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Abstract: Background: The importance of gender as an independent risk factor for poor outcome is not clear. We examined gender differences in patients' characteristic, management and outcome at discharge and 3-months after acute stroke in a national hospital-based registry. Methods: Data were derived from the triennial two-month national Acute Stroke Israeli Registry (Feb–March 2004, March–April 2007, April–May 2010). Unselected patients in all Israeli hospitals (n=28) were included. Outcome at 3-month was assessed in a sub-sample. Logistic regression models were used in the study of gender as an independent risk factor for poor outcome. Results: In total, 5034 patients (88.5% ischemic stroke, 9.6% ICH and 1.9% undetermined stroke) were included, of them 2285 (45.4%) women. Follow-up at 3-month was completed for 1040 patients, 41.9% women. Women showed higher rates of cardiovascular risk factors in-hospital death (p=0.007) and poor functional outcome (p<0.0001). Following adjustment for age, prior disability, NIHSS, prior stroke and risk factors, risk estimates (ORs, 95%CI) for women compared to men were 0.72 (0.55–0.96) for in-hospital death, 1.03 (0.83–1.29) for discharge to a nursing home or death, and 1.01 (0.86–1.20) for disability. Poor outcomes at 3-month were significantly more common in women; however, adjusted risk estimates were not significantly increased: OR 0.95 (95%CI 0.50–1.81) for death at 3-months, 1.41 (0.99–2.01) for Barthel Index≤60, 1.24 (0.90–1.72) for dependency and 0.88 (0.55–1.39) for living in a nursing home or death. Conclusion: Gender-differences in risk of death and poor functional outcome after stroke are mainly explained by dissimilarities in patients' characteristics and stroke severity. [Copyright &y& Elsevier]

Abstract: Introduction: Chronic environmental exposure to particulate matter <2.5μm in diameter (PM2.5) has been associated with cardiovascular disease; however, the effect of air pollution on myocardial infarction (MI) survivors is not clear. We studied the association of chronic exposure to PM2.5 with death and recurrent cardiovascular events in MI survivors. Methods: Consecutive patients aged ≤65years admitted to all medical centers in central Israel after first-MI in 1992–1993 were followed through 2005 for cardiovascular events and 2011 for survival. Data on sociodemographic and prognostic factors were collected at baseline and during follow-up. Residential exposure to PM2.5 was estimated for each patient based on data recorded at air quality monitoring stations. Cox and Andersen–Gill proportional hazards models were used to study the pollution-outcome association. Results: Among the 1120 patients, 469 (41.9%) died and 541 (48.3%) experienced one or more recurrent cardiovascular event. The adjusted hazard ratios associated with a 10μg/m3 increase in PM2.5 exposure were 1.3 (95% CI 0.8–2.1) for death and 1.5 (95% CI 1.1–1.9) for multiple recurrences of cardiovascular events (MI, heart failure and stroke). Conclusion: When adjustment for socio-demographic factors is performed, cumulative chronic exposure to PM2.5 is positively associated with recurrence of cardiovascular events in patients after a first MI. [Copyright &y& Elsevier]

Background: Reports on differences between patients with and without wake-up stroke are inconsistent. We studied the proportion, characteristics, and outcomes of wake-up ischemic stroke (IS) and estimated the number of potential candidates for reperfusion therapy in a national registry of hospitalized patients. Methods: IS patients in all three National Acute Stroke ISraeli (NASIS) registry periods (2004, 2007, and 2010; 2 months each) were included. In-hospital neurological complications, poor functional outcome (death, modified Rankin scale ≥2, or discharge to a nursing home), and in-hospital mortality were the study outcomes. Risks of poor outcomes were estimated with logistic regression analysis. Results: Wake-up IS was reported for 820/4,408 (18.6%) patients. Baseline characteristics were similar for patients with and without wake-up IS. ORs (95% CIs) for wake-up compared to non-wake-up IS were 1.2 (0.9-1.6) for neurological complications, 0.8 (0.7-0.98) for poor functional outcome, and 0.8 (0.5-1.2) for death. According to an estimated 20- 40% prevalence of penumbra, wake-up stroke patients could add 3.7-7.4% to the number of patients potentially eligible for reperfusion therapy. Conclusions: Stroke on awakening is present in almost one fifth of IS patients. Characteristics and stroke outcomes are similar for patients with and without wake-up IS. Confirmation of a valid approach for the detection of wake-up stroke patients who can potentially benefit from reperfusion therapy is essential. [ABSTRACT FROM AUTHOR]

Background: High cholesterol has been associated with better stroke outcomes. Conversely, a protective effect of prestroke statin use in the acute phase of stroke has been reported. The effect of low cholesterol on outcome in patients with and without prestroke statin treatment has not been studied. We assessed the association between low cholesterol and ischemic stroke short- and long-term outcomes and studied potential interactions with statin treatment in patients with a first-ever ischemic stroke in a prospective national registry. Methods: Ischemic stroke patients in the National Acute Stroke Israeli (NASIS) registry with a first-ever stroke and no previous disability, dementia or cancer admitted in all hospitals nationwide during 2-month periods in 2004, 2007 and 2010 were included (n = 1,895). Cholesterol levels ≤155 mg/dl (1st quintile) were defined as low cholesterol and patients treated with statins for at least 7 days before stroke onset were categorized as prestroke statin treated. Severe stroke (NIHSS ≥11), total anterior circulation infarction, poor functional outcome (defined as discharged to a nursing facility or modified Rankin Scale >3 or death), and mortality at discharge and at 3 years were the study outcomes. Associations between low cholesterol and outcomes at discharge were assessed separately in patients with and without prestroke statin treatment using multiple logistic regression analyses. Mortality at 3 years was assessed in a subset of 681 patients with Cox proportional hazard models. Results: Patients were 67.4 ± 13.5 years old on average; 43.1% were women. Low cholesterol was associated with higher rates of stroke risk factors. Controlling for age, sex, hypertension, diabetes, current smoking, ischemic heart disease, congestive heart failure and atrial fibrillation, low cholesterol was significantly associated with severe stroke, total anterior circulation infarction and poor functional outcome in patients with and without statin treatment. There were no interactions between low cholesterol and prestroke statin therapy in association with outcomes. Short- and long-term mortality rates were increased for patients with low cholesterol (5.2% at discharge and 35% at 3-years) compared with higher levels (2.5% at discharge and 20.5% at 3 years). Adjusted mortality risks were increased for patients with low cholesterol; however, this finding was statistically significant only for patients not on statins before the stroke. Conclusions: Low cholesterol is associated with increased stroke severity and poorer functional outcome in patients with and without prestroke statin use. Low-cholesterol statin-naive patients show increased risks of mortality. 'Reverse epidemiology' in the association between cholesterol and outcome is possible in patients with ischemic stroke. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

A response by Silvia Koton and colleagues to a letter to the editor on their article "Cerebral artery calcification in patients with acute cerebrovascular diseases: determinants and long-term clinical outcome" in the 2012 issue is presented.

Abstract: Background: Atrial fibrillation (AF) is a major risk factor of ischemic stroke. We tested whether the adoption of the CHADS2 score in clinical guidelines has impacted treatment strategies for stroke prevention, and examined how AF affects stroke outcome. Methods: In the setting of two national surveys [National Acute Stroke Israeli Surveys; all patients hospitalized for stroke in Israel during February–March 2004, and March–April 2007] data of patients with and without AF were analyzed with respect to patient characteristics, use of anticoagulation, stroke severity, clinical course, and long-term outcome. Results: Of 3040 patients with acute ischemic stroke, 586 patients (19%) had a history of AF. Severe strokes on admission were significantly more frequent in patients with AF, as was the proportion of total anterior circulation strokes. Ischemic stroke associated with AF predicted poor outcome at discharge (adjusted OR 1.56; 95%CI 1.24–1.96) and higher mortality rates throughout follow-up. Among patients with a CHADS2 score ≥2 prior to the index stroke and without known contraindications, 41% received anticoagulation. This proportion increased to only 62% after the index stroke, even after excluding patients with severe disability and no significant increase between 2004 and 2007 was detectable. Increasing age, in-hospital infectious complications, and unfavorable functional status at discharge were independently associated with decreased likelihood of receiving anticoagulation. Conclusions: In deviation from current recommendations and in spite of the introduction of CHADS2 criteria, anticoagulation for stroke prevention remains underutilized, despite the particularly poor outcome of strokes associated with AF. [Copyright &y& Elsevier]