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Rissanen I, Basten M, Exalto LG, Peters SAE, Visseren FLJ, Geerlings MI. Sex differences in modifiable risk factors for stroke incidence and recurrence: the UCC-SMART study. J Neurol 2024; 271:3347-3358. [PMID: 38493278 PMCID: PMC11136802 DOI: 10.1007/s00415-024-12268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/16/2024] [Accepted: 02/18/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND AND PURPOSE Risk factors for stroke differ between women and men in general populations. However, little is known about sex differences in secondary prevention. We investigated if sex interacted with modifiable risk factors for stroke in a large arterial disease cohort. METHODS Within the prospective UCC-SMART study, 13,898 patients (35% women) with atherosclerotic disease or high-risk factor profile were followed up to 23 years for stroke incidence or recurrence. Hypertension, smoking, diabetes, overweight, dyslipidemia, high alcohol use, and physical inactivity were studied as risk factors. Association between these factors and ischemic and hemorrhagic stroke incidence or recurrence was studied in women and men using Cox proportional hazard models and Poisson regression models. Women-to-men relative hazard ratios (RHR) and rate differences (RD) were estimated for each risk factor. Left-truncated age was used as timescale. RESULTS The age-adjusted stroke incidence rate was lower in women than men (3.9 vs 4.4 per 1000 person-years), as was the age-adjusted stroke recurrence rate (10.0 vs 11.7). Hypertension and smoking were associated with stroke risk in both sexes. HDL cholesterol was associated with lower stroke incidence in women but not in men (RHR 0.49; CI 0.27-0.88; and RD 1.39; CI - 1.31 to 4.10). Overweight was associated with a lower stroke recurrence in women but not in men (RHR 0.42; CI 0.23-0.80; and RD 9.05; CI 2.78-15.32). CONCLUSIONS In high-risk population, sex modifies the association of HDL cholesterol on stroke incidence, and the association of overweight on stroke recurrence. Our findings highlight the importance of sex-specific secondary prevention.
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Affiliation(s)
- Ina Rissanen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Maartje Basten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Mental Health program, Amsterdam, The Netherlands
- Amsterdam Public Health, Health Behaviors and Chronic Diseases program, Amsterdam, The Netherlands
| | - Lieza G Exalto
- Department of Neurology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Sanne A E Peters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mirjam I Geerlings
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands.
- Department of General Practice, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Public Health, Aging & Later Life, Amsterdam, The Netherlands.
- Amsterdam Neuroscience, Neurodegeneration, and Mood, Anxiety, Psychosis, Stress, and Sleep, Amsterdam, The Netherlands.
- Amsterdam Public Health, Personalized Medicine, Amsterdam, The Netherlands.
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Elhefnawy M, Noor Harun S, Leykhim T, Tangiisuran B, Zainal H, Looi I, Sidek N, Abdul Aziz Z, Maisharah Sheikh Ghadzi S. A Parametric Time-to-Event Modelling of Recurrent Ischemic Stroke After Index Stroke Among Patients With and Without Diabetes Mellitus: Implementation of Temporal Validation of the Model. Cureus 2023; 15:e50794. [PMID: 38239519 PMCID: PMC10796130 DOI: 10.7759/cureus.50794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 01/22/2024] Open
Abstract
Objectives Compared with the first stroke, neurological impairment caused by stroke recurrence is more serious, more difficult to treat, and has a higher mortality rate, especially among ischemic stroke (IS) patients with diabetes mellitus (DM). Although there are established correlations between factors and IS recurrence, there were some issues regarding the naive hazard of IS recurrence with no risk factor influence, and how does the baseline hazard differ among patients with DM and non-DM? To answer all these questions, two time-to-event (TTE) models of recurrent IS after the index IS were developed among IS patients with DM and non-DM. Method A total of 7697 patients with an index IS attack were extracted from the Malaysian Registry of Neurology and stratified according to DM status. Several parametric survival models were evaluated using nonlinear mixed-effect modeling software (NONMEM 7.5). The final model was determined according to the lowest objective function value, graphical evaluation, numerical diagnostics, and clinical plausibility. Additionally, the final model was validated internally and temporally using Kaplan-Meier visual predictive checks (KM-VPCs). Results One hundred ninety-five (5.82%) of 3493 DM patients and 138 (3.28%) of 4204 non-DM patients developed a recurrent IS with a maximum follow-up of 7.37 years. Gompertz's model best fitted the data. With no influence on risk factors, the index IS attack was predicted to contribute to the hazard of recurrent IS by 0.356 and 0.253 within the first six months after the index IS among patients with and without DM, respectively. Even after six months of index IS, the recurrent IS baseline hazard was not equal to zero among both groups (0.0023, 0.0018). Moreover, after incorporating the time and risk factors, the recurrent hazards increased exponentially during the first three years after the index IS followed by an exponential reduction afterward. The recurrent IS predictors among DM patients were ischemic heart disease (IHD) and hyperlipidemia (HPLD). IHD and HPLD increased the hazard of recurrent IS by 2.40 and 1.88 times, respectively, compared to those without IHD and HPLD before index IS (HR, 2.40 (1.79-3.20)), and (HR, 1.88 (1.44-2.45)) respectively. Conclusion The baseline hazard was the highest during the first six months after the index IS. Moreover, receiving medications for secondary prevention failed to demonstrate a significant association with reducing IS recurrence among IS patients with DM, suggesting a need for more intensive patient screening and new strategies for secondary prevention among IS patients with DM.
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Affiliation(s)
- Marwa Elhefnawy
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MYS
| | - Sabariah Noor Harun
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MYS
| | - Teo Leykhim
- Clinical Research Centre, Hospital Pulau Pinang, Penang, MYS
| | - Balamurgan Tangiisuran
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MYS
| | - Hadzliana Zainal
- Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MYS
| | - Irene Looi
- Neurology Unit, Hospital Seberang Jaya, Penang, MYS
| | - Norsima Sidek
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Terengganu, MYS
| | - Zariah Abdul Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Terengganu, MYS
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Nindrea RD, Hasanuddin A. Non-modifiable and modifiable factors contributing to recurrent stroke: A systematic review and meta-analysis. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2023. [DOI: 10.1016/j.cegh.2023.101240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Elhefnawy ME, Sheikh Ghadzi SM, Albitar O, Tangiisuran B, Zainal H, Looi I, Sidek NN, Aziz ZA, Harun SN. Predictive model of recurrent ischemic stroke: model development from real-world data. Front Neurol 2023; 14:1118711. [PMID: 37188311 PMCID: PMC10176964 DOI: 10.3389/fneur.2023.1118711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/13/2023] [Indexed: 05/17/2023] Open
Abstract
Background There are established correlations between risk factors and ischemic stroke (IS) recurrence; however, does the hazard of recurrent IS change over time? What is the predicted baseline hazard of recurrent IS if there is no influence of variable predictors? This study aimed to quantify the hazard of recurrent IS when the variable predictors were set to zero and quantify the secondary prevention influence on the hazard of recurrent ischemic stroke. Methods In the population cohort involved in this study, data were extracted from 7,697 patients with a history of first IS attack registered with the National Neurology Registry of Malaysia from 2009 to 2016. A time-to-recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility, and visual predictive checks. Results Within the maximum 7.37 years of follow-up, 333 (4.32%) patients had at least one incident of recurrent IS. The data were well described by the Gompertz hazard model. Within the first 6 months after the index IS, the hazard of recurrent IS was predicted to be 0.238, and 6 months after the index attack, it reduced to 0.001. The presence of typical risk factors such as hyperlipidemia [HR, 2.22 (95%CI: 1.81-2.72)], hypertension [HR, 2.03 (95%CI: 1.52-2.71)], and ischemic heart disease [HR, 2.10 (95%CI: 1.64-2.69)] accelerated the hazard of recurrent IS, but receiving antiplatelets (APLTs) upon stroke decreased this hazard [HR, 0.59 (95%CI: 0.79-0.44)]. Conclusion The hazard of recurrent IS magnitude differs during different time intervals based on the concomitant risk factors and secondary prevention.
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Affiliation(s)
| | | | - Orwa Albitar
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - Hadzliana Zainal
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Irene Looi
- Clinical Research Center, Hospital Seberang Jaya, Penang, Malaysia
| | | | - Zariah Abdul Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia
| | - Sabariah Noor Harun
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- *Correspondence: Sabariah Noor Harun
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Mirror Therapy Rehabilitation in Stroke: A Scoping Review of Upper Limb Recovery and Brain Activities. Rehabil Res Pract 2022; 2021:9487319. [PMID: 35003808 PMCID: PMC8741383 DOI: 10.1155/2021/9487319] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background Mirror therapy (MT) has been used as a treatment for various neurological disorders. Recent application of electroencephalogram (EEG) to the MT study allows researchers to gain insight into the changes in brain activity during the therapy. Objective This scoping review is aimed at mapping existing evidence and identifying knowledge gaps about the effects of MT on upper limb recovery and its application for individuals with chronic stroke. Methods and Materials A scoping review through a systematic literature search was conducted using PubMed, CINAHL, PsycINFO, and Scopus databases. Twenty articles published between 2010 and 2020 met the inclusion criteria. The efficacy of MT on upper limb recovery and brain activity during MT were discussed according to the International Classification of Functioning, Disability and Health (ICF). Results A majority of the studies indicated positive effects of MT on upper limb recovery from the body structure/functional domain. All studies used EEG to indicate brain activation during MT. Conclusion MT is a promising intervention for improving upper limb function for individuals with chronic stroke. This review also highlights the need to incorporate EEG into the MT study to capture brain activity and understand the mechanism underlying the therapy.
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Penlioglou T, Stoian AP, Papanas N. Diabetes, Vascular Aging and Stroke: Old Dogs, New Tricks? J Clin Med 2021; 10:jcm10194620. [PMID: 34640636 PMCID: PMC8509285 DOI: 10.3390/jcm10194620] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Stroke remains a leading cause of death and disability throughout the world. It is well established that Diabetes Mellitus (DM) is a risk factor for stroke, while other risk factors include dyslipidaemia and hypertension. Given that the global prevalence of diabetes steadily increases, the need for adequate glycaemic control and prevention of DM-related cardiovascular events remains a challenge for the medical community. Therefore, a re-examination of the latest data related to this issue is of particular importance. OBJECTIVE This review aims to summarise the latest data on the relationship between DM and stroke, including epidemiology, risk factors, pathogenesis, prevention and biomarkers. METHODS For this purpose, comprehensive research was performed on the platforms PubMed, Google Scholar and EMBASE with a combination of the following keywords: diabetes mellitus, stroke, macrovascular complications, diabetic stroke, cardiovascular disease. CONCLUSIONS Much progress has been made in stroke in people with DM in terms of prevention and early diagnosis. In the field of prevention, the adaptation of the daily habits and the regulation of co-morbidity of individuals play a particularly important role. Simultaneously, the most significant revolution has been brought by the relatively new treatment options that offer protection to the cardiovascular system. Moreover, many prognostic and diagnostic biomarkers have been identified, paving the way for early and accurate diagnoses. However, to date, there are crucial points that remain controversial and need further clarification.
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Affiliation(s)
- Theano Penlioglou
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, 68132 Alexandroupolis, Greece;
| | - Anca Pantea Stoian
- Diabetes, Nutrition and Metabolic Diseases Department, “Carol Davila” University of Medicine, 020021 Bucharest, Romania;
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, 68132 Alexandroupolis, Greece;
- Correspondence: ; Fax: +30-25513-51723
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Elhefnawy ME, Sheikh Ghadzi SM, Tangiisuran B, Zainal H, Looi I, Ibrahim KA, Sidek NN, Loo KW, Yee Lee K, Abdul Aziz Z, Harun SN. Population-based Study Comparing Predictors of Ischemic Stroke Recurrence After Index Ischemic Stroke in Non-elderly Adults with or without Diabetes. Int J Gen Med 2021; 14:1205-1212. [PMID: 33854362 PMCID: PMC8039196 DOI: 10.2147/ijgm.s303641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/08/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND PURPOSE Factors associated with ischemic stroke (IS) recurrence and the contribution of pharmacological treatment as secondary preventions among nondiabetics especially in the non-elderly population are unclear and not widely investigated. This was a population-based study that aimed to identify recurrent IS predictors and to determine the possible impact of secondary preventive medications on the IS recurrence in non-elderly adults with or without diabetes. METHODS Data of 3386 patients <60 years old who had a history of index IS were extracted from the Malaysian National Neurology Registry (NNEUR) from 2009 to 2016. Recurrent IS was defined as any IS event recorded after the index IS in the NNEUR database. Multivariate logistic regression analysis was performed by using SPSS version 22. RESULTS Ischemic heart disease (IHD) was the significant predictor of IS recurrence in non-elderly adults both with or without diabetes (adjusted odds ratio (AOR) of 3.210; 95%CI: 1.909-5.398 and 2.989; 95%CI: 1.515-5.894) respectively). Receiving antiplatelet as secondary stroke prevention (AOR: 0.194; 95%CI: 0.046-0.817) and continuation of antidiabetic medication after the index IS event (AOR: 0.510; 95%CI: 0.298-0.872) reduced the odds of IS recurrence only in non-elderly diabetic adults. Among non-elderly adults without diabetes, hyperlipidemia and every increased in 1 mmHg of systolic blood pressure significantly increased the odds of IS recurrence following the indexing event (AOR: 1.796; 95%CI: 1.058-3.051 and 1.009; 95%CI: 1.002-1.016 respectively). CONCLUSION IHD was found as the main predictor of IS recurrence regardless of diabetes status in non-elderly adults after the index IS event. Receiving antidiabetic and antiplatelet medications upon discharge after index IS were significant predictors of recurrent IS in non-elderly diabetic adults. A proper randomized clinical trial may be required to determine the impact of secondary preventive medication on IS recurrence, especially in non-elderly adults.
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Affiliation(s)
| | | | | | - Hadzliana Zainal
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, 11800, Malaysia
| | - Irene Looi
- Clinical Research Centre, Seberang Jaya Hospital, Penang, Malaysia
| | | | | | - Keat Wei Loo
- Department of Biological Science, Faculty of Science, Universiti Tunku Abdul Rahman (UTAR) Kampar Campus, Perak, Malaysia
| | - Keng Yee Lee
- National Clinical Research Centre, Kuala Lumpur, Malaysia
| | - Zariah Abdul Aziz
- Clinical Research Centre, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia
| | - Sabariah Noor Harun
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, 11800, Malaysia
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