Functional outcome prediction of ischemic stroke patients with atrial fibrillation accepting post-acute care training

Sen-Yung Liu; Ying-Lin Hsu; Yi-Chun Tu; Ching-Hsiung Lin; Shih-Chun Wang; Ya-Wen Lee; Yin-Tzer Shih; Ming-Chih Chou; Chih-Ming Lin

doi:10.3389/fneur.2022.954212

Functional outcome prediction of ischemic stroke patients with atrial fibrillation accepting post-acute care training

Front Neurol. 2022 Sep 23:13:954212. doi: 10.3389/fneur.2022.954212. eCollection 2022.

Authors

Sen-Yung Liu^{1

2}, Ying-Lin Hsu³, Yi-Chun Tu⁴, Ching-Hsiung Lin^{5

6

7}, Shih-Chun Wang⁸, Ya-Wen Lee⁹, Yin-Tzer Shih³, Ming-Chih Chou^{1

10

11

12}, Chih-Ming Lin^{13

14

15}

Affiliations

¹ Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.
² Department of Rehabilitation Medicine, Changhua Christian Hospital, Changhua, Taiwan.
³ Department of Applied Mathematics and Institute of Statistics, National Chung Hsing University, Taichung, Taiwan.
⁴ Institute of Data Science and Information Computing, National Chung Hsing University, Taichung, Taiwan.
⁵ Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.
⁶ Institute of Genomics and Bioinformatics and Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan.
⁷ Department of Recreation and Holistic Wellness, MingDao University, Changhua, Taiwan.
⁸ Department of Medicine Imaging, Changhua Christian Hospital, Changhua, Taiwan.
⁹ Department of Nursing, Hanming Christian Hospital, Changhua, Taiwan.
¹⁰ Division of Thoracic Surgery, Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan.
¹¹ School of Medicine, Chung Shan Medical University, Taichung, Taiwan.
¹² Department of Family and Community Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan.
¹³ Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan.
¹⁴ Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.
¹⁵ Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.

Abstract

Background: Ischemic stroke poses a major threat to human health and represents the third leading cause of death worldwide and in Taiwan. Post-acute care (PAC) training has been reported to be beneficial for post-index stroke events. However, knowledge is still lacking on the outcome of stroke events with cardiac origin. The focus of the current study is to investigate the effectiveness of PAC in this subgroup of patients as well as identify key baseline pointers that are capable of early prediction of patients' physical recovery. In addition, the authors hypothesize that the routinely arranged non-invasive carotid duplex that evaluates the characteristics of the carotid lumen could play a significant role in providing an early outcome prediction.

Methods: For the current research, 142 ischemic stroke patients with underlying cardiac arrhythmia (atrial fibrillation) were retrospectively recruited. The patients' basic demographics, neuroimaging, carotid duplex, and basic biochemistry datasets were accurately documented. The pre and post-admission National Institutes of Health Stroke Scale (NIHSS) (6-month follow-ups), Barthel Index, and mRS score (12-month follow-ups) were also recorded. All statistical analyses were performed using R for Windows (version 3.6.3). Barthel Index, NIHSS, and mRS scores obtained before and after hospitalization were compared to determine the patients' outcomes and were classified as improved or unimproved. A multivariate logistic analysis was designed and applied to assess the significance of risk factors and to obtain the odds ratios (ORs). The receiver operating characteristic (ROC) curve and the Youden Index was used to find the important cut-off point information, and the area under the curve (AUC) was calculated to provide accuracy.

Results: The average age of the 142 ischemic stroke patients enrolled in the current study was about 66 years, of which 88 patients were male and 54, female. Many of them had other comorbidities: 86 patients had mixed hyperlipidemia (60.56%), 115 had hypertension (80.99%), and 49 suffered from diabetes mellitus (34.51%). The mRS showed an improvement in the condition of only 40 patients (28.175%), whereas the Barthel Index showed improvement in 71 patients (50%), and 68 patients (47.89%) showed recovery on the NIHSS. The Barthel Index and NIHSS were selected because they already had an almost equal number of samples among the improved and unimproved groups (50%), rather than mRS, which had a lower number (28.17%) of improved cases. While conducting the EuroQol-5 Dimension (EQ-5D) assessment, anxiety/depression stood out as the most prominent issue, affecting 44 patients (30.99%). Self-care was another factor that was involved in the ongoing improvement of 36 patients (25.35%). Multivariate logistic analysis of both NIHSS and Barthel Index showed improvement with a contralateral plaque index statistical significance (P<0.05), whereas NIHSS showed a relevant significance in anxiety/depression and Barthel Index registered usual activity in the data analysis (P<0.05). ROC curve and Youden index analysis showed similar results in both NIHSS and Barthel Index of contralateral plaque index of 4.5, this being the cutoff point value for this group of patients.

Conclusion: In the current study, nearly half of the enrolled patients showed favorable functional recovery. The outcome assessments seem to correlate well with NIHSS and Barthel Index scores, rather than mRS. The anxiety/depression and usual activities domains of the EQ-5D results are associated with and have a great impact after the patients undertake the PAC rehabilitative strategy. Moreover, the variables obtained through carotid duplex and plaque index might also play a significant role in determining the patient's functional outcome.

Keywords: Barthel Index; EQ-5D; NIHSS; atrial fibrillation; ischemic stroke; mRS; plaque index; post-acute care.