The Predictive Value of CHA2DS2–VASc Score as a Predictor for Left Ventricular Thrombus After Acute Anterior ST-Elevation Myocardial Infarction: A Case-Control Retrospective Analysis

Objective: To determine the predictive value of CHA 2 DS 2 –VASc score as a predictor for left ventricular thrombus after acute anterior ST-elevation myocardial infarction (STEMI). Methods: We performed a case–control retrospective study of 30 patients with left ventricular thrombus (median age: 60.6 years, range: 38–75 years old; 26 males, 74 females) and 60 age- and sex-matched controls without left ventricular thrombus. Correlation analysis was performed and receiver operating characteristic (ROC) curve was used to evaluate the predictive value of CHA 2 DS 2 –VASc score in detecting left ventricular thrombus. Result: Patients with left ventricular thrombus after acute anterior STEMI had higher CHA 2 DS 2 –VASc scores than controls (P < 0.001). Correlation analysis revealed that CHA 2 DS 2 –VASc scores were positively correlated with left ventricular thrombus after acute anterior STEMI (r = 0.413; P < 0.001). Multiple logistic regression analyses indicated that CHA 2 DS 2 –VASc scores (P = 0.001) and heart failure (P = 0.023) were risk factors of left ventricular thrombus. The ROC curve of CHA 2 DS 2 –VASc scores revealed that area under curve was 0.746 (95% condence interval: 0.638–0.853, P < 0.001), sensibility was 86.7%, and specicity was 50.0%. Conclusion: Patients with heart failure have a high incidence of left ventricular thrombus after acute anterior STEMI. CHA 2 DS 2 –VASc scores contribute to the prediction for left ventricular thrombus after acute anterior STEMI.


Introduction
Despite widespread uptake of primary percutaneous coronary intervention and improved overall periprocedural care, left ventricular thrombus remains a complication of acute anterior ST-elevation myocardial infarction (STEMI) and is associated with a high thromboembolic risk. [1][2][3] Previousstudies reported that the incidence of left ventricular thrombus in patients presenting with acute anterior STEMI ranges from 2.1-12.3%. 4,5 Moreover, the detection, prevention, and treatment of this condition is replete with distinct challenges. 6 Transesophageal echocardiography is considered the gold standard technique for left ventricular thrombus detection. [7][8][9] However, it is time-consuming, expensive, and not readily available in all centers, especially when repeated examinations are necessary. Accumulating evidence illustrates the meaningful clinical information of CHA 2 DS 2 -VASc score in coronary heart and thrombotic diseases (whether diagnostic information or prognostic information). However, data regarding the role of the CHA 2 DS 2 -VASc score in left ventricular thrombus after acute anterior STEMI are lacking. Thus, we performed this retrospective study to determine the predictive value of the CHA 2 DS 2 -VASc score as a predictor for left ventricular thrombus after acute anterior STEMI.

Ethics and consent
This study was approved by the Medical Ethics Committee of Cangzhou Central Hospital (No. 2020-170-01) and conducted in accordance with the Declaration of Helsinki. Informed consent was waived given the retrospective nature of this study. Patient information was anonymized prior to analysis.

Patients
We performed a case-control retrospective study of 30 patients with left ventricular thrombus (median age: 60.6 years, range: 38-75 years old; 26 males, 74 females) and 60 age-and sex-matched controls without left ventricular thrombus. The inclusion criteria were as follows: (1) aged > 18 years old, (2)with acute anterior STEMI diagnosed via coronary angiography and subsequently underwent revascularization, and (3) had complete medical data. Patients with any of the following criteria were excluded: (1) hypertrophic cardiomyopathy, (2) congenital heart disease, (3) organic valvular heart diseases, (4) history of any cardiac surgery and/or cardiac device insertion, and (5) signi cant associated systemic illness.
Acute left ventricular thrombus was de ned as the presence of an echo dense mass seen in the left ventricular cavity on transthoracic echocardiogram within 7 days from acute anterior STEMI. 10,11 STEMI was de ned according to the WHO criteria as revised in 2000. 12 Each patient received standard pharmacologic treatment according to AMI treatment guidelines. 13 Clinical Data Clinical baseline characteristics, including age, gender, body mass index, echocardiographic data, and medical history, were collected from medical record and analyzed. CHA 2 DS 2 -VASc score was calculated with 1 point assigned for a history of congestive heart failure, hypertension, 74 years ≥ age ≥ 65 years, female, diabetes mellitus, and vascular disease and 2 points assigned for age ≥ 75 years and a history of stroke or transient ischemic attacks. The maximum score is 9. The CHA 2 DS 2 -VASc score was calculated by the researcher without knowledge of the transthoracic echocardiogram result.

Statistical analysis
All statistical analyses were performed by SPSS for Windows version 13.0 (SPSS Inc., Chicago, IL). Twosample t test was used to compare continuous variables with normal distribution and presented as mean ± standard deviation, whereas nonparametric tests were utilized to compare continuous variables with abnormal distribution and presented as median (interquartile range). Chi-squared two-group proportion test was employed to compare categorical data. Correlation analyses using the Spearman method were conducted to test the relationship between CHA 2 DS 2 -VASc score and left ventricular thrombus. In univariate logistic analysis, when P < 0.10, signi cant correlation factors were included in a forward stepwise multivariate logistic regression. The predictive value of CHA 2 DS 2 -VASc scores was evaluated by receiver operating characteristic (ROC) curve analyses, and their speci city and sensitivity in detecting left ventricular thrombus were analyzed. All tests were two-sided, and a P value < 0.05 was considered statistically signi cant.

Patient characteristics
All patient characteristics are summarized in Table 1. The CHA 2 DS 2 -VASc scores of the patients ranged from 0 to 6, and the mean score was 1.98. The patients with left ventricular thrombus were characterized by heart failure, stroke, vascular disease, and high CHA 2 DS 2 -VASc scores.

Correlation Analysis
Correlation analysis revealed that CHA 2 DS 2 -VASc scores were related to left ventricular thrombus in patients with this condition (r = 0.413; P < 0.001).

Multiple logistic regression analyses of factors associated with left ventricular thrombus
Multiple logistic regression analyses indicated that CHA 2 DS 2 -VASc scores (P = 0.001) and heart failure (P = 0.023) were signi cant risk factors of left ventricular thrombus ( Table 2). In addition, the incidence of left ventricular thrombus increased with higher CHA 2 DS 2 -VASc scores (Fig. 1).

Declarations
Ethics approval and consent to participate This study provided further evidence of the predictive value of CHA 2 DS 2 -VASc score as a predictor for left ventricular thrombus after acute anterior STEMI. Our results showed that the AUC of CHA 2 DS 2 -VASc score was 0.746, sensibility was 86.7%, and speci city was 50.0%, suggesting that CHA 2 DS 2 -VASc score was a predictor for left ventricular thrombus after acute anterior STEMI. Moreover, our results showed patients with heart failure had a high incidence of left ventricular thrombus after acute anterior STEMI.
Although our research showed that CHA 2 DS 2 -VASc score was related to left ventricular thrombus after acute anterior STEMI, the precise mechanism remains unknown; a study suggested that the possible mechanism is platelet activity. Asher et al. 14 reported that in patients with acute coronary syndrome treated with clopidogrel following PCI, high CHA 2 DS 2 -VASc scores correlated with high on-treatment platelet reactivity, whereas low scores correlated with optimal platelet reactivity. Another study 15 showed that CHA 2 DS 2 -VASc score is linearly correlated with residual platelet reactivity (R = 0.77; P < 0.001).
Multivariable analysis demonstrated that CHA 2 DS 2 -VASc score is an independent predictor of high residual platelet reactivity.
Another nding of the present study was that patients with heart failure had a higher incidence of left ventricular thrombus after acute anterior STEMI. A previous meta-analysis 16 showed that the incidence of left ventricular thrombus in patients with acute anterior STEMI was 6.3%; however, the incidence was 19.2% when only acute anterior STEMI with LVEF < 50% was considered. This observation is pathophysiologically plausible because the larger the areas of damage, the larger the probability of regional wall motion disturbances, or even aneurysm formation, will be, leading to a reduced blood ow, ultimately resulting in thrombus formation. 17,18 The present study has several limitations. First, the sample size of this study was relatively small. Second, the ndings were restricted to a yellow race cohort and may not be generalized to other ethnic cohorts. Third, although these ndings are important, the retrospective nature of this study limits its generalizability. Fourth, the results were in uenced by variabilities among intra-and intersonographers, thereby introducing a signi cant bias and affecting the measured outcomes.
In conclusion, patients with heart failure have a high incidence of left ventricular thrombus after STEMI.

Consent for publication
Not applicable.
Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to privacy or ethical restrictions, but are available from the corresponding author on reasonable request.