Research Article| Volume 25, ISSUE 3, P656-664, March 2016

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Recurrent Stroke, Myocardial Infarction, and Major Vascular Events during the First Year after Acute Ischemic Stroke: The Multicenter Prospective Observational Study about Recurrence and Its Determinants after Acute Ischemic Stroke I


      Patients with acute ischemic stroke (AIS) are at high risk of subsequent vascular events. The aim of this study was to estimate rates of recurrent stroke, myocardial infarction (MI), and major vascular events during the first year after AIS in Korea.


      Through a multicenter stroke registry in Korea, 12,227 consecutive cases of AIS were identified between November 2010 and May 2013 and were followed up for recurrent stroke, MI, and major vascular events up to 1 year after stroke.


      Cumulative 30-day, 90-day and 1-year rates were 2.7%, 3.9%, and 5.7% for recurrent stroke; .1%, .3%, and .5% for MI; and 8.1%, 10.6%, and 13.7% for major vascular events, indicating that the early period is at high risk of recurrent stroke and major vascular events. The risk of recurrent stroke was substantially higher than the risk of MI: 13.0 times at 90 days and 11.4 times at 1 year. Compared to those with small-vessel occlusion (SVO), those with ischemic stroke subtypes other than SVO had a higher risk of recurrent stroke as well as major vascular events. Other common independent predictors for recurrent stroke and major vascular events were diabetes and prior stroke history.


      During the first year after AIS, one in 18 had recurrent stroke and one in 7 major vascular events. More than two thirds of recurrent stroke and three quarters of major vascular events developed within 90 days in a Korean cohort of stroke patients. Better prevention strategies are required for high-risk patients during this high-risk period.

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        • Bejot Y.
        • Rouaud O.
        • Durier J.
        • et al.
        Decrease in the stroke case fatality rates in a French population-based twenty-year study.
        Cerebrovasc Dis. 2007; 24: 439-444
        • Dormandy J.A.
        • Charbonnel B.
        • Eckland D.J.
        • et al.
        Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial in macroVascular Events): a randomised controlled trial.
        Lancet. 2005; 366: 1279-1289
        • Kim A.S.
        • Johnston S.C.
        Global variation in the relative burden of stroke and ischemic heart disease.
        Circulation. 2011; 124: 314-323
        • Jackson C.A.
        • Hutchison A.
        • Dennis M.S.
        • et al.
        Differences between ischemic stroke subtypes in vascular outcomes support a distinct lacunar ischemic stroke arteriopathy: a prospective, hospital-based study.
        Stroke. 2009; 40: 3679-3684
        • Dhamoon M.S.
        • Sciacca R.R.
        • Rundek T.
        • et al.
        Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study.
        Neurology. 2006; 66: 641-646
        • Hillen T.
        • Coshall C.
        • Tilling K.
        • et al.
        Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register.
        Stroke. 2003; 34: 1457-1463
        • Petty G.W.
        • Brown Jr, R.D.
        • Whisnant J.P.
        • et al.
        Ischemic stroke subtypes: a population-based study of functional outcome, survival, and recurrence.
        Stroke. 2000; 31: 1062-1068
        • Sacco R.L.
        • Foulkes M.A.
        • Mohr J.P.
        • et al.
        Determinants of early recurrence of cerebral infarction. The Stroke Data Bank.
        Stroke. 1989; 20: 983-989
        • Jones S.B.
        • Sen S.
        • Lakshminarayan K.
        • et al.
        Poststroke outcomes vary by pathogenic stroke subtype in the Atherosclerosis Risk in Communities Study.
        Stroke. 2013; 44: 2307-2310
        • Ko Y.
        • Park J.H.
        • Kim W.J.
        • et al.
        The long-term incidence of recurrent stroke: single hospital-based cohort study.
        J Korean Neurol Assoc. 2009; 27: 110-115
        • Bang O.Y.
        • Lee P.H.
        • Joo S.Y.
        • et al.
        Frequency and mechanisms of stroke recurrence after cryptogenic stroke.
        Ann Neurol. 2003; 54: 227-234
        • Lee Y.S.
        • Bae H.J.
        • Kang D.W.
        • et al.
        Cilostazol in Acute Ischemic Stroke Treatment (CAIST Trial): a randomized double-blind non-inferiority trial.
        Cerebrovasc Dis. 2011; 32: 65-71
        • Suzuki N.
        • Sato M.
        • Houkin K.
        • et al.
        One-year atherothrombotic vascular events rates in outpatients with recent non-cardioembolic ischemic stroke: the EVEREST (Effective Vascular Event REduction after STroke) registry.
        J Stroke Cerebrovasc Dis. 2012; 21: 245-253
        • Yokota C.
        • Minematsu K.
        • Hasegawa Y.
        • et al.
        Long-term prognosis, by stroke subtypes, after a first-ever stroke: a hospital-based study over a 20-year period.
        Cerebrovasc Dis. 2004; 18: 111-116
        • Kim B.J.
        • Han M.K.
        • Park T.H.
        • et al.
        Current status of acute stroke management in Korea: a report on a multicenter, comprehensive acute stroke registry.
        Int J Stroke. 2014; 9: 514-518
        • Adams Jr, H.P.
        • Bendixen B.H.
        • Kappelle L.J.
        • et al.
        Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment.
        Stroke. 1993; 24: 35-41
        • Ko Y.
        • Lee S.
        • Chung J.W.
        • et al.
        MRI-based algorithm for acute ischemic stroke subtype classification.
        J Stroke. 2014; 16: 161-172
        • Hankey G.J.
        • Jamrozik K.
        • Broadhurst R.J.
        • et al.
        Long-term risk of first recurrent stroke in the Perth Community Stroke Study.
        Stroke. 1998; 29: 2491-2500
        • Coull A.J.
        • Rothwell P.M.
        Underestimation of the early risk of recurrent stroke: evidence of the need for a standard definition.
        Stroke. 2004; 35: 1925-1929
        • Vickrey B.G.
        • Rector T.S.
        • Wickstrom S.L.
        • et al.
        Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease.
        Stroke. 2002; 33: 901-906
        • Kaplan R.C.
        • Tirschwell D.L.
        • Longstreth Jr, W.T.
        • et al.
        Vascular events, mortality, and preventive therapy following ischemic stroke in the elderly.
        Neurology. 2005; 65: 835-842
        • Pennlert J.
        • Eriksson M.
        • Carlberg B.
        • et al.
        Long-term risk and predictors of recurrent stroke beyond the acute phase.
        Stroke. 2014; 45: 1839-1841
        • Lakshminarayan K.
        • Schissel C.
        • Anderson D.C.
        • et al.
        Five-year rehospitalization outcomes in a cohort of patients with acute ischemic stroke: Medicare linkage study.
        Stroke. 2011; 42: 1556-1562
        • Xu G.
        • Liu X.
        • Wu W.
        • et al.
        Recurrence after ischemic stroke in Chinese patients: impact of uncontrolled modifiable risk factors.
        Cerebrovasc Dis. 2007; 23: 117-120
        • Feng W.
        • Hendry R.M.
        • Adams R.J.
        Risk of recurrent stroke, myocardial infarction, or death in hospitalized stroke patients.
        Neurology. 2010; 74: 588-593
        • Navi B.B.
        • Kamel H.
        • Sidney S.
        • et al.
        Validation of the Stroke Prognostic Instrument-II in a large, modern, community-based cohort of ischemic stroke survivors.
        Stroke. 2011; 42: 3392-3396
        • Kamouchi M.
        • Kumagai N.
        • Okada Y.
        • et al.
        Risk score for predicting recurrence in patients with ischemic stroke: the Fukuoka stroke risk score for Japanese.
        Cerebrovasc Dis. 2012; 34: 351-357
        • Hong K.S.
        • Yegiaian S.
        • Lee M.
        • et al.
        Declining stroke and vascular event recurrence rates in secondary prevention trials over the past 50 years and consequences for current trial design.
        Circulation. 2011; 123: 2111-2119
        • Rothwell P.M.
        • Coull A.J.
        • Giles M.F.
        • et al.
        Change in stroke incidence, mortality, case-fatality, severity, and risk factors in Oxfordshire, UK from 1981 to 2004 (Oxford Vascular Study).
        Lancet. 2004; 363: 1925-1933
        • Carandang R.
        • Seshadri S.
        • Beiser A.
        • et al.
        Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years.
        JAMA. 2006; 296: 2939-2946
        • Hong K.S.
        • Bang O.Y.
        • Kim J.S.
        • et al.
        Stroke statistics in Korea: part II stroke awareness and acute stroke care, a report from the Korean stroke society and clinical research center for stroke.
        J Stroke. 2013; 15: 67-77
        • Hong K.S.
        • Oh M.S.
        • Choi H.Y.
        • et al.
        Statin prescription adhered to guidelines for patients hospitalized due to acute ischemic stroke or transient ischemic attack.
        J Clin Neurol. 2013; 9: 214-222
        • Toyoda K.
        • Okada Y.
        • Kobayashi S.
        Early recurrence of ischemic stroke in Japanese patients: the Japan standard stroke registry study.
        Cerebrovasc Dis. 2007; 24: 289-295
        • Wong L.K.
        Global burden of intracranial atherosclerosis.
        Int J Stroke. 2006; 1: 158-159
        • Kang J.
        • Park T.H.
        • Lee K.B.
        • et al.
        Symptomatic steno-occlusion in patients with acute cerebral infarction: prevalence, distribution, and functional outcome.
        J Stroke. 2014; 16: 36-43
        • Chimowitz M.I.
        • Lynn M.J.
        • Howlett-Smith H.
        • et al.
        Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis.
        N Engl J Med. 2005; 352: 1305-1316
        • Chimowitz M.I.
        • Lynn M.J.
        • Derdeyn C.P.
        • et al.
        Stenting versus aggressive medical therapy for intracranial arterial stenosis.
        N Engl J Med. 2011; 365: 993-1003
        • Norrving B.
        Long-term prognosis after lacunar infarction.
        Lancet Neurol. 2003; 2: 238-245
        • Benavente O.R.
        • Hart R.G.
        • McClure L.A.
        • et al.
        Effects of clopidogrel added to aspirin in patients with recent lacunar stroke.
        N Engl J Med. 2012; 367: 817-825
        • Wang Y.
        • Zhao X.
        • Liu L.
        • et al.
        Clopidogrel with aspirin in acute minor stroke or transient ischemic attack.
        N Engl J Med. 2013; 369: 11-19
        • Park T.H.
        • Ko Y.
        • Lee S.J.
        • et al.
        Gender differences in the age-stratified prevalence of risk factors in Korean ischemic stroke patients: a nationwide stroke registry-based cross-sectional study.
        Int J Stroke. 2013; 9: 759-765
        • Hong K.S.
        • Bang O.Y.
        • Kang D.W.
        • et al.
        Stroke statistics in Korea: part I. epidemiology and risk factors: a report from the Korean stroke society and clinical research center for stroke.
        J Stroke. 2013; 15: 2-20