Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies

Slot, Karsten Bruins; Berge, Eivind; Dorman, Paul; Lewis, Steff; Dennis, Martin; Sandercock, Peter

doi:10.1136/bmj.39456.688333.be

Cited by 162 publications

(133 citation statements)

References 31 publications

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“…Our finding that 3‐month mRS score predicts 5‐year mortality, suggesting that reduction of early disability might reduce long‐term mortality, is in agreement with 4 prior studies that examined early stroke disability and long‐term mortality 9, 10, 11, 13. Our study adds a robust population‐based design, high rates of ascertainment of all incident strokes, assessment of causes of late poststroke death, completeness of follow‐up (1.5% missing), and replication of findings in important subgroups.…”

Section: Discussionsupporting

confidence: 91%

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

Ganesh

Luengo-Fernández

Wharton

et al. 2017

JAHA

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BackgroundOutcome in stroke trials is often based on a 3‐month modified Rankin scale (mRS). How 3‐month mRS relates to longer‐term outcomes will depend on late recovery, delayed stroke‐related deaths, recurrent strokes, and nonstroke deaths. We evaluated 3‐month mRS and death/disability at 1 and 5 years in a population‐based cohort study.Methods and ResultsIn 3‐month survivors of ischemic stroke (Oxford Vascular Study; 2002‐2014), we related 3‐month mRS to disability (defined as mRS >2) at 1 and 5 years and/or death rates (age/sex adjusted). Accrual of disability and index‐stroke‐related and nonstroke deaths in each poststroke year was categorized according to 3‐month mRS. Among 1606 patients with acute ischemic stroke, 181 died within 3 months, but 126 index‐stroke‐related deaths and 320 other deaths occurred during the subsequent 4866 patient‐years of follow‐up up to 5 years. Although 69/126 (54.8%) post‐3‐month index‐stroke‐related deaths occurred after 1 year, mRS>2 at 1 year strongly predicted these deaths (adjusted hazard ratio=21.94, 95%CI 7.88‐61.09, P<0.0001). Consequently, a 3‐month mRS >2 was a strong independent predictor of death at both 1 year (adjusted hazard ratio=6.67, 95%CI 4.16‐10.69, P<0.0001) and 5 years (adjusted hazard ratio=2.93, 95%CI 2.38‐3.60, P<0.0001). Although mRS improved by ≥1 point from 3 months to 1 year in 317/1266 (25.0%) patients with 3‐month mRS ≥1, improvement in mRS after 1 year was limited (improvement by ≥1 point: 91/858 [10.6%]; improvement to mRS ≤2: 13/353 [3.7%]).ConclusionsOur results reaffirm use of the 3‐month mRS outcome in stroke trials. Although later recovery does occur, extending follow‐up to 1 year would capture most long‐term stroke‐related disability. However, administrative mortality follow‐up beyond 1 year has the potential to demonstrate translation of early disability gains into additional reductions in long‐term mortality without much erosion by non‐stroke‐related deaths.

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Section: Discussionsupporting

confidence: 91%

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

Ganesh

Luengo-Fernández

Wharton

et al. 2017

JAHA

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“…, boxes [1][2][3][4][5][6][7] 149 Prognosis among patients with suspected transient ischaemic attack and minor stroke 149 Prognosis scoring systems in patients with transient ischaemic attack/minor stroke (see Table 61 , box 54) 152 Proportion of ischaemic stroke/transient ischaemic attack with a relevant lesion on computed tomography, diffusion-weighted imaging (see Table 61 , boxes [50][51][52][53] 152 Accuracy of computed tomography and magnetic resonance (diffusion-weighted imaging, gradient echo, T2/fluid-attenuated inversion recovery) for non-vascular compared with ischaemic stroke/transient ischaemic attack compared with haemorrhagic stroke/transient ischaemic attack by time after index event (see Table 61 , boxes [59][60][61][62][63][64] 153 Population of the model 157 Epidemiological data: profile of the patients who have suffered a transient ischaemic attack 320 …”

mentioning

confidence: 99%

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Wardlaw

Brazzelli

Miranda

et al. 2014

Health Technol Assess

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BackgroundPatients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment.ObjectivesIs MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as ‘one-stop’ brain-carotid imaging? What is the current UK availability of services for stroke prevention?Data sourcesPublished literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion.Review methodsSystematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios.ResultsThe pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35–41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40–45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51–54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with ‘CT scan all patients’ MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. ‘One-stop’ CT/MR angiographic-plus-brain imaging was not cost-effective.LimitationsData on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity.ConclusionsMagnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…no recurrent stroke 2. recurrent ischaemic stroke 3. haemorrhagic stroke 4. vascular death 5. non-vascular death. 91 to estimate the overall death rate among stroke patients compared with the general population. A multiplier of 1.5 was used to generate an overall expected age-related death rate beyond the trial period from the Office for National Statistics death rate data for the general population.…”

Section: Review Of Boehringer Ingelheim Submissionmentioning

confidence: 99%

“…Death rates amongst patients who have had strokes have been derived from two main papers; 90,91 when these papers were checked, the figures quoted in appendix 9 of the manufacturer's submission do not clearly match with those in the published papers. In relation to the TIA incidence rates, the manufacturer has assumed that patients who experienced TIAs had a rate of ischaemic stroke events equal to 80% of those who had experienced a previous ischaemic stroke; there is no evidence to support this assumption and it has not been tested in the one-way univariate sensitivity analysis.…”

Section: Critique Of Boehringer Ingelheim's Economic Model By the Assmentioning

confidence: 99%

“…91 The model includes a binary measure of functional disability equivalent to scores of ≥ 3 on the modified Rankin Scale. 60 The ) has been provided to the Assessment Group in order to allow calibration of the model, and, in particular, to facilitate development of risk models incorporating all relevant modifying variables, and avoiding errors arising from incorrect application of competing risks.…”

Section: Disabilitymentioning

confidence: 99%

See 1 more Smart Citation

Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (review of Technology Appraisal No. 90): a systematic review and economic analysis

Greenhalgh

Bagust²,

Boland³

et al. 2011

Health Technol Assess

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Impact of functional status at six months on long term survival in patients with ischaemic stroke: prospective cohort studies

Cited by 162 publications

References 31 publications

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation

Clopidogrel and modified-release dipyridamole for the prevention of occlusive vascular events (review of Technology Appraisal No. 90): a systematic review and economic analysis

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