Determinants of Early Case-Fatality among Stroke Patients in Maputo, Mozambique and Impact of in-Hospital Complications

Abstract

The burden of stroke is increasing in developing countries that struggle to manage it efficiently. We identified determinants of early case-fatality among stroke patients in Maputo, Mozambique, to assess the impact of in-hospital complications. Patients admitted to any hospital in Maputo with a new stroke event were prospectively registered (n = 651) according to the World Health Organization's STEPwise approach, in 2005-2006. We assessed the determinants of in-hospital and 28-day fatality, independently of age, gender and education, and computed population attributable fractions. In-hospital mortality was higher among patients with Glasgow score at admission ≤ 6 (more than fivefold) or needing cardiopulmonary resuscitation during hospitalization (approximately 2.5-fold). Pneumonia and deep vein thrombosis/other cardiovascular complications during hospitalization were responsible for 19.6% (95% confidence interval, 5.3 to 31.7) of ischaemic stroke and 15.9% (95% confidence interval, 5.8 to 24.9) of haemorrhagic stroke deaths until the 28th day. Ischaemic stroke patients with systolic blood pressure 160-200 mmHg had lower in-hospital mortality (relative risk = 0.32, 95% confidence interval, 0.13 to 0.78), and, for those with haemorrhagic events (haemorrhagic stroke), 28-day mortality was higher when systolic blood pressure was over 200 mmHg (hazard ratio = 3.42; 95% confidence interval, 1.02 to 11.51), compared with systolic blood pressure 121-140 mmHg. Regarding diastolic blood pressure, the risk was lowest at 121-150 mmHg for ischaemic stroke and at 61-90 mmHg for haemorrhagic stroke. Early case-fatality was mostly influenced by stroke severity and in-hospital complications. The allocation of resources to the latter may have a large impact on the reduction of the burden of stroke in this setting.

Cardiovascular risk in Mozambique

“…Although we do not have such information in this study, the prevalence of these conditions is expectedly low, due to the high case fatality associated with major cardiovascular events [7,8]. …”

“…In Mozambique, hypertension affects one-third of the adult population [5] and cardiovascular diseases already have an important public health impact [6–8], especially stroke, and mainly among older dwellers from urban areas [9]. In 1994, cerebrovascular diseases were the leading cause of death among Maputo inhabitants aged over 60 [6].…”

“…In 1994, cerebrovascular diseases were the leading cause of death among Maputo inhabitants aged over 60 [6]. Between 2005 and 2006, the incidence of stroke hospitalization in Maputo was estimated to be 148.7 per 100 000, one of the highest in developing settings [7], and the early case-fatality rates were also high [8]. …”

The Effect of Season and Temperature Variation on Hospital Admissions for Incident Stroke Events in Maputo, Mozambique

“…18,19 During a 12-month period, from August 1, 2005, to July 31, 2006, all patients admitted to any governmental or private hospital in Maputo (the Maputo Central Hospital, 3 general public hospitals, the military hospital, and 6 private clinics), living in town for more than 12 months, and suspected of having an incident stroke event were registered. Stroke was defined according to the World Health Organization clinical definition: “a focal (or at times global) neurological impairment of sudden onset, and lasting more than 24 hours (or leading to death), and of presumed vascular origin.” 22 During this period, 651 stroke events were registered in a population of 1.2 million inhabitants.…”

“…Although Mozambique is in its early steps in the epidemiological transition, stroke is already a frequent condition, responsible for high morbidity and mortality. 18,19 The recognition of an association between atmospheric temperature and the incidence of stroke in Maputo may allow a more efficient allocation of the limited resources available in this setting for an appropriate management of the cases that seek medical attention. 1,20,21 Therefore, we aimed to describe the variation in the incidence of stroke hospitalizations across seasons and with short-term temperature variation, in Maputo, Mozambique.…”