Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality

Abstract

Objective: To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults.

Methods: We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate.

Results: Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93).

Conclusion: The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

© 2018 American Academy of Neurology.

Figures

Figure 1. Exclusion cascade

HMO = health maintenance organization; ICD-9 = International Classification of Diseases, 9th edition.

Figure 2. Cumulative incidence of 1-year recurrent ischemic stroke in blacks and whites over time, accounting for the competing risk of death

Figure 3. Forest plot for adjusted hazard ratios and 95% confidence intervals for 1-year recurrent ischemic stroke among patients hospitalized with index ischemic stroke

AF = atrial fibrillation; CHD = coronary heart disease; CKD = chronic kidney disease; HF = heart failure; SNF = skilled nursing facility.

Figure 4. Forest plot for adjusted hazard ratios and 95% confidence intervals for 30-day case fatality after hospitalization for ischemic stroke

AF = atrial fibrillation; CHD = coronary heart disease; CKD = chronic kidney disease; HF = heart failure; SNF = skilled nursing facility.