Burden Of Cerebrovascular Disease Research Articles

The national burden of cerebrovascular diseases in Spain: A population-based study using disability-adjusted life years

Background and objectiveThe aim of the present study was to determine the national burden of cerebrovascular diseases in the adult population of Spain. Patients and methodsCross-sectional, descriptive population-based study. We calculated the disability-adjusted life years (DALY) metric using country-specific data from national statistics and epidemiological studies to obtain representative outcomes for the Spanish population. DALYs were divided into years of life lost due to premature mortality (YLLs) and years of life lived with disability (YLDs). DALYs were estimated for the year 2008 by applying demographic structure by sex and age-groups, cause-specific mortality, morbidity data and new disability weights proposed in the recent Global Burden of Disease study. In the base case, neither YLLs nor YLDs were discounted or age-weighted. Uncertainty around DALYs was tested using sensitivity analyses. ResultsIn Spain, cerebrovascular diseases generated 418,052 DALYs, comprising 337,000 (80.6%) YLLs and 81,052 (19.4%) YLDs. This accounts for 1,113 DALYs per 100,000 population (men: 1,197 and women: 1,033) and 3,912 per 100,000 in those over the age of 65 years (men: 4,427 and women: 2,033). Depending on the standard life table and choice of social values used for calculation, total DALYs varied by 15.3% and 59.9% below the main estimate. ConclusionsEstimates provided here represent a comprehensive analysis of the burden of cerebrovascular diseases at a national level. Prevention and control programmes aimed at reducing the disease burden merit further priority in Spain.

Abstract T P310: The Acute Carotid Clinic: A Paradigmatic Shift to Facilitate Reduced Wait Times for Carotid Artery Stenting in Ontario

Introduction: North American guidelines on stroke prevention recommend carotid artery revascularization for symptomatic carotid disease within 2 weeks of the index event. Achieving this benchmark has proven historically challenging in the context of the universal coverage afforded by the Ontario Health Insurance Plan (OHIP), which is the sole provider of healthcare in Ontario (approximately 13.5 million people). Recent literature has indicated that wait times for carotid revascularization are unacceptably high. We sought to examine how the implementation of a dedicated Acute Carotid Clinic (ACC) in a Canadian academic stroke center would impact this public health dilemma. Methods: Retrospective analysis was preformed on 48 consecutive patients with symptomatic carotid artery disease who underwent endovascular treatment (carotid stenting) via the Acute Carotid Clinic’s expedited evaluation process over a 13-month period (July 2012 to July 2013). All patients were triaged based on direct physician referral with concurrent vascular imaging demonstrating high-grade carotid stenosis in the appropriate vessel. Patients were not placed on wait lists, and seen urgently. Results: The average time from consultation to revascularization was under 1 week (mean time 6.7 days). Historical controls of average wait times in Ontario for Carotid Endartarectomy have been previously published at 25.7 days. The percentage of patients who achieved revascularization within 2 weeks of the index event was 38%. Previously published series from Ontario for Carotid Endartarectomy showed 8 to 30% of patients were revascularized within 2 weeks of the index event. Conclusion: The paradigm of an Acute Carotid Clinic could allow for the rapid triage, assessment, and treatment of symptomatic carotid disease for the 13.5 million residents of Ontario. Adoption of this paradigm by other centers in Ontario could significantly reduce the burden of cerebrovascular disease in the province. Further research and government wide initiatives could be aimed at increasing the awareness of referring physicians to this expedited evaluation process.

Abstract W MP102: Disparities in Access to Primary Stroke Centers: Geography, Not Gender, Race, or Ethnicity

Background: Primary Stroke Centers (PSCs) have lower mortality than non-PSCs. Disparities in access to PSCs could widen existing disparities in cerebrovascular disease. We examined whether the proportion of the US population with ≤ 60 minute access to PSCs varies based on geography, gender, race, or ethnicity. Methods: A cross-sectional geographic analysis of the US was conducted at the block group level (n=208,667). Prehospital time from the population weighted center of each block group to the nearest PSC (as of 12/31/10) via ground ambulance was estimated using validated prehospital time intervals and accounting for existing road networks. Neilsen-Claritas 2010 Census estimates were used to describe the population of each block group. The population with ≤ 60 minute access was calculated overall, and stratified by urbanicity (major cities, minor cities, suburbs, rural). Access was compared by stroke belt location (AL, AR, GA, LA, MS, NC, SC, TN vs. all other states), gender, race, and ethnicity. Results: There were 811 PSCs in the US on 12/31/2010. Of the 309 million people in the US, 65.8% had ≤ 60 minute PSC access by ground ambulance. The proportion of the population with PSC access ≤ 60 minutes was: 87% in major cities, 59% in minor cities, 9% in suburbs, and 1% in rural areas. PSC access was lower in stroke belt states, due to poor access in stroke belt cities (Table). Non-White and Hispanic individuals were more likely to have PSC access than Whites and non-Hispanics; there was no meaningful difference in access by gender (Table). Conclusions: There are significant geographic and demographic disparities in access to PSCs. Access is poor in suburban and rural areas. Despite the higher burden of cerebrovascular disease in stroke belt states, access to care is lower in these areas. Public policy and systems planning is needed to ensure acute stroke therapies are available in these areas.

Abstract 93: Adherence to Mediterranean Diet and Prediction of Incident Stroke

Background&Purpose: There are limited diet regarding the potential association of adherence to Mediterranean Diet (MeD) with incident stroke. We sought to determine longitudinally the relationship between higher adherence to Mediterranean diet and lower likelihood of incident stroke before and after controlling for factors that are independently related to cerebrovascular disease burden by capitalizing on the large, geographically dispersed, race- and gender-balanced sample of REGARDS subjects. Subjects&Methods: A prospective, population-based, cohort of individuals enrolled in REGARDS Study was evaluated after excluding participants with history of stroke and missing data with respect to demographic, cognitive or food intake variables. Adherence to a MeD was computed from Food Frequency Questionnaires (FFQ) and was categorized as high, moderate and low using MeD-score tertiles (MeD-score: 6-9, 4-5 & 0-3 respectively). The main outcome of the present analyses was incident stroke that had been diagnosed by a committee of trained clinicians during a mean follow-up period of 5 years. The association of adherence to MeD with incident stroke (ischemic and hemorrhagic) was evaluated using a set of incremental logistic regression models. Results: Incident stroke was identified in 565 (1.9%; 497 cases of ischemic and 68 cases of hemorrhagic stroke) out of 30,239 individuals fulfilling the inclusion criteria. After adjusting for age, race, region, gender, income, education, total energy, smoking status, sedentary behavior, body mass index, waist circumference and vascular risk factors, low adherence to MeD was associated with a higher likelihood of incident ischemic stroke (OR versus high adherence: 1.29; 95%CI:0.99-1.67; p=0.057). A similar relationship was documented for moderate adherence to MeD (OR versus high adherence: 1.25; 95%CI:0.98-1.58; p=0.079). We documented no association of adherence to MeD with incident hemorrhagic stroke (p=0.38). There was no interaction of race (p=0.38) on the association of adherence to MeD with incident ischemic stroke. Conclusions: Low adherence to MeD was associated with a higher likelihood of incident ischemic stroke independent of numerous potential confounders.

Worldwide Reported Use of IV Tissue Plasminogen Activator for Acute Ischemic Stroke

Intravenous tissue plasminogen activator is the most effective treatment for acute ischemic stroke, and its use may therefore serve as an indicator of the available level of acute stroke care. The greatest burden of stroke is in low- and middle-income countries, but the extent to which intravenous tissue plasminogen activator is used in these countries is unreported. A systematic review was performed searching each country name AND 'stroke' OR 'tissue plasminogen activator' OR 'thrombolysis' using PubMed, Embase, Global Health, African Index Medicus, and abstracts published in the International Journal of Stroke (Jan. 1, 1996-Oct. 1, 2012). The reported use of intravenous tissue plasminogen activator was then analyzed according to country-level income status, total expenditure on health per capita, and mortality and disability-adjusted life years due to stroke. There were 118,780 citations reviewed. Of 214 countries and independent territories, 64 (30%) reported use of intravenous tissue plasminogen activator for acute ischemic stroke in the medical literature: 3% (1/36) low-income, 19% (10/54) lower-middle-income, 33% (18/54) upper-middle-income, and 50% (35/70) high-income-countries (test for trend, P < 0.001). When considering country-level determinants of reported intravenous tissue plasminogen activator use for acute ischemic stroke, total healthcare expenditure per capita (odds ratio 3.3 per 1000 international dollar increase, 95% confidence interval 1.4-9.9, P = 0.02) and reported mortality rate from cerebrovascular disease (odds ratio 1.02, 95% confidence interval 0.99-1.06, P = 0.02) were significant, but reported disability-adjusted life years from cerebrovascular diseases and gross national income per capita were not (P > 0.05). Of the 10 countries with the highest disability-adjusted life years due to stroke, only one reported intravenous tissue plasminogen activator use. By reported use, intravenous tissue plasminogen activator for acute ischemic stroke is available to some patients in approximately one-third of countries. Access to advanced acute stroke care is most limited where the greatest burden of cerebrovascular disease is reported.

Blood pressure control and primary prevention of stroke: summary of the recent clinical trial data and meta-analyses.

Stroke is the second most common cause of death worldwide and of adult disability, but in the near future the global burden of cerebrovascular diseases will rise due to ageing and adverse lifestyle changes in populations worldwide. The risk of stroke increases at blood pressure levels above 115/75 mm Hg and high blood pressure (BP) is the most important modifiable risk factor for stroke, associated with 54 % episodes of stroke worldwide. There is strong evidence from clinical trials that antihypertensive therapy reduces substantially the risk of any type of stroke, as well as stroke-related death and disability. The risk attributed to BP is associated not only with absolute values but also with certain parameters describing BP diurnal pattern as well as short-term and long-term variability. Many studies reported that certain features of BP like nocturnal hypertension, morning surge or increased variability predict an increased stroke risk. However, there is no accepted effective modality for correction of these disturbances (chronotherapy, certain classes of antihypertensive drugs). In the elderly, who are mostly affected by stroke, the primary prevention guidelines recommend treatment with diuretics and calcium channel blockers to lower blood pressure to the standard level.

APOE genotype and MRI markers of cerebrovascular disease

We aimed to examine the association of APOE ε genotype with MRI markers of cerebrovascular disease (CVD): white matter hyperintensities, brain infarcts, and cerebral microbleeds. We performed a systematic review and meta-analysis of 42 cross-sectional or longitudinal studies identified in PubMed from 1966 to June 2012 (n = 29,965). This included unpublished data from 3 population-based studies: 3C-Dijon, Framingham Heart Study, and Sydney Memory and Ageing Study. When necessary, authors were contacted to provide effect estimates for the meta-analysis. APOE ε4 carrier status and APOE ε44 genotype were associated with increasing white matter hyperintensity burden (sample size-weighted z score meta-analysis [meta]-p = 0.0034 and 0.0030) and presence of cerebral microbleeds (meta odds ratio [OR] = 1.24, 95% confidence interval [CI] [1.07, 1.43], p = 0.004, and 1.87 [1.26, 2.78], p = 0.002), especially lobar. APOE ε2 carrier status was associated with increasing white matter hyperintensity load (z score meta-p = 0.00053) and risk of brain infarct (meta OR = 1.41[1.09, 1.81], p = 0.008). APOE ε4 and APOE ε2 were associated with increasing burden in MRI markers for both hemorrhagic and ischemic CVD. While the association of APOE ε4 with an increased burden of CVD could be partly contributing to the relationship between APOE ε4 and AD, APOE ε2 was associated with MRI markers of CVD in the opposite direction compared to AD.

Cerebrovascular disease in South Asia - Part II: Risk factors and prevention.

In South Asian countries, conventional vascular risk factors like hypertension, diabetes mellitus, cardiac disease, smoking, obesity, atrial fibrillation are the dominant ones, while other aetiologies like rheumatic heart disease, infective meningitis-related infarcts and postpartum cerebral venous thrombosis also constitute a big fraction. This review discusses the evidence of prevalence of various risk factors in South Asian countries and possible measures to combat the rising burden of cerebrovascular disease. The last part of the review discusses prevention and identification of risk factors that are unique to or especially found in patient population of South Asia.

Natural vs. Drug-Modified Cholesterol Levels and the Incidence of Ischemic Stroke (P06.228)

Objective: To determine whether naturally low LDL and high HDL levels are associated with a lower incidence of first-time ischemic stroke compared to drug-modified low LDL and high HDL levels. Background High LDL and low HDL levels have been associated with a higher risk of ischemic stroke. However, most studies investigating this relationship are a subset of drug clinical trials where variation in cholesterol levels is considered only as a factor in drug-related reduction of stroke incidence. Clinical observation reveals that patients with a very low burden of cerebrovascular disease share low LDL and high HDL levels and, frequently, these patients are not taking any cholesterol-modifying drug. Design/Methods: In this cross-sectional study we included patients 55 years or older admitted to an academic institution with a diagnosis of ischemic stroke (stroke) or any other diagnosis (control) and who had MRI brain with diffusion-weighted and T2/FLAIR sequences. We excluded patients who had negative DWI (stroke group) or T2/FLAIR lesions suggestive of previous stroke as well as patients with a reported history of stroke. Univariate analysis and logistic regression were performed for statistical analysis. Results: Older age, hypertension, atrial fibrillation, higher LDL and triglycerides levels were associated with increased incidence of ischemic stroke in the univariate analysis. In the logistic regression analysis, after matching LDL values and age, patients who were on cholesterol-modifying drugs had a lower incidence of ischemic stroke compared to patients who weren9t. After dividing LDL levels in 3 groups, the preventive effect of not being on a cholesterol-modifying drug was strong and significant in the group with the lowest LDL values ( Conclusions: Patients in the group with the lowest LDL-cholesterol who are not on a cholesterol-modifying drug (i.e who have naturally low LDL-cholesterol) have a lower incidence of first-time ischemic stroke compared to patients who have drug-modified low LDL-cholesterol levels. Disclosure: Dr. Osorio Flores has nothing to disclose. Dr. Venkatesh has nothing to disclose.

Antipsychotic Use Is Not Associated with an Increased Burden of Cerebrovascular Pathology at Autopsy (S04.004)

Objective: Assess the correlations between antipsychotic medication use in elderly dementia persons with neuropathological outcomes data, including cerebrovascular disease (CVD) pathology. Background A 2006 FDA-issued black box indicated that elderly patients with dementia treated with antipsychotics are at an increased risk of death, primarily from vascular complications (myocardial infarction and stroke) and infections (pneumonia). Despite the profound impact this warning has had on the field, the cerebrovascular consequences of antipsychotic use in dementia remain poorly understood. Design/Methods: We identified all subjects with a history of dementia related psychosis treated with antipsychotic agents (DPAP; n=32) in the University of Kentucky Alzheimer9s Disease Center Brain Bank. Control subjects were placed in two cohorts matched for age, gender, apoe, education and MMSE including subjects with dementia but no psychosis or antipsychotic medication (DNPNAP group; n=32), and subjects with dementia and psychosis but no antipsychotic medication (DPNAP group; n=32). Demographic, clinical, genetic, and neuropathological features were compared between groups. Results: Comparative analysis of vascular risk factors (hypertension, hyperlipidemia, myocardial infarction, smoking, diabetes mellitus, cardiac arrhythmia, and Hachinski scores) revealed no significant between group differences. Clinical diagnoses including Alzheimer9s, Lewy-Body, frontotemporal, and vascular dementia did not differ between groups. Cause of death including myocardial infarction, stroke, and pneumonia did not differ between groups (p=0.73, χ2 test). Braak, CERAD, amyloid angiopathy, and Lewy body scores supported the diagnoses of moderate to severe dementia in the majority of cases (86%), but did not differ between groups. No statistically significant differences were found between the 3 groups for degree of atherosclerosis (p=0.25) or lacunar (p=0.34), micro- (p= 0.67), hemorrhagic (p= 0.81), or macro (p= 0.90) infarcts. Conclusions: Antipsychotic medication use is not associated with increased burden of cerebrovascular disease on neuropathological examination. Future studies investigating causal relationship between antipsychotic use and increased risk of death in dementia patients is warranted. Disclosure: Dr. Singhal has nothing to disclose. Dr. Abner has nothing to disclose. Dr. Schmitt has nothing to disclose. Dr. Nelson has nothing to disclose. Dr. Jicha has received personal compensation for activities with Pfizer Inc, Janssen Immunotherapy, and Eli Lilly & Company. Dr. Jicha has received research support from Baxter, Janssen, Pfizer Inc, Medivation, and Danone.

Abstract 2585: Disparities in Evaluation by Certified Primary Stroke Centers within the REGARDS cohort

Background: There are known disparities in stroke incidence and mortality on the basis of race, income, region, and population density. Disparate access to specialized stroke care may contribute to these disparities. We sought to evaluate access to Joint Commission certified primary stroke centers (PSC) by race, education, income, population density, and region within the REGARDS cohort. Methods: The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is a prospective population-based cohort of adults 45 years or older. 30,239 participants were recruited between 1 2003 and October 2007. Participants are contacted at 6 month intervals to ascertain suspected stroke events. The analysis was limited to the first suspected stroke event for each subject between 12/9/2005 and 1/6/2011. Medical records were retrieved and we determined if the evaluating hospital was a certified PSC at the time of the event. Region was dichotomized to stroke-belt or non-belt. Population density was dichotomized to urban or non-urban. Subjects evaluated at a PSC were compared to those evaluated at a non-PSC. Multivariable regression was used to determine independent predictors of PSC evaluation. Results: There were 1000 suspected stroke events during the study interval, of which 204 were evaluated at a certified PSC. Women were less likely to be evaluated at a PSC than men, 17.8% vs 23.0% (p=0.04). Subjects with a history of stroke were less likely to be evaluated at a PSC than those without a history of stroke, 15.1% vs 21.6% (p=0.04). Subjects who reside in non-urban locations were less likely to be evaluated at a PSC than those in urban areas, 9.1% vs 23.9% (p&lt;0.001). Subjects residing within the stroke belt were less likely to be evaluated at a PSC than those living in other regions, 14.7% vs 27.3% (p&lt;0.001). In the univariate analyses, no disparities were found on the basis of race, education, or income. In the multivariable analysis, living in non-urban areas (OR 2.6, 95% CI 1.5-4.5), living within the stroke belt (OR 1.9, 95% CI: 1.3-2.7), and having a prior history of stroke (OR 2.2, 95% CI 1.3-3.7) predicted evaluation at non-certified hospitals. Conclusion: Disparities in evaluation by certified PSC’s are related to geographic factors, region and population density, but not to most individual characteristics including race, education, or income. Despite an increased burden of cerebrovascular disease in the stroke belt and in rural areas, subjects in these areas were less likely to be treated at certified hospitals. This may be attributable to a reduced number of stroke centers in these locations. Public policy and systems planning should ensure specialized stroke care is rapidly accessible in areas with the greatest need.

Obesity Paradox and Stroke

See related articles, pages 3397 and 3646. Obesity has a well-known association with initial incidence of cardiovascular disease, stroke, cancer, and early death. However, a growing number of studies have found that overweight and frankly obese patients who survive the first event tend to have improved subsequent cardiovascular (CVD)1,2 and cerebrovascular disease burden,3,4 morbidity, and mortality. The idea that a known risk factor somehow transforms into a “protective” agent after an occurrence of a vascular clinical event—the obesity paradox—is both surreal and troubling. Should we conclude that our advice of weight loss as the yellow brick road of secondary stroke prevention (for those with above-normal body mass index [BMI]) causes actual harm? First, the definition and measurement of obesity, techniques of statistical analysis, and the various effects of the initial cerebrovascular event on the patients' weight all deserve a closer look. The article by Ovibagele et al5 is the latest study in assessing the link between obesity and recurrent vascular events in stroke survivors. The data from the PRoFESS (Prevention Regimen for Effectively Avoiding Second Strokes Trial) was reviewed with 20 246 subjects being stratified by their BMI measurements and waist circumference. The groups had some important differences: the obese subjects were younger and had a higher proportion of women but a smaller percentage of smokers. They were also more likely to have a lacunar stroke and a greater likelihood of carrying a diagnosis of diabetes, hyperlipidemia, or hypertension, and of taking antihypertensive drugs. Despite differences in the diagnosis of hypertension, the baseline median blood pressure levels were comparable between obese and nonobese subjects. After adjusting for common confounders, the authors found no statistically significant difference in the recurrence of stroke for lean (9.06%), overweight (8.82%), and obese (8.89%) groups over 2.5-year …

Mediterranean diet and magnetic resonance imaging–assessed cerebrovascular disease

Cerebrovascular disease is 1 of the possible mechanisms of the previously reported relationship between Mediterranean-type diet (MeDi) and Alzheimer's disease (AD). We sought to investigate the association between MeDi and MRI infarcts. High-resolution structural MRI was collected on 707 elderly 65 years or older community residents of New York with available dietary assessments administered an average of 5.8 years (3.22 standard deviations [SDs]) before the MRI. Participants were divided into 3 groups of adherence to MeDi (low, middle, and high tertiles). We examined the association of increasing adherence to MeDi with presence of infarcts on MRI. Models were run without adjustment, adjusted for basic demographic and clinical factors, and adjusted for vascular risk factors. A total of 222 participants had at least 1 infarct. In the unadjusted model, compared to the low adherence group, those in the moderate MeDi adherence group had a 22% reduced odds of having an infarct (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.55-1.14), while participants in the highest MeDi adherence group had a 36% reduced odds (OR, 0.64; 95% CI, 0.42-0.97; p for trend = 0.04). In adjusted models, the association between MeDi adherence and MRI infarcts remained essentially unchanged. The association of high MeDi adherence with infarcts was comparable to that of hypertension (40% reduced probability), did not vary by infarct size or after excluding patients with dementia (n = 46) or clinical strokes (n = 86). There was no association between MeDi and white matter hyperintensities. Higher adherence to the MeDi is associated with reduced cerebrovascular disease burden.

Poststroke dementia—an underestimated burden?

The burden of cerebrovascular disease is thought to be greater than current official estimates. A new systematic review shows that a history of stroke is associated with an increased risk of incident dementia in the elderly. The findings also highlight the confusion in the classification of dementia and the need for more recognition of vascular-related cognitive disorders.

The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study

BackgroundThe burden of cerebrovascular disease in developing countries is rising sharply. The prevalence of established risk factors of stroke is exceptionally high in Pakistan. However, there is limited data on the burden of stroke and transient ischemic attack (TIA) in South Asia. We report the first such study conducted in an urban slum of Karachi, Pakistan.MethodsIndividuals 35 years of age or older were invited for participation in this investigation through simple random sampling. A structured face-to-face interview was conducted using a pre-tested stroke symptom questionnaire in each participant to screen for past stroke or TIA followed by neurological examination of suspected cases. Anthropometric measurements and random blood glucose levels were recorded. Multivariable logistic regression was used to determine the association of vascular risk factors with prevalence of stroke.ResultsFive hundred and forty five individuals (49.4% females) participated in the study with a response rate of 90.8%. One hundred and four individuals (19.1%) were observed to have a prior stroke while TIA was found in 53 individuals (9.7%). Overall, 119 individuals (21.8% with 66.4% females) had stroke and/or TIA. Female gender, old age, raised random blood glucose level and use of chewable tobacco were significantly associated with the prevalence of cerebrovascular disease.ConclusionThis is the first study demonstrating an alarmingly high life-time prevalence of cerebrovascular disease in Pakistan. Individual and public health interventions in Pakistan to increase awareness about stroke, its prevention and therapy are warranted.

The influence of stroke unit care to mortality and morbidity outcomes in patients surviving first ischemic stroke

Background Centralized treatment of patients with acute stroke on specific unit should reduce the global burden of cerebrovascular diseases. We aimed to establish the mortality, recurrence, neurological impairment and quality of life outcomes in stroke patients regarding to stroke unit hospitalisation. Methods 581 patients (mean age 66.8±9.2, 36.9% of females; the Czech sample of EuroAspire-stroke study) hospitalized between 1.9.2003 and 31.8.2006 for first ischemic stroke in two centers were included into the long-term follow-up.

MOST STROKE PATIENTS DO NOT GET A WARNING: A POPULATION-BASED COHORT STUDY

In longitudinal studies with active outcome surveillance, the 3-month risk of stroke after TIA is approximately 17%.1 Recent reports suggest that expedient management of TIA can reduce this risk by as much as 80%.2,3 For such a strategy to have a major impact on the burden of cerebrovascular disease in the general population, stroke with preceding TIA must be a relatively common occurrence. Using data from the Registry of the Canadian Stroke Network (RCSN), we sought to ascertain the frequency, characteristics, and outcomes of acute stroke patients with a prior TIA. ### Methods. We prospectively identified consecutive patients with a final diagnosis of acute stroke admitted to 12 Ontario hospitals through data recorded in the RCSN (accrual interval July 1, 2003, to September 30, 2007). Chart validation studies have shown excellent agreement with the RCSN database, with duplicate data abstraction performed on a random sample of 10% of charts. Patients with in-hospital strokes (n = 78) or unknown final diagnosis (n = 615) were excluded. Further details regarding the RCSN have been published …

Mediterranean Diet and Late-Life Cognitive Impairment

Mediterranean Diet and Late-Life Cognitive Impairment

Angiotensin Receptor Blockers Should Be Regarded as First-Line Drugs for Stroke Prevention in Both Primary and Secondary Prevention Settings

Geoffrey A. Donnan MD, FRACP Stephen M. Davis MD, FRACP Section Editors: Each year, stroke is responsible for 5.5 million deaths worldwide and the loss of >49 million disability-adjusted life-years. Interventions that effectively and efficiently prevent stroke therefore exert major economic, societal, and personal impact. An important modifiable risk factor for stroke is blood pressure, abnormal levels of which account for 54% of the worldwide burden of cerebrovascular disease.1 Unequivocal evidence supports blood pressure-lowering for preventing stroke both in primary and secondary prevention settings. Although most systematic reviews, including the series of analyses produced by the Blood Pressure Lowering Treatment Trialists’ Collaboration, suggest that all major classes of …

Disparities in carotid revascularisation procedures exceed disparities in cerebrovascular disease burden among people with diabetes of south Asian and chinese origin

Disparities in carotid revascularisation procedures exceed disparities in cerebrovascular disease burden among people with diabetes of south Asian and chinese origin