Ischemic Stroke in Poland and the United States
To the Editor:
We, as neurologists, read with interest the report of Massing et al1 on stroke mortality trends in Poland and the United States. The authors found different stroke mortality trends in the 2 countries (a decrease in the United States, an increase in Poland), a difference that was more pronounced in younger groups of patients. They concluded that the difference could have resulted from the effects of lifestyles and socioenvironmental and medical care determinants.
Our study on stroke in young adult patients has led us to similar conclusions. Between 1988 and 1995 in the Department of Neurology of the Medical Academy in Warsaw, we saw 71 patients (38 men and 33 women) aged 18 to 45 years (mean, 36.89±6.77 years) with a diagnosis of first-ever ischemic stroke. Four of our patients died within 28 days. All the deaths were atributed to the stroke. To assess long-term prognosis among this group of patients, we performed a follow-up study. We obtained precise information on 66 of 67 patients (98.5%) who survived the first stroke episode. The observation times varied from 4 months to 7 years (mean, 45.85±21.84 months). Two of the patients died during the observation time (both vascular deaths), and 9 others experienced a second ischemic stroke between 1 month and 6 years after the first (see the Figure⇓).
Calculated 28-day mortality in our group was 5.6%; the incidence of vascular death or recurrent stroke was 5.6%/y (95% CI, 3.2 to 9.7), and after 24 months it was 10.9% (95% CI, 7 to 14.8).
The 28-day mortality rate, regarded as one of the methods to judge hospital performance,2 was similar in our group to the data in the literature (3.65% to 7%).3 4 5 It could suggest that acute care in stroke in our center is similar to that in others. Quite to the contrary, recurrent stroke and vascular deaths appeared in our data twice as often as in the literature. In the similar group described by Kappelle et al,4 the risk of vascular death, stroke, or nonfatal myocardial infarction was 2.6%/y; in the study of Hier et al,6 5.2% of the patients (of similar age) experienced recurrent stroke within 24 months after the first-ever stroke. As far as risk factors are concerned, we found cigarette smoking in 63% of our patients and hypertension in 44%. These results are also different compared with published data. Rohr et al7 found cigarette smoking among young stroke patients (in 40% of whites and 52% of blacks). Kapelle et al4 noticed this risk factor in 57% of their patients (mainly white Americans), but the data were collected between 1977 and 1992. As far as hypertension is concerned, it was present in 44% of the patients in our group whereas in similar groups in the literature 19% to 33% were hypertensive.3 4 8 Rohr et al7 found hypertension present in 60% of the black young adults in their study.
Our results confirm, although indirectly, the conclusion formed by Massing et al1 in their study. Both the high rate of recurrent strokes in our study and the mortality trends found in that of Massing et al could be the effects of lifestyle and socioenvironmental determinants.
- Copyright © 1999 by American Heart Association
Massing MW, Rywik SL, Jasinski B, Manolio TA, Williams OD, Tyroler HA. Opposing national stroke mortality trends in Poland and for African Americans and whites in the United States. Stroke. 1998;29:1366–1372.
Iezzoni LI, Shwartz M, Ash AS, Hughes JS, Daley J, Mackiernan YD. Using severity-adjusted stroke mortality rates to judge hospitals. Int J Qual Health. 1995;7:81–94.
Biller J, Adams HPJ, Bruno A, Love BB, Marsh EE. Mortality in acute cerebral infarction in young adults: a ten-year experience. Angiology. 1991;42:224–230.
Kappelle LJ, Adams HP Jr, Heffner ML, Torner JC, Gomez F, Biller J. Prognosis of young adults with ischemic stroke: a long term follow-up study assessing recurrent vascular events and functional outcome in the Iowa Registry of Stroke in Young Adults. Stroke. 1994;25:1360–1365.
Kristensen B, Malm J, Carlberg B, Stegmayr B, Backman C, Fagerlund M, Olsson T. Epidemiology and etiology of ischemic stroke in young adults aged 18 to 44 years in northern Sweden. Stroke. 1997;28:1702–1709.
Hier DB, Foulkes MA, Swiontoniowski M, Sacco RL, Gorelick PB, Mohr JP, Price TR, Wolf PA. Stroke recurrence within 2 years after ischemic infarction. Stroke. 1991;22:155–161.
Rohr J, Kittner S, Feeser B, Hebel JR, Whyte MG, Weinstein A, Kanarak N, Buchholz D, Earley C, Johnson C, Macko R, Price T, Sloan M, Stern B, Wityk R, Wozniak M, Sherwin R. Traditional risk factors and ischemic stroke in young adults: the Baltimore-Washington Cooperative Young Stroke Study. Arch Neurol. 1996;53:603–607.
Carolei A, Marini C, Ferranti E, Frontoni M, Prencipe M, Fieschi C. A prospective study of cerebral ischemia in the young: analysis of pathogenic determinants. Stroke. 1993;24:362–367.