Letter by Cao et al Regarding Article, "History of Stroke Is Independently Associated With In-Hospital Death in Patients With COVID-19".

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HomeStrokeVol. 52, No. 1Letter by Cao et al Regarding Article, “History of Stroke Is Independently Associated With In-Hospital Death in Patients With COVID-19” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Cao et al Regarding Article, “History of Stroke Is Independently Associated With In-Hospital Death in Patients With COVID-19” Shugang Cao, Tingting Ge and Mingwu Xia Shugang CaoShugang Cao Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, China. Search for more papers by this author , Tingting GeTingting Ge Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, China. Search for more papers by this author and Mingwu XiaMingwu Xia https://orcid.org/0000-0002-8287-1234 Department of Neurology, The Affiliated Hefei Hospital of Anhui Medical University, China. Search for more papers by this author Originally published28 Dec 2020https://doi.org/10.1161/STROKEAHA.120.032328Stroke. 2021;52:e29–e30To the Editor:We read with great interest the recently published article by Kummer et al.1 This study revealed that the history of stroke was associated with in-hospital death among hospitalized patients with coronavirus disease 2019 (COVID-19). Previous studies have argued that COVID-19 complicated with acute stroke is associated with a poorer prognosis and higher mortality.2,3 However, the relationship between the history of stroke and mortality in patients with COVID-19 has been controversial.1,4 A pooled analysis of published studies did not confirm a significant trend between a history of cerebrovascular disease and in-hospital death in patients with COVID-19.4 What’s impressive is that the present study yielded an opposite result in a larger sample size of patients with COVID-19 but with some limitations. Therefore, the interpretation of this finding may be enhanced by the following considerations.COVID-19 has contributed to a large spread of infection across the world, with respiratory symptoms predominating. Severe respiratory symptoms have been considered to be positively correlated with poor outcomes and in-hospital death in patients with COVID-19. As the authors indicated, they did not stratify analyses according to the severity of respiratory symptoms of COVID-19, such as oxygenation status, intubation, or pulmonary lesions on chest computed tomography, to determine its relationship with in-hospital mortality.1 The severity of respiratory symptoms is believed to be the most important determinant of in-hospital death and should be included in the analysis as a main influencing factor.Except for the history of stroke, many risk factors for stroke were associated with in-hospital death in patients with COVID-19 in this study. The Essen score, as a assessment scale of the risk of recurrent ischemic stroke, contains many vascular risk factors. A recent study used it to evaluate the risk of myocardial infarction in a subset of transient ischemic attack/stroke patients without known prior coronary artery disease.5 Therefore, we suggest that the Essen score can be used as a surrogate marker for risk factors to evaluate its impact on in-hospital death of patients with COVID-19. In addition, the acute stroke incidence is 1.1% to 2.8% among all hospitalized COVID-19 patients, and the presence of acute stroke is a strong prognostic marker of poor outcomes.2 This study had a large sample size. Therefore, the incidence of acute stroke and its impact on prognosis should also be investigated. It may be more reliable in predicting the prognosis than the history of stroke.We again congratulate the authors for their impressive work on the finding of a significant and independent association between the history of stroke and in-hospital death in patients with COVID-19. As the authors point out, further studies should confirm these findings with a larger cohort size and more detailed patient-level data. Furthermore, the relationship between the history of stroke and long-term outcomes should also be investigated in patients with COVID-19.Sources of FundingNone.DisclosuresNone.FootnotesThis article was sent to Marc Fisher, Senior Consulting Editor, for editorial decision and final disposition.For Sources of Funding and Disclosures, see page e29.