Acute Effects of Particulate Air Pollution on Ischemic Stroke and Hemorrhagic Stroke Mortality

Background and Purpose: A large body of literature reported the association of particulate matter (PM) with stroke in high-income countries. Few studies have examined the association between PM and stroke in middle- and low-income countries and considered the types of stroke. In this study, we examined the short-term effects of particulate matter <2.5 μm in diameter (PM2.5) and particulate matter <10 μm in diameter (PM10) on ischemic stroke mortality and hemorrhagic stroke mortality in Beijing, China.Methods: We used an ecological study design and quasi-Poisson generalized additive models to evaluate the association of PM2.5 and PM10 and cerebrovascular diseases mortality, as well as ischemic- and hemorrhagic stroke mortality. In the model, we controlled long-term and season trends, temperature, and relative humidity, the day of the week and air pollution. For cerebrovascular diseases mortality, we examined the effects stratified by sex and age with different lag days.Results: A total of 48,122 deaths for cerebrovascular disease (32,799 deaths for ischemic stroke and 13,051 deaths for hemorrhagic stroke) were included in the study. PM2.5 was associated with stroke mortality. The 10 μg/m3 increase of PM2.5 was associated with the increase of mortality, 0.27% (95% CI, 0.12–0.43%) for cerebrovascular diseases, 0.23% (95% CI, 0.04–0.42%) for ischemic stroke and 0.37% (95% CI, 0.07–0.67%) for hemorrhagic stroke -. The associations between PM10 and mortality were also detected for cerebrovascular diseases and ischemic stroke, but not in hemorrhagic stroke. The stratified analysis suggested age and gender did not modify the effects of PM on mortality significantly.Conclusions: Our study suggested that short-term exposure to ambient PM was associated with the risk of stroke mortality

Time Course for Benefit and Risk of Ticagrelor and Aspirin in Acute Ischemic Stroke or Transient Ischemic Attack

Aspirin; Acute Ischemic Stroke, BenefitAspirina; Accidente cerebrovascular isquémico agudo; BeneficioAspirina; Accident cerebrovascular isquèmic agut; BeneficiBackground and objectives: The goal of this work was to investigate the short-term time-course benefit and risk of ticagrelor with aspirin in acute mild-moderate ischemic stroke or high-risk TIA in The Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and ASA for Prevention of Stroke and Death (THALES) trial. Methods: In an exploratory analysis of the THALES trial, we evaluated the cumulative incidence of irreversible efficacy and safety outcomes at different time points during the 30-day treatment period. The efficacy outcome was major ischemic events defined as a composite of ischemic stroke or nonhemorrhagic death. The safety outcome was major hemorrhage defined as a composite of intracranial hemorrhage and fatal bleedings. Net clinical impact was defined as the combination of these 2 endpoints. Results: This analysis included a total of 11,016 patients (5,523 in the ticagrelor-aspirin group, 5,493 in the aspirin group) with a mean age of 65 years, and 39% were women. The reduction of major ischemic events by ticagrelor occurred in the first week (4.1% vs 5.3%; absolute risk reduction 1.15%, 95% CI 0.36%-1.94%) and remained throughout the 30-day treatment period. An increase in major hemorrhage was seen during the first week and remained relatively constant in the following weeks (absolute risk increase ≈0.3%). Cumulative analysis showed that the net clinical impact favored ticagrelor-aspirin in the first week (absolute risk reduction 0.97%, 95% CI, 0.17%-1.77%) and remained constant throughout the 30 days. Discussion: In patients with mild-moderate ischemic stroke or high-risk TIA, the treatment effect of ticagrelor-aspirin was present from the first week. The ischemic benefit of ticagrelor-aspirin outweighs the risk of major hemorrhage throughout the treatment period, which may support the use of 30-day treatment with ticagrelor and aspirin in these patients. Classification of evidence: This study provides Class II evidence that, for patients with mild-moderate ischemic stroke or high-risk TIA, the ischemic benefit of ticagrelor-aspirin outweighs the risk of major hemorrhage throughout the 30-day treatment period.This study is supported by AstraZeneca

Is there a correlation between socioeconomic disparity and functional outcome after acute ischemic stroke?

Background To investigate the impact of low socioeconomic status (SES), indicated by low level of education, occupation and income, on 3 months functional outcome after ischemic stroke. Methods We analyzed data from the China National Stroke Registry (CNSR), a multicenter and prospective registry of consecutive patients with acute cerebrovascular events occurred between September 2007 and August 2008. 11226 patients with ischemic stroke had SES and clinical characteristics data collected at baseline and mRS measured as indicator of functional outcome in 3 months follow up. Multinomial and ordinal logistic regression models were performed to examine associations between SES and the functional outcome. Results At 3 months after stroke, 5.3% of total patients had mRS scored at 5, 11.3% at score 4, 11.1% at score 3, 14.4% at score 2, 34.2% at score 1 and 23.7% at score 0. Compared to patients with educational level of ≥ 6 years and non-manual laboring, those < 6 years and manual laboring tended to have higher mRS score (P<0.001). Multinomial adjusted odds ratios (ORs) of outcome in manual workers were significantly increased (ORs from1.38 to 1.87), but OR in patients with less income was not significant. There were similar patterns of association The impact may be stronger in patients aged <65 years (P = 0.003, P<0.001 respectively) and being male (P = 0.001, P<0.001 respectively). Conclusions Our study provides evidence that people who are relatively more deprived in socioeconomic status suffer poorer outcome after ischemic stroke. The influence of low educational level and manual laboring can be more intensive than low income level on 3-month outcome. Health policy and service should target the deprived populations to reduce the public health burden in the society.This study is supported by grants from the Ministry of Science and Technology of the People’s Republic of China (2006BAI01A11, 2011BAI08B01, 2011BAI08B02, 2012ZX09303-005-001, and 2013BAI09B03), a grant from the Beijing Biobank of Cerebral Vascular Disease (D131100005313003) and a grant from Beijing Institute for Brain Disorders (BIBD-PXM2013_014226_07_000084

Socioeconomic Status and the Quality of Acute Stroke Care

Background and Purpose—The association of socioeconomic status (SES) with quality of stroke care is not well understood, and few studies have examined the association with different indicators of SES simultaneously. We assessed the impacts of low levels of education, occupation, and income on the quality of stroke care. Methods—We examined data from the China National Stroke Registry recording consecutive stroke patients between September 2007 and August 2008. Baseline low SES was measured using educational level <6 years, occupation as manual workers or no job, and average family income per capita at ≤¥1000 per month. Compliance with 11 performances was summarized in a composite score defined as the proportion of all needed care given. Poor quality of care was defined as having a composite score of 0.71 or less. Results—Among 12 270 patients with ischemic stroke, 38.6% had <6 educational years, 37.6% had manual workers/no job, and 34.7% had income ≤¥1000 per month. There was an increased chance of receiving poor quality of care in patients with low education (adjusted odds ratio 1.15, 95% confidence interval 1.03–1.28), low occupation (adjusted odds ratio 1.16, 95% confidence interval 1.01–1.32), and low income (adjusted odds ratio 1.18, 95% confidence interval 1.06–1.30), respectively. People with low SES had poor performances on some aspects of care quality. Combined effects existed among these SES indicators; those with low SES from all 3 indicators had the poorest quality of care. Conclusions—There was a social gradient in the quality of stroke care. Continuous efforts of socioeconomic improvement will increase the quality of acute stroke care.The Ministry of Science and Technology of the People’s Republic of China (2006BAI01A11, 2011BAI08B01, 2011BAI08B02, 2012ZX09303-005-001, and 2013BAI09B03), The Beijing Biobank of Cerebral Vascular Disease (D131100005313003), Beijing Institute for Brain Disorders (BIBD-PXM2013_014226_07_000084

Impacts of undetected and inadequately treated hypertension on incident stroke in China

OBJECTIVES: China carries the greatest burden of stroke given its largest volume of people with hypertension. This study assessed the impacts of suboptimal controls of hypertension on incident stroke and projected the number of patients with stroke saved after the control of blood pressure improved in population. SETTING: Anhui, China. PARTICIPANTS: We examined data from the Anhui cohort of 2001-2011, consisting of 3336 participants aged ≥60 years who were randomly recruited from the urban and rural Anhui. 2852 participants (89.2%) had hypertensive status measured and no stroke at baseline, and were followed up until 2011 in three surveys using a standard method of interview. RESULTS: At baseline, 1646 participants (57.7%) were identified to have hypertension, among whom 912 (55.4%) were previously undetected, 115 (7.0%) detected but not treated, 452 (27.5%) treated but not controlled and only 127 (7.7%) controlled. During the 10-year follow-up, 211 incident stroke cases (12.8/1000 person-years) occurred. Compared with normotensive individuals at baseline, multivariate adjusted HR for having stroke increased in those with undetected hypertension by 1.63 (95%CI 1.15 to 2.32), untreated by 2.21 (1.26-3.85) and uncontrolled hypertension by 3.34 (2.28-4.88), but did not differ from those with controlled hypertension (1.34; 0.60-2.99). Based on a two-fold increase in the detection and management of current levels of hypertension and algorithms on the current situation in China, approximately 250 000 incident stroke cases could be prevented annually. CONCLUSIONS: In China, hypertension is frequently undetected or inadequately treated. With appropriate management of hypertension, a substantial number of people could be saved form stroke

Comparison of the Effect of Glycemic Control in Type 2 Diabetes Outpatients Treated With Premixed and Basal Insulin Monotherapy in China

Background: Basal and premixed insulin have been widely used for insulin therapy of type 2 diabetes mellitus (T2DM) in China. The aim of this study is to compare the sustained efficacy of basal and premixed insulin therapies in T2DM outpatients with insulin monotherapy.Materials and Methods: The survey was conducted in 602 hospitals across China from April to June in 2013. The participants included outpatients who were receiving basal or premixed insulin monotherapy for more than 3 months, and the outcome was attaining a glycated hemoglobin A1C (HbA1c) of &lt;7.0% as a measure of sustained glycemic control.Results: A total of 49,119 T2DM outpatients on basal (n = 11,967) or premixed insulin (n = 37,152) monotherapy were included in the final analyses. Using multivariable model analysis, patients using premixed insulin exhibited a better glycemic control, with more outpatients achieving the target HbA1c level than those using basal insulin (model 1, OR 0.695, 95%CI 0.664–0.728; model 2, OR 0.708, 95%CI 0.676–0.742; model 3, OR 0.717, 95%CI 0.684–0.752; model 4, OR 0.750, 95%CI 0.715–0.787). Using subgroup analysis stratified by age, sex, duration of diabetes, duration of insulin treatment, and complications, still more outpatients in every subgroup treated with premixed insulin achieved the target HbA1c (HbA1c &lt; 7%) than those receiving basal insulin.Conclusions: Premixed insulin monotherapy had a better glycemic control (HbA1c &lt; 7.0%) than basal insulin monotherapy for Chinese T2DM outpatients in daily

Platelet Count Predicts Adverse Clinical Outcomes After Ischemic Stroke or TIA: Subgroup Analysis of CNSR II

Background: The clinical significance of platelet count (PC) for ischemic cerebrovascular disease is not well-established and further risk stratification according to baseline PC within normal range has not been reported before. We aim to evaluate the prognostic effect of baseline circulating PC within normal range on the risk of long-term recurrent stroke, mortality and functional outcomes after ischemic stroke or TIA.Methods: We derived data from eligible patients with ischemic stroke or TIA from the China National Stroke Registry (CNSR) II. Participants were divided into quintiles according to baseline PC within normal range (100–450 × 109/L). Multivariable cox regression and logistic regression were adopted to explore the correlation of baseline PC with recurrent stroke, mortality and poor functional outcomes (modified Rankin Scale 3~6) within 1-year follow-up.Results: Among the16842 eligible participants, the average age was 64.7 ± 11.9, 1,241 (7.4%) had recurrent stroke, 1,377 (8.2%) died, and 3,557 (21.1%) ended up with poor functional outcomes after 1-year follow-up. Compared with the third PC quintile (186–212 × 109/L), patients in the top quintile (249–450 × 109/L) presented with increased risk of recurrent stroke (adjusted hazard ratio 1.21, [1.02–1.45]), all-cause mortality (adjusted hazard ratio 1.43, [1.19–1.73]), and poor functional outcome (adjusted odds ratio 1.49, [1.28–1.74]), while patients in the lowest PC quintile(100–155 × 109/L) had higher risk of poor functional outcome (adjusted odds ratio 1.19, [1.02–1.38]).Conclusion: In ischemic stroke or TIA patients with platelet count within normal range, platelet count may be a qualified predictor for long-term recurrent stroke, mortality, and poor functional outcome

Risk score to predict gastrointestinal bleeding after acute ischemic stroke

© 2014 Ji et al.; licensee BioMed Central Ltd. Background: Gastrointestinal bleeding (GIB) is a common and often serious complication after stroke. Although several risk factors for post-stroke GIB have been identified, no reliable or validated scoring system is currently available to predict GIB after acute stroke in routine clinical practice or clinical trials. In the present study, we aimed to develop and validate a risk model (acute ischemic stroke associated gastrointestinal bleeding score, the AIS-GIB score) to predict in-hospital GIB after acute ischemic stroke.Methods: The AIS-GIB score was developed from data in the China National Stroke Registry (CNSR). Eligible patients in the CNSR were randomly divided into derivation (60%) and internal validation (40%) cohorts. External validation was performed using data from the prospective Chinese Intracranial Atherosclerosis Study (CICAS). Independent predictors of in-hospital GIB were obtained using multivariable logistic regression in the derivation cohort, and β-coefficients were used to generate point scoring system for the AIS-GIB. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively.Results: A total of 8,820, 5,882, and 2,938 patients were enrolled in the derivation, internal validation and external validation cohorts. The overall in-hospital GIB after AIS was 2.6%, 2.3%, and 1.5% in the derivation, internal, and external validation cohort, respectively. An 18-point AIS-GIB score was developed from the set of independent predictors of GIB including age, gender, history of hypertension, hepatic cirrhosis, peptic ulcer or previous GIB, pre-stroke dependence, admission National Institutes of Health stroke scale score, Glasgow Coma Scale score and stroke subtype (Oxfordshire). The AIS-GIB score showed good discrimination in the derivation (0.79; 95% CI, 0.764-0.825), internal (0.78; 95% CI, 0.74-0.82) and external (0.76; 95% CI, 0.71-0.82) validation cohorts. The AIS-GIB score was well calibrated in the derivation (P = 0.42), internal (P = 0.45) and external (P = 0.86) validation cohorts.Conclusion: The AIS-GIB score is a valid clinical grading scale to predict in-hospital GIB after AIS. Further studies on the effect of the AIS-GIB score on reducing GIB and improving outcome after AIS are warranted.Link_to_subscribed_fulltex

Risk score to predict gastrointestinal bleeding after acute ischemic stroke

BackgroundGastrointestinal bleeding (GIB) is a common and often serious complication after stroke. Although several risk factors for post-stroke GIB have been identified, no reliable or validated scoring system is currently available to predict GIB after acute stroke in routine clinical practice or clinical trials. In the present study, we aimed to develop and validate a risk model (acute ischemic stroke associated gastrointestinal bleeding score, the AIS-GIB score) to predict in-hospital GIB after acute ischemic stroke.MethodsThe AIS-GIB score was developed from data in the China National Stroke Registry (CNSR). Eligible patients in the CNSR were randomly divided into derivation (60%) and internal validation (40%) cohorts. External validation was performed using data from the prospective Chinese Intracranial Atherosclerosis Study (CICAS). Independent predictors of in-hospital GIB were obtained using multivariable logistic regression in the derivation cohort, and β-coefficients were used to generate point scoring system for the AIS-GIB. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively.ResultsA total of 8,820, 5,882, and 2,938 patients were enrolled in the derivation, internal validation and external validation cohorts. The overall in-hospital GIB after AIS was 2.6%, 2.3%, and 1.5% in the derivation, internal, and external validation cohort, respectively. An 18-point AIS-GIB score was developed from the set of independent predictors of GIB including age, gender, history of hypertension, hepatic cirrhosis, peptic ulcer or previous GIB, pre-stroke dependence, admission National Institutes of Health stroke scale score, Glasgow Coma Scale score and stroke subtype (Oxfordshire). The AIS-GIB score showed good discrimination in the derivation (0.79; 95% CI, 0.764-0.825), internal (0.78; 95% CI, 0.74-0.82) and external (0.76; 95% CI, 0.71-0.82) validation cohorts. The AIS-GIB score was well calibrated in the derivation (P = 0.42), internal (P = 0.45) and external (P = 0.86) validation cohorts.ConclusionThe AIS-GIB score is a valid clinical grading scale to predict in-hospital GIB after AIS. Further studies on the effect of the AIS-GIB score on reducing GIB and improving outcome after AIS are warranted