Predictors of Long-Term Recurrent Vascular Events After Ischemic Stroke at Young Age

Abstract

Background-Data on long-term risk and predictors of recurrent thrombotic events after ischemic stroke at a young age are limited. Methods and Results-We followed 1867 patients with first-ever ischemic stroke who were 18 to 45 years of age (mean age, 36.8±7.1 years; women, 49.0%), as part of the Italian Project on Stroke in Young Adults (IPSYS). Median follow-up was 40 months (25th to 75th percentile, 53). The primary end point was a composite of ischemic stroke, transient ischemic attack, myocardial infarction, or other arterial events. One hundred sixty-three patients had recurrent thrombotic events (average rate, 2.26 per 100 person-years at risk). At 10 years, cumulative risk was 14.7% (95% confidence interval, 12.2%-17.9%) for primary end point, 14.0% (95% confidence interval, 11.4%-17.1%) for brain ischemia, and 0.7% (95% confidence interval, 0.4%-1.3%) for myocardial infarction or other arterial events. Familial history of stroke, migraine with aura, circulating antiphospholipid antibodies, discontinuation of antiplatelet and antihypertensive medications, and any increase of 1 traditional vascular risk factor were independent predictors of the composite end point in multivariable Cox proportional hazards analysis. A point-scoring system for each variable was generated by their β-coefficients, and a predictive score (IPSYS score) was calculated as the sum of the weighted scores. The area under the receiver operating characteristic curve of the 0-to 5-year score was 0.66 (95% confidence interval, 0.61-0.71; mean, 10-fold internally cross-validated area under the receiver operating characteristic curve, 0.65).© 2014 American Heart Association, Inc. 1 Although it is well documented that such a risk is much lower in young patients with stroke than in elderly patients, information on what specific factors may predict recurrent events in younger age groups are limited. Most data derive from single-center studies enrolling several hundred patients or less, 2 using different thresholds of age to define young, and sometimes being biased by the inadequate capture of cases, the inclusion of different ethnic groups, and the high number of patients lost to follow-up.3 This makes such studies somewhat heterogeneous and their findings poorly comparable. In addition, the influential effect of some specific factors is missing in most previous studies. This is the case, for example, of patients' adherence to secondary prevention therapies, which is likely to impact the recurrence of potentially avoidable vascular events. The Italian Project on Stroke in Young Adults (IPSYS) provides the opportunity to investigate these issues owing to its large sample size, the homogeneous demographic characteristics and clinical phenotype of the subjects included, and the standard diagnostic workup. Therefore, in the present study we aimed at (1) elucidating the predictors of long-term recurrent vascular events after first-ever IS, and the extent to which these factors can be modified, which implicates the potential of reducing this risk,...

Trends in risk of recurrence after the first ischemic stroke in adults younger than 55 years of age in Sweden

“…The four-year cumulative risk of recurrent IS was 11.8% in men and 9.8% in women during the last five-year period (2002)(2003)(2004)(2005)(2006), which is slightly higher than that in other previous studies. 10,11,14 In addition, we observed that stroke-free survival improved throughout the study period, but International Journal of Stroke, 11 (1) despite these improvements, almost one in six patients had either died or had a recurrent stroke within four years in the last period. In a report from the population-based Monitoring Trends and Determinants of Cardiovascular Disease Stroke Incidence Registry, a 36% decline in recurrence of stroke was observed in 6700 stroke patients when comparing the periods of 1995-1998 with 2004-2008.…”

“…Previous studies have reported that the risk of a recurrent stroke among younger people within the first year varies from 2 to 4%, decreasing thereafter to less than 3% yearly. [8][9][10][11] Most prior studies on younger adults have been limited by small sample sizes. To the best of our knowledge, no studies have investigated trends and changes in risk over a long period of time in younger patients with ischemic stroke (IS).…”

Migraine and risk of stroke in older adults

“…4 However, previous studies suggested that in young patients with ischemic stroke, migraine with aura is an independent risk factor of recurrent ischemic stroke and other vascular events. 20 Stroke risk associated with migraine with aura was greater in younger than in older women (45-49 years of age) in the Women's Health Study. 21 Perhaps our participants were too old to display such a relationship between migraine with aura and stroke in both men and women of postmenopausal age.…”

Antiphosphatidylserine Antibodies and Clinical Outcomes in Patients With Acute Ischemic Stroke

“…The primary outcome was a combination of death and major disability (modified Rankin Scale score, [3][4][5][6]. 18 Secondary outcomes were death, major disability, recurrent fatal and nonfatal stroke, and vascular events (eg, vascular deaths, nonfatal stroke, nonfatal myocardial infarction, hospitalized and treated angina, hospitalized and treated congestive heart failure, and hospitalized and treated peripheral arterial disease).…”

“…3 Anticardiolipin antibodies (aCL) and lupus anticoagulant antibodies were the most frequently studied members and had been associated with an increased risk of recurrent thrombo-occlusive events and death after stroke in some but not in all studies. [4][5][6][7][8] Recently, studies suggest that antibodies directed against phosphatidylserine (antiphosphatidylserine antibodies [aPS]) may be a useful marker for the syndrome. [9][10][11][12] Population-based studies showed an independent association of aPS with ischemic stroke.…”