American Heart Association


Sociodemographic Factors Limit Stroke Symptom Awareness Among Young Adults in the United States

Kevin O’Connor, MD

Mszar R, Mahajan S, Valero-Elizondo J, Yahya T, Sharma R, Grandhi GR, Khera R, Virani SS, Lichtman J, Khan SU, et al. Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults. Stroke. 2020;51:3552-3561.

Although the majority of U.S. adults know at least some stroke symptoms, awareness is lower among the younger population (i.e., age 18 to 44 years) and in various sociodemographic subgroups. The 2017 National Health Interview Survey assessed the participants’ (n=26,742) awareness of five sets of stroke symptoms: “(1) sudden numbness or weakness of the face, arm, or leg, especially on one side; (2) sudden confusion or trouble speaking; (3) sudden trouble seeing in one or both eyes; (4) sudden trouble walking, dizziness, or loss of balance; and (5) sudden severe headache with no known cause.” Mszar et al. compared survey responses to evaluate knowledge of stroke symptoms and understanding of the importance of contacting EMS for stroke symptoms.

Among 9,844 adults age < 45-years (39.7%), 7,126 (71.1% [95% CI, 69.6–72.5]) identified all five stroke symptoms. The most infrequently identified stroke symptom was severe headache (n=7,709 [77.5%; 95% CI, 76.3–78.7]), and 242 were unable to identify any stroke symptoms (2.7% [95% CI, 2.2–3.3]). Adults 45-64 (n=6,477 [76.0%; 95% CI, 74.8–77.3]) and those age 65+ (n=5,044 [77.9%; 95% CI, 76.5–79.3]) had greater awareness of stroke symptoms. Hispanic ethnicity (OR, 1.96 [95% CI, 1.17–3.28]), non-U.S. born immigration status (OR, 2.02 [95% CI, 1.31–3.11]), and lower education level (OR, 2.77 [95% CI, 1.76–4.35]) were associated with lack of awareness of any stroke symptoms among young adults.

Poor Socioeconomic Status as a Risk Factor of Incidental Stroke in Those Under 75? Analysis of the U.S. REGARDS Study

Csilla Manoczki, MD

Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, Safford MM. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020;51:2445–2453.

Studies have suggested that stroke disparities may be explained by other risk factors, such as social determinants of health (SDOH), beyond the traditional Framingham Stroke Risk Profile. According to the WHO: “the social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries”. This study investigated the association between incident stroke and the increasing number of multiple SDOH in the individual.

Data was used from the REGARDS study, a population-based prospective cohort study designed to identify the mechanisms of higher stroke mortality observed in the southeastern United States and among the Black population. The analytic sample of this study included 27813 individuals. Mean age at baseline was 64.7 years; 55.4% were women; 40.4% were of Black race; and 83.4% of all participants were <75 years old. Those with reported history of stroke at baseline were excluded. The primary outcome of the study was incident stroke based on expert adjudication following review of medical records.

Bridging and Anticoagulation After Acute Atrial Fibrillation-Related Ischemic Stroke

Kevin O’Connor, MD

Yaghi S, Mistry E, Liberman AL, Giles J, Asad SD, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, et al. Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study. Stroke. 2020;51: 2724–2732.

The risk of recurrence is reduced with anticoagulation in patients with an ischemic stroke in the setting of atrial fibrillation, but whether bridging therapy with either heparin or low molecular weight heparin is needed and the choice of oral anticoagulant (warfarin versus direct oral anticoagulant [DOAC]) remains controversial.

This retrospective analysis of pooled data from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study examined the risk of recurrent ischemic events and delayed symptomatic intracranial hemorrhage (d-sICH) when employing bridging therapy (or not) and when starting warfarin or a DOAC within 90 days of a stroke. Of 2084 patients, 1289 were included in the analysis of benefits and harms of bridging therapy (bridging, n=203; no bridging, n=1086) and 1251 in the analysis of warfarin versus DOAC (warfarin n=389, DOAC n=862). 

World Stroke Day: #DontStayAtHome: Stroke Symptoms Awareness Among Young Adults — Education is Key

Victor J. Del Brutto, MD

Mszar R, Mahajan S, Valero-Elizondo J, Yahya T, Sharma R, Grandhi GR, Khera R, Virani SS, Lichtman J, Khan Su, et al. Association Between Sociodemographic Determinants and Disparities in Stroke Symptom Awareness Among US Young Adults. Stroke. 2020.

Stroke is a devastating disease with potentially catastrophic consequences to its victims and their families. In the acute setting, immediate specialized evaluation and rapid delivery of time-sensitive therapies are crucial to improve the chances of a meaningful neurological recovery. Stroke systems of care across the world work daily in maximizing their treatment times in order to save neurons. However, time from symptoms onset to hospital arrival mainly depends on community awareness of stroke warning signs and the emergent response to stroke-like symptoms when they are perceived.

The World Stroke Day observed annually on October 29 was launched in 2006 with the main goal of raising awareness of the prevention and treatment of stroke. Mszar and colleagues bring us a timely analysis on the association between sociodemographic characteristics and disparities in awareness of stroke symptoms among U.S. young adults, a population group that has shown increasing trends in stroke incidence and stroke-related hospitalizations during the last few decades.

The Effects of Age on Traditional Risk Factors for Stroke

Wern Yew Ding, MBChB

Ahmed A, Pinto Pereira SM, Lennon L, Papacosta O, Whincup P, Wannamethee G. Cardiovascular Health and Stroke in Older British Men: Prospective Findings From the British Regional Heart Study. Stroke. 2020.

I read with interest the cohort study by Ahmed and colleagues, which sought to evaluate the influence of cardiovascular health on stroke risk. The authors used data from the British Regional Heart Study to identify men with no prior history of cardiovascular disease at baseline who were then re-examined 20 years later. Cardiovascular health was assessed using 7 traditional health metrics, including smoking status, body mass index, level of physical activity, dietary patterns, total cholesterol, blood pressure, and fasting glucose. Outcome data comprised of fatal and non-fatal stroke.

At baseline, there was a total of 7274 men with a mean age of 50 years. As highlighted by the authors, blood pressure was the only parameter at both baseline and 20-year follow-up that was consistently associated with stroke risk in this population. Better levels of physical activity and smoking status at baseline were related to reduced stroke risk, but similar results were not observed using data from 20-year follow-up when the mean age was 69 years. Overall, the authors concluded that stroke prevention strategies should prioritize blood pressure control and other risk factors.

Fire and Forget, or Treat to Target?

Vera Sharashidze, MD

Endres M, Kernan WN. LDL (Low-Density Lipoprotein) Cholesterol Below 70: Good to Go! Stroke. 2020;51:2276–2278.

The current guidelines of the American Heart Association/American Stroke Association (AHA/ASA) recommend high-intensity statin therapy initiation or continuation with the aim of achieving a 50% or greater reduction in low-density lipoprotein cholesterol (LDL-C) levels in patients with stroke who are 75 years of age or younger. In patients who are unable to tolerate high-intensity therapy, moderate intensity statins should be started with the goal of achieving a 30% to 49% reduction in LDL-C levels.

The first evidence that stroke patients could benefit from statins came out from the Heart Protection Study that was a double-blind, randomized, placebo-controlled study in which patients received either placebo or simvastatin 40 mg daily. This study showed that in patients with high risk for cardiovascular disease, cholesterol lowering with simvastatin was associated with reduction in all-cause mortality and major vascular event risk.

Article Commentary: “Impact of Multiple Social Determinants of Health on Incident Stroke”

Jennifer Harris, MD

Reshetnyak E, Ntamatungiro M, Pinheiro LC, Howard VJ, Carson AP, Martin KD, Safford MM. Impact of Multiple Social Determinants of Health on Incident Stroke. Stroke. 2020.

Health disparities have emerged as one of the great challenges to our health care system and a critical concern for the health of our U.S. population. Among the most dramatic disparities are seen in cardiovascular disease (CVD). Disparities in stroke outcomes are also widely reported in the literature. Whereas stroke rates in the U.S. have declined over the last decades, stroke mortality rates in nonwhites (predominantly Non-Hispanic (NH) Blacks) have remained substantially higher than in NH Whites [1]. This disparity may be due to differences in stroke incidence, with relative risk=2.77 (95%CI 1.37-5.62) between NH blacks and NH whites among those <55 years of age and 2.23 (95%CI 1.66-3.00) in those >55 years of age [2]. Data from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study suggest that the prevalence of stroke risk factors, particularly hypertension and diabetes, while clearly higher among NH Blacks, account for only 40% of the Black-White disparities in stroke incidence. The reasons for the remaining 60% are elusive [3].

Various socioeconomic determinants of health have been shown to predispose patients to developing CVD and stroke. According to national health disparities data for cardiovascular disease outcomes, there are several social determinants of health (SDOH) that may help explain stroke disparities. SDOH are defined as economic and social conditions that influence individual and group differences in health status. SDOH include low education, low income, living in an impoverished area, social isolation, and lacking health insurance, among others. To further investigate the association between incident stroke and SDOH, Reshetnyak et al. analyzed data from the REGARDS study to determine the individual and cumulative effect of SDOH on incident stroke.

PICASSO Trial: The Shades of Anti-Platelets

Rachel Forman, MD

Kim BJ, Kwon SU, Park J-H, Kim Y-J, Hong K-S, Wong LKS, et al. Cilostazol Versus Aspirin in Ischemic Stroke Patients With High-Risk Cerebral Hemorrhage: Subgroup Analysis of the PICASSO Trial. Stroke. 2019.

One of the most common discussions on any given stroke service involves the balance of preventing ischemic strokes (IS) and preventing intracranial hemorrhage (ICH). Whether it is about resuming anticoagulation in a hemorrhage patient or resuming aspirin in a patient with cerebral amyloid angiopathy there is always much debate on timing and decisions.  The decision to resume aspirin in a patient with an MRI full of cerebral microbleeds (CMBs) is often difficult. This paper looks into an alternative agent, cilostazol, for reducing hemorrhage risk in patients who warrant anti-platelet therapy. The background of the study is that cilostazol has shown to have less hemorrhagic events than aspirin among patients with ischemic stroke. 

The PICASSO trial (Prevention of Cardiovascular Events in Asian Ischemic Stroke Patients with High Risk of Cerebral Hemorrhage) was an Asian trial that aimed to determine which antiplatelet agent is more effective and safe in patients with prior hemorrhagic stroke or multiple CMBs. Cilostazol is an antiplatelet agent with additional vasodilatory effects. The trial, published in 2018, showed that cilostazol was noninferior to aspirin in preventing a composite of major vascular events; however, it failed to reduce ICH. This paper reviews the subgroup analysis to identify patients who would show greater benefit with cilostazol. 

Stroke Secondary to Atherosclerotic Aortic Arch Plaques: A Reminder

Victor J. Del Brutto, MD

Ntaios G, Pearce LA, Meseguer E, Endres M, Amarenco P, Ozturk S, et al. Aortic Arch Atherosclerosis in Patients With Embolic Stroke of Undetermined Source: An Exploratory Analysis of the NAVIGATE ESUS Trial. Stroke. 2019

When it comes to establishing the mechanism of injury in a stroke victim, the label “unknown/undetermined” deprives the patient of receiving the appropriate prognosis and strategy for secondary prevention. One-fourth of ischemic strokes are identified as cryptogenic without a definite understanding of the cause, and a sizable proportion of them will fit into the concept of embolic stroke of undetermined source (ESUS). The cause of ESUS could be an under-recognized cardiac source or a non-stenosing arterial lesion. Despite seminal studies in the 1990s that have identified a causal association between protruding plaques in the aortic arch and ischemic stroke, aortic arch atherosclerosis (AAA) is often overlooked during routine stroke work-up, thus falling into the category of stroke of undetermined etiology.

The current manuscript published by Ntaios and colleagues reports the exploratory analysis of the subgroup of individuals who participated in the New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism in Embolic Stroke of Undetermined Source (NAVIGATE-ESUS) trial and underwent transesophageal echocardiogram (TEE) for evaluation of AAA. The authors found a prevalence of 19% of AAA among patients with ESUS, from which one-third (8% of the total cohort) were considered to have high-risk complex plaques as defined by the presence of ulceration, thickness greater than 4 mm, or presence of a mobile thrombus. As noticed by the authors, the prevalence of AAA might be underestimated due to lower atherosclerotic risk factors in those who underwent TEE. Increasing age, diabetes mellitus and aortic valve disease, as well as geographic region (east Asia and eastern Europe), were significant determinants of AAA in the multivariable analysis. In addition, chronic infarcts and multi-territorial infarcts were associated with AAA, arguing against the common belief that multifocal strokes are exclusively cardioembolic. There was a non-significant trend for higher rate of stroke recurrence in patients with complex AAA (7.2% annualized rate) when compared to those without AAA (5.6% annualized rate). Data from this analysis was merged with two other randomized controlled trials to construct a meta-analysis of anticoagulation versus antiplatelet therapy in patients with cryptogenic stroke and AAA. The meta-analysis found no significant difference in the rate of stroke recurrence between the two antithrombotic approaches.

ESUS Subpopulation with Carotid Atherosclerosis: Do the Overall Results Differ?

Piyush Ojha, MBBS, MD, DM

Ntaios G, Swaminathan B, Berkowitz SD, Gagliardi RJ, Lang W, Siegler JE, et al. Efficacy and Safety of Rivaroxaban Versus Aspirin in Embolic Stroke of Undetermined Source and Carotid Atherosclerosis. Stroke. 2019;50:2477–2485.

Embolic stroke of undetermined source (ESUS), accounting for approximately 20% of all ischemic strokes, has been a hotly debated topic in the stroke community. The term encompasses cryptogenic strokes believed to be embolic in origin, which are not lacunar and without a cardiac or proximal large artery source. Patients qualifying as ESUS show a lot of pathophysiological heterogeneity, reflecting in the lack of sufficient evidence of trend towards a particular class of drugs and hence difficult to formulate a pharmacological plan. Multiple possible sources of emboli in these patients may explain the non-uniform response to anticoagulation over antiplatelets.

Several studies (including two major trials, NAVIGATE ESUS and RE-SPECT ESUS) have compared direct oral anticoagulants and aspirin in patients with recent ESUS for secondary stroke prevention, and failed to show any benefit of anticoagulation over antiplatelets, with associated higher risk of bleeding.