Younger stroke survivors have a significantly greater risk of dying prematurely, especially from vascular problems, according to what is believed to be the largest population-based study to date focused exclusively on mortality and stroke in individuals under age 50.
Researchers in the Netherlands found that individuals who suffered a stroke between the ages of 18 and 50 years had significantly poorer 20-year survival when compared with the general population in the Netherlands, with death rates more than twice as high as expected. After surviving the first year, patient death rates trended upward, with elevated risk continuing for several decades.
The results of the Follow-Up of Transient Ischemic Attack and Stroke Patients and Unelucidated Risk Factor Evaluation (FUTURE) study were published in the Mar. 20 issue of the Journal of the American Medical Association (JAMA).
The researchers studied 20-year mortality in nearly 1,000 patients under age 50 who suffered an ischemic stroke, hemorrhagic stroke, or transient ischemic attack (TIA). They then calculated life expectancy based on the population as a whole. Cause of death records showed that most patients succumbed to vascular disease, according to authors Loes C. A. Rutten-Jacobs, MSc, and Frank-Erik de Leeuw, MD, PhD, in the department of neurology at the Radboud University Nijmegen Medical Centre in Nijmegen, the Netherlands.
The researchers found that the cumulative 20-year mortality risk was 24.9 percent for patients with TIA; 26.8 percent for patients with ischemic stroke; and 13.7 percent for patients with hemorrhagic stroke. Analysis of the data indicated that after surviving the first 30 days after ischemic stroke, the cumulative mortality tracked higher than expected, based on nationwide mortality data.
“Stroke is no longer considered a disease of old age,” according to Rutten-Jacobs, the PhD student who co-authored the paper. “In the 20 years following stroke, younger patients had almost four times higher risk of death.”
The proportion of all strokes among people under 50 is now 10 percent and is increasing, she told Neurology Today, yet only limited data exist on long-term prognosis. “However, long-term prognosis is particularly important in this age group given that they have a long life expectancy during a demanding time of life, when they are beginning their families and building a career.”
The prognosis for younger stroke patients has generally been considered benign, she added, given that short-term mortality is lower when compared with older patients. “But these older patients have a much higher a priori mortality rate, simply because of their age.”
Although data are lacking, the observation of long-term increased risk for vascular disease could have important implications for the implementation of secondary prevention — both medical and lifestyle — treatment strategies. “Future studies should address the role of this stringent implementation in these patients with young stroke,” she said.
Half of the premature deaths resulted from underlying vascular problems, with cardiac events most prevalent, at 26.2 percent, followed by ischemic stroke (13.8 percent); intracranial hemorrhage (5.5 percent); other vascular causes (6.2 percent); malignancies (23.4 percent); and infections and other causes (24.8 percent).
“This suggests that the underlying disease that causes stroke at relatively young age continues to put these patients at an increased risk for vascular disease throughout their lives,” said Dr. de Leeuw.
“This mortality remained at this higher level even in the second and third decade after young stroke. In patients who survived the first 30 days after an intracerebral hemorrhage, mortality gradually coincided with that expected.”
The cumulative 20-year mortality for ischemic stroke among 30-day survivors was higher in men than in women (33.7 percent vs. 19.8 percent).
In an accompanying editorial, Graeme J. Hankey, MD, clinical professor of neurology at the University of Western Australia in Perth, said researchers should start looking beyond acute stroke treatment in younger patients and begin investigating “the effectiveness, safety, and cost of interventions” to prevent recurrent cardiovascular events.
“The study by Rutten-Jacobs et al indicates that secondary prevention after stroke in young adults is a long-term, and probably lifelong, endeavor,” he wrote. “Presumably the excess mortality… stems from the cardiovascular disease or lesion underlying the index ischemic brain event remaining active, having not been diagnosed accurately and managed successfully.”
He also called for more research on lifestyle factors that appear to increase stroke risk in younger individuals, especially smoking and drug abuse.
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