Incidence Rate Of Stroke Research Articles

Temporal Trends and Determinants of Stroke Risk in Patients With Medically Treated Asymptomatic Carotid Stenosis.

Effectiveness of carotid procedures (surgery and stenting) in patients with asymptomatic carotid artery stenosis (ACAS) depends on the absolute risk reduction that patients might receive from these procedures. We aimed to quantify the risk of ipsilateral ischemic stroke and examined temporal trends and determinants of these risks in patients with ACAS treated conservatively. We conducted a systematic review from inception to March 9, 2023, of peer-reviewed trials and cohort studies describing ipsilateral ischemic stroke risk in medically treated patients with ACAS of ≥50%. Risk of bias was assessed with an adapted version of the Quality in Prognosis Studies tool. We calculated the annual incidence rates of ipsilateral ischemic stroke. We explored temporal trends and associations of sex and degree of stenosis with ipsilateral ischemic stroke using Poisson metaregression analysis and incidence rate ratios, respectively. After screening 5915 reports, 73 studies describing ipsilateral ischemic stroke rates of 28 625 patients with midyear of recruitment ranging from 1976 to 2014 were included. The incidence of ipsilateral ischemic stroke was 0.98 (95% CI, 0.93-1.04) per 100 patient-years (median duration of follow-up, 3.3 years). The incidence decreased 24% with every 5 years more recent midyear of recruitment (rate ratio, 0.76 [95% CI, 0.73-0.78]). Incidence rates of ipsilateral ischemic stroke were lower in female patients (rate ratio, 0.74 [95% CI, 0.63-0.87]) and in patients with moderate versus severe stenosis when assessed in cohort studies, with incidence rate ratios of 0.41 ([95% CI, 0.35-0.49] cutoff, 70%) and 0.42 ([95% CI, 0.30-0.59] cutoff, 80%). Reported risks of ipsilateral ischemic stroke in patients with ACAS have declined 24% every 5 years from mid-1970s onward, further challenging the routine use of carotid procedures. Risks were lower in female patients and more than twice as high with severe compared with moderate ACAS. Inclusion of these findings in individualized risk assessment can help to determine the benefit of carotid procedures in selected individual patients with ACAS. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021222940.

Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015.

We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015. Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time. The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)]. Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

Implications of decreasing incidence of dementia in some countries during 1990‐2019: A global burden of disease study

AbstractBackgroundStroke and dementia share the same risk and protective factors and pose risks for each other, consequently they are considered together. Their prevalence is rising, making them the most burdensome neurological diseases worldwide. However, their incidence is falling in some countries. It becomes imperative to find out what is happening or being done right in these countries and help apply the lessons widely.MethodWe analyzed systematically trends of changes in age‐standardized dementia and stroke incidence rate per 100,000 population in 204 countries from 1990 to 2019 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. We also calculated the changes in the age‐standardized population attributable fraction (PAF) of dementia and stroke burden, measured by disability‐adjusted life years (DALYs), and deaths attributed to 12 risk factors with 95% uncertainty intervals (UIs).ResultFrom 1990 to 2019, dementia incidence declined in 71 countries, of which 18 showed statistically significant declines, ranging from ‐12.1% (95% UI ‐16.9 to ‐6.8) to ‐2.4% (‐4.6 to ‐0.5). However, from 2010 to 2019, only 16 countries showed declines, although non‐statistically significant. The PAF of global dementia DALYs attributable to metabolic risk factors increased by 25.3% (16.9 to 38.9) from 1990 to 2019, while it decreased for behavioral risk factors by ‐17.3% (‐22.8 to ‐13.0). In particular, 163 countries showed declines in the PAF of dementia DALYs attributable to tobacco use, and 160 countries in dementia mortality attributable to high fasting plasma glucose.ConclusionThe declining incidence of dementia in some countries, despite the growing and aging population is encouraging and urges further investigation. This approach would complement and enhance the search for a drug against Alzheimer’s disease pathology. Finding out what accounts for the decline of dementia in some countries and scaling up the lessons could begin having an impact in the near future.

Temporal trends in the incidence of atrial fibrillation‐related strokes in Sweden, 2001‐2020

AbstractBackgroundAtrial fibrillation (AF) increases the risk of stroke, which in turn elevates the risk of dementia in old age. Thus, changes in the incidence of stroke over time could greatly affect population brain health. The prevalence of AF is increasing worldwide, but how this impacts the incidence of stroke is unclear. We aimed to provide an up‐to‐date estimate on the temporal trends in the incidence of AF‐related stroke in Sweden during the period 2001‐2020.MethodData from the total Swedish population aged ≥60 years during the period 2001‐2020 were used. First‐ever stroke and AF diagnoses were identified through hospital admissions and deaths in the national health registers. AF‐related stroke is defined as stroke event with documented AF diagnosis within 5 years before the event, at the time of event, or within 2 months after the event.ResultThe annual incidence rate of overall stroke declined substantially in both men and women during 2001‐2020 (incidence rate [IR] 2001 vs. 2020 = 153.0 vs. 87.7 for men; 134.7 vs. 72.1 for women). There was only a slight decline in the incidence rate of AF‐related stroke (IR 2001 vs. 2020 = 32.0 vs. 28.3 for men; 30.6 vs. 21.9 for women). The strength of the association between AF and incident stroke also decreased over time. In men, AF was associated with a hazard ratio (HR) of 1.56 (confidence interval [CI]: 1.50‐1.62) for incident stroke in 2006‐2008 as compared to a HR of 1.46 (CI: 4.41‐1.52) in 2015‐2017. In women, the HR for incident stroke associated with AF is 2.15 (CI: 2.08‐2.22) in 2006‐2008 and 1.76 (CI: 1.69‐1.82) in 2015‐2017. On the other hand, the percentage of AF‐related strokes out of all strokes increased during 2001‐2020, from 21.8% to 33.6% for men and from 23.5% to 31.6% for women.ConclusionThe incidence of AF‐related strokes among people 60 years and over declined in Sweden during 2001‐2020, and so did the strength of the association between AF and risk of stroke. On the other hand, the percentage of AF‐related strokes out of all strokes increased over time, and one‐third of strokes were AF‐related by the end of 2020.

The Positive Predictive Value of Pediatric Stroke Diagnoses in Administrative Data: A Retrospective Validation Study.

This retrospective cohort study aimed to examine the positive predictive value (PPV) of pediatric stroke diagnoses in the Danish National Registry of Patients (DNRP) and the impact of different stroke definitions on the PPV. We included children registered with a stroke or stroke-related diagnosis in the DNRP between January 2017 through December 2020. Two assessors reviewed medical records and validated cases according to the American Heart and American Stroke Association (AHA/ASA) stroke definition. The level of interrater agreement was examined using kappa statistics. Validation by the AHA/ASA definition was compared with validation according to the definition in the International Classification of Disease 11th version (ICD-11) and the World Health Organization's definition. Stroke was confirmed in 120 of 309 included children, yielding an overall PPV of 0.39 (95% CI: 0.33-0.45). PPV varied across stroke subtypes from 0.83 (95% CI: 0.71-0.92) for ischemic stroke (AIS), 0.57 (95% CI: 0.37-0.76) for unspecified stroke, 0.42 (95% CI: 0.33-0.52) for intracerebral hemorrhage (ICH) to 0.31 (95% CI: 0.55-0.98) and 0.07 (95% CI: 0.01-0.22) for cerebral venous thrombosis and subarachnoid hemorrhage (SAH), respectively. Most non-confirmed ICH and SAH diagnoses were in children with traumatic intracranial hemorrhages (36 and 66% respectively). Among 70 confirmed AIS cases, 25 (36%) were identified in non-AIS code groups. PPV varied significantly across stroke definitions with the highest for the AHA/ASA definition (PPV = 0.39, 95% CI: 0.34-0.45) and the lowest for the WHO definition (PPV = 0.29, 95% CI: 0.24-0.34). Correspondingly, the incidence of pediatric AIS per 100.000 person-years changed from 1.5 for the AHA/ASA definition to 1.2 for ICD-11 and 1.0 for the WHO-definition. The overall interrater agreement was considered excellent (κ=0.85). After validation, stroke was confirmed in only half of the children registered in the DNRP with a stroke-specific diagnosis. Non-validated administrative data should be used with caution in pediatric stroke research. Pediatric stroke incidence rates may vary markedly depending on which stroke definition is used.

Does inclusion of cognitive measures improve the predictive performance of SCORE2 for future cardiovascular events in older adults?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): National Institute for Research of Metabolic and Cardiovascular Diseases (Programme EXCELES, ID Project No. LX22NPO5104) - Funded by the European Union – Next Generation EU. Introduction The cardiovascular disease (CVD) risk prediction model SCORE2 uses several biomedical and behavioural factors. It is likely that other factors also contribute to CVD risk prediction. Cognitive impairment and CVD are associated and share several risk factors. While the causality of this relationship remains unclear, adding cognitive measures to risk prediction may improve the prediction of future CVD events. Objective We tested the hypothesis that including simple measures of cognitive functions improve the prediction of SCORE2 for future CVD events among middle aged and older subjects. Methods We used data on 13,391 Polish, Lithuanian and Czech adults without CVD at baseline (45–69 years) from the Health, Alcohol and Psychosocial factors In Eastern Europe cohort. Incident cases of myocardial infarction (MI), stroke, CVD mortality and composite (fatal and non-fatal) CVD events were identified over a 10-year follow-up. Baseline cognitive measures included immediate and delayed word recall (verbal memory and learning), animal naming (verbal fluency) and letter cancellation (attention, mental speed and concentration). Using competing-risks regression, relationships between cognitive functions and CVD outcomes were examined. Improvement in Area Under Curve Receiver Operator Characteristic (AUC-ROC) was used to compare predictive performance for CVD events of models including SCORE2 variables combined with cognitive tests vs SCORE2 alone. Results The incidence rates of MI, stroke, CVD mortality and composite CVD events were 5%, 4%, 4% and 11%, respectively. In multivariable analyses, all four cognitive measures were inversely associated with CVD outcomes; e.g. one standard deviation increase in immediate word recall score was associated with a 28% and 17% reduction in risk of CVD mortality and composite CVD events, respectively (all p-values <0.001). Adding cognitive measures to SCORE2 variables slightly improved the AUC-ROC for prediction of MI, CVD mortality and composite CVD events. For example, for the composite CVD measure, inclusion of all four cognitive measures increased the AUC-ROC from 0.6948 to 0.7030 (p<0.001) and similar improvement was seen for word recall. The results were consistent across countries. Conclusion Inclusion of a simple cognitive test in the assessment of cardiovascular health is feasible and it may improve prediction of future CVD risk, although in our data the improvement was not clinically important (despite being statistically significant). Further studies are needed to assess this proposition in larger prospective datasets.

Stroke burden and attributable risk factors in China, 1990-2019.

Understanding the temporal trends of stroke burden and its attributable risk factors are essential for targeted prevention strategies. We aimed to describe the temporal trends and attributable risk factors of stroke in China. Data on the stroke burden [incidence, prevalence, mortality, and disability-adjusted life years (DALYs)] and the population-attributable fraction for stroke risk factors from 1990 to 2019 were obtained from the Global Burden of Disease Study 2019 (GBD 2019). We analyzed trends in the burden of stroke and its attributable risk factors from 1990 to 2019, and the characteristics of stroke-attributable risk factors by sex, age group, and stroke subtype. From 1990 to 2019, the age-standardized incidence, mortality, and DALY rates for total stroke decreased by 9.3% (3.3, 15.5), 39.8% (28.6, 50.7), and 41.6% (30.7, 50.9) respectively. The corresponding indicators all decreased for intracerebral hemorrhage and subarachnoid hemorrhage. The age-standardized incidence rate of ischemic stroke increased by 39.5% (33.5 to 46.2) for male patients and by 31.4% (24.7 to 37.7) for female patients, and the age-standardized mortality and DALY rates remained almost unchanged. The three leading stroke risk factors were high systolic blood pressure, ambient particulate matter pollution, and smoking. High systolic blood pressure has remained the leading risk factor since 1990. The attributable risk of ambient particulate matter pollution shows a clear upward trend. Smoking and alcohol consumption were important risk factors for men. This study reinforced the findings of an increased stroke burden in China. Precise stroke prevention strategies are needed to reduce the disease burden of stroke.

Systolic, diastolic blood pressure and pulse pressure and risk of stroke in young aged patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background It is well-known that higher blood pressure (BP) is associated with a higher risk of stroke with atrial fibrillation (AF). However, there is limited data about the effect of systolic BP (SBP), diastolic BP (DBP), and pulse pressure (PP) on the risk of ischemic stroke in young and low-risk AF patients Methods Using the Korean Health Insurance Service database, patients who were newly diagnosed with AF between January 2009 and December 2016 and had health screening examination data within 2-year after AF diagnosis were included. Patients aged between 20 and 39 years were finally included in this analysis. During follow-up, incident ischemic stroke was evaluated as a primary outcome. Hazard ratio (HR) and the corresponding 95% confidence intervals (CI) were calculated using multivariable Cox proportional hazard models. Results A total of 15,980 patients were included in this analysis (mean age 32.4±4.8 years, 66.9% of men). Mean CHA2DS2-VASc score was 0.7±0.8 and oral anticoagulation rate was 5.6%. During a median 5.2-year of follow-up, 73 patients had an incident ischemic stroke (incidence rate, 0.9 per 1,000 person-years). After multivariable adjustment, SBP ranging from 140 to 159 mmHg and 160 mmHg or higher were associated with a significantly higher risk of ischemic stroke by 8.4-fold and 11.6-fold compared to SBP under 100 mmHg (Figure). DBP 95mmHg or higher was associated with a higher risk of ischemic stroke by 4.2-fold than DBP under 65 mmHg (Figure). Patients with PP ranging from 50 to 59 mmHg and 60 mmHg or higher showed a significantly higher risk of ischemic stroke than those with PP ranging from 40 to 49 mmHg (HR [95% CI]; 1.81 [1.04-3.18] and 3.15 [1.49-6.64], respectively). Also, lower PP than 30 mmHg was associated with a higher risk of stroke (3.96 [1.36-11.53]). Conclusion Optimal BP control might be crucial to preventing ischemic stroke in these young and low-risk AF patients.

Advances in anticoagulant therapy for cirrhosis combined with atrial fibrillation

Relevant research in recent years has demonstrated that the atrial fibrillation occurrence rate is significantly higher in patients with cirrhosis. The most common indication for long-term anticoagulant therapy is chronic atrial fibrillation. The use of anticoagulant therapy greatly reduces the incidence rate of ischemic stroke. Patients with cirrhosis combined with atrial fibrillation have an elevated risk of bleeding and embolism during anticoagulant therapy due to cirrhotic coagulopathy. At the same time, the liver of such patients will go through varying levels of metabolism and elimination while consuming currently approved anticoagulant drugs, thereby increasing the complexity of anticoagulant therapy. This article summarizes the clinical studies on the risks and benefits of anticoagulant therapy in order to provide a reference for patients with cirrhosis combined with atrial fibrillation.

Impacts of exposure to ambient temperature and altitude on the burden of stroke.

To evaluate the impact of ambient temperature and altitude exposure on the burden of stroke in a Chinese cohort. This study was conducted using data from the National Stroke High-Risk Population Screening System 2020, which assess the overall prevalence, incidence, and mortality rate of stroke in China. For this study, we obtained the annual mean ambient temperature, diurnal temperature range, and altitude for each city. Body mass index (BMI) of participants were calculated. The sample comprised 676,394 adults aged 40years or older from 170 cities in 31 provinces in China. A negative linear relationship between mean ambient temperature and stroke risk (incidence and prevalence) as well as a negative association between mean ambient temperature and stroke mortality had been found. A nonlinear relationship with decreased risk in both high and low diurnal temperature range is observed for stroke burden (incidence, prevalence, and mortality). There is no significant correlation between city altitude and stroke burden. The U-shaped relationships of BMI with the incidence and prevalence of stroke indicate that the lowest incidence and prevalence are observed when BMI is approximately 20. Overall, our study provides important insights into the environmental and individual factors that contribute to the burden of stroke in China, and may inform public health interventions aimed at reducing this burden.

Projected Global Trends in Ischemic Stroke Incidence, Deaths and Disability-Adjusted Life Years From 2020 to 2030.

We projected global trends in ischemic stroke from 2020 to 2030 according to age, sex, and socio-demographic index (SDI) quintile. Estimated annual percentage changes (EAPCs) were used to project trends in the incidence of deaths from and disability-adjusted life years (DALYs) due to ischemic stroke between 2020 and 2030. EAPCs were computed using generalized additive models and data from the Global Burden of Disease study during the 1990 to 2019 period. The global age-standardized incidence rate of ischemic stroke was projected to increase to 89.32 per 100 000 population in 2030 (EAPC=0.89), whereas the associated global age-standardized death and DALY rates were projected to decrease to 18.28 (EAPC, -3.58) and 500.37 per 100 000 (EAPC=-1.75), respectively, in 2030. The projections indicated a higher age-standardized incidence rate of ischemic stroke among women than among men in 2030 (90.70 versus 87.64 per 100 000). The incidence rate of ischemic stroke was projected to increase across all age groups and SDI quintiles between 2020 and 2030. At the national level, the greatest increase in the age-standardized incidence rate of ischemic stroke between 2020 and 2030 was projected to occur in Cyprus (EAPC=4.16), followed by Palestine (EAPC=3.50) and South Africa (EAPC=2.64). Additionally, the projections suggested increases in the age-standardized death and DALY rates due to ischemic stroke for countries in low-SDI quintiles (EAPC=3.68 and EAPC=5.30, respectively). The projections indicated that the incidence rate of ischemic stroke will increase both sexes, all age groups, and all SDI quintiles and in some countries between 2020 and 2030. Furthermore, countries with a low SDI should be aware of potential increases in the age-standardized death and DALY due to ischemic stroke.

Cardiovascular events after the initiation of immune checkpoint inhibitors

We sought to clarify the incidence of major adverse cardiac events (MACE) after the initiation of immune checkpoint inhibitors (ICIs). We analyzed the JMDC Claims Database between 2005 and 2021. The study included 2972 patients with no history of cardiovascular disease and a prescription for an ICI. The primary outcome was the incidence of MACE, including myocarditis, pericarditis, Takotsubo cardiomyopathy, atrio-ventricular block, heart failure, myocardial infarction, and stroke. The median age of study participants was 59 (Q1-Q3 53–65) years, and 2163 participants (72.8%) were male. Lung cancer was the most common cancer site (n = 1603). Among ICIs, programmed cell death-1 (PD-1) was most frequently used, and a combination ICI treatment was conducted in 110 patients (3.7%). During a mean follow-up of 358 ± 327 days, 419 MACE events were recorded. The incidence rate of myocarditis, pericarditis, Takotsubo cardiomyopathy, atrio-ventricular block, heart failure, myocardial infarction, and stroke was 3.4, 142.3, 10.3, 17.2, 1191.2, 55.2, and 278.5 per 10,000 person-years, respectively. The incidence of cardiovascular events was higher within 180 days after the initial prescription of ICI. The continuation rate of ICI after MACE was 38.4%. In conclusion, our analysis of a nationwide epidemiological dataset demonstrated the incidence of MACE after the initiation of ICI treatment. The incidence of heart failure was higher than expected, and the continuation rate of ICI treatment after MACE was low. Our results indicated the importance of monitoring and prevention of cardiovascular events in cancer patients requiring ICI treatment.

Incidence of Ischemic Stroke in US Veterans Living with Spinal Cord Injury: Preliminary Data (S3.005)

<h3>Objective:</h3> In this preliminary study, we estimate the 4-year incidence of ischemic stroke and associated risk factors in United States (US) Veterans living with spinal cord injuries and disorders (SCI/D). <h3>Background:</h3> People with SCI/D have been reported to have an elevated risk of ischemic stroke, based on a study in the population of Taiwan [Wu et al, Neurology. 2012;78:1051–1057]. This prior study reported a cumulative incidence rate of ischemic stroke of 1.9% over 4 years subsequent to SCI, vs 0.6% in matched non-injured controls. <h3>Design/Methods:</h3> We used Department of Veterans Affairs (VA) administrative databases to examine the incidence of ischemic stroke between fiscal years 2018–2021. Veterans living with strokes were identified using ICD-9 or 10 codes for cerebral infarction or sequelae of cerebral infarction. Veterans with diagnoses of ischemic strokes or sequelae during 2013–2017 were excluded. Statistical analyses included frequencies and multiple regression models. <h3>Results:</h3> From FY 2018–2021, 394 of 12,547 Veterans living with SCI had a newly-recorded ischemic stroke, reflecting a 4-year incidence of 3.14%, and an average annual incidence of 0.79%. Compared to Veterans with a D injury classification by the American Spinal Injury Association (ASIA) Impairment Scale, Veterans with high tetraplegia had a higher likelihood of ischemic stroke (IRR=1.91, 95% CI: 1.37 – 2.67). Compared to Veterans with traumatic SCI, Veterans with non-traumatic SCI/D also had a higher likelihood of ischemic stroke (IRR = 1.43, 95% CI: 1.13 – 1.80). <h3>Conclusions:</h3> US Veterans with SCI/D have a higher incidence of ischemic stroke than that reported for the Taiwanese population with SCI. Tetraplegia and a non-traumatic injury etiology seem to be SCI-centric risk factors. Further study will include comparison of stroke incidence to that of age- and sex-matched US Veterans without SCI. <b>Disclosure:</b> The institution of Dr. Willenberg has received research support from Dept of Veterans Affairs. The institution of Dr. Smith has received research support from Dept of Veterans Affairs . Kevin Stroupe has received research support from Department of Veterans Affairs. Dr. Sippel has nothing to disclose. Zhiping Huo has nothing to disclose. Dr. Sabharwal has received publishing royalties from a publication relating to health care.

The relationship of income on stroke incidence in Finland and China.

Stroke incidence has continued to increase recently in most countries. The roles of individual-level income on the incidence of overall stroke and its subtypes are still unknown, especially in low- and middle-income countries and the cross-national evidence is also limited. We explored the association between individual-level income and stroke incidence in Finland and China. Changde Social Health Insurance Database (N=571843) and Finnish population register (N=4046205) data were used to calculate standard stroke incidence rates, which were employed to assess the absolute incidence difference between income quintiles. Cox regression was used to compare income differences in first-ever stroke incidence. The highest income quintile had lower overall and subtype stroke incidence when compared to lower-income quintiles. The relative difference was more evident in hemorrhagic stroke incidence. After adjusting for age and employment status, the disparity of stroke incidence between the lowest and highest income quintiles was high among both men and women and in Finland and China. The disparity was particularly notable among men: in Finland, the hazard ratio (HR) for hemorrhagic stroke was 0.633 [95% confidence interval (95% CI) 0.576-0.696] and HR 0.572 (95% CI 0.540-0.606) for ischemic stroke. The respective figures were HR 0.452 (95% CI 0.276-0.739) and HR 0.633 (95% CI 0.406-0.708) for China. Individual-level income is related to overall and subtype stroke incidence. Future studies should explore the causal relationship between individual-level income and stroke incidence.

Percutaneous atrial shunt closure and the risk of recurrent ischemic stroke: A register-based, nationwide cohort study

ObjectivesWe aimed to investigate the risk of recurrent stroke in patients with transcatheter closure of an atrial shunt (ASCIos), compared to patients with an atrial shunt and cerebrovascular event (CVE) but only medical treated (ASMed), and to age- and sex-matched control individuals without a previous CVE. MethodsIn total, 663 ASCIos patients were identified in the Swedish National Patient Register from 1997 to 2016 and matched by using propensity score with 663 ASMed patients. Nine age- and sex-matched controls to ASCIos patients (n = 6,302) without a diagnosis of atrial shunt or history of CVE were randomly selected from the general population. ResultsAt a mean follow-up of 6.5 years, the incidence rate of recurrent stroke in the ASCIos group vs ASMed group was 0.9 vs 0.7 per 100 patient-years. The hazard ratio of recurrent stroke in the ASCIos group compared with index stroke in the control group was 9.9 (95% confidence interval, 5.5–17.9). The incidence of atrial fibrillation was similar in the ASCIos and the ASMed group, however four times higher in the ASCIos than in the control group. ConclusionsOur large nationwide, register-based cohort study showed that, unexpectedly, the risk of recurrent stroke in the ASCos group was as high as in the ASMed group and almost ten times higher than the risk of an index stroke in matched controls without previous stroke.

Incidence and case-fatality rate of stroke in General Villegas, Buenos Aires, Argentina. The EstEPA population study

ObjectivesStroke epidemiology varies among different populations. The burden of stroke is high in low- and middle-income countries. Reliable population data is needed to assess the impact of stroke and to develop policies aimed to improve stroke care in our region. EstEPA is a population-based project assessing prevalence, incidence, mortality and burden of stroke in General Villegas Department, Buenos Aires, Argentina (pop=30,864 inhabitants). We determined incidence of stroke (first-ever and recurrent stroke) and stroke case-fatality rate from 2017 to 2020. MethodsFirst-ever strokes, recurrent strokes and transient ischemic attacks were ascertained and case-fatality rate was obtained. Diagnoses were based on standard AHA/WHO definitions. Study population included all persons residing in General Villegas during the three-year period. Hospitals, households, nursing homes, death certificates and several overlapping sources were surveyed. ResultsWe assessed 92,592 person-years. There were 155 cerebrovascular events aged 70 years (SD ± 13 years), of which 115 were first-ever strokes (74%), 21 recurrent strokes (13.5%) and 19 transient ischemic attacks (12.5%). The crude overall incidence rate of first-ever strokes was 124.2 per 100,000 population (86.9 per 100,000 [95% CI 58.5-115.2] when standardized by WHO World population and 109.7 per 100,000 [95% CI 89.7-129.8] when standardized by Argentine population) and 317.0 per 100,000 population in subjects older than 40 years. Case fatality rate at 30 days of first-ever strokes was 27%. ConclusionIn this population-based comprehensive stroke epidemiological study in Argentina, first-ever stroke incidence in an urban population was 124.2 per 100,000 population (86.9 per 100,000 adjusted by the WHO World population). This is lower than the incidence in other countries in the region and similar to a recent incidence study in Argentina. It is also comparable to reported incidence in most middle- and high-income countries. Stroke case-fatality rate was comparable to other population-based Latin-American studies.

Estimated Burden of Stroke in China in 2020

Stroke is the leading cause of death in China. However, recent data about the up-to-date stroke burden in China are limited. To investigate the urban-rural disparity of stroke burden in the Chinese adult population, including prevalence, incidence, and mortality rate, and disparities between urban and rural populations. This cross-sectional study was based on a nationally representative survey that included 676 394 participants aged 40 years and older. It was conducted from July 2020 to December 2020 in 31 provinces in mainland China. Primary outcome was self-reported stroke verified by trained neurologists during a face-to-face interviews using a standardized protocol. Stroke incidence were assessed by defining first-ever strokes that occurred during 1 year preceding the survey. Strokes causing death that occurred during the 1 year preceding the survey were considered as death cases. The study included 676 394 Chinese adults (395 122 [58.4%] females; mean [SD] age, 59.7 [11.0] years). In 2020, the weighted prevalence, incidence, and mortality rates of stroke in China were 2.6% (95% CI, 2.6%-2.6%), 505.2 (95% CI, 488.5-522.0) per 100 000 person-years, and 343.4 (95% CI, 329.6-357.2) per 100 000 person-years, respectively. It was estimated that among the Chinese population aged 40 years and older in 2020, there were 3.4 (95% CI, 3.3-3.6) million incident cases of stroke, 17.8 (95% CI, 17.5-18.0) million prevalent cases of stroke, and 2.3 (95% CI, 2.2-2.4) million deaths from stroke. Ischemic stroke constituted 15.5 (95% CI, 15.2-15.6) million (86.8%) of all incident strokes in 2020, while intracerebral hemorrhage constituted 2.1 (95% CI, 2.1-2.1) million (11.9%) and subarachnoid hemorrhage constituted 0.2 (95% CI, 0.2-0.2) million (1.3%). The prevalence of stroke was higher in urban than in rural areas (2.7% [95% CI, 2.6%-2.7%] vs 2.5% [95% CI, 2.5%-2.6%]; P = .02), but the incidence rate (485.5 [95% CI, 462.8-508.3] vs 520.8 [95% CI, 496.3-545.2] per 100 000 person-years; P < .001) and mortality rate (309.9 [95% CI, 291.7-328.1] vs 369.7 [95% CI, 349.1-390.3] per 100 000 person-years; P < .001) were lower in urban areas than in rural areas. In 2020, the leading risk factor for stroke was hypertension (OR, 3.20 [95% CI, 3.09-3.32]). In a large, nationally representative sample of adults aged 40 years or older, the estimated prevalence, incidence, and mortality rate of stroke in China in 2020 were 2.6%, 505.2 per 100 000 person-years, and 343.4 per 100 000 person-years, respectively, indicating the need for an improved stroke prevention strategy in the general Chinese population.

Abstract Number ‐ 194: Predisposition to Atrial Fibrillation in AIS of Undetermined Source in the Setting of LVO

Introduction It is estimated that 7.6 million Americans report having had a stroke. Every year, approximately 795,000 people develop a stroke, of which 610,000 are for the first time. Although stroke incidence rates in adults ≥ 65 years of age decreased by 32% per decade from 1987 to 2017, it remains both the fifth leading cause of death and the leading cause of disability in the United States1. Ischemic strokes make up 87% of all strokes and can be categorized by the TOAST classification scheme. Etiologies include large‐vessel atherosclerosis, small vessel disease, cardioembolism, stroke of other determined etiology, and stroke of undetermined etiology2. Cardioembolic strokes, accounting for up to 25% of ischemic strokes typically involve a cardiac insult resulting from either atrial disease, valvular heart disease, structural and functional ventricular diseases, or myocardial infarction. The most common etiology of cardioembolic stroke and focus of this study is atrial fibrillation3. Stroke of undetermined etiology, also called cryptogenic stroke accounts for nearly 30% of ischemic strokes and has been recently coined in the literature as embolic stroke of undetermined source (ESUS) due to the presence of embolic features in the majority of these cases. Atrial cardiomyopathy has been identified as a contributing cause to ESUS with the detection of atrial fibrillation sometimes after original classification4. Though a significant portion of ESUS patients are found to have atrial fibrillation, it is not often detected on presentation. Additionally, ESUS patients can present with a large‐vessel occlusion (LVO), often with a high initial NIHSS. It may be of benefit to compare ESUS patients with and without LVO on the basis of detection of atrial fibrillation. Methods This study is a retrospective cohort study of patients discharged from the Neurology general practice unit, Stroke step‐down unit, or Neurosurgical ICU from January 2014 to June 2022.Subject charts will be reviewed for the following variables: 1)Demographics: Age, race, sex, 2)Use of antithrombotics, 3)Specific antithrombotics prescribed, 4)Stroke etiology, 5)Initial NIHSS, 6)Presence of large vessel occlusion (LVO), 7)Received tPA, 8)Received MER, 9)Detection of atrial fibrillation, 10)Detection of arrhythmia, 11)Presence of reduced ejection fraction, 12)Received Holter monitor, 13)Underwent internal loop recorder placement, 14)Recurrence of stroke or TIA. Results ESUS patients often present with atrial fibrillation. ESUS patients can present with a large‐vessel occlusion (LVO). There was a higher rate of detection of atrial fibrillation in patients with ESUS who present with LVO in comparison to patients with ESUS who do not present with LVO. Conclusions This study demonstrated that there may be an increased likelihood of atrial fibrillation in patients with ESUS who present with LVO versus those who do not present with LVO. Areas of further development include prevention of LVO‐related ischemic stroke in patients with atrial fibrillation, targeted LVO education for patients with atrial fibrillation, earlier initiation of anticoagulant stroke preventive medication for high‐risk LVO patients. The study may also help elucidate whether extended cardiac monitoring would be beneficial for patients who present with an LVO.

Abstract P473: Early Onset Stroke in the Black Women's Health Study

Background: The impact of stroke in young adulthood and mid-life is disproportionately large due to greater disability-adjusted life-years lost and worsened quality of life. There is evidence that stroke incidence has increased among young adults in recent decades, although there is conflicting data, especially among subgroups defined by sex and race. We investigated incidence of early-onset stroke among U.S. Black women. Methods: The Black Women’s Health Study is a prospective study of 59,000 Black women from across the U.S. who have been followed since 1995 (aged 21-69 years, median age of 38 years). Both ischemic and hemorrhagic stroke were ascertained by self-report at biennial health questionnaires through December 31, 2019. Stroke mortality was determined through the National Death Index. We stratified by age group: ages 35-54 and ages 55 and older, to distinguish early onset stroke and stroke occurring in later life. We examined crude incidence rates of total stroke cases (per 1000 person-years) during two sequential 12-year follow up periods, 1995-2007 and 2007-2019. Stroke incidence rates were calculated and modeled with Poisson regression. Results: Incident stroke or stroke death occurred in 2093/58,386 participants (3.58%) during 1,316,545 person-years of follow-up from 1995 to 2019. Among women aged 35-54 years the incidence rate was 1.59 (95% CI 1.46-1.72) in the 1995-2007 period (564 cases/355,601 person-years) and 1.12 (95% CI 1.02-1.23) in the 2007-2019 period (460 cases/409,870 person-years). For participants aged 55 or older the incidence rate was 4.19 (95% CI 3.69-4.73) in the 1995-2007 period (257 cases/61,357 person-years) and 2.83 (95% CI 2.62-3.05) in the 2007-2019 period (678 cases/239,433 person-years). Conclusion: In this preliminary analysis, stroke incidence in Black women decreased across study time periods, from 1995-2019, most clearly among participants aged 55 years or older. These findings are similar to those observed in other population-based cohorts reporting incidence rates among Black Americans, for example in the Atherosclerosis Risk in Communities Study. Black women continue to be a high-risk subgroup for stroke and should be a focus for preventive public health efforts, from as early as young adulthood.

Early Rhythm Control in Patients With Incident Atrial Fibrillation Who Had a Prior Stroke

BackgroundThere are limited data regarding the benefit of early rhythm control therapy for secondary prevention for stroke in patients with atrial fibrillation (AF). ObjectivesThis study aimed to compare the risk of recurrent stroke between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke. MethodsUsing the Korean nationwide claims database, the investigators identified patients who were newly diagnosed with AF and had a history of prior stroke. Patients who received rhythm control therapy, including antiarrhythmic drug, direct current cardioversion, or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, and the others were the usual care group. The propensity score weighting method was used to balance baseline characteristics between the 2 groups. Incident stroke was evaluated as a primary outcome. ResultsA total of 53,509 patients were included (12,455 in the early rhythm control group and 41,054 in the usual care group). All patients were prescribed oral anticoagulants. During a median 2.6 years of follow-up, 4,382 patients had an incident stroke (incidence rate: 2.6 per 100 person-years). Early rhythm control was associated with a lower risk of recurrent stroke compared to the risk associated with usual care (weighted HR: 0.720; 95% CI: 0.666-0.779; P < 0.001). ConclusionsEarly rhythm control within 1 year after AF diagnosis might be beneficial to prevent recurrent stroke in patients with incident AF and a history of stroke. Integrated care, including optimal rhythm control with appropriate anticoagulation, should be considered in this population.