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Perez MA, Reyes-Esteves S, Mendizabal A. Racial and Ethnic Disparities in Neurological Care in the United States. Semin Neurol 2024; 44:178-192. [PMID: 38485124 DOI: 10.1055/s-0043-1778639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.
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Affiliation(s)
- Michael A Perez
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Adys Mendizabal
- Department of Neurology, University of California, Los Angeles, California
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Hsu CY, Saver JL, Ovbiagele B, Wu YL, Cheng CY, Lee M. Association Between Magnitude of Differential Blood Pressure Reduction and Secondary Stroke Prevention: A Meta-analysis and Meta-Regression. JAMA Neurol 2023; 80:506-515. [PMID: 36939729 PMCID: PMC10028545 DOI: 10.1001/jamaneurol.2023.0218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Importance The degree to which more intensive blood pressure reduction is better than less intensive for secondary stroke prevention has not been delineated. Objective To perform a standard meta-analysis and a meta-regression of randomized clinical trials to evaluate the association of magnitude of differential blood pressure reduction and recurrent stroke in patients with stroke or transient ischemic attack (TIA). Data Sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1980, to June 30, 2022. Study Selection Randomized clinical trials that compared more intensive vs less intensive blood pressure lowering and recorded the outcome of recurrent stroke in patients with stroke or TIA. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Risk ratio (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive blood pressure lowering with primary and secondary outcomes. The univariate meta-regression analyses were conducted to evaluate a possible moderating effect of magnitude of differential systolic blood pressure (SBP) and diastolic blood pressure (DBP) reduction on the recurrent stroke and major cardiovascular events. Main Outcomes and Measures The primary outcome was recurrent stroke and the lead secondary outcome was major cardiovascular events. Results Ten randomized clinical trials comprising 40 710 patients (13 752 women [34%]; mean age, 65 years) with stroke or TIA were included for analysis. The mean duration of follow-up was 2.8 years (range, 1-4 years). Pooled results showed that more intensive treatment compared with less intensive was associated with a reduced risk of recurrent stroke in patients with stroke or TIA (absolute risk, 8.4% vs 10.1%; RR, 0.83; 95% CI, 0.78-0.88). Meta-regression showed that the magnitude of differential SBP and DBP reduction was associated with a lower risk of recurrent stroke in patients with stroke or TIA in a log-linear fashion (SBP: regression slope, -0.06; 95% CI, -0.08 to -0.03; DBP: regression slope, -0.17; 95% CI, -0.26 to -0.08). Similar results were found in the association between differential blood pressure lowering and major cardiovascular events. Conclusions and Relevance More intensive blood pressure-lowering therapy might be associated with a reduced risk of recurrent stroke and major cardiovascular events. These results might support the use of more intensive blood pressure reduction for secondary prevention in patients with stroke or TIA.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L Saver
- UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, Los Angeles
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, Los Angeles
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Chun-Yu Cheng
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
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Kitagawa K. Blood pressure management for secondary stroke prevention. Hypertens Res 2022; 45:936-943. [DOI: 10.1038/s41440-022-00908-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 11/09/2022]
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Kitagawa K, Arima H, Yamamoto Y, Ueda S, Rakugi H, Kohro T, Yonemoto K, Matsumoto M, Saruta T, Shimada K. Intensive or standard blood pressure control in patients with a history of ischemic stroke: RESPECT post hoc analysis. Hypertens Res 2022; 45:591-601. [PMID: 35241817 DOI: 10.1038/s41440-022-00862-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 11/09/2022]
Abstract
The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed that intensive blood pressure (BP) lowering reduced recurrent stroke risk by 22% in patients with a history of stroke. Here, we report the effect of intensive BP lowering on the risk of recurrent stroke subtypes in patients with a history of ischemic stroke. RESPECT was a randomized clinical trial among 1280 people with a history of cerebral infarction or intracerebral hemorrhage. Participants were assigned to the intensive blood pressure control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg). In this post hoc analysis, we analyzed 1074 patients with a history of cerebral infarction. The mean BP at baseline was 140.7/81.4 mmHg. Throughout the follow-up period, the mean BP was 133.4/77.5 (95% CI, 132.7-134.1/76.9-78.2) mmHg in the standard group and 126.7/74.1 (95% CI, 126.0-127.4/73.5-74.8) mmHg in the intensive group. During a mean follow-up of 3.9 years, 78 first recurrent strokes occurred. Intensive treatment tended to reduce overall annual stroke recurrence (1.74% in intensive vs. 2.17% in standard; P = 0.351 by log-rank test) and did not change the risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999) but markedly reduced the risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effects of intensive BP control were observed for the risk of hemorrhagic stroke in patients with a history of ischemic stroke. The findings of this study indicate the benefit of intensive BP control for patients with a history of ischemic stroke at high risk of hemorrhagic stroke.
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Affiliation(s)
- Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
| | - Hisatomi Arima
- Department of Prevented Medicine and Public Health, Faculty of Medicine, Fukuoka University, Jonan, Fukuoka, Japan
| | - Yasumasa Yamamoto
- Department of Stroke Center, Kyoto Katsura Hospital, Nishikyo, Kyoto, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology & Therapeutics, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takahide Kohro
- Department of Cardiovascular Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Koji Yonemoto
- Division of Biostatistics, School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | | | - Takao Saruta
- Department of Internal Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazuyuki Shimada
- Cardiovascular Medicine, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
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Ip BY, Ko H, Wong GLH, Yip TCF, Lau LHS, Lau AYL, Leng X, Leung H, Chan HHW, Chan HYF, Mok VCT, Soo YOY, Leung TW. Thromboembolic Risks with Concurrent Direct Oral Anticoagulants and Antiseizure Medications: A Population-Based Analysis. CNS Drugs 2022; 36:1313-1324. [PMID: 36424415 PMCID: PMC9712286 DOI: 10.1007/s40263-022-00971-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Drug-drug interactions between direct oral anticoagulants (DOAC) and antiseizure medications via the cytochrome P450 (CYP) or the P-glycoprotein (P-gp) systems may lead to under-anticoagulation. The clinical relevance of these interactions is unclear. We aimed to elucidate the risk of thromboembolism with concurrent DOAC and CYP/P-gp modulating antiseizure medications. METHODS In this propensity score-weighted population-based retrospective cohort study, we used competing risk regression analyses to determine the risks of ischemic stroke, venous thromboembolism, and death in DOAC recipients taking CYP/P-gp-modulating antiseizure medications (phenytoin, valproate, levetiracetam, carbamazepine, or phenobarbital) versus those taking CYP/P-gp-neutral antiseizure medications (pregabalin, gabapentin, or clobazam). We also performed secondary analyses for the epilepsy and atrial fibrillation subgroups. RESULTS Among DOAC users, CYP/P-gp-modulating antiseizure medications were collectively associated with an increased risk of ischemic stroke (adjusted hazard ratio 1.28, 95% confidence interval 1.05-1.57, p = 0.017). In addition, phenytoin (adjusted hazard ratio 1.34, 95% confidence interval 1.07-1.68, p = 0.011) and valproate (adjusted hazard ratio 1.38, 95% confidence interval 1.10-1.74, p = 0.006) were associated with increased mortality. In the epilepsy subgroup, the risk of ischemic stroke and venous thromboembolism did not differ between CYP/P-gp-modulating and CYP/P-gp-neutral antiseizure medications. CONCLUSIONS Although CYP/P-gp-modulating antiseizure medications were associated with an increased risk of ischemic stroke when paired with DOAC in the primary analysis, such a phenomenon was not found among patients with epilepsy who took phenytoin, valproate, or levetiracetam with DOAC. Therefore, these antiseizure medication options among patients with epilepsy with concurrent DOAC should not be restricted solely based on their potential drug-drug interactions. Yet, the increased mortality during concurrent use of DOAC with phenytoin or valproate might call for caution.
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Affiliation(s)
- Bonaventure Y. Ip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Ho Ko
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Grace LH Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Terry CF Yip
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Medical Data Analytic Centre, The Chinese University of Hong Kong, Hong Kong, China
| | - Louis HS Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Alexander YL Lau
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Howan Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Howard HW Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Helen YF Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Vincent CT Mok
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China ,Li Ka Shing Institute of Health Sciences, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie OY Soo
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas W. Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
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Kamel H, Zhang C, Kleindorfer DO, Levitan EB, Howard VJ, Howard G, Soliman EZ, Johnston SC. Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic Attack: Secondary Analysis of the POINT Randomized Clinical Trial. JAMA Neurol 2021; 77:601-605. [PMID: 32091536 DOI: 10.1001/jamaneurol.2020.0010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective. Objective To examine the association between black race and early ischemic stroke recurrence. Design, Setting, and Participants This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data. Main Outcomes and Measures The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype. Results Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients. Conclusions and Relevance Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures. Trial Registration clinicaltrials.gov Identifier: NCT00991029.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York.,Deputy Editor
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | | | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Virginia J Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Internal Medicine-Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Predictors of Recurrent Ischemic Stroke in Obese Patients With Type 2 Diabetes Mellitus: A Population-based Study. J Stroke Cerebrovasc Dis 2020; 29:105173. [PMID: 32912507 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Diabetes and obesity are established risk factors for stroke. The current study aimed to assess risk factors of ischemic stroke recurrence in diabetic patients based on their body mass index (BMI). METHODS A total of 4005 diabetic patients who had a history of ischemic stroke were identified in a retrospective cross-sectional dataset from the Malaysian National Neurology Registry. Patients were classified based on BMI, and multivariable regression analysis was used to evaluate the association between risk factors and recurrent ischemic stroke. RESULTS Among obese patients, those with ischemic heart disease (aOR, 1.873; 95% CI, 1.131-3.103), received formal education (aOR, 2.236; 95% CI, 1.306-3.830), and received anti-diabetic medication (aOR, 1.788; 95% CI, 1.180-2.708) had a higher stroke recurrence risk, while receiving angiotensin receptors blockers (aOR, 0.261; 95% CI, 0.126-0.543) lowered the odds of recurrence. Overweight patients with hypertension (aOR, 1.011; 95% CI, 1.002-1.019) for over 10 years (aOR, 3.385; 95% CI, 1.088-10.532) and diabetes prior to the first stroke (aOR, 1.823; 95% CI, 1.020-3.259) as well as those received formal education (aOR, 2.403; 95% CI, 1.126-5.129) had higher odds of stroke recurrence, while receiving angiotensin-converting enzyme inhibitors (aOR, 0.244; 95% CI, 0.111-0.538) lowered the recurrence risk. Normal weight East Malaysians (aOR, 0.351; 95% CI, 0.164-0.750) receiving beta-blockers (aOR, 0.410; 95% CI, 0.174-0.966) had lower odds of stroke recurrence. CONCLUSIONS Ischemic heart disease, hypertension, receiving anti-hypertensive agents, and educational level were independent predictors of recurrent stroke in obese patients. Managing the modifiable risk factors can decrease the odds of stroke recurrence.
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Sun C, Song B, Jiang C, Zou JJ. Effect of antiplatelet pretreatment on safety and efficacy outcomes in acute ischemic stroke patients after intravenous thrombolysis: a systematic review and meta-analysis. Expert Rev Neurother 2019; 19:349-358. [PMID: 30807235 DOI: 10.1080/14737175.2019.1587295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Chao Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Baili Song
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chunlian Jiang
- Department of Pathology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jian-Jun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Albright KC, Huang L, Blackburn J, Howard G, Mullen M, Bittner V, Muntner P, Howard V. Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality. Neurology 2018; 91:e1741-e1750. [PMID: 30282770 DOI: 10.1212/wnl.0000000000006467] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 07/26/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults. METHODS We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate. RESULTS Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93). CONCLUSION The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.
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Affiliation(s)
- Karen C Albright
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia.
| | - Lei Huang
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - Justin Blackburn
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - George Howard
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - Michael Mullen
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - Vera Bittner
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - Paul Muntner
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
| | - Virginia Howard
- From the Departments of Epidemiology (K.C.A., L.H., P.M., V.H.), Health Care Organization and Policy (J.B.), Biostatistics (G.H.), and Medicine (V.B.), University of Alabama at Birmingham; Geriatric Research, Education and Clinical Center (K.C.A.), Birmingham VA Medical Center, AL; and Department of Neurology (M.M.), University of Pennsylvania, Philadelphia
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Ruediger CD, John B, Kumar S, Lim HS, Rangnekar G, Roberts-Thomson KC, Young GD, Chase D, Sanders P, Willoughby SR. Influence of ethnic background on left atrial markers of inflammation, endothelial function and tissue remodelling. Indian Pacing Electrophysiol J 2018; 18:1-5. [PMID: 29477215 PMCID: PMC5840760 DOI: 10.1016/j.ipej.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 08/21/2017] [Accepted: 08/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It has been suggested that ethnicity can make a significant difference to the likelihood of thromboembolic stroke related to atrial fibrillation. Ethnic differences have been shown to alter inflammatory and haemostatic factors; however, this may all be confounded by differences in cardiovascular risk factors between different ethnicity. The impact of different ethnicities on the thrombogenic profile is not known. The aim of this study was to investigate differences in markers of inflammation, endothelial function and tissue remodelling between Caucasian and Indian populations with supraventricular tachycardia (SVT). METHODS Patients with structurally normal hearts undergoing catheter ablation for SVT were studied. This study included 23 Australian (Caucasian) patients from the Royal Adelaide Hospital, Adelaide, Australia and 24 Indian (Indian) patients from the Christian Medical College, Vellore, India. Blood samples were collected from the femoral vein, and right and left atria. Blood samples were analysed for the markers of endothelial function (ADMA, ET-1), inflammation (CD40L, VCAM-1, ICAM-1), and tissue remodelling (MMP-9, TIMP-1) using ELISA. RESULTS The study populations were well matched for cardiovascular risk factors and the absence of structural heart disease. No difference in the echocardiographic measurements between the two ethnicities was found. In this context, there was no difference in markers of inflammation, endothelial function or tissue remodelling between the two SVT populations. CONCLUSION Caucasian and Indian populations demonstrate similar inflammatory, endothelial function or tissue remodelling profiles. This study suggests a lack of an impact of different ethnicity in these populations in terms of thrombogenic risk.
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Affiliation(s)
- Carlee D Ruediger
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Bobby John
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Sathesh Kumar
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Han S Lim
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Geetanjali Rangnekar
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Glenn D Young
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - David Chase
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Scott R Willoughby
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia.
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Choi HH, Lee JJ, Cho YD, Han MH, Cho WS, Kim JE, An SJ, Mun JH, Yoo DH, Kang HS. Antiplatelet Premedication for Stent-Assisted Coil Embolization of Intracranial Aneurysms: Low-Dose Prasugrel vs Clopidogrel. Neurosurgery 2017; 83:981-988. [PMID: 29301051 DOI: 10.1093/neuros/nyx591] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022] Open
Abstract
Abstract
BACKGROUND
The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized.
OBJECTIVE
To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms.
METHODS
This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group).
RESULTS
P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization.
CONCLUSION
Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Dongk-uk University Hospital, Dongkuk Unive-rsity College of Medicine, Ilsan, Korea
| | - Jung Jun Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Joon An
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Prevalence of Pragmatically Defined High CV Risk and its Correlates in LMIC: A Report From 10 LMIC Areas in Africa, Asia, and South America. Glob Heart 2017; 11:27-36. [PMID: 27102020 DOI: 10.1016/j.gheart.2015.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Currently available tools for assessing high cardiovascular risk (HCR) often require measurements not available in resource-limited settings in low- and middle-income countries (LMIC). There is a need to assess HCR using a pragmatic evidence-based approach. OBJECTIVES This study sought to report the prevalence of HCR in 10 LMIC areas in Africa, Asia, and South America and to investigate the profiles and correlates of HCR. METHODS Cross-sectional analysis using data from the National Heart, Lung, and Blood Institute-UnitedHealth Group Centers of Excellence. HCR was defined as history of heart disease/heart attack, history of stroke, older age (≥50 years for men and ≥60 for women) with history of diabetes, or older age with systolic blood pressure ≥160 mm Hg. Prevalence estimates were standardized to the World Health Organization's World Standard Population. RESULTS A total of 37,067 subjects ages ≥35 years were included; 53.7% were women and mean age was 53.5 ± 12.1 years. The overall age-standardized prevalence of HCR was 15.4% (95% confidence interval: 15.0% to 15.7%), ranging from 8.3% (India, Bangalore) to 23.4% (Bangladesh). Among men, the prevalence was 1.7% for the younger age group (35 to 49 years) and 29.1% for the older group (≥50); among women, 3.8% for the younger group (35 to 59 years) and 40.7% for the older group (≥60). Among the older group, measured systolic blood pressure ≥160 mm Hg (with or without other conditions) was the most common criterion for having HCR, followed by diabetes. The proportion of having met more than 1 criterion was nearly 20%. Age, education, and body mass index were significantly associated with HCR. Cross-site differences existed and were attenuated after adjusting for age, sex, education, smoking, and body mass index. CONCLUSIONS The prevalence of HCR in 10 LMIC areas was generally high. This study provides a starting point to define targeted populations that may benefit from interventions combining both primary and secondary prevention strategies.
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Role of Cilostazol Therapy in Hemodialysis Patients with Asymptomatic Peripheral Arterial Disease: A Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2016; 2016:8236903. [PMID: 27747241 PMCID: PMC5055930 DOI: 10.1155/2016/8236903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 08/11/2016] [Indexed: 12/29/2022]
Abstract
Background. Peripheral arterial disease (PAD) and its relevant complications are more common in hemodialysis (HD) patients, while the evidence regarding antiplatelet therapy in CKD patients is scarce. We retrospectively analyzed the efficacy of cilostazol on outcomes in HD patients with asymptomatic PAD (aPAD). Methods. This cohort study enrolled 217 HD patients (median follow-up time: 5.75 years). Associations between cilostazol use and the outcomes were evaluated by time-dependent Cox regression analysis. Results. During follow-up, 39.5% (47/119) patients used cilostazol for aPAD and 31.8% (69/217) patients died. Cilostazol users had significantly lower CVD and all-cause mortalities (adjusted HR [95% CI]: 0.11 [0.03, 0.51] and 0.2 [0.08, 0.52]) than nonusers. Both death risks were nonsignificantly higher in cilostazol users than in HD patients without aPAD. The unadjusted and adjusted HR [95% CI] of CVD death risk were 0.4 [0.07, 2.12] and 0.14 [0.02, 0.8] for patients with aPAD during follow-up and were 0.74 [0.16, 3.36] and 0.19 [0.04, 0.93] for those with aPAD at initial. Conclusions. In HD patients with aPAD, lower CVD and all-cause mortality rates were observed in low-dose cilostazol user. Further evidences from large-scale prospective study and randomization trial are desired to confirm the effect of cilostazol.
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Akhtar N, Salam A, Kamran S, Bourke P, Joseph S, Santos M, Khan R, Irfan F, Deleu D, Malik RA, Shuaib A. Ethnic variation in acute cerebrovascular disease: Analysis from the Qatar stroke registry. Eur Stroke J 2016; 1:231-241. [PMID: 31008284 DOI: 10.1177/2396987316663776] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 07/20/2016] [Indexed: 11/17/2022] Open
Abstract
Objective We analysed the Qatar stroke registry for ethnic variations in patients admitted with cerebrovascular disease at Hamad General Hospital, Qatar. Methods Patients admitted with acute stroke from January 2014 to December 2015, enrolled in the registry were included in the study. We evaluated the clinical presentation, risk factors, and outcome at discharge and 90 days post-discharge in relation to the patient's ethnic background. Results A total of 1727 patients were enrolled in the Hamad General Hospital stroke registry (Middle Eastern 594 (34.4%), South East Asian 924 (53.5%) and Far Eastern 209 (12.1%)). There were significant differences in risk factors, clinical presentation and prognosis. Compared to Middle Eastern patients, Far Eastern patients were younger (62.8 ± 13.7 vs. 48.9 ± 9.1 years; p < 0.001). Diabetes and hypertension were significantly more common in Middle Eastern patients (358 (60.3%), 458 (77.1%)) compared to South East Asian patients (420 (45.5%), 596 (64.5%)) and Far Eastern patients (57 (27.3%), 154 (73.7%)), respectively (p < 0.001). Stroke was more severe in the Far Eastern group (median (interquartile range) - 5.0 (2-11.5)) compared to the Middle Eastern group (median (interquartile range) - 4.0 (1-8)) and South East Asian (median (interquartile range) - 4.0 (2-9)), p = 0.011. Mortality at 90 days was highest in patients from the Far East (15/209 (8.2%)) compared to the Middle East (35/594 (6.5%)) and South East Asia (33/924 (4.0)), p = 0.028. Patients from the Far East had significantly higher rates of intracranial hemorrhage compared to the Middle East and South East Asia (70/209 (33.5%), 77/594 (13.0%), and 169/924 (18.3%)), respectively (p < 0.001). Conclusion The early age at presentation and the poor control of risk factors, especially in patients from South East Asia and the Far East requires attention.
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Affiliation(s)
- Naveed Akhtar
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Abdul Salam
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Saadat Kamran
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Paula Bourke
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Mark Santos
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Rabia Khan
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Furqan Irfan
- Department of Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Dirk Deleu
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation, Doha, Qatar
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ashfaq Shuaib
- The Neuroscience Institute (Stroke Center of Excellence), Hamad Medical Corporation & Department of Medicine, University of Alberta, Alberta, Canada
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15
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Shi L, Pu J, Xu L, Malaguit J, Zhang J, Chen S. The efficacy and safety of cilostazol for the secondary prevention of ischemic stroke in acute and chronic phases in Asian population--an updated meta-analysis. BMC Neurol 2014; 14:251. [PMID: 25527141 PMCID: PMC4301843 DOI: 10.1186/s12883-014-0251-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 12/11/2014] [Indexed: 12/23/2022] Open
Abstract
Backgrounds While previous meta-analysis have investigated the efficacy of cilostazol in the secondary prevention of ischemic stroke, they were criticized for their methodology, which confused the acute and chronic phases of stroke. We present a new systematic review, which differs from previous meta-analysis by distinguishing between the different phases of stroke, and includes two new randomized, controlled trials (RCTs). Methods All RCTs investigating the effect of cilostazol on secondary prevention of ischemic stroke were obtained. Outcomes were analyzed by Review Manager, including recurrence of cerebral infarction (ROCI), hemorrhage stroke or subarachnoid hemorrhage (HSSH), all-cause death (ACD), and modified Rankin Scale score (mRS). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessed the quality of the evidence. Results 5491 patients from six studies were included in the current study. In secondary prevention of ischemic stroke in chronic phase, cilostazol was associated with a 47% reduction in ROCI (relative risk [RR] 0.53, 95% confidence interval [CI] 0.34 to 0.81, p = 0.003), while no significant difference in HSSH and ACD compared with placebo; and 71% reduction in HSSH (RR 0.29, 95% CI 0.15 to 0.56, p = 0.0002) compared with aspirin, but not in ROCI and ACD. In the secondary prevention of ischemic stroke in acute phase, cilostazol did not show any effect in the ROCI, HSSH, ACD and mRS compared to placebo or aspirin. The quality of the evidence from chronic phase was high or moderate, and those from acute phase were moderate or low when analyzed by GRADE approach. Conclusion Cilostazol provided a protective effect in the secondary prevention of the chronic phase of ischemic stroke.
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Affiliation(s)
- LiGen Shi
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - JiaLi Pu
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Liang Xu
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - Jay Malaguit
- Department of Physiology and Pharmacology, Loma Linda University, Loma Linda, CA, USA.
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
| | - Sheng Chen
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, Zhejiang, China.
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