Reasons underlying racial differences in stroke incidence and mortality

A Retrospective Analysis of the Underlying Health Status of Patients Treated for Stroke in the Emergency Department of a Community Hospital Situated in a Health Professional Shortage Area

Background Hypertension, diabetes, and hyperlipidemia are known contributors to the incidence of stroke. These and other risk factors such as smoking can be managed with effective primary care, but living in a medically underserved area and racial background can limit access, thereby deleteriously affecting underlying medical conditions and disproportionately contributing to negative stroke outcomes. Our goal is to learn about the on-admission health of 1,731 stroke patients who presented to the Crouse Hospital emergency department (ED) between January 2019 and January 2021 to better understand the circumstances affecting these patients. Crouse Hospital is a community hospital in Syracuse, New York, and an award-winning comprehensive stroke center in the region. The hospital is located in a health professional shortage area (HPSA) and serves both rural and urban patients of various ethnic backgrounds and socioeconomic statuses. Methodology We retrospectively examined the stroke patient data to determine how access to primary care and race affected smoking status, arrival time following the onset of symptoms, stroke severity, thrombolytic administration, and metrics relating to hypertension, diabetes, hyperlipidemia, and depression. Results We determined that, while most patients stated that they had a primary care provider, stroke incidents were typically associated with high blood pressure and high blood glucose despite the prevalence of prescriptions to treat these conditions and that both conditions affected the underserved and non-White patients (Black, Hispanic, Asian, Indigenous, and Other) more so than the served and White populations. Underserved and non-White patients, were also more likely to be associated with smoking behavior. Conclusions The data indicated the major health factors affecting the patients and highlighted those influenced by limited access to primary care and racial background. As a result, we developed a survey to gauge patients' perspectives on primary care and underlying medical conditions before and after their stroke. This patient-centered approach will help refine our stroke education efforts to improve stroke outcomes in the community.

Towards a core outcome set for dysarthria after stroke: What should we measure?

OBJECTIVE

To identify and agree on what outcome domains should be measured in research and clinical practice when working with stroke survivors who have dysarthria.

DESIGN

Delphi process, two rounds of an online survey followed by two online consensus meetings.

SETTING

UK and Australia.

PARTICIPANTS

Stroke survivors with experience of dysarthria, speech and language therapists/pathologists working in stroke and communication researchers.

METHODS

Initial list of outcome domains generated from existing literature and with our patient and public involvement group to develop the survey. Participants completed two rounds of this survey to rate importance. Outcomes were identified as 'in', 'unclear' or 'out' from the second survey. All participants were invited to two consensus meetings to discuss these results followed by voting to identify critically important outcome domains for a future Core Outcome Set. All outcomes were voted on in the consensus meetings and included if 70% of meeting participants voted 'yes' for critically important.

RESULTS

In total, 148 surveys were fully completed, and 28 participants attended the consensus meetings. A core outcome set for dysarthria after stroke should include four outcome domains: (a) intelligibility of speech, (b) ability to participate in conversations, (c) living well with dysarthria, (d) skills and knowledge of communication partners (where relevant).

CONCLUSIONS

We describe the consensus of 'what' speech outcomes after stroke are valued by all stakeholders including those with lived experience. We share these findings to encourage the measurement of these domains in clinical practice and research and for future research to identify 'how' best to measure these outcomes.

Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression

BACKGROUND

Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality.

METHODS

We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions.

RESULTS

Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors.

CONCLUSIONS

Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

Trends in cause-specific mortality among persons with Alzheimer's disease in South Carolina: 2014 to 2019

Introduction

Inconsistencies of reports contributes to the underreporting of Alzheimer's disease (AD) on death certificates. Whether underreporting exists within South Carolina has not been studied.

Methods

We conducted a prospective, population-based study on a cohort of persons (N = 78,534) previously diagnosed with AD and died between 2014-2019. We linked vital records with the South Carolina Alzheimer's Disease and Related Dementias Registry to investigate their cause of death and survival rates. Descriptive analyses calculated frequencies of demographic and health-related characteristics. Turnbull's method estimated the survival probabilities for different subgroups of patients. Hazard ratios were computed from the Cox proportional hazards model, adjusting for the following confounding variables of age at diagnosis, education level, gender, and race.

Results

The top immediate cause of death was Alzheimer's disease among all racial groups, except for Native American/American Indian. More females (60.3%) were affected by AD compared to males (39.7%). There is a 25% probability of survival, beyond 5 years, after AD diagnosis. Black/African American AD patients have the smallest risk of all-cause mortality across all racial/ethnic groups (HR 0.87; 95% CI, 0.85-0.89). Individuals with lower education had a lower likelihood of mortality.

Conclusion

Although AD was not underreported in the state of South Carolina further research is needed to develop protocols around classification of deaths among those diagnosed with dementia and comorbidities, including cardiovascular disease, to ensure dementia is properly reported as we move to prevent and treat Alzheimer's disease by 2025 and beyond.

Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation

BACKGROUND

Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke.

METHODS AND RESULTS

Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease.

CONCLUSIONS

This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.

Post-Processing Automatic Transcriptions with Machine Learning for Verbal Fluency Scoring

Objective

To compare verbal fluency scores derived from manual transcriptions to those obtained using automatic speech recognition enhanced with machine learning classifiers.

Methods

Using Amazon Web Services, we automatically transcribed verbal fluency recordings from 1400 individuals who performed both animal and letter F verbal fluency tasks. We manually adjusted timings and contents of the automatic transcriptions to obtain "gold standard" transcriptions. To make automatic scoring possible, we trained machine learning classifiers to discern between valid and invalid utterances. We then calculated and compared verbal fluency scores from the manual and automatic transcriptions.

Results

For both animal and letter fluency tasks, we achieved good separation of valid versus invalid utterances. Verbal fluency scores calculated based on automatic transcriptions showed high correlation with those calculated after manual correction.

Conclusion

Many techniques for scoring verbal fluency word lists require accurate transcriptions with word timings. We show that machine learning methods can be applied to improve off-the-shelf ASR for this purpose. These automatically derived scores may be satisfactory for some applications. Low correlations among some of the scores indicate the need for improvement in automatic speech recognition before a fully automatic approach can be reliably implemented.

Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation

Background and Purpose

Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke.

Methods

Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia.

Results

Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease.

Conclusions

This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.

Sex Differences Define the Vulnerability to Atherosclerosis

For several decades, atherosclerosis has attracted the attention of researchers around the world. Even being a major cause of serious cardiovascular disease and events, atherosclerosis is still not fully understood. Despite the fact that the main players in the pathogenesis of atherosclerosis are well known, many mechanisms of their implementation and interactions remain unknown. The same can be said about the risk factors for atherosclerosis. Many of them are known, but exactly how they work remains to be seen. The main objective of this review is to summarize the latest data on sex as a biological variable in atherosclerosis in humans and animals; to determine what we do not still know about how sex affects the process of growth and complications of atherosclerosis. In this review, we summarized data on sex differences at 3 atherosclerotic aspects: inflammation, vascular remodeling, and plaque morphology. With all overviewed data, we came to the conclusion on the atheroprotective role of female sex.

Systemic Adverse Events Among Patients With Diabetes Treated With Intravitreal Anti-Vascular Endothelial Growth Factor Injections

Importance

Anti-vascular endothelial growth factor (VEGF) agents are currently the mainstay of treatment for diabetic retinopathy (DR). Although effective, data on their systemic safety remains inconclusive, particularly in high-risk patient groups.

Objective

To explore the systemic safety of intravitreal anti-VEGF agents among patients with diabetes.

Design, Setting, and Participants

This was a retrospective, longitudinal population-based analysis of the Corporate Data Warehouse, a large-scale database of patients within the US Veteran Health Affairs. All patients 18 years and older with type 2 diabetes who were seen at any Veterans Affairs health care facility in the US between January 1, 2011, and December 31, 2012, were identified. Data were then extracted on incident systemic adverse events among this patient cohort from January 1, 2013, to December 31, 2017. All individuals with diabetes who did and did not receive anti-VEGF injections were included. Patients with a history of prior systemic adverse events and those who received an intravitreal injection between January 1, 2011, and December 31, 2012, were excluded. Data were analyzed from October 2019 to March 2023.

Exposure

Anti-VEGF injection.

Main Outcomes and Measures

Proportion of patients with any incident systemic adverse event, acute myocardial infarction, cardiovascular disease, or kidney disease at 1-, 3-, and 5-year follow-up.

Results

A total of 1 731 782 patients (mean [SD] age, 63.8 [12.3] years; 1 656 589 [95.7%] male) with type 2 diabetes were included. DR was present in 476 013 (27.5%), and 14 022 (0.8%) received anti-VEGF injections. Of the total number of patients with type 2 diabetes, 321 940 (18.6%) developed systemic adverse events between 2013 and 2017. The 5-year cumulative incidence of any systemic adverse event was 37.0% (5187/14 022) in the injection group vs 18.4% (316 753/1 717 760) in the noninjection group (P < .001). Anti-VEGF injections were independently associated with a higher likelihood of developing any systemic adverse event (odds ratio, 1.8; 95% CI, 1.7-1.9) when controlling for age, race, sex, ethnicity, tobacco use, severity of DR, Deyo-Charlson Comorbidity Index score, mean hemoglobin A1c, total number of injections, and statin use.

Conclusion and Relevance

In this study, intravitreal anti-VEGF injections were independently associated with a higher likelihood of systemic adverse events among patients with diabetes.

Black representation in critical care randomized controlled trials: a meta-epidemiological study

PURPOSE

The under-representation of Black people within critical care research limits the generalizability of randomized controlled trials (RCTs). This meta-epidemiologic study investigated the proportionate representation of Black people enrolled at USA and Canadian study sites from high impact critical care RCTs.

SOURCE

We searched for critical care RCTs published in general medicine and intensive care unit (ICU) journals between 1 January 2016 and 31 December 2020. We included RCTs that enrolled critically ill adults at USA or Canadian sites and provided race-based demographic data by study site. We compared study-based racial demographics with site-level city-based demographics and pooled representation of Black people across studies, cities, and centres using a random effects model. We used meta-regression to explore the impact of the following variables on Black representation in critical care RCTs: country, drug intervention, consent model, number of centres, funding, study site city, and year of publication.

PRINCIPAL FINDINGS

We included 21 eligible RCTs. Of these, 17 enrolled at only USA sites, two at only Canadian sites, and two at both USA and Canadian sites. Black people were under-represented in critical care RCTs by 6% compared with population-based city demographics (95% confidence interval, 1 to 11). Using meta-regression, after controlling for pertinent variables, the country of the study site was the only significant source of heterogeneity (P = 0.02).

CONCLUSION

Black people are under-represented in critical care RCTs compared with site-level city-based demographics. Interventions are required to ensure adequate Black representation in critical care RCTs at both USA and Canadian study sites. Further research is needed to investigate the factors contributing to Black under-representation in critical care RCTs.

Association of Circulating Metabolites With Racial Disparities in Hypertension and Stroke in the REGARDS Study

BACKGROUND AND OBJECTIVES

In the United States, the risk of stroke is greater among Black compared with that among White individuals. However, the reasons for the difference in stroke incidence are not fully elucidated. We aimed to identify metabolites that account for higher prevalent hypertension and incident ischemic stroke among Black adults.

METHODS

We used a stroke case cohort nested within the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Targeted metabolomic profiling of 162 plasma metabolites was performed by liquid chromatography-tandem mass spectrometry. We identified metabolites that were associated with prevalent hypertension and incident ischemic stroke and mediated the relationship between hypertension and ischemic stroke by weighted logistic regression, Cox proportional hazard model, and inverse odds ratio weighting mediation analysis.

RESULTS

Incident ischemic stroke cases adjudicated through April 1, 2019 (n = 1,075) were included in the study. The random cohort sample was derived from the full cohort using stratified sampling (n = 968). Among 162 metabolites, gluconic acid was associated with prevalent hypertension in Black adults (odds ratio [OR] 1.86, 95% CI 1.39-2.47, p = 2.58 × 10-5) but not in White adults (OR 1.00, 95% CI 0.80-1.24, p = 0.97; p for interaction = 4.57 × 10-4). Gluconic acid also demonstrated an association with incident ischemic stroke among Black participants (hazard ratio [HR] 1.53, 95% CI 1.28-1.81, p = 1.76 × 10-6) but not White participants (HR 1.16, 95% CI 1.00-1.34, p = 0.057; p for interaction = 0.019). In mediation analysis, gluconic acid mediated 25.4% (95% CI 4.1%-46.8%, p = 0.02) of the association between prevalent hypertension and incident ischemic stroke among Black individuals. Specific socioeconomic factors were linked to elevated gluconic acid level among Black adults in multivariable analysis, including a Southern dietary pattern (β = 0.18, 95% CI 0.08-0.28, p < 0.001), lower educational attainment (β = 0.45, 95% CI 0.19-0.72, p = 0.001), and a lack of exercise (β = 0.26, 95% CI 0.01-0.51, p = 0.045).

DISCUSSION

Gluconic acid is associated with prevalent hypertension and incident ischemic stroke and mediates the relationship between hypertension and ischemic stroke in Black but not White adults. Gluconic acid is a biomarker that is associated with social determinants of health including a Southern diet, low educational attainment, and low physical activity.

Secondary Ischemic Stroke Prevention

The health burden of ischemic stroke is high and will continue to increase with an aging population. Recurrent ischemic stroke is increasingly recognized as a major public health concern with potentially debilitating sequelae. Thus, it is imperative to develop and implement effective strategies for stroke prevention. When considering secondary ischemic stroke prevention, it is important to consider the mechanism of the first stroke and the related vascular risk factors. Secondary ischemic stroke prevention typically includes multiple medical and, potentially, surgical treatments, but with the shared goal of reducing the risk of recurrent ischemic stroke. Providers, health care systems, and insurers also need to consider the availability of treatments, their cost and patient burden, methods for improving adherence, and interventions that target lifestyle risk factors such as diet or activity. In this article, we discuss aspects from the 2021 AHA Guideline on Secondary Stroke Prevention as well as highlight additional information relevant to best practices for reducing recurrent stroke risk.

Secondary Stroke Risk Reduction in Black Adults: a Systematic Review

OBJECTIVE

To address the fact that Black adults (BAs) experience significantly greater stroke burden than the general population, we conducted a systematic literature review which described evidence-based interventions targeting secondary stroke risk reduction in BAs.

DATA SOURCE

Publications were selected from PubMed, Ovid, Cochrane, and Web of Science databases. We included peer-reviewed, longitudinal, English-language studies performed in the USA which reported results for BAs separately and had adult participants who had experienced stroke-related events.

RESULTS

Six of the 7 studies employed behavioral interventions which promoted education on stroke risk factors, problem-solving skills, and healthy-coping strategies. These studies demonstrated improvements in one or more biologic outcomes including cholesterol control and systolic blood pressure.

CONCLUSIONS

Existing interventions on secondary stroke risk reduction approaches are effective in reducing secondary stroke risk among BAs, especially in individuals with poorly controlled blood pressure at baseline. However, additional research is needed because the current approaches may limit generalizability.

American Indians and atrial fibrillation

The American Indian population is known to experience high rates of cardiovascular disease and have a heightened vulnerability to severe outcomes driven by an overall poor health status and lower access to quality health care. Our group has previously published an analysis demonstrating that American Indians have the highest risk of atrial fibrillation (AF), as well as of AF-related stroke, when compared with other races and ethnicities. Despite this, AF in this population has not been extensively studied and additional publications are scarce. Our review article provides an up-to-date summary of the relevant literature addressing the relationship between race, ethnicity, and AF by focusing on American Indians.

Stroke Severity in Ischemic Stroke Patients with a History of Diastolic Blood Pressure Treated in a Telestroke Network

Background: The relationship between diastolic blood pressure (DBP), risk factors, and stroke severity in acute ischemic stroke (AIS) patients treated in a telestroke network is not fully understood. The present study aims to determine the effect of risk factors on stroke severity in AIS patients with a history of elevated DBP. Material and Methods: We retrospectively analyzed data on stroke severity for AIS patients treated between January 2014 and June 2016 treated in the PRISMA Health telestroke network. Data on the severity of stroke on admission were evaluated using NIHSS scores ≤7 for reduced, and >7 for increased, stroke severity. DBP was stratified as ≤80 mmHg for reduced DBP and >80 mmHg for elevated DBP. The study’s primary outcomes were risk factors associated with improving neurologic functions or reduced stroke severity and deteriorating neurologic functions or increased stroke severity. The associations between risk factors and stroke severity for AIS with elevated DBP were determined using multi-level logistic and regression models. Results: In the adjusted analysis, AIS patients with a DBP ≤ 80 mmHg, obesity (OR = 0.388, 95% Cl, 0.182−0.828, p = 0.014) was associated with reduced stroke severity, while an increased heart rate (OR = 1.025, 95% Cl, 1.001−1.050, p = 0.042) was associated with higher stroke severity. For AIS patients with a DBP > 80 mmHg, hypertension (OR = 3.453, 95% Cl, 1.137−10.491, p = 0.029), history of smoking (OR = 2.55, 95% Cl, 1.06−6.132, p = 0.037), and heart rate (OR = 1.036, 95% Cl, 1.009−1.064, p = 0.009) were associated with higher stroke severity. Caucasians (OR = 0.294, 95% Cl, 0.090−0.964, p = 0.002) and obesity (OR = 0.455, 95% Cl, 0.207−1.002, p = 0.05) were more likely to be associated with reduced stroke severity. Conclusions: Our findings reveal specific risk factors that can be managed to improve the care of AIS patients with elevated DBP treated in the telestroke network.

A comparison of techniques for deriving clustering and switching scores from verbal fluency word lists

Objective

To compare techniques for computing clustering and switching scores in terms of agreement, correlation, and empirical value as predictors of incident cognitive impairment (ICI).

Methods

We transcribed animal and letter F fluency recordings on 640 cases of ICI and matched controls from a national epidemiological study, amending each transcription with word timings. We then calculated clustering and switching scores, as well as scores indexing speed of responses, using techniques described in the literature. We evaluated agreement among the techniques with Cohen’s κ and calculated correlations among the scores. After fitting a base model with raw scores, repetitions, and intrusions, we fit a series of Bayesian logistic regression models adding either clustering and switching scores or speed scores, comparing the models in terms of several metrics. We partitioned the ICI cases into acute and progressive cases and repeated the regression analysis for each group.

Results

For animal fluency, we found that models with speed scores derived using the slope difference algorithm achieved the best values of the Watanabe–Akaike Information Criterion (WAIC), but with good net reclassification improvement (NRI) only for the progressive group (8.2%). For letter fluency, different models excelled for prediction of acute and progressive cases. For acute cases, NRI was best for speed scores derived from a network model (3.4%), while for progressive cases, the best model used clustering and switching scores derived from the same network model (5.1%). Combining variables from the best animal and letter F models led to marginal improvements in model fit and NRI only for the all-cases and acute-cases analyses.

Conclusion

Speed scores improve a base model for predicting progressive cognitive impairment from animal fluency. Letter fluency scores may provide complementary information.

Demographic and Regional Trends in Stroke-Related Mortality in Young Adults in the United States, 1999 to 2019

Background Despite improvements in the management and prevention of stroke, increasing hospitalizations for stroke and stagnant mortality rates have been described in young adults. However, there is a paucity of contemporary national mortality estimates in young adults. Methods and Results Trends in mortality related to stroke in young adults (aged 25-64 years) were assessed using the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Age-adjusted mortality rates per 100 000 people with associated annual percentage change were calculated. Joinpoint regression was used to assess the trends in the overall sample and different demographic (sex, race and ethnicity, and age) and geographical (state, urban-rural, and regional) subgroups. Between 1999 and 2019, a total of 566 916 stroke-related deaths occurred among young adults. After the initial decline in mortality in the overall population, age-adjusted mortality rate increased from 2013 to 2019 with an associated annual percentage change of 1.5 (95% CI, 1.1-2.0). Mortality rates were higher in men versus women and in non-Hispanic Black people versus individuals of other races and ethnicities. Non-Hispanic American Indian or Alaskan Native people had a marked increase in stroke-related mortality (annual percentage change 2010-2019: 3.3). Furthermore, rural (nonmetropolitan) counties experienced the greatest increase in mortality (annual percentage change 2012-2019: 3.1) compared with urban (metropolitan) counties. Conclusions Following the initial decline in stroke-related mortality, young adults have experienced increasing mortality rates from 2013 to 2019, with considerable differences across demographic groups and regions.

Long-term Changes in Depressive Symptoms Before and After Stroke

BACKGROUND AND OBJECTIVES

To determine the trajectory of depressive symptoms several years before and after incident stroke.

METHODS

We analyzed data from 10,797 participants from the English Longitudinal Study of Ageing without a history of stroke at baseline (wave 1). We matched participants with first-ever stroke during the 12-year follow-up (waves 2-7) to stroke-free individuals using propensity scores accounting for age, sex, education, ethnicity, and vascular risk factors. Trajectories of depressive symptoms before and after stroke were analyzed using multilevel models.

RESULTS

Among the 10,797 participants (mean age 64.6 ± 9.9 years, 54.8% women), we identified 425 individuals with incident stroke. At the assessment before stroke, these individuals demonstrated an increase in depressive symptoms when compared with matched controls. There was a further increase in depressive symptoms in stroke survivors after the acute event, which persisted for several years. Symptom-level analyses revealed that differences in depressive symptoms between stroke survivors and stroke-free controls before and after stroke were most pronounced for mood-related and fatigue-related symptoms.

DISCUSSION

Incident stroke is associated with long-term increases in depressive symptoms. A small part of this increase occurs in the years before stroke, perhaps indicating the incipient pathologic process. Particular attention should be paid to depressive symptoms in the long-term care of patients, and especially to fatigue-related symptoms.

Structural Inequities for Historically Underserved Communities in the Adoption of Stroke Certification in the United States

Importance

Stroke centers are associated with better outcomes. There is substantial literature surrounding disparities in stroke outcomes for underserved populations. However, the existing literature has focused primarily on discrimination at the individual or institutional level, and studies of structural discrimination in stroke care are scant.

Objective

To examine differences in hospitals' likelihood of adopting stroke care certification between historically underserved and general communities.

Design, Setting, and Participants

This study combined a data set of hospital stroke certification from all general acute nonfederal hospitals in the continental US from January 1, 2009, to December 31, 2019, with national, hospital, and census data to define historically underserved communities by racial and ethnic composition, income distribution, and rurality. For all categories except rurality, communities were categorized by the composition and degree of segregation of each characteristic. Cox proportional hazard models were then estimated to compare the hazard of adopting stroke care certification between historically underserved and general communities, adjusting for population size and hospital bed capacity. Data were analyzed from June 2021 to April 2022.

Main Outcomes and Measures

Hospitals' likelihood of adopting stroke care certification.

Results

A total of 4984 hospitals were included. From 2009 to 2019, the total number of hospitals with stroke certification grew from 961 to 1763. Hospitals serving Black, racially segregated communities had the highest hazard of adopting stroke care certification (hazard ratio [HR], 1.67; 95% CI, 1.41-1.97) in models not accounting for population size, but their hazard was 26% lower than among those serving non-Black, racially segregated communities (HR, 0.74; 95% CI, 0.62-0.89) in models controlling for population and hospital size. Adoption hazard was lower in low-income communities compared with high-income communities, regardless of their level of economic segregation, and rural hospitals were much less likely to adopt any level of stroke care certification relative to urban hospitals (HR, 0.43; 95% CI, 0.35-0.51).

Conclusions and Relevance

In this analysis of stroke certification adoption across acute care hospitals in the US from 2009 to 2019, hospitals in low-income and rural communities had a lower likelihood of receiving stroke certification than hospitals in general communities. Hospitals operating in Black, racially segregated communities had the highest likelihood of adopting stroke care, but because these communities had the largest population, patients in these communities had the lowest likelihood of access to stroke-certified hospitals when the model controlled for population size. These findings provide empirical evidence that the provision of acute neurological services is structurally inequitable across historically underserved communities.

Racial differences in the association of accelerated aging with future cardiovascular events and all-cause mortality: the coronary artery risk development in young adults study, 2007-2018

OBJECTIVE

Variability of Cardiovascular disease (CVD) risk, including racial difference, is not fully accounted for by the variability of traditional CVD risk factors. We used a multiple biomarker model as a framework to explore known racial differences in CVD burden.

DESIGN

We measured associations between accelerated aging (AccA) measured by a combination of biomarkers, and cardiovascular morbidity and all-cause mortality using data from the Coronary Artery Risk Development in Young Adults study (CARDIA). AccA was defined as the difference between biological age, calculated using biomarkers with the Klemera and Doubal method, and chronological age. Using logistic regression, we assessed overall and race-specific associations between AccA, CVD, and all-cause mortality.

RESULTS

Among our cohort of 2959 Black or White middle-aged adults, after adjustment, a one-year increase in AccA was associated with increased odds of CVD (Odds Ratio (OR) = 1.04; 95% CI: 1.02, 1.06), stroke (OR = 1.12; 95% CI: 1.07, 1.17), and all-cause mortality (OR = 1.05; 95% CI: 1.02, 1.08). We did not find significant overall racial differences, but we did find race by sex differences where Black men differed markedly from White men in the strength of association with CVD (OR = 1.06, 95% CI: 1.01, 1.12).

CONCLUSIONS

We provide evidence that AccA is associated with future CVD.

Educational Intervention in the Emergency Department to Address Disparities in Stroke Knowledge

OBJECTIVES

In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group.

MATERIALS AND METHODS

Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling.  Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention.

RESULTS

One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001).

CONCLUSIONS

Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.

Verbal fluency response times predict incident cognitive impairment

Introduction

In recent decades, researchers have defined novel methods for scoring verbal fluency tasks. In this work, we evaluate novel scores based on speed of word responses.

Methods

We transcribed verbal fluency recordings from 641 cases of incident cognitive impairment (ICI) and matched controls, all participants in a large national epidemiological study. Timing measurements of utterances were used to calculate a speed score for each recording. Traditional raw and speed scores were entered into Cox proportional hazards (CPH) regression models predicting time to ICI.

Results

Concordance of the CPH model with speed scores was 0.599, an improvement of 3.4% over a model with only raw scores and demographics. Scores with significant effects included animals raw and speed scores, and letter F speed score.

Discussion

Novel verbal fluency scores based on response times could enable use of remotely administered fluency tasks for early detection of cognitive decline.

Highlights

 The current work evaluates prognostication with verbal fluency speed scores. These speed scores improve survival models predicting cognitive decline. Cases with progressive decline have some characteristics suggestive of Alzheimer's disease. The subset of acute decliners is probably pathologically heterogeneous.

Prevalence and predictors of stroke among individuals with prediabetes and diabetes in Florida

BACKGROUND

The prevalence of both prediabetes and diabetes have been increasing in Florida. These increasing trends will likely result in increases of stroke burden since both conditions are major risk factors of stroke. However, not much is known about the prevalence and predictors of stroke among adults with prediabetes and diabetes and yet this information is critical for guiding health programs aimed at reducing stroke burden. Therefore, the objectives of this study were to estimate the prevalence and identify predictors of stroke among persons with either prediabetes or diabetes in Florida.

METHODS

The 2019 Behavioral Risk Factor Surveillance System (BRFSS) survey data were obtained from the Florida Department of Health and used for the study. Weighted prevalence estimates of stroke and potential predictor variables as well as their 95% confidence intervals were computed for adults with prediabetes and diabetes. A conceptual model of predictors of stroke among adults with prediabetes and diabetes was constructed to guide statistical model building. Two multivariable logistic models were built to investigate predictors of stroke among adults with prediabetes and diabetes.

RESULTS

The prevalence of stroke among respondents with prediabetes and diabetes were 7.8% and 11.2%, respectively. The odds of stroke were significantly (p ≤ 0.05) higher among respondents with prediabetes that were ≥ 45 years old (Odds ratio [OR] = 2.82; 95% Confidence Interval [CI] = 0.74, 10.69), had hypertension (OR = 5.86; CI = 2.90, 11.84) and hypercholesterolemia (OR = 3.93; CI = 1.84, 8.40). On the other hand, the odds of stroke among respondents with diabetes were significantly (p ≤ 0.05) higher if respondents were non-Hispanic Black (OR = 1.79; CI = 1.01, 3.19), hypertensive (OR = 3.56; CI = 1.87, 6.78) and had depression (OR = 2.02; CI = 1.14, 3.59).

CONCLUSIONS

Stroke prevalence in Florida is higher among adults with prediabetes and diabetes than the general population of the state. There is evidence of differences in the importance of predictors of stroke among populations with prediabetes and those with diabetes. These findings are useful for guiding health programs geared towards reducing stroke burden among populations with prediabetes and diabetes.

Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria

This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.

Depressive Symptoms and Risk of Stroke in a National Cohort of Black and White Participants From REGARDS

Objective

The purpose of this study was to examine depressive symptoms as a risk factor for incident stroke and determine whether depressive symptomatology was differentially predictive of stroke among Black and White participants.

Methods

The study comprised 9,529 Black and 14,516 White stroke-free participants, aged 45 and older, enrolled in the REasons for Geographic and Racial Differences in Stroke (2003-2007). Incident stroke was the first occurrence of stroke. Association between baseline depressive symptoms (assessed via the 4-item Center for Epidemiologic Studies Depression Scale [CES-D-4]: 0, 1-3, or ≥4) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographics, stroke risk factors, and social factors.

Results

There were 1,262 strokes over an average follow-up of 9.21 (SD 4.0) years. Compared to participants with no depressive symptoms, after demographic adjustment, participants with CES-D-4 scores of 1-3 had 39% increased stroke risk (hazard ratio [HR] = 1.39, 95% confidence interval [CI] = 1.23-1.57), with slight attenuation after full adjustment (HR = 1.27, 95% CI = 1.11-1.43). Participants with CES-D-4 scores of ≥4 experienced 54% higher risk of stroke after demographic adjustment (HR = 1.54, 95% CI = 1.27-1.85), with risk attenuated in the full model similar to risk with 1-3 symptoms (HR = 1.25, 95% CI = 1.03-1.51). There was no evidence of a differential effect by race (p = 0.53).

Conclusions

The association of depressive symptoms with increased stroke risk was similar among a national sample of Black and White participants. These findings suggest that assessment of depressive symptoms should be considered in primary stroke prevention for both Black and White participants.

The Obesity Paradox in Spontaneous Intracerebral Hemorrhage: Results from a Retrospective Analysis of the Nationwide Inpatient Sample

BACKGROUND/OBJECTIVE

Mild obesity is associated with a survival benefit in cardiovascular and cerebrovascular disease. Only a few studies have analyzed the effect of obesity on outcomes after spontaneous intracerebral hemorrhage (ICH), and none have used a national US database. We sought to determine whether or not obesity was associated with outcomes and in-hospital complications following ICH.

METHODS

The Nationwide Inpatient Sample was used to identify patients with ICH in the USA who were discharged between 2002 and 2011. The presence of obesity (body mass index [BMI] 30-39.9) or morbid obesity (BMI ≥ 40) was noted. The primary outcome of interest was in-hospital mortality, and secondary outcomes included non-routine discharge disposition, tracheostomy or gastrostomy placement, length of stay (LOS), inflation-adjusted hospital charges, and in-hospital complications.

RESULTS

A total of 123,415 patients with ICH met the inclusion criteria, and the 10-year overall incidence of obesity was 4.5%. Between 2002 and 2011, the incidence of obesity increased from 1.9 to 4.4% and the incidence of morbid obesity increased from 0.7 to 3.2%. Both obese (OR 0.62, 95% CI 0.56-0.69) and morbidly obese (OR 0.76, 95% CI 0.66-0.88) patients had lower odds of inpatient mortality. Obese (OR 0.85, 95% CI 0.78-0.93) but not morbidly obese patients had lower odds of non-routine discharge. Morbidly obese patients were twice as likely to require a tracheostomy than non-obese patients (OR 2.07, 95% CI 1.62-2.66). Both obese and morbidly obese patients had higher total hospital charges and rates of pulmonary, renal, and venous thromboembolic complications. There was no difference in LOS according to body habitus.

CONCLUSIONS

In patients with spontaneous ICH, obesity is associated with decreased in-hospital mortality but higher rates of in-hospital complications and greater total hospital charges. Non-morbid obesity carries lower odds of non-routine hospital discharge.

Incident Strokes Among American Indian Individuals With Atrial Fibrillation

BACKGROUND

American Indian individuals experience a relatively high risk for cardiovascular disease and have exhibited a higher risk of stroke compared with other racial and ethnic minorities. Although this population has the highest incidence of atrial fibrillation (AF) compared with other groups, the relationship between AF and nonhemorrhagic stroke among American Indian individuals compared with other groups has not been thoroughly studied.

METHODS and RESULTS

We used the Healthcare Cost and Utilization Project to evaluate risk of nonhemorrhagic stroke among American Indian individuals, with comparisons to White, Black, Hispanic, and Asian individuals, among all adult California residents receiving care in an emergency department, inpatient hospital unit, or ambulatory surgery setting from 2005 to 2011. Of 16 951 579 patients followed for a median 4.1 years, 105 822 (0.6%) were American Indian. After adjusting for age, sex, income level, insurance payer, hypertension, diabetes mellitus, coronary artery disease, congestive heart failure, cardiac surgery, valvular heart disease, chronic kidney disease, smoking, obstructive sleep apnea, pulmonary disease, and alcohol use, American Indian individuals with AF exhibited the highest risk of nonhemorrhagic stroke when compared with either non‐American Indian individuals with AF (hazard ratio, 1.38; 95% CI, 1.23–1.55; P<0.0001) or to each race and ethnicity with AF. American Indian individuals also experienced the highest overall risk for stroke, with no evidence that AF disproportionately heightened that risk in interaction analyses.

CONCLUSIONS

American Indian individuals experienced the highest risk of nonhemorrhagic stroke, whether in the presence or absence of AF. Our findings likely suggest an opportunity to further study, if not immediately address, guideline‐adherent anticoagulation prescribing patterns among American Indian individuals with AF.

The Targeted Management (TEAM) Intervention for Reducing Stroke Risk in African American Men: Rationale and Study Design of a Prospective Randomized Controlled Trial

BACKGROUND

African American (AA) male survivors of strokes or transient ischemic attacks (TIA) have the highest risk of recurrent stroke when compared to other racial-ethnic men. However, there is a paucity of evidence-based strategies, including organizational, educational, or behavioral interventions, that targets secondary stroke risk reduction in AA men.

METHODS

Targeted Management for Reducing Stroke Risk (TEAM) is an ongoing, 6-month prospective, randomized controlled trial that will determine whether a curriculum-guided self-management approach, using peer dyads (men who had a stroke or TIA and their care partners) will improve post-stroke care in AA men.

RESULTS

The study sample will consist of 160 AA men who have experienced a stroke or TIA within 5 years, randomized to TEAM or Wait-list control group. The primary outcome changes in systolic blood pressure (BP) and high-density lipoprotein (HDL), while secondary outcomes include diastolic BP, total cholesterol, low-density lipoprotein, triglycerides, and glycemic control for diabetics. We hypothesize that AA men in TEAM will have significantly lower systolic BP and higher HDL when compared to AA men in the Wait-list control group at 6-month.

CONCLUSION

Persistent disparities for stroke burden in AA men highlight the need for novel interventions to promote secondary stroke-risk reduction. Building on promising pilot data, TEAM uses a group format, with a nurse and patient co-led intervention focused on AA men and family needs, practice in problem-solving, and attention to emotional and role management. In addition, the TEAM approach may help reduce stroke risk factors and health disparities in AA men.

CLINICALTRIALSGOV IDENTIFIER

NCT04402125.

Racial Differences in Atrial Cardiopathy Phenotypes in Patients With Ischemic Stroke

OBJECTIVE

To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke.

METHODS

We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities.

RESULTS

Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, -0.11; 95% confidence interval [CI], -0.17 to -0.05) and adjusted (β, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21-1.97) and adjusted (β, 1.45; 95% CI, 1.00-1.80) models.

CONCLUSIONS

We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.

From Salt to Stroke-Evaluation of a Media Campaign for Sodium Reduction in Philadelphia

Excess dietary sodium contributes to the burden of chronic disease, including cardiovascular disease and stroke. Media-based health education campaigns are one strategy to raise awareness among populations at greater risk for stroke, including African Americans. During 2014–2015, the Philadelphia Department of Public Health conducted a health education campaign using radio, print news, and transit ads, to promote awareness of the link between dietary sodium, hypertension and stroke, and encourage reduced consumption of high sodium foods. Using a repeated cross-sectional design, street intercept surveys were conducted with ~400 Philadelphia residents representing the campaign's priority audience (African Americans ages 35–55) before and 6–13 weeks after the campaign, to evaluate both process (campaign exposure) and impact (recall of key health messages). Thirty percent of post-campaign respondents reported familiarity with one of the most engaging radio spots, and 17% provided accurate unaided recall of its key content, with greater recall among older respondents and frequent radio listeners. Forty-one percent of post-campaign respondents named stroke as a consequence of excess salt consumption, compared to only 17% of pre-campaign respondents, with greater awareness of the salt-stroke connection among those accurately recalling the radio spot from the campaign. Results suggest that priority populations for sodium reduction can be effectively reached through radio and transit campaigns. From a pragmatic perspective, street intercept surveys may offer one low resource strategy for evaluating public health education campaigns conducted by local health departments, especially among urban populations.

Disparities in all-cause mortality with potentially inappropriate medication use: Analysis of the Reasons for Geographic and Racial Differences in Stroke study

OBJECTIVES

Health disparities across different socioeconomic subgroups have been reported in previous studies. Mortality with potentially inappropriate medication (PIM) use may be subject to similar disparities. We aimed to assess the association between PIM use and all-cause mortality and the effect of disparity parameters (sex, race, income, education, and location of residence) on this relationship.

METHODS

This longitudinal cohort study included 26,399 U.S. adults aged 45 years and older from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, of which 13,475 participants were aged 65 years and older (recruited 2003-2007). PIM use and drug-drug interactions (DDIs) were identified through the 2015 Beers Criteria and a clinically significant DDIs list by the American Family Physicians, respectively. Cox regression was used to assess disparities in mortality with PIM use, iteratively adjusting for disparity parameters and other covariates. The full models included interaction terms between PIM use and other covariates. A similar method was used for the analyses of disparities in mortality with DDIs.

RESULTS

Approximately 87% of older adults used at least 1 drug listed in the Beers Criteria, and 3.8% of all participants used 2 or more drugs with DDIs. In the adjusted analysis, an increased risk of mortality was observed among whites with PIM use (hazard ratio [HR] = 1.27 [95% CI 1.10-1.47]). The higher mortality rate was observed among blacks without PIM use (1.34 [1.09-1.65]). Lower income and education were independent predictors for higher mortality.

CONCLUSION

Racial differences in all-cause mortality with PIM use were observed. Further research is needed to better understand the contributing factors of such disparities to develop appropriate interventions.

Spatial distribution and cognitive impact of cerebrovascular risk-related white matter hyperintensities

OBJECTIVES

White matter hyperintensities (WMHs) are considered macroscale markers of cerebrovascular burden and are associated with increased risk of vascular cognitive impairment and dementia. However, the spatial location of WMHs has typically been considered in broad categories of periventricular versus deep white matter. The spatial distribution of WHMs associated with individual cerebrovascular risk factors (CVR), controlling for frequently comorbid risk factors, has not been systematically investigated at the population level in a healthy ageing cohort. Furthermore, there is an inconsistent relationship between total white matter hyperintensity load and cognition, which may be due to the confounding of several simultaneous risk factors in models based on smaller cohorts.

METHODS

We examined trends in individual CVR factors on total WMH burden in 13,680 individuals (aged 45-80) using data from the UK Biobank. We estimated the spatial distribution of white matter hyperintensities associated with each risk factor and their contribution to explaining total WMH load using voxel-wise probit regression and univariate linear regression. Finally, we explored the impact of CVR-related WMHs on speed of processing using regression and mediation analysis.

RESULTS

Contrary to the assumed dominance of hypertension as the biggest predictor of WMH burden, we show associations with a number of risk factors including diabetes, heavy smoking, APOE ε4/ε4 status and high waist-to-hip ratio of similar, or greater magnitude to hypertension. The spatial distribution of WMHs varied considerably with individual cerebrovascular risk factors. There were independent effects of visceral adiposity, as measured by waist-to-hip ratio, and carriage of the APOE ε4 allele in terms of the unique spatial distribution of CVR-related WMHs. Importantly, the relationship between total WMH load and speed of processing was mediated by waist-to-hip ratio suggesting cognitive consequences to WMHs associated with excessive visceral fat deposition.

CONCLUSION

Waist-to-hip ratio, diabetes, heavy smoking, hypercholesterolemia and homozygous APOE ε4 status are important risk factors, beyond hypertension, associated with WMH total burden and warrant careful control across ageing. The spatial distribution associated with different risk factors may provide important clues as to the pathogenesis and cognitive consequences of WMHs. High waist-to-hip ratio is a key risk factor associated with slowing in speed of processing. With global obesity levels rising, focused management of visceral adiposity may present a useful strategy for the mitigation of cognitive decline in ageing.

Cigarette Smoking and Incident Stroke in Blacks of the Jackson Heart Study

Background Blacks are disproportionately affected by stroke compared with whites; however, less is known about the relationship between stroke and cigarette smoking in blacks. Therefore, we evaluated the relationship between cigarette smoking and all incident stroke in the JHS (Jackson Heart Study). Methods and Results JHS participants without a history of stroke (n=4410) were classified by self-reported baseline smoking status into current, past (smoked at least 400 cigarettes/life), or never smokers at baseline (2000-2004). Current smokers were further classified by smoking intensity (number of cigarettes smoked per day [1-19 and ≥20]) and followed up for incident stroke (through 2015). Hazard ratios (HRs) for incident stroke for current and past smoking compared with never smoking were estimated with adjusted Cox proportional hazard regression models. After adjusting for cardiovascular risk factors, the risk for stroke in current smokers was significantly higher compared with never smokers (HR, 2.48; 95% CI, 1.60-3.83) but there was no significant difference between past smokers and never smokers (HR, 1.10; 95% CI, 0.74-1.64). There was a dose-dependent increased risk of stroke with smoking intensity (HR, 2.28 [95% CI, 1.38-3.86] and HR, 2.78 [95% CI, 1.47-5.28] for current smokers smoking 1-19 and ≥20 cigarettes/day, respectively). Conclusions In a large cohort of blacks, current cigarette smoking was associated with a dose-dependent higher risk of all stroke. In addition, past smokers did not have a significantly increased risk of all stroke compared with never smokers, which suggests that smoking cessation may have potential benefits in reducing the incidence of stroke in blacks.

Sociodemographic Disparities in Long-Term Mortality Among Stroke Survivors in the United States

Background and Purpose- It is unclear whether disparities in mortality among stroke survivors exist long term. Therefore, the purpose of the current study is to describe rates of longer term mortality among stroke survivors (ie, beyond 30 days) and to determine whether socioeconomic disparities exist. Methods- This analysis included 1329 black and white participants, aged ≥45 years, enrolled between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) who suffered a first stroke and survived at least 30 days after the event. Long-term mortality among stroke survivors was defined in person-years as time from 30 days after a first stroke to date of death or censoring. Mortality rate ratios (MRRs) were used to compare rates of poststroke mortality by demographic and socioeconomic characteristics. Results- Among adults who survived ≥30 days poststroke, the age-adjusted rate of mortality was 82.3 per 1000 person-years (95% CI, 75.4-89.2). Long-term mortality among stroke survivors was higher in older individuals (MRR for 75+ versus <65, 3.2; 95% CI, 2.6-4.1) and among men than women (MRR, 1.3; 95% CI, 1.1-1.6). It was also higher among those with less educational attainment (MRR for less than high-school versus college graduate, 1.5; 95% CI, 1.1-1.9), lower income (MRR for <$20k versus >50k, 1.4; 95% CI, 1.1-1.9), and lower neighborhood socioeconomic status (SES; MRR for low versus high neighborhood SES, 1.4; 95% CI, 1.1-1.7). There were no differences in age-adjusted rates of long-term poststroke mortality by race, rurality, or US region. Conclusions- Rates of long-term mortality among stroke survivors were higher among individuals with lower SES and among those residing in neighborhoods of lower SES. These results emphasize the need for improvements in long-term care poststroke, especially among individuals of lower SES.

Severity of Hypertension Mediates the Association of Hyperuricemia With Stroke in the REGARDS Case Cohort Study

Previous studies do not widely support hyperuricemia as a risk factor for stroke and other cardiovascular diseases. We assessed the relationship between hyperuricemia and ischemic stroke (≈900 cases) using a large data set from the REGARDS study (Reasons for Geographic and Racial Differences in Stroke). We employed a case-cohort design (incident stroke cases and randomly selected cohort participants) and weighted Cox-proportional hazard models to estimate the association of serum urate level ≥6.8 mg/dL (ie, hyperuricemia) and 6.0 to <6.8 mg/dL versus <6.0 mg/dL (reference) with incident stroke. Analyses were stratified by race, gender, and age. Mediation of cardiovascular disease comorbidities on the serum urate-stroke association was tested. Hyperuricemia was associated with stroke (hazard ratio, 1.40 [95% CI, 1.10-1.78]) after adjustment for demographic variables and systolic and diastolic blood pressure. This association was substantially attenuated (hazard ratio, 1.17 [95% CI, 0.90-1.51]) by additional covariate adjustment. In particular, apparent treatment-resistant hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on 3 antihypertensive medications or use of ≥4 antihypertensive medications) and the count of antihypertensive medication classes significantly reduced the effect of hyperuricemia on ischemic stroke. Specifically, apparent treatment-resistant hypertension and number of antihypertensive, respectively, mediate 45% and 43% of the association. There was no effect modification in the association between hyperuricemia and stroke by age, race, or gender. We conclude that hyperuricemia may be a risk factor for stroke. The substantial attenuation of this association by apparent treatment-resistant hypertension and number of antihypertensive suggests that severe hypertension may be a mediator.

Baseline Obesity Increases 25-Year Risk of Mortality due to Cerebrovascular Disease: Role of Race

Background: Although obesity may have a role as a risk factor for cerebrovascular mortality, less is known about how demographic and social groups differ in this regard. Aims: This study had two aims: first to investigate the predictive role of baseline obesity on long-term risk of mortality due to cerebrovascular disease, and second, to test racial variation in this effect. Methods: the Americans' Changing Lives Study (ACL) 1986-2011 is a state of the art 25-year longitudinal cohort study. ACL followed a nationally representative sample of Blacks (n = 1156) and Whites (n = 2205) for up to 25 years. Baseline obesity was the main predictor of interest, time to cerebrovascular death was the main outcome of interest. Demographic characteristics, socioeconomic status (educational attainment and household income), health behaviors (exercise and smoking), and health (hypertension and depressive symptoms) at baseline were covariates. Cox proportional hazards models were used to test additive and multiplicative effects of obesity and race on the outcome. Results: From the total 3,361 individuals, 177 people died due to cerebrovascular causes (Whites and Blacks). In the pooled sample, baseline obesity did not predict cerebrovascular mortality (hazard ratio (HR) = 0.86, 0.49-1.51), independent of demographic, socioeconomic, health behaviors, and health factors at baseline. Race also interacted with baseline obesity on outcome (HR = 3.17, 1.09-9.21), suggesting a stronger predictive role of baseline obesity on cerebrovascular deaths for Black people compared to White individuals. According to the models that were run specific to each race, obesity predicted risk of cerebrovascular mortality for Blacks (HR = 2.51, 1.43-4.39) but not Whites (HR = 0.69, 0.31-1.53). Conclusions: Baseline obesity better predicts long-term risk of cerebrovascular death in Black individuals compared to White people. More research should explore factors that explain why racial differences exist in the effects of obesity on cerebrovascular outcome. Findings also have implications for personalized medicine.

Atrial cardiopathy and stroke mortality in the general population

BACKGROUND

Prior studies examining the link between atrial cardiopathy and stroke risk have focused mainly on non-fatal stroke.

AIMS

To examine the association between atrial cardiopathy and stroke mortality.

METHODS

This analysis included 8028 participants (60.0 ± 13.4 years, 51.9% women, 49.8% white) from the Third National Health and Nutrition Examination (NHANES III) Survey. Atrial cardiopathy was defined as abnormal deep terminal negativity of the P wave in V1 (DTNPV1 = negative p-wave in V1<-100 µv), an electrocardiographic marker of atrial cardiopathy. Stroke mortality was ascertained using the National Death Index over a median follow-up of 14 years.

RESULTS

2.95% (n = 237) of the participants had atrial cardiopathy, and the prevalence was slightly higher in blacks (4%) versus whites (3%). During follow-up, stroke mortality was more common in those with (5.9%) than those without (2.7%) atrial cardiopathy; p = .004. In a multivariable adjusted model, atrial cardiopathy was associated with a 76% increased risk of stroke mortality (HR (95% CI): 1.76 (1.02-3.04)]. This association was stronger in non-whites than whites (HR (95% CI): 3.50 (1.74-7.03) vs. 0.98 (0.40-2.42), respectively; interaction p = 0.03). Among those with baseline atrial cardiopathy, the annualized stroke mortality rates/1000 participants across CHA₂DS₂-VASc scores of 0, 1, and ≥2 were 0.0, 2.2, and 7.8, respectively.

CONCLUSIONS

Atrial cardiopathy is associated with an increased risk of stroke mortality, especially among non-whites. Among those with atrial cardiopathy, the risk of stroke mortality exponentially increases as the CHA₂DS₂-VASc score becomes 2 or above. Randomized controlled trials are needed to assess the efficacy of anticoagulation in the prevention of ischemic stroke and thus, stroke mortality in the presence of atrial cardiopathy.

Barriers and Facilitators of Stroke Recovery: Perspectives From African Americans With Stroke, Caregivers and Healthcare Professionals

INTRODUCTION AND GOAL

Stroke is a serious health condition that disproportionally affects African-Americans relative to non-Hispanic whites. In the absence of clearly defined reasons for racial disparities in stroke recovery and subsequent stroke outcomes, a critical first step in mitigating poor stroke outcomes is to explore potential barriers and facilitators of poststroke recovery in African-American adults with stroke. The purpose of this study was to qualitatively explore poststroke recovery across the care continuum from the perspective of African-American adults with stroke, caregivers of African-American adults with stroke, and health care professionals with expertise in stroke care.

MATERIALS AND METHODS

This qualitative descriptive study included in-depth key informant interviews with health care providers (n = 10) and focus groups with persons with stroke (n = 20 persons) and their family members or caregivers (n = 19 persons). Data were analyzed using thematic analysis according to the Social Ecological Model, using both inductive and deductive approaches.

FINDINGS

Persons with stroke and their caregivers identified social support, resources, and knowledge as the most salient factors associated with stroke recovery. Perceived barriers to recovery included: (1) physical and cognitive deficits, mood; (2) medication issues; (3) lack of support and resources; (4) stigma, culture, and faith. Health care providers identified knowledge/information, care coordination, and resources in the community as key to facilitating stroke recovery outcomes.

CONCLUSIONS

Key findings from this study can be incorporated into interventions designed to improve poststroke recovery outcomes and potentially reduce the current racial-ethnic disparity gap.

An Investigation of Selection Bias in Estimating Racial Disparity in Stroke Risk Factors

Selection due to survival or attrition might bias estimates of racial disparities in health, but few studies quantify the likely magnitude of such bias. In a large national cohort with moderate loss to follow-up, we contrasted racial differences in 2 stroke risk factors, incident hypertension and incident left ventricular hypertrophy, estimated by complete-case analyses, inverse probability of attrition weighting, and the survivor average causal effect. We used data on 12,497 black and 17,660 white participants enrolled in the United States (2003-2007) and collected incident risk factor data approximately 10 years after baseline. At follow-up, 21.0% of white participants and 23.0% of black participants had died; additionally 22.0% of white participants and 28.4% of black participants had withdrawn. Individual probabilities of completing the follow-up visit were estimated using baseline demographic and health characteristics. Adjusted risk ratio estimates of racial disparities from complete-case analyses in both incident hypertension (1.11, 95% confidence interval: 1.02, 1.21) and incident left ventricular hypertrophy (1.02, 95% confidence interval: 0.84, 1.24) were virtually identical to estimates from inverse probability of attrition weighting and survivor average causal effect. Despite racial differences in mortality and attrition, we found little evidence of selection bias in the estimation of racial differences for these incident risk factors.

Consumption of dairy product and its association with total and cause specific mortality - A population-based cohort study and meta-analysis

BACKGROUND

The intake of dairy products has been thought to be associated with an increased risk of coronary heart diseases (CHD) and total mortality due to its relatively high content of saturated fat. However, reports on this association particularly among US adults are conflicting and controversial. Therefore, we used data from the 1999-2010 National Health and Nutrition Examination Surveys (NHANES) study to examine whether consumption of total dairy and dairy subgroups was associated with total and cause specific (CHD, cerebrovascular and cancer) mortality. Further we carried out a systematic review and meta-analysis of prospective studies to check for consistency with the NHANES findings.

METHODS

In the NHANES cohort vital status through December 31, 2011 was ascertained. Cox proportional hazard regression models were used to relate baseline dairy intake with all-cause and cause-specific mortality. For the systematic review PubMed, SCOPUS, Web of Science and Google Scholar databases were searched (up to December 2017). The DerSimonian-Laird method and generic inverse variance methods were used for quantitative data synthesis.

RESULTS

In the NHANES data set of 24,474 participants, 3520 deaths occurred during follow-up. In multivariate adjusted Cox models, total mortality risk was lower when comparing the top (Q4) with the lower (Q1) quartiles of total dairy (hazard ratio [HR] 0.98, 95% confidence interval [CI]: 0.95-0.99) and cheese (HR: 0.92, 95% CI: 0.87-0.97) consumption. Using a similar model, we have found a negative association between total dairy and milk consumption with risk of cerebrovascular mortality (HR: 0.96, 95% CI: 0.94-0.98, HR: 0.93, 95% CI: 0.91-0.96, respectively), while milk consumption was associated with increased CHD mortality (HR: 1.04, 95% CI: 1.02-1.06). The meta-analysis with 636,726 participants indicated a significant inverse association between fermented dairy products and total mortality (RR: 0.97, 95% CI: 0.96-0.99), while milk consumption was associated with higher CHD mortality (RR: 1.04, 95% CI: 1.01-1.05). These findings were robust in sensitivity analyses.

CONCLUSIONS

Among American adults, higher total dairy consumption was associated with lower total and cerebrovascular mortality, while higher milk consumption was associated with higher risk of CHD. These findings do not support dogmatic public health advice to reduce total dairy fat consumption, although the association between milk consumption and CHD mortality requires further study.

Characterizing Beliefs about Stroke and Walking for Exercise among Seniors from Four Racial/Ethnic Minority Communities

We described and compared seniors' stroke-related health beliefs among four racial/ethnic communities to inform a culturally-tailored stroke prevention walking intervention. Specific attention was paid to how seniors combined pathophysiology-based biomedical beliefs with non-biomedical beliefs. We conducted twelve language-concordant, structured focus groups with African American, Chinese American, Korean American, and Latino seniors aged 60 years and older with a history of hypertension (n = 132) to assess stroke-related health beliefs. Participants were asked their beliefs about stroke mechanism and prevention strategies in addition to questions corresponding to four constructs from the Health Belief Model: perceived susceptibility, perceived severity, and benefits and barriers to walking for exercise. Using thematic analysis, we iteratively reviewed and coded focus group transcripts to identify recurrent themes within and between racial/ethnic groups. Participants across all four racial/ethnic groups believed that blockages in brain arteries caused strokes. Factors believed to increase susceptibility to stroke were often similar to biomedical risk factors across racial/ethnic groups, but participants also endorsed non-biomedical factors such as strong emotions. The majority of participants perceived stroke as a serious condition requiring urgent medical attention, fearing paralysis or death, but few mentioned severe disability as a stroke consequence. Participants largely believed stroke to be preventable through physical activity, dietary changes, and medication adherence. Perceived benefits of walking for exercise included improved physical health, decreased bodily pain, and ease of participation. Perceived barriers to walking included limited mobility due to chronic medical conditions, increased bodily pain, and low motivation. While seniors' stroke-related health beliefs were often similar to biomedical beliefs across racial/ethnic groups, we also identified several non-biomedical beliefs that were shared across groups. These non-biomedical beliefs regarding perceived stroke susceptibility and severity may warrant further discussion in stroke education interventions. Patterns in non-biomedical beliefs that vary between groups may reflect cultural differences. Stroke education could potentially increase cultural relevancy and impact by addressing such differences in health beliefs as well as perceived benefits and barriers to walking for exercise that vary between different racial/ethnic groups.

Breastfeeding History and Risk of Stroke Among Parous Postmenopausal Women in the Women's Health Initiative

Background Stroke is the third leading cause of death among US Hispanic and non-Hispanic black women aged 65 and older. One factor that may protect against stroke is breastfeeding. Few studies have assessed the association between breastfeeding and stroke and whether this association differs by race and ethnicity. Methods and Results Data were taken from the Women's Health Initiative Observational Study with follow-up through 2010; adjusted hazard ratios for stroke subsequent to childbirth were estimated with Cox regression models accounting for left and right censoring, overall and stratified by race/ethnicity. Of the 80 191 parous women in the Women's Health Initiative Observational Study, 2699 (3.4%) had experienced a stroke within a follow-up period of 12.6 years. The average age was 63.7 years at baseline. Fifty-eight percent (n=46 699) reported ever breastfeeding; 83% were non-Hispanic white, 8% were non-Hispanic black, 4% were Hispanic, and 5% were of other race/ethnicity. After adjustment for nonmodifiable potential confounders, compared with women who had never breastfed, women who reported ever breastfeeding had a 23% lower risk of stroke (adjusted hazard ratio=0.77; 95% confidence interval 0.70-0.83). This association was strongest for non-Hispanic black women (adjusted hazard ratio=0.52; 95% confidence interval 0.37-0.71). Further, breastfeeding for a relatively short duration (1-6 months) was associated with a 19% lower risk of stroke (adjusted hazard ratios=0.81; 95% confidence interval 0.74-0.89). This association appeared stronger with longer breastfeeding duration and among non-Hispanic white and non-Hispanic black women (test for trend P<0.01). Conclusions Study results show an association and dose-response relationship between breastfeeding and lower risk of stroke among postmenopausal women after adjustment for multiple stroke risk factors and lifestyle variables. Further investigation is warranted.

Ethnoracial differences in brain structure change and cognitive change

OBJECTIVE

The purpose of this study was to examine longitudinal associations between structural MRI and cognition in a diverse sample.

METHOD

Older adults (n = 444; Mage = 74.5)-121 African Americans, 212 Whites, and 111 Hispanics-underwent an average of 5.3 annual study visits. Approximately half were cognitively normal at baseline (global Clinical Dementia Rating M = 0.5). Of the patients with dementia, most (79%) were diagnosed with Alzheimer's disease (AD). MRI measures of gray matter volume (baseline and change), and hippocampal and white matter hyperintensity (WMH) volumes (baseline), were used to predict change in global cognition. Multilevel latent variable modeling was used to test the hypothesis that brain effects on cognitive change differed across ethnoracial groups.

RESULTS

In a multivariable model, global gray matter change was the strongest predictor of cognitive decline in Whites and African Americans and specific temporal lobe change added incremental explanatory power in Whites. Baseline WMH volume was the strongest predictor of cognitive decline in Hispanics and made an incremental contribution in Whites.

CONCLUSIONS

We found ethnoracial group differences in associations of brain variables with cognitive decline. The unique patterns in Whites appeared to suggest a greater influence of AD in this group. In contrast, cognitive decline in African Americans and Hispanics was most uniquely attributable to global gray matter change and baseline WMH, respectively. Brain changes underlying cognitive decline in older adults are heterogeneous and depend on fixed and modifiable risk factors that differ based on ethnicity and race. (PsycINFO Database Record

Racial Differences in the Association Between Nonexercise Estimated Cardiorespiratory Fitness and Incident Stroke

OBJECTIVE

To examine the association between estimated cardiorespiratory fitness (eCRF) and incident stroke by black and white race.

PARTICIPANTS AND METHODS

A total of 24,162 participants from the REasons for Geographic And Racial Differences in Stroke study (13,232 [54.8%] women; 9543 [39.5%] blacks; mean age, 64.6±9.3 years) without stroke at enrollment between January 15, 2003, and October 30, 2007, were followed for incident stroke through March 31, 2016. Baseline eCRF in maximal metabolic equivalents was determined using nonexercise sex-specific algorithms and further grouped into age- and sex-specific tertiles.

RESULTS

Over a mean of 8.3±3.2 years of follow-up, 945 (3.9%) incident strokes occurred (377 in blacks and 568 in whites). The association between eCRF and stroke risk differed significantly by race (PInteraction<.001). In whites, after adjustment for stroke risk factors and physical functioning score, the hazard ratio of stroke was 0.82 (95% CI, 0.67-1.00) times lower in the middle tertile of eCRF than in the lowest tertile and was 0.54 (95% CI, 0.43-0.69) times lower in the highest tertile of eCRF. The protective effect of higher levels of eCRF on stroke incidence was more pronounced in those 60 years or older among whites. No association between eCRF and stroke risk was observed in blacks.

CONCLUSION

Estimated cardiorespiratory fitness measured using nonexercise equations is a useful predictor of stroke in whites. The lack of an overall association between eCRF and stroke risk in blacks suggests that the assessment of eCRF in blacks may not be helpful in primary stroke prevention.