Secondary Prevention in Patients With Stroke Versus Myocardial Infarction: Analysis of 2 National Cohorts

BACKGROUND

The implementation of preventive therapies among patients with stroke remains inadequately explored, especially when compared with patients with myocardial infarction (MI), despite sharing similar vascular risk profiles. We tested the hypothesis that participants with a history of stroke have a worse cardiovascular prevention profile in comparison to participants with MI.

METHODS AND RESULTS

In cross-sectional analyses within the UK Biobank and All of Us Research Program, involving 14 760 (9193 strokes, 5567 MIs) and 7315 (2948 strokes, 4367 MIs) participants, respectively, we evaluated cardiovascular prevention profiles assessing low-density lipoprotein (<100 mg/dL), blood pressure (systolic, <140 mm Hg; and diastolic, <90 mm Hg), statin and antiplatelet use, and a cardiovascular prevention score that required meeting at least 3 of these criteria. The results revealed that, within the UK Biobank, patients with stroke had significantly lower odds of meeting all the preventive criteria compared with patients with MI: low-density lipoprotein control (odds ratio [OR], 0.73 [95% CI, 0.68-0.78]; P<0.001), blood pressure control (OR, 0.63 [95% CI, 0.59-0.68]; P<0.001), statin use (OR, 0.45 [95% CI, 0.42-0.48]; P<0.001), antiplatelet therapy use (OR, 0.30 [95% CI, 0.27-0.32]; P<0.001), and cardiovascular prevention score (OR, 0.42 [95% CI, 0.39-0.45]; P<0.001). Similar patterns were observed in the All of Us Research Program, with significant differences across all comparisons (P<0.05), and further analysis suggested that the odds of having a good cardiovascular prevention score were influenced by race and ethnicity as well as neighborhood deprivation levels (interaction P<0.05 in both cases).

CONCLUSIONS

In 2 independent national cohorts, patients with stroke showed poorer cardiovascular prevention profiles and lower adherence to guideline-directed therapies compared with patients with MI. These findings underscore the need to explore the reasons behind the underuse of secondary prevention in vulnerable stroke survivors.

Burden of Ischemic and Hemorrhagic Stroke Across the US From 1990 to 2019

Importance

Stroke is a leading cause of death and disability in the US. Accurate and updated measures of stroke burden are needed to guide public health policies.

Objective

To present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and describe trends from 1990 to 2019 by age, sex, and geographic location.

Design, Setting, and Participants

An in-depth cross-sectional analysis of the 2019 Global Burden of Disease study was conducted. The setting included the time period of 1990 to 2019 in the US. The study encompassed estimates for various types of strokes, including all strokes, ischemic strokes, intracerebral hemorrhages (ICHs), and subarachnoid hemorrhages (SAHs). The 2019 Global Burden of Disease results were released on October 20, 2020.

Exposures

In this study, no particular exposure was specifically targeted.

Main Outcomes and Measures

The primary focus of this analysis centered on both overall and age-standardized estimates, stroke incidence, prevalence, mortality, and DALYs per 100 000 individuals.

Results

In 2019, the US recorded 7.09 million prevalent strokes (4.07 million women [57.4%]; 3.02 million men [42.6%]), with 5.87 million being ischemic strokes (82.7%). Prevalence also included 0.66 million ICHs and 0.85 million SAHs. Although the absolute numbers of stroke cases, mortality, and DALYs surged from 1990 to 2019, the age-standardized rates either declined or remained steady. Notably, hemorrhagic strokes manifested a substantial increase, especially in mortality, compared with ischemic strokes (incidence of ischemic stroke increased by 13% [95% uncertainty interval (UI), 14.2%-11.9%]; incidence of ICH increased by 39.8% [95% UI, 38.9%-39.7%]; incidence of SAH increased by 50.9% [95% UI, 49.2%-52.6%]). The downturn in stroke mortality plateaued in the recent decade. There was a discernible heterogeneity in stroke burden trends, with older adults (50-74 years) experiencing a decrease in incidence in coastal areas (decreases up to 3.9% in Vermont), in contrast to an uptick observed in younger demographics (15-49 years) in the South and Midwest US (with increases up to 8.4% in Minnesota).

Conclusions and Relevance

In this cross-sectional study, the declining age-standardized stroke rates over the past 3 decades suggest progress in managing stroke-related outcomes. However, the increasing absolute burden of stroke, coupled with a notable rise in hemorrhagic stroke, suggests an evolving and substantial public health challenge in the US. Moreover, the significant disparities in stroke burden trends across different age groups and geographic locations underscore the necessity for region- and demography-specific interventions and policies to effectively mitigate the multifaceted and escalating burden of stroke in the country.

COVID-19 Infection Is Associated With Poor Outcomes in Patients With Intracerebral Hemorrhage

BACKGROUND

Patients with ischemic stroke and concomitant COVID-19 infection have worse outcomes than those without this infection, but the impact of COVID-19 on hemorrhagic stroke remains unclear. We aimed to assess if COVID-19 worsens outcomes in intracerebral hemorrhage (ICH).

METHODS AND RESULTS

We conducted an observational study of ICH outcomes using Get With The Guidelines Stroke data. We compared patients with ICH who were COVID-19 positive and negative during the pandemic (March 2020-February 2021) and prepandemic (March 2019-February 2020). Main outcomes were poor functional outcome (defined as a modified Rankin scale score of 4 to 6 at discharge), mortality, and discharge to a skilled nursing facility or hospice. The first stage included 60 091 patients with ICH who were COVID-19 negative and 1326 COVID-19 positive. In multivariable analyses, patients with ICH with versus without COVID-19 infection had 68% higher odds of poor outcome (odds ratio [OR], 1.68 [95% CI, 1.41-2.01]), 51% higher odds of mortality (OR, 1.51 [95% CI, 1.33-1.71]), and 66% higher odds of being discharged to a skilled nursing facility/hospice (OR, 1.66 [95% CI, 1.43-1.93]). The second stage included 62 743 prepandemic and 64 681 intrapandemic cases with ICH. In multivariable analyses, patients with ICH admitted during versus before the COVID-19 pandemic had 10% higher odds of poor outcomes (OR, 1.10 [95% CI, 1.07-1.14]), 5% higher mortality (OR, 1.05 [95% CI, 1.02-1.08]), and no significant difference in the risk of being discharged to a skilled nursing facility/hospice (OR, 0.93 [95% CI, 0.90-0.95]).

CONCLUSIONS

The pathophysiology of the COVID-19 infection and changes in health care delivery during the pandemic played a role in worsening outcomes in the patient population with ICH.

Blood pressure-related white matter microstructural disintegrity and associated cognitive function impairment in asymptomatic adults

BACKGROUND AND OBJECTIVES

We aimed to investigate the white matter (WM) microstructural/cytostructural disintegrity patterns related to higher systolic blood pressure (SBP), and whether they mediate SBP effects on cognitive performance in middle-aged adults.

METHODS

Using the UK Biobank study of community-dwelling volunteers aged 40-69 years, we included participants without a history of stroke, dementia, demyelinating disease or traumatic brain injury. We investigated the association of SBP with MRI diffusion metrics: fractional anisotropy (FA), mean diffusivity (MD), intracellular volume fraction (a measure of neurite density), isotropic (free) water volume fraction (ISOVF) and orientation dispersion across WM tracts. Then, we determined whether WM diffusion metrics mediated the effects of SBP on cognitive function.

RESULTS

We analysed 31 363 participants-mean age of 63.8 years (SD: 7.7), and 16 523 (53%) females. Higher SBP was associated with lower FA and neurite density, but higher MD and ISOVF. Among different WM tracts, diffusion metrics of the internal capsule anterior limb, external capsule, superior and posterior corona radiata were most affected by higher SBP. Among seven cognitive metrics, SBP levels were only associated with 'fluid intelligence' (adjusted p<0.001). In mediation analysis, the averaged FA of external capsule, internal capsule anterior limb and superior cerebellar peduncle mediated 13%, 9% and 13% of SBP effects on fluid intelligence, while the averaged MD of external capsule, internal capsule anterior and posterior limbs, and superior corona radiata mediated 5%, 7%, 7% and 6% of SBP effects on fluid intelligence, respectively.

DISCUSSION

Among asymptomatic adults, higher SBP is associated with pervasive WM microstructure disintegrity, partially due to reduced neuronal count, which appears to mediate SBP adverse effects on fluid intelligence. Diffusion metrics of select WM tracts, which are most reflective of SBP-related parenchymal damage and cognitive impairment, may serve as imaging biomarkers to assess treatment response in antihypertensive trials.

A genome-wide association study of frailty identifies significant genetic correlation with neuropsychiatric, cardiovascular, and inflammation pathways

Frailty is an aging-related clinical phenotype defined as a state in which there is an increase in a person's vulnerability for dependency and/or mortality when exposed to a stressor. While underlying mechanisms leading to the occurrence of frailty are complex, the importance of genetic factors has not been fully investigated. We conducted a large-scale genome-wide association study (GWAS) of frailty, as defined by the five criteria (weight loss, exhaustion, physical activity, walking speed, and grip strength) captured in the Fried Frailty Score (FFS), in 386,565 European descent participants enrolled in the UK Biobank (mean age 57 [SD 8] years, 208,481 [54%] females). We identified 37 independent, novel loci associated with the FFS (p < 5 × 10-8), including seven loci without prior described associations with other traits. The variants associated with FFS were significantly enriched in brain tissues as well as aging-related pathways. Our post-GWAS bioinformatic analyses revealed significant genetic correlations between FFS and cardiovascular-, neurological-, and inflammation-related diseases/traits, and subsequent Mendelian Randomization analyses identified causal associations with chronic pain, obesity, diabetes, education-related traits, joint disorders, and depressive/neurological, metabolic, and respiratory diseases. The GWAS signals were replicated in the Health and Retirement Study (HRS, n = 9,720, mean age 73 [SD 7], 5,582 [57%] females), where the polygenic risk score built from UKB GWAS was significantly associated with the FFS in HRS individuals (OR per SD of the score 1.27, 95% CI 1.22-1.31, p = 1.3 × 10-11). These results provide new insight into the biology of frailty by comprehensively evaluating its genetic architecture.

Autoimmune comorbidities associated with sarcoidosis: a case-control study in the All of Us research program

Objective

The degree to which sarcoidosis patients are affected by autoimmune diseases is poorly understood. Prior studies of autoimmune co-morbidities in sarcoidosis have focused on populations outside the USA or have been impeded by small sample sizes and limited scope. This case-control study evaluated the association between sarcoidosis and autoimmune diseases in a large, diverse cohort based in the USA.

Methods

We used data from the All of Us research programme to conduct a case-control study involving patients ≥18 years old, from 2018 to the present, diagnosed with sarcoidosis. Sarcoidosis cases and age-, sex- and race-matched controls were identified in a 1:4 ratio. Autoimmune co-morbidities were compared between sarcoidosis patients and controls in univariable and multivariable analyses using logistic regression. The degree of association was measured using the odds ratio (OR).

Results

A total of 1408 sarcoidosis cases and 5632 controls were included in this study. Seven of 24 examined autoimmune diseases were significantly associated with sarcoidosis in our multivariable analysis (P < 0.05). The composite variable of any autoimmune disease was also significantly associated with sarcoidosis (OR = 2.29, P < 0.001).

Conclusion

We demonstrate an association between sarcoidosis and multiple autoimmune diseases in a large and diverse cohort based in the USA. These results underscore the need for careful screening of sarcoidosis patients for concomitant autoimmune disease.

Polygenic Susceptibility to Hypertension and Blood Pressure Control in Stroke Survivors

BACKGROUND AND OBJECTIVES

Blood pressure (BP) is often not at goal in stroke survivors, leaving individuals vulnerable to additional vascular events. Given that BP is a highly heritable trait, we hypothesize that a higher polygenic susceptibility to hypertension (PSH) leads to worse BP control in stroke survivors.

METHODS

We conducted a study within the UK Biobank evaluating persons of European ancestry who survived an ischemic or hemorrhagic stroke. To model the PSH, we created polygenic risk scores (PRSs) for systolic and diastolic BP using 732 genetic variants. We divided the PRSs into quintiles and used linear/logistic regression to test whether higher PSH led to higher observed BP, uncontrolled BP (systolic BP > 140 mm Hg or diastolic BP > 90 mm Hg), and resistant BP (uncontrolled BP despite being on ≥3 antihypertensive drugs). We conducted an independent replication using data from the Vitamin Intervention for Stroke Prevention (VISP) trial.

RESULTS

We analyzed 5,940 stroke survivors. When comparing stroke survivors with very low vs very high PSH, the mean systolic BP was 137 (SD 18) vs 143 (SD 20, p < 0.001), the mean diastolic BP was 81 (SD 10) vs 84 (SD 11, p < 0.001), the prevalence of uncontrolled BP was 42.8% vs 57.2% (p < 0.001), and the prevalence of resistant hypertension was 3.9% vs 11% (p < 0.001). Results remained significant using multivariable models (p < 0.001) and were replicated in the VISP study (all tests with p < 0.05).

DISCUSSION

A higher PSH is associated with worse BP control in stroke survivors. These findings point to genetic predisposition as an important determinant of poorly controlled BP in this population.

Abstract WP130: Intracerebral Hemorrhage Outcomes And Trends During The Covid-19 Pandemic. An Observational Study Of 61,417 Cases

Background: Patients with ischemic stroke have worse outcome if there is concomitant coronavirus 2019 (COVID-19) infection. We hypothesize that patients with intracerebral hemorrhage (ICH) during the pandemic era had worse outcomes than ICH patients during the pre-pandemic period, and that concomitant COVID-19 in ICH patients is associated with worse outcome.

Methods: We analyzed data from Get With The Guidelines® Stroke. We implemented a two-stage design: first, we compared outcomes for ICH patients pre-pandemic (admitted between March 2019 and February 2020) with outcomes for ICH patients admitted during the pandemic (from March 2020 to February 2021); second, we compared outcomes of ICH patients with and without COVID-19 infection admitted during the pandemic (from March 2020 to February 2021). We used multivariable logistic regression adjusted by age, sex, race/ethnicity, and clinical covariates for in-hospital mortality and poor functional outcome using the modified Rankin Scale (mRS) at discharge (mRS >= 4) and a for length of stay (LOS).

Results: The first stage included 62,743 pre-pandemic and 64,681 intra-pandemic ICH cases 64,681. ICH patients during the pandemic had worse outcomes, including higher modified rankin scale (mRS) (OR 1.10, CI 1.06-1.14) and higher mortality (OR 1.04, CI 1.01-1.07). The second stage included 60,091 COVID-19-negative and 1,326 COVID-19-positive ICH patients. Patients with concomitant COVID-19 infection had worse outcomes, including higher LOS (RR 1.32, CI 1.25-1.39), high mRS (OR 1.68, CI 1.40-2.01), and increased mortality (OR 1.50, CI 1.33-1.71). (Table).

Conclusion: When comparing pre- and intra-pandemic cases of ICH, critically ill stroke patients admitted during the pandemic had worse outcomes. When comparing COVID-19 positive and negative ICH cases that happened during the pandemic, those with the infection had worse clinical outcomes. COVID-19 infection is an independent risk factor for poor outcomes in ICH.

Migraine among adults with atopic dermatitis: a cross-sectional study in the All of Us research programme

Atopic dermatitis (AD) has been previously associated with migraine headaches in paediatric and adolescent populations, though there is less evidence for this relationship among adults. In this cross-sectional study, we investigated the association between AD and migraine among a cohort of US adults in the All of Us research programme. After controlling for common comorbidities, we found that adults with AD were 89% more likely to have a diagnosis of migraine (OR = 1·89, P < 0·001).

The association of anxiety with granuloma annulare: a case-control study of the National Institutes of Health 'All of Us' research programme

Dear Editor, Granuloma annulare (GA) is an inflammatory skin disease that has been associated with diabetes, dyslipidaemia, hypothyroidism and autoimmune disorders.1,2 The annualized incidence and prevalence of GA in the USA are approximately 0.04% and 0.06%, respectively (with a female predominance).3 GA is clinically classified as localized (75% of cases), generalized or subcutaneous.4 There is a body of evidence supporting an association between several inflammatory dermatoses, such as psoriasis, and mental health conditions.5 Improvement of depression and anxiety following treatment of certain inflammatory dermatoses has also been described.5 It has been postulated that this association may, in part, relate to proinflammatory cytokines, which have been proposed to mechanistically connect inflammatory dermatoses and mental health conditions.6 A recent nested case-control study demonstrated a significant association of GA with depression, insomnia, opioid dependence and post-traumatic stress disorder.7 This study aims to investigate whether an association exists between GA and anxiety.

Association of Chronic Kidney Disease With Risk of Intracerebral Hemorrhage

Importance

The evidence linking chronic kidney disease (CKD) to spontaneous intracerebral hemorrhage (ICH) is inconclusive owing to possible confounding by comorbidities that frequently coexist in patients with these 2 diseases.

Objective

To determine whether there is an association between CKD and ICH risk.

Design, Setting, and Participants

A 3-stage study that combined observational and genetic analyses was conducted. First, the association between CKD and ICH risk was tested in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a multicenter case-control study in the US. All participants with available data on CKD from ERICH were included. Second, this analysis was replicated in the UK Biobank (UKB), an ongoing population study in the UK. All participants in the UKB were included in this study. Third, mendelian randomization analyses were implemented in the UKB using 27 CKD-related genetic variants to test for genetic associations. ERICH was conducted from August 1, 2010, to August 1, 2017, and observed participants for 1 year. The UKB enrolled participants between 2006 and 2010 and will continue to observe them for 30 years. Data analysis was performed from November 11, 2019, to May 10, 2022.

Exposures

CKD stages 1 to 5.

Main Outcomes and Measures

The outcome of interest was ICH, ascertained in ERICH via expert review of neuroimages and in the UKB via a combination of self-reported data and International Statistical Classification of Diseases, Tenth Revision, codes.

Results

In the ERICH study, a total of 2914 participants with ICH and 2954 controls who had available data on CKD were evaluated (mean [SD] age, 61.6 [14.0] years; 2433 female participants [41.5%]; 3435 male participants [58.5%]); CKD was found to be independently associated with higher risk of ICH (odds ratio [OR], 1.95; 95% CI, 1.35-2.89; P < .001). This association was not modified by race and ethnicity. Replication in the UKB with 1341 participants with ICH and 501 195 controls (mean [SD] age, 56.5 [8.1] years; 273 402 female participants [54.4%]; 229 134 male participants [45.6%]) confirmed this association (OR, 1.28; 95% CI, 1.01-1.62; P = .04). Mendelian randomization analyses indicated that genetically determined CKD was associated with ICH risk (OR, 1.56; 95% CI, 1.13-2.16; P = .007).

Conclusions and Relevance

In this 3-stage study that combined observational and genetic analyses among study participants enrolled in 2 large observational studies with different characteristics and study designs, CKD was consistently associated with higher risk of ICH. Mendelian randomization analyses suggest that this association was causal. Further studies are needed to identify the specific biological pathways that mediate this association.

Depression and Anxiety in Patients With Lichen Sclerosus

This case-control study uses data from the National Institutes of Health All of Us Research Program to investigate whether depression and anxiety are associated with lichen sclerosus among women.

Analysis of Clinical Traits Associated With Cardiovascular Health, Genomic Profiles, and Neuroimaging Markers of Brain Health in Adults Without Stroke or Dementia

IMPORTANCE

The American Heart Association (AHA) Life's Simple 7 (LS7) score captures 7 biological and lifestyle factors associated with promoting cardiovascular health.

OBJECTIVES

To test whether healthier LS7 profiles are associated with significant brain health benefits in persons without stroke or dementia, and to evaluate whether genomic information can recapitulate the observed LS7.

DESIGN, SETTING, AND PARTICIPANTS

This genetic association study was a nested neuroimaging study within the UK Biobank, a large population-based cohort study in the United Kingdom. Between March 2006 and October 2010, the UK Biobank enrolled 502 480 community-dwelling persons aged 40 to 69 years at recruitment. This study focused on a subset of 35 914 participants without stroke or dementia who completed research brain magnetic resonance imaging (MRI) and had available genome-wide data. All analyses were conducted between March 2021 and March 2022.

EXPOSURES

The LS7 (blood pressure, low-density lipoprotein cholesterol, hemoglobin A1c, smoking, exercise, diet, and body mass index) profiles were ascertained clinically and genomically. Independent genetic variants known to influence each of the traits included in the LS7 were assessed. The total LS7 score ranges from 0 (worst) to 14 (best) and was categorized as poor (≤4), average (>4 to 9) and optimal (>9).

MAIN OUTCOMES AND MEASURES

The outcomes of interest were 2 neuroimaging markers of brain health: white matter hyperintensity (WMH) volume and brain volume (BV).

RESULTS

The final analytical sample included 35 914 participants (mean [SD] age 64.1 [7.6] years; 18 830 [52.4%] women). For WMH, compared with persons with poor observed LS7 profiles, those with average profiles had 16% (β = -0.18; SE, 0.03; P < .001) lower mean volume and those with optimal profiles had 39% (β = -0.39; SE, 0.03; P < .001) lower mean volume. Similar results were obtained using the genomic LS7 for WMH (average LS7 profile: β = -0.06; SE, 0.014; P < .001; optimal LS7 profile: β = -0.08; SE, 0.018; P < .001). For BV, compared with persons with poor observed LS7 profiles, those with average LS7 profiles had 0.55% (β = 0.09; SE, 0.02; P < .001) higher volume, and those with optimal LS7 profiles had 1.9% (β = 0.14; SE, 0.02; P < .001) higher volume. The genomic LS7 profiles were not associated with BV.

CONCLUSIONS AND RELEVANCE

These findings suggest that healthier LS7 profiles were associated with better profiles of 2 neuroimaging markers of brain health in persons without stroke or dementia, indicating that cardiovascular health optimization was associated with improved brain health in asymptomatic persons. Genomic information appropriately recapitulated 1 of these associations, confirming the feasibility of modeling the LS7 genomically and pointing to an important role of genetic predisposition in the observed association among cardiometabolic and lifestyle factors and brain health.

Prevalence of eczema among adults in the United States: a cross-sectional study in the All of Us research program

INTRODUCTION

Eczema is a cause of significant morbidity in the US but few estimates of eczema prevalence in racially and ethnically diverse adult cohorts exist.

METHODS

We performed a cross-sectional analysis of All of Us. Eczema cases were identified in EHR data using ICD-9-CM 691, 691.8 and 705.8; ICD-10-CM L20, L20.8, L20.9, L30 and L30.1; and SNOMED codes 24079001 and 43116000. We calculated the prevalence of eczema and 95% confidence intervals (CI) among participants across age and self-identified racial and ethnic groups using the Wald method.

RESULTS

Of 203,813 All of Us participants with available EHR data (average age 55 years, standard deviation [SD] 17; 63% female), we identified 11,244 eczema cases with an average age of 59 years (SD 16) and a 2:1 female predominance (68% female).The prevalence of eczema increased with age, ranging from 3.6% (95% CI 3.4-3.8) in those age 18 to 34 to 8.3% (95% CI 8.0-8.7) in those age 75 and older. The prevalence of eczema also varied by race and ethnicity: eczema prevalence was significantly higher in Asian and white participants (6.5% [95% CI 5.9-7.2] and 6.2% [95% CI 6.1-6.4], respectively) compared to Black and Hispanic participants (5.1% [95% CI 4.9-5.3] and 4.1% [3.9-4.3], respectively) (all pairwise comparisons p < 0.001).

CONCLUSION

In the All of Us study, the prevalence of eczema among US adults was 5.4-5.6% and varied by age and race/ethnicity.

Abstract 9: Pervasive White Matter Microstructure Dysintegrity Related To High Blood Pressure Among Asymptomatic Population

Background: Blood pressure is the strongest contributor to clinically evident cerebrovascular disease. We investigated the role of blood pressure on white matter (WM) microstructure among asymptomatic individuals without clinically evident cerebrovascular disease.

Methods: We conducted a nested study within the UK Biobank, restricting our analysis to participants without cerebrovascular disease or dementia and with available brain diffusion tensor imaging (DTI). We tested for association between systolic blood pressure (SBP) and six different DTI metrics: fractional anisotropy (FA), mean diffusivity (MD), tensor mode (MO), intra-cellular volume fraction (ICVF), isotropic or free water volume fraction (ISOVF), and orientation dispersion index (OD) across 48 WM tracts using multivariable linear regression adjusted for potential confounders. We used Bonferroni-corrected p-values (0.05/48) for statistical significance.

Results: We analyzed 33,440 participants. Mean age was 63.0 (SD 7.7), and 17,688 (53%) were female. Higher SBP is independently associated with pervasive decrease in FA and ICVF and increase in MD (Figure), after adjustment for vascular risk-factors. SBP was also associated with lower neurite OD (a more specific metric of axonal damage) in bilateral posterior corona radiata, external capsule, medial lemniscus, and corticospinal tracs. FA and OD of external capsule and posterior corona radiata had the largest drop per 10 mmHg increase of SBP (steepest slope).

Conclusions: Higher SBP is associated with pervasive WM microstructure dysintegrity in asymptomatic individuals without evident cerebrovascular disease. DTI metrics of the posterior corona radiata and external capsule are most reflective of variations in SBP and may provide a potential biomarker to assess subtle WM microstructural damage in hypertensive patients or monitor treatment response in clinical trials.

Abstract 106: Twenty Year Trends In US Stroke Mortality In Younger Vs Older Adults

Introduction: After decades of consistent declines, stroke mortality started to level off beginning in 2013, with increases seen in younger stroke patients.

Methods: We performed a post hoc analysis of county-level stroke death rate per 100,000 adults, for ischemic and hemorrhagic stroke, from 1999-2018 using CDC estimates. We stratified by age 35-64 (young) and ≥65 (old), and by county-level geographic factors and unemployment rate.

Results: We included data from over 3,000 counties. Figure 1 shows stroke mortality began to increase for younger patients in 2013-14, but continued to decline for older patients. The second row shows that the disparity in stroke death rate for younger rural patients was no longer significant from 2005-13 (overlapping 95% CIs), but from 2014-18, younger rural patients had a significantly higher rate of stroke death compared to urban/suburban patients. Younger patients in counties with more unemployment (vs. less) or in the South (vs. other Census regions) had higher rates of stroke death. Figure 2 shows county-level changes by 5-year periods (e.g. 1999-2003 vs. 2004-08), which highlight the spread over time of increased stroke death rate in all regions of the contiguous United States for younger patients.

Conclusions: The trend of consistently decreasing stroke death rate stabilized in 2013, with subsequent increase seen for younger adults aged 35-64, particularly in rural, Southern, and high unemployment counties.

Abstract WP178: Biological Age Influences Clinically-evident And Asymptomatic Cerebrovascular Disease: Combined Analysis In The Uk Biobank And All Of Us

Background: While chronological age is defined by time, biological age (also known as phenotypic age) is defined by biological variables that summarize the status of key physiological processes. Mounting evidence indicates that biological age is a crucial determinant of longevity and other aging-related traits. We hypothesize that biological age influences clinically-evident and asymptomatic cerebrovascular disease.

Methods: We analyzed data from the UK Biobank (discovery) and All of Us (replication) studies. We ascertained ischemic and hemorrhagic stroke using questionnaires and EHR data. In the UK Biobank we also evaluated MRI-defined white matter hyperintensity (WMH) volume and brain volume (BV). We estimated biological age using PhenoAge, a validated tool that integrates information on albumin, creatinine, glucose, C reactive protein, lymphocyte percentage, mean corpuscular volume, red blood cell distribution width, alkaline phosphatase and white blood cell count. Biological age was divided into tertiles and entered in multivariate Cox and linear regression models adjusting for chronological age and vascular risk factors.

Results: The discovery phase included 416,415 UK Biobank participants. Compared to the biologically youngest tertile, the risk of stroke was 17% (HR 1.17, 95%CI 1.04-1.32) and 61% (HR 1.61, 95%CI 1.40-1.86) higher in tertiles 2 and 3 of biological age, respectively (test-for-trend p<0.001). All results were replicated on 56,513 All of Us participants (all associations p<0.05). In 34,095 UK Biobank participants with MRI data, compared to the biologically youngest tertile, those in tertile 2 had 83% (beta 0.003, se 0.014) higher WMH volume and 3.3% (beta -0.012, se 0.013) lower BV, whereas those in tertile 3 had 177% (beta 0.041, se 0.02) higher WMH volume and 5.6% (beta -0.049, se 0.019) lower BV (test-for-trend p<0.001).

Conclusion: Biological age is a significant contributor to clinically evident and silent cerebrovascular disease. Combined interventions targeting the biological processes that determine biological age could result in important synergistic effects for primary and secondary prevention. Further research is needed to determine the role of biological age in stroke outcome and recurrence.

Abstract 103: Burden Of Ischemic And Hemorrhagic Stroke Across The Us From 1990-2019: A Global Burden Of Disease Study

Introduction: We sought to present burden estimates of ischemic and hemorrhagic stroke in the US in 2019 and to describe trends from 1990 to 2019 by age, sex, and geographic location.

Methods: We performed an analysis of the Global Burden of Disease (GBD) 2019 study. Data on stroke incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) from 1990 to 2019 were obtained from the GBD results tool. We measured crude and age-standardized incidence, prevalence, mortality, and DALYs per 100,000 (with 95% uncertainty intervals) for all stroke, ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage from 1990 to 2019.

Results: In the US in 2019, there were 0.46 million (0.40-0.52) incident strokes, of which 67.5% were ischemic (0.31 million [0.26-0.38]), 0.19 million (0.17-0.21) stroke-related deaths and 3.83 million (3.47-4.16) stroke-attributable DALYs. The crude number of incident strokes, prevalent strokes, mortality, and DALYs increased from 1990 to 2019 but age-standardized stroke burden measures declined or remained flat (Figure 1). Trends in stroke incidence, prevalence, mortality, and DALYs varied by age group and geographic location, with stroke incidence decreasing in older adults nationwide and increasing in younger adults (15-49 years) in the South and Midwest US (Figure 2).

Conclusions: While age-standardized measures of stroke burden are decreasing, there is a large and increasing number of people affected by stroke in the US, especially among younger populations in the South and Midwest.Public health efforts to reduce stroke burden across the lifespan should incorporate location-specific stroke trends.

Abstract TP134: Association Of Neutrophil-lymphocyte Ratio With Functional Outcome In Spontaneous Intracerebral Hemorrhage

Introduction: Neutrophil-to-lymphocyte ratio (NLR) is a marker of acute inflammation after brain injury. We sought to evaluate the relationship between NLR at admission and 3-month outcome in patients with spontaneous intracerebral hemorrhage (ICH).

Methods: We pooled individual level data from 2 prospective ICH cohorts, the Acute Brain Injury Biorepository at Yale and Brown ICH registry. We included patients with ICH who had available NLR at admission (exposure of interest) and 3-month modified Rankin Scale (mRS). The primary endpoint was poor outcome at 3-months, defined as mRS 4-6. In each cohort, we fit multivariable logistic regression models to test for association between NLR (natural log transformed and quartiles) and 3-month mRS. Multivariable models were adjusted for sex and components of the ICH score. We then pooled study-specific results using a random-effects (with inverse variance-weighting) meta-analysis.

Results: 592 patients from Brown (69 years [SD 14], 47% female), and 107 patients from Yale (67 years [SD 14], 49% female) were included in the analysis. In the Brown cohort, average ICH volume was 9 cc and 64% of patients had lobar ICH. In the Yale cohort, ICH volume was 10.7 cc and 51% of patients had a lobar ICH. The NLR at admission was 8.21 [SD 9.39] in the Brown cohort and 6.98 [SD 11.35] in the Yale cohort (p=0.230). In the Brown cohort, NLR was associated with poor 3-month outcome in unadjusted (OR 1.28, 95% CI 1.06-1.54, p = 0.01) and adjusted analyses (OR 1.27, 95% CI 1.03-1.57, p = 0.03). In the Yale cohort, NLR yielded similar results in unadjusted (OR 1.80, 95% CI 1.11-2.92, p = 0.02) and adjusted analyses, although not statistically significant (OR 1.90, 95% 0.64-5.63, p = 0.24). Random effect models showed a consistent association in both unadjusted (OR 1.41; 95% CI, 1.04-1.90; p = 0.025; heterogeneity I 2 =40%; Q=1.67, p=0.2) and adjusted analyses (OR 1.29; 95% CI, 1.05-1.59; p=0.016; heterogeneity I 2 =68%; Q=0.49, p=0.48). Compared to the lowest quartile, the highest quartile of NLR had a 20% increase in the odds of having a poor outcome at 3 months (p=0.03).

Conclusions: In a pooled study of two prospective cohorts, NLR was associated with poor functional outcome at 3 months. Future studies are needed to further evaluate NLR as a prognostic marker.

Abstract WP215: Population Attributable Risks For Potentially Modifiable Risk Factors Of Cerebrovascular And Cardiovascular-related Mortality In The National Health And Nutrition Examination Survey

Introduction: Stroke and heart disease are leading causes of mortality in the United States. We studied population attributable risks (PARs) for potentially modifiable stroke and cardiovascular-related mortality risk factors in the National Health and Nutrition Examination Survey (NHANES)-National Death Index (NDI) linked dataset.

Methods: Adult NHANES participants surveyed from 1999-2014 with linked NDI data were included in this sample-level analysis. The primary outcome was death secondary to stroke (ischemic or hemorrhagic) or cardiovascular disease as recorded in NDI. Exposures were behavioral, environmental, clinical, and laboratory variables dichotomized at the sample median collected in NHANES. Missing data were imputed. PARs were calculated using adjusted hazard ratios from Cox proportional models.

Results: We included 47,356 participants (median age 46 years [IQR 30-64]; 51.8% female; 261 stroke- and 1,112 cardiac-related deaths, 2.9%). Mean follow-up time was 97.2 months (SD 54.4 months). Among men < 65 years, characteristics with the top 3 PARs were elevated cholesterol (PAR 42%), elevated systolic blood pressure (PAR 30%), and low platelet count (PAR 23%) (Table 1). Among women < 65 years, not using food label nutritional fact panels (PAR 29%), prescription medication use (PAR 34%), and an elevated white blood cell count (PAR 27%) were the top 3 risk factors by PAR. Among men ≥ 65 years, not using food label nutritional fact panels (PAR 32%), elevated systolic blood pressure (PAR 22%), and cigarette smoking (PAR 20%) were the top 3 factors by PAR. Among women ≥ 65 years, not using food label nutritional fact panels (17%), elevated cholesterol (29%), and elevated creatinine (22%) were the top 3 risk factors by PAR.

Conclusions: We provide age- and sex-specific adjusted PARs of potentially modifiable risk factors of stroke and cardiovascular-related mortality. These findings may inform targeted stroke and cardiovascular risk prevention strategies.

Abstract TMP22: Genetic Predisposition To Cardiovascular Disease Is Associated With Higher Risk Of Stroke In Persons With COVID-19

Background and Purpose: Stroke is a serious complication of COVID-19. However, the risk factors for this complication are poorly understood. We hypothesize that genetic predisposition to cardio- and cerebrovascular disease (CVD) leads to an increased risk of stroke in patients with COVID-19 infection.

Methods: We evaluated data from a nested cohort study conducted within the UK Biobank focused on persons with documented COVID-19. Incident strokes (ischemic and hemorrhagic) were identified by combining inpatient data (including critical care and discharge diagnostic codes) and primary care data, the latter entered by providers within 30 days of a positive COVID-19 test. Genetic predisposition to CVD was evaluated through a polygenic risk score that integrated genomic information on 2,176 independent genetic risk variants for stroke, coronary artery disease and cardiometabolic risk factors. This score was divided into low (0-20 th percentile), intermediate (20 th -80 th percentile), and high (80 th -100 th percentile) genetic risk.

Results: A total of 11,882 study participants (mean age 65.8, SD [8.6], female sex 6,306 [53.1%]) with documented COVID-19 infection were included in this study, including 99 (0.8%) persons that sustained a stroke during the infection. Compared to persons with low genetic predisposition to CVD, those with intermediate and high genetic risk had 35% (OR 1.35, 95%CI 1.14-1.55) and 2.4-fold (OR 2.38, 95% CI 1.71-3.05) higher risk of stroke (test for trend p=0.004). Sub-scoring analyses evaluating one polygenic risk score per CVD trait of interest indicated that genetic predisposition to hypertension (p=0.017) and smoking (p=0.03) were the most important genetic risk factors.

Conclusions: Genetic predisposition to CVD is associated with a higher risk of stroke in persons with acute COVID-19 infection. Genetic risk factors for hypertension and smoking appear to mediate a significant portion of this association. Genetic information should be considered in the multiple ongoing efforts to create risk-stratification strategies to identify COVID-19 patients at high risk of stroke.

Abstract 105: Polygenic Burden Of Hypertension-related Alleles Leads To Non-traumatic Subarachnoid Hemorrhage At Younger Ages

Introduction: Non-traumatic subarachnoid hemorrhage (SAH) is strongly linked to hypertension, a condition highly influenced by common genetic variants. For complex diseases influenced by genetic and environmental factors, genetic predisposition plays a key role in earlier onset. We tested the hypothesis that persons with a higher polygenic burden of hypertension-related alleles have SAH at younger ages.

Methods: We analyzed data from the UK Biobank, a large cohort study that enrolled over 500,000 Britons aged 40-69. We included participants of European descent. We constructed two polygenic risk scores (PRS) using 807 independent genetic variants known to associate with higher systolic and diastolic blood pressure (BP). We fitted linear regression to assess the relationship between these PRS and the age-of-onset of SAH, using product terms to test for interaction with sex. We subsequently implemented Mendelian Randomization analyses using the inverse variance weighted and weighted median methods to evaluate causality.

Results: We evaluated a total of 1,178 SAH cases (mean age, 58; female sex, 722 [61.3%]). When evaluating all participants jointly, there was no association between the systolic BP PRS and age-of-onset for SAH (p=0.130). There was a significant interaction between the PRS and sex (p=0.002): each additional standard deviation of the systolic BP PRS was associated with an earlier onset of SAH in females (beta, -1.45; 95% CI, -2.31 to -0.58; p=0.001), but not in males (adjusted beta, 0.83; 95% CI, -0.37 to 2.02; p=0.176). In MR analyses, a 10mmHg increase in genetically determined systolic BP was associated with a 5-year earlier onset of SAH in female participants using both the inverse variance weighted (beta, -4.72; 95% CI, -7.34 to -2.10; p<0.001) and weighted median approaches (beta, -5.05; 95% CI, -9.19 to -0.90; p=0.017). Analyses with the diastolic BP SNPs yielded comparable results (all p<0.05).

Conclusions: Genetically determined hypertension is associated with earlier onset of non-traumatic SAH in women. These results indicate that genetic predisposition may play a more important causal role in younger patients and point to genetic information as possible tools for early identification of high-risk individuals.

Abstract WP191: Genetic Analyses Support A Causal Role Of Lung Cancer In Ischemic Stroke

Introduction: Lung cancer has been linked to increased risk of thromboembolic events, including stroke. However, a causal relationship between lung cancer and ischemic stroke (IS) has yet to be established.

Methods: We conducted a two-stage study using observational and genetic data from the UK Biobank, a large cohort study that enrolled over 500,000 Britons aged 40-69. We included participants of European descent. In Stage I, we used logistic regression to test the association between self-reported / ICD-defined lung cancer and risk of IS. In Stage II, we constructed a polygenic risk score (PRS) using 31 independent genetic variants known to associate with lung cancer, fitted logistic regression to assess the relationship between this PRS and risk of IS, and implemented the inverse variance weighted method of Mendelian randomization (MR). We tested for horizontal pleiotropy using the MR-Egger and MR Pleiotropy Residual Sum and Outlier (MR-PRESSO) approaches.

Results: Out of 409,629 participants of European descent enrolled in the UK Biobank, there were 5,060 IS cases (mean age, 61.6 [standard deviation 6.5]; female sex, 1813 [35.8%]). The prevalence of lung cancer was 1.9% (n=94) and 0.5% (n=1,961) among persons with and without IS, respectively (unadjusted p<0.001). In multivariable analyses, self-reported / ICD-defined lung cancer was associated with a 54% increase in risk of IS (adjusted OR, 1.54; 95% CI, 1.30-1.81; p<0.001). Genetic analyses supported a causal link between lung cancer and IS. In PRS analysis, each additional standard deviation of the lung cancer-related PRS was associated with a 3% increase in risk of IS (adjusted OR, 1.03; 95% CI, 1.01-1.06; p=0.018). In MR analysis, genetically determined lung cancer was associated with a 5% increase in risk of IS (OR, 1.05; 95% CI, 1.01-1.09; p=0.022). There was no significant horizontal pleiotropy (MR-Egger intercept p=0.663; MR-PRESSO global test p=0.993).

Conclusions: Genetically determined lung cancer is associated with increased risk of ischemic stroke. These findings provide evidence for a causal link between lung cancer and ischemic stroke. Further studies are needed to identify the biological pathways that mediate this link.

Abstract 67: Observed And Genomic Life’S Simple 7 Influence Brain Health-related Neuroimaging Traits In Persons Without Stroke Or Dementia

Background: The AHA Life’s Simple 7 (LS7) promote cardiovascular health. We hypothesized that a better LS7 profile translates into significant brain health benefits in persons without stroke or dementia. We also evaluated whether genomic information can effectively recapitulate the observed LS7.

Methods: We conducted a nested study within the UK Biobank, restricting analysis to stroke- and dementia-free participants with brain MRI and genomic data. We ascertained the LS7 (blood pressure, LDL cholesterol, HbA1c, smoking, exercise, diet and BMI) clinically and genomically. For the latter, we used genetic variants known to influence each trait. The total LS7 score ranges from 0 (poor) to 14 (optimal), and was categorized as poor (≤4), average (4<score≤9) and optimal (>9). We tested for association between observed/genomic LS7 and two neuroimaging markers of brain health: white matter hyperintensities (WMH) volume and brain volume.

Results: We analyzed 35,914 participants. For WMH, compared to persons with poor observed LS7, those with average and optimal had 18% (beta -0.17; se=0.02; p<0.001) and 43% (beta -0.37; se=0.02; p<0.001) lower volumes. Similar results were obtained when using the genomic LS7 (all p<0.001). For brain volume, those with average and optimal LS7 had 0.86% (beta 0.12; se=0.02; p<0.001) and 2.4% (beta 0.18; se=0.02; p<0.001) higher volumes. The genomic LS7 were not associated with brain volume (all p>0.05). Blood pressure and HbA1c were the most powerful contributors to WMH and brain volume, respectively (Figure).

Conclusions: Better LS7 profiles are associated with better profiles of 2 brain health-related neuroimaging markers in persons without stroke/dementia. Genomic information appropriately recapitulated one of these associations. These results emphasize the beneficial role of cardiovascular health optimization in persons without stroke/dementia and point to genomic data as potentially useful to identify high risk individuals.

Association between atopic dermatitis and COVID-19 infection: A case-control study in the All of Us research program

BACKGROUND

There is an incomplete understanding of the risk of COVID-19 infection in atopic dermatitis (AD) patients.

OBJECTIVE

To evaluate the risk of COVID-19 infection in AD patients in a large, diverse cohort.

METHODS

A case-control study of the All of Us cohort to analyze the association between AD and COVID-19. Comorbidities and risk factors were compared between cases and controls using multivariable analyses.

RESULTS

In a cohort of 11,752 AD cases with 47,008 matched controls, AD patients were more likely to have a COVID-19 diagnosis (4.2% vs 2.8%, P < .001). AD remained significantly associated with COVID-19 in multivariable analysis (odds ratio, 1.29; P < .001) after adjusting for demographic factors and comorbidities.

LIMITATIONS

Ascertainment of AD and COVID-19 cases using electronic health records and lack of clinical data on AD severity or therapy and COVID-19 outcomes.

CONCLUSION

AD is associated with increased odds of COVID-19 infection even after controlling for common comorbidities.

Genetically Determined Low-Density Lipoprotein Cholesterol and Risk of Subarachnoid Hemorrhage

We evaluated whether genetically elevated low-density lipoprotein cholesterol (LDL-C) levels are associated with lower risk of intracranial aneurysms and subarachnoid hemorrhage (IA/SAH). We conducted a 2-sample Mendelian randomization (MR) study. Our primary analysis used the inverse-variance weighted method. In secondary analyses, we implemented the MR-PRESSO method, restricted our analysis to LDL-C-specific instruments, and performed multivariate MR. A 1-mmol/l increase in genetically instrumented LDL-C levels was associated with a 17% lower risk of IA/SAH (odds ratio = 0.83, 95% confidence interval = 0.73-0.94, p = 0.004). Results remained consistent in secondary and multivariate analyses (all p < 0.05). Our results provide evidence for an inverse causal relationship between LDL-C levels and risk of IA/SAH. ANN NEUROL 2021.

Cardiovascular Health Disparities in Racial and Other Underrepresented Groups: Initial Results From the All of Us Research Program

Background

All of Us is a novel research program that aims to accelerate research in populations traditionally underrepresented in biomedical research. Our objective was to evaluate the burden of cardiovascular disease (CVD) in broadly defined underrepresented groups.

Methods and Results

We evaluated the latest data release of All of Us. We conducted a cross‐sectional analysis combining survey and electronic health record data to estimate the prevalence of CVD upon enrollment in underrepresented groups defined by race, ethnicity, age (>75 years), disability (not able to carry out everyday physical activities), sexual orientation and gender identity lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA+), income (annual household income <$35 000 US dollars) and education (less than a high school degree). We used multivariate logistic regression to estimate the adjusted odds ratio (OR) and product terms to test for interaction. The latest All of Us data release includes 315 297 participants. Of these, 230 577 (73%) had information on CVD and 17 958 had CVD (overall prevalence, 7.8%; 95% CI, 7.7–7.9). Multivariate analyses adjusted by hypertension, hyperlipidemia, type 2 diabetes mellitus, body mass index, and smoking indicated that, compared with White participants, Black participants had a higher adjusted odds of CVD (OR, 1.21; 95% CI, 1.16–1.27). Higher adjusted odds of CVD were also observed in underrepresented groups defined by other factors, including age >75 years (OR, 1.90; 95% CI, 1.81–1.99), disability (OR, 1.60; 95% CI, 1.53–1.68), and income <$35 000 US dollars (OR, 1.22; 95% CI, 1.17–1.27). Sex significantly modified the odds of CVD in several of the evaluated groups.

Conclusions

Among participants enrolled in All of Us, underrepresented groups defined based on race, ethnicity and other factors have a disproportionately high burden of CVD. The All of Us research program constitutes a powerful platform to accelerate research focused on individuals in underrepresented groups.

Intracerebral Hemorrhage in Patients With COVID-19: An Analysis From the COVID-19 Cardiovascular Disease Registry

[Figure: see text].

Obstructive Sleep Apnea as a Risk Factor for Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

To determine whether obstructive sleep apnea (OSA) is associated with intracerebral hemorrhage (ICH) risk, we assessed premorbid OSA exposure of patients with nontraumatic ICH and matched controls.

METHODS

Ethnic/Racial Variations of Intracerebral Hemorrhage is a multicenter, case-control study evaluating risk factors for ICH that recruited 3000 cases with ICH and 3000 controls. OSA status was ascertained using the Berlin Questionnaire as a surrogate for premorbid OSA. We performed logistic regression analyses to evaluate the association between OSA and ICH.

RESULTS

Two thousand and sixty-four (71%) cases and 1516 (52%) controls were classified as having OSA by the Berlin Questionnaire. Cases with OSA were significantly more likely to be male and have hypertension, heart disease, hyperlipidemia, and higher body mass index compared with those without OSA. OSA was more common among cases compared with controls (71% versus 52%, odds ratio, 2.28 [95% CI, 2.05-2.55]). In a multivariable logistic regression model, OSA was associated with increased risk for ICH (odds ratio, 1.47 [95% CI, 1.29-1.67]).

CONCLUSIONS

OSA is a risk factor for ICH.

Admission Hemoglobin Levels Are Associated With Functional Outcome in Spontaneous Intracerebral Hemorrhage

OBJECTIVES

To test the hypothesis that admission hemoglobin levels are associated with outcome in primary, nontraumatic intracerebral hemorrhage.

DESIGN

Individual patient data meta-analysis of three studies of intracerebral hemorrhage.

SETTING

Two randomized clinical trials and one multiethnic observational study.

PATIENTS

Patients with spontaneous, nontraumatic intracerebral hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our exposure of interest was admission hemoglobin levels and the primary outcome was 3-month postintracerebral hemorrhage-dichotomized modified Rankin Scale (0-3 vs 4-6). Intermediate outcomes were admission hematoma volume and hematoma expansion defined as 6 mL or 33% increase in hemorrhage size on repeat CT. A total of 4,172 intracerebral hemorrhage patients were included in the study (mean age 63 [sd = 14]; female sex 1,668 [40%]). Each additional g/dL of admission hemoglobin was associated with 14% (odds ratio, 0.86; 95% CI, 0.82-0.91) and 7% (odds ratio, 0.93; 95% CI, 0.88-0.98) reductions in the risk of poor outcome in unadjusted and adjusted analyses, respectively. Dose-response analyses indicated a linear relationship between admission hemoglobin levels and poor outcome across the entire evaluated range (test-for-trend p < 0.001). No consistent associations were found between the admission hemoglobin levels and hematoma volume or hematoma expansion.

CONCLUSIONS

Higher hemoglobin levels are associated with better outcome in intracerebral hemorrhage. Further research is needed to evaluate admission hemoglobin levels as both a therapeutic target and predictor of outcome.

Association of Serum IL-6 (Interleukin 6) With Functional Outcome After Intracerebral Hemorrhage

BACKGROUND AND OBJECTIVES

IL-6 (interleukin 6) is a proinflammatory cytokine and an established biomarker in acute brain injury. We sought to determine whether admission IL-6 levels are associated with severity and functional outcome after spontaneous intracerebral hemorrhage (ICH).

METHODS

We performed an exploratory analysis of the recombinant activated FAST trial (Factor VII for Acute ICH). Patients with admission serum IL-6 levels were included. Regression analyses were used to assess the associations between IL-6 and 90-day modified Rankin Scale. In secondary analyses, we used linear regression to evaluate the association between IL-6 and baseline ICH and perihematomal edema volumes.

RESULTS

Of 841 enrolled patients, we included 552 (66%) with available admission IL-6 levels (mean age 64 [SD 13], female sex 203 [37%]). IL-6 was associated with poor outcome (modified Rankin Scale, 4-6; per additional 1 ng/L, odds ratio, 1.30 [95% CI, 1.04-1.63]; P=0.02) after adjustment for known predictors of outcome after ICH and treatment group. IL-6 was associated with ICH volume after adjustment for age, sex, and ICH location, and this association was modified by location (multivariable interaction, P=0.002), with a stronger association seen in lobar (β, 12.51 [95% CI, 6.47-18.55], P<0.001) versus nonlobar (β 5.32 [95% CI, 3.36-7.28], P<0.001) location. IL-6 was associated with perihematomal edema volume after adjustment for age, sex, ICH volume, and ICH location (β 1.22 [95% CI, 0.15-2.29], P=0.03). Treatment group was not associated with IL-6 levels or outcome.

CONCLUSIONS

In the FAST trial population, higher admission IL-6 levels were associated with worse 90-day functional outcome and larger ICH and perihematomal edema volumes.