In the current study, we investigated the effect
of CHA2DS2-VA score on one-year all-cause
mortality in patients with permanent AF. Our
study results showed a statistically significant
relationship between the CHA2DS2-VA score and
one-year mortality. However, the CHA2DS2-VA
score was not an independent predictor of one-year
all-cause mortality in patients with permanent
AF. In addition, age, LVEF, COPD, female sex,
hemoglobin level, and SBP were independent
predictors of one-year all-cause mortality in
permanent AF patients.
In previous studies investigating AF prognosis,
results regarding the effect of sex are confusing.
In the study by Dagres et al.,[16] male patients
were more likely to have CAD and idiopathic AF,
whereas female patients were older and more likely
to have DM, thyroid disease, valvular heart disease,
and HT. Overall, women were more likely than
males to have comorbidities, be at the highest risk
for stroke, and had symptoms. Other long-term
morbidities and mortality rates were similar. The
results from the Global Anticoagulant Registry in
the FIELD-Atrial Fibrillation (GARFIELD-AF)
study, which included over 28,000 patients, showed
that the unadjusted rate of all-cause mortality was
only slightly higher in women than in men and,
after adjustment for baseline risk factors, the rate of
all-cause mortality was similar between women and
men.[17] According to Emdin et al.'s[18] meta-analysis
of more than 4,000,000 patients, women with AF had a greater relative risk of heart failure,
cardiovascular death, stroke, all-cause mortality,
and cardiac events than males.[18] In our study,
similar results were found in the meta-analysis study
conducted by Emdin et al.[18] in female AF patients.
However, the effect of sex on mortality in AF
patients is debatable. Many studies have shown that
female patients have more comorbidities, more suffer
from obesity, and are older patients. The outcomes of
the female sex are expected to be worse, although its
effect on mortality is still unclear.
According to Goldhaber et al.,[19] compared to
patients under 65 years of age, the HRs for major
adverse clinical outcomes within 24 months of
follow-up for overall mortality, cardiovascular and
non-cardiovascular mortality, non-hemorrhagic
stroke or systemic embolism, major bleeding,
myocardial infarction/acute coronary syndrome, and
new or worsening heart failure increased with older
age category. Many comorbidities and frailties are
expected in older patients. It is not surprising that
many diseases are predictors of mortality in this
patient group. In our study, similar to previous
studies,[19,20] age was an independent predictor of
one-year mortality.
Previous studies have demonstrated that anemia
is associated with poor prognosis and death in
patients with AF.[21,22] Anemia was revealed to be an
independent predictor of major adverse cardiac and
cerebrovascular events as well as all-cause mortality
by the Atrial Fibrillation Undergoing Coronary
Stenting (AFCAS) registry.[22] Additionally,
compared to AF patients who were not anemic,
anemia was linked to a considerably higher risk
of severe bleeding events, stroke, thromboembolic
events, and all-cause death, according to the Danish
registry.[21] In our study, in line with these studies,
low hemoglobin level was an independent predictor
of one-year all-cause mortality.
Heart failure has also been shown to increase
one-year mortality in patients with AF in previous
studies. A significant relationship was demonstrated
between heart failure and mortality in the study
conducted by Fauchier et al.[1] The Randomized
Evaluation of Long-term Anticoagulant Therapy:
dabigatran vs. warfarin (RELY-AF) study[23] and
XANTUS (Xarelto® for Prevention of Stroke in
Patients with Atrial Fibrillation)[24] real-life data
also showed that heart failure was associated with one-year all-cause mortality in patients with AF.
The difference between our study and these studies
is the mortality rate in patients. In our study,
the one-year all-cause mortality rate was 8% and
the mortality rate was higher compared to other
studies. We believe that the reason for this is that
we only included permanent AF patients in our
study. Permanent AF is seen in more frail and older
patients than other types of AF, and worse clinical
outcomes are expected in permanent AF.
In Denmark, an observational study examined
whether death rates differed for patients with AF
and COPD based on the order of diagnosis.[25]
After five years, more than half of these patients
died, showing poor prognosis. Patients diagnosed
with AF before COPD had a 26% lower death risk
than those with COPD diagnosed first. Earlier
COPD diagnosis increased mortality risk. In the
meta-analysis study by Ye et al.,[26] AF patients with
COPD were found to be associated with increased
overall mortality, increased cardiovascular mortality,
and more frequent bleeding complications compared
to AF patients without COPD. Our study found
similar results to previous studies. Taken together, it
should be kept in mind that COPD is a risk factor
in predicting mortality, given the fact that it is
frequently seen in AF patients.
Nonetheless, there are some limitations to this
study. First, this study is a single-center and
retrospective study. Therefore, the results cannot be
generalized. Second, since our study is retrospective,
some bias could not have been completely eliminated.
Third, in the multivariate analyses, some other
parameters could have been included; however,
we have missing data. Finally, we have no data
on hemorrhagic or ischemic CVD that developed
during follow-up in the patients, and since we are
unaware of the causes of death, only predictors of
all-cause death were analyzed.
In conclusion, our study results showed that the
CHA2DS2-VA score was associated with one-year
all-cause mortality in AF patients, but it was not
an independent predictor when evaluated with all
parameters affecting mortality. In the management
of AF patients, the CHA2DS2-VA score may be
useful not only in determining oral anticoagulation
strategy, but also in the approach of clinicians to AF
patients, considering that it may be a predictor of
mortality.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: All authors contributed equally
to this article.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.
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