Development of a Prognostic Tool for the Stratification of Cardiovascular Risk in Patients With Ischemic Stroke

Background and rationale Patients with established cardiovascular disease are at very high risk for recurrent cardiovascular events and mortality1. Nevertheless, within this very high risk group, there is significant variation of the underlying risk with some patients being at the extreme edge of the spectrum2,3.

The identification of these patients is of utmost importance as it may have implications for management strategies such as prioritization of high-cost strategies like PCSK9 inhibitors and aggressive treatment of modifiable risk factors like arterial hypertension and dyslipidemia. Refined risk stratification may also guide treatment decisions in situations where the balance between the expected benefit and the risk of serious adverse events is borderline like in patients with high bleeding risk who need aggressive antithrombotic treatment, or patients with intracranial bleeding and an indication for antithrombotic treatment4. In addition, it may allow identify those patients who may benefit more from an intensive follow-up schedule. Finally, improved risk stratification may have a positive impact on the motivation of the patient to adhere to secondary prevention strategies.

Identification of patients at greater risk of secondary vascular events after ischaemic stroke is challenging because stroke is an etiologically heterogeneous syndrome which may be caused by a diverse set of pathophysiologically discrete diseases like atrial fibrillation (AF), small vessel disease, atherosclerosis and others5.

The CHA2DS2VASc score has been shown to predict long-term stroke outcomes in patients with ischaemic stroke, both with and without AF6-8.

The Essen Stroke Risk score (ESRS) was derived from patients with ischaemic stroke in the CAPRIE trial and was shown to stratify the 1-year risk of stroke recurrence or major vascular events9.