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Serna, María José; Rivera-Caravaca, José Miguel; López-Gálvez, Raquel; Soler-Espejo, Eva; Lip, Gregory Y.H.; Marín, Francisco; Roldán, Vanessa
Revista española de cardiologiaJournal Article
A menudo la evaluación de los riesgos de ictus y hemorragia en la fibrilación auricular (FA) es basal para predecir los resultados años después. Sin embargo, estos riesgos no son estáticos. Se investiga si los cambios dinámicos en CHA2DS2-VASc y HAS-BLED a lo largo del tiempo modifican la predicción del riesgo. Se incluyó a pacientes con FA estables en tratamiento con antagonistas de la vitamina K. Durante 6 años de seguimiento, se registraron todos los ictus isquémicos/accidentes isquémicos transitorios (AIT) y hemorragias mayores. El CHA2DS2-VASc y HAS-BLED se revaluaron cada 2 años y se investigaron los resultados clínicos en periodos de 2 años. Se incluyó a 1.361 pacientes (medias de CHA2DS2-VASc y HAS-BLED, 4,0±1,7 y 2,9±1,2). Durante el seguimiento, 156 pacientes (11,5%) sufrieron un ictus isquémico/AIT y 269 (19,8%), una hemorragia mayor. En comparación con el valor basal, el CHA2DS2-VASc recalculado a los 2 años presentó mayor capacidad predictiva de ictus isquémico/AIT durante el periodo de 2-4 años. El índice de mejoría de la discriminación (IDI) y el índice de reclasificación neta (NRI) mostraron mejoras en la sensibilidad y mejor reclasificación. El CHA2DS2-VASc recalculado a los 4 años arrojó un mejor rendimiento predictivo que el basal durante el periodo de 4-6 años, con una mejora en el IDI y una mejora de la reclasificación. El HAS-BLED recalculado a los 2 años presentó mayor capacidad predictiva de hemorragia mayor que el basal durante el período de 2-4 años, con mejoras significativas en la sensibilidad y la reclasificación. Se observó un ligero aumento en la sensibilidad del HAS-BLED recalculado a los 4 años respecto al basal. En pacientes con FA, los riesgos de ictus y hemorragia son dinámicos y cambian con el tiempo. Las escalas CHA2DS2-VASc y HAS-BLED deben revaluarse con regularidad, especialmente para una precisa predicción del riesgo de ictus. Stroke and bleeding risks in atrial fibrillation (AF) are often assessed at baseline to predict outcomes years later. We investigated whether dynamic changes in CHA2DS2-VASc and HAS-BLED scores over time modify risk prediction. We included patients with AF who were stable while taking vitamin K antagonists. During a 6-year follow-up, all ischemic strokes/transient ischemic attacks (TIAs) and major bleeding events were recorded. CHA2DS2-VASc and HAS-BLED were recalculated every 2-years and tested for clinical outcomes at 2-year periods. We included 1361 patients (mean CHA2DS2-VASc and HAS-BLED 4.0±1.7 and 2.9±1.2). During the follow-up, 156 (11.5%) patients had an ischemic stroke/TIA and 269 (19.8%) had a major bleeding event. Compared with the baseline CHA2DS2-VASc, the CHA2DS2-VASc recalculated at 2 years had higher predictive ability for ischemic stroke/TIA during the period from 2 to 4 years. Integrated discrimination improvement (IDI) and net reclassification improvement (NRI) showed improvements in sensitivity and better reclassification. The CHA2DS2-VASc recalculated at 4 years had better predictive performance than the baseline CHA2DS2-VASc during the period from 4 to 6 years, with an improvement in IDI and an enhancement of the reclassification. The recalculated HAS-BLED at 2-years had higher predictive ability than the baseline score for major bleeding during the period from 2 to 4 years, with significant improvements in sensitivity and reclassification. A slight enhancement in sensitivity was observed with the HAS-BLED score recalculated at 4 years compared with the baseline score. In AF patients, stroke and bleeding risks are dynamic and change over time. The CHA2DS2-VASc and HAS-BLED scores should be regularly reassessed, particularly for accurate stroke risk prediction.
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