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Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack
S Claiborne Johnston1, Peter M Rothwell, Mai N Nguyen-Huynh
1Stroke Service, Department of Neurology, University of California, San Francisco, CA 94143-0114, USA. clay.johnston@ucsfmedctr.org
Insights
This study validates existing stroke risk scores after transient ischemic attack (TIA) and introduces the ABCD(2) score for improved 2-day stroke prediction, aiding urgent patient management.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Public Health
Background:
- Transient ischemic attack (TIA) poses an early risk of stroke, necessitating accurate prognostic tools.
- Existing scores for predicting early stroke risk after TIA require validation in diverse populations.
- Optimizing emergency management of TIA patients depends on reliable risk stratification.
Purpose of the Study:
- To validate existing prognostic scores for early stroke risk following TIA.
- To derive and validate a unified score (ABCD(2)) for predicting 2-day stroke risk.
- To inform emergency management strategies for TIA patients based on refined risk assessment.
Main Methods:
- Validation of California and ABCD scores in 2893 TIA patients across US and UK cohorts.
- Quantification of prognostic value using c statistics.
- Derivation of a unified ABCD(2) score using logistic regression on 1916 patients.
Main Results:
- Existing scores showed similar predictive performance (c statistics 0.60-0.81) for 2, 7, and 90-day stroke risks.
- The unified ABCD(2) score, based on age, blood pressure, clinical features, duration, and diabetes, demonstrated improved prediction (c statistics 0.62-0.83).
- ABCD(2) classified patients into low (1.0% 2-day risk), moderate (4.1%), and high (8.1%) risk categories.
Conclusions:
- Existing TIA prognostic scores validate well across independent cohorts.
- The unified ABCD(2) score offers enhanced predictive accuracy for early stroke risk after TIA.
- Immediate evaluation for high-risk patients is crucial for optimizing stroke prevention.
Background:
We aimed to validate two similar existing prognostic scores for early risk of stroke after transient ischaemic attack (TIA) and to derive and validate a unified score optimised for prediction of 2-day stroke risk to inform emergency management.
Methods:
The California and ABCD scores were validated in four independent groups of patients (n=2893) diagnosed with TIA in emergency departments and clinics in defined populations in the USA and UK. Prognostic value was quantified with c statistics. The two groups used to derive the original scores (n=1916) were used to derive a new unified score based on logistic regression.
Findings:
The two existing scores predicted the risk of stroke similarly in each of the four validation cohorts, for stroke risks at 2 days, 7 days, and 90 days (c statistics 0.60-0.81). In both derivation groups, c statistics were improved for a unified score based on five factors (age >or=60 years [1 point]; blood pressure >or=140/90 mm Hg [1]; clinical features: unilateral weakness [2], speech impairment without weakness [1]; duration >or=60 min [2] or 10-59 min [1]; and diabetes [1]). This score, ABCD(2), validated well (c statistics 0.62-0.83); overall, 1012 (21%) of patients were classified as high risk (score 6-7, 8.1% 2-day risk), 2169 (45%) as moderate risk (score 4-5, 4.1%), and 1628 (34%) as low risk (score 0-3, 1.0%).
Implications:
Existing prognostic scores for stroke risk after TIA validate well on multiple independent cohorts, but the unified ABCD(2) score is likely to be most predictive. Patients at high risk need immediate evaluation to optimise stroke prevention.
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