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No early complications after stroke may increase long-term risk for recurrence, death

Survivors of stroke or transient ischemic attack who did not experience early complications have an elevated risk for recurrent stroke, death or myocardial infarction for at least 5 years following the initial stroke, suggesting that these patients require medical support to reduce their risk in the subsequent years, according to findings published in the Canadian Medical Association Journal.

“Secondary prevention after stroke and transient ischemic attack has focused on high early risk of recurrence, but survivors of stroke can have substantial long-term morbidity and mortality,” Jodi D. Edwards, PhD, from Sunnybrook Research Institute in Toronto, and colleagues wrote.

Edwards and colleagues conducted a longitudinal case-control study to determine long-term risks for morbidity and mortality for ambulatory or hospitalized patients who survived for 90 days after stroke or transient ischemic attack without recurrent stroke, MI, all-cause admission to hospital, admission to an institution or death. Participants included those who were admitted to regional stroke centers in Ontario between July 2003 and March 2013. They matched cases and controls based on age, sex and geographic location. Rates of composite and individual outcomes were calculated at 1, 3 and 5 years. The researchers estimated long-term hazards for cases and controls, as well as for patients with stroke and those with transient ischemic attack using cause-specific regression.

A total of 26,366 patients were initially stable after stroke or transient ischemic attack. Of those, hazard ratios for death, stroke, MI or admission to long-term or continuing care more than doubled relative to controls (n =263,660) at 1 year (HR = 2.4; 95% CI, 2.3–2.5), 3 years (HR = 2.2; 95% CI, 2.1–2.3) and 5 years (HR = 2.1; 95% CI, 2.1–2.2).

Patients who did not experience complications after stroke or transient ischemic attack were significantly more likely to have long-term complications than controls. Adverse events, such as death, stroke, MI or admission to long-term care, were experienced by 9.5%, 23.6% and 35.7% of patients at one, three and five years, respectively.

Recurrent stroke had the highest long-term risks at 1 year (HR = 6.8; 95% CI, 6.1–7.5), 3 years (HR = 5.6; 95% CI, 5.2–6) and 5 years (HR = 5.1; 95% CI, 4.8–5.5), indicating that stroke recurrence is the most important modifiable outcome. In addition, the risk for admission to an institution more than doubled for 5 years. Morbidity and mortality were higher in survivors of stroke; however, within 5 years, 31.5% of patients with transient ischemic attack had an adverse event.

“There is a real need to maintain risk reduction strategies, medical support and healthy lifestyle choices over the long-term, even years after a mild initial event,” Richard Swartz, MD, PhD, coauthor of the study from Sunnybrook Health Sciences Center in Toronto, said in a press release.

“These findings highlight the need for long-term management of modifiable risks, such as high BP, monitoring and treatment of irregular heart rhythms, quitting smoking and physical activity,” he added.

According to the researchers, adapting existing cardiac rehabilitation programs for stroke survivors, following patients for longer periods of time after their stroke or transient ischemic attack and incorporating long-term management into primary care practices may help to reduce long-term risk of morbidity and mortality. – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.