Susan M. Asai

Sex Differences in the Use of Early Do-Not-Resuscitate Orders After Intracerebral Hemorrhage

Background and Purpose— Studies show that women are more likely to receive do-not-resuscitate (DNR) orders after acute medical illnesses than men. However, the sex differences in the use of DNR orders after acute intracerebral hemorrhage (ICH) have not been described. Methods— We conducted a retrospective study of consecutive patients hospitalized for acute ICH at a tertiary stroke center between 2006 and 2010. Unadjusted and multivariable logistic regression analyses were performed to test for associations between female sex and early (<24 hours of presentation) DNR orders. Results— A total of 372 consecutive ICH patients without preexisting DNR orders were studied. Overall, 82 (22%) patients had early DNR orders after being hospitalized with ICH. In the fully adjusted model, early DNR orders were more likely in women (odds ratio, 3.18; 95% confidence interval, 1.51–6.70), higher age (odds ratio, 1.09 per year; 95% confidence interval, 1.05–1.12), larger ICH volume (odds ratio, 1.01 per cm3; 95% confidence interval, 1.01–1.02), and lower initial GCS score (odds ratio, 0.76 per point; 95% confidence interval, 0.69–0.84). Early DNR orders were less likely when the patients were transferred from another hospital (odds ratio, 0.28, 95% confidence interval, 0.11–0.76). Conclusions— Women are more likely to receive early DNR orders after ICH than men. Further prospective studies are needed to determine factors contributing to the sex variation in the use of early DNR order after ICH.

Racial disparities among Native Hawaiians and Pacific Islanders with intracerebral hemorrhage

Objectives: To evaluate disparities in stroke risk factors and outcome among the Native Hawaiians and other Pacific Islanders (NHPI) in Hawaii who are hospitalized with intracerebral hemorrhage (ICH). Methods: We performed a retrospective study on consecutive patients hospitalized for acute ICH at a single tertiary center on Oahu between 2004 and 2010. Clinical data were obtained from the Get With the Guidelines–Stroke database. Multivariable logistic regression was used to assess the predictors for young ICH (age <45). Results: A total of 562 patients hospitalized for acute ICH (Asian 63%, NHPI 18%, white 16%, other 3%) were studied. The NHPI were younger (mean ages, NHPI 55 ± 16 vs white 66 ± 16 years, p < 0.0001), and had higher prevalence of diabetes (NHPI 35% vs white 20%, p = 0.01) and history of hypertension (NHPI 77% vs white 64%, p = 0.04) compared to white patients. Independent predictors for young ICH were NHPI race (odds ratio [OR] 3.55; 95% confidence interval [CI] 1.33–9.45), being transferred from another hospital (OR 2.03; 95% CI 1.05–3.93), hypertension (OR 0.49; 95% CI 0.27–0.91), previous stroke or TIA (OR 0.21; 95% CI 0.05–0.91), and dyslipidemia (OR 0.15; 95% CI 0.05–0.50). Conclusions: NHPI with ICH are younger and have higher burden of risk factors compared to white patients. Further studies controlling for socioeconomic modifiers are needed to determine factors contributing to the younger age at presentation in this racial group.

Disparities among Asians and Native Hawaiians and Pacific Islanders with ischemic stroke

Objectives: To evaluate disparities in cardiovascular risk factors among Asians and Native Hawaiians and other Pacific Islanders (NHPI) in Hawaii who are hospitalized with ischemic stroke. Methods: We performed a retrospective study on consecutive patients hospitalized for ischemic stroke at a single tertiary center in Honolulu between 2004 and 2010. The prevalence of cardiovascular risk factors was compared for NHPI, Asians, and whites who were hospitalized for ischemic stroke. Results: A total of 1,921 patients hospitalized for ischemic stroke were studied. NHPI were less likely to be older (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.94–0.96), more likely to be female (OR 1.55, 95% CI 1.07–2.24), and more likely to have diabetes (OR 2.74, 95% CI 1.87–4.00), hypertension (OR 1.98, 95% CI 1.27–3.10), and obesity (OR 1.82, 95% CI 1.25–2.65) than whites. NHPI had higher low-density lipoprotein levels (114 ± 50 mg/dL vs 103 ± 45 mg/dL, p = 0.001) and lower high-density lipoprotein levels (38 ± 11 mg/dL vs 45 ± 15 mg/dL, p < 0.0001) than whites. Compared with Asians, NHPI were less likely to be older (OR 0.95, 95% CI 0.94–0.97) and more likely to have diabetes (OR 1.88, 95% CI 1.35–2.61), previous stroke or TIA (OR 1.57, 95% CI 1.09–2.25), and obesity (OR 6.05, 95% CI 4.31–8.48). Conclusions: Asians, NHPI, and whites with ischemic stroke have substantially different cardiovascular risk factors. Targeted secondary prevention will be important in reducing disparities among these racial groups.