Role of CHA₂DS₂-VASc score for severity and outcome prediction in acute ischemic stroke: a cross-sectional study from tertiary care center of Nepal

Abstract

Introduction:

Acute ischemic stroke (AIS) is a major cause of hospital admission and is responsible for a large proportion of disabilities. The CHA₂DS₂-VASc score was developed to improve the accuracy of stroke risk stratification in patients with non-valvular atrial fibrillation. It includes major risk factors for ischemic stroke and may be useful in prognostic risk stratification before and after the event of acute ischemic stroke. This study was conducted to study the role of CHA₂DS₂-VASc score in severity and outcome prediction of acute ischemic stroke.

Methods:

A cross-sectional study was conducted in a tertiary center in Nepal for the period of 12 months (June 2021 to June 2022) including patients more than 18 years presenting with symptoms of stroke and underwent neuroimaging studies at admission with the diagnosis of acute ischemic stroke. The National Institute of Health (NIH) stroke scale score, pre-stroke and current functional status according to modified Rankin scale (mRS) score were noted. The CHA₂DS₂-VASc score was calculated. Based on the result, patients were grouped into low-risk CHA₂DS₂-VASc score (0, 1) and high-risk CHA₂DS₂-VASc score. At discharge, patients were evaluated and their functional status was noted according to mRS score.

Results:

Seventy-five patients with acute ischemic stroke were enrolled in the study, in which 48 (64%) were male and only 35 (46.7%) of patients could reach the emergency department within 24 hours of onset of symptoms. The mean age of patients was 61.8 ± 16.04 years and 18 (24%) of patients were of age ≥75 years. Hemiplegia/paresis with UMN facial palsy was the most common presentation. Smoking and hypertension were the most common risk factors followed by diabetes mellitus. The severity of stroke as evaluated by NIH stroke scale score at the time of admission categorized as minor, moderate, moderately severe, and severe stroke was present in 7 (9.3%), 47 (62.7%), 11 (14.7%), and 10 (13.3%) patients, respectively. Low-risk CHA₂DS₂-VASc score (0, 1) was observed in 23 (30.7%) of patients, and a high-risk score (≥2) in the remaining patients. On evaluation of the functional status at the time of discharge, 28 (37.3%) patients had mRS scores of good outcome (0, 1, 2) and remaining had mRS score ≥3.

Conclusion:

The CHA₂DS₂-VASc score demonstrates significant predictive value in evaluating both the severity and functional outcomes of acute ischemic stroke patients. In this study, a higher CHA₂DS₂-VASc score was associated with more severe stroke presentations and poorer discharge outcomes. Given its simplicity and reliance on readily available clinical data, the CHA₂DS₂-VASc score can serve as a practical, cost-effective tool for early prognostic stratification in AIS management.

HIGHLIGHTS

• The CHA₂DS₂-VASc score was developed to improve the accuracy of stroke risk stratification in patients with non-valvular atrial fibrillation.

• Study was conducted to outline the role of CHA₂DS₂-VASc score in severity and outcome prediction of acute ischemic stroke in a tertiary center in Nepal.

• In patients with acute ischemic stroke, the higher CHA₂DS₂-VASc score was found to be significantly associated with the severity and poor discharge outcome.

• This simple scoring can be a very easy and useful measure for stratification of acute ischemic stroke patients according to their prognostic risk.

Introduction

Acute ischemic stroke (AIS) is a major cause of hospital admission and is responsible for a large proportion of disabilities. Stroke is the second most common cause of morbidity and mortality after ischemic heart disease. In 2015, 5.78 million people died from stroke worldwide and it has been the second leading cause of death in the last 16 years. In Southeast Asia, it was the fourth leading cause of death in 2000 which increased to the second leading cause of death tolling about 1.25 million in 2016 which amounts to 21.6% of worldwide deaths from stroke^[1].

Male sex, older age, smoking, hypertension, diabetes, hypercholesterolemia and atrial fibrillation are major conventional risk factors for stroke.^[2] Others behavioral risk factors include unhealthy diet, physical inactivity, and harmful use of alcohol. The effects of behavioral risk factors manifest in individuals with increased blood pressure, increased blood glucose, increased blood lipids and obesity.^[3] Among these, hypertension, physical inactivity and smoking were the most common risk factors of stroke in the Nepalese population.^[4]

For the estimation of stroke risk in patients with non-valvular atrial fibrillation (NVAF), the CHA₂DS₂-VASc (acronym for congestive heart failure, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack, vascular diseases, age 65–75 years, sex category (female)) score was developed to improve the accuracy of stroke risk stratification and to complement the CHADS₂ score (acronym for congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke/transient ischemic attack) by incorporating other common stroke risk factors.^[5] A score of 0 is considered low risk for stroke, and no anticoagulant therapy is recommended. Non-valvular AF with score of 1 is considered moderate risk which predicts 1.3% annual stroke rate, and antithrombotic therapy with aspirin is recommended, but anticoagulant therapy can be considered, on weighing with risk of bleeding. A score of 2 or more is considered high risk which predicts an increased annual stroke rate and anticoagulant therapy is recommended in all cases of non-valvular AF with routine monitoring.^[6] Most components of the CHA₂DS₂-VASc score are the risk factors of atherosclerosis. The frequency and burden of cerebral artery atherosclerosis were greater in patients with higher CHADS₂ scores. In this sense, the increased risk of stroke in patients with high CHA₂DS₂-VASc scores may be associated with an increased risk of atherothrombosis and hence ischemic stroke in AF as well as non-AF patients.^[7]

Various studies have established role of CHA₂DS₂-VASc score for stroke risk prediction in patients without AF with similar accuracy to that observed in historical populations with non-valvular AF but with lower absolute event rates.^[8] In particular, it is more useful for estimating the risk of stroke or transient ischemic attack in hypertensive patients without known atrial fibrillation in the older population.^[9] The CHA₂DS₂-VASc tool has also been found to predict thromboembolic events and overall mortality in patients without atrial fibrillation who were studied with implantable cardiac devices to rule out AF^[10]. Furthermore, the CHA₂DS₂-VASc score is found to be a sensitive tool for predicting new-onset atrial fibrillation and adverse outcomes in subjects both with and without atrial fibrillation. In addition, the high-risk score was an independent predictor of all causes of death.^[11]

Studies assessing the association between CHA₂DS₂-VASc score and AIS severity and its outcome are lacking in Nepalese population. This study aims to determine the pre-stroke CHA₂DS₂-VASc score in acute ischemic stroke patients in Nepalese population and assess the possible association of score with the severity of AIS, in-hospital mortality, and discharge outcome of those cases. Thus, knowing the factors that affect the stroke severity and prognosis in patients with ischemic stroke may be directive to risk stratification which may be used to decide primary prevention, and to manage such cases with a new treatment modality earlier before the onset of AIS and thus to prevent poor outcome in days to come.^[12]

Objectives

The primary objective was to evaluate the predictive value of the CHA₂DS₂-VASc score in predicting severity and outcome among patients of acute ischemic stroke. The secondary objectives were: (a) To analyze the distribution of CHA₂DS₂-VASc scores among patients with acute ischemic stroke, (b) to determine the risk factors profile of acute ischemic stroke, (c) to determine the association between CHA₂DS₂-VASc score with severity of acute ischemic stroke, and (d) to assess the relationship between CHA₂DS₂-VASc scores and discharge outcomes in acute ischemic stroke patients

Materials & methods

A cross-sectional study was conducted at tertiary center in Nepal for 1 year (June 2021 to June 2022). Ethical approval was obtained from the Institutional Review Board (IRB). All the patients admitted with clinical symptomatology of acute stroke and positive neuroimaging for evidence of ischemic stroke during the study period were enrolled.

Sample size

Sample size (n) = {z² P (1-P)/e²}/ [1 + {z² P (1-P)/Ne²}]

where n = required sample size, Z = reliability coefficient at 5% level of significance (for 95% level of confidence, Z = 1.96), P = proportion of high risk CHA₂DS₂-VASc score in acute ischemic stroke cases, e = precision or maximum tolerable error (1.96 at 95% confidence interval), and N = total number of cases of ischemic stroke in a year.

The data obtained from the studies: Shrestha et al^[13] where N = 121, and Topaz et al^[14] where P = 0.861, were placed in the formula, hence the sample size was calculated to be 75.

Inclusion criteria

Patients of either sex of age more than 18 years and those with an episode of acute ischemic stroke within 7 days of presentation and confirmed by neuroimaging.

Exclusion criteria

Patients with computerized tomography (CT) or magnetic resonance imaging (MRI) findings suggestive of hemorrhagic stroke, sub arachnoid hemorrhage (SAH) and cerebral sinus venous thrombosis and/or patients or their attendants not willing to take part in the study.

Data collection

Data were collected through face-to-face interviews using a structured questionnaire. A comprehensive pro forma recorded patient demographics, risk factors (smoking, alcohol use, atrial fibrillation, systemic illnesses), clinical examination findings, and relevant laboratory investigations. Neurological assessment, including the NIH Stroke Scale (NIHSS) and CHA₂DS₂-VASc score, was performed at admission. Blood parameters (CBC, blood glucose, renal function, HbA1C), ECG, and echocardiography were also recorded. Informed written consent was taken in native language. Every precaution was employed to maintain the privacy of the patient. For those who were not able to give consent because of their clinical state, informed consent was taken from their closest relative. Demographic data on age, gender, ethnicity, height, weight, family history, presence of other symptoms, and medications were noted.

National Institute of Health (NIH) stroke scale score and CHA₂DS₂-VASc score were calculated and noted to assess the severity of stroke^[15,16]. Blood parameters including complete blood count, blood sugar level, renal function tests, and glycated hemoglobin (HbA1C) level were measured on the day of admission. Electrocardiography and echocardiography were done and findings were noted. CHA₂DS₂-VASc stands for congestive heart failure, hypertension, age ≥75 years, diabetes and prior history of stroke or TIA, vascular diseases, age >65 years, sex category (female). It encompasses major risk factors for stroke. It was also incorporated into various guidelines for AF management and further prevention of stroke and thromboembolic events, the score ranges from 0 to 9 and is stratified as scores of 0 = low risk, 1 = intermediate risk, and ≥2 = high risk^[16]. Patients were re-examined at the time of discharge and their functional ability and improvement were assessed. The patient’s post-stroke clinical severity and disability were calculated by using the modified Rankin scale (mRS) score at the time of discharge. It is a 6 point disability scale with possible scores ranging from 0 to 6. The good outcome has a score of mRS ≤2 whereas the poor outcome has a score of mRS >2^[17] (Tables 1–3). This study has been reported in line with STROCSS criteria.^[18]

Table 2.

The 2009 Birmingham schema – CHA₂DS₂-VASc score

Definition and scores for CHA2DS2-VASc		Stroke risk stratification from CHA2DS2-VASc scores
CHA2DS2-VASc	Score	Score	Adjusted stroke rate (% per year)
Congestive HF	1	0	0
Hypertension	1	1	1.3
Age >75	2	2	2.2
Diabetes mellitus	1	3	3.2
Stroke/TIA/TE	2	4	4.0
Vascular disease (prior MI, PAD, or aortic plaque)	1	5	6.7
Age 65–74 y	1	6	9.8
Sex category (i.e., female sex)	1	7	9.6
Maximum score	9	8	6.7
		9	15.2

CHA₂DS₂-VASc score is acronym for congestive heart failure, hypertension, age >75 years, diabetes, previous stroke/transient ischemic attack, vascular diseases, age 65-75 years, sex category (female).

Table 1.

NIH stroke scale categories of stroke

NIH stroke scale score	Stroke severity
0	No stroke symptoms
1–4	Minor stroke
5–15	Moderate stroke
16–20	Moderate to severe stroke
21–42	Severe stroke

NIH (National Institution of Health).

Table 3.

Modified Rankin scale (mRS) score

Score	Description
0	No symptoms.
1	No significant disability. Able to carry out all usual activities, despite some symptoms.
2	Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities
3	Moderate disability. Requires some help, but able to walk unassisted.
4	Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.
5	Severe disability. Requires constant nursing care and attention, bedridden, incontinent.
6	Dead.

mRS (modified Ranking scale).

Statistical analysis

The data was entered in Microsoft Excel and then imported and analyzed using Statistical Package for Social Sciences (IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp). For this study, confidence interval of 95% was taken and a P value of <0.05 was considered statistically significant. The association between parameters was analyzed using chi-square test. Results were presented in tables.

Results

Seventy five patients with acute ischemic stroke were enrolled in the study. The mean age of patients was 61.79 years with age ranging from 25 to 88 years. 48 (64%) patients were male and 27 (36%) patients were female. Only 35 (46.7%) patients could reach the Emergency Department (ED) within 24 hours of symptom onset, while 40 (53.3%) patients could reach the ED only after 24 hours. A majority (70.7%) of patients presented with history of hemiplegia/paresis with features of Upper Motor Neuron (UMN) type facial nerve palsy (Table 4).

Table 4.

Patient demographics

Characteristics	Variables	Frequency	Percentage
Sex	Male	48	64
	Female	27	36
Age category	<65 years	34	45.3
	65–74 years	23	30.7
	<75 years	18	24.0
Presentation time to ED	<24 hrs	35	46.7
	>24 hrs	40	53.3
Clinical features at presentation	Hemiplegia/paresis with IL UMN facial palsy	53	70.7
	Hemiplegia/paresis with IL UMN facial palsy with aphasia	19	25.3
	UMN facial palsy without hemiparesis	3	4.0

Among 75 patients, 4 (5.3%) patients had a history or symptoms of heart failure and the remaining 71 (94.7%) had no such feature. Fifty-three (70.3%) patients either had a history of hypertension (HTN) or were under medication for hypertension, whereas 17 (22.7%) had a history of Diabetes Mellitus (DM) or were under treatment. Only 8 (10.7%) patients had a prior history of Stroke, Transient Ischemic Attack (TIA) or thromboembolism. Similarly, the prior history of vascular diseases including myocardial infarction (MI), peripheral artery disease (PAD), and aortic plaque was present in 3 (4%) patients. On analyzing the smoking history, 54 (72%) patients had history of smoking, and only 7 (9.3%) patients had a prior history or presentation of atrial fibrillation (AF) or were under treatment for AF. Among all the cases of AIS, only one patient (1.3%) had history of valvular heart disease (Table 5).

Table 5.

Associated risk factors of acute ischemic stroke

Characteristics	Variables	Frequency	Percentage
Heart failure	Yes	4	5.3
	No	71	94.7
HTN	Yes	53	70.3
	No	22	29.3
Diabetes	Yes	17	22.7
	No	58	77.3
Prior history of stroke, TIA or thromboembolism	Yes	8	10.7
	No	67	89.3
Prior vascular disease	Yes	3	4
	No	72	96
History of smoking	Yes	54	72
	No	21	28
History of AF	Yes	7	9.3
	No	68	90.7
History of valvular heart disease	Yes	1	1.3
	No	74	98.7

CHA₂DS₂-VASc score distribution

Among all, 23 (30.7%) patients had CHA2DS2-VASc score of either 0 or 1 at presentation, of which 19 were males and 4 were females. On the other hand, 52 patients had CHA₂DS₂-VASc score of 2 or more, of which 29 were males and 23 were females (Table 6).

Table 6.

CHA₂DS₂-VASc score at presentation

CHA2DS2-VASc score category	Male	Female	Total
Low risk CHA2DS2-VASc score (0, 1)	19	4	23 (30.7%)
High risk CHA2DS2-VASc score (≥2)	29	23	52 (69.3%)
Total	48	27	75 (100%)

The severity of stroke by NIHSS score at admission

Seven (9.3%) patients at admission had NIHSS score of less than 4. They were graded as “minor stroke.” Similarly, 47 (62.7%) patients had NIHSS scores between 5 and 15. Those were categorized as “moderate stroke.” Among them 31 were males and 16 were females. NIHS scores between 16 and 20 were graded as moderately severe stroke which was present in 11 patients, with 8 males and 3 females. Severe Stroke comprising of NIHS score at admission between 21 and 42 was present in 10, with 6 males and 4 females (Table 7).

Table 7.

Severity of acute ischemic stroke by NIHSS score at admission

NIHSS score at admission: severity grading	Male	Female	Total
Minor stroke (1–4)	3	4	7 (9.3%)
Moderate stroke (5–15)	31	16	47 (62.7%)
Moderate to severe stroke (16–20)	8	3	11 (14.7%)
Severe stroke (21–42)	6	4	10 (13.3%)
Total	48	27	75 (100%)

NIHSS (National Institute of Health Stroke Scale).

Association of CHA₂DS₂-vASc score with acute ischemic stroke severity

The association of stroke severity by NIHS at admission with CHA₂DS₂-VASc score was analyzed using the chi-square test (Table 8). There were 7 patients with minor stroke, among them 4 patients had CHA₂DS₂-VASc score of 0 or 1 (low risk), and 3 patients had CHA₂DS₂-VASc score of 2 or more. Similarly, among 47 patients with moderate stroke, 17 had a low-risk CHA₂DS₂-VASc score (0,1) and 30 patients had a high-risk CHA₂DS₂-VASc score (≥2). Among 11 patients with moderate to severe stroke, only 2 patients had low-risk CHA₂DS₂-VASc score and 9 patients had high-risk CHA₂DS₂-VASc score. All 10 patients with severe stroke had a high-risk CHA₂DS₂VASc score (≥2) (Table 9).

Table 8.

Analysis of level of significance between CHA₂DS₂-VASc score and severity of stroke

Chi-square tests
	Value	df	Significance (2-sided)
Pearson chi-square	8.207	3	.042
Likelihood ratio	10.957	3	.012

NIHSS (National Institute of Health Stroke Scale).

Table 9.

Association between CHA₂DS₂VASc score and severity of stroke at presentation

CHA2DS2-VASc score and stroke severity	Low risk score (0,1)	High risk score (≥2)	Total
Minor stroke (1–4)	4	3	7 (9.3%)
Moderate stroke (5–15)	17	30	47 (62.7%)
Moderate to severe stroke (16–20)	2	9	11 (14.7%)
Severe stroke (21–42)	0	10	10 (13.3%)
Total	23	52	75 (100%)

Discharge outcome in stroke patients

The outcome of AIS was measured by mRS score at the time of discharge from the hospital. Out of 75 cases, mRS of good outcome, i.e., 1 and 2 was found in 4 and 24 patients, respectively. Among them 22 were males and 6 were females. However, the bad outcome as denoted by mRS >2 was present in 47 patients, with 26 males and 21 females. Among them, 20, 18, and 4 patients had mRS scores of 3, 4, and 5, respectively. During the hospital stay, 5 patients died, therefore the mRS value was 6 (Table 10).

Table 11.

Analysis between CHA₂DS₂-VASc score and discharge outcome

Chi-square tests
	Value	df	Significance (2-sided)
Pearson chi-square	11.025	1	.001
Continuity correction	9.373	1	.002
Likelihood ratio	10.903	1	.001
Linear-by-linear association	10.878	1	.001

Table 12.

Association between CHA₂DS₂-VASc score and discharge outcome

CHA2DS2-VASc score and discharge outcome	Low risk score (0,1)	High risk score (≥2)	Total
mRS at discharge (≤2)	15	13	28 (37.3%)
mRS at discharge (>2)	8	39	52 (62.7%)
Total	23	52	75 (100%)

Table 10.

Discharge outcome in AIS patients

Modified Rankin scale score category	Outcome	Total
mRS at discharge (≤2)	Good	28 (37.3%)
mRS at discharge (>2)	Bad	52 (62.7%)
Total		75 (100%)

Association of CHA₂DS₂-vASc score with the discharge outcome

To find the association of CHA₂DS₂-VASc score at admission with the discharge outcome, i.e., mRS score at discharge, analysis was done using the chi-square test. Among 28 patients with good outcome scores (0, 1, and 2), there were 15 patients with low risk CHA₂DS₂-VASc scores (0, 1) and 13 patients had high-risk CHA₂DS₂-VASc score (≥2). Similarly, among 47 patients with mRS score of bad outcome (>2), 8 patients had low risk CHA₂DS₂-VASc score (0, 1) and 39 patients had CHA₂DS₂-VASc score of high risk (≥2). There was a significant association between CHA₂DS₂-VASc score with discharge outcome as denoted by P value <0.05 (Tables 11 and 12).

Discussion

Acute ischemic stroke constitutes a major public health problem as well as a major burden of inpatient admission in tertiary centers. CHADS₂ and CHA₂DS₂-VASc scores are primarily used for stroke or thromboembolic events risk prediction in patients with non-valvular atrial fibrillation. CHA₂DS₂-VASc score was incorporated into various guidelines for AF management and is practiced worldwide to reduce the incidence of stroke and thromboembolic events^[19]. The use of this score has recently gained attention as a tool at the pre-hospitalization stage or emergency during the first-ever hospital encounter and has been found useful in predicting AIS severity and early as well as late outcomes.^[20]

In this study the majority were male patients i.e., 48 (64%). Similar findings were observed in studies by Karn et al (n = 182)^[21], Jwarchan B et al (n = 56),^[22] Shakya D et al (n = 92),^[23] and Topaz et al (n = 8309)^[14] with the majority being males: 57.7%, 60.7%, 51.1%, and 53%, respectively. The mean age of presentation was 61.79 years, ranging from 25 to 88 years, out of which 18 (24%) patients were above 75 years and 34 (45.3%) patients were below 65 years. Karn et al reported an age range 25 to 87 years with mean of 65 years.^[21] Shakya D et al showed that 30 (32.65%) patients were above 70 years and 12 (13%) patients were below 45 years of age.^[23] Similarly, Vitturi et al (n = 973) reported 13.4% of patients above 75 years, and 66.9% of patients below 65 years of age with remaining in between. The mean age of presentation was 65 years, which was similar to our result.^[20]

Interestingly, only 46.7% of patients presented within 24 hours of symptom onset, reflecting potential systemic and sociocultural barriers to early medical intervention in Nepal. This delay could confound outcome severity, although the CHA2DS2-VASc score remained independently predictive. No patient had undergone thrombolysis because of the patient’s ineligibility for thrombolysis or due to delayed presentation. Moreover, 70.7% of patients presented with hemiplegia/paresis and UMN-type facial nerve palsy, 25% patients presented with additional features of aphasia, and 4% patients had dysarthria or UMN type facial palsy with no hemiparesis. This finding contrasts with the study by Dhungana S et al that showed the most common presentation was motor weakness (100%) followed by altered sensorium (66%) and aphasia (29%).^[24]

Regarding the risk factors, 53 (70%) and 17 (22.2%) had history of hypertension and diabetes mellitus respectively in our study. Similar findings have been reported by Karn et al, Jwarchan et al, and Shakya et al with 46.7%, 53.6%, and 50% of cases being hypertensive, respectively.^[21-23] Similarly, Karn et al, Shakya et al, and Dhungana et al reported diabetes mellitus in 16.5%, 15.2%, and 10.4% of patients, respectively.^[21,23,24] However, Jwarchan et al reported diabetes mellitus (48.2%) as a major risk factor in acute ischemic stroke patients.^[22] Eight patients (10.7%) had history of prior stroke/TIA or thromboembolism in this study, which is less than that reported by Shakya et al (14.1%) and Karna et al^[21,23] With regards to other risk factors, only 3% patients had history of vascular diseases like MI, peripheral arterial disease or history of aortic plaque in our study. This also contrasts with the study published by Karn et al with 18.7% patients having history of acute ischemic events.^[21] Similarly, we noted 54 (72%) patients being smokers. Shakya et al and Dhungana et al also reported the majority of patients were smokers, i.e., 59.2% and 50% patients, respectively.^[23,24] Furthermore, only 7 (9.3%) patients had prior history or presentation of AF or under treatment of AF. Karn et al and Dhungana et al reported 18.7% and 18.75% patients with history of AF or with presentation with AF, respectively.^[21,24] In addition, Shakya et al had reported even more frequent presentation of AF with 26.1% occurrence.^[23] In our study, only one patient had history of valvular heart disease. However, previous studies reported a range of prevalence of valvular heart diseases varying from 4.3% to 29.1%.^[22,24] Only 4 patients (5.3%) had history of heart failure in our study, which is less compared to the study by Karn et al (12.1%).^[21]

Demographically, the study population has a notable portion (24%) aged 75 and above – an age group contributing directly to higher CHA2DS2-VASc scores. The prevalence of common vascular risk factors such as hypertension, smoking, and diabetes aligns with established literature and underscores their role in the pathogenesis and worsening of stroke outcomes.

Regarding CHA₂DS₂-VASc scores distribution, 23 (30.7%) patients had score of either 0 or 1 at presentation and 52 patients (69.3%) had CHA₂DS₂-VASc score of ≥2. The findings are similar in comparison with the study by Vitturi et al (n = 973), in which 8.3% had low risk score (=0), 27.6% had intermediate risk score and 64.1% had high-risk scores.^[20] Similarly, Ntaios et al (n = 1757) had low, intermediate and high risk CHA₂DS₂-VASc scores in 6.3%, 14.5%, and 79.2% patients, respectively^[25]. Furthermore, Topaz et al reported 13.9% patients with low or intermediate risk CHA₂DS₂-VASc scores and the rest with high-risk scores.^[14]

In this study, 7 (9.3%) patients had NIHS score <4 at admission with remaining 47 (62.7%), 11 (14.7%), and 10 (13.3%) patients had scores between 5 and 15, 16 and 20, and 21 and 42, respectively. The range of score was 2 to 28 with the mean of 12.4 ± 6.5. Similar result was presented by Karn et al with the range of NIHS scale score 0 to 32, with mean of 13.6 ± 8.75^[21]. Similarly, in the study by Ghosh KC et al (n = 30) 10 had NIHSS score 0–4, 12 had scores 5–15 and 8 had scores of 16 or more^[26]. In our study, 4 among 7 patients with minor stroke had CHA2DS2-VASc score of 0 or 1 (low risk) and 3 patients had CHA₂DS₂-VASc score of ≥2. Among 47 patients with moderate stroke 17 had low risk score ^[0,1] and 30 patients had high risk score (≥2). Similarly among 11 patients with moderate to severe stroke only 2 patients had low risk score and 9 patients had high risk score. All 10 patients with severe stroke had high risk CHA₂DS₂-VASc score. There was significant association between CHA₂DS₂-VASc score and severity of stroke by NIHS scale score (P value = 0.042). This means those who have high CHA₂DS₂-VASc scores will suffer more severe form of stroke as assessed by NIHS scale score system.

We measured the outcome of AIS by mRS score at the time of discharge from the hospital. Out of 75 cases good outcomes mRS score, i.e., 1 and 2 were found in 4 and 24 patients, respectively. It amounts to 37.3% of total AIS cases enrolled in the study. Similarly bad outcome as denoted by mRS >2 was seen in 47 (62.7%) patients, among them 20, 18, and 4 patients had mRS scores of 3, 4, and 5, respectively, and 5 (6.66%) patients died during the hospital stay, i.e., MRS value of 6. Further analysis with pre stroke functional status as quantified by mRS score scale, showed 71 (94.7%) patients had mRS score of 0 and 2 (2.7%) patients each had scores of 2 and 3. However, at the time of admission, functional status as evaluated by mRS score, showed 5 (6.7%) 15 (20%), 43 (57.3%), and 12 (16%) patients had mRS of score 2, 3, 4, and 5, respectively.

The study by Karn et al reported mRS score of <3 in 91.1 patients with remaining 8.9% patients with pre-stroke mRS score of >3.^[21] However, this result differ if we compare it with their mRS functional status outcome at 30 days of AIS, which was found to be <3 in 70% of the patients and >3 in 30% of patients. This indicates that AIS patients had gradually improved functional status, as most of the patients were discharged after 7 to 10 days of hospital admission. Dewan KR et al (n = 100) reported that 13% of patients died due to AIS within 7 days of hospital admission, which is almost double as compared to our finding.^[27] In the study conducted by Gajurel BP et al (n = 200) mRS score was evaluated at 1-month period, which showed 24% of patients had good outcome scores (<3) and 66% of patients had bad outcome scores (>3). They also reported 18.5% mortality in the period of 1 month.^[28] Similarly, Kim D et al from South Korea studied AIS patients with AF (n = 298), where 58.3% and 41.6% of patients had good and bad outcome mRS scores at the time of hospital discharge, respectively.^[29] Furthermore, Vitturi K et al (n = 973), showed good outcome MRS score (≤2) in 41.5% of patients and reported mortality in 4.6% of cases, which was slightly lesser than our study. During the 2 year follow-up period, 43.7% of their patients still suffered MRS of >2^[20]. The bad outcome mRS scores in 62.7% patients at the time of discharge in our study, allows us to assume that there are chances of improvement in the functional outcome of AIS patients over the course of time (i.e., years).

In our study, significant association of CHA₂DS₂-VASc score at admission with the discharge outcome, i.e., mRS at discharge, was seen (P value = 0.01). Among 28 patients with good outcome MRS scores (0, 1, and 2), there were 15 patients with low risk CHA₂DS₂-VASc score (0, 1) and 13 patients with high risk CHA₂DS₂-VASc score (≥2). Similarly, among 47 patients with MRS score >2, indicating bad outcome, 8 had low risk CHA₂DS₂-VASc scores and 39 patients had high risk scores. This indicates that, poor functional outcome was related with the high pre-stroke CHA₂DS₂-VASc scores. Similar findings were observed in study by Vitturi K et al with an unfavorable outcome (mRS score ≥3) that was associated with a high-risk pre-stroke CHADS₂ (P < 0.001) and CHA₂DS₂-VASc (P < 0.001). Furthermore, in their study, the recurrence of stroke/TIA and major cardio-vascular events were positively associated with the scores as well (P < 0.01 for all comparisons).^[19] In study by Potpara et al (n = 240), CHA₂DS₂-VASc score was found to be reliably predicting 30-day outcome of stroke. They also evaluated predictability of score alone or with some blood biomarkers to the CHA₂DS₂-VASc score, but it did not significantly raise the prediction ability of the score.^[30] In similar study by Tu HTH et al (n = 6612), the pre-stroke CHA₂DS₂-VASc score was found to be a simple tool for identifying patients at lower risk of poor outcomes and serious cardiac complications within 3 months following ischemic stroke in patients with or without AF.^[31]

In our cohort, the majority of patients (69.3%) had a CHA2DS2-VASc score of ≥2, placing them in the high-risk category. These individuals were more likely to present with moderate to severe stroke based on the NIH stroke scale and had worse functional outcomes, as indicated by mRS scores ≥3 at discharge. The correlation between higher CHA2DS2-VASc scores and increased disability highlights the score’s capacity to predict not only the likelihood of a stroke but also its severity and recovery potential. While prior studies have primarily emphasized the CHA2DS2-VASc score in AF patients, our findings support its role as a simple and easily calculable tool that correlates with AIS outcomes, regardless of underlying rhythm abnormalities. Integrating this score into routine stroke assessment could enhance clinical decision-making and patient counseling, particularly in resource-limited settings.

Limitations

This study has several limitations that warrant consideration. It included the relatively small sample size for a limited time period from a single center. Further multi-center studies with larger sample sizes are warranted to validate these findings and consider its routine use in AIS risk stratification protocols. Additionally, we included in-hospital outcomes only without the follow-up of the patients after the discharge and hence could not document the long term outcomes. In contrast to other scores, the CHA₂DS₂-VASc score does not take into consideration of important factors such as clinical presentation and imaging findings. It is therefore recommended that CHA₂DS₂-VASc score may be combined with other clinical parameters and imaging findings for more accurate and comprehensive risk stratification. Similarly, some patients with history of paroxysmal AF did not demonstrate AF on ECG monitoring during their admission and this was the possible reason for relatively lower incidence of AF in our study. As the data regarding history of aortic plaques was not available, the calculated pre-stroke CHA₂DS₂-VASc score would have been lower than the actual score. Moreover, the data on the concomitant use of medications that could have affected outcome of stroke and frequency of cardiac complications such as antiplatelet, anticoagulant and antihypertensive agents were only available in some patients. Further studies including combination stroke scale, example: which may include the CHA₂DS₂-VASc score as well as neuroimaging could be used to strengthen the predictability of the severity and outcome of AIS.

Conclusions

The CHA₂DS₂-VASc score demonstrates significant predictive value in evaluating both the severity and functional outcomes of acute ischemic stroke patients. In this study, a higher CHA₂DS₂-VASc score was associated with more severe stroke presentations and poorer discharge outcomes. Given its simplicity and reliance on readily available clinical data, the CHA₂DS₂-VASc score can serve as a practical, cost-effective tool for early prognostic stratification in AIS management.

Ethical approval

Ethical approval was obtained from the Institutional Review Board (IRB) of the National Academy of Medical Sciences (NAMS), Bir Hospital, Kathmandu, Nepal (Reference No. 14/IM-185).

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

P.B. and Sushil.Gyawali: study concept, design, acquisition, interpretation of the data, writing the draft, review and editing, validation; K.N., K.P.Y., Sushila.Gyawali, R.K.S., S.K., and S.R.: acquisition, interpretation of the data, critical review for important intellectual content, validation; S.L.S.: concept, review critically for important intellectual content, validation, supervision of the work. All the authors provide final approval of the version to be published and are accountable for all aspects of the work ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of interest disclosure

None.

Research registration unique identifying number (UIN)

UIN: researchregistry10894 (https://researchregistry.knack.com/researchregistry#home/registrationdetails/6755298251e907030154ddf6/).

Guarantor

Sushil Gyawali.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

The data of the study are available upon reasonable request.