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      Differences in risk factors for 3 types of stroke : UK prospective study and meta-analyses

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          Abstract

          Objective

          To compare associations of behavioral and related factors for incident subarachnoid hemorrhage and intracerebral hemorrhage and ischemic stroke.

          Methods

          A total of 712,433 Million Women Study participants without prior stroke, heart disease, or cancer reported behavioral and related factors at baseline (1999–2007) and were followed up by record linkage to national hospital admission and death databases. Cox regression yielded adjusted relative risks (RRs) by type of stroke. Heterogeneity was assessed with χ 2 tests. When appropriate, meta-analyses were done of published prospective studies.

          Results

          After 12.9 (SD 2.6) years of follow-up, 8,128 women had an incident ischemic stroke, 2,032 had intracerebral hemorrhage, and 1,536 had subarachnoid hemorrhage. In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01, 95% confidence interval [CI] 1.84–2.20), risk of intracerebral hemorrhage was increased slightly (RR 1.31, 95% CI 1.04–1.65), but risk of subarachnoid hemorrhage was reduced (RR 0.43, 95% CI 0.26–0.69) (heterogeneity by stroke type, p < 0.0001). Stroke incidence was greater in women who rated their health as poor/fair compared to those who rated their health as excellent/good (RR 1.36, 95% CI 1.30–1.42). Among 565,850 women who rated their heath as excellent/good, current smokers were at an increased risk of all 3 stroke types, (although greater for subarachnoid hemorrhage [≥15 cigarettes/d vs never smoker, RR 4.75, 95% CI 4.12–5.47] than for intracerebral hemorrhage [RR 2.30, 95% CI 1.94–2.72] or ischemic stroke [RR 2.50, 95% CI 2.29–2.72]; heterogeneity p < 0.0001). Obesity was associated with an increased risk of ischemic stroke and a decreased risk of hemorrhagic stroke (heterogeneity p < 0.0001). Meta-analyses confirmed the associations and the heterogeneity across the 3 types of stroke.

          Conclusion

          Classic risk factors for stroke have considerably different effects on the 3 main pathologic types of stroke.

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          50-year trends in smoking-related mortality in the United States.

          Michael Thun, Brian Carter, Diane Feskanich … (2013)
          The disease risks from cigarette smoking increased in the United States over most of the 20th century, first among male smokers and later among female smokers. Whether these risks have continued to increase during the past 20 years is unclear. We measured temporal trends in mortality across three time periods (1959-1965, 1982-1988, and 2000-2010), comparing absolute and relative risks according to sex and self-reported smoking status in two historical cohort studies and in five pooled contemporary cohort studies, among participants who became 55 years of age or older during follow-up. For women who were current smokers, as compared with women who had never smoked, the relative risks of death from lung cancer were 2.73, 12.65, and 25.66 in the 1960s, 1980s, and contemporary cohorts, respectively; corresponding relative risks for male current smokers, as compared with men who had never smoked, were 12.22, 23.81, and 24.97. In the contemporary cohorts, male and female current smokers also had similar relative risks for death from chronic obstructive pulmonary disease (COPD) (25.61 for men and 22.35 for women), ischemic heart disease (2.50 for men and 2.86 for women), any type of stroke (1.92 for men and 2.10 for women), and all causes combined (2.80 for men and 2.76 for women). Mortality from COPD among male smokers continued to increase in the contemporary cohorts in nearly all the age groups represented in the study and within each stratum of duration and intensity of smoking. Among men 55 to 74 years of age and women 60 to 74 years of age, all-cause mortality was at least three times as high among current smokers as among those who had never smoked. Smoking cessation at any age dramatically reduced death rates. The risk of death from cigarette smoking continues to increase among women and the increased risks are now nearly identical for men and women, as compared with persons who have never smoked. Among men, the risks associated with smoking have plateaued at the high levels seen in the 1980s, except for a continuing, unexplained increase in mortality from COPD.
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            Risk factors for subarachnoid hemorrhage: an updated systematic review of epidemiological studies.

            Derrick Bennett, Jan van Lanschot, Carlene M M Lawes … (2005)
            After a 1996 review from our group on risk factors for subarachnoid hemorrhage (SAH), much new information has become available. This article provides an updated overview of risk factors for SAH. An overview of all longitudinal and case-control studies of risk factors for SAH published in English from 1966 through March 2005. We calculated pooled relative risks (RRs) for longitudinal studies and odds ratios (ORs) for case-control studies, both with corresponding 95% CIs. We included 14 longitudinal (5 new) and 23 (12 new) case-control studies. Overall, the studies included 3936 patients with SAH (892 cases in 14 longitudinal studies and 3044 cases in 23 case-control studies) for analysis. Statistically significant risk factors in longitudinal and case-control studies were current smoking (RR, 2.2 [1.3 to 3.6]; OR, 3.1 [2.7 to 3.5]), hypertension (RR, 2.5 [2.0 to 3.1]; OR, 2.6 [2.0 to 3.1]), and excessive alcohol intake (RR, 2.1 [1.5 to 2.8]; OR, 1.5 [1.3 to 1.8]). Nonwhite ethnicity was a less robust risk factor (RR, 1.8 [0.8 to 4.2]; OR, 3.4 [1.0 to 11.9]). Oral contraceptives did not affect the risk (RR, 5.4 [0.7 to 43.5]; OR, 0.8 [0.5 to 1.3]). Risk reductions were found for hormone replacement therapy (RR, 0.6 [0.2 to 1.5]; OR, 0.6 [0.4 to 0.8]), hypercholesterolemia (RR, 0.8 [0.6 to 1.2]; OR, 0.6 [0.4 to 0.9]), and diabetes (RR, 0.3 [0 to 2.2]; OR, 0.7 [0.5 to 0.8]). Data were inconsistent for lean body mass index (RR, 0.3 [0.2 to 0.4]; OR, 1.4 [1.0 to 2.0]) and rigorous exercise (RR, 0.5 [0.3 to 1.0]; OR, 1.2 [1.0 to 1.6]). In the studies included in the review, no other risk factors were available for the meta-analysis. Smoking, hypertension, and excessive alcohol remain the most important risk factors for SAH. The seemingly protective effects of white ethnicity compared to nonwhite ethnicity, hormone replacement therapy, hypercholesterolemia, and diabetes in the etiology of SAH are uncertain.
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              Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations: A Statement for Healthcare Professionals From the American Heart Association and the American College of Cardiology

              Scott M. Grundy, Richard Pasternak, Philip Greenland … (1999)
              Article 0 comments Cited 148 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Alison J. Price:
                Comment :

                Scientific Advisory Boards:

                1. NONE

                Gifts:

                1. NONE

                Funding for Travel or Speaker Honoraria:

                1. NONE

                Editorial Boards:

                1. International Journl Of Epidemiology, Editorial board member, 2017

                Patents:

                1. NONE

                Publishing Royalties:

                1. NONE

                Employment, Commercial Entity:

                1. NONE

                Consultancies:

                1. NONE

                Speakers' Bureaus:

                1. NONE

                Other Activities:

                1. NONE

                Clinical Procedures or Imaging Studies:

                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. NONE

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. Wellcome Trust, Postdoctoral Research Training Fellowship

                Stock/Stock Options/Board of Directors Compensation:

                1. NONE

                License Fee Payments, Technology or Inventions:

                1. NONE

                Royalty Payments, Technology or Inventions:

                1. NONE

                Stock/Stock Options, Research Sponsor:

                1. NONE

                Stock/Stock Options, Medical Equipment & Materials:

                1. NONE

                Legal Proceedings:

                1. NONE

                F. Lucy Wright:
                Comment :

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                1. NONE

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                1. NONE

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                1. NONE

                Editorial Boards:

                1. NONE

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                1. NONE

                Publishing Royalties:

                1. NONE

                Employment, Commercial Entity:

                1. NONE

                Consultancies:

                1. NONE

                Speakers' Bureaus:

                1. NONE

                Other Activities:

                1. NONE

                Clinical Procedures or Imaging Studies:

                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. NONE

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. NONE

                Stock/Stock Options/Board of Directors Compensation:

                1. NONE

                License Fee Payments, Technology or Inventions:

                1. NONE

                Royalty Payments, Technology or Inventions:

                1. NONE

                Stock/Stock Options, Research Sponsor:

                1. NONE

                Stock/Stock Options, Medical Equipment & Materials:

                1. NONE

                Legal Proceedings:

                1. NONE

                Jane Green:
                Comment :

                Scientific Advisory Boards:

                1. NONE

                Gifts:

                1. NONE

                Funding for Travel or Speaker Honoraria:

                1. NONE

                Editorial Boards:

                1. (1) Cancer Epidemiology, Associate Editor, 2010-2015

                Patents:

                1. NONE

                Publishing Royalties:

                1. NONE

                Employment, Commercial Entity:

                1. NONE

                Consultancies:

                1. NONE

                Speakers' Bureaus:

                1. NONE

                Other Activities:

                1. NONE

                Clinical Procedures or Imaging Studies:

                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. (1)Medical Research Council (UK), grant no. MR/K02700X/1, co-PI, 2013-2018

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. (1) Cancer Research UK, Programme Grant no. C570/A16491, co-PI, 2014-2019

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                1. NONE

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                1. NONE

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                Angela Balkwill:
                Comment :

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

                Consultancies:

                1. NONE

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                1. NONE

                Other Activities:

                1. NONE

                Clinical Procedures or Imaging Studies:

                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. NONE

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. Medical Research Council Cancer Research UK

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                1. NONE

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                1. NONE

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                Sau Wan Kan:
                Comment :

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

                Other Activities:

                1. NONE

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                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. NONE

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. Medical Research Council Cancer Research UK

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                1. NONE

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                1. NONE

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                TienYu Owen Yang:
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                1. NONE

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                1. NONE

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                Sarah Floud:
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                1. NONE

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                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. UK Medical Research Council MR/K02700X/1

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. Cancer Research UK C570/A16491

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                Mary E. Kroll:
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                1. Husband of author: scientific advisory board of 'Meningitis Now' (a UK charity, i.e. non-profit)

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                1. NONE

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                1. NONE

                Research Support, Academic Entities:

                1. Husband of author: Biomedical Research Centre, Imperial Healthcare NHS Trust, UK

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                Rachel Simpson:
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                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. (1) Medical Research Council, grant no. MR/K02700X/1

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. (1) Cancer Research UK (grant no. C570/A16491)

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                Cathie L.M. Sudlow:
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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

                Research Support, Government Entities:

                1. (1) UK MRC and Wellcome Trust: UK Biobank programme renewal, ?35 million, 2010-2017 (co-I) (2) UK MRC, Dementias Platform UK programme grant, ?12 million, 2014-2019 (co-I) (3) UK MRC, Wellcome Trust, British Heart Foundation: UK Biobank imaging study, ?43 million, 2013-2022 (co-I) (4) European Union Innovative Medicines Initiative Horizon 2020 programme, ROADMAP (real world outcomes in Alzheimer's Disease), 8 million euros (about 50% EU, 50% EFPIA pharma company partners), 2016-2018 (co-I)

                Research Support, Academic Entities:

                1. (1) British Heart Foundation, 2012-2017, RESTART trial of antiplatelet treatment in ICH ( co-I)

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                1. NONE

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                Valerie Beral:
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                Scientific Advisory Boards:

                1. (1) Non-Executive Director, Medicines and Healthcare Regulatory Products Regulatory Agency

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                Gillian K. Reeves:
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                1. (1) Was a member of the Grail Inc. Population Study Scientific Advisory Board (2017).

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                1. NONE

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                1. NONE

                Editorial Boards:

                1. (1) BMC Cancer, Associate Editor 2007-2015

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

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                1. NONE

                Research Support, Commercial Entities:

                1. NONE

                Research Support, Government Entities:

                1. (1) Medical Research Council, grant no MR/K02700X/1, Co-PI, Programme grant to support the Million Women Study cohort, 2013-2018.

                Research Support, Academic Entities:

                1. NONE

                Research Support, Foundations and Societies:

                1. (1) Cancer Research UK, grant no C570/A16491, Co-PI, Programme Grant to support the work of the Cancer Epidemiology Unit, 2014-2017.

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                1. NONE

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                Journal
                Journal ID (nlm-ta): Neurology
                Journal ID (iso-abbrev): Neurology
                Journal ID (hwp): neurology
                Journal ID (publisher-id): neur
                Journal ID (pmc): neurology
                Journal ID (publisher-id): NEUROLOGY
                Title: Neurology
                Publisher: Lippincott Williams & Wilkins (Hagerstown, MD )
                ISSN (Print): 0028-3878
                ISSN (Electronic): 1526-632X
                Publication date (Print): 23 January 2018
                Publication date PMC-release: 23 January 2018
                Volume: 90
                Issue: 4
                Pages: e298-e306
                Affiliations
                From the Nuffield Department of Population Health (A.J.P., F.L.W., J.G., A.B., S.W.K., T.Y.O.Y., S.F., R.S., V.B., G.K.R.) and National Perinatal Epidemiology Unit (M.E.K.), University of Oxford; London School of Hygiene and Tropical Medicine (A.J.P.); and Centre for Clinical Brain Science (C.L.M.S.), University of Edinburgh, UK.
                Author notes
                Correspondence Dr. Price alison.price@ 123456lshtm.ac.uk
                [*]

                These authors contributed equally to this work.

                Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

                The Article Processing Charge was funded by the Medical Research Council and Cancer Research UK.

                Article
                Publisher ID: NEUROLOGY2017812230
                DOI: 10.1212/WNL.0000000000004856
                PMC ID: 5798656
                PubMed ID: 29321237
                SO-VID: 7bbc4c89-311a-4416-8544-bbf5db7a6934
                Copyright © Copyright © 2018 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 04 May 2017
                Date accepted : 10 October 2017
                Funding
                Funded by: Wellcome Trust
                Categories
                Subject: 6
                Subject: 7
                Subject: 8
                Subject: 54
                Subject: 59
                Subject: Article
                Custom metadata
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                STATUS ONLINE-ONLY

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