Value of the A2DS2 Score Combined with the Neutrophil-to-lymphocyte Ratio in Predicting Acute Ischemic Stroke-associated Pneumonia

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Abstract

Objective:

We aimed to explore the risk factors for acute ischemic stroke-associated pneumonia (SAP) and evaluate the predictive value of the Age, Atrial fibrillation, Dysphagia, Sex, Stroke Severity (A2DS2) score, neutrophil-to-lymphocyte ratio (NLR), and a combination of both indices for acute ischemic SAP.

Methods:

Overall, 1,505 patients with acute ischemic stroke (AIS) were enrolled and divided into SAP and non-SAP groups. Patients’ age, sex, and medical history (alcohol consumption, hypertension, diabetes, hyperlipidemia, coronary disease, atrial fibrillation, chronic obstructive pulmonary disease, and stroke history) were recorded. Clinical data were recorded, including consciousness disturbance, dysphagia, indwelling nasogastric tube, thrombolytic therapy, hospital stay length, National Institute of Health Stroke Scale (NIHSS) score, stroke position, TOAST classification, and blood pressure on admission. Laboratory indicators, including white blood cell (WBC) count, neutrophil count, lymphocyte count, creatinine, homocysteine, and fasting blood glucose, were also recorded. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. All patients were scored using A2DS2. Binary logistic regression was used to analyze the relationships between A2DS2, NLR, and SAP. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic value of A2DS2, NLR, and their combined indices for predicting SAP.

Results:

SAP occurred in 203 (13.5%) of the 1,505 enrolled patients. Patients in the SAP group were older and had a higher proportion of hypertension and chronic obstructive pulmonary disease history, consciousness disorder, dysphagia, indwelling nasogastric tube, fasting blood glucose level, NIHSS score, and longer hospital stay. The SAP group had a higher A2DS2 score than the non-SAP group. Similarly, the WBC count, neutrophil count, and NLR were significantly higher in the SAP group than in the non-SAP group. After excluding confounding factors, binary logistic regression analysis showed that age, NIHSS score, NLR, and A2DS2 score were independent risk factors for SAP. The ROC curves showed the A2DS2 score and NLR predicted SAP with an area under the curve (AUC) of 0.855 (sensitivity: 73.3%, specificity: 86.1%) and 0.849 (sensitivity: 79.7%, specificity: 80.6%), respectively, and the combined prediction of SAP AUC was 0.924 (sensitivity: 87.7%, specificity: 82.8%), which was higher than that of a single index, with improved the sensitivity of prediction.

Conclusion:

In patients with AIS, the A2DS2 score combined with NLR is of greater value in predicting the risk of acute ischemic SAP than a single indicator.

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Most cited references 31

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Dysphagia after stroke: incidence, diagnosis, and pulmonary complications.

Rosemary Martino, Norine Foley, Sanjit Bhogal … (2005)

To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Databases were searched (1966 through May 2005) using terms "cerebrovascular disorders," "deglutition disorders," and limited to "humans" for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The reported incidence of dysphagia was lowest using cursory screening techniques (37% to 45%), higher using clinical testing (51% to 55%), and highest using instrumental testing (64% to 78%). Dysphagia tends to be lower after hemispheric stroke and remains prominent in the rehabilitation brain stem stroke. There is increased risk for pneumonia in patients with dysphagia (RR, 3.17; 95% CI, 2.07, 4.87) and an even greater risk in patients with aspiration (RR, 11.56; 95% CI, 3.36, 39.77). The high incidence for dysphagia and pneumonia is a consistent finding with stroke patients. The pneumonia risk is greatest in stroke patients with aspiration. These findings will be valuable in the design of future dysphagia research.

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High Neutrophil-to-Lymphocyte Ratio Predicts Stroke-Associated Pneumonia

Ki-Woong Nam, Tae Kim, Ji Lee … (2018)

Background and Purpose- Although there are a variety of risk factors and predictive models for stroke-associated pneumonia (SAP), more objective and easily accessible markers are still needed. In this study, we evaluated the relationship between the neutrophil-to-lymphocyte ratio (NLR) and SAP in patients with acute ischemic stroke. Methods- We assessed 1317 consecutive patients with acute ischemic stroke. SAP was defined according to the modified Centers for Disease Control and Prevention criteria. The severity of pneumonia was rated using scores from the Pneumonia Severity Index, the quick Sequential Organ Failure Assessment, and the Acute Physiology and Chronic Health Evaluation II. The NLR was calculated after dividing absolute neutrophil counts by absolute lymphocyte counts. Results- Among the total patients, SAP occurred in 112 (9.0%) patients. Using a multivariable analysis, the NLR (adjusted odds ratio=1.55; 95% confidence interval, 1.15-2.11; P=0.005) remained significant after adjusting for confounders. In addition, age, atrial fibrillation, previous stroke history, initial National Institutes of Health Stroke Scale score, and high-sensitivity C-reactive protein were also significant, independent of NLR. The NLR was higher in the severe pneumonia group when it was assessed by Pneumonia Severity Index ( P<0.001), quick Sequential Organ Failure Assessment ( P<0.001), and Acute Physiology and Chronic Health Evaluation II scores ( P=0.004). Furthermore, patients who had SAP had worse clinical outcomes both during hospitalization and after discharge. Conclusions- We demonstrated that a higher NLR predicted SAP in patients with acute ischemic stroke. The NLR may help to identify high-risk patients in time and provide clues for further studies about preventive antibiotic therapy.

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Development of a clinical score (A2DS2) to predict pneumonia in acute ischemic stroke.

Sarah Hoffmann, Uwe Malzahn, Hendrik Harms … (2012)

Poststroke pneumonia is a potentially preventable complication after stroke associated with poor outcome. We developed and externally validated a prognostic score for predicting risk of pneumonia after ischemic stroke. The prognostic score was developed based on clinical data routinely collected after admission from the Berlin Stroke Register, Germany. The association of demographics, comorbidities, and clinical characteristics with poststroke pneumonia was investigated using multivariable logistic regression analyses. Independent predictors of poststroke pneumonia were translated into a point scoring system based on the corresponding regression coefficients. The predictive properties of the developed prognostic score were externally validated using an independent data set from the Stroke Register Northwest-Germany. Between 2007 and 2009, 15 335 patients with ischemic stroke were registered within the Berlin Stroke Register. The observed rate of pneumonia in hospital was 7.2%. A 10-point score was derived for prediction of poststroke pneumonia (Age ≥ 75 years=1, Atrial fibrillation=1, Dysphagia=2, male Sex=1, stroke Severity, National Institutes of Health Stroke Scale 0-4=0, 5-15=3, ≥ 16=5; A(2)DS(2)). The proportion of pneumonia varied between 0.3% in patients with a score of 0 point to 39.4% in patients with a score of 10 points. The score demonstrated excellent discrimination (C-statistic 0.84; 95% CI, 0.83-0.85) and calibration (McFadden R(2)=0.21). Prediction, discrimination, and calibration properties were reproduced in the validation cohort consisting of 45 085 patients with ischemic stroke. The A(2)DS(2) score is a valid tool for predicting poststroke pneumonia based on routinely available data. A(2)DS(2) might be useful for guiding monitoring of high-risk patients or prophylactic pneumonia management in clinical routine.