Stroke in a biracial population: the excess burden of stroke among blacks

Age differences in the associations of behavioral and psychosocial factors with stroke

BACKGROUND

Stroke remains a major public health burden. Few studies have focused on the age differences in the associations of behavioral and psychosocial factors with stroke while no study focusing on the effect of severe psychological distress (SPD) on stroke has been conducted. The aim of this study was to examine the age differences in these risk factors for stroke as young (18-44 years), middle aged (45-64 years), and elderly (65 years or older).

METHODS

A total of 1,258 adults with stroke and 39,985 controls were selected from the 2005 California Health Interview Survey. Multiple logistic regression analyses were used to estimate the associations of the factors with stroke at different ages.

RESULTS

The prevalence of SPD was 10% in cases and 3.6% in controls, respectively. Overall, current smoking, lack of physical activity, alcohol consumption, SPD, type II diabetes, male, older age, and unemployment were all associated with a higher prevalence of stroke. Practically, we found that smoking and SPD were associated with the prevalence of stroke in young adults, lack of physical activity was associated with the prevalence of stroke in middle-aged adults, and lack of physical activity and SPD were associated with the prevalence of stroke in the elderly.

CONCLUSIONS

Appropriate intervention for reducing stroke and eliminating its disparities may be developed separately at each age.

Individual and community determinants of calling 911 for stroke among African Americans in an urban community

BACKGROUND

African Americans receive acute stroke treatment less often than non-Hispanic whites. Interventions to increase stroke preparedness (recognizing stroke warning signs and calling 911) may decrease the devastating effects of stroke by allowing more patients to be candidates for acute stroke therapy. In preparation for such an intervention, we used a community-based participatory research approach to conduct a qualitative study exploring perceptions of emergency medical care and stroke among urban African American youth and adults.

METHODS AND RESULTS

Community partners, church health teams, and church leaders identified and recruited focus group participants from 3 black churches in Flint, MI. We conducted 5 youth (11-16 years) and 4 adult focus groups from November 2011 to March 2012. A content analysis approach was taken for analysis. Thirty-nine youth and 38 adults participated. Women comprised 64% of youth and 90% of adult focus group participants. All participants were black. Three themes emerged from the adult and youth data: (1) recognition that stroke is a medical emergency; (2) perceptions of difficulties within the medical system in an under-resourced community, and; (3) need for greater stroke education in the community.

CONCLUSIONS

Black adults and youth have a strong interest in stroke preparedness. Designs of behavioral interventions to increase stroke preparedness should be sensitive to both individual and community factors contributing to the likelihood of seeking emergency care for stroke.

Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study

OBJECTIVES

to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.

METHODS

prospective cohort study with a follow-up of 11.5 years.

SETTING

the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.

MEASUREMENTS

the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.

RESULTS

of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01-1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00-1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.

CONCLUSIONS

psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.

The relationship between metabolic risk factors and incident cardiovascular disease in Europeans, South Asians, and African Caribbeans: SABRE (Southall and Brent Revisited) -- a prospective population-based study

Objectives

This study sought to determine whether ethnic differences in diabetes, dyslipidemia, and ectopic fat deposition account for ethnic differences in incident cardiovascular disease.

Background

Coronary heart disease risks are elevated in South Asians and are lower in African Caribbeans compared with Europeans. These ethnic differences map to lipid patterns and ectopic fat deposition.

Methods

Cardiovascular risk factors were assessed in 2,049 Europeans, 1,517 South Asians, and 630 African Caribbeans from 1988 through 1991 (mean age: 52.4 ± 6.9 years). Fatal and nonfatal events were captured over a median 20.5-year follow-up. Subhazard ratios (SHR) were calculated using competing risks regression.

Results

Baseline diabetes prevalence was more than 3 times greater in South Asians and African Caribbeans than in Europeans. South Asians were more and African Caribbeans were less centrally obese and dyslipidemic than Europeans. Compared with Europeans, coronary heart disease incidence was greater in South Asians and less in African Caribbeans. The age- and sex-adjusted South Asian versus European SHR was 1.70 (95% confidence interval [CI]: 1.52 to 1.91, p < 0.001) and remained significant (1.45, 95% CI: 1.28 to 1.64, p < 0.001) when adjusted for waist-to-hip ratio. The African Caribbean versus European age- and sex-adjusted SHR of 0.64 (95% CI: 0.52 to 0.79, p < 0.001) remained significant when adjusted for high-density lipoprotein and low-density lipoprotein cholesterol (0.74, 95% CI: 0.60 to 0.92, p = 0.008). Compared with Europeans, South Asians and African Caribbeans experienced more strokes (age- and sex-adjusted SHR: 1.45 [95% CI: 1.17 to 1.80, p = 0.001] and 1.50 [95% CI: 1.13 to 2.00, p = 0.005], respectively), and this differential was more marked in those with diabetes (age-adjusted SHR: 1.97 [95% CI: 1.16 to 3.35, p = 0.038 for interaction] and 2.21 [95% CI: 1.14 to 4.30, p = 0.019 for interaction]).

Conclusions

Ethnic differences in measured metabolic risk factors did not explain differences in coronary heart disease incidence. The apparently greater association between diabetes and stroke risk in South Asians and African Caribbeans compared with Europeans merits further study.

Racial differences in the incidence of and risk factors for atrial fibrillation in older adults: the cardiovascular health study

This study examined whether different associations between risk factors and atrial fibrillation (AF) according to race could explain the lower incidence of AF in blacks. Baseline risk factor information was obtained from interviews, clinical examinations, and echocardiography in 4,774 white and 911 black Cardiovascular Health Study participants aged 65 and older without a history of AF at baseline in 1989/90 or 1992/93. Incident AF was determined according to hospital discharge diagnosis or annual study electrocardiogram. Cox regression was used to assess associations between risk factors and race and incident AF. During a mean 11.2 years of follow-up, 1,403 whites and 182 blacks had incident AF. Associations between all examined risk factors were similar in both races, except left ventricular posterior wall thickness, which was more strongly associated with AF in blacks (per 0.2 cm, blacks: hazard ratio (HR) = 1.72, 95% confidence interval (CI) = 1.44-2.06; whites: HR = 1.30, 95% CI = 1.18-1.43). Overall, the relative risk of AF was 25% lower in blacks than whites after adjustment for age and sex (HR = 0.75, 95% CI = 0.64-0.87) and 45% lower after adjustment for all considered risk factors (HR = 0.55, 95% CI = 0.35-0.88). Different associations of the considered risk factors and incident AF by race do not explain the lower incidence of AF in blacks.

Ethnic differences in atrial fibrillation identified using implanted cardiac devices

INTRODUCTION

Atrial fibrillation (AF) is suggested to be less common among black and Asian individuals, which could reflect bias in symptom reporting and access to care. In the Asymptomatic AF and Stroke Evaluation in Pacemaker Patients and the AF Reduction Atrial Pacing Trial (ASSERT), patients with hypertension but no history of AF had AF recorded via an implanted pacemaker or defibrillator, thus allowing both symptomatic and asymptomatic AF incidence to be determined without ascertainment bias.

METHODS AND RESULTS

The ASSERT enrolled 2,580 patients in 23 countries in North America, Europe, and Asia. AF was defined as device-recorded AF episodes >190/min, lasting either for >6 minutes or >6 hours in duration. All ethnic groups with >50 patients were enrolled. Ethnic groups studied include Europeans (n = 1900), black Africans (n = 73), Chinese (n = 89), and Japanese (n = 105) patients. Compared to Europeans, black Africans had more risk factors for AF such as heart failure (27.8 vs 14.6%) and diabetes (41.7 vs 26.3%). At 2.5 years follow-up, all 3 non-European races had a lower incidence of AF (8.3%, 10.1%, and 9.5% vs 18.0%, respectively, for AF>6 minutes, P < 0.006). When adjusted for baseline difference, Chinese had a lower incidence of AF > 6 minutes (P < 0.007), and Japanese and black Africans had a lower incidence of AF > 6 hours (P < 0.04 and P = 0.057, respectively).

CONCLUSIONS

Black Africans, Chinese, and Japanese had lower incidence of AF compared to Europeans. In the case of black Africans, this is despite an increased prevalence of AF risk factors.

Trends and survival between ethnic groups after stroke: the South London Stroke Register

BACKGROUND AND PURPOSE

To identify trends and differences between ethnic groups in survival after first-ever stroke and examine factors influencing survival.

METHODS

Population-based stroke register of first in a lifetime strokes between 1995 and 2010. Baseline data were collection of sociodemographic factors, stroke subtype, case mix, risk factors before stroke, and receipt of effective acute stroke processes. Survival curves were estimated with Kaplan-Meier methods, and survival analyses were undertaken using Cox Proportional-hazards models.

RESULTS

Survival improved significantly over this 16-year period (P<0.0001). Black Caribbean and black African had a reduced risk of all-cause mortality compared with white patients (hazard ratio, 0.85 [95% confidence interval, 0.74-0.98] and 0.61 [0.49-0.77], respectively) after adjustment for confounders. This survival advantage of black Caribbean/black African over white mainly existed in older patients (over 65). Recent stroke, being black Caribbean/black African, and stroke unit admission were associated with better survival.

CONCLUSIONS

Survival has improved in a multiethnic population over time. The independent survival advantage of black Caribbean and black African over White group in those aged over 65 may be a healthy migrant effect of first generation migrants. The increase in admission to a stroke unit may contribute to the improvement in survival after stroke.

Comparison of ischemic stroke outcomes and patient and hospital characteristics by race/ethnicity and socioeconomic status

BACKGROUND AND PURPOSE

Current literature provides mixed evidence on disparities by race/ethnicity and socioeconomic status in discharge outcomes after hospitalization for acute ischemic stroke. Using comprehensive data from 8 states, we sought to compare inpatient mortality and length of stay by race/ethnicity and socioeconomic status.

METHODS

We examined all 2007 hospitalizations for acute ischemic stroke in all nonfederal acute care hospitals in Arizona, California, Florida, Maine, New Jersey, New York, Pennsylvania, and Texas. Population was stratified by race/ethnicity (non-Hispanic whites, non-Hispanic blacks, and Hispanics) and socioeconomic status, measured by median income of patient zip code. For each stratum, we estimated risk-adjusted rates of inpatient mortality and longer length of stay (greater than median length of stay). We also compared the hospitals where these subpopulations received care.

RESULTS

Hispanic and black patients accounted for 14% and 12% of all ischemic stroke admissions (N=147 780), respectively, and had lower crude inpatient mortality rates (Hispanic=4.5%, blacks=4.4%; all P<0.001) compared with white patients (5.8%). Hispanic and black patients were younger and fewer had any form of atrial fibrillation. Adjusted for patient risk, inpatient mortality was similar by race/ethnicity, but was significantly higher for low-income area patients than that for high-income area patients (odds ratio, 1.08; 95% confidence interval, 1.02-1.15). Risk-adjusted rates of longer length of stay were higher among minority and low-income area populations.

CONCLUSIONS

Risk-adjusted inpatient mortality was similar among patients by race/ethnicity but higher among patients from lower income areas. However, this pattern was not evident in sensitivity analyses, including the use of mechanical ventilation as a partial surrogate for stroke severity.

Carotid artery stenosis as a cause of stroke

BACKGROUND

Population-based studies have estimated that about 15% of ischemic strokes are caused by large-vessel cerebrovascular disease. We determined the types of large-vessel atherosclerosis responsible for ischemic strokes in a population-based stroke study.

METHODS

Patients with first-ever or recurrent ischemic stroke in the Greater Cincinnati area were identified during 2005 at all local hospitals. Study physicians assigned ischemic stroke subtypes. Overall event rates and incidence rates for first-ever events were calculated, and age-, race- and sex-adjusted to the 2000 US population.

RESULTS

There were 2,204 ischemic strokes, including 365 strokes of large-vessel subtype (16.6% of all ischemic strokes). Extracranial internal carotid artery (ICA) stenosis was associated with 8.0% of all ischemic strokes, while extracranial ICA occlusion and intracranial atherosclerosis were each associated with 3.5% of strokes. The annual rate of first-ever and recurrent stroke attributed to extracranial ICA was 13.4 (11.4-15.4) per 100,000 persons. We conservatively estimate that about 41,000 strokes may be attributed to extracranial ICA stenosis annually in the United States.

CONCLUSIONS

Large-vessel atherosclerosis is an important cause of stroke, with extracranial ICA stenosis being significantly more common than extracranial ICA occlusion or intracranial atherosclerotic disease.

Age at stroke: temporal trends in stroke incidence in a large, biracial population

OBJECTIVES

We describe temporal trends in stroke incidence stratified by age from our population-based stroke epidemiology study. We hypothesized that stroke incidence in younger adults (age 20-54) increased over time, most notably between 1999 and 2005.

METHODS

The Greater Cincinnati/Northern Kentucky region includes an estimated population of 1.3 million. Strokes were ascertained in the population between July 1, 1993, and June 30, 1994, and in calendar years 1999 and 2005. Age-, race-, and gender-specific incidence rates with 95 confidence intervals were calculated assuming a Poisson distribution. We tested for differences in age trends over time using a mixed-model approach, with appropriate link functions.

RESULTS

The mean age at stroke significantly decreased from 71.2 years in 1993/1994 to 69.2 years in 2005 (p < 0.0001). The proportion of all strokes under age 55 increased from 12.9% in 1993/1994 to 18.6% in 2005. Regression modeling showed a significant change over time (p = 0.002), characterized as a shift to younger strokes in 2005 compared with earlier study periods. Stroke incidence rates in those 20-54 years of age were significantly increased in both black and white patients in 2005 compared to earlier periods.

CONCLUSIONS

We found trends toward increasing stroke incidence at younger ages. This is of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable.

Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome

Context:

Kashmir, a snow bound and mountain locked valley, is populated by about 7 million ethnic and non-migratory Kashmiris who have specific dietary and social habits than rest of the world. The neurological disorders are common in Kashmiri population.

Aims:

To study the prevalence and outcome of spontaneous intracranial subarachnoid hemorrhage (SAH) in Kashmir compared withother parts of the world.

Settings and Design:

A retrospective and hospital based study from 1982 to 2010 in the single and only Neurosurgical Centre of the State of Jammu and Kashmir.

Materials and Methods:

A hospital based study, in which, information concerning all Kashmiri patients was collected from the case sheets, patient files, discharge certificates, death certificates, and telephonic conversations with the help of Medical Records Department and Central Admission Register of Sher–i-Kashmir Institute of Medical Sciences, Kashmir India.

Statistical Analysis:

Analysis of variance and students T-test were used at occasions.

Results:

Incidence of SAH in Kashmiris is about 13/100,000 persons per year. SAH comprises 31.02% of total strokes and aneurysmal ruptures are cause of 54.35% SAHs. The female suffers 1.78 times more than the male. Total mortality of 36.60% was recorded against a good recovery of 14.99%. The familial SAHs and multiple aneurysms were also common. Intra-operative finding of larger aneurysmal size than recorded on pre-operative computed tomography (CT) angiogram of same patients was noteworthy. In 493 patients of SAH, the angiography revealed 705 aneurysms.

Conclusion:

Spontaneous intracranial subarachnoid hemorrhage, due to aneurysmal rupture, is common in Kashmir, with worst outcome. Food habits like “salt-tea twice a day”, group-smoking of wet tobacco like “Jejeer”, winter season, female gender, hypertension, and inhalation of “Kangri” smoke are special risk factorsof SAH, in Kashmiris. The plain CT brain and CT angiography are best diagnostic tools. The preventive measures for aneurysmal formation and rupture seems most promising management of future. The detachable endovascular aneurysmal occupying video assisted micro-camera capsules or plugs may be future treatment.

Racial differences in albuminuria, kidney function, and risk of stroke

BACKGROUND

The objective of this study was to examine the joint associations of estimated glomerular filtration rate (eGFR) and urinary albumin excretion with incident stroke in a large national cohort study.

METHODS

Associations of urinary albumin to creatinine ratio (ACR) and eGFR with incident stroke were examined in 25,310 participants of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a prospective study of black and white US adults ≥45 years of age.

RESULTS

A total of 548 incident strokes were observed over a median of 4.7 years of follow-up. Higher ACR values were associated with lower stroke-free survival in both black and white participants. Among black participants, as compared to an ACR <10 mg/g, the hazard ratios of stroke associated with an ACR of 10-29.99, 30-300, and >300 mg/g were 1.41 (95% confidence interval [CI] 1.01-1.98), 2.10 (95% CI 1.48-2.99), and 2.70 (95% CI 1.58-4.61), respectively, in analyses adjusted for traditional stroke risk factors and eGFR. In contrast, the hazard ratios among white subjects were only modestly elevated and not statistically significant after adjustment for established stroke risk factors. eGFR <60 mL/min/1.73 m(2) was not associated with incident stroke in black or white participants after adjustment for established stroke risk factors.

CONCLUSIONS

Higher ACR was independently associated with higher risk of stroke in black but not white participants from a national cohort. Elucidating the reasons for these findings may uncover novel mechanisms for persistent racial disparities in stroke.

Frontal bur hole through an eyebrow incision for image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage

OBJECT

Surgical evacuation of spontaneous intracerebral hemorrhage (sICH) remains a subject of controversy. Minimally invasive techniques for hematoma evacuation have shown a trend toward improved outcomes. The aim of the present study is to describe a minimally invasive alternative for the evacuation of sICH and evaluate its feasibility.

METHODS

The authors reviewed records of all patients who underwent endoscopic evacuation of an sICH at the UCLA Medical Center between March 2002 and March 2011. All patients in whom the described technique was used for evacuation of an sICH were included in this series. In this approach an incision is made at the superior margin of the eyebrow, and a bur hole is made in the supraorbital bone lateral to the frontal sinus. Using stereotactic guidance, the surgeon advanced the endoscopic sheath along the long axis of the hematoma and fixed it in place at two specific depths where suction was then applied until 75%-85% of the preoperatively determined hematoma volume was removed. An endoscope's camera, then introduced through the sheath, was used to assist in hemostasis. Preoperative and postoperative hematoma volumes and reduction in midline shift were calculated and recorded. Admission Glasgow Coma Scale and modified Rankin Scale (mRS) scores were compared with postoperative scores.

RESULTS

Six patients underwent evacuation of an sICH using the eyebrow/bur hole technique. The mean preoperative hematoma volume was 68.9 ml (range 30.2-153.9 ml), whereas the mean postoperative residual hematoma volume was 11.9 ml (range 5.1-24.1 ml) (p = 0.02). The mean percentage of hematoma evacuated was 79.2% (range 49%-92.7%). The mean reduction in midline shift was 57.8% (p < 0.01). The Glasgow Coma Scale score improved in each patient between admission and discharge examination. In 5 of the 6 patients the mRS score improved from admission exam to last follow-up. None of the patients experienced rebleeding.

CONCLUSIONS

This minimally invasive technique is a feasible alternative to other means of evacuating sICHs. It is intended for anterior basal ganglia hematomas, which usually have an elongated, ovoid shape. The approach allows for an optimal trajectory to the long axis of the hematoma, making it possible to evacuate the vast majority of the clot with only one pass of the endoscopic sheath, theoretically minimizing the amount of damage to normal brain.

Circulatory Diseases in the U.S. Elderly in the Linked National Long-Term Care Survey-Medicare Database: Population-Based Analysis of Incidence, Comorbidity, and Disability

Incidence rates of acute coronary heart disease (ACHD; including myocardial infarction and angina pectoris), stroke, and heart failure (HF) were studied for their age, disability, and comorbidity patterns in the U.S. elderly population using the National Long Term Care Survey (NLTCS) data linked to Medicare records for 1991-2005. Incidence rates increased with age with a decrease in the oldest old (stroke and HF) or were stable at all ages (ACHD). For all diseases, incidence rates were lower among institutionalized individuals and higher in individuals with higher comorbidity indices. The results could be used for understanding currently debated effects of biomedical research, screening, and therapeutic innovations on changes in disease incidence with advancing age as well as for projecting future Medicare costs.

Comparison of two depression measures for predicting stroke outcomes

OBJECTIVES

Little is known about the effect of lifetime history of depression on ischemic stroke outcomes. This study compared a measure of current symptoms of depression at the time of the stroke and a measure of lifetime history of depression for their ability to predict quality of life and functioning at 3 and 12 months after stroke.

METHODS

A cohort of 460 ischemic stroke patients from the 2005 Greater Cincinnati/North Kentucky Stroke Study was assessed within 2 weeks of the stroke, including the 10-item Center for Epidemiological Studies Depression Scale (CESD) for current symptoms of depression. Lifetime history of depression was also assessed by a 2-question measure at 3 and 12 months after stroke. Two outcome measures, Stroke Specific Quality of Life (SSQOL) and the modified Rankin Scale (mRS) to assess functional status, were also collected at 3 and 12 months.

RESULTS

Of the 322 survivors included in the analysis, 52.2% reported depression on at least one measure. Both current symptoms and lifetime history of depression predicted poor functional outcomes and poor quality of life at 3 and 12 months, after adjustment for age, race, sex, prior stroke, baseline functional status, and stroke severity. The combination of depression measures was a better predictor of poor outcomes than either measure alone.

CONCLUSION

Depression by either measure was a frequent, substantial, and independent predictor of poor outcomes at 3 and 12 months after stroke. Stroke outcomes studies should further examine the predictive value of assessing both depressive symptoms at the time of the stroke and lifetime history of depression.

Racial differences in arterial stiffness among adolescents and young adults with type 2 diabetes

BACKGROUND

African-American adults demonstrate a higher prevalence of cardiovascular complications including myocardial infarction and stroke. Whether similar racial disparities are present to suggest African-Americans adolescents are at higher risk to develop cardiovascular disease is not known. Thus, we compared arterial stiffness, an early marker of cardiovascular disease, in African-American and Caucasian adolescents and young adults with type 2 diabetes.

METHODS

Demographic, anthropometric, laboratory data, and arterial stiffness measures including pulse wave velocity (PWV) and augmentation index (AIx) were collected in a cross-sectional study of 215 adolescents (average age 18 yr) with type 2 diabetes (55% African-American and 65% female).

RESULTS

Compared to Caucasians, African-Americans had increased PWV (6.21 ± 0.87 vs. 6.96 ± 1.30, p < .01) and AIx (4.44 ± 11.17 vs. 7.64 ± 12.02, p = 0.05). Regression modeling demonstrated age, lipids, blood pressure, and duration of diabetes were differently associated with arterial stiffness in each race group (p < 0.05).

CONCLUSIONS

African-American adolescents and young adults with type 2 diabetes have increased vascular stiffness than age-matched Caucasians. This process is mediated by different cardiovascular risk factors. These results suggest race-specific risk factor modification may be helpful to prevent early cardiovascular disease in this high risk population.

25-Hydroxyvitamin D deficiency is associated with fatal stroke among whites but not blacks: The NHANES-III linked mortality files

OBJECTIVE

Deficient 25-hydroxyvitamin D (25[OH]D) levels are associated with cardiovascular disease (CVD) events and mortality. 25(OH)D deficiency and stroke are more prevalent in blacks. We examined whether low 25(OH)D contributes to the excess risk of fatal stroke in blacks compared with whites.

METHODS

The Third National Health and Nutrition Examination Survey, a probability sample of U.S. civilians, measured 25(OH)D levels and CVD risk factors from 1988 through 1994. Vital status through December 2006 was obtained by a linkage with the National Death Index. In white and black adults without CVD reported at baseline (n = 7981), Cox regression models were fit to estimate hazard ratios (HR) for fatal stroke by 25(OH)D status and race.

RESULTS

During a median of 14.1 y, there were 116 and 60 fatal strokes in whites and blacks, respectively. The risk of fatal stroke was greater in blacks compared with whites in models adjusted for socioeconomic status and CVD risk factors (HR 1.60, 95% confidence interval 1.01-2.53). Mean baseline 25(OH)D levels were significantly lower in blacks compared with whites (19.4 versus 30.8 ng/mL, respectively). In multivariable-adjusted models, deficient 25(OH)D levels lower than 15 ng/mL were associated with fatal stroke in whites (HR 2.13, 1.01-4.50) but not blacks (HR 0.93, 0.49-1.80).

CONCLUSIONS

Vitamin D deficiency was associated with an increased risk of stroke death in whites but not in blacks. Although blacks had a higher rate of fatal stroke compared with whites, the low 25(OH)D levels in blacks were unrelated to stroke incidence. Therefore 25(OH)D levels did not explain this excess risk.

Risks and Benefits of Thrombolysis in the Elderly

Background and purpose

Stroke incidence continues to rise exponentially with age even as temporal trends in some population risk factors increase and others decline. In general, older patients with stroke have worse outcomes compared to their younger counterparts. Stroke severity, concurrent medical problems, prestroke disability, and less-aggressive acute and chronic management are a few contributing factors to account for this poor prognosis. Acute thrombolysis therapy is the only proven treatment in acute ischemic stroke. However, elderly patients have mostly been excluded from acute revascularization studies, due predominantly to their overall poor prognosis and the fear of hemorrhagic complications from these treatments. Despite this, there is no evidence to suggest that the risk benefit ratio of thrombolysis treatment is substantially different in the elderly than in younger ischemic stroke patients.

Summary of review

In this review, we briefly examine the stroke risk factor profile and outcome in the elderly and review the current evidence regarding intravenous and intra-arterial revascularization treatments.

Conclusion

We feel that carefully selected patients who meet eligibility criteria for thrombolysis should not be denied this therapy on the basis of age alone.

Stroke risk in women: the role of menopause and hormone therapy

Although women have a lower risk of stroke during middle age than men, the menopausal transition is a time when many women develop cardiovascular risk factors. Additionally, during the 10 years after menopause, the risk of stroke roughly doubles in women. Endogenous oestrogen concentrations decline by 60% during the menopausal transition, leading to a relative androgen excess, which could contribute to the increased cardiovascular risk factors in women. Earlier onset of menopause might affect the risk of stroke, but the data are not clear. Because of the stroke risk associated with it, hormone therapy is recommended only for treatment of vasomotor symptoms, and some formulations might be safer than others. More research is needed to understand which women are at greatest stroke risk during midlife and to identify the safest formulation, dose, and duration of hormone therapy that can be used to treat vasomotor symptoms without increasing the risk of stroke.

The epidemiology, evaluation and treatment of stroke in adults with sickle cell disease

Stroke is a frequent and severe complication in adults with sickle cell disease. Ischemic stroke often causes physical and cognitive disability, while hemorrhagic stroke has a high mortality rate. As more children survive, the number of strokes in adults is increasing, yet stroke remains poorly understood. We review the epidemiology of ischemic and hemorrhagic stroke in adults with sickle cell disease and outline a practical approach to the evaluation of stroke including both sickle cell disease specific and general risk factors. We discuss the acute treatment and secondary prevention of stroke in this population based on the evidence in children with sickle cell disease and the general population, in addition to the limited studies in adults with sickle cell disease.

MRI signal hyperintensities and failure to remit following antidepressant treatment

BACKGROUND

MRI signal hyperintensities predict poor remission to antidepressant treatment. Previous studies using volumetrics in outpatient samples have relied on total lesion volume. The purpose of this study was to test whether remission from geriatric depression depends on lesion volume by region of interest (ROI).

METHOD

Thirty-eight patients received baseline MRIs as part of a larger 12-week, randomized clinical trial comparing sertraline and nortriptyline in the treatment of late-life depression. MRIcro was used to quantify MRI-hyperintensity volume into total hyperintensity, deep white matter hyperintensity (DWMH), and periventricular hyperintensity (PVH) volumes. High versus low total, DWMH, and PVH volumes were defined based on the highest quartile of their respective distributions. Remission from depression was defined as a 24-item Hamilton Rating Scale for Depression score ≤ 7 for two consecutive weeks.

RESULTS

Patients classified as having high DWMH were 7.14 times more likely not to remit following antidepressant treatment compared to patients classified as having low DWMH (p=0.02). Similar odds ratios were obtained for PVH (OR=4.17, p=0.16) and total volumes (OR=5.00, p=0.05). Importantly, adjusting for age did not change the magnitude of these effects.

LIMITATIONS

A small and predominantly White sample.

CONCLUSIONS

This is the first study to test whether remission from geriatric depression depends on lesion volume by ROI in an outpatient sample. The pattern of remission rates and odds ratios was similar when patients were classified as having high DWMH, PVH or total volume suggesting that lesion location may not be critical.

The practice of carotid revascularization in a large metropolitan population

Carotid endartectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke when performed with acceptable perioperative morbidity and mortality. Studies from the 1980s in the greater Cincinnati/northern Kentucky population showed that perioperative risk after CEA exceeded the recommended boundaries of 3.0% for asymptomatic stenosis and 6.0% for symptomatic stenosis. We investigated the indications and outcomes for CEA and CAS in the same population during 2005. We identified all residents of the greater Cincinnati/northern Kentucky region who underwent CEA or CAS at any local hospital during 2005. Identified cases of transient ischemic attack or stroke occurring before or after CEA or CAS were abstracted by study nurses and reviewed by a study physician. The main outcome of interest was 30-day risk of stroke or death after CEA or CAS. Events were analyzed using Kaplan-Meier statistics. Among approximately 1.3 million greater Cincinnati/northern Kentucky residents, 525 CEAs were performed, 343 (65%) for asymptomatic stenosis and 182 (35%) for symptomatic stenosis. There were 43 CAS procedures, 23 (53%) for asymptomatic stenosis and 20 (47%) for symptomatic stenosis. The 30-day perioperative risk of stroke or death after CEA was 3.3% (95% confidence interval [CI], 1.8%-5.9%) for asymptomatic stenosis and 6.3% (95% CI, 3.5%-11.1%) for symptomatic stenosis. The 30-day perioperative risk of stroke or death after CAS was 4.6% (95% CI, 0.7%-28.1%) for asymptomatic stenosis and 21.1% (95% CI, 8.5%-46.8%) for symptomatic stenosis. Point estimates for perioperative risk after CEA were improved from previous studies but remained above the recommended benchmarks. The number of CAS procedures was low, but the perioperative risk was significant.

Neighborhood disadvantage and ischemic stroke: the Cardiovascular Health Study (CHS)

BACKGROUND AND PURPOSE

Neighborhood characteristics may influence the risk of stroke and contribute to socioeconomic disparities in stroke incidence. The objectives of this study were to examine the relationship between neighborhood socioeconomic status and incident ischemic stroke and examine potential mediators of these associations.

METHODS

We analyzed data from 3834 whites and 785 blacks enrolled in the Cardiovascular Health Study, a multicenter, population-based, longitudinal study of adults ages≥65 years from 4 US counties. The primary outcome was adjudicated incident ischemic stroke. Neighborhood socioeconomic status was measured using a composite of 6 census tract variables. Race-stratified multilevel Cox proportional hazard models were constructed adjusted for sociodemographic, behavioral, and biological risk factors.

RESULTS

Among whites, in models adjusted for sociodemographic characteristics, stroke hazard was significantly higher among residents of neighborhoods in the lowest compared with the highest neighborhood socioeconomic status quartile (hazard ratio, 1.32; 95% CI, 1.01-1.72) with greater attenuation of the hazard ratio after adjustment for biological risk factors (hazard ratio, 1.16; 0.88-1.52) than for behavioral risk factors (hazard ratio, 1.30; 0.99-1.70). Among blacks, we found no significant associations between neighborhood socioeconomic status and ischemic stroke.

CONCLUSIONS

Higher risk of incident ischemic stroke was observed in the most disadvantaged neighborhoods among whites, but not among blacks. The relationship between neighborhood socioeconomic status and stroke among whites appears to be mediated more strongly by biological than behavioral risk factors.

Recent patterns of sex-specific midlife stroke hospitalization rates in the United States

BACKGROUND AND PURPOSE

Little is known about sex-specific stroke hospitalization rates among middle-aged individuals. This study assessed recent temporal trends in stroke hospitalizations among persons aged 35 to 64 years in the United States.

METHODS

The Nationwide Inpatient Sample was used to identify individuals with a primary or secondary discharge diagnosis of stroke between 1997 and 2006 (n=3,161,752). Age-adjusted sex-specific rates of ischemic and hemorrhagic stroke hospitalizations were assessed among individuals aged 35 to 64 years.

RESULTS

Over the study period, stroke hospitalization rates per 100 000 decreased by 10% from 66.7 to 60.3 (trend P<0.01) in men and 8% from 52.7 to 48.3 (trend P<0.001) in women. The 55- to 64-year age group drove reductions in hospitalization rates: slope (rate of change per year)=-12.3 for men and -8.9 for women (both P<0.001). Rates increased slightly in men and women aged 35 to 44 years and remained stable for persons aged 45 to 54 years. Stroke subtype analysis revealed that rates of ischemic stroke hospitalization increased and hemorrhagic stroke hospitalization remained stable among individuals aged 35 to 44 years. Rates of ischemic and hemorrhagic stroke hospitalizations remained stable among those aged 45 to 54 years and decreased among persons aged 55 to 64 years.

CONCLUSIONS

From 1997 to 2006, ischemic and hemorrhagic stroke hospitalization rates declined among individuals aged 55 to 64 years and remained stable among persons aged 45 to 54 years; ischemic stroke hospitalization rates increased among individuals aged 35 to 44 years. Further studies are needed to assess and address increases in ischemic stroke hospitalizations among younger individuals.

Racial and geographic differences in prevalence, awareness, treatment and control of dyslipidemia: the reasons for geographic and racial differences in stroke (REGARDS) study

BACKGROUND/AIMS

There are racial and geographic disparities in stroke mortality, with higher rates among African Americans (AAs) and those living in the southeastern US ('stroke belt'). Racial and geographic differences in dyslipidemia prevalence, awareness, treatment and control may, in part, account for the observed disparities in stroke mortality.

METHODS

Reasons for Geographic and Racial Differences in Stroke (REGARDS) is a national observational study of community-dwelling black and white participants aged 45 and older, with oversampling from the stroke belt. As of January 15, 2007, 26,122 participants were enrolled and a fasting lipid panel was available of 21,068. Awareness, treatment and control of dyslipidemia were estimated overall and compared across race-sex-region strata.

RESULTS

There were 55% of the participants with dyslipidemia and no racial differences in prevalence. Adjusting for demographic and established stroke risk factors, AAs had a lower prevalence (OR 0.74; 95% CI: 0.66, 0.77) and were less likely to be aware (0.69; 0.61, 0.78), treated (0.77; 0.67, 0.89) and controlled (0.67; 0.58, 0.77) than whites. There was lower control outside of the stroke belt (0.87; 0.76, 0.99).

CONCLUSION

Racial, but not geographic, differences in dyslipidemia management may play a role in the excess stroke burden in the Southeast.

Epidemiology and etiology of young stroke

Introduction. Stroke in people under 45 years of age is less frequent than in older populations but has a major impact on the individual and society. In this article we provide an overview of the epidemiology and etiology of young stroke. Methods. This paper is based on a review of population-based studies on stroke incidence that have included subgroup analyses for patients under 45 years of age, as well as smaller community-based studies and case-series specifically examining the incidence of stroke in the young. Trends are discussed along with the relative frequencies of various etiologies. Discussion. Stroke in the young requires a different approach to investigation and management than stroke in the elderly given differences in the relative frequencies of possible underlying causes. It remains the case, however, that atherosclerosis contributes to a large proportion of stroke in young patients, thus, conventional risk factors must be targeted aggressively.

Population-based study of wake-up strokes

OBJECTIVE

Previous studies have estimated that wake-up strokes comprise 8%to 28% of all ischemic strokes, but these studies were either small or not population-based. We sought to establish the proportion and event rate of wake-up strokes in a large population-based study and to compare patients who awoke with stroke symptoms with those who were awake at time of onset.

METHODS

First-time and recurrent ischemic strokes among residents of the Greater Cincinnati/Northern Kentucky region (population 1.3 million) in 2005 were identified using International Classification of Diseases-9 codes 430-436 and verified via study physician review. Ischemic strokes in patients aged 18 years and older presenting to an emergency department were included. Baseline characteristics were ascertained, along with discharge modified Rankin Scale scores and 90-day mortality.

RESULTS

We identified 1,854 ischemic strokes presenting to an emergency department, of which 273 (14.3%) were wake-up strokes. There were no differences between wake-up strokes and all other strokes with regard to clinical features or outcomes except for minor differences in age and baseline retrospective NIH Stroke Scale score. The adjusted wake-up stroke event rate was 26.0/100,000. Of the wake-up strokes, at least 98 (35.9%) would have been eligible for thrombolysis if arrival time were not a factor.

CONCLUSIONS

Within our population, approximately 14% of ischemic strokes presenting to an emergency department were wake-up strokes. Wake-up strokes cannot be distinguished from other strokes by clinical features or outcome. We estimate that approximately 58,000 patients with wake-up strokes presented to an emergency department in the United States in 2005.

Differential impact of race and risk factors on incidence of atrial fibrillation

Despite some common risk factors for atrial fibrillation (AF) being more prevalent among blacks, African Americans are increasingly being reported with lower prevalence and incidence of AF compared with whites. Contemporary studies have not provided a complete explanation for this apparent AF paradox in African Americans. Although many traditional and novel risk factors for AF have been identified, the role of ethnic-specific risk factors has not been examined. Whereas hypertension has been the most common risk factor associated with AF, coronary artery disease also plays an important role in AF pathophysiology in whites. Thereby, elucidating the role of ethnic-specific risk factors for AF may provide important insight into why African Americans are protected from AF or why whites are more prone to develop the arrhythmia. The link between AF susceptibility and genetic processes has only been recently uncovered. Polymorphisms in renin-angiotensin system genes have been characterized as predisposing to AF under certain environmental conditions. Several ion channel genes, signaling molecules, and several genetic loci have been linked with AF. Thereby, studies investigating genetic variants contributing to the differential AF risk in individuals of African American versus European ancestry may also provide important insight into the etiology of the AF paradox in blacks.

Withdrawal of antithrombotic agents and its impact on ischemic stroke occurrence

BACKGROUND AND PURPOSE

Antithrombotic medications (anticoagulants and antiplatelets) are often withheld in the periprocedural period and after bleeding complications to limit the risk of new or recurrent bleeding. These medications are also stopped by patients for various reasons such as cost, side effects, or unwillingness to take medication.

METHODS

Patient records from the population-based Greater Cincinnati/Northern Kentucky Stroke Study were reviewed to identify cases of ischemic stroke in 2005 and determine the temporal association of strokes with withdrawal of antithrombotic medication. Ischemic strokes and reasons for medication withdrawal were identified by study nurses for subsequent physician review.

RESULTS

In 2005, 2197 cases of ischemic stroke among residents of the region were identified through hospital discharge records. Of the 2197 ischemic strokes, 114 (5.2%) occurred within 60 days of an antithrombotic medication withdrawal, 61 (53.5%) of these after stoppage of warfarin and the remainder after stoppage of an antiplatelet medication. Of the strokes after withdrawal, 71 (62.3%) were first-ever and 43 (37.7%) were recurrent; 54 (47.4%) occurred after withdrawal of medication by a physician in the periprocedural period.

CONCLUSIONS

The withdrawal of antiplatelet and antithrombotic medications in the 60 days preceding an acute ischemic stroke was associated with 5.2% of ischemic strokes in our study population. This finding emphasizes the need for thoughtful decision-making concerning antithrombotic medication use in the periprocedural period and efforts to improve patient compliance.

Elevated depressive symptoms and incident stroke in Hispanic, African-American, and White older Americans

Although depressive symptoms have been linked to stroke, most research has been in relatively ethnically homogeneous, predominantly white, samples. Using the United States based Health and Retirement Study, we compared the relationships between elevated depressive symptoms and incident first stroke for Hispanic, black, or white/other participants (N = 18,648) and estimated the corresponding Population Attributable Fractions. The prevalence of elevated depressive symptoms was higher in blacks (27%) and Hispanics (33%) than whites/others (18%). Elevated depressive symptoms prospectively predicted stroke risk in the whites/other group (HR = 1.53; 95% CI: 1.36-1.73) and among blacks (HR = 1.31; 95% CI: 1.05-1.65). The HR was similar but only marginally statistically significant among Hispanics (HR = 1.33; 95% CI: 0.92-1.91). The Population Attributable Fraction, indicating the percent of first strokes that would be prevented if the incident stroke rate in those with elevated depressive symptoms was the same as the rate for those without depressive symptoms, was 8.3% for whites/others, 7.8% for blacks, and 10.3% for Hispanics.

Burden of Stroke in Indigenous Western Australians

Background and Purpose—

Despite the disproportionate burden of cardiovascular disease among indigenous Australians, information on stroke is sparse. This article documents the incidence and burden of stroke (in disability-adjusted life years) in indigenous and non-indigenous people in Western Australia (1997–2002), a state resident to 15% of indigenous Australians comprising 3.4% of the population of Western Australia.

Methods—

Indigenous and non-indigenous stroke incidence and excess mortality rates were estimated from linked hospital and mortality data, with adjustment for nonadmitted events. Nonfatal burden was calculated from nonfatal incidence, duration (modeled from incidence, excess mortality, and remission), and disability weights. Stroke death counts formed the basis of fatal burden. Nonfatal and fatal burden were summed to obtain disability-adjusted life years, by indigenous status.

Results—

The total burden was 55 099 and 2134 disability-adjusted life years in non-indigenous and indigenous Western Australians, respectively. The indigenous to non-indigenous age-standardized stroke incidence rate ratio (≥15 years) was 2.6 in males (95% CI, 2.3–3.0) and 3.0 (95% CI, 2.6–3.5) in females, with similar rate ratios of disability-adjusted life years. The burden profile differed substantially between populations, with rate ratios being highest at younger ages.

Conclusions—

The differential between indigenous and non-indigenous stroke burden is considerable, highlighting the need for comprehensive intersectoral interventions to reduce indigenous stroke incidence and improve outcomes. Programs to reduce risk factors and increase access to culturally appropriate stroke services are required. The results here provide the quantitative basis for policy development and monitoring of stroke outcomes.

Decreased cerebrovascular brain-derived neurotrophic factor-mediated neuroprotection in the diabetic brain

OBJECTIVE

Diabetes is an independent risk factor for stroke. However, the underlying mechanism of how diabetes confers that this risk is not fully understood. We hypothesize that secretion of neurotrophic factors by the cerebral endothelium, such as brain-derived neurotrophic factor (BDNF), is suppressed in diabetes. Consequently, such accrued neuroprotective deficits make neurons more vulnerable to injury.

RESEARCH DESIGN AND METHODS

We examined BDNF protein levels in a streptozotocin-induced rat model of diabetes by Western blotting and immunohistochemistry. Levels of total and secreted BDNF protein were quantified in human brain microvascular endothelial cells after exposure to advanced glycation end product (AGE)-BSA by enzyme-linked immunosorbent assay and immunocytochemistry. In media transfer experiments, the neuroprotective efficacy of conditioned media from normal healthy endothelial cells was compared with AGE-treated endothelial cells in an in vitro hypoxic injury model.

RESULTS

Cerebrovascular BDNF protein was reduced in the cortical endothelium in 6-month diabetic rats. Immunohistochemical analysis of 6-week diabetic brain sections showed that the reduction of BDNF occurs early after induction of diabetes. Treatment of brain microvascular endothelial cells with AGE caused a similar reduction in BDNF protein and secretion in an extracellular signal-related kinase-dependent manner. In media transfer experiments, conditioned media from AGE-treated endothelial cells were less neuroprotective against hypoxic injury because of a decrease in secreted BDNF.

CONCLUSIONS

Taken together, our findings suggest that a progressive depletion of microvascular neuroprotection in diabetes elevates the risk of neuronal injury for a variety of central nervous system diseases, including stroke and neurodegeneration.

Racial-ethnic disparities in stroke care: the American experience: a statement for healthcare professionals from the American Heart Association/American Stroke Association

PURPOSE

Our goal is to describe the effect of race and ethnicity on stroke epidemiology, personal beliefs, access to care, response to treatment, and participation in clinical research. In addition, we seek to determine the state of knowledge on the main factors that may explain disparities in stroke care, with the goal of identifying gaps in knowledge to guide future research. The intended audience includes physicians, nurses, other healthcare professionals, and policy makers.

METHODS

Members of the writing group were appointed by the American Heart Association Stroke Council Scientific Statement Oversight Committee and represent different areas of expertise in relation to racial-ethnic disparities in stroke care. The writing group reviewed the relevant literature, with an emphasis on reports published since 1972. The statement was approved by the writing group; the statement underwent peer review, then was approved by the American Heart Association Science Advisory and Coordinating Committee.

RESULTS

There are limitations in the definitions of racial and ethnic categories currently in use. For the purpose of this statement, we used the racial categories defined by the US federal government: white, black or African American, Asian, American Indian/Alaskan Native, and Native Hawaiian/other Pacific Islander. There are 2 ethnic categories: people of Hispanic/Latino origin or not of Hispanic/Latino origin. There are differences in the distribution of the burden of risk factors, stroke incidence and prevalence, and stroke mortality among different racial and ethnic groups. In addition, there are disparities in stroke care between minority groups compared with whites. These disparities include lack of awareness of stroke symptoms and signs and lack of knowledge about the need for urgent treatment and the causal role of risk factors. There are also differences in attitudes, beliefs, and compliance among minorities compared with whites. Differences in socioeconomic status and insurance coverage, mistrust of the healthcare system, the relatively limited number of providers who are members of minority groups, and system limitations may contribute to disparities in access to or quality of care, which in turn might result in different rates of stroke morbidity and mortality. Cultural and language barriers probably also contribute to some of these disparities. Minorities use emergency medical services systems less, are often delayed in arriving at the emergency department, have longer waiting times in the emergency department, and are less likely to receive thrombolysis for acute ischemic stroke. Although unmeasured factors may play a role in these delays, the presence of bias in the delivery of care cannot be excluded. Minorities have equal access to rehabilitation services, although they experience longer stays and have poorer functional status than whites. Minorities are inadequately treated with both primary and secondary stroke prevention strategies compared with whites. Sparse data exist on racial-ethnic disparities in access to surgical care after intracerebral hemorrhage and subarachnoid hemorrhage. Participation of minorities in clinical research is limited. Barriers to participation in clinical research include beliefs, lack of trust, and limited awareness. Race is a contentious topic in biomedical research because race is not proven to be a surrogate for genetic constitution.

CONCLUSIONS

There are limitations in the current definitions of race and ethnicity. Nevertheless, racial and ethnic disparities in stroke exist and include differences in the biological determinants of disease and disparities throughout the continuum of care, including access to and quality of care. Access to and participation in research is also limited among minority groups. Acknowledging the presence of disparities and understanding the factors that contribute to them are necessary first steps. More research is required to understand these differences and find solutions.

Incident cognitive impairment is elevated in the stroke belt: the REGARDS study

OBJECTIVE

To determine whether incidence of impaired cognitive screening status is higher in the southern Stroke Belt region of the United States than in the remaining United States.

METHODS

A national cohort of adults age ≥45 years was recruited by the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study from 2003 to 2007. Participants' global cognitive status was assessed annually by telephone with the Six-Item Screener (SIS) and every 2 years with fluency and recall tasks. Participants who reported no stroke history and who were cognitively intact at enrollment (SIS >4 of 6) were included (N = 23,913, including 56% women; 38% African Americans and 62% European Americans; 56% Stroke Belt residents and 44% from the remaining contiguous United States and the District of Columbia). Regional differences in incident cognitive impairment (SIS score ≤4) were adjusted for age, sex, race, education, and time between first and last assessments.

RESULTS

A total of 1,937 participants (8.1%) declined to an SIS score ≤4 at their most recent assessment, over a mean of 4.1 (±1.6) years. Residents of the Stroke Belt had greater adjusted odds of incident cognitive impairment than non-Belt residents (odds ratio, 1.18; 95% confidence interval, 1.07-1.30). All demographic factors and time independently predicted impairment.

INTERPRETATION

Regional disparities in cognitive decline mirror regional disparities in stroke mortality, suggesting shared risk factors for these adverse outcomes. Efforts to promote cerebrovascular and cognitive health should be directed to the Stroke Belt.

Disparities in stroke incidence contributing to disparities in stroke mortality

OBJECTIVE

While black-white and regional disparities in U.S. stroke mortality rates are well documented, the contribution of disparities in stroke incidence is unknown. We provide national estimates of stroke incidence by race and region, contrasting these to publicly available stroke mortality data.

METHODS

This analysis included 27,744 men and women without prevalent stroke (40.4% black), aged ≥45 years from the REasons for Geographic And Racial Differences in Stroke (REGARDS) national cohort study, enrolled 2003-2007. Incident stroke was defined as first occurrence of stroke over 4.4 years of follow-up. Age-sex-adjusted stroke mortality rates were calculated using data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiological Research (WONDER) System.

RESULTS

There were 460 incident strokes over 113,469 person-years of follow-up. Relative to the rest of the United States, incidence rate ratios (IRRs) of stroke in the southeastern stroke belt and stroke buckle were 1.06 (95% confidence interval [CI], 0.87-1.29) and 1.19 (95% CI, 0.96-1.47), respectively. The age-sex-adjusted black/white IRR(black) was 1.51 (95% CI, 1.26-1.81), but for ages 45-54 years the IRR(black) was 4.02 (95% CI, 1.23-13.11) while for ages 85+ it was 0.86 (95% CI, 0.33-2.20). Generally, the IRRs(black) were less than the mortality rate ratios (MRRs) across age groups; however, only in ages 55-64 years and 65-74 years did the 95% CIs of IRRs(black) not include the MRR(black) . The MRRs for regions were within 95% CIs for IRRs.

INTERPRETATION

National patterns of black-white and regional differences in stroke incidence are similar to those for stroke mortality; however, the magnitude of differences in incidence appear smaller.

Stroke: a realistic approach to a growing problem in sub-Saharan Africa is urgently needed

Stroke is an increasing problem in sub-Saharan Africa, even in children. High rates of hypertension, diabetes, alcohol abuse, smoking, insufficient fruit and vegetable consumption, sickle cell disease, HIV infection, antiretroviral use and race are likely contributing factors. Although often considered as related to increasing wealth, stroke is more strongly related to poverty, and in turn increases it. Case-fatality rates are high and premature death and years of life lost are a major problem. We propose an approach to stroke prevention and treatment that takes into account the real situation on the ground and can be applied in sub-Saharan Africa, an area where stroke units are largely not feasible and many patients do not reach hospitals. Involvement of community and faith-based organisations, use of simple diagnostic tests, emphasis on clinical examination to differentiate between haemorrhagic and ischaemic stroke, prompt initiation of aspirin therapy and training of community nurses on essential management of stroke should be urgently implemented.

Racial differences in mortality among patients with acute ischemic stroke: an observational study

BACKGROUND

Black patients are commonly believed to have higher stroke mortality. However, several recent studies have reported better survival in black patients with stroke.

OBJECTIVE

To examine racial differences in stroke mortality and explore potential reasons for these differences.

DESIGN

Observational cohort study.

SETTING

164 hospitals in New York.

PARTICIPANTS

5319 black and 18 340 white patients aged 18 years or older who were hospitalized with acute ischemic stroke between January 2005 and December 2006.

MEASUREMENTS

Influence of race on mortality, examined by using propensity score analysis. Secondary outcomes were selected aspects of end-of-life treatment, use of tissue plasminogen activator, hospital spending, and length of stay. Patients were followed for mortality for 1 year after admission.

RESULTS

Overall in-hospital mortality was lower for black patients than for white patients (5.0% vs. 7.4%; P < 0.001), as was all-cause mortality at 30 days (6.1% vs. 11.4%; P < 0.001) and 1 year (16.5% vs. 24.4%; P < 0.001). After propensity score adjustment, black race was independently associated with lower in-hospital mortality (odds ratio [OR], 0.77 [95% CI, 0.61 to 0.98]) and all-cause mortality up to 1 year (OR, 0.86 [CI, 0.77 to 0.96]). The adjusted hazard ratio was 0.87 (CI, 0.79 to 0.96). After adjustment for the probability of dying in the hospital, black patients with stroke were more likely to receive life-sustaining interventions (OR, 1.22 [CI, 1.09 to 1.38]) but less likely to be discharged to hospice (OR, 0.25 [CI, 0.14 to 0.46]).

LIMITATIONS

The study used hospital administrative data that lacked a stroke severity measure. The study design precluded determination of causality.

CONCLUSION

Among patients with acute ischemic stroke, black patients had lower mortality than white patients. This could be the result of differences in receipt of life-sustaining interventions and end-of-life care.

Heart disease and stroke statistics--2011 update: a report from the American Heart Association

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.

Persistent sex disparity in midlife stroke prevalence in the United States

BACKGROUND

A recent study found that US women aged 45-54 years in 1999-2004 were twice as likely as men to report previous stroke. The aim of this study was to evaluate the validity of this finding by assessing the sex-specific midlife stroke prevalence in the most recent nationally representative, cross-sectional sample of US individuals.

METHODS

Sex-specific stroke prevalence, sex-specific vascular risk factor prevalence and sex-specific independent predictors of stroke were assessed among 35- to 64-year olds who participated in the National Health and Nutrition Examination Surveys in 2005-2006 (n = 2,274).

RESULTS

Women aged 35-64 years were almost 3 times more likely than men to report prior stroke (2.90 vs. 1.07%; p < 0.001). This disparity was driven by the 45- to 54-year age group, where women had thrice the odds of prior stroke compared with men (OR 3.12, 95% CI 1.30-7.50). Among 45- to 54-year olds, men were more likely than women to have a history of smoking, elevated homocysteine and elevated triglyceride levels, but less likely to be abdominally obese (p < 0.001). Independent stroke risk factors among women aged 35-64 years were a homocysteine level >8.5 μmol/l (OR 6.19, 95% CI 2.57-14.93), a history of myocardial infarction (OR 5.35, 95% CI 1.09-26.27) and diabetes mellitus (OR 6.63, 95% CI 2.47-17.81).

CONCLUSION

The midlife sex disparity in US stroke prevalence persists. Greater emphasis on prompt recognition and treatment of cardiovascular risk factors among young and middle-aged women may ameliorate this worrisome trend.

Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

CONCLUSIONS

Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

Chronic kidney disease and prevalent atrial fibrillation: the Chronic Renal Insufficiency Cohort (CRIC)

BACKGROUND

The epidemiology of atrial fibrillation (AF) has been mainly investigated in patients with end-stage renal disease, with limited data on less advanced chronic kidney disease (CKD) stages.

METHODS

A total of 3,267 adult participants (50% non-Hispanic blacks, 46% women) with CKD from the Chronic Renal Insufficiency Cohort were included in this study. None of the study participants had been on dialysis. Those with self-identified race/ethnicity other than non-Hispanic black or white (n = 323) or those without electrocardiographic data (n = 22) were excluded. Atrial fibrillation was ascertained by a 12-lead electrocardiogram and self-report. Age-, sex-, and race/ethnicity-specific prevalence rates of AF were estimated and compared between subgroups. Cross-sectional associations and correlates with prevalent AF were examined using unadjusted and multivariable-adjusted logistic regression analysis.

RESULTS

The mean estimated glomerular filtration rate was 43.6 (+/-13.0) mL/(min 1.73 m(2)). Atrial fibrillation was present in 18% of the study population and in >25% of those > or =70 years old. In multivariable-adjusted models, 1-SD increase in age (11 years) (odds ratio 1.27, CI 95% 1.13-1.43, P < .0001), male [corrected] sex (0.80, 0.65-0.98, P = .0303), smoking (former vs never) (1.34, 1.08-1.66, P = .0081), history of heart failure (3.28, 2.47-4.36, P < .001), and history of cardiovascular disease (1.94, 1.56-2.43, P < .0001) were significantly associated with AF. Race/ethnicity, hypertension, diabetes, body mass index, physical activity, education, high-sensitivity C-reactive protein, total cholesterol, and alcohol intake were not significantly associated with AF. An estimated glomerular filtration rate <45 mL/(min 1.73 m(2)) was associated with AF in an unadjusted model (1.35, 1.13-1.62, P = .0010), but not after multivariable adjustment (1.12, 0.92-1.35, P = .2710).

CONCLUSIONS

Nearly 1 in 5 participants in Chronic Renal Insufficiency Cohort, a national study of CKD, had evidence of AF at study entry, a prevalence similar to that reported among patients with end-stage renal disease and 2 to 3 times of that reported in the general population. Risk factors for AF in this CKD population do not mirror those reported in the general population.