Risk Factors for Acute Stroke among South Asians Compared to Other Racial/Ethnic Groups

Background

Studies of racial/ethnic variations in stroke rarely consider the South Asian population, one of the fastest growing sub-groups in the United States. This study compared risk factors for stroke among South Asians with those for whites, African-Americans, and Hispanics.

Methods

Data on 3290 stroke patients were analyzed to examine risk differences among the four racial/ethnic groups. Data on 3290 patients admitted to a regional stroke center were analyzed to examine risk differences for ischemic stroke (including subtypes of small and large vessel disease) among South Asians, whites, African Americans and Hispanics.

Results

South Asians were younger and had higher rates of diabetes mellitus, blood pressure, and fasting blood glucose levels than other race/ethnicities. Prevalence of diabetic and antiplatelet medication use, as well as the incidence of small-artery occlusion ischemic stroke was also higher among South Asians. South Asians were almost a decade younger and had comparable socioeconomic levels as whites; however, their stroke risk factors were comparable to that of African Americans and Hispanics.

Discussion

Observed differences in stroke may be explained by dietary and life style choices of South Asian-Americans, risk factors that are potentially modifiable. Future population and epidemiologic studies should consider growing ethnic minority groups in the examination of the nature, outcome, and medical care profiles of stroke.     

Genetic risk factors for BMI and obesity in an ethnically diverse population: Results from the population architecture using genomics and epidemiology (PAGE) study

Objective:

Several genome–wide association studies (GWAS) have demonstrated that common genetic variants contribute to obesity. However, studies of this complex trait have focused on ancestrally European populations, despite the high prevalence of obesity in some minority groups.

Design and Methods:

As part of the “Population Architecture using Genomics and Epidemiology (PAGE)” Consortium, we investigated the association between 13 GWAS‐identified single‐nucleotide polymorphisms (SNPs) and BMI and obesity in 69,775 subjects, including 6,149 American Indians, 15,415 African‐Americans, 2,438 East Asians, 7,346 Hispanics, 604 Pacific Islanders, and 37,823 European Americans. For the BMI‐increasing allele of each SNP, we calculated β coefficients using linear regression (for BMI) and risk estimates using logistic regression (for obesity defined as BMI ≥ 30) followed by fixed‐effects meta‐analysis to combine results across PAGE sites. Analyses stratified by racial/ethnic group assumed an additive genetic model and were adjusted for age, sex, and current smoking. We defined “replicating SNPs” (in European Americans) and “generalizing SNPs” (in other racial/ethnic groups) as those associated with an allele frequency‐specific increase in BMI.

Results:

By this definition, we replicated 9/13 SNP associations (5 out of 8 loci) in European Americans. We also generalized 8/13 SNP associations (5/8 loci) in East Asians, 7/13 (5/8 loci) in African Americans, 6/13 (4/8 loci) in Hispanics, 5/8 in Pacific Islanders (5/8 loci), and 5/9 (4/8 loci) in American Indians.

Conclusion:

Linkage disequilibrium patterns suggest that tagSNPs selected for European Americans may not adequately tag causal variants in other ancestry groups. Accordingly, fine‐mapping in large samples is needed to comprehensively explore these loci in diverse populations.     

Trends in Incidence of Stroke and Transition of Stroke Subtypes in Rural Tianjin China: A Population-Based Study from 1992 to 2012

Objectives

The incidence of ischemic stroke has increased and that of hemorrhagic stroke has decreased in urban China; however, the trends in rural areas are unknown. We aimed to explore the secular trends in incidence and transition of stroke subtypes among rural Chinese.

Methods

This was a population-based stroke surveillance through the Tianjin Brain Study. A total of 14,538 residents in a township of Ji County in Tianjin, China participated in the study since 1985. We investigated the age-standardized stroke incidence (sex-specific, type-specific, and age-specific), the annual proportion of change in the incidence of stroke, and the proportion of intracerebral hemorrhage in the periods 1992–1998, 1999–2005, and 2006–2012, because the neuroimaging technique was available since 1992 in this area.

Results

The age-standardized incidence per 100,000 person-years increased significantly for both intracerebral hemorrhage (37.8 in 1992–1998, 46.5 in 1999–2005, and 76.5 in 2006–2012) and ischemic stroke (83.9 in 1992–1998, 135.3 in 1999–2005, and 238.0 in 2006–2012). The age-standardized incidence of first-ever stroke increased annually by 4.9% for intracerebral hemorrhage and by 7.3% for ischemic stroke. The greatest increase was observed in men aged 45–64 years for both stroke types (P < 0.001). The proportion of intracerebral hemorrhage was stable overall, increased among men aged 45–64 years, and decreased among men aged ≥65 years. The average age of intracerebral hemorrhage in men reduced by 7.5 years from 1992 to 2012.

Conclusion

The age-standardized incidence of main stroke subtypes increased significantly in rural China over the past 21 years; the overall proportion of intracerebral hemorrhage was stable, but the incidence increased significantly among middle-aged men. These findings imply that it is crucial to control stroke risk factors in middle-aged men for stroke prevention in future decades.     

Human echinococcosis mortality in the United States, 1990-2007

Background

Despite the endemic nature of Echinococcus granulosus and Echinococcus multilocularis infection in regions of the United States (US), there is a lack of data on echinococcosis-related mortality. To measure echinococcosis-associated mortality in the US and assess possible racial/ethnic disparities, we reviewed national-death certificate data for an 18-year period.

Methodology/Principal Findings

Echinococcosis-associated deaths from 1990 through 2007 were identified from multiple-cause-coded death records and were combined with US census data to calculate mortality rates. A total of 41 echinococcosis-associated deaths occurred over the 18-year study period. Mortality rates were highest in males, Native Americans, Asians/Pacific Islanders, Hispanics and persons 75 years of age and older. Almost a quarter of fatal echinococcosis-related cases occurred in residents of California. Foreign-born persons accounted for the majority of echinococcosis-related deaths; however, both of the fatalities in Native Americans and almost half of the deaths in whites were among US-born individuals.

Conclusions/Significance

Although uncommon, echinococcosis-related deaths occur in the US. Clinicians should be aware of the diagnosis, particularly in foreign-born patients from Echinococcus endemic areas, and should consider tropical infectious disease consultation early.     

Racial disparities in clinical presentation,surgical procedures,and hospital outcomes among patients with hepatocellular carcinoma in the United States

BackgroundHepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths in the United States (US), with substantial disparities observed in cancer incidence and survival among racial groups. This study provides analyses on race and ethnicity disparities for patients with HCC.MethodsThis is a cross-sectional analysis of data from the National Inpatient Sample (NIS) between 2011 and 2016, utilizing the STROBE guidelines. Multivariate logistic regression analyses were used to examine the risk-adjusted associations between race and pre-treatment clinical presentation, surgical procedure allocation, and post-treatment hospital outcomes. All clinical parameters were identified using ICD-9-CM and ICD-10-CM diagnosis and procedure codes.Results83,876 weighted HCC hospitalizations were reported during the study period. Patient demographics were divided according to NIS racial/ethnic categorization, which includes Caucasian (57.3%), African American (16.9%), Hispanic (15.7%), Asian or Pacific Islanders (9.3%), and Native American (0.8%). Association between greater odds of hospitalization and Elixhauser Comorbidity Index > 4 was significantly higher among Native Americans (aOR=1.79; 95% CI: 1.23–2.73), African Americans (aOR=1.24; 95% CI: 1.12–1.38), and Hispanics (aOR=1.11; 95% CI, 1.01–1.24). Risk-adjusted association between race and receipt of surgical procedures demonstrated that the odds of having surgery was significantly lower for African Americans (aOR=0.64; 95% CI: 0.55–0.73) and Hispanics (aOR=0.70; 95% CI: 0.59–0.82), while significantly higher for Asians/Pacific Islanders (aOR=1.36; 95% CI: 1.28–1.63). Post-operative complications were significantly lower for African Americans (aOR=0.68; 95% CI: 0.55–0.86) while the odds of in-hospital mortality were significantly higher for African Americans (aOR=1.28; 95% CI: 1.11–1.49) and Asians/Pacific Islanders (aOR=1.26; 95% CI: 1.13–1.62).ConclusionsAfter controlling for potential confounders, there were significant racial disparities in pre-treatment presentations, surgical procedure allocations, and post-treatment outcomes among patients with HCC. Further studies are needed to determine the underlying factors for these disparities to develop targeted interventions to reduce these disparities of care.     

30-Year Trends in Stroke Rates and Outcome in Auckland,New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies

Background

Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years.

Methods

Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981–1982, 1991–1992, 2002–2003 and 2011–2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution.

Results

5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Māori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Māori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients.

Conclusions

In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.     

Early intervention to promote oral feeding in patients with intracerebral hemorrhage: a retrospective cohort study

Background  

Stroke is a major cause of dysphagia, but little is known about when and how dysphagic patients should be fed and treated after an acute stroke. The purpose of this study is to establish the feasibility, risks and clinical outcomes of early intensive oral care and a new speech and language therapist/nurse led structured policy for oral feeding in patients with an acute intracerebral hemorrhage (ICH).     

An unexpected evolution of symptomatic mild middle cerebral artery (MCA) stenosis: asymptomatic occlusion

Background  

The intracranial localization of large artery disease is recognized as the main cause of ischemic stroke in the world, considering all countries, although its global burden is widely underestimated. Indeed it has been reported more frequently in Asians and African-American people, but the finding of intracranial stenosis as a cause of ischemic stroke is relatively common also in Caucasians. The prognosis of patients with stroke due to intracranial steno-occlusion is strictly dependent on the time of recanalization. Moreover, the course of the vessel involvement is highly dynamic in both directions, improvement or worsening, although several data are derived from the atherosclerotic subtype, compared to other causes.     

Increased hemorrhagic transformation and altered infarct size and localization after experimental stroke in a rat model type 2 diabetes

Background  

Interruption of flow through of cerebral blood vessels results in acute ischemic stroke. Subsequent breakdown of the blood brain barrier increases cerebral injury by the development of vasogenic edema and secondary hemorrhage known as hemorrhagic transformation (HT). Diabetes is a risk factor for stroke as well as poor outcome of stroke. The current study tested the hypothesis that diabetes-induced changes in the cerebral vasculature increase the risk of HT and augment ischemic injury.     

A prospective controlled study: Minimally invasive stereotactic puncture therapy versus conventional craniotomy in the treatment of acute intracerebral hemorrhage

Background  

Spontaneous intracerebral hemorrhage (ICH) is a devastating form of stroke with the high mortality twofold to sixfold higher than that for ischemic stroke. But the treatment of haematomas within the basal ganglia continues to be a matter of debate among neurologists and neurosurgeons. The purpose of this study is to judge the clinical value of minimally invasive stereotactic puncture therapy (MISPT) on acute ICH.     

Effect of pre-stroke use of ACE inhibitors on ischemic stroke severity

Background  

Recent trials suggest that angiotensin-converting enzyme inhibitors (ACEI) are effective in prevention of ischemic stroke, as measured by reduced stroke incidence. We aimed to compare stroke severity between stroke patients who were taking ACEI before their stroke onset and those who were not, to examine the effects of pretreatment with ACEI on ischemic stroke severity.     

Risk of Ischemic Stroke after Intracranial Hemorrhage in Patients with Atrial Fibrillation

Background

We aimed to estimate the risk of ischemic stroke after intracranial hemorrhage in patients with atrial fibrillation.

Materials and Methods

Using discharge data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at the time of a first-recorded encounter with a diagnosis of atrial fibrillation. Ischemic stroke and intracranial hemorrhage were identified using validated diagnosis codes. Kaplan-Meier survival statistics and Cox proportional hazard analyses were used to evaluate cumulative rates of ischemic stroke and the relationship between incident intracranial hemorrhage and subsequent stroke.

Results

Among 2,084,735 patients with atrial fibrillation, 50,468 (2.4%) developed intracranial hemorrhage and 89,594 (4.3%) developed ischemic stroke during a mean follow-up period of 3.2 years. The 1-year cumulative rate of stroke was 8.1% (95% CI, 7.5–8.7%) after intracerebral hemorrhage, 3.9% (95% CI, 3.5–4.3%) after subdural hemorrhage, and 2.0% (95% CI, 2.0–2.1%) in those without intracranial hemorrhage. After adjustment for the CHA₂DS₂-VASc score, stroke risk was elevated after both intracerebral hemorrhage (hazard ratio [HR], 2.8; 95% CI, 2.6–2.9) and subdural hemorrhage (HR, 1.6; 95% CI, 1.5–1.7). Cumulative 1-year rates of stroke ranged from 0.9% in those with subdural hemorrhage and a CHA₂DS₂-VASc score of 0, to 33.3% in those with intracerebral hemorrhage and a CHA₂DS₂-VASc score of 9.

Conclusions

In a large, heterogeneous cohort, patients with atrial fibrillation faced a substantially heightened risk of ischemic stroke after intracranial hemorrhage. The risk was most marked in those with intracerebral hemorrhage and high CHA₂DS₂-VASc scores.     

Albumin Administration in Acute Ischemic Stroke: Safety Analysis of the ALIAS Part 2 Multicenter Trial

Background

Albumin treatment of ischemic stroke was associated with cardiopulmonary adverse events in previous studies and a low incidence of intracranial hemorrhage. We sought to describe the neurological and cardiopulmonary adverse events in the ALIAS Part 2 Multicenter Trial.

Methods

Ischemic stroke patients, aged 18–83 and a baseline NIHSS ≥ 6, were randomized to treatment with ALB or saline control within 5 hours of stroke onset. Neurological adverse events included symptomatic intracranial hemorrhage, hemicraniectomy, neurological deterioration and neurological death. Cardiopulmonary adverse events included pulmonary edema/congestive heart failure, acute coronary syndromes, atrial fibrillation, pneumonia and pulmonary thromboembolism.

Results

Among 830 patients, neurological and cardiopulmonary adverse events were not differentially associated with poor outcome between ALB and saline control subjects. The rate of symptomatic intracranial hemorrhage in the first 24h was low overall (2.9%, 24/830) but more common in the ALB treated subjects (RR = 2.4, CI₉₅ 1.01–5.8). The rate of pulmonary edema/CHF in the first 48h was 7.9% (59/830) and was more common among ALB treated subjects (RR = 10.7, CI₉₅ 4.3–26.6); this complication was expected and was satisfactorily managed with mandated diuretic administration and intravenous fluid guidelines. Troponin elevations in the first 48h were common, occurring without ECG change or cardiac symptoms in 52 subjects (12.5%).

Conclusions

ALB therapy was associated with an increase in symptomatic ICH and pulmonary edema/congestive heart failure but this did not affect final outcomes. Troponin elevation occurs routinely in the first 48 hours after acute ischemic stroke.

Trial Registration

ClincalTrials.gov NCT00235495     

Susceptibility-Weighted Imaging in Heat Stroke

Objective

To assess the role of susceptibility-weighted imaging in the detection of intracranial hemorrhage after heat stroke and in the prognosis.

Materials and Methods

The study group consisted of eight patients after heat stroke, with a score of 3 to 9 in Glasgow Coma Scale. The MR studies were performed with a 1.5 T scanner. Susceptibility-weighted imaging data were collected within 2–5 days after heat stroke. The study was approved by ethics committee, and written informed consents were obtained from family members of the patients.

Results

Punctate hemorrhages were detected in brain stem, corona radiata and frontal lobe by susceptibility-weighted imaging for three patients. Among the three cases, two patients came to death in the 5th day and the 25th day after heat stroke respectively. Another patient became a persistent vegetative state and died about 3 months later. Five patients with no hemorrhage detected gradually recovered and cerebellar dysfunction remained to various degrees.

Conclusions

Heat stroke is a life-threatening condition characterized by hyperthermia and accompanied by various complications such as disseminated intravascular coagulation. Susceptibility-weighted imaging is a very useful tool for detection of intracranial hemorrhage and may probably evaluate the prognosis after heat stroke.     

Association of CVD Candidate Gene Polymorphisms with Ischemic Stroke and Cerebral Hemorrhage in Chinese Individuals

Background

Contribution of cardiovascular disease related genetic risk factors for stroke are not clearly defined. We performed a genetic association study to assess the association of 56 previously characterized gene variants in 34 candidate genes from cardiovascular disease related biological pathways with ischemic stroke and cerebral hemorrhage in a Chinese population.

Methods

There were 1280 stroke patients (1101 with ischemic stroke and 179 with cerebral hemorrhage) and 1380 controls in the study. The genotypes for 56 polymorphisms of 34 candidate genes were determined by the immobilized probe approach and the associations of gene polymorphisms with ischemic stroke and cerebral hemorrhage were performed by logistic regression under an allelic model.

Results

After adjusting for age, sex, BMI and hypertension status by logistic regression analysis, we found that NPPA rs5063 was significantly associated with both ischemic stroke (odds ratio [OR] 0.69; 95% confidence interval [CI], 0.52 to 0.90; P = 0.006) and cerebral hemorrhage(OR = 0.39; 95%CI, 0.19 to 0.78; P = 0.007). In addition, MTHFR rs1801133 also was associated with cerebral hemorrhage (OR = 1.48; 95%CI, 1.16 to1.89; P = 0.001) but not with ischemic stroke (OR = 1.08; 95%CI, 0.96 to1.22; P = 0.210). After false discovery rate (FDR) correction, the association of NPPA rs5063 and MTHFR rs1801133 with cerebral hemorrhage remained significant.

Conclusions

The NPPA rs5063 is associated with reduced risk for cerebral hemorrhage and MTHFR rs1801133 is associated with increased risk of cerebral hemorrhage in a Chinese population.     

Sociodemographic,behavioral, and biological variables related to weight loss in native hawaiians and other pacific islanders

Objective:

Native Hawaiians and other Pacific Islanders (NHs/PIs) have a high obesity prevalence compared to other ethnic groups. We examined socio‐demographic, behavioral, and biological factors related to ≥3% weight loss in 100 overweight/obese NHs/PIs who completed a lifestyle intervention.

Design and Methods:

Data were from 56 Native Hawaiians, 22 Chuukese, and 22 Other Pacific Islanders who participated in a randomized controlled trial of the Partnership for Improving Lifestyle Intervention (PILI) 'Ohana Project. All completed a 3‐month weight loss program (WLP) to initiate weight loss and were then randomized into either a 6‐month family/community focused WLP called the PILI Lifestyle Program (PLP; n = 49) or a standard behavior WLP (SBP; n = 51). We collected baseline, 3‐ and 9‐month follow‐up data on socio‐demographics, weight (kg), a 6‐min. walk test, dietary fat, exercise frequency, and blood pressure.

Results and Conclusion:

Based on ANCOVA or logistic fit, ethnicity, sex, initial weight loss, fat in diet at baseline, change in systolic blood pressure, and intervention type were significantly associated (P ≤ .05) with ≥3% weight loss at 9‐month follow‐up. A logistic regression model indicated that Chuukese (OR = 6.04; CI = 1.14–32.17) and participants who had more weight loss in the first 3‐months (OR = 1.47; CI = 1.22–1.86) and who were in the PLP (OR = 4.50; CI = 1.50–15.14) were more likely to achieve ≥3% weight loss [model; χ² (7, N = 100) = 45.50, P < .0001]. The same lifestyle intervention does not benefit all NHs/PIs equally, possibly due to differences in acculturation status and social support. The findings also point to the importance of initial weight loss to sustain motivation toward long‐term weight loss maintenance.     

Mitochondrial DNA variation in Nicobarese Islanders.

The aboriginal populations living in the Nicobar Islands are hypothesized to be descendants of people who were part of early human dispersals into Southeast Asia. However, analyses of ethnographic histories, languages, morphometric data, and protein polymorphisms have not yet resolved which worldwide populations are most closely related to the Nicobarese. Thus, to explore the origins and affinities of the Nicobar Islanders, we analyzed mitochondrial DNA (mtDNA) hypervariable region 1 sequence data from 33 Nicobarese Islanders and compared their mtDNA haplotypes to those of neighboring East Asians, mainland and island Southeast Asians, Indians, Australian aborigines, Pacific Islanders, and Africans. Unique Nicobarese mtDNA haplotypes, including five Nicobarese mtDNA haplotypes linked to the COII/tRNA(Lys) 9-bp deletion, are most closely related to mtDNA haplotypes from mainland Southeast Asian Mon-Kmer-speaking populations (e.g., Cambodians). Thus, the dispersal of southern Chinese into mainland Southeast Asia may have included a westward expansion and colonization of the islands of the Andaman Sea.     

Blood Levels of Glial Fibrillary Acidic Protein (GFAP) in Patients with Neurological Diseases

Background and Purpose

The brain-specific astroglial protein GFAP is a blood biomarker candidate indicative of intracerebral hemorrhage in patients with symptoms suspicious of acute stroke. Comparably little, however, is known about GFAP release in other neurological disorders. In order to identify potential “specificity gaps” of a future GFAP test used to diagnose intracerebral hemorrhage, we measured GFAP in the blood of a large and rather unselected collective of patients with neurological diseases.

Methods

Within a one-year period, we randomly selected in-patients of our university hospital for study inclusion. Patients with ischemic stroke, transient ischemic attack and intracerebral hemorrhage were excluded. Primary endpoint was the ICD-10 coded diagnosis reached at discharge. During hospital stay, blood was collected, and GFAP plasma levels were determined using an advanced prototype immunoassay at Roche Diagnostics.

Results

A total of 331 patients were included, covering a broad spectrum of neurological diseases. GFAP levels were low in the vast majority of patients, with 98.5% of cases lying below the cut-off that was previously defined for the differentiation of intracerebral hemorrhage and ischemic stroke. No diagnosis or group of diagnoses was identified that showed consistently increased GFAP values. No association with age and sex was found.

Conclusion

Most acute and chronic neurological diseases, including typical stroke mimics, are not associated with detectable GFAP levels in the bloodstream. Our findings underline the hypothesis that rapid astroglial destruction as in acute intracerebral hemorrhage is mandatory for GFAP increase. A future GFAP blood test applied to identify patients with intracerebral hemorrhage is likely to have a high specificity.     

Temporal Trends in Incidence of Myocardial Infarction and Ischemic Stroke by Socioeconomic Position in Sweden 1987–2010

Background

We analyzed temporal trends in the incidence of myocardial infarction and ischemic stroke in Sweden by socioeconomic position and investigated whether social inequalities in incidence of these diseases changed over time.

Materials and Methods

We studied a cohort of almost three million Swedish residents born between 1932 and 1960 followed from 1987 until 2010. Incident cases of myocardial infarction and ischemic stroke were identified in the Swedish National Inpatient Register and Cause of Death Register. Socioeconomic position was retrieved from the Population and Housing Censuses. Incidence rates of myocardial infarction and ischemic stroke and incidence rate ratios comparing levels of socioeconomic position were estimated using flexible parametric survival models adjusted for calendar year, attained age, sex, and birth country.

Results

The overall incidences of myocardial infarction and ischemic stroke decreased over time among men, but were stable over time among women. With regard to ischemic stroke incidence, socioeconomic inequality increased over time in the age group 55 to 59: the incidence rate ratios for low manual compared to high non-manual increased from 1.3 (95% CI: 1.2–1.4) in 1997 to 1.5 (1.4–1.7) in 2010 among men, and from 1.4 (1.3–1.6) in 1997 to 2.1 (1.8–2.5) in 2010 among women. The socioeconomic inequality in incidence of myocardial infarction was stable over time for both men and women.

Conclusion

There was a decrease in myocardial infarction and ischemic stroke incidence over time among men but no significant change for women. Our study highlights existing, and in some cases increasing, social inequalities in the incidence of cardiovascular diseases.     

Loss of circadian rhythm of blood pressure following acute stroke

Background  

Epidemiology of acute stroke in developing countries differs from that in the developed world, for example, the age at stroke, risk factors, subtypes of stroke and prognosis. Hypertension remains a dominant risk factor and prognostic indicator in patients with stroke in all communities. The risk of stroke is directly related to elevations of blood pressure. A number of clinical studies have shown that the control of hypertension leads to a reduction in the incidence of stroke in a community. However there is still considerable controversy surrounds the changes in blood pressure in various subtypes of strokes and problem of management of elevated BP after stroke. We studied the circadian rhythm of blood pressure in patients following acute stroke.