Gaifen Liu

Using Recombinant Tissue Plasminogen Activator to Treat Acute Ischemic Stroke in China Analysis of the Results From the Chinese National Stroke Registry (CNSR)

Background and Purpose— Little is known about intravenous recombinant tissue plasminogen activator (rtPA) use in China. By accessing the Chinese National Stroke Registry (CNSR), the rate of intravenous rtPA use was reviewed. We specifically examined the issues of prehospital and in-emergency department delay and compared them with the published data from developed countries. Methods— Funded by Chinese government, CNSR is the only nationwide stroke registry that includes 132 urban hospitals. All patients eligible for intravenous rtPA were included for analysis. We then compared the onset-to-needle time and door-to-needle time in the emergency department in China with those in developed countries. Results— From September 2007 to August 2008, 14 702 patients with ischemic stroke were entered into CNSR. Among 11 675 patients with known time of stroke onset, 2514 (21.5%) presented to the emergency department within 3 hours, 1469 (12.6%) were eligible for thrombolytic treatment, and 284 (2.4%) were finally treated, 181 (1.6%) of them with intravenous rtPA. The median onset-to-needle time was 180 (interquartile range, 150 to 228) minutes; the median door-to-needle time was 116 (interquartile range, 70 to 150) minutes; the median imaging-to-needle time was 90 (interquartile range, 60 to 129) minutes. Patients who were younger, presented to the emergency department quicker, with higher National Institutes of Health Stroke Scale scores, having higher income, and better education had a better chance of receiving intravenous rtPA. Conclusions— Approximately 1 in 5 patients with stroke presenting within 3 hours received thrombolytic therapy. The onset-to-needle time, door-to-needle time, and especially imaging-to-needle time were significantly longer than those in developed countries. Reducing prehospital and in-emergency department response time would help increase intravenous rtPA use in China.

Abnormal Glucose Regulation in Patients With Acute Stroke Across China: Prevalence and Baseline Patient Characteristics

Background and Purpose— The prevalence of diabetes is high among patients with ischemic stroke. However, the prevalence of abnormal glucose regulation and clinical characteristics among patients with stroke in the Chinese population is uncertain. We investigated the prevalence of prediabetes and diabetes in Chinese patients after stroke onset in a nationwide cohort study and investigated abnormal glucose regulation in patients with acute stroke across China (ACROSS-China). Methods— The ACROSS-China study consecutively recruited patients hospitalized for acute stroke in 2008 to 2009 and investigated the prevalence of impaired glucose tolerance and diabetes among the patients on day 14 after stroke onset. Oral glucose tolerance test was performed in the diagnosis of abnormal glucose regulation. Results— The prevalence of abnormal glucose regulation was 68.7% among all the patients with stroke. Diabetes was identified in 42.3% of all the patients (45.8% for patients with ischemic stroke, 31.2% for patients with intracerebral hemorrhage, and 26.4% for patients with subarachnoid hemorrhage, respectively). Prediabetes (impaired fasting glucose and impaired glucose tolerance) was identified in 26.4% of all the patients with stroke. The prevalence of diabetes and impaired glucose tolerance was the highest in the patients with atherothrombotic infarction (73.4%). Conclusions— The prevalence of abnormal glucose regulation was high in Chinese patients with acute stroke, especially in patients with atherothrombotic infarction. Oral glucose tolerance test identified a large percentage of patients with newly diagnosed diabetes or impaired glucose tolerance after stroke onset.

Novel Risk Score to Predict Pneumonia After Acute Ischemic Stroke

Background and Purpose— To develop and validate a risk score (acute ischemic stroke-associated pneumonia score [AIS-APS]) for predicting in-hospital stroke-associated pneumonia (SAP) after AIS. Methods— The AIS-APS was developed based on the China National Stroke Registry, in which eligible patients were randomly classified into derivation (60%) and internal validation cohort (40%). External validation was performed using the prospective Chinese Intracranial Atherosclerosis Study. Independent predictors of in-hospital SAP after AIS were obtained using multivariable logistic regression, and &bgr;-coefficients were used to generate point scoring system of the AIS-APS. The area under the receiver operating characteristic curve and the Hosmer–Lemeshow goodness-of-fit test were used to assess model discrimination and calibration, respectively. Results— The overall in-hospital SAP after AIS was 11.4%, 11.3%, and 7.3% in the derivation (n=8820), internal (n=5882) and external (n=3037) validation cohort, respectively. A 34-point AIS-APS was developed from the set of independent predictors including age, history of atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease and current smoking, prestroke dependence, dysphagia, admission National Institutes of Health Stroke Scale score, Glasgow Coma Scale score, stroke subtype (Oxfordshire), and blood glucose. The AIS-APS showed good discrimination (area under the receiver operating characteristic curve) in the internal (0.785; 95% confidence interval, 0.766–0.803) and external (0.792; 95% confidence interval, 0.761–0.823) validation cohort. The AIS-APS was well calibrated (Hosmer–Lemeshow test) in the internal (P=0.22) and external (P=0.30) validation cohort. When compared with 3 prior scores, the AIS-APS showed significantly better discrimination with regard to in-hospital SAP after AIS (all P<0.0001). Conclusions— The AIS-APS is a valid risk score for predicting in-hospital SAP after AIS.

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.

Interrelationship Among Common Medical Complications After Acute Stroke Pneumonia Plays an Important Role

Background and Purpose— Medical complications are common among patients with stroke. However, little is known about the potential interrelationship among them. In the present study, we aimed to investigate the association between common in-hospital medical complications after acute ischemic stroke (AIS) and spontaneous intracerebral hemorrhage (ICH). Methods— We analyzed patients enrolled in the China National Stroke Registry from 2007 to 2008. The occurrence of 11 common stroke-associated medical complications during acute hospitalization was prospectively registered. Multivariable analysis using generalized estimation equation was performed to assess association between medical complications in AIS and ICH cohort, respectively. Results— A total of 14 702 patients with AIS and 5221 patients with ICH were enrolled. The median age was 65 years (interquartile range, 55–74 years), and 38.1% were female. The median length of hospital stay was 14 days (interquartile range, 10–20 days) for AIS and 18 days (interquartile range, 11–26 days) for ICH. Pneumonia was the most common medical complication after AIS (11.4%) and ICH (16.8%). In the AIS cohort, after adjusting for potential confounders, pneumonia was significantly associated with development of gastrointestinal bleeding (adjusted odds ratio [OR], 8.35; 95% confidence interval [CI], 6.27–11.1; P<0.001), decubitus ulcer (adjusted OR, 5.31; 95% CI, 3.39–8.31; P<0.001), deep vein thrombosis (adjusted OR, 4.27; 95% CI, 2.41–7.59; P<0.001), epileptic seizure (adjusted OR, 3.96; 95% CI, 2.67–5.88; P<0.001), urinary tract infection (adjusted OR, 3.34; 95% CI, 2.73–4.10; P<0.001), atrial fibrillation/flutter (adjusted OR, 3.17; 95% CI, 2.58–3.90; P<0.001), and recurrent stroke (adjusted OR, 2.65; 95% CI, 2.07–3.40; P<0.001). Similar significant association between pneumonia and development of several nonpneumonia medical complications was verified in ICH cohort as well. Conclusions— Pneumonia is closely associated with the development of several nonpneumonia medical complications after AIS and ICH.

Persistence of secondary prevention medications after acute ischemic stroke or transient ischemic attack in Chinese population: data from China National Stroke Registry

Abstract Objective: Although proven stroke secondary prevention medications are available, persistent use is required to be effective. The present study aimed to investigate the degree of secondary prevention medications persistence after acute ischemic stroke (AIS) or transient ischemic attack (TIA), factors influencing persistence and its association with stroke outcomes. Methods: We examined patients with AIS or TIA enrolled in China National Stroke Registry (CNSR) between 2007 and 2008. Three-month persistence was defined as medication continuation between hospital discharge and 3-month postdischarge. Recurrent stroke and modified Rankin scale (mRS)≤2 at 3-month postdischarge were used as stroke outcomes. Logistic regression was used to adjust for confounders. Results: Totally, 9998 patients were analyzed. At 3 months, 63·6% of patients continued taking all secondary prevention medications prescribed at hospital discharge. Younger age (P = 0·05), male gender (P = 0·03), present history of hypertension (P<0·001), absent history of atrial fibrillation (P<0·001), pre-stroke independence (P = 0·05), index cerebrovascular event of AIS (P = 0·005), being treated in an academic hospital (P = 0·003), longer hospital stay (P<0·001), and fewer number of class of baseline secondary prevention medications (P<0·001) were identified as determinants for 3-month persistence. 3-month persistence of secondary prevention medications were significantly associated with less recurrent stroke (adjusted OR = 0·78, 95% CI = 0·67–0·91, P = 0·002) and better functional outcome (mRS⩽2) (adjusted OR = 1·17, 95% CI = 1·04–1·32, P = 0·009) at 3-month postdischarge. Discussion: Almost one-third of patients of AIS/TIA had stopped one or more secondary prevention medications by 3-month postdischarge. Further studies on identifying potential barriers and means to improve persistent use of secondary prevention interventions are needed.

Decreased Uric Acid Levels Correlate with Poor Outcomes in Acute Ischemic Stroke Patients, but Not in Cerebral Hemorrhage Patients

BACKGROUND The relationship between uric acid and stroke prognosis is ambiguous. Some studies have explored this relationship in acute stroke but have different results. In this study, we explored the relationship between uric acid levels and 1-year outcomes and vascular events of acute ischemic stroke patients and cerebral hemorrhage patients. METHODS In all, 1452 continued first, acute ischemic stroke patients and 380 continued cerebral hemorrhage patients were admitted to our hospitals. Serum uric acid concentrations were measured in 1351 ischemic stroke patients and 380 cerebral hemorrhage patients at admission. We evaluated the relationship between uric acid levels and outcomes (modified Rankin scale [mRS] > 2, all-cause death, vascular events, stroke recurrent) at 14 days, 90 days, and 1 year after stroke onset. RESULTS The median uric acid concentration was 303.0 μmol/L in ischemic stroke patients and 269 μmol/L in cerebral hemorrhage patients. In univariate analysis, uric acid levels were not correlated with outcomes in cerebral hemorrhage patients. We used multiple logistic regression analysis to show that lower serum uric acid levels independently predicted poor functional outcomes (mRS >2) at 1 year after ischemic stroke onset (odds ratio [OR] = .335, 95% confidence interval [CI]: .164-.684, P = .003). Also, lower serum uric acid levels were independently correlated with vascular events in the first year in ischemic stroke patients. By multiple cox proportional hazards analysis, we obtained data which reveal that serum uric acid levels were not correlated with all-cause death (OR = .992, 95% CI: .683-1.443, P = .969) in ischemic stroke patients. CONCLUSIONS Serum uric acid may be neuroprotective in acute ischemic stroke patients.

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.

Use of Statin During Hospitalization Improves the Outcome After Intracerebral Hemorrhage

To examine the relationship between statin use in Chinese patients with intracerebral hemorrhage (ICH) during their hospitalization and the outcomes.

Serum 25-hydroxyvitamin D and the risk of cardiovascular disease: dose-response meta-analysis of prospective studies

Background: During the past decade, an increasing number of prospective studies have focused on the association between vitamin D and cardiovascular disease (CVD). However, the evidence on the relation between serum 25-hydroxyvitamin D [25(OH)D] and the risk of overt CVD is inconclusive.Objective: We performed a dose-response meta-analysis to summarize and prospectively quantify the RR of low serum 25(OH)D concentration and total CVD (events and mortality).Design: We identified relevant studies by searching PubMed and EMBASE up to December 2015 and by hand-searching reference lists. Prospective studies based on the general population and reported RRs and 95% CIs were included. A random-effects model was used to calculate the pooled RRs. Nonlinear association was assessed by using restricted cubic spline analyses.Results: A total of 34 publications with 180,667 participants were eligible for the meta-analysis. We included 32 publications (27 independent studies) for total CVD events and 17 publications (17 independent studies) for CVD mortality. We observed an inverse association between serum 25(OH)D and total CVD events and CVD mortality, and the pooled RRs per 10-ng/mL increment were 0.90 (95% CI: 0.86, 0.94) for total CVD events and 0.88 (95% CI: 0.80, 0.96) for CVD mortality. A nonlinear association was detected for total CVD events (P-nonlinear < 0.001) and CVD mortality (P-nonlinear = 0.022).Conclusion: Serum 25(OH)D concentration was inversely associated with total CVD events and CVD mortality from the observed studies.