Key result
NOAC stroke benefit in patients without AF begins at a CHA2DS2-VASc score of ~4.
Why the study?
NOAC therapy is preferred when stroke risk exceeds 0.9% per year, and CHA2DS2-VASc may identify high-risk patients who could benefit from anticoagulation even in sinus rhythm.
Does NOAC therapy prevent stroke in patients without atrial fibrillation who have high CHA2DS2-VASc scores?
Systematic Review (n=19,600,104)
Does NOAC therapy prevent stroke in patients without atrial fibrillation who have high CHA2DS2-VASc scores?
NOAC therapy may be beneficial for stroke prevention in patients without atrial fibrillation who have a high CHA2DS2-VASc score (≥4).
May support NOAC consideration at CHA2DS2-VASc ≥4 in non-AF patients; extends risk stratification beyond AF but requires RCT confirmation.
According to Quality-Adjusted Life Expectancy, novel oral anticoagulant therapy is preferred when the stroke risk is higher than 0.9% per year. CHA2DS2-VASc is a tool to select those patients at high risk for stroke due to atherosclerosis and atrial cardiopathy, who could benefit from anticoagulation even in sinus rhythm. Systematic electronic database searches were conducted using Pubmed and Scopus. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement 2020 was followed. Thirteen studies were included, comprising altogether 19,600,104 patients. Data show that the predictive accuracy for stroke of CHA2DS2-VASc among patients with and without atrial fibrillation (AF) is similar, but the benefit of anticoagulation, considering the 1-year risk of stroke for every CHA2DS2-VASc value, starts from higher cutoffs in patients without AF (around CHA2DS2-VASc 4). Atrial fibrillation should no longer be considered a sine qua non for the prevention of thromboembolism in patients at high risk of stroke due to atherosclerosis and atrial disease, but only an additional risk factor to be included in the predictive model used to select patients for novel oral anticoagulant therapy, regardless of the rhythm. CHA2DS2-VASc-AF may be an option. Additional randomized clinical trials are needed.
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Riccardo Maddalena (2023) conducted a systematic review in High risk for stroke without atrial fibrillation (n=19,600,104). Novel oral anticoagulant therapy (NOAC) vs. No anticoagulation / Patients with atrial fibrillation was evaluated on Predictive accuracy for stroke and benefit of anticoagulation. Novel oral anticoagulant therapy benefit in patients without atrial fibrillation starts at higher stroke risk cutoffs (around CHA2DS2-VASc 4) despite similar predictive accuracy for stroke.
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