Increased monitoring for ischemic stroke may improve care of patients with COVID-19
Comorbid COVID-19 occurred frequently among patients with ischemic stroke in 2020, especially in Black and Hispanic populations, according to results of a retrospective cohort study published in JAMA Network Open.
“This research was the largest cohort to date of patients with laboratory-confirmed COVID-19 and ischemic stroke,” Adam de Havenon, MD, assistant professor in the department of neurology at the University of Utah, told Healio Neurology. “We also were able to include data from all of 2020, so it showed the initial decrease in ischemic stroke followed by a rebound to normal or near normal by summer.”
De Havenon and colleagues aimed to evaluate hospital discharge rates, demographic factors and hospitalization outcomes linked to the COVID-19 pandemic among 282,847 patients with ischemic stroke before compared with during the pandemic. They obtained data via the Vizient Clinical Data Base from patients at 478 nonfederal hospitals across the United States between Jan. 1, 2019, and Dec. 31, 2020. Eligibility criteria included hospital admission on a nonelective basis and no receipt of hospice care at the time of admission. From the initial pool of 324,013 patients, the researchers excluded 41,166 patients between January 2020 and March 2020 because of unreliable data regarding COVID-19 status.
Ischemic stroke and laboratory-confirmed COVID-19 served as exposure measures and monthly counts of discharge among patients with ischemic stroke in 2020 served as the main outcome. De Havenon and colleagues compared demographic characteristics and outcomes, such as deaths in the hospital, among patients with ischemic stroke who were discharged in 2019 and served as the control group (n = 165,912; 50.7% men; 63.4% white; 26.3% aged 80 years and older) with those of patients who had an ischemic stroke with comorbid COVID-19 (n = 5,517 of 116,935; 58% men; 42.5% white; 21.3% aged 80 years and older) or without comorbid COVID-19 (n = 111,418 of 116,935; 51.9% men; 62.8% white; 24.6% aged 80 years and older) who were discharged between April 2020 and December 2020.
Patients with ischemic stroke had a mean 13,846 discharges per month during 2019, with discharges beginning to decrease in February 2020 and reaching a low of 10,846 patients in April 2020 prior to returning to a pre-pandemic level of 13,639 patients by July 2020. For the remainder of 2020, patients with ischemic stroke had a mean of 13,492 discharges per month. A total of 21.4% and 7% of ischemic stroke discharges occurred among Black and Hispanic patients, respectively, in 2019, compared with 27.5% and 16% of Black and Hispanic patients, respectively, discharged with ischemic stroke and comorbid COVID-19 in 2020.
Patients in the COVID-19 group had a lower likelihood of smoking compared with those in the control and non-COVID-19 groups, as well as a lower likelihood for hypertension or dyslipidemia; however, they had increased risk for diabetes, obesity, acute coronary syndrome or pulmonary embolus and needing intubation. Following adjustment for baseline factors, patients with ischemic stroke and COVID-19 had increased risk for dying in the hospital compared with patients with ischemic stroke in 2019 (adjusted OR = 5.17; 95% CI, 4.83-5.53; National Institute of Health Stroke Scale adjusted OR = 3.57; 95% CI, 3.15-4.05).
“We replicated many findings of earlier studies, in regard to the morbidity of comorbid COVID-19 and stroke as well as the predilection for certain populations, but were also able to show an interesting phenomenon,” de Havenon said. “Patients with comorbid COVID-19 and ischemic stroke were over three times as likely to have ischemic stroke identified after hospital admission. In those patients, we saw a particularly high rate of in-hospital death (46%), which may represent an opportunity to improve the care of patients with COVID-19 through increased monitoring for ischemic stroke while in the hospital and/or through strategies to prevent ischemic stroke.”