Key result
Brown ESUS-AF score predicts post-cryptogenic stroke AF with ~0.76 discriminatory accuracy.
Why the study?
Do published scoring systems (such as C2HEST, Brown ESUS-AF, and AS5F) accurately predict incident atrial fibrillation in patients with cryptogenic stroke or ESUS?
Observational (n=132)
No
Do published scoring systems (such as C2HEST, Brown ESUS-AF, and AS5F) accurately predict incident atrial fibrillation in patients with cryptogenic stroke or ESUS?
The C2HEST, Brown ESUS-AF, and AS5F scoring systems are capable of distinguishing cryptogenic stroke/ESUS patients at low versus higher risk of atrial fibrillation, aiding in optimizing resource allocation for prolonged cardiac monitoring.
These scores may aid AF risk stratification after cryptogenic stroke; extends validation but leaves open utility for guiding monitoring.
BACKGROUND: Atrial fibrillation (AF) is a common but often undetected cause of cryptogenic stroke (CS) and embolic stroke of undetermined source (ESUS). Implantable cardiac monitors aid in detecting subclinical AF, but their widespread use is limited by cost and logistical challenges. Several scoring systems exist to predict AF in patients with CS/ESUS, though few have been externally validated. This study was designed to externally validate 7 scoring systems for predicting incident AF in patients with CS/ESUS. METHODS: In this observational study, we analyzed 132 patients with CS or transient ischemic attack who received implantable cardiac monitors. After a comprehensive literature search, 7 prediction models (Coronary Artery Disease or Chronic Obstructive Pulmonary Disease, Hypertension, Elderly, Systolic Heart Failure, Thyroid Disease [C2HEST], Brown ESUS-AF, ESUS-AF, Hypertension, Age, Valvular Heart Disease, Peripheral Vascular Disease, Obesity, Congestive Heart Failure, Coronary Artery Disease [HAVOC], Age, Hypercholesterolemia, Tricuspid Regurgitation, Left Ventricular End-Diastolic Volume, Left Atrium [ACTEL], Age, Stroke Severity, National Institutes of Health Stroke Scale >5 to Find Atrial Fibrillation [AS5F], and Coronary, Heart Failure, Age, Stroke Severity, Lipidemia, Sugar, Prior Stroke [CHASE-LESS]) were applied. The primary outcome was the discriminatory ability to detect AF. Secondary outcomes included evaluating the threshold scores and the performance of such threshold-based criteria for predicting nonoccurrence of AF with high specificity. RESULTS: AF was detected in 40 patients (30.3%) over a mean follow-up of 13±12 months. Area under the receiver operating characteristic curves were C2HEST (0.704), Brown ESUS-AF (0.755), AS5F (0.726), ESUS-AF (0.607), HAVOC (0.661), ACTEL (0.650), and CHASE-LESS (0.671). C2HEST, Brown ESUS-AF, and AS5F showed acceptable predictive performance (area under the receiver operating characteristic curve >0.7). Threshold-based criteria using these scores achieved high specificity and positive predictive value. Combining thresholds across scores improved identification of patients unlikely to develop AF. CONCLUSIONS: C2HEST, Brown ESUS-AF, and AS5F scores reliably predicted AF in patients with CS/ESUS and may help identify low-risk individuals, supporting more targeted use of diagnostic tools and guiding stroke prevention strategies.
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Pinnacchio et al. (2026) conducted an observational in Cryptogenic stroke or embolic stroke of undetermined source (n=132). 7 clinical scoring systems (C2HEST, Brown ESUS-AF, ESUS-AF, HAVOC, ACTEL, AS5F, CHASE-LESS) was evaluated on Discriminatory ability to detect incident atrial fibrillation (AUC) (AUC 0.755 (Brown ESUS-AF), 95% CI 0.666-0.844). The Brown ESUS-AF, AS5F, and C2HEST scoring systems demonstrated acceptable discriminatory ability to predict incident atrial fibrillation in patients with cryptogenic stroke, with AUCs of 0.755, 0.726, and 0.704 respectively.
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