Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.
Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada.
JAMA Neurol. 2022 May 1;79(5):450-458. doi: 10.1001/jamaneurol.2022.0048.
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.
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.
Recurrent ischemic stroke and/or death, recurrent ischemic stroke, and prevalence of patent foramen ovale (PFO).
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).
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.
在年轻成年人中，约有 40%的缺血性中风是由隐源性中风引起的，其中大多数符合不明来源栓塞性中风（ESUS）的标准。两项随机临床试验，NAVIGATE ESUS 和 RESPECT ESUS，显示年龄较大的 ESUS 患者中风复发率较高，但年轻患者的预后和预后因素尚不确定。
确定年轻成年人中风复发和死亡以及新发心房颤动（AF）的发生率和相关因素。
设计、地点和参与者：这是一项多中心纵向队列研究，纳入了 2017 年 10 月至 2019 年 10 月期间的 41 个中风研究中心的连续患者，年龄在 50 岁及以下，诊断为 ESUS。共筛查了 576 例患者，其中 535 例在 1 例患者撤回同意后被纳入，41 例被认为不符合条件，2 例因其他原因被排除。最后一次随访完成于 520 例患者。
复发性缺血性中风和/或死亡、复发性缺血性中风以及卵圆孔未闭（PFO）的患病率。
参与者的平均（SD）年龄为 40.4（7.3）岁，297 名（56%）参与者为男性。最常见的血管危险因素是吸烟（240 例[45%]）、高血压（118 例[22%]）和血脂异常（109 例[20%]）。在接受经胸超声心动图和气泡研究的 177 名参与者（50%）中发现了 PFO。在最初的 ESUS 之后，468 名参与者（88%）正在接受抗血小板治疗，52 名（10%）接受抗凝治疗。缺血性中风和死亡率为 2.19/100 患者年，缺血性中风复发率为 1.9/100 患者年。在复发性中风中，9 例（64%）为 ESUS，2 例（14%）为心源性栓塞，3 例（21%）为其他明确病因。15 名患者（2.8%；95%CI，1.6-4.6）检测到 AF。多变量分析显示，以下因素与复发性缺血性中风相关：中风或短暂性脑缺血发作史（风险比，5.3；95%CI，1.8-15）、糖尿病（风险比，4.4；95%CI，1.5-13）和冠心病史（风险比，10；95%CI，4.8-22）。
在这项大型年轻成年 ESUS 患者队列中，随后发生缺血性中风的比率相对较低，新发 AF 的频率也较低。大多数复发性中风也符合 ESUS 的标准，这表明需要进一步研究，以提高我们对该人群中风机制的理解。
