bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P616: Characterization of the Associations Between Pre-Diabetes and Diabetes With Occurrence of Stroke by Its Types, Subtypes and Outcomes Among West Africans
Authors: Owolabi Mayowa , SARFO FRED S , Akinyemi Joshua , Wahab Kolawole , Komolafe Edward , Obiako Reginald , Akpalu Albert , Owolabi Lukman , Osaigbovo Godwin , Akinyemi Rufus O , Ovbiagele Bruce
Published: March 2021

Background:
Pre-diabetes and diabetes mellitus (DM) are dysglycemic states associated with stroke occurrence. However, there is limited data from sub-Saharan Africa on the burden and associations between pre-DM and DM and stroke occurrence in a region experiencing an astronomic rise in stroke burden

Purpose:
To characterize the associations between stroke occurrence, types, subtypes, severity and outcome indicators according to glycemic status among West Africans.

Methods:
The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with evidence of an acute stroke. Controls were age-and-gender matched stroke-free adults. Detailed evaluations for vascular, lifestyle, psychosocial factors, stroke severity and outcomes were performed. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

Results:
Among 2,935 stroke cases the mean age was 60.0 ± 14.2 years with 55.2% being males. By glycemic status, 931 (31.7%) were euglycemic, 633 (21.6%) had Pre-diabetes and 1371 (46.7%) had DM. The frequencies of euglycemia, pre-DM and DM among age- and sex-matched stroke-free controls were 69.2%, 13.3% and 17.5% respectively. Pre-diabetes was independently associated with stroke, adjusted odds ratio (95% CI) of 3.68 (2.61 - 5.21) as was having DM, aOR of 4.29 (3.19 - 5.74). The effect size of Pre-DM for ischemic stroke of 3.06 (95% CI: 2.01 - 4.64) was lower than that for DM of 4.82 (3.37-6.89). However, the effect size of Pre-DM for hemorrhagic stroke of 6.81 (95% CI: 3.29 - 14.08) is higher than 3.36 (1.94 - 5.86) for DM. Furthermore, the effect sizes of pre-DM for ischemic stroke subtypes were 9.64 (95% CI: 1.30-71.57) for cardio-embolic stroke, 3.64 (95% CI: 1.80-7.34) for small-vessel occlusive disease and 4.63 (95% CI: 0.80-26.65) for large-vessel disease.

Conclusion:
Every 2 out of 3 stroke cases admitted had a blood glucose abnormality. In addition to confirming the known associations between DM and stroke occurrence, we demonstrate that pre-DM is independently and more potently associated with hemorrhagic than ischemic strokes among West Africans.
Abstract P618: Cardiac Amyloidosis and Risk of Ischemic Stroke
Authors: Witsch Jens , Zhang Cenai , Murthy Santosh B , Buchman Rutrick Stephanie , Goyal Parag , Merkler Alexander E , Navi Babak B , Kamel Hooman
Published: March 2021

Background and Purpose:
Cardiac amyloidosis is increasingly recognized as an important cause of heart failure. Given the paucity of data on cerebrovascular complications of cardiac amyloidosis, we evaluated whether cardiac amyloidosis is associated with ischemic stroke.

Methods:
We performed a retrospective cohort study of Medicare beneficiaries using a 5% sample of inpatient and outpatient claims from January 1, 2008 through October 1, 2015. We identified patients with cardiac amyloidosis using
International Classification of Diseases, 9th Revision, Clinical Modification
(
ICD-9-CM
) code 277.3x in combination with a diagnosis code for heart failure or cardiomyopathy. The primary outcome was ischemic stroke, identified by a previously validated
ICD-9-CM
code algorithm. We used survival statistics to determine incidence rates. Cox proportional hazard analysis, adjusted for demographics, vascular risk factors, and the Elixhauser comorbidity index, was used to study the risk of ischemic stroke.

Results:
Among 1.8 million beneficiaries with mean follow-up of 4.6 years (standard deviation ±2.2), 454 (0.03%) had a diagnosis of cardiac amyloidosis. Patients with cardiac amyloidosis were older (78.1±7.4 versus 73.4±7.7 years) and had a greater comorbidity burden than those without the diagnosis. A total of 63,627 (3.6%) developed an ischemic stroke in the entire cohort. The incidence of ischemic stroke was 47 per 1,000 patients per year in those with cardiac amyloidosis compared to 7.8 per 1,000 patients per year in those without cardiac amyloidosis. In the adjusted Cox regression analysis, cardiac amyloidosis was associated with an increased risk of ischemic stroke (HR, 2.4; 95% confidence interval, 1.6-3.6).

Conclusions:
In a large heterogenous cohort of elderly patients, cardiac amyloidosis was associated with a 2.5-fold heightened risk of ischemic stroke.
Abstract P620: Non-O Blood Group and Risk of Early-Onset Ischemic Stroke in Oral Contraceptive Users
Authors: Chen Laura , Jaworek Thomas , Gaynor Brady , Ryan Kathleen , Liu Allen , Xu Huichun , Mitchell Braxton D , Stine O. C , McArdle Patrick , Fecteau Natalie , Mosher Julia , Dutta Tara M , Nunez Joel , Cole John W , Cronin Carolyn A , Wozniak Marcella A , Phipps Michael S , Mehndiratta Prachi , Chaturvedi Seemant , Kittner Steven J ,   on behalf of the Early-Onset Ischemic Stroke Consortium
Published: March 2021

Introduction:
While oral contraceptive (OC) use is generally safe, women at higher risk for vascular disease are advised to use alternative forms of contraception. Smoking, a prothrombotic factor, is a contraindication for OC use in women over age 35. ABO blood group, specifically the non-O blood types, has also been associated with thrombosis risk. We therefore hypothesized that the effects of smoking and OC use on stroke risk would be accentuated in women with non-O blood groups.

Methods:
Using data from the Genetics of Early Onset Stroke Study, we used 3 polymorphisms within the ABO locus to classify blood group type in women under age 50, including 347 cases and 383 controls. Logistic regression was used to assess the stroke risk of current OC use, defined as use within 30 days, adjusted for other risk factors, and stratified by O and non-O blood group type.

Results:
Of the 347 women with early-onset stroke, 45% had African ancestry, 51% had European ancestry, and 4% had other ancestry. The median age was 42 years. After adjusting for race, age, hypertension, diabetes, migraines and aura, and smoking status, the odds ratio (OR) for stroke for smoking alone and OC use alone were 3.0 (95% CI 2.1-4.2) and 3.7 (95% CI 1.7-8.4), respectively in this population. Blood group (O vs non-O) did not appreciably alter the magnitude of these associations. However, the joint risk of smoking and OC use was substantially higher in women with blood group non-O (OR = 9.5, 95% CI 3.2-34.9) vs in women with blood group O (OR=4.9, 95% CI 0.4-110.2).

Conclusions:
Our findings are consistent with the possibility that non-O type blood group confers an increased risk of early onset stroke among OC users who smoke. Further studies are needed to confirm or refute this possibility and to determine whether non-O blood type should be considered in assessing the risk of OC use.
Abstract P622: Racial Variation in White Matter Hyperintensity Progression in the ACCORDION MIND Study
Authors: Herman Alison L , De Havenon Adam H , Falcone Guido J , Yaghi Shadi , Prabhakaran Shyam , Sheth Kevin N
Published: March 2021

Introduction:
White matter hyperintensities (WMH) are linked to cognitive decline and stroke. We hypothesized that Black race would be associated with greater WMH progression in the ACCORDION MIND trial.

Methods:
The primary outcome is WMH progression in mL, evaluated by fitting linear regression to WMH volume on the month 80 MRI and including the WMH volume on the baseline MRI. The primary predictor is patient race, with the exclusion of patients defined as “other” race. We also derived predicted probabilities of our outcome for systolic blood pressure (SBP) levels.

Results:
We included 276 patients who completed the baseline and month 80 MRI, of which 207 were white, 48 Black, and 21 Hispanic. During follow-up, the mean number of SBP, LDL, and A1c measurements per patient was 21, 8, and 15. The mean (SD) WMH progression was 3.3 (5.4) mL for blacks, 2.5 (3.2) mL for Hispanics, and 2.4 (3.3) mL for whites. In the multivariate regression model (Table 1), Black, compared to white, patients had significantly more WMH progression (β Coefficient 1.26, 95% CI 0.45-2.06, p=0.002). Hispanic, compared to white, patients did not have significantly different WMH progression (p=0.392), nor was there a difference when comparing Hispanic to Black patients (p=0.162). The predicted WMH progression was significantly higher for Black compared to white patients across a mean SBP of 117 to 139 mm Hg (Figure 1).

Conclusions:
Black diabetic patients in ACCORDION MIND have a higher risk of WMH progression than white patients across a normal range of systolic blood pressure.
Abstract P625: Rate of Hemorrhagic Transformation After Ischemic Stroke and Associated Risk Factors: The Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS)
Authors: Stanton Robert J , Antzoulatos Eleni , Coleman Elisheva R , De Los Rios La Rosa Felipe , Demel Stacie L , ferioli simona , Haverbusch Mary , Jasne Adam , Khoury Jane C , Mackey Jason , Mistry Eva , Slavin Sabreena , Star Michael , Walsh Kyle B , Alwell Kathleen S , Woo Daniel , Kissela Brett M , Kleindorfer Dawn
Published: March 2021

Background:
Hemorrhagic transformation (HT) of ischemic stroke can have devastating consequences, leading to longer hospitalizations, increased morbidity and mortality. We sought to identify the rate of HT in stroke patients not treated with tPA within a large, biracial population.

Methods:
The GCNKSS is a population-based stroke epidemiology study from five counties in the Greater Cincinnati region. During 2015, we captured all hospitalized strokes by screening ICD-9 codes 430-436 and ICD-10 codes I60-I68, and G45-46. Study nurses abstracted all potential cases and physicians adjudicated cases, including classifying the degree of HT. Patients treated with thrombolytics were excluded. Incidence rates per 100,000 and associated 95% confidence intervals (CI) were estimated for HT cases, age and sex adjusted to the 2000 US population. Multiple logistic regression was used to examine risk factors associated with HT.

Results:
In 2015, there were 2301 ischemic strokes included in the analysis. Of these 104 (4.5%) had HT; 23 (22.1%) symptomatic, 55 (52.9%) asymptomatic and 26 (25%) unknown. Documented reasons for not receiving tPA in these patients were: time (71, 68.3%), anticoagulant use (1, 1.0%), other (18,17.3%) and unknown (14, 13.5%), which were not significantly different compared to those without HT. Only 29/104 (18.3%) had HT classified as PH-1 or PH-2. The age, sex and race-adjusted rate of HT was 9.8 (7.9, 11.6) per 100,000. The table shows rates of potential risk factors and the adjusted odds of developing HT. 90 day all-cause case fatality for patients with HT was significantly higher, 27.9% vs. 15.7%, p<0.0001.

Conclusion:
We found that 4.5% of non-tPA treated IS patients had HT. These patients had more severe strokes, were more likely to have abnormal coagulation tests or anticoagulant use, and were more likely to die within 90 days. We also report the first population-based incidence rate of HT in non-tPA treated of 9.8/100,000, a rate similar to the incidence of SAH.
Abstract P628: Long-Term Risk of Ischemic Stroke Among Survivors of Non-Traumatic Subarachnoid Hemorrhage
Authors: Parasram Melvin , Parikh Neal S , Merkler Alexander E , Navi Babak B , Kamel Hooman , Zhang Cenai , Murthy Santosh B
Published: March 2021

Background and Purpose:
Non-traumatic subarachnoid hemorrhage (SAH) is associated with poor long-term functional outcomes, but the risk of ischemic stroke among SAH survivors is poorly understood.

Methods:
We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008-2015. The exposure was a diagnosis of SAH, while the outcome was an acute ischemic stroke. The exposure and outcomes were identified using previously validated
ICD-9-CM
diagnosis codes. We excluded patients with prevalent ischemic stroke at the time of SAH diagnosis and those which occurred in the first 90 days after SAH discharge to avoid inclusion of stroke occurring as a medical or procedural complication of SAH. We used Cox regression adjusting for demographics and stroke risk factors to evaluate the association between SAH and long-term risk of ischemic stroke.

Results:
Among 1.3 million Medicare beneficiaries, 3,171 (0.18%) were diagnosed with non-traumatic SAH. During a median follow-up of 5.3 years (interquartile range [IQR], 2.7- 6.7), the cumulative incidence of ischemic stroke was 92 per 1,000 patients per year among patients with SAH, and 21 per 1,000 patients per year in those without SAH. In multivariable Cox regression analysis, SAH was associated with an increased risk of ischemic stroke (hazard ratio, 2.6; 95% confidence interval, 2.4-2.8) as compared to beneficiaries without SAH.

Conclusions:
In a large, heterogeneous national cohort of elderly patients, we found that survivors of SAH had more than double the long-term risk of ischemic stroke as compared to those without SAH. SAH survivors should be closely monitored and risk stratified for ischemic stroke.
Abstract P630: Detection of Atrial Fibrillation by Prolonged Cardiac Monitoring in Cryptogenic and Known Stroke Etiology
Authors: krawczyk Michal , Fridman Sebastián , Bres Bullrich Maria , Shah Palak , Vargas-Gonzalez Juan C , Mirian Ario , Lippert Corbin , Beauchamp Beth , Sposato Luciano A
Published: March 2021

Introduction:
Approximately 25% of strokes are classified as cryptogenic (CS), while greater than 50% have an identifiable or ‘known’ etiology (KS). Several studies have demonstrated that prolonged cardiac monitoring (PCM) after cryptogenic stroke substantially increases the detection of atrial fibrillation (AF), but the yield of PCM in KS stroke is unknown. As a result, the majority of guidelines recommend restricting PCM to patients with cryptogenic stroke. If the detection of AF in KS is no different to cryptogenic stroke, it would suggest that this group too would similarly benefit from PCM, with the potential to impact therapeutic decisions (e.g. initiating anticoagulation).

Methods:
In a cross-sectional study, we compared AF detection by PCM (minimum of 48 hrs) between CS and KS patients without a previous diagnosis of AF. We developed a multivariate logistic regression model by including known and significant clinical, echocardiographic, and radiological factors known to be associated with the detection of AF. We reported results as odds ratios (OR) and 95% confidence intervals (95% CI).

Results:
We included 561 ischemic stroke patients, 376 with CS and 185 with KS. The median duration of PCM was 167h for CS and 48h for KS. AF was detected in 30 of 376 (8%) CS patients, and 20 of 185 (7.9%) KS patients. Age, history of thyroid disease, clinical presentation of dysarthria, wake-up stroke, and left atrial volume index on echocardiography were significantly associated with a new diagnosis of AF after stroke in the univariable analysis and were thus included in the logistic regression analysis. Additionally, duration of PCM was included in the multivariate model. After adjustment for potential confounders, AF detection by PCM was not significantly higher for CS than KS (OR 0.95, 95% CI 0.25-3.32, P=0.94).

Conclusion:
To the best of our knowledge this is the first study directly comparing the incidence of AF between CS and KS as the pre-specified primary outcome. Our findings suggest that CS and KS patients have similar rates of AF detection by PCM. Future prospective research is required to confirm these findings and to determine the cost-effectiveness of PCM in non-cryptogenic stroke patients.
Abstract P631: The Relationship of Neighborhood Greenness to Stroke/ Transient Ischemic Attack in 249,405 US Medicare Beneficiaries
Authors: Brown Scott C , Aitken William , Lombard Joanna , Wang Kefeng , Rundek Tatjana , Dong Chuanhui , Gutierrez Carolina M , Byrne Margaret M , Toro Matthew , Nardi Maria , Kardys Jack , Parrish Abraham K , Szapocznik Jose
Published: March 2021

Introduction:
Nature exposures represent a novel environmental protective factor for chronic disease, which is understudied with respect to stroke and transient ischemic attack. The purpose of the present study is to investigate the relationship between objectively measured neighborhood greenness (vegetative presence) and Stroke/Transient Ischemic Attack (Stroke/TIA), in a population-based sample of Medicare beneficiaries.

Methods:
The sample was comprised of 249,405 U.S. Medicare beneficiaries ages
>
65 years with the same location (ZIP+4) in Miami-Dade County, Florida, from 2010-2011. Analyses examined the relationship of greenness, measured by mean block-level Normalized Difference Vegetation Index (NDVI) from satellite imagery, to a diagnosis of Stroke/TIA. Hierarchical regression analyses, in a multi-level framework, assessed the relationship of greenness to Stroke/TIA, adjusting successively for individual age, gender, race/ethnicity, neighborhood income, and biological risk factors (diabetes, hypertension, hyperlipidemia). Secondary analyses then examined the relationship of greenness separately for specific diagnoses of Transient Ischemic Attack (TIA), Ischemic Stroke, and Hemorrhagic Stroke, respectively.

Results:
Higher greenness was associated with reduced risk for Stroke/TIA, adjusting for individual sociodemographics and neighborhood income: When compared to individuals residing in the lowest tertile of greenness, those individuals residing in the highest tertile of greenness had a 20% lower odds of Stroke/TIA (OR=0.80; 95% CI: 0.74, 0.86, p<0.0001), as well as a 26% lower odds of TIA (OR=0.74; 95% CI: 0.66, 0.82; p<0.0001) and a 16% lower odds of Ischemic Stroke (OR=0.84; 95% CI: 0.75, 0.95; p=0.0050), but did not have a statistically significantly reduced odds of Hemorrhagic Stroke (OR=0.84; 95% CI: 0.61, 1.16; p=0.2990). Associations were attenuated after adjusting for biological risk factors, suggesting that cardiometabolic risk factors may partly mediate greenness’ relationship to stroke and TIA.

Conclusions:
Neighborhood greenness may be associated with reduced risk of Stroke/TIA. Policies and strategies to increase greenness may be a future means of reducing Stroke/TIA at the population level.
Abstract P634: Contemporary Trends of Oral Anticoagulant Utilization Among Texas Medicare Beneficiaries With Atrial Fibrillation
Authors: Kim Youngran , Krause Trudy , Gurol Edip , McCullough Louise D , Vahidy Farhaan S
Published: March 2021

Introductions:
Underutilization of oral anticoagulation (OAC) drugs among atrial fibrillation (AF) patients has been reported. We provide contemporary trends for utilization of warfarin and novel OACs (NOACs) among Medicare beneficiaries with AF in Texas.

Methods:
Using Texas Medicare Fee-for-Service claims data for 2014-2017, AF patients were identified if they had at least one inpatient or two outpatient claims with a diagnosis of AF using ICD 9/10 codes. AF patients having any medical claims with ICD 9/10 or CPT codes indicating vulvar stenosis or the presence of valve replacement were excluded. OACs included warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban and the use of a drug was assumed if the prescription was filled. The percentage of patients on OAC among AF patients, who were enrolled in Medicare Part D in the measurement year were reported with 95% CI and p-value for trends both overall and by CHA
2
DS
2
-VASc score and renal function.

Results:
Of 216,602 AF patients, 57% did not receive any OAC during any measurement year. Overall OAC utilization increased from 35.8% (35.4-36.2) in 2014 to 41.6 % (41.3-41.8) in 2017 (p <0.001). This increase was driven by NOAC use which increased from 18.6% (18.3-18.9) in 2014 to 29.3% (29.0-29.5) in 2017 (p <0.001) while the proportion of warfarin users decreased from 17.2% (16.9-17.5) in 2014 to 12.3% (12.1-12.5) in 2017 (p <0.001). Increasing trends for NOAC use and decreasing trends for warfarin were observed regardless of CHA
2
DS
2
-VASc scores and levels of renal function.

Conclusions:
The OAC use has been increasing but about 6 out of 10 AF patients do not receive OAC despite high CHA
2
DS
2
-VASc scores. Targeted strategies are required to address OAC underutilization among AF patients.
Abstract P636: Social Determinants of Stroke Hospitalization and Mortality in the United States
Authors: Yadav Randhir Sagar , Chaudhary Durgesh , Shahjouei Shima , Li Jiang , Abedi Vida , Zand Ramin
Published: March 2021

Introduction:
Stroke hospitalization and mortality are influenced by various social determinants. This ecological study aimed to determine the associations between social determinants and stroke hospitalization and outcome at county-level in the United States.

Methods:
County-level data were recorded from the Centers for Disease Control and Prevention as of January 7, 2020. We considered four outcomes: all-age (1) Ischemic and (2) Hemorrhagic stroke Death rates per 100,000 individuals (ID and HD respectively), and (3) Ischemic and (4) Hemorrhagic stroke Hospitalization rate per 1,000 Medicare beneficiaries (IH and HH respectively).

Results:
Data of 3,225 counties showed IH (12.5 ± 3.4) and ID (22.2 ± 5.1) were more frequent than HH (2.0 ± 0.4) and HD (9.8 ± 2.1). Income inequality as expressed by Gini Index was found to be 44.6% ± 3.6% and unemployment rate was 4.3% ± 1.5%. Only 29.8% of the counties had at least one hospital with neurological services. The uninsured rate was 11.0% ± 4.7% and people living within half a mile of a park was only 18.7% ± 17.6%. Age-adjusted obesity rate was 32.0% ± 4.5%. In regression models, age-adjusted obesity (OR for IH: 1.11; HH: 1.04) and number of hospitals with neurological services (IH: 1.40; HH: 1.50) showed an association with IH and HH. Age-adjusted obesity (ID: 1.16; HD: 1.11), unemployment (ID: 1.21; HD: 1.18) and income inequality (ID: 1.09; HD: 1.11) showed an association with ID and HD. Park access showed inverse associations with all four outcomes. Additionally, population per primary-care physician was associated with HH while number of pharmacy and uninsured rate were associated with ID. All associations and OR had p ≤0.04.

Conclusion:
Unemployment and income inequality are significantly associated with increased stroke mortality rates.
Abstract P637: Blood Pressure Stability Has a Closer Relationship With Atherosclerosis Burden of Carotid Sinuses Than Atherosclerosis Burden of Aortic Arch
Authors: Ma Xin , Kong Qi , Wang Chen , Du Xiangying
Published: March 2021

Background:
Instable blood pressure (BP) increased vascular risk independently of high BP level, which might be partially attributed to impaired arterial baroreflex. The receptors of baroreflex mainly distributed at carotid sinuses and aortic arch, where atherosclerosis (AS) is common in patients with ischemic stroke (IS) and potentially blunts the baroreflex. We aimed to test whether AS conditions of carotid sinuses and aortic arch would equally indicate BP instability in IS patients.

Methods:
The daytime and nighttime standard derivations (SDs) of systolic BP (SBP) and diastolic BP (DBP) were recorded by ambulatory BP monitoring on the sixth day after IS to measure BP stability (higher SD indicates less stability). Using computed tomography angiography, AS conditions of carotid sinuses (6 segments) and aortic arch (4 segments) were scored based on AS percentage of each segment circumference (0, none; 1, <25%; 2, 25%~49%; 3, 50%~74%; 4, ≥75%) and summed into “carotid sinuses AS burden (CSAB)” and “aortic arch AS burden (AAAB)”. AS conditions of cervicocephalic arteries were also scored.

Results:
Of the 245 patients with IS, 65.7% had carotid sinuses AS and 69.4% had aortic arch AS. Daytime SBP SD was positively correlated with CSAB (
r
=0.230;
P
<0.001) rather than AAAB (
P
=0.103). Patients with CSAB above the median had significantly higher daytime SBP SD than those with less CSAB (median 14 mmHg vs. 12 mmHg,
P
=0.001). CSAB remained related to
ln-
transformed daytime SBP SD after adjusting for age, sex, vascular risk factors, weighted 24-hour means of SBP and DBP, and cervicocephalic AS score (adjusted
B
=0.012; 95% CI, 0.004-0.020). In contrast, DBP SD and nighttime SBP SD had no statistically significant association with both CSAB and AAAB.

Conclusions:
Higher CSAB was independently associated with SBP instability during the daytime, while AAAB was less relevant to BP stability. Compared with AAAB, evaluating CSAB might be more important in the prediction of BP instability.
Abstract P638: Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Emergency Department Presentation Within a Population
Authors: Aziz Yasmin N , Demel Stacie L , Ridha Mohamed , Ades Laura M , Alwell Kathleen S , Woo Daniel , Sucharew Heidi , Ferioli Simona , Khatri Pooja , Adeoye Opeolu M , Flaherty Matthew L , Mackey Jason , De Los Rios La Rosa Felipe , Martini Sharyl , Mistry Eva , Coleman Elisheva R , Jasne Adam S , Slavin Sabreena J , Walsh Kyle B , Star Michael , Haverbusch Mary , Kissela Brett M , Kleindorfer Dawn O
Published: March 2021

Background:
Hypertension is an important risk factor in the development of acute ischemic stroke (AIS). African American (AA) race is strongly associated with both hypertension and uncontrolled hypertension despite treatment, yet little is known about racial differences in presenting blood pressure (BP) in AIS. This study sought to describe differences in presenting BP and acute antihypertensive treatment between AA and white AIS patients who received and did not receive alteplase within a population.

Methods:
Using the Greater Cincinnati/Northern Kentucky Stroke Study (GCNKSS) database for years 2005, 2010 and 2015, we selected patients with a diagnosis of AIS using ICD-9/10 codes in adults ≥ 18 yrs of age presenting to a local ED within 4.5 hrs of symptom onset. Candidates were stratified by race and alteplase use. Socio-demographics, stroke risk factors, stroke severity, BP on arrival, and acute BP treatment were compared using chi-square, t-tests or Wilcoxon rank sum test, as appropriate.

Results (Table 1):
Of 1838 AIS patients included in the analysis, 392 (21%) received IV alteplase. AA patients were younger in both groups who received and did not receive alteplase. On presentation, AA stroke patients had higher diastolic BP. AA patients were more likely to receive 2 or more BP lowering medications compared to white patients in the alteplase treated group and the untreated group.

Conclusion:
AA patients presenting within 4.5 hours of AIS symptom onset are more likely to have elevated diastolic BP and to receive multiple BP lowering medications compared to white patients. These findings were significant regardless of alteplase treatment. To our knowledge, we report the first population-based distribution of BP, and medical treatment of BP, upon presentation to an ED in AIS. Further study is needed to determine if these racial differences in elevated BP and refractoriness of BP and/or aggressive treatment contribute to outcome differences.
Abstract P640: Incident Atrial Fibrillation and Cardiovascular Risk Increases in Patients With Increased Burden of Atrial Ectopy
Authors: Sattin Michael N , Li Zhe , Mrkobrada Marko , Spicer Erin I
Published: March 2021

Introduction:
Atrial fibrillation (AF) is a major risk factor for cerebral ischemia in North America. Atrial ectopy has been associated with incident AF and increased stroke risk on short-duration ECG monitoring. The objective of this study was to characterize the relationship between the burden of atrial ectopy with future AF, stroke, and cardiovascular events on prolonged ECG monitoring.

Methods:
A retrospective, observational study was conducted at a single centre enrolling patients >18 years old referred from TIA clinic. Data was collected from 7- and 14-day Holter monitor reports, patient charts, and cardiac investigations. The final sample included 1124 patients; a subgroup of 759 patients had echocardiograms. Univariate and multivariate logistic regression determined the odds ratio (OR) of developing the composite outcome (AF, TIA/stroke, ACS, death) or secondary outcomes (AF or TIA/stroke).

Results:
The population was high-risk with a mean CHA
2
DS
2
-VASc of 4.0 (±1.8); during 1-year of follow-up, the primary outcome occurred amongst 116 (10.3%) patients. Univariate analysis ORs are displayed in Table 1. There was a statistically significant relationship (p<0.001) between percentage of PACs and the composite outcome (OR 4.066), and AF (11.886) for patients with 2-5% PACs. PAC runs/day was significant if >5/day for AF (OR 5.989, p<0.01) and for the composite (OR 2.231, p<0.05). Long PAC runs (>30 beats) also had significant ORs for AF (2.849, p<0.01) and the composite (5.320, p<0.01). In the subgroup analysis, reduced ejection fraction had an OR of 2.172 (1.407-5.771) for the composite outcome, and atrial dilatation had an OR of 2.778 (1.390-5.551) for AF.

Conclusions:
Increased burden of atrial ectopy is associated with increased odds of developing AF and a composite of cardiovascular events. Patients with increased ectopy should be considered for further, future ECG monitoring and risk stratification with echocardiogram.
Abstract P642: Original and Revised Framingham Stroke Risk Profile Performance in a South Texas Bi-Ethnic Cohort
Authors: Martinez Paola , Birnbaum Lee , Wang Chen-Pin , Seshadri Sudha , Hazuda Helen P
Published: March 2021

Introduction:
The original Framingham Stroke Risk Profile (oFSRP) was designed to predict first-time, 10-year stroke risk and has been updated as the revised FSRP (rFSRP) to reflect current temporal trends in stroke. We assessed the performance of both profiles in a South Texas bi-ethnic cohort which includes European Americans (EA) and Mexican Americans (MA).

Methods:
Both profiles were calculated from a sample of the San Antonio Longitudinal Study of Aging (SALSA) cohort and included 439 subjects (69.4 +/-3.3 years), 265 (60%) women, and 225 (51%) MA. All subjects were aged 65 and older, stroke-free at baseline examination performed from 1992-1996, and followed for up to 12 years. Calibration of both profiles was assessed using the Hosmer-Lemeshow goodness-of-fit test and by comparing the expected with the observed 10-year stroke risks. C-statistics were calculated for the overall SALSA cohort and subgroups by sex and ethnicity with outcome of first-time stroke.

Results:
After a mean follow-up of 9.3 +/- 2.0 years, a total of 55 (12.6%) stroke events occurred. Predicted stroke risks using the oFSRP and rFSRP were 13.2% and 9.1%, respectively (Table). Overall, neither profile demonstrated good calibration (p<0.001); however, by subgroup analysis, the rFSRP had good calibration for stroke events in men (p=.07), women (p=0.14), MA (p=0.08) and EA (p=0.64) (Table). The rFSRP and oFSRP c-statistics for stroke events were 0.81 (0.79-0.82) and 0.78 (0.75-0.80), respectively.

Conclusions:
Compared to the oFSRP, the rFSRP signaled better fit and discriminative ability for predicting 10-year stroke risk in our SALSA cohort sample. Although the rFSRP downgraded stroke risk, our sample spanned the 1990s and early 2000s and thus, may not represent current healthy lifestyle and stroke prevention trends. Our findings support the use of the rFSRP, rather than the oFSRP, for MA in South Texas and highlight the need for further studies with ongoing multi-ethnic cohorts.
Abstract P644: Average Daily Temperature Fluctuation and Hospitalizations and 30-Day Mortality for Stroke and AMI
Authors: Tran Phoebe , Leifheit Erica C , Wang Yun , Goldstein Larry B , Lichtman Judith H
Published: March 2021

Background:
Daily average temperature is associated with increased hospitalizations and mortality for vascular conditions, but it is unclear if daily temperature variation is also associated with these outcomes. We assessed the relationship of daily temperature fluctuations with stroke and AMI hospitalizations and mortality in the elderly.

Methods:
We identified fee-for-service Medicare beneficiaries aged ≥65 y with a primary discharge diagnosis of ischemic stroke or AMI in 2014-2015. Daily temperature data from the National Centers for Environmental Information were linked with Medicare beneficiary data by county and admission date. We fit a Poisson model for the relationship between daily temperature range (county daily maximum minus minimum) and 30-day hospitalizations, adjusted for season and patient demographics. Logistic regression assessed 30-day mortality, adjusted for season, patient demographics, and clinical characteristics. Overall and NOAA climate region-stratified relationships were assessed.

Results:
There were 311,213 unique stroke hospitalizations (mean age 78.8 y, 53% women, 84% White) and 274,703 for AMI (mean age 77.6 y, 45.4% women, 86% White). The national hospitalization rate per 100,000 beneficiary-years was 735 for stroke and 639 for AMI. Thirty-day mortality was 12.0% for stroke and 12.8% for AMI. Each 1
o
F increase in daily temperature range was associated with a 1.26 percentage point (95% CI 1.09-1.44) increase in stroke and a 1.48 percentage point (95% CI 1.43-1.53%) increase in AMI hospitalizations and varied by climate region (figure). Daily temperature range had little influence on stroke or AMI mortality (both OR 1.00, 95% CI 1.00-1.00).

Conclusions:
Daily temperature fluctuations were associated with increased hospitalizations for stroke and AMI. Additional research is needed to understand meteorological effects on vascular events to inform prevention efforts for vulnerable populations.
Abstract P646: The Aging Immune Transcriptome is Linked to Ischemic Stroke Outcome
Authors: Sykes Gina P , Falcione Sarina , Kamtchum Tatuene Joseph , Stamova Boryana , Ander Bradley , Sharp Frank R , Jickling Glen
Published: March 2021

Background:
Advancing age is associated with changes to the immune system, which affect stroke outcome. We previously demonstrated an age-associated alteration in leukocyte gene expression in patients with ischemic stroke. The aim of this study is to validate these findings in an independent stroke cohort and assess the relationship to stroke outcome.

Methods:
Genes associated with age were identified in a cohort of 57 patients with acute ischemic stroke. Peripheral blood RNA was measured using whole genome microarrays and genes associated with advancing age identified (FDR-corrected p < 0.05, partial correlation coefficient r > |0.3|); age-associated gene expression differences in patients with poor 90-day outcome (mRS < 2) were also compared. Genes were functionally characterized by pathway and enrichment analysis and verified against age-associated genes from two additional stroke cohorts containing a total of 173 patients.

Results:
There were 536 genes associated with age in the new stroke cohort, of which 286 decreased and 253 increased with age. Thirty-nine (39) of the age-associated genes were present in previous stroke cohorts analyzed, including a decrease in CCR6, CXCR5, BLNK and NT5E. A decrease in CXCR5 and CD79B was also identified in patients with poor outcome. Pathways and enriched terms relating to the humoral adaptive system immune system, including B-cell and lymphocyte activation, were among those represented in age-associated genes.

Conclusions:
Age-related changes in leukocyte gene expression were validated in an independent cohort of patients with ischemic stroke. Verified changes include alterations to the humoral immune system and a relationship to stroke outcome. Further investigation of the aging immune system in stroke is warranted.
Abstract P649: Extracranial Hemorrhage in the Setting of Gastrointestinal Or Genitourinary Cancer is Associated With Increased Risk of Ischemic Stroke in Patients With Atrial Fibrillation
Authors: Zhou Eric , Lord Aaron , Boehme Amelia K , Henninger Nils , De Havenon Adam H , Vahidy Farhaan S , Ishida Koto , Torres Jose L , Mistry Eva , Mac Grory Brian C , Sheth Kevin N , Gurol Edip , Furie Karen L , Elkind Mitchell S , Yaghi Shadi
Published: March 2021

Background and Purpose:
Anticoagulation therapy reduces the risk for ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. Patients with GI or GU cancer and AF are at higher risk of bleeding complications with anticoagulation therapy. There is limited knowledge on the risk of first-ever ischemic stroke in AF patients after extracranial hemorrhage (ECH) in patients with gastrointestinal or genitourinary (GI/GU) cancer.

Methods:
We conducted a retrospective study using the California State Inpatient Database (SID) including all non-federal hospital admissions in California from 2005-2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke prior to or at the time of ECH diagnosis. We calculated adjusted hazard ratios (HRs) for ischemic stroke during follow up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and co-morbidities and stratifying patients with ECH based on the presence/absence of a GI/GU cancer.

Results:
We identified 764,257 AF patients (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98,647 (13%) had an ECH-associated hospitalization, and 22,748 patients (3%) developed an ischemic stroke during a mean follow up. Compared to non-ECH patients, patients with ECH in the setting of a GI/GU cancer had a significantly higher risk of incident ischemic stroke (adjusted HR 1.40, 95% CI 1.20-1.64).Whereas there was only a modest increase in ischemic stroke risk in those without GI/GU cancer (adjusted HR 1.09 95% CI 1.05-1.13).

Conclusion:
AF patients hospitalized with ECH in the setting of GI/GU cancer have a particularly high risk of incident ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of non-anticoagulant alternatives such as left atrial appendage closure in this vulnerable population.
Abstract P656: Cardioembolic Risk Factors and Ischemic Stroke a Mendelian Randomization Analysis
Authors: Tian Danyang , Zhang Linjing , Zhuang Zhenhuang , Huang Tao , Fan Dongsheng
Published: March 2021

Background:
Cardioembolic stroke accounts for a large proportion of ischemic stroke. Observational studies have shown that several risk factors are associated with cardioembolic stroke. However, whether such associations reflect causality remains unknown.

Objectives:
We aimed to determine whether established and provisional cardioembolic risk factors are causally associated cardioembolic stroke, and whether they have pathways of causal influence on other ischemic stroke subtypes.

Methods:
Genetic instruments for atrial fibrillation (AF), myocardial infarction (MI), some electrocardiogram (ECG) indices and NT-pro BNP were obtained from large genetic consortiums. Summarized data of ischemic stroke and its subtypes were extracted from the MEGASTROKE consortium. Causal estimates were calculated by applying inverse variance-weighted analysis and other methods.

Results:
Genetically predicted AF was significantly associated with higher odds of ischemic stroke (OR 1.20, 95% CI 1.16-1.24, P=6.53х10
-30
) and cardioembolic stroke (OR 1.95, 95% CI 1.85-2.06, P=8.81х10
-125
). Genetically predicted MI was significantly associated with higher odds of large artery stroke (OR 1.487, 95% CI 1.25-1.77, P=9.53х10
-6
). Suggestive associations were found between genetically determined resting heart rate and higher odds of ischemic stroke (OR 1.01, 95% CI 1.00-1.02, P=0.005), large artery stroke (OR 1.02, 95% CI 1.00-1.04, P=0.026) and cardioembolic stroke (OR 1.02, 95% CI 1.00-1.04, P=0.028). There was no causal association of P-wave terminal force in the precordial lead V1 (PTFVI), P-wave duration (PWD), N-terminal-pro-brain Natriuretic Peptide (NT-pro BNP) or PR interval with ischemic stroke or any subtypes.

Conclusion:
Genetic predisposition to AF and heart rate are associated with cardioembolic stroke. No evidence of causality relationship of MI, PTFVI, PWD, NT-pro BNP and PR interval on cardioembolic stroke is found.
Abstract P659: Pre-Stroke Chads
2
Scores Should Be Associated With Onset Severity and Functional Outcome in Acute Stroke Patients With Atrial Fibrillation During Oral Anticoagulants: A Sub-Analysis of PASTA Registry Study
Authors: Sakai Kenichiro , Suda Satoshi , Ueda Masayuki , Iguchi Yasuyuki , Yagita Yoshiki , Kanzawa Takao , Okubo Seiji , Ohara Nobuyuki , Mizunari Takayuki , Yamazaki Mineo , Nakajima Nobuhito , Kondo Kimito , Fujimoto Shigeru , Inoue Takeshi , Iwanaga Takeshi , Terasawa Yuka , Shibazaki Kensaku , Kono Yu , NAKAJIMA Makoto , Nakajima Masataka , Mishina Masahiro , Adachi Koji , Imafuku Ichiro , Nomura Koichi , Nagao Takehiko , Yaguchi Hiroshi , Okamoto Sadahisa , Osaki Masato , Kimura Kazumi
Published: March 2021

Background and Purpose:
The impact of CHADS
2
score on neurological severity in patients with stroke during oral anticoagulant (OAC) has not yet been elucidated. We investigated the association between pre-stroke CHADS
2
score and severity on admission and functional outcome in acute cardioembolic stroke due to AF during OAC.

Methods:
We conducted an investigator-initiated, multicenter, prospective, observational cohort study, PASTA registry. One thousand forty-three patients with transient ischemic attack, ischemic stroke, and ICH who were taking OACs were prospectively enrolled in 25 medical institutions throughout Japan. We compared the clinical characteristics including severity onset and discharge outcome between low CHADS
2
score group (<2), and high CHADS
2
score group (≥2) in patients with cardioembolic stroke due to AF.

Result:
A total of 548 patients (237 women; median age 80 [quartiles 74-85] years) were enrolled. Of these, there were 76 patients (14%) in low CHADS
2
group and 472 (86%) in high CHADS
2
score group (Fig A). Along with increase of pre-stroke CHADS
2
score, NIHSS score was gradually increased (Fig B). Low CHADS
2
score group was associate with good outcome than high CHADS
2
group (p<0.001, Fig C). Age (p<0.001), male (p<0.001), pre-stroke CHADS
2
score (p<0.001), and initial NIHSS score (p<0.001) were significantly higher in non-excellent outcome (mRS≥2) group than excellent outcome group (mRS<2). In contrast, creatinine clearance and body weight were higher in excellent outcome group (Both p<0.001). Multivariate logistic regression analysis indicated that high pre-stroke CHADS
2
score independently associated with higher NIHSS score (NIHSS score≥6; OR 1.55, 95%CI 1.02-2.36, p=0.041) and non-excellent outcome (OR 1.94, 95%CI 1.01-3.80, p=0.047).

Conclusion:
The present study suggests that the pre-stroke CHADS
2
score should be useful for the prediction of clinical outcomes in patients with cardioembolic stroke due to AF even taking OAC.
Abstract P660: Statin Therapy is Associated With Lower Mortality One Year After Ischemic Stroke: A National Data Linkage Study
Authors: Sterling Kadie-Ann , Turner Melanie , Langhorne Peter , Barber Mark , Macleod Mary J
Published: March 2021

Introduction:
Statins significantly reduce the risk of fatal and non-fatal cardiovascular events in patients with atherosclerotic cardiovascular disease and other high-risk conditions. Current guidelines strongly recommend the use of statins in all eligible patients after an ischaemic stroke, but some patient groups (e.g. elderly, female) still miss out, suggesting more evidence of benefit is still needed.

Aim:
To investigate the effect of statins on one-year mortality outcomes in ischaemic stroke survivors.

Methods:
This retrospective study linked routinely collected health data from the Scottish Stroke Care Audit (SSCA), the Prescribing Information System (PIS) and the Scottish Morbidity Record (SMR) 01 and mortality data from the National Records of Scotland (NRS). The study population included patients from January 2010 to December 2015 who survived an ischaemic stroke. Statin therapy was defined as at least one statin prescription within six months of the stroke event (yes/no) and data modelled to analyse the effect on mortality outcomes up to one year. Data were analysed using Cox proportional hazards in SPSS version 25.

Results:
The study population included 24 499 patients discharged from hospital to their usual place of residence within thirty days after an incident ischaemic stroke and who survived to six months. Statins were prescribed to 21 356 (87.2%) within the first six months in the community setting. Patients on a statin were more likely to be younger [median age 71.2 (IQR 61.1 to 79.5) versus 73.2 (IQR 55.5 to 83.2) years] and male (53.7% versus 46.3%) but had similar Charlson Comorbidity Index scores compared with patients not prescribed a statin. Post stroke statin therapy significantly reduced the risk of death [HR 0.49 (95% confidence interval 0.41 to 0.59)] when adjusted for age, sex, prior statin therapy and baseline stroke severity. Separate analysis also revealed similar benefits regardless of age and sex.

Conclusion:
Post-stroke statin therapy was associated with a reduced risk of death within one year even accounting for age, sex or comorbidities. This reinforces the benefit of current guideline implementation.
Abstract P665: Different Predictive Factors for Early Neurological Deterioration Based on the Location of Single Subcortical Infarction
Authors: Nam Ki-woong , Kwon Hyung-min , Lee Yong-Seok
Published: March 2021

Introduction:
Patients with single subcortical infarction (SSI) have relatively favorable prognosis, but they often experience early neurological deterioration (END) in a clinical course. In addition, SSI is considered to differ in its prognosis and mechanism depending on the location of the lesion.

Hypothesis:
We compared the predictors for END in patients with SSI according to the location of the lesion.

Methods:
We included consecutive patients with SSI within 72 hours of symptom onset between 2010 and 2016. END was defined as an increase of ≥ 2 in the total NIHSS score or ≥ 1 in the motor NIHSS score within the first 72 hours of admission. Along with the analysis of the entire SSI patients, we also analyzed the predictors for END in the proximal/distal SSI patients and the anterior/posterior circulation SSI patients.

Results:
A total of 438 patients with SSI were evaluated. In multivariable analysis, initial NIHSS score [adjusted odds ratio (aOR) = 1.36, 95% confidence interval (CI): 1.15-1.60], pulsatility index (PI) (aOR = 1.25, 95% CI: 1.03-1.52), parent artery disease (PAD) (aOR = 2.14, 95% CI: 1.06-4.33), and neutrophil to lymphocyte ratio (NLR) (aOR = 1.24, 95% CI: 1.04-1.49) were positively associated with END. In patients with proximal SSI, initial NIHSS score, PI, PAD, and NLR showed positive associations with END. Meanwhile, no variable related to END was found in distal SSI. When we compared the predictors for END based on the involved vascular territory, initial NIHSS score and NLR were significantly associated with END in the anterior circulation. On the other hand, patient with SSI in the posterior circulation showed PI and PAD as independent predictors of END.

Conclusions:
Initial NIHSS score, PI, PAD, and NLR were associated with END in patients with SSI. The frequency and predictors for END were different depending on the location of SSI lesion.