Background: Stroke prognosis is related to the multimorbidity profile. Moreover, performing an individual evaluation of most common cerebrovascular risk factors (CVRF) not always identifies patients with poor prognosis. Thus, we decided to evaluate multimorbidity profile, focusing on the Charlson Comorbidity Index (CCI) validated by Goldstein for ischaemic stroke (IS) patients, a score that measures a burden of comorbidities and its related mortality in the long-term survival of the EMMA Study (Study of Stroke Mortality and Morbidity). Methods: Nine hundred fifty-nine individuals (median age 70 years) had validated data on the diagnosis of IS, main CVRF and clinical comorbidities pre index event such as atrial fibrillation (AF), stroke recurrence, diabetes, hypertension, heart failure and cancer. CCI modified by Goldstein was calculated, which includes 17 clinical conditions with scores ranging from 1 to 6 (0-31 points). Survival analyses were performed by Kaplan-Meier curves and Cox logistic regression models (cumulative hazard ratio [HR] with [95% CI]) for all-cause mortality at 180 days, and every 3 years up to 9-year follow-up. Mortality analyzes were performed by CCI categorized according to weight added to comorbidities (Reference group: zero, moderate: 1, severe: 2 and very severe: ≥3 points). We also tested the modification effect of AF and stroke recurrence including these conditions in the CCI. Results: The overall survival rate was 47% (508 deaths/959). The worst survival (577, 95% CI 381-773 days) and the highest risk of death after stroke were observed in the very severe CCI group (HR 3.18; 95% CI 2.16-4.69) up to 9 years. The inclusion of previous AF and stroke in the CCI slightly increased the risk of death for very severe CCI (HR 3.27; 95% CI 2.07-5.18). Conclusions: A high burden of comorbidities represented an independent predictor of poor prognosis increasing the risk of dying by 2 to 3 times among IS up to 9 years in the EMMA study. The inclusion of other CVRF such as AF and stroke recurrence slightly modified all-cause mortality risk.

GBD 2013 Mortality and Causes of Death Collaborators: Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;385:117-171.
Yusuf S, Rangarajan S, Teo K: Cardiovascular risk and events in 17 low-, middle-, and high-income countries. N Engl J Med 2014;371:818-827.
Johnston SC, Mendis S, Mathers CD: Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol 2009;8:345-354.
Lavados PM, Hennis AJ, Fernandes JG, Medina MT, Legetic B, Hoppe A, Sacks C, Jadue L, Salinas R: Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean. Lancet Neurol 2007;6:362-372.
Lotufo PA, Goulart AC, Fernandes TG, Benseñor IM: A reappraisal of stroke mortality trends in Brazil (1979-2009). Int J Stroke 2103;8:155-163.
Fernandes TG, Bando DH, Alencar AP, Benseñor IM, Lotufo PA: Income inequalities and stroke mortality trends in Sao Paulo, Brazil, 1996-2011. Int J Stroke 2015;10:34-37.
O'Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, et al: Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016;388:761-775.
Kesarwani M, Perez A, Lopez VA, Wong ND, Franklin SS: Cardiovascular comorbidities and blood pressure control in stroke survivors. J Hypertens 2009;27:1056-1063.
Feigin VL, Roth GA, Naghavi M, Parmar P, Krishnamurthi R, Chugh S, et al: Global burden of stroke and risk factors in 188 countries, during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet Neurol 2016;15:913-924.
Goulart AC, Fernandes TG, Santos IS, Alencar AP, Bensenor IM, Lotufo PA: Predictors of long-term survival among first-ever ischemic and hemorrhagic stroke in a Brazilian stroke cohort. BMC Neurol 2013;13:51.
Chen HF, Li CY, Lee SP, Kwok YT, Chu YT: Improving the one-year mortality of stroke patients: an 18-year observation in a teaching hospital. Tohoku J Exp Med 2014;232:47-54.
Schmidt M, Jacobsen JB, Johnsen SP, Botker HE, Sorensen HT: Eighteen-year trends in stroke mortality and the prognostic influence of comorbidity. Neurology 2014;82:340-350.
Charlson ME, Pompei P, Ales KL, MacKenzie C: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Diseases 1987;40:373-383.
Goldstein LB, Samsa GP, Matchar DB, et al: Charlson index comorbidity adjustment for ischemic stroke outcome studies. Stroke 2004;35:1941-1945.
Fischer U, Arnold M, Nedeltchev K, Schoenenberger RA, Kappeler L, Höllinger P, Schroth G, Ballinari P, Mattle HP: Impact of comorbidity on ischemic stroke outcome. Acta Neurol Scand 2006;113:108-113.
Solberg OG, Dahl M, Mowinckel P, Stavem K: Derivation and validation of a simple risk score for predicting 1-year mortality in stroke. J Neurol 2007;254:1376-1383.
Bushnell CD, Lee J, Duncan PW, Newby LK, Goldstein LB: Impact of comorbidities on ischemic stroke outcomes in women. Stroke 2008;39:2138-2140.
Arnold M, Halpern M, Meier N, Fischer U, Haefeli T, Kappeler L, Brekenfeld C, Mattle HP, Nedeltchev K: Age-dependent differences in demographics, risk factors, co-morbidity, etiology, management, and clinical outcome of acute ischemic stroke. J Neurol 2008;255:1503-1507.
Jiménez Caballero PE, López Espuela F, Portilla Cuenca JC, Ramírez Moreno JM, Pedrera Zamorano JD, Casado Naranjo I: Charlson comorbidity index in ischemic stroke and intracerebral hemorrhage as predictor of mortality and functional outcome after 6 months. J Stroke Cerebrovasc Dis 2013;22:e214-e218.
Denti L, Artoni A, Casella M, Giambanco F, Scoditti U, Ceda GP: Validity of the modified Charlson Comorbidity Index as predictor of short-term outcome in older stroke patients. J Stroke Cerebrovasc Dis 2015;24:330-336.
WHO STEPS stroke manual: the WHO STEPwise approach to stroke surveillance/noncommunicable diseases and mental health. World Health Organization, 2006. (cited June 12, 2010).
Lotufo PA, Bensenor IM: Improving WHO STEPS Stroke in Brazil. Lancet Neurol 2007;6:387-388.
Goulart AC, Bustos IR, Abe IM, Pereira AC, Fedeli LM, Benseñor IM, Lotufo PA: A stepwise approach to stroke surveillance in Brazil: the EMMA (Estudo de Mortalidade e Morbidade do Acidente Vascular Cerebral) study. Int J Stroke 2010;5:284-289.
Kaplan EL, Meier P: Nonparametric Estimation from incomplete observations. J Am Stat Assoc 1958;53:457-481.
Cox DR: Regression model and life tables. J Royal Stat Soc 1972;34:187-220.
Cabral NL, Muller M, Franco SC, Longo A, Moro C, Nagel V, Liberato RB, Garcia AC, Venancio VG, Gonçalves AR: Three-year survival and recurrence after first-ever stroke: the Joinville stroke registry. BMC Neurol 2015;15:70.
Ray BK, Hazra A, Ghosal M, Banerjee T, Chaudhuri A, Singh V, Das SK: Early and delayed fatality of stroke in Kolkata, India: results from a 7-year longitudinal population-based study. J Stroke Cerebrovasc Dis 2013;22:281-289.
Ducci RD, Lange MC, Zétola VH, Rundek T: Factors related to cardioembolism as major predictors of poor survival after first-ever middle cerebral artery stroke treated with thrombolysis. Cerebrovasc Dis 2017;43:178-185.
Fernandes TG, Goulart AC, Campos TF, Lucena NM, Freitas KL, Trevisan CM, Benseñor IM, Lotufo PA: Early stroke case-fatality rates in three hospital registries in the Northeast and Southeast of Brazil. Arq Neuropsiquiatr 2012;70:869-873.
Goulart AC, Fernandes TG, Alencar AP, Fedeli LM, Benseñor IM, Lotufo PA: Low education as a predictor of poor one-year stroke survival in the EMMA Study (Study of Stroke Mortality and Morbidity in Adults), Brazil. Int J Stroke 2012;7:E4.
Fernandes TG, Goulart AC, Santos-Junior WR, Alencar AP, Benseñor IM, Lotufo PA: Educational levels and the functional dependence of ischemic stroke survivors. Cad Saude Publica 2012;28:1581-1590.
Barros JB, Goulart AC, Alencar AP, Lotufo PA, Bensenor IM: The influence of the day of the week of hospital admission on the prognosis of stroke patients. Cad Saude Publica 2013;29:769-777.
Ribeiro AL, Duncan BB, Brant LC, Lotufo PA, Mill JG, Barreto SM: Cardiovascular Health in Brazil: trends and perspectives. Circulation 2016;133:422-433.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.