The prognostic role of the CHA₂DS₂-VASc score in patients with acute myocardial infarction receiving extracorporeal membrane oxygenation following out-of-hospital cardiac arrest

Year 2025, Volume: 6 Issue: 2, 116 - 123, 23.03.2025

Onur Yıldırım , Necmettin Çolak , Yunus Nazlı , Ömer Zühtü Yöndem , Sercan Okutucu

https://doi.org/10.47582/jompac.1642835

Abstract

Aims: The CHA₂DS₂-VASc scoring system has been widely used for stroke risk stratification in patients with atrial fibrillation, yet evidence regarding its prognostic value in other critical settings remains limited. This study aimed to assess the utility of the CHA₂DS₂-VASc score in predicting mortality in patients with acute myocardial infarction (AMI) who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support following out-of-hospital cardiac arrest.
Methods: This retrospective study included 41 patients with AMI requiring VA-ECMO after OHCA. Baseline demographics, clinical characteristics, and prognostic scores, including CHA₂DS₂-VASc, SAVE (Survival After Veno-Arterial ECMO), Glasgow Coma Scale (GCS), and acute physiology and chronic health evaluation (APACHE) II were recorded. Patients were categorized into three risk groups based on the CHA₂DS₂-VASc score: low (0 points), moderate (1 point), and high (≥2 points). According to the SAVE score, patients were classified into five risk groups: class I (≥5 points), class II (1–4 points), class III (−4 to 0 points), class IV (−9 to −5 points), and class V (≤−10 points). The primary outcome was in-hospital mortality.
Results: The overall in-hospital mortality rate was 58.5%. Patients with high risk group had a significantly higher mortality risk (HR: 3.12, 95% CI: 1.28-7.63, p=0.008). The SAVE score had the highest diagnostic performance, with a sensitivity of 81.2% and specificity of 76.5% (AUC=0.80). CHA₂DS₂-VASc (AUC=0.74) and APACHE II (AUC=0.72) also demonstrated good predictive performance. While CHA₂DS₂-VASc maintained a balanced sensitivity (70.8%) and specificity (64.7%), APACHE II had higher sensitivity (75.7%) but lower specificity (58.8%). GCS demonstrated the lowest diagnostic performance (AUC=0.68).
Conclusion: While the SAVE score, a risk model specifically designed for VA-ECMO, provides a strong prognostic evaluation, the CHA₂DS₂-VASc score could be a simple and easily applicable tool for early risk stratification in this high-risk population.

Keywords

CHA2DS2-VASc score, extracorporeal membrane oxygenation, cardiogenic shock, mortality

Ethical Statement

The study was approved by the XXX Hospital’s Ethics Committee (Date: 30.12.2024, Decision No: 2024/13) and was carried out in accordance with the relevant ethical guidelines and the Helsinki Declaration (2013 Brazil revision).

CHA₂DS₂-VASc skorunun hastane dışı kardiyak arrest sonrası ekstrakorporeal membran oksijenasyonu alan akut miyokard enfarktüsü hastalarındaki prognostik rolü

Abstract

Amaç: CHA₂DS₂-VASc skorlama sistemi, atriyal fibrilasyonu olan hastalarda inme riskini sınıflandırmak için yaygın olarak kullanılmaktadır. Ancak, bu skorun diğer kritik klinik durumlarda prognostik değerine ilişkin kanıtlar sınırlıdır. Bu çalışma, hastane dışı kardiyak arrest (OHCA) sonrası veno-arteriyel ekstrakorporeal membran oksijenasyonu (VA-ECMO) desteği alan akut miyokard enfarktüsü (AMI) hastalarında CHA₂DS₂-VASc skorunun mortaliteyi öngörmedeki etkinliğini değerlendirmeyi amaçladı.
Yöntemler: Bu retrospektif çalışmaya, OHCA sonrası VA-ECMO gerektiren 41 AMI hastası dahil edildi. Hastaların başlangıçtaki demografik özellikleri, klinik verileri ve CHA₂DS₂-VASc, SAVE (Veno-Arteriyel ECMO Sonrası Hayatta Kalma), Glasgow Koma Skalası (GCS) ve Akut Fizyoloji ve Kronik Sağlık Değerlendirmesi (APACHE) II gibi prognostik skorları kaydedildi. CHA₂DS₂-VASc skoruna göre hastalar üç risk grubuna ayrıldı: düşük (0 puan), orta (1 puan) ve yüksek (≥2 puan). SAVE skoruna göre ise hastalar beş risk sınıfına ayrıldı: Sınıf I (≥5 puan), Sınıf II (1–4 puan), Sınıf III (−4 ila 0 puan), Sınıf IV (−9 ila −5 puan) ve Sınıf V (≤−10 puan). Birincil sonuç ölçütü hastane içi mortaliteydi.
Bulgular: Genel hastane içi mortalite oranı %58,5 olarak bulundu. Yüksek risk grubundaki hastalarda mortalite riski anlamlı derecede yüksekti (HR: 3,12, %95 CI: 1,28-7,63, p = 0,008). En yüksek tanısal performans SAVE skoruna aitti (duyarlılık: %81,2, özgüllük: %76,5, AUC = 0,80). CHA₂DS₂-VASc (AUC = 0,74) ve APACHE II (AUC = 0,72) de iyi bir öngörü performansı gösterdi. CHA₂DS₂-VASc skoru dengeli bir duyarlılık (%70,8) ve özgüllük (%64,7) sergilerken, APACHE II daha yüksek duyarlılık (%75,7) ancak daha düşük özgüllük (%58,8) gösterdi. GCS ise en düşük tanısal performansa sahipti (AUC = 0,68).
Sonuç: VA-ECMO için özel olarak tasarlanmış bir risk modeli olan SAVE skoru güçlü bir prognostik değerlendirme sağlarken, CHA₂DS₂-VASc skoru bu yüksek riskli hasta grubunda erken risk sınıflandırması için basit ve kolay uygulanabilir bir araç olabilir.

Keywords

CHA₂DS₂-VASc skoru, ekstrakorporeal membran oksijenasyonu, kardiyojenik şok, mortalite

References

• Abbas R, Abbas A, Khan TK, Sharjeel S, Amanullah K, Irshad Y. Sudden cardiac death in young individuals: a current review of evaluation, screening and prevention. J Clin Med Res. 2023;15(1):1-9. doi:10.14740/jocmr4823
• Lott C, Truhlar A, Alfonzo A, et al. European resuscitation council guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021;161:152-219. doi:10.1016/j.resuscitation.2021.02.011
• Tsangaris A, Alexy T, Kalra R, et al. Overview of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support for the management of cardiogenic shock. Front Cardiovasc Med. 2021;8: 686558. doi:10.3389/fcvm.2021.686558
• Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest. Circ Heart Fail. 2018;11(9):e004905. doi:10.1161/CIRCHEARTFAILURE.118.004905
• De Charriere A, Assouline B, Scheen M, et al. ECMO in cardiac arrest: a narrative review of the literature. J Clin Med. 2021;10(3):534. doi:10. 3390/jcm10030534
• Aufderheide TP, Kalra R, Kosmopoulos M, Bartos JA, Yannopoulos D. Enhancing cardiac arrest survival with extracorporeal cardiopulmonary resuscitation: insights into the process of death. Ann N Y Acad Sci. 2022; 1507(1):37-48. doi:10.1111/nyas.14580
• Gill G, Patel JK, Casali D, et al. Outcomes of venoarterial extracorporeal membrane oxygenation for cardiac arrest in adult patients in the United States. J Am Heart Assoc. 2021;10(20):e021406. doi:10.1161/JAHA.121. 021406
• Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246-2256. doi:10.1093/eurheartj/ehv194
• Sudarsanan S, Sivadasan P, Chandra P, et al. Comparison of four intensive care scores in predicting outcomes after venoarterial extracorporeal membrane oxygenation: a single-center retrospective study. J Cardiothorac Vasc Anesth. 2025;39(1):131-142. doi:10.1053/j.jvca. 2024.10.027
• Fisser C, Rincon-Gutierrez LA, Enger TB, et al. Validation of prognostic scores in extracorporeal life support: a multi-centric retrospective study. Membranes (Basel). 2021;11(2):84. doi:10.3390/membranes11020084
• Muller G, Flecher E, Lebreton G, et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med. 2016;42(3):370-378. doi:10.1007/s00134-016-4223-9
• Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. 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(2):263-272. doi:10.1378/chest.09-1584
• Abouzid MR, Kamel I, Saleh A, Vidal Margenat A, Hariharan R. Assessing stroke and mortality risk in heart failure: the CHA2DS2-VASc score's prognostic value in patients with and without atrial fibrillation: a meta-analysis. Cardiol Rev. Published online August 15, 2024. doi:10.1097/CRD.0000000000000749
• Allam H, Mostafa S, Abd Khalek ES, Abdalla S. Predictive role of CHA(2)DS(2)-VASc score in acute coronary syndrome patients and value of adding global longitudinal strain to CHA(2)DS(2)-VASc score. Indian Heart J. Published online December 21, 2024.; doi:10.1016/j.ihj. 2024.12.001
• Cicek V, Cinar T, Hayiroglu MI, et al. Prognostic performance of CHA(2)DS(2)-VASc scores for predicting mortality among COVID-19 patients: a single pandemic center experience. Am J Emerg Med. 2021;45:635-637. doi:10.1016/j.ajem.2020.11.026
• Eckman PM, Katz JN, El Banayosy A, Bohula EA, Sun B, van Diepen S. Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: an introduction for the busy clinician. Circulation. 2019;140(24): 2019-2037. doi:10.1161/CIRCULATIONAHA.119.034512
• Harnisch LO, Moerer O. Contraindications to the initiation of veno-venous ECMO for severe acute respiratory failure in adults: a systematic review and practical approach based on the current literature. Membranes (Basel). 2021;11(8):584. doi:10.3390/membranes11080584
• Kurmani S, Squire I. Acute heart failure: definition, classification and epidemiology. Curr Heart Fail Rep. 2017;14(5):385-392. doi:10.1007/s11897-017-0351-y
• Hacke W, Bassand JP, Virdone S, et al. Prior stroke and transient ischemic attack as risk factors for subsequent stroke in atrial fibrillation patients: a report from the GARFIELD-AF registry. Int J Stroke. 2020; 15(3):308-317. doi:10.1177/1747493019891516
• Amin F, Lombardi J, Alhussein M, et al. Predicting survival after VA-ECMO for refractory cardiogenic shock: validating the SAVE score. CJC Open. 2021;3(1):71-81. doi:10.1016/j.cjco.2020.09.011
• Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893-2962. doi:10.1093/eurheartj/ehw 210
• DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics. 1988;44(3):837-45.
• Morimoto R, Kida H, Tachibana K, Watanabe T, Yamada T. Prognostic factors in patients with acute myocardial infarction underwent extracorporeal membrane oxygenation in hospital or out-of-hospital cardiac arrest. Eur Heart J. 2021;42(Supplement_1):ehab724.1480. doi: 10.1093/eurheartj/ehab724.1480
• Lee JJ, Han SJ, Kim HS, et al. Out-of-hospital cardiac arrest patients treated with cardiopulmonary resuscitation using extracorporeal membrane oxygenation: focus on survival rate and neurologic outcome. Scand J Trauma Resusc Emerg Med. 2016;24(1):74. doi:10.1186/s13049-016-0266-8
• Misumi K, Hagiwara Y, Kimura T, et al. Impact of center volume on in-hospital mortality in adult patients with out of hospital cardiac arrest resuscitated using extracorporeal cardiopulmonary resuscitation: a secondary analysis of the SAVE-J II study. Scientific Reports. 2024;14(1): 8309. doi:10.1038/s41598-024-58808-y
• Ravipati P, Murray S, Yannopoulos D, Drawz PE, Bartos JA. Impact of AKI in patients with out-of-hospital cardiac arrest managed with VA ECMO. Kidney360. 2021;2(11):1827-1830. doi:10.34067/KID.0006592020
• Schmidt M, Zogheib E, Roze H, et al. The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Intensive Care Med. 2013;39(10):1704-1713. doi:10.1007/s00134-013-3037-2
• Ng WT, Ling L, Joynt GM, Chan KM. An audit of mortality by using ECMO specific scores and APACHE II scoring system in patients receiving extracorporeal membrane oxygenation in a tertiary intensive care unit in Hong Kong. J Thorac Dis. 2019;11(2):445-455. doi:10.21037/jtd.2018.12.121
• Hayakawa K, Tasaki O, Hamasaki T, et al. Prognostic indicators and outcome prediction model for patients with return of spontaneous circulation from cardiopulmonary arrest: the Utstein Osaka Project. Resuscitation. 2011;82(7):874-880. doi:10.1016/j.resuscitation.2011.02. 045
• Grandbois van Ravenhorst C, Schluep M, Endeman H, Stolker RJ, Hoeks SE. Prognostic models for outcome prediction following in-hospital cardiac arrest using pre-arrest factors: a systematic review, meta-analysis and critical appraisal. Crit Care. 2023;27(1):32. doi:10.1186/s13054-023-04306-y
• Tran A, Rochwerg B, Fan E, et al. Prognostic factors associated with favourable functional outcome among adult patients requiring extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation. 2023;193:110004. doi:10.1016/j.resuscitation.2023.110004
• Tran A, Fernando SM, Rochwerg B, et al. Pre-arrest and intra-arrest prognostic factors associated with survival following traumatic out-of-hospital cardiac arrest -a systematic review and meta-analysis. Resuscitation. 2020;153:119-135. doi:10.1016/j.resuscitation.2020.05.052
• George N, Stephens K, Ball E, et al. Extracorporeal membrane oxygenation for cardiac arrest: does age matter? Crit Care Med. 2024; 52(1):20-30. doi:10.1097/CCM.0000000000006039
• Bemtgen X, Rilinger J, Jackel M, et al. Admission blood glucose level and outcome in patients requiring venoarterial extracorporeal membrane oxygenation. Clin Res Cardiol. 2021;110(9):1484-1492. doi:10.1007/s00392-021-01862-7
• Mariani S, Heuts S, van Bussel BCT, et al. Patient and management variables associated with survival after postcardiotomy extracorporeal membrane oxygenation in adults: the PELS-1 multicenter cohort study. J Am Heart Assoc. 2023;12(14):e029609. doi:10.1161/JAHA.123.029609
• Kang J, Lee H, Han S, Cho H. Predictors of mortality in patients with VA-extracorporeal membrane oxygenation. Eur Heart J. 2020; 41(Supplement_2):ehaa946.1237. doi:10.1093/ehjci/ehaa946.1237
• Gazova A, Leddy JJ, Rexova M, Hlivak P, Hatala R, Kyselovic J. Predictive value of CHA2DS2-VASc scores regarding the risk of stroke and all-cause mortality in patients with atrial fibrillation (CONSORT compliant). Medicine (Baltimore). 2019;98(31):e16560. doi:10.1097/MD. 0000000000016560
• Inan D, Genc D, Simsek B, et al. Relationship between CHA(2)DS(2)-VASc score on admission and in-hospital major adverse cardiovascular events in patients diagnosed with ST-elevation myocardial infarction. Angiology. 2024:33197241273382. doi:10.1177/00033197241273382
• Wang CH, Chen YY, Wu MC, et al. Pre-arrest atrial fibrillation and neurological recovery after cardiac arrest among hospitalized patients: a retrospective cohort study. Eur J Clin Invest. 2025;55(3):e14375. doi:10. 1111/eci.14375
• Mo R, Yang YM, Zhang H, Suo N, Wang JY, Lyu SQ. Clinical application of CHA(2)DS(2)-VASc versus GRACE scores for assessing the risk of long-term ischemic events in atrial fibrillation and acute coronary syndrome or PCI. Rev Cardiovasc Med. 2022;23(5):168. doi:10.31083/j.rcm2305168
• Chua SK, Lo HM, Chiu CZ, Shyu KG. Use of CHADS(2) and CHA(2)DS(2)-VASc scores to predict subsequent myocardial infarction, stroke, and death in patients with acute coronary syndrome: data from Taiwan acute coronary syndrome full spectrum registry. PLoS One. 2014;9(10): e111167. doi:10.1371/journal.pone.0111167
• Boriani G, Vitolo M, Mei DA. CHA2DS2-VA instead of CHA2DS2-VASc for stroke risk stratification in patients with atrial fibrillation: not just a matter of sex. Europace. 2024;26(11):euae281. doi:10.1093/europace/euae281
• Ibdah R, Obeidat O, Khader Y, et al. Validation of CHA2DS2 VASc score predictability of stroke and systemic embolization in a Middle Eastern population with AF: the Jordan atrial fibrillation (JoFib) study. Vasc Health Risk Manag. 2023;19:255-264. doi:10.2147/VHRM.S404575