Incidence, characteristics, and consequences of fractures after acute ischemic stroke and TIA-A prospective cohort study

Abstract

Background: Recent advances in acute stroke therapy improved short-term outcome, but some of this benefit may be lost due to post-stroke complications, including fractures.

Aims: We assessed the incidence of fractures before and after stroke and transient ischemic attack (TIA), the risk factors for fractures, and the consequences for mortality, functional outcome, and quality of life.

Methods: Consecutive patients with acute ischemic stroke or TIA from the prospective STROKE-CARD Registry and the randomized controlled STROKE-CARD trial and its long-term follow-up were analyzed. We prospectively assessed all fractures using self-report and documentation, records of hospitals and general practitioners, and electronic health records with all radiographs.

Results: A total of 2513 patients were included (median age = 72 years (interquartile range, IQR = 61-79), 39.2% female). In the first year after the event, 145 individuals (5.8%, 95% confidence interval (CI) = 4.9%-6.7%) experienced 152 fractures corresponding to an incidence rate of 61.87 (95% CI = 52.04-71.71) per 1000 person-years. Rates were similar after stroke and TIA (60.84 and 72.28 per 1000 person-years). The incidence of fractures was more than five times higher compared to the general population (age- and sex-adjusted hazard ratio (HR) for first fracture 5.36, 95% CI = 2.49-11.52). The risk of fractures 1 year before stroke/TIA was also increased (HR = 2.99, 95% CI = 1.39-6.42). Stroke/TIA further increased the risk of fractures as documented by a comparison between fractures 1 year before and 1 year after the event (age- and sex-adjusted risk ratio = 1.69, 95% CI = 1.10-2.58). The main risk factors for fractures were falls and osteoporosis. Fracture after stroke/TIA was associated with death (adjusted odds ratio (aOR) = 2.16, 95% CI = 1.20-3.89), inability to walk (aOR = 2.06, 95% CI = 1.08-3.93), and poor quality of life.

Conclusions: Patients with ischemic stroke and TIA are at high risk for future fractures. Fracture after stroke/TIA is strongly associated with death, poor functional outcome, and reduced health-related quality of life. Therefore, there is a need to incorporate fracture prevention into post-stroke care to improve patient outcomes.

Trial registration: STROKE-CARD Registry (NCT04582825, https://clinicaltrials.gov/study/NCT04582825); STROKE-CARD trial (NCT02156778, https://clinicaltrials.gov/study/NCT02156778); STROKE-CARD long-term follow-up (NCT04205006, https://clinicaltrials.gov/study/NCT04205006).

Keywords: Ischemic stroke; falls; fracture; mortality; prevention; transient ischemic attack.

Graphical abstract

Figure 1.

Consort flow chart of patient inclusion for STROKE-CARD trial and STROKE-CARD Registry.

Figure 2.

Kaplan–Meier curve of the cumulative incidence of fracture risk after ischemic stroke or TIA. Solid line shows the cumulative incidence of fracture after ischemic stroke or TIA with dashed lines indicating 95% CI; the dashed-dotted blue line represents a linear prognosis of fracture risk based on the event rate in the period from 0 to 365 days.