Long-Term Outcome After Stroke in Belarus
Background and Purpose—
Data concerning the long-term prognosis after stroke in low-income and middle-income countries are limited. We aimed to establish survival and dependency at 5 years after a first-ever-in-a-lifetime stroke in Grodno, Belarus.
All residents of Grodno with a suspected acute stroke were registered prospectively and assessed over a period of 12 months in 2001. Patients were followed-up prospectively at 3 and 12 months, and then annually up to 5 years after the index event.
There were 671 cases of first-ever-in-a-lifetime stroke, and follow-up data after 5 years were available for 653 of these patients (97.3%); 18 people (2.7%) were lost to follow-up. One hundred ninety patients (29.1%) died during the first 28 days of stroke. The case fatality rate at 3 months was 32.2% (210/653), at 12 months it was 37.4% (244/653), and at 5 years it was 58.8% (384/653). Of the 269 survivors at 5 years, 130 (48.3%) were independent (modified Rankin score, 0–2), and 139 (51.7%) were disabled (modified Rankin score, ≥3). At 5 years, the cumulative risk of death or disability after first-ever-in-a-lifetime stroke was 80.1% (523/653).
Stroke in Belarus is associated with a very high risk of death or dependency at 5 years.
Countries of low and middle incomes have the largest burden of stroke, accounting for >85% of stroke mortality worldwide,1 but few reliable data on long-term outcome are available in most of these regions. In this study, we aimed to follow-up for 5 years stroke patients who participated in the first year of the Grodno Stroke Study (GROSS).2
Subjects and Methods
The GROSS registered all strokes among 311 134 residents of the city of Grodno, Belarus, during a 3-year period from 2001 to 2003.2 A cohort of patients with a nonfatal first-ever-in-a-lifetime stroke (FELS) registered in 2001 was followed-up prospectively at 3 and 12 months, and then annually for up to 5 years after the index event for survival, recurrent strokes, and disability (Supplemental Methods, http://stroke.ahajournals.org).
Six hundred seventy-one cases of FELS were registered in the GROSS during 2001. After 5 years, 18 people (2.7%) were lost, and complete follow-up data were available for 653 patients (97.3%). The mean (±SD) age of these patients at baseline was 65.4±11.4 years. The 5-year cumulative risk of death (Figure and Supplemental Table I) was 58.8% (95% confidence interval [CI], 53.3%–64.7%). The risk of death was greatest during the first year after stroke (37.4%; 95% CI, 33.0%–42.3%) and, particularly, during the first 28 days after stroke (29.1%; 95% CI, 25.2%–33.6%). Stratification by age showed (Supplemental Figure I) that older patients had a worse prognosis (χ2 trend, 65.3; P<0.000001). Over the whole follow-up period there were 104 recurrent strokes (22.5%) among the 463 survivors of 28 days, with the case-fatality of 43.3% (45/104).
Data on the functional outcome 5 years after FELS by modified Rankin score (mRS) are presented in the Table. The proportion of disabled patients (mRS, ≥3) among all the survivors increased stepwise with age from 30.8% in the age group younger than 45 years to 90.5% in the age group of those aged 75 to 84 years. Of the survivors, <50% of the patients were functionally independent (mRS, <3). The mean (±SD) value of mRS for all 5-year survivors (n=269) was 2.52±1.28. The cumulative risk of death or disability after a first-ever stroke at 5 years was 80.1% (523/653; 95% CI, 73.3%–87.3%).
|Age, y||No. Disabled/No. Survived||Rate of Disability, %|
|Younger than 45||4/13||30.8|
|85 or older||1/1||100|
We conducted a community-based study of 5-year outcome after FELS in a large defined urban population of the east European non-European Union countries. Our study provides prognostic data from a large, unselected, community-based inception cohort of patients with FELS diagnosed prospectively after a standardized neurological assessment and using standardized diagnostic criteria. The outcome events were carefully defined, and only 2.7% of patients were lost to follow-up.
Our study has several limitations. Because of the low rate of imaging/autopsy at baseline (37.1%; 242/653), we could not perform stratification of outcomes by the type of stroke. Data on clinical features of FELS were not registered, and functional outcome estimates were limited to poststroke mRS value.
The cumulative risk of death at 5 years after FELS of 59% (95% CI, 53.3%–64.7%) in the Belarusian urban population is significantly higher than in Framingham, Massachusetts, United States (45%; 95% CI, 38.8%–52.2%),3 Auckland, New Zealand (49%; 95% CI, 46.2%–52.9%),4 Martinique, French West Indies (50%; 95% CI, 44.2%–55.4%),5 Oxford, United Kingdom (50%; 95% CI, 45.0%–55.6%),6 and 6 communities in Japan (52%; 95% CI, 44.5%–61.0%),7 but similar to those in Rochester, Minnesota, United States (56%; 95% CI, 48.3%–66.1%),8 and Perth, Australia (58%; 95% CI, 50.3%–66.7%).9 Mean age at baseline of patients in Grodno (65.4 years) was the lowest compares to that of other studies (70.1–73.0 years4,8,9). Five years after the FELS, 48.3% (130/269) of the survivors in Grodno were functionally independent (mRS, <3); it is significantly lower than in Rochester (65.2%; 75/115),8 Martinique (66.4%; 174/262),5 and Auckland (68.8%; 287/418).4 At the same time, the mean mRS score among 5-year survivors in the GROSS of 2.52±1.28 is 1.5-times higher compared to the corresponding index in the ASTRO (1.7±1.5; P<0.00001).4 In our opinion, these findings reflect greater severity of stroke in the Belarusian urban population and are in agreement with high incidence, case fatality, and prevalence of vascular risk factors in Grodno.2
Our findings of 59% cumulative risk of death at 5 years after FELS for the younger mean age at baseline of the initial cohort compared to other studies and the <50% rate of functionally independent survivors demonstrate a clear need for active and prolonged secondary prevention. Our data on the long-term stroke outcomes are important for public health prevention programs as well as for evidence-based rehabilitation service planning and health resource allocation.
Sources of Funding
This study was supported by grants from
Feigin VL. Stroke in developing countries: can the epidemic be stopped and outcomes improved?Lancet Neurol. 2007; 6:94–97.CrossrefMedlineGoogle Scholar
Kulesh SD, Filina NA, Frantava NM, Zhytko NL, Kastsinevich TM, Kliatskova LA,. Incidence and case-fatality of stroke on the east border of the European union: the Grodno Stroke Study. Stroke. 2010; 41:2726–2730.LinkGoogle Scholar
Sacco RL, Wolf PA, Kannel WB, McNamara PM. Survival and recurrence following stroke: the Framingham study. Stroke. 1982; 13:290–295.LinkGoogle Scholar
Feigin VL, Barker-Collo S, Parag V, Senior H, Lawes CM, Ratnasabapathy Y,. Auckland Stroke Outcomes Study. Part 1: Gender, stroke types, ethnicity, and functional outcomes 5 years poststroke. Neurology. 2010; 75:1597–1607.CrossrefMedlineGoogle Scholar
Chausson N, Olindo S, Cabre P, Saint-Vil M, Smadja D. Five-year outcome of a stroke cohort in Martinique, French West Indies: Etude Realisee en Martinique et Centree sur l'Incidence des Accidents Vasculaires Cerebraux, Part 2. Stroke. 2010; 41:594–599.LinkGoogle Scholar
Dennis MS, Burn JP, Sandercock PA, Bamford JM, Wade DT, Warlow CP. Long-term survival after first-ever stroke: the Oxfordshire Community Stroke Project. Stroke. 1993; 24:796–800.LinkGoogle Scholar
Ikebe T, Ozawa H, Lida M, Shimamoto T, Handa K, Komachi Y. Long-term prognosis after stroke: a community-based study in Japan. J Epidemiol. 2001; 11:8–15.CrossrefMedlineGoogle Scholar
Dombovy M, Basford J, Whisnant J, Bergstrahl E. Disability and use of rehabilitation services following stroke in Rochester, Minnesota, 1975–1979 Stroke. 1987; 18:830–836.Google Scholar
Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Burvill PW, Anderson CS,. Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study. Stroke. 2000; 31:2080–2086.LinkGoogle Scholar