Stroke risk tools need to include carotid disease


Future stroke risk stratification scores in AF patients should integrate carotid disease given the high rate of concomitant disease, Australian researchers say.

A meta-analysis of the evidence from 48 studies found AF and carotid stenosis co-exist in about 10% of patients and non-stenotic carotid disease is found in about half of patients with AF.

The pooled prevalence of carotid stenosis in 49,070 AF patients from 20 trials was 12.4% and the prevalence of carotid plaque was 48.4%.

The prevalence of AF in 2,288,265 patients with cardiac stenosis from 29 trials was 9.3%.

The investigators, including Professor Prash Sanders from the Centre for Heart Rhythm Disorders at the South Australian Health and Medical Research Institute, said other evidence had shown that carotid stenosis (CS) doubles the risk of stroke in AF patients.

“This means that, considering the significant prevalence of CS in AF patients, along with its high attributed stroke risk, CS should be a major component of stroke risk stratification in the AF population.”

Yet most stroke risk stratification schemes have only shown modest performance in predicting thromboembolism, they said.

“One of the reasons for this limited performance is that these stroke risk stratification tools do not appropriately take into account competing causes of stroke such as carotid or intracranial arterial stenosis.”

“For instance, the CHA2DS2-VASc score, which is the most commonly used stroke risk stratification tool, allocates one point (over a total of nine points) to vascular disease, an umbrella risk component including prior myocardial infarction, peripheral artery disease, and aortic plaque.”

“Indeed, this score, which was released about ten years ago, does not take into account carotid disease. Future stroke risk stratification scores in AF patients should integrate carotid disease,” they said.

“Importantly, the commonness of concomitant AF and CS highlights the need to intervene on common risk factors to reduce the development and progression of other conditions,” they added.

And there were questions about whether AF patients with concomitant CS should receive additional treatment beyond anticoagulation to mitigate any residual risk of stroke.

“Considering the frequency of CS in AF patients, it is important to conduct clinical trials in order to determine whether antiplatelet therapy in combination with oral anticoagulants can provide an additional benefit for stroke prevention, when balancing the risk of bleeding in patients with concomitant AF and CS.”

“Finally, these findings have important implications for AF screening in patients with CS, stroke prevention and the opportunities to intervene on common risk factors to reduce the development and progression of other conditions,” they concluded.

The meta-analysis was published in the American Journal of Cardiology.

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