Stroke: clinical features increased the risk of mortality and recurrence.

Clinical bottom line (level 1b)

  1. Nearly half of patients with cerebral infarction were dead at 5 years.
  2. Patients with cerebral infarction were at an increased risk of mortality at 5 years if they had major hemispheric or basilar syndrome, admission glucose >140 mg/dL, congestive heart failure, or a ten-year age increment.
  3. Patients are at a decreased risk of mortality at 5 years if they have lacunar syndrome.
Sacco et al: Neurology 1994; 44: 626-634
Expires December 2002

The study

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

Setting: urban community, USA

323 patients (aged range 40 to 98 years; mean 68, 52% female) cerebral infarction when aged >39y and race defined as Hispanic, white non-Hispanic or black non-Hispanic

Excluded if
  • not residents of the community involved
  • not hospitalised at the medical centre involved



    • Factors studied:
  • mortality and recurrence of stroke
  • major hemispheric or basilar syndrome
  • admission glucose >140 mg/dL
  • congestive heart failure
  • lacunar syndrome
  • 10-year age increase
  • heavy ethanol use
  • hypertension at discharge
  • 100 mg/dL increment in admission glucose




    • Multivariate analysis was used to adjust for confounding factors.

    94% followed for 5 years
    Outcomes studied:
  • mortality
  • recurrent stroke

    • Type of stroke defined by clinical, CT and angiographic, ECG or ECHO evidence.
    • Patients were 40% black non-Hispanic, 34% Hispanic and 26% white non-Hispanic.

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    mortality 5 years 143/323 44.3%
    (38.9% to 49.7%)
    recurrent stroke 5 years 72/323 22.3%
    (17.8% to 26.8%)

    prognostic factor for
    mortality     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    major hemispheric or basilar syndrome 5 years 2.00
    (1.30 to 3.00)     		2
    (1 to 5)
    admission glucose >140 mg/dL 5 years 1.70
    (1.40 to 2.80)     		4
    (2 to 7)
    congestive heart failure 5 years 2.60
    (1.70 to 4.10)     		2
    (1 to 4)
    lacunar syndrome 5 years 0.56
    (0.32 to 0.92)     		-4
    (-21 to -3)
    10-year age increase 5 years 1.40
    (1.20 to 1.70)

    prognostic factor for
    recurrent stroke     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    heavy ethanol use 5 years 2.50
    (1.40 to 4.40)     		3
    (1 to 11)
    hypertension at discharge 5 years 1.60
    (1.01 to 2.60)
    100 mg/dL increment in admission glucose 5 years 1.40
    (1.10 to 1.70)

    Comments

    1. There were no specific cut-off values for age and admission glucose level given, so NNF+ could not be calculated.

    Citation

    1. Sacco RL, Shi T, Zamanillo MC, et al: Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: The Northern Manhattan Stroke Study. Neurology 1994; 44: 626-634
    Contributor: Clare Wotton and Bob Phillips, December 1999
    Reviewer:

    Clinical Question.
    Patient ischaemic stroke
    Intervention or Exposure presence of prognostic factors
    Comparison absence of prognostic factors
    Outcome recurrence of stroke and mortality