Illicit drug use increases the risk of cerebrovascular events by a variety of mechanisms. A recent report suggested that universal urine toxicology (UTox) screening of patients with stroke may be ...warranted. We aimed to evaluate the diagnostic yield of urine drug screening among unselected patients admitted with acute stroke or transient ischemic attack (TIA).
Using a single-center prospective study design, we evaluated consecutive patients with acute ischemic stroke, TIA, intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) over one year. Urine samples were collected within 48 hours of admission and analyzed for common classes of abused drugs. Prevalence of positive UTox screening was determined. We evaluated whether baseline demographics and clinical factors were associated with UTox results.
Of 483 eligible patients (acute ischemic stroke 66.4%; TIA 18.8%; ICH 7.7%; SAH 7.0%), 414 (85.7%) completed UTox screening. The mean (standard deviation) age was 65.1 (15.6) years, 52.7% were male, and 64.3% were Caucasian. Twenty-two (4.6%) patients had positive screening-cannabinoids were detected in 13 cases (3.1%), cocaine in 5 cases (1.2%), amphetamines in 1 case, and phencyclidine in 1 case. The highest yield (14.1%) was observed in patients < 60 years old with history of tobacco use while it was < 5% in the remaining subgroups (p<0.01).
Consistent with current guidelines, a selective approach to UTox screening should be pursued in acute stroke evaluation. The highest diagnostic yield is likely to be for cannabinoids and cocaine testing in younger patients with a history of concurrent tobacco use.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
The use of cardiac magnetic resonance imaging is increasing, but its role in the diagnostic work-up following ischemic stroke has received limited study. We aimed to explore the added ...yield of cardiac magnetic resonance imaging to identify cardio-aortic sources not detected by transesophageal echocardiography among patients with cryptogenic stroke.
Methods
A retrospective single-center cohort study was performed from 01 January 2009 to 01 March 2013. Consecutive patients who had both a stroke protocol cardiac magnetic resonance imaging and a transesophageal echocardiography preformed during a single hospitalization were included. All cardiac magnetic resonance imaging studies underwent independent, blinded review by two investigators. We applied the causative classification system for ischemic stroke to all patients, first blinded to cardiac magnetic resonance imaging results; we then reapplied the causative classification system using cardiac magnetic resonance imaging. Standard statistical tests to evaluate stroke subtype reclassification rates were used.
Results
Ninety-three patients were included in the final analysis; 68.8% were classified as cryptogenic stroke after initial diagnostic evaluation. Among patients with cryptogenic stroke, five (7.8%) were reclassified due to cardiac magnetic resonance imaging findings: one was reclassified as “cardio-aortic embolism evident” due to the presence of a patent foramen ovale and focal cardiac infarct and four were reclassified as “cardio-aortic embolism possible” due to mitral valve thickening (n = 1) or hypertensive cardiomyopathy (n = 3). Overall, findings on cardiac magnetic resonance imaging reduced the percentage of patients with cryptogenic stroke by slightly more than 1%.
Conclusion
Our stroke subtype reclassification rate after the addition of cardiac magnetic resonance imaging results to a diagnostic work-up which includes transesophageal echocardiography was very low. Prospective studies evaluating the role of cardiac magnetic resonance imaging and transesophageal echocardiography among patients with cryptogenic stroke should be considered.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
IMPORTANCE: Accurate and up-to-date estimates on incidence, prevalence, mortality, and disability-adjusted life-years (burden) of neurological disorders are the backbone of evidence-based health care ...planning and resource allocation for these disorders. It appears that no such estimates have been reported at the state level for the US. OBJECTIVE: To present burden estimates of major neurological disorders in the US states by age and sex from 1990 to 2017. DESIGN, SETTING, AND PARTICIPANTS: This is a systematic analysis of the Global Burden of Disease (GBD) 2017 study. Data on incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) of major neurological disorders were derived from the GBD 2017 study of the 48 contiguous US states, Alaska, and Hawaii. Fourteen major neurological disorders were analyzed: stroke, Alzheimer disease and other dementias, Parkinson disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, traumatic brain injury, spinal cord injuries, brain and other nervous system cancers, meningitis, encephalitis, and tetanus. EXPOSURES: Any of the 14 listed neurological diseases. MAIN OUTCOME AND MEASURE: Absolute numbers in detail by age and sex and age-standardized rates (with 95% uncertainty intervals) were calculated. RESULTS: The 3 most burdensome neurological disorders in the US in terms of absolute number of DALYs were stroke (3.58 95% uncertainty interval UI, 3.25-3.92 million DALYs), Alzheimer disease and other dementias (2.55 95% UI, 2.43-2.68 million DALYs), and migraine (2.40 95% UI, 1.53-3.44 million DALYs). The burden of almost all neurological disorders (in terms of absolute number of incident, prevalent, and fatal cases, as well as DALYs) increased from 1990 to 2017, largely because of the aging of the population. Exceptions for this trend included traumatic brain injury incidence (−29.1% 95% UI, −32.4% to −25.8%); spinal cord injury prevalence (−38.5% 95% UI, −43.1% to −34.0%); meningitis prevalence (−44.8% 95% UI, −47.3% to −42.3%), deaths (−64.4% 95% UI, −67.7% to −50.3%), and DALYs (−66.9% 95% UI, −70.1% to −55.9%); and encephalitis DALYs (−25.8% 95% UI, −30.7% to −5.8%). The different metrics of age-standardized rates varied between the US states from a 1.2-fold difference for tension-type headache to 7.5-fold for tetanus; southeastern states and Arkansas had a relatively higher burden for stroke, while northern states had a relatively higher burden of multiple sclerosis and eastern states had higher rates of Parkinson disease, idiopathic epilepsy, migraine and tension-type headache, and meningitis, encephalitis, and tetanus. CONCLUSIONS AND RELEVANCE: There is a large and increasing burden of noncommunicable neurological disorders in the US, with up to a 5-fold variation in the burden of and trends in particular neurological disorders across the US states. The information reported in this article can be used by health care professionals and policy makers at the national and state levels to advance their health care planning and resource allocation to prevent and reduce the burden of neurological disorders.
Abstract only Recently, we showed that HDL particle concentration (HDL-P) and cholesterol efflux capacity (CEC) predict coronary artery disease (CAD) better than HDL-C in people with type 1 diabetes ...(T1D). Cardiovascular risk factors have been shown to associate with different cardiovascular outcomes differently. We therefore investigated the association of HDL-P and CEC with ischemic stroke (IS) incidence in people with T1D. We quantified HDL-P using calibrated differential ion mobility and total and ABCA1-specific HDL CEC in 549 participants with childhood-onset (<17 years) T1D from the Epidemiology of Diabetes Complications study using the first available blood sample. The participants were free of cerebrovascular disease at baseline (mean age 27.8 years, T1D duration 19.6 years, 49% women). Stroke incidence/type was determined by self-report of physician diagnosis and confirmed by medical record review. During the follow-up (median 25 years), there were 35 (6.5%) incident IS events. Participants with IS were more likely to be older, have a longer T1D duration, have hypertension, a history of smoking, and a worse lipid, inflammatory and renal markers’ profile at baseline; HDL-C, HDL-P, and CEC did not differ between participants with and without IS. While HDL-C, total HDL-P, and CEC were not associated with IS risk, extra-small HDL-P (xsHDL-P, ~7.8nm) subspecies were strongly associated with incident IS (HR=4.49, 95% CI: 1.72-11.74), even after adjustment for IS risk factors (including smoking, diabetes duration, hypertension as well as HDL-C), in multivariable Cox proportional hazards regression analyses. When all stroke events including hemorrhagic stroke were considered the association was weaker (n=47 events, HR=2.5, 95% CI: 0.97-6.47) suggesting specificity in the association of xsHDL-P with ischemic stroke.In contrast to a strong protective association of total HDL-P and CEC against CAD in the same T1D population, these HDL metrics were not associated with IS. However, the xsHDL-P subspecies were specifically associated with increased IS risk. These striking findings require further investigation and suggest a differential association of HDL particle metrics with CAD and IS.
Abstract only Background: Increased carotid intima-media thickness (cIMT) and moderate-severe carotid artery atherosclerosis (CAA≥50%) are associated with increased risk of stroke. We evaluated ...proteomic determinants of increased cIMT and CAA≥50% in the population-based Cardiovascular Health Study (CHS). Methods: Eligible participants underwent carotid artery ultrasound and aptamer-based SOMAScan platform measurement of 1298 serum proteins from the concurrent study visit. cIMT was defined as the average of the standardized values of the maximal common carotid artery IMT and maximal internal carotid artery IMT. CAA≥50% was defined as carotid plaque resulting in ≥50% luminal stenosis. The relationship between each log-normalized protein concentration with cIMT and CAA≥50% was modeled separately using multivariable linear regression and logistic regression, respectively, adjusting for demographics, estimated glomerular filtration rate (eGFR), and CAA risk factors. Bonferroni correction, based on the number of principal components that explained 95% of the protein concentration variance in CHS participants, was employed to account for multiple hypothesis testing, yielding a p -value for significance of <7.6x10 -5 (0.05/661). Results: For eligible participants (n=2783), mean age was 74.4 ± 4.9 years, 39.5% were men, and 15.8% were Black. After adjustment for demographics, eGFR, and CAA risk factors, 13 proteins were independently associated with increased cIMT (Table). The magnitude and direction of the associations were similar in subgroups defined by sex and race. Three proteins were associated with CAA≥50%, after adjusting for eGFR and demographics (Table); however, associations were no longer significant after adjusting for CAA risk factors. Conclusion: Multiple novel serum proteins - implicated in extracellular matrix remodeling, systemic inflammation, and coagulation - were independently associated with increased cIMT in a cohort of older adults.
Abstract only Introduction: Serum remnant lipoprotein particle cholesterol (RLP-C), which includes very-low density lipoproteins (VLDL) and its lipolytic products, contributes to atherosclerotic ...plaque formation. Novel methods for estimating RLP-C and VLDL-cholesterol (VLDL-C) from a serum fasting lipid profile (FLP) have been proposed (Figure). 1,2,3 We evaluated the relationship of estimated serum RLP-C and VLDL-C with the risk of incident ischemic stroke (IS) in the Cardiovascular Health Study (CHS), a population-based longitudinal cohort of older adults. Methods: Eligible CHS participants were free of prevalent stroke and completed an FLP at the 1989-1990 or 1992-1993 baseline study visit. The relationships of a two-fold increase in RLP-C Varbo , RLP-C Sampson , and VLDL-C estimates with incident total IS were evaluated using Cox proportional hazards regression, adjusting for demographics and IS risk factors, including low-density and high-density lipoprotein cholesterol. Secondary analyses evaluated the relationship with incident cardioembolic IS, non-cardioembolic IS, and large artery atherosclerotic or lacunar IS. Results: Of 5,427 eligible participants, mean age was 72.8 (±5.6) years, 57.6% were women, and 15.7% were Black. Over a median follow-up of 12.4 years, 895 participants experienced an incident IS. RLP-C Varbo , RLP-C Sampson , and VLDL-C were each associated with incident total IS risk, non-cardioembolic IS risk, and large artery atherosclerotic or lacunar IS risk, after adjusting for confounders, but not with cardioembolic IS risk (Table). Conclusions: In older adults, RLP-C and VLDL-C are associated with IS risk, especially atherosclerotic IS.
Abstract only Introduction: Socioeconomic status (SES) is an upstream determinant of cerebrovascular disease comorbidities and subsequently ischemic stroke. Here we examined the association of SES ...and modifiable ischemic stroke risk factors. Methods: Hospitalized ischemic stroke patient data from 10/1/2015 - 12/31/2018 was obtained via the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS). Demographic characteristics of age, sex, race, US region, SES (defined as median household income range by zip code) and ischemic stroke risk factors of atrial fibrillation/flutter (AF), type II diabetes (DM), hypertension (HTN), hyperlipidemia (HLD), tobacco use, and obesity were identified using published ICD-10 codes. Multivariable logistic regression was used to assess each condition individually and identify which comorbidities were associated with specific socioeconomic quartiles (Q1, Q4) when adjusted for the abovementioned demographics. Results: Of the 382,734 adult ischemic stroke patients identified, mean age was 70 ±14.2 years and 50.3% were female. Socioeconomic status quartiles ranged from <$43,749 (Q1) to >$73,000 (Q4); 30.9% of ischemic stroke patients were in SES Q1 (vs 19.1% in SES Q4). Patients in Q1 experienced ischemic stroke at a younger age (67.9 ±14.1) as compared to patients in Q4 (72.4 ±14), p<0.001. In adjusted models with Q4 as reference, Q1 patients had increased odds for DM OR 1.27, p<0.001, 95% CI 1.24 - 1.29, obesity OR 1.05, p<0.004, CI 1.02 - 1.08, and tobacco use OR 1.66, p<0.001, CI 1.51 - 1.83. Conversely, Q1 patients had decreased odds of AF OR 0.91, p<0.001, CI 0.89 - 0.93 and HLD OR 0.81, p<0.001, CI 0.79 - 0.82. There was no significant association between SES quartile and HTN. Conclusion: Lower SES was associated with higher odds of specific ischemic stroke risk factors. While the etiology of the risk factor variance is beyond the scope of current data analysis, the cause is likely multifactorial and influenced by underlying detection bias, income inequity, and level of education/health literacy. Further research and subgroup analysis is warranted as it may impact future preventative measures and treatment protocols.
Abstract only Introduction: Atrial fibrillation (AF), a well-defined ischemic stroke (IS) risk factor whose prevalence increases with age, is associated with higher stroke severity. We aimed to ...evaluate stroke severity and hospital mortality in a nationally representative sample of AF-related IS patients. Methods: We utilized data from the National (Nationwide) Inpatient Sample databases from 2015 - 2018 using ICD-10 diagnostic codes to identify individuals with IS and comorbid AF. The NIHSS was used to characterize stroke severity in a subset of cases after 10/1/2016. Nonparametric statistics and logistic regression analyses were conducted to evaluate associations between AF and hospital death. Results: Of the 382,758 IS cases, 99,566 (26%) had comorbid AF. AF increased linearly with age, reaching at 47% of all hospitalized IS patients 85+ years of age or older (Figure). Higher age, male sex, white race, obesity, and higher median income were associated with comorbid AF, whereas diabetes, hypertension, tobacco use, and hyperlipidemia were associated with reduced odds of comorbid AF. While 5.8% of all IS patients died during hospitalization, mortality was increased nearly two-fold in those with AF (9.0% vs. 4.6%, p<.001). Among in-hospital deaths from IS, comorbid AF increased with age, present in 59% of those 85+ years of age or older (Figure). NIHSS, reported in 21% of patients, was higher in AF patients (mean NIHSS 6 vs. 9, p<.001). High NIHSS was the strongest independent predictor of hospital death. Conclusion: The burden of AF in a nationally representative sample of hospitalized IS patients is substantial, present in nearly 50% of the 85+ age group. AF-related IS is more severe and more likely to be fatal. As our population ages, the prevalence of AF will only increase. Understanding the severity and fatality of AF-related IS will have profound implications for health systems and may better facilitate anticipatory guidance and AF treatment.
Abstract only Background: Cerebrovascular complications (ischemic stroke (IS), intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH)) of infective endocarditis (IE) are common and ...substantially increase morbidity and mortality. We aimed to identify risk factors for stroke in a nationally representative population of hospitalized IE patients from the US. Methods: Patient hospitalizations for IE and stroke were identified using validated International Classification of Diseases 10 diagnosis codes from the Q4 2015-2018 National Inpatient Sample. We evaluated the association between demographics, known risk factors (opioid use, cardiac valve replacement, and mitral valve disease), and Elixhauser comorbidity index-defined factors with the diagnosis of stroke using logistic regression. Results: Of the 53,557 patients with a diagnosis of IE, 5,754 (10.7%) had a concurrent diagnosis of stroke (75% IS, 6.9% ICH, 4.5% SAH, 14% multiple stroke types). The mean age at IE diagnosis was 59 years; 42.3% were female; 71.8% Caucasian, 14.2% Black, 7.8% Hispanic, 2.7% Asian, and 0.8% Native American; 9.2% of patients died during hospitalization (7.5% without stroke, 23% with stroke, p<0.001). Factors independently associated with stroke are shown in the Table; the C-statistic was 0.63. Opioid use and cardiac valve replacement were not associated with stroke. Conclusion: In this large, nationally representative sample of hospitalized IE patients, comorbidities independently associated with higher odds of stroke included mitral valve disease, metastatic cancer, coagulopathy, weight loss, and electrolyte disorders. Detailed clinical data, not available from this administrative data set, may allow better prediction of stroke, but our findings may suggest areas for additional research.
The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk ...factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).
The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.
Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.
The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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