Impact of living and socioeconomic characteristics on cardiovascular risk in ischemic stroke patients

High socioeconomic status is associated with stroke severity among stroke patients in the National Brain Centre Hospital, Jakarta, Indonesia

Rapid economic growth has widened the gap between the rich and the poor, contributing to inequalities in socioeconomic status (SES) in Indonesia and possibly inequalities in health care. Here, we aimed to assess the potential association between SES and stroke severity in Indonesia, one of the largest low- and middle-income countries. Patients diagnosed with stroke at National Brain Centre (NBC) Hospital, Jakarta, Indonesia, in 2020 were included in the study. SES was measured based on marital status, occupation, education level, source of payment, and hospitalized class with smoking status and sex as confounder. Stroke severity was classified based on the National Institutes of Health Stroke Scale score into minor stroke (Adams et al., 1993, Amarenco et al., 2014, Andersen and Olsen, 2018, Austin and Steyerberg, 2017) and moderate to severe stroke (>4). A total of 2,443 patients with moderate to severe stroke (58%) were analyzed. Currently employed patients had a lower adjusted OR (aOR) of 0.65 (95% confidence interval [CI], 0.51-0.83) than unemployed patients. Patients with the highest education level, at least a diploma degree, had a lower aOR of 0.67 (95% CI, 0.49-0.92) than those with an elementary or no education. Our findings showed that patients with a higher SES had a lower risk of more severe stroke than those with a lower SES. Hence, we must focus on improving SES as part of stroke management.

Occupational class differences in outcomes after ischemic stroke: a prospective observational study

BACKGROUND

Occupational class is an integral part of socioeconomic status. The studies focused on the occupational difference in ischemic stroke outcome in a Chinese population are limited. We aimed to investigate the associations between occupational class and the prognosis of patients with ischemic stroke in China.

METHODS

We included 1484 ischemic stroke participants (mean age: 63.42 ± 11.26 years) from the prospective cohort study: Infectious Factors, Inflammatory Markers and Prognosis of Acute Ischemic Stroke (IIPAIS). Occupational class was categorized into white-collar workers, blue-collar workers and farmers in our study. Study outcomes were cardiovascular events and all-cause mortality within 12 months after ischemic stroke onset. We applied Cox proportional hazard model to evaluate the associations between the occupational class and study outcomes after ischemic stroke.

RESULTS

Within 12 months after ischemic stroke, there were 106 (7.5%) cardiovascular events and 69 (4.9%) all-cause deaths. The Kaplan-Meier plots showed that white-collar workers had highest risk of cardiovascular events after 12-month follow-up (Log-rank P = 0.02). Multivariate adjusted hazard ratio and 95% confidence intervals (CIs) of farmers versus white-collar workers was 0.43(0.20-0.91) for cardiovascular events. No significant difference showed in blue-collar workers versus white-collar workers, with fully adjusted hazard ratio 0.62(95% CIs, 0.23-1.67).

CONCLUSIONS

Compared with white-collar workers, farmers are associated with less risk of cardiovascular events at 12 months after ischemic stroke, while there are no significant differences in blue-collar workers.

Two-level analysis of risk factors for ischemic cardiovascular disease-A community-based study from Henan, China

BACKGROUND

Ischemic cardiovascular disease (ICVD) has high incidence and high mortality worldwide. The studies of its risk factors were mostly concentrated on an individual level, and there are scarce studies on the two levels of risk factors which include individual and regional levels.

METHODS

The data were obtained from a community-based study in 4 cities and 6 counties of Henan, China. Risk factors were initially screened by one-way analysis of variance or chi-square test. Then, they were re-analyzed using a two-level logistic regression model to construct a personal disease risk prediction model.

RESULTS

A two-level ICVD risk prediction model comprised 11 variables: age, body mass index (BMI), family history of hypertension, marital status, salt intake, smoking, moderate recreational physical activities, alcohol intake, and education at the individual level. Among the unalterable risk factors, for each additional unit of age and family history of hypertension, the risk of ICVD increased by 1.08 and 1.07 units [β95% confidence interval (95%CI): 0.99-1.16, 0.97-1.17, both p < 0.0001], respectively. Among the modifiable risk factors, the ICVD risk increases by 0.67, 0.27, and 0.28 units for each additional unit of BMI, marital status, and education (β95%CI: 0.60-0.74, p < 0.0001; β95%CI: 0.14-0.40, p = 0.0012, 0.18-0.37, p = 0.0001).

CONCLUSIONS

The two-level ICVD risk model can predict that the risk of one person for ICVD will be lower if one is younger, thinner, and well-educated without a family history of hypertension. Overall, the two-level ICVD risk prediction model gets a better fitting effect than the single-level model.

Social determinants and cardiovascular disease mortality in Panama, 2012-2016

BACKGROUND

The aims of this study were to determine the geographic and time variation of social determinants of health (SDH) and cardiovascular disease (CVD) mortality in Panama from 2012 to 2016, and to identify which of the SDH has the strongest correlation with a socioeconomic index (SEI).

METHODS

We conducted an ecological study obtaining mortality from the National Mortality Register and socioeconomic variables derived from the National Household Survey (NHS). The International Classification of Diseases 10th revision codes I20-I25 and I60-I69 were used for ischemic heart disease (IHD) and stroke, respectively. Standardized age-adjusted mortality rates were calculated by direct method. Mortality rates and socioeconomic variables were evaluated together in a panel data model. A SEI was developed from factorial analysis by principal components with a polychoric correlation matrix. Provinces and regions were categorized in tertiles according to median value of the SEI score.

RESULTS

The NHS evaluated an average of 15,919 households per year. The mean of age throughout the study period was 41 years. The average monthly income increased, from US$ (SD) 331.94 (5.38) in 2012, to 406.24 (5.81) in 2016, whereas the social security health coverage remained in a range of 57-58%. The mean number of school years was twelve. Significant geographical and temporal variations in social determinants and mortality rates were observed throughout the country. Colon, categorized in the middle tertile according to the SEI, presented higher IHD mortality rates. Darién (in the lowest SEI tertile) Colón and Herrera had higher stroke mortality rates. The SEI categorized indigenous territories in the lowest tertile. Total years of education was the strongest correlated variable with the SEI, when we excluded the population living in indigenous territories. However, when this population was included, social security coverage had the strongest correlation with the SEI.

CONCLUSION

We observed geographical and temporal disparities in SDH and CVD mortality rates. Further epidemiological studies are warranted in the provinces of Colón, Darien, Herrera and Los Santos to explore in-depth the higher CVD mortality rates observed in these provinces.

Specificities of Ischemic Stroke Risk Factors in Arab-Speaking Countries

BACKGROUND

Stroke is largely preventable, and therefore, a better understanding of risk factors is an essential step in reducing the population stroke rate and resulting disease burden in Arab countries.

SUMMARY

We performed 2 separate analyses in 2 similar populations of patients with noncardioembolic ischemic stroke. This first involved 3,635 patients in the Outcomes in Patients with TIA and Cerebrovascular disease (OPTIC) registry (followed for 2 years), with baseline collection of the usual risk factors and 5 socioeconomic variables (unemployment status, residence in rural area, living in fully serviced accommodation, no health-insurance coverage, and low educational level). The second involved patients in the PERFORM trial (n = 19,100 followed up for 2 years), with baseline collection of the usual risk factors and 1 socioeconomic variable (low educational level). The primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death. Stroke risk factors were more prevalent in patients in Arab countries. The incidence of major cardiovascular events (MACE; age- and gender-adjusted) was higher in Arab countries (OPTIC, 18.5 vs. 13.3%; PERFORM, 18.4 vs. 9.7%; both p ≤ 0.0001). These results remained significant after adjustment on risk factors and were attenuated in OPTIC after further adjustment on socioeconomic variables (hazard ratio 1.24; 95% CI 0.98-1.55; p = 0.07). Key Messages: Patients with ischemic stroke living in Arab countries had a lower mean socioeconomic status, a much higher prevalence of diabetes mellitus, and a higher rate of MACE compared with patients from non-Arab countries. This finding is partly explained by a higher prevalence of risk factors and also by a high prevalence of poverty and low educational level.

Modeling of in hospital mortality determinants in myocardial infarction patients, with and without stroke: A national study in Iran

Background:

The data and determinants of mortality due to stroke in myocardial infarction (MI) patients are unknown. This study was conducted to evaluate the differences in risk factors for hospital mortality among MI patients with and without stroke history.

Materials and Methods:

This study was a retrospective, cohort study; 20,750 new patients with MI from April, 2012 to March, 2013 were followed up and their data were analyzed according to having or not having the stroke history. Stroke and MI were defined based on the World Health Organization's definition. The data were analyzed by logistic regression in STATA software.

Results:

Of the 20,750 studied patients, 4293 had stroke history. The prevalence of stroke in the studied population was derived 20.96% (confidence interval [CI] 95%: 20.13–21.24). Of the patients, 2537 (59.1%) had ST-elevation MI (STEMI). Mortality ratio in patients with and without stroke was obtained 18.8% and 10.3%, respectively. The prevalence of risk factors in MI patients with and without a stroke is various. The adjusted odds ratio of mortality in patients with stroke history was derived 7.02 (95% CI: 5.42–9) for chest pain resistant to treatment, 2.39 (95% CI: 1.97–2.9) for STEMI, 3.02 (95% CI: 2.5–3.64) for lack of thrombolytic therapy, 2.2 (95% CI: 1.66–2.91) for heart failure, and 2.17 (95% CI: 1.6–2.9) for ventricular tachycardia.

Conclusion:

With regards to the factors associated with mortality in this study, it is particularly necessary to control the mortality in MI patients with stroke history. More emphasis should be placed on the MI patients with the previous stroke over those without in the interventions developed for prevention and treatment, and for the prevention of avoidable mortalities.

Internal associations and dynamic expression of c-kit and nanog genes in ventricular remodelling induced by adriamycin

The present study aimed to investigate the dynamic expression of the c-kit and nanog genes in rats with left ventricular remodelling induced by adriamycin (ADR), and explore its internal association and mechanism of action. Sprague-Dawley male rats were randomly divided into a normal control group and a heart failure model group. Heart failure was induced by a single intraperitoneal injection of ADR (4 mg/kg) weekly for six weeks. The normal control group was given the same amount of saline. At the eighth week, rat cardiac function was examined to demonstrate the formation of heart failure. The rat hearts were harvested frozen and sectioned, and the expression levels of the nanog and c-kit genes in the myocardial tissue samples were detected using immunohistochemistry, immunofluorescence and reverse transcription-polymerase chain reaction (RT-PCR). Hematoxylin and eosin staining demonstrated various pathological changes in the myocardial cells in the heart failure model group, whereas myocardial infarction was not observed in the normal control group. Immunohistochemistry and immunofluorescence demonstrated that nanog-positive cells were predominantly expressed in the vascular endothelium, with a few myocardial cells and stem cells in normal myocardium. The expression levels of c-kit and nanog in the myocardium of the rats with heart failure decreased significantly. c-kit-positive cells clustered together in the epicardium and its vicinity, and c-kit expression significantly decreased in the myocardium of rats with heart failure, as compared with normal rats. In both groups, some cells co-expressed both the c-kit and nanog genes. The RT-PCR results demonstrated that the expression levels of the two genes in the heart failure model group were significantly lower compared with those in the normal control group (P<0.05). In conclusion, the c-kit- and nanog-positive stem cells decreased in the myocardium of the rats with left ventricular remodelling induced by ADR. Their abnormal expression was significantly correlated with left ventricular remodelling, thereby indicating an internal association (influences of two indexes in the experimental group and control group) between them.

Access to Care and Cardiovascular Disease Prevention: A Cross-Sectional Study in 2 Latino Communities

Cardiovascular disease (CVD) is the leading killer of Americans. CVD is understudied among Latinos, who have high levels of CVD risk factors. This study aimed to determine whether access to health care (ie, insurance status and having a usual source of care) is associated with 4 CVD prevention factors (ie, health care utilization, CVD screening, information received from health care providers, and lifestyle factors) among Latino adults and to evaluate whether the associations depended on CVD clinical risk/disease.Data were collected as part of a community-engaged food environment intervention study in East Los Angeles and Boyle Heights, CA. Logistic regressions were fitted with insurance status and usual source of care as predictors of the 4 CVD prevention factors while controlling for demographics. Analyses were repeated with interactions between self-reported CVD clinical risk/disease and access to care measures.Access to health care significantly increased the odds of CVD prevention. Having a usual source of care was associated with all factors of prevention, whereas being insured was only associated with some factors of prevention. CVD clinical risk/disease did not moderate any associations.Although efforts to reduce CVD risk among Latinos through the Affordable Care Act could be impactful, they might have limited impact in curbing CVD among Latinos, via the law's expansion of insurance coverage. CVD prevention efforts must expand beyond the provision of insurance to effectively lower CVD rates.