Long-term Risk Of Ischemic Stroke Research Articles

Using Artificial Intelligence in Predicting Ischemic Stroke Events After Percutaneous Coronary Intervention.

Ischemic stroke (IS) is an uncommon but severe complication in patients undergoing percutaneous coronary intervention (PCI). Despite significant morbidity and economic cost associated with post PCI IS, a validated risk prediction model is not currently available. We aim to develop a machine learning model that predicts IS after PCI. We analyzed data from Mayo Clinic CathPCI registry from 2003 to 2018. Baseline clinical and demographic data, electrocardiography (ECG), intra/post-procedural data, and echocardiographic variables were abstracted. A random forest (RF) machine learning model and a logistic regression (LR) model were developed. The receiver operator characteristic (ROC) analysis was used to assess model performance in predicting IS at 6-month, 1-, 2-, and 5-years post-PCI. A total of 17,356 patients were included in the final analysis. The mean age of this cohort was 66.9 ± 12.5 years, and 70.7% were male. Post-PCI IS was noted in 109 patients (.6%) at 6 months, 132 patients (.8%) at 1 year, 175 patients (1%) at 2 years, and 264 patients (1.5%) at 5 years. The area under the curve of the RF model was superior to the LR model in predicting ischemic stroke at 6 months, 1-, 2-, and 5-years. Periprocedural stroke was the strongest predictor of IS post discharge. The RF model accurately predicts short- and long-term risk of IS and outperforms logistic regression analysis in patients undergoing PCI. Patients with periprocedural stroke may benefit from aggressive management to reduce the future risk of IS.

Lipid management in ischaemic stroke or transient ischaemic attack in China: result from China National Stroke Registry III

ObjectivesThe aims of the study were to assess the management of low-density lipoprotein cholesterol (LDL-C) and the goal achievement, as well as to investigate the association between baseline LDL-C level,...

Left atrial reservoir strain predicts ischemic stroke after coronary artery bypass grafting independent of postoperative atrial fibrillation

Abstract Background Patients undergoing coronary artery bypass grafting (CABG) surgery face an elevated long-term risk of ischemic stroke. Left atrial (LA) mechanics including LA strain are known to predict both stroke and atrial fibrillation in other populations. Evidence is conflicting with regards to the clinical significance of postoperative atrial fibrillation (POAF) and its role in the association between LA mechanics and ischemic stroke is unclear. Purpose The aim of the study was to investigate the association between LA reservoir strain and long-term ischemic stroke in patients undergoing CABG surgery and whether the presence of POAF modified this relationship. Methods Patients undergoing isolated CABG were included from 2006–2011 as part of a retrospective cohort study. Echocardiography was performed prior to surgery. We included patients with available LA reservoir strain measurements, while patients with known atrial fibrillation and moderate to severe valvular disease were excluded. The primary endpoint was ischemic stroke. The association between LA reservoir strain and ischemic stroke was investigated in uni- and multivariable Cox proportional hazards regression models including adjustment for POAF. Poisson regression was used to create a restricted cubic spline model of the continuous association between LA reservoir strain and risk of ischemic stroke. Results We included 542 patients in the analysis. Mean age was 67.3±8.9 years, 89 (16.4%) were female, and median EuroSCORE II was 1.31 (IQR 0.93–1.96). Patients with LA reservoir strain <27.2% (median) were older, more likely to have diabetes, and had a higher EuroSCORE II. In total, 96 patients (17.7%) developed POAF. During a median follow-up period of 3.7 years (IQR 2.7–4.8 years), 21 (3.9%) patients experienced ischemic stroke. In univariable modeling, LA reservoir strain was significantly associated with ischemic stroke (HR 1.10 (95% CI 1.03–1.18, p=0.003) per 1% absolute decrease). After adjustment for EuroSCORE II, LA volume index (LAVi) and prior stroke, LA reservoir strain remained a significant predictor of ischemic stroke (HR 1.09 (95% CI 1.02–1.17, p=0.011) per 1% absolute decrease and HR 4.24 (95% CI 1.37–13.10, p=0.012) for < vs. >median). Adding POAF as a covariate did not alter the significance of LA reservoir strain in the model. In addition, POAF did not modify the association between LA reservoir strain and POAF (p for interaction = 0.07). The association between LA reservoir strain and ischemic stroke persisted in multiple sensitivity analyses including restricting the analysis to patients with normal left atrial volumes (LAVi <34 ml/m2), patients without POAF, and when excluding patients who developed atrial fibrillation during follow-up. Conclusion In patients undergoing CABG, LA reservoir strain was an independent long-term predictor of ischemic stroke. The predictive value of LA reservoir strain was unaffected by the presence of POAF. Funding Acknowledgement Type of funding sources: None.

Stroke Risk Stratification With the CHADS2 Score in Patients Without Atrial Fibrillation Who Underwent Percutaneous Coronary Intervention

The clinical significance of the CHADS2 score remains unclear in patients with coronary artery disease (CAD) without atrial fibrillation (AF). Therefore, the purpose of this study was to evaluate the association between the CHADS2 score and the long-term risk of ischemic stroke and its severity in patients with CAD with and without AF. Using the CREDO (Coronary Revascularization Demonstrating Outcome study)-Kyoto Registry Cohort-3, the present study population consisted of 11,516 patients with CAD who underwent percutaneous coronary intervention without oral anticoagulants at discharge. We divided the patients into 2 groups according to the presence (n=721) or absence (n=10,795) of AF. As the CHADS2 score increased from 0 or 1 to 6, the cumulative 5-year incidence of ischemic stroke incrementally increased from 2.1% to 17.1% in patients without AF and from 4.2% to 40.7% in patients with AF. The cumulative 5-year incidence of ischemic stroke in patients without AF and a CHADS2 score of 2 were numerically comparable to that in patients with AF and a CHADS2 score of 1 (3.4% and 3.7%). In the 423 patients who developed ischemic stroke, the modified Rankin Scale score was not significantly different between patients with and without AF (p for trend=0.12). In patients with and without AF, the increase in the CHADS2 score was significantly associated with the greater prevalence of higher modified Rankin Scale scores (p for trend=0.03 and <0.001, respectively). An increasing CHADS2 score was associated with an incrementally increased risk for ischemic stroke and greater severity of ischemic stroke in patients with and without AF.

Abstract 140: Real-world Efficacy Of Left Atrial Appendage Closure Versus Anticoagulation Therapy For Long-term Prevention Of Ischemic Stroke And All-cause Mortality Among Patients With Atrial Fibrillation

Introduction: There is limited data on real-world efficacy of left atrial appendage closure (LAAC) procedures compared to anticoagulants (AC) for stroke prevention among patients with atrial fibrillation (AF). Methods: We utilized a retrospective cohort of over 63 million patients from 51 healthcare organizations across 6 countries via a harmonized electronic medical record-based research data platform. Utilizing international classification of disease version 10 and current procedural terminology codes, adult (≥ 18 years) patients with AF (I48) were identified and grouped by treatment type (LAAC (33340, 02L73DK) vs AC (1015112, Z79.0, BL110)). Patients with a history of stroke prior to AC initiation or LAAC procedure were excluded. Subjects were followed for 5 years for incident ischemic stroke (I63), intracerebral hemorrhage (I61), and all-cause mortality. Treatment groups were propensity score matched by age, sex, race, ethnicity, and comorbidities. Risk ratio(RR) and 95% confidence intervals(CI) among unmatched and matched populations are reported. Results: Among a total of 1,980,130 AF patients; 1,374,013 were flagged for AC use and 8,004 were treated via LAAC. Treatment cohorts were propensity score matched by age, race, sex, hyperlipidemia, and hypertension resulting in an exact 1:1 matched cohort of 8,004 subjects, across all co-variates. In the matched population the mean (SD) age was 75.2 (8.05) years, 63.2% were male; 86.6% were white, 4.4% black, 0.89% Asian, and 3.5% Hispanic; with 64.4% hyperlipidemic and 79.2% hypertensive. Prior to matching, AC (vs. LAAC) was significantly associated with a higher 5-year risk of ischemic stroke, intracerebral hemorrhage, and all-cause mortality. The protective effect of LAAC (vs. AC) was maintained for 5-year risk of ischemic stroke (RR, CI: 0.68, 0.58 - 0.79) and all-cause mortality (RR, CI: 0.42, 0.39 - 0.45). However, the difference in 5-year risk for intracerebral hemorrhage for LAAC (vs. AC) was not statistically lower (RR, CI: 0.72, 0.50 - 1.05). Conclusion: Notwithstanding the possibility of residual confounding in our analyses, LAAC seems to be associated with a lower long-term risk of ischemic stroke and all-cause mortality as compared to AC treated AF patients in large real-world data.

Neuropsychological performance after carotid endarterectomy.

Background: Internal carotid endarterectomy (CEA) is a method of stroke prevention in patients with severe internal carotid artery (ICA) stenosis. Patients with significant carotid stenosis tend to have lower cognitive performance than those without significant stenosis. This is believed to be due to hypoperfusion or ongoing microembolization to the brain. Methods: We evaluated 60 patients with at least 70% ICA stenosis with the RBANS test (Repeatable Battery for the Assessment of Neuropsychological Status, Czech research version), preoperatively and one month after endarterectomy. Results: Neuropsychological follow-up was completed by N = 57 patients one month after the procedure. At the group level, there was a significant improvement in Language, Attention, Delayed Memory and Total Scale Index Scores (p < 0.05). Conclusions: CEA not only decreases the long-term risk of ischemic stroke, but may also improve cognitive performance. In a small percentage of cases, there is higher risk of embolic stroke and silent microembolization due to surgery, which may have a negative impact on cognitive function. However, we did not detect any cognitive impairment after CEA in our patients.

Gender Differences in the Impact of New-Onset Atrial Fibrillation on Long-Term Risk of Ischemic Stroke after Acute Myocardial Infarction.

Background: Atrial fibrillation (AF) has been identified as a major risk factor for mortality after acute coronary syndrome (ACS). However, the long-term risk of ischemic stroke associated with new-onset atrial fibrillation (NOAF) in ACS remains controversial, and its gender-specific association is unknown. Methods: We analyzed the data of 10,137 ACS survivors included in a multicenter, prospective registry for Korean patients with acute myocardial infarction (AMI) between January 2004 and August 2014. Subjects were categorized into three groups (non-AF vs. NOAF vs. previous AF) based on medical history and electrocardiographic evidence of AF, either at admission or during hospitalization. Results: Among the total study population (72.3% men), 370 patients (3.6%) had NOAF and 130 (1.3%) had previous AF. During a median follow-up of 61 months (interquartile range, 38.8 to 89.3 months), 245 (2.4%) patients (218 (2.3%) non-AF vs. 15 (4.1%) NOAF vs. 12 (9.2%) previous AF, p < 0.001) experienced ischemic stroke. After adjustment for confounding variables, both NOAF (adjusted hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.09–3.24, p = 0.024) and previous AF (adjusted HR 4.00, 95% CI 2.03–7.87, p < 0.001), along with older age, diabetes, current smoker, and previous stroke were independent risk factors of ischemic stroke. In the gender-stratified analysis, men with previous AF but not NOAF had a significantly higher risk of ischemic stroke (adjusted HR 4.14, 95% CI 1.79–9.55, p = 0.001) than those without AF. In women, NOAF (adjusted HR 2.54, 95% CI 1.21–5.35, p = 0.014) as well as previous AF (adjusted HR 3.72, 95% CI 1.16–11.96, p = 0.028) was a strong predictor of ischemic stroke, and the predictive value was comparable to that of previous AF among patients with a CHA2DS2-VASc score ≥ 2. Conclusions: Both NOAF and previous AF were associated with ischemic stroke after AMI, but the impact of NOAF as a risk factor of ischemic stroke was significant only in women.

Long-Term Risk of Ischemic Stroke among Elderly Survivors of Non-Traumatic Subarachnoid Hemorrhage

Introduction: Non-traumatic subarachnoid hemorrhage (SAH) is associated with poor long-term functional outcomes, but the risk of ischemic stroke among SAH survivors is poorly understood. Objectives: The aim of this study was to evaluate the risk of ischemic stroke among survivors of SAH. Methods: We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008 to 2015. The exposure was a diagnosis of SAH, while the outcome was an acute ischemic stroke, both identified using previously validated ICD-9-CM diagnosis codes. We used Cox regression analysis adjusting for demographics and stroke risk factors to evaluate the association between SAH and long-term risk of ischemic stroke. Results: Among 1.7 million Medicare beneficiaries, 912 were hospitalized with non-traumatic SAH. During a median follow-up of 5.2 years (IQR, 2.7–6.7), the cumulative incidence of ischemic stroke was 22 per 1,000 patients per year among patients with SAH, and 7 per 1,000 patients per year in those without SAH. In adjusted Cox models, SAH was associated with an increased risk of ischemic stroke (HR, 2.0; 95% confidence interval, 1.4–2.8) as compared to beneficiaries without SAH. Similar results were obtained in sensitivity analyses, when treating death as a competing risk (sub HR, 3.0; 95% CI, 2.8–3.3) and after excluding ischemic stroke within 30 days of SAH discharge (HR, 1.5; 95% CI, 1.1–2.3). Conclusions: In a large, heterogeneous national cohort of elderly patients, survivors of SAH had double the long-term risk of ischemic stroke. SAH survivors should be closely monitored and risk stratified for ischemic stroke.

Abstract P628: Long-Term Risk of Ischemic Stroke Among Survivors of Non-Traumatic Subarachnoid Hemorrhage

Background and Purpose: Non-traumatic subarachnoid hemorrhage (SAH) is associated with poor long-term functional outcomes, but the risk of ischemic stroke among SAH survivors is poorly understood. Methods: We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008-2015. The exposure was a diagnosis of SAH, while the outcome was an acute ischemic stroke. The exposure and outcomes were identified using previously validated ICD-9-CM diagnosis codes. We excluded patients with prevalent ischemic stroke at the time of SAH diagnosis and those which occurred in the first 90 days after SAH discharge to avoid inclusion of stroke occurring as a medical or procedural complication of SAH. We used Cox regression adjusting for demographics and stroke risk factors to evaluate the association between SAH and long-term risk of ischemic stroke. Results: Among 1.3 million Medicare beneficiaries, 3,171 (0.18%) were diagnosed with non-traumatic SAH. During a median follow-up of 5.3 years (interquartile range [IQR], 2.7- 6.7), the cumulative incidence of ischemic stroke was 92 per 1,000 patients per year among patients with SAH, and 21 per 1,000 patients per year in those without SAH. In multivariable Cox regression analysis, SAH was associated with an increased risk of ischemic stroke (hazard ratio, 2.6; 95% confidence interval, 2.4-2.8) as compared to beneficiaries without SAH. Conclusions: In a large, heterogeneous national cohort of elderly patients, we found that survivors of SAH had more than double the long-term risk of ischemic stroke as compared to those without SAH. SAH survivors should be closely monitored and risk stratified for ischemic stroke.

Association Between Carbon Monoxide Intoxication and Incidence of Ischemic Stroke: A Retrospective Nested Case-Control Study in South Korea

ObjectivesSevere neurological sequelae occur in patients with carbon monoxide (CO) intoxication; however, whether the latter increases the long-term risk of developing ischemic stroke is unclear. We investigated the association between CO intoxication and ischemic stroke using data from the Korean National Health Information Database. Materials and MethodsWe performed a retrospective, nested case-control study of 27,984 individuals treated for CO intoxication and 27,984 sex- and age-matched controls. Initially, we calculated the overall incidence and hazard ratio (HR) of ischemic stroke using conditional logistic regression. Thereafter, we calculated the incidences and HRs according to covariates and follow-up periods. ResultsThe CO intoxication group had a significantly higher risk of developing ischemic stroke than the control group (adjusted HR 2.31, 95% CI [confidence interval] = 2.01–2.65). Male sex (adjusted HR 2.73, 95% CI = 2.23-3.34), age <40 (adjusted HR 3.53, 95% CI = 2.15-5.82), low income (adjusted HR 2.55, 95% CI = 1.56–4.15), comorbidities (adjusted HR 2.59, 95% CI = 1.48–4.52), and current smokers (adjusted HR 3.55, 95% CI = 1.67–7.60) had a higher risk of ischemic stroke. The risk of ischemic stroke was highest within 2 years after CO intoxication (adjusted HR 7.47, 95% CI = 2.76–20.26), and even >6 years after, the risk remained significantly higher than in the control group (adjusted HR 1.84, 95% CI = 1.53–2.20). ConclusionsCO intoxication and the long-term risk of ischemic stroke are associated.

Abstract TMP81: Artificial Intelligence Beats Conventional Regression Analysis in Predicting Short and Long Term Risk of Stroke in Patients Undergoing Percutaneous Coronary Interventions

Introduction: Ischemic stroke (IS) causes substantial morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI) with a 5 yr incidence ~ 3%. We sought the test the accuracy of Machine learning (ML) algorithms in predicting IS in patients undergoing PCI. Methods: Mayo Clinic CathPCI registry data were retrospectively analyzed from Jan 2003 - June 2018 including 21,872 patients who underwent PCI. The cohort was randomly divided into a training sample (75%, n=16404) and a unique test sample (25%, n=5468) prior to model generation. The risk prediction model was generated utilizing a random forest algorithm (RF model) on 188 unique variables to predict the risk of IS at 6-month, 1, 2, and 5-year post PCI. Conventional risk factors for stroke were used for logistic regression. The receiver operating characteristic (ROC) curve and area under the curve for the RF and logistic regression models were compared for the test cohort. Results: The mean age was 66.9 ± 12.4 years, and 71% were male. Patient demographics and outcomes are shown in Table 1 . The ROC area under the curve for the RF model was superior compared to the logistic regression model in predicting IS at 6 months, 1,2 and 5 yrs for the test cohort ( Figure 1 .) Conclusions: The RF model accurately predicts short and long term risk of IS and outperforms logistic regression analysis in patients undergoing PCI.

Thirty-year risk of ischemic stroke in individuals with sickle cell trait and modification by chronic kidney disease: The atherosclerosis risk in communities (ARIC) study.

Sickle cell trait (SCT) has been associated with hypercoagulability, chronic kidney disease (CKD), and ischemic stroke. Whether concomitant CKD modifies long-term ischemic stroke risk in individuals with SCT is uncertain. We analyzed data from 3602 genotyped black adults (female = 62%, mean baseline age = 54 years) who were followed for a median 26 years by the Atherosclerosis Risk in Communities Study. Ischemic stroke was verified by physician review. Associations between SCT and ischemic stroke were analyzed using repeat-events Cox regression, adjusted for potential confounders. SCT was identified in 236 (7%) participants, who more often had CKD at baseline than noncarriers (18% vs 13%, P = .02). Among those with CKD, elevated factor VII activity was more prevalent with SCT genotype (36% vs 22%; P = .05). From 1987-2017, 555 ischemic strokes occurred in 436 individuals. The overall hazard ratio of ischemic stroke associated with SCT was 1.31 (95% CI: 0.95-1.80) and was stronger in participants with concomitant CKD (HR = 2.18; 95% CI: 1.16-4.12) than those without CKD (HR = 1.09; 95% CI: 0.74-1.61); P for interaction = .04. The hazard ratio of composite ischemic stroke and/or death associated with SCT was 1.20 (95% CI: 1.01-1.42) overall, 1.44 (95% CI: 1.002-2.07) among those with CKD, and 1.15 (95% CI: 0.94-1.39) among those without CKD; P for interaction = .18. The long-term risk of ischemic stroke associated with SCT relative to noncarrier genotype appears to be modified by concomitant CKD.

Increased Risk of Ischemic Stroke After Treatment of Infective Endocarditis: A Danish, Nationwide, Propensity Score-Matched Cohort Study.

Several studies have reported a high risk of ischemic stroke (IS) during the acute phase of infective endocarditis (IE). The long-term risk of IS after IE, however, is not fully illuminated. This Danish, nationwide, register-based, propensity score-matched cohort study used Cox regression to estimate hazard ratios (HRs) of IS for persons with vs without a history of left-sided IE, from 1977 to 2015. We followed 9312 patients exposed to a first-time IE and 91 996 nonexposed, matched control persons. Compared to persons without IE, patients with a history of IE had a significantly increased risk of IS; the risk was highest during the first 4 weeks after IE diagnosis (HR 57.20, 95% confidence interval [CI] 45.58-71.78; P < .0001) and a moderately elevated risk persisted until 2 years after IE (4 weeks to 3 months after IE, HR 5.40, 95% CI 4.11-7.19; 3 months to 2 years after IE, HR 1.73, 95% CI 1.48-2.01). Mediation analyses showed that the higher risk of IS the first 2 years after IE could not be explained by atrial fibrillation (AF) or inserted mechanical valves in IE patients. In the period from 4 weeks to 3 months after IE diagnosis, patients treated with anticoagulative therapy had a lower risk of IS (HR 0.30, 95% CI .10-0.96; P = .04). Patients with a history of IE had an increased risk of IS for up to 2 years after IE diagnosis. The increased risk was unrelated to AF and inserted mechanical valves. During the initial phase after IE, patients taking an anticoagulative medication had a lower risk of IS.

LONG-TERM RISK OF STROKE AFTER AN EPISODE OF ATRIAL FIBRILLATION OCCURRING TRANSIENTLY WITH STRESS FOLLOWING NON-CARDIAC SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Atrial fibrillation (AF) is one of the most common causes of stroke. AF occurring transiently with stress (AFOTS) describes a first episode of AF occurring after exposure to an acute reversible stressor, such as surgery or medical illness. Uncertainty exists regarding whether AFOTS is associated with an increased long-term risk of major adverse cardiovascular events. We performed a systematic review and meta-analysis aiming to determine the long-term risk of ischemic stroke and mortality after non-cardiac surgery in those who had AFOTS detected as compared to those who did not. The protocol was pre-registered with PROSPERO. We searched MEDLINE and EMBASE from inception to January 2017 for studies reporting on the long-term (≥30 days post-operatively) risk of stroke and mortality after an episode of AFOTS following non-cardiac surgery. Reference screening, study selection, data extraction, and quality assessment using the CLARITY tool were performed independently and in duplicate. Risk ratios were calculated using the inverse variance method. Data were pooled using a random-effects model. From 6252 unique citations, we identified 13 eligible studies with follow-up on 1,659,424 patients. Of these, 0.81% had AFOTS detected during their index hospitalization. A total of 1.05% of patients with AFOTS after non-cardiac surgery experienced an ischemic stroke during a mean follow-up of 25.20 ± 0.62 months, representing an increased risk when compared to patients who underwent non-cardiac surgery but did not have AFOTS detected (RR 2.86, 95% CI: 2.41-3.39, I2 = 0%). This risk was similar in the sub-group of patients who underwent thoracic surgery (RR 3.33, 95%CI: 0.91-12.14, I2 = 0%). AFOTS was also associated with a significantly higher risk of all-cause mortality (RR 1.72, 95%CI: 1.33-2.22, I2 = 76) (Table 1). Patients who had AFOTS detected after non-cardiac surgery have a higher long-term risk of ischemic stroke and mortality as compared to patients who did not have AFOTS detected. Whether this risk is modifiable with oral anticoagulation therapy should be investigated.

Risk of Stroke in Patients With Heart Failure: A Population-Based 30-Year Cohort Study.

The long-term risk of specific stroke subtypes among heart failure patients is largely unknown. We examined short-term and long-term risk of ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) in heart failure patients and in a general population comparison cohort. In this nationwide cohort study (1980-2012), we used Danish population-based medical registries to identify and follow (1) all patients hospitalized for the first time with heart failure and (2) a birth year-, sex-, and calendar year-matched general population comparison cohort. Age-, sex-, and comorbidity-adjusted stroke rate ratios were computed based on Cox regression analysis. We included 289 353 patients with heart failure and 1 446 765 individuals from the general population in the analysis. One- and 5-year risks among heart failure patients were 1.4% and 3.9% for ischemic stroke, 0.2% and 0.5% for ICH, and 0.03% and 0.07% for SAH. The 30-day adjusted stroke rate ratio was increased markedly for ischemic stroke (5.08; 95% confidence interval, 4.58-5.63] and was also elevated for ICH (2.13; 95% confidence interval, 1.53-2.97) and SAH (3.52; 95% confidence interval, 1.54-8.08). Between 31 days and 30 years, risk of all stroke subtypes remained positively associated with heart failure (1.5- to 2.1-fold for ischemic stroke, 1.4- to 1.8-fold for ICH, and 1.1- to 1.7-fold for SAH) in comparison with the general population cohort. Heart failure was associated with increased short-term and long-term risk of all stroke subtypes, suggesting that heart failure is a potent and persistent risk factor for ischemic stroke, ICH, and SAH.

Long-Term Risk of Ischemic Stroke After the Cox-Maze III Procedure for Atrial Fibrillation

The long-term risk of stroke after surgical treatment of atrial fibrillation is not well known. We performed an observational cohort study with long follow-up after the "cut-and-sew" Cox-maze III procedure (CM-III), including left atrial appendage excision. The aim was to analyze the incidence of stroke/transient ischemic attack (TIA) and the association to preoperative CHA2DS2-VASc (age in years, sex, congestive heart failure history, hypertension history, stroke/TIA, thromboembolism history, vascular disease history, diabetes mellitus) score. Preoperative and perioperative data were collected in 526 CM-III patients operated in four centers 1994 to 2009, 412 men, mean age of 57.1 ± 8.3 years. The incidence of any stroke/TIA was identified through analyses of the Swedish National Patient and Cause-of-Death Registers and from review of individual patient records. The cumulative incidence of stroke/TIA and association with CHA2DS2-VASc score was estimated using methods accounting for the competing risk of death. Mean follow-up was 10.1 years. There were 29 patients with any stroke/TIA, including 6 with intracerebral bleedings (2 fatal) and 4 with perioperative strokes (0.76%). The remaining 13 ischemic strokes and six TIAs occurred at a mean of 7.1 ± 4.0 years postoperatively, with an incidence of 0.36% per year (19 events per 5,231 patient-years). In all CHA2DS2-VASc groups, observed ischemic stroke/TIA rate was lower than predicted. A higher risk of ischemic stroke/TIA was seen in patients with CHA2DS2-VASc score 2 or greater compared with score 0 or 1 (hazards ratio 2.15, 95% confidence interval: 0.87 to 5.32) but no difference by sex or stand-alone versus concomitant operation. No patient had ischemic stroke as cause of death. This multicenter study showed a low incidence of perioperative and long-term postoperative ischemic stroke/TIA after CM-III. Although general risk of ischemic stroke/TIA was reduced, patients with CHA2DS2-VASc score 2 or greater had a higher risk compared with score 0 or 1. Complete left atrial appendage excision may be an important reason for the low ischemic stroke rate.

Metabolic Syndrome and the Risk of Ischemic Stroke

Metabolic syndrome (MetS) is recently proposed as a predictor for the occurrence of vascular defects causing ischemic stroke. However, details on the association of MetS with stroke are scare in our region. The present study aimed to assess the predictive value of MetS and its components for stoke among the Iranian population. A longitudinal population-based study was conducted on adults aged 35 years or older who were living in 3 districts in central part of Iran and followed for 10 years. Stroke was diagnosed using World Health Organization guidelines, and MetS was defined according to the Adult Treatment Panel-III definition. Among the 5398 subjects, 2021 suffered from MetS with an incidence of 37.4%. The incidence rates of stroke in those with and without MetS were 2.6% and 1.1%, respectively, with a higher significance in the former group (P = .026). Compared to the controls, participants with stroke exhibited a higher prevalence of some components of MetS including hyperglycemia and hypertension. On Cox proportional hazard analysis, the hazard ratio for a long-term risk of ischemic stroke was 1.37 overall (95% confidence interval: 1.15-1.63, P < .001) in subjects with MetS. Considering different components of MetS, hyperglycemia (hazard ratio = 1.83, P = .011) and hypertension (1.74, P = .019) could effectively predict occurrence of long-term ischemic stroke. MetS and its main components can be potent predictors for long-term ischemic stroke. Thus, the focus should be on identification and appropriate control of MetS components to prevent stroke occurrence.

Differential Effect of White-Matter Lesions and Covert Brain Infarcts on the Risk of Ischemic Stroke and Intracerebral Hemorrhage.

We examined the association of white-matter hyperintensity (WMH) volume and covert brain infarcts, which are the 2 major magnetic resonance imaging markers of covert cerebrovascular disease in older adults, with long-term risk of ischemic stroke and intracerebral hemorrhage (ICH) in the general population. Participants were 1731 individuals aged ≥65 years from the Three-City Dijon study. We studied the association of WMH volume and brain infarct, with incident ischemic stroke overall, and by subtype, and with incident ICH. High total, periventricular, and deep WMHs were associated with incident ICH. Extensive periventricular WMH volume was associated with increased risk of ischemic stroke (hazard ratio, 1.94; 95% confidence interval, 1.12-3.35), particularly cardioembolic stroke. Covert brain infarcts were associated with incident ICH but not with incident ischemic stroke or its subtypes. Although of ischemic nature, both WMH volume and covert brain infarcts portend a major risk of ICH. If confirmed in independent studies, these findings could have important implications for the clinical management of covert vascular brain lesions.

Abstract WP182: Long Term Risk of Ischemic Stroke After Acute Coronary Syndrome

Background: Prior studies have shown an increased risk of ischemic stroke (IS) after myocardial infarction (MI), particularly in the first few days after the event. There is limited evidence, however, on the long-term risk and whether it is directly related to cardiac injury. We hypothesized that the risk of IS after acute coronary syndrome (ACS) is significantly higher when there is evidence of cardiac injury such as ST elevation MI (STEMI) or non-STEMI (NSTEMI) than when there is no evidence of cardiac injury such as Unstable Angina (UA). Methods: Administrative claims data were obtained from all emergency department encounters and hospitalizations at California’s nonfederal acute care hospitals between 2008 and 2011. Patients with STEMI, NSTEMI, and UA were identified using appropriate ICD-9 codes. Age and ICD-9 codes for sex, race-ethnicity, hypertension, diabetes, hyperlipidemia, congestive heart failure, and atrial fibrillation were analyzed. The outcome was IS during 2 years follow-up. Unadjusted and adjusted Cox proportional hazards models were used to determine the association between ACS subtype and ischemic stroke risk. Results: We identified 74,962 ACS patients: 35.9% STEMI, 54.8% NSTEMI, and 9.3% UA. The mean age in years was 66.7 ± 14.4 and 61.5% females; 3.2% of patients had IS during the two year follow-up. When compared to UA, the long term risk of IS was higher in patients with STEMI (adjusted HR 2.07 95% CI 1.67-2.56) and NSTEMI (adjusted HR 1.87, 95% CI 1.51-2.30), even after adjusting for stroke risk factors at baseline and incident atrial fibrillation (Figure). Other stroke risk factors after ACS are shown in the Figure. Conclusion: Analysis from a large administrative dataset revealed that both NSTEMI and STEMI confer an increased risk of ischemic stroke, independent of risk factors, which may be related to cardiac injury. Studies exploring ischemic stroke mechanisms in cardiac patients are needed to improve and tailor stroke prevention strategies.

Abstract 134: Postoperative Atrial Fibrillation and the Short-term Risk of Ischemic Stroke

Introduction: We have recently shown an association between new-onset postoperative atrial fibrillation (AF) and the long-term risk of ischemic stroke after noncardiac surgery. However, the degree of stroke risk with AF in the postoperative setting remains unclear. Hypothesis: New-onset postoperative AF is associated with an increased risk of ischemic stroke in the 30 days after surgery. Methods: Administrative claims data from all discharges at nonfederal acute care hospitals in California, New York, and Florida were used to identify patients who underwent inpatient surgery in 2007-2012. Our predictor variable was new-onset AF, defined using validated ICD-9-CM diagnosis and present-on-admission codes. Patients with prior stroke or AF were excluded. The outcome was postoperative stroke, defined as ischemic stroke occurring within 30 days of surgery. Cox proportional hazards analysis was used to examine the association between postoperative AF and stroke while adjusting for demographics and vascular risk factors. In sensitivity analyses, we limited the outcome to stroke occurring after discharge but within 30 days of surgery. Cardiac and noncardiac surgeries were analyzed separately. Results: Among 7,139,472 patients with inpatient surgery, 102,831 (1.44%) developed postoperative AF and 17,117 (0.24%) developed a postoperative stroke. After noncardiac surgery, the 30-day cumulative risk of stroke was significantly higher in those with postoperative AF (2.07%) than those without AF (0.18%). This difference was significant after adjustment for demographics and potential confounders (hazard ratio [HR], 4.3; 95% CI, 4.1-4.6). After cardiac surgery, postoperative AF was also associated with an increased cumulative risk of stroke (2.27%) compared to those without AF (1.17%), but the strength of association (HR, 1.8; 95% CI, 1.6-1.9) was less marked than in the setting of noncardiac surgery ( P value for interaction &lt;0.001). Postoperative AF was associated with stroke occurring after discharge and within 30 days of noncardiac surgery (HR, 1.9; 95% CI, 1.6-2.3), but not cardiac surgery (HR, 1.1; 95% CI, 0.9-1.3). Conclusions: Postoperative AF is associated with an increased short-term risk of stroke after noncardiac surgery.