Stroke Pre and Post-Cardiac Event; a Predictive or a Prognostic Factor

摘要

Background: Cerebral and cardiovascular events can occur simultaneously in a patient and with differential timing. Despite large studies addressing the presence of one diagnosis preceding the other, there are no comparative studies that address the impact of stroke timing difference on coronary event and its subsequent outcomes. In this study we sought to describe the association of cerebrovascular and cardiac events and the impact of the order of the occurrence of these events on patients’ outcomes. Methods: A retrospective longitudinal cohort studyin a single tertiary center (King Abdulaziz University Hospital) from two separate databases were crossed matched to identify patients with both diagnoses, then temporal relationships were identified on both directions (stroke before or after cardiac event). Cardiac events include any suspected acute coronary events that triggered referral for coronary angiogram. We included all patients who underwent coronary angiogram and had a primary admitting diagnosis of stroke. The primary endpoint was the incidence of major adverse cardiac event (MACE), the secondary endpoint was a composite of death, recurrent stroke and rehospitlization within 30 days. Risk assessment was evaluated using odds ratio at 95% confidence intervals. Results: Among 500 stroke patients and 6300 cardiac patients admitted in the span of 5 years, 16 patients were identified with both diagnoses, all had ischemic strokes. The mean age was 56.9±18.5 years, 37.5% were females. The most common cerebrovascular risk factors were hypertension (94%) diabetes (81%), atrial fibrillation (25%), and renal impairment (6%). When classified based on stroke timing, a quarter (n=4) of patients had stroke pre cardiac event (SPRE) and 75% (n=12) had stroke post-cardiac event (SPOST). Comparatively major adverse cardiac events were similar on both group (p= 0.58 ) odds ratio of MACE was 1.3 95% CI (0.6-2.7) vs. 0.8 (0.4-1.6) for patients in the SPRE and SPOST cohorts, respectively. Secondary composite endpoint of death, recurrent stroke and rehospitlization within 30 days was higher in the SPRE group (p=0.0001 . This was primarily driven by increased risk of recurrent stroke; odds ratio 2.4 (1.2-4.7) vs. 0.4 (0.2-0.8). The mean time from stroke to cardiac event was 89.5 days compared to 40.5 months from cardiac event to stroke. Conclusions: In this cohort of patients with the diagnoses of both stroke and cardiac events, timing of stroke predicts and prognosticates future outcomes in a differential manner as stroke occurrence before a cardiac event (SPRE) tends to cause more recurrent strokes and possibly more cardiac events than its occurrence after a cardiac event (SPOST). Limitations: This was a small cohort identified retrospectively from a single center.