Race-ethnic differences in stroke risk factors among hospitalized patients with cerebral infarction: the Northern Manhattan Stroke Study

African-Americans have an unexplained increased incidence and mortality from stroke compared with whites, and little is known about stroke in Hispanics. To investigate cross-sectional differences in sociodemographic and stroke risk factors, we prospectively evaluated 430 patients hospitalized for acute ischemic stroke (black 35%. Hispanic 46%, white 19%) over the age of 39 from Northern Manhattan. Blacks and Hispanics were younger than whites (mean ages, blacks 70, Hispanics 67, whites 80; p < 0.001) and were more likely to have less than 12 years of education than whites. Hypertension was more prevalent in blacks and Hispanics with stroke than whites (blacks 76%, Hispanics 79%, whites 63%; p < 0.05) and was often untreated in blacks. Left ventricular hypertrophy by ECG was more frequent in blacks (blacks 20%, whites 9%; p = 0.02). History of cardiac disease (atrial fibrillation, myocardial infarction, angina, and congestive heart failure) was less prevalent in both blacks and Hispanics. Black women were significantly more obese than white women (mean Quetelet Index percent, blacks 3.9%, whites 3.6%; p < 0.05). Heavy alcohol use was more often reported by blacks and Hispanics; cigarette smoking was increased only in blacks. Moreover, blacks were less likely to have visited a physician 1 year after their stroke (blacks 85%, whites 98%; p < 0.05), and Hispanics less often lived alone compared with whites. These cross-sectional differences suggest that the burden of stroke risk factors is increased in both blacks and Hispanics with stroke. Further studies controlling for stroke risk factors are needed to establish whether race-ethnicity is an independent determinant of stroke risk

Predictors of mortality and recurrence after hospitalized cerebral infarction in an urban community: the Northern Manhattan Stroke Study

To identify determinants of recurrence and mortality after ischemic stroke in a mixed-ethnic region. The determinants of ischemic stroke outcome are not uniformly characterized and will be of increasing importance as the frequency of ischemic stroke survivors increases in our aging population. A cohort of 323 patients (40% black, 34% Hispanic, 26% white) with cerebral infarction from northern Manhattan over age 39 were followed for a mean of 3.3 years, with only 6% lost to follow-up. Cumulative life table risk of mortality and recurrence was calculated. Risk factors classified at the time of index ischemic stroke were selected based on univariate analyses and then entered into a Cox proportional hazards model for mortality and for recurrence. The life table cumulative risk of mortality was 8% at 30 days, 22% at 1 year, and 45% at 5 years after ischemic stroke. The immediate cause of death was related to vascular disease in 60%. After age adjustment, the significant predictors of mortality were congestive heart failure (risk ratio [RR] = 2.6), admission glucose > 140 mg/dl (RR = 1.7), and presentation with either a large dominant, nondominant, or major basilar syndrome (RR = 2.0). Patients with a lacunar syndrome had a better survival (RR = 0.6). Recurrent strokes occurred in 72 patients. The life table cumulative risk of recurrence was 6% at 30 days, 12% at 1 year, and 25% at 5 years after ischemic stroke. Ethanol abuse (RR = 2.5), hypertension requiring discharge medications (RR = 1.6), and elevated blood glucose within 48 hours of index ischemic stroke (RR = 1.2 per 50 mg/dl) were the independent predictors of recurrence. Among 30-day survivors, the effect of ethanol abuse was greater (RR = 3.5), indicating its impact on late recurrence. After accounting for age and presenting syndrome, initial glucose predicts stroke mortality and recurrence after ischemic stroke. This association may reflect uncontrolled and undiagnosed diabetes in our urban population. Furthermore, ethanol abuse may be a determinant of ischemic stroke recurrence. Reduction of the stroke public health burden will require targeted modification of such conditions and behaviors

Aortic atheromas and acute ischemic stroke: a transesophageal echocardiographic study in an ethnically mixed population

Proximal aortic atheromas have been suggested as a potential ischemic stroke determinant in the elderly, especially in cases of unexplained (cryptogenic) stroke. Our aim was to assess the potential role of proximal aortic atheromas as an independent risk factor for stroke by comparing their frequency in patients with acute ischemic stroke and in stroke-free control subjects. The frequency of atheromas was also compared among different ethnic groups. A case-control study was conducted in 106 patients with acute ischemic stroke and 114 stroke-free control subjects. The presence of atheromas of the proximal portion of the aorta was assessed by biplane transesophageal echocardiography. Atheromas were categorized on the basis of their thickness (0.2 to 0.4 cm, small; > or = 0.5 cm, large) and complexity (i.e., ulceration or mobility). The association between aortic atheromas and ischemic stroke was tested, controlling for patients' demographic variables and stroke risk factors. In stroke patients, subgroup analyses were performed to test the associations between aortic atheromas and stroke diagnostic subtypes (determined cause versus cryptogenic) and presence and degree of carotid stenoses by duplex Doppler examination. The frequency of large aortic atheromas was greater in stroke patients than in controls (26% versus 13%; crude odds ratio [OR] 2.4, 95% CI 1.2 to 4.7); ulcerated or mobile atheromas also tended to be more frequent in stroke patients (12% versus 5%; OR 2.5, 95% CI 1.0 to 6.8). Differences were entirely attributable to the subgroup of patients aged 60 years or older, in whom the frequency of ulcerated or mobile atheromas was particularly high among cryptogenic stroke patients (22% versus 8% in control subjects; OR 3.4, 95% CI 1.1 to 11.2). Multivariate analysis showed the presence of large atheromas to be independently associated with stroke in the entire study group (adjusted OR 2.6, 95% CI 1.1 to 5.9) and in the older subgroup (OR 2.4, 95% CI 1.1 to 5.7). Carotid stenosis > or = 60% was more frequent with increasing size and complexity of aortic atheromas but had low predictive value (16%) for presence of large atheromas; moreover, 36% of patients with mild or no carotid stenosis had large or complex aortic atheromas. No significant differences were found in the frequency of atheromas by ethnic group. Proximal aortic atheromas > or = 0.5 cm in size are a risk factor for ischemic stroke in patients aged 60 years or older. Ulcerated or mobile atheromas may play a role in explaining some cryptogenic strokes in the elderly. The risk for stroke of patients with aortic atheromas may be similar across different ethnic groups. The absence of carotid stenosis does not exclude aortic atheromas as a potential cause for ischemic stroke