Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort

African Caribbeans have greater subclinical cerebrovascular disease than Europeans: this is associated with both their elevated resting and ambulatory blood pressure and their hyperglycaemia

OBJECTIVES

Stroke is elevated in people of black African descent, but evidence for excess subclinical cerebrovascular disease is conflicting, and the role of risk factors in determining any ethnic differences observed unexplored.

METHODS

We compared prevalence of brain infarcts, and severe white matter hyperintensities (WMHs) on cerebral MRI, in a community-based sample of men and women aged 58-86 of African Caribbean (214) and European (605) descent, in London, UK. Resting, central and ambulatory blood pressure (BP) were measured; diabetes was assessed by blood testing and questionnaire.

RESULTS

Mean age was 70. Multiple (≥4) brain infarcts and severe WMH occurred more frequently in African Caribbeans (18/43%), than Europeans (7/33%, P=0.05/0.008). Separately, clinic and night-time ambulatory BP were significantly associated with severe WMH in both ethnic groups; when both were entered into the model, the association for clinic SBP was attenuated and lost statistical significance [1.00 (0.98-1.02) P=0.9 in Europeans, 1.00 (0.97-1.04) P=0.9 in African Caribbeans], whereas the association for night-time SBP was retained [1.04 (1.02-1.07) P<0.001 in Europeans, 1.08 (1.03-1.12), P=0.001 in African Caribbeans]. The greater age-adjusted and sex-adjusted risk of severe WMH in African Caribbeans compared with Europeans [2.08 (1.15-3.76) P=0.02], was attenuated to 1.45 [(0.74-2.83) P=0.3] on adjustment for clinic and night-time systolic pressure, antihypertensive medication use and glycated haemoglobin.

CONCLUSION

African Caribbeans have a greater burden of subclinical cerebrovascular disease than Europeans. This excess is related to elevated clinic and ambulatory BP, and to hyperglycaemia.

A comparative analysis of risk factors for stroke in blacks and whites: the Atherosclerosis Risk in Communities study

OBJECTIVE

Previous studies have speculated that the higher stroke incidence rate (IR) in blacks compared with whites may be due, in part, to stroke risk factors exerting a more adverse effect among blacks than whites. To determine whether such racial differences exist we compared the prospective associations between novel, traditional, and emerging stroke risk factors in blacks and whites.

DESIGN

Baseline characteristics on risk factor levels were obtained on 15,407 participants from the Atherosclerosis Risk in Communities Study. Stroke incidence was ascertained from 1987 to 2008. Adjusted Cox proportional hazard models were used to compute hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke in relation to stroke risk factor levels stratified by race.

RESULTS

During follow-up, 988 stroke events occurred: blacks had higher stroke incident rates compared with whites with the greatest difference in those aged <60 years: 4.34, 3.24, 1.20, and 0.84 per 1000 person-years, in black men, black women, white men, and white women, respectively. Associations between risk factors with incident stroke were similar in blacks and whites excluding diabetes which was more strongly associated with the risk of stroke in blacks than in whites: HR 2.54 (95% CI: 2.03-3.18) versus 1.74 (1.37-2.21), respectively; p for race interaction=0.02.

CONCLUSIONS

At all ages, blacks are at a considerably higher risk of incident stroke compared with whites, although the effect is most marked in younger age groups. This is most likely due to blacks having a greater burden of stroke risk factors rather than there being any substantial race differences in the associations between risk factors and stroke outcomes.

Endovascular treatment of carotid occlusive disease

Carotid occlusive disease is one of several etiologic factors for stroke. Of all strokes, an estimated 88% are ischemic in nature. Less than 20% of these are caused by atheroma in the carotid bifurcation. Traditionally, carotid artery stenosis has been treated with carotid endarterectomy (CEA); however, carotid artery balloon angioplasty and stent placement has enjoyed significant technological advances over the last decade and can now offer a comparable treatment alternative to CEA. In this review, the authors concentrate their discussion on the treatment of carotid atherosclerotic disease with particular attention on the endovascular treatment.

Incidence and trends of stroke and its subtypes in Changsha, China from 2005 to 2011

During the 1990s no significant changes were found for the high incidence of ischemic stroke (IS) in Changsha, in contrast to the increase observed in Beijing and Shanghai. However, the epidemiological patterns of stroke may change with economic development. This study aimed to examine the characteristics of stroke incidence transition in Changsha from 2005 to 2011. In 2007 two communities with a registered population of about 100,000 were selected and data from stroke patients who presented between 2005 and 2007 were retrospectively collected from January to June 2008. From January to December 2007 a stroke surveillance network was established and stroke patients who presented between 2008 and 2011 were prospectively registered. From 2005 to 2011 the mean annual age-adjusted incidence of first-ever stroke was 168.5/100,000 (95% confidence interval [CI] 159.0-178.0/100,000), with 189.3/100,000 (95% CI 175.1-178.0/100,000) for men and 148.7/100,000 (95% CI 136.0-161.4/100,000) for women. The mean annual age-adjusted incidence of IS, intracranial hemorrhage and subarachnoid hemorrhage was 72.6/100,000 (95% CI 66.3-78.9/100,000), 85.1/100,000 (95% CI 78.3-91.9/100,000) and 9.4/100,000 (95% CI 7.1-11.7/100,000), respectively. During the study period, the age-adjusted incidence of stroke increased at an annual rate of 3.7% (p=0.001); at 4.2% for men (p=0.001) and 3.1% for women (p=0.026). The age-adjusted incidence of IS increased at an annual rate of 3.5% (p=0.003) but no significant changes were seen for hemorrhagic stroke. Characteristics of stroke incidence transition may reflect underlying changes in risk factors and there is an urgent need to identify these factors and launch appropriate public health campaigns.

CKD and cardiovascular disease in the Atherosclerosis Risk in Communities (ARIC) study: interactions with age, sex, and race

BACKGROUND

Estimated glomerular filtration rate (eGFR) and albuminuria are central for diagnosis, staging, and risk evaluation in chronic kidney disease (CKD). Universal thresholds regardless of age, sex, and race are recommended, but relatively little is known about how these demographic factors alter the relationship of eGFR and albuminuria to cardiovascular outcomes.

STUDY DESIGN

Observational cohort study.

SETTING & PARTICIPANTS

11,060 whites and blacks aged 52-75 years in the Atherosclerosis Risk in Communities (ARIC) Study with median follow-up of 11.2 years.

PREDICTORS

eGFR by the CKD-EPI (CKD Epidemiology Collaboration) creatinine equation (reference, 95 mL/min/1.73 m(2)) and urinary albumin-creatinine ratio (ACR; reference, 5 mg/g).

OUTCOMES

Cardiovascular events (coronary disease, stroke, and heart failure) and all-cause mortality.

MEASUREMENTS

Adjusted HRs associated with eGFR and ACR in subgroups according to age, sex, and race.

RESULTS

Cardiovascular risk significantly increased at eGFR <70 mL/min/1.73 m(2) in all subgroups according to age (<65 vs ≥65 years), sex, and race (P for interaction >0.2 for these subgroups; eg, at eGFR of 30 mL/min/1.73 m(2), the adjusted HR was 2.19 [95% CI, 1.10-4.35] at age 52-64 years vs 2.23 [95% CI, 1.33-3.72] at age 65-75 years). Results were similar for mortality. Log(ACR) was associated linearly with cardiovascular risk without threshold effects in all subgroups, with some quantitative interactions. HRs according to ACR tended to be lower in men versus women (eg, at ACR of 40 mg/g, 1.18 [95% CI, 0.98-1.41] vs 1.77 [95% CI, 1.45-2.15]) and in the older versus younger population (1.24 [95% CI, 1.04-1.49] vs 1.73 [95% CI, 1.42-2.12]; P for interaction <0.01 for sex and age). Less evident interactions were observed for mortality.

LIMITATIONS

Single measurement of eGFR with creatinine and ACR and relatively narrow age range.

CONCLUSIONS

The associations of eGFR and ACR with cardiovascular events were largely similar, with some quantitative interactions, in age, sex, and racial subgroups, generally supporting universal thresholds of GFR and ACR for CKD definition/staging.

No racial differences in the association of glycated hemoglobin with kidney disease and cardiovascular outcomes

OBJECTIVE

There is debate regarding the clinical significance of well-established racial differences in HbA1c. We compared the associations of diabetes diagnostic categories for HbA1c and fasting glucose with clinical outcomes in black and white persons in the community.

RESEARCH DESIGN AND METHODS

We conducted a prospective cohort analysis of participants without diabetes or cardiovascular disease from the Atherosclerosis Risk in Communities study. We examined the associations of clinical categories of HbA1c (<5.7%, 5.7-6.4%, ≥6.5%) and fasting glucose (<100, 100-125, ≥126 mg/dL) with outcomes separately among 2,484 black and 8,593 white participants and tested for race interactions.

RESULTS

Baseline characteristics differed significantly in blacks compared with whites, including HbA1c (5.8 vs. 5.4%; P<0.001). During 18 years of follow-up, there were trends of increased risk of kidney disease, fatal and nonfatal coronary heart disease, and stroke across categories of HbA1c in both blacks and whites. The adjusted hazard ratios for each outcome across categories of HbA1c were similar in blacks and whites (P for interaction>0.05) except for all-cause mortality. Patterns of association were similar, but weaker, for fasting glucose. HbA1c and fasting glucose both were more strongly associated with all-cause mortality in whites compared with blacks, largely explained by racial differences in the rate of cardiovascular deaths.

CONCLUSIONS

HbA1c is a risk factor for vascular outcomes and mortality in both black and white adults. Patterns of association for HbA1c were similar to or stronger than those for fasting glucose. With respect to long-term outcomes, our findings support a similar interpretation of HbA1c in blacks and whites for diagnosis and treatment of diabetes mellitus.

Epidemiology of stroke and its subtypes in Chinese vs white populations: a systematic review

OBJECTIVE

We aimed to systematically assess the evidence for differences in the incidence of stroke and distribution of its subtypes in Chinese compared with white populations.

METHODS

We comprehensively sought studies conducted since 1990 in Chinese populations of 1) first-ever stroke incidence (community-based studies only), and 2) pathologic types/subtypes of stroke (hospital- or community-based studies of first-ever or recurrent strokes). We identified community-based studies in white populations from a recent systematic review. For each study, we calculated age-standardized stroke incidence and the proportions of each pathologic type and ischemic subtype, using random-effects meta-analysis to pool proportions of stroke types/subtypes in Chinese and in white populations.

RESULTS

Age-standardized annual first-ever stroke incidence in community-based studies was higher among Chinese than white populations (for ages 45-74 years, range 205-584 vs 170-335 per 100,000, respectively). Intracerebral hemorrhage accounted for a larger, more variable proportion of strokes in China than Taiwan (range 27%-51% vs 17%-28%), in Chinese community-based than hospital-based studies (27%-51% vs 17%-30%), and in community-based Chinese than white studies (pooled proportion 33% vs 12%). Although the overall proportion of lacunar ischemic stroke appeared higher in Chinese than white populations, variable study methodologies precluded reliable comparisons.

CONCLUSIONS

There is good evidence for a slightly higher overall stroke incidence and higher proportion of intracerebral hemorrhage in Chinese vs white populations, but no clear evidence for different distributions of ischemic stroke subtypes. Studies using comparable, population-based case ascertainment and similar classification methods are needed to address this.

Prognostic factors in acute stroke, regarding to stroke severity by Canadian Neurological Stroke Scale: A hospital-based study

Introduction:

Stroke is an acute vascular disease and the second leading cause of death in the world. We have assessed the patients on hospital admission with some other prognostic factors besides the preliminary neurological examinations in order to estimate their clinical status in the future.

Materials and Methods:

The present study was performed on the patients admitted to Valiasr Hospital of Arak within 72 h of stroke onset from April to October 2011. Diagnosis of stroke in the suspected patients was done by a neurologist and verified by the findings of the computed tomography scans. For each patient, a specific questionnaire, which described its stroke severity according to canadian neurological scale of stroke (CNSS), was prepared in order to define the severity of the stroke. Systolic as well as diastolic blood pressure of the patients was measured at the admission and their level of blood sugar, cholesterol, and triglyceride was also determined.

Results:

Out of 62 patients under study (mean age, 66.14 ± 10.9 years), 36 (58.1%) were males and 26 (41.9%) were females. Overall, 66.1% of the patients were diagnosed with the ischemic stroke, while 33.9% were diagnosed with the hemorrhagic stroke. Regression analysis showed that cholesterol and diastolic blood pressure were the most important prognostic factors of the severity of stroke (CNSS).

Conclusion:

Diastolic blood pressure and serum cholesterol level have the potential to be used for assessing the stroke outcome as well as to improve the stroke rehabilitation.

Carvacrol alleviates cerebral edema by modulating AQP4 expression after intracerebral hemorrhage in mice

Carvacrol is a natural compound extracted from many plants of the family Lamiaceae. Previous studies have demonstrated that carvacrol has potential neuroprotective effects in central nervous system diseases such as Alzheimer's disease and cerebral ischemia. In this study, we investigated the preclinical effect of carvacrol on cerebral edema after intracerebral hemorrhage (ICH) using a bacterial collagenase-induced ICH mouse model. Mice were randomly divided into sham (n=43), vehicle-treated (n=51), and carvacrol-treated groups (n=101). In carvacrol-treated group, carvacrol was administrated to mice at 0h, 1h, or 3h after ICH induction. Carvacrol was injected intraperitoneally with single doses of 10, 25, 50, or 100mg/kg. Neurologic dysfunctions, brain water content, aquaporins (AQPs) mRNAs level and AQP4 protein expression in the perihematomal area were evaluated post ICH. Our results showed that carvacrol administration improved neurological deficits after day 3 following ICH (p<0.05). Carvacrol reduced cerebral edema and Evans Blue leakage at day 3 (p<0.05). We also found that carvacrol treatment decreased AQP4 mRNA in a dose-dependent manner at 24h. Furthermore, AQP4 protein expression in the perihematomal area was reduced by carvacrol significantly at day 3 after ICH (p<0.05). Our findings suggest that carvacrol may exert its protective effect on ICH injury by ameliorating AQP4-mediated cerebral edema.

Female gender remains an independent risk factor for poor outcome after acute nontraumatic intracerebral hemorrhage

Objective. To study whether gender influences outcome after intracerebral hemorrhage (ICH). Methods. Cohort study of 245 consecutive adults presenting to the emergency department with spontaneous ICH from January 2006 to December 2008. Patients with subarachnoid hemorrhage, extradural hemorrhage, and recurrence of hemorrhage were excluded. Results. There were no differences noted between genders in stroke severity (NIHSS) at presentation, ICH volume, or intraventricular extension (IVE) of hemorrhage. Despite this, females had 1.94 times higher odds of having a bad outcome (modified Rankin score (mRs) ≥3) as compared to males (95% CI 1.12 to 3.3) and 1.84 times higher odds of early mortality (95% CI 1.02–3.33). analyzing known variables influencing mortality in ICH, the authors found that females did have higher serum glucose levels on arrival (P = 0.0096) and 4.2 times higher odds for a cerebellar involvement than males (95% CI 1.63–10.75). After adjusting for age, NIHSS, glucose levels, hemorrhage volume, and IVE, female gender remained an independent predictor of early mortality (P = 0.0127). Conclusions. Female gender may be an independent predictor of early mortality in ICH patients, even after adjustment for stroke severity, hemorrhage volume, IVE, serum glucose levels, and age.

Hypertensive retinopathy and risk of stroke

Although assessment of hypertensive retinopathy signs has been recommended for determining end-organ damage and stratifying vascular risk in persons with hypertension, its value remains unclear. In this study, we examine whether hypertensive retinopathy predicts the long-term risk of stroke in those with hypertension. A total of 2907 participants with hypertension aged 50 to 73 years at the 1993 to 1995 examination, who had gradable retinal photographs, no history of diabetes mellitus, stroke, and coronary heart disease at baseline and data on incident stroke, were included from the Atherosclerosis Risk in Communities (ARIC) Study. Retinal photographs were assessed for hypertensive retinopathy signs and classified as none, mild, and moderate/severe. Incident events of any stroke, cerebral infarction, and hemorrhagic stroke were identified and validated. After a mean follow-up period of 13.0 years, 165 persons developed incident stroke (146 cerebral infarctions and 15 hemorrhagic strokes). After adjusting for age, sex, blood pressure, and other risk factors, persons with moderate hypertensive retinopathy were more likely to have stroke (moderate versus no retinopathy: multivariable hazard ratios, 2.37 [95% confidence interval, 1.39-4.02]). In participants with hypertension on medication with good control of blood pressure, hypertensive retinopathy was related to an increased risk of cerebral infarction (mild retinopathy: hazard ratio, 1.96 [95% confidence interval, 1.09-3.55]; and moderate retinopathy: hazard ratio, 2.98 [95% confidence interval, 1.01-8.83]). Hypertensive retinopathy predicts the long-term risk of stroke, independent of blood pressure, even in treated patients with hypertension with good hypertension control. Retinal photographic assessment of hypertensive retinopathy signs may be useful for assessment of stroke risk.

Poststroke outcomes vary by pathogenic stroke subtype in the Atherosclerosis Risk in Communities Study

BACKGROUND AND PURPOSE

Early risk of recurrence and mortality after stroke differs by subtype, but less is known about long-term recurrence and hospital readmissions. These differences have economic implications and will affect long-term disability and stroke survivor quality of life. We examined recurrent stroke, all-cause hospital readmission, and mortality by index pathogenic subtype.

METHODS

We identified 987 Atherosclerosis Risk in Communities Study cohort participants with first-ever stroke and followed them for a median 5.3 years after first stroke. Outcomes were compared across index subtypes (infarction: thrombotic, cardioembolic, and lacunar; hemorrhagic: subarachnoid and intracerebral) using Kaplan-Meier analysis and Cox proportional hazards regression, adjusting for age, sex, and race.

RESULTS

There were 183 recurrent strokes among 147 participants, 3234 hospitalizations among 746 participants, and 529 deaths; only 14% of participants were event-free over follow-up. The majority of recurrent events were of the same subtype, except for lacunar infarcts, which were followed ≈3 quarters of the time by nonlacunar events. Adjusted mortality was higher for intracerebral hemorrhage (hazard ratio, 2.3; 95% confidence interval, 1.7-3.0) compared with thrombotic stroke and lower for lacunar infarcts. Lacunar infarcts had somewhat higher recurrence compared with thrombotic infarcts (hazard ratio, 1.3; 95% confidence interval, 0.9-1.9), but lower all-cause readmission (hazard ratio, 0.8; 95% confidence interval, 0.7-1.0). Readmission was 40% higher for cardioembolic stroke relative to thrombotic stroke (hazard ratio, 1.4; 95% confidence interval, 1.1-1.7).

CONCLUSIONS

Although the highest mortality was observed for intracerebral hemorrhage, there was significant burden of recurrent stroke and hospital readmissions for lacunar and cardioembolic strokes, respectively. There may be opportunities to reduce the relatively high rate of poststroke readmissions.

The association of plasma lactate with incident cardiovascular outcomes: the ARIC Study

We examined the association of plasma lactate at rest, a marker of oxidative capacity, with incident cardiovascular outcomes in 10,006 participants in the Atherosclerosis Risk in Communities (ARIC) Study visit 4 (1996-1998). We used Cox proportional-hazards models to estimate hazard ratios of incident coronary heart disease, stroke, heart failure, and all-cause mortality by quartiles of plasma lactate (Q1, ≤5.3 mg/dL; Q2, 5.4-6.6; Q3, 6.7-8.6; and Q4 ≥8.7). During a median follow-up time of 10.7 years, there were 1,105 coronary heart disease cases, 379 stroke cases, 820 heart failure cases, and 1,408 deaths. A significant graded relation between lactate level and cardiovascular events was observed in the demographically adjusted model (all P for trend < 0.001). After further adjustment for traditional and other potential confounders, the association remained significant for heart failure (Q4 vs. Q1: hazard ratio (HR) = 1.35, 95% confidence interval (CI): 1.07, 1.71) and all-cause mortality (HR = 1.27, 95% CI: 1.07, 1.51) (P for trend < 0.02 for these outcomes) but not for coronary heart disease (HR = 1.02, 95% CI: 0.84, 1.24) and stroke (HR = 1.26, 95% CI: 0.91, 1.75). The results for heart failure were robust across multiple subgroups, after further adjustment for N-terminal pro-B-type natriuretic peptide and after exclusion of participants with incident heart failure within 3 years. The independent associations of plasma lactate with heart failure and all-cause mortality suggest an important role for low resting oxidative capacity.

Plasma fatty acid composition and incident ischemic stroke in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

The association of individual fatty acids with ischemic stroke has not been thoroughly studied, and results have been inconsistent. Few prospective studies have systematically explored the association of biomarkers of fatty acid intake with stroke. The aim of this study was to explore which individual plasma fatty acids would be associated with higher risk of ischemic stroke among whites.

METHODS

We studied 3,870 white men and women from the Minneapolis field center of the Atherosclerosis Risk in Communities (ARIC) Study, aged 45-64 years at baseline (1987-1989), who had plasma cholesterol ester (CE) and phospholipid (PL) fatty acids measured. Participants were followed through 2008 for incident ischemic stroke. Hazard ratios (HRs) with 95% confidence intervals (CIs) across quartiles of each fatty acid, measured as the percentage of total fatty acids, were calculated using the Cox proportional hazards model.

RESULTS

During a maximum of 22 years of follow-up, we identified 168 cases of ischemic stroke. After adjustment for age and sex, plasma levels of saturated fatty acids were associated positively: HR (95% CI) of the highest versus the lowest quartile for CE fraction was 1.93 (1.23-3.04, p for trend = 0.01) and that for PL fraction was 1.64 (1.05-2.57, p for trend = 0.03). There was also a positive linear association with monounsaturated fatty acids, especially with palmitoleic acid: HR (95% CI) of the highest versus the lowest quartile for CE fraction was 1.86 (1.20-2.87, p for trend = 0.003) and that for PL fraction was 1.52 (0.99-2.34, p for trend = 0.005). No associations of ω-3 and ω-6 polyunsaturated fatty acids with ischemic stroke were observed, but linoleic acid was inversely and nonlinearly associated with ischemic stroke: HR (95% CI) of the highest versus the lowest quartile for CE fraction was 0.64 (0.43-0.97, p for trend = 0.13) and that for PL fraction was 0.69 (0.45-1.05, p for trend = 0.24). These associations were generally unchanged after adjustment for cardiovascular risk factors.

CONCLUSIONS

In this US cohort of whites, we found significant positive associations of plasma saturated and monounsaturated fatty acids, especially of palmitoleic acid, with ischemic stroke. We also found an inverse nonlinear association between linoleic acid and ischemic stroke.

Ceruloplasmin and heart failure in the Atherosclerosis Risk in Communities study

BACKGROUND

Ceruloplasmin (Cp) decreases nitric oxide bioavailability in blood and has been associated with cardiovascular disease (CVD) in clinical studies. We assessed the associations between Cp and incident heart failure (HF), death, and CVD in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS AND RESULTS

Cp was measured at ARIC visit 4 (1996-1998). We studied 9240 individuals without HF or CVD at ARIC visit 4 and followed them for a mean of 10.5 years. Genome-wide association study was performed to identify genetic determinants of Cp levels and evaluate their association with incident HF in ARIC participants. Cp levels (mean±SD) were higher in women versus men (335±79 versus 258±44 mg/L; P<0.0001), women on versus not on hormone-replacement therapy (398±89 versus 291±60 mg/L; P<0.0001), and African Americans versus whites (299±63 versus 293±74 mg/L; P=0.0005). After adjusting for traditional risk factors, high-sensitivity C-reactive protein, N-terminal pro-B-type natriuretic peptide, and high-sensitivity cardiac troponin T, higher levels of Cp were associated with HF (hazard ratio, 1.44; 95% confidence interval, 1.13-1.83) and mortality (hazard ratio, 1.38; 95% confidence interval, 1.11-1.63). A locus on the ceruloplasmin gene on chromosome 3 was significantly associated with Cp levels (normal 295.56±77.60 mg/L; heterozygote 316.72±88.02 mg/L; homozygote 331.04±85.40 mg/L; P=8.3×10(-13)) but not with incident HF. After adjustment for traditional risk factors, Cp levels were also weekly associated with CVD.

CONCLUSIONS

Cp was associated with incident HF, mortality, and CVD in the ARIC population. A single locus on chromosome 3 was associated with Cp levels but not with HF.

Incidence and clinical features of cerebrovascular disease among HIV-infected adults in the Southeastern United States

With aging of the HIV-infected population, non-AIDS conditions such as cardiovascular disease (CVD) now account for substantial mortality and morbidity. While myocardial infarction is the major outcome of interest in the field of HIV and CVD, cerebrovascular disease remains understudied, especially in the Southeastern United States. We determined the incidence and clinical features of cerebrovascular events (CVE) in a large HIV clinical cohort in North Carolina (NC). A total of 2,515 HIV-infected adults contributed a median of 4.5 years (IQR: 2.0, 7.8) of follow-up. Fifty-three CVEs were adjudicated for an incidence rate of 3.87 per 1,000 person-years (95% CI: 2.90, 5.06). The ischemic stroke incidence was 2.26 per 1,000 person-years (95% CI: 1.53, 3.21), approximately 1.5 times the rate of a population-based cohort in NC. At the time of CVE, the median age was 48 years (IQR: 42, 55). Of ischemic strokes 76% resulted from large artery atherosclerosis or small vessel (lacunar) disease. In multivariable analyses, age, hypertension, dyslipidemia, recent CD4(+) cell count ≤200 cells/mm(3), and recent HIV RNA >400 copies/ml were associated with an increased risk of CVE. Antiretroviral therapy (ART) was not associated with the risk of CVE. We concluded that in the post-ART era, HIV-infected individuals appear to be at moderately increased risk of stroke. Prevention of CVEs in this population will require modification of traditional CVD risk factors and early, effective treatment of HIV infection.

An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term "stroke" is not consistently defined in clinical practice, in clinical research, or in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrum: Ischemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.

Bilateral common carotid artery ultrasound for prediction of incident strokes using intima-media thickness and external diameter: an observational study

Background

External common carotid artery (CCA) diameter and intima-media thickness (IMT) are independently associated with incident stroke and other cardiovascular events. Arterial geometry such as large IMT and large diameter may reflect vulnerable plaques and so impact stroke risk. Finally, arterial changes that exist bilaterally may increase stroke risk.

Method

We studied middle-aged men and women (n=7276) from a prospective observational study who had right (R) and left (L) CCA IMT and external diameters measured via B-mode ultrasound (1987–89) in order to categorize CCA geometry. Using side- and gender-specific IMT and diameter medians, we categorized each measurement as large (≥ median) vs. not large (< median) and defined four geometries: both IMT and diameter were large, only one parameter was large, or neither was large (reference group). Participants were followed for first time stroke through December 31, 1999. We used proportional hazards models to assess associations between right and left CCA geometries with new stroke. We also calculated positive and negative likelihood ratios (+LR and -LR) for CCA bilateral phenotypes as a measure of diagnostic accuracy.

Results

Presence of both large CCA IMT and large diameter on one side was associated with strong stroke risk even after risk factor adjustment (men: RCCA hazard ratio [HR]=3.7 95% confidence interval [CI]=1.9-7.4; LCCA HR=2.4 95% CI=1.4-4.4; women: RCCA HR=4.0 95% CI=1.5-10.5; LCCA HR=5.7 95% CI=1.7-19.0). Presence of both large IMT and large diameter bilaterally was the strongest predictor of stroke identifying 64% of women and 44% of men who developed strokes. This phenotype showed potential for predicting stroke among individuals (women: +LR=3.1, 95% CI=2.6-3.8; men: +LR=2.3, 95% CI=1.8-2.8).

Conclusion

Bilateral carotid artery geometries may be useful for stroke risk prediction.

sRAGE and risk of diabetes, cardiovascular disease, and death

Advanced glycation end products (AGEs) and their receptors are strongly implicated in the development of diabetes complications. When stimulated by AGEs, the receptors for AGEs (RAGEs) induce inflammation and are thought to fuel disease progression. Soluble circulating RAGE (sRAGE) may counteract the detrimental effects of RAGE. We measured sRAGE in stored plasma from a random sample of 1,201 participants in the Atherosclerosis Risk in Communities (ARIC) Study who were aged 47-68 years, had normal kidney function, and had no history of cardiovascular disease. In cross-sectional analyses, black race, male sex, higher BMI, and higher C-reactive protein were independently associated with low sRAGE. The racial difference was striking, with blacks approximately three times more likely to have low sRAGE compared with whites even after adjustment. During ~18 years of follow-up, there were 192 incident coronary heart disease events, 53 ischemic strokes, 213 deaths, and 253 cases of diabetes (among the 1,057 persons without diabetes at baseline). In multivariable Cox models comparing risk in the first quartile with that in the fourth quartile of baseline sRAGE, low levels of sRAGE were significantly associated with risk of diabetes (hazard ratio 1.64 [95% CI 1.10-2.44]), coronary heart disease (1.82 [1.17-2.84]), and mortality (1.72 [1.11-2.64]) but not ischemic stroke (0.78 [0.34-1.79]). In conclusion, we found that low levels of sRAGE were a marker of future chronic disease risk and mortality in the community and may represent an inflammatory state. Racial differences in sRAGE deserve further examination.

Explicit consideration of baseline factors to assess recombinant tissue-type plasminogen activator response with respect to race and sex

BACKGROUND AND PURPOSE

Sex and race reportedly influence outcome after recombinant tissue-type plasminogen activator (rtPA). It is, however, unclear whether baseline imbalances (eg, stroke severity) or lack of response to thrombolysis is responsible. We applied balancing methods to test the hypothesis that race and sex influence outcome after rtPA independent of baseline conditions.

METHODS

We mapped group outcomes from the National Institute of Neurological Disorders and Stroke (NINDS) dataset based on race and sex onto a surrogate-control function to assess differences from expected outcomes at their respective National Institutes of Health Stroke Scale and age. Outcomes were also compared for subjects matched individually on key baseline factors using NINDS and 2 recent datasets from southeastern United States.

RESULTS

At similar National Institutes of Health Stroke Scale and age, 90-day good outcomes (modified Rankin Score, 0-2) in NINDS were similarly improved after rtPA for white men and women. There was a strong trend for improvement in black men. Conversely, black women treated with rtPA showed response rates no different from the controls. After baseline matching, there were nonsignificant trends in outcomes except for significantly fewer good outcomes in black versus matched white women (37% versus 63%; P=0.027). Pooling the 3 datasets showed a similar trend for poorer short-term outcome for black women (P=0.054; modified Rankin Score, 0-1).

CONCLUSIONS

Matching for key baseline factors indicated that race and sex influence outcome most strikingly in black women who demonstrated poorest outcomes after rtPA. This finding supports the hypothesis that poor response to rtPA, rather than differences in baseline conditions, contributes to the worse outcome. This finding requires prospective confirmation.

Circulating miRNAs: reflecting or affecting cardiovascular disease?

MicroRNAs are a class of small, noncoding RNAs encoded by the metazoan genome that regulate protein expression. A collection of studies point to vital roles for microRNAs in the onset and development of cardiovascular diseases. So far, microRNAs have been considered as important intracellular mediators in maintaining proper cardiac function and hemostasis, and have been proposed as potential therapeutic targets in cardiovascular disease. The recent discovery that microRNAs circulate in a stable form in many body fluids, including blood, suggests that circulating microRNAs can serve as a new generation of biomarkers for cardiovascular diseases. In this review, we summarize the findings of studies focusing on circulating microRNAs present in human blood cells or plasma/serum, where they potentially could serve as diagnostic or prognostic markers for a variety of cardiovascular pathologies, including acute myocardial infarction, heart failure, coronary artery disease, stroke, diabetes and hypertension. The significance and limitations of microRNAs as the new biomarker generation for cardiovascular disease are also discussed.

Public and professional education on urgent therapy for acute ischemic stroke: a community-based intervention in Changsha

Excessive delay of presentation for stroke in China is reported. In this study, an intervention trial was conducted to promote urgent therapy for acute ischemic stroke. Two communities in Changsha were selected as either intervention or control community from November 2007 to December 2011. Public and professional education was regularly implemented in the intervention community. Publics' knowledge about early identification and urgent therapy of ischemic stroke was surveyed before and after intervention in the two communities. During the intervention period, first-ever ischemic stroke cases occurring in the intervention community (intervention group) and that in the control community (control group) were collected and followed for 90 days. After intervention, the publics' knowledge levels in the intervention community improved significantly. Intervention group' average presentation time was shorter than control group (8.3 ± 5.8 vs. 10.5 ± 6.5 h, P = 0.018). Percentage of presentation time within 3 h (48.0 %), the rate of ambulance use (59.0 %), and thrombolytic therapy (9.3 %) in the intervention group was all obviously higher than that in the control group (21.5, 41.3, and 4.5, respectively). When admitted, the intervention group had lower mean systolic blood pressure (160.8 ± 26.7 vs. 164.7 ± 26.8 mmHg, P = 0.000) than control group. Survivors in the intervention group were more likely to be in higher Barthel index scoring groups than that in the control group at day 90 [(75, 50-100) vs. (65, 35-90), P = 0.035]. Public and professional education may promote prompt presentation and urgent therapy for ischemic stroke, which may be helpful for patients' prognosis.

Long-chain monounsaturated Fatty acids and incidence of congestive heart failure in 2 prospective cohorts

BACKGROUND

Decades-old animal experiments suggested that dietary long-chain monounsaturated fatty acids (LCMUFAs) caused cardiotoxicity, leading, for example, development of Canola oil (Canadian oil low in erucic acid) from rapeseed. However, potential cardiotoxicity in humans and contemporary dietary sources of LCMUFAs are unknown.

METHODS AND RESULTS

We prospectively investigated the associations of plasma phospholipid LCMUFAs (20:1, 22:1, and 24:1), assessed as objective biomarkers of exposure, with incidence congestive heart failure in 2 independent cohorts: 3694 older adults (mean age, 75.2±5.2 years) in the Cardiovascular Health Study (CHS; 1992-2006) and 3577 middle-aged adults (mean age, 54.1±5.8 years) in the Atherosclerosis Risk in Communities Study, Minnesota subcohort (ARIC; 1987-2008). We further examined dietary correlates of circulating LCMUFAs in CHS and ARIC and US dietary sources of LCMUFAs in the 2003-2010 National Health and Nutrition Examination Survey (NHANES). In CHS, 997 congestive heart failure events occurred during 39 238 person-years; in ARIC, 330 events congestive heart failure events occurred during 64 438 person-years. After multivariable adjustment, higher levels of 22:1 and 24:1 were positively associated with greater incident congestive heart failure in both CHS and ARIC; hazard ratios were 1.34 (95% confidence interval, 1.02-1.76) and 1.57 (95% confidence interval, 1.11-2.23) for highest versus lowest quintiles of 22:1, respectively, and 1.75 (95% confidence interval, 1.23-2.50) and 1.92 (95% confidence interval, 1.22-3.03) for 24:1, respectively (P for trend ≤0.03 each). A variety of foods were related to circulating LCMUFAs in CHS and ARIC, consistent with food sources of LCMUFAs in NHANES, including fish, poultry, meats, whole grains, and mustard.

CONCLUSIONS

Higher circulating levels of 22:1 and 24:1, with apparently diverse dietary sources, were associated with incident congestive heart failure in 2 independent cohorts, suggesting possible cardiotoxicity of LCMUFAs in humans.

Troponin T, N-terminal pro-B-type natriuretic peptide, and incidence of stroke: the atherosclerosis risk in communities study

BACKGROUND AND PURPOSE

Increased levels of plasma troponins and natriuretic peptides are associated with increased risk of cardiovascular disease, but only limited information exists on these biomarkers and stroke occurrence. In a prospective epidemiological study, we tested the hypothesis that high-sensitivity troponin T (TnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated positively with incidence of stroke.

METHODS

The Atherosclerosis Risk in Communities (ARIC) Study measured plasma TnT and NT-proBNP in 10 902 men or women initially free of stroke and followed them for a mean of 11.3 years for stroke occurrence (n=507).

RESULTS

Both biomarkers were associated positively with total stroke, nonlacunar ischemic, and especially cardioembolic stroke, but not with lacunar or hemorrhagic stroke. For example, after adjustment for prevalent risk factors and cardiac diseases, the hazard ratios (95% CIs) for jointly high values of TnT and NT-proBNP (versus neither biomarker high) were 2.70 (1.92-3.79) for total stroke and 6.26 (3.40-11.5) for cardioembolic stroke. Associations with stroke appeared somewhat stronger for NT-proBNP than TnT. Strikingly, ≈ 58% of cardioembolic strokes occurred in the highest quintile of prestroke NT-proBNP, and 32% of cardioembolic strokes occurred in participants who had both NT-proBNP in the highest quintile and were known by ARIC to have atrial fibrillation sometime before their cardioembolic stroke occurrence.

CONCLUSIONS

In the general population, elevated plasma TnT and NT-proBNP concentrations are associated with increased risk of cardioembolic and other nonlacunar ischemic strokes.

Troponin T, B-type natriuretic peptide, C-reactive protein, and cause-specific mortality

PURPOSE

We sought to evaluate the associations of high-sensitivity troponin T (Hs-TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP), and high sensitivity C-reactive protein (Hs-CRP) with mortality from any cause, cardiovascular disease (CVD), coronary heart disease (CHD), stroke, cancer, and respiratory disease in the Atherosclerosis Risk in Communities cohort.

METHODS

We included 11,193 participants aged 54 to 74 years, initially free of the conditions being studied, and who had biomarkers measured. Participants were followed for a mean of 9.9 years.

RESULTS

Hazard ratios (HR), adjusted for multiple risk factors, for mortality in participants in the highest Hs-TnT category compared with those with undetectable levels were: Total 3.42 (95% confidence interval [CI], 2.75-4.26); CVD, 7.34 (95% CI, 4.64-11.6); CHD, 6.06 (95% CI, 2.91-12.6); stroke, 3.31 (95% CI, 1.26-8.66); cancer, 1.60 (95% CI, 1.08-2.38); and respiratory, 3.85 (95% CI, 1.39-10.7). Comparing the highest NT-proBNP quintile with those in the lowest quintile, the adjusted HRs for mortality were: Total, 3.05 (95% CI, 2.46-3.77); CVD, 7.48 (95% CI, 4.67-12.0); CHD, 4.07 (95% CI, 2.07-7.98); and stroke, 10.4 (95% CI, 2.26-47.7). Comparing extreme Hs-CRP quintiles, the adjusted HRs for mortality were: Total, 1.61 (95% CI, 1.32-1.97); CVD, 1.76 (95% CI, 1.19-2.62); and respiratory, 3.36 (95% CI, 1.34-8.45). Having multiple markers elevated simultaneously greatly increased cause-specific mortality risks.

CONCLUSIONS

Greater levels of Hs-TnT, NT-proBNP and Hs-CRP are associated with increased risk of death, not just from CVD, but also from some noncardiovascular causes.

Amphetamines, atomoxetine and the risk of serious cardiovascular events in adults

Main Objective

To compare the incidence rates of serious cardiovascular events in adult initiators of amphetamines or atomoxetine to rates in non-users.

Methods

This was a retrospective cohort study of new amphetamines (n = 38,586) or atomoxetine (n = 20,995) users. Each medication user was matched to up to four non-users on age, gender, data source, and state (n = 238,183). The following events were primary outcomes of interest 1) sudden death or ventricular arrhythmia, 2) stroke, 3) myocardial infarction, 4) a composite endpoint of stroke or myocardial infarction. Cox proportional hazard regression was used to calculate propensity-adjusted hazard ratios for amphetamines versus matched non-users and atomoxetine versus matched non-users, with intracluster dependence within matched sets accounted for using a robust sandwich estimator.

Results

The propensity-score adjusted hazard ratio for amphetamines use versus non-use was 1.18 (95% CI: 0.55–2.54) for sudden death/ventricular arrhythmia, 0.80 (95% CI: 0.44–1.47) for stroke, 0.75 (95% CI: 0.42–1.35) for myocardial infarction, and 0.78 (95% CI: 0.51–1.19) for stroke/myocardial infarction. The propensity-score adjusted hazard ratio for atomoxetine use versus non-use was 0.41 (95% CI: 0.10–1.75) for sudden death/ventricular arrhythmia, 1.30 (95% CI: 0.52–3.29) for stroke, 0.56 (95% CI: 0.16–2.00) for myocardial infarction, and 0.92 (95% CI: 0.44–1.92) for stroke/myocardial infarction.

Conclusions

Initiation of amphetamines or atomoxetine was not associated with an elevated risk of serious cardiovascular events. However, some of the confidence intervals do not exclude modest elevated risks, e.g. for sudden death/ventricular arrhythmia.

National Surgical Adjuvant Breast and Bowel Project Study of Tamoxifen and Raloxifene trial: advancing the science of recruitment and breast cancer risk assessment in minority communities

BACKGROUND

One of the first chemoprevention trials conducted in the western hemisphere, the National Surgical Adjuvant Breast and Bowel Project's (NSABP) Breast Cancer Prevention Trial (BCPT), demonstrated the need to evaluate all aspects of recruitment in real time and to implement strategies to enroll racial and ethnic minority women.

PURPOSE

The purpose of this report is to review various patient recruitment efforts the NSABP developed to enhance the participation of racial and ethnic minority women in the Study of Tamoxifen and Raloxifene (STAR) trial and to describe the role that the recruitment process played in the implementation and understanding of breast cancer risk assessment in minority communities.

METHODS

The NSABP STAR trial was a randomized, double-blinded study comparing the use of tamoxifen 20 mg/day to raloxifene 60 mg/day, for a 5-year period, to reduce the risk of developing invasive breast cancer. Eligible postmenopausal women were required to have a 5-year predicted breast cancer risk of 1.66% based on the modified Gail Model. For the current report, eligibility and enrollment data were tabulated by race/ethnicity for women who submitted STAR risk assessment forms (RAFs).

RESULTS

A total of 184,460 RAFs were received, 145,550 (78.9%) from white women and 38,910 (21.1%) from minority women. Of the latter group, 21,444 (11.6%) were from African Americans/blacks, 7913 (4.5%) from Hispanics/Latinas, and 9553 (5.2%) from other racial or ethnic groups. The percentages of risk-eligible women among African Americans, Hispanics/Latinas, others, and whites were 14.2%, 23.3%, 13.7%, and 57.4%, respectively. Programs targeting minority enrollment submitted large numbers of RAFs, but the eligibility rates of the women referred from those groups tended to be lower than the rates among women referred outside of those programs. The average number of completed risk assessments increased among minority women over the course of the recruitment period compared to those from whites.

LIMITATIONS

We have not addressed all identified barriers to the recruitment of minorities in clinical research. Our risk assessments and recruitment results do not reflect the modified Gail Model for African Americans.

CONCLUSIONS

Recruitment strategies used in STAR for racial and ethnic minorities contributed to doubling the minority enrollment compared to that in the BCPT and increased the awareness of breast cancer risk assessment in minority communities. Incorporation of new information into models to improve the risk estimation of diverse populations should prove beneficial.

Racial differences in the impact of elevated systolic blood pressure on stroke risk

BACKGROUND

Between the ages 45 and 65 years, incident stroke is 2 to 3 times more common in blacks than in whites, a difference not explained by traditional stroke risk factors.

METHODS

Stroke risk was assessed in 27 748 black and white participants recruited between 2003 and 2007, who were followed up through 2011, in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Racial differences in the impact of systolic blood pressure (SBP) was assessed using proportional hazards models. Racial differences in stroke risk were assessed in strata defined by age (<65 years, 65-74 years, and ≥75 years) and SBP (<120 mm Hg, 120-139 mm Hg, and 140-159 mm Hg).

RESULTS

Over 4.5 years of follow-up, 715 incident strokes occurred. A 10-mm Hg difference in SBP was associated with an 8% (95% CI, 0%-16%) increase in stroke risk for whites, but a 24% (95% CI, 14%-35%) increase for blacks (P value for interaction, .02). For participants aged 45 to 64 years (where disparities are greatest), the black to white hazard ratio was 0.87 (95% CI, 0.48-1.57) for normotensive participants, 1.38 (95% CI, 0.94-2.02) for those with prehypertension, and 2.38 (95% CI, 1.19-4.72) for those with stage 1 hypertension.

CONCLUSIONS

These findings suggest racial differences in the impact of elevated blood pressure on stroke risk. When these racial differences are coupled with the previously documented higher prevalence of hypertension and poorer control of hypertension in blacks, they may account for much of the racial disparity in stroke risk.

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.

Factors and outcomes associated with early and delayed aneurysm treatment in subarachnoid hemorrhage patients in the United States

BACKGROUND

Recent studies from selected centers have shown that early surgical treatment of aneurysms in subarachnoid hemorrhage (SAH) patients can improve outcomes. These results have not been validated in clinical practice at large.

OBJECTIVE

To identify factors and outcomes associated with timing of ruptured intracranial aneurysm obliteration treatment in patients with SAH after hospitalization in the United States.

METHODS

We analyzed the data from the Nationwide Inpatient Sample (2005-2008) for all patients presenting with primary diagnosis of SAH, receiving aneurysm treatment (endovascular coil embolization or surgical clip placement). Early treatment was defined as aneurysm treatment performed within 48 hours and delayed treatment if treatment was performed after 48 hours of admission.

RESULTS

Of 32 048 patients with SAH who underwent aneurysm treatment, 24 085 (75.2%) underwent early treatment and 7963 (24.8%) underwent delayed treatment. Female sex (P = .002), endovascular embolization (P < .001), and weekday admission (P < .001) were independent predictors of early treatment. In the early treatment group, patients were more likely discharged with none to minimal disability (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.14-1.47) and less likely to be discharged with moderate to severe disability (OR 0.77, 95%CI 0.67-0.87) compared with those in the delayed treatment group. The in-hospital mortality was higher in the early treatment group compared with the delayed treatment group (OR 1.36 95%CI 1.12-1.66).

CONCLUSION

Patients with SAH who undergo aneurysm treatment within 48 hours of hospital admission are more likely to be discharged with none to minimal disability. Early treatment is more likely to occur in those undergoing endovascular treatment and in patients admitted on weekdays.

Racial differences in the effect of a telephone-delivered hypertension disease management program

BACKGROUND

African Americans are significantly more likely than whites to have uncontrolled hypertension, contributing to significant disparities in cardiovascular disease and events.

OBJECTIVE

The goal of this study was to examine whether there were differences in change in blood pressure (BP) for African American and non-Hispanic white patients in response to a medication management and tailored nurse-delivered telephone behavioral program.

PARTICIPANTS

Five hundred and seventy-three patients (284 African American and 289 non-Hispanic white) primary care patients who participated in the Hypertension Intervention Nurse Telemedicine Study (HINTS) clinical trial.

INTERVENTIONS

Study arms included: 1) nurse-administered, physician-directed medication management intervention, utilizing a validated clinical decision support system; 2) nurse-administered, behavioral management intervention; 3) combined behavioral management and medication management intervention; and 4) usual care. All interventions were activated based on poorly controlled home BP values.

MAIN MEASURES

Post-hoc analysis of change in systolic and diastolic blood pressure. General linear models (PROC MIXED in SAS, version 9.2) were used to estimate predicted means at 6-month, 12-month, and 18-month time points, by intervention arm and race subgroups (separate models for systolic and diastolic blood pressure).

KEY RESULTS

Improvement in mean systolic blood pressure post-baseline was greater for African American patients in the combined intervention, compared to African American patients in usual care, at 12 months (6.6 mmHg; 95 % CI: -12.5, -0.7; p=0.03) and at 18 months (9.7 mmHg; -16.0, -3.4; p=0.003). At 18 months, mean diastolic BP was 4.8 mmHg lower (95 % CI: -8.5, -1.0; p=0.01) among African American patients in the combined intervention arm, compared to African American patients in usual care. There were no analogous differences for non-Hispanic white patients.

CONCLUSIONS

The combination of home BP monitoring, remote medication management, and telephone tailored behavioral self-management appears to be particularly effective for improving BP among African Americans. The effect was not seen among non-Hispanic white patients.

Quantitative assessment of the association between MTHFR C677T polymorphism and hemorrhagic stroke risk

Many studies have investigated the association between methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism and hemorrhagic stroke, but the impact of MTHFR C677T on hemorrhagic stroke is unclear owing to the obvious inconsistence among those studies. This study aimed to quantify the strength of the association between MTHFR C677T polymorphism and hemorrhagic stroke risk. We searched Pubmed, Emabse and Wangfang databases for studies investigating the association between MTHFR C677T polymorphism and hemorrhagic stroke risk. We estimated the pooled odds ratio (OR) with its 95 % confidence intervals (95 % CI) to assess this possible association. Meta-analysis of included studies suggested that TT genotype was obviously associated with increased risk of hemorrhagic stroke (OR (TT versus CC) = 1.84, 95 % CI 1.45-2.34; OR (TT versus CT) = 1.53, 95 % CI 1.23-1.90; OR (TT versus CT/CC) = 1.64, 95 % CI 1.24-2.00) compared with CC or CT genotypes of MTHFR C677T polymorphism. Subgroup analyses by ethnicity further identified the association above in both Asians and Caucasians. No evidence of publication bias was observed. Thus, meta-analyses of available data suggest an obvious association between MTHFR C677T polymorphism and hemorrhagic stroke risk, and TT genotype contributes to increased risk of hemorrhagic stroke.

Premature cardiac contractions and risk of incident ischemic stroke

BACKGROUND

The etiologies of ischemic stroke remain undetermined in 15% to 40% of patients. Apart from atrial fibrillation, other arrhythmias are less well-characterized as risk factors. Premature cardiac contractions are known to confer long-term cardiovascular risks, like myocardial infarction. Ischemic stroke as cardiovascular risk outcome remains a topic of interest. We examined the prospective relationships in the Atherosclerosis Risk in Communities (ARIC) study, to determine whether premature atrial (PAC) or ventricular (PVC) contractions are associated with increased risk for incident ischemic stroke.

METHODS AND RESULTS

We analyzed 14 493 baseline stroke-free middle-aged individuals in the ARIC public-use data. The presence of PAC or PVC at baseline was assessed from 2-minute electrocardiogram. A physician-panel confirmed and classified all stroke cases. Average follow-up time was 13 years. Proportional hazards models assessed associations between premature contractions and incident stroke. PACs and PVCs were identified in 717 (4.9%) and 793 (5.5%) participants, respectively. In all, 509(3.5%) participants developed ischemic stroke. The hazard ratio (HR) (95% confidence interval [CI]) associated with PVC was 1.77 (1.30, 2.41), attenuated to 1.25 (0.91, 1.71) after adjusting for baseline stroke risk factors. The interaction between PVC and baseline hypertension was marginally significant (P=0.08). Among normotensives, having PVCs was associated with nearly 2-fold increase in the rate of incident ischemic stroke (HR 1.69; 95% CI 1.02, 2.78), adjusting for stroke risk factors. The adjusted risk of ischemic stroke associated with PACs was 1.30 (95% CI 0.92, 1.83).

CONCLUSIONS

Presence of PVCs may indicate an increased risk of ischemic stroke, especially in normotensives. This risk approximates risk of stroke from being black, male, or obese in normotensives from this cohort.

Association between physical activity and risk of stroke subtypes: the atherosclerosis risk in communities study

BACKGROUND

The relationship between stroke subtypes and physical activity is unclear.

METHODS

Using data from 13,069 men and women aged 45-64 years who participated in the Atherosclerosis Risk in Communities Study, physical activity was assessed by self-report using the Baecke questionnaire at baseline (1987-1989). The American Heart Association's ideal cardiovascular health guidelines served as a basis for the calculation of three physical activity categories: poor, intermediate, and ideal. Stroke and its subtypes were ascertained from physician review of medical records. Multivariable adjusted hazard ratios (HR) and 95% confidence intervals (CI) were calculated using Cox regression models.

RESULTS

During a median follow-up of 18.8 years, a total of 648 incident ischemic strokes occurred. Significant inverse associations were found between physical activity categories and total, total ischemic, and nonlacunar stroke in adjusted models (age, sex, race-center, education, cigarette-years). Compared with poor physical activity, the adjusted HR (95% CI) for ideal physical activity were 0.78 (0.62-0.97) for total, 0.76 (0.59-0.96) for total ischemic, 0.85 (0.51-1.40) for lacunar, 0.77 (0.47-1.27) for cardioembolic, and 0.71 (0.51-0.99) for nonlacunar stroke. Additional adjustments for waist-to-hip ratio, systolic blood pressure, antihypertensive medication, diabetes, left ventricular hypertrophy and laboratory parameters attenuated the HR. Further sex- and race-specific analyses revealed that the association was predominantly observed among males and among African-Americans.

CONCLUSION

These data suggest a tendency toward a reduced risk of total, total ischemic, and nonlacunar stroke with higher levels of physical activity.

Mid- to long-term factors influencing functional status of people affected by lower-limb amputation associated with hemiparesis due to stroke

PURPOSE

In people with lower-limb amputation and hemiparesis, prognostic factors of rehabilitation outcomes were investigated at hospital discharge. This study aims to identify which factors influence functional outcomes at mid- to long-term follow-up.

METHODS

Follow-up observational study on forty-four people (68 ± 9 years old) with unilateral amputation for vascular disease, temporally preceding or following hemiparesis due to stroke (26 patients prior amputation; 18 patients prior stroke), was performed. Barthel Index (BI) and Locomotor Capabilities Index (LCI) scores were recorded at discharge from the rehabilitation hospital and 3.4 years later. Use of the prosthesis was also recorded.

RESULTS

At the follow-up, BI and LCI scores had significantly decreased (10 and 13%, respectively). Contralaterality of the impairment was the main prognostic factor for reduced functional status (p = 0.025) and prosthesis abandonment (p = 0.028, OR = 4.4), especially for women (OR = 8). Severity of hemiparesis affected the BI score (p < 0.01) and level of amputation the LCI score (p < 0.01).

CONCLUSIONS

At the light of the observed decrement of functional status after discharge, particular attention should be paid to the patients more exposed to the risk of worsening and/or prosthesis abandon, such as women with contralateral impairment. The results of this study may assist rehabilitation teams in performing a more specific and effective long-term rehabilitative interventions.

Incidence of ischaemic and haemorrhagic stroke and the association with smoking and smoking cessation: a 10-year multicentre prospective study in China

OBJECTIVES

To examine the effects of cigarette smoking and smoking cessation on the incidence of ischaemic and haemorrhagic stroke in a multicentre prospective cohort study among Chinese.

STUDY DESIGN

A multicentre population-based prospective cohort study.

METHODS

The incidence of, and deaths from, stroke were monitored among 26,607 participants (12,560 men and 14,047 women) who were enrolled in 1986 and free from stroke until 2000. Cox's proportional hazard model was performed to obtain the hazard ratio (HR) of cigarette smoking for stroke risk after adjustment for major confounders.

RESULTS

After an average of 9.5 years of follow-up, 1108 subjects developed stroke. The excess risk of all types of stroke (total stroke) among male current smokers [HR 1.39, 95% confidence interval (CI) 1.15-1.67] was mainly due to a significantly elevated risk of ischaemic stroke (HR 1.49, 95% CI 1.17-1.90). A significantly increased risk for total stroke and ischaemic stroke was observed among men who smoked >15 cigarettes/day and men who had smoked for >25 years. The rate of smoking cessation was very low among Chinese men (7.2%) and women (1.5%). Smoking cessation did not appear to reduce the risk of haemorrhagic stroke, but may reduce the risk of ischaemic stroke; however, the possibility that this result was due to chance cannot be excluded (HR 0.74, 95% CI 0.26-2.08).

CONCLUSION

This study confirmed that cigarette smoking is a major determinant for the incidence of ischaemic and haemorrhagic stroke in Chinese men, and emphasizes the need for improved strategies to help people quit smoking.

Major depressive disorder and stroke risks: a 9-year follow-up population-based, matched cohort study

BACKGROUND AND PURPOSE

Major depressive disorder (MDD) is characterized by recurrent depressive episodes and one of the treatment choices is antidepressants. Patients with MDD are at greater risk of developing major metabolic diseases that may in turn lead to stroke. Moreover, both depressive symptoms and taking antidepressant medications are associated with higher risk of stroke. However, whether and how clinical depression increases stroke risk remains an unanswered question. Our aim was to provide answers to this question.

METHODS

A matched cohort study of 5015 subjects (1003 MDD patients and 4012 control subjects) was conducted using a nationwide database. Subjects were followed to a maximum of 9 years to determine rates of newly-developed strokes, and controls and MDD groups with different levels of antidepressant refractoriness were compared to determine the temporal relation between stroke and three major metabolic comorbidities (i.e., diabetes mellitus, hypertension and hyperlipidemia). The levels of depressive symptoms and the antidepressant medications before stroke onset were investigated.

RESULTS

Patients with MDD had significantly higher rates of stroke (4.3% vs. 2.8%, p<0.05) during the follow-up. Mediation regression analyses revealed that the occurrence of stroke in the MDD subjects was significantly mediated by the development of major metabolic diseases. Greater severity of depression, but not greater use of antidepressants, preceded the occurrence of stroke.

CONCLUSIONS

A clinical diagnosis of major depression leads to stroke indirectly through more intense depressive symptoms and the development of major comorbidities.

Comparison of CT and MR imaging in ischemic stroke

BACKGROUND

Cerebrovascular disease represents a major source of global mortality and morbidity. Imaging examinations play a critical role in the management of stroke patients, from establishing the initial diagnosis to determining and guiding further treatment.

METHODS

In this article, current CT and MRI methods employed in the management of stroke patients are reviewed, with an emphasis on ischemic stroke.

RESULTS

The advantages and disadvantages of these techniques are discussed, a number of cases emphasizing key points are presented, and a comparison between modern CT and MRI techniques is outlined.

CONCLUSION

The major drawback of CT is the high radiation dose, while in MRI it is the more complicated and time-consuming aspect of the examination.

MAIN MESSAGES

• Cerebrovascular disease represents a major source of global mortality and morbidity • Imaging examinations play a critical role in the management of stroke patients • The penumbra may be seen with both CT and MRI; however, this concept may be overly simplistic • The major drawback of CT is the high radiation dose, while MRI is a more complicated examination.

Alcohol is a risk factor not for thalamic but for putaminal hemorrhage: the Akita Stroke Registry

BACKGROUND

Although the risk factors of cerebral hemorrhage were established long ago, there is little agreement as to the risk factors for the site of cerebral hemorrhage.

METHODS

We obtained mass health screening data collected between 1990 and 2000 regarding 151,796 subjects from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare. A first-ever cerebral hemorrhage occurring <3 years after the screening examination was defined as an event. Stroke events were determined from the Akita stroke registry between 1990 and 2003. Clinical risk factors for stroke, such as age, blood pressure, severe obesity (body mass index >30 kg/m(2)), low serum total cholesterol, hepatic disorder, renal disorder, and drinking habits were then assessed.

RESULTS

Cerebral hemorrhage developed in 344 cases in the study population. The distribution of subtypes (putaminal hemorrhage [PH], thalamic hemorrhage [TH], and subcortical hemorrhage [SH]) were 122 cases (35.5%), 110 cases (32.0%), and 44 cases (12.8%), respectively. We evaluated the risk factors by multiple logistic regression analysis among these 3 groups. Age was a significant risk factor among these 3 groups, but blood pressure was not a risk factor in SH. Low serum cholesterol and drinking habits were significant risk factors only in PH. Hepatic disorder was a strong risk factor in PH and a weak risk factor in TH. Interestingly, a drinking habit was a significant risk factor only in PH.

CONCLUSIONS

Drinking habits had been a risk factor for cerebral hemorrhage, but it was a risk factor not for PH and not for TH or SH.

The rs11833579 and rs12425791 polymorphisms and risk of ischemic stroke in an Asian population: a meta-analysis

BACKGROUND

In 2009, a GWAS has confirmed that rs11833579 and rs12425791 near the NINJ2 gene could increase the stroke and ischemic stroke (IS) risk. Recently, several studies have been implemented to assess the relationship between the two SNPs and ischemic stroke risk in Asian. However, the results were poorly consistent. To study the association between the both polymorphisms and the risk of ischemic stroke, we performed a meta-analysis.

METHODS

We used odds ratios (ORs) with 95% confidence intervals (CIs) to evaluate the strength of association. The heterogeneity was checked by Q test and the inconsistency index (I(2)). Begg's test and Egger's test were used to assess the possible publication bias.

RESULTS

Our study included 6 articles, contained 9 independent case-control studies, involved a total of 9,142 cases and 10,652 controls about rs11833579, 10,165 cases and 11,592 controls about rs12425791. There was a significant association between rs12425791 and IS risk with dominant genetic model (OR=1.087, 95%CI=1.021-1.158, I(2)=34.6%, P=0.152), but not with recessive genetic model and allele A vs. allele G. For rs11833579, we failed to verify it relate with IS risk under allele A vs. allele G, dominant and recessive genetic model.

CONCLUSIONS

This meta-analysis suggest that rs12425791 is relative to ischemic stroke risk under dominant model in Asian population, but not for rs11833579.

The Influence of Stroke Risk Factors and Comorbidities on Assessment of Stroke Therapies in Humans and Animals

The main driving force behind the assessment of novel pharmacological agents in animal models of stroke is to deliver new drugs to treat the human disease rather than to increase knowledge of stroke pathophysiology. There are numerous animal models of the ischaemic process and it appears that the same processes operate in humans. Yet, despite these similarities, the drugs that appear effective in animal models have not worked in clinical trials. To date, tissue plasminogen activator is the only drug that has been successfully used at the bedside in hyperacute stroke management. Several reasons have been put forth to explain this, but the failure to consider comorbidities and risk factors common in older people is an important one. In this article, we review the impact of the risk factors most studied in animal models of acute stroke and highlight the parallels with human stroke, and, where possible, their influence on evaluation of therapeutic strategies.

Risk of intraparenchymal hemorrhage with magnetic resonance imaging-defined leukoaraiosis and brain infarcts

OBJECTIVE

To determine whether the burden of leukoaraiosis and the number of brain infarcts, defined by magnetic resonance imaging (MRI), are prospectively and independently associated with intraparenchymal hemorrhage (IPH) incidence in a pooled population-based study.

METHODS

Among 4,872 participants initially free of clinical stroke in the Atherosclerosis Risk in Communities Study and the Cardiovascular Health Study, we assessed white matter grade (range, 0-9), reflecting increasing leukoaraiosis, and brain infarcts using MRI. Over a median of 13 years of follow-up, 71 incident, spontaneous IPH events occurred.

RESULTS

After adjustment for other IPH risk factors, the hazard ratios (95% confidence intervals) across white matter grades 0 to 1, 2, 3, and 4 to 9 were 1.00, 1.68 (0.86-3.30), 3.52 (1.80-6.89), and 3.96 (1.90-8.27), respectively (p for trend <0.0001). These hazard ratios were weakened only modestly (p for trend = 0.0003) with adjustment for MRI-defined brain infarcts. The IPH hazard ratios for 0, 1, 2, or ≥3 MRI-defined brain infarcts were 1.00, 1.97 (1.10-3.54), 2.00 (0.83-4.78), and 3.12 (1.31-7.43) (p for trend = 0.002), but these were substantially attenuated when adjusted for white matter grade (p for trend = 0.049).

INTERPRETATION

Greater MRI-defined burden of leukoaraiosis is a risk factor for spontaneous IPH. Spontaneous IPH should be added to the growing list of potential poor outcomes in people with leukoaraiosis.

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.

Associations between incident ischemic stroke events and stroke and cardiovascular disease-related genome-wide association studies single nucleotide polymorphisms in the Population Architecture Using Genomics and Epidemiology study

BACKGROUND

Genome-wide association studies (GWAS) have identified loci associated with ischemic stroke (IS) and cardiovascular disease (CVD) in European-descent individuals, but their replication in different populations has been largely unexplored.

METHODS AND RESULTS

Nine single nucleotide polymorphisms (SNPs) selected from GWAS and meta-analyses of stroke, and 86 SNPs previously associated with myocardial infarction and CVD risk factors, including blood lipids (high density lipoprotein [HDL], low density lipoprotein [LDL], and triglycerides), type 2 diabetes, and body mass index (BMI), were investigated for associations with incident IS in European Americans (EA) N=26 276, African-Americans (AA) N=8970, and American Indians (AI) N=3570 from the Population Architecture using Genomics and Epidemiology Study. Ancestry-specific fixed effects meta-analysis with inverse variance weighting was used to combine study-specific log hazard ratios from Cox proportional hazards models. Two of 9 stroke SNPs (rs783396 and rs1804689) were significantly associated with [corrected] IS hazard in AA; none were significant in this large EA cohort. Of 73 CVD risk factor SNPs tested in EA, 2 (HDL and triglycerides SNPs) were associated with IS. In AA, SNPs associated with LDL, HDL, and BMI were significantly associated with IS (3 of 86 SNPs tested). Out of 58 SNPs tested in AI, 1 LDL SNP was significantly associated with IS.

CONCLUSIONS

Our analyses showing lack of replication in spite of reasonable power for many stroke SNPs and differing results by ancestry highlight the need to follow up on GWAS findings and conduct genetic association studies in diverse populations. We found modest IS associations with BMI and lipids SNPs, though these findings require confirmation.

The current role of carotid duplex ultrasonography in the management of carotid atherosclerosis: foundations and advances

The management of atherosclerotic carotid occlusive disease for stroke prevention has entered a time of dramatic change. Improvements in medical management have begun to challenge traditional interventional approaches to asymptomatic carotid stenosis. Simultaneously, carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy (CE). Finally, multiple factors beyond degree of stenosis and symptom status now mitigate clinical decision making. These factors include brain perfusion, plaque morphology, and patency of intracranial collaterals (circle of Willis). With all of these changes, it seems prudent to review the role of carotid duplex ultrasonography in the management of atherosclerotic carotid occlusive disease for stroke prevention. Carotid duplex ultrasonography (CDU) for initial and serial imaging of the carotid bifurcation remains an essential component in the management of carotid bifurcation disease. However, correlative axial imaging modalities (computer tomographic angiography (CTA) and contrast-enhanced magnetic resonance angiography (CE-MRA)) increasingly aid in the assessment of individual stroke risk and are important in treatment decisions. The purpose of this paper is twofold: (1) to discuss foundations and advances in CDU and (2) to evaluate the current role of CDU, in light of other imaging modalities, in the clinical management of carotid atherosclerosis.

Covert neurological symptoms associated with silent infarcts from midlife to older age: the Atherosclerosis Risk in Communities study

BACKGROUND AND PURPOSE

Unrecognized or unreported stroke-like symptoms, called covert symptoms, occur in persons free of clinical stroke. Whether covert symptoms are associated with subclinical brain infarcts (SBIs) is unknown. This study examined the association between covert stroke-like symptoms and SBI/stroke in persons with no history of stroke or transient ischemic attack.

METHODS

A total of 1881 Atherosclerosis Risk in Communities (ARIC) participants free of clinical stroke or transient ischemic attack (40% male, 50% black, 47-70 years) were queried for covert symptoms and underwent cerebral MRI during the baseline MRI visit. Symptoms were reassessed after 3 years at Visit 4 (n=1001; 39% male, 50% black) and approximately 10 years with a follow-up MRI (n=1006; 40% male, 50% black, 61-83 years).

RESULTS

Covert symptoms were associated with prevalent SBI (OR, 1.94; 95% CI, 1.21-3.11; P=0.006). No support was found for associations between baseline MRI symptoms and SBI at the follow up MRI visit. In participants without SBI at baseline, symptoms at Visit 4 (OR, 2.96; 1.23-7.13; P=0.016) and symptoms at the follow-up MRI visit (OR, 4.29; 2.51-7.33; P<0.001) were associated with a combined outcome of new SBI/clinical stroke on follow-up MRI. Covert symptoms at follow-up MRI visit were also associated with having new SBI (OR, 2.26; 1.18-4.32; P=0.014) on the follow-up MRI that were not seen on the baseline MRI.

CONCLUSIONS

Covert neurological symptoms were associated with prevalent SBI, and when ascertained at the time of follow-up MRI, with new SBI. Covert symptoms may reflect heightened risk for infarcts.