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(Stroke. 2007;38:2459.)
© 2007 American Heart Association, Inc.

Original Contributions

Can Patients at Elevated Risk of Stroke Treated With Anticoagulants Be Further Risk Stratified?

Lawrence Baruch, MD; Brian F. Gage, MD; Jay Horrow, MD; Steen Juul-Möller, MD; Arthur Labovitz, MD; Maria Persson, MS Miguel Zabalgoitia, MD

From the Department of Medicine (L.B.), Bronx Veterans Affairs Medical Center, Bronx, and the Mt. Sinai School of Medicine, New York, NY; the Department of Medicine (B.F.G.), Washington University, St. Louis, Mo; AstraZeneca LP (J.H.), Wilmington, Del; Department of Cardiology (S.J.-M.), University Hospital Malmö, University of Lund, Malmö, Sweden; Department of Medicine (A.L.), St. Louis University, St. Louis, Mo; AstraZeneca R&D Mölndal (M.P.), Mölndal, Sweden; and the University of Texas Health Science Center (M.Z.), San Antonio, Tex.

Correspondence to Lawrence Baruch, MD, Bronx VA Hospital, 130 West Kingsbridge Rd, Bronx, NY 10468. E-mail baruchlarry{at}att.net

Background and Purpose— Patients with atrial fibrillation have a varied risk of stroke, depending on age and comorbid conditions. The objective of this study was to assess the predictive value of stroke risk classification schemes and to identify patients with atrial fibrillation who are at substantial risk of stroke despite optimal anticoagulant therapy.

Methods— Seven recognized classification schemes—the American College of Chest Physicians 2001, American College of Chest Physicians 2004, Stroke Prevention in Atrial Fibrillation (SPAF), Atrial Fibrillation Investigators, Framingham, van Walraven, and CHADS₂—were compared for their ability to predict ischemic stroke in patients receiving anticoagulant therapy. Data came from the Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation III and V trials, which compared the efficacy of adjusted-dose warfarin and the direct thrombin inhibitor ximelagatran (36 mg twice daily) in preventing thromboembolic events in 7329 patients with chronic or paroxysmal nonvalvular atrial fibrillation who were at moderate or high risk of ischemic stroke. The main outcome measure was ischemic stroke, as determined by a central event adjudication committee.

Results— During 11 245 patient-years of follow-up, 159 patients had an ischemic stroke (1.4%/year). As indicated by c statistics and hazard ratios, 3 of the classification schemes predicted stroke significantly better than chance: Framingham (c=0.64), CHADS₂ (c=0.65), and SPAF (c=0.61).

Conclusions— In a large cohort of atrial fibrillation patients at moderate or high risk of ischemic stroke treated with warfarin or ximelagatran, the CHADS₂, SPAF, and Framingham schemes had greater predictive accuracy than chance. This predictive ability may allow clinicians to target high-risk patients for more aggressive intervention.

Key Words: anticoagulation • atrial fibrillation • direct thrombin inhibitors • risk prediction • stroke

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Predicting Stroke Risk in Patients With Atrial Fibrillation

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