- Stroke Survival Statistics: 9 Sobering Facts We Should All Be Aware Of
- Danish Study of Stroke Survival Rates
- First-Stroke Patients’ 5-Year Survival Rates Study
- Long-Term Mortality Rate Study, Ages 18–50
- Studies of Stroke Mortality Rates in England
- Stroke Survival Rates in Elderly Populations
- Variations in Effectiveness of Treatment Centers
- Moscow 7-Year Survival Rates Study
- Understanding Stroke Risk
- Life expectancy reduced by stroke, diabetes and heart attack combo
- Adults with cardiometabolic multimorbidity may face 23-year reduction in life expectancy
- Effects of ‘mini stroke’ can shorten life expectancy
- Long-Term Prognosis of Ischemic Stroke in Young Adults
- The value of qualitative studies
- Long-Term Survival of Young Stroke Patients: A Population-Based Study of Two Stroke Registries from Tartu, Estonia
Stroke Survival Statistics: 9 Sobering Facts We Should All Be Aware Of
Monday, June 11th, 2018
Although stroke has fallen from the third to fourth leading cause of death within the United States, outlook after survival is still grim. Medical treatment has become much more advanced for stroke survivors immediately following a stroke and through rehabilitation, but strokes are a very serious medical condition that require a lifetime of dedication to overcome.
Stroke severity and patient age are the two most important factors in predicting one’s chances of survival after a stroke. Stroke severity is measured by analyzing neurological impairments (in language and behaviors) and by conducting a CT scan or MRI.
Medical professionals will also use the National Institutes of Health Stroke Scale (NIHSS), within 24 hours of a stroke, to measure neurological impairment and predict the chance of survival. Each point a patient scores, his or her odds of survival after three months decreases by 17 percent.
The following studies examine the fatality rates of stroke so survivors and their families can better understand their outlook post stroke.
Danish Study of Stroke Survival Rates
A Danish study included 5,262 stroke patients who suffered a stroke between 1982 and 1991. All stroke patients in this study were at least 25 years old. The study found that those who survived a stroke were five times more likely to die between four weeks and one year after the first stroke. They were two times more likely to die after more than a year passed.
Fewer than 28 days after a stroke, the risk for death was estimated at 28 percent, but after one year, it was 41 percent; after five years, the risk increased to 60 percent. The study attributed excess mortality rates to other health issues, like cancer, cardiovascular disease and other diseases, suicide, or accidents.
First-Stroke Patients’ 5-Year Survival Rates Study
Another study analyzed 836 patients who suffered their first stroke between 1997 and 1998 in Tuzla, Herzegovina, and Bosnia. After one month, 36 percent of the patients died. The majority of these patients suffered from intracerebral hemorrhage.
Of the surviving patients, 60 percent who suffered an ischemic stroke and 38 percent with intracerebral hemorrhage survived one year, compared to 31 percent and 24 percent, respectively, after five years. At the end of the study, 29 percent of the stroke patients were still alive.
The study found that those 50 or younger had a higher survival rate than those 70 or older, at 57 percent and 9 percent, respectively. Additionally, the long-term survival rate (five years) is better in patients who suffered from intracerebral hemorrhage compared to those with ischemic stroke. However, those who suffered from intracerebral hemorrhage were more likely to pass away within the first 30 days of the stroke.
Long-Term Mortality Rate Study, Ages 18–50
A study was conducted on patients at Radbound University Nijmegan Medical Centre in the Netherlands who were admitted between January 1, 1980, and November 1, 2010. This study focused specifically on 18 to 50 year olds, since the long-term effects of first-stroke survivors in this age range is not widely studied. Another purpose of the study was to gain a more comprehensive look at stroke survivors by including those with ischemic stroke, intracerebral hemorrhage, and first-ever transient ischemic attack (TIA).
The majority of the 959 patients studied suffered from ischemic stroke. The study found that, among 30-day survivors, the risk of death by the twentieth year mark was highest for ischemic stroke patients, at 26.8 percent, with TIA sufferers close behind at 24.9 percent. Those with intracerebral hemorrhage had a 13.7 percent risk of death.
Melina Gattellari, a senior lecturer at the University of South Wales, states that TIAs can have significant effects on long-term survival rates, much like a stroke. As TIA patients age, survival rates steadily decline, with a 4-percent decline in life expectancy after the first year and a 20-percent decline by the ninth year.
Studies of Stroke Mortality Rates in England
England reviewed a collection of studies analyzing stroke patients in the U.K. between 1990 and 2010. During this time, U.K. stroke patient mortality rates decreased by 46 percent. Although this shows an improvement in medical care for stroke patients, the State of the Nation stroke statistics makes it clear that stroke can still be fatal.
By the time they reach their 75th birthday, one in five women and one in six men will suffer a stroke. In the U.K., stroke serves as the fourth highest cause of death; in the world, it’s the second. Out of those who suffered from stroke, three in ten will have a TIA or recurrent stroke. One in eight strokes will kill a survivor within the first 30 days and 25 percent within the first year. This is largely due to the disabilities nearly half of stroke patients will face after a stroke.
Stroke Survival Rates in Elderly Populations
A Canadian study was conducted on stroke survivors 61 years (on average) or older to determine the survival rates of the elderly population. Over a third (38 percent) of the patients were at least 80 years old, and this group also had the highest mortality rates during their hospital stays, at 24.2 percent. Those under 59 years old died at a rate of 5.7 percent; ages 60–69 reached 8.6 percent; and those 70–79 passed away at a rate of 13.4 percent.
Those over 80 who survived suffered from so many impairments that they were unable to return to their homes and, instead, had longer hospital stays or were cared for in medical facilities.
Variations in Effectiveness of Treatment Centers
A study on those who have United States Medicare benefits analyzed 91,000 patients who survived a stroke between April 2003 and December 2006. The patients were treated at 625 hospitals all over the country.
The study found that almost two-thirds of Medicare patients would either need to be readmitted within a year or would die after discharge. However, higher-performing hospitals saw a lower mortality rate in stroke patients (9.8 percent) than in lower-performing hospitals (17.8 percent).
Moscow 7-Year Survival Rates Study
A district in Moscow analyzed 1,538 stroke patients who suffered a stroke between January 1, 1972, and December 31, 1974. The purpose of this study was to gain a better understanding of stroke survival rates over a longer period of seven years.
This study found that within three weeks of suffering a stroke, 37.3 percent of the patients had passed away. Over the next seven years, the study followed 941 of the remaining stroke survivors to record both recurring strokes and deaths, while also finding links between recurring strokes and survival rates.
In the first three months, not counting the first three weeks after stroke, most of the patients who did not survive suffered from pulmonary thromboembolism. After three years, 63.6 percent of the patients died. After five years, 72.1 percent passed, and at 7 years, 76.5 percent of survivors died.
The study found that those who had multiple strokes had a higher mortality rate than those who suffered from other health issues, like cardiovascular disease. Interestingly, nearly half of all patients suffered from transient ischemic attacks.
Understanding Stroke Risk
Strokes have always posed a series of intense complication for survivors. While treatment options have gotten better and initial treatments are better than they have ever been, it is important to understand that all stroke patients face significant hurdles in recovery.
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Life expectancy reduced by stroke, diabetes and heart attack combo
Having a history of diabetes, stroke or heart attack can lower life expectancy significantly, according to new research, while a combination of two or more of these conditions – defined as cardiometabolic multimorbidity – can reduce it even further.
Share on PinterestResearchers estimate that 40-year-olds with a history of diabetes, stroke and heart attack may experience a 23-year reduction in life expectancy.
According to study co-author John Danesh, of the University of Cambridge in the UK, and colleagues, the prevalence of cardiometabolic multimorbidity is on the rise. It affects around 10 million adults within the US and the European Union (EU), they say.
Previous studies have established that a history of stroke, heart attack or diabetes alone can increase mortality risk. But Danesh and colleagues say few studies have looked at how a history of two or more of these conditions may impact life expectancy.
They note that to reach valid estimations of this, such studies need to compare individuals with cardiometabolic multimorbidity with those in the same cohorts who are free of such conditions at study baseline.
“However, few population cohorts have had sufficient power, detail and longevity to enable such comparisons,” they add. “We aimed to provide reliable estimates of the associations of cardiometabolic multimorbidity with mortality and reductions in life expectancy.”
The team analyzed data from the Emerging Rick Factors Collaboration, involving 689,300 participants from cohorts conducted between 1960 and 2007. This data were compared with that from the UK Biobank, involving 499,808 participants from cohorts conducted between 2006 and 2010.
Data from the Emerging Rick Factors Collaboration included 128,843 deaths, while data from the UK Biobank included 7,995 deaths.
The researchers used the data to estimate mortality rates among individuals with a history of either diabetes, heart attack or stroke, a history of two or more of these conditions or no history of any of these conditions.
Adults with cardiometabolic multimorbidity may face 23-year reduction in life expectancy
Compared with participants who had no history of diabetes, heart attack or stroke, those who had a history of one of these conditions was found to have twice the rate of death. However, the death rate was found to be even higher with each additional condition.
The rate of death among participants with a history of two of these conditions was four times higher, while the rate of death increased eight-fold for participants who had all three conditions.
Based on these findings, recently published in JAMA, the team estimates that a history of cardiometabolic multimorbidity is associated with a reduced life expectancy similar to that caused by lifelong smoking or HIV – a reduction of around 10 and 11 years, respectively.
At the age of 60, for example, the researchers estimate that an individual with a history of two of the conditions may experience a 12-year reduction in life expectancy, while a 15-year reduction is estimated for those with a history of all three conditions.
For younger individuals with a history of cardiometabolic multimorbidity, the reduction in life expectancy may be even higher. The researchers estimate that individuals aged 40 with a history of diabetes, stroke and heart attack could experience around 23 years of lost life.
On adjusting the results by sex, the team found that the association between a history of stroke or heart attack at study baseline and reduced life expectancy was stronger for men than for women, while the association between diabetes at study baseline and reduced life expectancy was stronger for women.
The researchers estimate that overall, men are likely to experience more lost life years than women as a result of cardiometabolic multimorbidity. “Nevertheless,” they note, “for both men and women, our findings indicate that associations of cardiometabolic multimorbidity extend beyond cardiovascular mortality. Future work will seek to elucidate explanations for these interactions by sex.”
Commenting on their overall findings, the researchers say:
“Our results highlight the need to balance the primary prevention and secondary prevention of cardiovascular disease.
About 1% of the participants in the cohorts we studied had cardiometabolic multimorbidity compared with an estimate of 3% from recent surveys in the United States. Nevertheless, an overemphasis on the substantial reductions in life expectancy estimated for the subpopulation with multimorbidity could divert attention and resources away from population-wide strategies that aim to improve health for the large majority of the population.”
Cardiovascular conditions such as stroke may not only reduce life expectancy. Last month, Medical News Today reported on a study suggesting stroke can result in the loss of cognitive function that is the equivalent to the brain aging by 8 years overnight.
Effects of ‘mini stroke’ can shorten life expectancy
“People experiencing a TIA won’t die from it, but they will have a high risk of early stroke and also an increased risk of future problems that may reduce life expectancy,” said Melina Gattellari, Ph.D., senior lecturer at the School of Public Health and Community Medicine in The University of New South Wales, Sydney and Ingham Institute in Liverpool, Australia.
“Our findings suggest that patients and doctors should be careful to intensely manage lifestyle and medical risk factors for years after a transient ischemic attack.”
The statistical analysis is the first to comprehensively quantify the impact of hospital-diagnosed TIA on life expectancy.
Researchers identified 22,157 adults hospitalized with a TIA from July 2000 to June 2007 in New South Wales, Australia, and tracked their medical records for a minimum two years (median 4.1 years). They gathered death registry data for the area through June 2009 and compared death rates in the study population to those in the general population. Median ages were 78 for female patients and 73 for male patients; 23.9 percent were younger than 65 and 19.4 percent were older than 85.
At one year after hospitalization, 91.5 percent of TIA patients were still living, compared to 95 percent expected survival in the general population. At five years, survival of TIA patients was 13.2 percent lower than expected — 67.2 percent were still alive, compared to an expected survival of 77.4 percent.
By the end of the study, at the nine-year mark, survival of TIA patients was 20 percent lower than expected.
Increasing age was associated with an increasing risk of death compared to the matched population. TIA had only minimal effect on patients younger than 50, but significantly reduced life expectancy in those older than 65. Compared to patients younger than 50, relative risk of death for patients 75-84 was 7.77 times higher and 11.02 times higher for those 85 and older.
“We thought the reverse may be true — that survival rates in older TIA patients would be more like other older people, who, although not affected by TIA, are affected by other conditions that may influence their survival,” Gattellari said. “But even a distant history of TIA is major determinant of prognosis; certainly, the risks faced by TIA patients go well beyond their early stroke risk.”
Researchers also examined TIA patients’ medical records for other common health risks:
- Congestive heart failure was associated with 3.3 times more risk of dying.
- Atrial fibrillation was associated with twice the risk of dying.
- Prior hospitalization for stroke meant 2.63 times the risk of dying compared to patients without it; further, this effect grew over time, peaking at 5.01 times more risk three years after TIA admission.
In general, adults with a history of TIA can maximize their chances of living a long life by adopting healthy lifestyle habits, such as exercising daily, maintaining a healthy weight, quitting smoking and eating healthy, Gattellari said.
Co-authors are Chris Goumas, M.P.H.; Frances Garden, M.Biost.; and John M. Worthington, M.B.B.S. Author disclosures are on the manuscript.The Clinical Excellence Commission and the Commonwealth Department of Health and Ageing partly funded the study.
WEDNESDAY, Oct. 9, 2013 (HealthDay News) — Despite life-saving advances in treating strokes, these “brain attacks” can shave years off of a person’s life and seriously impair the quality of the years they have left, a new study shows.
The damage is most pronounced after a severe stroke, but even those people who have a so-called mini-stroke or transient ischemic attack (TIA) are at risk. The new findings appear online in the Oct. 9 issue of the journal Neurology.
Experts stress that preventing strokes by taking control of known risk factors such as high blood pressure remains the best way to improve the outlook for patients. Strokes occur when blood flow to part of the brain is blocked. The National Stroke Association estimates that as many as 80 percent of strokes are preventable.
In the new study, nearly 750 people who had a stroke and about 450 who experienced a TIA were followed for five years. They completed questionnaires about their post-stroke quality of life. Of the full-blown strokes, close to 60 percent were considered minor, 23 percent were moderate and 18 percent were severe.
When compared to members of the general population, a person who has a stroke will, on average, lose 1.71 out of five years of perfect health due to an earlier death. In addition, the stroke will cost them another 1.08 years due to reduced quality of life, the study found.
In total, people who have had strokes lose an average of 2.79 “quality-adjusted life years.” This is a measure that quantifies survival and quality of life in the same scale.
And the more severe the stroke, the greater the loss in terms of quality-adjusted life years, the study showed. Older people, women and those who had a second stroke also were at higher risk for worsening quality of life and earlier death after the stroke.
Exactly how strokes affect quality of life varies. They can hamper a person’s ability to walk, talk or perform daily activities such as bathing, eating and getting dressed.
“The degree to which a stroke will impact an individual’s quality of life will be driven by the severity of the event,” said study co-author Ramon Luengo-Fernandez, a senior researcher and associate research fellow at the University of Oxford, in England. “Whereas in many cases a minor stroke may have little impact on a patient’s life, a severe stroke will almost invariably pose a considerable negative impact.”
This study is believed to be the first to assign such a value to mini-strokes. Like a stroke, a TIA is marked by an inability to move, numbness on one side of the body or difficulty speaking. Unlike in many strokes, however, these symptoms often are fleeting and leave little or no signs of permanent damage to the brain. Still, the study showed that they do affect quality of life going forward.
“TIA, on its own, would be expected to have little impact on quality of life; however, the combined impact of medication, anxiety about suffering subsequent events and, for those in employment, the impact on their working life will impact quality of life,” Luengo-Fernandez said. “We found that suffering subsequent strokes following TIA significantly and considerably reduced quality of life.”
Avoiding stroke is the key. “By preventing a stroke in the first place, we will also improve quality of life,” Luengo-Fernandez said. “Cost-effective treatments such as cholesterol-lowering drugs and treatments for reducing high blood pressure already exist that significantly reduce the risk not only of stroke, but also cardiovascular events.”
“In addition, reducing risk factors for stroke, obesity, smoking and physical inactivity, will also reduce the risk of suffering a stroke,” he said.
A U.S. expert agreed that preventing strokes is the way forward.
“We need to do a better job of addressing high blood pressure before stroke; controlling cholesterol and diabetes; and encouraging smoking cessation, daily exercise and a healthy diet,” said Dr. Zeshaun Khawaja, a neurologist at the Cleveland Clinic Foundation. These measures are all known to lower risk of stroke and heart disease.
The study showed what it’s like to survive a stroke from the vantage point of the person who suffered it, another expert said.
Dr. Richard Libman, vice chairman of neurology at Long Island Jewish Medical Center in New Hyde Park, N.Y., added: “The quality of life of the person is what counts. Even though we are doing well with treating strokes, a lot of patients will say their quality of life is compromised, and this is an incentive for us to do better.”
This includes prevention, but “we also need to focus more on measures which keep them alive and improve their quality of life,” Libman said. “It appears that there is much more to treating strokes than just clot-busting drugs or advanced technology.”
Clot busters are emergency drugs that, when given within a specific time window, can save lives and stave off lasting disability after some types of strokes.
Get schooled on stroke prevention at the National Stroke Association.
In our study, no significant differences in the 5-year cumulative risks of acute cardiovascular events (including stroke recurrence) were noted between first-ever LI and non-LI patients. After adjustment for baseline confounders, the risk of death for patients with LI and non-LI was similar to non-LI. Previously, in a community-based study, we found that the major difference in mortality between LI and non-LI patients was in the acute stage of stroke. The disparity in the mortality rates of the two groups decreased from one to 12 months of acute stroke onset, and disappeared after one year . Due to limitaltions in its initial design, the aforementioned study was unable to identify long-term risks for vascular endpoints and to analyze potential risk factors associated with death and acute cardiovascular events. The benefit of identifying the various possible outcomes and risk factors in post-ischemic stroke survivors allows the medical and scientific community to develop strategies aiming at reducing the burden of stroke on patients and their families, and by doing so increase quality as well as quantity of life in these patients. The results from this study reaffirm the notion that the post-stroke risks of acute cardiovascular events and mortality are higher than those of the general population . A recent report from urban Beijing showed that the average incidence of first stroke in general population was 0.178% with 95% CI of 0.113% to 0.131% during the period of 2003 to 2008 .
Our study demonstrated stroke recurrence to be the most common cause of death, followed by AMI in ischemic stroke survivors. In contrast, a meta-analysis by Sander et al. found that stroke survivors to be at great risk of recurrent stroke in the short term, while AMI posed a greater risk in the long term . However, most studies in Sander and colleagues’ report encompassed a European or American patient populations. Japanese scholars speculated that the risk factors for recurrent stroke in East Asian populations were different from those of European or American stroke survivors . Heterogeneity from a genetic or environmental standpoint and the interaction between the two might explain the reason for the disparity between the different populations. Another explanation might be that intracranial large-artery occlusive disease, the most common cause of stroke, is more prevalent in the Chinese population when compared to the Caucasian one .
The risk factor profiles associated with poor outcome were different between patients with LI and non-LI. Several significant predictors of poor outcome in LI patients were identified. They were age, male gender, diabetes, hypertension, ADL dependence, and depression. These findings are consistent with previous studies from China , , , , . The majority risk factors we identified to be prognostic of poor outcomes in LI patients are modifiable (only age and gender are fixed). These findings suggested that as long as the vascular risk factors controlling, as well as rehabilitation and psychological counseling are aggressively administrated, the prognosis of LI patients can possibly be shifted in a favorable direction. A meta-analysis by Hankam et al. showed that the risk of recurrent stroke could be reduced by 80% when stroke survivors were actively treated for carotid artery atherosclerosis, atrial fibrillation, diabetes, and combined anticoagulant therapy and smoking cessation . Improving functional ability and depression symptoms are also of benefit to stroke survivors , . In China, current guidelines for the secondary prevention of stroke put emphased of management of vascular risk factors; unfortunately, though, the rehabilitation and mental health care are not adequately stressed .
To our knowledge, this present study is the first large sample, long-term study focuses on multiple end-points and determinants related to the poor outcomes of stroke in mild to moderate ischemic stroke survivors in clinics in China. Due to limited resources in developing countries, the admission to a hospital after a stroke event depends mainly on the severity of the disease. Patient with a severe presentation is more likely to be admitted . As a result, hospital-based studies from developing countries are usually biased towards the more serious or complicated cases. In addition, a recent study showed that, in China, a patient’s socioeconomic status also influences health providers’ decisions regarding admission and treatment . Patients with a mild to moderate stroke or those whose healthcare are not covered by medical insurance would often present to the outpatient clinics for treatment. The baseline assessment in our study suggested that the demographic characteristics, vascular risk profiles, and the proportion of ischemic stroke subtype in clinics were different from those of inpatient services or who are in the acute stage of stoke. Compared with previous hospital-based studies, , , , the proportion of female gender and the prevalences of hypertension and dislipidemia were higher in our clinics’ patients. The proportion of LI was 66.8% (474/710), while the proportion was 42.3% in hospital-based study cover 5 hospitals in China Because the patients who present to the clinics are generally stable, their prognosis have been paid less attention in China now. According to our study, the strategies that are utilized for the inpatients in the acute stage of stroke should be adjusted if those are to be use in the outpatient in the stable phase of the disease in clinics. Hence, a well-organized and professional drive is needed for vascular risk management and rehabilitation. The results from this study might be of importance to clinical and public policy changes related to stroke prevention, rehabilitation, and long-term care.
Worth mentioning are several limitations presented in this study. It is possible that the cohorts we selected for the study were not be true representatives of the mild to moderate ischemic stroke patient subpopulation that presents to clinics for treatment in China. To ensure the accuracy of our diagnosis and classification of ischemic stroke, we excluded those patients whose diagnosis of stroke was not confirmed by neuroimaging. Secondly, we did not find significant difference in the proportion of hemorrhagic stroke, AMI, and sudden death between LI and non-LI groups. In addition, we also did not identify any modifiable risk factors related to poor prognoses in non-LI patients. These negative findings could be attributed to a relatively small number of non-LI patients enrolled at baseline and thereafter a small number of new-onset acute cardiovascular events occurring in this group during the follow-up period; thereby decreasing the power for detecting statistical significance. Clearly, in order to properly assess outcomes and identify underlying determinants of prognoses, a large long-term community-based study with adequate representation of the different subtypes of stroke is needed. Thirdly, the dropout rate among this study’s participants was 10%, mainly due to participants’ relocation. Fortunately, the baseline characteristics between patients lost to follow-up and those remained in the cohort were similar (data not shown), and dropout rates between LI and non-LI were similar (9.3% vs.11.4%, P = 0.219), which suggests that the impact of patients lost to follow-up is limited. Fourthly, at the baseline data collection, we only asked whether of not patients used tobacco or alcohol prior to their index stroke. Quantitative data (amount and duration of use) were not collected. Therefore the association between the use of tobacco or alcohol and poor outcomes may be underestimated, as patients experiencing a stroke are more likely to give up such habits.
Long-Term Prognosis of Ischemic Stroke in Young Adults
There is limited information about long-term prognosis of ischemic stroke in young adults. Giving the potentially negative impact in physical, social, and emotional aspects of an ischemic stroke in young people, providing early accurate long-term prognostic information is very important in this clinical setting. Moreover, detection of factors associated with bad outcomes (death, recurrence, moderate-to-severe disability) help physicians in optimizing secondary prevention strategies. The present paper reviews the most relevant published information concerning long-term prognosis and predictors of unfavorable outcomes of ischemic stroke affecting young adults. As a summary, we can conclude that, in the long term, stroke in the young adult increases slightly the risk of mortality, implies higher risk of future cardiovascular events, and determines functional limitations in a significant percentage of patients. Nevertheless, in every individual case the prognosis has to be considered depending on several factors (stroke subtype, initial severity, cardiovascular risk factors) that determine the long-term outcomes.
Ischemic stroke in young adults (15–45 years) is not exceptional and accounts for up to 12% of all first ischemic strokes, with a wide diversity of etiologies . Moreover, the impact on years of potential life lost and on socioeconomic cost is very important in this range of ages.
Many series have reported a favorable prognosis, but only the short-term prognosis has been widely evaluated and there are few investigations about long-term functional recovery of young adults with first-ever ischemic stroke.
Most of the investigations in long-term prognosis have described good functional recovery in young adults with ischemic stroke, since most patients are independent and at least 50% return to work . Moreover, some predictive factors for mortality, recurrence, and good/poor functional recovery have been identified .
In the main series, the mean followup after the initial episode ranges between 1 and 16 years (Table 1) . The most important methodological limitations in most of these studies are the retrospective design, but it is not so important to evaluate the long-term consequences of stroke, since events as recurrence, death, and disability can be easyly and accurately evaluated with this methodology. The review of the clinical records (including periodic outpatient reviews) complemented with telephone interviews is the main tools for obtaining information about the patients’ functional status after the stroke in the main studies about consequences of stroke in the young , including prospective series .
Table 1 Long-term followup series in young adults with ischemic stroke.
The prognosis of ischemic stroke in the young is much better than in the elderly, with lower mortality and recurrence and better functional recovery . Thus, prognosis of stroke in young as a whole has been described as favorable in most of the series , but the long-term prognosis is notably worse when compared with the general population of the same age, with higher death rate, higher risk of cardiovascular events, and significant limitations in quality of life . Moreover, in our series (with a mean followup of almost 12 years and mean age of 36 years old), only 57% of the patients followed for more than 3 years are alive, free of significant disability, stroke recurrence or other vascular event .
Table 2 Annual and cumulative rates of mortality and recurrent stroke in young adults after a first-ever ischemic stroke, based on data of study of Varona et al. .
The cumulative risk of mortality at 10 years in young adults with ischemic stroke is about almost 10 times higher than in the general population of the same age , as shown in Figure 1, which compares the survival of young patients with ischemic stroke in our series against the survival of persons between 15–45 years in the Madrid Community , indicating the negative impact on survival for suffering from ischemic stroke in the young .
Graph showing a comparative approximation of the different probabilities of survival at 10 years in young adult patients (15–45 years) with ischemic stroke and the general population aged 15–45 years. (based on data of study of Varona et al. ).
However, the mortality of young adults with ischemic stroke is much lower than in older patients, since survival at five years is more than 90% in the young and only 40% in the elderly .
2.1. Risk Factors for Mortality
Apart from patients with malignancies, several subgroups of patients and some factors have been identified as associated with notably higher risk of death: increasing age (above 35 years; relative risk of 2.0 and hazard ratio of 2.5), male gender (RR of 1.9; HR of 2.1), the presence of cardiovascular risk factors, in particular arterial hypertension (HR 1.3), completed stroke, with total anterior circulation involvement (HR: 3.3), heart failure (HR: 5.2), heart and/or vascular disease (HR: 1.7), heavy drinking (HR: 2.8), large artery atherosclerosis (HR: 4.4), smoking (HR: 1.4), and severe neurological deficit at presentation (RR of 5.1) have been associated with mortality in young adults with ischemic stroke . The majority of these factors are associated with an atherosclerotic risk profile, which is present in older and male patients in whom premature atherosclerosis is much more prevalent and prognosis is worse.
As “protective” factors, the following have been reported as associated with lower long-term mortality: stroke due to dissection of extracranial arteries, stroke associated with migraine, permanent poststroke anticoagulation therapy (in patients with cardioembolic stroke or potential cardiac sources of emboli and patients with hypercoagulable states) (RR 0.3), and hypercholesterolemia (RR 0.3). The protective role of hypercholesterolemia therapy has been reported in young as well as in elderly . This is due to the neuroprotective effect of drugs such as statins or fibrates, which are prescribed in young adults with stroke and hypercholesterolemia.
Ischemic stroke in relation to atherothrombotic (HR: 4.4) and cardioembolic (HR: 2.8) causes has been associated in some series with a poor prognosis. Conversely, several etiologies have been associated with better prognosis and lower percentages of mortality: lacunar infarct, nonatherosclerotic vasculopathy, hypercoagulable state, and undetermined/unknown etiology .
3. Long-Term Functional Deficits
With respect to functional recovery, the prognosis for young adults with stroke is good, especially compared with the elderly. Some series have reported that up to 90% of patients with a long-term followup are independent for all activities of daily living and 95% are able to walk without any assistance in spite of previous stroke (Figure 2) .
Functional outcome after long-term followup of young adults with ischemic stroke (number of patients: 240; mean followup time: 11.7 years), based on data of study of Varona et al. .
Functional recovery and residual disability outcomes are often rated with modified Rankin scale (MRS), Barthel Index (BI), and Glasgow Outcome Scale (GOS). According to these scales, in the long-term followup even more than 70%–80% of the patients report no significant problems for daily activities ( ; ), about 10%–20% report moderate handicaps ( ), and only about 10% report major handicaps and residual dependency after ischemic stroke (MRS score higher than 3 and/or BI score less than 90) .
These figures contrast with the figures in the elderly, in whom 35%–40% of patients with stroke are dependent on other persons after the stroke .
The reported predictive factors for better long-term functional recovery have been: age below 35, transient ischemic stroke, favorable initial course without severe handicaps at discharge, and stroke associated with migraine and/or oral contraceptives . No etiology has been significantly associated with a better or poorer functional recovery, but lacunar infarct and unknown etiology have been associated to a slightly better prognosis.
4. Occupational Status
Ischemic stroke in the young originates limitations in the quality of life and occupational status . Series have reported that between 50%–70% of young adults with stroke return to work, with a time period ranging from several days after stroke to 40 months, with a mean of 8 months. However, about 25% of them need adjustments in their occupation due to their inability after stroke to perform the prior activity, so less than half of the patients return to their previous work (Figure 2) .
5. Other Sequelae
In the reported series, between 20%–50% of patients have poststroke depression (using DSM-IIIR criteria and/or The Montgomery Asberg Depression Rating Scale). Most of these patients need specific psychiatric assistance. Stroke localization on carotid artery territory, a severe disability, and absence of return to work have been reported as associated with poststroke depression .
The poststroke headache has been reported in about 15%–20%, while poststroke seizures have been reported in about 10% .
6. Quality of Life
Few studies have evaluated specifically the quality of life after ischemic stroke in young people. In a Norwegian report, stroke had only moderate effects on self-reported health-related quality of life (HRQoL) among young adults with ischemic stroke as a group (the most affected domain was physical functioning), although some factors were associated with marked reduction in HRQoL: functionally dependant status, fatigue, depression, unmarried status, and unemployment . Other series conclude that aside from residual disability (mainly rated by MRS scale and BI), other factors which affect the quality of life are unemployment, motor impairment, aphasia, dysarthria, and dysphagia .
Thus, early identification and improved therapy for conditions such depression, fatigue, and physical disability may improve quality of life among young adults with ischemic stroke .
Recurrent stroke is frequent in the young, but lower compared with older patients, so cumulative recurrence rate at 5 years is almost 2 times lower in young (15%) than in older (29.5%) patients (Table 2) .
Recurrence is more frequent in patients with atherothrombotic stroke (about 5% annual) than in those with stroke due to non-atherosclerotic vasculopathy (about 2%) .
Recurrent stroke may result in an important limitation in vital and functional prognosis, so about 15%–20% of patients died as the result of the recurrence, 30%–40% had severe handicaps with residual dependent status, and more than 50% receive permanent disability pension as a result of the recurrent stroke. These findings underline the importance of a properly secondary prevention therapy to avoid recurrence.
The predictive factors for recurrence in most of the studies are age over 35 years (RR: 1.7), the presence of cardiovascular risk factors (especially, diabetes mellitus, RR: 2.5), previous transient ischemic attack (RR: 1.5), and atherothrombotic stroke in the carotid territory (RR: 1.7). Stroke associated with migraine, stroke due to extracranial artery dissection, and patients with an unknown etiology have been associated with lower risk of recurrence .
Although global risk of long-term death is low, first-ever ischemic stroke in young people has severe prognostic implications. The mortality risk is higher than general population, the risk of recurrent vascular events is considerable, and only about 50% of patients recover fully (without significant disability) and return to work after first-ever ischemic stroke. Several subgroups have notably increased risk of unfavorable outcomes in the long term and therefore need special attention. Thus, while the atherosclerotic risk profile is associated with the highest risk of recurrent stroke and mortality, age under 35 years and the stroke associated with dissection, migraine and/or contraceptives are associated with a good long-term outcome. Regarding young people with a long expected life span ahead, identifying factors associated to higher mortality is essential, because we can modify some of these factors with strict pharmacological control and/or invasive cardiovascular procedures in selected patients.
We conducted a qualitative studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. of patients’ quality of life and a dataData is the information collected through research. linkage studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. exploring patterns of death after a severe stroke. For the linkage studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies., we identified 219 patients with total anterior circulation syndrome admitted to three stroke units in Scotland. The fatality rateThe speed or frequency of occurrence of an event, usually expressed with respect to time. For instance, a mortality rate might be the number of deaths per year, per 100,000 people. within six months was 57%.
From this same cohort we recruited 34 patients and their informal caregivers for the qualitative longitudinal studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies.. They completed questionnaires and participated in in-depth interviews at up to six weeks, six months and one-year post-stroke. These participants’ mean age was 75 years, 18 were being tube fed, 24 had aphasia, 20 had a urinary catheter and 18 had an informal caregiver at home.
In the serial interviews, we identified several major themes:
Patients and relatives faced death or a life not worth living and experienced immediate and persistent emotional distress. Those who survived expressed grief for a former life. Families reported that, despite the high riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of death, care was overly focused on physical recovery with little attention to emotional needs or preparation for death.
“If they had told us the magnitude of the stroke as far back as the first hospital visit we would have done things differently, rather than pushing for something that was never going to happen”.
StudyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. participantA person who takes part in a trial, often but not necessarily a patient. whose father died
Professionals focused on physical rehabilitation rather than preparing the patient and caregiver for death or limited recovery. Like patients they associated palliative care with doing less rather than more care and planning.
“We need her thinking it’s going to get better otherwise she won’t commit and then you won’t get the same outcomeOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’.”.
“suppose it depends what we mean by ‘palliative care’, but it’s, you know, no more needles and no more drips and no more antibiotics …”
Hospital doctor — first interview
For all involved, although there were frequently good discussions, constructive planning was challenging.
“I mean, they sit and explain everything to you, but you’re still coming away with nothing”
Interview extract from a caregiver
As major stroke brings likelihood of death but little preparation, we suggest:
- Rehabilitation should incorporate the principles of palliative care to address the emotional, social and spiritual – as well as the physical – needs of patients.
- As dying is a real riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. with patients with major stroke, a model of care planning balancing hoping for the best with preparing for the worst from admission is realistic. This is acceptable to patients and their carers based on these interviews.
- Many people with a severe stroke die within 6 months despite excellent and speedy medical care. Whilst we hope for a good recovery, relatives and patients also should be supported in preparing for the worst to help them to focus on quality of life. Their care should reflect the possibility of death and disability. They should have a plan A and also a plan B. This aspect of care should be considered in overall care for patients with stroke
- Practising the principles of palliative care is appropriate and indeed needed, but the term ‘palliative care’ should possibly be avoided or reframed. The term “palliative care” had connotations of treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. withdrawal and imminent death.
Jessica Simon of the University of Calgary in Alberta, Canada, author of a related editorial in the same journal, commented:
“Using a palliative care approach that attends to prevention and relief of suffering, whether physical, social or emotional, can help patients and those close to them as they grieve the losses that come with that stroke and can help them to keep living as well as they can, whether or not death ensues”
The value of qualitative studies
Policymakers and guideline developers need relevant and context-sensitive evidence to support innovations and interventions. We would like to emphasize the usefulness and the value of qualitative evidence regarding the experience of people with life-threatening conditions during their last year of life. This type of evidence is useful to assess the needs, values, perceptions and experiences of stakeholders, including policymakers, providers, communities and patients, and is thus crucial for complex health decision-making.
We would like to congratulate Cochrane on their increased interest in reviews of qualitative evidence. In this regard, the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach, which has been developed in order to support the use of qualitative evidence in decision-making, is a very valuable development. This approach is now used by WHO, allowing qualitative evidence to support recommendations.
Dr Marilyn Kendall is a Senior Research Fellow at Edinburgh University with much experience in qualitative methods and conducting high-impact research. She is a Social Scientist and teaches qualitative research at Edinburgh University.
One of the main challenges we face moving from evidence to improved care is to be able to make recommendations regarding the services and interventions that would optimally meet the specific needs of patients and their carers. Synthesis of qualitative studies has great potential to generate many useful insights in helping people with stroke and other life-threatening illnesses live and die well. Based on a qualitative analysis , we have produced a 3-minute video that gives a rationale for early palliative care for people with different conditions. We now plan to extend this to include people with major stroke.
Useful links from the Primary Palliative Care Research Group, University of Edinburgh:
- Kendall, M., et al., OutcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’., experiences and palliative care in major stroke: a multicentre, mixed-method, longitudinal studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. CMAJ, 2018. 5(190): p. E238-246
- Primary Palliative Care Research Group (PPCRG), Usher Institute, University of Edinburgh
- Primary Palliative Care Research Group (PPCRG) – Videos
References may be found here. Scott Murray’s profile may be found below.
Scott Murray and Marilyn Kendall have nothing to disclose.
Long-Term Survival of Young Stroke Patients: A Population-Based Study of Two Stroke Registries from Tartu, Estonia
The aim of this paper was to evaluate the long-term survival of young stroke patients in Estonia, analyse time trends of survival, and compare the results with other studies. We have used 2 population-based first-ever stroke registry data (1991–1993 and 2001–2003) to analyse the 1-, 5-, and 7-year outcome of young stroke patients by the Kaplan-Meier method of analysis. From the group of 1206 patients, 129 (11%) were aged under 55 years. The overall survival rate at 1, 5, and 7 years was 0.70 (95% CI 0.62–0.78), 0.63 (95% CI 0.55–0.72), and 0.61 (95% CI 0.53–0.70), respectively. The survival was significantly worse for patients with intracerebral haemorrhage ( ) and for those aged from 45 to 54 years compared to the younger age group from 0 to 44 years ( ). For patients with ischemic stroke, aged from 15 to 44 years, the 1-, 5-, and 7-year survival rate was 0.89 (95% CI 0.79–1.00), 0.75 (95% CI 0.61–0.93), and 0.75 (0.61–0.93), respectively. There was no difference in overall survival between the two studied periods. We report a low long-term survival rate among young stroke patients in Estonia. Increasing age and hemorrhagic stroke subtype were associated with lower survival. We have previously shown a worse outcome for 1-year survival compared to other studies and currently this trend continues for 5- and 7-year survival rates. In fact, these are the lowest survival rates for the combined and separate stroke subtypes reported so far.
A young patient with a stroke is always a challenge, even for a stroke physician. Although the outcome of a stroke in the young is believed to be better, it still has a significant impact on the person’s quality of life and moreover can be fatal. Data about long-term survival of young stroke patients are scarce and are usually collected retrospectively or are hospital-based . Most of these studies have included ischemic strokes and have reported a rather good prognosis but some of the studies were performed years ago when the diagnostic criteria for stroke differed considerably.
Stroke incidence is known to be higher in developing countries, and also in Eastern Europe, compared to the Western countries. In Estonia, the total first-ever stroke incidence is comparable to that of other European countries, but is higher for the younger age groups . The incidence declined by 2001–2003, but it was still 13 per 100 000 for the subjects aged 0 to 44 and 118 per 100 000 for subjects aged 45 to 54 years in Tartu, Estonia . In addition, the 1-year outcome of stroke in terms of functional deficit and survival has also been worse compared to the data from several other study centres .
The aim of this paper was to evaluate long-term survival of young stroke patients in Estonia, analyse changes in survival between 1991 to 2003, and compare the results with other studies.
Data from the two population-based stroke registries from Tartu, Estonia, were used. The first registry included all first-ever in a lifetime strokes from 1991 to 1993 (3 years) and the other registry included patients from 2001 to 2003 (2 years). These registries included both hospitalised and nonhospitalised cases and prospective “hot pursuit” case-finding methods were used to assure the inclusion of all stroke patients in the area. The more detailed description of methods used for data collection, definitions, and other criteria for these registries have been published earlier .
In this current study, patients aged <55 years at stroke onset were included in the analysis. The Estonian Population Register was used for obtaining survival data. The cut-off point for survival data was February 2001 for the first and January 2011 for the second registry for the evaluation of the 7-year outcome.
The study was approved by the Ethics Review Committee on Human Research of the University of Tartu.
2.1. Statistical Methods
Survival rate was estimated by the Kaplan-Meier method (1-, 5-, and 7-year survival rate). Survival distributions were compared using the log-rank test. values less than 0.05 were considered significant. The analysis was carried out by the statistical software package R.
A total of 1280 patients, (501 men and 779 women) with first-ever stroke, were registered during the 5-year study period, with 829 patients from 1991 to 1993 and 451 patients from 2001 to 2003. Patients with subarachnoid haemorrhage (64 patients) were excluded from this current analysis and additionally 10 patients were lost for the long-term followup. From the group of 1206 patients, 129 (11%) were <55 years of age (38% women and 62% men), and these were included in the survival analysis. The mean age of patients was 46.1 (±9.6) years (range 1 to 55 years). Of them, 91 (71%) had a brain infarction (BI), 26 (20%) an intracerebral haemorrhage (ICH), and 12 (9%) had an undefined type of stroke (UND). Only 3 patients were <15 years of age (2 of them with BI and one with ICH). Perinatal strokes were not included.
Table 1 Median survival rates by age group, stroke subtype, and gender.
As expected, the survival rate was worse for patients with ICH and for the older age group. There was no significant difference in overall survival rates between the two studied periods nor in young ischemic stroke survival between the two study periods .
The main finding of our study is the low long-term survival rate among young first-ever stroke patients. At the same time most previous reports agree that although the survival of young stroke patients is lower than in the general population, it is still comparatively high . Our previous study has shown a worse outcome for 1-year survival compared to other studies and currently this trend continues for 5- and 7-year survival rates. In fact, these are the lowest survival rates for combined and separate stroke subtypes reported so far. In our study increasing age (0–44 years versus 45–54 years) and hemorrhagic stroke subtype were associated with lower long-term survival. Earlier studies have also found an association between the male gender and higher mortality in young stroke patients . Although this trend can also be seen in our study, it did not reach statistical significance. The more recent study by Putaala et al. could also not identify this association. Quite surprisingly, the survival rate for women remained unchanged after 1 year.
The survival rates for young ischaemic stroke patients from several studies are summarized in Figure 1. The general annual survival rate follows the pattern of earlier studies being clearly lowest in the first year and significantly increases thereafter, but is constantly lower than other studies. The differences in survival rates across the studies could be associated with several aspects. The study type, inclusion criteria, follow-up period, and type of data analysis differ across studies. All, with the exception of three , have been hospital based and do not represent a defined population. Although the follow-up periods in these studies are variable, the trend of outcome is still obvious. The results of our study come from two prospective population-based registries. However, a limitation of our study is the small sample size.
Survival of young patients with ischaemic stroke in different studies .
The main factor for low survival may be severe stroke, and although there are no comparative data, we speculate that stroke cases are more severe in Estonia. This may be related to a higher prevalence of risk factors leading to a worse outcome. However, in 38% of cases no cardiovascular risk factors were identified despite extensive diagnostic tests. This points to the fact that there may be also other possible causes for higher stroke incidence and lower survival among young subjects in Estonia, for example, genetics, lifestyle, or environmental factors. However, these hypotheses are difficult to prove. And finally, the life expectancy in Estonia was 75.8 years in 2010, 70.6 years for men and 80.8 years for women. Although this rate has constantly grown during the past decade, it is still 3 to 4 years less for women and 5 to 7 years less for men, compared to that of most other European countries . Still, there was no significant difference in stroke survival between the two study periods.
Unfortunately, we were not able to identify the causes of death of young stroke patients because of the strict Estonian data protection legislation. The causes of death are confidential and coded linking between registries is not allowed. As the cardiovascular mortality and deaths, due to accidents and excess alcohol intake, are high in the young Estonian population (especially in men), a number of our young stroke patients might die due to other causes rather than from stroke.
Long-term survival rates of young stroke patients differ significantly across the world. The causes of high stroke incidence and low survival rates in Eastern Europe can be explained in some terms, but the proportion of stroke patients with no identifiable risk factors is high. Future studies and everyday clinical practice should focus on thorough detection of the etiology of stroke, promoting a healthy lifestyle, optimizing primary and secondary prevention strategies thus decreasing the incidence of stroke and achieving a better outcome for young stroke patients.
The study was supported by targeted financing from the Estonian Ministry of Education and Research (Grant no. SF0180064s07).