Electrical risk score as a predictor of acute ischemic stroke and 30-day mortality: a prospective observational study

Ischemic stroke (IS) remains a leading cause of death and disability worldwide. Stroke–heart syndrome, triggered by acute cerebral ischemia, causes autonomic dysfunction that can result in myocardial injury, arrhythmias, and sudden cardiac death, even in the absence of preexisting cardiac disease. The Electrical Risk Score (ERS), derived from standard electrocardiographic (ECG) parameters, has prognostic value in cardiac conditions, but its utility in IS populations remains unclear. This study aimed to evaluate the discriminative performance of ERS between confirmed acute IS patients and matched healthy controls, and to assess its prognostic value for 30-day all-cause mortality among patients with IS. This prospective observational study enrolled 200 patients with acute IS and 101 age- and sex-matched healthy controls at a tertiary emergency department. ERS (range: 0–6) was calculated using six predefined ECG parameters: heart rate, QTc interval, Tp-e interval, frontal QRS-T angle, QRS transition zone, and left ventricular hypertrophy. ERS was significantly higher in IS patients compared to controls (p < 0.001). ERS independently predicted 30-day mortality (adjusted OR 1.66, 95% CI 1.14–2.42; p = 0.008). Receiver operating characteristic (ROC) analysis showed that ERS ≥ 3 discriminated confirmed IS cases from matched controls with 61% sensitivity and 77% specificity (AUC: 0.725; 95% CI: 0.669–0.781; PPV: 0.841; NPV: 0.500; p < 0.001). ERS ≥ 4 predicted 30-day mortality with 55% sensitivity and 74% specificity (AUC: 0.681; 95% CI: 0.585–0.778; PPV: 0.267; NPV: 0.907; p = 0.002). Higher ERS values showed a significant positive correlation with stroke severity based on Glasgow Coma Scale (GCS) scores (p = 0.005). ERS is a simple bedside ECG-based tool with moderate accuracy for predicting acute IS and short-term mortality. It may support early risk stratification in settings with limited stroke-specific resources. Further multicenter studies are needed for validation.