Association Between Pre-Admission ATRIA Scores and Initial Stroke Severity in Acute Ischemic Stroke: A Cross-Sectional Study

Abstract

Objectives: This study aimed to investigate the relationship between the anticoagulation and risk factors in atrial fibrillation (ATRIA) score and initial stroke severity in patients with acute ischemic stroke of varying etiologies, including atrial fibrillation (AF), large-artery atherosclerosis, and undetermined origin. Methods: In this prospective observational study, 416 patients admitted with acute ischemic stroke between June 2022 and December 2024 were analyzed. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and patients were categorized into two groups: mild-to-moderate (NIHSS ≤ 15) and moderate-to-severe/severe (NIHSS > 15). Pre-admission ATRIA scores were calculated based on demographic and clinical parameters. Multivariable logistic regression was performed to assess the association between ATRIA scores and stroke severity. Results: Patients with more severe strokes had significantly higher ATRIA scores (median 8.5 vs. 5.0, p < 0.001). AF was more frequent in the severe group (44.8% vs. 31.3%, p = 0.037). In multivariable analysis, each one-point increase in the ATRIA score was independently associated with a 1.82-fold increase in the odds of severe stroke (OR 1.823, 95% CI 1.568-2.119, p < 0.001). High ATRIA scores (>6) were associated with an 11.7-fold increased risk of severe stroke (OR 11.692, 95% CI 5.636-24.255, p < 0.001), independent of stroke etiology, ejection fraction, and inflammatory markers. Conclusions: The ATRIA score is independently associated with initial stroke severity across diverse ischemic stroke etiologies. It may serve as a simple, practical tool for early risk stratification in the acute setting, regardless of AF status. Further studies are warranted to confirm its utility in guiding early management and prognosis.

Keywords: ATRIA score; NIHSS score; acute ischemic stroke; atrial fibrillation; stroke severity.

Figure 1

Flow chart of the study. NIHSS: National Institutes of Health Stroke Scale.

Figure 2

The heat map of the frequency distribution of ATRIA scores of the patients according to mild (1–4), moderate (5–15), moderate-to-severe (16–20), and severe (21–42) stroke severity groups in terms of NIHSS. ATRIA: anticoagulation and risk factors in atrial fibrillation; NIHSS: National Institutes of Health Stroke Scale.

Figure 3

Scatter plot showing the correlation between ATRIA and NIHSS scores with regression line. ATRIA: anticoagulation and risk factors in atrial fibrillation, NIHSS: National institutes of Health Stroke Scale.

Figure 4

Subgroup forest plots demonstrating the association between candidate factors and stroke severity (NIHSS ≥ 15) across etiologic subgroups: (A) Cryptogenic stroke, (B) Carotid artery disease-related stroke, and (C) Atrial fibrillation-related stroke. ATRIA: anticoagulation and risk factors in atrial fibrillation score, EF: ejection fraction, CRP: C-reactive protein. Each square represents the regression-based effect size (standardized β coefficient, μ), with horizontal lines showing 95% confidence intervals (CI); square area is proportional to the inverse of variance. Note: These effect sizes are not odds ratios but standardized β coefficients from multivariable logistic regression models. Diamonds indicate fixed-effect, random-effect, and averaged estimates. CI bars not crossing zero reflect statistically significant associations.