Does ABCD2 Score Below 4 Allow More Time to Evaluate
Patients With a Transient Ischemic Attack?
Pierre Amarenco, MD; Julien Labreuche, BS; Philippa C. Lavallée, MD; Elena Meseguer, MD;
Lucie Cabrejo, MD; Tarik Slaoui, MD; Céline Guidoux, MD; Jean-Marc Olivot, MD, PhD;
Halim Abboud, MD; Bertrand Lapergue, MD; Isabelle F. Klein, MD, PhD;
Mikael Mazighi, MD, PhD; Pierre-Jean Touboul, MD
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Background and Purpose—The National Institute for Clinical Excellence (NICE) recommends that patients with a
transient ischemic attack and ABCD2 score ⱖ4 and those with ⬎2 transient ischemic attacks within 1 week be admitted
for urgent complete etiologic evaluation within 24 hours and that those with an ABCD2 score ⬍4 be evaluated less
urgently within 1 week.
Methods—Using data from 1176 patients with a definite or possible transient ischemic attack or minor stroke included in
the SOS-TIA registry (January 2003 to June 2007), we studied the usefulness of the conventional ABCD2 score cutoff
as well as the NICE criteria for urgent admission to a stroke unit defined as presence of symptomatic internal carotid
artery stenosis ⱖ50%, symptomatic intracranial artery stenosis ⱖ50%, or major cardiac source of embolism.
Results—Among 697 patients with an ABCD2 score ⬍4, 20% required immediate consideration for emergency treatment
(eg, symptomatic internal carotid stenosis ⱖ50% in 9.1% of patients, symptomatic intracranial stenosis in 5.0%, atrial
fibrillation in 5.9%, other major cardiac source of embolism in 2.1%) in comparison to 31.6% of 497 patients with an
ABCD2 score ⱖ4. The sensitivity and specificity of ABCD2 score ⱖ4 or NICE criteria for discriminating between
patients requiring admission or not were ⬍62% with low positive predictive values (⬍30%) and high negative
predictive values (ⱖ80%).
Conclusions—One in 5 patients with an ABCD2 score ⬍4 had high-risk disease requiring urgent treatment decisionmaking. When triaging on an ABCD2 score, we recommend adding systematic carotid ultrasound (or a default
angiographic CT scan) and electrocardiography within 24 hours before postponing complete transient ischemic attack
evaluation. (Stroke. 2009;40:3091-3095.)
Key Words: ABCD score 䡲 stroke 䡲 transient ischemic attack
ABCD2 score ⬍4, be evaluated within 1 week.3 This is based
on the fact that patients with an ABCD2 score ⬍4 have a
90-day stroke risk of ⬍3%.4 This provision of care would be
valid if no patient, or a minimum number of patients, with an
ABCD2 score ⬍4 has an underlying pathology needing
urgent (ie, immediate) treatment decision-making. Indeed,
immediate assessment of stroke mechanism and etiology may
better identify patients at risk of stroke as opposed to the
combination of age, risk factors, duration, and type of
symptoms.5
We analyzed data from the SOS-TIA cohort, which now
includes 1176 patients with proven TIAs, 679 with an
ABCD2 score ⬍4 and 497 with a score ⱖ4, to determine
differences in underlying pathologies. We paid particular
attention to ipsilateral carotid and intracranial stenoses ⱖ50%
and a cardiac source of embolism requiring urgent treatment
decision-making.
R
apid assessment and treatment of patients with suspected
transient ischemic attack (TIA) can decrease the 90-day
risk of stroke by up to 80%.1,2 We have shown previously that
TIA clinics with round-the-clock (24-hour) access permit
triage of patients based on stroke mechanism and etiology.2
After a 3-hour workup, including carotid ultrasound, brain
imaging, blood and cardiac evaluation, only 25% of patients
were admitted to the stroke unit; the remaining 75% were
discharged home from the “day” hospital (also open at night)
and started immediately on recommended secondary prevention treatments.2 Another approach is to base the patient’s admission to a stroke unit on an ABDC2 score ⱖ4 or
crescendo TIA within the previous 7 days as recommended
by the National Institute for Clinical Excellence (NICE)
guidelines.3 An ABCD2 score ⱖ4 predicts a 90-day stroke
risk between 8% and 22%.4 With this scoring system, NICE
guidelines recommend that the remaining patients, with an
Received March 9, 2009; final revision received April 9, 2009; accepted May 15, 2009.
From INSERM U-698 and Paris-Diderot University, Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France.
Correspondence to Pierre Amarenco, MD, Department of Neurology and Stroke Center, Bichat University Hospital, 46 rue Henri Huchard, 75018 Paris,
France. E-mail [email protected]
© 2009 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.109.552042
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Stroke
September 2009
1622 patients seen at the TIA clinic
374 with final vascular diagnosis other
than ischemic cerebrovascular disease
1248 patients seen at the TIA clinic
Figure. Flow diagram of study population.
72 had incomplete information on the
ABCD² score components
679 with an ABCD² <4
497 with an ABCD² = 4
Methods
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Patients
The SOS-TIA methods have been described in detail previously.2
Briefly, SOS-TIA is a TIA clinic with round-the-clock (24-hour)
access located in a “day” hospital (also open at night) nested in a
neurology department that also has a stroke unit. Primary care
physicians (ie, general practitioners, cardiologists, neurologists, and
ophthalmologists) and emergency department physicians in Paris
and its administrative regions can contact the SOS-TIA clinic
through a toll-free telephone number. Patients are admitted to the
SOS-TIA clinic if the suspicion of TIA is confirmed by a trained
nurse or vascular neurologist after a brief phone interview. After
triage based on etiologic workup performed in ⬍3 hours, patients are
either discharged home from the day hospital or further admitted to
the stroke unit according to published criteria.2,6 This report concerns
all patients admitted to the SOS-TIA clinic between January 2003
and June 2007.
Investigations
The SOS-TIA clinic was organized to provide an initial, standardized
evaluation within 4 hours of admission, including clinical evaluation
and diagnostic testing.
Carotid Ultrasonography
Cervical duplex ultrasonography was performed systematically and
immediately by a fully trained senior vascular neurologist to evaluate
the presence of plaques and quantify the degree of stenosis. The
carotid bifurcation and the internal carotid artery were assessed on
both sides of the neck. Carotid stenosis was measured on crosssections at the level of maximum stenosis. Patients were classified
into 2 groups: no atherosclerosis or internal carotid artery atherosclerosis defined by the presence of plaque regardless of the degree
of stenosis or carotid occlusion. Significant internal carotid artery
atherosclerosis was defined by a stenosis ⱖ50% (longitudinal section
on ultrasound, a proxy to the North American Surgical Carotid
Endarterectomy Trial (NASCET) method, or measured on an angiogram) or carotid occlusion. Stenoses ⱖ50% were considered symptomatic when they were ipsilateral to the ischemic field. Transcranial
Doppler was conducted systematically to evaluate the presence of
intracranial stenosis. Middle cerebral artery, carotid siphon, and basilar
trunk velocities were used for stenosis quantification.
Other Investigations
Other examinations included medical history, physical examination,
routine blood biochemistry (including lipid and glycemic profile),
brain MRI (or CT scan as a default, 100%), transcranial Doppler
(99%, n⫽1159), electrocardiography (98%, n⫽1154), and echocardiography (78%, n⫽917, including 812 transesophageal echocardiograms). Echocardiography was performed the same day in case a
high-risk cardiac source of embolism was clinically suspected and
later in other cases.
Diagnosis
Patients were classified according to 5 final diagnoses5: definite TIA
with a new lesion corresponding to clinical deficit on brain imaging;
definite TIA without a new lesion on brain imaging; minor stroke;
possible TIA; and nonischemic diagnosis.
Statistical Analysis
Data are presented as mean (SD) for continuous variables and
percentage (count) for dichotomous variables. We calculated the
ABCD2 score in 1176 patients with definite or possible TIA or minor
stroke who had complete information on the score components: age
(ⱖ60 years⫽1 point), blood pressure (ⱖ140/90 mm Hg⫽1), diabetes (yes⫽1), clinical features (unilateral weakness⫽2; speech disturbance without weakness⫽1), and duration of symptoms (ⱖ60
minutes⫽2; 10 to 59 minutes⫽1).4 Patients were divided into 2
groups according to the conventional ABCD2 score cutoff of 4.3
Patients’ characteristics, major examination findings, and processes
of care were compared between 2 groups using the ␹2 tests for
categorical variables and Student t test for continuous variables. We
calculated the sensitivity, specificity, positive predictive value, and
negative predictive value for an ABCD2 score ⱖ4 and for the NICE
criteria3 (ABCD2 score ⱖ4 or crescendo TIA for patients seen within
1 week of symptom onset) for discriminating patients requiring
urgent admission, defined as the presence of symptomatic internal
carotid stenosis ⱖ50%, symptomatic intracranial stenosis ⱖ50%, or
major source of cardioembolism. Sensitivity analyses were restricted
to patients seen within 24 hours of symptom onset. Statistical testing
was done at the 2-tailed ␣ level of 0.05. Data were analyzed using the
SAS package, Release 9.1 (SAS Institute, Cary, NC).
Results
Among 1622 patients seen at the TIA clinic, 1176 had a
definite or possible TIA or minor stroke and had complete
information on ABCD2 score components (Figure). Of these,
57% (n⫽670) were seen within 24 hours of symptom onset.
Table 1 describes selected baseline characteristics of the
study sample according to the conventional ABCD2 score
cutoff. Of the clinical characteristics other than ABCD2 score
components, history of coronary disease, atrial fibrillation,
and stroke were more frequent in patients with an ABCD2
score ⱖ4, whereas visual deficit and previous TIA within 1
week of the last symptom onset were less frequent in
comparison to patients with an ABCD2 score ⬍4. Diagnosis
of definite TIA with new ischemic lesions and of minor
Amarenco et al
Table 1. Patient’s Characteristics According to the
Conventional ABCD2 Score Cutoff
Triage Based on ABCD2 Score
Table 2. Major Examination Findings According to the
Conventional ABCD2 Score Cutoff
ABCD2 Score
⬍4 (n⫽679)
3093
ABCD2 Score
ⱖ4 (n⫽497)
Vascular risk factors
⬍4 (n⫽679)
ⱖ4 (n⫽497)
Symptomatic internal carotid
stenosis ⱖ50% or occlusion
9.1 (62)
13.7 (68)
0.014
Symptomatic intracranial
stenosis ⱖ50% or occlusion
5.0 (34)
7.7 (38)
0.06
Atrial fibrillation
5.9 (40)
10.7 (53)
0.003
Other major cardiac sources
of embolism*
2.1 (14)
3.2 (16)
0.21
19.7 (134)
31.6 (157)
⬍0.001
P
Total study sample
Age in years, mean⫾SD
59.7⫾15.4
70.5⫾13.1†
Male sex
55.4 (376)
53.3 (265)
Hypertension
57.0 (387)
86.1 (428)†
Dyslipidemia
40.8 (276)
42.1 (207)
6.2 (42)
17.5 (87)†
24.5 (159)
18.7 (86)*
Previous myocardial infarction or angina
6.8 (46)
13.7 (68)†
History of atrial fibrillation
3.7 (25)
6.7 (33)*
Previous stroke
3.9 (26)
7.3 (36)*
Patients seen at TIA clinics within
24 hours of symptom onset
Weakness
13.8 (94)
67.8 (337)†
8.1 (28)
11.7 (38)
0.12
Sensory symptoms
25.0 (169)
22.9 (114)
Symptomatic internal carotid
stenosis ⱖ50% or occlusion
Speech disturbance
26.5 (180)
53.5 (266)†
5.8 (20)
6.2 (20)
0.83
Visual deficit
44.0 (298)
9.5 (47)†
Symptomatic intracranial
stenosis ⱖ50% or occlusion
Atrial fibrillation
7.3 (25)
12.4 (40)
0.025
Other major cardiac sources
of embolism*
2.1 (7)
3.1 (10)
0.38
19.9 (69)
29.6 (96)
0.004
Diabetes
Current smoking
Clinical features
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Symptom duration in min, mean⫾SD
At least one major examination
finding
⬍10
55.1 (374)
13.1 (65)†
10–59
33.1 (225)
34.0 (169)
ⱖ60
11.8 (80)
53.0 (263)
Previous TIA ⱕ1 week of the last
symptom onset
26.1 (177)
12.9 (64)†
Values expressed as percentage (no.) unless otherwise indicated.
*Mural thrombus, dilated cardiomyopathy, fibroelastoma, mitral stenosis,
prosthetic heart valve, or recent myocardial infarction.
Minor ischemic stroke
1.3 (9)
11.9 (59)†
Definite TIA with new ischemic lesions
8.8 (60)
17.3 (86)
Definite TIA without new ischemic lesions
69.1 (469)
63.6 (316)
Possible TIA
20.8 (141)
7.2 (36)
was found in 8.6% (n⫽59) of patients with an ABCD2 score ⬍4
and in 11.9% (n⫽59) of patients with a score ⱖ4 (P⫽0.07). Of
the 118 diagnoses of intracranial stenosis ⱖ50%, 53.4% (n⫽63)
were considered symptomatic and 9 additional symptomatic
stenoses were diagnosed by MR angiography. The prevalence of
symptomatic intracranial carotid stenosis was 5.0% in patients
with an ABCD2 score ⬍4 and 7.7% in those with a score ⱖ4
(P⫽0.06; Table 2).
Fifty-eight (4.9%) patients had a clinical history of atrial
fibrillation (Table 1). The admission electrocardiogram diagnosed atrial fibrillation in an additional 20 patients. Atrial
fibrillation was diagnosed in a further 15 patients by examination during follow-up. Overall, 5.9% of patients with an
ABCD2 score ⬍4 had atrial fibrillation versus 10.7% with a
score ⱖ4 (P⫽0.003; Table 2). Other major cardiac sources of
embolism (mural thrombus, dilated cardiomyopathy, fibroelastoma, mitral stenosis, prosthetic heart valve, recent myocardial infarction) detected by echocardiography at admission
or during the second set of investigations were diagnosed
more frequently in patients with an ABCD2 score ⱖ4 (3.7%,
n⫽14) than in patients with a score ⬍4 (1.3%, n⫽7,
P⫽0.017). Ten patients had a prosthetic heart valve and one
had a recent myocardial infarction (within 3 weeks). Overall,
major cardiac sources of embolism other than atrial fibrillation were detected in 2.1% of patients with an ABCD2 score
⬍4 and in 3.2% of patients with a score ⱖ4 (Table 2). A
similar prevalence of major findings was found when the
analysis was restricted to patients seen within 24 hours of
symptom onset (Table 2).
Final vascular diagnosis
*P⬍0.05.
†P⬍0.001.
Values expressed as percentage (no.) unless otherwise indicated. Hypertension was defined as a history of treated hypertension or admission blood
pressure values ⱖ140/90 mm Hg. Dyslipidemia was defined as history of treated
dyslipidemia or admission low-density lipoprotein cholesterol ⱖ160 mg/dL.
stroke was more frequent in patients with an ABCD2 score
ⱖ4 (29.2%) versus those with a score ⬍4 (10.2%, P⬍0.001).
Major Examination Findings
Table 2 describes the main findings dichotomized according
to ABCD2 cutoff. Internal carotid stenosis ⱖ50% (including
complete occlusion) was more frequently diagnosed by duplex ultrasonography in patients with an ABCD2 score ⱖ4
(20.9%, n⫽102) versus patients with a score ⬍4 (14.2%,
n⫽95, P⫽0.003). Of the 197 diagnoses of internal carotid
stenosis ⱖ50%, 63.5% (n⫽125) were considered symptomatic. Five additional symptomatic carotid stenoses ⱖ50%
were diagnosed by MR angiography, giving a prevalence of
symptomatic internal carotid stenosis of 11.1% with a significant difference between patients with and without ABCD2
score ⱖ4 (Table 2; P⫽0.014). Among the 1159 patients with
at least one intracranial artery assessed by transcranial Doppler ultrasound, stenosis ⱖ50% (including complete occlusion)
At least one major examination
finding
3094
Stroke
September 2009
Table 3. Sensitivity, Specificity, Positive and Negative Predictive Values of Conventional ABCD2 Score Cutoff and NICE
Recommendations to Identify Patients Fulfilling Criteria for Urgent Admission to Stroke Unit (defined as symptomatic
carotid stenosis >50%, and/or a symptomatic intracranial stenosis >50%, and/or a major cardiac source of embolism)
Diagnostic Test (95% CI)
Sensitivity
Specificity
Positive Predictive Value
Negative Predictive Value
ABCD2 score ⱖ4 (n⫽497)
54.0 (48.2–59.7)
61.6 (58.4–64.8)
31.6 (27.5–35.7)
80.3 (77.3–83.3)
NICE criteria* (n⫽561)
57.7 (52.1–63.5)
55.6 (52.3–58.9)
30.0 (26.2–33.7)
80.0 (76.8–83.2)
ABCD2 score ⱖ4 (n⫽324)
58.2 (50.7–65.7)
54.9 (50.5–59.2)
29.6 (24.7–34.9)
80.0 (75.9–84.3)
NICE criteria* (n⫽421)
74.6 (67.9–81.2)
41.0 (36.7–45.3)
29.2 (24.9–33.6)
83.1 (78.5–87.8)
Total study sample (n⫽1176)
Patients seen at TIA clinics within 24 hours
of symptom onset (n⫽670)
*ABCD score ⱖ4 or crescendo TIA (2 or more TIAs in 1 week) for patients seen within 1 week of symptom onset.
2
Criteria for Urgent Admission to a Stroke Unit
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Among the 1176 patients with definite or possible TIA or
minor stroke, 24.7% (n⫽291) fulfilled the criteria for emergency treatment, defined as the presence of symptomatic
internal carotid stenosis ⱖ50%, symptomatic intracranial
stenosis ⱖ50%, or a major cardiac source of embolism. The
criteria for emergency treatment were more frequently diagnosed in patients with an ABCD2 ⱖ4 (31.6%, n⫽157)
compared with patients with a score ⬍4 (19.7%, n⫽134,
P⬍0.001). The sensitivity of the conventional ABCD2 score
cutoff of 4 was 54.0% (95% CI, 48.2 to 59.7) and the specificity
was 61.6% (95% CI, 58.4 to 64.8). Similar diagnostic values
were found using the NICE criteria and when the analysis was
restricted to patients seen at the TIA clinic within 24 hours of
symptom onset (Table 3).
Process of Care
Admission to a stroke unit occurred more frequently in
patients with versus without an ABCD2 ⱖ4 (Table 4). At
discharge, patients with a score ⱖ4 were more frequently
Table 4. Process of Care According to the Conventional
ABCD2 Score Cutoff
ABCD2 Score
⬍4 (n⫽679)
ⱖ4 (n⫽497)
P
28.8 (195)
40.6 (202)
⬍0.001
Blood pressure-lowering
46.3 (310)
73.0 (360)
⬍0.001
Lipid-lowering
66.3 (446)
72.2 (354)
0.03
Antiplatelet
90.2 (610)
88.7 (440)
0.40
Anticoagulant
10.2 (69)
12.9 (64)
0.15
Blood pressure-lowering
10.5 (70)
16.2 (80)
0.004
Lipid-lowering
40.1 (270)
41.2 (202)
0.71
Antiplatelet
73.3 (497)
62.2 (309)
⬍0.001
5.8 (39)
9.3 (46)
0.02
3.5 (24)
5.6 (28)
0.09
Admitted to stroke unit
Secondary prevention therapy
At discharge
New prescription
Anticoagulant
Cerebral revascularization*
*Including 5 angioplasty/stenting of carotid stenosis and 4 angioplasty/
stenting of intracranial stenosis.
treated for hypertension and hypercholesterolemia than patients with a lower score. New prescription of blood pressurelowering and anticoagulant drugs was more frequent in
patients with an ABCD2 ⱖ4, whereas antiplatelet drugs were
less frequently prescribed. Urgent cerebral revascularization
was performed in 3.5% of patients with an ABCD2 ⬍4 and in
5.6% of those with a score ⱖ4 (P⫽0.09).
Discussion
In this analysis of a large cohort of patients with suspected
TIA, a substantial proportion of cases with definite or
possible TIAs or minor stroke and an ABCD2 score ⬍4 had
underlying disease (eg, carotid stenosis ⬎50%, severe intracranial stenosis, or atrial fibrillation) associated with a high
risk for stroke recurrence.
In July 2008, NICE recommended immediate evaluation
(within 24 hours) of patients with a TIA in a TIA clinic when
their ABCD2 score was ⱖ4 or when the patient had had at
least 2 TIAs in the previous week. Triage of patients in many
TIA clinics is also based on an ABCD2 score of ⱖ4. Experts
from NICE decided that patients with an ABCD2 score ⬍4
can be evaluated within 1 week as well as patients with an
ABCD2 score ⬎4 but who were seen ⬎1 week after the TIA
event. Our data show that by following these criteria too
strictly, clinicians would miss 9.1% of patients with an
ABCD2 score ⬍4 who had a symptomatic internal carotid
stenosis ⱖ50%, 5.9% of patients with an ABCD2 score ⬍4
and atrial fibrillation, 2.1% of patients with other major
cardiac source of embolism who might be considered for oral
anticoagulation and/or cardioversion, and 5.0% of patients
with an ABCD2 score ⬍4 and symptomatic intracranial artery
disease, which carries a very high risk of recurrent stroke.
Altogether, in our cohort, this translates into 20% of patients
at very high risk of recurrence not detected by the ABCD2
score ⬍4 (Table 2).
Overall, an ABCD2 score ⱖ4 and the NICE criteria had a
reasonably good negative predictive value and a moderate
sensitivity and specificity for identification of patients fulfilling the criteria for admission to a stroke unit. These criteria
form part of the National Stroke Association guidelines for
stroke unit admission in patients with a TIA.6
In this analysis, we have focused on causes such as
extracranial carotid artery stenosis ⱖ50% or atrial fibrillation
Amarenco et al
for which potential therapeutic interventions (eg, carotid
endarterectomy) has been proven effective. However, a stateof-the-art neurosonography or CT angiography can detect
other location of atherosclerosis (eg, vertebral artery origin
stenosis) that might benefit from therapeutic intervention not
yet proven effective.
In conclusion, no patients with ipsilateral symptomatic
carotid stenosis ⱖ50% or with atrial fibrillation should be
missed or overlooked regardless of ABCD2 score. Based on
our data, when triaging patients based on ABCD2 score above
or below 4, clinicians should perform immediate (within 24
hours) carotid ultrasound examination (or default angiographic CT scan) and an electrocardiogram in patients with a
TIA before deciding to postpone the workup beyond the
24-hour window.
Acknowledgments
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Sophie Rushton-Smith, PhD, provided editorial assistance in the
final draft of this manuscript and was funded by SOS-ATTAQUE
CEREBRALE Association.
Source of Funding
Supported by the SOS-ATTAQUE CEREBARALE Association
(a not-for-profit stroke survivor and research organization).
Triage Based on ABCD2 Score
3095
Disclosures
None.
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Does ABCD2 Score Below 4 Allow More Time to Evaluate Patients With a Transient
Ischemic Attack?
Pierre Amarenco, Julien Labreuche, Philippa C. Lavallée, Elena Meseguer, Lucie Cabrejo, Tarik
Slaoui, Céline Guidoux, Jean-Marc Olivot, Halim Abboud, Bertrand Lapergue, Isabelle F.
Klein, Mikael Mazighi and Pierre-Jean Touboul
Downloaded from http://stroke.ahajournals.org/ by guest on June 16, 2017
Stroke. 2009;40:3091-3095; originally published online June 11, 2009;
doi: 10.1161/STROKEAHA.109.552042
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 2009 American Heart Association, Inc. All rights reserved.
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