Cardiac biomarkers combined with neuroimaging localization predict long-term outcomes in acute stroke patients.

Cardiac biomarker elevation is common after stroke, but its relationship with stroke localization and long-term outcomes remains incompletely characterized. This prospective observational cohort study enrolled 695 patients (380 ischemic stroke, 135 TIA, 180 hemorrhagic stroke) from October 2020 to July 2023. High-sensitivity cardiac troponin I (hs-cTnI), NT-proBNP, and CK-MB were measured at admission and at 12-24 h. Ischemic strokes were categorized by localization (insular involvement, anterior non-insular, posterior circulation, subcortical-only). Primary outcomes were 1-year all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). Biomarker elevations varied significantly by stroke type and localization. Hemorrhagic stroke showed the highest hs-cTnI (median 28.7 ng/L) and troponin elevation rate (54.4%). Among ischemic strokes, insular involvement demonstrated the highest biomarker levels (hs-cTnI 45.8 ng/L, NT-proBNP 892 pg/mL, troponin elevation 73.9%; all p < 0.001 versus other localizations). At 1 year, overall mortality was 20.4% and MACCE 31.4%. Elevated troponin independently predicted mortality (HR 3.24, 95% CI 2.18-4.82), MACCE (HR 2.86), and recurrent stroke (HR 1.92). A synergistic interaction between troponin elevation and insular involvement was identified for mortality (interaction HR 2.15, p = 0.029) and MACCE (interaction HR 1.84, p = 0.016). Hs-cTnI demonstrated good discriminative ability (AUC 0.782 for mortality, 0.745 for MACCE). Cardiac biomarker elevation, particularly in insular strokes, independently predicts adverse outcomes. Routine biomarker assessment combined with stroke localization data may enhance risk stratification and guide targeted interventions.