An Examination of Stroke Risk and Burden in South Asians

Temporal Mortality Trends Attributable to Stroke in South Asia: An Age-Period-Cohort Analysis

South Asia contributes the most to stroke mortality worldwide. This study aimed to determine the long-term trends in stroke mortality across four South Asian countries and its associations with age, period, and birth cohort. In 2019, nearly one million stroke deaths occurred across South Asia, and the associated age-standardized mortality rate (ASMR) was 80.2 per 100,000. Between 1990 and 2019, India had the largest decrease in the ASMR (-35.8%) across the four South Asian countries. While Pakistan had the smallest decrease in the ASMR (-7.6%), an increase was detected among males aged 15 to 34 years and females aged 15 to 19 years. Despite a 22.8% decrease in the ASMR, Bangladesh had the highest ASMR across the four South Asian countries. Nepal reported a witness increase in the stroke ASMR after 2006. Improved period and cohort effects on stroke mortality were generally indicated across the analyzed countries, except for recent-period effects in males from Nepal and cohort effects from those born after the 1970s in Pakistan. Stroke mortality has decreased in the four South Asian countries over the past 30 years, but potentially unfavorable period and cohort effects have emerged in males in Nepal and both sexes in Pakistan. Governmental and societal efforts are needed to maintain decreasing trends in stroke mortality.

The Apo gene's genetic variants: hidden role in Asian vascular risk

Vascular risk factors, including diabetes, hypertension, hyperlipidemia, and obesity, pose significant health threats with implications extending to neuropsychiatric disorders such as stroke and Alzheimer's disease. The Asian population, in particular, appears to be disproportionately affected due to unique genetic predispositions, as well as epigenetic factors such as dietary patterns and lifestyle habits. Existing management strategies often fall short of addressing these specific needs, leading to greater challenges in prevention and treatment. This review highlights a significant gap in our understanding of the impact of genetic screening in the early detection and tailored treatment of vascular risk factors among the Asian population. Apolipoprotein, a key player in cholesterol metabolism, is primarily associated with dyslipidemia, yet emerging evidence suggests its involvement in conditions such as diabetes, hypertension, and obesity. While genetic variants of vascular risk are ethnic-dependent, current evidence indicates that epigenetics also exhibits ethnic specificity. Understanding the interplay between Apolipoprotein and genetics, particularly within diverse ethnic backgrounds, has the potential to refine risk stratification and enhance precision in management. For Caucasian carrying the APOA5 rs662799 C variant, pharmacological interventions are recommended, as dietary interventions may not be sufficient. In contrast, for Asian populations with the same genetic variant, dietary modifications are initially advised. Should dyslipidemia persist, the consideration of pharmaceutical agents such as statins is recommended.

The Distribution of Lifestyle Risk Factors Among Patients with Stroke in the Indian Setting: Systematic Review and Meta-Analysis

Background

The burden of stroke is increasing in India, but there is limited understanding of the distribution of reported risk factors in the Indian setting. It is vital to generate robust data on these modifiable risk factors to scale up appropriate strategies for the prevention of cerebrovascular diseases in this setting.

Summary

The objective of this study is to estimate the overall proportion of life style risk factors of patients with stroke in the Indian setting. We searched PubMed and Google Scholar and relevant studies published till February 2022 were included. The risk of bias assessment was considered for the study selection criterion in the meta-analysis. The publication bias was evaluated by funnel plots and Egger's test. We identified 61 studies in the systematic review and after quality assessment, 36 studies were included for meta-analysis. Random effect model was used due to the significant inconsistency among the included studies (I2 > 97%). The mean age of the participants was 53.84±9.3 years and patients with stroke were predominantly males (64%). Hypertension (56.69%; 95% CI: - 48.45 - 64.58), obesity (36.61%; 95% CI: - 19.31 - 58.23), dyslipidemia (30.6%; 95% CI: - 22 - 40.81) and diabetes mellitus (23.8%; 95% CI: - 18.79 - 29.83) are the leading intermediate conditions associated with stroke. The Physical inactivity - 29.9% (95% CI: - 22.9 - 37.1), history of tobacco use (28.59 %; 95% CI: - 22.22 - 32.94) and alcohol use (28.15 %; 95% CI: - 20.49 - 37.33) were reported as the behavioral risk factors for stroke in this setting.

Key Messages

The current meta-analysis provides robust estimates of the life style related risk-factor of stroke in India based on the observational studies conducted from 1994 to 2019. Estimating the pooled analysis of stroke risk factors is crucial to predict the imposed burden of the illness and ascertain the treatment and prevention strategies for controlling the modifiable risk factors in this setting.

Ethnic differences between South Asians and White Caucasians in cardiovascular disease-related mortality in developed countries: a systematic literature review

BACKGROUND

Cardiovascular disease is the leading cause of death worldwide, with significantly worse mortality-related outcomes in ethnic minorities in developed countries. A systematic literature review and meta-analysis of observational studies was conducted to investigate cardiovascular disease-related mortality inequalities between South Asian and White Caucasian ethnic groups.

METHODS

Published studies on mortality between South Asians and Whites in developed countries were retrieved from MEDLINE, PubMed, Embase, Web of Science, and grey literature sources (inception-April 2021) and critically appraised using the Quality in Prognosis Studies tool. Bayesian random-effects meta-analyses were performed for both primary and secondary outcomes. Heterogeneity was determined using the I² statistic.

RESULTS

Of the 9879 studies screened originally, 41 were deemed eligible. A further 3 studies were included via the later search. Of these, 15 reported cardiovascular disease-related mortality, 23 reported all-cause mortality, and 6 reported both. The meta-analysis results showed that South Asians had a significantly increased risk of cardiovascular disease mortality compared to Whites (risk ratio = 1.32; 95% credible interval = 1.14 to 1.54) and a decreased risk of all-cause mortality (risk ratio = 0.95; 95% credible interval = 0.83 to 1.12).

DISCUSSION

South Asians had statistically significantly higher odds of cardiovascular disease-related mortality compared to Whites, but not for all-cause mortality. Risk of bias was a serious concern mainly due to a lack of confounders being reported.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42021240865.

The effect of empagliflozin on the total burden of cardiovascular and hospitalization events in the Asian and non-Asian populations of the EMPA-REG OUTCOME trial of patients with type 2 diabetes and cardiovascular disease

AIMS

The sodium-glucose co-transporter 2 inhibitor empagliflozin reduced the total burden of cardiovascular, mortality, and all-cause hospitalization events, including first and recurrent events, in EMPA-REG OUTCOME participants with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease (ASCVD). We investigated the effect of empagliflozin on the total burden of cardiovascular and hospitalization events in Asian participants.

MATERIALS AND METHODS

Participants were randomized to empagliflozin 10 mg, 25 mg or placebo plus standard of care. The primary and key secondary outcomes were the composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke and the primary outcome plus hospitalization for unstable angina, respectively. The effect of pooled empagliflozin versus placebo on total (first plus recurrent) cardiovascular and hospitalization events was analysed using a negative binomial model that preserves randomization and accounts for within-patient correlation of multiple events. We analysed Asian versus non-Asian EMPA-REG OUTCOME population subgroups post hoc.

RESULTS

Among 1517 Asian participants, empagliflozin reduced the relative risk of total events of the primary outcome by 39% versus placebo [rate ratio (95% confidence interval): 0.61 (0.43, 0.89)], the key secondary outcome by 33% [0.67 (0.48, 0.93)], the composite of cardiovascular death (excluding fatal stroke) and hospitalization for heart failure by 43% [0.57 (0.33, 0.996)], and all-cause hospitalization by 21% [0.79 (0.65, 0.97)]. The effects of empagliflozin were consistent between Asian and non-Asian populations (treatment-by-subgroup interaction p > .05).

CONCLUSIONS

Empagliflozin reduced the total burden of cardiovascular and hospitalization events in Asian and non-Asian EMPA-REG OUTCOME participants with T2D and established ASCVD, consistent with the overall trial population.

Burden of Stroke in India During 1960 to 2018: A Systematic Review and Meta-Analysis of Community Based Surveys

Background

Stroke is a heterogeneous disorder comprising of clinical subtypes and many risk factors, also alluded to as cerebrovascular disorders (CVDs). Increase in the global burden of stroke in developed and developing countries has been alarming. To galvanize the efforts towards the prevention and treatment, there is a need for robust data on the burden of stroke.

Objective

The aim of this study was to estimate the burden of stroke, a systematic review of community-based studies was conducted.

Material and Methods

Systematic search of PubMed and Google Scholar for studies from January 1960 to December 2018 was done. The articles were screened and the data was retrieved and sorted into incidence, prevalence and mortality rates. Meta-analysis was done on Medcalc statistical software version 19.2.6.

Results

Prevalence rate of stroke for total population inclusive of urban and rural population, varied from 44.54 to 150/100000.For the urban population prevalence rate was 45 to 487/100000 and 55 to 388.4/100000 for rural population. The incidence rate varied from 33 to 123/100000 in the urban population and in the rural population it was estimated to be 123.57/100000. The 30 days case fatality rate of stroke varied from 41.08% to 42.06% in urban population and 18% to 46.3%.in the rural population.

Conclusions

Systematic review and meta-analysis reveal that the stroke burden in India is quite high.

VIRTUAL REALITY TRAINING THROUGH NINTENDO WII GAMES IN STROKE PATIENTS: A RANDOMISED CLINICAL TRIAL (Preprint)

Background

Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial.

Objective

The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke.

Methods

It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22.

Results

The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted.

Conclusions

VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability.

Trial Registration

Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view

A National Memory Clinic Survey to Assess Provision for People from Diverse Ethnic Backgrounds in England and Wales

English national guidelines regarding dementia assessment and management recommend consideration of cultural and linguistic diversity when assessing people with cognitive complaints. To date there has been no assessment of adherence to these guidelines. We aimed to assess whether current services provided in memory assessment services (MAS) adhere to national policy, in their approach to the assessment and management of individuals with memory problems from minority ethnic backgrounds. We sent a survey to 213 memory services in England and Wales. Twenty MAS from seven regions responded to the survey. We found that 80% (16) provided translated resources, 70% (14) used cognitive assessment tools that are culturally sensitive and appropriate, and 65% (13) showed good use of sufficiently skilled and knowledgeable interpreters. Communication barriers, particularly language, were raised as a potential obstacle to diagnosing minority ethnic patients. Memory clinics appear to reflect national policy for the assessment and management of memory problems in minority ethnic patients. However, only a minority of services responded and they may be more engaged in considering these populations. We need wider knowledge of practice to explore how guidelines support healthcare professional’s assessment of patients from minority ethnic groups in memory service diagnostic procedures.

Impact of prior stroke on major clinical outcome in chronic kidney disease: the Salford kidney cohort study

Background

Chronic kidney disease (CKD) is an independent risk factor for stroke in the general population. The impact of prior stroke on major clinical outcomes in CKD populations is poorly characterised.

Methods

The Salford Kidney Study is a UK prospective cohort of more than 3000 patients recruited since 2002 and followed until March 2018. Multivariable Cox regression examined associations of stroke at two time points; cohort inception, and at dialysis initiation, with risks of death, non-fatal cardiovascular events (NFCVE) and end stage renal disease (ESRD).

Results

277 (9.1%) of 3060 patients suffered a prior stroke and this was associated with mortality, ESRD and future NFCVE after cardiovascular risk factor adjustments. Median survival for prior stroke patients was 40 months vs 77 months in patients without a stroke. Prior stroke was independently associated with mortality (HR 1.20 95%CI 1.0–1.43, p = 0.05). Of 579 patients who reached ESRD and commenced dialysis, a prior stroke (N = 48) was independently associated with mortality. Median survival for the prior stroke group was 29 months compared with 50 months for the non-stroke group. Only 70 and 75% of patients who had suffered an ischaemic stroke were prescribed antiplatelets or statins respectively.

Conclusions

A diagnosis of stroke is strongly and independently associated with several adverse clinical outcomes for patients with CKD. Prior stroke profoundly alters cardiovascular risk in CKD patients. Greater attention to primary and secondary preventive strategies is warranted which may improve these outcomes.