Has the Aetiology of Ischaemic Stroke Changed in the Past Decades? Analysis and Comparison of Data from Current and Historical Stroke Databases
Journal: Advances in Medicine and Engineering Interdisciplinary Research DOI: 10.32629/ameir.v2i4.2913
Abstract
Objectives: We aimed to determine whether the aetiology of ischaemic stroke has changed in recent years and, if so, to ascertain the possible reasons for these changes. Patients and methods: We analysed the epidemiological history and vascular risk factors of all patients diagnosed with ischaemic stroke at Complejo Hospitalario Universitario de Albacete (CHUA) from 2009 to 2014. Ischaemic stroke subtypes were established using the TOAST criteria. Our results were compared to data from the classic Stroke Data Bank (SDB); in addition, both series were compared to those of other hospital databases covering the period between the two. Results: We analysed 1664 patients (58% were men) with a mean age of 74 years. Stroke aetiology in both series (CHUA, SDB) was as follows: atherosclerosis (12%, 9%), small-vessel occlusion (13%, 25%), cardioembolism (32%, 19%), stroke of other determined aetiology (3%, 4%), and stroke of undetermined aetiology (40%, 44%). Sixty-three percent of the patients from the CHUA and 42% of the patients from the SDB were older than 70 years. Cardioembolic strokes were more prevalent in patients older than 70 years in both series. Untreated hypertension was more frequent in the SDB (SDB = 31% vs CHUA = 10%). The analysis of other databases shows that the prevalence of cardioembolic stroke is increasing worldwide. Conclusions: Our data show that the prevalence of lacunar strokes is decreasing worldwide whereas cardioembolic strokes are increasingly more frequent in both our hospital and other series compared to the SDB. These differences may be explained by population ageing and the improvements in management of hypertension and detection of cardioembolic arrhythmias in stroke units.
Keywords
stroke data bank; stroke aetiology; stroke subtypes; TOAST; vascular risk factors; atrial fibrillation
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[27] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;15: e101-98.
[28] Ziegler PD, Glotzer TV, Daoud EG, Singer DE, Ezekowitz MD, Hoyt RH, et al. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention. Am J Cardiol. 2012;110:1309-14.
[29] Sposato LA, Klein FR, Jáuregui A, Ferrúa M, Klin P, Zamora R, et al. Newly diagnosed atrial fibrillation after acute ischemic stroke and transient ischemic attack: importance of immediate and prolonged continuous cardiac monitoring. J Stroke Cerebrovasc Dis. 2012;21:210-6.
[30] Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014;45:520-6.
[31] Mar J, Masjuan J, Oliva-Moreno J, Gonzalez-Rojas N, Becerra V, Casado MÁ, et al. Outcomes measured by mortality rates, quality of life and degree of autonomy in the first year in stroke units in Spain. Health Qual Life Outcomes. 2015;17:36.
[32] Arias-Rivas S, Vivancos-Mora J, Castillo J, en nombre de los investigadores del Registro Epices. Epidemiología de los subtipos de ictus en pacientes hospitalizados atendidos por neurólogos: resultados del registro EPICES (I). Rev Neurol. 2012;54:385-93.
[33] Tsai CF, Anderson N, Thomas B, Sudlow CL. Risk factors for ischemic stroke and its subtypes in Chinese vs. Caucasians: systematic review and meta-analysis. Int J Stroke. 2015;10:485-93.
[34] Prieto-Díaz MÁ, Grupo de Trabajo de Hipertensión Arterial de SEMERGEN, European Society of Hypertension. Guías en el manejo de la hipertensión. Semergen. 2014;40 Suppl. 4:2-10.
[35] Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47:895-900.
[36] Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13:429-38.
[37] Diener HC, Easton JD, Granger CB, Cronin L, Duffy C, Cotton D, et al. Design of randomized, double-blind, evaluation in secondary stroke prevention comparing the efficacy and safety of the oral thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with embolic stroke of undetermined source (RE-SPECT ESUS). Int J Stroke. 2015;10:1309-12.
[2] Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095-128.
[3] Murray CJ, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life-years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223.
[4] Díaz-Guzmán J, Egido JA, Gabriel-Sánchez R, Barberá-Comes G, Fuentes-Gimeno B, Fernández-Pérez C. Stroke and transient ischemic attack incidence rate in Spain: The IBERICTUS study. Cerebrovasc Dis. 2012;34:272-81.
[5] Feigin VL, Krishnamurthi R, Bhattacharjee R, Parmar P, Theadom A, Hussein T, et al. New strategy to reduce the global burden of stroke. Stroke. 2015;46:1740-7.
[6] Álvarez-Sabín J, Ribó M, Masjuan J, Tejada JR, Quintana M. en nombre de los investigadores del estudio PRACTIC. Importancia de una atención neurológica especializada en el manejo intrahospitalario de pacientes con ictus. Neurologia. 2011;26:510-7.
[7] Alvarez Sabín J, Alonso de Lecinana M, Gállego J, Gil-Peralta A, Casado I, Castillo J, et al. Plan de atención sanitaria al ictus. Neurologia. 2006;21:717-26.
[8] Mohr JP. Stroke data banks. Stroke. 1986;17:171-2.
[9] Sudlow CL, Warlow CP. Comparing stroke incidence worldwide: what makes studies comparable. Stroke. 1996;27:550-8.
[10] Foulkes MA, Wolf PA, Price TR, Mohr JP, Hier DB. The Stroke Data Bank: design, methods, and baseline characteristics. Stroke. 1988;19:547-54.
[11] Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, et al. Classification of subtype of acute stroke: definitions for use in a multicenter clinical trial. Stroke. 1993;24:35-41.
[12] Chen PH, Gao S, Wang YJ, Xu AD, Li YS, Wang D. Classifying ischemic stroke, from TOAST to CISS. CNS Neurosci Ther. 2012;18:452-6.
[13] L Annual meeting of the Spanish Society of Neurology. Barcelona, Spain, 16-19 December 1998. Abstracts. Neurologia. 1998;13:449-549.
[14] The Publications Committee for the Trial of, ORG., 10172 in Acute Stroke Treatment (TOAST) Investigators. Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. JAMA. 1998;279:1265-72.
[15] Frey JL, Jahnke HK, Bulfinch EW. Differences in stroke between white, Hispanic, and native American patients. The Barrow Neurological Institute Stroke Database. Stroke. 1998;29:29-33.
[16] Schneider AT, Kissela B, Woo D, Kleindorfer D, Alwell K, Miller R, et al. Ischemic stroke subtypes: a population-based study of incidence rates among blacks and whites. Stroke. 2004;35:1552-6.
[17] Saposnik G, del Brutto OH, Iberoamerican Society of Cerebrovascular Diseases. Stroke in South America: a systematic review of incidence, prevalence, and stroke subtypes. Stroke. 2003;34:2103-7.
[18] Tsai CF, Thomas B, Sudlow CL. Epidemiology of stroke and its subtypes in Chinese vs white populations: a systematic review. Neurology. 2013;81:264-72.
[19] Yip PK, Jeng JS, Lee TK, Chang YC, Huang ZS, Ng SK, et al. Subtypes of ischemic stroke. A hospital-based stroke registry in Taiwan (SCAN-IV). Stroke. 1997;28:2507-12.
[20] Vemmos KN, Takis CE, Georgilis K, Zakopoulos NA, Lekakis JP, Papamichael CM, et al. The Athens stroke registry: results of a five-year hospital-based study. Cerebrovasc Dis. 2000;10:133-41.
[21] Morín-Martín M, González-Santiago R, Gil-Núnez AC, VivancosMora J. Women and strokes. Hospital epidemiology in Spain. Rev Neurol. 2003;37:701-5.
[22] Grau AJ, Weimar C, Buggle F, Heinrich A, Foertler M, Neumaier S, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: The German Stroke Data Bank. Stroke. 2001;32:2559-99.
[23] Carod-Artal FJ, Casanova Lanchipa JO, Cruz Ramírez LM, Pérez NS, Siacara Aguayo FM, Moreno IG, et al. Stroke subtypes and comorbidity among ischemic stroke patients in Brasilia and Cuenca: a Brazilian-Spanish cross-cultural study. J Stroke Cerebrovasc Dis. 2014;23:140-7.
[24] Feigin V, Carter K, Hackett M, Barber PA, McNaughton H, Dyall L, et al. Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003. Lancet Neurol. 2006;5:130-9.
[25] Jiménez-Caballero PE, López-Espuela F, Portilla-Cuenca JC, Jiménez-Gracia MA, Casado-Naranjo I. Detección de factores de riesgo vascular y fibrilación auricular no conocida en pacientes ingresados en la unidad de ictus. Rev Neurol. 2013;56:464-70.
[26] Andersen KK, Andersen ZJ, Olsen TS. Age and gender specific prevalence of cardiovascular risk factors in 40102 patients with first ever ischemic stroke. A nationwide Danish study. Stroke. 2010;41:2768-74.
[27] Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;15: e101-98.
[28] Ziegler PD, Glotzer TV, Daoud EG, Singer DE, Ezekowitz MD, Hoyt RH, et al. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention. Am J Cardiol. 2012;110:1309-14.
[29] Sposato LA, Klein FR, Jáuregui A, Ferrúa M, Klin P, Zamora R, et al. Newly diagnosed atrial fibrillation after acute ischemic stroke and transient ischemic attack: importance of immediate and prolonged continuous cardiac monitoring. J Stroke Cerebrovasc Dis. 2012;21:210-6.
[30] Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014;45:520-6.
[31] Mar J, Masjuan J, Oliva-Moreno J, Gonzalez-Rojas N, Becerra V, Casado MÁ, et al. Outcomes measured by mortality rates, quality of life and degree of autonomy in the first year in stroke units in Spain. Health Qual Life Outcomes. 2015;17:36.
[32] Arias-Rivas S, Vivancos-Mora J, Castillo J, en nombre de los investigadores del Registro Epices. Epidemiología de los subtipos de ictus en pacientes hospitalizados atendidos por neurólogos: resultados del registro EPICES (I). Rev Neurol. 2012;54:385-93.
[33] Tsai CF, Anderson N, Thomas B, Sudlow CL. Risk factors for ischemic stroke and its subtypes in Chinese vs. Caucasians: systematic review and meta-analysis. Int J Stroke. 2015;10:485-93.
[34] Prieto-Díaz MÁ, Grupo de Trabajo de Hipertensión Arterial de SEMERGEN, European Society of Hypertension. Guías en el manejo de la hipertensión. Semergen. 2014;40 Suppl. 4:2-10.
[35] Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47:895-900.
[36] Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O’Donnell MJ, et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13:429-38.
[37] Diener HC, Easton JD, Granger CB, Cronin L, Duffy C, Cotton D, et al. Design of randomized, double-blind, evaluation in secondary stroke prevention comparing the efficacy and safety of the oral thrombin inhibitor dabigatran etexilate vs. acetylsalicylic acid in patients with embolic stroke of undetermined source (RE-SPECT ESUS). Int J Stroke. 2015;10:1309-12.
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