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Traditional risk factors for stroke are those that lead to atherosclerosis or cause a higher risk of cardioembolic events. It has been increasingly recognized that some systemic illnesses may themselves independently predispose patients to stroke and therefore may warrant distinct prevention strategies. Cirrhosis has been associated with both systemic thrombotic and hemorrhagic complications, but whether cirrhosis itself places patients at higher risk for cerebrovascular disease remains uncertain. A recent study examined the association between cirrhosis and liver disease using a national dataset.

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Parikh and colleagues (2017) utilized a retrospective cohort of 1.6 million Medicare beneficiaries between 2008 and 2014. This data set includes most U.S. citizens over the age of 65 and includes both inpatient and outpatient claims data. ICD-9 codes for cirrhosis were used to identify patients with liver disease, an approach that has been previously validated. The primary outcome examined was hospital admissions for stroke, and the included covariates were traditional stroke risk factors as well as medical comorbidities.

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A total of 15,586 patients with cirrhosis were identified in the sample, with a mean age of 74 years. Compared with those in the cohort without cirrhosis, those with cirrhosis were more likely to be male and had more stroke risk factors. The incidence of stroke was found to be 2.17% per year among patients with cirrhosis and 1.11% per year among patients without cirrhosis. After adjustment for demographic characteristics, stroke risk factors, and comorbidities, patients with cirrhosis had a significantly higher risk of stroke (hazard ratio [HR], 1.4; 95% confidence interval [CI], 1.3–1.5).

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The authors also examined subtypes of stroke and found that the association between cirrhosis and stroke was highest for intracerebral hemorrhage (HR, 1.9; 95% CI, 1.5–2.4) and subarachnoid hemorrhage (HR, 2.4; 95% CI, 1.7–3.5) compared with ischemic stroke (HR, 1.3; 95% CI, 1.2–1.5). For etiologies of ischemic stroke, the association was seen only in non-embolic stroke (HR, 1.4; 95% CI, 1.3–1.5).

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Secondary analyses were performed looking at alcohol-related and non-alcohol-related cirrhosis and were consistent in both cases with the primary analysis—except that the association between alcohol-related cirrhosis and subarachnoid hemorrhage was not significant. Mild liver disease was not associated with stroke, and there were slightly higher associations when decompensated cirrhosis was examined alone. A sensitivity analysis was performed in part to test the accuracy of cirrhosis identification. In this analysis, only patients with cirrhosis identified by a gastroenterologist and those who had undergone abdominal imaging or liver biopsy were included, and the primary results remained unchanged.

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This important study demonstrates that cirrhosis is indeed associated with stroke. While the association was stronger for types of hemorrhagic stroke, it held for ischemic stroke as well. This finding may have implications for secondary prevention strategies in these patients. Whether mitigation of underlying causes of cirrhosis (e.g., cessation of alcohol use, treatment of hepatitis C with antiviral medications) would mitigate this risk remains to be determined in future investigations.

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Parikh  NS  et al.: Association between cirrhosis and stroke in a nationally representative cohort. JAMA Neurol, 2017
[PubMed: 28586894]