Long-term Mortality After Stroke Among Adults Aged 18 to 50 Years

Rutten-Jacobs, Loes C.A.; Arntz, Renate M.; Maaijwee, Noortje A.M.; Schoonderwaldt, Hennie C.; Dorresteijn, Lucille D.A.; Dijk, Ewoud J. van; Leeuw, Frank‐Erik de

doi:10.1001/jama.2013.842

Cited by 195 publications

(176 citation statements)

References 23 publications

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“…[18][19][20] In a general, predominantly non-atrial fibrillation population, 1-year mortality after ischemic stroke ranged from approximately 2% to 29% depending on patient factors. 4,18,[20][21][22] In contrast, among ATRIA atrial fibrillation cohort members sustaining an ischemic stroke, 40% had died within 1 year after their stroke event.…”

Section: Resultsmentioning

confidence: 99%

Long-term survival after ischemic stroke in patients with atrial fibrillation

Fang

Chang

et al. 2014

Neurology

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Objectives: While the short-term impact of atrial fibrillation-related stroke has been well studied, surprisingly little is known about its long-term effect on survival.Methods: We followed 13,559 patients with atrial fibrillation for a median of 6 years, identifying ischemic strokes through computerized databases and validating 1,025 events. Stroke severity was determined from hospital records. We compared survival of stroke patients with comparator nonstroke patients (matched for age, sex, race, comorbid conditions, and time of entry into the cohort) using proportional hazard models controlling for warfarin use and compared survival by degree of discharge deficit.Results: Median survival after stroke was 1.8 years compared with 5.7 years for matched nonstroke comparators (hazard ratio [HR] 2.8, 95% confidence interval [CI] 2.5-3.2). This increased risk of allcause death persisted even after restricting the analysis to the 576 stroke patients who survived 6 months after the initial stroke event (HR 2.0, 95% CI 1.7-2.5, adjusting for warfarin use). Risk of death was strongly associated with stroke severity: HR 2.9 (95% CI 2.3-3.5) for strokes resulting in major deficits and HR 8.3 (95% CI 5.2-13.2) for strokes resulting in severe deficits compared with matched comparators without stroke. Conclusions:Ischemic stroke approximately triples the mortality rate in patients with atrial fibrillation.This effect persists well beyond the immediate period poststroke and is strongly associated with disability after stroke. Stroke prevention by anticoagulation has even greater beneficial effects on survival than usually considered when focusing solely on 30-day mortality rates. Atrial fibrillation is an increasingly common medical condition, with an estimated prevalence of at least 2.5 million people in the United States, 1,2 and contributes to significant morbidity and mortality largely by raising the risk of ischemic stroke.3 Stroke is the fourth leading cause of death in the United States and median survival after stroke has been reported to be approximately 5 to 10 years, depending on stroke severity and patient factors.2,4-6 Strokes occurring in the setting of atrial fibrillation result in worse neurologic deficits and higher 30-day mortality than strokes occurring in people without atrial fibrillation. 7,8 As a result, we would anticipate that long-term survival after atrial fibrillation-related stroke would also be particularly poor. However, information on longterm outcomes after atrial fibrillation-related stroke is relatively scarce. The objective of this analysis was to provide precise estimates of the impact of atrial fibrillation-associated ischemic stroke on long-term survival. Such information is needed to fully inform the decision to use anticoagulants or other risky interventions to prevent stroke in patients with atrial fibrillation. 9,10

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Section: Resultsmentioning

confidence: 99%

Long-term survival after ischemic stroke in patients with atrial fibrillation

Fang

Chang

et al. 2014

Neurology

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“…Rutten-Jacobs and colleagues found similar findings in a prospective cohort analysis entitled The Follow-Up of Transient Ischemic Attack and Stroke Patients and Unelucidated Risk Factor Evaluation (FUTURE) study. 18 Long-term mortality was analyzed after either a transient ischemic attack, ischemic stroke, or hemorrhagic stroke in adults aged 18 through 50 years admitted to a single Dutch center between January 1, 1980, and November 1, 2010. The 20-year mortality among 959 subjects recruited in the study cohort was 20.0% (n = 192), with the 3 most common causes of death cardiovascular (26.2%), cerebrovascular (19.3%), and malignancy (23.4%).…”

Section: Discussionmentioning

confidence: 99%

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2016

Exp Clin Transplant

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Objectives: Stroke is a major cause of mortality in the general population but data regarding stroke-related hospitalization or mortality after a kidney transplant is limited. We determined risk for stroke-related episodes after a kidney transplant in a populationbased cohort study of 19 103 kidney allograft recipients in England between 2001 and 2012. Materials and Methods:The incidence of stroke-related events after a kidney transplant with pretransplant history of stroke, the incidence of stroke-related hospitalization or death among all kidney allograft recipients after a kidney transplant, and risk factors for stroke-related mortality after a kidney transplant were examined. Data were obtained from hospital episode statistics (an administrative data warehouse that contains admissions to all National Health Service hospitals in England) and is linked to the Office for National Statistics, which collects information on all registered deaths in England. Results: There were 782 nonfatal stroke-related hospitalizations and 113 stroke-related deaths (5.4% of total deaths) after a kidney transplant (median follow-up 4.4 y after a kidney transplant). Risk for allcause mortality was higher for those recipients with, compared to those without, a history of stroke (21.5% vs 10.8%; P < .001). However, risk for stroke-related mortality after a kidney transplant was no different. Kidney allograft recipients with nonfatal stroke episodes after a transplant were at a higher risk for allcause and stroke-related mortality. In a Cox regression model, pretransplant history of stroke was an independent risk factor for all-cause mortality, but not stroke-related mortality, while posttransplant hospitalization with nonfatal stroke was a risk factor for both. Conclusions: Fatal and nonfatal stroke-related events are common among kidney allograft recipients. Further research is warranted to allow better risk stratification and facilitate clinical trials for risk attenuation of stroke after a kidney transplant. Key words: Cerebrovascular accident, Death, Transplant IntroductionStroke, or cerebrovascular accidents, is one of the leading causes of mortality in the world, estimated to be the second leading cause of global death by the World Health Organization. 1 In 2010, the global absolute numbers of individuals developing their first stroke, surviving stroke, or having a stroke-related death were 16.9 million, 33.0 million, and 5.9 million, with 69% of events occurring in individuals aged greater than 65 years. 2 In addition, stroke-related disability represents a significant health burden, with disability-adjusted life years lost an estimated 102 million globally in 2010. 2 Although age-standardized rates of stroke-related mortality are decreasing worldwide, 2,3 absolute numbers are increasing and they represent a major public health burden.In the context of transplant, the effect of strokerelated morbidity or mortality after a transplant is unclear because of a lack of published data. Oliveras and colleagues observed a 10-...

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“…Hemorrhagic stroke, in particular, confers a major burden on both affected individuals and society as a whole (2)(3)(4)(5). In the general population, older age, male sex, and hypertension emerge as consistent risk factors for hemorrhagic stroke (6)(7)(8)(9).…”

Section: Introductionmentioning

confidence: 99%

“…That report focused on ischemic stroke, which is approximately 4.5-fold more common than hemorrhagic stroke in United States dialysis patients (12). However, because hemorrhagic stroke differs substantially from ischemic stroke in its pathophysiology (4,5), it is uncertain whether findings associated with the latter would be associated with the former. Although important work has previously been undertaken examining the epidemiology of hemorrhagic stroke in dialysis patients (13)(14)(15), no report to date has specifically examined geographic variation in hemorrhagic stroke rates and how race and ethnicity might affect any such potential association.…”

Section: Introductionmentioning

confidence: 99%

Race, Ethnicity, and State-by-State Geographic Variation in Hemorrhagic Stroke in Dialysis Patients

Wetmore

Phadnis

Mahnken

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives Geographic variation in stroke rates is well established in the general population, with higher rates in the South than in other areas of the United States. A similar pattern of geographic variation in ischemic strokes has also recently been reported in patients undergoing long-term dialysis, but whether this is also the case for hemorrhagic stroke is unknown.Design, setting, participants, & measurements Medicare claims from 2000 to 2005 were used to ascertain hemorrhagic stroke events in a large cohort of incident dialysis patients. A Poisson generalized linear mixed model was generated to determine factors associated with stroke and to ascertain state-by-state geographic variability in stroke rates by generating observed-to-expected (O/E) adjusted rate ratios (ARRs) for stroke.Results A total of 265,685 Medicare-eligible incident dialysis patients were studied. During a median follow-up of 15.5 months, 2397 (0.9%) patients sustained a hemorrhagic stroke. African Americans (ARR, 1.43; 95% confidence interval [CI], 1.30 to 1.57), Hispanics (ARR, 1.78; 95% CI, 1.57 to 2.03), and individuals of other races (ARR, 1.51; 95% CI, 1.26 to 1.80) had a significantly higher risk for hemorrhagic stroke compared with whites. In models adjusted for age and sex, four states had O/E ARRs for hemorrhagic stroke that were significantly greater than 1.0 (California, 1.15; Maryland, 1.25; North Carolina, 1.25; Texas, 1.19), while only 1 had an ARR less than 1.0 (Wisconsin, 0.79). However, after adjustment for race and ethnicity, no states had ARRs that varied significantly from 1.0.Conclusion Race and ethnicity, or other factors that covary with these, appear to explain a substantial portion of state-by-state geographic variation in hemorrhagic stroke. This finding suggests that the factors underlying the high rate of hemorrhagic strokes in dialysis patients are likely to be system-wide and that further investigations into regional variations in clinical practices are unlikely to identify large opportunities for preventive interventions for this disorder.

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Long-term Mortality After Stroke Among Adults Aged 18 to 50 Years

Abstract: Among adults aged 18 through 50 years, 20-year mortality following acute stroke was relatively high compared with expected mortality. These findings may warrant further research evaluating secondary prevention strategies in these patients.

Cited by 195 publications

References 23 publications

Long-term survival after ischemic stroke in patients with atrial fibrillation

Long-term survival after ischemic stroke in patients with atrial fibrillation

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Race, Ethnicity, and State-by-State Geographic Variation in Hemorrhagic Stroke in Dialysis Patients

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