Long-term prognosis of combined chronic heart failure and chronic renal dysfunction after acute stroke

Aims To assess the prevalence of combined chronic heart failure and chronic renal dysfunction (CHF-CRD) in acute stroke patients and to investigate any prognostic significance on long-term outcome.Methods and resultsFirst-ever acute stroke patients (n = 831) were divided into four groups based on the presence of heart failure (HF, NYHA II-IV with or without left ventricular ejection fraction <40) and/or renal dysfunction (RD, estimated glomerular filtration rate <60 mL/min/1.73 m 2). Patients with acute kidney injury and/or acute decompensated HF were excluded. Group 1 comprised patients without HF or RD (nHF + nRD), Group 2 patients with RD but no HF (nHF + RD), Group 3 those with HF and no RD (HF + nRD), whereas Group 4 included patients with both HF and RD (HF + RD). HF and RD were independent predictors of mortality at 10 years. Patients in Groups 2, 3, and 4 had an increased probability of death during follow-up compared with Group 1: HR 1.34 (95 CI 1.02-1.77, P < 0.05) for group 2; HR 2.24 (95 CI 1.50-3.36, P < 0.001) for group 3; and HR 3.42 (95 CI 2.36-4.95, P < 0.001) for group 4. Age, history of transient ischaemic attacks and combined HF and RD were independent predictors of new cardiovascular events. When compared with Group 1, patients in Group 2 had an HR of 1.48 (95 CI 1.11-1.98, P < 0.01), those in Group 3 an HR of 2.21 (95 CI 1.48-3.29, P < 0.001), and those in Group 4 an HR of 3.59 (95 CI 2.40-5.39, P < 0.001).ConclusionThe combination of CHF-CRD after acute stroke is an independent predictor for mortality and new cardiovascular morbidity over 10 years. © 2010 The Author

The Pathophysiological Mechanism Is an Independent Predictor of Long-Term Outcome in Stroke Patients with Large Vessel Atherosclerosis

Background: Etiopathological mechanisms underlying ischemic stroke play a crucial role in long-term prognosis. We aimed to investigate the association between the mechanism of stroke due to large vessel disease, and long-term outcome. Methods: All consecutive patients registered in the Athens Stroke Registry with atherosclerotic stroke between 1993 and 2010 were included in the analysis. The patients were subdivided into 3 groups according to the presumed underlying mechanism: low-flow infarcts, artery-to-artery embolism, and intrinsic atherosclerosis. They were followed up for up to 10 years or until death. The end points of the study were 10-year all-cause mortality, stroke recurrence, and composite cardiovascular events. Results: Five hundred two patients were classified as follows: 156 (31%) as low-flow (watershed) strokes, 256 (51%) as artery-to-artery embolic strokes, and 90 (18%) as intrinsic atherosclerotic strokes. The cumulative probability of 10-year mortality rate was similar between groups of patients with different stroke mechanisms: 49.9% (95% confidence interval [CI], 38.5-61.3) for patients with low-flow mechanism, 47.6% (95% CI, 39.4-55.8) for patients with artery-to-artery embolism, and 48.5% (95% CI, 34.0-63.0) for patients with intrinsic atherosclerosis. Patients in the intrinsic atherosclerosis group had significantly higher risks of recurrence (adjusted hazard ratio [HR]=2.1; 95% CI, 1.19-3.73) compared with those in the artery-to-artery embolism group. Moreover, patients in the intrinsic atherosclerosis and low-flow groups had significantly higher risks of composite cardiovascular events compared with those in the artery-to-artery embolism group (adjusted HR=1.94; 95% CI, 1.26-3.00; and adjusted HR=1.64; 95% CI, 1.13-2.38, respectively). Conclusion: Low-flow and intrinsic atherosclerosis strokes are associated with a high risk for future cardiovascular events and stroke recurrence. However, long-term mortality is similar across different subgroups. © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved

The type of atrial fibrillation is associated with long-term outcome in patients with acute ischemic stroke

Background/objectives: We aimed to investigate the association between the type of atrial fibrillation (AF) and long-term outcome in terms of mortality and stroke recurrence in patients with ischemic stroke and non-valvular AF. Methods: All consecutive patients admitted with acute ischemic stroke to Alexandra Hospital between 1993 and 2010 were included in the analysis. Patients were categorized in 3 groups according to the type of AF (paroxysmal, persistent, and permanent) and were followed up for up to 10 years after the index stroke or until death. The endpoints were inhospital, 30-day and 10-year stroke recurrence, and 30-day and 10-year all-cause mortality. The Kaplan-Meier product limit method was used to estimate the probability of 10-year stroke recurrence and survival. Multivariate Cox proportional hazard models were used to identify significant predictors of stroke recurrence and all-cause mortality. Results: There were 811 patients (419 females, 392 males) with non-valvular AF and mean age of 75.8 +/- 9.4 years. 277 (34.2%) patients had paroxysmal AF, 165 (20.3%) persistent and 369 (45.5%) permanent. Inhospital stroke recurrence rate was low (1.8%) and similar among the 3 patient groups; on the contrary, the probability of 10-year stroke recurrence was significantly higher in patients with permanent AF (p<0.01 by log-rank test). The probability of 10-year survival was significantly higher in patients with paroxysmal AF (p<0.001 by log-rank test). The type of AF was a significant predictor of 10-year stroke recurrence and mortality. Patients with permanent AF had higher risk of stroke recurrence (HR: 1.78, 95%CI: 1.21-2.61) and mortality (HR: 1.55, 95%CI: 1.20-1.99) compared to patients with paroxysmal AF. Conclusions: Long-term outcome in stroke patients with AF is associated with the type of AF; patients with paroxysmal AF have lower rates of stroke recurrence and mortality. (C) 2012 Elsevier Ireland Ltd. All rights reserved

ASTRAL Score Predicts 5-Year Dependence and Mortality in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: The ASTRAL score was externally validated showing remarkable consistency on 3-month outcome prognosis in patients with acute ischemic stroke. The present study aimed to evaluate ASTRAL score's prognostic accuracy to predict 5-year outcome. METHODS: All consecutive patients with acute ischemic stroke registered in the Athens Stroke Registry between January 1, 1998, and December 31, 2010, were included. Patients were excluded if admitted &gt;24 hours after symptom onset or if any ASTRAL score component was missing. End points were 5-year unfavorable functional outcome, defined as modified Rankin Scale 3 to 6, and 5-year mortality. For each outcome, the area under the receiver operating characteristics curve was calculated; also, a multivariate Cox proportional hazards analysis was performed to investigate whether the ASTRAL score was an independent predictor of outcome. The Kaplan-Meier product limit method was used to estimate the probability of 5-year survival for each ASTRAL score quartile. RESULTS: The area under the receiver operating characteristics curve of the score to predict 5-year unfavorable functional outcome was 0.89, 95% confidence interval 0.88 to 0.91. In multivariate Cox proportional hazards analysis, the ASTRAL score was independently associated with 5-year unfavorable functional outcome (hazard ratio, 1.09; 95% confidence interval, 1.08-1.10). The area under the receiver operating characteristics curve for the ASTRAL score's discriminatory power to predict 5-year mortality was 0.81 (95% confidence interval, 0.78-0.83). In multivariate analysis, the ASTRAL score was independently associated with 5-year mortality (hazard ratio, 1.09, 95% confidence interval, 1.08-1.10). During the 5-year follow-up, the probability of survival was significantly lower with increasing ASTRAL score quartiles (log-rank test &lt;0.001). CONCLUSIONS: The ASTRAL score reliably predicts 5-year functional outcome and mortality in patients with acute ischemic stroke

Long-term outcome in posterior cerebral artery stroke

Introduction: Previous studies on posterior cerebral artery (PCA) strokes focused mainly on topography and underlying pathophysiology. However, there are no data on long-term prognosis and its association with the localization of the infarct. Methods: All consecutive PCA strokes registered in the Athens Stroke Outcome Project between 01/1998 and 12/2009 were included in the analysis. The New England Posterior Circulation Registry criteria were applied to classify them in relation to topography: (i) pure PCA infarcts, including pure cortical-only and combined cortical/deep PCA infarcts (groups A and B respectively), and (ii) PCA-plus strokes, including cortical-only and combined cortical/deep PCA strokes with ≥1 concomitant infarcts outside PCA territory (groups C and D respectively). Patients were prospectively followed up to 10years after stroke. Results: Amongst 185 (8.1%) PCA patients that were followed up for 49.6±26.7months, 98 (53%), 24 (13%), 36 (19.5%), and 27 (14.6%) were classified in group A, B, C, and D, respectively. Infections and brain edema with mass effect were more frequently encountered in PCA-plus strokes compared to pure PCA (P&lt;0.05 and &lt;0.01 respectively). At 6months, 56% of cortical-only PCA patients had no or minor disability, compared to 37%, 36%, and 26% in the other groups (P=0.015). The 10-year probability of death was 55.1% (95%CI: 42.2-68.0) for pure PCA compared to 72.5% (95%CI: 58.8-86.2) for PCA-plus (log-rank 14.2, P=0.001). Long-term mortality was associated with initial neurologic severity and underlying stroke mechanism. Conclusions: Patients with pure PCA stroke have significantly lower risk of disability and long-term mortality compared to PCA strokes with coincident infarction outside the PCA territory. Click to view the accompanying paper in this issue. © 2011 The Author(s). European Journal of Neurology © 2011 EFNS

Prevalence of atrial fibrillation in Greece: The Arcadia Rural Study on Atrial Fibrillation

Introduction Atrial fibrillation (AF) is a major factor for stroke and stroke-associated mortality, and its incidence is increasing during the last decades. There are only scarce data about its prevalence in Greece. We designed an epidemiological cross-sectional study to estimate the prevalence of AF in Greece and evaluate the adequacy of anticoagulant treatment in AF patients. Subjects and methods The Arcadia Rural Study on Atrial Fibrillation (ARSAF) was conducted between 2002-2003 in five rural villages of the Arcadia province (Greece) with a permanent population of 1312 individuals. Patients had a thorough medical examination and electrocardiogram, and information was collected about their medical history and comorbidities. CHADS 2 score was used to determine stroke risk for participants with AF. Results 1155 subjects (88% of the entire population) participated in the study. The overall prevalence of AF was 3.9% showing an increasing trend with increasing age ranging from 0.4% in patients &amp;lt; 55 years to 10.7% in patients &amp;gt; 84 years. Among patients with AF, 14 (32%) had paroxysmal AF. The presence of AF was associated with increasing age (OR: 1.67 for every 10 years increase, 95% CI: 1.26-2.15), hypertension (OR: 2.12, 95% CI: 1.02-4.14), heart failure (OR: 11.85, 95% CI: 4.92-28.56) and prior cerebrovascular disease (OR: 4.17, 95% CI: 1.44-12.06). Among these subjects with AF, 12 (26.6%) were considered as low-risk (CHADS 2 = 0), 18 (40.0%) as intermediate-risk (CHADS 2 = 1), and 15 (33.3%) as high-risk (CHADS 2 &amp;gt; 1) patients for stroke. 25 (55.5%) patients with AF did not receive appropriate antithrombotic treatment. Conclusion The prevalence of AF in Greece is similar to other countries and increases with increasing age

Comparison of Risk Scores for the Prediction of the Overall Cardiovascular Risk in Patients with Ischemic Stroke: The Athens Stroke Registry

Background: Stratification of overall vascular risk in patients with ischemic stroke is important as it may guide management decisions. Currently available schemes have only modest prognostic accuracy. The TRA2°P score aids in vascular risk stratification in patients with previous myocardial infarction (MI). Aim: We investigated whether the prognostic performance of TRA2°P can be extended in patients with ischemic stroke and whether it can improve the risk stratification made by CHA2DS2VASc and Essen-Stroke-Risk-Score (ESRS). Methods: We analyzed the Athens Stroke Registry using Kaplan-Meier survival and Cox-regression analyses to assess if TRA2°P (in different categorizations) predicts the composite endpoint of stroke recurrence, MI or cardiovascular death. We compared its incremental predictive value over CHA2DS2-VASc and ESRS and calculated continuous net reclassification indices (cNRI). Results: In 2833 patients (followed for 9278 patient-years) and 776 events, there was decreased survival probability for TRA2°P-based high-risk patients compared to low-risk (log-rank-test P &amp;lt; .001), but the discriminatory power for the occurrence of the composite endpoint was only modest (Harrell&apos;s-C:.566, 95% CI:.545-.587). Combined with ESRS, TRA2°P conferred incremental discrimination (Harrell&apos;s-C:.544, 95% CI:.513-.574 versus .574, 95% CI:.543-.605 respectively, P = .049) and reclassification value (cNRI = 9.8%, P = .02). Combined with CHA2DS2-VASc, TRA2°P did not improve discrimination (Harell&apos;s-C:.578, 95% CI: .547-.608 versus .585, 95% CI:.554-.616, P = .738). Conclusion: The currently available prognostic scores have generally low performance to predict the overall cardiovascular risk in ischemic stroke patients. Further research is needed to improve vascular risk stratification in ischemic stroke patients. © 2019 Elsevier Inc