Stroke Risk Assessment Tools Research Articles

Diagnosis and management of atrial fibrillation in primary care: a case study

This critically reflective case study will look at a 65-year-old male presenting with dyspnoea and an incidental diagnosis of atrial fibrillation (AF) in a primary care setting. The article critically analyses the diagnosis and management of the patient, considers potential differential diagnoses, current guidelines, and areas for service improvement. The author, a trainee advanced clinical practitioner (ACP) prescriber with a paramedic background, discusses the complexity of managing AF and the need for collaboration with a general practitioner. AF is a common cardiac arrhythmia associated with a significantly increased risk of stroke. The primary focus of AF management is stroke prevention. This article delves into the pathophysiology of AF, discussing its various causes and classifications, emphasising the role of left atrial appendage (LAA) in stroke risk. The limitations of AF screening methods, especially for paroxysmal AF, are also discussed. Recent advancements in opportunistic screening, including the use of artificial intelligence (AI) and smartwatches, show promise but require further research and validation. This article explores stroke risk assessment tools like CHA2DS2VASc and ATRIA, bleeding risk assessment using HAS-BLED and ORBIT scores, as well as rhythm control in newly diagnosed AF cases. Finally, the importance of lifestyle modifications and regular patient follow-up are underscored. AF diagnosis and management are multifaceted, involving stroke prevention, rate or rhythm control, and lifestyle modifications. Technological advancements hold promise in improving early AF detection. Collaborative efforts between healthcare providers and adherence to current guidelines are crucial in achieving optimal patient outcomes, while future practice may benefit from enhanced diagnostic screening and treatment options as further research unfolds.

Pulmonary hypertension: An unexplored risk factor for stroke in patients with atrial fibrillation

BackgroundAtrial fibrillation (Afib) is one of the most common and significant risk factors for stroke, with the CHADsVAsc score used as the tool for stroke risk assessment. Pulmonary hypertension (PH) has not been studied as an independent risk factor for stroke in individuals with Afib. MethodsIn this retrospective case-control study, National Inpatient Sample Database was used to sample individuals with atrial fibrillation, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data, age under 18, history of thromboembolic diseases, or stroke were excluded. Greedy propensity matching using R was performed to match patients with and without PH on age, race, gender, and 19 other comorbidities, including anticoagulation use. Binary logistic regression was performed after matching to assess whether PH was an independent risk factor for stroke. A p-value of <0.05 was considered statistically significant. ResultsOf the 2,421,545 patients included in the study, 158,545 (6.5%) had PH. PH patients were more likely to be elderly, females, and smokers. Comorbidities were more common in the PH group. Patients with PH were more likely to have an ischemic stroke (3.6% vs. 2.9%, p<0.001), hemorrhagic stroke (2.2% vs. 0.7%, p<0.001), and transient ischemic attack (TIA) (2.3% vs. 0.7%, p<0.001). After matching, the presence of PH was associated with increased ischemic stroke (OR: 1.2 [1.1-1.2]; p<0.001), hemorrhagic stroke (OR: 2.4 [2.1-2.6]; p<0.001) and TIA (OR: 2.2 [2.0-2.4]; p<0.001). PH patients also had increased length of stay (β = 0.8; p<0.001) mortality (OR: 1.1 [1.0-1.2]; p<0.001). ConclusionApart from demonstrating the deleterious effect of PH on mortality and length of hospital stay, this study is the first to report on such a large scale that PH independently increases the incidence of all types of strokes in patients with Afib.

Development of rapid and effective risk prediction models for stroke in the Chinese population: a cross-sectional study

ObjectivesThe purpose of this study was to use easily obtained and directly observable clinical features to establish predictive models to identify patients at increased risk of stroke.Setting and participantsA total...

Machine learning provides evidence that stroke risk is not linear: The non-linear Framingham stroke risk score.

Current stroke risk assessment tools presume the impact of risk factors is linear and cumulative. However, both novel risk factors and their interplay influencing stroke incidence are difficult to reveal using traditional additive models. The goal of this study was to improve upon the established Revised Framingham Stroke Risk Score and design an interactive Non-Linear Stroke Risk Score. Leveraging machine learning algorithms, our work aimed at increasing the accuracy of event prediction and uncovering new relationships in an interpretable fashion. A two-phase approach was used to create our stroke risk prediction score. First, clinical examinations of the Framingham offspring cohort were utilized as the training dataset for the predictive model. Optimal Classification Trees were used to develop a tree-based model to predict 10-year risk of stroke. Unlike classical methods, this algorithm adaptively changes the splits on the independent variables, introducing non-linear interactions among them. Second, the model was validated with a multi-ethnicity cohort from the Boston Medical Center. Our stroke risk score suggests a key dichotomy between patients with history of cardiovascular disease and the rest of the population. While it agrees with known findings, it also identified 23 unique stroke risk profiles and highlighted new non-linear relationships; such as the role of T-wave abnormality on electrocardiography and hematocrit levels in a patient’s risk profile. Our results suggested that the non-linear approach significantly improves upon the baseline in the c-statistic (training 87.43% (CI 0.85–0.90) vs. 73.74% (CI 0.70–0.76); validation 75.29% (CI 0.74–0.76) vs 65.93% (CI 0.64–0.67), even in multi-ethnicity populations. The clinical implications of the new risk score include prioritization of risk factor modification and personalized care at the patient level with improved targeting of interventions for stroke prevention.

Abstract 153: Novel Machine Learning Proves Stroke Risk is Not Linear

Background: Current stroke risk assessment tools presume the impact of risk factors is linear and cumulative. However, both novel risk factors and their interplay influencing stroke incidence are difficult to reveal using traditional linear models. Objective: To improve upon the Revised-Framingham Stroke Risk Score and design an interactive non-linear Stroke Risk Score (NSRS). Our work aimed at increasing the accuracy of event prediction and uncovering new relationships in an interpretable user-friendly fashion. Methods: A two phase approach was used to develop our stroke risk score predictor. First, clinical examinations of the Framingham offspring cohort were utilized as the training dataset for the predictive model consisting of 14,196 samples where each clinical examination was considered an independent observation. Optimal Classification Trees (OCT) were used to train a model to predict 10-year stroke risk. Second, this model was validated with 17,527 observations from the Boston Medical Center. The NSRS was developed into an online user friendly application in the form of a questionnaire (http://www.mit.edu/~agniorf/files/questionnaire_Cohort2.html). Results: The algorithm suggests a key dichotomy between patients with or without history of cardiovascular disease. While the model agrees with known findings, it also identified 23 unique stroke risk profiles and introduced new non-linear relationships; such as the role of T-wave abnormality on electrocardiography and hematocrit levels in a patient’s risk profile. Our results in both the training and validation populations suggested that the non-linear approach significantly improves upon the existing revised Framingham stroke risk calculator in the c-statistic (training 87.43% (CI 0.85-0.90) vs. 73.74% (CI 0.70-0.76); validation 75.29% (CI 0.74-0.76) vs 65.93% (CI 0.64-0.67), even in multi-ethnicity populations. Conclusions: We constructed a highly predictive, interpretable and user-friendly stroke risk calculator using novel machine-learning uncovering new risk factors, interactions and unique profiles. The clinical implications include prioritization of risk factor modification and personalized care improving targeted intervention for stroke prevention.

AN EVALUATION OF PRACTITIONERS' PREFERENCE OF STROKE RISK TOOLS IN NONVALVULAR ATRIAL FIBRILLATION: CHA2DS2VASC VERSUS CHADS2

Several stroke risk assessment tools exist. However, current nonvalvular atrial fibrillation (NVAF) guidelines differ in utilization of these tools. For instance, the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines recommend use of the

Web-based accurate measurements of carotid lumen diameter and stenosis severity: An ultrasound-based clinical tool for stroke risk assessment during multicenter clinical trials

BackgroundThis pilot study presents a completely automated, novel, smart, cloud-based, point-of-care system for (a) carotid lumen diameter (LD); (b) stenosis severity index (SSI) and (c) total lumen area (TLA) measurement using B-mode ultrasound. The proposed system was (i) validated against manual reading taken by the Neurologist and (ii) benchmarked against the commercially available system. MethodOne hundred patients (73 M/27 F, mean age: 68 ± 11 years), institutional review board approved, written informed consent, consisted of left/right common carotid artery (200 ultrasound scans) were acquired using a 7.5-MHz linear transducer. ResultsThe measured mean LD for left and right carotids were (in mm): (i) for proposed system (6.49 ± 1.77, 6.66 ± 1.70); and (ii) for manual (6.29 ± 1.79, 6.45 ± 1.63), respectively and coefficient of correlation between cloud-based automated against manual were 0.98 (P < 0.0001) and 0.99 (P < 0.0001), respectively. The corresponding TLA error, Precision-of-Merit, and Figure-of-Merit when measured against the manual were: 4.56 ± 3.54%, 96.18 ± 3.21%, and 96.85%, respectively.The AUC for the receiving operating characteristics for the cloud-based system was: 1.0. Four statistical tests such as: Two-tailed z-test, Mann-Whitney test, Kolmogorov-Smirnov (KS) and one-way ANOVA were performed to demonstrate consistency and reliability. ConclusionsThe proposed system is reliable, accurate, fast, completely automated, anytime-anywhere solution for multi-center clinical trials and routine vascular screening.

CHA2DS2-VASc Calculations in Patients with Atrial Fibrillation receiving oral anticoagulants in Scotland: an analysis of linked administrative data

ABSTRACT&#x0D; ObjectivesPatients with atrial fibrillation (AF) have an increased risk of developing stroke, and oral anticoagulants (OACs) are commonly used in stroke prevention. The CHA2DS2-VASc score has been proved to be a simple and effective tool for stroke risk assessment which guides the selection of treatment with OACs. This score is calculated using disease diagnoses; however, a range of different versions exist, making comparability questionable.&#x0D; The aim of this study was to compare CHA2DS2-VASc scores in OAC treated patients with a hospital-confirmed diagnosis of AF in Scotland using different subsets of ICD-10 codes.&#x0D; Approach This is a retrospective study, covering AF patients in Scotland who received at least one prescription for any OAC between January 2009 and June 2014. The Prescribing Information System (PIS) was used to identify patients with OAC prescriptions, while the Scottish Morbidity Records (SMR) provided patients’ diagnoses. Different sets of ICD-10 codes, using varying definitions, were used to classify the stroke risk in AF patients in order to account for heterogenous definitions applied in previously published studies. The main differences in codes used were the inclusion or exclusion of unclassified stroke (ICD-10 code I64), and the inclusion of pulmonary embolism (PE) (I26) as either “prior thromboembolic event” or “vascular disease”.&#x0D; ResultsIn our study, a cohort of 71012 AF patients with OAC prescription were analysed. Using narrow disease definitions, 18.15% of patients were categorised as being at low risk of stroke (score 0-1), 74.80% at medium risk (score 2-5), and 7.04% at high risk (score 6-9). With an extended disease definition, including PE in “prior thromboembolic event”, 14.81% of patients were at low risk (score 0-1), 72.60% at medium risk (score 2-5), and 12.59% at high risk (score 6-9); while including PE in “vascular disease”, 14.99% of the patients had a score 0-1, 73.54% a score 2-5, and 11.48% a score 6-9.&#x0D; Conclusion The change in score definitions makes a difference mainly in the number of patients categorised as very low risk or high risk. Standardisation in ICD-10 code definition of risk diseases could be useful in order to make the results comparable from different studies and further evaluate OAC choice according to risk group.

Analysis of Cerebral Vascular Lesion Pools in Ischemic Stroke Based on the Analysis and the Prognostic Assessment of Risk Factors in Patients with Primary and Recurrent Ischemic Stroke

Stroke is an important medical and social problem, and stroke risk assessment tools have difficulty on the interaction of risk factors and the effects of certain risk factors with analysis by age, gender, race, because this information fully available to global risk assessment tools. In addition, these tools tend to be focused and usually do not include the entire range of possible factors contributing. The aim of the study was to conduct a comparison of brain vascular lesions pool with ischemic stroke (II) based predictive analysis and assessment of the main risk factors in patients with primary and recurrent ischemic stroke. Prognostically significant risk factors for recurrent ischemic stroke is not effective antihypertensive therapy, multiple stenoses any one pool vascular brain, duration of hypertension (AH) over 5 years and regular smoking patients (p&lt;0.001). In the initial localization in the second vertebrobasilar recurrent stroke was significantly (p&lt;0.05) more developed in the same pool in women than in men; and the localization of the primary carotid AI in the pool, re-developed stroke often unreliable in the same pool in women than in men.

Practical Considerations for the Use of Direct Oral Anticoagulants in Patients With Atrial Fibrillation.

Atrial fibrillation (AF) is a significant risk factor for stroke and peripheral thromboembolic events (TEs). Preventing blood clots in the heart to reduce stroke and TE risk is a key goal of AF therapy. Traditional stroke risk assessment tools for patients with nonvalvular AF include the CHADS2 and CHA(2)DS(2)-VASc scores, while long-term outcome data with the newer direct oral anticoagulants (DOACs) are emerging. The goals of this review were to assess traditional therapies and existing treatment guidelines and to discuss key pharmacologic properties of the DOACS, noting how these may benefit at-risk patients with AF. This narrative review was developed on the basis of the authors' clinical knowledge, extensive reading of the literature, and broad pharmacy experience in the management of patients with AF. Limitations of oral vitamin K antagonists (VKAs) include slow onset of action, the need for regular monitoring of their anticoagulation effect, significant food and drug interactions, and unpredictable dose-response properties. Key clinical trial data led to the approvals of apixaban, dabigatran etexilate, edoxaban, and rivaroxaban in the United States to reduce the risk of stroke and systemic embolism in patients with nonvalvular AF. With predictable pharmacologic properties and limited drug and/or dietary interactions, the DOACs offer several benefits over traditional oral anticoagulation therapy with VKA. However, they have limitations, including the absence of immediate reversal agents and limited options for monitoring their anticoagulation effects in clinical practice. As experience with the use of DOACs grows, optimized treatment regimens and improved patient care are expected.

P094: The frequency of stroke risk assessment tools used to assess patients presenting to the emergency department with atrial fibrillation and flutter

Introduction: Acute atrial fibrillation or flutter (AFF) is the most common dysrhythmia managed in the emergency department (ED). A key component of managing AFF in the ED is the prevention of stroke. Predictive indices (e.g., CHADS2 , HAS-BLED) should be used to assess each patient’s risk of stroke and bleeding to determine the appropriate anticoagulation therapy. The frequency of use of these predictive indices in the emergency department to determine appropriate anticoagulation therapy remains unclear. This systematic review is designed to examine the use of risk scores in the ED to determine the management of patients presenting to the ED for atrial fibrillation and flutter. Methods: An extensive search of eight electronic databases and grey literature was conducted. Quasi-experimental studies were eligible for inclusion. Studies had to report on the ED management of adult patients presenting with AFF to be included. Two independent reviewers judged the relevance, inclusion, and risk of bias of the studies. Individual and pooled statistics were calculated as odds ratios (OR) with 95% CI using a random effects model and heterogeneity (I2) was reported. Results: From 1,648 citations, 37 studies were included in this review. Heterogeneity was very high, precluding pooling. Only one of the included studies documented the use of CHADS2 scores by attending physicians; while no studies documented the use of HAS-BLED. There was variability in the ED management strategies of AFF. The utilization of rhythm control in the treatment of AFF ranged considerable (OR: 0.04-9.84) in comparison to rate control. Of the 17 studies reporting cardioversion approaches, chemical (9 {53%}) cardioversion was the most common management strategy of AFF. Conclusion: Our results suggests that either few physicians are documenting stroke risk scores in adult patients with AFF, or that research studies assessing ED management of AFF are not reporting scores documented by the attending physicians. Future research needs to examine the use of stroke risk scores to determine the optimal and appropriate care for patients.

Abstract 164: Comparison Between Transcranial Doppler and Functional MRI With Breath Holding Test for Cerebral Vasoreactivity Assessment in Patients with Carotid Stenosis

Background: Impaired cerebral vasoreactivity (CVR) detected by Transcranial Doppler (TCD) is predictive of stroke in patients with carotid stenosis. Functional MRI (fMRI) can evaluate CVR either. Few studies have compared both methods for CVR assessment already. However, none of them used breath holding test (BHT) as the vasodilatory stimulus. Objectives: To assess CVR through BHT using TCD and fMRI in patients with carotid stenosis and controls in order to verify whether fMRI can detect any difference on BOLD-signal intensities between these groups. Additionally, we aimed to verify if fMRI can discriminate correctly any subject with impaired CVR as compared to TCD. Methods: Fifteen patients with carotid stenosis defined as stenosis ≥50% by angiography or ≥70% by ultrasound or ≥70% by CTA or MRA (11men;52-90yo;mean:67.7yo) and 7 matched-controls (5men:51-85yo;mean:64.6yo) performed BHT during TCD. Impaired CVR was diagnosed if mean percentage increase of MCA velocities ≤31% on 3-consecutive intervals of 30s of apnea intercalated by 4-minute-interval of normal breathing. During fMRI, BHT was performed using a traffic lights-based code for instruction on when it was time to stop breathing and was composed by 3-consecutive intervals of 24s of apnea intercalated by 4-minute-intervals of normal breathing. BOLD-signal intensity was measured in the lentiform nucleus ipsilateral to the carotid stenosis. In controls, the mean signal intensity of both lentiform nuclei was considered. Results: Patients and controls showed significantly different BOLD-signal intensities (p:0,0053). Based on CVR defined by TCD, there was an agreement between TCD and fMRI of 6/7 (85,7%) in controls, 11/15 (73.3%) in patients, and 17/22 (77,2%) overall. Conclusion: fMRI showed different BOLD signal intensities in patients and controls using BHT as the vasodilatory stimulus for CVR assessment. Additionally, there was a good agreement between fMRI and TCD on detecting patients with impaired CVR. Further studies are needed to evaluate whether impaired CVR on fMRI with BHT is predictive of stroke in patients with carotid stenosis, but these results suggest that fMRI may be a potentially useful tool for stroke risk assessment in clinical practice.

Safe use of antithrombotics for stroke prevention in atrial fibrillation: consideration of risk assessment tools to support decision-making.

Clinical guidelines advocate stroke prevention therapy in atrial fibrillation (AF) patients, specifically anticoagulation. However, the decision to initiate treatment is based on the risk (bleeding) versus benefit (prevention of stroke) of therapy, which is often difficult to assess. This review identifies available risk assessment tools to facilitate the safe and optimal use of antithrombotic therapy for stroke prevention in AF. Using key databases and online clinical resources to search the literature (1992-2012), 19 tools have been identified and published to date: 11 addressing stroke risk, 7 addressing bleeding risk and 1 integrating both risk assessments. The stroke risk assessment tools (e.g. CHADS2, CHA2DS2-VASc) share common risk factors: age, hypertension, previous cerebrovascular attack. The bleeding risk assessment tools (e.g. HEMORR2HAGES, HAS-BLED) share common risk factors: age, previous bleeding, renal and liver impairment. In terms of their development, six of the stroke risk assessment tools have been derived from clinical studies, whilst five are based on refinement of existing tools or expert consensus. Many have been evaluated by prospective application to data from real patient cohorts. Bleeding risk assessment tools have been derived from trials, or generated from patient data and then validated via further studies. One identified tool (i.e. Computerised Antithrombotic Risk Assessment Tool [CARAT]) integrates both stroke and bleeding, and specifically considers other key factors in decision-making regarding antithrombotic therapy, particularly those increasing the risk of medication misadventure with treatment (e.g. function, drug interactions, medication adherence). This highlights that whilst separate tools are available to assess stroke and bleeding risk, they do not estimate the relative risk versus benefit of treatment in an individual patient nor consider key medication safety aspects. More effort is needed to synthesize these separate risk assessments and integrate key medication safety issues, particularly since the introduction of new anticoagulants into practice.

Relationship of Indices of Inflammation and Thrombogenesis to Arrhythmia Burden in Paroxysmal Atrial Fibrillation

Atrial fibrillation (AF) is associated with a high risk of stroke. The contribution of arrhythmia to events is clear in sustained forms of AF, but in paroxysmal AF, presently available data have yet to identify what proportion of time spent in AF (ie, arrhythmia burden [AFB]) is of clinical relevance. We aimed to assess this relationship using surrogate blood markers for the hypercoagulable state associated with AF. One hundred twenty-one consecutive outpatients (mean age 74.7 +/- 7.8 years; 73 [60.3%] men) with pacemakers capable of arrhythmia detection were recruited. AFB was assessed over a 1-month period and classified as AFB = 0%, 0.1% to 10%, 10.1% to 50%, or > 50%. Baseline characteristics and comorbidities were comparable between groups. There were no significant differences in levels of soluble E-selectin (sE-selectin), von Willebrand factor (vWf), high-sensitivity C-reactive protein, interleukin-6, soluble P-selectin (sP-selectin), or tissue factor (TF) across the four patient groups. Levels of plasma brain natriuretic peptide (BNP) were approximately twofold greater in the group with the highest AFB (P < .001). Following a stepwise multiple linear regression analysis, age was a significant predictor of vWf (P = .010), sP-selectin (P = .042), and BNP (P = .012). Left ventricular fractional shortening was predictive of BNP (P = .001) and sE-selectin (P = .012). Anticoagulation was a predictor of vWf levels (P = .005), and hypertension was predictive of TF (P < .001). Given no appreciable difference in levels of prothrombotic markers in relation to AFB in this study, it is plausible that these abnormalities do, in fact, relate to underlying risk factors, and that such patients should be anticoagulated if risk factors dictate. Thus, AFB per se should probably not influence the decision to anticoagulate, but rather the presence of AF combined with clinical risk scoring should remain the predominant tool for stroke risk assessment.