Risk factors for ischemic stroke: Dubbo Study of the elderly

Psychological distress as a risk factor for death from cerebrovascular disease

BACKGROUND

Little is known about psychological risk factors in cerebrovascular disease. We examined the association between psychological distress and risk of death due to cerebrovascular disease.

METHODS

We obtained data from 68 652 adult participants of the Health Survey for England (mean age 54.9 [standard deviation 13.9] yr, 45.0% male sex) with no known history of cardiovascular diseases at baseline. We used the 12-item General Health Questionnaire (GHQ-12) to assess the presence of psychological distress. We followed participants for eight years for cause-specific death using linkage to national registers.

RESULTS

There were 2367 deaths due to cardiovascular disease during follow-up. Relative to participants with no symptoms of psychological distress (GHQ-12 score 0) at baseline, people with psychological distress (GHQ-12 score ≥ 4, 14.7% of participants) had an increased risk of death from cerebrovascular disease (adjusted hazard ratio [HR] 1.66, 95% confidence interval [CI] 1.32-2.08) and ischemic heart disease (adjusted HR 1.59, 95% CI 1.34-1.88). There was also evidence of a dose-response effect with increasing GHQ-12 score (p for trend < 0.001 in all analyses). Associations were only marginally attenuated after we adjusted for possible confounders, including socioeconomic status, smoking and use of antihypertensive medications.

INTERPRETATION

Psychological distress was associated with increased risk of death due to cerebrovascular disease in a large population-representative cohort. These data suggest that the cardiovascular effects of psychological distress are not limited to coronary artery disease.

Sulfur dioxide and emergency department visits for stroke and seizure

The purpose of this study was to assess an association between ambient sulfur dioxide and the number of emergency department (ED) visits for ischemic stroke and seizure. The study used data collected in a Vancouver (Canada) hospital in the years 1999–2003. Daily ED visits diagnosed as ministroke, stroke, or seizure were investigated using the case-crossover technique. Conditional logistic regression models were applied to estimate the odds ratios (ORs) and their respective 95% confidence intervals (CIs). The models included temperature and relative humidity in the form of natural splines. The results were reported for an increase in interquartile range ((IQR), IQR = 1.9 ppb for SO₂). Positive and statistically significant associations were obtained for SO₂ and ischemic stroke for all patients (OR = 1.12; CI 1.02, 1.23; lag 3) and for female patients (OR = 1.17; CI 1.01, 1.33; lag 0). In the case of ED visits for seizure, for female patients the results were also statistically significant (OR = 1.15; CI 1.02, 1.28; lag 1 and OR = 1.18; CI 1.05, 1.32; lag 2). These findings suggest that cases of ischemic cerebrovascular accidents are associated with acute exposure to ambient sulfur dioxide.

Depression and risk of stroke morbidity and mortality: a meta-analysis and systematic review

CONTEXT

Several studies have suggested that depression is associated with an increased risk of stroke; however, the results are inconsistent.

OBJECTIVE

To conduct a systematic review and meta-analysis of prospective studies assessing the association between depression and risk of developing stroke in adults.

DATA SOURCES

A search of MEDLINE, EMBASE, and PsycINFO databases (to May 2011) was supplemented by manual searches of bibliographies of key retrieved articles and relevant reviews.

STUDY SELECTION

We included prospective cohort studies that reported risk estimates of stroke morbidity or mortality by baseline or updated depression status assessed by self-reported scales or clinician diagnosis.

DATA EXTRACTION

Two independent reviewers extracted data on depression status at baseline, risk estimates of stroke, study quality, and methods used to assess depression and stroke. Hazard ratios (HRs) were pooled using fixed-effect or random-effects models when appropriate. Associations were tested in subgroups representing different participant and study characteristics. Publication bias was evaluated with funnel plots and Begg test.

RESULTS

The search yielded 28 prospective cohort studies (comprising 317,540 participants) that reported 8478 stroke cases (morbidity and mortality) during a follow-up period ranging from 2 to 29 years. The pooled adjusted HRs were 1.45 (95% CI, 1.29-1.63; P for heterogeneity <.001; random-effects model) for total stroke, 1.55 (95% CI, 1.25-1.93; P for heterogeneity = .31; fixed-effects model) for fatal stroke (8 studies), and 1.25 (95% CI, 1.11-1.40; P for heterogeneity = .34; fixed-effects model) for ischemic stroke (6 studies). The estimated absolute risk differences associated with depression were 106 cases for total stroke, 53 cases for ischemic stroke, and 22 cases for fatal stroke per 100,000 individuals per year. The increased risk of total stroke associated with depression was consistent across most subgroups.

CONCLUSION

Depression is associated with a significantly increased risk of stroke morbidity and mortality.

Elevated depressive symptoms and incident stroke in Hispanic, African-American, and White older Americans

Although depressive symptoms have been linked to stroke, most research has been in relatively ethnically homogeneous, predominantly white, samples. Using the United States based Health and Retirement Study, we compared the relationships between elevated depressive symptoms and incident first stroke for Hispanic, black, or white/other participants (N = 18,648) and estimated the corresponding Population Attributable Fractions. The prevalence of elevated depressive symptoms was higher in blacks (27%) and Hispanics (33%) than whites/others (18%). Elevated depressive symptoms prospectively predicted stroke risk in the whites/other group (HR = 1.53; 95% CI: 1.36-1.73) and among blacks (HR = 1.31; 95% CI: 1.05-1.65). The HR was similar but only marginally statistically significant among Hispanics (HR = 1.33; 95% CI: 0.92-1.91). The Population Attributable Fraction, indicating the percent of first strokes that would be prevented if the incident stroke rate in those with elevated depressive symptoms was the same as the rate for those without depressive symptoms, was 8.3% for whites/others, 7.8% for blacks, and 10.3% for Hispanics.

Antioxidant enzymes are differently changed in experimental ischemic hippocampal CA1 region following repeated restraint stress

Restraint stress induces physiological changes in the brain. In the present study, we observed the effects of repeated stress on ischemic damage associated with oxidative stress in gerbils. Animals were placed into restrainers for 5h (between 09:30 h and 14:30 h) for 21 consecutive days prior to 5 min of transient cerebral ischemia. Experimental groups were divided into 4 groups; 1) sham-operated control-group (sham-group), 2) ischemia-operated control-group (ischemia-group), 3) sham-operated stress-group (stressed-sham-group), and 4) ischemia-operated stress-group (stressed-ischemia-group). Serum corticosterone level in the ischemia-group was highest (330% vs the sham-group) at 12h post-ischemia, and serum corticosterone levels in the stressed-ischemia-group were significantly lower than the ischemia-group. Locomotor activity in the ischemia-group was significantly increased (300% vs the sham-group) at 1 day post-ischemia; however, locomotor activity in the stressed-ischemia-group was less increased compared to the ischemia-group. A few NeuN (neuron-specific soluble nuclear antigen)-positive ((+)) cells were found in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) 4 days post-ischemia in the ischemia-group; however, in the stressed-ischemia-group at 4 days post-ischemia, 83.8% of NeuN(+) neurons were found. In addition, we found a few Fluro-Jade B (a marker for neuronal degeneration)(+) and TUNEL(+) cells in the stressed-ischemia-group at 4 days post-ischemia. In gliosis, glial fibrillary acidic protein(+) astrocytes in the stressed-ischemia-groups was similar to the ischemia-groups; however, ionized calcium-binding adapter molecule 1(+) microglia in the stressed-ischemia-groups were much less activated than the ischemia-groups. Among antioxidants, Cu,Zn-superoxide dismutase (SOD1) immunoreactivity in the SP was higher in the stressed-ischemia-groups than the ischemia-groups. Catalase immunoreactivity in the SP of the stressed-ischemia-groups was similar to the ischemia-groups. However, Mn-superoxide dismutase and glutathione peroxidase immunoreactivity were lower than the ischemia-groups. In brief, our results indicate that repeated restraint stress significantly attenuates ischemic neuronal damage and locomotor activity following ischemia. In addition, SOD1 among antioxidants significantly increases in the stressed-ischemia-groups.

Changes in corticosteroid hormone receptors in the ischemic gerbil hippocampal CA1 region following repeated restraint stress

Restraint stress produces physiological changes including suppression of long-term potentiation in the brain. We observed the effects of repeated stress on ischemic damage associated with corticosteroid hormone receptors in gerbils. Animals were placed into restrainers for 5 h (between 09:30 h and 14:30 h) for 21 consecutive days prior to induction of transient cerebral ischemia. The animals were divided into 4 groups; (1) sham-operated-control-group (sham-group), (2) ischemia-operated-control-group (ischemia-group), (3) sham-operated-stress-group (stressed-sham-group), and (4) ischemia-operated-stress-group (stressed-ischemia-group). We found that serum corticosterone level in the ischemia-group was highest (374% of the sham-group) 12 h after ischemia/reperfusion and its level in the stressed-ischemia-group was significantly lower than the ischemia-group. Locomotor activity in the ischemia-group was significantly increased (295% of the sham-group) at 1 day post-ischemia; however, the locomotor activity in the stressed-ischemia-group was less increased compared to the ischemia-group. Cresyl violet positive (CV(+)) cells were significantly decreased in the stratum pyramidale (SP) of the hippocampal CA1 region (CA1) of the 4 days post-ischemia-group, while 79.4% of CV(+) cells were detected in the CA1 of the stressed-ischemia-group. Also, a few NeuN (neuron-specific soluble nuclear antigen)(+) cells were detected in the SP of the 4 days post-ischemia-group; however, in the 4 days stressed-post-ischemia-group, 77.2% of NeuN(+) neurons were found in the SP. Glial fibrillary acidic protein(+) astrocytes in the CA1 in the stressed-ischemia-groups were similar to those in the ischemia-groups; however, ionized calcium-binding adapter molecule 1(+) microglia in the stressed-ischemia-groups were less activated compared to the ischemia-groups. Mineralocorticoid receptor (MCR) and glucocorticoid receptor (GR) immunoreactivity in the SP of the stressed-ischemia-group were higher than the ischemia-group; at 4 days post-ischemia, MCR and GR immunoreactivity were expressed in non-pyramidal cells. In brief, our results indicate that repeated restraint stress significantly increase levels of corticosteroid hormone receptors and attenuates neuronal damage in the ischemic hippocampal CA1 region.

Testosterone and the metabolic syndrome

Metabolic syndrome and testosterone deficiency in men are closely Linked. Epidemiological studies have shown that Low testosterone Levels are associated with obesity, insulin resistance and an adverse Lipid profile in men. Conversely in men with metabolic syndrome and type 2 diabetes have a high prevalence of hypogonadism. Metabolic syndrome and Low testosterone status are both independently associated with increased all-cause and cardiovascular mortality. Observational and experimental data suggest that physiological replacement of testosterone produces improvement in insulin resistance, obesity, dyslipidae-mia and sexual dysfunction along with improved quality of Life. However, there are no Long-term interventional studies to assess the effect of testosterone replacement on mortality in men with Low testosterone Levels. This article reviews the observational and interventional clinical data in relation to testosterone and metabolic syndrome.

The science of stroke: mechanisms in search of treatments

This review focuses on mechanisms and emerging concepts that drive the science of stroke in a therapeutic direction. Once considered exclusively a disorder of blood vessels, growing evidence has led to the realization that the biological processes underlying stroke are driven by the interaction of neurons, glia, vascular cells, and matrix components, which actively participate in mechanisms of tissue injury and repair. As new targets are identified, new opportunities emerge that build on an appreciation of acute cellular events acting in a broader context of ongoing destructive, protective, and reparative processes. The burden of disease is great, and its magnitude widens as a role for blood vessels and stroke in vascular and nonvascular dementias becomes more clearly established. This review then poses a number of fundamental questions, the answers to which may generate new directions for research and possibly new treatments that could reduce the impact of this enormous economic and societal burden.

Triglyceride level modifying functional variants of GALTN2 and MLXIPL in patients with ischaemic stroke

BACKGROUND

Recent genome-wide studies identified several genetic variants associated with blood lipid level alterations. Because affected lipid metabolism can confer risk to the development of ischaemic stroke, we studied three polymorphisms reportedly associated with triglyceride-level changes, rs17145738 and rs3812316 of the MLXIPL locus, and rs4846914 variant of GALNT2 gene in biobanked samples of patients with stroke. This pool of samples was previously investigated for haplotype tagging minor alleles of apolipoprotein A5 gene (T-1131C, T1259C, IVS3+G476A and C56G), and an association was found between the minor allele carriage and the triglyceride levels, and also these variants were found to confer risk to the development of stroke.

METHODS

Here, a total of 467 patients with stroke, stratified as large vessel, small vessel and mixed stroke groups, and 156 control subjects were genotyped using PCR-RFLP methods.

RESULTS

In the current study, we could not verify association of the variants analyzed either with triglyceride and total cholesterol levels or with the risk of ischaemic stroke susceptibility.

CONCLUSIONS

The data presented here revealed differentiated risk nature of the triglyceride level modifying natural gene variants.

Magnetic resonance angiography findings in patients with ischemic stroke from North India

BACKGROUND

We sought to evaluate the magnetic resonance (MR) angiography (MRA) findings in patients with ischemic stroke (IS) from North India and correlate the changes with various conventional and nonconventional risk factors.

METHODS

The study took place at a tertiary care teaching hospital. The patients with IS were clinically evaluated including body mass index, dietary habits, and family history of stroke. MR imaging, MRA, and testing for blood sugar, lipid profile, B12, folic acid, and homocysteine were carried out. The MRA abnormalities were considered significant if stenosis was 50% or greater and these were categorized into extracranial (EC), intracranial (IC), or combined lesions. The location of infarct on MR imaging was also noted.

RESULTS

There were 151 patients whose median age was 60 (22-85) years. The EC MRA was abnormal in 56.3% and the IC MRA in 63.3% of patients, the internal carotid artery being the most common site. Corresponding infarct was present in 64.7% and noncorresponding in 45.3% of patients. The MRA abnormality positively correlated with hypertension and diabetes, and negatively with alcohol consumption. The EC MRA abnormality was more common in upper caste Hindus and Muslims and in the city dwellers.

CONCLUSION

In North Indian patients with IS, the frequency of EC and IC MRA abnormality lies between Whites and the Orientals.

Does depression predict coronary heart disease and cerebrovascular disease equally well? The Health and Social Support Prospective Cohort Study

BACKGROUND

The relationship between depression and cerebrovascular disease (CBVD) continues to be debated although little research has compared the predictive power of depression for coronary heart disease (CHD) with that for CBVD within the same population. This study aimed to compare the importance of depression for CHD and CBVD within the same population of adults free of apparent cardiovascular disease.

METHODS

A random sample of 23,282 adults (9507 men, 13,775 women) aged 20-54 years were followed up for 7 years. Fatal and first non-fatal CHD and CBVD events were documented by linkage to the National-hospital-discharge and mortality registers.

RESULTS

Sex-age-education-adjusted hazard ratio (HR) for CHD was 1.66 [95% confidence interval (CI) 1.24-2.24] for participants with mild to severe depressive symptoms, i.e. those scoring > or =10 on the 21-item Beck Depression Inventory, and 2.04 (1.27-3.27) for those who filled antidepressant prescriptions compared with those without depression markers in 1998, i.e. at study baseline. For CBVD, the corresponding HRs were 1.01 (0.67-1.53) and 1.77 (0.95-3.29). After adjustment for behavioural and biological risk factors these associations were reduced but remained evident for CHD, the adjusted HRs being 1.47 (1.08-1.99) and 1.72 (1.06-2.77). For CBVD, the corresponding multivariable adjusted HRs were 0.87 (0.57-1.32) and 1.52 (0.81-2.84).

CONCLUSIONS

Self-reported depression using a standardized questionnaire and clinical markers of mild to severe depression were associated with an increased risk for CHD. There was no clear evidence that depression is a risk factor for CBVD, but this needs further confirmation.

The Berlin ‘Cream&Sugar’ Study: the Prognostic Impact of an Oral Triglyceride Tolerance Test in Patients after Acute Ischaemic Stroke

Rationale

Stratification according to risk factors is crucial for secondary prevention after acute ischaemic stroke. Nonfasting triglyceride levels seem to be associated with stroke in the general population. However, the exact role of triglyceride levels for the risk of recurrent stroke is unknown.

Hypothesis

We hypothesise that the results of a standardised oral triglyceride tolerance test in the subacute setting (3–7 days) after the first ischaemic stroke are associated with the risk of recurrent stroke within 12 months after the index event.

Design

Prospective observational study.

Study outcome(s)

The primary end-point of the study is recurrent fatal or nonfatal stroke within 12 months. The secondary outcomes are myocardial infarction, coronary revascularisation, cardiovascular death (death due to any cardiovascular or cerebrovascular event), or a transient ischaemic attack within 12 months after the qualifying event.

Discussion

The study has the potential to change clinical practice. It will show whether the oral triglyceride tolerance test in the subacute setting is a useful tool to predict the risk of recurrent stroke.

Vital exhaustion increases the risk of ischemic stroke in women but not in men: results from the Copenhagen City Heart Study

BACKGROUND

Several studies have indicated an association between depression and the development of stroke, but few studies have focused on gender differences, although both depression and stroke are more common in women than in men. The aim of the present study was to describe whether vital exhaustion, a measure of fatigue and depression, prospectively predicts ischemic and hemorrhagic strokes in a large cohort, with particular focus on gender differences.

METHODS

The cohort was composed of 5219 women and 3967 men without cardiovascular disease who were examined in the Copenhagen City Heart Study in 1991-1994. Subjects were followed for 6-9 years. Fatal and nonfatal strokes were ascertained from the Danish National Register of Patients. Cox proportional hazards model was used to describe vital exhaustion as a potential risk factor for stroke.

RESULTS

Four hundred nine validated strokes occurred. A dose-response relationship between vital exhaustion score and the risk of stroke was found in women reaching a hazard ratio (HR) of 2.27 (95% confidence interval: 1.42-3.62) for the group with the highest score. HR was only slightly attenuated by multivariate adjustment. There was no association between vital exhaustion score and stroke in men. HR was strongest for ischemic stroke, whereas no association was seen for hemorrhagic stroke.

CONCLUSION

Vital exhaustion, a measure of fatigue, conveyed an increased risk of ischemic stroke in women, but not in men, in this study sample.

Functional variants of glucokinase regulatory protein and apolipoprotein A5 genes in ischemic stroke

Both the natural variants of the apolipoprotein A5 (APOA5) and the glucokinase regulatory protein gene (GCKR) have been shown to associate with increased fasting triglyceride levels. Here, we investigated the possible association of the functional variants of these two genes with non-fasting triglyceride levels and their susceptibility nature in ischemic stroke. A total of 513 stroke patients and 172 healthy controls were genotyped. All the APOA5 variants (T-1131C, IVS3 + G476A, C56G, and T1259C) were associated with increased triglyceride levels in all stroke patients and controls; except for T1259C, they all conferred risk for the disease. No such association was found for the examined GCKR rs1260326 (C1337T) variant. Furthermore, we examined the effects of specific combinations of the GCKR rs1260326 and APOA5 polymorphisms. Our findings confirmed the previous results regarding the association of APOA5 variants with triglyceride-level increase and stroke susceptibility of these alleles. By contrast, we could not detect any association of the studied GCKR allele with triglyceride levels or with the susceptibility of stroke in the same cohort of patients. In addition, the effect of APOA5 did not change significantly when specific combinations of the two genes were present.

Prospective studies on the relationship between high-density lipoprotein cholesterol and cardiovascular risk: a systematic review

Epidemiological studies have extensively evaluated the association between high-density lipoprotein cholesterol (HDL-C) and cardiovascular disease (CVD) risk. The objective of this systematic review was to enumerate the number of original prospective studies that showed a significant association between HDL-C and CVD risk and provided evidence of the consistency of this association across other lipid risk factors. A systematic MEDLINE literature search identified 53 prospective cohort and five nested case-control studies that provided multivariate assessments of the association between HDL-C and CVD risk. Among these 58 prospective studies, 31 studies found a significant inverse association between HDL-C and CVD risk for all CVD outcomes and subpopulations studied, whereas 17 studies found a significant association for some CVD outcomes and/or subpopulations assessed. The ratio of studies that found a significant association out of the total studies identified was similar across all CVD outcomes, although there was less evidence for stroke and atherosclerotic outcomes. Only seven studies tested for the consistency of this association across other lipid risk factors, of which six studies suggested that the association was consistent across other lipid levels. In conclusion, the association between HDL-C and CVD risk is significant and strong, although further evidence may be needed to establish whether this association is consistent across other lipid risk factors. Furthermore, uncertainties remain regarding the mechanism in which HDL-C exerts its effects, suggesting a need for further research focused on new methods for reliable measurement.

Trend in incidence of cardiovascular risk factors in elderly and over-aged stroke patients between 2003 and 2007 in Greece

The aim of this study is to identify the main cardiovascular risk factors (CRFs) in patients over 65 years with ischemic stroke. This is a retrospective study in 175 patients that were hospitalized in our department due to ischemic stroke in the period 2006-2007. The patients were divided in two groups: Group I--elderly (65-80 years) and Group II--over-aged (>or=81 years). The results were compared with a similar study performed in our department in the period 2002-2003 in 160 ischemic stroke patients. Statistical analysis was made by the chi2-test. Hypertension, either alone or in combination with other CRFs, constitutes the main CRF. Diabetes mellitus (DM) is not frequently the sole CRF but its coexistence with other CRFs ranks DM as the second most important CRF, with the largest percentage in the elderly. Dyslipipidemia is 4th CRF in order following the coronary heart disease (CHD). Taking into account that the provision of acute therapeutic intervention in elderly and over-aged ischemic stroke patients is in most cases difficult, because of their age and the high risk of thrombolysis in these patients, there is increased need to focus on primary prevention of ischemic stroke by treating associated CRF.

Risk factors for first-ever stroke in the EPIC-Norfolk prospective population-based study

BACKGROUND

Many studies examining stroke risk factors have focused on men and younger age groups. We examined stroke risk factors over a wide age range including elderly and women in a British population.

METHODS

We examined the prospective relationship between known risk factors for stroke and stroke incidence in 22 516 men and women aged 40-79 years without stroke at baseline in the years 1993-1997 participating in the European Prospective Investigation into Cancer-Norfolk.

RESULTS

During a total of 214 542 person-years of follow-up, 507 incident strokes occurred (fatal=162). Stroke risk increased with increasing age [relative risk (RR) 1.65, 95% confidence interval: 1.54, 1.75 per increase in 5 years]. Our results confirm the importance of modifiable risk factors for stroke in men and women, in particular, blood pressure and smoking. Higher systolic blood pressure of 10 mmHg was associated with RR of 1.19 (1.13, 1.24) and current smokers had RR of 1.70 (1.29, 2.23) compared with never smokers independent of age, sex, body mass index, cholesterol, triglycerides and diabetes. Having a systolic blood pressure greater than 140 mmHg compared with less than 140 mmHg was equivalent to being 6 years older and current smoking compared with nonsmoking equivalent to being 5 years older and diabetes 5 years older in terms of stroke risk.

CONCLUSION

Classical modifiable stroke risk factors, blood pressure and smoking, may have a substantial impact on the age-related increase in stroke risk in men and women.

Gender risk of nonfatal stroke in type 2 diabetic patients differs depending on the type of treatment

BACKGROUND

The gender differences in stroke risk among diabetic patients with different treatments have not been studied previously. We aim to determine if there is a gender difference in nonfatal stroke risk in diabetic patients receiving different types of glucose-lowering treatments.

METHODS

In December 2005, data of type 2 diabetic patients were extracted from a nationwide population-based diabetes registry covering 11 Ukrainian regions. Male/female odds ratios (OR) for nonfatal stroke were calculated in three treatment groups: diet only 7,273/15,901, oral glucose-lowering drugs 15,109/33,913, and insulin 5,529/12,462 male/female. Male/female ORs of stroke were estimated using a logistic regression model.

RESULTS

The age-adjusted ORs of stroke were higher among diabetic men compared with diabetic women with oral glucose-lowering drug treatment (OR 1.37, 95% CI 1.22-1.54) and diet treatment only (OR 1.53, 95% CI 1.35-1.73). No differences were found among patients who used insulin (OR 0.97, 95% CI 0.84-1.11). Further adjustment for duration of type 2 diabetes, body mass index (BMI), systolic blood pressure, total cholesterol, and smoking affected the results only slightly.

CONCLUSIONS

The gender risks of nonfatal stroke in patients with type 2 diabetes appear to differ considerably depending on treatment types.

Severely depressed young patients have over five times increased risk for stroke: a 5-year follow-up study

BACKGROUND

This study aims to estimate the risk of developing stroke within 5 years of discharge among young patients ages 18 to approximately 44 who were hospitalized for depressive disorders.

METHODS

Our study design features a study cohort and a comparison cohort. The study cohort included patients ages 18 to approximately 44 who were hospitalized with a principal diagnosis of depressive disorder (n = 827), whereas the comparison cohort consisted of 4,135 patients selected randomly (five for every depressed patient) and matched with the study group in terms of gender, age, and date of discharge. Each patient was tracked for 5 years after their discharge in 1998. Cox proportional hazard regressions were performed to compute the 5-year stroke-free survival rates after adjusting for possible confounding factors.

RESULTS

During the 5-year follow-up period, 50 depressed patients (6.05% of the study cohort) and 48 non-depressed subjects (1.16% of the comparison cohort) developed strokes. The adjusted hazard of stroke was 5.43 (95% confidence interval = 3.47-8.51, p < .001) times greater for depressed patients than for non-depressed subjects.

CONCLUSIONS

Our findings show young patients ages 18 to approximately 44 who were hospitalized for depressive disorders were at over five times greater risk of developing stroke within 5 years of discharge compared with non-depressed age- and gender-matched subjects.

Serum lipids in patients with stroke--a cross-sectional case-control study

BACKGROUND

Vascular disease remains the prime contributor to the pathogenesis of stroke, but dyslipidemia has not been clearly established as a risk factor for stroke the same way it has been for coronary artery disease. There is no case-controlled study on the contribution of serum lipids to stroke in Nigerians. This study aimed at assessing the possibility of serum lipids as risk factor for stroke in Nigerian patients.

METHOD

The demography, blood pressure, fasting plasma glucose and fasting serum lipids of 87 consecutive patients with first-ever stroke managed at the University of Benin teaching hospital between January and December 2005 were analyzed and compared with those of age- and sex-matched controls.

RESULTS

Eighty-seven stroke patients (55 males and 32 females; mean age 61.25 +/- 14.77 years) were compared with age- and sex-matched controls. Ischemic stroke constituted 64.37%, while the rest had hemorrhagic stroke. There were no significant differences in the serum cholesterol, HDL-C and LDL-C levels of stroke patients and controls (p > 0.05), but the serum triglyceride level was higher among the stroke patients (p < 0.001) with a significant relative risk (RR = 1.77; p < 0.01).

CONCLUSION

In this cross-sectional case-control study, there is no significant difference in the serum lipids of Nigerian patients with stroke with the exception of serum triglyceride, which seems to confer significant stroke risk.

Niacin for stroke prevention: evidence and rationale

Low levels of high-density lipoprotein (HDL) cholesterol are associated with increased atherothrombotic events, including stroke. Niacin is a safe and effective means of raising HDL, yet its role in stroke prevention is not well characterized. The purpose of the study is to determine the role of niacin in stroke prevention. A search of the PUBMED database using the keywords niacin, stroke, atherosclerosis, and/or carotid artery was undertaken to identify studies for review. National guidelines from the American Heart Association and National Cholesterol Education Program were reviewed. Treatment of low serum HDL (<40 mg/dL) is an identified goal of dyslipidemic therapy. Niacin is effective in raising HDL levels and reducing cardiovascular events in individuals with high vascular risk and can be used for treatment of stroke patients with low serum HDL. Niacin can be used safely in combination with statins, the first-line dyslipidemic treatment for secondary stroke risk reduction, with increased efficacy. Studies are needed to better define the role for niacin in secondary stroke prevention. Treatment of stroke patients with extended-release (ER) of niacin, alone or in combination with statins, should be considered in stroke patients with atherosclerotic mechanisms with low serum HDL-C levels.

Diversity of risk factors for stroke: The putative roles and mechanisms of depression and air pollution

Several conventional risk factors for stroke and cerebrovascular disease, such as hypertension, smoking, and atrial fibrillation, are widely recognized. Correct management of these modifiable factors significantly reduces stroke risk. We review the research evidence that depressive symptoms and increased atmospheric pollution are associated with an increased risk of stroke, and outline putative mechanisms that may account for these associations. The data on depression and stroke risk strongly indicate the need for treatment intervention studies. The design and implementation of intervention studies related to air pollution requires better understanding of the pathophysiologic mechanisms linking exposures to the onset of stroke.

Sex differences in the relation of HDL cholesterol to progression of carotid intima-media thickness: The Los Angeles Atherosclerosis Study

Epidemiologic studies have revealed that the protective association of high-density lipoprotein cholesterol (HDL-C) with CHD is stronger in older men and younger women. We aimed to investigate sex differences in the relation of HDL-C to progression of carotid intima-media thickness (IMT) (an indicator of subclinical atherosclerosis) in middle age. IMT progression and serum HDL-C were determined for a cohort of 500 women and men aged 40-60 years over three examinations (1.5-year intervals). IMT at baseline was inversely associated with serum levels of HDL-C and the associations were comparable in women and men. However, in multivariate longitudinal growth models adjusting for potential confounders, IMT progression was inversely associated with serum levels of HDL-C in men, but directly associated in women (p=0.0007 for interaction). Our results suggest that although HDL-C was protective against progression of carotid atherosclerosis in middle-aged men, anti-atherogenic effects of HDL may diminish in women around the age of menopause.

The differential effects of single or repeated restraint stress on kainic acid-induced neuronal death in the hippocampal CA3 region: the role of glucocorticoid and various signal molecules

The effect of stress mediators following the stress period and addition time is a controversial issue until now. Thus, we aim to clarify the differential effects of single restraint stress (SS) or repeated restraint stress (RS) on kainic acid (KA)-induced neuronal death especially as addressing not only the role of glucocorticoid (Gc) and its receptor but also the signal pathway leading to cAMP response element binding protein phosphorylation (pCREB) and its functional role during stress. In the present study, we found that although RS did not show any difference on serum Gc level and hippocampal Gc receptor level compared to SS, SS exacerbated KA-induced neuronal death in hippocampal CA3 region, but RS did not. Moreover, pre-treatment with RU 38486 (Gc receptor antagonist) abolished the effect of SS on KA-induced neuronal death without an effect on KA toxicity itself. Furthermore, RS aggravates KA-induced neuronal death when CREB phosphorylation was deprived by KN-93 (calcium/calmodulin-dependent protein kinase II inhibitor). However, other signal molecules inhibitors such as PD98059 (MEK1/2 inhibitor) and SP600125 (p-p38 inhibitor) have no effect on KA-induced neuronal death after RS although these signal molecule were increased during SS or RS. These findings suggest that pCREB expression via calcium/calmodulin-dependent protein kinase II phosphorylation during RS comprise one of the balancers against Gc induced by stress.

Involvement of IL-1beta in acute stress-induced worsening of cerebral ischaemia in rats

Stress is known to be one of the risk factors of stroke. Most of the knowledge on the effects of stress on cerebrovascular disease in humans is restricted to catecholamines and glucocorticoids effects on blood pressure and/or development of atherosclerosis. However, few experimental studies have examined the possible mechanisms by which stress may affect stroke outcome. We have used an acute stress protocol consisting of the exposure of male Fischer rats to an acute, single exposure immobilisation protocol (6 h) prior to permanent middle cerebral artery occlusion (MCAO), and we have found that stress worsens behavioural and neurological outcomes and increased infarct size after MCAO. The possible regulatory role of the TNFalpha and IL-1beta was studied by looking at the release of these cytokines in brain. The results of the present study showed an increase in IL-1beta release in cerebral cortex after exposure to acute stress. Brain levels of IL-1beta are also higher in previously stressed MCAO rats than in MCAO animals without stress. Pharmacological blockade of IL-1beta with an antibody anti-IL-1beta led to a decrease in the infarct size as well as in neurological and behavioural deficits after MCAO. In summary, our results indicate that IL-1beta, but not TNFalpha, accounts at least partly for the worsening of MCAO consequences in brain of rats exposed to acute stress.

Prospective study of type 1 and type 2 diabetes and risk of stroke subtypes: the Nurses' Health Study

OBJECTIVE

The aim of this study was to examine the relationship between type 1 and type 2 diabetes and risk of stroke subtypes in women.

RESEARCH DESIGN AND METHODS

We followed 116,316 women aged 30-55 years in 1976 through 2002 for incidence of stroke. At baseline and through biennial follow-up, women were asked about their history and treatment of diabetes and other potential risk factors for stroke.

RESULTS

During 2.87 million person-years of follow-up, 3,463 incident strokes occurred. In multivariate analyses, the incidence of total stroke was fourfold higher in women with type 1 diabetes (relative risk [RR] 4.7 [95% CI 3.3-6.6]) and twofold higher among women with type 2 diabetes (1.8 [1.7-2.0]) than for nondiabetic women. The multivariate RR of ischemic stroke was increased sixfold (6.3 [4.0-9.8]) in type 1 diabetes and twofold (2.3 [2.0-2.6]) in type 2 diabetes. Risks for large-artery infarction and lacunar stroke were similar. Type 1 diabetes was also significantly associated with the risk of hemorrhagic stroke (3.8 [1.2-11.8]), but type 2 diabetes was not (1.0 [0.7-1.4]).

CONCLUSIONS

Both type 1 and type 2 diabetes are associated with substantially increased risks of total and most subtypes of stroke.

[Post-stroke depression: clinical aspects, epidemiology, therapy, and pathophysiology]

Post-stroke depression (PSD) is the most frequent psychiatric complication following ischemic stroke, affecting up to 50% of all such patients. Moreover, PSD is associated with increased morbidity and mortality following ischemic stroke. In clinical practice, PSD is underdiagnosed and many affected patients do not receive adequate treatment. This review article summarizes current knowledge regarding epidemiogy, clinical features, risk factors and predisposition, therapy, and prophylaxis of PSD.

Apolipoprotein A5 gene promoter region T-1131C polymorphism associates with elevated circulating triglyceride levels and confers susceptibility for development of ischemic stroke

The possible pathogenic role of triglycerides (TG) in the development of ischemic stroke is still under extensive investigation. Recently, apolipoprotein (apo)A5 gene promoter region T-1131C polymorphism has been shown to associate with elevated serum TG levels. In the current work, a total of 302 subjects were classified as being large vessel-associated, small vessel-associated, or belonging to a mixed group of ischemic stroke-affected patients. The level of TG was increased in all groups (p < 0.01). The apoA5-1131C allele frequency was approximately twofold in all groups of stroke patients compared with the controls (5 vs 10-12%; p < 0.05); and the apoA5-1131C allele itself was also found to associate with increased TG levels in all groups. In a multivariate logistic regression analysis model adjusted for differences in age, gender, serum cholesterol, hypertension, presence of diabetes mellitus, smoking and drinking habits, and ischemic heart disease, a significantly increased risk of developing stroke disease was found in patients carrying the apoA5-1131C allele (p < 0.05; odds ratio OR = 2.1 [1.3-4.7]); this association was also proven for all subtypes of the stroke. The results presented here suggest that the apoA5-1131C allele is an independent risk factor for the development of stroke. Being that apoA5 gene is under the control of the peroxisome proliferator-activated receptor alpha, theoretically, the current observations also can have long-term therapeutic consequences.

Mortality Trends in Patients Diagnosed With First Atrial Fibrillation

OBJECTIVES

The purpose of this study was to assess the mortality trends of atrial fibrillation (AF) in a community.

BACKGROUND

Limited data exist regarding the mortality trends of patients diagnosed with first AF.

METHODS

A community-based cohort of adult residents of Olmsted County, Minnesota, who had electrocardiogram-confirmed first-documented AF in the years 1980 to 2000 were identified and followed to 2004 or death. The primary outcome was all-cause mortality.

RESULTS

Of a total of 4,618 residents (mean age 73 +/- 14 years) diagnosed with first AF, 3,085 died during a mean follow-up of 5.3 +/- 5.0 years. Relative to the age- and gender-matched general Minnesota population, the mortality risk was increased (p < 0.0001) with a hazard ratio (HR) of 9.62 (95% confidence interval [CI] 8.93 to 10.32) within the first 4 months and 1.66 (95% CI 1.59 to 1.73) thereafter. Cox proportional hazards modeling showed no change in overall age- and gender-adjusted mortality (HR for the year 2000 vs. 1980: 0.99; 95% CI 0.86 to 1.13; p = 0.84), even after adjustment for comorbidities. In secondary analyses, no changes in mortality were seen for early (within first 4 months) or late (after 4 months) mortality for the entire group or within the subgroup of patients who did not have cardiovascular disease at baseline.

CONCLUSIONS

In this cohort of patients newly diagnosed with AF, mortality risk was high, especially within the first 4 months. There was no evidence for any significant changes over the 21 years in terms of overall mortality, early or late mortality, or mortality among patients without pre-existing cardiovascular disease.

The effect of diabetes and stroke at baseline and during follow-up on stroke mortality

AIMS/HYPOTHESIS

The aim of this study was to compare the magnitude of the effect of diabetes and stroke at baseline and during follow-up on risk of stroke mortality.

MATERIALS AND METHODS

Study cohorts included 25,155 Finnish men and 26,423 women aged 25-74 years. Data on diabetes and stroke history at baseline, their incidence during follow-up, and stroke death were obtained from national registers.

RESULTS

During a mean follow-up of 18.9 years, 838 stroke deaths were recorded. In the baseline study, hazard ratios (HRs) for stroke mortality were 5.26 for men with prior diabetes only, 4.76 for men with prior stroke only, and 13.4 for men with both prior diabetes and stroke compared with men without diabetes and stroke at baseline and during follow-up. In women, the corresponding hazard ratios were 7.29, 5.27 and 5.52, respectively. When only diabetes and stroke status during the follow-up were considered, the hazard ratios for stroke mortality were 1.41 for men and 1.56 for women with incident diabetes only, 5.62 for men and 5.58 for women with incident stroke only, and 5.59 for men and 4.48 for women with both incident diabetes and stroke compared with men and women without diabetes and stroke at baseline and during follow-up.

CONCLUSIONS/INTERPRETATION

Diabetes and stroke, present either at baseline or during follow-up, markedly increase the risk of stroke death. Prior stroke at baseline carries a similar risk of stroke mortality as prior diabetes. There is a greater risk of stroke mortality associated with incident stroke during follow-up than with incident diabetes.

The role of tumor necrosis factor-alpha in stress-induced worsening of cerebral ischemia in rats

Whereas stress is known to be one of the risk factors of stroke, few experimental studies have examined the possible mechanisms by which stress may affect stroke outcome. Most of the knowledge on the effects of stress on cerebrovascular disease in humans is restricted to catecholamines and glucocorticoids effects on blood pressure and/or development of atherosclerosis. By using an experimental paradigm consisting of the exposure of Fischer rats to repeated immobilization sessions (1 h daily during seven consecutive days) prior to permanent middle cerebral artery occlusion (MCAO), we have found that stress worsens behavioral outcome and increases infarct size after MCAO. These changes occur concomitantly to an increase in inducible nitric oxide synthase (iNOS) expression and to the accumulation of lipid peroxidation markers in brain tissue. The possible regulatory role of TNFalpha was studied by looking at the mechanisms of release of this cytokine as well as to the expression of its receptors (TNFR1 and 2). The results of the present study suggest an increase in TNFalpha expression and release after stress, as well as an increase in the expression of TNFR1. Pharmacological blockade of TNFalpha with anti-TNFalpha led to a decrease in the infarct size as well as in the oxidative/nitrosative biochemical parameters seen after ischemia. In summary, our results indicate that TNFalpha accounts, at least partly, for the worsening of MCAO consequences in brain of rats exposed to stress. Furthermore, the data presented here provide evidence that stress can increase brain ischemic damage and support a possible protective effect of treatment of stressful situations before and during the development of the brain ischemia.

Edaravone inhibits JNK-c-Jun pathway and restores anti-oxidative defense after ischemia-reperfusion injury in aged rats

Edaravone, a potent antioxidant, is currently being used in the management of acute ischemic stroke in relatively high-aged populations. Mitogen activated protein kinase (MAPK) pathways have been shown to play important roles in neuronal cell death. We examined the role of MAPK pathways and the effect of treatment with edaravone in the brain after cerebral ischemia-reperfusion (I/R) injury in a bilateral carotid artery occlusion (BCAO) model with ischemia for 85 min followed by reperfusion for 45 min in aged rats. Western immunoblotting, immunostaining, enzyme-linked immunosorbent assay (ELISA), spectrophotometry, terminal deoxynucleotidyl transferase nick end labeling (TUNEL) and triphenyl tetrazolium chloride (TTC) staining were performed to evaluate various proteins in the homogenate, c-Jun NH2-terminal kinase (JNK) in the tissue sections, protein carbonyl, glutathione peroxidase (GSHPx), apoptosis and infarct size, respectively. Our results showed that I/R injury resulted in a reduction of GSHPx, but protein carbonyl content and inducible nitric oxide synthase were increased. The activation of JNK and its downstream molecule c-Jun was significantly increased after injury, whereas the activities of p38 MAPK and extracellular-regulated kinase 1/2 were slightly but not significantly increased. Edaravone (3 mg/kg, i.v.) treatment significantly reduced all of these changes. Our findings suggest that the JNK pathway differentially mediates neuronal injury in aged rats after BCAO, and edaravone treatment significantly reduces the neuronal damage after I/R injury by inhibiting oxidative stress and the JNK-c-Jun pathway with concomitant inhibition of overall MAPK activity in the brains of aged rats.

Relation of serum total cholesterol and other factors to risk of cerebral infarction in Japanese men with hypercholesterolemia

BACKGROUND

Risk factors for cerebral infarction have not been well clarified, except for hypertension (HT), and few studies have examined the risk factors in the elderly.

METHODS AND RESULTS

Clinical and behavioral risk factors for cerebral infarction were examined in 4,349 Japanese men aged 45-74 years with a serum total cholesterol (TC) concentration of 220 mg/dl or greater who participated in the Kyushu Lipid Intervention Study. A total of 81 men developed definite cerebral infarction in a 5-year follow-up period. The Cox proportional hazards model was used with serum TC at baseline and during the follow-up, serum high-density lipoprotein-cholesterol (HDL-C), HT, diabetes mellitus (DM), and other factors as covariates. Serum TC during the follow-up, not at baseline, was positively associated with cerebral infarction, showing a stronger association in the elderly (>or=65 years old) than in the middle-aged (<65 years old). Statin use was related to a moderate decrease in the risk of cerebral infarction when follow-up TC was not considered, but the decrease was almost nullified after adjustment for follow-up TC. A low concentration of serum HDL-C, diabetes mellitus, hypertension, and angina pectoris were each related to an increased risk. No clear association was observed for body mass index, smoking or alcohol use.

CONCLUSIONS

Lowering cholesterol is important in the prevention of cerebral infarction in men with moderate hypercholesterolemia. A low concentration of HDL-C, DM, and HT are independent predictors of cerebral infarction.

Lipid‐modifying drugs

An elevated concentration of low-density-lipoprotein cholesterol (LDL-C) plays a causal role in the development of coronary heart disease and ischaemic stroke. Placebo-controlled intervention studies of statin drugs for lowering LDL-C provide clear evidence of cardiovascular disease prevention. LDL-C concentration below 2.5 mmol/L is an arbitrary goal, and recent trials support the benefit of achieving this goal, or even lower levels. Pharmacological treatment is warranted in patients with high absolute risk of future cardiovascular events. Effective monotherapy is available for predominant hypercholesterolaemia and predominant hypertriglyceridaemia, but combination therapy may be required for severe cases or in those with mixed hyperlipidaemia. Side-effects are infrequent and usually mild, but widespread use of lipid-modifying medication demands caution because of the possibility of muscle or liver dysfunction or drug interactions.

Preoperative state of mind among patients undergoing CABG: effect on length of stay and postoperative complications

This study was undertaken to determine if a pessimistic self-assessment prior to an elective coronary artery bypass graft (CABG) was predictive of postoperative complications and increased length of stay (LOS). Subjects (n = 565), aged 65 and older and undergoing elective CABG, were stratified into 2 groups (optimistic, pessimistic) based on their mental health subscale scores prior to surgery. After adjusting for age, gender, and severity of disease, the average LOS for pessimistic patients was 1.3 days longer than for optimistic patients. Despite adjustment for previous CABG, renal failure, peripheral vascular disease, and gender, pessimism was associated with an increased risk of prolonged ventilation time and permanent stroke. Negative state of mind prior to a major cardiovascular intervention may be predictive of increased LOS, permanent stroke, and prolonged ventilation time.

Potential Confounding by Intermediate Phenotypes in Studies of the Genetics of Ischaemic Stroke

BACKGROUND

Family history (FHx) of stroke is perceived to be an important risk factor for ischaemic stroke. However, there are several intermediate phenotypes that are often involved in the aetiology of ischaemic stroke and that have a substantial genetic component themselves. We studied FHx of ischaemic heart disease (IHD), hypertension (HTN) and diabetes mellitus (DM) as risk factors for ischaemic stroke.

METHODS

We performed a systematic review of case-control and cohort studies reporting on FHx(IHD), FHx(HTN) or FHx(DM) as risk factors for stroke using bibliographic databases, and by hand searching reference lists and journals. Odds ratios of FHx as a risk factor for stroke were calculated within individual studies. We included unpublished data from two Oxfordshire population-based studies to assess effects on subtypes of ischaemic stroke.

RESULTS

We identified 54 studies that investigated the odds of stroke conferred by a positive FHx, 24 of which reported data on FHx of one or more intermediate phenotypes in addition to FHx of stroke. Most studies reported an increased frequency of FHx(IHD) and FHx(HTN) in stroke patients versus controls. The association was significant in 6 out of 14 studies for FHx(IHD) and 4 out of 11 studies for FHx(HTN). In contrast, FHx(DM) was not associated with stroke. FHx(IHD) was particularly associated with large vessel strokes (OR 1.72, CI 1.3-2.2, p = 0.00004).

CONCLUSIONS

FHx(IHD) and FHx(HTN) are both risk factors for stroke. It is likely that the apparent heritability of stroke is partly accounted for by heritability of HTN and large vessel atherosclerosis. Analyses of heritability of stroke and candidate gene studies should be adjusted accordingly.

Differences between hypertensive and non-hypertensive ischemic stroke

We compared risk factors, clinical features, neuroimaging data, and outcome between hypertensive and non-hypertensive ischemic stroke patients. Differential features of ischemic stroke patients with hypertension (n = 768) and without hypertension (n = 705) were assessed by bivariate analysis. Independent predictors of hypertensive ischemic stroke were determined by multivariate analysis. Atherothrombotic infarction and lacunar infarct were significantly more common in the hypertensive group, in which older age and a higher occurrence of previous cerebral infarction, hyperlipidemia, acute stroke onset, lacunar syndrome, and pons topography was also observed. Age of 85 years or older, valvular heart disease, and decreased consciousness were more common in non-hypertensive patients. After multivariate analysis, lacunar syndrome, female gender, and previous infarction were directly associated with hypertensive ischemic stroke. Age of 85 years or older and valvular heart disease were inversely associated with hypertensive ischemic stroke. Hypertension was the main cardiovascular risk factor only for lacunes and atherothrombotic infarction, that is, ischemic stroke associated with small- and large-artery disease.

Marital Dissolution Is Followed by an Increased Incidence of Stroke

BACKGROUND

Many studies have reported lower mortality in married people. The relation between marital status and incidence of haemorrhagic and ischaemic stroke is unclear. It is largely unknown whether the risk of stroke is increased the first years after divorce or death of spouse.

METHODS

Incidence of first-ever stroke (n = 6,184) was followed over 10 years in a cohort consisting of all 40- to 89-year-old inhabitants (n = 118,134) in the city of Malmö, Sweden. Marital dissolution (i.e. divorce or death of spouse) prior to the date of stroke was compared in a nested case-control design (3,134 initially married stroke cases, 9,402 initially married controls).

RESULTS

As compared to the married groups, the incidence of stroke was increased in divorced men and women (RR = 1.23, CI: 1.10-1.39 and RR = 1.26, CI: 1.12-1.41, respectively) and widowed men and women (RR = 1.13, CI: 0.99-1.28 and RR = 1.13, CI: 1.02-1.24, respectively) after adjustments for age, country of birth and socioeconomic indicators. The risk of stroke was not increased in never married men. Marital dissolution was followed by increased risk of stroke, which was significant for men (adjusted odds ratio: 1.23, CI: 1.03-1.5) and borderline significant for women below 65 years of age (odds ratio: 1.45, CI: 0.99-2.14).

CONCLUSION

The incidence of stroke is increased in divorced and widowed individuals. Never married men do not have an increased incidence. The risk of stroke is elevated during the first years after divorce or death of spouse.

Physiologic monitoring and anesthesia considerations in acute ischemic stroke

Acute ischemic stroke is considered a neurologic emergency. The perioperative anesthesia management of acute ischemic stroke is challenging owing to the dynamic pathophysiology of the disease itself and the patients' comorbid factors and conditions. Herein, the authors review preoperative assessment, intraoperative and postoperative physiologic monitoring, and anesthesia management, with a focus on the control of the cerebrovascular and cardiovascular circulations. Issues specific to anesthesia monitoring and management in the radiology suite are emphasized.

Is poststroke depression a vascular depression?

As we learn more about the relationships between depression and cerebrovascular disease (CVD), a complex picture is emerging in which the chain of causality seems to spiral on itself: progressive or focal brain damage, cognitive impairment, depressive symptoms, dementia, and cardiovascular diseases, all seem to be liable to lead to one or another. Stroke may lead to depression, and the inverse may also be true. Depression may lead to cognitive impairment and cardiovascular diseases, which in turn may lead to subtle brain impairment, thereby causing more depression and cognitive impairments, and so on. In this presentation, we provide a rapid glance at the complexities of such issues.

Left atrial volume in the prediction of first ischemic stroke in an elderly cohort without atrial fibrillation

OBJECTIVE

To determine the clinical importance of left atrial (LA) volume in the prediction of first ischemic stroke.

PATIENTS AND METHODS

This retrospective cohort study included randomly selected residents of Olmsted County, Minnesota, aged 65 years or older, who had undergone transthoracic echocardiography at least once at the Mayo Clinic in Rochester, Minn, between January 1, 1990, and December 31, 1998, were in sinus rhythm, and had no history of stroke, transient ischemic attack, atrial fibrillation, or valvular heart disease. Patients were monitored through medical records for first ischemic stroke or death.

RESULTS

Of 1554 residents (59% women) aged 75+/-7 years, 92 (6%) had experienced at least 1 ischemic stroke over 4.3+/-2.7 years (incident stroke rate, 1.4 per 100 person-years). Left atrial volume of 32 mL/m2 or greater (hazard ratio [HR], 1.63; confidence interval [CI], 1.08-2.46) was independent of age (HR, 1.04; CI, 1.02-1.07), diabetes (HR, 1.91; CI, 1.07-3.41), myocardial infarction (HR, 1.64; CI, 1.01-2.64), and hyperlipidemia (HR, 1.55; CI, 1.01-2.37) for the prediction of first ischemic stroke. When quartiles of LA dimension were plotted against quartiles of indexed LA volume, a stepwise increase in risk with each quartile increment was evident only for indexed LA volume. Also, an LA volume of 32 mL/m2 or greater was associated with an increased mortality risk (HR, 1.30; CI, 1.09-1.56), independent of age, sex, and stroke status.

CONCLUSIONS

In our elderly cohort with no prior atrial fibrillation, LA volume was independently predictive of first ischemic stroke, incremental to age, diabetes, myocardial infarction, and hyperlipidemia. It was also an independent predictor of death.

High density lipoprotein cholesterol and the risk of stroke in elderly men: the Honolulu heart program

High density lipoprotein (HDL) cholesterol has been inversely associated with coronary heart disease. Associations with stroke are less clear, particularly among the elderly. In this study, the authors examined the relation between HDL cholesterol levels and the risk of stroke in elderly men. Levels of HDL cholesterol were measured in 2,444 Honolulu Heart Program men aged 71-93 years at the 1991-1993 examinations. The participants, who were free of prevalent stroke, coronary heart disease, and cancer at baseline, were followed to the end of 1998 for thromboembolic and hemorrhagic stroke. While HDL cholesterol was unrelated to hemorrhagic events, incidence of thromboembolic stroke declined consistently with increasing HDL cholesterol level (p = 0.003). There was a nearly threefold excess of thromboembolic stroke in men with low HDL cholesterol levels (<1.0 mmol/liter (<40 mg/dl)) compared with men with high levels (> or =1.6 mmol/liter (> or =60 mg/dl)) (10.6/1,000 person-years vs. 3.6/1,000 person-years; p = 0.001). Adjustment for other risk factors had little effect on these findings, although associations appeared strongest in elderly men with "desirable" total cholesterol levels, hypertension, or diabetes mellitus. These findings suggest that HDL cholesterol level is inversely related to the risk of thromboembolic stroke in elderly men. Whether HDL cholesterol alters the effect of other factors on stroke risk in elderly men warrants further study.

Synergism between smoking and vital exhaustion in the risk of Ischemic stroke: evidence from the ARIC study

PURPOSE

To examine the synergism between vital exhaustion and cigarette smoking in producing ischemic stroke. Vital exhaustion (VE), a state characterized by unusual fatigue, irritability, and feelings of demoralization, is measured by the Maastricht questionnaire (MQ), a 21-item inventory of symptoms.

METHODS

The Atherosclerosis Risk in Communities (ARIC) Study is an ongoing cohort study, initiated in 1987. The MQ was administered at the second follow-up visit (1990-1992), and participants were subsequently followed for an average of 6.27 years. Four US communities (Minneapolis, Minnesota; Washington County, Maryland; Forsyth County, North Carolina; and Jackson, Mississippi). 13,066 participants aged 48 to 67 years at baseline (Visit 2) with no history of stroke. Validated hospitalized ischemic stroke.

RESULTS

During the follow-up period, there were 202 incident ischemic strokes. After multivariate adjustment, current smoking, and high VE were independent risk factors for incident stroke: (smoking vs. non-smoking HR=1.76, p < 0.01; high VE vs. low VE HR=1.94, p < 0.01). For persons with both VE and smoking vs. persons with neither, HR=2.71 (p < 0.001). The proportion of stroke disease burden due to VE and smoking that could be attributed to their interaction was 81 to 93 percent.

CONCLUSIONS

The combination of cigarette smoking and VE is synergistic in the production of stroke.

Impaired Angiogenesis in the Aged

The process of angiogenesis, during which new blood vessels are formed, is impaired during aging. This Perspective describes many of the myriad components of the angiogenic response that are altered with age. In addition, the impact of impaired angiogenesis on wound healing, vascular disease, and cancer in the aged is discussed.