BACKGROUND AND PURPOSE—Stroke mortality is 30% higher in the rural United States. This could be because of either higher incidence or higher case fatality from stroke in rural areas.
METHODS—The ...urban–rural status of 23 280 stroke-free participants recruited between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) was classified using the Rural–Urban Commuting Area scheme as residing in urban, large rural town/city, or small rural town or isolated areas. The risk of incident stroke was assessed using proportional hazards analysis, and case fatality (death within 30 days of stroke) was assessed using logistic regression. Models were adjusted for demographics, traditional stroke risk factors, and measures of socioeconomic status.
RESULTS—After adjustment for demographic factors and relative to urban areas, stroke incidence was 1.23-times higher (95% confidence intervals, 1.01–1.51) in large rural town/cities and 1.30-times higher (95% confidence intervals, 1.03–1.62) in small rural towns or isolated areas. Adjustment for risk factors and socioeconomic status only modestly attenuated this association, and the association became marginally nonsignificant (P=0.071). There was no association of rural–urban status with case fatality (P>0.47).
CONCLUSIONS—The higher stroke mortality in rural regions seemed to be attributable to higher stroke incidence rather than case fatality. A higher prevalence of risk factors and lower socioeconomic status only modestly contributed to the increased risk of incident stroke risk in rural areas. There was no evidence of higher case fatality in rural areas.
We describe temporal trends in stroke incidence stratified by age from our population-based stroke epidemiology study. We hypothesized that stroke incidence in younger adults (age 20-54) increased ...over time, most notably between 1999 and 2005.
The Greater Cincinnati/Northern Kentucky region includes an estimated population of 1.3 million. Strokes were ascertained in the population between July 1, 1993, and June 30, 1994, and in calendar years 1999 and 2005. Age-, race-, and gender-specific incidence rates with 95 confidence intervals were calculated assuming a Poisson distribution. We tested for differences in age trends over time using a mixed-model approach, with appropriate link functions.
The mean age at stroke significantly decreased from 71.2 years in 1993/1994 to 69.2 years in 2005 (p < 0.0001). The proportion of all strokes under age 55 increased from 12.9% in 1993/1994 to 18.6% in 2005. Regression modeling showed a significant change over time (p = 0.002), characterized as a shift to younger strokes in 2005 compared with earlier study periods. Stroke incidence rates in those 20-54 years of age were significantly increased in both black and white patients in 2005 compared to earlier periods.
We found trends toward increasing stroke incidence at younger ages. This is of great public health significance because strokes in younger patients carry the potential for greater lifetime burden of disability and because some potential contributors identified for this trend are modifiable.
PURPOSE—To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type ...plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.
METHODS—Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.
RESULTS—After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.
Although other studies (in largely white populations) have found that stroke incidence declined during the 1990s, we previously reported that stroke incidence in our population (18% of which was ...black) did not change during that decade and that incidence rates in blacks were significantly higher than in whites. We sought to update temporal trends in stroke incidence by adding new data obtained from our large, biracial population in 2005. The objective of this study was to examine temporal trends in stroke incidence and case-fatality within a large biracial population over time by comparing stroke incidence rates from 1993 to 1994, 1999, and 2005.
Within the Greater Cincinnati/Northern Kentucky population of 1.3 million, all strokes among area residents were ascertained at all local hospitals during July 1993 to June 19/94 and calendar years 1999 and 2005. A sampling scheme was used to ascertain cases in the out-of-hospital setting. Only first-ever strokes were included in this analysis. Race-specific incidence rates, standardized to the 2000 US Census population, and case-fatality rates were calculated.
The number of physician-confirmed first-ever strokes in patients >or=20 years of age was 1942 in 1993 to 1994, 2041 in 1999, and 1921 in 2005. In all study periods, blacks had higher stroke incidence than whites, and case-fatality rates were similar between races. In contrast to previous study periods, we found a significant decrease in overall stroke incidence in 2005. When stratified by race and stroke subtype, this change was driven by a decrease in ischemic stroke incidence among whites, whereas ischemic stroke incidence in blacks was unchanged. Hemorrhagic stroke incidence was unchanged in both races.
For the first time, we report a significant decrease in stroke incidence within our population, which is consistent with other reports in the literature. This decrease was found only among whites, which suggests a worsening of the racial disparity in stroke incidence.
Despite the global impact and advances in understanding the pathophysiology of cerebrovascular diseases, the term “stroke” is not consistently defined in clinical practice, in clinical research, or ...in assessments of the public health. The classic definition is mainly clinical and does not account for advances in science and technology. The Stroke Council of the American Heart Association/American Stroke Association convened a writing group to develop an expert consensus document for an updated definition of stroke for the 21st century. Central nervous system infarction is defined as brain, spinal cord, or retinal cell death attributable to ischemia, based on neuropathological, neuroimaging, and/or clinical evidence of permanent injury. Central nervous system infarction occurs over a clinical spectrumIschemic stroke specifically refers to central nervous system infarction accompanied by overt symptoms, while silent infarction by definition causes no known symptoms. Stroke also broadly includes intracerebral hemorrhage and subarachnoid hemorrhage. The updated definition of stroke incorporates clinical and tissue criteria and can be incorporated into practice, research, and assessments of the public health.
BACKGROUND AND PURPOSE—Prophylactic anticoagulation for deep venous thrombosis prevention after intracerebral hemorrhage (ICH) is safe. Current guidelines recommend prophylactic anticoagulation after ...cessation of hematoma growth. We aimed to evaluate nationwide trends in deep venous thrombosis prophylaxis after ICH.
METHODS—In an analysis of the Premier database, we identified adult patients with ICH (International Classification of Diseases Ninth edition code 431) from 2006 to 2010 who survived to day 2 of hospitalization. We excluded those with trauma or who underwent craniotomy or angiography. We abstracted type of anticoagulant used and date of first administration. We used univariate statistics and multivariable logistic regression to assess factors associated with prophylactic anticoagulation after ICH.
RESULTS—Among 32 690 (mean age, 69.7 years; 50.1% men) patients with spontaneous ICH, 5395 (16.5%) patients received any prophylactic anticoagulation during the hospital stay. Among these patients, 2416 (44.8%) received prophylactic anticoagulation by day 2. The most commonly used agents were heparin (71.1%), enoxaparin (27.5%), and dalteparin (1.4%). The proportion of patients receiving prophylactic anticoagulation increased slightly during the study period from 14.3% to 18.0% (P<0.01 for trend). Use of prophylactic anticoagulation varied by geographic region (P<0.001) in the United StatesNortheast (23.2%), South (19.0%), Midwest (10.8%), and West (9.8%). In multivariable analysis, geographic region remained an independent predictor of prophylactic anticoagulation.
CONCLUSIONS—Less than 20% of patients with ICH receive anticoagulation for deep venous thrombosis in the United States. When used, the time to initiation is <2 days in less than half of the patients. Further study should focus on understanding variations in practice and emphasize guideline-driven care.
IMPORTANCE: Race-specific and sex-specific stroke risk varies across the lifespan, yet few reports describe sex differences in stroke risk separately in black individuals and white individuals. ...OBJECTIVE: To examine incidence and risk factors for ischemic stroke by sex for black and white individuals. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study included participants 45 years and older who were stroke-free from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, enrolled from the continental United States 2003 through 2007 with follow-up through October 2016. Data were analyzed from March 2018 to September 2018. EXPOSURES: Sex and race. MAIN OUTCOMES AND MEASURES: Physician-adjudicated incident ischemic stroke, self-reported race/ethnicity, and measured and self-reported risk factors. RESULTS: A total of 25 789 participants (14 170 women 54.9%; 10 301 black individuals 39.9%) were included. Over 222 120 person-years of follow-up, 939 ischemic strokes occurred: 159 (16.9%) in black men, 326 in white men (34.7%), 217 in black women (23.1%), and 237 in white women (25.2%). Between 45 and 64 years of age, white women had 32% lower stroke risk than white men (incidence rate ratio IRR, 0.68 95% CI, 0.49-0.94), and black women had a 28% lower risk than black men (IRR, 0.72 95% CI, 0.52-0.99). Lower stroke risk in women than men persisted at age 65 through 74 years in white individuals (IRR, 0.71 95% CI, 0.55-0.94) but not in black individuals (IRR, 0.94 95% CI, 0.68-1.30); however, the race-sex interaction was not significant. At 75 years and older, there was no sex difference in stroke risk for either race. For white individuals, associations of systolic blood pressure (women: hazard ratio HR, 1.13 95% CI, 1.05-1.22; men: 1.04 95% CI, 0.97-1.11; P = .099), diabetes (women: HR, 1.84 95% CI, 1.35-2.52; men: 1.13 95% CI, 0.86-1.49; P = .02), and heart disease (women: HR, 1.76 95% CI, 1.30-2.39; men, 1.26 95% CI, 0.99-1.60; P = .09) with stroke risk were larger for women than men, while antihypertensive medication use had a smaller association in women than men (women: HR, 1.17 95% CI, 0.89-1.54; men: 1.61 95% CI, 1.29-2.03; P = .08). In black individuals, there was no evidence of a sex difference for any risk factors. CONCLUSIONS AND RELEVANCE: For both races, at age 45 through 64 years, women were at lower stroke risk than men, and there was no sex difference at 75 years or older; however, the sex difference pattern may differ by race from age 65 through 74 years. The association of risk factors on stroke risk differed by race-sex groups. While the need for primordial prevention, optimal management, and control of risk factors is universal across all age, racial/ethnic, and sex groups, some demographic subgroups may require earlier and more aggressive strategies.
Little is known about whether the relationship between hypertension and ischemic stroke differs by sex. We examined sex differences in the association between hypertension severity and treatment and ...ischemic stroke risk. We used a longitudinal cohort study in the continental United States, with oversampling of black individuals and those living in the stroke belt. We included 26 461 participants recruited from 2003 to 2007 without prevalent stroke at baseline. The main outcome was incident ischemic stroke ascertained by telephone surveillance (with physician adjudication for suspected events). Proportional hazards regression was used to assess the sex-specific association between systolic blood pressure and stroke and between classes of antihypertensive medications and stroke after adjustment for age, race, sex, and age-by-race and sex-by-treatment interaction terms. A priori, P<0.10 was considered significant for interactions. Among participants (55.4% women, 40.2% black), there were 1084 confirmed ischemic stroke events. In the adjusted model, the risk of stroke per each level of hypertension (referent/systolic blood pressure <120 mm Hg/120–129 mm Hg/130–139 mm Hg/>140 mm Hg) was higher in women (hazard ratio, 1.25; 95% CI, 1.16–1.34) than men (hazard ratio, 1.14; 95% CI, 1.05–1.23; sex–systolic blood pressure interaction term, P=0.09). Compared with no medications, with each additional class of medications, stroke risk increased by 23% (hazard ratio, 1.23; 95% CI, 1.14–1.33) for women and 21% (hazard ratio, 1.21; 95% CI, 1.12–1.31) for men (P=0.79). Further work on the biological mechanisms for sex differences in stroke risk associated with hypertension severity and a need for sex-specific clinical guidelines may be warranted.
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