A new model to predict ischemic stroke in patients with atrial fibrillation using warfarin or direct oral anticoagulants

J'Neka S. Claxton, Richard F. MacLehose, Pamela L. Lutsey, Faye L. Norby, Lin Y. Chen, Wesley T. O'Neal, Alanna M. Chamberlain, Lindsay G.S. Bengtson, Alvaro Alonso

Research output: Contribution to journalArticlepeer-review

1 Scopus citations

Abstract

Background: Stroke risk stratification scores (eg, CHA2DS2-VASc) are used to tailor therapeutic recommendations for patients with atrial fibrillation (AF) in different risk groups. Objective: The purpose of this study was to develop a tool to estimate stroke risk in patients receiving oral anticoagulants (OACs) and to identify patients who remain at high risk for stroke despite anticoagulation therapy. Methods: Patients with nonvalvular AF initiating OACs were identified in the MarketScan data from 2007 to 2015. Using bootstrapping methods and backward selection of 44 candidate variables, we developed a model that selected variables predicting stroke. The final model was validated in patients with nonvalvular AF in the Optum database in the period 2009–2015. In both databases, the discrimination of existing stroke scores were individually evaluated and compared with our new model termed the AntiCoagulaTion-specific Stroke (ACTS) score. Results: Among 135,523 patients with AF initiating OACs in the MarketScan dataset, 2028 experienced an ischemic stroke after anticoagulant initiation. The stepwise model identified 11 variables (including type of OAC) associated with ischemic stroke. The discrimination (C statistic) of the model was adequate (0.68; 95% confidence interval [CI] 0.66–0.70), showing excellent calibration (χ2 = 6.1; P = .73). ACTS was then applied to 84,549 AF patients in the Optum dataset (1408 stroke events) and showed similar discrimination (C statistic 0.67; 95% CI 65-0.69). However, previously developed predictive models had similar discriminative ability (CHA2DS2-VASc 0.67; 95% CI 0.65–0.68). Conclusion: A novel model to identify AF patients at higher risk of ischemic stroke, using extensive administrative health care data including type of anticoagulant, did not perform better than established simpler models.

Original languageEnglish (US)
Pages (from-to)820-826
Number of pages7
JournalHeart Rhythm
Volume16
Issue number6
DOIs
StatePublished - Jun 2019

Bibliographical note

Funding Information:
This work was supported by the National Heart, Lung, and Blood Institute and National Institute of Aging of the National Institutes of Health (Grant Numbers R01-HL122200, F32-HL134290, R21-AG058445); and American Heart Association (Grant Number 16EIA2641000). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the American Heart Association. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Dr. Bengtson is an employee of Optum. All other authors have no potential conflicts of interest. This work was supported by the National Heart, Lung, and Blood Institute and National Institute of Aging of the National Institutes of Health (Grant Numbers R01-HL122200, F32-HL134290, R21-AG058445); and American Heart Association (Grant Number 16EIA2641000). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the American Heart Association. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Dr. Bengtson is an employee of Optum. All other authors have no potential conflicts of interest.

Publisher Copyright:
© 2018 Heart Rhythm Society

Keywords

  • Anticoagulation
  • Atrial fibrillation
  • Epidemiology
  • Ischemic stroke
  • Risk model

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