Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites.

BACKGROUND AND PURPOSE: Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. METHODS: Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. RESULTS: From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]). CONCLUSIONS: Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Ischemic Stroke and Atrial Fibrillation.

Background and Purpose- Ischemic stroke (IS) secondary to atrial fibrillation (AF) is largely preventable with the use of anticoagulation. We sought to identify race-ethnicity and sex disparities with the use of direct oral anticoagulants (DOACs), aspirin, and warfarin in IS patients with AF and to identify temporal trends in the utilization of these medications. Methods- The FLiPER-AF Stroke Study (Florida Puerto Rico Atrial Fibrillation) included 24 040 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2016. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin, and warfarin for stroke prevention in AF after adjustment for sociodemographic, hospital, and clinical factors. Results- Among 24 040 IS cases, 54% were women and 10% black, 12% FL-Hispanics, 4% PR-Hispanic, and 74% whites. From 2010 to 2016, DOAC use increased from 0% to 36%, warfarin use decreased from 51% to 17%, and aspirin use remained relatively stable (42%-40%). After adjustment, blacks had higher odds of warfarin (odds ratio, 1.22; 95% CI, 1.07-1.40) prescription at discharge compared with whites. Men had higher rates of aspirin (42.1% versus 38.8%), warfarin (33.6% versus 28.9%), and DOAC (21.3% versus 19.3%) use compared with women. After adjustment, women had lower odds of being discharged on aspirin (odds ratio, 0.92; 95% CI, 0.86-0.98) or warfarin (odds ratio, 0.91; 95% CI, 0.84-0.99). There was no sex difference in use of DOACs. Conclusions- Our study confirmed the increasing use of DOACs, downtrending use of warfarin, whereas aspirin use remained similar over the years. There are sex and race-ethnicity disparities in anticoagulation use in IS patients with AF. It is critical to understand underlying drivers of these disparities to develop better practice strategies for stroke prevention in patients with AF. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT03627806.

The spectrum of neuropsychiatric lupus in a Black Caribbean population: a report of the Barbados National Lupus Registry.

Objective The objective of this study was to examine neuropsychiatric lupus in a Black Caribbean population. Methods We reviewed Barbados National Lupus Registry patients with ≥4 American College of Rheumatology criteria and a diagnosis of neuropsychiatric lupus using the American College of Rheumatology 19 case definitions. Results From 366 patients with four or more American College of Rheumatology criteria for systemic lupus erythematosus, 55 (15%) had evidence of neuropsychiatric lupus. There were 51 females and four males (F:M = 13:1) with a median age of 31 years. A total of 76.4% had a single neuropsychiatric lupus complication and 23.6% had two or three complications occurring sequentially or concurrently. The top three complications were psychosis - 49.1% (95% CI 35.8, 62.5); ischaemic stroke - 32.7% (21.4, 46.5); and generalized tonic-clonic seizures - 12.7% (6.0, 24.8). Twelve of the American College of Rheumatology 19 neuropsychiatric syndromes were represented: 91.2% central; 8.8% peripheral. There were 521 observation years, and for 32 patients (58%) neuropsychiatric lupus was a presenting feature. For the remaining 23 (42%) the first neuropsychiatric lupus event came after systemic lupus erythematosus diagnosis - median time of two years. Of the 22 deaths, systemic lupus erythematosus nephritis caused almost half (45.5%) at a median age of 32. The prevalence of nephritis was lower in the neuropsychiatric lupus subgroup (25.5%) compared with the Barbados National Lupus Registry data (47%) ( P = 0.01). Ischaemic stroke caused 22.7% of deaths at a median age of 46 and was the main cause of chronic neurologic deficits amongst survivors. Conclusion Neuropsychiatric lupus was an early cause of morbidity in systemic lupus erythematosus with predominantly singular central nervous system complications, the most common of which was psychosis. Most deaths occurred at a young age, principally from systemic lupus erythematosus nephritis. Ischaemic stroke was the main neurologic cause of death and disability.

Racial-Ethnic Disparities in Acute Stroke Care in the Florida-Puerto Rico Collaboration to Reduce Stroke Disparities Study.

BACKGROUND: Racial-ethnic disparities in acute stroke care can contribute to inequality in stroke outcomes. We examined race-ethnic disparities in acute stroke performance metrics in a voluntary stroke registry among Florida and Puerto Rico Get With the Guidelines-Stroke hospitals. METHODS AND RESULTS: Seventy-five sites in the Florida Puerto Rico Stroke Registry (66 Florida and 9 Puerto Rico) recorded 58 864 ischemic stroke cases (2010-2014). Logistic regression models examined racial-ethnic differences in acute stroke performance measures and defect-free care (intravenous tissue plasminogen activator treatment, in-hospital antithrombotic therapy, deep vein thrombosis prophylaxis, discharge antithrombotic therapy, appropriate anticoagulation therapy, statin use, smoking cessation counseling) and temporal trends. Among ischemic stroke cases, 63% were non-Hispanic white (NHW), 18% were non-Hispanic black (NHB), 14% were Hispanic living in Florida, and 6% were Hispanic living in Puerto Rico. NHW patients were the oldest, followed by Hispanics, and NHBs. Defect-free care was greatest among NHBs (81%), followed by NHWs (79%) and Florida Hispanics (79%), then Puerto Rico Hispanics (57%) (P<0.0001). Puerto Rico Hispanics were less likely than Florida whites to meet any stroke care performance metric other than anticoagulation. Defect-free care improved for all groups during 2010-2014, but the disparity in Puerto Rico persisted (2010: NHWs=63%, NHBs=65%, Florida Hispanics=59%, Puerto Rico Hispanics=31%; 2014: NHWs=93%, NHBs=94%, Florida Hispanics=94%, Puerto Rico Hispanics=63%). CONCLUSIONS: Racial-ethnic/geographic disparities were observed for acute stroke care performance metrics. Adoption of a quality improvement program improved stroke care from 2010 to 2014 in Puerto Rico and all Florida racial-ethnic groups. However, stroke care quality delivered in Puerto Rico is lower than in Florida. Sustained support of evidence-based acute stroke quality improvement programs is required to improve stroke care and minimize racial-ethnic disparities, particularly in resource-strained Puerto Rico.

Association of phosphodiesterase 4D gene and interleukin-6 receptor gene polymorphisms with ischemic stroke in a Chinese hypertensive population.

Genetic factors have been shown to be associated with the risk of stroke. However, due to individual differences, the extent of the association between genetic factors and stroke varies widely. Hypertension is considered one of the most important risk factors for stroke, but it remains unknown whether the genetic association with stroke in a hypertensive population is the same as that in a non-hypertensive population. The aim of the present study was to explore the association between the phosphodiesterase 4D gene (PDE4D) and interleukin-6 receptor gene (IL6R) single nucleotide polymorphisms and ischemic stroke in a hypertensive population. The study included 307 ischemic stroke cases with hypertension and 227 controls (simple hypertension). The polymorphic loci rs12188950 and rs918592 in PDE4D, and rs4075015 and rs4537545 in IL6R were selected for analyzing the genotype and allele frequencies between cases and controls. rs12188950 was not found in the study population. In the univariate analysis, the rs918592 polymorphism in PDE4D was found to be significantly associated with ischemic stroke with the recessive model (P = 0.02), whereas no association with ischemic stroke was observed for rs4075015 and rs4537545 in IL6R. Following adjustment for binary logistic regression, the rs918592 polymorphism was not found to be associated with ischemic stroke. While prior studies have found an association between PDE4D and IL6R polymorphisms and ischemic stroke, our results suggest that this association may be different in a hypertensive population. Therefore, the association between PDE4D and IL6R polymorphisms and ischemic stroke among a hypertensive population requires further investigation.

Loss of the Mexican American survival advantage after ischemic stroke.

BACKGROUND AND PURPOSE: Mexican Americans (MAs) were previously found to have lower mortality after ischemic stroke than non-Hispanic whites. We studied mortality trends in a population-based design. METHODS: Active and passive surveillance were used to find all ischemic stroke cases from January 2000 to December 2011 in Nueces County, TX. Deaths were ascertained from the Texas Department of Health through December 31, 2012. Cumulative 30-day and 1-year mortality adjusted for covariates was estimated using log-binomial models with a linear term for year of stroke onset used to model time trends. Models used data from the entire study period to estimate adjusted mortality among stroke cases in 2000 and 2011 and to calculate projected ethnic differences. RESULTS: There were 1974 ischemic strokes among non-Hispanic whites and 2439 among MAs. Between 2000 and 2011, model estimated mortality declined among non-Hispanic whites at 30 days (7.6% to 5.6%; P=0.24) and 1 year (20.8% to 15.5%; P=0.02). Among MAs, 30-day model estimated mortality remained stagnant at 5.1% to 5.2% (P=0.92), and a slight decline from 17.4% to 15.3% was observed for 1-year mortality (P=0.26). Although ethnic differences in 30-day (P=0.01) and 1-year (P=0.06) mortality were apparent in 2000, they were not so in 2011 (30-day mortality, P=0.63; 1-year mortality, P=0.92). CONCLUSIONS: Overall, mortality after ischemic stroke has declined in the past decade, although significant declines were only observed for non-Hispanic whites and not MAs at 1 year. The survival advantage previously documented among MAs vanished by 2011. Renewed stroke prevention and treatment efforts for MAs are needed.

Role of inflammatory parameters in the susceptibility of cerebral thrombosis.

We aimed to investigate the association of inflammation-related genes such as IL-10, IL-6 and IL-1B with risk of ischemic stroke. We included 426 cases with ischemic stroke and 426 health controls from Xinxiang, China. Genomic DNA was extracted from the buffy coat layer of collected blood with the TIANamp blood DNA kit. Diabetes, hypertension, obesity, and smoking habits were associated with risk of ischemic stroke. We found that individuals carrying the CC genotype of IL-1B rs1864169 had a higher risk of ischemic stroke when compared with the TT genotype (OR = 1.80, 95%CI = 1.16-2.80). The IL-6 rs1800796 TT genotype was associated with increased risk of ischemic stroke. We found that IL-1B rs1864169 and IL-6 rs1800796 polymorphisms may interact with diabetes, hypertension and obesity. Our study suggests that IL-6 rs1800796 and IL-1B rs1864169 polymorphisms are associated with ischemic stroke risk in the Chinese population.

Persistent ischemic stroke disparities despite declining incidence in Mexican Americans.

OBJECTIVE: To determine trends in ischemic stroke incidence among Mexican Americans and non-Hispanic whites. METHODS: We performed population-based stroke surveillance from January 1, 2000 to December 31, 2010 in Corpus Christi, Texas. Ischemic stroke patients 45 years and older were ascertained from potential sources, and charts were abstracted. Neurologists validated cases based on source documentation blinded to ethnicity and age. Crude and age-, sex-, and ethnicity-adjusted annual incidence was calculated for first ever completed ischemic stroke. Poisson regression models were used to calculate adjusted ischemic stroke rates, rate ratios, and trends. RESULTS: There were 2,604 ischemic strokes in Mexican Americans and 2,042 in non-Hispanic whites. The rate ratios (Mexican American:non-Hispanic white) were 1.94 (95% confidence interval [CI] = 1.67-2.25), 1.50 (95% CI = 1.35-1.67), and 1.00 (95% CI = 0.90-1.11) among those aged 45 to 59, 60 to 74, and 75 years and older, respectively, and 1.34 (95% CI = 1.23-1.46) when adjusted for age. Ischemic stroke incidence declined during the study period by 35.9% (95% CI = 25.9-44.5). The decline was limited to those aged ≥60 years, and happened in both ethnic groups similarly (p > 0.10), implying that the disparities seen in the 45- to 74-year age group persist unabated. INTERPRETATION: Ischemic stroke incidence rates have declined dramatically in the past decade in both ethnic groups for those aged ≥60 years. However, the disparity between Mexican American and non-Hispanic white stroke rates persists in those <75 years of age. Although the decline in stroke is encouraging, additional prevention efforts targeting young Mexican Americans are warranted.

Stroke burden in Mexican Americans: the impact of mortality following stroke.

PURPOSE: To estimate ethnic-specific all-cause mortality risk following ischemic stroke and to compare mortality risk by ethnicity. METHODS: DATA from the Brain Attack Surveillance in Corpus Christi Project, a population-based stroke surveillance study, were used. Stroke cases between January 1, 2000 and December 31, 2002 were identified from emergency department (ED) and hospital sources (n = 1,234). Deaths for the same period were identified from the surveillance of stroke cases, the Texas Department of Health, the coroner, and the Social Security Death Index. Ethnic-specific all-cause cumulative mortality risk was estimated at 28 days and 36 months using Kaplan Meier analysis. Cox proportional hazards regression was used to compare mortality risk by ethnicity. RESULTS: Cumulative 28-day all-cause mortality risk for Mexican Americans (MAs) was 7.8% and for non-Hispanic whites (NHWs) was 13.5%. Cumulative 36-month all-cause mortality risk was 31.3% in MAs and 47.2% in NHWs. MAs had lower 28-day (RR = 0.58; 95% CI: 0.41, 0.84) and 36-month all-cause mortality risk (RR = 0.79, 95% CI: 0.64, 0.98) compared with NHWs, adjusted for confounders. CONCLUSIONS: Better survival after stroke in MAs is surprising considering their similar stroke subtype and severity compared with NHWs. Social or psychological factors, which may explain this difference, should be explored.

Ischemic stroke subtypes among Mexican Americans and non-Hispanic whites: the BASIC Project.

Ischemic stroke subtype distribution was compared between Mexican Americans (MAs) and non-Hispanic whites (NHWs) in a community-based stroke surveillance study in Nueces County, TX. There was no difference in the distribution of stroke subtype by ethnicity (p = 0.19). There was a similar proportion of small-vessel and large-artery strokes between the two ethnic groups (p = 0.32). Differences in stroke rates among MAs and NHWs are not explained by the distribution of ischemic stroke subtypes.

Survey of the causes of stroke among Mexican Americans in South Texas.

Management strategies for optimal stroke prevention depend on the cause of threatened stroke. We know relatively little about the etiology of stroke in Mexican Americans, who make up one quarter of the population in Texas. A retrospective case series of 159 consecutive patients hospitalized in San Antonio, Tex, for acute, first-ever stroke compared risk factors, features, and causes of stroke between Mexican Americans and whites. Mexican Americans who had strokes were significantly younger than whites and had diabetes mellitus more often. Intracerebral hemorrhage and lacunar infarcts occurred often in Mexican Americans. Ethnicity appeared to be an independent risk factor for lacunar infarction. Mortality and functional outcome at the time of hospital discharge were similar in Mexican Americans and whites. Intrinsic small-vessel disease causing lacunar infarcts and intracerebral hemorrhage accounts for about one half of strokes in Mexican Americans. Stroke among Mexican Americans in South Texas has a distinctive profile with implications for its prevention.

Clinical features of ischemic stroke in Hispanics and non-Hispanic whites in New Mexico: a study of 341 consecutive patients at two hospitals.

This study was undertaken to determine whether there are any differences in the clinical features of ischemic stroke between Hispanics and non-Hispanic whites in New Mexico. From August 1988 to August 1990, one investigator prospectively evaluated consecutive patients who presented within 30 days of onset of stroke or transient ischemic attack and entered data into a computerized stroke registry. Several important vascular factors were recorded. Patients presented to either a Veterans Affairs Medical Center or a University Medical Center (a county facility). There were 112 Hispanics and 229 non-Hispanic whites with ischemic stroke or transient ischemic attack. Non-Hispanic whites were more likely to have ischemic heart disease (P = .01) and ischemic (vs nonischemic) causes of potential cardiogenic emboli (p = .05) than were Hispanics. The following were not significantly different between Hispanics and non-Hispanic whites: prevalence of vascular risk factors, death within 30 days of stroke, vascular territory involved, infarct location, prevalence of extracranial carotid stenosis, or cardiac sources of emboli. Our study does not show an obvious difference in the clinical features of ischemic stroke between Hispanics and non-Hispanic whites in New Mexico.