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

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

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

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