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Hyacinth HI, Carty CL, Seals SR, Irvin MR, Naik RP, Burke GL, Zakai NA, Wilson JG, Franceschini N, Winkler CA, David VA, Kopp JB, Judd SE, Adams RJ, Longstreth WT, Egede L, Lackland DT, Taylor H, Manson JE, Howard V, Allison M, Gee BE, Correa A, Safford MM, Arnett DK, Howard G, Reiner AP, Cushman M. Association of Sickle Cell Trait With Ischemic Stroke Among African Americans: A Meta-analysis. JAMA Neurol 2019; 75:802-807. [PMID: 29710269 DOI: 10.1001/jamaneurol.2018.0571] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance African Americans and individuals of African ancestry have a higher risk of stroke compared with non-Hispanic white individuals. Identifying the source of this disparity could provide an opportunity for clinical stroke risk stratification and more targeted therapy. Whether sickle cell trait (SCT) is an indicator of increased risk of ischemic stroke among African Americans is still unclear. Objective To examine whether SCT is associated with a higher risk of incident ischemic stroke among African Americans. Design, Setting, and Participants This meta-analysis assessed the association of SCT with the risk of incident ischemic stroke. Four large, prospective, population-based studies with African American cohorts were assessed: Jackson Heart Study (September 1, 2005, through December 31, 2012), Multi-Ethnic Study of Atherosclerosis (July 1, 2002, through December 31, 2012), Reasons for Geographic and Racial Differences in Stroke (January 1, 2003, through December 31, 2014), and Women's Health Initiative (October 1, 1998, through December 31, 2012). Using a Cox proportional hazards regression model adjusted for major stroke risk factors, this study estimated the hazard ratio for incident ischemic stroke associated with SCT. Data analysis was performed from July 10, 2016, to February 2, 2017. Interventions or Exposures Participants' SCT status determined by polymerase chain reaction assay genotyping or a combination of whole-exome sequencing and imputation. Main Outcomes and Measures Incident ischemic stroke. Results This meta-analysis included 19 464 African American individuals (1520 with SCT, 17 944 without SCT, and 620 with ischemic stroke) from 4 studies, with a mean (SD) age of 60.0 (13.0) years (5257 [27.0%] men and 14 207 [73.0%] women). No differences were found in the distribution of risk factors for ischemic stroke comparing participants with and those without SCT at study visit 1 in each cohort. The crude incidence of ischemic stroke was 2.9 per 1000 person-years (95% CI, 2.2-4.0 per 1000 person-years) among those with SCT and 3.2 per 1000 person-years (95% CI, 2.7-3.8 per 1000 person-years) among those without SCT. After stroke risk factors were adjusted for, the hazard ratio of incident ischemic stroke independently associated with SCT in the meta-analysis of all 4 cohorts was 0.80 (95% CI, 0.47-1.35; P = .82). The results of the meta-analysis were similar to those of individual cohorts, in which the results were also similar. Conclusions and Relevance Sickle cell trait may not be associated with incidence of ischemic stroke among African Americans. The results of this study suggest performing a more thorough clinical evaluation of a stroke patient with SCT rather than assuming that SCT is the etiologic factor for the stroke.
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Affiliation(s)
- Hyacinth I Hyacinth
- Aflac Cancer and Blood Disorder Center, Emory Children's Center, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Cara L Carty
- Women's Health Initiative, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Samantha R Seals
- Department of Mathematics and Statistics, Hal Marcus College of Science and Engineering, University of West Florida, Pensacola
| | - Marguerite R Irvin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Rakhi P Naik
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Gregory L Burke
- Division of Public Health Science, Wake Forest University, Winston-Salem, North Carolina
| | - Neil A Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington.,Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington
| | - James G Wilson
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson
| | | | - Cheryl A Winkler
- Basic Science Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, National Cancer Institute, Frederick, Maryland
| | - Victor A David
- Basic Science Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research, National Cancer Institute, Frederick, Maryland
| | - Jeffrey B Kopp
- National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Suzanne E Judd
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Robert J Adams
- Stroke Center, Department of Neurology, Medical University of South Carolina, Charleston
| | - W T Longstreth
- Departments of Neurology and Epidemiology, University of Washington, Seattle
| | - Leonard Egede
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee
| | - Daniel T Lackland
- Stroke Center, Department of Neurology, Medical University of South Carolina, Charleston
| | - Herman Taylor
- Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, Georgia
| | - JoAnn E Manson
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Virginia Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Matthew Allison
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego
| | - Beatrice E Gee
- Department of Pediatrics, Morehouse School of Medicine, Atlanta, Georgia
| | - Adolfo Correa
- Jackson Heart Study, University of Mississippi Medical Center, Jackson
| | - Monika M Safford
- Division of General Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Donna K Arnett
- College of Public Health, University of Kentucky College of Public Health, Lexington
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham
| | - Alexander P Reiner
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington.,Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington
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Caughey MC, Loehr LR, Key NS, Derebail VK, Gottesman RF, Kshirsagar AV, Grove ML, Heiss G. Sickle cell trait and incident ischemic stroke in the Atherosclerosis Risk in Communities study. Stroke 2014; 45:2863-7. [PMID: 25139879 DOI: 10.1161/strokeaha.114.006110] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Numerous case reports describe stroke in individuals with sickle cell trait (SCT) in the absence of traditional risk factors for cerebrovascular disease. To date, no prospective epidemiological studies have investigated this association. METHODS A population-based sample of blacks (n=3497; mean age=54 years; female=62%) was followed from 1987 to 2011 in the Atherosclerosis Risk in Communities (ARIC) study, contributing a total of 65 371 person-years. Hazard ratios and incidence rate differences for ischemic stroke were estimated, contrasting SCT to homozygous hemoglobin A. Models were adjusted for age, sex, smoking, diabetes mellitus, hypertension, total cholesterol, atrial fibrillation, and coronary heart disease. RESULTS SCT was identified in 223 (6.4%) participants. During a median follow-up of 22 years, 401 subjects experienced incident stroke (89% ischemic). Incident ischemic stroke was more frequent among those with SCT (13%) than those with homozygous hemoglobin A (10%). SCT was associated with an ischemic stroke hazard ratio of 1.4 (1.0-2.0) and an incidence rate difference amounting to 1.9 (0.4-3.8) extra strokes per 1000 person-years. CONCLUSIONS We observed an increased risk of ischemic stroke in blacks with SCT. Further investigation of the incidence and pathophysiology of stroke in patients with SCT is warranted.
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Affiliation(s)
- Melissa C Caughey
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Laura R Loehr
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Nigel S Key
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Vimal K Derebail
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Rebecca F Gottesman
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Abhijit V Kshirsagar
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Megan L Grove
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
| | - Gerardo Heiss
- From the Departments of Medicine (M.C.C., N.S.K., V.K.D., A.V.K.) and Epidemiology (M.C.C., L.R.L., G.H.), University of North Carolina at Chapel Hill; Department of Neurology, Johns Hopkins University School of Medicine; Baltimore, MD (R.F.G.); and School of Public Health, Human Genetics Center, The University of Texas Health Science Center, Houston (M.L.G.)
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Abstract
The sickle cell (HbS) gene occurs at a variable frequency in the Middle Eastern Arab countries, with characteristic distribution patterns and representing an overall picture of blood genetic disorders in the region. The origin of the gene has been debated, but studies using β-globin gene haplotypes have ascertained that there were multiple origins for HbS. In some regions the HbS gene is common and exhibits polymorphism, while the reverse is true in others. A common causative factor for the high prevalence and maintenance of HbS and thalassaemia genes is malaria endemicity. The HbS gene also co-exists with other haemoglobin variants and thalassaemia genes and the resulting clinical state is referred to as sickle cell disease (SCD). In the Middle Eastern Arab countries, the clinical picture of SCD expresses two distinct forms, the benign and the severe forms, which are related to two distinct β-globin gene haplotypes. These are referred to as the Saudi-Indian and the Benin haplotypes, respectively. In a majority of the Middle Eastern Arab countries the HbS is linked to the Saudi-Indian haplotype, while in others it is linked to the Benin haplotype. This review outlines the frequency, distribution, clinical feature, management and prevention as well as gene interactions of the HbS genes with other haemoglobin disorders in the Middle Eastern Arab countries.
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Steen RG, Hankins GM, Xiong X, Wang WC, Beil K, Langston JW, Helton KJ. Prospective brain imaging evaluation of children with sickle cell trait: initial observations. Radiology 2003; 228:208-15. [PMID: 12759471 DOI: 10.1148/radiol.2281020600] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine whether sickle cell trait (hemoglobin AS) is associated with abnormalities in the brain of asymptomatic children. MATERIALS AND METHODS Magnetic resonance (MR) imaging and MR angiography were performed prospectively in 26 siblings (eight girls, 18 boys; mean age, 10.5 years) of patients with sickle cell disease. Two neuroradiologists, blinded as to whether a child had hemoglobin AS or AA, reviewed images obtained in siblings. With MR imaging, lacunae, loss of white matter volume, encephalomalacia, or leukoencephalopathy was identified. With MR angiography, arterial stenosis, occlusion, or tortuosity was identified. Images with definite or possible abnormalities were mixed with randomly selected images and were referred to a third neuroradiologist for a completely blinded review. In cases in which all neuroradiologists concurred, a score was assigned that indicated the sibling had an abnormality. MR angiographic findings were assigned a score for tortuosity with a new quantitative scale. RESULTS Among 26 siblings screened, 21 children had sickle cell trait. Among these 21 children, two had mild abnormalities at MR imaging (sample prevalence rate, 10% [95% CI: 1%, 29%]), and four had arterial tortuosity (sample prevalence rate, 19% [95% CI: 5%, 42%]). When children with sickle cell trait were compared with 31 control subjects without the trait, arterial tortuosity was significantly more common in children with sickle cell trait (P =.014). Among children with sickle cell trait, percentage of hemoglobin S was significantly greater in children who had tortuosity than percentage of hemoglobin S in children who had normal blood vessels at MR angiography (P <.03). CONCLUSION Findings suggest that greater percentage of hemoglobin S is associated with mild vasculopathy. This vasculopathy may explain some of the excess risk of stroke among African Americans.
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Affiliation(s)
- R Grant Steen
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, 332 N Lauderdale St, Memphis, TN 38105-2794, USA.
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