Hélène Pessah-Rasmussen

Geographic Distribution of Stroke Incidence Within an Urban Population Relations to Socioeconomic Circumstances and Prevalence of Cardiovascular Risk Factors

Background and Purpose Geographic differences in stroke incidence indicate a potential for prevention. The present study from the city of Malmö, Sweden, sought to investigate whether incidence of stroke in residential areas is related to prevalence of cardiovascular risk factors and socioeconomic circumstances. Methods The Stroke Register in Malmö, Sweden, was used for retrieval of the 3540 patients who suffered a first stroke between 1989 and 1998. The Malmö Diet and Cancer cohort (n=28 466) was used to assess area specific prevalence of hypertension, diabetes, smoking, and being overweight and for computation of a cardiovascular risk score. Socioeconomic circumstances for the 17 administrative areas were expressed in terms of a composite score. Results Standardized stroke incidence ranged among areas from 437 to 743 per 100 000 for men and from 223 to 518 per 100 000 for women. Socioeconomic score correlated significantly with area-specific stroke rates among men (r =−0.62, P =0.008) and women (r =−0.67, P =0.004). Incidence of stroke was significantly associated with cardiovascular risk score for each area (men, r =0.53, P <0.05; women, r =0.76, P <0.001). The cardiovascular score and the socioeconomic score together accounted for 44% of the geographic variance among men and 63% among women. Conclusions Marked differences occurred in stroke incidence among residential areas within this urban population. High-rate areas were characterized by a higher prevalence of smoking, hypertension, diabetes, and being overweight and by inferior socioeconomic circumstances. These risk factors accounted for a substantial proportion of the geographic variance in incidence of stroke.

Blood pressure in relation to the incidence of cerebral infarction and intracerebral hemorrhage. Hypertensive hemorrhage: debated nomenclature is still relevant.

Background and Purpose— Data regarding the association between blood pressure level and incidence of stroke subtype, especially primary intracerebral hemorrhage (PICH) subtypes, is sparse. This population-based study explored the relationship between blood pressure and the incidence of cerebral infarction, and PICH, with lobar and nonlobar location. Methods— Risk factors were assessed in 27 702 men and women without prior stroke from the city of Malmö, Sweden. Results— Mean age was 58.1 years. In all, 701 subjects had stroke (613 cerebral infarction and 88 PICH) during the follow-up period (mean, 7.5 years). The age- and sex-standardized incidences of cerebral infarction in subjects with hypertension grade 3 (≥180/110 mm Hg) and normal blood pressure (<140/90 mm Hg) were 6.8 and 1.7 per 1000 person-years, respectively. Compared with the normotensive group, the adjusted relative risk of cerebral infarction was 3.4 (95% CI: 2.6 to 4.5) in subjects with hypertension grade 3. The corresponding incidences of lobar PICH were 0.5 versus 0.08 per 1000 person-years, respectively (adjusted relative risk: 9.2, 95% CI: 2.6 to 32.6) and for nonlobar PICH 1.6 versus 0.09 per 1000 person-years, respectively (adjusted relative risk: 25.9, 95% CI: 8.2 to 82.3). Conclusions— The incidence of hemorrhagic and ischemic stroke increased progressively with increasing blood pressure. Although hypertension was associated with substantially higher incidence rates and absolute numbers of cerebral infarction, which is most important in the public health perspective, the relationship with nonlobar PICH was strongest in terms of relative risks.

Seasonal Patterns of Incidence and Case Fatality of Stroke in Malmö, Sweden: The STROMA Study.

Background: Studies on the temporal variation in stroke incidence have reported inconsistent results. Few have studied the temporal variations in case fatality. No study on incidence and case fatality of stroke by season in Sweden has been found. This study explores the weekly, monthly and seasonal variations in incidence and 28-day case fatality of stroke. Methods: A total of 7,129 patients with first-ever stroke during the period 1989–1999 were retrieved from the Stroke Register of Malmö, Sweden. χ2 test was performed to test the seasonal differences and Poisson regression analysis was used to calculate the case fatality ratios adjusted for sex and age. Results: The stroke cases were on the whole randomly distributed over the study period of 4,017 days. Incidence of all types of stroke, intracerebral hemorrhage and subarachnoid hemorrhage showed no variation by season, month or weekday, but incidence of cerebral infarction for the total population was higher in autumn and winter. Twenty-eight-day case fatality (930 fatal events, 13%) clustered significantly over the study period. Winter emerged as the peak season among men (12.5%), women (17.2%) and total population (15.1%). No consistent variation of incidence and case fatality of stroke by month or weekday was found. Conclusion: Case fatality after stroke demonstrates a seasonal variation with a peak in winter. Incidence of stroke showed no consistent association with season, month or weekday.

Three-Year Survival and Stroke Recurrence Rates in Patients With Primary Intracerebral Hemorrhage

Background and Purpose— There are few studies on the prognosis after primary intracerebral hemorrhages, and they reported big differences in mortality rates. Our aim was to evaluate mortality and stroke recurrence rates in relation to hemorrhage characteristics, demographic and clinical factors, in a large unselected patient cohort. Methods— We analyzed consecutive cases of first-ever primary intracerebral hemorrhages from 1993 to 2000 in a prospective stroke register covering the Malmö region, Sweden (population approximately 250 000). Mortality rates during 28 days and 3 years of follow-up and recurrence rates were analyzed. Results— A total of 474 cases were identified (46% women). In patients <75 years of age, 20% of the women and 23% of the men died within 28 days (P=0.38). The corresponding figures in patients ≥75 years were 26% and 41%, respectively (P=0.02). Male sex was an independent risk factor both for 28-day (OR, 1.5; 95% CI, 1.008 to 2.2) and 3-year mortality (OR, 1.7; 95% CI, 1.3 to 2.3). Other independent predictors of death were high age, central and brain stem hemorrhage location, intraventricular hemorrhage, increased volume, and decreased consciousness level. The recurrence rate was 5.1 per 100 person-years, 2.3 per 100 person-years for intracerebral hemorrhage and 2.8 per 100 person-years for cerebral infarction. Only age >65 years was significantly related to recurrent stroke. Conclusion— Women had better survival than men after primary intracerebral hemorrhages. The difference is largely explained by a higher 28-day mortality in male patients >75 years. However, the underlying reasons are yet to be explored.

Increasing Stroke Incidence and Decreasing Case Fatality, 1989–1998: A Study From the Stroke Register in Malmö, Sweden

Background and Purpose— Although the incidence of and mortality from myocardial infarction (MI) have declined in most industrialized countries, incidence studies of stroke have shown less consistent trends. This study examines time trends in the incidence of stroke and case fatality rates in relation to socioeconomic circumstances and history of MI. Methods— Stroke incidence in the city of Malmö, Sweden (250 000 citizens), has been continuously monitored since 1989. All patients 50 to 79 years of age who experienced a first-ever stroke between 1989 and 1998 were included. Results— We included 3621 patients (1969 men, 1652 women). The age-standardized incidence was 647 per 100 000 persons-years for men and 400 per 100 000 persons-years for women. The annual increase—3.1% in men (P <0.05) and 2.9% in women (P <0.05)—was more pronounced in the younger age groups and was lowest in areas with poor socioeconomic circumstances. We found that 13% of the men and 6% of the women had a history of MI; this proportion was stable over the study period. The average case fatality rates in 1989 to 1998 were 10% for men and 9.3% for women. Rates remained stable for men but declined significantly in women (odds ratio per year, 0.895; 95% confidence interval, 0.84 to 0.95). Conclusions— In this urban population, stroke incidence increased between 1989 and 1998. The rate of increase tended to be lower in residential areas with least favorable socioeconomic circumstances. The proportion with a history of MI remained unchanged during the study period. There has been significant improvement in the case fatality rate in women but not in men.

Marital Dissolution Is Followed by an Increased Incidence of Stroke

Background: Many studies have reported lower mortality in married people. The relation between marital status and incidence of haemorrhagic and ischaemic stroke is unclear. It is largely unknown whether the risk of stroke is increased the first years after divorce or death of spouse. Methods: Incidence of first-ever stroke (n = 6,184) was followed over 10 years in a cohort consisting of all 40- to 89-year-old inhabitants (n = 118,134) in the city of Malmö, Sweden. Marital dissolution (i.e. divorce or death of spouse) prior to the date of stroke was compared in a nested case-control design (3,134 initially married stroke cases, 9,402 initially married controls). Results: As compared to the married groups, the incidence of stroke was increased in divorced men and women (RR = 1.23, CI: 1.10–1.39 and RR = 1.26, CI: 1.12–1.41, respectively) and widowed men and women (RR = 1.13, CI: 0.99–1.28 and RR = 1.13, CI: 1.02–1.24, respectively) after adjustments for age, country of birth and socioeconomic indicators. The risk of stroke was not increased in never married men. Marital dissolution was followed by increased risk of stroke, which was significant for men (adjusted odds ratio: 1.23, CI: 1.03–1.5) and borderline significant for women below 65 years of age (odds ratio: 1.45, CI: 0.99–2.14). Conclusion: The incidence of stroke is increased in divorced and widowed individuals. Never married men do not have an increased incidence. The risk of stroke is elevated during the first years after divorce or death of spouse.

Risk Factors for Primary Intracerebral Hemorrhage. A Population-Based Nested Case-Control Study.

Purpose: In this population-based study, risk factors for primary intracerebral hemorrhage (PICH) and PICH subtypes were explored in a nested case-control design. Method: Risk factors were determined in 22,444 men and 10,902 women (mean age 47 years) who participated in a health-screening programme between 1974 and 1991. 147 subjects with CT or autopsy-verified first-ever PICH during the follow-up period (mean 14 years) were compared with 1,029 stroke-free controls, matched for age, sex and screening-year. Results: As compared to controls, PICH cases had significantly higher blood pres- sure (135/91 vs. 127/85 mm Hg), triglycerides (1.7 vs. 1.4 mmol/l), BMI (25.5 vs. 24.8) and shorter stature (1.73 vs. 1.74 m). Diabetes (6.9 vs. 2.8 %) and history of psychiatric morbidity (19.7 vs. 11.0 %) were more common in PICH cases and more of them were living alone (35.4 vs. 25.5%). After adjustment in a backward logistic regression model, high systolic blood pressure, diabetes, high triglycerides, short stature and psychiatric morbidity remained significantly associated with PICH. As compared to the control group, high systolic blood pressure was significantly associated both with nonlobar and lobar PICH. Diabetes and psychiatric morbidity were associated with nonlobar PICH. Smoking doubled the risk for lobar PICH, but was unrelated to nonlobar PICH. Conclusion: In this prospective population-based study, hypertension, diabetes, height, triglycerides and psychiatric morbidity were risk factors for PICH. Smoking was a risk factor for lobar PICH only.

Pyridoxine reduces cholesterol and low-density lipoprotein and increases antithrombin III activity in 80-year-old men with low plasma pyridoxal 5-phosphate

We have previously observed that pyridoxine treatment reduced plasma total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol concentrations and increased antithrombin III (AT III) activity in atherosclerotic patients with subnormal plasma pyridoxal 5-phosphate (PLP) levels. In order to confirm these results, we selected 17 males with low plasma PLP levels from a group of 122 80-year-old males in whom PLP has been determined. After supplementation with 120 mg of pyridoxine per day for 8 weeks their mean plasma TC and LDL cholesterol concentrations were decreased by 10% (p less than 0.01) and 17% (p less than 0.001), respectively. There was no effect on high-density lipoprotein cholesterol and triglycerides but plasma AT III activity was increased by 6% (p less than 0.05). The mechanism by which pyridoxine acts is unclear but it is hypothesized that pyridoxine-derived PLP may enhance the catabolism of LDL and the activity of AT III by inhibiting their glycosylation.

Eighty-year-old men without cardiovascular disease in the community of Malmö. Part II. Smoking characteristics and ultrasound findings, with special reference to glutathione transferase and pyridoxal-5-phosphate

Abstract. A total of 1280 80‐year‐old men in the community of Malmö were questioned about smoking habits and the occurrence of cardiovascular disease (CVD). After a careful medical and duplex ultrasound examination, four groups were selected for further studies: (1) no CVD, non‐smokers; (2) no CVD, smokers; (3) CVD, smokers; (4) CVD, non‐smokers. In total 122 individuals participated. The average tobacco consumption by smokers was 13 g d−1 for 59 years. In the CVD group 45% of subjects had atherosclerotic symptoms at more than one site. Smoking was found to be correlated with lower extremity atherosclerosis, cholesterol and LDL cholesterol were correlated with carotid artery lesions and pathological ankle/arm index, and blood pressure was correlated with lower extremity lesions. In contrast with middle‐aged populations, individuals with an increasing degree of lesions in the lower extremities had a larger percentage of high glutathione transferase activity than subjects without CVD. Smokers had significantly lower pyridoxal‐5‐phosphate levels than non‐smokers. It is concluded that some heavy smokers might reach an advanced age in good health. Smoking was also operative as a risk indicator for lower extremity atherosclerosis in 80‐year‐old individuals.

Early do-not-resuscitate orders in intracerebral haemorrhage; frequency and predictive value for death and functional outcome. A retrospective cohort study

IntroductionIn former studies from North America early Do-Not–Resuscitate orders (DNR orders) in patients with intracerebral haemorrhage (ICH) had negative prognostic impact on mortality. The influence of DNR orders on functional outcome and whether DNR orders are grounded on relevant patient characteristics is unknown. We aimed to determine the frequency and predictive factors of DNR-orders and its association to prognosis, in ICH patients, in Scandinavia.MethodsIn 197 consecutive ICH patients admitted to Skåne University Hospital, Malmö, Sweden, between January 2007 and June 2009, information of the presence of DNR orders within 48 hours, clinical and radiological characteristics was retrieved by review of patient medical journal and computed tomography scans. Determinants of DNR-orders, one-month case fatality and bad functional outcome (modified Rankin Scale, grade 4–6) were assessed by logistic regression analysis.ResultsDNR orders were made in 41% of the cases. After adjustment for confounding factors, age ≥ 75 years (Odds Ratio (95% confidence interval) 4.2(1.8-9.6)), former stroke (5.1(1.9-3.1)), Reaction Level Scale grade 2–3 and 4 (7.0(2.8-17.5) and (4.1(1.2-13.5), respectively) and intraventricular haemorrhage (3.8(1.6-9.4)) were independent determinants of early DNR orders. Independent predictors of one-month case fatality was age ≥ 75 years (3.7(1.4-9.6)) volume ≥ 30 ml (3.5(1.3-9.6)) and DNR orders (3.5(1.5-8.6)). Seizure (6.0(1.04-34.2) and brain stem hemorrhage (8.0(1.1-58.4)) were related to bad functional outcome, whereas early DNR order was not (3.5(0.99-12.7)).ConclusionsWell known prognostic factors are determinants for DNR orders, however DNR orders are independently related to one-month case fatality. In addition to improvements of the local routines, we welcome a change of attitude with an enhanced awareness of the definition of, and a more careful approach with respect to DNR orders.