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Stroke in Adults With Congenital Heart Disease
Study Questions:
What are the incidence, cumulative risk, and predictors of stroke in adults with congenital heart disease (ACHD)?
Methods:
A retrospective, population-based, cohort study was performed using the Québec Congenital Heart Disease Database.
Results:
A total of 29,638 ACHD patients ages 18-64 years were studied from 1998-2010. The cumulative risk of ischemic stroke estimated up to age 64 was 6.1% (95% confidence interval [CI], 5.0-7.0%) in women and 7.7% (95% CI, 6.4-8.8%) in men. The risk of hemorrhagic stroke was 0.8% (95% CI, 0.4-1.2%) in women and 1.3% (95% CI, 0.8-1.8%) in men. Compared to rates reported for the general population, age-sex-standardized incidence rates of ischemic stroke were 9-12 times higher below age 55 and 2-4 times higher for those ages 55-64 years. Hemorrhagic stroke rates were 5-6 times higher than the general population for the younger group and 2-3 times higher for the older group. Using a combination of stepwise model selection and Bayesian model averaging, the strongest predictors of ischemic stroke were heart failure (odds ratio [OR] for age group 18-49 years, 5.94 [95% CI, 3.49-10.14]; age group 50-64 years: OR, 1.68 [95% CI, 1.06-2.66]), diabetes (OR, 2.33 [95% CI, 1.66-3.28]), and recent myocardial infarction (OR, 8.38 [95% CI, 1.77-39.58]).
Conclusions:
The authors concluded that stroke incidence is considerably higher for ACHD than the general population. This is particularly true in younger patients. The most important predictors for ischemic stroke were heart failure, diabetes, and recent myocardial infarction.
Perspective:
This population-based study assessed the incidence of ischemic and hemorrhagic stroke in patients with CHD using a provincial database. The incidence of stroke was much higher in patients with CHD than in the general population. Given the high rate of atrial arrhythmias in patients with CHD, one might speculate that atrial arrhythmia might have been associated with increased risk for stroke. However, this did not appear to be an independent predictor in this population. Generic risk factors such as heart failure, diabetes, and recent myocardial infarction did appear to be significant. Given the high rate of stroke, it will be important to better understand the etiology and determine whether indications for anticoagulation need to be broadened in this patient population.
Keywords: Arrhythmias, Cardiac, Diabetes Mellitus, Heart Defects, Congenital, Heart Failure, Intracranial Hemorrhages, Myocardial Infarction, Risk Factors, Stroke
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