Conventional thrombotic risk score has role in COVID-19 risk prediction: Europace study

Major concern exists regarding a prothrombotic state complicating the clinical course of COVID-19. However, useful tools for the prediction of thromboembolic events are lacking. In this regard, Codon et al in the recent issue of Europace journal have shown that the CHADS2, CHA2DS2-VASc, and an improvised version of the same- the CHA2DS2-VASc-M scores are significantly associated with all-cause in COVID-19 patients. They are simple scoring systems in everyday use that may facilitate initial 'quick' prognostic stratification in COVID-19.

Since the beginning of the pandemic, data from China and Italy suggested a significant prevalence of cardiovascular (CV) risk factors among hospitalized and critically ill patients with COVID-19. Age and underlying CV disease are associated with poorer outcomes and thromboembolic complications play a key role in the clinical course of these patients.

In patients with SARS-CoV-2 infection, there is the need to have a simple and practical approach to clinical prognostication, especially for the risks of mortality and thromboembolism. In very busy settings, e.g., during the peak of the pandemic, easy and practical risk assessment tools are essential.

The aim of this study was to assess the value of the CHADS2 and CHA2DS2-VASc scores to predict thromboembolic events and all-cause mortality in patients with COVID-19. Secondly, the authors explored the value of giving extra weight to male sex in the CHA2DS2-VASc score, given the extra risk associated with males compared with females (1 an extra point to male sex instead of female).

COVID-19 hospitalized patients with confirmed SARS-CoV-2 infection who completed at least 1-month follow-up or died were studied. CHADS2 and CHA2DS2-VASc scores were calculated. A modified CHA2DS2-VASc score (CHA2DS2-VASc-M) in which 1 point was given to was also calculated. The associations of these scores with laboratory results, thromboembolic events, and death were analysed.

A total of 3042 patients (mean age 62.3 ± 20.3 years, 54.9% male) were studied and 115 (3.8%) and 626 (20.6%) presented a definite thromboembolic event or died, respectively, during the study period [median follow 59 (50–66) days]. Higher score values were associated with more marked abnormalities of inflammatory and cardiac biomarkers.

Mortality was significantly higher with increasing scores for CHADS2, CHA2DS2-VASc, and CHA2DS2-VASc-M (P < 0.001 for trend). The CHA2DS2-VASc-M showed the best predictive value for mortality [area under the receiver operating characteristic curve (AUC) 0.820, P < 0.001 for comparisons]. All scores had poor predictive value for thromboembolic events (AUC 0.497, 0.490, and 0.541, respectively).

The study illustrates that higher CHADS2 and CHA2DS2-VASc predict higher mortality in COVID-19. Not surprisingly, the CHA2DS2-VASc-M showed an even better predictive value compared with the former scores, although statistical differences were small. A simple categorization of the three scores was found to be highly significantly associated with survival as assessed by Kaplan-Meier analysis and the log-rank test.

The study concludes that CHADS2, CHA2DS2-VASc, and the modified CHA2DS2-VASc-M do not predict the incidence of thromboembolic events in COVID-19 patients. However, they do predict mortality risk during follow-up. Therefore, implementation of these simple, commonly used risk scores may facilitate prognostic stratification at the initial medical contact without additional laboratory or hospital tests.

SOURCE: Europace journal: Prediction of thromboembolic events and mortality by the CHADS2 and the CHA2DS2-VASc in COVID-19, EP Europace, 2021;euab015, https://doi.org/10.1093/europace/euab015