Strokes, treatment delayed

Too many people die from strokes because treatment is delayed

A film x-ray of a human skull and cervical spine. (stockdevil/Getty Images/iStock)

By Kevin Sheth April 8

Recently, I cared for an 82-year-old grandfather who was having some trouble opening a jar of jelly. Twenty minutes later, the fork he was using fell out of his hand. Feeling tired, he lay down, and on waking four hours later, he and his wife discovered that his arm was flaccid. That’s when they called 911 and he was taken to a local hospital. The hospital wasn’t a specialized stroke center and transferred him to Yale New Haven Hospital, where I work and where he arrived two hours after his original emergency response call — and almost seven hours from when his symptoms first started. That was too late to prevent permanent disability./.../

INTERSTROKE

Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study

Dr Martin J O'Donnell, PhD

, et al Published Online: 15 July 2016
BackgroundStroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke.

Methods

We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals.

Findings

Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72–3·28; PAR 47·9%, 99% CI 45·1–50·6), regular physical activity (0·60, 0·52–0·70; 35·8%, 27·7–44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65–2·06 for highest vs lowest tertile; 26·8%, 22·2–31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53–0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2–28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27–1·64 for highest vs lowest tertile; 18·6%, 13·3–25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78–2·72; 17·4%, 13·1–22·6), current smoking (1·67, 1·49–1·87; 12·4%, 10·2–14·9), cardiac causes (3·17, 2·68–3·75; 9·1%, 8·0–10·2), alcohol consumption (2·09, 1·64–2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4–9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05–1·30; 3·9%, 1·9–7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0 p="">

Interpretation

Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke./...,/

GB Stroke 1990-2013 in 188 countries

Global burden of stroke and risk factors in 188 countries, during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Prof Valery L Feigin, MD

,

Gregory A Roth, MD

,

Prof Mohsen Naghavi, MD

,

Priya Parmar, PhD

,

Rita Krishnamurthi, PhD

,

Sumeet Chugh, MD

,

George A Mensah, MD

,

Prof Bo Norrving, MD

,

Ivy Shiue, PhD

,

Marie Ng, PhD

,

Kara Estep, BA

,

Kelly Cercy, BA

,

Prof Christopher J L Murray, MD

,

Prof Mohammad H Forouzanfar, PhD

 for the Global Burden of Diseases, Injuries and Risk Factors Study 2013 and Stroke Experts Writing Group†

†Members listed at the end of the Article

Published Online: 09 June 2016

DOI: http://dx.doi.org/10.1016/S1474-4422(16)30073-4

 |

Article Info

• Summary

• Full Text

• Tables and Figures
• References
• Supplementary Material

Summary

Jump to SectionIntroductionMethodsResultsDiscussionSupplementary MaterialReferences

Background

The contribution of modifiable risk factors to the increasing global and regional burden of stroke is unclear, but knowledge about this contribution is crucial for informing stroke prevention strategies. We used data from the Global Burden of Disease Study 2013 (GBD 2013) to estimate the population-attributable fraction (PAF) of stroke-related disability-adjusted life-years (DALYs) associated with potentially modifiable environmental, occupational, behavioural, physiological, and metabolic risk factors in different age and sex groups worldwide and in high-income countries and low-income and middle-income countries, from 1990 to 2013.

Methods

We used data on stroke-related DALYs, risk factors, and PAF from the GBD 2013 Study to estimate the burden of stroke by age and sex (with corresponding 95% uncertainty intervals [UI]) in 188 countries, as measured with stroke-related DALYs in 1990 and 2013. We evaluated attributable DALYs for 17 risk factors (air pollution and environmental, dietary, physical activity, tobacco smoke, and physiological) and six clusters of risk factors by use of three inputs: risk factor exposure, relative risks, and the theoretical minimum risk exposure level. For most risk factors, we synthesised data for exposure with a Bayesian meta-regression method (DisMod-MR) or spatial-temporal Gaussian process regression. We based relative risks on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks, such as high body-mass index (BMI), through other risks, such as high systolic blood pressure (SBP) and high total cholesterol.

Findings

Globally, 90·5% (95% UI 88·5–92·2) of the stroke burden (as measured in D

Helping Stroke victims

New synthesized molecule could reduce brain damage in stroke victims

March 14, 2016

A new molecule known as 6S has reduced the death of brain tissue from ischemic stroke by up to 66 percent in rats while reducing the accompaning inflammation, researchers at the University of Nebraska-Lincoln and the National University of Singapore reported March 9 in an open-access paper published by the journal ACS Central Science. The … more…

Heart Diseases and Stroke Guidelines and Statistics 2014

AHA Stroke Statements and Guidelines The American Heart Association and American Stroke Association publish medical scientific statements on various cardiovascular disease and stroke topics. Read More

Heart Disease & Stroke Statistics – 2014 Update The most up-to-date statistics on heart disease, stroke, other vascular diseases. Read More

Gene Fingerprint Points Out Dangerous Plaques

By Crystal Phend, Senior Staff Writer, MedPage Today Published: August 04, 2011 Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco. Action Points   Explain that a genetic signature might pinpoint arterial plaques that are prone to cause strokes. Point out that a profile of above average expression of five microRNA segments characterized about three-quarters of the stroke patients whereas traditional risk factors didn't differ from asymptomatic cases. Note that the results could not prove a causal role of the microRNA signature in plaque destabilization. A genetic signature might pinpoint arterial plaques that are prone to cause strokes, Italian researchers found. Carotid atherosclerosis in ischemic stroke patients expressed higher levels of five microRNA segments compared with asymptomatic cases, Francesco Cipollone, MD, of "G. d'Annunzio" University in Chieti, Italy, and colleagues reported. A profile of above average expression of the microRNAs characterized about three-quarters of the stroke patients whereas traditional risk factors didn't differ from asymptomatic cases, they reported online in Stroke: Journal of the American Heart Association. Thus, this profile might pick out unstable plaques to identify patients at risk for ischemic events while also presenting a way to treat them, Cipollone's group suggested./.../

Stroke Burden Varies Considerably Around the World

Pauline Anderson

July 12, 2011 — Stroke mortality and disease burden relative to ischemic heart disease varies considerably around the world, with certain developing countries carrying a higher relative stroke burden, a new comprehensive global analysis shows.

"The most striking finding of this study was that even though heart disease was number 1 in terms of mortality burden as a whole worldwide, there are a substantial minority of countries where stroke is a larger burden than heart disease and many of these countries are in the developing world," said lead author Anthony S. Kim, MD, assistant professor of neurology, University of California, San Francisco.

The new study suggests that the greater stroke burden in developing areas of the world may be due to lower national income and vascular risk factors.China in particular is a "big outlier" when it comes to stroke burden relative to heart disease, said Dr. Kim. "The high mortality from stroke in this nation far outpaces ischemic heart disease, which is the exact opposite of the situation in the US, where heart disease outstrips stroke as a cause of death."

The study was published online July 5 in Circulation.

Researchers used data on mortality and rates of disability-adjusted life-years lost from stroke and ischemic heart disease from 192 World Health Organization (WHO) member countries. They also accessed national estimates of risk factors developed by the WHO Burden of Disease Program and income data from World Bank estimates/.../
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The Best Part of Waking Up Also Lowers Stroke Risk

By Crystal Phend, Senior Staff Writer, MedPage Today
Published: March 10, 2011
Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston.

Women who start their day with a cup of coffee may be protecting themselves from stroke, according to a Swedish prospective cohort study.

Among 34,670 women, those who reported drinking at least one cup a day at baseline had a 24% reduction in stroke risk (95% CI 0.66 to 0.88) over a decade, Susanna C. Larsson, PhD, of the Karolinska Institute in Stockholm, and colleagues found.

"Given that coffee is one of the most popular beverages consumed worldwide, even small health effects of substances in coffee may have large public health consequences," they wrote online in Stroke: Journal of the American Heart Association./.../

Heart Disease and Stroke Statistics—2011 Update

AHA Statistical Update

Heart Disease and Stroke Statistics—2011 Update

A Report From the American Heart Association

Véronique L. Roger, MD, MPH, et al...
Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited 1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year's edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA's 2020 Impact Goals. Below are a few highlights from this year's Update./.../

PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE

CONSIDERABLE UNCERTAINTY REMAINS IN THE EVIDENCE FOR PRIMARY PREVENTION OF CARDIOVASCULAR DISEASE BY CARL HENEGHAN

• By: Carl Heneghan
• On: January 14, 2011, 15:39

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide,[1] and therefore strategies that aim to improve prevention in people without existing disease (primary prevention) are important for managing the overall burden of disease. This edition of The Cochrane Library adds to the evidence-base in this area with publication of two Cochrane Reviews on such preventive strategies: multiple risk factor interventions for primary prevention of coronary heart disease,[2] and statins for the primary prevention of CVD.[3]

Multiple risk factor interventions aim to alter modifiable risk factors such as smoking, hypertension, hyperlipidaemia, high intake of dietary salt, lack of exercise, obesity and high glucose levels in people with diabetes, which increase the risk of coronary heart disease. The Cochrane Review by Ebrahim and colleagues focuses on counselling and educational interventions, and includes 55 trials (an addition of 16 studies compared with the previous version of this review) aimed at modifying one or more cardiovascular risk factors in the adult general population.[2]

World Stroke Campaign November 2010 News

World Stroke Campaign November 2010 News About World Stroke Day 2010: Tell Six This year’s World Stroke Day (WSD) was a major success, setting the record for the largest number of events being commemorated across the world in honor of stroke survivors, their family, care givers, and the medical community. Members from Australia to Chile, Greece to Mongolia, and South Africa to Croatia all planned events for WSD. On WSD the “One in Six” campaign was launched, highlighting the fact that one in six people worldwide will have a stroke in their lifetime./.../

INTERSTROKE: Ten modifiable risk factors explain 90% of stroke risk

JUNE 18, 2010 | Michael O'Riordan

 Download slides

Beijing, China - A large case-control study evaluating risk factors for stroke has shown that 10 risk factors are associated with 90% of the risk of stroke and that of these modifiable risk factors, hypertension is the most important for all stroke subtypes and is a particularly dangerous risk factor for intracerebral hemorrhage [1]./.../

Coffe & Stroke

ASA: Coffee Drinkers Have Lower Stroke Risk

By Todd Neale, Staff Writer, MedPage TodayPublished: February 26, 2010 Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner SAN ANTONIO -- Drinking just one cup of coffee a day -- either regular or decaffeinated -- was associated with a 30% reduced risk of stroke, a large, prospective study showed. Greater consumption did not heighten the apparent protective effect, according to Yangmei Li, MPhil, of the University of Cambridge in England./.../

Stenting and endarterectomy: similar

CREST: Stenting and endarterectomy show similar net safety and efficacy for carotid stenosis

FEBRUARY 26, 2010 | Susan Jeffrey

From Medscape Medical News—a professional news service of WebMD

San Antonio, TX - Final results of the long-awaited Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) show similar net outcomes with carotid artery stenting (CAS) and carotid endarterectomy (CEA) for the treatment of carotid stenosis, researchers report [1]. The results were presented here at the American Stroke Association International Stroke Conference 2010.

On the composite primary end point of any stroke, MI, or death during the periprocedural period or ipsilateral stroke on follow-up, stenting was associated with a 7.2% rate of these events vs 6.8% with surgery, a nonsignificant difference.

However, individual risks varied, they found. At 30 days, the rate of stroke was significantly higher with stenting, at 4.1% vs 2.3% with surgery. Major stroke, though, was not different, at less than 1% in both groups. Conversely, MI was higher with carotid endarterectomy, at 2.3% vs 1.1% with stenting, again a statistically significant difference.

Patients who had an MI, however, reported a better quality of life after recovery than those who had a stroke, the authors noted.

Rates of ipsilateral stroke during a mean follow-up of 2.5 years were equal between groups, at 2.0% for stenting and 2.4% with surgery./.../

Salt Habit: Stroke, CV Disease

By Crystal Phend, Senior Staff Writer, MedPage Today Published: November 24, 2009 Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine.

Cutting the average salt intake in half could prevent a substantial proportion of strokes and heart disease in most Western countries, a meta-analysis showed. A decrease of 5 grams of salt a day (about one teaspoon) was associated with a 23% lower stroke rate and up to 17% less total cardiovascular disease, reported Pasquale Strazzullo, MD, of the "Federico II" University of Naples, Italy, and colleagues online in BMJ. This kind of change at the population level "could avert some 1.25 million deaths from stroke and almost three million deaths from cardiovascular disease worldwide," the researchers wrote. Americans, like those in many Western countries, average about 10 g of daily salt intake; whereas the World Health Organization recommends only 5 g per day, and the U.S. Department of Agriculture recommends daily intake be limited to 5.8 g.

World Stroke Day 2009: 29 October

WORLD STROKE DAY 2009: "Stroke, what can I do?"

The theme for the World Stroke Day 2009 is "Stroke, what can I do?"

This question implies that everyone can do something about stroke. Individuals can learn their risk for stroke and do something about it, they can learn the symptoms of stroke and what to do about them, and they can help advance the stroke cause in many other roles: as a physician, a nurse, a healthcare professional, a patient, a caregiver, a donor, a business person, a citizen, a member of a voluntary organization, a policymaker, a member of government etc. The theme has been developed to prompt individuals, groups and governments to take action against stroke either at a personal, or group level.

This year we are encouraging people all over the world to run World Stroke Day events. The WSO will be delivering tools to support this activity including lists of ideas for activities and media releases. The WSO will also be providing an award to the best, most innovative, and most powerful activities in different regions to recognize efforts that heighten stroke awareness.

WSD 2009 Brochure | Printable version

WSD 2009 Poster | Printable version

Translating Research Into Practice for Healthcare Providers: The American Heart Association's Strategy for Building Healthier Lives, Free of Cardiovascular Diseases and Stroke -- Jones et al. 118 (6): 687 -- Circulation

Translating Research Into Practice for Healthcare Providers: The American Heart Association's Strategy for Building Healthier Lives, Free of Cardiovascular Diseases and Stroke -- Jones et al. 118 (6): 687 -- Circulation

Daniel W. Jones, MD, FAHA; Eric D. Peterson, MD, MPH, FAHA; Robert O. Bonow, MD, FAHA; Frederick A. Masoudi, MD, MSPH; Gregg C. Fonarow, MD, FAHA; Sidney C. Smith, Jr, MD, FAHA; Penelope Solis, JD; Meighan Girgus, MBA; Patricia C. Hinton, MA, MS; Anne Leonard, MPH, RN, FAHA; Raymond J. Gibbons, MD, FAHA
Abstract—The American Heart Association’s (AHA’s) mission is “to build healthier lives, free of cardiovascular diseases and stroke.” This first article in a 2-part series will serve to present an overview of the work the AHA has undertaken to translate evidence into practice for healthcare professionals. It describes the extensive work of the AHA to support and further the delivery of evidence-based medicine, which includes the following: (1) supporting scientific discovery and the next generation of healthcare professionals and researchers; (2) disseminating scientific information; (3) developing evidence-based guidelines and statements; (4) creating and advocating for the implementation of performance indicators/measures; (5) developing clinical decision support and quality improvement tools; and (6) developing directed-cause campaigns, all of which can lead to improved patient care. This article also discusses the need for novel approaches and some of the AHA’s evolving strategies to help address gaps in care. The second article, which will be published shortly after this one, will examine the AHA’s efforts to engage and empower healthcare consumers to become more involved with their own health and health care. (Circulation. 2008;118:687-696.)
Key Words: cardiovascular diseases
research
stroke

Silent Strokes Predicted by Traditional Cardiovascular Risk Factors

By Todd Neale, Staff Writer, MedPage TodayPublished: June 26, 2008Reviewed by Zalman S. Agus, MD; Emeritus Professor University of Pennsylvania School of Medicine.
BOSTON, June 26 -- Among more than 2,000 participants in the Framingham Offspring Study, about one in every 10 have had a silent cerebral infarction, with none of the clinical signs or symptoms of a stroke. Researchers found the lesions when 2,040 participants were screened by MRI, Sudha Seshadri, M.D., of Boston University, and colleagues reported online in Stroke: Journal of the American Heart Association. The prevalence of silent cerebral infarcts (10.7%) increased with age, from less than 8% in those 30 to 49 to greater than 15% in those 70 to 89. /.../

Wealth and Income Provide Buffer against Stroke

By Charles Bankhead, Staff Writer, MedPage Today
Published: April 24, 2008
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
ROTTERDAM, The Netherlands, April 24 -- Money might not buy love, but it can protect some people against stroke, investigators found.

Action Points

---

• Explain to patients that lower levels of wealth and income appear to be associated with an increased risk of stroke in people ages 50 to 64.
  
  
• Point out that the findings came from an analysis of a database, not a randomized, controlled clinical trial.

In a study of more than 1,500 stroke patients, wealth and income independently predicted stroke risk in people ages 50 to 64 but not in older individuals, Mauricio Avendano, Ph.D., of Erasmus University Medical Center here, reported in the May issue of Stroke.

Dr. Avendano and co-author M. Maria Glymour, Ph.D., of Harvard, suggested that the association they found between affluence and stroke probably understate the impact of social disparities on stroke risk.

Several studies have suggested that lower socioeconomic status is associated with higher stroke risk in developing countries. In the United States, however, the association goes in the opposite direction, as stroke disparities across education and income appear to reverse at age 74, the authors said.

Almost 90% of strokes occur after 65, but the influence of socioeconomic status on stroke risk in that older age group had not been examined, they continued.

So Drs. Avendano and Glymour analyzed data from the Health and Retirement Study, a longitudinal survey of a national sample of U.S. adults 50 and older. They included 19,965 participants who were stroke-free at baseline.

Baseline assessments of wealth, income, and education were included in a Cox proportional hazards model to predict time to stroke.

Separate models were developed for the age groups 50 to 64, 65 to 74, and 75 and older, incorporating known stroke risk factors.

During a mean follow-up of 8.5 years, 1,542 participants had strokes.

Higher education predicted a reduced stroke risk in the age group of 50 to 64, but not after adjustment for wealth and income.

In contrast, wealth and income were independent predictors of stroke in that age group.

Poor awareness of cardiac, stroke symptoms can delay care

Poor awareness of cardiac, stroke symptoms can delay care
Care for cardiovascular and cerebrovascular conditions has improved dramatically, but not knowing the initial signs may prevent timely treatment.
By Victoria Stagg Elliott, AMNews staff. March 24/31, 2008.
Patients experiencing a heart attack or stroke face a significant barrier to receiving care -- getting themselves and others to recognize what is happening to them.
That's the conclusion of three studies published or presented in February. The problem can be a lack of knowledge of those around someone having a heart attack, according to one paper. In the case of a stroke, the problem could be delays caused by calling the physician's office first, or someone at the office not recognizing the signs, according to two papers presented at a recent conference/.../