Fall in the Proportion of Atherothrombotic Strokes During the Last Decade
Introduction
Etiologic subtypes of ischemic strokes (IS) are influenced by the vascular risk factors profile of patients.1, 2, 3, 4 Large artery atherosclerosis (LAA) strokes are related to dyslipidemia, hypertension, diabetes, prior transient ischemic attacks, smoking and male gender.1, 2, 3 Small vessel occlusion (SVO) strokes are strongly associated with hypertension and diabetes.2,5 Cardioembolic strokes are mostly caused by atrial fibrillation, valvular heart disease and ischemic heart disease.1, 2, 3
In recent years, there has been a substantial change in vascular risk factors definitions, including more strict and individualized criteria. Dyslipidemia targets depend on individual vascular risk rather than a fixed and universal cholesterol level.6 Hypertension definition also evolved over time. Since 1993 the JNC 5 lowered the target to 140/90 for all patients and to 130/80 mmHg for diabetics and/or chronic kidney disease subjects.7 Criteria for normal blood pressure have been set at even lower values recently.8 In addition to stricter definitions, there is a trend towards more intense vascular risk factors control, especially in developed countries.9,10 Better control of vascular risk factors could reflect greater adherence to primary and secondary prevention guidelines, greater availability of effective drugs, lower blood pressure and lipids targets, changes in lifestyle and more efficient public health policies. This scenario may lead to a lower proportion of atherothrombotic subtypes of IS, especially those secondary to large and small vessel disease. This phenomenon has recently been described in a Dutch cohort.11 The substantial drop in the number of carotid procedures performed in the United Stated between appears to support this presumption.12
The objective of this study was to determine the evolution in the proportion of the different subtypes of ischemic stroke, vascular risk factors profile and medical treatment prior to stroke in subjects admitted between 1997 and 2018 in a single institution in Argentina.
Section snippets
Materials and methods
We assessed patients older than 18 years admitted to our hospital with diagnosis of IS during a 22-year period. Most of our patients live in the city of Buenos Aires in upper-middle class neighborhoods and 72% of them have private health insurance or pay from their own pockets for health care. Clinical records of consecutive patients were evaluated between January 1st, 1997 and December 31th, 2018. We excluded patients with incomplete medical records and those with no follow-up after discharge.
Results
We studied a total of 2747 patients (64% men), aged 67 ± 15 years. There were 920 patients in P1 and 1827 in P2. The Table summarizes demographic data, vascular risk factors, previous medical treatment and IS etiological subtypes of total population and by periods. There were no differences in gender distribution and age between both periods.
There was a significant decrease in the proportion of LAA strokes from 29% in P1 to 14% in P2 (p <0.0001), SVO strokes proportion also decreased from 15%
Discussion
This report from a single institution in Argentina demonstrates a substantial decrease in the proportion of strokes associated with large and small vessel atherothrombosis between 1997 and 2018. LAA strokes decreased from 29% to 14% and SVO strokes from 15% to 11%. In addition, cardioembolic strokes mostly associated to AF, increased from 17% to 25% and undetermined strokes from 30% to 41%, with stable proportion of strokes due to other etiologies. In a context of stable prevalence of
Conclusion
Our study shows a robust trend for a decline in the proportion of IS associated to large and small vessel atherothrombosis. In the same period there was an increase in the proportion of cardioembolic strokes. Higher rates of use of preventive medical strategies leading to better control of hypertension and dyslipidemia in this population, and higher prevalence and/or better detection of AF, could explain, at least in part, these findings.
Acknowledgements
None.
Sources of funding
None.
Disclosures
Nothing to disclose.
References (36)
- et al.
2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American college of cardiology/American heart association task force on clinical practice guidelines
J Am Coll Cardiol
(2018) - et al.
The Heart of 25 by 25: achieving the goal of reducing global and regional premature deaths from cardiovascular diseases and stroke: a modeling study from the american heart association and world heart federation
Glob Heart
(2016) - et al.
SMART study group. Decline in risk of recurrent cardiovascular events in the period 1996 to 2014 partly explained by better treatment of risk factors and less subclinical atherosclerosis
Int J Cardiol
(2018) - et al.
Has the aetiology of ischaemic stroke changed in the past decades? Analysis and comparison of data from current and historical stroke databases
Neurologia
(2018) - et al.
Auckland regional community stroke study group. Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003
Lancet Neurol
(2006) - et al.
Incidence, 30-day case-fatality rate, and prognosis of stroke in Iquique, Chile: a 2-year community-based prospective study (PISCIS project)
Lancet
(2005) - et al.
Differences in vascular risk factors between etiological subtypes of ischemic stroke: importance of population-based studies
Stroke
(2003) Cardiovascular risk factors for acute stroke: Risk profiles in the different subtypes of ischemic stroke
World J Clin Cases
(2015)- et al.
Different vascular risk factor profiles in ischemic stroke subtypes: a study from the "Sagrat Cor Hospital of Barcelona Stroke Registry
Acta Neurol Scand
(2000) - et al.
Risk factors, outcome, and treatment in subtypes of ischemic stroke: the German Stroke Data Bank
Stroke
(2001)
Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute 11 stroke treatment
Stroke
Guideline writing committee for the 2018 cholesterol guidelines. 2018 cholesterol clinical practice guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline
Ann Intern Med
The fifth report of the joint national committee on detection, evaluation, and treatment of high blood pressure (JNC V)
Arch Intern Med
Heart disease and stroke statistics-2018 update: a report from the American heart association council on epidemiology and prevention statistics committee and stroke statistics subcommittee
Circulation
American heart association statistics committee and stroke statistics subcommittee. Heart disease and stroke statistics–2015 update: a report from the American Heart Association
Circulation
Experience from a multicentre stroke register: a preliminary report
Bull World Health Organ
An updated definition of stroke for the 21st century a statement for healthcare professionals from the American heart association/American stroke association
Stroke
Diagnosis and classification of diabetes mellitus
Diabetes Care
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