The Risk of Developing Ischemic Stroke in Patients After Exacerbation of Ischemic Heart Disease

Aim      To develop a model for evaluating the risk of stroke in patients after exacerbation of ischemic heart disease who were admitted to the hospitals included into a vascular program.

Materials and methods This study included 1803 patients with acute coronary syndrome (ACS) from four institutions of Moscow, Kazan, Astrakhan, and Krasnodar where the vascular program was established. Mean age of patients was 64.9±12.78 years, 62,1 % of them were men. The patients were followed up for one year after the discharge from the hospital. External validation of the developed prognostic model was performed on a cohort of patients with ACS included into the RECORD-3 study.

Results During the follow-up period, 42 cases of ischemic stroke were observed. The risk of ischemic stroke was associated with the presence of atrial fibrillation (odd ratio (OR) 2.640; р=0.037), diabetes mellitus (OR 2.718; р=0.041), and chronic heart failure (OR 7.049; р=0.011). Protective factors were high-density lipoprotein cholesterol >1 mmol/l (OR 0.629; р=0.041), percutaneous coronary intervention during an index hospitalization (OR 0.412; р=0.042), anticoagulant treatment (OR 0.670; р=0.049), and achieving the blood pressure goal (OR 0.604; р=0.023). The prognostic model developed on the basis of regression analysis showed a good predictive value (area under the ROC curve, 0.780), sensitivity of 80 %, and specificity of 64.6 %. The diagnostic value of other scales for risk assessment was somewhat lower. The area under the ROC curve was 0.692±0.0245 for the GRACE scale and 0.708±0.0334 for CHA₂DS₂‑VASc. In the external validation of the scale based on data of the RECORD-3 study, the diagnostic value was lower although satisfactory as well (area under the ROC curve, 0.651); sensitivity was 78.9 %, and specificity was 52.3 %.

Conclusion      The study resulted in development of a simple clinical scale, which will probably allow identifying groups at risk of stroke more precisely than with standard scales.

1. Park KL, Budaj A, Goldberg RJ, Anderson FA, Agnelli G, Kennelly BM et al. Risk-Prediction Model for Ischemic Stroke in Patients Hospitalized With an Acute Coronary Syndrome (from the Global Registry of Acute Coronary Events [GRACE]). The American Journal of Cardiology. 2012;110(5):628–35. DOI: 10.1016/j.amjcard.2012.04.040

2. Yaghi S, Pilot M, Song C, Blum CA, Yakhkind A, Silver B et al. Ischemic Stroke Risk After Acute Coronary Syndrome. Journal of the American Heart Association. 2016;5(7):e002590. DOI: 10.1161/JAHA.115.002590

3. Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB, Gibbons R et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S49–73. DOI: 10.1161/01. cir.0000437741.48606.98

4. Guerra F, Scappini L, Maolo A, Campo G, Pavasini R, Shkoza M et al. CHA(2)DS(2)-VASc risk factors as predictors of stroke after acute coronary syndrome: A systematic review and meta-analysis. European Heart Journal: Acute Cardiovascular Care. 2018;7(3):264–74. DOI: 10.1177/2048872616673536

5. Averkova A.O., Brazhnik V.A., Koroleva O.S., Zubova E.A., Hasanov N.R., Chichkov Yu.M. et al. Acute coronary syndrome in young patients with familial hyperchoolesterolemia based on the results of Oracul II observation trial. Medical news of the North Caucasus. 2017;12(1):5–8. DOI: 10.14300/mnnc.2017.12001

6. Erlikh A.D., Gratsiansky N.A. Registry of Acute Coronary Syndromes ‘RECORD-3’. Characteristics of Patients and Treatment During Initial Hospitalization. Kardiologiia. 2016;56(4):16–24. DOI: 10.18565/cardio.2016.4.16-24

7. Chandiramani R, Chen H, Aoi S, Giustino G, Claessen B, Sartori S et al. Incidence, predictors and impact of stroke on mortality among patients with acute coronary syndromes following percutaneous coronary intervention – Results from the PROMETHEUS registry. Catheterization and Cardiovascular Interventions. 2020;95(5):885–92. DOI: 10.1002/ccd.28369

8. Ge Z, Baber U, Claessen BE, Farhan S, Chandrasekhar J, Li SX et al. The prevalence, predictors and outcomes of guideline-directed medical therapy in patients with acute myocardial infarction undergoing PCI, an analysis from the PROMETHEUS registry. Catheterization and Cardiovascular Interventions. 2019;93(3):E112–9. DOI: 10.1002/ccd.27860

9. Wang Y, Yan BP, Nichol MB, Tomlinson B, Lee VWY. Real-world study of low-density lipoprotein cholesterol levels and cardiovascular outcomes in Chinese: A retrospective cohort study in post-percutaneous coronary intervention acute coronary syndrome patients. International Journal of Cardiology. 2017;249:18–24. DOI: 10.1016/j.ijcard.2017.07.016

10. Cordero A, Rodriguez-Mañero M, García-Acuña JM, BertomeuGonzález V, Agra-Bermejo R, Cid B et al. Incidence and predictors of stroke in patients discharged with the diagnosis of acute coronary syndrome. International Journal of Cardiology. 2019;276:20–5. DOI: 10.1016/j.ijcard.2018.10.082

11. Lucà F, Caretta G, Vagnarelli F, Marini M, Iorio A, Di Fusco SA et al. Clinical characteristics, management and outcomes of patients with acute coronary syndrome and atrial fibrillation: real-world data from two nationwide registries in Italy. Journal of Cardiovascular Medicine. 2020;21(2):99–105. DOI: 10.2459/JCM.0000000000000911

12. Luo J, Li H, Qin X, Liu B, Zhao J, Maihe G et al. Increased risk of ischemic stroke associated with new-onset atrial fibrillation complicating acute coronary syndrome: A systematic review and meta-analysis. International Journal of Cardiology. 2018;265:125–31. DOI: 10.1016/j.ijcard.2018.04.096

13. Shen Y, Shi L, Nauman E, Katzmarzyk PT, Price-Haywood EG, Bazzano AN et al. Inverse Association Between HDL (High-Density Lipoprotein) Cholesterol and Stroke Risk Among Patients With Type 2 Diabetes Mellitus. Stroke. 2019;50(2):291–7. DOI: 10.1161/STROKEAHA.118.023682

14. Zheng J, Sun Z, Zhang X, Li Z, Guo X, Xie Y et al. Non-traditional lipid profiles associated with ischemic stroke not hemorrhagic stroke in hypertensive patients: results from an 8.4 years follow-up study. Lipids in Health and Disease. 2019;18(1):9. DOI: 10.1186/s12944-019-0958-y

15. Reina SA, Llabre MM, Allison MA, Wilkins JT, Mendez AJ, Arnan MK et al. HDL cholesterol and stroke risk: The Multi-Ethnic Study of Atherosclerosis. Atherosclerosis. 2015;243(1):314–9. DOI: 10.1016/j.atherosclerosis.2015.09.031

16. Álvarez-Álvarez B, Raposeiras-Roubín S, Abu-Assi E, CambeiroGonzález C, Gestal-Romaní S, López-López A et al. Is 6-month GRACE risk score a useful tool to predict stroke after an acute coronary syndrome? Open Heart. 2014;1(1):e000123. DOI: 10.1136/openhrt-2014-000123