Abstract
Background
The occurrence of a stroke after an acute myocardial infarction is associated with increased morbidity and mortality. However, limited data are available, particularly from a population-based perspective, about recent trends in the incidence and death rates associated with stroke complicating an acute myocardial infarction.
Objectives
To examine 25-year trends (1986–2011) in the incidence and in-hospital death rates of initial episodes of stroke complicating acute myocardial infarction.
Methods
The study population consisted of 11,436 adults hospitalized with acute myocardial infarction at all 11 medical centers in central Massachusetts on a biennial basis between 1986–2011.
Results
In this study cohort, 159 patients (1.4%) experienced an acute first-ever stroke during hospitalization for acute myocardial infarction. The proportion of patients with acute myocardial infarction who developed a stroke increased through the 1990’s but declined slightly thereafter. Compared to patients who did not experience a stroke, those who experienced a stroke were significantly older, more likely to be female, had a previous acute myocardial infarction, had a significant burden of comorbidities, and were more likely to have died (32.1% versus 10.8%) during their index hospitalization. Patients who developed a first stroke in the most recent study years (2003–2011) were more likely to have died during hospitalization than those hospitalized during earlier study years.
Conclusions
Although the incidence rates of acute stroke complicating acute myocardial infarction remained relatively stable during the years under study, the in-hospital death rates of those experiencing a stroke have not declined.
Introduction
Stroke is a relatively infrequent, yet potentially devastating, complication of acute myocardial infarction, occurring in less than 2% of patients who experience an acute myocardial infarction and this acute event is associated with increased morbidity and mortality [1–5]. Despite the improved in-hospital and long-term survival for all patients hospitalized with acute myocardial infarction during recent years due, in part, to current interventional and pharmacological management strategies [6–9], it remains important to examine whether the incidence and outcomes of patients who develop a stroke while hospitalized for acute myocardial infarction have changed over time. Most of the previous studies that have described the epidemiology of stroke in patients hospitalized with acute myocardial infarction were conducted in the setting of a randomized controlled trial, which may have limited the generalizability of their findings [1, 2, 10–12].
Despite the clinical significance of stroke in patients hospitalized for acute myocardial infarction, there are very limited contemporary data describing long-term trends in the characteristics, magnitude, treatment practices, and in-hospital case-fatality rates of stroke complicating acute myocardial infarction. Using data from a community-based population of patients hospitalized with independently validated acute myocardial infarction at all medical centers in central Massachusetts [13–15], we examined multi-decade-long trends (1986–2011) in the incidence rates of initial episodes of stroke complicating acute myocardial infarction, patient characteristics associated with the occurrence of stroke, patient’s in-hospital management, and the impact of stroke on hospital death rates.
Methods
Data for this investigation were derived from the Worcester Heart Attack Study [4, 7, 13, 16, 17]. This is an ongoing population-based investigation that is examining long-term trends in the incidence, hospital, and post-discharge case-fatality rates of acute myocardial infarction among residents of central Massachusetts, hospitalized at all 16 greater Worcester medical centers. Fewer hospitals (n=11) have been included during recent study years due to hospital closures, mergers, and conversion to chronic care facilities.
The details of this study have been described previously [5, 13, 14]. In brief, the medical records of residents of the Worcester metropolitan area hospitalized for possible acute myocardial infarction at all central Massachusetts medical centers on an approximate biennial basis between 1986 and 2011 were individually reviewed and a diagnosis of acute myocardial infarction was validated according to pre-defined criteria [5, 13, 14]. Patients who developed acute myocardial infarction secondary to an interventional procedure or surgery were excluded from this study. Because we were interested in examining multi-decade long trends in the magnitude of incident (first-ever) cases of acute stroke, patients with a history of stroke (n=1,371) were excluded from the present study. This study was approved by the Institutional Review Board at the University of Massachusetts Medical School.
Data Collection
Demographic, clinical, and in-hospital management data were abstracted from hospital medical records of geographically eligible patients with confirmed acute myocardial infarction by trained study physicians and nurses. Information was collected about patient’s age, sex, comorbidities (e.g., angina, diabetes, hypertension, stroke, atrial fibrillation), acute myocardial infarction order (initial vs. prior) and type ((ST-elevation Myocardial Infarction (STEMI) vs. Non-ST-elevation Myocardial Infarction (NSTEMI)), in-hospital pharmacologic management and receipt of diagnostic/interventional procedures, and hospital discharge status. Information was also collected about the occurrence of clinically significant in-hospital acute myocardial infarction-related complications including stroke [16], atrial fibrillation [18], heart failure [19], and cardiogenic shock [20]. The occurrence of an acute stroke was defined as the development of neurologic changes consistent with a stroke based on information contained in medical charts and reviewed by our team of trained nurse and physician abstractors [16].
Data Analysis
We examined differences between patients who developed, as compared with those who did not develop, an acute stroke during hospitalization for acute myocardial infarction with respect to their demographic and clinical characteristics, treatment practices, and in-hospital case- fatality rates (CFRs) through the use of chi-square and t-tests for discrete and continuous variables, respectively. We examined differences in the distribution of selected characteristics for patients at risk of developing an acute stroke in the early (1986–1993), intermediate (1995–2001), and more recent study cohorts (2003–2011) for purposes of describing potentially changing trends in these characteristics using chi-square tests for trend.
Multivariate logistic regression analysis was used to examine changes over time in the odds of developing an acute stroke, simultaneously controlling for previously described demographic and clinical factors associated with the risk of stroke. Multivariate logistic regression analysis was also used to examine the association between the occurrence of an acute stroke and in-hospital mortality after controlling for a number of potentially confounding socio-demographic and clinical factors of prognostic importance.
Results
The mean age of the study population was 69 years, 42% were women, and 92% were Caucasian. Among the 11,436 patients hospitalized with confirmed acute myocardial infarction at all hospitals in the Worcester metropolitan area without a previously diagnosed stroke during the period under study (1986–2011), 159 patients (1.4%) developed a stroke during their acute hospitalization.
Multi-decade long trends in the hospital incidence rates of acute stroke
Following slight declines in the rates of incident stroke between 1986 and 1990, these rates increased through the 1990’s peaking at 2.5% in 1999 (Figure 1). Beginning in 2003, the incidence rates of acute stroke began to decline slightly, reaching 1.4% in our most recent study year (2011). After controlling for several demographic factors, comorbid conditions, acute myocardial infarction order, and important hospital complications (e.g., heart failure, atrial fibrillation), the odds of developing an acute stroke during hospitalization for acute myocardial infarction was significantly higher in 1995–2001 than in the earliest study cohorts 1986–1993 (Table 3). In the most recent study period (2003–2011), the odds of developing an acute stroke were similar to those observed during the reference study years (1986–1993).
Figure 1.
Changes over time in the incidence rates of acute stroke in patients hospitalized with acute myocardial infarction
Table 3.
Changing trends in the occurrence of acute stroke after acute myocardial infarction
| Study year | Odds ratio (95% confidence interval) | ||
|---|---|---|---|
| Model 1 | Model 2 | Model 3 | |
| 1986–1993 | Reference | Reference | Reference |
| 1995–2001 | 1.54(1.02;2.30) | 1.88(1.23;2.87) | 2.32(1.37;3.64) |
| 2003–2011 | 1.21(0.79;1.85) | 1.47(0.93;2.31) | 2.05(1.13;3.73) |
Model 1: Adjusted for age and sex
Model 2: Model 1 + comorbid conditions (hypertension, diabetes, heart failure, and atrial fibrillation) and acute myocardial infarction order, length of stay and the development of hospital complications (atrial fibrillation, heart failure, and cardiogenic shock)
Model 3: Model 2 + and the receipt of in-hospital thrombolytic therapy and cardiac procedures (cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery).
Characteristics of patients who developed an acute stroke
Patients who experienced an acute stroke were significantly older, more likely to be females, have a do not resuscitate order, have developed a previous acute myocardial infarction, and were slightly more likely to have developed an STEMI than those who did not experience a stroke (Table 1). Patients who developed a stroke were more likely to have been previously diagnosed with several of the chronic medical conditions examined in this study (e.g., hypertension, peripheral vascular disease, atrial fibrillation).
Table 1A.
Patient characteristics according to the development of incident stroke during hospitalization for acute myocardial infarction
| Characteristic | Patients who developed a stroke (n=159) | Patients who did not develop a stroke (n=11,277) |
|---|---|---|
| Age, mean, years (SD) | 74.5 (12.2) | 68.7 (13.9)* |
| Age, years (%) | ||
| <65 | 15.7 | 36.2 |
| 65–74 | 24.5 | 24.3 |
| 75–84 | 34.0 | 24.9 |
| >=85 | 25.8 | 14.7 |
| Male (%) | 38.4 | 58.3** |
| White (%) | 93.7 | 91.1 |
| ST-segment myocardial infarction (%) | 24.5 | 22.6 |
| Initial myocardial infarction (%) | 58.5 | 66.8* |
| Do not resuscitate order (%) | 42.6 | 18.8** |
| Hospital length of stay (days, mean) | 11.3 | 7.2** |
| Medical History (%) | ||
| Atrial fibrillation | 15.1 | 9.2* |
| Chronic kidney disease | 14.5 | 10.0 |
| Chronic lung disease/asthma | 13.2 | 9.9 |
| Diabetes mellitus | 27.0 | 29.5 |
| Heart failure | 22.6 | 19.0 |
| Hyperlipidemia | 33.3 | 35.2 |
| Hypertension | 71.1 | 62.4* |
| Peripheral vascular disease | 14.5 | 9.1* |
| PCI | 6.9 | 10.0 |
| Laboratory and physiologic findings (mean, SD) | ||
| Cholesterol mg/dL | 184.8 (46.3) | 190.7(50.6) |
| Glucose, mg/dL | 187.6(92.8) | 171.2(78.7)* |
| Hematocrit, % | 38.9 | 40.0** |
| Troponin I | 6.7 (25.8) | 4.7(19.1) |
| GFR mL/min/1.73m2, | 52.2 (20.2) | 59.5(22.5) |
| HR (beats/min) | 93.1(27.3) | 85.3(22.3) |
| Diastolic blood pressure, initial, mmHg, | 79.7(20.6) | 77.9(19.3) |
| Systolic blood pressure, initial, mmHg, | 148.5(33.2) | 141.7(31.5) |
| In-Hospital Clinical Complications (%) | ||
| Atrial fibrillation | 34.6 | 16.8** |
| Cardiogenic shock | 6.3 | 6.2 |
| Heart failure | 44.0 | 35.8* |
| Death | 32.1 | 10.8** |
p<0.05
p<0.001
Physiologic and laboratory data at the time of hospital admission were available for patients hospitalized during the mid-1990’s to the most recent year under study (2011). Patients who experienced an acute stroke had lower serum hematocrit findings, lower total serum cholesterol levels, and a lower estimated glomerular filtration rate, but higher heart rate and systolic blood pressure findings at admission, and higher peak systolic and diastolic blood pressure levels during their hospital stay, compared with those who did not develop an acute stroke (Table 1). Patients who experienced an acute stroke were significantly more likely to have their hospital stay complicated by atrial fibrillation or heart failure.
Trends in the characteristics of patients who developed an acute stroke
There were few changes observed during the years under study in the demographic and clinical characteristics of patients who experienced an acute stroke. Patients who experienced a stroke during the most recent study years (2003–2011) were more likely to be women, non-white, to have been previously diagnosed with an acute myocardial infarction, had developed atrial fibrillation or heart failure during their index hospitalization for acute myocardial infarction, and were less likely to have been previously diagnosed with atrial fibrillation or chronic lung disease compared with those in the earliest study cohorts (1986–1993) (Table 1A).
Hospital management practices
Patients who experienced an acute stroke were significantly less likely to have been treated with anticoagulants, aspirin, and lipid-lowering medications during their acute hospitalization, but were more likely to have received diuretics, compared with those who did not develop a stroke (Table 2). Patients who developed a stroke were less likely to have undergone cardiac catheterization or a percutaneous coronary intervention (PCI) than those who did not experience a stroke (Table 2).
Table 2.
Hospital management practices according to the development of incident stroke during hospitalization for acute myocardial infarction
| Diagnostic/Interventional Procedure (%) | Patients who developed a stroke (n=159) | Patients who did not develop a stroke (n=11,277) |
|---|---|---|
| Cardiac catheterization | 30.8 | 47.3** |
| Coronary bypass surgery | 5.7 | 5.1 |
| Percutaneous coronary intervention | 13.8 | 27.0** |
| Thrombolytic therapy | 14.5 | 14.1 |
| Medications (%) | ||
| Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers | 47.2 | 46.4 |
| Aspirin | 73.6 | 83.6* |
| Beta blockers | 78.0 | 78.7 |
| Lipid lowering medications | 37.1 | 42.0 |
| Anticoagulants | 68.6 | 77.9* |
| Diuretics | 62.3 | 52.7* |
| Calcium channel blockers | 32.7 | 33.3 |
| Any 1 medication | 15.7 | 11.6 |
| Any 2 medications | 20.8 | 15.9 |
| Any 3 medications | 25.2 | 25.7 |
| Any 4 medications | 15.1 | 22.7 |
| All 5 medications | 23.3 | 24.2 |
Cumulative variable of all 5 medications = Angiotensin converting enzyme inhibitors/Angiotensin receptor blockers +aspirin+ beta-blockers + Lipid lowering medications+ anticoagulants
p<0.05
p<0.001
Risk of dying during hospitalization
Overall, patients who experienced an acute stroke were significantly more likely to have died during hospitalization compared with those who did not experience a stroke (32.1% vs. 10.8%) (Table 1). In the fully adjusted logistic regression model, patients who developed a stroke were 5 times more likely to have died during their acute hospitalization compared with those who did not (OR: 5.02; 95% CI: 3.32,7.56).
In examining trends in the odds of dying during hospitalization, patients who had experienced a stroke were 4 times more likely to have died in the earliest study years (1986–1993) (OR: 4.25; 95% CI: 1.81; 9.94) compared with those who did not develop a stroke during this period. Patients who experienced an acute stroke during the most recent study years (2003–2011) were 5 times more likely to have died (OR: 5.05; 95% CI: 2.34,10.90) compared with those who did not experience an acute stroke during this period (Table 4).
Table 4.
Changing trends in the risk of dying during hospitalization in those who developed an acute stroke after acute myocardial infarction
| Study year | Odds ratio (95% confidence interval) | ||
|---|---|---|---|
| Model 1 | Model 2 | Model 3 | |
| 1986–1993 | 2.46(1.21;5.00) | 3.65(1.61;8.28) | 4.25(1.81;9.94) |
| 1995–2001 | 3.16(1.83;5.46) | 6.70(3.73;12.04) | 5.07(2.73;9.41) |
| 2003–2011 | 4.83(2.55;9.16) | 5.91(2.93;11.91) | 5.05(2.34;10.90) |
Model 1: Adjusted for age and sex
Model 2: Model 1 + comorbid conditions (hypertension, diabetes, heart failure, and atrial fibrillation) and acute myocardial infarction order, length of hospital stay, and the development of hospital complications (atrial fibrillation, heart failure, and cardiogenic shock)
Model 3: Model 2 + and the receipt of in-hospital thrombolytic therapy and cardiac procedures (cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery).
Discussion
The results of this community-wide study of residents of central Massachusetts who were hospitalized with an acute myocardial infarction at all metropolitan Worcester medical centers on a biennial basis between 1986 and 2011 show that the frequency of initial stroke events increased from the mid-1980’s through the late 1990’s, but has slowly declined thereafter. We also found that patients who developed an acute stroke during hospitalization for an acute myocardial infarction were at significantly greater risk for dying during their acute hospitalization than those who did not develop a stroke, and the risk of surviving an acute stroke has not improved during the years under study.
Time trends in the incidence rates of stroke complicating acute myocardial infarction
The development of an acute stroke in patients hospitalized with an acute myocardial infarction is an infrequent but important clinical complication. The overall incidence rate of stroke that we observed in the present study (1.5%) was relatively similar to that observed in previously published studies [1]. Most studies that have examined the occurrence of stroke during hospital admission for acute myocardial infarction have reported first-ever stroke frequency rates ranging between 0.8% and 2.3% [12, 21–25].
Large clinical trials and observational studies, such as the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-1 (GUSTO-1) [26] and the Second National Registry of Myocardial Infarction (NRMI-2) [27], reported that 1.4% and 2.0% of patients who received thrombolytic therapy experienced an acute cerebrovascular event, respectively. However, unlike prior studies, the majority of patients with confirmed acute myocardial infarction in our investigation (85%) did not receive thrombolytic therapy, and the use of thrombolytic therapy did not differ between those who did and did not develop an acute stroke.
Similar rates of stroke to those observed in our investigation have been reported in other population-based observational studies, which have observed stroke incidence rates ranging between 1.1% and 1.5% [5, 28]. In the population-based Rochester (MN) Epidemiology Project, the overall frequency of an acute, first-ever, episode of stroke observed within the first 30 days after acute myocardial infarction between 1979 and 1998 was 2.3%; this rate increased from the late 1970’s through the 1980’s with a leveling off thereafter in the 1990’s [12]. In the multinational Global Registry of Acute Coronary Events (GRACE) study, the frequency of acute stroke among 35,233 patients hospitalized with an acute coronary syndrome at approximately 100 medical centers throughout the U.S, Europe, and South America between 1999 and 2005 remained relatively stable at approximately 0.9 % [3].
The overall downward trend seen in the frequency of acute stroke in our most recently hospitalized patient cohorts may be attributed to advances in the contemporary management of patients hospitalized for acute myocardial infarction or due to changes in the risk profile of these patients. With the introduction of PCI and effective adjuvant medical therapies, the outcomes of patients hospitalized with acute myocardial infarction have improved over time [9], including declines in several of the major complications associated with acute myocardial infarction including heart failure, cardiogenic shock, and atrial fibrillation, each of which are important risk factors for the development of stroke [29, 30]. The decreased rate of stroke we observed during the most recent years under study is also coincident with marked declines in the use of thrombolytic therapy, and increases in the use of PCI in this patient population, which may have reduced the risk of hemorrhagic stroke in patients with acute myocardial infarction [31]. Moreover, we observed an increased hospital use of evidence-based medical therapies, including aspirin, antihypertensive agents, and statins for patients hospitalized with acute myocardial infarction during the years under study, which may have led to declines in the occurrence of stroke in this patient population [32]. Irrespective of the reasons for the encouraging decline in the frequency of stroke complicating acute myocardial infarction that we observed during the most recent years under study, this remains a devastating clinical complication. Efforts should continue to carefully monitor patients who are at an increased risk for acute stroke and treat these patients accordingly.
Characteristics of patients who developed a stroke complicating acute myocardial infarction
We identified several patient characteristics that differed between those who did and did not develop a stroke during hospitalization for acute myocardial infarction. Patients who developed a stroke were older, were more likely to be females, and had a worse clinical profile in terms of select co-morbidities than patients who did not develop a stroke. Each of these characteristics represents major risk factors for developing an acute stroke [29]. Advanced age has consistently been shown to be one of the strongest predictors of acute myocardial infarction -associated stroke in clinical trials and observational studies [3, 25]. Moreover, patients who developed a stroke were more likely to have developed important in-hospital complications including atrial fibrillation and heart failure. These findings are consistent with the results of previously published studies [1, 5, 12, 17, 33, 34].
Despite our enhanced understanding of several risk factors for acute stroke in the setting of acute myocardial infarction, the mechanisms underlying the development of this acute neurologic event remain somewhat speculative [35, 36]. Predisposing pathophysiologic factors include embolization from left ventricular thrombi, adverse hemodynamic changes, atherosclerosis in the cerebral vessels that renders them susceptible to blockage or bleeding, systemic inflammatory responses to acute ischemic changes, and hemostatic abnormalities [37, 38].
Our findings suggest that those who did not develop a stroke received more comprehensive interventional and medical management of their acute myocardial infarction. These patients were more likely to have undergone a cardiac catheterization and PCI and have received antithrombotic therapy in the form of aspirin and anticoagulation. However, patients who did not receive these diagnostic/interventional procedures or evidence-based medications may have been perceived by their physicians as being at high risk for experiencing drug or procedure-related adverse events and were not managed aggressively with these therapeutic approaches. For example, a significantly higher percentage of patients who developed a stroke had a DNR order compared with those who did not develop a stroke. Although PCI has been shown to reduce the risk of stroke in the setting of acute myocardial infarction [12], a meta-analysis of more than 20 published studies did not identify any therapies associated with a reduced risk for stroke in patients hospitalized with acute myocardial infarction [1]. Overall, our findings suggest that patients at increased risk of developing a stroke can be identified early on in the setting of acute myocardial infarction.
Hospital case-fatality rates
Our results suggest that while there has been an overall decrease in the incidence rates of stroke during the multi-decade long period under study, especially during the most recent years under investigation, this was not accompanied by a concomitant decrease in the hospital death rates associated with stroke. After adjusting for multiple potentially confounding factors of prognostic importance, the in-hospital death rates associated with acute stroke failed to decline during the most recent study years. Compared with patients who did not develop a stroke, the risk of dying during hospitalization remained markedly elevated and was approximately five times higher in those who developed a stroke after their acute myocardial infarction.
Previously published studies have shown an increased odds of dying among those who developed, as compared with those who did not develop, a stroke after hospitalization for acute myocardial infarction [1, 12, 17, 33, 39]. While our discouraging finding that patients who developed an acute stroke failed to improve their survival over time, the lack of improvement in short-term survival may be explained, in part, by the progressively worse demographic (older age) and clinical profile (increased prevalence of chronic conditions) of patients hospitalized during more recent as compared with earlier cohorts. Moreover, these patients were less likely to have received optimal anticoagulation and antiplatelet therapy, cornerstones in the management of stroke, likely due to their high risk of bleeding. Therefore, it remains important to continue to monitor changing trends in the magnitude and outcomes of stroke in patients hospitalized with acute myocardial infarction as the therapeutic management of these patients continues to evolve.
Study Strengths and Limitations
The strengths of our descriptive investigation include the study of all patients from a well-characterized urban community in central Massachusetts hospitalized with independently validated acute myocardial infarction. Moreover, we were able to control for a number of potentially confounding factors in examining changing trends in the magnitude and impact of stroke in patients hospitalized with acute myocardial infarction. The limitations of our study include that the diagnosis of stroke was not always confirmed by a neurologist or imaging studies, and we did not have information available about the severity or subtype of acute stroke. Since stroke subtype has been shown to affect the risk of dying in patients with acute myocardial infarction [40], changes over time in the relative magnitude of hemorrhagic as compared with ischemic strokes may have played a role in the changing epidemiology of stroke and associated short-term case-fatality rates. In addition, since we were unable to determine whether in-hospital treatment approaches were prescribed either prior to or after the acute stroke occurred, we did not adjust for the receipt of in-hospital medications in the multivariable-adjusted regression models. We were also unable to examine the role of other risk factors for stroke, such as cigarette smoking, and information on cause-specific death rates was not available.
Conclusions
The results of our study among residents of a large central New England community suggest that the risk of stroke complicating acute myocardial infarction has progressively declined since the late 1990’s, while the short-term survival rates of those experiencing a stroke have not improved over time. It remains crucial to identify factors associated with the risk of stroke among patients hospitalized for acute myocardial infarction, particularly those associated with fatal stroke, in order to further improve the management of these patients and decrease the considerable morbidity and mortality associated with this disease.
Table 1B.
Proportion of patients at risk of acute stroke according to selected baseline characteristics
| Characteristic (%) | 1986–1993 (n=3,611) | 1995–2001 (n=3,792) | 2003–2011 (n=4,033) |
|---|---|---|---|
| Age (years) | 75.4 (13.3) | 75.7(11.6) | 73.3(12.2) |
| < 65 | 0.5 | 0.9 | 0.5 |
| 65–74 | 1.0 | 1.4 | 1.9 |
| 75–84 | 1.3 | 2.3 | 2.0 |
| >=85 | 2.8 | 3.1 | 1.8 |
| Female | 1.2 | 2.6 | 2.2 |
| Male | 0.9 | 1.1 | 0.8 |
| White | 1.1 | 1.7 | 1.5 |
| Non-white | 5.3 | 7.7 | 5.4 |
| ST-segment myocardial infarction | NA | 2.0 | 1.0 |
| Non- ST-segment myocardial infarction | NA | 1.6 | 1.6 |
| Initial myocardial infarction | 1.0 | 1.5 | 1.2 |
| Prior myocardial infarction | 1.2 | 2.1 | 1.9 |
| Medical history (%) | |||
| Anemia | NA | NA | 1.6 |
| Atrial fibrillation | 3.6 | 2.4 | 1.8 |
| Chronic kidney disease | NA | 1.9 | 2.1 |
| Chronic lung disease/asthma | NA | 2.2 | 1.6 |
| Diabetes mellitus | 0.7 | 1.7 | 1.3 |
| Heart failure | 1.3 | 1.9 | 1.7 |
| Hyperlipidemia | NA | 1.4 | 1.3 |
| Hypertension | 1.0 | 2.0 | 1.6 |
| Peripheral vascular disease | NA | 2.5 | 2.1 |
| Previous PCI | NA | 0.7 | 1.1 |
| In-hospital complication | |||
| Atrial fibrillation | 2.9 | 3.3 | 2.4 |
| Cardiogenic shock | 1.8 | 0.7 | 1.9 |
| Heart failure | 1.2 | 1.9 | 2.0 |
| Died | 2.7 | 4.9 | 5.0 |
NA: not available; data on some of the chronic conditions were not collected in early study cohorts
Clinical Significance.
The incidence rates of stroke among patients hospitalized with acute myocardial infarction have remained stable over time (1986–2011).
The hospital death rates of those experiencing a stroke have not improved during the 25 years under study.
It remains crucial to identify factors associated with the risk of stroke among patients hospitalized for acute myocardial infarction to improve their management and decrease their morbidity and mortality.
Acknowledgments
This study was made possible through the cooperation of the administration, medical records, and cardiology departments of participating central Massachusetts area hospitals.
Footnotes
Authors’ Contribution: All authors had access to the data and contributed to the writing of this manuscript.
Conflicts of Interest
The authors declare no conflicts of interest.
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