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Results From the National Registry of Atrial Fibrillation

Brian F. Gage, MD,MSc; Amy D. Waterman, PhD; William Shannon, PhD; Michael Boechler, PhD; Michael W. Rich, MD; Martha J. Radford, MD

JAMA. 2001;285:2864-2870.

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 CHADS₂ index, and all 3 classification schemes were validated. The CHADS₂ 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 CHADS₂ 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 CHADS₂ 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, CHADS₂, can quantify risk of stroke for patients who have AF and may aid in selection of antithrombotic therapy.

Author Affiliations: Divisions of General Medical Sciences (Drs Gage, Waterman, and Shannon) and Cardiology (Dr Rich), Washington University School of Medicine, St Louis, Mo; Innovative Emergency Management Inc, Baton Rouge, La (Dr Boechler); and Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Conn (Dr Radford).

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