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Multiple risk factors raise ischaemic stroke risk
comparable to AF in the elderly:
A large Chinese insurance analysis from 425,600 Chinese individuals without prior stroke
Guo Yutao, MD, PhDAssistant Professor
Medical School of Chinese PLAPhysician, Cardiovascular Medicine
PLA General HospitalBeijing, China
2015 ESC Congress-Registry I Atrial Fibrillation session
Declarations of Interest•The study was supported by Chinese PLA Healthcare Foundation (13BJZ40), Beijing Natural Science Foundation (7142149), and National Natural Science Foundation of China (H2501)
Ethic Approval•Approval number: 13BJZ40
•IRB: Medical Ethics Committee of PLA General Hospital
•Registry number of IRB by China Food and Drug Administration :XZF20120145
Introduction
US age-standardized death rates from CVD
A stroke/40 seconds 1 stroke death/ 20 death
Sino-MONICA-Beijing: Age standardized incidence rates of
ischaemic stroke in population aged 25-74 years
Mozaffarian D, et al. Circulation. 2015 Jan 27;131(4):e29-322Zhao D, et al. Stroke. 2008 Jun;39(6):1668-74
Stroke is a major burden in elderly patients in China
Elderly population
Primary prevention
China
• 75% of strokes occur in patients age ≥65
• >76% of strokes are first events
• Stroke mortality in Asia is higher than in
Europe or North America
Kim JS. Int J Stroke. 2014 Oct; 9(7):856-7.Meschia JF, et al. Stroke. 2014 Dec; 45(12):3754-832.
Mozaffarian D, et al. Circulation. 2015 Jan 27;131(4):e29-322
Objective
• To investigate incident ischaemic stroke in relation to age and increasing cardiovascular risk factor(s), and the incremental impact of AF on stroke rates
• To explore the risk factors for developing incident stokes in the general population without prior stroke
Major risk factors (i.e. AF) for stroke have been identified, however, how AF incrementally contributes to the risk for ischaemic stroke with
increasing age and multiple cardiovascular risk factors is unclear
Major risk factors (i.e. AF) for stroke have been identified, however, how AF incrementally contributes to the risk for ischaemic stroke with
increasing age and multiple cardiovascular risk factors is unclear
The accuracy and sensitivity of identifying AF using ICD codes has been tested in the
large Chinese insurance dataset. Guo Y, et al. Chest. 2014 Jun 12. doi:
10.1378/chest.14-0321
Patient flow chart
Results
Number Patient-yearsTotal individuals 425,600 1,864,232
Non-AF population 424,720 1,859,589
AF population 880 4,643
Ischaemic stroke 13,242 64,834
Mean time to ischaemic stroke was 4.93 (standard deviation(SD) 3.44) years, with a median of 5 (IQR 1-8) years.
The follow-up period
Observational period
Stroke incidence (per 100 person-years, 95% CI) stratified by
CHA2DS2-VASc score in non-AF and AF populations
Ischemic stroke as classified by CHA2DS2-VASc
scores
With increasing CHA2DS2-VASc scores, ischaemic stroke increased in both non-AF and AF populations
With increasing CHA2DS2-VASc scores, ischaemic stroke increased in both non-AF and AF populations
Ischemic stroke (n=13242) CHA2DS2-VASc Non-AF (n=424720) AF (n=880) 0 0.31 (0.29-0.32) 0.39 (0.11-1.40) 1 0.59 (0.57-0.60) 0.19 (0.06-0.55) 2 1.30 (1.25-1.34) 1.35 (0.79-2.30) 3 1.61 (1.55-1.67) 1.77 (1.14-2.75) 4 1.86 (1.71-2.02) 2.89 (1.62-5.10) 5 3.17 (2.48-4.04) 4.23 (1.45-11.70) Total 0.35 (0.34-0.35) 1.11 (0.84-1.45) p value for trend <0.001 <0.001
* 95% CI: confidential interval
Stroke and CHA2DS2-VASc scores
For patients age ≥75, there was no significant difference in mean CHA2DS2-VASc score between the non-AF and AF
population
* Compared between non-AF and AF individuals. SD: Standard deviation
CHA2DS2-VASc scores in the elderly
CHA2DS2-VASc scores in non-AF and AF individuals in relation to age group
Age Whole population
(n= 425600)
Non-AF (n=424720)
AF (n=880)
P*
<65, n=348431 (mean, SD)
0.69(0.66) 0.68(0.66) 1.07(0.76) <0.001
65-74, n=56952 (mean, SD)
2.34(0.88) 2.34(0.88) 2.68(0.97) <0.001
≥ 75, n=20217 (mean, SD)
2.66(0.63) 2.65(0.63) 2.77(0.74) 0.086
Comorbidities were defined as vascular disease (coronary artery disease, peripheral vascular disease), hypertension, diabetes, or heart failure
Compared to non-AF, p<0.05. A: Rate of comorbidities in population aged <65 years. B: Rate of comorbidities in population aged 65 – 74 years. C: Rate of comorbidities in population aged ≥ 75 years.
The AF population more commonly had multiple
morbidities compared to the non-AF population, especially
in the elderly
Distribution of comorbidities in non-AF and AF
The rate of comorbidities in non-AF and AF population stratified by age group
*
*
*
1
2
3
4
5
Stroke incidence in non-AF and AF population. The left X and Y axes show the stroke incidence in non-AF population associated with age and comorbidities, while the right X and Y axis showed the stroke incidence in AF population classified by CHA2DS2-VASc scores. Comorbidities were defined as vascular disease (coronary artery disease, peripheral vascular disease), hypertension, diabetic, or heart failure. Comorbidity=1: any one disease of the four comorbidities. Comorbidities ≥2 : two disease or above of the four comorbidities.
Non-AF population aged over 75 years with multiple comorbidities had the highest risk for the incident stroke, similar to AF population with CHA2DS2-VASc
= 5
AF population: CHA2DS2-VASc score
Multivariate analysis of risk factors for ischaemic stroke in non-AF population and AF population
Hypertension, diabetic, age ≥75 years, and hyperlipidemia also predicted the occurrence of ischaemic stroke in the AF population
Myocardial infarction, aged ≥75 years, hypertension, vascular disease, hyperlipidemia, diabetic, female, and dilated cardiomyopathy were the independent risk factors for ischaemic stroke in the non-AF population
Non-AF population (n=424720) Risk factors Hazard ratio 95% CI P value Dilated cardiomyopathy 4.00 1.00-16.01 0.048 Myocardial infarction 2.93 1.53-5.64 0.001 Age ≥ 75 years 2.77 2.67-2.87 <0.001 Hypertension 1.70 1.63-1.78 <0.001 Vascular disease 1.70 1.52-1.90 <0.001 Hyperlipidemia 1.52 1.36-1.69 <0.001 Diabetic 1.28 1.17-1.39 <0.001 Female 1.18 1.14-1.22 <0.001 Renal dysfunction 1.10 0.82-1.47 0.532 Heart failure 0.83 0.54-1.28 0.413 AF population (n=880) Risk factors Hazard ratio 95% CI P value Hyperlipidemia 5.32 1.83-15.45 0.002 Hypertension 3.30 1.83-5.95 <0.001 Diabetic 3.07 1.29-7.34 0.011 Vascular disease 2.80 0.65-11.99 0.165 Age ≥ 75 years 2.78 1.53-5.06 0.001 Female 1.18 0.65-2.11 0.584 Renal dysfunction 1.01 0.13-7.67 0.99 Heart failure 0.42 0.06-3.13 0.399 Myocardial infarction* - - 0.994 Dilated cardiomyopathy* - - 0.978
* 95% CI: confidential interval.
Risk factors for ischaemic stroke
Cumulative hazard of ischaemic stroke associated with CHA2DS2-VASc scores in the non-AF and AF population.(a) Non-AF population (all p<0.001). (b) AF population (all p<0.01). HR: Hazard ratio, 95% CI: Confidential interval.
A B
High risk for ischaemic stroke increases with CHA2DS2-VASc score ≥2
Conclusions Multiple risk factors raise ischaemic stroke risk in non-AF patients,
comparable to that for AF in the elderly
CHA2DS2-VASc score shows the good predictive ability of ischaemic stoke in the ‘general’ population, AF and non-AF
Prevention strategies for stroke adapted to the changing risk profile of geographical difference are needed to reduce the stroke burden
2015 ESC Congress-Registry I Atrial Fibrillation session
• Not “Specific" risk factor, but multiple risk factors contribute to stroke• Not “Independent effect”, but concomitant effects of
risk factors confer to stroke
The key issue of stroke risk is not if the patient suffers AF or not, but the numbers of risk factors
and the weight of these risk factors
Take home message
Multiple risk factors and ischaemic stroke in the elderly Asian population with and without atrial fibrillation.An analysis of 425,600 Chinese individuals without prior stroke
Yutao Guo1; Hao Wang1; Yingchun Tian4; Yutang Wang1; Gregory Y. H. Lip1,2,3
1Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China; 2University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK; 3Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; 4Department of Gerontology, Second People’s Hospital, Yunnan Province, China
Thromb Haemostat 2015 http://dx.doi.org/10.1160/TH15-07-0577
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