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Non-valvular atrial fibrillation patients with none or one additional risk factor of the CHA2DS2-VASc score: A comprehensive net clinical benefit analysis for warfarin, aspirin, or no therapy
Abstract
Oral anticoagulation (OAC) to prevent stroke has to be balanced against the potential harm of serious bleeding, especially intracranial haemorrhage (ICH). We determined the net clinical benefit (NCB) balancing effectiveness and safety of no antithrombotic therapy, aspirin and warfarin in AF patients with none or one stroke risk factor. Using Danish registries, we determined NCB using various definitions intrinsic to our cohort (Danish weights at 1 and 5 year follow-up), with risk weights which were derived from the hazard ratio (HR) of death following an event, relative to HR of death after ischaemic stroke. When aspirin was compared to no treatment, NCB was neutral or negative for both risk strata. For warfarin vs no treatment, NCB using Danish weights was neutral where no risk factors were present and using five years follow-up. For one stroke risk factor, NCB was positive for warfarin vs no treatment, for one year and five year follow-up. For warfarin vs aspirin use in patients with no risk factors, NCB was positive with one year follow-up, but neutral with five year follow-up. With one risk factor, NCB was generally positive for warfarin vs aspirin. In conclusion, we show a positive overall advantage (i.e. positive NCB) of effective stroke prevention with OAC, compared to no therapy or aspirin with one additional stroke risk factor, using Danish weights. 'Low risk' AF patients with no additional stroke risk factors (i.e.CHA2DS2-VASc 0 in males, 1 in females) do not derive…
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“The rates of stroke and thromboembolism vary considerably in patients with CHA 2 DS 2 -VASc scores of 1 or 2 due to differences in outcomes, populations, and anticoagulation status (Web Addenda Table 1).371,376,377,1041”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [377]
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Cites
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
January, C. T., Wann, L. S., Alpert, J. S., Calkins, H. G., Cigarroa, J. E., Cleveland, J. C., CONTI, J. B., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., et al. (2014) · Circulation · doi:10.1161/cir.0000000000000041 · Cited by 7,145
Edoxaban versus warfarin in patients with atrial fibrillation
Giugliano, R. P., Ruff, C. T., Braunwald, E., Murphy, S. A., Wiviott, S. D., Halperin, J. L., Waldo, A. L., Ezekowitz, M. D., Weitz, J. I., Špinar, J., et al. (2013) · New England Journal of Medicine · doi:10.1056/nejmoa1310907 · Cited by 5,164
Ruff, C. T., Giugliano, R. P., Braunwald, E., Hoffman, E. B., Deenadayalu, N., Ezekowitz, M. D., Camm, A. J., Weitz, J. I., Lewis, B. S., Parkhomenko, A., et al. (2014) · The Lancet · doi:10.1016/s0140-6736(13)62343-0 · Cited by 5,051
Hart, R. G., Pearce, L. A., & Aguilar, M. I. (2007) · Annals of Internal Medicine · doi:10.7326/0003-4819-146-12-200706190-00007 · Cited by 4,793 · cited 2×
“Importantly, we should not forget that OAC also reduces all cause mortality in AF patients, compared to placebo/control (1).”
Background2012 focused update of the ESC Guidelines for the management of atrial fibrillation
Authors Task Force Members, Camm, A. J., Lip, G. Y. H., Caterina, R. D., Savelieva, I., Atar, D., Hohnloser, S. H., Hindricks, G., Kirchhof, P. F., Bax, J. J., et al. (2012) · EP Europace · doi:10.1093/europace/eus305 · Cited by 3,823
Self-citation2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation
January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., Conti, J. B., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., et al. (2014) · Journal of the American College of Cardiology · doi:10.1016/j.jacc.2014.03.022 · Cited by 2,955
2012 focused update of the ESC Guidelines for the management of atrial fibrillation
Authors Task Force Members, Camm, A. J., Lip, G. Y. H., Caterina, R. D., Savelieva, I., Atar, D., Hohnloser, S. H., Hindricks, G., Kirchhof, P. F., Bax, J. J., et al. (2012) · European Heart Journal · doi:10.1093/eurheartj/ehs253 · Cited by 2,929
Self-citationEvaluating medication effects outside of clinical trials: new-user designs
Ray, W. A. (2003) · American Journal of Epidemiology · doi:10.1093/aje/kwg231 · Cited by 1,646
2012 Focused Update of the ESC Guidelines for the Management of Atrial Fibrillation
Camm, A. J., Lip, G. Y. H., Caterina, R. D., Savelieva, I., Atar, D., Hohnloser, S. H., Hindricks, G., & Kirchhof, P. F. (2012) · Revista Española de Cardiología (English Edition) · doi:10.1016/j.rec.2012.11.003 · Cited by 687
Self-citationThe Net Clinical Benefit of Warfarin Anticoagulation in Atrial Fibrillation
Singer, D. E., Chang, Y., Fang, M. C., Borowsky, L. H., Pomernacki, N. K., Udaltsova, N., & Go, A. S. (2009) · Annals of Internal Medicine · doi:10.7326/0003-4819-151-5-200909010-00003 · Cited by 655
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Research works printed but not linked: 2
- 10.1161/CIRCULATIONAHA.111.055079 · DOI · Paper page
- 10.1160/TH11-05-0364 · DOI · Paper page
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Ringelstein, E. B. (2019) · Springer Reference Medizin · doi:10.1007/978-3-662-44768-0_149-2
Schlaganfall – Prävalenz, Bedeutung und Implikationen für die Prävention und Gesundheitsförderung
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Primärprävention und Sekundärprävention des Hirninfarkts
Ringelstein, E. B. (2018) · Springer Reference Medizin · doi:10.1007/978-3-662-44768-0_149-1
Polymeris, A. A., Rossel, J., Koga, M., Strbian, D., Adhiyaman, V., Krishnan, M., Branca, M., Meinel, T. R., Kristoffersen, E. S., Yoshimoto, T., et al. (2025) · European Stroke Journal · doi:10.1177/23969873251360974
“Weight values were derived from previous empirical research, 25–28 with ischemic stroke being assigned a weight of 1.0 (reference event), SE a weight of 0.9 (weight SE ), and MEB a weight of 0.7 (weight MEB ), while the weight for ICH varies from 1.5 to 3.3 (weight ICH ).”
InfluentialAtrial fibrillation through the lens of precision medicine: what clinicians need to know
Namjouyan, K., Lamata, P., Virk, H. U. H., Glicksberg, B. S., Giudicessi, J. R., & Krittanawong, C. (2025) · Future Cardiology · doi:10.1080/14796678.2025.2603897
Polymeris, A. A., Rossel, J., Koga, M., Strbian, D., Vedamurthy, A., Krishnan, M., Branca, M., Meinel, T. R., Kristoffersen, E. S., Yoshimoto, T., et al. (2026) · European Stroke Journal · doi:10.1093/esj/23969873251360974
“Weight values were derived from previous empirical research, 25–28 with ischemic stroke being assigned a weight of 1.0 (reference event), SE a weight of 0.9 (weight SE ), and MEB a weight of 0.7 (weight MEB ), while the weight for ICH varies from 1.5 to 3.3 (weight ICH ).”
Influential
Metadata
- Authors
- Skjøth, F., Nielsen, P., Larsen, T. B., & Lip, G.
- Affiliations
- Birmingham City Hospital (GB)
- Aalborg University Hospital (DK)
- Corresponding author
- Lip, Gregory
- Venue
- Thrombosis and Haemostasis
- Publisher
- Georg Thieme Verlag KG
- Published
- 2015
- Volume
- 114
- Issue
- 10
- Pages
- 826-834
- ISSN
- 0340-6245 (ISSN-L)
- 2567-689X
- OpenAlex
- W2160740406
- Cited by
- 106
- References
- 30
- Citations by year
- 2026: 2 · 2025: 5 · 2024: 2 · 2023: 1 · 2022: 2 · 2021: 9 · 2020: 7 · 2019: 9 · 2018: 11 · 2017: 15 · 2016: 39 · 2015: 4
- FWCI
- 16.87
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Thrombosis and Haemostasis (publishedVersion)
- PubMed (publishedVersion)
- VBN Forskningsportal (Aalborg Universitet) (submittedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Clinical Neurology › Acute Ischemic Stroke Management
- Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
- Keywords
- non-valvular atrial fibrillation, CHA2DS2-VASc score, oral anticoagulation, warfarin, aspirin, stroke prevention, intracranial hemorrhage, bleeding risk, net clinical benefit
- MeSH terms
- Administration, Oral, Aged, Aged, 80 and over, Aspirin, Atrial Fibrillation, Decision Support Techniques, Denmark, Female, Fibrinolytic Agents, Hemorrhage, Humans, Male, Middle Aged, Predictive Value of Tests, Registries, Risk Factors, Time Factors, Warfarin, Treatment Outcome, Risk Assessment, Patient Selection, Stroke
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