Egle Marco, Wang Wei-Chun, Fann Yang C, Johansen Michelle C, Lee Jiunn-Tay, Yeh Chung-Hsin, Jason Lin Chih-Hao, Jeng Jiann-Shing, Sun Yu, Lien Li-Ming, Gottesman Rebecca F
From the National Institute of Neurological Disorders and Stroke (M.E., W.-C.W., Y.C.F., R.F.G.), Intramural Research Program, National Institutes of Health, Bethesda, MD; Department of Neurology (W.-C.W.), China Medical University Hospital, Taichung, Taiwan; Department of Neurology (M.C.J.), The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (J.-T.L.), Tri-Service General Hospital, National Defense Medical Center, Taipei; Department of Nursing (C.-H.Y.), College of Nursing and Health, Da-Yeh University; Department of Neurology (C.-H.Y.), Yuan Rung Hospital, Changhua, Taiwan; Director of Stroke Center (C.-H.J.L.), Department of Neurology Stroke Center, Lin Shin Hospital; Stroke Center and Department of Neurology (J.-S.J.), National Taiwan University Hospital; Department of Neurology (Y.S.), En Chu Kong Hospital, New Taipei City; and Department of Neurology (L.-M.L.), Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.
Neurology. 2024 Mar 12;102(5):e209140. doi: 10.1212/WNL.0000000000209140. Epub 2024 Feb 8.
Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex.
In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models.
Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (-interaction = 0.04).
Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.
多种疾病共存于中风患者中很常见。关于特定的多种疾病共存模式对中风患者长期残疾的影响，人们了解较少。此外，鉴于女性与男性患者中风后残疾情况常见增加，尚不清楚多种疾病共存与两性残疾是否有类似关联。我们评估了特定的多种疾病共存集群是否总体上以及按性别与更大的中风后长期残疾负担相关。
在台湾中风登记处（一个正在进行的全国性前瞻性登记处），纳入首次发生缺血性中风的患者；本分析仅限于中风后存活至少6个月的个体。使用分层聚类方法，基于16个风险因素生成中风前多种疾病共存的集群；该算法识别出5个不同的集群。使用逻辑回归模型确定集群与中风后12个月残疾（使用改良Rankin量表[mRS]定义）之间的关联，并建立按性别分层的额外模型。使用混合效应模型评估多种疾病共存与功能状态变化之间的纵向关联。
纳入了9818例首次发生缺血性中风的患者。无风险因素的集群为参照“更健康”风险组（N = 1373）。患有糖尿病、外周动脉疾病（PAD）和慢性肾病（CKD）集群特征的患者（N = 1882）在1个月（比值比[95%置信区间]=1.36[1.13 - 1.63]）、3个月（比值比[95%置信区间]=1.27[1.04 - 1.55]）和6个月（比值比[95%置信区间]=1.30[1.06 - 1.59]）时残疾（mRS≥3）显著更高，但在12个月时（比值比[95%置信区间]=1.16[0.95 - 1.42]）不比具有更健康风险因素特征的患者高。在按性别分层的分析中，12个月时男性患者与该风险集群的关联保持一致（比值比[95%置信区间]=1.42[1.06 - 1.89]），其合并症负担也更高，但女性患者不一致（比值比[95%置信区间]=0.95[0.71 - 1.26]），女性患者严重中风和严重残疾的比例更高（交互作用 = 0.04）。
台湾患有多种疾病共存的患者，特别是同时患有糖尿病、PAD和CKD的患者，中风后前6个月功能结局较差的几率更高。多种疾病共存集群对女性患者长期残疾的信息可能较少。进一步的研究应评估女性患者中风后残疾更严重的其他机制。
