Stroke risk factor profiles in African American women: an interim report from the African-American Antiplatelet Stroke Prevention Study

Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study

BACKGROUND

The prognostic implications of metabolic syndrome (METS) among African stroke patients are poorly understood. This study aimed to investigate the determinants of METS and its prognostic implications among Africans with newly diagnosed stroke in the SIREN study.

METHODS

We included stroke cases (adults aged >18 years with CT/MRI confirmed stroke). The validated tools comprehensively evaluated vascular, lifestyle, and psychosocial factors. We used logistic regression to estimate adjusted odds ratios (OR) with 95% CIs for the association between METS and risk factors. We also computed the prediction power of the domain of covariates in a sequential manner using the area under the receiver operating curve (ROC) curve.

RESULTS

Among 3998 stroke subjects enrolled in the study, 76.8% had METS by at least one of the clinical definitions. Factors associated with METS were age > 50 years (OR- 1.46, CI-1.19-1.80), male gender (OR 4.06, CI- 3.28-5.03), income >100USD (OR1.42, CI-1.17-1.71), stress (OR1.46, CI-1.14-1.87), family history of diabetes mellitus (OR1.38, CI-1.06-1.78), and cardiac disease (OR1.42, CI-1.18-1.65). Stroke severity was higher among those with METS (SLS = 5.8 ± 4.3) compared with those without METS (6.2 ± 4.5) at p = 0.037. METS was associated with higher odds (aOR 1.31, CI-1.08-1.58) of one-month fatality after adjusting for stroke severity, age > 50 years, and average monthly income >100USD.

CONCLUSION

METS is very common among African stroke patients and is associated with stroke severity and worse one-month fatality. Lifestyle interventions may prevent METS and attenuate its impact on stroke occurrence and outcomes.

Community Engagement: Lessons Learned From the AAASPS and SDBA

Community engagement is a means to help overcome challenges to the delivery of health care and preventative services. On the occasion of the 2021 International Stroke Conference Edgar J. Kenton III Lecture, I review community engagement strategies utilized in the AAASPS trial (African-American Antiplatelet Stroke Prevention Study) and SDBA (Studies of Dementia in the Black Aged) observational studies that I directed. The main community engagement strategies included use of home visits (bringing the study to the community), engagement of churches, community advisors, community physicians, other healthcare providers, major Black community organizations, and utilization of diversity training. Community engagement strategies were a major component of AAASPS and SDBA that helped to ensure successful recruitment and retention of an underrepresented community in clinical trial and observational studies. Lessons learned from these studies largely carried out in the 1980s and 1990s helped to dispel myths that Blacks could not be recruited into large-scale clinical trials, emphasized the importance of studying underrepresented groups with adequate statistical power to test primary study hypotheses, and provided foundational recruitment and retention methods for future consideration.

Delays in presentation and mortality among Black patients with mechanical thrombectomy after large-vessel stroke at a US hospital

OBJECTIVE

The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution.

METHODS

All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders.

RESULTS

In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14).

CONCLUSIONS

Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.

Three-year outcomes after carotid artery revascularization: Gender-related differences

Objectives

Carotid artery stenosis is thought to cause up to 10% of ischemic strokes. Historically, carotid artery endarterectomy has shown a higher risk of perioperative adverse events for women. More recent trials reported conflicting results regarding the benefit of carotid artery endarterectomy and carotid artery stenting for men and women. The aim of the present retrospective study was to investigate the influence of gender on the short- (30 days) and long-term (3 years) outcomes of carotid artery endarterectomy and carotid artery stenting in a single centre.

Methods

From 2010 to 2017, 912 consecutive symptomatic and asymptomatic patients who underwent carotid artery endarterectomy (389, 42.7%) or carotid artery stenting (523, 57.3%) in a single institution had been evaluated to determine the influence of sex (540 men, 59.2%, vs. 372 women, 40.8%) on the outcomes after both revascularization procedures during three years of follow-up. The primary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the short-term follow-up. The secondary endpoint was the incidence of death, stroke, myocardial infarction, and restenosis in the long-term follow-up.

Results

Mean clinical follow-up was 21.1 (16.1) months. Women had internal and common carotid artery diameters significantly smaller with respect to men. For peri-procedural outcomes, women undergoing carotid artery stenting had a higher risk of moderate (50–70%) restenosis (6 women, 2.9%, vs. 3 men, 1.0%). For long-term outcomes, women undergoing carotid artery endarterectomy had a higher rate of moderate restenosis (16 women, 16.3%, vs. 11 men, 7.6%). No significant differences in long-term outcomes were observed between men and women undergoing carotid artery stenting, even after stratification for baseline risk factors.

Conclusions

Contrary to previous reports, from this single-centre study, long-term risk of events seems to be higher in women who underwent carotid artery endarterectomy than in those who underwent carotid artery stenting, while fewer differences were observed in men.

Sex differences in long-term outcomes among acute ischemic stroke patients with diabetes in China

BACKGROUND

Diabetes has been shown to be significantly associated with poor outcome after stroke. However, the sex differences in stroke outcome among patients with diabetes are unknown. Therefore, we aimed to assess the sex differences in long-term prognosis among acute ischemic stroke patients with diabetes.

METHODS

The ischemic stroke patients with diabetes were recruited to this study between May 2005 and September 2014 in Tianjin, China. Sex differences in mortality, dependency (modified rank scale > 2), and recurrence at 3, 12, and 36 months after stroke were analyzed.

RESULTS

A total of 2360 patients were recruited in this study. The age of stroke onset, National Institute of Health stroke scale (NIHSS), and modified rank scale (mRS) on admission were greater in women than in men (P < 0.05). Women were more likely to have hypertension, obesity, atrial fibrillation, and dyslipidemias. In contrast, men were more likely to have artery stenosis, current smoking, and alcohol consumption (P < 0.001). There was higher mortality in women than in men at 3 months (7.9 % vs 5.2 %), 12 months (12.2 % vs 8.2 %), and 36 months (21.9 % vs 16.1 %) after stroke; but no differences were found in dependency and recurrence. Sex differences were found in associated factors of outcomes by time-point. Trial of Org 10172 in Acute Stroke Treatment (TOAST) of large artery atherothrombosis (LAA), cardioembolism (CE), and smoking were risk factors of outcomes in women at short term and medium term; but atrial fibrillation (AF), obesity, and alcohol were risk factors of outcomes in men at medium term and long term.

CONCLUSIONS

These findings suggest that it is crucial to establish the individual scheme of therapy for every patient by different risk factors of stroke, strengthen the rehabilitation of stroke, and carry on the health education early for the secondary prevention of stroke in patients with diabetes mellitus (DM).

Family history of stroke among African Americans and its association with risk factors, knowledge, perceptions, and exercise

BACKGROUND

African Americans are at greater risk for stroke than whites are; however, it is unclear what role family history of stroke (FHS) plays in the adoption of healthier lifestyles among African Americans.

OBJECTIVE

The aim of this study was to compare modifiable risk factors, knowledge of stroke risk factors, perceived threat of stroke, perceived control of stroke, and exercise behaviors and intentions in African Americans with a FHS and those without a FHS.

METHODS

A cross-sectional study was conducted with rural African Americans aged 19 to 54 years participating in a mobile health clinic. Participants' stroke knowledge, perceptions of risk, exercise history and intent, physiologic data, and health history were collected.

RESULTS

Participants (N = 66) had a mean (SD) age of 43.3 (9.4) years and were mostly women, high school graduates, and unemployed. Participants with a FHS (n = 33) did not differ on average number of risk factors from those without a FHS. However, participants with a FHS were more likely to report a history of hypertension than were those without. There were no significant differences between groups in stroke knowledge, perceived threat and perceived control, or recent exercise performance, although participants with a FHS had significantly lower future intentions to exercise than did those without a FHS.

CONCLUSIONS

Family history of stroke was common in this sample; however, it did not translate into better understanding of stroke or better exercise behaviors and intentions. More can be done to identify African Americans with a FHS, especially those with multiple risk factors, to educate them about the significance of FHS while promoting lifestyle change and self-management.

Sex differences in stroke case fatality: a meta-analysis

BACKGROUND

In recent years, there were great controversies about gender disparities in stroke outcome. The study was aimed to investigate sex differences in stroke case fatality on all published studies based in a comprehensive meta-analysis.

METHODS

A systematic search of Pubmed, EMBASE, SCOPUS, ISI Web of Science, and Cochrane Library was conducted for the included papers between 1992 and 2009. For the pooled group and subgroup analysis, fixed effects or random effects model were used to find sex differences in case fatality of stroke with a Mantel-Haenszel method. Meta-regression analysis was performed to study methodological heterogeneity.

RESULTS

Thirty-six population-based studies, together with three randomized clinical trials (RCTs), were included in the present study. For the pooled group, there was an overall hazard risk of 1.13 for women compared with men. A hazard risk of 1.27 was observed for women in RCTs subgroup and 1.12 for women in population-based subgroup. The regression analysis found no significant correlation between methodological variables and heterogeneity.

CONCLUSIONS

Due to the limited data about sex differences in stroke case fatality, the findings should be treated cautiously as preliminary. More large multicenter clinical trials should be performed to verify the reliability of the results.

Risk factors and treatment of stroke in Chinese young adults

OBJECTIVE

To evaluate the risk factors and treatment status of Chinese stroke patients aged 35-45 years old.

METHODS

We collected data from 1988 in-hospital stroke patients aged 35-45 years old from 36 hospitals in mainland China and compared it to 12,260 health controls with the same age. Information about stroke risk factors was obtained through a questionnaire. Multiple logistic regression and chi-square test were performed to explore the association between risk factors and stroke in young patients.

RESULTS

Of the stroke patients, 94.3% had an ischemic stroke and 73.0% were male. Frequencies of stroke risk factors were significantly higher in patients than those in controls, including history of hypertension (41.0% versus 9.0%, p<0.05), diabetes (5.2% versus 1.7%, p<0.05), hypercholesterolemia (4.2% versus 2.9%, p<0.05), heart diseases (7.2% versus 1.6%, p<0.05), stroke (14.9% versus 1.3%, p<0.05), smoking (38.8% versus 33.3%, p<0.05) and drinking (38.0% versus 24.9%, p<0.05). Furthermore, only 12.8% of patients with hypertension took antihypertensive drugs regularly, and 27.9% of diabetic patients took hypoglycemic drugs regularly. Risk factors when compared between male and female patients were as follows: history of heart diseases (5.9 versus 10.8, p<0.05), smoking (50.9 versus 6.5, p<0.05) and drinking (50.4 versus 5.8, p<0.05).

CONCLUSION

Majority of the Chinese stroke patients aged 35-45 years were male and had suffered an ischemic stroke. The history of stroke, heart disease and hypercholesterolemia could increase the risk of stroke in young adults, and the risk factors in the order of importance were hypertension, smoking, alcohol drinking, previous stroke, heart disease, diabetes mellitus and hyperlipidemia. Hypertension, smoking and alcohol drinking were found to be the main risk factors; treatment state and lifestyle should be improved for young stroke patients.

Effect of sex on outcome after recurrent stroke in African Americans: results from the African American Antiplatelet Stroke Prevention Study

BACKGROUND

Sex-related disparities in stroke have been previously reported. However, the influence of sex on the outcome of recurrent stroke in African Americans is less clear. Our objective was to investigate the effect of sex on the outcome of recurrent nonfatal stroke in the African American Antiplatelet Stroke Prevention Study (AAASPS).

METHODS

The AAASPS is a double-blind, randomized, controlled trial of recurrent stroke prevention in African Americans. Participants (967 women and 842 men) with noncardioembolic ischemic stroke were assigned to receive ticlopidine or aspirin and were followed up for up to 2 years. The National Institutes of Health Stroke Scale (NIHSS) score, modified Barthel score (mBS), and Glasgow Outcome Scale (GOS) score were determined at enrollment, at prespecified times thereafter, and at the time of recurrent stroke. Survival analysis was used to test for a significant difference in the time to recurrent stroke between women and men.

RESULTS

Of the total 1809 subjects enrolled in AAASPS, 186 (89 women and 97 men) experienced recurrent nonfatal stroke. At enrollment, the NIHSS score (2.87 for women and 3.00 for men; P=.73), the mBS (18.26 for women and 18.52 for men; P=.47) and the GOS score (1.49 for women and 1.51 for men; P=.86) were not significantly different. In follow-up and at the time of stroke recurrence, the NIHSS score, mBS, and GOS score were similar for both groups, except for the mBS at the 6-month visit, which was lower in women (18.49) than in men (19.37) (P=.02). In the survival analysis, no significant difference in the time to recurrent stroke was found between women and men (P=.69).

CONCLUSIONS

Although sex-related stroke disparities have been reported, in the AAASPS cohort outcomes for recurrent nonfatal noncardioembolic ischemic stroke for women were not significantly different than for men. Differences in study populations and methodologies may explain discrepancies in results from the various studies.

Stroke in minorities

Minorities in the United States have higher stroke risks, stroke occurrence at an earlier age, and for some groups, more severe strokes than non-Hispanic whites. Factors contributing to these disparities are explored. Characteristics of African American, Hispanic, and Native American stroke risk and incidence are reviewed. The authors describe recent interventions to raise the awareness of stroke risk factors and symptoms in minorities. The importance of the problem is highlighted, and the authors suggest ways that stroke in minorities may be reduced.

Stroke in Black Americans

Black Americans bear a disproportionate stroke burden in the United States compared with other racial and ethnic groups. Poor stroke awareness, higher vascular risk factor burden, limited access to care, mistrust of the medical system, and inequities in diagnostic testing and treatment usage may account for some of the disparity. In addition, blacks have historically been under-represented in observational studies and clinical trials of stroke prevention and treatment. Therefore, our knowledge regarding stroke in black Americans is somewhat limited. This article provides an update on developments in our understanding regarding stroke in this at-risk population.