確認了年輕缺血性中風病患的死亡危險因子


  July 21, 2009 — 根據一項線上發表於7月9日中風期刊的芬蘭研究結果,酗酒、心臟衰竭、癌症、第一型糖尿病與中風前感染都與年輕中風病患死亡率增加有關。
  
  芬蘭赫爾辛基大學中央醫院的Jukka Putaala醫師與其同事們寫到,有關年輕病患發生缺血性中風後的死亡率與預後因子的數據相當缺乏,目前只有相對小型且病患差異大的研究。因為中風對年輕病患有潛在災難性的影響,臨床醫師在疾病初期儘可能提供病患正確的預後資訊相當重要。此外,有關長期預後與死亡率相關因子的資訊,將可協助最佳化次級預防措施。
  
  研究者們檢驗所有在1994年1月到2003年9月間,因為第一次中風到赫爾辛基中央醫院就診之15至49歲病患的數據,這些數據來自於芬蘭死亡註冊統計研究,且有生命圖表分析,以供確認死亡風險。臨床上不同亞群的存活率以Kaplan-Meier方法比較,而死亡率預測因子以Cox比例危險模式確認。以國家衛生研究院中風分數以及格拉斯哥昏迷指數評估中風嚴重度。
  
  研究樣本包括731位病患(其中62.8%為男性;平均年齡為41.5±7.4歲)。在後續追蹤中,78位病患過世,換算累計死亡風險在1個月時為2.7%(95%信賴區間[CI]為1.5%-3.9%),1年時為4.7%(95% CI為3.1%-6.3%),5年時為10.7%(95% CI為9.9%-11.5%)。男性與女性之間的死亡率並無差異,但是45歲以上病患的死亡率較高。
  
  30天時仍然存活的病患(共711位),最終死亡原因為中風者有21%、心臟主動脈與其他血管原因者有36%、癌症12%、感染9%。在校正年齡、性別、相關危險因子、中風嚴重度與中風亞型後,5年獨立預測死亡因子包括癌症(增加16倍風險)、心臟衰竭(7倍危險因子)、酗酒、中風前感染、第一型糖尿病、高齡、以及因為大血管粥狀動脈硬化引起的中風。
  
  這項研究的限制包括,回溯性收集起始相關資料、依賴自我通報有關危險因子的數據、整體死亡率低,使得根據血管死亡原因進行的次組分析可靠性降低;缺乏有關於使用藥物的數據、以及無法考慮到過去20年間中風治療的進步。
  
  研究作者們寫到,儘管年輕中風病患整體死亡率較低,許多可辨認的亞群病患長期死亡風險較高。對於預計生命周期較長的年輕病患而言,偵測這些因子是很重要的,因為對大部分病患來說,當需要時,他們可以透過生活型態改變、嚴格控制的藥物、或是侵入性介入,來降低這些因子所帶來的風險。
  
  赫爾辛基大學中央醫院贊助這項研究。研究作者們表示沒有相關資金上的往來。
  

Risk Factors Identified for Mortality After Ischemic Stroke in Young Adults

By Laurie Barclay, MD
Medscape Medical News

July 21, 2009 — Heavy drinking, heart failure, cancer, type 1 diabetes, and preceding infection are linked to increased mortality rates in young patients who have had a stroke, according to the results of a Finnish study reported in the July 9 Online First issue of Stroke.

"Data on mortality and its prognostic factors after an acute ischemic stroke in young adults are scarce and based on relatively small heterogeneous patient series," write Jukka Putaala, MD, from Helsinki University Central Hospital, Helsinki, Finland, and colleagues. "[Given] the potentially disastrous impact of a stroke in a young adult, it is important that the treating physician will be able to give as accurate prognostic information as possible early in the course of the disease. In addition, information on long-term outcome and factors associated with mortality help in optimizing secondary prevention strategies."

The investigators examined 5-year mortality data of all consecutive patients aged 15 to 49 years with first-ever ischemic stroke from January 1994 to September 2003 who presented to Helsinki University Central Hospital. Data from the mortality registry of Statistics Finland and life table analyses allowed determination of mortality risks. Survival rates between clinical subgroups were compared with use of the Kaplan-Meier method, and predictors of mortality were identified with the Cox proportional hazards model. The National Institutes of Health Stroke Scale and the Glasgow Coma Scale assessed stroke severity.

The study sample consisted of 731 patients (62.8% men; mean age, 41.5 ± 7.4 years). During follow-up, 78 patients died, yielding cumulative mortality risks of 2.7% (95% confidence interval [CI], 1.5% - 3.9%) at 1 month, 4.7% (95% CI, 3.1% - 6.3%) at 1 year, and 10.7% (95% CI, 9.9% - 11.5%) at 5 years. Mortality rates were not different for men vs women, but they were higher for those at least 45 years old.

Ultimate cause of death among those still alive at 30 days (n = 711) was stroke in 21%, cardioaortic and other vascular causes in 36%, cancer in 12%, and infections in 9% of deaths. After adjustment for age, sex, pertinent risk factors, stroke severity, and etiologic subtype of stroke, independent predictors of 5-year mortality were active cancer (16-fold risk), heart failure (7-fold risk), heavy drinking, preceding infection, type 1 diabetes, increasing age, and index stroke caused by large-artery atherosclerosis.

Limitations of this study include retrospective collection of baseline data; reliance on self-report for data regarding risk factors; overall low mortality rates, preventing reliable subgroup analyses on deaths from vascular causes; lack of data regarding medication use; and inability to consider advances in stroke therapy during the last 2 decades.

"Despite the overall low mortality after an ischemic stroke in young adults, several recognizable subgroups had substantially increased risk of death in the long term," the study authors write. "Regarding young adults with a long expected lifespan ahead, detecting these factors [is] important, because in most patients, they can be modified by lifestyle changes, strictly controlled medication, or invasive interventions, when indicated."

The Helsinki University Central Hospital supported this study. The study authors have disclosed no relevant financial relationships.

Stroke. Published online July 9, 2009.

    
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