Trends in one-year mortality for stroke in a tertiary academic center in Saudi Arabia: a 5-year retrospective analysis

One-year recurrence of stroke and death in Lebanese survivors of first-ever stroke: Time-to-Event analysis

BACKGROUND

To date, despite the application of secondary prevention worldwide, first-ever stroke survivors remain at imminent risk of stroke recurrence and death in the short and long term. The present study aimed to assess the cumulative risk rates and identify baseline differences and stroke characteristics of Lebanese survivors.

METHODS

A prospective longitudinal study was conducted among survivors ≥18 years old who were followed-up for 15 months through a face-to-face interview. Kaplan-Meier method was used to calculate the cumulative rates of stroke mortality and recurrence. Cox-regression univariate and multivariable analyses were performed to identify the predictors of both outcomes.

RESULTS

Among 150 subjects (mean age 74 ± 12 years; 58.7% men vs. 44.3% women; 95.3% with ischemic stroke vs. 4.3% with intracerebral hemorrhage), high cumulative risk rates of stroke recurrence (25%) and death (21%) were highlighted, especially in the acute phase. Survival rates were lesser in patients with stroke recurrence compared to those without recurrence (Log rank test p < 0.001). Older age was the main predictor for both outcomes (p < 0.02). Large artery atherosclerosis was predominant in patients with stroke recurrence and death compared to small vessel occlusion (p < 0.02). Higher mental component summary scores of quality of life were inversely associated with stroke recurrence (p < 0.01). Lebanese survivors exhibited the highest percentages of depression and anxiety; elevated Hospital Anxiety and Depression Scale (HADS) scores were seen in those with stroke recurrence and those who died (≥80% with mean HADS scores ≥8). Lower Mini-Mental State Examination scores at the acute phase increased the risk of both outcomes by 10% (p < 0.03). Three out of 13 mortalities (23.1%) were presented with early epileptic seizures (p = 0.012). High educational level was the protective factor against stroke recurrence (p = 0.019). Administration of intravenous thrombolysis decreased the risk of both outcomes by 10% (p > 0.05).

CONCLUSION

Higher rates of stroke recurrence and death were observed in the first year following a stroke in Lebanon. Various factors were identified as significant determinants. Thus, health care providers and officials in Lebanon can use these findings to implement effective preventive strategies to best address the management of these factors to reduce the stroke burden and improve the short and long-term prognosis of stroke survivors.

Stroke Seasonality and Weather Association in a Middle East Country: A Single Tertiary Center Experience

Background: Stroke is a medical condition that leads to major disability and mortality worldwide. Some evidence suggests that weather and seasonal variations could have an impact on stroke incidence and outcome. However, the current evidence is inconclusive. Therefore, this study examines the seasonal variations and meteorological influences on stroke incidence and outcome in the largest city in Saudi Arabia.

Methods: From February 2016 to July 2019, we retrospectively reviewed data from all patients with acute ischemic (AIS) or hemorrhagic stroke (HS) admitted to the stroke unit in a tertiary academic center in Saudi Arabia. The corresponding daily meteorological data were obtained for the same period. We considered the months from November to March as the cold season and April to October as the hot season.

Results: The final cohort included 1,271 stroke patients; 60.89% (n = 774) cases occurred in the hot season, while 39.1% (n = 497) in the cold season. Males accounted for 69.6% (n = 884) of the cases. The proportion of ischemic stroke was 83.2% [hot season 83.9% (n = 649) vs. cold season 82.3% (n = 409)]. We found no statistically significant difference between seasons (hot or cold) in stroke incidence, severity [National Institutes of Health Stroke Scale (NIHSS)], hospital course (pneumonia, thromboembolism, intensive care stay, or length of stay), or outcome [modified Rankin scale (mRS) on discharge and death].

Conclusions: In Riyadh, Saudi Arabia, our study found no impact of weather or seasonal variations on stroke incidence, hospital course, or outcomes. However, our findings warrant further research in different country regions.

May Measurement Month 2019: an analysis of blood pressure screening results from Saudi Arabia

High blood pressure (BP) is a major risk factor for cardiovascular diseases and was identified as the most significant single preventable cause of mortality. The prevalence of hypertension in Saudi Arabia is high. To raise awareness and identify undiagnosed hypertension, the Saudi Ministry of Health participated in the May Measurement Month (MMM) 2019 global screening initiative of the International Society of Hypertension. Ninety-two primary care centres across the Kingdom recruited respondents aged ≥18 years through opportunistic sampling, from 1 May to 30 August of 2019. Data collection included sociodemographic, lifestyle habits, environmental, and anthropometric indicators. Blood pressure was measured twice using automated BP devices. A total of 25 023 adults were screened with a mean age of 42.4 (16.7) years and a mean body mass index of 27.5 (6.0) kg/m2. In total, 43.6% of participants were females and 56.4% were males. Of all the participants with hypertension, 60.8% were aware, 60.8% were on antihypertensive medication, and 39.3% had controlled BP (systolic BP <140 mmHg and diastolic BP <90 mmHg). Moreover, out of 4440 participants on antihypertensive medication, only 64.6% had controlled BP. The high numbers of individuals with hypertension and with undiagnosed hypertension highlight the importance of BP screening campaigns to increase awareness, detection, and target treatment on a national level. Findings from this study can form a baseline by which to measure progress in future iterations of MMM.

Demographic characteristics and types of stroke in Southwestern Saudi Arabia, and the potential demand of neuro endovascular specialists

OBJECTIVES

To identify demographic characteristics, and types of stroke in Southwestern (Aseer) Region, Saudi Arabia.

METHODS

This study is a retrospective and hospital-based. The data of all stroke patients (n=562) admitted to the tertiary care hospital in the province, Aseer Central Hospital (ACH) within the period from January 2016 until December 2017 are included.

RESULTS

The mean ± SD of stoke patients' age was 62.6 ± 17.0 years. Male patients were more than female patients (62.6% and 37.4%, respectively). The majority (93.2%) were Saudi, while 91.5% had below university education and 6.4% were smokers. Interestingly, only 2% of patients had a family history of stroke, while 68.1% were diabetic, 80.4% were hypertensive, 91.6% had high serum cholesterol level, and 10.7% had history of transient ischemic attacks (TIA). Despite the lack of awareness, and leading to delay in reaching health care facility, 58.1% of stroke patients, were arriving to emergency department (ED) in less than 24 hours (potential endovascular therapeutic window).

CONCLUSIONS

In Aseer Region, Saudi Arabia, stroke affects mainly those who are older, less educated, diabetic, hypertensive, with hypercholesterolemia and previous history of TIA. Associated factors for stroke differ significantly according to their nationality.

Patterns and outcomes of stroke thrombolysis in a large tertiary care hospital in Riyadh, Saudi Arabia

Objectives:

To present the experience on stroke thrombolysis of a tertiary care center in Riyadh, KSA.

Methods:

Cross-sectional, observational study of patients thrombolyzed between January 2012 and December 2018.

Results:

Thrombolysis was performed in 148 patients (mean age: 58.2±14.5 years), 94 (63.5%) of them were men. The median onset-to-door time was 81 minutes, and 25% of the patients arrived within 1 hour. The median National Institute of Health Stroke Scale score upon admission was 13. Hypertension (68.9%), diabetes (56.1%), and dyslipidemia (40.5%) were the most common risk factors for stroke. The most common mechanism of stroke was cardioembolism (43.2%), which was associated with a more severe presentation (p=0.031). Intravenous thrombolysis alone was given to 98 patients (66.2%); the rest received intravenous tissue plasminogen activator plus endovascular therapy or endovascular therapy alone. The median door-to-needle (DTN) time was 70.5 min, with a significant improvement from 2012 (111.6 minutes) to 2018 (69.9 minutes) (p<0.001). Among the patients, 53 (35.8%) showed a good outcome (with a modified Rankin score of 0–2) whereas 14 (9.5%) died. Symptomatic intracranial hemorrhage (sICH) was seen in 8.1%. All vascular risk factors were more common in patients aged >60 years, except smoking, which was more common in the younger age group (p=0.007).

Conclusion:

In our cohort, the utilization of thrombolysis and the DTN time improved over time. One-thirds of the patients received endovascular treatment. Moreover, the frequency of the vascular risk factors was high. Compared with the published findings, our results showed that cardioembolic strokes were the most frequent and had severe presentation and were likely the cause of the slight increase in mortality and sICH.

Burden of stroke in the Kingdom of Saudi Arabia: A soaring epidemic

Stroke is a key cerebrovascular disease that is related to high morbidity and mortality in the globe. The Kingdom of Saudi Arabia (KSA) is not an exception where stroke is fast developing into a serious challenge due to the high mortality rate. Additionally, stroke presents a tremendous economic burden and has a devastating effect on the quality of lives of individuals. The number of stroke cases are increasing yearly, thus posing a major challenge to the health care system. Therefore, it is crucial to implement primary and secondary prevention strategies in the KSA. Nevertheless, as compared with developed countries, information on the prevalence, socio-demographic properties and prevention of stroke remains scarce that could be attributed to the shortage of research conducted in this specified region. The review is written to address the various aspects of stroke in the KSA, based on current literatures search using PubMed, Scopus, Web of Science and Google Scholar databases, to identify studies published since inception to Dec 2020.

Incidence of stroke among Saudi population: a systematic review and meta-analysis

BACKGROUND AND AIMS

Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is not known. Thus, we aimed to determine the pooled annual incidence of stroke in Saudi Arabia. We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate for both first and recurrent. A total of five studies met the inclusion criteria for this review. The pooled annual incidence of stroke in Saudi Arabia was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29 strokes per 100,000 people annually (95% CI: 15 to 47).

CONCLUSION

The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia. Our values were lower than those of other high-income countries. Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.

Preference and Values of Stroke Interventions, Kingdom of Saudi Arabia

Background. Acute ischemic stroke (AIS) occurs when there is a sudden occlusion of the arterial blood supply to part of the brain resulting in sudden focal neurological deficits. Recent major clinical trials of reperfusion therapy had proved the efficacy of timely stroke intervention to restore blood flow. Development of acute stroke protocols waiving the informed consent to obtain necessarily brain images or provide thrombolytic therapy is important to streamline and organize efforts to achieve the goal of early intervention and better functional outcome. Objective. This study aims to identify the preference and values of acute stroke interventions standard of care therapy without informed consent in the absence of surrogate decision-makers. Methods. A cross-sectional survey was conducted in the Kingdom of Saudi Arabia using an electronic questionnaire. The questionnaire addressed the patients' preference of acute stroke protocol waiving the informed consent for hyperacute brain images and delivering thrombolytic therapy or mechanical thrombectomy in absence of surrogate. All Saudi population aging from 18 to 65 years were invited to participate. Results. The study included 2004 participants with ages ranging from 18 to 65 years with mean age of 30.1 years. About 66% of the participants were females and 95% were Saudi. Overall, 90.5% of the participants agreed on performing computed tomography angiography (CTA) by the medical staff for the acute strokes without consenting followed by 79% for thrombolytic therapy, 70.8% for mechanical thrombectomy, and only 49.3% for acute lifesaving surgical intervention. Conclusion. Researchers found that the high percentage of participants had favorable response and positive perception toward providing acute stroke intervention and mechanical thrombectomy without informed consent. However, the study showed skeptical acceptance among participants regarding invasive surgical measures.

Outcome of stroke patients on clopidogrel plus proton-pump inhibitors: a single-center cohort study

BACKGROUND

Recent studies suggest a higher risk of adverse cardiovascular outcome and mortality in patients co-prescribed clopidogrel with proton pump inhibitors (PPI).

OBJECTIVE

Investigate the impact of concomitant prescription of clopidogrel and PPI on 30-day unplanned readmission and one-year all-cause mortality.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Single academic tertiary center.

PATIENTS AND METHODS

The study included patients admitted with a diagnosis of ischemic or hemorrhagic stroke between 2010 and 2014. Demographic and outcome data were collected and compared for patients on clopidogrel plus PPI vs those on clopidogrel plus H2blockers and those not on clopidogrel.

MAIN OUTCOME MEASURES

One-year mortality and 30-day unplanned readmissions were compared among different patient groups using multivariable logistic regression modeling.

SAMPLE SIZE

464 patients.

RESULTS

Out of 464 patients, 175 (37.7%) were discharged on clopidogrel. The concomitant prescription of clopidogrel and PPI was noted in 107 (24.4%) and clopidogrel and H2 blockers in 36 patients (7.8%). The one-year all-cause mortality in the entire cohort was 22.2%. Patients on clopidogrel plus PPI did not have a higher risk of one-year mortality compared to the non-PPI cohort (6.2% vs. 4.8%, p 0.7). There was a non-significant suggestion of lower one-year mortality in patients on clopidogrel plus PPI vs those not on clopidogrel (6.2% vs. 10.1%, p 0.23). In multivariable logistic regression, the use of clopidogrel plus PPI did not predict higher one-year mortality (odds ratio 0.6, P=0.6). The risk of unplanned 30-day readmission was lower in those with clop-idogrel plus PPI (odds ratio 0.6, P=.03).

CONCLUSION

The use of clopidogrel plus PPI resulted in lower readmission rates and was not associated with higher mortality compared with the non-PPI cohorts.

LIMITATIONS

Single center study, not generalizable. Given the retrospective nature of this study, we did not collect data on duration of treatments or patient compliance.

CONFLICT OF INTEREST

None.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran

OBJECTIVE

The aim of this study was to determine the in-hospital survival of patients referred to the 2 stroke centers in North-West of Iran during a full seasonal year from April 2015.

METHODS

All the consecutive patients with stroke admitted to the 2 main stroke centers at Tabriz (Imam Reza University Hospital and Razi University Hospital) were recruited in this study. Stroke patients from both ischemic and hemorrhagic subtypes were selected based on the registry data and International Classification of Diseases, 10th edition. At admission, details of examination including vital signs, neurologic and systemic examination, Modified Rankin Scale, and Glasgow Coma Scale were recorded. Baseline hematological and biochemical parameter assessments as well as computerized tomographic scanning were conducted. Cox regression was used to investigate and detect potential predictors of in-hospital survival.

RESULTS

A total of 1,990 patients with stroke were studied. Males comprised 52.1% (1,036) of the subjects. The mean age of the patients was 65.8 years. Three hundred and fifty-seven (17.9%) patients had hemorrhagic stroke vs 1,633 (82.1%) with ischemic stroke. In-hospital case-fatality proportion was 12.5% (95% CI: 11.1-14). Based on modified Rankin Scale score at admission, 1,377 of 1,990 patients (69.2%) had a poor outcome (modified Rankin Scale score ≥3) at the admission time. The regression analysis showed that at least 7 variables could independently predict hospital survival of patients with stroke including age ≥65 years, higher admission modified Rankin Scale score, lower admission Glasgow Coma Scale score, hemorrhagic stroke nature, diabetes, having valvular heart disease, and having aspiration pneumonia.

CONCLUSION

The case-fatality of stroke in the present study setting is high and needs to be appropriately addressed through prevention or management of some of these factors such as diabetes, pneumonia, and valvular heart diseases.

In Hospital Stroke Mortality: Rates and Determinants in Southwestern Saudi Arabia

Objectives: The present study analyzed in-hospital first-time stroke mortality in southwestern Saudi Arabia over one-year to assess the in-hospital stroke case fatality rate, mortality rate and explore the factors associated with in-hospital stroke mortality. Study Design: Hospital based follow-up study. Methods: First-time stroke patients admitted to all hospitals in Asser region over one-year period (January through December 2016) were included in the study. Data about personal characteristics, pre-stroke history and clinical criteria, on admission clinical criteria, in-hospital complications and survival status were collected. The last reported Aseer region population was used to calculate age and sex stroke mortality rate per 100,000 population/year. Hazard ratios (HR) and concomitant 95% confidence intervals (95% CI) were computed using multivariate Cox regression survival analysis. Kaplan-Meier curve survival analysis for stroke patients were plotted. Results: A total of 121 in-hospital deaths out of 1249 first-time stroke patients giving an overall case fatality rate (CFR) of 9.7%. Non-significant difference with gender and age were observed in CFR. Overall, in-hospital stroke mortality rate was 5.58 per 100,000/year. Males and elders showed a significantly higher mortality rates. Multivariable Cox regression analyses revealed pre-stroke smoking (HR = 2.36), pre-stroke hypertension (HR = 1.77), post-stroke disturbed consciousness (HR = 6.86), poor mobility (HR = 2.60) and developing pulmonary embolism (HR = 2.63) as significant predictors of in-hospital stroke mortality. Conclusions: In Southwestern Saudi Arabia, the in-hospital stroke mortality rate is higher in men and increases with aging. The prognosis of acute stroke could be improved by smoking cessation, better control of hypertension and prevention of in hospital complication particularly pulmonary embolism.