An Epidemiological Survey of Stroke among Rural Chinese Adults Results from the Liaoning Province

Association of Vegetable Consumption with Stroke in China: A Longitudinal Study

Research on the relationship between vegetable consumption and stroke among the Chinese population is still rare. This study aimed to explore the association between vegetable consumption and stroke. Using data from the China Health and Nutrition Survey (1991-2018), we included 15,145 participants over 40 years old without stroke as the baseline. Participants were categorized into five groups according to vegetable consumption. The adjusted HRs of stroke associated with vegetable consumption were calculated using the COX proportional hazards model. During the follow-up, 504 stroke cases were detected (303 men and 201 women). For the females, compared with the Q1 group of vegetable consumption, the multivariable-adjusted HRs for stroke were 0.60 (95%CI 0.36, 1.00) in the group of Q4. No significant associations between vegetable consumption and stroke were found among males. Furthermore, compared with the Q1 group of dark vegetable consumption, for the whole subjects, the multivariable-adjusted HRs for stroke were 0.68 (95%CI 0.50, 0.92) in the group of Q4. For the females, compared with the Q1 group of dark vegetable consumption, the multivariable-adjusted HRs for stroke were 0.49 (95%CI 0.30, 0.80) in the group of Q4. In conclusion, this study suggested that vegetable consumption decreases the risk of stroke among Chinese females. In addition, the intake of dark vegetables was inversely associated with stroke.

Pooled incidence and case-fatality of acute stroke in Mainland China, Hong Kong, and Macao: A systematic review and meta-analysis

Background

Stroke incidence and case-fatality in Mainland China, Hong Kong, and Macao vary by geographic region and rates often differ across and within regions. This systematic review and meta-analysis (SR) estimated the pooled incidence and short-term case-fatality of acute first ever stroke in mainland China, Hong Kong, and Macao.

Methods

Longitudinal studies published in English or Chinese after 1990 were searched in PubMed/Medline, EMBASE, CINAHL, Web of Science, SinoMed and CQVIP. The incidence was expressed as Poisson means estimated as the number of events divided by time at risk. Random effect models calculated the pooled incidence and pooled case-fatality. Chi-squared trend tests evaluated change in the estimates over time. When possible, age standardised rates were calculated. Percent of variation across studies that was due to heterogeneity rather than chance was tested using the I2 statistic.The effect of covariates on heterogeneity was investigated using meta-regressions. Publication bias was tested using funnel plots and Egger’s tests.

Results

Overall, 72 studies were included. The pooled incidences of total stroke (TS), ischaemic stroke (IS) and haemorrhagic stroke (HS) were 468.9 (95% confidence interval (CI): 163.33–1346.11), 366.79 (95% CI: 129.66–1037.64) and 106.67 (95% CI: 55.96–203.33) per 100,000 person-years, respectively, varied according to the four economic regions (East Coast, Central China, Northeast and Western China) with the lowest rates detected in the East Coast. Increased trends over time in the incidence of TS and IS were observed (p<0.001 in both). One-month and three-to-twelve-month case-fatalities were 0.11 (95% CI: 0.04–0.18) and 0.15 (95% CI: 0.12–0.17), respectively for IS; and 0.36 (95% CI: 0.26–0.45) and 0.25 (95% CI: 0.18–0.32), respectively for HS. One-month case-fatality of IS and HS decreased over time for both (p<0.001). Three-to-twelve-month fatalities following IS increased over time (p<0.001). Publication bias was not found.

Conclusions

Regional differences in stroke incidence were observed with the highest rates detected in less developed regions. Although 1-month fatality following IS is decreasing, the increased trends in 3-12-month fatality may suggest an inappropriate long-term management following index hospital discharge.

Registration

Registration-URL: https://www.crd.york.ac.uk/prospero/; Reference code: CRD42020170724

Serum Spermidine in Relation to Risk of Stroke: A Multilevel Study

The relationship between serum spermidine levels and future cardiovascular disease risk has not yet been well elucidated in the general population based on community studies. Using a nested case-control study, we estimated the association between serum spermidine level and future stroke. New stroke cases had higher baseline levels of spermidine than controls [182.8 (141.8–231.5) vs. 152.0 (124.3–193.0), P < 0.001]. After multivariable adjustment, individuals with spermidine ≥ 205.9 nmol/L (T3) higher risks of stroke (HR 5.02, 95% CI 1.58–16.02) with the lowest quartile (< 136.9 nmol/L) as reference. The association between serum spermidine levels and risk of stroke seemed to be consistent and was reproducible in our cross-sectional studies. In addition, comparisons of the areas under receiver operator characteristics curves confirmed that a model including spermidine had better discrimination than without (0.755 vs. 0.715, P = 0.04). Here we report a close relationship exists between serum spermidine levels and risk of stroke.

Implementation of regional Acute Stroke Care Map increases thrombolysis rates for acute ischaemic stroke in Chinese urban area in only 3 months

Background

The rate of intravenous thrombolysis for acute ischaemic stroke remains low in China. We investigated whether the implementation of a citywide Acute Stroke Care Map (ASCaM) is associated with an improvement of acute stroke care quality in a Chinese urban area.

Methods

The ASCaM comprises 10 improvement strategies and has been implemented through a network consisting of 20 tertiary hospitals. We identified 7827 patients with ischaemic stroke admitted from April to October 2017, and 506 patients underwent thrombolysis were finally included for analysis.

Results

Compared with ‘pre-ASCaM period’, we observed an increased rate of administration of tissue plasminogen activator within 4.5 hours (65.4% vs 54.5%; adjusted OR, 1.724; 95% CI 1.21 to 2.45; p=0.003) during ‘ASCaM period’. In multivariate analysis models, ‘ASCaM period’ was associated with a significant reduction in onset-to-door time (114.1±55.7 vs 135.7±58.4 min, p=0.0002) and onset-to-needle time (ONT) (169.2±58.1 vs 195.6±59.3 min, p<0.0001). Yet no change was found in door-to-needle time. Clinical outcomes such as symptomatic intracranial haemorrhage, favourable functional outcome (modified Rankin Scale ≤2) and in-hospital mortality remained unchanged.

Conclusion

The implementation of ASCaM was significantly associated with increased rates of intravenous thrombolysis and shorter ONT. The ASCaM may, in proof-of-principle, serve as a model to reduce treatment delay and increase thrombolysis rates in Chinese urban areas and possibly other highly populated Asian regions.

Elevated blood pressure level based on 2017 ACC/AHA guideline in relation to stroke risk in rural areas of Liaoning province

Background

The new ACC/AHA hypertension guideline lower the definition of hypertension from 140/90 mmHg to 130/80 mmHg and eliminate the category of prehypertension thus increasing the prevalence of hypertension. A purpose of this study is to explore the applicability of the new guidelines in rural China.

Methods

In total, 3229 participants aged ≥35 years and free of stroke at baseline were followed for up to 4.8 years during 2012 to 2017 in a rural community-based prospective cohort study of Xifeng County. The hazard ratio (HR) and 95% Confidence interval (CI) of different blood pressure (BP) levels for risk of incident stroke were analyzed by multivariable Cox proportional hazard models.

Results

During the follow-up, 81 new strokes occurred among the 3229 participants. Compared with normal BP (Systolic BP (SBP)<120 mmHg and Diastolic BP (DBP)<80 mmHg), stage 2 hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) had approximately 2.1 greater risks for stroke (HR: 2.10, 95% CI: 1.13 to 3.91, P = 0.020). However, there was no significant association between elevated (SBP:120-129 mmHg and DBP<80 mmHg), stage1 hypertension (SBP:130-139 mmHg or DBP:80-89 mmHg) and stroke incidence (HR: 0.93, 95% CI: 0.33 to 2.61, P = 0.888; HR: 0.96, 95% CI: 0.46 to 2.02, P = 0.920, respectively). An increase of the SBP by 1-SD increases the risk for stroke by 56% (HR: 1.56, 95%CI: 1.29 to 1.88, P < 0.001). An increase of the SBP by 20 mmHg increases the risk for stroke by 51% (HR: 1.51, 95%CI: 1.27 to 1.80, P < 0.001).

Conclusions

Compared with normal BP, the stage 2 hypertension based on 2017 ACC/AHA guideline significantly increases the risk of stroke incidence, but this association was not observed between elevated, stage1 hypertension and stroke incidence in Chinese rural adults.

Stroke epidemiology and stroke policies in China from 1980 to 2017: A systematic review and meta-analysis

Background

Stroke is the leading cause of death and years of life lost in China, and this problem is growing because stroke risk factors such as hypertension and hypercholesteremia have been on the rise as China experiences the demographic transition. The Chinese government has created public health initiatives in the form of guidelines, policies and programs to combat this problem, but the dissemination and effectiveness of these policies are not well known.

Aims

The aim of this study was to determine trends in stroke incidence, prevalence, and stroke-related mortality in China and to report these trends in the context of stroke initiatives that have been enacted by the Chinese government.

Summary of review

We systematically reviewed articles on stroke rates and stroke initiatives from 1980 to 2017. A meta-regression including 11 studies showed that stroke incidence remained stable at 128.3 per 100,000 per year from 1980 to 2005 and has increased by 21.3 per 100,000 per year since then to 298.7 per 100,000 per year in 2013. A meta-regression including seven studies demonstrated a gradual decline in stroke-related mortality by 6.5 per 100,000 per year since 1980 (a decline from 369.2 in 1980 to 154.7 per 100,000 per year in 2013). Average stroke prevalence was 898.4 per 100,000 over the entire time-period. Limitations included heterogeneity between the studies. We identified 12 stroke initiatives, the first of which was enacted in 2006.

Conclusions

Despite numerous public health initiatives aimed at combating stroke that started in 2006, stroke incidence in China has increased over the last decade, likely as a result of aging and urbanization of the Chinese population.

Prevalence of stroke and associated risk factors among middle-aged and older farmers in western China

Objectives

China has the world’s largest population and the stroke has become the leading cause of death in recent years. The purpose of this study was to explore the associations between hypertension, family history of stroke, diabetes mellitus, obesity and stroke among middle-aged and older farmers of western China. A population-based study was conducted from June 2014 to April 2015 in Shaanxi and Sichuan provinces.

Methods

Twenty thousand five hundred twenty-five Chinese middle-aged and older farmers (≥40 years) were recruited to the Qinling-Daba Mountains Region Stroke Study. A structured-questionnaire was used to collect data through face-to-face interviews. Demographic characteristics, risk factors, medical history, and other clinical characteristics were recorded for all participants. The association between hypertension, family history of stroke, diabetes mellitus, obesity and stroke were analyzed by using univariate and multivariate logistic regression analysis.

Results

The stoke prevalence rate was 1380/100,000 in middle-aged and older farmers of western China. The difference in hypertension, diabetes mellitus, obesity and family history between different age groups had statistical significance (p < 0.05). The prevalence rate of hypertension and family history of stroke were higher in male population than in the female population. The difference was statistically significant (p < 0.05). Univariate logistic regression analysis demonstrated age, gender, hypertension, obesity and family history of stroke were stroke risk factors (p < 0.05). Multivariate logistic regression analysis revealed that the odds ratios of family history of stroke, obesity and hypertension were 7.177, 4.389 and 3.647 respectively.

Conclusions

Family history is the strongest stroke risk factor in middle-aged and older farmers of western China.

Stroke incidence, prevalence and mortality in women worldwide

BACKGROUND

The study of sex differences on stroke incidence, prevalence and mortality is an emerging field of stroke epidemiology and care.

AIMS

This study sought to determine the information available on stroke epidemiology in women worldwide and possible sex differences in stroke epidemiology, and, if so, describe the nature of these differences and whether they are consistent across countries/groups of countries.

SUMMARY

We searched the available literature in English published between 1 January 2008 and 5 May 2015. Out of 17.789 papers only 56 peer-reviewed papers (29 community-based studies, 17 retrospective studies, 6 reviews, and 4 cross-sectional studies) have been included in the study. This review adopted the epidemiologic transition theory, which classifies countries into four stages according to their levels of industrialization and economy. For the first and second stages, reliable registries and health certification are lacking, and therefore our sought after data were very limited.In the third stage, specifically for Eastern Europe (post-socialist countries), the burden from stroke in women was on the rise, while in the fourth stage, despite an aging population, decreases in stroke incidence, prevalence and mortality have been observed, even in subjects older than 80 years for both sexes. However, regarding studies of US populations, these trends for women were less pronounced for African Americans, and Hispanics as well as Indians. This suggests a "gender-gap" regarding access to treatment and care.In conclusion, identifying the presence of differing global burden between the sexes will allow us to better understand how to prevent, treat, and manage both men and women.

Differences in the distribution of risk factors for stroke among the high-risk population in urban and rural areas of Eastern China

INTRODUCTION

Considering the program of screening for risk factors of stroke in Eastern China, the aim of this study was to compare the distribution differences in risk factors for stroke among the high-risk population living in urban and rural areas.

METHODS

A total of 231,289 residents were screened and basic information collected. Risk factors for stroke among the high-risk population were compared between the urban and rural groups.

RESULTS

A total of 117,776 high-risk residents from urban areas and 113,513 from rural areas were included in the analysis. The prevalence of hypertension was much higher in rural areas (73.3%) than that in urban areas (64.1%). Dyslipidemia (48.9% vs. 26.9%), sport lack (46.6% vs. 31.6%), diabetes mellitus (21.3% vs. 16.5%), and atrial fibrillation (18.7% vs. 9.8%) were more prevalent in the urban group, while smoking (26.5% vs. 28.8%), previous stroke (10.1% vs. 16.9%), and transient ischemic attack (20.9% vs. 24.6%) were less prevalent.

CONCLUSION

Among the population at high risk of stroke, there were significant differences in the distribution of the following risk factors between the urban and rural groups: hypertension, atrial fibrillation, dyslipidemia, lack of physical exercise, and a previous stroke.

A guideline-based program may improve the outcome of stroke among illiterate patients

BACKGROUND

Education level is considered as an important factor for post-stroke functional outcome. Our previous study confirms the feasibility of SMART program to improve adherence of secondary stroke prevention in China.

AIMS

We aim to investigate whether this program can influence the impact of educational level on post-stroke functional outcome in this sub-group analysis of SMART study.

METHODS

We enrolled 3722 patients with acute ischemic stroke from multicenter (n = 47) SMART cohort. Patient's educational level was categorized as three: illiterate, 6th grade or lower, and 7th grade or higher. Functional outcome at six-month post-stroke was assessed by Modified Rankin Scale (mRS) and categorized as favorable (mRS: 0-2) or poor (mRS: 3-5). Binary logistic model, adjusting for age, gender, stroke history, hypertension, diabetes, hyperlipidemia, educational level, and NIHSS was performed, respectively, in SMART group and usual care group to evaluate the effect of the SMART program on stroke functional outcome among different educated patients.

RESULTS

In both groups, logistic regression analysis showed that poor functional outcome was independently associated with older age [OR(95% CI):1.81(1.41-2.33), p < 0.001(SMART); OR (95% CI):1.38 (1.09-1.73), p = 0.007(usual care)], higher baseline NIHSS [OR (95% CI): 2.90 (2.38-3.53), p < 0.001(SMART); OR (95% CI): 2.82 (2.32-3.44), p < 0.001(usual care)], and diabetes [OR(95% CI):1.88 (1.18-3.00), p = 0.008(SMART); OR (95%CI):1.68 (1.03-2.73), p = 0.037(usual care)]. Compared to illiterate, higher educational levels were independently associated with favorable outcome in usual care group [OR (95% CI): 0.43 (0.20-0.93), p = 0.032 (6th grade or lower) and OR (95% CI): 0.40 (0.19-0.84), p = 0.016 (7th Grade or higher)], but not in SMART group (p = 0.806 and p = 0.889, respectively).

CONCLUSIONS

This study demonstrates that implementation of SMART program may improve post-stroke functional outcome among illiterate. This suggests special attention should be paid to illiterate patients with intensive education in order to improve post-stroke disability.

Efficacy of a Community-Based Physical Activity Program KM2H2 for Stroke and Heart Attack Prevention among Senior Hypertensive Patients: A Cluster Randomized Controlled Phase-II Trial

Objective

To evaluate the efficacy of the program Keep Moving toward Healthy Heart and Healthy Brain (KM2H²) in encouraging physical activities for the prevention of heart attack and stroke among hypertensive patients enrolled in the Community-Based Hypertension Control Program (CBHCP).

Design

Cluster randomized controlled trial with three waves of longitudinal assessments at baseline, 3 and 6 months post intervention.

Setting

Community-based and patient-centered self-care for behavioral intervention in urban settings of China.

Participants

A total of 450 participants diagnosed with hypertension from 12 community health centers in Wuhan, China were recruited, and were randomly assigned by center to receive either KM2H² plus standard CBHCP care (6 centers and 232 patients) or the standard care only (6 centers and 218 patients).

Intervention

KM2H² is a behavioral intervention guided by the Transtheoretical Model, the Model of Personalized Medicine and Social Capital Theory. It consists of six intervention sessions and two booster sessions engineered in a progressive manner. The purpose is to motivate and maintain physical activities for the prevention of heart attack and stroke.

Outcome Measures

Heart attack and stroke (clinically diagnosed, primary outcome), blood pressure (measured, secondary outcome), and physical activity (self-report, tertiary outcome) were assessed at the individual level during the baseline, 3- and 6-month post-intervention.

Results

Relative to the standard care, receiving KM2H² was associated with significant reductions in the incidence of heart attack (3.60% vs. 7.03%, p < .05) and stroke (5.11% vs. 9.90%, p<0.05), and moderate reduction in blood pressure (-3.72mmHg in DBP and -2.92 mmHg in DBP) at 6-month post-intervention; and significant increases in physical activity at 3- (d = 0.53, 95% CI: 0.21, 0.85) and 6-month (d = 0.45, 95% CI: 0.04, 0.85) post-intervention, respectively.

Conclusion

The program KM2H² is efficacious to reduce the risk of heart attack and stroke among senior patients who are on anti-hypertensive medication. Findings of this study provide solid data supporting a formal phase-III trial to establish the effectiveness of KM2H² for use in community settings for prevention.

Trial Registration

ISRCTN Register ISRCTN12608966

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

OBJECTIVE

We aimed to stratify the risk of vascular event recurrence in patients with cerebral infarction according to living and socioeconomic characteristics and geographic region.

METHOD

The Outcomes in Patients with TIA and Cerebrovascular Disease (OPTIC) study is an international prospective study of patients aged 45 years or older who required secondary prevention of stroke [following either an acute transient ischemic attack, minor ischemic strokes, or recent (less than six-months previous), stable, first-ever, nondisabling ischemic stroke]. A total 3635 patients from 245 centers in 17 countries in four regions (Latin America, Middle East, North Africa, South Africa) were enrolled between 2007 and 2008. The outcome measure was the two-year rate of a composite of major vascular events (vascular death, myocardial infarction and stroke).

RESULTS

During the two-year follow-up period, 516 patients experienced at least one major cardiovascular event, resulting in an event rate of 15·6% (95% confidence interval 14·4-16·9%). Event rates varied across geographical region (P < 0·001), ranging from 13·0% in Latin America to 20·7% in North Africa. Unemployment status, living in a rural area, not living in fully serviced accommodation (i.e., house or apartment with its own electricity, toilet and water supply), no health insurance coverage, and low educational level (less than two-years of schooling) were predictors of major vascular events. Major vascular event rates steeply increased with the number of low-quality living/socioeconomic conditions (from 13·4% to 47·9%, adjusted P value for trend <0·001).

CONCLUSION

Vascular risk in stroke patients in low- and middle-income countries varies not only with the number of arterial beds involved but also with socioeconomic variables.