Hankey Graeme J
Stroke Unit, Royal Perth Hospital and Department of Medicine, University of Western Australia, Perth, WA, Australia.
Cerebrovasc Dis. 2003;16 Suppl 1:14-9. doi: 10.1159/000069936.
During the first 30 days after a stroke, the case fatality is about 25% and the major cause of death is the index stroke and its sequelae. The most consistent predictor of 30-day mortality after stroke is stroke severity. Other predictors include increasing age, a history of previous stroke, cardiac failure, and a high blood glucose concentration and white blood cell count. Other less common, but important, causes of early mortality are recurrent ischaemic stroke and a coronary event. The risk of a recurrent cerebrovascular event is highest in the first month (4%) and year (12%) after a stroke and transient ischaemic attack (TIA), probably reflecting the presence of active, unstable atherosclerotic plaque. Thereafter, the risk of a recurrent cerebrovascular event falls to about 5% per year, similar to the risk of a coronary event. During years 1-5 after a TIA and ischaemic stroke, cardiovascular disease increasingly becomes the major cause of death, reflecting the generalized nature of atherothrombosis, the most common cause of the index stroke. The most robust predictor of death within 1-5 years after stroke is increasing age, closely followed by cardiac failure. Additional baseline predictors of longer-term mortality include a history of previous symptomatic atherothrombosis (TIA, ischaemic stroke, peripheral arterial disease, and early-onset ischaemic heart disease), risk factors for atherothrombosis (smoking), other heart diseases (cardiac failure, atrial fibrillation) and increasing stroke severity. Lacunar syndromes can be predictive of relative longevity. At 5 years after stroke, survival is about 40%, and about half of survivors are disabled and dependent. The most robust predictors of disability at 5 years after stroke are increasing age, stroke severity, and recurrent stroke. The most powerful predictor of early recurrent stroke (within 30 days after stroke) is an atherosclerotic ischaemic stroke caused by large-artery atherosclerosis with >50% stenosis, whereas the strongest predictor of stroke recurrence over 5 years is diabetes. Other predictors of recurrent stroke include increasing age, previous TIA, atrial fibrillation, high alcohol consumption, haemorrhagic index stroke, and hypertension at discharge. The clinical implication of these findings is that strategies for optimizing long-term outcome after TIA and stroke should be directed toward reducing the high risk of recurrent stroke and coronary events by removing/recanalizing the symptomatic atherosclerotic plaque, controlling the underlying causal vascular risk factors, and administering long-term, effective antiplatelet therapy.
在中风后的头30天内，病死率约为25%，主要死亡原因是首发中风及其后遗症。中风后30天死亡率最一致的预测因素是中风严重程度。其他预测因素包括年龄增长、既往中风史、心力衰竭、高血糖浓度和白细胞计数。早期死亡的其他不太常见但重要的原因是复发性缺血性中风和冠状动脉事件。中风和短暂性脑缺血发作（TIA）后的第一个月（4%）和第一年（12%），复发性脑血管事件的风险最高，这可能反映了活跃、不稳定的动脉粥样硬化斑块的存在。此后，复发性脑血管事件的风险降至每年约5%，与冠状动脉事件的风险相似。在TIA和缺血性中风后的1至5年里，心血管疾病越来越成为主要死亡原因，这反映了动脉粥样硬化血栓形成的普遍性，而动脉粥样硬化血栓形成是首发中风最常见的原因。中风后1至5年内死亡最有力的预测因素是年龄增长，紧随其后的是心力衰竭。长期死亡率的其他基线预测因素包括既往有症状性动脉粥样硬化血栓形成史（TIA、缺血性中风、外周动脉疾病和早发性缺血性心脏病）、动脉粥样硬化血栓形成的危险因素（吸烟）、其他心脏病（心力衰竭、心房颤动）以及中风严重程度增加。腔隙综合征可预测相对较长的寿命。中风后5年，生存率约为40%，约一半的幸存者有残疾且需要依赖他人。中风后5年残疾最有力的预测因素是年龄增长、中风严重程度和复发性中风。中风后早期复发（中风后30天内）最有力的预测因素是由大动脉粥样硬化导致的狭窄>50%的动脉粥样硬化缺血性中风，而中风复发超过5年的最强预测因素是糖尿病。复发性中风的其他预测因素包括年龄增长、既往TIA、心房颤动、大量饮酒、出血性首发中风以及出院时的高血压。这些发现的临床意义在于，优化TIA和中风后长期预后的策略应旨在通过清除/再通有症状的动脉粥样硬化斑块、控制潜在的因果血管危险因素以及给予长期有效的抗血小板治疗来降低复发性中风和冠状动脉事件的高风险。
