Incidence, trends, and predictors of ischemic stroke 1 year after an acute myocardial infarction.

BACKGROUND AND PURPOSE: Ischemic stroke after acute myocardial infarction is an important complication. It is unknown whether the risk has changed because the treatment of acute myocardial infarction has improved during the past decade. There is also conflicting data about predictors of stroke risk. METHODS: To obtain the 1-year incidence of stroke after acute myocardial infarction, the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions database for the years 1998 to 2008 was merged with the Swedish National Patient Register (NPR). The time trend was studied by dividing the entire time period into 5 separate periods. Independent predictors were identified using a multivariable Cox proportional hazards regression model. RESULTS: Between 1998 and 2008, 7185 of 173 233 patients with acute myocardial infarction had an ischemic stroke within 1 year (4.1%). There was a 20% relative risk reduction during the study period (1998-2000 versus 2007-2008) relative risk 0.80 (95% confidence interval, 0.75-0.86; P<0.001. Independent predictors of stroke were age, female sex, ST-segment-elevation myocardial infarction, previous stroke, previous diabetes mellitus, heart failure at admission, angiotensin-converting enzyme inhibitor treatment and atrial fibrillation. Reperfusion treatment with fibrinolysis and percutaneous coronary intervention and treatment with aspirin, P2Y12-inhibitors, and statins predicted a reduced risk of stroke. CONCLUSIONS: The risk of ischemic stroke within a year after myocardial infarction is substantial but has clearly been reduced during the studied time period. The major predictive factors found to correlate well with previous investigations. Reperfusion treatment, thrombocyte aggregation inhibition, and lipid lowering are the main contributors to the observed risk reduction.

The Nurse-Based Age Independent Intervention to Limit Evolution of Disease After Acute Coronary Syndrome (NAILED ACS) Risk Factor Trial: Protocol for a Randomized Controlled Trial.

BACKGROUND: Secondary prevention after acute coronary syndrome (ACS) is essential to reduce morbidity and mortality, but related studies have been fairly small or performed as clinical trials with non-representative patient selection. Long-term follow-up data are also minimal. A nurse-led follow-up for risk factor improvement may be effective, but the evidence is limited. OBJECTIVE: The aims of this study are to perform an adequately sized, nurse-led, long-term secondary preventive follow-up with inclusion of an unselected population of ACS patients. The focus will be on lipid and blood pressure control as well as tobacco use and physical activity. METHODS: The study will consist of a randomized, controlled, long-term, population-based trial with two parallel groups. Patients will be included during the initial hospital stay. Important outcome variables are total cholesterol, low-density lipoprotein (LDL) cholesterol, and sitting systolic and diastolic blood pressure. Outcomes will be measured after 12, 24, and 36 months of follow-up. Trained nurses will manage the intervention group with the aim of achieving set treatment goals as soon as possible. The control group will receive usual care. At least 250 patients will be included in each group to reliably detect a difference in mean LDL of 0.5 mmol/L and in mean systolic blood pressure of 5 mmHg. RESULTS: The study is ongoing and recruitment of participants will continue until December 31, 2014. CONCLUSIONS: This study will test the hypothesis that a nurse-led, long-term follow-up after an ACS with a focus on achieving treatment goals as soon as possible is an effective secondary preventive method. If proven effective, this method could be implemented in general practice at a low cost. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN): 96595458; http://www.controlled-trials.com/ISRCTN96595458 (Archived by WebCite at http://www.webcitation.org/6RlyhYTYK).

Incidence, trends, and predictors of ischemic stroke 30 days after an acute myocardial infarction.

BACKGROUND AND PURPOSE: Ischemic stroke is a known complication of acute myocardial infarction (AMI). Treatment of AMI has undergone great changes in recent years. We aimed to investigate whether changes in treatment corresponded to a lower incidence of ischemic stroke and which factors predicted ischemic stroke after AMI. METHODS: Data were taken from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions. Patients with their first registered AMI between 1998 and 2008 were included. To identify ischemic strokes, we used the Swedish national patient register. To study a potential trend in the incidence of ischemic stroke after AMI over time, we divided the patient population into 5 time periods. Event-free survival was studied by Kaplan-Meier analysis. Cox proportional hazards regression model was used to identify stroke predictors. RESULTS: Of 173,233 patients with AMI, 3571 (2.1%) developed ischemic stroke within 30 days. The incidence of ischemic stroke was significantly lower during the years 2007 to 2008 compared with 1998 to 2000, with respective rates of 2.0% and 2.2% (P=0.02). Independent predictors of an increased risk of stroke were age, female sex, prior stroke, diabetes mellitus, atrial fibrillation, clinical signs of heart failure in hospital, ST-segment-elevation myocardial infarction, coronary artery bypass grafting, and angiotensin-converting enzyme inhibitor treatment at discharge. Percutaneous coronary intervention, fibrinolysis, acetylsalicylic acid, statins, and P2Y12 inhibitors were predictors of reduced risk of stroke. CONCLUSIONS: The incidence of ischemic stroke within 30 days of an AMI has decreased during the period 1998 to 2008. This decrease is associated with increased use of acetylsalicylic acid, P2Y12 inhibitors, statins, and percutaneous coronary intervention.