Dissertation > Medicine, health > Neurology and psychiatry > Neurology > Cerebrovascular disease

The Clinical Characteristics and Prognosis of Ischemic Cerebrovascular Disease Patients with Atrial Fibrillation

Author LiZuoYa
Tutor WangYongJun
School Capital University of Medical Sciences
Course Neurology
Keywords Ischemic cerebrovascular disease Atrial fibrillation Prognosis Anticoagulant treatmentsischemic stroke atrial fibrillation rick stratification risk factorsatrial fibrillation ischemic stroke risk stratification Antithrombotictherapy clinical prediction
CLC R743
Type PhD thesis
Year 2013
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Background Ischemic stroke is a kind of clinical syndrome with strong heterogeneity,and different etiology results in different prognosis such as stroke recurrence, deathand disability. This study was to explore the clinical characteristics and prognosis ofischemic stroke and TIA patients with atrial fibrillation (AF) in China.Methods Selecting hospitalized patients with ischemic Stroke or TIA from CNSR(The China National Stroke Registry, CNSR) as the study population for this research.The China National Stroke Registry is a nationwide, prospective, observationalregistration including132secondary and tertiary hospitals. It has enrolled multicenterhospitalized patients with acute cerebrovascular disease, collecting patients’ basicdata such as demographic information, clinical characteristics and drug information.The longest follow-up is1year. Prognostic outcome includes stroke recurrence, deathand vascular events. The chi-square test was used to compare the baseline data andoutcomes between ischemic stroke and TIA patients with or without AF, P <0.01asthe significant difference.Results Comparing clinical characteristics and prognosis between ischemic stroke andTIA patients with or without AF in China, we could find patients with AF are older(71.24±11.74vs.64.49±12.14, P <0.01), with higher proportion of women (54.5%vs.36.3%, P <0.01) and more severe neurologic deficits (NIHSS score: median10vs.4,P <0.01). On the aspect of complications, the prevalence rates of congestive heartfailure (10.3%vs.0.8%, P <0.01), coronary heart disease (32.4%vs.11.9%, P <0.01)and peripheral arterial disease (1.6%vs.0.5%, P <0.01) were higher in patients withAF. On the aspect of the use of medical resources, the average length of hospital stay(15vs.14, P<0.01) and hospitalization cost (10309.57vs.8055.65, P<0.01) ofpatients with AF was much higher than patients without AF.On the aspect of anticoagulant drugs, the patients with AF’s usage of warfarin was10.3%at discharge.Compared with11.9%at the time of3months’ follow-up,6months’ follow-upremained at11.8%and at1year follow-up was9.1%.65.9%of Ischemic stroke orTIA patients have antiplatelet drugs overall. The utilization rate of antiplatelet drug atthe time of one year follow-up was at64%. Compared to clopidogrel, aspirin is morecommonly used (55.2%vs7.6%, P <0.01), the rate of dual antiplatelet therapy was3%. The prognosis of ischemic stroke and TIA patients with or without atrialfibrillation AF in China are obvious different. The hospital mortality rates of ischemicstroke or TIA patients with AF was as4.7times as that in patients without AF (12.3%vs.2.6%), and the stroke recurrence rate in hospital of AF patients was2.2time asthat in patients without AF (6.6%vs.2.9%, P<0.01). At the3months follow-up, therates of stroke recurrence, disability and mortality of patients with AF were higherthan patients without AF (the rate of stroke recurrence23.3%vs.10.0%, P<0.01;mortality23.5%vs.5.8%, P<0.01; the rate of disability43.6%vs.23.6%, P<0.01).6months and1year follow-up showed the the rates of stroke recurrence, disability andmortality of patients with AF were higher than patients without AF (P<0.01).Conclusions In China, ischemic stroke and TIA patients with AF are older, morefemale predominance, more severe neurologic deficits, longer hospital stays, higherhospitalization costs and lower utilization ratio of warfarin than patients without AF.The prognosis in patients with AF is poor, about a third patients died after one year,and more than half of the patients suffered disabilities. The advanced age and lowproportion of anticoagulant drugs use might contribute to the poor outcome of AFpatients. Background Prognosis assessment on the early stage is helpful to make morereasonable decisions of medical treatment. The risk of death is higher for ischemicstroke patients with atrial fibrillation (AF). The aim of the study is to assess the valueof the predictive models in Chinese ischemic stroke patients with AF and to givebetter instruction of medical decisions.Methods Patients with ischemic Stroke selected from CNSR (The China NationalStroke Registry, CNSR) were divided into AF group and non-AF group.Demographic information, clinical characteristics and drug information werecollected. One year stroke recurrence and death were the main outcome measures.Using chi-square test compared the baseline data for patients with ischemic strokewith or without AF, with P <0.05as the significant difference. Calculated IScorescores, PLAN scores and ASTRAL scores. The C statistic was used to assess thevalue of prediction for the three risk scores in different groups.Results12415ischemic stroke patients were selected from22216acutecerebrovascular disease patients who were enrolled in the CNSR study. The ischemicstroke patients were composed of10847(87.37%)non-AF patients and1568(12.63%)AF patients. The ischemic patients’1year mortality was13.4%, while mortality ofpatients with AF was34.6%and patients without AF was10.3%. The C statistic ofIScore score was0.820for ischemic stroke patients,0.800for patients without AF and0.784for patients with AF. The C statistic of PLAN score was0.806for ischemicstroke patients,0.780for patients without AF and0.769for patients with AF. The Cstatistic of ASTRAL score was0.823for ischemic stroke patients,0.798for patientswithout AF and0.793for patients with AF. IScore score distinguished44.26%low-risk patients with the1mortality of3.4%. PLAN score distinguished8.96% low-risk patients with the1mortality of2.5%. ASTRAL score distinguished17.17%low-risk patients with the1mortality of2.9%.Conclusions IScore score, PLAN score and ASTRAL score could preliminary stratifyischemic stroke patients based on the risk of1year death. The event rates increasedwith the increase of score. IScore score, PLAN score and ASTRAL score performedwell in1year prediction of death. The validation of all risk scores in patients withoutAF was higher than in patients with AF. PLAN score is superior to IScore score andASTRAL score for distinguishing the low-risk patients. Background Great efforts have been directed toward risk stratification to identifypatients with atrial fibrillation at highest risk. We investigated if CHADS2andCHA2DS2-VASc scores, which are associated with stroke risk in patients withnon-valvular atrial fibrillation (NVAF), could be used to predict one year prognosis instroke recurrence, mortality and disability of ischemic stroke or transient ischemicattack (TIA) patients with NVAF for secondary prevention of stroke.Methods Ischemic stroke or transient ischemic attack (TIA) patients with NVAF wereselected from The China National Stroke Registry (CNSR). One year strokerecurrence, death and dependence were the main outcome measures.The C statisticwas calculated to assess Clinical prediction of the CHADS2and CHA2DS2-VAScscores. Univariate and multivariate logistic regressions were performed to analyze therelevant risk factors. Based on the results of the logistic regressions, modified thestratified scores and testing the new stratified scores by using C statistic.Results1297patients with NVAF were selected from22216acute cerebrovasculardisease patients who were enrolled in the CNSR study. All selected patients werecompleted1year follow-up. For stroke recurrence rate, the C statistic value was0.53(odds ratio [OR]1.15,95%confidence interval [CI]:1.01to1.32) for CHADS2and0.55(OR1.14,95%CI:1.05to1.24) for CHA2DS2-VASc.For all-cause mortality,theC statistic value was0.525(OR1.122,95%CI:0.987to1.276) for CHADS2,and0.574(OR1.201,95%CI:1.105to1.305) for CHA2DS2-VASc. For disability rate,the C statistic value was0.542(OR1.195,95%CI:1.023to1.397), and0.593(OR1.276,95%CI:1.156to1.409)for these two scores respectively.The multivariatelogistic-regression analysisdemonstrated thatolder age (≥75years) and a higher NIHSS score(≥15) were associated with ahigher risk for one-year strokerecurrencewith the adjusted odds ratio of1.659(95%CI:1.144to2.405) and1.886(95%CI:1.341to2.653) after controlling other confounders. These two risk factorswere also associated with the all-cause death (OR2.167,95%CI:1.417to3.317forage≥75years; OR7.916,95%CI:5.435to11.529for the NIHSS score≥15) anddisability (OR2.322,95%CI:1.500to3.594for age≥75years; OR14.829,95%CI:7.762to28.330for the NIHSS score≥15).After adding NIHSS into the riskstratification scores, the C statistic values of CHADS2N and CHA2DS2-VAScNwere0.578(OR1.250,95%CI:1.137to1.374) and0.580(OR1.185,95%CI:1.105to1.272) for stroke recurrence rate,0.691(OR1.183,95%CI:1.635to2.010) and0.689(OR1.528,95%CI:1.023to1.397)for all-cause mortality, and0.668(OR1.184295%CI:1.603to2.116) and0.681(OR1.579,95%CI:1.430to1.743) for disability rate,respectively.`Conclusions Both CHADS2and CHA2DS2-VASc scores have limitations inpredicting the one-year prognosis ofstroke/TIA patients with NVAF in china. NIHSSscore, as the independent risk factor of poor outcomes, was added to these twostratified scores in order to improve the predictive value of stratified scores, while didnot increase the difficulty of the standards of scoring.

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