Role of the combined CHADS2 score and echocardiographic abnormalities in predicting stroke in patients with paroxysmal atrial fibrillation

The purpose of the study was to determine if adding echocardiographic abnormalities (EA) to the CHADS2 score is superior to the CHADS2 score alone in predicting ischemic stroke in patients with atrial fibrillation (AF). We then determined if the presence of these criteria in patients with cryptogenic stroke (CS) could be used “backwards” to predict paroxysmal AF. Of 1633 patients with ischemic stroke admitted from January 2003 to December 2008, we retrospectively analyzed CHADS2 and/or EA prior to stroke in 276 patients with stroke with documented AF. We then assessed the presence of these abnormalities in 169 patients with CS. Additionally, the follow up electrocardiogram (ECG) in patients with CS for six months post stroke were reviewed. In AF stroke patients, 88.8% (245/276) had CHADS2 ⩾ 2 alone prior to the stroke, however the ability to predict stroke increased to 97.5% (269/276) with addition of EA. Of 169 patients with CS, 63.1% (106/169) had CHADS2⩾ 2 and/or EA prior to this stroke. Of 63 patients with six-month follow-up ECG available, AF was detected in six (9.5%) patients, all with high CHADS2 or EA. We found that the combined use of CHADS2 criteria and EA is more sensitive in determining the occurrence of ischemic stroke and the need for anticoagulation in patients with AF (97.5% compared to 88.8%). The detection of concealed AF in 9.5% of patients with CS on follow up ECG and the presence of high CHADS2 and EA in these patients emphasize the need for long-term event monitoring in these patients.