Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study

Cutting-edge stroke prevention strategies

Stroke represents a major public health problem, ranking as a leading cause of death and long-term disability worldwide (1-3). The goal of prevention strategies is to avoid the occurrence of stroke by educating both healthcare professionals and patients about the reduction of risk factors. Despite increasing improvements in acute revascularization therapies, preventive measures remain more effective in decreasing the burden of stroke, as evidenced by the fact that over 75 % of strokes are first events (2). This paper attempts to provide a comprehensive approach by outlining risk factors and new therapeutic approaches. Understanding these is essential for healthcare providers and the general public to develop effective prevention strategies and ultimately reduce the overall incidence of stroke.

Association between cardiometabolic index and the incidence of stroke: a prospective nationwide cohort study in China

Objectives

Cardiometabolic index (CMI), based on triglycerides (TG) to high-density lipoprotein cholesterol (HDL-C) ratio and waist-to-height ratio (WHtR), has been recognized as a novel and practical marker for the assessment of cardiometabolic risk. However, the relationship between CMI and the incidence of stroke remains to be elucidated. This investigation aimed to explore the association between CMI and stroke incidence.

Methods

The investigation included 6,633 individuals aged over 45 years from the China Health and Retirement Longitudinal Study. Logistic regressions and restricted cubic spline regression were uitilized to determine the relationship between CMI and the incidence of stroke. Weighted quantile sum regression was used to offer a comprehensive explanation of the CMI by calculating the weights of triglyceride-glucose (TG), high-density lipoprotein cholesterol (HDL-C), weight, and height.

Results

During the 9-year follow-up, 827 (12%) incident stroke participants were identified. With CMI as a continuous variable, the OR (95% CI) for the risk of incident stroke was 1.09 (1.01-1.19) (p = 0.047) after adjusting for potential confounders, indicating a significant link between increased CMI and an elevated incidence of stroke. Additionally, when CMI was categorized into quartiles, compared to the first quartile, the incident stroke was significantly higher in the fourth quartile (OR 1.57, 95%CI 1.22-2.04, p <0.001). The association between CMI and stroke incidence was nonlinear (p overall=0.002, p non-linear = 0.006). TG emerged as the primary contributor when the weights were assigned to the constituent elements of the CMI (weight = 0.645).

Conclusions

The CMI was independently associated with stroke incidence in middle-aged and elderly Chinese populations. Long-term CMI monitoring is of great importance for early identification and prevention of stroke, with significant implications for clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01530-3.

National cohort study on cardiometabolic index and incident stroke in middle-aged and older adults in China

Background The Cardiometabolic Index (CMI), a novel marker integrating central obesity and lipid metabolism, serves as a comprehensive indicator of metabolic health. While CMI has been linked to metabolic disorders like diabetes and cardiovascular diseases, its role in predicting stroke risk remains unclear. This study examines the association between CMI and stroke risk in Chinese adults aged 45 and older, highlighting its potential as a predictive tool for public health.

METHODS

Data from the China Health and Retirement Longitudinal Study (CHARLS) were analyzed. Participants were divided into CMI quartiles. Stroke incidence was the primary endpoint. Cox proportional hazards models evaluated the CMI-stroke risk association. Kaplan-Meier curves compared stroke incidence across quartiles, while restricted cubic splines (RCS) assessed non-linear trends. Subgroup analyses verified robustness.

RESULTS

Among 7,821 participants (47 % male), 418 strokes (5.3 %) occurred over a mean follow-up of 7 years. Higher CMI was significantly associated with increased stroke risk [HR, 1.153 (95 % CI: 1.048-1.269), P = 0.004]. RCS revealed a non-linear rise in stroke risk with increasing CMI (P for nonlinearity = 0.005). No significant interactions were observed between CMI and subgroups (all P > 0.05).

CONCLUSION

Elevated CMI correlates with higher stroke risk in middle-aged and older Chinese adults. Incorporating CMI into routine assessments could improve early stroke prevention strategies, addressing the increasing burden of cerebrovascular disease in aging populations.

Reassessing the Association of Sedentary Behavior and Physical Activity with Ischemic Stroke: A Mendelian Randomization Study

PURPOSE

Findings from previous Mendelian randomization (MR) studies disagreed with the current scientific consensus regarding the role of physical activity (PA) and sedentary behavior in ischemic stroke (IS). We reassessed these associations with a focus on etiological subtypes of IS and the potential mediating roles of cardiometabolic traits and brain imaging-derived phenotypes (IDPs).

METHODS

We performed MR analyses using summary statistics from genome-wide association studies of sedentary behavior and PA ( n = 88,411 ~ 608,595), cardiometabolic traits ( n = 393,193 ~ 694,649), brain IDPs ( n = 33,224), and the latest IS data (62,100 cases and 1,234,808 controls). Inverse-variance weighted regression was used as the primary method, complemented by several sensitivity analyses. A two-step MR approach was employed to assess the mediating effects of cardiometabolic traits and brain IDPs.

RESULTS

Genetic liability to leisure-time moderate-to-vigorous PA (MVPA) and higher overall PA (OPA) were associated with reduced risks of IS and small vessel stroke (Benjamini-Hochberg adjusted P < 0.05). Suggestive associations were observed between longer leisure-screen time and higher IS risk and between higher OPA and lower cardioembolic stroke risk ( P < 0.05). The isotropic volume fraction in the anterior limb of the left internal capsule, as well as some cardiometabolic metrics, partially mediated these associations. There was no evidence for causal effects of overall MVPA, overall light-intensity PA, or overall sedentary duration on IS.

CONCLUSIONS

Longer leisure screen time, less OPA, and not engaging in MVPA during leisure time were associated with higher risk of IS. The associations between PA and IS depended on different subtypes and were mediated by changes in anterior limb of the left internal capsule and cardiometabolic biomarkers.

Current status of elevated blood pressure and hypertension among adolescents in Asia: a systematic review

Background

Hypertension among adolescents in Asia is an emerging public health concern that is directly associated with early onset cardiovascular risks. As such, it can also lead to further health issues and challenges for health care in the future. As existing studies have predominantly focussed on adult populations, we sought to provide targeted insights into adolescent hypertension across Asia, elucidating the impact of rapid lifestyle and environmental changes on this younger population. Therefore, in this systematic review, we aimed to evaluate the prevalence and trends of elevated blood pressure (BP) and hypertension among adolescents aged 10-19 years across Asia, address gaps in region-specific data, and determine any demographic risk factors.

Methods

Following PRISMA guidelines, we searched PubMed, EMBASE, Science Direct, Web of Science, Google Scholar, and Scopus for cross-sectional studies on adolescent hypertension/elevated BP in Asia published from January 2019 to June 2024, after which we narratively synthesised their findings.

Results

Of the 2634 retrieved studies, 39 met the inclusion criteria, covering over 200 000 adolescents in Asia. The prevalence of hypertension ranges from 0.7% in urban Bangladesh to 24.5% in urban Malaysia, with urban areas generally showing higher rates than rural areas (e.g. India: 8.4% urban vs. 5.7% rural). By region, East Asia has the highest overall prevalence (14.25%), followed by West Asia (14.14%), South Asia (13.77%), Southeast Asia (13.16%), and Central Asia (12.37%). Males had higher prevalence rates (for example, 22.3% in Chinese males vs. 20% in females).

Conclusions

The increasing prevalence of adolescent hypertension in urban Asia is a significant public health concern. Although extensive research has been conducted in East and South Asia, there is a dearth of studies in Western, Southeast, and Central Asia, emphasising a need for future research. Standardised diagnostic criteria and targeted interventions are crucial for addressing regional disparities and reducing long-term cardiovascular risks.

The relationship between Alzheimer's disease and intracerebral hemorrhage based on Mendelian randomization

BackgroundTraditional epidemiologic studies suggest that Alzheimer's disease (AD) may be associated with intracerebral hemorrhage (ICH).ObjectiveTo explore whether there is a causal relationship between AD and ICH and the underlying mechanisms involved.MethodsMendelian randomization (MR) approach was used to explore causal relationships. The genetic instrumental variables of the candidate genetic instrumental variable AD were obtained from genome-wide association studies. The inverse variance weighted method was the primary method for MR analysis and meta-analysis. The obtained single nucleotide polymorphisms were analyzed for corresponding genes for subsequent pathway enrichment and protein-protein interaction analysis.ResultsFor the single AD dataset, our MR analysis of the AD datasets versus the ICH datasets revealed a genetically predicted causal relationship between AD and ICH (OR 5.947, 95%CI 1.165-30.356, pIVW = 0.032). In addition, the MR-Egger method and MR-PRESSO method revealed no horizontal pleiotropic effect of AD on the risk of ICH. Meta-analysis of each dataset using IVW revealed a final calculated OR of 1.08 (95%CI 1.02-1.15, p = 0.01). Subsequent pathway enrichment analysis revealed that the corresponding genes were involved mainly in the metabolic process of amyloid-β (Aβ) and negatively regulated Aβ formation. In the PPI network analysis, proteins such as ApoE, SROL1, CLU, ABCA7, and AβPP were found to be closely related and located in the key position of the center.ConclusionsWe verified the causal relationship between AD and ICH via MR, and identified the possible pathological mechanisms involved. We also discovered that Aβ plays an important role in this process.

Stroke with White Matter Lesions: Potential Pathophysiology and Therapeutic Targets

Stroke is one of the most common causes of morbidity and mortality among adults globally. Significant advancements have been made in elucidating its pathophysiology, with stroke categorized into pathological subtypes, such as ischemic stroke (IS) and hemorrhagic stroke. White matter lesions (WMLs) identified on magnetic resonance imaging rank as a hallmark of cerebral small vessel disease and are associated with vascular risk factors. They are linked to adverse outcomes like dementia, depression, and an increased risk of both first-ever and recurrent strokes, independent of other risk factors. Despite the evidence indicating the close link between WMLs and stroke, their underlying pathophysiological relationship remains unclear. This study aims to provide an overview of the current knowledge and recent advances in epidemiology, risk factors, and pathophysiological mechanisms of WMLs and stroke, focusing on their interconnection and emerging therapeutic targets.

Recurrent Stroke Prediction by Applying a Stroke Polygenic Risk Score in the Japanese Population

BACKGROUND

Recently, various polygenic risk score (PRS)-based methods were developed to improve stroke prediction. However, current PRSs (including cross-ancestry PRS) poorly predict recurrent stroke. Here, we aimed to determine whether the best PRS for Japanese individuals can also predict stroke recurrence in this population by extensively comparing the methods and maximizing the predictive performance for stroke onset.

METHODS

We used data from the disease-oriented BBJ1 (BioBank Japan first cohort; recruited between 2003 and 2007, n=179 938) to derive and optimize the PRSs using a 10-fold cross-validation. We integrated the optimized PRSs for multiple traits, such as vascular risk factors and stroke subtypes to generate a single PRS using the meta-scoring approach (metaGRS). We used an independent BBJ2 (BBJ second cohort; recruited between 2012 and 2017, n=41 929) as a test sample to evaluate the association of the metaGRS with stroke and recurrent stroke. In addition, we analyzed its association stratified by risk factors. We administered 3 distinct tests to consider the potential index event bias.

RESULTS

We analyzed recurrent stroke cases (n=174) and nonrecurrent stroke controls (n=1153) among subjects within the BBJ2. After adjusting for known risk factors, metaGRS was associated with stroke recurrence (adjusted odds ratio per SD, 1.18 [95% CI, 1.00-1.39]; P=0.044), although no significant correlation was observed with the published PRSs. The outcomes derived from these examinations did not provide any significant indication of the influence of index event bias. The high metaGRS group without a history of hypertension had a higher risk of stroke recurrence than that of the low metaGRS group (adjusted odds ratio, 2.24 [95% CI, 1.07-4.66]; P=0.032). There was no association at all in the hypertension group (adjusted odds ratio, 1.21 [95% CI, 0.69-2.13]; P=0.50).

CONCLUSIONS

The metaGRS developed in a Japanese cohort predicted stroke recurrence in an independent cohort of patients. In particular, it predicted an increased risk of recurrence among stroke patients without hypertension. These findings provide clues for additional genetic risk stratification and help in developing personalized strategies for stroke recurrence prevention.

A protection motivation theory-guided telehealth coaching program for middle-aged adults with cardiometabolic risk: A feasibility trial

BACKGROUND

Health coaching to address the escalated cardiometabolic risk in middle-aged adults in primary health care is underexplored. This study aimed to examine the feasibility and acceptability of a protection motivation theory-guided telehealth coaching program among middle-aged adults with cardiometabolic risks.

METHODS

This was a pretest-posttest study. The three-month intervention included four nurse-facilitated telehealth sessions tailored to individual cardiometabolic risks.

RESULTS

Thirty participants were recruited through social media and a community center. The eligibility and enrollment rates were 16.1% and 78.9%, respectively. Attrition at six months after enrollment was 33.3%, and intervention attendance was 82.5%. Most of the participants (76.7%) were satisfied with the program. Significant improvements were noted in the INTERHEART score for cardiometabolic risks, self-efficacy, anxiety, stress, and central obesity but not in health-promoting behaviors, depression, sleep quality, physical activity level, and physiological outcomes at six-month post-enrolment.

CONCLUSION

A theory-based telehealth coaching was feasible and well-accepted among middle-aged adults, with potential in reducing cardiometabolic risks among middle-aged adults in primary care. This study revealed significant improvement in cardiometabolic risk, self-efficacy, anxiety, stress, and central obesity but changes for health-promoting behaviors, depression, sleep quality, physical activity level, and physiological outcomes were not noted. Progression to a definitive trial was supported with implication for future trials, including lowering the threshold of cardiometabolic risk to improve subject recruitment, change of assessment sessions to promote adherence to fasting instruction, and use of digital recording to facilitate health coaching process.

TRIAL REGISTRATION

This trial was retrospectively registered on 05/07/2022 at ClinicalTrials.gov (identifier: NCT05444140).

Effects of Different Intensities of Endurance Training on Neurotrophin Levels and Functional and Cognitive Outcomes in Post-Ischaemic Stroke Adults: A Randomised Clinical Trial

This study aimed to examine the effects of different intensities of endurance training combined with standard neurorehabilitation on selected blood biomarkers and physical outcomes of post-stroke individuals. We randomised patients with first-episode ischaemic stroke to an experimental group that received 4 × 45 min sessions of moderate-intensity continuous training (MICT) each week and 2 × 45 min of standard rehabilitation each day or to a control group that received 4 × 45 min sessions of low-intensity continuous training (LICT) each week and 2 × 45 min of standard rehabilitation each day. We measured the following outcomes at baseline and 3 weeks after the intervention: aerobic capacity; cognitive and motor function; and blood levels of brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic factor (GDNF), vascular endothelial growth factor A (VEGF-A), insulin-like growth factor-1 (IGF-1), and irisin. We included 52 patients with a mean age of 66.1 ± 8.0 years. After 3 weeks of rehabilitation, there was a clinically significant improvement in the Rivermead Motor Assessment-arm score in the MICT group. The study showed that after 3 weeks, an intervention combining MICT with standard neurorehabilitation was significantly more beneficial in improving aerobic capacity and arm motor function than an intervention combining LICT and standard neurorehabilitation.

Description of the Risk Factors for Ischemic Stroke in the Lebanese Population: Their Association with Age at First Stroke Incidence and the Predictors of Recurrence

Background: Stroke is the third most common cause of death in Lebanon. With many preventive strategies identified, stroke remains a national burden, especially in developing countries, where risk factors and epidemiological states are understudied. This study aims to investigate the association of sociodemographic factors and health-related risk factors with age at first ischemic stroke and its recurrence in the Lebanese population. Methods: A retrospective study including 214 ischemic stroke cases was carried out. Sociodemographic characteristics and health-related risk factors were assessed, in addition to disability levels (modified Rankin score (mRS)), age at first ischemic stroke incidence, and number of ischemic strokes. Data were analyzed using SPSS software version 25, including descriptive, bivariate, and multivariate analyses. Results: This study showed that stressful factors were significantly associated with a younger age at first ischemic stroke, such as having no partner (p < 0.001), having employment (p < 0.001), and having migraines (p < 0.001). However, metabolic risk factors were associated with an older age of ischemic stroke, such as hypertension (p < 0.001) and hyperlipidemia (p < 0.001). Moreover, having a partner (OR: 2.136), having a family history of stroke (OR: 2.873), having hyperlipidemia (OR: 3.71), and having atrial fibrillation (OR: 2.521) were associated with ischemic stroke recurrence. Conclusions: Many modifiable factors are associated with age at first ischemic stroke and its recurrence. This study sheds light on the necessity of increasing knowledge and awareness of well-known risk factors in the Lebanese population. These results suggest implementing targeted preventive strategies and highlight the importance of complying with early detection and follow-up measures.

Electroacupuncture promotes neural function recovery by alleviating mitochondria damage in cerebral ischemia mice

AIMS

This study aimed to observe the effect of electroacupuncture (EA) at Zusanli point (ST36) on motor function of cerebral ischemia mice, and to observe the effect of EA on mitochondrial morphology of peri-infarct cortex neurons in cerebral ischemia mice.

METHODS

Middle cerebral artery occlusion (MCAO) was used to develop an ischemic stroke mice model. EA treatment was performed for three consecutive days for 15 min per day after MCAO modeling. We investigated the therapeutic effects of EA on MCAO mice by performing neurobehavioral assessment (modified Neurological Severity Score, Rotarod test, Open-field test and Gait analysis) and TTC staining. The morphology and function of neuronal mitochondria were evaluated by transmission electron microscopy, qRT-PCR, chemiluminescence, and western blot. Nissl staining, TUNEL staining and immunofluorescence staining were used to observe neuronal morphology and apoptosis. Furthermore, ELISA was employed to measure the expression levels of inflammatory factors in mouse serum.

RESULTS

EA alleviated motor dysfunction and infarct volume in mice with cerebral ischemia. It improved the neuronal mitochondria damage in MCAO mice, and decreased the protein and mRNA expression level of mitochondrial fission related proteins (FIS1 and Drp1). In addition, EA can reduce neuronal damage and apoptosis of nerve cells, and decrease the level of inflammatory factors (IL-1β, TNF-α, IL-6 and IL-8) in cerebral ischemia mice.

CONCLUSION

EA therapy can improve motor dysfunction and alleviate the damage of neuron mitochondria in cerebral ischemic mice.

Empowerment and mobile technology in the detection and treatment of main cardiovascular risk factors of patients with ischemic stroke or transient ischemic attack: a protocol for a multicenter randomized controlled trial (CARDIOSTROKE)

BACKGROUND

Hypertension and atrial fibrillation (AF) are major treatable risk factors for ischemic stroke and transient ischemic attack (TIA). However, most of the patients with an ischemic stroke or TIA fail to reach desired blood pressure (BP) control and AF remains underdiagnosed with standard ECG monitoring. The aim of the CARDIOSTROKE study is to (1) test the effect of 3-week non-invasive ECG monitoring combined with (2) self-monitoring of BP and (3) patient-controlled titration of antihypertensives over 12 months in patients with recent non-cardioembolic ischemic stroke or TIA.

METHODS

CARDIOSTROKE is an investigator-initiated, multicenter, open, prospective trial aiming to randomize patients with recent (within 1 month) ischemic stroke or TIA to receive in a 2:1 fashion either (1) standard diagnostic work-up and follow-up (control arm) or (2) 3-week ECG monitoring combined with self-monitoring of BP and mobile-device-assisted self-titration of antihypertensives (intervention arm). The co-primary outcomes are (1) mean reduction in systolic BP and (2) detection of new AF at 12 months.

DISCUSSION

Mobile technology assisted control of the two major risk factors of stroke recurrence has not previously been studied in patients with recent stroke or TIA, which supports conducting a randomized trial in this patient population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03710902. Registered on October 16, 2018.

Public interest and engagement in care for brain health in Slovenia: the role of education

Background and objective

Knowledge gap theory posits that individuals with better education have better opportunities to obtain, understand and utilise available information. In a health-related context, this insight could lead to a more effective disease prevention. The aim of our study was to test the hypothesis that knowledge gap underlies differences in behaviour aimed at maintaining brain health.

Methods

We conducted an online survey investigating Slovenian public view on brain, brain research, and science-based recommendations for brain health. The survey was filled out by a total of 2,568 respondents, of whom 2,450 completed it in full. They were divided into two subgroups based on their self-reported brain-related education, i.e., the lay subgroup (n = 1,012) and a topically educated group (n = 1,438), i.e., the educated subgroup. Among the latter, 728 participants reported to have a Bachelor's degree or higher education. We analysed the views of this sample subgroup on brain, neuroscience, and science-based brain health recommendations, and compared them with age- and education-matched lay subgroup (n = 565) from the same survey.

Results

Educated individuals showed greater awareness and adherence to science-based recommendations compared to the lay respondents, specifically in the perceived importance of following a healthy diet, exercising, ensuring time for rest, relaxation and maintenance of social contacts, acquiring new knowledge and skills and using supplements that are considered to improve mental abilities (all p < 0.005), but not in the perceived importance of getting enough sleep, avoiding drugs and alcohol or injuries and performing mentally-challenging activities or cognitive training (all p > 0.10). Educated individuals more frequently reported following a healthy diet, engaging in physical activity and socialising, acquiring new knowledge and skills, performing mental challenges and cognitive training, and using supplements (all p < 0.005), but not getting sufficient sleep, avoiding drugs, alcohol or injury, or ensuring time for rest and relaxation (all p > 0.08). A larger proportion of lay than educated participants (32 and 17%, respectively) identified lack of information as a reason for not engaging in healthy practices (p < 0.001). Educated participants outperformed lay individuals in identifying diseases amenable to lifestyle modification.

Conclusion

Understanding the differences in brain health perceptions between educated and lay individuals is crucial for developing effective public health strategies. Our results highlight a substantial knowledge gap in the Slovenian population and the need for targeted educational interventions that account for varying degrees of knowledge in different population segments which could lead to better adherence to healthy lifestyle practices.

Impact of sodium butyrate on stroke-related intestinal injury in diabetic mice: Interference with Caspase-1/GSDMD pyroptosis pathway and preservation of intestinal barrier

Diabetic stroke-associated acute intestinal injury is characterized by high mortality, disability, and poor prognosis due to the lack of effective therapies. Our prior research demonstrated that administration of 300 mg/kg sodium butyrate (NaB) can improve neurological outcomes post-diabetic stroke. Nonetheless, whether the effect of NaB is related to intestinal regulation, along with its underlying mechanisms, remains uncertain. This study aims to investigate the effects and mechanistic pathways of NaB on diabetic stroke-associated acute intestinal injury. A middle cerebral artery occlusion/reperfusion model was established in mice with streptozotocin-induced diabetes. The results demonstrated that NaB alleviated colonic injury 24 h after reperfusion in diabetic stroke. Pyroptosis-related protein levels in colonic tissues were significantly elevated following diabetic stroke but were markedly reduced with NaB treatment. NaB also improved gut barrier integrity and reduced inflammation, promoting epithelial barrier self-repair. In the NaB combined with lipopolysaccharide group, lipopolysaccharide administration induced a significant inflammatory response in the colonic tissue. Conversely, treatment with NaB and VX-765 (an inhibitor for Caspase-1) led to a notable alleviation in intestinal inflammation. These findings suggest that NaB mitigates colonic injury and enhances barrier function following diabetic stroke, potentially through the Caspase-1/Gasdermin D pyroptosis pathway. This study may provide a novel strategy and direction for intestinal rehabilitation in diabetic stroke patients.

Global, regional, and national burden and trends of stroke among youths and young adults aged 15-39 years from 1990 to 2021: findings from the Global Burden of Disease study 2021

Background

Stroke is a leading cause of disability and mortality worldwide, with rising incidence rates among youths and young adults aged 15-39 years. However, comprehensive assessments of stroke burden in this age group at global, regional, and national levels are limited. This study examines trends in stroke incidence, mortality, and disability-adjusted life years (DALYs) from 1990 to 2021 using data from the Global Burden of Disease (GBD) study.

Methods

Data from the GBD study (1990-2021) were analyzed to assess the age-standardized incidence, mortality, and DALYs related to stroke in individuals aged 15-39 years. The relationship between stroke burden and the Socio-Demographic Index (SDI) was explored across 204 countries and 21 regions. Trends were analyzed using the estimated annual percentage change (EAPC) and average annual percentage change (AAPC).

Results

This study reveals global, regional, and national trends in stroke burden among youths and young adults (15-39 years) from 1990 to 2021. In 2021, the global age-standardized stroke incidence was 757,234.61 cases, with 8.72 million DALYs and 122,742 stroke-related deaths. Although global incidence increased by 19.09%, age-standardized rates (ASRs) declined by 0.67% annually. DALYs and mortality rates also decreased globally. Notably, stroke burden increased in low and low-middle SDI regions. South Asia had the highest number of cases, while Oceania reported the highest mortality rate. These findings underscore regional disparities in stroke trends. Globally, metabolic risks (46.2%) and high systolic blood pressure (37.87%) are major contributors to stroke-related mortality.

Factors influencing participation and engagement in post-stroke cardiac rehabilitation and exercise: an exploratory qualitative study

The secondary prevention benefits of cardiac rehabilitation and similar exercise classes for stroke survivors are well established, however post-stroke exercise participation remains low. This research aimed to explore the factors affecting participation and engagement in UK-based post-stroke cardiac rehabilitation and exercise, from the perspective of the service user and service provider. An exploratory study, using semi-structured interviews, was conducted ( n  = 8, service user = 4), adopting a phenomenological approach. All interviews applied a topic guide informed by the Health Belief Model and the International Classification of Functioning, Disability and Health, and were analysed using inductive thematic analysis. Post-stroke cardiac rehabilitation and exercise participation was influenced by numerous factors, encompassed into three themes: Accessibility (describing the environmental pre-class limiting factors), Programme Structure (valuing in-class supervision, socialisation and adaptations) and Patient Characteristics (encompassing the influence of the service user's personality and experiences). Effective secondary prevention of stroke through cardiac rehabilitation and other exercise-based rehabilitation requires policy development and commissioning to ensure appropriate delivery. Further research should determine the feasibility of novel exercise class formats, in addition to larger trials investigating their clinical benefit and cost effectiveness.

Outcomes and Antithrombotic Regimens in Nonvalvular Atrial Fibrillation Patients With Acute Ischemic Stroke and Competing Large-Artery Atherosclerosis

OBJECTIVES

This study aimed to investigate the outcomes and effectiveness of different antithrombotic regimens at discharge in nonvalvular atrial fibrillation (NVAF) patients with acute ischemic stroke (AIS) and competing large artery atherosclerosis (LAA) mechanisms.

METHODS

In an observational study, we retrospectively analyzed the clinical and follow-up data of NVAF patients with AIS from January 2018 to December 2021 (NCT04080830). The subjects were grouped into 2 groups based on the presence or absence of competing LAA mechanisms. Stroke severity, short-term prognosis, and ischemic recurrence (a composite of ischemic stroke/TIA, myocardial infarction, or systemic embolism after index stroke), were compared between the 2 groups. Antithrombotic regimens at discharge were further categorized into antiplatelet and anticoagulant subgroups to analyze their effectiveness.

RESULTS

Five hundred-one NVAF patients with AIS (129 with and 372 without competing LAA mechanisms) were included. Compared with the other group, the group with competing LAA mechanisms had a higher proportion of patients with a nondisabling mRS score (P <0.001), lower mortality rates at the 90-day follow-up ( P =0.048), and higher 180-day ischemic outcomes ( P =0.023). Subgroup analysis showed that the ischemic outcomes were not significantly different ( P =0.166) between the anticoagulant and antiplatelet subgroups in patients with competing LAA mechanisms. In contrast, it was numerically higher in the anticoagulant subgroup.

CONCLUSION

NVAF patients with AIS due to competing LAA mechanisms had mild severity and a comfortable short-term prognosis; however, these patients had a higher risk of ischemic events. The optimal antithrombotic regimens in these patients remain unclear, and stroke mechanisms should be considered.

Gastrointestinal Dysfunction and Dysbiosis in Ischemic Stroke: Opportunities for Therapeutic Intervention

Although strokes originate in the brain, it is now widely appreciated that peripheral organ systems are also impacted by stroke. The gastrointestinal system is one peripheral organ system that is impaired during ischemic stroke. This impairment results in numerous complications, which impede post-stroke recovery. Many of the gastrointestinal mechanisms that contribute to the pathophysiology of ischemic stroke remain poorly understood. This review will highlight the molecular and cellular mechanisms underlying gastrointestinal outcomes in stroke by focusing on the complex interactions that largely occur in the small intestine. The final portion of this review will focus on therapeutic interventions that target the gut as a strategy to prevent or delay functional impairment and cognitive disability in stroke patients.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association of cardiorespiratory fitness with the incidence and progression trajectory of cardiometabolic multimorbidity

OBJECTIVES

This study examined the relationship of cardiorespiratory fitness (CRF) in the transition from healthy status to first cardiometabolic disease, subsequent cardiometabolic multimorbidity and further to death.

METHODS

We used data from the UK Biobank of 47 484 participants without cardiometabolic diseases at baseline. CRF was assessed via a 6 min incremental ramp cycle ergometer test and expressed in metabolic equivalent of tasks (METs, 1 MET=3.5 mL/kg/min). Cardiometabolic multimorbidity was defined as at least two diseases among diabetes, hypertension, coronary heart disease and stroke.

RESULTS

Over 12.5 years median follow-up, 8123 participants developed first cardiometabolic disease, 1958 developed cardiometabolic multimorbidity and 2177 died. CRF was associated with different transition stages in cardiometabolic multimorbidity development. The HRs (95% CIs) per MET increase in CRF were 0.94 (0.93 to 0.95) and 0.97 (0.96 to 0.99) for transitions from healthy baseline to first cardiometabolic disease and subsequent cardiometabolic multimorbidity. Per MET increase in CRF was associated with reduced risk of transition from healthy baseline to death (HR: 0.97, 95% CI 0.95 to 0.99), but not for the transition from first cardiometabolic disease and cardiometabolic multimorbidity to death. When first cardiometabolic disease was divided into specific cardiometabolic diseases, there were comparable trends of CRF on the disease-specific transitions from healthy baseline to first cardiometabolic disease and subsequent cardiometabolic multimorbidity.

CONCLUSION

Higher CRF was associated with a lower risk of progression from a healthy state to first cardiometabolic disease and subsequently to cardiometabolic multimorbidity. These findings suggest that improving CRF is a potential strategy for preventing cardiometabolic multimorbidity development.

Direct Oral Anticoagulant Use in Older Adults with Atrial Fibrillation: Challenges and Solutions

AF is the most common arrhythmia in clinical practice, with a large preponderance in the older (>75 years) adult population. Stroke is the most feared complication of AF, with huge corresponding morbidity and mortality. Anticoagulation is the mainstay for stroke prevention in AF, but is commonly underutilised in clinical practice due to the fear of intracerebral bleeding. Bleeding is the primary concern in older patients with conventional vitamin K antagonist use. Direct oral anticoagulants (DOACs) have been used for a decade in clinical practice and have been found to reduce major bleeds. The advantages of DOAC use in older patients include obviating the need for intermittent international normalised ratio monitoring, fewer drug interactions and reduction in intracerebral haemorrhage. The disadvantages of DOAC use include older patients having to take multiple doses per day and a lack of a universal antidote, as opposed to vitamin K antagonists. However, a lack of head-to-head trials among DOACs and specific randomised controlled trials in older patients preclude a definite conclusion regarding the ideal DOAC that should be used in the older population. Factor XI inhibition is an emerging approach for oral anticoagulation that holds promise for dissociating thrombosis from haemostasis. This provides an additional avenue for reducing bleeding in the older adult population.

Leukemia and risk of stroke: a Mendelian randomization analysis

BACKGROUND

Observational studies suggest an association between leukemia and stroke, but causality remains unclear. Certain leukemia types may increase stroke risk, but variations exist in stroke and mortality rates across leukemia subtypes. This study employed Mendelian randomization (MR) to investigate links between leukemia subtypes and stroke.

METHODS

We conducted a two-sample Mendelian randomization (TSMR) study utilizing genetic variants linked to various subtypes of leukemia as instruments to investigate their causal effects on stroke, specifically ischemic stroke (IS) and intracerebral hemorrhage (ICH). The leukemia dataset comprised 456,276 subjects from the UK Biobank, while the stroke dataset was sourced from the FINNGEN consortium, encompassing 212,774 participants.

RESULTS

In the present study, there was suggestive evidence that genetically predicted chronic lymphocytic leukemia (CLL) is associated with ischemic stroke (odds ratio, 1.02; 95% confidence intervals, 1.01-1.05; P = 0.024), but no significant association was observed with intracerebral hemorrhage (ICH) (0.74; 0.99-1.03; P = 0.237). Additionally, chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) was no significant associations between with stroke according to genetical prediction even if heterogeneity test and pleiotropic test was performed.

CONCLUSIONS

Our Mendelian randomization analysis revealed that chronic lymphocytic leukemia (CLL) was associated with an increased risk of ischemic stroke (IS) but not intracerebral hemorrhage (ICH). Conversely, there was no evidence supporting causal associations of chronic myeloid leukemia (CML), acute lymphoblastic leukemia (ALL), or acute myeloid leukemia (AML) with either type of stroke. These findings enhance our comprehension of the intricate interplay between various leukemia subtypes and the risk of stroke. Further research is essential to delve into the underlying mechanisms and potential clinical implications of these observed associations.

Sex differences and trends in managing cardiovascular risk factors in primary care: a dynamic cohort study

BACKGROUND

Treatment targets for cardiovascular risk management (CVRM) make no distinction between women and men.

AIM

To explore sex differences in achieving treatment targets in patients who participated in a nurse-led, integrated CVRM care programme in primary care between 2013 and 2019.

DESIGN & SETTING

We conducted a dynamic cohort study in the Eindhoven region, which is the south-eastern part of the Netherlands.

METHOD

We assessed outcomes of three biological risk factors (systolic blood pressure [SBP], low-density lipoprotein [LDL] cholesterol, and estimated glomerular filtration rate [eGFR]) and four lifestyle factors (smoking, physical activity, alcohol intake, and body mass index [BMI]). Points (1 = on target; 0 = not on target) were assigned for biological risk factors, lifestyle factors, and an overall score. Using the annual results, we applied multivariable regression models to study trends over time and differences in trends between women and men.

RESULTS

The number of participants increased from 24,889 to 38,067, mean age increased from 67.3 years to 71.5 years, with around 52 % women each year. The average of seven risk factors on target increased significantly from 4.6 to 4.9 in women, and from 4.7 to 5.0 in men, with no statistical difference between women and men. Differences between women and men in 2013 in the number of both biological and lifestyle factors on target did not materially change over time.

CONCLUSION

Integrated cardiovascular management care led to improvements in cardiovascular risk factors on target, equally well in women than in men. Differences in risk factors on target between women and men in 2013 were still present in 2019.

Efficacy of an avocado-based Mediterranean diet on serum lipids for secondary prevention after ischemic stroke: a randomized phase 2 controlled pilot trial

BACKGROUND

The impact of a healthy diet on the secondary prevention of ischemic stroke (IS) remains uncertain. Levels of low-density lipoprotein cholesterol (LDL-C) are inversely associated with the risk of IS recurrence. A Mediterranean diet (MeDi), consisting of a preference for fish/poultry, monosaturated fats from olive oil, fruit, vegetables, whole grains, legumes/nuts and limited red meats, animal fats and sweetened beverages, reduces metabolic syndrome, LDL-C levels and stroke risk. Avocados also reduce metabolic syndrome and LDL-C levels but are not part of the traditional MeDi diet. The effects of an avocado-based Mediterranean diet on LDL-C were investigated and compared to those of a low-fat diet in patients with previous IS.

METHODS

The Avocado-Based Mediterranean Diet on Serum Lipids for Secondary Prevention after Ischemic Stroke (ADD-SPISE) was a prospective, randomized, open-label, blinded outcome assessment, phase 2, clinical trial. The participants were adults with an IS in the previous month who were randomly assigned at a 1:1 ratio to a MeDi or a low-fat diet for three months. Outcome assessors of laboratory results and data analysts were masked. The primary outcome was the mean difference in LDL-C between groups at 90 days, adjusted by statin use. Safety, feasibility and acceptability (assessed through a 14-item questionnaire administered to all patients who completed the follow-up) were also evaluated.

RESULTS

From August 2018 to October 2022, 200 participants were enrolled (97 randomized to the low-fat diet and 103 to the MeDi), with 189 (94.5%) completing the study. There were no significant differences in LDL-C levels between the MeDi group and the low-fat group at 90 days: 66.5 mg/dL (95% confidence interval [CI] 59.6, 73.4) in the MeDi group and 69.9 mg/dL (62.6, 77.2) in the low-fat group at the end of follow-up. The adjusted difference was - 3.4 mg/dL (-13.4, -6.62); P = 0.50. The intervention group showed significant improvements in Mediterranean diet adherence (P < 0.01). Moreover, no significant differences in adverse events were observed between the groups.

CONCLUSION

Compared with a low-fat diet, the avocado-based MeDi did not significantly lower LDL-C in IS patients after three months. The intervention was safe, feasible, and well accepted. Larger trials should establish whether longer dietary interventions could yield clinically significant benefits in these patients. The study is registered under ADD-SPISE at www.

CLINICALTRIALS

gov . Identifier: NCT03524742.

Exploring Sex Differences in Outcomes of Dual Antiplatelet Therapy for Patients With Noncardioembolic Mild-to-Moderate Ischemic Stroke or High-Risk Transient Ischemic Attack: A Propensity-Matched Analysis of the READAPT Study Cohort

BACKGROUND

Sex may impact clinical outcomes in patients with stroke treated with dual antiplatelet therapy (DAPT). We aimed to investigate the sex differences in the short-term outcomes of DAPT within a real-world population of patients with noncardioembolic mild-to-moderate ischemic stroke or high-risk transient ischemic attack.

METHODS

We performed a propensity score-matched analysis from a prospective multicentric cohort study (READAPT [Real-Life Study on Short-Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or Transient Ischemic Attack]) by including patients with noncardioembolic mild-to-moderate stroke (National Institutes of Health Stroke Scale score of 0-10) or high-risk transient ischemic attack (age, blood pressure, clinical features, duration of transient ischemic attack, presence of diabetes [ABCD2] ≥4) who initiated DAPT within 48 hours of symptom onset. The primary effectiveness outcome was the 90-day risk of new ischemic stroke or other vascular events. The secondary effectiveness outcomes were the 90-day modified Rankin Scale score ordinal shift, vascular and all-cause mortality, and 24-hour early neurological improvement or deterioration. The safety outcomes included the 90-day risk of moderate-to-severe and any bleeding, symptomatic intracranial hemorrhage, and 24-hour hemorrhagic transformation. Outcomes were compared between sexes using Cox and generalized ordinal logistic regression analyses, along with calculating risk differences and ratios.

RESULTS

From 2278 patients in the READAPT study cohort, we included 1643 mild-to-moderate strokes or high-risk transient ischemic attacks treated with DAPT (mean age, 69.8±12.0 years; 34.3% women). We matched 531 women and men. The 90-day risk of new ischemic stroke or other vascular events was significantly lower among women than men (hazard ratio, 0.53 [95% CI, 0.28-0.99]; P=0.039). There were no significant differences in secondary effectiveness outcomes. The 90-day risk of safety outcomes was extremely low and did not differ between women and men (moderate-to-severe bleedings: 0.4% versus 0.8%; P=0.413; symptomatic intracranial hemorrhage: 0.2% versus 0.4%; P=0.563). Subgroup analysis for primary effectiveness outcome showed a lower 90-day risk of new ischemic stroke or other vascular events among women aged <50 years, baseline National Institutes of Health Stroke Scale score of 0 to 5, prestroke modified Rankin Scale score <2, large artery atherosclerosis cause, and no diabetes.

CONCLUSIONS

Our findings suggest that women with noncardioembolic mild-to-moderate stroke or high-risk transient ischemic attack treated with DAPT may have lower short-term risk of recurrent ischemic events than men. Further research is needed to understand the mechanisms behind potential sex-based differences in outcomes after DAPT use.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05476081.

The stroke seesaw: unveiling the enigma of stuttering acute ischemic stroke

Introduction

Beyond the familiar face of the acute ischemic stroke, lies the unexpected display of symptoms challenging our preconceptions and beckoning us to explore the intriguing nuances that lie beneath the surface.

Presentation of case

We introduce an unusual case of an older adult who presented to our institution with repetitive focal neurologic deficits (FND). Initial investigation was negative for any brain hemorrhage or infarcts. Repeat investigation during readmission showed findings of brain infarct for which appropriate treatment was provided. The fluctuating pattern of FND is what we refer to as a stuttering presentation of stroke.

Discussion

Our case brings attention to stuttering, an atypical presentation of ischemic stroke, not previously well described in medical literature. Our case demonstrates that stuttering stroke presentations may imitate more short-lived neurologic events such as transient ischemic attacks.

Conclusion

All the patient events throughout the entirety of their time course should be thoroughly reviewed so that thrombolytics can then be considered in the earliest window of opportunity for patients with stuttering stroke presentations to prevent disability due to ischemic stroke.

Cardiovascular disease in the Americas: the epidemiology of cardiovascular disease and its risk factors

This first article of the Series about Cardiovascular Disease in the Americas summarizes the epidemiology of CVD and its risk factors, and population-level strategies in place aimed at CVD prevention. While age-standardized CVD incidence and CV mortality rates have been decreasing across in the Americas since 1990, the annual number of CVD cases and related deaths have increased due to population growth and ageing. The burden of CVD is also slowly transitioning from high-income countries in North America to middle-income countries in Latin America and the Caribbean. Trends in CV risk factor levels have been mixed, with declines in smoking and mean cholesterol counterbalanced by higher prevalence of obesity and diabetes. Population-wide strategies aimed at controlling cardiometabolic risk factors and tobacco use have been implemented with varying degrees of success. There is a need to better implement existing CVD prevention strategies in the region.

The effect of clinical pharmacist-led pharmaceutical care services on medication adherence, clinical outcomes and quality of life in patients with stroke: a randomised controlled trial

BACKGROUND

Stroke is a major cause of morbidity and mortality worldwide. Pharmaceutical care services play a significant role in managing the risk factors associated with stroke.

AIM

This study aimed to examine the effects of a one-year pharmaceutical care programme on medication adherence, quality of life and clinical outcomes of patients with stroke.

METHOD

This study was conducted as a randomised controlled trial at the neurology clinic of a university hospital in Türkiye. Patients were randomly assigned to either an intervention group or usual care group (IG vs UCG). A simple randomization method using computer-based random numbers was used to assign participants in a 1:1 ratio. The IG received pharmaceutical care including medication reconciliation, medication review and patient education in addition to routine health services. The medication adherence, quality of life and clinical parameters of the patients were evaluated at the beginning and the end of the 12th month.

RESULTS

This study included 193 patients (89 and 104 patients in the IG and the UCG, respectively; mean age: 60.1 years), of whom 67.4% were male. At the one-year follow-up evaluation, the percentage of adherent patients (86.5% vs 47.1%, p < 0.001) and the total Stroke-Specific Quality of Life score (184.9 vs 166.0, p < 0.001) were higher in the IG than in the UCG. The stroke recurrence rate at the one-year follow-up (2.2% vs 10.6%, p = 0.044) was lower in the IG than in the UCG.

CONCLUSION

Pharmaceutical care services improved the medication adherence, quality of life and clinical outcomes of patients with stroke.

THE CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06129318; Study Registration Date: 13 November 2023.

Remnant Cholesterol and Residual Risk of Atherosclerotic Cardiovascular Disease

Remnant cholesterol (RC) is increasingly recognized as a key target in the treatment of atherosclerotic cardiovascular disease (ASCVD), addressing much of the residual risk that persists despite standard therapies. However, integrating RC into clinical practice remains challenging. Key issues, such as the development of accessible RC measurement methods, the identification of safe and effective medications, the determination of optimal target levels, and the creation of RC-based risk stratification strategies, require further investigation. This article explores the complex role of RC in ASCVD development, including its definition, metabolic pathways, and its association with both the overall risk and residual risk of ASCVD in primary and secondary prevention. It also examines the effect of current lipid-lowering therapies on RC levels and their influence on cardiovascular outcomes. Recent research has highlighted promising advancements in therapies aimed at lowering RC, which show potential for reducing major adverse cardiovascular events (MACEs). Inhibitors such as angiopoietin-like protein 3 (ANGPTL3), apolipoprotein C-III (apoCIII), and proprotein convertase subtilisin/kexin type 9 (PCSK9) have demonstrated their ability to modulate RC and reduce MACEs by targeting specific proteins involved in RC synthesis and metabolism. There is a pressing need for larger randomized controlled trials to clarify the role of RC in relevant patient populations. The development of targeted RC-lowering therapies holds the promise of significantly reducing the high rates of morbidity and mortality associated with ASCVD.

Physical Activity Habits and Incident First-Ever Stroke in Middle-Aged Adults-A Prospective Cohort Study

BACKGROUND

Lifestyle affects the risk of cardiovascular events such as myocardial infarction and stroke. Several lifestyle factors, such as physical activity (PA), are modifiable, and in this study, we examined the association between leisure-time PA habits and the risk of a first-ever stroke.

METHODS

This prospective study included residents in Västerbotten, Sweden, who participated in the Västerbotten Intervention Programme at 40, 50, and 60 years of age. Altogether, 31,855 individuals (50.5% women, mean age: 42.6 [6.9] y at baseline) participated between 1989 and 2016. Leisure-time PA was categorized as irregular (never/now and then) or regular (once a week/2 or 3 times a week/more than 3 times a week). Changes in PA were compared between examinations (10 y apart). Cases of stroke were validated according to World Health Organization MONICA (Monitoring Trends and Determinants of Cardiovascular Disease) criteria. The risk related to changes in leisure-time PA was estimated using a multivariable Cox regression model.

RESULTS

During an average follow-up of 9.8 years (4.4), 609 incident first-ever stroke cases occurred (1.9%). A multivariable model showed that, compared with individuals with irregular PA at both examinations, those reporting regular PA over time had a lower risk of stroke (hazard ratio: 0.78, 95% CI, 0.61-0.99).

CONCLUSION

Middle-aged adults who maintained regular PA during their leisure time over 10 years had a lower risk of a first-ever stroke. This association is probably partly mediated by lower body mass index and a reduced risk of hypertension and diabetes.

Co-designing interprofessional education in primary healthcare: an illustration from the Make My Day stroke prevention project

The aim of this paper is to describe a research process of actively engaging stakeholders using co-design in the development of interprofessional education and a health intervention program targeting stroke prevention. Stakeholders included potential patients, healthcare professionals, and healthcare experts/researchers. Collaborating through co-design can be utilized in developing primary healthcare interventions including educational strategies for interprofessional learning. In this paper, an intervention in primary healthcare (Make My Day) will be used to illustrate how co-design was applied, partly as a method for developing educational resources together with stakeholders, and partly by engaging interprofessional healthcare teams in adapting intervention materials to address the needs of groups more specifically at risk of stroke in local contexts. There is a need to actively involve stakeholders, build on user experiences, and integrate interprofessional knowledge in the design and evaluation of health interventions. However, there is a lack of detailed accounts about how this can be accomplished. This study illustrates collaborative research process components and thus contributes with knowledge about how co-design methods can be applied in health intervention design as well as in interprofessional education within primary healthcare settings.

Parental divorce's long shadow: Elevated stroke risk among older Americans

Although studies have investigated the association between adverse childhood experiences and chronic health outcomes including stroke, few studies have investigated the association between parental divorce and stroke among adults with no history of childhood abuse. The objectives of this study were to investigate the association between parental divorce in childhood and stroke in older adulthood among those who did not experience child abuse and to examine whether this association differs between men and women. This study utilized population-based data from the 2022 Behavioral Risk Factor Surveillance System. An analytic sample of 13,205 adults aged 65 and above (56.6% female) who have never experienced childhood physical nor sexual abuse were analyzed using binary logistic regression. The outcome variable investigated was self-report of a physician-diagnosis of stroke, and the main exposure of interest was parental divorce. In this sample of older adults, 7.3% reported having stroke, while 13.9% reported that their parents had divorced before the respondent was 18 years old. Controlling for the effects of other factors, respondents who experienced parental divorce had 1.61 times higher odds of having a stroke when compared to their counterparts who did not experience parental divorce (AOR = 1.61, 95% CI = 1.15-2.24). The association between parental divorce and stroke was not dependent on sex; however, compared to females, males had 1.47 times higher odds of having a stroke (AOR = 1.47, 95% CI = 1.11-1.93). The findings of this study suggest that individuals in this cohort whose parents divorced as children were at greater risk for stroke later in life. Potentially moderating variables were hypothesized, including childhood poverty, sleep hygiene, and hypertension.

Clinical significance of a new diagnosis of atrial fibrillation in patients with vascular disease

BACKGROUND

The Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial enrolled patients with vascular disease but excluded patients requiring oral anticoagulation.

OBJECTIVE

We aimed to explore the clinical significance of a new diagnosis of atrial fibrillation (AF) during follow-up.

METHODS

New AF was identified from hospitalization, study drug discontinuation, and adverse event reports. Multivariable Cox regression was used to determine risk factors for new AF. Time-updated covariate analysis was used to study the association of new AF with outcomes.

RESULTS

During a mean follow-up of 23 months, 655 of 27,395 participants (2.4%) were diagnosed with AF (incidence, 1.3 per 100 patient-years). In adjusted analyses, advanced age, male sex, White ethnicity, higher body mass index, higher systolic blood pressure, heart failure, and prior myocardial infarction were associated with new AF. Compared with participants without a new diagnosis of AF during follow-up or before receiving a diagnosis of new AF, participants were at increased risk of a composite outcome of cardiovascular death, stroke, or myocardial infarction after a new diagnosis of AF (8.8 vs 2.4 per 100 patient-years; hazard ratio [HR], 3.66; 95% confidence interval [CI], 2.81-4.75). Risk increases with new AF were also observed for hospitalization for heart failure (6.8 vs 0.8 per 100 patient-years; HR, 8.64; 95% CI, 6.31-11.83) and major bleeding (3.9 vs 1.3 per 100 patient-years; HR, 3.18; 95% CI, 2.15-4.69).

CONCLUSION

In patients with vascular disease, a new diagnosis of AF was associated with a marked increase in risk of adverse outcomes, especially hospitalization for heart failure.

Blood pressure targets, medication considerations and special concerns in elderly hypertension III: Focus on stroke and neurodegenerative disorders

Controlling hypertension has become an important issue in the elderly population in whom neurological comorbidities are highly prevalent. Most of the large-scale trials focusing on hypertension management in older populations have excluded patients with comorbid neurological disorders. However, this population requires special considerations, as the benefits of antihypertensive agents are mostly uncertain and there is a higher risk of adverse events. In this review article, we discuss current evidence regarding the management of elderly patients with hypertension and common neurological disorders, including stroke and neurodegenerative diseases. In elderly patient with a history of stroke, the blood pressure management strategy is generally similar to that for young patients, however the benefits of stroke prevention from blood pressure control are less significant. For patients with neurodegenerative disorders such as cognitive dysfunction and Parkinson's disease, achieving adequate blood pressure control may be beneficial in reducing cardiovascular risks, although the higher risk of adverse events from antihypertensive treatment may offset some of these benefits. Special considerations for factors such as orthostatic hypotension, risk of falls, polypharmacy, and significant drug-drug interactions are required but frequently neglected in clinical practice. More efforts are warranted to determine the optimal treatment strategy for elderly populations with neurological disorders.

Association between alcohol consumption and stroke in Nigeria and Ghana: A case-control study

BACKGROUND

The aim of the study was to examine the association between alcohol consumption and stroke in Nigeria and Ghana.

METHODS

The study is a multicentre, case-control study. Cases included consenting adults 18 years of age and older with acute stroke and controls were age-and -gender -matched stroke -free adults. Alcohol consumption was self-reported. The participants were classified into three alcohol-drinking status, which included abstainers, former drinkers, and current drinkers. The current drinkers were further classified into different alcohol drinking levels, including infrequent, light, moderate, heavy, and binge drinkers. Conditional logistic regression was used to determine associations between the drinking status and stroke, and the association between the different levels of current alcohol consumption and stroke. Five models were evaluated. Model 1 was unadjusted. Model 2 was adjusted for demographic characteristics. Model 3 included Model 2, lifestyle and psychosocial characteristics. Model 4 included Model 3 and dietary characteristics. Model 5 included Model 4 and metabolic characteristics.

RESULTS

A total of 7368 participants took part in the study. Half were stroke participants, and half were control participants. On the associations between drinking status and stroke, respectively, former drinkers showed no significant association with stroke. However, a significant association was observed between current drinkers and stroke in Models 1 and 2, with an odds ratio of 1.19 (95% CI: 1.04-1.38; p < 0.05) and 1.17 (95% CI: 1.01-1.36; p < 0.05), respectively. Regarding the various levels of current alcohol drinking and their association with stroke, no significant association was observed between light drinking and stroke in Model 5. In contrast, moderate drinkers, binge drinkers, and heavy drinkers showed a persistent and significant association with stroke respectively.

CONCLUSION

There is a significant association between stroke and current alcohol consumption, especially among heavy, binge, and moderate drinkers.

Six-year change in high-sensitivity cardiac troponin T with subsequent stroke risk in the general population

BACKGROUND

The association between change in high-sensitivity cardiac troponin T (hs-cTnT) and stroke risk in the general population remains unknown. We aimed to assess the association of a 6-year change in hs-cTnT with incident stroke and its subtypes in the general American adult population.

METHODS

8675 middle-aged adults without prevalent cardiovascular disease from the Atherosclerosis Risk in Communities study were included. Hs-cTnT was measured at two time points (visits 2 and 4), 6 years apart. The relative percentage change of hs-cTnT was defined as hs-cTnT at visit 4 minus that at visit 2, divided by hs-cTnT at visit 2. The study outcome was incident stroke and its subtypes. All data were analysed in 2023.

RESULTS

Over a median follow-up of 20.1 years, 682 incident strokes occurred, including 593 ischaemic and 89 haemorrhagic strokes. For absolute change, using low/low group as reference category, the low/high (adjusted HR 1.44, 95% CI 1.03 to 2.02) and high/high (adjusted HR 1.47, 95% CI 0.93 to 2.34) groups were associated with higher risk of stroke. Moreover, the relative percentage change in hs-cTnT with stroke followed an inverted L-shaped association, levelling off at about 75% increase in hs-cTnT (P for nonlinearity=0.009). Compared with those with ≤50% change in hs-cTnT, participants with >50% increase in hs-cTnT had a higher risk of stroke (adjusted HR 1.30, 95% CI 1.03 to 1.64). Similar results were found for ischaemic stroke. No significant association was found for haemorrhagic stroke.

CONCLUSION

Temporal increase in hs-cTnT was associated with a higher risk of incident total and ischaemic stroke in the general population.

Genetic insights into the risk of hip osteoarthritis on stroke: A single-variable and multivariable Mendelian randomization

BACKGROUND

Hip osteoarthritis has been identified as a potential risk factor for stroke, with previous studies have demonstrated an association between hip osteoarthritis and stroke. This study aims to further elucidate the causal relationship between the two, employing Two-Sample and Multivariable Mendelian randomization methods.

METHODS

SNPs, derived from two extensive GWAS, served as instruments in exploring the association between genetically predicted hip osteoarthritis and stroke risk, utilizing two-sample Mendelian randomization. In Multivariable Mendelian randomization, factors such as cigarettes per day, alcoholic drinks per week, hypertension, body mass index, type 2 diabetes, C-reactive protein, rheumatoid arthritis were incorporated to further account for the independent causal effects of multiple correlated exposures.

RESULTS

Two-sample Mendelian randomization analysis revealed that hip osteoarthritis exerts a potential causal effect on any stroke, any ischemic stroke, and cardioembolic stroke, while it did not influence large artery stroke and small vessel stroke. Multivariable MR analysis indicated that the causal effect of hip osteoarthritis on any ischemic stroke and cardioembolic stroke was no longer evident after adjusting for C-reactive protein, and similarly, the effect on any ischemic stroke was not observed after adjusting for type 2 diabetes. However, the effects on any stroke, any ischemic stroke, and cardioembolic stroke remained significant after adjustments for hypertension, alcoholic drinks per week, cigarettes per day, body mass index, and rheumatoid arthritis.

CONCLUSION

The study demonstrated that elevated hip osteoarthritis, as predicted by genetic factors, was potential associated with an increased risk of any stroke, any ischemic stroke, and cardioembolic stroke, but showed no correlation with hypertension, alcoholic drinks per week, cigarettes per day, type 2 diabetes, C-reactive protein, body mass index levels, and rheumatoid arthritis.

Study on the relationship among typhoon, weather change and acute ischemic stroke in southern Zhejiang Province of China

OBJECTIVE

This study aimed to investigate the relationship between the unique weather change and acute ischemic stroke (AIS) in the southern Zhejiang Province of China and to provide evidence for better predicting and preventing stroke.

METHODS

We retrospectively collected 14,996 ischemic stroke patients data and weather data from January 2019 to December 2021 in the southern Zhejiang Province of China. The correlation and risk between meteorological factors and the number of AIS daily cases were calculated. Wilcoxon rank sum test was used to calculate the difference in the number of cases between typhoon-affected and non-affected periods. A prediction model obeying Poisson regression was established, and the accuracy of the correlation factors in predicting the number of cases was verified.

RESULTS

In southern Zhejiang Province, the number of AIS was the highest in summer and the lowest in spring. Stroke onset is associated with temperature, water vapor pressure and typhoons (P < 0.05). The presence of typhoon (RR 0.882; 95% CI 0.834 to 0.933, P < 0.001) was a protective factor, while maximum temperature (RR 1.021; 95% CI 1.008 to 1.033, P = 0.043) and the water vapor pressure (RR 1.036; 95% CI 1.006 to 1.067, P = 0.036) were risk factors. The occurrence under the influence of typhoons was lower than that without the influence of typhoons (P < 0.05). The prediction model can predict the occurrence of stroke.

CONCLUSION

An association was observed between the occurrence of AIS, temperature, water vapor pressure and typhoon in the southern Zhejiang Province of China. Typhoon occurrence was associated with fewer cases. The predictive model may help high-risk populations prevent diseases early and assist hospitals in allocating resources promptly.

Application of Dragonnet and Conformal Inference for Estimating Individualized Treatment Effects for Personalized Stroke Prevention: Retrospective Cohort Study

Background

Stroke is a major cause of death and disability worldwide. Identifying individuals who would benefit most from preventative interventions, such as antiplatelet therapy, is critical for personalized stroke prevention. However, traditional methods for estimating treatment effects often focus on the average effect across a population and do not account for individual variations in risk and treatment response.

Objective

This study aimed to estimate the individualized treatment effects (ITEs) for stroke prevention using a novel combination of Dragonnet, a causal neural network, and conformal inference. The study also aimed to determine and validate the causal effects of known stroke risk factors-hypertension (HT), diabetes mellitus (DM), dyslipidemia (DLP), and atrial fibrillation (AF)-using both a conventional causal model and machine learning models.

Methods

A retrospective cohort study was conducted using data from 275,247 high-risk patients treated at Ramathibodi Hospital, Thailand, between 2010 and 2020. Patients aged >18 years with HT, DM, DLP, or AF were eligible. The main outcome was ischemic or hemorrhagic stroke, identified using International Classification of Diseases, 10th Revision (ICD-10) codes. Causal effects of the risk factors were estimated using a range of methods, including: (1) propensity score-based methods, such as stratified propensity scores, inverse probability weighting, and doubly robust estimation; (2) structural causal models; (3) double machine learning; and (4) Dragonnet, a causal neural network, which was used together with weighted split-conformal quantile regression to estimate ITEs.

Results

AF, HT, and DM were identified as significant stroke risk factors. Average causal risk effect estimates for these risk factors ranged from 0.075 to 0.097 for AF, 0.017 to 0.025 for HT, and 0.006 to 0.010 for DM, depending on the method used. Dragonnet yielded causal risk ratios of 4.56 for AF, 2.44 for HT, and 1.41 for DM, which is comparable to other causal models and the standard epidemiological case-control study. Mean ITE analysis indicated that several patients with DM or DM with HT, who were not receiving antiplatelet treatment at the time of data collection, showed reductions in total risk of -0.015 and -0.016, respectively.

Conclusions

This study provides a comprehensive evaluation of stroke risk factors and demonstrates the feasibility of using Dragonnet and conformal inference to estimate ITEs of antiplatelet therapy for stroke prevention. The mean ITE analysis suggested that those with DM or DM with HT, who were not receiving antiplatelet treatment at the time of data collection, could potentially benefit from this therapy. The findings highlight the potential of these advanced techniques to inform personalized treatment strategies for stroke, enabling clinicians to identify individuals who are most likely to benefit from specific interventions.

The association between the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and lymphocyte-to-monocyte ratio and delirium in ischemic stroke patients

Background

Delirium is a severe neuropsychiatric symptom following acute ischemic stroke (IS) and is associated with poor outcomes. Systemic inflammation and immune dysregulation are believed to contribute to the pathophysiology of delirium. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are widely recognized as convenient and reliable biomarkers of systemic inflammation. However, their association with delirium after IS remains unclear.

Methods

In this study, we identified IS patients requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC)-IV database. We employed multivariable logistic regression and restricted cubic splines (RCS) to assess the association between the NLR, PLR, and LMR and delirium. Two-sample Mendelian randomization (MR) analysis was performed to further explore their causal relationship at the genetic level.

Results

A total of 1,436 patients with IS were included in this study, of whom 214 (14.9%) had delirium. In the multivariate logistic regression analysis, after adjustment for confounders, the patients in the highest quartile of the NLR (odds ratio [OR] 2.080, 95% confidence interval [CI], 1.282-3.375) and LMR (OR 0.503, 95% CI 0.317-0.798) and the patients in the second quartile of the PLR (OR 1.574, 95% CI 1.019-2.431) were significantly associated with delirium. The RCS function showed a progressive increase in the risk of delirium with higher NLR and PLR and lower LMR. In the MR analysis, only the PLR was negatively associated with the risk of delirium.

Conclusion

The observational studies found significant associations between the NLR, PLR, and LMR and delirium. However, the MR analysis only demonstrated a potential protective causal relationship between the PLR and delirium. Further prospective studies are needed to validate their association and to elucidate the underlying mechanisms.

Association between metabolic score for insulin resistance and stroke: a nationally representative cross-sectional study from NHANES 2007-2018

Background

Stroke is a significant cerebrovascular disease and remains one of the leading causes of death and disability worldwide. Insulin resistance has been strongly linked to the incidence of stroke. Employing characteristics of metabolic syndrome, the Metabolic Score for Insulin Resistance (METS-IR) accurately measures insulin resistance. Nonetheless, the relationship between METS-IR and stroke risk is not well-established.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) covering the years 2007-2018. Participants providing complete METS-IR data and self-reported stroke information were included in the study. We utilized weighted multivariate regression to explore the relationship between METS-IR and stroke, performing subgroup analyses as well.

Results

A total of 14,794 participants were included, with an average METS-IR of 43.44 ± 12.68. The overall prevalence of self-reported stroke was 3.79%, with higher rates observed in upper METS-IR tertiles. An increase of one unit in METS-IR was associated with a 1% increase in stroke risk (OR = 1.01; 95% CI: 1.01-1.02). Interaction tests indicated no significant effects of gender, smoking status, alcohol consumption, hypertension, diabetes, physical activity, or serum cholesterol levels on this relationship. Notably, for participants younger than 60 years, the association was significantly stronger (OR = 1.02; 95% CI: 1.01-1.03), with a marked interaction (p = 0.0061).

Conclusion

Our findings indicate a positive correlation between higher METS-IR and increased stroke risk. Early intervention targeting insulin resistance may be a viable preventive measure against stroke, particularly in individuals under 60 years of age.

Modifiable Risk Factors for Stroke in Syria: A Nationwide Multi-centre Case-Control Study

Stroke is the second-leading cause of death worldwide, including in Syria, and the third-leading cause of death and disability combined. With approximately 90% of strokes worldwide linked to modifiable risk factors, identifying and quantifying these factors within a specific population is essential for effective prevention. This is the first study to investigate primary risk factors for stroke in Syria. This study included the six primary stroke centres across four major cities in Syria. Data was collected through case files and a questionnaire answered by the cases or their proxies through personal interviews, as well as selected controls. A total of 411 cases were recruited, comprising 363 ischemic strokes (IS) and 48 haemorrhagic strokes, and with a matched ratio of 1:1 for age and sex. IS was significantly associated with multiple chronic conditions including atrial fibrillation AF [AOR 5.04 (2.64-9.62)], high body mass index (overweight [AOR 2.09 (1.28-3.40)], obesity [AOR 4.17 (2.32-7.50)]), hypercholesterolemia [AOR 2.10 (1.34-3.28], hypertension HTN [AOR 1.83 (1.23-2.73)], and diabetes mellitus DM [AOR 1.79 (1.18-2.71)]. Moreover, several lifestyle risk factors contributed to IS: Alcohol consumption [AOR 4.80 (1.72-13.41)], a diet lacking fruits and vegetables [AOR 2.04 (1.28-3.23)], and low physical activity PA [AOR 1.75 (1.01-2.86)]. Notably, over 40% of the population exhibited medication nonadherence. IS showed no significant association with cigarette smoking, heart failure (HF), ischemic heart disease (IHD), or a family history of stroke (p > 0.05). In contrast, haemorrhagic stroke was linked to higher BMI, HTN, DM, and AF (p < 0.05), but not to hypercholesterolemia, cigarette smoking, IHD, or HF (p > 0.05). This first nationwide multicentre case-controlled study in Syria identified critical modifiable risk factors for stroke, including hypertension, diabetes, atrial fibrillation, and obesity, with high rates of medication non-adherence, especially among hypertensive patients, complicating stroke risk. These findings underscore the urgent need for targeted health interventions promoting lifestyle modifications, medication adherence, and public health policies tailored to Syria's current resource-limited context to reduce the stroke burden and improve population health.

Peripheral blood ABCG1 gene DNA methylation: mediating the relationship between dietary intake of methyl donor nutrients and stroke risk

Dysregulation of methyl donor nutrients interferes with DNA methylation and is associated with neurological diseases. ABCG1 gene regulates cholesterol to HDL-C, maintains lipid homeostasis, and has been linked to both methyl nutrition and neurological risks. The aim was to investigate whether there is an effect of ABCG1 DNA methylation on the relationship between intake of methyl donor nutrients and the risk of stroke occurrence. We hypothesize that the intake of methyl donor nutrients may influence stroke occurrence by modulating the methylation status of ABCG1. This study utilized a case-control design and selected 52 stroke patients along with 52 healthy controls from Northwest China. Dietary information was collected using a FFQ, and methylation levels were measured at 29 CpG sites of the ABCG1 gene. A significant linear trend was found between dietary intake of the methyl donor nutrient choline and CpG_19.20 methylation of the ABCG1 gene (β = -0.037, P = 0.033). Additionally, a significant association was observed between CpG_19.20 methylation and the risk of stroke (OR 2.325, 95% CI 1.210-4.466). Mediation analysis revealed that choline intake indirectly influenced stroke occurrence through its effect on CpG_19.20 methylation levels in the ABCG1 gene (β = -0.015, SE = 0.013, 95% CI = [-0.053, -0.001]). We found that DNA methylation at specific CpG sites of the peripheral blood ABCG1 gene mediates the association between dietary methyl donor nutrient intake and stroke risk in an adult population from Northwest China. New insights are provided on the prevention and treatment of stroke.

Association between short-term exposure to meteorological factors on hospital admissions for hemorrhagic stroke: an individual-level, case-crossover study in Ganzhou, China

BACKGROUND

Hemorrhagic stroke (HS) is associated with significant disability and mortality. However, the relationship between meteorological factors and hemorrhagic stroke, as well as the potential moderating role of these factors, remains unclear.

METHODS

Daily data on HS, air pollution, and meteorological conditions were collected from January 2015 to December 2021 in Ganzhou to analyze the relationship between meteorological factors and HS admissions. This analysis employed a time-stratified case-crossover design in conjunction with a distributional lag nonlinear model. Additionally, a bivariate response surface modelling was utilized to further investigate the interaction between meteorological factors and particulate matter. The study also stratified the analyses by gender and age. To investigate the potential impact of extreme weather conditions on HS, this study defined the 97.5th percentile as representing extremely high weather conditions, while the 2.5th percentile was classified as extremely low.

RESULTS

In single-day lags, the risk of admissions for HS was significantly associated with extremely low temperature (lag 1-2 and lag 13-14), extremely low humidity (lag 1 and lag 9-12), and extremely high precipitation (lag 2-7). Females exhibited greater susceptibility to extremely low temperature than males within the single-day lag pattern in the subcomponent layer, with a maximum relative risk (RR) that was 7% higher. In the cumulative lag analysis, the risk of HS admissions was significantly associated with extremely high temperature (lag 0-8∼lag 0-14), extremely low humidity (lag 0-2∼lag 0-14), and extremely high precipitation (lag 0-4∼lag 0-14). Within the cumulative lag day structure of the subcomponent layer, both extremely low and extremely high temperature had a more pronounced effect on females and aged ≥65 years. The risk of HS admissions was positively associated with extremely high barometric pressure in the female subgroups (lag 0-1 and lag 0-2). The highest number of HS admissions occurred when high PM2.5 concentrations coexisted with low precipitation.

CONCLUSIONS

Meteorological factors were significantly associated with the risk of hospital admissions for HS. Individuals who were female and aged ≥65 years were found to be more susceptible to these meteorological influences. Additionally, an interaction was observed between airborne particulate matter and meteorological factors. These findings contributed new evidence to the association between meteorological factors and HS.

Posttreatment Blood Pressure as a Key Predictor in a 5-Year Stroke Prediction Model

Evidence suggests that approximately 63.0%-84.2% of stroke survivors have hypertension, yet there is currently no stroke prediction tool specifically designed for individuals with hypertension. Using data from 20 702 hypertensive patients from the China Stroke Primary Prevention Trial (CSPPT), we developed a 5-year stroke risk prediction model. This prospective study collected treated blood pressure every 3 months, resulting in 22 measurements over the study period. The model was internally validated using bootstrap resampling, and its predictive performance was assessed with the C-index and calibration curves. We also developed a random forest model to rank the variable importance. The 5-year stroke risk prediction model for hypertensive individuals includes 10 risk factors, ranked by importance as follows: average systolic blood pressure during treatment, age, average diastolic blood pressure during treatment, baseline systolic blood pressure, history of diabetes, baseline total cholesterol level, baseline folate level, self-reported stress, smoking, and folic acid supplementation or not. The C statistic of the equation was 0.74 and there were no significant differences by gender or treatment group. Calibration plots indicate good internal consistency between observed and predicted 5-year stroke risk. We also developed an online calculator to assist clinicians and patients (https://zhouziyi.shinyapps.io/CSPPT/). Our study indicates that for patients with hypertension, long-term posttreatment blood pressure is the primary predictor of stroke risk. Trial Registration: The CSPPT (clinicaltrials.gov Identifier: NCT00794885).

Association between physical activity levels and stroke risk among Chinese adults aged 45 and over based on CHARLS

Stroke is one of the leading causes of death in developing countries, and China bears the largest global burden of stroke. This study aims to investigate the relationship between different dimensions of physical activity levels and stroke risk using a nationally representative database. We performed a cross-sectional analysis using data from the China Health and Retirement Longitudinal Study (CHARLS) 2020. Binary logistic regression models were used to analyze the associations between different dimensions of physical activity levels (intensity, frequency, duration, and total physical activity (TPA)) and stroke risk in Chinese middle-aged and older adults. Subgroups were analyzed according to participants' age, sex, residency, hypertension, dyslipidemia, and diabetes stratification. The results showed that after adjusting for all covariates, almost all frequencies and durations of moderate physical activity (MPA), and high-frequency and long-duration vigorous physical activity (VPA) were associated with lower stroke risk. No significant relationship was observed between light physical activity (LPA) and stroke risk. TPA was categorized into quartiles (Q1, Q2, Q3, Q4). Compared with the first quartile, the third and fourth quartiles were significantly associated with lower stroke risk, with risk reductions of 35% (OR 0.65, 95% CI 0.50-0.84) and 42% (OR 0.58, 95% CI 0.44-0.76), respectively. Subgroup analysis revealed differences in the association between TPA and stroke risk in different populations, and the interaction test indicated no significant interactions between these variables and TPA. Our findings suggested that appropriate participation in physical activity is effective in preventing stroke in middle-aged and older adults. Both MPA and high-frequency or long-duration VPA were significantly associated with lower stroke risk, and keeping TPA at a high level was significantly associated with lower stroke risk.

Global burden of stroke attributable to dietary risk factors in the GBD 2021 study

Objective

We sought to assess the impact of dietary risk on the worldwide burden of stroke, focusing specifically on ischemic stroke.

Methods

Utilizing information from the Global Burden of Disease Study 2021 (GBD2021), we evaluated the age-standardized death rate (ASDR), the age-standardized disability-adjusted life years (DALYs) rate, and the age, sex, and regional distribution of the estimated annual percentage change (EAPC) of the stroke burden linked to dietary risk from 1990 to 2021.

Results

The global overall ASDR and the age-standardized DALY rate per 100,000 population for stroke linked to dietary risk from 1990 to 2021 exhibited a declining trend [EAPC = -1.95; EAPC = -1.70, respectively]. The reduction in ASDR was statistically more pronounced in female (EAPC = -2.42) compared to males (EAPC = -1.60). The dietary factor exerting the most significant impact on stroke in 2021 was a high sodium diet, succeeded by a diet deficient in fruit. The regions and countries most affected by a high-sodium diet on the ASDR for ischemic stroke are Central Europe (9.86 per 100,000 population) and North Macedonia (33.13 per 100,000 population), respectively; the regions and countries with the most substantial influence on the age-standardized DALY rate are East Asia (187.15 per 100,000 population) and North Macedonia (477.26 per 100,000 population). The ASDR and age-standardized DALY rates across 5 Socio-Demographic Index (SDI) regions, 20 regions, and over 170 countries worldwide demonstrated a notable downward trend, with the regions experiencing the most significant decline being High SDI (EAPC: -3.64; EAPC: -2.74, respectively). The sole increase in ASDR was recorded in southern sub-Saharan Africa.

Conclusion

The worldwide toll of stroke linked to dietary risks may have diminished from 1990 to 2021. Nevertheless, the most significant dietary contributors are diets rich in sodium and deficient in fruit, with the stroke burden associated with dietary risks remaining especially elevated in Central Europe, East Asia, and Eastern Europe. Lowering sodium consumption and enhancing fruit intake can aid in alleviating the global disease burden.

Effectiveness and compliance of telemedicine on blood pressure management in poststroke patients: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To examine the effectiveness of telemedicine on blood pressure control and compliance.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search of PubMed, Web of Science, Embase and Cochrane Library for studies of randomised controlled trials (RCTs) of telemedicine on blood pressure control in poststroke survivors from the time of their construction until November 2023. Inclusion criteria were as follows: (1) studies that were RCTs; (2) enrolment of patients who were stroke survivors; (3) studies that compared subjects who received telemedicine with usual care treatment. Exclusion criteria were as follows: (1) studies in which telemedicine was used for other diseases; (2) study protocols with no data; (3) non-English language articles and (4) case reports, conference papers, letters or articles with incomplete data. Quality assessment of included studies was performed using the Cochrane Risk of Bias Tool.

PRIMARY OUTCOME MEASURES

The primary outcomes was the systolic blood pressure (SBP) (mm Hg), diastolic blood pressure (DBP) (mm Hg), patient compliance and the proportion of patients achieving target blood pressure.

RESULTS

A total of 11 studies with 2903 patients were included in this paper. There were 1453 cases in the telemedicine group and 1450 cases in the usual care group. Meta-analysis showed a statistically significant decrease in SBP (mm Hg) in the telemedicine group compared with the usual care group at weeks 3, 6 and 12 of follow-up (week 3: mean difference (MD), -8.8; 95% CI, -12.05 to -5.56; p<0.00001; week 6: MD, -5.13; 95% CI, -8.07 to -2.18; p=0.0007; week 12: MD, -2.78; 95% CI, -4.68 to -0.89; p=0.004). At week 12 of follow-up, there was a statistically significant decrease in DBP (mm Hg) in the telemedicine group compared with the usual care group (MD, -1.57; 95% CI, -2.59 to -0.55; p=0.003). In addition, patient compliance was better in the telemedicine group than in the usual care group (OR, 1.61; 95% CI, 1.29 to 2.01; p<0.0001), and the proportion of patients achieving target blood pressure was higher than in the usual care group (OR, 3.49; 95% CI, 2.64 to 4.63; p<0.00001).

CONCLUSIONS

Compared with usual care, telemedicine interventions can better improve blood pressure control in poststroke survivors and increase patient compliance.

TRIAL REGISTRATION NUMBER

CRD42022382001.

Global and Regional Burden of Ischemic Stroke Disease from 1990 to 2021: An Age-Period-Cohort Analysis

Ischemic stroke is a significant global public health issue that impacts health burdens across various regions. This study analyzed data from the Global Burden of Disease Study 2021 to assess the incidence, mortality, and disability-adjusted life years (DALYs) associated with ischemic stroke worldwide and across different Socio-demographic Index (SDI) regions. Using joinpoint regression and age-period-cohort (APC) models, we examined trends in disease burden and made projections for 2022 to 2035. As of 2021, approximately 7,804,449 (95% UI, 6,719,760-8,943,692) individuals were affected by ischemic stroke, resulting in 3,591,499 (95% UI, 3,213,281-3,888,327) deaths and 70,357,912 (95% UI, 64,329,576-76,007,063) DALYs. These numbers represent increases of 88.0%, 55.0%, and 52.4% since 1990. Despite these increases, age-standardized incidence, mortality, and DALYs rates are declining, with annual percentage change rates (AAPC) of - 0.578%, - 0.927%, and - 14.372%, consistent across all SDI regions. The global rates of IS are influenced by age, period, and cohort, showing increased rates with age but declining over time, particularly in high SDI regions. Major risk factors include hypertension, environmental pollution, and low-density lipoprotein cholesterol (LDL-C). Projections indicate that by 2035, incidence, mortality, and DALYs will rise among those aged 45 and above, while decreasing for those under 35. This highlights the urgent need for preventive and therapeutic strategies targeting ischemic stroke, particularly for individuals over 45, while addressing the impact of major risk factors in high-burden regions.