Contemporary management of atrial fibrillation and the predicted vs. absolute risk of ischaemic stroke despite treatment: a report from ESC-EHRA EORP-AF Long-Term General Registry

Background Risk stratification in patients with atrial fibrillation (AF) is important to facilitate guideline-directed therapies. The Calculator of Absolute Stroke Risk (CARS) scheme enables an individualized estimation of 1-year absolute risk of stroke in AF. We aimed to investigate the predicted and absolute risks of ischaemic stroke, and evaluate whether CARS (and CHA(2)DS(2)-VASc score) may be useful for identifying high risk patients with AF despite contemporary treatment. Methods We utilized the EORP-AF General Long-Term Registry which prospectively enrolled patients with AF from 250 centres across 27 participating European countries. Patients with sufficient data to determine CARS and CHA(2)DS(2)-VASc score, and reported outcomes of ischaemic stroke were included in this analysis. The primary outcome of ischaemic stroke was recorded over a 2-year follow-up period. Results A total of 9444 patients were included (mean age 69.1 [+/- 11.4] years; 3776 [40.0%] females). There was a high uptake (87.9%) of anticoagulation therapy, predominantly with vitamin K antagonist (50.0%). Over a mean follow-up period of 24 months, there were a total of 101 (1.1%) ischaemic stroke events. In the entire cohort, the median CARS and absolute annual risks of ischaemic stroke were 2.60 (IQR 1.60-4.00) and 0.53% (95%CI 0.43-0.64%), respectively. There was no statistical difference between the predictive performance of CARS and CHA(2)DS(2)-VASc score (0.621 [95%CI 0.563-0.678] vs. 0.626 [95%CI 0.573-0.680], P = 0.725). Conclusion Contemporary management of AF was associated with a low risk of ischaemic stroke. CARS and CHA(2)DS(2)-VASc score may be useful to identify high risk patients despite treatment who may benefit from more aggressive treatment and follow-up.

Automated summary

This study investigated the absolute risk of ischemic stroke and the predictive performance of the Calculator of Absolute Stroke Risk (CARS) scheme in atrial fibrillation (AF) patients. The results showed that contemporary management of AF was associated with a low risk of ischemic stroke. CARS and CHA(2)DS(2)-VASc score may be helpful in identifying high-risk patients who may benefit from more aggressive treatment and follow-up.