Both HFrEF and HFpEF Should be Included in Calculating CHA2DS2–VASc score: a Taiwanese Longitudinal Cohort

Background Congestive heart failure (CHF) in the context of AF-related stroke risk, was coined when it mainly referred to patients with left ventricular systolic dysfunction (HFrEF). However, the term now encompasses patients with preserved ejection fraction (HFpEF) as well. Given this change, it becomes essential to investigate the variation in stroke risk between atrial fibrillation (AF) patients with HFpEF and HFrEF for enhancing risk assessment and subsequent management strategies. Methods In a longitudinal study utilizing the National Taiwan University Hospital Integrated Medical Database (iMED), 8358 patients with AF were followed up for 10 years from January 2010 to December 2020 (mean follow-up 3.76 years). The study evaluated the risk of ischemic stroke, using Cox models adjusted for potential risk factors of AF-related stroke. Results Comparing AF patients of different CHF subgroups, HFpEF patients had a higher mean CHA2DS2–VASc score (4.08±1.502 vs. 3.83±1.571, p<0.001) and a higher risk of stroke during follow-up (HR 1.151 (1.013-1.308), p=0.031). In contrast, patients with HFrEF had a higher prevalence of myocardial infarction (MI) and coronary artery disease (CAD). After adjusting for other risk factors, there was no significant difference in the risk of new-onset stroke between HFpEF and HFrEF patients (HR 1.001 (0.877-1.142), p=0.994). Conclusion After adjusting for other risk factors of stroke, both HFpEF and HFrEF were found to have a similar risk of stroke in AF patients. Therefore, it is important to extend the criteria for “C” in the CHA2DS2–VASc score to include HFpEF patients. Prior to multivariable adjustment, HFpEF patients had a higher risk than those with HFrEF, likely due to their higher CHA2DS2–VASc score, indicating a greater prevalence of stroke-related comorbidities.