Nancy A. Melville

October 17, 2017

SAN DIEGO — The risk for recurrent stroke after an index stroke is increased in patients aged 18 to 45 years, as is observed in older patients The risk for cardiac events is also increased, although to a lesser degree.

"Our study suggests that there is a high risk for cardiac events and recurrent strokes in the 1-year postdischarge period after first ischemic stroke in young adults," first author, Peter Jin, MD, from the Icahn School of Medicine at Mount Sinai in New York City, told Medscape Medical News.

"Physicians should be aware of the increased risk…and should work on minimizing a patient's vascular risk factors to potentially mitigate these complications."

The findings were presented this week at ANA 2017: 142nd Annual Meeting of the American Neurological Association and were published in the International Journal of Stroke.

While the incidence of stroke in young adults has been on the rise and now accounts for approximately 10% of all strokes, research on the prevention of secondary strokes in younger patients is lacking.

In the new study, Dr Jin and colleagues identified 12,812 patients in the Nationwide Readmissions Database aged 18 to 45 years who were admitted with an index ischemic stroke in 2013.

At the time of hospitalization, the prevalence of vascular risk factors was significant; 48.8% had hypertension, 32% had hypercholesterolemia, and 36.3% were smokers. More than half of patients were discharged to home or self-care after the index hospitalization, and 6.3% died.

The risk for recurrent stroke was overall three times higher than the risk for cardiac events, with a rate of 2913.3 readmissions per 100,000 index hospitalizations at 90 days for stroke vs 1132.2 for cardiac events.

Among patients without any vascular risk factors at the time of index hospitalization, the respective rates were 2534.9 vs 676 per 100,000 index hospitalizations.

The cumulative risk for hospitalization, according to Kaplan-Meier analysis, for recurrent stroke was higher at each time point compared than for cardiac events, with rates of 0.034 vs 0.025, respectively, at 100 days; 0.045 vs 0.032 at 200 days; and 0.057 vs 0.039 at 300 days.

The cumulative risk factors shown to increase the likelihood of cardiac events included baseline diabetes, hypercholesterolemia, and atrial fibrillation.

Predictors of recurrent stroke were diabetes and hypercholesterolemia.

"We found that the presence of diabetes or hypercholesterolemia was associated with an increased risk for post-stroke cardiac events and recurrent stroke, suggesting that the treatment of these comorbidities may be of specifically high importance in young adults with first-time stroke," Dr Jin said.

Interestingly, a risk factor so common in adults — hypertension — was not found to be associated with recurrent stroke or cardiovascular events in younger adults.

"It was surprising that hypertension, the strongest associated risk factor for recurrent stroke in older adults, was not associated with recurrent stroke or cardiac events in young adults," Dr Jin said.

"This may suggest that the impact of hypertension on stroke may not manifest until older age."

Important limitations of the study include the lack of data on characteristics of stroke, such as severity, size, and location, due to the reliance on administrative billing codes, Dr Jin noted.

"There is also no information on secondary stroke prevention measures started in patients, such as antiplatelets and statins," he said.

The findings nevertheless offer unique insights on the risks just after stroke, the authors noted.

"These findings are novel because they are drawn from nationally representative data, focus on the intermediate risk period, and demonstrate relationships between baseline vascular risk factors and subsequent risk," they reported.

The findings offer important insights on the patterns and risks of stroke and recurrent stroke in younger patients, commented Seemant Chaturvedi, MD, professor of clinical neurology at the University of Miami Miller School of Medicine in Florida.

"I think it is an intriguing study since there have not been many studies of young adults with such a large database," he told Medscape Medical News. "It is important to note that stroke is more common and that we should focus on stroke prevention."

He agreed that an important limitation is that such large databases make it difficult to determine exact stroke mechanisms.

"It would be interesting to determine the cause of recurrent strokes," Dr Chaturvedi said. "Although diabetes is a risk factor, the cause is typically blockage in the blood vessels or emboli from the heart."

The authors and Dr Chaturvedi have disclosed no relevant financial relationships.

ANA 2017: 142nd Annual Meeting of the American Neurological Association. Abstract S139. Presented October 15, 2017.

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