A new study shows that rates of recurrent stroke, myocardial infarction (MI), and all-cause and vascular death increase during the first 4 years after hospitalization for a stroke.   Researchers used a state hospital database to capture subsequent vascular events among more than 10,000 patients hospitalized for ischemic or hemorrhagic strokes in South Carolina. The risk for recurrent stroke or death in particular was highest in these patients at 1 year, but rates continued to increase at a steady rate up to 4 years after the event.  “Our findings suggest considerable improvement in secondary stroke prevention is needed to reduce those events in South Carolina,” the researchers, with first author Wuwei Feng, MD, from the Medical University of South Carolina, Charleston, conclude.

Their results appear in the February 16 issue of Neurology.

Recurrent Risk

Existing data on the risk for stroke recurrence among stroke survivors have largely been drawn from clinical trials or community-based cohort studies, the study authors write. However, community-based studies have shown large interstudy variability in their findings and have relatively small sample sizes. Randomized trials on the other hand may have exclusion criteria that would prevent the findings from being applicable to the more general stroke population, they note.

In this study, the researchers identified 10,399 patients with a primary diagnosis of stroke discharged in 2002 using the South Carolina state hospital discharge database. They calculated Kaplan-Meier estimates of recurrent stroke, MI, vascular death, all-cause death, and composite events, including recurrent stroke, MI, and death at various time points from 1 month to 4 years, and identified prognostic factors using Cox proportional hazard models.

Their data show that the risk for recurrent stroke and death was higher in the first year, with an 8% risk for recurrent stroke and a 24.5% risk for death, but the rates continued to increase at a steady rate up to 4 years. The risk for MI was much lower than that for recurrent stroke.

Table. Kaplan-Meier Cumulative Risk for Events After Hospitalized Stroke

The risk for composite events, including recurrent stroke, MI, or death, increased with age, was higher for African Americans compared with whites and for those with a higher comorbidity index.

Patients with hemorrhagic strokes were less likely to have recurrent strokes compared with those with ischemic strokes but more likely to die of a vascular disease or any cause or to have one of the composite events, the study authors report. “This may be due in part to the death of these patients before experiencing a recurrent stroke, as patients with SAH [subarachnoid hemorrhage] and ICH [intracerebral hemorrhage] are known to have a much higher mortality rate than ones with ischemic stroke,” they note.

They also point out that because their work does not capture patients seen in military hospitals or those in border areas that might opt to be seen in other states, it represents “a close but not a complete picture of stroke epidemiology in South Carolina.”

In addition, they lacked data on whether the hospitalized stroke was a first-ever or recurrent stroke that may carry different risks for recurrent events. In addition, there was no information available on risk factors or secondary prevention strategies used for these patients.

“Thus, while we have highlighted the short- and long-term risk of stroke in South Carolina, the study is not designed to be able to elucidate the underlying causes, which requires a focused study,” Dr. Feng and colleagues conclude.

Solid Documentation

Asked by Medscape Neurology for comment on these findings, Philip B. Gorelick, MD, MPH, from the University of Illinois College of Medicine at Chicago, called the paper “a solid documentation of risk of recurrent stroke, MI, or death in hospitalized stroke patients.

“The data are important for planning stroke and other cardiovascular disease prevention efforts,” he noted.

The study was supported by an internal fund from the South Carolina Center of Economic Excellence in Stroke. Senior author Dr. Robert Adams serves on scientific advisory boards for Boehringer Ingelheim and American Health Benefits; serves on a speaker’s bureau and has received speaker honoraria from Genentech Inc; serves as an adviser to the American Health & Drug Benefits Journal; holds IP rights for, receives royalty payments for, may accrue revenue on a patent for, and holds stock in REACHCall Inc; and has received research support from the Duke Endowment. He is also an uncompensated member of the editorial advisory board for Medscape Neurology. The other study authors have disclosed no relevant financial relationships.

In an editorial, Dr. John A. Bittl, from the Ocala Heart Institute, Florida, and Dr. David J. Maron at Vanderbilt University Medical Center, Nashville, Tennessee, comment that advantages of an early conservative approach include the ability to safely postpone invasive procedures in bleeding patients and to perform semi-elective invasive evaluations.

On the other hand, physicians may prefer an immediate procedure to avoid long hospital stays or discharging potentially high-risk patients

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