Highlights
- •Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2 (any two coexisting CVD); CASH-3 (any three or all four coexisting CVD).
- •Compared to CASH-0, individuals with CASH-3 had twice the risk of in-hospital mortality, prolonged length of stay on hyperacute stroke units, and disability at discharge; two and half to three times the risk of nosocomial infections within seven days of admission.
- •CASH is a novel and simple outcome risk scale which can used to identify patients who are at increased risk of a variety of stroke associated adverse outcomes.
Abstract
Objective
Indicators for outcomes following acute stroke are lacking. We have developed novel
evidence-based criteria for identifying outcomes of acute stroke using the presence
of clusters of coexisting cardiovascular disease (CVD).
Materials and methods
Analysis of prospectively collected data from the Sentinel Stroke National Audit Programme
(SSNAP). A total of 1656 men (mean age ±SD=73.1yrs±13.2) and 1653 women (79.3yrs±13.0)
were admitted with acute stroke (83.3% ischaemic, 15.7% intracranial haemorrhagic),
1.0% unspecified) in four major UK hyperacute stroke units (HASU) between 2014 and
2016. Four categories from cardiovascular disease Congestive heart failure, Atrial fibrillation, pre-existing Stroke and Hypertension (CASH).were constructed: CASH-0 (no coexisting CVD); CASH-1 (any one coexisting CVD); CASH-2
(any two coexisting CVD); CASH-3 (any three or all four coexisting CVD). These were
tested against outcomes, adjusted for age and sex.
Results
Compared to CASH-0, individuals with CASH-3 had greatest risks of in-hospital mortality
(11.1% vs 24.5%, OR=1.8, 95%CI=1.3-2.7) and disability (modified Rankin Scale score ≥4) at
discharge (24.2% vs 46.2%, OR=1.9, 95%CI=1.4-2.7), urinary tract infection (3.8% vs 14.6%, OR= 3.3, 95%CI= 1.9-5.5), and pneumonia (7.1% vs 20.6%, OR= 2.6, 95%CI= 1.7-4.0); length of stay on HASU >14 days (29.8% vs 39.3%, OR=1.8, 95%CI=1.3-2.6); and joint-care planning (20.9% vs 29.8%, OR=1.4, 95%CI=1.0-2.0).
Conclusions
We present a simple tool for estimating the risk of adverse outcomes of acute stroke
including death, disability at discharge, nosocomial infections, prolonged length
of stay, as well as any joint care planning. CASH-0 indicates a low level and CASH-3
indicates a high level of risk of such complications after stroke.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Stroke and Cerebrovascular DiseasesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chron Dis. 1987; 40: 373-383
- Comorbidity measures for use with administrative data.Med care. 1998; 36: 8-27
- Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases.BMC Health Serv Res. 2008; 8: 1-7
- Impact of multimorbidity on risk and outcome of stroke: Lessons from chronic kidney disease.Int J Stroke. 2020; (Online ahead of print)1747493020975250https://doi.org/10.1177/1747493020975250
- Measuring multimorbidity beyond counting diseases: systematic review of community and population studies and guide to index choice.BMJ. 2020; 368: m160
- Charlson Index comorbidity adjustment for ischemic stroke outcome studies.Stroke. 2004; 35: 1941-1945
- Stroke: the Elixhauser Index for comorbidity adjustment of in-hospital case fatality.Neurology. 2008; 71: 283-287
- Defining and measuring multimorbidity: a systematic review of systematic reviews.Eur J Public Health. 2019; 29: 182-189
- Acute stroke with atrial fibrillation: the Copenhagen Stroke Study.Stroke. 1996; 27: 1765-1769
- Evaluation of anticoagulation status for atrial fibrillation on early ischaemic stroke outcomes: a registry-based, prospective cohort study of acute stroke care in Surrey, UK.BMJ Open. 2017; 7e019122
- Developing an adapted Charlson comorbidity index for ischemic stroke outcome studies.BMC Health Serv Res. 2019; 19: 930
- Effect of rehabilitation setting on dependence following stroke: an analysis of the French inpatient database.Neurorehabil Neural Repair. 2014; 28: 36-44
- Impact of comorbidities on stroke rehabilitation outcomes: does the method matter?.Arch Phys Med Rehabil. 2008; 89: 1903-1906
Royal College of Physicians. Clinical effectiveness and evaluation unit on behalf of the intercollegiate stroke working party. SSNAP January–March 2016. Public Report. https://www.strokeaudit.org/Documents/National/AcuteOrg/2016/2016-AOANationalReport.aspx . Accessed May 09, 2021.
- Anticoagulation therapy in patients with stroke and atrial fibrillation: a registry-based study of acute stroke care in Surrey, UK.BMJ Open. 2018; 8e022558
- New evidence-based A1, A2, A3 alarm time zones for transferring thrombolysed patients to hyper-acute stroke units: faster is better.Neurol Sci. 2019; 40: 1659-1665
- Incidence and prevalence of cardiovascular disease in English primary care: a cross-sectional and follow-up study of the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC).BMJ Open. 2018; 8e020282
- Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice.J Am Geriatr Soc. 1999; 47: 1255-1256
- Eighteen-year trends in stroke mortality and the prognostic influence of comorbidity.Neurology. 2014; 82: 340-350
- Increasing comorbidity and health services utilization in older adults with prior stroke.Neurology. 2016; 87: 2091-2098
- Interobserver agreement for the assessment of handicap in stroke patients.Stroke. 1988; 19: 604-607
- Prestroke disability predicts adverse poststroke outcome: a registry-based prospective cohort study of acute stroke.Stroke. 2020; 51: 594-600
- ESPEN guidelines for nutrition screening 2002.Clin Nutr. 2003; 22: 415-421
- Increased association with malnutrition and malnourishment in older adults admitted with hip fractures who have cognitive impairment and delirium, as assessed by 4AT.Nutr Clin Pract. 2021; 36: 1053-1058https://doi.org/10.1002/ncp.10614
- Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 18. 2019: 439-458
- The global burden of stroke: persistent and disabling.Lancet Neurol. 2019; 18: 417-418
Article info
Publication history
Published online: October 22, 2021
Accepted:
October 3,
2021
Received in revised form:
September 25,
2021
Received:
August 17,
2021
Identification
DOI: https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106162
Copyright
© 2021 Elsevier Inc. All rights reserved.
