For healthcare professionals
Essen Stroke Risk Score (ESRS)
The Essen Stroke Risk Score adds up eight risk factors in a patient who has had an ischemic stroke or TIA, for a total from 0 to 9. Scores of 3 or more put the patient in the high risk group for a further stroke. This calculator is written for clinicians planning secondary prevention and is not a diagnosis.
Score the risk factors
Items and points as printed in Table 1 of Kongwatcharapong and colleagues (Kongwatcharapong 2023). Nothing you enter leaves this page.
What you will see
The total from 0 to 9 and whether it falls in the low (0 to 2) or high (3 to 9) risk group.
Educational only, not medical advice. Not a diagnosis. Treatment decisions belong to the treating team.
Source
Items, points and the low (0 to 2) and high (3 to 9) split as printed in Table 1 of Kongwatcharapong J and colleagues, BMC Neurology 2023 (open access, CC BY 4.0). The same point rules are written out in Xiong Y and colleagues, Brain and Behavior 2023 (open access, CC BY 4.0). Original score: Diener HC and colleagues 2005; validation in the REACH registry: Weimar C and colleagues, Stroke 2009 (both cited only). Licences were checked in the Europe PMC full text. The tests check every item, the age bands, both ends of the range and the split.
Validated in
Kongwatcharapong 2023: 543 patients after acute ischemic stroke at one hospital in Bangkok, Thailand, 2014 to 2018, followed for three years; patients with atrial fibrillation or cerebral embolism were excluded. Xiong 2023: 50,374 patients with acute ischemic stroke or TIA in three China National Stroke Registries, 2007 to 2018, followed for one year.
Limits
Both open studies found only moderate or limited accuracy: an area under the curve of 0.614 in Thailand and 0.58 in China, falling over 13 years (Kongwatcharapong 2023, Xiong 2023). The score was built in mostly white patients in high-income health systems. It was not designed for atrial fibrillation; for that, see CHA2DS2-VASc. It does not replace a full stroke work-up.
Points table
| Risk factor | Points |
|---|---|
| Age under 65 years | 0 |
| Age 65 to 75 years | 1 |
| Age over 75 years | 2 |
| Hypertension | 1 |
| Diabetes mellitus | 1 |
| Previous myocardial infarction | 1 |
| Other cardiovascular disease (except myocardial infarction and atrial fibrillation) | 1 |
| Peripheral arterial disease | 1 |
| Smoking | 1 |
| Previous TIA or ischemic stroke, in addition to the qualifying event | 1 |
| Total | 0 to 9 |
Source: Table 1 of Kongwatcharapong and colleagues 2023 (Kongwatcharapong 2023), with the age bands and the qualifying-event wording as written by Xiong and colleagues 2023 (Xiong 2023). A patient with a past myocardial infarction who now has angina scores two points, one for each item (Kongwatcharapong 2023). The score was first described by Diener and colleagues in 2005 (Diener 2005) and validated in the REACH registry by Weimar and colleagues in 2009 (Weimar 2009).
Low and high risk groups
The score sorts patients into a low risk group (0 to 2 points) or a high risk group (3 to 9 points) (Kongwatcharapong 2023). Xiong and colleagues note that patients with a score above 2 had an annual risk of a further stroke above 4% in the original report (Xiong 2023).
Worked example: a 70-year-old (+1) with hypertension (+1), diabetes (+1) and no other listed factor scores 3, in the high risk group.
What studies found
In 543 Thai patients followed for three years after an ischemic stroke, 181 had a further stroke. Of those, 65.74% (119 of 181) had been in the ESRS high risk group. The area under the curve was 0.614 (Kongwatcharapong 2023).
In 50,374 patients with ischemic stroke or TIA in three Chinese national registries, 10.7% had a further stroke within one year. The area under the curve was 0.58, and it fell from 0.60 in the first registry to 0.56 in the third. The authors concluded the score may not be useful for current practice (Xiong 2023).
Related calculators
For a 0 to 9 outcome score after acute ischemic stroke from age, NIHSS and three chronic diseases, see the THRIVE score. For early stroke risk in the days after a TIA, see the ABCD2 score. To grade disability after a stroke, see the modified Rankin Scale. For a plain-language check of stroke risk factors with a CHA2DS2-VASc explainer for atrial fibrillation, see the stroke risk factor check. For a weighted 0 to 15 score on similar risk factors, see the Stroke Prognosis Instrument II (SPI-II). Other bedside scores are listed under For healthcare professionals.
Sources
- Kongwatcharapong J, Sornkhamphan A, Kaveeta C, Nathisuwan S. Validation and comparison of the stroke prognosis instrument (SPI-II) and the essen stroke risk score (ESRS) in predicting stroke recurrence in Asian population. BMC Neurol. 2023;23(1):287. doi:10.1186/s12883-023-03329-w. PMID 37528418. Open access (CC BY 4.0). Table 1: ESRS items, points, total 9, low 0 to 2 and high 3 to 9; Table 3 and results: 543 patients, AUROC 0.614. pmc.ncbi.nlm.nih.gov/articles/PMC10391888/
- Xiong Y, Wang S, Li Z, Fisher M, Wang L, Jiang Y, Huang X, Zhao XQ, Meng X, Wang Y. Thirteen-year trends in risk scores predictive values for subsequent stroke in patients with acute ischemic event. Brain Behav. 2023;13(5):e2962. doi:10.1002/brb3.2962. PMID 36978218. Open access (CC BY 4.0). Methods: ESRS point rules; results: 50,374 patients in CNSR-I to III, AUC 0.58. pmc.ncbi.nlm.nih.gov/articles/PMC10176011/
- Diener HC, Ringleb PA, Savi P. Clopidogrel for the secondary prevention of stroke. Expert Opin Pharmacother. 2005;6(5):755-764. doi:10.1517/14656566.6.5.755. PMID 15934902. Original description of the Essen Stroke Risk Score (cited only; not open access). doi.org/10.1517/14656566.6.5.755
- Weimar C, Diener HC, Alberts MJ, Steg PG, Bhatt DL, Wilson PW, Mas JL, Röther J; REduction of Atherothrombosis for Continued Health (REACH) Registry Investigators. The Essen stroke risk score predicts recurrent cardiovascular events: a validation within the REduction of Atherothrombosis for Continued Health (REACH) registry. Stroke. 2009;40(2):350-354. doi:10.1161/STROKEAHA.108.521419. PMID 19023098. Validation (cited only). doi.org/10.1161/STROKEAHA.108.521419
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