Cardiac Risk Scores May Be Useful for Predicting Outcome of Acute Ischemic Stroke: Study

A recent study published in Neurology India shows that HEART (History, ECG, Age, Risk factors, and Troponin) score is effective in determining re-hospitalization and recurrent cerebral ischemic event risk as well as mortality within 30 days and 1 year in patients presenting with acute ischemic stroke.

Stroke is one of the most common causes of death and disability among adults. Advanced age, female gender, and comorbidities such as hypertension (HT), diabetes mellitus (DM), heart failure (HF), history of previous vascular disease, stroke, and transient ischemic attack (TIA) are well-known risk factors for stroke. CHA2DS2-VASc score is a frequently used scoring system originally created to tailor anticoagulant therapy in patients with atrial fibrillation (AF). Moreover, patients with high prestroke CHA2DS2-VASc score were shown to have worse clinical and functional outcomes regardless of AF. The prestroke CHA2DS2-VASc score has also been used to determine 1-year and 10-year stroke recurrency risk.

The CHA2DS2-VASc score is mainly involved of risk factors and comorbidities, whereas hemodynamic and laboratory findings that are also essential for risk stratification in stroke patients are not used. For instance, measurement of cardiac troponin (cTn) is recommended in all patients with suspected stroke according to the current guidelines to define high-risk patients for worse clinical outcomes. cTn was thought to be increased as a result of cardiac injury via elevated catecholamine levels and nonspecific physiologic stress response. Involvement of insular cortex was shown to be associated with myocardial injury which may end up with increased cTn levels. Additionally, electrocardiography (ECG) findings like nonspecific ST-segment and T-wave abnormalities on admission were shown to be associated with the increased risk of adverse outcomes in stroke patients. On the other hand, the HEART score was created to assess the risk of major adverse cardiac event (MACE) occurrence within 30 days to 6 weeks in patients who were admitted to emergency department with a suspicion of acute coronary syndrome (ACS).

Ozcan et al from Turkey hypothesized that HEART risk score could predict 30-day and 1-year mortality, in addition to re-hospitalization and recurrent cardiac or cerebral ischemic events. Patients hospitalized with a diagnosis of acute ischemic stroke in our tertiary center between 2019 and 2021 were included in this retrospective study. CHA2DS2-VASc and HEART scores on admission were calculated. In-hospital, 1-month, and 1-year mortalities, as well as re-hospitalization due to recurrent ischemic (cardiac/cerebral), were defined as major adverse cardiac and cerebrovascular events (MACCE), and occurrence of MACCE was accepted as the primary endpoint of the study. Comparative statistical and regression analyses were obtained.

They found that patients with MACCE had higher BMI, higher smoking, and hyperlipidemia rates. Similarly, ACE inhibitor/ARB and calcium channel blockers were found to be more in those patients. This significance correlated with the higher rates of HT diagnosis in these patients and might be attributable to uncontrolled HT in them. Blood pressure control must be the target for secondary prevention regardless of the agent.

Elevated cTn levels were found to be associated with an increased risk of in-hospital and all-cause mortality in long-term follow-up. Though cardiac troponin T (cTnT) levels were found to be more sensitive to predict adverse outcomes in acute ischemic stroke patients, cardiac troponin I was used in their study and found to be significantly elevated in patients who experienced MACCE. Baseline CRP and cTn levels were significantly higher in MACCE patients and these two markers were associated with recurrent ischemic stroke and mortality in both 30 days and 1 year according to our results.

"HEART score comprises cTn as a variable and provides the benefit of using a biomarker in conjunction with clinical risk factors. Thus, HEART score could predict recurrent ischemic stroke and mortality risk with a significantly higher proficiency than the guideline-recommended CHA2DS2-VASc score, which only consist of traditional risk factors.", conclude the authors.

The study revealed that the HEART score is effective in determining re-hospitalization and recurrent cerebral ischemic event risk as well as mortality within 30 days and 1 year in patients presenting with acute ischemic stroke. Thus, concomitant use of HEART and CHA2DS2-VASc scores may provide better characterization of worse prognosis in ischemic stroke patients with high sensitivity and specificity.

Refernece:

Ozcan, Sevgi; Donmez, Esra; Coban, Eda1; Korkut, Elif1; Ziyrek, Murat; Sahin, Irfan; Okuyan, Ertuğrul. Role of Cardiac Risk Scores in Clinical Use to Predict Outcomes of Acute Ischemic Stroke. Neurology India 71(6):p 1197-1204, Nov–Dec 2023. | DOI: 10.4103/0028-3886.391383