Arterial Events after Ischemic Stroke at a Young Age: A Cross-Sectional Long-Term Follow-Up of Patients and Controls in Western Norway

Are 12-lead ECG findings associated with the risk of cardiovascular events after ischemic stroke in young adults?

INTRODUCTION

Ischemic stroke (IS) in a young patient is a disaster and recurrent cardiovascular events could add further impairment. Identifying patients with high risk of such events is therefore important. The prognostic relevance of ECG for this population is unknown.

MATERIALS AND METHODS

A total of 690 IS patients aged 15-49 years were included. A 12-lead ECG was obtained 1-14 d after the onset of stroke. We adjusted for demographic factors, comorbidities, and stroke characteristics, Cox regression models were used to identify independent ECG parameters associated with long-term risks of (1) any cardiovascular event, (2) cardiac events, and (3) recurrent stroke.

RESULTS

Median follow-up time was 8.8 years. About 26.4% of patients experienced a cardiovascular event, 14.5% had cardiac events, and 14.6% recurrent strokes. ECG parameters associated with recurrent cardiovascular events were bundle branch blocks, P-terminal force, left ventricular hypertrophy, and a broader QRS complex. Furthermore, more leftward P-wave axis, prolonged QTc, and P-wave duration >120 ms were associated with increased risks of cardiac events. No ECG parameters were independently associated with recurrent stroke.

CONCLUSION

A 12-lead ECG can be used for risk prediction of cardiovascular events but not for recurrent stroke in young IS patients. KEY MESSAGES ECG is an easy, inexpensive, and useful tool for identifying young ischemic stroke patients with a high risk for recurrent cardiovascular events and it has a statistically significant association with these events even after adjusting for confounding factors. Bundle branch blocks, P-terminal force, broader QRS complex, LVH according to Cornell voltage duration criteria, more leftward P-wave axis, prolonged QTc, and P-wave duration >120 ms are predictors for future cardiovascular or cardiac events in these patients. No ECG parameters were independently associated with recurrent stroke.

Cardiovascular events after ischemic stroke in young adults: A prospective follow-up study

OBJECTIVES

To study the long-term risk of recurrent cardiac, arterial, and venous events in young stroke patients, and whether these risks differed between etiologic subgroups.

METHODS

The study population comprised 970 patients aged 15-49 years from the Helsinki Young Stroke Registry (HYSR) who had an ischemic stroke in 1994-2007. We obtained follow-up data until 2012 from the Finnish Care Register and Statistics Finland. Cumulative 15-year risks were analyzed with life tables, whereas relative risks and corresponding confidence intervals (CI) were based on hazard ratios (HR) from Cox regression analyses.

RESULTS

There were 283 (29.2%) patients with a cardiovascular event during the median follow-up of 10.1 years (range 0.1-18.0). Cumulative 15-year risk for venous events was 3.9%. Cumulative 15-year incidence rate for composite vascular events was 34.0 (95% CI 30.1-38.2) per 1,000 person-years. When adjusted for age and sex, patients with an index stroke caused by high-risk sources of cardioembolism had the highest HR for any subsequent cardiovascular events (3.7; 95% CI 2.6-5.4), whereas the large-artery atherosclerosis group had the highest HR (2.7; 95% CI 1.6-4.6) for recurrent stroke compared with patients with stroke of undetermined etiology.

CONCLUSIONS

The risk for future cardiovascular events after ischemic stroke in young adults remains high for years after the index stroke, in particular when the index stroke is caused by high-risk sources of cardioembolism or large-artery atherosclerosis.

Recurrent ischemic stroke is associated with the burden of risk factors

AIM

To determine the characteristics of acute ischemic stroke patients admitted to hospital with history of prior ischemic stroke(s). We hypothesized that there is an association between the number of risk factors and prior ischemic stroke irrespective of age.

METHODS

All patients with acute ischemic stroke admitted to Haukeland University Hospital between 2006 and 2013 were registered in the NORSTROKE database. Variables included prior ischemic stroke(s) (based on self-report and patient records), risk factors, TOAST classification, and CT and MRI findings. Comparison was made between patients with prior ischemic stroke and first-ever ischemic stroke. Multivariate analyses were performed.

RESULTS

In total, 2697 patients were included and 461 (17.1%) had a history of prior ischemic stroke(s). Logistic regression analyses showed that prior ischemic stroke was associated with the number of risk factors, leukoaraiosis, hypertension, atrial fibrillation, and atherosclerosis.

CONCLUSION

History of prior ischemic stroke in patients with acute ischemic stroke was associated with the burden of risk factors, atherosclerosis, and atrial fibrillation compared to first-ever ischemic stroke. This has important implications for secondary preventive treatment.

Risk factors and their impact on carotid intima-media thickness in young and middle-aged ischemic stroke patients and controls: the Norwegian Stroke in the Young Study

Background

Vascular morbidity and mortality due to cardiovascular disease (CVD) are high after ischemic stroke at a young age. Data on carotid intima-media thickness (cIMT) as marker of atherosclerosis are scarce for young stroke populations. In this prospective case–control study, we examined cIMT, the burden of vascular risk factors (RF) and their associations among young and middle-aged ischemic stroke patients and controls. We aimed to detect clinical and sub-clinical arterial disease.

Methods

This study was conducted in 150 patients aged 15–60 years and 84 controls free of CVD. We related RF to ultrasonographic B-mode cIMT-measurements obtained from 12 standardized multiangle measurements in the common carotid artery (CCA), carotid bifurcation (BIF) and internal carotid artery (ICA).

Results

RF burden was higher among patients than among controls (p < 0.001). In multivariate analyses of all 234 participants, increased cIMT was associated with age in each carotid segment. Incident stroke was associated with increased ICA-IMT. ICA-IMT increase was associated with a family history of CVD among patients aged 15–44 years, and with RF at mid-age. The overall cIMT difference between patients and controls was 12% for CCA, 17% for BIF and 29% for ICA. Further, increased CCA-IMT was associated with male sex and hypertension. Increased BIF-IMT was associated with dyslipidemia, coronary heart disease and smoking. Increased ICA-IMT was associated with dyslipidemia and stroke.

Conclusions

Ischemic stroke is associated with increased ICA-IMT, related to a family history of CVD among patients aged <45 years, and to increasing RF burden with increasing age. Preventive strategies and aggressive RF treatment are indicated to avoid future cardiovascular events.

Trial registration

NOR-SYS is registered in ClinicalTrials.gov (NCT01597453).

High incidence of diabetes after stroke in young adults and risk of recurrent vascular events: the FUTURE study

Background

Diabetes diagnosed prior to stroke in young adults is strongly associated with recurrent vascular events. The relevance of impaired fasting glucose (IFG) and incidence of diabetes after young stroke is unknown. We investigated the long-term incidence of diabetes after young stroke and evaluated the association of diabetes and impaired fasting glucose with recurrent vascular events.

Methods

This study was part of the FUTURE study. All consecutive patients between January 1, 1980, and November 1, 2010 with TIA or ischemic stroke, aged 18–50, were recruited. A follow-up assessment was performed in survivors between November 1, 2009 and January 1, 2012 and included an evaluation for diabetes, fasting venous plasma glucose and recurrent vascular events. The association of diabetes and IFG with recurrent vascular events was assessed by logistic regression analysis, adjusted for age, sex and follow-up duration.

Results

427 survivors without a medical history of diabetes were included in the present analysis (mean follow-up of 10.1 (SD 8.4) years; age 40.3 (SD 7.9) years). The incidence rate of diabetes was 7.9 per 1000 person-years and the prevalence of IFG was 21.1%. Patients with diabetes and IFG were more likely to have experienced any vascular event than those with normal fasting glucose values (OR 3.5 (95%CI 1.5–8.4) for diabetes and OR 2.5 (95%CI 1.3–4.8) for IFG).

Conclusions

Diabetes or IFG in young stroke survivors is frequent and is associated with recurrent vascular events. Regular screening for IFG and diabetes in this population, yields potential for secondary prevention.

The Norwegian Stroke in the Young Study (NOR-SYS): rationale and design

BACKGROUND

Ischemic stroke in young adults is a major health problem being associated with a higher vascular morbidity and mortality compared to controls, and a stroke recurrence rate of 25% during the first decade. The assumed cause of infarction and the detected risk factors determine the early- and long-term treatment. However, for many patients the cause of stroke remains unknown. Risk factor profile and etiology differ in young and elderly ischemic stroke patients, and atherosclerosis is the determined underlying condition in 10 to 15%. However, subclinical atherosclerosis is probably more prevalent and may go unrecognized.

METHODS/DESIGN

NOR-SYS is a prospective long-term research program. Standardized methods are used for anamnestic, clinical, laboratory, imaging, and ultrasound data collection in ischemic stroke patients aged ≤60 years, their partners and joint adult offspring. The ultrasound protocol includes the assessment of intracranial, carotid and femoral arteries, abdominal aorta, and the estimation of VAT. To date, the study is a single centre study with approximately 400 patients, 250 partners and 350 adult offspring expected to be recruited at our site.

DISCUSSION

NOR-SYS aims to increase our knowledge about heredity and the development of arterial vascular disease in young patients with ischemic stroke and their families. Moreover, optimization of diagnostics, prophylaxis and early intervention are major targets with the intention to reduce stroke recurrence and other clinical arterial events, physical disability, cognitive impairment and death.

Ischaemic stroke at a young age is a serious event--final results of a population-based long-term follow-up in Western Norway

BACKGROUND AND PURPOSE

Our population-based long-term follow-up of young ischaemic stroke patients and controls showed 10-fold increased mortality and fivefold increased arterial event rate nearly 12 years after study inclusion. We now assess memory, anxiety, depression and sleep in relation to employment and functional outcome, treatment goals and results from a last alive-dead survey.

METHODS

Patients (n = 232) ≤ 49 years with an index-stroke between 1988 and 1997 were retrospectively selected and compared with age- and sex-matched controls (n = 453). At follow-up from 2004 to 2005, 144 (77%) of 187 patients were clinically examined. Self-assessment information about memory problems, anxiety, depression, sleeping problems, education and employment was compared with answers from standardized questionnaires from 167 controls. Functional outcome was measured by the modified Rankin Scale (mRS).

RESULTS

Patients compared with controls had more memory problems (41.0% vs. 5.4%, P < 0.001), anxiety (19.4% vs. 9%, P = 0.009), depression (29.2% vs. 13.2%, P = 0.001) and sleeping problems (36.1% vs. 19.2%, P = 0.001). In the multiple regression analysis male gender (OR 9.3, 95%CI 0.10-0.61, P = 0.002), normal memory (OR 12.7, 95%CI 0.07-0.47, P < 0.001) and mRS 0-1 (OR 15.7, 95%CI 0.002-0.12, P < 0.001) were factors for full-time employment. Blood pressure was < 140/90 mmHg in 39% of patients, 49% stopped smoking and 38.2% used statins. After a mean observation time of 18.3 years, 63 (27.2%) of 232 patients were dead.

CONCLUSIONS

Our data show a heterogeneous prognosis and high mortality even for long-time survivors of ischaemic stroke at a young age. Prospective studies of young stroke patients and controls are necessary for direct comparison.

Acute stroke centre - the changing focus of stroke unit care. The Bergen NORSTROKE Study

OBJECTIVES

The basic stroke unit studies selected patients primarily for rehabilitation and did not deal with the critical first hours after stroke. The aim of this study was to analyse a unselected cohort of patients admitted to an acute stroke centre with primary focus on emergency diagnosis and treatment.

MATERIALS AND METHODS

All patients with suspected stroke were admitted as emergencies. Patients with definite cerebrovascular disease were prospectively included in the Bergen Stroke Study, patients with other diseases were excluded, but final diagnosis was registered.

RESULTS

Fifty per cent of the admitted patients had other diagnosis than stroke. Of 1267 consecutive patients with cerebrovascular disease, 70% had no or minor neurological deficits on admission. After 1 week, 56% were independent, 30% needed long-term rehabilitation, 10% were bedridden and 4% were dead.

CONCLUSION

An acute stroke centre today requires a high degree of neurological expertise in assessing patients admitted with possible stroke. Most patients with stroke have no or mild deficits and need above all rapid diagnostic work-up, acute and prophylactic treatment. In-hospital rehabilitation is essential for a smaller number of patients who suffer from persisting neurological deficits after stroke.

[Treatment of cerebrovascular disease in a comprehensive stroke unit]

BACKGROUND

Development of stroke units during the last decade has changed management of patients with stroke. The aim of this study is to assess unselected patients admitted to an acute stroke unit with respect to daily functioning (neurological deficits), treatment and 7-day outcome.

MATERIAL AND METHODS

All patients with suspected neurovascular disease were admitted to the stroke unit as emergencies. Patients with confirmed cerebrovascular disease were prospectively included in the Bergen Stroke Study in the period 1 February 2006-30 April 2009. Patients who had other diagnoses were not included, but their diagnoses were prospectively recorded in a 3 month-period.

RESULTS

49.8% of the patients had other diagnoses than acute stroke. Of 1101 patients with neurovascular disease; 10% had transient ischemic attacks, 79% had ischemic and 10% had hemorrhagic stroke. On admission, 72% of the patients had none or minor neurological deficits. After one week 63% of the patients were independent, 25% needed long-term rehabilitation and 10% were bedridden.

INTERPRETATION

Most patients in our study had mild deficits and first of all need an exact diagnostic work-up, acute and prophylactic treatment. Rehabilitation is important for a minority of patients.

Ultrasound, atherosclerosis and stroke at a young age: a cross-sectional long-term follow-up in western Norway

BACKGROUND AND PURPOSE

Previous studies have shown significantly higher mortality and vascular morbidity amongst patients with ischaemic stroke onset at a young age compared with controls after a mean observation time of more than 11 years.

METHODS

In the present cross-sectional study, we measured the carotid intima-media thickness (IMT) in 140 (75%) of 187 survivors of ischaemic stroke after a mean observation time of 11.9 years. Their mean age when included was 41.1 years. IMT was measured by B-mode ultrasonography.

RESULTS

Total maximum IMT <1.0 mm was found in 34 (24%) patients, [1.0-1.2 mm) in 29 (21%) patients, [1.2-1.5 mm) in 29 (21%) patients and >or=1.5 mm in 48 (34%) patients. Increasing total maximum IMT was related to increasing age, male gender, recurrent ischaemic stroke, coronary atherosclerosis, peripheral atherosclerosis, smoking, hypertension and diabetes mellitus.

DISCUSSION

IMT changes confirm increased vascular morbidity in patients who suffered ischaemic stroke at a young age.