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Springer MV, Lisabeth LD, Gibbs R, Shi X, Case E, Chervin RD, Dong L, Brown DL. Racial and ethnic differences in sleep-disordered breathing and sleep duration among stroke patients. J Stroke Cerebrovasc Dis 2022; 31:106822. [PMID: 36244278 PMCID: PMC9802657 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE We sought to characterize racial and ethnic differences in pre- and post-stroke sleep-disordered breathing (SDB) and pre-stroke sleep duration. METHODS Within the Brain Attack Surveillance in Corpus Christi cohort of patients with ischemic stroke (8/26/2010-1/31/2020), pre-stroke SDB risk was assessed retrospectively using the Berlin Questionnaire. Post-stroke SDB was defined by prospective collection of the respiratory event index (REI) using the ApneaLink Plus performed shortly after stroke. Pre-stroke sleep duration was self-reported. We used separate regression models to evaluate the association between race/ethnicity and each outcome (pre-stroke SDB, post-stroke SDB, and pre-stroke sleep duration), without and with adjustment for potential confounders. RESULTS There was no difference in pre-stroke risk of SDB between Black and non-Hispanic white (NHW) participants (odds ratio (OR) 1.07, 95% CI 0.77-1.49), whereas MA (Mexican American), compared to NHW, participants had a higher risk of SDB before adjusting for demographic and clinical variables (OR 1.26, 95% CI 1.08-1.47). Post-stroke SDB risk was higher in MA (estimate 1.16, 95% CI 1.06-1.28) but lower in Black (estimate 0.79, 95% CI 0.65-0.96) compared to NHW participants; although, only the ethnic difference remained after adjustment. MA and Black participants had shorter sleep duration than NHW participants (OR 0.83, 95% CI 0.72-0.96 for MA; OR 0.67, 95% CI 0.49-0.91 for Black participants) before but not after adjustment. CONCLUSIONS Racial/ethnic differences appear likely to exist in pre- and post-stroke SDB and pre-stroke sleep duration. Such differences might contribute to racial/ethnic disparities in stroke incidence and outcomes.
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Affiliation(s)
- Mellanie V Springer
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA.
| | - Lynda D Lisabeth
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA; Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan 4810, USA9
| | - River Gibbs
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan 4810, USA9
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan 4810, USA9
| | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan 4810, USA9
| | - Ronald D Chervin
- Michael S Aldrich Sleep Disorders Laboratory, University of Michigan Health System, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA
| | - Liming Dong
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, Michigan 4810, USA9
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA
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Horvat M, Lisabeth LD, Lim J, He K, Dasgupta R, Case E, Chervin RD, Brown DL. Ethnic differences exist in sleepiness 3 Months after ischemic stroke. Sleep Med 2022; 100:219-224. [PMID: 36115141 PMCID: PMC9669219 DOI: 10.1016/j.sleep.2022.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 07/13/2022] [Accepted: 08/25/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE/BACKGROUND To examine the association between ethnicity and 90-day post-stroke subjective sleepiness, an important determinant of quality of life, as measured by the Epworth Sleepiness Scale (ESS), among ischemic stroke survivors. PATIENTS/METHODS Mexican American (MA) and non-Hispanic white (NHW) recent ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2016). Subjects completed a baseline interview and 90-day outcome assessment that included the ESS. Excessive daytime sleepiness was defined as an ESS >10. Tobit regression models were used to assess associations between ethnicity and ESS unadjusted and adjusted for multiple potential confounders. RESULTS Among 1,181 (62.5% MA) subjects, mean ESS at 90 days was 8.9 (SD 6.0) among MA and 7.4 (SD 4.9) among NHW subjects: 1.45 (95% CI: 0.75, 2.15) points higher among MA than NHW subjects. After adjustment, mean ESS at 90 days was 1.16 (95% CI: 0.38, 1.94) points higher among MAs than NHWs. The prevalence of excessive daytime sleepiness was 39% among MA and 30% among NHW subjects (p = 0.0013). CONCLUSIONS Ninety days after stroke, sleepiness is worse in MAs compared to NHWs, even after accounting for potential confounding variables. Further studies should address ways to reduce this disparity.
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Affiliation(s)
- Marri Horvat
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lynda D Lisabeth
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA; Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jaewon Lim
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, USA
| | - Kevin He
- Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, USA
| | - Rahul Dasgupta
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Erin Case
- Department of Epidemiology, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA; Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Ronald D Chervin
- Sleep Disorders Center, Department of Neurology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Devin L Brown
- Stroke Program - Cardiovascular Center, Department of Neurology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Affiliation(s)
- Sandeep P Khot
- From the Department of Neurology, University of Washington School of Medicine, Seattle (S.P.K.)
| | - Lewis B Morgenstern
- Stroke Program, Medical School, and the Center for Social Epidemiology and Population Health, School of Public Health, University of Michigan, Ann Arbor (L.B.M.)
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Brown DL, Shafie-Khorassani F, Kim S, Chervin RD, Case E, Morgenstern LB, Yadollahi A, Tower S, Lisabeth LD. Sleep-Disordered Breathing Is Associated With Recurrent Ischemic Stroke. Stroke 2019; 50:571-576. [PMID: 30744545 PMCID: PMC6389387 DOI: 10.1161/strokeaha.118.023807] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/03/2019] [Indexed: 01/06/2023]
Abstract
Background and Purpose- Limited data are available about the relationship between sleep-disordered breathing (SDB) and recurrent stroke and mortality, especially from population-based studies, large samples, or ethnically diverse populations. Methods- In the BASIC project (Brain Attack Surveillance in Corpus Christ), we identified patients with ischemic stroke (2010-2015). Subjects were offered screening for SDB with the ApneaLink Plus device, from which a respiratory event index (REI) score ≥10 defined SDB. Demographics and baseline characteristics were determined from chart review and interview. Recurrent ischemic stroke was identified through active and passive surveillance. Cause-specific proportional hazards models were used to assess the association between REI (modeled linearly) and ischemic stroke recurrence (as the event of interest), and all-cause poststroke mortality, adjusted for multiple potential confounders. Results- Among 842 subjects, the median age was 65 (interquartile range, 57-76), 47% were female, and 58% were Mexican American. The median REI score was 14 (interquartile range, 6-26); 63% had SDB. SDB was associated with male sex, Mexican American ethnicity, being insured, nonsmoking status, diabetes mellitus, hypertension, lower educational attainment, and higher body mass index. Among Mexican American and non-Hispanic whites, 85 (11%) ischemic recurrent strokes and 104 (13%) deaths occurred, with a median follow-up time of 591 days. In fully adjusted models, REI was associated with recurrent ischemic stroke (hazard ratio, 1.02 [hazard ratio for one-unit higher REI score, 95% CI, 1.01-1.03]), but not with mortality alone (hazard ratio, 1.00 [95% CI, 0.99-1.02]). Conclusions- Results from this large population-based study show that SDB is associated with recurrent ischemic stroke, but not mortality. SDB may therefore represent an important modifiable risk factor for poor stroke outcomes.
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Affiliation(s)
| | | | - Sehee Kim
- Department of Biostatistics, School of Public Health, University of Michigan
| | - Ronald D. Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan Medical School
| | - Erin Case
- Stroke Program, University of Michigan Medical School
- Department of Epidemiology, School of Public Health, University of Michigan
| | - Lewis B. Morgenstern
- Stroke Program, University of Michigan Medical School
- Department of Epidemiology, School of Public Health, University of Michigan
| | - Azadeh Yadollahi
- University Health Network-Toronto Rehabilitation Institute
- Institute of Biomaterials & Biomedical Engineering, University of Toronto
| | | | - Lynda D. Lisabeth
- Stroke Program, University of Michigan Medical School
- Department of Epidemiology, School of Public Health, University of Michigan
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Abstract
INTRODUCTION Stroke is a major cause of disability and death in the United States and across the world, and the incidence and prevalence of stroke are expected to rise significantly due to an aging population. Obstructive sleep apnea, an established independent risk factor for stroke, is a highly prevalent disease that is estimated to double the risk of stroke. It remains uncertain whether non-apnea sleep disorders increase the risk of stroke. Areas covered: This paper reviews the literature describing the association between incident stroke and sleep apnea, rapid eye movement sleep behavior disorder, restless legs syndrome, periodic limb movements of sleep, insomnia, and shift work. Expert commentary: Trials of continuous positive airway pressure for stroke prevention in sleep apnea patients have been largely disappointing, but additional trials that target populations not yet optimally studied are needed. Self-reported short and long sleep duration may be associated with incident stroke. However, abnormal sleep duration may be a marker of chronic disease, which may itself be associated with incident stroke. The relationship between non-apnea sleep disorders and incident stroke deserves further attention. Identification of specific non-apnea sleep disorders or sleep problems that convey an increased risk for stroke may provide novel targets for stroke prevention.
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Affiliation(s)
- Mollie McDermott
- Michigan Medicine Stroke Program, Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Devin L. Brown
- Michigan Medicine Stroke Program, Cardiovascular Center, Ann Arbor, Michigan, USA
- Michigan Medicine Michael S. Aldrich Sleep Disorders Laboratory, Ann Arbor, Michigan, USA
| | - Ronald D. Chervin
- Michigan Medicine Stroke Program, Cardiovascular Center, Ann Arbor, Michigan, USA
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High prevalence of poststroke sleep-disordered breathing in Mexican Americans. Sleep Med 2016; 33:97-102. [PMID: 28449915 DOI: 10.1016/j.sleep.2016.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 12/28/2015] [Accepted: 01/26/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study is to compare sleep-disordered breathing (SDB) prevalence and severity after stroke between Mexican Americans (MAs) and non-Hispanic whites (NHWs). PATIENTS/METHODS Ischemic stroke (IS) patients within ∼30 days of onset were identified from the population-based BASIC Project (2010-2014) and offered screening with an overnight cardiopulmonary monitoring device, ApneaLink Plus™. The number of apneas and hypopneas per hour, as reflected by the apnea/hypopnea index (AHI), was used to measure SDB severity; SDB was defined as AHI ≥10. Ethnicity, demographics, and risk factors were collected from interviews and medical records. Log and negative-binomial regression models were used to determine prevalence ratios (PRs) and apnea/hypopnea event rate ratios (RRs) comparing MAs with NHWs after adjustment for demographics, risk factors, and stroke severity. RESULTS A total of 549 IS cases had AHI data. The median age was 65 years (interquartile range (IQR): 57-76), 55% were men, and 65% were MA. The MAs had a higher prevalence of SDB (68.5%) than NHWs (49.5%) in unadjusted (PR = 1.38; 95% confidence interval (CI): 1.14-1.67) and adjusted analyses (PR = 1.21; 95% CI: 1.01-1.46). The median AHI was 16 (IQR: 7-31) in MAs and nine (IQR: 5-24) in NHWs. The severity of SDB (rate of apneas/hypopneas) was higher in MAs than NHWs in unadjusted (RR = 1.31; 95% CI: 1.09-1.58) but not adjusted analysis (RR = 1.14; 95% CI: 0.95-1.38). There was no ethnic difference in severity among subjects with SDB. CONCLUSION More than two-thirds of MA stroke patients had SDB, which was almost 40% more common among MAs than NHWs. Physicians treating MA patients after stroke should have a high index of suspicion for SDB, a treatable condition that could otherwise have adverse impact.
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Ramos AR, Seixas A, Dib SI. Obstructive sleep apnea and stroke: links to health disparities. Sleep Health 2015; 1:244-248. [PMID: 29073399 DOI: 10.1016/j.sleh.2015.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 09/16/2015] [Accepted: 09/16/2015] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnea (OSA) is a novel cardiovascular and cerebrovascular risk factor that presents unique opportunities to understand and reduce seemingly intractable stroke disparity among non-Hispanic blacks and Hispanic/Latinos. Individuals from these 2 groups have up to a 2-fold risk of stroke and greater burden of OSA. Obstructive sleep apnea directly and indirectly increases risk of stroke through a variety of autonomic, chemical, and inflammatory mechanisms and vascular risk factors such as hypertension, obesity, and diabetes mellitus. Untreated OSA exacerbates poststroke prognosis, as it may also influence rehabilitation efforts and functional outcomes such as cognitive function after a stroke. Conversely, treatment of OSA may reduce the risk of stroke and may yield better poststroke prognosis. Unfortunately, in racial/ethnic minority groups, there are limited awareness, knowledge, and screening opportunities for OSA. Increasing awareness and improving screening strategies for OSA in minorities may alleviate stroke risk burden and improve stroke outcomes in these populations. This review article is intended to highlight the epidemiology, clinical characteristics, pathophysiology, diagnosis, and treatment of OSA in relation to stroke risk, with an emphasis on race-ethnic disparities.
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Affiliation(s)
- Alberto R Ramos
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL; Sleep Disorders Program, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL.
| | - Azizi Seixas
- Center for Healthful Behavior Change, Department of Population Health, New York University, School of Medicine, New York, NY
| | - Salim I Dib
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, FL; Sleep Disorders Program, Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, Miami, FL
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