The Incidence of Stroke after Myocardial Infarction: A Meta-Analysis

doi:10.1016/j.amjmed.2005.10.058

The American Journal of Medicine

Volume 119, Issue 4, April 2006, Pages 354.e1-354.e9

https://doi.org/10.1016/j.amjmed.2005.10.058 Get rights and content

Abstract

Purpose

While the risk of stroke after myocardial infarction (MI) is increased compared with the risk among those without MI, the magnitude of this risk remains unclear. Although numerous clinical trials have reported the incidence of stroke following MI, these are among selected populations. We reviewed cohort studies reporting the incidence of stroke after MI to better define the risk of ischemic stroke in an unselected population.

Methods

A computerized literature search (MEDLINE and PubMed) and manual review of reference lists of identified articles were conducted. Population-based studies published from 1978-2004 with at least 100 subjects that reported number or percent of ischemic strokes experienced by MI survivors were identified. Data were extracted using standardized forms, and study quality was assessed by 2 independent reviewers. Ischemic stroke rates were reported as number of events per 1000 MI with 95% confidence intervals (CI) calculated by Poisson distribution. A combined stroke rate was calculated for in-hospital, 30 days, and 1-year post-MI using weights of 1/variance. A random-effects model also was created to estimate in-hospital stroke rate. Variability in study designs and outcome definitions limit synthesis of available data.

Results

During hospitalization for the index MI, 11.1 ischemic strokes occurred per 1000 MI compared with 12.2 at 30 days and 21.4 at 1 year. Using a random-effects model, 14.5 strokes occurred per 1000 MI. Positive predictors of stroke after MI included: advanced age, diabetes, hypertension, history of prior stroke, anterior location of index MI, prior MI, atrial fibrillation, heart failure, and nonwhite race.

Conclusions

The public health implications of stroke among MI survivors, as well as the large number of MI survivors, underscore the need to be aware of this devastating complication. Further research is needed to determine the optimal stroke prevention strategies for MI survivors.

Section snippets

Methods

The primary investigator (BJW) searched two medical literature databases (MEDLINE and PubMed) using the medical subject headings “myocardial infarction” and “cerebrovascular accident,” and all subheadings. Search terms were entered individually into the OVID search engine (OVID Technologies, Inc., New York, NY) and exploded, then combined using the “and” operator. Non-English language studies were included and evaluated with language assistance when needed from the Mayo Clinic Translation

Results

The search of PubMed resulted in 1508 articles, and a search in MEDLINE resulted in 903 articles. As shown in Figure 1, evaluation of these articles for relevance and by the inclusion and exclusion criteria yielded 9 articles from MEDLINE and 9 articles from PubMed for inclusion in the study. Manual search of the reference lists of these 18 articles yielded another 4 articles, resulting in a total of 22 articles included in this review, presented in Table 1.

Stroke Rate and Its Implications

In order to provide an estimate of the stroke rate after MI in the community, we performed a meta-analysis of the observational studies while excluding reports from clinical trials. Additionally, the exclusion of clinical trials avoids the potential bias introduced by incomplete ascertainment of the large number of clinical trials in this field. The pooled stroke rate of 14.5 events per 1000 MI is markedly lower than the rate found among persons in Olmsted County,²⁷ a much higher rate as

Conclusion

Although the absolute number of persons experiencing stroke after MI is relatively small, the public health implications are important. As the population ages and more persons experience MI, the absolute number of persons experiencing stroke after MI also increases. Furthermore, the cost of caring for one stroke is large, thus, prevention of this devastating complication is also paramount from an economic perspective. The risk appears highest early after MI, a finding corroborated by other

Acknowledgment

We thank Apoor S. Gami, MD and Francesca Bursi, MD for assistance with the quality analysis, Ryan Lennon for assistance with the statistical analysis, and Kristie Shorter for secretarial support.

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: This study was funded by NIH grants HL07111-28, R01HL59205, and K24 HL68765.

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ReviewThe Incidence of Stroke after Myocardial Infarction: A Meta-Analysis

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Methods

Results

Stroke Rate and Its Implications

Conclusion

Acknowledgment

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

Control Clin Trials

Control Clin Trials

Control Clin Trials

J Clin Epidemiol

Mayo Clin Proc

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Atherosclerosis

Am J Cardiol

J Am Coll Cardiol

Am J Med

Heart and Stroke Statistical Update

Dyslipidemia, other risk factors, and the prevention of coronary heart disease

Pathogenesis, classification, and epidemiology of cerebrovascular disease

Atherogenesis and its determinants

Percutaneous coronary intervention

The risk of stroke following coronary revascularization-a population-based, long-term study

Scand Cardiovasc J

Acute myocardial infarction complicated by atrial fibrillation in the elderlyprevelence and outcomes

Circulation

Right atrial appendage thrombosis in atrial fibrillationits frequency and its clinical predictors

Am J Cardiol

Neurovascular disorders

Treatment and prevention of stroke

Quality scores are useless and potentially misleading

Am J Epidemiol

Myocardial infarction and stroke

Neurology

Myocardial infarction, thrombolytic therapy, and stroke

Stroke

Review
The Incidence of Stroke after Myocardial Infarction: A Meta-Analysis