Relative Risk Of Stroke Research Articles

Stroke incidence in heart failure and atrial fibrillation: population cohort study.

Heart failure (HF) is a risk factor for stroke among people with atrial fibrillation (AF). Prognosis following a HF diagnosis is often poor, but this is not accounted for in existing stroke risk scores. To examine stroke incidence in people with HF and AF compared to AF alone, considering the competing risk of death. Population-based cohort study. We identified 2,381,941 people aged ≥45 years in the Clinical Practice Research Datalink (2000-2018). HF and AF were included as time-varying covariates; 69,575 had HF and AF, 141,562 had AF alone and 91,852 had HF alone. We report hazard ratios for first stroke using Cox and Fine and Gray models. Over median follow-up of 6.62 years, 93,665 people (3.9%) had a first stroke and 314,042 (13.2%) died. Over half (51.3%) of those with HF and AF died. In the fully-adjusted Cox model, relative stroke risk was highest among people with AF alone (HR 2.43, 95%CI: 2.38-2.48) than HF and AF (HR 2.20, 95%CI: 2.14-2.26). In a Fine and Gray model accounting for all-cause mortality, the relative risk of stroke was similar for people with AF alone (HR 2.38, 95%CI: 2.33-2.43), but there was significant attenuation among those with HF and AF (HR 1.48, 95%CI: 1.44-1.53). HF is an aetiological risk factor for stroke yet its prognostic significance is reduced by the high incidence of death. Use of the CHA2DS2VASc score may over-estimate stroke incidence in some people with HF, particularly those with a poor prognosis.

The impact of tobacco smoking and smoking cessation on lung cancer and stroke incidence among people with HIV on antiretroviral therapy in South Africa: a simulation modeling study

IntroductionWith declining HIV-related mortality, over 20% of people with HIV (PWH) in South Africa are now over age 50 years, and tobacco-related non-communicable disease burden is increasing. We quantified the...

Education level and the incidence of heart failure, acute myocardial infarction, and stroke in patients with atrial fibrillation

Abstract Background Education level is an important socioeconomic factor affecting the incidence, symptoms, and treatment of atrial fibrillation (AF). Despite this, data on the association between education level and the incidence of major AF consequences – heart failure (HF), acute myocardial infarction (AMI), and stroke – are limited. Aim To investigate the association between education level and the risk of HF, AMI, and stroke in patients hospitalized with AF. Methods This retrospective cohort study is based on data generated by crosslinking of several Swedish national registries. All patients hospitalized between 1998 and 2003 with a diagnosis of AF were included. The relative risk for incident HF, AMI, and stroke were assessed according to education level categories during a 5–year follow–up. Education levels were categorised as primary, secondary, and academic. Kaplan-Meier curves and Cox regression models adjusted for age, sex, time of AF diagnosis, and the variables of Charlson´s Comorbidity Index were used to estimate the relative risk of the examined outcomes. Hazard ratios (HR) with 95% confidence intervals (CI) were used as estimate of associations and statistical significance level was 5%. Results The study included 263,172 patients (56.2% male; mean age 72.5±10.4 years). There was a statistically significant dose-dependent association between education level and the risk of AMI and HF in both sexes. Compared to primary education, the HR for AMI was 0.89 (95% CI: 0.85-0.93) for secondary education and 0.71 (95% CI: 0.65-0.78) for academic education in women; and 0.91 (95% CI: 0.87-0.94) for secondary education and 0.75 (95% CI: 0.71-0.80) for academic education in men. The relative risk for HF was similar, with HRs of 0.96 (95% CI: 0.93-1.00) for secondary and 0.82 (95% CI: 0.77-0.87) for academic education in women, and HRs of 0.93 (95% CI: 0.90-0.96) for secondary and 0.76 (95% CI: 0.72-0.80) for academic education in men. Patients with academic education had a significantly lower risk for stroke compared to those with primary education (HR 0.77 (95% CI: 0.71-0.84) in women; HR 0.84 (95% CI: 0.79-0.90) in men), while patients with secondary education did not have a significantly different relative risk for stroke compared to those with primary education. Conclusion Secondary and academic education levels were associated with a significantly lower risk of HF and AMI in both women and men with AF compared to primary education. Furthermore, academic education was associated with a lower risk of stroke. In conclusion, , higher education levels were associated with a lower 5-year risk of HF, AMI, and stroke compared to primary education

Time-trends of sex differences in stroke risk in atrial fibrillation: Are female patients still at higher risk today? A nationwide cohort study

Abstract Background Female sex is associated with higher risk of stroke in patients with atrial fibrillation (AF), particularly in the presence of other stroke risk factors. This has implications for oral anticoagulant treatment (OAC) decision-making, based on points of the CHA2DS2-VASc score. However, stroke rates have declined over recent years, and management has evolved over time towards a holistic approach that may have diminished the sex differences in AF-related stroke. Purpose To examine the changes in stroke risk over time in relation to risk differences between males and females not treated with oral anticoagulants in a nationwide cohort study. Methods This was an observational cohort study including patients with a hospital diagnosis of AF between 2007 and 2021. Data were obtained from the Danish nationwide registries. We identified a cohort of adult patients who were not receiving OAC treatment for up to 30 days after their AF diagnosis. Patients were followed up for thromboembolic events within one year after the AF diagnosis. Survival analysis was applied to describe the yearly rate of events and to estimate the risk ratio for females vs males of thromboembolism according to baseline risk levels, i.e., the CHA2DS2-VA score level (leaving out the ‘Sc’ sex criterion). Results A total of 188,704 AF patients (median age 75 years (IQR: 64 to 84); 49.7% female) who did not receive OAC treatment were included. The risk of thromboembolism during the entire study period was overall higher in females (3.5% in males vs. 4.7% among females). The overall one-year thromboembolic risk declined over time from 4.9% between 1997-2000 to 3.3% between 2017-2020, with male-female risk differences less evident in recent years (Figure 1a). The relative risk of stroke diminished from 1.22 (95%CI 1.10-1.34) in years 1997-2000 to 1.02 (95%CI 0.85-1.19) in years 2017-2020 for patients with a CHA2DS2-VA score of ≥2 (Figure 1b). For patients with a score of <2, the relative risk was lowest between 2005-2008 (1.02 (95%CI 0.63-1.42)) and was 1.18 (95%CI 0.54-1.83) in the latest time period. Formal statistical test for time trends according to score level revealed non-significant results (p-value=0.10 for score 0-1; p-value=0.17 for score levels of ≥2). Conclusion The risk of stroke among patients with AF has been declining over the last two decades. The excess stroke risk observed among females relative to males has also diminished, most evident among AF patients with ≥2 prevalent stroke risk factors.

Risk of Ischemic Stroke in Relation to Helicobacter pylori Infection and Eradication Status: A Large-Scale Prospective Observational Cohort Study.

: A few studies have suggested the association between Helicobacter pylori (HP) infection and ischemic stroke. However, the impact of HP eradication on stroke risk has not been well evaluated. This study aimed to assess the influence of HP eradication on the incidence of ischemic stroke, considering the potential effect of sex. : This prospective observational cohort study was conducted at Seoul National University Bundang Hospital, from May 2003 to February 2023, and involved gastroscopy-based HP testing. Propensity score (PS) matching was employed to ensure balanced groups by matching patients in the HP eradicated group (n=2,803) in a 3:1 ratio with patients in the HP non-eradicated group (n=960). Cox proportional hazard regression analysis was used to evaluate the risk of ischemic stroke. : Among 6,664 patients, multivariate analysis after PS matching indicated that HP eradication did not significantly alter the risk of ischemic stroke (hazard ratio, 0.531; 95% confidence interval, 0.221 to 1.270; p=0.157). Sex-specific subgroup analyses, both univariate and multivariate, did not yield statistically significant differences. However, Kaplan-Meier analysis revealed a potential trend: the females in the HP eradicated group exhibited a lower incidence of ischemic stroke than those in the HP non-eradicated group, although this did not reach statistical significance (p=0.057). : This finding suggests that HP eradication might not impact the risk of ischemic stroke. However, there was a trend showing that females potentially had a lower risk of ischemic stroke following HP eradication, though further investigation is required to establish definitive evidence.

Primary and secondary prevention of stroke and cardiovascular events using evolocumab and alirocumab: Meta-analysis of randomized controlled trials.

Although the clinical role of protein convertase subtilisin kexin type 9 (PCSK9) inhibitors for cholesterol management is increasing, the post-marketing period of use is short compared to other lipid-lowering drugs, so there is still insufficient evidence for their efficacy and safety. In this meta-analysis, we evaluated preventive effects of stroke and cardiovascular (CV) events using evolocumab and alirocumab. We assessed the relative risk of stroke and CV events after alirocumab or evolocumab treatment in individuals with or without clinical CV diseases compared with that in controls. In addition, we evaluated the relative risk of hemorrhagic stroke. A total of 25 articles were included (median of study duration = 52 weeks). The risk of stroke was significantly decreased after treatment with alirocumab or evolocumab (primary prevention in patients without CV diseases: RR = 0.733; 95% CI, 0.618-0.870; secondary prevention in patients with CV diseases: RR = 0.703; 95% CI, 0.562-0.880). The risk of CV events also significantly decreased in patients treated with alirocumab or evolocumab (primary prevention: RR = 0.818; 95% CI, 0.777-0.861; secondary prevention: RR = 0.725; 95% CI, 0.578-0.910). The relative risk of hemorrhagic stroke was not significantly different between PCSK9 inhibitor-treated patients and controls (RR=1.041; 95% CI, 0.690-1.573). Our findings indicate that evolocumab and alirocumab are significantly effective without increasing the risk of hemorrhagic stroke. Based on this, the PCSK9 inhibitors can be highly recommended for cholesterol management.

The risk of stroke and post-stroke mortality in people with schizophrenia: A systematic review and meta-analysis study

Sources of heterogeneity in risk of stroke and mortality risk following acute-stroke in schizophrenia are understudied. We systematically searched four electronic-databases until 1-November-2022, and conducted meta-analysis to synthesize estimates of stroke-risk and post-stroke mortality for schizophrenia patients relative to non-schizophrenia counterparts. Subgroup-analyses and meta-regression models stratified by sex, nature of sample (incident/prevalent), geographical region, study-period and time-frame following stroke were conducted when applicable. Fifteen and 5 studies were included for meta-analysis of stroke-risk (n=18,368,253; 129,095 schizophrenia patients) and all-cause post-stroke mortality (n=289,231; 4,477 schizophrenia patients), respectively. Schizophrenia patients exhibited elevated stroke-risk (relative-risk =1.55[95% CI:1.31–1.84]) relative to non-schizophrenia controls. Schizophrenia was associated with increased stroke-risk in both sexes, study-periods of 1990s and 2000s, and irrespective of nature of sample and geographical regions. Meta-regression revealed regional differences in relative-risk for stroke, but limited by small number of studies. After removal of an outlier study, meta-analysis demonstrated that schizophrenia was associated with increased overall (hazard-ratio=1.37[1.30–1.44]), short-term (≤90 days; 1.29[1.14–1.46]) and longer-term (≥1 year; 1.45[1.32–1.60]) post-stroke mortality rates. Raised post-stroke mortality rate for schizophrenia was observed irrespective of nature of sample, geographical regions and study-periods. Taken together, schizophrenia is associated with increased stroke-risk and post-stroke mortality. Multilevel-interventions are required to reduce these physical-health disparities.

Fine Particulate Matter Exposure, Genetic Susceptibility, and the Risk of Incident Stroke: A Prospective Cohort Study.

Both genetic factors and environmental air pollution contribute to the risk of stroke. However, it is unknown whether the association between air pollution and stroke risk is influenced by the genetic susceptibilities of stroke and its risk factors. This prospective cohort study included 40 827 Chinese adults without stroke history. Satellite-based monthly fine particulate matter (PM2.5) estimation at 1-km resolution was used for exposure assessment. Based on 534 identified genetic variants from genome-wide association studies in East Asians, we constructed 6 polygenic risk scores for stroke and its risk factors, including atrial fibrillation, blood pressure, type 2 diabetes, body mass index, and triglyceride. The Cox proportional hazards model was applied to evaluate the hazard ratios and 95% CIs for the associations of PM2.5 and polygenic risk score with incident stroke and the potential effect modifications. Over a median follow-up of 12.06 years, 3147 incident stroke cases were documented. Compared with the lowest quartile of PM2.5 exposure, the hazard ratio (95% CI) for stroke in the highest quartile group was 2.72 (2.42-3.06). Among individuals at high genetic risk, the relative risk of stroke was 57% (1.57; 1.40-1.76) higher than those at low genetic risk. Although no statistically significant interaction was found, participants with both the highest PM2.5 and high genetic risk showed the highest risk of stroke, with ≈4× that of the lowest PM2.5 and low genetic risk group (hazard ratio, 3.55 [95% CI, 2.84-4.44]). Similar upward gradients were observed in the risk of stroke when assessing the joint effects of PM2.5 and genetic risks of blood pressure, type 2 diabetes, body mass index, atrial fibrillation, and triglyceride. Long-term exposure to PM2.5 was associated with a higher risk of incident stroke across different genetic susceptibilities. Our findings highlighted the great importance of comprehensive assessment of air pollution and genetic risk in the prevention of stroke.

THU219 Vascular Damage After Craniopharyngioma

Abstract Disclosure: J. Beckhaus: None. S. Boekhoff: None. B. Bison: None. C. Friedrich: None. H.L. Muller: None. Craniopharyngiomas are rare, embryonic, malformational tumors of the (supra-)sellar region. Due to tumor and/or treatment-related hypothalamic lesions, patients develop morbid obesity. Obesity is a major vascular risk factor, leading to reduced 20-year overall survival and a 3- to 19-fold higher cardiovascular mortality after craniopharyngioma compared to the general population. An analysis within the Childhood Cancer Survivor Study (CCSS) revelaed a 10-fold higher relative risk for stroke in adult survivors of childhood/young adult cancers compared to their siblings. To study craniopharyngioma-specific risk factors for vascular damages we searched three databases (Pubmed, CINAHL and Web of Science) and included 49 articles after title and abstract screening. Eligible studies were case reports, cohort and cross-sectional studies. Neurovascular damages due to surgical interventions included cerebral infarcts, stroke, aneurysms, anterior/middle cerebral artery syndrome (ACA/MCA), cerebral venous sinus thrombosis, and seizures. Radiation-induced vascular disease described Moyamoya syndrome, radionecrosis and thrombosis. Tumor-induced inflammation is suspected to play a causal role in the etiology of vascular complications in proximity of the tumor. Therefore, early diagnostics such as echocradiography or cardial MRI and risk-adapted prevention and treatment options for vascular disease are needed to improve long-term prognosis after craniopharyngioma treatment. This review summarizes the available evidence for vascular disease after pediatric- and adult-onset craniopharyngioma to derive possible treatment pathways. Individualized, tertiary prevention programs are required for craniopharyngioma patients and survivors to overcome or reduce the risk of vascular complications and elevate their quality of survival. Presentation: Thursday, June 15, 2023

Stroke Riskometer Application (SRA™) influence on lifestyle changes of home bound familial Malaysian stroke caregivers: a randomised controlled trial in a primary care based longer term stroke care facility

BackgroundIn countries where access to Specialist stroke care services are limited, primary care physicians often manage stroke patients and the caregiving family members. This study aimed to evaluate the impact of Stroke Riskometer Application (SRA™) on promoting healthier lifestyles among familial stroke caregivers for primary prevention.MethodsA parallel, open-label, 2-arm prospective, pilot randomised controlled trial was conducted at a long-term stroke service at a university based primary care clinic. All stroke caregivers aged ≥ 18 years, proficient in English or Malay and smartphone operation were invited. From 147 eligible caregivers, 76 participants were randomised to either SRA™ intervention or conventional care group (CCG) after receiving standard health counselling. The intervention group had additional SRA™ installed on their smartphones, which enabled self-monitoring of modifiable and non-modifiable stroke risk factors. The Stroke Riskometer app (SRATM) and Life's Simple 7 (LS7) questionnaires assessed stroke risk and lifestyle practices. Changes in clinical profile, lifestyle practices and calculated stroke risk were analysed at baseline and 3 months.The trial was registered in the Australia-New Zealand Clinical Trial Registry, ACTRN12618002050235.ResultsThe demographic and clinical characteristics of the intervention and control group study participants were comparable. Better improvement in LS7 scores were noted in the SRA™ arm compared to CCG at 3 months: Median difference (95% CI) = 0.88 (1.68–0.08), p = 0.03. However, both groups did not show significant changes in median stroke risk and relative risk scores at 5-, 10-years (Stroke risk 5-years: Median difference (95% CI) = 0.53 (0.15–1.21), p = 0.13, 10-years: Median difference (95% CI) = 0.81 (0.53–2.15), p = 0.23; Relative risk 5-years: Median difference (95% CI) = 0.84 (0.29–1.97), p = 0.14, Relative risk 10-years: Median difference (95% CI) = 0.58 (0.36–1.52), p = 0.23).ConclusionSRA™ is a useful tool for familial stroke caregivers to make lifestyle changes, although it did not reduce personal or relative stroke risk after 3 months usage.Trial registrationNo: ACTRN12618002050235 (Registration Date: 21st December 2018).

Global and Regional Estimate of HIV-Associated Stroke Burden: A Meta-Analysis and Population Attributable Modeling Study.

This study aimed to determine the correlation between human-immunodeficiency-virus (HIV) infection and stroke, as well as to estimate the global, regional, and national burden of HIV-associated stroke. A registered meta-analysis was performed by searching PubMed, Embase, and Web of Science for relevant literature up to October 31, 2022. The pooled relative risk of stroke in HIV-infected people was calculated using a random-effects model. HIV prevalence and disability-adjusted life years (DALYs) datasets were obtained from the Joint United Nations Program on HIV and AIDS, and the Global Health Data Exchange, respectively. The population attributable fraction was estimated and delivered to calculate the HIV-associated DALYs of stroke from 1990 to 2019, at the global, regional, and national levels. Pearson correlation analysis were conducted to assess the correlation between the age-standardized rate or estimated annual percentage changes and the sociodemographic index. Out of 10 080 identified studies, 11 were included in this meta-analysis. Compared with individuals without HIV-infection, the pooled relative risk of stroke in HIV-infected individuals was 1.40 (95% CI, 1.18-1.65). From 1990 to 2019, the global population attributable fraction of HIV-associated stroke increased almost 3-fold, while the HIV-associated DALYs increased from 18 595 (95% CI, 7485-31 196) in 1990 to 60 684 (95% CI, 24 281-101 894) in 2019. Meanwhile, HIV-associated DALYs varied by region, with Eastern and Southern Africa having the highest value of 126 160 in 2019. Moreover, countries with middle social development index were shouldering the highest increase trend of the HIV-associated DALYs age-standardized rates. HIV-infected individuals face a significantly higher risk of stroke, and the global burden of HIV-associated stroke has increased over the past 3 decades, showing regional variations. Eastern and Southern Africa bear the highest burden, while Eastern Europe and Central Asia have seen significant growth. Health care providers, researchers, and decision-makers should give increased attention to stroke prevention and management in HIV-endemic areas. URL: https://www. gov; Unique identifier: CRD42022367450.

Calibration of the IQVIA Core Diabetes Model to the stroke outcomes from the SUSTAIN 6 cardiovascular outcomes trial of once-weekly semaglutide

AimsIn the SUSTAIN 6 cardiovascular outcomes trial, once-weekly semaglutide was associated with a statistically significant reduction in major adverse cardiovascular events compared with placebo. To date, no studies have assessed how accurately existing diabetes models predict the outcomes observed in SUSTAIN 6. The aims of this analysis were to investigate the performance of the IQVIA Core Diabetes Model when used to predict the SUSTAIN 6 trial outcomes, to calibrate the model such that projected outcomes reflected observed outcomes, and to examine the impact of calibration on the cost-effectiveness of once-weekly semaglutide from a UK healthcare payer perspective.MethodsThe IQVIA Core Diabetes Model was calibrated to ensure that the projected non-fatal stroke event rates reflected the non-fatal stroke event rates observed in SUSTAIN 6 over a two-year time horizon. Cost-effectiveness analyses of once-weekly semaglutide versus placebo plus standard of care were conducted over a lifetime horizon using the uncalibrated and calibrated models to assess the impact on cost-effectiveness outcomes.ResultsTo replicate the non-fatal stroke event rate in SUSTAIN 6, calibration of the model through the application of relative risks for stroke of 1.07 and 1.65 with once-weekly semaglutide and placebo, respectively, was required. In the long-term cost-effectiveness analysis, the uncalibrated model projected an incremental cost-effectiveness ratio for once-weekly semaglutide versus placebo plus standard of care of GBP 22,262 per quality-adjusted life year (QALY) gained, which fell to GBP 17,594 per QALY gained when the calibrated model was used.ConclusionsThe requirement for calibration to replicate the outcomes observed in SUSTAIN 6 suggests that the reductions in risk of cardiovascular complications observed with once-weekly semaglutide cannot be solely explained by differences in conventional risk factors. Accurate estimation of the risk of diabetes-related complications using methods such as calibration is important to ensure accurate cost-effectiveness analyses are conducted.

Factors associated with stroke after COVID-19 vaccination: a statewide analysis.

The objective of our study was to evaluate vaccine type, COVID-19 infection, and their association with stroke soon after COVID-19 vaccination. In a retrospective cohort study, we estimated the 21-day post-vaccination incidence of stroke among the recipients of the first dose of a COVID-19 vaccine. We linked the Georgia Immunization Registry with the Georgia Coverdell Acute Stroke Registry and the Georgia State Electronic Notifiable Disease Surveillance System data to assess the relative risk of stroke by the vaccine type. Approximately 5 million adult Georgians received at least one COVID-19 vaccine between 1 December 2020 and 28 February 2022: 54% received BNT162b2, 41% received mRNA-1273, and 5% received Ad26.COV2.S. Those with concurrent COVID-19 infection within 21 days post-vaccination had an increased risk of ischemic (OR = 8.00, 95% CI: 4.18, 15.31) and hemorrhagic stroke (OR = 5.23, 95% CI: 1.11, 24.64) with no evidence for interaction between the vaccine type and concurrent COVID-19 infection. The 21-day post-vaccination incidence of ischemic stroke was 8.14, 11.14, and 10.48 per 100,000 for BNT162b2, mRNA-1273, and Ad26.COV2.S recipients, respectively. After adjusting for age, race, gender, and COVID-19 infection status, there was a 57% higher risk (OR = 1.57, 95% CI: 1.02, 2.42) for ischemic stroke within 21 days of vaccination associated with the Ad26.COV2.S vaccine compared to BNT162b2; there was no difference in stroke risk between mRNA-1273 and BNT162b2. Concurrent COVID-19 infection had the strongest association with early ischemic and hemorrhagic stroke after the first dose of COVID-19 vaccination. Although not all determinants of stroke, particularly comorbidities, were considered in this analysis, the Ad26.COV2.S vaccine was associated with a higher risk of early post-vaccination ischemic stroke than BNT162b2.

Age and sex-specific stroke epidemiology in COVID-19.

COVID-19 has emerged as an independent risk factor for stroke. We aimed to determine age and sex-specific stroke incidence and risk factors with COVID-19 in the US using a large electronic health record (EHR) that included both inpatients and outpatients. A retrospective cohort study was conducted using individual-level data from Optum® de-identified COVID-19 EHR. A total of 387,330 individuals aged ≥18 with laboratory-confirmed COVID-19 between March 1, 2020 and December 31, 2020 were included. The primary outcome was cumulative incidence of stroke after COVID-19 confirmation within 180 days of follow-up or until death. Kaplan-Meier cumulative incidence curves for acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and a composite outcome of all strokes were stratified by sex and age, and the differences in curves were assessed using a log-rank test. The relative risk of stroke by demographics and risk factors was estimated using multivariable Cox-proportional hazards regressions and adjusted hazard ratios (aHRs). Of 387,330 COVID-19 patients, 2,752 patients (0.71%, 95% CI 0.68-0.74) developed stroke during the 180-day follow-up, AIS in 0.65% (95% CI 0.62-0.67), and ICH in 0.11% (95% CI 0.10-0.12). Of strokes among COVID-19 patients, 57% occurred within 3 days. Advanced age was associated with a substantially higher stroke risk, with aHR 6.92 (5.72-8.38) for ages 65-74, 9.42 (7.74-11.47) for ages 75-84, and 11.35 (9.20-14.00) for ages 85 and older compared to ages 18-44 years. Men had a 32% higher risk of stroke compared to women. African-American [aHR 1.78 (1.61-1.97)] and Hispanic patients [aHR 1.48 (1.30-1.69)] with COVID-19 had an increased risk of stroke compared to white patients. This study has several important findings. AIS and ICH risk in patients with COVID-19 is highest in the first 3 days of COVID-19 positivity; this risk decreases with time. The incidence of stroke in patients with COVID-19 (both inpatient and outpatient) is 0.65% for AIS and 0.11% for ICH during the 180-day follow-up. Traditional stroke risk factors increase the risk of stroke in patients with COVID-19. Male sex is an independent risk factor for stroke in COVID-19 patients across all age groups. African-American and Hispanic patients have a higher risk of stroke from COVID-19.

Abstract 12213: A Description of Left Atrial Appendage Morphologies by Race

Introduction : The left atrial appendage (LAA) is the origin of most thromboemboli in patients with atrial fibrillation (AF). Certain LAA morphologies are associated with higher risk of thrombus formation and stroke. Blacks with AF suffer more ischemic strokes than non-Blacks despite adjustment for conventional stroke risk factors and differences in anticoagulation prescription. The association of certain LAA morphologies with race as a contributing explanation for the racial difference in stroke risk has not been examined. We hypothesized that, among those with AF, Blacks have higher risk LAA morphologies compared to non-Blacks. Methods : We performed a retrospective analysis of consecutive patients with AF who underwent a contrast-enhanced CT scan in preparation for Watchman device placement to determine LAA morphology. Based on prior literature, we assigned a score to each morphology based on relative risk of stroke associated with each morphology: chicken wing, 1 (lowest risk, reference); windsock or cactus, 4; and cauliflower, 8. Mean scores among Blacks vs non-Blacks, defined as White, Asian, or Hispanic, were compared using Students T-test. Results : Among 85 patients (Black, n=36), there was no significant difference in the proportion of individuals with the low risk chicken wing morphology between races (29% Black versus 36% non-Black, p = 0.69). However, Blacks were more likely to have the high risk cauliflower morphology (n=5, 6% versus n=1, 1%, p=0.04). The summative mean score for morphology-associated stroke risk was higher among Blacks (2.1 vs 2.5, p=0.017) ( Figure ). Conclusions : Black patients with AF had higher-risk LAA morphologies compared to non-Black patients. These findings may explain the previously observed racial differences in AF-associated stroke risk.Figure: Distribution of LAA morphologies by Black versus Non-Black and difference in summative relative risk between Black and Non-Black patients.

Risk of future stroke in patients with a diagnosis of peripheral vertigo in the emergency department.

The temporal characteristics of stroke risks were evaluated in emergency department patients who had a diagnosis of peripheral vertigo. It was also attempted to reveal the stroke risk factor amongst those with peripheral vertigo. This is a parallel-group cohort study in a tertiary referral hospital. After assigning each of 4367 matched patients to the comparative set of peripheral vertigo and appendicitis-ureterolithiasis groups and each of 4911 matched patients to the comparative set of peripheral vertigo and ischaemic stroke groups, the relative stroke risk was evaluated. In addition, to predict the individual stroke risk in patients with peripheral vertigo, any association between the demographic factors and stroke events was evaluated in the peripheral vertigo group. The peripheral vertigo group had a higher stroke risk than the appendicitis-ureterolithiasis group (hazard ratio 1.73, 95% confidence interval 1.18-2.55) but a lower risk than the ischaemic stroke group (hazard ratio 0.30, 95% confidence interval 0.24-0.37). The stroke risk of the peripheral vertigo group was just below that of small vessel stroke. The stroke risk of the peripheral vertigo group differed markedly by time: higher within 7 days, moderate between 7 days and 1 year, and diminished thereafter. Old age (>65 years), male gender and diabetes mellitus were the risk factors for stroke in the peripheral vertigo group. Patients with a diagnosis of peripheral vertigo in the emergency department showed a moderate future stroke risk and so a stroke preventive strategy tailored to the timing of symptom onset and individual risk is required.

Risks of Stroke and Heart Disease Following Hysterectomy and Oophorectomy in Chinese Premenopausal Women.

Background:Little is known about the long-term risks of stroke and ischemic heart disease (IHD) in women who had a hysterectomy alone (HA) or with bilateral oophorectomy (HBO) for benign diseases, particularly in China where the burden of cardiovascular diseases (CVD) is high. We assessed mean levels of cardiovascular risk factors and relative risks of stroke and IHD in Chinese women who had a HA or HBO.Methods:A total of 302 510 women, aged 30 to 79 years were enrolled in the China Kadoorie Biobank from 2004 to 2008 and followed up for a mean of 9.8 years. The analysis involved premenopausal women without prior cardiovascular disease or cancer at enrollment. We calculated adjusted hazard ratios for incident cases of CVD and their pathological types (ischemic stroke, hemorrhagic stroke, and IHD) after HA and HBO. Analyses were stratified by age and region and adjusted for levels of education, household income, smoking status, alcohol consumption, physical activity, body mass index, systolic blood pressure, diabetes, self-reported health, and number of pregnancies.Results:Among 282 722 eligible women, 8478 had HA, and 1360 had HBO. Women who had HA had 9% higher risk of CVD after HA (hazard ratio, 1.09 [95% CI, 1.06–1.12]) and 19% higher risk of CVD after HBO (1.19 [95% CI, 1.12–1.26]) compared with women who did not. Both HA and HBO were associated with higher risks of ischemic stroke and IHD but not with hemorrhagic stroke. The relative risks of CVD associated with HA and HBO were more extreme at younger age of surgery.Conclusions:Women who had either HA or HBO have higher risks of ischemic stroke and IHD, and these risks should be evaluated when discussing these interventions. Additional screening for risk factors for CVD should be considered in women following HA and HBO operations, especially if such operations are performed at younger age.

Vascular risk factors and stroke risk across the life span: A population-representative study of half a million people.

Background:The incidence of stroke in developed countries is increasing selectively in young individuals, but whether this is secondary to traditional vascular risk factors is unknown.Methods:We used the Canadian Community Health Survey from 2000 to 2016 to create a large population-representative cohort of individuals over the age of 30 and free from prior stroke. All analyses were stratified by age decile. We linked with administrative databases to determine emergency department visits or hospitalizations for acute stroke until December 2017. We calculated time trends in risk factor prevalence (hypertension, diabetes, obesity, and smoking) using meta-regression. We used Cox proportional hazard models to evaluate the association between vascular risk factors and stroke risk, adjusted for demographic, co-morbid, and social variables. We used competing risk regression to account for deaths and calculated population-attributable fractions. In a sensitivity analysis, we excluded those with prior heart disease or cancer.Results:We included 492,400 people in the analysis with 8865 stroke events over a median follow-up time of 8.3 years. Prevalence of hypertension, diabetes, and obesity increased over time while smoking decreased. Associations of diabetes, hypertension, and obesity with stroke risk were progressively stronger at younger age (adjusted hazard ratio for diabetes was 4.47, 95% confidence interval (CI) = 1.95–10.28 at age 30–39, vs 1.21, 95% CI = 0.93–1.57 at age 80+), although the obesity association was attenuated with adjustment. Smoking was associated with higher risk of stroke without a gradient across age deciles, although had the greatest population-attributable fraction at younger age. The hazard ratio for stroke with multiple concurrent risk factors was much higher at younger age (adjusted hazard ratio for 3–4 risk factors was 8.60, 95% CI = 2.97–24.9 at age 30–39 vs 1.61, 95% CI = 0.88–2.97 at age 80+) and results were consistent when accounting for the competing risk of death and excluding those with prior heart disease or cancer.Conclusions:Diabetes and hypertension were associated with progressively elevated relative risk of stroke in younger individuals and prevalence was increasing over time. The association of obesity with stroke was not significant after adjustment for other factors. Smoking had the greatest prevalence and population-attributable fraction for stroke at younger age. Our findings assist in understanding the relationship between vascular risk factors and stroke across the life span and planning public health measures to lower stroke incidence in the young.

Obstructive Sleep Apnea Screened by Overnight Pulse Oximetry and Higher Risk of Serious Cardiovascular Events: Prospective Cohort Study in the Primary Care

Introduction: Obstructive sleep apnea (OSA) is a condition characterized by sleep disordered breathing which results in health impairment and other related injuries. Cardiovascular and neurocognitive morbidities and increased risk of motor vehicle accidents have been demonstrated in patients with untreated OSA. Overnight pulse oximetry is a good screening tool for OSA. There is no study to examine the prospective outcome of patients with screening positive OSA in the primary care setting. Methodology: This is a prospective cohort study involving consecutive patients whom had performed OSA screening by overnight pulse oximetry in a primary care clinic of Hong Kong from year 2011 to year 2012. One hundred and eighty consecutive OSA screening positive patients were the cohort group while 180 consecutive OSA screening negative patients were the control group. The five year incidence of serious cardiovascular complications and associated predictive factors were examined. Results: Both of cohort and control group patients were followed prospectively for 5 years. There was higher proportion of male (68.3% versus 45.0%, p<0.001) and obesity (58.3% versus 41.1%, p=0.001) patients in the cohort group. There was no statistical difference in concomitant chronic disease or difference in mean blood pressure and Epworth Sleepiness Scale (ESS) score among two groups. At five year follow up, there was no cardiovascular related mortality among two groups. The five year relative risk (RR) of screening positive OSA versus screening negative for serious cardiovascular event is 3.03 (95% CI, 1.16-7.86; p=0.018). By stratification, the relative risk for stroke is 1.69 (95% CI, 0.40-7.16; p=0.475), while for coronary artery disease (CAD) is 4.24 (95%CI, 1.18-15.29; p=0.017). Conclusion: Overnight pulse oximetry screening positive obstructive sleep apnea is the independent risk factor for coronary artery disease.

Abstract 13362: Patient-centered Assessment Of Risk Of Stroke Vs. Bleeding In Patients With Atrial Fibrillation

Introduction: Clinicians use CHA 2 DS 2 -VASc to predict stroke at one year and HAS-BLED to predict bleeding at one year in patients with atrial fibrillation. However, the scores do not consider the fear of the two outcomes in the individual patient. Hypothesis: A new algorithm predicting the relative risk of stroke versus bleeding at one year implemented as a web application will classify individual patients with high degree of precision. Methods: Using the Myocardial Infarction Data Acquisition System (MIDAS) database, we developed an algorithm that considers the preferences of each individual patient as estimated from data from history in predicting the risk of bleeding or stroke from CHA 2 DS 2 -VASc and HAS-BLED. Given the patient demographics and comorbidities, the confidence intervals of predicted risks of the outcomes were first obtained by fitting a multinomial regression model. The estimates were fed into a Deming regression model to correlate the risks of the outcomes in subgroups of patients with similar risk factors. The line of best fit between the two outcomes represented the objective relationship between the outcomes. Each patient would state their fears of the outcomes on a 0 to 100 scale and adding up to 100, e.g. 20 vs. 80 for fear of stroke vs. fear of bleeding respectively. A prediction region around the line of best fit was then calculated based on the patient’s fears. Results: Based on the predicted risks of stroke and bleeding and the patient’s fears of bleeding, the algorithm produces a graph with two regions corresponding to whether the patient should be treated with anticoagulants. Thus, patients who feared stroke more than bleeding would be more likely to receive anticoagulation compared to a decision based on objective data. Conclusions: The algorithm shown in the figure and implemented as a web application helps clinicians make decisions on whether to prescribe anticoagulants or not based on objective data modified by individual patient preferences.