Role of CHADS2 Score in Evaluation of Thromboembolic Risk and Mortality in Patients With Atrial Fibrillation Undergoing Direct Current Cardioversion (from the ACUTE Trial Substudy)

      The CHADS2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke or transient ischemic attack [2 points]) scoring scheme has been found to be a good predictor of stroke risk in patients with nonvalvular atrial fibrillation (AF). However, the value of the CHADS2 scoring system in the risk stratification of patients with AF who undergo direct-current cardioversion has not yet been specifically investigated. In this study, a subgroup of 541 patients from the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) study who had AF for >48 hours and planned to undergo transesophageal echocardiography before direct-current cardioversion were enrolled. Each patient had a CHADS2 score calculated. Of the patients with CHADS2 scores of 0, 14 (10%) were found to have left atrial appendage thrombi on transesophageal echocardiography. After 6 months of follow up, patients with CHADS2 scores of 3 to 6 showed a significantly higher mortality rate in comparison with patients with lower CHADS2 scores (4.3% vs 0.5%, p = 0.004), despite their similar prevalence of left atrial appendage thrombus and stroke (thrombus: 13.4% vs 11.6%, p = 0.60; stroke: 0% vs 0.3%, p = 0.70). In conclusion, the CHADS2 scoring system may be useful for predicting short-term mortality risk in patients with AF receiving elective direct-current cardioversion. However, in the preprocedural risk assessment of these patients, the CHADS2 scoring system is not reliable in predicting risk for left atrial appendage thrombus formation, especially in patients with low CHADS2 scores.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Puwanant S.
        • Varr B.C.
        • Shrestha K.
        • Hussain S.K.
        • Tang W.H.
        • Gabriel R.S.
        • Wazni O.M.
        • Bhargava M.
        • Saliba W.I.
        • Thomas J.D.
        • Lindsay B.D.
        • Klein A.L.
        Role of the CHADS2 score in the evaluation of thromboembolic risk in patients with atrial fibrillation undergoing transesophageal echocardiography before pulmonary vein isolation.
        J Am Coll Cardiol. 2009; 54: 2032-2039
        • Klein A.L.
        • Grimm R.A.
        • Murray R.D.
        • Apperson-Hansen C.
        • Asinger R.W.
        • Black I.W.
        • Davidoff R.
        • Erbel R.
        • Halperin J.L.
        • Orsinelli D.A.
        • Porter T.R.
        • Stoddard M.F.
        • Assessment of Cardioversion Using Transesophageal Echocardiography Investigators
        Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.
        N Engl J Med. 2001; 344: 1411-1420
        • Gage B.F.
        • Waterman A.D.
        • Shannon W.
        • Boechler M.
        • Rich M.W.
        • Radford M.J.
        Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
        jama. 2001; 285: 2864-2870
        • Steering and Publications Committees of the ACUTE Study
        Design of a clinical trial for the assessment of cardioversion using transesophageal echocardiography (the ACUTE multicenter study).
        Am J Cardiol. 1998; 81: 877-883
        • Laupacis A.
        • Albers G.
        • Dalen J.
        • Dunn M.
        • Feinberg W.
        • Jacobson A.
        Antithrombotic therapy in atrial fibrillation.
        Chest. 1995; 108: 352S-359S
        • Laupacis A.
        • Albers G.
        • Dunn M.
        • Feinberg W.
        Antithrombotic therapy in atrial fibrillation.
        Chest. 1992; 102: 426S-433S
        • Wazni O.M.
        • Tsao H.M.
        • Chen S.A.
        • Chuang H.H.
        • Saliba W.
        • Natale A.
        • Klein A.L.
        Cardiovascular imaging in the management of atrial fibrillation.
        J Am Coll Cardiol. 2006; 48: 2077-2084
        • Fatkin D.
        • Kelly R.P.
        • Feneley M.P.
        Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo.
        J Am Coll Cardiol. 1994; 23: 961-969
        • Aschenberg W.
        • Schluter M.
        • Kremer P.
        • Schroder E.
        • Siglow V.
        • Bleifeld W.
        Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus.
        J Am Coll Cardiol. 1986; 7: 163-166
        • Manning W.J.
        • Leeman D.E.
        • Gotch P.J.
        • Come P.C.
        Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation.
        J Am Coll Cardiol. 1989; 13: 617-623
        • Fatkin D.
        • Kuchar D.L.
        • Thorburn C.W.
        • Feneley M.P.
        Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning” as a mechanism of thromboembolic complications.
        J Am Coll Cardiol. 1994; 23: 307-316
        • Klein A.L.
        • Grimm R.A.
        • Black I.W.
        • Leung D.Y.
        • Chung M.K.
        • Vaughn S.E.
        • Murray R.D.
        • Miller D.P.
        • Arheart K.L.
        Cardioversion guided by transesophageal echocardiography: the ACUTE pilot study.
        Ann Intern Med. 1997; 126: 200-209
        • Corrado G.
        • Tadeo G.
        • Beretta S.
        • Tagliagambe L.M.
        • Manzillo G.F.
        • Spata M.
        • Santarone M.
        Atrial thrombi resolution after prolonged anticoagulation in patients with atrial fibrillation.
        Chest. 1999; 115: 140-143
        • Khan M.N.
        • Usmani A.
        • Noor S.
        • Elayi S.
        • Ching C.K.
        • Di Biase L.
        • Patel D.
        • Burkhardt J.D.
        • Cummings J.
        • Schweikert R.
        • Saliba W.
        • Natale A.
        Low incidence of left atrial or left atrial appendage thrombus in patients with paroxysmal atrial fibrillation and normal EF who present for pulmonary vein antrum isolation procedure.
        J Cardiovasc Electrophysiol. 2008; 19: 356-358
        • Kleemann T.
        • Becker T.
        • Strauss M.
        • Schneider S.
        • Seidl K.
        Prevalence of left atrial thrombus and dense spontaneous echo contrast in patients with short-term atrial fibrillation < 48 hours undergoing cardioversion: value of transesophageal echocardiography to guide cardioversion.
        J Am Soc Echocardiogr. 2009; 22: 1403-1408
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation.
        Chest. 2010; 137: 263-272
        • Kimura K.
        • Minematsu K.
        • Yamaguchi T.
        • Japan Multicenter Stroke Investigators' Collaboration (J-MUSIC)
        Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke.
        J Neurol Neurosurg Psychiatry. 2005; 76: 679-683
        • Wolf P.A.
        • Mitchell J.B.
        • Baker C.S.
        • Kannel W.B.
        • D'Agostino R.B.
        Impact of atrial fibrillation on mortality, stroke, and medical costs.
        Arch Intern Med. 1998; 158: 229-234
        • Benjamin E.J.
        • Wolf P.A.
        • D'Agostino R.B.
        • Silbershatz H.
        • Kannel W.B.
        • Levy D.
        Impact of atrial fibrillation on the risk of death: the Framingham Heart Study.
        Circulation. 1998; 98: 946-952
        • Crandall M.A.
        • Horne B.D.
        • Day J.D.
        • Anderson J.L.
        • Muhlestein J.B.
        • Crandall B.G.
        • Weiss J.P.
        • Osborne J.S.
        • Lappe D.L.
        • Bunch T.J.
        Atrial fibrillation significantly increases total mortality and stroke risk beyond that conveyed by the CHADS2 risk factors.
        Pacing Clin Electrophysiol. 2009; 32: 981-986
        • Khumri T.M.
        • Idupulapati M.
        • Rader V.J.
        • Nayyar S.
        • Stoner C.N.
        • Main M.L.
        Clinical and echocardiographic markers of mortality risk in patients with atrial fibrillation.
        Am J Cardiol. 2007; 99: 1733-1736

      Linked Article