Outros exames complementares
• Glicemia e eletrólitos
– Descartar hipoglicemia e distúrbio metabólico
• Coagulograma
– Base para anticoagulação/ trombólise
• HMG e plaquetas
– Afastar coagulopatias
• Enzimas cardíacas
– Identificar IAM/ risco de cardioembolismo
• Perfil lipídico
– Identificar fator de risco
• ECG
– Arritimias/ risco de cardioembolismo
• LCR
Escala de
Cincinnati
Medidas gerais
TAC/ RM de crânio
ECG
Testes sanguíneos
ABCD2 ≥4
Terapia
apropriada
Articles
Score ABCD2
Validation and reﬁnement of scoresto predict very early
stroke risk after transient ischaemicattack
SClaiborneJohnston, Peter M Rothwell, Mai N Nguyen-Huynh, Matthew FGiles, Jacob SElkins, Allan LBernstein, Stephen Sidney
Summary
Background We aimed to validate two similar existing prognostic scores for early risk of stroke after transient ischaemic
attack (TIA) and to derive and validate a uniﬁed score optimised for prediction of 2-day stroke risk to inform emergency
management.
Methods The California and ABCD scores were validated in four independent groups of patients (n=2893) diagnosed
with TIA in emergency departments and clinics in deﬁned populations in the USA and UK. Prognostic value was
quantiﬁed with c statistics. The two groups used to derive the original scores (n=1916) were used to derive a new
uniﬁed score based on logistic regression.
Findings The two existing scores predicted the risk of stroke similarly in each of the four validation cohorts, for stroke
risks at 2 days, 7 days, and 90 days (c statistics 0· 60–0· 81). In both derivation groups, c statistics were improved for a
uniﬁed score based on ﬁve factors (age ≥60 years [1 point]; blood pressure ≥140/ 90 mm H g [1]; clinical features:
unilateral weakness [2], speech impairment without weakness [1]; duration ≥60 min [2] or 10–59 min [1]; and diabetes
[1]). This score, ABCD2, validated well (c statistics 0· 62–0· 83); overall, 1012 (21%) of patients were classiﬁed as high
risk (score 6–7, 8· 1% 2-day risk), 2169 (45%) as moderate risk (score 4–5, 4· 1%), and 1628 (34%) as low risk (score
0–3, 1· 0%).
Implications Existing prognostic scores for stroke risk after TIA validate well on multiple independent cohorts, but the
uniﬁed ABCD2 score is likely to be most predictive. Patients at high risk need immediate evaluation to optimise stroke
prevention.
Introduction
score was developed to predict stroke within 90 days and
Lancet 2007; 369: 283–92
SeeComment page251
StrokeService, Department of
Neurology, University of
California, SanFrancisco,
CA94143-0114, USA
(SCJohnston MD,
MNNguyen-Huynh MD,
JSElkinsMD); Stroke
Prevention ResearchUnit,
UniversityDepartment of
Clinical Neurology, Radcliffe
Inﬁrmary, Oxford, UK
(PMRothwell MD,
MFGilesMRCP); and Division of
Research, Kaiser-Permanente
Northern California, Oakland,
CA, USA(SCJohnston,
ALBernstain MD, SSidneyMD)
Correspondenceto:
Dr SClaiborneJohnston
[email protected]
Score ABCD2
• Age ≥60  1 ponto
• Blood pressure  1 ponto
– PS≥140mmHg
– PD≥90mmHg
• Baixo risco: <4
• Moderado risco: 4-5
• Alto risco: >5
• Clinical features
– Hemiparesia ou  2 pontos
– Distúrbio de fala sem hemiparesia  1 ponto
• Duration of TIA
– 10-59min  1 ponto
– ≥60min  2 pontos
• Diabetes  1 ponto
Score ABCD2
Stroke risk
•1628 (34%) – low risk (<4)
– 1,0% at 2 days
– 1,2% at 7 days
– 3,1% at 90 days
•2169 (45%) – moderate risk (4
or 5)
– 4,1% at 2 days
– 5,9% at 7 days
– 9,8% at 90 days
•1012 (21%) – high risk (>5)
– 8,1% at 2 days
– 11,7% at 7 days
– 17,8% at 90 days
Score ABCD2
Stroke risk
•1628 (34%) – low risk (<4)
– 1,0% at 2 days
– 1,2% at 7 days
– 3,1% at 90 days
•2169 (45%) – moderate risk (4
or 5)
– 4,1% at 2 days
– 5,9% at 7 days
– 9,8% at 90 days
•1012 (21%) – high risk (>5)
– 8,1% at 2 days
– 11,7% at 7 days
– 17,8% at 90 days
Escala de
Cincinnati
Medidas gerais
TAC de crânio
ECG
Testes sanguíneos
ABCD2 ≥4
Terapia
apropriada
Não
Investigação
ambulatorial
Escala de
Cincinnati
Medidas gerais
TAC de crânio
ECG
Testes sanguíneos
SIM
Internação
Testes sanguíneos
Ecodoppler de carótidas
Ecocardiograma
RM
AngioTC
Holter
ABCD2 ≥4
Terapia
apropriada
Não
Investigação
ambulatorial
Tratamento pós fase aguda
•
•
•
•
•
Monitorização de dados vitais
Avaliação de risco
Prevenir acidente vascular encefálico grave
Controlar hipertensão
Iniciar terapia antitrombótica após descartar
hemorragia
• Tratar doença base
Regime
•Clopidogrel + Aspirina – 21 dias
•Clopidogrel – 90 dias
Superior a Aspirina isolada em
•Prevenção de AVE
•Sem diferença em eventos hemorrágicos
fter transient ischaemicattack:
and meta-analysis
Articles
Prognóstico
y transient
attack (TIA),
studies ofischaemic
stroke risk after
TIA are
Risk ofischaemic
stroke early
afterbut
transient
attack:
onﬂicting results. However, reliable estimation of this risk is necessary for
a systematic
review
and
nical
trials, and public
education.
Wemeta-analysis
therefore did a systematic review of all
Matthew FGiles, Peter M Rothwell
Summary
Lancet Neurol 2007; 6: 1063–72
Published Online
November 12, 2007
DOI:10.1016/S14744422(07)70274-0
StrokePreventionResearch
n7
days of Stroke
TIA were
use of
electronic
databases
andofby
hand
Background
is oftenidentiﬁ
precededed
by by
transient
ischaemic
attack (TIA),
but studies
stroke
risk after
areUnivers
Lancet Ne
urol 2007; 6: 10
Unit,TIA
Oxford
ity
logistically
difficult and abstracts.
have yielded Stroke
conﬂicting
results.
reliable
estimation
thiswere
risk is necessary
forof C
Publis
he
d Online
nals,
and conference
risks
at 2However,
days and
7 days
after of
TIA
Department
linic
al
November 12, 2007
planning effective service provision, clinical trials, and public education. We therefore did a systematic Neurology,
review of all
Radc
liffeInﬁrmary,
ogeneity
were
done,
if
possible,
after
categorisation
by
study
method,
setting,
DOI:10.1016/S1474studies of stroke risk early af ter TIA.
•Em pessoas com AIT
•Incidência de AVE:
Oxford, UK(MF4422(07
GilesD
hil,
)7P
0274-0
PMRothwell FRS
C
P) PreventionResea
troke
Methods All studies of stroke risk within 7 days of TIA were identiﬁed by use of electronic databases and by hand Unit, OxfordUniversity
Corre
sponde
searches of reference lists, relevant journals, and conference abstracts. Stroke risks at 2 days and 7 days after
TIA
werenceDto:
epartment of Clinical
ncluded,
which
reported
stroke
risk
in
10
126
TIA
patients.
The
pooled
stroke
calculated overall and analyses for heterogeneity were done, if possible, after categorisation by study method,
setting,
Matthe
wFGiles,Neurology,
Stroke RadcliffeInﬁr
xford, UK(MFGilesDPh
ys,population,
but there
was
substantial heterogeneity between studies (p<0· 0001), with Prevention ReseaOPrc
and
treatment.
h Unit, Oxford
MRothwell FRCP)
ofnc
Celinic
wever, the risks reported in individual studies over different durations of UniversityDepartme
Corresnt
ponde
to: al
Findings 18 independent cohorts were included, which reported stroke risk in 10 126 TIA patients. The pooled
stroke
atthe
wFrma
Gilesry,
, Stroke
Neurology, RadcM
liff
eInﬁ
aysrisk
vswas
8–90
days,
89,5)p<0·
0001),
andwas
thesubstantial
heterogeneity
between
5· 2%
(95% r=0·
CI 3· 9–6·
at 7 days,
but there
heterogeneity
betweenstudies
studies (p<0· 0001), with Prevention Research Unit,
WoodstockRoad, Oxford
risks ranging
fromand
0% totreatment.
12· 8%. However,
risks reported
individual
over different
of UniversityDepartment of
method,
setting,
Thethelowest
risks inwere
seenstudies
in studies
of durations
OX26HA, UK Neurology, RadcliffeInﬁrm
were highly correlated (0–7 days vs 8–90 days, r=0· 89, p<0· 0001), and the heterogeneity between studies
WoodstockRoad, Oxford
ke follow-up
services
(0· 9% [95% CI 0· 0–1· 9], four studies) and the highest risks in
was almost fully explained by study method, setting, and treatment. The lowest risks were seen inmatthew.giles
studies of @
OX26HA, UK
clneuro.ox.ac
t treatment
(11· 0% in
[8·specialist
6–13· 5],
three
studies).
Results
were
forand
stroke
emergency treatment
stroke
services
(0· 9% [95%
CI 0· 0–1·
9], similar
four studies)
the highest
risks in .uk
matthew.giles@
– 11% na 1ª semana
– 24-29% ao longo dos 5 anos seguintes
population-based studies without urgent treatment (11· 0% [8· 6–13· 5], three studies). Results were similar for stroke
risk at 2 days.
clneuro.ox.ac.uk
Prognóstico
Conclusões
• AIT é preditor de AVEi
• Até 20% dos AVEi são precedidos por AIT
• Até 30% dos pacientes não buscam auxílio
médico após AIT
• Mudança no estilo de vida
• Tratamento da doença base
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