This article has Open Peer Review reports available.
Risk factors and in-hospital outcomes in stroke and myocardial infarction patients
© Ivanusa and Ivanusa; licensee BioMed Central Ltd. 2004
Received: 18 January 2004
Accepted: 05 July 2004
Published: 05 July 2004
Acute stroke (AS) and acute myocardial infarction (AMI) share major risk factors such as age, gender, and high blood pressure. The main objective of this study was to compare vascular risk factor profiles with in-hospital outcomes in AS and AMI patients.
We evaluated 486 consecutive patients who were admitted to Bjelovar General Hospital with diagnoses of AS (ischaemic stroke or intracerebral haemorrhage; N = 380) or AMI (N = 106) during a one year period. The frequency of risk factors and in-patient mortality rates were assessed in both groups. For statistical analysis we used t-tests and χ2 tests.
AS patients were significantly older than AMI patients: the mean age for AS patients was 68.9 ± 9.1 years, and for AMI patients was 62.8 ± 11.7 years (p < 0.001). AMI was significantly more common than AS in patients younger than 65 years; 51% of this group had AMI and 26% had AS (p < 0.001). Hypertension was a more common risk factor in AS patients (69% AS patients vs. 58% AMI patients; p = 0.042). Patients who died did not differ significantly in age between the groups. In-patient mortality rates were significantly higher in AS than AMI cases (31% vs. 12%, p < 0.001 for all patients; 37% vs.5%, p < 0.001 for men). Women hospitalized for AMI were more likely to die in hospital than men (28% vs. 5%; p = 0.002).
We found that age at the time of presentation was a significant differentiating factor between patients with AS and AMI. The only exceptions were women, whose ages at the onset of AS and AMI were similar. In contrast, patients who died did not differ significantly in age. We observed significantly higher inpatient mortality for men (when adjusted for age) than for women with AS. The five-fold higher in-patient mortality rate in women than in men with AMI is most likely to have resulted from other factors related to treatment.
Epidemiological studies [1–5] have shown that acute stroke (AS) and acute myocardial infarction (AMI) have common risk factors such as age, gender and hypertension, but the strength and directions of the associations may be different. Whereas AMI is a disease caused by ischemic changes of the myocardium, the diagnosis of AS refers to a heterogeneous group of cerebrovascular diseases.
Several practice guidelines for prevention and treatment of each of these disorders have recently been published [2, 6–9]. Furthermore, some groups have proposed plans for regionalization of the care of AS and AMI patients [10–13].
A substantial population of patients with AS and AMI receive medical care in regional county hospitals. However, only a few articles [14–16] have evaluated the quality of care in these institutions, which have limited diagnostic and therapeutic facilities.
In our study we examined the differences in demographic characteristics of AS and AMI patients in the county hospital in Croatia, their common risk factors, and the uniformity of recommendations for drugs for secondary prevention of AS and AMI at the time of discharge. We also evaluated the in-patient mortality rates for these two disorders.
Patients and setting
This was a retrospective study of patients admitted to Bjelovar General Hospital. This is the only hospital in Bjelovar-Bilogora County, which is a centrally located region in continental Croatia, with area 2637 km2 and a population of 144,042 inhabitants.
During a one-year period, a total of 486 consecutive patients were admitted to the Department of Neurology with diagnosis of AS and to the Department of Internal Medicine with diagnosis of AMI. Demographic and clinical data, laboratory results, 12-lead ECG findings, lists of all medications and clinical outcome data were collected from medical records and stored in our computer database.
Acute stroke was defined using the World Health Organization (WHO) definition  as "rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 h (unless interrupted by surgery or death) with no apparent cause other than that of vascular origin". Patients with both ischaemic stroke and intracerebral haemorrhage were included in the study.
Acute myocardial infarction was diagnosed according to the WHO definition  when the patients had at least two of the following three criteria: typical chest pain for myocardial ischaemia, initial and serial conventional electrocardiographic changes in standard or precordial leads, and enzymatic evidence of myocardial necrosis.
In-patient mortality rate was used to assess the mortality rates of patients during hospitalization.
Patients with a history of hypertension in their medical records or with three or more successive blood pressure measurements exceeding 140/90 mmHg during hospitalization were considered hypertensive. Patients with left-ventricular failure had symptoms of breathlessness accompanied by basal crepitations, and/or a third heart sound and radiological signs of interstitial or alveolar pulmonary oedema. Diabetes mellitus was determined if a history of this disease had been documented in prior medical records or if patients required dietary sugar restriction, insulin, or oral hypoglycaemic drugs during hospitalization, in addition to the positive criteria for diabetes .
Standard care for AS and AMI patients in our hospital consists of monitoring vital functions, pulmonary function support, repeated blood pressure measurement, glucose metabolism, and fluid and electrolyte evaluation. Acetylsalicylic acid (ASA), hemodilution therapy and neuroprotective agents were used in patients with ischaemic AS. Anti-ischaemic and antiplatelet agents were used in the AMI patients.
Thrombolytic therapy (TT) was used only in AMI patients who had ST-segment elevation and whose onset of disease occurred in less than 12 h. It was administered together with standard or low-molecular-weight heparin, which was also used for patients without persistent ST-segment elevation. TT was not used in the AS patients.
Frequency of use of ASA, beta-blockers, angiotensin converting enzyme inhibitors, calcium blockers, and statins at the time of discharge were also evaluated in both groups of patients.
In general, patients with AS and AMI are hospitalized for 13 to 15 days.
Data were analyzed as mean ± SD for continuous variables and as frequencies for variables on a nominal scale. For group comparisons we used Student's t-test and the χ2 test (Yates corrected test, if indicated, and Fisher exact test for comparisons of small samples). Values of p <0.05 were considered significant.
During a one-year period, 380 patients were treated for AS: 310 (82%) had ischaemic stroke and 70 (18%) had intracerebral haemorrhage. There was no gender difference between the two patient groups. Urgent computerized tomography (CT) was performed on 43% of patients with AS (63% with intracerebral haemorrhage vs. 39% with ischaemic stroke; p < 0.001).
Age (years) and gender of patients with acute stroke and acute myocardial infarction
Men vs. Women
Mean ± SD
Mean ± SD
66.7 ± 9.4
70.8 ± 8.4
p* < 0.001
59.9 ± 11.6
69.7 ± 8.9
p* < 0.001
AS vs. AMI
p* < 0.001
p* = 0.056
64.7 ± 10.5
70.6 ± 8.5
Risk factors and prior medical history in patients with acute stroke and acute myocardial infarction
Percent of patients with a risk factor and
OR† (95% CI)
acute myocardial infarction
Previous myocardial infarction
Prescribed medications in surviving patients with acute stroke (N = 262) and acute myocardial infarction (N = 93)
Percent of patients at discharge who had medication and had
acute myocardial infarction
Calcium channel blockers
Age (years) and gender of patients who died with acute stroke or acute myocardial infarction
Men vs. Women
Mean ± SD
Mean ± SD
68.0 ± 9.1
70.5 ± 8.4
p* = 0.137
66.8 ± 14.0
72.6 ± 10.4
p* = 0.495
AS vs. AMI
p* = 0.868
p* = 0.581
68.0 ± 9.3
70.8 ± 8.7
In-patient mortality rates according to sex and age in acute stroke and acute myocardial infarction
Group (age in years)
No. of patients with the event/ No. of patients in the given group (%) who had
RR† (95% CI)
acute myocardial infarction
We also found a significantly higher mortality rate in patients with intracerebral haemorrhage than with ischaemic stroke (54.3% vs. 25.8%; p < 0.001). In patients with ischemic stroke, mortality in males was higher than in females (31.5% for men vs. 20.9% for women; p = 0.047).
Despite the continuing decline in the incidence of cardiovascular diseases (CVD) in developed countries, the incidence is still increasing in developing nations [2, 3, 5]. In Croatia, for example, death rates from coronary heart disease increased by over 60% in both men and women between 1988 and 1998 .
In the current study, we assessed all patients admitted to Bjelovar General Hospital during a one-year period with AS (ischaemic stroke or intracerebral haemorrhage) and AMI.
Our data show that the number of AS patients admitted was three times greater than the number of AMI patients. We hypothesize that more AMI patients died at home; it has previously been suggested that AMI is the most common cause of sudden death .
The number of acute CT scans performed on our hospitalized AS patients was relatively low, as noted in previous reports from developing countries .
The majority of our AMI patients were men (70%) and this is in agreement with other hospital based registries [22–24]. Further, most of these patients were younger than 65 years, as in the European Network for Acute Coronary Treatment (ENACT) group of patients . In contrast, most of our AS patients were older than 65, as reported in other studies [14, 26, 27]. Nearly one half (47%) of our AS patients were men, which is also consistent with recent studies .
We found more hypertensive patients with AS, and especially with AMI, than some groups have reported [25, 26, 28, 29]. The frequencies of other risk factors did not differ from those reported by other groups [14, 26, 27].
Hospitals vary greatly in their approaches to secondary prevention treatment for AS patients. About 65–70% of our AS patients received ASA and antihypertensive drugs at the time of discharge. Only a very small proportion of AS patients (3%) received statins. The reasons for this were probably uncertainty about the benefit of these drugs and their high cost [14, 26, 30, 31].
The percentage of AMI patients who were given ASA at the time of discharge was similar to that reported in the European Action on Secondary Prevention through Intervention to Reduce Events II (EUROASPIRE II) study . We prescribed ACE inhibitors more frequently than reported in EUROASPIRE II, but fewer patients were prescribed beta-blockers and statins. Critical reviews by the EUROASPIRE I and II groups  and Cohen  argued that such inconsistency in medical practice in Europe and North America is a major problem for reducing the risk of recurrent disease and death.
Our data also showed an increased mortality rate for in-patients with AS compared those with AMI. The overall mortality rate for AMI in-patients was 12.3%, which is similar to other studies using hospital-based registries [33, 34]. The overall mortality rate for AS in-patients was 31.1%, which is similar to the studies from Italy , and Poland  but higher than the rates observed in Western Europe, North America and Australia [14, 21, 22, 25–27, 37–39]. We can partially explain this by the high prevalence of hypertension; also, our patients had higher rates of intracerebral haemorrhage than other groups have reported (18% vs. <15% in Western Europe) . We also observed significantly higher inpatient mortality for men (when adjusted for age) than for women with AS. Previous studies have indicated gender differences in outcome for patients with CVD. Women who present with AMI are older and have more co-morbidity than men; they are more likely to be misdiagnosed, possibly because "atypical" symptoms can potentially delay their treatment and diminish its aggressiveness . This is associated with higher in-patient and outpatient mortality rates for AMI. However, for patients with AS, the influence of gender on outcomes is controversial [40–43].
In summary, we found that age at the time of presentation was a significant factor in patients with AS and AMI. The only exception was that women were of similar ages at the onset of AS and AMI. In contrast, patients who died did not differ significantly in age. The five-fold higher in-patient mortality rate in women than in men with AMI is most likely to be the result of other factors related to treatment. We believed that the major reasons for observed geographical differences in hospital mortality are largely related to methodological differences between studies compared (e.g. local differences in approaches to hospitalization, availability of acute stroke services etc.).
Our study has several limitations. We assessed patients from a single county hospital, which has particular restrictions; so, for example, our CT scanning rates for AS patients were relatively low. Therefore, these findings should not be generalized.
Our results suggest that appropriate measures are needed to reduce the high mortality rates in our patients and to increase the awareness of putative risk factors for patients with cardiovascular disease. At the county level, reducing the burden of AS and AMI will require continuous public education and focus on controlling common risk factors, early recognition of symptoms, and the importance of urgent transport to the hospital. In county hospitals, there is a burning need for easier access to health-care facilities with better and more efficacious organization of the emergency care system. Further, developing countries should improve the management of AS and AMI in hospitals with appropriate evaluation and early treatment of these patients.
- Adams RJ, Chimowitz MI, Alpert JS, Awad IA, Cerqueria MD, Fayad P, Taubert KA: Coronary risk evaluation in patients with transient ischemic attack and ischemic stroke: A scientific statement for healthcare professionals from the Stroke Council and the Council on clinical cardiology of the American Heart Association/American Stroke Association. Circulation. 2003, 108: 1278-1290. 10.1161/01.CIR.0000090444.87006.CF.View ArticlePubMedGoogle Scholar
- De Backer G, Ambrosioni E, Borch-Johnsen K, Brotons C, Cifkova R, Dallongeville J, Ebrahim S, Faergeman O, Graham I, Mancia G, Cats VM, Orth-Gomer K, Perk J, Pyorala I, Rodicio JL, Sans S, Sansoy V, Sechtem U, Silber S, Thomsen T, Wood D: European guidelines on cardiovascular disease prevention in clinical practice – Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of eight societies and by invited experts). Atherosclerosis. 2003, 171: 145-155. 10.1016/j.atherosclerosis.2003.10.001.View ArticlePubMedGoogle Scholar
- Feigin VL, Lawes CMM, Bennett DA, Anderson CS: Stroke epidemiology: A review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol. 2003, 2: 43-53. 10.1016/S1474-4422(03)00266-7.View ArticlePubMedGoogle Scholar
- Truelsen T, Mahonen M, Tolonen H, Asplund K, Bonita R, Vanuzzo D: Trends in stroke and coronary heart disease in the WHO MONICA Project. Stroke. 2003, 34: 1346-1352. 10.1161/01.STR.0000069724.36173.4D.View ArticlePubMedGoogle Scholar
- Yusuf S, Reddy S, Ounpuu S, Anand S: Global burden of cardiovascular diseases: Part I: General considerations, the epidemiologic transition, risk factors, and impact of urbanization. Circulation. 2001, 104: 2746-2753.View ArticlePubMedGoogle Scholar
- Bertrand ME, Simoons ML, Fox KAA, Wallentin LC, Hamm CW, McFadden E, De Feyter PJ, Specchia G, Ruzyllo W: Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2002, 23: 1809-1840. 10.1053/euhj.2002.3385.View ArticlePubMedGoogle Scholar
- Brainin M, Olsen TS, Chamorro A, Diener HC, Ferro J, Hennerici MG, Langhorne P, Sivenius J, For The EUSI Executive Committee And The EUSI Writing Committee: Organization of stroke care: Education, referral, emergency management and imaging, stroke units and rehabilitation. Cerebrovasc Dis. 2004, 1-14. 10.1159/000074816. Suppl 2Google Scholar
- Demarin V, Lovrencic-Huzjan A, Seric V, Vargek-Solter V, Trkanjec Z, Vukovic V, Lupret V, Kalousek M, DeSyo D, Kadojic D, Lusic I, Dikanovic M, Vitas M: Recommendations for stroke management. Neurol Croat. 2002, 51: 41-87.Google Scholar
- Van de Werf F, Ardissino D, Betriu A, Cokkinos DV, Falk E, Fox KAA, Julian D, Lengyel M, Neumann FJ, Ruzyllo W, Thygesen C, Underwood SR, Vahanian A, Verheugt FWA, Wijns W: Management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2003, 24: 28-66. 10.1016/S0195-668X(02)00618-8.View ArticlePubMedGoogle Scholar
- Dalby M, Bouzamondo A, Lechat P, Montalescot G: Transfer for primary angioplasty versus immediate thrombolysis in acute myocardial infarction: A meta-analysis. Circulation. 2003, 108: 1809-1814. 10.1161/01.CIR.0000091088.63921.8C.View ArticlePubMedGoogle Scholar
- Goodacre SW, Morris FM, Campbell S, Arnold J, Angelini K: A prospective, observational study of a chest pain observation unit in a British hospital. Emerg Med J. 2002, 19: 117-121. 10.1136/emj.19.2.117.View ArticlePubMedPubMed CentralGoogle Scholar
- Ivanusa M: Fibrinolytic therapy: What size to fit all?. Circulation. 2003, 108: E170-10.1161/01.CIR.0000108167.21070.15.View ArticlePubMedGoogle Scholar
- Topol EJ, Kereiakes DJ: Regionalization of care for acute ischemic heart disease: A call for specialized centers. Circulation. 2003, 107: 1463-1466. 10.1161/01.CIR.0000063680.45780.A0.View ArticlePubMedGoogle Scholar
- Handschu R, Garling A, Heuschmann PU, Kolominsky-Rabas PL, Erbguth F, Neundorfer B: Acute stroke management in the local general hospital. Stroke. 2001, 32: 866-870.View ArticlePubMedGoogle Scholar
- Polanczyk CA, Lane A, Coburn M, Philbin EF, Dec GW, DiSalvo TG: Hospital outcomes in major teaching, minor teaching, and nonteaching hospitals in New York State. Am J Med. 2002, 112: 255-261. 10.1016/S0002-9343(01)01112-3.View ArticlePubMedGoogle Scholar
- Wee AS, Cooper WB, Chatham RK, Cobb AB, Murphy T: The development of a stroke clinical pathway: An experience in a medium-sized community hospital. J Miss State Med Assoc. 2000, 41: 648-653.PubMedGoogle Scholar
- Gillum RF, Fortmann SP, Prineas RJ, Kottke TE: International diagnostic criteria for acute myocardial infarction and acute stroke. Am Heart J. 1984, 108: 150-158. 10.1016/0002-8703(84)90558-1.View ArticlePubMedGoogle Scholar
- Harris MI, Hadden WC, Knowler WC, Bennett PH: International criteria for the diagnosis of diabetes and impaired glucose tolerance. Diabetes Care. 1985, 8: 562-567.View ArticlePubMedGoogle Scholar
- Petersen S, Peto V, Rayner M: Coronary heart disease statistics. 2003, London: British Heart FoundationGoogle Scholar
- el Fawal MA, Berg GA, Wheatley DJ, Harland WA: Sudden coronary death in Glasgow: Nature and frequency of acute coronary lesions. Br Heart J. 1987, 57: 329-335.View ArticlePubMedPubMed CentralGoogle Scholar
- Brainin M, Bornstein N, Boysen G, Demarin V: Acute neurological stroke care in Europe: Results of the European Stroke Care Inventory. Eur J Neurol. 2000, 7: 5-10. 10.1046/j.1468-1331.2000.007001005.x.View ArticlePubMedGoogle Scholar
- Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U, Sans S: Clinical reality of coronary prevention guidelines: A comparison of EUROASPIRE I and II in nine countries. Lancet. 2001, 357: 995-1001. 10.1016/S0140-6736(00)04235-5.View ArticleGoogle Scholar
- Ivanusa M, Klobucic M, Podravec VS, Ivanusa Z: Age-related differences in presentation and in-hospital outcome of patients with acute myocardial infarction [abstract]. J Hypertens. 2002, R129-Suppl 4Google Scholar
- Di Chiara A, Chiarella F, Savonitto S, Lucci D, Bolognese L, De Servi S, Greco C, Boccanelli A, Zonzin P, Coccolini S, Maggioni AP: Epidemiology of acute myocardial infarction in the Italian CCU network – The BLITZ Study. Eur Heart J. 2003, 24: 1616-1629. 10.1016/S0195-668X(03)00278-1.View ArticlePubMedGoogle Scholar
- Fox KAA, Cokkinos DV, Deckers J, Keil U, Maggioni A, Steg G: The ENACT study: A pan-European survey of acute coronary syndromes. Eur Heart J. 2000, 21: 1440-1449. 10.1053/euhj.2000.2185.View ArticlePubMedGoogle Scholar
- Grieve R, Hutton J, Bhalla A, Rastenyte D, Ryglewicz D, Sarti C, Lamassa M, Giroud M, Dundas R, Wolfe CDA: A comparison of the costs and survival of hospital-admitted stroke patients across Europe. Stroke. 2001, 32: 1684-1691.View ArticlePubMedGoogle Scholar
- Caro JJ, Huybrechts KF, Duchesne I: Management patterns and costs of acute ischemic stroke: An international study. Stroke. 2000, 31: 582-590.View ArticlePubMedGoogle Scholar
- Kjeldsen SE, Julius S, Hedner T, Hansson L: Stroke is more common than myocardial infarction in hypertension: Analysis based on 11 major randomized intervention trials. Blood Press. 2001, 10: 190-192. 10.1080/08037050152669684.View ArticlePubMedGoogle Scholar
- Kannel WB: The Framingham Study: Historical insight on the impact of cardiovascular risk factors in men versus women. J Gend Specif Med. 2002, 5: 27-37.PubMedGoogle Scholar
- Brainin M: Statins and stroke: A promising approach towards stroke prevention. J Clin Basic Cardiol. 2002, 5: 159-162. [http://www.kup.at/kup/pdf/1140.pdf]Google Scholar
- Yoon SS, Dambrosia J, Chalela J, Ezzeddine M, Warach S, Haymore J, Davis L, Baird A: Rising statin use and effect on ischemic stroke outcome. BMC Medicine. 2004, 2: 4-10.1186/1741-7015-2-4.View ArticlePubMedPubMed CentralGoogle Scholar
- Cohen JD: ABCs of secondary prevention of CHD: Easier said than done. Lancet. 2001, 357: 972-973. 10.1016/S0140-6736(00)04252-5.View ArticlePubMedGoogle Scholar
- Kuch B, Bolte HD, Hoermann A, Meisinger C, Loewel H: What is the real hospital mortality from acute myocardial infarction? – Epidemiological vs clinical view. Eur Heart J. 2002, 23: 714-720. 10.1053/euhj.2001.2947.View ArticlePubMedGoogle Scholar
- Zaputovic L, Mavric Z, Mlinaric B, Kupanovac Z, Matana A, Marinovic D: Eligibility of patients with acute myocardial infarction for thrombolytic therapy: Retrospective cohort study. Croat Med J. 2000, 41: 401-405.PubMedGoogle Scholar
- Iemolo F, Beghi E, Cavestro C, Micheli A, Giordano A, Caggia E: Incidence, risk factors and short-term mortality of stroke in Vittoria, southern Italy. Neurol Sci. 2002, 23: 15-21. 10.1007/s100720200018.View ArticlePubMedGoogle Scholar
- Ryglewicz D: Stroke epidemiology in Poland. Acta clin Croat. 1998, 80-83. Suppl 1Google Scholar
- Hall MJ, Owings MF: 2000 National Hospital Discharge Survey. 2002, Hyattsville: National Center for Health StatisticsGoogle Scholar
- Heart, Stroke and Vascular Diseases: Australian Facts 2001. [http://www.aihw.gov.au/publications/cvd/hsvd01/index.html]
- Barakat K, Wilkinson P, Suliman A, Ranjadayalan K, Timmis A: Acute myocardial infarction in women: Contribution of treatment variables to adverse outcome. Am Heart J. 2000, 140: 740-746. 10.1067/mhj.2000.110089.View ArticlePubMedGoogle Scholar
- American Heart Association: 2002 Heart and Stroke Statistical Update. 2002, Dallas, Tex: American Heart AssociationGoogle Scholar
- Arboix A, Oliveres M, Garcia-Eroles L, Maragall C, Massons J, Targa C: Acute cerebrovascular disease in women. Eur Neurol. 2001, 45: 199-205. 10.1159/000052130.View ArticlePubMedGoogle Scholar
- Holroyd-Leduc JM, Kapral MK, Austin PC, Tu JV: Sex differences and similarities in the management and outcome of stroke patients. Stroke. 2000, 31: 1833-1837.View ArticlePubMedGoogle Scholar
- Glader EL, Stegmayr B, Norrving B, Terent A, Hulter-Asberg K, Wester PO, Asplund K: Sex differences in management and outcome after stroke: A Swedish national perspective. Stroke. 2003, 34: 1970-1975. 10.1161/01.STR.0000083534.81284.C5.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://0-www.biomedcentral.com.brum.beds.ac.uk/1471-2458/4/26/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.