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Wang X, Liu X, O'Donnell MJ, McQueen M, Sniderman A, Pare G, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Zhang H, Liu L, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Nilanont Y, Yusuf S. Tobacco use and risk of acute stroke in 32 countries in the INTERSTROKE study: a case-control study. EClinicalMedicine 2024; 70:102515. [PMID: 38516107 PMCID: PMC10955659 DOI: 10.1016/j.eclinm.2024.102515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/23/2024] Open
Abstract
Background Smoking is a major risk factor for the global burden of stroke. We have previously reported a global population attributable risk (PAR) of stroke of 12.4% associated with current smoking. In this study we aimed to explore the association of current tobacco use with different types of tobacco exposure and environmental tobacco smoke (ETS) exposure on the risk of stroke and stroke subtypes, and by regions and country income levels. Methods The INTERSTROKE study is a case-control study of acute first stroke and was undertaken with 13,462 stroke cases and 13,488 controls recruited between January 11, 2007 and August 8, 2015 in 32 countries worldwide. Association of risk of tobacco use and ETS exposure were analysed with overall stroke, ischemic and intracerebral hemorrhage (ICH), and with TOAST etiological stroke subtypes (large vessel, small vessel, cardioembolism, and undetermined). Findings Current smoking was associated with an increased risk of all stroke (odds ratio [OR] 1.64, 95% CI 1.46-1.84), and had a stronger association with ischemic stroke (OR 1.85, 95% CI 1.61-2.11) than ICH (OR 1.19 95% CI 1.00-1.41). The OR and PAR of stroke among current smokers varied significantly between regions and income levels with high income countries (HIC) having the highest odds (OR 3.02 95% CI 2.24-4.10) and PAR (18.6%, 15.1-22.8%). Among etiological subtypes of ischemic stroke, the strongest association of current smoking was seen for large vessel stroke (OR 2.16, 95% CI 1.63-2.87) and undetermined cause (OR 1.97, 95% CI 1.55-2.50). Both filtered (OR 1.73, 95% CI 1.50-1.99) and non-filtered (OR 2.59, 95% CI 1.79-3.77) cigarettes were associated with stroke risk. ETS exposure increased the risk of stroke in a dose-dependent manner, exposure for more than 10 h per week increased risk for all stroke (OR 1.95, 95% CI 1.69-2.27), ischemic stroke (OR 1.89, 95% CI 1.59-2.24) and ICH (OR 2.00, 95% CI 1.60-2.50). Interpretation There are significant variations in the magnitude of risk and PAR of stroke according to the types of tobacco used, active and ETS exposure, and countries with different income levels. Specific strategies to discourage tobacco use by any form and to build a smoke free environment should be implemented to ease the global burden of stroke. Funding The Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, and through unrestricted grants from several pharmaceutical companies with major contributions from Astra Zeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MERCK, Sharp and Dohme, Swedish Heart and Lung Foundation, UK Chest, and UK Heart and Stroke.
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Affiliation(s)
- Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
| | - Xin Liu
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
| | - Martin J. O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- NUI Galway, Galway, Ireland
| | - Matthew McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Graeme J. Hankey
- St John's Medical College and Research Institute, Bangalore, India
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Denis Xavier
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Lisheng Liu
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John's Medical College and Research Institute, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | | | - Peter Langhorne
- Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
| | - Annika Rosengren
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L. Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | | | - Romana Iqbal
- Department of Medicine, Aga Khan University Hospitals in Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Khalid Yusoff
- UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
| | - Aytekin Oguz
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S. Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
| | - A. Ogunniyi
- Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
| | | | | | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - INTERSTROKE Investigators
- Beijing Hypertension League Institute, Beijing, China
- National Genetic Resources Research Center, National Research Institute for Family Planning, Beijing, China
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- NUI Galway, Galway, Ireland
- McGill University Health Centre, Montreal, QC, Canada
- St John's Medical College and Research Institute, Bangalore, India
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
- Eduardo Mondlane University, Maputo, Mozambique
- Glasgow Royal Infirmary, University of Glasgow, Glasgow, Scotland, UK
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
- College of Medicine, University of Philippines, Manila, Philippines
- Al Shaab Teaching Hospital, Khartoum, Sudan
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
- Department of Neurology, University Hospital, Essen, Germany
- Institute of Psychiatry and Neurology, Warsaw, Poland
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
- Department of Medicine, Aga Khan University Hospitals in Karachi, Pakistan
- Estudios Clinicos Latinoamerica, Rosario, Argentina
- UCSI University, Cheras, Kuala Lumpur 56000, Malaysia
- Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
- Department of Cardiology, Hospital Luis Vernaza, Guayaquil, Ecuador
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
- Department of Medicine, University College Hospital, Ibadan PMB 5116, Nigeria
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Universidad Peruana Cayetano Heredia, Lima, Peru
- University of Split, Croatia
- Rush Alzheimer Disease Research Center in Chicago, Chicago, IL, USA
- University of Limpopo, Pretoria, South Africa
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Murphy R, Damasceno A, Reddin C, Hankey GJ, Iversen HK, Oveisgharan S, Lanas F, Czlonkowska A, Langhorne P, Ogunniyi A, Wasay M, Rumboldt Z, Judge C, Oguz A, Mondo C, Winter Y, Rosengren A, Pogosova N, Avezum A, Nilanont Y, Penaherrera E, Xavier D, Lopez-Jaramillo P, Wang X, Yusuf S, O'Donnell M. Variations in the prevalence of atrial fibrillation, and in the strength of its association with ischemic stroke, in countries with different income levels: INTERSTROKE case-control study. Int J Stroke 2024:17474930241227783. [PMID: 38204182 DOI: 10.1177/17474930241227783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND The contribution of atrial fibrillation (AF) to the etiology and burden of stroke may vary by country income level. AIMS We examined differences in the prevalence of AF and described variations in the magnitude of the association between AF and ischemic stroke by country income level. METHODS In the INTERSTROKE case-control study, participants with acute first ischemic stroke were recruited across 32 countries. We included 10,363 ischemic stroke cases and 10,333 community or hospital controls who were matched for age, sex, and center. Participants were grouped into high-income (HIC), upper-middle-income (subdivided into two groups-UMIC-1 and UMIC-2), and lower-middle-income (LMIC) countries, based on gross national income. We evaluated the risk factors for AF overall and by country income level, and evaluated the association of AF with ischemic stroke. RESULTS AF was documented in 11.9% (n = 1235) of cases and 3.2% (n = 328) of controls. Compared to HIC, the prevalence of AF was significantly lower in UMIC-2 (aOR 0.35, 95% CI 0.29-0.41) and LMIC (aOR 0.50, 95% CI 0.41-0.60) on multivariable analysis. Hypertension, female sex, valvular heart disease, and alcohol intake were stronger risk factors for AF in lower-income countries, and obesity a stronger risk factor in higher-income countries. The magnitude of association between AF and ischemic stroke was significantly higher in lower-income countries compared to higher-income countries. The population attributable fraction for AF and stroke varied by region and was 15.7% (95% CI 13.7-17.8) in HIC, 14.6% (95% CI 12.3-17.1) in UMIC-1, 5.7% (95% CI 4.9-6.7) in UMIC-2, and 6.3% (95% CI 5.3-7.3) in LMIC. CONCLUSION Risk factors for AF vary by country income level. AF contributes to stroke burden to a greater extent in higher-income countries than in lower-income countries, due to a higher prevalence and despite a lower magnitude of odds ratio.
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Affiliation(s)
- Robert Murphy
- HRB Clinical Research Facility Galway, School of Medicine, University of Galway, Galway, Ireland
| | | | - Catriona Reddin
- HRB Clinical Research Facility Galway, School of Medicine, University of Galway, Galway, Ireland
| | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Shahram Oveisgharan
- Rush Alzheimer's Disease Research Center, Rush University Medical Center, Chicago, IL, USA
| | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Adesola Ogunniyi
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | - Conor Judge
- HRB Clinical Research Facility Galway, School of Medicine, University of Galway, Galway, Ireland
| | - Aytekin Oguz
- Metabolic Syndrome Association, Istanbul, Turkey
| | - Charles Mondo
- Department of Cardiology, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Yaroslav Winter
- Department of Neurology, Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Nana Pogosova
- National Medical Research Center of Cardiology Named After Academician E.I. Chazov, Moscow, Russia
| | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Denis Xavier
- St. John's Research Institute, St. John's Medical College, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | - Xingyu Wang
- Laboratory of Human Genetics, Beijing Hypertension League Institute, Beijing, China
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Martin O'Donnell
- HRB Clinical Research Facility Galway, School of Medicine, University of Galway, Galway, Ireland
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
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O’Donnell MJ, McQueen M, Sniderman A, Pare G, Wang X, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Nilanont Y, Yusuf S. Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE). J Stroke 2022; 24:224-235. [PMID: 35677977 PMCID: PMC9194539 DOI: 10.5853/jos.2021.02152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.
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Affiliation(s)
- Martin J. O’Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
- Correspondence: Martin J. O’Donnell Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Newcastle Rd., Galway, Ireland Tel: +353-91-494-098 Fax: +353-905-297-3781 E-mail:
| | - Matthew McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Allan Sniderman
- Division of Cardiology, McGill University Health Center, Montreal, QC, Canada
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xingyu Wang
- National Center of Cardiovascular Disease, Beijing, China
| | - Graeme J. Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - John Ferguson
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Denis Xavier
- St John’s Medical College and Research Institute, Bangalore, India
| | - Liu Lisheng
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John’s Medical College and Research Institute, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | | | - Peter Langhorne
- Department of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L. Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Ahmed Elsayed
- Department of Surgery, Al Shaab Teaching Hospital, Khartoum, Sudan
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Charles Mondo
- Department of Cardiology, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Conor Judge
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | | | - Anna Czlonkowska
- Department of Neurology, Military Institute of Aviation Medicine, Warsaw, Poland
| | - Nana Pogosova
- National Research Center for Preventive Medicine, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Christian Weimar
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Romana Iqbal
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- University College Sedaya International (UCSI) University, Kuala Lumpur, Malaysia
| | - Afzalhussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Health Authority, Dubai Medical College, Dubai, United Arab Emirates
| | - Aytekin Oguz
- Department of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | | | - Fernando Lanas
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Okechukwu S. Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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Arreaga-Perez C, Evangelista-Barragan D, Zarate-Zapata A, Penaherrera E, Zuniga-Bohorquez JJ, Garcia-Matamoros F, Flores-Delgado M, Barrera-Rivera M, Bravo-Sanchez P, Tejada-Franco A, Gilbert-Orus MD, Morejon-Barragan PA. Direct oral anticoagulants vs warfarin in non-valvular atrial fibrillation. Meta-analysis, includes all published trials. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Warfarin, despite its limitations, is still used as standard treatment in patients with Atrial Fibrillation, but it has been demonstrated that Direct Oral Anticoagulants (DOAC) offer many advantages over warfarin in the prevention of strokes.
Purpose
The goal was to determinate the safety and effectiveness in reducing systemic thromboembolism, ischemic stroke, hemorrhagic stroke, cerebral hemorrhage and cardiovascular mortalityof the direct oral anticoagulants (DOACs) over warfarin in patients with non-valvular atrial fibrillation, conducting an analysis of the studies of DOACs, including the ENGAGE study on the use of edoxaban, affirming its safety including the pivotal essays available.
Method
A systematic search of PubMed's bibliographic database was made for the selection of the articles.Clinical essays from less than 10 years, in phase III and multicentric studies were selected.
Results
The main objective was the significant reduction in the incidence of stroke/systemic thromboembolism with the use of DOACs vs. Warfarin (2,73% vs. 3,24%), the reduction of hemorrhagic stroke was (0.41% vs. 0.94%), ischemic stroke (3.12% vs. 3.5%), cardiovascular death with DOACs was 6.02% vs. Warfarin 6.84%, (compared with previous studies that demonstrated effectiveness with max doses affirming safety and effectiveness).
Conclusion
Our meta-analysis is the first to date to evaluate all the pivotal trials published,we include the ENGAGE trial. In non-valvular atrial fibrillation, the use of DOACs, in comparison with Warfarin, significantly reduced the risk of stroke/systemic thromboembolism by 16.3%, ischemic stroke by 11.1%, hemorrhagic stroke by 54.6%, cardiovascular mortality by 12.9%.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
| | | | | | - E Penaherrera
- Luis Vernaza Hospital, Cardiology, Guayaquil, Ecuador
| | | | | | | | | | | | | | - M D Gilbert-Orus
- Guayaquil Clinic, Cardiovascular Surgery Department, Guayaquil, Ecuador
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O' Donnell M, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Smyth A, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, AlHussain F, Daliwonga M, Nilanont Y, Yusuf S. Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level. Heart 2020; 107:heartjnl-2019-316515. [PMID: 33318082 DOI: 10.1136/heartjnl-2019-316515] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke. METHODS We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension. RESULTS Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46). CONCLUSIONS Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.
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Affiliation(s)
- Martin O' Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sumathy Rangarajan
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Siu Lim Chin
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Ferguson
- National University of Ireland Galway, Galway, Ireland
| | - Denis Xavier
- St John's Research Insitiute, Bangalore, Karnataka, India
| | - Liu Lisheng
- National Center for Cardiovascular Diseases China, Xicheng District, Beijing, China
- Beijing Hypertension League Institute, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Antonio L Dans
- University of the Philippines Manila College of Medicine, Manila, Metro Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Andrew Smyth
- National University of Ireland Galway, Galway, Ireland
| | - Conor Judge
- Medicine, National University of Ireland Galway, Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | | | | | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russia, Moskva, Russian Federation
| | - Christian Weimar
- Neurology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
- BDH-clinic Elzach, Elzach, Germany
| | - Romana Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Istanbul, Turkey
| | - Xingyu Wang
- Laboratory of Human Genetics, Beijing Hypertension League Institute, Beijing, China
| | - Ernesto Penaherrera
- Department of Cardiology, Luis Vernaza General Hospital, Guayaquil, Guayas, Ecuador
| | - Fernando Lanas
- Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Adensola Ogunniyi
- Neurology Unit, Department of Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Helle K Iversen
- Department of Neurology, University of Copenhagen, Rigshospitalet, Denmark
| | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Zvonko Rumboldt
- Department of Medicine, University of Split, Split, Splitsko-dalmatinska, Croatia
| | | | | | - Magazi Daliwonga
- Department of Medicine, University of Limpopo, Sovenga, Limpopo, South Africa
| | - Yongchai Nilanont
- Division of Neurology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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6
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Langhorne P, O'Donnell MJ, Chin SL, Zhang H, Xavier D, Avezum A, Mathur N, Turner M, MacLeod MJ, Lopez-Jaramillo P, Damasceno A, Hankey GJ, Dans AL, Elsayed A, Mondo C, Wasay M, Czlonkowska A, Weimar C, Yusufali AH, Hussain FA, Lisheng L, Diener HC, Ryglewicz D, Pogosova N, Iqbal R, Diaz R, Yusoff K, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Magazi D, Nilanont Y, Rosengren A, Oveisgharan S, Yusuf S. Practice patterns and outcomes after stroke across countries at different economic levels (INTERSTROKE): an international observational study. Lancet 2018; 391:2019-2027. [PMID: 29864018 DOI: 10.1016/s0140-6736(18)30802-x] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/07/2018] [Accepted: 03/21/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Stroke disproportionately affects people in low-income and middle-income countries. Although improvements in stroke care and outcomes have been reported in high-income countries, little is known about practice and outcomes in low and middle-income countries. We aimed to compare patterns of care available and their association with patient outcomes across countries at different economic levels. METHODS We studied the patterns and effect of practice variations (ie, treatments used and access to services) among participants in the INTERSTROKE study, an international observational study that enrolled 13 447 stroke patients from 142 clinical sites in 32 countries between Jan 11, 2007, and Aug 8, 2015. We supplemented patient data with a questionnaire about health-care and stroke service facilities at all participating hospitals. Using univariate and multivariate regression analyses to account for patient casemix and service clustering, we estimated the association between services available, treatments given, and patient outcomes (death or dependency) at 1 month. FINDINGS We obtained full information for 12 342 (92%) of 13 447 INTERSTROKE patients, from 108 hospitals in 28 countries; 2576 from 38 hospitals in ten high-income countries and 9766 from 70 hospitals in 18 low and middle-income countries. Patients in low-income and middle-income countries more often had severe strokes, intracerebral haemorrhage, poorer access to services, and used fewer investigations and treatments (p<0·0001) than those in high-income countries, although only differences in patient characteristics explained the poorer clinical outcomes in low and middle-income countries. However across all countries, irrespective of economic level, access to a stroke unit was associated with improved use of investigations and treatments, access to other rehabilitation services, and improved survival without severe dependency (odds ratio [OR] 1·29; 95% CI 1·14-1·44; all p<0·0001), which was independent of patient casemix characteristics and other measures of care. Use of acute antiplatelet treatment was associated with improved survival (1·39; 1·12-1·72) irrespective of other patient and service characteristics. INTERPRETATION Evidence-based treatments, diagnostics, and stroke units were less commonly available or used in low and middle-income countries. Access to stroke units and appropriate use of antiplatelet treatment were associated with improved recovery. Improved care and facilities in low-income and middle-income countries are essential to improve outcomes. FUNDING Chest, Heart and Stroke Scotland.
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Affiliation(s)
- Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Martin J O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Nandini Mathur
- St John's Medical College and Research Institute, Bangalore, India
| | - Melanie Turner
- Division of Applied Medicine, University of Aberdeen, Aberdeen, UK
| | | | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | | | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | - Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | | | | | | | | | - Liu Lisheng
- National Center of Cardiovascular Disease, Beijing, China
| | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Romana Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | | | - Aytekin Oguz
- Istanbul Medeniyet Üniversitesi, Istanbul, Turkey
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Annika Rosengren
- Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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7
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Cobos-Segarra L, Lopez-Jaramillo P, Ponte-Negretti Ci C, Villar R, Penaherrera E. Pharmacological Treatment of Hypertension: Effects in Endothelial Function. Curr Hypertens Rev 2018; 14:123-127. [PMID: 29737254 DOI: 10.2174/1573402114666180508104828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/29/2018] [Accepted: 04/02/2018] [Indexed: 11/22/2022]
Abstract
The vascular endothelium plays an important role to maintain the functional integrity of the cardiovascular system. The synthesis and secretion of substances with biological activity such as prostacyclin and NO give endothelium the vasodilator, antithrombotic, and antiatherosclerotic properties. Endothelial dysfunction participates in the genesis of HTA, but also hypertension produces endothelial damage. The major class of antihypertensive drugs has beneficial effects in the recuperation of the endothelial function, actions that are contributing to explain the impact of the adequate control of HTA in the reduction of CV events.
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Affiliation(s)
- Leonardo Cobos-Segarra
- Unidad de Cardiologia, Hospital El Pino, Santiago, Chile.,Colegio Panamericano del Endotelio, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador
| | - Patricio Lopez-Jaramillo
- Colegio Panamericano del Endotelio, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador.,Direccion de Investigaciones, FOSCAL, Bucaramanga, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador
| | - Carlos Ponte-Negretti Ci
- Colegio Panamericano del Endotelio, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador.,Fundacion Venezolana de Cardiologia Preventiva, Caracas, Venezuela
| | - Raul Villar
- Colegio Panamericano del Endotelio, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador.,Departamento de Medicina Interna, Seccion Enfermedades Cardio Metabolicas, La Serena, Chile
| | - Ernesto Penaherrera
- Colegio Panamericano del Endotelio, Colombia and Facultad de Ciencias de la Salud Eugenio Espejo, UTE, Quito, Ecuador.,Servicio de Cardiologia, Hospital Luis Vernaza de Guayaquil, Ecuador
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8
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O'Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, Rao-Melacini P, Zhang X, Pais P, Agapay S, Lopez-Jaramillo P, Damasceno A, Langhorne P, McQueen MJ, Rosengren A, Dehghan M, Hankey GJ, Dans AL, Elsayed A, Avezum A, Mondo C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Magazi D, Nilanont Y, Ferguson J, Pare G, Yusuf S. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388:761-75. [PMID: 27431356 DOI: 10.1016/s0140-6736(16)30506-2] [Citation(s) in RCA: 1157] [Impact Index Per Article: 144.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. METHODS We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. FINDINGS Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72-3·28; PAR 47·9%, 99% CI 45·1-50·6), regular physical activity (0·60, 0·52-0·70; 35·8%, 27·7-44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65-2·06 for highest vs lowest tertile; 26·8%, 22·2-31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53-0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2-28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27-1·64 for highest vs lowest tertile; 18·6%, 13·3-25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78-2·72; 17·4%, 13·1-22·6), current smoking (1·67, 1·49-1·87; 12·4%, 10·2-14·9), cardiac causes (3·17, 2·68-3·75; 9·1%, 8·0-10·2), alcohol consumption (2·09, 1·64-2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4-9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05-1·30; 3·9%, 1·9-7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). INTERPRETATION Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
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Affiliation(s)
- Martin J O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland.
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Lisheng Liu
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prem Pais
- St John's Medical College and Research Institute, Bangalore, India
| | - Steven Agapay
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Matthew J McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | | | - Romaina Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Helle K Iversen
- Stroke Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | | | | | - Shahram Oveisgharan
- Rush Alzheimer Disease Research Center, Rush University Medical Center, Chicago, IL, USA
| | | | - Daliwonga Magazi
- Department of Medicine, University of Limpopo, Pretoria, South Africa
| | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - John Ferguson
- Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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