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Leukoaraiosis and stroke recurrence risk in patients with and without atrial fibrillation
George Ntaios1, Gregory Y H Lip2, Dimitris Lambrou2
1From the Department of Medicine (G.N., D.L., V.P., K.M.), Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece; University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, Birmingham, UK; Department of Clinical Therapeutics (E.M., K.V.), Medical School of Athens, Alexandra Hospital, Athens; Department of Medicine (H.M.), Ioannina University Hospital, School of Medicine, University of Ioannina; and Department of Neurology (K.S.), Eginition Hospital, University of Athens Medical School, Greece. gntaios@med.uth.gr.
Insights
Leukoaraiosis predicts stroke recurrence in patients without atrial fibrillation (AF). However, it does not improve stroke risk prediction scores like CHADS2 or CHA2DS2-VASc in AF or non-AF patients.
Area of Science:
- Neurology
- Radiology
- Cardiology
Background:
- Leukoaraiosis, a marker of small vessel disease, is associated with stroke.
- Predictive scores like CHADS2 and CHA2DS2-VASc are used to assess stroke recurrence risk.
- The independent prognostic value of leukoaraiosis in relation to these scores is not fully understood.
Purpose of the Study:
- To investigate the association between leukoaraiosis and long-term stroke recurrence risk.
- To determine if leukoaraiosis improves the predictive accuracy of CHADS2 and CHA2DS2-VASc scores.
- To analyze these associations separately in patients with and without atrial fibrillation (AF).
Main Methods:
- Analysis of 1,892 patients from the Athens Stroke Registry.
- Categorization into subgroups based on the presence of atrial fibrillation (AF).
- Cox proportional hazards analysis and Kaplan-Meier analyses to assess predictors of stroke recurrence.
- Likelihood ratio tests to evaluate the added prognostic value of leukoaraiosis to CHADS2 and CHA2DS2-VASc scores.
Main Results:
- Leukoaraiosis was present in 16.9% of patients; AF in 35.4%.
- Leukoaraiosis independently predicted stroke recurrence in non-AF patients (HR 1.86 for CHADS2, HR 1.82 for CHA2DS2-VASc).
- Leukoaraiosis did not predict recurrence in AF patients and did not improve the predictive accuracy of CHADS2 or CHA2DS2-VASc scores in either group.
Conclusions:
- Leukoaraiosis is an independent predictor of stroke recurrence in non-AF stroke patients.
- Leukoaraiosis does not enhance the predictive capabilities of CHADS2 and CHA2DS2-VASc scores for stroke recurrence.
- Findings highlight the prognostic significance of leukoaraiosis in specific stroke patient subgroups.
Objective:
We aimed to investigate the association between leukoaraiosis and long-term risk of stroke recurrence adjusting for clinical scores developed and validated for the prediction of stroke risk, such as CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and stroke or TIA) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or TIA, vascular disease, age 65-74 years, sex category).
Methods:
Study population was derived from the Athens Stroke Registry and was categorized in 2 subgroups according to the presence of atrial fibrillation (AF). Cox proportional hazards analysis was performed to assess the independent predictors of stroke recurrence. To investigate whether leukoaraiosis adds to the prognostic accuracy of CHADS2 and CHA2DS2-VASc scores, we used the likelihood ratio test. Overall model assessment was performed with Nagelkerke R(2) and Harrell C statistic. Kaplan-Meier analyses were also performed.
Results:
Among 1,892 patients, there were 320 (16.9%) with leukoaraiosis and 670 (35.4%) with AF. In the Kaplan-Meier analysis, there was significant difference in cumulative probability of stroke recurrence between patients with and without leukoaraiosis in the non-AF group (p < 0.01), but not in the AF group (p = 0.46). On Cox multivariate analysis, leukoaraiosis was found to be a significant independent predictor of stroke recurrence only in the non-AF group, in the models adjusting for CHADS2 (hazard ratio: 1.86, 95% confidence interval: 1.35-2.56) and CHA2DS2-VASc (hazard ratio: 1.82, 95% confidence interval: 1.32-2.51) scores. Leukoaraiosis was not a predictor of stroke recurrence in the AF group. Leukoaraiosis did not improve the predictive accuracy of the 2 scores, whether in the non-AF group (Harrell C statistic: 0.56 vs 0.59 [p = 0.31] for the model including CHADS2; 0.56 vs 0.59 [p = 0.44] for the model including CHA2DS2-VASc) or the AF group (Harrell C statistic: 0.63 vs 0.62 for the model including CHADS2; 0.64 vs 0.64 for the model including CHA2DS2-VASc).
Conclusions:
Leukoaraiosis is an independent predictor of stroke recurrence in non-AF stroke patients. However, leukoaraiosis did not increase the accuracy of the CHADS2 and CHA2DS2-VASc scores to predict stroke recurrence in AF or non-AF stroke patients.
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