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A more accurate estimate of stroke risk in hospitalized patients with COVID-19 infection has come from a large American Heart Association registration study.
Results from the American Heart Association’s COVID-19 Cardiovascular Disease Registry, which included more than 20,000 U.S. adults hospitalized with COVID-19 from March to November 2020, showed an overall ischemic stroke rate of 0.75%.
While that is lower than previous estimates of ischemic stroke risk with severe COVID-19 infection, it is still higher than that seen with other diseases such as influenza or sepsis.
Twice the risk of in-hospital mortality
Results also show that patients who had an ischemic stroke while in hospital for COVID-19 were twice as likely to die compared to those who did not have a stroke.
“These findings suggest that COVID-19 may increase the risk for stroke, although the exact mechanism for this is not known for sure,” said study lead author Saate S. Shakil, MD , a cartographer at the University of Washington in Seattle. “As the pandemic continues, we are discovering that coronavirus is not just a respiratory illness, but a viral infection that can affect many organ systems,” she said. .
The findings were presented on March 19 at the 2021 International Stroke Conference (ISC).
Shakil explained that when the COVID-19 pandemic first appeared, there were reports of ischemic stroke occurring more frequently in hospitalized patients with this disease than would be expected. Studies to date have estimated the stroke rate in COVID-19 patients between 0.9% and 2%, and to date the largest study to examine this involves 8000 patients, she noted.
The current findings come from a much larger database, with the current report enrolling 21,073 hospitalized patients with COVID-19 between March and November 2020.
Results showed that 160 of these patients had an ischemic stroke while in hospital for COVID-19, which translates to a rate of 0.75%.
Patients who had an ischemic stroke were more likely to be older (65 years on average) than hospitalized patients with COVID who did not have a stroke (61 years) and to be male (63% vs. 54%).
Patients who had a stroke were also more likely to have known comorbidities to increase risk for stroke, such as hypertension, atrial fibrillation, diabetes, and pre-existing cerebrovascular disease or a history of stroke. “This is not entirely surprising as these are known to be risk factors for having an ischemic stroke regardless of COVID-19 infection.”
Findings showed that 44% of patients with ischemic stroke had type 2 diabetes compared with about one-third of patients without stroke.
Diabetes was “very common,” occurring in 60% of hospitalized COVID patients who did not have a stroke and in 80% of those who did have a stroke, Shakil noted.
Atrial fibrillation was present in 18% of COVID patients who had an ischemic stroke versus 9% of those without a stroke.
Stroke patients were twice as likely to be seriously ill, as can be seen from intensive care unit admissions, and in need of mechanical ventilation or dialysis compared to those who did not have a stroke, Shakil said.
In addition, those who had an ischemic stroke had twice the number of hospital stays (20 days) compared with 10 days for those who did not have a stroke, and had twice the mortality rate, with in-hospital mortality rates of 37% compared to 16% for those who did not have a stroke.
Black patients have the highest risk of stroke
When the findings were analyzed by race / ethnicity, major racial differences were found, Shakil observed, with pre-represented non-Hispanic black patients among COVID-19 patients who had an ischemic stroke compared to their overall performance in the table. “Interestingly, this trend seems to have reversed among Hispanic patients,” she said.
The number of non-Hispanic white patients with ischemic stroke was similar to their overall representation in the table.
Hispanic patients had the lowest risk for ischemic stroke, at 0.52%; the risk in non-Hispanic whites was 0.75%, and in non-Hispanic whites it was 0.91%. Non-Hispanic blacks made up 26% of the record but 31% of those who experienced an ischemic stroke.
Shakil said she wasn’t sure what she would make of the data about showing lower risk in Hispanic patients. “We’ll look at that going forward.”
“These results are for all entrants in all ethnic groups and the results have not been adjusted for baseline demographics or co-morbidities,” Shakil warned, adding that the researchers plan to conduct further analyzes to understand the drivers of these inequalities.
“We know that COVID-19 pandemic disease has had a disproportionate impact on color communities, but our research shows that Black Americans may have a higher risk of ischemic stroke after get a virus, too, “Shakil said. “Stroke alone can have a devastating effect and overcoming COVID-19 is often a difficult path for those who survive. Together, they can impose a huge tax on patients who have acquired both conditions.”
She said, “It is more important than ever that we prevent the spread of COVID-19 through public health interventions and widespread vaccine circulation.”
ISC news conference moderator of the study, Louise McCullough, MD, PhD, head of neurology at Hermann-Texas Memorial Medical Center, Houston, and chair of the ISC meeting, said this study shows the strength of large numbers.
“It’s really interesting that we’ve been able to get this data in such a short time,” she said. “It really speaks to the value of getting such big data. “
McCullough said the impact of COVID on stroke may not be limited to the actual time in the hospital. “Millions of people have been diagnosed and recovered from this disease and the question is what is it [this] disease over the next ten years for these people? Will there be a long-term slowdown syndrome and is that going to affect future levels of depression and viral infection?
“This is something [that] Following in the footsteps of individuals can be found in these databases, “she said.” Even if COVID disappears next year it will not disappear because of the numbers. large numbers of people affected. “
Mitchell Elkind, MD, professor of neurology at Columbia University in New York City and president of the American Heart Association / American Stroke Association, pointed out that diseases such as seizures or urinary tract disease are common complications of stroke and there is evidence In the presence of stroke, patients with the disease also appear to be at increased risk of developing poststroke depression or dementia.
“Something about having a stroke seems to affect your immune system and that leads to secondary degenerative problems in the brain and if you throw a disease on top of that this can make that problem worse, “he said.” COVID may turn out to be a model for addressing some of these issues as well. “
International Conference on Stroke (ISC) 2021. Summary of Late Breaks 12. Presented March 19, 2021.
The study was funded by the American Heart Association. Shakil did not disclose any material financial relationships.
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