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Recurrent stroke and cardiac risks after first ischemic stroke

The Northern Manhattan Study

From the Mount Sinai School of Medicine (M.S.D.) and Departments of Medicine (R.R.S.) and Neurology (T.R., R.L.S., M.S.V.E.) and Sergievsky Center (R.L.S., M.S.V.E.), College of Physicians and Surgeons, and Division of Epidemiology (R.L.S.), Joseph P. Mailman School of Public Health, Columbia University, New York, NY.

Address correspondence and reprint requests to DrV. Elkind, Neurological Institute, 710 W. 168 St., New York, NY 10032; e-mail: mse13{at}columbia.edu

Background: Few population-based studies with long-term follow-up have compared risk of recurrent stroke and cardiac events after first ischemic stroke. The relative risk of these two outcomes may inform treatment decisions.

Methods: In the population-based Northern Manhattan Study, first ischemic stroke patients age 40 or older were prospectively followed for recurrent stroke, myocardial infarction (MI), and cause-specific mortality. Fatal cardiac events were defined as death secondary to MI, congestive heart failure, sudden death/arrhythmia, and cardiopulmonary arrest. Risk of events (with 95% CIs) was calculated using Kaplan–Meier survival analysis and adjusted for sex and age using Cox proportional hazard models.

Results: Mean age (n = 655; median follow-up 4.0 years) was 69.7 ± 12.7 years. The risk of recurrent stroke was more than twice that of cardiac events (including nonfatal MI) at 30 days and approximately twice cardiac risk at 5 years. The age- and sex-adjusted 5-year risk of fatal or nonfatal recurrent stroke was 18.3% (14.8 to 21.7%), and the 5-year risk of MI or fatal cardiac event was 8.6% (6.0 to 11.2%). The adjusted 5-year risk of nonfatal stroke (14.8%, 11.6 to 17.9%) was approximately twice as high as fatal cardiac events (6.4%, 4.1 to 8.6%) and four times higher than risk of fatal stroke (3.7%, 2.1 to 5.4%).

Conclusions: Cardiac mortality is nearly twice as high as mortality owing to recurrent stroke, but long-term risk of all stroke, fatal or nonfatal, is approximately twice the risk of all cardiac events. The high risk of nonfatal recurrent stroke reinforces the importance of therapies aimed at preventing stroke recurrence in addition to preventing cardiac events.

Supported by grants from the National Institute of Neurologic Disorders and Stroke (K23 NS42912, R01 NS48134, MSVE; R01 29993; R.L.S.) the General Clinical Research Center (2 M01 RR00645), and the Kathleen Scott Research Fellowship of the American Heart Association (GIA 0355596T; M.S.V.E.).

Disclosure: The authors report no conflicts of interest.

Received March 28, 2005. Accepted in final form November 9, 2005.

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