence of vascular disease, and age (≥ 65 yrs) as stroke risk factors. Since both CHADS2 score and CHA2DS2-VASc score include coronary risk factors, there may be a relationship between these scores and coronary arteriosclerosis [1]. In studies evaluating coronary arteries using 64–256 slice CT, subjects with AF are usually excluded from the study population. However, 320-slice CT may detect coronary arteries with high image quality even in these subjects because of the wide coverage to the through plane in which whole heart images can be obtained using data from only a single heart beat [2]. Subjects with AF are known to have many coronary risk factors. Therefore, the prediction of both cerebral infarction and coronary atherosclerosis using the CHA2DS2-VASc score in subjects with AF may be very useful in clinical practice [3,4]. The purpose of this study is to predict the risk of coronary arteriosclerosis in subjects with AF using CHA2DS2-VASc score correlation with 320-slice CT data. ⁎ Corresponding author. Tel.: +81 43 222 7171x5264. E-mail address: [email protected] (N. Funabashi). 1 These authors contributed equally to this work. 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.148

204 consecutive subjects (153 male; age, 64 ± 11 yrs) with prior diagnosis of chronic or paroxysmal AF who underwent retrospective ECG-gated 320-slice CT (Aquilion One, Toshiba Medical) were enrolled [2]. The reasons for performing MSCT were represented in Table 1. All CT examinations were appropriate or uncertain by ACCF/SCCT/ACR/AHA/ ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac CT [5]. On 320-slice CT, the presence of calcified plaque, non-calcified plaque, mixed plaque, or any plaque, non-calcified plaque with outward remodeling, and N50% or N75% stenosis in coronary arteries was evaluated. We also calculated the Agatston calcium score in coronary arteries. All of these coronary artery findings were compared between groups with CHA2DS2-VASc scores of 0, 1, 2, and ≥3. CT data were used in multiple logistic regression models for prediction of calcified plaque, non-calcified plaque, mixed plaque, or any plaque, and N50% or N 75% stenosis in coronary arteries taking into account the following variables: chronic or paroxysmal AF, presence of hyperlipidemia, smoking habits, body mass index, and the CHA2DS2VASc score. All 204 subjects with AF were followed up for a mean of 19.2 months, and the composite end point of sudden death and cardiac death was compared between groups using CHA2DS2-VASc score in Kaplan–Meier analysis. Distribution of CHA2DS2-VASc score in this study was represented in Fig. 1. 29 subjects (14.2%), 51 subjects (25.0%), 41 subjects (20.1%), and 83 subjects (40.7%) revealed CHA2DS2-VASc score 0, 1, 2, and ≥3, respectively. Background of subjects with CHA2DS2-VASc score 0, 1, 2, and ≥ 3 was represented in Table 2. There were significant differences of age, frequencies of male, hypertension, hyperlipidemia, diabetes mellitus,

Table 1 The reasons for performing multislice computed tomography. All subjects (n = 204)

N (%)

Evaluating anatomy of left atrium and pulmonary vein before radiofrequency catheter ablation procedure Evaluating coronary arteries because of chest symptoms Unknown cause for developing heart failure Evaluating presence of thrombi in left atrium Evaluating aortic disease Others

70 (34.3%) 48 (23.5%) 60 (29.4%) 15 (7.4%) 8 (3.9%) 3 (1.5%)

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Fig. 1. Distribution of CHA2DS2-VASc score in this study.

impaired left ventricular function, past history of ischemic heart disease, past history of cerebral infarction, and chronic AF among four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥3. Coronary CT findings among four groups classified by CHA2DS2VASc score 0, 1, 2, and ≥ 3 were represented in Fig. 2A and B. The presence of calcified plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in those with CHA2DS2-VASc score 1, 2, and ≥3 (all P b 0.01). The presence of non-calcified plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in that with CHA2DS2-VASc score ≥3 (P b 0.01). The presence of any plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in those with CHA2DS2-VASc score 1, 2, and ≥3 (all P b 0.01). The presence of N50% and N75% stenosis on CT was significantly higher in the group with CHA2DS2-VASc score ≥ 3 than in those with CHA2DS2VASc score 0 (P = 0.009), and score 1 (P = 0.048), respectively. There were significant differences of Agatston calcium score among the four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥ 3 (Mann–Whitney U test, P b 0.01) and the Agatston calcium score was higher in high CHA2DS2-VASc score groups, especially CHA2DS2-VASc score ≥3 group than any other groups (Table 3). CHA2DS2-VASc score was used as an independent variable in multivariate logistic regression models for the prediction of calcified plaque, non-calcified plaque, mixed plaque, any plaque, N50% and N75% stenosis in coronary arteries observed on CT as dependent variables, while chronic or paroxysmal AF, the presence of hyperlipidemia, smoking habits, and body mass index were used as independent variables (Fig. 3A–C). In comparison of CHA2DS2-VASc score ≥ 1 with CHA2DS2-VASc score 0 (Fig. 3A), the odd ratios of the group with CHA2DS2-VASc score ≥1 against the group with score 0 were 7.9 for calcified plaque, 12.9 for non-calcified plaque, and 7.8 for any plaque (All P b 0.05).

Fig. 2. Coronary computed tomographic findings among four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥3. A: The presence of calcified plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in those with CHA2DS2-VASc score 1, 2, and ≥3 (all P b 0.01). The presence of non-calcified plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in that with CHA2DS2-VASc score ≥3 (P b 0.01). The presence of any plaque was significantly lower in the group with CHA2DS2-VASc score 0 than in those with CHA2DS2-VASc score 1, 2, and ≥3 (all P b 0.01). B: The presence of N50% and N75% stenosis on computed tomography was significantly higher in the group with CHA2DS2-VASc score ≥3 than in those with CHA2DS2-VASc score 0 (P = 0.009), and score 1 (P = 0.048), respectively.

In comparison of CHA2DS2-VASc score ≥2 with that b2, (Fig. 3B), the odd ratios of the group with CHA2DS2-VASc score ≥2 against the group with score b 2 were 2.6 for calcified plaque, 2.4 for non-calcified plaque, and 3.6 for any plaque (All P b 0.05). In comparison of CHA2DS2-VASc score ≥3 with that b 3 (Fig. 3C), the odd ratios of the group with CHA2DS2-VASc score ≥3 against the group with score b3 were 3.1 for calcified plaque, 2.1 for mixed plaque, 4.5 for any plaque, and 3.6 for N50% stenosis (All P b 0.05). Significant predictors in multivariable logistic regression models for the prediction of plaques and stenosis in coronary arteries on CT using

Table 2 Background of subjects with CHA2DS2-VASc Score 0, 1, 2, and ≥3. There were significant differences of age, frequencies of male, hypertension, hyperlipidemia, diabetes mellitus, impaired left ventricular function, past history of ischemic heart disease, past history of cerebral infarction, and chronic atrial fibrillation among the four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥3. N (%)

Score 0 n = 29

Score 1 n = 51

Score 2 n = 41

Score ≥ 3 n = 83

P-value

Age Sex(male) Hypertension Hyperlipidemia Diabetesmellitus Smoking habits Body mass index Impaired left ventricular function Pasthistoryofischemic heart disease Pasthistoryof cerebral infarction Chronicatrialfibrillation

50.0 ± 9.1 29 (100.0) 0 4 (13.8) 0 14 (48.3) 23.2 ± 2.9 0 0 0 6 (20.7)

59.0 ± 7.8 41 (80.4) 26(51.0) 15 (29.4) 0 22 (45.8) 24.0 ± 3.0 7 (13.7) 1 (2.0) 0 22 (43.1)

63.9 ± 7.6 31 (75.6) 25 (61.0) 13 (31.7) 8 (19.5) 19 (50.0) 24.1 ± 3.7 14 (34.1) 1 (2.4) 4 (9.8) 26 (63.4)

72.0 ± 7.0 52 (62.7) 62 (74.7) 35 (42.2) 17 (20.5) 31 (37.3) 22.7 ± 3.8 35 (42.2) 15 (18.1) 22 (26.5) 58 (69.4)

P b 0.001** P = 0.001** P b 0.001** P = 0.039* P b 0.001** P = 0.511 P = 0.079 P b 0.001** P = 0.001** P b 0.001** P b 0.001**

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Table 3 Agatston calcium score on computed tomography among four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥3. There were significant differences of Agatston calcium score among the four groups classified by CHA2DS2-VASc score 0, 1, 2, and ≥3 (Mann–Whitney U test P b 0.01) and the Agatston calcium score was higher in high CHA2DS2-VASc score groups, especially CHA2DS2-VASc score ≥3 group than any other groups. Calcium score

Score 0 (n = 29)

Score 1 (n = 51)

score 2 (n = 41)

Score ≥ 3 (n = 83)

Average ± SD 113 ± 520 Median

113 ± 520 0.0

144 ± 436 13.2

125 ± 199 35.1

451 ± 1108 144.3

Table 4 Significant predictors in multivariable logistic regression models for prediction of plaque and stenosis in coronary arteries on computed tomography using only components of the CHA2DS2-VASc score. Among the components of the CHA2DS2-VASc score, age was a significant predictor for findings of calcified plaque, non-calcified plaque, mixed plaque, any plaque, and ≥75% stenosis; hypertension was significant for calcified plaque, and diabetes mellitus was significant for non-calcified plaque as observed on computed tomography.

only components of the CHA2DS2-VASc score were represented in Table 4. Among the components of the CHA2DS2-VASc score, age was a significant predictor for findings of calcified plaque, non-calcified plaque, mixed plaque, any plaque, and ≥ 75% stenosis; hypertension was significant for calcified plaque, and diabetes mellitus was significant for non-calcified plaque as observed on CT. In Kaplan–Meier survival curves for the composite end point of sudden death and cardiac death (median follow up was 19.2 months), the survival rate was significantly worse in the group with CHA2DS2-VASc score ≥3 compared with the group with score b3 (P = 0.048) (Fig. 4). In this study, the risk of Agatston calcium score, the frequency of the presence of various types of coronary plaques, and coronary artery stenosis evaluated by 320-slice CT were found to be significantly higher in subjects with CHA2DS2-VASc score ≥ 3 than in subjects with CHA2DS2-VASc score b 3. Because of higher frequency of various types of coronary plaques and coronary stenosis in the group with CHA2DS2-VASc score ≥3 compared with the other groups, the prognosis of patients in this group was estimated to be worse and was actually significantly worse in Kaplan–Meier analysis. Therefore patients with CHA2DS2-VASc score ≥3 have risks of not only cerebral infarction, but also coronary artery disease, and the use of statin or antiplatelet drug may be necessary in such patients in addition to anticoagulant therapy

Fig. 3. Multivariate logistic regression analyses for prediction of calcified plaque, noncalcified plaque, mixed plaque, any plaque, N50% and N75% stenosis in coronary arteries observed on computed tomography using CHA2DS2-VASc score, CHA2DS2-VASc score was used as an independent variable in multivariate logistic regression models for the prediction of calcified plaque, non-calcified plaque, mixed plaque, any plaque, N50% and N75% stenosis in coronary arteries observed on computed tomography as dependent variables, while chronic or paroxysmal atrial fibrillation, the presence of hyperlipidemia, smoking habits, and body mass index were used as independent variables. A: CHA2DS2-VASc score ≥1 versus 0. The odd ratios of the group with CHA2DS2-VASc score ≥1 against the group with score 0 were 7.9 for calcified plaque, 12.9 for non-calcified plaque, and 7.8 for any plaque (All P b 0.05). B: CHA2DS2-VASc score ≥2 versus b2. The odd ratios of the group with CHA2DS2-VASc score ≥2 against the group with score b2 were 2.6 for calcified plaque, 2.4 for non-calcified plaque, and 3.6 for any plaque (All P b 0.05). C: CHA2DS2-VASc score ≥3 versus b3. The odd ratios of the group with CHA2DS2-VASc score ≥3 against the group with score b3 were 3.1 for calcified plaque, 2.1 for mixed plaque, 4.5 for any plaque, and 3.6 for N50% stenosis (All P b 0.05).

Fig. 4. Kaplan–Meier survival curves for the composite end point of sudden death and cardiac death. Median follow up was 19.2 months. The survival rate was significantly worse in the group with CHA2DS2-VASc score ≥3 compared with the group with score b3 (P = 0.048).

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for the prevention of cerebral infarction and acute coronary syndrome. Conversely, patients with CHA2DS2-VASc score 0 may have a low risk of both cerebral infarction and coronary artery disease. Generally patients with Agatston calcium score of 0 are known to have a low risk of coronary artery disease [6]. Therefore a combination of CHA2DS2-VASc score 0 and Agatston calcium score 0 may indicate an extremely low risk of coronary artery disease. As the limitation of this study, although beta-blockers were used prior to 320-slice CT to lower the heart rate when heart rate was ≥65 beats per minute to reduce radiation exposure and improve image quality [2,7,8], some cases needed to be imaged for several heart beats because of high heart rate with irregular R-to-R interval due to AF. In these cases, radiation exposure was higher than in cases with low heart rate with normal sinus rhythm. The follow up period averaged only 19.2 months. Further study with a larger population, longer follow up, and in a multicenter setting is necessary. In conclusion, the CHA2DS2-VASc score is a useful predictor of coronary arteriosclerosis in subjects with AF.

Acknowledgments This work is supported by a Grant from the Okinaka Memorial Institute for Medical Research. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

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The CHA2DS2-VASc score predicts 320-slice CT-based coronary artery plaques and >50% stenosis in subjects with chronic and paroxysmal atrial fibrillation.

The CHA2DS2-VASc score predicts 320-slice CT-based coronary artery plaques and >50% stenosis in subjects with chronic and paroxysmal atrial fibrillation. - PDF Download Free
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