The Skeptics Guide to Emergency Medicine
Date: October 2012
Title: ABCD2 Not as Simple as 1,2,3
Featuring: Dr. Chris Carpenter, Washington University, St. Louis

Case Scenario:

68yo woman with unilateral weakness lasting 20 minutes. Blood pressure 165/95.


Does the ABCD2 score predict who will go on to have a stroke in the next 7 or 90 days?


Perry JJ et al. Prospective validation of the ABCD2 score for patients in the emergency department with transient ischemic attack. CMAJ. 2011 Jul 12;183(10):1137-45. Epub 2011 Jun 6.


Prospective cohort trial done in eight Canadian emergency departments. N=2056. Mean age 68yrs with 50.9% women.


Application fo the ABCD2 scored by treating ED physician




Stroke at 7d or 90d as determined by treating neurologist or adjudicating committee.



Authors Conclusions:

“This multicentre prospective study involving patients in emergency depart- ments with transient ischemic attack found the ABCD2 score to be inaccurate, at any cut- point, as a predictor of imminent stroke. Furthermore, the ABCD2 score of more than 2 that is recommended by the American Heart Association is nonspecific.”

BEEM Comments (Dr. Chris Carpenter):

Dr. Chris Carpenter This prospective, ED-based multicenter Canadian trial represents the highest quality evidence to assess the ABCD2 thus far.  Although an ABCD2 score of 0 or 1 is 100% sensitive for 30-day stroke risk, very few ED patients with a suspected TIA fall within this low-risk category.  Therefore, the ABCD2 is not an accurate post-TIA stroke risk prognostic instrument and should NOT be used to risk-stratify ED patients.   Instead, clinical gestalt and local resource availability should be used to determine the disposition and timing for the diagnostic work-up of post-TIA ED patients.

EBM Information:

BEEM Bottom Line:

ABCD2 score is not a reliable way to risk stratify patients presenting to the ED with TIAs on who will go on to have a stroke.