The PLAN for stroke prognosis

Researchers have developed a new prediction rule, which they say predicts both short-term and 1-year mortality after acute ischemic stroke.

The PLAN is straightforward to use, being composed of routinely collected variables that do not require specialist interpretation. It does not even require use of a stroke severity scale, such as the National Institutes of Health Stroke Scale.

And the name is a mnemonic: P for preadmission comorbidities; L for level of consciousness; A for age; and N for neurologic focal deficit.

The report appears in the Archives of Internal Medicine. Deputy editor Mitchell Katz (Los Angeles County Department of Health Services, California, USA) comments that the PLAN has several merits setting it apart from the many prediction rules that are submitted to, and rejected from, the journal. He believes that "while not perfect, [the PLAN] will be of use to clinicians."

The researchers, led by Martin O'Donnell (National University of Ireland, Galway), derived the PLAN from data for 4943 stroke patients in the Canadian Stroke Network registry and validated it in a further 4904.

Despite the simplicity of the PLAN, it has "adequate discrimination for use in clinical practice," say O'Donnell et al. In the validation cohort, it was 87% accurate for distinguishing patients who died within 30 days, 88% accurate for death or severe disability at discharge, and 84% accurate for 1-year mortality. It was also 80% accurate for predicting a favorable outcome (modified Rankin Scale 0‑2).

The PLAN has a maximum possible score of 25 points, from nine clinical variables. Preadmission comorbidites include functional dependence as well as specific ailments (cancer, heart failure, atrial fibrillation). The team tried adding four other routine variables ‑ glucose and hemoglobin levels, white cell count, and body temperature ‑ but these improved discrimination only marginally and had little effect on the proportions of patients classified as very low or high risk.

Katz comments that the PLAN should be validated in a different patient population and observes that its accuracy seemed reduced if patients underwent thrombolysis.

And he adds: "We hope that future studies will test whether the PLAN rule enables better decision making and planning for patients with ischemic stroke.

"If use of the PLAN rule leads to deeper discussions among patients, their families, and the medical profession with regard to decisions about extraordinary interventions, such as intensive care units or feeding tubes, or if the PLAN rule results in better planning for long-term care, the rule would be invaluable."

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