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

Abstract

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

The main factors affecting the long-term outcomes in patients after acute cerebrovascular disorder: results of the LIS-2 study

“…Абсолют-ные показатели отдаленной смертности по данным на-шего исследования оказались сопоставимыми с таковыми, полученными в ряде других регистров МИ [12,13].…”

“…Из сопутствующих сердечно-сосудистых заболева-ний отрицательную прогностическую роль на отда-ленную выживаемость сыграли хроническая сердечная недостаточность и фибрилляция предсердий, что вы-глядит вполне логичным и подтверждается рядом дру-гих исследований [13]. Ранее перенесенный (перед ре-ференсным) МИ не оказал существенного влияния на отделенную выживаемость больных.…”

Who will benefit from anticoagulant therapy? Use of the CHADS2 score and its variants

“…Despite substantial effort, the predictive ability of these scores was modest and highly variable. 20 The discriminating ability of multiple risk schemes, as measured by c statistics, ranges from 0.56 to 0.62, where a value of 1.0 represents perfect discrimination. The proportion of patients categorized as low risk ranges from 11.7% to 37.1% across schemes, and the proportion who were high risk ranged from 16.4% to 80.4%.…”

“…The proportion of patients categorized as low risk ranges from 11.7% to 37.1% across schemes, and the proportion who were high risk ranged from 16.4% to 80.4%. 20 In a comparative study of risk stratification scores, it was noted that when various schemes were applied to the same patient cohort, the number of patients classified as low risk ranged from 9% to 49%. 1 These studies highlighted the need for more robust risk stratification schemes, which could allow consistent recommendations for anticoagulant therapy in AF patients at risk for thromboembolism.…”

Health Economic Evaluations of Screening Programs - Applications and Method Improvements

“…[95] This assumption was based on two studies: a study of long-term stroke survival in individuals with AF and a study of first-ever stroke survivors in Australia. [135,136] …”