Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack

Abstract

Background: The ABCD2 score (Age, Blood pressure, Clinical features, Duration of symptoms and Diabetes) is used to identify patients having a transient ischemic attack who are at high risk for imminent stroke. However, despite its widespread implementation, the ABCD2 score has not yet been prospectively validated. We assessed the accuracy of the ABCD2 score for predicting stroke at 7 (primary outcome) and 90 days.

Methods: This prospective cohort study enrolled adults from eight Canadian emergency departments who had received a diagnosis of transient ischemic attack. Physicians completed data forms with the ABCD2 score before disposition. The outcome criterion, stroke, was established by a treating neurologist or by an Adjudication Committee. We calculated the sensitivity and specificity for predicting stroke 7 and 90 days after visiting the emergency department using the original "high-risk" cutpoint of an ABCD2 score of more than 5, and the American Heart Association recommendation of a score of more than 2.

Results: We enrolled 2056 patients (mean age 68.0 yr, 1046 (50.9%) women) who had a rate of stroke of 1.8% at 7 days and 3.2% at 90 days. An ABCD2 score of more than 5 had a sensitivity of 31.6% (95% confidence interval [CI] 19.1-47.5) for stroke at 7 days and 29.2% (95% CI 19.6-41.2) for stroke at 90 days. An ABCD2 score of more than 2 resulted in sensitivity of 94.7% (95% CI 82.7-98.5) for stroke at 7 days with a specificity of 12.5% (95% CI 11.2-14.1). The accuracy of the ABCD2 score as calculated by either the enrolling physician (area under the curve 0.56; 95% CI 0.47-0.65) or the coordinating centre (area under the curve 0.65; 95% CI 0.57-0.73) was poor.

Interpretation: This multicentre prospective study involving patients in emergency departments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cut-point, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific.

Figure 1:

Receiver operator characteristic curves comparing the sensitivity and specificity of the ABCD2 scores calculated by the coordinating centre versus the scores calculated by the treating physician for predicting stroke. (A) Comparison of scores calculated by the coordinating centre (area under the curve [AUC] 0.65 [95% confidence interval (CI) 0.58–0.73]) and by the treating physician (AUC 0.56 [95%CI 0.47–0.65]) for predicting stroke at 7 days. (B) Comparison of scores calculated by the coordinating centre (AUC 0.65 [95% CI 0.59–0.70]) and by the treating physician (AUC 0.60 [95% CI 0.54–0.67]) for predicting stroke at 90 days.

Figure 2:

Receiver operator characteristic curve comparing sensitivity and specificity of the ABCD2 scores calculated by the coordinating centre versus the scores calculated by the treating physician for predicting recurrent transient ischemic attack. (A) Comparison of scores calculated by the coordinating centre (area under the curve [AUC] 0.52 [95% confidence interval (CI) 0.45–0.59]) and by the treating physician (AUC 0.54 [95%CI 0.46–0.61]) for predicting recurrent attack at 7 days. (B) Comparison of scores calculated by the coordinating centre (AUC 0.52 [95% CI 0.48–0.57]) and by the treating physician (AUC 0.53 [95% CI 0.484–0.58]) for predicting recurrent attack at 90 days.