What is the mortality rate of recurrent cerebrovascular accident (CVA) or stroke?

From the Guidelines

The mortality rate after a recurrent stroke is approximately 41%, which is significantly higher than the 22% mortality rate after an initial stroke. This is based on the most recent and highest quality study available, which was published in 2018 in the Journal of the American College of Cardiology 1. The study found that the annual risk of a subsequent or "secondary" stroke is approximately 4%, and that the risk of recurrent stroke is heightened by the presence of elevated blood pressure.

Key Factors Contributing to Mortality

• The presence of premorbid hypertension, which is approximately 70% in patients with a recent stroke or TIA 1
• The cumulative effect of multiple strokes, which leads to greater disability and higher mortality
• The presence of additional comorbidities that complicate recovery

Reducing Mortality Risk

To reduce the risk of recurrent stroke and its associated mortality, aggressive secondary prevention strategies are essential, including:

• Blood pressure control
• Antiplatelet or anticoagulation therapy as appropriate
• Cholesterol management
• Diabetes control
• Smoking cessation
• Lifestyle modifications including diet and exercise 1

These strategies can help reduce the risk of recurrent stroke and improve overall outcomes for patients who have experienced a stroke. The evidence for using antihypertensive treatment to prevent recurrent stroke in stroke patients with elevated blood pressure is compelling, with RCT meta-analyses showing an approximately 30% decrease in recurrent stroke risk with BP-lowering therapies 1.

From the Research

Mortality Rate of Recurrent Stroke

• The mortality rate after a recurrent stroke is higher compared to a first-time stroke, making secondary stroke prevention a priority 2.
• Studies have shown that the risk of mortality after recurrent stroke is significantly higher, with a standardized mortality ratio of 14.43 (95% confidence interval, 10.11-18.74) 3.
• Recurrent stroke is a major risk factor for mortality after first-ever ischemic stroke, with a hazard ratio of 16.68 (95% confidence interval, 2.33-119.56; P=0.005) 3.
• The cumulative risk of mortality after recurrent stroke is 23.0% (95% confidence interval, 19.1%-26.9%) 3.
• Stroke recurrence rates seem unchanged over time despite the use of secondary prevention, with a summary proportion recurrence rate of 0.12 and 0.14 in studies using TOAST-criteria and TOAST-like criteria, respectively 4.

Risk Factors for Mortality after Recurrent Stroke

• Hypertension, diabetes mellitus, atrial fibrillation, previous transient ischemic attack, and high stroke severity are independent risk factors for recurrence 4.
• The highest recurrence rate is seen in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke, with recurrent stroke similar to index stroke subtype 4.
• A lower recurrence rate is seen with small vessel occlusion (SVO) stroke, with a more diverse recurrence pattern 4.

Prevention and Management of Recurrent Stroke

• Lifestyle modification, including diet, physical activity, smoking cessation, and alcohol consumption, is important for secondary stroke prevention 2.
• Antithrombotic drugs, such as aspirin, clopidogrel, and anticoagulants, are effective in preventing recurrent major vascular events 5, 6.
• Novel oral anticoagulants (NOACs), such as dabigatran, apixaban, and rivaroxaban, have shown promise in reducing the incidence of stroke and therapeutic complications related to warfarin 5.