Document Type : Original Article

Authors

1 1 Healthy Aging Research Centre, Neyshabur University of Medical Sciences, Neyshabur, Iran

2 Neurosciences Research Centre, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran

Abstract

BACKGROUND AND OBJECTIVE: Data on the factors affecting long‑term mortality following a
stroke in Iran are scarce. The current research aimed at investigating the extent of 2‑year mortality
following a stroke and the factors affecting it in the northwest of Iran.
MATERIALS AND METHODS: This prospective cohort study was conducted in Tabriz, Northwest
of Iran. Patients with computed tomography/magnetic resonance imaging confirmed the first‑ever
stroke were included in this study and followed up to 2 years. Clinical examinations, including the
severity of the stroke using the modified National Institutes of Health Stroke Scale (mNIHSS), were
conducted by a neurologist. The general characteristics, lifestyle factors, and laboratory tests were
also completed. To estimate the survival, Kaplan–Meier analysis was used; and for group comparison,
the log‑rank method was applied. To identify the factors predicting 2‑year mortality, semiparametric
Cox regression analysis was used.
RESULTS: A total of 1036 first‑ever stroke patients were included in the present study. The
mortality rates of stroke in 6‑month, 1‑year, and 2‑years follow‑up periods were 31.6%, 34.5%, and
38%, respectively. The two‑year mortality rate was 33.6% in ischemic and 58.7% in hemorrhagic
stroke (P < 0.001). In the multivariate Cox model, variables age, type of stroke, diabetes, and severity
of the stroke, according to the mNIHSS index, were identified as factors predicting 2‑year mortality
following the stroke.
CONCLUSION: The 2‑year mortality following acute stroke was relatively high compared to that of in
developed countries. Implementation of secondary prevention is recommended to better management
of modifiable predictors of mortality.

Keywords

1. Roth GA, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N,
et al. Global, regional, and national age‑sex‑specific mortality for
282 causes of death in 195 countries and territories, 1980‑2017:
A systematic analysis for the global burden of disease study 2017.
Lancet 2018;392:1736‑88.
2. Feigin VL, Norrving B, Mensah GA. Global burden of stroke. Circ
Res 2017;120:439‑48.
3. Omama S, Yoshida Y, Ogasawara K, Ogawa A, Ishibashi Y,
Ohsawa M, et al. Incidence rate of cerebrovascular diseases
in northern japan determined from the iwate stroke registry
with an inventory survey system. J Stroke Cerebrovasc Dis
2013;22:e317‑22.
4. Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J,
Anderson CS, et al. Adelaide stroke incidence study: Declining
stroke rates but many preventable cardioembolic strokes. Stroke
2013;44:1226‑31.
5. Béjot Y, Osseby GV, Aboa‑Eboulé C, Durier J, Lorgis L, Cottin Y,
et al. Dijon’s vanishing lead with regard to low incidence of stroke.
Eur J Neurol 2009;16:324‑9.
6. Azarpazhooh MR, Etemadi MM, Donnan GA, Mokhber N,
Majdi MR, Ghayour‑Mobarhan M, et al. Excessive incidence
of stroke in iran: Evidence from the mashhad stroke incidence
study (MSIS), a population‑based study of stroke in the middle
east. Stroke 2010;41:e3‑10.
7. Truelsen T, Mähönen M, Tolonen H, Asplund K, Bonita R,
Vanuzzo D, et al. Trends in stroke and coronary heart disease in
the WHO MONICA project. Stroke 2003;34:1346‑52.
8. Carter AM, Catto AJ, Mansfield MW, Bamford JM, Grant PJ.
Predictive variables for mortality after acute ischemic stroke.
Stroke 2007;38:1873‑80.
9. Pekmezovic T, Tepavcevic DK, Jarebinski M, Kostic M,
Bumbasirevic L. Trends in mortality from different subtypes
of stroke in the population of belgrade (Serbia). Clin Neurol
Neurosurg 2008;110:51‑7.
10. Reggiani M, Società Inter‑Regionale Piemonte e Valle d’Aosta per
le Cerebrovasculopatie Group. Five‑year survival after first‑ever
ischaemic stroke is worse in total anterior circulation infarcts: The
SINPAC cohort. Cerebrovasc Dis 2009;27:29‑36.
11. BravataDM, Ho SY, MeehanTP, BrassLM, Concato J. Readmission
and death after hospitalization for acute ischemic stroke: 5‑year
follow‑up in the medicare population. Stroke 2007;38:1899‑904.
12. Dhamoon MS, Tai W, Boden‑Albala B, Rundek T, Paik MC,
Sacco RL, et al. Risk of myocardial infarction or vascular death
after first ischemic stroke: The northern manhattan study. Stroke
2007;38:1752‑8.
13. Hankey GJ. Long‑term outcome after ischaemic stroke/transient
ischaemic attack. Cerebrovasc Dis 2003;16 Suppl 1:14‑9.
14. Hardie K, Jamrozik K, Hankey GJ, Broadhurst RJ, Anderson C.
Trends in five‑year survival and risk of recurrent stroke after
first‑ever stroke in the perth community stroke study. Cerebrovasc
Dis 2005;19:179‑85.
15. Appelros P, Nydevik I, Viitanen M. Poor outcome after first‑ever
stroke: Predictors for death, dependency, and recurrent stroke
within the first year. Stroke 2003;34:122‑6.
16. Jeng JS, Huang SJ, Tang SC, Yip PK. Predictors of survival and
functional outcome in acute stroke patients admitted to the stroke
intensive care unit. J Neurol Sci 2008;270:60‑6.
17. Putaala J, Curtze S, Hiltunen S, Tolppanen H, Kaste M,
Tatlisumak T. Causes of death and predictors of 5‑year mortality
in young adults after first‑ever ischemic stroke: The helsinki
young stroke registry. Stroke 2009;40:2698‑703.
18. Rønning OM. Very long‑term mortality after ischemic stroke:
Predictors of cardiovascular death. Acta Neurol Scand
Suppl 2013;127:69‑72.
19. Aminisani N, Oskoui S. One‑month mortality of stroke in the
province of Ardabil, 2005. JARUMS 2007;7:353‑6.
20. Khosravi H, Khosravi F, Salari H. One‑year survival and related
factors in patients with ischemic stroke. Int J Health Stud
2017;4:32‑5.
21. Sarbazi E, Sarbakhsh P, Savadi Oskooei D, Yazdchi M,
Ghaffari‑Fam S, Shamshirgaran SM. Factors related to 6‑month
mortality after the first‑ever stroke. J Educ Health Promot
2018;7:113.
22. Shamshirgaran SM, Barzkar H, Savadi‑Oskouei D,
Yazdchi Marandi M, Safaiyan A, Sarbazi E, et al. Predictors
of short‑term mortality after acute stroke in East Azerbaijan
province, 2014. J Cardiovasc Thorac Res 2018;10:36‑40.
23. Shoeibi A, Salehi M, Thrift AG, Kapral MK, Farzadfard MT,
Azarpazhooh A, et al. One‑year case fatality rate following stroke
in the mashhad stroke incidence study: A population‑based study
of stroke in Iran. Int J Stroke 2015;10 Suppl A100:96‑102.
24. Vittinghoff E, McCulloch CE. Relaxing the rule of ten events
per variable in logistic and cox regression. Am J Epidemiol
2007;165:710‑8.
25. Kasner SE, Cucchiara BL, McGarvey ML, Luciano JM,
Liebeskind DS, Chalela JA. Modified national institutes of health
stroke scale can be estimated from medical records. Stroke
2003;34:568‑70.
26. Meyer BC, Lyden PD. The modified national institutes of health
stroke scale: Its time has come. Int J Stroke 2009;4:267‑73.
27. Savio K, Pietra GL, Oddone E, Reggiani M, Leone MA. Reliability
of the modified Rankin Scale applied by telephone. Neurol Int
2013;5:e2.
28. Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI,
Ezekowitz MD, et al. Guidelines for the prevention of stroke in
patients with stroke and transient ischemic attack: A guideline
for healthcare professionals from the american heart association/
American stroke association. Stroke 2014;45:2160‑236.
29. Jellinger PS, Handelsman Y, Rosenblit PD, Bloomgarden ZT,
Fonseca VA, Garber AJ, et al. American association of clinical
endocrinologists and American college of endocrinology
guidelines for management of dyslipidemia and prevention of
cardiovascular disease. Endocr Pract 2017;23:1‑87.
30. Chang KC, Lee HC, Tseng MC, Huang YC. Three‑year survival
after first‑ever ischemic stroke is predicted by initial stroke
severity: A hospital‑based study. Clin Neurol Neurosurg
2010;112:296‑301.
31. Brønnum‑Hansen H, Davidsen M, Thorvaldsen P, Danish
MONICA Study Group. Long‑term survival and causes of death
after stroke. Stroke 2001;32:2131‑6.
32. Cabral NL, Muller M, Franco SC, Longo A, Moro C, Nagel V, et al. Three‑year survival and recurrence after first‑ever stroke:
The joinville stroke registry. BMC Neurol 2015;15:70.
33. Markaki I, Nilsson U, Kostulas K, Sjöstrand C. High cholesterol
levels are associated with improved long‑term survival after acute
ischemic stroke. J Stroke Cerebrovasc Dis 2014;23:e47‑53.
34. Dehghan M, Mente A, Zhang X, Swaminathan S, Li W,
Mohan V, et al. Associations of fats and carbohydrate intake
with cardiovascular disease and mortality in 18 countries from
five continents (PURE): A prospective cohort study. Lancet
2017;390:2050‑62.
35. Vemmos K, Ntaios G, Spengos K, Savvari P, Vemmou A,
Pappa T, et al. Association between obesity and mortality after
acute first‑ever stroke: The obesity‑stroke paradox. Stroke
2011;42:30‑6.
36. Goulart AC, Fernandes TG, Santos IS, Alencar AP, Bensenor IM,
Lotufo PA. Predictors of long‑term survival among first‑ever
ischemic and hemorrhagic stroke in a Brazilian stroke cohort.
BMC Neurol 2013;13:51.
37. De Wit L, Putman K, Devos H, Brinkmann N, Dejaeger E,
De Weerdt W, et al. Five‑year mortality and related prognostic
factors after inpatient stroke rehabilitation: A European
multi‑centre study. J Rehabil Med 2012;44:547‑52.
38. Gnonlonfoun DD, Adjien C, Ossou‑Nguiet PM, Avlessi I,
Goudjinou Gr, Houannou O, et al. Stroke: Medium and long‑term
mortality and associated factors in french‑speaking West Africa,
case of Benin. World J Neurosci 2014;4:7.
39. Andersen KK, Olsen TS, Dehlendorff C, Kammersgaard LP.
Hemorrhagic and ischemic strokes compared: Stroke severity,
mortality, and risk factors. Stroke 2009;40:2068‑72.
40. Wang Y, Rudd AG, Wolfe CD. Trends and survival between
ethnic groups after stroke: The South London stroke register.
Stroke 2013;44:380‑7.