Kidney disease affects stroke risk prediction
The Modified CHADS2 score to estimate risk of ischaemic stroke (IS) in AF patients has the best, most consistent discrimination and calibration across the spectrum of kidney function.
Six commonly used risk scores for stroke were externally validated in a Swedish cohort study of 36,004 patients with AF.
Although most risk scores showed moderate to good discrimination in patients with normal kidney function, the predictive performance of the majority of risk scores was poor in the most clinically relevant stages of CKD.
The researchers said this poor performance increases the risk of misclassification and of over- or undertreatment.
“Underprediction of IS risk, when weighed with bleeding risk, will result in less patients being treated with anticoagulation and consequently, an increased IS incidence, while overprediction will result in overtreatment and increased bleeding incidence.”
“These findings can inform the choice of risk scores in clinical practice, particularly in patients with mild to severe forms of CKD, which have not always been considered when these scores were developed,” they concluded.
Effect of dapagliflozin on HF underestimated
The SGLT2 inhibitor dapagliflozin reduces the risk of first and total HF hospitalisations as well as cardiovascular death by about 25% in patients with heart failure and reduced ejection fraction (HFrEF).
A study of the DAPA-HF trial data from 4,744 participants found 548 patients experienced a total of 809 heart failure hospitalisations. There were also 500 CV and 273 non-CV deaths.
“The rate of total (first and recurrent) heart failure hospitalisations and cardiovascular death was 21.6 per 100 patient-years in the placebo group and 16.3 per 100 patient-years in the dapagliflozin group,” said the study authors, noting this equated to a rate ratio of 0.75 for the effect of dapagliflozin versus control.
The authors said repeat hospitalisations were often ignored in conventional analysis yet each hospitalisation was prognostically important as well as a burden on the patients and costly for the health system.
They concluded the original DADA-HF analysis underestimated the absolute benefit of therapy.
More action on diabetes in heart disease required
Heart patients are three times more likely to have diabetes than the general population, according to an analysis of the CLARIFY registry of more than 32,000 patients with chronic coronary syndromes from across 45 countries
The study found the overall prevalence of diabetes was 29% compared to the estimated prevalence of diabetes in the general population of 8-10%.
The study noted marked disparities in diabetes prevalence across geographical regions – from 14% in Ireland to 67% in Saudi Arabia – yet heart patients with diabetes had worse outcomes than those without diabetes regardless of geographic region and ethnicity.
The study found the hazard ratio for the primary outcome, a composite of CV death, MI and stroke, was 1.28.
Similarly, the risks of all secondary outcomes were higher for patients with diabetes – HR 1.38 for all-cause death, 1.39 for cardiovascular death, 1.26 for myocardial infarction, 1.29 for stroke, 1.15 for hospital admission for heart failure, and 1.14 for coronary revascularisation.
They concluded improved strategies to slow the progression of diabetes and more effective intervention to prevent its adverse consequences were urgently needed.