Stroke prevention: managing modifiable risk factors

Liver Enzymes and the Risk of Stroke among the General Japanese Population: A Prospective Cohort Study

INTRODUCTION

Stroke is a major cause of morbidity and mortality. Liver enzymes, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma-glutamyl transpeptidase (GGT), are markers of liver diseases with potential cardiovascular implications. This study aimed to investigate the prospective association between liver enzymes and stroke risk.

METHODS

We analyzed data from 3,379 men and 4,007 women without cardiovascular disease and registered in the Suita Study, a Japanese population-based prospective cohort study. The hazard ratios (HRs) and 95% confidence intervals (95% CIs) of stroke risk were estimated per quintiles of ALT, AST, and GGT in men and women.

RESULTS

Within a median follow-up period of 16.7 years, 438 incident stroke events were diagnosed. In men, compared to the second quintiles, the fifth (highest) quintiles of liver enzymes showed increased stroke risks: HRs (95% CIs) = 2.07 (1.35, 3.18) in ALT, 1.66 (1.10, 2.53) in AST, and 1.76 (1.11, 2.81) in GGT. The associations did not change with cerebral infarction risk: HRs (95% CIs) = 2.09 (1.24, 3.50) in ALT, 1.84 (1.11, 3.06) in AST, and 1.74 (1.00, 3.04) in GGT. The lowest ALT, AST, and GGT quintiles tended to show increased stroke and cerebral infarction risks, yet these associations were statistically insignificant. No such associations were shown in women.

CONCLUSION

Elevated ALT, AST, and GGT levels were associated with increased stroke and cerebral infarction risks among Japanese men.

Relationship Between In-Hospital Adverse Events and Hospital Performance on 30-Day All-cause Mortality and Readmission for Patients With Heart Failure

BACKGROUND

Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. We sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events.

METHODS

This cross-sectional study linked the 2009 to 2019 patient-level adverse events data from the Medicare Patient Safety Monitoring System, a randomly selected medical records-abstracted patient safety database, to the 2005 to 2016 hospital-level HF-specific 30-day all-cause mortality and readmissions data from the United States Centers for Medicare & Medicaid Services. Hospitals were classified to one of 3 performance categories based on their risk-standardized 30-day all-cause mortality and readmission rates: better (both in <25th percentile), worse (both >75th percentile), and average (otherwise). Our main outcome was the occurrence (yes/no) of one or more adverse events during hospitalization. A mixed-effect model was fit to assess the relationship between a patient's risk of having adverse events and hospital performance categories, adjusted for patient and hospital characteristics.

RESULTS

The study included 39 597 patients with HF from 3108 hospitals, of which 252 hospitals (8.1%) and 215 (6.9%) were in the better and worse categories, respectively. The rate of patients with one or more adverse events during a hospitalization was 12.5% (95% CI, 12.1-12.8). Compared with patients admitted to better hospitals, patients admitted to worse hospitals had a higher risk of one or more hospital-acquired adverse events (adjusted risk ratio, 1.24 [95% CI, 1.06-1.44]).

CONCLUSIONS

Patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.

Developing a Stroke Risk Prediction Model Using Cardiovascular Risk Factors: The Suita Study

INTRODUCTION

Stroke remains a major cause of death and disability in Japan and worldwide. Detecting individuals at high risk for stroke to apply preventive approaches is recommended. This study aimed to develop a stroke risk prediction model among urban Japanese using cardiovascular risk factors.

METHODS

We followed 6,641 participants aged 30-79 years with neither a history of stroke nor coronary heart disease. The Cox proportional hazard model estimated the risk of stroke incidence adjusted for potential confounders at the baseline survey. The model's performance was assessed using the receiver operating characteristic curve and the Hosmer-Lemeshow statistics. The internal validity of the risk model was tested using derivation and validation samples. Regression coefficients were used for score calculation.

RESULTS

During a median follow-up duration of 17.1 years, 372 participants developed stroke. A risk model including older age, current smoking, increased blood pressure, impaired fasting blood glucose and diabetes, chronic kidney disease, and atrial fibrillation predicted stroke incidence with an area under the curve = 0.76 and p value of the goodness of fit = 0.21. This risk model was shown to be internally valid (p value of the goodness of fit in the validation sample = 0.64). On a risk score from 0 to 26, the incidence of stroke for the categories 0-5, 6-7, 8-9, 10-11, 12-13, 14-15, and 16-26 was 1.1%, 2.1%, 5.4%, 8.2%, 9.0%, 13.5%, and 18.6%, respectively.

CONCLUSION

We developed a new stroke risk model for the urban general population in Japan. Further research to determine the clinical practicality of this model is required.

Sex Differences in Severity of Stroke in the INSTRUCT Study: a Meta-Analysis of Individual Participant Data

Background

Women have worse outcomes after stroke than men, and this may be partly explained by stroke severity. We examined factors contributing to sex differences in severity of acute stroke assessed by the National Institutes of Health Stroke Scale.

Methods and Results

We pooled individual participant data with National Institutes of Health Stroke Scale assessment (N=6343) from 8 population‐based stroke incidence studies (1996–2014), forming part of INSTRUCT (International Stroke Outcomes Study). Information on sociodemographics, stroke‐related clinical factors, comorbidities, and pre‐stroke function were obtained. Within each study, relative risk regression using log‐binominal modeling was used to estimate the female:male relative risk (RR) of more severe stroke (National Institutes of Health Stroke Scale>7) stratified by stroke type (ischemic stroke and intracerebral hemorrhage). Study‐specific unadjusted and adjusted RRs, controlling for confounding variables, were pooled using random‐effects meta‐analysis. National Institutes of Health Stroke Scale data were recorded in 5326 (96%) of 5570 cases with ischemic stroke and 773 (90%) of 855 participants with intracerebral hemorrhage. The pooled unadjusted female:male RR for severe ischemic stroke was 1.35 (95% CI 1.24–1.46). The sex difference in severity was attenuated after adjustment for age, pre‐stroke dependency, and atrial fibrillation but remained statistically significant (pooled RR_adjusted 1.20, 95% CI 1.10–1.30). There was no sex difference in severity for intracerebral hemorrhage (RR_crude 1.08, 95% CI 0.97–1.21; RR_adjusted 1.08, 95% CI 0.96–1.20).

Conclusions

Although women presented with more severe ischemic stroke than men, much although not all of the difference was explained by pre‐stroke factors. Sex differences could potentially be ameliorated by strategies to improve pre‐stroke health in the elderly, the majority of whom are women. Further research on the potential biological origin of sex differences in stroke severity may also be warranted.

Pattern of stroke in a rural Kenyan hospital

Background

The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital.

Patients and Methods

The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts.

Results

Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32–96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%).

Conclusion

Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.

Baduanjin exercise intervention for community adults at risk of ischamic stroke: A randomized controlled trial

The aim of current study was to assess the effects of Baduanjin exercise on cerebrovascular function, cardiac structure and cardiac function, static pulmonary function, traditional risk factors of CVD and the related psychological outcomes in older community adults at risk for ischaemic stroke. A randomized controlled trial was conducted in three community between November 2013 and October 2015. Older community-dwelling adults (N = 170) were randomly allocated into either a Baduanjin training (5 × 60 min/weekly) or control group who kept their unaltered lifestyle during a 12-week intervention period. Primary (cerebral haemodynamic parameters) and secondary outcomes (cardiac structure, cardiac function, static pulmonary function, traditional risk factors and the related psychological outcomes) were measured at baseline, after a 12-week intervention period and after an additional 12-week follow-up period. After the 12-week intervention period and additional 12-week follow-up period, the Baduanjin exercise group displayed significant changes in most cerebral haemodynamic parameters compared to the control group: lower systolic blood pressure, diastolic blood pressure, plasma total cholesterol levels, waist circumference, hip circumference and waist/hip ratio; and improved mood, self-confidence, self-esteem, quality of life and sleep quality. A supervised 12-week Baduanjin exercise intervention was effective and safe in modulating cerebral haemodynamics, reducing blood pressure and improving anthropometric parameters and related psychological outcomes in older community adults at risk for ischaemic stroke.

Therapeutic effects of dietary intervention on neuroinflammation and brain metabolism in a rat model of photothrombotic stroke

INTRODUCTION

A possible target for stroke management is modulation of neuroinflammation. Evidence suggests that food components may exert anti-inflammatory properties and thus may reduce stroke-induced brain damage.

AIM

To investigate the efficacy of a diet, containing anti-inflammatory ingredients, as treatment for focal ischemic brain damage induced by photothrombotic stroke in the somatosensory cortex of rats.

RESULTS

Brain lesions were surrounded by strong astrogliosis on both day 7 and day 21 after stroke and were accompanied by a trend toward globally decreased glucose metabolism on day 7. The investigational diet applied 2 weeks before the ischemia did not affect astrocyte activation on day 7, but reduced it at day 21. The investigational diet applied immediately after the ischemia, increased astrocyte activation on day 7 and completely reversed this effect on day 21. Moreover, postischemic intervention increased glucose metabolism in somatosensory cortex ipsilateral to the lesion on day 7.

CONCLUSION

This study reveals potentially beneficial effects of a diet containing elevated amounts of anti-inflammatory nutrients on the recovery from ischemic brain damage. Therefore, dietary intervention can be considered as an adjuvant therapy for recovery from this brain pathology.

Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013

INTRODUCTION

The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke.

MATERIAL AND METHODS

This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995-1999, 2000-2004, 2005-2009 and 2010-2013.

RESULTS

During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients' age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged.

CONCLUSIONS

Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal.

Prevention, management, and rehabilitation of stroke in low- and middle-income countries

Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.

Qualitative Evaluation of Baduanjin (Traditional Chinese Qigong) on Health Promotion among an Elderly Community Population at Risk for Ischemic Stroke

Background. Baduanjin is a traditional Chinese qigong that has been practiced for a long time in China as a mind-body exercise in community elderly populations. The objective of this study was to qualitatively evaluate the perceived benefit of regular Baduanjin qigong in community elders. Methods. A total of 20 participants who had completed the 12-week Baduanjin qigong training were interviewed regarding their perceived effect on physical and psychological health and whether Baduanjin qigong was suitable for the elderly. Results. Almost all participants agreed that Baduanjin qigong could promote their multisystem or organ functions (e.g., digestive and circulatory systems), increase their immunity, make their bodies relax, and improve their mood and confidence. Most of the participants also agreed that Baduanjin qigong was appropriate for elderly individuals. Few individuals felt bored because of an hour Baduanjin training each day. Conclusions. The findings suggest that regular Baduanjin qigong may be potentially helpful to promote the overall physical and psychological health of elderly community populations and may be useful and feasible as a body-mind exercise in the health promotion in the elderly community populations.

Presence and extent of coronary calcified plaque evaluated by coronary computed tomographic angiography are independent predictors of ischemic stroke in patients with suspected coronary artery disease

Although ischemic stroke and coronary artery disease (CAD) share common risk factors and pathophysiology, the risk of stroke in patients with CAD remains unclear. We sought to evaluate the risk of ischemic stroke in patients with suspected CAD according to coronary computed tomographic angiography (CCTA) and single-photon emission computed tomography (SPECT) findings. Presence, severity, and extent of CAD were evaluated in 1137 patients with suspected CAD who underwent CCTA and SPECT. Primary outcome was the occurrence of ischemic stroke. During follow-up (median 26 months), ischemic stroke was observed in 25 patients (2.2%). The presence of coronary plaque on CCTA was associated with the occurrence of ischemic stroke (2.8 vs. 0.6%; p = 0.029), while the presence of PD on SPECT was not (2.0 vs. 2.3%; p = 0.768). Stroke occurrence was not increased by the presence of significant stenosis of ≥50% DS (2.8%; p = 0.943), but was further increased by the plaque presence in ≥2 vessels (6.1 %; p = 0.001) or ≥3 segments (4.1%; p = 0.019). Presence of calcified plaque, and calcified plaque in ≥2 segments were also associated with ischemic stroke occurrence (4.3%; p < 0.001, and 5.6%; p < 0.001, respectively) and were the independent risk factors when adjusted to age of ≥65, hypertension, presence of any coronary plaque and plaque in ≥3 segments (adjusted HR 6.09; 95% CI 1.38-26.87; p = 0.017, and adjusted HR 5.47; 95% CI 1.85-16.19; p = 0.002, respectively). The risk of ischemic stroke was associated with the presence and extent of coronary atherosclerotic plaque evaluated by CCTA, but not with the presence and extent of myocardial ischemia evaluated by SPECT. Especially, calcified coronary plaque presence and extent were the independent predictors of ischemic stroke and allowed further risk stratification.

Primary prevention for risk factors of ischemic stroke with Baduanjin exercise intervention in the community elder population: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a major cause of death and disability in the world, and the prevalence of stroke tends to increase with age. Despite advances in acute care and secondary preventive strategies, primary prevention should play the most significant role in the reduction of the burden of stroke. As an important component of traditional Chinese Qigong, Baduanjin exercise is a simple, safe exercise, especially suitable for older adults. However, current evidence is insufficient to inform the use of Baduanjin exercise in the prevention of stroke.The aim of this trail is to systematically evaluate the prevention effect of Baduanjin exercise on ischemic stroke in the community elder population with high risk factors.

METHODS

A total of 170 eligible participants from the community elder population will be randomly allocated into the Baduanjin exercise group and usual physical activity control group in a 1:1 ratio. Besides usual physical activity, participants in the Baduanjin exercise group will accept a 12-week Baduanjin exercise training with a frequency of five days a week and 40 minutes a day. Primary and secondary outcomes will be measured at baseline, 13 weeks (at end of intervention) and 25 weeks (after additional 12-week follow-up period).

DISCUSSION

This study will be the randomized trial to evaluate the effectiveness of Baduanjin exercise for primary prevention of stroke in community elder population with high risk factors of stroke. The results of this trial will help to establish the optimal approach for primary prevention of stroke.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR-TRC-13003588.Registration date: 24 July, 2013.

Cross-sectional analysis of data from the U.S. clinical trials database reveals poor translational clinical trial effort for traumatic brain injury, compared with stroke

Traumatic brain injury (TBI) is an important public health problem, comparable to stroke in incidence and prevalence. Few interventions have proven efficacy in TBI, and clinical trials are, therefore, necessary to advance management in TBI. We describe the current clinical trial landscape in traumatic brain injury and compare it with the trial efforts for stroke. For this, we analysed all stroke and TBI studies registered on the US Clinical Trials (www.clinicaltrials.gov) database over a 10-year period (01/01/2000 to 01/31/2013). This methodology has been previously used to analyse clinical trial efforts in other specialties. We describe the research profile in each area: total number of studies, total number of participants and change in number of research studies over time. We also analysed key study characteristics, such as enrolment number and scope of recruitment. We found a mismatch between relative public health burden and relative research effort in each disease. Despite TBI having comparable prevalence and higher incidence than stroke, it has around one fifth of the number of clinical trials and participant recruitment. Both stroke and TBI have experienced an increase in the number of studies over the examined time period, but the rate of growth for TBI is one third that for stroke. Small-scale (<1000 participants per trial) and single centre studies form the majority of clinical trials in both stroke and TBI, with TBI having significantly fewer studies with international recruitment. We discuss the consequences of these findings and how the situation might be improved. A sustained research effort, entailing increased international collaboration and rethinking the methodology of running clinical trials, is required in order to improve outcomes after traumatic brain injury.