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Introduction: The new American Heart Association Life's Essential 8 construct of ideal cardiovascular health now includes sleep duration. Little is known, however, about sleep duration in individuals with prior stroke. Our objective was to compare sleep duration among individuals with and without prior stroke., Methods: Using the National Health and Nutrition Examination Surveys (NHANES) database (2005-2018), individuals 18 years or older were identified (n = 37,987 without self-reported stroke; n = 1,572 with self-reported stroke). Prevalence of normal sleep duration (7-8 or 6-8 hours/night because of multiple definitions in the literature) was compared between persons with and without self-reported history of stroke using the Rao-Scott χ 2 test. Multinomial logistic regression analysis was used to evaluate the relationship between prior stroke and abnormal sleep before and after adjusting for demographic and clinical variables., Results: Compared with individuals without stroke, those with prior stroke were more likely to report >8 hours/night (unadjusted odds ratio (OR) 2.03, 95% confidence interval (CI) 1.64-2.51), <7 hours/night (1.29, 1.08-1.53), and <6 hours/night (1.87, 1.53-2.29). After adjustment, these associations were attenuated (adjusted OR 1.54, 95% CI 1.22-1.94 and 1.15, 0.96-1.38 and 1.50, 1.21-1.85)., Discussion: US stroke survivors are more likely to have abnormal sleep duration than those without prior stroke. Limitations of this study include the cross-sectional and self-reported nature of the data.

Background: After a stroke, poorly controlled blood pressure (BP) is associated with a higher risk of recurrent vascular events. Despite the importance of controlling BP to avert recurrent vascular events, fewer than half of stroke survivors in the United States achieve BP control. It is unclear to what extent insurance status affects BP levels after stroke., Methods: We assessed BP control among adults with a history of stroke who participated in the National Health and Nutrition Examination Surveys from 1999 through 2016. The relationship between insurance type and BP level (low normal: <120/80 mmHg and normal: <140/90 mmHg) were evaluated using logistic regression before and after adjusting for sociodemographic characteristics and medical comorbidities for those <65 years and ≥ 65 years., Results: Among 1646 adult stroke survivors (weighted n = 5,586,417), 30% had BP in the low normal range while 64% had BP in the normal range. Among 613 stroke survivors <65 years (weighted n = 2,396,980), only those with other government insurance (CHAMPVA, CHAMPUS/TRICARE) had better BP control than the uninsured (adjusted HR 2.68, 95% CI 0.99-7.25). Among 1033 participants ≥65 years (weighted n = 3,189,437), those with private insurance plus Medicare trended toward better normal BP compared to Medicare alone (adjusted HR 1.34, 95% CI 0.94-1.90)., Conclusions: Only stroke survivors with CHAMPVA, CHAMPUS/TRICARE government insurance in the United States have lower odds of controlled BP compared to no insurance among those <65 years. Insurance alone does not improve BP control among stroke survivors., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background Little is known about the effect of region of origin on all-cause mortality, cardiovascular mortality, and stroke mortality among Black individuals. We examined associations between nativity and mortality (all-cause, cardiovascular, and stroke) in Black individuals in the United States. Methods and Results Using the National Health Interview Service 2000 to 2014 data and mortality-linked files through 2015, we identified participants aged 25 to 74 years who self-identified as Black (n=64 717). Using a Cox regression model, we examined the association between nativity and all-cause, cardiovascular, and stroke mortality. We recorded 4329 deaths (205 stroke and 932 cardiovascular deaths). In the model adjusted for age and sex, compared with US-born Black individuals, all-cause (hazard ratio [HR], 0.44 [95% CI, 0.37-0.53]) and cardiovascular mortality (HR, 0.66 [95% CI, 0.44-0.87]) rates were lower among Black individuals born in the Caribbean, South America, and Central America, but stroke mortality rates were similar (HR, 1.01 [95% CI, 0.52-1.94]). African-born Black individuals had lower all-cause mortality (HR, 0.43 [95% CI, 0.27-0.69]) and lower cardiovascular mortality (HR, 0.42 [95% CI, 0.18-0.98]) but comparable stroke mortality (HR, 0.48 [95% CI, 0.11-2.05]). When the model was further adjusted for education, income, smoking, body mass index, hypertension, and diabetes, the difference in mortality between foreign-born Black individuals and US-born Black individuals was no longer significant. Time since migration did not significantly affect mortality outcomes among foreign-born Black individuals. Conclusions In the United States, foreign-born Black individuals had lower all-cause mortality, a difference that was observed in recent and well-established immigrants. Foreign-born Black people had age- and sex-adjusted lower cardiovascular mortality than US-born Black people.

Background: Patients with stroke in the United States can be transferred for higher level of care. Little is known about possible inequities in interhospital transfers (IHTs) for acute ischemic stroke. We hypothesized that historically marginalized populations would have lower odds of IHT., Methods: A cross-sectional analysis was done for adults with a primary diagnosis of acute ischemic stroke in 2010 to 2017; n=747 982 were identified in the National Inpatient Sample. Yearly rates for IHT were assessed and adjusted odds ratios (aORs) of IHT in 2014 to 2017 were compared with that of 2010 to 2013. Multinomial logistic regression was used to determine the aOR of IHT, adjusting for sociodemographic variables (model 1), sociodemographic and medical variables such as comorbidity and mortality risk (model 2), and sociodemographic, medical, and hospital variables (model 3)., Results: After adjusting for sociodemographic, medical, and hospital characteristics, there were no significant temporal differences in IHT from 2010 to 2017. Overall, women were less likely than men to be transferred in all models (model 3: aOR, 0.89 [0.86-0.92]). Compared with those who were White, individuals who were Black (aOR, 0.93 [0.88-0.99]), Hispanic (aOR, 0.90 [0.83-0.97]), other (aOR, 0.90 [0.82-0.99]), or of unknown race, ethnicity (aOR, 0.89 [0.80-1.00]) were less likely to be transferred (model 2), but these differences dissipated when further adjusting for hospital-level characteristics (model 3). Compared with those with private insurance, those with Medicaid (aOR, 0.86 [0.80-0.91]), self-pay (aOR, 0.64 [0.59-0.70]), and no charge (aOR, 0.64 [0.46-0.88]) were less likely to be transferred (model 3). Individuals with lower income were less likely to be transferred compared with those with higher income (model 3: aOR, 0.85 [0.80-0.90], third versus fourth quartile)., Conclusions: Adjusted odds of IHT for acute ischemic stroke remained stable from 2010 to 2017. There are numerous inequities in the rates of IHT by race, ethnicity, sex, insurance, and income. Further studies are needed to understand these inequities and develop policies and interventions to mitigate them.

Background: Food insecurity (FI)-lack of consistent access to food due to poor financial resources-limits the ability to eat a healthy diet, which is essential for secondary stroke prevention. Yet, little is known about FI in stroke survivors., Methods: Using data from the US National Health and Nutrition Examination Survey from 1999 to 2015, we analyzed the prevalence, predictors, and temporal trends in FI among adults with and without self-reported prior stroke in this cross-sectional study. Age-standardized prevalence estimates were computed by self-reported history of stroke over survey waves. Multivariable logistic regression models were performed for the National Health and Nutrition Examination Survey participants who had a prior stroke to identify independent predictors of FI by self-reported history of stroke., Results: Among 48 242 adults ≥20 years of age, 1877 self-reported history of stroke. FI was more prevalent among people with prior stroke (17%) versus those without prior stroke (12%; P <0.001). Prevalence of FI increased over time from 7.8% in 1999 to 42.1% in 2015 among stroke survivors and from 8% to 17% among individuals without prior stroke ( P <0.001). The age-standardized prevalence of FI over the entire time was 24% among stroke survivors versus 11% among individuals without prior stroke ( P <0.001). In the adjusted model, younger age (adjusted odds ratio [aOR], 0.96 [0.95-0.97]; P <0.01), Hispanic ethnicity (aOR, 2.12 [1.36-3.31]; P <0.01), lower education (aOR, 1.67 [1.17-2.38]; P <0.01), nonmarried status (aOR, 1.49 [1.01-2.19]; P =0.04), and poverty income ratio <130% (aOR, 3.78 [2.55-5.59]; P <0.01) were associated with FI in those with prior stroke., Conclusions: One in 3 stroke survivors reported FI in 2015, nearly double the prevalence in those without stroke. Addressing the fundamental drivers of FI and targeting vulnerable demographic groups may have a profound influence on stroke prevalence.

Objectives: Since 2000, medical treatment for epilepsy and cardiovascular risk-reduction strategies have advanced significantly in the United States (US). However, seizure-free rates remain unchanged, and people with epilepsy are at higher risk than the general population for heart disease and stroke. The purpose of this study is to determine how cardiovascular, epilepsy-related, and other causes of death are changing in epilepsy in comparison with the US population., Materials & Methods: Changes in the 15 underlying causes of death in epilepsy (ICD-10 G40-G40.9) and the US population were analyzed and compared from 2000 to 2018. The CDC multiple cause-of-death database was utilized as the primary data source. Changes in the relative proportions for each cause-of-death over were evaluated using logistic regression., Results: The proportions of deaths in epilepsy due to heart disease declined 34.4% (p < .001), a rate similar to the general population (39.9%). Epilepsy-related deaths declined 25% as a percentage of all epilepsy deaths (p < .001). The proportions of deaths due to stroke and neoplasms increased significantly in epilepsy versus the US population (p < .001 linear trend)., Conclusions: The reduction in ischemic heart disease in epilepsy is a novel and highly significant finding, which reflects widespread implementation of cardiovascular risk-factor reduction and treatment in the United States. Reductions in epilepsy-related deaths are an exciting development which requires further investigation into causality. The increase in deaths due to neoplasms and stroke relative to the US population is concerning, warranting vigilance and increased efforts at recognition, prevention, and treatment., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background and Purpose: Up to 25% of the U.S. population has undiagnosed diabetes. Diabetes and stroke both disproportionately afflict race/ethnic minorities. We assessed race/ethnic differences in the prevalence of undiagnosed diabetes, prediabetes, and cardiometabolic risk profiles among stroke survivors in the United States., Methods: The prevalence of diabetes and prediabetes among adults (≥20 years) with a self-reported history of stroke was assessed using the National Health and Nutrition Examination Surveys (NHANES) from 1999 to 2010. Cardiometabolic risk factors across race/ethnic groups were compared using linear and logistic regression before and after adjusting for covariates., Results: From 1999 to 2010, 1070 individuals who participated in NHANES had a self-reported history of stroke. Among stroke survivors without a formal diagnosis of diabetes and prediabetes, 233 (32%) had undiagnosed prediabetes and 27 (3.7%) had undiagnosed diabetes. The prevalence of undiagnosed diabetes and prediabetes was the highest among non-Hispanic (NH) blacks (8% and 38%) compared with Mexican Americans (4% and 26%) and NH whites (3% and 32%). Compared with NH whites, NH blacks were significantly younger, more likely to take antihypertensive medications, more likely to smoke, and have poorly controlled diabetes. NH blacks were twice as likely as NH whites to have poorly controlled blood pressure, after adjustment for sociodemographic and vascular risk factors., Conclusion: In the United States, NH black stroke survivors have the highest rates of undiagnosed diabetes and prediabetes, and have poorer cardiometabolic risk factor control than their NH white counterparts., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Poststroke depression is common, affecting approximately 1 in 3 stroke survivors. We aimed to evaluate the association between depression and mortality in adults with and without prior stroke., Methods: Using the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (1982-1992), we investigated the association between depression and all-cause mortality among adults aged 25-74 years with and without prior stroke, and stroke mortality among stroke survivors, adjusting for covariates., Results: Among 9919 individuals, 121 (1.2%) reported prior stroke. The adjusted depression prevalence was 37.1% among stroke survivors and 17.3% among individuals without stroke. In persons aged 25-64 years, neither stroke nor depression was associated with all-cause mortality. The combination of depression and stroke was not associated with all-cause mortality (adjusted hazard ratio [HR] 2.83, 95% confidence interval [CI] .67-12.04). Among persons aged 65-74 years, depression alone (adjusted HR 1.24, 95% CI 1.04-1.47), stroke alone (adjusted HR 1.64, 95% CI 1.17-2.32), and the combination of depression and stroke (adjusted HR 2.28, 95% CI 1.79-2.90) were associated with all-cause mortality, consistent with an additive relationship. Among all ages, the combination of depression and stroke was associated with all-cause mortality (adjusted HR 1.93, 95% CI 1.28-2.92). Higher stroke mortality was only observed in those aged 65-74 years (adjusted HR 2.43, 95% CI 1.05-5.60). Compared with stroke survivors without depression, those with depression were ~35 times more likely to die from a stroke (adjusted HR 35.33, 95% CI 7.79-160.32)., Conclusions: The combination of prior stroke and depression is associated with higher all-cause mortality than either condition alone. The presence of depression after stroke increases stroke mortality 35-fold, highlighting the importance of identifying and treating depression among stroke survivors., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Approximately half of never smokers are exposed to secondhand smoke (SHS). Smoking is a well-established stroke risk factor, yet associations between SHS, stroke, and poststroke mortality remain uncertain. We aimed to determine the prevalence of exposure to SHS among those with and without stroke and its impact on mortality., Methods: Data were obtained from the US National Health and Nutrition Examination Surveys for 27 836 never smokers with/without self-reported stroke aged ≥18 years, sampled from 1988 to 1994 and 1999 to 2012, with linked mortality through 2010. Household exposure to SHS was determined by self-report; exposure severity was quantified by serum cotinine level. Independent relationships between SHS and all-cause mortality were assessed using Cox regression models, before and after adjusting for sociodemographics and comorbidities., Results: From 1988 to 1994 to 1999 to 2012, age-adjusted prevalence of exposure to SHS declined from 11.5% to 6.6% among survivors of stroke (P=0.08), and 14.6% to 5.9% among persons without stroke (P<0.01). Factors associated with high exposure to SHS were male sex, black race, ≤12th-grade education, poverty income ratio ≤200%, high alcohol intake, and history of myocardial infarction (all P<0.05). High exposure to SHS was associated with higher odds of previous stroke (odds ratio, 1.46; P=0.026). There was a dose-dependent relationship between exposure to SHS and all-cause mortality after stroke., Conclusions: Individuals with previous stroke have 50% greater odds to have been exposed to SHS; SHS is associated with a 2-fold increase in mortality after stroke. This study highlights the importance of obtaining exposure to SHS history and counseling patients and their families on the potential impact of SHS on poststroke outcomes., (© 2016 American Heart Association, Inc.)

Background: Depression, one of the most common complications encountered after stroke, is associated with poorer outcomes. The aim of this study was to determine the factors independently associated with and predictive of poststroke depression (PSD)., Methods: We assessed the prevalence of depression (Patient Health Questionnaire [PHQ-8] score >10) among a national sample of adults (≥20 years) with stroke who participated in the National Health and Nutrition Examination Surveys from 2005 to 2010. Logistic regression and random forest models were used to determine the factors associated with and predictive of PSD, after adjusting for sociodemographic and clinical factors., Results: Of the 17,132 individuals surveyed, 546 stroke survivors were screened for depression, and 17% had depression, corresponding to 872,237 stroke survivors with depression in the United States. In the logistic regression model, after adjustment for sociodemographic variables, poverty (poverty index <200% versus ≥200%, odds ratio [OR] 2.61, 95% confidence interval [CI] 1.23-5.53) and 3 or more medical comorbidities (OR 1.59, 95% CI 1.01-2.49) were associated with higher odds of PSD; increasing age was associated with lower odds of PSD (per year OR .95, 95% CI .94-.97). In the random forest model, the 10 most important factors predictive of PSD were younger age, lower education level, higher body mass index, black race, poverty, smoking, female sex, single marital status, lack of cancer history, and previous myocardial infarction (specificity = 70%, sensitivity = 64%)., Conclusion: Although numerous factors were predictive of developing PSD, younger age, poverty, and multiple comorbidities were strong and independent factors. More aggressive screening for depression in these individuals may be warranted., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Expert consensus guidelines recommend antihypertensive treatment to lower secondary stroke risk, but patterns and predictors of blood pressure (BP) treatment and control among stroke survivors in the United States remain unknown. Understanding predictors of poor control can facilitate development of targeted strategies., Methods: We reviewed the prevalence and control of hypertension among adults 40 years or older with self-reported stroke who participated in the National Health and Nutrition Examination Surveys 1999-2004 with mortality follow-up through 2006. Predictors of poorly controlled BP (>140/90 mm Hg) and nontreatment were determined via logistic regression. Independent association between antihypertensive use and mortality was determined using Cox models., Results: Among 9145 participants, 490 reported previous stroke; 72% had known hypertension, 8% had undiagnosed hypertension, and 47% had poorly controlled BP. In multivariable analyses, age (odds ratio [OR] per year 1.06, 95% confidence interval [CI] 1.03-1.09), female sex (OR 1.70, 95% CI 1.12-2.57), non-Mexican Hispanic ethnicity (OR 4.54, 95% CI 1.76-11.70), black race (OR 3.15, 95% CI 1.59-6.25), hypercholesterolemia (OR 2.46, 95% CI 1.44-4.21), and diabetes (OR 1.96, 95% CI 1.16-3.33) were associated with poorly controlled BP. Obesity was associated with lower odds of poorly controlled BP (OR .51, 95% CI .26-.99). Non-Mexican Hispanic ethnicity (OR 7.37, 95% CI 2.25-24.10) and black race (OR 3.13, 95% CI 1.05-9.34) were predictors of nontreatment, whereas diabetes was linked to treatment (OR 3.57, 95% CI 1.21-10.43). There was no association between antihypertensive treatment and mortality after adjustment for demographics and comorbidities., Conclusions: One in 2 stroke survivors in the United States has poorly controlled BP; the most vulnerable groups include women, non-Mexican Hispanics, blacks, diabetics, and older individuals. Understanding causes of this evidence-practice gap may assist in developing effective targeted interventions., (Copyright © 2016 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Retrospective analyses of randomized controlled trials suggest that antiplatelet therapy may modify the potential cerebrovascular benefits of lowering homocysteine with B-vitamins among individuals with cardiovascular disease. We evaluated the effects of B-vitamin supplementation on risk of subsequent stroke among high cardiovascular risk individuals who are not taking antiplatelet medications., Methods: We systematically searched the Cochrane Central Register of controlled trials, PubMed, the Internet Stroke Center stroke trials, and the clinical trials.gov website from 1966 to April 2015. Inclusion criteria included: randomized controlled trials of homocysteine-lowering therapy with B-vitamins; high cardiovascular risk population and follow-up ≥1 year. We considered stroke as the primary outcome. Among 11 randomized controlled trials meeting inclusion criteria, three studies assessed stroke as an outcome and reported event rates according to whether or not individuals were taking antiplatelets: Vitamin Intervention for Stroke Prevention (VISP), VITAmins TO Prevent Stroke (VITATOPS), and Heart Outcomes Prevention Evaluation 2 (HOPE-2)., Results: A total of 4643 high vascular risk subjects not taking antiplatelets were evaluated. The overall effect size across studies was summarized using the fixed effects model after confirming there was no significant heterogeneity. Heterogeneity was assessed using the Cochran's Q and I(2) statistics. Compared with the control group, those taking B-vitamin supplementation had a lower risk of recurrent stroke (HR 0.86, 95% CI 0.62 to 1.19 for VISP; 0.65, 0.46 to 0.91 for VITATOPS; and 0.60, 0.39 to 0.92 for HOPE-2; overall HR 0.71, 0.58 to 0.88)., Conclusion: Homocysteine lowering with B-vitamins among high vascular risk patients who are not taking antiplatelet therapy is related to a significant reduction (29%) in overall stroke risk. A clinical trial of B-vitamins in this group may be warranted., (© 2016 World Stroke Organization.)

Background: The American Heart Association developed criteria dubbed "Life's Simple 7" defining ideal cardiovascular health: not smoking, regular physical activity, healthy diet, maintaining normal weight, and controlling cholesterol, blood pressure, and blood glucose levels. The impact of achieving these metrics on survival after stroke is unknown. We aimed to determine cardiovascular health scores among stroke survivors in the United States and to assess the link between cardiovascular health score and all-cause mortality after stroke., Methods and Results: We assessed cardiovascular health metrics among a nationally representative sample of US adults with stroke (n=420) who participated in the National Health and Nutrition Examination Surveys in 1988-1994 (with mortality assessment through 2006). We determined cumulative all-cause mortality by cardiovascular health score under the Cox proportional hazards model after adjusting for sociodemographic characteristics and comorbidities. No stroke survivors met all 7 ideal health metrics. Over a median duration of 98 months (range, 53-159), there was an inverse dose-dependent relationship between number of ideal lifestyle metrics met and 10-year adjusted mortality: 0 to 1: 57%; 2: 48%; 3: 43%; 4: 36%; and ≥5: 30%. Those who met ≥4 health metrics had lower all-cause mortality than those who met 0 to 1 (hazard ratio, 0.51; 95% confidence interval, 0.28-0.92). After adjusting for sociodemographics, higher health score was associated with lower all-cause mortality (trend P-value, 0.022)., Conclusions: Achieving a greater number of ideal cardiovascular health metrics is associated with lower long-term risk of dying after stroke. Specifically targeting "Life's Simple 7" goals might have a profound impact, extending survival after stroke., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Lack of insurance is a barrier to optimal stroke risk factor control but data on its long-term impact on stroke outcomes are sparse. We assessed the association between health insurance and long-term mortality after stroke., Methods: Using data from the National Health and Nutrition Examination Surveys 1999-2004 with follow-up mortality assessment through 2006, we examined the independent effect of health insurance on (1) stroke mortality among all adult participants (n = 15,049) and (2) vascular and all-cause mortality rates among participants with self-reported stroke (n = 563)., Results: Among individuals without a previous stroke, uninsured individuals aged less than 65 years were more likely to die of stroke than those with insurance (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], .96-10.23); however, among those aged 65 years or older, those with private insurance, private plus Medicare, or Medicare plus Medicaid had similar risk of stroke mortality when compared to those with Medicare alone. Stroke survivors aged 65 years or older with private insurance were less likely to die from vascular causes (adjusted HR, .38; 95% CI, .23-.63) compared to those with Medicare alone. For stroke survivors aged less than 65 years, uninsured individuals had similar all-cause mortality rates compared to their counterparts with insurance., Conclusions: Insurance status influences risk of dying from a stroke in the general population, as well as long-term mortality rates among stroke survivors in the United States, but these relationships vary by age., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Recent studies suggest a J-shaped association between systolic blood pressure (SBP) and cardiovascular events. The optimal SBP target after stroke remains unknown. We assessed the link between SBP and mortality after stroke., Methods: We included adults (≥20 years) with self-reported stroke who participated in the National Health and Nutrition Examination Surveys 1998 to 2004, with mortality assessment in 2006. Baseline SBP was categorized as low to normal (<120 mm Hg), normal (120-140 mm Hg), and high (≥140 mm Hg). Independent relationships between baseline SBP and all-cause and vascular mortality were assessed using Cox proportional hazards., Results: Of 31 126 adult participants, 455 had self-reported stroke and baseline BP readings: 19% had low to normal, 31% had normal, and 50% had high SBP. Two years after assessment, the low to normal SBP group tended to have the highest cumulative all-cause mortality (11.5%), compared with mortality rates of 8.5% and 7.5% in the normal and high SBP groups, respectively. Similar patterns were seen with vascular mortality. After adjusting for covariates, compared with the high SBP group, the low to normal group had higher all-cause mortality (adjusted hazard ratio, 1.96; 95% confidence interval, 1.13-3.39; P=0.017) and trended toward higher vascular mortality (adjusted hazard ratio, 2.08; 95% confidence interval, 0.93-4.68; P=0.075). Compared with the normal BP group, the risk of all-cause and vascular mortality trended higher in low to normal BP group but did not achieve statistical significance., Conclusions: After stroke, compared with SBP in the high range, low to normal SBP is associated with poorer mortality outcomes., (© 2015 American Heart Association, Inc.)

Background and Purpose: Although several randomized controlled trials failed to show a benefit of B vitamin therapy on composite outcomes of cardiovascular death, myocardial infarction, and stroke among individuals with elevated homocysteine, recent post hoc analyses have suggested that several factors may interact with the effects of vitamin treatment. One post hoc analysis revealed an interaction between B vitamin therapy and antiplatelet use; however, those results have not been replicated in other studies or populations., Methods: We conducted a post hoc analysis of the Vitamin Intervention for Stroke Prevention (VISP) trial, a randomized controlled trial evaluating treatment with high- versus low-dose B vitamin therapy for secondary prevention of vascular events among stroke survivors with elevated homocysteine. Cox regression models were used to assess primary (recurrent stroke) and secondary (stroke, myocardial infarction, or vascular death) outcomes among individuals on high- versus low-dose vitamin therapy, categorized by antiplatelet use, after adjusting for covariates., Results: Among 3680 participants, 52% took antiplatelet medications. When compared with low-dose therapy, high-dose vitamin therapy was associated with higher stroke risk among individuals on antiplatelets (hazard ratio, 1.43; 95% confidence interval, 1.02-2.01), but trended toward lower risk among those not on antiplatelets (hazard ratio, 0.86; 95% confidence interval, 0.62-1.19)., Conclusions: High-dose B vitamin therapy may be associated with a higher risk of recurrent stroke among stroke survivors taking antiplatelets, but does not have a significant effect on recurrent stroke risk in those who are not on antiplatelets. Future randomized controlled trials may consider evaluating the effect of homocysteine lowering among stroke survivors with elevated homocysteine who are not on antiplatelet therapy., (© 2015 American Heart Association, Inc.)

Background and Purpose: Blood pressure (BP) reduction lowers vascular risk after stroke; however, little is known about the relationship between consistency of BP control and risk of subsequent vascular events., Methods: In this post hoc analysis of the Vitamin Intervention for Stroke Prevention trial (n=3680), individuals with recent (<120 days) stroke, followed up for 2 years, were divided according to proportion of visits in which BP was controlled (<140/90 mm Hg): <25%, 25% to 49%, 50% to 74%, and ≥75%. Multivariable models adjusting for demographic and clinical variables determined the association between consistency of BP control versus primary (stroke) and secondary (stroke, myocardial infarction, or vascular death) outcomes., Results: Only 30% of participants had BP controlled ≥75% of the time. Consistency of BP control affected outcomes in individuals with baseline systolic BP>132 mm Hg. Among individuals with baseline systolic BP>75th percentile (>153 mm Hg), risks of primary and secondary outcomes were lower in those with BP controlled ≥75% versus <25% of visits (adjusted hazard ratio, 0.46; 95% confidence interval, 0.26-0.84 and adjusted hazard ratio, 0.51; 95% confidence interval, 0.32-0.82). Individuals with mean follow-up BP<140/90 mm Hg had lower risk of primary and secondary outcomes than those with BP≥140/90 mm Hg (adjusted hazard ratio, 0.76; 95% confidence interval, 0.59-0.98 and adjusted hazard ratio, 0.76; 95% confidence interval, 0.62-0.92)., Conclusions: In this rigorous clinical trial, fewer than one third of patients with stroke had BP controlled ≥75% of the time for 2 years. Furthermore, consistency of BP control among those with elevated baseline systolic BP was linked to reduction in risk of recurrent stroke and stroke, myocardial infarction, and vascular death.

Background: Clinical trials have failed to show a benefit of B vitamin therapy in reducing composite outcomes of cardiovascular death, myocardial infarction, and stroke among stroke survivors with elevated total serum homocysteine (tHcy) levels. Recent post hoc analyses have shown that numerous factors including age, baseline tHcy levels, folic acid fortification of grains, B12 status, renal function, comorbidities, and medications may modify the effect of B vitamin therapy on vascular risk in individuals with high tHcy. It remains possible that tHcy-lowering therapy may reduce cardiovascular risk in certain subgroups of stroke survivors. Post hoc subgroup analysis of the Heart Outcomes Prevention Evaluation-2 randomized controlled trial, which randomized participants with known cardiovascular disease to tHcy-lowering therapy or placebo, revealed larger treatment benefit for patients aged younger than 69 years; however, that analysis did not control for other factors. The aim of this study was to determine the effect of age on the impact of tHcy-lowering therapy for reducing vascular risk after stroke while controlling for other factors known to modify the effect of tHcy and tHcy-lowering therapy on vascular risk., Methods: In this post hoc analysis of the Vitamin Intervention for Stroke Prevention (VISP) trial, a randomized controlled trial of tHcy lowering for secondary stroke prevention, we excluded individuals who had poor renal function (glomerular filtration rate <47; the 10th percentile) or were treated with vitamin B12 injections. We assessed the effects of high-dose vitamin replacement on primary (stroke, myocardial infarction, or death) and secondary (stroke) outcomes, after stratifying by age (< vs. ≥ median age, 67 years) and adjusting for demographic and clinical factors., Results: This subgroup consisted of 2,993 individuals. Among individuals older than 67 years, high-dose vitamin therapy was associated with reduced risk of stroke, myocardial infarction or death (adjusted HR 0.76, 95% CI 0.58-0.99) and a trend towards reduced likelihood of stroke (adjusted HR 0.86, 95% CI 0.59-1.25). High-dose vitamin therapy did not impact outcomes among individuals younger than 67 years., Conclusions: In this post hoc subgroup analysis of the VISP trial, age modified the association between B vitamin therapy and recurrent vascular risk among stroke survivors with elevated serum tHcy levels. Older individuals with stroke were more likely to benefit from B vitamin therapy than younger individuals. These findings can help inform the future design of clinical trials of tHcy-lowering therapy for cardiovascular risk reduction after stroke. © 2014 S. Karger AG, Basel., (© 2014 S. Karger AG, Basel.)

Background: Although the ambulatory setting is recognized as the best arena for optimizing antihypertensive drug treatment after a stroke, little is known about recent office-based antihypertensive drug treatment patterns in the United States. We assessed national trends in antihypertensive treatment for stroke patients in office-based medical practice., Methods: Data from the 2000-2009 National Ambulatory Medical Care Surveys were analyzed comprising outpatient visits to physicians in office-based practice by patients aged 40 years or older with a diagnosis of stroke (weighted estimate=46,317,269). The main outcome measure was visits with a prescription of antihypertensive medication(s)., Results: The proportion of total visits that included a prescription of antihypertensive medication was 35.6% in 2000-2002, 29.5% in 2003-2005, and 49.3% in 2006-2009 (P=.002); 50.9% were primary care physician (PCP) visits versus 26.2% neurologist visits (P<.0001). Age-adjusted logistic regression analyses confirmed a higher prescription rate in 2006-2009 versus 2000-2002 (1.81; 95% confidence interval [CI], 1.10-2.96) and PCP versus neurologists (2.82; 95% CI, 1.86-4.27). Use of 2 or more agent classes was 31.6% in 2000-2002, 44.2% in 2003-2005, and 56.7% in 2006-2009 (P=.014). Age-adjusted logistic regression analyses confirmed a higher prescription rate of 2 or more agent classes in 2006-2009 versus 2000-2002 (2.96; 95% CI, 1.40-6.24). There were no significant differences in agent class type or number between neurologists versus PCPs., Conclusions: Over the last decade, there was a significant rise in the use of antihypertensive drugs and combination of agent classes for patients aged 40 years or older seen in an ambulatory setting with a diagnosis of stroke. PCPs were more likely than neurologists to prescribe these agents., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Studies suggest that women are less likely than men to receive intravenous (IV) tissue plasminogen activator (tPA) for acute ischemic stroke (AIS). Relatively little is known about whether this sex disparity in AIS management extends beyond IV tPA use, reflects national practice patterns, or is changing., Methods: Data from the Nationwide Inpatient Sample from 1997 to 2006 were used to identify adults (≥18 years of age) who were discharged with a primary diagnosis of AIS (n = 4,453,207) in the United States. Of 605,960 individuals admitted to 1056 hospitals that performed reperfusion/revascularization procedures, sex-specific rates of cerebrovascular reperfusion (e.g., IV tPA, intra-arterial therapy, angioplasty, stent, or carotid endarterectomy [CEA]), and cardiac reperfusion (e.g., catheterization, angioplasty, stent, or bypass graft) were determined before and after adjustment for sociodemographic, clinical, and hospital factors., Results: Men were more likely than women to receive IV tPA (prevalence ratio [PR] 1.37, 95% confidence interval [CI] 1.32-1.42), catheter angiography (PR 1.36, 95% CI 1.33-1.38), intracranial or extracranial angioplasty/stent (PR 1.73, 95% CI 1.49-2.01), CEA (PR 1.79, 95% CI 1.72-1.86), or any cardiac reperfusion therapy (PR 1.62, 95% CI 1.53-1.71). Multivariable adjustment slightly attenuated the sex disparity. Use of all procedures except CEA rose from 1997 to 2006 in both sexes, but IV tPA use increased at a higher rate for women (compared to men); by 2006, there was no sex difference., Conclusions: Over the last decade, women hospitalized for AIS in the United States were less likely than men to receive cerebrovascular and cardiac reperfusion therapies. However, the IV tPA treatment sex disparity may have been eliminated., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Concerns about ready access to neurosurgery after acute ischemic stroke (AIS) may delay or prevent intravenous thrombolysis, thereby leading to poor outcomes. A randomized trial exploring the need for back-up neurosurgery in AIS is unlikely. However, insight may be gained from routine clinical practice. We analyzed the odds and temporal trends of cranial neurosurgery procedure use in patients with AIS using a large U.S. administrative database., Methods: Data from AIS patients in the Nationwide Inpatient Sample (October 1998 to 2006) who underwent a cranial neurosurgical procedure were analyzed. Multivariate logistic regression with covariate adjustment was used for statistical analysis. Results were stratified by thrombolysis status. Intracerebral hemorrhage (ICH) was used as a key covariate., Results: Intravenous thrombolysis use increased significantly over time (0.8% to 2.5%; P<.001). Cranial neurosurgical procedures were observed infrequently but increased significantly over time (0.12% to 0.19%; P=.0013), and thrombolysis doubled the odds of a procedure (odds ratio 2.18; 95% confidence interval 1.48-3.21; P<.001). However, thrombolysis only significantly increased the odds of a neurosurgical procedure in the absence of ICH (P<.001)., Conclusions: Thrombolysis should probably not be withheld from eligible AIS patients, even if a concern exists about the lack of readily available neurosurgery, because neurosurgical procedure use is low in routine clinical practice, even after intravenous thrombolysis. Future studies and prospective data might help define the need for standby neurosurgery after AIS and provide further focus on the specific linkage to ICH as a possible mediator variable., (Copyright © 2013 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Low estimated glomerular filtration rate (eGFR) has been linked to higher risk of primary stroke, but little is known about the relation of low eGFR to recurrent vascular risk after stroke. B Vitamin therapy has been used to lower homocysteine levels, but its interaction with kidney function on future major vascular events has not been assessed. The objective of this study was to conduct a secondary analysis based on the Vitamin Intervention for Stroke Prevention (VISP) trial to clarify these issues., Study Design: In the VISP trial, patients with a prior ischemic stroke were randomly assigned to receive the high- or low-dose B vitamin therapy. The trial did not find a difference between randomly assigned groups. The present study is a secondary analysis of the VISP trial., Setting & Participants: We analyzed the database of a multicenter trial comprising 3,673 patients with recent ischemic stroke who were followed up for 2 years., Predictor: We subdivided the cohort based on eGFR into 6 groups (≥105, 90-104, 75-89, 60-74, 45-59, and <45 mL/min/1.73 m²) for the analyses and used eGFR of 60-74 mL/min/1.73 m² as the reference category. Low eGFR was defined as <45 mL/min/1.73 m²., Outcomes: The primary end point for this analysis was major vascular events, defined as the composite of nonfatal ischemic stroke, nonfatal myocardial infarction, and vascular death (whichever event came first). The secondary end point was recurrent ischemic stroke. Also, the effects of high-dose B vitamin treatment on future major vascular events according to baseline eGFR categories were analyzed and reported separately., Results: Mean baseline eGFR was 73.9 ± 21.8 (SD) mL/min/1.73 m². 471 major vascular events during an average of 20 months of follow-up, including 300 recurrent strokes, were recorded. Baseline low eGFR was associated with increased risk of major vascular events (HR, 1.83; 95% CI, 1.32-2.52; P < 0.001) and recurrent stroke (HR, 1.53; 95% CI, 1.01-2.32; P = 0.04) after adjustment for traditional vascular risk factors and homocysteine level. At baseline eGFR <45 mL/min/1.73 m², high-dose B vitamin therapy compared to low dose showed a trend of higher risk of future major vascular events (HR, 1.49; 95% CI, 0.95-2.34; P = 0.08). The overall P value for interaction between B vitamin dose and eGFR was not significant (P = 0.6)., Limitations: No data for albuminuria., Conclusions: Low eGFR is associated with higher risk of future major vascular events and recurrent stroke after a recent ischemic stroke., (Copyright © 2013 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Coronary heart disease (CHD) is a major cause of mortality among stroke patients after the acute period. Simple risk stratification of stroke patients without known CHD may permit prompt implementation of CHD-specific management strategies for those who are at high risk for cardiac events. We assessed the utility of the Framingham Coronary Heart Disease Risk Score (FCRS) as a prognosticator in stroke patients without known CHD., Methods: Post hoc analysis of a trial dataset of 3509 recent ischemic stroke patients who were aged 35 years or older, recruited from 56 centers, and followed-up for 2 years. Patients were categorized as having known CHD, high FCRS (≥20%), and low/intermediate FCRS (<20%). The predictive values between baseline FCRS and primary (myocardial infarction [MI]), secondary (MI or vascular death), and tertiary (recurrent stroke) outcomes were assessed in multivariate analyses., Results: Rates of first MI at 2 years were 6.34%, 4.65%, and 1.44% for the known CHD, high FCRS, and low/intermediate FCRS groups. Compared with stroke patients with low/intermediate FCRS, individuals with high FCRS had a higher risk of MI (adjusted hazard ratio, 3.70; 95% confidence interval, 2.14-6.38) and MI or vascular death (adjusted hazard ratio, 2.21; 95% confidence interval, 1.48-3.28). High FCRS did not predict recurrent stroke., Conclusions: Among patients with a recent ischemic stroke without known CHD, high FCRS was associated with a higher risk of MI and vascular death, but not stroke. FCRS could be a simple way to identify recent stroke patients who may benefit from additional CHD-specific management.

Background: Long term, stroke survivors have a higher risk of death from cardiac causes than incident stroke. However, little is known about temporal trends in age- and gender-specific risk of future cardiac events among stroke survivors., Aims: To determine temporal trends in 10-year risk of future major cardiac events (measured using the Framingham Cardiovascular Risk Score) and components of the Framingham Cardiovascular Risk Score among a nationally representative population of stroke survivors in the United States., Methods: Framingham Cardiovascular Risk Score was assessed among individuals with a self-reported history of stroke (n = 748) who participated in the National Health and Nutrition Examination Surveys in the United States during the years 1988-1994 and 1999-2006., Results: In both National Health and Nutrition Examination Surveys waves, male stroke survivors had higher mean Framingham Cardiovascular Risk Scores than their female counterparts. This gender disparity was driven by the >64 years age group, where men had a threefold higher Framingham Cardiovascular Risk Scores compared to women (P < 0·01). Analysis of temporal trends revealed that mean Framingham Cardiovascular Risk Scores was lower in 1999-2006 compared to 1988-1994 in men (21% (standard error 1%) vs. 28% (standard error 0·2%), P = 0·01) and women (9% (standard error 1%) vs. 11% (standard error 1%), P = 0·06). Temporal comparisons revealed that diastolic blood pressure and total cholesterol levels were better in 1999-2006 compared to 1988-1994 for both genders., Conclusions: Male stroke survivors, particularly those over the age of 64, are at higher risk for future cardiac events than their female counterparts. For both genders, the risk of future cardiac events after stroke has declined in recent years; this reduction is most pronounced in men and likely due to improvements in blood pressure and cholesterol levels., (© 2012 The Authors. International Journal of Stroke © 2012 World Stroke Organization.)

Background: Little is known about the effects of a healthy lifestyle on mortality after stroke. This study assessed whether five healthy lifestyle factors had independent and dose dependent associations with all-cause and cardiovascular mortality after stroke., Methods: In a nationally representative sample of the US population (n=15,299) with previous stroke (n=649) followed from survey participation (1988-1994) through to mortality assessment (2000), the relationship between five factors (eating ≥5 servings of fruits/vegetables per day, exercising >12 times/month, having a body mass index of 18.5-29.9 mg/kg(2), moderate alcohol use [1 drink/day for women and 2 drinks/day for men] and not smoking) and all-cause and cardiovascular mortality was assessed., Results: Mean age was 67.0 years (SE 1.1 years) and 53% were women. After adjusting for covariates, abstaining from smoking (HR 0.57, CI 0.34 to 0.98) and exercising regularly (HR 0.66, CI 0.44 to 0.99) were associated with lower all-cause mortality but no individual factors had independent associations with cardiovascular mortality. All-cause mortality decreased with higher numbers of healthy behaviours (1-3 factors vs none: HR 0.12, CI 0.03 to 0.47; 4-5 factors vs none: HR 0.04, CI 0.01 to 0.20; 4-5 factors vs 1-3 factors: HR 0.38, CI 0.22 to 0.66; trend p=0.04). Similar effects were observed for cardiovascular mortality (4-5 factors vs none: HR 0.08, CI 0.01 to 0.66; 1-3 factors vs none: HR 0.15, CI 0.02 to 1.15; 4-5 factors vs 1-3 factors: HR 0.53, CI 0.28 to 0.98; trend p=0.18)., Conclusions: Regular exercise and abstinence from smoking were independently associated with lower all-cause mortality after stroke. Combinations of healthy lifestyle factors were associated with lower all-cause and cardiovascular mortality in a dose dependent fashion.

Background: Type 2 diabetes rates in the general population have risen with the growing obesity epidemic. Knowledge of temporal patterns and factors associated with comorbid diabetes among stroke patients may enable health practitioners and policy makers to develop interventions aimed at reducing diabetes rates, which may consequently lead to declines in stroke incidence and improvements in stroke outcomes., Methods: Using the Nationwide Inpatient Sample (NIS), a nationally representative data set of US hospital admissions, we assessed trends in the proportion of acute ischemic stroke (AIS) patients with comorbid diabetes from 1997 to 2006. Independent factors associated with comorbid diabetes were evaluated using multivariable logistic regression., Results: Over the study period, the absolute number of AIS hospitalizations declined by 17% (from 489,766 in 1997 to 408,378 in 2006); however, the absolute number of AIS hospitalizations with comorbid type 2 diabetes rose by 27% [from 97,577 (20%) in 1997 to 124,244 (30%) in 2006, p < 0.001]. The rise in comorbid diabetes over time was more pronounced in patients who were relatively younger, Black or 'other' race, on Medicaid, or admitted to hospitals located in the South. Factors independently associated with higher odds of diabetes in AIS patients were Black or 'other' versus White race, congestive heart failure, peripheral vascular disease, history of myocardial infarction, renal disease and hypertension., Conclusions: Although hospitalizations for AIS in the US decreased from 1997 to 2006, there was a steep rise in the proportion with comorbid diabetes (from 1 in 5 to almost 1 in 3). Specific patient populations may be potential targets for mitigating this trend., (Copyright © 2012 S. Karger AG, Basel.)

Background and Purpose: Little is known about sex-specific stroke hospitalization rates among middle-aged individuals. This study assessed recent temporal trends in stroke hospitalizations among persons aged 35 to 64 years in the United States., Methods: The Nationwide Inpatient Sample was used to identify individuals with a primary or secondary discharge diagnosis of stroke between 1997 and 2006 (n=3,161,752). Age-adjusted sex-specific rates of ischemic and hemorrhagic stroke hospitalizations were assessed among individuals aged 35 to 64 years., Results: Over the study period, stroke hospitalization rates per 100 000 decreased by 10% from 66.7 to 60.3 (trend P<0.01) in men and 8% from 52.7 to 48.3 (trend P<0.001) in women. The 55- to 64-year age group drove reductions in hospitalization rates: slope (rate of change per year)=-12.3 for men and -8.9 for women (both P<0.001). Rates increased slightly in men and women aged 35 to 44 years and remained stable for persons aged 45 to 54 years. Stroke subtype analysis revealed that rates of ischemic stroke hospitalization increased and hemorrhagic stroke hospitalization remained stable among individuals aged 35 to 44 years. Rates of ischemic and hemorrhagic stroke hospitalizations remained stable among those aged 45 to 54 years and decreased among persons aged 55 to 64 years., Conclusions: From 1997 to 2006, ischemic and hemorrhagic stroke hospitalization rates declined among individuals aged 55 to 64 years and remained stable among persons aged 45 to 54 years; ischemic stroke hospitalization rates increased among individuals aged 35 to 44 years. Further studies are needed to assess and address increases in ischemic stroke hospitalizations among younger individuals.

Background: Advancements in diagnosis and treatment have resulted in better clinical outcomes after stroke; however, the influence of age and gender on recent trends in death during stroke hospitalization has not been specifically investigated. We assessed the impact of age and gender on nationwide patterns of in-hospital mortality after stroke., Methods: Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 1998 (n=1 351 293) and 2005 and 2006 (n=1 202 449), with a discharge diagnosis of stroke (identified by the International Classification of Diseases, Ninth Revision procedure codes), were included. Time trends for in-hospital mortality after stroke were evaluated by gender and age group based on 10-year age increments (<55, 55-64, 65-74, 75-84, >84) using multivariable logistic regression., Results: Between 1997 and 2006, in-hospital mortality rates decreased across time in all sub-groups (all P<0·01), except in men >84 years. In unadjusted analysis, men aged >84 years in 1997-1998 had poorer mortality outcomes than similarly aged women (odds ratio 0·93, 95% confidence interval=0·88-0·98). This disparity worsened by 2005-2006 (odds ratio 0·88, 95% confidence interval=0·84-0·93). After adjusting for confounders, compared with similarly aged women, the mortality outcomes among men aged >84 years were poorer in 1997-1998 (odds ratio 0·97, 95% confidence interval=0·92-1·02) and were poorer in 2005-2006 (odds ratio 0·92, 95% confidence interval=0·87-0·96), P=0·04, for gender × time trend., Conclusions: Over the last decade, in-hospital mortality rates after stroke in the United States have declined for every age/gender group, except men aged >84 years. Given the rapidly ageing US population, avenues for boosting in-hospital survival among very elderly men with stroke need to be explored., (© 2011 The Authors. International Journal of Stroke © 2011 World Stroke Organization.)

Background and Purpose: Recent studies have revealed an increase in stroke prevalence among middle-aged women in the United States. To determine whether this is due to improved survival, we assessed temporal trends in sex-specific in-hospital mortality after stroke., Methods: Individuals aged 35 to 64 years hospitalized in 1997 to 2006 with a primary discharge diagnosis of stroke (N=2 537 097) in the United States were identified by the Nationwide Inpatient Sample. Temporal trends in sex-specific mortality after stroke and sex differences in mortality were assessed, before and after controlling for covariates., Results: From 1997 to 2006, poststroke mortality decreased in both men (6.06% to 5.15%) and women (6.02% to 4.88%) aged 35 to 64 years. Unadjusted analysis revealed that women aged 35 to 44 years (odds ratio=0.89; 95% CI, 0.83 to 0.95) and 45 to 54 years (odds ratio=0.93; 95% CI, 0.89 to 0.97) had lower mortality compared with men, whereas women aged 55 to 64 years had similar mortality compared with men. After adjustment for covariates, stroke type accounted for the better survival in women aged 35 to 44 years. After adjustment for covariates, women aged 45 to 54 years persistently had better survival than did men. Women aged 55 to 64 years had better survival than did men, once race and insurance type were accounted for., Conclusions: This study revealed a decline in stroke mortality rates from 1997 to 2006 among individuals aged 35 to 64 years. Better survival among women compared with men aged 35 to 54 years may partially explain the sex disparity in stroke prevalence.

Background: A recent study found that US women aged 45-54 years in 1999-2004 were twice as likely as men to report previous stroke. The aim of this study was to evaluate the validity of this finding by assessing the sex-specific midlife stroke prevalence in the most recent nationally representative, cross-sectional sample of US individuals., Methods: Sex-specific stroke prevalence, sex-specific vascular risk factor prevalence and sex-specific independent predictors of stroke were assessed among 35- to 64-year olds who participated in the National Health and Nutrition Examination Surveys in 2005-2006 (n = 2,274)., Results: Women aged 35-64 years were almost 3 times more likely than men to report prior stroke (2.90 vs. 1.07%; p < 0.001). This disparity was driven by the 45- to 54-year age group, where women had thrice the odds of prior stroke compared with men (OR 3.12, 95% CI 1.30-7.50). Among 45- to 54-year olds, men were more likely than women to have a history of smoking, elevated homocysteine and elevated triglyceride levels, but less likely to be abdominally obese (p < 0.001). Independent stroke risk factors among women aged 35-64 years were a homocysteine level >8.5 μmol/l (OR 6.19, 95% CI 2.57-14.93), a history of myocardial infarction (OR 5.35, 95% CI 1.09-26.27) and diabetes mellitus (OR 6.63, 95% CI 2.47-17.81)., Conclusion: The midlife sex disparity in US stroke prevalence persists. Greater emphasis on prompt recognition and treatment of cardiovascular risk factors among young and middle-aged women may ameliorate this worrisome trend., (Copyright © 2011 S. Karger AG, Basel.)

Background: Although the original homocysteine hypothesis for atherothrombotic disease is falling out of favor, prior studies did not comprehensively adjust for confounders or explore specific subgroups of patients who may benefit from serum homocysteine-lowering. We aimed to determine (1) if elevated total homocysteine (tHcy) affects odds of prevalent stroke after adjusting for a broad array of pertinent covariates and (2) whether particular vascular risk factors amplify the effect of high homocysteine on prevalent stroke., Methods: The independent and interactive effects of elevated tHcy (≥10 μmol/L) on likelihood of prevalent stroke was assessed in the National Health and Nutrition Examination Survey, a nationally representative cross-sectional sample of the US population conducted from 1999 to 2004 (n=12,683)., Results: After adjusting for 17 covariates, those with elevated tHcy were more likely to have prevalent stroke vs. those without elevated tHcy (OR 1.52, 95% CI 1.01-2.29; p=0.045). Individuals with a combination of elevated tHcy and hypertension were substantially more likely to have prevalent stroke compared to individuals without either condition (OR 12.02, 95% CI 6.36-22.73 for men and OR 17.34, 95% CI 10.49-28.64 for women). The association of tHcy with prevalent stroke was strongest in younger individuals and declined linearly with increasing age., Conclusions: Elevated tHcy independently increases odds of prevalent stroke. Younger individuals and those with concomitant hypertension may particularly benefit from tHcy-lowering., (Copyright © 2010 Elsevier B.V. All rights reserved.)