1
|
Aziz YN, Sucharew H, Stanton RJ, Alwell K, Ferioli S, Khatri P, Adeoye O, Flaherty ML, Mackey J, De Los Rios La Rosa F, Martini SR, Mistry EA, Coleman E, Jasne AS, Slavin SJ, Walsh K, Star M, Ridha M, Ades LMC, Haverbusch M, Demel SL, Woo D, Kissela BM, Kleindorfer DO. Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Presentation: A Population Study. J Am Heart Assoc 2024; 13:e032645. [PMID: 38700029 DOI: 10.1161/jaha.123.032645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/10/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Hypertension is a stroke risk factor with known disparities in prevalence and management between Black and White patients. We sought to identify if racial differences in presenting blood pressure (BP) during acute ischemic stroke exist. METHODS AND RESULTS Adults with acute ischemic stroke presenting to an emergency department within 24 hours of last known normal during study epochs 2005, 2010, and 2015 within the Greater Cincinnati/Northern Kentucky Stroke Study were included. Demographics, histories, arrival BP, National Institutes of Health Stroke Scale score, and time from last known normal were collected. Multivariable linear regression was used to determine differences in mean BP between Black and White patients, adjusting for age, sex, National Institutes of Health Stroke Scale score, history of hypertension, hyperlipidemia, smoking, stroke, body mass index, and study epoch. Of 4048 patients, 853 Black and 3195 White patients were included. In adjusted analysis, Black patients had higher presenting systolic BP (161 mm Hg [95% CI, 159-164] versus 158 mm Hg [95% CI, 157-159], P<0.01), diastolic BP (86 mm Hg [95% CI, 85-88] versus 83 mm Hg [95% CI, 82-84], P<0.01), and mean arterial pressure (111 mm Hg [95% CI, 110-113] versus 108 mm Hg [95% CI, 107-109], P<0.01) compared with White patients. In adjusted subanalysis of patients <4.5 hours from last known normal, diastolic BP (88 mm Hg [95% CI, 86-90] versus 83 mm Hg [95% CI, 82-84], P<0.01) and mean arterial pressure (112 mm Hg [95% CI, 110-114] versus 108 mm Hg [95% CI, 107-109], P<0.01) were also higher in Black patients. CONCLUSIONS This population-based study suggests differences in presenting BP between Black and White patients during acute ischemic stroke. Further study is needed to determine whether these differences influence clinical decision-making, outcome, or clinical trial eligibility.
Collapse
Affiliation(s)
- Yasmin N Aziz
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Heidi Sucharew
- Department of Emergency Medicine University of Cincinnati Cincinnati OH
| | - Robert J Stanton
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Opeolu Adeoye
- Department of Emergency Medicine Washington University St Louis MO
| | - Matthew L Flaherty
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Jason Mackey
- Department of Neurology Indiana University Indianapolis IN
| | | | - Sharyl R Martini
- Department of Neurology Michael E. DeBakey VA Medical Center Houston TX
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | | | - Adam S Jasne
- Department of Neurology Yale University New Haven CT
| | | | - Kyle Walsh
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Michael Star
- Soroka University Medical Center Beersheva Israel
| | - Mohamed Ridha
- Department of Neurology The Ohio State University Columbus OH
| | - Laura M C Ades
- Department of Neurology NYU Grossman School of Medicine Brooklyn NY
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Stacie L Demel
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine University of Cincinnati Cincinnati OH
| | | |
Collapse
|
2
|
Robinson DJ, Ding L, Rademacher E, Stanton R, Anderson AM, Khoury JC, Broderick JP, Kissela BM, Kleindorfer D. Temporal Trends in Public Stroke Knowledge, 1995-2021. Stroke 2023; 54:3169-3172. [PMID: 37916458 PMCID: PMC10715711 DOI: 10.1161/strokeaha.123.044017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 09/25/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Outreach campaigns have sought to reduce the burden of stroke by improving knowledge of stroke risk factors (RF) and warning signs (WS). We describe trends in stroke knowledge from 1995 to 2021. METHODS From 1995 to 2021, 6 separate surveys were conducted in the Greater Cincinnati Northern Kentucky Region. Temporal trends in RF/WS knowledge were analyzed using logistic regression adjusting for Race, sex, age, and education. RESULTS In 1995, 28.6% of participants (537/1880) could name ≥2 WS, compared with 50.6% (983/1944) in 2021 (trend P<0.0001 after adjustment). In 1995, 44.5% of participants (836/1880) knew ≥2 RF, compared with 56.7% (1103/1944) in 2021 (trend P<0.0001 after adjustment). Although still improved compared with 1995, fewer participants could identify ≥2 RF in 2021 (1103/1944, 56.7%) when compared with 2011 (1287/2036, 63.2%, pairwise P<0.05). This decline in RF knowledge was disproportionately larger in women (odds ratio of 0.67 for knowledge in 2021 compared with 2011 in females, P=0.047 for the interaction between sex and study year). CONCLUSIONS Although stroke knowledge has overall improved since 1995, there is evidence for lost gains since 2011, particularly in women. Stroke outreach campaigns need ongoing evaluation.
Collapse
Affiliation(s)
- David J Robinson
- Department of Neurology (D.J.R., R.S., J.P.B., B.M.K.), University of Cincinnati, OH
| | - Lili Ding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (L.D., J.C.K.)
| | - Eric Rademacher
- Institute for Policy Research (E.R.), University of Cincinnati, OH
| | - Robert Stanton
- Department of Neurology (D.J.R., R.S., J.P.B., B.M.K.), University of Cincinnati, OH
| | | | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (L.D., J.C.K.)
| | - Joseph P Broderick
- Department of Neurology (D.J.R., R.S., J.P.B., B.M.K.), University of Cincinnati, OH
| | - Brett M Kissela
- Department of Neurology (D.J.R., R.S., J.P.B., B.M.K.), University of Cincinnati, OH
| | - Dawn Kleindorfer
- Department of Neurology, University of Michigan, Ann Arbor (D.K.)
| |
Collapse
|
3
|
Awosika OO, Garver A, Drury C, Sucharew HJ, Boyne P, Schwab SM, Wasik E, Earnest M, Dunning K, Bhattacharya A, Khatri P, Kissela BM. Insufficiencies in sensory systems reweighting is associated with walking impairment severity in chronic stroke: an observational cohort study. Front Neurol 2023; 14:1244657. [PMID: 38020645 PMCID: PMC10656616 DOI: 10.3389/fneur.2023.1244657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Background Walking and balance impairment are common sequelae of stroke and significantly impact functional independence, morbidity, and mortality. Adequate postural stability is needed for walking, which requires sufficient integration of sensory information between the visual, somatosensory, and vestibular centers. "Sensory reweighting" describes the normal physiologic response needed to maintain postural stability in the absence of sufficient visual or somatosensory information and is believed to play a critical role in preserving postural stability after stroke. However, the extent to which sensory reweighting successfully maintains postural stability in the chronic stages of stroke and its potential impact on walking function remains understudied. Methods In this cross-sectional study, fifty-eight community-dwelling ambulatory chronic stroke survivors underwent baseline postural stability testing during quiet stance using the modified Clinical test of Sensory Interaction in Balance (mCTSIB) and assessment of spatiotemporal gait parameters. Results Seventy-six percent (45/58) of participants showed sufficient sensory reweighting with visual and somatosensory deprivation for maintaining postural stability, albeit with greater postural sway velocity indices than normative data. In contrast, survivors with insufficient reweighting demonstrated markedly slower overground walking speeds, greater spatiotemporal asymmetry, and limited acceleration potential. Conclusion Adequate sensory system reweighting is essential for chronic stroke survivors' postural stability and walking independence. Greater emphasis should be placed on rehabilitation strategies incorporating multisensory system integration testing and strengthening as part of walking rehabilitation protocols. Given its potential impact on outcomes, walking rehabilitation trials may benefit from incorporating formal postural stability testing in design and group stratification.
Collapse
Affiliation(s)
- Oluwole O. Awosika
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Amanda Garver
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Colin Drury
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Heidi J. Sucharew
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Sarah M. Schwab
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Emily Wasik
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Melinda Earnest
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Kari Dunning
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Amit Bhattacharya
- EDDI Lab—Early Detection of Degenerative Disorders and Innovative Solutions, Department of Environmental Health, University of Cincinnati, Cincinnati, OH, United States
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| |
Collapse
|
4
|
Stanton RJ, Robinson DJ, Aziz YN, Sucharew H, Khatri P, Broderick JP, Janis LS, Kemp S, Mlynash M, Lansberg MG, Albers GW, Saver JL, Flaherty ML, Adeoye O, Woo D, Ferioli S, Kissela BM, Kleindorfer DO. Using Epidemiological Data to Inform Clinical Trial Feasibility Assessments: A Case Study. Stroke 2023; 54:1009-1014. [PMID: 36852687 PMCID: PMC10050115 DOI: 10.1161/strokeaha.122.041650] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/06/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Clinical trial enrollment and completion is challenging, with nearly half of all trials not being completed or not completed on time. In 2014, the National Institutes of Health StrokeNet in collaboration with stroke epidemiologists from GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study) began providing proposed clinical trials with formal trial feasibility assessments. Herein, we describe the process of prospective feasibility analyses using epidemiological data that can be used to improve enrollment and increase the likelihood a trial is completed. METHODS In 2014, DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trialists, National Institutes of Health StrokeNet, and stroke epidemiologists from GCNKSS collaborated to evaluate the initial inclusion/exclusion criteria for the DEFUSE 3 study. Trial criteria were discussed and an assessment was completed to evaluate the percent of the stroke population that might be eligible for the study. The DEFUSE 3 trial was stopped early with the publication of DAWN (Thrombectomy 6 to 24 Hours After Stroke With a Mismatch Between Deficit and Infarct), and the Wilcoxon rank-sum statistic was used to analyze whether the trial would have been stopped had the proposed changes not been made, following the DEFUSE 3 statistical analysis plan. RESULTS After initial epidemiological analysis, 2.4% of patients with acute stroke in the GCNKSS population would have been predicted to be eligible for the study. After discussion with primary investigators and modifying 4 key exclusion criteria (upper limit of age increased to 90 years, baseline modified Rankin Scale broadened to 0-2, time since last well expanded to 16 hours, and decreased lower limit of National Institutes of Health Stroke Scale score to <6), the number predicted to be eligible for the trial increased to 4%. At the time of trial conclusion, 57% of the enrolled patients qualified only by the modified criteria, and the trial was stopped at an interim analysis that demonstrated efficacy. We estimated that the Wilcoxon rank-sum value for the unadjusted predicted enrollment would not have crossed the threshold for efficacy and the trial not stopped. CONCLUSIONS Objectively assessing trial inclusion/exclusion criteria using a population-based resource in a collaborative and iterative process including epidemiologists can lead to improved recruitment and can increase the likelihood of successful trial completion.
Collapse
Affiliation(s)
- Robert J Stanton
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - David J Robinson
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Yasmin N Aziz
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Heidi Sucharew
- Emergency Medicine (H.S.), University of Cincinnati College of Medicine, OH
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - L Scott Janis
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (L.S.J.)
| | - Stephanie Kemp
- Departments of Neurology (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
- Neurological Sciences (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
| | - Michael Mlynash
- Departments of Neurology (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
- Neurological Sciences (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
| | - Maarten G Lansberg
- Departments of Neurology (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
- Neurological Sciences (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
| | - Gregory W Albers
- Departments of Neurology (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
- Neurological Sciences (S.K., M.M., M.G.L., G.W.A.), Stanford University School of Medicine, Palo Alto, CA
| | - Jeffrey L Saver
- Department of Neurology, UCLA David Geffen School of Medicine (J.L.S.)
| | - Matthew L Flaherty
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University, St. Louis (O.A.)
| | - Daniel Woo
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Simona Ferioli
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | - Brett M Kissela
- Departments of Neurology and Rehabilitation Medicine (R.J.S., D.J.R., Y.N.A., P.K., J.P.B., M.L.F., D.W., S.F., B.M.K.), University of Cincinnati College of Medicine, OH
| | | |
Collapse
|
5
|
Boyne P, Billinger SA, Reisman DS, Awosika OO, Buckley S, Burson J, Carl D, DeLange M, Doren S, Earnest M, Gerson M, Henry M, Horning A, Khoury JC, Kissela BM, Laughlin A, McCartney K, McQuaid T, Miller A, Moores A, Palmer JA, Sucharew H, Thompson ED, Wagner E, Ward J, Wasik EP, Whitaker AA, Wright H, Dunning K. Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial. JAMA Neurol 2023; 80:342-351. [PMID: 36822187 PMCID: PMC9951105 DOI: 10.1001/jamaneurol.2023.0033] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/08/2022] [Indexed: 02/25/2023]
Abstract
Importance For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization. Objective To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke. Design, Setting, and Participants This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled. Interventions Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated. Main Outcomes and Measures The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training. Results Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue. Conclusions and Relevance These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains. Trial Registration ClinicalTrials.gov Identifier: NCT03760016.
Collapse
Affiliation(s)
- Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Sandra A. Billinger
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
- Department of Cell Biology and Integrative Physiology, School of Medicine, University of Kansas Medical Center, Kansas City
- University of Kansas Alzheimer’s Research Disease Center, Fairway
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Darcy S. Reisman
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Oluwole O. Awosika
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Sofia Buckley
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jamiah Burson
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Daniel Carl
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Matthew DeLange
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Sarah Doren
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Melinda Earnest
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Myron Gerson
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
- Department of Cardiology, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Madison Henry
- Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City
| | - Alli Horning
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Abigail Laughlin
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Kiersten McCartney
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Thomas McQuaid
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Allison Miller
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Alexandra Moores
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Jacqueline A. Palmer
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Elizabeth D. Thompson
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Erin Wagner
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Jaimie Ward
- Department of Neurology, School of Medicine, University of Kansas Medical Center, Kansas City
| | - Emily Patton Wasik
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Alicen A. Whitaker
- Department of Physical Therapy, Rehabilitation Sciences, and Athletic Training, School of Health Professions, University of Kansas Medical Center, Kansas City
| | - Henry Wright
- Department of Physical Therapy, College of Health Sciences, University of Delaware, Newark
| | - Kari Dunning
- Department of Rehabilitation, Exercise and Nutrition Sciences, College of Allied Health Sciences, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
6
|
Madsen TE, Khoury JC, Haverbusch M, Adeoye OM, Coleman ER, De Los Rios La Rosa F, Demel SL, Ferioli S, Flaherty ML, Jasne A, Khatri P, Mackey J, Martini SR, Mistry E, Slavin S, Star M, Walsh KB, Woo D, Broderick JP, Kissela BM, Kleindorfer DO. Abstract WP176: Prior TIAs Among Patients With Ischemic Stroke In The Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS). Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
TIAs serve as an opportunity to identify and modify risk factors and to prevent future events. Given known epidemiologic differences in strokes by race and sex, our objective was to investigate the rates of prior TIAs among those with incident ischemic stroke (IS) in the GCNKSS.
Methods:
We included all physician adjudicated, incident IS among adults age ≥20 years in the GCNKSS, a population-based stroke surveillance study in a 5-county region of southern Ohio/ northern Kentucky, in 2005, 2010, and 2015. We calculated the frequency of cases in which a TIA (sudden onset of focal neurologic symptoms lasting ≤ 24 hours) was documented in the 365 days prior to IS. Frequencies and proportions of prior TIA were compared by sex, race, and age, and location at which patients sought care for their TIA was described. Finally, multivariable logistic regression was performed to investigate demographic and clinical predictors of cases in which TIA preceded stroke; covariates were chosen a priori.
Results:
We included 5310 IS events; mean age was 69.7 (SD 14.8) years, 54.7% were female, and 20.4% were Black. A total of 351 patients (6.6%) had a documented TIA the year preceding their IS. Overall, 42.2% did not seek care for their TIA, 21.6% called 911 and/or came to the ED, 6.0% saw a PCP, and 6.6% sought other care. In 22.5% of cases, location of care was unknown. In adjusted results, older age, female sex, history of hypertension, and CAD were associated with having had a prior TIA, while Black race was not. NIHSS was inversely associated with prior TIA (Table). Prior TIAs were similar between study years.
Conclusions:
We conservatively estimate that ≥ 6% of patients with first-ever IS had a TIA in the preceding year, though underreporting is likely. Many patients did not report seeking care for the TIA, suggesting missed opportunities for risk factor modification. Further research is needed to understand the implications of sex and race differences in frequencies of prior TIA.
Collapse
|
7
|
Kleindorfer DO, Stanton RJ, Sucharew H, Broderick JP, Khatri P, Haverbusch M, Herbers L, Alwell K, Robinson D, ferioli S, Flaherty ML, Woo D, Demel S, De Los Rios La Rosa F, Mackey J, Mistry E, Jasne A, Slavin S, MARTINI SHARYL, Walsh K, Adeoye OM, Star M, Kissela BM. Abstract WMP5: How Do Clinical Trial Exclusion Criteria Impact The Inclusivity Of Clinical Trials? Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intro:
Enrolling women and under-represented minorities into clinical trials is a top priority for the stroke community. Common trial exclusions for medical conditions or demographics may negatively impact enrollment for these groups. We sought to describe the potential impact that various exclusion criteria have on trial eligibility of ischemic stroke (IS) patients by race and sex within the large, biracial Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) population.
Methods:
The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio/ Northern Kentucky. During 7/1/14-12/31/15 for blacks, and 2015 for whites, we captured all hospitalized ischemic strokes by screening ICD-9 codes 430-436 and ICD10 codes I60-I68, and G45-46. Commonly used exclusion criteria from stroke clinical trials were applied to the GCNKSS IS population, and were compared by sex and race. All comparisons were evaluated with chi-square test and corrected for multiple comparisons, as necessary.
Results:
In 2014-2015, there were 2806 ischemic stroke patients, which were 53% female, and 30% black. Table 1 presents common clinical trial exclusion criteria and the % excluded among IS patients, stratified by sex and race. Every trial exclusion evaluated had significant differences by sex, race, or both.
Discussion:
Within our population, we found that commonly-used age and disability clinical trial exclusion criteria exclude more women than men, and exclusion of milder strokes affects more men than women. Blood pressure, renal function, and early arrival time criteria exclude more blacks than whites, while older age exclude more whites than blacks. Optimal clinical trial design should be informed by epidemiology data to ensure representation of underrepresented populations in clinical trials. We will continue to provide epidemiology feedback on acute trial exclusion criteria to NIH StrokeNet proposals in the future.
Collapse
|
8
|
Robinson D, Ding L, Khoury JC, Stanton RJ, Alwell K, Khatri P, Adeoye OM, Broderick JP, Mackey J, Mistry E, Star M, Martini SR, Haverbusch M, Ferioli S, Woo D, De Los Rios La Rosa F, Demel SL, Flaherty ML, Slavin S, Walsh KB, Coleman ER, Jasne A, Kleindorfer DO, Kissela BM. Abstract 71: Temporal Trends In 30-day And 5-year Stroke Case Fatality Rates. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Previous studies spanning the 1990s-2010s have inconsistently identified a decline in 30-day stroke case-fatality rate (CFR), and little is known about trends in longer term stroke CFR over that period. We studied temporal trends in 30-day and 5-year CFRs in the well-defined Greater Cincinnati/Norther Kentucky (GCNK) stroke population.
Methods:
The NIH-funded GCNK Stroke Study is a population-based study conducted in a 5-county region that is representative of the USA in terms of Black race, income, and education. The study ascertained all strokes in 1993/4, 1999, 2005, 2010, and 2015 using well-validated methods. All stroke subtypes were included: ischemic strokes (IS), intracerebral hemorrhages (ICH), and subarachnoid hemorrhages (SAHs). Deaths were identified via the National Death Index. Cox proportional hazards models were used to assess all-cause fatality, by subtype, to examine temporal trends adjusting for age, sex, and race.
Results:
A total of 10372 stroke cases were ascertained over the five study periods (8428 IS, 443 SAH, and 1501 ICH). IS patients did not demonstrate a decline in 30-day CFRs over time, but did show a nonsignificant decrease in 5-year CFR. Among IS patients, female sex was associated with a lower 5-year CFR, whereas Black individuals had a lower 30-day CFR but a higher 5-year CFR. For ICH, there was a small increase in both 30-day and 5-year CFR in later study periods, although this did not reach significance in all years. SAH showed a lower 30-day CFR over time but no change in 5-year CFR. Older age was associated with a higher 30-day and 5-year CFR in all subtypes.
Discussion:
Despite widespread advances in post-stroke care, adjusted 5-year CFR has not clearly improved for any stroke subtype and may have slightly worsened for ICH. 30-day CFR has shown a modest improvement among SAH patients. Future studies should investigate why Black individuals with IS experience lower early CFR but a higher late CFR.
Collapse
|
9
|
Robinson D, Khoury JC, Ding L, Rademacher E, Alwell K, Broderick JP, Stanton RJ, Kissela BM, Kleindorfer DO. Abstract WMP107: Temporal Trends In Public Awareness Of Stroke: 1996-2021. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Knowledge of stroke risk factors (RF) and warning signs (WS) may improve adherence to primary stroke prevention and encourage more rapid presentation after symptom onset. As a result, improving stroke knowledge has been a major public health focus. We sought to study trends in stroke knowledge between 1996 and 2021 in a well-defined population.
Methods:
Surveys were conducted in 1996, 2000, 2005, 2011, 2016, and 2021 in the 5-county Greater Cincinnati Northern Kentucky region, a population of 1.3 million that reflects the USA in terms of Black race, income, and educational attainment. Respondents were selected to reflect the age, race and sex distribution of the local ischemic stroke population. Potential subjects were contacted using random-digit dialing (with adjustment for cell phone use after 2005) and asked open-ended questions regarding stroke WS and RF knowledge. Correct answers for all years were determined based upon current AHA guidelines and public health messaging. Trends in knowledge were then evaluated over time adjusting for age, Race, sex, and education. Multiple logistic regression models and a cumulative model were used for analysis.
Results:
Over the 25-year period, 12,322 surveys were completed. After adjustment for age, sex, Race, and education, RF and WS knowledge significantly increased between 1996 and 2021 (P<0.0001), but this was not consistent across years (Figure). The percentage of participants that could identify at least two WS improved significantly in 2000 and then again in 2011. Stroke WS knowledge was then stagnant in 2016 and worsened slightly in 2021. Knowledge of at least two RFs steadily improved from 1996 to 2011, but then declined modestly in 2016 and was stagnant in 2021.
Discussion:
While stroke RF and WS knowledge has overall improved since 1996, knowledge remains suboptimal and some gains may have been lost in recent years. More research on the most effective methods for improving stroke awareness is needed.
Collapse
|
10
|
Madsen TE, Sucharew H, Haverbusch M, Adeoye OM, Coleman ER, Demel SL, De Los Rios La Rosa F, Ferioli S, Jasne A, Li J, Mackey J, Mistry E, Slavin S, Star M, Walsh KB, Woo D, Kissela BM, Kleindorfer DO. Abstract 68: Socioeconomic Factors Associated With Ems-documented Stroke Chief Complaints In The Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS). Stroke 2023. [DOI: 10.1161/str.54.suppl_1.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Accurate identification of stroke by EMS is necessary for triage and pre-notification within stroke systems of care. Our objective was to describe disparities in the documentation of stroke as the patient’s chief complaint (CC) by EMS in a large population-based stroke study.
Methods:
We included physician-adjudicated strokes and TIAs occurring among adults ≥18 years old in 2015 in the GCNKSS study population, based in a 5-county area of Southern Ohio/Northern Kentucky. Strokes in which EMS was not used and events occurring in the hospital, during EMS transport, at an unknown location, or outside the study region were excluded. The documented CC by EMS (stroke/CVA, MI, seizure, fall, weakness/numbness, headache, or other) were compared between race/sex subgroups. Sequential multivariable logistic regression was performed to identify associations between race, sex, and social determinants of health with an EMS-documented stroke CC. Social determinants included living arrangement and census tract social deprivation index (SDI).
Results:
A total of 1451 stroke/TIA events were included. White women had the highest proportion of EMS-documented stroke CCs (56%), more than Black women (48%), White men (45%), and Black men (42%), (p=0.02). Black race was inversely associated with an EMS-documented stroke CC in initial models but was collinear with SDI and no longer significant when SDI was included. In the full model, age, previous stroke, and living with others were associated with an EMS-documented stroke CC, while SDI and CAD were inversely associated with EMS-documented stroke CCs. (Table)
Conclusion:
Patients living in census tracts characterized by social deprivation were less likely to have EMS-documented stroke CCs, suggesting differences in either patient or EMS recognition of stroke. Further work is needed to explore potential confounders including EMS protocols and to improve identification of stroke by patients and EMS providers.
Collapse
|
11
|
LaPorta JC, Robinson D, Stanton RJ, Kleindorfer DO, Ferioli S, Aziz Y, Sucharew H, Haverbusch M, Kissela BM. Abstract WP43: Characteristics And Management Of Hospitalized Retinal Artery Occlusion Patients In The Era Of Updated Guidelines: A Population-based Study. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Retinal artery occlusion (RAO) is a stroke equivalent that causes significant morbidity. There has been growing emphasis on urgent in-hospital evaluation of these patients, both to facilitate potential thrombolytic therapy and expedite workup; however, little is known regarding its effect on systems of care. We thus examined presenting characteristics and management of hospitalized RAO patients using the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS).
Methods:
The GCNKSS is a population-based study of stroke in a 5-county region with a population of 1.3 million representative of the USA in terms of Black race, income, and education. All cases of RAO among Black individuals from July 2019-December 2020 and among White individuals from 2020 were chart abstracted using ICD codes. All cases underwent physician adjudication. Demographic and clinical data were recorded.
Results:
We identified 57 hospitalizations with acute RAO among 55 patients. Characteristics of their hospitalization and demographics are shown (Table). Notably, 19% (11/57) of patients presented in a thrombolytic window of ≤3.5 and average time from symptom onset to evaluation was 17 hours. Most patients initially interacted with a subspecialist (53%) and presented to the ED in delayed fashion. One patient received thrombolytic therapy, four (7%) patients underwent carotid revascularization, and no patients had newly identified atrial fibrillation, cardiac thrombus, or endocarditis.
Discussion:
Our population-based study found only a minority of patients presented within a thrombolytic window, suggesting that systems of care need to promote more rapid evaluation of these patients. Very few patients received select intervention, but the high impact of carotid revascularization may warrant urgent evaluation of even low risk patients. Further study of long-term outcomes in this patient population is called for.
Collapse
|
12
|
Weil EL, Ding L, Khoury JC, Kissela BM, Alwell K, Woo D, De Los Rios La Rosa F, Mackey J, Ferioli S, Mistry E, Demel SL, Coleman ER, Jasne AS, Slavin SJ, Walsh K, Star M, Haverbusch M, Kleindorfer DO. Abstract TP161: Predictors Of Undiagnosed Risk Factors For Cerebrovascular Ischemic Events: A Population-based Study. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Primary prevention reduces the burden of acute ischemic stroke (AIS), yet cerebrovascular risk factors (RF) remain underdiagnosed in certain populations. We aimed to identify predictors of undiagnosed RF among patients with cerebrovascular ischemic events in a large bi-racial population.
Methods:
Individuals 20 years and older with an incident TIA or AIS from the population-based Greater Cincinnati/Northern Kentucky 2015 stroke study period were screened for inclusion. We included all hospital ascertained, physician-verified cases of AIS and TIAs. Outpatient and ED-only cases were excluded. Abstracted medical record data included determination of newly diagnosed hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLD) or atrial fibrillation (AF). Multivariable models were used to identify predictors for each undiagnosed RF. Model variables included: age, sex, race, insurance status and number of cerebrovascular RF (additionally including coronary artery disease and smoking).
Results:
A total of 1604 ischemic events were included (1485 stroke, 119 TIA) with 52.9% female; 22.4% Black; median age 70 (IQR 59, 82)). Only 6% (n=102) had no history of RF. The prevalence of each undiagnosed RF was: HTN 4.1%; HLD 7.9%; DM 3.1%; AF 3.2%. In unadjusted bivariate analysis, uninsured/unknown status was predictive of undiagnosed HTN (OR = 3.97, 95% CI 1.48, 10.68;
p
=.006) and HLD (OR=5.53, 95% CI 2.68, 11.4;
p
<.0001). After adjustment, insurance status remained a predictor for only undiagnosed HLD (
Table 1
). No relationship was found with race.
Conclusions:
The most consistent predictor for an undiagnosed RF was absence of other RF and lack of insurance, both suggestive of suboptimal cardiovascular screening in this population. Further studies assessing known but undertreated RF and socioeconomic factors could be of benefit.
Collapse
|
13
|
Madsen TE, Cummings OW, De Los Rios La Rosa F, Khoury JC, Alwell K, Woo D, Ferioli S, Martini S, Adeoye O, Khatri P, Flaherty ML, Mackey J, Mistry EA, Demel SL, Coleman E, Jasne AS, Slavin SJ, Walsh K, Star M, Broderick JP, Kissela BM, Kleindorfer DO. Substance Use and Performance of Toxicology Screens in the Greater Cincinnati Northern Kentucky Stroke Study. Stroke 2022; 53:3082-3090. [PMID: 35862206 PMCID: PMC9529778 DOI: 10.1161/strokeaha.121.038311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/10/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Though stroke risk factors such as substance use may vary with age, less is known about trends in substance use over time or about performance of toxicology screens in young adults with stroke. METHODS Using the Greater Cincinnati Northern Kentucky Stroke Study, a population-based study in a 5-county region comprising 1.3 million people, we reported the frequency of documented substance use (cocaine/marijuana/opiates/other) obtained from electronic medical record review, overall and by race/gender subgroups among physician-adjudicated stroke events (ischemic and hemorrhagic) in adults 20 to 54 years of age. Secondary analyses included heavy alcohol use and cigarette smoking. Data were reported for 5 one-year periods spanning 22 years (1993/1994-2015), and trends over time were tested. For 2015, to evaluate factors associated with performance of toxicology screens, multiple logistic regression was performed. RESULTS Overall, 2152 strokes were included: 74.5% were ischemic, mean age was 45.7±7.6, 50.0% were women, and 35.9% were Black. Substance use was documented in 4.4%, 10.4%, 19.2%, 24.0%, and 28.8% of cases in 1993/1994, 1999, 2005, 2010, and 2015, respectively (Ptrend<0.001). Between 1993/1994 and 2015, documented substance use increased in all demographic subgroups. Adjusting for gender, comorbidities, and National Institutes of Health Stroke Scale, predictors of toxicology screens included Black race (adjusted odds ratio, 1.58 [95% CI, 1.02-2.45]), younger age (adjusted odds ratio, 0.70 [95% CI, 0.53-0.91], per 10 years), current smoking (adjusted odds ratio, 1.62 [95% CI, 1.06-2.46]), and treatment at an academic hospital (adjusted odds ratio, 1.80 [95% CI, 1.14-2.84]). After adding chart-reported substance use to the model, only chart-reported substance abuse and age were significant. CONCLUSIONS In a population-based study of young adults with stroke, documented substance use increased over time, and documentation of substance use was higher among Black compared with White individuals. Further work is needed to confirm race-based disparities and trends in substance use given the potential for bias in screening and documentation. Findings suggest a need for more standardized toxicology screening.
Collapse
Affiliation(s)
- Tracy E. Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Olivia W. Cummings
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
| | - Felipe De Los Rios La Rosa
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Sharyl Martini
- Neurology Program, Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, Texas
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University, St. Louis, MO
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Matthew L. Flaherty
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN
| | - Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Stacie L. Demel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | | | - Adam S. Jasne
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Kyle Walsh
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | | | - Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| | - Dawn O. Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
- UC Gardner Neuroscience Institute, Cincinnati, OH
| |
Collapse
|
14
|
Frid P, Xu H, Mitchell BD, Drake M, Wasselius J, Gaynor B, Ryan K, Giese AK, Schirmer M, Donahue KL, Irie R, Bouts MJRJ, McIntosh EC, Mocking SJT, Dalca AV, Giralt-Steinhauer E, Holmegaard L, Jood K, Roquer J, Cole JW, McArdle PF, Broderick JP, Jimenez-Conde J, Jern C, Kissela BM, Kleindorfer DO, Lemmens R, Meschia JF, Rosand J, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Thijs V, Woo D, Worrall BB, Kittner SJ, Petersson J, Golland P, Wu O, Rost NS, Lindgren A. Migraine-Associated Common Genetic Variants Confer Greater Risk of Posterior vs. Anterior Circulation Ischemic Stroke☆. J Stroke Cerebrovasc Dis 2022; 31:106546. [PMID: 35576861 PMCID: PMC10601407 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/01/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To examine potential genetic relationships between migraine and the two distinct phenotypes posterior circulation ischemic stroke (PCiS) and anterior circulation ischemic stroke (ACiS), we generated migraine polygenic risk scores (PRSs) and compared these between PCiS and ACiS, and separately vs. non-stroke control subjects. METHODS Acute ischemic stroke cases were classified as PCiS or ACiS based on lesion location on diffusion-weighted MRI. Exclusion criteria were lesions in both vascular territories or uncertain territory; supratentorial PCiS with ipsilateral fetal posterior cerebral artery; and cases with atrial fibrillation. We generated migraine PRS for three migraine phenotypes (any migraine; migraine without aura; migraine with aura) using publicly available GWAS data and compared mean PRSs separately for PCiS and ACiS vs. non-stroke control subjects, and between each stroke phenotype. RESULTS Our primary analyses included 464 PCiS and 1079 ACiS patients with genetic European ancestry. Compared to non-stroke control subjects (n=15396), PRSs of any migraine were associated with increased risk of PCiS (p=0.01-0.03) and decreased risk of ACiS (p=0.010-0.039). Migraine without aura PRSs were significantly associated with PCiS (p=0.008-0.028), but not with ACiS. When comparing PCiS vs. ACiS directly, migraine PRSs were higher in PCiS vs. ACiS for any migraine (p=0.001-0.010) and migraine without aura (p=0.032-0.048). Migraine with aura PRS did not show a differential association in our analyses. CONCLUSIONS Our results suggest a stronger genetic overlap between unspecified migraine and migraine without aura with PCiS compared to ACiS. Possible shared mechanisms include dysregulation of cerebral vessel endothelial function.
Collapse
Affiliation(s)
- P Frid
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden; Section of Neurology, Skåne University Hospital, Malmö, Sweden.
| | - H Xu
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - B D Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Geriatric Research and Education Clinical Center, Veterans Administration Medical Center, Baltimore, MD, USA
| | - M Drake
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden; Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - J Wasselius
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden; Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - B Gaynor
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - K Ryan
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A K Giese
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - K L Donahue
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Irie
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - M J R J Bouts
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - E C McIntosh
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - S J T Mocking
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - A V Dalca
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
| | - E Giralt-Steinhauer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain
| | - L Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J Roquer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain
| | - J W Cole
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - P F McArdle
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Jimenez-Conde
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Spain
| | - C Jern
- Department of Laboratory Medicine, Institute of Biomedicine, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - B M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - D O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - R Lemmens
- Department of Neurosciences, Experimental Neurology, VIB Center for Brain & Disease Research, Department of Neurology, University Hospitals Leuven, KU Leuven - University of Leuven, Leuven, Belgium
| | - J F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - J Rosand
- Henry and Allison McCance Center for Brain Health Massachusetts General Hospital, Boston, USA
| | - T Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL, USA
| | - R L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, The Evelyn F. McKnight Brain Institute, FL, USA
| | - R Schmidt
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University Graz, Austria
| | - P Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham, United Kingdom
| | - A Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - V Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, and Department of Neurology, Austin Health, Heidelberg, Australia
| | - D Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - B B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - S J Kittner
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - J Petersson
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | - P Golland
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
| | - O Wu
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - N S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden; Section of Neurology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
15
|
Awosika OO, Chan D, Rizik BA, Sucharew HJ, Boyne P, Bhattacharya A, Dunning K, Kissela BM. Serial Backward Locomotor Treadmill Training Improves Bidirectional Walking Performance in Chronic Stroke. Front Neurol 2022; 13:800757. [PMID: 35359661 PMCID: PMC8963981 DOI: 10.3389/fneur.2022.800757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/14/2022] [Indexed: 01/16/2023] Open
Abstract
Background and Research Question Walking impairment remains a major limitation to functional independence after stroke. Yet, comprehensive and effective strategies to improve walking function after stroke are presently limited. Backward Locomotor Treadmill Training (BLTT) is a promising training approach for improving walking function; however, little is known about its mechanism of effect or the relationship between backward walking training and resulting overground forward walking performance. This study aims to determine the effects of serial BLTT on spatial aspects of backward and forward walking in chronic post-stroke individuals with residual walking impairment. Methods Thirty-nine adults (>6 months post-stroke) underwent 6 days of BLTT (3 × /week) over 2 weeks. Outcome measures included PRE-POST changes in backward and forward walking speeds, paretic and non-paretic step lengths, and single-support center of pressure distances. To determine the association between BLTT and overground walking, correlation analyses comparing training-related changes in these variables were performed. Results We report an overall improvement in BLTT and overground walking speeds, bilateral step lengths, and single-support center of pressure distances over six training sessions. Further, there were weak positive associations between PRE-POST changes in BLTT speed, BLTT paretic step length, and overground forward walking speed. Conclusion and Significance Our findings suggest that individuals with chronic post-stroke walking impairment experience improvements in spatial walking measures during BLTT and overground. Therefore, BLTT may be a potential adjunctive training approach for post-stroke walking rehabilitation.
Collapse
Affiliation(s)
- Oluwole O Awosika
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Dorothy Chan
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Bridget A Rizik
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Heidi J Sucharew
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Amit Bhattacharya
- Biomechanics-Ergonomics Research Laboratories, Department of Environmental Health, University of Cincinnati Medical College, Cincinnati, OH, United States
| | - Kari Dunning
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH, United States
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
| |
Collapse
|
16
|
Robinson D, Stanton RJ, Ferioli S, Sucharew H, Khoury JC, Haverbusch M, Adeoye OM, Jasne A, Slavin S, Star M, De Los Rios La Rosa F, Walsh KB, Demel SL, Coleman ER, Martini SR, Alwell K, Mackey J, Mistry E, Woo D, Kleindorfer DO, Kissela BM. Abstract 113: Duration Between Stroke Onset And Presentation Over Time: A Population-based Study. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In acute stroke, reducing delays between symptom onset and treatment can improve outcomes. While in-hospital delays have been successfully reduced, pre-hospital delays have persisted. Public health campaigns have attempted to reduce these delays by increasing stroke symptom awareness, but it is unknown whether these efforts have improved the percentage of patients presenting early after symptom onset.
Methods:
We performed an analysis of the Greater Cincinnati/Northern Kentucky Stroke Study, a population-based study of all stroke patients in a large geographic area. We looked at the 2010 and 2015 study years. All stroke cases (ischemic and hemorrhagic) presenting to the 16 regional EDs were included. We examined the time between symptom onset and ED arrival times, dichotomized into ≤3.5 hours and >3.5 hours. In cases without a clear onset, estimates were derived using wake-up or last known well times. Comparisons were made using multivariable logistic regression.
Results:
Among 4633 total stroke patients, 1359 patients presented early (29%). Results of the multivariable analysis are shown in the
Table
. There was no improvement the rate of early presentation in 2015 (aOR 1.01, 95% CI 0.89-1.16). EMS utilization, night arrival, higher NIHSS scores, and better premorbid function were associated with early arrival. Patients who lived alone were less likely to arrive early.
Conclusion:
We found no evidence for improvement in the rate of early presentation over the years studied. Work is needed to address other barriers to early hospital arrival, including underutilization of EMS.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | |
Collapse
|
17
|
Short SAP, Wilkinson K, Long DL, Judd S, Schulte J, Kissela BM, Howard G, Cushman M. Plasma Pro-Enkephalin A and Ischemic Stroke Risk: The Reasons for Geographic and Racial Differences in Stroke Cohort. J Stroke Cerebrovasc Dis 2022; 31:106237. [PMID: 34896817 PMCID: PMC8792292 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/05/2021] [Accepted: 11/20/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The opioid neuropeptide pro-enkephalin A (PENK-A) may be a circulating marker of cardiovascular risk, with prior findings relevant to heart failure, kidney disease, and vascular dementia. Despite these findings, the association of PENK-A with ischemic stroke is unknown, so we examined this association in a prospective cohort study and analyzed differences by race and sex. MATERIALS AND METHODS The REasons for Geographic and Racial Differences in Stroke study (REGARDS) is a prospective cohort study of 30,239 Black and White adults. Plasma PENK-A was measured in 473 participants that developed first-time ischemic stroke over 5.9 years and 899 randomly selected participants. Cox models adjusted for demographics and stroke risk factors were used to calculate hazard ratios (HRs) of stroke by baseline PENK-A. RESULTS PENK-A was higher with increasing age, female sex, White race, lower body mass index, and antihypertensive medication use. Each SD higher increment of PENK-A was associated with an adjusted HR of 1.20 (95% CI 1.01-1.42) for stroke, with minimal confounding by stroke risk factors. Spline plots suggested a U-shaped relationship, particularly in White men, with an adjusted HR 3.88 (95% CI 1.94-7.77) for the 95th versus 50th percentile of PENK-A in White men. CONCLUSIONS Higher baseline plasma PENK-A was independently associated with future stroke risk in REGARDS. This association was most apparent among White men. There was little confounding by established stroke risk factors, suggesting a possible causal role in stroke etiology. Further research is needed to understand the role of endogenous opioids in stroke pathogenesis.
Collapse
Affiliation(s)
- Samuel AP Short
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Katherine Wilkinson
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Suzanne Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | | | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Mary Cushman
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT,Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT,Address for Correspondence: Mary Cushman, MD MSc, University of Vermont, 360 South Park Drive, Colchester, VT 05446,
| |
Collapse
|
18
|
Madsen T, Khoury JC, De Los Rios La Rosa F, Alwell KS, Woo D, Mackey J, Mistry E, Ferioli S, Demel SL, Coleman ER, Jasne A, Slavin S, Walsh KB, Star M, Haverbusch M, Martini SR, Adeoye OM, Flaherty ML, Khatri P, Broderick JP, Kissela BM, Kleindorfer DO. Abstract WP192: Ischemic Stroke Mechanisms By Sex And Race Over Time In The Greater Cincinnati Northern Kentucky Stroke Study. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Identifying the mechanism of acute ischemic stroke (AIS) is critical to determining secondary stroke prevention strategies. As past data conflict on sex and race differences in stroke mechanism, we aimed to describe stroke mechanisms by sex and race over time in a population-based study of AIS cases with a focus on strokes with unknown mechanism.
Methods:
We included physician adjudicated, hospital ascertained incident AIS among adults over five study periods (1993/4, 1999, 2005, 2010, 2015) from the Greater Cincinnati Northern Kentucky Stroke Study. Stroke mechanisms were adjudicated by trained study physicians and included: small vessel disease, cardioembolic, large artery disease, other, and unknown. The percentage of AIS cases in each of the 5 categories was reported by sex and race in each of our five 1-year study periods, and trends over time by subgroup were tested using the Cochran-Armitage trend test.
Results:
We included 8349 AIS over 5 study periods: 4693 (56%) were women, 1607 (19%) were Black, mean age was 70.5 (14.3). Over the 22-year time period, the proportion of strokes whose mechanism was ‘unknown’ decreased in women (46.1%, 1993/4 to 38.5%, 2015
,
p<0.0001), men (46.2%, 1993/4 to 33.9%, 2015, p<0.0001), Black (51.8%, 1993/4 to 40.7%, 2015, p=0.004), and White (45.0%, 1993/4 to 40.7%, 2015, p<0.0001) patients. The proportion of small vessel strokes increased over time in men, strokes of ‘other’ mechanisms increased in all subgroups, and cardioembolic strokes increased in women and White individuals only (Figure).
Conclusions:
In a large population-based stroke study, the proportion of AIS with an unknown mechanism has decreased over time in all demographic groups, while trends in those categorized as cardioembolic or small vessel disease varied by sex and/or race. As changes in imaging utilization may be a contributor to our findings, future work investigating possible sex and race differences in diagnostic evaluations of AIS is warranted.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Mistry E, Sucharew H, De Los Rios La Rosa F, Mackey J, Ferioli S, Demel SL, Coleman ER, Jasne A, Slavin S, Walsh KB, Star M, Haverbusch M, Alwell K, Woo D, Kleindorfer DO, Kissela BM. Abstract WMP12: Disparities In Acute Stroke Care According To Pre-stroke Functional Status. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wmp12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Disparities in acute ischemic stroke (IS) care due to patients’ pre-stroke disabilities remain understudied. Using the Greater Cincinnati Northern Kentucky (GCNK) Stroke Study, we aimed to understand the differences in acute stroke presentation and care according to patients’ pre-stroke functional status.
Methods:
We ascertained all hospitalized IS patients ≥18 years old presenting to emergency departments in the GCNK region in 2015 using ICD-9 430-436; ICD-10 I60-I67, G45-G46; all cases were physician-reviewed. Trained nurses ascertained pre-stroke functional status from the medical record. Acute IS presentation, time metrics, and treatment were compared between patients with pre-stroke mRS 0-1 vs ≥2 using Wilcoxon rank-sum or chi-square tests. Logistic regression was used to evaluate the association between pre-stroke mRS and intravenous thrombolysis (IVT) and endovascular treatment adjusting for age, presenting NIHSS, time to presentation, and baseline anticoagulation use.
Results:
Of 2191 patients with IS, 1134 had a pre-stroke mRS ≥2. Patients in the latter group were older, more likely be female, had higher rates of medical comorbidities, had higher presenting NIHSS (3[1-8] vs 2[1-5], p<0.01, Table). They were less likely to receive IVT (aOR 0.43[0.28-0.68], p<0.01, for patients presenting within 0-4 hours) and EVT (aOR 0.32[0.13-0.78], p=0.01, for patients presenting within 0-23.5 hours). They had a higher rate of presentation via EMS, but the time from stroke onset to ED presentation was longer.
Conclusions:
Acute IS patients with pre-stroke disability presented later, with more severe strokes, and were less likely to receive reperfusion treatments. Further research into factors driving acute stroke medical decision-making for patients with a pre-stroke disability is needed to ensure optimal acute neurovascular care for all IS patients across the nation and worldwide.
Collapse
|
20
|
Ridha M, Aziz Y, Ades LM, Alwell KS, Woo D, Khoury JC, Khatri P, Adeoye OM, Broderick JP, Ferioli S, Mackey J, Martini SR, Demel S, De Los Rios La Rosa F, Madsen T, Star M, Coleman ER, Walsh KB, Slavin S, Jasne A, Mistry E, Haverbusch M, Kissela BM, Kleindorfer DO, Flaherty ML. Abstract WP177: Trends In The Clinical Phenotype Of Infective Endocarditis Related Stroke From 2005-2015: A Population-Based Study Of The Greater Cincinnati/ Northern Kentucky Region. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Prior studies have demonstrated a rising incidence of infective endocarditis related stroke (IERS) in the US due to the opioid epidemic. The Greater Cincinnati/Northern Kentucky (GCNK) region has one of the highest opioid abuse rates in the nation. A modern epidemiologic description is necessary to understand the impact of the opioid epidemic on the clinical phenotype of IERS.
Methods:
Using the GCNK Stroke Study, all patients hospitalized with IERS in 2005, 2010, and 2015 were abstracted and physician reviewed. IERS was defined as an acute stroke clinically attributed to infective endocarditis in patients meeting modified Duke Criteria for possible or definite endocarditis. Comparison between years were by chi-square or Fisher’s exact test for categorical variables; ANOVA or Kruskal-Wallis test for numerical variables. Cochran-Armitage test was used to examine trend. Secondary analysis compared characteristics between intravenous drug users (IVDU) and non-IVDU.
Results:
A total of 54 patients with IERS were identified in 2005, 2010, and 2015. Over the period, there was a significant decline in hypertension (91.7% in 2005, 36.0% in 2015; p=0.0005) and increase in IVDU (8.3% in 2005, 44.0% in 2015; p=0.02). They trended towards increased white race, younger age, and fewer vascular risk factors. Compared to non-IVDU, IVDU were significantly younger (41.1±14.1vs 63.1±14.3 years; p<0.001), less often female (12.5% vs 47.4%; p=0.02), had higher rates of sepsis (50% vs 18.4%; p=0.04), less atrial fibrillation (0% vs 31.6%; p=0.01), and less renal disease (0% vs 23.7%; p=0.045). The incidence of IERS per 100,000 increased from 1.31 (CI: 0.56-2.06) in 2005, to 1.66 (CI: 0.87-2.45) in 2010, and to 2.41(CI:1.46-3.36) in 2015.
Conclusion:
From 2005 to 2015, IERS was increasingly associated with IVDU and an absence of hypertension. These trends likely reflect the demographics of the opioid epidemic, which has affected younger patients with less comorbidities.
Collapse
|
21
|
Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2147] [Impact Index Per Article: 1073.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
22
|
Awosika OO, Chan D, Sucharew HJ, Boyne P, Bhattacharya A, Dunning K, Kissela BM. Backward Locomotor Treadmill Training Differentially Improves Walking Performance across Stroke Walking Impairment Levels. Brain Sci 2022; 12:brainsci12020133. [PMID: 35203897 PMCID: PMC8870096 DOI: 10.3390/brainsci12020133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 12/25/2022] Open
Abstract
Background: Post-stroke walking impairment is a significant cause of chronic disability worldwide and often leads to loss of life roles for survivors and their caregivers. Walking impairment is traditionally classified into mild (>0.8 m/s), moderate (0.41–0.8 m/s), and severe (≤0.4 m/s), and those categorized as “severe” are more likely to be homebound and at greater risk of falls, fractures, and rehospitalization. In addition, there are minimal effective walking rehabilitation strategies currently available for this subgroup. Backward locomotor treadmill training (BLTT) is a novel and promising training approach that has been demonstrated to be safe and feasible across all levels of impairment; however, its benefits across baseline walking impairment levels (severe (≤0.4 m/s) vs. mild–moderate (>0.4 m/s)) have not been examined. Methods: Thirty-nine adults (>6 months post-stroke) underwent 6 days of BLTT (3×/week) over 2 weeks. Baseline and PRE to POST changes were measured during treadmill training and overground walking. Results: Individuals with baseline severe walking impairment were at a more significant functional disadvantage across all spatiotemporal walking measures at baseline and demonstrated fewer overall gains post-training. However, contrary to our working hypothesis, both groups experienced comparable increases in cadence, bilateral percent single support times, and step lengths. Conclusion: BLTT is well tolerated and beneficial across all walking impairment levels, and baseline walking speed (≤0.4 m/s) should serve as a covariate in the design of future walking rehabilitation trials.
Collapse
Affiliation(s)
- Oluwole O. Awosika
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (D.C.); (B.M.K.)
- Correspondence:
| | - Dorothy Chan
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (D.C.); (B.M.K.)
| | - Heidi J. Sucharew
- Cincinnati Children’s Hospital Medical Center, Division of Biostatistics and Epidemiology, Cincinnati, OH 45229, USA;
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Pierce Boyne
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH 45221, USA; (P.B.); (K.D.)
| | - Amit Bhattacharya
- EDDI Lab—Early Detection of Degenerative Disorders & Innovative Solutions, Department of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA;
| | - Kari Dunning
- Department of Rehabilitation, Exercise and Nutrition Sciences, University of Cincinnati, Cincinnati, OH 45221, USA; (P.B.); (K.D.)
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (D.C.); (B.M.K.)
| |
Collapse
|
23
|
Ford CD, Gray MS, Crowther MR, Wadley VG, Austin AL, Crowe MG, Pulley L, Unverzagt F, Kleindorfer DO, Kissela BM, Howard VJ. Depressive Symptoms and Risk of Stroke in a National Cohort of Black and White Participants From REGARDS. Neurol Clin Pract 2021; 11:e454-e461. [PMID: 34484944 DOI: 10.1212/cpj.0000000000000983] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/17/2020] [Indexed: 12/21/2022]
Abstract
Objective The purpose of this study was to examine depressive symptoms as a risk factor for incident stroke and determine whether depressive symptomatology was differentially predictive of stroke among Black and White participants. Methods The study comprised 9,529 Black and 14,516 White stroke-free participants, aged 45 and older, enrolled in the REasons for Geographic and Racial Differences in Stroke (2003-2007). Incident stroke was the first occurrence of stroke. Association between baseline depressive symptoms (assessed via the 4-item Center for Epidemiologic Studies Depression Scale [CES-D-4]: 0, 1-3, or ≥4) and incident stroke was analyzed with Cox proportional hazards models adjusted for demographics, stroke risk factors, and social factors. Results There were 1,262 strokes over an average follow-up of 9.21 (SD 4.0) years. Compared to participants with no depressive symptoms, after demographic adjustment, participants with CES-D-4 scores of 1-3 had 39% increased stroke risk (hazard ratio [HR] = 1.39, 95% confidence interval [CI] = 1.23-1.57), with slight attenuation after full adjustment (HR = 1.27, 95% CI = 1.11-1.43). Participants with CES-D-4 scores of ≥4 experienced 54% higher risk of stroke after demographic adjustment (HR = 1.54, 95% CI = 1.27-1.85), with risk attenuated in the full model similar to risk with 1-3 symptoms (HR = 1.25, 95% CI = 1.03-1.51). There was no evidence of a differential effect by race (p = 0.53). Conclusions The association of depressive symptoms with increased stroke risk was similar among a national sample of Black and White participants. These findings suggest that assessment of depressive symptoms should be considered in primary stroke prevention for both Black and White participants.
Collapse
Affiliation(s)
- Cassandra D Ford
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Marquita S Gray
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Martha R Crowther
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Virginia G Wadley
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Audrey L Austin
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Michael G Crowe
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - LeaVonne Pulley
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Frederick Unverzagt
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Dawn O Kleindorfer
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Brett M Kissela
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| | - Virginia J Howard
- Capstone College of Nursing (CDF), the University of Alabama (UA), Tuscaloosa; Department of Biostatistics (MSG), the University of Alabama at Birmingham (UAB); Department of Community Medicine and Population Health (MRC), UA, Tuscaloosa; Division of Gerontology, Geriatrics and Palliative Care (VGW), Department of Medicine, UAB; Tuscaloosa Veterans Affairs Medical Center (ALA), AL; Department of Psychology (MGC), College of Arts and Sciences, UAB; Independent Contractor (LP); Department of Psychiatry (FU), Indiana University School of Medicine, Indianapolis; Department of Neurology and Rehabilitation Medicine (DOK, BMK), University of Cincinnati College of Medicine, OH; and Department of Epidemiology (VJH), School of Public Health, UAB
| |
Collapse
|
24
|
Kamin Mukaz D, Dawson E, Howard VJ, Cushman M, Higginbotham JC, Judd SE, Kissela BM, Safford MM, Soliman EZ, Howard G. Rural/urban differences in the prevalence of stroke risk factors: A cross-sectional analysis from the REGARDS study. J Rural Health 2021; 38:668-673. [PMID: 34270125 DOI: 10.1111/jrh.12608] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE We previously described the magnitude of rural-urban differences in the prevalence of stroke risk factors and stroke mortality. In this report, we sought to extend the understanding of rural-urban differences in the prevalence of stroke risk factors by using an enhanced definition of rural-urban status and assessing the impact of neighborhood socioeconomic status (nSES) on risk factor differences. METHODS This analysis included 28,242 participants without a history of stroke from the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort. Participants were categorized into the 6-level ordinal National Center for Health Statistics Urban-Rural Classification Scheme. The prevalence of stroke risk factors (hypertension, diabetes, smoking, atrial fibrillation, left ventricular hypertrophy, and heart disease) was assessed across the rural-urban scale with adjustment for demographic characteristics and further adjustment for nSES score. FINDINGS Hypertension, diabetes, and heart disease were more prevalent in rural than urban regions. Higher odds were observed for these risk factors in the most rural compared to the most urban areas (odds ratios [95% CI]: 1.25 [1.11-1.42] for hypertension, 1.15 [0.99-1.33] for diabetes, and 1.19 [1.02-1.39] for heart disease). Adjustment for nSES score partially attenuated the odds of hypertension and heart disease with rurality, completely attenuated the odds of diabetes, and unmasked an association of current smoking. CONCLUSIONS Some of the higher stroke mortality in rural areas may be due to the higher burden of stroke risk factors in rural areas. Lower nSES contributed most notably to rural-urban differences for diabetes and smoking.
Collapse
Affiliation(s)
- Debora Kamin Mukaz
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Erica Dawson
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA.,Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John C Higginbotham
- Department of Community Medicine and Population Health, University of Alabama College of Community Health Sciences, Tuscaloosa, Alabama, USA.,Institute for Rural Health Research, University of Alabama, Tuscaloosa, Alabama, USA
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Monika M Safford
- Department of Medicine, Weill Medical College of Cornell University, New York, New York, USA
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
25
|
Sucharew H, Kleindorfer D, Khoury JC, Alwell K, Haverbusch M, Stanton R, Demel S, De Los Rios La Rosa F, Ferioli S, Jasne A, Mistry E, Moomaw CJ, Mackey J, Slavin S, Star M, Walsh K, Woo D, Kissela BM. Deriving Place of Residence, Modified Rankin Scale, and EuroQol-5D Scores from the Medical Record for Stroke Survivors. Cerebrovasc Dis 2021; 50:567-573. [PMID: 34107479 DOI: 10.1159/000516571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Dawn Kleindorfer
- Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Robert Stanton
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Stacie Demel
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Felipe De Los Rios La Rosa
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Baptist Health Neuroscience Center, Baptist Hospital of Miami, Miami, Florida, USA
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Jasne
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Eva Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jason Mackey
- Department of Neurology, Indiana University, Indianapolis, Indiana, USA
| | - Sabreena Slavin
- Department of Neurology, University of Kansas Medical Center, Kansas, Kansas, USA
| | - Michael Star
- Department of Neurology, Soroka Medical Center, Beersheva, Israel
| | - Kyle Walsh
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| |
Collapse
|
26
|
De Los Rios La Rosa F, Khoury JC, Alwell KS, Haverbusch M, Woo D, Mackey J, Ferioli S, Martini SR, Mistry E, Demel SL, Coleman ER, Jasne A, Slavin SJ, Walsh KB, Star M, Madsen TE, Adeoye OM, Broderick JP, Flaherty ML, Khatri P, Kissela BM, Kleindorfer DO. Abstract P264: Trends in Diagnostic Testing and Mechanism of Stroke Determination. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
A main goal for hospital admission following acute ischemic stroke (AIS) is to establish the mechanism of stroke (MoS) allowing for patient specific secondary prevention of stroke interventions. We previously reported on diagnostic testing trends and MoS determination from 1993 through 2010. We updated this analysis with 2015 data to better understand the effects of trends in diagnostic testing on MoS determination.
Methods:
Patients with AIS aged
>
20 years from all study time periods (Table) of the population based GCNKSS were included. Charts were abstracted in a systematic way for tests performed during the hospital stay. Only first-ever ischemic stroke cases, evaluated in an emergency department were used for this analysis. Stroke experts reviewed these events and adjudicated the mechanism of stroke according to modified TOAST criteria. We looked at and compared trends for testing and MoS.
Results:
Our analysis included 7226 patients. Basic patient demographics, MoS categories and tests across study periods are detailed in the Table. There were significant increases in EKG (7%), TTE (35%), TEE (7%), HCT (4%), brain MRI (65%), MRA (30%) and CTA (28%). Across study periods, cardioembolic (4.1%), small vessel disease (3%), large artery disease (0.9%) and other (1.5%) MoS increased while unknown MoS decreased (-9.5%).
Discussion:
From 1993/1994 to 2015 there has been a significant increase of in-hospital testing in AIS and decreases in undetermined MoS. Cardioembolic and small vessel disease MoS categories increased the most. Despite a significant increase in vessel imaging, large artery disease and “other determined” MoS categories are largely unchanged. Further research is required to elucidate the occult MoS underlying the undetermined category. Based on our analysis it appears unlikely to be significantly associated with our current definition of stroke associated with large artery disease defined as ≥ 50% ipsilateral stenosis.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Short SA, Wilkinson K, Long DL, Judd SE, Schulte J, Kissela BM, Howard G, Cushman M. Abstract P611: Plasma Pro-Enkephalin a and Ischemic Stroke Risk in the Regards Cohort. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The opioid precursor peptide pro-enkephalin A (PENK-A) is believed to be a plasma marker of blood brain barrier dysfunction or cardiovascular risk. PENK-A is previously described in acute ischemic stroke, but PENK-A’s impact on stroke development is unknown. The objective of this study was to test the independent association of plasma PENK-A concentration with incident stroke and describe potential differences by race and sex.
Methods:
The REGARDS cohort is a population-based cohort of 30,239 black and white adults. Baseline plasma PENK-A was measured in 547 participants who developed stroke and 857 who did not. Participants were followed for a median of 5.6 years (interquartile range 4.4-7.2). PENK-A’s association with incident stroke was examined with multivariable adjusted Cox models.
Results:
Cross-sectionally, PENK-A was higher with female sex, white race, older age, lower body mass index, and antihypertensive medication use. Continuously, higher PENK-A was independently associated with stroke risk (fully adjusted hazard ratio 1.20 per standard deviation higher, 95% confidence interval 1.01-1.42). Restricted cubic spline plots revealed a U-shaped relationship (Figure). Among subgroups, this U-shaped association was most apparent in white men and black women. Adjustment for demographics and established stroke risk factors had minimal impact. PENK-A concentration was not associated with stroke severity or subtype.
Conclusions:
Higher plasma PENK-A concentration was independently associated with incident stroke in REGARDS. This association was U-shaped, and PENK-A may be most relevant to white men and black women. PENK-A’s association with stroke was not impacted by established stroke risk factor suggesting a possible causal role in stroke etiology. Further work is needed to understand the role of PENK-A in stroke pathogenesis.
Collapse
Affiliation(s)
- Samuel A Short
- Univ of Vermont Larner College of Medicine, Burlington, VT
| | - Katherine Wilkinson
- Laboratory for Clinical Biomedical Rsch, Univ of Vermont Larner College of Medicine, Burlington, VT
| | - D Leanne Long
- Dept of Biostatistics, Univ of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | |
Collapse
|
28
|
Kleindorfer D, Sucharew H, Haverbusch M, Alwell KS, Rothenberg F, WASHKO DANIEL, Demel SL, Merkler AE, Jasne A, Slavin S, De Los Rios La Rosa F, Woo D, Mackey J, Mistry E, Coleman ER, Walsh KB, Star M, Kissela BM. Abstract P591: A Significant Dose-Response in Elevated Troponin Levels for Case-Fatality Among Patients With Acute Ischemic Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
About 21% of acute ischemic stroke (AIS) patients present to medical attention with an elevated cardiac troponin (cTn). Previously, we described that elevated cTn is associated with an increased case-fatality at 1 year. However, it is not clear if there is a dose-dependent relationship between cTn and case-fatality, or if this effect is related to causes of death.
Methods:
Within a catchment area of 1.3 million we screened local hospital admissions using ICD-9/10 codes 430-436/I60-I68, G45-46 in 2014/2015, and ascertained all physician-confirmed AIS cases by retrospective chart review. Positive cTn was defined by the standard 99th percentile. To account for by hospital variance in cTn results in machine brands and normal ranges, cTn values were log-transformed and centered. Case fatality at 1 year and cause of death was obtained from the National Death Index database. Logistic regression evaluated the impact of cTn on case fatality, and included demographic and clinical risk factors in the model. The percentage with all-cause and cardiac/non-cardiac case-fatality was computed by quartiles of centered cTn levels and compared using the chi-square test.
Results:
In 2014/2015, there were 2989 AIS cases ascertained, which were 53% female, 30% black, with a mean age of 70 (SD 14). 441 patients with hypertropinemia were included in the analysis. See Table for case fatality at 1 year by quartile of centered cTn levels. There was no association between cTN and non-cardiac case-fatality. After adjustment for demographic and clinical characteristics, every 0.5 point increase in the centered cTn level increased the cardiac case-fatality by OR 1.19 (1.09, 1.31), p<0.01.
Discussion:
We found that the impact of hypertropinemia on case fatality after AIS appears to be a dose-dependent association: as cTn increases, so does the cardiac case-fatality. This suggests that the degree of cTn elevation is likely an important prognostic marker for cardiac death in AIS patients.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | |
Collapse
|
29
|
Madsen TE, Khoury JC, Alwell KS, Adeoye OM, Coleman ER, Demel SL, De Los Rios La Rosa F, Flaherty ML, Khatri P, Jasne A, Haverbusch M, Ferioli S, Martini SR, Mackey J, Mistry E, Slavin S, Star M, Walsh KB, Woo D, Broderick JP, Kissela BM, Kleindorfer D. Abstract P224: Management of TIA Over Time in the Greater Cincinnati Northern Kentucky Stroke Study. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
The availability of rapid tissue and vessel imaging for TIA has increased, but the utilization rates of these and other diagnostic and management strategies for TIA over time are unknown.
Objective:
To investigate trends in TIA diagnostic and management strategies over time in the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS).
Methods:
The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio and Northern Kentucky. For this study, all physician-adjudicated, first-ever cases of TIA (defined clinically as sudden onset of focal symptoms lasting < 24 hours) presenting to an emergency department over five study periods (1993/4, 1999, 2005, 2010, 2015) were included. Use of AHA-recommended aspects of TIA management as well as disposition of TIA patients (admission to hospital or discharge from ED) and length of stay were compared across study periods. Rates of acute infarct on MRI were also reported. Trends were examined using the Cochran-Armitage test for trend.
Results:
In total, over all study periods, there were 2251 first-ever TIAs. Overall, 14% (n=311) occurred in Black individuals, and 57% (n=1275) occurred in women. Utilization of diagnostic modalities [non-contrast CT brain, vascular imaging (CTA, MRA, or carotid dopplers), tissue imaging (MRI), and echocardiogram] increased significantly over time (all p<0.0001). In terms of management, both admission to the hospital and discharge from the hospital on an antiplatelet agent increased over time (both p<0.0001; Table).
Conclusions:
The management of TIA has changed significantly over time. Utilization of tissue and vessel imaging as well as echocardiogram during the hospital stay has increased; in 2015, the vast majority of patients with TIA in this population-based study received each of these testing modalities and were admitted to a hospital for TIA work-up. Further work is needed to understand the best practices for work-up of suspected TIA.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Stanton RJ, Antzoulatos E, Coleman ER, De Los Rios La Rosa F, Demel SL, ferioli S, Haverbusch M, Jasne A, Khoury JC, Mackey J, Mistry E, Slavin S, Star M, Walsh KB, Alwell KS, Woo D, Kissela BM, Kleindorfer D. Abstract P625: Rate of Hemorrhagic Transformation After Ischemic Stroke and Associated Risk Factors: The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS). Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Hemorrhagic transformation (HT) of ischemic stroke can have devastating consequences, leading to longer hospitalizations, increased morbidity and mortality. We sought to identify the rate of HT in stroke patients not treated with tPA within a large, biracial population.
Methods:
The GCNKSS is a population-based stroke epidemiology study from five counties in the Greater Cincinnati region. During 2015, we captured all hospitalized strokes by screening ICD-9 codes 430-436 and ICD-10 codes I60-I68, and G45-46. Study nurses abstracted all potential cases and physicians adjudicated cases, including classifying the degree of HT. Patients treated with thrombolytics were excluded. Incidence rates per 100,000 and associated 95% confidence intervals (CI) were estimated for HT cases, age and sex adjusted to the 2000 US population. Multiple logistic regression was used to examine risk factors associated with HT.
Results:
In 2015, there were 2301 ischemic strokes included in the analysis. Of these 104 (4.5%) had HT; 23 (22.1%) symptomatic, 55 (52.9%) asymptomatic and 26 (25%) unknown. Documented reasons for not receiving tPA in these patients were: time (71, 68.3%), anticoagulant use (1, 1.0%), other (18,17.3%) and unknown (14, 13.5%), which were not significantly different compared to those without HT. Only 29/104 (18.3%) had HT classified as PH-1 or PH-2. The age, sex and race-adjusted rate of HT was 9.8 (7.9, 11.6) per 100,000. The table shows rates of potential risk factors and the adjusted odds of developing HT. 90 day all-cause case fatality for patients with HT was significantly higher, 27.9% vs. 15.7%, p<0.0001.
Conclusion:
We found that 4.5% of non-tPA treated IS patients had HT. These patients had more severe strokes, were more likely to have abnormal coagulation tests or anticoagulant use, and were more likely to die within 90 days. We also report the first population-based incidence rate of HT in non-tPA treated of 9.8/100,000, a rate similar to the incidence of SAH.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Madsen TE, Khoury JC, Alwell KS, Ferioli S, Woo D, Mackey J, De Los Rios La Rosa F, Demel SL, Star M, Haverbusch M, Coleman ER, Walsh KB, Slavin S, Jasne A, Mistry E, Kissela BM, Kleindorfer D. Abstract P244: Association Between Diagnostic Work-Up and Outcomes of TIA in the Greater Cincinnati Northern Kentucky Stroke Study. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Substantial practice variability exists with respect to the diagnostic workup and disposition of patients with TIA. Identifying the workup needed to prevent adverse outcomes is critical. We aimed to determine whether there is an association between specific elements of TIA management and outcomes.
Methods:
The GCNKSS is a population-based study of 1.3 million people living in a 5-county area of southern Ohio/ Northern Kentucky. For this study, all physician adjudicated, first-ever TIAs (clinically defined as sudden onset, focal neurologic symptoms lasting < 24 hours, with or without MRI correlate) presenting to the ED during 2015 were included; those with prior stoke or TIA were excluded. Multivariable logistic regression was performed to investigate associations between specific aspects of TIA management and an adverse outcome, defined as stroke, recurrent TIA, or all-cause mortality within 30 days, adjusted for demographics, co-morbidities, and symptom type and length as classified in the ABCD2 score.
Results:
In 2015, there were 477 adjudicated first ever TIA events presenting to the ED. Overall, 13% (n=62) occurred in Black individuals and 51% (n=243) in women. Regarding outcomes, 3% (n=16) had a stroke within 30 days, 6% (n=30) had a recurrent TIA within 30 days, and 1% (n=4) died within 30 days (all-cause mortality). 16.4% had acute infarct on MRI. In multivariable analysis, having an MRI was associated with reduced risk of adverse outcome, while performance of vessel imaging, echocardiogram, or admission to hospital were not significantly associated with outcomes (Table).
Conclusions:
Among common diagnostic and management strategies for TIA, only performance of MRI was associated with a lower likelihood of having an adverse outcome within 30 days. Possible contributors include variability in care between hospitals with differing MRI performance rates and changes in management of risk factors based on MRI results, though further work is needed.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | |
Collapse
|
32
|
Richards CT, Sucharew H, Kissela BM, Kleindorfer D, Alwell KS, Woo D, Khoury JC, De Los Rios La Rosa F, Mackey J, Ferioli S, Mistry E, Demel SL, Coleman ER, Jasne A, Slavin S, Walsh KB, Star M, Haverbusch M, McMullan J, Khatri P, Adeoye OM. Abstract 19: Prehospital Identification of Acute Ischemic Stroke is Associated With Faster and More Frequent Thrombolysis. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Functional outcomes are improved when AIS patients receive faster treatment. The first medical contact for many AIS patients is with emergency medical services (EMS) providers. We hypothesize that AIS treatment is faster when EMS providers suspect stroke.
Methods:
We performed a retrospective analysis of the Greater Cincinnati/Northern Kentucky Stroke Study, a comprehensive study of stroke patients in a large geographical area with 1.3 million inhabitants whose demographics are representative of the United States. We compared AIS patients age ≥18 years transported by EMS in 2015 with an EMS impression of “stroke” or “weakness/numbness” to those with other EMS impressions. Primary outcome was thrombolysis rate, and secondary outcomes were times from EMS scene arrival to ED arrival, CT, and treatment and times from ED arrival to CT and treatment. Chi-square and Mann-Whitney U-tests were used to compare treatment rates and times, respectively. Logistic regression (for rates) and median regression (for times) adjusted for NIHSS, GCS, age, sex, race, and prior stroke history.
Results:
Among 2,486 confirmed AIS patients from 1/1/2015-12/31/2015, 868 were transported by EMS, including 595 (69%) with EMS suspected stroke. Compared to EMS non-suspected strokes, patients with EMS suspected stroke patients were more likely to receive thrombolysis (18% vs 8%; OR 2.67, 95% CI 1.63-4.47) and had faster prehospital transport (30 vs 32 min, p=0.02), ED arrival to CT (27 vs 46 min, p<0.01) and thrombolysis (64 vs 83 min, p=0.03), and EMS scene arrival to thrombolysis (91 vs 118 min, p=0.03) and EVT (164 vs 250 min, p=0.03). Findings were maintained in the adjusted models except for EMS arrival to EVT (Table).
Conclusions:
In a large population-based study, EMS stroke identification is associated with a higher rate of and faster thrombolysis. Efforts to increase accuracy of EMS stroke identification is likely to have significant clinical impact by shortening treatment times.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Madsen TE, Khoury JC, Alwell KS, Adeoye OM, De Los Rios La Rosa F, Coleman ER, Demel SL, Ferioli S, Flaherty ML, Jasne A, Haverbusch M, Khatri P, Mackey J, Martini SR, Mistry E, Slavin S, Star M, Walsh KB, Woo D, Broderick JP, Kissela BM, Kleindorfer D. Abstract P602: Stroke Risk Factors Among the Young Over Time in the GCNKSS. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Data from the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) have demonstrated stable or increasing stroke incidence rates in young adults with differences by sex and race, suggesting the need for targeted approaches to stroke prevention in the young. We aimed to describe trends over time in prevalence of stroke risk factors among adults ages 20-54 with stroke by sex and race.
Methods:
Cases of incident stroke (IS, ICH, SAH) occurring in those 20-54 years old and living in a 5-county area of southern Ohio/northern Kentucky were ascertained during 5 study periods (1993-1994, 1999, 2005, 2010, 2015). All physician-adjudicated inpatient events and a sampling of outpatient events were included, excluding nursing home events. Data on risk factors (hypertension, diabetes, obesity (BMI≥30), and high cholesterol) diagnosed prior to stroke were abstracted from medical records, and prevalence of each risk factor was reported over time in race/sex groups. Trends over time were examined using the Cochran-Armitage test.
Results:
Over the 5 study periods, 1204 incident strokes were included; 49% were women, 33% were black, and mean age was 46 (SD 7) years. Premorbid hypertension increased over time in Black women (48% in 1993/4 to 76% in 2015, p=0.005) but not in any other race/sex group (all p>0.05). Premorbid high cholesterol increased significantly in all race/sex groups (Figure, all p<0.05) except for White men (p=0.06). There were no significant trends over time in pre-stroke diagnoses of diabetes or obesity in any of the race/sex groups (Figure).
Conclusions:
Among patients aged 20-54 with incident stroke in a large population-based study, the change in the prevalence of hypertension and high cholesterol differed by sex and race, while obesity and diabetes were stable over time in all race/sex groups. Future research is needed to address risk factor control at a population level and to understand the role of undiagnosed pre-stroke risk factors in the young.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Antzoulatos E, Sucharew H, Stanton RJ, Demel SL, Haverbusch M, Alwell K, De Los Rios La Rosa F, Coleman ER, Mackey J, Ferioli S, Mistry E, Jasne A, Slavin SJ, Walsh KB, Star M, Flaherty ML, Martini SR, Broderick JP, Adeoye OM, Khatri P, Kissela BM, Woo D, Kleindorfer DO. Abstract P716: Factors Associated With Functional Dependence at Hospital Discharge in Patients With Low NIHSS Strokes Who Do Not Receive Intravenous Alteplase. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Patients without prior functional deficits who suffer mild stroke (NIHSS <6) have a 20-30% likelihood of disability (mRS ≥2). Predictors of disability have been described mostly in clinical trials and single center registries. We identified variables associated with functional dependence (mRS ≥3) in mild stroke using a retrospective population-based sample.
Methods:
Hospitalized strokes from the Greater Cincinnati Northern Kentucky Stroke Study were used. Included patients had an initial NIHSS <6 and baseline mRS 0, both extrapolated from chart review. To minimize the inclusion of patients with disabling symptoms, tPA treatment was excluded. Demographic and clinical characteristics were analyzed by discharge disability status. A multivariable logistic model with least absolute shrinkage and selection operator (lasso) regression analysis identified independent predictors of disability.
Results:
Of 1268 ischemic strokes, 353 (28%) were functionally dependent at discharge. Increased baseline NIHSS was associated with worse outcome on the mRS. Leg, LOC questions, and sensation NIHSS subscores were the best predictors of outcome. Multivariable analysis identified age, race, hypertension, chronic kidney disease, heart failure, and post-stroke dysphagia as independently associated with discharge mRS ≥3.
Discussion:
Our results agree with and complement the results of prior studies. They are not limited by inclusion/exclusion criteria or referral bias. Rather, our major limitation is the retrospective estimation of NIHSS and mRS based on physician descriptive documentation rather than direct score assessment. Our results may allow for modeling to better predict outcome which in turn can inform clinical decision making and trial design.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Aziz YN, Demel SL, Ridha M, Ades LM, Alwell KS, Woo D, Sucharew H, Ferioli S, Khatri P, Adeoye OM, Flaherty ML, Mackey J, De Los Rios La Rosa F, Martini S, Mistry E, Coleman ER, Jasne AS, Slavin SJ, Walsh KB, Star M, Haverbusch M, Kissela BM, Kleindorfer DO. Abstract P638: Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Emergency Department Presentation Within a Population. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Hypertension is an important risk factor in the development of acute ischemic stroke (AIS). African American (AA) race is strongly associated with both hypertension and uncontrolled hypertension despite treatment, yet little is known about racial differences in presenting blood pressure (BP) in AIS. This study sought to describe differences in presenting BP and acute antihypertensive treatment between AA and white AIS patients who received and did not receive alteplase within a population.
Methods:
Using the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) database for years 2005, 2010 and 2015, we selected patients with a diagnosis of AIS using ICD-9/10 codes in adults ≥ 18 yrs of age presenting to a local ED within 4.5 hrs of symptom onset. Candidates were stratified by race and alteplase use. Socio-demographics, stroke risk factors, stroke severity, BP on arrival, and acute BP treatment were compared using chi-square, t-tests or Wilcoxon rank sum test, as appropriate.
Results (Table 1):
Of 1838 AIS patients included in the analysis, 392 (21%) received IV alteplase. AA patients were younger in both groups who received and did not receive alteplase. On presentation, AA stroke patients had higher diastolic BP. AA patients were more likely to receive 2 or more BP lowering medications compared to white patients in the alteplase treated group and the untreated group.
Conclusion:
AA patients presenting within 4.5 hours of AIS symptom onset are more likely to have elevated diastolic BP and to receive multiple BP lowering medications compared to white patients. These findings were significant regardless of alteplase treatment. To our knowledge, we report the first population-based distribution of BP, and medical treatment of BP, upon presentation to an ED in AIS. Further study is needed to determine if these racial differences in elevated BP and refractoriness of BP and/or aggressive treatment contribute to outcome differences.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Eva Mistry
- Vanderbilt Univ Med Cente, Nashville, TN
| | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Virani SS, Alonso A, Aparicio HJ, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Cheng S, Delling FN, Elkind MSV, Evenson KR, Ferguson JF, Gupta DK, Khan SS, Kissela BM, Knutson KL, Lee CD, Lewis TT, Liu J, Loop MS, Lutsey PL, Ma J, Mackey J, Martin SS, Matchar DB, Mussolino ME, Navaneethan SD, Perak AM, Roth GA, Samad Z, Satou GM, Schroeder EB, Shah SH, Shay CM, Stokes A, VanWagner LB, Wang NY, Tsao CW. Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association. Circulation 2021; 143:e254-e743. [PMID: 33501848 DOI: 10.1161/cir.0000000000000950] [Citation(s) in RCA: 2860] [Impact Index Per Article: 953.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease. RESULTS Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
37
|
Kamel H, Alwell K, Kissela BM, Sucharew HJ, Woo D, Flaherty M, Ferioli S, Demel SL, Moomaw CJ, Walsh K, Mackey J, De Los Rios La Rosa F, Jasne A, Slavin S, Martini S, Adeoye O, Baig T, Chen ML, Levitan EB, Soliman EZ, Kleindorfer DO. Racial Differences in Atrial Cardiopathy Phenotypes in Patients With Ischemic Stroke. Neurology 2021; 96:e1137-e1144. [PMID: 33239363 PMCID: PMC8055350 DOI: 10.1212/wnl.0000000000011197] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 10/23/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To test the hypothesis that thrombogenic atrial cardiopathy may be relevant to stroke-related racial disparities, we compared atrial cardiopathy phenotypes between Black vs White patients with ischemic stroke. METHODS We assessed markers of atrial cardiopathy in the Greater Cincinnati/Northern Kentucky Stroke Study, a study of stroke incidence in a population of 1.3 million. We obtained ECGs and reports of echocardiograms performed during evaluation of stroke during the 2010/2015 study periods. Patients with atrial fibrillation (AF) or flutter (AFL) were excluded. Investigators blinded to patients' characteristics measured P-wave terminal force in ECG lead V1 (PTFV1), a marker of left atrial fibrosis and impaired interatrial conduction, and abstracted left atrial diameter from echocardiogram reports. Linear regression was used to examine the association between race and atrial cardiopathy markers after adjustment for demographics, body mass index, and vascular comorbidities. RESULTS Among 3,426 ischemic stroke cases in Black or White patients without AF/AFL, 2,391 had a left atrial diameter measurement (mean, 3.65 ± 0.70 cm). Black race was associated with smaller left atrial diameter in unadjusted (β coefficient, -0.11; 95% confidence interval [CI], -0.17 to -0.05) and adjusted (β, -0.15; 95% CI, -0.21 to -0.09) models. PTFV1 measurements were available in 3,209 patients (mean, 3,434 ± 2,525 μV*ms). Black race was associated with greater PTFV1 in unadjusted (β, 1.59; 95% CI, 1.21-1.97) and adjusted (β, 1.45; 95% CI, 1.00-1.80) models. CONCLUSIONS We found systematic Black-White racial differences in left atrial structure and pathophysiology in a population-based sample of patients with ischemic stroke. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that atrial cardiopathy phenotypes differ in Black people with acute stroke compared to White people.
Collapse
Affiliation(s)
- Hooman Kamel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC.
| | - Kathleen Alwell
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brett M Kissela
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Heidi J Sucharew
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Daniel Woo
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Matthew Flaherty
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simona Ferioli
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Stacie L Demel
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Charles J Moomaw
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Kyle Walsh
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason Mackey
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Felipe De Los Rios La Rosa
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Adam Jasne
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sabreena Slavin
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sharyl Martini
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Opeolu Adeoye
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Tehniyat Baig
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Monica L Chen
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Emily B Levitan
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Elsayed Z Soliman
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Dawn O Kleindorfer
- From the Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., T.B., M.L.C.), Weill Cornell Medicine, New York, NY; Departments of Neurology and Rehabilitation Medicine (K.A., B.M.K., D.W., M.F., S.F., S.L.D., C.J.M., D.O.K.) and Emergency Medicine (K.W., O.A.), University of Cincinnati; Division of Biostatistics and Epidemiology (H.J.S.), Cincinnati Children's Hospital Medical Center; Department of Pediatrics (H.J.S.), University of Cincinnati College of Medicine, OH; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Baptist Health Neuroscience Center (F.D.L.R.L.R.), Miami, FL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Michael E. DeBakey VA Medical Center (S.M.), Houston, TX; Department of Epidemiology (E.B.L.), University of Alabama at Birmingham; and Division of Cardiology and Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, and Department of Internal Medicine-Cardiology (E.Z.S.), Wake Forest School of Medicine, Winston-Salem, NC
| |
Collapse
|
38
|
Arce Rentería M, Gillett SR, McClure LA, Wadley VG, Glasser SP, Howard VJ, Kissela BM, Unverzagt FW, Jenny NS, Manly JJ, Cushman M. C-reactive protein and risk of cognitive decline: The REGARDS study. PLoS One 2020; 15:e0244612. [PMID: 33382815 PMCID: PMC7774911 DOI: 10.1371/journal.pone.0244612] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 12/11/2020] [Indexed: 01/08/2023] Open
Abstract
Markers of systemic inflammation are associated with increased risk of cognitive impairment, but it is unclear if they are associated with a faster rate of cognitive decline and whether this relationship differs by race. Our objective was to examine the association of baseline C-reaction protein (CRP) with cognitive decline among a large racially diverse cohort of older adults. Participants included 21,782 adults aged 45 and older (36% were Black, Mean age at baseline 64) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. CRP was measured at baseline and used as a continuous variable or a dichotomous grouping based on race-specific 90th percentile cutoffs. Cognitive measures of memory and verbal fluency were administered every 2 years for up to 12 years. Latent growth curve models evaluated the association of CRP on cognitive trajectories, adjusting for relevant demographic and health factors. We found that higher CRP was associated with worse memory (B = -.039, 95% CI [-.065,-.014]) and verbal fluency at baseline (B = -.195, 95% CI [-.219,-.170]), but not with rate of cognitive decline. After covariate adjustment, the association of CRP on memory was attenuated (B = -.005, 95% CI [-.031,-.021]). The association with verbal fluency at baseline, but not over time, remained (B = -.042, 95% CI [-.067,-.017]). Race did not modify the association between CRP and cognition. Findings suggest that levels of CRP at age 45+, are a marker of cognitive impairment but may not be suitable for risk prediction for cognitive decline.
Collapse
Affiliation(s)
- Miguel Arce Rentería
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
| | - Sarah R. Gillett
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States of America
| | - Leslie A. McClure
- Departments of Epidemiology and Biostatistics, Drexel University, Philadelphia, Pennsylvania, United States of America
| | - Virginia G. Wadley
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Stephen P. Glasser
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Virginia J. Howard
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Brett M. Kissela
- Department of Neurology and Rehabilitation Medicine at the University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Frederick W. Unverzagt
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Nancy S. Jenny
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States of America
| | - Jennifer J. Manly
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
| | - Mary Cushman
- Departments of Medicine and Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, United States of America
| |
Collapse
|
39
|
Drake M, Frid P, Hansen BM, Wu O, Giese AK, Schirmer MD, Donahue K, Cloonan L, Irie RE, Bouts MJRJ, McIntosh EC, Mocking SJT, Dalca AV, Sridharan R, Xu H, Giralt-Steinhauer E, Holmegaard L, Jood K, Roquer J, Cole JW, McArdle PF, Broderick JP, Jiménez-Conde J, Jern C, Kissela BM, Kleindorfer DO, Lemmens R, Meschia JF, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Thijs V, Woo D, Worrall BB, Kittner SJ, Mitchell BD, Rosand J, Golland P, Lindgren A, Rost NS, Wassélius J. Diffusion-Weighted Imaging, MR Angiography, and Baseline Data in a Systematic Multicenter Analysis of 3,301 MRI Scans of Ischemic Stroke Patients-Neuroradiological Review Within the MRI-GENIE Study. Front Neurol 2020; 11:577. [PMID: 32670186 PMCID: PMC7330135 DOI: 10.3389/fneur.2020.00577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Magnetic resonance imaging (MRI) serves as a cornerstone in defining stroke phenotype and etiological subtype through examination of ischemic stroke lesion appearance and is therefore an essential tool in linking genetic traits and stroke. Building on baseline MRI examinations from the centralized and structured radiological assessments of ischemic stroke patients in the Stroke Genetics Network, the results of the MRI-Genetics Interface Exploration (MRI-GENIE) study are described in this work. Methods: The MRI-GENIE study included patients with symptoms caused by ischemic stroke (N = 3,301) from 12 international centers. We established and used a structured reporting protocol for all assessments. Two neuroradiologists, using a blinded evaluation protocol, independently reviewed the baseline diffusion-weighted images (DWIs) and magnetic resonance angiography images to determine acute lesion and vascular occlusion characteristics. Results: In this systematic multicenter radiological analysis of clinical MRI from 3,301 acute ischemic stroke patients according to a structured prespecified protocol, we identified that anterior circulation infarcts were most prevalent (67.4%), that infarcts in the middle cerebral artery (MCA) territory were the most common, and that the majority of large artery occlusions 0 to 48 h from ictus were in the MCA territory. Multiple acute lesions in one or several vascular territories were common (11%). Of 2,238 patients with unilateral DWI lesions, 52.6% had left-sided infarct lateralization (P = 0.013 for χ2 test). Conclusions: This large-scale analysis of a multicenter MRI-based cohort of AIS patients presents a unique imaging framework facilitating the relationship between imaging and genetics for advancing the knowledge of genetic traits linked to ischemic stroke.
Collapse
Affiliation(s)
- Mattias Drake
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden.,Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Petrea Frid
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Malmö, Sweden
| | - Björn M Hansen
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden.,Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Ona Wu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States
| | - Anne-Katrin Giese
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, United States
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Department of Population Health Sciences, German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Kathleen Donahue
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Lisa Cloonan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert E Irie
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States
| | - Mark J R J Bouts
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States
| | - Elissa C McIntosh
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States
| | - Steven J T Mocking
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States
| | - Adrian V Dalca
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States.,Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, MA, United States
| | - Ramesh Sridharan
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, MA, United States
| | - Huichun Xu
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Eva Giralt-Steinhauer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), University at Autonoma de Barcelona, Barcelona, Spain
| | - Lukas Holmegaard
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Katarina Jood
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), University at Autonoma de Barcelona, Barcelona, Spain
| | - John W Cole
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, United States
| | - Patrick F McArdle
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jordi Jiménez-Conde
- Department of Neurology, Neurovascular Research Group (NEUVAS), IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), University at Autonoma de Barcelona, Barcelona, Spain
| | - Christina Jern
- Department of Laboratory Medicine, Institute of Biomedicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), Leuven, Belgium.,Department of Neurology, VIB, Vesalius Research Center, Laboratory of Neurobiology, University Hospitals Leuven, Leuven, Belgium
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States
| | - Tatjana Rundek
- Department of Neurology and the Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Ralph L Sacco
- Department of Neurology and the Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Reinhold Schmidt
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University Graz, Graz, Austria
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham, United Kingdom.,Ashford and St Peter's Hospital, Surrey, United Kingdom
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia.,Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Bradford B Worrall
- Departments of Neurology and Public Health Sciences, University of Virginia, Charlottesville, VA, United States
| | - Steven J Kittner
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, United States
| | - Braxton D Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.,Geriatric Research and Education Clinical Center, Veterans Administration Medical Center, Baltimore, MD, United States
| | - Jonathan Rosand
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, United States.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Henry and Allison McCancer Center for Brain Health and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Polina Golland
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, MA, United States
| | - Arne Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.,Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Lund, Sweden
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Johan Wassélius
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden.,Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
40
|
Awosika OO, Matthews S, Staggs EJ, Boyne P, Song X, Rizik BA, Sucharew HJ, Zhang C, Mungcal G, Moudgal R, Bhattacharya A, Dunning K, Woo D, Kissela BM. Backward locomotor treadmill training combined with transcutaneous spinal direct current stimulation in stroke: a randomized pilot feasibility and safety study. Brain Commun 2020; 2:fcaa045. [PMID: 32954299 PMCID: PMC7425394 DOI: 10.1093/braincomms/fcaa045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/17/2022] Open
Abstract
Walking impairment impacts nearly 66% of stroke survivors and is a rising cause of morbidity worldwide. Despite conventional post-stroke rehabilitative care, the majority of stroke survivors experience continued limitations in their walking speed, temporospatial dynamics and walking capacity. Hence, novel and comprehensive approaches are needed to improve the trajectory of walking recovery in stroke survivors. Herein, we test the safety, feasibility and preliminary efficacy of two approaches for post-stroke walking recovery: backward locomotor treadmill training and transcutaneous spinal direct current stimulation. In this double-blinded study, 30 chronic stroke survivors (>6 months post-stroke) with mild-severe residual walking impairment underwent six 30-min sessions (three sessions/week) of backward locomotor treadmill training, with concurrent anodal (N = 19) or sham transcutaneous spinal direct current stimulation (N = 11) over the thoracolumbar spine, in a 2:1 stratified randomized fashion. The primary outcomes were: per cent participant completion, safety and tolerability of these two approaches. In addition, we collected data on training-related changes in overground walking speed, cadence, stride length (baseline, daily, 24-h post-intervention, 2 weeks post-intervention) and walking capacity (baseline, 24-h post-intervention, 2 weeks post-intervention), as secondary exploratory aims testing the preliminary efficacy of these interventions. Eighty-seven per cent (N = 26) of randomized participants completed the study protocol. The majority of the study attrition involved participants with severe baseline walking impairment. There were no serious adverse events in either the backward locomotor treadmill training or transcutaneous spinal direct current stimulation approaches. Also, both groups experienced a clinically meaningful improvement in walking speed immediately post-intervention that persisted at the 2-week follow-up. However, in contrast to our working hypothesis, anodal-transcutaneous spinal direct current stimulation did not enhance the degree of improvement in walking speed and capacity, relative to backward locomotor treadmill training + sham, in our sample. Backward locomotor treadmill training and transcutaneous spinal direct current stimulation are safe and feasible approaches for walking recovery in chronic stroke survivors. Definitive efficacy studies are needed to validate our findings on backward locomotor treadmill training-related changes in walking performance. The results raise interesting questions about mechanisms of locomotor learning in stroke, and well-powered transcutaneous spinal direct current stimulation dosing studies are needed to understand better its potential role as a neuromodulatory adjunct for walking rehabilitation.
Collapse
Affiliation(s)
- Oluwole O Awosika
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Saira Matthews
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Emily J Staggs
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Pierce Boyne
- College of Allied Health and Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Xiao Song
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Bridget A Rizik
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Heidi J Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Christina Zhang
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Gabrielle Mungcal
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Rohitha Moudgal
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Amit Bhattacharya
- Biomechanics-Ergonomics Research Laboratories, Department of Environmental Health, University of Cincinnati Medical College, USA
| | - Kari Dunning
- College of Allied Health and Sciences, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| |
Collapse
|
41
|
Frid P, Drake M, Giese AK, Wasselius J, Schirmer MD, Donahue KL, Cloonan L, Irie R, Bouts MJRJ, McIntosh EC, Mocking SJT, Dalca AV, Sridharan R, Xu H, Giralt-Steinhauer E, Holmegaard L, Jood K, Roquer J, Cole JW, McArdle PF, Broderick JP, Jimenez-Conde J, Jern C, Kissela BM, Kleindorfer DO, Lemmens R, Meschia JF, Rundek T, Sacco RL, Schmidt R, Sharma P, Slowik A, Thijs V, Woo D, Worrall BB, Kittner SJ, Mitchell BD, Petersson J, Rosand J, Golland P, Wu O, Rost NS, Lindgren A. Detailed phenotyping of posterior vs. anterior circulation ischemic stroke: a multi-center MRI study. J Neurol 2020; 267:649-658. [PMID: 31709475 PMCID: PMC7035231 DOI: 10.1007/s00415-019-09613-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Posterior circulation ischemic stroke (PCiS) constitutes 20-30% of ischemic stroke cases. Detailed information about differences between PCiS and anterior circulation ischemic stroke (ACiS) remains scarce. Such information might guide clinical decision making and prevention strategies. We studied risk factors and ischemic stroke subtypes in PCiS vs. ACiS and lesion location on magnetic resonance imaging (MRI) in PCiS. METHODS Out of 3,301 MRIs from 12 sites in the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Genetics Network (SiGN), we included 2,381 cases with acute DWI lesions. The definition of ACiS or PCiS was based on lesion location. We compared the groups using Chi-squared and logistic regression. RESULTS PCiS occurred in 718 (30%) patients and ACiS in 1663 (70%). Diabetes and male sex were more common in PCiS vs. ACiS (diabetes 27% vs. 23%, p < 0.05; male sex 68% vs. 58%, p < 0.001). Both were independently associated with PCiS (diabetes, OR = 1.29; 95% CI 1.04-1.61; male sex, OR = 1.46; 95% CI 1.21-1.78). ACiS more commonly had large artery atherosclerosis (25% vs. 20%, p < 0.01) and cardioembolic mechanisms (17% vs. 11%, p < 0.001) compared to PCiS. Small artery occlusion was more common in PCiS vs. ACiS (20% vs. 14%, p < 0.001). Small artery occlusion accounted for 47% of solitary brainstem infarctions. CONCLUSION Ischemic stroke subtypes differ between the two phenotypes. Diabetes and male sex have a stronger association with PCiS than ACiS. Definitive MRI-based PCiS diagnosis aids etiological investigation and contributes additional insights into specific risk factors and mechanisms of injury in PCiS.
Collapse
Affiliation(s)
- Petrea Frid
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden.
- Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Malmö, Sweden.
- Department of Neurology, Skåne University Hospital, Jan Waldenströms gata 19, 205 02, Malmö, Sweden.
| | - Mattias Drake
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden
- Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - A K Giese
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - J Wasselius
- Department of Clinical Sciences Lund, Radiology, Lund University, Lund, Sweden
- Department of Radiology, Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - M D Schirmer
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
- Department of Population Health Sciences, German Centre for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - K L Donahue
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - L Cloonan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Irie
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - M J R J Bouts
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - E C McIntosh
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - S J T Mocking
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - A V Dalca
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - R Sridharan
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
| | - H Xu
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E Giralt-Steinhauer
- Neurovascular Research Group (NEUVAS), Department of Neurology, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - L Holmegaard
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - K Jood
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - J Roquer
- Neurovascular Research Group (NEUVAS), Department of Neurology, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - J W Cole
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - P F McArdle
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - J Jimenez-Conde
- Neurovascular Research Group (NEUVAS), Department of Neurology, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autonoma de Barcelona, Barcelona, Spain
| | - C Jern
- Institute of Biomedicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - B M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - D O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - R Lemmens
- Department of Neurosciences, Experimental Neurology, KU Leuven-University of Leuven, Louvain, Belgium
- VIB Center for Brain and Disease Research, Louvain, Belgium
- Department of Neurology, University Hospitals Leuven, Louvain, Belgium
| | - J F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - T Rundek
- Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - R L Sacco
- Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - R Schmidt
- Clinical Division of Neurogeriatrics, Department of Neurology, Medical University Graz, Graz, Austria
| | - P Sharma
- Institute of Cardiovascular Research, Royal Holloway University of London (ICR2UL), Egham, UK
- Ashford and St Peter's Hospital, Ashford, UK
| | - A Slowik
- Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - V Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, Australia
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - D Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - B B Worrall
- Department of Neurology, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - S J Kittner
- Department of Neurology, University of Maryland School of Medicine and Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - B D Mitchell
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Geriatric Research and Education Clinical Center, Veterans Administration Medical Center, Baltimore, MD, USA
| | - J Petersson
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Malmö, Sweden
| | - J Rosand
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
- Center for Genomic Research, Massachusetts General Hospital, Boston, MA, USA
- Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - P Golland
- Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge, USA
| | - O Wu
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital (MGH), Harvard Medical School, Charlestown, MA, USA
| | - N S Rost
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - A Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
- Department of Neurology and Rehabilitation Medicine, Neurology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
42
|
Madsen TE, Khoury JC, Leppert M, Alwell K, Moomaw CJ, Sucharew H, Woo D, Ferioli S, Martini S, Adeoye O, Khatri P, Flaherty M, De Los Rios La Rosa F, Mackey J, Mistry E, Demel SL, Coleman E, Jasne A, Slavin SJ, Walsh K, Star M, Broderick JP, Kissela BM, Kleindorfer DO. Temporal Trends in Stroke Incidence Over Time by Sex and Age in the GCNKSS. Stroke 2020; 51:1070-1076. [PMID: 32078459 DOI: 10.1161/strokeaha.120.028910] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background and Purpose- Sex differences in stroke incidence over time were previously reported from the GCNKSS (Greater Cincinnati/Northern Kentucky Stroke Study). We aimed to determine whether these differences continued through 2015 and whether they were driven by particular age groups. Methods- Within the GCNKSS population of 1.3 million, incident (first ever) strokes among residents ≥20 years of age were ascertained at all local hospitals during 5 periods: July 1993 to June 1994 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100 000 were adjusted for age and race and standardized to the 2010 US Census. Trends over time by sex were compared (overall and age stratified). Sex-specific case fatality rates were also reported. Bonferroni corrections were applied for multiple comparisons. Results- Over the 5 study periods, there were 9733 incident strokes (56.3% women). For women, there were 229 (95% CI, 215-242) per 100 000 incident strokes in 1993/1994 and 174 (95% CI, 163-185) in 2015 (P<0.05), compared with 282 (95% CI, 263-301) in 1993/1994 to 211 (95% CI, 198-225) in 2015 (P<0.05) in men. Incidence rates decreased between the first and last study periods in both sexes for IS but not for intracerebral hemorrhage or subarachnoid hemorrhage. Significant decreases in stroke incidence occurred between the first and last study periods for both sexes in the 65- to 84-year age group and men only in the ≥85-year age group; stroke incidence increased for men only in the 20- to 44-year age group. Conclusions- Overall stroke incidence decreased from the early 1990s to 2015 for both sexes. Future studies should continue close surveillance of sex differences in the 20- to 44-year and ≥85-year age groups, and future stroke prevention strategies should target strokes in the young- and middle-age groups, as well as intracerebral hemorrhage.
Collapse
Affiliation(s)
- Tracy E Madsen
- From the Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI (T.E.M.)
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K., H.S.)
| | - Michelle Leppert
- Department of Neurology, University of Colorado School of Medicine, Aurora (M.L.)
| | - Kathleen Alwell
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Charles J Moomaw
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Heidi Sucharew
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH (J.C.K., H.S.)
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Sharyl Martini
- Department of Neurology, Baylor College of Medicine, Houston, TX (S.M.).,Veterans Affairs National Telestroke Program (S.M.)
| | - Opeolu Adeoye
- Department of Emergency Medicine (O.A.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Matthew Flaherty
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | | | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M.)
| | - Eva Mistry
- Department of Neurology, Vanderbilt University, Nashville, TN (E.M.)
| | - Stacie L Demel
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Elisheva Coleman
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Adam Jasne
- Department of Neurology, Yale School of Medicine, New Haven, CT (A.J.)
| | - Sabreena J Slavin
- Department of Neurology, University of Kansas Medical Center, MO (S.J.S.)
| | - Kyle Walsh
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH
| | - Michael Star
- Department of Neurology, Soroka Medical Center, Beersheva, Israel (M.S.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine (K.A., C.J.M., D.W., S.F., P.K., M.F., S.L.D., E.C., K.W., J.P.B., B.M.K., D.O.K.), University of Cincinnati College of Medicine, OH.,UC Gardner Neuroscience Institute (D.W., S.F., O.A., P.K., M.F., S.L.D., J.P.B., B.M.K., D.O.K.)
| |
Collapse
|
43
|
Madsen TE, Khoury JC, Leppert M, Alwell K, Moomaw CJ, Woo D, Ferioli S, Martini S, Adeoye O, Khatri P, Flaherty M, De Los Rios La Rosa F, Mackey JS, Mistry E, Demel SL, Coleman ELISHEVA, Jasne A, Slavin SJ, Walsh K, Star M, Broderick J, Kissela BM, Kleindorfer DO. Abstract 72: Temporal Trends in Stroke Incidence Over Time by Sex and Age in the Greater Cincinnati Northern Kentucky Stroke Study. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Data from the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) through 2010 showed that over time, stroke incidence rates decreased to a greater extent in men than in women. We aimed to determine whether this difference continued through 2015 and whether the differences are driven by particular age groups.
Methods:
Within the GCNKSS population of 1.3 million, all incident strokes among residents ≥20 years old were ascertained at all local hospitals during 7/93–6/94 and calendar years 1999, 2005, 2010, and 2015. Out-of-hospital cases were sampled. Sex-specific incidence rates per 100,000 were adjusted for age and race, standardized to the 2010 U.S. Census. Trends over time by sex were compared (overall and age-stratified); a Bonferroni correction was applied for multiple comparisons.
Results:
In total over the five study periods, there were 9721 incident strokes (ischemic, ICH, and SAH); 56.4% were women. Incidence of ischemic strokes decreased from 254 (95%CI 236,272) in 1993/4 to 177 (95%CI 164,189) in 2015 among men (p<.0001 for trend over time) and from 204 (95%CI 192,217) in 1993/4 to 151 (95%CI 141,161) in 2015 among women (p<.0001). Incidence of ICH/ SAH did not change significantly over time in either sex. In age-stratified analyses, among women, incidence of all strokes decreased among older adults (65–84 years) but not in other age categories (Figure). Among men, incidence over time decreased among older adults (65–84 and ≥ 85 years) but increased in young adults (20–44 years).
Conclusions:
Stroke incidence decreased between the early 1990s and 2015 for both sexes, contrary to previous data on trends through 2010 which demonstrated a significant decrease in men but not women. Temporal changes are being driven by the 65–84 year age group in both men and women, as well as the ≥ 85 age group in men. Future prevention strategies should target young and middle age adults for both sexes as well as those over 85 for women.
Collapse
Affiliation(s)
- Tracy E Madsen
- Emergency Medicine, Alpert Med Sch of Brown Univ, Providence, RI
| | - Jane C Khoury
- Pediatrics, Cincinnati Children’s Hosp, Cincinnati, OH
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michael Star
- Soroka Med Cntr, Beersheva, Israel, Beersheva, Israel
| | | | | | | |
Collapse
|
44
|
Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Shay CM, Spartano NL, Stokes A, Tirschwell DL, VanWagner LB, Tsao CW. Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association. Circulation 2020; 141:e139-e596. [PMID: 31992061 DOI: 10.1161/cir.0000000000000757] [Citation(s) in RCA: 4641] [Impact Index Per Article: 1160.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals. RESULTS Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
Collapse
|
45
|
Arora P, Kalra R, Callas PW, Alexander KS, Zakai NA, Wadley V, Arora G, Kissela BM, Judd SE, Cushman M. Lipoprotein(a) and Risk of Ischemic Stroke in the REGARDS Study. Arterioscler Thromb Vasc Biol 2020; 39:810-818. [PMID: 30786745 DOI: 10.1161/atvbaha.118.311857] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective- Increased Lp(a) [lipoprotein(a)] is associated with coronary heart disease risk, but links with stroke are less consistent. Blacks have higher Lp(a) levels and stroke incidence than whites but have been underrepresented in studies. We hypothesized that Lp(a) is a risk factor for ischemic stroke and that risk differs by race. Approach and Results- REGARDS (Reasons for Geographic and Racial Differences in Stroke) recruited 30 239 black and white US adults aged ≥45 in 2003-2007 to study regional and racial differences in stroke mortality. We measured baseline Lp(a) by immunonephelometric assay in 572 cases of incident ischemic stroke and a 967-person cohort random sample. The hazard ratio of stroke by baseline Lp(a) was calculated using Cox proportional hazards models, stratified by race. Lp(a) was modeled in sex- and race-specific quartiles, given known differences in distributions by race and sex. Interactions were tested by including interaction terms in the proportional hazards models, with P<0.10 considered statistically significant. After adjustment for age, sex, and stroke risk factors, being in the fourth versus the first Lp(a) quartile was weakly associated with ischemic stroke overall, hazard ratio, 1.45 (95% CI, 0.96-2.19). In blacks, the hazard ratio was 1.96 (95% CI, 1.10-3.46), whereas in whites HR was 1.14 (95% CI, 0.64-2.04); P interaction=0.12. Lp(a) was lower in men than women, but associations with stroke in men and women were similar. Conclusions- We confirm that Lp(a) is a risk factor for ischemic stroke. Further research is needed to confirm the role of racial differences of the Lp(a) risk multiplier in ischemic stroke.
Collapse
Affiliation(s)
- Pankaj Arora
- From the Division of Cardiology, Department of Medicine (P.A., G.A.), University of Alabama at Birmingham.,Section of Cardiology, Birmingham Veterans Affairs Medical Center, AL (P.A.)
| | - Rajat Kalra
- Cardiovascular Division, University of Minnesota, Minneapolis (R.K.)
| | - Peter W Callas
- Department of Mathematics, University of Vermont, Burlington (P.W.C.)
| | - Kristine S Alexander
- Department of Medicine (K.S.A., N.A.Z., M.C.), Larner College of Medicine at the University of Vermont, Burlington
| | - Neil A Zakai
- Department of Medicine (K.S.A., N.A.Z., M.C.), Larner College of Medicine at the University of Vermont, Burlington.,Department of Pathology and Laboratory Medicine (N.A.Z., M.C.), Larner College of Medicine at the University of Vermont, Burlington
| | - Virginia Wadley
- Department of Medicine (V.W.), University of Alabama at Birmingham
| | - Garima Arora
- From the Division of Cardiology, Department of Medicine (P.A., G.A.), University of Alabama at Birmingham
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (B.M.K.)
| | - Suzanne E Judd
- Department of Biostatistics (S.E.J.), University of Alabama at Birmingham
| | - Mary Cushman
- Department of Medicine (K.S.A., N.A.Z., M.C.), Larner College of Medicine at the University of Vermont, Burlington.,Department of Pathology and Laboratory Medicine (N.A.Z., M.C.), Larner College of Medicine at the University of Vermont, Burlington
| |
Collapse
|
46
|
Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L, Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O'Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS. Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association. Circulation 2019; 139:e56-e528. [PMID: 30700139 DOI: 10.1161/cir.0000000000000659] [Citation(s) in RCA: 5138] [Impact Index Per Article: 1027.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
47
|
Howard VJ, Madsen TE, Kleindorfer DO, Judd SE, Rhodes JD, Soliman EZ, Kissela BM, Safford MM, Moy CS, McClure LA, Howard G, Cushman M. Sex and Race Differences in the Association of Incident Ischemic Stroke With Risk Factors. JAMA Neurol 2019; 76:179-186. [PMID: 30535250 DOI: 10.1001/jamaneurol.2018.3862] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Race-specific and sex-specific stroke risk varies across the lifespan, yet few reports describe sex differences in stroke risk separately in black individuals and white individuals. Objective To examine incidence and risk factors for ischemic stroke by sex for black and white individuals. Design, Setting, and Participants This prospective cohort study included participants 45 years and older who were stroke-free from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, enrolled from the continental United States 2003 through 2007 with follow-up through October 2016. Data were analyzed from March 2018 to September 2018. Exposures Sex and race. Main Outcomes and Measures Physician-adjudicated incident ischemic stroke, self-reported race/ethnicity, and measured and self-reported risk factors. Results A total of 25 789 participants (14 170 women [54.9%]; 10 301 black individuals [39.9%]) were included. Over 222 120 person-years of follow-up, 939 ischemic strokes occurred: 159 (16.9%) in black men, 326 in white men (34.7%), 217 in black women (23.1%), and 237 in white women (25.2%). Between 45 and 64 years of age, white women had 32% lower stroke risk than white men (incidence rate ratio [IRR], 0.68 [95% CI, 0.49-0.94]), and black women had a 28% lower risk than black men (IRR, 0.72 [95% CI, 0.52-0.99]). Lower stroke risk in women than men persisted at age 65 through 74 years in white individuals (IRR, 0.71 [95% CI, 0.55-0.94]) but not in black individuals (IRR, 0.94 [95% CI, 0.68-1.30]); however, the race-sex interaction was not significant. At 75 years and older, there was no sex difference in stroke risk for either race. For white individuals, associations of systolic blood pressure (women: hazard ratio [HR], 1.13 [95% CI, 1.05-1.22]; men: 1.04 [95% CI, 0.97-1.11]; P = .099), diabetes (women: HR, 1.84 [95% CI, 1.35-2.52]; men: 1.13 [95% CI, 0.86-1.49]; P = .02), and heart disease (women: HR, 1.76 [95% CI, 1.30-2.39]; men, 1.26 [95% CI, 0.99-1.60]; P = .09) with stroke risk were larger for women than men, while antihypertensive medication use had a smaller association in women than men (women: HR, 1.17 [95% CI, 0.89-1.54]; men: 1.61 [95% CI, 1.29-2.03]; P = .08). In black individuals, there was no evidence of a sex difference for any risk factors. Conclusions and Relevance For both races, at age 45 through 64 years, women were at lower stroke risk than men, and there was no sex difference at 75 years or older; however, the sex difference pattern may differ by race from age 65 through 74 years. The association of risk factors on stroke risk differed by race-sex groups. While the need for primordial prevention, optimal management, and control of risk factors is universal across all age, racial/ethnic, and sex groups, some demographic subgroups may require earlier and more aggressive strategies.
Collapse
Affiliation(s)
- Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Tracy E Madsen
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center, Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston Salem, North Carolina.,Department of Internal Medicine, Cardiology Section, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Monika M Safford
- Department of Medicine, Weill-Cornell Medicine, New York, New York
| | - Claudia S Moy
- Department of Health and Human Services, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Leslie A McClure
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, Colchester, Vermont
| |
Collapse
|
48
|
Evans CR, Long DL, Howard G, McClure LA, Zakai NA, Jenny NS, Kissela BM, Safford MM, Howard VJ, Cushman M. C-reactive protein and stroke risk in blacks and whites: The REasons for Geographic And Racial Differences in Stroke cohort. Am Heart J 2019; 217:94-100. [PMID: 31520899 DOI: 10.1016/j.ahj.2019.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 08/01/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND C-reactive protein (CRP) is an inflammatory biomarker used in vascular risk prediction, though with less data in people of color. Blacks have higher stroke incidence and also higher CRP than whites. We studied the association of CRP with ischemic stroke risk in blacks and whites. METHODS REGARDS, an observational cohort study, recruited and followed 30,239 black and white Americans 45 years and older for ischemic stroke. We calculated hazard ratios and 95% CIs of ischemic stroke by CRP category (<1, 1-3, 3-10, and ≥10 mg/L) adjusted for age, sex and stroke risk factors. RESULTS There were 292 incident ischemic strokes among blacks and 439 in whites over 6.9 years of follow-up. In whites, the risk was elevated for CRP in the range from 3 to 10 mg/L and even higher for CRP >10 mg/L, whereas in blacks, an association was only seen for CRP >10 mg/L. Considered as a continuous variable, the risk factor-adjusted hazard ratios per SD higher lnCRP were 1.18 (95% CI 1.09-1.28) overall, 1.14 (95% CI 1.00-1.29) in blacks, and 1.22 (95% CI 1.10-1.35) in whites. Spline regression analysis visually confirmed the race difference in the association. CONCLUSIONS CRP may not be equally useful in stroke risk assessment in blacks and whites. Confirmation, similar study for coronary heart disease, and identification of reasons for these racial differences require further study.
Collapse
|
49
|
Howard G, Schwamm LH, Donnelly JP, Howard VJ, Jasne A, Smith EE, Rhodes JD, Kissela BM, Fonarow GC, Kleindorfer DO, Albright KC. Participation in Get With The Guidelines-Stroke and Its Association With Quality of Care for Stroke. JAMA Neurol 2019; 75:1331-1337. [PMID: 30083763 DOI: 10.1001/jamaneurol.2018.2101] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Get With The Guidelines-Stroke (GWTG-Stroke) is an American Heart Association/American Stroke Association stroke-care quality-improvement program; however, to our knowledge, there has not been a direct comparison of the quality of care between patients hospitalized at participating hospitals and those at nonparticipating hospitals. Objective To contrast quality of stroke care measures for patients admitted to hospitals participating and not participating in GWTG-Stroke. Design, Setting, and Participants Subpopulation of 546 participants with ischemic stroke occurring during a 9-year follow-up of the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a population-based cohort study of 30 239 randomly selected black and white participants 45 years and older recruited between 2003 and 2007. Of those with stroke, 207 (36%) were treated in a hospital participating in GWTG-Stroke and 339 in a nonparticipating hospital. Data were analyzed between July 29, 2017, and April 17, 2018. Main Outcomes and Measures Quality of care measures including use of tissue plasminogen activator, performance of swallowing evaluation, antithrombotic use in first 48 hours, lipid profile assessment, discharge receiving antithrombotic therapy, discharge receiving a statin, neurologist evaluation, providing weight loss and exercise counseling, education on stroke risk factors and warning signs, and assessment for rehabilitation. Results Participants treated at participating hospitals had a mean (SD) age of 74 (8) years and 100 of 207 were men (48%), while those seen at nonparticipating hospitals had a mean (SD) age of 73 (9) years, and 161 of 339 were men (48%). Those seen in participating hospitals were more likely to receive 5 of 10 evidence-based interventions recommended for patients hospitalized with ischemic stroke, including receiving tissue plasminogen activator (RR, 3.74; 95% CI, 1.65-8.50), education on risk factors (RR, 1.54; 95% CI, 1.16-2.05), having an evaluation for swallowing (RR, 1.25; 95% CI, 1.04-1.50), a lipid evaluation (RR, 1.18; 95% CI, 1.05-1.32), and an evaluation by a neurologist (RR, 1.12; 95% CI, 1.05-1.20). Those seen in participating hospitals received a mean of 5.4 (95% CI, 5.2-5.6) interventions compared with 4.8 (95% CI, 4.6-5.0) in nonparticipating hospitals (P < .001). Conclusions and Relevance These data collected independently of the GWTG-Stroke program document improved stroke care for patients with ischemic stroke hospitalized at participating hospitals.
Collapse
Affiliation(s)
- George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Lee H Schwamm
- Comprehensive Stroke Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John P Donnelly
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Adam Jasne
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Eric E Smith
- Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Gregg C Fonarow
- Department of Neurology, University of California, Los Angeles.,Section Editor
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Karen C Albright
- Section Editor.,Center for Global Health and Traslational Science, Department of Neurology, Upstate Medical University, Syracuse, New York
| |
Collapse
|
50
|
Malla G, Long DL, Judd SE, Irvin MR, Kissela BM, Lackland DT, Safford MM, Levine DA, Howard VJ, Howard G, Rhodes JD, Voeks JH, Kleindorfer DO, Anderson A, Meschia JF, Carson AP. Does the Association of Diabetes With Stroke Risk Differ by Age, Race, and Sex? Results From the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. Diabetes Care 2019; 42:1966-1972. [PMID: 31391199 PMCID: PMC7011202 DOI: 10.2337/dc19-0442] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/15/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Given temporal changes in diabetes prevalence and stroke incidence, this study investigated age, race, and sex differences in the diabetes-stroke association in a contemporary prospective cohort, the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study. RESEARCH DESIGN AND METHODS We included 23,002 non-Hispanic black and white U.S. adults aged ≥45 years without prevalent stroke at baseline (2003-2007). Diabetes was defined as fasting glucose ≥126 mg/dL, random glucose ≥200 mg/dL, or use of glucose-lowering medication. Incident stroke events were expert adjudicated and available through September 2017. RESULTS The prevalence of diabetes was 19.1% at baseline. During follow-up, 1,018 stroke events occurred. Among adults aged <65 years, comparing those with diabetes to those without diabetes, the risk of stroke was increased for white women (hazard ratio [HR] 3.72 [95% CI 2.10-6.57]), black women (HR 1.88 [95% CI 1.22-2.90]), and white men (HR 2.01 [95% CI 1.27-3.27]) but not black men (HR 1.27 [95% CI 0.77-2.10]) after multivariable adjustment. Among those aged ≥65 years, diabetes increased the risk of stroke for white women and black men, but not black women (HR 1.05 [95% CI 0.74-1.48]) or white men (HR 0.86 [95% CI 0.62-1.21]). CONCLUSIONS In this contemporary cohort, the diabetes-stroke association varied by age, race, and sex together, with a more pronounced effect observed among adults aged <65 years. With the recent increase in the burden of diabetes complications at younger ages in the U.S., additional efforts are needed earlier in life for stroke prevention among adults with diabetes.
Collapse
Affiliation(s)
- Gargya Malla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - D Leann Long
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Suzanne E Judd
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Marguerite R Irvin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH
| | - Daniel T Lackland
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Monika M Safford
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Deborah A Levine
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Virginia J Howard
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - George Howard
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - J David Rhodes
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH
| | - Aaron Anderson
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | | | - April P Carson
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|