ABSTRACT
BACKGROUND: Atrial fibrillation (AF) is a risk factor for cerebral ischemia. Identifying the presence of AF, especially in paroxysmal cases, may take time and lacks clear support in the literature regarding the optimal investigative approach; in resource-limited settings, identifying a higher-risk group for AF can assist in planning further investigation. OBJECTIVE: To develop a scoring tool to predict the risk of incident AF in the poststroke follow-up. METHODS: A retrospective longitudinal study with data collected from electronic medical records of patients hospitalized and followed up for cerebral ischemia from 2014 to 2021 at a tertiary stroke center. Demographic, clinical, laboratory, electrocardiogram, and echocardiogram data, as well as neuroimaging data, were collected. Stepwise logistic regression was employed to identify associated variables. A score with integer numbers was created based on beta coefficients. Calibration and validation were performed to evaluate accuracy. RESULTS: We included 872 patients in the final analysis. The score was created with left atrial diameter ≥ 42 mm (2 points), age ≥ 70 years (1 point), presence of septal aneurysm (2 points), and score ≥ 6 points at admission on the National Institutes of Health Stroke Scale (NIHSS; 1 point). The score ranges from 0 to 6. Patients with a score ≥ 2 points had a fivefold increased risk of having AF detected in the follow-up. The area under the curve (AUC) was of 0.77 (0.72-0.85). CONCLUSION: We were able structure an accurate risk score tool for incident AF, which could be validated in multicenter samples in future studies.
ANTECEDENTES: Fibrilação atrial (FA) é um fator de risco para isquemia cerebral. Identificar a presença de FA, especialmente em casos paroxísticos, pode demandar tempo, e não há fundamentos claros na literatura quanto ao melhor método de proceder à investigação; em locais de parcos recursos, identificar um grupo de mais alto risco de FA pode auxiliar no planejamento da investigação complementar. OBJETIVO: Desenvolver uma ferramenta de escore para prever o risco de FA no acompanhamento após acidente vascular cerebral (AVC). MéTODOS: Estudo longitudinal retrospectivo, com dados coletados dos prontuários eletrônicos de pacientes hospitalizados e acompanhados ambulatorialmente por isquemia cerebral, de 2014 a 2021, em um centro de AVC terciário. Foram coleados dados demográficos, clínicos, laboratoriais, de eletrocardiograma e ecocardiograma, além de dados de neuroimagem. Mediante uma regressão logística por stepwise, foram identificadas variáveis associadas. Um escore com números inteiros foi criado com base nos coeficientes beta. Calibração e validação foram realizadas para avaliar a precisão. RESULTADOS: Foram incluídos 872 pacientes na análise final. O escore foi criado com diâmetro de átrio esquerdo ≥ 42 mm (2 pontos), idade ≥ 70 anos (1 ponto), presença de aneurisma septal (2 pontos) e pontuação à admissão ≥ 6 na escala de AVC dos National Institutes of Health (National Institutes of Health Stroke Scale, NIHSS, em inglês; 1 ponto). O escore tem pontuação que varia de 0 a 6. Pacientes com escore ≥ 2 pontos tiveram cinco vezes mais risco de terem FA detectada no acompanhamento. A área sob a curva (area under curve, AUC, em inglês) foi de 0.77 (0.720.85). CONCLUSãO: Pudemos estruturar uma ferramenta precisa de escore de risco de FA, a qual poderá ser validada em amostras multicêntricas em estudos futuros.
Subject(s)
Atrial Fibrillation , Humans , Atrial Fibrillation/diagnostic imaging , Atrial Fibrillation/etiology , Male , Female , Aged , Retrospective Studies , Risk Factors , Middle Aged , Longitudinal Studies , Risk Assessment/methods , Stroke/etiology , Stroke/diagnostic imaging , Stroke/complications , Aged, 80 and over , Predictive Value of Tests , Logistic Models , Ischemic Stroke/diagnostic imaging , Ischemic Stroke/etiology , Brain Ischemia/diagnostic imaging , Brain Ischemia/etiologyABSTRACT
BACKGROUND AND OBJECTIVE: The Modified Rankin Scale (mRS) is a widely adopted scale for assessing stroke recovery. Despite limitations, the mRS has been adopted as primary outcome in most recent clinical acute stroke trials. Designed to be used by multidisciplinary clinical staff, the congruency of this scale is not consistent, which may lead to mistakes in clinical or research application. We aimed to develop and validate an interactive and automated digital tool for assessing the mRS-the iRankin. METHODS: A panel of five board-certified and mRS-trained vascular neurologists developed an automated flowchart based on current mRS literature. Two international experts were consulted on content and provided feedback on the prototype platform. The platform contained five vignettes and five real video cases, representing mRS grades 0-5. For validation, we invited neurological staff from six comprehensive stroke centers to complete an online assessment. Participants were randomized into two equal groups usual practice versus iRankin. The participants were randomly allocated in pairs for the congruency analysis. Weighted kappa (kw) and proportions were used to describe agreement. RESULTS: A total of 59 professionals completed the assessment. The kw was dramatically improved among nurses, 0.76 (95% confidence interval (CI) = 0.55-0.97) × 0.30 (0.07-0.67), and among vascular neurologists, 0.87 (0.72-1) × 0.82 (0.66-0.98). In the accuracy analysis, after the standard mRS values for the vignettes and videos were determined by a panel of experts, and considering each correct answer as equivalent to 1 point on a scale of 0-15, it revealed a higher mean of 10.6 (±2.2) in the iRankin group and 8.2 (±2.3) points in the control group (p = 0.02). In an adjusted analysis, the iRankin adoption was independently associated with the score of congruencies between reported and standard scores (beta coefficient = 2.22, 95% CI = 0.64-3.81, p = 0.007). CONCLUSION: The iRankin adoption led to a substantial or near-perfect agreement in all analyzed professional categories. More trials are needed to generalize our findings. Our user-friendly and free platform is available at https://www.irankinscale.com/.
Subject(s)
Stroke , Humans , Stroke/diagnosis , Stroke/therapy , Female , Observer Variation , Male , Reproducibility of Results , Severity of Illness Index , NeurologistsABSTRACT
Abstract Background Atrial fibrillation (AF) is a risk factor for cerebral ischemia. Identifying the presence of AF, especially in paroxysmal cases, may take time and lacks clear support in the literature regarding the optimal investigative approach; in resource-limited settings, identifying a higher-risk group for AF can assist in planning further investigation. Objective To develop a scoring tool to predict the risk of incident AF in the poststroke follow-up. Methods A retrospective longitudinal study with data collected from electronic medical records of patients hospitalized and followed up for cerebral ischemia from 2014 to 2021 at a tertiary stroke center. Demographic, clinical, laboratory, electrocardiogram, and echocardiogram data, as well as neuroimaging data, were collected. Stepwise logistic regression was employed to identify associated variables. A score with integer numbers was created based on beta coefficients. Calibration and validation were performed to evaluate accuracy. Results We included 872 patients in the final analysis. The score was created with left atrial diameter ≥ 42 mm (2 points), age ≥ 70 years (1 point), presence of septal aneurysm (2 points), and score ≥ 6 points at admission on the National Institutes of Health Stroke Scale (NIHSS; 1 point). The score ranges from 0 to 6. Patients with a score ≥ 2 points had a fivefold increased risk of having AF detected in the follow-up. The area under the curve (AUC) was of 0.77 (0.72-0.85). Conclusion We were able structure an accurate risk score tool for incident AF, which could be validated in multicenter samples in future studies.
Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco para isquemia cerebral. Identificar a presença de FA, especialmente em casos paroxísticos, pode demandar tempo, e não há fundamentos claros na literatura quanto ao melhor método de proceder à investigação; em locais de parcos recursos, identificar um grupo de mais alto risco de FA pode auxiliar no planejamento da investigação complementar. Objetivo Desenvolver uma ferramenta de escore para prever o risco de FA no acompanhamento após acidente vascular cerebral (AVC). Métodos Estudo longitudinal retrospectivo, com dados coletados dos prontuários eletrônicos de pacientes hospitalizados e acompanhados ambulatorialmente por isquemia cerebral, de 2014 a 2021, em um centro de AVC terciário. Foram coleados dados demográficos, clínicos, laboratoriais, de eletrocardiograma e ecocardiograma, além de dados de neuroimagem. Mediante uma regressão logística por stepwise, foram identificadas variáveis associadas. Um escore com números inteiros foi criado com base nos coeficientes beta. Calibração e validação foram realizadas para avaliar a precisão. Resultados Foram incluídos 872 pacientes na análise final. O escore foi criado com diâmetro de átrio esquerdo ≥ 42 mm (2 pontos), idade ≥ 70 anos (1 ponto), presença de aneurisma septal (2 pontos) e pontuação à admissão ≥ 6 na escala de AVC dos National Institutes of Health (National Institutes of Health Stroke Scale, NIHSS, em inglês; 1 ponto). O escore tem pontuação que varia de 0 a 6. Pacientes com escore ≥ 2 pontos tiveram cinco vezes mais risco de terem FA detectada no acompanhamento. A área sob a curva (area under curve, AUC, em inglês) foi de 0.77 (0.72-0.85). Conclusão Pudemos estruturar uma ferramenta precisa de escore de risco de FA, a qual poderá ser validada em amostras multicêntricas em estudos futuros.