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March 12, 2013; 80 (11) Article

CHADS2, CHA2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation

George Ntaios, Gregory Y.H. Lip, Konstantinos Makaritsis, Vasileios Papavasileiou, Anastasia Vemmou, Eleni Koroboki, Paraskevi Savvari, Efstathios Manios, Haralampos Milionis, Konstantinos Vemmos
First published February 13, 2013, DOI: https://doi.org/10.1212/WNL.0b013e318287281b
George Ntaios
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Gregory Y.H. Lip
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Konstantinos Makaritsis
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Vasileios Papavasileiou
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Anastasia Vemmou
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Eleni Koroboki
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Paraskevi Savvari
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Efstathios Manios
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Haralampos Milionis
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Konstantinos Vemmos
From the Department of Medicine (G.N., K.M., V.P.), University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Acute Stroke Unit (A.V., E.K., P.S., E.M., K.V.), Department of Clinical Therapeutics, Alexandra Hospital, Athens; and Department of Internal Medicine (H.M.), School of Medicine, University of Ioannina, Ioannina, Greece.
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Citation
CHADS2, CHA2DS2-VASc, and long-term stroke outcome in patients without atrial fibrillation
George Ntaios, Gregory Y.H. Lip, Konstantinos Makaritsis, Vasileios Papavasileiou, Anastasia Vemmou, Eleni Koroboki, Paraskevi Savvari, Efstathios Manios, Haralampos Milionis, Konstantinos Vemmos
Neurology Mar 2013, 80 (11) 1009-1017; DOI: 10.1212/WNL.0b013e318287281b

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Abstract

Objective: CHADS2 and CHA2DS2-VASc scores are used to assess stroke risk in patients with atrial fibrillation (AF). We investigated whether these scores are associated with stroke outcome in non-AF stroke patients.

Methods: Consecutive patients with acute first-ever ischemic stroke but without AF were classified into subgroups according to prestroke CHADS2 and CHA2DS2-VASc scores and followed up for 5 years. The end points were death, stroke recurrence, and a composite of major cardiovascular events.

Results: Among 1,756 patients (aged 67.2 ± 12.3 years, 68.2% males), there were 258 (14.7%), 617 (35.3%), and 878 (50.0%) patients with low, intermediate, and high CHADS2 score, respectively. The corresponding figures for CHA2DS2-VASc subgroups were 110 (6.3%), 255 (14.5%), and 1,391 (79.2%). There were significant differences between CHADS2 subgroups in 5-year mortality (log-rank test = 74.5, p < 0.0001), stroke recurrence (log-rank test = 12.3, p = 0.002), and cardiovascular events (log-rank test = 19.4, p < 0.001). Similarly, there were significant differences between CHA2DS2-VASc subgroups in 5-year mortality (log-rank test = 74.5, p < 0.0001), stroke recurrence (log-rank test = 10.6, p = 0.005), and cardiovascular events (log-rank test = 16.4, p < 0.001). Compared with the low-risk group, patients in intermediate- and high-risk CHADS2 subgroups had higher 5-year mortality (hazard ratio [HR]: 2.22 [95% confidence interval {CI}: 1.78–2.77] and 3.66 [95% CI: 2.38–5.62], respectively), stroke recurrence (HR: 1.74 [95% CI: 1.09–2.79] and 1.71 [95% CI: 1.08–2.71], respectively), and cardiovascular events (HR: 1.78 [95% CI: 1.23–2.57] and 1.86 [95% CI: 1.30–2.67], respectively). Compared with the low-risk group, patients in the high-risk CHA2DS2-VASc subgroup also had higher 5-year mortality (HR: 3.56, 95% CI: 1.89–6.70), stroke recurrence (HR: 2.93, 95% CI: 1.30–6.61), and cardiovascular events (HR: 2.71, 95% CI: 1.49–4.95).

Conclusions: Prestroke CHADS2 and CHA2DS2-VASc scores predict long-term stroke outcomes in non-AF patients with acute ischemic stroke. These scores may provide a simple way of stroke prognostic risk stratification among non-AF stroke patients.

GLOSSARY

AF=
atrial fibrillation;
ASTRAL=
Acute Stroke Registry and Analysis of Lausanne;
CI=
confidence interval;
HR=
hazard ratio;
NIHSS=
NIH Stroke Scale;
SSS=
Scandinavian Stroke Scale;
TOAST=
Trial of Org 10172 in Acute Stroke Treatment

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Supplemental data at www.neurology.org

  • Received July 27, 2012.
  • Accepted November 19, 2012.
  • © 2013 American Academy of Neurology
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