Clinical implications of the recalibrated CHA₂DS₂-VA score for women after ischemic stroke: a prospective cohort study.

Background: The 2024 ESC atrial fibrillation guidelines introduced the CHA₂DS₂-VA score, eliminating female sex as an independent risk criterion for stroke risk stratification. This revision aimed to improve clarity and avoid sex-based overtreatment. However, its real-world impact on women with ischemic stroke remains unclear. Methods: In a prospective cohort of 714 consecutive stroke patients, 161 (22.5%) had documented atrial fibrillation. Risk stratification was performed using both CHA₂DS₂-VASc and the revised CHA₂DS₂-VA score. Stroke severity and functional outcome were analyzed by sex. Propensity score matching and multivariable logistic regression were used to examine the independent association between sex and stroke severity. Results: Female patients with atrial fibrillation were older and had a higher vascular risk burden than men. They presented with significantly more severe strokes (median NIHSS 12 vs. 8; P< 0.01) and tended toward worse outcomes. After score recalibration, 11 of 81 women (13.6%) had a CHA₂DS₂-VA score ≤1, falling below the European Society of Cardiology anticoagulation threshold—despite having experienced an ischemic stroke. Most of these patients had cardioembolic strokes and moderate-to-severe neurological deficits. In matched analyses, female sex remained independently associated with severe stroke (aOR 1.54, 95% CI 1.03–2.29). Conclusion: The removal of female sex from the CHA₂DS₂-VA score does not eliminate sex-specific disparities in stroke risk. A clinically meaningful subgroup of women now falls below treatment thresholds, raising concern for under-treatment. Women present significantly more disabilities and neurological deficits after stroke. These findings call for nuanced anticoagulation strategies that go beyond score-based decisions and better reflect real-world risk in female stroke patients with atrial fibrillation.

Background: Stroke is defined by the World Health Organization(WHO) as ‘a clinical syndrome consisting of rapidly developing clinical signs of focal (or sometimes global) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin. Objective: To study the pattern of ischemic stroke subtypes in a sample Egyptian patients, common risk factor profiles and management methods. Patients: A retrospective study was conducted on 321 patients who were admitted to Al-Azhar University Hospitals and Nasser Institute with a main primary diagnosis of acute ischemic stroke during the period from January 2017 until December 2018. Results: Small vessel strokes were the most common accounting for 51.1% of all patients, followed by large vessel getting affected 24% of the cases. Cardio embolic stroke was present in 20.8%of the cases, Hypertension was the most prevalent risk factor among patients accounting for 61.1%, diabetes (49.5%), obesity (38.6%), and smoking (32.1%). A significant difference in stroke severity among stroke patients regarding smoking status was found in univariate analysis and obesity. Multivariate analysis using multiple linear regressions showed that the relationship with obesity was significant. Conclusion: In spite of the high prevalence of stroke risk factors among the study patients, the power wasn’t enough to show any association with stroke severity except for smoking and obesity, where smokers and obese patients are more likely to have higher stroke severity.

Background: Stroke is defined by the World Health Organization(WHO) as ‘a clinical syndrome consisting of rapidly developing clinical signs of focal (or sometimes global) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than a vascular origin. Objective: To study the pattern of ischemic stroke subtypes in a sample Egyptian patients, common risk factor profiles and management methods. Patients: A retrospective study was conducted on 321 patients who were admitted to Al-Azhar University Hospitals and Nasser Institute with a main primary diagnosis of acute ischemic stroke during the period from January 2017 until December 2018. Results: Small vessel strokes were the most common accounting for 51.1% of all patients, followed by large vessel getting affected 24% of the cases. Cardio embolic stroke was present in 20.8%of the cases, Hypertension was the most prevalent risk factor among patients accounting for 61.1%, diabetes (49.5%), obesity (38.6%), and smoking (32.1%). A significant difference in stroke severity among stroke patients regarding smoking status was found in univariate analysis and obesity. Multivariate analysis using multiple linear regressions showed that the relationship with obesity was significant. Conclusion: In spite of the high prevalence of stroke risk factors among the study patients, the power wasn’t enough to show any association with stroke severity except for smoking and obesity, where smokers and obese patients are more likely to have higher stroke severity.

Hospital cost of ischemic stroke and intracerebral hemorrhage in Japanese stroke centers

Background: A wide variety of racial and ethnic disparities in stroke epidemiology and treatment have been reported. Race-ethnic differences in initial stroke severity may be one important determinant of differences in the outcome after stroke. The overall goal of this study was to move beyond ethnic comparisons in the mean or median severity, and instead investigate ethnic differences in the entire distribution of initial stroke severity. Additionally, we investigated whether age modifies the relationship between ethnicity and initial stroke severity as this may be an important determinant of racial differences in the outcome after stroke. Methods: Ischemic stroke cases were identified from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project. National Institutes of Health Stroke Scale (NIHSS) was determined from the medical record or abstracted from the chart. Ethnicity was reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS score by age category (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5 percentile increments). Crude models examined the interaction between age category and ethnicity; models were then adjusted for history of stroke/transient ischemic attack, hypertension, atrial fibrillation, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons. Results: There were 4,366 ischemic strokes, with median age 72 (IQR: 61-81), 55% MA, and median NIHSS of 4 (IQR: 2-8). MAs were younger, more likely to have a history of hypertension and diabetes, but less likely to have atrial fibrillation compared to NHWs. In the crude model, the ethnicity-age interaction was not statistically significant. After adjustment, the ethnicity-age interaction became significant at the 85th and 95th percentiles of NIHSS distribution. MAs in the younger age category (45-59) were significantly less severe by 3 and 6 points on the initial NIHSS than NHWs, at the 85th and 95th percentiles, respectively. However, in the older age category (75+), there was a reversal of this pattern; MAs had more severe strokes than NHWs by about 2 points, though not reaching statistical significance. Conclusions: There was no overall ethnic difference in stroke severity by age in our crude model. However, several potentially important ethnic differences among individuals with the most severe strokes were seen in younger and older stroke patients that were not explained by traditional risk factors. Age should be considered in future studies when looking at the complex distributional relationship between ethnicity and stroke severity.

Background: Ethnic differences in stroke severity may vary by age or be explained by differences in risk factors (e.g. atrial fibrillation (Afib), diabetes). Our goal was to investigate ethnic differences in initial stroke severity. Methods: Ischemic stroke cases were identified from the population-based BASIC project. NIHSS was determined from the medical record or abstracted from the chart. Ethnicity was ascertained from the medical records and reported as Mexican American (MA) or non-Hispanic white (NHW). Quantile regression was used to model the distribution of NIHSS by age group (45-59, 60-74, 75+) to test whether ethnic differences exist over different quantiles of NIHSS (5% increments). Crude models were run to examine the interaction between age group and ethnicity; models were then adjusted for hypertension, Afib, coronary artery disease, and diabetes. Results were adjusted for multiple comparisons across 19 quantiles (5 to 95%). Results: There were 4,366 ischemic strokes, with median age 72 years (IQR: 61-81), 55% MA and median NIHSS of 4 (IQR: 2-8). In the crude model, in younger (45-59) and older (75+) age groups, MAs had one point higher NIHSS than NHWs at the median and for some lower quantiles (all p<0.001), but no severity difference was seen in the 60-74 group. At the 95% quantile of NIHSS in the younger age group (Figure), MAs had significantly less severe strokes than NHWs by 6 points (p<0.001). However, in the older age group, there was a reversal of this pattern, with MAs’ strokes being more severe than NHWs by about 1 point. After full adjustment, similar trends could be seen at the lower quantiles, but the pattern of older MAs having more severe strokes at the higher quantiles became more apparent at the 85% and 95% quantiles, suggesting that this severity difference was not due to differences in risk factors. Conclusion: Ethnic differences in initial stroke severity varied by age. Age should be considered when looking at race/ethnic differences in severity.

Introduction: Atrial fibrillation is one of the most common rhythmic disorders in general population and a major risk factor of ischemic stroke. We investigated whether there was any difference in initial stroke severity and short term outcome in patients with acute ischemic stroke and known non-valvular atrial fibrillation according to their prior medication status. Methods: We retrospectively reviewed patients with acute ischemic stroke and non-valvular atrial fibrillation who admitted at six hospitals from 2013 to 2016. We selected patients with known non-valvular atrial fibrillation before admission and a CHA 2 DS 2 -VASc score of ≥2. We categorized their prior medication status as follows: 1) no antithrombotics, 2) only antiplatelet, 3) warfarin with a subtherapeutic range, 4) warfarin with a therapeutic range, 5) under-dosed novel oral anti-coagulant (NOAC), and 6) standard-dosed NOAC. We compared the initial NIHSS score and 3 month modified Rankin Scale (mRS) between the groups. Results: Total 741 patients were enrolled for analysis. Patients were categorized as follows: 177 no antithrombotics, 296 only antiplatelet, 169 warfarin with a subtherapeutic range, 36 warfarin with a therapeutic range, 25 under-dosed NOAC, and 38 standard-dosed NOAC. Median NIHSS score was lowest in patients with standard-dosed NOAC (3, interquartile range [IQR] 1-7) compared to no antithrombotics (7, IQR 2-17), only antiplatelet (4, IQR 1-12.75), warfarin with a subtherapeutic range (6, IQR 2-15), warfarin with a therapeutic range (3.5 IQR 1-7), and under-dosed NOAC (7, IQR 2-16). Proportions of the patients with good functional outcome (mRS 0-2) are as follows; 45.5% no antithrombotics, 60.4% only antiplatelet, 56.5% warfarin with subtherapeutic range, 62.1% warfarin with therapeutic range, 40.9% under-dosed NOAC, and 64.7% standard-dosed NOAC. Conclusions: Large portion of non-valvular atrial fibrillation patients do not receive proper anticoagulation, although they have higher risk of embolization. Therapeutic anticoagulation reduces the initial severity of neurologic deficit in patient with ischemic stroke.

Influence of oral anticoagulation on stroke severity and outcomes: A propensity score matching case-control study

Effects of preceding antiplatelet agents on severity of ischemic stroke in patients with a history of stroke

<i>Stroke</i> : Highlights of Selected Articles

The aims of the study were (i) to examine which antithrombotic therapy patients with known atrial fibrillation use at the point of time when they suffer an ischaemic stroke, (ii) to evaluate the effects of optimal antithrombotic treatment on outcome and severity of the stroke. Patients with known atrial fibrillation before onset of acute ischaemic stroke, and age >60 years were included. Antithrombotic therapy on admission was classified into four groups: no antithrombotic therapy, aspirin, sub-optimal anticoagulation (warfarin and international normalized ratio, INR<2.0) and optimal anticoagulation (warfarin and INR>or=2.0). modified Rankin Scale (mRS) 5 or 6 at day 7 poststroke. (i) death or discharge to a nursing home, (ii) death, (iii) stroke severity on admission assessed by Scandinavian Stroke Scale. A total of 394 patients were included. On admission 109 (28%) patients used no antithrombotic therapy, 169 (43%) aspirin, 52 (13%) warfarin and had an INR<2.0, and 64 (16%) used warfarin and had an INR>or=2.0. The proportion of patients with an mRS 5 or 6 and the corresponding odds ratios were: in the warfarin group with INR<2.0, 16 (31%), OR 3.1 (CI: 1.2-8.0), (P=0.019), in the group with no antithrombotic therapy 29 (27%), 2.5 (1.1-5.9), (P=0.034), and in the aspirin group 41(24%), 2.2 (1.0-5.1) (P=0.054), compared with the warfarin group with INR>or=2.0, where eight (13%) patients had a poor outcome. A significantly higher proportion of patients died or were discharged to a nursing home in the warfarin group with an INR<2.0 (P=0.014), in the aspirin group (P=0.018) and in the no-treatment group (P=0.035), compared with the warfarin group with an INR>or=2.0. No significant differences were found regarding death alone and stroke severity on admission. Few patients with known atrial fibrillation who suffer an ischaemic stroke receive optimal antithrombotic therapy prior to the onset of stroke. Optimal anticoagulation does not only reduce the risk of ischaemic stroke, but also appears to reduce death and severe dependency as well as the need for nursing home care, if an ischaemic stroke occurs.

Introduction: While men suffer from more strokes in younger and middle age, the incidence of stroke is higher among women in older age. Specifically, 60% of stroke fatalities occur in females and 40% occur in males. Recent findings have attributed these sex-specific differences to a surge in the prevalence of cardiovascular risk factors among women. Traditionally, men have presented more frequently with micro-vascular complications (hypertension, diabetes, hyperlipidemia, and obesity), but now these risks are increasing in women. Hypothesis: Whether the modifiable risk factors examined, both alone and together, will differ in their ability to predict stroke severity across sex. Methods: A retrospective analysis of 811 primary stroke cases from two comprehensive and two primary stroke centers in a single region were analyzed for prevalence of modifiable and non-modifiable risk factors. Risk factors such as medical comorbidities, clinical findings and behavioral risk factors were compared across sexes and then assessed for correlation with initial presentation severity and ambulatory status. The relative influence of risk factors on sex differences in stroke severity (NIH Stroke Scale) and symptomatology were tested. Results: Females were more likely to present as non-Hispanic, with history of migraines and more severe levels of hypertension, with hypertensive crisis status at presentation relative to normal hypertensive state (all p &lt; 0.05). Males were more likely to present with history of coronary artery disease, documentation of drug or alcohol use, higher fasting blood sugar, A1c, and BMI levels at presentation (all p &lt; 0.05). Multivariate models improved the observed association between female sex and severe NIHSS score (OR = 2.1 [1.03-4.35]) through inclusion of hypertension, fasting blood sugar, and diabetes status. Conclusions: While the sex differences in strokes are well studied, the complex interrelationships between sex, variance in known medical risk factors, and severity of stroke presentation are not so well understood. This study identifies new patterns in risk by building independent models for odds of stroke severity for each sex, which may in turn help to explain sex differences in stroke presentation phenotype.

Sex Differences in Stroke Severity, Symptoms, and Deficits After First-ever Ischemic Stroke

Background and Purpose: Once a stroke occurs in a patient with atrial fibrillation (AF), it is likely to be severe. Patients with newly diagnosed AF after stroke and those with known AF before stroke have different background characteristics, yet the difference in stroke severity has not been sufficiently evaluated. In the current study, we compared the stroke severity and in-hospital outcomes between these patient groups.Methods: We retrospectively analyzed a database of 196 patients with acute ischemic stroke and AF between January 2010 and October 2019. We divided the patients into two groups: patients with “newly diagnosed AF” and those with “known AF.” We assessed the stroke severity using the National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital outcomes using the modified Rankin Scale (mRS) score at discharge.Results: The proportion of newly diagnosed AF was 33% (64/196). There were no differences in age, hypertension, diabetes mellitus, and past history of heart failure between patients with newly diagnosed AF and those with known AF. Patients with newly diagnosed AF were associated with a lower proportion of male sex (male; 50 vs. 67%, p < 0.05), a lower proportion of past history of stroke (12 vs. 35%, p < 0.01), a lower CHA2DS2-VASc score (median [interquartile range]; 3 [2–4] vs. 3.5 [3–5], p < 0.01), and a lower proportion of pre-stroke oral anticoagulation (5 vs. 59%, p < 0.01). There were no differences in the NIHSS score on admission (12 [4–19] vs. 9 [3–19]) or the mRS score at discharge (3 [1–5] vs. 3 [1–5]). After adjustment for relevant covariates, newly diagnosed AF was not associated with the NIHSS score on admission [adjusted common odds ratio (OR), 0.85; 95% confidence interval (CI), 0.45–1.60] or the mRS score at discharge (adjusted common OR, 1.67; 95% CI, 0.88–3.18). After propensity score matching, newly diagnosed AF was not associated with the NIHSS score on admission (adjusted common OR, 0.91; 95% CI, 0.48–1.73) and the mRS score at discharge (adjusted common OR, 1.77; 95% CI, 0.92–3.43).Conclusion: Stroke severity and in-hospital outcomes in patients with newly diagnosed AF did not differ from those in patients with known AF after adjustment for clinically relevant factors. The importance of detection of latent AF and subsequent anticoagulation in preventing severe stroke should be further emphasized.

Background Sex category (Sc, ie, female sex) confers 1 point on CHA2DS2-VASc score. So, no woman with atrial fibrillation (AF) can have a CHA2DS2-VASc score of 0. This study aimed to compare CHA2DS2-VA (excluding female sex) and CHA2DS2-VASc score in Korean AF patients. Methods Using the Korean National Health Insurance Service database, we analyzed the risk of ischemic stroke in non-valvular AF patients between 2013 and 2017. The predictive value of the CHA2DS2-VA and CHA2DS2-VASc scores for ischemic stroke was evaluated by c-statistic difference and net reclassification improvement (NRI). The propensity score matching method was used to balance covariates across male and female AF patients. Results A total of 182,133 patients with AF (49.2% women) were included to this study. The adjusted incidence rate (IR) of ischemic stroke was not significantly different between males and females (0.89%/y and 0.90%/y, respectively, p=0.411) in low-risk patients without risk factor. Also, no sex difference was found in high-risk patients with above 2 risk factors for ischemic stroke (4.46%/y for male and 4.49%/y for male, p=0.498). In c-statistic analysis for ischemic stroke, there was no significant difference between the CHA2DS2-VA and CHA2DS2-VASc scores (AUC 0.662 vs. 0.664, z=1.572, p=0.116). When compared with CHA2DS2-VASc score, CHA2DS2-VA score was not significantly inferior in net reclassification improvement (NRI 0.031, 95% CI 0.002–0.037, p=0.118) for ischemic stroke. C-statistics Conclusions In Korean AF patients, the CHA2DS2-VA score excluding female sex is a useful risk scoring system for ischemic stroke.