Pre-stroke CHA2DS2-VASc Scores Research Articles

Impact of prior use of antiplatelet agents and non-vitamin K antagonist oral anticoagulants on stroke outcomes among endovascular-treated patients with high pre-stroke CHA2DS2-VASc score

BackgroundWe assessed the influence of prior non-vitamin K antagonist (NOAC) use on stroke outcomes after endovascular treatment (EVT) in patients at a high risk of stroke based on their pre-stroke...

Relationship between Arterial Stiffness and CHA2DS2-VASc Score in AF-related Stroke Patients

Aim: Arterial stiffness is related with both atrial fibrillation (AF) and stroke. The CHA2DS2-VASc score is used to assess stroke risk in patients with AF. In this study, it was aimed to examine the relationship between arterial stiffness and CHA2DS2-VASc score in AF-related stroke patients. Material and Methods: Thirty stroke patients with paroxysmal AF participated in this research. Calculations of the patients' pre-stroke CHA2DS2-VASc scores were made. The SphygmoCor device was used to assess the Carotid-Femoral Pulse Wave Velocity (cfPWV), which served as a surrogate for arterial stiffness. It was determined whether or not there was a statistical connection between the CHA2DS2-VASc score and arterial stiffness. Results: The patients were seperated into groups based on their CHA2DS2-VASc scores prior to the stroke (group 1: score=0-1, group 2: score=≥2). The two groups' characteristics were comparable, except for age, BMI and systolic blood pressure. Patients with high CHA2DS2-VASc scores (group 2) demonstrated significantly greater cfPWV values than those with low scores (group 1). The CHA2DS2-VASc score and the cfPWV revealed a favourable association in the correlation study. Conclusion: The CHA2DS2-VASc score and cfPWV were substantially and linearly associated. Calculation of CHA2DS2-VASc and monitoring of arterial stiffness in stroke-prone individuals may be stimulus for taking preventive measures from stroke in these patients.

Detection of atrial fibrillation in patients with cryptogenic stroke: The Nordic Atrial Fibrillation and Stroke (NOR-FIB) study - topline results

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): NOR-FIB is an investigator driven academic study. 100 of 259 devices are supported by Medtronic. BRT and ATL are recipients of a PhD grants from the South-Eastern Norway Regional Health Authority. The study is supported by the research infrastructure of the European Cerebrovascular Research Infrastructure (ECRI). Background Cardioembolism due to occult atrial fibrillation (AF) is one of the common causes often identified by additional investigations in patients with cryptogenic stroke (CS). A large proportion of recurrent cerebral infarctions caused by AF can probably be prevented if more patients receive optimal cardiac monitoring after CS and TIA. Purpose The aim of the prospective observational multi-center NOR-FIB study was to detect and quantify AF in patients with cryptogenic stroke or TIA under continuous 12 months cardiac rhythm monitoring with an implantable cardiac monitor (ICM) and to possibly identify biomarkers predicting incident AF. Methods Patients with cryptogenic stroke and TIA diagnosed after state-of-the-art work-up had their ICM implanted by a stroke physician within 14 days after symptom onset. All patients were followed clinically and by rhythm monitoring for 12 months. AF was defined by detected atrial arrhythmia episodes ≥ 2 min, and these patients were considered for a change of their secondary prevention from antiplatelet drugs to oral anticoagulants (OAC). Results A total of 259 patients with cryptogenic stroke or TIA from 18 hospitals in Norway, Sweden and Denmark were included. After 12 months follow-up 74 (28.6 %) patients were diagnosed with paroxysmal AF, of which 91.9% were asymptomatic. Patients with AF had significantly higher mean age (72.6 vs 62.2, p<0.001), more severe stroke (median National Institute Stroke Scale Score on admission 2 vs 1, p 0.002) and higher pre-stroke median CHA2DS2-VASc score (3 vs 2, p<0.001) than patients without AF. Both hypertension and hyperlipidemia was more common in patients with AF. In 64 (86.5%) cases AF was detected early after index stroke, i.e., within the first two months of monitoring (mean 47.7 days + 52,1). Recurrent AF episodes were detected in 68 (91.9%) cases. Of the 74 AF patients, 72 (97.3%) were switched to OAC. Recurrent strokes during follow-up occurred in 2 AF patients (2.7 %) and in 9 non-AF patients (4.9 %). Conclusion AF was detected in 29% of all cryptogenic stroke/TIA patients. Most of the patients were asymptomatic for their arrhythmia, and would have gone undiagnosed without a continuous monitoring approach. Since most of the patients with detected AF were switched to OAC, the 12 months risk of recurrent stroke in this group was low. Prolonged cardiac rhythm monitoring with ICMs is an effective tool for diagnosing underlying asymptomatic AF in a patient population typically confined to a stroke unit.

Association of CHA2DS2-VASc score with successful recanalization in acute ischemic stroke patients undergoing endovascular thrombectomy.

The CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease and sex) score is a simple risk stratification algorithm to estimate stroke/thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Higher pre-stroke CHA2DS2-VASc score is known to be associated with greater stroke severity and poorer outcomes. AF patients generally have higher CHA2DS2-VASc scores than non-AF patients. The Modified Thrombolysis in Cerebral Infarction (mTICI) score is the most widely used grading system to assess the result of recanalizing therapies in acute ischemic stroke (AIS). mTICI 2c and mTICI 3 are conventionally accepted as successful recanalization. We investigated whether pre-stroke CHA2DS2-VASc score is associated with mTICI recanalization score in AIS patients with and without AF undergoing percutaneous thrombectomy. One hundred fifty-nine patients with the diagnosis of AIS who were admitted within 6 h from symptom onset were included in the study (mean age: 65.7 ±12.9). All subjects underwent endovascular treatment. CHA2DS2-VASc scores of the participants were calculated. Subjects were grouped according to mTICI scores achieved after endovascular treatment. mTICI 2c and mTICI 3 were accepted as successful recanalization. Successful reperfusion was observed in 130 (81.8%) of all patients who underwent endovascular treatment (mTICI flow ≥ 2c) and first-pass reperfusion was observed in 107 (67.3%) patients. When the patients with successful (mTICI flow ≥ 2c) and unsuccessful (mTICI flow ≤ 2b) reperfusion were divided into groups, no significant difference was observed between the patients in terms of comorbidities such as AF, hypertension, hyperlipidemia, coronary artery disease and cerebrovascular accident history. Patients with unsuccessful reperfusion were older than patients with successful reperfusion (71.4 ±11.2 vs. 64.5 ±13.01, p = 0.006), with a higher CHA2DS2-VASc score (4.1 ±1.5 vs. 3.04 ±1.6, p = 0.002). In addition, the duration of the procedure was longer in the unsuccessful reperfusion group (92.4 ±27.2 min vs. 65.0 ±25.1 min, p < 0.001). CHA2DS2-VASc score significantly correlated with successful recanalization (correlation coefficient; 0.243, p = 0.002). Multivariate logistic regression analysis revealed that only CHA2DS2-VASc score (OR = 1.43, 95% CI: 1.09-1.87, p = 0.006) and procedure time (OR = 1.03, 95% CI: 1.01-1.05, p < 0.001) were independent predictors of successful reperfusion. The receiver-operating characteristic (ROC) curve was used to determine the cut-off value for the CHA2DS2-VASc score that best predicts successful reperfusion. The optimal threshold was 3.5, with a sensitivity of 58.6% and specificity of 59.2% (area under the curve (AUC): 0.669, p = 0.005). For the first time in the literature, we investigated and demonstrated that pre-stroke CHA2DS2-VASc score was associated with success of recanalization as assessed with mTICI 2c and mTICI 3 in a cohort of AIS patients regardless of AF presence who underwent endovascular treatment. Our findings deserve to be tested with large scale long term studies.

Similar thrombolysis outcomes in acute stroke patients with and without atrial fibrillation if pre-stroke CHA2DS2-VASc score is low: A retrospective study.

The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.

Cerebrovascular accidents differ between patients with atrial flutter and patients with atrial fibrillation.

IntroductionFew studies have explored the potential impact of atrial flutter (AFl) on ischaemic stroke (IS) outcome. The aim of the present study was to compare the clinical course of IS in patients with AFl and patients with atrial fibrillation (AF).Material and methodsA retrospective analysis of patients consecutively admitted to a tertiary care centre between 2013 and 2015 due to IS or transient ischaemic attack with permanent AFl or permanent or persistent AF was performed.ResultsThe study groups consisted of 528 patients, including 490 (92.8%) patients with AF and 38 (7.2%) patients with AFl. The mean age and prestroke CHA2DS2-VASc scores were similar between the patients with AFl and those with AF. Most IS cases in the AF group were classified as cardioembolic strokes (74.9% vs. 39.5% in AFl, p < 0.01), and lacunar strokes were the most common in the AFl group (47.4% vs. 14.3% in AF, p < 0.01). The multivariable analysis revealed that the presence of AF (OR = 8.6, 95% CI: 1.2–57, p = 0.02), lacunar stroke (OR = 0.1, 95% CI: 0.03–0.31, p < 0.001), baseline Rankin scale score (OR = 16.6, 95% CI: 9.8–28), lack of prestroke therapeutic anticoagulation (OR = 6.1, 95% CI: 1.1–33), diabetes (OR = 2.9, 95% CI: 1.3–6.5, p < 0.01), chronic heart failure (OR = 14.2, 95% CI: 5.8–34, p < 0.001), and current smoking (OR = 0.92, 95% CI: 0.39–0.99, p < 0.01) were significantly associated with the stroke outcome.ConclusionsDisabling or fatal IS was observed less often in patients with AFl than in patients with AF. This finding can possibly be explained by the more frequent occurrence of lacunar strokes in the AFl group compared with that in the AF group.

Use of CHADS2 and CHA2DS2-VASc scores to predict prognosis after stroke

IntroductionStroke is one of the most devastating neurological disorders. Currently, we don’t have an ideal score that predicts the prognosis of stroke patients. The CHADS2 and CHA2DS2-VASc scores are well-validated tools for the estimation of stroke risk in patients with atrial fibrillation. The purpose of this study was to investigate if these scores can predict the outcomes of all the patients who suffered an ischemic stroke regardless of atrial fibrillation. MethodsConsecutive patients that were admitted with an acute ischemic stroke were classified into subgroups according to pre-stroke CHADS2 and CHA2DS2-VASc scores and after 2 years the functional outcome, stroke recurrence, major cardiovascular events and mortality were assessed. ResultsAmong the 973 patients that were included in analysis, the mean age was 56.7 (SD 15.7) and 46.6% were female. There were 226 (23.2%), 365 (37.5%) and 382 (39.3%) patients with low, intermediate and high CHADS2 score, respectively. For CHADS2-VASc score there were 81 (8.3%), 268 (27.6%), and 624 (64.1%) patients with low, intermediate and high, respectively. Both high-risk scores were associated with middle-term poor functional outcome, stroke recurrence, major cardiovascular events and all-cause mortality. CHADS2 and CHA2DS2-VASc scores presented a high sensitivity and a high negative predictive value. CHA2DS2-VASc was more sensitive than CHADS2 score. ConclusionCHADS2 and CHA2DS2-VASc scores were both associated with stroke outcomes regardless of atrial fibrillation. These scores can be useful tools for the prognosis stratification of a patient with an ischemic stroke.

Abstract WP416: Preceding Therapeutic Anticoagulation in Patients With Atrial Fibrillation Reduces Both the Severity of Stroke and the Risk of In-Hospital Complications--Data From the Chinese Stroke Center Alliance (CSCA)

Objectives: To determine the association of preceding therapeutic anticoagulation with stroke severity and in-hospital complications. Method: All acute ischemic stroke patients with known history of AF, who were included into CSCA, were divided into five groups: not receiving any antithrombotic therapy, only antiplatelet therapy, receiving subtherapeutic warfarin (international normalized ratio [INR] &lt;2), receiving therapeutic warfarin (INR≥2) and receiving non-vitamin K antagonist oral anticoagulants (NOACs). Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS, a score ≥16 indicating moderate or severe stroke), and in-hospital complications included pneumonia, deep vein thrombosis, pulmonary embolism, seizures, hydrocephalus, urinary tract infections, hemorrhoids, depression, myocardial infarction and gastrointestinal bleeding. Results: Of 25 475 patients (mean [SD] age, 73.7 [10.6] years; 51.1% male), none were receiving NOACs, 438 (1.7%) were receiving therapeutic warfarin, 2 520 (9.9%) were receiving subtherapeutic warfarin, 5 847 (23.0%) were receiving antiplatelet therapy only, and 16 670 (65.4%) were not receiving any antithrombotic treatment before onset of stroke. Among 22 113 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 19 546 (88.4%) were neither receiving warfarin nor NOACs before stroke. After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, untheraputic warfarin, or antiplatelet therapy only was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.71 [0.53-0.93], 0.88 [0.78-0.99], and 0.87 [0.80-0.96], respectively) and in-hospital complications (adjusted odds ratio [95% CI], 0.79 [0.62-1.00], 0.88 [0.79-0.98], and 0.99 [0.91-1.07], respectively). Conclusions: Among Chinese patients with acute ischemic stroke and known history of atrial fibrillation, therapeutic anticoagulation was associated not only with lower odds of moderate or severe stroke but also with lower odds of in-hospital complications.

Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation

Antithrombotic therapies are effective in both primary and secondary stroke prophylaxis in high-risk patients with atrial fibrillation (AF), but they are often underused in community practice. To examine prestroke and poststroke antithrombotic treatment patterns and long-term outcomes in patients with AF presenting with ischemic stroke. A retrospective cohort study of Danish patients with AF, with a prestroke CHA2DS2-VASc score of 1 or higher for men and 2 or higher for women, and presenting with ischemic stroke was conducted from January 1, 2004, to January 31, 2017. Data on hospital admission, prescription fillings, and vital status were assessed using several Danish nationwide registries. Patients who survived 100 days after discharge were divided into 3 groups according to poststroke antithrombotic therapy: oral anticoagulation (OAC) therapy, antiplatelet therapy alone, or no antithrombotic therapy. Long-term outcomes (thromboembolic events and bleeding complications) were examined using multivariable Cox regression analyses across the 3 groups. Among 30 626 patients with AF admitted with ischemic stroke, 11 139 patients (36.3%) received OAC therapy (44.3% female; median age, 79 years [interquartile range, 73-85 years]), 11 874 (38.8%) received antiplatelet therapy alone (55.0% female; median age, 82 years [interquartile range, 75-88 years]), and 7613 (24.9%) received no antithrombotic therapy before stroke (53.8% female; median age, 80 years [interquartile range, 71-86 years]). Following stroke, 31.3% of those receiving antiplatelet therapy alone and 43.7% of those receiving no antithrombotic therapy before stroke shifted to OAC therapy. Yet, 37.5% of patients with stroke did not receive OAC therapy following stroke. However, OAC treatment rates increased over time. During a maximum of 10 years of follow-up, 17.5%, 21.2%, and 21.5% experienced a new thromboembolic event and 72.7%, 86.4%, and 86.2% died among those treated with OAC therapy, antiplatelet therapy, or no antithrombotic therapy, respectively. Poststroke OAC therapy was associated with lower risk of recurrent thromboembolic events (adjusted hazard ratio, 0.81; 95% CI, 0.73-0.89) and no significant difference in bleeding complications (adjusted hazard ratio, 0.97; 95% CI, 0.86-1.10), compared with no poststroke antithrombotic therapy. In contrast, there were no significant differences for those treated with poststroke antiplatelet therapy and no antithrombotic therapy. Patients with AF receiving poststroke OAC therapy had lower risk of recurrent thromboembolic events. Our findings suggest a substantial opportunity for improving primary and secondary stroke prophylaxis in high-risk patients with AF.

CHA2DS2–VASc score predicts short- and long-term outcomes in patients with acute ischemic stroke treated with intravenous thrombolysis

The CHA2DS2-VASc score is a validated tool to assess the thromboembolic risk in patients with atrial fibrillation. Pre-stroke CHA2DS2-VASc score may predict outcome in patients with acute ischemic stroke (AIS) without atrial fibrillation. The aim of this study was to investigate if the pre-stroke CHA2DS2-VASc score is able to predict short- and long-term outcomes in AIS patients treated with intravenous thrombolysis (IVT). The study group consisted of 256 consecutive patients admitted to the Udine University Hospital with AIS and underwent IVT between January 2015 to March 2017. The pre-stroke CHA2DS2-VASc score for each patient was calculated from the collected baseline data. Patients were classified into three groups according to their pre-stroke CHA2DS2-VASc score: a score of 0 of 1, a score of 2 or 3 and a score above 3. Primary outcome measures were: rate of favorable outcome at 90-days and at 1-year, and mortality at 90-days and at 1-year. Data on functional outcome and mortality 1year after stroke were collected in 165 patients (65% of the entire sample). Favorable outcome was defined as a modified Rankin Scale score ≤ 2. Compared with the CHA2DS2-VASc score 0-1 group, patients with higher CHA2DS2-VASc scores had a worse outcome and a higher mortality 3months and 1year after stroke. The diagnostic performance of the CHA2DS2-VASc score as judged with AUC-ROC was 0.70 (95% CI, 0.64-0.76; p < 0.001) for favorable outcome at 90-days, 0.78 (95% CI, 0.71-0.85; p < 0.001) for favorable outcome at 1-year, 0.71 (95% CI 0.61-0.79) for mortality at 90-days, 0.73 (95% CI 0.64-0.80; p < 0.001) for mortality at 1-year. Pre-stroke CHA2DS2-VASc score represents a good predictor for short- and long-term outcomes in AIS patients treated with IVT.

Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation

Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. Antithrombotic therapy before stroke. Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score ≥16 indicating moderate or severe stroke), and in-hospital mortality. Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0% women), 7176 (7.6%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥2) and 8290 (8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008 patients (83.6%) were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeutic warfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%) were receiving antiplatelet therapy only, and 28 583 (30.3%) were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 76 071 (83.5%) were not receiving therapeutic warfarin or NOACs before stroke. The unadjusted rates of moderate or severe stroke were lower among patients receiving therapeutic warfarin (15.8% [95% CI, 14.8%-16.7%]) and NOACs (17.5% [95% CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1% [95% CI, 26.6%-27.7%]), antiplatelet therapy only (24.8% [95% CI, 24.3%-25.3%]), or subtherapeutic warfarin (25.8% [95% CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality also were lower for those receiving therapeutic warfarin (6.4% [95% CI, 5.8%-7.0%]) and NOACs (6.3% [95% CI, 5.7%-6.8%]) compared with those receiving no antithrombotic therapy (9.3% [95% CI, 8.9%-9.6%]), antiplatelet therapy only (8.1% [95% CI, 7.8%-8.3%]), or subtherapeutic warfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, NOACs, or antiplatelet therapy was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.56 [0.51-0.60], 0.65 [0.61-0.71], and 0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95% CI], 0.75 [0.67-0.85], 0.79 [0.72-0.88], and 0.83 [0.78-0.88], respectively). Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.

Prestroke CHA2DS2-VASc Score and Severity of Acute Stroke in Patients with Atrial Fibrillation: Findings from RAF Study

The aim of this study was to investigate for a possible association between both prestroke CHA2DS2-VASc score and the severity of stroke at presentation, as well as disability and mortality at 90 days, in patients with acute stroke and atrial fibrillation (AF). This prospective study enrolled consecutive patients with acute ischemic stroke, AF, and assessment of prestroke CHA2DS2-VASc score. Severity of stroke was assessed on admission using the National Institutes of Health Stroke Scale (NIHSS) score (severe stroke: NIHSS ≥10). Disability and mortality at 90 days were assessed by the modified Rankin Scale (mRS <3 or ≥3). Multiple logistic regression was used to correlate prestroke CHA2DS2-VASc and severity of stroke, as well as disability and mortality at 90 days. Of the 1020 patients included in the analysis, 606 patients had an admission NIHSS score lower and 414 patients higher than 10. At 90 days, 510 patients had mRS ≥3. A linear correlation was found between the prestroke CHA2DS2-VASc score and severity of stroke (P = .001). On multivariate analysis, CHA2DS2-VASc score correlated with severity of stroke (P = .041) and adverse functional outcome (mRS ≥3) (P = .001). A logistic regression with the receiver operating characteristic graph procedure (C-statistics) evidenced an area under the curve of .60 (P = .0001) for severe stroke. Furthermore, a correlation was found between prestroke CHA2DS2-VASc score and lesion size. In patients with AF, in addition to the risk of stroke, a high CHA2DS2-VASc score was independently associated with both stroke severity at onset and disability and mortality at 90 days.

Abstract WP302: Atrial Fibrillation First Diagnosed at the Time of Ischemic Stroke: A Missed Opportunity

Introduction: Atrial fibrillation (AF) is a major cause of ischemic stroke. Individuals with undiagnosed AF lack the stroke risk reduction afforded by oral anticoagulant therapy. In 1983 Wolf documented that 24% (95% CI 14-37) of AF-related strokes had AF first diagnosed at the time of stroke. Given increased medical and lay attention to AF-stroke, we sought to determine whether this percentage had decreased in contemporary care. Hypothesis: Less than 20% of patients with AF-related stroke have their AF first diagnosed at the time of stroke. Methods: We identified patients admitted to Massachusetts General Hospital from 01-01-2010 to 12-31-2013 with a new ischemic stroke and either previously or newly diagnosed AF by searching comprehensive hospital databases for stroke and AF ICD-9 codes in conjunction with a hospital stroke registry. Physician reviewers screened 1037 potentially eligible patients, categorized AF as previously known or newly diagnosed, and performed a structured chart review of the stroke event. To confirm the diagnosis of AF was new, we conducted automated searches for AF terms in the patients’ electronic medical records (EMRs) prior to the stroke admission. Results: We validated 856 cases (83%) as AF and ischemic stroke. AF was considered newly diagnosed in 156/856 (18%; 95%CI: 16-21). In the newly diagnosed group, no patient was on oral anticoagulants and the strokes were consequential (median NIHSS=12; 60% with mRankin of ≥3 at discharge, including 15% deaths). Pre-stroke CHA 2 DS 2 -VASc score was ≥2 in 89%. About half (76/156) had a prior medical encounter in the EMR. Evidence of pre-stroke AF was found in 8/76 records, often peri-procedural, but the AF diagnosis was not carried forward. Conclusions: In this large, contemporary cohort, nearly one in five AF-related strokes occurred in patients who did not carry a pre-stroke AF diagnosis, similar to Wolf’s 1983 finding. The vast majority would have been at high enough pre-stroke risk to merit anticoagulation. Our findings support screening for AF in patients before they have strokes. Further, patients with past transient AF identified via automated EMR searches might merit more intensive screening.

CHADS&lt;sub&gt;2&lt;/sub&gt;, CHA&lt;sub&gt;2&lt;/sub&gt;DS&lt;sub&gt;2&lt;/sub&gt;-VASc, and R&lt;sub&gt;2&lt;/sub&gt;CHADS&lt;sub&gt;2&lt;/sub&gt; Scores Are Associated With 3-Month Functional Outcome of Stroke in Patients With Prior Coronary Artery Disease

Recent reports have shown that CHADS2 score can be applied to stroke risk in coronary artery disease (CAD) patients. This study evaluated the efficacy of CHADS2, CHA2DS2-VASc and R2CHADS2 scores as prognostic tools for stroke subsequent to CAD. We enrolled 159 consecutive patients with acute ischemic stroke who were (1) living independently before stroke; and (2) diagnosed with CAD before stroke. Comparisons were made between patients with poor and good 3-month functional outcome (modified Rankin scale ≥3 and <3, respectively) with regard to clinical characteristics and pre-stroke CHADS2, CHA2DS2-VASc and R2CHADS2 scores. Multivariate analysis was used to assess the predictive value of each of the 3 scores for poor outcome. The patients with poor and good outcomes had significant differences in intracranial artery stenosis (31.4% vs. 14.9%; P=0.016), carotid artery stenosis (41.9% vs. 23.9%; P=0.019), atrial fibrillation (37.2% vs. 17.9%; P=0.008), NIHSS (11 vs. 5; P<0.001), CHADS2 (3 vs. 2; P=0.004), CHA2DS2-VASc (5 vs. 4; P=0.003), and R2CHADS2 (3 vs. 3; P=0.005). Multivariate analysis showed that CHADS2 >2 (OR, 1.65; 95% CI: 1.05-2.65; P=0.032), CHA2DS2-VASc >4 (OR, 1.60; 95% CI: 1.02-1.78; P=0.042), and R2CHADS2 >3 (OR, 1.57; 95% CI: 1.01-2.49; P=0.049) positively predicted poor outcome. CHADS2, CHA2DS2-VASc and R2CHADS2 are useful in predicting functional status after stroke in CAD patients.

Pre-Stroke CHADS2 and CHA2DS2-VASc Scores Are Useful in Stratifying Three-Month Outcomes in Patients with and without Atrial Fibrillation

Background: CHADS₂ and CHA₂DS₂-VASc scores are validated tools for assessing stroke risk in patients with atrial fibrillation (AF). We investigated whether these scores are associated with 3-month stroke outcomes and evaluated the utility of these scores in stratifying 3-month stroke outcomes in both patients with and without AF. Methods: We analysed 6,612 acute ischaemic stroke patients from the Virtual International Stroke Trials Archive who received either placebo or ineffective active treatments not associated with significant cardiac complications. Outcomes included 3-month mortality, good functional outcomes defined as modified Rankin Scale score ≤1 and serious cardiac adverse events (SCAEs) defined as one of acute coronary syndrome, symptomatic heart failure, cardiopulmonary arrest, life-threatening arrhythmia and cardiac death. The association between the pre-stroke CHADS₂ and CHA₂DS₂-VASc scores and 3-month stroke outcomes was assessed using binary logistic regression. The utility of the two scores in estimating 3-month stroke outcomes was assessed using area under the receiver operator characteristic curves (AUC) and compared using the χ² test. Results: In this cohort, 26.5% had AF, 35.3% received IV tissue plasminogen activator (tPA), 17.7% died, 25.1% achieved good functional outcomes and 9.5% had ≥1 SCAE at 3 months. High-risk (≥2) pre-stroke CHADS₂ and CHA₂DS₂-VASc scores are both associated with 3-month mortality (CHADS₂: odds ratio, OR, 2.33, 95% confidence interval 1.81-3.00; CHA₂DS₂-VASc: OR 3.01, 2.00-4.80), good functional outcomes (CHADS₂: OR 0.47, 0.39-0.57; CHA₂DS₂-VASc: OR 0.55, 0.42-0.71) and SCAEs (CHADS₂: OR 1.76, 1.28-2.42; CHA₂DS₂-VASc: OR 2.69, 1.53-4.73) after adjusting for baseline differences in neurological impairment, tPA use and AF. The pre-stroke CHA₂DS₂-VASc score is better than the CHADS₂ score in estimating 3-month stroke outcomes in both patients with and without AF (p ≤ 0.005 in all AUC comparisons). High-risk pre-stroke CHA₂DS₂-VASc score has high sensitivity for mortality (AF: 0.96, 0.94-0.98; no AF: 0.88, 0.86-0.91) and negative predictive value for SCAE (AF: 0.93, 0.87-0.96; no AF: 0.96, 0.95-0.97) within 3 months. Low risk pre-stroke CHA₂DS₂-VASc score has high specificity for good functional outcome (AF: 0.99, 0.98-0.994; no AF: 0.94, 0.93-0.95) at 3 months. Conclusions: The pre-stroke CHA₂DS₂-VASc score appears to be a simple tool for identifying patients at lower risk of poor outcomes and serious cardiac complications within 3 months following ischaemic stroke in patients with and without AF.

The risk stratification based on the CHA2DS2-VASc may predict the response to intravenous thrombolysis after stroke

CHA2DS2-VASc score influences the outcome in stroke patients with or without atrial fibrillation (AF). We assessed whether the risk stratification based on the prestroke CHA2DS2-VASc score may predict the response to intravenous (IV) thrombolysis in stroke patients. We conducted an analysis on prospectively collected data of 516 consecutive AF and non-AF patients treated with IV thrombolysis. Outcome measures were major improvement (NIH Stroke Scale [NIHSS] ≤8 points from baseline or NIHSS score 0) and deterioration (death or NIHSS ≥1 points from baseline) or no improvement (NIHSS score equivalent to baseline) at 24 h; excellent (modified Rankin Scale [mRS] score ≤1) and unfavorable outcome (mRS score >2) at 3 months. Multivariate analysis showed that ORs for major improvement and excellent outcome were lower in patients with intermediate risk (CHA2DS2-VASc = 1) (OR 0.39, 95 % CI 0.16-0.92, p = 0.032; OR 0.10, 95 % CI 0.02-0.56, p = 0.009), moderately high risk (CHA2DS2-VASc = 2) (OR 0.43, 95 % CI 0.19-0.96, p = 0.040; OR 0.16, 95 % CI 0.03-0.76, p = 0.022), and very high risk (CHA2DS2-VASc > 3) (OR 0.31, 95 % CI 0.15-0.65, p = 0.002; OR 0.17, 95 % CI 0.04-0.81, p = 0.026), whereas ORs for deterioration or no improvement and unfavorable outcome were higher only in patients with very high risk (OR 4.26, 95 % CI 1.24-14.65, p = 0.021; OR 9.26, 95 % CI 1.15-74.65, p = 0.037), compared with low risk (CHA2DS2-VASc = 0). Low-risk level based on the prestroke CHA2DS2-VASc score was predictor of effective response to IV thrombolysis. Very high-risk level was predictor of failed response, compared with low-risk level.

CHADS 2 , CHA 2 DS 2 -VASc, and long-term stroke outcome in patients without atrial fibrillation

CHADS2 and CHA2DS2-VASc scores are used to assess stroke risk in patients with atrial fibrillation (AF). We investigated whether these scores are associated with stroke outcome in non-AF stroke patients. Consecutive patients with acute first-ever ischemic stroke but without AF were classified into subgroups according to prestroke CHADS2 and CHA2DS2-VASc scores and followed up for 5 years. The end points were death, stroke recurrence, and a composite of major cardiovascular events. Among 1,756 patients (aged 67.2 ± 12.3 years, 68.2% males), there were 258 (14.7%), 617 (35.3%), and 878 (50.0%) patients with low, intermediate, and high CHADS2 score, respectively. The corresponding figures for CHA2DS2-VASc subgroups were 110 (6.3%), 255 (14.5%), and 1,391 (79.2%). There were significant differences between CHADS2 subgroups in 5-year mortality (log-rank test = 74.5, p < 0.0001), stroke recurrence (log-rank test = 12.3, p = 0.002), and cardiovascular events (log-rank test = 19.4, p < 0.001). Similarly, there were significant differences between CHA2DS2-VASc subgroups in 5-year mortality (log-rank test = 74.5, p < 0.0001), stroke recurrence (log-rank test = 10.6, p = 0.005), and cardiovascular events (log-rank test = 16.4, p < 0.001). Compared with the low-risk group, patients in intermediate- and high-risk CHADS2 subgroups had higher 5-year mortality (hazard ratio [HR]: 2.22 [95% confidence interval {CI}: 1.78-2.77] and 3.66 [95% CI: 2.38-5.62], respectively), stroke recurrence (HR: 1.74 [95% CI: 1.09-2.79] and 1.71 [95% CI: 1.08-2.71], respectively), and cardiovascular events (HR: 1.78 [95% CI: 1.23-2.57] and 1.86 [95% CI: 1.30-2.67], respectively). Compared with the low-risk group, patients in the high-risk CHA2DS2-VASc subgroup also had higher 5-year mortality (HR: 3.56, 95% CI: 1.89-6.70), stroke recurrence (HR: 2.93, 95% CI: 1.30-6.61), and cardiovascular events (HR: 2.71, 95% CI: 1.49-4.95). Prestroke CHADS2 and CHA2DS2-VASc scores predict long-term stroke outcomes in non-AF patients with acute ischemic stroke. These scores may provide a simple way of stroke prognostic risk stratification among non-AF stroke patients.