Predictors of a 30-day mortality following the first episode of stroke among patients admitted at referral hospitals in Dodoma, central Tanzania: A prospective longitudinal Observational Study
Authors: Chongolo Anna M. , Baraka Alphonce , Mbelele Peter M. , Meda John , Nyundo Azan 
Published: June 2023

Background

Stroke is the leading cause of disability and the second most common cause of death after ischemic heart disease worldwide. A better understanding of the predictors of early post-stroke mortality provides opportunity for interventions that promote favourable post-stroke outcomes.

Objective

This study aimed to determine incidence and risk factors associated with 30-day mortality among adult patients admitted with first episode of stroke at referral hospitals in Dodoma.

Methods

The study employed a prospective longitudinal observational design. Adult patients with confirmed acute stroke by Computed Tomography scan or Magnetic Resonance Imaging, admitted to Dodoma Referral Hospitals were enrolled in the study. The National Institute of Health Stroke Scale was used to assess stroke severity at baseline. A comparison of risk factors, clinical profiles, and mortality was done using the Chi-square test. A binomial logistic regression model was used to determine the predictors of 30 days mortality in patients with stroke while 30-days probability of survival was estimated using Kaplan-Meier analysis.

Results

Out of 226 patients with first-ever stroke, 121(54%) were males and the population mean age was 63(15) years. 140(62%) had Ischaemic stroke subtype, and 154(68%) survived at 30 days of stroke after admission. Patient with history of smoking 2.4 [95% CI (1.0 - 5.6), p = 0.048], loss of consciousness 2.7 [95% CI (1.2 - 6.4; p = 0.019] and unequal pupil size 13.7 [95% CI (4.1 - 58.1, p < 0.001 were significantly more associated with mortality within 30-days. The median survival was 7 (3-9) days, whereas alcohol drinkers and those aged above 60 years had a shorter time to mortality compared to non-alcohol drinkers and those aged < 60 years.

Conclusion

The study reveals high incidence of mortality within 30 days after the first episode of stroke, with the highest proportion die within seven days of being hospitalized. Advanced age of 60 years and above, smokers, alcoholic users, and severe stroke at admission warrant special attention. remains the most catastrophic and disabling conditions, with profound residual impairment and a high fatality rate, that puts a significant strain on community health expenditures as well as patients and their families (1–3). Globally, after ischemic heart disease, stroke is the second leading cause of mortality accounting for 11.8% of total deaths (4). Most of stroke related deaths occur in developing countries, accounting for about 87% of stroke deaths (5). Worldwide, one out of six persons will experience a stroke in their lifetime, with 5 to 10% of all stroke victims being under the age of 50 (6). In a 2004-2006 Tanzanian population-based study, the crude stroke incidence was 107.9 per 100,000 for urban and 94.5 per 100,000 for rural areas, and 315.9 and 108.6 per 100,000 for rural and urban respectively following age standardization (7); interestingly, the study highlighted higher incidence of stroke in urban Tanzania compared to developed countries(7).

The most common conventional risk factors for stroke in Africa are hypertension, diabetes, smoking, a sedentary lifestyle, sickle cell disease, African race, an increasing in ageing population and alcohol abuse (8). Meanwhile, over 80% of published studies in Sub-Saharan Africa (SSA) identify hypertension as the most frequently identified risk factor (9). Both the rapid rise of hypertension and the poor control of blood pressure in Africa contribute to an increase in haemorrhagic stroke, which has a worse outcome than ischemic stroke (10,11).

Thirty-day stroke mortality ranges between 3.1 to 9.7 % in high-income countries (12–14); however, it remains higher in Sub-Saharan Africa, ranging between 27 and 46% (7,15–17). Because of a lack of specialized facilities like stroke units, low- and middle-income countries have a greater stroke death rate than industrialized nations(18). Other predictors include premorbid conditions such as diabetes mellitus, advanced age, the severity of stroke on admission, haemorrhagic type of stroke, and infections (5,19,20). Two previous studies done in Tanzania reported a 33.3% and 61.3% in hospital stroke fatality rates, mortality rate was significantly higher in patients with septicaemia, age above 45 years, and aspiration pneumonia(21)

Given the high global prevalence of stroke, there is limited information on the epidemiology, prevention, treatment, and outcome of stroke in African settings and other LMICs (3,22); therefore, limiting the baseline evidence for designing interventions to reduce this burden in developing countries (23). Consequently, the purpose of this study was to determine predictors of early mortality among adult patients admitted with first episode of stroke in referral hospitals in Dodoma.