Abstracts
Aims
To measure the incidence and mortality rates of ischemic stroke (IS) subtypes in Joinville, Brazil.
Methods
All first-ever IS patients that occurred in Joinville from January 2005 to December 2006 were identified. The IS subtypes were classified by the TOAST criteria, and the patients were followed-up for one year after IS onset.
Results
The age-adjusted incidence per 100,000 inhabitants was 26 (17-39) for large-artery atherosclerosis (LAA), 17 (11-27) for cardioembolic (CE), 29 (20-41) for small vessel occlusion (SVO), 2 (0.6-7) for stroke of other determined etiology (OTH) and 30 (20-43) for stroke of undetermined etiology (UND). The 1-year mortality rate per 100,000 inhabitants was 5 (2-11) for LAA, 6 (3-13) for CE, 1 (0.1-6) for SVO, 0.2 (0-0.9) for OTH and 9 (4-17) for UND.
Conclusion
In the population of Joinville, the incidences of IS subtypes were similar to those found in other populations. These findings highlight the importance of better detection and control of atherosclerotic risk factors.
stroke; risk factors; Latin America; epidemiology
Objetivos
Avaliar as incidências e as taxas de mortalidade dos subtipos de acidente vascular cerebral (AVC) isquêmico em Joinville, Brasil.
Métodos
A partir do Registro de AVC de Joinville, um banco de dados de base populacional em curso, foram identificados todos os primeiros eventos de AVC isquêmico que ocorreram em Joinville entre janeiro de 2005 e dezembro de 2006. Os subtipos foram classificados pelos critérios de TOAST, e os pacientes foram seguidos por um ano após o evento.
Resultados
A incidência ajustada por idade por 100.000 habitantes foi de 26 (17-39) para a aterosclerose da artéria grande (AGA), 17 (11-27) para cardioembolia (CE), 29 (20-41) para a oclusão de pequena artéria (OPA), 2 (0,6-7) para outras etiologias determinadas (OTR) e 30 (20-43) para etiologia indeterminada (IND). A taxa de mortalidade de 1 ano por 100.000 habitantes foi de 5 (2-11) para AGA, 6 (3-13) para CE, 1 (0,1-6) para OPA, 0,2 (0-0,9) para OTR e 9 (4-17) para IND.
Conclusão
Na população de Joinville, as incidências dos subtipos foram semelhantes aos encontrados em outras populações. Estes resultados destacam a importância de uma melhor detecção e controle dos fatores de risco para aterosclerose.
acidente vascular cerebral; fatores de risco; América Latina; epidemiologia
Previous population-based studies reported the incidence and mortality of ischemic stroke
(IS) subtypes in different settings, most of them on the White population from
high-income countries11 .Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O”Fallon WM, Wiebers
DO. Ischemic stroke subtypes: a population-based study of functional outcome,
survival, and recurrence. Stroke. 2000;31(5):1062-8.
http://dx.doi.org/10.1161/01.STR.31.5.1062
https://doi.org/10.1161/01.STR.31.5.1062...
,22 .Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann
PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria:
incidence, recurrence, and long-term survival in ischemic stroke subtypes: a
population-based study. Stroke. 2001;32(12):2735-40.
http://dx.doi.org/10.1161/hs1201.100209
https://doi.org/10.1161/hs1201.100209...
,33 .White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB et
al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the
Northern Manhattan Study. Circulation. 2005;111(10):1327-31.
http://dx.doi.org/10.1161/01.CIR.0000157736.19739.D0
https://doi.org/10.1161/01.CIR.000015773...
,44 .Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J, Anderson
CS et al. Adelaide stroke incidence study: declining stroke rates but many
preventable cardioembolic strokes. Stroke. 2013;44(5):1226-31.
http://dx.doi.org/10.1161/STROKEAHA.113.675140
https://doi.org/10.1161/STROKEAHA.113.67...
,55 .Palm F, Urbanek C, Wolf J, Buggle F, Kleemann T, Hennerici MG et
al. Etiology, risk factors and sex differences in ischemic stroke in the
Ludwigshafen Stroke Study, a population-based stroke registry. Cerebrovasc Dis.
2012;33(1):69-75. http://dx.doi.org/10.1159/000333417
https://doi.org/10.1159/000333417...
,66 .Schneider AT, Kissela B, Woo D, Kleindorfer D, Alwell K, Miller R
et al. Ischemic stroke subtypes: a population-based study of incidence rates
among blacks and whites. Stroke. 2004;35(7):1552-6.
http://dx.doi.org/10.1161/01.STR.0000129335.28301.f5
https://doi.org/10.1161/01.STR.000012933...
,77 .Hajat C, Heuschmann PU, Coshall C, Padayachee S, Chambers J, Rudd
AG et al. Incidence of aetiological subtypes of stroke in a multi-ethnic
population based study: the South London Stroke Register. J Neurol Neurosurg
Psychiatry. 2011;82(5):527-33.
http://dx.doi.org/10.1136/jnnp.2010.222919
https://doi.org/10.1136/jnnp.2010.222919...
,88 .Bejot Y, Caillier M, Ben Salem D, Couvreur G, Rouaud O, Osseby GV
et al. Ischaemic stroke subtypes and associated risk factors: a French
population based study. J Neurol Neurosurg Psychiatry. 2008;79(12):1344-8.
http://dx.doi.org/10.1136/jnnp.2008.150318
https://doi.org/10.1136/jnnp.2008.150318...
.
In Latin America, there is only one study, which was conducted in a Spanish and Mestizo
population in Iquique, Chile99 .Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F et al.
Incidence, case-fatality rate, and prognosis of ischaemic stroke subtypes in a
predominantly Hispanic-Mestizo population in Iquique, Chile (PISCIS project): a
community-based incidence study. Lancet Neurol. 2007;6(2):140-8.
http://dx.doi.org/10.1016/S1474-4422(06)70684-6
https://doi.org/10.1016/S1474-4422(06)70...
. As far
as we know, no previous study has reported IS subtypes rates among predominantly White
people from Latin America.
The crude annual incidence rate of IS in Brazil range from 62 to 92 per 100,000
inhabitants with a mixed pattern of cardiovascular risk, characterized by high
prevalence of ischemic heart disease, dyslipidemia, hypertension and diabetes1010 .Cabral NL, Gonçalves AR, Longo AL, Moro CH, Costa G, Amaral CH et
al. Incidence of stroke subtypes, prognosis and prevalence of risk factors in
Joinville, Brazil: a 2 year community based study. J Neurol Neurosurg
Psychiatry. 2009;80(7):755-61.
http://dx.doi.org/10.1136/jnnp.2009.172098
https://doi.org/10.1136/jnnp.2009.172098...
,1111 .Minelli C, Fen LF, Minelli DP. Stroke incidence, prognosis, 30-day,
and 1-year case fatality rates in Matão, Brazil: a population-based prospective
study. Stroke. 2007;38(11):2906-11.
http://dx.doi.org/10.1161/STROKEAHA.107.484139
https://doi.org/10.1161/STROKEAHA.107.48...
. Determining the incidence, mortality and risk
factors among IS subtypes may help to improve the public health actions and reduce the
IS disease burden1212 .Martins SC, Pontes-Neto OM, Alves CV, Freitas GR, Oliveira Filho J,
Tosta ED et al. Past, present, and future of stroke in middle-income countries:
the Brazilian experience. Int J Stroke. 2013; 8(Suppl A100):100-6.
http://dx.doi.org/10.1111/ijs.12062
https://doi.org/10.1111/ijs.12062...
,1313 .Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of
delayed epidemiological cardiovascular transition. Int J Stroke, 2009;4(1):40-1.
http://dx.doi.org/10.1111/j.1747-4949.2009.00240.x
https://doi.org/10.1111/j.1747-4949.2009...
.
Our aim was to determine the incidence, mortality and the risk factors for IS subtypes in Joinville, Brazil.
METHOD
Study population
The data were extracted from the Joinville Stroke Registry, an ongoing
prospective population-based data bank started in 2005 in Joinville, southern
Brazil. The city population was 487 047 inhabitants in 2005 and 496 050 in
20061414 .Ministério da Saúde (BR). [Estimativas preliminares para os anos
intercensitários dos totais populacionais, estratificadas por idade e sexo pelo
MS/SGEP/Datasus]. Brasília, DF: Datasus; 2013 [cited 2013 May 20]. Available
from:
http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popsc.def
http://tabnet.datasus.gov.br/cgi/deftoht...
. The city has four
general hospitals and one public institutional care facility, for a total of 840
beds, all four hospitals have computed tomography (CT) services available on a
24-h basis. The predominantly race-ethnicity based on skin color from the
Joinville is White (85.6%)1515 .Instituto Brasileiro de Geografia e Estatística – IBGE. Censo 2010.
Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2013 [cited
2013 May 20]. Available from:
www.censo2010.ibge.gov.br/apps/mapa/
www.censo2010.ibge.gov.br/apps/mapa/...
.
We identified all cases of first-ever IS (FEIS) occurring between January 1, 2005
and December 31, 2006. The detailed methods of cohort recruitment have been
reported previously1010 .Cabral NL, Gonçalves AR, Longo AL, Moro CH, Costa G, Amaral CH et
al. Incidence of stroke subtypes, prognosis and prevalence of risk factors in
Joinville, Brazil: a 2 year community based study. J Neurol Neurosurg
Psychiatry. 2009;80(7):755-61.
http://dx.doi.org/10.1136/jnnp.2009.172098
https://doi.org/10.1136/jnnp.2009.172098...
.
Diagnosis work-up and criteria
Ischemic stroke was defined as the presence of signs of sudden focal or global
cerebral dysfunction that lasted longer than 24 h without any apparent
nonvascular cause, with brain CT revealing hypodense brain areas with a
topography consistent with the clinical syndrome1616 .Aho K, Harmsen P, Hatano S, Marquardsen J, Smirnov VE, Strasser T.
Cerebrovascular disease in the community: results of a WHO collaborative study.
Bull World Health Organ. 1980;58(1):113-30.,1717 .Sociedade Brasileira de Doenças Cerebrovasculares. [Brazilian
guideline for the management of acute stroke]. Arq Neuropsiquiatr.
2001;59(4):972-80. Portuguese.
http://dx.doi.org/10.1590/S0004-282X2001000600026
https://doi.org/10.1590/S0004-282X200100...
.
All patients underwent biochemical, electrocardiographic and radiological tests.
For the diagnosis of IS subtypes, all patients underwent extracranial and
intracranial Doppler ultrasound, transthoracic echocardiography and at least one
brain CT. Whenever possible, imaging of the brain or vessels by magnetic
resonance imaging, transesophageal echocardiography or digital angiography was
performed. The routine for stroke investigation followed the guidelines issued
by the Brazilian Society of Cerebrovascular Diseases1717 .Sociedade Brasileira de Doenças Cerebrovasculares. [Brazilian
guideline for the management of acute stroke]. Arq Neuropsiquiatr.
2001;59(4):972-80. Portuguese.
http://dx.doi.org/10.1590/S0004-282X2001000600026
https://doi.org/10.1590/S0004-282X200100...
. All patients were clinically classified by
the Bamford classification and pathophysiologically classified by the TOAST
classification in large-artery atherosclerosis (LAA), cardioembolic (CE), small
vessel occlusion (SVO), stroke of other determined etiology (OTH) and stroke of
undetermined etiology (UND)1818 .Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification
and natural history of clinically identifiable subtypes of cerebral infarction.
Lancet. 1991;337(8756):1521-6.
http://dx.doi.org/10.1016/0140-6736(91)93206-O
https://doi.org/10.1016/0140-6736(91)932...
,1919 .Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL
et al. Classification of subtype of acute ischemic stroke. Definitions for use
in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke
Treatment. Stroke. 1993;24(1):35-41.
http://dx.doi.org/10.1161/01.STR.24.1.35
https://doi.org/10.1161/01.STR.24.1.35...
.
The following cardiovascular risk factors were analyzed: hypertension, diabetes, coronary artery disease, congestive heart failure, previous antiplatelet and anticoagulant treatment, hypercholesterolemia and current smoking. After discharge, a trained nurse contacted all patients by telephone at 30 days and 12 months after IS onset. This routine investigation was performed after obtaining written informed consent. This study was approved by the ethics committee of the hospitals and universities involved.
Statistical analysis
The data are summarized by their mean and standard deviation for continuous
variables and percentage for categorical variables. The non-parametric
Kruskal-Wallis test was used to compare the different IS subtypes with respect
to categorical variables. The Chi-square test was used to compare the IS
subtypes with respect to the homogeneity of the distribution of the qualitative
variables and to evaluate the independence between the qualitative variables.
The Jarque-Bera test was used to determine how well the continuous variable fit
a normal distribution. Student’s t test for independent samples (normal
distribution) and the Mann-Whitney test were used to examine the differences
between IS subtypes with respect to quantitative variables. The annual incidence
and the mortality rate per 100,000 inhabitants of the different IS subtypes were
analyzed. A 95% confidence interval (CI) was calculated assuming a Poisson
distribution for the number of events. The incidence and mortality rates were
calculated using intercensus data from the 2005–2006 periods as the
denominators1414 .Ministério da Saúde (BR). [Estimativas preliminares para os anos
intercensitários dos totais populacionais, estratificadas por idade e sexo pelo
MS/SGEP/Datasus]. Brasília, DF: Datasus; 2013 [cited 2013 May 20]. Available
from:
http://tabnet.datasus.gov.br/cgi/deftohtm.exe?ibge/cnv/popsc.def
http://tabnet.datasus.gov.br/cgi/deftoht...
. The crude
incidence rates and crude mortality rates were calculated for the years 2005 and
2006, using the sum of the intercensus population from those years as the
denominator and the sum of the cases (deaths) from the same years as the
numerator. The incidence and mortality rates were age adjusted by the direct
method, using the population of Brazil as the standard according to the
intercensus projection for the years 2005-20062020 .Ministério da Saúde (BR). [Estimativas preliminares para os anos
intercensitários dos totais populacionais, estratificadas por idade e sexo pelo
MS/SGEP/Datasus]. Brasília, DF: Datasus; 2013 [cited 2013 May 20]. Available
from:
http://tabnet.datasus.gov.br/cgi/tabcgi.exe?ibge/cnv/popuf.def
http://tabnet.datasus.gov.br/cgi/tabcgi....
and Segi´s World2121 .Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJL, Lozano R, Inone M.
Age standardisation of rates: a new WHO world standard. Geneve: World Health
Organization; 2001 [cited 2013 May 20]. (GPE Discussion Paper Series, vol 31).
Available from: www.who.int/healthinfo/paper31.pdf
www.who.int/healthinfo/paper31.pdf...
population. The results were expressed as
multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs),
[OR(95%CI)]. The age-specific and sex-specific analyses for IS subtypes were
also included.
All tests were two tailed. All data analyses were performed using Microsoft Excel 2010 (Microsoft Corporation, USA).
RESULTS
Incidence
Over 2 years, we registered 610 patients who had IS. Among them, two who had no brain images were excluded. The final sample was 608 patients. The adjusted 2-year cummulative incidence per 100,000 inhabitants for all IS subtypes was 86 (95%CI, 79-93). For all IS subtypes, patients were predominantly White, with percentages ranging from 84% for the OTH subtype to 98% for CE.
Table 1 shows the crude total, age-adjusted and sex-specific incidences. The highest adjusted incidence rates were registered for UND [30(20-43)] and SVO [29(20-41)]. Among the subtypes, OTH had the lowest incidence [2(0.6-7)]. It was observed an increase of incidence rates with age to all IS subtypes and the age-adjusted incidences for the SVO, UND and LAA subtypes were not significantly higher in men for all age groups.
Stroke risk factors
Table 2 shows baseline characteristics and risk factors. In the final sample, 427 (70%) had a previous diagnosis of hypertension, and 287 of those (67%) were in regular treatment before the ictus. Only 107 (25%) of all the hypertensive patients had controlled blood pressure, 90 (21%) of the patients did not have control, and in 90 (21%) the control state was unknown. As expected, compared to all other IS subtype groups, the OTH subtype group contained fewer patients who had hypertension (36.8%; p = 0.004). Diabetes was previously recognized in 30% (184); 52% (96) were using an oral antidiabetic drug, and 21% (39) were using insulin therapy. Dyslipidemia was previously recognized in 25% (149); 56% (83) of these patients were regularly using medication. Current smokers were most prevalent in the LAA subtype group (p = 0.036). Previous CHF (p = 0.041), AF (p < 0.001), the use of antiplatelet medication (p = 0.001) and age (p < 0.001) were most prevalent among CE IS.
Mortality
After one year, the overall age-adjusted mortality rate to IS in the present study was 5 (4-6). Table 3 shows the one-year mortality rate. The highest adjusted mortality rates were registered for UND [9 (4-17)] and CE [6 (3-13)], followed by LAA [5 (2-11)]. The OTH subtype [0.2 (0-0.9)] had a lower mortality rate than the UND, CE and LAA subtypes. In men and women separately, the OTH subtype had a lower mortality rate than all other IS subtypes to both sexes.
DISCUSSION
In Joinville, in the years 2005 and 2006, the higher incidence rates observed in the present study were for UND, SVO and LAA subtypes. The incidence of LAA was almost two-fold higher in men than in women. One year after FEIS, the higher mortality rate was observed for UND and CE subtypes. The OTH subtype presented lower mortality rates than for the other subtypes.
In Iquique, Chile, the world standardized incidence for atherothrombotic IS was
2.8/100,000. However, only 25% of those patients underwent carotid duplex
ultrasound99 .Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F et al.
Incidence, case-fatality rate, and prognosis of ischaemic stroke subtypes in a
predominantly Hispanic-Mestizo population in Iquique, Chile (PISCIS project): a
community-based incidence study. Lancet Neurol. 2007;6(2):140-8.
http://dx.doi.org/10.1016/S1474-4422(06)70684-6
https://doi.org/10.1016/S1474-4422(06)70...
. In our sample, all
patients were assessed using confirmatory methods, and those patients who had an
incomplete investigation were included in the UND subtype. The rates for the SVO, CE
and UND subtypes were similar in both studies99 .Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F et al.
Incidence, case-fatality rate, and prognosis of ischaemic stroke subtypes in a
predominantly Hispanic-Mestizo population in Iquique, Chile (PISCIS project): a
community-based incidence study. Lancet Neurol. 2007;6(2):140-8.
http://dx.doi.org/10.1016/S1474-4422(06)70684-6
https://doi.org/10.1016/S1474-4422(06)70...
.
Despite performance of biochemical, electrocardiographic, extracranial and
intracranial Doppler ultrasound, transthoracic echocardiography and at least one
brain CT in all the patients in the current study, a significant number of strokes
of UND subtype was observed. This was previously reported in epidemiological studies
based on the same pathophysiological classification22 .Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann
PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria:
incidence, recurrence, and long-term survival in ischemic stroke subtypes: a
population-based study. Stroke. 2001;32(12):2735-40.
http://dx.doi.org/10.1161/hs1201.100209
https://doi.org/10.1161/hs1201.100209...
,33 .White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB et
al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the
Northern Manhattan Study. Circulation. 2005;111(10):1327-31.
http://dx.doi.org/10.1161/01.CIR.0000157736.19739.D0
https://doi.org/10.1161/01.CIR.000015773...
,44 .Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J, Anderson
CS et al. Adelaide stroke incidence study: declining stroke rates but many
preventable cardioembolic strokes. Stroke. 2013;44(5):1226-31.
http://dx.doi.org/10.1161/STROKEAHA.113.675140
https://doi.org/10.1161/STROKEAHA.113.67...
,1010 .Cabral NL, Gonçalves AR, Longo AL, Moro CH, Costa G, Amaral CH et
al. Incidence of stroke subtypes, prognosis and prevalence of risk factors in
Joinville, Brazil: a 2 year community based study. J Neurol Neurosurg
Psychiatry. 2009;80(7):755-61.
http://dx.doi.org/10.1136/jnnp.2009.172098
https://doi.org/10.1136/jnnp.2009.172098...
. Recent studies have chosen different criteria for stroke
subtype definition55 .Palm F, Urbanek C, Wolf J, Buggle F, Kleemann T, Hennerici MG et
al. Etiology, risk factors and sex differences in ischemic stroke in the
Ludwigshafen Stroke Study, a population-based stroke registry. Cerebrovasc Dis.
2012;33(1):69-75. http://dx.doi.org/10.1159/000333417
https://doi.org/10.1159/000333417...
,2222 .Marnane M, Duggan CA, Sheehan OC, Merwick A, Hannon N, Curtin D et
al. Stroke subtype classification to mechanism-specific and undetermined
categorie by TOAST, A-S-C-O, and causative classification system: direct
comparison in the North Dublin populaiton stroke study. Stroke.
2010;41(8):1579-86.
http://dx.doi.org/10.1161/STROKEAHA.109.575373
https://doi.org/10.1161/STROKEAHA.109.57...
. These new criteria, combined with advanced diagnostic
techniques, could help reducing the cryptogenic stroke observed in UND subtype2323 .Bang OY, Ovbiagele B, Kim JS. Evaluation of cryptogenic stroke with
advanced diagnostic techniques. Stroke. 2014;45(4):1186-94.
http://dx.doi.org/10.1161/STROKEAHA.113.003720
https://doi.org/10.1161/STROKEAHA.113.00...
. In addition, not all of the
patients in the present study were submitted to Holter monitoring and/or
transesophageal echocardiography. This may partially explain the relative low
incidence of CE subtype Unfortunately, we do not have the exact number of patients
submitted to these methods.
The epidemiology of IS subtypes in White patients from South America was previously
analyzed in two hospital-based studies2424 .Saposnik G, Caplan LR, Gonzalez LA, Baird A, Dasche J, Luraschi A
et al. Differences in stroke subtypes among natives and caucasians in Boston and
Buenos Aires. Stroke. 2000;31(10):23859.
http://dx.doi.org/10.1161/01.STR.31.10.2385
https://doi.org/10.1161/01.STR.31.10.238...
,2525 .Porcello Marrone LC, Diogo LP, Oliveira FM, Trentin S, Scalco RS,
Almeida AG et al. Risk factors among stroke subtypes in Brazil. J Stroke
Cerebrovasc Dis. 2013;22(1):32-5.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.05.022
https://doi.org/10.1016/j.jstrokecerebro...
. In Buenos Aires, Argentina, 42% of all IS subtypes were
SVO2424 .Saposnik G, Caplan LR, Gonzalez LA, Baird A, Dasche J, Luraschi A
et al. Differences in stroke subtypes among natives and caucasians in Boston and
Buenos Aires. Stroke. 2000;31(10):23859.
http://dx.doi.org/10.1161/01.STR.31.10.2385
https://doi.org/10.1161/01.STR.31.10.238...
. In Porto Alegre city,
also in southern Brazil, 32% were LAA2525 .Porcello Marrone LC, Diogo LP, Oliveira FM, Trentin S, Scalco RS,
Almeida AG et al. Risk factors among stroke subtypes in Brazil. J Stroke
Cerebrovasc Dis. 2013;22(1):32-5.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.05.022
https://doi.org/10.1016/j.jstrokecerebro...
. These finding could be related to dietary conditions, the
poor control of risk factors, socioeconomic conditions, age, sex and race2424 .Saposnik G, Caplan LR, Gonzalez LA, Baird A, Dasche J, Luraschi A
et al. Differences in stroke subtypes among natives and caucasians in Boston and
Buenos Aires. Stroke. 2000;31(10):23859.
http://dx.doi.org/10.1161/01.STR.31.10.2385
https://doi.org/10.1161/01.STR.31.10.238...
,2525 .Porcello Marrone LC, Diogo LP, Oliveira FM, Trentin S, Scalco RS,
Almeida AG et al. Risk factors among stroke subtypes in Brazil. J Stroke
Cerebrovasc Dis. 2013;22(1):32-5.
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2011.05.022
https://doi.org/10.1016/j.jstrokecerebro...
. However, the study design was not suitable for
these analyses because non-hospitalized patients had differences in the etiological
subtypes and risk factors compared to hospitalized patients2626 .Schulz UG, Rothwell PM. Differences in vascular risk factors
between etiological subtypes of ischemic stroke: importance of population-based
studies. Stroke. 2003;34(8):2050-9.
http://dx.doi.org/10.1161/01.STR.0000079818.08343.8C
https://doi.org/10.1161/01.STR.000007981...
.
The incidence of LAA in Joinville was similar to that in previous studies of mostly
White populations. In two recent population-based studies focused on a predominantly
White population, a high incidence of the LAA subtype was reported, which might be
related to the stroke pathophysiology classification system used, distinct of the
classic TOAST classification55 .Palm F, Urbanek C, Wolf J, Buggle F, Kleemann T, Hennerici MG et
al. Etiology, risk factors and sex differences in ischemic stroke in the
Ludwigshafen Stroke Study, a population-based stroke registry. Cerebrovasc Dis.
2012;33(1):69-75. http://dx.doi.org/10.1159/000333417
https://doi.org/10.1159/000333417...
,88 .Bejot Y, Caillier M, Ben Salem D, Couvreur G, Rouaud O, Osseby GV
et al. Ischaemic stroke subtypes and associated risk factors: a French
population based study. J Neurol Neurosurg Psychiatry. 2008;79(12):1344-8.
http://dx.doi.org/10.1136/jnnp.2008.150318
https://doi.org/10.1136/jnnp.2008.150318...
. In our study, the incidence observed could be explained by
the prevalence of risk factors and possibly genetic susceptibility, because most of
the Brazilian population has some amount of African genomic ancestry, and it is
recognized that ethnicity is an important contributor to atherosclerotic risk
factors33 .White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB et
al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the
Northern Manhattan Study. Circulation. 2005;111(10):1327-31.
http://dx.doi.org/10.1161/01.CIR.0000157736.19739.D0
https://doi.org/10.1161/01.CIR.000015773...
,66 .Schneider AT, Kissela B, Woo D, Kleindorfer D, Alwell K, Miller R
et al. Ischemic stroke subtypes: a population-based study of incidence rates
among blacks and whites. Stroke. 2004;35(7):1552-6.
http://dx.doi.org/10.1161/01.STR.0000129335.28301.f5
https://doi.org/10.1161/01.STR.000012933...
,77 .Hajat C, Heuschmann PU, Coshall C, Padayachee S, Chambers J, Rudd
AG et al. Incidence of aetiological subtypes of stroke in a multi-ethnic
population based study: the South London Stroke Register. J Neurol Neurosurg
Psychiatry. 2011;82(5):527-33.
http://dx.doi.org/10.1136/jnnp.2010.222919
https://doi.org/10.1136/jnnp.2010.222919...
,2727 .Cardena MM, Ribeiro-Dos-Santos A, Santos S, Mansur AJ, Pereira AC,
Fridman C. Assessment of the relationship between self-declared ethnicity,
mitochondrial haplogroups and genomic ancestry in brazilian individuals. PLoS
One. 2013;8(4):e62005.
http://dx.doi.org/10.1371/journal.pone.0062005
https://doi.org/10.1371/journal.pone.006...
,2828 .Pena SD, Di Pietro G, Fuchshuber-Moraes M, Genro JP, Hutz MH, Kehdy
FS et al. The genomic ancestry of individuals from different geographical
regions of Brazil is more uniform than expected. PLoS One. 2011;6(2):e17063.
http://dx.doi.org/10.1371/journal.pone.0017063
https://doi.org/10.1371/journal.pone.001...
.
In a recent case-control study, hypertension, current smoking, abdominal obesity,
diet and physical activity accounted for more than 80% of the global risk of
stroke2929 .O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P et
al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22
countries (the INTERSTROKE study): a case-control study. Lancet.
2010;376(9735):112-23.
http://dx.doi.org/10.1016/S0140-6736(10)60834-3
https://doi.org/10.1016/S0140-6736(10)60...
. The hypertension
treatment measures taken previous to stroke in the current study (67%) were similar
to those in a recent study (77%)44 .Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J, Anderson
CS et al. Adelaide stroke incidence study: declining stroke rates but many
preventable cardioembolic strokes. Stroke. 2013;44(5):1226-31.
http://dx.doi.org/10.1161/STROKEAHA.113.675140
https://doi.org/10.1161/STROKEAHA.113.67...
.
However, in the Adelaide Study, only 2.5% of hypertension patients did not have it
controlled44 .Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J, Anderson
CS et al. Adelaide stroke incidence study: declining stroke rates but many
preventable cardioembolic strokes. Stroke. 2013;44(5):1226-31.
http://dx.doi.org/10.1161/STROKEAHA.113.675140
https://doi.org/10.1161/STROKEAHA.113.67...
. In contrast, we
found that 21% of previous hypertensive patients, even when regularly treated, did
not have it controlled before hospital admission. In the last decade, measures were
started to reduce the cardiovascular death in Brazil by controlling risk
factors1212 .Martins SC, Pontes-Neto OM, Alves CV, Freitas GR, Oliveira Filho J,
Tosta ED et al. Past, present, and future of stroke in middle-income countries:
the Brazilian experience. Int J Stroke. 2013; 8(Suppl A100):100-6.
http://dx.doi.org/10.1111/ijs.12062
https://doi.org/10.1111/ijs.12062...
,3030 .Schmidt MI, Duncan BB, Silva GA, Menezes AM, Monteiro CA, Barreto
SM et al. Chronic non-communicable diseases in Brazil: burden and current
challenges. Lancet. 2011;377(9781):1949-61.
http://dx.doi.org/10.1016/S0140-6736(10)60834-3
https://doi.org/10.1016/S0140-6736(10)60...
,3131 .Ministério da Saúde (BR). Protocolos clínicos e diretrizes
terapêuticas. Brasília, DF: Ministério da Saúde; 2012 [cited 2013 May 20].
Available from:
http://portal.saude.gov.br/portal/arquivos/pdf/pcdt_trombolise_avc_isq_agudo.pdf
http://portal.saude.gov.br/portal/arquiv...
. However, a Brazilian telephone survey
demonstrated that obesity and diabetes have been continuously increasing in the last
five years, though fortunately smoking has been reduced by 2.1% in the same
period3232 .Ministério da Saúde (BR), Secretaria de Vigilância em Saúde.
Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças
crônicas por inquérito telefônico. Brasília, DF: Ministério da Saúde; 2012
[cited 2013 May 20]. (Série G. Estatística e Informação em Saúde). Available
from:
http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2011_final.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...
.
The higher mortality rates observed for UND and CE were described previously in the
Mestizo sample in Chile99 .Lavados PM, Sacks C, Prina L, Escobar A, Tossi C, Araya F et al.
Incidence, case-fatality rate, and prognosis of ischaemic stroke subtypes in a
predominantly Hispanic-Mestizo population in Iquique, Chile (PISCIS project): a
community-based incidence study. Lancet Neurol. 2007;6(2):140-8.
http://dx.doi.org/10.1016/S1474-4422(06)70684-6
https://doi.org/10.1016/S1474-4422(06)70...
and in
other predominantly White population studies, where the authors also demonstrated
that LAA had elevate mortality rates as shown in the present study11 .Petty GW, Brown RD Jr, Whisnant JP, Sicks JD, O”Fallon WM, Wiebers
DO. Ischemic stroke subtypes: a population-based study of functional outcome,
survival, and recurrence. Stroke. 2000;31(5):1062-8.
http://dx.doi.org/10.1161/01.STR.31.5.1062
https://doi.org/10.1161/01.STR.31.5.1062...
,22 .Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann
PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria:
incidence, recurrence, and long-term survival in ischemic stroke subtypes: a
population-based study. Stroke. 2001;32(12):2735-40.
http://dx.doi.org/10.1161/hs1201.100209
https://doi.org/10.1161/hs1201.100209...
.
This study has some limitations. First, race-ethinicity was based on skin color
classification of the IBGE, responsible for the official census of Brazil3333 .Ministério do Planejamento, Orçamento e Gestão (BR); Instituto
Brasileiro de Geografia e Estatística. Características étnico-raciais da
população: um estudo das categorias de classificação de cor ou raça: 2008. Rio
de Janeiro: Instituto Brasileiro de Geografia e Estatística;
2011.. Most Brazilians, have a
predominantly European genomic ancestry, with some proportion of African and
Amerindian genomic ancestry2727 .Cardena MM, Ribeiro-Dos-Santos A, Santos S, Mansur AJ, Pereira AC,
Fridman C. Assessment of the relationship between self-declared ethnicity,
mitochondrial haplogroups and genomic ancestry in brazilian individuals. PLoS
One. 2013;8(4):e62005.
http://dx.doi.org/10.1371/journal.pone.0062005
https://doi.org/10.1371/journal.pone.006...
,2828 .Pena SD, Di Pietro G, Fuchshuber-Moraes M, Genro JP, Hutz MH, Kehdy
FS et al. The genomic ancestry of individuals from different geographical
regions of Brazil is more uniform than expected. PLoS One. 2011;6(2):e17063.
http://dx.doi.org/10.1371/journal.pone.0017063
https://doi.org/10.1371/journal.pone.001...
. Second, a large number of patients were included in the
UND subtype because of a failure to be put in one of the other groups. Despite the
extensive investigation performed, patients who had cryptogenic etiology were not
distinguished from those who had two or more mechanisms in the UND group. Making
this distinction could improve the understanding of the high incidence and mortality
rates in this subtype. Still, previous studies with similar methodology did not
report the percentage of complementary tests performed, and did not provide
information about the numbers of cryptogenic strokes or of strokes caused by two or
more in the UND subtype22 .Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann
PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria:
incidence, recurrence, and long-term survival in ischemic stroke subtypes: a
population-based study. Stroke. 2001;32(12):2735-40.
http://dx.doi.org/10.1161/hs1201.100209
https://doi.org/10.1161/hs1201.100209...
,44 .Leyden JM, Kleinig TJ, Newbury J, Castle S, Cranefield J, Anderson
CS et al. Adelaide stroke incidence study: declining stroke rates but many
preventable cardioembolic strokes. Stroke. 2013;44(5):1226-31.
http://dx.doi.org/10.1161/STROKEAHA.113.675140
https://doi.org/10.1161/STROKEAHA.113.67...
. Therefore, we understand that these limitations do not
reduce the importance of the present work, the first study in Latin America to
demonstrate the real incidence and mortality rates of ischemic stroke subtypes in a
predominantly White population.
Some risk factors were not analyzed in the current study, primarily abdominal
circumference, diet and physical activity, all of which are clearly recognized as
important risks to control2929 .O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P et
al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22
countries (the INTERSTROKE study): a case-control study. Lancet.
2010;376(9735):112-23.
http://dx.doi.org/10.1016/S0140-6736(10)60834-3
https://doi.org/10.1016/S0140-6736(10)60...
.
Another important issue is the non-differentiation between intracranial and
extracranial atherosclerosis, a disease with high incidence in Black and Hispanic
populations33 .White H, Boden-Albala B, Wang C, Elkind MS, Rundek T, Wright CB et
al. Ischemic stroke subtype incidence among whites, blacks, and Hispanics: the
Northern Manhattan Study. Circulation. 2005;111(10):1327-31.
http://dx.doi.org/10.1161/01.CIR.0000157736.19739.D0
https://doi.org/10.1161/01.CIR.000015773...
. Furthermore, the
current study does not represent the whole population of Brazil; the heterogeneity
present in the country, where some regions are more than 40% Brown (Northeast, North
and Central-West), could change the predominant risk factors and the frequency of
the IS subtypes3333 .Ministério do Planejamento, Orçamento e Gestão (BR); Instituto
Brasileiro de Geografia e Estatística. Características étnico-raciais da
população: um estudo das categorias de classificação de cor ou raça: 2008. Rio
de Janeiro: Instituto Brasileiro de Geografia e Estatística;
2011.. An ongoing
study could help to address this variation in future studies because the sample is
representative of different regions3434 .Aquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB
et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives
and design. Am J Epidemiol. 2012;175(4):315-24.
http://dx.doi.org/10.1093/aje/kwr294
https://doi.org/10.1093/aje/kwr294...
.
In conclusion, the incidence and mortality rates of IS subtypes in Joinville, Brazil, were similar to those from other predominantly White population-based studies. These findings highlight the importance of better detection and control of atherosclerotic risk factors in the Brazilian population.
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28Pena SD, Di Pietro G, Fuchshuber-Moraes M, Genro JP, Hutz MH, Kehdy FS et al. The genomic ancestry of individuals from different geographical regions of Brazil is more uniform than expected. PLoS One. 2011;6(2):e17063. http://dx.doi.org/10.1371/journal.pone.0017063
» https://doi.org/10.1371/journal.pone.0017063 -
29O’Donnell MJ, Xavier D, Liu L, Zhang H, Chin SL, Rao-Melacini P et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet. 2010;376(9735):112-23. http://dx.doi.org/10.1016/S0140-6736(10)60834-3
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32Ministério da Saúde (BR), Secretaria de Vigilância em Saúde. Vigitel Brasil 2011: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília, DF: Ministério da Saúde; 2012 [cited 2013 May 20]. (Série G. Estatística e Informação em Saúde). Available from: http://bvsms.saude.gov.br/bvs/publicacoes/vigitel_brasil_2011_final.pdf
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33Ministério do Planejamento, Orçamento e Gestão (BR); Instituto Brasileiro de Geografia e Estatística. Características étnico-raciais da população: um estudo das categorias de classificação de cor ou raça: 2008. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2011.
-
34Aquino EM, Barreto SM, Bensenor IM, Carvalho MS, Chor D, Duncan BB et al. Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): objectives and design. Am J Epidemiol. 2012;175(4):315-24. http://dx.doi.org/10.1093/aje/kwr294
» https://doi.org/10.1093/aje/kwr294
-
Support: Fundação de Amparo a Pesquisa do Estado de Santa Catarina, University of the Region of Joinville and the Joinville Municipal Health Department.
Publication Dates
-
Publication in this collection
Aug 2015
History
-
Received
10 Dec 2014 -
Received
12 Mar 2015 -
Accepted
02 Apr 2015