Validation and Refinement of the ABCD2 Score

Abstract

Background and Purpose-Transient ischemic attacks are a frequent diagnosis in the emergency department setting, yet expert opinion as to the proper follow-up and need for hospitalization differs widely. Recently, an effort has been made to risk-stratify patients presenting with transient ischemic attacks through scoring systems such as the ABCD and ABCD2 scales. The aim of our study was to independently validate these scores using a population-based cohort. Methods-Using the data from the Rochester Stroke and Transient Ischemic Attack Registry and resources of the Rochester Epidemiology Project, medical records of all residents of Rochester, Minn, with a diagnosis of incident transient ischemic attack from 1985 through 1994 were examined (Nϭ284). Patients were scored on the ABCD and ABCD2 scales and new scores were created by adding hyperglycemia and a history of hypertension. The end points of stroke and death were collected previously and were verified through the Rochester Epidemiology Project data. Results-Although our study did find that scores Ͼ4 had a statistically significant predictive value for future stroke, a substantial proportion of strokes within 7 days (9 of 36 cases [25%]) occurred in patients with low or intermediate risk scores (Յ4) on the ABCD2 scale. Including history of hypertension and hyperglycemia on presentation increased the sensitivity of the score to identify patients who had a stroke within 7 days. Conclusions-Reliance on the ABCD and ABCD2 scores misses some patients who will have a stroke within 7 days of a transient ischemic attack. Adding hyperglycemia and a history of hypertension to the predictive model could be useful, but the value of these additions need to be evaluated further.

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

“…With respect to the timing of patient assessment after the index event, in 10 studies TIA patients were assessed within 24 hours of symptoms onset, 62,69,87,[134][135][136]138,143,155,161 in six studies within 48 hours, 137,139,141,142,150,165 in one study 140 within 72 hours and in one study 160 within 7 days. Another four studies 9,61,132,144 reported that 'patients were assessed as soon as possible after the event' but did not give a time.…”

“…The ascertainment of stroke events after TIA was carried out by face-to-face patient assessment or telephone interviews in 25 studies, 9,21,24,61,69,81,119,122,128,[132][133][134][137][138][139]144,[149][150][151][152]155,156,161,164,165 by medical records in 15 studies, 23,62,87,120,126,127,129,130,130,135,136,140,143,145,157,159 by mixed methods involving face-to-face assessment plus another method (i.e. telephone interviews, medical records, letters) in 11 studies, 65,131,[146][147][148]153,154,158,…”

Factors Influencing Hospital Admission of Non-critically Ill Patients Presenting to the Emergency Department: a Cross-sectional Study

“…These alternative care pathways require clinical decision tools to assess risk; evidence-based diagnostic and treatment protocols to minimize variability in care; outpatient follow-up that is reliably available on an urgent schedule; efficient communications among patients and providers; support for shared decision-making with patients; and qualitybased financial incentives to encourage their development and utilization as an alternative to admission. 30 Decision rules currently utilized by EM physicians, such as the TIMI score 31 for chest pain and the ABCD2 score 32 for TIA, may lead to the admission of clinically stable patients because of a low or intermediate risk of serious illness. It is unclear whether these patients would be captured by the Bstrongly acuity-driven^or Bmoderately acuity-driven^admission groups in our study, but many could likely be managed in an alternative environment if evidence-based protocols for urgent outpatient testing were established.…”

National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk

“…[17][18][19][20][21][22] Unfortunately, the ACBD2 Score has not performed well in prospective validation (c-statistic: 0.56). 23 We recently conducted a prospective, multicentre study to determine clinical features of TIA patients presenting to emergency departments (EDs), associated with high risk of stroke and to develop a new clinical prediction score for impending stroke.…”