Stroke-heart syndrome: sex-specific incidence, risk factors, and major adverse cardiovascular events in 486,515 patients with incident ischaemic stroke
Authors: Buckley B J R , Harrison S , Hill A , Underhill P , Lane D A , Lip G Y H 
Published: October 2022

Abstract

Background
Newly diagnosed cardiovascular complications post-stroke, termed stroke-heart syndrome, are common and associate with worsened prognosis.

Purpose
To investigate the sex-specific incidence and 5-year major adverse cardiovascular events following stroke-heart syndrome, stratified by pre-existing risk factors (sex, age, obesity, hypertension, type 2 diabetes mellitus, and high LDL cholesterol).

Methods
A retrospective cohort study was conducted using anonymised electronic medical records from 56 participating healthcare organizations. Patients with incident ischaemic stroke aged ≥18 years with 5-years of follow-up were included. Patients diagnosed with new-onset cardiovascular complications (heart failure, severe ventricular arrhythmia, atrial fibrillation, ischaemic heart disease, takotsubo syndrome) within 4-weeks of incident ischaemic stroke (exposure) were 1:1 propensity score-matched (age, sex, ethnicity, comorbidities, cardiovascular care) with ischaemic stroke patients without newly diagnosed cardiovascular complications (control). Cox proportional hazards regression models produced hazard ratios (HR) with 95% confidence intervals (CIs) and Kaplan-Meier curves for 5-year risk of all-cause mortality, recurrent stroke, and acute myocardial infarction (AMI).

Results
Of 486,515 patients with ischaemic stroke, 18% (n=87,786) presented with stroke-heart syndrome (47% (n=41,088) female and 52% (n=45,891) male). Following propensity score matching, composite stroke-heart syndrome associated with significantly higher risk of 5-year mortality (HR 1.66 (95% CI 1.62,1.70), P&lt;0.01), recurrent stroke (1.26 (1.24,1.28), P&lt;0.01), and AMI (2.58 (2.50,2.67), P&lt;0.01). These outcomes were similar for both males and females (Figure 1). The risk of mortality, recurrent stroke and AMI following stroke-heart syndrome was relatively higher for patients aged &lt;75 compared to those &gt;75. The risk of all adverse outcomes were relatively higher for females aged &lt;75 compared to males aged &lt;75. Pre-existing obesity associated with a lower risk of mortality for females and males, but a higher risk of recurrent stroke for females. Pre-existing hypertension associated with a lower risk of all outcomes, except recurrent stroke in males. Pre-existing diabetes associated with higher risks for mortality and AMI for both females and males. High LDL cholesterol associated with lower risk of mortality but a higher risk of recurrent stroke and AMI in males and females (Figure 1).

Conclusions
In this cohort study of patients with incident ischaemic stroke, stroke-heart syndrome occurred in 18% of patients. The overall incidence and subsequent 5-year major adverse cardiovascular events following stroke-heart syndrome were similar for females and males, but with important sex-specific differences when stratified by pre-existing risk factors, including age, obesity, and hypertension.

Funding Acknowledgement
Type of funding sources: None.