Guang-Rong Fu describes for SIIC his article published in International Journal of Gerontology 9(2):63-66, June 2015

Heng Shui, China (special for SIIC)
The recurrence rate of ischemic stroke in community-based studies has been estimated at approximately 12% during the first year,¹ and is higher in the Chinese compared with Western populations. In the WHO MONICA project study, the reported rates of recurrence after stroke is 27%. Strokes are major contributors to disability and mortality and are a major public health problem. Identification of those patients at high risk of recurrent stroke is critically important for both inpatient management and outpatient care. Previous studies have identified several independent predictors of stroke recurrence, but the predictors of stroke recurrence in the old and the young remain unknown. Therefore, the aim of this study is to investigate the relationship between the clinical characteristics of non-atrial fibrillation patients and stroke recurrence within the first year in order to compare the predicative risk factors of recurrent stroke in non-atrial fibrillation patients younger than 65 years compared to the elderly.

The study was conducted in accordance with the international guidelines and was approved by the ethics committee of the Fifth Hospital of Hengshui China. During the 72-month study period, from January 2009 to January 2012, 1062 patients with ischemic stroke were admitted to our hospital. A total of 1017 patients with a mean age of 63.26 ± 0.61 years (31-87 years) were included in this study. The patients were divided into two groups based on age: < 65 and = 65 years old. The exclusion criteria were transient ischemic attack; intracerebral, intraventricular, or subarachnoid hemorrhage; and cerebral venous infarction. Literature on recurrent stroke have considered gender, smoking history, previous history of ischemic stroke or transient ischemic attack, hypertension, diabetes mellitus, coronary atherosclerotic heart disease, previous myocardial infarction, and smoking as factors. All patients were formally followed up in person by a physician for a period of one year.

In total, we received basic follow-up information for 1017 patients about stroke recurrence.Statistical analysis was performed by using the statistical package for the social sciences (SPSS) 15.5 software. Multivariate analysis was conducted by using stepwise logistic regression and considered all predictors that were significantly associated.Among all patients who completed the follow-up visits, 258 patients had recurrent strokes, Among them, 143 and 115 cases were aged < 65 and = 65 years, respectively.

A study in Taiwan showed differences in the risk factors of stroke between the young and elderly, and a high prevalence of stroke observed were in younger patients, predominantly male, with a history of smoking, hypercholesterolemia, hypertriglyceridemia, and a high body mass index. Compared to elderly patients, these patients were less likely to have atrial fibrillation, a prior history of stroke, systemic infection, upper gastrointestinal bleeding, a low National Institutes of Health Stroke Scale score on admission, or a prolonged hospital stay. Younger patients also showed a higher frequency of stroke of other demonstrated etiology or lacunar infarct compared to elderly patients who were more likely to have a cardio embolism or total anterior circulation infarct. Therefore, our study showed that there are differences predicative in the risk factors of recurrent stroke between younger and elderly stroke patients.

We found that for elderly men, the significant independent predictors of recurrent stroke were previous myocardial infarction, a previous history of ischemic stroke or transient ischemic attack, diabetes mellitus, and coronary atherosclerotic heart disease. For younger men they were hypertension, coronary atherosclerotic heart disease and a previous history of ischemic stroke or transient ischemic attack.

For elderly men with a history of myocardial infarction, the probability of recurrence is 6.761 times that of the same patient with no such history, in keeping with recent literature. Similarly, in elderly men, diabetes mellitus was the risk factor of stroke recurrence. One study outlines only one other published study had identified diabetes mellitus as an independent predictor of recurrent stroke in the elderly.

Our study also found that in elderly men, hypertension was not a risk factor for stroke recurrence. Recent literature shows that there is a higher proportion of stroke of undetermined etiology in the elderly, suggesting that the proportion of small-vessel disease is not high. Wang et al. showed that hypertension is specifically related to recurrent strokes in patients with small-vessel diseases, but not other subtypes of ischemic attack. A previous history of ischemic stroke or transient ischemic attack is a risk factor for complete stroke and stroke recurrence transient ischemic attack. However, some studies found that nearly all cases of transient ischemic attack could eventually lead to recurrence or complete stroke.

This study showed that a history of ischemic stroke or transient ischemic attack was a strong prognostic factor for stroke recurrence, suggesting that their prevention and treatment is important in preventing stroke recurrence. We also found that in younger men, hypertension and coronary atherosclerotic heart were important risk factors. Similar findings suggesting that hypertension and coronary atherosclerotic disease prevention and treatment is important in the prevention of stroke recurrence. We also found that in younger men, diabetes mellitus was not a risk factor. This finding is similar to that of a study from finland, in which DM was reported to be a contributing factor for recurrent stroke mainly in older patients.

Our study had several limitations. First, we chose eight stroke recurrence risk factors that influence each other might have had some influence on the results. Second, our results were based on the history that previous history of ischemic stroke or transient ischemic attack, hypertension, diabetes mellitus, coronary atherosclerotic heart disease, previous myocardial infarction of the stroke patients. Finally, we could not obtain detailed information on the long-term outcomes of the patients.

The independent predictive risk factors of recurrent stroke differ between young and older stroke patients. Our study reconfirmed that a history of IS or TIA was a strong independent prognostic factor for stroke recurrence, suggesting that the prevention and treatment of these conditions. In addition, DM may not play an important role in the risk of stroke recurrence in younger patients.