Physicians' Academy for Cardiovascular Education

Predictive performance of risk scores for ischemic stroke in AF

Comprehensive comparison of stroke risk score performance: a systematic review and meta-analysis among 6 267 728 patients with atrial fibrillation

Literature - Van der Endt VHW, Milders J, Penning de Vries BBL, et al. - Europace. 2022 Jul 27;euac096. doi: 10.1093/europace/euac096

Introduction and methods


In patients with AF, the risk of ischemic stroke (IS) can be predicted by several different risk scores. However, current risk scores appear to have a limited overall ability to predict IS in AF patients [1-3]. At the same time, newer risk scores and updates of earlier scores seem to be understudied.

Aim of the study

The objectives of this study were to identify and systematically review all available risk scores predicting IS risk in AF patients, their external validations, and updates, to assess the methodological quality of the studies on these risk scores, and to calculate a pooled estimate of the predictive performance.


The authors conducted a literature search in PubMed and Web of Science for studies in which a multivariable prognostic IS risk score for AF patients was developed, validated, or updated. The Prediction model Risk Of Bias ASsessment Tool (PROBAST) was used to examine the methodological quality of the studies. To assess discrimination (i.e., score’s ability to discriminate between events and nonevents), pooled c-statistics were calculated for 6,267,728 patients and 359,373 events of IS using a random-effects meta-analysis. The level of calibration (i.e., agreement between predicted and observed risk) was also estimated based on different statistics . For each of the validation studies included in the meta-analysis, 8 sensitivity analyses were performed.

Main results

Methodological quality of studies

Development studies

Validation studies

Update studies

Pooled c-statistic

Sensitivity analyses


This systematic review and meta-analysis identified 19 risk scores (with 329 validations and 76 updates in total) to predict IS risk in patients with AF. Although all risk scores showed poor to reasonable performance, newer scores tended to have a slightly better discriminative ability than the conventional, guideline-endorsed CHA2DS2-VASc score. The modified CHADS2 score showed overall the best discriminative abilities. Methodological bias was observed in all studies. The authors stress that “additional external validations and data on calibration are required before considering the newer scores in clinical practice.”


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