Young Stroke Survivors With No Early Recurrence at High Long-Term Risk of Adverse Outcomes

Background-Approximately 8% to 21% of strokes affect adults aged <45 years. Although early stroke recurrence conveys the largest risk, long-term risks for young survivors with no early complications are unclear. Methods and Results-Longitudinal matched case-control study (2003-2013). Consecutive patients with ischemic stroke or transient ischemic attack (young, <= 44 years) discharged from emergency or regional stroke centers in Ontario, Canada, with no death, recurrent stroke/transient ischemic attack, myocardial infarction, all-cause hospitalization, or admission to a long-term or continuing care facility (<= 90 days) were matched 10:1 to general population controls on age (+/- 1 year), sex, income, geography, and case date (+/- 50 days). The primary outcome was a composite of death, stroke, myocardial infarction, and long-term or continuing care facility admission at 1, 3, and 5 years. Absolute event rates for young stroke/transient ischemic attack patients were lower than for older patients at 1 (2.2% versus 9.9%), 3 (4.7% versus 24.6%), and 5 (7.1% versus 37.2%) years. However, piecewise constant hazard modeling revealed that, even after adjustment for vascular comorbidities, young patients showed a 7-fold increased hazard of the composite outcome compared with young controls at 1 year (hazard ratio, 7.3; 95% CI, 4.0-13.6). Adjusted 5-year piecewise hazard also remained >5x that of young controls (hazard ratio, 5.2; 95% CI, 2.8-9.4), compared with a 30% increase at 5 years for older patients (hazard ratio, 1.3; 95% CI, 1.3-1.4). Conclusions-Young stable stroke/transient ischemic attack survivors show a higher long-term hazard of adverse outcomes compared with matched controls than older patients. Findings support the need for long-term follow-up and aggressive risk reduction in young survivors and suggest secondary prevention guidelines for these patients are required.