Stroke: some clinical characteristics increased risk of stroke, MI and vascular death.

Clinical bottom line (level 1b)

  1. A sixth of patients who have had a transient ischaemic attack or nondisabling stroke will have a stroke, myocardial infarction or vascular death within 2 years.
  2. Patients who have had a TIA or nondisabling stroke are at an increased risk of stroke, MI or vascular death at 2 years if they are/have: male, aged more than 65 years, dysarthria, multiple attacks, diabetes mellitus, angina pectoris, intermittent claudication, border zone infarct, any other infarct, white matter hypodensity, anteroseptal infarct, ST depression, increased terminal P wave or left ventricular hypertrophy.
  3. Patients were at a decreased risk if they have vertigo.
Dippel and Koudstaal: Stroke 1997; 28 (4): 774-776
Expires February 2003

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: Dutch TIA of low-dose versus medium-dose aspirin

3126 patients (aged ?, ?% male) within 3 months after onset of a transient ischaemic attack. amaurosis fugax or nondisabling stroke

Factors studied:
  • stroke, MI or vascular death
  • male
  • age >65 years
  • dysarthria
  • multiple attacks
  • diabetes mellitus
  • angina pectoris
  • intermittent claudication
  • border zone infarct
  • any other infarct
  • white matter hypodensity
  • anteroseptal infarct
  • ST depression
  • increased terminal P wave
  • left ventricular hypertrophy (Cassale criteria)
  • vertigo


    • low- or medium-dose aspirin

    Multiple regression was used to adjust for confounding factors.

    100% followed for 2 years
    Outcomes studied:
  • stroke, myocardial infarction or vascular death

    • Although each of the identified factors was significantly associated with future risk measured as relative risk, individually or combined they were poor at predicting an individuals absolute risk. Better prognostic factors need to be found.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    stroke, myocardial infarction or vascular death 2 years 469/3126 15.0%
    (13.8% to 16.3%)

    prognostic factor for
    stroke, myocardial infarction or vascular death     		time to outcome control rate (%) adjusted OR
    (95% CI)
    male ? 1.60
    (1.30 to 2.00)
    age >65 years ? 1.60
    (1.30 to 2.00)
    dysarthria ? 1.30
    (1.10 to 1.60)
    multiple attacks ? 1.20
    (1.00 to 1.50)
    diabetes mellitus ? 1.90
    (1.50 to 2.50)
    angina pectoris ? 1.30
    (1.00 to 1.70)
    intermittent claudication ? 1.60
    (1.20 to 2.30)
    border zone infarct ? 2.10
    (1.30 to 3.50)
    any other infarct ? 1.30
    (1.10 to 1.50)
    white matter hypodensity ? 1.40
    (1.10 to 1.80)
    anteroseptal infarct ? 1.50
    (1.20 to 1.90)
    ST depression ? 1.30
    (1.00 to 1.80)
    increased terminal P wave ? 1.30
    (1.10 to 1.50)
    left ventricular hypertrophy (Cassale criteria) ? 1.70
    (1.20 to 2.40)
    vertigo ? 0.50
    (0.40 to 0.80)

    • In the predictive model, the median number of prognostic factors for stroke, MI or vascular death was 3. The proportion of patients with a predicted probability exceeding 30% was less than 5%, ie. the calibration of the model was poor.

    Citation

    1. Dippel DWJ, and Koudstaal PJ: We need stronger predictors of major vascular events in patients with a recent transient ischaemic attack or nondisabling stroke. Stroke 1997; 28 (4): 774-776
    Contributor: Clare Wotton and Musab Hayatli, February 2000
    Reviewer: Kev Hopayian

    Clinical Question.
    Patient TIA or nondisabling stroke
    Intervention or Exposure presence of prognostic factors
    Comparison absence of prognostic factors
    Outcome risk of recurrent major vascular events