The CHA2DS2-VASc score and Geriatric Multidimensional Assessment tools in elderly patients with persistent atrial fibrillation undergoing electrical cardioversion. A link with arrhythmia relapse?


      • The CHA2DS2-VASc score correlates with cognitive status and depressive symptoms.
      • The CHA2DS2-VASc score is also associated with physical performance.
      • Such a correlation is enhanced by simultaneously considering depressive symptoms.
      • The CHA2DS2-VASc score could give an indication of frailty status.
      • The CHA2DS2-VASc score is higher in patients with a new post-cardioversion AF.



      The CHA2DS2-VASc score is widely used for stroke risk stratification in patients with atrial fibrillation (AF). Our endpoints were to evaluate in an old population undergoing electrical cardioversion (ECV) of persistent AF if the CHA2DS2-VASc was associated with some of the Geriatric Multidimensional Assessment tools and with the presence of sinus rhythm at the follow-up.


      We enrolled all the consecutive patients admitted in a day-hospital setting aged ≥60 years. The Mini-Mental State Examination (MMSE; neurocognitive function), the 15-item Geriatric Depression Scale (GDS; depressive symptoms) and the Short Physical Performance Battery (SPPB; physical functioning) were administered before ECV.


      Between 2017 and 2019, 134 patients were enrolled (mean age: 77±9 years, range: 60-96; men: 63.4%; EF: 60±12%). Hypertension was the most frequent comorbid condition (82.1%). The CHA2DS2-VASc score was 3.8±1.6. Abnormal values of MMSE, GDS and SPPB were observed in 7.9, 19.8 and 22.3% of cases, respectively. There were significant correlations between the CHA2DS2-VASc score and the MMSE (p=0.008), the GDS (p<0.001) and the SPPB (p<0.001). Depressive symptoms increased CHA2DS2-VASc correlation with SPPB of about 20%. CHA2DS2-VASc score was higher in patients with arrhythmia relapse (p=0.048; mean length of follow-up: 195 days). This association persisted even after adjustment for amiodarone therapy.


      The CHA2DS2-VASc score significantly correlated with neuro-cognitive performance, depressive symptoms and physical functioning. It was also associated with AF relapse. Accordingly, in the elderly, the CHA2DS2-VASc could help quantify thrombo-embolic risk, give an indication of frailty status and help to choose between a rate- and a rhythm-control strategy.



      AF (atrial fibrillation), GDS (Geriatric Depression Scale), ECV (electrical cardioversion), MMSE (Mini-Mental State Examination), SPPB (Short Physical Performance Battery)
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        • 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
        • Kirchhof P.
        • Benussi S.
        • Kotecha D.
        • Ahlsson A.
        • Atar D.
        • Casadei B.
        • et al.
        2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.
        EP Europace. 2016; 18: 1609-1678
        • Toyoda K.
        • Yasaka M.
        • Uchiyama S.
        • Iwade K.
        • Koretsune Y.
        • Nagata K.
        • et al.
        CHADS2 and CHA2DS2-VASc scores as bleeding risk indices for patients with atrial fibrillation: the bleeding with antithrombotic therapy study.
        Hypertens Res. 2014; 37: 463-466
        • Saliba W.
        • Rennert G.
        CHA2DS2-VASc score is directly associated with the risk of pulmonary embolism in patients with atrial fibrillation.
        Am J Med. 2014; 127: 45-52
        • Potpara T.S.
        • Polovina M.M.
        • Djikic D.
        • Marinkovic J.M.
        • Kocev N.
        • Lip G.Y.
        The association of CHA2DS2-VASc score and blood biomarkers with ischemic stroke outcomes: the Belgrade stroke study.
        PloS ONE. 2014; 9e106439
        • Beyer-Westendorf J.
        • Kreutz R.
        • Posch F.
        • Ay C.
        The CHA2DS2-VASc score strongly correlates with glomerular filtration rate and predicts renal function decline over time in elderly patients with atrial fibrillation and chronic kidney disease.
        Int J Cardiol. 2018; 253: 71-77
        • Benjamin E.J.
        • Muntner P.
        • Alonso A.
        • Bittencourt M.S.
        • Callaway C.W.
        • Carson A.P.
        • et al.
        Heart Disease and Stroke Statistics-2019 Update: a report from the American Heart Association.
        Circulation. 2019; 139: e56-e66
        • Fumagalli S.
        • Potpara T.S.
        • Bjerregaard Larsen T.
        • Haugaa K.H.
        • Dobreanu D.
        • Proclemer A.
        • et al.
        Frailty syndrome: an emerging clinical problem in the everyday management of clinical arrhythmias. The results of the European Heart Rhythm Association survey.
        EP Europace. 2017; 19: 1896-1902
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Burke W.J.
        • Roccaforte W.H.
        • Wengel S.P.
        The short form of the Geriatric Depression Scale: a comparison with the 30-item form.
        J Geriatr Psychiatry Neurol. 1991; 4: 173-178
        • Guralnik J.M.
        • Ferrucci L.
        • Simonsick E.M.
        • Salive M.E.
        • Wallace R.B.
        Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability.
        N Engl J Med. 1995; 332: 556-561
        • Rubenstein L.Z.
        • Siu A.L.
        • Wieland D.
        Comprehensive geriatric assessment: toward understanding its efficacy.
        Aging (Milano). 1989; 1: 87-98
        • Lafuente-Lafuente C.
        • Mouly S.
        • Longas-Tejero M.A.
        • Mahe I.
        • Bergmann J.F.
        Antiarrhythmic drugs for maintaining sinus rhythm after cardioversion of atrial fibrillation: a systematic review of randomized controlled trials.
        Arch Intern Med. 2006; 166: 719-728
        • Guralnik J.M.
        • Simonsick E.M.
        • Ferrucci L.
        • Glynn R.J.
        • Berkman L.F.
        • Blazer D.G.
        • et al.
        A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission.
        J Gerontol. 1994; 49: M85-M94
        • Wieczorek J.
        • Mizia-Stec K.
        • Lasek-Bal A.
        • Wieczorek P.
        • Hoffmann A.
        • Nowak S.
        • et al.
        CHA2DS2-Vasc score, age and body mass index as the main risk factors of hyperintense brain lesions in asymptomatic patients with paroxysmal non-valvular atrial fibrillation.
        Int J Cardiol. 2016; 215: 476-481
        • Steinberg B.A.
        • Turner J.
        • Lyons A.
        • Biber J.
        • Chelu M.G.
        • Fang J.C.
        • et al.
        Systematic collection of patient-reported outcomes in atrial fibrillation: feasibility and initial results of the Utah mEVAL AF programme.
        EP Europace. 2020; 22: 368-374
        • Fumagalli S.
        • Cardini F.
        • Roberts A.T.
        • Boni S.
        • Gabbai D.
        • Calvani S.
        • et al.
        Psychological effects of treatment with new oral anticoagulants in elderly patients with atrial fibrillation: a preliminary report.
        Aging Clin Exp Res. 2015; 27: 99-102
        • Michal M.
        • Prochaska J.H.
        • Keller K.
        • Gobel S.
        • Coldewey M.
        • Ullmann A.
        • et al.
        Symptoms of depression and anxiety predict mortality in patients undergoing oral anticoagulation: Results from the thrombEVAL study program.
        Int J Cardiol. 2015; 187: 614-619
        • Chiarantini D.
        • Volpato S.
        • Sioulis F.
        • Bartalucci F.
        • Del Bianco L.
        • Mangani I.
        • et al.
        Lower extremity performance measures predict long-term prognosis in older patients hospitalized for heart failure.
        J Card Fail. 2010; 16: 390-395
        • Afilalo J.
        • Kim S.
        • O'Brien S.
        • Brennan J.M.
        • Edwards F.H.
        • Mack M.J.
        • et al.
        Gait speed and operative mortality in older adults following cardiac surgery.
        JAMA Cardiology. 2016; 1: 314-321
        • Kato M.
        • Saitoh M.
        • Kawamura T.
        • Iwata K.
        • Sakurada K.
        • Okamura D.
        • et al.
        Postoperative atrial fibrillation is associated with delayed early rehabilitation after heart valve surgery: a multicenter study.
        Phys Ther Res. 2019; 22: 1-8
        • Kim S.W.
        • Yoon S.J.
        • Choi J.Y.
        • Kang M.G.
        • Cho Y.
        • Oh I.Y.
        • et al.
        Clinical implication of frailty assessment in older patients with atrial fibrillation.
        Arch Gerontol Geriatr. 2017; 70: 1-7
        • Ethun C.G.
        • Bilen M.A.
        • Jani A.B.
        • Maithel S.K.
        • Ogan K.
        • Master V.A.
        Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology.
        CA Cancer J Clin. 2017; 67: 362-377
        • Fumagalli S.
        • Said S.A.
        • Laroche C.
        • Gabbai D.
        • Boni S.
        • Marchionni N.
        • et al.
        Management and prognosis of atrial fibrillation in diabetic patients: an EORP-AF General Pilot Registry report.
        Eur Heart J Cardiovasc Pharmacother. 2018; 4: 172-179
        • Bisbal F.
        • Baranchuk A.
        • Braunwald E.
        • Bayes de Luna A.
        • Bayes-Genis A.
        Atrial failure as a clinical entity: JACC review topic of the week.
        J Am Coll Cardiol. 2020; 75: 222-232
        • Nielsen P.B.
        • Overvad T.F.
        Female sex as a risk modifier for stroke risk in atrial fibrillation: using CHA2DS2-VASc versus CHA2DS2-VA for stroke risk stratification in atrial fibrillation: a note of caution.
        Thromb Haemost. 2020; 120: 894-898
        • Fumagalli S.
        • Boni N.
        • Padeletti M.
        • Gori F.
        • Boncinelli L.
        • Valoti P.
        • et al.
        Determinants of thoracic electrical impedance in external electrical cardioversion of atrial fibrillation.
        Am J Cardiol. 2006; 98: 82-87
        • Tromp J.
        • Shen L.
        • Jhund P.S.
        • Anand I.S.
        • Carson P.E.
        • Desai A.S.
        • et al.
        Age-related characteristics and outcomes of patients with heart failure with preserved ejection fraction.
        J Am Coll Cardiol. 2019; 74: 601-612
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: a systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Nguyen T.N.
        • Cumming R.G.
        • Hilmer S.N.
        Atrial fibrillation in older inpatients: are there any differences in clinical characteristics and pharmacological treatment between the frail and the non-frail?.
        Intern Med J. 2016; 46: 86-95
        • Fumagalli S.
        • Said S.A.M.
        • Laroche C.
        • Gabbai D.
        • Marchionni N.
        • Boriani G.
        • et al.
        Age-related differences in presentation, treatment, and outcome of patients with atrial fibrillation in Europe: The EORP-AF General Pilot Registry (EURObservational Research Programme-Atrial Fibrillation).
        JACC Clin Electrophysiol. 2015; 1: 326-334
        • Gardarsdottir M.
        • Sigurdsson S.
        • Aspelund T.
        • Rokita H.
        • Launer L.J.
        • Gudnason V.
        • et al.
        Atrial fibrillation is associated with decreased total cerebral blood flow and brain perfusion.
        EP Europace. 2018; 20: 1252-1258
        • Gardarsdottir M.
        • Sigurdsson S.
        • Aspelund T.
        • Gardarsdottir V.A.
        • Forsberg L.
        • Gudnason V.
        • et al.
        Improved brain perfusion after electrical cardioversion of atrial fibrillation.
        EP Europace. 2020; 22: 530-537
        • Connolly S.J.
        • Camm A.J.
        • Halperin J.L.
        • Joyner C.
        • Alings M.
        • Amerena J.
        • et al.
        Dronedarone in high-risk permanent atrial fibrillation.
        N Engl J Med. 2011; 365: 2268-2276