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Neurological Institute, Columbia-Presbyterian Medical Center, New York, NY (Drs. Sacco, Shi, Zamanillo, and Kargrnan)
Public Health (Epidemiology), Columbia-Presbyterian Medical Center, New York, NY (Dr. Sacco)
Sergievsky Center, Columbia-Presbyterian Medical Center, New York, NY (Drs. Sacco and Kargman).
Objective: To identify determinants of recurrence and mortality after ischemic stroke in a mixed-ethnic region.
Background: The determinants of ischemic stroke outcome are not uniformly characterized and will be of increasing importance as the frequency of ischemic stroke survivors increases in our aging population.
Methods: A cohort of 323 patients (40% black, 34% Hispanic, 26% white) with cerebral infarction from northern Manhattan over age 39 were followed for a mean of 3.3 years, with only 6% lost to follow-up. Cumulative life table risk of mortality and recurrence was calculated. Risk factors classified at the time of index ischemic stroke were selected based on univariate analyses and then entered into a Cox proportional hazards model for mortality and for recurrence.
Results: The life table cumulative risk of mortality was 8% at 30 days, 22% at 1 year, and 45% at 5 years after ischemic stroke. The immediate cause of death was related to vascular disease in 60%. After age adjustment, the significant predictors of mortality were congestive heart failure (risk ratio [RR] = 2.6), admission glucose >140 mg/dl (RR = 1.7), and presentation with either a large dominant, nondominant, or major basilar syndrome (RR = 2.0). Patients with a lacunar syndrome had a better survival (RR = 0.6). Recurrent strokes occurred in 72 patients. The life table cumulative risk of recurrence was 6% at 30 days, 12% at 1 year, and 25% at 5 years after ischemic stroke. Ethanol abuse (RR = 2.5), hypertension requiring discharge medications (RR = 1.6), and elevated blood glucose within 48 hours of index ischemic stroke (RR = 1.2 per 50 mg/dl) were the independent predictors of recurrence. Among 30-day survivors, the effect of ethanol abuse was greater (RR = 3.5), indicating its impact on late recurrence.
Conclusions: After accounting for age and presenting syndrome, initial glucose predicts stroke mortality and recurrence after ischemic stroke. This association may reflect uncontrolled and undiagnosed diabetes in our urban population. Furthermore, ethanol abuse may be a determinant of ischemic stroke recurrence. Reduction of the stroke public health burden will require targeted modification of such conditions and behaviors.
Address correspondence and reprint requests to Dr. Ralph L. Sacco, Neurological Institute, 710 West 168th Street, New York, NY 10032.
Supported by grants from the National Institute of Neurological Disorders and Stroke ( RO1 NS 27517 and T32 NS 07153).
Presented in part at the 45th annual meeting of the American Academy of Neurology, New York, NY, April 1993.
Received July 14, 1993. Accepted for publication in final form September 29, 1993.
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C. Marini, R. Totaro, and A. Carolei Long-Term Prognosis of Cerebral Ischemia in Young Adults Stroke, November 1, 1999; 30(11): 2320 - 2325. [Abstract] [Full Text] [PDF]
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P. A. Wolf, G. P. Clagett, J. D. Easton, L. B. Goldstein, P. B. Gorelick, M. Kelly-Hayes, R. L. Sacco, and J. P. Whisnant Preventing Ischemic Stroke in Patients With Prior Stroke and Transient Ischemic Attack : A Statement for Healthcare Professionals From the Stroke Council of the American Heart Association Stroke, September 1, 1999; 30(9): 1991 - 1994. [Full Text] [PDF]
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 J. T. Moroney, M.-X. Tang, L. Berglund, S. Small, C. Merchant, K. Bell, Y. Stern, and R. Mayeux Low-Density Lipoprotein Cholesterol and the Risk of Dementia With Stroke JAMA, July 21, 1999; 282(3): 254 - 260. [Abstract] [Full Text] [PDF]
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T. G. Kwiatkowski, R. B. Libman, M. Frankel, B. C. Tilley, L. B. Morgenstern, M. Lu, J. P. Broderick, C. A. Lewandowski, J. R. Marler, S. R. Levine, et al. Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year N. Engl. J. Med., June 10, 1999; 340(23): 1781 - 1787. [Abstract] [Full Text] [PDF]
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R. A. Swanson Intravenous heparin for acute stroke: What can we learn from the megatrials? Neurology, June 1, 1999; 52(9): 1746 - 1746. [Abstract] [Full Text] [PDF]
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L. N. Joseph, V. L. Babikian, N. C. Allen, and M. R. Winter Risk Factor Modification in Stroke Prevention : The Experience of a Stroke Clinic Stroke, January 1, 1999; 30(1): 16 - 20. [Abstract] [Full Text] [PDF]
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G. J. Hankey, K. Jamrozik, R. J. Broadhurst, S. Forbes, P. W. Burvill, C. S. Anderson, and E. G. Stewart-Wynne Long-Term Risk of First Recurrent Stroke in the Perth Community Stroke Study Stroke, December 1, 1998; 29(12): 2491 - 2500. [Abstract] [Full Text] [PDF]
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P. B. Gorelick Cerebrovascular Disease in African Americans Stroke, December 1, 1998; 29(12): 2656 - 2664. [Full Text] [PDF]
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J. T. Moroney, E. Bagiella, M. C. Paik, R. L. Sacco, and D. W. Desmond Risk Factors for Early Recurrence After Ischemic Stroke : The Role of Stroke Syndrome and Subtype Stroke, October 1, 1998; 29(10): 2118 - 2124. [Abstract] [Full Text] [PDF]
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H. Yamamoto and J. Bogousslavsky Mechanisms of second and further strokes J. Neurol. Neurosurg. Psychiatry, June 1, 1998; 64(6): 771 - 776. [Abstract] [Full Text] [PDF]
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M. Prencipe, F. Culasso, M. Rasura, A. Anzini, M. Beccia, M. Cao, F. Giubilei, and C. Fieschi Long-term Prognosis After a Minor Stroke : 10-Year Mortality and Major Stroke Recurrence Rates in a Hospital-Based Cohort Stroke, January 1, 1998; 29(1): 126 - 132. [Abstract] [Full Text] [PDF]
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S. Homma, M. R. Di Tullio, R. L. Sacco, R. R. S. , C. Smith, and J. P. Mohr Surgical Closure of Patent Foramen Ovale in Cryptogenic Stroke Patients Stroke, December 1, 1997; 28(12): 2376 - 2381. [Abstract] [Full Text]
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P.-K. Yip, J.-S. Jeng, T.-K. Lee, Y.-C. Chang, Z.-S. Huang, S.-K. Ng, and R.-C. Chen Subtypes of Ischemic Stroke : A Hospital-Based Stroke Registry in Taiwan (SCAN-IV) Stroke, December 1, 1997; 28(12): 2507 - 2512. [Abstract] [Full Text]
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R. L. Sacco, E. J. Benjamin, J. P. Broderick, M. Dyken, J. D. Easton, W. M. Feinberg, L. B. Goldstein, P. B. Gorelick, G. Howard, S. J. Kittner, et al. Risk Factors Stroke, July 1, 1997; 28(7): 1507 - 1517. [Full Text]
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L. B. Morgenstern, W. D. Spears, D. C. Goff, J. C. Grotta, and M. Z. Nichaman African Americans and Women Have the Highest Stroke Mortality in Texas Stroke, January 1, 1997; 28(1): 15 - 18. [Abstract] [Full Text]
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H. Haapaniemi, M. Hillbom, and S. Juvela Lifestyle-Associated Risk Factors for Acute Brain Infarction Among Persons of Working Age Stroke, January 1, 1997; 28(1): 26 - 30. [Abstract] [Full Text]
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P. B. Gorelick Stroke Prevention Arch Neurol, April 1, 1995; 52(4): 347 - 355. [Abstract] [PDF]
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M. Hillbom, H. Haapaniemi, S. Juvela, H. Palomaki, H. Numminen, and M. Kaste Recent Alcohol Consumption, Cigarette Smoking, and Cerebral Infarction in Young Adults Stroke, January 1, 1995; 26(1): 40 - 45. [Abstract] [Full Text]
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