Current issues of ACP Journal Club are published in Annals of Internal Medicine


Prognosis

Elderly patients had an increased 5-year risk for death, coronary events, and stroke after retinal infarction

ACP J Club. 1991 July-Aug;115:24. doi:10.7326/ACPJC-1991-115-1-024

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Endarterectomy was not effective for moderate symptomatic carotid stenosis


Source Citation

Hankey GJ, Slattery JM, Warlow CP. Prognosis and prognostic factors of retinal infarction: a prospective cohort study. BMJ. 1991 Mar 2;302:499-504. [PubMed ID: 2012845]


Abstract

Objective

To investigate the prognosis of patients with retinal infarction and without previous stroke and to identify predictive factors for death, stroke, and coronary events.

Design

Inception cohort followed until death or the end of the study (range 1 to 10 years).

Setting

Patients were referred between 1977 and 1986 (91% from the Oxford Eye Hospital) to a neurologist (CPW).

Patients

98 consecutive patients (mean age 64 y) with retinal infarction (acute, painless, monocular loss of visual acuity or visual field for > 24 hours) thought to be caused by atheroma (n = 74), cardiogenic embolism (n = 17), or both (n = 7), were seen by 1 neurologist at a median interval of 28 days after the infarction.

Assessment of prognostic factors

Age, sex, and smoking status; causes of the infarction; cardiac, vascular, and other diseases; carotid bruit; blood pressure; blood lipids; and therapeutic interventions were included at baseline and in 4- to 12-month reviews. Doppler studies were not available but 55 patients who were candidates for carotid endarterectomy had angiography.

Main outcome measures

Deaths, major or minor strokes, coronary events, and contralateral retinal infarctions were assessed by 1 neurologist at follow-up; all records were reviewed by a second observer at the end of the study.

Main results

Mean follow-up was 4.2 years. In the first 5 years average annual risk for death was 8.0% (95% CI 5.1% to 11.3%); for stroke, 2.5% (CI 0.7% to 4.2%), but 7.4% in the first year; for a coronary event, 5.3% (CI 2.9% to 8.0%); and for any of stroke, myocardial infarction, or death, 9.7% (CI 7.3% to 12.4%). A coronary event was more likely than a stroke; 17 of 29 deaths (59%) resulted from a coronary event compared with 1 death (3%) from stroke. The risk for a coronary event was increased by cardiomegaly (hazard ratio 3.6 CI 1.3 to 10) and by carotid bruit (hazard ratio 2.8 CI 1.1 to 7.3). The risk for stroke, myocardial infarction, or vascular death was related to carotid bruit (hazard ratio 3.2 CI 1.5 to 7.1) and cardiomegaly (hazard ratio 2.8 CI1.2 to 6.3).

Conclusion

Elderly patients with retinal infarction and no history of stroke had poor 5-year prognosis for death, coronary events, and stroke, particularly if they had carotid bruit and cardiomegaly.

Sources of funding: The Chest, Heart and Stroke Association and the Medical Research Council.

Address for article reprint: Dr. G.J. Hankey, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, Scotland, UK.


Commentary

The natural history of amaurosis fugax caused by transient interference with the blood supply to the ophthalmic artery has been well studied. Little or no comparable information is available about retinal artery infarction, a much rarer event. The article by Hankey and colleagues describes a careful prospective study of 98 patients with retinal artery infarction and reports results that are similar to those in amaurosis fugax. Specifically, there is a much higher risk for ipsilateral stroke for the first 6 months after either event. After that, coronary artery disease is more common than stroke, and death from myocardial infarction far exceeds that from cerebrovascular accidents. Thus, both amaurosis fugax and retinal infarction are important as markers of generalized vascular disease as well as warning of possible impending stroke.

In 1991, the NASCET Investigators (1) indicated that carotid endarterectomy is beneficial for patients with recent transient ischemic attack or stroke (including retinal infarction) and ipsilateral severe (>70%) stenosis of the carotid artery. In a 1998 update of their study they reported that patients with >70% carotid artery stenosis had a durable benefit from endarterectomy at 8 years of follow up. They also reported only a moderate reduction in the risk for stroke following endarterectomy in patients with symptomatic carotid stenosis of 50% to 69% and no benefit from surgery in patients with stenosis <50% (2).

Arthur W. Feinberg, MD
Manhasset, New York, USA.


References

1. NASCET Investigators. Benefit of carotid endarterectomy for patients with high-grade stenosis of the internal carotid artery. Clinical Alert. National Institute of Neurological Disorders and Stroke. 1991 Feb 25.

2. Barnett HJ, Taylor DW, Eliasziw M, et al., for the North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med. 1998;339:1415-25.