Long-Term Prognosis of Patients With Transient Ischemic Attack or Stroke and Symptomatic Vascular Disease in Multiple Arterial Beds.

Mirjam R Heldner,Nicola G Lovett,Shane Lyons,Peter M Rothwell,Linxin Li,Magdalena M Kubiak

doi:10.1161/strokeaha.118.020913

Abstract

Cerebrovascular, coronary, and peripheral vascular disease have common underlying arterial pathology and risk factors, but the clinical significance of multiple-territory disease in patients with transient ischemic attack (TIA)/ischemic stroke is unclear, particularly whether the number of clinically affected territories still predicts long-term outcome on current standard secondary prevention therapies. In a population-based study of 92 728 individuals in Oxfordshire, United Kingdom (Oxford Vascular Study), we studied patients presenting with TIA/ischemic stroke (2002-2014) in relation to the number of other vascular beds (coronary, peripheral) affected by symptomatic (current or previous) disease. We compared the risk factor profile and long-term prognosis in patients with single- versus multiple-territory disease. Among 2554 patients with 10 679 patient-years of follow-up, 1842 (72.1%) had single- (TIA/stroke only), 608 (23.8%) double-, and 104 (4.1%) triple-territory symptomatic vascular disease. The number of affected vascular beds increased with the number of atherosclerotic risk factors (Ptrend<0.0001). Compared with patients with TIA/stroke only, those with multiple-territory disease had more hypertension (age/sex-adjusted odds ratio [OR], 3.43; 95% confidence interval [CI], 2.76-4.27; P<0.0001), diabetes mellitus (OR, 2.89; 95% CI, 2.27-3.66; P<0.0001), hypercholesterolemia (OR, 4.67; 95% CI, 3.85-5.66; P<0.0001), and current or previous smoking (OR, 1.52; 95% CI, 1.26-1.84; P<0.0001). Triple-territory disease was particularly strongly associated with hypercholesterolemia (OR, 6.80; 95% CI, 4.39-10.53; P<0.0001). Despite more intensive secondary prevention in patients with multiple-territory disease, the 5-year risk of vascular death increased steeply with the number of territories affected (17.2% versus 30.0% versus 42.9%; P<0.0001). Compared with patients with single-territory, patients with multiple-territory disease also had higher postacute long-term risks (90 days to 10 years) of recurrent ischemic stroke (age/sex-adjusted hazard ratio, 1.38; 95% CI, 1.04-1.81; P=0.02) and nonstroke acute vascular events (hazard ratio, 3.06; 95% CI, 2.23-4.20; P<0.0001). Number of affected vascular beds appeared to be a simple clinical rule in identifying TIA/ischemic stroke patients who are at high long-term risk of nonstroke vascular events and vascular death.

Highlights

Background and PurposeCerebrovascular, coronary, and peripheral vascular disease have common underlying arterial pathology and risk factors, but the clinical significance of multiple-territory disease in patients with transient ischemic attack (TIA)/ischemic stroke is unclear, whether the number of clinically affected territories still predicts long-term outcome on current standard secondary prevention therapies
The risks were higher in patients with TIA/stroke plus peripheral vascular disease than in patients with TIA/stroke plus coronary artery disease (10-year major cardiovascular events: 60.8% versus 46.1%; age/sex-adjusted HR, 1.58, 95% CI, 1.03–2.43; P=0.04), and were highest in those with triple-territory disease
Exploratory multivariate analyses adjusting for other vascular risk factors suggested that multiple-territory disease was associated with post 90-day longterm risks of recurrent cardiovascular events independent of age, male sex, history of hypertension, diabetes mellitus, hypercholesterolemia, atrial fibrillation, cardiac failure, and history of smoking (Tables IV and V in the online-only Data Supplement). In this population-based study, we showed that over a quarter of patients presenting with TIA or ischemic stroke had known symptomatic disease in other vascular beds

Summary

Introduction

Background and PurposeCerebrovascular, coronary, and peripheral vascular disease have common underlying arterial pathology and risk factors, but the clinical significance of multiple-territory disease in patients with transient ischemic attack (TIA)/ischemic stroke is unclear, whether the number of clinically affected territories still predicts long-term outcome on current standard secondary prevention therapies.

Results

Conclusion