Door-in-Door-out Times for Interhospital Transfer of Patients With Stroke

Importance

Treatments for time-sensitive acute stroke are not available at every hospital, often requiring interhospital transfer. Current guidelines recommend hospitals achieve a door-in-door-out time of no more than 120 minutes at the transferring emergency department (ED).

Objective

To evaluate door-in-door-out times for acute stroke transfers in the American Heart Association Get With The Guidelines-Stroke registry and to identify patient and hospital factors associated with door-in-door-out times.

Design, Setting, and Participants

US registry-based, retrospective study of patients with ischemic or hemorrhagic stroke from January 2019 through December 2021 who were transferred from the ED at registry-affiliated hospitals to other acute care hospitals.

Exposure

Patient- and hospital-level characteristics.

Main Outcomes and Measures

The primary outcome was the door-in-door-out time (time of transfer out minus time of arrival to the transferring ED) as a continuous variable and a categorical variable (≤120 minutes, >120 minutes). Generalized estimating equation (GEE) regression models were used to identify patient and hospital-level characteristics associated with door-in-door-out time overall and in subgroups of patients with hemorrhagic stroke, acute ischemic stroke eligible for endovascular therapy, and acute ischemic stroke transferred for reasons other than endovascular therapy.

Results

Among 108 913 patients (mean [SD] age, 66.7 [15.2] years; 71.7% non-Hispanic White; 50.6% male) transferred from 1925 hospitals, 67 235 had acute ischemic stroke and 41 678 had hemorrhagic stroke. Overall, the median door-in-door-out time was 174 minutes (IQR, 116-276 minutes): 29 741 patients (27.3%) had a door-in-door-out time of 120 minutes or less. The factors significantly associated with longer median times were age 80 years or older (vs 18-59 years; 14.9 minutes, 95% CI, 12.3 to 17.5 minutes), female sex (5.2 minutes; 95% CI, 3.6 to 6.9 minutes), non-Hispanic Black vs non-Hispanic White (8.2 minutes, 95% CI, 5.7 to 10.8 minutes), and Hispanic ethnicity vs non-Hispanic White (5.4 minutes, 95% CI, 1.8 to 9.0 minutes). The following were significantly associated with shorter median door-in-door-out time: emergency medical services prenotification (-20.1 minutes; 95% CI, -22.1 to -18.1 minutes), National Institutes of Health Stroke Scale (NIHSS) score exceeding 12 vs a score of 0 to 1 (-66.7 minutes; 95% CI, -68.7 to -64.7 minutes), and patients with acute ischemic stroke eligible for endovascular therapy vs the hemorrhagic stroke subgroup (-16.8 minutes; 95% CI, -21.0 to -12.7 minutes). Among patients with acute ischemic stroke eligible for endovascular therapy, female sex, Black race, and Hispanic ethnicity were associated with a significantly higher door-in-door-out time, whereas emergency medical services prenotification, intravenous thrombolysis, and a higher NIHSS score were associated with significantly lower door-in-door-out times.

Conclusions and Relevance

In this US registry-based study of interhospital transfer for acute stroke, the median door-in-door-out time was 174 minutes, which is longer than current recommendations for acute stroke transfer. Disparities and modifiable health system factors associated with longer door-in-door-out times are suitable targets for quality improvement initiatives.

Hyperglycemia, Ischemic Lesions, and Functional Outcomes After Intracerebral Hemorrhage

Background Ischemic lesions observed on diffusion-weighted imaging (DWI) magnetic resonance imaging are associated with poor outcomes after intracerebral hemorrhage (ICH). We evaluated the association between hyperglycemia, ischemic lesions, and functional outcomes after ICH. Methods and Results This was a retrospective observational analysis of 1167 patients who received magnetic resonance imaging in the ERICH (Ethnic and Racial Variations in Intracerebral Hemorrhage) study. A machine learning strategy using the elastic net regularization and selection procedure was used to perform automated variable selection to identify final multivariable logistic regression models. Sensitivity analyses with alternative model development strategies were performed, and predictive performance was compared. After covariate adjustment, white matter hyperintensity score, leukocyte count on admission, and non-Hispanic Black race (compared with non-Hispanic White race) were associated with the presence of DWI lesions. History of ICH and ischemic stroke, presence of DWI lesions, deep ICH location (versus lobar), ICH volume, age, lower Glasgow Coma Score on admission, and medical history of diabetes were associated with poor 6-month modified Rankin Scale outcome (4-6) after covariate adjustment. Inclusion of interactions between race and ethnicity and variables included in the final multivariable model for functional outcome improved model performance; a significant interaction between race and ethnicity and medical history of diabetes and serum blood glucose on admission was observed. Conclusions No measure of hyperglycemia or diabetes was associated with presence of DWI lesions. However, both medical history of diabetes and presence of DWI lesions were independently associated with poor functional outcomes after ICH.

Ischemic stroke in COVID-19: An urgent need for early identification and management

OBJECTIVE

In the setting of the Coronavirus Disease 2019 (COVID-19) global pandemic caused by SARS-CoV-2, a potential association of this disease with stroke has been suggested. We aimed to describe the characteristics of patients who were admitted with COVID-19 and had an acute ischemic stroke (AIS).

METHODS

This is a case series of PCR-confirmed COVID-19 patients with ischemic stroke admitted to an academic health system in metropolitan Atlanta, Georgia (USA) between March 24th, 2020 and July 17th, 2020. Demographic, clinical, and radiographic characteristics were described.

RESULTS

Of 396 ischemic stroke patients admitted during this study period, 13 (2.5%) were also diagnosed with COVID-19. The mean age of patients was 61.6 ± 10.8 years, 10 (76.9%) male, 8 (61.5%) were Black Americans, mean time from last normal was 4.97 ± 5.1 days, and only one received acute reperfusion therapy. All 13 patients had at least one stroke-associated co-morbidity. The predominant pattern of ischemic stroke was embolic with 4 explained by atrial fibrillation. COVID-19 patients had a significantly higher rate of cryptogenic stroke than non-COVID-19 patients during the study period (69% vs 17%, p = 0.0001).

CONCLUSIONS

In our case series, ischemic stroke affected COVID-19 patients with traditional stroke risk factors at an age typically seen in non-COVID populations, and mainly affecting males and Black Americans. We observed a predominantly embolic pattern of stroke with a higher than expected rate of cryptogenic strokes, a prolonged median time to presentation and symptom recognition limiting the use of acute reperfusion treatments. These results highlight the need for increased community awareness, early identification, and management of AIS in COVID-19 patients.

Nomogram for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage in the Chinese population

BACKGROUND

Delayed cerebral ischemia is a serious complication of aneurysmal subarachnoid hemorrhage with debilitating and fatal consequences. Lack of well-established risk factors impedes early identification of high-risk patients with delayed cerebral ischemia. A nomogram provides personalized, evidence-based, and accurate risk estimation. To offset the lack of a predictive tool, we developed a nomogram to predict delayed cerebral ischemia before performing surgical interventions for aneurysmal subarachnoid hemorrhage to aid surgical decision-making.

METHODS

We retrospectively collected data from 887 consecutive eligible Chinese patients who underwent surgical clipping or endovascular coiling for aneurysmal subarachnoid hemorrhage. Patients who previously underwent surgery formed the training cohort (n = 621) for nomogram development; those who underwent surgery later formed the validation cohort (n = 266) to confirm the performance of the model. A multivariate logistic regression analysis identified the independent risk factors associated with delayed cerebral ischemia, which were then incorporated into the nomogram.

RESULTS

Delayed cerebral ischemia was identified in 158/621 patients (25.4%) in the training cohort and in 66/266 patients (24.8%) in the validation cohort. Preoperative factors associated with delayed cerebral ischemia were age > 65 years, modified Fisher grade of 3-4, ruptured aneurysm in the anterior circulation, Hunt-Hess grade of 4-5, high blood pressure on admission, and plasma homocysteine level ≥ 10 μmol/L. Incorporating these six factors in the nomogram achieved efficient concordance indices of 0.73 (95% confidence interval, 0.68-0.77) and 0.65 (95% confidence interval, 0.57-0.72) in predicting delayed cerebral ischemia in the training and validation cohorts, respectively.

CONCLUSIONS

Our model can help determine an individual's risk of developing delayed cerebral ischemia in the Chinese population, and thereby, facilitate reasonable treatment-related decision-making.

Long-term trends in death and dependence after ischaemic strokes: A retrospective cohort study using the South London Stroke Register (SLSR)

BACKGROUND

There have been reductions in stroke mortality over recent decades, but estimates by aetiological subtypes are limited. This study estimates time trends in mortality and functional dependence by ischaemic stroke (IS) aetiological subtype over a 16-year period.

METHODS AND FINDINGS

The study population was 357,308 in 2011; 50.4% were males, 56% were white, and 25% were of black ethnic backgrounds. Population-based case ascertainment of stroke was conducted, and all participants who had their first-ever IS between 2000 and 2015 were identified. Further classification was concluded according to the underlying mechanism into large-artery atherosclerosis (LAA), cardio-embolism (CE), small-vessel occlusion (SVO), other determined aetiologies (OTH), and undetermined aetiologies (UND). Temporal trends in survival rates were examined using proportional-hazards survival modelling, adjusted for demography, prestroke risk factors, case mix variables, and processes of care. We carried out additional regression analyses to explore patterns in case-fatality rates (CFRs) at 30 days and 1 year and to explore whether these trends occurred at the expense of greater functional dependence (Barthel Index [BI] < 15) among survivors. A total of 3,128 patients with first-ever ISs were registered. The median age was 70.7 years; 50.9% were males; and 66.2% were white, 25.5% were black, and 8.3% were of other ethnic groups. Between 2000-2003 and 2012-2015, the adjusted overall mortality decreased by 24% (hazard ratio [HR] per year 0.976; 95% confidence interval [CI] 0.959-0.993). Mortality reductions were equally noted in both sexes and in the white and black populations but were only significant in CE strokes (HR per year 0.972; 95% CI 0.945‒0.998) and in patients aged ≥55 years (HR per year 0.975; 95% CI 0.959‒0.992). CFRs within 30 days and 1 year after an IS declined by 38% (rate ratio [RR] per year 0.962; 95% CI 0.941‒0.984) and 37% (RR per year 0.963; 95% CI 0.949‒0.976), respectively. Recent IS was independently associated with a 23% reduced risk of functional dependence at 3 months after onset (RR per year 0.983; 95% CI 0.968-0.998; p = 0.002 for trend). The study is limited by small number of events in certain subgroups (e.g., LAA), which could have led to insufficient power to detect significant trends.

CONCLUSIONS

Both mortality and 3-month functional dependence after IS decreased by an annual average of around 2.4% and 1.7%, respectively, during 2000‒2015. Such reductions were particularly evident in strokes of CE origins and in those aged ≥55 years.

Association of CYP3A4*1G and CYP3A5*3 With the 1-year Outcome of Acute Ischemic Stroke in the Han Chinese Population

BACKGROUND AND PURPOSE

Previous studies have shown that common variants within CYP3A4 and CYP3A5 are associated with statin pharmacokinetics and the risk of cardiovascular disease. However, the association of variants in CYP3A4 and CYP3A5 with the prognosis of ischemic stroke remains undetermined. Therefore, we investigated this herein.

METHODS

Four hundred thirty-three consecutive patients with acute ischemic stroke were recruited. The outcome at the 1-year follow-up was assessed using the modified Rankin Scale (mRS). Two variants, CYP3A4*1G and CYP3A5*3, were genotyped by the improved Multiple Ligase Detection Reaction platform.

RESULTS

Binary logistic regression analysis showed that the CYP3A4*1G/*1G homozygote was associated with poor outcome at 1 year (mRS score ≥2) after adjustment for conventional factors in the additive model (odds ratio [OR] = 2.92; 95% confidence interval, 1.07-7.98; P = .037) and recessive model (OR = 3.37; 95% confidence interval, 1.26-9.04; P = .016). Subgroup analysis indicated that the CYP3A4*1G/*1G homozygote was associated with poor prognosis at 1 year among patients with stable high-intensity atorvastatin therapy (40-80 mg/d) after adjustment for conventional factors in the additive model (OR = 8.16; 95% confidence interval, 1.50-44.44; P = .015) and recessive model (OR = 9.06; 95% confidence interval, 1.72-47.64; P = .009). No significant association was identified between CYP3A5*3 and the 1-year outcome of patients with ischemic stroke.

CONCLUSIONS

Our study findings suggest that the CYP3A4*1G/CYP3A4*1G genotype may be associated with poor prognosis at 1 year after acute ischemic stroke in the Han Chinese population.

Serum asymmetric dimethylarginine and nitric oxide levels in Turkish patients with acute ischemic stroke

BACKGROUND

Nitric oxide synthase (NOS) is present in the brain and cerebral arteries and it enables the synthesis of nitric oxide (NO), which plays a critical role in brain perfusion. Asymmetrical dimethylarginine (ADMA) is an endogenous NOS inhibitor.

OBJECTIVES

The aim of this study was to evaluate serum ADMA levels, which are an indicator of endothelial dysfunction of the renal functions in patients with acute ischemic stroke, and to determine whether there is a possible correlation between ADMA and NO levels and the l-arginine-to-ADMA ratio.

MATERIAL AND METHODS

Fifty-two patients (22 male and 30 female; mean age: 75.2 ±10.1 years) with a diagnosis of acute ischemic stroke in the first 24 h post-stroke and 48 healthy individuals (controls; 13 male and 35 female; mean age: 60.1 ±7.92 years) were included in this study. The risk factors recorded and evaluated were age and gender of the patients, serum lipid levels, serum ADMA levels, nitrate-to-nitrite ratios, l-arginine, l-arginine-to-ADMA ratios, sedimentation rate, C-reactive protein (CRP), urea and creatinine levels, and glomerular filtration ratio (eGFR).

RESULTS

The mean serum ADMA level was 0.48 ±0.23 μM for the patients and 0.36 ±0.18 μM for the controls. The mean NO level was 2.78 ±0.59 μM for the patient group and 4.49 ±2.84 μM for the controls. The ADMA levels for the patient group were significantly higher than for the control group (p = 0.011); the NO levels for the patients were significantly lower than for the controls (p < 0.001). The logistic regression method demonstrated that ADMA and NO levels may be independent risk factors for the patient group, and the receiver operating characteristic (ROC) curve analysis showed that both of these variables were discriminative risk factors.

CONCLUSIONS

An increased serum level of the NOS inhibitor ADMA was found to be a possible independent risk factor for ischemic stroke.

[Chinese expert consensus on the assessment and management of stroke-related sleep disorders]

Stroke-related sleep disorders (SSD) are common symptoms after stroke, which are common but easily ignored. Studies have shown that sleep disorders in stroke patients would have negative impact on prognosis. However, there is still a lack of consensus and guidance on SSD evaluation and management worldwide. This consensus proposes the concept of SSD based on systemic literature review and discussion with experts. It comprises recommendations of assessment and management for all types of SSD, including insomnia, excessive daytime sleepiness, sleep apnea, rapid eye movement (REM) sleep behavior disorder, restless leg syndrome/periodic limb movements of sleep, circadian rhythm sleep-wake disorders. The purpose of this consensus is to provide a standard reference of SSD management.

Disparities in Inter-hospital Helicopter Transportation for Hispanics by Geographic Region: A Threat to Fairness in the Era of Thrombectomy

BACKGROUND AND PURPOSE

Mechanical thrombectomy (MT) is a time-dependent therapy that is only available at a limited number of hospitals. As such, patients that live at a considerable distance of those specialized centers often require rapid interhospital emergent evacuation with Helicopter Emergency Medical Services (HEMS) to be considered for MT. It is not known whether the use of HEMS is equitable across different groups of patients.

METHODS

Acute ischemic stroke patients emergently transferred to another facility were identified in a retrospective review of a large Medicare claims database. Mode of transportation (HEMS, advanced, or basic ground ambulances) was determined by CPT codes. Distance from patient's residence to the closest center with MT capabilities was calculated. Generalized linear mixed logit models were used to determine the odds of HEMS relative to ground services for Hispanic and non-Hispanic black (NHB) patients relative to non-Hispanic white (NHW) patients while controlling for confounders.

RESULTS

A total of 8027 patients that underwent emergent interhospital transportation were analyzed. HEMS utilization was 18.1% for NHB, 20.6% for Hispanics, and 21.6% for NHW (P = .054). In adjusted analyses for confounders, including distance to a MT-capable hospital, Hispanic patients were less likely than NHWs to be transported by HEMS. While that association had marginal significance for the whole United States (OR = .76; 95% CI, .57-1.01; P = .055), it was statistically significant for patients living in the southern region of the United States (OR = .6; 95% CI, .40-.92; P = .019).

DISCUSSION

Our findings suggest there is a disparity in the use of HEMS in Hispanic stroke patients compared to NHW. Such a disparity may delay arrival to a MT-capable hospital, delay treatment times, or lead to ineligibility for MT altogether. Given the known benefit of MT and known existing disparities in stroke treatment and outcomes, it is important to further investigate and address disparities in mode of interhospital transportation.

Genetic polymorphisms of methylenetetrahydrofolate reductase C677T and risk of ischemic stroke in a southern Chinese Hakka population

Previous studies have shown that methylenetetrahydrofolate reductase (MTHFR) gene to be a genetic risk factor for the susceptibility to ischemic stroke. The aim of this case-control study was to investigate whether the polymorphisms of MTHFR C677T were associated with the susceptibility to ischemic stroke in a southern Chinese Hakka population. In this study, a total of 1967 ischemic stroke patients and 2565 controls of Chinese Hakka ethnicity were recruited. The MTHFR C677T polymorphisms were genotyped by polymerase chain reaction (PCR) amplification and microarray method. The risk of ischemic stroke was estimated by logistic regression analysis. The frequencies of CC, CT, and TT genotypes were 52.67% versus 55.63%, 40.31% versus 38.52%, and 7.02% versus 5.85% in patients with ischemic stroke versus controls, respectively. The frequency of T allele was significantly higher in ischemic stroke patients (27.17%) than in controls (25.11%) (P = .026, odds ratio [OR] 1.113, 95% confidence interval [CI] 1.013-1.223). The homozygous TT genotype in the ischemic stroke patients was associated with increased risk (P = .049, OR 1.132, 95% CI 1.001-1.281) when compared with the controls after adjustment for age and sex. The positive association was only found in dominant model without adjustment for age and sex (P = .047, OR 1.127, 95% CI 1.002-1.268). Also, the carrier status of the MTHFR T allele was identified as an independent risk factor for the development ischemic stroke even after the adjustment for conventional risk factors (P = 0.047, OR 1.109, 95% CI 0.964-1.225). Our results provide evidence that variants of MTHFR C677T gene may influence the risk of developing ischemic stroke in a southern Chinese Hakka population. Further studies are needed to confirm this association, which will promote the development of strategies for prevention and treatment of ischemic stroke in our study population.

International Comparison of Patient Characteristics and Quality of Care for Ischemic Stroke: Analysis of the China National Stroke Registry and the American Heart Association Get With The Guidelines--Stroke Program

Background Adherence to evidence-based guidelines is an important quality indicator; yet, there is lack of assessment of adherence to performance measures in acute ischemic stroke for most world regions. Methods and Results We analyzed 19 604 patients with acute ischemic stroke in the China National Stroke Registry and 194 876 patients in the Get With The Guidelines--Stroke registry in the United States from June 2012 to January 2013. Compared with their US counterparts, Chinese patients were younger, had a lower prevalence of comorbidities, and had similar median, lower mean, and less variability in National Institutes of Health Stroke Scale (median 4 [25th percentile-75th percentile, 2-7], mean 5.4±5.6 versus median 4 [1-10], mean 6.8±7.7). Chinese patients were more likely to experience delays from last known well to hospital arrival (median 1318 [330-3209] versus 644 [142-2055] minutes), less likely to receive thrombolytic therapy (2.5% versus 8.1%), and more likely to experience treatment delays (door-to-needle time median 95 [72-112] versus 62 [49-85] minutes). Adherence to early and discharge antithrombotics, smoking cessation counseling, and dysphagia screening were relatively high (eg >80%) in both countries. Large gaps existed between China and the United States with regard to the administration of thrombolytics within 3 hours (18.3% versus 83.6%), door-to-needle time ≤60 minutes (14.6% versus 48.0%), deep venous thrombosis prophylaxis (65.0% versus 97.8%), anticoagulation for atrial fibrillation (21.0% versus 94.4%), lipid treatment (66.3% versus 95.8%), and rehabilitation assessment (58.8% versus 97.4%). Conclusions We found significant differences in clinical characteristics and gaps in adherence for certain performance measures between China and the United States. Additional efforts are needed for continued improvements in acute stroke care and secondary prevention in both nations, especially China.

Matrix metalloproteinase-2 gene polymorphisms are associated with ischemic stroke in a Hainan population

Ischemic stroke is a complex vascular disease, which has become 1 of the major causes of morbidity and mortality worldwide. More and more data showed that matrix metalloproteinases (MMPs), in particular, MMP-2 are deleterious after ischaemic stroke. This study investigated the relationship between MMP-2 and stroke risk in the Southern Chinese population.We evaluated single nucleotide polymorphisms (SNP) of MMP-2 in stroke patients in an association study using a case-control design. Six SNPs of MMP2 were selected and genotyped by Agena MassARRAY. SNPStats, Haploview was used to analyze genetic data.Two SNPs in the MMP-2 gene were significantly associated with stroke risk.For rs1132896 (C versus G allele), the C allele was significantly reduced stroke risk (OR = 0.56, 95% confidence intervals [95% CI] = 0.39-0.81, P = .002). The effect of the T allele of rs243849 was IS risk according to an additive genetic model (OR = 0.67, 95% CI = 0.47-0.96, P = .028). We did not found any strong linkage between the six SNPs (rs1132896, rs1053605, rs243849, rs243847, rs243832, rs7201)The results presented strongly indicate that MMP-2 genetic variants are an important mediator of stroke risk.

Ischemic stroke/transient ischemic attack events and carotid artery disease in the absence of or with minimal coronary artery calcification: Results from the Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

The association between minimally elevated coronary artery calcification (CAC) and cerebrovascular disease is not well known. We assessed whether individuals with minimal CAC (Agatston scores of 1-10) have higher ischemic stroke or transient ischemic attack (TIA) frequencies compared with those with no CAC. We also investigated the relative prevalence of carotid atherosclerosis in these two groups.

METHODS

A total of 3924 participants from the Multi-Ethnic Study of Atherosclerosis (MESA) without previous cardiovascular events, including stroke, and with baseline CAC scores of 0-10 were followed for the occurrence of incident ischemic stroke/TIA. We used carotid ultrasound to detect carotid artery plaques and to measure the intima-media thickness (IMT).

RESULTS

During a median follow-up of 13.2 years, 130 participants developed incident ischemic stroke/TIA. There was no significant difference in the ischemic stroke/TIA incidence between those with minimal CAC and no CAC (3.7 versus 2.7 per 1000 person-years). In participants with minimal CAC, we observed a significant association of the condition with an internal carotid artery (ICA) that had a greater-than-average IMT (ICA-IMT; β = 0.071, p = 0.001) and a higher odds ratio (OR) for carotid artery plaques (OR 1.46; with a 95% confidence interval [CI] of 1.18-1.80; p < 0.001).

CONCLUSIONS

A CAC score of 0-10 is associated with a low rate of ischemic stroke/TIA, and thus a minimal CAC score is not a valuable predictive marker for ischemic stroke/TIA. A minimal CAC score may, however, provide an early and asymptomatic sign of carotid artery disease.

Significant Association between OPG/TNFRSF11B Variant and Common Complex Ischemic Stroke

BACKGROUND

The serum level of osteoprotegerin (encoded by OPG or TNFRSF11B) was previously shown to be increased in patients with ischemic stroke. A single nucleotide polymorphism rs3134069 in the TNFRSF11B gene was previously associated with ischemic stroke in a population of diabetic patients in Italy. It remains to be determined whether rs3134069 is associated with ischemic stroke in the general population or populations without diabetes.

MATERIALS AND METHODS

We genotyped rs3134069 and performed a case-control association study to test whether rs3134069 is associated with ischemic stroke in 2 independent Chinese Han populations, including a China-Central population with 1629 cases and 1504 controls and a China-Northern population with 1206 cases and 720 controls.

RESULTS

rs3134069 showed significant association with ischemic stroke in the China-Central population (P = 9.24 × 10^-3, odds ratio [OR] = 1.50). The association was replicated in the independent China-Northern population (P = 2.45 × 10^-4, OR = 1.53). The association became more significant in the combined population (P = 7.09 × 10^-6, OR = 1.41). The associations remained significant in the male population, female population, and population without type 2 diabetes. Our expression quantitative trait loci analysis found that the minor allele C of rs3134069 was significantly associated with a decreasedexpression level of TNFRSF11B (P = .002).

CONCLUSIONS

This study demonstrates that rs3134069 in TNFRSF11B increases risk of ischemic stroke by decreasing TNFRSF11B expression.

Intracranial Arterial Calcification in Black Africans with Acute Ischaemic Stroke

Background

Intracranial arterial calcification (IAC), a recognized marker of atherosclerosis on cranial computed tomography (CT), is an independent risk factor for ischaemic stroke. This study aimed to determine the prevalence, distribution, severity, and associations of IAC in adults with acute ischaemic stroke (AIS) at the University College Hospital, Ibadan, Nigeria.

Methods

Cranial CT images of 130 consecutive adults who presented with AIS were acquired on a 64-slice multi-detector Toshiba Aquilion scanner and evaluated for IAC in bone window on Vitrea® software using a semi-quantitative scoring method for extent, thickness, and length of calcifications in the large intracranial arteries. Associations of IAC with clinical and laboratory data were determined by statistical analysis at p < 0.05.

Results

There were 71 males (54.6%), and the mean age of all patients was 63.0 ± 13.2 years. Hypertension was the most common risk factor (83.1%). IAC was found in 121 patients (93.1%), predominantly in the carotid siphon (86.1%) followed by the intracranial vertebral arteries (9.3%), middle cerebral arteries (2.4%), basilar artery (1.2%), and the anterior cerebral arteries (1%). The burden of IAC ranged from mild (17.4%) to moderate (52.1%) to severe (30.6%). Age (p < 0.001), diastolic blood pressure (p = 0.037), and alcohol use (0.046) were significantly different among the patients with mild, moderate, and severe degrees of IAC. IAC was associated with age (p < 0.001), hypertension (p = 0.03), diabetes mellitus (p = 0.02), hyperlipidaemia (p = 0.04), and alcohol use (p < 0.001) but not with sex (p = 0.35).

Conclusions

The burden of IAC is very high among native African patients with AIS and preferentially involves proximal inflow arteries. Therefore, the role of large vessel atherosclerosis in ischaemic stroke in native Africans should be explored in future multinational, multimodality studies.

Low- versus Standard-Dose Intravenous Tissue-Type Plasminogen Activator for Acute Ischemic Stroke: An Updated Meta-Analysis

BACKGROUND

We performed a meta-analysis to compare the efficacy and safety between low- and standard-dose intravenous (IV) tissue-type plasminogen activator (tPA) for acute ischemic stroke (AIS) patients within 4.5 hours of symptom onset.

METHODS

We searched PubMed and EMBASE for relevant studies from inception to June1, 2017. Cohort or randomized controlled studies for AIS within 4.5 hours of symptom onset with comparison between low-dose and standard-dose tPA were included. The primary efficacy end point was favorable functional outcome (modified Rankin scale scores [mRS] of 0-1) at 90 days. The primary safety end point was the incidence rate of symptomatic intracerebral hemorrhage (sICH). The secondary end points were independent functional outcome (mRS scores of 0-2) and mortality.

RESULTS

A total of 11 studies were pooled in this meta-analysis. The low-dose strategy appeared to be as effective as standard-dose tPA (43.4% versus 45.4%; odds ratio [OR] = 0.93, 95% confidence interval [CI]: 0.78-1.10; P = .38) in primary efficacy outcome. The secondary efficacy outcome produced similar results (57.3% versus 57.0%; OR = 0.95, 95% CI: 0.86-1.05; P= .33). There was no evidence of statistical difference for sICH (4.2% versus 4.9%; OR = 1.02 [0.66-1.55]; P = .94) and mortality (9.0% versus 10.6%; OR = 0.99 [0.74-1.31]; P = .92) at 90 days between low- and standard-dose therapy. In a subgroup analysis by ethnicity, there was no significant difference between patients of Asian and non-Asian descent for any of the end points.

CONCLUSIONS

This study showed that AIS patients receiving low-dose IV-tPA had comparably efficacy and safety to those receiving standard-dose IV-tPA. However, the effect is especially pronounced within the Asian population, which limits the generalizability of these results.

Professional Medical Interpreters Influence the Quality of Acute Ischemic Stroke Care for Patients Who Speak Languages Other than English

BACKGROUND

The inability to communicate effectively in a common language can jeopardize clinicians' efforts to provide quality patient care. Professional medical interpreters (PMIs) can help provide linguistically appropriate health care, in particular for the >25 million Americans who identify speaking English less than very well. We aimed to evaluate the relationship between use of PMIs and quality of acute ischemic stroke care received by patients who preferred to have their medical care in languages other than English.

METHODS AND RESULTS

We analyzed data from 259 non-English-preferring acute ischemic stroke patients who participated in the American Heart Association Get With The Guidelines-Stroke program at our hospital from January 1, 2003, to April 30, 2014. We used descriptive statistics and logistic regression models to examine associations between involvement of PMIs and patients' receipt of defect-free stroke care. A total of 147 of 259 (57%) non-English-preferring patients received PMI services during their hospital stays. Multivariable analyses adjusting for other socioeconomic factors showed that acute ischemic stroke patients who did not receive PMIs had lower odds of receiving defect-free stroke care (odds ratio: 0.52; P=0.04).

CONCLUSIONS

Our findings suggest that PMIs may influence the quality of acute ischemic stroke care.

Is there a correlation between socioeconomic disparity and functional outcome after acute ischemic stroke?

BACKGROUND

To investigate the impact of low socioeconomic status (SES), indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke.

METHODS

We analyzed data from the China National Stroke Registry (CNSR), a multicenter and prospective registry of consecutive patients with acute cerebrovascular events occurred between September 2007 and August 2008. 11226 patients with ischemic stroke had SES and clinical characteristics data collected at baseline and mRS measured as indicator of functional outcome in 3 months follow up. Multinomial and ordinal logistic regression models were performed to examine associations between SES and the functional outcome.

RESULTS

At 3 months after stroke, 5.3% of total patients had mRS scored at 5, 11.3% at score 4, 11.1% at score 3, 14.4% at score 2, 34.2% at score 1 and 23.7% at score 0. Compared to patients with educational level of ≥ 6 years and non-manual laboring, those < 6 years and manual laboring tended to have higher mRS score (P<0.001). Multinomial adjusted odds ratios (ORs) of outcome in manual workers were significantly increased (ORs from1.38 to 1.87), but OR in patients with less income was not significant. There were similar patterns of association The impact may be stronger in patients aged <65 years (P = 0.003, P<0.001 respectively) and being male (P = 0.001, P<0.001 respectively).

CONCLUSIONS

Our study provides evidence that people who are relatively more deprived in socioeconomic status suffer poorer outcome after ischemic stroke. The influence of low educational level and manual laboring can be more intensive than low income level on 3-month outcome. Health policy and service should target the deprived populations to reduce the public health burden in the society.

Association between the Matrix Metalloproteinase-9 rs3918242 Polymorphism and Ischemic Stroke Susceptibility: A Meta-Analysis

BACKGROUND

In recent years, dozens of case-control studies showed that matrix metalloproteinase (MMP)-9 rs3918242 variants were associated with ischemic stroke (IS) susceptibility. However, the conclusions of case-control studies that evaluated the relationship between MMP-9 rs3918242 variants and the risk of IS were still equivocal. Herein, we conducted a comprehensive meta-analysis to investigate the association between MMP-9 rs3918242 variants and the risk of IS.

METHODS

We searched 5 databases (PubMed, EMBASE, Google Scholar, Web of Science, and Chinese Biomedical Literature Database) to identify the eligible studies up to October of 2016. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to evaluate the association of MMP-9 rs3918242 variants with IS susceptibility under the allelic model (T versus C) and the dominant model (TT + CT versus CC).

RESULTS

A total of 14 studies with 3233 cases and 3123 controls were included in this meta-analysis. Our meta-analysis indicated that MMP-9 rs3918242 variants were associated with significantly increased risk of IS in overall populations (T versus C: OR = 1.43, 95% CI = 1.20-1.71, P < .001; TT + CT versus CC: OR = 1.39, 95% CI = 1.16-1.67, P < .001). Subgroup analysis based on ethnicity (Chinese and Caucasian) suggested that MMP-9 rs3918242 variants contributed to increase the risk of IS in Chinese population; However, no association was detected between MMP-9 rs3918242 variants and the risk of IS in Caucasian population.

CONCLUSION

Therefore, our meta-analysis suggested that MMP-9 rs3918242 variants (T allele, TT and CT genotypes) contributed to significantly increase the risk of IS in the Chinese population.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study

BACKGROUND

Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals.

METHODS AND RESULTS

Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%).

CONCLUSIONS

Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.

Racial Differences in Association of Serum Calcium with Mortality and Incident Cardio- and Cerebrovascular Events

CONTEXT

Abnormalities in calcium metabolism may potentially contribute to the development of vascular disease. Calcium metabolism may be different in African American (AA) vs white individuals, but the effect of race on the association of serum calcium with clinical outcomes remains unclear.

OBJECTIVE

This study sought to examine race-specific associations of serum calcium levels with mortality and with major incident cardiovascular events.

DESIGN AND SETTING

This was a historical cohort study in the U.S. Department of Veterans Affairs health care facilities.

PARTICIPANTS

Participants included veterans (n = 1 967 622) with estimated glomerular filtration rate ≥ 60 mL/min/1.73 m².

MAIN OUTCOME MEASURES

The association between serum calcium levels with all-cause mortality, incident coronary heart disease (CHD), and ischemic stroke incidence was examined in multivariable adjusted Cox proportional hazards models, including an interaction term for calcium and race.

RESULTS

The association of calcium with all-cause mortality was U-shaped in both AA and white patients, but race modified the association of calcium with all-cause mortality. Compared with white patients, AA patients experienced lower risk of mortality when calcium was ≥ 8.8 mg/dL, with a statistically significant interaction (P < .001). Conversely, AA vs white race was associated with higher mortality when calcium was < 8.8 mg/dL. Calcium showed no significant association with ischemic stroke or CHD in both races; and race did not modify these associations (P = .37 and 0.11, respectively for interaction term).

CONCLUSIONS

Race modified the U-shaped association between calcium and all-cause mortality. Serum calcium is not associated with incident stroke or CHD in either AA or white patients. The race-specific difference in the association of calcium levels with mortality warrants further examination.

Ethnic differences in ambient air pollution and risk of acute ischemic stroke

OBJECTIVES

To investigate the association between short-term changes in ambient pollution (particulate matter <2.5 μm in aerodynamic diameter (PM2.5) and ozone (O3)) and the risk of ischemic stroke among individuals living in a bi-ethnic community and whether this association is modified by ethnicity.

METHODS

We identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Associations between PM2.5 (mean 24-h) and O3 (maximal 8-h) levels, measured on the same-day and lags of 1-3 days, and odds of ischemic stroke were assessed using a time-stratified case-crossover design and modeled using conditional logistic regression. We explored race/ethnicity (Mexican American versus non-Hispanic white) as a modifier by including interaction terms in the models.

RESULTS

There were 2948 ischemic strokes with median age 71 years (IQR: 59-80). We observed no overall associations between the air pollutants and odds of ischemic stroke at any lag. When stratified by ethnicity, higher O3 was consistently associated with greater odds of ischemic stroke for non-Hispanic whites, but not for Mexican Americans. Higher PM2.5 was generally associated with lower odds of ischemic stroke for non-Hispanic whites but modestly greater odds for Mexican Americans.

CONCLUSION

Ethnic differences in the associations between ischemic stroke and short-term exposures to O3 and PM2.5 were suggested indicating that further study in diverse populations may be warranted.

Association of Race With Mortality and Cardiovascular Events in a Large Cohort of US Veterans

BACKGROUND

In the general population, blacks experience higher mortality than their white peers, attributed in part to their lower socioeconomic status, reduced access to care, and possibly intrinsic biological factors. Patients with kidney disease are a notable exception, among whom blacks experience lower mortality. It is unclear if similar differences affecting outcomes exist in patients with no kidney disease but with equal or similar access to health care.

METHODS AND RESULTS

We compared all-cause mortality, incident coronary heart disease, and incident ischemic stroke using multivariable-adjusted Cox models in a nationwide cohort of 547 441 black and 2 525 525 white patients with baseline estimated glomerular filtration rate ≥ 60 mL·min⁻¹·1.73 m⁻² receiving care from the US Veterans Health Administration. In parallel analyses, we compared outcomes in black versus white individuals in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004. After multivariable adjustments in veterans, black race was associated with 24% lower all-cause mortality (adjusted hazard ratio, 0.76; 95% confidence interval, 0.75-0.77; P<0.001) and 37% lower incidence of coronary heart disease (adjusted hazard ratio, 0.63; 95% confidence interval, 0.62-0.65; P<0.001) but a similar incidence of ischemic stroke (adjusted hazard ratio, 0.99; 95% confidence interval, 0.97-1.01; P=0.3). Black race was associated with a 42% higher adjusted mortality among individuals with estimated glomerular filtration rate ≥ 60 mL·min⁻¹·1.73 m⁻² in NHANES (adjusted hazard ratio, 1.42; 95% confidence interval, 1.09-1.87).

CONCLUSIONS

Black veterans with normal estimated glomerular filtration rate and equal access to healthcare have lower all-cause mortality and incidence of coronary heart disease and a similar incidence of ischemic stroke. These associations are in contrast to the higher mortality experienced by black individuals in the general US population.

Coagulation factor XII genetic variation, ex vivo thrombin generation, and stroke risk in the elderly: results from the Cardiovascular Health Study

BACKGROUND

The relationships of thrombin generation (TG) with cardiovascular disease risk are underevaluated in population-based cohorts.

OBJECTIVES

To evaluate the relationships of TG influenced by the contact and tissue factor coagulation pathways ex vivo with common single-nucleotide polymorphisms (SNPs) and incident cardiovascular disease and stroke.

PATIENTS/METHODS

We measured peak TG (pTG) in baseline plasma samples of Cardiovascular Health Study participants (n = 5411), both with and without inhibitory anti-factor XIa antibody (pTG/FXIa(-) ). We evaluated their associations with ~ 50 000 SNPs by using the IBCv2 genotyping array, and with incident cardiovascular disease and stroke events over a median follow-up of 13.2 years.

RESULTS

The minor allele for an SNP in the FXII gene (F12), rs1801020, was associated with lower pTG in European-Americans (β = - 34.2 ± 3.5 nm; P = 3.3 × 10(-22) ; minor allele frequency [MAF] = 0.23) and African-Americans (β = - 31.1 ± 7.9 nm; P = 9.0 × 10(-5) ; MAF = 0.42). Lower FXIa-independent pTG (pTG/FXIa(-) ) was associated with the F12 rs1801020 minor allele, and higher pTG/FXIa(-) was associated with the ABO SNP rs657152 minor allele (β = 16.3 nm; P = 4.3 × 10(-9) ; MAF = 0.37). The risk factor-adjusted ischemic stroke hazard ratios were 1.09 (95% confidence interval CI 1.01-1.17; P = 0.03) for pTG, 1.06 (95% CI 0.98-1.15; P = 0.17) for pTG/FXIa(-) , and 1.11 (95% CI 1.02-1.21; P = 0.02) for FXIa-dependent pTG (pTG/FXIa(+) ), per one standard deviation increment (n = 834 ischemic strokes). In a multicohort candidate gene analysis, rs1801020 was not associated with incident ischemic stroke (β = - 0.02; standard error = 0.08; P = 0.81).

CONCLUSIONS

These results support the importance of contact activation pathway-dependent TG as a risk factor for ischemic stroke, and indicate the importance of F12 SNPs for TG ex vivo and in vivo.

[Epidemiological survey of cerebrovascular disease among population in Inner Mongolia autonomous region]

OBJECTIVE

To understand the epidemiological characteristics of cerebrovascular disease among population in Inner Mongolia.

METHODS

From September 2013 to January 2014, a total of 19 315 local residents in all age groups were selected through cluster random sampling, and face to face questionnaire survey was conducted among them, than health examination was provided for them.

RESULTS

The overall prevalence of cerebrovascular diseases among the population in all age group was 1 812.06/100 000 (2 008.86/100 000 in males and 1 613.24/100 000 in females). The prevalence of cerebrovascular diseases increased with age, and the prevalence was higher in males than in females, in rural population than in urban population and in people with lower educational level than in people with higher educational level. The annual incidence stroke was 392.54/100 000, the difference in the incidence between males and females had no statistical significance (χ(2)=0.380, P=0.846). The incidence of stroke was higher in rural population than in urban population, the difference was statistically significant (χ(2)=13.029, P=0.000). The incidence of stroke increased with age (χ(2)=410.130, P=0.000). The annual mortality of stroke was 149.67/100 000 and the case fatality rate was 15.14%. Compared with the elderly, the prevalence of cerebral hemorrhage and cerebral infarction were higher in young people.

CONCLUSION

The prevalence, incidence, mortality and recurrence rate of cerebrovascular disease were high in the population in Inner Mongolia, ischemic stroke was the major form of cerebrovascular disease.

Association of two polymorphisms in the FADS1/FADS2 gene cluster and the risk of coronary artery disease and ischemic stroke

Little is known about the association of the FADS1/FADS2 SNPs and serum lipid levels and the risk of coronary artery disease (CAD) and ischemic stroke (IS) in the Chinese southern population. The present study aimed to determine such association in the Chinese southern population. A total of 1,669 unrelated subjects (CAD, 534; IS, 553; and healthy controls, 582) were recruited in the study. Genotypes of the FADS1 rs174546 SNP and the FADS2 rs174601 SNP were determined by the SNaPshot Multiplex Kit. The T allele and TT genotype frequencies of the two SNPs were predominant in our study population. The T alleles were associated with increased risk of CAD and IS. Correspondingly, the C alleles were associated with reduced risk of CAD and IS. Haplotype analyses showed that the haplotype of T-T (rs174546-rs174601) was associated with an increased risk for IS, and the haplotype of C-C (rs174546-rs174601) was associated with a reduced risk for CAD and IS. The two SNPs were likely to influence serum lipid levels. The T allele carriers of the two SNPs and rs174601 TT genotype were associated with decreased serum HDL-C and ApoAI levels in the patient groups and with an increased risk of CAD and IS. The present study suggests that the FADS1 rs174546 SNP and the FADS2 rs174601 SNP are associated with the risk of CAD and IS, and are likely to influence serum lipid levels. However, further functional studies are needed to clarify how the two SNPs actually affect serum lipid levels and the risk of CAD and IS.

Association of Hispanic ethnicity with acute ischemic stroke care processes and outcomes

BACKGROUND

Few studies have examined the actual hospital arrival mode, emergency department (ED) care processes, and early outcomes in Hispanic vs non-Hispanic acute ischemic stroke (AIS) patients. We evaluated processes and prognosis by Hispanic ethnicity among AIS patients encountered in urban setting.

METHODS

We retrospectively reviewed prospectively-collected data on 1,117 AIS patients presenting within 12 hours of ictus to five hospitals in a tertiary-level stroke center network in San Diego, California. Variables of interest included pre-hospital factors, ED care processes, and favorable outcome (day-90 modified Rankin Scale [mRS] score of 0-1); all of which were adjusted for pre-specified covariates in a multivariable logistic regression model.

RESULTS

There were 192 Hispanic AIS patients (17.2% of cohort) encountered from June 2004 to March 2011. Hispanic patients were significantly more likely to be younger, female, and diabetic. Hispanic patients arrived by ambulance (vs other arrival modes) less frequently (adjusted OR .56; 95% CI: .38-.81), trended toward a longer time of stroke onset to treatment decision (351.6 vs. 320.02 minutes, P=.07), and experienced a favorable day-90 outcome less often (adjusted OR .52, CI: .28-.96). However, for the day-90 outcome, there was no interaction between ambulance arrival and Hispanic ethnicity (P=.5614).

DISCUSSION

Hispanic AIS patients in this study were less likely to arrive at the hospital by ambulance, and experienced half the odds of a favorable outcome compared to others. Strategies to boost ambulance utilization among Hispanic AIS patients and identify contributors to this worrisome outcome disparity are needed.

Impact of diabetes on prolonged hospital stay among Native Hawaiians and other Pacific Islanders with ischemic stroke

Recent evidence suggests that minority groups have prolonged hospital stays after ischemic stroke. However, disparities in the hospital stay after ischemic stroke among Native Hawaiians and other Pacific Islanders (NHPI) have not been studied. A retrospective study on consecutive patients hospitalized for ischemic stroke at a single tertiary center in Honolulu between 2008 and 2010 was performed. Logistic regression analyses were performed to assess the independent predictors of prolonged hospital stay (hospitalization > 12 days after admission) after ischemic stroke. A total of 740 patients (whites 22%, Asians 53%, NHPI 21%, others 4%) hospitalized for ischemic stroke were studied. NHPI were significantly younger (59 ± 14 years vs 72 ± 13 years) and had significantly higher prevalence of female sex (51% vs 38%), no insurance (10% vs 4%), diabetes (53% vs 18%), hypertension (82% vs 62%), obesity (55% vs 20%) and prolonged hospital stay (20% vs 11%), and lower prevalence of residence outside of O'ahu (12% vs 23%) compared to whites. Univariate analyses showed that NHPI were more likely to have prolonged hospital stay (OR 1.87, 95% CI: 1.01, 3.49) compared to whites. After adjusting for age, sex, race, risk factors, health insurance status, and geographical factor, diabetes (OR 1.76, 95% CI: 1.07, 2.89) was the only independent predictor of prolonged hospital stay. NHPI are associated with prolonged hospitalization after ischemic stroke. However, this effect was attenuated by the impact of diabetes. Further prospective studies are needed to understand the relationship between diabetes and prolonged hospital stay after ischemic stroke.

Blood pressure, low-density lipoprotein cholesterol, and incidences of coronary artery disease and ischemic stroke in Japanese: the Suita study

BACKGROUND

Blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) are risk factors for coronary artery disease (CAD) and ischemic stroke. However, the hazards of their coexistence are not fully understood in Asian populations. We investigated whether the relationship between BP and cardiovascular disease (CVD) outcomes are modified by LDL-C level in a Japanese population.

METHODS

Individuals aged 30-79 years (n = 5,151) were classified into 6 groups according to LDL-C levels (<140 and ≥140mg/dL or lipid medication) and BP levels (optimal BP, prehypertension, and hypertension; reference: low LDL-C and optimal BP). Hazard ratios (HRs) were calculated after adjusting for age, high-density lipoprotein cholesterol, diabetes, smoking status, and alcohol consumption. The effect modification of LDL-C on BP-CVD association was assessed using likelihood ratio tests.

RESULTS

There were 264 CAD and 215 ischemic stroke events during 13 years of follow-up. With low LDL-C, the HRs of prehypertension and hypertension for CAD were 2.01 and 4.71, respectively. Similar trends of HRs were observed with high LDL-C (optimal BP = 2.09, prehypertension = 3.45, hypertension = 5.94). However, the HRs for ischemic stroke did not differ between normal and high LDL-C levels at the same BP level. The apparent effect modification of LDL-C was not observed in the BP-CVD association in either CAD (P = 0.48) or ischemic stroke (P = 0.39).

CONCLUSIONS

The HRs for CAD in prehypertensive and hypertensive groups were higher than those in the optimal BP group at the same LDL-C levels in a Japanese population; however, there was no statistical effect modification of LDL-C on the BP-CAD association.

The predictive value of waist-to-height ratio for ischemic stroke in a population-based prospective cohort study among Mongolian men in China

Objective

To explore the associations between waist-to-height ratio (WHtR), body mass index (BMI) and waist circumference (WC) and risk of ischemic stroke among Mongolian men in China.

Methods

A population-based prospective cohort study was conducted from June 2003 to July 2012 in Inner Mongolia, an autonomous region in north China. A total of 1034 men aged 20 years and older free of cardiovascular disease were included in the cohort and followed up for an average of 9.2 years. The subjects were divided into four groups by WHtR levels (WHtR<0.40, 0.40≤WHtR≤0.50, 0.50<WHtR≤0.60, WHtR>0.60). The cumulative survival rates of ischemic stroke among the four groups were estimated with the Kaplan-Meier curves and compared by log-rank test. Cox proportional hazards models and Receiver Operating Characteristic (ROC) curves were employed to evaluate the associations between obesity indices and ischemic stroke.

Results

A total of 47 ischemic stroke patients were observed during the follow-up period. The cumulative incidence and incidence density of ischemic stroke were 4.55% and 507.61/100 000 person-years, respectively. After the major risk factors were adjusted, individuals with WHtR>0.60 had a 3.56-fold increased risk of ischemic stroke compared with those with 0.40≤WHtR≤0.50. Hazard ratio (HR) and 95% confidence intervals (CI) of ischemic stroke for a 1-SD increase in WHtR was 1.34(95% CI: 1.00–1.81). After adding BMI or WC to models, higher WHtR remained significantly associated with increased risk of ischemic stroke. The Kaplan-Meier survival curves showed that the cumulative survival rate in the group with WHtR>0.60 was significantly lower than in the group with 0.40≤WHtR≤0.50 (log-rank test, P = 0.025). The areas under the curve for each index were as follows: 0.586 for WHtR, 0.543 for WC; 0.566 for BMI.

Conclusions

Higher WHtR is associated with risk of ischemic stroke in Mongolian males. WHtR may be useful in predicting ischemic stroke incidence in males.

Green space and mortality following ischemic stroke

BACKGROUND

Residential proximity to green space has been associated with physical and mental health benefits, but whether green space is associated with post-stroke survival has not been studied.

METHODS

Patients ≥ 21 years of age admitted to the Beth Israel Deaconess Medical Center (BIDMC) between 1999 and 2008 with acute ischemic stroke were identified. Demographics, presenting symptoms, medical history and imaging results were abstracted from medical records at the time of hospitalization for stroke onset. Addresses were linked to average Normalized Difference Vegetation Index, distance to roadways with more than 10,000 cars/day, and US census block group. Deaths were identified through June 2012 using the Social Security Death Index.

RESULTS

There were 929 deaths among 1645 patients with complete data (median follow up: 5 years). In multivariable Cox models adjusted for indicators of medical history, demographic and socioeconomic factors, the hazard ratio for patients living in locations in the highest quartile of green space compared to the lowest quartile was 0.78 (95% Confidence Interval: 0.63-0.97) (p-trend = 0.009). This association remained statistically significant after adjustment for residential proximity to a high traffic road.

CONCLUSIONS

Residential proximity to green space is associated with higher survival rates after ischemic stroke in multivariable adjusted models. Further work is necessary to elucidate the underlying mechanisms for this association, and to better understand the exposure-response relationships and susceptibility factors that may contribute to higher mortality in low green space areas.

Stroke incidence and mortality trends in US communities, 1987 to 2011

IMPORTANCE

Prior studies have shown decreases in stroke mortality over time, but data on validated stroke incidence and long-term trends by race are limited.

OBJECTIVE

To study trends in stroke incidence and subsequent mortality among black and white adults in the Atherosclerosis Risk in Communities (ARIC) cohort from 1987 to 2011.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 14,357 participants (282,097 person-years) free of stroke at baseline was facilitated in 4 different US communities. Participants were recruited for the purpose of studying all stroke hospitalizations and deaths and for collection of baseline information on cardiovascular risk factors (via interviews and physical examinations) in 1987-1989. Participants were followed up (via examinations, annual phone interviews, active surveillance of discharges from local hospitals, and linkage with the National Death Index) through December 31, 2011. The study physician reviewers adjudicated all possible strokes and classified them as definite or probable ischemic or hemorrhagic events.

MAIN OUTCOMES AND MEASURES

Trends in rates of first-ever stroke per 10 years of calendar time were estimated using Poisson regression incidence rate ratios (IRRs), with subsequent mortality analyzed using Cox proportional hazards regression models and hazard ratios (HRs) overall and by race, sex, and age divided at 65 years.

RESULTS

Among 1051 (7%) participants with incident stroke, there were 929 with incident ischemic stroke and 140 with incident hemorrhagic stroke (18 participants had both during the study period). Crude incidence rates were 3.73 (95% CI, 3.51-3.96) per 1000 person-years for total stroke, 3.29 (95% CI, 3.08-3.50) per 1000 person-years for ischemic stroke, and 0.49 (95% CI, 0.41-0.57) per 1000 person-years for hemorrhagic stroke. Stroke incidence decreased over time in white and black participants (age-adjusted IRRs per 10-year period, 0.76 [95% CI, 0.66-0.87]; absolute decrease of 0.93 per 1000 person-years overall). The decrease in age-adjusted incidence was evident in participants age 65 years and older (age-adjusted IRR per 10-year period, 0.69 [95% CI, 0.59-0.81]; absolute decrease of 1.35 per 1000 person-years) but not evident in participants younger than 65 years (age-adjusted IRR per 10-year period, 0.97 [95% CI, 0.76-1.25]; absolute decrease of 0.09 per 1000 person-years) (P = .02 for interaction). The decrease in incidence was similar by sex. Of participants with incident stroke, 614 (58%) died through 2011. The mortality rate was higher for hemorrhagic stroke (68%) than for ischemic stroke (57%). Overall, mortality after stroke decreased over time (hazard ratio [HR], 0.80 [95% CI, 0.66-0.98]; absolute decrease of 8.09 per 100 strokes after 10 years [per 10-year period]). The decrease in mortality was mostly accounted for by the decrease at younger than age 65 years (HR, 0.65 [95% CI, 0.46-0.93]; absolute decrease of 14.19 per 100 strokes after 10 years [per 10-year period]), but was similar across race and sex.

CONCLUSIONS AND RELEVANCE

In a multicenter cohort of black and white adults in US communities, stroke incidence and mortality rates decreased from 1987 to 2011. The decreases varied across age groups, but were similar across sex and race, showing that improvements in stroke incidence and outcome continued to 2011.

Lipoprotein-associated phospholipase A2 is associated with atherosclerotic stroke risk: the Northern Manhattan Study

Background

Lipoprotein-associated phospholipase A2 (LpPLA2) levels are associated with stroke, though whether this extends to all populations and stroke subtypes is unknown.

Methods

Serum samples from stroke-free community participants in the Northern Manhattan Study were assayed for LpPLA2 mass and activity. Participants were followed annually for stroke. Cox-proportional-hazard models were fitted to estimate hazard-ratios and 95% confidence intervals (HR, 95% CI) for the association of LpPLA2 levels with ischemic stroke (IS), after adjusting for demographic and medical risk factors.

Results

Serum samples were available in 1946 participants, of whom 151 (7.8%) experienced a first IS during median follow-up 11 years. Mean age was 69 (SD 10), 35.6% were men, 20% non-Hispanic Whites, 22% non-Hispanic Blacks, and 55% Hispanics. LpPLA2 mass and activity levels were not associated with overall IS risk.

LpPLA2 mass but not activity levels were associated with strokes due to large artery atherosclerosis (LAA; adjusted HR per SD 1.55, 95% CI 1.17–2.04). There was a dose-response relationship with LAA (compared to first quartile, 2nd quartile HR = 1.43, 95% CI 0.23–8.64; 3rd quartile HR = 4.47, 95% CI 0.93–21.54; 4th quartile HR = 5.07, 95% CI 1.07–24.06). The associations between LpPLA2-mass and LAA-stroke risk differed by race-ethnicity (p = 0.01); LpPLA2-mass was associated with increased risk of LAA among non-Hispanic Whites (adjusted HR per SD 1.44, 95% CI 0.98–2.11), but not other race-ethnic groups.

Conclusion

LpPLA2-mass levels were associated with risk of atherosclerotic stroke among non-Hispanic White participants, but not in other race-ethnic groups in the cohort. Further study is needed to confirm these race-ethnic differences and the reasons for them.

[Analysis of the effect of N5, N10-methylenetetrahydrofolate reductase gene C(677)-->T polymorphism on the ischemic stroke development in persons with various risk factors]

The results ofMTHFR gene C(677)-->T (rs1801133) polymorphism determined in 170 patients with ischemic atherothrombotic stroke (IATS) and 124 healthy subjects (control group) are presented in the paper. It has been shown that in patients with IATS, the frequencies of main homozygotes (CC), heterozygotes (CT) and minor homozygotes (TT) are 52.4, 35.9, 11.8% (in control--46.0, 48.4, 5.6%, P = 0.044 by chi2-test). TT homozygotes have a greater chance of developing IATS than carriers of main C-allele (CT + CC) (OR = 2.3, CI = 0.911-5.449, P = 0.049). In the representatives of the Ukrainian population there is a relationship between the frequency of MTHFR gene C(677)-->T polymorphism genotypes and the risk of IATS. This connection is manifested in male patients, in persons with normal blood pressure, and in people who do not have the habit of smoking. The sex of the patients, body mass index, blood pressure and smoking affect the level of the studied polymorphism association with stroke.

Analysis of risk factors of acute ischemic stroke for different ethnic groups in Changde

OBJECTIVES

The aim of our study was to explore the risk factors of acute ischemic stroke (AIS) for different ethnic groups in Changde city (a multi-ethnic residence inhabited mainly by Han and Tujia), Hunan Province, China.

DESIGN, SETTING AND PARTICIPANTS

A multicenter study was performed and the demography data, etiology data and clinical features of 5338 AIS patients from 17 hospitals in Changde city were collected from January 2011 through December 2011.

MAIN MEASURES

Student's t-test and Chi2-test were used to compare the differences between the Han and Tujia ethnic group in the AIS.

RESULTS

In Changde, the incidence of AIS in the Tujia ethnic group was higher than that in the Han ethnic group (233.14 per million vs. 84.38 million, respectively). We found statistically significant differences between the Tujia and Han ethnicities in demographic, etiology and clinical data (eg, sex, living environment, diet, smoking, payment methods, cerebral hemorrhage and transient ischemic attack [P < .05]). In addition, compared with the Han population, the Tujia patients had a higher rate of the incidence of the anterior circulation infarction, partial anterior circulation infarction, lacunar infarction and cerebral hemorrhage.

CONCLUSIONS

Our results indicate that lifestyle choices (eg, diet, smoking cigarettes), location, family heritage, and sex are associated with AIS and is useful for informing AIS rates and treatment for AIS.

Net clinical benefit of rivaroxaban versus warfarin in Japanese patients with nonvalvular atrial fibrillation: a subgroup analysis of J-ROCKET AF

BACKGROUND

The risk factors that have been identified for bleeding events with rivaroxaban are predominantly the same as those predicting thromboembolic ones in patients with atrial fibrillation (AF). Our aim was to determine the net clinical benefit (NCB) from the results of the J-ROCKET AF trial, in which rivaroxaban was compared with warfarin in Japanese patients with AF.

METHODS

Two strategies were adopted to quantify the NCB. First, the NCB was calculated as the number of ischemic strokes avoided with anticoagulation minus the number of excess intracranial hemorrhage (ICH) with a weight of 1.5. Second, the composite end point of major bleeding events and secondary efficacy end points (stroke, noncentral nervous system systemic embolism, myocardial infarction and death) to ascertain the NCB were established. Subgroup analysis by CHADS2 score or creatinine clearance was also performed.

RESULTS

The adjusted NCB, which was given a weight of 1.5 for ICH, was nominally significant in favor of rivaroxaban therapy (difference in incidence rate -2.13; 95% confidence interval [CI]: -.26 to -3.99). Furthermore, the event rate of the composite end point tended to be lower in patients treated with rivaroxaban than in those treated with warfarin (rivaroxaban: 4.97% per year, warfarin: 6.11% per year; difference in incidence rate: -1.14; 95% CI: -3.40 to 1.12). The event rate of the composite end point tended to be consistently low in patients treated with rivaroxaban in the subanalysis by CHADS2 score and renal function.

CONCLUSION

Analysis of the NCB supports that rivaroxaban therapy provides clinical benefit for Japanese patients with AF.

Two novel susceptibility SNPs for ischemic stroke using exome sequencing in Chinese Han population

Genome-wide association studies (GWAS) of ischemic stroke (IS) have been performed on several cohorts of Caucasian or African population and Japanese, resulting in somewhat inconsistent conclusion. We aimed to identify susceptibility loci for IS by exome sequencing in a Chinese Han population. Exome sequencing was used to screen susceptibility loci among 100 cases and 100 matched controls. Significant SNPs from the first stage were verified in up to 3,554 participants from three hospital-based case-control studies. In the initial exome sequencing analysis, rs10489177 in c1orf156 gene located on chromosome 1q24 (p < 1 × 10(-8)) and rs17118 in XYLB gene located on chromosome 3p21 (p < 1 × 10(-6)) were found to be significantly associated with IS. In the following validation stage, significantly increased odds ratios were observed in individuals with rs10489177 GG (OR = 2.02, 95 % CI = 1.35-3.03) or rs17118 AA genotype (OR = 1.50, 95 % CI = 1.17-1.91). The rs10489177 GG genotype was associated with significantly increased risk for IS in individuals without hypertension (OR = 2.78, 95 % CI = 1.59-4.86) and in individuals without diabetes (OR = 1.93, 95 % CI = 1.27-2.94). In contrast, the rs17118 AA genotype may significantly increase the risk for IS, particularly for individuals with hypertension (OR = 1.73, 95 % CI = 1.08-2.78) and for individuals without diabetes (OR = 1.52, 95 % CI = 1.17-1.98) or non-smoker (OR = 1.59, 95 % CI = 1.16-2.19). Collectively, our study identified two novel loci (rs17118 and rs10489177) which were associated with an increased risk for IS in Chinese Han populations. Further studies are needed to confirm these associations in other populations and elucidate the biological mechanisms underlying the observed associations.

Exploring psychosocial pathways between neighbourhood characteristics and stroke in older adults: the cardiovascular health study

OBJECTIVES

to investigate whether psychosocial pathways mediate the association between neighbourhood socioeconomic disadvantage and stroke.

METHODS

prospective cohort study with a follow-up of 11.5 years.

SETTING

the Cardiovascular Health Study, a longitudinal population-based cohort study of older adults ≥65 years.

MEASUREMENTS

the primary outcome was adjudicated incident ischaemic stroke. Neighbourhood socioeconomic status (NSES) was measured using a composite of six census-tract variables. Psychosocial factors were assessed with standard measures for depression, social support and social networks.

RESULTS

of the 3,834 white participants with no prior stroke, 548 had an incident ischaemic stroke over the 11.5-year follow-up. Among whites, the incident stroke hazard ratio (HR) associated with living in the lowest relative to highest NSES quartile was 1.32 (95% CI = 1.01-1.73), in models adjusted for individual SES. Additional adjustment for psychosocial factors had a minimal effect on hazard of incident stroke (HR = 1.31, CI = 1.00-1.71). Associations between NSES and stroke incidence were not found among African-Americans (n = 785) in either partially or fully adjusted models.

CONCLUSIONS

psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among white older adults.

Ethnic disparities trump other risk factors in determining delay to emergency department arrival in acute ischemic stroke

OBJECTIVES

Historically, Blacks receive treatment for acute ischemic stroke (AIS) less frequently than Whites, even after considering contraindications to treatment and socioeconomic status. Blacks also experience a longer delay between symptom onset and Emergency Department (ED) arrival for unclear reasons. The purpose of our study was to determine if these disparities exist within our biracial patient population and why.

METHODS

All patients who presented to our center with AIS between July, 2008 and December 2010 were identified from a prospective registry. The relationship between patient demographics and delay to ED arrival was investigated, excluding patients with unknown time of last seen normal (LSN), race other than Black or White, in-hospital strokes, and patients who bypassed the ED.

RESULTS

Of the 596 patients screened, 368 met inclusion criteria (median age 65 years, 39.8% female, 67.8% Black). Blacks were more likely to have a longer delay from LSN to ED arrival compared to Whites (median delay of 339 min vs 151 min, P = .0028). Black race remained an independent predictor for delayed ED arrival even after adjusting for age, sex, stroke severity, and home medication use. The same proportion of Whites and Blacks who presented within the 3-hour window received thrombolytic treatment (P = .9763).

CONCLUSION

Black race appeared to be the driving force in a multivariate analysis evaluating predictors of ED arrival >3 hours after LSN. Despite the increased delay to ED arrival Blacks were just as likely to receive IV tPA as Whites. Improving stroke awareness and symptom recognition may reduce delays in seeking hospitalization.

Genome-wide association study validation identifies novel loci for atherosclerotic cardiovascular disease

BACKGROUND

Genetic variants influencing lipid levels and risk of coronary artery disease (CAD) have been identified by recent genome-wide association studies (GWAS).

OBJECTIVES

To test the association of single nucleotide polymorphisms (SNPs) implicated in lipoprotein metabolism and CAD in GWAS with atherosclerotic cardiovascular disease (ASCVD, including ischemic stroke [IS] and myocardial infarction [MI] phenotypes).

PATIENTS AND METHODS

A two-stage genetic association study was conducted in the Chinese Hans population. Stage I included a cohort with 451 IS cases and 462 controls for association analysis using 92 SNPs. Stage II examined the associations of eight positive variants and five additional variants with IS, MI and ASCVD in a cohort with 779 IS cases and 836 controls and a cohort with 824 MI cases and 737 controls.

RESULTS

The T allele of rs4731702 located near the KLF14 gene was associated with a decreased risk of MI with an odds ratio (OR) of 0.72 (P<3.85×10(-3)). The rs4731702-T allele was also associated with a decreased risk of ASCVD with an OR of 0.78 (Pmeta-analysis<5.43×10(-4)). In addition, we found that a missense variant of KLF14, rs111400400 (Ser58Pro), was associated with MI.

CONCLUSION

Genetic variants newly identified near/in the KLF14 gene were implicated in the aetiology of atherosclerotic-related phenotypes.

Thrombolysis and outcome of young stroke patients over the last decade: insights from the Nationwide Inpatient Sample

BACKGROUND

A recent study found a trend toward increasing hospitalizations for acute ischemic stroke (AIS) among young adults, raising concern for this subgroup. In the present study, we evaluated trends of use of thrombolysis and outcome among young adults (19-44 years of age) with AIS using a nationally representative administrative database.

METHODS

Discharge data were obtained from Nationwide Inpatient Sample between 2001 and 2009. Hospitalizations with a discharge diagnosis of AIS for patients 19 to 44 years of age were included. Use of thrombolysis was determined within this subset. The Cochran-Armitage test was used for trend analysis.

RESULTS

Thrombolysis in young patients with AIS increased from 354 (1.84%) in 2001 to 1,237 (4.97%) in 2009 (P < .0001). The highest increase was noted at urban teaching hospitals. There was a progressive decrease in mortality in young AIS patients, from 6.81% in 2001 to 5.43% in 2009 (trend P = .027) and significant increase in discharges to rehabilitation (3.42% in 2002 to 12.7% in 2009 [trend P < .0001]). Discharge to other facilities decreased significantly (29.1% in 2001 to 17.8% in 2009 [trend P < .0001]). The rate of intracranial hemorrhage (2.70% in 2001; 2.69% in 2009) did not show any significant change despite the increase in the use of thrombolysis (trend P = .39).

CONCLUSIONS

The rate of thrombolysis among young patients with AIS increased significantly between 2001 and 2009. A decrease in deaths with increased rehabilitation placements of young patients with AIS was noted over the last decade, suggesting improving outcomes. The lower rate of use of thrombolysis in rural hospitals may be improved with the widespread use of telestroke.

[The cerebrovascular pathology and the condition of brain blood circulation according to ultrasonic dopplerographic investigation depending on ethnos]

The condition of brain blood circulation in patients with discirculatory encephalopathies (DE) depending on ethnos was studied according to ultrasonic dopplergraphic investigation. The analysis of dopplerogramms has shown that sizes of indicators of brain blood circulation: linear speed of a blood-groove, pulse index (LS, PI) are in direct dependence on age of the patient, duration and the stage of diseases. The highest indicators LS and PI were in representatives of the 1-st basic group of supervision (aboriginals) and in patients of the control group.

Use of antiplatelets. A survey of secondary prevention of ischemic stroke with intracranial hemorrhage history in Chinese patients

OBJECTIVE

To explore whether antiplatelet (AP) agent therapy increased intracranial hemorrhage (ICH) incidence and reduced ischemic stroke recurrence.

METHODS

A single-center retrospective cohort study involving 256 cases from 336 Chinese in-patients who had ischemic stroke with ICH history in Beijing Chaoyang Hospital, Beijing, China between May 2005 and October 2009 was conducted. Subjects were divided into 2 groups (with AP and without AP), followed by stroke events for 12-38 months. Logistic regression analysis was used to evaluate the effects of AP on cerebral infarction and ICH recurrence.

RESULTS

The AP agent did not increase ICH recurrence in the secondary prevention of ischemic stroke with ICH history (odds ratio [OR] 1.431, confidence interval [CI] 0.198-2.467, p=0.577). Hypertension and lobar hemorrhage were risk factors of ICH recurrence. However, there was no statistical difference between recurrence of lobar hemorrhage and AP use (x2=0.516, p=0.468). The AP agent significantly decreased the incidence of cerebral infarction (OR 0.424, CI 0.190-0.950, p=0.037).

CONCLUSION

The AP agents may be beneficial to secondary prevention of ischemic stroke with ICH history, with no increased incidence of cerebral hemorrhage. It would be safer to maintain blood pressure in the normal range and to exclude lobar hemorrhage when AP is used.

Provision of acute stroke care and associated factors in a multiethnic population: prospective study with the South London Stroke Register

OBJECTIVES

To investigate time trends in receipt of effective acute stroke care and to determine the factors associated with provision of care.

DESIGN

Population based stroke register.

SETTING

South London.

PARTICIPANTS

3800 patients with first ever ischaemic stroke or primary intracerebral haemorrhage registered between January 1995 and December 2009.

MAIN OUTCOME MEASURES

Acute care interventions, admission to hospital, care on a stroke unit, acute drugs, and inequalities in access to care.

RESULTS

Between 2007 and 2009, 5% (33/620) of patients were still not admitted to a hospital after an acute stroke, particularly those with milder strokes, and 21% (124/584) of patients admitted to hospital were not admitted to a stroke unit. Rates of admission to stroke units and brain imaging, between 1995 and 2009, and for thrombolysis, between 2005 and 2009, increased significantly (P<0.001). Black patients compared with white patients had a significantly increased odds of admission to a stroke unit (odds ratio 1.76, 95% confidence interval 1.35 to 2.29, P<0.001) and of receipt of occupational therapy or physiotherapy (1.90, 1.21 to 2.97, P=0.01), independent of age or stroke severity. Patients with motor or swallowing deficits were also more likely to be admitted to a stroke unit (1.52, 1.12 to 2.06, P=0.001 and 1.32, 1.02 to 1.72, P<0.001, respectively). Length of stay in hospital decreased significantly between 1995 and 2009 (P<0.001). The odds of brain imaging were lowest in patients aged 75 or more years (P=0.004) and those of lower socioeconomic status (P<0.001). The likelihood of those with a functional deficit receiving rehabilitation increased significantly over time (P<0.001). Patients aged 75 or more were more likely to receive occupational therapy or physiotherapy (P=0.002).

CONCLUSION

Although the receipt of effective acute stroke care improved between 1995 and 2009, inequalities in its provision were significant, and implementation of evidence based care was not optimal.

[The clinical and ethnic characteristics of elderly and senile patients with discirculatory encephalopathy, living in separate regions of the Sakha (Yakutia) Republic]

The clinical and ethnic characteristics of patients with discirculatory encephalopathy in separate regions of The Republic Sakha (Yakutia) were studied. The analysis of risk factors has shown that the leading reasons of vascular defeat of a brain in all surveyed patients were the atherosclerosis and an arterial hypertension. However, in the patients living in Northern areas of The Republic Sakha (Yakutia) where the ecological situation has remained better, these risk factors were present less often. Clinical symptoms of discirculatory encephalopathy, as well as numerous subjective and clinical displays, have been most expressed in the patients living in Viljujsky region of the Republic, adverse ecologically.

Race- and sex-specific associations of obesity measures with ischemic stroke incidence in the Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND PURPOSE

Studies have suggested differences in the association between obesity and ischemic stroke in black versus white populations. In this study, we explored ischemic stroke risk in relation to a variety of obesity measures by sex and race.

METHODS

Using data from the Atherosclerosis Risk in Communities Study, we obtained information on body mass index, waist circumference, and waist-to-hip ratio from 13 549 black and white participants who were aged 45 to 65 years between 1987 and 1989. All were free of cardiovascular disease and cancer at baseline. Incident strokes over a median follow-up of 16.9 years were ascertained from hospital records.

RESULTS

Although crude incidence rates of ischemic stroke varied more than 3-fold by race and sex, the relationship between higher measures of obesity and ischemic stroke risk was positive and linear across all groups. The crude incidence of ischemic stroke was 1.2 per 1000 person-years for white women with the lowest body mass index, ranging up to 8.0 per 1000 person-years for black men with the highest body mass index. Hazard ratios for the highest versus lowest quintile of body mass index, waist circumference, and waist-to-hip ratio ranged from 1.43 to 3.19, indicating increased stroke risk associated with obesity, however it was measured, even after adjustment for potential confounders. Additional adjustment for factors that may mediate the relationship, such as diabetes and hypertension, significantly attenuated the associations, suggesting that these factors may explain much of the stroke risk associated with obesity.

CONCLUSIONS

Degree of obesity, defined by body mass index, waist circumference, or waist-to-hip ratio, was a significant risk factor for ischemic stroke regardless of sex or race.