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From the Duke Clinical Research Institute, Durham, North Carolina
(K.W.M., C.B.G., T.D.T., R.M.C.); University of Maryland School of Medicine,
Baltimore (M.A.S.); University of Massachusetts Medical Center, Worcester
(J.M.G.); University of Washington, Seattle (W.D.W.); Green Lane Hospital,
Auckland, New Zealand (H.D.W.); Thoraxcenter, Erasmus University, Rotterdam,
The Netherlands (M.L.S.); Sourasky Medical Center, Tel Aviv, Israel (G.I.B.);
and the Cleveland Clinic Foundation, Cleveland, Ohio (E.J.T.).
E-mail mahaf002{at}mc.duke.edu
Methods and Results—We studied the 247 patients with
nonhemorrhagic stroke who were randomly assigned to one of four
thrombolytic regimens within 6 hours of symptom onset
in the GUSTO-I trial. We assessed the univariable and
multivariable baseline risk factors for nonhemorrhagic stroke and
created a scoring nomogram from the baseline multivariable
modeling. We used time-dependent Cox modeling to determine
multivariable in-hospital predictors of nonhemorrhagic stroke.
Baseline and in-hospital predictors were then combined to determine the
overall predictors of nonhemorrhagic stroke. Of the 247 patients, 42
(17%) died and another 98 (40%) were disabled by 30-day follow-up.
Older age was the most important baseline clinical predictor of
nonhemorrhagic stroke, followed by higher heart rate, history of stroke
or transient ischemic attack, diabetes, previous angina, and
history of hypertension. These factors remained statistically
significant predictors in the combined model, along with worse Killip
class, coronary angiography, bypass surgery, and atrial
fibrillation/flutter.
Conclusions—Nonhemorrhagic stroke is a serious event in patients
with acute myocardial infarction who are treated with
thrombolytic, antithrombin, and antiplatelet
therapy. We developed a simple nomogram that can predict the risk of
nonhemorrhagic stroke on the basis of baseline clinical
characteristics. Prophylactic anticoagulation may be an
important treatment strategy for patients with high probability for
nonhemorrhagic stroke, but further study is needed.
Recently, multivariable regression models have been developed to
help identify patients at increased risk for intracranial
hemorrhage after thrombolysis, including a
model based on the GUSTO-I trial
experience.7 8 9 13 14 15 16 Less is known about the
risk factors for nonhemorrhagic stroke in patients with acute
myocardial infarction treated with thrombolytic
therapy, although several investigators have reported clinical and
echocardiographic factors associated with an increased
risk for nonhemorrhagic
stroke.7 8 10 11 12 17 18 19 20 21 22 23 24 25
We used prospectively collected information from the GUSTO-I trial for
patients with and without nonhemorrhagic stroke to determine
independent risk factors associated with in-hospital nonhemorrhagic
stroke in patients with acute myocardial infarction treated with
thrombolytic therapy.
Definitions
Sustained Hypotension
Cardiogenic Shock
Congestive Heart Failure
Killip Class
Ejection Fraction
Data Collection
Nonhemorrhagic Stroke Adjudication
Patient Functional Assessment
Statistical Analysis
We created a scoring nomogram on the basis of coefficients from the
baseline multivariable regression modeling. Each independent
predictor was assigned a particular score according to its predictive
value. The sum of the scores indicates the probability of a
nonhemorrhagic stroke based on baseline predictors for individual
patients (F. E. Harrell: Design S plus functions for
biostatistical/epidemiological modeling, testing, estimation,
validation, graphics, prediction, and typesetting by storing enhanced
model design attributes in the fit. UNIX version available from
statlib@lib.stat.cmu.edu; 1996).
The baseline clinical characteristics for the 246 patients with
in-hospital nonhemorrhagic stroke (1 patient had a nonhemorrhagic
stroke after hospital discharge and 30-day follow-up and is not
included in the analyses) and the 40 688 patients without
nonhemorrhagic stroke are shown in Table 2
Patients with nonhemorrhagic stroke were more likely to have adverse
in-hospital events and bypass surgery (Table 3
Baseline Multivariable Predictors
In-hospital Multivariable Predictors
Combined Multivariable Predictors
Several investigators have reported that patients with increased
age,7 8 10 anterior myocardial
infarction,8 10 11 and worse Killip
class7 10 are at increased risk for
nonhemorrhagic stroke. In our analysis, anterior infarct was
not a univariable predictor of nonhemorrhagic stroke, although
there was a trend toward a higher incidence of anterior infarction in
patients with nonhemorrhagic stroke than in those without stroke
(44.5% versus 39.0%; P=.13). In addition, isolated apical
infarct and combined anteroapical infarct also were not statistically
significant univariable predictors of nonhemorrhagic stroke
(
From 28% to 40% of patients with anterior infarction and 0% to 1.5%
of patients with inferior infarction have a left
ventricular thrombus, according to small
echocardiographic studies performed primarily in the
era before the routine use of thrombolysis and
aggressive anticoagulation.17 18 19 20 23 24 25 The
incidence of systemic embolization was 0% to 33% in patients with
documented thrombus, lower in patients receiving anticoagulation, and
exceedingly rare in patients with no observed
thrombus.17 18 19 20 21 22 23 24 25 Echocardiographic
features associated with an increased risk of embolization include
older age,19 larger thrombus
size,19 thrombus
mobility,20 21 22 23 and pendulousness of the
clot.19 20 21 22 23 Because
echocardiography was not mandated by the GUSTO-I
protocol, the incidence of left ventricular thrombus in the
GUSTO-I population is unknown. In addition, data were not collected on
warfarin therapy, which may have influenced these findings. Further
study is required to clarify the relationship among location of
infarction, incidence of thrombus, impact of anticoagulation, and risk
of nonhemorrhagic stroke.
The incidence of stroke associated with the procedures and events that
this study found to correlate with increased risk of nonhemorrhagic
stroke—specifically, atrial fibrillation/flutter, cardiac
catheterization, and coronary artery bypass
surgery—has been well established by previous investigators. The risk
of stroke in patients with nonvalvular atrial fibrillation is
A unique aspect of this study was the incorporation of in-hospital
events in the analysis, to examine not only baseline clinical
characteristics but also in-hospital factors common in patients after
acute myocardial infarction—such as atrial arrhythmias,
coronary interventions, and bypass surgery—that may predict
nonhemorrhagic stroke. The finding of the Fibrinolytic Therapy
Trialists' Cooperative Group that 62% of the nonhemorrhagic strokes
in patients treated with thrombolysis occurred >24
hours after enrollment emphasizes the importance of this
analysis.6 In addition, 60% of
nonhemorrhagic strokes in the GUSTO-I trial occurred >48 hours after
randomization (Fig. 2
Study Limitations
Because information was not collected about the use of warfarin
therapy, the impact of anticoagulation in this patient population
cannot be assessed. In addition, information was not collected about
postdischarge events (other than mortality and procedures that may be
associated with nonhemorrhagic stroke). However, only one
nonhemorrhagic stroke occurred after hospital discharge and before
30-day follow-up. A proportion of the GUSTO-I population may have had a
cerebrovascular event that was
pathophysiologically related to the index
myocardial infarction >30 days after enrollment.
In the in-hospital model, patients who presented with or
developed atrial fibrillation/flutter (compared with those without the
arrhythmia) were at higher risk for nonhemorrhagic stroke.
However, in the baseline multivariable model, atrial
fibrillation/flutter at enrollment did not independently predict
nonhemorrhagic stroke. Duration of atrial fibrillation/flutter before
enrollment, which we were unable to assess, may have been a
contributing factor.
The GUSTO-I stroke dataset, which included 247 nonhemorrhagic stroke
patients, is the largest single-trial experience to date. The
systematic review of all suspected strokes by the Stroke Review
Committee and the availability of computed axial tomographic, magnetic
resonance imaging, or autopsy data for 93% of stroke patients resulted
in definitive classification of stroke subtypes; thus, the number of
"unknowns" was small. The mechanism of nonhemorrhagic stroke was
not determined, and some strokes may not have been related to cardiac
events or procedures. Despite the relatively large numbers, the sample
size still limited the ability to perform more extensive
multivariable regression modeling.
Finally, these results are only applicable to the patients with acute
myocardial infarction treated with thrombolytic therapy
and should not be generalized to all patients with acute myocardial
infarction.
Conclusions
Patients with several risk factors or a high probability for
nonhemorrhagic stroke may benefit from prophylactic
anticoagulation, but further study is needed.
Members of the GUSTO-I Stroke Committee are listed in the "Appendix."
Received June 23, 1997;
revision received October 9, 1997;
accepted October 20, 1997.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Risk Factors for In-hospital Nonhemorrhagic Stroke in Patients With Acute Myocardial Infarction Treated With Thrombolysis
Results From GUSTO-I
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
Background—Nonhemorrhagic
stroke occurs in 0.1% to 1.3% of patients with acute myocardial
infarction who are treated with thrombolysis, with
substantial associated mortality and morbidity. Little is known about
the risk factors for its occurrence.
Key Words: thrombolysis • myocardial infarction • stroke • cerebral infarction
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
Stroke is one of the
most feared complications in patients with acute myocardial infarction.
In the era before the routine use of thrombolytic
therapy and anticoagulation, stroke was observed in 1.7% to 3.2% of
patients.1 2 3 4 5 Intracranial hemorrhage was
exceedingly rare. In the thrombolytic era, the overall
incidence of stroke in large clinical trials is lower, but the types of
strokes have changed. Nonhemorrhagic stroke now occurs in 0.1% to
1.3% of patients, and intracranial hemorrhage occurs in 0.07%
to 1.5% of patients.6 7 8 9 10 11 12
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
Study Population
The study population was the 41 021 patients enrolled in the
GUSTO-I trial.26 In brief, patients
presenting with acute myocardial infarction within 6 hours of
symptom onset were randomly assigned to one of four
thrombolytic strategies: (1) 1.5 million U
streptokinase IV over 1 hour and 12 500 heparin U SC BID; (2) 1.5
million U streptokinase IV over 1 hour and 5000 U heparin IV bolus
followed by 1000 U/h; (3) alteplase in an accelerated regimen (15-mg IV
bolus followed by 0.75 mg/kg over 30 minutes and then 0.5 mg/kg over
the next hour) and 5000 U heparin IV bolus followed by 1000 U/h; or (4)
both 1 million U streptokinase and 1.0 mg/kg alteplase IV over 1 hour
and 5000 U heparin IV bolus followed by 1000 U/h. All patients received
aspirin (160 to 325 mg) daily. The overall experience with stroke in
the GUSTO-I has been previously reported.9
Nonhemorrhagic Stroke
Nonhemorrhagic stroke was defined as an acute new neurological
deficit resulting in death or lasting for >24 hours without
hemorrhage on computed tomography or magnetic resonance
imaging, as classified by a physician with supporting documentation
from discharge summaries, progress notes, brain images,
neurological/neurosurgical evaluation, or autopsy reports.
Sustained hypotension was defined as systolic blood
pressure of <90 mm Hg for >1 hour despite fluid
replacement.
Cardiogenic shock was defined as systolic blood pressure
of <90 mm Hg for 
1 hour, not responsive to fluid
replacement alone, thought to be secondary to cardiac dysfunction, and
associated with signs of hypoperfusion (cool, clammy skin, oliguria, or
altered sensorium or cardiac index of 
2.2 L ·
min-1 · /m-2). If
the systolic blood pressure increased to >90 mm Hg
as a result of positive inotropic agents alone within 1 hour, this was
still classified as cardiogenic shock.
Congestive heart failure was considered to be signs or symptoms
of congestion (rales above the lung base, dyspnea, pulmonary
edema on chest radiograph, or peripheral edema) or low
cardiac output (weakness, fatigue) thought to be secondary to cardiac
dysfunction.
Killip class I was defined as the absence of rales over the lung
fields and the absence of S3 gallop. Class II included patients who had
rales across 50% of the lung fields or the presence of an S3 gallop.
Class III was defined as rales across >50% of the lung fields, and
class IV was defined as pulmonary edema with hypoperfusion
(cardiogenic shock).
Ejection fraction was determined by the site investigator at the
time of cardiac catheterization and, therefore, is
available only for patients undergoing angiography.
The evaluation of patients with stroke and the collection of
specific data about stroke treatment and clinical outcomes in the trial
were prospectively planned. The protocol specified that all patients
with a new focal neurological deficit undergo a complete evaluation
including brain imaging. Patients with nonhemorrhagic stroke were
identified from the responses to specific questions on the Case Report
Form or from a two-page supplemental Stroke Details Form, which was
completed for each patient with a suspected stroke. In addition, the
study collected available supporting documents, such as physicians'
notes, operative reports, discharge summaries, autopsy reports, and
results of computed tomographic and magnetic resonance imaging
studies.
A Stroke Review Committee (see "Appendix") was established
to adjudicate and categorize all suspected strokes. For each suspected
nonhemorrhagic stroke, the medical records and brain imaging
studies were independently reviewed by two teams, each consisting of a
cardiologist and neurologist. Each team was responsible for determining
whether a nonhemorrhagic stroke had occurred. Disagreements were
resolved by a third team.
Functional status was determined for all patients with
nonhemorrhagic stroke at hospital discharge or 30 days, whichever came
first. Patients were classified as not disabled if they had no deficit
(no sequelae) or minor deficits (functional status unchanged) and as
disabled if they had moderate deficits (significant limitations of
activity) or severe deficits (unable to live independently or
work).9
Continuous variables are shown as medians with 25th, and
75th percentiles; discrete variables are shown as frequencies and
percentages. Cox proportional hazards modeling was used to determine
the univariable predictors of nonhemorrhagic stroke and determine
the multivariable baseline risk factors for nonhemorrhagic stroke.
When examining the effect of interventions on nonhemorrhagic stroke, we
considered that some patients may have had a nonhemorrhagic stroke
before they could receive an intervention or may have had a planned
intervention canceled. Crediting the nonintervention group with all of
these early events would unfairly inflate the lack of association of
the stroke and the intervention. As a result, we used time-dependent
Cox modeling to determine multivariable in-hospital predictors of
nonhemorrhagic stroke. The interventions included as time-dependent
covariates were cardiac catheterization,
percutaneous transluminal coronary angioplasty,
coronary artery bypass graft surgery, and intra-aortic balloon
counterpulsation. In-hospital congestive heart failure and cardiogenic
shock were similarly treated as time-dependent covariates. A
backward-elimination method was used to determine the significant
predictors from the baseline and in-hospital analyses
(elimination criterion, P<.05). Baseline and in-hospital
predictors were then combined to determine the overall predictors of
nonhemorrhagic stroke. Predictors in each analysis were tested
using the likelihood ratio 
2 test. Results are
also presented as hazard ratios and 95% confidence
intervals.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
There were 247 patients with nonhemorrhagic stroke in the GUSTO-I
population (0.6%), of whom 42 (17%) died. In all, 56.7% of patients
with nonhemorrhagic stroke died or were disabled at the time of
hospital discharge (Table 1
).
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[in a new window]
Table 1. Clinical Outcomes . Patients with nonhemorrhagic stroke
were older and more often female and had a higher incidence of previous
coronary disease, hypertension, and diabetes. They also tended
to have a worse baseline Killip class and more often had atrial
fibrillation/flutter and anterior infarcts at enrollment.
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[in a new window]
Table 2. Baseline Clinical Characteristics ). The univariable
2 values and hazard ratios for the baseline
and in-hospital factors associated with in-hospital nonhemorrhagic
stroke are shown in Tables 4 and 5.
View this table:
[in a new window]
Table 3. In-hospital Coronary Events and Procedures
View this table:
[in a new window]
Table 4. Univariable Baseline Predictors of
Nonhemorrhagic Stroke
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[in a new window]
Table 5. Univariable In-hospital Predictors of
Nonhemorrhagic Stroke
Six baseline clinical and historical characteristics were
significant independent predictors of in-hospital nonhemorrhagic stroke
(Table 6). Age was the most important
baseline clinical predictor. Higher heart rate, history of stroke or
transient ischemic attack, diabetes, previous angina, and
history of hypertension were the other statistically significant
baseline predictors. Atrial fibrillation/flutter on the baseline ECG
and Killip class at the time of enrollment were not statistically
significant independent predictors of nonhemorrhagic stroke
(2=3.13, P=.08; and
2=5.23, P=.16, respectively). The
predicted probability of nonhemorrhagic stroke based on baseline
clinical and historical data can be calculated for individual patients
with the nomogram shown in Fig. 1.
View this table:
[in a new window]
Table 6. Multivariable Baseline Predictors of
Nonhemorrhagic Stroke
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[in a new window]
Figure 1. Nomogram for the prediction of nonhemorrhagic
stroke after thrombolysis for acute myocardial
infarction. CVD indicates cerebrovascular disease. In 1, find the value
most closely matching the patient's risk factors and circle the
corresponding point assignment. In 2, sum the points for all predictive
factors. In 3, determine the probability of in-hospital nonhemorrhagic
stroke. For example, a 71-year-old nondiabetic patient with previous
CVD, a history of hypertension, and previous angina who presents
with a heart rate of 121 bpm would have a total score of
60+32+0+20+7+9=128. This score corresponds to a predicted probability
of in-hospital nonhemorrhagic stroke of 10%.
Worse Killip class was the most potent predictor for
nonhemorrhagic stroke, followed by atrial fibrillation/flutter and
performance of coronary artery bypass surgery and
cardiac catheterization (Table 7). In the analysis of
in-hospital factors, patients with atrial fibrillation/flutter at
baseline were compared with those who did not have atrial
fibrillation/flutter at baseline and did not develop the
arrhythmia during the hospital stay. In addition, patients who
develop atrial fibrillation/flutter during hospitalization were
compared with patients without atrial fibrillation at baseline or
in-hospital. Patients developing atrial fibrillation/flutter after
enrollment had a greater than twofold higher incidence of
nonhemorrhagic stroke than patients who did not have atrial
fibrillation/flutter at baseline or during hospitalization (hazard
ratio, 2.08; 95% confidence interval, 1.52 to 2.86). Patients with
atrial fibrillation/flutter at baseline also had a higher likelihood of
nonhemorrhagic stroke than patients who never had atrial
fibrillation/flutter during the hospital stay (hazard ratio, 2.44; 95%
confidence interval, 1.43 to 4.16).
View this table:
[in a new window]
Table 7. Multivariable In-hospital Predictors of
Nonhemorrhagic Stroke
All 10 independent predictors from the baseline and in-hospital
multivariable analyses except history of hypertension
remained statistically significant, independent predictors of
nonhemorrhagic stroke in the combined analysis (Table 8). Worse Killip class and older age were
the two most important predictors, followed by performance of
cardiac catheterization and bypass surgery. A second
combined analysis included only the 15 220 (37.1%) patients
undergoing angiography who had a documented ejection fraction (Table 9). Age, performance of cardiac
catheterization, and bypass surgery were significant
and potent independent predictors of nonhemorrhagic stroke. Lower
ejection fraction, higher heart rate, diabetes, and worse Killip class
had borderline statistical significance as predictors of nonhemorrhagic
stroke in the combined model of patients with known ejection fraction.
Atrial fibrillation/flutter, previous angina, previous hypertension,
and stroke or transient ischemic attack were no longer
statistically significant independent predictors.
View this table:
[in a new window]
Table 8. Combined (Baseline and In-hospital)
Multivariable Predictors of Nonhemorrhagic Stroke
View this table:
[in a new window]
Table 9. Combined (Baseline and In-hospital)
Multivariable Predictors of Nonhemorrhagic Stroke Including
Ejection Fraction
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
Stroke is a well-documented event in patients with acute
myocardial infarction. The routine use of anticoagulant and
thrombolytic therapies has reduced the occurrence of
nonhemorrhagic stroke but increased the risk of intracranial
hemorrhage. Nonhemorrhagic stroke, however, is associated with
significant morbidity and mortality.9 We
identified six easily determined baseline patient clinical and
historical factors (older age, higher heart rate, history of stroke or
transient ischemic attack, diabetes, previous angina, and
history of hypertension) that independently predict nonhemorrhagic
stroke in patients with acute myocardial infarction treated with
thrombolysis, heparin, and aspirin. In addition, four
common in-hospital characteristics (worse Killip class, atrial
fibrillation/flutter, bypass surgery, and cardiac
catheterization) are independently associated with
nonhemorrhagic stroke. 2=0.75, P=.39; and
2=3.23, P=.072, respectively). 
5% per year, or a fivefold to sevenfold higher incidence compared
with patients without the
arrhythmia.27 28 Several large registries
have reported that stroke occurs in <0.01% of patients undergoing
cardiac catheterization.29 30 The
incidence of stroke in patients undergoing coronary artery
bypass surgery has been reported to occur in 0.4% to 5.4% of
patients.31 32 33 One of the largest most
comprehensive multicenter series reported nonfatal stroke in 2.6% of
patients after coronary artery bypass
surgery.34 ).9
View larger version (14K):
[in a new window]
Figure 2. Cumulative frequency distribution of hours from
enrollment to onset of nonhemorrhagic stroke in GUSTO-I. Nonfatal
nonhemorrhagic stroke is indicated by the heavy line, and fatal
nonhemorrhagic stroke is indicated by the light line.
Our study has several limitations. An important aspect of the
study was the time-dependent analysis of clinical events and
procedures in relation to the onset of stroke symptoms. The time of
onset for atrial fibrillation or worse Killip class was not known, so
only the day of occurrence was used in the time-dependent
analysis and compared with the day of stroke symptom onset.
Dates and times for cardiac interventions and other in-hospital events
were available.
Nonhemorrhagic stroke remains a serious event in patients with
acute myocardial infarction treated with thrombolytic,
antithrombin, and antiplatelet therapy and is associated with
significant morbidity and mortality. Older age, higher heart rate,
history of stroke or transient ischemic attack, diabetes,
previous angina, and history of hypertension are independent clinical
and historical predictors of nonhemorrhagic stroke; physicians can use
these factors to determine the baseline probability of nonhemorrhagic
stroke with a simple scoring nomogram (Fig 1
). This information may
enhance awareness of the potential for nonhemorrhagic stroke early
after myocardial infarction. Beyond the baseline characteristics,
adverse in-hospital cardiac events, such as worsening Killip class,
atrial fibrillation/flutter, and performance of cardiac
catheterization or bypass surgery also are potent,
independent predictors of nonhemorrhagic stroke.
Appendix 1
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
The following are GUSTO-I Stroke Committee Members: Gabriel I.
Barbash, MD, MPH, Cardiologist, and Rina Tadmor, MD, Neurologist,
Israel; Joel M. Gore, MD, Cardiologist, and Michael A. Sloan, MD,
Neurologist, USA; Maarten L. Simoons, MD, Cardiologist, and Peter
Koudstaal, MD, Neurologist, The Netherlands; W. Douglas Weaver, MD,
Cardiologist, and W.T. Longsteth, Jr, MD, Neurologist, USA; and Harvey
D. White, MV, DSc, Cardiologist, and Neil Anderson, Neurologist, New
Zealand.
Acknowledgments
This study was supported by Bayer (New York, NY), CIBA-Corning
(Medfield, Mass), Genentech (South San Francisco, Calif), ICI
Pharmaceuticals (Wilmington, Del), and Sanofi Pharmaceuticals (Paris,
France). The authors thank John Daniel for his help with manuscript
preparation and editorial support.
Footnotes
Reprint requests to Kenneth W. Mahaffey, MD, Box 3630, Duke University Medical Center, Durham, NC 27710.
References
Top
Abstract
Introduction
Methods
Results
Discussion
Appendix 1
References
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 Predicting Ischemic Stroke After AMI Journal Watch Emergency Medicine, April 1, 1998; 1998(401): 10 - 10. [Full Text]
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 Risk Factors for Nonhemorrhagic Stroke in Thrombolized AMI Patients Journal Watch Women's Health, April 1, 1998; 1998(401): 16 - 16. [Full Text]
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 Risk Factors for Nonhemorrhagic Stroke in AMI Journal Watch Cardiology, March 31, 1998; 1998(331): 8 - 8. [Full Text]
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