Stroke incidence and risk factors for stroke in Copenhagen, Denmark

High-resolution MRI vessel wall enhancement in moyamoya disease: risk factors and clinical outcomes

OBJECTIVES

Intracranial vessel wall enhancement (VWE) on high-resolution magnetic resonance imaging (HRMRI) is associated with the progression and poor prognosis of moyamoya disease (MMD). This study assessed potential risk factors for VWE in MMD.

METHODS

We evaluated MMD patients using HRMRI and traditional angiography examinations. The participants were divided into VWE and non-VWE groups based on HRMRI. Logistic regression was performed to compare the risk factors for VWE in MMD. The incidence of cerebrovascular events of the different subgroups according to risk factors was compared using Kaplan-Meier survival and Cox regression.

RESULTS

We included 283 MMD patients, 84 of whom had VWE on HRMRI. The VWE group had higher modified Rankin Scale scores at admission (p = 0.014) and a higher incidence of ischaemia and haemorrhage (p = 0.002) than did the non-VWE group. Risk factors for VWE included the ring finger protein 213 (RNF213) p.R4810K variant (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.08-3.76, p = 0.028), hyperhomocysteinaemia (HHcy) (OR 5.08, 95% CI 2.34-11.05, p < 0.001), and smoking history (OR 3.49, 95% CI 1.08-11.31, p = 0.037). During the follow-up of 63.9 ± 13.2 months (median 65 months), 18 recurrent stroke events occurred. Cox regression showed that VWE and the RNF213 p.R4810K variant were risk factors for stroke.

CONCLUSION

The RNF213 p.R4810K variant is strongly associated with VWE and poor prognosis in MMD. HHcy and smoking are independent risk factors for VWE.

CLINICAL RELEVANCE STATEMENT

Vessel wall enhancement in moyamoya disease is closely associated with poor prognosis, especially related to the ring finger protein 213 p.R4810K variant, hyperhomocysteinaemia, and smoking, providing crucial risk assessment information for the clinic.

KEY POINTS

• The baseline presence of vessel wall enhancement is significantly associated with poor prognosis in moyamoya disease. • The ring finger protein 213 p.R4810K variant is strongly associated with vessel wall enhancement and poor prognosis in moyamoya disease. • Hyperhomocysteinaemia and smoking are independent risk factors for vessel wall enhancement in moyamoya disease.

Comparing Explainable Machine Learning Approaches With Traditional Statistical Methods for Evaluating Stroke Risk Models: Retrospective Cohort Study

BACKGROUND

Stroke has multiple modifiable and nonmodifiable risk factors and represents a leading cause of death globally. Understanding the complex interplay of stroke risk factors is thus not only a scientific necessity but a critical step toward improving global health outcomes.

OBJECTIVE

We aim to assess the performance of explainable machine learning models in predicting stroke risk factors using real-world cohort data by comparing explainable machine learning models with conventional statistical methods.

METHODS

This retrospective cohort included high-risk patients from Ramathibodi Hospital in Thailand between January 2010 and December 2020. We compared the performance and explainability of logistic regression (LR), Cox proportional hazard, Bayesian network (BN), tree-augmented Naïve Bayes (TAN), extreme gradient boosting (XGBoost), and explainable boosting machine (EBM) models. We used multiple imputation by chained equations for missing data and discretized continuous variables as needed. Models were evaluated using C-statistics and F1-scores.

RESULTS

Out of 275,247 high-risk patients, 9659 (3.5%) experienced a stroke. XGBoost demonstrated the highest performance with a C-statistic of 0.89 and an F1-score of 0.80 followed by EBM and TAN with C-statistics of 0.87 and 0.83, respectively; LR and BN had similar C-statistics of 0.80. Significant factors associated with stroke included atrial fibrillation (AF), hypertension (HT), antiplatelets, HDL, and age. AF, HT, and antihypertensive medication were common significant factors across most models, with AF being the strongest factor in LR, XGBoost, BN, and TAN models.

CONCLUSIONS

Our study developed stroke prediction models to identify crucial predictive factors such as AF, HT, or systolic blood pressure or antihypertensive medication, anticoagulant medication, HDL, age, and statin use in high-risk patients. The explainable XGBoost was the best model in predicting stroke risk, followed by EBM.

Association of Atrial Fibrillation With Stroke and Dementia Accounting for Left Atrial Function and Size

BACKGROUND

Atrial fibrillation (AF) is associated with higher risks of ischemic stroke (IS) and dementia. Whether alterations in left atrial (LA) function or size-atrial myopathy-confound these associations remains unknown.

OBJECTIVES

The purpose of this study was to examine the association of prevalent and incident AF with ischemic stroke and dementia in the ARIC (Atherosclerosis Risk In Communities) study, adjusting for LA function and size.

METHODS

Participants at visit 5 (2011-2013) with echocardiographic LA function (reservoir, conduit, contractile strain, and emptying fraction) and size (maximal, minimal volume index) data, and without prevalent stroke or dementia were followed through 2019. For analysis, we used time-varying Cox regression.

RESULTS

Among 5,458 participants (1,193 with AF, mean age of 76 years) in the stroke analysis and 5,461 participants (1,205 with AF, mean age of 75 years) in the dementia analysis, 209 participants developed ischemic stroke, and 773 developed dementia over 7.1 years (median). In a demographic and risk factor-adjusted model, AF was significantly associated with ischemic stroke (HR, 1.63; 95% CI: 1.11-2.37) and dementia (HR: 1.38, 95% CI: 1.13-1.70). After additionally adjusting for LA reservoir strain, these associations were attenuated and no longer statistically significant (stroke [HR: 1.33, 95% CI: 0.88-2.00], dementia [HR: 1.15, 95% CI: 0.92-1.43]). Associations with ischemic stroke and dementia were also attenuated and not statistically significant after adjustment for LA contractile strain, emptying fraction, and minimal volume index.

CONCLUSIONS

AF-ischemic stroke and AF-dementia associations were not statistically significant after adjusting for measures of atrial myopathy. This proof-of-concept analysis does not support AF as an independent risk factor for ischemic stroke and dementia.

Eating Behaviors, Lifestyle, and Ischemic Stroke: A Lebanese Case-Control Study

BACKGROUND

Stroke is the second leading cause of death and the third leading cause of disability on a global scale. Most clinicians tend to underestimate the importance of diet and inadequate or dysfunctional eating attitudes in patients with a complicated relationship with food. Concerned about the potential of an independent Lebanese approach, and also because prior international research has revealed a link between eating intake or choice and ischemic stroke risk, it was considered vital to broaden the scope of the literature and evaluate further the association of disordered eating attitudes and focus on the distinct relationship with food in the case of orthorexia nervosa (ON) in the Lebanese community. Consequently, the purpose of the present study is to investigate the potential association between pre-existing disordered eating attitudes, specifically ON, and ischemic stroke risk, with an emphasis on the evidence supporting a Mediterranean-style diet.

METHODS

This research is a case-control survey study involving 113 Lebanese individuals with ischemic stroke and 451 age-(within 5 years) and sex-matched controls recruited from several hospitals in Lebanon (April 2020-April 2021).

RESULTS

According to the findings of our first regression model, living 100 m from a crowded road (adjusted odds ratio [aOR]: 3.421, 95% confidence interval [CI]: 1.585-7.387), living 100 m from an electricity generator (aOR: 3.686, 95% CI: 1.681-8.085), higher waterpipe dependence (aOR: 1.204, 95% CI: 1.117-1.297), higher exposure to passive smoking (aOR: 2.651, 95% CI: 2.051-3.426), being married (aOR: 3.545, 95% CI: 1.297-9.689), having a low educational attainment (aOR: 0.239, 95% CI: 0.084-0.679), vigorous physical activity (aOR: 1.003, 95% CI: 1.001-1.006), and having more inappropriate eating (aOR: 1.040, 95% CI: 1.006-1.074) were all associated with higher odds of having ischemic stroke. Furthermore, atrial fibrillation (aOR: 2.945, 95% CI: 1.010-8.585), diabetes (aOR: 2.550, 95% CI: 1.169-5.561), heart diseases (aOR: 6.193, 95% CI: 2.196-17.463), and hypertension (aOR: 2.744, 95% CI: 1.049-7.180) were also linked to an increased risk of stroke. Moreover, having more orthorexia nervosa tendencies (aOR: 1.123, 95% CI: 1.021-1.235) was related to a higher odds of having an ischemic stroke, whereas better adherence to the MeD was significantly linked (aOR: 0.691, 95% CI: 0.583-0.819) to lower odds of ischemic stroke.

CONCLUSIONS

Ischemic stroke patients were more likely to have disordered eating attitudes and orthorexic behaviors. Furthermore, the MeD has been found to be beneficial in reducing ischemic stroke risk. Despite the study's focus, outdoor pollution, waterpipe dependence, and passive smoking were linked to ischemic stroke. In summary, this review suggests that improving one's nutritional status and making a few lifestyle changes are key stroke prevention and treatment methods.

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.

Long-term safety of gamma knife radiosurgery (SRS) for acromegaly

PURPOSE

Acromegaly has high morbidity and mortality when growth hormone secretion remains uncontrolled. Stereotactic radiosurgery (SRS) may be used when pituitary surgery is not suitable or unsuccessful, but there are few very long-term safety data available, especially for significant adverse events such as stroke.

METHODS

118 patients with acromegaly were treated with SRS between 1985 and 2015, at the National Centre for Stereotactic Radiosurgery, Sheffield, UK. Data were gathered from case notes, hospital databases, and patient questionnaires. Stroke incidence in comparison to the normal population was quantified using the standardised incidence ratio (SIR), and visual complications assessed.

RESULTS

88% (104/118) had complete morbidity follow up data for analysis. The mean follow-up was 134 months, and median SRS dose was 30 Gy. 81% of tumours had cavernous sinus invasion. There was no excess stroke rate relative to that seen in two age- and sex-matched large population studies (SIR = 1.36, 95% CI 0.27-3.96; SIR = 0.52, 95% CI 0.06-1.89). In 68/104 patients who had MRI-guided SRS with no further radiation treatment (SRS or fractionated radiotherapy) there was no loss of visual acuity and 3% developed ophthalmoplegia. There was a positive correlation between > 1 radiation treatment and both ophthalmoplegia and worsening visual acuity.

CONCLUSION

Stroke rate is not increased by SRS for acromegaly. Accurate MRI-based treatment planning and single SRS treatment allow the lowest complication rates. More than one radiation treatment (SRS or fractionated radiotherapy) was associated with increased visual complications.

Late stroke after transcatheter aortic valve replacement: a nationwide study

Transcatheter aortic valve replacement (TAVR) is a rapidly growing field. Short-term safety and efficacy of these procedures have been studied extensively. However, little is known about the safety of these devices over time. Stroke is one feared long-term complication, and an increased stroke rate could affect guidelines for treating both the aortic stenosis and choosing antithrombotic therapy after TAVR. The primary objective was to study the incidence of stroke up to 8 years after TAVR implantation, comparing it with the risk of stroke in the general population. Secondary objectives were to study risk factors for late stroke and to study outcomes after stroke. A nationwide, all-comers study of patients who underwent TAVR in Sweden 2008–2018 was performed. The study was based on data from three national registries: a TAVR registry, a stroke registry, and a diagnosis registry. The main outcome was stroke incidence 30-days or more after TAVR implantation and was compared to a standardized incidence. The annual risk for stroke varied between 2.0% and 3.1% as compared to 1.5% and 1.9% in an age- and sex-matched cohort. Risk factors for developing stroke were reduced renal function, diabetes, history of stroke, age, and male sex. The 1-year mortality after stroke was 44%. This study demonstrated an increased rate of stroke after TAVR, but the findings suggest that this can in part be attributed to the group’s higher frequency of pre-disposing risk factors.

Walking pace and the risk of stroke: A meta-analysis of prospective cohort studies

PURPOSE

The extent to which walking pace is associated with a reduced risk for stroke remains unclear. This study examined the association between walking pace and stroke risk based on prospective cohort studies.

METHODS

Databases of PubMed, EMBASE, Web of Science, Scopus, and China National Knowledge Internet were searched from the inception dates to January 31, 2019, for prospective cohort studies focusing on walking pace and risk of stroke in adults. Two reviewers independently extracted data and assessed the quality of the studies. The dependent measure was stroke incidence. Using random-effects models, a meta-analysis was performed to estimate the overall relative risks (RR) of stroke incidence and 95% confidence intervals (CIs) for the individuals with the fastest walking paces vs. individuals with the slowest walking paces. A dose-response relationship was also examined.

RESULTS

After screening 1294 titles/abstracts and 14 full-text studies identified in the search, 7 studies (from 8 cohorts) were included in the meta-analysis. The 7 studies included a total of 135,645 participants (95.2% women; mean age 63.6 years) and 2229 stroke events (median follow-up time = 8.0 years). Compared to individuals in the slowest walking-pace category (median = 1.6 km/h), individuals in the fastest walking-pace category (median = 5.6 km/h) had a 44% lower risk of stroke (pooled RR = 0.56, 95%CI: 0.48-0.65). There was also a linear dose-response relationship (RR = 0.87; 95%CI: 0.83-0.91), with the risk of stroke decreased by 13% for every 1 km/h increment in baseline walking pace. We observed similar results across walking-pace assessment, type of stroke ascertainment, stroke subtypes, sex, sample size, and duration of follow-up.

CONCLUSION

Findings from this meta-analysis indicate that walking pace is inversely associated with the risk of stroke.

Association Between the Onset Pattern of Adult Moyamoya Disease and Risk Factors for Stroke

BACKGROUND AND PURPOSE

Few previous studies have comprehensively explored the relationship between the onset pattern of adult moyamoya disease and risk factors for stroke. We performed a retrospective analysis focusing on risk factors for stroke and related findings on magnetic resonance imaging/angiography with respect to the pattern of disease onset. We also examined whether risk factors for stroke were associated with an increased risk for symptomization in asymptomatic patients.

METHODS

A total of 178 adult patients with moyamoya disease (asymptomatic, n=84; ischemic, n=71; hemorrhagic, n=23) at the University of Tokyo Hospital from 2000 to 2018 were included in this study. Data pertaining to patient background and magnetic resonance imaging findings were analyzed retrospectively. In the asymptomatic group, the effects of stroke-associated risk factors on symptom onset were analyzed.

RESULTS

Comparisons among the 3 groups revealed no significant difference in the frequency of risk factors for stroke. The proportion of patients with magnetic resonance imaging/angiography findings indicating anterior choroidal artery anastomosis or microbleeds was significantly higher in the hemorrhagic group than in the asymptomatic or ischemic group. Among asymptomatic patients, the hazard ratios for symptomization with hypertension and dyslipidemia were 6.69 ([95% CI, 1.23-36.4] P=0.028) and 8.14 ([95% CI, 1.46-45.2] P=0.017), respectively.

CONCLUSIONS

The development of anterior choroidal artery anastomosis and microbleeds on magnetic resonance imaging/angiography was significantly associated with hemorrhagic onset. Hypertension and dyslipidemia may increase the risk of cerebrovascular events in asymptomatic patients, and thus, early intervention to these factors may be important.

Cardiovascular Risk and Atherosclerosis Progression in Hypertensive Persons Treated to Blood Pressure Targets

Arterial hypertension promotes atherosclerosis and cardiovascular events. We evaluated how cardiovascular risk and atherosclerosis progression are associated with blood pressure, antihypertensive treatment, and treatment efficacy. In 3555 participants of the population-based Heinz Nixdorf Recall study without previous cardiovascular disease (mean±SD; age, 58.9±7.6 years, 46.9% men), we analyzed associations of baseline antihypertensive treatment efficacy (normotension without antihypertensives, normotension with antihypertensives, hypertension without antihypertensives, hypertension with antihypertensives, based on 140/90 mmHg cutoffs) with incident coronary artery calcification (CAC) and CAC progression during 5-year-follow-up and with incident cardiovascular events during 13.5-year-follow-up. We further evaluated associations of incident arterial hypertension and efficacy of new antihypertensive treatment at the 5-year-follow-up with subsequent cardiovascular events. At baseline, 1706 participants had normotension without antihypertensives, 553 normotension with antihypertensives, 786 hypertension without antihypertensives, and 510 hypertension with antihypertensives. Six hundred forty-seven participants experienced rapid CAC progression. One hundred seven, 132, and 249 had incident stroke, coronary event, and cardiovascular event, respectively. Compared with normotensives without antihypertensives, normotensives with antihypertensives had an elevated stroke (hazard ratio, 2.33 [95% CI, 1.19–4.55]), coronary (2.04 [95% CI, 1.20–3.45]), and cardiovascular (2.23 [95% CI, 1.48–3.36]) risk, and increased baseline CAC, but not increased CAC progression. Participants without hypertension at baseline, who were newly hypertensive but achieved normotension with antihypertensives at the 5-year-follow-up, again exhibited elevated stroke (4.80 [95% CI, 1.38–16.70]) and cardiovascular (2.99 [95% CI, 1.25–7.16]) risk, whereas coronary risk was less elevated (2.24 [95% CI, 0.70–7.18]). Normotensives with antihypertensives have an elevated cardiovascular risk. They are characterized by elevated baseline CAC but show no signs of increased CAC progression.

Effect of Preoperative Administration of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor on Carotid Artery Stenting

BACKGROUND

Perioperative embolic stroke is one of the most serious complications during carotid artery stenting (CAS). Proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) is a low-density lipoprotein-lowering drug that inhibits proprotein convertase subtilisin/kexin type 9, which normally binds to the low-density lipoprotein cholesterol (LDL-C) receptor. Its combination with statin significantly decreases LDL-C levels. PCSK9i is expected to achieve lower LDL-C levels than single use of statin. This study aimed to investigate whether perioperative PCSK9i administration stabilizes carotid artery plaque and reduces perioperative complications of CAS.

METHODS

Nine patients with symptomatic stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] 50%) or asymptomatic stenosis (NASCET ≥ 80%) were included. PCSK9i was administered at least twice (once in 2 weeks) in the outpatient clinic before CAS. Perioperative complications; results from blood tests, magnetic resonance imaging (MRI), magnetic resonance angiography, and carotid ultrasonography (US); and modified Rankin scale score at discharge were assessed.

RESULTS

High intensity on diffusion-weighted imaging was not observed in 8 patients. Changes in carotid plaque characteristics were found with MRI and/or carotid US in 7 patients. The plaque to muscle ratio decreased in 3 patients. The carotid plaque became hyperechoic in 2 patients, and the fibrous cap was seen more clearly on carotid US. Two patients had findings of stabilized plaque on MRI and carotid US, which indicates that plaque transformation was more stable.

CONCLUSIONS

Lowering LDL-C level could reduce ischemic complications, and low LDL-C level affects plaque stability and antithrombus formation. PCSK9i can possibly stabilize carotid plaque and reduce perioperative complications of CAS.

The Relationship between Scabies and Stroke: A Population-Based Nationwide Study

BACKGROUND

Scabies is a commonly occurring infectious skin infestation that substantially impacts the quality of life, while stroke, which consists of a neurological deficit resulting from a lack of blood flow to the brain, carries sizable economic costs. The pathophysiologic mechanisms underlying both diseases involve inflammatory processes that are mediated by the immune system; however, no prior research has been conducted to explore the relationship between the two conditions.

METHODS

This population-based nationwide study utilized data from the National Health Insurance Research Database (NHIRD) of Taiwan for a total of 6628 scabies patients, who comprised a scabies group, and a randomly selected cohort of 26,509 matching patients, who served as a control group. More specifically, the medical records for the patients in both groups were checked for seven years to identify any new cases of stroke within that seven-year follow-up period. The hazard ratio (HR) of stroke for the follow-up period was then calculated using Cox proportional hazards regressions, while comorbidities and demographic characteristics were likewise analyzed.

RESULTS

During the follow-up period, 2892 patients, or 8.7%, of the overall total of 33,137 patients included in the study were newly diagnosed with a stroke. Of those newly diagnosed stroke patients, 833 were from the scabies group, and 2059 were from the control group, accounting for 12.6% and 7.8%, respectively, of the individuals in each group. With a crude hazard ratio of 1.67, the patients in the scabies group had a significantly higher risk of subsequent stroke than those in the control group, although the adjusted hazard ratio (aHR) for the scabies patients, which was determined by adjusting for covariates, was only 1.32 (95% confidence interval (CI): 1.21-1.43).

CONCLUSIONS

The results of the study indicated an elevated risk of stroke among scabies patients, an association that might be contributed to by immunopathological factors. This information could serve as a reminder to clinicians to remain alert to any indications of neurological impairment in patients previously infected with scabies.

Increased ischemic stroke risk in patients with Behçet's disease: A nationwide population-based cohort study

Background

Behçet’s disease (BD) is a recurrent, multisystemic, inflammatory disorder that mainly affects blood vessels. Because recurrent inflammation of blood vessels in the brain plays a crucial role in the development of ischemic stroke, we hypothesized that patients with BD might have an elevated risk of ischemic stroke. This potential association has been suggested in a few case reports, but not epidemiological studies. Hence, the present study aimed to examine the relation between BD and subsequent ischemic stroke in Taiwan using a nationwide, population-based database.

Methods

To establish a study cohort, the longitudinal data of 306 patients newly diagnosed with BD during 2000–2010 were extracted from the National Health Insurance Research Database, Taiwan. For comparison of ischemic stroke incidence, a control cohort of 1224 subjects without BD was established using a frequency-matched ratio of 1:4 for age, sex, and pre-existing comorbidities.

Results

During the 10-year follow-up, 13 (4.2%) patients with BD and 20 (1.6%) control subjects experienced ischemic stroke. Kaplan–Meier analysis revealed the higher prevalence of ischemic stroke in the BD group (log-rank test, p = 0.001). After adjusting for comorbidities and demographic characteristics, Cox regression analysis revealed that patients with BD had a 2.77-fold risk of ischemic stroke (95% confidence interval, 1.38–5.57) compared to control subjects.

Conclusions

Patients with BD have an elevated risk of ischemic stroke. Hence, BD may affect the vascular system in the brain, resulting in a stroke event.

ACAT-1 gene rs1044925 SNP and its relation with different clinical forms of chronic Chagas disease

Chagas disease, caused by the protozoan Trypanosoma cruzi (T. cruzi), although discovered more than a century ago, is still a not very well-elucidated aspect. Individuals in the chronic phase of the disease may present asymptomatic clinical form or symptomatologies related to the cardiac, digestive systems, or both (mixed clinical form). SNPs (single nucleotide polymorphisms) have been identified as important markers because they constitute about 90% of the variation in the human genome. One of them is localized to the ACAT-1 gene (cholesterol acyltransferase 1) (rs1044925) and has been linked to lipid disorders. Some studies have suggested the interaction between T. cruzi and the lipid metabolism of the host. Therefore, the objective of the present study was to evaluate the association between the ACAT-1 gene rs1044925 SNP in relation to clinical manifestations in patients with chronic Chagas disease. A total of 135 individuals with chronic Chagas disease, 86 (63.7%) asymptomatic individuals and 49 (36.3%) symptomatic patients (22 with cardiac clinical form, 18 with digestive form and 9 with mixed form) participated in the study. To evaluate the polymorphism, the PCR-RFLP technique were used. There was a significant difference and a higher frequency of AA and AC genotypes (p = 0.047 and p = 0.016, respectively) of the ACAT-1 gene in asymptomatic chagasic individuals. The result suggests a protective character of the AA and AC genotypes of the rs1044925 SNP in relation to the presence of symptomatic clinical manifestations of the disease in chronic chagasic individuals.

Married, unmarried, divorced, and widowed and the risk of stroke

OBJECTIVES

Most studies report that marriage carries a lower risk of stroke than single living. Whether the marriage advantage is applicable with respect to all other marital status categories (unmarried, divorced, widow) remains unclear. We studied marital status and its association with incident stroke.

MATERIAL AND METHODS

We included all patients > 40 years of age admitted to hospital for stroke in Denmark during 2003-2012 and compared marital status to the general Danish population (5.5 millions). Relative risks (RR) for stroke were estimated in log-linear Poisson regression models adjusting for age, sex, calendar year, income, and length of education.

RESULTS

A total of 58 847 patients with incident stroke were included. Crude incidence rates of stroke (per 1000 per year) among the four marital status categories were as follows: 1.96 (married), 1.52 (unmarried), 2.36 (divorced), and 5.43 (widowed). Compared to married persons, adjusted risk of stroke was significantly increased for divorced (RR 1.23; CI 1.19-1.27) and unmarried men (RR 1.07; CI 1.03-1.11) but not for widowed men (RR 1.02; CI 0.98-1.06); risk was slightly increased for divorced women (RR 1.10; CI 1.06-1.15) while not for widowed (RR 1.0; CI 0.97-1.03) and unmarried women (RR 0.97; CI 0.97-1.03).

CONCLUSIONS

Divorce was associated with higher risk of stroke, especially in men. Living in marriage or as unmarried or widower had only little or no impact on the risk of stroke.

Association between Serum Uric Acid Level and Activity of Daily Living in Japanese Patients with Ischemic Stroke

BACKGROUND

An association between serum uric acid and outcomes of ischemic stroke has been reported, but the results are controversial. The aim of this study is to clarify how uric acid may affect activities of daily living after acute ischemic stroke.

METHODS

Consecutive Japanese patients with acute ischemic stroke were analyzed. Serum uric acid quartiles and activities of daily living at hospitalization and discharge in men and women were examined. Activities of daily living were evaluated using the modified Rankin scale score, and a score of 3 or higher was defined as poor activities of daily living. P values less than .05 were considered significant.

RESULTS

A total of 987 patients with acute ischemic stroke (591 men; mean age, 72.3 years) were analyzed in this study. We observed a U-shaped relationship between serum uric acid and poor activities of daily living in both men and women at hospitalization and discharge. Multivariate analysis demonstrated that the first quartile group of serum uric acid was significantly associated with poor activities of daily living in both men and women, using the third quartile group as the reference.

CONCLUSIONS

Lower serum uric acid can be a marker for predicting poor activities of daily living in patients with acute ischemic stroke, irrespective of sex.

The association between wind-related variables and stroke symptom onset: A case-crossover study on Jeju Island

BACKGROUND

Although several studies have investigated the effects of ambient temperature on the risk of stroke, few studies have examined the relationship between other meteorological conditions and stroke. Therefore, the aim of this study was to analyze the association between wind-related variables and stroke symptoms onset.

METHODS

Data regarding the onset of stroke symptoms occurring between January 1, 2006, and December 31, 2007 on Jeju Island were collected from the Jeju National University Hospital stroke registry. A fixed-strata case-crossover analysis based on time of onset and adjusted for ambient temperature, relative humidity, air pressure, and pollutants was used to analyze the effects of wind speed, the daily wind speed range (DWR), and the wind chill index on stroke symptom onset using varied lag terms. Models examining the modification effects by age, sex, smoking status, season, and type of stroke were also analyzed.

RESULTS

A total of 409 stroke events (381 ischemic and 28 hemorrhagic) were registered between 2006 and 2007. The odds ratios (ORs) for wind speed, DWR, and wind chill among the total sample at lag 0-8 were 1.18 (95% confidence interval (CI): 1.06-1.31), 1.08 (95% CI: 1.02-1.14), and 1.22 (95% CI: 1.07-1.39) respectively. The ORs for wind speed, DWR, and wind chill for ischemic stroke patients were slightly greater than for patients in the total sample (OR=1.20, 95% CI: 1.08-1.34; OR=1.09, 95% CI: 1.03-1.15; and OR=1.22, 95% CI: 1.07-1.39, respectively). Statistically significant season-specific effects were found for spring and winter, and various delayed effects were observed. In addition, age, sex, and smoking status modified the effect size of wind speed, DWR, and wind chill.

CONCLUSIONS

Our analyses showed that the risk of stroke symptoms onset was associated with wind speed, DWR, and wind chill on Jeju Island.

Hypertension phenotypes and incident cardiovascular disease and mortality events in a decade follow-up of a Middle East cohort

OBJECTIVE

To investigate the association of hypertension phenotypes, with the risk of cardiovascular disease (CVD) and mortality.

METHODS

We examined the risk of hypertension phenotypes, that is, isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), systolic-diastolic hypertension (SDH), controlled blood pressure (CBP), and uncontrolled blood pressure (UBP) among 6974 middle-aged and 882 elderly participants. Cox regression analysis was used to estimate the hazard ratio for hypertension phenotypes, considering those with normotension as the reference.

RESULTS

During more than 10 years of follow-up, in the middle-aged group, 490 CVD events and 152 deaths occurred; corresponding rates for the elderly group were 194 and 183, respectively. In middle-aged patients, ISH, SDH, and UBP increased the risk of CVD, whereas UBP increased the risk of mortality due to CVD and any cause (hazard ratio 5.67 and 2.95, respectively) and IDH increased only the risk of total mortality in the middle-aged group (hazard ratio 2.01; all P values <0.05). In elderly patients, ISH, SDH, and UBP significantly increased the risks of CVD. IDH (hazard ratio 3.20 and 2.01), SDH (hazard ratio 3.80 and 3.23) and CBP (hazard ratio 2.86 and 1.87) increased the risks of CVD and all-cause mortality in this group, respectively (all P values <0.05).

CONCLUSION

In both middle-aged and elderly population, ISH, SDH, and UBP increase the risk of CVD. Controlling of BP to less than 140/90 mmHg decreases the risk of mortality events among the middle-aged population; however, it is not suitable for the elderly as it was associated with higher risk of mortality.

The Swedish CArdioPulmonary BioImage Study: objectives and design

Cardiopulmonary diseases are major causes of death worldwide, but currently recommended strategies for diagnosis and prevention may be outdated because of recent changes in risk factor patterns. The Swedish CArdioPulmonarybioImage Study (SCAPIS) combines the use of new imaging technologies, advances in large-scale 'omics' and epidemiological analyses to extensively characterize a Swedish cohort of 30 000 men and women aged between 50 and 64 years. The information obtained will be used to improve risk prediction of cardiopulmonary diseases and optimize the ability to study disease mechanisms. A comprehensive pilot study in 1111 individuals, which was completed in 2012, demonstrated the feasibility and financial and ethical consequences of SCAPIS. Recruitment to the national, multicentre study has recently started.

Parity and Risk of Stroke among Chinese Women: Cross-sectional Evidence from the Dongfeng-Tongji Cohort Study

Epidemiological studies have investigated the association between parity and the risk of stroke, but the results have been inconsistent. The objective of this study was to assess the association among middle-aged and older Chinese women. We used data from the Dongfeng-Tongji Cohort Study. In total, 14,277 women were included in the analysis. Participants were classified into four groups according to parity. Stroke cases were self-reported during face-to-face interviews. Multivariable logistic regression models were used to investigate the association between parity and the risk of stroke while controlling for potential confounders. The prevalence of stroke among the study subjects was 2.7% (380 of 14,277). In the fully adjusted model, women who had experienced two, three, or four or more live births had 1.24 times (95% CI, 0.85-1.81), 1.97 times (95% CI, 1.30-2.98) and 1.86 times (95% CI, 1.14-3.03), higher risk of stroke, respectively, compared with women who had experienced one live birth. High parity was associated with an increasing risk of stroke in the present study. Further longitudinal studies are needed to confirm the association and to explore the unclear mechanism underlying the link between parity and stroke risk.

Is Pseudoexfoliation Syndrome a Risk Factor for Cerebro Vascular Disease?

PURPOSE

To determine the relationship between cerebro vascular disease and pseudoexfoliation syndrome.

MATERIALS AND METHODS

This cross-sectional case control study consisted of 50 patients with ischemic-type cerebro vascular disease and 50 control subjects. All subjects were investigated for diabetes mellitus and hypertension status and underwent a detailed ophthalmic examination. A diagnosis of pseudoexfoliation syndrome was made if characteristic greyish particulate matter was found on the anterior lens capsule after pupillary dilatation by slit-lamp examination. All subjects were compared in terms of pseudoexfoliation syndrome, diabetes mellitus, and hypertension. Pearson Chi Square and Student's t test were used for statistical analysis. Logistic regression analyses of the risk factors between groups were also made.

RESULTS

The presence of pseudoexfoliation syndrome was significantly higher in patients with cerebro vascular disease when compared to the control subjects (p = 0.02). The frequency of diabetes mellitus was similar between the two groups. Arterial hypertension was significantly more frequent in the patient group when compared to the control subjects (p < 0.01). The logistic regression analysis showed that both pseudoexfoliation syndrome and hypertension were significantly associated with cerebro vascular disease.

CONCLUSION

In the present study, we found that pseudoexfoliation syndrome frequency was found to be higher in patients with cerebro vascular disease than in control subjects. A slit-lamp examination of the eye could be an important marker that indicates the risk of cerebro vascular disease. We recommend an evaluation of all subjects with pseudoexfoliation syndrome for the presence of cerebro vascular disease. Longitudinal studies with larger populations are needed to confirm this relationship.

Arachidonic Acid and Cerebral Ischemia Risk: A Systematic Review of Observational Studies

Background

Arachidonic acid (ARA) is a precursor of various lipid mediators. ARA metabolites such as thromboxane A₂ cause platelet aggregation and vasoconstriction, thus may lead to atherosclerotic disease. It is unclear whether dietary ARA influences the ARA-derived lipid mediator balance and the risk for atherosclerotic diseases, such as cerebral ischemia. Considering the function of ARA in atherosclerosis, it is reasonable to focus on the atherothrombotic type of cerebral ischemia risk. However, no systematic reviews or meta-analyses have been conducted to evaluate the effect of habitual ARA exposure on cerebral ischemia risk. We aimed to systematically evaluate observational studies available on the relationship between ARA exposure and the atherothrombotic type of cerebral ischemia risk in free-living populations.

Summary

The PubMed database was searched for articles registered up to June 24, 2014. We designed a PubMed search formula as follows: key words for humans AND brain ischemia AND study designs AND ARA exposure. Thirty-three articles were reviewed against predefined criteria. There were 695 bibliographies assessed from the articles that included both ARA and cerebral ischemia descriptions. Finally, we identified 11 eligible articles and categorized them according to their reporting and methodological quality. We used the Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) checklist to score the reporting quality. The methodological quality was qualitatively assessed based on the following aspects: subject selection, ARA exposure assessment, outcome diagnosis, methods for controlling confounders, and statistical analysis. We did not conduct a meta-analysis due to the heterogeneity among the studies. All eligible studies measured blood ARA levels as an indicator of exposure. Our literature search did not identify any articles that evaluated dietary ARA intake and tissue ARA as assessments of exposure. Seven of the 11 eligible articles were considered to be of low quality. No articles reported a dose-dependent positive association between an increased cerebral ischemia risk and ARA exposure. However, most studies did not assess the risk in each subtype of cerebral ischemia, thus various etiological types of cerebral ischemia risk were involved in their results.

Key Messages

We did not find a positive association between ARA exposure and cerebral ischemia risk. Eligible studies reported inconsistent findings: cerebral ischemia risk did not change or significantly decreased. We could not draw any conclusions due to the limited number of eligible high-quality studies. Further evidence from well-designed observational studies is required. Simultaneously, in order to develop effective preventive measures against cerebral ischemia, it is imperative to establish standardized definitions, nomenclatures, classifications, and diagnostic procedures.

Global stroke statistics

In many countries, stroke is a lower priority than other diseases despite its public health impact. One issue is a lack of readily accessible comparative data to help make the case for the development of national stroke strategies. To assist in this process, we need to have a common repository of the latest published information on the impact of stroke worldwide. We aim to provide a repository of the most current incidence and mortality data on stroke available by country and illustrate the gaps in these data. We plan to update this repository annually and expand the scope to address other aspects of the burden of stroke. Data were compiled using two approaches: (1) an extensive literature review with a major focus on published systematic reviews on stroke incidence (between 1980 and May 14, 2013); and (2) direct acquisition and collation of data from the World Health Organization to present the most current estimates of stroke mortality for each country recognized by the World Health Organization. For mortality, ICD8, ICD9, and ICD10 mortality codes were extracted. Using population denominators crude stroke mortality was calculated, as well as adjusting for the World Health Organization world population. We used only the most recent year reported to the World Health Organization. Incidence rates for stroke were available for 52 countries, with some countries having incidence studies undertaken in more than one region. When adjusted to the World Health Organization world standard population, incidence rates for stroke ranged from 41 per 100 000 population per year in Nigeria (1971-74) to 316/ 100 000/year in urban Dar-es-Salaam (Tanzania). Some regions had three to fivefold greater incidence than other countries. Of the 123 countries reporting mortality data, crude mortality was greatest in Kazhakstan (in 2003). In many regions data were very old or nonexistent. Such country-level data are important for citizens, clinicians, and policy makers so that local and global strategies to reduce the overall burden of stroke can be implemented. Through this first annual review of country-specific stroke epidemiology, we hope to promote discussion and provide insights into the worldwide burden of stroke.

Socioeconomic position and incidence of ischemic stroke in Denmark 2003-2012. A nationwide hospital-based study

BACKGROUND

A greater burden of stroke risk factors in general is associated with a higher risk for stroke among people of lower than those of higher socioeconomic position. The relative impact of individual stroke risk factors is still unclear.

METHODS AND RESULTS

We studied the relations between socioeconomic position, measured as household income and length of education, and all hospital admissions for a first ischemic stroke among 54 048 people over the age of 40 years in Denmark in 2003-2012 in comparison with the general Danish population (23.5 million person-years). We also studied the cardiovascular risk factor profile associated with socioeconomic position in stroke patients. Relative risks for stroke were estimated in log-linear Poisson regression models. The risk for hospitalization for a first ischemic stroke was almost doubled for people in the lowest income group, and the risk of those of working age (<65 years) was increased by 36% among people with the shortest education. Diabetes, obesity, smoking, and high alcohol consumption in particular and, to a lesser extent, previous myocardial infarction or intermittent arterial claudication were significantly overrepresented among stroke patients with lower socioeconomic position. Atrial fibrillation and hypertension were not.

CONCLUSIONS

In Denmark, there is a strong relation between low socioeconomic position and risk for hospitalization for stroke. Lifestyle, as indicated by smoking, obesity, and alcohol consumption, and diabetes appears to increase the risk for stroke in people with lower socioeconomic position.

Menopausal hormone treatment cardiovascular disease: another look at an unresolved conundrum

Cardiovascular disease (CVD) is the most common cause of death in women. Before the Women's Health Initiative (WHI) hormone trials, evidence favored the concept that menopausal hormone treatment (MHT) protects against CVD. WHI studies failed to demonstrate CVD benefit, with worse net outcomes for MHT versus placebo in the population studied. We review evidence regarding the relationship between MHT and CVD with consideration of mechanisms and risk factors for atherogenesis and cardiac events, results of observational case-control and cohort studies, and outcomes of randomized trials. Estrogen effects on CVD risk factors favor delay or amelioration of atherosclerotic plaque development but may increase risk of acute events when at-risk plaque is present. Long-term observational studies have shown ∼40% reductions in risk of myocardial infarction and all-cause mortality. Analyses of data from randomized control trials other than the WHI show a ∼30% cardioprotective effect in recently menopausal women. Review of the literature as well as WHI data suggests that younger and/or more recently menopausal women may have a better risk-benefit ratio than older or remotely menopausal women and that CVD protection may only occur after >5 years; WHI women averaged 63 years of age (12 years postmenopausal) and few were studied for >6 years. Thus, a beneficial effect of long-term MHT on CVD and mortality is still an open question and is likely to remain controversial for the foreseeable future.

Effects of sling exercise therapy on trunk muscle activation and balance in chronic hemiplegic patients

Weakening of trunk muscles in stroke patients hinders functional ability, safety and balance. To confirm whether strengthening trunk muscles could facilitate rehabilitation of stroke patients, we investigated the effectiveness of sling exercise therapy (SET) using closed kinetic chain exercises to activate trunk muscles and improve balance in stroke patients. [Subjects and Methods] Twenty stroke patients with chronic hemiplegia were equally divided into 2 groups, a SET group and a control group that performed regular exercises on a mat with the assistance of a table. Patients in both groups exercised for 30 min, three times per week for 4 weeks. Trunk muscle activity was measured using surface electromyography, whereas balance was measured using the Berg Balance Scale, Frailty and Injuries Cooperative Studies of Intervention Technique, Timed Up & Go test, and BioRescue before and after the 4-week experimental period. [Results] Trunk muscle activity and balance before and after intervention in both groups were significantly different. However, no significant differences were observed between the 2 groups. [Conclusion] Although SET was not more effective than regular exercise, significant improvement was observed before and after SET. Therefore, SET can be considered effective in strengthening trunk muscles in stroke patients with chronic hemiplegia.

Hypercholesterolemia and risk of incident psoriasis and psoriatic arthritis in US women

OBJECTIVE

Psoriasis is a systemic inflammatory disorder associated with an increased risk of cardiovascular disease. Hypercholesterolemia is a major risk factor for cardiovascular disease, and patients with psoriasis or psoriatic arthritis (PsA) have been shown to have elevated cholesterol levels. However, it is not known whether hypercholesterolemia is associated with an increased risk of psoriasis or psoriasis with PsA. We undertook this study to determine whether a history of hypercholesterolemia is associated with the risk of developing incident psoriasis and psoriasis with PsA in a cohort of US women.

METHODS

We included a total of 95,540 participants from the Nurses' Health Study II (1991-2005). Information on personal history of physician-diagnosed hypercholesterolemia and related medication use was collected during the followup period. Clinician-diagnosed psoriasis and psoriasis with PsA were ascertained and confirmed using supplementary questionnaires. Hazard ratios (HRs) were calculated with 95% confidence intervals (95% CIs).

RESULTS

During 1,320,765 person-years of followup, we documented 646 participants with incident psoriasis, 165 of whom had concomitant PsA. Hypercholesterolemia was associated with elevated risks of incident psoriasis (HR 1.25 [95% CI 1.04-1.50]) and psoriasis with PsA (HR 1.58 [95% CI 1.13-2.23]) in multivariate-adjusted models. Participants with hypercholesterolemia lasting for ≥7 years were at a higher risk of developing psoriasis (HR 1.29 [95% CI 1.03-1.61]) (P for trend = 0.0002) and psoriasis with PsA (HR 1.68 [95% CI 1.12-2.52]) (P for trend = 0.002). These associations persisted among participants who never took cholesterol-lowering medications. There was no association between cholesterol-lowering drugs and risk of psoriasis or psoriasis with PsA.

CONCLUSION

Our study provides evidence that hypercholesterolemia, a well-known cardiovascular risk factor, is also associated with an elevated risk of psoriasis and psoriasis with PsA.

Nationwide incidence of clinically diagnosed retinal vein occlusion in Korea, 2008 through 2011: preponderance of women and the impact of aging

OBJECTIVE

This study aimed at defining the incidence and demographics of clinically diagnosed retinal vein occlusion (RVO) in Korea.

DESIGN

Nationwide population-based retrospective study using data entered into the Korean national health claims database from 2007 through 2011.

PARTICIPANTS

Data of the entire population of Korea (n = 47,990,761, based on the 2010 census) were analyzed.

METHODS

The Korean national health claims database was analyzed to identify patients with RVO. Incident cases included individuals with no RVO claims in 2007, but with RVO claims in the years 2008 through 2011. The incidence rate of RVO was estimated for the entire Korean population.

MAIN OUTCOME MEASURES

The person-time incidence rates of clinically diagnosed RVO in Korea, including the age- and gender-specific incidence rates, were estimated.

RESULTS

A total of 92 730 RVO cases (56.4% in women) were identified. The incidence rate of clinically diagnosed RVO during the study period was 48.31 per 100,000 person-years (95% confidence interval [CI], 48.00-48.62). The incidence rate among men and women was 42.40 (95% CI, 41.99-42.81) and 54.14 (95% CI, 53.67-54.60) per 100,000 person-years, respectively (P < 0.001). The highest incidence of 214.92 per 100,000 person-years (95% CI, 211.29-218.56) was observed in the age group of 70 to 74 years (186.62 [95% CI, 181.46-191.78] and 236.25 [95% CI, 231.21-241.29] per 100,000 person-years for men and women aged 70 to 74 years, respectively). The incidence rate of RVO increased as the age of the population increased-more than doubling approximately every 10 years from the second to the seventh decade of life. Retinal vein occlusion occurred more often in men 30 to 54 years of age and in men older than 85 years, but was more common in women 55 to 84 years of age.

CONCLUSIONS

This study reports the population-based RVO incidence in Korea. The RVO incidence increased exponentially as the age of the population increased, and the RVO incidence in women was 1.28 times higher than that in men.

Stroke and coronary heart disease: predictive power of standard risk factors into old age--long-term cumulative risk study among men in Gothenburg, Sweden

Aims

The aim of this study was to examine the short-term and long-term cumulative risk of coronary heart disease (CHD) and stroke separately based on age, sex, smoking status, systolic blood pressure, and total serum cholesterol.

Methods and results

The Primary Prevention Study comprising 7174 men aged between 47 and 55 free from a previous history of CHD, stroke, and diabetes at baseline examination (1970–73) was followed up for 35 years. To estimate the cumulative effect of CHD and stroke, all participants were stratified into one of five risk groups, defined by their number of risk factors. The estimated 10-year risk for high-risk individuals when adjusted for age and competing risk was 18.1% for CHD and 3.2% for stroke which increased to 47.8 and 19.6%, respectively, after 35 years. The estimates based on risk factors performed well throughout the period for CHD but less well for stroke.

Conclusion

The prediction of traditional risk factors (systolic blood pressure, total serum cholesterol, and smoking status) on short-term risk (0–10 years) and long-term risk (0–35 years) of CHD of stroke differs substantially. This indicates that the cumulative risk in middle-aged men based on these traditional risk factors can effectively be used to predict CHD but not stroke to the same extent.

The phenotype of infiltrating macrophages influences arteriosclerotic plaque vulnerability in the carotid artery

BACKGROUND

Proinflammatory (M1) macrophages and anti-inflammatory (M2) macrophages have been identified in atherosclerotic plaques. While these macrophages have been speculated to be related to plaque vulnerability, there are limited studies investigating this relationship. Therefore, we examined the association between macrophage phenotype (M1 versus M2) and plaque vulnerability and clinical events.

METHODS

Patients undergoing carotid endarterectomy received an ultrasound of the carotid artery before surgery. Plaques were processed for analysis by immunohistochemistry, Western blotting, and real-time polymerase chain reaction studies. Medical history and clinical data were obtained from medical records.

RESULTS

Patients were divided into 2 groups: those suffering from acute ischemic attack (symptomatic, n = 31) and those that did not present with symptoms (asymptomatic, n = 34). Ultrasound analysis revealed that plaque vulnerability was greater in the symptomatic group (P= .033; Chi-square test). Immunohistochemistry revealed that plaques from the symptomatic group had a greater concentration of M1 macrophages (CD68-, CD11c-positive) while plaques from the asymptomatic group had more M2 macrophages (CD163-positive). This observation was confirmed by Western blotting. Characterization by real-time polymerase chain reaction studies revealed that plaques from the symptomatic group had increased expression of the M1 markers CD68 and CD11c, as well as monocyte chemoattractive protein-1, interleukin-6, and matrix metalloproteinase-9. In addition, more M1 macrophages expressed in unstable plaques were defined by ultrasound analysis, while more M2 macrophages were expressed in stable plaques.

CONCLUSIONS

Our data show that M1 macrophage content of atherosclerotic plaques is associated with clinical incidence of ischemic stroke and increased inflammation or fibrinolysis. We also show the benefits of using ultrasound to evaluate vulnerability in the plaques.

Stock or stroke? Stock market movement and stroke incidence in Taiwan

This paper investigates the impact of stock market movement on incidences of stroke utilizing population-based aggregate data in Taiwan. Using the daily data from the Taiwan Stock Exchange Capitalization Weighted Stock Index and from the National Health Insurance Research Database during 2001/1/1–2007/12/31, which consist of 2556 observations, we examine the effects of stock market on stroke incidence – the level effect and the daily change effects. In general, we find that both a low stock index level and a daily fall in the stock index are associated with greater incidences of stroke. We further partition the data on sex and age. The level effect is found to be significant for either gender, in the 45–64 and 65≥ age groups. In addition, two daily change effects are found to be significant for males and the elderly. Although stockholdings can increase wealth, they can also increase stroke incidence, thereby representing a cost to health.

Clinical neuroprotective drugs for treatment and prevention of stroke

Stroke is an enormous public health problem with an imperative need for more effective therapies. In therapies for ischemic stroke, tissue plasminogen activators, antiplatelet agents and anticoagulants are used mainly for their antithrombotic effects. However, free radical scavengers, minocycline and growth factors have shown neuroprotective effects in the treatment of stroke, while antihypertensive drugs, lipid-lowering drugs and hypoglycemic drugs have shown beneficial effects for the prevention of stroke. In the present review, we evaluate the treatment and prevention of stroke in light of clinical studies and discuss new anti-stroke effects other than the main effects of drugs, focusing on optimal pharmacotherapy.

Profile of modifiable and non-modifiable risk factors in stroke in a rural based tertiary care hospital - a case control study

Background:

Stroke, a major public health problem in India and worldwide, is associated with many risk factors. The modification of risk factors, an important public health strategy, has been shown to reduce the risk of stroke. Hence the present study was carried out to document the risk factor profile of stroke.

Methods:

It was a case-control study. Patients with stroke admitted in a tertiary care centre in central India and age and sex matched controls were included. Detail history and clinical examination was done in all cases and controls. The risk factors studied were education, socioeconomic status (according to Kuppuswamy’s classification), level of physical activity, alcohol intake, and smoking, tobacco chewing, family history of stroke and history of systemic hypertension, transient ischemic attack or ischemic heart disease. Anthropometric (weight, height, body mass index and waist circumference) measurements were done in all patients. Electrocardiogram was done in cases as well as controls and abnormalities noted.

Statistical Analysis:

The data was analyzed using Epi info version 3.4.1 software. Chi-square test was used as test of significance and p value less than 0.05 was considered as significant.

Results:

On comparing the cases with controls, sedentary life-style (p=0.02), history of transient ischemic attack (p=0.002), coronary artery disease (p=0.014), family history of stroke (p=0.001), systemic hypertension (p<0.001) and ECG abnormalities (p=0.04) were significant risk factors whereas low socio-economic status (p=0.40), smoking (p=0.12), tobacco chewing (p=0.35), alcohol consumption (p=0.22), obesity [both central and generalized as assessed by waist circumference (p=0.33) and BMI respectively (p=0.43)] and Diabetes mellitus (p=0.07) were not found to be statistically significant risk factors. The most significant risk factor was systemic hypertension (OR= 15.92, 95% CI, 1.78-6.85) followed by coronary artery disease (OR=3.86, 95% CI, 1.13-14.50), abnormal ECG (OR=2.49, 95% CI, 0.97-6.96) and sedentary life-style (OR=2.41, 95% CI, 1.07-5.49).

Conclusions:

In the present hospital based case control study in patients with stroke, sedentary life-style, history of transient ischemic attack, family history of stroke, coronary artery disease, systemic hypertension and abnormal ECG were significant risk factors. This could be helpful in early identification of subjects at risk for stroke and formulating public health strategy, if proven by larger population based studies.

Hormone therapy administration in postmenopausal women and risk of stroke

HRT, consisting of estrogens alone, or in combination with a progestogen, is widely used for the relief of symptoms in postmenopausal women. Early observational studies have suggested that HRT might be associated with a reduced risk of cardio- and cerebro-vascular events. These encouraging results prompted randomized controlled trials assessing the risks and benefits of HRT in primary and secondary prevention of arterial vascular events. However, these clinical trials and further observational studies did not confirm the protective effect of HRT; it is now established that HRT increases the risk of stroke. This increased risk is mainly related to an increased risk of ischemic stroke. Oral estrogen alone and combined with progestogen are associated with a similar increased risk, which may be dose dependent. Conversely, a low dose of transdermal estrogens with or without a progestogen does not seem to be associated with such an increased risk of stroke, whereas the impact of tibolone, a synthetic steroid, remains uncertain. In summary, there is now a large amount of evidence demonstrating that HRT is associated with increased risk of stroke, in particular, ischemic subtype.

Atrial fibrillation and upper limb thromboembolectomy: a national cohort study

BACKGROUND

The risk factors associated with, and the incidence of systemic embolism in patients with atrial fibrillation (AF) are poorly understood.

OBJECTIVES

We studied the association between AF and upper limb thromboembolectomy involving brachial, ulnar or radial artery in a national cohort study that included all individuals aged 40-99 years with incident AF.

METHODS

Data were retrieved from the Danish National Vascular Registry, the National Registry of Patients, the Danish Civil Registration System and Statistics Denmark.

RESULTS

In total, 131,476 patients (68,042 men and 63,434 women) with AF without previous thromboembolectomy in the upper limb were registered. In the study cohort, 130 men underwent upper limb thromboembolectomy over 220,890 person-years of observation, whilst 275 women underwent thromboembolectomy over 197,777 patient-years. The incidence per 100,000 person-years was 58.9 (95% CI, 49.2-69.8) for men and 139.1 (95% CI, 123.1-156.5) for women. The relative risk of thromboembolectomy among patients with AF compared to the background population was 7.5 (95% CI, 6.3-8.9) for men, and 9.3 (95% CI, 8.3-10.5) for women. Women with AF had a relative thromboembolectomy risk of 1.8 (95% CI, 1.5-2.3) compared to men with AF. Among patients with AF, history of hypertension (HR 2.2-2.9), myocardial infarction (HR 2.9-3.9), heart failure (HR 1.6-1.9) and stroke (HR 2.2-3.8) were significantly associated with increased risk of thromboembolectomy in both men and women.

CONCLUSIONS

AF substantially increases the risk of upper limb thromboembolectomy. This risk is higher with increasing age, female gender, and associated with hypertension, myocardial infarction, heart failure and stroke.

Population pharmacokinetic-pharmacodynamic analysis of vernakalant hydrochloride injection (RSD1235) in atrial fibrillation or atrial flutter

Vernakalant hydrochloride is a novel, relatively atrial-selective antiarrhythmic agent that rapidly converts atrial fibrillation (AF) to sinus rhythm (SR). This analysis integrates pharmacokinetic (PK) and safety data from 5 clinical trials of patients with AF or atrial flutter (AFL). Patients were initially given a 10-min intravenous (IV) infusion of vernakalant 3 mg/kg or placebo. If SR was not evident after a 15-min observation, then a second 10-min IV infusion of vernakalant 2 mg/kg or placebo was given. Population pharmacokinetic/pharmacodynamic (PK/PD) models were constructed for QT interval prolongation corrected for heart rate by Fridericia's formula (QTcF) and for changes in systolic blood pressure (SBP). The exposure-response relationships for QTcF and SBP were best described by sigmoidal maximum-effect (E (max)) models. For QTcF, the model was characterized by a typical E (max) of 20.3 ms, and by a vernakalant median effective concentration dependent (EC₅₀) on conversion status (4,222 ng/ml for patients converting to SR and 2,276 ng/ml for those remaining in AF/AFL). For SBP, the model was characterized by E (max) of 3.05 mmHg and EC₅₀ of 1,141 ng/ml. Risk of hypotension (SBP <90 mmHg) was primarily associated with low baseline SBP and to a smaller extent with a history of congestive heart failure (CHF); plasma vernakalant concentrations showed a small contribution to the risk of hypotension (relative risk = 1.4 at 4,000 ng/ml), which may be significant with a baseline SBP of <105 mmHg. These results show that vernakalant had a smaller effect on QTcF in patients who demonstrated conversion to SR than those remaining in AF or AFL, and it had a relatively small effect on SBP.

The Link between Atrial Fibrillation and Stroke in Women

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. The most serious complication of AF is thromboembolic stroke. The individual risk of stroke in the setting of AF varies. Several clinical factors have been identified as independent predictors of stroke in AF, including prior stroke, age, hypertension and diabetes. The bulk of available data identifies female gender as another independent predictor of stroke risk in AF. In this article, we review the link between AF and an elevated stroke risk in women, explore the potential pathophysiologic basis for this association and examine the data regarding the effectiveness of anticoagulation in reducing this risk.

Lifetime risk of stroke and impact of hypertension: estimates from the adult health study in Hiroshima and Nagasaki

Very few reports have been published on lifetime risk (LTR) of stroke by blood pressure (BP) group. This study included participants in the Radiation Effects Research Foundation Adult Health Study who have been followed up by biennial health examinations since 1958. We calculated the LTR of stroke for various BP-based groups among 7847 subjects who had not been diagnosed with stroke before the index age of 55 years using cumulative incidence analysis adjusting for competing risks. By 2003, 868 subjects had suffered stroke (512 (58.9%) were women and 542 (62.4%) experienced ischemic stroke). BP was a significant factor in determining risk of stroke for men and women, with distributions of cumulative risk for stroke significantly different across BP groups. The LTR of all-stroke for normotension (systolic BP/diastolic BP < 120/80 mm Hg), prehypertension (120-139/80-89 mm Hg), stage 1 hypertension (140-159/90-99 mm Hg) and stage 2 hypertension (> 160/100 mm Hg) were 13.8-16.9-25.8-25.8% in men and 16.0-19.9-24.0-30.5% in women, respectively (P < 0.001 among BP groups in both sexes). The estimates did not differ significantly (P = 0.16) between normotensive and prehypertensive subjects. One in five Japanese atomic bomb survivor subjects experienced stroke over their lifetime from the age of 55 years. Long-term stroke risks were elevated in those with hypertension (> 140/90 mm Hg) at any of the index ages of 45, 55, 65 and 75 years.

Atrial fibrillation is a major risk factor for stroke, especially in women: the Jichi Medical School cohort study

Background

Only a few population-based cohort studies have investigated the impact of atrial fibrillation (AF) on stroke in Japan.

Methods

A total of 10 929 participants (4147 men and 6782 women) were included in this population-based prospective cohort study. Baseline data, including electrocardiograms (ECGs) to ascertain AF status, were obtained from April 1992 through July 1995 in 12 areas in Japan. Cox proportional hazards models were used to analyze the association of AF with stroke.

Results

A total of 54 participants had AF (0.49%). The mean follow-up period was 10.7 years, during which 405 strokes were identified; 12 of these occurred in participants with AF. The crude incidence of stroke in participants with and without AF was 14.9 and 4.5 per 1000 person-years in men, respectively, and 39.3 and 2.7 per 1000 person-years in women. After adjusting for geographical area, sex, age, smoking status, drinking status, obesity, hypertension, dyslipidemia, and diabetes mellitus, the hazard ratios (95% confidence interval) of AF in all participants and in male and female participants were 4.11 (2.28–7.41), 2.12 (0.77–5.84), and 10.6 (5.01–22.4), respectively. The population attributable fraction (PAF) of stroke caused by AF was 2.2%; the PAFs were 1.0% and 3.6% in men and women, respectively.

Conclusions

The present Japanese population-based prospective cohort study showed that AF is a major risk factor for stroke, especially in women.

Smoking and stroke: the more you smoke the more you stroke

Cigarette smoking is a well-established risk factor for all forms of stroke. While both the general public and the global healthcare system are aware of the vascular risks associated with smoking, the prevalence of tobacco use has remained largely unchanged over the last quarter of a century. Approximately one in five US adults are classified as regular smokers, with the initiation of smoking typically occurring during the teenage years. Although the increased risk of stroke associated with smoking is generally acknowledged, it is less well recognized that considerable scientific evidence implicates a strong dose-response relationship between smoking and stroke risk. In this article, we summarize the literature regarding smoking-related stroke risk, the dose-response relationship, and the costs of this detrimental habit to both the individual and society as a whole.

Parental occurrence of stroke and risk of stroke in their children: the Framingham study

BACKGROUND

Data relating parental history of stroke to stroke risk in offspring remain surprisingly inconsistent, largely because of heterogeneity of study design and the absence of verified, as opposed to historical, data on parental stroke status.

METHODS AND RESULTS

We determined whether prospectively verified parental occurrence of stroke increased incident stroke risk among offspring in a community-based sample by studying 3443 stroke-free Framingham offspring (53% female; mean age, 48+/-14 years) with verified parental stroke status (by 65 years of age) who attended the first, third, fifth, and/or seventh offspring examinations and were followed up for up to 8 years after each baseline examination. Over up to 11,029 such person-observation periods (77,534 person-years), we documented 106 parental strokes by 65 years of age and 128 offspring strokes (74 parental and 106 offspring strokes were ischemic). Using multivariable Cox models adjusted for age, sex, sibship, and baseline stroke risk factors, we observed that parental stroke, both all stroke generally and ischemic stroke specifically, was associated with an increased risk of incident stroke of the same type in the offspring (hazard ratio, 2.79; 95% confidence interval, 1.68 to 4.66; P<0.001 for all stroke; and hazard ratio, 3.15; 95% confidence interval, 1.69 to 5.88; P<0.001 for ischemic stroke). This was true for both maternal and paternal stroke.

CONCLUSIONS

Documented parental stroke by 65 years of age was associated with a 3-fold increase in risk of offspring stroke. This increased risk persisted after adjustment for conventional stroke risk factors. Thus, verified parental stroke may serve as a clinically useful risk marker of an individual's propensity to stroke.