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Original Investigation
December 2017

Disability Trajectories Before and After Stroke and Myocardial Infarction: The Cardiovascular Health Study

Author Affiliations
  • 1Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
  • 2Departments of Neurology and Epidemiology, University of Washington, Seattle
  • 3Department of Biostatistics, University of Washington, Seattle
  • 4Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
  • 5Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
  • 6Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York
JAMA Neurol. 2017;74(12):1439-1445. doi:10.1001/jamaneurol.2017.2802
Key Points

Question  Is the slope of disability different before stroke and after recovery from stroke?

Findings  In this population-based cohort study, the slope of increase in disability was 3-fold greater after recovery from stroke compared with before stroke. The slope before and after the comparison event—myocardial infarction—was not different.

Meaning  Stroke may be associated with potentially treatable long-term adverse effects on the brain that lead to accelerated accumulation of disability.


Importance  Ischemic strokes may accelerate long-term functional decline apart from their acute effects on neurologic function.

Objective  To test whether the increase in long-term disability is steeper after than before the event for ischemic stroke but not myocardial infarction (MI).

Design, Settings, and Participants  In the population-based, prospective cohort Cardiovascular Health Study (1989-2013), longitudinal follow-up was conducted for a mean (SD) of 13 (6.2) years. Follow-up data were used until September 1, 2013; data analysis was performed from August 1, 2013, to June 1, 2016. Models based on generalized estimating equations adjusted for baseline covariates and included a test for different slopes of disability before and after the event. Participants included 5888 Medicare-eligible individuals 65 years or older who were not institutionalized, expected to reside in the area for 3 or more years, and able to provide informed consent. Exclusions were needing a wheelchair, receiving hospice care, and undergoing radiotherapy or chemotherapy.

Exposures  Ischemic stroke and MI.

Main Outcomes and Measures  Annual assessments with a disability scale (measuring activities of daily living [ADLs] and instrumental ADLs). The number of ADLs and instrumental ADLs (range, 0-12) that the participant could not perform was analyzed continuously.

Results  The mean (SD) age of the entire cohort (n = 5888) was 72.8 (5.6) years; 2495 (42.4%) were male. During follow-up, 382 (6.5%) participants had ischemic stroke and 395 (6.7%) had MI with 1 or more disability assessment after the event. There was a mean of 3.7 (2.4) visits before stroke and 3.7 (2.3) visits after stroke; there was a mean of 3.8 (2.5) visits before MI and 3.8 (2.4) visits after MI. The increase in disability near the time of the event was greater for stroke (0.88 points on the disability scale; 95% CI, 0.57 to 1.20; P < .001) than MI (0.20 points on the disability scale; 95% CI, 0.06 to 0.35; P = .006). The annual increase in disability before stroke (0.06 points per year; 95% CI, 0.002 to 0.12; P = .04) more than tripled after stroke (0.15 additional points per year; 95% CI, 0.004 to 0.30; P = .04). The annual increase in disability before MI (0.04 points per year; 95% CI, 0.004 to 0.08; P = .03) did not change significantly after MI (0.02 additional points per year; 95% CI, −0.07 to 0.11; P = .69).

Conclusions and Relevance  In this large, population-based study, a trajectory of increasing disability became significantly steeper after stroke but not after MI. Thus, in addition to the acute brain injury and consequent impairment, ischemic stroke may also be associated with potentially treatable long-term adverse effects on the brain that lead to accelerated functional decline.