Contents lists available at ScienceDirect Clinical Epidemiology and Global Health journal homepage: www.elsevier.com/locate/cegh Development of a risk of stroke score in the Lebanese population Maya El-Hajj a,b, ⁎ , Pascale Salameh a , Samar Rachidi a , Amal Al-Hajje a , Hassan Hosseini b,c a Lebanese University, Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Hadath, Lebanon b Université Paris-Est, UMR 955, IMRM, Institut Mondor de Recherche Biomédicale, Créteil, France c Service de Neurologie, Hôpital Henri-Mondor, UPEC, Assistance Publique-Hôpitaux de Paris (AP-HP), Créteil, France ARTICLE INFO Keywords: Stroke Risk Score Stroke/Cerebrovascular disease Epidemiology Lebanon ABSTRACT Background/Aims: As in all developing countries, there could be a large number of stroke cases that can be prevented provided that individuals at risk are recognized. We aim to develop a score for screening individuals at risk of stroke in the Lebanese population. Methods: A hospital-based case-control study was conducted for the score generation. Data were collected through a designed data collection sheet at two Lebanese tertiary hospitals between January 1st, 2012 and December 31st, 2014. A logistic regression determined the association of stroke risk factors with stroke, and the rounded coefficients generated the Risk of Stroke Score (ROSS). Another case-control study was conducted for the score validation. Data were collected through a standardized questionnaire at five different Lebanese tertiary hospitals between January 1st, 2015 and December 31st, 2016. ROSS was validated by comparing it to hospitals final diagnosis. Results: ROSS was constructed with good properties, comprising 10 items. The area under the curve was high at 0.869 (0.838–0.899; p < 0.001). A score < 2 points indicated a 94.4% high negative predictive value of stroke. A score > 10 points had more than 85.4% positive predictive value of stroke. In the validation study, ROSS had an area under the curve of 0.826 (0.790–0.863; p < 0.05), 88.7% negative prediction value and 96.2% positive prediction value. Conclusion: It is highly recommended to use the ROSS, particularly in the primary care setting, as a good as- sessment tool to predict stroke among high-risk people and encourage them to get involved in intervention programs to prevent this disease. 1. Introduction Stroke, or cerebrovascular accident (CVA), is a common cause of morbidity and mortality worldwide. Over the 1990–2013 period, there was a significant increase in stroke incident events, survivors, and deaths for both ischemic and hemorrhagic stroke and a substantial in- crease in the absolute number of DALYs (disability-adjusted life years) due to ischemic stroke. 1 Developing countries had the greatest share of global stroke burden and death compared to developed countries, comprising 75.2% of stroke mortality and 81.0% of stroke-related DALYs. 1 Lebanon is a developing upper-middle-income country located in the Middle East. Although stroke is the second leading cause of death in Lebanon after cardiac diseases, there is still a scarcity of reliable in- formation about stroke in this country. In general, the adjusted stroke prevalence in Lebanon was 0.50% (95% CI, 0.33–0.66) in 2012, and the rate of stroke mortality has reached 62.7/100,000 population in 2011, indicating that around 8 Lebanese people die every day because of stroke. 2,3 According to the Global Burden of Disease Study 2016 (GBD 2016) causes of premature death in Lebanon, stroke is striking at a younger age in this country. It took the fourth place in the top 10 causes of death in 2016. 4 The GBD 2016 assessed the years of life lost (YLLs) as well which quantifies premature mortality by weighing younger deaths more than older deaths. In 2016, stroke ranked 6th among the top 11 causes of YLLs in Lebanon. 4 Despite having stroke intervention rate in Lebanon higher than other reported rates in developing countries, Le- banon still struggles with limited intervention (administration rate of rt-PA is 10.3% for stroke cases at the largest tertiary care center in Lebanon) due to large time interval between arrival at the hospital and computerized tomography (CT) completion. 5 Major stroke risk factors are common among populations and modifiable with effective interventions. It is well known that many unchangeable and treatable risk factors may increase the risk of having a stroke and speed up the process. In Lebanon, the prevalence of many stroke risk factors has reached high measures to a point where it is threatening the life of its population. 6 Modifying, treating and https://doi.org/10.1016/j.cegh.2018.02.003 Received 4 December 2017; Received in revised form 11 February 2018; Accepted 19 February 2018 ⁎ Corresponding author at: Lebanese University, Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Hadath, Lebanon. E-mail addresses: hajj_maya@hotmail.com (M. El-Hajj), hassan.hosseini@aphp.fr (H. Hosseini). Clinical Epidemiology and Global Health xxx (xxxx) xxx–xxx 2213-3984/ © 2018 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of INDIACLEN. Please cite this article as: Maya, E.-H., Clinical Epidemiology and Global Health (2018), https://doi.org/10.1016/j.cegh.2018.02.003