Higher Incidence of Ischemic Stroke in Young Women Than in Young Men: Mind the Gap

Sex differences and risk factors in recurrent ischemic stroke

Introduction

Recurrent ischemic stroke (RIS) is associated with increased mortality and poor outcomes. Therefore, secondary prevention is critical for reducing the risk of recurrent stroke. Previous studies have found sex differences in risk factors in patients with first-ever stroke; however, the results have been inconsistent for recurrent stroke. Therefore, this study aimed to investigate whether there are significant sex differences in the clinical characteristics and risk factors for recurrent ischemic stroke.

Methods

We retrospectively studied 787 patients with recurrent ischemic stroke after first-ever stroke confirmation using magnetic resonance imaging (MRI) after visiting a regional tertiary hospital between 2014 and 2020. Demographic characteristics, laboratory findings, and risk factors were compared between the male and female patients. In addition, multivariate logistic regression was performed to identify the independent factors associated with stroke recurrence in male patients.

Results

Among the 787 patients, 466 (59.2%) were males. Males were younger than females (67.6 vs. 71.9 years). Females had higher rates of hypertension, diabetes mellitus, dyslipidemia, and overweight than those of males. However, the alcohol drinking and smoking rate were significantly higher in males than that in females. There were no statistically significant sex-based differences in the laboratory findings. Among males, hypertension, alcohol drinking, smoking and dyslipidemia was a significant risk factor for ischemic stroke recurrence.

Conclusion

Hypertension and dyslipidemia were significant risk factors of recurrent ischemic stroke in both genders. Smoking and alcohol drinking were significant risk factors associated with ischemic stroke recurrence in males. Therefore, smoking cessation and alcohol abstinence are recommended after the first stroke to prevent recurrent ischemic stroke especially for males. Diabetes was a significant risk factor of ischemic stroke recurrence in females. More extensive studies are needed to understand the causal relationship of each factors with ischemic stroke recurrence according to sex differences and specification of preventive management is needed.

Shexiang Baoxin Pill reduces major adverse cardiovascular events in women with stable coronary artery disease: A subgroup analysis of a phase IV randomized clinical trial

Background

A previous phase IV trial revealed sex as a potential effect modifier of MUSKARDIA efficacy in stable coronary artery disease (CAD).

Objective

To assess the clinical effect of MUSKARDIA as a supplemental treatment to optimal medical therapy (OMT) in stable CAD cases.

Methods

This study was a subgroup analysis of a multicenter, randomized, double-blinded, placebo-controlled phase IV clinical study. Eligible individuals underwent randomization to the oral MUSKARDIA and placebo groups and were treated for 24 months. All participants received OMT according to existing guidelines. The primary composite outcome was the major adverse cardiovascular event (MACE), included cardiovascular death, non-fatal myocardial infarction (MI), or non-fatal stroke. The secondary composite outcome encompassed all-cause mortality, non-fatal MI, non-fatal stroke, hospitalization for unstable angina and/or heart failure, and undergoing coronary procedure/surgery during treatment. Safety signals, especially cardiovascular adverse events (AEs), were analyzed.

Results

The female subgroup included 776 participants (384 and 392 in the MUSKARDIA and placebo groups, respectively). The occurrence of the primary composite outcome was lower in the MUSKARDIA group compared with placebo-treated individuals (HR = 0.27, 95%CI: 0.09–0.83; P = 0.02), but the secondary composite outcome showed no significant difference (HR = 0.77, 95%CI: 0.47–1.25; P = 0.29). The MUSKARDIA group had reduced incidence of cardiovascular AEs compared with placebo-treated cases (2.9% vs. 5.6%).

Conclusion

As a supplemental treatment to OMT, 24-month administration of MUSKARDIA is effective and safe in female stable CAD cases.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT01897805].

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

OBJECTIVE

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

DESIGN, SETTING AND PARTICIPANTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Sex-Specific Immune Responses in Stroke

In both acute and chronic diseases, functional differences in host immune responses arise from a multitude of intrinsic and extrinsic factors. Two of the most important factors affecting the immune response are biological sex and aging. Ischemic stroke is a debilitating disease that predominately affects older individuals. Epidemiological studies have shown that older women have poorer functional outcomes compared with men, in part due to the older age at which they experience their first stroke and the increased comorbidities seen with aging. The immune response also differs in men and women, which could lead to altered inflammatory events that contribute to sex differences in poststroke recovery. Intrinsic factors including host genetics and chromosomal sex play a crucial role both in shaping the host immune system and in the neuroimmune response to brain injury. Ischemic stroke leads to altered intracellular communication between astrocytes, neurons, and resident immune cells in the central nervous system. Increased production of cytokines and chemokines orchestrate the infiltration of peripheral immune cells and promote neuroinflammation. To maintain immunosurveillance, the host immune and central nervous system are highly regulated by a diverse population of immune cells which are strategically distributed within the neurovascular unit and become activated with injury. In this review, we provide a comprehensive overview of sex-specific host immune responses in ischemic stroke.

Sex differences in the risk of recurrent ischemic stroke after ischemic stroke and transient ischemic attack

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.

Patients Hospitalized for Ischemic Stroke and Intracerebral Hemorrhage in France: Time Trends (2008-2019), In-Hospital Outcomes, Age and Sex Differences

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.

Sex Differences in Ischemic Stroke Within the Younger Age Group: A Register-Based Study

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.