Korean Circ J.  2021 Aug;51(8):668-680. 10.4070/kcj.2021.0170.

Stroke and Bleeding Risk Assessment in Atrial Fibrillation: Where Are We Now?

• Kuo L
• Chan YH
• Liao JN
• Chen SA
• Chao TF

• KMID: 2519148
• DOI: http://doi.org/10.4070/kcj.2021.0170

Abstract

Most important international guidelines recommend the use of CHA ₂ DS ₂ -VASc and HASBLED scores for stroke and bleeding risk assessments in atrial fibrillation (AF) patients, respectively. The 2020 AF guidelines of European Society of Cardiology have revised the definition of “C: congestive heart failure (HF)” component, and now patients with either HF with reduced ejection fraction or preserved ejection fraction should be assigned 1 point. Hypertrophic cardiomyopathy was also included. Besides, the revised “V: vascular diseases” component included both prior myocardial infarction and “angiographically significant coronary artery disease”. It is important to understand that the stroke and bleeding risks of AF patients were not static and should be re-assessed regularly. A high HAS-BLED score itself should not be the only reason to withhold or discontinue oral anticoagulants, but remind physicians for the corrections of modifiable bleeding risk factors and more regular follow up. In the future, the AF duration and left atrial function may play an important role for personalized evaluation of individual stroke risk while more studies are necessary.

Keyword

Atrial fibrillation; Stroke; Bleeding; CHA₂ DS₂ -VASc; HAS-BLED

Figure

• 

  Figure 1 Key points about the use of CHA2DS2-VASc and HAS-BLED scores for stroke and bleeding risk assessments.ACCP = American College of Chest Physicians; AF = atrial fibrillation; APHRS = Asia Pacific Heart Rhythm Society; CAD = coronary artery disease; ESC = European Society of Cardiology; HCM = hypertrophic cardiomyopathy; LV = left ventricular; OAC = oral anticoagulant; PAD = peripheral artery disease.

• 

  Figure 2 Considerations and proposed age thresholds about the use of NOACs for Asian AF patients with single one stroke risk factor beyond gender.Data used in the figure were adopted form the papers by Chao et al.17)32)33)AF = atrial fibrillation; F = female; M = male; NOACs = non-vitamin K antagonist oral anticoagulants.

• 

  Figure 3 Interactions between AF duration and CHA2DS2-VASc score regarding risk of ischemic stroke and systemic embolism. Data used in the figure were adopted form the papers by Kaplan et al.55)AF = atrial fibrillation; NOACs = non-vitamin K antagonist oral anticoagulants.

• 

  Figure 4 Potential role of LA strain in the prediction of ischemic stroke in AF.Data used in the figure were adopted form the papers by Liao et al.50)51)58)AF = atrial fibrillation; CI = confidence interval; HR = hazard ratio; LA = left atrium.

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