Prediction of Ischemic Stroke Risk in Patients with Rheumatoid Arthritis Using a Simplified Score

Strokes in Patients with RA

Rheumatoid arthritis is one of the most common chronic inflammatory polyarthropathies. Its prevalence is reported between 0.5 and 1%, and it occurs more frequently in women. Patients with rheumatoid arthritis have a higher risk of ischemic strokes compared to the general population. After a stroke, these patients also have a higher risk of long-term consequences and increased mortality. According to available studies, the association between RA and the risk of iCMP is explained by the presence of autoantibodies, autoantigens, and pro-inflammatory cytokines, which may contribute to changes leading to the formation of atherosclerotic plaques, for example, through the induction of endothelial dysfunction and changes in intima-media thickness.

Scoring Systems for Stroke and Their Use in Other Diagnoses

A number of tools have already been used in the past to estimate the risk of iCMP. Examples include the CHADS₂ score or its modernized version CHA₂DS₂-VASc. Each of the risk factors (C – heart failure; H – arterial hypertension; A – age ≥ 75 years; D – diabetes mellitus; S – stroke or TIA in history; V – vascular disease; A – age 65–74 years; S – female sex) in these scales is assigned a certain number of points, whose sum gives the final score. These scoring systems are widely used to assess the risk of serious (ischemic) cardiovascular events in patients with atrial fibrillation. Recently, however, they have also been used to assess the risk of iCMP in specific groups of patients. They have found application, for example, in heart failure, systemic lupus, diabetes, or rheumatoid arthritis.

Does RA Need Its Own Scoring System?

A recently published study addressed whether the above-mentioned scoring systems are really suitable for patients with rheumatoid arthritis. Therefore, a retrospective cohort study was developed aimed at creating a new and simplified score that would be capable of predicting the risk of iCMP in patients with rheumatoid arthritis who do not have atrial fibrillation (non-AF RA). The researchers analyzed data from the Taiwanese national registry containing 1 million patients, where they identified patients with rheumatoid arthritis based on codes derived from the International Classification of Diseases (ICD-9-CM). Individuals under 20 years of age and patients with concurrent atrial fibrillation or flutter were not included in the study. Data from a total of 592 patients with non-AF RA were evaluated, who were followed until the occurrence of the first iCMP or for a maximum of 10 years.

The study yielded 3 main findings:

1. The CHADS₂ score was assessed as insufficient to predict the risk of iCMP in patients with non-AF RA.
2. A CHA₂DS₂-VASc score ≥ 2 was associated with a higher risk of iCMP in these patients. However, not all parameters of this score were suitable for patients with RA.
3. A new RA-CHADSV score was developed, specifically designed for patients with non-AF RA.

RA-CHADSV and Its Advantages

Based on data analysis, a new and simpler stratification scale was created, which only assesses the following risk factors:

• C: congestive heart failure
• H: arterial hypertension
• A: age ≥ 75 years 
• D: diabetes mellitus
• S: stroke, TIA, or thromboembolism in history
• V: vascular disease

Each risk factor is assigned 1 point, and the final sum gives the value of the RA-CHADSV score. If the score is ≥ 1 in patients with non-AF RA, they are assumed to have a higher risk of iCMP. This tool provides comparable results to the CHA₂DS₂-VASc score, but its use is simpler. It can therefore be a useful tool for managing patients with non-AF RA, easily applicable in clinical practice.

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Source: Hsu C.-W., Ng, K.-J., Lu M.-C., Koo M. Predicting the risk of ischemic stroke among patients with rheumatoid arthritis using a simplified RA-CHADSV score based on the CHA₂DS₂-VASc score. Medicina (Kaunas) 2020 Feb 12; 56 (2): 73, doi: 10.3390/medicina56020073.