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Abstract

This study identifies prognostic factors for premature mortality in patients with acute ischemic stroke. As a retrospective observational study, it was based on hospital information on patients with acute ischemic stroke referred to Golestan Ahvaz Hospital from February 2022 to the end of July 2023. Premature mortality was recorded in the first 14 days after stroke. It used a multivariable logistic regression model to identify factors of early death in patients.

619 acute ischemic stroke patients participated in this study (mean age 66.01 ± 13.86 years, 47.33% female). The frequency of premature death after stroke was 7.75% (95% CI: 5.31 - 9.83%). High severity of stroke (OR: 12.24; P<0.0001), old age (OR: 2.86; P=0.001), mRS score >0 (OR: 5.68; P=0.0001), presence of AF (OR: 9.35; P<0.0001), ischemic heart disease (OR: 4.65; P=0.0001), cerebrovascular disease (OR: 2.06; P=0.016), level of consciousness (OR: 1.98; P=0.030), and high white blood cell count at hospital admission (OR: 2.11; P=0.002) are independently associated with increased risk of premature death. In contrast, antiplatelet therapy (P=0.001) and thrombolytic therapy (P<0.0001) were associated with a decrease in mortality. Likewise, hypertension, heart failure, use of statins, and accompanying initial symptoms with seizures were associated with premature death only in univariate analysis.

Acute ischemic stroke was associated with a high mortality rate. The risk factors for premature mortality were similar to the results and evidence reported in other articles. Therefore, this higher mortality is avoidable with early diagnosis and adequate management‎.

Keywords: Predictive factors, Risk factor, Premature death, Ischemic stroke

 

 

 

 

 

 

 

 

 

 

 

As the results showed, old age, high severity of stroke (high NIHSS score), presence of AF, history of ischemic heart disease, cerebrovascular disease, functional status before stroke (mRS score >0), decreased level of consciousness upon entering the hospital, and a high white blood cell count at hospital admission are independently associated with an increased risk of premature death. In contrast, antiplatelet therapy (including aspirin and clopidogrel) and thrombolytic therapy were associated with a reduction in mortality. Likewise, having hypertension and heart failure, taking statins, and accompanying early symptoms with seizures had a relationship with premature death only in univariate analysis.

Other variables under study including gender and smoking, hyperlipidemia, diabetes mellitus, blood pressure, body temperature on arrival, anticoagulant treatment, renal function tests, and serum levels of Hb, platelets, sodium, and potassium have no relationship with decreasing or increasing the risk of premature death.

The results showed that premature death within two weeks (≤14 days) after the occurrence of acute ischemic stroke was 7.75%. The rate of premature death in ischemic stroke patients was almost similar to some other previous studies. Kortazar-Zubizarreta et al. (2019) in Spain reported early in-hospital mortality during the first two weeks after the occurrence of acute ischemic stroke to be 13.7% [16]. Bustamante et al. (2017) in Spain, who investigated 12,227 ischemic stroke patients, showed that the in-hospital mortality rate in the first 14 days was 5.9% [19]. The risk of stroke (ischemic or hemorrhagic) during life in adults is generally 25% and the risk of ischemic stroke from the age of 25 years onwards is 18% [20].

The present study found a significant and independent relationship between old age and early death in acute ischemic stroke patients, which is consistent with the findings of previous research. Zhang et al. [21], Gattringer et al. [11], Kortazar-Zubizarreta et al. [16], Bustamante et al. [19], Ong et al. [12], and Ho et al. [13] have reported also the higher age as a risk factor for early mortality in ischemic stroke patients. Furlan et al. [22] and Schmidt et al. [23] also identified the age factor as an independent predictor of early in-hospital mortality in stroke patients. Various studies found old age as an important risk factor for stroke so increasing age is associated with a higher risk of occurrence and severity of stroke [24].

The present study used the NIHSS score as a measure of stroke severity. The results showed that a high NIHSS score was an independent predictor for increasing the risk of premature death in patients with acute ischemic stroke. These results are consistent with the findings of past studies, including the studies by Adams et al. [25] and Ho et al. [13]. Iluţ et al. [7] showed a relationship between a higher NIHSS score at admission (NIHSS ≥ 9) and a higher probability of premature death in stroke patients. Kortazar-Zubizarreta et al. [16] revealed high stroke severity (NIHSS≥14) associated with a higher probability of premature death in ischemic stroke patients. Similar results have been reported in other studies. Ramachandran et al. recently showed that functional status (mRS) and NIHSS on day 1 are a valid predictor of early mortality in patients with ischemic stroke.

The present study showed the independent effect of ischemic heart disease, atrial fibrillation (AF), and cerebrovascular disease on premature death. Blood pressure and heart failure were also predictors of premature death in ischemic stroke patients only in univariate analysis. The history of heart disease significantly increased in other studies the early mortality in ischemic stroke patients [12, 16]. Dabilgou et al. showed that a previous history of ischemic heart disease was predictive of an increased incidence of early death after ischemic stroke [9]. Heart failure (CHF), MI, ischemic cardiomyopathy, aortic stenosis, and aortic insufficiency were not associated with the mortality of patients. Some differences in the results can be because of differences in the study population and patient characteristics, especially stroke severity.

The current study showed that hypertension was associated with premature death only in univariate analysis. Some studies reported that high blood pressure is associated with adverse outcomes in patients with acute ischemic stroke. Dabilgou et al. [9] showed that although high blood pressure was the most common vascular risk factor in 54.2% of ischemic stroke patients, hypertension and diabetes did not play a predictive role in premature death.

The present study showed that some factors such as gender and smoking, hyperlipidemia, and diabetes mellitus were not associated with reducing or increasing the risk of premature death. Likewise, as mentioned, our results are not in line with previous studies in some cases and some potential predictors have not been well studied. For example, while hypertension and hyperlipidemia are known risk factors for stroke, their association with premature mortality in ischemic stroke patients is unclear. So some studies have reported high blood pressure as a predictor of premature death in ischemic stroke patients [10].

The present study observed a significant relationship between antiplatelet therapy and lower mortality in ischemic stroke patients. As these results show, the use of antiplatelet drugs before stroke has a preventive role in mortality. This finding is confirmed by previous studies that showed the positive effect of antiplatelet treatment in reducing premature mortality after ischemic stroke [26] and reducing the risk of stroke recurrence

Thrombolysis in a limited period can help reduce infarction and other complications such as cardiopulmonary complications and mortality Although Kortazar-Zubizarreta et al. [16] showed no relationship between thrombolytic treatment and premature death in ischemic stroke patients [16]. Iluţ et al. [7] showed that anticoagulant treatment, thrombolysis, thrombectomy, and statin treatment were not associated with early mortality in ischemic stroke patients.

Decreased levels of consciousness and high white blood cell count at hospital admission were independently associated with an increased risk of premature death. The symptoms of seizures were associated with the occurrence of death in univariate analysis. But other laboratory parameters, kidney function, body temperature, and blood pressure on arrival were not related to premature death. As Bustamante et al. showed, seizures in ischemic stroke patients with premature death were higher (3.7% vs. 1.6%) [19]. The number of WBCs in the group of deceased patients increased significantly in the present study and was higher than that of the surviving group, and high WBC count in the multivariate model was associated with premature death of ischemic stroke patients. Ho et al. reported a similar result: high WBC count at admission was significantly associated with increased in-hospital mortality in ischemic stroke patients [13].

Conclusion

This study identified the advanced age, high severity of stroke (high NIHSS at the time of admission), presence of AF, history of ischemic heart disease, cerebrovascular disease, functional status before stroke (mRS score >0), decreased level of consciousness, and high white blood cell count at hospital admission as independent risk factors for predicting premature death in ischemic stroke patients. Likewise, hypertension, heart failure, use of statins, and accompanying initial symptoms with seizures were associated with premature death only in univariate analysis. Antiplatelet and thrombolytic therapy was associated with a reduction in premature death.

The current study had several limitations because of its single-center, retrospective, and cross-sectional characteristics. There was a lack of information in the files of some patients, which caused them to be excluded from the analysis. Likewise, our results are potentially not generalizable to the general population of all ischemic 0stroke patients.

A model for predicting early and long-term death in ischemic stroke should be prepared through a nomogram to help make early decisions in stroke.

Acknowledgments: None

Conflict of interest: None

Financial support: None

Ethics statement: None

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