Stroke: increased age, heart failure, atrial fibrillation and ischaemic heart disease by age 70 increased the risk of death.

Clinical bottom line (level 2b)

  1. Two thirds of patients who had a first-ever cerebral infarction died within 5 years.
  2. Patients with first-ever cerebral infarction were at an increased risk of death at 5 years if they had an age increase of 10 years, congestive heart failure, persistent atrial fibrillation, or ischaemic heart disease.
  3. A quarter of patients with first-ever cerebral infarction will had a recurrence at 5 years.
  4. Patients were at an increased risk of recurrence if they had diabetes mellitus or were older.
Petty et al: Neurology 1998; 50: 208-216
Expires December 2002

The study

Retrospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: population-based, USA

1111 patients (aged mean 75 years, 58% male) stroke, transient ischaemic attack or disorders that could be mistaken for stroke or TIA between January 1, 1975 to December 31, 1989

Excluded if
  • had not lived in the area for at least one year before the stroke
  • died within 24 hours of symptom onset with no clinical evidence of a focal neurologic deficit, no CT or MRI studies done or no autopsy performed



    • Factors studied:
  • mortality and recurrence
  • ischaemic heart disease by age 50
  • congestive heart failure
  • ischaemic heart disease by age 60
  • age increase of 10 years
  • persistent atrial fibrillation
  • ischaemic heart disease by age 70
  • diabetes mellitus
  • age increase of 10 years




    • Multivariate analysis (with bootstraping) was used to adjust for confounding factors.

    100% followed for 5 years
    Outcomes studied:
  • mortality
  • recurrence new neurologic deficit occurring after a period of stability or improvement lasting at least 24 hours, and not caused by oedema, mass effect, brain shift syndrome orhaemorrhagic transformation of incident infarction

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    mortality 5 years 764/1111 68.8%
    (66.0% to 71.5%)
    recurrence 5 years 272/1111 24.5%
    (22.0% to 27.0%)

    prognostic factor for
    mortality     		time to outcome adjusted RR
    (95% CI)
    ischaemic heart disease by age 50 5 years 3.14
    (2.05 to 4.81)
    congestive heart failure 5 years 2.28
    (1.90 to 2.74)
    ischaemic heart disease by age 60 5 years 2.26
    (1.68 to 3.04)
    age increase of 10 years 5 years 1.85
    (1.70 to 2.02)
    persistent atrial fibrillation 5 years 1.69
    (1.38 to 2.07)
    ischaemic heart disease by age 70 5 years 1.63
    (1.35 to 1.97)

    prognostic factor for
    recurrence     		time to outcome adjusted RR
    (95% CI)
    diabetes mellitus 5 years 1.70
    (1.26 to 2.24)
    age increase of 10 years 5 years 1.20
    (1.10 to 1.36)

    Comments

    1. Not enough data was given to calculate NNF+s.

    Citation

    1. Petty GW, Brown RD, Whisnant JP, et al: Survival and recurrence after first cerebral infarction: A population-based study in Rochester, Minnesota, 1975 through 1989. Neurology 1998; 50: 208-216
    Contributor: Clare Wotton and Musab Hayatli, December 1999
    Reviewer:

    Clinical Question.
    Patient first cerebral infarction
    Intervention or Exposure presence of prognostic factors
    Comparison absence of prognostic factors
    Outcome mortality and recurrence