Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review

This systematic review of population-based studies of the incidence and early (21 days to 1 month) case fatality of stroke is based on studies published from 1970 to 2008. Stroke incidence (incident strokes only) and case fatality from 21 days to 1 month post-stroke were analysed by four decades of study, two country income groups (high-income countries and low to middle income countries, in accordance with the World Bank's country classification) and, when possible, by stroke pathological type: ischaemic stroke, primary intracerebral haemorrhage, and subarachnoid haemorrhage. This Review shows a divergent, statistically significant trend in stroke incidence rates over the past four decades, with a 42% decrease in stroke incidence in high-income countries and a greater than 100% increase in stroke incidence in low to middle income countries. In 2000-08, the overall stroke incidence rates in low to middle income countries have, for the first time, exceeded the level of stroke incidence seen in high-income countries, by 20%. The time to decide whether or not stroke is an issue that should be on the governmental agenda in low to middle income countries has now passed. Now is the time for action.

Sex differences in stroke epidemiology: a systematic review

BACKGROUND AND PURPOSE

Epidemiological studies, mainly based on Western European surveys, have shown that stroke is more common in men than in women. In recent years, sex-specific data on stroke incidence, prevalence, subtypes, severity and case-fatality have become available from other parts of the world. The purpose of this article is to give a worldwide review on sex differences in stroke epidemiology.

METHODS

We searched PubMed, tables-of-contents, review articles, and reference lists for community-based studies including information on sex differences. In some areas, such as secular trends, ischemic subtypes and stroke severity, noncommunity-based studies were also reviewed. Male/female ratios were calculated.

RESULTS

We found 98 articles that contained relevant sex-specific information, including 59 incidence studies from 19 countries and 5 continents. The mean age at first-ever stroke was 68.6 years among men, and 72.9 years among women. Male stroke incidence rate was 33% higher and stroke prevalence was 41% higher than the female, with large variations between age bands and between populations. The incidence rates of brain infarction and intracerebral hemorrhage were higher among men, whereas the rate of subarachnoidal hemorrhage was higher among women, although this difference was not statistically significant. Stroke tended to be more severe in women, with a 1-month case fatality of 24.7% compared with 19.7% for men.

CONCLUSIONS

Worldwide, stroke is more common among men, but women are more severely ill. The mismatch between the sexes is larger than previously described.

[Smoking and stroke]

Up to one quarter of all strokes are directly attributable to cigarette smoking, that percentage can get up to 50% for young adults admitted for an cryptogenic ischemic stroke. Cigarette smoking increases the relative risk of ischemic stroke about two-fold, three-fold for subarachnoid haemorrhage. Current smoking is not clearly identified as a risk factor for intra-cerebral haemorrhage. The risk is consistent for all subtypes of stroke according aetiology and is strongest for ischemic stroke caused by arterial atherothromboembolism. The risk is dependent upon the amount of cigarettes smoked and passive smoking is a substantial risk of stroke. The relative risk is maximal in middle age, declining with advancing years. The toxicity is higher among female smokers, especially when they have several risk factors such as oral contraceptiveS and migraine with aura. Whereas it is well known that the effectiveness of cigarette withdrawal reduces the risk of new vascular event, two thirds of young patients continue to smoke.

Minimally invasive craniopuncture therapy vs. conservative treatment for spontaneous intracerebral hemorrhage: results from a randomized clinical trial in China

BACKGROUND AND PURPOSES

To evaluate the effects of minimally invasive craniopuncture therapy compared with conservative treatment in treating intracerebral hemorrhage (25-40 ml) in the basal ganglion.

METHODS

A multicenter, randomized control clinical trial comprised 465 cases of hemorrhage in the basal ganglion from 42 hospitals in China. Three hundred and seventy-seven patients with hemorrhage were randomly assigned to receive minimally invasive craniopuncture therapy (n=195) or conservative control treatment (n=182). The main indices of evaluation were the degree of neurological impairment at the 14th day after treatment, activities of daily living at the end of the 3rd month and the case fatality within 3 months.

RESULTS

Improvement of neurological function in the minimally invasive craniopuncture group was significantly better than that in the control group at the 14th day (chi(2)=7.93, P=0.02). At the end of the 3rd month, there was a significant difference between the two groups in activities of daily living score (chi(2)=23.13, P<0.001). The proportion of dependent survival patients (modified Rankin scale >2) in the craniopuncture group (40.9%) was significantly lower than that in the conservative group (63.0%) at the end of the 3rd month (chi(2)=16.95, P<0.01). There was no significant difference in the cumulative fatality rates within three months between the two groups [6.7% (13/195) in the craniopuncture group and 8.8% (16/182) in the conservative group].

CONCLUSIONS

This minimally invasive craniopuncture technique can improve the independent survival of patients with small basal ganglion hemorrhage. It is a safe and practical technique in treating cerebral hemorrhage.

Blood pressure has a greater impact on cardiovascular mortality than other components of metabolic syndrome in Koreans

OBJECTIVE

Limited information is currently available on the association of metabolic syndrome or individual components with risk of cardiovascular morbidity and mortality in diverse populations. Here, we investigate the relationship of metabolic syndrome and its individual components with cardiovascular mortality in Korean adults.

METHODS

Data were obtained from 57,237 patients (32,819 men and 24,418 women), aged 40-89 years, subjected to regular health examinations at the Health Promotion Center of Asan Medical Center, Seoul, Korea (1999-2001) and subsequently followed up for a median time of 5.6 years. The risk of cardiovascular mortality was analyzed in relation to metabolic syndrome and its individual components.

RESULTS

The risk of cardiovascular mortality attributable to elevated blood pressure was approximately 52% in men and 72% in women, respectively. Compared to subjects without metabolic syndrome, individuals with metabolic syndrome presented a relative risk (RR) of cardiovascular disease (CVD)-induced death of 1.75 (95% CI, 1.15-2.66). After mutual adjustment for the individual components of metabolic syndrome, elevated blood pressure was significantly associated with CVD death, with RR values of 2.08 (95% CI, 1.27-3.42) in men and 3.56 (95% CI, 1.55-8.19) in women.

CONCLUSION

In Koreans, metabolic syndrome increases the risk of CVD death, with the blood pressure component being the key predictor of mortality.

Metabolic syndrome and physical activity in southern Brazilian community-dwelling elders: a population-based, cross-sectional study

BACKGROUND

The association between a sedentary lifestyle and obesity is well documented, and is linked to an increased prevalence of metabolic syndrome (MS). There is some evidence that information regarding the health benefits of physical activity is beginning to impact on the elderly people and is beginning to change their behavior. We aimed to investigate the level of physical activity undertaken by elderly people with MS and those without this condition.

METHODS

We evaluated 362 community-dwelling elders of Novo Hamburgo, southern Brazil. Diagnosis of MS was based on the International Diabetes Federation criteria and the physical activity (PA) level was estimated by the International Physical Activity Questionnaire. Analysis of covariance was carried out to verify associations between MS risk factors and the level of PA. Logistic regression was used to estimate the MS odds ratio for each level of PA.

RESULTS

No significant association was found between MS and the level of physical activity, irrespective of sex. The odds ratio for the presence of MS adjusted for sex and age and using insufficiently active elderly people as reference was 1.04 (95% CI, 0.6 to 1.7) in sufficiently active elderly people and 1.15 (95% CI, 0.7 to 2.0) in very active elderly people.

CONCLUSION

The elderly citizens of a southern Brazilian community who were diagnosed with MS presented the same levels of PA as the individuals who did not have this diagnosis. This may imply that information on the importance of physical activity has already reached this higher risk population.

Metabolic syndrome in the elderly: an overview of the evidence

We reviewed the literature concerning the prevalence and correlates of metabolic syndrome (MetS) in older adults and assessed the impact of MetS with regard to life expectancy and comorbidity in the elderly (aged 65 years and over). Using the PubMed database and the Cochrane Library, we found 16 eligible studies, of which 8 were prospective cohort studies, 7 cross-sectional studies, and 1 a case-control study. The World Health Organisation (WHO) and National Cholesterol Education Program (NCEP) are the most popular definitions to describe MetS experienced by the elderly. The prevalence of metabolic syndrome in an elderly population varied from 11% to 43% (median 21%) according to the WHO, and 23% to 55 % (median 31%) according to NCEP. Obesity and hypertension are the most prevalent individual components. MetS in an elderly population is a proven risk factor for cardiovascular (CV) morbidity, especially stroke and coronary heart disease (CHD), and mortality. Preventing and treating MetS would be useful in preventing disability and promoting normal aging. Results from the different studies of elderly population-based cohorts provide support for earlier investigations in middle-aged populations to prevent MetS components. In conclusion, it is possible to say that the results from the different elderly study populations link the presence of the MetS with the development of cardiovascular disease (CVD) and functional disability, and further underscore the importance of recognising and treating its individual components, particularly high blood pressure.

Soy protein intake has sex-specific effects on the risk of metabolic syndrome in middle-aged and elderly Chinese

Soy protein intake has been postulated to improve lipid profiles, glucose homeostasis, and blood pressure. However, data linking soy protein intake and metabolic syndrome (MetS) are limited. We evaluated the association between soy protein intake and the risk of MetS and its components among middle-aged and elderly Chinese. A cross-sectional study was conducted among 2811 Chinese men and women aged 50-70 y, who were free of diagnosed cardiovascular diseases and cancers. Dietary data, including soy protein intake, was collected using a 74-item FFQ. MetS was defined using the updated National Cholesterol Education Program Adult Treatment Panel III criteria for Asian-Americans. We used multivariate logistical regression models to quantify these associations. The median level of soy protein intake was 7.82 g/d (7.64 g/d in men and 8.02 g/d in women). Overall, the association of soy protein intake and the risk of MetS differed between men and women (P for interaction = 0.008). In men, the adjusted odds ratio comparing the extreme quartiles was 1.64 (95% CI: 0.95-2.81; P-trend = 0.077), whereas for women, it was 0.66 (95% CI: 0.42-1.03; P-trend = 0.138). Soy protein intake was positively associated with hyperglycemia (P-trend = 0.005) in men, whereas it was inversely associated with elevated blood pressure (P-trend = 0.049). It was not associated with any component in women. In conclusion, habitual soy protein intake may have sex-dependent effects on risk of MetS in middle-aged and elderly Chinese.

Alcohol consumption and the prevalence of metabolic syndrome: a meta-analysis of observational studies

BACKGROUND

In the past two decades, the metabolic syndrome has given rise to much clinical and research interest. The broad overlap of alcohol consumption with different components of metabolic syndrome makes alcohol-metabolic syndrome relationship a controversial topic.

OBJECTIVES

To support the evidence available about the relationship between alcohol consumption and metabolic syndrome as a comprehensive clinical entity, as well as to identify the gender-specific dose-response, by performing a meta-analysis based on information from published data.

METHODS

Manual and computer searches in different bibliographic databases were performed to identify the relevant scientific publications, on the relation between alcohol consumption and metabolic syndrome. Alcohol intake was converted into a same unit (g/day) and then categorized using standard classification in order to provide relevant comparisons. Fixed and random effects models were used to aggregate individual odds ratios and to derive pooled estimates and 95% confidence intervals.

RESULTS

Fourteen relevant publications were identified on the relation between alcohol consumption and the prevalence of metabolic syndrome. 7 studies were included in the meta-analysis. The results showed that alcohol consumption of less than 40 g/day in men and 20 g/day in women significantly reduced the prevalence of metabolic syndrome.

CONCLUSION

"Responsible alcohol intake" appears to be associated with a reduced prevalence of metabolic syndrome. Favorable metabolic effect seemed to be restricted to alcohol consumption of less than 20 g/day among women, and of less than 40 g/day among men. These findings support the actual recommendations regarding alcohol consumption among apparently healthy people.

Survey of blood pressure control status in patients with ischemic stroke or transient ischemic attack in China

OBJECTIVE

We sought to assess the current status of blood pressure control and the use of antihypertensive drugs in patients with ischemic stroke (IS) or transient ischemic attack (TIA) in China.

SUBJECTS AND METHODS

A cross-sectional study (across 19 urban outpatient clinics) on secondary stroke prevention measures was conducted. All subjects diagnosed with IS or TIA at neurological clinics were enrolled consecutively. Face to face interviews were conducted by a trained neurologist and research assistant using questionnaire at the same day of enrollment.

RESULTS

A total of 2283 IS or TIA patients were included in the survey. A history of hypertension was present in 1509 patients, of which 896 (59.4%) had uncontrolled blood pressure. A history of hypertension was absent in 603 patients, of whom 162 (26.9%) had uncontrolled blood pressure. In addition, 495 (88.9%) of patients with diabetes mellitus had uncontrolled blood pressure (systolic blood pressure > or = 130 mmHg or diastolic blood pressure > or = 80 mmHg). In multivariate logistic regression analysis, having monthly income of > 1000 yuan [odds ratio (OR): 2.040; 95% confidence interval (CI): 1.277-3.259), female (OR: 1.546; 95% CI: 1.174-2.034) and smoking habits (OR: 1.428; 95% CI: 1.014-2.013) remained significantly associated with blood pressure control. In contrast, compound preparation (OR: 0.685; 95% CI: 0.473-0.993) was inversely associated with the likelihood of blood pressure control.

CONCLUSION

Blood pressure control rate among IS or TIA patients in major metropolitan clinics is an important issue in China which might largely influence the efforts in stroke prevention and treatment. Further works are needed to develop substantive quality improvement strategies of stroke secondary prevention care.

Aggravation of albuminuria by metabolic syndrome in type 2 diabetic Asian subjects

AIMS

We investigated the relationship of urinary albumin excretion (UAE) to metabolic syndrome and type 2 diabetes in Asian.

METHODS

A total of 446 subjects (187 without diabetes and 259 with type 2 diabetes) were enrolled in this study. The components of metabolic syndrome, high sensitivity C-reactive protein (hs-CRP) and UAE were assessed. Based on metabolic syndrome and diabetes status, participants were categorized into one of the following groups: neither metabolic syndrome nor diabetes (MS-DM-), metabolic syndrome without diabetes (MS+DM-), diabetes without metabolic syndrome (MS-DM+) and both metabolic syndrome and diabetes (MS+DM+).

RESULTS

The UAE in the MS+DM- group was higher than that in the MS-DM- group (P<0.001) and lower than that in the MS+DM+ group (P<0.001), but not significantly different from that in the MS-DM+ group (P=0.349). The trend of increasing UAE in these four groups was independent of hs-CRP.

CONCLUSION

UAE was lowest in subjects with neither metabolic syndrome nor diabetes and highest in subjects with both metabolic syndrome and type 2 diabetes; however, there was no significant difference between the metabolic syndrome alone group and the type 2 diabetes alone group.

The metabolic syndrome in East Asians

The metabolic syndrome is an emerging epidemic in developing nations, including East Asian countries such as China, Japan, and Korea. Studies examining the metabolic syndrome have used different definitions, with prevalence often highly dependent on the cut points for abdominal obesity utilized, which have been recommended by the International Diabetes Federation to be lower than standards used in Caucasians and other ethnic groups. Prevalence rates have generally varied from 8% to 13% in men and 2% to 18% in women, depending on ethnic group and definition used, and are consistently lower than most Western Caucasian populations. While recent dramatic changes in lifestyle from Westernization of dietary habits and reduced physical activity present challenges, an emphasis on healthful lifestyle changes remains the cornerstone for metabolic syndrome management. In addition, clinical management focusing on control of obesity, elevated blood pressure, dyslipidemia, and hyperglycemia, with consideration of pharmacologic therapy issues unique to certain Asian populations, remains important for reducing associated cardiometabolic risks.

The metabolic syndrome and dyslipidemia among Asian Indians: a population with high rates of diabetes and premature coronary artery disease

South Asians have high rates of diabetes and the highest rates of premature coronary artery disease in the world, both occurring about 10 years earlier than in other populations. The metabolic syndrome (MS), which appears to be the antecedent or "common soil" for both of these conditions, is also common among South Asians. Because South Asians develop metabolic abnormalities at a lower body mass index and waist circumference than other groups, conventional criteria underestimate the prevalence of MS by 25% to 50%. The proposed South Asian Modified National Cholesterol Education Program criteria that use abdominal obesity as an optional component and the South Asian-specific waist circumference recommended by the International Diabetes Federation appear to be more appropriate in this population. Furthermore, Asian Indians have at least double the risk of coronary artery disease than that of whites, even when adjusted for the presence of diabetes and MS. This increased risk appears to be due to South Asian dyslipidemia, which is characterized by high serum levels of apolipoprotein B, lipoprotein (a), and triglycerides and low levels of apolipoprotein A1 and high-density lipoprotein (HDL) cholesterol. In addition, the HDL particles are small, dense, and dysfunctional. MS needs to be recognized as a looming danger to South Asians and treated with aggressive lifestyle modifications beginning in childhood and at a lower threshold than in other populations.

Prevalence of metabolic syndrome compared between native Japanese and Japanese-Americans

Metabolic syndrome is a condition characterized by the accumulation of multiple risk factors for atherosclerosis. Japanese-Americans in the U.S. have a more rapid and intense progression of atherosclerosis than native Japanese in Japan due to a westernization of their lifestyle. We investigated the prevalence of metabolic syndrome between 416 native Japanese (194 men and 222 women) in Hiroshima and 574 Japanese-Americans (217 men and 357 women) in Los Angeles, aged 30-89 years. According to the criteria proposed by the Japanese Society of Internal Medicine, the prevalence was 13.9 and 2.7% for native Japanese men and women, and 32.7 and 3.4% for Japanese-American men and women, respectively. According to the IDF or AHA/NHLBI criteria, the prevalence was 20.1 and 6.3%, and 38.7 and 4.5%, or 13.4 and 14.4%, and 30.9 and 27.7%, respectively. Thus, the prevalence of metabolic syndrome in men was significantly higher in Japanese-American than in native Japanese by all the three criteria. However, the prevalence in women was similar between native Japanese and Japanese-American by the Japanese and IDF criteria, whereas it was significantly higher in Japanese-American than in native Japanese by the AHA/NHLBI criteria. This report demonstrates that a westernization of lifestyle can increase the prevalence of metabolic syndrome among Japanese-Americans as compared to native Japanese.

Cerebral White Matter Lesions and Cognitive Function in a Non-demented Chinese Veteran Cohort

This study examined the association between cerebral white matter lesions (WMLs) and cognitive function in a male, non-demented Chinese veteran cohort. A total of 662 participants underwent CT scan and cognitive function assessments; 51 were excluded from the analysis because they exhibited non-lacunar infarcts or suspected dementia. Subjects were allocated to one of four groups according to WML status and between-group comparisons were made for seven cognitive function tests. Logistic regression was used to assess odds ratios for impaired performance associated with WML status. In all cognitive tests, subjects with severe WMLs differed significantly from those without WMLs or with mild WMLs, and in three tests subjects with severe WMLs differed significantly from those with moderate WMLs. For each cognitive test severe WMLs were strongly associated with increased risk of impaired performance. Severe WMLs were associated with greater diminished cognitive function and there may be a WML threshold after which, in elderly Chinese subjects, an impact on cognitive function occurs.

Genetic variation in cytochrome P450 2J2 and soluble epoxide hydrolase and risk of ischemic stroke in a Chinese population

OBJECTIVE

Epoxyeicosatrienoic acids have been recognized for their protective effects on the cardiovascular system. This study investigated whether two common polymorphisms in genes believed to be influential in regulating circulating levels of epoxyeicosatrienoic acids, namely cytochrome P450 2J2 (CYP2J2) G-50T and soluble epoxide hydrolase (EPHX2) G860A, were associated with ischemic stroke risk in a Chinese population.

METHODS AND RESULTS

Screening of 200 patients with ischemic stroke and 350 control participants revealed that CYP2J2-50T allele frequency was not significantly different in ischemic stroke cases versus controls. In contrast, EPHX2 860A allele frequency was 16.8% in ischemic stroke cases versus 21.7% in controls (P=0.047), and the presence of this variant allele was associated with a significantly lower risk of ischemic stroke after adjustment for sex, age and multiple cardiovascular risk factors (adjusted odds ratio=0.50, 95% confidence interval 0.29-0.86). Moreover, there was a significant interaction between the EPHX2 G860A polymorphism, smoking and ischemic stroke risk such that nonsmokers carrying the EPHX2 G860A variant allele were at the lowest risk of ischemic stroke (odds ratio=0.33, 95% confidence interval, 0.17-0.67, P=0.002), whereas no significant association was observed in smokers.

CONCLUSIONS

Collectively, these data indicate a protective influence of the G860A polymorphism of EPHX2 on ischemic stroke in Chinese nonsmokers.

Stroke incidence and survival in the beginning of the 21st century in southern Sweden: comparisons with the late 20th century and projections into the future

BACKGROUND AND PURPOSE

We report trends of stroke incidence and survival up to year 2001/2002 in Lund-Orup, Sweden, and projections of future stroke incidence in Sweden.

METHODS

Lund Stroke Register, a prospective population-based study, included all first-ever stroke patients, between March 1, 2001 and February 28, 2002, in the Lund-Orup health care district. Institution-based studies for 1983 to 1985 and 1993 to 1995 were used for comparison. We calculated age-standardized incidence and Cox proportional hazards analysis of survival (stroke subtype, sex, age group, and study period in the analysis). Minimum follow-up was 46 months. Based on our register's stroke incidence and the official Swedish population projection, a projection for future stroke incidence on a national basis was calculated.

RESULTS

We included 456 patients with first-ever stroke in 2001/2002. The age-standardized incidence (to the European population) was 144 per 100 000 person-years (95%CI 130 to 158) in 2001/2002, 158 (95%CI 149 to 168) in 1993 to 1995, and 134 (95%CI 126 to 143) in 1983 to 1985. Cox proportional hazard analysis indicated decreased risk of death after stroke in 2001/2002 (hazard ratio 0.80; 95%CI 0.67 to 0.94) compared with 1993 to 1995. Up to year 2050, the annual number of new stroke patients in Sweden may increase by 59% based solely on demographic changes.

CONCLUSIONS

Despite possible underestimation of stroke incidence during the previous institution-based studies, the increased stroke incidence between 1983 to 1985 and 1993 to 1995 did not continue in 2001/2002. The long-term survival after stroke continues to improve. As the elderly population is growing in Sweden, stable incidence and increasing survival will result in a rapidly increasing prevalence of stroke patients in Sweden.

Elevated retinol-binding protein 4 levels are associated with metabolic syndrome in Chinese people

CONTEXT

High retinol-binding protein 4 (RBP4) is thought to be associated with insulin resistance in humans. However, evidence from large-scale populations about the relationship between RBP4 and metabolic diseases is scarce.

OBJECTIVE

We evaluated plasma RBP4 distribution and its association with metabolic syndrome (MetS) among middle-aged and older Chinese.

RESEARCH DESIGN AND METHODS

We evaluated plasma RBP4 in a cross-sectional sample of 3289 Chinese aged from 50 to 70 yr in Beijing and Shanghai by using an in-house developed and validated sandwich ELISA. MetS was defined according to the updated National Cholesterol Education Program Adult Treatment Panel III criteria for Asian-Americans.

RESULTS

RBP4 levels were higher in male and Beijing residents, compared with female and Shanghai participants (both P < 0.001). RBP4 levels were associated positively with body mass index, waist circumference, triglycerides, total and low-density lipoprotein cholesterol, blood pressure, fasting insulin, and homeostatic model assessment of insulin resistance and negatively with high-density lipoprotein cholesterol and adiponectin (all P < 0.001). In the highest RBP4 quartile, the MetS risk was significantly higher (odds ratio 2.58; 95% confidence interval 2.08-3.20) than in the lowest quartile after adjustment for potential confounders. This association remained strong (odds ratio 2.25; 95% confidence interval 1.72-2.94) after further controlling for C-reactive protein, adiponectin, homeostatic model assessment of insulin resistance, and body mass index.

CONCLUSIONS

This first large-scale population study shows that elevated RBP4 levels are strongly and independently associated with MetS. Prospective studies are needed to establish the role of RBP4 in the development of MetS and related diseases.

Alcohol consumption and risk for stroke among Chinese men

OBJECTIVE

Stroke is a leading cause of death and long-term disability in China. The objective of this study was to examine the relation between alcohol consumption and risk for stroke among Chinese men.

METHODS

We conducted a prospective cohort study among 64,338 Chinese men aged > or = 40 years who were free of stroke at baseline. Data on frequency and type of alcohol consumed were collected at the baseline examination in 1991 using a standard protocol. Follow-up evaluation was conducted in 1999 to 2000, which included determining vital status, interviewing participants or proxies, and obtaining hospital and medical records for incident and fatal strokes.

RESULTS

Over the course of 493,351 person-years of follow-up, we documented 3,434 incident strokes (1,848 stroke deaths). After adjustment for age, body mass index, physical activity, urbanization (urban vs rural), geographic variation (north vs south), cigarette smoking, history of diabetes, and education, compared with nondrinkers, relative risk (95% confidence interval) of incident stroke was 0.92 (0.80-1.06) for participants consuming 1 to 6 drinks/week, 1.02 (0.93-1.13) for those consuming 7 to 20 drinks/week, 1.22 (1.07-1.38) for those consuming 21 to 34 drinks/week, and 1.22 (1.08-1.37) for those consuming 35 or more drinks per week (p for linear trend < 0.0001). The corresponding relative risks for stroke mortality were 0.93 (0.76-1.14), 0.98 (0.85-1.13), 1.15 (0.95-1.38), and 1.30 (1.11-1.52), respectively (p for linear trend = 0.0004; p for quadratic trend = 0.03).

INTERPRETATION

These results suggest that heavy alcohol drinking may increase the risk for stroke in Chinese men and should be the target of strategies for prevention.

Treatment and prevention of spontaneous intracerebral hemorrhage: comparison of EUSI and AHA/ASA recommendations

Stroke is a leading cause of death and the primary cause of permanent disability in adults in Western countries and has an enormous socioeconomic impact. Among all stroke subtypes, intracerebral hemorrhage is the deadliest form, especially in patients with intraventricular hemorrhage. In recent years, intracerebral hemorrhage has become a major focus within stroke research. The latest data from randomized controlled trials, however, have shown disappointing results. In 2006, the European Stroke Initiative published recommendations for the management of spontaneous intracerebral hemorrhage, followed by an updated recommendation by the American Heart Association/American Stroke Association in 2007. This review gives a comprehensive overview and comparison of the two recommendations. Finally, we provide an overview of ongoing clinical trials in intracerebral hemorrhage.

A comparison of two proposed definitions for metabolic syndrome in the Chinese adult population

BACKGROUND

The metabolic syndrome is a major risk factor for cardiovascular disease (CVD). We estimated the prevalence of the metabolic syndrome using the definitions proposed by the International Diabetes Federation (IDF) and the American Heart Association and the National Heart, Lung, and Blood Institute (revised ATP III), and compared the 2 definitions in the Chinese adult population.

METHODS

We conducted a cross-sectional study among a nationally representative sample of 15,838 Chinese adults ages 35 to 74 years in 2000 to 2001. Waist girth, blood pressure, and blood levels of HDL-cholesterol, triglycerides, and glucose were measured according to standard methods.

RESULTS

The overall age-standardized prevalence of the metabolic syndrome by the IDF and revised-ATP III definitions was 16.5% and 23.3%, respectively. The overall agreement of being classified as having or not having the metabolic syndrome was 93.2% for the 2 definitions, with a Kappa coefficient of 0.80. The prevalence significantly increased with age and was higher in women than in men by both definitions (23.3% vs 10.0% for IDF and 29.1% vs 17.7% for revised ATP III). Compared with men, women had a significantly higher prevalence of central obesity (37.6% vs 16.0%) and reduced HDL-cholesterol (46.5% vs 21.9%), whereas men had a significantly higher prevalence of raised blood pressure (44.2% vs 38.0%) compared with women.

CONCLUSIONS

The metabolic syndrome is very common in China regardless of the definition used. Prevention and treatment of the metabolic syndrome should become a public health priority to reduce the CVD-related burden in China.

Prevalence of the metabolic syndrome in Peruvian Andean hispanics: the PREVENCION study

Data regarding the prevalence of metabolic syndrome (MTS) in Andean populations are limited. We evaluated the prevalence of MTS according to American Heart Association/National Heart, Lung and Blood Institute criteria among 1878 subjects in the PREVENCION study in Peru. In women, the most common component was low HDL cholesterol (60.9%) followed by abdominal obesity (36.9%). In men, the most common component was elevated triglycerides (52.0%) followed by low HDL cholesterol (32.5%), whereas the prevalence of abdominal obesity was 14%. Abnormal fasting glucose was the least common component in men (5.4%) and women (5.0%). The prevalence of MTS was significantly higher in women compared to men (23.2% versus 14.3%) and increased steeply with age, particularly in women (p<0.0001). Using body mass index (BMI>or=30kg/m2) instead of waist circumference as a component of the MTS lead to equivalent prevalence estimates of MTS in men but significantly underestimated the prevalence in women. The MTS is highly prevalent among Peruvian Andeans, particularly in older women. The pattern of MTS components in this Andean population is characterized by a high prevalence of dyslipidemia and a relatively low prevalence of elevated fasting glucose. Further studies are required to characterize genetic and environmental determinants of these patterns.

Cholesterol, diabetes and major cardiovascular diseases in the Asia-Pacific region

AIMS/HYPOTHESIS

The aim of this study was to assess the association between total cholesterol and major cardiovascular diseases among persons with and without diabetes in the Asia-Pacific region.

METHODS

We used data on individual participants in 30 cohort studies from the Asia-Pacific region to compute the hazards ratios and 95% CIs for participants with and without diabetes at baseline, using Cox proportional models. Analyses were stratified by sex and region (Asia vs Australia or New Zealand) and adjusted for age. Repeat measurements of total cholesterol were used to adjust for regression dilution bias.

RESULTS

The analysis included 333,533 individuals (6.3% with diabetes at baseline) who experienced 6,074 fatal and non-fatal cardiovascular events over a median follow-up period of 4.0 years. Total cholesterol was positively associated with coronary heart disease (CHD) and ischaemic stroke, and negatively with haemorrhagic stroke in a continuous, log-linear fashion, similarly among participants with and without diabetes. Each 1 mmol/l increase above the 'usual' level for total cholesterol was associated with a 41% (95% CI 23-63%) and 42% (95% CI 35-50%) greater risk of CHD among participants with and without diabetes. The corresponding values for ischaemic stroke were 23% (95% CI 0-52%) and 31% (95% CI 20-44%), respectively. These results were broadly consistent for sex, age and region.

CONCLUSIONS/INTERPRETATION

Total cholesterol is associated with similarly increased risks of cardiovascular events in people with and without diabetes. While abnormal levels of other lipid fractions are frequently observed in people with diabetes, these data support aggressive lowering of total cholesterol and LDL-cholesterol levels for prevention of cardiovascular events.

Recurrent stroke: the role of common carotid artery intima-media thickness

The etiology of recurrent stroke is probably multifactorial and many recurrences remain unexplained by conventional risk factors. The purpose of this study is to investigate if common carotid artery intima-media thickness (CCA-IMT), an established vascular risk factor, can predict recurrence in first-ever stroke survivors. Two hundred and eighty-four consecutive patients with a first-ever ischemic stroke were investigated with carotid ultrasonography and were screened for the first recurrent stroke up to 12 months. Sixteen (5.6%, 95% CI: 3.5-9.0%) recurrent ischemic strokes were recorded. Among demographic data, conventional vascular risk factors, presenting stroke features and ultrasonographic measurements, CCA-IMT was the only parameter that differed significantly between those who suffered a recurrent stroke and those who did not. Cox's regression analysis adjusted for confounding factors, showed that CCA-IMT was the only independent predictor of stroke recurrence (HR 1.65; 95% CI: 1.11-2.46%). We propose that CCA-IMT measurements may help to identify stroke patients at higher risk for recurrence and to plan secondary prevention strategies.

Are soy foods protective against ischemic stroke?

Ischemic stroke is one of the leading causes of mortality and morbidity in the world. A large number of studies have observed the beneficial effects of soy protein and soy polyunsaturated fat in lowering blood cholesterol, reducing blood pressure and improving cardiovascular health. This study aims to investigate the potential of a soy food diet in the prevention of ischemic stroke through evaluation of evidence from clinical trials, meta-analyses, experimental and epidemiological studies.

Age-specific prevalence of the metabolic syndrome defined by the International Diabetes Federation and the National Cholesterol Education Program: the Norwegian HUNT 2 study

BACKGROUND

The 2005 International Diabetes Federation (IDF) definition of the metabolic syndrome was designed to be useful worldwide, but to date few prevalence studies have used that definition in European populations. We estimated the age- and sex-stratified prevalence of IDF-defined metabolic syndrome in a county of Norway and compared it with the prevalence estimated using the revised National Cholesterol Education Program-Adult Treatment Panel-III definition (2005 ATP III).

METHODS

Cross-sectional analysis of 10,206 participants aged 20-89 years in the Nord-Trøndelag Health Study 1995-97 (HUNT 2).

RESULTS

Prevalence of IDF-defined metabolic syndrome was 29.6% (95% CI: 28.8 to 30.5), compared to 25.9% (95% CI: 25.0 to 26.7) using the 2005 ATP III criteria. The prevalence of IDF-defined metabolic syndrome increased from 11.0% in the 20-29 years age group to 47.2% in the 80-89 years group in men, and from 9.2% to 64.4% for women in the corresponding age groups. Among men and women aged >or=60 years, the IDF criteria classified 56.7% and 75.0%, respectively, as having central obesity, and 89.3% and 90.9%, respectively, as being hypertensive.

CONCLUSION

According to both definitions, the prevalence of the metabolic syndrome increased strongly with age. The IDF and the American Heart Association/National Heart, Lung, and Blood Institute guidelines for clinical management of metabolic syndrome would classify a high proportion of elderly Norwegians as in need of overall risk assessment for cardiovascular disease.

Age-specific prevalence of the metabolic syndrome defined by the International Diabetes Federation and the National Cholesterol Education Program: the Norwegian HUNT 2 study

Background

The 2005 International Diabetes Federation (IDF) definition of the metabolic syndrome was designed to be useful worldwide, but to date few prevalence studies have used that definition in European populations. We estimated the age- and sex-stratified prevalence of IDF-defined metabolic syndrome in a county of Norway and compared it with the prevalence estimated using the revised National Cholesterol Education Program-Adult Treatment Panel-III definition (2005 ATP III).

Methods

Cross-sectional analysis of 10,206 participants aged 20–89 years in the Nord-Trøndelag Health Study 1995–97 (HUNT 2).

Results

Prevalence of IDF-defined metabolic syndrome was 29.6% (95% CI: 28.8 to 30.5), compared to 25.9% (95% CI: 25.0 to 26.7) using the 2005 ATP III criteria. The prevalence of IDF-defined metabolic syndrome increased from 11.0% in the 20–29 years age group to 47.2% in the 80–89 years group in men, and from 9.2% to 64.4% for women in the corresponding age groups. Among men and women aged ≥60 years, the IDF criteria classified 56.7% and 75.0%, respectively, as having central obesity, and 89.3% and 90.9%, respectively, as being hypertensive.

Conclusion

According to both definitions, the prevalence of the metabolic syndrome increased strongly with age. The IDF and the American Heart Association/National Heart, Lung, and Blood Institute guidelines for clinical management of metabolic syndrome would classify a high proportion of elderly Norwegians as in need of overall risk assessment for cardiovascular disease.

BMI versus the metabolic syndrome in relation to cardiovascular risk in elderly Chinese individuals

OBJECTIVE

The purpose of this study was to evaluate the associations of BMI versus metabolic syndrome with cardiovascular diseases (CVDs) in elderly Chinese individuals.

RESEARCH DESIGN AND METHODS

We conducted a population-based cross-sectional study in an urban sample of 2,334 elderly subjects (943 men and 1,391 women). Subjects were classified by BMI (< or = 18.5, < 24, < 28, and > or = 28 kg/m2) and the presence or absence of metabolic syndrome, which was defined by International Diabetes Federation (IDF) criteria. CVDs included clinically diagnosed coronary heart disease (CHD), stroke, and peripheral arterial disease (PAD).

RESULTS

The prevalence rates of overweight (BMI > or = 25 kg/m2) and metabolic syndrome according to the IDF criteria were 56.3% (53.9% in men and 57.9% in women) and 46.3% (34.8% in men and 54.1% in women), respectively. Increasing BMI was strongly associated with a higher risk of CHD, stroke, and PAD even after adjustments for metabolic syndrome and other CVD risk factors. Stratified analysis of participants with or without metabolic syndrome showed that BMI was independently associated with CHD, stroke, and PAD.

CONCLUSIONS

Both overweight and metabolic syndrome are highly prevalent in this elderly Chinese population. BMI, as a measure of overall adiposity, is strongly associated with increased prevalence of CVD independent of metabolic syndrome.

The risk of recurrent stroke after intracerebral haemorrhage

BACKGROUND AND AIM

The risks of recurrent intracerebral haemorrhage (ICH) vary widely (0-24%). Patients with ICH also have risk factors for ischaemic stroke (IS) and a proportion of ICH survivors re-present with an IS. This dilemma has implications for prophylactic treatment. This study aims to determine the risk of recurrent stroke events (both ICH and IS) following an index bleed and whether ICH recurrence risk varies according to location of index bleed.

PATIENTS AND METHODS

All patients diagnosed with an acute ICH presenting over an 8.5 year period were identified. Each ICH was confirmed by reviewing all of the radiology results and, where necessary, the clinical case notes or post-mortem data. Recurrent stroke events (ICH and IS) were identified by reappearance of these patients in our stroke database. Coronal post-mortem results for the same period were also reviewed. Each recurrent event was reviewed to confirm the diagnosis and location of the stroke.

RESULTS

Of the 7686 stroke events recorded, 768 (10%) were ICH. In the follow-up period, there were 19 recurrent ICH and 17 new IS in the 464 patients who survived beyond the index hospital stay. Recurrence rate for ICH was 2.1/100 in the first year but 1.2/100/year overall. This compares with 1.3/100/year overall for IS. Most recurrences were "lobar-lobar" type.

CONCLUSION

The cumulative risk of recurrent ICH in this population is similar to that of IS after the first year.

Environmental vascular risk factors: new perspectives for stroke prevention

Despite intensive evaluation of acute stroke patients, perhaps only half of the attributable stroke risk is usually identified. In addition to traditional and non-traditional vascular risk factors-including most recently homocysteine, inflammation, and alterations of coagulation-a number of environmental risk factors for stroke have been identified in the last decade. In this update we review the following: lower education and poor socioeconomic status (probable surrogates for exposure to traditional high-risk behaviors such as smoking, poor nutrition, lack of prenatal control, absence of preventive medical and dental care, and non-compliance of treatment of conditions such as hypertension); depression, stress and affective disorders; obstructive sleep apnea; passive smoking and environmental pollution; infections, in particular periodontal diseases that increase C-reactive protein (CRP); raised body mass index (obesity); exercise, and diet. The possible role of high-fructose corn syrup in the epidemic of obesity in the USA is reviewed. Protective diets include higher consumption of fish, olive oil, grains, fruits and vegetables (Mediterranean diet), as well as probiotic bacteria in yogurt and dairy products. Careful attention should be given to the patient's environment looking for modifiable factors. The effects of clean environmental air and water, adequate diet and appropriate nutrition, healthy teeth, exercise, and refreshing sleep in the prevention of stroke and cardiovascular disease appear to be quite compelling. Although some of these modifiable risk factors lack evidence-based information, judicious clinical sense should be used to counteract the potentially damaging effects of adverse environmental vascular risk factors.

Impact of sex, metabolic syndrome, and diabetes mellitus on cardiovascular events

Although cardiovascular events occur more frequently among patients with metabolic syndrome (MS) or diabetes mellitus (DM), the impact of gender is unclear. We aimed to determine the relation of MS and DM on cardiovascular events between men and women. The National Health Survey of 1992 provided information on outcomes for 3,414 Singaporeans aged 18 to 69 years without cardiovascular diseases. Definition of MS was based on the National Cholesterol Education Program criteria. Cardiovascular events included hospital admissions for coronary heart disease, stroke, and cardiovascular mortality. The proportion of subjects with MS was 12.4%. After 10 years, the annual cardiovascular event rates (per 1,000 person-years) for men without DM were 3.0 and 15.9 among subjects without and with MS, respectively, and the respective rates for men with DM were 22.5 and 21.4. The corresponding rates for women were 0.9, 3.7, 5.3, and 21.5, respectively. Among nondiabetic subjects, cardiovascular events occurred more frequently among men than women among subjects with MS (adjusted hazard ratios [HRs] 4.71, 95% confidence interval [CI] 1.56 to 14.2) and those without MS (HR 3.35, 95% CI 1.78 to 6.31). Among patients with DM, cardiovascular events occurred more commonly among men than women without MS (HR 6.04, 95% CI 1.43 to 25.6). Rates for cardiovascular events were comparable between men and women with DM and MS (HR 0.98, 95% CI 0.48 to 1.99). In conclusion, the adverse impact of MS or DM was greater among men, and the presence of both conditions increases the risk substantially for cardiovascular events among women.

The reasons coronary heart disease mortality has increased in China

To inaugurate the fifth year of its publication, The American Heart Hospital Journal (AHHJ) focused its Winter 2007 issue on health care systems from around the world, with 8 articles contributed by national leaders in their respective countries. Due to the interest and wide range of expertise in the international cardiac community, we will continue to publish Special Reports throughout 2007 on this topic. We invite members of the international community to share with readers of the AHHJ, their insights on the strengths and weaknesses of their respective health care and cardiac care systems, as well as their ideas and aspirations for future change.

Urbanization and stroke prevalence in Taiwan: analysis of a nationwide survey

This study aims to explore the prevalence of strokes among individuals and the association with urbanization levels. A total sample of 9,794 individuals was obtained from a nationwide survey on Taiwan for subsequent analysis in this study. After adjusting for gender, age, other risk factors for stroke and individual socioeconomic status, a multivariate logistic regression model was employed to investigate the relationships existing between the prevalence of strokes and the level of urbanization. This study finds that those living in areas at the highest level of urbanization (level 1) had the highest prevalence of strokes (2.49%). With decreasing urbanization level, there was a general decline in stroke prevalence. After adjusting for other factors, the multivariate logistic regression analyses showed that compared to participants living in the highest urbanization level, the respective odds ratios of suffering a stroke for those living in areas at the lowest levels of urbanization (levels 7 and 8), were 0.43 and 0.30. We conclude that after adjusting for other stroke risk factors, the level of urbanization is an important contributory factor to the overall prevalence of strokes in Taiwan.

Change in stroke incidence from a population-based intervention trial in three urban communities in China

Stroke has been the main cause of death in most urban residents in China since the 1990s. A community-based intervention trial carried out in China aimed to reduce the incidence and mortality of stroke. In 1991, two well-matched communities each with approximately 50,000 people were selected as intervention or control communities in the urban areas of Beijing, Shanghai and Changsha. Regular health education and health promotion activities were carried out between 1991 and 2000 in the intervention communities but no special action was taken in the control communities. Both fatal and nonfatal stroke cases were meticulously registered during the study in the two communities to assess the effect of long-term intervention. The trend in stroke incidence and the effect of intervention on stroke incidence were analyzed using a Poisson regression model adjusted for age, sex, year and city. Between 1991 and 2000, 2,273 first-ever stroke cases were registered in the intervention communities and 3,015 in the control communities. Geographic variation and changes in the incidence of stroke and its subtypes were found among these 3 cities. Through 10 years of intervention, incidence risks of all, ischemic and hemorrhagic strokes decreased by 11.4% (relative risk 0.8959; 95% confidence interval, CI, 0.8483-0.9460; p < 0.0001), 13.2% (relative risk 0.8676; 95% CI 0.8054-0.9345; p = 0.0002) and 7.2% (relative risk 0.9283; 95% CI 0.8517-1.0117; p = 0.0899), respectively, in the intervention compared with control communities. Accordingly, comprehensive community-based intervention measures could effectively reduce the incidence of stroke in the population.

Prevalence of metabolic syndrome in a rural area of Brazil

CONTEXT AND OBJECTIVE

Metabolic syndrome (MS) is recognized worldwide as an important public health concern. However, little information is available for rural populations in Brazil. The aim was to determine the prevalence and risk factors associated with MS in a rural village in Brazil in 2004.

DESIGN AND SETTING

Cross-sectional population-based study, in Virgem das Graças, a rural community in the Jequitinhonha Valley, State of Minas Gerais.

METHODS

MS was the dependent variable, defined as any three of these risk factors: arterial hypertension, high glucose or triglyceride concentrations, low high-density lipoprotein cholesterol and abdominal obesity. MS prevalence, according to selected socioeconomic and demographic variables (age, skin color, marital status, schooling and smoking habits), was determined in 251 subjects aged 20-88 years. Multivariate logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals.

RESULTS

MS prevalence was 21.6% (7.7% for men and 33.6% for women); the age-adjusted prevalence was 19.0%. The highest prevalences were observed for women > 60 years of age (52.9%) and women with body mass index (BMI) >or= 25 kg/m(2) (64%). Age, sex and BMI were associated risk factors for MS, while skin color was only significantly associated with MS for women. The models were adjusted for age, smoking habits, marital status, skin color and schooling.

CONCLUSIONS

BMI and age were independently associated factors for MS in this rural community. These findings provide important evidence on the prevalence of MS as a public health problem, particularly for women and overweight individuals.

Metabolic syndrome: stronger association with coronary artery disease in young men in comparison with higher prevalence in young women

BACKGROUND

Being overweight, a constituent of the metabolic syndrome, is also an important contributing factor to the development of coronary artery disease in younger patients, compared with the older patient population. Owing to the above-mentioned fact, we sought to assess the association of the metabolic syndrome with premature coronary artery disease.

METHODS

In an analytic cross-sectional study, 940 patients (553 women<or=55 years and 387 men<or=45 years), 637 with coronary artery disease and 303 without coronary artery disease, were evaluated. The extent of atherosclerosis was assessed with a clinical vessel score. Besides established coronary artery disease risk factors, all patients were evaluated for the presence of metabolic syndrome based on the National Cholesterol Education Program Adult Treatment Panel III criteria.

RESULTS

The overall prevalences of metabolic syndrome and coronary artery disease were 56 and 67.8%, respectively. Metabolic syndrome prevalence was higher in women than in men (69.6 vs. 36.4%, P<0.001). The odds ratio of metabolic syndrome for premature coronary artery disease was 1.82 (95% confidence interval 1.17-2.82) after adjusting for age and multiple established coronary artery disease risk factors; the strength of this association varied by sex (2.17 in men vs. 1.22 in women).

CONCLUSIONS

This study revealed a stronger association between metabolic syndrome and coronary artery disease in men<or=45 years than in women<or=55 years. It seems that endogenous estrogens may play a role in reducing the effects of metabolic syndrome-related risk and therefore in spite of higher prevalence of metabolic syndrome in young women, the effect of this syndrome on coronary artery disease is more dominant in young men.

Metabolic syndrome increases all-cause and vascular mortality: the Hong Kong Cardiovascular Risk Factor Study

OBJECTIVE

The metabolic syndrome has been associated with increased mortality in some Caucasian populations, but data in Asian populations are not available. We present data describing the association of the metabolic syndrome with mortality.

METHODS

The impact of the US National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) metabolic syndrome guidelines definition (using Asian central obesity criteria) on mortality was examined using Cox regression analyses in a population-based cohort (n = 2863) of Chinese subjects.

RESULTS

The cohort was followed up for a mean duration of 8.45 years, a total of 24 101 person-years, with 89 deaths (33.7% of vascular origin). Compared to those without any component of the metabolic syndrome, following adjustment for age, socioeconomic status and a range of lifestyle habits, those with the metabolic syndrome had increased risk of both all-cause [hazard ratio (HR) 2.02, 95% confidence interval (CI) 1.02-4.00, P for trend = 0.037] and vascular disease (HR 6.39, 95% CI 1.40-29.2, P < 0.05, P for trend = 0.002) mortality. When those with 0-2 components were compared to those with the metabolic syndrome, the HRs were 1.49 (95% CI 0.95-2.33, P = 0.084) and 3.36 (95% CI 1.57-7.19, P = 0.002), respectively.

CONCLUSION

This study shows that the metabolic syndrome is associated with increased mortality risk in an Asian population. The high prevalence of the metabolic syndrome, particularly in the elderly, forewarns of a rapidly increasing problem in mainland China, and other Asian populations, which could have overwhelming public health ramifications.