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Cited by 4,832Atrial Fibrillation Management and OutcomesAcute Ischemic Stroke ManagementCardiovascular and Diving-Related Complications

Validation of Clinical Classification Schemes for Predicting Stroke: Results From the National Registry of Atrial Fibrillation

Gage, Brian F., Waterman, Amy D., Shannon, William, Boechler, Michael, Rich, Michael W., Radford, Martha J.·2001·JAMA
DOI 10.1001/jama.285.22.2864
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Abstract

CONTEXT: Patients who have atrial fibrillation (AF) have an increased risk of stroke, but their absolute rate of stroke depends on age and comorbid conditions. OBJECTIVE: To assess the predictive value of classification schemes that estimate stroke risk in patients with AF. DESIGN, SETTING, AND PATIENTS: Two existing classification schemes were combined into a new stroke-risk scheme, the CHADS( 2) index, and all 3 classification schemes were validated. The CHADS( 2) was formed by assigning 1 point each for the presence of congestive heart failure, hypertension, age 75 years or older, and diabetes mellitus and by assigning 2 points for history of stroke or transient ischemic attack. Data from peer review organizations representing 7 states were used to assemble a National Registry of AF (NRAF) consisting of 1733 Medicare beneficiaries aged 65 to 95 years who had nonrheumatic AF and were not prescribed warfarin at hospital discharge. MAIN OUTCOME MEASURE: Hospitalization for ischemic stroke, determined by Medicare claims data. RESULTS: During 2121 patient-years of follow-up, 94 patients were readmitted to the hospital for ischemic stroke (stroke rate, 4.4 per 100 patient-years). As indicated by a c statistic greater than 0.5, the 2 existing classification schemes predicted stroke better than chance: c of 0.68 (95% confidence interval [CI], 0.65-0.71) for the scheme developed by the Atrial Fibrillation Investigators (AFI) and c of 0.74 (95% CI, 0.71-0.76) for the Stroke Prevention in Atrial Fibrillation (SPAF) III scheme. However, with a c statistic of 0.82 (95% CI, 0.80-0.84), the CHADS( 2) index was the most accurate predictor of stroke. The stroke rate per 100 patient-years without antithrombotic therapy increased by a factor of 1.5 (95% CI, 1.3-1.7) for each 1-point increase in the CHADS( 2) score: 1.9 (95% CI, 1.2-3.0) for a score of 0; 2.8 (95% CI, 2.0-3.8) for 1; 4.0 (95% CI, 3.1-5.1) for 2; 5.9 (95% CI, 4.6-7.3) for 3; 8.5 (95% CI, 6.3-11.1) for 4; 12.5 (95% CI, 8.2-17.5) for 5; and 18.2 (95% CI, 10.5-27.4) for 6. CONCLUSION: The 2 existing classification schemes and especially a new stroke risk index, CHADS( 2), can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

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  • Simple, clinically applicable stroke risk-stratification schemes in AF patients were developed in the late 1990s in small cohort studies and later refined and validated in larger populations.

    “Simple, clinically applicable stroke risk-stratification schemes in AF patients were developed in the late 1990s in small cohort studies and have later been refined and validated in larger populations.[364][365][366][367][368]”

    From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [365]

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Authors
Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., & Radford, M. J.
Affiliations
  • Washington University in St. Louis (US)
  • Houston Methodist (US)
  • Yale New Haven Hospital (US)
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2001-06-13
Volume
285
Issue
22
Pages
2864
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.285.22.2864
OpenAlex
W2062786076
Cited by
4,832
References
32
Citations by year
2026: 40 · 2025: 81 · 2024: 106 · 2023: 108 · 2022: 148 · 2021: 180 · 2020: 196 · 2019: 197 · 2018: 253 · 2017: 266 · 2016: 367 · 2015: 400 · 2014: 427 · 2013: 432 · 2012: 409
FWCI
15.23
Type
journal article
Language
en
Open access
closed
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health (500-99-NH01)
  • Agency for Healthcare Research and Quality (R01 HS10133)
  • U.S. Public Health Service (500-96-P549, 500-99-VT01, 500-99-ME01, 500-96-P612, 500-99-LA02)
  • National Cancer Institute (500-99-CA02)
Topics
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
  • Health Sciences › Medicine › Epidemiology › Acute Ischemic Stroke Management
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Cardiovascular and Diving-Related Complications
Keywords
atrial fibrillation, ischemic stroke, stroke risk prediction, Medicare beneficiaries, antithrombotic therapy, warfarin, congestive heart failure, hypertension, diabetes mellitus, transient ischemic attack, model validation
MeSH terms
Aged, Aged, 80 and over, Atrial Fibrillation, Female, Humans, Male, Severity of Illness Index, Cohort Studies, Comorbidity, Proportional Hazards Models, Survival Analysis, Risk Assessment, Stroke

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