Stroke risk stratification

Table A17.4 Stroke risk stratification guide (from CKS [3])...

Gage BF, van Walraven C, Pearce LA et al. (2004). Selecting patients with atrial fibrillation for anticoagulation. Stroke risk stratification in patients taking aspirin. Circulation 110 2287-2292 Giles MF, Rothwell PM (2007). Risk of stroke early after transient ischaemic attack a systematic review and meta-analysis. Lancet Neurology 6 1063-1072... 

Persistent and paroxysmal atrial fibrillation (AF) are potent risk factors for first and recurrent stroke. It has been estimated that AF affects more than 2,000,000 Americans and becomes more frequent with age, being the most frequent cardiac arrhythmia in the elderly [6,38], The prevalence of AF peaks at 8.8% among people over the age of 80 years, hi the Framingham Stroke Study, 14% of strokes occurred because of AF. The absolute risk of stroke in patients with AF varies 20-fold, according to age and the presence of vascular risk factors [6,7]. Several stroke risk stratification schemes have been developed and validated. Overall, patients with prior stroke or transient ischanic attack carry the highest stroke risk [6,39]. 

TIA-related infarctions on DWI can be predicted on the basis of certain clinical TIA features. Transient motor symptoms, preceding non-stereotypic attacks, the presence of an established cause of stroke, and presentation with aphasia are independent predictors of infarction on DWI (Ay et al. 2002 Crisostomo et al. 2003). In contrast, limb paresthesias, slurred speech, and brief attacks of dizziness or imbalance are not associated with occurrence of infarction. Of note, most symptoms that are not associated with infarction on DWI are based on patients subjective feelings and sensations in contrast to motor deficit or aphasia, it is not possible to objectively assess such symptoms and mark the brain as their origin. Of particular relevance to this point is that, according to a recent study, the independent predictors of infarction on DWI such as motor deficit and speech impairment are also independently associated with increased risk of stroke after TIA (Johnston et al. 2003), suggesting a potential role for DWI in the risk stratification for stroke following TIA. 

CKS recommends that antithrombotic treatment is indicated in all people with atrial fibrillation (AF). The choice of treatment should be determined by the person s risk of stroke. CKS uses the risk stratification recommended by NICE see Table A17.4. 

Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy. Stroke 25 2022-2027... 

Most experts agree that certain patients with asymptomatic CAS are at high risk for stroke and may derive significant benefit from carotid revascularization. Identification of those patients, however, has been elusive in clinical trials. Risk stratification of patients with asymptomatic CAS is particularly important among patients with 60% to 79% stenosis, in whom the appropriate management is more uncertain. Identifying high-risk patients will certainly lead to better resource utilization for both medical and revascularization therapies for patients with asymptomatic CAS. 

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