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Otite FO, Morris N. Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke. Crit Care Clin 2024; 40:709-740. [PMID: 39218482 DOI: 10.1016/j.ccc.2024.05.006] [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] [Indexed: 09/04/2024]
Abstract
Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.
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Affiliation(s)
- Fadar Oliver Otite
- Cerebrovascular Division, Upstate Neurological Institute, Syracuse, NY, USA.
| | - Nicholas Morris
- Neurocritical Care Division, Department of Neurology, University of Maryland, Baltimore, MD, USA
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Kelly DM, Engelbertz C, Rothwell PM, Anderson CD, Reinecke H, Koeppe J. Age- and Sex-Specific Analysis of Stroke Hospitalization Rates, Risk Factors, and Outcomes From German Nationwide Data. Stroke 2024; 55:2284-2294. [PMID: 39145389 PMCID: PMC11346720 DOI: 10.1161/strokeaha.123.046118] [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: 12/06/2023] [Revised: 06/23/2024] [Accepted: 07/18/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Significant age and sex differences have been reported at each stage of the stroke pathway, from risk factors to outcomes. However, there is some uncertainty in previous studies with regard to the role of potential confounders and selection bias. Therefore, using German nationwide administrative data, we aimed to determine the magnitude and direction of trends in age- or sex-specific differences with respect to admission rates, risk factors, and acute treatments of ischemic and hemorrhagic stroke. METHODS We obtained and analyzed data from the Research Data Centres of the Federal Statistical Office for the years 2010 to 2020 with regard to all acute stroke hospitalizations, risk factors, treatments, and in-hospital mortality, stratified by sex and stroke subtype. This database provides a complete national-level census of stroke hospitalizations combined with population census counts. All hospitalized patients ≥15 years with an acute stroke (diagnosis code: I60-64) were included in the analysis. RESULTS Over the 11-year study period, there were 3 375 157 stroke events; 51.2% (n=1 728 954) occurred in men. There were higher rates of stroke admissions in men compared with women for both ischemic (378.1 versus 346.7/100 000 population) and hemorrhagic subtypes (75.6 versus 65.5/100 000 population) across all age groups. The incidence of ischemic stroke admissions peaked in 2016 among women (354.0/100 000 population) and in 2017 among men (395.8/100 000 population), followed by a consistent decline from 2018 onward. There was a recent decline in hemorrhagic stroke admissions observed for both sexes, reaching its nadir in 2020 (68.9/100 000 for men; 59.5/100 000 for women). Female sex was associated with in-hospital mortality for both ischemic (adjusted odds ratio, 1.11 [1.09-1.12]; P<0.001) and hemorrhagic stroke (adjusted odds ratio, 1.18 [95% CI, 1.16-1.20]; P<0.001). CONCLUSIONS Despite improvements in stroke prevention and treatment pathways in the past decade, sex-specific differences remain with regard to hospitalization rates, risk factors, and mortality. Better understanding the mechanisms for these differences may allow us to develop a sex-stratified approach to stroke care.
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Affiliation(s)
- Dearbhla M. Kelly
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom (D.M.K., P.M.R.)
| | - Christiane Engelbertz
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Germany (C.E., H.R.)
| | - Peter M. Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom (D.M.K., P.M.R.)
| | - Christopher D. Anderson
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston (C.D.A.)
- McCance Center for Brain Health, Massachusetts General Hospital, Boston (C.D.A.)
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA (C.D.A.)
| | - Holger Reinecke
- Department of Cardiology I – Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Germany (C.E., H.R.)
| | - Jeanette Koeppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Germany (J.K.)
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Ma J, Qian S, Ma N, Zhang L, Xu L, Liu X, Meng G. Effect of short-term 10 Hz repeated transcranial magnetic stimulation on postural control ability in patients with mild hemiparesis in acute ischemic stroke: a single-blinded randomized controlled trial. Front Neurol 2024; 15:1439904. [PMID: 39206286 PMCID: PMC11350563 DOI: 10.3389/fneur.2024.1439904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 07/26/2024] [Indexed: 09/04/2024] Open
Abstract
Background Previous studies have demonstrated that repetitive transcranial magnetic stimulation (rTMS) can improve postural control in subacute and chronic ischemic stroke, but further research is needed to investigate the effect of rTMS on acute ischemic stroke. Objective We compared the therapeutic effects of rTMS plus conventional rehabilitation and conventional rehabilitation on postural control in patients with mild hemiparesis in acute ischemic stroke. Methods Eighty-six patients with acute ischemic stroke were randomly assigned to either the experimental group or the control group within 1-7 days of onset. Patients in both groups received conventional rehabilitation for 2 weeks. Patients in the experimental group received rTMS treatments lasting for 2 weeks. Before and after the 2-week treatment, patients were assessed based on the Timed up and Go (TUG) test, Dual-Task Walking (DTW) test, Functional Ambulation Category (FAC), Tinetti Performance Oriented Mobility Assessment (POMA), gait kinematic parameters, Barthel Index (BI), Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and National Institutes of Health Stroke Scale (NIHSS). Additionally, TUG and single-task gait velocity were assessed at 2 months after the start of treatment, and independent walking recovery was also followed up. Results After 2 weeks of treatment, compared to conventional rehabilitation, participants who underwent rTMS treatment plus conventional rehabilitation exhibited notable enhancements in TUG, FAC, POMA, and some gait parameters [single-task gait velocity, gait stride length, gait cadence, gait cycle]. Changes in cognitive function partially mediated the improvement in single-task gait velocity and gait stride length by rTMS plus conventional rehabilitation. Generalized Estimating Equation (GEE) analysis showed that the trend of improvement in single-task gait velocity over time was more pronounced in the experimental group than in the control group. The results of the Kaplan-Meier curve indicated a median gait recovery time of 90 days for patients in the experimental group and 100 days for the control group. Multifactorial Cox regression analyses showed that rTMS plus conventional rehabilitation promoted faster recovery of independent walking compared with conventional rehabilitation. Conclusion rTMS plus conventional rehabilitation outperformed conventional rehabilitation in improving postural control in patients with acute ischemic stroke. Improvements in cognitive function may serve as a mediating factor in the favorable treatment outcome of rTMS plus conventional rehabilitation for improving postural control. Clinical trial registration https://www.chictr.org.cn, identifier ChiCTR1900026225.
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Affiliation(s)
- Jiangping Ma
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siyu Qian
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Neurology, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Nuo Ma
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lu Zhang
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linghao Xu
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xueyuan Liu
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guilin Meng
- Department of Neurology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
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Peacock M, Drumm B, Klein P, Raymond J, Huo X, Chen Y, Abdalkader M, Schonewille WJ, Liu X, Hu W, Li C, Ji X, Alemseged F, Liu L, Siegler JE, Nagel S, Strbian D, Sacco S, Yaghi S, Qureshi MM, Fischer U, Aguiar de Sousa D, Yamagami H, Michel P, Puetz V, Mujanovic A, Marto JP, Kristoffersen ES, Sandset EC, Demeestere J, Hanning U, Novakovic R, Kenmuir C, Agid R, Romoli M, Diana F, Lobotesis K, Roi D, Masoud HE, Ma A, Zhu Y, Sang H, Sun D, Ton MD, Raynald, Li F, Nasreldein A, Jesser J, Kaesmacher J, Weyland CS, Meyer L, Yeo LLL, Yang Q, Thomalla G, Yang P, Poli S, Campbell BCV, Qureshi AI, Chen HS, Zaidat OO, Qiu Z, Nogueira RG, Jovin TG, Miao Z, Nguyen TN, Banerjee S. Basilar artery occlusion management: An international survey of gender influence on management. Interv Neuroradiol 2024:15910199241265590. [PMID: 39140366 DOI: 10.1177/15910199241265590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND The superiority of endovascular thrombectomy (EVT) over medical management was not established in two early basilar artery occlusion (BAO) randomized controlled trials. Despite this, many clinicians recommended EVT for acute BAO under certain circumstances. This paper aims to compare physicians' diagnostic and management strategies of BAO according to gender. METHODS From January to March 2022 an international survey was conducted regarding management strategies in acute BAO. We compared responses between clinicians by identifying gender. Questions were designed to examine clinical and imaging parameters influencing management of patients with BAO. RESULTS Among the 1245 respondents from 73 countries, 311 (25.0%) identified as female. This figure was 13.6% amongst interventionists. Geographically, female respondents were lowest in Asia (14.5%) and North America (23.9%). The proportion of respondents identifying as female was consistent regardless of their years of experience. Female respondents were more likely to choose time of onset as time of first estimated stroke like symptom (48.0% vs. 38.5%, p < .01), were less likely to favor thrombectomy in the V4 segment of vertebrobasilar artery occlusions (31.5% vs. 43.3%, p < .01), and were less likely to find it acceptable to enroll all patients who met trial criteria in the standard medical treatment arm of a clinical trial (41.2% vs. 47.0%, p = .01). Male respondents were more likely to agree that thrombolysis would not alter their decision on proceeding with EVT (93.7% vs. 88.3%, p < .01). CONCLUSIONS Female clinicians appear to be significantly underrepresented in stroke medicine. This is most pronounced amongst interventionists and in Asia. Although male and female opinions were closely aligned on many aspects of BAO management, differences in opinion were observed in a number of significant areas which influence decision making.
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Affiliation(s)
- Meabh Peacock
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Brian Drumm
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
- Department of Stroke Medicine, Chelsea and Westminster NHS Trust, London, UK
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jean Raymond
- Department of Radiology, Interventional Neuroradiology Division, Centre Hospitalier de l'Universite de Montreal, Montreal, Canada
| | - Xiaochuan Huo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, China
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | - Xinfeng Liu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wei Hu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | | | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Beijing, China
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Liping Liu
- Neurology, Beijing Tiantan Hospital, Beijing, China
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Muhammad M Qureshi
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Urs Fischer
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital and Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization, Osaka National Hospital, Japan
| | - Patrik Michel
- Stroke Center, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway and Department of General Practice, University of Oslo, Oslo, Norway
| | - Else C Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
- The Norwegian Air Ambulance, Oslo, Norway
| | - Jelle Demeestere
- Neurology Department, Leuven University Hospital, Leuven, Belgium
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Robin Novakovic
- Department of Neurology and Radiology, UT Southwestern, Dallas, TX, USA
| | | | - Ronit Agid
- Division of Interventional Neuroradiology, Toronto Western Hospital, JDMI, UHN, University of Toronto, Toronto, Canada
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Francesco Diana
- Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Kyriakos Lobotesis
- Interventional Neuroradiology Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Dylan Roi
- Interventional Neuroradiology Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Alice Ma
- Department of Neurosurgery, Royal North Shore Hospital, Sydney, Australia
| | - Yuyou Zhu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Mai Duy Ton
- Stroke Center, Bach Mai Hospital, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Stroke and Cerebrovascular Disease, VNU-University of Medicine and Pharmacy, Hanoi, Vietnam
| | - Raynald
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Ahmed Nasreldein
- Neurology, Assiut University Hospitals, Assiut University, Assiut, Egypt
| | - Jessica Jesser
- Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | | | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Sven Poli
- Department of Neurology, University of Tuebingen, Tübingen, Germany
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO, USA
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Soma Banerjee
- Department of Stroke Medicine, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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Nuñez M, Allende MI, González F, Cavada G, Anderson CS, Muñoz Venturelli P. Sex Differences in Profile and In-Hospital Death for Acute Stroke in Chile: Data From a Nationwide Hospital Registry. J Am Heart Assoc 2024; 13:e035152. [PMID: 39023058 DOI: 10.1161/jaha.123.035152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/20/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Knowledge of local contextual sex differences in the profile and outcome for stroke can improve service delivery. We aimed to determine sex differences in the profile of patients with acute stroke and their associations with in-hospital death in the national hospital database of Chile. METHODS AND RESULTS We present a retrospective cohort based on the analysis of the 2019 Chilean database of Diagnosis-Related Groups, which represents 70% of the operational expenditure of the public health system. Random-effects multiple logistic regression models were used to determine independent associations of acute stroke (defined by main diagnosis International Classification of Diseases, Tenth Revision [ICD-10] codes) and in-hospital death, and reported with odds ratios (ORs) and 95% CIs. Of 1 048 575 hospital discharges, 15 535 were for patients with acute stroke (7074 [45.5%] in women), and 2438 (15.6%) of them died during hospitalization. Differences by sex in sociodemographic and clinical characteristics were identified for stroke and main subtypes. After fully adjusted model, women with ischemic stroke had lower in-hospital death (OR, 0.79 [95% CI, 0.69-0.91]) compared with men; other independent predictors included age per year increase (OR, 1.03 [95% CI, 1.03-1.04]), chronic kidney disease (OR, 1.47 [95% CI, 1.20-1.80]), atrial fibrillation (OR, 1.50 [95% CI, 1.26-1.80]), and other risk factors. Conversely, for intracerebral hemorrhage, women had a higher in-hospital mortality rate than men (OR, 1.19 [95% CI, 1.02-1.40]); other independent predictors included age per year increase (OR, 1.009 [95% CI, 1.003-1.01]), chronic kidney disease (OR, 1.55 [95% CI, 1.23-1.97]), oral anticoagulant use (OR, 1.88 [95% CI, 1.37-2.58]), and other risk factors. CONCLUSIONS Sex differences in characteristics and in-hospital death of hospitalized patients exist for acute stroke in Chile. In-hospital death is higher for acute ischemic stroke in men and higher for intracerebral hemorrhage in women. Future research is needed to better identify contributing factors.
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Affiliation(s)
- Marilaura Nuñez
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Ma Ignacia Allende
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
| | - Francisca González
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- Facultad de Ciencias de la Salud Blanquerna Universitat Ramon Llull Barcelona Spain
| | - Gabriel Cavada
- Escuela de Salud Pública Facultad de Medicina Universidad de Chile Santiago Chile
- Facultad de Medicina Universidad Finis Terrae Santiago Chile
- Unidad de Investigación Clínica Clínica Alemana de Santiago Santiago Chile
| | - Craig S Anderson
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
| | - Paula Muñoz Venturelli
- Centro de Estudios Clínicos Instituto de Ciencias e Innovación en Medicina, Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
- The George Institute for Global Health Faculty of Medicine, University of New South Wales Sydney NSW Australia
- Servicio de Neurología, Departamento de Neurología y Psiquiatría, Clínica Alemana de Santiago Facultad de Medicina Clínica Alemana Universidad del Desarrollo Santiago Chile
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Qu HL, Sun XY, He C, Chen HS. Sex Differences in the Dual Antiplatelet Therapy Versus Alteplase for Patients with Minor Nondisabling Acute Ischemic Stroke: A Secondary Analysis of the ARAMIS Study. CNS Drugs 2024; 38:649-659. [PMID: 38806883 DOI: 10.1007/s40263-024-01096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND PURPOSE Sex is associated with clinical outcome in stroke. The present study aimed to determine the effect of sex on efficacy of dual antiplatelet (DAPT) versus alteplase in ischemic stroke based on Antiplatelet versus recombinant tissue plasminogen activator (R-tPA) for Acute Mild Ischemic Stroke (ARAMIS) trial. METHODS In this secondary analysis of the ARAMIS study, eligible patients aged 18 years or older with minor nondisabling stroke who received dual antiplatelet therapy or intravenous alteplase within 4.5 h of stroke onset were divided into two groups: men and women. The primary endpoint was an excellent functional outcome, defined as a modified Rankin Scale (mRS) 0-1 at 90 days. Binary logistic regression analyses and generalized linear models were used. RESULTS Of the 719 patients who completed the study, 31% (223) were women, and 69% (496) were men. There were no significant sex differences in excellent functional outcome (unadjusted p = 0.304 for men and p = 0.993 for women; adjusted p = 0.376 for men and p = 0.918 for women) and favorable functional outcome (mRS score of 0-2; unadjusted p = 0.968 for men and p = 0.881 for women; adjusted p = 0.824 for men and p = 0.881 for women). But for the secondary outcomes, compared with alteplase, DAPT was associated with a significantly decreased proportion of early neurological deterioration within 24 h in men {unadjusted odds ratio [OR] = 0.440 [95% confidence interval (CI), 0.221-0.878]; p = 0.020; adjusted OR = 0.436 [95% CI, 0.216-0.877]; p = 0.020}, but not in women [unadjusted OR = 0.636 (95% CI, 0.175-2.319), p = 0.490; adjusted OR = 0.687 (95% CI, 0.181-2.609), p = 0.581]. For the safety outcomes, compared with the DAPT group, alteplase was associated with a significantly increased proportion of any bleeding events in men [unadjusted OR = 3.110 (95% CI, 1.103-8.770); p = 0.032], but not in women [unadjusted OR = 5.333 (95% CI, 0.613-46.407), p = 0.129; adjusted OR = 5.394 (95% CI, 0.592-49.112), p = 0.135]. CONCLUSION Sex did not influence the effect of dual antiplatelet therapy versus intravenous alteplase in minor nondisabling stroke, but more early neurological deterioration and bleeding events occurred in men who received alteplase.
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Affiliation(s)
- Hui-Ling Qu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Xiao-Yu Sun
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Chao He
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Hui-Sheng Chen
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China.
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7
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de Graaf JA, van Miltenburg S, Wermer MJH, Post MWM, Visser-Meily JMA. Gender differences in participation one year after stroke: exploring biopsychosocial predictors for women and men. Top Stroke Rehabil 2024:1-11. [PMID: 39045812 DOI: 10.1080/10749357.2024.2377518] [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: 12/16/2023] [Accepted: 06/29/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Women appear to have a higher risk for long term restrictions in participation than men. This gender difference is poorly understood, as solely biomedical factors have been examined to date. OBJECTIVES The aims of this study are (1) to map gender differences in participation outcome one year after stroke, and (2) to identify demographic, stroke-related, or psychological predictors of participation for women and men separately. METHODS A total of 326 patients (mean age 66.5 ± 12.4y, 35.0% women) completed the restriction and satisfaction subscales of the Utrecht Scale of Evaluation of Rehabilitation-Participation (USER-P) at one year after stroke. Bivariate and multiple linear regression analyses were performed. RESULTS Women reported worse scores for restrictions in participation compared to men (median 75.4 versus 87.9 respectively, p = 0.001), especially in physical activities such as daytrips and going out. Satisfaction with participation was similar between women and men. Worse cognitive functioning (β = 0.17) was associated with more restrictions in participation in men only, other predictors of restrictions in participation were similar between women and men. The presence of depressive symptoms (β = -0.49) was associated with worse satisfaction with participation in men, whereas an increased stroke severity (β = -0.29) and the presence of maladaptive psychological factors (β = -0.36) were associated with worse satisfaction with participation in women. CONCLUSIONS Women experience more restrictions in participation compared to men one year after stroke. Taking into account gender-specific predictors of participation in stroke aftercare is important, as different biopsychosocial factors contribute to problems in participation across women and men.
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Affiliation(s)
- Joris A de Graaf
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sanne van Miltenburg
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - Marcel W M Post
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- Center for Rehabilitation, Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Johanna M A Visser-Meily
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
- Department of Rehabilitation, Physical Therapy Science & Sports, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
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8
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López Ferreruela I, Obón Azuara B, Malo Fumanal S, Rabanaque Hernández MJ, Aguilar-Palacio I. Gender inequalities in secondary prevention of cardiovascular disease: a scoping review. Int J Equity Health 2024; 23:146. [PMID: 39044250 PMCID: PMC11264402 DOI: 10.1186/s12939-024-02230-3] [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: 02/03/2024] [Accepted: 07/09/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Despite significant progress in cardiovascular disease (CVD) management, it remains a public health priority and a global challenge. Within the disease process, health care after a cardiovascular event (secondary prevention) is essential to prevent recurrences. Nonetheless, evidence has suggested the existence of gender disparities in CVD management, leaving women in a vulnerable situation. The objective of this study is to identify all available evidence on the existence of gender differences in health care attention after a major adverse cardiovascular event. METHODS A scoping review following the structure of PRISMA-ScR was conducted. To define the inclusion criteria, we used Joanna Briggs Institute (JBI) population, concept, context framework for scoping reviews. A systematic search was performed in MEDLINE (PubMed), EMBASE and Cochrane. The methods of this review are registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) (INPLASY202350084). RESULTS The initial search retrieved 3,322 studies. 26 articles were identified manually. After the reviewing process, 93 articles were finally included. The main intervention studied was the pharmacological treatment received (n = 61, 66%), distantly followed by guideline-recommended care (n = 26, 28%) and cardiac rehabilitation (CR) referral (n = 16)". Literature described gender differences in care and management of secondary prevention of CVD. Women were less frequently treated with guideline-recommended medications and seem more likely to be non-adherent. When analysing guideline recommendations, women were more likely to make dietary changes, however, men were more likely to increase physical activity. Studies also showed that women had lower rates of risk factor testing and cholesterol goals attainment. Female sex was associated with lower rates of cardiac rehabilitation referral and participation. CONCLUSIONS This review allowed us to compile knowledge on the existence of gender inequalities on the secondary prevention of CVD. Additional research is required to delve into various factors influencing therapeutic disparities, referral and non-participation in CR programs, among other aspects, in order to improve existing knowledge about the management and treatment of CVD in men and women. This approach is crucial to ensure the most equitable and effective attention to this issue.
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Affiliation(s)
- Irene López Ferreruela
- Internal Medicine Service, Miguel Servet University Hospital, Saragossa, Spain.
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain.
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain.
| | - Blanca Obón Azuara
- Intensive Medicine Service, Lozano Blesa University Hospital, Saragossa, Spain
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
| | - Sara Malo Fumanal
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
| | - María José Rabanaque Hernández
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
| | - Isabel Aguilar-Palacio
- GRISSA Research Group. IIS Aragón, Aragon Health Sciences Institute, Saragossa, Spain
- Faculty of Medicine, University of Zaragoza, Saragossa, Spain
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9
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Apostolaki-Hansson T, Kremer C, Pihlsgård M, Petersson J, Norrving B, Ullberg T. Diverging Trends in Survival and Functional Outcome between Males and Females after Intracerebral Hemorrhage. Neuroepidemiology 2024:1-11. [PMID: 38981450 DOI: 10.1159/000539958] [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: 03/25/2024] [Accepted: 06/11/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Compared to ischemic stroke, sex differences in patient outcomes following intracerebral hemorrhage (ICH) are underreported. We aimed to determine sex differences in mortality and functional outcomes in a large, unselected Swedish cohort. METHODS In this observational study, data on 22,789 patients with spontaneous ICH registered in the Swedish Stroke Register between 2012 and 2019 were used to compare sex differences in 90-day mortality and functional outcome using multivariable Cox and logistic regression analyses, adjusting for relevant confounders. Multiple imputation was used to impute missing data. RESULTS The crude 90-day mortality rate was 36.7% in females (3,820/10,405) and 31.7% in males (3,929/12,384) (female hazard ratio [HR] 1.20 95% confidence interval [CI]: 1.15-1.25). In multivariable analysis, the HR for 90-day mortality following ICH in females was 0.89 (95% CI: 0.85-0.94). Age was an important driving factor for the effect of sex on mortality. After adjustment for age, vascular risk factors, and stroke severity, the 90-day functional outcome in pre-stroke independent patients was worse in females compared to males (odds ratio: 1.27 95% CI: 1.16-1.40). CONCLUSION In this large observational study, despite lower 90-day mortality, the female sex was independently associated with a worse functional outcome compared to males after ICH, even after adjusting for significant covariates. These diverging trends have not been previously reported for ICH. Given the observational design, our findings should be interpreted with caution, thus further external validation is warranted.
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Affiliation(s)
- Trine Apostolaki-Hansson
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Christine Kremer
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Mats Pihlsgård
- Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
| | - Jesper Petersson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Bo Norrving
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Teresa Ullberg
- Department of Neurology, Skåne University Hospital, Malmö/Lund, Lund, Sweden
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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10
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Sterling KA, MacLeod MJ, Barber M, Turner M. Acute Care, Secondary Prevention, and Outcomes after Ischaemic and Haemorrhagic Stroke in Men and Women: A Data-Linkage Study. Cerebrovasc Dis 2024:1-8. [PMID: 39019023 DOI: 10.1159/000540371] [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: 03/30/2024] [Accepted: 07/08/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION There is evidence that sex differences exist in stroke presentation, risk factors, severity, treatment, and outcomes. To further understand this, we explored how sex differences influence acute stroke management, secondary prevention prescribing, and mortality outcomes in a well-characterised cohort of first-ever stroke patients in Scotland. METHODS This is a retrospective, population-based, data-linkage study of stroke admissions to acute care hospitals in Scotland between January 1, 2011, and December 31, 2018. Data sources included the Scottish Stroke Care Audit (SSCA), the Prescribing Information System (PIS), the Scottish Morbidity Record 01 (SMR01), and the National Records of Scotland (NRS) death records. Multivariable logistic regression was used to explore the association between patient sex, acute stroke care, and secondary prevention prescribing, while Cox proportional hazards models were used to explore the association between patient sex and all-cause mortality up to 1 year after index event. RESULTS This study included 5,901 patients with a first-ever intracerebral haemorrhage (ICH) and 47,087 patients with a first-ever acute ischaemic stroke (AIS). After an ICH, women had significantly lower odds of receiving all components of the stroke care bundle (adjusted odds ratio [aOR], 0.78; 95% confidence interval [CI], 0.69-0.87) and were less likely to be prescribed antihypertensives within 90 days after discharge to the usual place of residence (aOR, 0.78; 95% CI, 0.63-0.97). There was no sex difference in stroke care bundle achievement for those admitted with AIS; however, women had significantly lower odds of receiving antihypertensives, lipid-lowering drugs, or oral anticoagulants after discharge. The risk of all-cause mortality was lower in women at 1 year after both ICH (adjusted hazard ratio [aHR], 0.90; 95% CI, 0.83-0.98) and AIS (aHR, 0.91; 95% CI, 0.87-0.95) after adjusting for potential confounders. CONCLUSION The sex differences in stroke treatment and outcomes may be partly explained by the older age of women at the time of stroke, which influences stroke presentation, severity, and prognosis. However, following adjustment, women had a reduced risk of all-cause mortality after both ICH and AIS.
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Affiliation(s)
- Kadie-Ann Sterling
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Mark Barber
- Stroke Unit, University Hospital Monklands, NHS Lanarkshire, Airdrie, UK
| | - Melanie Turner
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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11
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Medlin F, Strambo D, Lambrou D, Caso V, Michel P. Service delivery in acute ischemic stroke patients: Does sex matter? Eur J Neurol 2024; 31:e16287. [PMID: 38553933 PMCID: PMC11235595 DOI: 10.1111/ene.16287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND AND PURPOSE Women with acute ischemic stroke (AIS) are older and have greater preexisting handicap than men. Given that these factors do not fully explain their poorer long-term outcomes, we sought to investigate potential sex differences in the delivery of acute stroke care in a large cohort of consecutive AIS patients. METHODS We analyzed all patients from ASTRAL (Acute Stroke Registry and Analysis of Lausanne) from March 2003 to December 2019. Multivariable analyses were performed on acute time metrics, revascularization therapies, ancillary examinations for stroke workup, subacute symptomatic carotid artery revascularization, frequency of change in goals of care (palliative care), and length of hospital stay. RESULTS Of the 5347 analyzed patients, 45% were biologically female and the median age was 74.6 years. After multiple adjustments, female sex was significantly associated with higher onset-to-door (adjusted hazard ratio [aHR] = 1.09, 95% confidence interval [CI] = 1.04-1.14) and door-to-endovascular-puncture intervals (aHR = 1.15, 95% CI = 1.05-1.25). Women underwent numerically fewer diagnostic examinations (adjusted odds ratio [aOR] = 0.94, 95% CI = 0.85-1.04) and fewer subacute carotid revascularizations (aOR = 0.69, 95% CI = 0.33-1.18), and had longer hospital stays (aHR = 1.03, 95% CI = 0.99-1.07), but these differences were not statistically significant. We found no differences in the rates of acute revascularization treatments, or in the frequency of change of goals of treatments. CONCLUSIONS This retrospective analysis of a large, consecutive AIS cohort suggests that female sex is associated with unfavorable pre- and in-hospital time metrics, such as a longer onset-to-door and door-to-endovascular-puncture intervals. Such indicators of less effective stroke care delivery may contribute to the poorer long-term functional outcomes in female patients and require further attention.
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Affiliation(s)
- Friedrich Medlin
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
- Stroke and Neurology UnitFribourg HospitalFribourgSwitzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
| | - Dimitris Lambrou
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia HospitalUniversity of PerugiaPerugiaItaly
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical NeurosciencesLausanne University HospitalLausanneSwitzerland
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12
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Chen Y, Zeng X, Kwan ATH, Mofatteh M, Nguyen TN, Zhou S, Wei H, Dmytriw AA, Regenhardt RW, Yan Z, Yang S, Cai X, Abdalkader M, Liao X. Sex Differences in Outcomes after Endovascular Thrombectomy for Patients with Acute Ischemic Stroke. Eur Neurol 2024; 87:113-121. [PMID: 38797167 DOI: 10.1159/000539269] [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: 08/25/2023] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is the standard of care for patients with large-vessel occlusion acute ischemic stroke (AIS). There may be differing recanalization effectiveness based on patients' sex, and understanding such variations can improve patient outcomes by adjusting for differences. We aimed to assess the sex differences in outcome after EVT for patients with AIS. METHODS We retrospectively analyzed 250 consecutive AIS patients who underwent EVT from July 2019 to February 2022 across two large comprehensive tertiary care stroke centers in China. Outcomes of male patients were compared to females, where poor outcome was defined as a modified Rankin score (mRS) of 3-6 at 90 days. RESULTS Male patients had higher rates of symptomatic intracranial hemorrhage (sICH) (12.50% vs. 4.05%, p = 0.042) and higher hospitalization costs (114,541.08 vs. 105,790.27 RMB, p = 0.024). Male patients also had a longer median onset-to-needle time (ONT) (146.00 [104.00, 202.00] versus 120.00 [99.25, 144.75], p = 0.026). However, there were no differences in hospitalization length (p = 0.251), 90-day favorable outcome (p = 0.952), and 90-day mortality (p = 0.931) between the sexes. CONCLUSION Female patients had lower hospitalization costs and sICH rates than males after EVT for AIS. Identifying such differences and implementing measures, including adaptations to workflow optimization, would help to reduce the ONT and last known normal-to-puncture time seen in males to improve patient outcomes. Despite such variations, favorable outcomes and mortality are similar in female and male AIS patients.
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Affiliation(s)
- Yimin Chen
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, China
| | - Xuehua Zeng
- Department of Research and Education, Foshan Sanshui District People's Hospital, Foshan, China
| | - Angela T H Kwan
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mohammad Mofatteh
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK,
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Sijie Zhou
- Department of Surgery of Cerebrovascular Diseases, First People's Hospital of Foshan, Foshan, China
| | - Hongquan Wei
- Department of 120 Command Center, Foshan Sanshui District People's Hospital, Foshan, China
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging and Clinical Neurological Sciences, London Health Sciences Center, Western University, London, Ontario, Canada
- Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zile Yan
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, China
| | - Shuiquan Yang
- Department of Neurology and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, China
| | - Xiaodong Cai
- Department of Neurosurgery, First People's Hospital of Foshan, Foshan, China
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Xuxing Liao
- Department of Neurosurgery, First People's Hospital of Foshan, Foshan, China
- Department of Neurosurgery and Advanced National Stroke Center, Foshan Sanshui District People's Hospital, Foshan, China
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13
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Trout AL, McLouth CJ, Westberry JM, Sengoku T, Wilson ME. Estrogen's sex-specific effects on ischemic cell death and estrogen receptor mRNA expression in rat cortical organotypic explants. AGING BRAIN 2024; 5:100117. [PMID: 38650743 PMCID: PMC11033203 DOI: 10.1016/j.nbas.2024.100117] [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: 10/19/2023] [Revised: 02/14/2024] [Accepted: 04/09/2024] [Indexed: 04/25/2024] Open
Abstract
Estrogens, such as the biologically active 17-β estradiol (E2), regulate not only reproductive behaviors in adults, but also influence neurodevelopment and neuroprotection in both females and males. E2, contingent upon the timing and concentration of the therapy, is neuroprotective in female and male rodent models of stroke. In Vivo studies suggest that E2 may partially mediate this neuroprotection, particularly in the cortex, via ERα. In Vitro studies, utilizing a chemically induced ischemic injury in cortical explants from both sexes, suggest that ERα or ERβ signaling is needed to mediate the E2 protection. Since we know that the timing and concentration of E2 therapy may be sex-specific, we examined if E2 (1 nM) mediates neuroprotection when female and male cortical explants are separately isolated from postnatal day (PND) 3-4 rat. Changes in basal levels ERα, ERβ, and AR mRNA expression are compared across early post-natal development in the intact cortex and the corresponding days in vitro (DIV) for cortical explants. Following ischemic injury at 7 DIV, cell death and ERα, ERβ and AR mRNA expression was compared in female and male cortical explants. We provide evidence that E2-mediated protection is maintained in isolated cortical explants from females, but not male rats. In female cortical explants, the E2-mediated protection at 24 h occurs secondarily to a blunted transient increase in ERα mRNA at 12 h. These results suggest that cortical E2-mediated protection is influenced by sex and supports data to differentially treat females and males following ischemic injury.
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Affiliation(s)
- Amanda L. Trout
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
- Department of Neurosurgery, University of Kentucky, Lexington, KY 40536, USA
| | - Christopher J McLouth
- Department of Neurology, University of Kentucky, Lexington, KY, 40536, USA
- Department of Biostatistics, University of Kentucky, Lexington, KY, 40536, USA
| | - Jenne M. Westberry
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
| | - Tomoko Sengoku
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
| | - Melinda E. Wilson
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA
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14
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Rosso M, Stengl H, Ganeshan R, Hellwig S, Klammer MG, von Rennenberg R, Böhme S, Nolte CH, Audebert HJ, Endres M, Kasner SE, Scheitz JF. Sex Differences in Outcomes of Acute Myocardial Injury After Stroke. J Am Heart Assoc 2024; 13:e032755. [PMID: 38410952 PMCID: PMC10944046 DOI: 10.1161/jaha.123.032755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/11/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Sex differences in presentation, treatment, and prognosis of cardiovascular disorders are well recognized. Although an association between acute myocardial injury and mortality after ischemic stroke has been demonstrated, it is unclear whether prevalence and outcome of poststroke acute myocardial injury differ between women and men. METHODS AND RESULTS We prospectively screened consecutive patients with acute ischemic stroke and serial high-sensitivity cardiac troponin T measurements admitted to our center. Acute myocardial injury was defined as at least 1 high-sensitivity cardiac troponin T value above the upper reference limit (14 ng/L) with a rise/fall of >20%. Rates of acute myocardial injury were also calculated using sex-specific high-sensitivity cardiac troponin T cutoffs (women upper reference limit, 9 ng/L; men upper reference limit, 16 ng/L). Logistic regression analyses were performed to evaluate the association between acute myocardial injury and outcomes. Of 1067 patients included, 494 were women (46%). Women were older, had a higher rate of known atrial fibrillation, were more likely to be functionally dependent before admission, had higher stroke severity, and more often had cardioembolic strokes (all P values <0.05). The crude prevalence of acute myocardial injury differed by sex (29% women versus 23% men, P=0.024). Statistically significant associations between acute myocardial injury and outcomes were observed in women (7-day in-hospital mortality: adjusted odds ratio [aOR], 3.2 [95% CI, 1.07-9.3]; in-hospital mortality: aOR, 3.3 [95% CI, 1.4-7.6]; modified Rankin Scale score at discharge: aOR, 1.6 [95% CI, 1.1-2.4]) but not in men. The implementation of sex-specific cutoffs did not increase the prognostic value of acute myocardial injury for unfavorable outcomes. CONCLUSIONS The prevalence of acute myocardial injury after ischemic stroke and its association with mortality and greater disability might be sex-dependent. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03892226.
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Affiliation(s)
- Michela Rosso
- Department of Neurology University of Pennsylvania Philadelphia PA USA
| | - Helena Stengl
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
| | - Ramanan Ganeshan
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Simon Hellwig
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
| | - Markus G Klammer
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Regina von Rennenberg
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
| | - Sophie Böhme
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Christian H Nolte
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
| | - Heinrich J Audebert
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
| | - Matthias Endres
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin Germany
- German Center for Mental Health (DZPG) Partner Site Berlin Germany
| | - Scott E Kasner
- Department of Neurology University of Pennsylvania Philadelphia PA USA
| | - Jan F Scheitz
- Department of Neurology Charité - Universitätsmedizin Berlin Berlin Germany
- Center for Stroke Research Berlin (CSB) Charité - Universitätsmedizin Berlin Berlin Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin Berlin Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin Germany
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15
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Wang JJ, Katz JM, Sanmartin M, Naidich JJ, Rula E, Sanelli PC. Gender-Based Disparity in Acute Stroke Imaging Utilization and the Impact on Treatment and Outcomes: 2012 to 2021. J Am Coll Radiol 2024; 21:128-140. [PMID: 37586470 PMCID: PMC10840948 DOI: 10.1016/j.jacr.2023.07.015] [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: 04/26/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Prior studies have revealed significant socio-economic disparities in neuro-imaging and treatment utilization for patients with acute ischemic stroke (AIS). In this study, we sought to evaluate whether a sex-based disparity exists in neuro-imaging and to determine its etiology and association with acute treatment and outcomes. MATERIALS AND METHODS This was a retrospective study of consecutive patients with AIS admitted to a comprehensive stroke center between 2012 and 2021. Patient demographic and clinical characteristics, neuro-imaging, acute treatment, and early clinical outcomes were extracted from the electronic medical records. Trend analysis, bivariate analysis of patient characteristics by sex, and multivariable logistic regression analyses were conducted. RESULTS Of the 7,540 AIS episodes registered from 2012 to 2021, 47.9% were female patients. After adjusting for demographic, clinical, and temporal factors, significantly higher utilization of CTA was found for male patients (odds ratio = 1.20 [95% confidence interval 1.07-1.34]), particularly from socio-economically advantaged groups, and in years 2015 and 2019, representing the years endovascular thrombectomy recommendations changed. Despite this, male patients had significantly lower intravenous thrombolysis utilization (odds ratio = 0.83 [95% confidence interval 0.71-0.96]) and similar endovascular thrombectomy rates as female patients. There were no significant sex differences in early clinical outcomes, and no relevant clinical or demographic factors explained the CT angiography utilization disparity. CONCLUSION Despite higher CT angiography utilization in socio-economically advantaged male patients with AIS, likely overutilization due to implicit biases following guideline updates, the rates of acute treatment, and early clinical outcomes were unaffected.
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Affiliation(s)
- Jason J Wang
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York; and Professor and Health Economist, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.
| | - Jeffrey M Katz
- Associate Professor of Neurology & Radiology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York; Chief, Neurovascular Services and Neurology Service Line Director, Neuroendovascular Surgery; Director, Comprehensive Stroke Center and Stroke Unit, North Shore University Hospital; Director, Neuroendovascular Surgery, South Shore University Hospital
| | - Maria Sanmartin
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York; and Assistant Professor and Health Economist, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Jason J Naidich
- Chair, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and Senior Vice President and Chief Innovation Officer, Northwell Health, Hempstead, New York
| | - Elizabeth Rula
- Executive Director, The Harvey L. Neiman Health Policy Institute, Reston, Virginia
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, New York, and Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Rosso M, Ramaswamy S, Kvantaliani N, Mulatu Y, Little JN, Marczak I, Brahmaroutu A, Deo R, Lewey J, Messé SR, Cucchiara BL, Levine SR, Kasner SE. Stroke-Heart Syndrome: Does Sex Matter? J Am Heart Assoc 2023; 12:e029799. [PMID: 37850436 PMCID: PMC10727394 DOI: 10.1161/jaha.123.029799] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/09/2023] [Indexed: 10/19/2023]
Abstract
Background Cardiovascular complications after acute ischemic stroke (AIS) can be related to chronic/comorbid cardiac conditions or acute disruption of the brain-heart autonomic axis (stroke-heart syndrome). Women are known to be more vulnerable to certain stress-induced cardiac complications, such as Takotsubo cardiomyopathy. We investigated sex differences in cardiac troponin (cTn) elevation, cardiac events, and outcomes after AIS. Methods and Results We retrospectively analyzed consecutive patients with AIS from 5 stroke centers. Patients with AIS with elevated baseline cTn and at least 2 cTn measurements were included, while patients with acute comorbid conditions that could impact cTn levels were excluded. Poststroke acute myocardial injury was defined as the presence of a dynamic cTn pattern (rise/fall >20% in serial measurements) in the absence of acute atherosclerotic coronary disease (type 1 myocardial infarction) or cardiac death (type 3 myocardial infarction). From a total cohort of 3789 patients with AIS, 300 patients were included in the study: 160 were women (53%). Women were older, had a lower burden of cardiovascular risk factors, and more frequently had cardioembolic stroke and right insula involvement (P values all <0.05). In multivariate analysis, women were more likely to have a dynamic cTn pattern (adjusted odds ratio, 2.1 [95% CI, 1.2-3.6]) and develop poststroke acute myocardial injury (adjusted odds ratio, 2.1 [95% CI, 1.1-3.8]). Patients with poststroke acute myocardial injury had higher 7-day mortality (adjusted odds ratio, 5.5 [95% CI, 1.2-24.4]). Conclusions In patients with AIS with elevated cTn at baseline, women are twice as likely to develop poststroke acute myocardial injury, and this is associated with higher risk of short-term mortality. Translational studies are needed to clarify mechanisms underlying sex differences in cardiac events and mortality in AIS.
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Affiliation(s)
- Michela Rosso
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | - Srinath Ramaswamy
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Yohannes Mulatu
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Izabela Marczak
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | | | - Rajat Deo
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Jennifer Lewey
- Division of Cardiology, Department of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Steven R. Messé
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
| | | | - Steven R. Levine
- Department of NeurologySUNY Downstate Health Sciences UniversityBrooklynNY
| | - Scott E. Kasner
- Department of NeurologyUniversity of PennsylvaniaPhiladelphiaPA
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17
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Vyas MV, Fang J, de Oliveira C, Austin PC, Yu AYX, Kapral MK. Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health. Stroke 2023; 54:2824-2831. [PMID: 37823307 DOI: 10.1161/strokeaha.123.043369] [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: 03/26/2023] [Accepted: 07/14/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health. METHODS We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health. RESULTS The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731). CONCLUSIONS Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.
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Affiliation(s)
- Manav V Vyas
- Division of Neurology, Department of Medicine (M.V.V., A.Y.X.Y.), University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Division of Neurology, Li Ka Shing Knowledge Institute, St. Michael's Hospital-Unity Health Toronto, Canada (M.V.V.)
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Jiming Fang
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Claire de Oliveira
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Health Economics, Centre for Addictions and Mental Health, Toronto, Canada (C.d.O.)
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
| | - Amy Y X Yu
- Division of Neurology, Department of Medicine (M.V.V., A.Y.X.Y.), University of Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada (A.Y.X.Y.)
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health (M.V.V., C.d.O., P.C.A., A.Y.X.Y., M.K.K.), University of Toronto, Canada
- Division of General Internal Medicine, Department of Medicine (M.K.K.), University of Toronto, Canada
- ICES, Toronto, Canada (M.V.V., J.F., C.d.O., P.C.A., A.Y.X.Y., M.K.K.)
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18
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Dawson J, MacDonald A. Sex and hypertensive organ damage: stroke. J Hum Hypertens 2023; 37:644-648. [PMID: 37059829 PMCID: PMC10403348 DOI: 10.1038/s41371-023-00830-0] [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: 06/27/2022] [Revised: 02/08/2023] [Accepted: 04/05/2023] [Indexed: 04/16/2023]
Abstract
Stroke is a common cause of death and disability in both men and women. Differences in the incidence, presenting features and outcome after stroke have been reported between men and women. The global lifetime risk of stroke of approximately 25% is similar in men and women, although in women, the first cardiovascular event is more likely to be stroke than in men. Concerningly, there are reports of underuse of some treatments in women, although these differences may be diminishing over time. In addition, there are specific clinical challenges that can arise in women with stroke, such as stroke in people taking hormonal therapy, and stroke during pregnancy and stroke in the post-partum period. This review will cover these areas highlighting important differences and areas for future research. We found there are important differences in incidence of stroke, which differ by age. Further, there is concerning evidence that some treatments such as intravenous thrombolysis are underused in women. While there may be some differences in the relative effectiveness of treatments such as antiplatelet therapy and blood pressure reduction between men and women, for most aspects of stroke care, benefit is clear in both men and women and the emphasis must be on more equitable access. There is limited evidence to inform decision making during pregnancy and the post-partum period, but guidelines now exist and further research is needed in these areas.
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Affiliation(s)
- Jesse Dawson
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Alexander MacDonald
- School of Cardiovascular and Metabolic Health, College of Medical, Veterinary & Life Sciences, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
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Silva Y, Sánchez-Cirera L, Terceño M, Dorado L, Valls A, Martínez M, Abilleira S, Rubiera M, Quesada H, Llull L, Rodríguez-Campello A, Martí-Fàbregas J, Seró L, Purroy F, Payo I, García S, Cánovas D, Krupinski J, Mas N, Palomeras E, Cocho D, Font MÀ, Catena E, Puiggròs E, Pedroza C, Marín G, Carrión D, Costa X, Almendros MC, Torres I, Colom C, Velasquez JA, Diaz G, Jiménez X, Subirats T, Deulofeu A, Hidalgo V, Salvat-Plana M, Pérez de la Ossa N. Sex and gender differences in acute stroke care: metrics, access to treatment and outcome. A territorial analysis of the Stroke Code System of Catalonia. Eur Stroke J 2023; 8:557-565. [PMID: 37231687 PMCID: PMC10334164 DOI: 10.1177/23969873231156260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/23/2023] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Previous studies have reported differences in the management and outcome of women stroke patients in comparison with men. We aim to analyze sex and gender differences in the medical assistance, access to treatment and outcome of acute stroke patients in Catalonia. PATIENTS AND METHODS Data were obtained from a prospective population-based registry of stroke code activations in Catalonia (CICAT) from January/2016 to December/2019. The registry includes demographic data, stroke severity, stroke subtype, reperfusion therapy, and time workflow. Centralized clinical outcome at 90 days was assessed in patients receiving reperfusion therapy. RESULTS A total of 23,371 stroke code activations were registered (54% men, 46% women). No differences in prehospital time metrics were observed. Women more frequently had a final diagnosis of stroke mimic, were older and had a previous worse functional situation. Among ischemic stroke patients, women had higher stroke severity and more frequently presented proximal large vessel occlusion. Women received more frequently reperfusion therapy (48.2% vs 43.1%, p < 0.001). Women tended to present a worse outcome at 90 days, especially for the group receiving only IVT (good outcome 56.7% vs 63.8%; p < 0.001), but not for the group of patients treated with IVT + MT or MT alone, although sex was not independently associated with clinical outcome in logistic regression analysis (OR 1.07; 95% CI, 0.94-1.23; p = 0.27) nor in the analysis after matching using the propensity score (OR 1.09; 95% CI, 0.97-1.22). DISCUSSION AND CONCLUSION We found some differences by sex in that acute stroke was more frequent in older women and the stroke severity was higher. We found no differences in medical assistance times, access to reperfusion treatment and early complications. Worse clinical outcome at 90 days in women was conditioned by stroke severity and older age, but not by sex itself.
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Affiliation(s)
| | | | | | - Laura Dorado
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Adrián Valls
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Marina Martínez
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | - Marta Rubiera
- Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Helena Quesada
- Hospital Universitari de Bellvitge, L’Hospitalet de llobregat, Spain
| | - Laura Llull
- Hospital Clínic of Barcelona, Barcelona, Spain
| | | | | | - Laia Seró
- Hospital Universitari Joan XXIII, Tarragona, Spain
| | | | - Iago Payo
- Hospital Verge de la Cinta, Tortosa, Spain
| | - Sònia García
- Complex Hospitalari Moisès Broggi, Sant Joan Despí, Spain
| | | | | | | | | | | | | | - Esther Catena
- Consorci Sanitari Alt Penedès-Garraf, Vilafranca del Penedès, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mercè Salvat-Plana
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Pla Director de les Malalties Vasculars Cerebrals. Agència de Qualitat i Avaluació Sanitàries de Catalunya (AQuAS) CIBER en Epidemiolgia i Salut Pública (CBERESP), Departament de Salut, Barcelona, Spain
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20
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Naveed H, Almasri M, Kazani B, Nauman A, Akhtar N, Singh R, Kamran S, Al Jerdi S, Thermalingem S, Shuaib A. Women and stroke: disparities in clinical presentation, severity, and short- and long-term outcomes. Front Neurol 2023; 14:1147858. [PMID: 37255725 PMCID: PMC10225500 DOI: 10.3389/fneur.2023.1147858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 06/01/2023] Open
Abstract
Objectives There are limited data from the Middle East on sex-related differences in short- and long-term stroke outcomes. We present 8 years of experience based on the Qatar stroke database. Setting The Qatar stroke database prospectively collects data on all stroke patients admitted to Hamad General Hospital. For this study, we compared female and male acute ischemic stroke patients on their characteristics at admission, short-term outcomes [modified Rankin Scale (mRS) score], and long-term outcomes [incidence of major adverse cardiovascular events (MACEs)]. Participants A total of 7,300 patients [F: 1,406 (19.3%), M: 5,894 (80.7%); mean age 55.1 ± 13.3 (F: 61.6 ± 15.1, M: 53.5 ± 12.3; p < 0.001)] were admitted with acute ischemic stroke. Results Significantly fewer women presented within 4.5 h of onset (F: 29% vs. M: 32.8%; p = 0.01). Although women were more likely to experience severe stroke (NIHSS >10; F: 19.9% vs. M: 14.5%; p < 0.001), fewer were treated with thrombolysis (F: 9.8% vs. M: 12.1%; p = 0.02). Women experienced more medical complications (F: 11.7% vs. M: 7.4%; p < 0.001) and tended to have a more prolonged length of stay in the hospital (F: 6.4 ± 7.6 days vs. M: 5.5 ± 6.8 days; p < 0.001). Primary and secondary outcome measures Good outcomes at 90 days (mRS score of 0-2) were less frequent in women (F: 53.3% vs. M: 71.2%; p < 0.001). Fewer female patients were taking antiplatelets (F: 78% vs. M: 84.8%; p < 0.001) or statins (F: 81.2% vs. M: 85.7%; p < 0.001). Significantly more female patients experienced a MACE (F: 12.6% vs. M: 6.5%; p < 0.001). Conclusion Older age at presentation contributes to poor outcomes following acute stroke in women. Other contributing factors include delays in admission to the hospital, lower rates of thrombolysis, and lower rates of provision of preventative treatments.
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Affiliation(s)
- Hiba Naveed
- Weill Cornell College of Medicine, Doha, Qatar
| | | | | | | | - Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | | | - Sathvika Thermalingem
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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21
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Kimiagar I, Khiri F, Tal S, Levite R, Kalmanovich-Avnery S, Aroesty R, Bhonkar S, Wainstein J, Kenan G, Shimon N, Khadija A, Agajani N, Galinskaya S, Wolfson S, Haitov Z, Kalmanovich E, Trotsky D, Ilgiyaev E, Armon C. Sex-dependent outcomes of recanalization-treated acute ischemic stroke patients at Shamir (Assaf Harofeh) medical center, Israel, 2011-2020. J Neurol Sci 2023; 450:120674. [PMID: 37182423 DOI: 10.1016/j.jns.2023.120674] [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: 12/16/2022] [Revised: 05/01/2023] [Accepted: 05/06/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND/OBJECTIVES Sex-based differences in incidence, etiologies, severity and recanalization treatment outcomes of patients with acute ischemic stroke (AIS) have been studied extensively. We set out to determine if there were sex-based differences in outcomes among AIS patients who received recanalization treatments at Shamir (Assaf Harofeh) Medical Center (SMC), Israel, between 2011 and 2020. METHODS This was a single-center, retrospective chart review. The primary analysis compared outcomes for men and women, overall and stratifying by disease severity. We compared also demographics, risk factors and workflow data. RESULTS Eight hundred and eleven patients received recanalization treatment between 2011 and 2020: 472 (58.1%) men and 339 (41.8%) women. Mean age, NIHSS score and proportion with an NIHSS score ≥ 6 were higher for women. Cerebrovascular risk factors were more prevalent in women, particularly atrial fibrillation, except that current smoking was more prevalent in men. Six hundred and twenty patients (78.1%) were treated with TPA alone, 89 (11.2%) with TPA and endovascular treatment (EVT), and 85 (10.7%) with EVT alone. Fifty percent of patients were discharged home, 41% to a rehabilitation hospital or nursing home, and 9% did not survive. Twenty-four patients (3%) sustained symptomatic bleeds. Outcomes were worse in patients with NIHSS score ≥ 6. Outcomes did not differ by sex. CONCLUSIONS While treated women presented with more severe AIS and more risk factors, we did not find significant sex-related differences in outcomes. Meticulous adherence to risk factor modification remains the best strategy to reduce stroke incidence, morbidity, and mortality in women and in men.
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Affiliation(s)
- Itzhak Kimiagar
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Fikri Khiri
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Sigal Tal
- Radiology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Ronen Levite
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Shani Kalmanovich-Avnery
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Rina Aroesty
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Sarah Bhonkar
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Jochay Wainstein
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Gilad Kenan
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Nitai Shimon
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Ahmed Khadija
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Neta Agajani
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Sofia Galinskaya
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Sharon Wolfson
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Zoya Haitov
- Anesthesiology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Eran Kalmanovich
- Cardiac Intensive Care, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Daniel Trotsky
- Emergency Medicine, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Eduard Ilgiyaev
- Intensive Care, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel
| | - Carmel Armon
- Departments of Neurology, Tel Aviv University Faculty of Medicine and Shamir (Assaf Harofeh) Medical Center, Israel.
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Noseda R, Rea F, Pagnamenta A, Agazzi P, Bianco G, Sihabdeen S, Seiffge D, Michel P, Nedeltchev K, Bonati L, Kägi G, Niederhauser J, Nyffeler T, Luft A, Wegener S, Schelosky L, Medlin F, Rodic B, Peters N, Renaud S, Mono ML, Carrera E, Fischer U, Ceschi A, Cereda CW. Sex Differences in Outcomes of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Preadmission Use of Antiplatelets. CNS Drugs 2023; 37:351-361. [PMID: 36976463 PMCID: PMC10126038 DOI: 10.1007/s40263-023-00997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
AIM To compare safety and functional outcomes of intravenous thrombolysis (IVT) between females and males with acute ischaemic stroke (AIS) in relation to preadmission use of antiplatelets. METHODS Multicentre cohort study of patients admitted from 1 January 2014 to 31 January 2020 to hospitals participating in the Swiss Stroke Registry, presenting with AIS and receiving IVT. Primary safety outcome was in-hospital symptomatic intracerebral haemorrhage (sICH). Primary functional outcome was functional independence at 3 months after discharge. Multivariable logistic regression models were fitted to assess the association between sex and each outcome according to preadmission use of antiplatelets. RESULTS The study included 4996 patients (42.51 % females, older than males, median age 79 vs 71 years, p < 0.0001). Comparable proportions of females (39.92 %) and males (40.39 %) used antiplatelets before admission (p = 0.74). In total, 3.06 % females and 2.47 % males developed in-hospital sICH (p = 0.19), with similar odds (adjusted odds ratio, [AOR] 0.93, 95 % confidence interval, [CI] 0.63-1.39). No interaction was found between sex and preadmission use of either single or dual antiplatelets in relation to in-hospital sICH (p = 0.94 and p = 0.23). Males had higher odds of functional independence at 3 months (AOR 1.34, 95 % CI 1.09-1.65), regardless of preadmission use of antiplatelets (interaction between sex and preadmission use of either single or dual antiplatelets p = 0.41 and p = 0.58). CONCLUSION No sex differences were observed in the safety of IVT regarding preadmission use of antiplatelets. Males showed more favourable 3-month functional independence than females; however, this sex difference was apparently not explained by a sex-specific mechanism related to preadmission use of antiplatelets.
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Affiliation(s)
- Roberta Noseda
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Federico Rea
- Department of Statistics and Quantitative Methods, Unit of Biostatistics, Epidemiology and Public Health, University of Milano-Bicocca, Milan, Italy
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, Milan, Italy
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | - Pamela Agazzi
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Giovanni Bianco
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - Shairin Sihabdeen
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Thomas Nyffeler
- Center of Neurology and Neurorehabilitation, Luzerner Kantonsspital, Luzern, Switzerland
| | - Andreas Luft
- Universitätsspital Zürich, Neurology, Zürich, Switzerland
| | | | - Ludwig Schelosky
- Division of Neurology, Kantonsspital Münsterlingen, Münsterlingen, Switzerland
| | - Friedrich Medlin
- Division of Neurology, HFR Fribourg, Stroke Unit, Fribourg, Switzerland
| | - Biljana Rodic
- Kantonsspital Winterthur, Neurology, Winterthur, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, Hirslanden Hospital, Zurich, Switzerland
| | - Susanne Renaud
- Division of Neurology, Pourtalès Hospital, Neuchatel, Switzerland
| | | | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical Trial Unit, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
| | - Carlo Walter Cereda
- Neurocenter of Southern Switzerland, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, via Tesserete 46, 6900, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera italiana, Lugano, Switzerland.
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Li JX, Wang X, Henry A, Anderson CS, Hammond N, Harris K, Liu H, Loffler K, Myburgh J, Pandian J, Smyth B, Venkatesh B, Carcel C, Woodward M. Sex differences in pain expressed by patients across diverse disease states: individual patient data meta-analysis of 33,957 participants in 10 randomized controlled trials. Pain 2023:00006396-990000000-00275. [PMID: 36972472 DOI: 10.1097/j.pain.0000000000002884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/28/2022] [Indexed: 03/29/2023]
Abstract
ABSTRACT The experience of pain is determined by many factors and has a significant impact on quality of life. This study aimed to determine sex differences in pain prevalence and intensity reported by participants with diverse disease states in several large international clinical trials. Individual participant data meta-analysis was conducted using EuroQol-5 Dimension (EQ-5D) questionnaire pain data from randomised controlled trials published between January 2000 and January 2020 and undertaken by investigators at the George Institute for Global Health. Proportional odds logistic regression models, comparing pain scores between females and males and fitted with adjustments for age and randomized treatment, were pooled in a random-effects meta-analysis. In 10 trials involving 33,957 participants (38% females) with EQ-5D pain score data, the mean age ranged between 50 and 74. Pain was reported more frequently by females than males (47% vs 37%; P < 0.001). Females also reported greater levels of pain than males (adjusted odds ratio 1.41, 95% CI 1.24-1.61; P < 0.001). In stratified analyses, there were differences in pain by disease group (P for heterogeneity <0.001), but not by age group or region of recruitment. Females were more likely to report pain, and at a higher level, compared with males across diverse diseases, all ages, and geographical regions. This study reinforces the importance of reporting sex-disaggregated analysis to identify similarities and differences between females and males that reflect variable biology and may affect disease profiles and have implications for management.
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Oliveira LC, Ponciano A, Tuozzo C, Viswanathan A, Rost NS, Etherton MR. Poststroke Disability: Association Between Sex and Patient-Reported Outcomes. Stroke 2023; 54:345-353. [PMID: 36689580 DOI: 10.1161/strokeaha.122.041502] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Ischemic stroke (IS) is a leading cause of long-term disability with sex-specific differences in outcomes. Identifying the influential factors that contribute to sex-specific disparities in stroke outcomes, therefore, holds potential to develop individualized interventions for reducing long-term disability. Further, investigating the association between sex and Patient-Reported Outcome Measures (PROMs) provides additional information on the individual impact and heterogeneity of IS. We aimed to identify sex-specific differences in stroke outcomes and relationship with PROMs in IS patients with 3-month follow-up. METHODS Between February 2017 and February 2020, a total of 410 patients admitted with IS to the Massachusetts General Hospital, in Boston, were enrolled in this prospective cohort. At 3-month poststroke, patients were assessed for Barthel Index, modified Rankin Scale, and PROM-10 questionnaires. T scores for physical and mental health were determined from the summing of PROM-10 responses in each domain. Regression analysis was performed to identify sex-specific determinants of functional and patient-reported outcomes. RESULTS At baseline, 242 participants were male (mean age, 65 years) and 168 were female (mean age, 70 years). Groups had similar rates of cardiovascular risk factors, admission National Institutes of Health Stroke Scale, and discharge modified Rankin Scale. At follow-up, male participants were more likely to have better rates of T Physical and Barthel Index. In regression analysis, PROMs T Physical (odds ratio, 1.06; P=0.01), Barthel Index (odds ratio, 1.06; P=0.01), and modified Rankin Scale score of ≥2 (odds ratio, 2.60; P=0.01) were associated with female sex. Female sex was also associated with lower scores for PROMs Physical subcomponents and with patient-reported general health and emotional problems. CONCLUSIONS Women have worse outcomes after ischemic stroke, including objective measures of functional disability and patient-reported outcomes. Incorporating PROMs into IS outcome measures may offer additional insight into sex-specific differences in stroke recovery and outcomes.
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Affiliation(s)
- Lara C Oliveira
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Ana Ponciano
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Carissa Tuozzo
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Anand Viswanathan
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Natalia S Rost
- J Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (L.C.O., A.P., C.T., A.V., N.S.R.)
| | - Mark R Etherton
- Biogen Inc, Stroke/Acute Neurology Neurovascular Therapeutics Development Unit, Cambridge, MA (M.R.E.)
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Ouyang M, Shajahan S, Liu X, Sun L, Carcel C, Harris K, Anderson CS, Woodward M, Wang X. Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis. Front Glob Womens Health 2023; 3:1032592. [PMID: 36741299 PMCID: PMC9889638 DOI: 10.3389/fgwh.2022.1032592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results. Methods We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis. Results 6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively). Conclusions No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Liu
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lingli Sun
- Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Katie Harris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Correspondence: Xia Wang
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Yu AYX, Austin PC, Rashid M, Fang J, Porter J, Vyas MV, Smith EE, Joundi RA, Edwards JD, Reeves MJ, Kapral MK. Sex Differences in Intensity of Care and Outcomes After Acute Ischemic Stroke Across the Age Continuum. Neurology 2023; 100:e163-e171. [PMID: 36180239 DOI: 10.1212/wnl.0000000000201372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sex differences in stroke care and outcomes have been previously reported, but it is not known whether these associations vary across the age continuum. We evaluated whether the magnitude of female-male differences in care and outcomes varied with age. METHODS In a population-based cohort study, we identified patients hospitalized with ischemic stroke between 2012 and 2019 and followed through 2020 in Ontario, Canada, using administrative data. We evaluated sex differences in receiving intensive care unit services, mechanical ventilation, gastrostomy tube insertion, comprehensive stroke center care, stroke unit care, thrombolysis, and endovascular thrombectomy using logistic regression and reported odds ratios (ORs) and 95% CIs. We used Cox proportional hazard models and reported the hazard ratios (HRs) and 95% CI of death within 90 or 365 days. Models were adjusted for covariates and included an interaction between age and sex. We used restricted cubic splines to model the relationship between age and care and outcomes. Where the p-value for interaction was statistically significant (p < 0.05), we reported age-specific OR or HR. RESULTS Among 67,442 patients with ischemic stroke, 45.9% were female and the median age was 74 years (64-83). Care was similar between both sexes, except female patients had higher odds of receiving endovascular thrombectomy (OR 1.35, 95% CI [1.19-1.54] comparing female with male), and these associations were not modified by age. There was no overall sex difference in hazard of death (HR 95% CI 0.99 [0.95-1.04] for death within 90 days; 0.99 [0.96-1.03] for death within 365 days), but these associations were modified by age with the hazard of death being higher in female than male patients between the ages of 50-70 years (most extreme difference around age 57, HR 95% CI 1.25 [1.10-1.40] at 90 days, p-interaction 0.002; 1.15 [1.10-1.20] at 365 days, p-interaction 0.002). DISCUSSION The hazard of death after stroke was higher in female than male patients aged 50-70 years. Examining overall sex differences in outcomes without accounting for the effect modification by age may miss important findings in specific age groups.
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Affiliation(s)
- Amy Ying Xin Yu
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada.
| | - Peter C Austin
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mohammed Rashid
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jiming Fang
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Joan Porter
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Manav V Vyas
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Eric E Smith
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Raed A Joundi
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Jodi D Edwards
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Mathew J Reeves
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
| | - Moira K Kapral
- From the Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada; ICES (A.Y.X.Y., P.C.A., M.R., J.F., J.P., M.V.V., J.E., M.K.K.), Toronto, Ontario, Canada; Institute of Health Policy Management and Evaluation (A.Y.X.Y., P.C.A., M.V.V., M.K.K.), University of Toronto, Ontario, Canada; Department of Medicine (Neurology) (M.V.V.), University of Toronto, Unity Health Toronto, Ontario, Canada; Department of Clinical Neurosciences (E.S.), Community Health Sciences, and Hotchkiss Brain Institute, University of Calgary, Alberta, Canada; Department of Medicine (R.A.J.), Hamilton Health Sciences Centre, McMaster University, Ontario, Canada; University of Ottawa Heart Institute (J.E.), Ontario, Canada; School of Epidemiology and Public Heath (J.E.), University of Ottawa, Ontario, Canada; Department of Epidemiology and Biostatistics M.J.R., College of Human Medicine, Michigan State University, East Lansing; and Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario, Canada
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Kremer C, Lorenzano S, Kruuse C. Editorial: Sex differences in cerebrovascular diseases. Front Neurol 2023; 13:1128177. [PMID: 36712426 PMCID: PMC9878284 DOI: 10.3389/fneur.2022.1128177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Affiliation(s)
- Christine Kremer
- Neurology Department, Skåne University Hospital Malmö, Malmö, Sweden,Department of Clinical Sciences, Lund University, Lund, Sweden,*Correspondence: Christine Kremer ✉
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Christina Kruuse
- Stroke Unit and Neurovascular Research Unit, Neurology Department, University of Copenhagen Herlev Gentofte Hospital, Hellerup, Denmark
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González-Santos J, Rodríguez-Fernández P, Pardo-Hernández R, González-Bernal JJ, Fernández-Solana J, Santamaría-Peláez M. A Cross-Sectional Study: Determining Factors of Functional Independence and Quality of Life of Patients One Month after Having Suffered a Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:995. [PMID: 36673749 PMCID: PMC9859177 DOI: 10.3390/ijerph20020995] [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: 10/20/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 06/17/2023]
Abstract
(1) Background: loss of quality of life (QoL) and functional independence are two of the most common consequences of suffering a stroke. The main objective of this research is to study which factors are the greatest determinants of functional capacity and QoL a month after suffering a stroke so that they can be considered in early interventions. (2) Methods: a cross-sectional study was conducted which sample consisted of 81 people who had previously suffered a stroke. The study population was recruited at the time of discharge from the Neurology Service and Stroke Unit of the hospitals of Burgos and Córdoba, Spain, through a consecutive sampling. Data were collected one month after participants experienced a stroke, and the main study variables were quality of life, measured with the Stroke-Specific Quality of Life Measure (NEWSQOL), and functional independence, measured with the Functional Independence Measure-Functional Assessment Measure (FIM-FAM). (3) Results: the factors associated with a worse QoL and functional capacity one month after having suffered a stroke were living in a different dwelling than the usual flat or house (p < 0.05), a worse cognitive capacity (p < 0.001) and a worse functional capacity of the affected upper limb (p < 0.001). A higher age was related to a worse functional capacity one month after suffering a stroke (p = 0.048). (4) Conclusions: the type of dwelling, age, cognitive ability and functional capacity of the affected upper limb are determining aspects in functional independence and QoL during the first weeks after a stroke.
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29
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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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30
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Singh SK, McCullough L. Sex Differences in the Evaluation and Treatment of Stroke. Handb Exp Pharmacol 2023; 282:77-106. [PMID: 37460659 DOI: 10.1007/164_2023_682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
There are differences in the prevalence and strength of risk factors in women, along with sex-specific risk factors such as pregnancy. Women have a higher lifetime risk of stroke compared to men, with worse outcomes including higher rates of death and disability. We have made strides in the identification of sex-specific risk factors but with the paucity of sex-specific end points in clinical trials, stroke treatment and research are hindered.
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Affiliation(s)
- Sonia K Singh
- McGovern Medical School, UTHealth Houston, Houston, TX, USA
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Lu P, Cao Z, Gu H, Li Z, Wang Y, Cui L, Wang Y, Zhao X. Association of sex and age with in-hospital mortality and complications of patients with intracerebral hemorrhage: A study from the Chinese Stroke Center Alliance. Brain Behav 2023; 13:e2846. [PMID: 36495127 PMCID: PMC9847591 DOI: 10.1002/brb3.2846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/06/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND PURPOSE The impact of sex and age on prognosis in patients with intracerebral hemorrhage (ICH) in the Chinese population remains unclear. Our study aimed to investigate the relationship between sex and age of Chinese ICH patients and adverse prognosis. METHODS We used the Chinese Stroke Center Alliance database with in-hospital mortality as the primary outcome and hospital complications as the secondary outcome. Patients were divided into four groups by sex and age. Logistic regression analyses were performed to assess the association between sex and age and the prognosis of ICH patients. RESULTS We enrolled 60,911 ICH patients, including 22,284 young and middle-aged males, 15,651 older males, 11,948 young and middle-aged females, and 11,028 older females. After adjusting for variables, older male patients had a higher mortality rate (OR = 1.21, 95% CI 1.01-1.45), combined with more frequent hematoma expansion (OR = 1.14, 95% CI 1.03-1.26), pneumonia (OR = 1.91, 95% CI 1.81-2.03), and hydrocephalus (OR = 1.28, 95% CI 1.04-1.59). Young and middle-aged female patients had a lower mortality rate (OR = 0.74, 95% CI 0.58-0.95) and less frequent combined pneumonia (OR = 0.81, 95% CI 0.75-0.87). In-hospital mortality was not significantly different in older females compared with young and middle-aged males, but the odds of deep vein thrombosis, swallowing disorders, urinary tract infections, and gastrointestinal bleeding were significantly higher. CONCLUSION Among young and middle-aged patients, females are related to a lower in-hospital mortality rate from ICH. Older patients are at an increased risk of ICH complications, with higher in-hospital mortality in older men.
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Affiliation(s)
- Ping Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Zhentang Cao
- Department of Neurology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, People's Republic of China
| | - Hongqiu Gu
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China
| | - Yu Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lingyun Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, People's Republic of China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes. Can J Cardiol 2022; 38:1865-1880. [PMID: 36116747 DOI: 10.1016/j.cjca.2022.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/21/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022] Open
Abstract
Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely to seek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.
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Wang X, Carcel C, Hsu B, Shajahan S, Miller M, Peters S, Randall DA, Havard A, Redfern J, Anderson CS, Jorm L, Woodward M. Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales. Med J Aust 2022; 217:143-148. [PMID: 35831059 PMCID: PMC9541458 DOI: 10.5694/mja2.51652] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 03/29/2022] [Accepted: 05/10/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. DESIGN, SETTING, PARTICIPANTS Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. MAIN OUTCOME MEASURES Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. RESULTS Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89; 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95; 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01; 95% CI, 0.99-1.04). CONCLUSION Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.
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Affiliation(s)
- Xia Wang
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Cheryl Carcel
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Benjumin Hsu
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sultana Shajahan
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
| | - Matthew Miller
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Sanne Peters
- The George Institute for Global HealthOxfordUnited Kingdom
| | - Deborah A Randall
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Alys Havard
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Julie Redfern
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,School of Health Sciences, Faculty of Medicine and HealthUniversity of Sydney, NSW
| | - Craig S Anderson
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW,Royal Prince Alfred HospitalSydneyNSW
| | - Louisa Jorm
- Centre for Big Data Research in HealthUniversity of New South WalesSydneyNSW
| | - Mark Woodward
- The George Institute for Global HealthUniversity of New South WalesSydneyNSW
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Demel SL, Reeves M, Xu H, Xian Y, Mac Grory B, Fonarow GC, Matsouaka R, Smith EE, Saver J, Schwamm L. Sex Differences in Endovascular Therapy for Ischemic Stroke: Results From the Get With The Guidelines-Stroke Registry. Stroke 2022; 53:3099-3106. [PMID: 35880521 DOI: 10.1161/strokeaha.122.038491] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In 2015, endovascular therapy (EVT) for large vessel occlusions became standard of care for acute ischemic stroke. Lower utilization of IV alteplase has been reported in women, but whether sex differences in EVT use in the United States exists has not been established. METHODS We identified all acute ischemic stroke discharges from Get With The Guidelines-Stroke hospitals between 2012 and 2019 who were potentially eligible for EVT, based on National Institutes of Health Stroke Scale score ≥6 and arrival <6 hours, according to 2018 American Heart Association/ASA guidelines. Multivariable regression analyses were used to determine the association between sex and EVT utilization, and outcomes (including mortality, discharge home, functional status) after EVT. Separate analyses were conducted for the 2 time periods: 2012 to 2014, and 2015 to 2019. RESULTS Of 302 965 patients potentially eligible for EVT, 42 422 (14%) received EVT. Before 2015, EVT treatment rates were 5.3% in women and 6.6% in men. From 2015 to 2019, treatment rates increased in both sexes to 16.7% in women and 18.5% in men. The adjusted odds ratio for EVT in women compared with men was 0.93 (95% CI, 0.87-0.99) before 2015, and 0.98 (95% CI, 0.96-1.01) after 2015. There were no significant sex differences in outcomes except that after 2015, women were less able to ambulate at discharge (adjusted odds ratio, 0.95 [95% CI, 0.95-0.99]) and had lower in-hospital mortality (adjusted odds ratio, 0.93 [95% CI, 0.88-0.99]). CONCLUSIONS EVT utilization has increased dramatically in both women and men since EVT approval in 2015. Following statistical adjustment, women were less likely to receive EVT initially, but after 2015, women were as likely as men to receive EVT. After EVT, women were more likely to be disabled at discharge but less likely to experience in-hospital death compared with men.
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Affiliation(s)
- Stacie L Demel
- Department of Neurology, University of Cincinnati, OH (S.L.D.)
| | - Mathew Reeves
- Dsepartment of Epidemiology and Biostatistics, Michigan State University, East Lansing (M.R.)
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC. (H.X.)
| | - Ying Xian
- UT Southwestern Medical Center, Department of Neurology, Dallas, TX (Y.X.)
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC. (B.M.G.)
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Roland Matsouaka
- Department of Medicine, Duke University School of Medicine, Durham, NC. (R.M.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada (E.E.S.)
| | - Jeff Saver
- Department of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, CA (J.S.)
| | - Lee Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston (L.S.)
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Corsi T, Ciaramella MA, Palte NK, Carlson JP, Rahimi SA, Beckerman WE. Female Sex Is Associated With Reintervention and Mortality Following Elective Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg 2022; 76:1494-1501.e1. [PMID: 35705120 DOI: 10.1016/j.jvs.2022.05.011] [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: 02/25/2022] [Revised: 04/15/2022] [Accepted: 05/01/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While sex differences in endovascular abdominal aortic aneurysm repair (EVAR) outcomes are increasingly reported, but contributing factors remain without consensus. We investigated disparities in sex-specific outcomes following elective EVAR at our institution and evaluated factors that may predispose females to increased morbidity and mortality. METHODS A retrospective chart review of all patients undergoing elective EVAR from 2011 to 2020 at a suburban tertiary care center was performed. The primary outcomes were five-year survival and freedom from reintervention. Fisher's exact test, t-tests, and Kaplan-Meier analysis using the rank-log test investigated associations between sex and outcomes. A multivariable Cox proportional hazard model controlling for age and common comorbidities evaluated the effect of sex on survival and freedom from reintervention. RESULTS Two hundred and seventy-three patients underwent elective EVAR during the study period, including 68 (25%) females and 205 (75%) males. Females were older on average than males (76 years vs. 73 years, p= <0.01) and were more likely to have chronic obstructive pulmonary disease (COPD; 38% versus 23%, p=0.01), require home oxygen therapy (9% versus 2%, p=0.04) or dialysis preoperatively (4% versus 0%, p=0.02). Distribution of other common vascular comorbidities was similar between the sexes. Thirty-day readmission was greater in females than males (18% versus 8%, p=0.02). Females had significantly lower survival at five years (48% ± 7.9% versus 65% ± 4.3%, p<0.01) and significantly lower one-year (89% ± 4.1% for females vs. 94% ± 1.7% for males, p=0.01) and five-year freedom from reintervention (69% ± 8.9% versus 84% ± 3.3%, p=0.02). On multivariable analysis, female sex (hazard ratio [HR]: 1.8, 95% confidence interval [CI]: 1.1-2.9), congestive heart failure (HR: 2.2, 95% CI: 1.2-3.9) and age (HR: 1.1, 95% CI: 1.0-1.1) were associated with 5-year mortality. Female sex remained as the only variable with a statistically significant association with five-year reintervention (HR: 2.4, 95% CI: 1.1-4.9). CONCLUSIONS Female sex was associated with decreased five-year survival and increased one and five-year reintervention following elective EVAR. Data from our institution suggests factors beyond patient age and baseline health risk likely contribute to greater surgical morbidity and mortality for females following elective EVAR.
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Affiliation(s)
- Taylor Corsi
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Nadia K Palte
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - John P Carlson
- Rutgers Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Saum A Rahimi
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ.
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Corrigan AE, Carter B, Smith A, Pennington A, Hewitt J. MORe PREcISE: a multicentre prospective study of patient reported outcome measures in stroke morbidity: a cross sectional study. BMC Neurol 2022; 22:145. [PMID: 35443653 PMCID: PMC9020003 DOI: 10.1186/s12883-022-02634-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background and Purpose The use of patient reported outcomes measures (PROMs) may offer utility that are important for stroke survivors. This study assessed the PROMIS-10, which contains Mental health (MH) and Physical Health (PH) domains, with an additional five stroke specific questions. The aim of this study was to evaluate the association between the MH and PH measures following a stroke and pre-existing health conditions. Methods A multicentre prospective cohort study at 19 hospital sites across England and Wales during 2019 was conducted. The association between each PROMIS-10 domain and demographic and health conditions were calculated using a multilevel multivariable linear and present the adjusted mean difference (aMD). Results The study enrolled 549 stroke survivors within 14 days of the index event, 232 were women (42.3%) and with a mean age of 72.7 years (SD = 12.9, range 25 to 97). The MH domain was scored as poor in 3.9% of participants, and very good or excellent in almost a half (48.4%). In contrast the PH domain was scored as poor in 39.9%, compared to very good or excellent in 8.5%. The MH domain was associated with pre-existing diabetes (aMD = − 2.01; 95%CI -3.91, − 0.12; p = 0.04), previous stroke (aMD = − 3.62; 95%CI -5.86, − 1.39; p = 0.001), age (aMD = 0.07; 95%CI: 0.01, 0.14; p = 0.037), and female sex (aMD = 1.91; 95%CI 0.28, 3.54; p = 0.022). The PH domain was found to be associated with sex (female) (aMD = 2.09; 95%CI 0.54, 3.65; p = 0.008) and previous stroke (aMD = − 3.05; 95%CI -5.17, − 0.93; p = 0.005). Conclusions Almost half of stroke survivors reported poor PH using a PROM with less reporting poor MH. age, and sex were associated with both MH and PH domains, and additionally pre-exising diabetes and stroke were associated with poorer MH. Clinical management offers an opportunity to investigate and intervene to prevent long term poorer health in stroke survivors. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02634-0.
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Affiliation(s)
- Amber E Corrigan
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Alexander Smith
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Anna Pennington
- Aneurin Bevan University Health Board, Newport, South Wales, UK
| | - Jonathan Hewitt
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK. .,Aneurin Bevan University Health Board, Newport, South Wales, UK.
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Cao M, Li B, Rong J, Li Q, Sun C. Sex differences in global disability-adjusted life years due to ischemic stroke: findings from global burden of diseases study 2019. Sci Rep 2022; 12:6235. [PMID: 35422061 PMCID: PMC9010406 DOI: 10.1038/s41598-022-10198-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/01/2022] [Indexed: 12/28/2022] Open
Abstract
To investigate the sex differences in disability-adjusted life years (DALYs) due to ischemic stroke (IS) by year, location and age. We extracted sex-specific data on DALYs number, age-standardized DALYs rate (ASDR) and all-age DALYs rate of IS by year, location and age from the Global Burden of Diseases study 2019. The estimated annual percentage changes (EAPC) were calculated to evaluate the temporal trend of ASDR. For both sexes, although the ASDR of IS slightly decreased from 1990 to 2019, there has been an 60.3% increase in DALYs number worldwide. Sex difference in DALYs number (men minus women) decreased from − 2.83 million in 1990 to 0.14 million in 2019, while the men to women’s ASDR ratio slightly increased from 1.10 in 1990 to 1.21 in 2019. The sex differences in IS DALYs showed remarkable regional variation. The largest sex differences in DALYs number and ASDR were in China and Vietnam. Middle-aged men had a higher IS DALYs than their age-matched counterparts. High systolic blood pressure accounted for the highest DALYs number in 2019, but the top three attributable risk factors that had the greatest sex differences were tobacco, dietary risk, and alcohol use. Sex differences in IS DALYs varied by year, location and age, mostly attributed to the disproportion of cardiovascular risk factors between sexes. Considering the population growth and aging, it is necessary to monitor the sex difference in IS DALYs in different populations and thus provide evidence for local administration to improve current preventive and management strategies of IS.
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Affiliation(s)
- Miaomiao Cao
- Department of Cardiology, Institute of Cardiovascular Channelopathy, Key Laboratory of Molecular Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, People's Republic of China
| | - Bolin Li
- Department of Cardiology, Institute of Cardiovascular Channelopathy, Key Laboratory of Molecular Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, People's Republic of China
| | - Jie Rong
- Department of Encephalopathy, Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, People's Republic of China
| | - Qian Li
- Department of Cardiology, Institute of Cardiovascular Channelopathy, Key Laboratory of Molecular Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, People's Republic of China
| | - Chaofeng Sun
- Department of Cardiology, Institute of Cardiovascular Channelopathy, Key Laboratory of Molecular Cardiology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, People's Republic of China.
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Walter S, Phillips D, Wells B, Moon R, Bertsch T, Grunwald IQ, Fassbender K. Detection to Hospital Door: Gender Differences of Patients With Acute Stroke Symptoms. Front Neurol 2022; 13:833933. [PMID: 35463123 PMCID: PMC9021751 DOI: 10.3389/fneur.2022.833933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
Abstract
Although prehospital stroke management is challenging, it is a crucial part of the acute stroke chain to enable equal access to highly specialised stroke care. It involves a critical understanding of players usually not specialized in acute stroke treatments. There is contradictory information about gender inequity in prehospital stroke detection, dispatch, and delivery to hospital stroke centers. The aim of this narrative review is to summarize the knowledge of gender differences in the first three stages of acute stroke management. Information on the detection of acute stroke symptoms by patients, their relatives, and bystanders is discussed. Women seem to have a better overall knowledge about stroke, although general understanding needs to be improved. However, older age and different social situations of women could be identified as reasons for reduced and delayed help-seeking. Dispatch and delivery lie within the responsibility of the emergency medical service. Differences in clinical presentation with symptoms mainly affecting general conditions could be identified as a crucial challenge leading to gender inequity in these stages. Improvement of stroke education has to be applied to tackle this inequal management. However, specifically designed projects and analyses are needed to understand more details of sex differences in prehospital stroke management, which is a necessary first step for the potential development of substantially improving strategies.
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Affiliation(s)
- Silke Walter
- Neurology, Saarland University, Homburg, Germany
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
- *Correspondence: Silke Walter
| | - Daniel Phillips
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Brittany Wells
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Robert Moon
- East of England Ambulance Service NHS Trust, Melbourn, United Kingdom
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Iris Q. Grunwald
- Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, United Kingdom
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Ganesh A, Fraser JF, Gordon Perue GL, Amin-Hanjani S, Leslie-Mazwi TM, Greenberg SM, Couillard P, Asdaghi N, Goyal M. Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2022; 53:e204-e217. [PMID: 35343235 DOI: 10.1161/str.0000000000000406] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with premorbid disability or dementia have generally been excluded from randomized controlled trials of reperfusion therapies such as thrombolysis and endovascular therapy for acute ischemic stroke. Consequently, stroke physicians face treatment dilemmas in caring for such patients. In this scientific statement, we review the literature on acute ischemic stroke in patients with premorbid disability or dementia and propose principles to guide clinicians, clinician-scientists, and policymakers on the use of acute stroke therapies in these populations. Recent clinical-epidemiological studies have demonstrated challenges in our concept and measurement of premorbid disability or dementia while highlighting the significant proportion of the general stroke population that falls under this umbrella, risking exclusion from therapies. Such studies have also helped clarify the adverse long-term clinical and health economic consequences with each increment of additional poststroke disability in these patients, underscoring the importance of finding strategies to mitigate such additional disability. Several observational studies, both case series and registry-based studies, have helped demonstrate the comparable safety of endovascular therapy in patients with premorbid disability or dementia and in those without, complementing similar data on thrombolysis. These data also suggest that such patients have a substantial potential to retain their prestroke level of disability when treated, despite their generally worse prognosis overall, although this remains to be validated in higher-quality registries and clinical trials. By pairing pragmatic and transparent decision-making in clinical practice with an active pursuit of high-quality research, we can work toward a more inclusive paradigm of patient-centered care for this often-neglected patient population.
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High-Intensity Post-Stroke Rehabilitation Is Associated with Lower Risk of Pressure Ulcer Development in Patients with Stroke: Real-World Evidence from a Nationwide, Population-Based Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58030402. [PMID: 35334578 PMCID: PMC8955381 DOI: 10.3390/medicina58030402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022]
Abstract
Background and Objectives: Multiple factors are associated with pressure ulcer (PU) development, including limited mobility following stroke. We performed a nationwide cohort study to investigate the impact of rehabilitation intensity on the incidence of post-stroke PU. Materials and Methods: Data of patients diagnosed with stroke between 2000 and 2012 were collected from the 2000 Longitudinal Health Insurance Database (Taiwan). Based on the number of rehabilitation sessions attended within 90 days of discharge, the rehabilitation intensity was classified as low, medium, or high. After adjusting for sociodemographic factors and comorbidities, the Cox proportional hazards model evaluated the risk of PU development during the 12-year follow-up period. Kaplan−Meier curves were used to estimate the cumulative incidence of PUs. Results: Our study included 18,971 patients who had their first episode of stroke. Of these, 9829 (51.8%) underwent rehabilitation therapy after discharge. Female patients and patients with a National Institutes of Health Stroke Scale (NIHSS) score >13 points, who commenced high-intensity post-stroke rehabilitation after discharge had a significantly lower risk of PU development than those who underwent low-intensity post-stroke rehabilitation after discharge. Cumulative survival analysis showed a significantly lower cumulative incidence of PU during the 12-year follow-up period in the high-intensity rehabilitation group. Conclusion: Compared with low-intensity post-stroke rehabilitation, high-intensity post-stroke rehabilitation after discharge from hospital is associated with a lower risk of post-stroke PU development, especially in female stroke patients and patients with a NIHSS score >13 points. High-intensity rehabilitation is also associated with a significantly lower cumulative incidence of PU events during the 12-year follow-up period.
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Grundtvig J, Ovesen C, Steiner T, Carcel C, Gaist D, Christensen L, Marstrand J, Meden P, Rosenbaum S, Iversen HK, Kruuse C, Christensen T, Ægidius K, Havsteen I, Christensen H. Sex-Differences in Oral Anticoagulant-Related Intracerebral Hemorrhage. Front Neurol 2022; 13:832903. [PMID: 35309585 PMCID: PMC8927802 DOI: 10.3389/fneur.2022.832903] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/31/2022] [Indexed: 12/21/2022] Open
Abstract
Introduction and Aim Data remain limited on sex-differences in patients with oral anticoagulant (OAC)-related intracerebral hemorrhage (ICH). We aim to explore similarities and differences in risk factors, acute presentation, treatments, and outcome in men and women admitted with OAC-related ICH. Method This study was a retrospective observational study based on 401 consecutive patients with OAC-related ICH admitted within 24 h of symptom onset. The study was registered on osf.io. We performed logarithmic regression and cox-regression adjusting for age, hematoma volume, Charlson Comorbidity Index (CCI), and pre-stroke modified Ranking Scale (mRS). Gender and age were excluded from CHA2DS2-VASc and CCI was not adjusted for age. Results A total of 226 men and 175 women were identified. More men were pre-treated with vitamin K-antagonists (73.5% men vs. 60.6% women) and more women with non-vitamin K-antagonist oral anticoagulants (26.5% men vs. 39.4% women), p = 0.009. Women were older (mean age 81.9 vs. 76.9 years, p < 0.001). CHA2DS2-VASc and CCI were similar in men and women. Hematoma volumes (22.1 ml in men and 19.1 ml in women) and National Institute of Health Stroke Scale (NIHSS) scores (13 vs. 13) were not statistically different, while median Glasgow Coma Scale (GCS) was lower in women, (14 [8;15] vs. 14 [10;15] p = 0.003). Women's probability of receiving reversal agents was significantly lower (adjusted odds ratio [aOR] = 0.52, p = 0.007) but not for surgical clot removal (aOR = 0.56, p = 0.25). Women had higher odds of receiving do-not-resuscitate (DNR) orders within a week (aOR = 1.67, p = 0.04). There were no sex-differences in neurological deterioration (aOR = 1.48, p = 0.10), ability to walk at 3 months (aOR = 0.69, p = 0.21) or 1-year mortality (adjusted hazard ratio = 1.18, p = 0.27). Conclusion Significant sex-differences were observed in age, risk factors, access to treatment, and DNRs while no significant differences were observed in comorbidity burden, stroke severity, or hematoma volume. Outcomes, such as adjusted mortality, ability to walk, and neurological deterioration, were comparable. This study supports the presence of sex-differences in risk factors and care but not in presentation and outcomes.
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Affiliation(s)
- Josefine Grundtvig
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- *Correspondence: Josefine Grundtvig
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Thorsten Steiner
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Louisa Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Marstrand
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Meden
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sverre Rosenbaum
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Helle K. Iversen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Herlev Hospital, Copenhagen, Denmark
| | | | - Karen Ægidius
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Inger Havsteen
- Department of Radiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Hanne Christensen
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Yang Z, Huang C, Wen X, Liu W, Huang X, Li Y, Zang J, Weng Z, Lu D, Tsang CK, Li K, Xu A. Circular RNA circ-FoxO3 attenuates blood-brain barrier damage by inducing autophagy during ischemia/reperfusion. Mol Ther 2022; 30:1275-1287. [PMID: 34763084 PMCID: PMC8899525 DOI: 10.1016/j.ymthe.2021.11.004] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/23/2021] [Accepted: 11/03/2021] [Indexed: 02/08/2023] Open
Abstract
Blood-brain barrier (BBB) damage can be a result of central nervous system (CNS) diseases and may be a cause of CNS deterioration. However, there are still many unknowns regarding effective and targeted therapies for maintaining BBB integrity during ischemia/reperfusion (I/R) injury. In this study, we demonstrate that the circular RNA of FoxO3 (circ-FoxO3) promotes autophagy via mTORC1 inhibition to attenuate BBB collapse under I/R. Upregulation of circ-FoxO3 and autophagic flux were detected in brain microvessel endothelial cells in patients with hemorrhagic transformation and in mice models with middle cerebral artery occlusion/reperfusion. In vivo and in vitro studies indicated that circ-FoxO3 alleviated BBB damage principally by autophagy activation. Mechanistically, we found that circ-FoxO3 inhibited mTORC1 activity mainly by sequestering mTOR and E2F1, thus promoting autophagy to clear cytotoxic aggregates for improving BBB integrity. These results demonstrate that circ-FoxO3 plays a novel role in protecting against BBB damage, and that circ-FoxO3 may be a promising therapeutic target for neurological disorders associated with BBB damage.
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Affiliation(s)
- Zhenguo Yang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China,Affiliated Hospital of Guangdong Medical University, 57 South Renmin Ave, Zhanjiang 524001, China
| | - Cheng Huang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Xueyi Wen
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Wenlin Liu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China,Affiliated Hospital of Guangdong Medical University, 57 South Renmin Ave, Zhanjiang 524001, China
| | - Xiaoxiong Huang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Yufeng Li
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Jiankun Zang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Zean Weng
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Dan Lu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Chi Kwan Tsang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China
| | - Keshen Li
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China.
| | - Anding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, & Clinical Neuroscience Institute of Jinan University, 613 West Huangpu Ave, Guangzhou 510632, China.
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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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Adedinsewo DA, Pollak AW, Phillips SD, Smith TL, Svatikova A, Hayes SN, Mulvagh SL, Norris C, Roger VL, Noseworthy PA, Yao X, Carter RE. Cardiovascular Disease Screening in Women: Leveraging Artificial Intelligence and Digital Tools. Circ Res 2022; 130:673-690. [PMID: 35175849 PMCID: PMC8889564 DOI: 10.1161/circresaha.121.319876] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease remains the leading cause of death in women. Given accumulating evidence on sex- and gender-based differences in cardiovascular disease development and outcomes, the need for more effective approaches to screening for risk factors and phenotypes in women is ever urgent. Public health surveillance and health care delivery systems now continuously generate massive amounts of data that could be leveraged to enable both screening of cardiovascular risk and implementation of tailored preventive interventions across a woman's life span. However, health care providers, clinical guidelines committees, and health policy experts are not yet sufficiently equipped to optimize the collection of data on women, use or interpret these data, or develop approaches to targeting interventions. Therefore, we provide a broad overview of the key opportunities for cardiovascular screening in women while highlighting the potential applications of artificial intelligence along with digital technologies and tools.
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Affiliation(s)
- Demilade A. Adedinsewo
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Amy W. Pollak
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Sabrina D. Phillips
- Department of Cardiovascular Medicine (D.A.A., A.W.P., S.D.P.), Mayo Clinic, Jacksonville, FL
| | - Taryn L. Smith
- Division of General Internal Medicine (T.L.S.), Mayo Clinic, Jacksonville, FL
| | - Anna Svatikova
- Department of Cardiovascular Diseases (A.S.), Mayo Clinic, Phoenix, AZ
| | - Sharonne N. Hayes
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Sharon L. Mulvagh
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada (S.L.M.)
| | - Colleen Norris
- Cardiovascular Health and Stroke Strategic Clinical Network, Edmonton, Canada (C.N.)
| | - Veronique L. Roger
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
- Department of Quantitative Health Sciences (V.L.R.), Mayo Clinic, Rochester, MN
- Epidemiology and Community Health Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD (V.L.R.)
| | - Peter A. Noseworthy
- Department of Cardiovascular Medicine (S.N.H., S.L.M., V.L.R., P.A.N.), Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y.), Mayo Clinic, Rochester, MN
| | - Rickey E. Carter
- Department of Quantitative Health Sciences (R.E.C.), Mayo Clinic, Jacksonville, FL
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Hammerbeck U, Abdulle A, Heal C, Parry-Jones AR. Hyperacute prediction of functional outcome in spontaneous intracerebral haemorrhage: systematic review and meta-analysis. Eur Stroke J 2022; 7:6-14. [PMID: 35300252 PMCID: PMC8921779 DOI: 10.1177/23969873211067663] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To describe the association between factors routinely available in hyperacute care of spontaneous intracerebral haemorrhage (ICH) patients and functional outcome. Methods We searched Medline, Embase and CINAHL in February 2020 for original studies reporting associations between markers available within six hours of arrival in hospital and modified Rankin Scale (mRS) at least 6 weeks post-ICH. A random-effects meta-analysis was performed where three or more studies were included. Findings Thirty studies were included describing 40 markers. Ten markers underwent meta-analysis and age (OR = 1.06; 95%CI = 1.05 to 1.06; p < 0.001), pre-morbid dependence (mRS, OR = 1.73; 95%CI = 1.52 to 1.96; p < 0.001), level of consciousness (Glasgow Coma Scale, OR = 0.82; 95%CI = 0.76 to 0.88; p < 0.001), stroke severity (National Institutes of Health Stroke Scale, OR=1.19; 95%CI = 1.13 to 1.25; p < 0.001), haematoma volume (OR = 1.12; 95%CI=1.07 to 1.16; p < 0.001), intraventricular haemorrhage (OR = 2.05; 95%CI = 1.68 to 2.51; p < 0.001) and deep (vs. lobar) location (OR = 2.64; 95%CI = 1.65 to 4.24; p < 0.001) were predictive of outcome but systolic blood pressure, CT hypodensities and infratentorial location were not. Of the remaining markers, sex, medical history (diabetes, hypertension, prior stroke), prior statin, prior antiplatelet, admission blood results (glucose, cholesterol, estimated glomerular filtration rate) and other imaging features (midline shift, spot sign, sedimentation level, irregular haematoma shape, ultraearly haematoma growth, Graeb score and onset to CT time) were associated with outcome. Conclusion Multiple demographic, pre-morbid, clinical, imaging and laboratory factors should all be considered when prognosticating in hyperacute ICH. Incorporating these in to accurate and precise models will help to ensure appropriate levels of care for individual patients.
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Affiliation(s)
- Ulrike Hammerbeck
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- School of Physiotherapy, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| | - Aziza Abdulle
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Calvin Heal
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Division of Population Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Adrian R Parry-Jones
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester, UK
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
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Wang M, Wang C, Gu HQ, Meng X, Jiang Y, Yang X, Zhang J, Xiong Y, Zhao X, Liu L, Wang Y, Wang Y, Li Z. Sex Differences in Short-term and Long-term Outcomes among Acute Ischemic Stroke Patients in China. Stroke 2022; 53:2268-2275. [PMID: 35130717 DOI: 10.1161/strokeaha.121.037121] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Sex differences in stroke outcomes are crucial to secondary prevention but previous reports showed inconsistent results. We aimed to explore the sex differences in stroke outcomes in the Third China National Stroke Registry, a prospective multi-center registry study. Methods: Among the 15166 patients enrolled between 2015 and 2018, 9038 patients with acute ischemic stroke (AIS) were included. The primary outcomes were stroke recurrence, mortality, and unfavorable functional outcome (modified Rankin Scale [mRS] > 2) at 3, 6, and 12 months. Cox regression model was used for stroke recurrence and mortality and logistic regression was used for the unfavorable functional outcome, and adjusted as follows: (1) Model 1: without adjustment; (2) Model 2: adjusted for potential risk factors, National Institutes of Health Stroke Scale (NIHSS) at admission, pre-stroke mRS, tissue plasminogen activator (TPA) treatment, TOAST classification, and onset-to-door time; (3) Model 3: adjusted for covariates from model 2 in addition to blood pressure and blood serum covariates. Multiple imputation was used for missing values, and sensitivity analyses were conducted to describe sex differences by age groups. Results: One-third (2802/9038) of the patients were women. Women were significantly older than men (64.78±10.84 vs. 61.26±11.42, p<0.001). In the fully adjusted model, female patients were more likely to have unfavorable functional outcomes at 3 months (odds ratio [OR], 1.28 [1.09, 1.50]), especially among patients aged 65 years or older (OR, 1.39 [1.14, 1.70]), but no difference was discovered in patients aged < 65 years. There were no sex differences in stroke recurrence and mortality at 3, 6, or 12 months or unfavorable functional outcomes at 6 or 12 months after adjustment. Conclusions: Compared to men, women with AIS were less likely to have favorable outcomes at three months in China, especially among those over 65 years of age. Experts should aim to tailor secondary prevention strategies for high-risk patients.
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Affiliation(s)
- Meng Wang
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China;China National Clinical Research Center for Neurological Diseases, Beijing, China;, CHINA
| | - Chunjuan Wang
- neurology department, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, CHINA
| | - Hong-Qiu Gu
- Department of Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, CHINA
| | - Xia Meng
- neurology, Beijing Tiantan Hospital, Capital Medical University, CHINA
| | - Yong Jiang
- Beijing Tiantan Hospital, Capital Medical University, CHINA
| | - Xin Yang
- Neurology, Beijing Tiantan Hospital affiliated to Capital Medical University, CHINA
| | - Jing Zhang
- Beijing TianTan Hospital, Capital Medical University, CHINA
| | - Yunyun Xiong
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China, CHINA
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, CHINA
| | - Liping Liu
- Neurology, Beijing Tiantan Hospital,Capital Medical University, CHINA
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, CHINA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases, CHINA
| | - Zixiao Li
- Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing TianTan Hospital, Capital Medical University, CHINA
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Cao Y, Chen Y, Zhang X, Wang Y. Analysis of Prognostic Risk Factors for Ischemic Stroke in China: A Multicentre Retrospective Clinical Study; A National Survey in China. Curr Neurovasc Res 2022; 19:117-126. [PMID: 35362370 PMCID: PMC10556397 DOI: 10.2174/1567202619666220331160024] [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: 02/01/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stroke is a serious disease that threatens human health both in China and worldwide. Identifying and establishing its risk factors are prerequisites for intervention and evaluation of prognosis. Over the years, risk factors, such as age, diabetes, and hypertension, have gradually been established. However, at present, there is no consensus on the influence of sex on the prognosis of ischaemic stroke. AIMS The aims of our research was to analyse the correlation between sex and poststroke prognosis based on the results of the Third China National Stroke Registry [CNSR-III], as well as the influence of other risk factors that may be confounded by sex on ischaemic stroke and potential interventions. METHODS The CNSR-III recruited 14146 acute ischaemic stroke [AIS] patients between 2015 and 2018. Our study included 13,972 patients who had complete follow-up information. This research analysed basic information, socioeconomic status, lifestyle habits, medical history, and poststroke prognosis. RESULTS There was a conspicuous relationship between sex and functional prognosis, stroke recurrence and all-cause death due to ischemic stroke in univariate analysis. Male stroke patients had a better prognosis than female patients. In multivariate analysis, we found that age, atrial fibrillation [AF], diabetes, hypertension and the severity of stroke had adverse effects on ischemic stroke prognosis. After adjustment for other risk factors, the functional prognosis of female patients at 3 months was worse than that of male patients [odds ratio [OR] 1.16, 95% confidence interval [CI], 1.025- 1.314]. Sex had a nonsignificant association with stroke recurrence at 3 months [hazard ratio [HR] 1.141, 95% CI, 0.975-1.336]. Furthermore, compared to male patients, female stroke patients had a lower cumulative death rate at 12 months [HR 0.777, 95% CI, 0.628-0.963]. CONCLUSION Our study identified sex differences in stroke-related disability, recurrence, and death and attempted to explain the causes of these differences. Our study clearly showed that a large proportion of this difference could be attributed to age, socioeconomic factors, lifestyle habits, and medical history, confounded by sex differences rather than sex per se.
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Affiliation(s)
- Yuting Cao
- These authors contributed equally to this work and should be considered co-first authors.
| | - Ying Chen
- These authors contributed equally to this work and should be considered co-first authors.
| | | | - Yongjun Wang
- Address correspondence to this author at the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China E-mail:
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Ingwersen T, Wolf S, Birke G, Schlemm E, Bartling C, Bender G, Meyer A, Nolte A, Ottes K, Pade O, Peller M, Steinmetz J, Gerloff C, Thomalla G. Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation. Neurol Res Pract 2021; 3:66. [PMID: 34955097 PMCID: PMC8711154 DOI: 10.1186/s42466-021-00164-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Background Impaired motor functions after stroke are common and negatively affect patients' activities of daily living and quality of life. In particular, hand motor function is essential for daily activities, but often returns slowly and incompletely after stroke. However, few data are available on the long-term dynamics of motor recovery and self-reported health status after stroke. The Interdisciplinary Platform for Rehabilitation Research and Innovative Care of Stroke Patients (IMPROVE) project aims to address this knowledge gap by studying the clinical course of recovery after inpatient rehabilitation. Methods In this prospective observational longitudinal multicenter study, patients were included towards the end of inpatient rehabilitation after ischemic or hemorrhagic stroke. Follow-up examination was performed at three, six, and twelve months after enrollment. Motor function was assessed by the Upper Extremity Fugl-Meyer Assessment (FMA), grip and pinch strength, and the nine-hole peg test. In addition, Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10) was included. Linear mixed effect models were fitted to analyze change over time. To study determinants of hand motor function, patients with impaired hand function at baseline were grouped into improvers and non-improvers according to hand motor function after twelve months. Results A total of 176 patients were included in the analysis. Improvement in all motor function scores and PROMIS-10 was shown up to 1 year after inpatient rehabilitation. FMA scores improved by an estimate of 5.0 (3.7–6.4) points per year. In addition, patient-reported outcome measures increased by 2.5 (1.4–3.6) and 2.4 (1.4–3.4) per year in the physical and mental domain of PROMIS-10. In the subgroup analysis non-improvers showed to be more often female (15% vs. 55%, p = 0.0155) and scored lower in the Montreal Cognitive Assessment (25 [23–27] vs. 22 [20.5–24], p = 0.0252). Conclusions Continuous improvement in motor function and self-reported health status is observed up to 1 year after inpatient stroke rehabilitation. Demographic and clinical parameters associated with these improvements need further investigation. These results may contribute to the further development of the post-inpatient phase of stroke rehabilitation. Trial registration: The trial is registered at ClinicalTrials.gov (NCT04119479).
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Affiliation(s)
- Thies Ingwersen
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Silke Wolf
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Gunnar Birke
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | | | - Gabriele Bender
- RehaCentrum Hamburg GmbH, Martinistraße 66, 20246, Hamburg, Germany
| | - Alfons Meyer
- MediClin Klinikum Soltau, Oeninger Weg 59, 29614, Soltau, Germany
| | - Achim Nolte
- VAMED Klinik Geesthacht, Johannes-Ritter-Straße 100, 21502, Geesthacht, Germany
| | - Katharina Ottes
- RehaCentrum Hamburg GmbH, Martinistraße 66, 20246, Hamburg, Germany
| | - Oliver Pade
- Klinikum Bad Bramstedt, Klinik Für Neurologische Rehabilitation, Oskar-Alexander-Straße 26, 24576, Bad Bramstedt, Germany
| | - Martin Peller
- VAMED Rehaklinik Damp, Seute-Deern-Ring 30, 24351, Damp, Germany
| | - Jochen Steinmetz
- Klinikum Bad Bramstedt, Klinik Für Neurologische Rehabilitation, Oskar-Alexander-Straße 26, 24576, Bad Bramstedt, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Gasbarrino K, Di Iorio D, Daskalopoulou SS. Importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease. Eur Heart J 2021; 43:460-473. [PMID: 34849703 DOI: 10.1093/eurheartj/ehab756] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/25/2021] [Accepted: 10/26/2021] [Indexed: 12/14/2022] Open
Abstract
Stroke is a leading cause of death and disability worldwide. Women are disproportionately affected by stroke, exhibiting higher mortality and disability rates post-stroke than men. Clinical stroke research has historically included mostly men and studies were not properly designed to perform sex- and gender-based analyses, leading to under-appreciation of differences between men and women in stroke presentation, outcomes, and response to treatment. Reasons for these differences are likely multifactorial; some are due to gender-related factors (i.e. decreased social support, lack of stroke awareness), yet others result from biological differences between sexes. Unlike men, women often present with 'atypical' stroke symptoms. Lack of awareness of 'atypical' presentation has led to delays in hospital arrival, diagnosis, and treatment of women. Differences also extend to carotid atherosclerotic disease, a cause of stroke, where plaques isolated from women are undeniably different in morphology/composition compared to men. As a result, women may require different treatment than men, as evidenced by the fact that they derive less benefit from carotid revascularization than men but more benefit from medical management. Despite this, women are less likely than men to receive medical therapy for cardiovascular risk factor management. This review focuses on the importance of sex and gender in ischaemic stroke and carotid atherosclerotic disease, summarizing the current evidence with respect to (i) stroke incidence, mortality, awareness, and outcomes, (ii) carotid plaque prevalence, morphology and composition, and gene connectivity, (iii) the role of sex hormones and sex chromosomes in atherosclerosis and ischaemic stroke risk, and (iv) carotid disease management.
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Affiliation(s)
- Karina Gasbarrino
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Glen Site, 1001 Decarie Boulevard, EM1.2230 Montreal, QC H4A 3J1, Canada
| | - Diana Di Iorio
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Glen Site, 1001 Decarie Boulevard, EM1.2230 Montreal, QC H4A 3J1, Canada
| | - Stella S Daskalopoulou
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, Glen Site, 1001 Decarie Boulevard, EM1.2230 Montreal, QC H4A 3J1, Canada
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Lamberti N, Manfredini F, Lissom LO, Lavezzi S, Basaglia N, Straudi S. Beneficial Effects of Robot-Assisted Gait Training on Functional Recovery in Women after Stroke: A Cohort Study. Medicina (B Aires) 2021; 57:medicina57111200. [PMID: 34833418 PMCID: PMC8618864 DOI: 10.3390/medicina57111200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/27/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Robot-assisted gait training (RAGT) could be a rehabilitation option for patients after experiencing a stroke. This study aims to determine the sex-related response to robot-assisted gait training in a cohort of subacute stroke patients considering mixed results previously reported. Materials and Methods: In this study, 236 participants (145 males, 91 females) were admitted to a rehabilitation facility after experiencing a stroke and performed RAGT within a multidisciplinary rehabilitation program. Functional Independence Measure (FIM) and Functional Ambulatory Category (FAC) were assessed at admission and discharge to determine sex-related outcomes. Results: At the baseline, no significant difference among sexes was observed. At the end of rehabilitation, both males and females exhibited significant improvements in FIM (71% of males and 80% of females reaching the MCID cut-off value) and FAC (∆score: men 1.9 ± 1.0; women 2.1 ± 1.1). A more remarkable improvement was observed in women of the whole population during the study, but statistical significance was not reached. When analysing the FAC variations with respect to the total number of RAGT sessions, a more significant improvement was observed in women than men (p = 0.025). Conclusion: In conclusion, among subacute stroke patients, benefits were observed following RAGT during a multidisciplinary rehabilitation program in both sexes. A greater significant recovery for women with an ischemic stroke or concerning the number of sessions attended was also highlighted. The use of gait robotics for female patients may favour a selective functional recovery after stroke.
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Affiliation(s)
- Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.B.); (S.S.)
- Correspondence: ; Tel.: +39-05-3223-6187
| | - Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.B.); (S.S.)
- Unit of Rehabilitation Medicine, University Hospital of Ferrara, 44124 Ferrara, Italy;
| | - Luc Oscar Lissom
- Doctoral Program in Translational Neurosciences and Neurotechnologies, University of Ferrara, 44121 Ferrara, Italy;
| | - Susanna Lavezzi
- Unit of Rehabilitation Medicine, University Hospital of Ferrara, 44124 Ferrara, Italy;
| | - Nino Basaglia
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.B.); (S.S.)
| | - Sofia Straudi
- Department of Neuroscience and Rehabilitation, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (N.B.); (S.S.)
- Unit of Rehabilitation Medicine, University Hospital of Ferrara, 44124 Ferrara, Italy;
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