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Background: In patients with incident heart failure, the risk of venous thromboembolism (VTE), defined as pulmonary embolism (PE) and/or deep venous thrombosis (DVT), is sparsely described, especially potential sex differences. We conducted an observational study to evaluate risk of VTE among male and female heart failure patients., Methods: Population-based cohort study of patients diagnosed with incident heart failure during 2000-2015, identified by record linkage between nationwide registries in Denmark. Using a pseudo-value approach, we calculated relative risks [RR] of VTE at 1 and 3 years of follow-up. Crude VTE risk for males and females are reported and contrasted after adjustment for established clinical risk factors for VTE., Results: A total of 32,330 heart failure patients were included, of which 15,238 (47%) were females. For the combined endpoint of VTE, female sex was associated with a higher risk (1-year adjusted RR: 1.30, 95% confidence interval [CI]: 0.97-1.73; 3-year adjusted RR: 1.34, 95% CI: 1.07-1.67) compared to male patients. For the individual endpoints of PE and DVT after 1-year of follow-up, female sex was only associated with a higher risk of PE and not DVT, compared to male patients. However, female sex was associated with a higher risk of both PE and DVT after 3 years of follow-up., Conclusions: Among incident heart failure patients, female sex is associated with a higher risk of VTE, mainly driven by an excess risk of PE. This finding may help improve clinical decision-making regarding VTE prophylaxis in patients with heart failure.

Background: Various bleeding risk scores have been proposed to assess the risk of bleeding in patients with atrial fibrillation taking oral anticoagulants. Limited data are available with these scores, in users of non-vitamin K antagonist oral anticoagulants., Methods: Using the Danish registries, we evaluated and compared the risk classification properties of the Hypertension, Age, Stroke, Bleeding tendency/predisposition, Labile international normalized ratios, Elderly age/frailty, Drugs such as concomitant aspirin/nonsteroidal anti-inflammatory drugs or alcohol excess (HAS-BLED), Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA), and Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) scores for predicting major bleeding in 57,930 atrial fibrillation patients (44.6% female; mean age 73.5 years, standard deviation 11.4 years; mean CHA 2 DS 2 -VASc score 3.2, standard deviation 1.8)., Results: At 1-year follow-up, C-statistics for ATRIA, HAS-BLED, and ORBIT were approximately 0.59, with only minor differences between scores. Both ATRIA and ORBIT categorized more patients as "low risk" (both >83%, when compared with HAS-BLED, only 53%), and qualitatively, the receiver operating characteristic curves revealed higher sensitivity (62.8%) for HAS-BLED compared with ATRIA (29.7%) and ORBIT (37.1%). The clinical usefulness of scores was evaluated using decision curve analyses at a 1-year perspective. If the intervention threshold is low (<1.7%), the benefit is toward monitoring all patients. If preference is for a major bleeding risk threshold between 1.7% and 2.0%, most benefit was obtained by using HAS-BLED. The ORBIT and ATRIA scores provided better benefit for thresholds between 2.0% and 6.0%., Conclusion: This analysis of contemporary bleeding risk score stratification in a "real-world" non-vitamin K antagonist oral anticoagulant users population with atrial fibrillation showed modest predictive values using C-statistics. The scores represent different risk thresholds, with HAS-BLED classifying least patients at low risk and achieving the highest benefit if applying a major bleeding intervention threshold of approximately 2%, whereas benefit from using either ATRIA score or ORBIT score was only evident using higher intervention thresholds., (Copyright © 2018 Elsevier Inc. All rights reserved.)

After a hemorrhagic stroke, it is uncertain whether this event scores one point (either for stroke or bleeding) or two points (one point each for stroke and bleeding) on the bleeding risk score termed HAS-BLED (hypertension, abnormal renal/liver function [one or two points], stroke, bleeding history or predisposition, labile international normalized ratio [INR], elderly [> 65 years], drugs/alcohol concomitantly [one or two points]). We investigated the value of a recalibration of the HAS-BLED score to account for two points from a hemorrhagic stroke. Data were analyzed from the Danish nationwide cohort of patients with incident atrial fibrillation (AF) from January 1999 to December 2013. The primary outcome in this observational study was major bleeding. The original and the recalibrated HAS-BLED scores were assessed, and the event rates of major bleeding were calculated. The predictive accuracy of major bleeding was compared by using C-statistics, the net reclassification index (NRI), and integrated discrimination improvement (IDI). An event rate for major bleeding of 4.3 per 100 person-years was recorded in the 210,299 patients with AF. The C-statistics for the two scores were modest: 0.613 (95% CI, 0.607-0.619) for the original score and 0.616 (95% CI, 0.610-0.622) for the recalibrated score. The NRI was 10.0% (95% CI, 7.6-12.4). The relative IDI was 23.6% (95% CI, 15.7-31.5), reflecting that the recalibrated HAS-BLED score more accurately predicted bleeding events. Recalibration of the "S" component in the HAS-BLED score (counting two points for a hemorrhagic stroke) resulted in an increase in the C-statistics, NRI, and IDI. This approach could potentially aid physicians in more accurate assessments of bleeding risk in patients with AF., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Oral anticoagulation (OAC) is highly effective for stroke prevention in nonvalvular atrial fibrillation. We explored rates of stroke/thromboembolism/transient ischemic attack among the "OAC not recommended" patient group defined according to the 2014 Canadian Cardiovascular Society (CCS) algorithm (based on the Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack [CHADS2] score) who would have been offered OAC using the European Society of Cardiology (ESC) guidelines approach (based on the Congestive Heart Failure, Hypertension, Age [≥75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female]; CHA2DS2-VASc score)., Methods: We identified 22,582 nonanticoagulated patients age < 65 years with a CHADS2 score of 0 who were stratified according to the CHA2DS2-VASc score, except female sex, which would be an indication for OAC according to the ESC guidelines. Event rates for each risk strata were compared using Cox proportional hazard ratios., Results: The overall rate of the combined end point of ischemic stroke/systemic embolism/transient ischemic attack was 4.32 per 100 person-years (95% confidence interval [CI], 3.26-5.74) at 1 year, among the patients who would have had an indication for OAC therapy according to ESC guidelines and "OAC not recommended" according to CCS algorithm. This corresponded to an adjusted hazard ratio of 3.08 (95% CI, 2.21-4.29) relative to the subgroup with no indication for OAC according to the ESC guidelines. A subgroup of patients with previous vascular disease and CHADS2 score of 0 (ie, recommended only aspirin treatment according to the CCS algorithm) had an event rate of 4.84 (95% CI, 3.53-6.62) per 100 person-years at 1-year follow-up., Conclusions: Based on the 2014 CCS algorithm, the "OAC not recommended" subgroup can have a high 1-year stroke rate overall, showing that such patients are not "low risk." Use of the ESC guideline approach (based on the CHA2DS2-VASc) offers refinement of stroke risk stratification in such patients., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Our objective was to determine stroke and thromboembolism event rates in patients with atrial fibrillation (AF) classified as "low risk" using the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) score and to ascertain event rates in this group in relation to the stroke risk assessment advocated in the 2012 European Society of Cardiology (ESC) guidelines (based on the CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 years, diabetes, previous stroke/transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score). We tested the hypothesis that the stroke risk assessment scheme advocated in the ESC guidelines would be able to further refine stroke risk stratification in the low-risk category defined by the ATRIA score., Methods: In our cohort of 207,543 incident patients with AF from 1999 to 2012, we identified 72,452 subjects who had an ATRIA score of 0 to 5 (low risk)., Results: Even among these patients categorized as low risk using the ATRIA score, the 1-year stroke/thromboembolic event rate ranged from 1.13 to 36.94 per 100 person-years, when subdivided by CHA2DS2-VASc scores. In patients with an ATRIA score 0 to 5, C statistics at 1 year follow-up in the Cox regression model were significantly improved from 0.626 (95% CI, 0.612-0.640) to 0.665 (95% CI, 0.651-0.679) when the CHA2DS2-VASc score was used for categorizing stroke risk instead of the ATRIA score (P < .001)., Conclusions: Patients categorized as low risk using an ATRIA score 0 to 5 are not necessarily low risk, with 1-year event rates as high as 36.94 per 100 person-years. Thus, the stroke risk stratification scheme recommended in the ESC guidelines (based on the CHA2DS2-VASc score) would be best at identifying the "truly low risk" subjects with AF who do not need any antithrombotic therapy.

Introduction: Patients with incident venous thromboembolism carry a chronic risk of suffering a recurrent event. Anticoagulation is effective at preventing recurrence during treatment but also associated with risk of bleeding. Hence, the dilemma of optimal anticoagulant treatment duration beyond the acute treatment phase remains a clinical challenge in the management of venous thromboembolism.Areas covered: This review summarizes the current evidence for extended oral anticoagulant treatment after incident venous thromboembolism, and discusses dilemmas involved in treatment decisions related to extended secondary prevention.Expert opinion: Results from landmark venous thromboembolism-extended treatment studies focused on direct oral anticoagulants suggest a paradigm shift of the risk-benefit balance in favor of extended anticoagulant treatment. Nevertheless, patient preferences need to be considered while persistent concerns about enduring risk of bleeding must be addressed for the new paradigm to be implemented into clinical practice. [ABSTRACT FROM AUTHOR]

Background: Stroke risk in atrial fibrillation is assessed by using the CHA2DS2-VASc score. Sex category (Sc, ie, female sex) confers 1 point on CHA2DS2-VASc. We hypothesized that female sex is a stroke risk modifier, rather than an overall risk factor, when added to a CHA2DS2-VA (sex-independent thromboembolism risk) score scale.Methods: Using 3 nationwide registries, we identified patients with incident nonvalvular atrial fibrillation from January 1, 1997, through December 31, 2015. Patients receiving oral anticoagulant treatment at baseline were excluded, and person-time was censored at the time of treatment initiation (if any). CHA2DS2-VA scores were calculated for men and women, and were followed for up to 1 year in the Danish National Patient Registry. The primary outcome was a primary hospital code for ischemic stroke or systemic embolism (thromboembolism). We calculated crude event rates for risk strata as events per 100 person-years. For quantifying absolute risk of stroke, we calculated risks based on the pseudovalue method. Female sex as a prognostic factor was investigated by inclusion as an interaction term on the CHA2DS2-VA score to calculate the thromboembolic risk ratio for different score points.Results: A total of 239 671 patients with atrial fibrillation (48.7% women) contributed to the analyses. The mean ages for women and men were 76.6 years and 70.3 years, respectively; the mean CHA2DS2-VA scores were 2.7 for women and 2.3 for men. The overall 1-year thromboembolic rate per 100 person-years for women was 7.3 and 5.7 for men. The 1-year absolute risk of thromboembolism was 0.5% among men and women with a CHA2DS2-VA score of 0 and increased up to >7% among very comorbid patients (score >5). The risk ratio (male as reference) across points >1 indicated that women exhibit a higher stroke risk. The interaction was statistically significant (P<0.001).Conclusions: Female sex is a risk modifier for stroke in patients with atrial fibrillation. Initial decisions on oral anticoagulant treatment could be guided by a CHA2DS2-VA score (ie, excluding the sex category criterion), but the Sc risk component modifies and accentuates stroke risk in women who would have been eligible for oral anticoagulant treatment on the basis of ≥2 additional stroke risk factors. [ABSTRACT FROM AUTHOR]

Atrial flutter confers a thromboembolic risk, but contrary to atrial fibrillation the relationship has only been addressed in few studies. This study performs an up to date systematic review of the literature to investigate the association between atrial flutter and thromboembolic events. Articles were found by MEDLINE, EMBASE search and a manual search of references list in included articles. International guidelines, meta-analyses, reviews, case reports, studies reporting thromboembolic events in relation to ablation, or cardioversion procedures, echocardiography, and observational studies were found eligible in this review. A total of 52 articles were included in this review. During cardioversion, thromboembolic event rates varied from 0% to 6% with a follow-up from 1?week to 6?years. Echocardiographic studies reported prevalence of thrombus material from 0% to 38% and a prevalence of spontaneous echo contrast (SEC) from 21% to 28%. One ablation study in non-anticoagulated patients reported thromboembolic events at 13.9%. Observational studies reported an overall elevated stroke risk (risk ratio 1.4, 95% CI 1.35 to 1.46) and mortality risk (HR 1.9, 95% CI 1.2 to 3.1) with long time follow-up compared with a control group in both studies. Given the limitations and heterogeneity of the data, a meta-analysis was not a part of this systematic review. Notwithstanding the limitations of observational studies and indirect data from echocardiographic studies, this systematic review confirms that clinical thromboembolic events, left atrial thrombus and SEC are highly prevalent in atrial flutter. [ABSTRACT FROM AUTHOR]

A response from the authors of the article "Should Patients With Atrial Fibrillation and 1 Stroke Risk Factor (CHA2DS2-VASc Score 1 in Men, 2 in Women) Be Anticoagulated? Yes: Even 1 Stroke Risk Factor Confers a Real Risk of Stroke" in the 2016;133 issue, is presented.