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Previous Volume 336:251-257 January 23, 1997 Number 4 Next

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ABSTRACT

Background In patients who have had a myocardial infarction, the long-term risk of stroke and its relation to the extent of left ventricular dysfunction have not been determined. We studied whether a reduced left ventricular ejection fraction is associated with an increased risk of stroke after myocardial infarction and whether other factors such as older age and therapy with anticoagulants, thrombolytic agents, or captopril affect long-term rates of stroke.

Methods We performed an observational analysis of prospectively collected data on 2231 patients who had left ventricular dysfunction after acute myocardial infarction who were enrolled in the Survival and Ventricular Enlargement trial. The mean follow-up was 42 months. Risk factors for stroke were assessed by both univariate and multivariate Cox proportional-hazards analysis.

Results Among these patients, 103 (4.6 percent) had fatal or nonfatal strokes during the study (rate of stroke per year of follow-up, 1.5 percent). The estimated five-year rate of stroke in all the patients was 8.1 percent. As compared with patients without stroke, patients with stroke were older (mean [±SD] age, 63±9 years vs. 59±11 years; P<0.001) and had lower ejection fractions (29±7 percent vs. 31±7 percent, P = 0.01). Independent risk factors for stroke included a lower ejection fraction (for every decrease of 5 percentage points in the ejection fraction there was an 18 percent increase in the risk of stroke), older age, and the absence of aspirin or anticoagulant therapy. Patients with ejection fractions of <28 percent after myocardial infarction had a relative risk of stroke of 1.86, as compared with patients with ejection fractions of >35 percent (P = 0.01). The use of thrombolytic agents and captopril had no significant effect on the risk of stroke.

Conclusions During the five years after myocardial infarction, patients have a substantial risk of stroke. A decreased ejection fraction and older age are both independent predictors of an increased risk of stroke. Anticoagulant therapy appears to have a protective effect against stroke after myocardial infarction.

Source Information

From the Hospital of the University of Pennsylvania, Philadelphia (E.L., M.S.S.); the University of Texas Health Science Center, Houston (C.-C.C.W., L.A.M.); Montreal Heart Institute, Montreal (J.L.R.); the University of Missouri Hospital and Clinics, Columbia (G.C.F.); the University of Maryland Hospital, Baltimore (S.S.G.); Mt. Sinai Medical Center, Miami Beach, Fla. (G.A.L.); and Brigham and Women's Hospital, Boston (S.Z.G., M.A.P.).

Address reprint requests to Dr. Loh at the Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce St., Philadelphia, PA 19104.

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Risk of Stroke after Myocardial Infarction
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N Engl J Med 1997; 336:1916-1917, Jun 26, 1997. Correspondence

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