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Increasing relevance of acute cerebrovascular disease in very old patients

Ischemic stroke and risk factors for acute cerebrovascular disease in subjects of 80 years of age or older are poorly characterized. Currently, one-third of all cases of acute ischemic stroke occur in people older than 80 years of age [1,2]. As life expectancy continues to increase in industrialized countries, elderly patients will eventually constitute a vast majority of stroke victims [3,4]. The study of Rojas et al. [5] published in the current issue of the Journal is a timely piece of work in the current climate of interest for a better knowledge of stroke in very old patients. This study shows that risk factors profile and stroke subtypes vary according to age and that very old patients may constitute a subgroup of stroke patients with differential characteristics compared with patients younger than 80 years. Of the 535 consecutive patients with cerebral ischemia or transient ischemic attack, 179 (33.5%) were over 80 years and showed a demographic profile and cerebrovascular risk factors clearly different, with a marked predominance of the female sex (61.8%) and a higher frequency of hypertension (82.7%) and atrial fibrillation (24.6%). With regard to stroke subtype, lacunar infarcts accounted for 41.7% of cases followed by infarctions of unknown cause (31.8%) and cardioembolic infarctions (19.7%). It is well known that the incidence of ischemic stroke is higher in men than in women in all age groups except in the elderly [2,6], probably due to a survival effect of the female gender or because women at risk for stroke suffer from the disorder later in life than men [7]. The attributable risk of stroke for atrial fibrillation increased significantly rising from 1.5% for those aged 50–59 years to 23.5% for those aged 80– 89 years [8]. Atrial fibrillation is a risk factor clearly associated with cardioembolic stroke, one of the most frequent cerebral ischemic subtype in very old patients as shown in the present study and in previous reports [2,3]. Eighty years of age is arbitrarily considered a reasonable entry age cut-off in clinical trials of recombinant tissue plasminogen activator (rtPA) or anticoagulation in presumed cardioembolic stroke. However, a recent study suggests that the benefits of anticoagulation for secondary stroke prevention in patients with atrial fibrillation extend to the oldest old [9]. In another recent retrospective study, management of acute stroke with rtPA appears to be safe and effective in the older population [10]. Therefore, randomized clinical trials are needed to confirm the potential benefits of anticoagulation and thrombolysis in stroke patients aged 80 years or older. The study of Rojas et al. emphasizes the increasing relevance of stroke in the oldest old. Aspects that merit further investigation include the following: (i) knowledge of clinical and prognostic data at the time of discharge from the hospital and in the long-term follow-up, (ii) individualized analysis of risk factors, clinical features, and outcome of different ischemic stroke subtypes [11], (iii) characterization of the subset of very old patients with hemorrhagic stroke [12], and (iv) confirmation of the efficacy of anticoagulant and thrombolytic treatment in very old stroke victims.