Association of modifiable risk factors with ischaemic stroke subtypes in Asian versus Caucasian populations: A systematic review and meta-analysis

Statin Overuse in Cerebral Ischemia Without Indications: Systematic Review and Annual US Burden of Adverse Events

BACKGROUND

Statin agents play a major role in secondary prevention after acute cerebral ischemia (ACI) events but are not indicated in all patients with ischemic stroke and transient ischemic attack. National guidelines recommend statins for patients with ACI of large or small vessel atherosclerotic origin and without these stroke mechanisms but coexisting coronary artery disease or primary prevention indications. The potential adverse effect burden of statin overuse in the remaining ACI patients have not been well delineated.

METHODS

Per Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines, we performed systematic meta-analyses of: (1) statin randomized clinical trials to determine absolute risk increases for 6 major adverse events; (2) large clinical series to determine the proportion of ACI events due to large or small vessel atherosclerotic disease; and (3) the proportion of remaining patients with coronary artery disease/primary prevention statin indications.

RESULTS

For adverse effects, data were available from 63 randomized clinical trials enrolling 155 107 patients. Statin therapy was associated with an increased risk of the occurrence of 6 conditions: diabetes, myalgia or muscle weakness, myopathy, liver disease, renal insufficiency, and eye disease. Across 55 large series enrolling 53 501 patients, the rate of ACI due to large and small artery atherosclerosis was 45.0% (large artery atherosclerosis 21.6%, small vessel disease 23.4%), the rate of remaining patients with coronary artery disease/primary prevention statin indications was 31.8%, and the rate of patients without statin indications was 23.2%. Data synthesis indicated that, in the United States, were all patients with ACI without statin indications treated with statins, a total of 5601 patients would develop needless adverse events each year, most commonly diabetes, myopathy, and eye disease.

CONCLUSIONS

More than one-fifth of patients with ACI do not have an indication for statins, and statin overuse in these patients could annually lead to over 5600 adverse events each year in the United States, including diabetes, myopathy, and eye disease. These findings emphasize the importance of adhering to guideline indications for the start of statin therapy in ACI.

Single-Centre Experience with Endovascular Therapy in Acute Occlusion of ICAS: Preferred Stent Thrombectomy Versus Preferred Angioplasty

OBJECTIVES

The preferred endovascular therapy (EVT) for large-vessel occlusion in intracranial atherosclerosis (ICAS) is unknown. We compared the efficacy of preferred stent thrombectomy and preferred angioplasty in patients with acute large-vessel occlusion in ICAS.

METHODS

Data from consecutive EVT patients (May 2020 to September 2023) with acute middle cerebral artery occlusion in ICAS were retrospectively analyzed. Preferred angioplasty was performed if there was a preoperative "microcatheter first-pass effect;" otherwise, preferred stent thrombectomy was performed. Analyses were grouped according to the two EVT treatments. Clinical data of all patients, including the time from puncture to recanalization, rate of successful reperfusion, early neurological improvement, intracranial hemorrhage, and modified Rankin Scale score at 90 days, were recorded and analyzed.

RESULTS

Six-two patients were enrolled in this study (mean age was 60.66±13.21 y, 22.6% female). The preferred angioplasty group had a higher first-pass recanalization rate than the preferred stent thrombectomy group (61.3% vs. 21.9%, P<0.001) and a higher proportion of patients who were functionally independent (defined as a modified Rankin Scale score of 0 to 3) at 90 days [odds ratio,3.681; 95% confidence interval (CI):1.009 to 13.428; P=0.048]. There was no significant difference between the groups in the time from puncture to recanalization, the frequency of successful reperfusion, and early neurological improvement, or intracranial hemorrhage (P>0.05).

CONCLUSIONS

This study suggests that for acute middle cerebral artery occlusion in ICAS, preferred angioplasty may be a safe and effective procedure.

Stroke Demographics, Risk Factors, Subtypes, Syndromes, Mechanisms and Inter-Ethnic Differences between Chinese, Malays and Indians in Singapore-A Hospital-Based Study

Disparities in stroke may be due to socioeconomics, demographics, risk factors (RF) and ethnicity. Asian data are scant. This retrospective hospital-based study aimed to explore demographics, RF, stroke subtypes and mechanisms among the Chinese, Malays and Indians in Singapore. Stroke was subtyped into haemorrhagic stroke (HS) and ischaemic stroke (IS). For IS, the clinical syndrome was classified using the Oxfordshire Community Stroke Project (OCSP) classification while the stroke mechanism was categorised using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification. During the study period 1 June 2015 to 31 December 2023, data were collected on 1165 patients, with a mean age of 65.6 ± 12.9 yr; 47.4% were female, 83% were Chinese and hypertension (63.5%) and hyperlipidaemia (60.3%) were the most common RF. HS comprised 23.5% (95%CI 21.1-26.1%) (intracerebral 21.7%, subarachnoid 1.3%) of the patients, while IS comprised 76.5% (95%CI 73.9-78.9%) (small artery occlusion 29.0%, cardioembolism 13.3%, large artery atherosclerosis 9.4%, stroke of other determined aetiology 6.2%, stroke of undetermined aetiology 18.6%); 55% of patients had lacunar syndrome. A multivariable analysis showed that HS was associated with ethnicity (p = 0.044), diabetes mellitus (OR 0.27, 95%CI 0.18-0.41, p < 0.001) and smoking (OR 0.47, 95%CI 0.34-0.64, p < 0.001). There were no significant inter-ethnic differences by the OCSP (p = 0.31) or TOAST (p = 0.103) classification. While differences in stroke subtype in Asia may be due to RF, ethnicity has a role. More studies are needed to further explore this.

Global impact of particulate matter on ischemic stroke

Objective

This study assesses the worldwide impact of ischemic stroke caused by ambient particulate matter pollution between 1990 and 2019, utilizing data from the Global Burden of Disease (GBD) 2019.

Methods

An analysis was conducted across various subgroups, including region, Socio-demographic Index (SDI) level, country, age, and gender. The study primarily examined metrics such as death cases, death rate, Disability-Adjusted Life Years (DALYs), DALY rate, and age-standardized indicators. The Estimated Annual Percentage Change (EAPC) was calculated to assess trends over time.

Results

The study found a moderate increase in the global burden of ischemic stroke attributed to ambient particulate matter, with the age-standardized DALY rate showing an EAPC of 0.41. Subgroup analyses indicated the most substantial increases in Western Sub-Saharan Africa (EAPC 2.64), East Asia (EAPC 2.77), and Eastern Sub-Saharan Africa (EAPC 3.80). Low and middle SDI countries displayed the most notable upward trends, with EAPC values of 3.36 and 3.58 for age-standardized death rate (ASDR) and DALY rate, respectively. Specifically, countries like Equatorial Guinea, Timor-Leste, and Yemen experienced the largest increases in ASDR and age-standardized DALY rate. Furthermore, both death and DALY rates from ischemic stroke due to particulate matter showed significant increases with age across all regions.

Conclusion

The study highlights the increasing worldwide health consequences of ischemic stroke linked to particulate matter pollution, particularly in Asia and Africa. This emphasizes the critical necessity for tailored public health interventions in these regions.

Association between cerebrovascular disease and perioperative neurocognitive disorders: a retrospective cohort study

BACKGROUND

Previous studies have shown that patients with cerebrovascular disease (CVD) have a significantly increased risk of cognitive decline or dementia; however, the association between preoperative CVD and perioperative neurocognitive disorders (PNDs) remains unclear. This study aimed to explore the correlation between preoperative CVD and PNDs, as well as combine logistic regression and receiver operating characteristic (ROC) curves to construct a clinical prediction PND model.

MATERIALS AND METHODS

This retrospective cohort study evaluated 13 899 surgical patients of a large-scale comprehensive hospital between January 2021 and January 2022 to explore the association between preoperative CVD and PNDs, with follow-up to monitor postoperative survival until 28 February 2023, unless the patient died. The study participants comprised all inpatients from the Bone and Joint Surgery, Spine Surgery, Urology, Hepatobiliary Surgery, Gastrointestinal Surgery, and Thoracic Surgery departments. Patients were classified into two groups: the CVD group with a confirmed diagnosis and the noncerebrovascular disease group. The incidence of PNDs was measured, and potential associations between patient demographic information, preoperative comorbidities, and CVD, as well as the correlation between preoperative CVD and PNDs, were investigated by multivariate logistic regression analysis. Next, the authors constructed a clinical prediction PND model by drawing the ROC curve. The postoperative survival of all patients was tracked, and a survival curve was constructed and incorporated into the Cox proportional hazard regression model to analyze the relationship between preoperative CVD and the overall postoperative survival rate.

RESULTS

Of the included 13 899 patients, propensity score matching yielded 1006 patient pairs. Multivariate logistic regression analysis revealed that CVD was an independent risk factor for PNDs [odds ratio: 10.193; 95% CI: 7.454-13.938; P <0.001]. Subsequently, the authors developed a clinical prediction model for PNDs by multivariate logistic regression analysis. The area under the ROC curve was 0.798 (95% CI: 0.765-0.830). The survival of 11 702 patients was followed up. Multivariate Cox hazard ratio regression analysis revealed that CVD affected the overall postoperative survival rate (hazard ratio, 1.398; 95% CI: 1.112-1.758; P <0.001).

CONCLUSION

CVD was an independent risk factor for PNDs and affected the overall postoperative survival rate of surgical patients with preoperative CVD.

Effect of fenofibrate and selective PPARα modulator (SPPARMα), pemafibrate on KATP channel activity and insulin secretion

OBJECTIVE

Insulin secretion is regulated by ATP-sensitive potassium (KATP) channels in pancreatic beta-cells. Peroxisome proliferator-activated receptors (PPAR) α ligands are clinically used to treat dyslipidemia. A PPARα ligand, fenofibrate, and PPARγ ligands troglitazone and 15-deoxy-∆12,14-prostaglandin J2 are known to close KATP channels and induce insulin secretion. The recently developed PPARα ligand, pemafibrate, became a new entry for treating dyslipidemia. Because pemafibrate is reported to improve glucose intolerance in mice treated with a high fat diet and a novel selective PPARα modulator, it may affect KATP channels or insulin secretion.

RESULTS

The effect of fenofibrate (100 µM) and pemafibrate (100 µM) on insulin secretion from MIN6 cells was measured by using batch incubation for 10 and 60 min in low (2 mM) and high (10 mM) glucose conditions. The application of fenofibrate for 10 min significantly increased insulin secretion in low glucose conditions. Pemafibrate failed to increase insulin secretion in all of the conditions experimented in this study. The KATP channel activity was measured by using whole-cell patch clamp technique. Although fenofibrate (100 µM) reduced the KATP channel current, the same concentration of pemafibrate had no effect. Both fenofibrate and pemafibrate had no effect on insulin mRNA expression.

Burden and attributable risk factors of ischemic stroke in China from 1990 to 2019: an analysis from the Global Burden of Disease Study 2019

Background

The epidemiologic characteristics and attributable risk factors of ischemic stroke in China have changed over the past three decades. An up-to-date analysis on deaths, disability-adjusted life-years (DALYs), prevalence, incidence, and attributable risk factors of ischemic stroke for China is needed. This study aims to provide a comprehensive analysis of burden and attributable risk factors of ischemic stroke at national level in China by sex from 1990 to 2019.

Methods

This is a secondary analysis of the Global Burden of Disease (GBD) study 2019. All data used in this study was derived from the 2019 GBD study. Deaths, DALYs, prevalence, incidence, and attributable risk factors of ischemic stroke in China by sex from 1990 to 2019 were analyzed.

Results

From 1990 to 2019, the age-standardized deaths rate decreased by 3.3%, age-standardized DALYs rate decreased by 4%, age-standardized prevalence rate increased by 33.5%, and age-standardized incidence rate of ischemic stroke in China increased by 34.7%. In 2019, ambient particulate matter pollution became an important risk factor, whereas household air pollution from solid fuels was no longer a major risk factor for ischemic stroke in China. Burden of ischemic stroke was higher in China compared to other regions. Ambient particulate matter pollution among men, and diet high in sodium, smoking, household air pollution from solid fuels among women account for the increased deaths/DALYs due to ischemic stroke in China.

Conclusion

Our study revealed that great changes have occurred in burden and attributable risk factors of ischemic stroke in China in the past three decades. Distinct sex-specific differences are observed in burden and attributable risk factors.