Trends in stroke and acute myocardial infarction in Barbados, 2009–2013

OBJECTIVE: To describe trends in incidence, mortality and 28-day case fatality rate (CFR) for stroke and acute myocardial infarction (MI) in Barbados during the first 5 years of the Barbados National Registry for Chronic Non-communicable Disease (BNR). DESIGN AND METHODS: BNR data on strokes and acute MIs diagnosed nationwide were collected prospectively from data sources including public and private healthcare providers. Analyses included annual incidence and mortality rates per 100,000 (IR and MR), and 28 day post-event CFR, with 95% CI and trend estimation (fitting models to data using Poisson regression). RESULTS: Approximately 593 strokes and 349 acute MIs were registered annually with the BNR between 2009 and 2013, with a small 5-year decline in acute MI IR and a small 5-year increase in stroke IR by 2013. The MR for acute MI showed a small 5-year decline, but stroke MR increased significantly over the 5 years, from 78.9 (95%CI 68.8–90.0) in 2009 to 131.7 (118.8–145.8) in 2013 (p<0.03). Similar trends to MR were seen in CFR for both stroke and acute MI. CONCLUSION: We are cautiously optimistic about the (albeit non-significant) decline in IR, MR and CFR for acute MI, which could imply improvements in healthcare service provision. However, despite little change in stroke annual incidence, significant MR increase highlights the need for improved stroke care in Barbados. Thrombolysis for acute ischaemic stroke has only been available since the new stroke unit was implemented in late 2013; continued monitoring will allow assessment of this important initiative.

Cardiovascular disease (CVD) risk factors: a patient’s perspective

OBJECTIVES: To identify CVD risk factors present in patients presenting with stroke; to assess knowledge of patients on risk factors for CVD; and to identify management methods employed (prior to admission) by patients to deal with these risk factors. DESIGN AND METHODS: This study used a cross-sectional, incident case design. All patients admitted to the hospital, within a 6 week period, given an initial diagnosis of stroke by the attending physician, were eligible for the study. Patients were recruited using consecutive sampling. Data on patient risk awareness and management methods were gathered using a survey. Data on risk factors present in patients were collected using patient records. RESULTS: A total of 102 patients were interviewed. The two major risk factors present in patients were hypertension (80.2%) and diabetes (57.8%). 83.3% of patients identified hypertension as a risk factor and 78.8% identified diabetes. However, 32.2% of hypertensive patients and 40.5% of diabetics reported not taking medication despite being awareness of their risk. Similarly 81.3% of patients knew lack of exercise was a risk factor, but only half were exercising frequently in the past 2 years. CONCLUSION: In this study, hypertension and diabetes were found to be the two major risk factors present in stroke patients. While patient knowledge about risk factors was high, their management of their risk factors as well as general knowledge about stroke prevention were lacking. This could be helpful in formulating public health strategy, if supported by larger population based studies.

The management of acute stroke on Montserrat

OBJECTIVE: To assess the management of acute stroke on Montserrat over a sixteen (16) year period in order to highlight areas in which the quality of the service provided can be improved.DESIGN AND METHODS: Forty five patients were studied from a sample frame of 117. Mean age 70 (range 38-100) of whom 29 (64%) were male. A data collection sheet was designed. Information was collected on areas of patient management. Logrank and Cox regression methods were used to test association between survival after stroke and other independent factors. RESULTS: Only 7% of patients (3) had a CT scan. All 3 had the scan within 24 hours. 49% of patients received Aspirin without a CT Diagnosis. Having Glasgow Coma Scale (GCS) <13 (p <0.001), papilledema or neck stiffness (p = 0.003), receiving oxygen for having an oxygen saturation <95% (p = 0.041) and having a swallow assessment (p<0.001) were negatively associated with survival. The estimated median survival time was 1.1 years. CONCLUSION: Access to CT scanning was a problem for patients with acute stroke on Montserrat. Providing CT scanning locally would allow for long term cost reductions and is likely to reduce morbidity and mortality from stroke. This, in combination with Stoke-unit quality ward care, may improve the median survival time.

Prediction of 10-year coronary heart disease risk in Caribbean type 2 diabetic patients using the UKPDS risk engine

OBJECTIVE: Primary prevention of Coronary Heart Disease (CHD) in diabetic patients should be based on absolute CHD risk calculation. This study was aimed to determine the levels of 10-year CHD risk in Caribbean type 2 diabetic patients using the diabetes specific United Kingdom Prospective Diabetes Study (UKPDS) risk engine calculator. SUBJECTS AND METHODS: Three hundred and twenty-five (106 males, 219 females) type 2 diabetic patients resident in two Caribbean Islands of Tobago and Trinidad met the UKPDS risk engine inclusion criteria. Records of their sex, age, ethnicity, smoking habit, diabetes duration, systolic blood pressure, total cholesterol, HDL-cholesterol and glycated haemoglobin were entered into the UKPDS risk engine calculator programme and the absolute 10-year CHD and stroke risk levels were computed. The 10-year CHD and stroke risks were statistically stratified into <15%, 15-30% and >30% CHD risk levels and differences between patients of African and Asian-Indian origin were compared. RESULTS: In comparison with patients in Tobago, type 2 diabetic patients in Trinidad, irrespective of gender, had higher proportion of 10-year CHD risk (10.4 vs. 23.6%, P<0.001) whereas the overall 10-year stroke risk prediction was higher in patients resident in Tobago (16.9 vs. 11.4%, P<0.001). Ethnicity-based analysis revealed that irrespective of gender, higher proportion of patients of Indian origin scored >30% of absolute 10-year CHD risk compared with patients of African descent (3.2 vs. 28.2%, P<0.001). CONCLUSIONS: The results of the study identified diabetic patients resident in Trinidad and patients of Indian origin as the most vulnerable groups for CHD. These groups of diabetic patients should have priority in primary or secondary prevention of coronary heart disease.

Knowledge attitudes and perceptions of health workers towards the management of stroke at the University Hospital of the West Indies

Stroke continues to be a world-wide and national problem. In spite of all this there is little data published about the level of stroke knowledge among health workers in Jamaica. This study aimed to gain insight into the knowledge, attitudes and practices of health workers at the University Hospital of the West Indies towards the management of stroke. Quantitative as well as qualitative surveys were carried out at the hospital. A total of 102 nurses and doctors completed a forty-nine (49) item self-administered questionnaire evaluating their knowledge, attitudes and practices toward stroke, on which statistical analyses of scores were performed. Focus group discussion sought clarification on the attitude component of the questionnaire among the nursing sample. Respondents were from both the public and private sections of the hospital. There were generally good attitudes demonstrated by both professions towards stroke. The minimun knowledge criterion score was met by 58 percent of the respondents, doctors scored significantly higher than nurses did. This was despite the fact that over seventy-five percent (75 percent)in both groups expressed satisfaction with their current level of stroke knowledge. Scoring high on the knowledge component was positively correlated with one's attitude. In discussion with the nurses, views were expressed in relation to the management of the stroke victim. There was a definite willingness to participate in courses aimed at improving stroke knowledge. Overall, the health workers demonstrated good attitudes towards stroke care but there are some suggestions of deficiencies in some areas of stroke management. Because of their role in the health care process health workers should be seen as important partners in the community health education process. Further research to confirm and develop strategies to manage stroke victim could have substantial public health impact, as stroke is so common (AU)

Risk factors associated with ischaemic stroke in Guadeloupe

We carried out a case control study at the University Hospital of Pointe-a-Pitre, Guadeloupe, during eight months. Seventy patients with ischaemic stroke and seventy age- and sex matched controls were involved. A standard questionnaire reported clinical characteristics and medical history. Seventy-six per cent of patients suffered from hypertension. Obesity and diabetes were more frequent in the case group than in the control group. Serum creatinine concentration (86 vs 74umol/l; p <0.001), total cholesterol (5.9 vs 5.2 mmol/l; p < 0.001), apolipoprotein B (1.2 vs 1.0 g/l' p < 0.001) and lipoprotein (a) (82 vs 48 mg/dl; p< 0.001) were significantly higher in patients than controls. Multiple logistic regression analysis revealed that in addition to serum creatinine, serum apolipoprotein B, hypertension, obesity, serum lipoprotein (a) and diabetes mellitus were associated independently and significantly with ischaemic stroke. These findings have implications for clinical practice and further research particularly with respect to serum creatinine concentration as a marker of renal damage from hypertension and as risk factor itself for cerebrovascular disease.(Au)

International trends in mortality from stroke, 1968 to 1994

BACKGROUND AND PURPOSE: The World Health Organization data bank is an invaluable source of information for international comparison of mortality trends. We present rates and trends in mortality from stroke up to 1994, with a particular emphasis on the last 10-year period. Data are presented for men and women in 51 industrialized and developing countries from different parts of the world. METHODS: We included all deaths from cerebrovascular disease for the population aged 35 to 84 years from all the countries in which death certificates were estimated to be available for at least 80% for the period from 1968 to 1994. Age-standardized mortality rates from stroke were calculated for each country for the last available 5 years. Time trends were calculated by using ordinary linear regression and are presented for the entire study period and for 3 separate time periods: 1968 to 1974, 1975 to 1984, and 1985 to 1994. The last 10-year period was further subdivided into 2 parts of 5 years each. We analyzed data separately for men and women and for groups aged 35 to 74 years and 75 to 84 years. RESULTS: The highest rates at the end of the study period for the population aged 35 to 74 years were observed in eastern Europe and previous Soviet Union countries (309 to 156/100 000 per year among men and 222 to 101/100 000 per year among women), Mauritius (268/100 000 per year among men and 138/100 000 per year among women), and Trinidad and Tobago (185/100 000 per year among men and 134/100 000 per year among women). Relatively low to average rates (<100/100 000 per year among men and <70/100 000 per year among women) were reported for Western Europe, with an exception of Portugal (162/100 000 per year among men and 95/100 000 per year among women). The countries with lowest stroke mortality rates at the end of the study period, such as the United States, Canada, Switzerland, France, and Australia, experienced steep declining trends. However, the slope of the decline was substantially reduced during the last 5 years in these countries. Mortality from stroke increased most in the eastern European countries, especially during the last 5 years. Among other high-risk populations, no change in stroke mortality trends was observed in Mauritius, whereas somewhat declining trends were seen in Trinidad and Tobago. CONCLUSIONS: We observed large differences in mortality rates from stroke around the world together with a wide variation in mortality trends. A widening gap was observed between 2 groups of nations, those with low and declining stroke mortality rates and those with high and increasing mortality, in particular, between western and eastern Europe. Eastern European countries should initiate actions aiming at the reduction of stroke risk, perhaps by looking at the examples of Japan and Finland and the other countries that have been the most successful in reducing previously very high mortality from stroke.

Cardiovascular problems in the hypertensive diabetic patient

Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes and has become the subject of intensive recent investigation. One hundred years following the initial description of the relationship between diabetes and anginal chest pain, major scientific organizations in the United States have come together and focused much attention on this topic. The importance of heart disease and diabetes has been emphasised in a recent American Heart Association Scientific Statement and accompanying editorial written jointly by the American Diabetes Association (ADA), the National Heart, Lung and Blood Institute, the Juvenile Diabetes Foundation International, the National Institute of Diabetes and Digestive and Kidney Diseases, and the American Heart Association. Hypertension is not only a risk factor for the development of cardiovascular disease, but is also a strong, independent predictor of renal disease and retinopathy. Cardiovascular problems that result from diabetes and hypertension include stroke, coronary artery disease, hypertensive cardiomyopathy, and congestive heart failure. (AU)

Morbus Rendu-Osler-Weber and cerebrovascular accidents at an early age: An investigational study in the Netherlands Antilles - abstract

Thirty-two patients (17 men and 15 women) are presented in whom the diagnosis Rendu-Osler-Weber disease was established between 1980 and 1990 in the Leeward Islands of the Netherlands Antilles during hospitalization. Among these patients, there were eight families, each of which contained two patients. Estimated point-prevalence rate of the disease in 1991 was 19.4/100,000, which is ten times higher than has been reported so far. Epistaxis, gastrointestinal blood loss and cerebrovascular accidents (CVA) were the three main presenting symptoms. Mean age at diagnosis was 53.2 years, while the delay in reaching the diagnosis averaged 8.3 years. Arteriovenous fistulae in the lung developed in 11 patients (34 percent). Eleven patients experienced a total of twelve CVAs at a mean age of 48 years; four of these patients had an ischaemic CVA in the presence of pulmonary fistulae, while three patients had an haemorrhagic stroke in the presence of a cerebral arteriovenous malformation. Thus, Morbus Rendu-Osler-Weber is a prevalent, but rather under-diagnosed disease and frequently presents with cerebrovascular accidents at an early age in inhabitants of the Leeward Islands of the Netherlands Antilles (AU)