Risk of hemorrhagic stroke in Asian American ethnic groups.
ABSTRACT The sparseness of prospective data about hemorrhagic stroke (HS) risk among Asian American ethnic groups led to the investigation of 128,934 persons with self-classified ethnicity at health examinations in 1978-1985. Subsequently, 431 persons were hospitalized for HS; 31% for subarachnoid hemorrhage (SAH) and 69% for intracerebral hemorrhage (ICH). Ethnic predictors of HS were studied by Cox proportional hazard models with 7 covariates. With whites as reference, the adjusted relative risk (95% CI) of all Asians for HS was 1.6 (1.1-2.3, p = 0.01), due substantially to increased risks of SAH in Japanese people and ICH in Filipinos. These data mandate emphasis upon preventive measures in these groups.
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ABSTRACT: Atrial fibrillation (AF) is an emerging epidemic in both high-income and low-income countries, mainly because of global population aging. Stroke is a major complication of AF, and AF-related ischemic stroke is more disabling and more fatal than other types of ischemic stroke. However, because of concerns about bleeding complications, particularly intracranial hemorrhage, and the limitations of a narrow therapeutic window, warfarin is underused. Four large phase III randomized controlled trials in patients with non-valvular AF (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) demonstrated that new oral anticoagulants (NOACs) are superior or non-inferior to warfarin as regards their efficacy in preventing ischemic stroke and systemic embolism, and superior to warfarin in terms of intracranial hemorrhage. Among AF patients receiving warfarin, Asians compared to non-Asians are at higher risk of stroke or systemic embolism and are also more prone to develop major bleeding complications, including intracranial hemorrhage. The extra benefit offered by NOACs over warfarin appears to be greater in Asians than in non-Asians. In addition, Asians are less compliant, partly because of the frequent use of herbal remedies. Therefore, NOACs compared to warfarin may be safer and more useful in Asians than in non-Asians, especially in stroke patients. Although the use of NOACs in AF patients is rapidly increasing, guidelines for the insurance reimbursement of NOACs have not been resolved, partly because of insufficient understanding of the benefit of NOACs and partly because of cost concerns. The cost-effectiveness of NOACs has been well demonstrated in the healthcare settings of developed countries, and its magnitude would vary depending on population characteristics as well as treatment cost. Therefore, academic societies and regulatory authorities should work together to formulate a scientific healthcare policy that will effectively reduce the burden of AF-related stroke in this rapidly aging society.05/2014; 16(2):73-80. DOI:10.5853/jos.2014.16.2.73
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ABSTRACT: Because of its association with death and disability, stroke is a focus of outcomes in atrial fibrillation (AF) research. International Classification of Disease-Ninth Revision (ICD-9) edition codes are commonly used to identify stroke in research, particularly in large administrative data. We sought to assess the validity of ICD-9 codes in stroke case ascertainment and for AF across 3 institutions. Participating centers included Boston Medical Center (safety net hospital), Geisinger Health System (rural Pennsylvania), and the University of Alabama (academic center in the southeastern stroke belt). ICD-9 codes for ischemic stroke (433-434, 436) and intracranial hemorrhage (430-432) identified 1812 stroke cases with an associated code for AF (427.31) from 2006 to 2010. Cases were vetted through chart review with final adjudication by a stroke neurologist. Review considered 94.2% of ICD-9 identified stroke cases valid with decreased accuracy for concurrent AF diagnosis (82.28%) and stroke attributable to AF (72.8%). Among events with "without infarction" modifiers, 7.2% were valid strokes. ICD-9 stroke code accuracy did not differ by stroke type or site. Stroke code 434 displayed higher accuracy than 433 (94.4% versus 85.2%; P<0.01), and primary stroke codes were more accurate than nonprimary codes (97.2% versus 83.7%; P<0.0001). Using ICD-9 stroke and AF codes to identify patients with stroke plus AF resulted in inaccuracies. Given the expanded financial and policy implications of patient-oriented research, conclusions derived solely from administrative data without validation of outcome events should be interpreted with caution. © 2015 American Heart Association, Inc.Circulation Cardiovascular Quality and Outcomes 01/2015; 8(1):8-14. DOI:10.1161/CIRCOUTCOMES.113.000371 · 5.66 Impact Factor
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ABSTRACT: Data on dementia in Native Hawaiians and many Asian subgroups in the United States are limited. Inpatients with dementia have higher costs, longer stays, and higher mortality than those without dementia. This study compared rates of inpatients with a dementia diagnosis for disaggregated Asian and Pacific Islanders (Native Hawaiian, Chinese, Japanese, Filipino) with those of whites according to age (18-59, 60-69, 70-79, 80-89, ≤90) for all adults hospitalized in Hawai'i between December 2006 and December 2010; 13,465 inpatients with a dementia diagnosis were identified using International Classification of Diseases, Ninth Revision, codes. Rates were calculated using population size denominators derived from the U.S. Census. In all age categories, Native Hawaiians had the highest unadjusted rates of inpatients with dementia and were more likely to have a dementia diagnosis at discharge at younger ages than other racial and ethnic groups. In adjusted models (controlling for sex, residence location, and insurer), Native Hawaiian inpatients aged 18 to 59 (aRR = 1.50, 95% CI = 0.84-2.69), 60 to 69 (aRR = 2.53, 95% CI = 1.74-3.68), 70 to 79 (aRR = 2.19, 95% CI = 1.78-2.69), and 80 to 89 (aRR = 2.53, 95% CI = 1.24-1.71) were significantly more likely to have dementia than whites, as were Japanese aged 70 to 79 (aRR = 1.30, 95% CI = 1.01-1.67), 80 to 89 (aRR = 1.29, 95% CI = 1.05-1.57), and 90 and older (aRR = 1.51, 95% CI = 1.24-1.85). Japanese aged 18 to 59 had were significantly less likely to have dementia than whites (aRR = 0.40, 95% CI = 0.17-0.94). These patterns have important public health and clinical care implications for Native Hawaiians and older Japanese populations. Future studies should consider whether preventable medical risk, caregiving, socioeconomic conditions, genetic disposition, or a combination of these factors are responsible for these findings. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.Journal of the American Geriatrics Society 12/2014; 63(1). DOI:10.1111/jgs.13182 · 4.22 Impact Factor