(Stroke. 2001;32:2206.)
© 2001 American Heart Association, Inc.
Letters to the Editor |
Re: Characteristics, Outcome, and Care of Stroke Associated With Atrial Fibrillation in Europe
Stroke Unit, Kings Mill Center, Sutton-in-Ashfield, Nottinghamshire, UK, jsharma@lineone.net
To the Editor:
I read with great interest the detailed study of atrial fibrillation1 in the context of acute stroke with particular relevance to the higher 3-month mortality of acute stroke patients who have atrial fibrillation (AF). We have previously reported2 the higher 3-month mortality of AF patients presenting with a stroke. It should be recognized, however, that AF is only one aspect of the cardiovascular disease (CVD) of these patients and does not usually exist independently of other types of CVD (eg, ischemic heart disease and cardiac failure) in the older age group. It is vital that a more detailed assessment be performed for outcome measurement in patients with AF to take into account the presence of other CVDs. We have reported2 that although AF was associated with a higher 3-month mortality in acute stroke patients (P=0.05), there was no significant association of AF with acute phase mortality, ie, death in acute wards (P=0.24). More significantly, we found that it is the presence of any degree of cardiac failure in addition to AF or other CVDs that is significantly associated with higher mortality both in the acute phase and at 3 months (P<0.001). Any future studies of the relationship of AF in the context of acute stroke should also study the influence of coexistent cardiac failure and other CVDs, eg, ischemic heart disease. In addition, it is also difficult to completely separate the independent influence of higher age on stroke mortality, because the patients with AF are much older than those without AF. Higher age is an independent factor that influences mortality after acute stroke.3 It is similarly important that these factors be considered in intervention studies in acute stroke.
References
1.
Lamassa M, Di Carlo AD, Pracucci G, Basile AM, Trefoloni G, Vanni P, Spolveri S, Baruffi MC, Landini G, Ghetti A, Wolfe CD, Inzitari D. Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital–based registry (The European Community Stroke Project). Stroke. 2001; 32: 392–398.
2.
Sharma JC, Fletcher, Vassallo M, Ross IN. Cardiovascular disease and outcome of acute stroke: influence of pre-existing cardiac failure. Eur J Heart Failure. 2000; 2: 145–150.
3. Sharma JC, Fletcher, Vassallo M. Strokes in the elderly-higher acute and three month mortality-an explanation. Cerebrovasc Dis. 1999; 9: 2–9.
National Research Council of Italy (CNR-CSFET), Italian Longitudinal Study on Aging, Florence, Italy
Department of Neurological and Psychiatric Sciences, University of Florence, Florence, Italy
Response
We thank Dr Sharma for his interest in our article evaluating the impact of atrial fibrillation (AF) on survival and function of acute stroke patients.
The problem of comorbidity is obviously relevant when considering stroke outcome, especially in the elderly population. In fact, the multivariate OR (1.57; 95% CI 1.29 to 1.90) indicating the relationship between AF and 3-month death was controlled for all baseline variables, including age, sex, hypertension, diabetes, smoking, alcohol consumption, previous myocardial infarction, and previous transient ischemic attacks. We did not include heart failure in our assessment in the acute phase. While heart failure may reveal an additive independent impact on stroke outcome, this cardiac disease is an end stage of different conditions,1 for the great part considered in our analyses.
The effect of age on survival has already been reported in our study population.2 Although no statistical method is perfect in separating the effect of single exposures on considered outcomes, the above reported multivariate OR was age controlled. We entirely agree with Dr Sharma that all demographics and risk factors have to be carefully considered when planning interventions studies in acute stroke.
References
1.
He J, Ogden LG, Bazzano LA, Vupputuri S, Loria C, Whelton PK. Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study. Arch Intern Med;. 2001; 161: 996–1002.
2.
Di Carlo A, Lamassa M, Pracucci G, Basile AM, Trefoloni G, Vanni P, Wolfe CD, Tilling K, Ebrahim S, Inzitari D. Stroke in the very old: clinical presentation and determinants of 3-month functional outcome: a European perspective. European BIOMED Study of Stroke Care Group. Stroke. 1999; 30: 2313–2319.
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