Stroke Hospitalization Rates Research Articles

Age- and Sex-Specific Analysis of Stroke Hospitalization Rates, Risk Factors, and Outcomes From German Nationwide Data.

Significant age and sex differences have been reported at each stage of the stroke pathway, from risk factors to outcomes. However, there is some uncertainty in previous studies with regard to the role of potential confounders and selection bias. Therefore, using German nationwide administrative data, we aimed to determine the magnitude and direction of trends in age- or sex-specific differences with respect to admission rates, risk factors, and acute treatments of ischemic and hemorrhagic stroke. We obtained and analyzed data from the Research Data Centres of the Federal Statistical Office for the years 2010 to 2020 with regard to all acute stroke hospitalizations, risk factors, treatments, and in-hospital mortality, stratified by sex and stroke subtype. This database provides a complete national-level census of stroke hospitalizations combined with population census counts. All hospitalized patients ≥15 years with an acute stroke (diagnosis code: I60-64) were included in the analysis. Over the 11-year study period, there were 3 375 157 stroke events; 51.2% (n=1 728 954) occurred in men. There were higher rates of stroke admissions in men compared with women for both ischemic (378.1 versus 346.7/100 000 population) and hemorrhagic subtypes (75.6 versus 65.5/100 000 population) across all age groups. The incidence of ischemic stroke admissions peaked in 2016 among women (354.0/100 000 population) and in 2017 among men (395.8/100 000 population), followed by a consistent decline from 2018 onward. There was a recent decline in hemorrhagic stroke admissions observed for both sexes, reaching its nadir in 2020 (68.9/100 000 for men; 59.5/100 000 for women). Female sex was associated with in-hospital mortality for both ischemic (adjusted odds ratio, 1.11 [1.09-1.12]; P<0.001) and hemorrhagic stroke (adjusted odds ratio, 1.18 [95% CI, 1.16-1.20]; P<0.001). Despite improvements in stroke prevention and treatment pathways in the past decade, sex-specific differences remain with regard to hospitalization rates, risk factors, and mortality. Better understanding the mechanisms for these differences may allow us to develop a sex-stratified approach to stroke care.

Impact of surface ultraviolet radiation intensity on hospital admissions for ischemic and hemorrhagic stroke: A large-scale database study using distributed lag nonlinear analysis, 2015-2022, in Harbin, China

ObjectivesOur aim is to evaluate the impact of surface ultraviolet radiation intensity on hospital admissions for stroke and to compare the correlation and differences among different subtypes of strokes. Materials and methodsWe collected daily data on surface ultraviolet radiation intensity, temperature, air pollution, and hospital admissions for stroke in Harbin from 2015 to 2022. Using a distributed lag non-linear model, we determined the correlation between daily surface ultraviolet radiation intensity and the stroke admission rate. Relative risks (RR) with 95% confidence intervals (CI) and attributable fractions (AF) with 95% CI were calculated based on stroke subtypes, gender, and age groups. ResultsA total of 132,952 hospitalized stroke cases (including hemorrhagic and ischemic strokes) were included in the study. We assessed the non-linear effects of ultraviolet intensity on hospitalized patients with ischemic and hemorrhagic strokes. Compared to the maximum morbidity benchmark ultraviolet intensity (19.2 × 10^5 for ischemic stroke and 20.25 for hemorrhagic stroke), over the 0-10 day lag period, the RR for extreme low radiation (1st percentile) was 0.86 (95% CI: 0.77, 0.96), and the RR for extreme high radiation (99th percentile) was 0.86 (95% CI: 0.77, 0.96). In summary, -4.842% (95% CI: -7.721%, -2.167%) and -1.668% (95% CI: -3.061%, -0.33%) of ischemic strokes were attributed to extreme low radiation intensity with a lag of 0 to 10 days and extreme high radiation intensity with a lag of 0 to 5 days, respectively. The reduction in stroke hospitalization rates due to low or high ultraviolet intensity was more pronounced in females and younger individuals compared to males and older individuals. None of the mentioned ultraviolet intensity intensities and lag days had a statistically significant impact on hemorrhagic stroke. ConclusionsOur study fundamentally suggests that both lower and higher levels of surface ultraviolet radiation intensity in Harbin, China, contribute to a reduced incidence of ischemic stroke, with this effect lasting approximately 10 days. This finding holds significant potential for public health and clinical relevance.

Impact of new drug releases on heart failure management and hospitalizations in France: A repeated cross-sectional study between 2014 and 2023

Real-life data on the impact of sacubitril-valsartan and sodium-glucose cotransporter type 2 (SGLT-2) inhibitors on heart failure (HF) in France is lacking. Using French health insurance databases, we examined the ten-year evolution in HF medication use, focusing on SGLT-2 inhibitors and sacubitril/valsartan, and incidence of HF hospitalizations during the same period. We conducted a repeated cross-sectional study using medical-administrative data from French health insurance databases between 2014 and 2023. These included "OpenMedic" for outpatient medication reimbursements and "ScanSanté" for annual hospitalization data. Medications were classified using ATC codes, and hospitalizations were identified using ICD-10 codes. Statistical analyses encompassed annual rates of users and boxes dispensed for HF medications, along with HF, ischemic heart disease and ischemic stroke hospitalization rates. Prevalence of SGLT-2 inhibitors and sacubitril-valsartan use was also studied regionally, with direct standardization by age and sex, with the French population as the standard population. Between 2014 and 2023, HF drug use increased significantly, with beta-blockers and ACE inhibitors/ARBs leading in prevalence of use. ARNi and SGLT-2 inhibitors, introduced later, showed remarkable rises: +506% and +3766% in users since their market introduction, respectively. Meanwhile, HF hospitalizations slightly increased by +3.6% between 2016 and 2019, followed by a notable decline of -12.5% during 2019-2023, coinciding with the introduction of SGLT-2 inhibitors. In contrast, hospitalizations for ischemic heart disease rose by 11.6% over the period 2016-2019 and by +5.2% over the period 2019-2023, and hospitalizations for ischemic stroke rose by 8.2% over the period 2016-2019 and declined by -0.6% over the period 2019-2023. We observed regional disparities in SGLT-2 inhibitors use, with prevalence ranging from 0.9% in Bretagne to 1.5% in Hauts-de-France. The data suggests a temporal correlation between the increase in SGLT-2 inhibitors use and the decline in HF hospitalizations since 2019. More studies are needed to measure real life effectiveness of SGLT-2 inhibitors in heart failure.

Abstract TP120: Racial Disparities and Predictors of All-Cause Mortality in Postmenopausal Women Hospitalized for Stroke: A Nationwide Analysis, 2019

Background: Racial disparities in stroke prevalence and outcomes have been well documented in previous studies, but there is not sufficient data based on post-menopausal women. In this study, we aim to analyze stroke hospitalization rates and subsequent mortality rates by race among females aged 55 years and older. We also sought to identify independent predictors of mortality based on race. Methods: We queried the 2019 National Inpatient Sample to identify stroke hospitalizations in women aged &gt;55 years by using ICD-10 CM codes. Demographics were analyzed after stratifying the population by race. Multivariable regression analysis was performed taking stroke admission rates and mortality by race as a primary outcome of interest and the co-primary outcome was independent predictors of mortality by race. Results: A total of 140,805 patients with a median age of 76 [67-85] were included in the study of which 66.9% were white, 16.5% black, 7.5% Hispanic, 3.6% Asian/Pacific Islander 0.6% Native Americans, and 2.5% in the other race category. Blacks (52.8%) and Native Americans (47.9%) were significantly present in the lowest national household income quartile compared to Asians/Pacific Islanders (26.1%). COPD (OR: 1.19 95%, p- 0.017), cancer (OR: 1.27 p - 0.030), and age at admission (OR: 1.02 p &lt;0.001) were independent positive predictors for all-cause mortality in whites, while complicated hypertension (OR: 2.64 p - 0.039), and age at admission (OR: 1.04 p - 0.004) were the independent positive predictors for the Asian population. Conclusion: Among post-menopausal women hospitalized with stroke, all-cause mortality was the highest in Asians, followed by whites and Hispanics. Interventions and targeted strategies can be developed to address these disparities, further studies should be conducted to investigate the causes and etiologies of these disparities.

Cardiovascular hospitalizations and mortality among adults aged 25-64 years in the USA.

Declines in cardiovascular mortality have stagnated in the USA since 2011. There is growing concern that these patterns reflect worsening cardiovascular health in younger adults. However, little is known about how the burden of acute cardiovascular hospitalizations and mortality has changed in this population. Changes in cardiovascular hospitalizations and mortality among adults aged 25-64 years were evaluated, overall and by community-level income. Using the National Inpatient Sample, age-standardized annual hospitalization and in-hospital mortality rates for acute myocardial infarction (AMI), heart failure, and ischaemic stroke were determined among adults aged 25-64 years. Quasi-Poisson and quasi-binominal regression models were fitted to compare outcomes between individuals residing in low- and higher-income communities. Between 2008 and 2019, age-standardized hospitalization rates for AMI increased among younger adults from 155.0 (95% confidence interval: 154.6, 155.4) per 100 000 to 160.7 (160.3, 161.1) per 100 000 (absolute change +5.7 [5.0, 6.3], P < .001). Heart failure hospitalizations also increased (165.3 [164.8, 165.7] to 225.3 [224.8, 225.8], absolute change +60.0 (59.3, 60.6), P < .001), as ischaemic stroke hospitalizations (76.3 [76.1, 76.7] to 108.1 [107.8, 108.5], absolute change +31.7 (31.2, 32.2), P < .001). Across all conditions, hospitalizations rates were significantly higher among younger adults residing in low-income compared with higher-income communities, and disparities did not narrow between groups. In-hospital mortality decreased for all conditions over the study period. There was an alarming increase in cardiovascular hospitalizations among younger adults in the USA from 2008 to 2019, and disparities between those residing in low- and higher-income communities did not narrow.

Outcomes after ischemic stroke for dual-eligible Medicare-Medicaid beneficiaries in the United States.

Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone. We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors. At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson's r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03-1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02-1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17-1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality. Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.

Does altitude have an effect on stroke mortality and hospitalization risk? A comprehensive evaluation of United States data

BackgroundGlobally, stroke is a leading cause of death among people over 50 years of age. In the United States alone, over 150,000 people die due to stroke every year. Environmental factors such as altitude may play a role in these outcomes; however, their effects have not yet been comprehensively explored. The objective of this study is to evaluate the effect of altitude along with other covariates on stroke mortality and hospitalization rates in adults.MethodsThis study utilized altitude, stroke mortality and hospitalization rates; antihypertensive and cholesterol-lowering medication usage; smoking prevalence; and sociodemographic data (MH-SVI) obtained from government databases for 3,141 counties in the United States from 2018 to 2020. Data were analyzed using generalized additive models with and without adjustments for covariates.ResultsUnadjusted models show that altitude has a comparable significant negative effect on mortality rates for Black and white populations. When including all covariates, altitude continues to have a significant protective effect against stroke fatalities in white populations (retaining 26.6 and 53.8% of the effect magnitude for cardiovascular disease (CVD) and stroke mortality, respectively), a non-significant effect in the Black population, and a detrimental effect in Hispanic and Asian Pacific populations for CVD mortality (a 21.6 and 39.1% effect increase, respectively).ConclusionOur findings add to the growing body of evidence that environmental factors add to disparities between racial groups and play a significant role in CVD and stroke mortality. The effect of altitude is comparable in size to that of smoking, medication usage, and social determinants of health.

626 From the Stroke Belt to San Francisco: Racial Disparities in Stroke Persist

INTRODUCTION: Racial disparities in stroke are classically observed in geographical areas carrying the greatest stroke burden and mortality, namely the Stroke Belt region of the Southeastern U.S. In these territories, African Americans experience a substantially greater stroke incidence than Caucasians, however there is a paucity of in-depth analyses for regions of vastly different demographic variation and socioeconomic profile. The authors seek to determine if the same disparity exists in the surrounding counties of the San Francisco Bay Area. METHODS: A county-specific search of the CDC Interactive Atlas of Heart Disease and Stroke was conducted for seventeen Bay Area counties (2017-2019) using stroke hospitalization rates by race, population counts, race distribution, and percent aged ≥65. Percent estimates of the racial distribution of IS and HS hospitalizations were calculated. The probability of Black racial identity and IS was estimated to observe the relationship between population distribution across counties and the likelihood of IS hospitalization among Blacks. RESULTS: Stroke hospitalization rates among Blacks/African Americans averaged 10.67 per 1000 for IS (95% CI [10.01, 11.32]), 2.19 for HS (95% CI [1.96, 2.42]); average rates among whites/Caucasians were 7.04 (95% CI [6.64, 7.45]) and 1.37 (95% CI [1.30, 1.43]), respectively. While the probability of Black racial identity and IS hospitalization was expectedly higher in counties with a larger Black population, it was disproportionate in counties like Alameda and Sacramento. CONCLUSIONS: Examination of CDC data revealed a 1.5-fold greater disparity in stroke hospitalization rates among African Americans in the San Francisco Bay Area, indicating a persistence of established racial disparities in other parts of the country. Further analysis of socioeconomic data by county and regional comparisons are necessary to uncover the mechanisms of racial disparity in stroke.

The Effect of Prognostic Nutritional Index on Infection in Acute Ischemic Stroke Patients.

Objectives: Malnutrition is frequently seen in stroke patients. Malnutrition worsens the prognosis and increases the mortality rate in acute ischemic stroke patients. Malnutrition is a significant factor not only in the initiation of infection but also in its progression. The prognostic nutritional index (PNI) is a new index that evaluates the nutrition and inflammatory status. This study aims to investigate the relationship between PNI and stroke-related infection (SRI) development during hospitalization in patients with acute ischemic stroke. Materials and Methods: Acute ischemic stroke was the primary diagnosis for 158 patients who were admitted to the neurology intensive care unit. Patients' demographic, clinical, and laboratory parameters were recorded. PNI was calculated according to the formula given below. PNI: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (mm3). PNI > 380 normal, PNI: 350-380 moderate malnutrition risk, PNI < 350 severe malnutrition risk. Results: A total of 158 patients with acute ischemic stroke were included in the study. There were 70 male and 88 female patients, whereas the mean age of the patients was 67.79 ± 14.0 years. Nosocomial infection developed in 34 (21%) of the patients. Compared to high PNI scores, patients with low PNI scores were generally older, and the National Institutes of Health Stroke Scale (NIHSS) score, atrial fibrillation, infection, mortality rate, and hospitalization rates were all significantly higher. Conclusions: In this study, we discovered that patients with poor PNI had a considerably increased rate of infection development. It is vital to evaluate the nutritional status of patients with acute ischemic stroke during hospitalization.

Trends of stroke hospitalisation and fatality rates in young vs. elderly people in Poland during 2010-2019 decade.

Since the turn of the century, epidemiological studies have shown an increase in stroke hospitalisation rates among young adults in contrast to a decline in rates seen among the older population. The aim of the present study was to investigate the trends of stroke hospitalisation rates and case fatality ratios (CFR) over the decade starting in 2010 in different age groups of the Polish population. The patients were identified on the basis of the Polish National Health Fund that gathers all the data of the Hospital Discharge Registry as well as the National Cause of Death Registry of patients with stroke who were hospitalised between 2010 and 2019 and who were diagnosed according to the International Classification of Diseases - Tenth Revision (ICD-10) with haemorrhagic stroke (HS; codes I61* and I62*) and ischaemic stroke (IS; codes I63*). From a total nationwide cohort of 799,132 stroke patients (86.2% with IS and 13.8% with HS) treated between 2010 and 2019, a group of 22,329 patients (2.79%) aged 18-44 years was selected, among whom 69.6% had IS and 30.4% had HS. We documented a statistically significant increase in the IS hospitalisation rate in young adults alongside a decrease of this rate in those aged > 64. Among young adults with IS, the highest increase (p = 0.001) was observed for those aged 35-44 in 2019 (up to 39.2), and was significant each year starting from 2017 (2017-2019: p < 0.01). In the case of HS, the annual number of patients did not change significantly. In 2019 (compared to 2010), a decrease in 30-day, 90-day and 1-year CFR was noted in all age groups of patients with IS and HS. Stroke aetiology of IS was diagnosed in 60% of patients. More than 40% of patients with IS were discharged with the diagnosis of stroke of unspecified cause. In the case of IS, opposite trends of hospitalisation rates in younger and older age groups were documented, with the highest increase of IS in patients aged 35-44. A decline in CFR was observed for both IS and HS in all age groups.

Social Determinants of Stroke Hospitalization and Mortality in United States' Counties.

(1) Background: Stroke incidence and outcomes are influenced by socioeconomic status. There is a paucity of reported population-level studies regarding these determinants. The goal of this ecological analysis was to determine the county-level associations of social determinants of stroke hospitalization and death rates in the United States. (2) Methods: Publicly available data as of 9 April 2021, for the socioeconomic factors and outcomes, was extracted from the Centers for Disease Control and Prevention. The outcomes of interest were “all stroke hospitalization rates per 1000 Medicare beneficiaries” (SHR) and “all stroke death rates per 100,000 population” (SDR). We used a multivariate binomial generalized linear mixed model after converting the outcomes to binary based on their median values. (3) Results: A total of 3226 counties/county-equivalents of the states and territories in the US were analyzed. Heart disease prevalence (odds ratio, OR = 2.03, p < 0.001), blood pressure medication nonadherence (OR = 2.02, p < 0.001), age-adjusted obesity (OR = 1.24, p = 0.006), presence of hospitals with neurological services (OR = 1.9, p < 0.001), and female head of household (OR = 1.32, p = 0.021) were associated with high SHR while cost of care per capita for Medicare patients with heart disease (OR = 0.5, p < 0.01) and presence of hospitals (OR = 0.69, p < 0.025) were associated with low SHR. Median household income (OR = 0.6, p < 0.001) and park access (OR = 0.84, p = 0.016) were associated with low SDR while no college degree (OR = 1.21, p = 0.049) was associated with high SDR. (4) Conclusions: Several socioeconomic factors (e.g., education, income, female head of household) were found to be associated with stroke outcomes. Additional research is needed to investigate intermediate and potentially modifiable factors that can serve as targeted interventions.

Temporal Trends in Acute Haemorrhagic Stroke Hospitalisation Rates Between Males and Females From 2002 to 2017 in New South Wales, Australia: A Statewide-Population Study

Temporal Trends in Acute Haemorrhagic Stroke Hospitalisation Rates Between Males and Females From 2002 to 2017 in New South Wales, Australia: A Statewide-Population Study

Clinical and Economic Burden of Stroke Among Young, Midlife, and Older Adults in the United States, 2002-2017.

ObjectiveTo assess trends of stroke hospitalization rates, inpatient mortality, and health care resource use in young (aged ≤44 years), midlife (aged 45-64 years), and older (aged ≥65 years) adults.Patients and MethodsWe studied the National Inpatient Sample database (January 1, 2002 to December 31, 2017) to analyze stroke-related hospitalizations. We identified data using the International Classification of Diseases, Ninth/Tenth Revision codes.ResultsOf 11,381,390 strokes, 79% (n=9,009,007) were ischemic and 21% (n=2,372,383) were hemorrhagic. Chronic diseases were more frequent in older adults; smoking, alcoholism, and migraine were more prevalent in midlife adults; and coagulopathy and intravenous drug abuse were more common in young patients with stroke. The hospitalization rates of stroke per 10,000 increased overall (31.6 to 33.3) in young and midlife adults while decreasing in older adults. Although mortality decreased overall and in all age groups, the decline was slower in young and midlife adults than older adults. The mean length of stay significantly decreased in midlife and older adults and increased in young adults. The inflation-adjusted mean cost of stay increased consistently, with an average annual growth rate of 2.44% in young, 1.72% in midlife, and 1.45% in older adults owing to the higher use of health care resources. These trends were consistent in both ischemic and hemorrhagic stroke.ConclusionStroke-related hospitalization and health care expenditure are increasing in the United States, particularly among young and midlife adults. A higher cost of stay counterbalances the benefits of reducing stroke and mortality in older patients.

Impact of the COVID-19 pandemic and a national lockdown on hospitalizations for stroke and related 30-day mortality in France: A nationwide observational study.

Background and purposeThe aim of this nationwide study was to assess the impact of the COVID‐19 pandemic on stroke hospitalization rates, patient characteristics and 30‐day case fatality rates.MethodsAll hospitalizations for stroke from January to June of each year from 2017 to 2020 were selected using International Classification of Diseases, 10th revision, codes I60 to I64 in the national hospital discharge database. Patient characteristics and management were described according to three time periods: pre‐lockdown, lockdown, and post‐lockdown. Weekly incidence rate ratios (IRRs) were computed to compare time trends in the rates of patients hospitalized for stroke as well as in‐hospital and 30‐day case fatality rates between the years 2017–2019 and 2020.ResultsIn 2020, between weeks 1 and 24, 55,308 patients were hospitalized for stroke in France. IRRs decreased by up to 30% for all age groups, sex, and stroke types during the lockdown compared to the period 2017–2019. Patients hospitalized during the second and third weeks of the lockdown had higher in‐hospital case fatality rates compared to 2017–2019. In‐hospital case fatality rates increased by almost 60% in patients aged under 65 years. Out‐of‐hospital 30‐day case fatality rates increased between weeks 11 and 15 among patients who returned home after their hospitalization. Important changes in care management were found, including fewer stroke patients admitted to resuscitation units, more admitted to stroke care units, and a shorter mean length of hospitalization.ConclusionsDuring the first weeks of the lockdown, rates of patients hospitalized for stroke fell by 30% and there were substantial increases of both in‐hospital and out‐of‐hospital 30‐day case fatality rates.

Abstract P636: Social Determinants of Stroke Hospitalization and Mortality in the United States

Introduction: Stroke hospitalization and mortality are influenced by various social determinants. This ecological study aimed to determine the associations between social determinants and stroke hospitalization and outcome at county-level in the United States. Methods: County-level data were recorded from the Centers for Disease Control and Prevention as of January 7, 2020. We considered four outcomes: all-age (1) Ischemic and (2) Hemorrhagic stroke Death rates per 100,000 individuals (ID and HD respectively), and (3) Ischemic and (4) Hemorrhagic stroke Hospitalization rate per 1,000 Medicare beneficiaries (IH and HH respectively). Results: Data of 3,225 counties showed IH (12.5 ± 3.4) and ID (22.2 ± 5.1) were more frequent than HH (2.0 ± 0.4) and HD (9.8 ± 2.1). Income inequality as expressed by Gini Index was found to be 44.6% ± 3.6% and unemployment rate was 4.3% ± 1.5%. Only 29.8% of the counties had at least one hospital with neurological services. The uninsured rate was 11.0% ± 4.7% and people living within half a mile of a park was only 18.7% ± 17.6%. Age-adjusted obesity rate was 32.0% ± 4.5%. In regression models, age-adjusted obesity (OR for IH: 1.11; HH: 1.04) and number of hospitals with neurological services (IH: 1.40; HH: 1.50) showed an association with IH and HH. Age-adjusted obesity (ID: 1.16; HD: 1.11), unemployment (ID: 1.21; HD: 1.18) and income inequality (ID: 1.09; HD: 1.11) showed an association with ID and HD. Park access showed inverse associations with all four outcomes. Additionally, population per primary-care physician was associated with HH while number of pharmacy and uninsured rate were associated with ID. All associations and OR had p ≤0.04. Conclusion: Unemployment and income inequality are significantly associated with increased stroke mortality rates.

Greater decline of acute stroke admissions compared with acute coronary syndromes during COVID‐19 outbreak in Greece: Cerebro/cardiovascular implications amidst a second wave surge

A remarkable decline in admissions for acute stroke and acute coronary syndrome (ACS) has been reported in countries severely hit by the COVID-19 pandemic. However, limited data are available from countries with less COVID-19 burden focusing on concurrent stroke and ACS hospitalisation rates from the same population. The study was conducted in three geographically and demographically representative COVID-19 referral university hospitals in Greece. We recorded the rate of stroke and ACS hospital admissions during a 6-week period of the COVID-19 outbreak in 2020 and compared them with the rates of the corresponding period in 2019. We found a greater relative reduction of stroke admissions (51% [35 vs. 71]; incidence rate ratio [IRR]: 0.49, p=0.001) compared with ACS admissions (27% [123 vs. 168]; IRR: 0.73, p=0.009) during the COVID-19 outbreak (p=0.097). Fewer older (>65years) patients (stroke: 34.3% vs. 45.1%, odds ratio [OR]: 0.64, p=0.291; ACS: 39.8% vs. 54.2%, OR: 0.56, p=0.016) were admitted during the COVID-19 compared with the control period. Hospitalisation rates both for stroke and ACS were reduced during the COVID-19 outbreak in a country with strict social distancing measures, low COVID-19 incidence and low population mortality. Lack of triggers for stroke and ACS during social distancing/quarantining may explain these observations. However, medical care avoidance attitudes among cerebro/cardiovascular patients should be dissipated amidst the rising second COVID-19 wave.

A Four-Year Observational Study regarding the Characteristics and Causes of the Ischemic Stroke in Young Adults: one center study report

Introduction. Stroke is the second cause of mortality worldwide, after the ischemic coronary disease, and the first cause of long term-disability. Recent studies report that ischemic stroke (IS) in young patients is increasing in incidence, even though the overall stroke hospitalization rate is decreasing. Stroke in the young, working individuals significantly affects the quality of life (QoL) and also determines an important, negative economic impact by reducing the workforce. Material and method. The aim of this paper is to present the results of a 4-year observational, retrospective study on all patients between 18-49 years, who suffered from acute IS and were admitted and investigated in the Neurology Clinic of Sibiu and the CVASIC Research Center. Clinical evaluations, imaging investigations, and risk factor evaluations were performed on all patients in order to elucidate the etiology and organize according to the TOAST classification. Results and discussions. 114 patients with ischemic stroke were included in the study. 76% of the subjects fall into the 40-49 age class. In respect to the TOAST classification, most cases of IS were of UE (rural&lt;urban), while the fewest cases of IS were represented by SAA in both populations. The most frequent vascular risk factors were hypertension, dyslipidemia, smoking and thrombophilia. Confirmed cervical arteries dissection caused 2/3 of the severe carotid stenosis and 45,5% of the carotid occlusions. Conclusions. Hypertension, dyslipidemia and smoking are the main risk factors for stroke in young patients. The most common TOAST stroke subtype was stroke of undetermined etiology, followed by stroke of other determined etiology (carotid artery dissection and thrombophilia). Keywords: ischemic stroke, young patients, vascular risk factors, TOAST classification, disability,

Time trends in incidence rates of atrial fibrillation-related strokes in Norway 2001–2014: a nationwide analysis using data from the cardiovascular disease in Norway (CVDNOR) project

Abstract Background Stroke incidence rates declined in Norway during 2001 to 2014. Atrial fibrillation (AF) incidence rates were stable in the same period. Purpose We aimed to study time trends in incidence (first time) of acute stroke hospitalizations and stroke deaths associated with AF in Norway in the period 2001–2014. Methods Nationwide hospital discharge diagnoses in the Cardiovascular Disease in Norway (CVDNOR) database and in the National Patient Registry were linked to the National Cause of Death Registry. All hospitalizations with acute stroke (including ischemic stroke, intracerebral bleeding and unspecified stroke) and out-of-hospital deaths with stroke as underlying cause in individuals 25 years and older were obtained during 1994–2014. Incident stroke was defined as the first hospitalization or out-of-hospital death due to stroke with no hospitalization for acute stroke or stroke sequela the past 7 years. Stroke was defined as AF-related if AF was registered during a hospitalization the past 7 years, or as underlying or contributing cause of death up to 28 days after the stroke hospitalization. Age-standardized incidence rates with 95% confidence intervals (CIs) were calculated using direct standardization to the age-distribution in the Norwegian population per 2001. Age-adjusted average yearly incidence rate ratios (IRR) with 95% CIs were estimated by negative binomial regression analyses. Results From 2001 to 2014 we identified 157 580 incident stroke cases of which 38 317 were AF-related. The proportion of incident strokes that were related to AF increased from 20.6% in 2001 to 26.3% in 2014. Age-standardized incidence rates of AF-related strokes per 100,000 person years were stable at 88 (85, 92) in 2001 and 79 (76, 83) in 2014, corresponding to a 0% average yearly change, IRR 1.00 (0.99, 1.00). The age-standardized incidence rates of non-AF-related strokes per 100,000 person years decreased from 334 (328, 341) in 2001 to 214 (209, 219) in 2014, corresponding to a 3% average yearly decrease, IRR 0.97 (0.97, 0.97). Conclusion The favourable trend in total stroke incidence rates from 2001 to 2014 does not include AF-related strokes. This may suggest that AF has become accountable for a higher proportion of incident strokes or that AF detection improved over this period. Figure 1. Age-standardized incidence rates of stroke hospitalizations or out-of-hospital deaths per 100,000 person years (py) by year, illustrated as all strokes (blue horizontal line) and AF-related strokes (red horizontal line/height of red area). The height of the blue area illustrates the rate for non-AF related strokes. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Vestre Viken Hospital Trust (public hospital research fund)

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results

BackgroundThe emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. MethodsThis study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. ResultsDuring the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). ConclusionIn Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

Effect of seasonal and temperature variation on hospitalizations for stroke over a 10-year period in Brazil.

Seasonal variation in stroke incidence remains controversial. We aimed to describe the pattern of seasonality in hospitalizations for stroke in Brazil. We evaluated age-adjusted hospitalization rates for stroke per month using data from the Brazilian Unified Healthcare System and median monthly temperature data obtained from the National Institute of Meteorology. To detect a seasonality pattern in time series, we used seasonal-trend decomposition using LOESS. We calculated a seasonal strength statistic and used Kruskal-Wallis test to evaluate the presence of seasonality in Brazil and its five regions. We also assessed the association of temperature and stroke hospitalization rates using Spearman's rho correlation. We identified 1,422,496 stroke-related hospitalizations between 2009 and 2018. Mean age was 67 years, 51% were male and 77.5% of stroke diagnoses were not specified as ischemic or hemorrhagic. Median temperature was 23.8℃ (IQR 22.3-24.4). Age-adjusted hospitalizations demonstrated significant seasonal variation during all the years analyzed, with increased rates during the winter. When regional differences were analyzed, seasonal behavior was present in the south, southeast and northeast regions of the country. These were also the regions with lower median temperatures during the winter months and greater amplitude of average temperatures between warmer and colder months. In this large national cohort of stroke patients in Brazil, we demonstrated the presence of seasonal variation in the age-adjusted hospitalization rate, with peak rates during the winter months. The regional gradient of incidence of stroke was directly associated with colder winters and greater amplitude of temperature.