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- Title
Evaluating Rates of Recurrent Ischemic Stroke Among Young Adults With Embolic Stroke of Undetermined Source: The Young ESUS Longitudinal Cohort Study.
- Authors
Perera, Kanjana S.; de Sa Boasquevisque, Danielle; Rao-Melacini, Purnima; Taylor, Amanda; Cheng, Anna; Hankey, Graeme J.; Lee, Sarah; Fabregas, Joan Marti; Ameriso, Sebastian F.; Field, Thalia S.; Arauz, Antonio; Coutts, Shelagh B.; Arnold, Marcel; Mikulik, Robert; Toni, Danilo; Mandzia, Jennifer; Veltkamp, Roland C.; Meseguer, Elena; Haeusler, Karl Georg; Hart, Robert G.
- Abstract
Key Points: Question: What are the rates of recurrent ischemic stroke and new-onset atrial fibrillation (AF) in younger adults with embolic stroke of undetermined source (ESUS), and what factors are associated with these prognoses? Findings: In this longitudinal cohort study of 535 patients, recurrent stroke risk was 1.9 per 100 patient-years. History of stroke or transient ischemic attack, diabetes, and coronary artery disease were associated with recurrence, and AF was detected in 2.8% of participants during follow-up. Meaning: These findings suggest that young adults with ESUS may have a relatively low rate of subsequent ischemic stroke and new-onset AF compared with older adults. This cohort study evaluates rates of and factors associated with recurrent ischemic stroke and death as well as new-onset atrial fibrillation among younger adults. Importance: Cryptogenic strokes constitute approximately 40% of ischemic strokes in young adults, and most meet criteria for the embolic stroke of undetermined source (ESUS). Two randomized clinical trials, NAVIGATE ESUS and RESPECT ESUS, showed a high rate of stroke recurrence in older adults with ESUS but the prognosis and prognostic factors among younger individuals with ESUS is uncertain. Objective: To determine rates of and factors associated with recurrent ischemic stroke and death and new-onset atrial fibrillation (AF) among young adults. Design, Setting, and Participants: This multicenter longitudinal cohort study with enrollment from October 2017 to October 2019 and a mean follow-up period of 12 months ending in October 2020 included 41 stroke research centers in 13 countries. Consecutive patients 50 years and younger with a diagnosis of ESUS were included. Of 576 screened, 535 participants were enrolled after 1 withdrew consent, 41 were found to be ineligible, and 2 were excluded for other reasons. The final follow-up visit was completed by 520 patients. Main Outcomes and Measures: Recurrent ischemic stroke and/or death, recurrent ischemic stroke, and prevalence of patent foramen ovale (PFO). Results: The mean (SD) age of participants was 40.4 (7.3) years, and 297 (56%) participants were male. The most frequent vascular risk factors were tobacco use (240 patients [45%]), hypertension (118 patients [22%]), and dyslipidemia (109 patients [20%]). PFO was detected in 177 participants (50%) who had transthoracic echocardiograms with bubble studies. Following initial ESUS, 468 participants (88%) were receiving antiplatelet therapy, and 52 (10%) received anticoagulation. The recurrent ischemic stroke and death rate was 2.19 per 100 patient-years, and the ischemic stroke recurrence rate was 1.9 per 100 patient-years. Of the recurrent strokes, 9 (64%) were ESUS, 2 (14%) were cardioembolic, and 3 (21%) were of other determined cause. AF was detected in 15 participants (2.8%; 95% CI, 1.6-4.6). In multivariate analysis, the following were associated with recurrent ischemic stroke: history of stroke or transient ischemic attack (hazard ratio, 5.3; 95% CI, 1.8-15), presence of diabetes (hazard ratio, 4.4; 95% CI, 1.5-13), and history of coronary artery disease (hazard ratio, 10; 95% CI, 4.8-22). Conclusions and Relevance: In this large cohort of young adult patients with ESUS, there was a relatively low rate of subsequent ischemic stroke and a low frequency of new-onset AF. Most recurrent strokes also met the criteria for ESUS, suggesting the need for future studies to improve our understanding of the underlying stroke mechanism in this population.
- Publication
JAMA Neurology, 2022, Vol 79, Issue 5, p450
- ISSN
2168-6149
- Publication type
Article
- DOI
10.1001/jamaneurol.2022.0048