Mortality risk ‘lifelong’ for young stroke survivors
By Eleanor McDermid, Senior medwireNews Reporter
21 March 2013
JAMA 2013; 309: 1136–1144, 1171–1172

medwireNews: The excess risk for mortality in people who survive stroke at a relatively young age lasts a lifetime, shows a 20-year follow-up Dutch study.

As reported in JAMA, survivors' risk for dying was highest in the year immediately after their stroke, but was at least threefold higher than that of the general population across the whole study period.

The findings indicate that "secondary prevention after stroke in young adults is a long-term, and probably lifelong, endeavor," writes Graeme Hankey (Royal Perth Hospital, Australia) in an editorial accompanying the study.

He stresses the importance of accurate diagnosis and management of the underlying cause of stroke, and of minimizing risk factors. "A recurrent stroke, particularly of the same pathologic and etiologic type as the index stroke, represents failed secondary prevention and is a further signal that the cause or causes of the index stroke have not been diagnosed and managed successfully," he says.

The "young" stroke patients in the study were aged between 18 and 50 years. Of the 959 patients, 606 had an ischemic stroke, 262 had a transient ischemic attack (TIA), and 91 had an intracerebral hemorrhage (ICH). Twenty percent of this cohort died during the follow-up period (average 11.1 years).

The mortality risk was highest during the first year after the initial event for survivors of ischemic stroke and ICH, at 2.4% and 2.9%, respectively, and then fell to annual rates of 1.2-1.8% and 0.6-2.9%. The mortality rate was fairly constant in TIA survivors, at 0.4-1.5%. However, cumulative 20-year mortality was consistently higher than expected based on Dutch population norms - 3.9-fold higher for both ischemic stroke survivors and ICH survivors. Mortality was increased a significant 2.6-fold among survivors of TIA, although the difference only became apparent from about 10 years after the initial event.

Mortality after ischemic stroke exceeded the expected rate for all etiologic subtypes (according to TOAST classification), most notably for cardioembolic stroke, which was associated with a 9.2-fold increased mortality rate.

Vascular causes, including cardiac causes and stroke, accounted for just over half of the deaths among the stroke survivors, report Frank-Erik de Leeuw (Radboud University Nijmegen Medical Centre, the Netherlands) and colleagues. This suggests that "the underlying disease causing the stroke at a young age continues to be active throughout life," they say.

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