Hemorrhagic Strokes Attributable to Chronic Alcohol Consumption and Heavy Episodic Drinking in France

OBJECTIVES

To estimate the number of cases and deaths related to hemorrhagic stroke (HS) attributable to a chronic alcohol consumption and to heavy episodic drinking (HED) in France.

METHODS

A population-attributable fraction (PAF) estimation approach was used. Relative risks for HS with alcohol consumption were extracted from the INTERSTROKE study. Levels of alcohol consumption in the French population were collected from the 2017 Health Barometer. Data on HS morbidity and mortality were extracted from the French National Health Data System (SNDS).

RESULTS

We estimated that 7.2% (n = 2,100) and 6.6% (n = 1,900) of cases with HS were attributable to chronic alcohol consumption and HED, respectively. PAFs were higher in men than in women with 11.5% vs 2.6% for a chronic consumption and 10.7% vs 2.1% for HED, respectively. We estimated that 7.0% of HS deaths (n = 1,100) were attributable to chronic alcohol consumption and 5.1% attributable to HED (n = 800). Finally, 16.3% of patients with HS (n = 4,700) and 14.1% of HS deaths (n = 2,300) were attributable to overall chronic alcohol consumption or to monthly HED.

DISCUSSION

These results remind the importance of alcohol consumption in the occurrence of HS and the importance of implementing primary and secondary prevention measures, particularly among young people, where HED is most common.

Temporal trends in admission for cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021: Persistent sex, age and social disparities

BACKGROUND

Cardiac rehabilitation after an acute coronary syndrome is recommended to decrease patient morbidity and mortality and to improve quality of life.

AIMS

To describe time trends in the rates of patients undergoing cardiac rehabilitation after an acute coronary syndrome in France from 2009 to 2021, and to identify possible disparities.

METHODS

All patients hospitalized for acute coronary syndrome in France between January 2009 and June 2021 were identified from the national health insurance database. Cardiac rehabilitation attendance was identified within 6 months of acute coronary syndrome hospital discharge. Age-standardized cardiac rehabilitation rates were computed and stratified for sex and acute coronary syndrome subtypes (ST-segment elevation and non-ST-segment elevation). Patient characteristics and outcomes were described and compared. Factors independently associated with cardiac rehabilitation attendance were identified.

RESULTS

In 2019, among 134,846 patients with an acute coronary syndrome, 22.3% underwent cardiac rehabilitation within 6 months of acute coronary syndrome hospital discharge. The mean age of patients receiving cardiac rehabilitation was 62 years. The median delay between acute coronary syndrome hospitalization and cardiac rehabilitation was 32 days, with about 60% receiving outpatient cardiac rehabilitation. Factors significantly associated with higher cardiac rehabilitation rates were male sex, younger age (35-64 years), least socially disadvantaged group, ST-segment elevation, percutaneous coronary intervention and coronary artery bypass graft. Between 2009 and 2019, cardiac rehabilitation rates increased by 40% from 15.9% to 22.3%. Despite greater upward trends in women, their cardiac rehabilitation rate was significantly lower than that for men (14.8% vs. 25.8%). In 2020, cardiac rehabilitation attendance dropped because of the coronavirus disease 2019 pandemic.

CONCLUSIONS

Despite the health benefits of cardiac rehabilitation, current cardiac rehabilitation attendance after acute coronary syndrome remains insufficient in France, particularly among the elderly, women and socially disadvantaged people.

Maternal and neonatal outcomes according to the timing of diagnosis of hyperglycaemia in pregnancy: a nationwide cross-sectional study of 695,912 deliveries in France in 2018

AIMS/HYPOTHESIS

We aimed to assess maternal-fetal outcomes according to various subtypes of hyperglycaemia in pregnancy.

METHODS

We used data from the French National Health Data System (Système National des Données de Santé), which links individual data from the hospital discharge database and the French National Health Insurance information system. We included all deliveries after 22 gestational weeks (GW) in women without pre-existing diabetes recorded in 2018. Women with hyperglycaemia were classified as having overt diabetes in pregnancy or gestational diabetes mellitus (GDM), then categorised into three subgroups according to their gestational age at the time of GDM diagnosis: before 22 GW (GDM<22); between 22 and 30 GW (GDM22-30); and after 30 GW (GDM>30). Adjusted prevalence ratios (95% CI) for the outcomes were estimated after adjusting for maternal age, gestational age and socioeconomic status. Due to the multiple tests, we considered an association to be statistically significant according to the Holm-Bonferroni procedure. To take into account the potential immortal time bias, we performed analyses on deliveries at ≥31 GW and deliveries at ≥37 GW.

RESULTS

The study population of 695,912 women who gave birth in 2018 included 84,705 women (12.2%) with hyperglycaemia in pregnancy: overt diabetes in pregnancy, 0.4%; GDM<22, 36.8%; GDM22-30, 52.4%; and GDM>30, 10.4%. The following outcomes were statistically significant after Holm-Bonferroni adjustment for deliveries at ≥31 GW using GDM22-30 as the reference. Caesarean sections (1.54 [1.39, 1.72]), large-for-gestational-age (LGA) infants (2.00 [1.72, 2.32]), Erb's palsy or clavicle fracture (6.38 [2.42, 16.8]), preterm birth (1.84 [1.41, 2.40]) and neonatal hypoglycaemia (1.98 [1.39, 2.83]) were more frequent in women with overt diabetes. Similarly, LGA infants (1.10 [1.06, 1.14]) and Erb's palsy or clavicle fracture (1.55 [1.22, 1.99]) were more frequent in GDM<22. LGA infants (1.44 [1.37, 1.52]) were more frequent in GDM>30. Finally, women without hyperglycaemia in pregnancy were less likely to have preeclampsia or eclampsia (0.74 [0.69, 0.79]), Caesarean section (0.80 [0.79, 0.82]), pregnancy and postpartum haemorrhage (0.93 [0.89, 0.96]), LGA neonate (0.67 [0.65, 0.69]), premature neonate (0.80 [0.77, 0.83]) and neonate with neonatal hypoglycaemia (0.73 [0.66, 0.82]). Overall, the results were similar for deliveries at ≥37 GW. Although the estimation of the adjusted prevalence ratio of perinatal death was five times higher (5.06 [1.87, 13.7]) for women with overt diabetes, this result was non-significant after Holm-Bonferroni adjustment.

CONCLUSIONS/INTERPRETATION

Compared with GDM22-30, overt diabetes, GDM<22 and, to a lesser extent, GDM>30 were associated with poorer maternal-fetal outcomes.

Cross-sectional study examining factors impacting on uptake of postpartum type 2 diabetes screening among women diagnosed with hyperglycaemia in pregnancy

AIMS

Early postpartum glucose screening of women with hyperglycaemia in pregnancy (HIP) can identify women who have the highest risk of developing impaired glucose tolerance and T2DM. This study examines the association between demographics, events during pregnancy, socioeconomic status and postpartum T2DM screening.

METHODS

Using the French National Health Data System, this cross-sectional study included all deliveries where the mother had HIP in France in 2015, (n = 76,862). The odds ratio (OR) for attending postpartum screening was calculated via multi-level logistic regression.

RESULTS

T2DM screening uptake at six months postpartum was 42·9% [95 % Confidence Interval: 42·6-43·3]. Several characteristics were associated with lower uptake: living in the most deprived area(OR = 0·78[0·74-0·83]); being < 25 years-old (reference age group 25-29;≤17: 0.53 [0·31-0·90];18-24: 0.73[0·69-0·78]); smoking (0·65[0·62-0·68]); obesity (0·93[0·89-0·97]); caesarean delivery (0·95[0·92-0·99]). Factors associated with higher uptake included primiparity (1·30[1·26-1·34]); having followed the French recommendations for HIP screening (1·24[1·20-1·28]); insulin prescription (1·75[1·69-1·81]) and pre-eclampsia (1·30[1·19-1·42]). p < 0.01 is justified due to sample size.

CONCLUSION

Improving identification of factors affecting postpartum T2DM screening uptake, such as demographics, socioeconomic context and events during pregnancy, may lead to development of target interventions to aide adherence to screening regime and thereby diagnosis of women with prediabetes or diabetes, for whom secondary and tertiary prevention is crucial.

Nationwide time trends in patients hospitalized for acute coronary syndrome: a worrying generational and social effect among women

AIMS

To estimate the time trends in the annual incidence of patients hospitalized for acute coronary syndrome (ACS) in France from 2009 to 2021 and to analyse the current sex and social differences in ACS, management, and prognosis.

METHODS AND RESULTS

All patients hospitalized for ACS in France were selected from the comprehensive National Health Insurance database. Age-standardized rates were computed overall and according to age group (over or under 65 years), sex, proxy of socioeconomic status, and ACS subtype [ST-segment elevation (STSE) and non-ST-segment elevation]. Patient characteristics and outcomes were described for patients hospitalized in 2019. Differences in management (coronarography, revascularization), and prognosis were analysed by sex, adjusting for cofonders. In 2019, 143,670 patients were hospitalized for ACS, including 53,227 STSE-ACS (mean age = 68.8 years; 32% women). Higher standardized incidence rates among the most socially deprived people were observed. Women were less likely to receive coronarography and revascularization but had a higher excess in-hospital mortality. In 2019, the age-standardized rate for hospitalized ACS patients reached 210 per 100 000 person-year. Between 2009 and 2019, these rates decreased by 11.4% (men: -11.2%; women: -14.0%). Differences in trends of age-standardized incidence rate have been observed according to sex, age, and social status. Middle aged women (45-64 years) showing more unfavourable trends than in other age classes or in men. In addition, among women the temporal trends were more unfavourable as social deprivation increased.

CONCLUSION

Despite encouraging overall trends in patients hospitalized for ACS rates, the increasing trends observed among middle-aged women, especially socially deprived women, is worrying. Targeted cardiovascular prevention and close surveillance of this population should be encouraged.

Comparison of Stroke Recurrence, Cardiovascular Events, and Death Among Patients With Pregnancy-Associated vs Non-Pregnancy-Associated Stroke

Importance

Women with pregnancy-associated stroke might have different risks of stroke recurrence, including during subsequent pregnancies, and other cardiovascular events due to pregnancy-specific stroke risk factors, such as gestational hypertension, preeclampsia, or gestational diabetes.

Objective

To estimate the rate of stroke recurrence, cardiovascular hospitalization, and death in women with pregnancy-associated stroke compared with women with non-pregnancy-associated stroke.

Design, Setting, and Participants

This cohort study included all women aged 15 to 49 years in France who were affiliated with the general scheme of French health care insurance (94% of women) and had a first hospitalization for stroke between January 1, 2010, and December 31, 2018. Women were followed up until December 31, 2020, with the registration of stroke recurrence, hospitalization for cardiovascular conditions, and death. Data were from the French health care database Système National des Données de Santé. Statistical analyses were conducted between December 2021 and September 2022.

Exposure

Pregnancy status at the time of stroke.

Main Outcomes and Measures

Poisson regressions were used to estimate incidence rates of these events with 95% CIs. We used Cox proportional hazards regression models to estimate the hazard ratios (HRs) of each event during the follow-up for women with a pregnancy-associated stroke vs women with a non-pregnancy-associated stroke.

Results

Among women aged between 15 and 49 years between 2010 and 2018 and living in France, 1204 had a pregnancy-associated stroke at a mean (SD) age of 31.5 (5.8) years, and 31 697 had a non-pregnancy-associated stroke at a mean age of 39.6 (8.2) years. Among the 1204 women with a pregnancy-associated stroke, the incidence rate was 11.4 (95% CI, 9.0-14.3) per 1000 person-years, with 2 recurrent events during a subsequent pregnancy. Compared with women with non-pregnancy-associated stroke, women with pregnancy-associated stroke had lower risks of ischemic stroke (adjusted HR, 0.53; 95% CI, 0.36-0.77), cardiovascular events (adjusted HR, 0.58; 95% CI, 0.49-0.69), and death (adjusted HR, 0.42; 95% CI, 0.22-0.79). In contrast, the risk of recurrent intracerebral hemorrhage and cerebral venous thrombosis did not differ significantly, whereas the risks of venous thromboembolism (HR, 2.02; 95% CI, 1.14-3.58) and acute coronary syndrome with ST-segment elevation (HR, 3.93; 95% CI, 1.10-14.0) were increased.

Conclusions and Relevance

In this cohort study, although the risks of ischemic stroke, overall cardiovascular events, and mortality were lower after a pregnancy-associated stroke than after a non-pregnancy-associated stroke, the risks of venous thromboembolism and acute coronary syndrome with ST-segment elevation were higher. Recurrent stroke during a subsequent pregnancy remained rare.

Need for improvement of cardiovascular health: a clustering method to identify cardiovascular health profiles

BACKGROUND

In France, the overall trend in the incidence of cardiovascular disease is unfavourable, especially in young subjects. This highlights the need to promote cardiovascular health by targeting the main risk factors. Social marketing campaigns to improve cardiovascular health should identify unhealthy behaviour and understand the target audience. The objective of this study was to identify poor cardiovascular health profiles in the French population using a clustering method.

METHODS

Subjects aged 18-74 years with no history of cardiovascular disease were included from the Esteban cross-sectional survey (2014-16). To evaluate cardiovascular health, seven items were considered as defined by the American Heart Association: blood glucose, blood cholesterol, blood pressure, body mass index, cigarette smoking, diet and physical activity. Cardiovascular health profiles were identified from these seven items by combining multiple correspondence analysis with hierarchical clustering and partitioning.

RESULTS

A total of 1673 subjects were included in the main analysis. Five cardiovascular health profiles were identified: two profiles corresponded to subjects with poor cardiovascular health (mainly older men with a low socioeconomic status), two to subjects with intermediate cardiovascular health (one mainly comprised of young women with a low socioeconomic status and the other of young subjects with a high socioeconomic status) and one to subjects with good cardiovascular health (mainly older women).

CONCLUSION

This description of cardiovascular health profiles, which led to the identification and characterization of target audiences for future population-based prevention campaigns, should be the starting point for improving cardiovascular health in the French population.

Adverse Maternal and Infant Outcomes in Women With Chronic Hypertension in France (2010-2018): The Nationwide CONCEPTION Study

Background It has been suggested that chronic hypertension is a risk factor for negative maternal and fetal outcomes during pregnancy and postpartum. We aimed to estimate the association of chronic hypertension on adverse maternal and infant outcomes and assess the impact of antihypertensive treatment and these outcomes. Methods and Results Using data from the French national health data system, we identified and included in the CONCEPTION cohort all women in France who delivered their first child between 2010 and 2018. Chronic hypertension before pregnancy was identified through antihypertensive medication purchases and by diagnosis during hospitalization. We assessed the incidence risk ratios (IRRs) of maternofetal outcomes using Poisson models. A total of 2 822 616 women were included, and 42 349 (1.5%) had chronic hypertension and 22 816 were treated during pregnancy. In Poisson models, the adjusted IRR (95% CI) of maternofetal outcomes for women with hypertension were as follows: 1.76 (1.54-2.01) for infant death, 1.73 (1.60-1.87) for small gestational age, 2.14 (1.89-2.43) for preterm birth, 4.58 (4.41-4.75) for preeclampsia, 1.33 (1.27-1.39) for cesarean delivery, 1.84 (1.47-2.31) for venous thromboembolism, 2.62 (1.71-4.01) for stroke or acute coronary syndrome, and 3.54 (2.11-5.93) for maternal death postpartum. In women with chronic hypertension, being treated with an antihypertensive drug during pregnancy was associated with a significantly lower risk of obstetric hemorrhage, stroke, and acute coronary syndrome during pregnancy and postpartum. Conclusions Chronic hypertension is a major risk factor of infant and maternal negative outcomes. In women with chronic hypertension, the risk of pregnancy and postpartum cardiovascular events may be decreased by antihypertensive treatment during pregnancy.

Recurrence of hypertensive disorders of pregnancy: results from a nationwide prospective cohort study (CONCEPTION)

OBJECTIVE

To assess the risk of gestational hypertension (GH) and pre-eclampsia (PE) during a second pregnancy after occurrence during a first pregnancy.

DESIGN

Prospective cohort study.

SETTING

CONCEPTION is a French nationwide cohort study that used data from the National Health Data System (SNDS) database.

METHODS

We included all women who gave birth for the first time in France in 2010-2018 and who subsequently gave birth. We identified GH and PE through hospital diagnoses and the dispensing of anti-hypertensive drugs. The incidence rate ratios (IRR) of all hypertensive disorder of pregnancy (HDP) during the second pregnancy were estimated using Poisson models adjusted for confounding.

MAIN OUTCOME MEASURES

Incidence rate ratios of HDP during the second pregnancy.

RESULTS

Of the 2 829 274 women included, 238 506 (8.4%) were diagnosed with HDP during their first pregnancy. In women with GH during their first pregnancy, 11.3% (IRR 4.5, 95% confidence interval [CI] 4.4-4.7) and 3.4% (IRR 5.0, 95% CI 4.8-5.3) developed GH and PE during their second pregnancy, respectively. In women with PE during their first pregnancy, 7.4% (IRR 2.6, 95% CI 2.5-2.7) and 14.7% (IRR 14.3, 95% CI 13.6-15.0) developed GH and PE during their second pregnancy, respectively. The more severe and earlier the PE during the first pregnancy, the stronger the likelihood of having PE during the second pregnancy. Maternal age, social deprivation, obesity, diabetes and chronic hypertension were all associated with PE recurrence.

CONCLUSION

These results can guide policymaking that focuses on improving counselling for women who wish to become pregnant more than once, by identifying those who would benefit more from tailored management of modifiable risk factors, and heightened surveillance during post-first pregnancies.

Acute revascularization therapy for ischemic stroke during pregnancy and post-partum in France

Introduction:

Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in women with ischemic stroke (IS) during pregnancy/post-partum is challenging, and recent guidelines claimed for additional information to better argue its effectiveness and safety. This observational national study aimed to describe characteristics, rates and outcomes of pregnant/post-partum women receiving acute revascularization therapy for IS compared to their non-pregnant counterparts, and pregnant women with IS not receiving such therapy.

Patients and methods:

In this cross-sectional study, all women aged 15–49 years hospitalized in France for IS between 2012 and 2018 were retrieved from the French hospital discharge databases. Pregnant or post-partum (⩽6 weeks after delivery) women were identified. Data about patients’ characteristics, risk factors, revascularization therapy, delivery, post-stroke survival, and recurrent vascular events during follow-up were recorded.

Results:

Over the study period, 382 women with pregnancy-related IS were registered. Among them, 7.3% ( n = 28) received a revascularization therapy, including nine cases during pregnancy, one the same day as delivery, and 18 during the post-partum period, compared with 8.5% ( n = 1285) in women with non-pregnancy-related IS ( n = 15,084). Treated pregnant/post-partum women had more severe IS than not-treated pregnant/post-partum. Compared with treated not-pregnant women, they were younger, but did not differ regarding other characteristics including stroke severity. There were no differences in systemic or intracranial hemorrhages or in the length of hospital stay between pregnant/post-partum women compared with treated not-pregnant women. All women receiving revascularization during pregnancy had a live baby. After a mean follow-up of 4.3 years, all pregnant/post-partum women were alive, one had recurrent IS and none had other vascular events.

Discussion and conclusion:

Only a few women with pregnancy-related IS were treated with acute revascularization therapy, but this was proportionately similar to their non-pregnant counterparts, from whom they did not differed regarding characteristics, survival, and risk of recurrent events. These findings suggest that stroke physicians applied treatment strategies of IS in a similar way regardless of pregnancy in France, and this attitude was an anticipation but consistent with the recently published guidelines on the topic.

Modelling the end of a Zero-COVID strategy using nirmatrelvir/ritonavir, vaccination and NPIs in Wallis and Futuna

Background

Ending Zero-COVID is challenging, particularly when vaccine coverage is low. Considering Wallis and Futuna, a French Zero-COVID territory affected by reluctance to vaccination, low immunity and high levels of comorbidities, we investigate how targeted use of nirmatrelvir/ritonavir (brand name Paxlovid) can complement vaccination and non-pharmaceutical interventions (NPIs), and mitigate the epidemic rebound expected when Zero-COVID ends.

Methods

We developed a discrete age-stratified compartmental model describing SARS-CoV-2 spread and healthcare impact once Wallis and Futuna reopens. It accounts for comorbidity risk groups (CRG), vaccine coverage (2 doses, 3 doses), the effectiveness of vaccines (recent or old injection), treatments and NPIs. In our baseline scenario, cases aged 65+ in intermediate/high CRG and 40+ in high CRG are eligible for treatment.

Findings

The epidemic is expected to start 13–20 days after reopening with a doubling time of 1.6-3.7 days. For medium transmission intensity (R₀ = 5), 134 (115–156) hospital admissions are expected within 3 months, with no pharmaceutical measures. In our baseline scenario, admissions are reduced by 11%–21% if 50% of the target group receive treatment, with maximum impact when combined with NPIs and vaccination. The number of hospitalisations averted (HA) per patient treated (PT) is maximum when 65+ in high CRG are targeted (0.124 HA/PT), quickly followed by 65+ in intermediate/high CRG (0.097 HA/PT), and any 65+ (0.093 HA/PT). Expanding the target group increases both PT and HA, but marginal gains diminish.

Interpretation

Modelling suggests that test and treat may contribute to the mitigation of epidemic rebounds at the end of Zero-COVID, particularly in populations with low immunity and high levels of comorbidities.

Funding

RECOVER, VEO, AXA, Groupama, SpF, IBEID, INCEPTION, EMERGEN.

How to avoid overestimating the burden of hypertension in epidemiological studies? A new methodology to account for within-person variability of blood pressure

BACKGROUND

Hypertension (HT) is a major modifiable risk factor for cardiovascular and renal diseases. HT is diagnosed as blood pressure (BP) exceeding a certain threshold. Because of the high within-person variability of BP, the estimation of HT in epidemiological studies based on single visit measurements tends to overestimate HT prevalence. Our study aimed to determine the correction factors to correct the bias in the estimation of HT prevalence in epidemiological studies.

METHODS

We used data from the National Health and Nutrition Examination Survey study in which BP was measured at three visits. A Bayesian hierarchical model was used to estimate the different components of BP variability (between individuals, between visits or between measures) by age and sex. These components allowed us to calculate the correction factors necessary to correct HT prevalence in epidemiological studies with single BP measurement. The method was then applied to data from the French Esteban study in which three standardized BP measurements were performed at a single clinical examination.

RESULTS

The components of BP variability varied with age and sex, with different patterns observed for systolic and diastolic BP. Between-visit and between-individual variations drove BP variability, with between-measure variability being much lower. The uncorrected prevalence of HT in the Esteban study overestimated the burden of HT by 12.6% in the French population, with more than one in five untreated individuals being misclassified. The overestimation was higher in younger adults and women.

CONCLUSION

Taking into account within-person BP variability in epidemiological studies could avoid a substantial overestimation of the burden of HT.

Underuse of lifestyle recommendations in hypertension management in France: The Esteban study

Lifestyle recommendations are first‐line elements in the management of arterial hypertension. This cross‐sectional study aimed to analyze the level to which lifestyle recommendations are used in hypertension management in France, using data from the Esteban study, which was implemented by Santé Publique France, France's public health agency, from 2014 to 2016 on a representative sample of the French population. The study sample comprised 440 adult Esteban participants who were aware they had hypertension and were aged 18–74 years old. The main outcomes were the proportion of participants who received lifestyle recommendations in their hypertension management plan, and the proportion of recommendations according to the three following dimensions: physical activity, weight loss, and changes in diet. Over half (57.0%) of the 440 participants declared they did not receive lifestyle recommendations as part of their hypertension management plan in the year preceding the study. Of these, 39.0% did not receive pharmacological treatment either. Physical activity was recommended to 31.8% of sedentary participants and weight loss to 26.8% of participants with overweight or obesity. One‐fifth of the study sample (20.1%) received dietary recommendations. Of these, 69% and 10.7% were advised to limit their salt and alcohol intake, respectively. Lifestyle interventions are too rarely recommended in hypertension management plans in France. Adherence to lifestyle recommendations needs in‐depth discussion not only at the time of diagnosis but also throughout follow‐up.

Incidence and Time Trends of Pregnancy-Related Stroke Between 2010 and 2018: The Nationwide CONCEPTION Study

BACKGROUND AND OBJECTIVES

- Despite the potentially devastating effects of pregnancy-related stroke, few studies have examined its incidence by type of stroke. We aimed to study the nationwide incidence rates and recent temporal trends for all types of pregnancy-related stroke and to compare these incidence with stroke incidence in nonpregnant women.

METHODS

- We conducted a study of 6 297 698 women aged 15 to 49 years who gave birth in France between 2010 and 2018 with no history of stroke before pregnancy by collecting data from the French National Health Insurance Information System database. Poisson regression were used to estimate incidence by types of stroke for the different pregnancy periods and the incidence rate ratio of stroke in pregnant versus nonpregnant French women.

RESULTS

- Among the 6 297 698 women, 1261 (24.0 per 100,000 person-years) experienced a first ever stroke during , antepartum peripartum, or the first 6 weeks of postpartum. Of the pregnancy-related strokes, 42.9% were ischemic (IS), 41.9% were hemorrhagic (with similar proportion of intracerebral and subarachnoid hemorrhage) and 17.4% were cerebral venous thrombosis (CVT). Compared with nonpregnant women, incidence rates of stroke were similar during pregnancy for IS (aIRR=0.9(0.8-1.1), slightly higher for all hemorrhagic strokes (IRR=1.4(1.2-1.8), and considerably increased for CVT (IRR=8.1(6.5-10.1). Pregnancy-related stroke incidence rose between 2010 and 2018 for ischemic and hemorrhagic stroke but was stable for CVT.

DISCUSSION

- The risk of pregnancy related CVT was more than eight-fold higher than that observed in nonpregnant women.The incidence of pregnancy-related ischemic and hemorrhagic stroke is increasing over time, and efforts should be made in terms of prevention considering treatable cardiovascular risk factors and hypertensive disorders in pregnant women.

Recurrence after stopping anticoagulants in women with combined oral contraceptive-associated venous thromboembolism: A systematic review and meta-analysis

The risk of recurrence after discontinuation of anticoagulation for a combined oral contraceptive (COC)-associated venous thromboembolism (VTE) is unclear. Therefore, we conducted a systematic review and meta-analysis to estimate the incidence of recurrent VTE among women with COC-associated VTE, unprovoked VTE and to compare the incidence of recurrent VTE between the two groups. The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase Classic +Embase and Medline ALL to July 2020 and citations from included studies were searched. Randomized controlled trials, prospective cohort studies and meta-analyses of these study types were selected. The analysis was conducted by random-effects model. Nineteen studies were identified including 1537 women [5828 person-years (PY)] with COC-associated VTE and 1974 women (7798 PY) with unprovoked VTE. Studies were at low risk of bias. The incidence rate of VTE recurrence was 1.22/100 PY [95% confidence interval (CI) 0.92-1.62, I²  = 6%] in women with COC-associated VTE, 3.89/100 PY (95% CI 2.93-5.17, I²  = 74%) in women with unprovoked VTE and the unadjusted incidence rate ratio was 0.34 (95% CI 0.26-0.46, I²  = 3%). The recurrence risk in women after COC-associated VTE is low and lower than after an unprovoked VTE.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives

This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population.

Methods

For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017–2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017–2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists.

Results

In 2020, IRR significantly decreased for initiations of antihypertensives (−11.1%[CI95%, −11.4%;−10.8%]), lipid-lowering drugs (−5.2%[CI95%, −5.5%;−4.8%]), oral anticoagulants in atrial fibrillation (−8.6%[CI95%, −9.1%;−8.0%]), and smoking cessation medications (−50.9%[CI95%, −51.1%;−50.7%]) compared to 2017–2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017–2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women.

Conclusion

The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

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

Background: Rates of patients hospitalized for stroke increased among people aged under 65 years in France, as has been found in other countries. Methods: To analyze time trends in the rates of patients hospitalized for ischemic stroke (IS) and intracerebral hemorrhage (ICH) in France between 2008 and 2019 and determine related short-term outcomes mainly, we selected all patients hospitalized for stroke using the French national hospital database. Results: The average annual percentage change in the rates of patients hospitalized for IS increased significantly in men and women aged 50–64 years (+2.0%) and in men aged 18–34 years (+1.5%) and 35–44 years (+2.2%). A decrease in the average annual percentage change was observed for IS among people aged over 75 years and among those over 50 years for ICH. After adjustment on confounding factors, women were less likely to die in hospital. Case fatality rates decreased overtime in all age groups for both sexes, with a more pronounced decrease for IS than ICH. Conclusions: The increasing trend of IS among adults under 65 years is ongoing, highlighting the urgent need for stroke prevention programs in that age. For the first time, we recorded a decrease in the rates of patients hospitalized for ICH among the population over 50 years.

One Year Prevalence of Venous Thromboembolism in Hospitalized COVID-19 Patients in France: Patients' Characteristics, Time Trends, and Outcomes

BACKGROUND

 Patients hospitalized with coronavirus disease-2019 (COVID-19) are at high risk of deep venous thrombosis (DVT) and pulmonary embolism (PE).

OBJECTIVES

 The aims were to provide time trends in the 2020 nation-wide prevalence of venous thromboembolism (VTE) in patients hospitalized with a COVID-19 diagnosis in France, and to describe in-hospital and up to 30-day postdischarge death.

METHODS

 All patients hospitalized in France with a COVID-19 diagnosis in 2020 were selected. Crude and age-adjusted prevalence of VTE and PE was computed by 4-week intervals and for the overall study period using Poisson regression. Time trends in in-hospital and 30-day postdischarge case-fatality rates were evaluated by comparing each 4-week intervals to weeks 10 to 14 corresponding to the first part of the first lockdown using logistic regression models.

RESULTS

 Among the 287,638 patients hospitalized with a COVID-19 diagnosis in 2020 in France, 14,985 (5.2%) had a concomitant VTE, with 10,453 (3.6%) having PE and 4,532 (1.6%) having DVT. In patients admitted to intensive care units, the crude prevalence of VTE and PE reached 16.1 and 11.0% respectively during the first lockdown. After adjustment, the prevalence of VTE and PE decreased during the year 2020 but a rebound was observed during the second lockdown. In-hospital case-fatality rates among hospitalized COVID-19 patients with PE globally decreased between the first and the second epidemic waves.

CONCLUSION

 Our study showed a decrease in the incidence of symptomatic VTE and PE in hospitalized COVID-19 patients, and a decreased time trend of outcomes during the second wave compared with the first one.

Estimating the Future Burden of Myocardial Infarction in France Until 2035: An Illness-Death Model-Based Approach

Purpose

In France, myocardial infarction (MI) was the second leading cause of years of life lost in 2019. Estimating the burden of MI in future years could help policymakers and other actors anticipate care and prevention needs and guide them in public health decision-making.

Materials and Methods

Using data from the French hospital discharge database from 2007 to 2015 (n = 519,400), demographic data, and an illness-death model, we projected incidence, prevalence, number of prevalent cases and mean age of incident MI cases in France. The methodology took into account the age-cohort effect on MI incidence, mortality of healthy and diseased subjects, and the time since disease onset.

Results

Projections highlighted an increase in MI prevalence in men between 2015 and 2035 from 2.52% (95% uncertainty interval (UI): [2.48–2.56]) in 2015 to 4.02% ([3.92–4.12]) in 2035, and from 0.85% ([0.83–0.87]) to 1.44% ([1.38–1.50]) in women. This corresponds to an increase of 365,000 cases between 2015 and 2035 (+81.1%) for men and 146,000 cases for women (+88.0%). The difference in the mean age of incident cases between men and women decreased from 9.52 in 2015 to 5.49 years in 2035.

Conclusion

Our projections forecast an increase in MI prevalence between 2015 and 2035 in men and women, especially in relatively younger women. Using statistical models such as ours can help assess the impact of prevention campaigns for the main cardiovascular disease risk factors on the future MI prevalence.

Les infarctus du myocarde pendant un an de pandémie de COVID-19 - Étude nationale française des taux d'hospitalisation, du pronostic et de la mortalité à 90 jours

Introduction

Au début de la pandémie de COVID-19, plusieurs études ont signalé une diminution des séjours hospitaliers hors COVID-19. L'objectif de cette étude était de décrire les tendances nationales des admissions pour infarctus du myocarde (IDM) à l'hôpital en 2020 et comparer les caractéristiques, le pronostic hospitalier et la mortalité à 90 jours des patients admis en 2020, à ceux des patients admis en 2017-19.

Méthodes

Tous les patients hospitalisés pour IDM en France entre 2017 et 2020 ont été inclus à partir du PMSI-MCO. Les analyses ont comparé les tendances temporelles d'admissions pour IDM, les taux de complications cardiaques hospitalières, la réadmission et la mortalité hospitalière et à 90 jours en 2020 versus 2017-19 ; puis ont été stratifiées par période d'admission, type d'IDM, sexe, âge et régions.

Résultats

En 2020, 94 747 patients ont été hospitalisés pour IDM, correspondant à une diminution de 6 % des admissions pour IDM par rapport à 2017-2019. Cette diminution était plus importante durant le premier confinement (-24 %, p<0,0001) que pendant le deuxième (-8 %, p<0,0001), et a atteint -40 % en semaine 13. Les diminutions d'hospitalisation pour IDM étaient plus élevées et ont persisté plus longtemps pour les NSTEMI, pour les personnes âgées et pour les femmes. Une augmentation des hospitalisations pour STEMI a été observée entre les confinements (+4 %, p=0,0005). Globalement et après ajustement sur l’âge, le sexe et l'effet temporel, les taux de mortalité hospitalière et dans les 90 jours qui suivaient la sortie d'hospitalisation ne différaient pas entre 2020 et 2017-2019 (IRRaj-hosp =1,03[0,98 ; 1,08], p=0,19 - IRRaj 90j-post-sortie=1,06[0,98 ; 1,13], p=0,14).

Discussion/Conclusion

En 2020, une diminution significative des hospitalisations pour IDM a été observée et était particulièrement importante au début de l'année. L'impact de la crise du COVID-19 sur les complications aiguës et le pronostic à trois mois des patients admis apparaît limité. Néanmoins, la surveillance des complications chroniques de l'IDM et de l'impact sur les personnes non hospitalisées devra être poursuivie.

Hypertension prevalence, awareness, treatment and control in 2019 in the adult population of Mayotte

BACKGROUND

Mayotte is a French overseas territory with significant socio-economic and health challenges. This study updates the prevalence of hypertension in Mayotte to estimate the awareness, treatment and control of this disease and identify any associated factors.

METHODS

Data were taken from the cross-sectional Unono Wa Maore survey conducted in Mayotte in 2019. Analyses were based on the adult population aged 18-69 years who underwent a clinical examination with at least two blood pressure measurements (n = 2620).

RESULTS

In 2019, the prevalence of hypertension was estimated at 38.4% (36.1-40.7%) in the Mayotte population aged 18-69 years. The prevalence was similar in men (38.5%) and women (38.3%; P = 0.95). The prevalence of certain risk factors was high, with 75% of hypertensives being overweight or obese, 13% reporting diabetes and 69% being occupationally inactive. Among the hypertensives, 48% was aware of their diagnosis, with women more likely to be aware than men (P < 0.0001). Of those who were aware, 45% were treated pharmacologically and 49% reported engaging in physical activity to lower their blood pressure. The control rate was 30.2% among pharmacologically treated hypertensives. Overall, 80% of hypertensive patients had too high blood pressure during the survey's clinical examination.

CONCLUSION

The prevalence of hypertension remains high in Mayotte, where certain risk factors like obesity are particularly common in the population. Awareness, treatment and control remain insufficient. Primary prevention measures, access to a healthy food, and screening and treatment of hypertension should be encouraged by targeting the most affected populations.

Care management and 90-day mortality in patients hospitalized for myocardial infarction and COVID-19 in France

Background

Concomitant COVID-19 in patients with myocardial infarction (MI) may lead to difficulties in acute care management and may impair prognosis. To date, studies have involved a limited number of patients.

Purpose

To estimate and compare the characteristics, care management and 90-day outcomes of patients hospitalized for MI who didn’t have Covid-19, with those having concomitant hospital diagnosis of Covid-19 from the French National Health Data System, an exhaustive and nationwide database.

Methods

All patients hospitalised for MI in France between 30 December 2019 and 4 October 2020 were included. Patients with a previous hospitalization with Covid-19 were excluded (n = 135). Patients’ characteristics were compared according to Covid-19 status. 90-day mortality rates and follow-up outcomes were estimated and adjusted on age, sex and comorbidities.

Results

Among the 55,389 patients hospitalized for MI, 329 had concomitant Covid-19 (21% asymptomatic). MI patients with concomitant Covid-19 were more comorbid than patients without Covid-19. They had longer hospital stays, more admissions to resuscitation unit, underwent less percutaneous coronary intervention, and discharged more often to rehabilitation units than patients without Covid-19. The in-hospital and 90-day-out-of hospital mortality rates of MI patients with Covid-19 were 11.9% and 6.2%, respectively, compared to 3.5% and 2.8% in MI patients without Covid-19. The risk of in-hospital and out-of-hospital death remained increased after adjustment on comorbidities (OR_ajin-hosp = 3.31[2.32;4.72], OR_{ajout-of-hosp} = 1.79 [1.02;3.15]).

Conclusions

The prognosis of patients hospitalized for MI who had concomitant Covid-19 was impaired in the short term but also in the medium term. These results underline the need of an urgent protection of the population at cardiovascular risk from Covid-19, as well as a systematized and rapid management despite the pandemic context, and then a close follow-up of these patients.

One year of Covid-19: French nationwide study of hospitalisation, 90-day readmission and mortality rates from myocardial infarction

Background

Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 due to Covid19 crisis, but these were restricted to the early weeks of the pandemic.

Purpose

To describe patient characteristics, in-hospital management and 90-day mortality of MI patients throughout the year 2020, in particular during periods of lockdowns.

Methods

All patients hospitalised for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Incidence rate ratios were computed to analyze time trends in MI admissions and mortality rates and stratified by type of MI, sex, age, and period of admission. Characteristics and management of patients in 2020 were described and compared to 2017-19 (OR adjusted on temporality, sex, age)

Results

In 2020, 94,747 patients were hospitalized for MI corresponding to a 6% decrease in MI admissions compared to 2017-19. This decrease was more significant during the first lockdown (−24%, P < 0.0001), in particular in week 13 (−40%) than during the second lockdown (−8%). Decreases in MI admissions were more pronounced and longer for NSTEMI, older people and for women. An increase in the rate of STEMI admissions was observed between the two 2020 lockdowns (+4%, P = 0.0005). Admission to a resuscitation unit and complications rates did not differ between 2017-19 and 2020. In early 2020, there was also a decrease in 90-days readmission. In 2020, the in-hospital and 90-days-out-of hospital mortality rates were 5.5% and 3.8%, compared to 5.7% and 3.6% in reference years. Globally and after adjustment, mortality rates did not differ in 2020 vs. 2017-19 (IRR_in-hosp = 1.03[0.98;1.08], P = 0.19 - IRR_out-hosp = 1.04[0.97;1.27], P = 0.21).

Conclusions

This nationwide study showed significant decrease in MI hospitalization during 2020, in particular during the first lockdown, with a slight STEMI increase during the summer. However, these trends were not associated with more cardiac complications or mortality.

Care management and 90-day post discharge mortality in patients hospitalized for myocardial infarction and COVID-19: A French nationwide observational study

BACKGROUND

Concomitant or cured coronavirus disease 2019 (COVID-19) in patients with myocardial infarction (MI) may lead to difficulties in acute care management and impair prognosis.

AIMS

To describe and compare the characteristics, care management and 90-day post discharge outcomes of patients hospitalized for MI who did not have COVID-19 with those of patients with concomitant or previous hospital-diagnosed COVID-19.

METHODS

This population-based French study included all patients hospitalized for MI in France (30 December 2019 to 04 October 2020) from the French National Health Data System. Outcomes were described for each COVID-19 group and compared using adjusted logistic regression analysis.

RESULTS

Among 55,524 patients hospitalized for MI, 135 had previous hospital-diagnosed COVID-19 and 329 had concomitant COVID-19. Patients with previous hospital-diagnosed COVID-19 had more personal history of cardiovascular diseases than those without concomitant/previous confirmed COVID-19. In-hospital and 90-day post discharge mortality rates of patients with previous COVID-19 were 8.1% and 4.0%, respectively, compared with 3.5% and 3.0% in patients without concomitant/previous confirmed COVID-19 (odds ratio [OR]_{adjin-hospital} 1.83, 95% confidence interval [CI] 0.97-3.46; OR_{adjpostdischarge} 0.77, 95% CI 0.28-2.13). Patients with concomitant COVID-19 had more personal history of cardiovascular diseases, but also a poorer prognosis than their no concomitant/no previous confirmed COVID-19 counterparts; they presented excess cardiac complications during hospitalization (OR_adj 1.62, 95% CI 1.29-2.04), in-hospital mortality (OR_adj 3.31, 95% CI 2.32-4.72) and 90-day post discharge mortality (OR_adj 2.09, 95% CI 1.24-3.51).

CONCLUSIONS

In-hospital and 90-day post discharge mortality of patients hospitalized for MI who had previous hospital-diagnosed COVID-19 did not seem to differ from those hospitalized for MI alone. Conversely, concomitant COVID-19 and MI carried a poorer prognosis extending beyond the hospital stay. Special attention should be given to patients with simultaneous COVID-19 and MI, in terms of acute care and secondary prevention.

Myocardial infarction throughout 1 year of the COVID-19 pandemic: French nationwide study of hospitalization rates, prognosis and 90-day mortality rates

Background

Studies reported a decrease in hospital admissions for myocardial infarction (MI) in early 2020 as a result of the coronavirus disease 2019 (COVID-19) crisis, mainly restricted to the beginning of the pandemic.

Aims

To describe national trends in hospital admissions for MI in 2020, and to compare patient characteristics, in-hospital prognosis and 90-day mortality between patients who had an MI in 2020 and those admitted in 2017–2019.

Methods

All patients hospitalized for MI in France from 2017 to 2020 were selected from the national hospital discharge database. Analyses compared temporal trends in MI admissions, in-hospital cardiac complications and mortality rates in 2020 versus 2017–2019.

Results

In 2020, 94,747 patients were hospitalized for MI, corresponding to a 6% decrease in MI admissions compared with 2017–19. This decrease was larger during the first lockdown (–24%; P < 0.0001) than during the second lockdown (–8%; P < 0.0001). Reductions in MI admissions were more pronounced and longer among patients with non-ST-segment elevation MI, older people and women. An increase in ST-segment elevation MI admissions was observed between lockdowns (+4%; P = 0.0005). Globally, and after adjustment for age, sex and calendar year, in-hospital and 90-day post-discharge mortality rates did not differ in 2020 versus 2017–19: incidence rate ratio (IRR)_{adjin-hospital} 1.03, 95% confidence interval (CI) (0.98–1.08); IRR_{adj90-daypost-discharge} 1.06, 95% CI (0.98–1.13).

Conclusions

In 2020, a significant decrease in MI admissions was observed, and was marked at the beginning of the year. This highlights the need to disseminate public information on the importance of maintaining care and regular medical follow-up. The effect of the COVID-19 crisis on acute and 3-month outcomes of patients hospitalized for MI appears limited. Nevertheless, monitoring of chronic MI complications and the impact on non-hospitalized patients should continue.

Changes in the epidemiology of patients hospitalized in France with deep venous thrombosis and pulmonary embolism during the COVID-19 pandemic

INTRODUCTION

The onset of the COVID-19 pandemic and the first national lockdown implemented might have disrupted the epidemiology of deep venous thrombosis (DVT) and pulmonary embolism (PE). This study aimed to analyze time trends in patients hospitalized for DVT and PE in France and related in-patient and 90-day post-admission mortality rates.

MATERIALS AND METHODS

All patients hospitalized in France for DVT or PE between January and September (weeks 1-40) for each year from 2017 to 2020, were selected. Weekly incidence rate ratios (IRR) were computed to compare the rates of patients hospitalized in 2020 with those hospitalized in 2017-2019.

RESULTS

Compared with the 2017-2019 study period, the rates of patients hospitalized with a primary diagnosis (PD) of DVT or PE in 2020 were significantly (50 and 40%, respectively) lower during weeks 12-13. The rate of patients hospitalized with an associated diagnosis (AD) of PE during weeks 12-19 of 2020 was twice as high as in the same period in 2017-2019. The prevalence of COVID-19 in patients hospitalized with a PD of DVT and PE, and in those hospitalized with an AD of DVT and PE reached respectively 4.0, 9.6, 17.2 and 44.6 during the country's first lockdown. Inpatients case-fatality rates in patients hospitalized with an AD of PE increased significantly during weeks 12-13.

CONCLUSIONS

Epidemiology of VT and PE was seriously impacted by the COVID-19 pandemic in 2020 in France, with a significant decrease in the rate of patients hospitalized for PE and a threefold increase in the related in-patient mortality rate. This highlight the need to inform the general population about the symptoms of PE and about the need to immediately seek medical care, particularly those infected with SARS-CoV-2.

Hypertensive disorders of pregnancy and onset of chronic hypertension in France: the nationwide CONCEPTION study

AIMS 

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and foetal morbidity and mortality. We aimed to estimate the impact of HDP on the onset of chronic hypertension in primiparous women in the first years following childbirth.

METHODS AND RESULTS 

This nationwide cohort study used data from the French National Health Data System (SNDS). All eligible primiparous women without pre-existing chronic hypertension who delivered between 2010 and 2018 were included. Women were followed up from six weeks post-partum until onset of hypertension, a cardiovascular event, death, or the study end date (31 December 2018). The main outcome was a diagnosis of chronic hypertension. We used Cox models to estimate hazard ratios (HRs) of chronic hypertension for all types of HDP. Overall, 2 663 573 women were included with a mean follow-up time of 3.0 years. Among them, 180 063 (6.73%) had an HDP. Specifically 66 260 (2.16%) had pre-eclampsia (PE) and 113 803 (4.27%) had gestational hypertension (GH). Compared with women who had no HDP, the fully adjusted HRs of chronic hypertension were 6.03 [95% confidence interval (CI) 5.89-6.17] for GH, 8.10 (95% CI 7.88-8.33) for PE (all sorts), 12.95 (95% CI 12.29-13.65) for early PE, 9.90 (95% CI 9.53-10.28) for severe PE, and 13.17 (95% CI 12.74-13.60) for PE following GH. Hypertensive disorders of pregnancy exposure duration was an additional risk factor of chronic hypertension for all PE subgroups. Women with HDP consulted a general practitioner or cardiologist more frequently and earlier.

CONCLUSION 

Hypertensive disorders of pregnancy exposure greatly increased the risk of chronic hypertension in the first years following delivery.

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

BACKGROUND

Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories.

METHODS

We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age.

FINDINGS

The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran.

INTERPRETATION

Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings.

FUNDING

WHO.

Atrial Fibrillation in Spontaneous Intracerebral Hemorrhage, Dijon Stroke Registry (2006-2017)

Background

Atrial fibrillation (AF) represents a major indication for oral anticoagulants (OAC) that contribute to spontaneous intracerebral hemorrhage (ICH). This study evaluated AF prevalence among patients with ICH, temporal trends, and early functional outcomes and death of patients.

Methods and Results

Patients with first‐ever ICH were prospectively recorded in the population‐based stroke registry of Dijon, France, (2006–2017). Association between AF and early outcome of patients with ICH (ordinal modified Rankin Scale score and death at discharge) were analyzed using ordinal and logistic regressions. Among 444 patients with ICH, 97 (21.9%) had AF, including 65 (14.6%) with previously known AF treated with OAC, and 13 (2.9%) with newly diagnosed AF. AF prevalence rose from 17.2% (2006–2011) to 25.8% (2012–2017) (P‐trend=0.05). An increase in the proportion of AF treated with OAC (11.3% to 17.5%, P‐trend=0.09) and newly diagnosed AF (1.5% to 4.2%, P‐trend=0.11) was observed. In multivariable analyses, after adjustment for premorbid OAC, AF was not significantly associated with ordinal modified Rankin Scale score (odds ratio [OR], 1.29; 95% CI, 0.69–2.42) or death (OR, 0.89; 95% CI, 0.40–1.96) in patients with ICH. Nevertheless, adjusted premorbid OAC use remained highly associated with a higher probability of death (OR, 2.53; 95% CI, 1.11–5.78).

Conclusions

AF prevalence and use of OAC among patients with ICH increased over time. Premorbid use of OAC was associated with poor outcome after ICH, thus suggesting a need to better identify ICH risk before initiating or pursuing OAC therapy in patients with AF, and to develop acute treatment and secondary prevention strategies after ICH in patients with AF.

A modelling study investigating short and medium-term challenges for COVID-19 vaccination: From prioritisation to the relaxation of measures

BACKGROUND

The roll-out of COVID-19 vaccines is a multi-faceted challenge whose performance depends on pace of vaccination, vaccine characteristics and heterogeneities in individual risks.

METHODS

We developed a mathematical model accounting for the risk of severe disease by age and comorbidity, and transmission dynamics. We compared vaccine prioritisation strategies in the early roll-out stage and quantified the extent to which measures could be relaxed as a function of the vaccine coverage achieved in France.

FINDINGS

Prioritizing at-risk individuals reduces morbi-mortality the most if vaccines only reduce severity, but is of less importance if vaccines also substantially reduce infectivity or susceptibility. Age is the most important factor to consider for prioritization; additionally accounting for comorbidities increases the performance of the campaign in a context of scarce resources. Vaccinating 90% of ≥65 y.o. and 70% of 18-64 y.o. before autumn 2021 with a vaccine that reduces severity by 90% and susceptibility by 80%, we find that control measures reducing transmission rates by 15-27% should be maintained to remain below 1000 daily hospital admissions in France with a highly transmissible variant (basic reproduction number R0  = 4). Assuming 90% of ≥65 y.o. are vaccinated, full relaxation of control measures might be achieved with a vaccine coverage of 89-100% in 18-64 y.o or 60-69% of 0-64 y.o.

INTERPRETATION

Age and comorbidity-based vaccine prioritization strategies could reduce the burden of the disease. Very high vaccination coverage may be required to completely relax control measures. Vaccination of children, if possible, could lower coverage targets necessary to achieve this objective.

Characteristics, Management, and Case-Fatality of Patients Hospitalized for Stroke with a Diagnosis of COVID-19 in France

Introduction

COVID-19 was found to be associated with an increased risk of stroke. This study aimed to compare characteristics, management, and outcomes of hospitalized stroke patients with or without a hospital diagnosis of CO­VID-19 at a nationwide scale.

Methods

This is a cross-sectional study on all French hospitals covering the entire French population using the French national hospital discharge databases (Programme de Médicalisation des Systèmes d'Information, included in the Système National des Données de Santé). All patients hospitalized for stroke between 1 January and 14 June 2020 in France were selected. A diagnosis of COVID-19 was searched for during the index hospitalization for stroke or in a prior hospitalization that had occurred after 1 January 2020.

Results

Among the 56,195 patients hospitalized for stroke, 800 (1.4%) had a concomitant COVID-19 diagnosis. Inhospital case-fatality rates were higher in stroke patients with COVID-19, particularly for patients with a primary diagnosis of COVID-19 (33.2%), as compared to patients hospitalized for stroke without CO­VID-19 diagnosis (14.1%). Similar findings were observed for 3-month case-fatality rates adjusted for age and sex that reached 41.7% in patients hospitalized for stroke with a concomitant primary diagnosis of COVID-19 versus 20.0% in strokes without COVID-19.

Conclusion

Patients hospitalized for stroke with a concomitant COVID-19 diagnosis had a higher inhospital and 3 months case-fatality rates compared to patients hospitalized for stroke without a COVID-19 diagnosis. Further research is needed to better understand the excess of mortality related to these cases.

Prevalence of hypertensive disorders during pregnancy in France (2010-2018): The Nationwide CONCEPTION Study

Hypertensive disorders of pregnancy (HDP) are one of the leading causes of maternal and fetal morbidity and mortality. We aimed to estimate the prevalence of each HDP in France and to study their associations. All pregnant women who delivered in France between 2010 and 2018 were included in a cohort and followed during their pregnancy and 6 weeks of postpartum. Each HDP occurring during the follow-up was identified. Prevalence of each HDP and cumulative incidence by gestational age were estimated. Incidence rate ratio (IRR) and 95% confidence interval (CI) for preeclampsia among women with preexisting or gestational hypertension (GH) were estimated using Poisson regression and adjusted for age were estimated. Between 2010 and 2018, 6 302 810 deliveries were included. HDP complicated 7.4% of pregnancies. Preeclampsia and GH complicated 2.0% and 4.2% of pregnancies, respectively. Most of preeclampsia cases occurred without a prior HDP. HELLP syndrome represented 10.4% of preeclampsia cases. Compared to nulliparous pregnancies without HDP prior preeclampsia, the age-adjusted IRR of preeclampsia was 6.2 [95% CI: 6.1-6.4] in nulliparous pregnancies with preexisting hypertension and 2.9 [95% CI: 2.8-3.0] in nulliparous pregnancies with GH. In France, HDP occurred in 7.4% of all pregnancies. Women with preexisting chronic hypertension are at high risk to present preeclampsia during pregnancy. Preeclampsia complicated 2.0% of pregnancies in France. Tailoring management of women according to the HDP is a major challenge to avoid complications related to these disorders.

Ischemic Stroke With Atrial Fibrillation: Characteristics and Time Trends 2006 to 2017 in the Dijon Stroke Registry

[Figure: see text].

Emergency department admissions for myocardial infarction and stroke in France during the first wave of the COVID-19 pandemic: National temporal trends and regional disparities

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic and the national lockdown have led to significant changes in the use of emergency care by the French population.

AIMS

To describe the national and regional temporal trends in emergency department (ED) admissions for myocardial infarction (MI) and stroke, before, during and after the first national lockdown.

METHODS

The weekly numbers of ED admissions for MI and stroke were collected from the OSCOUR® network, which covers 93.3% of all ED admissions in France. National and regional incidence rate ratios from 02 February until 31 May (2020 versus 2017-2019) were estimated using Poisson regression for MI and stroke, before, during and after lockdown.

RESULTS

A decrease in ED admissions was observed for MI (-20% for ST-segment elevation MI and-25% for non-ST-segment elevation MI) and stroke (-18% for ischaemic and-22% for haemorrhagic) during the lockdown. The decrease became significant earlier for stroke than for MI. No compensatory increase in ED admissions was observed at the end of the lockdown for these diseases. Important regional disparities in ED admissions were observed, without correlation with the regional levels of COVID-19 cases. The impact of lockdown on ED admissions was particularly significant in six regions (Ile-de France, Occitanie, Provence-Alpes-Côte d'Azur, Nouvelle Aquitaine, Hauts-de-France and Bretagne).

CONCLUSIONS

The decrease in ED admissions for MI and stroke observed during the lockdown was probably caused by fear of COVID-19 and augmented by the lockdown, and was heterogeneous across the French territory. ED admissions were slow to return to the usual levels from previous years, without a compensatory increase. These results underline the need to reinforce messages directed at the population to encourage them to seek care without delay in case of cardiovascular symptoms.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for stroke and related 30-day mortality in France: A nationwide observational study

BACKGROUND AND PURPOSE

The aim of this nationwide study was to assess the impact of the COVID-19 pandemic on stroke hospitalization rates, patient characteristics and 30-day case fatality rates.

METHODS

All hospitalizations for stroke from January to June of each year from 2017 to 2020 were selected using International Classification of Diseases, 10th revision, codes I60 to I64 in the national hospital discharge database. Patient characteristics and management were described according to three time periods: pre-lockdown, lockdown, and post-lockdown. Weekly incidence rate ratios (IRRs) were computed to compare time trends in the rates of patients hospitalized for stroke as well as in-hospital and 30-day case fatality rates between the years 2017-2019 and 2020.

RESULTS

In 2020, between weeks 1 and 24, 55,308 patients were hospitalized for stroke in France. IRRs decreased by up to 30% for all age groups, sex, and stroke types during the lockdown compared to the period 2017-2019. Patients hospitalized during the second and third weeks of the lockdown had higher in-hospital case fatality rates compared to 2017-2019. In-hospital case fatality rates increased by almost 60% in patients aged under 65 years. Out-of-hospital 30-day case fatality rates increased between weeks 11 and 15 among patients who returned home after their hospitalization. Important changes in care management were found, including fewer stroke patients admitted to resuscitation units, more admitted to stroke care units, and a shorter mean length of hospitalization.

CONCLUSIONS

During the first weeks of the lockdown, rates of patients hospitalized for stroke fell by 30% and there were substantial increases of both in-hospital and out-of-hospital 30-day case fatality rates.

Stroke Incidence and Death in Atrial Fibrillation Patients Newly Treated with Direct Oral Anticoagulants

Purpose

The objectives were to analyse the determinants of stroke incidence and mortality as a competing event in AF patients newly treated with DOAC and to assess the impact of non-adherence to DOAC treatment.

Methods

It is a population-based retrospective cohort study using the French national healthcare data system. AF patients aged >20 years were affiliated to the general health insurance scheme (66% of the French population) and newly treated with DOAC between 2012 and 2015 were included and followed for 2 years.

Results

Overall 76,795 AF patients were newly treated with DOAC in 2015. Stroke incidence reached 10.1 (95% CI: 9.6–10.6) per 1000 person-year and death 39.7 (95% CI: 38.6–40.8) as a competitive risk. Female sex was associated with a lower risk of death but not of stroke. Non-adherence to DOAC treatment increased the risk of both stroke (42%) and death (38%). Acute coronary syndrome was associated with an increased risk of stroke alone, whereas heart failure decompensation, social deprivation, and haemorrhage were associated with an increased risk of death alone.

Conclusion

Both stroke and death risks remain non-negligible in AF patients treated with DOAC. Non-adherence was associated with an increased risk of stroke and death.