Stroke incidence and mortality correlated to stroke risk factors in the WHO MONICA Project. An ecological study of 18 populations

Temporal trend of first-ever ischaemic stroke incidence from 2010 to 2019 in South Korea: a nationwide retrospective cohort study

OBJECTIVE

Ischaemic stroke incidence is on the decline globally, but the trend in South Korea is unknown. In this study, the 10-year incidence trends of first-ever ischaemic stroke in South Korea were evaluated.

DESIGN, SETTING AND PARTICIPANTS

The National Health Insurance Services medical claim data were used to construct 10 annual cohorts of adults aged 20 years and older, who had not been diagnosed with stroke, to find out the incidence trends of first-ever ischaemic stroke from 2010 to 2019.

OUTCOME MEASURES

The primary outcomes were crude and age-adjusted incidence rates for 10 years. Crude incidence rates of the age groups and incidence age statistics were calculated. For comparison among the income groups, age-adjusted incidence rates were used. Incidence rates in all the groups were analysed separately by sex.

RESULTS

Age-standardised incidence rates of ischaemic stroke per 100 000 were 101.0 in men, and 67.6 in women in 2010; and 92.2 in men, and 55.0 in women in 2019. By age group, there was a decrease in women over 40 years of age, and men over 60 years of age. The relative difference in stroke incidence rates between medical aid beneficiaries and the highest income group increased from 1.5 to 1.87 over 10 years.

CONCLUSIONS

Age-standardised incidence rate of ischaemic stroke has decreased from 2010 to 2019 for both man and women. The incidence rate was stable in the younger age groups and decreased in the older age groups, and the disparities between income groups have widened over the past decade. Stroke prevention strategies are needed for the younger age group and the low-income group. Further research is needed to study the risk factors contributing to the incidence of ischaemic stroke in different groups.

The Beneficial Role of Natural Endocrine Disruptors: Phytoestrogens in Alzheimer's Disease

Alzheimer's disease (AD) is the most common form of dementia with a growing incidence rate primarily among the elderly. It is a neurodegenerative, progressive disorder leading to significant cognitive loss. Despite numerous pieces of research, no cure for halting the disease has been discovered yet. Phytoestrogens are nonestradiol compounds classified as one of the endocrine-disrupting chemicals (EDCs), meaning that they can potentially disrupt hormonal balance and result in developmental and reproductive abnormalities. Importantly, phytoestrogens are structurally, chemically, and functionally akin to estrogens, which undoubtedly has the potential to be detrimental to the organism. What is intriguing, although classified as EDCs, phytoestrogens seem to have a beneficial influence on Alzheimer's disease symptoms and neuropathologies. They have been observed to act as antioxidants, improve visual-spatial memory, lower amyloid-beta production, and increase the growth, survival, and plasticity of brain cells. This review article is aimed at contributing to the collective understanding of the role of phytoestrogens in the prevention and treatment of Alzheimer's disease. Importantly, it underlines the fact that despite being EDCs, phytoestrogens and their use can be beneficial in the prevention of Alzheimer's disease.

Anthology of stroke epidemiology in the 20th and 21st centuries: Assessing the past, the present, and envisioning the future

This narrative overview of stroke epidemiology shows dramatic changes in stroke incidence, prevalence, mortality, disability, and the understanding of risk factors and primary stroke prevention strategies over the last few decades. Likely future directions of stroke epidemiology and prevention are outlined.

Age, sex, and setting in the etiology of stroke study (ASSESS): Study design and protocol

RATIONALE

Stroke etiology and risk factors vary by age, sex, setting (hospital or community-based) and by region. Identifying these differences would improve our understanding of stroke etiology, diagnosis, and treatment.

AIM

The Age, Sex and Setting in the Etiology of Stroke Study (ASSESS) is a multicenter cohort study to assess differences in stroke etiology.

METHODS AND DESIGN

Data from all centers will be categorized according to age, sex, setting, stroke subtypes. Centers with extensive hospital- or community-based data regarding stroke from Argentina, Australia, Canada, India, Iran, Italy, Ghana, Nigeria, Thailand, the United Kingdom and the United States have agreed to participate so far.

STUDY OUTCOMES

The primary outcome includes differences in stroke etiology in study centers. The secondary outcomes include stroke incidence, risk factors, preventive strategies, and short- and long-term outcomes.

CONCLUSION

ASSESS will enable comparisons of data from different regions to determine the age and sex distribution of the most common causes of stroke in each setting. This will help clinicians to tailor the assessment and treatment of stroke patients on the basis of their specific local characteristics. It will also empower stroke epidemiologists to design preventive measures by targeting the specific characteristics of each population.

Oophorectomy Reduces Estradiol Levels and Long-Term Spontaneous Neurovascular Recovery in a Female Rat Model of Focal Ischemic Stroke

Although epidemiological evidence suggests significant sex and gender-based differences in stroke risk and recovery, females have been widely under-represented in preclinical stroke research. The neurovascular sequelae of brain ischemia in females, in particular, are largely uncertain. We set out to address this gap by a multimodal in vivo study of neurovascular recovery from endothelin-1 model of cortical focal-stroke in sham vs. ovariectomized female rats. Three weeks post ischemic insult, sham operated females recapitulated the phenotype previously reported in male rats in this model, of normalized resting perfusion but sustained peri-lesional cerebrovascular hyperreactivity. In contrast, ovariectomized (Ovx) females showed reduced peri-lesional resting blood flow, and elevated cerebrovascular responsivity to hypercapnia in the peri-lesional and contra-lateral cortices. Electrophysiological recordings showed an attenuation of theta to low-gamma phase-amplitude coupling in the peri-lesional tissue of Ovx animals, despite relative preservation of neuronal power. Further, this chronic stage neuronal network dysfunction was inversely correlated with serum estradiol concentration. Our pioneering data demonstrate dramatic differences in spontaneous recovery in the neurovascular unit between Ovx and Sham females in the chronic stage of stroke, underscoring the importance of considering hormonal-dependent aspects of the ischemic sequelae in the development of novel therapeutic approaches and patient recruitment in clinical trials.

Influence of family history on the willingness of outpatients to undergo genetic testing for salt-sensitive hypertension: a cross-sectional study

OBJECTIVES

It is unclear whether family medical history influences the willingness to undergo genetic testing. This study aimed to determine how family history affected the willingness to undergo genetic testing for salt-sensitive hypertension in patients with and without hypertension.

DESIGN

Cross-sectional study using a self-administered questionnaire.

SETTING

Six primary care clinics and hospitals in Japan.

PARTICIPANTS

Consecutive 1705 outpatients aged >20 years, 578 of whom had hypertension.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome variable was the willingness to undergo genetic testing to determine the risk of salt-sensitive hypertension, and the secondary variables were age, sex, education level, family history and concerns about hypertension. Factors associated with a willingness to undergo genetic testing were evaluated in patients with and without hypertension using a logistic regression model.

RESULTS

In the hypertension and non-hypertension groups, 323 (55.9%) and 509 patients (45.2%), respectively, were willing to undergo genetic testing. This willingness was related with a high level of education (adjusted OR (ad-OR): 1.81, 95% CI 1.12 to 2.93), family history of stroke (1.55, 1.04 to 2.31) and concerns about hypertension (2.04, 1.27 to 3.28) in the hypertension group, whereas in the non-hypertension group, it was influenced by education level (ad-OR: 1.45, 95% CI 1.13 to 1.86), family history of hypertension (1.52, 1.17 to 1.98) and concerns about hypertension (2.03, 1.53 to 2.68).

CONCLUSIONS

The influence of family history on the willingness to undergo genetic testing for risk of salt-sensitivity hypertension differed between participants with and without hypertension. In particular, participants without hypertension wished to know their likelihood of developing hypertension, whereas those with hypertension were interested to know the risk of stroke (a complication of hypertension). Family history could help better counsel patients about genetic testing on the basis of their medical history.

Carotid Artery Plaques, Carotid Intima-Media Thickness, and Risk of Cardiovascular Events and All-Cause Death in Older Adults: A 5-Year Prospective, Community-Based Study

We assessed the effect of asymptomatic carotid atherosclerosis (CAS) on the development of cardiovascular diseases (CVDs) in a community-based population aged ≥55 years in China. A total of 1376 residents underwent CAS assessment by ultrasonography in July 2009. New CVD events, including stroke and coronary heart events, were collected at the follow-up survey at the end of 2014. After adjusting for baseline demographic characteristics and traditional CVD risk factors, the risk of CVD in patients with minimal CAS (mean common carotid artery intima-media thickness [CCA-IMT] ≥1 mm and no plaques), nonstenotic plaques (carotid stenosis <50%), and stenotic plaques (carotid stenosis ≥50%) was 0.8 (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.33-1.69), 2.0 (HR: 2.01, 95% CI: 1.24-3.25), and 3.1 (HR: 3.05, 95% CI: 1.62-5.74) times greater, respectively, than that of patients without CAS (CCA-IMT <1 mm and no plaques). Our findings provide direct evidence of the independent predictive value of the severity of asymptomatic CAS for the development of CVD in older Chinese adults.

Stroke in Northern Sweden

Background: Stroke is one of the most common causes of death and long-term disability worldwide. Although stroke mortality has decreased in most industrialized countries, there are populations, particularly in East Europe, in which the mortality has increased. The WHO initiated, 20 years ago, the MONICA Project. The aim of the study was to measure trends in coronary heart disease and stroke and to assess the extent to which these were related to changes in known risk factors. Design: The Northern Sweden MONICA stroke study started in 1985 and is still ongoing. All individuals with an acute stroke in the age group 25 - 74 years have been included in the stroke register. Death certificates, discharge records, and GPs' records are screened and validated using strict MONICA criteria. Results: Stroke event rates (first ever and recurrent stroke) per 100,000 and year in the age group 25 - 74 years varied little over the years. Between 1985 and 1998 the annual incidence varied between 318 and 372 in men and between 195 and 240 in women, with no secular trends at all. The 28-day case fatality decreased in both men and women, from 19% to 11%. Logistic regression analyses showed a risk reduction in dying from stroke to 0.55 (p<0.0001) the last year compared with the first, with an absolute annual reduction in case fatality of 3%, in both men and women. In international comparison Northern Sweden shows an intermediately high incidence and one of the lowest case fatality rates of all participating populations. The incidence in subarachnoid haemorrhage was among the highest. Conclusion: The ongoing decline in stroke mortality in Sweden is driven exclusively by declining case fatality, whereas event rates (first ever and recurrent stroke) have remained the same since 1985. This, together with more people entering advanced, stroke-prone age groups, implies that the burden of stroke will continue to increase in Sweden.

Overground walking training with the i-Walker, a robotic servo-assistive device, enhances balance in patients with subacute stroke: a randomized controlled trial

BACKGROUND

Patients affected by mild stroke benefit more from physiological overground walking training than walking-like training performed in place using specific devices. The aim of the study was to evaluate the effects of overground robotic walking training performed with the servo-assistive robotic rollator (i-Walker) on walking, balance, gait stability and falls in a community setting in patients with mild subacute stroke.

METHODS

Forty-four patients were randomly assigned to two different groups that received the same therapy in two daily 40-min sessions 5 days a week for 4 weeks. Twenty sessions of standard therapy were performed by both groups. In the other 20 sessions the subjects enrolled in the i-Walker-Group (iWG) performed with the i-Walker and the Control-Group patients (CG) performed the same amount of conventional walking oriented therapy. Clinical and instrumented gait assessments were made pre- and post-treatment. The follow-up observation consisted of recording the number of fallers in the community setting after 6 months.

RESULTS

Treatment effectiveness was higher in the iWG group in terms of balance improvement (Tinetti: 68.4 ± 27.6 % vs. 48.1 ± 33.9 %, p = 0.033) and 10-m and 6-min timed walking tests (significant interaction between group and time: F(1,40) = 14.252, p = 0.001; and F(1,40) = 7.883, p = 0.008, respectively). When measured, latero-lateral upper body accelerations were reduced in iWG (F = 4.727, p = 0.036), suggesting increased gait stability, which was supported by a reduced number of falls at home.

CONCLUSIONS

A robotic servo-assisted i-Walker improved walking performance and balance in patients affected by mild/moderate stroke, leading to increased gait stability and reduced falls in the community.

TRIAL REGISTRATION

This study was registered on anzctr.org.au (July 1, 2015; ACTRN12615000681550 ).

H-type hypertension and risk of stroke in chinese adults: A prospective, nested case-control study

Objectives

To investigate the independent and joint associations of hyperhomocysteinemia and hypertension with incident stroke and stroke death in Chinese adults.

Methods

About 39,165 rural Chinese adults aged 35 years or older who had no history of stroke at the baseline study were prospectively followed to determine major cardiovascular events, with an average follow-up of 6.2 years. Using a nested case–control design, this report includes 179 incident stroke cases (121 stroke deaths) and 179 controls without vascular events from the original cohort matched by age, sex, community, and length of plasma storage. Baseline plasma total homocysteine (tHcy) measurements were obtained for all subjects. Logistic regression analysis was performed to investigate the independent and joint associations between H-type hypertension, defined as subjects with concomitant hypertension and elevated homocysteine (≥10 μmol/L), and risk of incident stroke and stroke death, after adjusting for important covariates.

Results

We analyzed each risk factor independently and jointly. For analysis, homocysteine was divided into three groups: low (tHcy <10 μmol/L), moderate (≥10 μmol/L tHcy <20 μmol/L), and high (tHcy≥20μmol/L). Compared to subjects in the low group, the odds ratios (95% CI) of incident stroke for those in the moderate group and the high group were 1.7 (0.8–3.7) and 3.1 (1.2–8.6), respectively. The odds ratios (95% CI) of stroke death for the moderate and high groups were 2.8 (1.1–7.4) and 5.1 (1.6–16.4), respectively. Hypertension was also independently associated with a higher risk of incident stroke and stroke death: 3.8 (2.3–6.4) and 3.2 (1.8–6.0), respectively, compared to those without hypertension. When analyzed jointly, the highest risk was found among patients with H-type hypertensive with both hyperhomocysteinemia and hypertension: 12.7 (2.8–58.0) for incident stroke and 11.7 (2.5–54.7) for stroke death.

Conclusions

This study provides strong evidence that hyperhomocysteinemia and hypertension are two independent, modifiable risk factors, which act additively to increase the risk of incident stroke and stroke death. The results strongly suggest that H-type hypertension is a major risk factor for vascular disease and mortality, and those with H-type hypertension may particularly benefit from homocysteine-lowering therapy along with anti-hypertension therapy in Chinese populations.

Management of ischemic stroke in Central and Eastern Europe

Stroke is one of the leading causes of disability in Europe. Central and Eastern European countries have the highest incidence and mortality rates through Europe. The improvements in stroke prevention and treatment in Central and Eastern European countries did not completely reach the quality parameters present in Western European countries. We present features of current management of stroke in Central and Eastern European countries.

Risk factors of stroke in Western and Asian countries: a systematic review and meta-analysis of prospective cohort studies

Background

There has been an increasing trend in the incidence of stroke worldwide in recent years, and the number of studies focusing on the risk factors for stroke has also increased every year. To comprehensively evaluate the risk factors of stroke identified in prospective Western and Asian cohort studies.

Methods

Population-based cohort studies on stroke were searched in databases (PubMed, EMBASE, Web of Science, Google Scholar, etc.), and the library of the Third Military Medical University was manually searched for relevant information. A meta-analysis of Western and Asian studies on risk factors was performed. The pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to assess the final group of cohort studies.

Results

After screening, 22 prospective cohort studies were included in the analyses of this investigation. Two factors, smoking and alcohol consumption, showed statistically significant differences between Western and Asian populations, and the results were as follows (W/A): 2.05 (95% CI, 1.68 ~ 2.49)/1.27 (95% CI, 1.04 ~ 1.55) and 0.89 (95% CI, 0.76 ~ 1.04)/1.28 (95% CI, 1.07 ~ 1.53). The factor BMI = 18.5-21.9 kg/m² showed statistically significant differences only in Western populations, 0.96 (95% CI, 0.93 ~ 0.99); the factor SBP = 120-139 mm Hg showed statistically significant differences only in Asian populations, 2.29 (95% CI, 1.04 ~ 5.09).

Conclusions

The prevalences of risk factors affect the stroke morbidity in Western and Asian populations, which may be biased by race. The meta-analysis of population-based studies suggests that different preventive measures should be adopted for Western and Asian population groups that are at high risk for stroke.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-776) contains supplementary material, which is available to authorized users.

All-cause, cardiovascular, and cancer mortality in western Alaska Native people: western Alaska Tribal Collaborative for Health (WATCH)

OBJECTIVES

We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths.

METHODS

Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics.

RESULTS

Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7).

CONCLUSIONS

We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

Comparison of stroke mortality in Finnish-born migrants living in Sweden 1970-1999 and in Swedish-born individuals

A limited number of studies have been found on stroke mortality in migrants showing higher mortality for some groups. Influence of time of residence has been studied by one research group. An earlier study showed a significantly higher number of deaths in Diseases of the circulatory system in Finnish migrants compared with native Swedes. To test the hypothesis of a higher mortality in and a decrease in mortality over time in stroke among Finnish migrants in Sweden. The study was based on National Population data, the study population included 321,407 Swedish and 307,174 foreign born persons living in Sweden 1987-1999. Mean age was lower at time for death for Finnish migrants than native Swedes, men 5.1 years difference and women 2.3 years. The difference decreased over time. The risk of death by stroke was higher for migrants with short time of residence than with long time (≤10 years, OR 1.61-1.36 vs ≥11 year, OR 1.18). Migrants with short time of residence died 9.8-5.3 years earlier than native Swedes. The hypothesis was confirmed and an indication of adjustment to life in the new country was found. International studies show similar results for other migrant groups but further studies are needed to verify if the same pattern can be found in other migrants groups in Sweden and to generalise the findings.

Epidemiology of nonfatal stroke and transient ischemic attack in Al-Kharga District, New Valley, Egypt

BACKGROUND

Stroke is a medical emergency. Nonfatal stroke may cause permanent neurologic damage, complications, and disability. The aim of this study was to determine the epidemiology of nonfatal stroke in Al-Kharga District, New Valley, Egypt.

METHODS

The total population (62,583) was screened via a door-to-door study by three neurology specialists and 15 female social workers for demographic data collection. All subjects with probable stroke were subjected to a full clinical examination, neuroimaging (computed tomography and/or magnetic resonance imaging of the brain), and laboratory investigations including blood sugar, lipid profile, serum uric acid, a complete blood count, blood urea, and serum creatinine. Stroke severity and outcome were assessed using the Scandinavian Stroke Scale and Barthel Index. Carotid Doppler, echocardiography, and thyroid function tests were done in selected cases.

RESULTS

During the study period (June 1, 2005 to May 31, 2008), 351 subjects were diagnosed as having suffered a cerebrovascular stroke at some point during their lives, yielding a total lifetime prevalence of 5.6 per 1,000 population. Of these, 156 subjects were identified as having suffered a stroke during the year from January 1 to December 31, 2007, with an incidence rate of 2.5 per 1,000. Both prevalence and incidence rates were higher in urban (5.8 per 1,000 and 2.6 per 1,000, respectively) than rural communities (5.2 per 1,000 and 2.3 per 1,000), and were higher in males (6.1 per 1,000 and 2.7 per 1,000, respectively) than in females (5.1 per 1,000 and 2.3 per 1,000). Thrombotic stroke had the highest prevalence and incidence rates (4.2 per 1,000 and 1.7 per 1,000, respectively), whereas subarachnoid hemorrhage had the lowest prevalence and incidence rates (0.03 per 1,000 and 0.02 per 1,000).

CONCLUSION

The prevalence of cerebrovascular accident in Al-Kharga lies in the lower range of that in developing countries, and is similar to that in industrialized countries.

The prevalence of stroke and the association between stroke and depression among a very old population

There are few studies comparing those who have had and have not had a stroke among those aged 80 years and over, the very old. The aim of this paper was to investigate the prevalence of stroke and the association between stroke and depression in a very old population. This paper is based on cross-sectional data from a population-based study performed between 2005 and 2007. Half of those aged 85 years, all 90-, and 95-year-olds and older in eight urban and rural municipalities in northern Sweden and Finland were invited to participate. A sample of 601 individuals who participated fully in the study was selected. Data were collected through assessments, structured interviews and investigation of medical charts. A specialist in geriatric medicine determined disease status for depression based on medical records and results from the Geriatric Depression Scale (GDS)-15, the Montgomery Åsberg Depression Rating Scale (MADRS) and the Organic Brain Syndrome (OBS) scale, and for stroke based on medical records and reported disease. The prevalence of stroke was 21.5%. The prevalence of depression was 50.4% among those with stroke compared to 34.3% among those without stroke (OR 1.944, p<0.001). In a logistic regression model adjusted for several demographic variables, diseases and functional level, stroke was independently associated with depression (OR 1.644, p=0.038). A large proportion of those with depression, both with and without stroke, were not receiving antidepressant medication. In conclusion, the stroke prevalence was high and stroke showed a strong association with depression among very old people.

Incidence of Transient Ischemic Attack and Early Stroke Risk

Background and Purpose—

The importance of transient ischemic attack (TIA) lies on the short-term risk of stroke, and the ABCD2 score may improve early stroke risk prediction. However, population-based studies are still needed. We aimed to provide data on TIA incidence and to evaluate the ABCD2 predictive ability for early recurrent stroke in a population-based study.

Methods—

This study is part of a 2-year prospective community-based registry of all cerebrovascular events in the district of Udine (153 312 inhabitants), Friuli Venezia Giulia region, northeast of Italy, between April 1, 2007 and March 31, 2009. Multiple overlapping sources for finding cases were used, combining hot and cold pursuit.

Results—

We identified 178 TIA, 161 (90.4%) of which were incident. The crude overall annual TIA incidence rate per 1000 residents was 0.52 (95% confidence interval [CI], 0.45–0.61). Incidence rate was 0.45 (95% CI, 0.31–0.65) when standardized to the 2007 Italian population and 0.25 (95% CI, 0.16–0.39) when standardized to the European standard population. Estimates of stroke risk after the index TIA within 2, 7, 30, and 90 days were, respectively, 2.5% (95% CI, 0.7–6.2), 5.6% (95% CI, 2.6–10.3), 6.2% (95% CI, 3.0–11.1), and 11.2% (95% CI, 6.8–17.1). ABCD2 score was strongly associated with stroke occurrence after index TIA: the areas under the receiver operating characteristic curve at 2, 7, 30, and 90 days were, respectively, 0.85 (95% CI, 0.72–0.97), 0.69 (95% CI, 0.56–0.82), 0.69 (95% CI, 0.56–0.85), and 0.76 (95% CI, 0.67–0.86). No patients with an ABCD2 score <4 had a stroke within the 90-day follow-up period.

Conclusions—

This study adds new data on TIA incidence and prognosis and it further validates the ability of the ABCD2 score to identify patients at early risk for stroke.

One-year cardiovascular event rates in Japanese outpatients with myocardial infarction, stroke, and atrial fibrillation. -Results From the Japan Thrombosis Registry for Atrial Fibrillation, Coronary, or Cerebrovascular Events (J-TRACE).-

BACKGROUND

There remains uncertainty about the risk of cardiovascular events in stable outpatients with a history of myocardial infarction (MI), stroke, and atrial fibrillation in Japan.

METHODS AND RESULTS

In the Japan Thrombosis Registry for Atrial Fibrillation, Coronary, or Cerebrovascular Events (J-TRACE), a nationwide prospective cohort of stable outpatients with a history of MI (n=2,291), stroke (n=3,554), and/or atrial fibrillation (n=2,242), 1-year follow-up data were available for 7,513 of 8,087 patients (follow-up rate: 92.9%). The primary endpoint (death/MI/stroke) was reported in 3.53 events per 100 person-years (95% confidence interval [CI]: 3.11-3.99) within 1 year. The rates of all-cause death, death from stroke, and death from MI within 1 year were 1.35 (95%CI: 1.10-1.65), 0.15 (95%CI: 0.08-0.27), and 0.06 (95%CI: 0.02-0.14) per 100 person-years, respectively. The rate of non-fatal stroke was 1.85 (95%CI: 1.55-2.19), while that of non-fatal MI was 0.33 (95%CI: 0.21-0.49). The rate of non-fatal stroke was highest among stroke patients (2.95; 95%CI: 2.39-3.60 per 100 person-years), while that of non-fatal MI was similar across all disease categories. Investigator-decided serious non-fatal bleeding events occurred in 0.21 events (95%CI: 0.12-0.34) per 100 person-years.

CONCLUSIONS

In this large, nationwide Japanese registry, the highest stroke event rate was seen in patients with a history of stroke.

Education level explains differences in stroke incidence among city districts in Joinville, Brazil: a three-year population-based study

BACKGROUND

Current evidence suggests an inverse association between socioeconomic status and stroke incidence. Our aim was to measure the variation in incidence among different city districts (CD) and their association with socioeconomic variables.

METHODS

We prospectively ascertained all possible stroke cases occurring in the city of Joinville during the period 2005-2007. We determined the incidence for each of the 38 CD, age-adjusted to the population of Joinville. By linear regression analysis, we correlated incidence data with mean years of education (MYE) and mean income per month (MIPM).

RESULTS

Of the 1,734 stroke cases registered, 1,034 were first-ever strokes. In the study period, the crude incidence in Joinville was 69.5 per 100,000 (95% confidence interval, 65.3-73.9). The stroke incidence among CD ranged from 37.5 (22.2-64.6) to 151.0 per 100,000 (69.0-286.6). The stroke incidence was inversely correlated with years of education (r = -0.532; p < 0.001). MYE and MIPM were strongly related (R = 0.958), resulting in exclusion of MIPM by collinearity.

CONCLUSIONS

Years of education can explain a wide incidence variation among CD. These results may be useful to guide the allocation of resources in primary prevention policies.

Young women have poorer outcomes than men after stroke

BACKGROUND AND PURPOSE

Gender differences in stroke outcome have not been fully assessed in young patients.

METHODS

We conducted an observational study of consecutive young ischemic stroke patients (≤ 50 years of age) admitted to a stroke unit (January 1999 to December 2009). Basal data, subtype of ischemic stroke, stroke severity [Canadian Neurological Scale (CNS)], length of hospital stay, inhospital complications, mortality and functional outcome at discharge [modified Rankin Scale (mRS) score] were analyzed. For stroke severity and outcome analyses, 2 age groups were established: 15-30 (very young group) and 31-50 years old (middle-aged young group).

RESULTS

A total of 310 patients were enrolled; 128 females and 182 males. The mean age was similar in women and men (41.07 ± 8.6 vs. 42.12 ± 8.2, NS). Migraine was more frequent in women, whereas arterial hypertension, hyperlipidemia, alcohol abuse, current smoking and atherothrombotic infarction were more frequent in men (p < 0.05). Females presented greater stroke severity than men [median CNS (IQR) = 8 (3.5) vs. 9 (2.5), p = 0.014] except in the very young group [median CNS (IQR) = 9 (1.8) vs. 8 (5), p = 0.022]. Female sex was a predictor of unfavorable outcomes (mRS >2) at discharge in the total sample (OR = 3.33; 95% CI = 1.41-7.84) and in the middle-aged young group (OR = 2.62; 95% CI = 1.05-6.53), adjusted by baseline data, stroke subtype, inhospital complications, length of stay and stroke severity.

CONCLUSIONS

Female gender is associated with worse outcomes in adult ischemic stroke patients up to 50 years old. However, this effect is not observed in younger patients (15-30 years).

Risk-factor profile, drug usage and cardiovascular events within a year in patients with and at high risk of atherothrombosis recruited from Asia as compared with those recruited from non-Asian regions: a substudy of the REduction of Atherothrombosis for Continued Health (REACH) registry

OBJECTIVE

To clarify the differences in the baseline characteristics, prevalence and incidence of atherothrombosis in patients recruited from Asia versus non-Asian regions.

DESIGN

International Prospective Cohort Study.

SETTING

Region focused substudy.

PATIENTS

The Reduction of Atherothrombosis for Continued Health (REACH) Registry recruited 68 236 stable outpatients with established atherothrombosis or ≥3 atherothrombotic risk factors from 44 countries.

INTERVENTIONS

No intervention.

MAIN OUTCOME MEASURES

Risk factors, use of medications, vascular disease bed location, and 1-year cardiovascular (CV) outcomes (CV death, myocardial infarction, stroke).

RESULTS

The percentages of patients recruited with CVD (Cerebrovascular Disease) were higher in Asia (41.0%) than in non-Asian regions (25.1%) (p<0.0001). The prevalence of diabetes mellitus was higher in Asia (46.6%) than in non-Asian regions (43.3%) (p<0.0001) despite the former having a lower body mass index (BMI) (24.4±3.9 vs 28.8±5.6) (p<0.0001). The combined endpoint of CV death/myocardial infarction/stroke of patients recruited from non-Asian regions of 4.38% (95% CI 4.20 to 4.56) is equivalent to those from the Asian region excluding Japan of 4.65% (95% CI 4.04 to 5.25), but that is significantly lower in patients recruited from Japan of 3.40% (95% CI 2.76 to 4.04, p<0.05).

CONCLUSIONS

There is a higher prevalence of CVD and higher prevalence of diabetus mellitus with lower body mass index in patients recruited from the Asian region as compared those recruited from non-Asian regions. The CV event rate in patients recruited from non-Asian regions is equivalent to that of patients recruited from the Asian region excluding Japan, but significantly lower in patients recruited from Japan.

Social status and cardiovascular disease: a Mediterranean case. Results from the Italian Progetto CUORE cohort study

BACKGROUND

Social factors could offer useful information for planning prevention strategy for cardiovascular diseases. This analysis aims to explore the relationship between education, marital status and major cardiovascular risk factors and to evaluate the role of social status indicators in predicting cardiovascular events and deaths in several Italian cohorts.

METHODS

The population is representative of Italy, where the incidence of the disease is low. Data from the Progetto CUORE, a prospective study of cohorts enrolled between 1983-1997, were used; 7520 men and 13127 women aged 35-69 years free of previous cardiovascular events and followed for an average of 11 years. Educational level and marital status were used as the main indicators of social status.

RESULTS

About 70% of the studied population had a low or medium level of education (less than high school) and more than 80% was married or cohabitating. There was an inverse relationship between educational level and major cardiovascular risk factors in both genders. Significantly higher major cardiovascular risk factors were detected in married or cohabitating women, with the exception of smoking. Cardiovascular risk score was lower in married or cohabitating men. No relationship between incidence of cardiac events and the two social status indicators was observed. Cardiovascular case-fatality was significantly higher in men who were not married and not cohabitating (HR 3.20, 95%CI: 2.21-4.64). The higher cardiovascular risk observed in those with a low level of education deserves careful attention even if during the follow-up it did not seem to determine an increase of cardiac events.

CONCLUSIONS

Preventive interventions on cardiovascular risk should be addressed mostly to people with less education. Cardiovascular risk score and case-fatality resulted higher in men living alone while cardiovascular factors were higher in women married or cohabitating. Such gender differences seem peculiar of our population and require further research on unexpected cultural and behavioural influences.

Different methods for administering 17beta-estradiol to ovariectomized rats result in opposite effects on ischemic brain damage

Background

Numerous stroke studies have controversially shown estrogens to be either neuroprotective or neurodamaging. The discordant results observed in rat brain ischemia models may be a consequence of discrepancies in estrogen administration modes resulting in plasma concentration profiles far from those intended. To test this hypothesis we reproduced in detail and extended an earlier study from our lab using a different mode of 17β-estradiol administration; home-made silastic capsules instead of commercial slow-release 17β-estradiol pellets. Four groups of female rats (n = 12) were ovariectomized and administered 17β-estradiol or placebo via silastic capsules. All animals underwent MCAo fourteen days after ovariectomy and were sacrificed three days later.

Results

In contrast to our earlier results using the commercial pellets, the group receiving 17β-estradiol during the entire experiment had significantly smaller lesions than the group receiving placebo (mean ± SEM: 3.85 ± 0.70% versus 7.15 ± 0.27% of total slice area, respectively; p = 0.015). No significant neuroprotection was found when the 17β-estradiol was administered only during the two weeks before or the three days immediately after MCAo.

Conclusions

The results indicate that different estrogen treatment regimens result in diametrically different effects on cerebral ischemia. Thus the effects of estrogens on ischemic damage seem to be concentration-related, with a biphasic, or even more complex, dose-response relation. These findings have implications for the design of animal experiments and also have a bearing on the estrogen doses used for peri-menopausal hormone replacement therapy.

Stem cells in the treatment of stroke

Stroke is an often devastating insult resulting in neurological deficit lasting greater than 24 hours. In the United States, stroke is the third leading cause of death. In those who do not succumb, any outcome from total recovery over a period of weeks to months to persistent profound neurological deficits is possible. Present treatment centers on the decision to administer tissue plasminogen activator, subsequent medical stabilization and early intervention with rehabilitation and risk factor management. The advent of stem cell therapy presents an exciting new frontier for research in stroke treatment, with the potential to cause a paradigm shift from symptomatic control and secondary prevention to reconstitution of neural networks and prevention of neuronal cell death after neurologic injury.

Dose-related neuroprotective versus neurodamaging effects of estrogens in rat cerebral ischemia: a systematic analysis

Numerous studies of the effects of estrogens for stroke prevention have yielded conflicting results in human and animal studies alike. We present a systematical analysis of study design and methodological differences between 66 studies where estrogens' impact on ischemic brain damage in rat models has been investigated, providing evidence that the differences in results may be explained by high estrogen doses produced by slow-release pellets. These pellets have been used in all studies showing increased neurologic damage because of estrogens. Our data indicate that the increased neurologic damage is related to the pellets' plasma concentration profile with an early, prolonged, supraphysiological peak. Neither the method of inducing the ischemic brain lesions, the choice of variables for measuring outcome, the measured plasma concentrations of estrogens at the time of ischemia nor rat population attributes (sex, strain, age, and diseases) are factors contributing to the discrepancies in results. This suggests that the effects of estrogens for stroke prevention are concentration related with a complex dose-response curve, and underscores the importance of carefully validating the experimental methods used. Future studies of hormone-replacement therapy in women may have to take dosage and administration regimens into account.

Apolipoprotein E genotype in patients with cerebrovascular diseases and its effect on the disease outcome

A total of 100 hospitalized stroke patients and 30 healthy controls were included in a study aiming to determine the predictive role of ApoE genotype polymorphism for stroke outcome in the Turkish population. The most frequent ApoE genotype was epsilon3/3 reflecting Asian population polymorphic distribution. ApoE polymorphism in the Eastern Turkish population was found to be independent of stroke type, OSCP subtypes of infarction, localization of hemorrhage, severity of carotid artery stenosis, and resultant stroke outcome. Distinct polymorphic results in populations from nearby regions suggest a multifactorial pathogenesis and presence of very complex genetic factors in the development of stroke and stroke outcome.

Antihypertensive treatment in elderly hypertensives without a history of stroke and the risk of cognitive disorders

OBJECTIVES

The role of the antihypertensive therapy in preventing cognitive disorders in elderly persons without a history of stroke is a matter of debate. This review focuses on the pathogenesis of the cognitive disorders in elderly hypertensives and on the risk factors of their occurrence.

METHODS

Relevant papers were identified by searches in PubMed from 1946 until October 2007, using the key words 'vascular risk factors', 'vascular cognitive impairment', 'vascular dementia', 'neuroimaging in hypertension' and 'antihypertensive treatment'.

RESULTS

Blood pressure lowering in elderly patients with long-standing hypertension below a certain critical level may increase the risk of cerebral hypoperfusion and cognitive decline, particularly in cases with additional vascular risk factors. Cerebral white matter lesions have been found in the majority of elderly hypertensives. They have been shown to correlate with cognitive disorders.

CONCLUSIONS

Appropriate neuropsychological assessment and follow-up of the cognitive functions could be considered with the aim to individualize the antihypertensive therapy and slow down cognitive decline. Prospective studies are needed to confirm such a treatment strategy.

Incidence of total stroke, stroke subtypes, and myocardial infarction in the Japanese population: the JMS Cohort Study

Background

Previous reports indicated that the incidence rate of stroke was higher in Japan than in Western countries, but the converse was true in the case of myocardial infarction (MI). However, few population-based studies on the incidence rates of stroke and MI have been conducted in Japan.

Methods

The Jichi Medical School (JMS) Cohort Study is a multicenter population-based cohort study that was conducted in 12 districts in Japan. Baseline data were collected between April 1992 and July 1995. We examined samples from 4,869 men and 7,519 women, whose mean ages were 55.2 and 55.3 years, respectively. The incidence of stroke, stroke subtypes, and MI were monitored.

Results

The mean follow-up duration was 10.7 years. A total of 229 strokes and 64 MIs occurred in men, and 221 strokes and 28 MIs occurred in women. The age-adjusted incidence rates (per 100,000 person-years) of stroke were 332 and 221 and those of MI were 84 and 31 in men and women, respectively. In the case of both sexes, the incidence rates of stroke and MI were the highest in the group of subjects aged > 70 years.

Conclusion

We reported current data on the incidence rates of stroke and MI in Japan. The incidence rate of stroke remains high, considerably higher than that of MI, in both men and women. The incidence rates of both stroke and MI were higher in men than in women.

The metabolic syndrome predicts cardiovascular events in subjects with normal fasting glucose: Results of a 15 years follow-up in a Mediterranean population

The aim of this study was to evaluate the cardiovascular (CV) risk due to the metabolic syndrome in a 15-year prospective study of a Sicilian population. In the Mediterranean area obesity is highly prevalent, but epidemiological data on the metabolic syndrome are limited.

METHODS AND RESULTS

Among the 1351 subjects enrolled in the "Ventimiglia di Sicilia" epidemiological project, we selected 687 subjects between 35 and 75 years of age; baseline parameters were assessed and subjects have been followed for 15 years recording CV events, total and cardiovascular mortality. The metabolic syndrome was defined according to both the Adult Treatment Panel III and the International Diabetes Federation criteria. Metabolic syndrome (ATPIII criteria) was significantly (p<0.00001) more prevalent in women (31.5%) than in men (12.4%). The metabolic syndrome increased the risk of CV events with a hazard ratio of 1.9 (confidence interval CI; 1.46-2.46). Using a Cox proportional hazards estimation model, the survival curve of subjects with metabolic syndrome and normal fasting glucose did not significantly differ from the curve of subjects with metabolic syndrome and impaired fasting glucose (IFG).

CONCLUSIONS

In a 15-year follow-up the metabolic syndrome is predictive of CV events regardless of the presence of IFG or diabetes mellitus.

Explanation for the Japanese paradox: prevention of increase in coronary heart disease and reduction in stroke

Japan's age-adjusted rate for mortality from stroke increased after the Second World War until 1965 and then showed a significant decline until 1990; however, the age-adjusted rate for mortality from all heart disease and coronary heart disease (CHD) increased until 1970 and then declined slowly. A puzzling question is why the rate of mortality from CHD declined in spite of an increase in serum total cholesterol level following an increase in fat consumption. It was confirmed that CHD incidence was far lower in several Japanese populations compared to Western countries in the " Monitoring Trends and Determinants in Cardiovascular Disease " (MONICA) project; therefore, the lower CHD mortality in Japan stems from the lower CHD incidence. CHD risk factors based on epidemiologic cohort studies in Japan were no different from those of other industrialized countries: hypertension, hypercholesterolemia, smoking and diabetes mellitus (DM). So, how can we explain this phenomenon?There are three possible explanations. One is the decline in population blood pressure level and the prevalence of hypertension during the years 1965-1990; the second is the decline in smoking rate in men and women; the third is that the serum total cholesterol level for middle-aged and elderly populations remains 5-15 mg/dL lower than that of the US elderly counterpart, although men aged 40-49 in Japan and the US had similar serum total cholesterol levels. It was also noted that elderly people in Japan, as observed in the Seven Countries Study, had far lower serum total cholesterol levels in midlife, i.e., around 160 mg/dL in the 1960s. This was not the case for elderly in the US where a higher serum total cholesterol level was observed in midlife. In conclusion, the lower serum cholesterol level in the past of Japanese middle-aged and elderly people compared to Western counterparts helps to maintain the low CHD incidence and mortality supported by the declining trend in blood pressure level and smoking rate for both men and women.

Incidence of subarachnoid haemorrhage: a systematic review with emphasis on region, age, gender and time trends

BACKGROUND AND AIM

To update our 1996 review on the incidence of subarachnoid haemorrhage (SAH) and assess the relation of incidence with region, age, gender and time period.

METHODS

We searched for studies on the incidence of SAH published until October 2005. The overall incidences with corresponding 95% confidence intervals were calculated. We determined the relationship between the incidence of SAH and determinants by means of univariate Poisson regression.

RESULTS

We included 51 studies (33 new), describing 58 study populations in 21 countries, observing 45,821,896 person-years. Incidences per 100,000 person-years were 22.7 (95% CI 21.9 to 23.5) in Japan, 19.7 (18.1 to 21.3) in Finland, 4.2 (3.1 to 5.7) in South and Central America, and 9.1 (8.8 to 9.5) in the other regions. With age category 45-55 years as the reference, incidence ratios increased from 0.10 (0.08 to 0.14) for age groups younger than 25 years to 1.61 (1.24 to 2.07) for age groups older than 85 years. The incidence in women was 1.24 (1.09 to 1.42) times higher than in men; this gender difference started at age 55 years and increased thereafter. Between 1950 and 2005, the incidence decreased by 0.6% (1.3% decrease to 0.1% increase) per year.

CONCLUSIONS

The overall incidence of SAH is approximately 9 per 100,000 person-years. Rates are higher in Japan and Finland and increase with age. The preponderance of women starts only in the sixth decade. The decline in incidence of SAH over the past 45 years is relatively moderate compared with that for stroke in general.

The Italian register of cardiovascular diseases: attack rates and case fatality for cerebrovascular events

BACKGROUND

The Italian register of cardiovascular diseases is a surveillance system of fatal and nonfatal cardiovascular events in the general population aged 35-74 years. It was launched in Italy at the end of the 1990 s with the aim of estimating periodically the occurrence and case fatality rate of coronary and cerebrovascular events in the different geographical areas of the country. This paper presents data for cerebrovascular events.

METHODS

Current events were assessed through record linkage between two sources of information: death certificates and hospital discharge diagnosis records. Events were identified through the ICD codes and duration. To calculate the number of estimated events, current events were multiplied by the positive predictive value of each specific mortality or discharge code derived from the validation of a sample of suspected events. Attack rates were calculated by dividing estimated events by resident population, and case fatality rate at 28 days was determined from the ratio of estimated fatal to total events.

RESULTS

Attack rates were found to be higher in men than in women: mean age-standardized attack rate was 21.9/10,000 in men and 12.5/10,000 in women; age-standardized 28-day case fatality rate was higher in women (17.1%) than in men (14.5%). Significant geographical differences were found in attack rates of both men and women. Case fatality was significantly heterogeneous in both men and women.

CONCLUSIONS

Differences still exist in the geographical distribution of attack and case fatality rates of cerebrovascular events, regardless of the north-south gradient. These data show the feasibility of implementing a population-based register using a validated routine database, necessary for monitoring cardiovascular diseases.

Stroke in Qatar: a one-year, hospital-based study

BACKGROUND AND PURPOSE

Stroke is a major health problem in Qatar, yet no stroke studies have been reported from this region. This hospital-based study was conducted to determine the types and the 30-day fatality rate of stroke. The data were collected from the only hospital in Qatar and, therefore, are considered to be community-based estimations.

METHODS

Clinical information was collected from discharge records of all patients with International Classification of Diseases, 9th Revision, (ICD 9) codes 430 to 438 from January 1 to December 31, 1997. Identification of cases included review of death certificates and brain computed tomography (CT) records for the same period.

RESULTS

First-ever stroke was found in 217 patients (157 men and 60 women). The overall incidence rate was 41 per 100,000 inhabitants per year (95% CI, 30.2-52.4/100,000/year) and 238/100,000/year for the population over 45 years old. The age standardized incidence was 57.5 per 100,000 inhabitants per year (95% CI, 43.1-73.8). The crude incidence for native Qataris was 75 per 100,000 inhabitants per year. The mean age of patients experiencing their first stroke was 57 years. Thirty-nine (18%) patients were younger than 45 years. Clinical subtypes of stroke were ischemic (80%), intracerebral hemorrhage (19%), and subarachnoid hemorrhage (1%). Risk factors included hypertension (63%), diabetes mellitus (42%), ischemic heart disease (17%), and atrial fibrillation (4.5%). The overall patient fatality rate at 30 days was 16%.

CONCLUSION

Stroke incidence in Qatar is lower than in other countries; a low incidence of subarachnoid hemorrhage was noted. The low mean age of stroke patients reflects the demographic characteristics of the population in Qatar. The high percentage of stroke patients suffering from hypertension and diabetes reflects the high prevalence of these risk factors in the population.

Hypertension, vascular cognitive disorders and neuroprotection

OBJECTIVE

The role of the antihypertensive therapy in preventing vascular cognitive disorders in elderly persons without a history of stroke is a matter of debate. This review focuses on cognitive disorders in elderly hypertensive patients.

METHODS

Relevant papers were identified by searches in PubMed from 1946 until February 2007 using the keywords 'cerebral blood flow autoregulation', 'vascular cognitive disorders', 'neuroimaging in hypertension', 'antihypertensive treatment' and 'neuroprotection in cerebral ischemia'.

RESULTS

Excessive blood pressure lowering in patients with long-standing hypertension may increase the risk of cerebral hypoperfusion, white matter lesions and consequent cognitive decline. White matter lesions have been found in the majority of patients with long-standing hypertension. They correlate with vascular cognitive disorders, particularly impairments of attention and executive function, while memory is relatively preserved. Cerebral small vessel disease in elderly patients should be taken into account when antihypertensive treatment is considered. Renin-angiotensin blockade, some calcium channel blockers and statins are thought to possess neuroprotective action.

CONCLUSION

For prevention of cerebral hypoperfusion in elderly hypertensives blood pressure lowering should be cautiously controlled. The increased risk of white matter lesions is an indication for early neuroprotection. The combination of renin-angiotensin blockade or calcium channel blockers with statins may become a promising preventive strategy against cognitive decline in elderly hypertensives. Cerebral white matter protection is a future challenge.

Drinking water arsenic exposure and blood pressure in healthy women of reproductive age in Inner Mongolia, China

The extremely high exposure levels evaluated in prior investigations relating elevated levels of drinking water arsenic and hypertension prevalence make extrapolation to potential vascular effects at lower exposure levels very difficult. A cross-sectional study was conducted on 8790 women who had recently been pregnant in an area of Inner Mongolia, China known to have a gradient of drinking water arsenic exposure. This study observed increased systolic blood pressure levels with increasing drinking water arsenic, at lower exposure levels than previously reported in the literature. As compared to the referent category (below limit of detection to 20 microg of As/L), the overall population mean systolic blood pressure rose 1.29 mm Hg (95% CI 0.82, 1.75), 1.28 mm Hg (95% CI 0.49, 2.07), and 2.22 mm Hg (95% CI 1.46, 2.97) as drinking water arsenic concentration increased from 21 to 50, 51 to 100, and >100 microg of As/L, respectively. Controlling for age and body weight (n=3260), the population mean systolic blood pressure rose 1.88 mm Hg (95% CI 1.03, 2.73), 3.90 mm Hg (95% CI 2.52, 5.29), and 6.83 mm Hg (95% CI 5.39, 8.27) as drinking water arsenic concentration increased, respectively. For diastolic blood pressure effect, while statistically significant, was not as pronounced as systolic blood pressure. Mean diastolic blood pressure rose 0.78 mm Hg (95% CI 0.39, 1.16), 1.57 mm Hg (95% CI 0.91, 2.22) and 1.32 mm Hg (95% CI 0.70, 1.95), respectively, for the overall population and rose 2.11 mm Hg (95% CI 1.38, 2.84), 2.74 mm Hg (95% CI 1.55, 3.93), and 3.08 mm Hg (95% CI 1.84, 4.31), respectively, for the adjusted population (n=3260) at drinking water arsenic concentrations of 21 to 50, 51 to 100, and >100 microg of As/L. If our study results are confirmed in other populations, the potential burden of cardiovascular disease attributable to drinking water arsenic is significant.

Effects of hypertension and type 2 diabetes mellitus on the risk of total cardiovascular events in Japanese patients with hypercholesterolemia: implications from the Japan Lipid Intervention Trial (J-LIT)

Hyperlipidemia, hypertension, and diabetes mellitus (DM) are well-established risk factors for cardiovascular disease. We analyzed the cardiovascular events in hyperlipidemic patients with or without DM who were administered open-labeled simvastatin in groups stratified by blood pressure level using data from the Japan Lipid Intervention Trial (J-LIT). Hyperlipidemic patients with DM (n=6,288) had significantly more cardiovascular events than those without DM (n=33,933). The incidence rates of total cardiovascular events in the Non-DM and DM groups were 15.40 and 25.76 per 1,000 patients for the 6-year period, respectively. The relative risk of total cardiovascular events in the DM vs. the Non-DM group was 1.68, and the relative risk was significantly higher in the DM than in the Non-DM group. The relative risks of total cardiovascular events were significantly higher in DM and Non-DM patients whose systolic blood pressure (SBP) was greater than or equal to 130 mmHg compared to that of Non-DM patients whose SBP was less than 130 mmHg, and in DM and Non-DM patients whose diastolic blood pressure (DBP) was greater than or equal to 80 mmHg compared to that of Non-DM patients whose DBP was less than 80 mmHg. In all groups stratified by SBP and DBP, relative risks of total cardiovascular events were higher in DM patients than in Non-DM patients. For patients with hypercholesterolemia and DM, blood pressure should be strictly controlled in order to prevent both coronary events and stroke. These results are in good agreement with the JNC 7 and the ESH/ESC guidelines for DM patients, which recommended that the SBP and DBP be less than 130 and 80 mmHg, respectively.

Stroke Associated with Diabetes among Canadians: Sex and Age Differences

OBJECTIVE

To determine the age and sex variations in the relationship between diabetes and stroke.

METHODS

This analysis was based on data from 61,327 Canadians > or =45 years of age who participated in the Canadian Community Health Survey in 2000-2001. Logistic regression analysis was conducted to evaluate the association between diabetes and stroke, and effect modification by age and sex.

RESULTS

The association between diabetes and stroke was stronger in the 45- to 64-year age group than the > or =65 year age group in men but not in women. The increased risk of stroke associated with diabetes was much stronger in men (adjusted OR = 3.86, 95% CI = 2.44-6.13) than in women (adjusted OR = 1.63, 95% CI = 0.88-2.99), and this difference was only observed in the younger age group. The results were similar after further adjustment for hypertension and heart disease.

CONCLUSIONS

There is a stronger association between stroke and diabetes in men than in women 45-64 years of age, suggesting men are more susceptible to stroke than women when they have diabetes.

The Enigma of Hypertensive ESRD: Observations on Incidence and Trends in 18 European, Canadian, and Asian-Pacific Populations, 1998 to 2002

BACKGROUND

Despite improved treatment of hypertension and decreasing rates of stroke and coronary heart disease, the reported incidence of hypertensive end-stage renal disease (ESRD) increased during the 1990s. However, bias, particularly from variations in acceptance into ESRD treatment (ascertainment) and diagnosis (classification), has been a major source of error when comparing ESRD incidences or estimating trends.

METHODS

Age-standardized rates were calculated in persons aged 30 to 44, 45 to 64, and 65 to 74 years for 15 countries or regions (separately for the Europid and non-Europid populations of Canada, Australia, and New Zealand), and temporal trends were estimated by means of Poisson regression. For 10 countries or regions, population-based estimates of mean systolic blood pressures and prevalences of hypertension were extracted from published sources.

RESULTS

Hypertensive ESRD, comprising ESRD attributed to essential hypertension or renal artery occlusion, was least common in Finland, non-Aboriginal Australians, and non-Polynesian New Zealanders; intermediate in most European and Canadian populations; and most common in Aboriginal Australians and New Zealand Maori and Pacific Island people. Rates correlated with the incidence of all other nondiabetic ESRD, but not with diabetic ESRD or community rates of hypertension. Between 1998 and 2002, hypertensive ESRD did not increase in Northwestern Europe or non-Aboriginal Canadians, although it did so in Australia.

CONCLUSION

Despite the likelihood of classification bias, the probability remains of significant variation in incidence of hypertensive ESRD within the group of Europid populations. These between-population differences are not explained by community rates of hypertension or ascertainment bias.

Estrogens as neuroprotectants against ischemic stroke

Estrogens have proven vasoprotective properties against atherosclerosis that depend on the direct effect on vascular smooth muscle and endothelium and on systemic actions that imply serum lipids, coagulation and fibrinolytic cascades, vasoactive proteins and antioxidant systems. They also have neuroprotective effects against cerebral ischemia that include antioxidant and anti-inflammatory effects, modulation of protein synthesis, inhibition of apoptosis and trophic effects and preservation of microvascular blood flow in the ischemic area. Estrogenic actions depend on activation of specific estrogen receptors that modulate gene expression and produce long-term effects on vascular endothelial and smooth muscle cells, neurons and glia, on interaction with plasma membrane sites that produce rapid non-genomic actions and also on receptor-independent mechanisms. This paper reviews what it is known about the mechanisms underlying the vaso- and neuroprotective effects of estrogens. Experimental and clinical evidences of such protective effects are also discussed. Therapeutical implications for stroke prevention and treatment derived from the available evidence are considered.

Pharmacologic management of ischemic stroke: relevance to stem cell therapy

Pharmacologic management of the acute phase of the ischemic stroke includes treating the physical and medical conditions that can worsen cerebral injury; administering intravenous thrombolytic therapy (recombinant tissue plasminogen activator) in those who meet current guidelines; instituting prophylactic measures to prevent medical complications; and initiating passive rehabilitation measures. New approaches under investigation include intra-arterial thrombolytic therapy; endovascular embolectomy and clot disruption; and neuroprotective treatments to preserve surviving ischemic tissue. One neuroprotective agent given within 6 h after stroke onset, NXY059, recently met the primary outcome measure in a phase III clinical trial. Pharmacologic management of the subacute and chronic phases involves treatment of risk factors for recurrent stroke and other forms of cardiovascular disease, including hypercholesterolemia, hypertension, and diabetes mellitus. In this phase, antiplatelet therapy can be initiated or continued; smoking, obesity and alcohol intake can be managed; and active rehabilitation can begin through physical, occupational, and speech therapy. A few medications to augment rehabilitation have shown promising results in small clinical trials, but none have been tested in large phase III trials or approved by the US or European regulatory agencies. Thus, there are no pharmacologic measures available to enhance central nervous system restorative processes after acute stroke, and implantation of stem cells provides one promising approach, not only for cell replacement but also for the provision of therapeutic molecules.