This study aimed to identify the risk factors
of recurrent ischemic stroke in a large crosssectional
sample of Turkish patients. Our results
had confirmed the importance of recurrence as a
complication of ischemic stroke among our ischemic
stroke patients. First of all the recurrence
rate was very prevalent (16.1%) and second,
the hospital outcomes which were indicated as
modified Rankin scores were worse than control
group in recurrence patients.
The clinicians treating stroke patients are confronted
with the question of how to reduce the
risk of a second stroke. The present strategies for
prevention can be divided into management of
comorbidities, life-style modifications, surgical,
and pharmacological interventions.13 Several
comorbidities are known to influence the risk
of recurrent stroke. In particular, hypertension,
diabetes mellitus, carotid stenosis (>70%) and
atrial fibrillation have been shown to be associated
with the risk of recurrent stroke.
It was shown that blood pressure levels are
directly and continuously associated with the
initial occurrence of ischemic stroke.14 However,
there are fewer data about the associations with
recurrence. Irei et al.15 had investigated the
effect of blood pressure in the first admission
and during follow-up with the recurrence rates
in 368 hypertensive stroke patients. In that study,
there was a J-type relation between poststroke
diastolic blood pressure and recurrence stroke.
The stroke recurrence rate was 3.8% per patient
who had a poststroke diastolic blood pressure
of 80-84 mm Hg, significantly lower than others.
Hier et al.4 had confirmed the preventing
effect of the low diastolic blood pressure (≥100
mmHg) (OR: 1.0) in recurrence stroke. In three
other major studies (Copenhagen Stroke Study,
North Manhattan Stroke Study and Framingham
study)5,8,16 hypertension was identified as an
independent risk factor for ischemic stroke.
Lowering blood pressure strongly diminishes
the risk for cardiovascular diseases but also
few studies have evaluated the effect of antihypertensive
treatment after stroke. In the United
Kingdom TIA (UK-TIA) Trial, risk for recurrent
stroke increased by 28% for every incremental
increase of 10 mmHg in systolic blood pressure
from 130 and 160 mmHg.17 The results of the
Perindopril Protection Against Recurrent Stroke
Study (PROGRESS) showed that the blood pressure
is lowered by 9/4 mm Hg on average in
the active treatment group resulting in a 28%
risk reduction of all kinds of major stroke.18
This reduction of risk is extended to patients
with and without hypertension, and those with
and without diabetes. The most beneficial effect
was observed in the patient group receiving the
combination of perindopril plus indapamide
rather than perindopril alone. This result suggested
a hypothesis of that, diuretics in addition
to their antihypertensive action; confer a specific
cerebrovascular effect. Blood pressure-lowering
therapy is now established as the most important
measure for primary and secondary stroke
prevention.19 In the fact that the hypertension
was associated with a 1.9 fold increase in recurrence
underlies the importance of close monitoring
of blood pressure in hypertensive patients
with a previous stroke in our study.
Patients with atrial fibrillation and a first
stroke run a high risk of a second stroke, 12%
per year in European Atrial Fibrillation Trial
(EAFT).20 While in Warfarin-Aspirin Recurrent
Stroke Study (WARSS)21 there weren’t any
difference between aspirin and warfarin for
secondary prevention effect in non-cardioembolic
stroke, in EAFT, anticoagulation therapy
reduced the stroke risk by 75% as compared to
19% by aspirin. In atrial fibrillation and recent
TIA or stroke, the number needed to treat any
anticoagulation to prevent one event per year
is in the range of 12 to 15. In the present study,
a 1.7 relative risk of recurrence found in stroke
patients with atrial fibrillation, emphasizes the
need of routine use of anticoagulation therapy
in these patients. Tight control of anticoagulation
treatment targeting the International Ratio
(INR) between 2.0 and 3.0 should be current
practice.13 But still the physicians are somewhat
hesitant to prescribe this kind of treatment and
stroke patients with atrial fibrillation have poor
compliance.22
Although the recurrent subtype was not
found as a risk factor for recurrence in this
study, in Erlangen Stroke Register23 the patients
with cardioembolic etiology had higher risk for
recurrence over a two-year follow-up (22%)
than other etiological subtypes. Yamamoto and
Bogousslavsky24 showed that recurrent strokes
were most often caused by the same mechanism,
as the index strokes and the most frequent type
was the embolic etiology. But they pointed out
that in many patients, the second and third
strokes had different etiologies than the first
stroke. They pointed out that the recurrent
strokes were often caused by the coexistent
pathology, present at the time of the index event
but not etiologically related to that event. They
assumed that the preventive treatment should be
directed to all potential causes of future strokes
as well as all remediable stroke risk factors. But
the use of anticoagulant therapy in patients who
had their index stroke in cardioembolic stroke
for secondary prevention is a logical and practical
strategy.
As far as we know, this is the only regional
study about this topic in Turkey. Although
Trakya University is the most advanced referral
center in Trakya region, our results might not
represent the epidemiological data of the entire
area. There might be some patients who was out
of our hospital’s referral system, neglected very
mild symptoms, or had fatal episodes in other
medical centers in the study period. These factors
might decrease the apparent rate of recurrence
rate.
In conclusion, the predictors for recurrence
were TIA, hypertension and atrial fibrillation in
our study. Our results emphasize the importance
of close blood pressure monitoring and control in
hypertensive patients and anticoagulation therapy
in patients with atrial fibrillation in prevention
of recurrence. The reasons for the lack of anticoagulation
use in atrial fibrillation patients must
be investigated in future researches.
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