(Stroke. 1997;28:762-767.)
© 1997 American Heart Association, Inc.
Articles |
Ischemic Stroke After Acute Myocardial Infarction
A Population-Based Study
From the Department of Internal Medicine, Norrland University Hospital, Umeå, Sweden.
Correspondence to Thomas Mooe, MD, Department of Internal Medicine, Norrland University Hospital, S-901 85 Umeå, Sweden. E-mail thomas.mooe{at}medicin.umu.se
 |
Abstract |
|---|
 Top Abstract IntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Background and Purpose Modern treatment may have influenced the risk of stroke after myocardial infarction (MI). The purpose of this study was to examine the incidence of ischemic stroke during the first month after an acute MI in an unselected population, to identify predictors of MI-related stroke, and to investigate the secular trend in MI-related stroke incidence.
Methods In this case-control study, from a population of approximately 310 000 25- to 74-year-old inhabitants, case subjects with a stroke within 1 month after an MI were prospectively recorded in the population-based Northern Sweden MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) study from 1985 to 1994. The same number of control subjects with an MI but without a stroke were matched for age, sex, and year when MI occurred.
Results One hundred twenty-four case subjects were recorded. Fifty-one percent (63/124) of the strokes occurred within 5 days after onset of MI. The odds ratios (ORs) of an MI-related stroke were for a history of hypertension 1.7 (95% confidence interval [CI], 1.0 to 3.2), previous stroke 2.4 (CI, 1.0 to 6.1), chronic atrial fibrillation 3.0 (CI, 1.1 to 9.2), onset of atrial fibrillation during the hospital stay 3.5 (CI, 1.4 to 10.1), ST-segment elevation 2.4 (CI, 1.4 to 4.6), and anterior infarction 1.5 (CI, 0.9 to 2.6). In a conditional multiple logistic regression model, previous stroke (OR, 2.8; CI, 1.1 to 7.6), chronic atrial fibrillation (OR, 3.8; CI, 1.3 to 11.0), new-onset atrial fibrillation (OR, 4.6; CI, 1.6 to 12.8), and ST-segment elevation (OR, 3.4; CI, 1.6 to 7.4) were independent predictors of stroke. MIs preceding stroke were larger and in 51% were located anteriorly. There was a decrease in the incidence and event rate of MI-related stroke during the study period (P<.01 and P<.05, respectively).
Conclusions The risk of stroke is highest the first 5 days after MI. Only approximately half of the strokes occurring the first month after an MI are preceded by an anterior MI. The most important predictors of MI-related stroke are atrial fibrillation (chronic or new onset), ST elevation, and a history of a previous stroke. There is a long-term trend toward a lower incidence of MI-related stroke. These findings have important implications concerning both the pathophysiology and prevention of MI-related stroke.
Key Words: case-control studies • cerebral ischemia • myocardial infarction • risk factors
|
Introduction |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Ischemic strokes are commonly defined as "cardioembolic" if there is a coexisting potential cardiac embolic source.1 Intracardiac thrombi associated with atrial fibrillation or MI are considered important embolic sources.2 The vast majority of left ventricular thrombi develop in anteriorly located MIs,3 and preventive efforts with anticoagulants have therefore focused on patients with anterior infarctions.4 However, the mechanisms behind strokes related to MI are not clearly identified.5 6 The importance of anterior location of the infarction (and therefore a left ventricular thrombus) as a risk factor for stroke has recently been disputed.5 Moreover, the routine use of thrombolytic therapy and aspirin for acute MI has not changed the incidence of left ventricular thrombi but may have influenced the risk for embolism.7 8
The aims of the present study were to examine the secular trend in the incidence of ischemic stroke the first month after acute MI in an unselected population, to study the time relationship between MI and stroke, to identify risk factors for MI-related stroke, and to study the long-term prognosis.
|
Subjects and Methods |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
The two northernmost counties in Sweden constitute one of the centers in the WHO MONICA Project. In this population-based study, all stroke events occurring in the age range of 25 to 74 years have been prospectively recorded since 1985 with a specific code given to patients with an MI within 28 days before the stroke. The area has a population of approximately 510 000 inhabitants, of whom 310 000 are between 25 and 74 years old. The registry has been validated, and routine case-finding procedures identify 96% of all stroke events in the target population.9 Home care of suspected or definite MI is not practiced in Sweden.
The WHO definition of stroke was used: rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death) with no apparent cause other than a vascular origin.10 The inclusion period was between January 1, 1985, and December 31, 1994. Seven subjects with a hemorrhagic stroke diagnosed by CT, all occurring after thrombolytic therapy, were excluded from the study.
A diagnosis of MI was based on either autopsy findings or typical chest
pain, electrocardiographic findings, and a diagnostic
elevation of cardiac enzymes. Two of three of the clinical criteria
were required. An anterior MI was defined as either the development of
pathological Q waves in two or more precordial leads or an
ST-segment elevation 
0.15 mV in two or more of leads V1 through V3 or
0.1 mV in two or more of leads V4 through V6.
An ST-segment elevation 0.15 mV in two or more of leads V1 through V3
or 0.1 mV in two or more of leads V4 through V6 or the extremity
leads was evaluated as a predictor of stroke.
Patients with a diagnosis of MI but without a complicating stroke during the first month were used as control subjects. Each case subject was matched to one control subject for age, sex, and year of MI onset.
All information of the case patients and control subjects was obtained from medical records, registry data, and death certificates.
Incidence and event rate were used to describe the occurrence of stroke within 1 month after MI. Event rate was defined as the rate of stroke in a group of patients with MI. The yearly number of patients younger than 75 years with an MI was achieved from hospital statistics and used for calculation of MI-related stroke event rate. Incidence was defined as the number of MI-related strokes per 100 000 25- to 74-year-old inhabitants per year.
Mortality follow-up was made until December 31, 1995, one year after the end of inclusion.
Statistical Analysis
Data were analyzed with the STATISTICA 4.0 software
modules (StatSoft Inc). Group data are expressed as mean±SD for
continuous variables and as rates for variables on a nominal
scale. Differences between two means were assessed with the
t test for unpaired data or the Mann-Whitney U
test when appropriate. Differences between proportions were
analyzed with the 
2 test. Differences in
stroke event rate associated with age and year of onset, respectively,
were assessed by linear regression. A difference in stroke incidence
associated with year of onset was also assessed by linear regression.
The null hypothesis was rejected for values of P<.05.
The risk of MI-related stroke associated with different clinical characteristics is given by OR with 95% CI for a matched case-control study.11 Conditional multiple logistic regression (Stata 4.0, Stata Corp) was used to identify independent predictors of MI-related stroke. Variables associated with a risk for MI-related stroke in univariate analysis or considered to be of potential clinical interest were included in the model. Kaplan-Meier survival curves were calculated for patients with and without MI-related stroke and compared between groups with the log-rank test. The Cox proportional hazards model was used to identify predictors of death.
|
Results |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
One hundred twenty-four case subjects with a stroke within 28 days after an acute MI were identified from January 1, 1985, to December 31, 1994. A CT (n=73), autopsy (n=10), or lumbar puncture (n=4) was performed in 83 of 124 patients (67%), excluding hemorrhage. Seventy of the 73 CT scans were done within 14 days of the stroke. Of the remaining 41 patients, 7 were treated with thrombolytics. In this group of 7 patients, the strokes occurred at 2 to 27 (median, 10) days after MI onset. Clinically defined lacunar strokes were present in 6 patients.12
During the 10-year period, 11 620 patients younger than 75 years had
an MI, resulting in an overall event rate of ischemic
MI-related stroke of 1.07%. The event rate in women was 1.05% and in
men 1.08%. Seventy-eight strokes occurred during the first 5 years
compared with 46 during the later 5 years. The annual stroke event rate
and the incidence of MI-related ischemic stroke decreased
during the study period (P<.05 and P<.01,
respectively) (Figs 1
and 2).
|
|
Fig 3 shows the time relationship between MI and onset
of stroke. Fifty-one percent of the strokes occurred within 5 days
after first appearance of MI symptoms.
|
Clinical characteristics, medical treatment at admission, and clinical
findings during the hospital stay of the case and control subjects are
compared in Tables 1 and 2. Patients with
an MI-related stroke more often had a history of hypertension, previous
stroke, and chronic atrial fibrillation. The medication at admission
was similar. ST-segment elevation, onset of atrial fibrillation after
the debut of MI, and pulmonary congestion on the chest
radiogram were more common in patients with MI-related stroke. These
patients also had more extensive infarctions according to cardiac
enzyme levels. Anterior location of the infarction tended to be
marginally more common in patients with stroke (51% versus 40%;
P=.08).
|
|
Autopsy or echocardiography was performed in 37 of 124 patients (30%) with a stroke and in 35 of 124 patients (28%) without a stroke. A left ventricular thrombus was found in 7 of 37 (19%) versus 2 of 35 (6%) (P=.09).
The risk of MI-related stroke calculated as matched ORs for
hypertension, previous stroke, chronic atrial fibrillation, new-onset
atrial fibrillation, ST-segment elevation, and anterior location of MI
is shown in Table 3. In a conditional multiple logistic
regression model (P<.001), a previous stroke (OR, 2.8; 95%
CI, 1.1 to 7.6), chronic atrial fibrillation (OR, 3.8; 95% CI, 1.3 to
11.0), new-onset atrial fibrillation (OR, 4.6; 95% CI, 1.6 to 12.8),
and ST-segment elevation (OR, 3.4; 95% CI, 1.6 to 7.4) were
independent predictors of stroke, whereas hypertension, anterior
location of the MI, previous MI, and signs of heart failure were
not.
|
The MI-related stroke event rate increased by age (P<.05)
(Fig 4). No stroke occurred before the age of 40 years.
A marked increase in stroke event rate was observed in patients 65
years or older.
|
Fig 5 shows the long-term survival in case and
control subjects (P<.0001). Patients with a stroke after MI
had a 75% cumulative survival at 28 days and a 54% cumulative
survival at 1 year. The corresponding figures for patients without a
stroke were 85% and 77%. In a Cox regression model including age,
sex, post-MI stroke, and the clinical variables in Table 3
, only
occurrence of stroke was independently predictive of death.
|
|
Discussion |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
Stroke after an acute MI is an infrequent but important clinical problem. The incidence of MI-related stroke has been estimated in several studies both before and after the introduction of aspirin and thrombolytics as standard therapy. In early studies examining the effect of warfarin in acute MI, stroke occurred in 2.3% to 3.8% of the untreated patients.13 14 15 16 In observational studies from coronary care units in the 1970s and 1980s, the stroke event rate was 0.9% to 1.9%.6 17 18 19 In the large thrombolysis trials, the event rate of stroke in the placebo groups was 0.8% to 1.1%.20 21 22 A possible decrease in the event rate of stroke after MI has been suggested but is difficult to substantiate because of divergences in patient inclusion, exclusion of high-risk patients, dissimilar diagnostic criteria, and varying follow-up times in different studies.23 The present study was population based; it included a large number of unselected patients and covered a time period of 10 years. The same diagnostic criteria were used during the entire study period, and every recorded stroke was evaluated for a possible relationship to an MI. Our results support a declining trend in the incidence and event rate of MI-related ischemic stroke. There is no declining trend in overall stroke incidence in the present population.24
The lower event rate during the last years of the study period, approximately 0.8%, may have several explanations. The general care of patients with acute MI has gradually changed with early mobilization and routine use of thrombolytics and aspirin. Aspirin has shown an impressive reduction (42%) of post-MI stroke in a large randomized study.21
After adjustment for other clinical variables, atrial fibrillation
(chronic or new onset), previous stroke, and ST-segment elevation were
identified as independent predictors of stroke in the present
study. Older age was also associated with a higher event rate of stroke
(Fig 4). Our results agree favorably with previous
findings.19
The mortality is very high if an MI is complicated by a stroke. The
increased mortality is most obvious the first few months after the
infarction (Fig 5).
Preventive measures are often considered when a patient presents with an anterior infarction, particularly if a left ventricular thrombus is discovered.25 However, the mechanisms behind MI-related stroke remain largely unresolved. In particular, our data show that anterior location of the infarction is not an important predictor of stroke. This is in agreement with results from multivariate analyses in previous large studies.19 22 An anterior infarction precedes approximately 50% of MI-related strokes. A left ventricular thrombus develops in 30% to 40% of anterior infarctions but in only 1.5% to 3% in nonanterior infarctions.3 7 26 Moreover, only 19% (7/37) of patients with a stroke undergoing autopsy or echocardiography in the present study had a ventricular thrombus. Consequently, embolization from a left ventricular thrombus can explain only a lesser fraction of MI-related strokes. Hemodynamic changes, atherosclerosis in cerebral vessels, the inflammatory response to infarction, and hemostatic abnormalities27 28 may be other factors predisposing to ischemic stroke.
A limitation of the present study is that a pathological stroke diagnosis is lacking in 33% of the patients. CT was not a routine procedure in all hospitals at the beginning of this study. This means that some hemorrhagic strokes may have been misclassified as ischemic. However, without thrombolytic treatment an intracranial hemorrhage after MI is very infrequent. In the two largest placebo-controlled trials of thrombolytic treatment after MI, no hemorrhagic strokes were found in the placebo groups.21 22 Moreover, a hemorrhagic stroke after administration of thrombolytics usually occurs within 24 hours,21 22 29 but the strokes in the 7 patients given thrombolytic therapy in the present study all occurred after 48 hours (median, 10 days). Another limitation is that echocardiography or autopsy was undertaken in only approximately 30% of the patients. However, the number of examined patients (n=72) seems sufficient to confirm that the proportion of patients with a ventricular thrombus was relatively low.
We conclude that the incidence of ischemic post-MI stroke
has decreased during the recent decade, and this is possibly related to
changes in treatment, including the routine use of
thrombolytics and aspirin. Although several independent
risk factors for MI-related stroke can be identified, the precise
mechanism of stroke remains uncertain in most cases. The majority of
strokes occur early (Fig 36 ), which is important if
preventive treatment is considered. However, if anticoagulant treatment
is started, aspirin is usually withdrawn despite its well-documented
stroke-preventive effect. Moreover, a large proportion of strokes in
patients with a verified left ventricular thrombus occur
despite administration of anticoagulants,30 and the risk
of serious bleeding must also be considered if anticoagulants are
used.8 31 Because of the low stroke event rate, any
prophylactic intervention must have few side effects, and
if other indications for anticoagulants (eg, chronic atrial
fibrillation) are lacking, aspirin seems to be a reasonable alternative
to anticoagulants in anteriorly located infarctions as well.
|
Selected Abbreviations and Acronyms |
|---|
|
|
Acknowledgments |
|---|
This study was supported by grants from the Medical Faculty, Umeå University; the Joint Committee of the Northern Swedish Health Care Region; the Swedish Public Health Institute; and the Västerbotten County Council.
Received November 4, 1996; revision received January 14, 1997; accepted January 16, 1997.
|
References |
|---|
|
TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
|---|
1. Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neurol. 1986;43:71-84.
2. Lindgren A, Roijer A, Norrving B, Wallin L, Eskilsson J, Johansson BB. Carotid artery and heart disease in subtypes of cerebral infarction. Stroke. 1994;25:2356-2362. [Abstract]
3. Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction: long-term follow-up with serial echocardiography. Ann Intern Med. 1984;100:789-794.
4. Turpie AG, Robinson JG, Doyle DJ, Mulji AS, Mishkel GJ, Sealey BJ, Cairns JA, Skingley L, Hirsh J, Gent M. Comparison of high-dose with low-dose subcutaneous heparin to prevent left ventricular mural thrombosis in patients with acute transmural anterior myocardial infarction. N Engl J Med. 1989;320:352-357. [Abstract]
5. Bodenheimer MM, Sauer D, Shareef B, Brown MW, Fleiss JL, Moss AJ. Relation between myocardial infarct location and stroke. J Am Coll Cardiol. 1994;24:61-66. [Abstract]
6. Puletti M, Morocutti C, Tronca M, Fattapposta F, Borgia C, Curione M, Cusmano E. Cerebrovascular accidents in acute myocardial infarction. Ital J Neurol Sci. 1987;8:245-248. [Medline] [Order article via Infotrieve]
7. Mooe T, Teien D, Karp K, Eriksson P. Left ventricular thrombosis after anterior myocardial infarction with and without thrombolytic treatment. J Intern Med. 1995;237:563-569. [Medline] [Order article via Infotrieve]
8.
Mooe T, Teien D, Karp K, Eriksson P. Long-term
follow-up of patients with anterior myocardial infarction complicated
by left ventricular thrombus in the
thrombolytic era. Heart. 1996;75:252-256.
9. Stegmayr B, Asplund K. Measuring stroke in the population: quality of routine statistics in comparison with a population-based stroke registry. Neuroepidemiology. 1992;11:204-213. [Medline] [Order article via Infotrieve]
10. WHO MONICA Project Principle Investigators (prepared by Tunstall-Pedoe H). The World Health Organization MONICA Project (Monitoring of Trends and Determinants in Cardiovascular Disease): a major international collaboration. J Clin Epidemiol. 1988;41:105-114. [Medline] [Order article via Infotrieve]
11. Gardner MJ, Altman DG. Statistics with confidence. Br Med J. 1989:57-58.
12. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet. 1991;337:1521-1526. [Medline] [Order article via Infotrieve]
13.
Wright IS, Marple CD, Beck DF. Anticoagulant
therapy of coronary thrombosis with myocardial
infarction. JAMA. 1948;138:1074-1079.
14. Assessment of short-anticoagulant administration after cardiac infarction: report of the Working Party on Anticoagulant Therapy in Coronary Thrombosis to the Medical Research Council. Br Med J. 1969;1:335-342.
15.
Drapkin A, Merskey C. Anticoagulant therapy
after acute myocardial infarction: relation of therapeutic benefit to
patient's age, sex, and severity of infarction.
JAMA. 1972;222:541-548.
16.
Anticoagulants in acute myocardial infarction: results
of a cooperative clinical trial. JAMA. 1973;225:724-729.
17. Thompson PL, Robinson JS. Stroke after acute myocardial infarction: relation to infarct size. Br Med J. 1978;2:457-459.
18.
Komrad MS, Coffey CE, Coffey KS, McKinnis R, Massey EW,
Califf RM. Myocardial infarction and stroke.
Neurology. 1984;34:1403-1409.
19. Behar S, Tanne D, Abinader E, Agmon J, Barzilai J, Friedman Y, Kaplinsky E, Kauli N, Kishon Y, Palant A, Peled B, Reisin L, Schlesinger Z, Zahavi I, Zion M, Goldbourt U, for the SPRINT Study Group. Cerebrovascular accident complicating acute myocardial infarction: incidence, clinical significance and short- and long-term mortality rates. Am J Med. 1991;91:45-50. [Medline] [Order article via Infotrieve]
20. Wilcox RG, von-der-Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET). Lancet. 1988;2:525-530. [Medline] [Order article via Infotrieve]
21. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2. Lancet. 1988;2:349-360. [Medline] [Order article via Infotrieve]
22. Maggioni AP, Franzosi MG, Farina ML, Santoro E, Celani MG, Ricci S, Tognoni G. Cerebrovascular events after myocardial infarction: analysis of the GISSI trial: Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI). Br Med J. 1991;302:1428-1431.
23.
Vaitkus PT, Berlin JA, Schwartz JS, Barnathan
ES. Stroke complicating acute myocardial infarction: a
meta-analysis of risk modification by anticoagulation and
thrombolytic therapy. Arch Intern
Med. 1992;152:2020-2024.
24. Stegmayr B, Asplund K. Exploring the declining case fatality in acute stroke: population-based observations in the Northern Sweden MONICA Project. J Intern Med. 1996;240:143-149. [Medline] [Order article via Infotrieve]
25. Gunnar RM, Passamani ER, Bourdillon PD, Pitt B, Dixon DW, Rapaport E, Fuster V, Reeves TJ, Karp RB, Russell RO, Kennedy JW, Sobel BE, Klocke FJ, Winters WL, Fisch C, Beller GA, DeSanctis RW, Dodge HT, Weinberg SL. Guidelines for the early management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Develop Guidelines for the Early Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol. 1990;16:249-292. [Medline] [Order article via Infotrieve]
26.
Visser CA, Kan G, Meltzer RS, Lie KI, Durrer D.
Long-term follow-up of left ventricular thrombus after
acute myocardial infarction: a two-dimensional
echocardiographic study in 96 patients.
Chest. 1984;86:532-536.
27. Fulton RM, Duckett K. Plasma-fibrinogen and thromboemboli after myocardial infarction. Lancet. 1976;2:1161-1164. [Medline] [Order article via Infotrieve]
28.
Gustafsson C, Blombäck M, Britton M, Hamsten A,
Svensson J. Coagulation factors and the increased risk of stroke
in nonvalvular atrial fibrillation. Stroke. 1990;21:47-51.
29.
Gore JM, Granger CB, Simoons ML, Sloan MA, Weaver WD,
White HD, Barbash GI, Van de Werf F, Aylward PE, Topol EJ, Califf
RM. Stroke after thrombolysis: mortality and
functional outcomes in the GUSTO-I trial: global use of strategies to
open occluded coronary arteries.
Circulation. 1995;92:2811-2818.
30.
Johannessen KA, Nordrehaug JE, von-der-Lippe G, Vollset
SE. Risk factors for embolisation in patients with left
ventricular thrombi and acute myocardial
infarction. Br Heart J. 1988;60:104-110.
31. Levine MN, Raskob G, Hirsh J. Hemorrhagic complications of long-term anticoagulant therapy. Chest. 1986;89:16S-25S.[Medline] [Order article via Infotrieve]
This article has been cited by other articles:
 |
|
 |
|
  Y. Dotan, I. Pinchuk, D. Lichtenberg, and M. Leshno Decision Analysis Supports the Paradigm That Indiscriminate Supplementation of Vitamin E Does More Harm than Good Arterioscler Thromb Vasc Biol, September 1, 2009; 29(9): 1304 - 1309. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. S. Saczynski, F. A. Spencer, J. M. Gore, J. H. Gurwitz, J. Yarzebski, D. Lessard, and R. J. Goldberg Twenty-Year Trends in the Incidence of Stroke Complicating Acute Myocardial Infarction: Worcester Heart Attack Study Arch Intern Med, October 27, 2008; 168(19): 2104 - 2110. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Doufekias, A. Z. Segal, and J. R. Kizer Cardiogenic and aortogenic brain embolism. J. Am. Coll. Cardiol., March 18, 2008; 51(11): 1049 - 1059. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. Kinlay, G. G. Schwartz, A. G. Olsson, N. Rifai, M. Szarek, D. D. Waters, P. Libby, P. Ganz, and for the Myocardial Ischemia Reduction with Aggress Inflammation, Statin Therapy, and Risk of Stroke After an Acute Coronary Syndrome in the MIRACL Study Arterioscler Thromb Vasc Biol, January 1, 2008; 28(1): 142 - 147. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Van De Graaff, M. Dutta, P. Das, E. A. Shry, P. D. Frederick, M. Blaney, D. J. Pasta, and S. R. Steinhubl Early Coronary Revascularization Diminishes the Risk of Ischemic Stroke With Acute Myocardial Infarction Stroke, October 1, 2006; 37(10): 2546 - 2551. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G D Batty, M J Shipley, R J Jarrett, E Breeze, M G Marmot, and G Davey Smith Obesity and overweight in relation to disease-specific mortality in men with and without existing coronary heart disease in London: the original Whitehall study Heart, July 1, 2006; 92(7): 886 - 892. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. J. Witt, R. D. Brown Jr., S. J. Jacobsen, S. A. Weston, B. P. Yawn, and V. L. Roger A Community-Based Study of Stroke Incidence after Myocardial Infarction Ann Intern Med, December 6, 2005; 143(11): 785 - 792. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Bibliography Scand J Public Health, November 1, 2003; 31(61_suppl): 85 - 91. [PDF]
|
|
|
|
 |
|
 J. A. Cairns, P. Theroux, H. D. Lewis Jr., M. Ezekowitz, and T. W. Meade Antithrombotic Agents in Coronary Artery Disease Chest, January 1, 2001; 119 (2009): 228S - 252S. [Full Text] [PDF]
|
|
|
|
|
|
T. Mooe, B.-O. Olofsson, B. Stegmayr, and P. Eriksson Ischemic Stroke : Impact of a Recent Myocardial Infarction Stroke, May 1, 1999; 30(5): 997 - 1001. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. H. Lichtman, H. M. Krumholz, Y. Wang, M. J. Radford, and L. M. Brass Risk and Predictors of Stroke After Myocardial Infarction Among the Elderly: Results From the Cooperative Cardiovascular Project Circulation, March 5, 2002; 105(9): 1082 - 1087. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||