Shihong Zhang

Stroke in China: epidemiology, prevention, and management strategies

In this review, we examine the current status of stroke epidemiology, prevention, and management strategies in mainland China. The main findings suggested that total age-adjusted incidence of first-ever stroke in China is not very different from that in developed countries. Stroke incidence, mortality, and prevalence varied widely among different regions within China, with a noticeable north-south gradient. The proportion of intracerebral haemorrhage was high and reached 55% in one city. Hypertension is the most important risk factor for stroke. The mass approach combined with a high-risk approach for stroke prevention showed encouraging effects, and various unconventional local therapeutic traditions are commonly used to treat stroke in China. Several national guidelines on stroke prevention and treatment have been developed. Because of methodological limitations in the epidemiology studies, data are unreliable in terms of making any firm conclusions. Up-to-date, well-designed, and well-done epidemiological studies and therapeutic trials in China are urgently needed.

Meta-Analysis of Traditional Chinese Patent Medicine for Ischemic Stroke

Background and Purpose— A large number of traditional Chinese patent medicine (TCPM) are widely used for ischemic stroke in China. The aim of this study was to systematically review the existing clinical evidence on TCPM for ischemic stroke. Methods— We identified all TCPM that were listed in the Chinese National Essential Drug list of 2004 and those commonly used TCPM in current clinical practice for ischemic stroke. Fifty-nine TCPM were identified for further evaluation. We applied Cochrane systematic review methods. We searched for reports of randomized controlled trials and controlled clinical trials on any of the 59 TCPM for ischemic stroke comparing one TCPM with control. Primary outcomes included death or dependency at the end of follow-up (at least 3 months) and adverse events. Effects on neurological impairments were a secondary outcome. Results— One-hundred ninety-one trials (19 338 patients) on 22 TCPM were available and included, of which 120 were definite or possible randomized controlled trials and 71 were controlled clinical trials. The methodological quality of included trials was generally “poor.” Few trials reported methods of randomization. Three trials were randomized, double blind, and placebo-controlled. Primary outcomes: one trial on Puerarin and one trial on Shenmai injection assessed death or dependency at the end of long-term follow-up (at least 3 months) and found no statistically significant difference between 2 groups. The reported adverse events including allergic reaction, headache, nausea, diarrhea, bellyache, blood pressure change, and subcutaneous ecchymosis. Most of the adverse events were not severe. Secondary outcomes: analysis of the secondary outcome, “marked improvement in neurological deficit,” showed apparent benefits of about the same magnitude for all the TCPM studied. Of the 22 TCPM, 8 drugs (Milk vetch, Mailuoning, Ginkgo biloba, Ligustrazine, Danshen agents, Xuesetong, Puerarin, and Acanthopanax) had relatively more studies and patient numbers. Conclusions— There was insufficient good quality evidence on the effects of TCPM in ischemic stroke on the primary outcome (death or dependency). We considered the apparent benefit on neurological impairment was as likely to be attributable to bias from poor methodology as to a real treatment effect. However, because the agents assessed appeared potentially beneficial and nontoxic, further randomized controlled trials are justified. Eight drugs could be further research priorities.

Role of health insurance in averting economic hardship in families after acute stroke in China

Background and Purpose— Stroke is a major health burden in China, but there are limited data on its economic effects on households. We aimed to examine the economic impact of stroke and to assess the influence of health insurance. Methods— In a nationwide, prospective, 62-hospital registry study of acute stroke in China, we recorded information on patient demographics, clinical features, socioeconomic factors, management, and costs of medical care. Information on out-of-pocket health expenses was obtained in surviving patients at 3- and 12-month follow-up. Catastrophic healthcare payments, defined as ≥30% of total household annual income, were estimated from reported household annual income. Results— Among 4739 3-month survivors of stroke with outcome data, average hospital and medication costs were 16 525 Chinese Yuan Renminbi (US

Association between Metabolic Syndrome and Risk of Stroke: A Meta-Analysis of Cohort Studies

2361) and out-of-pocket costs were 14 478 Chinese Yuan Renminbi (US

Prognostic Significance of Perihematomal Edema in Acute Intracerebral Hemorrhage Pooled Analysis From the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial Studies

2068). Overall, 3384 (71%) patients had experienced catastrophic out-of-pocket expenditure. Workers without health insurance were 7 times (OR, 6.9; 95% CI, 4.6 to 10.3) more likely to experience catastrophic payments than workers with insurance. Health insurance also protected against catastrophic payments in patients who were either retired or not working (no insurance: OR, 4.7; 95% CI, 3.1 to 7.2; OR, 1.82; 95% CI, 1.3 to 2.6, respectively). Conclusions— Because healthcare costs are high relative to income in China, families face considerable economic hardship after stroke. Health insurance protects families against catastrophic healthcare payments, thus highlighting the need to accelerate the ongoing process of building a comprehensive healthcare system in both urban and rural settings in China.

Acupuncture Efficacy on Ischemic Stroke Recovery Multicenter Randomized Controlled Trial in China

Background: Our purpose was to investigate the association between metabolic syndrome and risk of stroke by meta-analysis. Methods: Electronic databases through July 2007 were searched to identify prospective cohort studies that examined the association between metabolic syndrome and risk of stroke. Two reviewers independently assessed eligibility and used a standardized form to collect data from published studies. The study quality was assessed by the Newcastle-Ottawa Scale. Results: We found 13 eligible studies that included 92,732 participants.Compared to individuals without metabolic syndrome, subjects with metabolic syndrome had a 1.6-fold increased risk of stroke (95% CI, 1.48–1.75). The relative risk of stroke associated with metabolic syndrome was 2.2 in the studies using the World Health Organization definition and 1.6 in those using the Adult Treatment Panel III definition, but the difference was not statistically significant. Conclusions: This analysis shows that metabolic syndrome is an important risk factor for incident stroke. A diagnosis of metabolic syndrome may prove useful in clinical management, and its elements should ultimately become important therapeutic targets for the reduction of the stroke burden in the general population.

Proportion, Risk Factors and Outcome of Lacunar Infarction: A Hospital-Based Study in a Chinese Population

Background and Purpose— Controversy exists over the prognostic significance of perihematomal edema (PHE) in intracerebral hemorrhage. We aimed to determine the association of early PHE and clinical outcome among participants of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT) studies. Methods— Pooled analyses of computed tomographic substudies in the pilot phase (INTERACT1) and main phase (INTERACT2), both international, prospective, open, blinded end point, randomized controlled trials, of patients with spontaneous intracerebral hemorrhage (<6 hours) and elevated systolic blood pressure, randomly assigned to intensive (target systolic blood pressure, <140 mm Hg) or guideline-based (systolic blood pressure, <180 mm Hg) blood-pressure management. Substudy participants (n=1310; 346 INTERACT1, 964 INTERACT2) had blinded central analyses of digital images from standardized baseline and 24-hour computed tomography. Predictors of death or dependency (modified Rankin scale scores, ≥3) at 90 days were assessed in logistic regression models and reported with odds ratios and 95% confidence intervals. INTERACT studies are registered at ClinicalTrials.gov (NCT00226096 and NCT00716079). Results— Of 1138 (87%) patients with 2 CTs available for edema analysis and outcome information, time from intracerebral hemorrhage onset to baseline computed tomography, baseline hematoma volume, 24-hour hematoma growth, and intraventricular extension were independent predictors of 24-hour PHE growth. Absolute growth in PHE volume was significantly associated with death or dependency (adjusted odds ratio, 1.17; 95% confidence interval, 1.02–1.33 per 5 mL increase from baseline; P=0.025) at 90 days after adjustment for demographic, clinical, and hematoma parameter prognostic factors. Associations were consistent across various sensitivity analyses. Conclusion— PHE growth is an independent prognostic factor in intracerebral hemorrhage. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00226096 and NCT00716079.

Acute ischemic stroke in the very elderly Chinese: Risk factors, hospital management and one-year outcome

Background and Purpose— Acupuncture is a frequently used complementary treatment for ischemic stroke in China but the evidence available from previous randomized trials is inconclusive. The objective of this study was to assess the efficacy and safety of acupuncture in a more robustly designed larger scale trial. Methods— This is a multicenter, single-blinded, randomized controlled trial. Eight hundred sixty-two hospitalized patients with limb paralysis between 3 to 10 days after ischemic stroke onset were allocated acupuncture plus standard care or standard care alone. The acupuncture was applied 5 times per week for 3 to 4 weeks. The primary outcomes were defined as follows: (1) death/disability according to Barthel index and (2) death/institutional care at 6 months. Results— There was a tendency of fewer patients being dead or dependent in acupuncture group (80/385, 20.7%) than in control group (102/396, 25.8%) at 6 months (odds ratio, 0.75; 95% confidence interval, 0.54–1.05). The benefit was noted in subgroup receiving ≥10 sessions of acupuncture (odds ratio, 0.68; 95% confidence interval, 0.47–0.98). There was no statistical difference in death or institutional care between the 2 groups (odds ratio, 1.06; 95% confidence interval, 0.63–1.79). Severe adverse events occurred in 7.6% and 8.3% of patients in the 2 groups, respectively. Conclusions— Acupuncture seemed to be safe in the subacute phase of ischemic stroke. If the potential benefits observed are confirmed in future larger study, the health gain from wider use of the treatment could be substantial. Clinical Trial Registration— URL: http://www.chictr.org/en/. Unique identifier: ChiCTR-TRC-11001353.

Features of Acute Ischemic Stroke With Rheumatic Heart Disease in a Hospitalized Chinese Population

Background: There is scant information on the proportion, risk factors and outcome of lacunar infarction in China. Methods: Prospective registry data entered within 1 month after a first-ever stroke between March 2002 and March 2007 were used from 4 Chinese hospitals. Data regarding stroke risk factors and baseline characteristics were examined in a long-term follow-up. Case fatality, death and dependency, and stroke recurrence were assessed at 30, 90, 180 days and 1 year. Predictive factors for death at 1 year in patients with lacunar infarction were tested by logistic regression analysis. We constructed Kaplan-Meier survival curves and compared groups with lacunar infarction and nonlacunar infarction by means of log rank tests for significant difference. Results: A total of 3,905 patients with first-ever cerebral infarction were included, of whom 1,650 (42.3%) had a lacunar infarction and 2,255 (57.7%) a nonlacunar infarction. Case fatality was lower in patients with lacunar infarction at all 4 time points (5.3, 6.4, 7.8 and 17.4%, respectively), as compared to patients with nonlacunar infarction (9.5, 14.3, 16.5 and 20.1%, respectively). Age, diabetes, smoking and NIHSS score at admission were the independent predictors for 1-year case fatality in patients with lacunar infarction. Death and dependency rates were also lower in patients with lacunar infarction than in those with nonlacunar infarction. Recurrent stroke was an important cause of death for lacunar infarction patients. Conclusions: The proportion of lacunar infarction in China is much higher than that in Western countries. The long-term prognosis of lacunar infarction is not benign.

Mannitol and Outcome in Intracerebral Hemorrhage Propensity Score and Multivariable Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial 2 Results

BACKGROUND Little information is available on Asian patients over 80 years with stroke. We aimed to investigate characteristics of the very elderly ischemic stroke hospitalized patients in China. METHODS We prospectively enrolled consecutive patients with acute ischemic stroke from March, 2002 to October, 2008 into the analysis. Patients were divided into two groups: <80 years versus ≥80 years and risk factors, hospital management and one-year outcome were compared. RESULTS Of the 2619 cases included, 302 (11.5%) patients were 80 years or older. Compared with patients <80 years, patients over 80 years old had higher rates of hypertension (66.2% versus 56.1%, p=0.001), atrial fibrillation (23.5% versus 14.5%, p=0.000), and coronary heart disease (13.6% versus 5.7%, p=0.000). In addition, they were less likely to have received transthoracic echocardiography (45.4% versus 55.4%, p=0.001), color Doppler of extracranial vessels (54.0% versus 61.2%, p=0.015), antiplatelet agents (80.8% versus 86.8%, p=0.004), or anticoagulants (4.0% versus 9.0%, p=0.003). After adjusting for sex and stroke severity on admission, the very elderly patients had higher case-fatality and disability rates at one year (33.8% versus 13.2%, p=0.000; 37.8% versus 20.9%, p=0.000; respectively). CONCLUSIONS In China, the proportion of the very elderly in hospitalized stroke population is lower than that in western countries whereas the most common risk factors seem similar. The hospital management for these patients is relatively insufficient and the long-term outcome is generally unfavorable compared with patients under 80 years old.