Original article
Stroke subtype and mortality: a follow-up study in 998 patients with a first cerebral infarct

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Abstract

The aim of this article was to study mortality following a first-ever cerebral infarct, accounting for ischemic stroke subtypes (lacunar, cardioembolic, atherothrombotic) and relevant prognostic variables. This study was done from s a hospital-based prospective registry of all patients with a first cerebral infarct, with a high case ascertainment of first and recurrent stroke by CT. We used a cross-sectional follow-up, using standardized methods. Analyses were performed using crude comparison of mortality data and death causes between stroke subtypes. We analyzed 30-day case fatality and 1-year mortality in 30-day survivors by means of logistic regression analysis, and mortality in 1-year survivors by means of Cox proportional hazard modeling. We also constructed Kaplan-Meier survival curves, and used log-rank testing for differences between stroke subtypes. Thirty-day case fatality was 10%, 1-year mortality 15%, and after 1-year mortality 16%. Mean follow-up was 691, SD 521 days. At the end of follow-up 36% of all patients had died. Mortality was at all three time points lowest in lacunar stroke (2, 12, and 14%, respectively), intermediate in atherothrombotic stroke (10, 16, and 15%, respectively), and highest in cardioembolic stroke (23, 22, and 21%, respectively). Death related to recurrent stroke was similar in all three stroke subtypes (13–16%). Although 30-day case fatality rate was low in lacunar stroke, a quarter of lacunar stroke patients had died at the end of follow-up. Diabetes mellitus, age, stroke subtype, and initial stroke severity were independent predictors of 30-day case fatality, but only diabetes and age were consistent independent predictors for later mortality. Recurrent stroke and heart failure were important death causes. Prognosis for (future) death following a first cerebral infarct differs between stroke subtypes; lacunar stroke patients have the lowest mortality. However, lacunar stroke cannot be regarded as a mild stroke type, as after 2 years more than a quarter of such stroke patients had died. Cardioembolic stroke patients have the grimmest prognosis: more than half of them had died within 1.5 years. Better prognosis for long-term survival following stroke may be achieved by therapies which lower the risk of stroke recurrence, provide better treatment of heart failure, or both.

Introduction

Stroke is a highly prevalent disease, which ranks third as cause of death in the Western World [1]. Survival is the most fundamental measure of stroke outcome [2]. Although the literature is rich in follow-up studies on survival after stroke, most are based on selected series of patients, and predictors of poststroke mortality have usually been analyzed without accounting for other prognostic variables. Few studies evaluated factors predicting long-term mortality after stroke in an unselected series of patients in whom the underlying cerebrovascular pathology had clearly been defined 2, 3, 4, 5.

The risk of death is not only elevated acutely following stroke, but also in the longer term 4, 5, 6, 7. The annual risk of dying after stroke is about 9%, which is approximately 2.3 times that of the general population, with an even higher risk of about 15% in the first year 4, 5. This excessive death risk also exists in younger patients [4]. Long-term follow-up studies showed that up to 20 years after stroke mortality was still higher than in controls [6]. Average loss of life after stroke is estimated to be 14 years [8]. Preventive measures would be important to lower mortality following stroke, but any effect may vary depending on stroke subtype. Apart from this, it is unknown whether treatment of risk factors lowers poststroke mortality. Several clinical trials have shown a protective effect from blood pressure reduction on recurrent stroke after minor ischemic stroke or transient ischemic attack (TIA), but it is not clear if this is true for mortality after stroke [9]. Time-trend studies show a decline in stroke mortality (stronger decline than coronary mortality) but geographic regions with the highest mortality rate also show the least favorable trend or even an increase 10, 11.

The present analysis was performed to gain more insight into factors, including stroke subtype, which predict mortality following a first cerebral infarct, and to identify possibly treatable risk factors.

Section snippets

General aspects

Patients had been registered in the Maastricht Stroke Registry (MSR), which is a prospective registry at the University Hospital of Maastricht of all stroke patients older than 18 years with symptoms lasting longer than 24 hr. Only patients with a supratentorial brain infarct were included in the study, as hindbrain infarcts may be rather heterogeneous in stroke cause and consequent subgroups too small for comprehensive analyses. However, some of the lacunar infarcts, especially those without

Results

There were 998 patients with a first-ever ischemic stroke. Duration of follow-up was 691 days (mean, SD 521) for the whole group, and for those surviving 881 days (mean, SD 465). CT was performed in 961 (96%); on the day of stroke in 153 (16%), within 1 week in 597 (62%), and within 3 weeks in 877 (91%). There were 138 recurrent strokes, with CT verification in 84 (61%). During follow-up 361 (36%) patients died. Table 1 shows baseline characteristics and mortality figures for all patients and

Discussion

We found a 30-day case fatality rate of ten percent in our 998 patients with a first cerebral infarct, which is similar to methodologically sound community-based studies 17, 18, 19, 20, 21. We found significant differences between the three stroke subtypes: LACI patients had the lowest, and CE infarct patients the highest 30-day case fatality. Others also found a low early death rate among lacunar stroke patients 2, 3, 17, 18, 19, 20, 21, 22, 23. A low early case fatality rate in LACI was also

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