Factors related to stroke incidence in Hawaii Japanese men. The Honolulu Heart Study

Lessons Learned from Immigrant Health Cohorts: A Review of the Evidence and Implications for Policy and Practice in Addressing Health Inequities among Asian Americans, Native Hawaiians, and Pacific Islanders

The health of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPI) is uniquely impacted by structural and social determinants of health (SSDH) shaped by immigration policies and colonization practices, patterns of settlement, and racism. These SSDH also create vast heterogeneity in disease risks across the AANHPI population, with some ethnic groups having high disease burden, often masked with aggregated data. Longitudinal cohort studies are an invaluable tool to identify risk factors of disease, and epidemiologic cohort studies among AANHPI populations have led to seminal discoveries of disease risk factors. This review summarizes the limited but growing literature, with a focus on SSDH factors, from seven longitudinal cohort studies with substantial AANHPI samples. We also discuss key information gaps and recommendations for the next generation of AANHPI cohorts, including oversampling AANHPI ethnic groups; measuring and innovating on measurements of SSDH; emphasizing the involvement of scholars from diverse disciplines; and, most critically, engaging community members to ensure relevancy for public health, policy, and clinical impact.

Use of Lipid-Lowering Drugs After Intracerebral Hemorrhage

Hyperlipidemia is common in patients with intracerebral hemorrhage (ICH). Accumulating evidence indicates that patients with ICH are at risk for future hemorrhage recurrence, cardiovascular disease, and ischemic stroke and highlights the importance of secondary prevention of vascular events after ICH. Although the benefits of intensive treatment of hyperlipidemia for reducing ischemic cardiac and vascular events in patients with ischemic stroke are well established, the benefit versus harm in patients with ICH are less clear. Epidemiological studies suggest that hyperlipidemia is protective against ICH and that intensive lowering of lipids is associated with increased risk for ICH. Similarly, although currently available lipid-lowering treatments have been thoroughly studied in patients with ischemic cardiac and vascular disease, only few randomized trials of these therapies included a very small number of patients with history of ICH. Thus, limiting any definitive conclusions regarding the safety and net benefit of these treatments in ICH populations. Currently, there is no consensus regarding the optimal strategy for management of hyperlipidemia after ICH. In this article, we review relevant literature to outline the competing risks and benefits of lipid-lowering treatments in this vulnerable patient population. We suggest a treatment paradigm based on available data but note that data from dedicated randomized trials are needed to build the necessary evidence to guide optimal lipid-lowering strategy in patients with a history of ICH.

Artificial intelligence framework for predictive cardiovascular and stroke risk assessment models: A narrative review of integrated approaches using carotid ultrasound

RECENT FINDINGS

Cardiovascular disease (CVD) is the leading cause of mortality and poses challenges for healthcare providers globally. Risk-based approaches for the management of CVD are becoming popular for recommending treatment plans for asymptomatic individuals. Several conventional predictive CVD risk models based do not provide an accurate CVD risk assessment for patients with different baseline risk profiles. Artificial intelligence (AI) algorithms have changed the landscape of CVD risk assessment and demonstrated a better performance when compared against conventional models, mainly due to its ability to handle the input nonlinear variations. Further, it has the flexibility to add risk factors derived from medical imaging modalities that image the morphology of the plaque. The integration of noninvasive carotid ultrasound image-based phenotypes with conventional risk factors in the AI framework has further provided stronger power for CVD risk prediction, so-called "integrated predictive CVD risk models."

PURPOSE

of the review: The objective of this review is (i) to understand several aspects in the development of predictive CVD risk models, (ii) to explore current conventional predictive risk models and their successes and challenges, and (iii) to refine the search for predictive CVD risk models using noninvasive carotid ultrasound as an exemplar in the artificial intelligence-based framework.

CONCLUSION

Conventional predictive CVD risk models are suboptimal and could be improved. This review examines the potential to include more noninvasive image-based phenotypes in the CVD risk assessment using powerful AI-based strategies.

Stroke in the patient with diabetes (part 1) - Epidemiology, etiology, therapy and prognosis

There is a higher incidence of stroke in both the type 2 diabetic and the non-diabetic insulin resistant patient which is accompanied by higher morbidity and mortality. The increase in the frequency of stroke is due to an increase in cerebral infarction, mainly lacunar infarcts, with the incidence of cerebral hemorrhage being less frequent. The major risk factors for stroke in the type 2 diabetic patient are age, hypertension, the number of features of the Metabolic Syndrome, the presence of diabetic nephropathy in both the type 1 and type 2 patient, the presence of peripheral and coronary artery disease and especially the presence of atrial fibrillation. Hyperglycemia is associated with a poor outcome from stroke but is not causative.

Association Between Occupational Exposure to Pesticides and Cardiovascular Disease Incidence: The Kuakini Honolulu Heart Program

Background

Previously, Kuakini Honolulu Heart Program researchers reported that occupational exposure to pesticides was significantly associated with total mortality. The current study examines occupational exposure to pesticides in relation to incident cardiovascular disease, defined as coronary heart disease or cerebrovascular accident.

Methods and Results

With the Occupational Safety Health Administration exposure scale used as an estimate of exposure, statistical analyses were performed on a cohort of 7557 Japanese‐American men from the Kuakini Honolulu Heart Program. Hazard ratios for cardiovascular disease incidence were calculated for various levels of pesticide exposure using Cox proportional hazards models. In the first 10 years of follow‐up, a positive association was observed between age‐adjusted cardiovascular disease incidence and high levels of pesticide exposure (hazard ratio=1.46, 95% CI=1.10‐1.95, P=0.009). This relationship remained significant after adjustment for other cardiovascular disease risk factors (hazard ratio=1.42, 95% CI=1.05‐1.92, P=0.021). No significant association for coronary heart disease or cerebrovascular accident incidence with pesticide exposure was observed when examined separately, possibly due to a smaller number of events.

Conclusions

These findings suggest that occupational exposure to pesticides may play a role in the development of cardiovascular diseases. The results are novel, as the association between occupational exposure to pesticides and cardiovascular disease incidence has not been examined previously in this unique cohort.

The Lipid Paradox Among Acute Ischemic Stroke Patients-A Retrospective Study of Outcomes and Complications

Background and objectives: The Studies have suggested hypercholesterolemia is a risk factor for cerebrovascular disease. However, few of the studies with a small number of patients had tested the effect of hypercholesterolemia on the outcomes and complications among acute ischemic stroke (AIS) patients. We hypothesized that lipid disorders (LDs), though risk factors for AIS, were associated with better outcomes and fewer post-stroke complications. Materials and Method: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2003–2014) in adult hospitalizations for AIS to determine the outcomes and complications associated with LDs, using ICD-9-CM codes. In 2014, we also aimed to estimate adjusted odds of AIS in patients with LDs compared to patients without LDs. The multivariable survey logistic regression models, weighted to account for sampling strategy, were fitted to evaluate relationship of LDs with AIS among 2014 hospitalizations, and outcomes and complications amongst AIS patients from 2003–2014. Results and Conclusions: In 2014, there were 28,212,820 (2.02% AIS and 5.50% LDs) hospitalizations. LDs patients had higher prevalence and odds of having AIS compared with non-LDs. Between 2003–2014, of the total 4,224,924 AIS hospitalizations, 451,645 (10.69%) had LDs. Patients with LDs had lower percentages and odds of mortality, risk of death, major/extreme disability, discharge to nursing facility, and complications including epilepsy, stroke-associated pneumonia, GI-bleeding and hemorrhagic-transformation compared to non-LDs. Although LDs are risk factors for AIS, concurrent LDs in AIS is not only associated with lower mortality and disability but also lower post-stroke complications and higher chance of discharge to home.

Dyslipidaemia as a risk factor in the occurrence of stroke in Nigeria: prevalence and patterns

INTRODUCTION

Stroke is a major public health problem worldwide. Hypertension, diabetes mellitus, dyslipidaemia and smoking are some of the common modifiable risk factors in the occurrence of stroke. Therefore, this study was designed to assess the prevalence and patterns of dyslipidaemia among individuals with acute stroke.

METHODS

This is a retrospective descriptive cross-sectional study, carried out in the Departments of Medicine at the LAUTECH Teaching hospital, Ogbomoso and General Hospital, Orile-Agege, Lagos, South-West, Nigeria, over a 18-month period between September 2012 and February 2014. One hundred and six (106) patients with acute stroke confirmed with computed tomography (CT) brain scan were recruited. Clinical features, risk factors, lipid profiles and stroke patterns were identified.

RESULTS

Mean age was significantly higher in ischaemic stroke compared to haemorrhagic (64.08±10.87 Vs, 56.21±12.38years, p=0.001). There was slight male preponderance in both stroke types (1.3:1). Out of 106 patients, 65 (61.3%) had ischaemic stroke, 38 (35.8%) intracerebral haemorrhage and 3 (2.9%) with subarachnoid haemorrhage. Dyslipidaemia is the most frequent risk factor (85.9%), followed by hypertension (66.0%) and diabetes mellitus (15.1%). Dyslipidaemia was significantly higher in the ischaemic stroke compared to haemorrhagic. Reduced HDL-cholesterol is the most prevalent fraction of lipid abnormalities (74.5%).

CONCLUSION

Dyslipidaemia, particularly low HDL-C, was the most frequent risk factor in our patients with stroke. Hence, prevention of dyslipidaemia as well as other risk factors is key to reducing the burden of stroke in our country.

Development of sotagliflozin, a dual sodium-dependent glucose transporter 1/2 inhibitor

The sodium-dependent glucose transporter 2 (SGLT2) inhibitors are an important emerging class for the treatment of diabetes. Development of SGLT2 inhibitors has been oriented around a desire for high selectivity for the SGLT2 protein relative to the SGLT1 protein. More recently, genetic and pharmacology research in mice has indicated that gastrointestinal SGLT1 inhibition may also be an appropriate therapeutic target to treat diabetes. Combining SGLT1 and SGLT2 inhibition in a single molecule would provide complementary insulin-independent mechanisms to treat diabetes. Therefore, sotagliflozin (LX4211) has been developed as a dual inhibitor of SGLT1 and SGLT2. The differentiating clinical features of dual inhibitor of SGLT1 and SGLT2 include a large postprandial glucose reduction, elevation of glucagon-like peptide 1 and modest urinary glucose excretion. These features may have clinical implications for the use of sotagliflozin in the treatment of both type 1 and type 2 diabetes.

Pulse pressure and stroke risk: development and validation of a new stroke risk model

OBJECTIVE

This study aims to develop and validate a stroke risk model incorporating pulse pressure (PP) as a potential risk factor. Recent evidence suggests that PP, defined as the difference between systolic blood pressure (SBP) and diastolic blood pressure (DBP), could be an incremental risk factor beyond SBP.

METHODS

Electronic health records (EHRs) of hypertensive patients from a US integrated health delivery system were analyzed (January 2004 to May 2012). Patients with ≥ 1 PP reading and ≥ 6 months of observation prior to the first diagnosis of hypertension were randomly split into development (two-thirds of sample) and validation (one-third of sample) datasets. Stroke events were identified using ICD-9-CM 433.xx-436.xx. Cox proportional hazards models assessed time to first stroke event within 3 years of first hypertension diagnosis based on baseline risk factors, including PP, age, gender, diabetes, and cardiac comorbidities. The optimal model was selected using the least absolute shrinkage and selection operator (LASSO); performance was evaluated by the c-statistic.

RESULTS

Among 34,797 patients selected (mean age 59.3 years, 48% male), 4272 patients (12.3%) had a stroke. PP was higher among patients who developed stroke (mean [SD] PP, stroke: 02.0 [15.3] mmHg; non-stroke: 58.1 [14.0] mmHg, p < 0.001). The best performing risk model (c-statistic, development: 0.730; validation: 0.729) included PP (hazard ratio per mmHg increase: 1.0037, p < 0.001) as a significant risk factor.

LIMITATIONS

This study was subject to limitations similar to other studies using EHRs. Only patient encounters occurring within the single healthcare network were captured in the data source. Though the model was tested internally, external validation (using a separate data source) would help assess the model's generalizability and calibration.

CONCLUSIONS

This stroke risk model shows that greater PP is a significant predictive factor for increased stroke risk, even in the presence of known risk factors. PP should be considered by practitioners along with established risk factors in stroke treatment strategies.

Association between body mass index and cardiovascular disease mortality in east Asians and south Asians: pooled analysis of prospective data from the Asia Cohort Consortium

OBJECTIVE

To evaluate the association between body mass index and mortality from overall cardiovascular disease and specific subtypes of cardiovascular disease in east and south Asians.

DESIGN

Pooled analyses of 20 prospective cohorts in Asia, including data from 835,082 east Asians and 289,815 south Asians. Cohorts were identified through a systematic search of the literature in early 2008, followed by a survey that was sent to each cohort to assess data availability.

SETTING

General populations in east Asia (China, Taiwan, Singapore, Japan, and Korea) and south Asia (India and Bangladesh).

PARTICIPANTS

1,124,897 men and women (mean age 53.4 years at baseline).

MAIN OUTCOME MEASURES

Risk of death from overall cardiovascular disease, coronary heart disease, stroke, and (in east Asians only) stroke subtypes.

RESULTS

49,184 cardiovascular deaths (40,791 in east Asians and 8393 in south Asians) were identified during a mean follow-up of 9.7 years. East Asians with a body mass index of 25 or above had a raised risk of death from overall cardiovascular disease, compared with the reference range of body mass index (values 22.5-24.9; hazard ratio 1.09 (95% confidence interval 1.03 to 1.15), 1.27 (1.20 to 1.35), 1.59 (1.43 to 1.76), 1.74 (1.47 to 2.06), and 1.97 (1.44 to 2.71) for body mass index ranges 25.0-27.4, 27.5-29.9, 30.0-32.4, 32.5-34.9, and 35.0-50.0, respectively). This association was similar for risk of death from coronary heart disease and ischaemic stroke; for haemorrhagic stroke, the risk of death was higher at body mass index values of 27.5 and above. Elevated risk of death from cardiovascular disease was also observed at lower categories of body mass index (hazard ratio 1.19 (95% confidence interval 1.02 to 1.39) and 2.16 (1.37 to 3.40) for body mass index ranges 15.0-17.4 and <15.0, respectively), compared with the reference range. In south Asians, the association between body mass index and mortality from cardiovascular disease was less pronounced than that in east Asians. South Asians had an increased risk of death observed for coronary heart disease only in individuals with a body mass index greater than 35 (hazard ratio 1.90, 95% confidence interval 1.15 to 3.12).

CONCLUSIONS

Body mass index shows a U shaped association with death from overall cardiovascular disease among east Asians: increased risk of death from cardiovascular disease is observed at lower and higher ranges of body mass index. A high body mass index is a risk factor for mortality from overall cardiovascular disease and for specific diseases, including coronary heart disease, ischaemic stroke, and haemorrhagic stroke in east Asians. Higher body mass index is a weak risk factor for mortality from cardiovascular disease in south Asians.

Effect of lipid profile upon prognosis in ischemic and haemorrhagic cerebrovascular stroke

Stroke is the third major cause of death worldwide. Elevated plasma concentration of low density lipoproteins and low plasma concentration of high density lipoprotein concentration are associated with an increased risk of atherosclerosis and coronary heart disease but the relation between serum lipids, and cerebrovascular disease is less clear. The aim of this study was to investigate the reliability and accuracy of serum lipid profile in assessing the prognosis/neurological worsening in patients with ischemic and hemorrhagic cerebrovascular stroke. The subjects in the present study comprised of 101 healthy controls and 150 cerebrovascular stroke patients (including 90 with ischemic stroke and 60 with intracerebral hemorrhagic stroke). In both the groups fasting lipid profile was determined within 72 h of the stroke. A statistically significant association was observed (p < 0.001) between the parameters of lipid profile of cases and healthy controls, and also with the prognosis of the stroke.

Epidemiology of Diabetes

The incidence of diabetes mellitus, particularly type 2 diabetes, is increasing dramatically in the United States and in other Westernized, industrialized societies because of increasing obesity, sedentary lifestyle, and population aging. There are currently 20 million persons with diabetes in the United States, of whom more than 5 million remain undiagnosed. The diabetic population consumes a disproportionate share of health care resources because of both microvascular and macrovascular complications. Diabetes is a major cause of new-onset blindness, end-stage renal disease, and nontraumatic amputation in the United States. Cardiovascular disease accounts for up to 80% of premature excess mortality in diabetic patients. Strategies to lessen the disease burden in these patients include hygienic measures (diet and exercise) as well as rigorous treatment of hypertension, dyslipidemia, and hyperglycemia.

Does cultural assimilation influence prevalence and presentation of depressive symptoms in older Japanese American men? The Honolulu-Asia aging study

OBJECTIVE

: Sociocultural factors have been implicated in affecting prevalence, incidence, and diagnosis of depression but previous studies have included heterogeneous ethnic populations. We studied the influence of cultural assimilation on the prevalence and presentation of depressive symptoms in elderly Japanese American men.

METHOD

: This analysis was based on 3,139 Japanese American men aged 71-93 years who were participants in the Honolulu-Asia Aging Study between 1991 and 1993. We created a Cultural Assimilation Scale (CAS) using 8 questions assessing the degree of Japanese identity and lifestyle compared to a Western one. Subjects were divided into tertiles of CAS score for analysis. Prevalence of depressive symptoms was measured using an 11-question version of the Centers for Epidemiologic Studies Depression Scale questionnaire, and presence of depressive symptoms was defined as score 9 or more.

RESULTS

: Prevalent depressive symptoms did not reach a statistically significant association with CAS tertiles (Western, 10.8%; Mixed, 9.6%; and Japanese, 8.5%). However after adjusting for demographic, functional, and disease factors, the most culturally Japanese group had significantly lower odds for prevalent depressive symptoms, compared to the most Western group. Among the subset of subjects with a high-Centers for Epidemiologic Studies Depression Scale-11 score, there were no significant differences in both mean psychological scores and mean somatic scores between the three CAS groups.

CONCLUSIONS

: Prevalent depressive symptoms were significantly lower among elderly Japanese American men who were most culturally Japanese, compared to more westernized men. Improving knowledge and understanding about the pathogenesis of depression will have important public health implications.

The C825T GNB3 polymorphism, independent of blood pressure, predicts cerebrovascular risk at a population level

BACKGROUND

The role of C825T polymorphism of the candidate GNB3 gene in predicting cerebrovascular outcome has been poorly explored in longitudinal setting at a population level.

METHODS

In an epidemiological setting, 1,678 men and women from general population were genotyped for C825T polymorphism of GNB3 gene and follow-up for 10 years to detect nonfatal and fatal cerebrovascular events (CE). Established cerebrovascular risk factors were used to adjust the multivariate Cox analysis for confounders.

RESULTS

Seventy-three nonfatal and 30 fatal CE were recorded. Incidence of CE was higher in TT than in C-carriers (fatal: 2.6 vs. 1.7%, P < 0.03; nonfatal: 7.8 vs. 3.9%, P < 0.03; fatal recurrences: 1.6 vs. 0.6%, P < 0.03). In Cox analysis, the TT genotype predicted nonfatal (hazard ratio 1.99, 95% confidence interval 1.05-3.79, P = 0.03), fatal (2.91, 1.05-8.12, P = 0.04), and fatal recurrent CE (6.82, 1.50-31.1, P = 0.02) also after adjustment for age, gender, systolic and diastolic blood pressure, body adiposity, atherogenetic blood lipids, serum uric acid, diabetes, calories, caffeine and ethanol intake, and coronary events at baseline. Further adjustment for historical CE made the association between TT genotype and incident fatal CE nonsignificant (hazard ratio 2.72, 95% confidence interval 0.96-7.22, P = 0.06).

CONCLUSIONS

The TT genotype of GNB3 gene predicts incident CE independent of blood pressure and other established risk factors at a population level. Further studies are needed to clarify the nature and pathways of this association.

Cardiovascular risk profiles and outcomes of Chinese living inside and outside China

AIM

To assess whether cardiovascular risk differs among the Chinese living inside and outside mainland China.

METHODS AND RESULTS

Three thousand, four hundred and eighty-two East Asians were enrolled in the REduction of Atherothrombosis for Continued Health Registry in mainland China, Hong Kong/Singapore/Taiwan, Western Europe, and North America. Baseline demographics, medication use, risk factor control, and 30-month cardiovascular outcomes of the 2938 patients with atherothrombotic disease were compared. Rates of hypertension, hypercholesterolemia, diabetes, abdominal obesity, and body mass index ≥25 kg/m² were lowest in mainland China, were increased in Hong Kong/Singapore/Taiwan, and were highest in Western Europe and North America. Diabetes prevalence was 23% in mainland China, approximately two-fold lower than the other regions. Antihypertensive, antidiabetic, and antiplatelet agent use was similar in all regions. Risk factor control was significantly poorer in Western Europe and, except for glucose control, significantly better in North America. Thirty-month nonfatal stroke rates were highest in mainland China and fell in a stepwise manner in more westernized societies. Conversely, nonfatal myocardial infarction rates increased in more westernized societies.

CONCLUSION

Obesity and other risk factors progressively worsen as patients move from mainland China to Hong Kong/Singapore/Taiwan and overseas. Despite similar medication use, risk factor control and cardiovascular outcomes were significantly different. The magnitude of these changes is larger than formerly estimated, suggesting population differences in cardiovascular risk and disease prevalence, likely to be more closely associated with lifestyle and cultural habits than genetic differences.

Doppler study of cerebral arteries in hypercholesterolemia

Background:

Hypercholesterolemia is one of the major modifiable risk factors for atherosclerosis of the coronary and carotid arteries. Although transcranial Doppler (TCD) studies of the cerebral arteries are indicative of decreased cerebral blood flow velocities in patients with hypercholesterolemia, the number of these studies has been limited. The aim of this study was to assess the hemodynamic status of the cerebral arteries in patients with hypercholesterolemia using TCD.

Methods:

In a case-control study, 60 individuals, including 30 hypercholesterolemic cases (low-density lipoprotein [LDL] > 160 mg/dL) and 30 healthy controls were enrolled. Other arterial risk factors, including diabetes mellitus, hypertension, smoking, and obesity (body mass index > 30), were evaluated and matched as well. TCD was used to assess the hemodynamics of the intracranial arteries as well as the internal carotid arteries. The mean blood flow velocity, pulsatility index, and resistance index were recorded in all the arteries.

Results:

The mean blood flow velocity, pulsatility index, and resistance index of the intracranial arteries and internal carotid arteries were not significantly different between the two groups (P > 0.05). However, those with higher levels of LDL (>180 mg/dL) showed significantly lower mean blood flow velocity and resistance index of the internal carotid arteries than the healthy controls. In addition, individuals with high-density lipoprotein (HDL) <35 mg/dL had significantly lower mean blood flow velocity in the internal carotid arteries.

Conclusion:

Hypercholesterolemia (LDL >160 mg/dL) does not seem to have a detrimental effect on the hemodynamic status of the intracranial arteries and internal carotid arteries. However, in cases of higher LDL (>180 mg/dL) and lower HDL, decreased TCD parameters in the internal carotid arteries, as a surrogate of the peripheral arteries, are prominent.

Glucose level and brain infarction: a prospective case-control study and prospective study

BACKGROUND

Hyperglycaemia in the acute phase of stroke has been established as a predictor of higher mortality. But recent data regarding active treatment of hyperglycaemia showed no clinical benefit suggesting that hyperglycaemia may not have a detrimental effect in brain infarction. Additional data are needed to resolve this uncertainty and identify patients at higher risk if any.

METHODS

A total of 477 adult Caucasian patients with brain infarction and 395 age- and sex-matched controls admitted at the same centres for nonneurological causes were recruited consecutively from 12 neurological centres in France. Electrocardiographic, carotid ultrasonography, and transcranial Doppler studies were performed. Blood was drawn in the morning from fasting subjects for glucose measurement. Functional outcome was measured on admission, at 10 days and at 6 months after the onset of stroke using the modified Rankin scale.

RESULTS

Among 477 brain infarction patients and 395 hospitalised controls the adjusted mean (+/-SEM) glucose level was higher in cases (6.4+/-1.0 mmol/l) than in controls (6.0+/-1.01 mmol/l, P=0.006), with a significant heterogeneity across sexes. The fully adjusted odds ratio of brain infarction per 1-standard deviation increase in log-glucose level was 1.02 (95% confidence interval, 0.77-1.37) in men and 2.21 (95% confidence interval, 1.44-3.40) in women. Among the 477 brain infarction cases elevated admission glucose levels were associated with poor outcomes and higher poststroke mortality after adjustment for conventional vascular risk factors and infarct volume. These relationships were not modified by sex.

CONCLUSIONS

Elevated admission glucose levels were associated with brain infarction in women only and with a higher 5-year mortality. Further investigation focusing on the impact of glucose level in different target population is needed to optimise glycaemic management in acute brain infarction patients.

Association between cholesterols, homocysteine and silent brain infarcts

BACKGROUND

The aim of this study was to assess the relationship between total plasma homocysteine, cholesterol levels, vitamin B(12), folate, thyroid hormones, urea, ferritin, uric acid, C-reactive protein, cardiovascular risk factors and silent brain infarct (SBI) in patients without any neurological disorder. Whether the factors of interest were associated with SBI is investigated.

METHODS

One hundred and forty-two subjects with a mean age of 52.1 +/- 13.1 years (21-87 years) without any history of stroke, transient ischaemic attack and neurological abnormality were enrolled in this cross-sectional study. The subjects underwent brain magnetic resonance imaging and blood chemistry determinations. Student's t-test was used to compare differences in means of laboratory results between the groups with and without SBI. The chi(2)-test was used for categorized variables. Multiple logistic regression analysis was used to determine the independent predictors of SBI.

RESULTS

The group comprised 56 men and 86 women. SBI were found in 40 patients (28%). The low-density lipoprotein levels were significantly higher in the infarct group (P = 0.019), homocysteine concentrations were significantly higher in the men-infarct group (P = 0,029) and total cholesterol levels were significantly higher in the women-infarct group than the women non-infarct group (P = 0.006).

CONCLUSION

Serum low-density lipoprotein, total cholesterol and homocysteine levels were associated with SBI.

Strength and influence of geriatrics departments in academic health centers

The United States is establishing new medical schools and increasing class size by 30% in response to the predicted increased needs of the baby boom generation, which will retire soon and live longer than prior generations. Society in general and the medical profession in particular are ill equipped to care for the special needs of the elderly. Since the early 1980s, departments of geriatric medicine have been developed in the United States. However, the prevailing U.S. system for the training of physicians in geriatrics is through sections, divisions, or institutes. This article reviews the advantages and disadvantages of departments of geriatrics, using case examples from three (University of Oklahoma College of Medicine, Florida State University College of Medicine, and University of Hawaii at Mãnoa John A. Burns School of Medicine) of the extant 11 medical schools in the United States with departments of geriatrics. Commonalities among the three departments include a seat at the planning table in academic life, equal treatment and collaboration with other departments in academic and research program development, and direct access to key decision makers and opportunities for negotiation for funds. Each department has outreach to all undergraduate medical students through its training program. All three departments were launched through the investment of significant resources obtained both internally and externally. The challenge for the future will be to definitively demonstrate the efficacy of the department model versus the more prevalent section, division, and institute approach to training physicians to care for the elderly.

Association of low cholesterol with primary intracerebral haemorrhage: a case control study

OBJECTIVES

Epidemiological studies have shown that the incidence of intracerebral haemorrhage (ICH) is high in patients with low cholesterol levels. The aim of this study was to investigate the correlation between ICH and low cholesterol in cases of primary ICH.

MATERIAL AND METHODS

Two hundred and fifty-nine patients with primary intracerebral haemorrhage and 137 healthy individuals were included in this study. Patients with prior cerebrovascular accident, secondary ICH, hereditary lipid metabolism disorders, thyroid diseases and those using lipid-lowering drugs were excluded. In all subjects, cholesterol levels were measured after 12 h of fasting.

RESULTS

Mean cholesterol levels were 205.8 +/- 51.4 mg/dl in the ICH group and 230.2 +/- 38.9 mg/dl in the control group. Mean cholesterol levels of patients were significantly lower than the controls (P < 0.000). In ICH group, the frequency of patients who had very low cholesterol levels was significantly higher than the control group (P < 0.000).

CONCLUSIONS

Individuals with lower cholesterol levels have an increased risk of ICH. Therefore, before treatment with statins, clinicians must be aware of the possible ICH risk.

PPARs as new therapeutic targets for the treatment of cerebral ischemia/reperfusion injury

Stroke is a leading cause of death and long-term disability in industrialized countries. Despite advances in understanding its pathophysiology, little progress has been made in the treatment of stroke. The currently available therapies have proven to be highly unsatisfactory (except thrombolysis) and attempts are being made to identify and characterize signaling proteins which could be exploited to design novel therapeutic modalities. The peroxisome proliferator-activated receptors (PPARs) are ligand-activated transcription factors that control lipid and glucose metabolism. PPARs regulate gene expression by binding with the retinoid X receptor (RXR) as a heterodimeric partner to specific DNA sequences, termed PPAR response elements. In addition, PPARs may modulate gene transcription also by directly interfering with other transcription factor pathways in a DNA-binding independent manner. To date, three different PPAR isoforms, designated alpha, beta/delta, and gamma, have been identified. Recently, they have been found to play an important role for the pathogenesis of various disorders of the central nervous system and accumulating data suggest that PPARs may serve as potential targets for treating ischemic stroke. Activation of all PPAR isoforms, but especially of PPARgamma, was shown to prevent post-ischemic inflammation and neuronal damage in several in vitro and in vivo models, negatively regulating the expression of genes induced by ischemia/ reperfusion (I/R). This paper reviews the evidence and recent developments relating to the potential therapeutic effects of PPAR-agonists in the treatment of cerebral I/R injury.

Potential therapeutic role of statins in neurological disorders

Statins, the inhibitors of HMG-CoA reductase, are currently among the most commonly prescribed agents for the prevention of cardiovascular disease. It is well established that statins reduce cholesterol levels and prevent coronary heart disease. Moreover, evidence suggests that statins have additional properties such as endothelial protection via actions on the nitric oxide synthetase system as well as antioxidant, anti-inflammatory and antiplatelet effects. There is evidence that all these actions might have potential therapeutic implications not only in stroke, but also in various neurological disorders, such as Alzheimer's disease, Parkinson's disease, multiple sclerosis and primary brain tumors. In this review, we summarize the protective effects of statins on various neurological diseases. Currently available data suggest that statins are safe and effective in the treatment of these neurological disorders, although further experiments and new data are required.

Effect of protein convertase subtilisin/kexin type 9 (PCSK9) 46L gene polymorphism on LDL cholesterol concentration in a Polish adult population

The purpose was to study the effect of PCSK9 46L on cholesterol concentration and cardiovascular morbidity. By comparing 176 carriers with 6618 non-carriers identified through a cross-sectional population study (WOBASZ) we confirmed the LDL lowering effect of PCSK9 46L and demonstrated that it increases with the concentration of LDL. We noted that PCSK9 46L was associated with tendency for protection from myocardial infarction but not stroke suggesting a difference in the effect on susceptibility to these disorders.

Serum total cholesterol levels and risk of mortality from stroke and coronary heart disease in Japanese: The JACC study

The relation between serum total cholesterol and coronary heart disease is well established, but the relations with total stroke and stroke subtypes are controversial. We conducted a nested case-control study as part of the JACC study. A total of 39,242 subjects, 40-79 years of age, provided serum samples at baseline between 1988 and 1990. During the 10-year follow-up, 345 deaths from total strokes (including 76 intraparenchymal hemorrhages) and 150 deaths from coronary heart diseases were recorded. The control subjects were matched for sex, age, community, and year of serum storage, and further adjusted for systolic blood pressure, high density lipoprotein (HDL)-cholesterol, ethanol intake category, smoking status, and diabetes. Serum total cholesterol levels were measured using an enzymatic method. Cases with total stroke and more specifically intraparenchymal hemorrhage had lower mean values of serum total cholesterol levels compared with control subjects. The risk of mortality from intraparenchymal hemorrhage was significantly higher for persons with low total cholesterol levels [less than 4.14 mmol/l (160 mg/dl)] than with those with higher levels. The risk of mortality from coronary heart disease for persons with serum total cholesterol levels more than or equal to 6.72 mmol/l (260 mg/dl) was significantly higher than those with levels less than 4.14 mmol/l (160 mg/dl). Low serum total cholesterol levels are associated with high mortality from intraparenchymal hemorrhage while high levels are associated with high mortality from coronary heart disease among Japanese.

Lipid levels and the risk of ischemic stroke in women

OBJECTIVE

To evaluate the association between total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol to HDL-C ratio, and non-HDL-C with the risk of ischemic stroke in a large cohort of apparently healthy women.

METHODS

Prospective cohort study among 27,937 US women aged > or =45 years participating in the Women's Health Study who provided baseline blood samples. Stroke occurrence was self-reported and confirmed by medical record review. We categorized plasma lipid measurements into quintiles. We used Cox proportional hazards models to evaluate the association between lipids and risk of ischemic stroke.

RESULTS

During 11 years of follow-up, 282 ischemic strokes occurred. All lipid levels were strongly associated with increased risk of ischemic stroke in age-adjusted models. The association attenuated particularly for HDL-C after adjustment for potential confounders. For the comparison of the highest to the lowest quintile, the multivariable-adjusted hazard ratios (95% CI; p for trend across mean quintile values) of ischemic stroke were 2.27 (1.43, 3.60; p(trend) < 0.001) for total cholesterol; 1.74 (1.14, 2.66; p(trend) = 0.003) for LDL-C; 0.78 (0.52, 1.17; p(trend) = 0.27) for HDL-C; 1.65 (1.06, 2.58; p(trend) = 0.02) for the total cholesterol to HDL-C ratio; and 2.45 (1.54, 3.91; p(trend) < 0.001) for non-HDL-C.

CONCLUSIONS

In this large cohort of apparently healthy women, total cholesterol, low-density lipoprotein cholesterol, the total cholesterol to high-density lipoprotein cholesterol ratio, and non-high-density lipoprotein cholesterol were significantly associated with increased risk of ischemic stroke.

Comparative carotid echo-doppler study in diabetic and non-diabetic patients with atherosclerotic carotid macroangiopathy

Diabetes mellitus is one of the main risk factors of cerebrovascular disease (CVD). Comparing non-diabetic and diabetic patients, the latter ones have a higher incidence of stroke, which tends to occur at younger ages. This paper deals with Echo Doppler evaluation of arteries in diabetic and non-diabetic patients. The findings allow us to conclude that the correct and early treatment of diabetes as well as a possible lowering of the risks for cerebrovascular disease are obligatory steps in the primary and secondary prevention of the cerebral ischemic events in diabetic patients with carotid atheromatous lesions. This consideration may help the physicians to have a deeper understanding of the pathophysiology, and to implement the necessary treatment and prevention of CVD in the diabetic population of high-risk.

[Estimation of effect of lipid lowering treatment on total mortality rate and its cost-effectiveness determined by intervention study of hypercholesterolemia]

OBJECTIVES

Total cholesterol (TC) level reduction decreases coronary heart disease (CHD) risk, but it is also associated with an increase in non-CHD mortality rate. Our objectives are to estimate the effect of TC level reduction on total mortality and other mortalities in the Japanese population using published data and to analyze the cost-effectiveness of drug therapy.

METHODS

We analyzed three data sets for the estimation. The first data set comprised Japanese mortality rates of cardiac diseases, cerebrovascular/other vascular diseases, malignancy, and all causes according to sex and age. The second data set comprised the distributions of serum TC levels in the Japanese population. The third data set comprised the relative risks of mortality rates for the above causes according to the TC level classified into discrete intervals of 20 mg/dl from an intervention study. We estimated the mortality rates of people aged 30-69, with each TC level classification group on the basis of each cause. On the assumption that TC level decreases from 240-259 mg/dl to 160-179 mg/dl or 180-199 mg/dl with drug therapy, we calculated the differences between the mortalities of the classification. When we found a positive effect of TC level reduction, we performed cost-effectiveness analyses of Number Needed to Treat (NNT).

RESULTS

TC level reduction increased the mortality rates except for that of cardiac diseases, and the NNT for cardiac diseases was in the range of 4,202-17,533. The cost of simvastatin, for example, was 0.25-1.05 billion yen per year.

CONCLUSIONS

TC level reduction from 240-259 mg/dl to 160-199 mg/dl leads to an increase in total mortality rate in the Japanese population. The treatment should be reevaluated from both viewpoints of risk benefit and cost-effectiveness.

Lipids and stroke: the opportunity of lipid-lowering treatment

Dyslipemia is a clear risk factor (RF) for ischemic heart disease and peripheral artery disease, but its relation with ischemic stroke (IS) is not so clear. HMG-CoA reductase inhibitor drugs or statins (simvastatin, atorvastatin, pravastatin) reduce the relative risk of IS by between 18 and 51% in patients with IHD, in patients with high vascular disease risk and in hypertensive patients with other RFs, acute coronary syndrome, and type 2 diabetes mellitus. According to the guidelines for use, statins are indicated in the majority of patients with IS since the risk is equivalent to that of IHD or high vascular disease risk. In view of the existing clinical evidence of benefit, it would not seem unreasonable to proceed with treatment of patients using statins while awaiting specific studies justifying their use. The non-lipid-lowering mechanisms of the statins and results of studies, such as the Heart Protection Study, provide evidence for widening the indications of statins beyond the prevention of dyslipemia, as a new therapeutic approach in the prevention of IS in patients with plasma levels of total cholesterol or low density lipoproteins currently considered within the normal distribution. The neuroprotective role, which these drugs may play in the acute phase of cerebral ischemia, remains to be clarified, but very recent evidence suggests that such patients may also benefit.

Natural menopause and risk of stroke in elderly women

Although early natural menopause has been postulated to increase stroke risk, studies have not produced convincing results. We examined the associations between stroke risks and age at natural menopause or time since natural menopause. 5,731 naturally postmenopausal women more than 65 yr of age were followed from 1993 to 1998. Information on age at menopause and risk factors were obtained using mailed questionnaires. 186 cases of stroke occurred over a total 27,936 person-years. After adjusting for age, hypertension, and physical activity, age at menopause was not found to be significantly associated with stroke or cerebral infarction. However, adjusted relative risks (aRRs) showed a significant increasing tendency of hemorrhagic stroke versus age at menopause (aRRs, 0.66, 0.48, 1.00 and 2.33 for the following age groups at menopause; 40-44, 45-49, 50-54 [reference group], and > or =55 yr). Time since menopause (11-20, 21-30, and > or =31 yr) was not found to be significantly associated with cerebral infarction, or hemorrhagic stroke. Late menopause (menopause age > or =55 yr) showed a tendency of a lower risk of cerebral infarction (aRR, 0.79) and a higher risk of hemorrhagic stroke (aRR, 2.33). Further study is warranted to determine stroke risk in women during the decade following menopause.

Drug Insight: statins and stroke

Stroke is the third leading cause of death in the US and a common cause of long-term disability worldwide. Ischemic strokes, which are often atherothrombotic, account for more than 80% of all strokes. Current stroke prevention focuses on optimizing the treatment of modifiable risk factors, such as hypertension, diabetes and dyslipidemia. The epidemiologic association between serum cholesterol levels and adjusted stroke rates is not as strong as the link between serum cholesterol levels and coronary heart disease. Clinical trials of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins), which are potent inhibitors of cholesterol synthesis, have demonstrated, however, a marked reduction in stroke risk in hypercholesterolemic and atherosclerotic individuals, with benefits extending to normocholesterolemic individuals. These findings suggest that statins might have additional effects in stroke protection beyond cholesterol reduction. Because statins inhibit the synthesis of isoprenoid intermediates in the cholesterol biosynthetic pathway, which are important lipid attachments for intracellular signaling molecules, they might have direct noncholesterol-dependent effects on inflammatory and endothelial cells. Here we discuss data from clinical trials assessing the effects of statins on stroke risk, as well as outline the mechanisms underlying the cholesterol-independent effects of statins and provide evidence-based recommendations for stroke prevention, based on achieved serum cholesterol levels in patients at risk of stroke.

Statins and stroke

Inhibitors of HMG-CoA reductase (statins) are potent cholesterol-lowering drugs. Large clinical trials have shown that statins reduce the incidence of cerebrovascular events, which might be surprising because cholesterol is not an established risk factor for stroke. In addition to their cholesterol-lowering properties, statins exert a number of pleiotropic, vasculoprotective actions that include improvement of endothelial function, increased nitric oxide (NO) bioavailability, antioxidant properties, inhibition of inflammatory responses, immunomodulatory actions, regulation of progenitor cells, and stabilization of atherosclerotic plaques. In fact, statins augment cerebral blood flow and confer significant protection in animal models of stroke partly via mechanisms related to the upregulation of endothelial nitric oxide synthase. Retrospective clinical evidence suggests that long-term statin administration may not only reduce stroke risk but also improve outcome. Early secondary prevention trials are underway to test the hypothesis that statin treatment initiated immediately after an event improves short-term outcome. Lastly, recent evidence suggests that sudden discontinuation of statin treatment leads to a rebound effect with downregulation of NO production. Withdrawal of statin treatment may impair vascular function and increase morbidity and mortality in patients with vascular disease.

Stroke prevention in diabetic and other high cardiovascular risk patients

Diabetes is a major risk factor for stroke that is usually associated with risk factors such as hypertension, obesity, albuminuria, and dyslipidemia. Furthermore, atrial fibrillation and heart failure, two of the most important risk factors of stroke, are common in the diabetic population. With the rising epidemic of diabetes, the incidence of stroke is also on the rise. Implementations of effective stroke prevention strategies appear to be the most rational option to curb this growing epidemic. In this review, we examine the epidemiologic and the pathophysiologic association between stroke and diabetes, highlighting the population-based stroke preventive measures. These include hygienic and lifestyle changes, that if applied effectively could offer a great potential for stroke prevention and reduction of the cardiovascular burden in the diabetic populations.

Age-related changes in risk factor effects on the incidence of thromboembolic and hemorrhagic stroke

We examined the changes in risk factor effects on the incidence of thromboembolic and hemorrhagic stroke as they may occur with age. Findings were based on repeated risk factor measurements at four examinations over a 26-year period in 7589 men in the Honolulu Heart Program. After each examination, 6 years of follow-up were available to assess risk factor effects on the incidence of stroke over a broad range of ages (45-93 years). As compared with normotensive men, the risk of thromboembolic stroke in the presence of hypertension declined from a 7-fold excess in men aged 45 to 54 years to a 1.4-fold excess in men aged > or =75 (P<.001). Adverse effects of diabetes and atrial fibrillation seemed to be equally important across all ages, whereas a protective effect of physical activity increased with age. Except for men with atrial fibrillation, the incidence of thromboembolic stroke increased significantly with age regardless of risk factor status, including men with normal blood pressure (P<.001). Although hemorrhagic events were less common, positive relations with cigarette smoking seemed to strengthen with age, whereas those with hypertension tended to decline. Our findings suggest that strategies for the prevention of stroke may need to account for changes in risk factor effects as they occur with age. Control of diabetes and the encouragement of active lifestyles in the elderly seem to be especially important.

Predictors of stroke mortality in elderly people from the general population. The CArdiovascular STudy in the ELderly

Stroke occurs particularly frequently in elderly people and, being more often disabling than fatal, entails a high social burden. The predictors of stroke mortality have been identified in 3282 subjects aged > or = 65 years, taking part in the CArdiovascular STudy in the ELderly (CASTEL), a population-based study performed in Northeast Italy. Historical and clinical data, blood tests and 14-year fatal events were recorded. Continuous items were divided into quintiles and, for each quintile, adjusted relative risk (RR) with 95% confidence intervals [CI] was derived from multivariate Cox analysis. Age, historical stroke (RR: 5.2; 95% CI: 3.18-8.6) and coronary artery disease (RR: 1.38; CI: 1.18-2.1), atrial fibrillation (RR: 2.40; CI: 1.42-4.0), arterial hypertension (RR: 1.33; CI: 1.15-1.76), systolic blood pressure > or = 163 mmHg (RR: 1.84; CI: 1.20-2.59), pulse pressure > or = 74 mmHg (RR: 1.50; CI: 1.13-2.40), cigarette smoking (RR: 1.60; CI: 1.03-2.47), electrocardiographic left ventricular hypertrophy (RR: 1.72; CI: 1.10-2.61), impaired glucose tolerance (IGT, RR: 1.83; CI: 1.10-3.0), uric acid (UA) > 0.38 mmol/l (RR: 1.61; CI: 1.14-2.10), serum potassium > or = 5 mEq/l (RR: 1.70; CI: 1.24-2.50) and serum sodium < or = 139 mEql/l (RR: 1.34; 1.10-2.10) increased the risk of stroke. In the CASTEL, stroke was the first cardiovascular cause of death. Some independent predictors usually unrelated to stroke mortality (namely pulse pressure, pre-diabetic IGT, UA and blood electrolytes disorders) have been identified.

Smoking raises the risk of total and ischemic strokes in hypertensive men

To examine the relation between cigarette smoking and risk of stroke and coronary heart disease among Japanese, we conducted a 14-year prospective study of 3,626 men aged 40-69, initially free from history of stroke and coronary heart disease. We identified 257 strokes (75 hemorrhagic and 173 ischemic strokes) and 100 coronary heart disease events. When we adjusted for age and other cardiovascular risk factors, a significant excess risk among current smokers of > 20 cigarettes/day vs. never-smokers was found for total stroke (relative risk (RR) = 1.6 (95% confidence interval (CI), 1.1-2.4)). The excess risk of total stroke was particularly evident among hypertensives (RR = 2.3 (1.2-4.4)). The multivariate RR of ischemic stroke was 1.6 (1.0-2.5) for total subjects, and 2.2 (1.0-5.0) among hypertensives. Significant excess risks among current smokers of > 20 cigarettes/day vs. never-smokers were also found for coronary heart disease (RR = 4.6 (1.6-12.9)) and total cardiovascular disease (1.9 (1.3-2.7)). The estimated proportion of the events attributable to current smoking was 30 (95% CI, 11-44)% for total stroke and 34 (5-54)% for coronary heart disease. In conclusion, current smoking of > 20 cigarettes per day increased the risk of both total stroke and ischemic stroke among Japanese middle-aged men, and particularly among middle-aged hypertensive men.

Current intracerebral haemorrhage management

Primary intracerebral haemorrhage (ICH) refers to spontaneous bleeding from intraparenchymal vessels. It accounts for 10-20% of all strokes, with higher incidence rates amongst African and Asian populations. The major risk factors are hypertension and age. In addition to focal neurological findings, patients may present with symptoms of elevated intracranial pressure. The diagnosis of ICH can only be made through neuro-imaging. A CT scan is presently standard, although MRI is increasingly important in the evaluation of acute cerebrovascular disease. A significant proportion of intracerebral haematomas expand in the first hours post-ictus and this is often associated with clinical worsening. There is evidence that the peri-haematomal region is compromised in ICH. This tissue is oedematous, although the precise pathogenesis is controversial. An association between elevated arterial pressure and haematoma expansion has been reported. Although current guidelines recommend conservative management of arterial pressure in ICH, an acute blood pressure lowering trial is overdue. ICH is associated with a high early mortality rate, although a significant number of survivors make a functional recovery. Current medical management is primarily aimed at prevention of complications including pneumonia and peripheral venous thromboembolism. Elevated intracranial pressure may be treated medically or surgically. Although the latter definitively lowers elevated intracranial pressure, the optimal patient selection criteria are not clear. Aggressive treatment of hypertension is essential in the primary and secondary prevention of ICH.

Alcohol consumption and risk of stroke: a meta-analysis

CONTEXT

Observational studies suggest that heavy alcohol consumption may increase the risk of stroke while moderate consumption may decrease the risk.

OBJECTIVE

To examine the association between alcohol consumption and relative risk of stroke.

DATA SOURCES

Studies published in English-language journals were retrieved by searching MEDLINE (1966-April 2002) using Medical Subject Headings alcohol drinking, ethanol, cerebrovascular accident, cerebrovascular disorders, and intracranial embolism and thrombosis and the key word stroke; Dissertation Abstracts Online using the keywords stroke and alcohol; and bibliographies of retrieved articles.

STUDY SELECTION

From 122 relevant retrieved reports, 35 observational studies (cohort or case control) in which total stroke, ischemic stroke, or hemorrhagic (intracerebral or total) stroke was an end point; the relative risk or relative odds and their variance (or data to calculate them) of stroke associated with alcohol consumption were reported; alcohol consumption was quantified; and abstainers served as the reference group.

DATA EXTRACTION

Information on study design, participant characteristics, level of alcohol consumption, stroke outcome, control for potential confounding factors, and risk estimates was abstracted independently by 3 investigators using a standardized protocol.

DATA SYNTHESIS

A random-effects model and meta-regression analysis were used to pool data from individual studies. Compared with abstainers, consumption of more than 60 g of alcohol per day was associated with an increased relative risk of total stroke, 1.64 (95% confidence interval [CI], 1.39-1.93); ischemic stroke, 1.69 (95% CI, 1.34-2.15); and hemorrhagic stroke, 2.18 (95% CI, 1.48-3.20), while consumption of less than 12 g/d was associated with a reduced relative risk of total stroke, 0.83 (95%, CI, 0.75-0.91) and ischemic stroke, 0.80 (95% CI, 0.67-0.96), and consumption of 12 to 24 g/d was associated with a reduced relative risk of ischemic stroke, 0.72 (95%, CI, 0.57-0.91). The meta-regression analysis revealed a significant nonlinear relationship between alcohol consumption and total and ischemic stroke and a linear relationship between alcohol consumption and hemorrhagic stroke.

CONCLUSIONS

These results indicate that heavy alcohol consumption increases the relative risk of stroke while light or moderate alcohol consumption may be protective against total and ischemic stroke.

Lowering lipids after a stroke or transient ischaemic attack

There is a lot of clinical uncertainty about how to aggressively pursue elevated cholesterol levels in patients following stroke or transient ischaemic attack. This article reviews the evidence linking cholesterol level with stroke and looks at whether treatment with lipid-lowering drugs can be justified.

Ankle-brachial blood pressure in elderly men and the risk of stroke: the Honolulu Heart Program

Although low ankle/brachial blood pressure index (ABI) is a marker of generalized atherosclerosis in the elderly, it has not been identified as a risk factor for stroke. The purpose of this report is to examine the relation between ABI and stroke in elderly men. ABI was measured from 1991 to 1993 in 2767 men aged 71 to 93 years in the Honolulu Heart Program without a history of stroke and coronary heart disease. Subjects were followed for 3 to 6 years for fatal and nonfatal thromboembolic and hemorrhagic stroke. During follow-up, there were 91 strokes. There was an age-adjusted 2-fold excess in men with an ABI < 0.9 (6.0%) versus men with an ABI > or = 0.9 (2.9%, P < 0.01). Thromboembolic events occurred in 4.6% of men with an ABI < 0.9 and in 2.0% in those with an ABI > or = 0.9 (P < 0.01). Hemorrhagic stroke was also more frequent in men with a low ABI (< 0.9) versus a higher ABI (1.9 vs. 0.8%, respectively). After adjusting for other factors, the risk of total and thromboembolic strokes increased with declining ABI (P = 0.019 and P = 0.004, respectively). The relation between ABI and stroke was similar and statistically significant in the presence and absence of diabetes and hypertension (P < 0.05). Findings suggest that ABI is inversely related to the incidence of stroke. Simple measurement of ABI in an outpatient setting could be an important tool for assessing the risk of stroke in the elderly.

Use of statins in CNS disorders

It is well established that 3-hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase inhibitors ("statins") reduce cholesterol levels and prevent coronary heart disease (CHD). Although a causal relation between elevated cholesterol levels and stroke has not been well defined, a number of large secondary prevention studies and meta-analyses have shown that statin therapy reduces stroke in patients with CHD and hypercholesterolemia. In addition to the vascular effects of statins (stabilization of atherosclerotic plaques, decreased carotid intimal-medial thickness), there are increasing data to suggest that these agents have additional properties that are potentially neuroprotective. These include endothelial protection via actions on the nitric oxide synthase system, as well as antioxidant, anti-inflammatory and anti-platelet effects. These actions of statins might have potential uses in other neurological disorders such as Alzheimer's disease and certain types of brain tumors.