Anxin Wang

Ideal Cardiovascular Health Metrics and the Risks of Ischemic and Intracerebral Hemorrhagic Stroke

Background and Purpose— Previous studies showed an inverse association between ideal cardiovascular health (CVH) metrics and the total risk of cardiovascular diseases and stroke. This study aimed to investigate the relationship between ideal CVH metrics and the risks of ischemic and hemorrhagic stroke, respectively. Methods— We collected information on the 7 ideal CVH metrics (including smoking status, body mass index, dietary intake, physical activity, blood pressure, total cholesterol, and fasting blood glucose) among 91  698 participants from the Kailuan study, China (72 826 men and 18 872 women between the ages of 18 and 98 years), free of myocardial infarction and stroke at baseline (2006–2007). Cox proportional hazards models were used to estimate stroke risk. Results— During the 4-year follow-up, we identified 1486 incident stroke events (1057 ischemic, 386 intracerebral hemorrhagic, and 43 subarachnoid hemorrhagic). The hazard ratios (95% confidence interval) for total stroke with adherence to 0 (reference), 1, 2, 3, 4, 5, and 6/7 ideal CVH metrics were: 1, 0.92 (0.69–1.23), 0.69 (0.52–0.92), 0.52 (0.39–0.68), 0.38 (0.28–0.51), 0.27 (0.18–0.40), and 0.24 (0.11–0.54), respectively (P trend <0.01), after adjusting for age, sex, education, income, and hospital. Similar inverse associations were observed for both ischemic and intracerebral hemorrhagic stroke (both P trend <0.01). Conclusions— We observed a clear inverse gradient relationship between the number of ideal CVH metrics and the risk of stroke in a Chinese population, supporting the importance of ideal health behaviors and factors in stroke prevention.

Clopidogrel With Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) Trial One-Year Outcomes

Background— The Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial showed that the combined treatment of clopidogrel and aspirin decreases the 90-day risk of stroke without increasing hemorrhage in comparison with aspirin alone, but provided insufficient data to establish whether the benefit persisted over a longer period of time beyond the trial termination. We report the 1-year follow-up outcomes of this trial. Methods and Results— The trial was a randomized, double-blind, placebo-controlled trial conducted at 114 centers in China. We randomly assigned 5170 patients within 24 hours after onset of minor stroke or high-risk transient ischemic attack to clopidogrel-aspirin therapy (loading dose of 300 mg of clopidogrel on day 1, followed by 75 mg of clopidogrel per day for 90 days, plus 75 mg of aspirin per day for the first 21 days) or to the aspirin-alone group (75 mg/d for 90 days). The primary outcome was stroke event (ischemic or hemorrhagic) during 1-year follow-up. Differences in outcomes between groups were assessed by using the Cox proportional hazards model. Stroke occurred in 275 (10.6%) patients in the clopidogrel-aspirin group, in comparison with 362 (14.0%) patients in the aspirin group (hazard ratio, 0.78; 95% confidence interval, 0.65–0.93; P=0.006). Moderate or severe hemorrhage occurred in 7 (0.3%) patients in the clopidogrel-aspirin group and in 9 (0.4%) patients in the aspirin group (P=0.44). Conclusions— The early benefit of clopidogrel-aspirin treatment in reducing the risk of subsequent stroke persisted for the duration of 1-year of follow-up. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979589.

Measures of Adiposity and Risk of Stroke in China: A Result from the Kailuan Study

Objective The objective of this study was to explore the association between adiposity and risk of incident stroke among men and women. Methods We studied the relationship between adiposity and stroke among 94,744 participants (18–98 years old) in the Kailuan study. During a follow-up of 4 years, 1,547 ischemic or hemorrhagic strokes were recorded. Measurements of adiposity included body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHpR), and waist-to-height ratio (WHtR). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated from Cox regression models and each model fit was assessed using −2log-likelihood. Results Every measurement of adiposity was associated with the risk for total stroke and ischemic stroke, but not for hemorrhagic stroke. After adjusting for confounders and intermediates, the HR (comparing the mean of the highest quintile with that of the lowest quintile) for total stroke was 1.34(1.13–1.60) for BMI, 1.26(1.06–1.52) for WC, 1.29(1.08–1.56) for WHpR, and 1.38(1.15–1.66) for WHtR. The HR for ischemic stroke was 1.52(1.24–1.88) for BMI, 1.46(1.17–1.81) for WC, 1.40(1.12–1.74) for WHpR, and 1.62(1.29–2.04) for WHtR. The model fit for each of the indices was similar. Conclusions Adiposity increases the total risk of stroke and ischemic stroke, but not of hemorrhagic stroke. No clinically meaningful differences among the associations between BMI, WC, WHpR, and WHtR and stroke incidence were identified in this study.

Dual antiplatelet therapy in stroke and ICAS Subgroup analysis of CHANCE

Objective: We aimed to investigate whether the efficacy and safety of clopidogrel plus aspirin vs aspirin alone were consistent between patients with and without intracranial arterial stenosis (ICAS), in the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. Methods: We assessed the interaction of the treatment effects of the 2 antiplatelet therapies among patients with and without ICAS, identified by magnetic resonance angiography (MRA) in CHANCE (ClinicalTrials.gov identifier NCT00979589). Results: Overall, 1,089 patients with MRA images available in CHANCE were included in this subanalysis, 608 patients (55.8%) with ICAS and 481 (44.2%) without. Patients with ICAS had higher rates of recurrent stroke (12.5% vs 5.4%; p < 0.0001) at 90 days than those without. But there was no statistically significant treatment by presence of ICAS interaction on either the primary outcome of any stroke (hazard ratio for clopidogrel plus aspirin vs aspirin alone: 0.79 [0.47–1.32] vs 1.12 [0.56–2.25]; interaction p = 0.522) or the safety outcome of any bleeding event (interaction p = 0.277). Conclusions: The results indicated higher rate of recurrent stroke in minor stroke or high-risk TIA patients with ICAS than in those without. However, there was no significant difference in the response to the 2 antiplatelet therapies between patients with and without ICAS in the CHANCE trial. Classification of evidence: This study provides Class II evidence that for patients with acute minor stroke or TIA with and without ICAS identified by MRA, clopidogrel plus aspirin is not significantly different than aspirin alone in preventing recurrent stroke.

Resting heart rate and risk of hypertension: results of the Kailuan cohort study.

Objective: Resting heart rate (RHR) is a predictive risk factor of the development of cardiovascular diseases, but its association with arterial hypertension has remained unclear. This study investigated the relationship between RHR and new-onset hypertension (NOH) in an Asian population. Methods: The Kailuan study is a prospective longitudinal cohort study on cardiovascular risk factors and cardiovascular or cerebrovascular events. Hazard ratios with 95% confidence intervals (CIs) were calculated using Cox regression modelling. Results: Out of 101 510 individuals originally included into the Kailuan study, 31 507 participants (mean age: 46.3 ± 11.5 years) were selected with no previous arterial hypertension or cardiac arrhythmias. After a mean follow-up period of 3.5 ± 0.9 years, 12 565 (39.88%) individuals developed arterial hypertension. Incidence of hypertension was 104.4, 109.7, 114.2 and 124.6 per 1000 person-years for each RHR quartile. In multivariate analysis with adjustment for blood pressure, blood lipids, diabetes mellitus and other parameters, hazard ratios for NOH increased significantly (P < 0.0001) with increasing RHR quartile. Increase in RHR by 10 beats/minute was associated with an 8% increase in NOH. Individuals in the highest RHR quartile as compared with participants in the lowest quartile demonstrated a 16% greater risk of developing NOH [hazard ratio 1.16; 95% confidence interval (CI) 1.11–1.23]. There were no significant interactions between RHR and prehypertension, diabetes mellitus, age and BMI in terms of NOH risk, respectively. Conclusion: Independently of other baseline parameters such as blood pressure, blood lipids and diabetes mellitus, elevated RHR significantly increases the risk of incident hypertension. Measuring RHR is helpful in predicting the risk of eventual arterial hypertension.

Gender Differences in 1-Year Clinical Characteristics and Outcomes after Stroke: Results from the China National Stroke Registry

Background Previous reports have shown inconsistent results on clinical outcomes between women and men after stroke, and little is known about gender differences on outcomes in Chinese post-stroke patients. The aim of this study was to explore whether there were gender differences on clinical characteristics and outcomes in Chinese patients after ischemic stroke by using the data from the China National Stroke Registry (CNSR). Methods and Findings Out of 12,415 consecutively recruited patients with acute ischemic stroke in the CNSR from 2007 to 2008, 11,560 (93.1%) patients were followed up for 12 months. Their clinical characteristics and outcomes on death, recurrence, and dependency were recorded. The multivariate logistic regression was performed to determine whether there were gender differences in these outcomes. Women were older than men at baseline (67.9 vs. 64.0 years, P<0.001). Women had a higher mortality, recurrence rate, and dependency rate at 3, 6, and 12 months than men, but after adjusting for age, history of diabetes, pre-stroke dependency, stroke severity, in-hospital complications, and other confounders, there were no statistically significant differences in gender on mortality and recurrence rate at 3, 6, and 12 months; and dependency rate at 3, and 6 months. However, the dependency rate at 12 months remained significantly higher in women (odds ratio, 1.24; 95% confidence interval, 1.06 to 1.45). Conclusions There are many differences in clinical characteristics between women and men after ischemic stroke in China. Compared with men, women are more dependent at 12 months after stroke. This difference still exists after controlling the potential confounders.

Association of Hypertension With Stroke Recurrence Depends on Ischemic Stroke Subtype

Background and Purpose— The association between hypertension (HTN) and stroke recurrence is unclear, but may be influenced by different subtypes of stroke. This study aims to explore whether HTN contributes to the recurrence of certain subtypes of ischemic stroke (IS). Methods— Data from the China National Stroke Registry was examined and 1-year follow-up data for stroke recurrence was analyzed. Trial of Org 10172 in Acute Stroke Treatment criteria was used to classify the subtypes of all IS. HTN was defined when resting blood pressure was ≥140/90 mm Hg on repeated measurements during hospitalization or a patient had been on antihypertensive medication. Recurrent stroke was defined as a new neurological deficit compatible to IS or intracerebral hemorrhage. The association between HTN and stroke recurrence in patients with different IS subtypes was analyzed by using univariable and multivariable logistic regression models. Results— Of 11 560 patients with IS, 8409 (72.7%) had HTN and 2050 (17.7%) experienced a recurrent stroke within 1 year. Patients with HTN had an insignificantly higher stroke recurrence rate than those without (18.0% versus 17.0%; P=0.21). After stratification by Trial of Org 10172 in Acute Stroke Treatment subtypes, multivariable analysis revealed a significant association between HTN and stroke recurrence in small-artery occlusion subtype (odds ratio, 1.52; 95% confidence interval, 1.03–2.31), but not in the other subtypes (large-artery atherosclerosis: odds ratio, 0.99; 95% confidence interval, 0.81–1.21; cardioembolic: odds ratio, 1.14; 95% confidence interval, 0.75–1.73; other: odds ratio, 0.88; 95% confidence interval, 0.71–1.09). Conclusions— Our results showed that HTN is specifically related to the recurrent strokes in patients with small-vessel diseases, not other subtypes of IS.

Resting Heart Rate and Risk of Cardiovascular Diseases and All-Cause Death: The Kailuan Study

Background Resting heart rate (RHR) predicts both cardiovascular and noncardiovascular death in different populations. However, the results of the association between RHR and cardiovascular diseases (CVDs) are inconsistent, especially for each subtype of CVDs. Objective The aim of this study was to prospectively explore the relationship between RHR and CVDs including myocardial infarction (MI), ischemic stroke, and hemorrhagic stroke and all-cause death in a general population. Methods The Kailuan study is a prospective longitudinal cohort study on cardiovascular risk factors and cardiovascular or cerebrovascular events. Hazard ratio (HR) with 95% confidence intervals (CI) were calculated using Cox regression modeling. Results We analyzed 92,562 participants (18–98 years old) in the Kailuan Study. CVDs were developed in 1,903 people during follow-ups. In multivariate analysis with adjustment for major traditional cardiovascular risk factors, HRs of the highest quintile group compared with the lowest quintile group of RHR for all-cause CVDs, MI, any stroke, ischemic stroke, hemorrhagic stroke, and all-cause death were 1.03 (95% CI, 0.98–1.07), 1.10 (95% CI, 1.01–1.20), 1.01 (95% CI, 0.97–1.06), 1.02 (95% CI, 0.96–1.07), 1.01 (95% CI, 0.92–1.11) and 1.18, (95% CI, 1.13–1.23), respectively. Conclusions The elevated RHR was independently associated with the increased risk for MI and all-cause death, but not for all-cause CVDs, any stroke, ischemic stroke, nor hemorrhagic stroke. This indicates that the elevated RHR might be a risk marker for MI and all-cause death in general populations.

Favorable Functional Recovery in Overweight Ischemic Stroke Survivors: Findings from the China National Stroke Registry

BACKGROUND Obesity paradox has been reported because of the inverse relationship between the body mass index (BMI) and mortality in stroke patients. The relationship between BMI and functional recovery in stroke survivors is less well established. We explored the impact of BMI on functional recovery and mortality in stroke patients in the China National Stroke Registry (CNSR). METHODS Patients were consecutively recruited based on a standard protocol and prospectively followed up for outcomes at 3 months after disease onset. Patients were divided into 5 groups according to their BMI: underweight (<18.5 kg/m(2)), normal weight (18.5-22.9 kg/m(2)), overweight (23-27.4 kg/m(2)), obese (27.5-32.4 kg/m(2)), or severely obese (≥32.5 kg/m(2)). Multivariate logistic regression was performed to analyze the association between BMI and functional recovery or mortality. RESULTS CNSR enrolled 22,216 patients hospitalized for acute cerebrovascular events, and 10,905 eligible acute ischemic stroke patients were analyzed in our study. Favorable functional recovery (modified Rankin Scale score 0-1) was seen in 52.4% of underweight, 55.0% of normal weight, 61.0% of overweight, 59.2% of obese, and 60.3% of severely obese stroke survivors (P < .001). Overweight was independently associated with favorable 3-month functional recovery (odds ratio [OR] 1.24; 95% confidence interval [CI] 1.12-1.38). Mortality rate was 14.9% in underweight, 7.8% in normal weight, 7.1% in overweight, 7.2% in obese, and 11.5% in severely obese patients (P < .001). Severe obesity was independently associated with higher 3-month mortality (OR 2.01; 95% CI 1.10-3.69). CONCLUSIONS The stroke obesity paradox can be extended to include functional recovery but should not be interpreted as the fatter the better.

Ideal Cardiovascular Health Metrics on the Prevalence of Asymptomatic Intracranial Artery Stenosis: A Cross-Sectional Study

Background and Purpose Intracranial Artery Stenosis (ICAS) is one of the most common causes of ischemic stroke in Asia. Previous studies have shown the number of ideal cardiovascular health (CVH) metrics was associated with lower risk of stroke. This study aimed to investigate the relationship between ideal CVH metrics and prevalence of ICAS. Methods A random sample of 5,412 participants (selected from Kailuan Study as a reference population) aged 40 years or older (40.10% women), free of stroke, transient ischemic attack, and coronary disease, were enrolled in the Asymptomatic Polyvascular Abnormalities Community study from 2010 to 2011. We collected information on the seven CVH metrics (including smoking, body mass index, dietary intake, physical activity, blood pressure, total cholesterol and fasting blood glucose); and assessed ICAS by transcranial Doppler. The relationship between the ideal CVH metrics and prevalence of ICAS was analyzed using the multivariate logistic regression. Results After adjusting for age, sex, and other potential confounders, the adjusted odds ratios(95% confidence interval) for ICAS were 0.76(0.58–0.99), 0.55(0.43–0.72), 0.49(0.37–0.65), 0.43(0.31–0.61), and 0.36(0.22–0.62), respectively, for those having 2, 3, 4, 5, and 6–7 ideal CVH metrics compared with those having 0–1 ideal metric(p-trend<0.0001). Similar inverse associations were observed in different age and gender groups (all p-trends<0.05). Conclusion We found a clear gradient relationship between the number of ideal CVH metrics and lower prevalence of ICAS in a Chinese population, which supports the importance of ideal health behaviors and factors in the prevention of ICAS.