高龄人群晚发缺血性卒中的病因与预测：ARIC研究
基于ARIC队列中6213名无卒中参与者，分析首次急性缺血性卒中（AIS）的病因亚型与预测。中位随访5.1年间277人（4.4%）发生AIS；≥80岁发生AIS者更倾向栓塞性亚型（OR 1.90，95%CI 1.09-3.31），该效应部分由房颤、左房容积指数异常和P波轴异常介导；纳入栓塞危险因素后预测性能改善。
要点
- ≥80岁发生AIS者栓塞性亚型风险更高，OR 1.90（95%CI 1.09-3.31）。
- 房颤、左房容积指数异常和P波轴异常部分介导年龄与栓塞性卒中的关联。
- 现有PREDICT与CHA2DS2-VASc对≥80岁AIS预测差，加入栓塞危险因素后改善。
核心结论
- 高龄人群AIS以栓塞性亚型更常见，识别和控制栓塞危险因素对降低卒中风险至关重要，仍需更好的卒中专用预测工具。
研究设计与样本
- ARIC研究：visit 5（2011-2013）无卒中参与者中，病因分析纳入至visit 10（2023）发生AIS者，预测分析纳入visit 5无卒中者。
- 共6213名无卒中参与者，随访中位5.1年（Q1-Q3 2.6-7.1），277人（4.4%）发生AIS。
- AIS者中位年龄81岁（Q1-Q3 77-86），女性62%，栓塞性99例、血栓性178例。
- 采用logistic回归、1000次bootstrap中介分析及C统计量比较预测性能。
主要发现
- ≥80岁发生AIS者相比<80岁者，栓塞性（对比血栓性）缺血性卒中的比值比为1.90（95%CI 1.09-3.31）。
- 年龄对栓塞性卒中的效应由房颤介导44%（P=0.03）、左房容积指数异常介导45%（P=0.048）、P波轴异常介导43%（P=0.04）。
- PREDICT方程预测≥80岁AIS的C统计量0.49（95%CI 0.45-0.53，N=5702），CHA2DS2-VASc为0.57（95%CI 0.55-0.59，N=5739）。
- 纳入栓塞危险因素后，PREDICT的C统计量升至0.77（95%CI 0.74-0.80），CHA2DS2-VASc升至0.63（95%CI 0.59-0.67）。
临床怎么用
- 对高龄人群应重视房颤、左房扩大及P波轴异常等栓塞危险因素的识别与控制。
- 现有通用心血管风险工具对≥80岁AIS预测不佳，纳入栓塞因素可提升判别能力。
- 临床预测高龄卒中风险时不宜单独依赖PREDICT或CHA2DS2-VASc。
局限性
- 单队列ARIC研究，AIS事件数有限（277例，其中栓塞性99例）。
- 中介分析为观察性设计，不能确立因果关系。
- 预测模型性能比较基于同一队列，外部推广性需验证。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
BACKGROUND: As life expectancy rises, identifying causes and risk factors for incident acute ischemic stroke (AIS) among the oldest-old (≥80 years) is increasingly important. We examined whether the effect of age at stroke on AIS subtype is mediated by embolic risk factors and whether these factors improve AIS prediction. METHODS: Stroke-free participants from the ARIC study (Atherosclerosis Risk in Communities) who developed AIS between visit 5 (2011-2013) and visit 10 (2023) were included for causal analysis; Stroke-free participants at visit 5 were included for prediction analysis. In logistics regression models, the association between age at stroke-onset (≥80 versus <80 years) and adjudicated AIS subtype (embolic ischemic stroke versus thrombotic ischemic stroke) was determined. Bootstrapped mediation analyses (1000-iterations) tested whether atrial fibrillation, myocardial infarction, coronary heart disease, heart failure, and electro/echocardiogram measures mediated the age-AIS subtype relationship. C statistics were calculated for AIS prediction (Predicting Risk of Cardiovascular Disease Events, CHA2DS2-VASc) and compared preinclusion and postinclusion of embolic risk factors. RESULTS: Of 6213 stroke-free participants at visit 5, 277 (4.4%) developed AIS during a median (Q1-Q3) of 5.1 (2.6-7.1) years (median [Q1-Q3] age: 76 [72-80] years; median [Q1-Q3] age at AIS: 81 [77-86] years; 62% female; 99 embolic ischemic stroke and 178 thrombotic ischemic stroke). Individuals with AIS ≥80 years had higher odds of embolic ischemic stroke (versus thrombotic ischemic stroke) compared with those aged <80 years (odds ratio, 1.90 [95% CI, 1.09-3.31]). The effect of age at stroke-onset on embolic ischemic stroke was mediated by atrial fibrillation (44%; P=0.03), an abnormal left atrium volume index (45%; P=0.048), or an abnormal P-wave axis (43%; P=0.04). The predictive performance for AIS ≥80 years using the Predicting Risk of Cardiovascular Disease Events equation (N=5702, C statistic, 0.49 [95% CI, 0.45-0.53]), or CHA2DS2-VASc score (N=5739, C statistic, 0.57 [95% CI, 0.55-0.59]) was poor, but inclusion of embolic risk factors improved the performance (Predicting Risk of Cardiovascular Disease Events: C statistics, 0.77 [95% CI, 0.74-0.80]; CHA2DS2-VASc: C statistics, 0.63 [95% CI, 0.59-0.67]). CONCLUSIONS: These findings suggest that identification and control of embolic risk factors are critical to reduce stroke risk as people age, and better stroke-specific prediction tools are needed.
引用
- Wang J, Egle M, Jin Z, et al. Late-Life Incident Stroke in the Atherosclerosis Risk in Communities Study: Etiology and Prediction. Stroke. 2026. PMID: 42059062. doi:10.1161/STROKEAHA.125.054194
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。