Abstract： Objective:To investigate the predictive value of adding P-wave terminal force in lead V 1 (PTFV 1) to ASTRAL score for poor functional prognosis in patients with acute ischemic stroke. Methods:The study was a prospective cohort study. The hospitalized ischemic stroke patients within 7 days of onset from January 2019 to December 2021 in The First Affiliated Hospital of Zhengzhou University were enrolled. The baseline characteristics were collected, the values of PTFV 1 were measured, and ASTRAL scores were evaluated. The unfavorable outcome was defined as 1-year modified Rankin Scale score (mRS) >2. Logistic regression model was conducted to determine the association of PTFV 1 with unfavorable outcome. P-ASTRAL score was established by adding PTFV 1 to ASTRAL score. The receiver operating characteristics (ROC) curves were plotted, and areas under the curves ( AUC) were calculated to evaluate the prognostic significance. Results:A total of 3?399 acute stroke patients were enrolled. The average age were (59±12) years old (range: 16-95 years), 70.3% (2?390/3?399) of patients were male, 8.8% (299/3?399) patients had an increased PTFV 1 value. In comparison with patients with mRS≤2, patients with poor functional outcome were much older ( t=12.40, P<0.001), had a higher proportion of male ( χ2=23.85, P<0.001), had much more risk factors [diabetes mellitus ( χ2=5.54, P=0.019), stroke history ( χ2=56.38, P<0.001), coronary heart disease ( χ2=22.72, P<0.001) ], had a higher proportion of increased PTFV 1 value ( χ2=229.65, P<0.001), and higher ASTRAL score ( χ2=424.02, P<0.001). After adjusting confounding factors, PTFV 1>5?000 μV·ms ( OR=4.168, 95% CI 3.101-5.602, P<0.001) and ASTRAL score ( OR=1.122, 95% CI 1.097-1.148, P<0.001) could increased the risk of 1-year poor functional outcome. The AUC for P-ASTRAL score was higher than ASTRAL score (0.753 vs. 0.739, Z=2.317, P=0.021) . Conclusion:PTFV 1 was an independent risk factor of unfavorable outcome for stroke. P-ASTRAL score could improve the predictive value of poor functional outcome for ischemic stroke.