Stroke incidence in heart failure and atrial fibrillation: a population-based retrospective cohort study

Nicholas R Jones; Margaret Smith; Sarah Lay-Flurrie; Yaling Yang; Richard Hobbs; Clare J Taylor

doi:10.3399/BJGP.2024.0470

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Primary care research exposes limitations in specialist-developed risk scores: a call for inclusive guideline development
Juan Sebastian Theran Leon and Carlos Enrique Arenas

Published on: 21 December 2025

Published on: (21 December 2025)
Page navigation anchor for Primary care research exposes limitations in specialist-developed risk scores: a call for inclusive guideline development
Primary care research exposes limitations in specialist-developed risk scores: a call for inclusive guideline development
Juan Sebastian Theran Leon, MD, MSc Cardiology, MSc Rheumatology, Universidad de Santander (UDES), Bucaramanga, Colombia
Other Contributors:
Carlos Enrique Arenas, Doctor
We read with great interest the study by Jones et al.¹ demonstrating that CHA₂DS₂-VASc may overestimate stroke risk in patients with heart failure and atrial fibrillation when competing mortality risk is considered.¹ This finding has profound implications for clinical practice and, importantly, for how cardiovascular guidelines are developed.

The authors elegantly show that while heart failure is an aetiological risk factor for stroke, its prognostic significance is substantially attenuated by the high incidence of death; over 51% of patients with heart failure died during follow-up. This insight emerged from primary care data precisely because general practitioners manage the full spectrum of patients, including those with poor prognosis who may never reach specialist care.

This raises a critical question: would this limitation of CHA₂DS₂-VASc have been identified earlier if practising primary care physicians had been meaningfully involved in its development and validation? The original CHA₂DS₂-VASc score was developed predominantly by cardiologists and electrophysiologists,² and current international atrial fibrillation guidelines continue to exclude family physicians from voting membership.³,⁴

Jones et al. note that "existing approaches to stroke risk estimation using the CHA₂DS₂-VASc score do not account for competing risks." This methodological oversight is not coincidental—specialist-developed sc...
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We read with great interest the study by Jones et al.¹ demonstrating that CHA₂DS₂-VASc may overestimate stroke risk in patients with heart failure and atrial fibrillation when competing mortality risk is considered.¹ This finding has profound implications for clinical practice and, importantly, for how cardiovascular guidelines are developed.

The authors elegantly show that while heart failure is an aetiological risk factor for stroke, its prognostic significance is substantially attenuated by the high incidence of death; over 51% of patients with heart failure died during follow-up. This insight emerged from primary care data precisely because general practitioners manage the full spectrum of patients, including those with poor prognosis who may never reach specialist care.

This raises a critical question: would this limitation of CHA₂DS₂-VASc have been identified earlier if practising primary care physicians had been meaningfully involved in its development and validation? The original CHA₂DS₂-VASc score was developed predominantly by cardiologists and electrophysiologists,² and current international atrial fibrillation guidelines continue to exclude family physicians from voting membership.³,⁴

Jones et al. note that "existing approaches to stroke risk estimation using the CHA₂DS₂-VASc score do not account for competing risks." This methodological oversight is not coincidental—specialist-developed scores often reflect populations seen in referral centres rather than the broader primary care population where most atrial fibrillation is managed. As the authors acknowledge, many patients with heart failure and atrial fibrillation have such a poor prognosis that the benefits of anticoagulation may be overestimated.

We propose that international guideline committees include practising family physicians as full voting members. Their clinical perspective on competing risks, multimorbidity, and patient prognosis could prevent future tools from overestimating benefits in populations they were never designed to serve.

Reference

1. Jones NR, Smith M, Lay-Flurrie S, Yang Y, Hobbs R, Taylor CJ. Stroke incidence in heart failure and atrial fibrillation: a population-based retrospective cohort study. Br J Gen Pract. 202; 75(753):e258-e265. doi: 10.3399/BJGP.2024.0470.

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Competing Interests: None declared.

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