Inpatient Rehabilitation and Major Adverse Cardiovascular Events After Ischemic Stroke

Acute ischemic stroke (AIS) survivors are at high risk of major adverse cardiovascular events (MACE), highlighting the need to identify modifiable secondary prevention targets. We assessed whether postacute discharge destination is associated with 1-year MACE risk among AIS survivors.

In this retrospective cohort study, adult AIS survivors were identified from the state inpatient and emergency department databases of 5 US states (2016-2019) and categorized by discharge destination: home, inpatient rehabilitation facility (IRF), or skilled nursing facility (SNF). Other destinations were excluded. The primary outcome was 1-year MACE, defined as recurrent stroke, acute myocardial infarction, systemic embolism, or vascular death. Multivariable Cox models, adjusted for demographic and clinical factors, were used to evaluate the association between discharge disposition and MACE risk. Fine-Gray models were used for nonfatal secondary outcomes, and restricted mean survival time analyses were used to estimate absolute risk. Effect modification by age (<65 versus ≥65 years) was examined. Confounder-adjusted number-needed-to-be-exposed was estimated by marginal standardization.

Among 213 511 AIS survivors (median age, 71 years), 16 237 (7.6%) experienced MACE within 1-year. MACE incidence was lowest after IRF discharge (6.6%) versus home (7.6%) or SNF (8.3%). In adjusted analyses, IRF discharge was associated with lower MACE risk versus home (adjusted hazard ratio, 0.88 [95% CI, 0.83-0.93]) and SNF (0.84 [95% CI, 0.79-0.89]). The association persisted across age strata but was more pronounced in patients <65 years (P_interaction=0.014). Restricted mean survival time analyses indicated that IRF discharge was associated with 3.47 and 3.87 additional MACE-free days versus home and SNF discharge, respectively (both P<0.001). Adjusted number-needed-to-be-exposed were 115 (95% CI, 80-207) for IRF versus home and 87 (95% CI, 64-136) for IRF versus SNF.

Postacute IRF discharge is associated with a lower 1-year MACE risk after AIS, highlighting the postacute care setting as a potentially modifiable system-level target for secondary prevention of long-term vascular outcomes.