Sex-Specific Differences in Short-Term and Long-Term Outcomes in Acute Stroke Patients from Qatar

Association between serum triglycerides and stroke type, severity, and prognosis. Analysis in 6558 patients

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia (HT) may increase the risk of stroke. Limited studies have shown that stroke severity and infarction size are smaller in patients with HT. We explored the relationship between triglyceride levels and stroke risk factors, severity and outcome in a large prospective database.

DESIGN

Prospective Cross-sectional study.

SETTING

We retrospectively interrogated the Qatar Stroke Database in all patients admitted between 2014-2022 with acute ischemic stroke and evaluated the relationship between triglyceride, diabetes, stroke severity (measured on NIHSS), stroke type (TOAST classification) and the short- (mRS at 90 days) and long-term outcomes (MACE at 1 year) in patients with HT.

PARTICIPANTS

Six thousand five hundred fifty-eight patients ≥20 years were included in this study RESULTS: Six thousand five hundred fifty-eight patients with ischemic stroke [mean age 54.6 ± 12. 9; male 82.1%) were included. Triglyceride levels upon admission were low-normal (≤1.1 mmol/L) in 2019 patients, high-normal (1.2-1.7 mmol/L) in 2142 patients, borderline-high (1.8-2.2 mmol/L) in 1072 patients and high (≥2.3 mmol/L) in 1325 patients. Higher triglyceride levels were associated with stroke and increased likelihood of having diabetes, obesity, active smoking, and small vessel/lacunar stroke type. An inverse relationship was noted whereby higher triglyceride levels were associated with lower stroke severity and reduced likelihood of poorer outcome (mRS 3-6) at discharge and 90 days. Long-term MACE events were less frequent in patients with higher triglyceride levels. After adjusting age, gender, diabetes, prior stroke, CAD, and obesity, multivariate analysis showed that hypertension and triglyceride levels were higher in mild ischemic strokes patients.

CONCLUSIONS

Increasing triglycerides are associated with higher risk of small vessel disease and requires further prospective cohort studies for confirmation.

Predicting 90-day prognosis for patients with stroke: a machine learning approach

Background

Stroke is a significant global health burden and ranks as the second leading cause of death worldwide.

Objective

This study aims to develop and evaluate a machine learning-based predictive tool for forecasting the 90-day prognosis of stroke patients after discharge as measured by the modified Rankin Score.

Methods

The study utilized data from a large national multiethnic stroke registry comprising 15,859 adult patients diagnosed with ischemic or hemorrhagic stroke. Of these, 7,452 patients satisfied the study's inclusion criteria. Feature selection was performed using the correlation and permutation importance methods. Six classifiers, including Random Forest (RF), Classification and Regression Tree, Linear Discriminant Analysis, Support Vector Machine, and k-Nearest Neighbors, were employed for prediction.

Results

The RF model demonstrated superior performance, achieving the highest accuracy (0.823) and excellent discrimination power (AUC 0.893). Notably, stroke type, hospital acquired infections, admission location, and hospital length of stay emerged as the top-ranked predictors.

Conclusion

The RF model shows promise in predicting stroke prognosis, enabling personalized care plans and enhanced preventive measures for stroke patients. Prospective validation is essential to assess its real-world clinical performance and ensure successful implementation across diverse healthcare settings.

Appropriate use of antiplatelet medications following transient ischemic attacks and stroke: a 9-year study from the Middle East

Background and purpose

Guidelines recommend that patients with high-risk TIAs and minor strokes presenting within 1-3 days from onset should be offered dual antiplatelet therapy (DAPT). There are little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective database.

Methods

The Qatar Stroke Database began the enrollment of patients with TIAs and acute stroke in 2014 and currently has ~16,000 patients. For this study, we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with an ABCD2 score of 4, and a minor stroke was defined as an NIHSS of 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed.

Results

After excluding patients with ICH, mimics, and rare secondary causes, 8,082 patients were available for final analysis (TIAs: 1,357 and stroke: 6,725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor strokes, 1,207 of 3,572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) low-risk TIAs and 809 of 3,153 (25.7%) non-minor stroke patients.

Conclusion

This large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from the hospital. This requires urgent attention and further investigation.

Women and stroke: disparities in clinical presentation, severity, and short- and long-term outcomes

Objectives

There are limited data from the Middle East on sex-related differences in short- and long-term stroke outcomes. We present 8 years of experience based on the Qatar stroke database.

Setting

The Qatar stroke database prospectively collects data on all stroke patients admitted to Hamad General Hospital. For this study, we compared female and male acute ischemic stroke patients on their characteristics at admission, short-term outcomes [modified Rankin Scale (mRS) score], and long-term outcomes [incidence of major adverse cardiovascular events (MACEs)].

Participants

A total of 7,300 patients [F: 1,406 (19.3%), M: 5,894 (80.7%); mean age 55.1 ± 13.3 (F: 61.6 ± 15.1, M: 53.5 ± 12.3; p < 0.001)] were admitted with acute ischemic stroke.

Results

Significantly fewer women presented within 4.5 h of onset (F: 29% vs. M: 32.8%; p = 0.01). Although women were more likely to experience severe stroke (NIHSS >10; F: 19.9% vs. M: 14.5%; p < 0.001), fewer were treated with thrombolysis (F: 9.8% vs. M: 12.1%; p = 0.02). Women experienced more medical complications (F: 11.7% vs. M: 7.4%; p < 0.001) and tended to have a more prolonged length of stay in the hospital (F: 6.4 ± 7.6 days vs. M: 5.5 ± 6.8 days; p < 0.001).

Primary and secondary outcome measures

Good outcomes at 90 days (mRS score of 0-2) were less frequent in women (F: 53.3% vs. M: 71.2%; p < 0.001). Fewer female patients were taking antiplatelets (F: 78% vs. M: 84.8%; p < 0.001) or statins (F: 81.2% vs. M: 85.7%; p < 0.001). Significantly more female patients experienced a MACE (F: 12.6% vs. M: 6.5%; p < 0.001).

Conclusion

Older age at presentation contributes to poor outcomes following acute stroke in women. Other contributing factors include delays in admission to the hospital, lower rates of thrombolysis, and lower rates of provision of preventative treatments.

Loneliness, Social Isolation, and Living Alone Associations With Mortality Risk in Individuals Living With Cardiovascular Disease: A Systematic Review, Meta-Analysis, and Meta-Regression

OBJECTIVE

This study aimed to conduct a systematic review and meta-analysis of associations between loneliness, social isolation, and living alone and risk of mortality among individuals with established cardiovascular disease.

METHODS

Five electronic databases were searched (MEDLINE [Ovid], PsycINFO, EMBASE, PubMed, and SCOPUS) from inception to November 25, 2021. In all, 35 studies were included in a narrative synthesis and, where appropriate, a meta-analytic evaluation using a random-effects model.

RESULTS

Living alone was associated with increased risk of all-cause mortality ( k = 15, n = 80,243, hazard ratio [HR] = 1.48, 95% confidence interval [CI] = 1.20-1.83, I2 = 83%), and meta-regressions found that the effects were stronger in studies from Europe and with longer follow-up. However, there was evidence of publication bias. Social isolation was associated with increased risk of all-cause mortality, measured both as a dichotomous variable ( k = 3, n = 2648, HR = 1.46, 95% CI = 1.08-2.04, I2 = 31%) and as a continuous variable ( k = 5, n = 2388, HR = 1.11, 95% CI = 1.02-1.24, I2 = 51%). Meta-analysis was not feasible for loneliness as exposure, but narrative synthesis of four studies suggested a tentative association between loneliness and increased risk of all-cause mortality.

CONCLUSIONS

Supporting public health concerns, our review finds that loneliness, social isolation, and living alone are associated with premature mortality among individuals with established cardiovascular disease. However, evidence of publication bias and large methodological differences across studies point to the need for more rigorous research.

Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities

BACKGROUND

Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution.

OBJECTIVES

This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels.

DESIGN

Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women.

METHODS

Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes.

RESULTS

Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734).

CONCLUSION

While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.

Toward a Better Understanding of Sex- and Gender-Related Differences in Endovascular Stroke Treatment: A Scientific Statement From the American Heart Association/American Stroke Association

There are many unknowns when it comes to the role of sex in the pathophysiology and management of acute ischemic stroke. This is particularly true for endovascular treatment (EVT). It has only recently been established as standard of care; therefore, data are even more scarce and conflicting compared with other areas of acute stroke. Assessing the role of sex and gender as isolated variables is challenging because they are closely intertwined with each other, as well as with patients' cultural, ethnic, and social backgrounds. Nevertheless, a better understanding of sex- and gender-related differences in EVT is important to develop strategies that can ultimately improve individualized outcome for both men and women. Disregarding patient sex and gender and pursuing a one-size-fits-all strategy may lead to suboptimal or even harmful treatment practices. This scientific statement is meant to outline knowledge gaps and unmet needs for future research on the role of sex and gender in EVT for acute ischemic stroke. It also provides a pragmatic road map for researchers who aim to investigate sex- and gender-related differences in EVT and for clinicians who wish to improve clinical care of their patients undergoing EVT by accounting for sex- and gender-specific factors. Although most EVT studies, including those that form the basis of this scientific statement, report patient sex rather than gender, open questions on gender-specific EVT differences are also discussed.

Major cardiovascular events in patients presenting with acute stroke: a 5-year follow-up study in patients who had ischaemic stroke and stroke mimics

OBJECTIVES

The long-term acute stroke outcome has not been well studied in the Middle-Eastern population. The primary objective of our study is to compare the long-term outcome of acute ischaemic stroke (IS) with/without previous cerebrovascular/cardiovascular disease (CVD) to stroke mimics (SM) with CVD.

SETTINGS AND PARTICIPANTS

The Qatar stroke database was reviewed for IS and SM admissions in Qatari Nationals between 2013 and 2019.

OUTCOMES

Patients were prospectively assessed for development of recurrent stroke, myocardial infarction or death. Frequency of major cardiovascular events (MACEs) were compared between patients with or without a previous CVD.

RESULTS

There were 1114 stroke admissions (633 IS (prior CVD 211/18.9%), 481 SM (prior CVD 159/14.3%)). Patients with IS/CVD were significantly older versus others (IS/CVD: 68.3±12.2; IS/no CVD: 63.3±14.4; SM/CVD: 67.6±13.1; SM/no CVD: 52.4±17.9. p<0.0001). Vascular risk factors were significantly higher in patients with IS and SM with previous CVD. Functional recovery (90-day mRS 0-2) was significantly better in SM/no CVD (IS/CVD: 55.0%; IS/no CVD: 64.2%; SM/CVD 59.7%; SM/no CVD: 88.8%. p<0.001). MACE occurred in 36% (76/211) IS/CVD, 24.9% (105/422) IS/no CVD, 22.0% (35/179) SM/CVD and only 6.8% (22/322) SM/no CVD. MACE occurred mostly during the first year of follow-up. Mortality 90 days was significantly higher in IS/CVD (IS/CVD 36%; IS/no CVD 24.9%; SM/CVD: 22%; SM/no CVD: 6.8%. p<0.0001).

CONCLUSIONS

Prior CVD significantly increases the risk of MACE and early mortality in IS or SM patients. Age, male gender, obesity, atrial fibrillation and admission National Institute of Health Stroke Scale also increases risk of MACE during follow-up. Hence, aggressive vascular risk factor modification is needed even in patients with SM.

Stroke in the adult Qatari population (Q-stroke) a hospital-based retrospective cohort study

BACKGROUND

Studies assessing the burden of stroke in Qataris are limited. We aim to study stroke in the Qatari population.

METHODS

A retrospective review was undertaken of all Qatari adults presenting with stroke to Hamad Medical Corporation over a 5-year period. Descriptive statistics were used to summarize demographic and all other clinical characteristics of the patients. The primary outcome was the incidence of stroke in the Qatari patients. Comparison was made between the sexes.

RESULTS

862 patients were included, with 58.9% being male. The average incidence of stroke over the 5-year period was 92.04 per 100,000 adult Qatari population. The mean age of the cohort was 64.3±14.4 years, (range 19-105 years). The mean age of first ever cerebrovascular event was 63.2±14.5 years. The diagnosis was ischemic stroke in (73.7%), transient ischemic attack in (13.8%), intracerebral hemorrhage (ICH) in (11.6%), subarachnoid hemorrhage in (0.7%) and (0.2%) cerebral venous sinus thrombosis. Small vessel disease was the most common cause of ischemic stroke accounting for (46.5%), followed by large artery atherosclerosis (24.5%). Hypertension (82.7%) and diabetes (71.6%) were particularly prevalent in this cohort. Females were older (65.8±14.1 vs 63.4±14.5 years), had more hypertension and diabetes and more disability or death at 90 days (p<0.05) compared to Qatari males.

CONCLUSION

Stroke occurs at a significantly lower age in Qataris compared to the western population. This study has uncovered sex differences that need to be studied further.