Risk Stratification for Acute Pulmonary Embolism in Patients with Atrial Fibrillation: Role of CHADS₂ Score

Abstract

Pulmonary embolism (PE) is associated with atrial fibrillation (AF). This study sought to explore if the CHADS₂ score could predict the prognosis of PE in patients with AF. In a tertiary hospital, 4,288 consecutive patients with diagnosis of PE were screened. In total, 305 patients with PE had AF and were included in this retrospective study. In-hospital outcome was defined as at least one of the following: death from any cause, need for intravenous catecholamine administration, endotracheal intubation, cardiopulmonary resuscitation, or thrombolytic therapy. The in-hospital outcome occurred in 10.2% of the patients. Patients with adverse outcome had higher CHADS₂ score, CHA₂DS₂-VASc score, and simplified pulmonary embolism severity index (sPESI) score. The area under the receiver operating characteristics curve was 0.66, 0.62, and 0.71 for CHADS₂ score, CHA₂DS₂-VASc score, and sPESI score, respectively, in predicting in-hospital outcome. The incidence of in-hospital outcome was 3.4 and 14.4% in sPESI = 0 and sPESI ≥1 groups (p < 0.01). CHADS₂ also had good predictive value with the incidence of in-hospital outcome, being 4.6% in CHADS₂ < 2 and 14.3% in CHADS₂ ≥ 2 groups (p < 0.01). The incidences of in-hospital outcome were 2.6, 4.8, 7.4, and 17.3% in patients with sPESI = 0 and CHADS₂ < 2, sPESI = 0 and CHADS₂ ≥ 2, sPESI ≥ 1 and CHADS₂ < 2, and sPESI ≥ 1 and CHADS₂ ≥ 2 (p < 0.01), respectively. In multivariable analysis, CHADS₂ (odds ratio: 1.50; 95% confidence interval: 1.11–2.02; p < 0.01) was an independent predictor of in-hospital adverse outcome. High CHADS₂ score could predict worse in-hospital outcome in patients with PE and AF.

Keywords

pulmonary embolism - atrial fibrillation - prognosis - CHADS₂ score

• References

• 1 Ogren M, Bergqvist D, Eriksson H, Lindblad B, Sternby NH. Prevalence and risk of pulmonary embolism in patients with intracardiac thrombosis: a population-based study of 23 796 consecutive autopsies. Eur Heart J 2005; 26 (11) 1108-1114
• 2 Konstantinides SV, Torbicki A, Agnelli G. , et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
• 3 Becattini C, Cohen AT, Agnelli G. , et al. Risk stratification of patients with acute symptomatic pulmonary embolism based on presence or absence of lower extremity DVT: systematic review and meta-analysis. Chest 2016; 149 (01) 192-200
• 4 Jiménez D, Aujesky D, Moores L. , et al; RIETE Investigators. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170 (15) 1383-1389
• 5 Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest 2010; 137 (02) 263-272
• 6 Chan YH, Yiu KH, Lau KK. , et al. The CHADS2 and CHA2DS2-VASc scores predict adverse vascular function, ischemic stroke and cardiovascular death in high-risk patients without atrial fibrillation: role of incorporating PR prolongation. Atherosclerosis 2014; 237 (02) 504-513
• 7 Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GY. Assessment of the CHA2DS2-VASc score in predicting ischemic stroke, thromboembolism, and death in patients with heart failure with and without atrial fibrillation. JAMA 2015; 314 (10) 1030-1038
• 8 Saliba W, Rennert G. CHA2DS2-VASc score is directly associated with the risk of pulmonary embolism in patients with atrial fibrillation. Am J Med 2014; 127 (01) 45-52
• 9 Camm AJ, Kirchhof P, Lip GY. , et al; European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31 (19) 2369-2429
• 10 Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285 (22) 2864-2870
• 11 Wang CC, Lin CL, Wang GJ, Chang CT, Sung FC, Kao CH. Atrial fibrillation associated with increased risk of venous thromboembolism. A population-based cohort study. Thromb Haemost 2015; 113 (01) 185-192
• 12 Donzé J, Le Gal G, Fine MJ. , et al. Prospective validation of the Pulmonary Embolism Severity Index. A clinical prognostic model for pulmonary embolism. Thromb Haemost 2008; 100 (05) 943-948
• 13 Svendsen JH, Nielsen JC, Darkner S, Jensen GV, Mortensen LS, Andersen HR. ; DANPACE Investigators CHADS2 and CHA2DS2-VASc score to assess risk of stroke and death in patients paced for sick sinus syndrome. Heart 2013; 99 (12) 843-848
• 14 Podolecki T, Lenarczyk R, Kowalczyk J. , et al. Stroke and death prediction with CHA2DS2-vasc score after myocardial infarction in patients without atrial fibrillation. J Cardiovasc Med (Hagerstown) 2015; 16 (07) 497-502
• 15 Orvin K, Bental T, Assali A, Lev EI, Vaknin-Assa H, Kornowski R. Usefulness of the CHADS-VASc score to predict adverse outcomes in patients having percutaneous coronary intervention. Am J Cardiol 2016; 117 (09) 1433-1438
• 16 Taşolar H, Çetin M, Ballı M. , et al. CHA2DS2-VASc-HS score in non-ST elevation acute coronary syndrome patients: assessment of coronary artery disease severity and complexity and comparison to other scoring systems in the prediction of in-hospital major adverse cardiovascular events. Anatol J Cardiol 2016; 16 (10) 742-748
• 17 Onuk T, Karataş MB, İpek G. , et al. Higher CHA2DS2-VASc score is associated with increased mortality in acute pulmonary embolism. Clin Appl Thromb Hemost 2016; 1076029615627341
• 18 Dellas C, Puls M, Lankeit M. , et al. Elevated heart-type fatty acid-binding protein levels on admission predict an adverse outcome in normotensive patients with acute pulmonary embolism. J Am Coll Cardiol 2010; 55 (19) 2150-2157