Prediction of recurrent stroke among ischemic stroke patients with atrial fibrillation: Development and validation of a risk score model

Abstract

Background There is currently no validated risk prediction model for recurrent events among patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). Considering that the application of conventional risk scores has contextual limitations, new strategies are needed to develop such a model. Here, we set out to develop and validate a comprehensive risk prediction model for stroke recurrence in AIS patients with AF. Methods AIS patients with AF were collected from multicenter registries in South Korea and Japan. A developmental dataset was constructed with 5648 registered cases from both countries for the period 2011‒2014. An external validation dataset was also created, consisting of Korean AIS subjects with AF registered between 2015 and 2018. Event outcomes were collected during 1 year after the index stroke. A multivariable prediction model was developed using the Fine–Gray subdistribution hazard model with non-stroke mortality as a competing risk. The model incorporated 21 clinical variables and was further validated, calibrated, and revised using the external validation dataset. Results The developmental dataset consisted of 4483 Korean and 1165 Japanese patients (mean age, 74.3 ± 10.2 years; male 53%); 338 patients (6%) had recurrent stroke and 903 (16%) died. The clinical profiles of the external validation set (n = 3668) were comparable to those of the developmental dataset. The c-statistics of the final model was 0.68 (95% confidence interval, 0.66 ‒0.71). The developed prediction model did not show better discriminative ability for predicting stroke recurrence than the conventional risk prediction tools (CHADS2, CHA2DS2-VASc, and ATRIA). Conclusions Neither conventional risk stratification tools nor our newly developed comprehensive prediction model using available clinical factors seemed to be suitable for identifying patients at high risk of recurrent ischemic stroke among AIS patients with AF in this modern direct oral anticoagulant era. Detailed individual information, including imaging, may be warranted to build a more robust and precise risk prediction model for stroke survivors with AF.

Covert Brain Infarction as a Risk Factor for Stroke Recurrence in Patients With Atrial Fibrillation

“…25,26 However, we should acknowledge that the use of our extensive clinical database failed to improve the limited predictability of the convention risk prediction models for stroke recurrence in AF. 3 Neuroimaging parameters other than CBI could be considered in estimating the risk of stroke recurrence in AIS patients with AF. Furthermore, as brain MRI is widely used in the elderly population without stroke for various purposes, the role of CBI in stroke risk estimation for AF in general population should be explored more extensively.…”

David G. Sherman Lecture Award: 15-Year Experience of the Nationwide Multicenter Stroke Registry in Korea

“…A list of collaborations in the CRCS-K is presented in Figure 5. [46][47][48][49][50] with those who wish to seek evidence to improve stroke outcomes and share knowledge.…”

Rekürren İskemik İnme / Geçici İskemik Atak ile Atriyal Fibrilasyon İlişkisi

“…Atriyal fibrilasyonu ve akut iskemik inmesi olan hastalarda, inme rekürrensi için prediktif bir model yoktur. Bu risk faktörlerini saptamaya yönelik bir oldukça yeni bir çalışmada da ne CHA2DS2Vasc skoru, ATRİA skoru gibi araçların, ne de klinik faktörlerin kullanıldığı yeni geliştirilen prediktif modelin inme rekürrensi yüksek hastaları tahmin etmede uygun olmadığı gösterilmiştir 6 . Çalışmamız kronik AF zemininde rekürren inme geçiren hastalar ile rekürrens sonrası AF saptanmış ya da hiç AF saptanmamış hastaları karşılaştırması açısından değerlidir.…”

“…Atriyal fibrilasyonu ve akut iskemik inmesi olan hastalarda, inme rekürrensi için prediktif bir model yoktur. CHA2DS2Vasc skoru AF'li hastalarda inme riskini tahmin etmekte yaygın olarak kullanılırken, bu skorun inme rekürrensini predikte etmede yetersiz kaldığı gösterilmiştir 6 . Çalışmamızda AF tanısı 2020 Avrupa Kardiyoloji Derneği kılavuzlarına uygun olarak tek kayıtta 30 saniye ve üzeri süreli AF ritminin gösterilmesi ile konmuş 7 , paroksizmal (7 gün içinde sonlanan) ve kalıcı AF sınıflarının her ikisi de AF grubuna dahil edilmiştir.…”

“…İskemik inme geçiren hastalarda %15-20 oranında kronik AF tanısı olduğu gösterilmiştir 4,11 . Nonvalvüler AF'ye bağlı akut iskemik inme geçiren 5000 üzeri hastanın 1 yıllık takibinde %6 oranında rekürren inme izlenmiştir 6 .…”