Stroke in Latin America

Predictive value of functional disability scales among stroke survivors: A long-term mortality evaluation in a Brazilian stroke cohort

OBJECTIVE

To assess the influence of two functional scales- Modified Rankin Scale (m-RS) and Modified Katz Index (m-Katz Index) on long-term mortality in a stroke cohort.

MATERIAL AND METHODS

Among 760 stroke survivors (median age: 66 (IQR:56-75), 56.4 % women) m-Katz Index and m-RS scales applied at 1 and 6 months after stroke, were investigated in relation to 12-years of all-cause mortality. Kaplan-Meier survival curves were computed, and time-varying covariate Cox regression models were fitted to calculate hazard ratios (HRs) with 95 % confidence intervals (CIs) in all sample and by sex. The prognostic ability of the fitted models was computed for each model by six different measures.

RESULTS

After 12 years of follow-up (median survival time: 7.3 years), 311 participants died. Overall survival curves show lower survival rates among those with the highest levels of disability/dependence (all log-rank p-values <0.0001). These findings were confirmed in all regression models for both sexes, particularly in men who had higher levels of dependence on Activities of Daily Living (ADLs) by m-Katz Index and severe disability by m-RS and presented the highest HR of dying (HR: 3.34 (95 %CI: 2.27-4.92) and HR: 4.94 (95 % CI: 3.15-7.75), respectively).

CONCLUSIONS

Both the m-Katz Index and the m-RS scale were good predictors of long-term mortality, which is of importance for guiding the functional rehabilitation of stroke patients. Besides, high levels of disability and dependence were implicated with high mortality risks, regardless of sex.

Prognostic performance of neutrophil/lymphocyte ratio and platelet/lymphocyte ratio for mortality in patients with acute stroke

OBJECTIVE

To evaluate the prognostic performance of the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) for mortality in patients with acute stroke treated at a Peruvian hospital.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care hospital.

PATIENTS

Patients aged ≥18 years with a diagnosis of acute stroke and admitted to the hospital from May 2019 to June 2021.

INTERVENTIONS

None.

MAIN VARIABLES OF INTERESTS

Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and mortality.

RESULTS

A total of 165 patients were included. The mean age was 66.1±14.2 years, and 59.4% were male. Only NLR had a performance superior to 0.7 (AUC: 0.75; 95%CI: 0.65-0.85), and its elevated levels were associated with an increased risk of mortality (aRR: 3.66; 95%CI: 1.77-8.85) after adjusting for confounders.

CONCLUSION

The neutrophil-to-lymphocyte ratio has an acceptable prognostic performance for mortality in patients with acute stroke. Its use may be considered to stratify patients' risk and to consider timely alternative care and management.

Stroke in Latin America: Systematic review of incidence, prevalence, and case-fatality in 1997-2021

BACKGROUND

Stroke is a major global cause of death and disability. Most strokes occur in populations of low-middle-income country (LMIC); therefore, the subsequent disease burden is greater than in populations of high-income countries. Few epidemiological data exist for stroke in Latin America, composed primarily of LMIC.

AIMS

To determine epidemiological measures of incidence, prevalence, and 1-month case-fatality for stroke in Latin America/Caribbean (LAC) during 1997-2021.

SUMMARY OF REVIEW

A structured search was conducted to identify relevant references from MEDLINE, WOS, and LILACS databases for prospective observational and cross-sectional studies in LAC populations from January 1997 to December 2021. A total of 9242 records were screened and 12 selected for analysis, seven incidence studies and five prevalence studies. Case-fatality was reported in six articles. Sub-group analysis by age, sex, and income countries was performed. A narrative synthesis of the findings was performed. Meta-analysis was performed using random-effect model to obtain pooled estimates with 95% confidence intervals (CIs). Studies quality was assessed according to the risk of bias criteria described in the Joanna Briggs Institute's guide. The overall crude annual incidence rate of first-ever stroke in LAC was 119.0 (95% CI = 95.9-142.1)/100,000 people (with high heterogeneity between studies (I² = 98.1%)). The overall crude prevalence was 3060 (95% CI: 95.9-142.1)/100,000 people (with high heterogeneity between studies (I² = 98.8%)). The overall case-fatality at 1 month after the first stroke was 21.1% (95% CI = 18.6-23.7) (I² = 49.40%).

CONCLUSION

This review contributes to our understanding regarding the burden caused by stroke in LAC. More studies with comparable designs are needed to generate reliable data and should include both standardized criteria, such as the World Health Organization clinical criteria and updated standard methods of case assurance, data collection, and reporting.

Disparities Influencing Functional Outcomes Between Rural and Urban Patients With Acute Stroke

Introduction

There is scarce information in Latin America about factors related to stroke patient outcomes in rural areas compared to urban ones.

Objective

To evaluate functional outcomes of stroke code patients from rural and urban areas and their relationship with socioeconomic disparity.

Methods

Prospective cohort study included patients of urban, semi-urban, and rural origin with stroke code from a high complexity hospital in southwestern Colombia between 2018 and 2019. Demographic, clinical data modified Rankin at discharge, and 3-month follow-up were analyzed. The poverty index, barriers to health access and availability of ambulances by the municipality was assessed at an ecological level.

Results

Five hundred and fifty five stroke patients were registered, 21.2% from rural areas, 432 (77.98%) had an ischemic stroke. There were no significant differences in sociodemographic factors and medical background. Urban patients had lower reperfusion therapies rates (23.25%). Favorable mRS at discharge (&lt;3) was higher in urban areas (63.03%) and mortality was superior in rural patients (13.56%). The ambulance rate in semi-urban and rural areas was as low as 0.03 per 100.000 inhabitants, the poverty index was 11.9% in urban areas vs. 23.3% in semi urban and rural areas.

Conclusions

Rural patients treated in our center were more likely to present with severe strokes and unfavorable mRS at hospital discharge and 3-month follow-up compared to urban, despite having similar risk factors. There is an inverse relationship, which is not related to the poverty rate or the percentage of people with barriers to access to health. There is a need for further studies that assess barriers inherent in rural patients and establish a regional stroke network.

Trends in Mortality from Stroke in Latin America and the Caribbean, 1979–2015

Background:

Stroke is the second largest single cause of death and disability in Latin America and the Caribbean (LAC). There have been large overall declines in stroke mortality rates in most LAC countries in recent decades.

Objective:

To analyze trends in mortality caused by stroke in LAC countries in the period 1979–2015.

Methods:

We extracted data for age-standardized stroke mortality rates per 100,000 in LAC for the period 1979–2015 from the World Health Organization Mortality Database. Joinpoint regression was used to analyze the trends and compute the annual percent change (APC) in LAC as a whole and by country. Analyses were conducted by gender, region and World Bank income classification.

Results:

Mortality from stroke has decreased in LAC over the study period by an average APC of –1.9%. Most countries showed significant downward trends, with the sharpest decreases in Chile, Colombia and Uruguay. We recorded statistically significant decreases of –1.4% and –2.4% in mortality rates in men and women, respectively, in the whole LAC. Southern and high-income countries showed the steepest decreases.

Conclusions:

Stroke mortality has decreased in LAC, in both sexes, especially in southern and high-income countries. Our results could serve as a reference for the development of primary prevention and acute management of stroke policies focused on countries with higher mortality.

Prevalence of stroke survival in rural communities living in northern Peru

BACKGROUND AND PURPOSE

Stroke is the leading cause of neurological impairment in the South American Andean region. However, the epidemiology of stroke in the region has been poorly characterized.

METHODS

We conducted a staged three-phase population-based study applying a validated eight-question neurological survey in 80 rural villages in Tumbes, northern Peru, then confirmed presence or absence of stroke through a neurologist's examination to estimate the prevalence of stroke.

RESULTS

Our survey covered 90% of the population (22,278/24,854 individuals, mean age 30±21.28, 48.45% females), and prevalence of stroke was 7.05/1,000 inhabitants. After direct standardization to WHO's world standard population, adjusted prevalence of stroke was 6.94/1,000 inhabitants. Participants aged ≥85 years had higher stroke prevalence (>50/1000 inhabitants) compared to other stratified ages, and some unusual cases of stroke were found among individuals aged 25-34 years. The lowest age reported for a first stroke event was 16.8 years. High blood pressure (aPR 4.2 [2.7-6.4], p>0.001), and sedentary lifestyle (aPR 1.6 [1.0-2.6], p = 0.045) were more prevalent in people with stroke.

CONCLUSIONS

The age-standardized prevalence of stroke in this rural coastal Peruvian population was slightly higher than previously reported in studies from surrounding rural South American settings, but lower than in rural African and Asian regions. The death rate from stroke was much higher than in industrialized and middle-income countries.

Care of the Patient with Acquired Brain Injury in Latin America and the Caribbean

Traumatic brain injury and stroke are the leading causes of death and disability in Latin American and Caribbean countries. Specific characteristics, models of health care systems, and risk factors may influence the patient's outcome in this region. Relevant literature suggest that important delay problems exist in seeking care, reaching care, and receiving care in patients with acute neurologic injuries. Minimizing the time lost before care can be provided are vital to reduce the morbidity, long-term disability, and improved survival.

Neuroemergencies in South America: How to Fill in the Gaps?

South America is a subcontinent with 393 million inhabitants with widely distinct countries and diverse ethnicities, cultures, political and societal organizations. The epidemiological transition that accompanied the technological and demographic evolution is happening in South America and leading to a rise in the incidence of neurodegenerative and cardiovascular diseases that now coexist with the still high burden of infectious diseases. South America is also quite heterogeneous regarding the existence of systems of care for the various neurological emergencies, with some countries having well-organized systems for some diseases, while others have no plan of action for the care of patients with acute neurological symptoms. In this article, we discuss the existing systems of care in different countries of South America for the treatment of neurological emergencies, mainly stroke, status epilepticus, and traumatic brain injury. We also will address existing gaps between the current systems and recommendations from the literature to improve the management of such emergencies, as well as strategies on how to solve these disparities.

Investigation of the cardiovascular risk profile in a south Brazilian city: surveys from 2012 to 2016

The aim of this study was to investigate the cardiovascular risk profile of the participants recruited from stroke awareness campaigns in Santa Maria RS, Brazil, from 2012 to 2016, using the simplified version of the Framingham Risk Score (FRS). Questionnaires were used to evaluate 1,061 participants from 20 to 74 years old. Data on cardiovascular risk factors were obtained. The prevalence of risk factors and mean FRS for men and women were estimated. The FRS for women was 11.8% (moderate risk) and 24.7% for men (high risk). The vascular age for women was 61.6 years, whereas the vascular age for men was 66 years. Two percent of women had hypertension and diabetes, while both these risk factors were present in 5% of men. Based on the data, the prevalence of stroke risk factors is worrisome, as are the numbers of individuals with moderate and high cardiovascular risk in Santa Maria.

Efficacy and safety of dabigatran versus warfarin from the RE-LY trial

Background

Current data for atrial fibrillation (AF) and stroke are predominantly derived from North American and European patients. Although the burden of AF is high in Latin America (LA), little is known about current management of AF in the region.

Methods

We aimed to assess the consistency of efficacy and safety outcomes associated with dabigatran etexilate (DE) versus warfarin in patients with AF in LA from the RE-LY (Randomised Evaluation of Long-Term Anticoagulant Therapy) trial. Data from 956 LA patients and 17 157 non-LA patients were included in this analysis. χ² test and Cox proportional regression analysis were performed. The primary efficacy outcome included all strokes or systemic embolism (SE). Main safety outcome was major bleeding.

Results

LA patients were more often female, had higher proportion of permanent AF and lower creatinine clearance, among other characteristics. Vitamin K antagonist use at randomisation and time in therapeutic range were lower in LA than in non-LA patients (44% vs 63%, p<0.001; and 61.3±22.6% vs 64.6±19.6%, p=0.015, respectively). Efficacy endpoints were 0.91% versus 1.68% for DE 150 mg twice daily versus warfarin, respectively. Stroke/SE risk was lower in LA patients treated with DE 150 mg twice daily compared with warfarin, although not significant (HR 0.54; 95% CI 0.18 to 1.62). The annual stroke/SE rates for DE 110 mg twice daily versus warfarin were 1.82 versus 1.68, also not significantly different (HR 1.09; CI 0.44 to 2.67). There were no treatment-by-region interactions for either dose of DE on efficacy and safety outcomes.

Conclusion

Despite differences in the clinical profile and AF management, the efficacy and safety benefits of dabigatran over warfarin in LA patients relative to non-LA patients are consistent with those observed in the main RE-LY trial.

Stroke Literacy in a South Brazilian City: A Community Based Survey

BACKGROUND

This community-based and cross-sectional study was performed in a Brazilian city and aimed to evaluate stroke literacy.

METHODS

A stroke knowledge survey was administered to passersby of a public square from December 2015 to October 2016, in Santa Maria, Rio Grande do Sul. Convenience sampling was performed.

RESULTS

A total of 633 respondents completed the survey. Of the respondents, 33% knew the meaning of "AVC"; 29.5% incorrectly localized stroke in the heart. Any warning sign of stroke (open-ended question) could not be remembered by 50.7% of the respondents; individuals with a higher level of schooling (>7 years of education) and those who localized stroke in the brain were more likely to call an emergency in the case of a stroke (adjusted odds ratio [OR] 1.040, 95% confidence interval [CI] 1.004-1.078 for years of schooling; adjusted OR 1.542, 95% CI 1.102-2.156 for replying "yes" to brain as the organ affected in stroke).

CONCLUSIONS

Brazilian public knowledge about stroke is still scarce, even in a population with levels of formal education above the national average or in a city where annual promotion of Stroke Awareness Campaigns have taken place for almost a decade. Thus, it might be necessary to design different informative strategies targeted to our study's population to improve stroke campaigns in Brazil. In Brazil, increasing awareness of stroke focused on stroke prevention and recognition of its warning signs should be a national priority in public health as the access to stroke treatment remains limited.

Stroke and Thrombolysis in Developing Countries

Summary of review

The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas.

Conclusion

Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.

Door-to-door survey of cardiovascular health, stroke, and ischemic heart disease in rural coastal Ecuador--the Atahualpa Project: methodology and operational definitions

RATIONALE

Stroke and cardiovascular diseases will be the next health epidemics in Latin America due to increased life expectancy and changes in the lifestyle and dietary habits of the population. Knowledge of the cardiovascular health status of the inhabitants will allow the implementation of policies directed to reduce the burden of stroke and cardiovascular diseases in the region.

AIMS

To evaluate the cardiovascular health status of the inhabitants of Atahualpa (a rural village in coastal Ecuador) and to determine the prevalence and incidence of stroke and ischemic heart disease in the region.

DESIGN

Three-phase epidemiologic survey. During phase I, Atahualpa residents aged ≥40 years will be screened with standardized questionnaires to evaluate their cardiovascular health and to identify those with suspected stroke or ischemic heart disease. In phase II, neurologists and cardiologists will examine suspected cases of stroke or ischemic heart disease, as well as a random sample of matched negative individuals, to assess the prevalence and incidence of these conditions. In phase III, patients with a diagnosis of stroke and ischemic heart disease will undergo complementary tests for achieving a more specific diagnosis.

DISCUSSION

Implementation of public health strategies directed to improve the cardiovascular health status of a given population must be based on studies evaluating specific risk factors at regional levels. Epidemiologic surveys such as the Atahualpa Project may prove cost-effective in improving the cardiovascular health status of people living in Latin American rural villages by increasing the knowledge on the particular needs of these populations.

Awareness of stroke risk factors and warning signs in southern Brazil

OBJECTIVE: To evaluate the knowledge about stroke in Caxias do Sul. METHOD: A closed-ended, self-administered questionnaire was used to assess the knowledge about stroke among residents of Caxias do Sul. In order to verify variables associated to lack of knowledge we defined three main end points: (1) the inability to recognize that stroke is a disease that affects the brain; (2) insufficient knowledge of risk factors; (3) insufficient knowledge of signs and symptoms of acute stroke. RESULTS: A total of 952 subjects answered the questionnaire. Lower income and lower educational level were independent factors associated to inability to recognize that stroke affects the brain. Lower income and being under 50 years old were independent risk factors to lack of knowledge concerning stroke risk factors. Lower educational level was the unique risk factor for insufficient knowledge about stroke warning signs. CONCLUSION: There is a lack of knowledge about stroke in Caxias do Sul. People with lower socioeconomic status and lower education level should be the targets of educational campaigns.

High blood pressure in Latin America: a call to action

High blood pressure (BP) is an enormous global problem, and is especially challenging for low- and middle-income countries such as those of Latin America. Although developed countries have benefited from significant reductions in cardiovascular and cerebrovascular disease in recent decades, comparable reductions have not been achieved in Latin America. In fact, the prevalence of high BP is increasing in many Latin American countries, and the situation will worsen without definitive efforts to correct it. The growing preponderance of hypertension and chronic diseases, coupled with expected increases in population growth, present a mounting threat to Latin American economies. This report provides a comprehensive overview of the burden of high BP throughout Latin America, and presents recommendations for change. The dismal observations warrant a call to action for improved control of high BP and other cardiovascular risk factors across Latin America. Achieving these ambitious goals will require collaborative efforts by many groups, including policymakers, international organizations, healthcare providers, schools and society as a whole.

Stroke Awareness in Brazil

Background and Purpose— Stroke is the leading cause of death in Brazil. This community-based study assessed lay knowledge about stroke recognition and treatment and risk factors for cerebrovascular diseases and activation of emergency medical services in Brazil.

Methods— The study was conducted between July 2004 and December 2005. Subjects were selected from the urban population in transit about public places of 4 major Brazilian cities: São Paulo, Salvador, Fortaleza, and Ribeirão Preto. Trained medical students, residents, and neurologists interviewed subjects using a structured, open-ended questionnaire in Portuguese based on a case presentation of a typical patient with acute stroke at home.

Results— Eight hundred fourteen subjects were interviewed during the study period (53.9% women; mean age, 39.2 years; age range, 18 to 80 years). There were 28 different Portuguese terms to name stroke. Twenty-two percent did not recognize any warning signs of stroke. Only 34.6% of subjects answered the correct nationwide emergency telephone number in Brazil (#192). Only 51.4% of subjects would call emergency medical services for a relative with symptoms of stroke. In a multivariate analysis, individuals with higher education called emergency medical services ( P =0.038, OR=1.5, 95%, CI: 1.02 to 2.2) and knew at least one risk factor for stroke ( P <0.05, OR=2.0, 95% CI: 1.2 to 3.2) more often than those with lower education.

Conclusions— Our study discloses alarming lack of knowledge about activation of emergency medical services and availability of acute stroke treatment in Brazil. These findings have implications for public health initiatives in the treatment of stroke and other cardiovascular emergencies.

Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean

Stroke is a major health problem in Latin American and Caribbean countries. In this paper, we review the epidemiology, aetiology, and management of stroke in the region based on a systematic search of articles published in Spanish, Portuguese, and English. Stroke mortality is higher than in developed countries but rates are declining. Population-based studies show variations in incidence of strokes: lower rates of ischaemic stroke and similar rates of intracranial haemorrhages, compared with other regions. A significant proportion of strokes in these populations can be attributed to a few preventable risk factors. Some countries have published national clinical guidelines, although much needs to be done in the organisation of care and rehabilitation. Even though the burden of stroke is high, there is a paucity of information for implementing evidence-based management. The Global Stroke Initiative, the WHO STEPS Stroke surveillance, and WHO-PREMISE projects provide opportunities for surveillance at institutional and community levels.

Incidence, case-fatality rate, and prognosis of ischaemic stroke subtypes in a predominantly Hispanic-Mestizo population in Iquique, Chile (PISCIS project): a community-based incidence study

BACKGROUND

Incidence of ischaemic stroke subtypes, classified by cause, seems to vary between communities. We aimed to prospectively ascertain the incidence of first-ever ischaemic stroke in a predominantly Hispanic-Mestizo population in the northern desertic region of Chile.

METHODS

Between July, 2000, and June, 2002, all patients with possible stroke or transient ischaemic attacks were identified from multiple overlapping sources and were rapidly assessed by two field neurologists. All identified patients were diagnosed by at least two stroke neurologists according to Trial of Org 10172 in Acute Stroke Treatment (TOAST) definitions and were followed up at 6 months. Annual incidence rates were age adjusted to WHO, European, and US populations by the direct method to allow comparisons.

FINDINGS

A total of 239 ischaemic strokes were identified, of which 185 (77%) were first-ever cases. 151 (82%) patients were hospitalised, of whom only 70 (38%) were assessed within 6 h of symptom onset. The mean age of patients was 66.4 years (SD 14.9) and 56% were men. The crude annual incidence rates (per 100 000) according to stroke subtype were: cardioembolic, 9.3; large-artery disease, 2.0; small-vessel disease, 15.8; other determined cause, 0.2; and undetermined cause, 17.4. Hypertension was the most common cardiovascular risk factor in all subtypes and atrial fibrillation was the most common cause of cardioembolic stroke. Case fatality at 30 days was highest in cardioembolic strokes (28%) and lowest in small-vessel disease (0%). Dependency or death at 6 months was also highest in cardioembolic strokes (62%) and lowest in small-vessel disease (21%).

INTERPRETATION

Incidence and prognosis of small vessel and cardioembolic infarction was similar to that in other populations and incidence of large-artery atherothrombotic infarction was lower than in most previous reports. Hypertension and atrial fibrillation were the most common risk factor and cause, respectively, of ischemic stroke in this population. These findings should help the national stroke programme in the prevention of cardioembolic stroke, increase access to specialists and acute brain imaging and vascular studies, and improve stroke care.