Is there a sex or race difference in stroke mortality?

Depression may not be a risk factor for mortality in stroke patients with nonsurgical treatment: A retrospective case-controlled study

Patients with depression have more comorbidities than those without depression. The cost of depression-associated comorbidities accounts for the largest portion of the growing cost of depression treatment. Patients with depression have a higher risk of stroke with poor prognoses than those without depression; however, previous studies evaluating the relationship between depression and stroke prognosis have not accounted for surgical treatment or other risk factors. Therefore, we investigated whether depression is a risk factor for mortality in stroke patients with nonsurgical treatment after adjusting for other risk factors.We retrospectively analyzed the data of patients with major depressive disorder (MDD) and age and sex-matched controls without MDD during 1999 to 2005. We then identified patients who developed stroke in both groups and analyzed risk factors for death in these stroke patients who received nonsurgical treatments during a follow-up period from 2006 to 2012.Patients with MDD had higher Charlson Comorbidity Index Scores (CCISs) and exhibited higher frequencies of comorbidities such as diabetes mellitus, hypertension, hyperlipidemia, and coronary heart disease than controls without MDD, and most of MDD patients had very low or high socioeconomic status (SES) and lived in urban settings. Most stroke patients with MDD who received nonsurgical treatment were female, had very low or high SES, and lived in urban settings; in addition, stroke patients with MDD who received nonsurgical treatment had higher CCISs and frequencies of hyperlipidemia and coronary heart disease than those without MDD who received nonsurgical treatment. However, depression was not a risk factor for death in stroke patients with nonsurgical treatment.Hemorrhagic stroke, age, sex, and CCISs were risk factors for death in stroke patients with nonsurgical treatment, but depression did not affect the mortality rate in these patients.

Subarachnoid hemorrhage and the female sex: analysis of risk factors, aneurysm characteristics, and outcomes

OBJECT

The pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH) is unclear. Sex may play a role in the outcome of patients with aSAH.

METHODS

The authors retrospectively identified 617 patients with aSAH (April 2005 to February 2010) and analyzed sex differences in risk factors (age, hypertension, smoking, alcohol consumption, and family history), admission-related factors (World Federation of Neurosurgical Societies grade and admission delay), aneurysm characteristics (site, side, location, and multiplicity), and outcomes (treatment modalities [coiling/clipping/both/conservative], complications [vasospasm and hydrocephalus], length of stay, and modified Rankin Scale score at 3 months).

RESULTS

The female patients with aSAH were older than the male patients (mean age 56.6 vs 51.9 years, respectively, p < 0.001), and more women than men were ≥ 55 years old (56.2% vs 40.4%, respectively, p < 0.001). Women exhibited higher rates of bilateral (6.8% vs 2.6%, respectively, p < 0.05), multiple (11.5% vs 5.2%, respectively, p < 0.05), and internal carotid artery (ICA) (36.9% vs 17.5%, respectively, p < 0.001) aneurysms and a lower rate of anterior cerebral artery aneurysms (26.3% vs 44.8%, respectively, p < 0.001) than the men, but no side differences were noted. There were no sex differences in risk factors, admission-related factors, or outcome measures. For both sexes, outcomes varied according to aneurysm location, with odds ratios for a poor outcome of 1.62 (95% CI 0.91-2.86, p = 0.1) for middle cerebral artery, 2.41 (95% CI 1.29-4.51, p = 0.01) for ICA, and 2.41 (95% CI 1.29-4.51, p = 0.006) for posterior circulation aneurysms compared with those for anterior cerebral artery aneurysms. The odds ratio for poor outcome (modified Rankin Scale score of 4-6) in women compared with men after adjusting for significant prognostic factors was 0.71 (95% CI 0.45-1.11, p > 0.05).

CONCLUSIONS

The overall outcomes after aSAH between women and men are similar.

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.

Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study

OBJECTIVES

To determine the extent to which secondary drug prevention for patients with stroke in routine primary care varies by sex, age, and socioeconomic circumstances, and to quantify the effect of secondary drug prevention on one year mortality by sociodemographic group.

DESIGN

Cohort study using individual patient data from the health improvement network primary care database.

SETTING

England.

PARTICIPANTS

12 830 patients aged 50 or more years from 113 general practices who had a stroke between 1995 and 2005 and who survived the first 30 days after the stroke.

MAIN OUTCOME MEASURES

Multivariable associations between odds of receiving secondary prevention after a stroke, and sex, age group, and socioeconomic circumstances; hazard ratios for all cause mortality from 31 days after the stroke and within the first year among patients receiving treatment and by social group; and probabilities of one year mortality for social factors of interest and treatment.

RESULTS

Only 25.6% of men and 20.8% of women received secondary prevention. Receipt of secondary prevention did not vary by socioeconomic circumstances or by sex. Older patients were, however, substantially less likely to receive treatment. The adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.53 (95% confidence interval 0.41 to 0.69). This was because older people were less likely to receive lipid lowering drugs-for example, the adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.44 (95% confidence interval 0.33 to 0.59). Secondary prevention was associated with a 50% reduction in mortality risk (adjusted hazard ratio 0.50, 95% confidence interval 0.42 to 59). On average, mortality within the first year was 5.7% for patients receiving treatment compared with 11.1% for patients not receiving treatment. There was little evidence that the effect of treatment differed between the social groups examined.

CONCLUSION

Under-treatment among older people with stroke in routine primary care cannot be justified given the lack of evidence on variations in effectiveness of treatment by age.

Is there a sex or race difference in 30-day mortality after interruption of vena cava in a Medicare population?

PURPOSE

Disparities in health care and its outcome often indicate an opportunity for improving the quality of health care. Sex and rare differences in short-term mortality following interruption of vena cava are not known. The objective of this study was to determine such differences.

MATERIALS AND METHODS

With use of Medicare administrative data, 1,823 interruption of vena cava procedures performed between 1994 and 1997 were identified among beneficiaries aged 65-99 years residing in Indiana and Kentucky. In Cox proportional hazard regression models, male-to-female and nonwhite-to-white 30-day mortality ratios were adjusted for age, sex or race, weighted Charlson comorbidity score, length of hospital stay, and fatal coexisting conditions (ascertained from death certificate data).

RESULTS

Altogether, 277 patients died within 30 days after the procedure. Women were older than men. The comorbidity score was associated with male sex and mortality. There was no significant race difference in unadjusted or adjusted 30-day mortality after interruption of the vena cava. Unadjusted mortality was higher in men than in women (odds ratio, 1.49; 95% confidence interval [CI]=1.15, 1.92). Although adjustment for age, race, Charlson score, and length of hospital stay reduced the magnitude of sex difference, it remained significant. Further adjustment for fatal coexistent conditions reduced the sex difference to an insignificant level (odds ratio, 1.22; 95% CI=0.96, 1.56).

CONCLUSIONS

There was no significant sex or race difference in adjusted 30-day mortality after interruption of vena cava procedure in the elderly Medicare beneficiary population of two states.