European Journal of Cardiovascular Medicine

Stroke remains one of the leading causes of mortality and long-term disability worldwide, posing a major public health challenge and socioeconomic burden. According to the World Health Organization, stroke accounts for nearly 12% of all deaths globally and is the second most common cause of death and the third most common cause of disability-adjusted life years (DALYs) lost.¹ The prevalence and incidence of stroke are rising steadily in low- and middle-income countries, particularly in South Asia, where demographic transition, urbanization, and lifestyle modifications have accelerated the burden.² India contributes substantially to the global stroke burden, with an estimated incidence of 119–152 per 100,000 population per year and increasing trends in both ischemic and hemorrhagic subtypes.³ Although advances in acute stroke care have improved survival, the risk of recurrent stroke remains high and significantly influences long-term outcomes.

Recurrent stroke is defined as the occurrence of a new cerebrovascular event after recovery from an index episode. ⁴ Recurrence represents a critical stage in the natural history of stroke, with higher mortality, accelerated functional deterioration, and profound decline in quality of life compared to first-ever stroke. Studies have indicated that up to 30% of patients may develop recurrent stroke within five years of the first episode, and the risk is highest within the first year. ⁵ the factors contributing to recurrence are often modifiable, making secondary prevention a cornerstone of stroke management. Identifying and addressing these risk factors early is essential to reduce morbidity and mortality.

Among the determinants of recurrent stroke, lifestyle factors play a pivotal role. Tobacco use, alcohol consumption, physical inactivity, obesity, and unhealthy dietary habits significantly aggravate cerebrovascular risk.⁶ Nicotine-induced endothelial dysfunction, oxidative stress, and hypercoagulability contribute to thrombogenesis and impaired cerebral perfusion, increasing the likelihood of recurrent ischemic events.⁷ Excessive alcohol intake is associated with hypertension, atrial fibrillation, and structural cardiac changes, all of which predispose to stroke recurrence.⁸ Similarly, sedentary behaviour and central obesity promote insulin resistance, dyslipidaemia, and chronic inflammation, thereby increasing the risk of repeated cerebrovascular insults.⁹ Evidence shows that adherence to healthy lifestyle practices including a balanced diet, regular exercise, smoking cessation, and moderated alcohol use reduces recurrence risk and enhances clinical outcomes.¹⁰

Clinical risk factors also have a substantial impact on recurrent stroke outcomes. Hypertension remains the most important and consistent contributor to recurrence, with poor blood pressure control doubling the risk of subsequent events.¹¹ Diabetes mellitus accelerates atherosclerosis and microvascular damage, increasing the probability of both ischemic and hemorrhagic recurrence.¹² Dyslipidemia, particularly elevated low-density lipoprotein (LDL) and triglycerides, further aggravates atherothrombotic processes, while inadequate lipid-lowering therapy is strongly associated with recurrent stroke.¹³ Cardiac disorders such as atrial fibrillation, valvular heart disease, and heart failure contribute to cardiogenic embolization and are key predictors of recurrence.¹⁴ Other clinical determinants include chronic kidney disease, carotid artery stenosis, hypercoagulable states, and medication non-adherence.¹⁵

The outcomes of recurrent stroke depend not only on risk exposure but also on the timely control of comorbidities and adherence to secondary prevention strategies. Functional disability measured by scales such as the Modified Rankin Scale (mRS) and Barthel Index is significantly higher in patients with recurrent episodes.¹⁶ Cognitive decline, aphasia, gait disturbances, and post-stroke depression are more prevalent, leading to impaired independence and poorer health-related quality of life.¹⁷ Moreover, recurrent strokes are associated with increased length of hospital stay, higher treatment costs, greater caregiver burden, and reduced return-to-work rates.¹⁸ In tertiary care settings, the presence of trained neurologists, advanced diagnostics, rehabilitation units, and thrombolysis/thrombectomy services may influence clinical outcomes; however, late presentation, lack of awareness, and inadequate follow-up contribute to adverse prognoses.¹⁹

Given this background, the present study aims to investigate lifestyle and clinical risk factors influencing outcomes after recurrent stroke in a tertiary care centre, providing critical evidence for strengthening secondary prevention and improving post-stroke quality of life.

Aim:

To assess the influence of lifestyle and clinical risk factors on functional and clinical outcomes among patients with recurrent stroke in a tertiary care centre.

Objectives:

1. To identify the lifestyle risk factors (such as smoking, alcohol consumption, physical inactivity, dietary habits, and obesity) associated with recurrent stroke among patients attending a tertiary care centre.
2. To determine the key clinical risk factors (including hypertension, diabetes mellitus, dyslipidaemia, cardiovascular disorders, and other comorbidities) contributing to recurrent stroke.
3. To assess the relationship between lifestyle and clinical risk factors and the functional outcomes of recurrent stroke using standardized assessment scales.

Study Design: Prospective study.    

Study area: Department of Neurology, Narayana Medical College, Nellore.

Study Period: 1/1/2017- 31/12/2018.

Study population: patients attending neurology OPD, Emergency and patients admitted in Neurology Department.

Sample size: The study consisted of a total of 104 subjects.

Sampling Technique: Simple random sampling method.  

Inclusion Criteria: 

 1. All the patients with clinical features suggestive of second or subsequent stroke.

2. Either ischemic infarcts or intraparenchymal haemorrhage in the brain as confirmed by imaging of brain.

Exclusion criteria:

1. First ever episode of stroke

2. Evolving stroke.

3. Imaging showing evidence of venous infarct.

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

Study tools and Data collection procedure:

A proforma was prepared which includes detailed history, clinical examination and requisite investigations available.

DEFINITIONS (for the risk factors observed):

1) Past and present smokers were termed as smokers.

2) Past and present alcoholics were termed as alcoholics.

3) Hypertension, according to JNC VII criteria, was diagnosed when the systolic or diastolic BP was ≥140/ ≥90 mmHg on a repeated single day measurement or if the individual was a known hypertensive and was receiving antihypertensive drugs.

4) Dyslipidaemia was defined by the presence of high total cholesterol (≥200mg/dl)

And low HDL cholesterol (<45mg/dl for men, <50mg/dl for women), LDL-cholesterol

>130 mg/dl, VLDL >40 mg/dl and triglycerides ≥165 mg/dL according to the National Cholesterol Education Program (2001).

5) Diabetes mellitus was diagnosed based on history and fasting serum glucose levels (>110 mg/dl) atleast2times and HbA1c levels > 6.5 or if the patient was receiving insulin or hypoglycaemic drugs.

6) ECG was done for atrial fibrillation, sick sinus syndrome, left ventricular hypertrophy etc., and 2D Echo was done in all patients to work up for cardio embolic source of ischemic stroke like rheumatic heart disease, prosthetic valve, coronary artery disease etc.,

The functional outcome of the patient in the present study, was evaluated by mRS (modified Rankin scale) at the time of admission, discharge and after 3 months of follow up.

Modified ranking scale was further classified into no significant disability (0-2), significant disability (mRS 3-5), Death (6) .

Statistical analysis:

The data values were entered into MS-Excel and statistical analysis was done by using IBM SPSS Version 24.0. For categorical variables, the data values were represented as number and percentages, to test the association between two or more groups, chi square test was used. For continuous variables, data values are expressed as mean standard deviation, to test the mean difference between two groups the students T- test was used. All p values are having less than 0.05 are considered as statistically significant.

Table 1. Baseline Characteristics of Study Population (N = 104)

The majority of recurrent stroke patients belonged to the ischemic category (86.5%). The mean age was similar between ischemic (60.28 years) and hemorrhagic (60.64 years) stroke groups, indicating no age-related predisposition. Male predominance was observed, particularly in the hemorrhagic group (92.9%), which was statistically significant (p = 0.039). 

Table 2. Distribution of Lifestyle and Clinical Risk Factors

Hypertension (66.3%) and dyslipidemia (63.5%) were the most prevalent risk factors among recurrent stroke patients. Both conditions showed statistically significant association with hemorrhagic stroke (p = 0.024 and p = 0.014 respectively). Diabetes, smoking, alcohol consumption, coronary artery disease, atrial fibrillation, and poor drug compliance were more frequent among ischemic strokes, but none of these variables reached statistical significance. This suggests that uncontrolled hypertension and dyslipidemia are critical drivers of stroke recurrence, particularly hemorrhagic subtype.

Table 3. Stroke Characteristics Based on Imaging Findings

Among ischemic strokes, the middle cerebral artery (MCA) territory was the most commonly involved (50%), followed by the vertebrobasilar territory (19.23%), posterior cerebral artery (12.5%), and anterior cerebral artery (4.8%). For hemorrhagic strokes, capsuloganglionic hemorrhages were most frequent (35.71%), followed by thalamus (28.57%), pons (21.43%), and cerebellum (14.29%). These findings indicate that recurrent ischemic strokes predominantly affect the MCA territory, whereas recurrent hemorrhagic strokes commonly occur within deep brain structures supplied by small perforator arteries—reflecting long-standing vascular pathology.

Table 4. Time Gap Between First and Recurrent Stroke

The majority of patients (67.31%) experienced recurrence after more than 12 months from the initial episode. Only 6.73% had recurrence within the first 3 months, and about one-fourth (25%) recurred within 3–9 months. This shows that although early recurrence occurs in a subset of patients, the larger burden of recurrence develops after one year, possibly due to long-term inadequate secondary prevention, poor follow-up, and uncontrolled risk factors.

Table 5. Functional Outcome Based on Modified Rankin Scale (mRS)

At admission, most patients (81.7%) showed poor functional outcomes (mRS 3–6), reflecting high disability at presentation. By discharge, there was notable clinical improvement, with 53.8% attaining good outcome. At 3-month follow-up, 88.5% achieved good functional status, signifying substantial recovery. These results reinforce the importance of timely management, rehabilitation, and long-term secondary prevention. However, the progression highlights that early functional prognosis is poor in recurrent stroke, but rehabilitation leads to marked improvement over time.

Table 6. Mortality and Survival Outcomes

Overall, in-hospital mortality was 4.8%. Mortality was higher in hemorrhagic patients (14.3%) compared to ischemic patients (3.3%), although not statistically significant. Most patients (92.3%) survived, demonstrating that with appropriate treatment, survival is high among recurrent stroke patients. A small proportion (2.9%) were lost to follow-up, which may affect long-term outcome monitoring. This table suggests that recurrent hemorrhagic stroke poses greater fatality risk compared to ischemic recurrence.

Understanding the etiology, clinical characteristics, and outcomes of recurrent stroke is crucial for improving secondary prevention and therapeutic strategies in patients with cerebrovascular accidents. In the present study, 104 patients with recurrent stroke were evaluated. The proportion of ischemic recurrent strokes far exceeded hemorrhagic strokes (86.5% vs 13.5%). This pattern aligns with multiple international studies, including the RESCUE study (91% vs 9%), ⁽20⁾ Thomas Hillen et al. (84.5% vs 16.5%), ⁽21⁾ and Sema Demirci et al. (89% vs 9%), ⁽22⁾ confirming that ischemic stroke recurrence is globally more common.

The mean age in the present study was 60.28 years in the ischemic group and 60.64 years in the hemorrhagic group, which is comparable to the mean age described by Wei-Qi Chen et al. (62 years),⁽23⁾ but lower than those observed in studies conducted by Laloux et al. (72.3 years),⁽24⁾ the RESCUE study (77.6 years),⁽20⁾ and Sema Demirci et al. (67.6 years).⁽22⁾ The relatively younger age of presentation in the current study may be attributed to demographic differences, lifestyle factors, healthcare accessibility, and variations in population awareness levels.

Gender distribution showed marked male predominance (M:F = 2.25:1). Although other studies also report male preponderance, the male:female ratio was significantly higher in our study compared to Laloux et al. (1.13:1),⁽24⁾ RESCUE study (1.27:1),⁽20⁾ and Gulsen Kokamen et al. (1.22:1).⁽25⁾ The disproportionately high male representation may reflect sociocultural patterns in India, where males have greater exposure to behavioral vascular risks (smoking, alcohol) and higher health-seeking behavior compared to females.

The present study also observed a strong rural predominance (89.4%), a variable scarcely explored in earlier work. Rural burden of recurrence may be linked to lower literacy, limited awareness of stroke warning signs, socioeconomic constraints, poor access to healthcare, and lack of continuity of care. Similar demographic disparities have been previously highlighted in low- and middle-income countries. ⁽26⁾

The mean BMI in our cohort (26.69–26.72 kg/m²) falls within the overweight category, consistent with AHA/ASA guidelines that emphasize a near-linear association between increasing BMI and recurrent stroke risk, with each 1 kg/m² rise increasing risk by ~5%. ⁽27⁾ Comparable findings were noted by Wei-Qi Chen et al.⁽23⁾

Left hemiparesis (29.81%) and right hemiparesis (25.86%) were the most common presenting complaints, which can be explained by the predominance of middle cerebral artery involvement (57.8%). MCA involvement in recurrent ischemic stroke is widely reported due to its large vascular territory and susceptibility to atherosclerosis. ⁽28⁾ Bulbar symptoms and seizures were also frequent, reflecting vertebrobasilar territory involvement and cortical irritation.

Hypertension emerged as the most prevalent risk factor (66.3%), followed by dyslipidemia (63.5%), smoking (49%), diabetes mellitus (39.4%), alcohol (36.5%), coronary artery disease (17.3%), and atrial fibrillation (11.5%). Hypertension and dyslipidemia were the only statistically significant factors. The risk factor pattern corresponds with the findings of Laloux et al., ⁽24⁾ RESCUE study, ⁽20⁾ and Sema Demirci et al., ⁽22⁾ all of which recognized hypertension as the dominant determinant of recurrence. Hypertension continues to be the strongest contributor to recurrent stroke risk globally, reaffirming the critical importance of strict BP control in secondary prevention. ⁽27⁾

Another notable observation was poor drug compliance (32.7%). Despite lacking statistical significance, poor compliance represented a major modifiable driver of recurrence. Low adherence rates may be linked to low health literacy and inadequate follow-up—factors previously reported in South Asian populations. ⁽29⁾

A novel element in this study was the evaluation of cumulative risk factor impact. Patients with more than one vascular risk factor had an 89% recurrence rate, consistent with Laloux et al. (84%). ⁽24⁾ The accumulation of risk factors clearly enhances disease vulnerability; for instance, coexistence of hypertension with diabetes and dyslipidemia intensifies the probability of recurrence due to synergistic vascular inflammatory mechanisms. ⁽27⁾

Regarding temporal patterns, most patients experienced recurrence after 12 months (67.3%), agreeing with studies by Laloux et al.⁽24⁾ and the RESCUE group. ⁽20⁾ This highlights that long-term secondary prevention should extend beyond the first year after stroke.

Mortality in the present cohort was 4.8%, comparable to the RESCUE study (6%). ⁽20⁾ Mortality was higher in hemorrhagic recurrence (14.3%) than ischemic recurrence (3.3%), though not statistically significant. This trend mirrors global patterns, where hemorrhagic stroke carries higher fatality. ⁽30⁾

Functional outcome evaluated using modified Rankin Scale (mRS) revealed substantial improvement over time. Patients with good functional outcome (mRS 0–2) increased from 18.3% at admission to 53.9% at discharge and 88.5% at 3-month follow-up. This confirms that appropriate acute stroke care, rehabilitation, and risk factor control dramatically improve prognosis. Although previous studies used varied functional scales, few used mRS prospectively for recurrent stroke, underscoring the contribution of this study to literature.

Overall, the findings emphasize that recurrent stroke is largely preventable through aggressive management of modifiable factors — especially hypertension, dyslipidemia, and treatment adherence. Long-term risk-factor monitoring, patient education, and improved healthcare access are crucial to minimizing recurrence and disability.

Recurrent stroke is not an inevitable consequence of a first stroke; rather, it reflects missed opportunities in secondary prevention. Strengthening patient awareness, treatment adherence and risk-factor management can substantially reduce recurrence and thereby improve survival, functional independence, and long-term quality of life.

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