不明来源栓塞性卒中且新发心房颤动风险低的患者识别：AF-ESUS 评分。
Identification of patients with embolic stroke of undetermined source and low risk of new incident atrial fibrillation: The AF-ESUS score.
机构信息
Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
Stroke Center, Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
出版信息
Int J Stroke. 2021 Jan;16(1):29-38. doi: 10.1177/1747493020925281. Epub 2020 May 19.
BACKGROUND AND AIMS
Only a minority of patients with Embolic Stroke of Undetermined Source (ESUS) receive prolonged cardiac monitoring despite current recommendations. The identification of ESUS patients who have low probability of new diagnosis of atrial fibrillation (AF) could potentially support a strategy of more individualized allocation of available resources and hence, increase their diagnostic yield. We aimed to develop a tool that can identify ESUS patients who have low probability of new incident AF.
METHODS
We performed multivariate stepwise regression in a pooled dataset of consecutive ESUS patients from three prospective stroke registries to identify predictors of new incident AF. The coefficient of each independent covariate of the fitted multivariable model was used to generate an integer-based point scoring system.
RESULTS
Among 839 patients (43.1% women, median age 67.0 years) followed-up for a median of 24.3 months (2999 patient-years), 125 (14.9%) had new incident AF. The proposed score assigns 3 points for age ≥ 60 years; 2 points for hypertension; -1 point for left ventricular hypertrophy reported at echocardiography; 2 points for left atrial diameter >40 mm; -3 points for left ventricular ejection fraction <35%; 1 point for the presence of any supraventricular extrasystole recorded during all available 12-lead standard electrocardiograms performed during hospitalization for the ESUS; -2 points for subcortical infarct; -3 points for the presence of non-stenotic carotid plaques. The rate of new incident AF during follow-up was 1.97% among the 42.3% of the cohort who had a score of ≤0, compared to 26.9% in patients with > 0 (relative risk: 13.7, 95%CI: 5.9--31.5). The area under the curve of the score was 84.8% (95%CI: 79.9--86.9%). The sensitivity and negative predictive value of a score of ≤0 for new incident AF during follow-up were 94.9% (95%CI: 89.3--98.1%) and 98.0% (95%CI: 95.8--99.3%), respectively.
CONCLUSIONS
The proposed AF-ESUS score has high sensitivity and high negative predictive value to identify ESUS patients who have low probability of new incident AF. Patients with a score of 1 or more may be better candidates for prolonged automated cardiac monitoring.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov/ Unique identifier: NCT02766205.
背景与目的
尽管目前有相关推荐，但只有少数不明来源栓塞性脑卒中（ESUS）患者接受了延长的心脏监测。确定新诊断心房颤动（AF）可能性较低的 ESUS 患者，可能有助于支持更个体化地分配现有资源的策略，从而提高其诊断率。我们旨在开发一种能够识别新诊断 AF 可能性较低的 ESUS 患者的工具。
方法
我们对来自三个前瞻性卒中登记处的连续 ESUS 患者的汇总数据集进行了多变量逐步回归分析，以确定新诊断 AF 的预测因子。对拟合多变量模型的每个独立协变量的系数进行了分析，生成了一个基于整数的评分系统。
结果
在中位随访 24.3 个月（2999 患者年）的 839 例患者（43.1%为女性，中位年龄 67.0 岁）中，125 例（14.9%）发生了新诊断的 AF。所提出的评分系统为：年龄≥60 岁记 3 分；高血压记 2 分；超声心动图报告左心室肥厚记-1 分；左心房直径>40mm 记 2 分；左心室射血分数<35%记-3 分；住院期间 12 导联标准心电图记录到任何室上性期前收缩记 1 分；皮质下梗死记-2 分；存在非狭窄性颈动脉斑块记-3 分。在评分≤0 的患者中，新诊断 AF 的发生率为 42.3%（269/636），而评分>0 的患者中为 26.9%（96/359）（相对风险：13.7，95%CI：5.9--31.5）。评分的曲线下面积为 84.8%（95%CI：79.9--86.9%）。评分≤0 对随访中新诊断 AF 的敏感性和阴性预测值分别为 94.9%（95%CI：89.3--98.1%）和 98.0%（95%CI：95.8--99.3%）。
结论
所提出的 AF-ESUS 评分具有较高的敏感性和阴性预测值，可用于识别新诊断 AF 可能性较低的 ESUS 患者。评分≥1 的患者可能是延长自动心脏监测的更好候选者。
临床试验注册
URL：https://www.clinicaltrials.gov/ 唯一标识符：NCT02766205.
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