Antonio Di Carlo

Sex Differences in the Clinical Presentation, Resource Use, and 3-Month Outcome of Acute Stroke in Europe: Data From a Multicenter Multinational Hospital-Based Registry

Background and Purpose— The information on the existence of sex differences in management of stroke patients is scarce. We evaluated whether sex differences may influence clinical presentation, resource use, and outcome of stroke in a European multicenter study. Methods— In a European Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin Scale). Results— Overall, 2239 patients were males and 2260 females. Compared with males, female patients were significantly older (mean age 74.5±12.5 versus 69.2±12.1 years), more frequently institutionalized before stroke, and with a worse prestroke Rankin score (all values P <0.001). History of hypertension (P =0.007) and atrial fibrillation (P <0.001) were significantly more frequent in female stroke patients, as were coma (P <0.001), paralysis (P <0.001), aphasia (P =0.001), swallowing problems (P =0.005), and urinary incontinence (P <0.001) in the acute phase. Brain imaging, Doppler examination, echocardiogram, and angiography were significantly less frequently performed in female than male patients (all values P <0.001). The frequency of carotid surgery was also significantly lower in female patients (P <0.001). At the 3-month follow-up, after controlling for all baseline and clinical variables, female sex was a significant predictor of disability (odds ratio [OR], 1.41; 95% CI 1.10 to 1.81) and handicap (OR, 1.46; 95% CI 1.14 to 1.86). No significant gender effect was observed on 3-month survival. Conclusions— Sex-specific differences existed in a large European study of hospital admissions for acute stroke. Both medical and sociodemographic factors may significantly influence stroke outcome. Knowledge of these determinants may positively impact quality of care.

Characteristics, Outcome, and Care of Stroke Associated With Atrial Fibrillation in Europe Data From a Multicenter Multinational Hospital–Based Registry (The European Community Stroke Project)

Background and Purpose — The role of atrial fibrillation (AF) as a determinant of stroke outcome is not well established. Studies focusing on this topic relied on relatively small samples of patients, scarcely representative of the older age groups. We aimed at evaluating clinical characteristics, care, and outcome of stroke associated with AF in a large European sample. Methods — In a European Concerted Action involving 7 countries, 4462 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month survival, disability (Barthel Index), and handicap (Rankin scale). Results — AF was present in 803 patients (18.0%). AF patients, compared with those without AF, were older, were more frequently female, and more often had experienced a previous myocardial infarction; they were less often diabetics, alcohol consumers, and smokers (all P <0.001). At 3 months, 32.8% of the AF patients were dead compared with 19.9% of the non-AF patients (P <0.001). With control for baseline variables, AF increased by almost 50% the probability of remaining disabled (multivariate odds ratio 1.43, 95% CI 1.13 to 1.80) or handicapped (multivariate odds ratio 1.51, 95% CI 1.13 to 2.02). Before stroke, only 8.4% of AF patients were on anticoagulants. The chance of being anticoagulated was reduced by 4% per year of increasing age. AF patients underwent CT scan and other diagnostic procedures less frequently and received less physiotherapy or occupational therapy. Conclusions — Stroke associated with AF has a poor prognosis in terms of death and function. Prevention and care of stroke with AF is a major challenge for European health systems.

Cognitive impairment without dementia in older people : prevalence, vascular risk factors, impact on disability. The Italian Longitudinal Study on aging

OBJECTIVES: To investigate prevalence of “cognitive impairment, no dementia” (CIND) in the Italian older population, evaluating the association with cardiovascular disease and the impact on activities of daily living (ADL). CIND may provide pathogenic clues to dementia and independently affect ADL.

Stroke in the Very Old Clinical Presentation and Determinants of 3-Month Functional Outcome: A European Perspective

BACKGROUND AND PURPOSE The oldest old represent the fastest-growing segment of the elderly population in developed countries. Knowledge of age-specific aspects of stroke is essential to establish diagnostic and therapeutic pathways and to set up prevention and rehabilitation programs. We sought to evaluate stroke features and functional outcome in patients aged >/=80 years compared with the younger age groups. METHODS In a European Union Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month disability (Barthel Index) and handicap (Rankin Scale). RESULTS Overall, 3141 patients (69.8%) were aged <80 years, and 1358 (30.2%) were aged >/=80 years. At baseline, female sex, prestroke institutionalization, and a worse prestroke Rankin score were significantly more frequent in the older patients, as were coma, paralysis, swallowing problems, and urinary incontinence in the acute phase (all P values <0.001). Brain imaging and other diagnostic tools were significantly less used in the older patients. Paralysis, swallowing problems, and incontinence during hospitalization independently predicted 3-month disability or handicap in both groups. For the older patients, prestroke institutionalization proved a further strong and independent determinant of 3-month disability (odds ratio, 2.33; 95% CI, 1.22 to 4.45) and handicap (odds ratio, 7.04; 95% CI, 1.62 to 30. 69). CONCLUSIONS In the very old, both medical and sociodemographic factors may significantly influence stroke outcome, showing peculiar characteristics. Knowledge of these determinants may reduce the burden on health systems, improving quality of care.

Human and economic burden of stroke

Stroke is a costly disease from human, family and societal perspectives. Starting from human costs, stroke is a leading cause of death and disability. Annually, about 16 million firstever strokes occur in the world, causing a total of 5.7 million deaths [1]. As a consequence, stroke ranks as the second cause of death in the world population after ischaemic heart disease (the third only if neoplastic diseases are considered as a group). In the United States, figures indicate a total of 5,800,000 prevalent stroke cases, with 780,000 first-ever or recurrent strokes expected each year [2]. In the elderly population of the 15-country Europe, estimates showed 2,700,000 prevalent cases, and 536,000 incident cases each year [3, 4]. Total number of stroke deaths in 48 European countries is currently estimated at 1,239,000 per year (508,000 per year in the 27 European Union members) [5]. Stroke is a global epidemic, and by no way a problem limited to western or high-income countries. About 85% of all stroke deaths are registered in lowand middle-income countries, which also account for 87% of total losses due to stroke in terms of disability-adjusted life years (DALYs), calculated, worldwide, in 72 millions per year [6]. Present and future figures of stroke are strictly related to the demographic transition, occurring in both developed and developing countries. The world population aged 60 and over was 488 millions in 1990, and was projected to about 1,363 millions in 2030, with a percentage increase of 180%. In 1990, developing countries contained the 58% of the world elderly, while in 2030 about twothirds of the total elderly population will be dwelling in these countries [7]. Given that age is one of most substantiated risk factor for stroke, the ageing of the world population implies a growing number of persons at risk. Among EU members, for instance, Italy is the country with the highest percentage of people over the age of 65 years (19.9%). About 153,000 new stroke cases are expected each year in the Italian elderly population. Assuming stable incidence rates, a total of 195,000 new cases per year are expected in 2020, simply due to the ageing population [8]. While stroke will firmly remain the second cause of death in the world by 2030, its ranking as a major cause of DALY loss will increase during the same period [9]. About half of stroke survivors are left with some degree of physical or cognitive impairment [10, 11]. The need of support for common daily activities directly impacts quality of life of patients and their relatives, frequently taking the role of caregivers. Although often neglected, informal care is of paramount relevance to maintain stroke survivors in the community, and a valuable economic resource for health care systems. Available facts and figures may easily explain why the economic burden of stroke is requiring increasing attention for more effective health care planning and resources allocation. An international comparison of stroke cost studies showed that, on average, 0.27% of gross domestic product was spent on stroke by national health systems, and stroke care accounted for ∼3% of total health care expenditures [12]. In the United States, the total direct and indirect cost of stroke for 2008 is estimated at

Incidence of Stroke in Europe at the Beginning of the 21st Century: The European Registers of Stroke (EROS) Investigators

65.5 billion. Direct costs, which include the cost of physicians and other health professionals, acute and long-term care, medications and other medical durables, account for 67% of total costs, while the remaining 33% is due to indirect costs, which consider lost productivity resulting from morbidity and mortality [2]. In the 27 EU countries, total annual cost of stroke is estimated at €27 billion: €18.5 billion (68.5%) for direct and €8.5 billion (31.5%) for indirect costs. A further sum of €11.1 billion is calculated for the value of informal care [5]. Including informal care in the total amount, percentages would change to 48.6% for direct, 22.3% for indirect and 29.1% for informal care costs. This issue of Age and Ageing presents a report on cost of stroke in the United Kingdom (UK) [13]. Direct, indirect and informal care costs were evaluated from a societal perspective, using data from the South London Stroke Register (SLSR) and other national sources. The percentage of elderly people in the UK is over 16% of total population; 130,000 new stroke cases are expected each year, and stroke survivors are more than one million. Considering the burden of stroke in the UK, economic evaluations are essential for an appropriate allocation of available resources. Total societal costs were estimated at £8.9 billion a year. Percentage distribution was very close to the EU figures, with direct costs accounting for 49%, indirect costs for 24% and informal care for 27% of the total. Direct costs, evaluated at £4.4 billion, represent, approximately, 5.5% of the total UK national health expenditures. Assuming resource use as gained mainly from the SLSR, a particular attention was paid to calculation of cost of inpatient stay, cost of physicians and therapists, diagnostic visits, tests and drugs in the acute phase, together with an analysis of expenses for residential, nursing or sheltered home. A careful evaluation of indirect costs was made with an estimation of loss of earnings due to premature death and strokerelated morbidity. Informal care was also evaluated, although

Incidence of Dementia, Alzheimer's Disease, and Vascular Dementia in Italy. The ILSA Study

BACKGROUND AND PURPOSE Comparable data on stroke incidence across European countries are lacking because previous studies have used different methods of case ascertainment, different periods of observation, and different age restrictions. METHODS Population-based stroke registers were established in 6 European countries: France (Dijon); Italy (Sesto Fiorentino); Lithuania (Kaunas); the United Kingdom (London); Spain (Menorca); and Poland (Warsaw). Standardized criteria were used among these register including overlapping sources of notification. Overall, a source population of 1087048 inhabitants was observed, ranging from 47236 in Sesto Fiorentino to 365191 in Kaunas. All patients with first-ever stroke of all age groups from the source populations were included. Data collection took part between 2004 and 2006; 4 centers collected data for a 24-month and 2 for a 12-month time period. Crude annual incidence rates were age-adjusted to the European population. RESULTS A total of 2129 patients with first stroke were registered. Median age was 73 years and 51% were female. Annual stroke incidence adjusted to the European population was found in men to be higher in Kaunas and lower in Sesto Fiorentino and Menorca and in women to be higher in Kaunas and Warsaw and lower in Sesto Fiorentino and Menorca compared with mean incidence rates. Total stroke incidence ranged in men from 101.2 per 100000 (95% CI, 82.5 to 123.0) in Sesto Fiorentino to 239.3 per 100000 (95% CI, 209.9 to 271.6) in Kaunas and in women from 63.0 per 100000 (95% CI, 48.5 to 80.7) in Sesto Fiorentino to 158.7 per 100000 (95% CI, 135.0 to 185.4) in Kaunas. Differences in prior-to-stroke risk factors were found among the populations with prevalence of hypertension highest in Warsaw and Kaunas (76% and 67%, respectively) and lowest in Menorca and Sesto Fiorentino (54% and 62%, respectively). CONCLUSIONS The risk of stroke among European populations in our study varied more than 2-fold in men and women. On average, higher rates of stroke were observed in eastern and lower rates in southern European countries.

Metabolic syndrome and the risk of vascular dementia: the Italian Longitudinal Study on Ageing

OBJECTIVES: To estimate the incidence of dementia, Alzheimers disease (AD), and vascular dementia (VaD) in older Italians and evaluate the relationship of age, gender, and education to developing dementia.

Risk factors and outcome of subtypes of ischemic stroke. Data from a multicenter multinational hospital-based registry. The European Community Stroke Project

Objective The authors investigated the relationship of metabolic syndrome (MetS) and its individual components with incident dementia in a prospective population-based study with a 3.5-year follow-up. Methods A total of 2097 participants from a sample of 5632 subjects (65–84 years old) from the Italian Longitudinal Study on Ageing were evaluated. MetS was defined according to the Third Adults Treatment Panel of the National Cholesterol Education Program criteria. Dementia, Alzheimer disease (AD) and vascular dementia (VaD) were classified using current published criteria. Results MetS subjects (N=918) compared with those without MetS (N=1179) had an increased risk for VaD (1.63% vs 0.85%, adjusted hazard ratio (HR) 3.71, 95% CI 1.40 to 9.83). After excluding 338 subjects with baseline undernutrition, MetS subjects compared with those without MetS had an elevated risk of VaD (adjusted HR, 3.82; 95% CI 1.32 to 11.06). Moreover, those with MetS and high inflammation had a still further higher risk of VaD (multivariate adjusted HR, 9.55; 95% CI 1.17 to 78.17) compared with those without MetS and high inflammation. On the other hand, those with MetS and low inflammation compared with those without MetS and low inflammation did not exhibit a significant increased risk of VaD (adjusted HR, 3.31, 95% CI 0.91 to 12.14). Finally, a synergistic MetS effect versus its individual component effects was verified on the risk of VaD. Conclusion In our population, MetS subjects had an elevated risk of VaD that increased after excluding patients with baseline undernutrition and selecting MetS subjects with high inflammation.

Incidence and Determinants of Poststroke Dementia as Defined by an Informant Interview Method in a Hospital-Based Stroke Registry

BACKGROUND Information on determinants and prognosis of ischemic stroke subtypes is scarce. We aimed at evaluating risk factors, pathogenesis, treatment and outcome of different ischemic stroke subtypes. METHODS In a European Concerted Action involving seven countries, ischemic stroke subtypes defined according to the Oxfordshire Community Stroke Project (OCSP) were evaluated for demographics, baseline risk factors, resource use, 3-month survival, disability (Barthel Index) and handicap (Rankin Scale). RESULTS During the 12-month study period, cerebral infarction was diagnosed in 2740 patients with first-in-a-lifetime stroke (mean age 70.5+/-12.4 years, 53.4% males). OCSP classification was achieved in 2472 (90.2%). Of these, 26.7% were total anterior circulation infarctions (TACI), 29.9% partial anterior circulation infarctions (PACI), 16.7% posterior circulation infarctions (POCI) and 26.7% lacunar infarctions (LACI). In multivariate analysis, atrial fibrillation was predictive of TACI (odds ratio [OR], 1.61; 95% CI, 1.28-2.03), hypertension (OR, 1.38; 95% CI, 1.16-1.65) and myocardial infarction (OR, 1.42; 95% CI, 1.08-1.86) predictive of PACI, hypertension (OR, 1.25; 95% CI, 1.04-1.50) predictive of LACI. A negative association was observed between TACI and hypertension (OR, 0.51; 95% CI, 0.42-0.61). Discharge home was 50% less probable in TACI and PACI than in LACI patients. As compared to LACI, TACI significantly increased the risk of 3-month death (OR, 5.73; 95% CI, 3.91-8.41), disability (OR, 3.27; 95% CI, 2.30-4.66) and handicap (OR, 2.71; 95% CI, 1.91-3.85). CONCLUSIONS Ischemic stroke subtypes have different risk factors profile, with consequences on pathogenesis and prognosis. Information on determinants of the clinical syndromes may impact on prevention and acute-phase interventions.