Demographics, socio-economic characteristics, and risk factor prevalence in patients with non-cardioembolic ischaemic stroke in low- and middle-income countries: the OPTIC registry

Stroke as the index presentation of traditional cardiovascular risk factors and Human Immunodeficiency Virus in a South African population

OBJECTIVES

We sought to identify what proportion of each cardiovascular risk factor and Human Immunodeficiency Virus (HIV) was first diagnosed at the time of stroke, compared to those that were diagnosed prior to the event, and to explore if this had any impact on the severity of stroke.

METHODS

Adult patients presenting with a new stroke to a quaternary hospital in Johannesburg between 2014 and 2017 were prospectively recruited. Patients were investigated for undiagnosed traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, obesity and smoking), as well as HIV infection. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS).

RESULTS

346 patients were included. Stroke was the index presentation for at least one risk factor in 199 (57.5 %) patients. Dyslipidaemia was newly diagnosed in 76.0 % of all dyslipidaemics (95 out of 125). Newly-diagnosed dyslipidaemia was associated with a more severe neurological deficit (Median NIHSS of 12 (8-16) vs 7 (4-12), p=0.0007) and younger age on presentation (53 (44-63) years vs 62 (51-71) years, p=0.02) as compared to previously-diagnosed dyslipidaemia.

CONCLUSIONS

More than half of patients had previously undiagnosed modifiable risk factors at the time of their stroke. Dyslipidaemia was undiagnosed in a very high proportion, and this was associated with a higher stroke severity and younger age of presentation.

Shedding Light on the Causes and Characteristics of Stroke in Lebanon: A Systematic Review of Literature

BACKGROUND

The prevalence and severity of stroke in Lebanon has increased over the past decade and stroke is currently the second leading cause of death in the country.

METHODS

We systematically reviewed existing research on stroke prevalence, risk factors, mortality and morbidity of stroke, stroke treatment, and stroke education to assess the epidemiology of stroke in Lebanon. A literature search was conducted on the PubMed database for articles presenting data in any of these 5 categories in Lebanon, as well as articles discussing the Middle East and North Africa region generally.

RESULTS

A high prevalence of modifiable risk factors (cigarette and waterpipe smoking) and risk factors that could be mitigated by lifestyle changes (obesity and hypertension) were found in Lebanon. Stroke mortality rates and risk factors of mortality were consistent with global trends, though the cost of treatment in Lebanon was significantly higher than in other developing nations.

CONCLUSION

Urgent public health initiatives are needed to educate the public about the dangers of modifiable stroke risk factors and to reduce the burden of stroke in Lebanon.

Prevalence of uncontrolled hypertension in people with comorbidities in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

The burden of uncontrolled hypertension in sub-Saharan Africa (SSA) is high and hypertension is known to coexist with other chronic diseases such as kidney disease, diabetes among others. This is the first systematic review and meta-analysis to determine the burden of uncontrolled hypertension among patients with comorbidities in SSA.

METHODS

A comprehensive search was conducted on MEDLINE, Excerpta Medica Database (Embase) and Web of Science to identify all relevant articles published between 1 January 2000 and 17 June 2021. We included studies that reported on the prevalence of uncontrolled hypertension among people in SSA who report taking antihypertensive treatment and have another chronic condition. A random-effects meta-analysis was performed to obtain the pooled estimate of the prevalence of uncontrolled hypertension among patients with comorbid conditions while on treatment across studies in SSA.

RESULTS

In all, 20 articles were included for meta-analyses. Eleven articles were among diabetic patients, five articles were among patients with HIV, two were among patients with stroke while chronic kidney disease and atrial fibrillation had one article each. The pooled prevalence of uncontrolled hypertension among patients with comorbidities was 78.6% (95% CI 71.1% to 85.3%); I² 95.9%, varying from 73.1% in patients with stroke to 100.0% in patients with atrial fibrillation. Subgroup analysis showed differences in uncontrolled hypertension prevalence by various study-level characteristics CONCLUSION: This study suggests a high burden of uncontrolled hypertension in people with comorbidities in SSA. Strategies to improve the control of hypertension among people with comorbidities are needed.

PROSPERO REGISTRATION NUMBER

CRD42019108218.

Long-Term Trends in Stroke Management and Burden Among Low-Income Women in a Rural Area From China (1992-2019): A Prospective Population-Based Study

Although an increasing number of studies are considering sex-related differences in stroke burden, the trends in stroke burden and management among women in China, especially among low-income women, remain unclear. This study evaluated the long-term trends in stroke management and burden among low-income Chinese women during the period between 1992 and 2019. Stroke burden was assessed using the age-adjusted incidence of first-ever stroke, whereas stroke management was assessed using the rates of neuroimaging diagnoses, hospitalizations, case fatalities, and stroke recurrence. Stroke burden and management were analyzed during four study periods: 1992–1998, 1999–2004, 2005–2012, and 2013–2019. During the 193,385 person-years of surveillance in this study, 597 female stroke patients were identified. The stroke incidences per 100,000 person-years were 88.1 cases during 1992–1998, 145.4 cases during 1999–2004, 264.3 cases during 2005–2012, and 309.8 cases during 2013–2019 (P < 0.001). Between 1992 and 2019, the incidence of stroke significantly increased (6.4% annually) as did the incidence of ischemic stroke (7.8% annually; both, P < 0.001). The rates of neuroimaging diagnoses and hospitalizations significantly increased during the four periods, while the case fatality rates and 1-year recurrence rates decreased significantly for both overall strokes and ischemic strokes, especially among patients ≥45 years old (all, P < 0.001). Among low-income women in China, stroke management is gradually improving, despite the increasing stroke burden. Thus, improved healthcare coverage is needed to further reduce the stroke burden among low-income Chinese women.

Occupational class differences in outcomes after ischemic stroke: a prospective observational study

BACKGROUND

Occupational class is an integral part of socioeconomic status. The studies focused on the occupational difference in ischemic stroke outcome in a Chinese population are limited. We aimed to investigate the associations between occupational class and the prognosis of patients with ischemic stroke in China.

METHODS

We included 1484 ischemic stroke participants (mean age: 63.42 ± 11.26 years) from the prospective cohort study: Infectious Factors, Inflammatory Markers and Prognosis of Acute Ischemic Stroke (IIPAIS). Occupational class was categorized into white-collar workers, blue-collar workers and farmers in our study. Study outcomes were cardiovascular events and all-cause mortality within 12 months after ischemic stroke onset. We applied Cox proportional hazard model to evaluate the associations between the occupational class and study outcomes after ischemic stroke.

RESULTS

Within 12 months after ischemic stroke, there were 106 (7.5%) cardiovascular events and 69 (4.9%) all-cause deaths. The Kaplan-Meier plots showed that white-collar workers had highest risk of cardiovascular events after 12-month follow-up (Log-rank P = 0.02). Multivariate adjusted hazard ratio and 95% confidence intervals (CIs) of farmers versus white-collar workers was 0.43(0.20-0.91) for cardiovascular events. No significant difference showed in blue-collar workers versus white-collar workers, with fully adjusted hazard ratio 0.62(95% CIs, 0.23-1.67).

CONCLUSIONS

Compared with white-collar workers, farmers are associated with less risk of cardiovascular events at 12 months after ischemic stroke, while there are no significant differences in blue-collar workers.

Impact of Lower Versus Higher LDL Cholesterol Targets on Cardiovascular Events After Ischemic Stroke in Patients With Diabetes

After an ischemic stroke with evidence of atherosclerosis, lipid-lowering treatment with a target LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL reduced the risk of subsequent cardiovascular events. In this analysis, we explored the effect in the subgroup of patients with diabetes compared with the subgroup without, as well as in those with newly diagnosed diabetes. Patients with ischemic stroke in the previous 3 months or transient ischemic attack within the previous 15 days and evidence of cerebrovascular or coronary artery atherosclerosis were randomly assigned at a 1:1 ratio to a target LDL cholesterol of <70 mg/dL or 100 ± 10 mg/dL using statin or ezetimibe. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization, and death resulting from vascular disease. We performed a prespecified analysis to evaluate the effect in patients with diabetes. Of 2,860 patients enrolled, 643 had diabetes at baseline, with a mean age of 66.2 years and baseline LDL cholesterol of 127 mg/dL, and were followed for a median of 3 years. The primary composite end point occurred in 27 (8.2%) of 328 patients in the lower-target group and in 44 (14.0%) of 315 patients in the higher-target group (adjusted hazard ratio [HR] 0.56; 95% CI 0.34-0.89; P = 0.016). In patients without diabetes, the HR was 0.87 (95% CI 0.66-1.14; P = 0.31; interaction P = 0.15). In those with diabetes, there were three intracranial hemorrhages in both randomization groups (0.9% vs. 1.0%, respectively). Newly diagnosed diabetes occurred in 98 (9.2%) of 1,070 and in 80 (7.4%) of 1,085 patients in the lower- and higher-target groups, respectively (HR 1.27; 95% CI 0.94-1.71; P = 0.11), and baseline higher HbA_1c was the unique multivariable predictor. In conclusion, after an ischemic stroke with evidence of atherosclerosis, targeting an LDL cholesterol of <70 mg/dL compared with 100 ± 10 mg/dL consistently reduced the risk of subsequent stroke and other major vascular events in patients with and without diabetes, but the higher risk in those with diabetes yielded a higher absolute risk reduction, with number needed to treat of 17.

Diabetes in ischaemic stroke in a regional Australian hospital - uncharted territory

BACKGROUND

Stroke and diabetes (DM) are significant interrelated healthcare issues but there is a dearth of data on the prevalence of DM among Australia's regional stroke population.

AIMS

We aimed to determine the prevalence of DM in stroke patients at a large regional centre, including sub-analyses on stroke subtypes, glycaemic control and renal function in ischaemic stroke (IS).

METHODS

We conducted a retrospective analysis of all patients (n = 323) with IS or transient ischaemic attack (TIA) admitted to Ballarat Base Hospital from January 2015 to December 2016. Demographic data, cardiovascular risk factors, aetiology/territory of IS, pre-morbid DM status, indicators of glycaemic control and renal impairment were recorded.

RESULTS

DM was present in 28.5% of IS and TIA patients including 4% being newly diagnosed. Among diabetic IS patients, 45.3% had poor glycaemic control (HbA1c ≥7.0%) while 16% had moderate to severe renal impairment (eGFR of <30). The majority of IS were partial anterior circulation stroke (53.4%) and cardioembolism was the commonest mechanism (43.5%). We found no significant association between DM and a specific stroke location or mechanism.

CONCLUSION

Almost a third of IS/TIA patients had DM with a significant proportion showing poor glycaemic control. The DM prevalence in our cohort was comparable to reported rates from other developed countries. While we found no association between DM and a particular stroke type or mechanism, it is likely a reflection of our cohort size. Our study demonstrated that DM, as a significant risk factor in IS, warrants early detection and better management strategies. This article is protected by copyright. All rights reserved.

Impact of Low Ankle-Brachial Index on the Risk of Recurrent Vascular Events

Background and Purpose- Low ankle-brachial index (ABI) identifies a stroke subgroup with high risk of recurrent stroke, cardiovascular events, and death. However, limited data exist on the relationship between low ABI and stroke in low and middle-income countries. Therefore, we evaluated the prevalence of ABI ≤0.90 (which is diagnostic of peripheral artery disease) in nonembolic stroke patients or transient ischemic attack and assessed the correlation of low ABI with stroke risk, factors, and recurrent vascular events and death. Methods- Patients ≥45 years with acute transient ischemic attack or minor ischemic strokes were recruited consecutively from over 17 low-income and middle-income countries (Latin America [1543 patients], Middle East [1041 patients], North Africa [834 patients], and South Africa [217 patients]). The ABI measurement was performed at a single visit. Stroke recurrence and risk of new vascular events were assessed after 24 months of follow-up. Results- Among 3487 enrolled patients, abnormal ABI (<0.9) was present in 22.3 %. Patients with an ABI of ≤0.9 were more likely ( P<0.05) to be male, older, and have a history of peripheral artery disease, hypertension, and diabetes mellitus. During 2-year follow-up, the rate of major cardiovascular event was higher in patients with ABI <0.9 than those with ABI ≥0.9 (Kaplan-Meier estimates, 22.5%; 95% CI, 19.6-25.8 versus 13.7%; 21.4-15.1; P<0.001), and when ABI was categorized into 4 groups (≤0.6; 95% CI, 0.6-0.9; 0.9-1; 1-1.4), the rate of major cardiovascular event was higher in those with ABI ≤0.6 than the other groups (Kaplan-Meier estimates, 32.6%; 95% CI, 21.0-48.3 for ABI≤0.6 versus 21.7%; 95% CI, 18.8-25.0 for ABI 0.6-0.9 versus 14.3%; 95% CI, 12.4-16.6 for ABI 0.9-1 versus 13.3%; 95% CI, 11.6-15.2 for ABI 1-1.4; P<0.001). Conclusions- Among patients with nonembolic ischemic stroke or transient ischemic attack, those with low ABI had a higher rate of vascular events and death in this population. Screening for ABI in stroke patients may help identify patients at high risk of future events.

Ischemic stroke and infectious diseases in low-income and middle-income countries

PURPOSE OF REVIEW

To address the important relationships between stroke and infection, focusing on the most frequent infections found in low-income and middle-income countries.

RECENT FINDINGS

Stroke is one of the leading causes of mortality and disability worldwide, with a great proportion of the stroke burden occurring in low-income and middle-income countries. Infectious diseases are still a great health problem in developing countries and it is possible that the proportion of infection-related strokes is greater in these nations. Infectious diseases and stroke have a bidirectional relationship. Common infections may act as risk factors and can trigger stroke through different mechanisms in their acute phase. Several intracranial and systemic infections can cause stroke as a direct complication, such as Chagas disease, neurosyphilis, tuberculous meningitis, and neurocysticercosis. These conditions are of particular interest to low-income and middle-income countries, but also relevant to high-income nations because of increasing migration. Finally, infection is a frequent poststroke complication, with great impact in the patient outcome.

SUMMARY

Infectious diseases and stroke are common problems in low-income and middle-income countries. More studies are necessary to fully elucidate the real impact of infectious diseases on stroke burden, especially in countries where epidemiological data are still scarce.

Stroke in the Middle-East and North Africa: A 2-year prospective observational study of stroke characteristics in the region-Results from the Safe Implementation of Treatments in Stroke (SITS)-Middle-East and North African (MENA)

BACKGROUND AND METHODS

Stroke incidence and mortality are reported to have increased in the Middle-East and North African (MENA) countries during the last decade. This was a prospective observational study to examine the baseline characteristics of stroke patients in the MENA region and to compare the MENA vs. the non-MENA stroke cohort in the Safe Implementation of Treatments in Stroke (SITS) International Registry.

RESULTS

Of the 13,822 patients with ischemic and hemorrhagic stroke enrolled in the SITS-All Patients Protocol between June 2014 and May 2016, 5897 patients (43%) were recruited in MENA. The median onset-to-door time was 5 h (IQR: 2:20-13:00), National Institutes of Health Stroke Scale (NIHSS) score was 8 (4-13) and age was 65 years (56-76). Hypertension (66%) and diabetes (38%) were the prevailing risk factors; large artery stenosis > 50% (25.3%) and lacunar strokes (24.1%) were the most common ischemic stroke etiologies. In comparison, non-MENA countries displayed an onset-to-door time of 5:50 h (2:00-18:45), a median of NIHSS 6 (3-14), and a median age of 66 (56-76), with other large vessel disease and cardiac embolism as the main ischemic stroke etiologies. Hemorrhagic strokes (10%) were less common compared to non-MENA countries (13.9%). In MENA, only a low proportion of patients (21%) was admitted to stroke units.

CONCLUSIONS

MENA patients are slightly younger, have a higher prevalence of diabetes and slightly more severe ischemic strokes, commonly of atherosclerotic or microvascular etiology. Admission into stroke units and long-term follow-up need to be improved. It is suspected that cardiac embolism and atrial fibrillation are currently underdiagnosed in MENA countries.

Factors associated with hospital arrival time after the onset of stroke symptoms: A cross-sectional study at two teaching hospitals in Harare, Zimbabwe

Background

Late presentation to hospital after onset of stroke affects management and outcomes of the patients. This study aimed to determine the factors associated with time taken to present to hospital after the onset of acute stroke symptoms.

Methods

A descriptive cross sectional study was conducted at two teaching hospitals in Zimbabwe. Participants included patients admitted with stroke and their relatives. A self-administered questionnaire was used to collect information on history of stroke occurrence and time taken to present to hospital. Data was analysed for means, frequencies, percentages and Odds ratios.

Results

Less than half (33%) of the participants were able to recognize symptoms of stroke. Not having money to pay for hospital bills was a predictor of late hospital presentation (OR =6.64; 95% CI, (2.05–21.53); p=0.002). The other factors, though not statistically significant included not perceiving stroke as a serious illness (OR = 2.43; 95% CI (0.78–5.51); p=0.083) and unavailability of transport (OR=2.33; 95% CI (0.71–7.56); p=0.161). Predictors for early presentation included receiving knowledge about stroke from the community (OR=0.46; 95% CI (0.15–1.39); p=0.170); seeking help at the hospital (OR=0.50; 95% CI (0.18–1.37); p=0.177) and having a stroke while at the workplace (OR =0.46; 95% CI (0.08–2.72); p=0.389).

Conclusions

Regarding stroke as an emergency that does not require prerequisite payment for services at hospitals and improved community awareness on stroke may improve time taken to present to hospital after the onset of stroke symptoms.

A retrospective analysis of 254 acute stroke cases admitted to two university hospitals in Beirut: classification and associated factors

Lebanon is a developing country where the prevalence of stroke subtypes and their correlation with risk factors have not been studied, even though stroke management is an ongoing major national healthcare challenge. In a retrospective study conducted in two university hospitals, data were collected on all stroke cases admitted in 2012 and 2013. Ischemic strokes were then classified according to a modified TOAST classification. A total of 254 inpatients (mean age 68.41 years ±13.34, 55.1% males) was included in the study; of these, 15% had had a hemorrhagic stroke and was therefore excluded. Conversely to findings from studies in other Arab and Asian countries, where small vessel disease is the most frequent subtype, our study showed a predominance of large artery atherosclerosis (53.5%) which, in comparison with other subtypes, was found to be associated with dyslipidemia (OR= 3.82, 95% CI= [1.76-8.28]; p=0.001). Cardioembolic stroke and small vessel disease were found to be positively associated with aging and living in Beirut, respectively. Larger studies are needed to explain these findings.

Specificities of Ischemic Stroke Risk Factors in Arab-Speaking Countries

BACKGROUND

Stroke is largely preventable, and therefore, a better understanding of risk factors is an essential step in reducing the population stroke rate and resulting disease burden in Arab countries.

SUMMARY

We performed 2 separate analyses in 2 similar populations of patients with noncardioembolic ischemic stroke. This first involved 3,635 patients in the Outcomes in Patients with TIA and Cerebrovascular disease (OPTIC) registry (followed for 2 years), with baseline collection of the usual risk factors and 5 socioeconomic variables (unemployment status, residence in rural area, living in fully serviced accommodation, no health-insurance coverage, and low educational level). The second involved patients in the PERFORM trial (n = 19,100 followed up for 2 years), with baseline collection of the usual risk factors and 1 socioeconomic variable (low educational level). The primary outcome was a composite of nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death. Stroke risk factors were more prevalent in patients in Arab countries. The incidence of major cardiovascular events (MACE; age- and gender-adjusted) was higher in Arab countries (OPTIC, 18.5 vs. 13.3%; PERFORM, 18.4 vs. 9.7%; both p ≤ 0.0001). These results remained significant after adjustment on risk factors and were attenuated in OPTIC after further adjustment on socioeconomic variables (hazard ratio 1.24; 95% CI 0.98-1.55; p = 0.07). Key Messages: Patients with ischemic stroke living in Arab countries had a lower mean socioeconomic status, a much higher prevalence of diabetes mellitus, and a higher rate of MACE compared with patients from non-Arab countries. This finding is partly explained by a higher prevalence of risk factors and also by a high prevalence of poverty and low educational level.

Metabolic Syndrome Is a Strong Risk Factor for Minor Ischemic Stroke and Subsequent Vascular Events

Background

Minor ischemic stroke (MIS) represents a major global public health problem worldwide due to high incidence. The aim of this study was to investigate whether metabolic syndrome (MetS) is a strong risk for MIS and subsequent vascular events (SVE).

Methods

A retrospective cohort study was performed examining symptomatic MIS in a Chinese neurologic outpatient population aged over 25 years without history of stroke. MetS was defined using the International Diabetes Federation criteria. MIS was diagnosed by magnetic resonance imaging-diffusion weighted images or fluid-attenuated inversion recovery.

Results

Of 1361 outpatients, a total of 753 (55.3%) patients were diagnosed with MIS; of them, 80% had a score of 0 using the MIS had a 0 score on the National Institutes of Health Stroke Scale. Among these, 303 (40.2%) individuals with MIS were diagnosed with MetS. Diagnosed of MIS with MetS significantly correlated with abdominal obesity (30.7% v.s 18.0%), hypertension (91.1% v.s 81.6%), increased blood glucose (6.9±2.4 v.s 5.0±0.4), dyslipidemia (78.2% v.s 48.2%), and SVE (50.5% v.s 11.3%) when compared with the controls group. On adjusted analysis, the risk of SVE was also significantly associated with three additional MetS criterion (RR,9.0; 95% CI, 5.677–14.46). Using Cox proportional analysis, risk of SVE in patient with MIS was significantly associated with MetS (RR, 3.3; 95% CI, 1.799–6.210), older age (RR, 1.0; 95% CI, 1.001–1.048), and high blood glucose (RR,1.1; 95%CI, 1.007–1.187).

Conclusions

The MetS is a strong risk factor for MIS, and patients presenting with MIS and MetS are at a high risk of SVE. Further studies are required to determine the improvement of Mets prevention in the reduction of MIS and SVE.

Maintenance Dialysis throughout the World in Years 1990 and 2010

Rapidly rising global rates of chronic diseases portend a consequent rise in ESRD. Despite this, kidney disease is not included in the list of noncommunicable diseases (NCDs) targeted by the United Nations for 25% reduction by year 2025. In an effort to accurately report the trajectory and pattern of global growth of maintenance dialysis, we present the change in prevalence and incidence from 1990 to 2010. Data were extracted from the Global Burden of Disease 2010 epidemiologic database. The results are on the basis of an analysis of data from worldwide national and regional renal disease registries and detailed systematic literature review for years 1980-2010. Incidence and prevalence estimates of provision of maintenance dialysis from this database were updated using a negative binomial Bayesian meta-regression tool for 187 countries. Results indicate substantial growth in utilization of maintenance dialysis in almost all world regions. Changes in population structure, changes in aging, and the worldwide increase in diabetes mellitus and hypertension explain a significant portion, but not all, of the increase because increased dialysis provision also accounts for a portion of the rise. These findings argue for the importance of inclusion of kidney disease among NCD targets for reducing premature death throughout the world.

Impact of living and socioeconomic characteristics on cardiovascular risk in ischemic stroke patients

OBJECTIVE

We aimed to stratify the risk of vascular event recurrence in patients with cerebral infarction according to living and socioeconomic characteristics and geographic region.

METHOD

The Outcomes in Patients with TIA and Cerebrovascular Disease (OPTIC) study is an international prospective study of patients aged 45 years or older who required secondary prevention of stroke [following either an acute transient ischemic attack, minor ischemic strokes, or recent (less than six-months previous), stable, first-ever, nondisabling ischemic stroke]. A total 3635 patients from 245 centers in 17 countries in four regions (Latin America, Middle East, North Africa, South Africa) were enrolled between 2007 and 2008. The outcome measure was the two-year rate of a composite of major vascular events (vascular death, myocardial infarction and stroke).

RESULTS

During the two-year follow-up period, 516 patients experienced at least one major cardiovascular event, resulting in an event rate of 15·6% (95% confidence interval 14·4-16·9%). Event rates varied across geographical region (P < 0·001), ranging from 13·0% in Latin America to 20·7% in North Africa. Unemployment status, living in a rural area, not living in fully serviced accommodation (i.e., house or apartment with its own electricity, toilet and water supply), no health insurance coverage, and low educational level (less than two-years of schooling) were predictors of major vascular events. Major vascular event rates steeply increased with the number of low-quality living/socioeconomic conditions (from 13·4% to 47·9%, adjusted P value for trend <0·001).

CONCLUSION

Vascular risk in stroke patients in low- and middle-income countries varies not only with the number of arterial beds involved but also with socioeconomic variables.