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Stroke. 2017 Mar;48(3):726-732. doi: 10.1161/STROKEAHA.116.015770. Epub 2017 Feb 9.

Prediction of Early Recurrent Thromboembolic Event and Major Bleeding in Patients With Acute Stroke and Atrial Fibrillation by a Risk Stratification Schema: The ALESSA Score Study.

Author information

1
From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M.P., G. Agnelli, V.C., C.B., N.F., A.A., M.V., M. Acciarresi, C.D., M.G.M., L.A.C., A. Procopio); Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (G.T., K.V.); International Clinic Research Center, St Anne's University Hospital Brno, Czech Republic (G.T.); Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni); Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., P.T., S.Y.); Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy (M.Z.); Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.); Unità Semplice Dipartimentale (USD) Stroke Unit, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Sweden (T. Tatlisumak); Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.); Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S. Marcheselli); Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani); Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V. Vannucchi); Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.); Stroke Unit, AOU Senese, Siena, Italy (G.L.); SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Pontedera o Volterra, Azienda USL Toscana Nord Ovest, Italy (R.T., F. Guideri, M. Acampa, G. Martini); Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., G. Athanasakis, K.M.); Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.); Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F. Galati); Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy (S.S., A. Carolei, C.T.); UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno (F.C.); Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy (W.A., M.B., G.C.); S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone); Stroke Unit, Neuroscience Department, University of Parma, Italy (U.S.); Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.); Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, G.O., N.G., G.G., A. Chiti); Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.); Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T. Tassinari); Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L. D.L., G.B.); Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.); Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy (A.B., S.D.); Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni); U.O. Neurologia Stroke Unit, Ospedale SM delle Croci, Ravenna, Italy (E.M.L.); Stroke and Neurorehabilitation Unit, MC 'Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.); Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.); 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.); Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M.M.B.); Stroke Unit, University of Debrecen, Hungary (L.C., L.S.); Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G., M.D.S.); Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.); Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.); City Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V. Volodina); Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne (Switzerland) (P.M.); Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium (P.V.); Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.K., U.B., J.G.); Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.); and Department of Neurology, Evangelismos Hospital, Athens (V.G.). maurizio.paciaroni@unipg.it.
2
From the Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M.P., G. Agnelli, V.C., C.B., N.F., A.A., M.V., M. Acciarresi, C.D., M.G.M., L.A.C., A. Procopio); Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (G.T., K.V.); International Clinic Research Center, St Anne's University Hospital Brno, Czech Republic (G.T.); Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Greece (G.T., C.L., M. Chondrogianni); Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (K.L.F., P.T., S.Y.); Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy (M.Z.); Medical School and Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.H.A.-R., K.R.L.); Unità Semplice Dipartimentale (USD) Stroke Unit, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, A.R., M. Cappellari); Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Sweden (T. Tatlisumak); Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.); Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S. Marcheselli); Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L.P., A. Padovani); Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (L.M., V. Vannucchi); Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.S.); Stroke Unit, AOU Senese, Siena, Italy (G.L.); SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Pontedera o Volterra, Azienda USL Toscana Nord Ovest, Italy (R.T., F. Guideri, M. Acampa, G. Martini); Department of Medicine, University of Thessaly, Larissa, Greece (G.N., E.K., G. Athanasakis, K.M.); Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.); Stroke Unit, Jazzolino Hospital, Vibo Valentia, Italy (D.C., F. Galati); Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy (S.S., A. Carolei, C.T.); UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno (F.C.); Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy (W.A., M.B., G.C.); S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone); Stroke Unit, Neuroscience Department, University of Parma, Italy (U.S.); Stroke Unit, Dipartimento Geriatrico Riabilitativo, University of Parma, Italy (L.D.); Clinica Neurologica, Azienda Ospedaliero-Universitaria, Pisa, Italy (M. Mancuso, M. Maccarrone, G.O., N.G., G.G., A. Chiti); Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M.G.); Stroke Unit, Department of Neurology, Santa Corona Hospital, Pietra Ligure (Savona), Italy (T. Tassinari); Stroke Unit, Department of Neurology, Insubria University, Varese, Italy (M.L. D.L., G.B.); Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.); Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy (A.B., S.D.); Department of Neurology and Psychiatry, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni); U.O. Neurologia Stroke Unit, Ospedale SM delle Croci, Ravenna, Italy (E.M.L.); Stroke and Neurorehabilitation Unit, MC 'Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.); Stroke Unit, Metropolitan Hospital, Piraeus, Greece (O.K.); 2nd Department of Neurology, AHEPA University Hospital, Thessaloniki, Greece (T.K.); Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco, M.M.B.); Stroke Unit, University of Debrecen, Hungary (L.C., L.S.); Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G., M.D.S.); Divisione di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.); Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.); City Hospital No. 1, Novosibirsk State Medical University, Russia (B.D., V. Volodina); Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne (Switzerland) (P.M.); Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium (P.V.); Department of Neurology, Dresden University Stroke Center, Germany (K.B., L.-P.P., J.K., U.B., J.G.); Neurology, Hamad Medical Corporation, Doha, Qatar (D.D., G. Melikyan, F.I., N.A.); and Department of Neurology, Evangelismos Hospital, Athens (V.G.).

Abstract

BACKGROUND AND PURPOSES:

This study was designed to derive and validate a score to predict early ischemic events and major bleedings after an acute ischemic stroke in patients with atrial fibrillation.

METHODS:

The derivation cohort consisted of 854 patients with acute ischemic stroke and atrial fibrillation included in prospective series between January 2012 and March 2014. Older age (hazard ratio 1.06 for each additional year; 95% confidence interval, 1.00-1.11) and severe atrial enlargement (hazard ratio, 2.05; 95% confidence interval, 1.08-2.87) were predictors for ischemic outcome events (stroke, transient ischemic attack, and systemic embolism) at 90 days from acute stroke. Small lesions (≤1.5 cm) were inversely correlated with both major bleeding (hazard ratio, 0.39; P=0.03) and ischemic outcome events (hazard ratio, 0.55; 95% confidence interval, 0.30-1.00). We assigned to age ≥80 years 2 points and between 70 and 79 years 1 point; ischemic index lesion >1.5 cm, 1 point; severe atrial enlargement, 1 point (ALESSA score). A logistic regression with the receiver-operating characteristic graph procedure (C statistic) showed an area under the curve of 0.697 (0.632-0.763; P=0.0001) for ischemic outcome events and 0.585 (0.493-0.678; P=0.10) for major bleedings.

RESULTS:

The validation cohort consisted of 994 patients included in prospective series between April 2014 and June 2016. Logistic regression with the receiver-operating characteristic graph procedure showed an area under the curve of 0.646 (0.529-0.763; P=0.009) for ischemic outcome events and 0.407 (0.275-0.540; P=0.14) for hemorrhagic outcome events.

CONCLUSIONS:

In acute stroke patients with atrial fibrillation, high ALESSA scores were associated with a high risk of ischemic events but not of major bleedings.

KEYWORDS:

atrial fibrillation; myocardial infarction; risk stratification; stroke

PMID:
28183856
DOI:
10.1161/STROKEAHA.116.015770
[Indexed for MEDLINE]

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