Ali Fokar

Racial Disparities in Tissue Plasminogen Activator Treatment Rate for Stroke A Population-Based Study

Background and Purpose— Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods— Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Results— Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). Conclusions— In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia

Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack. Within one-year of hospital discharge, up to one-third of patients no longer adhere to secondary prevention behaviors. Adherence rates are lower in minority-underserved groups, contributing to health disparities. In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals. In these groups, low literacy, limited healthcare access, and sparse community resources may reduce adherence. Lay community health workers (navigators) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services. Aims and design PROTECT DC is a Phase II, single-blind, randomized, controlled trial comparing in-hospital education plus stroke navigators to usual care. Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington, DC hospitals. Navigators meet with participants during the index hospitalization, perform home visits, and meet by phone. They focus on stroke education, medication compliance, and overcoming practical barriers to adherence. The interventions are driven by the theories of reasoned action and planned behavior. Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control: systolic blood pressure, low-density lipoprotein, hemoglobin Hb A1C, and antiplatelet agent pill counts. Secondary outcomes include stroke knowledge, exercise, dietary modification, and smoking cessation. Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted.

Characteristics and Incidence of Chronic Illness in Community-Dwelling Predominantly Male U.S. Veteran Centenarians

To assess the incidence of chronic illness and its effect on veteran centenarians.

Recruitment of Black Subjects for a Natural History Study of Intracerebral Hemorrhage

Historically, recruitment of minority subjects for clinical research has been challenging. We developed culturally-tailored recruitment materials for a longitudinal, natural history study of intracerebral hemorrhage (ICH) and trained recruiting coordinators in cultural competence. Of 285 subjects meeting inclusion criteria, 158 (55% of those eligible) agreed to participate (60% of eligible Blacks vs. 45% of eligible non-Blacks, p..02). Of those enrolled, 138 (87%) agreed to participate in the genetic sub-study (86% of Blacks vs. 90% of non-Blacks enrolled, p..78). Of those subjects who refused enrollment, lack of interest in research (42%) was the most common reason given for the study as a whole. A higher rate of enrollment was achieved in Blacks vs. non-Blacks in this ICH clinical research study employing culturally tailored recruitment approaches and training of recruitment coordinators to overcome traditional recruitment barriers to research participation in minority patients.

A 108-Year-Old Centenarian Survivor of Acute Decompensated Heart Failure and Acute Kidney Injury

To the Editor: Heart failure in centenarians is an especially challenging syndrome, as these patients frequently suffer from comorbidities and functional impairments. Age-related physiological changes can also affect pharmacokinetics and pharmacodynamics and may influence patient response tomedication. Unfortunately, in this growing segment of the nation’s population, evidence-based treatment guidelines are lacking. We report our experience treating a 108-year-old centenarian with acute decompensated heart failure and acute kidney injury. The goals of care, as articulated by the patient, were to reduce disease burden and to improve her quality of life and survival. These goals were accomplished through an involved interdisciplinary treatment team, closely monitored conservative medical care, and the cooperation of our resilient patient. Heart failure (HF) is a worldwide complex and chronic clinical syndrome that increaseswith age.1 The changing demographics of the rapidly growing segment of the oldest old seem to be contributing to the increasing prevalence of HF with an age-adjusted mortality that appears to be increasing as well.2 The lifetime risk for HF in octogenarians is estimated to be 20%.3 For persons residing in skilled nursing facilities (SNFs) in the United States, HF is commonwith an estimated prevalence of 25% and 1-year mortality exceeding 50%.4 Despite the high prevalence of HF in the oldest old, there is a lack of large randomized clinical trials for octogenarians, nonagenarians, centenarians, or patients residing in SNFs. We will present the case of our patient and review the literature regarding medical management of elderly patients with HF accompanied by kidney injury.

Racial Disparities in Tissue Plasminogen Activator Treatment Rate for Stroke

Background and Purpose— Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods— Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Results— Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). Conclusions— In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.

Association between lifetime risk of atrial fibrillation and mortality in the oldest old

Age is the strongest predictor of atrial fibrillation (AF), yet little is known about AF incidence in the oldest old.

CHARACTERISTICS AND INCIDENCE OF ATRIAL FIBRILLATION IN US VETERAN CENTENARIANS

Background: Centenarians are the fastest growing segment of US population yet little is known about the incidence of cardiovascular illness and its impact on longevity We examined the incidence of atrial fibrillation (AFIB) in centenarians as compared with nonagenarians and octogenarians Methods:

RACIAL DISPARITIES IN TPA TREATMENT RATE FOR STROKE: A POPULATION-BASED STUDY

Background and Purpose— Some prior studies have shown that racial disparities exist in intravenous tissue plasminogen activator (tPA) use for acute ischemic stroke. We sought to determine whether race was associated with tPA treatment for stroke in a predominantly black urban population. Methods— Systematic chart abstraction was performed on consecutive hospitalized patients with ischemic stroke from all 7 acute care hospitals in the District of Columbia from February 1, 2008, to January 31, 2009. Results— Of 1044 patients with ischemic stroke, 74% were black, 19% non-Hispanic white, and 5% received intravenous tPA. Blacks were one third less likely than whites to receive intravenous tPA (3% versus 10%, P<0.001). However, blacks were also less likely than whites to present within 3 hours of symptom onset (13% versus 21%, P=0.004) and also less likely to be tPA-eligible (5% versus 13%, P<0.001). Of those who presented within 3 hours, blacks were almost half as likely to be treated with intravenous tPA than whites (27% versus 46%, P=0.023). The treatment rate for tPA-eligible patients was similar for blacks and whites (70% versus 76%, P=0.62). Conclusions— In this predominantly black urban population hospitalized for acute ischemic stroke, blacks were significantly less likely to be treated with intravenous tPA due to contraindications to treatment, delayed presentation, and stroke severity. Effective interventions designed to increase treatment in this population need to focus on culturally relevant education programs designed to address barriers specific to this population.