Korean J Intern Med.  2021 Mar;36(2):342-351. 10.3904/kjim.2019.099.

Impact of carotid atherosclerosis in CHA₂DS₂-VASc-based risk score on predicting ischemic stroke in patients with atrial fibrillation

• Cho DH
• Choi JI
• Choi J
• Kim YG
• Oh SK
• Kook H
• Lee KN
• Shim J
• Park SM
• Shim WJ
• Kim YH

• KMID: 2513745
• DOI: http://doi.org/10.3904/kjim.2019.099

Abstract

Background/Aims
Vascular disease is an established risk factor for stroke in patients with atrial fibrillation (AF), which is included in CHA₂DS₂-VASc score. However, the role of carotid atherosclerosis remains to be determined.
Methods
Three hundred-ten patients with AF who underwent carotid sonography were enrolled.
Results
During a median follow-up of 31 months, 18 events (5.8%) of stroke were identified. Patients with stroke had higher carotid intima-media thickness (CIMT) (1.16 ± 0.33 mm vs. 0.98 ± 0.25 mm, p = 0.017). CIMT was significantly increased according to the CHA₂DS₂-VASc score (p < 0.001) and it was correlated with left ventricular mass index and early diastolic mitral annular velocity (e’), a ratio of early transmitral flow velocity to e’ (E/e’) and pulmonary artery systolic pressure (all p < 0.05). Cox regression using multivariate models showed that carotid plaque was associated with the risk of stroke (hazard ratio, 3.748; 95% confidence interval [CI], 1.107 to 12.688; p = 0.034). C-statistics increased from 0.648 (95% CI, 0.538 to 0.757) to 0.716 (95% CI, 0.628 to 0.804) in the CHA₂DS₂-VASc score model after the addition of CIMT and carotid plaque as a vascular component (p = 0.013).
Conclusions
Increased CIMT and presence of carotid plaque are associated with a high risk of ischemic stroke, and CIMT is related to myocardial remodeling and diastolic dysfunction, suggesting that carotid atherosclerosis can improve risk prediction of stroke in patients with AF, when included under vascular disease in the CHA₂DS₂-VASc scoring system.

Keyword

Atrial fibrillation; Stroke; Carotid stenosis Carotid intima media thickness; Risk assessment