Search

Background and Purpose: We investigated whether low blood pressure increases the risk of stroke recurrence., Methods: A cohort of 662 patients, obtaining care at the 8 acute care hospitals serving the Lehigh Valley in Pennsylvania, was enrolled within 1 month of an initial stroke and was followed twice annually for up to 4 years. Cox proportional hazard models were developed to examine the relationship between risk of recurrent stroke and blood pressure, controlling for other significant risk factors. Our analyses investigated both lowest follow-up and average follow-up blood pressures as predictors of stroke recurrence., Results: There were 52 recurrent strokes among the 535 patients (mean age, 71 years; 51% men) with follow-up blood pressure. The risk ratio for stroke recurrence for diastolic blood pressure > or =80 mm Hg compared with <80 mm Hg was 2.4 (95% CI, 1.38 to 4.27) and for systolic blood pressure > or =140 mm Hg compared with <140 mm Hg was also 2.4 (95% CI, 1.39 to 4.15). For isolated systolic blood pressure (>140/<90 mm Hg), the risk ratio was 2.2 (95% CI, 1.23 to 3.79) relative to <140/<90 mm Hg. Using the Cox model, we also showed that patients who had at least 1 measured diastolic blood pressure <80 mm Hg during follow-up had a reduced risk of stroke recurrence compared with those with diastolic blood pressures 80 to 90 mm Hg (0.4 versus 1.0; 95% CI, 0.21 to 0.88) even after controlling for the possible confounding factors of hypertension and atrial fibrillation on ECG. Myocardial infarction on ECG, history of transient ischemic attack, and diabetes mellitus were not significant predictors of increased risk of recurrent stroke., Conclusions: Our results imply that "lower is better" for blood pressure control as a goal in reducing stroke recurrence risk.

Background: Known demographic and clinical characteristics of stroke survivors that affect selection of the facility to which they are discharged after hospitalization for an acute stroke are, for the most part, not population based and therefore may be unrepresentative. We present an analysis of such characteristics using the Lehigh Valley stroke cohort which is population based., Method: We enrolled patients within 1 month of onset of their initial acute stroke who were hospitalized between 1987 and 1989 at one of the eight hospitals in the Lehigh Valley, and 662 patients were discharged alive. The facility to which they were discharged was known for 660. Data on age, sex, presence of five selected comorbidities (hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus and transient ischemic attacks), length of hospitalization and neurologic deficits from the stroke were systematically collected on standardized forms. Polytomous logistic regression was used to determine the factors associated with not being discharged home. Relative risk (RR) associated with discharge to a nursing or rehabilitation facility for each independent predictor was calculated using as the referent, those who went home., Results: Older age was a statistically significant predictor of not being sent home (RR = 1.2 for nursing home placement), but gender and living with a spouse were not. Having a selected comorbidity did not increase the RR of not being sent home regardless of the type, nor did risk of not being sent home increase with more than one illness. Considering neurologic deficits from the stroke, patients with lower extremity weakness had a 2.6- and 3.5-fold risk of being sent to a nursing or a rehabilitation facility, respectively, compared to those without such weakness while for those with upper extremity weakness, the RR was 1.5 and 4.9, respectively. Language deficit imposed a RR of 3.1 and 2.3 of going to a nursing or rehabilitation facility, respectively. Right facial weakness also emerged as a significant risk factor for not being discharged home, perhaps because of its association with language deficit. The longer a patient was hospitalized after a stroke, the less likely it was that such a patient would go home (RR = 1.1/hospitalization day)., Conclusion: Using population-based data on stroke survivors, our study showed the characteristics of patients who are less likely to be discharged home and, instead, are discharged to a nursing or a rehabilitation facility. Data like ours which were population based may be useful in discharge planning for stroke patients by policy makers and health care providers.

Background and Purpose: Hypertension is a risk factor for initial stroke, but its relation to stroke recurrence is unclear. Therefore, we sought to analyze the effect of hypertension and its control on risk of stroke recurrence., Methods: Within 1 month of onset, a population-based cohort of 662 patients from the Lehigh Valley with an initial stroke were enrolled. Hypertension was determined at enrollment by history. Blood pressure was also measured at enrollment and at each follow-up at 4- to 6-month intervals for up to 48 months (mean, 24 months). Stroke recurrence was verified by history, examination, and review of medical reports. Various criteria for control of blood pressure were defined. History of hypertension, measured blood pressure, and its control were analyzed in relation to stroke recurrence frequency using Kaplan-Meier and univariate, multivariate, and time-dependent Cox proportional hazards models., Results: At enrollment, 59.4% of the cohort had a history of hypertension and 81 patients had a second stroke. Those with a history of hypertension had a significantly higher stroke recurrence rate than those without such a history (P = .01). Among those with measured diastolic blood pressure at enrollment > or = 95 mm Hg, 43% had a stroke recurrence by the end of the study compared with only 19% below this cutoff (P = .005). Recurrence risk was reduced in a multivariate analysis as quality of diastolic blood pressure control increased (relative risk = 8.4, 3.9, and 2.0 among those with poor, fair, and good control, respectively, compared with nonhypertensive subjects). Systolic blood pressure and its control appeared less or not significantly associated with stroke recurrence., Conclusions: History of hypertension and elevated measured diastolic pressure after the initial stroke were associated with an increased risk of second stroke. Controlling diastolic pressure substantially reduced this risk.

A community-based, prospective study was carried out in the Lehigh Valley to determine how 5 selected risk factors and their control affected the frequency of stroke recurrence and death after an initial stroke. The initial stroke was verified clinically and by computerized tomography. Between 1987 and 1989, 662 patients with an initial stroke were enrolled and followed regularly every 4-6 months for up to 7 visits. The average follow-up period was 2 years. The risk factors selected included hypertension, myocardial infarction, cardiac arrhythmia, diabetes mellitus and transient ischemic attacks. Interim death and its cause were noted. Surviving patients were interviewed and examined to determine whether a second stroke has occurred. At enrollment, 51.4% of the cohort was male. The average age of men was 69.6, while women were older, averaging 74.3 years. Stroke types were thrombosis, 14%; embolus, 23%; lacune, 9%; nonspecific infarct, 48%, and intracerebral hemorrhage, 6%. There were 138 deaths (21%) and 81 second strokes (12%) during follow-up. The frequency of risk factors at enrollment was as follows; hypertension, 59%; myocardial infarction, 25%, cardiac arrhythmia, 47% (of which 16% had atrial fibrillation); diabetes mellitus, 29%, and transient ischemic attack, 18%. Of course many patients had multiple risk factors. We analyzed whether the presence of a risk factor at enrollment and its quality of control during follow-up affected stroke recurrence frequency and the mortality rates. These results will be reported in future papers.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of transient ischemic attacks (TIAs) in the Lehigh Valley was analyzed using the Lehigh Valley Stroke Register based on data collected between July 1, 1982, and June 30, 1986. The overall average annual incidence rate was 22.9 per 100,000 population, and 23.2 and 22.5 per 100,000 population in men and women, respectively. Men had a statistically significant higher age-specific rate of TIAs than women. Our incidence appears to be lower than that reported in earlier studies but, because of methodologic differences, only continued observations in our population and in similar populations using a standardized methodology will resolve the question of whether TIA frequency is, in fact, declining.

Morbidity and mortality of asthma has been on the upswing since the 1960s, as marked by increased hospitalizations with asthma since the early 1980s. This has not been explained adequately. The possibility of change in the natural history or increased exposure to environmental irritant chemicals or allergens has been suggested by some. There probably has been better recognition and diagnosis of asthma by distinguishing it from bronchitis, recurrent croup, and bronchiolitis in children. Despite evidence to suggest that this is the case, there are still some missing factors. The increase in asthma mortality is more understandable when one considers the fact the management of asthma has changed greatly in the past two decades. The use of corticosteroids orally, parenterally, and by inhalation has been a double-edged sword. There is no doubt that many asthmatics have a much improved sense of well-being and have lived more normal lives due to the use of corticosteroids. The inability of some patients, parents, or physicians to perceive impending respiratory difficulty, however, may result in underuse of drugs, including corticosteroids, leading to increased mortality. Other factors have led to increased mortality from asthma in recent years, and they include arrhythmias with combinations of theophylline, beta-agonists, and hypoxia. The psychological factors attendant to adolescence and psychological problems are probably quite important in the recent upsurge in asthma deaths in the 15- to 25-year age group. Many deaths are occurring outside of the hospital environment and may be largely preventable. There must be increased awareness by the patient, the family, and the physician. In view of the increased hospitalizations, the total number of deaths is not increasing at an alarming rate, yet it is necessary to make all of us who care for asthmatics aware and take corrective action as soon as we are aware of an asthmatic with respiratory problems.

We investigated black/white differences in stroke rate (standardized morbidity), severity, and subtype, and the relative frequencies of 5 primary risk factors (hypertension, diabetes, myocardial infarction, other heart diseases, and transient ischemic attack [TIA]) using the Lehigh Valley Stroke Register. Blacks had a statistically significant higher, age-adjusted rate of stroke than whites. We found no differences in stroke severity using our measures but blacks had a statistically higher proportion of lacunar stroke, while whites had a higher proportion of embolic stroke. There were no differences in proportions of thrombotic stroke or intracerebral hemorrhage. The relative frequencies of hypertension, myocardial infarction, other heart diseases, and diabetes were higher for blacks, while the relative frequency of TIA was higher for whites. These observations are consistent with other reports that blacks have a higher frequency of stroke and tend to have more small-vessel cerebrovascular pathology than whites.

We investigated the seasonal pattern of stroke using the Lehigh Valley Stroke Register. This register includes all patients hospitalized with stroke or transient ischemic attack (TIA) from among the 600,000 Lehigh Valley residents. Meterological data were obtained from the National Oceanic and Atmospheric Administration. The study, which uses 18 months of data, included 1,944 cases. Using single harmonic regression analysis, the seasonal pattern of TIA and infarction, but not hemorrhage, fit a sine-cosine wavefunction with a 12-month period (R2 = 41% and 36%, respectively). For infarction, the strongest seasonal pattern was exhibited for women of all ages and for both sexes in the age groups 65-74 and 75-84, but only the sine component was significant. The peak months for TIA were June-August, while the peak months for infarcts were February-April. Correlations between ambient temperature and each type of stroke were computed. A significant positive correlation for TIA was found (r = 0.57, p = 0.01). After adjusting for a 2-month lag between the low for infarction and the peak for temperature, a significant negative correlation was found (r = -0.64, p = 0.01). No significant correlation was found for hemorrhage. Possible reasons for the opposite relations of TIA and infarct are discussed.