Taiwan Stroke Registry Research Articles

Sex Differences in the Role of Multimorbidity on Poststroke Disability: The Taiwan Stroke Registry.

Multimorbidity is common in patients who experience stroke. Less is known about the effect of specific multimorbidity patterns on long-term disability in patients with stroke. Furthermore, given the increased poststroke disability frequently seen in female vs male patients, it is unknown whether multimorbidity has a similar association with disability in both sexes. We assessed whether specific multimorbidity clusters were associated with greater long-term poststroke disability burden overall and by sex. In the Taiwan Stroke Registry, an ongoing nationwide prospective registry, patients with first-ever ischemic stroke were enrolled; this analysis is restricted to those individuals surviving to at least 6 months poststroke. Using a hierarchical clustering approach, clusters of prestroke multimorbidity were generated based on 16 risk factors; the algorithm identified 5 distinct clusters. The association between clusters and 12-month poststroke disability, defined using the modified Rankin Scale (mRS), was determined using logistic regression models, with additional models stratified by sex. The longitudinal association between multimorbidity and functional status change was assessed using mixed-effects models. Nine-thousand eight hundred eighteen patients with first-ever ischemic stroke were included. The cluster with no risk factors was the reference, "healthier" risk group (N = 1,373). Patients with a cluster profile of diabetes, peripheral artery disease (PAD), and chronic kidney disease (CKD) (N = 1882) had significantly greater disability (mRS ≥ 3) at 1 month (OR [95% CI] = 1.36 [1.13-1.63]), 3 months (OR [95% CI] = 1.27 [1.04-1.55]), and 6 months (OR [95% CI] = 1.30 [1.06-1.59]) but not at 12 months (OR [95% CI] = 1.16 [0.95-1.42]) than patients with a healthier risk factor profile. In the sex-stratified analysis, the associations with this risk cluster remained consistent in male patients (OR [95% CI] = 1.42 [1.06-1.89]) at 12 months, who also had a higher comorbidity burden, but not in female patients (OR [95% CI] = 0.95 [0.71-1.26]), who had higher proportions of severe strokes and severe disability (p-interaction = 0.04). Taiwanese patients with multimorbidity, specifically the concurrent presence of diabetes, PAD, and CKD, had higher odds of a worse functional outcome in the first 6 months poststroke. Clusters of multimorbidity may be less informative for long-term disability in female patients. Further studies should evaluate other mechanisms for worse disability in female patients poststroke.

Patient and hospital characteristics associated with do-not-resuscitate/do-not-intubate orders: a cross-sectional study based on the Taiwan stroke registry

BackgroundPrevious studies of do-not-resuscitate (DNR) or do-not-intubate (DNI) orders in stroke patients have primarily been conducted in North America or Europe. However, characteristics associated with DNR/DNI orders in stroke patients in Asia have not been reported.MethodsBased on the Taiwan Stroke Registry, this nationwide cross-sectional study enrolled hospitalized stroke patients from 64 hospitals between 2006 and 2020. We identified characteristics associated with DNR/DNI orders using a two-level random effects model.ResultsAmong the 114,825 patients, 5531 (4.82%) had DNR/DNI orders. Patients with acute ischemic stroke (AIS) had the highest likelihood of having DNR/DNI orders (adjusted odds ratio [aOR] 1.76, 95% confidence interval [CI] 1.61–1.93), followed by patients with intracerebral hemorrhage (ICH), and patients with subarachnoid hemorrhage (SAH) had the lowest likelihood (aOR 0.53, 95% CI 0.43–0.66). From 2006 to 2020, DNR/DNI orders increased in all three types of stroke. In patients with AIS, women were significantly more likely to have DNR/DNI orders (aOR 1.23, 95% CI 1.15–1.32), while patients who received intravenous alteplase had a lower likelihood (aOR 0.74, 95% CI 0.65–0.84). Patients with AIS who were cared for by religious hospitals (aOR 0.55, 95% CI 0.35–0.87) and patients with SAH who were cared for by medical centers (aOR 0.40, 95% CI 0.17–0.96) were significantly less likely to have DNR/DNI orders.ConclusionsIn Taiwan, DNR/DNI orders increased in stroke patients between 2006 and 2020. Hospital characteristics were found to play a significant role in the use of DNR/DNI orders.

Abstract WMP29: Sex Differences On The Importance Of Multimorbidity In Post-stroke Disability:the Taiwan Stroke Registry

Background: Experiencing a clinical stroke may further aggravate the clinical condition of patients with multimorbidity and pose significant challenges regarding recommended poststroke therapies. However, there is limited evidence regarding the impact of multimorbidity on long-term disability in stroke patients, or whether any associations differ by sex. Hypotheses: Clusters of multimorbidity are associated with post-stroke disability. The association may depend on sex membership. Methods: In the Taiwan Stroke Registry study, 9818 patients with their first-ever recorded ischemic stroke were examined. Employing a hierarchical clustering approach, clusters of multimorbidity were generated based on 16 risk factors and were characterized using the observed/expected prevalence ratio ≥1.5 and the prevalence exclusivity measure ≥25%. Post-stroke disability was assessed using the mRS and categorized into less (mRS <3) vs. more disability (mRS ≥3) over 12 months. The association between clusters of multimorbidity and post-stroke disability adjusted for age, sex, education, and stroke severity (NIHSS) was determined using logistic regression models, overall and stratified by sex. Results: Patients with a cluster profile of diabetes, peripheral artery disease and uremia had more disability than patients with a healthier cluster profile (Table 1). The association only remained significant in males, who had a higher multimorbidity burden, but not in females who more frequently had more severe strokes and more severe post-stroke disability. Conclusion: Patients with multimorbidity involving diabetes, peripheral artery disease and uremia have greater post-stroke disability and may require a more targeted rehabilitative approach. Certain clusters of multimorbidity may be more important for long-term post-stroke disability outcomes in males than in females.

Renal function is associated with one-month and one-year mortality in patients with intracerebral hemorrhage.

This study evaluated short-term (1-month) and long-term (1-year) mortality risks associated with the glomerular filtration rate (eGFR) on admission for patients with intracerebral hemorrhage. From the Taiwan Stroke Registry data from April 2006 to December 2016, we identified and stratified patients with intracerebral hemorrhage into five subgroups by the eGFR level on admission: ≥90, 60-89, 30-59, 15-29, and <15 mL/min/1.73 m2 or on dialysis. Risks for 1-month and 1-year mortality after intracerebral hemorrhage were compared by the eGFR levels. Both the 1-month and 1-year mortality rates progressively increased with the decrease in eGFR levels. The 1-month mortality rate in patients with eGFR < 15 mL/min/1.73 m2 or on dialysis was approximately 5.5-fold greater than that in patients with eGFR ≥ 90 mL/min/1.73 m2 (8.31 versus 1.50 per 1000 person-days), with an adjusted hazard ratio (HR) of 4.59 [95% confidence interval (CI) = 2.71-7.78]. Similarly, the 1-year mortality in patients with eGFR < 15 mL/min/1.73 m2 or on dialysis was 7.5 times that in patients with eGFR ≥ 90 mL/min/1.73 m2 (2.34 versus 0.31 per 1000 person-days), with an adjusted HR of 4.54 (95% CI 2.95-6.98). Impairment of renal function is an independent risk factor for mortality in patients with intracerebral hemorrhage in a gradual way. The eGFR level is a prognostic indicator for patients with intracerebral hemorrhage.

CHA2DS2-VASc score as an independent outcome predictor in patients hospitalized with acute ischemic stroke.

PurposeAtrial fibrillation (AF) is a significant independent risk factor for 1-year mortality in patients with first acute ischemic stroke (AIS). The CHA2DS2-VASc score was initially developed to assess the risk of stroke in patients with AF. Recently, this scoring system has been demonstrated to have clinical value for predicting long-term clinical outcomes in AIS but the evidence is insufficient. This large-scale prospective cohort study investigated the independent predictive value of the score in such patients.MethodsWe included patients with AIS from the Taiwan Stroke Registry (TSR) during 2006–2016 as the present study population. Patients were divided into those with high (≥2) and low (<2) CHA2DS2-VASc scores. We further analyzed and classified patients according to the presence of AF. The clinical endpoint was major adverse cardiac and cerebrovascular events (MACCEs) at 1 year after the index AIS.ResultsA total of 62,227 patients with AIS were enrolled. The median age was 70.3 years, and 59% of the patients were women. After confounding factors were controlled, patients with high CHA2DS2-VASc scores had significantly higher incidence of 1-year MACCEs (adjusted hazard ratio [HR] = 1.63; 95% confidence interval [CI] = 1.52, 1.76), re-stroke (adjusted HR = 1.28; 95% CI = 1.16, 1.42), and all-cause mortality (adjusted HR = 2.03; 95% CI = 1.83, 2.24) than those with low CHA2DS2-VASc scores did. In the comparison between AF and non-AF groups, the AF group had increased MACCEs (adjusted HR = 1.74; 95% CI = 1.60, 1.89), myocardial infarction (adjusted HR = 4.86; 95% CI = 2.07, 11.4), re-stroke (adjusted HR = 1.47; 95% CI = 1.26, 1.71), and all-cause mortality (adjusted HR = 1.90; 95% CI = 1.72, 2.10). The Kaplan–Meier curve revealed that both CHA2DS2-VASc scores and AF were independent risk predictors for 1-year MACCEs and mortality.ConclusionsThe CHA2DS2-VASc score and AF appeared to consistently predict 1-year MACCEs of AIS patients and provide more accurate risk stratification. Therefore, increased use of the CHA2DS2-VASc score may help improve the holistic clinical assessment of AIS patients with or without AF.

Low-Density Lipoprotein Cholesterol and Mortality in Patients With Intracerebral Hemorrhage in Taiwan.

Objective: Lower serum low-density lipoprotein cholesterol (LDL-C) levels are associated with increased intracerebral hemorrhage (ICH) risk. However, reverse causality and residual confounding has not attracted public attention. Therefore, we assessed whether people with LDL-C have increased risk of mortality adjusting for potential confounders using two large Taiwan cohorts.Methods: The Mei-Jhao (MJ) cohort has 414,372 adults participating in a medical screening program with 378 ICH deaths within 15 years of follow-up (1994–2008). Cox proportional hazards regressions estimated hazard death ratios according to LDL-C levels. We identified 4,606 ICH patients from the Taiwan Stroke Registry (TSR) and analyzed the impact of LDL-C on 3-month mortality.Results: Low cholesterol (LDL-C <100 mg/dL), found in 1/4 of the MJ cohort, was highly prevalent (36%) among young adults (age 20–39). There was a graded relationship between cholesterol and mortality for ICH [Hazard ratio, 1.56; 95% confidence interval (CI), 1.13–2.16]. Compared with patients with an LDL-C of 110–129 mg/dL in TSR, the risk for mortality was 1.84 (95% CI, 1.28–2.63) with an LDL-C of <100 mg/dL.Conclusion: Lower serum LDL-C level independently predicts higher mortality after acute ICH. While its causative role may vary, low cholesterol may pose potential harms in Taiwan.

CHA2DS2-VASc score as independent outcome predictor in patients with acute ischemic stroke with and without atrial fibrillation

Abstract Introduction Atrial fibrillation (AF) was a significant independent risk factor for 1-year mortality of first acute ischemic stroke. The CHA2DS2-VASc scores were initially developed to assess the risk of stroke or systemic embolism in patients with AF. Recently, this scoring system have been demonstrated to have clinical value for predicting the severity of infarction and long-term clinical outcomes in acute ischemic stroke but the evidence is not strong enough due to limited numbers and single center data. Purpose This large-scale prospective cohort study aimed to investigate the independent predictive value of CHA2DS2-VASc scores and AF in such patients. Materials and methods We included patients from Taiwan Stroke Registry (TSR) with ischemic stroke within 2006 to 2016 as the present study population. Patients were mainly divided in atrial fibrillation (AF) group and non-AF group. We future classified patient by CHA2DS2-VASc (congestive heart failure, hypertension, age≥75 years, diabetes, previous stroke, vascular disease, age 65–74 years, sex category) score 0–1 and ≥2. The primary outcome was major adverse cardiovascular events (MACE), which include re-stroke, myocardial infarction and cardiovascular death, occurred within 1 year after the onset of stroke. The secondary outcome was the all-cause mortality. Results We defined 2972 patients with MACE and 61,937 patients without MACE. With adjusting with the confounding of CHA2DS2-VASc scores, The AF group was associated with increased MACE (OR=1.15; 95% CI=1.00, 1.33), myocardial infarction (adjusted OR=3.89; 95% CI=1.81, 8.34), CV death (OR=5.73; 95% CI=3.77, 8.69) and all-cause mortality (OR=1.50; 95% CI=1.37, 1.65) but not in re-stroke (adjusted OR=1.02; 95% CI=0.88, 1.18). After controlling for AF, patients with CHA2DS2-VASc scores ≥2 had significantly higher odds of MACE (OR=1.28; 95% CI=1.16, 1.41), re-stroke (OR=1.27; 95% CI=1.16, 1.40) and all-cause mortality (OR=2.26; 95% CI=2.06, 2.48) than that of patients with CHA2DS2-VASc scores 0–1. The survival curve revealed both AF and CHA2DS2-VASc scores are independent risk factors of 1 year MACE and mortality. By investigating the individual risk factor of CHA2DS2-VASc score, diabetes, hypertension and age over 65 years old increase the risk of MACE significantly. Conclusions CHA2DS2-VASc scores appear to have potent independent value as AF for predicting 1 year MACE and all-cause mortality in patients of acute ischemic stroke. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Renal dysfunction is associated with lower odds of home discharge for patients with stroke

ABSTRACT Objectives Studies on the association of estimated glomerular filtration rate (eGFR) levels with hospital discharge disposition after stroke are limited with inconsistent results. This study investigated the odds of home discharge with eGFR levels at admission for patients with stroke using the Taiwan Stroke Registry (TSR) data. Methods From the TSR database, a total of 51,338 stroke patients from 2006 to 2015 were categorized into five groups based on eGFR levels at admission. The proportion of home discharge by the eGFR levels was calculated and logistic regression analysis was used to estimate the related odds ratio (OR) and 95% confidence interval. Results Near 85% of stroke patients were discharged to home. The proportion of home discharges decreased as the eGFR level declined. Compared to patients with eGFR ≥90 mL/min/1.73 m2, the adjusted ORs of home discharge were 0.91, 0.85, 0.63, 0.56 for patients with eGFR 60–89, eGFR 30–59, eGFR 15–29, and eGFR < 15 mL/min/1.73 m2 or on dialysis, respectively, in a graded relationship. The trends were consistent in the ischemic stroke and hemorrhagic stroke patients. The areas under the receiver operating characteristic curve for all stroke patients, ischemic stroke patients, and hemorrhagic stroke patients were 0.801, 0799, 0.815, respectively. Conclusion The odds of home discharge for stroke patients decreased with a significant independent graded association with declining eGFR levels. Renal function could predict home discharge after stroke.

Comparison of outcome prediction models post-stroke for a population-based registry with clinical variables collected at admission vs. discharge

The ability to predict outcomes can help clinicians to better triage and treat stroke patients. We aimed to build prediction models using clinical data at admission and discharge to assess predictors highly relevant to stroke outcomes. A total of 37,094 patients from the Taiwan Stroke Registry (TSR) were enrolled to ascertain clinical variables and predict their mRS outcomes at 90 days. The performances (i.e., the area under the curves (AUCs)) of these independent predictors identified by logistic regression (LR) based on clinical variables were compared. Several outcome prediction models based on different patient subgroups were evaluated, and their AUCs based on all clinical variables at admission and discharge were 0.85-0.88 and 0.92-0.96, respectively. After feature selections, the input features decreased from 140 to 2-18 (including age of onset and NIHSS at admission) and from 262 to 2-8 (including NIHSS at discharge and mRS at discharge) at admission and discharge, respectively. With only a few selected key clinical features, our models can provide better performance than those previously reported in the literature. This study proposed high performance prognostics outcome prediction models derived from a population-based nationwide stroke registry even with reduced LR-selected clinical features. These key clinical features can help physicians to better focus on stroke patients to triage for best outcome in acute settings.

Prognostic impact of renal dysfunction on embolic stroke of undetermined source—Role beyond CHA2DS2‐VASc score: Results from Taiwan Stroke Registry

AbstractBackground and purposeThe CHA2DS2‐VASc score has immense prognostic value in patients with embolic stroke of undetermined source (ESUS). We aimed to determine the usefulness of advanced renal dysfunction and its addition to the CHA2DS2‐VASc score in improving predictive accuracy.MethodsIn total, 3775 ESUS patients were enrolled from a nationwide hospital‐based prospective study. Advanced renal dysfunction was defined as estimated glomerular filtration rate &lt;30 ml/min per 1.73 m2 or patients under dialysis. Clinical outcomes included recurrent stroke and 1‐year all‐cause mortality. Poor functional outcome was defined as a modified Rankin Scale &gt;2 at first‐, third‐, and sixth‐month post‐stroke. The renal (R)‐CHA2DS2‐VASc score was derived by including advanced renal dysfunction in the CHA2DS2‐VASc score. Risk stratification improvement after including advanced renal dysfunction was assessed using C statistic, integrated discrimination improvement (IDI), and category‐free net reclassification index (NRI).ResultsAfter adjusting for confounding factors and CHA2DS2‐VASc score, advanced renal dysfunction showed significant associations with all‐cause mortality (HR: 2.88, 95% CI: 1.92–4.34) and poor functional outcome at third‐ (OR: 2.69, 95% CI: 1.47–4.94) and sixth‐month post‐stroke (OR: 2.67, 95% CI: 1.47–4.83). IDI and NRI showed that incorporating advanced renal dysfunction significantly improved risk discrimination over the original CHA2DS2‐VASc score. R‐CHA2DS2‐VASc score ≥2 increased risk by 1.94‐fold (95% CI: 1.15–3.27) for all‐cause mortality, and ≥4 increased risk by 1.62‐fold (95% CI: 1.05–2.50) of poor functional outcome at third‐month post‐stroke and by 1.81‐fold (95% CI: 1.19–2.75) at sixth‐month post‐stroke.ConclusionsAdvanced renal dysfunction was significantly associated with clinical and functional outcomes in ESUS patients and may improve prognostic impact of the CHA2DS2‐VASc score.

Intravenous tissue plasminogen activator for acute ischemic stroke in patients with renal dysfunction.

This study used the Taiwan Stroke Registry data to evaluate the efficacy and safety of intravenous tissue plasminogen activator (tPA) in treating acute ischemic stroke in patients with renal dysfunction. We identified 3525 ischemic stroke patients and classified them into two groups according to the estimated glomerular filtration rate (eGFR) at the emergency department: ≥60, and <60 ml/min/1.73 m2 or on dialysis and by the propensity score from August 2006 to May 2015. The odds ratio of poor functional outcome (modified Rankin Scale ≥2) was calculated for patients with tPA treatment (N = 705), compared to those without tPA treatment (N = 2820), by eGFR levels, at 1, 3 and 6 months after ischemic stroke. We also evaluated the risks of intracerebral hemorrhage, upper gastrointestinal bleeding, mortality, between the two groups by eGFR levels. Among patients with eGFR levels of <60 ml/min/1.73 m2, tPA therapy reduced the odds ratio of poor functional outcome to 0.60 (95% confidence interval = 0.42-0.87) at 6 months after ischemic stroke. The tPA therapy was not associated with increased overall risk of upper gastrointestinal bleeding, but with increased risk of intracerebral hemorrhage. The low eGFR was not a significant risk factor of intracerebral hemorrhage among ischemic stroke patients receiving tPA treatment. tPA for acute ischemic stroke could improve functional outcomes without increasing the risks of upper gastrointestinal bleeding for patients with or without renal dysfunction. The low eGFR was not a significant risk factor for intracerebral hemorrhage among patients receiving tPA treatment.

Renal Function-Dependent Associations of Statins with Outcomes of Ischemic Stroke.

Aim: Chronic kidney disease (CKD) is associated with unfavorable outcomes in patients with ischemic stroke. One major metabolic derangement of CKD is dyslipidemia, which can be managed by statins. This study aimed to investigate whether the association of statins with post-stroke outcomes would be affected by renal function.Methods: We evaluated the association of statin therapy at discharge with 3-month outcomes according to the estimated glomerular filtration rate (eGFR) of 50,092 patients with acute ischemic stroke from the Taiwan Stroke Registry from August 2006 to May 2016. The outcomes were mortality, functional outcome as modified Rankin Scale (mRS), and recurrent ischemic stroke at 3 months after index stroke.Results: Statin therapy at discharge was associated with lower risks of mortality (adjusted hazard ratio [aHR], 0.41; 95% confidence interval [CI], 0.34 to 0.50) and unfavorable functional outcomes (mRS 3–5; aHR, 0.80; 95% CI, 0.76 to 0.84) in ischemic stroke patients. After stratification by eGFR, the lower risk of mortality associated with statins was limited to patients with an eGFR above 15 mL/min/1.73 m2. Using statins at discharge was correlated with a lower risk of unfavorable functional outcomes in patients with an eGFR of 60–89 mL/min/1.73 m2. Statin therapy in patients with an eGFR of 60–89 mL/min/1.73 m2 may be associated with a higher risk of recurrent ischemic stroke compared with nonusers (aHR, 1.29; 95% CI, 1.07 to 1.57).Conclusions: In patients with acute ischemic stroke, the associations of statins with mortality and functional outcomes was dependent on eGFR.

Smoking Paradox in Stroke Survivors?: Uncovering the Truth by Interpreting 2 Sets of Data.

Background and Purpose- The observation that smokers with stroke could have better outcome than nonsmokers led to the term "smoking paradox." The controversy of such a complex claim has not been fully settled, even though different case mix was noted. Analyses were conducted on 2 independent data sets to evaluate and determine whether such a paradox truly exists. Methods- Taiwan Stroke Registry with 88 925 stroke cases, and MJ cohort with 541 047 adults participating in a medical screening program with 1630 stroke deaths developed during 15 years of follow-up (1994-2008). Primary outcome for stroke registry was functional independence at 3 months by modified Rankin Scale score ≤2, for individuals classified by National Institutes of Health Stroke Scale score at admission. For MJ cohort, mortality risk by smoking status or by stroke history was assessed by hazard ratio. Results- A >11-year age difference in stroke incidence was found between smokers and nonsmokers, with a median age of 60.2 years for current smokers and 71.6 years for nonsmokers. For smokers, favorable outcome in mortality and in functional assessment in 3 months with modified Rankin Scale score ≤2 stratified by the National Institutes of Health Stroke Scale score was present but disappeared when age and sex were matched. Smokers without stroke history had a ≈2-fold increase in stroke deaths (2.05 for ischemic stroke and 1.53 for hemorrhagic stroke) but smokers with stroke history, 7.83-fold increase, overshadowing smoking risk. Quitting smoking at earlier age reversed or improved outcome. Conclusions- "The more you smoke, the earlier you stroke, and the longer sufferings you have to cope." Smokers had 2-fold mortality from stroke but endured stroke disability 11 years longer. Quitting early reduced or reversed the harms.

Evaluation of machine learning methods to stroke outcome prediction using a nationwide disease registry

IntroductionBeing able to predict functional outcomes after a stroke is highly desirable for clinicians. This allows clinicians to set reasonable goals with patients and relatives, and to reach shared after-care decisions for recovery or rehabilitation. The aim of this study was to apply various machine learning (ML) methods for 90-day stroke outcome predictions, using a nationwide disease registry. MethodsThis study used the Taiwan Stroke Registry (TSR) which has prospectively collected data from stroke patients since 2006. Three known ML models (support vector machine, random forest, and artificial neural network), and a hybrid artificial neural network were implemented and evaluated by 10-time repeated hold-out with 10-fold cross-validation. ResultsML techniques present over 0.94 AUC in both ischemic and hemorrhagic stroke using preadmission and inpatient data. By adding follow-up data, the prediction ability improved to 0.97 AUC. We screened 206 clinical variables to identify 17 important features from the ischemic stroke dataset and 22 features from the hemorrhagic stroke dataset without losing much performance. Error analysis revealed that most prediction errors come from more severe stroke patients. ConclusionThe study showed that ML techniques trained from large, cross-reginal registry datasets were able to predict functional outcome after stroke with high accuracy. The follow-up data is important which can further improve the predictive models’ performance. With similar performances among different ML techniques, the algorithm's characteristics and performance on severe stroke patients will be the primary focus when we further develop inference models and artificial intelligence tools for potential medical.

Antiplatelet agents for the secondary prevention of ischaemic stroke in patients with or without renal dysfunction.

Studies on using antiplatelet agents for secondary prevention in ischaemic stroke patients with renal dysfunction are limited. The Taiwan Stroke Registry database was used to compare the efficacy of antiplatelet agents. From the Taiwan Stroke Registry data, 39174 acute ischaemic stroke patients were identified and were classified into three groups by antiplatelet agent: aspirin, clopidogrel and dual antiplatelet therapy (DAPT) with a combination of aspirin and clopidogrel. The re-stroke incidence and 1-year mortality were stratified by estimated glomerular filtration rate (eGFR) levels at admission: ≥90, 60-89 and <60ml/min/1.73m2 or on dialysis. Compared to the aspirin group, the re-stroke differences were not statistically significant for the clopidogrel group [adjusted subhazard ratio 0.95, 95% confidence interval (CI) 0.84-1.08] and the DAPT group (adjusted subhazard ratio1.03, 95% CI 0.77-1.39) after controlling for the competing risk of death. The mortality rate increased as the eGFR level declined. In addition, compared to patients taking aspirin, there was no statistically significant difference in overall 1-year mortality for the clopidogrel group (adjusted hazard ratio 1.11, 95% CI 0.95-1.29) and for the DAPT group (adjusted hazard ratio 1.01, 95% CI 0.67-1.54). The results were consistent in different subgroups stratified by eGFR levels. There was no difference in the risks of recurrent stroke and 1-year mortality amongst ischaemic stroke patients with or without renal dysfunction receiving antiplatelet agents with aspirin, clopidogrel or dual agents with a combination of aspirin and clopidogrel, regardless of their renal dysfunction status.

Warfarin use, intensity of anticoagulation, and occurrence of intracerebral hemorrhage in stroke patients: An analysis of Taiwan Stroke Registry data (S15.001)

Warfarin use, intensity of anticoagulation, and occurrence of intracerebral hemorrhage in stroke patients: An analysis of Taiwan Stroke Registry data (S15.001)

One-Year Risk of Recurrent Stroke and Death Associated with Vertebrobasilar Artery Stenosis and Occlusion in a Cohort of 10,515 Patients

Background: The natural history of vertebrobasilar artery (VBA) stenosis or occlusion remains understudied. Methods: Patients with diagnosis of ischemic stroke or transient ischemic attack (TIA) who were noted to have VBA stenosis based on computed tomography or magnetic resonance imaging or catheter-based angiogram were selected from Taiwan Stroke Registry. Cox proportional hazards model was used to determine the hazards ratio (HR) of recurrent stroke and death within 1 year of index event in various groups based on severity of VBA stenosis (none to mild: 0–49%; moderate to severe: 50–99%: occlusion: 100%) after adjusting for differences in demographic and clinical characteristics between groups at baseline evaluation. Results: None to mild or moderate to severe VBA stenosis was diagnosed in 6972 (66%) and 3,137 (29.8%) among 10,515 patients, respectively, and occlusion was identified in 406 (3.8%) patients. Comparing with patients who showed none to mild stenosis of VBA, there was a significantly higher risk of recurrent stroke (HR 1.21, 95% CI 1.01–1.45) among patients with moderate to severe VBA stenosis. There was a nonsignificantly higher risk of recurrent stroke (HR 1.49, 95% CI 0.99–2.22) and significantly higher risk of death (HR 2.21, 95% CI 1.72–2.83), among patients with VBA occlusion after adjustment of potential confounders. Conclusions: VBA stenosis or occlusion was relatively prevalent among patients with TIA or ischemic stroke and associated with higher risk of recurrent stroke and death in patients with ischemic stroke or TIA who had large artery atherosclerosis.

Renal dysfunction increases the risk of recurrent stroke in patients with acute ischemic stroke

Background and aimsThis study investigated risks of short-term (1 and 3 months) and long-term (1-year) recurrent stroke associated with glomerular filtration rate (eGFR) in patients with acute ischemic stroke. MethodsFrom the Taiwan Stroke Registry data, we identified 45,876 acute ischemic stroke patients from April 2006 to April 2014 and classified them into 4 groups based on the eGFR at admission: ≥ 90, 60–89, 30–59, and <30 mL/min/1.73 m2 or on dialysis. The risks of 1-month, 3-month and 1-year recurrent stroke related to the eGFR levels were investigated. ResultsBoth the risks of short-term and long-term recurrent stroke increased as the eGFR levels declined. The 1-month recurrent incidence rates increased steadily from 0.54 to 0.59, 0.84 and 0.89 per 1000 person-days, as the eGFR declined from ≥90 to 60–89, 30–59, and <30 mL/min/1.73 m2 or on dialysis, respectively. Compared to patients with eGFR ≥90 mL/min/1.73 m2, the adjusted subhazard ratio of 1-month recurrent stroke decreased from 1.69 (95% confidence interval (CI) = 1.24–2.31) for patients with eGFR < 30 mL/min/1.73 m2 or on dialysis to 1.14 (95% CI = 0.91–1.43) for patients with eGFRs of 60–89 mL/min/1.73 m2, considering the competing risk of deaths. Similar patterns were also observed for the adjusted HRs of 3-month and 1-year recurrent stroke, but with reduced hazard values, by the corresponding eGFR levels. ConclusionsThere is an independent graded association between an increased risk of recurrent stroke and declining eGFR levels in patients with acute ischemic stroke.

Abstract WP121: One-Year Risk of Recurrent Stroke Associated With Vertebral and Basilar Artery Stenosis and Occlusion in a Cohort of 10,515 Ischemic Stroke Patients

Background: The risk of recurrent stroke in patients with ischemic stroke with vertebral/basilar artery stenosis remains to be systematically studied. Methods: We analyzed data from Taiwan Stroke Registry (TSR), with stroke registries provided by 59 hospitals. Patients who had diagnosis of ischemic stroke and were categorized into the “large artery atherosclerosis” group by TOAST who underwent CTA, MRA, or catheter- based angiography were identified for the present study. The patients were divided into 3 groups based on the extent of vertebral (VA) and/or basilar artery (BA) stenosis as follows: 0-49%, 50-99%, and 100% (total occlusion). Cox proportional hazards model was used to determine the hazard ratios (HRs) of recurrent stroke within 1 year of index event after adjusting for all relevant risk factors by univariable Cox model. Results: In the TSR data base, 84,831patients were in the ischemic stroke group. Based on TOAST, 20,220 patients were in the large-artery atherosclerosis group. Among these patients, a total of 10,515 were of age 18 or greater who had CTA, MRA or angiographic studies that included VA/BA. There were 6,972 subjects with VA/BA stenosis in the 0-49%, 3,137 in the 50-99% and 406 in the 100% (total occlusion) groups respectively. With VA/BA stenosis in the 0-49% range as the reference, HRs of recurrent stroke in one year by multivariable modeling with adjustment of all relevant risk factors by univariable Cox model was 1. 29 (95% CI, 1.05 - 1.58, p&lt;0.05) in the 50-99% and 1.64 (95% CI, 1.07 - 2.52, p&lt;0.05) in the 100 % group with P trend &lt; 0.02, denoting that a greater extent of VA/BA stenosis was associated with a relatively greater risk of recurrent stroke in 1 year after stroke. Conclusions: Vertebral or basilar artery stenosis or occlusion was relatively prevalent among patients with ischemic stroke categorized in the large artery artherosclerosis group by TOAST with greater extent of VA/BA stenosis carrying greater risk of recurrent stroke within 1 year after stroke.

Lower Fasting Serum Triglyceride Levels on Admission are Associated with Increased Risks of 30-Day and 1-Year Mortality in Patients with Ischemic Stroke

Objective: This study was to assess the 30-day and 1-year mortality associated with serum triglyceride levels on admission for patients with acute ischemic stroke using the Taiwan Stroke registry (TSR) data. Patients and methods: From the TSR database, we identified 45931 acute ischemic stroke patients from April 2006 to April 2014 and stratified them into 3 groups by the serum triglyceride level measured on admission: <150 mg/dL, 150 mg/dL -199 mg/dL, and ≥ 200 mg/dL. They were prospectively followed to measure the 30-day and 1- year mortality after acute ischemic stroke. Result: The mortality rate after acute ischemic stroke decreased as the triglyceride level increased. The 30-day mortality rate was 2.3-fold greater in patients with triglyceride levels 200 mg/dL (1.62 vs.0.72 per 1000 person-days), with an adjusted hazard ratio (HR) of 1.25 (95% confidence interval (CI)=1.06-1.46). The 1-year mortality rate was also greater in patients with lower triglyceride levels than in patients with higher levels (0.47 vs. 0.22 per 1000 person-days), with an adjusted HR of 1.21 (95% CI=1.09-1.34). Compared to patients with triglyceride levels >200 mg/dL, those with triglyceride levels <150 mg/dL had 2.2% lower 30-day survival rate and 6.3% lower 1-year survival rate after acute ischemic stroke. Conclusion: Acute ischemic stroke patients with lower fasting serum triglyceride levels on admission are at a higher risk of both 30-day mortality and 1-year mortality.