Increased Incidence Of Stroke Research Articles

Abstract 13658: Impact of Risk Factors for Atrial Fibrillation on the Incidence of Stroke in African American Females

Background: It is well-known that African American (AA) patients with Atrial Fibrillation (AF) have a higher incidence of stroke in comparison to the general population. To our knowledge, limited data exist on gender disparities in risk factors contributing to a higher incidence of stroke among AA patients. The objective of this study is to identify gender disparities in risk factors for AF by comparing AA females and males with AF. Methods: AA patients aged 18 years old or above with a diagnosis of AF were included in this study. Patients were selected from the 2019 national inpatient sample. The primary outcome of interest was incidence of stroke. T-test was used to compare differences in continuous variables. For categorical variables, pearson chi-square was used to compare differences. Multivariate logistic regression was used to adjust for potential confounders. A 2-sided P<0.05 was considered significant throughout the analyses. Results: This study included 45,102 AA female patients with AF, and 46,768 AA male patients with AF. In our study, female patients had higher prevalence of Hypertension (HTN) (22.3% vs 19.0, P<0.001), Diabetes Mellitus (DM) (48.1 vs 46.0, P<0.001), Obesity (27.8 vs 20.8), Hyperlipidemia (HLD) (50.9% vs 49.1%, P<0.001), Hyperthyroidism (2.2% vs 1.2%, P<0.001), and Chronic Obstructive Pulmonary Disease (COPD) (24.8% vs 23.2%, P<0.001). AA female patients with AF experienced higher incidence of stroke compared to AA male patients with AF, (4.9% vs 4.1%, p-value <0.001) and the odds of stroke also showed higher in female patients (aOR=1.10, 95% CI: 1.03-1.18, p <0.005) after controlling for comorbidities. Only HTN and HLD showed statistically significant association with stroke in univariate analysis, (OR=2.02, 95% CI: 1.89-2.16 and OR=1.24, 95% CI:1.16-1.31, respectively) Conclusion: In our study, we identified that AA female patients with AF had a higher incidence of stroke compared to AA male patients with AF. Only HTN and HLD were significant risk factors contributing to the increased stroke incidence in the female group. The findings of our study are hypothesis-generating, and well-powered randomized controlled trials are needed to validate these findings.

Low-to-Moderate Risk Transient Ischemic Attack Patients Can Be Safely Discharged From the Emergency Department to a Nurse Practitioner-Led Clinic.

BACKGROUND: Unnecessary admissions fuel rising healthcare costs and take away resources from higher acuity patients without evidence of increased safety. The purpose of this quality improvement project was to determine whether the care diversion for transient ischemic attack (TIA), from inpatient to a nurse practitioner (NP)-led specialty clinic, resulted in no increase in stroke incidence at 90 days. METHODS: The sample included all adults presenting to the emergency department with TIA at a low-to-moderate risk for stroke. Risks were defined by the ABCD 2 score and noninvasive vessel imaging. Patients who met the criteria were discharged and evaluated by a stroke NP at the TIA clinic within 7 days. These patients were compared with those who were admitted before clinic launch. Medical record reviews were conducted to determine stroke incidence at 90 days post TIA. Descriptive statistics were used to evaluate clinical variables, and Fisher exact test was used to assess difference in stroke rates. Patient satisfaction score was collected using the existing institutional survey. RESULTS: Eighty-one participants were included, 40 in the clinic group and 41 in the admission group. The mean ages in the clinic and admission groups were 72.8 and 75.2 years, respectively ( P = .37). Women comprised 45% of patients in the clinic group, compared with 51.2% in the admission group ( P = .58). The mean ABCD 2 scores were 4.08 and 3.95 in the clinic and admission groups, respectively ( P = .63). The median clinic follow-up time was 6 days. There was no stroke incidence in the clinic group and 1 in the admission group within 90 days post TIA. Patient satisfaction score metrics for the NP exceeded the institutional benchmark of 90%. CONCLUSION: Referral to an NP-led clinic in patients with low- to moderate-risk TIA was equally safe as hospital admission.

Urban exposome and stroke incidence across Europe

Background and Aim: Multiple environmental factors of urban environments may influence cardiovascular health, however their complex interplay has scarcely been studied. Within the EXPANSE project, we evaluated the association between multiple urban exposures and stroke incidence across Europe. Methods: We will conduct a meta-analysis including 3 population-based cohorts (from Sweden, Netherlands, Germany) and 6 administrative cohorts (from Greece, Rome, Catalonia, Switzerland, Sweden, Netherlands). Participants were followed-up until incident stroke, death, migration, disappearance or end of study period. We estimated multiple long-term exposures at residential addresses from different domains: ambient air pollution (nitrogen dioxide, particulate matter <2.5m, black carbon, ozone), built environment (green and blue spaces, impervious surface) and meteorology (mean and standard deviation temperatures during summer and winter). Associations between environmental exposures and incident stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component Analyses (PCA) derived prototypes for exposures domain (i.e built environment). Results: Preliminary results from Sweden (N=19,247), from single and multiple exposures, indicate associations between increased levels of NDVI and reduced incident stroke (hazard ratio (HR) per 0.1 units = 0.92, 95%CI 0.85; 0.99). The first component of each domain in the PCA explained more than 60% of the variability. The built environment domain (capturing high levels of green spaces and low levels of impervious surface) showed a borderline association with incident stroke (HR per interquartile range of the component = 0.92, 95%CI 0.83; 1.01). We also found a suggestive association between air pollution and increased stroke incidence. Conclusions: In preliminary results in Sweden, we found a suggestion for independent effects of green space and air pollution on incident stroke. Further analyses on the other cohorts are ongoing. Keywords: stroke, urban exposome, meta-analysis, air pollution, green space, temperature, blue space.

Efficacy of Robots-Assisted Therapy in Patients With Stroke: A Meta-analysis Update.

Robot-assisted therapy (RAT) could address an unmet need to relieve the strain on healthcare providers and intensify treatment in the context of an increasing stroke incidence. A comprehensive meta-analysis could provide firmer data about the topic by considering methodology limitations discovered in previous reviews and providing more rigorous evidence. This meta-analysis study identifies RAT's efficacy for patients with stroke. A systematic search of the 7 databases from January 10 to February 1, 2022, located relevant publications. We used the updated Cochrane risk-of-bias checklist for 52 trials to assess the methodologic quality of the included studies. The efficacy of RAT for patients with stroke was estimated using a pooled random-effects model in the Stata 16 software application. The final analysis included 2774 patients with stroke from 52 trials. In those patients, RAT was proven to improve quality of movement (mean difference, 0.15; 95% confidence interval, 0.03-0.28) and to reduce balance disturbances (mean difference, -1.28; 95% confidence interval, -2.48 to -0.09) and pain (standardized mean difference, -0.34; 95% confidence interval, -0.58 to -0.09). Robot-assisted therapy seems to improve the quality of mobility and reduce balance disturbances and pain for patients with stroke. These findings will help develop advanced rehabilitation robots and could improve health outcomes by facilitating health services for healthcare providers and patients with stroke.

Air Pollution and Cerebrovascular Disorders with Special Reference to Asia: An Overview.

Background:Among the primary environmental issues affecting global health, air pollution is considered the leading cause of concern. Globally, around 800,000 deaths were attributed to air pollution according to WHO. Evidence suggests that there has been a strong association of air pollution with stroke. Approximately, 25% of stroke mortality was due to air pollution according to a study in 2013.Objective:The aim of this review was to analyze the association between stroke, intracerebral hemorrhage, and subarachnoid hemorrhage and air pollution and its burden globally with a special focus on South Asia along with its association with the COVID-19 pandemic.Results:There is growing research data linking air pollution to cardiovascular disorders including stroke. Short-term and long-term air pollution exposures have been shown to increase stroke incidence in epidemiological data. Air pollution, both gaseous and particle, show a strong and tight temporal relationship with stroke hospitalizations and death. The link between ICH and SAH to air pollution is less strong and less well studied as compared to ischemic stroke. Stroke and air pollution both are highly prevalent in South Asia. It is possible that the high prevalence of stroke in south Asia may be linked to the high frequency of air pollution in addition to other conventional risk factors. Decreased stroke admissions and mortality and reduced cardiovascular mortality reported during coronavirus disease 2019 (COVID) lockdown may be attributable to decreased levels of air pollution.Conclusion:Even though air pollution poses a significant threat to human health, a great number of countries still fail to achieve internationally agreed air quality standards. Air pollution should be recognized among the most significant controllable risk factors for cardiovascular and cerebrovascular disease prevention and treatment.

Association of Younger vs Older Ages With Changes in Incidence of Stroke and Other Vascular Events, 2002-2018

Some studies have reported increasing stroke incidence at younger ages (<55 years) but have often relied only on administrative data, and more population-based studies of adjudicated stroke are required. An understanding of the drivers of any increase in incidence of young stroke also requires comparisons with stroke trends at older ages and with trends in incidence of other vascular events at younger ages. To determine temporal changes in incidence of stroke and other major vascular events at younger vs older ages. Prospective population-based incidence study conducted from April 2002 to March 2018 with a mean catchment population of 94 567 in Oxfordshire, England. Calendar time, premorbid vascular risk factors, and occupation. Changes in incidence of stroke, transient ischemic attack (TIA), and other major vascular events (myocardial infarction, sudden cardiac death, and peripheral vascular events) stratified by age, sex, diagnostic workup, etiology, and severity. A total of 2429 incident strokes were ascertained (mean age, 73.6 [SD, 14.4] years; 51.3% female). From 2002-2010 to 2010-2018, stroke incidence increased significantly among participants younger than 55 years (incidence rate ratio [IRR], 1.67; 95% CI, 1.31-2.14) but fell significantly among participants aged 55 years or older (IRR, 0.85; 95% CI, 0.78-0.92; P < .001 for difference). The significant increase in incidence at younger than 55 years was independent of sex, stroke severity, pathological subtype, and changes in investigation and was also seen for TIA (IRR, 1.87; 95% CI, 1.36-2.57) but not for myocardial infarction and other major vascular events (IRR, 0.73; 95% CI, 0.58-0.93). Although TIA and stroke at younger than 55 years were significantly associated with diabetes (risk ratio [RR], 3.47; 95% CI, 2.54-4.74), hypertension (RR, 2.52; 95% CI, 2.04-3.12), current smoking (RR, 2.38; 95% CI, 1.92-2.94), and obesity (RR, 1.36; 95% CI, 1.07-1.72), the significant increase in incidence from 2002-2010 to 2010-2018 was still seen in individuals without these risk factors. The increase was greatest in professional/managerial occupations (IRR, 2.52; 95% CI, 1.75-3.62) and least in partially skilled/unskilled occupations (IRR, 1.17; 95% CI, 0.79-1.74). The proportion of TIAs and strokes among those younger than 55 years without known vascular risk factors increased significantly over time (45 [30.4%] vs 115 [42.4%]; absolute difference, 12.0%; 95% CI, 2.6-21.5), especially in patients with cryptogenic events (10 [18.5%] vs 63 [49.2%]; absolute difference, 30.7%; 95% CI, 17.2-44.2; P < .001; P = .002 for heterogeneity). Comparing persons living in Oxfordshire, England, in 2002-2010 vs 2010-2018, there was a significant increase in stroke incidence in those younger than 55 years, but a decrease in those aged 55 years or older. Given the absence of this divergence for other vascular events, further research is needed to understand the causes of this difference.

Acute Ischemic Stroke in the Context of SARS-CoV-2 Vaccination: A Systematic Review.

BackgroundThere have been reports suggesting an increased incidence of acute ischemic stroke among anti-SARS-CoV-2 vaccinees. We aimed to systematically review the literature to summarize the available evidence on the association between SARS-CoV-2 vaccination and acute ischemic stroke.MethodsA systematic literature search on MEDLINE, LitCovid and LIVIVO databases was performed for eligible randomized controlled trials, observational studies, registries and case reports that reported on imaging-confirmed acute ischemic stroke in the context of any SARS-CoV-2 vaccination with BNT162b2, mRNA-1273, Ad26.COV2.S, ChAdOx1 or Gam-COVID-Vac. Literature search was limited to English and German languages and publication date before October 19, 2021.ResultsWe identified a total of 395,105,670 individuals who underwent vaccination. We found 21 sources, including 2 cohort studies, 4 registry studies, 3 randomized clinical trials, and 12 case reports. Individuals included in these studies were at least 16 years old. Cari et al observed a higher likelihood of acute ischemic stroke in vaccinees aged 18–64 years, compared to Whiteley et al observing vaccinees older than 70 years when vaccinated. In addition, differences in the likelihood of acute ischemic stroke were found among the vaccines studied, although no overall increased stroke incidence was demonstrated with vaccination.ConclusionIn this systematic review of the available literature, we found that the risk of acute ischemic stroke does not appear to be increased in vaccinated individuals who have received any of the currently licensed SARS-CoV-2 vaccines compared with the baseline incidence of stroke.

Bringing rehabilitation home with an e-health platform to treat stroke patients: study protocol of a randomized clinical trial (RGS@home)

BackgroundThere is a pressing need for scalable healthcare solutions and a shift in the rehabilitation paradigm from hospitals to homes to tackle the increase in stroke incidence while reducing the practical and economic burden for patients, hospitals, and society. Digital health technologies can contribute to addressing this challenge; however, little is known about their effectiveness in at-home settings. In response, we have designed the RGS@home study to investigate the effectiveness, acceptance, and cost of a deep tech solution called the Rehabilitation Gaming System (RGS). RGS is a cloud-based system for delivering AI-enhanced rehabilitation using virtual reality, motion capture, and wearables that can be used in the hospital and at home. The core principles of the brain theory-based RGS intervention are to deliver rehabilitation exercises in the form of embodied, goal-oriented, and task-specific action.MethodsThe RGS@home study is a randomized longitudinal clinical trial designed to assess whether the combination of the RGS intervention with standard care is superior to standard care alone for the functional recovery of stroke patients at the hospital and at home. The study is conducted in collaboration with hospitals in Spain, Sweden, and France and includes inpatients and outpatients at subacute and chronic stages post-stroke. The intervention duration is 3 months with assessment at baseline and after 3, 6, and 12 months. The impact of RGS is evaluated in terms of quality of life measurements, usability, and acceptance using standardized clinical scales, together with health economic analysis. So far, one-third of the patients expected to participate in the study have been recruited (N = 90, mean age 60, days after stroke ≥ 30 days). The trial will end in July 2023.DiscussionWe predict an improvement in the patients’ recovery, high acceptance, and reduced costs due to a soft landing from the clinic to home rehabilitation. In addition, the data provided will allow us to assess whether the prescription of therapy at home can counteract deterioration and improve quality of life while also identifying new standards for online and remote assessment, diagnostics, and intervention across European hospitals.Trial registrationClinicalTrials.gov NCT04620707. Registered on November 3, 2020

English

BACKGROUND COVID-19 is associated with a hypercoagulable state and stroke is one of its most common neurological complications. The current study is aimed at investigating the effect of the COVID-19 pandemic on hospital admissions for stroke. METHODS We conducted a retrospective observational study to determine if there was a significant difference in the number of hospital admissions for stroke during the 2 months of lockdown and the two preceding months, (starting on 24 March 2020). The numbers were also compared with the figures during the same months in the previous year. The numbers were also compared to the same months one year prior. The secondary objectives were to compare the time between the onset of stroke and presentation to the hospital, type of strokes that presented to the hospital, severity of stroke, number of code activations, number of thrombolysis conducted, and in-hospital mortality between the same time periods. RESULTS The total number of patients admitted for stroke during the time periods from 25th March 2019 to 24th May 2019, 25th January 2020 to 24th March 2020 and 25th March 2020 to 24th May 2020 were 82, 72 and 75 respectively, and there was no statistically significant difference between these numbers. However, there was a significant increase in the proportion of stroke cases when compared to total hospital admissions. This suggests that an increase in stroke incidence may have been masked by a reduction in the total number of patients presenting to the hospital. The National Institutes of Health Stroke Scale (NIHSS) score of the patients who presented during the lockdown were higher. There were no significant differences in the time between the onset of stroke and presentation to the hospital, type of strokes that presented to the hospital, severity of stroke, number of code activations, number of thrombolysis conducted, and in-hospital mortality between the periods under study. CONCLUSIONS The present study suggests that there may be a relative increase in the incidence of stroke in the community, as a result of the COVID-19 pandemic. The patients who presented with stroke during the lockdown period had a higher NIHSS score. KEYWORDS COVID-19, Stroke, Lockdown

Long-term air pollution exposure and incident stroke in American elderly population: a national cohort study

BACKGROUND AND AIM: Literature has linked air pollution and cerebrovascular diseases including stroke. However, evidence is limited for the simultaneous effects of multiple air pollutants on stroke incidence. METHODS: A nationwide population-based open cohort study was used to estimate the association between long-term exposure to PM2.5, NO2, ozone, and stroke incidence. The study population included all free-for-service Medicare enrollees (aged ≥65 years) in the contiguous United States from 2000-2017. We estimated the hazard ratios (HRs) for the first diagnosis with stroke using single-, bi-, and tri-pollutant Cox proportional hazards models that controlled for demographic characteristics, Medicaid eligibility, and area-level covariates. We further looked at this relationship in two sub-cohorts of enrollees who were always exposed to pollutant levels below the US EPA National Ambient Air Quality Standards [NAAQS] (annual PM2.5 ≤12 μg/m³, annual NO2 ≤53 ppb, and warm-season ozone ≤50 ppb) and the WHO air quality guideline (annual PM2.5 ≤10 μg/m³, annual NO2 ≤20 ppb, and warm-season ozone ≤40 ppb). RESULTS:Increases of 10 μg/m³ in PM2.5, 10 ppb in NO2, and 10 ppb in ozone were associated with increased risk of first diagnosis with stroke, with HRs of 1.063 (95% CI, 1.048-1.077), 1.048 (1.043-1.052), and 1.031 (1.026-1.037), respectively. Among the below EPA low-exposure sub-cohort, the corresponding HRs were 1.041 (95% CI, 1.008-1.075), 1.067 (1.056-1.077), and 1.123 (1.108-1.138), respectively. When restricting analyses to levels below the WHO air quality guidelines, increasing pollution levels were consistently associated with a greater hazard estimate. CONCLUSIONS:Long-term exposure to air pollution, even at concentrations below NAAQS or international standards, was significantly associated with increased stroke incidence among the US elderly population. KEYWORDS: Air pollution, Multi-pollutant, Stroke

Comparative assessment of in vitro BBB tight junction integrity following exposure to cigarette smoke and e-cigarette vapor: a quantitative evaluation of the protective effects of metformin using small-molecular-weight paracellular markers

BackgroundThe blood–brain barrier (BBB) plays a critical role in protecting the central nervous system (CNS) from blood-borne agents and potentially harmful xenobiotics. Our group’s previous data has shown that tobacco smoke (TS) and electronic cigarettes (EC) affect the BBB integrity, increase stroke incidence, and are considered a risk factor for multiple CNS disorders. Metformin was also found to abrogate the adverse effects of TS and EC.MethodsWe used sucrose and mannitol as paracellular markers to quantitatively assess TS and EC’s impact on the BBB in-vitro. Specifically, we used a quantitative platform to determine the harmful effects of smoking on the BBB and study the protective effect of metformin. Using a transwell system and iPSCs-derived BMECs, we assessed TS and EC’s effect on sucrose and mannitol permeability with and without metformin pre-treatment at different time points. Concurrently, using immunofluorescence (IF) and Western blot (WB) techniques, we evaluated the expression and distribution of tight junction proteins, including ZO-1, occludin, and claudin-5.ResultsOur data showed that TS and EC negatively affect sucrose and mannitol permeability starting after 6 h and up to 24 h. The loss of barrier integrity was associated with a reduction of TEER values. While the overall expression level of ZO-1 and occludin was not significantly downregulated, the distribution of ZO-1 was altered, and discontinuation patterns were evident through IF imaging. In contrast to occludin, claudin-5 expression was significantly decreased by TS and EC, as demonstrated by WB and IF data.ConclusionIn agreement with previous studies, our data showed the metformin could counteract the negative impact of TS and EC on BBB integrity, thus suggesting the possibility of repurposing this drug to afford cerebrovascular protection.

Trends of Stroke Incidence and 28-Day All-Cause Mortality after a Stroke in Malaysia: A Linkage of National Data Sources.

Background:Data on nationwide trends for stroke metrics are crucial to understand the extent of the disease burden to a country’s health system. Yet, this information remains scarce in low- and middle-income countries.Objectives:This study investigated trends of stroke incidence and 28-day all-cause mortality after a stroke from 2008 to 2016 in Malaysia, through linkage across national data sources.Methods:Hospital admissions with a principal diagnosis of stroke or transient ischemic attack were included. Cases with first stroke were identified through linkage of hospital admission registers where age and sex-standardized trends of stroke incidence and its subtypes were calculated. By linking hospital registers to the National Death Register, the 28-day all-cause mortality rates after a stroke were estimated. Mann-Kendall’s test was used for trend evaluation.Results:From 243,765 records, the trend of stroke incidence showed an increase of 4.9% in men and a drop of 3.8% among women. Incidences were higher in men, at 99.1 per 100,000 population in 2008 and 103.9 per 100,000 in 2016 than women (80.3 per 100,000 in 2008 and 77.2 per 100,000 in 2016). There was a substantial increase in stroke incidence among those below 65 years old, with the largest increase of 53.3% in men aged between 35–39 years and 50.4% in women of similar age group. The trend for 28-day all-cause mortality showed a decline for men at –13.1% and women, –10.6%. Women had higher mortality from stroke (22.0% in 2008 and 19.7% in 2016) than men (19.4% in 2008 to 17.2% in 2016).Conclusion:This first empirical study on stroke trends in Malaysia revealed a worrying increase in stroke incidence among the younger population. Despite a declining trend, mortality rates remained moderately high especially in women. Comprehensive strategies to strengthen the prevention and management of stroke care are warranted.

Abstract P602: Stroke Risk Factors Among the Young Over Time in the GCNKSS

Background: Data from the Greater Cincinnati Northern Kentucky Stroke Study (GCNKSS) have demonstrated stable or increasing stroke incidence rates in young adults with differences by sex and race, suggesting the need for targeted approaches to stroke prevention in the young. We aimed to describe trends over time in prevalence of stroke risk factors among adults ages 20-54 with stroke by sex and race. Methods: Cases of incident stroke (IS, ICH, SAH) occurring in those 20-54 years old and living in a 5-county area of southern Ohio/northern Kentucky were ascertained during 5 study periods (1993-1994, 1999, 2005, 2010, 2015). All physician-adjudicated inpatient events and a sampling of outpatient events were included, excluding nursing home events. Data on risk factors (hypertension, diabetes, obesity (BMI≥30), and high cholesterol) diagnosed prior to stroke were abstracted from medical records, and prevalence of each risk factor was reported over time in race/sex groups. Trends over time were examined using the Cochran-Armitage test. Results: Over the 5 study periods, 1204 incident strokes were included; 49% were women, 33% were black, and mean age was 46 (SD 7) years. Premorbid hypertension increased over time in Black women (48% in 1993/4 to 76% in 2015, p=0.005) but not in any other race/sex group (all p&gt;0.05). Premorbid high cholesterol increased significantly in all race/sex groups (Figure, all p&lt;0.05) except for White men (p=0.06). There were no significant trends over time in pre-stroke diagnoses of diabetes or obesity in any of the race/sex groups (Figure). Conclusions: Among patients aged 20-54 with incident stroke in a large population-based study, the change in the prevalence of hypertension and high cholesterol differed by sex and race, while obesity and diabetes were stable over time in all race/sex groups. Future research is needed to address risk factor control at a population level and to understand the role of undiagnosed pre-stroke risk factors in the young.

The study of the risk factor profile of stroke in young: a retrospective study

Background: Cerebrovascular accidents (CVA) is the second leading cause of mortality and morbidity in the world. Traditional risk factors for stroke are not very frequent in young population. However, other permanent or transient risk factors such as smoking, alcohol consumption, use of oral contraceptives, migraine, and puerperium have a more important role in young population. The objective of our study is to establish the risk factor profile in stroke in young.Methods: This retrospective study of 100 patients of stroke, in the age group of 18–40 years, admitted in the medical wards of BMCRI, Bangalore. The patients were identified from the medical records from January 2018 to June 2019.Results: Out of 100 patients of stroke in young, males were (58%) than females (42%) sex ratio was 1.38:1. Most common age group was 36-40 years (34%), mean age was 31.24 years. Most common risk factor was Hypertension (34%) followed by smoking (33%), alcohol consumption (28%), diabetes (21%), morbid obesity (12%). Most common type of stroke was ischemic (78%) and hemorrhagic (22%). In our study, 63.6% of hemorrhagic patients had hypertension showing statistically significant. Among patients of ischemic stroke, most common risk factor was smoking and tobacco chewing (32%).Conclusions: There is rising trend in stroke among young, hence we should evaluate for various risk factors and identification these factors in otherwise healthy individuals and with life style modifications, we can prevent the increase in incidence of Stroke among young.

PRADI cohort case‐control study on related factors of Alzheimer’s disease

AbstractBackgroundAlzheimer’s disease (AD) has become a burden of social and economic importance, affecting millions of families and society at large. The Puerto Rico Alzheimer and Related Dementias Initiatives (PRADI) cohort was developed to investigate AD and genetics factors of AD in the Puerto Rican population. PRADI recruitment was a snowball sampling, with both island‐wide geographic distribution, as well as extensions to PR communities in the continental US. In this study we assessed the relationship between AD and cardiovascular risk factors of AD in the PR population.MethodWe assessed over 700 elderly PR individuals for dementia, as well as medical history. Affection status was assessed using standard AD clinical criteria (NINCDS‐ADRDA) or mild cognitive impairment. All medical history was obtained by a self‐report or informant report. Differences between affected and unaffected were initially tested using a chi‐square test (for sex, diabetes, hypercholesterolemia, heart disease, hypertension, and stroke) and a t‐test for the age of the exam. Follow‐up analyses on stroke were performed using logistic regression with age at exam and sex as covariates in the model.ResultThe analysis revealed no differences sex differences between AD and unaffected (p‐value &gt; 0.05). Similarly, affected and unaffected showed similar levels of type 2 diabetes, hypercholesterolemia, heart disease, and hypertension (p‐value &gt; 0.05). Affected individuals did however show an increase in stroke incidence (14.0% vs 5.2%; p‐value = 8.3e‐5). This difference persisted even when controlling for age of exam and sex. We did see a difference in age of exam between cases and controls, but this is likely due to ascertainment scheme.ConclusionThis analysis suggests that stroke may be a contributing factor to dementia in the PR population. However, given biases in the ascertainment scheme, additional assessments need to be performed. Additionally, work is ongoing to assess the role of ancestry and genetic factors in this association.

Current Understanding of the Role of Frailty in Cardiovascular Disease.

The elderly population is increasing because of increasing life expectancy, and the prevalence of frailty increases with age. Frailty commonly coexists with cardiovascular diseases (CVDs), such as coronary artery disease (CAD), heart failure (HF), aortic stenosis (AS), and atrial fibrillation (AF). Frail patients who undergo revascularization for CAD have higher complication rates; those with HF have a high prevalence of poor outcomes, and those with AF are vulnerable to increased stroke incidence. Moreover, frailty and asymptomatic severe AS were independent factors for mortality. The presence of frailty can lead to poor clinical outcomes, and frailty has been identified as a risk factor for mortality. Thus, the identification of frail patients who are at higher risks of disability and adverse clinical outcomes is important. In this review, the relationship between frailty and CVD is appraised and optimal treatments for frail patients are discussed.

Daylight saving time and the incidence of thrombolysis to treat acute ischemic stroke

Twenty-five percent of the global population lives in one of the more than 70 countries that observe daylight saving time (DST). These people are exposed to 1hour of time transition twice a year, influencing the circulatory system. We aimed to analyze the incidence of thrombolysis to treat acute ischemic stroke in relation to clock changes in Hungary over a 10-year period. The number of thrombolytic treatments performed within the period between 2006 and 2015 was analyzed. Anonymized nationwide data on the dates and exact daily numbers of thrombolysis interventions were provided by the National Health Insurance Fund. We compared the mean number of thrombolytic treatments on the day before with that on the day after each transition, and also between the preceding and following one week and month. Our data including the last days of each month suggested a significant increase in thrombolysis numbers both in spring and in autumn on the day and the week after the clock change. However, when the last days of each month were excluded from analysis (as this in itself was associated with a 7-fold increase in stroke incidence in our earlier study), no significant difference in the number of thrombolysis treatments between the days and weeks before and after the clock change was detectable. The long-term, monthly analysis also did not reveal a significant difference. Our findings reflect that psychosocial factors, such as the approach of the last day of the month override the intrinsic effect of disturbances of the circadian rhythm on stroke incidence.

Abstract WMP52: Age, Sex and Regional Differences in Recent Stroke Incidence Trends Among Young Adults

Background: In the US, one third of strokes occur among younger adults (&lt; 65 years). While stroke incidence among elderly has declined, trends in younger adults by age, sex and region are unknown. We report recent trends in stroke incidence among commercially-insured young adults aged 20 - 64. Methods: Stroke incidence was estimated using 2011 - 2017 IBM MarketScan® Commercial Database stratified by age (20 - 34, 35 - 44, 45 - 54, 55 - 64), sex, and US Census region and was extrapolated to the US population using census data. Stroke cases were identified based on a primary diagnosis of either ischemic stroke (IS) or intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) using validated ICD-9 / 10 codes. We report incidence rates (IR) per 100,000 person-years, 95% confidence intervals and proportional change in IR between 2011 and 2017. Results: We identified 115,276 stroke admissions resulting in 172 million person-years. The overall stroke IR increased by 7% from 60.0 to 64.2 per 100,000 person-years between 2011 and 2017. The increase was greater among males as compared to females (9.8% vs 3.3%) and across both sexes the largest increase was observed for age category of 35 - 44 years (Table 1). Age-specific IR increased in all age categories except 20 - 34. Across US regions, the South showed the highest IR increase (10.0%) (Figure 1). IR for IS and ICH increased while a decrease in SAH IR was observed. The IR for IS was higher for males vs females (12.7% vs 5.4%), whereas it was higher for females vs males for ICH (14.5% vs 3.6%). Conclusions: Our analyses indicate an overall increase in stroke incidence for commercially-insured younger adults during a contemporary time period. Males between the ages of 35 - 44 have experienced the greatest increase in stroke incidence. Furthermore, the Southern US continues to experience highest increases in stroke incidence and there are gender differences in IR for stroke subtypes. Targeted strategies for stroke prevention may be warranted.

Endothelial dysfunction on cerebral small vessel disease

Globally, Stroke represents the second leading cause of death and the third leading cause of disability and stroke incidence in low- and middle-income countries has more than doubled in the last decades [[2]Johnson W. Onuma O. Owolabi M. et al.Stroke: a global response is needed.Bull World Health Organ. 2016 Sep 1; 94 (634–634A)Google Scholar, [4]Rodríguez-Salinas L.C. Medina M.T. Stroke in developing countries.in: Bogousslvasky Stroke; Selected Topics. World Federation of Neurology (WFN) Seminars in Clinical Neurology, Demos, New York2006: 49-62Google Scholar] and is responsible for 85% of the deaths due to neurological disorders. Cerebral small vessel disease causes 25% of strokes [[1]Cannistraro R.J. Badi M. Eidelman B.H. et al.CNS small vessel disease: a clinical review.Neurology. 2019 Jun 11; 92: 1146-1156Google Scholar]. Cerebral Small vessel disease (CSVD), is a heterogeneous vascular entity, that includes lacunar cerebral infarctions which are small deep infarcts in the territory of small penetrating arteries (Deep perforator arteriopathy) or cerebral amyloid angiopathy among others, due to a local disease of these vessels which cause ischaemic stroke, intracebral haemorrhage, vascular cognitive impairment, abnormal movement disorders, focal neurologic syndromes, etc (Norrving et al. 2013; Sacco et al. 2013; Fisher 1982). CSVD is associated with blood-brain barrier disruption and endothelial dysfunction [[5]Schreiber S. Wilisch-Neumann A. Schreiber F. et al.The spectrum of age-related small vessel diseases: potential overlap and interactions of amyloid and non-amyloid vasculopathies.Neuropathol Appl Neurobiol. 2019 Aug; : 6Google Scholar]. Endothelial dysfunction represents a reduction on the nitric oxide-dependent-vascular dilatation and can be described as an imbalance between vasodilatation and vasoconstriction produced by the endothelium( [[3]Moncada S. Higgs E.A. The discovery of nitric oxide and its role in vascular biology.Br J Pharmacol. 2006; 147: S193-S201Google Scholar]). CSVD can be evaluated using Neuroimaging. Recent small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces and microbleeds are usually the most frequent findings [[6]Wardlaw J.M. Smith E.E. Biessels G.J. et al.Standards for reporting vascular changes on neuroimaging (STRIVE v1). Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration.Lancet Neurol. 2013; 12: 822-838Google Scholar]. Several risk factors are strongly associated with CSVD and endothelial dysfunction such as : High blood pressure, metabolic syndrome, hyper homocysteine, low plasma levels of vitamin B12, abnormal endothelium-dependent vasodilation among others. These factors associated with genetics factors and lifestyle changes in low- and middle-income countries can explain the increased stroke incidence mainly in CSVD patients from these countries.

51SHOULD WE CONSIDER FRAILTY WHEN TREATING ATRIAL FIBRILLATION?

Introduction: Despite a large and growing population of older people with frailty and atrial fibrillation (AF), there is a lack of guidance on optimal AF management in this high-risk group. We synthesised the existing evidence base on the association between frailty, AF and clinical outcomes. Methods: A systematic review of studies examining the association between validated measures of frailty, AF and clinical outcomes, and meta-analysis of the association between frailty and oral anticoagulation (OAC) prescription. Results: Twenty studies (30,883 patients) were included, all observational. Fifteen were in hospital, four in the community and one in nursing care. Risk of bias was low-to-moderate. AF prevalence was 3%–38%. In people with AF, frailty was associated with increased stroke incidence, all-cause mortality, symptom severity and length of hospital stay. Meta-analysis of six studies showed frailty was associated with decreased OAC prescription at hospital admission (pooled adjusted OR 0.45 [95%CI 0.22–0.93], three studies), but not at discharge (pooled adjusted OR 0.40 [95%CI 0.13–1.23], three studies). A community-based study showed increased OAC prescription associated with frailty (OR 2.33 [95%CI 1.03–5.23]). Conclusion: Frailty is common, and associated with adverse clinical outcomes in patients with AF. There is evidence of an association between frailty status and OAC prescription, with different direction of effect in community compared with hospital cohorts. Despite the majority of care for older people being provided in the community, there is a lack of evidence on the association between frailty, AF, anticoagulation and clinical outcomes to guide optimal care in this setting.