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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Modifications of the ABCD2 score do not improve the risk stratification of transient ischemic attack patients
Jonathan M Raser1, Brett L Cucchiara
1Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
Insights
Modified ABCD2 scores for predicting stroke risk did not improve accuracy. Minor changes in risk categories were observed, and the predictive value remained similar to the standard score.
Area of Science:
- Neurology
- Emergency Medicine
- Cardiology
Background:
- The ABCD2 score is used to predict stroke risk after transient ischemic attack (TIA).
- Modifications incorporating hypertension history, hyperglycemia, and blood pressure (BP) timing have been proposed to enhance prediction.
- Emergency department (ED) triage hypertension may affect initial BP measurements.
Purpose of the Study:
- To evaluate the predictive value of modified ABCD2 scores compared to the standard score.
- To assess the impact of incorporating additional factors and timing of BP measurements on risk reclassification.
Main Methods:
- Compared standard ABCD2 score with modified versions using different combinations of factors (hypertension, hyperglycemia, BP elevation, diabetes history).
- Assessed reclassification rates into alternate risk categories (low, moderate, high).
- Evaluated predictive performance using c-statistics for stroke, death, or high-risk TIA.
Main Results:
- Modified ABCD2 scores resulted in minimal patient reclassification (2-10%) and did not improve predictive performance (c-statistics 0.61-0.65 vs. 0.63 for standard).
- ED triage hypertension was common, but using a second BP measurement did not significantly reclassify patients or improve score performance (c-statistic 0.61).
Conclusions:
- Modifications to the ABCD2 score did not substantially alter risk categories for most patients.
- The overall predictive value of the ABCD2 score was not improved by the tested modifications.
Background:
Modifications to the age, blood pressure, clinical symptoms, duration of symptoms, and diabetes (ABCD2) score, which incorporate history of hypertension and acute hyperglycemia in addition to acute blood pressure (BP) elevation and history of diabetes, have been proposed to increase the predictive value of the score. In addition, the timing of acute BP measurement may be important in the emergency department (ED) setting, given the phenomenon of "ED triage hypertension".
Methods:
The standard ABCD2 score was compared to modified scores incorporating various combinations of acute BP elevation or hyperglycemia, history of hypertension or diabetes, and subsequent versus initial ED BP measurements. The number of patients reclassified into an alternate risk category (low/moderate/high) with different schemes was determined. Predictive value using the composite outcome of stroke, death, or high-risk transient ischemic attack mechanism was assessed using c statistics.
Results:
Modified ABCD2 scores resulted in few patients shifting risk categories (between 2% and 10% for six alternate schemes), and did not improve the performance of the ABCD2 score (c-statistics, 0.61-0.65, compared to 0.63 for the standard score). ED triage hypertension was frequent (mean systolic blood pressure [SBP]/diastolic blood pressure [DBP] decrease of 8/9 mm Hg on subsequent measurement; P < .001), but the use of second BP did not reclassify many patients (10%) nor did it improve score performance (c-statistic, 0.61).
Conclusions:
Modifications of the ABCD2 score changed the risk category for few patients and did not improve the overall predictive value of the score.
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