Essen risk score in prediction of myocardial infarction after transient ischemic attack or ischemic stroke without prior coronary artery disease

Abstract

Background and Purpose-More intensive secondary prevention with newer drugs may be cost-effective in patientswith coronary artery disease (CAD). Whether some subgroups of patients who had a transient ischemic attack (TIA)or ischemic stroke, but no prior CAD are at similar high risk of myocardial infarction as those with prior CAD remainsunclear. We determined whether the Essen score identified a subset of TIA/stroke patients without known prior CADwho, nevertheless, had a high risk of myocardial infarction on current secondary prevention management.Methods-In a population-based cohort (Oxford Vascular Study) of consecutive TIA or ischemic stroke patients recruitedfrom 2002 to 2014, 10-year actuarial risks of myocardial infarction and of recurrent ischemic stroke were determinedby face-to-face follow-up in patients with and without prior CAD using Kaplan-Meier analyses. Predictive value of theEssen score was assessed with C statistic.Results-Of 2555 patients with TIA/stroke (13 070 patient-years of follow-up), 10-year risk of myocardial infarction inthose without prior CAD (n=2017, 78.9%) ranged from 0.9% (95% CI, 0-1.9) at Essen score =1 to 29.8% (95% CI, 7.7-46.6) in those with a score =5 (C statistic =0.64 [95% CI, 0.57-0.71]; P<0.001). The score tended to be less predictive(difference: P=0.0460) for the risk of recurrent ischemic stroke (C statistic =0.57 [95% CI, 0.54-0.60]). Compared withpatients with prior CAD (n=538, 21.1%), an Essen risk score of =4 (n=294, 11.5%) in those without prior CAD identifieda subgroup at similar high 10-year risks of myocardial infarction (17.2% [95% CI, 6.9-26.3] versus 16.9% [95% CI,11.5-22.0]) and of recurrent stroke (40.4% [95% CI, 26.7-51.6] versus 32.4% [95% CI, 25.2-38.8]).Conclusions-The Essen score is a simple clinical score to risk-stratify patients with TIA/stroke without prior CAD andto identify subsets who may be at sufficiently high risk of myocardial infarction and recurrent stroke to justify moreintensive treatment or inclusion in trials.