Relationship between Hemorrhagic Stroke and Mortality in Chronic Complex Outpatients: Results from a Community Cohort of Patients

Abstract

Question: In the developed countries, around 3-4% of the people could be identified as chronic complex patient and they are increasingly at risk of hemorrhagic stroke. The main objective of this study was to explore risk factors differences in the association of outcome factors on mortality. Material(s) and Method(s): We carried out a multicenter and prospective cohort study of mortality incidence from 01.01.2013 to 30.09.2016 among 932 adult patients registered in the electronic health record of Primary Care as Chronic Complex Outpatient. To predict hazard ratios, mean survival time, and survival probabilities used a multivariate Cox regression. Result(s): 932 CCP cases were included (52.3% women). Average age was 82.5 yr (CI95% 81.8-83.2). During a mean follow-up period of 2.8 years, 65 (6.98%) stroke episodes happened [37 (56.9%) ischemic; 28 (43.1%) hemorrhagic]. The percentage of ICH almost doubled (21.0% to 43.1) after diagnosis as CCP. 26.1% of ICH had polypharmacy (>10); the 57.6% VKA-treated patients evidenced TTR<60% vs 46.7% of ischemic cases, and had higher (p <0.001) bleeding risk/year than ischemic patients; and had a higher incidence of fall (31.9% vs 19.2%, p 0.002). The patients who had a previous ischemic stroke were at a significantly higher risk of death if they have been registered as fall risk. The average survival time was significantly shorter among those with hemorrhagic stroke. In the survival analyses the outcome independent factors were: Charlson score [HR 1.22 CI95% 1.13-1.32, p <0.001], the Barthel <60 score [HR 2.48 CI95% 1.97-3.13, p O.001], the genre male [HR 1.33 CI95% 1.06-1.67, p 0.013], the basal hypertension [HR 1.42 CI95% 1.03-1.96, p 0.029]; and the polypharmacy as protector factor [HR 0.95 CI95% 0.92-0.98, p 0.008]. Conclusion(s): The hemorrhagic episodes in CCP people were associated with previous stroke episode [HR 9.11 CI95% 5.34-15.5, p < 0.001] and fall risk [HR 1.83 CI95% 1.07-3.11, p <0.025). Given the co-occurrence of hemorrhagic strokes with poor performance status, multi-morbidity, and polypharmacy, multi-dimensional interventions are needed to improve health outcomes.