Dose-Response Association Between High-Density Lipoprotein Cholesterol and Stroke: A Systematic Review and Meta-Analysis of Prospective Cohort Studies

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Association between HDL levels and stroke outcomes in the Arab population

Low HDL levels are associated with an increased stroke incidence and worsened long-term outcomes. The aim of this study was to assess the relationship between HDL levels and long-term stroke outcomes in the Arab population. Patients admitted to the Qatar Stroke Database between 2014 and 2022 were included in the study and stratified into sex-specific HDL quartiles. Long-term outcomes included 90-Day modified Rankin Score (mRS), stroke recurrence, and post-stroke cardiovascular complications within 1 year of discharge. Multivariate binary logistic regression analyses were performed to identify the independent effect of HDL levels on short- and long-term outcomes. On multivariate binary logistic regression analyses, 1-year stroke recurrence was 2.24 times higher (p = 0.034) and MACE was 1.99 times higher (p = 0.009) in the low-HDL compared to the high-HDL group. Mortality at 1 year was 2.27-fold in the low-normal HDL group compared to the reference group (p = 0.049). Lower sex-specific HDL levels were independently associated with higher adjusted odds of 1-year post-stroke mortality, stroke recurrence, and MACE (p < 0.05). In patients who suffer a stroke, low HDL levels are associated with a higher risk of subsequent vascular complication.

Impact of lipid profiles on parenchymal hemorrhage and early outcome after mechanical thrombectomy

OBJECTIVE

We aimed to investigate the association of lipid parameters with parenchymal hemorrhage (PH) and early neurological improvement (ENI) after mechanical thrombectomy (MT) in stroke patients.

METHODS

We retrospectively analyzed consecutive patients who underwent MT between January 2019 and February 2022 at a tertiary stroke center. PH was diagnosed and classified as PH-1 and PH-2 according to the European Cooperative Acute Stroke Study definition. ENI was defined as a decrease in the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 or an NIHSS score of ≤1 at 24 h after MT.

RESULTS

Among 155 patients, PH occurred in 41 (26.5%) patients, and 34 (21.9%) patients achieved ENI. In multivariate analysis, lower triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) value (OR = 0.51; 95% CI 0.30-0.89; p = 0.017) and higher HDL-C level (OR = 5.83; 95% CI 1.26-26.99; p = 0.024) were independently associated with PH. The combination of TG <0.77 mmol/L and HDL-C ≥ 0.85 mmol/L was the strongest predictor of PH (OR = 10.73; 95% CI 2.89-39.87; p < 0.001). A low HDL-C level was an independent predictor of ENI (OR 0.13; 95% CI 0.02-0.95; p = 0.045), and PH partially accounts for the failure of ENI in patients with higher HDL-C levels (estimate: -0.05; 95% CI: -0.11 to -0.01; p = 0.016).

INTERPRETATION

The combination of lower TG level and higher HDL-C level can predict PH after MT. Postprocedural PH partially accounts for the failure of ENI in patients with higher HDL-C levels. Further studies into the pathophysiological mechanisms underlying this observation are of interest.

Association between gut microbiome and intracerebral hemorrhage based on genome-wide association study data

OBJECTIVES

Intracerebral hemorrhage (ICH) has the highest mortality and disability rates among various subtypes of stroke. Previous studies have shown that the gut microbiome (GM) is closely related to the risk factors and pathological basis of ICH. This study aims to explore the causal effect of GM on ICH and the potential mechanisms.

METHODS

Genome wide association study (GWAS) data on GM and ICH were obtained from Microbiome Genome and International Stroke Genetics Consortium. Based on the GWAS data, we first performed Mendelian randomization (MR) analysis to evaluate the causal association between GM and ICH. Then, a conditional false discovery rate (cFDR) method was conducted to identify the pleiotropic variants.

RESULTS

MR analysis showed that Pasteurellales, Pasteurellaceae, and Haemophilus were negatively correlated with the risk of ICH, whileVerrucomicrobiae, Verrucomicrobiales, Verrucomicrobiaceae, Akkermansia, Holdemanella, and LachnospiraceaeUCG010 were positively correlated with ICH. By applying the cFDR method, 3 pleiotropic loci (rs331083, rs4315115, and rs12553325) were found to be associated with both GM and ICH.

CONCLUSIONS

There is a causal association and pleiotropic variants between GM and ICH.

Neutrophil to high-density lipoprotein cholesterol ratio, a novel risk factor associated with acute ischemic stroke

To investigate the relationship between neutrophil to high-density lipoprotein cholesterol ratio (NHR) and Acute Ischemic Stroke (AIS), and provide a new direction for the diagnosis and prevention of AIS. A total of 158 patients with AIS and 162 healthy individuals were recruited. Demographic, clinical, and laboratory data of participants were obtained and the multivariable logistic regression analysis was employed to assess risk factors for AIS. The receiver operating characteristic (ROC) curve was plotted to analyze the diagnostic value of NHR for AIS. The spearman correlation analysis was used to estimate the correlation between NHR and national institute of health stroke scale (NIHSS) score. The age, White blood cell, MONO (monocyte), NEUT (neutrophil), creatinine, TG (triglyceride), NHR, neutrophil to lymphocyte ratio and MONO to high-density lipoprotein cholesterol ratio were remarkably greater and HDL-C (high-density lipoprotein cholesterol) was dramatically lower in the case group compared with in the control group (P < .05). The multivariable logistic regression analysis revealed that age [OR = 1.095, 95% CI (1.056, 1.135)], TG [OR = 6.188, 95% CI (2.900, 13.206)] and NHR [OR = 11.394, 95% CI (1.196, 108.585)] were independent risk factors for AIS (P < .05). The areas under the curve (AUCs) for the prediction of AIS by the age, TG and NHR were 0.694, 0.686, 0.782, respectively, the specificity were 56.8%, 88.3%, 87.0%, and the sensitivity were 75.3%, 44.3%, 56.3%, respectively (P < .05). In addition, spearman correlation analysis indicated that there was a positive correlation between NHR and NIHSS score (R = 0.558, P < .05). The level of NHR was higher in patients with a NIHSS score of above 5 points compared with those with a NIHSS score of 5 points or lower (P < .0001). The age, TG, and NHR were independent risk factors for AIS, and the level of NHR was positively correlated with severity of AIS.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Development of a Nomogram for Predicting Asymptomatic Coronary Artery Disease in Patients with Ischemic Stroke

BACKGROUND

Coronary artery stenosis (CAS) ≥50% often coexists in patients with ischemic stroke, which leads to a significant increase in the occurrence of major vascular events after stroke. This study aimed to develop a nomogram for diagnosing the presence of ≥50% asymptomatic CAS in patients with ischemic stroke.

METHODS

A primary cohort was established that included 275 non-cardioembolic ischemic stroke patients who were admitted from January 2011 to April 2013 to a teaching hospital in southern China. The preoperative data were used to construct two models by the best subset regression and the forward stepwise regression methods, and a nomogram between these models was established. The assessment of the nomogram was carried out by discrimination and calibration in an internal cohort.

RESULTS

Out of the two models, model 1 contained eight clinical-related variables and exhibited the lowest Akaike Information Criterion value (322.26) and highest concordance index 0.716 (95% CI, 0.654-0.778). The nomogram showed good calibration and significant clinical benefit according to calibration curves and the decision curve analysis.

CONCLUSION

The nomogram, composed of age, sex, NIHSS score on admission, hypertension history, fast glucose level, HDL cholesterol level, LDL cholesterol level, and presence of ≥50% cervicocephalic artery stenosis, can be used for prediction of ≥50% asymptomatic coronary artery disease (CAD). Further studies are needed to validate the effectiveness of this nomogram in other populations.

Altered Effective Connectivity of the Primary Motor Cortex in Transient Ischemic Attack

Objective

This study is aimed at exploring alteration in motor-related effective connectivity in individuals with transient ischemic attack (TIA).

Methods

A total of 48 individuals with TIA and 41 age-matched and sex-matched healthy controls (HCs) were recruited for this study. The participants were scanned using MRI, and their clinical characteristics were collected. To investigate motor-related effective connectivity differences between individuals with TIA and HCs, the bilateral primary motor cortex (M1) was used as the regions of interest (ROIs) to perform a whole-brain Granger causality analysis (GCA). Furthermore, partial correlation was used to evaluate the relationship between GCA values and the clinical characteristics of individuals with TIA.

Results

Compared with HCs, individuals with TIA demonstrated alterations in the effective connectivity between M1 and widely distributed brain regions involved in motor, visual, auditory, and sensory integration. In addition, GCA values were significantly correlated with high- and low-density lipoprotein cholesterols in individuals with TIA.

Conclusion

This study provides important evidence for the alteration of motor-related effective connectivity in TIA, which reflects the abnormal information flow between different brain regions. This could help further elucidate the pathological mechanisms of motor impairment in individuals with TIA and provide a new perspective for future early diagnosis and intervention for TIA.

TG/HDL-C ratio as a predictor of stroke in the population with healthy BMI: The Jichi Medical School Cohort Study

BACKGROUND AND AIMS

The triglycerides-to-high-density lipoprotein cholesterol ratio (TG/HDL-C) is a predictor of metabolic syndrome and cardiovascular disease onset. However, the relationship between TG/HDL-C and stroke has not been established. This study examined whether TG/HDL-C helps in predicting stroke onset; this was compared between the whole population and healthy body mass index (BMI) population.

METHODS AND RESULTS

The Jichi Medical School Cohort Study is a prospective cohort study involving baseline data collected in 12 Japanese districts between April 1992 and July 1995. We used data from 11,699 participants; participants with a healthy BMI (20.0-24.9 kg/m²) were grouped into sex-specific TG/HDL-C quartiles. Using the first quartile groups as references, the hazard ratios (HRs) and 95% confidence intervals (CIs) of the Cox proportional hazards model were calculated. During the mean 10.8 years of follow-up, 419 new stroke events were recorded. The multivariable-adjusted HRs (95% CIs) in the fourth quartile of the whole population were 1.28 (0.94-1.75), 1.78 (0.91-3.48), 1.20 (0.82-1.77), and 1.13 (0.50-2.54), as compared to those in the fourth quartile of the healthy BMI population, which were 1.87 (1.24-2.83), 3.06 (1.21-7.74), 1.79 (1.05-3.05), and 1.29 (0.49-3.41) for all patients with all stroke, intracerebral hemorrhage, cerebral infarction, and subarachnoid hemorrhage, respectively.

CONCLUSION

Increased TG/HDL-C correlated with a significant increase in stroke risk only in the healthy BMI population and not the whole population. Furthermore, it was primarily associated with increased intracerebral hemorrhage and cerebral infarction risk.

A Nomogram That Includes Neutrophils and High-Density Lipoprotein Cholesterol Can Predict the Prognosis of Acute Ischaemic Stroke

Lipids are implicated in inflammatory responses affecting acute ischaemic stroke prognosis. Therefore, we aimed to develop a predictive model that considers neutrophils and high-density lipoprotein cholesterol to predict its prognosis. This prospective study enrolled patients with acute ischaemic stroke within 24 h of onset between January 2015 and December 2017. The main outcome was a modified Rankin Scale score ≥3 at the 90th day of follow-up. Patients were divided into training and testing sets. The training set was divided into four states according to the median of neutrophils and high-density lipoprotein cholesterol levels in all patients. Through binary logistic regression analysis, the relationship between factors and prognosis was determined. A nomogram based on the results was developed; its predictive value was evaluated through internal and external validations. Altogether, 1,090 patients were enrolled with 872 (80%) and 218 (20%) in the training and testing sets, respectively. In the training set, the major outcomes occurred in 24 (10.4%), 24 (11.6%), 37 (17.2%), and 49 (22.3%) in states 1–4, respectively (P = 0.002). Validation of calibration and decision curve analyses showed that the nomogram showed better performance. The internal and external testing set receiver operating characteristics verified the predictive value [area under the curve = 0.794 (0.753–0.834), P &lt; 0.001, and area under the curve = 0.973 (0.954–0.992), P &lt; 0.001, respectively]. A nomogram that includes neutrophils and high-density lipoprotein cholesterol can predict the prognosis of acute ischaemic stroke, thus providing us with an effective visualization tool.

High-density lipoprotein cholesterol and cardiovascular mortality: a prospective cohort study among 15.8 million adults

AIMS

We aimed to investigate whether the associations between high-density lipoprotein cholesterol (HDL-C) and cardiovascular disease (CVD) mortality and the optimal range differ by age and CVD subtypes.

METHODS AND RESULTS

Korean adults (n = 15,859,501) with no CVD/cancer who received routine health examinations during 2009-2010 were followed until 2018 for CVD mortality. During a mean 8.8 years of follow-up, 108,123 individuals died from CVD. U-curve associations were found between HDL-C and CVD mortality, regardless of sex, age, and CVD subtype. The optimal range was 50-79 mg/dL (1.29-2.06 mmol/L), while it was 40-69 (1.03-1.80), 50-79 (1.29-2.06), and 60-89 (1.55-2.32) mg/dL (mmol/L) in adults aged <45 years, 45-64 years, and 65-99 years, respectively. Assuming linear associations <60 mg/dL, the multivariable-adjusted hazard ratios (HRs) per 39 mg/dL (1 mmol/L) higher level were 0.58 (95% CI = 0.56-0.60), and they were 0.61 (0.52-0.72), 0.58 (0.54-0.62), and 0.59 (0.56-0.61) in individuals aged 18-44, 45-64, and 65-99 years, respectively (P  interaction[age]=0.845). Assuming linear associations in the 60-150 mg/dL range, HDL-C was positively associated with CVD mortality (HR = 1.09, 1.04-1.14). The strongest association was for sudden cardiac death (HR = 1.37), followed by heart failure (HR = 1.20) and intracerebral hemorrhage (HR = 1.13). The HRs were 1.47 (1.23-1.76), 1.17 (1.08-1.28), and 1.03 (0.97-1.08) in individuals aged 18-44, 45-64, and 65-99 years, respectively (P  interaction[age]<0.001).

CONCLUSIONS

Both low and high levels of HDL-C were associated with increased mortality from CVD in the general population, especially sudden cardiac death, heart failure, and intracerebral hemorrhage. High HDL-C levels are not necessarily a sign of good cardiovascular health, especially in younger adults.