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Burton TM, Madsen TE, Karb R, Furie KL. Importance of sex and gender differences in enrollment and interpretation of stroke clinical trials. J Stroke Cerebrovasc Dis 2024; 33:107735. [PMID: 38679215 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 04/11/2024] [Accepted: 04/25/2024] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVES This review aims to reinforce the importance of improving sex balance in preclinical trials and sex and gender diversity and proportional balance in clinical trials enrollment and how this influences interpretation of stroke clinical trials. It also aims to identify strategies for improvement in data collection. MATERIALS AND METHODS A PubMed search was conducted of publications in English, using MeSH terms sex, sex characteristics, gender identity, transgender, gender-nonconforming persons, clinical trials as topic, stroke. Of 249 search results, 217 were human or animal studies related to stroke, the majority of which were reviews, secondary analyses of stroke clinical trials, meta analyses, or retrospective studies, subject to the methods of sex and gender acquisition per the primary data source. Articles were reviewed, noting inclusion or absence of sex and gender definitions and trial design. Selected articles were supplemented with United States Food and Drug Administration, National Institutes of Health, and National Academy of Science, Engineering, and Medicine publications. RESULTS The majority of preclinical studies continue to report sex as a binary variable, and the majority of stroke clinical trials report sex and gender as interchangeable and binary. Mindful trial design and statistical analysis can improve accuracy in the interpretation of sex and gender differences. Guidance exists to improve reporting on currently accepted sex and gender definitions, recommended data collection instruments, and appropriate statistical analyses. CONCLUSIONS Despite acknowledgement of having failed to achieve diverse and proportionally balanced enrollment, sex and gender imbalance across the research continuum remains prevalent. Responsible incorporation of sex and gender in stroke clinical trials can be achieved through thoughtful study design, use of contemporary sex and gender definitions, inclusive prospective data collection, balanced enrollment with prespecified goals, and appropriate statistical analysis.
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Affiliation(s)
- Tina M Burton
- The Warren Alpert Medical School of Brown University, Department of Neurology, USA.
| | - Tracy E Madsen
- The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, USA; Brown University School of Public Health, USA
| | - Rebecca Karb
- The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, USA
| | - Karen L Furie
- The Warren Alpert Medical School of Brown University, Department of Neurology, USA
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Dawood MH, Mahmood K, Roshan M, Sherani LR, Perveen H. Evaluation of stroke in pregnant and non-pregnant women of reproductive years: A multicenter ambispective cohort study in a low- to middle-income country. SAGE Open Med 2024; 12:20503121241242610. [PMID: 38601136 PMCID: PMC11005509 DOI: 10.1177/20503121241242610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 03/11/2024] [Indexed: 04/12/2024] Open
Abstract
Objective Early recognition of stroke symptoms and risk factors is important for timely intervention to improve outcomes. This study aimed to investigate differences in stroke frequency, risk factors, and presentation in pregnant and non-pregnant women of reproductive years. Methods This multicenter ambispective cohort study, conducted from 4th August 2021 to 4th March 2023, examined strokes in women of reproductive years at the neurology outpatient/emergency department of five busiest/referred neuro-medical facilities in Karachi, Pakistan, where patients from across the nation are assessed. In all, 1210 patients were enrolled via consecutive or convenient sampling retrospectively from January 2017 to August 2021 and prospectively from August 2021 to March 2023. Pregnancy-related and non-pregnancy-related stroke occurrence and characteristics were compared using the chi-square/Fischer's exact test. Results 56% were non-pregnancy-related strokes and 44% were pregnancy-related strokes with non-pregnancy-related strokes approximately equal throughout the reproductive years (15-24 years = 34%, 25-34 years = 25%, 35-45 years = 41%) and pregnancy-related stroke between 15 and 35 years (82%). In the non-pregnancy-related stroke, arterial stroke dominated (96.4%); while in pregnancy-related stroke, arterial stroke accounted for 61.4% and venous stroke for 38.6% of cases. Middle cerebral artery was a typical stroke site (66%). Infarction was the most significant CT/MRI finding (PRS = 89%, NPRS = 66%), with pregnancy-related stroke hemorrhagic stroke occurring in only 11% of cases and non-pregnancy-related stroke comprising one-third (34%). The most prevalent etiologies were eclampsia in pregnancy-related stroke (32%), hypertension in non-pregnancy-related stroke (40%), and cardiac problems among both groups (25%:33%). Weakness and headache were the common clinical manifestations among both groups. In the pregnancy-related and non-pregnancy-related stroke groups, the initial presentation of stroke resulted in severe disability for 91% and 75%, respectively. With timely treatment, the outcome improved significantly. The mortality rate was 7% for the pregnancy-related stroke group and 4% for the non-pregnancy-related stroke group. Conclusions Our findings show that stroke is prevalent among reproductive-year women, posing a significant mortality risk if not adequately recognized and treated. Awareness, research, and screening of stroke risk factors and their often-overlooked early presentation (i.e., headache and weakness) in reproductive years are essential to reducing stroke occurrence among reproductive-year women.
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Affiliation(s)
- Muhammad Hamza Dawood
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Kauser Mahmood
- Department of Neurology, Fazaia Ruth Fau Medical College PAF base Faisal (Air University, Islamabad), Karachi, Pakistan
| | - Mavra Roshan
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Lailamah Rehman Sherani
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
| | - Haseefa Perveen
- United Medical and Dental College, Affiliated with Jinnah Sindh Medical University, Karachi, Pakistan
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Leppert MH, Poisson SN, Scarbro S, Suresh K, Lisabeth LD, Putaala J, Schwamm LH, Daugherty SL, Bradley CJ, Burke JF, Ho PM. Association of Traditional and Nontraditional Risk Factors in the Development of Strokes Among Young Adults by Sex and Age Group: A Retrospective Case-Control Study. Circ Cardiovasc Qual Outcomes 2024; 17:e010307. [PMID: 38529631 PMCID: PMC11021148 DOI: 10.1161/circoutcomes.123.010307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 01/11/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Despite women having fewer traditional risk factors (eg, hypertension, diabetes), strokes are more common in women than men aged ≤45 years. This study examined the contributions of traditional and nontraditional risk factors (eg, migraine, thrombophilia) in the development of strokes among young adults. METHODS This retrospective case-control study used Colorado's All Payer Claims Database (2012-2019). We identified index stroke events in young adults (aged 18-55 years), matched 1:3 to stroke-free controls, by (1) sex, (2) age±2 years, (3) insurance type, and (4) prestroke period. All traditional and nontraditional risk factors were identified from enrollment until a stroke or proxy-stroke date (defined as the prestroke period). Conditional logistic regression models stratified by sex and age group first assessed the association of stroke with counts of risk factors by type and then computed their individual and aggregated population attributable risks. RESULTS We included 2618 cases (52% women; 73.3% ischemic strokes) and 7827 controls. Each additional traditional and nontraditional risk factors were associated with an increased risk of stroke in all sex and age groups. In adults aged 18 to 34 years, more strokes were associated with nontraditional (population attributable risk: 31.4% men and 42.7% women) than traditional risk factors (25.3% men and 33.3% women). The contribution of nontraditional risk factors declined with age (19.4% men and 27.9% women aged 45-55 years). The contribution of traditional risk factors peaked among patients aged 35 to 44 years (32.8% men and 39.7% women). Hypertension was the most important traditional risk factor and increased in contribution with age (population attributable risk: 27.8% men and 26.7% women aged 45 to 55 years). Migraine was the most important nontraditional risk factor and decreased in contribution with age (population attributable risk: 20.1% men and 34.5% women aged 18-35 years). CONCLUSIONS Nontraditional risk factors were as important as traditional risk factors in the development of strokes for both young men and women and have a stronger association with the development of strokes in adults younger than 35 years of age.
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Affiliation(s)
- Michelle H. Leppert
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
- Colorado Cardiovascular Outcomes Research (CCOR) Group, Denver, Colorado
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, School of Medicine, Aurora, CO
| | - Sharon N. Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO
| | - Sharon Scarbro
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, School of Medicine, Aurora, CO
- Rocky Mountain Prevention Research Center, Colorado School of Public Health, Aurora, CO
| | - Krithika Suresh
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Lynda D. Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Stacie L. Daugherty
- Colorado Cardiovascular Outcomes Research (CCOR) Group, Denver, Colorado
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cathy J. Bradley
- Colorado Comprehensive Cancer Center, University of Colorado, Aurora, CO
| | - James F. Burke
- Department of Neurology, The Ohio State University, Columbus, OH
| | - P. Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO
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Pradhyumnan H, Patel SH, Furones-Alonso O, Zhao W, Bramlett HM, Raval AP. Electronic Cigarette Vape Exposure Exacerbates Post-Ischemic Outcomes in Female but Not in Male Rats. Stroke 2024; 55:735-746. [PMID: 38323450 PMCID: PMC10940219 DOI: 10.1161/strokeaha.123.046101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/11/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Nicotine-containing electronic cigarette (EC) vaping has become popular worldwide, and our understanding of the effects of vaping on stroke outcomes is elusive. Using a rat model of transient middle cerebral artery occlusion, the current exploratory study aims to evaluate the sex-dependent effects of EC exposure on brain energy metabolism and stroke outcomes. METHODS Adult Sprague-Dawley rats of both sexes were randomly assigned to air/EC vapor (5% nicotine Juul pods) exposure for 16 nights, followed by randomization into 3 cohorts. The first cohort underwent exposure to air/EC preceding randomization to transient middle cerebral artery occlusion (90 minutes) or sham surgery, followed by survival for 21 days. During the survival period, rats underwent sensorimotor and Morris water maze testing. Subsequently, brains were collected for histopathology. A second cohort was exposed to air/EC after which brains were collected for unbiased metabolomics analysis. The third cohort of animals was exposed to air/EC and received transient middle cerebral artery occlusion/sham surgery, and brain tissue was collected 24 hours later for biochemical analysis. RESULTS In females, EC significantly increased (P<0.05) infarct volumes by 94% as compared with air-exposed rats, 165±50 mm3 in EC-exposed rats, and 85±29 mm3 in air-exposed rats, respectively, while in males such a difference was not apparent. Morris water maze data showed significant deficits in spatial learning and working memory in the EC sham or transient middle cerebral artery occlusion groups compared with the respective air groups in rats of both sexes (P<0.05). Thirty-two metabolites of carbohydrate, glycolysis, tricarboxylic acid cycle, and lipid metabolism were significantly altered (P≤0.05) due to EC, 23 of which were specific for females. Steady-state protein levels of hexokinase significantly decreased (P<0.05) in EC-exposed females; however, these changes were not seen in males. CONCLUSIONS Even brief EC exposure over 2 weeks impacts brain energy metabolism, exacerbates infarction, and worsens poststroke cognitive deficits in working memory more in female than male rats.
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Affiliation(s)
- Hari Pradhyumnan
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Shahil H. Patel
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Ofelia Furones-Alonso
- Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Weizhao Zhao
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL 33146, USA
| | - Helen M. Bramlett
- Department of Neurological Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Neuroscience Program, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL 33136, USA
| | - Ami P. Raval
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Neuroscience Program, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL 33136, USA
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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Pregnancy, delivery and neonatal outcomes in women with a cerebrovascular-accident history prior to delivery - Evaluation of a population database. Heliyon 2024; 10:e25631. [PMID: 38375247 PMCID: PMC10875378 DOI: 10.1016/j.heliyon.2024.e25631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Objective Cerebrovascular accidents (CVA) in childbearing-age women are rare. We aimed to evaluate the association between CVA events prior to delivery and obstetrical and neonatal outcomes. Methods A retrospective cohort study was conducted using data from the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS) database. All pregnant women who delivered or had a maternal death in the US from 2004 to 2014 were included in the study. We performed a comparison between women with an ICD-9 diagnosis of CVA before the delivery admission and those without. Obstetrical and neonatal outcomes were compared between the two groups. Results In total, 9,096,788 women fulfilled the inclusion criteria. Among them, 695 women (7.6 per 100,000) were diagnosed with a CVA before delivery. Women with a history of CVA, compared to those without, were more likely to be Black, older than 35 years of age, and suffer from obesity, chronic hypertension, pregestational diabetes, and thyroid disease. Patients with a prior CVA, compared to those without, had higher rates of pregnancy-induced hypertension (aOR 6.41, 95% CI 5.03-8.39, p < 0.001), preeclampsia (aOR 7.65, 95% CI 6.03-9.71, p < 0.001), and eclampsia (aOR 171.56, 95% CI 124.63-236.15, p < 0.001). Additionally, they had higher rates of preterm delivery (aOR 1.72, 95% CI 1.33-2.22,p = 0.003), cesarean section (aOR 2.69, 95% CI 2.15-3.37, p < 0.001), and maternal complications such as a peripartum hysterectomy (aOR 11.62, 95% CI 5.77-23.41, p < 0.001), postpartum hemorrhage (aOR 3.39, 95 % CI 2.52-4.54, p < 0.001), disseminated intravascular coagulation (aOR 16.32, 95% CI 11.33-23.52, p < 0.001), venous thromboembolism (aOR 45.08, 95% CI 27.17-74.8, p < 0.001), and maternal death (aOR 486.11, 95% CI 307.26-769.07, p < 0.001). Regarding neonatal outcomes, patients with a prior CVA, compared to those without, had a higher rate of intrauterine fetal demise and congenital anomalies. Conclusion Women with a CVA event before delivery have a significantly higher incidence of maternal complications, including hypertensive disorders of pregnancy, and neonatal complications, such as intrauterine fetal demise and congenital anomalies. Rates of maternal death were dramatically increased, and this association requires further evaluation.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Michael H. Dahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
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Feng Y, Huang Z, Ma X, Zong X, Wu CY, Lee RH, Lin HW, Hamblin MR, Zhang Q. Activation of testosterone-androgen receptor mediates cerebrovascular protection by photobiomodulation treatment in photothrombosis-induced stroke rats. CNS Neurosci Ther 2024; 30:e14574. [PMID: 38421088 PMCID: PMC10851319 DOI: 10.1111/cns.14574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/22/2023] [Accepted: 12/06/2023] [Indexed: 03/02/2024] Open
Abstract
RATIONALE Numerous epidemiological studies have reported a link between low testosterone levels and an increased risk of cerebrovascular disease in men. However, there is ongoing controversy surrounding testosterone replacement therapy due to potential side effects. PBMT has been demonstrated to improve cerebrovascular function and promote testosterone synthesis in peripheral tissues. Despite this, the molecular mechanisms that could connect PBMT with testosterone and vascular function in the brain of photothrombosis (PT)-induced stroke rats remain largely unknown. METHODS We measured behavioral performance, cerebral blood flow (CBF), vascular permeability, and the expression of vascular-associated and apoptotic proteins in PT-induced stroke rats treated with flutamide and seven consecutive days of PBM treatment (350 mW, 808 nM, 2 min/day). To gain further insights into the mechanism of PBM on testosterone synthesis, we used testosterone synthesis inhibitors to study their effects on bEND.3 cells. RESULTS We showed that PT stroke caused a decrease in cerebrovascular testosterone concentration, which was significantly increased by 7-day PBMT (808 nm, 350 mW/cm2 , 42 J/cm2 ). Furthermore, PBMT significantly increased cerebral blood flow (CBF) and the expression of vascular-associated proteins, while inhibiting vascular permeability and reducing endothelial cell apoptosis. This ultimately mitigated behavioral deficits in PT stroke rats. Notably, treatment with the androgen receptor antagonist flutamide reversed the beneficial effects of PBMT. Cellular experiments confirmed that PBMT inhibited cell apoptosis and increased vascular-associated protein expression in brain endothelial cell line (bEnd.3) subjected to oxygen-glucose deprivation (OGD). However, these effects were inhibited by flutamide. Moreover, mechanistic studies revealed that PBMT-induced testosterone synthesis in bEnd.3 cells was partly mediated by 17β-hydroxysteroid dehydrogenase 5 (17β-HSD5). CONCLUSIONS Our study provides evidence that PBMT attenuates cerebrovascular injury and behavioral deficits associated with testosterone/AR following ischemic stroke. Our findings suggest that PBMT may be a promising alternative approach for managing cerebrovascular diseases.
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Affiliation(s)
- Yu Feng
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Zhihai Huang
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Xiaohui Ma
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Xuemei Zong
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Celeste Yin‐Chieh Wu
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Reggie Hui‐Chao Lee
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Hung Wen Lin
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
| | - Michael R. Hamblin
- Wellman Center for PhotomedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Quanguang Zhang
- Department of NeurologyLouisiana State University Health Sciences CenterShreveportLouisianaUSA
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Eissa MA, Gohar EY. Aromatase enzyme: Paving the way for exploring aromatization for cardio-renal protection. Biomed Pharmacother 2023; 168:115832. [PMID: 37931519 PMCID: PMC10843764 DOI: 10.1016/j.biopha.2023.115832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/15/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
Documented male-female differences in the risk of cardiovascular and chronic kidney diseases have been largely attributed to estrogens. The cardiovascular and renal protective effects of estrogens are mediated via the activation of estrogen receptors (ERα and ERβ) and G protein-coupled estrogen receptor, and involve interactions with the renin-angiotensin-aldosterone system. Aromatase, also called estrogen synthase, is a cytochrome P-450 enzyme that plays a pivotal role in the conversion of androgens into estrogens. Estrogens are biosynthesized in gonadal and extra-gonadal sites by the action of aromatase. Evidence suggests that aromatase inhibitors, which are used to treat high estrogen-related pathologies, are associated with the development of cardiovascular events. We review the potential role of aromatization in providing cardio-renal protection and highlight several meta-analysis studies on cardiovascular events associated with aromatase inhibitors. Overall, we present the potential of aromatase enzyme as a fundamental contributor to cardio-renal protection.
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Affiliation(s)
- Manar A Eissa
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Merit University, New Sohag, Sohag, Egypt
| | - Eman Y Gohar
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.
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Poisson SN, Leppert MH, Orjuela KD. Cryptogenic Stroke and PFO Closure: Does Sex Matter? J Am Heart Assoc 2023; 12:e031857. [PMID: 37776208 PMCID: PMC10727266 DOI: 10.1161/jaha.123.031857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
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Christopher KM, Gao X, Abdelsalam A, Miremadi B, Scott J, Ilorah C, Xaverius P, Linares G. Stroke-related risk factors during pregnancy in women who underwent metabolic and bariatric surgery compared with women who have not undergone metabolic and bariatric surgery. Surg Obes Relat Dis 2023; 19:1142-1147. [PMID: 37150625 DOI: 10.1016/j.soard.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 02/20/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Stroke during pregnancy is rare, occurring in 30 of 100,000 pregnancies and accounting for 7% of maternal deaths in the United States from 2016 to 2018. Metabolic and bariatric surgery (MBS) has been shown to reduce symptoms of chronic conditions that are risk factors for stroke, including hypertension, hypercholesterolemia, and diabetes in women. However, little is known about the impact of MBS on stroke risk during pregnancy. OBJECTIVES To examine stroke and stroke risk factors including preeclampsia, eclampsia, gestational hypertension, and embolism/thrombosis in women of reproductive age who have had MBS. SETTING We used the National Inpatient Sample, a publicly available data set from the Healthcare Cost and Utilization Project that samples 20% of hospital discharges in the United States. METHODS This cross-sectional study included women between the ages of 20 and 44 years who had a maternal admission code. Weighted logistic regression was conducted to assess the odds of stroke and stroke risk factors in women with a history of MBS compared with other women of reproductive age. RESULTS Women with a history of MBS have 12% lower adjusted odds of developing preeclampsia/eclampsia and 10% lower adjusted odds of gestational hypertension than women who did not undergo MBS. When stratified by race, the difference was significant in White women (preeclampsia/eclampsia: adjusted odds ratio [aOR] = .89; 95% confidence interval [CI], .81-.98; gestational hypertension: aOR = .91; 95% CI, .83-1.00). Latinas with MBS had significantly lower odds of preeclampsia/eclampsia (aOR = .75; 95% CI, .64-.90). CONCLUSIONS MBS helps women lose weight and decrease the incidence of some pregnancy-related risk factors for stroke. However, there is a notable racial health disparity.
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Affiliation(s)
- Kara M Christopher
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri.
| | - Xiaoyi Gao
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ahmed Abdelsalam
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Brian Miremadi
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Jordan Scott
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Chike Ilorah
- Brookwood Baptist Health Specialty Services, Neurology, Birmingham, Alabama
| | - Pamela Xaverius
- University of Health Sciences and Pharmacy, St. Louis, Missouri
| | - Guillermo Linares
- Souers Stroke Institute, Department of Neurology, Saint Louis University School of Medicine, St. Louis, Missouri
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Jong GP, Lin TK, Liao PL, Huang JY, Yang TY, Pan LF. Risk of New-onset Stroke in Patients with Type 2 Diabetes with Chronic Kidney Disease on Sodium-glucose Co-transporter-2 Inhibitor Users. Transl Stroke Res 2023:10.1007/s12975-023-01174-0. [PMID: 37442919 DOI: 10.1007/s12975-023-01174-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 07/15/2023]
Abstract
Clinical studies have investigated the effects of using sodium-glucose co-transporter-2 (SGLT2) inhibitors on the development of new-onset stroke (NOS) in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD), but the findings are inconsistent. This study aimed to examine the association between the use of SGLT2 inhibitors and NOS risk in patients with T2D and CKD. We conducted a nationwide retrospective cohort study using data from the Taiwan Health Insurance Review and Assessment Service database for the years 2004 to 2019. The primary outcome was the risk of incident stroke, which was estimated using hazard ratios (HRs) and 95% confidence intervals (CIs). We used multiple Cox regression modeling to analyze the association between SGLT2 inhibitor use and the risk of stroke in patients with T2D and CKD. In a cohort of 113,710 patients with T2D and CKD who were using SGLT2 inhibitors and 227,420 patients with T2D and CKD who were not using SGLT2 inhibitors, after applying a 1:2 sex- and age-matching strategy, 2,842 and 7,169 NOS events were recorded, respectively. The event rate per 10,000 person-months was 10.60 (95% CI 10.21 to 11.03) for SGLT2 inhibitor users and 13.71 (13.39-14.03) for non-SGLT2 inhibitor users. After adjusting for the index year, sex, age, comorbidities, and concurrent medication, there was a decreased risk of NOS for SGLT2 inhibitor users (adjusted HR 0.80; 95% CI 0.77-0.84) compared with non-SGLT2 inhibitor users. The sensitivity test for the propensity score 1:1-matched analyses showed similar results (adjusted HR 0.80; 95% CI 0.76-0.84). The type of SGLT2 inhibitor subgroup analysis for incident stroke showed consistent results. We concluded that the use of SGLT2 inhibitors in patients with T2D and CKD was associated with significantly low rates of NOS. The significantly low rates of NOS in patients with T2D and CKD were greater among females and less than 50 years patients.
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Affiliation(s)
- Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Tsung-Kun Lin
- Department of Pharmacy, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan, ROC
- School of Pharmacy, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Pei-Lun Liao
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Jing-Yang Huang
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
| | - Tsung-Yuan Yang
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, ROC
- Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Lung-Fa Pan
- Department of Cardiology, Taichung Armed Forces General Hospital, Taichung, Taiwan, ROC.
- Department of Medical Imaging and Radiological Science, Central Taiwan University of Science and Technology, Takun, Taichung, Taiwan, ROC.
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11
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Miller EC, Kauko A, Tom SE, Laivuori H, Niiranen T, Bello NA. Risk of Midlife Stroke After Adverse Pregnancy Outcomes: The FinnGen Study. Stroke 2023; 54:1798-1805. [PMID: 37212139 PMCID: PMC10330298 DOI: 10.1161/strokeaha.123.043052] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 04/25/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Adverse pregnancy outcomes (APO) contribute to higher risk of maternal cerebrovascular disease, but longitudinal data that include APO and stroke timing are lacking. We hypothesized that APO are associated with younger age at first stroke, with a stronger relationship in those with >1 pregnancy with APO. METHODS We analyzed longitudinal Finnish nationwide health registry data from the FinnGen Study. We included women who gave birth after 1969 when the hospital discharge registry was established. We defined APO as a pregnancy affected by gestational hypertension, preeclampsia, eclampsia, preterm birth, small for gestational age infant, or placental abruption. We defined stroke as first hospital admission for ischemic stroke or nontraumatic intracerebral or subarachnoid hemorrhage, excluding stroke during pregnancy or within 1 year postpartum. We used Kaplan-Meier survival curves and multivariable-adjusted Cox and generalized linear models to assess the relationship between APO and future stroke. RESULTS We included 144 306 women with a total of 316 789 births in the analysis sample, of whom 17.9% had at least 1 pregnancy with an APO and 2.9% experienced an APO in ≥2 pregnancies. Women with APO had more comorbidities including obesity, hypertension, heart disease, and migraine. Median age at first stroke was 58.3 years in those with no APO, 54.8 years in those with 1 APO, and 51.6 years in those with recurrent APO. In models adjusted for sociodemographic characteristics and stroke risk factors, risk of stroke was greater in women with 1 APO (adjusted hazard ratio, 1.3 [95% CI, 1.2-1.4]) and recurrent APO (adjusted hazard ratio, 1.4 [95% CI, 1.2-1.7]) compared with those with no APO. Women with recurrent APO had more than twice the stroke risk before age 45 (adjusted odds ratio, 2.1 [95% CI, 1.5-3.1]) compared with those without APO. CONCLUSIONS Women who experience APO have earlier onset of cerebrovascular disease, with the earliest onset in those with more than 1 affected pregnancy.
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Affiliation(s)
- Eliza C Miller
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
| | - Anni Kauko
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
| | - Sarah E Tom
- Department of Neurology, Columbia University, New York (E.C.M., S.E.T.)
- Department of Epidemiology, Columbia University, New York (S.E.T.)
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Finland (H.L.)
- Center for Child, Adolescent, and Maternal Health Research, Tampere University, Finland (H.L.)
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Tampere University (H.L.)
| | - Teemu Niiranen
- Department of Internal Medicine, University of Turku, Finland (A.K., T.N.)
- Department of Health, Finnish Institute for Health and Welfare (T.N.)
| | - Natalie A Bello
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA (N.A.B.)
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12
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Abstract
PURPOSE OF REVIEW The purpose of this review is to review recent findings regarding stroke epidemiology, etiologies, and treatment in children and young adults. RECENT FINDINGS Incidence in young adults is increasing, and incidence, recurrence, and survival is worse in patients with cryptogenic stroke and in developing countries. Careful consideration of patent foramen ovale closure is now recommended in young adults with cryptogenic stroke. Thrombectomy has recently been extended to carefully selected children with acute ischemic stroke, and two recent publications strongly suggest that it can be beneficial for children. Sickle cell is also an important global contributor to stroke burden, but hydroxyurea can be a cost effective medication for stroke prevention in children. Recent advances in genetic testing and treatments may improve outcomes for patients with monogenic causes of stroke, such as deficiency of adenosine deaminase 2, hemophilia, and Fabry's disease. SUMMARY Stroke in children and young adults is a morbid disease responsible for enormous indirect societal costs and a high burden of years with disability per affected patient. Recent advances have improved access to care for children with large vessel occlusion and adults with rare causes of stroke. Future research may bring effective treatments for other monogenic causes of stroke as well as increasing access to hyperacute therapies for young stroke patients.
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Affiliation(s)
- Stuart Fraser
- Division of Child and Adolescent Neurology, Department of Pediatrics, The University of Texas McGovern Medical School
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center Houston, Houston, Texas
| | - Lisa Pabst
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Fiona Smith
- Cizik School of Nursing, The University of Texas Health Science Center at Houston, Houston, Texas and Houston Methodist Sugar Land Hospital, Sugar Land, Texas
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13
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Yoon CW, Bushnell CD. Stroke in Women: A Review Focused on Epidemiology, Risk Factors, and Outcomes. J Stroke 2023; 25:2-15. [PMID: 36746378 PMCID: PMC9911842 DOI: 10.5853/jos.2022.03468] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Stroke is a particularly important issue for women. Women account for over half of all persons who experienced a stroke. The lifetime risk of stroke is higher in women than in men. In addition, women have worse stroke outcomes than men. Several risk factors have a higher association with stroke in women than in men, and women-specific risk factors that men do not have should be considered. This focused review highlights recent findings in stroke epidemiology, risk factors, and outcomes in women.
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Affiliation(s)
- Cindy W. Yoon
- Department of Neurology, Inha University School of Medicine, Incheon, Korea
| | - Cheryl D. Bushnell
- Department of Neurology, Wake Forest University School of Medicine, Winston Salem, NC, USA,Correspondence: Cheryl D. Bushnell Department of Neurology, Wake Forest University School of Medicine, Medical Center Blvd, Winston Salem, NC 27157, USA Tel: +1-336-716-2983
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14
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Jacobs MM, Ellis C. Stroke in women between 2006 and 2018: Demographic, socioeconomic, and age disparities. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231199061. [PMID: 37735849 PMCID: PMC10515531 DOI: 10.1177/17455057231199061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Black Americans have a higher prevalence of stroke and stroke-related deaths than any other racial group. Racial disparities in stroke outcomes are even wider among women than men. Conventional studies have cited differences in lifestyle (i.e. smoking, alcohol consumption, etc.) and vascular risk factors between races as the source of these disparities. However, these studies fail to account for the higher prevalence of minoritized populations at the lower end of the socioeconomic distribution. OBJECTIVES This study explores differences in stroke risk factors across age and socioeconomic cohorts to determine whether comorbidities can sufficiently explain disparities at all ages and income levels. DESIGN Using the 2006-2018 National Health Interview Survey data, statistical analysis evaluated differences in risk factors among a full sample cohort (aged 18-85 years; n = 131,091) and a "young" subsample cohort (aged 18-59 years; n = 6183) of women. METHODS Logistics and unconditional quantile regression models assessed the relationship between stroke and comorbid, demographic, and behavioral characteristics across socioeconomic classes. RESULTS Results suggest that Black women had a 1.415-fold (confidence interval = 1.259, 1.591) higher likelihood of stroke compared with White women after controlling for age, behavior, and comorbidities. Racial disparities were not statistically significant at the higher income ranges for either the full (odds ratio = 1.404, p = 0.3114) or young samples (odds ratio = 1.576, p = 0.7718). However, Blacks had significantly higher odds of stroke in the lower quartiles (lower odds ratio: 1.329, p = 0.0242; lower middle odds ratio: 1.233, p = 0.0486; and upper middle odds ratio: 1.994, p = 0.0005). Disparities were larger among young women (odds ratio = 1.449, confidence interval = 1.211, 1.734). CONCLUSION While comorbidities were highly associated with stroke prevalence in all socioeconomic cohorts, Blacks only had higher relative odds in the lower income classes. Lack of biological or behavioral explanations for these findings suggests that unobserved or uncontrolled factors such as systemic racism, prejudicial institutions, or differential treatment may contribute to this.
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Affiliation(s)
- Molly M Jacobs
- Department of Health Services Research, Management & Policy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Charles Ellis
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
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15
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Patel SH, Timón-Gómez A, Pradhyumnan H, Mankaliye B, Dave KR, Perez-Pinzon MA, Raval AP. The Impact of Nicotine along with Oral Contraceptive Exposure on Brain Fatty Acid Metabolism in Female Rats. Int J Mol Sci 2022; 23:ijms232416075. [PMID: 36555717 PMCID: PMC9780830 DOI: 10.3390/ijms232416075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/06/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
Smoking-derived nicotine (N) and oral contraceptive (OC) synergistically exacerbate ischemic brain damage in females, and the underlying mechanisms remain elusive. In a previous study, we showed that N + OC exposure altered brain glucose metabolism in females. Since lipid metabolism complements glycolysis, the current study aims to examine the metabolic fingerprint of fatty acids in the brain of female rats exposed to N+/-OC. Adolescent and adult Sprague-Dawley female rats were randomly (n = 8 per group) exposed to either saline or N (4.5 mg/kg) +/-OC (combined OC or placebo delivered via oral gavage) for 16-21 days. Following exposure, brain tissue was harvested for unbiased metabolomic analysis (performed by Metabolon Inc., Morrisville, NC, USA) and the metabolomic profile changes were complemented with Western blot analysis of key enzymes in the lipid pathway. Metabolomic data showed significant accumulation of fatty acids and phosphatidylcholine (PC) metabolites in the brain. Adolescent, more so than adult females, exposed to N + OC showed significant increases in carnitine-conjugated fatty acid metabolites compared to saline control animals. These changes in fatty acyl carnitines were accompanied by an increase in a subset of free fatty acids, suggesting elevated fatty acid β-oxidation in the mitochondria to meet energy demand. In support, β-hydroxybutyrate was significantly lower in N + OC exposure groups in adolescent animals, implying a complete shunting of acetyl CoA for energy production via the TCA cycle. The reported changes in fatty acids and PC metabolism due to N + OC could inhibit post-translational palmitoylation of membrane proteins and synaptic vesicle formation, respectively, thus exacerbating ischemic brain damage in female rats.
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Affiliation(s)
- Shahil H. Patel
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Alba Timón-Gómez
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Hari Pradhyumnan
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Berk Mankaliye
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Kunjan R. Dave
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Neuroscience Program, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Miguel A. Perez-Pinzon
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Neuroscience Program, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Ami P. Raval
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratories, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Neuroscience Program, Leonard M. Miller School of Medicine, University of Miami, Miami, FL 33136, USA
- Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL 33136, USA
- Correspondence: ; Tel.: +1-(305)-243-7491; Fax: +1-(305)-243-6955
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16
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Stroke and stroke risk factors in women of reproductive age with a history of metabolic or bariatric surgery. J Stroke Cerebrovasc Dis 2022; 31:106814. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022] Open
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17
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Schaefer JH, Bohmann FO, Lieschke F, Misselwitz B, Foerch C. Divergence and Convergence of Sex-Specific Time Trends in Ischemic Stroke: 10-Year Analysis of a State-Wide Registry in Germany. J Am Heart Assoc 2022; 11:e027130. [PMID: 36250659 DOI: 10.1161/jaha.122.027130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The incidence of ischemic stroke was previously expected to rise among countries with an aging population. Lately, several studies from developed countries have reported a decline in certain cohorts. Whether this applies to all sexes, however, is uncertain, with limited data on the temporal development in incidence, treatment, and recovery. Methods and Results We analyzed a prospective stroke inpatient quality-assurance registry of the federal state of Hesse, Germany. Recruitment of all patients with a final diagnosis of ischemic stroke at hospital discharge (International Classification of Diseases, Tenth Revision [ICD-10]: I63) is mandatory by law. Incidence rates were calculated based on census data of all inhabitants and stratified according to age. Between 2010 and 2019, there were 141 277 patients included, 73 770 (52.2%) male patients and 67 507 (47.8%) female patients. Overall, the incidence of ischemic stroke was 228 per 100 000 in 2010 and 226 per 100 000 in 2019 (-0.8%; odds ratio [OR], 0.99 [95% CI, 0.96-1.02]; P=0.50). For male patients, the incidence increased continuously from 236 per 100 000 to 245 per 100 000 (+3.8%); in female patients it decreased from 220 per 100 000 to 208 per 100 000 (-5.6%). After adjusting for age, the OR for ischemic stroke between male and female patients was 1.40 in 2010 (95% CI, 1.35-1.44; P<0.001) and 1.48 in 2019 (95% CI, 1.43-1.53; P<0.001). This development was most pronounced in male patients aged 45 to 59 years with an increase from 151 per 100 000 to 176 per 100 000. In this age group, male patients showed increasing rates of prior strokes and atrial fibrillation, surpassing the prevalence in female patients over time. After multivariable regression analysis, male patients had a lower modified Rankin Scale at discharge compared with female patients, but this difference has decreased since 2015 (common OR in 2010, 0.83 [95% CI, 0.78-0.88]; common OR in 2019, 0.90 [95% CI, 0.84-0.95]), which coincided with rising rates of endovascular treatment. Conclusions Over the past decade in the federal state of Hesse, the overall incidence of ischemic stroke has declined predominantly in the female population. In contrast, for male patients, the incidence has risen by about 4%, with a steeper increase of 16% in male patients aged 45 to 59 years, which might be related to increasing rates of recurrent strokes and atrial fibrillation in this cohort. This finding provides a cautionary tale for effective secondary prevention. Female patients were generally less likely to achieve a favorable outcome, but since the introduction of endovascular treatment, the outcome gap is decreasing.
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Affiliation(s)
- Jan Hendrik Schaefer
- Department of Neurology University Clinic Frankfurt, Goethe University Frankfurt am Main Germany
| | - Ferdinand O Bohmann
- Department of Neurology University Clinic Frankfurt, Goethe University Frankfurt am Main Germany
| | - Franziska Lieschke
- Department of Neurology University Clinic Frankfurt, Goethe University Frankfurt am Main Germany
| | - Björn Misselwitz
- Federal State Consortium of Quality Assurance Hesse Eschborn Germany
| | - Christian Foerch
- Department of Neurology University Clinic Frankfurt, Goethe University Frankfurt am Main Germany
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18
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Weber R, Winezki E, Katsanos AH, Cueillette M, Hajjar K, Yamac E, Veltkamp R, Chapot R. Sex differences in etiology and short-term outcome in young ischemic stroke patients receiving mechanical thrombectomy. Neurol Res Pract 2022; 4:50. [PMID: 36244994 PMCID: PMC9575275 DOI: 10.1186/s42466-022-00215-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background Although there are well known sex differences in older patients with ischemic stroke receiving acute reperfusion treatments, there is paucity of data in younger patients. Methods We investigated sex-related differences in clinical presentation, stroke etiology and short-term outcomes in consecutive young patients with acute ischemic stroke (AIS) below the age of 50 years receiving mechanical thrombectomy (MT) between January 2011 and May 2021 in a tertiary stroke center. Results We identified a total of 202 young ischemic stroke patients with MT, with 51% being female. Young female AIS patients were significantly younger (39 ± 8 vs. 43 ± 7 years, p < 0.001), and presented with a trend for more severe stroke on admission (median NIHSS 12 vs. 9, p = 0.065), compared to males, respectively. Young female AIS patients had higher rates of embolic strokes of determined or undetermined sources in the anterior circulation, while young male AIS patients suffered more often strokes of arterio-arterial embolism. Complete reperfusion (TICI score 3) was achieved significantly less often in young female AIS patients (69% vs. 83%, p = 0.006), and in-hospital mortality was 2-times higher (5% vs. 2%, p = 0.271) compared to males. Conclusions Young female AIS patients receiving MT have higher rates of severe embolic strokes and less often complete reperfusion due to different occlusion sites and stroke etiology compared to males.
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Affiliation(s)
- Ralph Weber
- Department of Neurology, Alfried Krupp Hospital Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany.
| | - Evgenia Winezki
- Department of Neurology, Alfried Krupp Hospital Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University & Population Health Research Institute, Hamilton, Canada
| | - Melissa Cueillette
- Department of Neurology, Alfried Krupp Hospital Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Karim Hajjar
- Department of Neurology, Alfried Krupp Hospital Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany
| | - Elif Yamac
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Hospital Essen, Alfried-Krupp-Str. 21, 45131, Essen, Germany.,Department of Brain Sciences, Imperial College London, London, United Kingdom
| | - Rene Chapot
- Department of Neuroradiology, Alfried Krupp Hospital, Essen, Germany
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19
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Reddy V, Wurtz M, Patel SH, McCarthy M, Raval AP. Oral contraceptives and stroke: Foes or friends. Front Neuroendocrinol 2022; 67:101016. [PMID: 35870646 DOI: 10.1016/j.yfrne.2022.101016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/23/2022] [Accepted: 07/06/2022] [Indexed: 01/09/2023]
Abstract
Incidents of strokes are increased in young women relative to young men, suggesting that oral contraceptive (OC) use is one of the causes of stroke among young women. Long-term exposures to the varying combinations of estrogen and progestogen found in OCs affect blood clotting, lipid and lipoprotein metabolism, endothelial function, and de novo synthesis of neurosteroids, especially brain-derived 17β-estradiol. The latter is essential for neuroprotection, memory, sexual differentiation, synaptic transmission, and behavior. Deleterious effects of OCs may be exacerbated due to comorbidities like polycystic ovary syndrome, sickle cell anemia, COVID-19, exposures to endocrine disrupting chemicals, and conventional or electronic cigarette smoking. The goal of the current review is to revisit the available literature regarding the impact of OC use on stroke, to explain possible underlying mechanisms, and to identify gaps in our understanding to promote future research to reduce and cure stroke in OC users.
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Affiliation(s)
- Varun Reddy
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Megan Wurtz
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Shahil H Patel
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Micheline McCarthy
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA
| | - Ami P Raval
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami Florida 33136, USA; Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL, USA.
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20
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Lee J, Kim H, Moon J, Shin J, Jeong H, Kim Y. Temporal trend of first-ever ischaemic stroke incidence from 2010 to 2019 in South Korea: a nationwide retrospective cohort study. BMJ Open 2022; 12:e059956. [PMID: 36002224 PMCID: PMC9413172 DOI: 10.1136/bmjopen-2021-059956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Ischaemic stroke incidence is on the decline globally, but the trend in South Korea is unknown. In this study, the 10-year incidence trends of first-ever ischaemic stroke in South Korea were evaluated. DESIGN, SETTING AND PARTICIPANTS The National Health Insurance Services medical claim data were used to construct 10 annual cohorts of adults aged 20 years and older, who had not been diagnosed with stroke, to find out the incidence trends of first-ever ischaemic stroke from 2010 to 2019. OUTCOME MEASURES The primary outcomes were crude and age-adjusted incidence rates for 10 years. Crude incidence rates of the age groups and incidence age statistics were calculated. For comparison among the income groups, age-adjusted incidence rates were used. Incidence rates in all the groups were analysed separately by sex. RESULTS Age-standardised incidence rates of ischaemic stroke per 100 000 were 101.0 in men, and 67.6 in women in 2010; and 92.2 in men, and 55.0 in women in 2019. By age group, there was a decrease in women over 40 years of age, and men over 60 years of age. The relative difference in stroke incidence rates between medical aid beneficiaries and the highest income group increased from 1.5 to 1.87 over 10 years. CONCLUSIONS Age-standardised incidence rate of ischaemic stroke has decreased from 2010 to 2019 for both man and women. The incidence rate was stable in the younger age groups and decreased in the older age groups, and the disparities between income groups have widened over the past decade. Stroke prevention strategies are needed for the younger age group and the low-income group. Further research is needed to study the risk factors contributing to the incidence of ischaemic stroke in different groups.
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Affiliation(s)
- Jeehye Lee
- National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Hyeongsu Kim
- Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Jusun Moon
- Department of Neurology, National Medical Center, Seoul, Korea
| | - Jinyoung Shin
- Department of Family Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Hojin Jeong
- Department of Preventive Medicine, School of Medicine, Konkuk University, Seoul, Korea
| | - Youngtaek Kim
- Department of Preventive Medicine, Chungnam National University Hospital, Daejeon, Korea
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21
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Poisson SN, Hills NK, Sidney S, Fullerton HJ. Prevalence of Atherosclerotic Risk Factors Among Children and Young Adults With Arterial Ischemic Stroke. JAMA Neurol 2022; 79:901-910. [PMID: 35913708 PMCID: PMC9344389 DOI: 10.1001/jamaneurol.2022.2077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Arterial ischemic stroke (AIS) incidence has decreased overall in recent decades yet has increased in young adults. The potential associations with atherosclerotic risk factors (ARFs) remain unknown. Objective To assess the ages at which ARFs may be risk factors associated with AIS. Design, Setting, and Participants A nested case-control study was conducted within Kaiser Permanente Northern California (KPNC) from January 1, 2000, through December 31, 2014. Data were analyzed from 2019 to 2022. Cases were identified using diagnostic codes and radiology reports. A total of 2 to 3 controls per case, matched on age and enrollment dates, were randomly identified and confirmed as stroke-free by medical record review. Only ARFs documented prior to stroke diagnosis (or the same date in controls) were considered to ensure the same period of observation. Comparisons were stratified by decade of life. Cases and controls were selected from the KPNC population (4.7 million children and 7.5 million young adults). Medical record review was conducted of all children (aged 29 days to 19 years) and a sample of young adults (aged 20-49 years) with International Classification of Diseases, Ninth Revision code or radiology text string search suggestive of AIS. Stroke-free controls were randomly selected. Exposures Hypertension, hyperlipidemia, diabetes, obesity, and smoking history. Main Outcomes and Measures Odds of AIS. In all analyses, cases and controls were compared using logistic regression. Results A total of 141 pediatric cases (69 [48.9%] aged 29 days to 9 years; 72 [51.1%] aged 10-19 years) and 364 pediatric controls (168 [46.2%] aged 0-9 years; 196 [53.8%] aged 10-19 years) and 455 young adult cases (71 [15.6%] aged 20-29 years; 144 [31.6%] aged 30-39 years; and 240 [52.7%] aged 40-49 years) and 1018 young adult controls (121 [11.9%] aged 20-29 years; 298 [29.3%] aged 30-39 years; and 599 [58.8%] aged 40-49 years) were identified. The percent of the cases that were male or female did not differ from the percent in the control group. The odds ratio (OR) of having any ARFs on AIS was 1.87 (95% CI, 0.72-4.88) for age range 0 to 9 years; OR, 1.00 (95% CI, 0.51-1.99) for age range 10 to 19 years; OR, 2.3 (95% CI, 1.17- 4.51) for age range 20 to 29 years; OR, 3.57 (95% CI, 2.34-5.45) for age range 30 to 39 years; and OR, 4.91 (95% CI, 3.52-6.86) for age range 40 to 49 years. The risk associated with multiple ARFs was OR, 5.29 (95% CI, 0.47-59.4) for age range 0 to 9 years; OR, 2.75 (95% CI, 0.77-9.87) for age range 10 to 19 years; OR, 7.33 (95% CI, 1.92-27.9) for age range 20 to 29 years; OR, 9.86 (95% CI, 4.96-19.6) for age range 30 to 39 years; and OR, 9.35 (95% CI, 6.31-13.8) for age range 40 to 49 years. The ARF findings by both definitions were significant in all young adult groups. Atherosclerosis was the presumed etiology in 0% of cases in the age group 0 to 9 years, 1.4% in the age group 10 to 19 years, 8.5% in the age group 20 to 29 years, 21.5% in the age group 30 to 39 years, and 42.5% in the age group 40 to 49 years. Conclusions and Relevance Although atherosclerosis may not be a common cause of AIS in children or in early young adulthood, findings of this study suggest that ARFs associated with stroke in older adults are present in childhood and increase with age. Efforts to reduce these risk factors should begin as early as possible.
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Affiliation(s)
- Sharon N Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora
| | - Nancy K Hills
- Department of Neurology, University of California, San Francisco.,Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Heather J Fullerton
- Department of Neurology, University of California, San Francisco.,Department of Pediatrics, University of California, San Francisco
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22
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Sefiani A, Rusyn I, Geoffroy CG. Novel adult cortical neuron processing and screening method illustrates sex- and age-dependent effects of pharmaceutical compounds. Sci Rep 2022; 12:13125. [PMID: 35908049 PMCID: PMC9338961 DOI: 10.1038/s41598-022-17389-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/25/2022] [Indexed: 11/22/2022] Open
Abstract
Neurodegenerative diseases and neurotraumatic injuries are typically age-associated disorders that can reduce neuron survival, neurite outgrowth, and synaptic plasticity leading to loss of cognitive capacity, executive function, and motor control. In pursuit of reducing the loss of said neurological functions, novel compounds are sought that promote neuron viability, neuritogenesis, and/or synaptic plasticity. Current high content in vitro screenings typically use cells that are iPSC-derived, embryonic, or originate from post-natal tissues; however, most patients suffering from neurodegenerative diseases and neurotrauma are of middle-age and older. The chasm in maturity between the neurons used in drug screens and those in a target population is a barrier for translational success of in vitro results. It has been historically challenging to culture adult neurons let alone conduct screenings; therefore, age-appropriate drug screenings have previously not been plausible. We have modified Miltenyi’s protocol to increase neuronal yield, neuron purity, and neural viability at a reduced cost to expand our capacity to screen compounds directly in primary adult neurons. To our knowledge, we developed the first morphology-based screening system using adult cortical neurons and the first to incorporate age and sex as biological variables in a screen using adult cortical neurons. By using primary adult cortical neurons from mice that were 4 to 48 weeks old for screening pharmaceutical agents, we have demonstrated age- and sex-dependent effects on neuritogenesis and neuron survival in vitro. Utilizing age- and sex-appropriate in vitro models to find novel compounds increasing neuron survival and neurite outgrowth, made possible by our modified adult neuron processing method, will greatly increase the relevance of in vitro screening for finding neuroprotective compounds.
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Affiliation(s)
- Arthur Sefiani
- Department of Neuroscience and Experimental Therapeutics, School of Medicine, Texas A&M University, Bryan, TX, 77807, USA
| | - Ivan Rusyn
- Department of Veterinary Integrative Biosciences, College of Veterinary Medicine & Biomedical Sciences, Texas A&M University, College Station, TX, 77843, USA
| | - Cédric G Geoffroy
- Department of Neuroscience and Experimental Therapeutics, School of Medicine, Texas A&M University, Bryan, TX, 77807, USA.
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23
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Carcel C, Caso V, Aguiar de Sousa D, Sandset EC. Sex differences in neurovascular disorders. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:69-99. [PMID: 36038210 DOI: 10.1016/bs.irn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital University of Perugia, Perugia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal; CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway.
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24
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Basu E, Salehi Omran S, Kamel H, Parikh NS. Sex differences in the risk of recurrent ischemic stroke after ischemic stroke and transient ischemic attack. Eur Stroke J 2022; 6:367-373. [PMID: 35342804 DOI: 10.1177/23969873211058568] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/20/2021] [Indexed: 10/19/2022] Open
Abstract
Background Sex differences in stroke outcomes have been noted, but whether this extends to stroke recurrence is unclear. We examined sex differences in recurrent stroke using data from the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. Patients and methods We assessed the risk of recurrent stroke in women compared to men using data from the POINT trial. Adults >18 years old were randomized within 12 hours of onset of minor ischemic stroke or transient ischemic attack (TIA), and followed for up to 90 days for ischemic stroke, our primary outcome. We used Cox proportional hazards model adjusted for demographics and stroke risk factors to evaluate the association between sex and stroke recurrence. We used interaction term testing and prespecified subgroup analyses to determine if the association between sex and recurrent stroke differed by age (<60 versus >60 years old), locale (US versus non-US), and index event type (stroke versus TIA). Last, we evaluated whether sex modified the effect of common stroke risk factors on stroke recurrence. Results Of 4,881 POINT trial participants with minor stroke or high-risk TIA, 2,195 (45%) were women. During the 90-day follow-up period, 267 ischemic strokes occurred; 121 were in women and 146 in men. The cumulative risk of recurrent ischemic stroke was not significantly different among women (5.76%; 95% CI, 4.84%-6.85%) compared to men (5.67%; 95% CI, 4.83%-6.63%). Women were not at a different risk of recurrent ischemic stroke compared to men (hazard ratio [HR], 1.02; 95% CI, 0.80-1.30) in unadjusted models or after adjusting for covariates. However, there was a significant interaction of age with sex (P=0.04). Among patients <60 years old, there was a non-significantly lower risk of recurrent stroke in women compared to men (HR 0.66; 95% CI 0.42-1.05). Last, sex did not modify the association between common stroke risk factors and recurrent stroke risk. Discussion and Conclusion Among patients with minor stroke or TIA, the risk of recurrent ischemic stroke and the impact of common stroke risk factors did not differ between men and women.
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Affiliation(s)
- Elora Basu
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | | | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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25
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Olié V, Grave C, Tuppin P, Duloquin G, Béjot Y, Gabet A. Patients Hospitalized for Ischemic Stroke and Intracerebral Hemorrhage in France: Time Trends (2008-2019), In-Hospital Outcomes, Age and Sex Differences. J Clin Med 2022; 11:jcm11061669. [PMID: 35329995 PMCID: PMC8949281 DOI: 10.3390/jcm11061669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Rates of patients hospitalized for stroke increased among people aged under 65 years in France, as has been found in other countries. Methods: To analyze time trends in the rates of patients hospitalized for ischemic stroke (IS) and intracerebral hemorrhage (ICH) in France between 2008 and 2019 and determine related short-term outcomes mainly, we selected all patients hospitalized for stroke using the French national hospital database. Results: The average annual percentage change in the rates of patients hospitalized for IS increased significantly in men and women aged 50–64 years (+2.0%) and in men aged 18–34 years (+1.5%) and 35–44 years (+2.2%). A decrease in the average annual percentage change was observed for IS among people aged over 75 years and among those over 50 years for ICH. After adjustment on confounding factors, women were less likely to die in hospital. Case fatality rates decreased overtime in all age groups for both sexes, with a more pronounced decrease for IS than ICH. Conclusions: The increasing trend of IS among adults under 65 years is ongoing, highlighting the urgent need for stroke prevention programs in that age. For the first time, we recorded a decrease in the rates of patients hospitalized for ICH among the population over 50 years.
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Affiliation(s)
- Valérie Olié
- Department of Non-Communicable Diseases, Santé Publique France, 94410 Saint-Maurice, France; (V.O.); (C.G.)
| | - Clémence Grave
- Department of Non-Communicable Diseases, Santé Publique France, 94410 Saint-Maurice, France; (V.O.); (C.G.)
| | - Philippe Tuppin
- Department of Health Studies and Statistics, Caisse Nationale de l’Assurance Maladie, 75020 Paris, France;
| | - Gauthier Duloquin
- Dijon Stroke Registry, University Hospital of Burgundy, 21000 Dijon, France; (G.D.); (Y.B.)
| | - Yannick Béjot
- Dijon Stroke Registry, University Hospital of Burgundy, 21000 Dijon, France; (G.D.); (Y.B.)
| | - Amélie Gabet
- Department of Non-Communicable Diseases, Santé Publique France, 94410 Saint-Maurice, France; (V.O.); (C.G.)
- Correspondence:
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26
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Wong ND, Budoff MJ, Ferdinand K, Graham IM, Michos ED, Reddy T, Shapiro MD, Toth PP. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK ASSESSMENT: An American Society for Preventive Cardiology Clinical Practice Statement. Am J Prev Cardiol 2022; 10:100335. [PMID: 35342890 PMCID: PMC8943256 DOI: 10.1016/j.ajpc.2022.100335] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/17/2022] [Accepted: 03/05/2022] [Indexed: 01/08/2023] Open
Abstract
Risk for atherosclerotic cardiovascular disease (ASCVD) shows considerable heterogeneity both in generally healthy persons and in those with known ASCVD. The foundation of preventive cardiology begins with assessing baseline ASCVD risk using global risk scores based on standard office-based measures. Persons at low risk are generally recommended for lifestyle management only and those at highest risk are recommended for both lifestyle and pharmacologic therapy. Additional “risk enhancing” factors, including both traditional risk factors and novel biomarkers and inflammatory factors can be used to further assess ASCVD risk, especially in those at borderline or intermediate risk. There are also female-specific risk enhancers, social determinants of health, and considerations for high-risk ethnic groups. Screening for subclinical atherosclerosis, especially with the use of coronary calcium screening, can further inform the treatment decision if uncertain based on the above strategies. Persons with pre-existing ASCVD also have variable risk, affected by the number of major ASCVD events, whether recurrent events have occurred recently, and the presence of other major risk factors or high-risk conditions. Current guidelines define high to very high risk ASCVD accordingly. Accurate ASCVD risk assessment is crucial for the appropriate targeting of preventive therapies to reduce ASCVD risk. Finally, the clinician-patient risk discussion focusing on lifestyle management and the risks and benefits of evidence-based pharmacologic therapies to best lower ASCVD risk is central to this process. This clinical practice statement provides the preventive cardiology specialist with guidance and tools for assessment of ASCVD risk with the goal of appropriately targeting treatment approaches for prevention of ASCVD events.
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Affiliation(s)
- Nathan D. Wong
- Heart Disease Prevention Program, Division of Cardiology, University of California, Irvine, CA, United States
- Corresponding author.
| | - Matthew J. Budoff
- Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Keith Ferdinand
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA United States
| | - Ian M. Graham
- Department of Cardiology, Trinity College, Dublin, Ireland
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Tina Reddy
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, LA United States
| | | | - Peter P. Toth
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- CGH Medical Center, Sterling, IL, United States
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27
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Hoyer C, Schlenker J, Sandikci V, Ebert A, Wittayer M, Platten M, Szabo K. Sex-Specific Differences in Pre-Stroke Characteristics Reveal Vulnerability of Elderly Women. J Pers Med 2022; 12:jpm12030344. [PMID: 35330344 PMCID: PMC8951678 DOI: 10.3390/jpm12030344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/17/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
While the sexually dimorphic character of ischemic stroke has been acknowledged along several dimensions, age-specific sex disparities regarding pre-stroke characteristics in particular have received comparatively little attention. This study aimed to identify age-dependent associations between sex and risk factors, premorbidity, and living situation in patients with ischemic stroke to foster the continuing development of dedicated preventative strategies. In a retrospective single-center study, data of patients with acute ischemic stroke (AIS) admitted to the Department of Neurology, University Hospital Mannheim, Germany, between June 2004−June 2020 were included; AIS frequency, vascular risk factors, premorbidity, living situation, and stroke etiology were analyzed across sexes and different age spectra. From a total of 11,003 patients included in the study, 44.1% were female. Women aged >70−≤90 years showed a pronounced increase in stroke frequency, lived alone significantly more frequently, and had a significantly higher degree of pre-stroke disability than men; however, only hypertension and atrial fibrillation were more prevalent in women in this age segment. The seventh and eighth decades are a critical time in which the pre-stroke risk profile changes resulting in an increase in stroke morbidity in women. This emphasizes the relevance of and need for an approach to stroke prevention that is both targeted and integrative.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
| | - Jan Schlenker
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Vesile Sandikci
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Anne Ebert
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Matthias Wittayer
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
| | - Michael Platten
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
| | - Kristina Szabo
- Department of Neurology, Medical Faculty Mannheim, Mannheim Center for Translational Neuroscience (MCTN), Heidelberg University, 68167 Mannheim, Germany; (C.H.); (J.S.); (V.S.); (A.E.); (M.W.); (M.P.)
- CCU Healthy Brain, Competence Network Preventive Medicine Baden-Württemberg, 68167 Mannheim, Germany
- Correspondence:
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28
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Abstract
Women face a disproportionate burden of stroke mortality and disability. Biologic sex and sociocultural gender both contribute to differences in stroke risk factors, assessment, treatment, and outcomes. There are substantial differences in the strength of association of stroke risk factors, as well as female-specific risk factors. Moreover, there are differences in presentation, response to treatment, and stroke outcomes in women. This review outlines current knowledge of impact of sex and gender on stroke, as well as delineates research gaps and areas for future inquiry.
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Affiliation(s)
- Kathryn M. Rexrode
- Division of Women’s Health, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Tracy E. Madsen
- Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI; Department of Epidemiology, Brown University School of Public Health, Providence RI
| | - Amy Y. X. Yu
- Department of Medicine (Neurology), University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cheryl Carcel
- Neurology Program, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Judith H. Lichtman
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Eliza C. Miller
- Division of Stroke and Cerebrovascular Disease, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
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29
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Leopold JA, Antman EM. Ideal Cardiovascular Health in Young Adults With Established Cardiovascular Diseases. Front Cardiovasc Med 2022; 9:814610. [PMID: 35252395 PMCID: PMC8893279 DOI: 10.3389/fcvm.2022.814610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
There has been an increase in the prevalence of cardiovascular diseases among young adults in the United States that has been attributed, in part, to a rise in overweight and obesity, use of combustible tobacco and unhealthy diet and exercise patterns. These factors are influenced further by socioeconomic status and other social determinants of health. In the My Research Legacy study, we examined ideal cardiovascular health in young adults aged 18– <50 years with cardiovascular disease using the Life's Simple 7 survey and data from digital health devices. Young adults with cardiovascular disease (n = 349) were older, had a lower socioeconomic status, a higher prevalence of risk factors, and lower Life's Simple 7 Health Scores (6.4 ± 1.5 vs. 7.1 ± 1.5, p < 0.01) compared to young adults without cardiovascular disease (n = 696). Analysis of digital health device data revealed that young adults with cardiovascular disease performed a similar number of weekly minutes of moderate and vigorous exercise as those without disease leading to similar ideal activity scores. Young adults with cardiovascular disease also shared similarities in modifiable risk factors with adults aged ≥50 years with cardiovascular disease (n = 217), including weight, dietary habits, and weekly minutes of exercise. Latent class analysis identified two phenogroups of young adults with cardiovascular disease: phenogroup 1 was characterized by more advantageous cardiovascular health factors and behaviors resulting in higher Life's Simple 7 Health Scores than phenogroup 2 (7.4 ± 1.2 vs. 5.5 ± 1.1, p < 0.01). These findings in young adults with cardiovascular disease may inform the design of behavioral and therapeutic interventions in the future to decrease cardiovascular morbidity and mortality.
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30
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Norman K, Eriksson M, von Euler M. Sex Differences in Ischemic Stroke Within the Younger Age Group: A Register-Based Study. Front Neurol 2022; 13:793181. [PMID: 35237226 PMCID: PMC8882967 DOI: 10.3389/fneur.2022.793181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background Stroke incidence is decreasing in most developing countries. However, worrisome trends of an increase in the younger population have been described. Aim To investigate sex differences and longitudinal changes in ischemic stroke regarding incidence, cardiovascular risk factors, and outcome, in the young. Methods This is an observational study based on the data from the Swedish national stroke registry, Riksstroke. Patients, 18–54 years of age, having ischemic stroke between 2005 and 2018 were included, resulting in a study population of 16,210 patients. Results The incidence was higher in men than in women (30.6 vs. 19.1 per 100,000, P < 0.001). After an initial increase, the incidence stabilized and then decreased, resulting in a similar level in 2018 as in 2005. Atrial fibrillation, diabetes, and usage of anti-hypertensives at stroke onset were more common among men and did not change over time. Smoking was common and slightly more so in women, but with a reduced prevalence in both men and women during the study period. Dependency in Activities of Daily Living (ADL) and case fatality showed no clear trends or sex differences. Conclusions The results show that there are sex differences in ischemic stroke in the younger age group regarding incidence and vascular risk factors, particularly smoking. Temporal trends in stroke incidence are difficult to interpret as fluctuations are substantial, largely due to stroke being quite uncommon in the younger population.
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Affiliation(s)
| | - Marie Eriksson
- Department of Statistics, USBE, Umeå University, Umeå, Sweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, School of Medicine, Örebro University, Örebro, Sweden
- *Correspondence: Mia von Euler
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31
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Leppert MH, Burke JF, Lisabeth LD, Madsen TE, Kleindorfer DO, Sillau S, Schwamm LH, Daugherty SL, Bradley CJ, Ho PM, Poisson SN. Systematic Review of Sex Differences in Ischemic Strokes Among Young Adults: Are Young Women Disproportionately at Risk? Stroke 2022; 53:319-327. [PMID: 35073188 PMCID: PMC8852306 DOI: 10.1161/strokeaha.121.037117] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Recent evidence suggests that young women (18-45 years) may be at higher risk of ischemic strokes than men of the same age. The goal of this systematic review is to reconcile and synthesize existing evidence of sex differences among young adults with ischemic strokes. METHODS We searched PubMed from January 2008 to July 2021 for relevant articles and reviews and consulted their references. We included original studies that (1) were population based and (2) reported stroke incidence by sex or sex-specific incidence rate ratios of young adults ≤45 years. We excluded studies that (1) omitted measurements of error for incidence rates or incidence rate ratios, (2) omitted age adjustment, and (3) were not in English. Statistical synthesis was performed to estimate sex difference by age group (≤35, 35-45, and ≤45) and stroke type. RESULTS We found 19 studies that reported on sex-specific stroke incidence among young adults, including 3 that reported on overlapping data. Nine studies did not find a statistically significant sex difference among young adults ≤45 years. Three studies found higher rates of ischemic stroke among men among young adults ≥30 to 35 years. Four studies found more women with ischemic strokes among young adults ≤35 years. Overall, in young adults ≤35 years, the estimated effect size favored more ischemic strokes in women (incidence rate ratio, 1.44 [1.18-1.76], I2=82%) and a nonsignificant sex difference in young adults 35 to 45 years (incidence rate ratio, 1.08 [0.85-1.38], I2=95%). CONCLUSIONS Overall, there were 44% more women ≤35 years with ischemic strokes than men. This gap narrows in young adults, 35 to 45 years, and there is conflicting evidence whether more men or women have ischemic strokes in the 35 to 45 age group.
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Affiliation(s)
- Michelle H. Leppert
- Department of Neurology,University of Colorado School of Medicine,Aurora,CO,Corresponding Author:/919-906-2068/Twitter:@humich
| | - James F. Burke
- Department of Neurology,University of Michigan Health System,Ann Arbor,MI
| | - Lynda D. Lisabeth
- Department of Epidemiology,School of Public Health,University of Michigan,Ann Arbor,MI
| | - Tracy E. Madsen
- Department of Emergency Medicine,Alpert Medical School of Brown University,Providence,RI
| | | | - Stefan Sillau
- Department of Neurology,University of Colorado School of Medicine,Aurora,CO
| | - Lee H. Schwamm
- Department of Neurology,Massachusetts General Hospital,Boston,MA
| | - Stacie L. Daugherty
- Division of Cardiology,University of Colorado Anschutz Medical Campus,Aurora,CO
| | - Cathy J. Bradley
- Colorado Comprehensive Cancer Center,University of Colorado,Aurora,CO
| | - P. Michael Ho
- Division of Cardiology,University of Colorado Anschutz Medical Campus,Aurora,CO
| | - Sharon N. Poisson
- Department of Neurology,University of Colorado School of Medicine,Aurora,CO
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Affiliation(s)
- Cheryl D Bushnell
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC (C.D.B)
| | - Moira K Kapral
- Department of Medicine, University of Toronto, ON, Canada (M.K.K.)
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A Contemporary Review of Epidemiology, Risk Factors, Etiology, and Outcomes of Premature Stroke. Curr Atheroscler Rep 2022; 24:939-948. [PMID: 36374365 PMCID: PMC9660017 DOI: 10.1007/s11883-022-01067-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW Recent data identifies increases in young ischemic and hemorrhagic strokes. We provide a contemporary overview of current literature on stroke among young patients or premature stroke along with directions for future investigation. RECENT FINDINGS Strokes in the young are highly heterogenous and often cryptogenic. Sex distribution and risk factors shift from women among the youngest age groups (< 35) to men over the age of 45, with a coinciding rise in traditional vascular risk factors. Incidence is higher in minority and socioeconomically disadvantaged populations, and the impact of stroke among these communities may be exaggerated by disparities in symptom recognition and access to care. Special diagnostic work-up may be needed, and a lower threshold for diagnosis is warranted as potential misdiagnosis is a concern and may preclude necessary triage and management. Although "premature strokes" form a relatively small proportion of total incidence, they vary greatly across subgroups and present an outsized impact on quality of life and productivity.
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Reddy V, McCarthy M, Raval AP. Xenoestrogens impact brain estrogen receptor signaling during the female lifespan: A precursor to neurological disease? Neurobiol Dis 2021; 163:105596. [PMID: 34942334 DOI: 10.1016/j.nbd.2021.105596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/08/2021] [Accepted: 12/18/2021] [Indexed: 02/07/2023] Open
Abstract
Xenoestrogens, foreign synthetic chemicals mimicking estrogens, are lurking in our surroundings. Climate change may alter their toxicity and bioavailability. Since xenoestrogens have extremely high lipid solubility and are structurally similar to natural endogenous estrogens, they can bind to estrogen receptors (ERs) -alpha (ER-α) and -beta (ER-β). Scientific evidence accumulated over the past decades have suggested that natural 17β-estradiol (E2; a potent estrogen), via activation of its receptors, plays a pivotal role in regulation of brain development, differentiation, metabolism, synaptic plasticity, neuroprotection, cognition, anxiety, body temperature, feeding and sexual behavior. In the brain, ER-β is predominantly expressed in the various regions, including cerebral cortex and hippocampus, that have been shown to play a key role in cognition. Therefore, disturbances in function of ER-β mediated E2 signaling by xenoestrogens can lead to deleterious effects that potentiate a variety of neurological diseases starting from prenatal to post-menopause in women. The goal of this review is to identify the possible neurological effects of xenoestrogens that can alter estrogen receptor-mediated signaling in the brain during different stages of the female lifespan.
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Affiliation(s)
- Varun Reddy
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Micheline McCarthy
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, 33136, USA
| | - Ami P Raval
- Peritz Scheinberg Cerebral Vascular Disease Research Laboratory, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, 33136, USA; Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.
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35
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Florijn BW, Bijkerk R, Kruyt ND, van Zonneveld AJ, Wermer MJH. Sex-Specific MicroRNAs in Neurovascular Units in Ischemic Stroke. Int J Mol Sci 2021; 22:11888. [PMID: 34769320 PMCID: PMC8585074 DOI: 10.3390/ijms222111888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 12/24/2022] Open
Abstract
Accumulating evidence pinpoints sex differences in stroke incidence, etiology and outcome. Therefore, more understanding of the sex-specific mechanisms that lead to ischemic stroke and aggravation of secondary damage after stroke is needed. Our current mechanistic understanding of cerebral ischemia states that endothelial quiescence in neurovascular units (NVUs) is a major physiological parameter affecting the cellular response to neuron, astrocyte and vascular smooth muscle cell (VSMC) injury. Although a hallmark of the response to injury in these cells is transcriptional activation, noncoding RNAs such as microRNAs exhibit cell-type and context dependent regulation of gene expression at the post-transcriptional level. This review assesses whether sex-specific microRNA expression (either derived from X-chromosome loci following incomplete X-chromosome inactivation or regulated by estrogen in their biogenesis) in these cells controls NVU quiescence, and as such, could differentiate stroke pathophysiology in women compared to men. Their adverse expression was found to decrease tight junction affinity in endothelial cells and activate VSMC proliferation, while their regulation of paracrine astrocyte signaling was shown to neutralize sex-specific apoptotic pathways in neurons. As such, these microRNAs have cell type-specific functions in astrocytes and vascular cells which act on one another, thereby affecting the cell viability of neurons. Furthermore, these microRNAs display actual and potential clinical implications as diagnostic and prognostic biomarkers in ischemic stroke and in predicting therapeutic response to antiplatelet therapy. In conclusion, this review improves the current mechanistic understanding of the molecular mechanisms leading to ischemic stroke in women and highlights the clinical promise of sex-specific microRNAs as novel diagnostic biomarkers for (silent) ischemic stroke.
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Affiliation(s)
- Barend W. Florijn
- Department of Neurology, Leiden University Medical Center, 2333 ZR Leiden, The Netherlands; (N.D.K.); (M.J.H.W.)
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.B.); (A.J.v.Z.)
| | - Roel Bijkerk
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.B.); (A.J.v.Z.)
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Nyika D. Kruyt
- Department of Neurology, Leiden University Medical Center, 2333 ZR Leiden, The Netherlands; (N.D.K.); (M.J.H.W.)
| | - Anton Jan van Zonneveld
- Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.B.); (A.J.v.Z.)
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Marieke J. H. Wermer
- Department of Neurology, Leiden University Medical Center, 2333 ZR Leiden, The Netherlands; (N.D.K.); (M.J.H.W.)
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36
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Dinh QN, Vinh A, Arumugam TV, Drummond GR, Sobey CG. G protein-coupled estrogen receptor 1: a novel target to treat cardiovascular disease in a sex-specific manner? Br J Pharmacol 2021; 178:3849-3863. [PMID: 33948934 DOI: 10.1111/bph.15521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 12/19/2022] Open
Abstract
As an agonist of the classical nuclear receptors, estrogen receptor-α and -β (NR3A1/2), estrogen has been assumed to inhibit the development of cardiovascular disease in premenopausal women. Indeed, reduced levels of estrogen after menopause are believed to contribute to accelerated morbidity and mortality rates in women. However, estrogen replacement therapy has variable effects on cardiovascular risk in postmenopausal women, including increased serious adverse events. Interestingly, preclinical studies have shown that selective activation of the novel membrane-associated G protein-coupled estrogen receptor, GPER, can promote cardiovascular protection. These benefits are more evident in ovariectomised than intact females or in males. It is therefore possible that selective targeting of the GPER in postmenopausal women could provide cardiovascular protection with fewer adverse effects that are caused by conventional 'receptor non-specific' estrogen replacement therapy. This review describes new data regarding the merits of targeting GPER to treat cardiovascular disease with a focus on sex differences.
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Affiliation(s)
- Quynh Nhu Dinh
- Department of Physiology, Anatomy and Microbiology and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Antony Vinh
- Department of Physiology, Anatomy and Microbiology and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Thiruma V Arumugam
- Department of Physiology, Anatomy and Microbiology and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Grant R Drummond
- Department of Physiology, Anatomy and Microbiology and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Christopher G Sobey
- Department of Physiology, Anatomy and Microbiology and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
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37
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Sarecka-Hujar B, Kopyta I. The Impact of Sex on Arterial Ischemic Stroke in Young Patients: From Stroke Occurrence to Poststroke Consequences. CHILDREN-BASEL 2021; 8:children8030238. [PMID: 33803901 PMCID: PMC8003301 DOI: 10.3390/children8030238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023]
Abstract
The male sex has been suggested to predominate in paediatric patients with arterial ischemic stroke (AIS), especially in newborns. The explanation for this phenomenon remains unsatisfactory since it focuses on the analysis of the potential relationship with trauma and arterial dissection. In turn, in some populations of young adults, men suffer from AIS more frequently than women, which may be related to the protective role of oestrogen. On the other hand, certain data indicate that women dominate over men. Some of the disparities in the frequencies of particular symptoms of AIS and poststroke consequences in both children and young adults have been suggested; however, data are scarce. Unfortunately, the low number of studies on the subject does not allow certain conclusions to be drawn. For adults, more data are available for patients aged over 60 years, the results of which are more obvious. The present literature review aimed to discuss available data on the prevalence of AIS, its clinical presentations, and poststroke consequences in regard to the sex of young patients. We considered young patients to be children from birth up to the age of 19 years of life and young adults to be individuals up to the age of 55 years. The role of sex hormones in AIS and possible gender differences in genetic risk factors for AIS were also discussed briefly.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Basic Biomedical Science, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200 Sosnowiec, Poland
- Correspondence: or ; Tel.: +48-32-269-98-30
| | - Ilona Kopyta
- Department of Pediatric Neurology, Faculty of Medical Sciences in Katowice, Medical University of Silesia in Katowice, Medykow Str 16, 40-752 Katowice, Poland;
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Vyas MV, Silver FL, Austin PC, Yu AYX, Pequeno P, Fang J, Laupacis A, Kapral MK. Stroke Incidence by Sex Across the Lifespan. Stroke 2021; 52:447-451. [PMID: 33493057 DOI: 10.1161/strokeaha.120.032898] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE We evaluated the influence of age on the association between sex and the incidence of stroke or transient ischemic attack (TIA) using a population-based cohort from Ontario, Canada. METHODS We followed a cohort of adults (≥18 years) without prior stroke from January 1, 2003 (cohort start date) to March 31, 2018, to identify incident events. We calculated hazard ratios (HRs), in women compared to men, of incident stroke or TIA, adjusted for demographics and comorbidities, overall and stratified by stroke type. We calculated piecewise adjusted HRs for each decade of age to evaluate the effect of age on sex differences in stroke incidence. RESULTS We followed 9.2 million adults for a median of 15 years and observed 280,197 incident stroke or TIA events. Compared with men, women had an overall lower adjusted hazard of stroke or TIA (HR, 0.82 [95% CI, 0.82-0.83]), with similar findings across all stroke types except for subarachnoid hemorrhage (HR, 1.29 [95% CI, 1.24-1.33]). We found a U-shaped association between age and sex differences in the incidence of stroke or TIA: compared with men, the hazard of stroke was higher in women among those aged ≤30 years (HR, 1.26 [95% CI, 1.10-1.45]), lower among those between ages 40 and 80 years (eg, age 50-59, HR, 0.69 [95% CI, 0.68-0.70]), and similar among those aged ≥80 years (HR, 0.99 [95% CI, 0.98-1.01]). CONCLUSIONS Overall, women have a lower hazard of stroke than men, but this association varies by age and across stroke types. Recognition of age-sex variations in stroke incidence can help guide prevention efforts to reduce stroke incidence in both men and women.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Frank L Silver
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Amy Y X Yu
- Division of Neurology, Department of Medicine (M.V.V., F.L.S., A.Y.X.Y.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Priscila Pequeno
- ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
| | - Andreas Laupacis
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation (M.V.V., P.C.A., A.L., M.K.K.), University of Toronto, Canada.,Division of General Internal Medicine, and Department of Medicine (M.K.K.), University of Toronto, Canada.,ICES, Toronto, Canada (M.V.V., F.L.S., P.C.A., A.Y.X.Y., P.P., J.F., M.K.K.)
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39
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Ekker MS, de Leeuw FE. Higher Incidence of Ischemic Stroke in Young Women Than in Young Men: Mind the Gap. Stroke 2020; 51:3195-3196. [PMID: 32942968 DOI: 10.1161/strokeaha.120.032062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Merel S Ekker
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, the Netherlands
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