Serum Albumin and Post-Stroke Outcomes: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis

Hypoalbuminemia associates with poor acute ischemic stroke (AIS) outcomes. We hypothesised a non-linear relationship and aimed to systematically assess this association using prospective stroke data from the Norfolk and Norwich Stroke and TIA Register. Consecutive AIS patients aged ≥40 years admitted December 2003-December 2016 were included. Outcomes: In-hospital mortality, poor discharge, functional outcome (modified Rankin score 3-6), prolonged length of stay (PLoS) > 4 days, and long-term mortality. Restricted cubic spline regressions investigated the albumin-outcome relationship. We updated a systematic review (PubMed, Scopus, and Embase databases, January 2020-June 2023) and undertook a meta-analysis. A total of 9979 patients were included; mean age (standard deviation) = 78.3 (11.2) years; mean serum albumin 36.69 g/L (5.38). Compared to the cohort median, albumin < 37 g/L associated with up to two-fold higher long-term mortality (HRmax; 95% CI = 2.01; 1.61-2.49) and in-hospital mortality (RRmax; 95% CI = 1.48; 1.21-1.80). Albumin > 44 g/L associated with up to 12% higher long-term mortality (HRmax1.12; 1.06-1.19). Nine studies met our inclusion criteria totalling 23,597 patients. Low albumin associated with increased risk of long-term mortality (two studies; relative risk 1.57 (95% CI 1.11-2.22; I2 = 81.28)), as did low-normal albumin (RR 1.10 (95% CI 1.01-1.20; I2 = 0.00)). Strong evidence indicates increased long-term mortality in AIS patients with low or low-normal albumin on admission.

Sex-specific lifetime risk of cardiovascular events: the European Prospective Investigation into Cancer-Norfolk prospective population cohort study

AIMS

Better understanding of sex differences in cardiovascular disease (CVD) is essential in tailoring appropriate preventative strategies. Using a large population-based study with follow-up >25 years, we aimed to determine sex-specific lifetime risks of incident CVD and cardiovascular (CV) mortality amongst populations with and without prevalent CVD.

METHODS AND RESULTS

Participants were drawn from the European Prospective Investigation into Cancer-Norfolk and followed up for a median of 26.2 years. Sex-specific lifetime risks were ascertained accounting for the competing risk of death. Models were adjusted for ethnicity and time-updated covariates: material deprivation, CV risk factors, lifestyle factors, comorbidities, and medication. A total of 23 859 participants [54.5% women; mean age (standard deviation) 59.2 (9.3) years at baseline] were included. Adjusted lifetime risks of incident CVD were higher in men than in women (69.1 vs. 57.7% at age 75): cause-specific hazard ratio (cHR) (99% confidence interval)-1.49 (1.41-1.57), while the risks of CV mortality at age 75 were 4.4% (men) and 3.1% (women): cHR-1.42 (1.31-1.54). Myocardial infarction was the predominant first presentation in men until the eighth decade. In women, the first CVD manifestations after their sixth decade were predominantly atrial fibrillation and stroke. The male-associated excess relative risks of incident CVD and CV mortality were halved in people with prevalent CVD.

CONCLUSION

We characterized the sex-specific lifetime CV risks in a large cohort. Men had substantially higher risk of incident CVD and CV mortality than women, which was attenuated amongst people with prevalent CVD. Our findings provide an evidence base for sex-specific CV prevention.

Orthostatic hypertension and major adverse events: A systematic review and meta-analysis

INTRODUCTION

The role of orthostatic hypertension (OHT) in cardiovascular disease (CVD) and mortality is unclear. We aimed to determine if this association exists through a systematic review and meta-analysis.

METHODS

Study inclusion criteria included: (i) any observational/interventional studies of participants aged ≥18 years (ii) which assessed the relationship between OHT and (iii) at least one outcome measure - all-cause mortality (primary outcome), coronary heart disease, heart failure, stroke/cerebrovascular disease, or neurocognitive decline. MEDLINE, EMBASE, Cochrane, clinicaltrials.gov and PubMed were independently searched by two reviewers (inception-19th April 2022). Critical appraisals were conducted using the Newcastle-Ottawa Scale. Random-effects meta-analysis was performed using a generic inverse variance method, and narrative synthesis, or pooled results were presented as an odds or hazards ratio (HR/OR), with 95% confidence interval.

RESULTS

Twenty studies (n = 61669; 47.3% women) were eligible, of which thirteen were included in the meta-analysis (n = 55456; 47.3% women). Median (IQR) follow-up for prospective studies was 7.85 (4.12, 10.83) years. Eleven studies were of good quality, eight fair and one poor. Relative to orthostatic normotension (ONT), systolic OHT (SOHT) was associated with a significant 21% greater risk of all-cause mortality (HR:1.21,1.05-1.40), 39% increased risk of CVD mortality based on 2 studies (HR:1.39, 1.05-1.84) and near doubled odds of stroke/cerebrovascular disease (OR:1.94, 1.52-2.48). Lack of association with other outcomes may be due to weak evidence or low statistical power.

CONCLUSIONS

Patients with SOHT may have higher mortality risk relative to those with ONT and increased odds of stroke/cerebrovascular disease. Whether interventions can reduce OHT and improve outcomes should be explored.

Race and sex disparities in acute outcomes of patients with acute ischemic stroke and diabetes mellitus. A national inpatient sample study

BACKGROUND

Diabetes Mellitus (DM) disproportionately affects racial minority groups and is a well-established risk factor for ischemic stroke and worse stroke outcomes. Whether racial disparities exist in acute outcomes of patients presenting with Acute Ischemic Stroke (AIS) and comorbid DM, including potential differences in the administration of evidence-based reperfusion therapy, remains unclear. We aimed to assess whether racial and sex differences exist in the acute outcomes and treatment of patients with DM presenting with AIS.

METHODS

January 2016-December 2018 AIS admissions with diabetes were extracted from the US National Inpatient Sample (NIS). Multivariable logistic regressions assessed the association between race, sex, and differences in in-hospital outcomes (mortality, hospitalisation >4 days, routine discharge, and stroke severity). Further models assessed the relationship between race, sex, and receipt of thrombolysis and thrombectomy. All models were adjusted for relevant confounders, including comorbidities and stroke severity.

RESULTS

92,404 records representative of 462,020 admissions were extracted. Median (IQR) age was 72 (61-79), with 49 % women, 64 % White, 23 % African American, and 10 % Hispanic patients. African Americans had lower odds of in-hospital mortality compared to Whites (adjusted odds ratio; 99 % confidence interval=0.72;0.61-0.86), but were more likely to have prolonged hospitalisation (1.46;1.39-1.54), be discharged to locations other than home (0.78;0.74-0.82) and have moderate/severe stroke (1.17;1.08-1.27). Additionally, African American (0.76;0.62-0.93) and Hispanic patients (0.66;0.50-0.89) had lower odds of receiving thrombectomy. Compared to men, women had increased odds of in-hospital mortality (1.15;1.01-1.32).

CONCLUSIONS

Racial and sex disparities exist in both evidence-based reperfusion therapy and in-hospital outcomes amongst patients with AIS and diabetes. Further measures are needed to address these disparities and reduce the excess risk of adverse outcomes among women and African American patients.

Body Fat Percentage and the Long-term Risk of Fractures. The EPIC-Norfolk Prospective Population Cohort Study

BACKGROUND

This cohort study aimed to determine the association between body fat percentage (BF%), incident fractures and calcaneal broadband ultrasound attenuation (BUA).

METHODS

Participants were drawn from the EPIC-Norfolk Prospective Population Cohort Study (median follow-up = 16.4 years). Cox models analysed the relationship between BF% and incident fractures (all and hip). Linear and restricted cubic spline (RCS) regressions modelled the relationship between BF% and BUA.

RESULTS

14,129 participants (56.2 % women) were included. There were 1283 and 537 incident all and hip fractures respectively. The participants had a mean (standard deviation) age of 61.5 (9.0) years for women and 62.9 (9.0) years for men. Amongst men, BF% was not associated with incident all fractures. While BF% < 23 % (median) was not associated with hip fractures, BF% > 23 % was associated with increased risk of hip fractures by up to 50 % (hazard ratio (95 % confidence interval) = 1.49 (1.06-2.12)). In women, BF% < 39 % (median) was associated with up to 32 % higher risk of all fractures (1.32 (1.13-1.44)), while BF% > 35 % was not associated with this outcome. Higher BF% was associated with lower risk of incident hip fractures in women. Higher BF% was associated with higher BUA amongst women. Higher BF% up to ~23 % was associated with higher BUA amongst men.

CONCLUSIONS

Higher BF% is associated with lower risk of fractures in women. While there was no association between BF% and all fractures in men, increasing BF% >23 % was associated with higher risk of hip fractures in men. This appears to be independent of estimated bone mineral density. Fracture prevention efforts need to consider wider physical, clinical, and environmental factors.

[Sex differences in stroke mortality in Thailand : A National cohort study]

BACKGROUND

Over half of the growing global stroke-mortality burden is accounted for by the East-Asian-subcontinent alone. Sex differences in stroke-mortality in the Asian population is yet to be assessed in the literature. We aimed to assess the sex-differences in mortality following stroke in a large cohort of Thai-patients.

METHOD

All stroke admissions between 2004-2015 were included from the Thailand public-health-insurance-database. The association between sex and mortality was assessed in-hospital, at 1 month, 1 year and 5 years, using multivariable Cox-regressions, separately for ischaemic-stroke (IS), haemorrhagic-stroke (HS) and stroke-of-undetermined-type(SUT), adjusting for confounders.

RESULTS

608,890 patients were included: 370,527 patients with IS(60.9%), 173,236 with HS(28.5%) and 65,127 with SUT(10.6%). Women were older than men in all three groups and had higher prevalence of comorbidities. Adjusted hazard-ratios(HRs) of mortality showed women had higher mortality post-IS compared to men (in-hospital: HR: 1.20; 95% CI: 1.17-1.23; 1 month: HR: 1.17; 95% CI: 1.15-1.20; 1 year: HR: 1.10; 95% CI: 1.09-1.12 and 5 years: HR: 1.02; 95% CI: 1.01-1.03). Women also had higher mortality after HS (in-hospital: HR: 1.02; 95% CI: 1.00-1.04; 1 month: HR: 1.08; 95% CI: 1.06-1.10; 1 year: HR: 1.04; 95% CI: 1.03-1.06 and 5 years: HR: 1.09; 95% CI: 1.08-1.11), and SUT (in-hospital: HR: 1.04; 95% CI: 1.03-1.06; 1 month: HR: 1.20; 95% CI: 1.14-1.27; 1 year: HR: 1.14; 95% CI: 1.09-1.18 and 5 years: HR: 1.06; 95% CI: 1.03-1.10).

CONCLUSIONS

Compared to men, women were older at time of stroke-diagnosis and had higher burden of stroke risk-factors. Women also had higher mortality after stroke regardless of stroke-type or duration since stroke-onset. Post-IS, excess stroke-mortality in women was greatest during the in-hospital period, whereas excess stroke-mortality increased with time in women who had HS. No clear relationship was found between duration since stroke-onset and mortality in patients who had SUT.

Sex-Specific Outcomes of Acute Stroke in Patients with Systemic Lupus Erythematosus: A National Inpatient Sample Study

Background: Systemic lupus erythematosus (SLE) is an autoimmune disorder associated with increased stroke risk. Its association with stroke outcomes remains poorly understood. In this study, we aimed to compare the sex-specific SLE-associated acute stroke outcomes. Methods: Stroke hospitalisations between 2015 and 2018 from the National Inpatient Sample were analysed. The associations between SLE and outcomes (inpatient mortality, length-of-stay > 4 days and routine discharge) were examined using multivariable logistic regressions, stratifying by sex and adjusting for age, race, stroke type, revascularisation, hospital characteristics and comorbidities. Results: A total of 316,531 records representing 1,581,430 hospitalisations were included. Median (interquartile range) age was 71 (60−82) years. There were 940 (0.06%) males and 6110 (0.39%) females with SLE. There were no associations between SLE and mortality amongst either females (odds ratio (95% confidence interval) = 1.11 (0.84−1.48)) or males (0.81 (0.34−1.94)). Nevertheless, SLE was associated with prolonged hospitalisation (1.17 (1.03−1.32)) and lower odds of routine discharge (0.82 (0.72−0.94)) amongst females. There were no associations between SLE and other adverse outcomes amongst males. Conclusions: The association between SLE and acute stroke outcomes was influenced by sex. While SLE was not associated with mortality in either sex, females with SLE had higher odds of prolonged hospitalisation and lower odds of routine home discharge compared to patients without SLE, while males did not exhibit this increased risk.

Does Estimated Glomerular Filtration Rate Predict In-Hospital Mortality in Acutely Unwell Hospitalized Oldest Old?

Globally the population of older adults is the fastest growing age group. Estimated glomerular filtration rate (eGFR) is an estimation of true kidney function with lower eGFR associated with higher mortality. However, few studies explore eGFR's prognostic value in the nonagenarian. We investigated the association between eGFR on admission and mortality among the nonagenarians hospitalised with acute illness. A retrospective analysis of a prospective cohort study included patients aged ≥ 90 admitted into three acute medical assessment units or acute geriatric wards in England and Scotland between November 2008 and January 2009. Association between eGFR and all-cause mortality was evaluated using the Cox proportional hazard models controlling for potential confounders including frailty. 392 patients with mean (SD) 93.0 ± 2.6 years (68.45% women) were included. The median (IQR) eGFR was 26.61 (18.41-40.41) mL/min/1.73². 63 died in in hospital. Low eGFR was not associated with mortality (Hazard ratio (HR) 1.00 (95% CI 0.98-1.02) overall or in sub-group analysis by frailty (HR 0.96 (0.92-1.01)) or by eGFR of ≤30 (HR 1.01 (0.95-1.06). We found no evidence of prognostic value of eGFR in predicting in-hospital mortality in the acutely unwell hospitalised nonagenarians.

The relationship between nutritional status at the time of stroke on adverse outcomes: a systematic review and meta-analysis of prospective cohort studies

CONTEXT AND OBJECTIVE

The impact of existing malnutrition on stroke outcomes is poorly recognised and treated. Evidence was systematically reviewed and quantified by meta-analysis.

METHODS

MEDLINE, EMBASE and Web of Science were searched from inception to 11 January 2021 and updated in July. Prospective cohort studies, in English, evaluating anthropometric and biomarkers of nutrition on stroke outcomes were included. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network checklist.

RESULTS

Twenty-six studies (n = 156 249) were eligible (follow-up: One month-14 years). Underweight patients had increased risk of long-term mortality (adjusted hazard ratio = 1.65,1.41-1.95), whilst overweight (0.80,0.74-0.86) and obese patients (0.80,0.75-0.85) had decreased risk compared to normal weight. Odds of mortality decreased in those with high serum albumin (odds ratio = 0.29,0.18-0.48) and increased with low serum albumin (odds ratio = 3.46,1.78-6.74) compared to normal serum albumin (30-35 g/L). Being malnourished compared to well-nourished, as assessed by the Subjective Global Assessment (SGA) or by a combination of anthropometric and biochemical markers increased all-cause mortality (odds ratio = 2.38,1.85-3.06) and poor functional status (adjusted odds ratio = 2.21,1.40-3.49).

CONCLUSION

Nutritional status at the time of stroke predicts adverse stroke outcomes.

Elevated inflammatory biomarkers and poor outcomes in intracerebral hemorrhage

Background

Accumulating evidence suggests that spontaneous intracerebral hemorrhage (ICH) is associated with a reactive neuroinflammatory response. However, it remains unclear if circulating inflammatory biomarkers are associated with adverse outcomes in ICH. To address this knowledge gap, we conducted a cohort study using a prospectively maintained stroke register in the United Kingdom to assess the prognostic value of admission inflammatory biomarkers in ICH.

Methods

The Norfolk and Norwich Stroke and TIA Register recorded consecutive ICH cases. The primary exposures of interest were elevation of white cell count (WCC; > 10 × 10⁹/L), elevation of c-reactive protein (CRP; > 10 mg/L), and co-elevation of both biomarkers, at the time of admission. Modified Poisson and Cox regressions were conducted to investigate the relationship between co-elevation of WCC and CRP at admission and outcomes following ICH. Functional outcome, multiple mortality timepoints, and length of stay were assessed.

Results

In total, 1714 ICH cases were identified from the register. After adjusting for covariates, including stroke-associated pneumonia, co-elevation of WCC and CRP at admission was independently associated with significantly increased risk of poor functional outcome (RR 1.08 [95% CI 1.01–1.15]) and inpatient mortality (RR 1.21 [95% CI 1.06–1.39]); and increased 90-day (HR 1.22 [95% CI 1.03–1.45]), and 1-year mortality (HR 1.20 [95% CI 1.02–1.41]). Individual elevation of WCC or CRP was also associated with poor outcomes.

Conclusions

Elevated inflammatory biomarkers were associated with poor outcomes in ICH. This study indicates that these readily available biomarkers may be valuable for prognostication and underscore the importance of inflammation in ICH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11284-8.

Gender differences in mortality of hospitalised stroke patients. Systematic review and meta-analysis

OBJECTIVE

Gender differences in mortality after stroke remains unclear in the current literature. We therefore aimed to systematically review the gender differences in mortality up to five years after ischaemic (IS) or haemorrhagic stroke (HS) to address this evidence gap.

METHODS

The literature was systematically searched using Ovid EMBASE, Ovid Medline, and Web of Science databases, from inception-November 2021. The quality of evidence was appraised using the CASP Cohort-study checklist. Unadjusted and adjusted odds and hazard ratios were meta-analysed, separately for IS and HS and a subgroup analysis of age-stratified mortality data was conducted.

RESULTS

Forty-one studies were included (n = 8,128,700; mean-age 68.5 yrs; 47.1% female). 37 studies were included in meta-analysis (n = 8, 8008, 110). Compared to men, women who had an IS had lower mortality risk in-hospital (0.94; 95%CI 0.91-0.97), at one-month (0.87; 95%CI 0.77-0.98), 12-months (0.94; 95%CI 0.91-0.98) and five-years (0.93 95%CI 0.90-0.96). The subgroup analysis showed that this gender difference in mortality was present in women ≥ 70 years up to one-month post-IS (in-hospital: 0.94; 95%CI 0.91-0.97; one-month: 0.87; 95% CI 0.77-0.98), however, in women < 70 years this difference was no longer present. Nevertheless, analysis of crude data showed women were at higher risk of mortality in-hospital, at 12-months and five-years (in-hospital: 1.05; 95%CI 1.03-1.07, 12-months: 1.10; 95%CI 1.06-1.14, five-years: 1.06; 95%CI 1.02-1.10). After HS, women had higher mortality risk in-hospital (1.03; 95%CI 1.01-1.04) however, no gender differences were found post-discharge.

CONCLUSION

The gender differences in post-stroke mortality differ by stroke type, age group and follow-up. Crude stroke mortality in women is higher than in men and this appears to be driven by pre-existing comorbidities. In adjusted models, women have a lower mortality risk following IS, independent of duration of follow-up. After HS, women had higher mortality in hospital however, no gender differences after hospital discharge were found.

Higher anticholinergic burden from medications is associated with significant increase in markers of inflammation in the EPIC-Norfolk prospective population-based cohort study

BACKGROUND

Higher medication anticholinergic burden is associated with increased risk of cardiovascular disease and cognitive decline. A mechanistic pathway has not been established. We aimed to determine whether inflammation may mediate these associations.

METHODS

Participants were drawn from the European Prospective Investigation into Cancer, Norfolk cohort (40-79 years at baseline). Anticholinergic burden score (ACB) was calculated at first (1HC) (1993/97) and second (2HC) (1998/2000) health checks. Fibrinogen and C-reactive protein (CRP) were measured during 1HC and tumour necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) during 2HC. Cross-sectional associations between ACB and inflammatory markers were examined for both health checks. Prospective associations were also examined between 1HC ACB and 2HC inflammatory markers. Models were adjusted for age, sex, lifestyle factors, comorbidities and medications.

RESULTS

In total, 17 678 and 22 051 participants were included in cross-sectional analyses for CRP, and fibrinogen, respectively. Furthermore, 5101 participants with data on TNF-α and IL-6 were included in the prospective analyses. Cross-sectionally, compared to ACB = 0, ACB ≥ 4 was associated with higher fibrinogen, beta (95% confidence interval) = 0.134 g/L (0.070, 0.199), CRP 1.175 mg/L (0.715, 1.634), IL-6 0.593 pg/mL (0.254, 0.932) and TNF-α 0.137 pg/mL (0.033, 0.241). In addition, a point increase in ACB was associated with higher levels of all markers. Prospectively, compared to ACB = 0, ACB ≥ 4 was associated with higher IL-6(pg/mL) of 0.019 (-0.323, 0.361) and TNF-α (pg/mL) of 0.202% (0.81, 0.323). A unit increase in ACB was associated with a significantly higher TNF-α and IL-6.

CONCLUSION

Higher ACB was associated with higher inflammatory markers. Inflammation may mediate the relationship between anticholinergic medications and adverse outcomes.

Biomarker Determinants of Early Anthracycline-Induced Left Ventricular Dysfunction in Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVE

Breast cancer is the leading cause of cancer-related mortality amongst women. One of the most common chemotherapeutic agents used to treat breast cancer, anthracyclines, are associated with anthracycline-induced cardiotoxicity (ACIC). The aim of this meta-analysis was to quantify the predictive performance of biomarkers for early ACIC presentation in the breast cancer population.

METHODS

Five databases were searched from inception to 1 January, 2022. Studies reporting the association between worsening left ventricular ejection fraction and biomarker level change were included. Overall, study heterogeneity varied between I² 0 and 78%. The primary outcome was incident left ventricular dysfunction, defined as left ventricular ejection fraction < 50-55% or a 10%-point decrease, in patients with breast cancer with congruent ≥ doubling of biomarker serology levels (growth differentiation factor 15, Galectin-3, pro B-type natriuretic peptide, high-sensitivity cardiac troponin T, placental growth factor, myeloperoxidase, high-sensitivity C-reactive protein, Fms-Related Tyrosine Kinase 1), 3 months after anthracycline exposure, relative to pre-anthracycline exposure levels, expressed as random effects, hazard ratios. The STRING protein interaction database was explored for experimentally validated biomarker interactions.

RESULTS

Of 1458 records screened, four observational studies involving 1167 patients, with a low risk of bias, were included in this systematic review and meta-analysis. Doubling of growth differentiation factor 15 and Galectin-3 levels was associated with an increased risk of early ACIC, hazard ratio 3.74 (95% confidence interval 2.68-5.24) and hazard ratio 4.25 (95% confidence interval 3.1-5.18), respectively. Biomarker interactome analysis identified two putative ACIC biomarkers, neuropilin-1 and complement factor H.

CONCLUSIONS

This is the first meta-analysis quantifying the association of biomarkers and early ACIC presentation in the breast cancer population. This may be of clinical relevance in the timely identification of patients at high risk of ACIC, allowing for closer monitoring and chemotherapy adjustments.

Body Mass Index and Mortality, Recurrence and Readmission after Myocardial Infarction: Systematic Review and Meta-Analysis

The following study aimed to systematically review and meta-analyse the literature on the relations between markers of nutritional status and long-term mortality, recurrence and all-cause hospital readmission following myocardial infarction (MI). Medline, EMBASE and Web of Science were searched for prospective cohort studies reporting the relationship between anthropometric and biochemical markers of nutritional status and nutritional assessment tools on long-term mortality, recurrence and all-cause hospital readmission in adult patients with an MI. Two reviewers conducted screening, data extraction and critical appraisal independently. Random-effects meta-analysis was performed. Twenty-seven studies were included in the qualitative synthesis and twenty-four in the meta-analysis. All eligible studies analysed BMI as their exposure of interest. Relative to normal weight, mortality was highest in underweight patients (adjusted Hazard Ratio (95% confidence interval): 1.42 (1.24–1.62)) and lower in both overweight (0.85 (0.76–0.94)) and obese patients (0.86 (0.81–0.91)), over a mean follow-up ranging from 6 months to 17 years. No statistically significant associations were identified between different BMI categories for the outcomes of recurrence and hospital readmission. Patients with low BMI carried a significant mortality risk post-MI; however due to the known limitations associated with BMI measurement, further evidence regarding the prognostic utility of other nutritional markers is required.

OA18 The sex-specific outcomes of acute stroke in patients with comorbid Systemic Lupus Erythematosus - National Inpatient Sample Study

Background/Aims

Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease with variable presentation and clinical manifestations. Previous research has established the higher risk of incident cardiovascular disease and stroke in SLE patients. However, the evidence on how stroke outcomes differ between SLE and non-SLE patient groups in contemporary practice is limited. Furthermore, given that SLE tends to affect predominantly females, with a female-to-male ratio of 9:1, the question remains if and to what extent stroke outcomes might differ between males and females with SLE. Thus, we aimed to explore sex-specific acute stroke outcomes amongst patients with comorbid SLE.

Methods

A total of 316,531 records representing 1,581,430 acute stroke hospitalisations between 2015 and 2018 from the United States National Inpatient Sample (NIS) were analysed. The primary exposure of interest was comorbid SLE. Patients were grouped according to SLE status and sex (no SLE-reference, male with SLE, female with SLE). Outcome measures of interest (in-patient mortality, length-of-stay in hospital [LoS] and routine home discharge) were examined utilising multivariable logistic regressions, adjusting for age, ethnicity, stroke type, receipt of revascularisation therapies, region, hospital status and 49 comorbidities including major cardiovascular disease.

Results

The median (interquartile range) age was 71 (60-82) years. There were 940 (0.06%) males and 6110 (0.39%) females with SLE. After adjustments, female patients with SLE had 21% increased odds of dying in hospital, adjusted odds ratios (aOR) = 1.21, 95% CI (0.92 - 1.61), whereas the risk of in-patient mortality for male patients with SLE was 24% lower compared to the reference group, aOR = 0.76 (0.32 - 1.81). However, none of the differences in the in-patient mortality were of statistical significance. Secondly, compared to patients without SLE, females with SLE had significantly longer hospitalisation, aOR=1.20 (1.06 - 1.36), while there was no significant difference for males with SLE, aOR=1.06 (0.75 - 1.49). The odds of being routinely discharged were 28% lower for females with SLE, aOR=0.72, (0.63 - 0.82), in comparison to a non-significant increase in the odds of 18% for males with SLE, aOR=1.18, (0.84 - 1.65).

Conclusion

Our results highlight the sex differences in acute stroke outcomes in patients with SLE. Due to a small sample size of males with SLE, our findings need to be cautiously interpreted. Further understanding of the influence of SLE amongst male patients with acute stroke is needed.

Disclosure

S. Jesenakova: None. T.A. Pana: None. B. Carter: None. M.O. Mohamed: None. M.A. Mamas: None. P.K. Myint: None.

Thrombolysis in acute ischaemic stroke patients with chronic kidney disease

OBJECTIVE

We aimed to determine whether chronic kidney disease (CKD) is associated with adverse in-hospital outcomes after acute ischaemic stroke (AIS) and whether this association is dependent on thrombolysis administration.

METHODS

885,537 records representative of 4,283,086 AIS admissions were extracted from the US National Inpatient Sample (2005-2015) and categorized into 3 mutually exclusive groups: no CKD, CKD without end-stage renal disease (ESRD) and ESRD. Outcomes (mortality, prolonged hospitalisation >4 days and disability on discharge-derived using discharge destination as a proxy) were compared between groups using multivariable logistic regressions. Separate models containing interaction terms with thrombolysis were also computed.

RESULTS

The median age (interquartile range) of the cohort was 73 (61-83) years and 47.32% were men. Compared with the no CKD group, both CKD/no ESRD group (odds ratio (99% confidence interval) = 1.04 (1.0003-1.09), p = 0.009) and the ESRD groups (2.06 (1.90-2.25), p < 0.001) had significantly increased odds of in-hospital mortality. Patients with CKD/No ESRD (1.03 (1.02-1.06), p < 0.001) and ESRD (1.44 (1.37-1.51), p < 0.001) were at higher odds of prolonged hospitalisation. Patients with CKD/No ESRD (1.13 (1.10-1.15), p < 0.001) and ESRD (1.34 (1.26-1.41), p < 0.001) were also at higher odds of moderate-to-severe disability on discharge. Interaction terms between thrombolysis and the CKD/ESRD groups were not statistically significant (p > 0.01) for any outcome.

CONCLUSIONS

Renal dysfunction was independently associated with worse in-hospital outcomes in the acute phase of AIS. These associations were not influenced by the use of thrombolysis as an emergency treatment for AIS. CKD/ESRD should not represent sole contraindications to thrombolysis for AIS.

Shock index predicts up to 90-day mortality risk after intracerebral haemorrhage

BACKGROUND

Shock index (SI - heart rate/systolic blood pressure) has been studied as a measure of haemodynamic status. We aimed to determine whether SI measures within 72 h of admission were associated with adverse outcomes in intracerebral haemorrhage (ICH).

METHODS

Patients were drawn from the Virtual International Stroke Trials Archive-Intracerebral Haemorrhage (VISTA-ICH). Multivariable Cox regressions modelled the relationship between SI (on admission, 24, 48, 72 h) and mortality (at 3-, 7-, and 90-days), 90-day incident pneumonia and cardiovascular events (MACE). Ordinal logistic regressions modelled the relationship between SI and 90-day modified Rankin Scale (mRS).

RESULTS

979 patients were included. Baseline SI was not associated with mortality. 24 h SI > 0.7 was associated with 7-day mortality (hazard ratio (95% confidence interval) = 3.14 (1.37-7.19)). 48 h and 72 h SI > 0.7 were associated with 7-day (4.23 (2.07-8.66) and 3.24 (1.41-7.42) respectively) and 90-day mortality (2.97 (1.82-4.85) and 2.05 (1.26-3.61) respectively). SI < 0.5 at baseline, 48 h and 72 h was associated with decreased pneumonia risk. 24 h and 48 h SI > 0.7was associated with increased MACE risk. 48 h and 72 h SI > 0.7 was associated with increased odds of higher 90-day mRS.

CONCLUSION

Higher-than-normal SI subsequent to initial encounter was associated with higher post-ICH mortality at 3, 7, and 90 days. Lower-than-normal SI was associated with a decreased risk of incident pneumonia.

Distribution, management and outcomes of AMI according to principal diagnosis priority during inpatient admission

BACKGROUND

In recent years, there has been a growing interest in outcomes of patients with acute myocardial infarction (AMI) using large administrative datasets. The present study was designed to compare the characteristics, management strategies and acute outcomes between patients with primary and secondary AMI diagnoses in a national cohort of patients.

METHODS

All hospitalisations of adults (≥18 years) with a discharge diagnosis of AMI in the US National Inpatient Sample from January 2004 to September 2015 were included, stratified by primary or secondary AMI. The International Classification of Diseases, ninth revision and Clinical Classification Software codes were used to identify patient comorbidities, procedures and clinical outcomes.

RESULTS

A total of 10 864 598 weighted AMI hospitalisations were analysed, of which 7 186 261 (66.1%) were primary AMIs and 3 678 337 (33.9%) were secondary AMI. Patients with primary AMI diagnoses were younger (median 68 vs 74 years, P < .001) and less likely to be female (39.6% vs 48.5%, P < .001). Secondary AMI was associated with lower odds of receipt of coronary angiography (aOR 0.19; 95%CI 0.18-0.19) and percutaneous coronary intervention (0.24; 0.23-0.24). Secondary AMI was associated with increased odds of MACCE (1.73; 1.73-1.74), mortality (1.71; 1.70-1.72), major bleeding (1.64; 1.62-1.65), cardiac complications (1.69; 1.65-1.73) and stroke (1.68; 1.67-1.70) (P < .001 for all).

CONCLUSIONS

Secondary AMI diagnoses account for one-third of AMI admissions. Patients with secondary AMI are older, less likely to receive invasive care and have worse outcomes than patients with a primary diagnosis code of AMI. Future studies should consider both primary and secondary AMI diagnoses codes in order to accurately inform clinical decision-making and health planning.

An Ecological Study Assessing the Relationship between Public Health Policies and Severity of the COVID-19 Pandemic

Reliance on government-led policies have heightened during the COVID-19 pandemic. Further research on the policies associated with outcomes other than mortality rates remains warranted. We aimed to determine associations between government public health policies on the severity of the COVID-19 pandemic. This ecological study including countries reporting ≥25 daily COVID-related deaths until end May 2020, utilised public data on policy indicators described by the Blavatnik school of Government. Associations between policy indicators and severity of the pandemic (mean mortality rate, time to peak, peak deaths per 100,000, cumulative deaths after peak per 100,000 and ratio of mean slope of the descending curve to mean slope of the ascending curve) were measured using Spearman rank-order tests. Analyses were stratified for age, income and region. Among 22 countries, containment policies such as school closures appeared effective in younger populations (rs = -0.620, p = 0.042) and debt/contract relief in older populations (rs = -0.743, p = 0.009) when assessing peak deaths per 100,000. In European countries, containment policies were generally associated with good outcomes. In non-European countries, school closures were associated with mostly good outcomes (rs = -0.757, p = 0.049 for mean mortality rate). In high-income countries, health system policies were generally effective, contrasting to low-income countries. Containment policies may be effective in younger populations or in high-income or European countries. Health system policies have been most effective in high-income countries.

An Ecological Study Assessing the Relationship between Public Health Policies and Severity of the COVID-19 Pandemic

Reliance on government-led policies have heightened during the COVID-19 pandemic. Further research on the policies associated with outcomes other than mortality rates remains warranted. We aimed to determine associations between government public health policies on the severity of the COVID-19 pandemic. This ecological study including countries reporting ≥25 daily COVID-related deaths until end May 2020, utilised public data on policy indicators described by the Blavatnik school of Government. Associations between policy indicators and severity of the pandemic (mean mortality rate, time to peak, peak deaths per 100,000, cumulative deaths after peak per 100,000 and ratio of mean slope of the descending curve to mean slope of the ascending curve) were measured using Spearman rank-order tests. Analyses were stratified for age, income and region. Among 22 countries, containment policies such as school closures appeared effective in younger populations (r_s = -0.620, p = 0.042) and debt/contract relief in older populations (r_s = -0.743, p = 0.009) when assessing peak deaths per 100,000. In European countries, containment policies were generally associated with good outcomes. In non-European countries, school closures were associated with mostly good outcomes (r_s = -0.757, p = 0.049 for mean mortality rate). In high-income countries, health system policies were generally effective, contrasting to low-income countries. Containment policies may be effective in younger populations or in high-income or European countries. Health system policies have been most effective in high-income countries.

Long Term Prognostic Impact of Sex-specific Longitudinal Changes in Blood Pressure. The EPIC-Norfolk Prospective Population Cohort Study

AIMS

We aimed to determine the sex differences in longitudinal systolic and diastolic blood pressure (SBP and DBP) trajectories in mid-life and delineate the associations between these and mortality (all-cause, cardiovascular, and non-cardiovascular) and incident cardiovascular disease (CVD) in old age.

METHODS AND RESULTS

Participants were selected from the European Prospective Investigation into Cancer, Norfolk (EPIC-Norfolk) cohort study. Sex-specific trajectories were determined using group-based trajectory models using three clinic BP measurements acquired between 1993 and 2012 (mean exposure ∼12.9 years). Multivariable Cox regressions determined the associations between trajectories and incident outcomes over the follow-up (median follow-up 9.4 years). A total of 2897 men (M) and 3819 women (F) were included. At baseline, women were younger (F-55.5, M-57.1), had a worse cardiometabolic profile and were less likely to receive primary CVD prevention including antihypertensive treatment (F-36.0%, M-42.0%). Over the exposure period, women had lower SBP trajectories while men exhibited more pronounced SBP decreases over this period. Over the follow-up period, women had lower mortality (F-11.9%, M-20.5%) and CVD incidence (F-19.8%, M-29.6%). Compared to optimal SBP (≤120 mmHg) and DBP (≤70 mmHg) trajectories, hypertensive trajectories were associated with increased mortality and incident CVD in both men and women during follow-up at univariable level. These associations were nevertheless not maintained upon extensive confounder adjustment including antihypertensive therapies.

CONCLUSION

We report sex disparities in CVD prevention which may relate to worse cardiometabolic profiles and less pronounced longitudinal SBP decreases in women. Effective anti-hypertensivetherapy may offset the adverse outcomes associated with prolonged exposure to high blood pressure.

Calcium intake, calcium supplementation and cardiovascular disease and mortality in the British population: EPIC-norfolk prospective cohort study and meta-analysis

The role of dietary calcium in cardiovascular disease prevention is unclear. We aimed to determine the association between calcium intake and incident cardiovascular disease and mortality. Data were extracted from the European Prospective Investigation of Cancer, Norfolk (EPIC-Norfolk). Multivariable Cox regressions analysed associations between calcium intake (dietary and supplemental) and cardiovascular disease (myocardial infarction, stroke, heart failure, aortic stenosis, peripheral vascular disease) and mortality (cardiovascular and all-cause). The results of this study were pooled with those from published prospective cohort studies in a meta-analsyis, stratifying by average calcium intake using a 700 mg/day threshold. A total of 17,968 participants aged 40-79 years were followed up for a median of 20.36 years (20.32-20.38). Compared to the first quintile of calcium intake (< 770 mg/day), intakes between 771 and 926 mg/day (second quintile) and 1074-1254 mg/day (fourth quintile) were associated with reduced all-cause mortality (HR 0.91 (0.83-0.99) and 0.85 (0.77-0.93), respectively) and cardiovascular mortality [HR 0.95 (0.87-1.04) and 0.93 (0.83-1.04)]. Compared to the first quintile of calcium intake, second, third, fourth, but not fifth quintiles were associated with fewer incident strokes: respective HR 0.84 (0.72-0.97), 0.83 (0.71-0.97), 0.78 (0.66-0.92) and 0.95 (0.78-1.15). The meta-analysis results suggest that high levels of calcium intake were associated with decreased all-cause mortality, but not cardiovascular mortality, regardless of average calcium intake. Calcium supplementation was associated with cardiovascular and all-cause mortality amongst women, but not men. Moderate dietary calcium intake may protect against cardiovascular and all-cause mortality and incident stroke. Calcium supplementation may reduce mortality in women.

Prognosis of Acute Ischaemic Stroke Patients with Cancer: A National Inpatient Sample Study

Whilst cancer is a risk factor for acute ischaemic stroke (AIS), its impact on AIS prognosis between metastatic and non-metastatic (MC and NMC) disease is poorly understood. Furthermore, the receipt of intravenous thrombolysis (IVT) and endovascular thrombectomy (ET) and their outcomes is poorly researched. AIS admissions from the National Inpatient Sample (NIS) were included (October 2015-December 2017). Multivariable logistic regressions adjusting for a wide range of confounders analysed the relationship between NMC and MC and AIS in-hospital outcomes (mortality, prolonged hospitalisation >4 days and routine home discharge). Interaction terms with IVT and ET were also computed to explore their impact amongst cancer patients. A total of 221,249 records representative of 1,106,045 admissions were included. There were 38,855 (3.51%) AIS admissions with co-morbid cancer: NMC = 53.78% and MC = 46.22%. NMC was associated with 23% increased odds of in-hospital mortality (odds ratio (95% confidence interval) = 1.23 (1.07-1.42)), which was mainly driven by pancreatic and respiratory cancers. This association was entirely offset by both IVT and ET. MC was associated with two-fold increased odds of in-hospital mortality (2.16 (1.90-2.45)), which was mainly driven by respiratory, pancreatic and colorectal cancers. This association was only offset by ET. Both NMC and MC were significantly associated with prolonged hospitalisation and decreased odds of routine discharge. Cancer patients are at higher odds of acute adverse outcomes after AIS and warrant robust primary prevention. IVT and ET improve these outcomes and should thus be offered routinely unless otherwise contraindicated in this group of stroke patients.

Association of Circulating Monocyte Chemoattractant Protein-1 Levels With Cardiovascular Mortality: A Meta-analysis of Population-Based Studies

Importance

Human genetics and studies in experimental models support a key role of monocyte-chemoattractant protein-1 (MCP-1) in atherosclerosis. Yet, the associations of circulating MCP-1 levels with risk of coronary heart disease and cardiovascular death in the general population remain largely unexplored.

Objective

To explore whether circulating levels of MCP-1 are associated with risk of incident coronary heart disease, myocardial infarction, and cardiovascular mortality in the general population.

Data Sources and Selection

Population-based cohort studies, identified through a systematic review, that have examined associations of circulating MCP-1 levels with cardiovascular end points.

Data Extraction and Synthesis

Using a prespecified harmonized analysis plan, study-specific summary data were obtained from Cox regression models after excluding individuals with overt cardiovascular disease at baseline. Derived hazard ratios (HRs) were synthesized using random-effects meta-analyses.

Main Outcomes and Measures

Incident coronary heart disease (myocardial infarction, coronary revascularization, and unstable angina), nonfatal myocardial infarction, and cardiovascular death (from cardiac or cerebrovascular causes).

Results

The meta-analysis included 7 cohort studies involving 21 401 individuals (mean [SD] age, 53.7 [10.2] years; 10 012 men [46.8%]). Mean (SD) follow-up was 15.3 (4.5) years (326 392 person-years at risk). In models adjusting for age, sex, and race/ethnicity, higher MCP-1 levels at baseline were associated with increased risk of coronary heart disease (HR per 1-SD increment in MCP-1 levels: 1.06 [95% CI, 1.01-1.11]; P = .01), nonfatal myocardial infarction (HR, 1.07 [95% CI, 1.01-1.13]; P = .02), and cardiovascular death (HR, 1.12 [95% CI, 1.05-1.20]; P < .001). In analyses comparing MCP-1 quartiles, these associations followed dose-response patterns. After additionally adjusting for vascular risk factors, the risk estimates were attenuated, but the associations of MCP-1 levels with cardiovascular death remained statistically significant, as did the association of MCP-1 levels in the upper quartile with coronary heart disease. There was no significant heterogeneity; the results did not change in sensitivity analyses excluding events occurring in the first 5 years after MCP-1 measurement, and the risk estimates were stable after additional adjustments for circulating levels of interleukin-6 and high-sensitivity C-reactive protein.

Conclusions and Relevance

Higher circulating MCP-1 levels are associated with higher long-term cardiovascular mortality in community-dwelling individuals free of overt cardiovascular disease. These findings provide further support for a key role of MCP-1-signaling in cardiovascular disease.

Sex Differences in Ischemic Stroke Outcomes in Patients With Pulmonary Hypertension

Background The association between systemic hypertension and cerebrovascular disease is well documented. However, the impact of pulmonary hypertension (PH) on acute ischemic stroke outcomes is unknown despite PH being recognized as a risk factor for acute ischemic stroke. We aimed to determine the association between PH and adverse in-hospital outcomes after acute ischemic stroke, as well as whether there are sex differences in this association. Methods and Results Acute ischemic stroke admissions from the US National Inpatient Sample between October 2015 and December 2017 were included. The relationship between PH and outcomes (mortality, prolonged hospitalization >4 days, and routine home discharge) was analyzed using logistic regressions adjusting for demographics, comorbidities, and revascularization therapies. Interaction terms between PH and sex and age groups were also included. A total of 221 249 records representative of 1 106 045 admissions were included; 2.9% of patients had co-morbid PH, and 35.34% of those were male. PH was not associated with in-hospital mortality (odds ratio [OR], 0.96; 95% CI, 0.86-1.09) but was associated with increased odds of prolonged hospitalization (OR, 1.15; 95% CI, 1.09-1.22) and decreased odds of routine discharge (OR, 0.87; 95% CI, 0.81-0.94) for both sexes. Older patients with PH were significantly less likely to be discharged routinely (P=0.028) than their younger counterparts. Compared with female patients with PH, men were 31% more likely to die in hospital (P=0.024). Conclusions PH was not significantly associated with in-hospital mortality but was associated with prolonged hospitalization and adverse discharge status. Male patients with PH were more likely to die in hospital than female patients.

Country-level determinants of the severity of the first global wave of the COVID-19 pandemic: an ecological study

OBJECTIVE

We aimed to identify the country-level determinants of the severity of the first wave of the COVID-19 pandemic.

DESIGN

Ecological study of publicly available data. Countries reporting >25 COVID-19 related deaths until 8 June 2020 were included. The outcome was log mean mortality rate from COVID-19, an estimate of the country-level daily increase in reported deaths during the ascending phase of the epidemic curve. Potential determinants assessed were most recently published demographic parameters (population and population density, percentage population living in urban areas, population >65 years, average body mass index and smoking prevalence); economic parameters (gross domestic product per capita); environmental parameters (pollution levels and mean temperature (January-May); comorbidities (prevalence of diabetes, hypertension and cancer); health system parameters (WHO Health Index and hospital beds per 10 000 population); international arrivals; the stringency index, as a measure of country-level response to COVID-19; BCG vaccination coverage; UV radiation exposure; and testing capacity. Multivariable linear regression was used to analyse the data.

PRIMARY OUTCOME

Country-level mean mortality rate: the mean slope of the COVID-19 mortality curve during its ascending phase.

PARTICIPANTS

Thirty-seven countries were included: Algeria, Argentina, Austria, Belgium, Brazil, Canada, Chile, Colombia, the Dominican Republic, Ecuador, Egypt, Finland, France, Germany, Hungary, India, Indonesia, Ireland, Italy, Japan, Mexico, the Netherlands, Peru, the Philippines, Poland, Portugal, Romania, the Russian Federation, Saudi Arabia, South Africa, Spain, Sweden, Switzerland, Turkey, Ukraine, the UK and the USA.

RESULTS

Of all country-level determinants included in the multivariable model, total number of international arrivals (beta 0.033 (95% CI 0.012 to 0.054)) and BCG vaccination coverage (-0.018 (95% CI -0.034 to -0.002)), were significantly associated with the natural logarithm of the mean death rate.

CONCLUSIONS

International travel was directly associated with the mortality slope and thus potentially the spread of COVID-19. Very early restrictions on international travel should be considered to control COVID-19 outbreaks and prevent related deaths.

Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure

BACKGROUND

Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood.

METHOD

National Inpatient Sample (NIS) AIS admissions (January 2004-September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET).

RESULTS

69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75-85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively.

CONCLUSIONS

We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.

Myocardial infarction after acute ischaemic stroke: Incidence, mortality and risk factors

OBJECTIVES

To determine the risk factor profiles associated with post-acute ischaemic stroke (AIS) myocardial infarction (MI) over long-term follow-up.

METHODS

This observational study includes prospectively identified AIS patients (n = 9840) admitted to a UK regional centre between January 2003 and December 2016 (median follow-up: 4.72 years). Predictors of post-stroke MI during follow-up were examined using logistic and Cox regression models for in-hospital and post-discharge events, respectively. MI incidence was determined using a competing risk non-parametric estimator. The influence of post-stroke MI on mortality was examined using Cox regressions.

RESULTS

Mean age (SD) of study participants was 77.3 (12.2) years (48% males). Factors associated with in-hospital MI (OR [95% CI]) were increasing blood glucose (1.80 [1.17-2.77] per 10 mmol/L), total leucocyte count (1.25 [1.01-1.54] per 10 × 10⁹ /L) and CRP (1.05 [1.02-1.08] per 10 mg/L increase). Age (HR [95% CI] = 1.03 [1.01-1.06]), coronary heart disease (1.59 [1.01-2.50]), chronic kidney disease (2.58 [1.44-4.63]) and cancers (1.76 [1.08-2.89]) were associated with incident MI between discharge and one-year follow-up. Age (1.02 [1.00-1.03]), diabetes (1.96 [1.38-2.65]), congestive heart failure (2.07 [1.44-2.99]), coronary heart disease (1.81 [1.31-2.50]), hypertension [1.86 (1.24-2.79)] and peripheral vascular disease (2.25 [1.40-3.63]) were associated with incident MI between 1 and 5 years after discharge. Diabetes (2.01 [1.09-3.72]), hypertension (3.69 [1.44-9.45]) and peripheral vascular disease (2.46 [1.02-5.98]) were associated with incident MI between 5 and 10 years after discharge. Cumulative MI incidence over 10 years was 5.4%. MI during all follow-up periods (discharge-1, 1-5, 5-10 years) was associated with increased risk of death (respective HR [95% CI] = 3.26 [2.51-4.15], 1.96 [1.58-2.42] and 1.92 [1.26-2.93]).

CONCLUSIONS

In conclusion, prognosis is poor in post-stroke MI. We highlight a range of potential areas to focus preventative efforts.

Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes

Background and Purpose- We aimed to determine individual and combined effects of atrial fibrillation (AF) and heart failure (HF) on acute ischemic stroke outcomes: in-hospital mortality, length-of-stay, and poststroke disability; long-term mortality and stroke recurrence. Methods- Prospective cohort study of patients with acute ischemic stroke admitted to a UK center with a catchment population of ≈900 000 between 2004 and 2016. Exposure groups were patients with neither AF nor HF (reference group), those with AF but without HF, those with HF but without AF, and those with AF+HF. Logistic and Cox regressions were used to model in-hospital and long-term outcomes, respectively. Results- A total of 10 816 patients with a mean age±SD =77.9±12.1 years, 48% male were included. Only 30 (4.9%) of the patients with HF but not AF were anticoagulated at discharge. Both AF (odds ratio, 1.24 [95% CI, 1.07-1.43]), HF (odds ratio, 1.40 [1.10-1.79]), and their combination (odds ratio, 2.23 [1.83-2.72]) were associated with increased odds of in-hospital mortality. All 3 exposure groups were associated with increased length-of-stay, while only AF predicted increased disability (1.36 [1.12-1.64]). Patients were followed for a median of 5.5 and 3.7 years for mortality and recurrence, respectively. Long-term mortality was associated with AF (hazard ratio, 1.45 [95% CI, 1.33-1.59]), HF (2.07 [1.83-2.36]), and their combination (2.20 [1.96-2.46]). Recurrent stroke was associated with AF 1.50 (1.26-1.78), HF (1.33 [1.01-1.75]), and AF with HF (1.62 [1.28-2.07]). Conclusions- The AF-associated excess risk of stroke recurrence was independent of comorbid HF. HF without AF was also associated with a significant risk of recurrence. Anticoagulation for secondary stroke prevention in patients with HF without AF may require further evaluation in a clinical trial setting.

Impact of heart failure on stroke mortality and recurrence

Objective

We aimed to examine the impact of heart failure (HF) on stroke mortality (in-hospital and postdischarge) and recurrence in a national stroke cohort from Thailand.

Methods

We used a large, insurance-based database including all stroke admissions in the public health sector in Thailand between 2004 and 2015. Logistic and Royston-Parmar regressions were used to quantify the effect of HF on in-hospital and long-term outcomes, respectively. All models were adjusted for age, sex and comorbidities and stratified by stroke type: acute ischaemic stroke (AIS) or intracerebral haemorrhage (ICH). Multistate models were constructed using flexible survival techniques to predict the impact of HF on the disease course of a patient with stroke (baseline-[recurrence]-death). Only first-ever cases of AIS or ICH were included in the multistate analysis.

Results

608 890 patients (mean age 64.29±13.72 years, 55.07% men) were hospitalised (370 527 AIS, 173 236 ICH and 65 127 undetermined pathology). There were 398 663 patients with first-ever AIS and ICH. Patients were followed up for a median (95% CI) of 4.47 years (4.45 to 4.49). HF was associated with an increase in postdischarge mortality in AIS (HR [99% CI] 1.69 [1.64 to 1.74]) and ICH (2.59 [2.07 to 3.26]). HF was not associated with AIS recurrence, while ICH recurrence was only significantly increased within the first 3 years after discharge (1.79 [1.18 to 2.73]).

Conclusions

HF increases the risk of mortality in both AIS and ICH. We are the first to report on high-risk periods of stroke recurrence in patients with HF with ICH. Specific targeted risk reduction strategies may have significant clinical impact for mortality and recurrence in stroke.