Key result
Combined CHADS-BLED score strongly predicts 30-day mortality after transfemoral TAVR with a 0.83 c-index.
Why the study?
High CHA2DS2-VASC and HAS-BLED scores link to increased mortality in cardiovascular interventions, prompting evaluation of these scores to quantify short-term risks across different TAVR access routes.
Does the combined CHADS-BLED score predict 30-day mortality, major vascular and bleeding events, and cerebrovascular insults in patients undergoing TAVR?
Cohort (n=1,329)
No
Does the combined CHADS-BLED score predict 30-day mortality, major vascular and bleeding events, and cerebrovascular insults in patients undergoing TAVR?
Effect estimate: c-index 0.83 (95% CI 0.76-0.91)
p-value: p=<0.0001
The combined CHADS-BLED score strongly predicts 30-day mortality in transfemoral TAVR patients with atrial fibrillation, but fails to predict adverse events in transapical TAVR.
May aid 30-day mortality stratification in transfemoral TAVR with AF; hypothesis-generating for transapical access and requires prospective validation.
Background. High CHA2DS2-VASC and HAS-BLED scores are linked to increased mortality in structural and nonstructural cardiovascular interventions irrespective of the presence of atrial fibrillation (AF) or oral anticoagulation. We aimed to use the aforementioned scores to quantify the risk of 30-day mortality, major vascular and bleeding events (MVASC/BARC), and cerebrovascular insults (CVI) in patients undergoing different access routes in transcatheter aortic valve replacement (TAVR). Methods. Out of 1329 patients, 980 transfemoral (TF) TAVR (73.7%) and 349 transapical (TA) TAVR (26.3%) were included. CHA2DS2-VASC, HAS-BLED, and combined “CHADS-BLED” scores were calculated and compared to the predictive value of the established EuroSCORE and STS score. Results. In all-comers TF TAVR patients, the applied risk models showed only poor association with 30-day mortality while, in patients with concomitant AF, a strong association was observed using the combined CHADS-BLED score (c-index: 0.83; 95% CI: 0.76–0.91; <a:math xmlns:a="http://www.w3.org/1998/Math/MathML" id="M1"> <a:mi>p</a:mi> </a:math> < 0.0001). Concerning 30-day mortality, only the STS score for TF TAVR (c-index: 0.68; 95% CI: 0.59–0.76; <c:math xmlns:c="http://www.w3.org/1998/Math/MathML" id="M2"> <c:mi>p</c:mi> </c:math> = 0.001) and EuroSCORE for TA TAVR (c-index: 0.66; 95% CI: 0.56–0.76; <e:math xmlns:e="http://www.w3.org/1998/Math/MathML" id="M3"> <e:mi>p</e:mi> </e:math> = 0.005) could show some predictive value. High CHADS-BLED was associated with enhanced CVI (3.0% vs. 7.2%; <g:math xmlns:g="http://www.w3.org/1998/Math/MathML" id="M4"> <g:mi>p</g:mi> <g:mo>=</g:mo> <g:msup> <g:mrow> <g:mn>0.0039</g:mn> </g:mrow> <g:mrow> <g:mi>∗</g:mi> </g:mrow> </g:msup> </g:math> ) and more frequent MVASC/BARC (3.2% vs. 6.3%; <i:math xmlns:i="http://www.w3.org/1998/Math/MathML" id="M5"> <i:mi>p</i:mi> </i:math> = 0.0362) in the all-comers TAVR cohort. All risk models failed in the prediction of CVI and MVASC/BARC for TA TAVR patients. Conclusion. The combined CHADS-BLED score was a strong predictor for 30-day mortality in TF TAVR patients with AF. A high CHADS-BLED score showed a good predictive value for major vascular and bleeding events as well as CVI in TF TAVR patients. This study is registered at clinical trials (NCT01805739).
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Veulemans et al. (2020) conducted a cohort in Symptomatic severe aortic stenosis (n=1,329). Combined CHADS-BLED score vs. Traditional risk scores (EuroSCORE, STS) or low CHADS-BLED score was evaluated on 30-day mortality in transfemoral TAVR patients with atrial fibrillation (c-index 0.83, 95% CI 0.76-0.91, p=<0.0001). The combined CHADS-BLED score strongly predicted 30-day mortality in transfemoral TAVR patients with atrial fibrillation (c-index 0.83), but failed to predict adverse events in transapical TAVR.
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