Effect of coexisting vascular disease on long-term risk of recurrent events after TIA or stroke

Abstract

Objective: To determine whether patients with TIA or ischemic stroke with coexisting cardiovascular disease (i.e., history of coronary or peripheral artery disease) are still at high risk of recurrent ischemic events despite current secondary prevention guidelines.

Methods: In a population-based study in Oxfordshire, UK (Oxford Vascular Study), we studied consecutive patients with TIA or ischemic stroke for 2002-2014. Patients were treated according to current secondary prevention guidelines and we determined risks of coronary events, recurrent ischemic stroke, and major bleeding stratified by the presence of coexisting cardiovascular disease.

Results: Among 2,555 patients (9,148 patient-years of follow-up), those (n = 640; 25.0%) with coexisting cardiovascular disease (449 coronary only; 103 peripheral only; 88 both) were at higher 10-year risk of coronary events than those without (22.8%, 95% confidence interval 17.4-27.9; vs 7.1%, 5.3-8.8; p < 0.001; age- and sex-adjusted hazard ratio [HR] 3.07, 2.24-4.21) and of recurrent ischemic stroke (31.5%, 25.1-37.4; vs 23.4%, 20.5-26.2; p = 0.0049; age- and sex-adjusted HR 1.23, 0.99-1.53), despite similar rates of use of antithrombotic and lipid-lowering medication. However, in patients with noncardioembolic TIA/stroke, risk of extracranial bleeds was also higher in those with coexisting cardiovascular disease, particularly in patients aged <75 years (8.1%, 2.8-13.0; vs 3.4%, 1.6-5.3; p = 0.0050; age- and sex-adjusted HR 2.71, 1.16-6.30), although risk of intracerebral hemorrhage was not increased (age- and sex-adjusted HR 0.36, 0.04-2.99).

Conclusions: As in older studies, patients with TIA/stroke with coexisting cardiovascular disease remain at high risk of recurrent ischemic events despite current management. More intensive lipid-lowering might therefore be justified, but benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.

Figure 1. Risks of coronary events, recurrent ischemic stroke, major ischemic vascular events, and major bleeds after TIA or ischemic stroke, stratified by history of coexisting cardiovascular disease

(A) Coronary events. (B) Recurrent ischemic stroke. (C) Major ischemic vascular events. (D) Major bleeds. Major ischemic vascular event was a component of coronary event or recurrent ischemic stroke. Risk of major bleeds was calculated in noncardioembolic patients with TIA or ischemic stroke and after exclusion of those on anticoagulants.

Figure 2. Risks of coronary events and recurrent ischemic stroke after TIA or ischemic stroke, stratified by stroke subtype (Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification)

(A) Coronary events. (B) Recurrent ischemic stroke.

Figure 3. Risks of coronary events, recurrent ischemic stroke, major ischemic vascular events, and major bleeds after TIA or ischemic stroke due to large artery disease (Trial of Org 10172 in Acute Stroke Treatment [TOAST] classification), stratified by history of coexisting cardiovascular disease

(A) Coronary events. (B) Recurrent ischemic stroke. (C) Major ischemic vascular events. (D) Major bleeds. Major ischemic vascular event was a component of coronary event or recurrent ischemic stroke. Risk of major bleeds was calculated in noncardioembolic patients with TIA or ischemic stroke and after exclusion of those on anticoagulants.