Association between sleep-disordered breathing and post-stroke fatigue in patients with ischemic stroke

OBJECTIVES

Post-stroke fatigue (PSF) is common and often disabling. Sleep-disordered breathing (SDB) is highly prevalent among stroke survivors and can cause fatigue. We explored the relationship between SDB and PSF over time.

MATERIALS AND METHODS

Ischemic stroke (IS) patients within the BASIC project were offered SDB screening with a well-validated cardiopulmonary sleep apnea test at 0, 3-, 6-, and 12-months post-stroke. The primary exposure was the respiratory event index (REI; sum of apneas plus hypopneas per hour). The primary outcome was PSF, measured by the SF-36 vitality scale. Associations between REI and PSF were evaluated using linear regression including time-by-REI interactions, allowing the effect of REI to vary over time.

RESULTS

Of the 411 IS patients who completed at least one outcome interview, 44 % were female, 61 % Mexican American (MA), 26 % non-Hispanic white, with a mean age of 64 (SD 10). Averaged across timepoints, REI was not associated with PSF. In a time-varying model, higher REI was associated with greater PSF at 3-months (β = 1.75, CI = 0.08, 3.43), but not at 6- or 12-months. Across timepoints, female sex, depressive symptoms, and comorbidity burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF.

CONCLUSIONS

Higher REI was associated with modestly greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. SDB may be a modest modifiable risk factor for early PSF, but its treatment is unlikely to have a substantial impact on long-term PSF. MA ethnicity seems to be protective against PSF.

Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association

Accumulating evidence supports a link between sleep disorders, disturbed sleep, and adverse brain health, ranging from stroke to subclinical cerebrovascular disease to cognitive outcomes, including the development of Alzheimer disease and Alzheimer disease-related dementias. Sleep disorders such as sleep-disordered breathing (eg, obstructive sleep apnea), and other sleep disturbances, as well, some of which are also considered sleep disorders (eg, insomnia, sleep fragmentation, circadian rhythm disorders, and extreme sleep duration), have been associated with adverse brain health. Understanding the causal role of sleep disorders and disturbances in the development of adverse brain health is complicated by the common development of sleep disorders among individuals with neurodegenerative disease. In addition to the role of sleep disorders in stroke and cerebrovascular injury, mechanistic hypotheses linking sleep with brain health and biomarker data (blood-based, cerebrospinal fluid-based, and imaging) suggest direct links to Alzheimer disease-specific pathology. These potential mechanisms and the increasing understanding of the "glymphatic system," and the recognition of the importance of sleep in poststroke recovery, as well, support a biological basis for the indirect (through the worsening of vascular disease) and direct (through specific effects on neuropathology) connections between sleep disorders and brain health. Given promising evidence for the benefits of treatment and prevention, sleep disorders and disturbances represent potential targets for early treatment that may improve brain health more broadly. In this scientific statement, we discuss the evidence supporting an association between sleep disorders and disturbances and poor brain health ranging from stroke to dementia and opportunities for prevention and early treatment.

Heterogeneity of obstructive sleep apnea phenotypes after ischemic stroke: Outcome variation by cluster analysis

INTRODUCTION

Obstructive sleep apnea (OSA) is common but under-recognized after stroke. The aim of this study was to determine whether post-stroke phenotypic OSA subtypes are associated with stroke outcome in a population-based observational cohort.

METHODS

Ischemic stroke patients (n = 804) diagnosed with OSA (respiratory event index ≥10) soon after ischemic stroke were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project. Functional, cognitive, and quality of life outcomes were assessed at 90 days post-stroke and long-term stroke recurrence was ascertained. Latent profile analysis was performed based on demographic and clinical features, pre-stroke sleep characteristics, OSA severity, and vascular risk factors. Regression models were used to assess the association between phenotypic clusters and outcomes.

RESULTS

Four distinct phenotypic clusters provided the best fit. Cluster 1 was characterized by more severe stroke; cluster 2 by severe OSA and higher prevalence of medical comorbidities; cluster 3 by mild stroke and mild OSA; and cluster 4 by moderate OSA and mild stroke. Compared to cluster 3 and after adjustment for baseline stroke severity, cluster 1 and cluster 2 had worse 90-day functional outcome and cluster 1 also had worse quality of life. No difference in cognitive outcome or stroke recurrence rate was noted by cluster.

CONCLUSION

Post-stroke OSA is a heterogeneous disorder with different clinical phenotypes associated with stroke outcomes, including both daily function and quality of life. The unique presentations of OSA after stroke may have important implications for stroke prognosis and personalized treatment strategies.

Novel metrics of sleep-disordered breathing are associated with outcome after ischemic stroke

OBJECTIVE/BACKGROUND

Standard measures of sleep-disordered breathing (SDB) that rely on count data may not sufficiently capture SDB severity or reflect downstream consequences of SDB. We hypothesized that novel metrics derived from pulse rate, oxygen saturation, and nasal pressure would be associated with stroke outcomes.

PATIENTS/METHODS

Shortly after ischemic stroke, participants in a population-based study were offered ApneaLink Plus testing. Signal analysis was used to generate 166 metrics from the nasal pressure cannula and finger probe, categorized as: autonomic (based on pulse rate variability), oximetry-derived, nasal pressure-derived, and mixed oxygen and nasal pressure-derived measures. Three-month outcome assessments included functional and cognitive outcomes and stroke recurrence. Tobit regression and Cox proportional hazards models were used to examine associations between each sleep apnea metric and the three outcomes, unadjusted and adjusted for multiple potential confounders. Models were adjusted for multiple comparisons.

RESULTS

Of the 530 participants, the median age was 65 (IQR: 57, 73), 49 % were female, and 64 % were Mexican American. Without covariate adjustment, 23 of 166 variables were associated with functional outcome, 43 were associated with cognitive outcome, and 1 was associated with stroke recurrence. After adjustment, 7 mixed, oximetry, or nasal pressure-based metrics and 1 autonomic metric were associated with functional outcome, but none was associated with cognitive outcome or stroke recurrence.

CONCLUSIONS

Many novel metrics of SDB were associated with important stroke outcomes, and 8 novel metrics were associated with functional outcome in adjusted models. This raises hypotheses about pathways by which SDB may negatively impact stroke outcomes.

Association of Neighborhood Recreation Centers and Poststroke Outcomes in a Population-Based Cohort

BACKGROUND

Higher neighborhood socioeconomic status has been favorably associated with stroke outcomes. This may be due to these areas having more beneficial resources such as recreational centers. We aimed to determine if neighborhood density of recreation centers is favorably associated with stroke outcomes.

METHODS

We conducted analyses of data from the Brain Attack Surveillance in Corpus Christi project, a cohort of stroke survivors ≥45 years of age residing in Nueces County, TX (2009-2020). We included non-Hispanic White and Mexican American incident stroke survivors, who were not institutionalized prestroke and completed baseline and follow-up assessments (N=1392). We calculated the density of fitness and recreational sports centers within their residential census tract during the year of their stroke. Outcomes included function (self-ratings on activities of daily living and instrumental activities of daily living), cognition (modified mini-mental state exam), depression (Patient Health Questionnaire-8), and quality of life (abbreviated Stroke-Specific Quality of Life Scale). We fit confounder-adjusted gamma-distributed mixed generalized linear models with a log link for each outcome and considered interaction with stroke severity.

RESULTS

On average, participants were 65 years old, 53% male, and 63% Mexican American. Median recreational centers were 1.60 per square mile (interquartile range, 0.41-3.06). Among moderate-severe stroke survivors, greater density of recreation centers (75th versus 25th percentile) was associated with more favorable function and possibly quality of life (activities of daily living/instrumental activities of daily living, 4.8% change [95% CI, -0.11% to -9.27%]; Stroke-Specific Quality of Life Scale, 3.7% change [95% CI, -0.7% to 8.2%]). Minimal nonsignificant differences were observed among the overall stroke population and those with mild stroke.

CONCLUSIONS

The availability of recreation centers may be beneficial for poststroke function and quality of life among those with moderate-severe stroke. If further research confirms recreation centers to be beneficial, this could inform rehabilitation following stroke.

Longitudinal Assessment of Sleep Apnea in the Year After Stroke in a Population-Based Study

BACKGROUND

The aim of this study was to characterize change in sleep-disordered breathing severity in the year following stroke, overall, and by ethnicity, within the population-based Brain Attack Surveillance in Corpus Christi Project.

METHODS

First-ever ischemic strokes (n=414) were ascertained by active and passive surveillance and validated by stroke-trained physicians. Patients with stroke were invited to participate in portable sleep apnea testing (ApneaLink Plus) at baseline and 3, 6, and 12 months poststroke. Sleep-disordered breathing severity was assessed by the respiratory event index (apneas and hypopneas/hour of recording). The component obstructive apnea index and central apnea index were also assessed. Time and ethnicity effects on outcomes, as well as ethnic differences in time effects, were analyzed using generalized estimating equations with multivariable adjustment for confounding factors.

RESULTS

Mean age (n=414) was 63.9 years (SD=10.9); 68.4% were Mexican American. Baseline mean respiratory event index, obstructive apnea index, and central apnea index were 21.3 (SD=16.6), 8.6 (SD=11.5), and 1.5 (SD=3.2), respectively. There was no time effect on respiratory event index (P=0.35) but obstructive apnea index increased over time (P<0.01). Averaged over follow-up, respiratory event index and obstructive apnea index were significantly higher in Mexican American than non-Hispanic White persons. No ethnic difference in the time effect was found for either outcome. For central apnea index, there was an ethnicity-time interaction (P=0.01) such that central apnea index increased in non-Hispanic White but did not change in Mexican American persons.

CONCLUSIONS

Sleep-disordered breathing severity was significant and stable for most individuals in the year after stroke. These results do not confirm previous reports of diminishing sleep-disordered breathing severity over time after stroke and would support early assessment and treatment where indicated.

College students' knowledge and attitudes toward clinical trials and their relationship with willingness to participate in COVID-19 trials or vaccines

OBJECTIVE

We examined clinical trial knowledge and attitudes, and their relationship with willingness to participate in COVID-19 vaccine trials, and willingness to accept a COVID-19 vaccine among college students.

PARTICIPANTS

331 undergraduates: mean age 25; 72% women; and 78% white.

METHODS

We administered an online, anonymous survey to undergraduate students in July, 2020, during the COVID-19 pandemic.

RESULTS

The mean clinical trial knowledge score was 65% (SD = 16) correct. The mean attitudes toward clinical trials score (1 most negative: 5 most positive) was 3.3 (SD = 0.5). Attitudes toward clinical trials were associated with likelihood of COVID-19 trial participation (positive 76% vs. negative 35%, p = 0.001) and a trend toward likelihood of accepting a COVID-19 vaccine if available (positive 89% vs. negative 67%, p = 0.066).

CONCLUSIONS

General clinical trial knowledge and attitudes appear to be important targets for educational interventions. Furthermore, fostering positive attitudes may lead to improved COVID-19 trial participation and vaccine uptake.

Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan

Importance

Acute stroke treatment rates in the US lag behind those in other high-income nations.

Objective

To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis.

Design, Setting, and Participants

This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023.

Intervention

Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted.

Main Outcomes and Measures

The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type.

Results

In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30).

Conclusions and Relevance

This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage.

Trial Registration

ClinicalTrials.gov Identifier: NCT036455900.

Positive airway pressure treatment for sleep-disordered breathing is rare during the first year after stroke: The BASIC project

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is very common after ischemic stroke, and its treatment may have a positive impact on recovery from stroke and on secondary stroke prevention. This study sought to determine the prevalence of positive airway pressure (PAP) use after stroke.

PATIENTS/METHODS

Participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Demographics and co-morbidities were ascertained from the medical record. Self-reported PAP use (present vs absent) was assessed at 3, 6, and 12 months after stroke. Fisher exact tests and t-tests were used to compare PAP users versus non-users.

RESULTS

Of 328 participants who were found to have SDB after stroke, only 20 (6.1%) indicated using PAP at any point during the 12-month follow up period. High pre-stroke sleep apnea risk based on Berlin Questionnaire score, neck circumference, and co-morbid atrial fibrillation were associated with any self-reported PAP use; race/ethnicity, insurance status and other demographic variables were not associated with PAP use.

CONCLUSIONS

Only a small proportion of individuals with ischemic stroke and SDB received treatment with PAP during the initial year after stroke among participants in this population-based cohort study in Nueces County, Texas. Closing the substantial treatment gap for SDB after stroke might improve sleepiness and neurologic recovery.

Reach Out Emergency Department: A Randomized Factorial Trial to Determine the Optimal Mobile Health Components to Reduce Blood Pressure

BACKGROUND

Mobile health (mHealth) strategies initiated in safety-net Emergency Departments may be one approach to address the US hypertension epidemic, but the optimal mHealth components or dose are unknown.

METHODS

Reach Out is an mHealth, health theory-based, 2×2×2 factorial trial among hypertensive patients evaluated in a safety-net Emergency Department in Flint, Michigan. Reach Out consisted of 3 mHealth components, each with 2 doses: (1) healthy behavior text messaging (yes versus no), (2) prompted self-measured blood pressure (BP) monitoring and feedback (weekly versus daily), and (3) facilitated primary care provider appointment scheduling and transportation (yes versus no). The primary outcome was a change in systolic BP from baseline to 12 months. In a complete case analysis, we fit a linear regression model and accounted for age, sex, race, and prior BP medications to explore the association between systolic BP and each mHealth component.

RESULTS

Among 488 randomized participants, 211 (43%) completed follow-up. Mean age was 45.5 years, 61% were women, 54% were Black people, 22% did not have a primary care doctor, 21% lacked transportation, and 51% were not taking antihypertensive medications. Overall, systolic BP declined after 6 months (-9.2 mm Hg [95% CI, -12.2 to -6.3]) and 12 months (-6.6 mm Hg, -9.3 to -3.8), without a difference across the 8 treatment arms. The higher dose of mHealth components were not associated with a greater change in systolic BP; healthy behavior text messages (point estimate, mmHG=-0.5 [95% CI, -6.0 to 5]; P=0.86), daily self-measured BP monitoring (point estimate, mmHG=1.9 [95% CI, -3.7 to 7.5]; P=0.50), and facilitated primary care provider scheduling and transportation (point estimate, mmHG=0 [95% CI, -5.5 to 5.6]; P=0.99).

CONCLUSIONS

Among participants with elevated BP recruited from an urban safety-net Emergency Department, BP declined over the 12-month intervention period. There was no difference in change in systolic BP among the 3 mHealth components. Reach Out demonstrated the feasibility of reaching medically underserved people with high BP cared for at a safety-net Emergency Departments, yet the efficacy of the Reach Out mHealth intervention components requires further study.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03422718.

Abstract WMP34: Neighborhood Density Of Recreation, Civic, And Social Sites And Post-stroke Recurrence And Mortality

Introduction: Neighborhood socioeconomic status is associated with stroke recovery and mortality. Researchers suggest increased recreation, civic, and social sites (referred to as sites) may support physical, social, and cognitive activity resulting in more favorable outcomes.

Hypothesis: Stroke survivors in neighborhoods with lower versus higher number of sites will have a higher rate of mortality and stroke recurrence; these associations will be modified by stroke severity, ethnicity, and sex.

Methods: We included non-Hispanic white and Mexican American first-ever stroke survivors enrolled in the Brain Attack Surveillance in Corpus Christi project (2009-19), a population-based cohort in Nueces County, Texas. From a national database, we linked sites per square mile by census tract. We censored at second stroke (stroke recurrence model), death, or 1/1/2020, whichever occurred first. We fit cox regression models using a shared frailty model, adjusting for individual, interpersonal, and neighborhood factors. We considered interactions with stroke severity, sex, and ethnicity. We applied inverse probability weighting and multiple imputation to account for missing data.

Results: There were 1,688 survivors; 408 deaths, 189 stroke recurrences, over median follow-up of 1372 days. Median age was 64 years, 74% with mild stroke, 54% male and 60% Mexican American. There was no association between site density and mortality (HR comparing 75 th to 25 th percentile=1.01, 95% CI=0.83-1.23) or stroke recurrence (HR=0.98, 95% CI=0.74-1.30). Stroke severity, sex, and ethnicity did not modify the effect of site density on post-stroke mortality (p=0.33, p=0.17, p=0.58, respectively) or stroke recurrence (p=0.43, p=0.91, p=0.99, respectively).

Conclusions: We did not observe associations between neighborhood density of sites and post-stroke recurrence or mortality. Future research is needed to determine if other neighborhood features may support secondary stroke prevention or post-stroke survival.

Outcomes in the Year After First-Ever Ischemic Stroke in a Bi-Ethnic Population

OBJECTIVE

To investigate stroke outcomes at 3, 6, and 12 months post-stroke overall and by ethnicity in a population-based, longitudinal study.

METHODS

First-ever ischemic strokes (2014-2019, n = 1,332) among Mexican American persons (n = 807) and non-Hispanic white persons (n = 525) were identified from the Brain Attack Surveillance in Corpus Christi Project. Data were collected from patient or proxy interviews (baseline, 3, 6, and 12 months post-stroke) and medical records, including functional (activities of daily living/instrumental activities of daily living score), neurological (National Institutes of Health Stroke Scale), cognitive (Modified Mini-Mental State Examination), and quality of life (QOL) outcomes (12-domain Stroke-specific Quality of Life scale). Outcome trajectories were analyzed using multivariable adjusted linear models, with generalized estimating equations to account for within-subject correlations; interactions between ethnicity and time were included to investigate ethnic differences in outcomes.

RESULTS

The median age was 67 years (interquartile range 58,78), 48.5% were women, and 60.6% were Mexican American persons. For all outcomes, significant improvement was seen between 3 and 6 months (p < 0.05 for all), with stability between 6 and 12 months. Mexican American persons had significantly worse outcomes compared with non-Hispanic white persons at all time points (3, 6, and 12 months), with the exception of the National Institutes of Health Stroke Scale, which did not differ by ethnicity at 6 and 12 months, and the average change in outcomes did not vary significantly by ethnicity.

INTERPRETATION

Outcomes were at their worst at 3 months post-stroke, and ethnic disparities were already present, suggesting the need for early assessment and strategies to improve outcomes and possibly reduce disparities. ANN NEUROL 2023;93:348-356.

Racial and ethnic differences in sleep-disordered breathing and sleep duration among stroke patients

OBJECTIVE

We sought to characterize racial and ethnic differences in pre- and post-stroke sleep-disordered breathing (SDB) and pre-stroke sleep duration.

METHODS

Within the Brain Attack Surveillance in Corpus Christi cohort of patients with ischemic stroke (8/26/2010-1/31/2020), pre-stroke SDB risk was assessed retrospectively using the Berlin Questionnaire. Post-stroke SDB was defined by prospective collection of the respiratory event index (REI) using the ApneaLink Plus performed shortly after stroke. Pre-stroke sleep duration was self-reported. We used separate regression models to evaluate the association between race/ethnicity and each outcome (pre-stroke SDB, post-stroke SDB, and pre-stroke sleep duration), without and with adjustment for potential confounders.

RESULTS

There was no difference in pre-stroke risk of SDB between Black and non-Hispanic white (NHW) participants (odds ratio (OR) 1.07, 95% CI 0.77-1.49), whereas MA (Mexican American), compared to NHW, participants had a higher risk of SDB before adjusting for demographic and clinical variables (OR 1.26, 95% CI 1.08-1.47). Post-stroke SDB risk was higher in MA (estimate 1.16, 95% CI 1.06-1.28) but lower in Black (estimate 0.79, 95% CI 0.65-0.96) compared to NHW participants; although, only the ethnic difference remained after adjustment. MA and Black participants had shorter sleep duration than NHW participants (OR 0.83, 95% CI 0.72-0.96 for MA; OR 0.67, 95% CI 0.49-0.91 for Black participants) before but not after adjustment.

CONCLUSIONS

Racial/ethnic differences appear likely to exist in pre- and post-stroke SDB and pre-stroke sleep duration. Such differences might contribute to racial/ethnic disparities in stroke incidence and outcomes.

Ethnic differences exist in sleepiness 3 Months after ischemic stroke

OBJECTIVE/BACKGROUND

To examine the association between ethnicity and 90-day post-stroke subjective sleepiness, an important determinant of quality of life, as measured by the Epworth Sleepiness Scale (ESS), among ischemic stroke survivors.

PATIENTS/METHODS

Mexican American (MA) and non-Hispanic white (NHW) recent ischemic stroke patients were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2016). Subjects completed a baseline interview and 90-day outcome assessment that included the ESS. Excessive daytime sleepiness was defined as an ESS >10. Tobit regression models were used to assess associations between ethnicity and ESS unadjusted and adjusted for multiple potential confounders.

RESULTS

Among 1,181 (62.5% MA) subjects, mean ESS at 90 days was 8.9 (SD 6.0) among MA and 7.4 (SD 4.9) among NHW subjects: 1.45 (95% CI: 0.75, 2.15) points higher among MA than NHW subjects. After adjustment, mean ESS at 90 days was 1.16 (95% CI: 0.38, 1.94) points higher among MAs than NHWs. The prevalence of excessive daytime sleepiness was 39% among MA and 30% among NHW subjects (p = 0.0013).

CONCLUSIONS

Ninety days after stroke, sleepiness is worse in MAs compared to NHWs, even after accounting for potential confounding variables. Further studies should address ways to reduce this disparity.

Ten-Year Trends in Sleep-Disordered Breathing After Ischemic Stroke: 2010 to 2019 Data From the BASIC Project

Background Despite good evidence that the prevalence of sleep-disordered breathing (SDB) is increasing in the general population, no data are available about trends in poststroke SDB. We therefore sought to assess changes in poststroke SDB over a 10-year period (2010-2019). Methods and Results Participants in the BASIC (Brain Attack Surveillance in Corpus Christi) project were offered a home sleep apnea test to assess for SDB after stroke. SDB assessment procedures remained unchanged throughout the study period. Respiratory event index was calculated as the sum of apneas and hypopneas per hour of recording. SDB was defined as respiratory event index ≥10/h for optimal sensitivity and specificity of the home sleep apnea test device compared with in-laboratory polysomnography. Regression models were used to test associations between SDB prevalence and severity and time, with adjustment for multiple potential confounders. Among the 1215 participants who completed objective sleep apnea testing, the prevalence of SDB grew from 61% in the first year of the study to 76% in the last, with 1.1 times higher odds each year (95% CI, 1.07-1.19), after adjustment. A linear association was identified between time and respiratory event index (average annual respiratory event index increase of 0.56/h; 95% CI, 0.20/h-0.91/h), after adjustment. There was no difference in time trends by sex or ethnicity. Conclusions The prevalence and severity of SDB after ischemic stroke has increased over the past 10 years in this population-based cohort. These data highlight the need to determine whether SDB treatment improves stroke outcomes.

Process Evaluation of a Faith-Based Multicomponent Behavioral Intervention to Reduce Stroke Risk in Mexican Americans in a Catholic Church Setting: The SHARE (Stroke Health and Risk Education) Project

Church-based stroke prevention programs for Hispanics are underutilized. The Stroke Health and Risk Education (SHARE) project, a multicomponent cluster-randomized trial, addressed key stroke risk factors among predominantly Mexican Americans in a Catholic Church setting. Process evaluation components (implementation, mechanisms of impact, and context) are described. Partner support promoted positive health behavior change. Motivational interviewing calls were perceived as helpful, however, barriers with telephone delivery were encountered. Intervention exposure was associated with theory constructs for targeted behaviors. We conclude that health behavior interventions to prevent stroke can be successfully implemented for Mexican Americans within a Catholic Church setting, with parish priest support.

Temporal Trends in Ischemic Stroke Rates by Ethnicity, Sex, and Age (2000-2017): The Brain Attack Surveillance in Corpus Christi Project

OBJECTIVE

To compare 18-year (2000-2017) temporal trends in ischemic stroke rates by ethnicity, sex, and age.

METHODS

Data are from a population-based stroke surveillance study conducted in Nueces County, Texas, a geographically isolated, biethnic, urban community. Active (screening hospital admission logs, hospital wards, intensive care units) and passive (screening inpatient/emergency department discharge diagnosis codes) surveillance were used to identify cases aged ≥45 (n = 4,875) validated by stroke physicians using a consistent stroke definition over time. Ischemic stroke rates were derived from Poisson regression using annual population counts from the US Census to estimate the at-risk population.

RESULTS

In those aged 45-59 years, rates increased in non-Hispanic Whites (104.3% relative increase; p < 0.001) but decreased in Mexican Americans (-21.9%; p = 0.03) such that rates were significantly higher in non-Hispanic Whites in 2016-2017 (p for ethnicity-time interaction < 0.001). In those age 60-74, rates declined in both groups but more so in Mexican Americans (non-Hispanic Whites -18.2%, p = 0.05; Mexican Americans -40.1%, p = 0.002), resulting in similar rates for the 2 groups in 2016-2017 (p for ethnicity-time interaction = 0.06). In those aged ≥75, trends did not vary by ethnicity, with declines noted in both groups (non-Hispanic Whites -33.7%, p = 0.002; Mexican Americans -26.9%, p = 0.02). Decreases in rates were observed in men (age 60-74, -25.7%, p = 0.009; age ≥75, -39.2%, p = 0.002) and women (age 60-74, -34.3%, p = 0.007; age ≥75, -24.0%, p = 0.02) in the 2 older age groups, while rates did not change in either sex in those age 45-59.

CONCLUSION

Previously documented ethnic stroke incidence disparities have ended as a result of declining rates in Mexican Americans and increasing rates in non-Hispanic Whites, most notably in midlife.

Is myocardial infarction a surrogate endpoint for all-cause mortality? A trial-level meta-analysis of 144 randomized controlled trials enrolling 1.2 million patients from 1972–2020

Background

Nonfatal myocardial infarction (MI) is commonly included as an endpoint in studies of treatment or prevention of coronary artery disease driven by the assumption that MI is a surrogate for downstream mortality and that preventing MI will reduce mortality. Though biologically plausible and frequently associated in epidemiological studies, the validity of MI as a surrogate marker for all-cause mortality in randomized controlled trials (RCTs) has not been previously demonstrated with trial-level meta-analytic evidence.

Purpose

To assess MI as a surrogate endpoint for all-cause mortality in RCTs

Methods

In December 2020, PubMed was searched for all RCTs reporting all-cause mortality and MI published in the New England Journal of Medicine, the Lancet, or the Journal of the American Medical Association. RCTs with a minimum sample size of 1000 patients and 24 months of follow up were included. Trial-level correlation between MI and all-cause mortality was then assessed for surrogacy using the coefficient of determination (R2) between the natural logarithm of the odds ratios for MI and mortality using a weighted linear regression where each study was weighted by the number of observations. Criteria for surrogacy was set at 0.8. Prespecified subgroup analyses based on era of trial enrollment (before 2000, 2000–2009, 2010+), duration of follow up (2–3.9, 4–5.9, or 6+ years), and study subject (revascularization, primary prevention, secondary prevention, mixed primary/secondary prevention) were also assessed.

Results

1025 RCTs were retrieved and reviewed with 144 articles representing 1,211,897 patients ultimately meeting criteria for inclusion in the meta-analysis. Overall, MI had no correlation with all-cause mortality (R2=0.02, 95% CI: 0.00–0.08) (figure 1). In terms of era of trial enrollment, before year 2000 MI had low correlation with all-cause mortality (R2=0.22, 95% CI: 0.08–0.36) and had no correlation for the periods 2000–2009 (R2=0.02, 95% CI: 0.00–0.17) and 2010 and beyond (R2=0.01, 95% CI: 0.00–0.09). By follow-up period, MI had low correlation with all-cause mortality at 6+ years (R2=0.30, 95% CI: 0.01–0.55) and had no correlation with mortality at 2–3.9 years (R2=0.004, 95% CI: 0.00–0.08) or 4–5.9 years (R2=0.06, 95% CI: 0.001–0.16). MI had low correlation with all-cause mortality in revascularization trials (R2=0.21, 95% CI: 0.002–0.50) and no correlation with mortality in primary (R2=0.10, 95% CI: 0.001–0.26), secondary (R2=0.03, 95% CI: 0.00–0.20), and mixed primary/secondary prevention trials (R2=0.001, 95% CI: 0.00–0.08).

Conclusions

MI cannot be validated as a surrogate endpoint for all-cause mortality in RCTs of treatments for or to prevent CAD. Thus, treatments that reduce MI cannot be assumed to reduce mortality. Inclusion of MI as an endpoint in RCTs may still be justified based upon its association with impaired quality of life and increased utilization of health care resources but not based on its surrogacy for mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Overall analysis of 144 trials

Rare Missense Functional Variants at COL4A1 and COL4A2 in Sporadic Intracerebral Hemorrhage

OBJECTIVE

To test the genetic contribution of rare missense variants in COL4A1 and COL4A2 in which common variants are genetically associated with sporadic intracerebral hemorrhage (ICH), we performed rare variant analysis in multiple sequencing data for the risk for sporadic ICH.

METHODS

We performed sequencing across 559 Kbp at 13q34 including COL4A1 and COL4A2 among 2,133 individuals (1,055 ICH cases; 1,078 controls) in United States-based and 1,381 individuals (192 ICH cases; 1,189 controls) from Scotland-based cohorts, followed by sequence annotation, functional impact prediction, genetic association testing, and in silico thermodynamic modeling.

RESULTS

We identified 107 rare nonsynonymous variants in sporadic ICH, of which 2 missense variants, rs138269346 (COL4A1I110T) and rs201716258 (COL4A2H203L), were predicted to be highly functional and occurred in multiple ICH cases but not in controls from the United States-based cohort. The minor allele of rs201716258 was also present in Scottish patients with ICH, and rs138269346 was observed in 2 ICH-free controls with a history of hypertension and myocardial infarction. Rs138269346 was nominally associated with nonlobar ICH risk (p = 0.05), but not with lobar ICH (p = 0.08), while associations between rs201716258 and ICH subtypes were nonsignificant (p > 0.12). Both variants were considered pathogenic based on minor allele frequency (<0.00035 in European populations), predicted functional impact (deleterious or probably damaging), and in silico modeling studies (substantially altered physical length and thermal stability of collagen).

CONCLUSIONS

We identified rare missense variants in COL4A1/A2 in association with sporadic ICH. Our annotation and simulation studies suggest that these variants are highly functional and may represent targets for translational follow-up.

Overnight Rostral Fluid Shifts Exacerbate Obstructive Sleep Apnea After Stroke

BACKGROUND AND PURPOSE

Overnight shifts of fluid from lower to upper compartments exacerbate obstructive sleep apnea (OSA) in some OSA populations. Given the high prevalence of OSA after stroke, decreased mobility and use of IV fluids among hospitalized patients with stroke, and improvement in OSA in the months after stroke, we hypothesized that overnight fluid shifts occur and are associated with OSA among patients with subacute ischemic stroke.

METHODS

Within a population-based project, we performed overnight sleep apnea tests (ApneaLink Plus) during ischemic stroke hospitalizations. Before sleep that evening, and the following morning before rising from bed, we assessed neck and calf circumference, and leg fluid volume (bioimpedance spectroscopy). The average per subject overnight change in the 3 fluid shift measurements was calculated and compared with zero. Linear regression was used to test the crude association between each of the 3 fluid shift measurements and the respiratory event index (REI).

RESULTS

Among the 292 participants, mean REI was 24 (SD=18). Within individuals, calf circumference decreased on average by 0.66 cm (SD=0.75 cm, P<0.001), leg fluid volume decreased by a mean of 135.6 mL (SD=132.8 mL, P<0.001), and neck circumference increased by 0.20 cm (SD=1.71 cm, P=0.07). In men, when the overnight change of calf circumference was negative, an interquartile range (0.8 cm) decrease in calf circumference overnight was significantly associated with a 25.1% increase in REI (P=0.02); the association was not significant in women. The relationship between overnight change in leg fluid volume and REI was U shaped.

CONCLUSIONS

This population-based, multicenter, cross-sectional study showed that in hospitalized patients with ischemic stroke, nocturnal rostral fluid shifts occurred, and 2 of the 3 measures were associated with greater OSA severity. Interventions that limit overnight fluid shifts should be tested as potential treatments for OSA among patients with subacute ischemic stroke.

Prevalence and Course of Depression During the First Year After Mild to Moderate Stroke

Background This study examined the prevalence and longitudinal course of depression during the first year after mild to moderate stroke. Methods and Results We identified patients with mild to moderate ischemic stroke or intracerebral hemorrhage (National Institutes of Health Stroke Scale score <16) and at least 1 depression assessment at 3, 6, or 12 months after stroke (n=648, 542, and 533, respectively) from the Brain Attack Surveillance in Corpus Christi project (2014-2016). Latent transition analysis was used to examine temporal profiles of depressive symptoms assessed by the 8-item Patient Health Questionnaire between 3 and 12 months after stroke. Mean age was 65.6 years, 49.4% were women, and 56.7% were Mexican Americans. The prevalence of depression after stroke was 35.3% at 3 months, decreased to 24.9% at 6 months, and remained stable at 25.7% at 12 months. Approximately half of the participants classified as having depression at 3 or 6 months showed clinical improvement at the next assessment. Subgroups with distinct patterns of depressive symptoms were identified, including mild/no symptoms, predominant sleep disturbance and fatigue symptoms, affective symptoms, and severe/all symptoms. A majority of participants with mild/no symptoms retained this symptom pattern over time. The probability of transitioning to mild/no symptoms was higher before 6 months compared with the later period, and severe symptoms were more likely to persist after 6 months compared with the earlier period. Conclusions The observed dynamics of depressive symptoms suggest that depression after stroke tends to persist after 6 months among patients with mild to moderate stroke and should be continually monitored and appropriately managed.

Extending Advance Care Planning to Black Americans in the Community: A Pilot Study of the PREPARE Program

CONTEXT

Advance care planning (ACP) is underutilized, especially among Black Americans. Yet, no ACP interventions have been tested at the community level.

OBJECTIVES

Within an established academic and community partnership, we sought to determine whether ACP is a community-identified need and if so, to conduct a pilot study of an evidence-based ACP program, PREPARE (PrepareForYourCare.org).

METHODS

We conducted open discussions and in-depth interviews to determine the relevance of ACP to the community. We then conducted a pre- to 3-week postpilot study of a virtual peer facilitated brief session to introduce ACP and encourage participants to engage with PREPARE. We conducted thematic content analysis for qualitative data and used paired t-tests to assess within-participant changes in the validated ACP Engagement Survey measured on a 1-5 scale (5 = greatest engagement).

RESULT

We conducted two discussion groups with community leaders (n = 12) and key informant interviews (n = 6), including leaders in aging, public health, health care and faith. We concluded that ACP is a community priority. In the pilot study, we enrolled 13 Black Americans; 85% were women and the mean age was 59.7 years (SD 15.1). There was a trend toward increased ACP engagement after the peer facilitated PREPARE (mean 3.2 (SD 0.6) pre vs. 3.5 (SD 0.6) post, paired t-test P = 0.06). All participants found the intervention to be acceptable and were satisfied with it.

CONCLUSION

Community members identified ACP as important for their community. Peer facilitated PREPARE program is a promising community-based strategy to increase engagement in ACP and may promote health equity.

Obstructive Sleep Apnea and Cardiovascular Disease: A Scientific Statement From the American Heart Association

Obstructive sleep apnea (OSA) is characterized by recurrent complete and partial upper airway obstructive events, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation. Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA. Sleep disturbances are common and underdiagnosed among middle-aged and older adults, and the prevalence varies by race/ethnicity, sex, and obesity status. OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure, coronary artery disease, pulmonary hypertension, atrial fibrillation, and stroke. Despite its high prevalence in patients with heart disease and the vulnerability of cardiac patients to OSA-related stressors and adverse cardiovascular outcomes, OSA is often underrecognized and undertreated in cardiovascular practice. We recommend screening for OSA in patients with resistant/poorly controlled hypertension, pulmonary hypertension, and recurrent atrial fibrillation after either cardioversion or ablation. In patients with New York Heart Association class II to IV heart failure and suspicion of sleep-disordered breathing or excessive daytime sleepiness, a formal sleep assessment is reasonable. In patients with tachy-brady syndrome or ventricular tachycardia or survivors of sudden cardiac death in whom sleep apnea is suspected after a comprehensive sleep assessment, evaluation for sleep apnea should be considered. After stroke, clinical equipoise exists with respect to screening and treatment. Patients with nocturnally occurring angina, myocardial infarction, arrhythmias, or appropriate shocks from implanted cardioverter-defibrillators may be especially likely to have comorbid sleep apnea. All patients with OSA should be considered for treatment, including behavioral modifications and weight loss as indicated. Continuous positive airway pressure should be offered to patients with severe OSA, whereas oral appliances can be considered for those with mild to moderate OSA or for continuous positive airway pressure-intolerant patients. Follow-up sleep testing should be performed to assess the effectiveness of treatment.

Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

BACKGROUND

Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention.

METHODS

The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]).

RESULTS

Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I ²=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I ²=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I ²=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I ²=75.5%).

CONCLUSIONS

DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.

Tissue-Based Stroke Definition Impacts Stroke Incidence but not Ethnic Differences

OBJECTIVES

We explored how the new, tissue-based stroke definition impacted incidence estimates, including an ethnic comparison, in a population-based study.

METHODS

Stroke patients, May, 2014-May, 2016 in Nueces County, Texas were ascertained and validated using source documentation. Overall, ethnic-specific and age-specific Poisson regression models were used to compare first-ever ischemic stroke and intracerebral hemorrhage (ICH) incidence between old and new stroke definitions, adjusting for age, ethnicity, sex, and National Institutes of Health Stroke Scale score.

RESULTS

Among 1308 subjects, 1245 (95%) were defined as stroke by the old definition and 63 additional cases (5%) according to the new. There were 12 cases of parenchymal hematoma (PH1 or PH2) that were reclassified from ischemic stroke to ICH. Overall, incidence of ischemic stroke was slightly higher under the new compared to the old definition (RR 1.07; 95% CI 0.99-1.16); similarly higher in both Mexican Americans (RR 1.06; 95% CI 1.00-1.12) and Non Hispanic whites (RR 1.09, 95% CI 0.97-1.22), p(ethnic difference)=0.36. Overall, incidence of ICH was higher under the new definition compared to old definition (RR 1.16; 95% CI 1.05-1.29), similarly higher among both Mexican Americans (RR 1.14; 95% CI 1.06-1.23) and Non Hispanic whites (RR 1.20, 95% CI 1.03-1.39), p(ethnic difference)=0.25.

CONCLUSION

Modest increases in ischemic stroke and ICH incidence occurred using the new compared with old stroke definition. There were no differences between Mexican Americans and non Hispanic whites. These estimates provide stroke burden estimates for public health planning.

Abstract P597: Growing Prevalence of Post-Stroke Sleep-Disordered Breathing

Introduction: Sleep-disordered breathing (SDB) is common after stroke and is associated with poor functional and cognitive outcomes, and recurrent stroke. Despite increasing prevalence of SDB in the general population, no data are available about trends in post-stroke SDB. We therefore sought to assess changes in post-stroke SDB prevalence over a 10-year period.

Methods: Within the Brain Attack Surveillance In Corpus Christi (BASIC) project, a population-based stroke surveillance study in south Texas, participants with acute ischemic stroke were offered assessment of SDB with the ApneaLink Plus device. Medical record abstraction and baseline interviews were conducted and included the Berlin questionnaire to assess SDB status in reference to the prestroke state. SDB testing was performed shortly after stroke presentation (median 12 days (IQR: (6, 21)). Respiratory event index (REI) was calculated as the sum of apneas and hypopneas per hour of overnight recording. SDB was defined as an REI ≥10. SDB assessment procedures remained unchanged throughout (2010-2020). Logistic (SDB) and linear (REI) regression were used to test associations with time (parameterized as years since 2010) adjusted for demographics, and stroke and SDB risk factors including BMI and pre-stroke SDB status.

Results: Among the 1,197 participants, median age was 65, 53% were male, and 65% were Mexican American. SDB prevalence was 61% in 2010-2011 and 75% in 2018-2019. Median REI was 19 in 2010-2011 and 23 in 2018-2019. A linear association was identified between time and SDB (REI≥10), with an odds ratio of 1.123 (95% CI: 1.062, 1.187) per year, after adjustment. Similarly, a linear association was identified between time and REI, with an average increase of 0.504 (95% CI: 0.148, 0.860) per year, after adjustment. Based on models with interaction terms added, no differences in time trends were found by sex or ethnicity.

Conclusions: Post-stroke SDB prevalence in this population-based sample has increased over the last 10 years. These data highlight the importance of post-stroke SDB and the pressing need to determine whether its treatment improves outcomes.

Wake-up stroke is not associated with obstructive sleep apnea

OBJECTIVE/BACKGROUND

Obstructive sleep apnea is a risk factor for stroke. This study sought to assess the relationship between obstructive sleep apnea (OSA) and wake-up strokes (WUS), that is, stroke symptoms that are first noted upon awakening from sleep.

PATIENTS/METHODS

In this analysis, 837 Brain Attack Surveillance in Corpus Christi (BASIC) project participants completed an interview to ascertain stroke onset during sleep (WUS) versus wakefulness (non-wake-up stroke, non-WUS). A subset of 316 participants underwent a home sleep apnea test (HSAT) shortly after ischemic stroke to assess for OSA. Regression models were used to test the association between OSA and WUS, stratified by sex.

RESULTS

Of 837 participants who completed the interview, 251 (30%) reported WUS. Among participants who underwent an HSAT, there was no significant difference in OSA severity [respiratory event index (REI)] among participants with WUS [median REI 17, interquartile range (IQR) 10, 29] versus non-WUS (median REI 18, IQR 9, 30; p = 0.73). OSA severity was not associated with increased odds of WUS among men [unadjusted odds ratio (OR) 1.011, 95% confidence interval (95% CI) 0.995, 1.027] or women (unadjusted OR 0.987, 95% CI 0.959, 1.015). These results remained unchanged after adjustment for age, congestive heart failure, body mass index, and pre-stroke depression in men (adjusted OR 1.011, 95% CI 0.994, 1.028) and women (adjusted OR 0.988, 95% CI 0.959, 1.018).

CONCLUSIONS

Although OSA is a risk factor for stroke, the onset of stroke during sleep is not associated with OSA in this large, population-based stroke cohort.

Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches

Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.

Central sleep apnea is uncommon after stroke

OBJECTIVE/BACKGROUND

Stroke is often considered a risk factor for central sleep apnea (CSA). The goal of this study was to determine the prevalence and clinical correlates of CSA in patients with ischemic stroke.

PATIENTS/METHODS

In this analysis, 1346 participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Respiratory events during sleep were classified as central apneas, obstructive apneas, or hypopneas. Central apnea index (CAI) was defined as number of central apneas divided by recording time. CSA was defined as CAI ≥5/hour with at least 50% of all scored respiratory events classified as central apneas. Demographics and co-morbidities were ascertained from the medical record.

RESULTS

Median CAI was 0/hour. Nineteen participants (1.4%) met criteria for CSA. Participants with CSA were more likely to be male, and had lower prevalence of obesity than participants without CSA. There was no association between CSA and other co-morbidities.

CONCLUSIONS

CSA was uncommon in this large cohort of patients with recent ischemic stroke.

Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions

The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.

Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites

BACKGROUND AND PURPOSE

Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study.

METHODS

Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms.

RESULTS

From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]).

CONCLUSIONS

Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Genetically Elevated LDL Associates with Lower Risk of Intracerebral Hemorrhage

OBJECTIVE

Observational studies point to an inverse correlation between low-density lipoprotein (LDL) cholesterol levels and risk of intracerebral hemorrhage (ICH), but it remains unclear whether this association is causal. We tested the hypothesis that genetically elevated LDL is associated with reduced risk of ICH.

METHODS

We constructed one polygenic risk score (PRS) per lipid trait (total cholesterol, LDL, high-density lipoprotein [HDL], and triglycerides) using independent genomewide significant single nucleotide polymorphisms (SNPs) for each trait. We used data from 316,428 individuals enrolled in the UK Biobank to estimate the effect of each PRS on its corresponding trait, and data from 1,286 ICH cases and 1,261 matched controls to estimate the effect of each PRS on ICH risk. We used these estimates to conduct Mendelian Randomization (MR) analyses.

RESULTS

We identified 410, 339, 393, and 317 lipid-related SNPs for total cholesterol, LDL, HDL, and triglycerides, respectively. All four PRSs were strongly associated with their corresponding trait (all p < 1.00 × 10-100 ). While one SD increase in the PRSs for total cholesterol (odds ratio [OR] = 0.92; 95% confidence interval [CI] = 0.85-0.99; p = 0.03) and LDL cholesterol (OR = 0.88; 95% CI = 0.81-0.95; p = 0.002) were inversely associated with ICH risk, no significant associations were found for HDL and triglycerides (both p > 0.05). MR analyses indicated that 1mmol/L (38.67mg/dL) increase of genetically instrumented total and LDL cholesterol were associated with 23% (OR = 0.77; 95% CI = 0.65-0.98; p = 0.03) and 41% lower risks of ICH (OR = 0.59; 95% CI = 0.42-0.82; p = 0.002), respectively.

INTERPRETATION

Genetically elevated LDL levels were associated with lower risk of ICH, providing support for a potential causal role of LDL cholesterol in ICH. ANN NEUROL 2020 ANN NEUROL 2020;88:56-66.

Genome-wide association study of cerebral small vessel disease reveals established and novel loci

Intracerebral haemorrhage and small vessel ischaemic stroke (SVS) are the most acute manifestations of cerebral small vessel disease, with no established preventive approaches beyond hypertension management. Combined genome-wide association study (GWAS) of these two correlated diseases may improve statistical power to detect novel genetic factors for cerebral small vessel disease, elucidating underlying disease mechanisms that may form the basis for future treatments. Because intracerebral haemorrhage location is an adequate surrogate for distinct histopathological variants of cerebral small vessel disease (lobar for cerebral amyloid angiopathy and non-lobar for arteriolosclerosis), we performed GWAS of intracerebral haemorrhage by location in 1813 subjects (755 lobar and 1005 non-lobar) and 1711 stroke-free control subjects. Intracerebral haemorrhage GWAS results by location were meta-analysed with GWAS results for SVS from MEGASTROKE, using 'Multi-Trait Analysis of GWAS' (MTAG) to integrate summary data across traits and generate combined effect estimates. After combining intracerebral haemorrhage and SVS datasets, our sample size included 241 024 participants (6255 intracerebral haemorrhage or SVS cases and 233 058 control subjects). Genome-wide significant associations were observed for non-lobar intracerebral haemorrhage enhanced by SVS with rs2758605 [MTAG P-value (P) = 2.6 × 10-8] at 1q22; rs72932727 (P = 1.7 × 10-8) at 2q33; and rs9515201 (P = 5.3 × 10-10) at 13q34. In the GTEx gene expression library, rs2758605 (1q22), rs72932727 (2q33) and rs9515201 (13q34) are significant cis-eQTLs for PMF1 (P = 1 × 10-4 in tibial nerve), NBEAL1, FAM117B and CARF (P < 2.1 × 10-7 in arteries) and COL4A2 and COL4A1 (P < 0.01 in brain putamen), respectively. Leveraging S-PrediXcan for gene-based association testing with the predicted expression models in tissues related with nerve, artery, and non-lobar brain, we found that experiment-wide significant (P < 8.5 × 10-7) associations at three genes at 2q33 including NBEAL1, FAM117B and WDR12 and genome-wide significant associations at two genes including ICA1L at 2q33 and ZCCHC14 at 16q24. Brain cell-type specific expression profiling libraries reveal that SEMA4A, SLC25A44 and PMF1 at 1q22 and COL4A1 and COL4A2 at 13q34 were mainly expressed in endothelial cells, while the genes at 2q33 (FAM117B, CARF and NBEAL1) were expressed in various cell types including astrocytes, oligodendrocytes and neurons. Our cross-phenotype genetic study of intracerebral haemorrhage and SVS demonstrates novel genome-wide associations for non-lobar intracerebral haemorrhage at 2q33 and 13q34. Our replication of the 1q22 locus previous seen in traditional GWAS of intracerebral haemorrhage, as well as the rediscovery of 13q34, which had previously been reported in candidate gene studies with other cerebral small vessel disease-related traits strengthens the credibility of applying this novel genome-wide approach across intracerebral haemorrhage and SVS.

Prediction of sleep-disordered breathing after stroke

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is associated with poor outcomes. Currently, after stroke, objective testing must be used to differentiate patients with and without SDB. Within a large, population-based study, we evaluated the usefulness of a flexible statistical model based on baseline characteristics to predict post-stroke SDB.

PATIENTS/METHODS

Within a population-based study, participants (2010-2018) underwent SDB screening, shortly after ischemic stroke, with a home sleep apnea test. The respiratory event index (REI) was calculated as the number of apneas and hypopneas per hour of recording; values ≥10 defined SDB. The distributed random forest classifier (a machine learning technique) was applied to predict SDB with the following as predictors: demographics, stroke risk factors, stroke severity (NIHSS), neck and waist circumference, palate position, and pre-stroke symptoms of snoring, apneas, and sleepiness.

RESULTS

Within the total sample (n = 1330), median age was 65 years; 47% were women; 32% non-Hispanic white, 62% Mexican American, and 6% African American. SDB was found in 891 (67%). The area under the receiver operating characteristic curve, a measure of predictive ability, applied to the validation sample was 0.75 for the random forest model. Random forest correctly classified 72.5% of validation samples.

CONCLUSIONS

In this large, ethnically diverse, population-based sample of ischemic stroke patients, prediction models based on baseline characteristics and clinical measures showed fair rather than clinically reliable performance, even with use of advanced machine learning techniques. Results suggest that objective tests are still needed to differentiate ischemic stroke patients with and without SDB.

Pre-stroke sleep duration and post-stroke depression

OBJECTIVE

Sleep disturbance and depression are common in stroke patients, however, little is known about the role of sleep in post-stroke depression. This study examined the association between pre-stroke sleep duration and depression at 90 days post-stroke in a population-based bi-ethnic sample.

METHODS

The study included 1369 stroke patients from the Brain Attack Surveillance in Corpus Christi project who survived 90 days post-stroke. Depression at 90 days post-stroke was assessed by the 8-item Patient Health Questionnaire, and pre-stroke sleep duration was self-reported shortly after stroke in reference to the pre-stroke state. Multiple imputation and inverse probability weighting were used to deal with missing data and attrition. Weighted logistic regression models were fit to examine the association between pre-stroke sleep duration and post-stroke depression.

RESULTS

The mean age was 68.2 years, and 63.6% were Mexican American. The prevalence of post-stroke depression was highest among participants reporting less than 6 hours of sleep before stroke (52.4%, 95% confidence interval = 45.7%-59.0%). Compared with participants reporting 7-8 hours of sleep before stroke, those with short sleep duration had significantly increased odds for post-stroke depression (odds ratio = 1.96; 95% confidence interval = 1.38-2.79), after adjustment for sociodemographic, stroke and pre-stroke characteristics including pre-stroke depression.

CONCLUSIONS

Pre-stroke short sleep duration may be an independent risk factor for post-stroke depression.

Reach Out Emergency Department: Partnering With an Economically Disadvantaged Community in the Development of a Text-Messaging Intervention to Address High Blood Pressure

Background. Hypertension affects nearly 30% of the U.S. adult population. Due to the ubiquitous nature of mobile phone usage, text messaging offers a promising platform for interventions to assist in the management of chronic diseases including hypertension, including among populations that are historically underserved. We present the intervention development of Reach Out, a health behavior theory-based, mobile health intervention to reduce blood pressure among hypertensive patients evaluated in a safety net emergency department primarily caring for African Americans. Aims. To describe the process of designing and refining text messages currently being implemented in the Reach Out randomized controlled trial. Method. We used a five-step framework to develop the text messages used in Reach Out. These steps included literature review and community formative research, conception of a community-centered behavioral theoretical framework, draft of evidence-based text messages, community review, and revision based on community feedback and finalization. Results. The Reach Out development process drew from pertinent evidence that, combined with community feedback, guided the development of a community-centered health behavior theory framework that led to development of text messages. A total of 333 generic and segmented messages were created. Messages address dietary choices, physical activity, hypertension medication adherence, and blood pressure monitoring. Discussion. Our five-step framework is intended to inform future text-messaging-based health promotion efforts to address health issues in vulnerable populations. Conclusion. Text message-based health promotion programs should be developed in partnership with the local community to ensure acceptability and relevance.

Sleep for Stroke Management and Recovery Trial (Sleep SMART): Rationale and methods

RATIONALE

Obstructive sleep apnea is common among patients with acute ischemic stroke and is associated with reduced functional recovery and an increased risk for recurrent vascular events.

AIMS AND/OR HYPOTHESIS

The Sleep for Stroke Management and Recovery Trial (Sleep SMART) aims to determine whether automatically adjusting continuous positive airway pressure (aCPAP) treatment for obstructive sleep apnea improves clinical outcomes after acute ischemic stroke or high-risk transient ischemic attack.

SAMPLE SIZE ESTIMATE

A total of 3062 randomized subjects for the prevention of recurrent serious vascular events, and among these, 1362 stroke survivors for the recovery outcome.

METHODS AND DESIGN

Sleep SMART is a phase III, multicenter, prospective randomized, open, blinded outcome event assessed controlled trial. Adults with recent acute ischemic stroke/transient ischemic attack and no contraindication to aCPAP are screened for obstructive sleep apnea with a portable sleep apnea test. Subjects with confirmed obstructive sleep apnea but without predominant central sleep apnea proceed to a run-in night of aCPAP. Subjects with use (≥4 h) of aCPAP and without development of significant central apneas are randomized to aCPAP plus usual care or care-as-usual for six months. Telemedicine is used to monitor and facilitate aCPAP adherence remotely.

STUDY OUTCOMES

Two separate primary outcomes: (1) the composite of recurrent acute ischemic stroke, acute coronary syndrome, and all-cause mortality (prevention) and (2) the modified Rankin scale scores (recovery) at six- and three-month post-randomization, respectively.

DISCUSSION

Sleep SMART represents the first large trial to test whether aCPAP for obstructive sleep apnea after stroke/transient ischemic attack reduces recurrent vascular events or death, and improves functional recovery.

Abstract WP216: Predicting Sleep Apnea After Ischemic Stroke

Introduction: Sleep apnea (SA) is highly prevalent after stroke and is associated with poor stroke outcomes. Currently, after stroke, a physiological test must be used to differentiate patients with and without SA. Within a large, population-based study, we tested the usefulness of statistical models based on baseline characteristics to predict SA.

Methods: Within the Brain Attack Surveillance in Corpus Christi (BASIC) project, participants with ischemic stroke (2010-2018) underwent SA screening, shortly after stroke, with the ApneaLink Plus portable sleep apnea testing device. The respiratory event index (REI) was calculated as the number of apneas and hypopneas per hour of recording; values ≥10 defined SA. Logistic regression and the Distributed Random Forest Classifier (a machine learning technique) were applied to predict SA with the following as predictors: demographics, stroke risk factors, stroke severity (NIHSS), neck and waist circumference, palate position, and pre-stroke symptoms of snoring, apneas, and sleepiness. Models were internally validated with cross-validation.

Results: Within the total sample (n=1,330), median age was 65; 47% were women; 32% non-Hispanic white, 62% Mexican American, and 6% African American. SA was found in 67%. The area under the receiver operating characteristic curve, a measure of predictive ability, applied to the validation sample, was 0.69 for logistic regression and 0.74 for the random forest model. Random forest correctly classified 72.3% of validation samples, while logistic regression correctly classified 70.7% of validation samples. The most important features for predicting SA were waist circumference, neck circumference, body mass index, NIHSS, and pre-stroke daytime sleepiness.

Conclusions: In this large, ethnically diverse, population-based sample of ischemic stroke patients, prediction models based on easily obtained baseline characteristics and simple measurements resulted in fair performance, despite use of advanced statistical and machine learning techniques. Physiological tests are still needed to differentiate ischemic stroke patients with and without SA.

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial

STUDY OBJECTIVE

We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits.

METHODS

We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews.

RESULTS

We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program.

CONCLUSION

These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

Do apneas and hypopneas best reflect risk for poor outcomes after stroke?

OBJECTIVE/BACKGROUND

Sleep apnea (SA) is associated with poor outcomes after stroke. The best sleep apnea-related measure to capture this relationship is currently unknown. This measure or its underlying pathophysiology could serve as a treatment target.

PATIENTS/METHODS

Within the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project, the ApneaLink Plus was used to perform sleep apnea tests shortly after ischemic stroke (2010-2015). Functional and cognitive outcomes were measured via in-person interviews 90-days post-stroke. Recurrent stroke was assessed longitudinally through active and passive surveillance procedures. After standardization to allow direct comparisons, adjusted models were built for each ApneaLink Plus measure and each outcome, to assess the effect of 1 standard deviation difference in the measure.

RESULTS

Among 995 subjects, median age was 67 years (interquartile range: 59, 78) and 52% were women. The respiratory event index had the strongest relationship with functional outcome (mean difference = 0.094, 95% confidence interval (CI): 0.040, 0.147). Desaturations ≤85% were associated with worse functional outcome (mean difference = 0.016, 95% CI: 0.002, 0.030), but desaturations ≤ 90% were not. Obstructive apnea index (OAI) showed the strongest association with cognitive outcome (mean difference = -0.079, 95% CI: -0.162, 0.005), but was not significant. Oxygen desaturation index (ODI) showed the strongest association with recurrent ischemic stroke (hazard ratio = 1.338, 95% CI: 1.016, 1.759).

CONCLUSIONS

Measurements easily obtained from a commonly used home sleep apnea test predicted outcomes differentially. This suggests the possibility of different SA-associated targets (perhaps using strategies more tolerable than standard treatment) based on the outcome of interest.

P3584Optimal medical therapy improves survival in patients with ischaemic cardiomyopathy: an analysis of the STICH trial

Background

Prior studies have demonstrated underuse of optimal medical therapy (OMT) in patients with coronary artery disease (CAD) after revascularization. However, there are limited studies assessing compliance with OMT on long-term survival in patients with CAD and no studies evaluating the impact of OMT in patients with severe CAD and reduced left ventricular (LV) function. The Surgical Treatment for Ischaemic Heart Failure (STICH) Trial was a randomized clinical trial that compared coronary-artery bypass grafting (CABG) with medical therapy versus medical therapy alone in the treatment of ischemic cardiomyopathy.

Purpose

This study sought to determine compliance with OMT over time and the impact of OMT compliance on survival in patients with or without revascularization.

Methods

STICH was a multicenter, randomized clinical trial of patients with an LV ejection fraction of 35% or less and CAD amenable to CABG who were randomized to CABG plus medical therapy (N=610) or medical therapy alone (N=602). A medication history was obtained at hospital discharge or 30 days after enrollment, 1 year, 5 years, and 10 years. OMT was defined as the combination of at least 1 antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The primary outcome was all-cause mortality. Comparison of mortality between the OMT and non-OMT groups was performed using multivariate Cox regression modeling with OMT as a time-dependent covariate.

Results

Of the 1212 patients randomized, at a median follow-up of 9.8 years, all-cause mortality was 58.9% in the CABG group and 66.1% in the medical therapy group. In the CABG arm, 63.6% of patients were on OMT throughout the study period compared to 66.5% of patients in the medical therapy arm (p=0.3). Those on OMT were younger (59.6 vs. 61.4 years, p<0.001); were more often in NYHA class I-II (67.4% vs. 56%, p<0.001); and lower rates of atrial fibrillation (9.4% vs. 18.1%, p<0.001), current smoking (18.6% vs. 24.5%, p=0.015), and depression (4.8% vs. 8.8%, p=0.005). Those on OMT had higher rates of hyperlipidemia (63.8% vs. 54.4%, p=0.001) and prior myocardial infarction (79.4% vs. 73.1%, p=0.01). There was no difference in sex, diabetes, and hypertension between those on OMT and non-OMT. In multivariate survival analysis, OMT was associated with a significant reduction in mortality (adjusted hazard ratio, 0.69; 95% confidence interval, 0.58–0.81; p<0.001). The treatment effect with OMT (31% relative reduction in mortality over 10 years) was numerically greater than the treatment effect of CABG (24% relative reduction in mortality with CABG versus medical therapy alone).

Conclusions

OMT improves long-term survival in patients with ischaemic cardiomyopathy regardless of revascularization status. Strategies to improve OMT use and adherence in this population is needed to maximize survival.

P3343Association of minority status with mortality and hospital readmission in patients with ischemic cardiomyopathy in the STICH trial

Background

Racial and ethnic minorities with coronary artery disease (CAD) suffer worse outcomes than their non-minority counterparts, including increased mortality and hospital readmissions. Proposed explanations include impaired access to care, reduced quality of care, comorbidity burden and medication access. Study of the outcomes of minorities in randomized controlled trials (RCT) allows controlling for some of these factors.

Purpose

The purpose of the current study was to evaluate the impact of minority status on mortality and hospital readmission in patients enrolled in the Surgical Treatment for Ischaemic Heart Failure (STICH) trial.

Methods

STICH was a multicenter, international RCT of patients with an ejection fraction (EF) of 35% or less and CAD amenable to coronary artery bypass graft surgery (CABG) who were randomized to undergo CABG plus medical therapy or medical therapy alone. Median follow-up was 9.8 years. Minority status was defined by self-reported black race or Hispanic ethnicity. Optimal medical therapy (OMT) was the combination of at least 1 antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The primary outcomes of interest were mortality and hospital readmission. Separate Cox proportional hazards models were constructed to examine the independent associations between minority status and mortality and readmission.

Results

Of 1212 patients randomized, 421 (35%) were members of a minority. CABG was the treatment assignment in 52.5% of minority participants whereas 47.5% were randomized to medical therapy (P=0.27). Minority patients were significantly younger than non-minority patients (57.8 vs 61.6 years, P=0.003). Sex, smoking status, and the prevalence of diabetes, hypertension, stroke and chronic kidney disease did not differ between minority and non-minority patients. Fewer minority patients had hyperlipidemia (49% vs. 66%, P<0.001), prior MI (72% vs 80%, P=0.003), atrial fibrillation (8.1% vs. 15%, P=0.001) or prior percutaneous coronary intervention (9% vs. 15%, P=0.004). Minority patients were less often on OMT at 30 days (56% vs. 66%, P=0.001), 1 year (70% vs. 76%, P=0.048) and 5 years (66% vs. 75%, P=0.002). Crude mortality rates were lower in minority patients (57% vs. 65%, P=0.004). However, minority status was independently associated with an increased hazard of mortality (HR 2.3, 95% CI: 1.5–2.5, P<0.001) but had no effect on rehospitalization (HR 1.01, 95% CI: 0.78–1.31, P=0.97).

Conclusion

Despite being a low risk population, minority status in the STICH trial was associated with a 2.3-fold increased hazard of mortality in patients with ischaemic cardiomyopathy. Additional research is urgently needed to delineate and address the causes of disparate outcomes among minority patients.

Sleep-disordered breathing and poststroke outcomes

OBJECTIVE

To examine the association between sleep-disordered breathing and stroke outcomes, and determine the contribution of sleep-disordered breathing to outcome disparities in Mexican Americans.

METHODS

Ischemic stroke patients (n = 995), identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2010-2015), were offered participation in a sleep-disordered breathing study including a home sleep apnea test (ApneaLink Plus). Sleep-disordered breathing (respiratory event index ≥10) was determined soon after stroke. Neurologic, functional, cognitive, and quality of life outcomes were assessed at 90 days poststroke. Regression models were used to assess associations between sleep-disordered breathing and outcomes, adjusted for sociodemographics, prestroke function and cognition, health-risk behaviors, stroke severity, and vascular risk factors.

RESULTS

Median age was 67 years (interquartile range [IQR] = 59-78); 62.1% were Mexican American. Median respiratory event index was 14 (IQR = 6-25); 62.8% had sleep-disordered breathing. Sleep-disordered breathing was associated with worse functional outcome (mean difference in activities of daily living/instrumental activities of daily living score = 0.15, 95% confidence interval [CI] = 0.01-0.28) and cognitive outcome (mean difference in modified Mini-Mental State Examination = -2.66, 95% CI = -4.85 to -0.47) but not neurologic or quality of life outcomes. Sleep-disordered breathing accounted for 9 to 10% of ethnic differences in functional and cognitive outcome and was associated with cognitive outcome more strongly for Mexican Americans (β = -3.97, 95% CI = -6.63 to -1.31) than non-Hispanic whites (β = -0.40, 95% CI = -4.18 to 3.39, p-interaction = 0.15).

INTERPRETATION

Sleep-disordered breathing is associated with worse functional and cognitive function at 90 days poststroke. These outcomes are reasonable endpoints for future trials of sleep-disordered breathing treatment in stroke. If effective, sleep-disordered breathing treatment may somewhat lessen ethnic stroke outcome disparities. ANN NEUROL 2019;86:241-250.

Electrocardiomatrix Facilitates Accurate Detection of Atrial Fibrillation in Stroke Patients

Background and Purpose- Cardiac telemetry is a routine part of inpatient ischemic stroke/transient ischemic attack evaluation to assess for atrial fibrillation (AF). Yet, tools to assist stroke clinicians in the evaluation of the large quantities of telemetry data are limited. The investigators developed a new method to evaluate electrocardiographic signals, electrocardiomatrix, that was applied to stroke unit telemetry data to determine its feasibility, validity, and usefulness. Electrocardiomatrix displays telemetry data in a 3-dimensional matrix that allows for more accurate and less time consuming P-wave analysis. Methods- In this single-center, prospective, observational study conducted in a stroke unit, all telemetry data from ischemic stroke and transient ischemic attack patients were collected (April 2017-January 2018) for examination facilitated by electrocardiomatrix. AF>30 seconds was identified through review of electrocardiomatrix-generated matrices by a nonphysician researcher. Electrocardiomatrix results were compared with the clinical team's medical record documentation of AF identified through telemetry. A study cardiologist reviewed the standard telemetry associated with all AF episodes identified by electrocardiomatrix and each case of disagreement. Results- Telemetry data (median 46 hours [interquartile range: 22-90]) were analyzed among 265 unique subjects (88% ischemic stroke). Electrocardiomatrix was successfully applied in 260 (98%) of cases. The positive predictive value of electrocardiomatrix compared with the clinical documentation was 86% overall and 100% among the subset with no prior history of AF. For the 5 false-positive and 5 false-negative cases, expert overview disagreed with the clinical documentation and confirmed the electrocardiomatrix-based diagnosis. Conclusions- The application of electrocardiomatrix to stroke unit-acquired telemetry data is feasible and appears to have superior accuracy compared with traditional monitor analysis by noncardiologists.

Diplopia-Related Ambulatory and Emergency Department Visits in the United States, 2003-2012

Importance

Diplopia is believed to be a common eye-related symptom. However, to date, there are no available population-based estimates, which are necessary to understand the impact of this disabling symptom on the health care system and to identify steps to optimize patient care.

Objective

To describe diplopia presentations in US ambulatory and emergency department (ED) settings.

Design, Setting, and Participants

Ambulatory and ED visits in the United States by patients with diplopia were analyzed in this prespecified secondary analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey data collected for a 10-year period (2003-2012). Data were analyzed for the present study from October 6, 2016 to August 18, 2017.

Main Outcomes and Measures

Numbers of ambulatory and ED diplopia presentations were estimated using weighted sample data. Weighted proportions of patient and clinician (ie, ophthalmologists, general practitioners, and specialty physicians) characteristics, diagnoses, and imaging use were calculated.

Results

In total, 804 647 (95% CI, 662 075-947 218) ambulatory and 49 790 (95% CI, 38 318-61 262) diplopia-related ED visits occurred annually; 12.3% of ambulatory visits were primarily for acute- or subacute-onset diplopia. Mean (SD) patient age was 62.1 (20.3) years for ambulatory vs 48.1 (22.3) years for diplopia-related ED visits. Most visits primarily for diplopia were by patients 50 years or older (ambulatory, 79.1% [95% CI, 72.9%-84.2%]; ED, 51.8% [95% CI, 41.0%-62.4%]) who were white (ambulatory, 81.7% [95% CI, 74.8%-87.0%]; ED, 86.1% [95% CI, 77.8%-91.6%]) women (ambulatory, 51.1% [95% CI, 44.1-58.1]; ED, 52.8% [95% CI, 41.6%-63.7%]). Most diplopia-related ambulatory visits were conducted by ophthalmologists (70.4% [95% CI, 62.2%-77.5%]) even when symptoms were acute or subacute (89.0% [95% CI, 81.0%-93.9%]). The most common diagnosis in both settings was diplopia (International Classification of Diseases, Ninth Revision, Clinical Modification code 368.2). None of the 10 most frequent diagnoses was life threatening in the ambulatory setting, but approximately 16% of diplopia-related ED visits resulted in a stroke or transient ischemic attack diagnosis. Computed tomography or magnetic resonance imaging was ordered in 6.2% (95% CI, 2.8%-12.9%) of ambulatory and 59.7% (95% CI, 38.6%-77.7%) of ED visits, primarily for diplopia.

Conclusions and Relevance

Approximately 850 000 diplopia visits occur in the United States annually; 95% were outpatient visits, and diagnoses were rarely serious in the ambulatory setting but potentially life threatening in 16% of diplopia-related ED visits. Given the low probability of a serious neurologic diagnosis in the ambulatory setting and higher probability in an ED, future cohort studies are needed to define the association of various diagnostic practice patterns, such as imaging, with patient outcomes.

Ethnic Differences in 90-Day Poststroke Medication Adherence

Background and Purpose- We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods- Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ² tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results- Mexican Americans (n=692) were younger (median 65 years versus 68 years, P<0.001), had more diabetes mellitus ( P<0.001) and hypertension ( P<0.001) and less atrial fibrillation ( P=0.003), smoking ( P=0.003), and education ( P<0.001) than non-Hispanic whites (n=422). Sex, insurance status, high cholesterol, previous stroke/transient ischemic attack history, excessive alcohol use, tPA (tissue-type plasminogen activator) treatment, National Institutes of Health Stroke Scale score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the 5 drug classes between Mexican Americans and non-Hispanic whites. Conclusions- This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.