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AGE AND GENDER SPECIFIC STROKE RISK FACTORS IN A TEACHING HOSPITAL IN KHYBER PAKHTUNKHWA.

Byline: Muhammad Abdur Rahman Afridi, Zafar Ali, Riaz Muhammad, Aftab Ahmad and Intekhab Alam

ABSTRACT

Objective: To determine age and gender specific stroke risk factors in a teaching hospital in Khyber Pakhtunkhwa.

Methodology: A hospital based descriptive study was performed in medical units of Lady Reading Hospital, Peshawar, from July 2011 to March 2012. A total of 100 patients of 18 years and above and of both genders were included. Study patients with first-ever acute stroke were divided into three groups; Group A young adult (less than 40 years), Group B, middle-aged (40-60 years), and Group C elderly (greater than 60 years). In these 03 groups, stroke risk factors were compared. Patients were assessed for hypertension, ischemic heart disease, hyperlipidemia, atrial fibrillation, diabetes mellitus and smoking. SPSS version 18.0 was used for statistical analysis.

Results: A sample of 100 patients was taken comprising 68% males and 32% females. Study patients had a mean age of 63.44 +13.849. There were 08 patients in Group A, 29 in Group B, and 63 patients in Group C. Overall, hypertension was found in (62%), followed by smoking (47%), coronary artery disease (33%), diabetes mellitus (28%), hyperlipidemia (24%) and atrial fibrillation (21%).

Conclusion: Pattern of distribution of stroke risk factors is age and gender specific. Majority were found to have hypertension. Hypertension, diabetes mellitus, atrial fibrillation and hyperlipidemia differ significantly among the 03 age groups. Smoking was significantly different in males and females.

Key words: Stroke, Acute Ischemic Stroke, Cerebral infarction, Cerebral hemorrhage, Stroke risk factors.

INTRODUCTION

Being a significant health issue worldwide, stroke is a major cause of social incapability, intellectual disability and death. As estimated by World Health Organization, worldwide each year, about 15 million people sustain stroke. Out of these, about 5 million die and an additional 5 million are left handicapped1,2. The incidence of stroke in United States is about 795,000 annually3.

The magnitude of stroke is anticipated to rise in low to middle earnings countries. In contrast the incidence of stroke has decreased in the West4.

Stroke is defined as a focal neurological deficit (hemi- plegia/ hemiparesis, dysphasia, cranial nerve palsies or hemianopia) of sudden onset that persists beyond 24 hours; and neuroimaging technique indicating the presence of infarction or hemorrhage, with no obvious cause besides vascular origin5. About 85% of all strokes are due to ischemia and 15% are due to hemorrhage (intra-cerebral and sub-arachnoid)6.

Stroke is a heterogeneous disease and occurs due to a multitude of underlying risk factors. These include hypertension, ischemic heart disease, hyperlipidemia, atrial fibrillation, diabetes mellitus and smoking. Majority of risk factors for stroke are modifiable and preventable through recognition, medication adherence and life style modification. Individuals at risk for sustaining stroke can be recognized and appropriately treated7. By controlling modifiable risk factors and adjustments in lifestyle, about 50% of strokes can be prevented8.

In patients with different ages and genders, discrepancy is present regarding stroke risk factors, clinical features and improvement9-10. Stroke is the major reason of physical handicap in patients above 40 years of age. In the USA, about 32,000 more women died of stroke in 2000 than men, and this number is predicted to be 68,000 in 205011.

Previously published local studies mainly focused on frequency of different risk factors in stroke patients. The aim of this study was to identify different risk factors for stroke in patients of different genders and ages. Depending on gender and age of patients, timely recognition and control of stroke risk factors may help in contribution to therapeutic decision making and health improvement by developing better stroke prevention strategies.

METHODOLOGY

This was a hospital based descriptive study. The study was performed in medical units of Lady Reading Hospital, Peshawar, Khyber Pakhtunkhwa, from July 2011 to March 2012. Admission of stroke patients was done through casualty department (AandE) and Out-patient (OPD).

A total of 100 patients with first-ever acute stroke were included. Sample was taken by consecutive method. Patients age 18 years and above and of both genders were included. An informed written consent was taken for their inclusion in the study.

Study patients were divided into three groups; Group A young adult (less than 40 years), Group B middle-aged (4060 years) and Group C elderly (greater than 60 years). In these 03 groups, stroke risk factors were compared.

Patients presenting with Transient ischemic attacks (TIA), recurrent stroke, hypertensive encephalopathy and those who were admitted more than 07 days after the onset of symptoms were excluded from the study.

Acute stroke was diagnosed clinically and radiologically as:

A focal neurological deficit (hemiparesis, dysphasia, cranial nerve palsies or hemianopia) of sudden onset that persist beyond 24 hours and documented by a brain CT scan indicating the presence of infarction or hemorrhage.

Evaluation of risk factors for stroke was performed in study patients by complete history and focused clinical examination. History of smoking (including both current and past smoking), stroke in the family members, medications for control of diabetes, anti-hypertensive or cholesterol-lowering medications, coronary artery diseases and atrial fibrillation were recorded. Consciousness level was assessed on Glasgow Coma Scale (GCS).

Appropriate investigations were carried out. Blood Samples from all patients were tested in hospital laboratory for blood complete with ESR, fasting lipid profile, fasting and random blood sugar. Twelve lead ECG (with rhythm strip) and Echocardiography (to look for Structural cardiovascular abnormalities as well) were done. Facilities for measurement of Homocysteine levels are not routinely available locally. To assess for stroke and its sub-type, a CT scan brain was performed on every patient. All the findings were recorded on a standard, pre-designed proforma.

For the purpose of this study, following definitions were used:

1. Hypertension: blood pressure of greater than 140 and 90 mm Hg;

2. Diabetes mellitus: fasting blood sugar greater than 126 mg/ dl, and/or random blood sugar of greater than 200 mg/dl; or use of anti-diabetic therapy.

3. Coronary artery disease: prior myocardial infarction, cardiac intervention or a history of angina pectoris or evidence of ischemia on ECG;

4. Atrial fibrillation: clinical or ECG evidence of AF;

5. Hyperlipidemia: serum cholesterol greater than 200 mg/dl and/or triglycerides value of greater than 150 mg/dl;

6. Smoking: daily tobacco use (current or past).

SPSS version 18.0 was used for statistical analysis. Numerical and categorical variables were measured by mean+SD, percentages and ratio accordingly. Data were presented in the form of tables.

For outlined attributes of stroke patients, Fisher's exact tests for frequencies were used. Quantitative variables were analyzed by Mann-Whitney test and qualitative variables by chi-square test to perform Uni-variate analyses. Level of significance was taken at p value less than 0.05.

RESULTS

A sample of 100 patients was taken comprising 68% males and 32% females. Overall male to female ratio was 2.125: 1.

Age of the study patients were from 2590 years (mean 63.44+13.85 years). Males were from 2690 years (mean 64.37+13.66 years). Females were from 2585 years (mean 61.44+14.26 years).

There were 08 patients in group A, 29 in group B and 63 patients in group C (Table 1).

Blood sugar level of the patients ranged from 65 345 mg/dl (mean 135.07+66.23). Serum Cholesterol of the patients ranged from 100397 mg/dl (mean 158.35+56.95). Serum Triglycerides of the patients ranged from 89-1100 mg/dl (mean 153.11+118.66).

Electrocardiography and echocardiography were abnormal in 34 (34%) and 35 (35%) of patients respectively.

Cerebral infarction constituted 76% and intracerebral hemorrhage 24% of the cases (Table 2).

Hemiplegia alone was present in 17%, speech disturbance alone in 08%, hemiplegia and dysphasia in 32%. Consciousness was impaired in 43% of patients.

Hypertension was found in (62%), Coronary artery

Table 1: Gender and Age group cross-tabulation (n=100).

Gender###Age groups###Total

###Group A###Group B###Group C

###(Less than 40 years)###(40-60 years)###(Above 60 years)

Male###5###19###44###68

Female###3###10###19###32

Total###8###29###63###100

Table 2: Stroke types among the Gender and Age groups (n=100)

Stroke type###Age groups###Total

###Group A###Group B###Group C

###(Less than 40 years)###(40-60 years)###(Above 60 years)

Infarct###5###2###12###09###37###11###76

Intra-Cerebral###0###01###07###01###07###08###24

Bleed

Total###05###03###19###10###44###19###100

Table 3: Gender wise comparison of risk factors

Risk factors###Total###Male###Female###p value###95% C.I.

###Lower###Upper

Hypertension###62###40###22###0.981###.296###3.486

Smoking###47###46###01###0.000###8.604###650.268

Coronary artery disease###33###26###07###0.842###.271###4.966

Diabetes mellitus###28###14###14###0.288###.125###1.850

Hyper-lipidemia###24###13###11###0.170###.074###1.582

Atrial fibrillation###21###19###02###0.157###.577###30.627

Table 4: Age group wise comparison of risk factors

###Group A###Group C

###Group B

Risk factors###Total###(Less than 40###(Above 60###Significance

###(40-60 years)

###years)###years)

Hypertension###62###0###18###44###0.001

Coronary artery disease###33###04###07###22###0.357

Diabetes mellitus###28###0###07###21###0.017

Hyper-lipidemia###24###02###09###13###0.030

Atrial fibrillation###21###01###03###17###0.054

Smoking###47###02###14###31###0.206

Disease (33%), DM (28%), hyperlipidemia (24%), atrial fibrillation (21%) and smoking (47%).

Gender-wise distribution of risk factors, as shown in Table 3, revealed that Hypertension, CAD, AF and smoking was more prevalent in male patients; whereas Age group wise distribution of risk factors showed that Hypertension, DM, CAD, AF, Hyperlipidemia and smoking were more common in Group C patients, as shown in Table 4.

DISCUSSION

Risk factors for stroke are influenced by age and gender. The complicated relationship of stroke risk factors with gender and age is shown by studies conducted in western countries and China9-14.

Both genders (male and females) have similar conventional risk factors for stroke. However, AF and hypertension are more prevalent in women at stroke onset in most studies. Prevalence of smoking, drinking alcohol, coronary artery disease and diabetes is shown to be higher in men10.

Similarly, prevalence of stroke risk factors may vary with age. Advancing age is shown to be related with increased incidence and prevalence of stroke9,15.

In the Global Burden of Disease Study' by Feigin et al, it was found that age-standardized incidence of stroke increased by 12% in the low- and middle-income countries4.

Although there is deficient publication of research data, the magnitude of stroke looks to be substantial in Pakistan. Contrary to the mean age of stroke patients in the developed world, our patients suffered stroke at a younger age. About 20% of our patients are below the age of 45 years at stroke onset16. A similar rise in stroke incidence in most Asian countries and an earlier age at onset compared with the West was observed by Mehndiratta et al17.

In our study, 68% of stroke patients were males and 32% were females. These findings are comparable to a Chinese study by Yao et al, in which 60.5% of the patients were male18.

In the meta-analysis regarding stroke in Pakistan by Khan et al, it was observed in different studies, that there is an obvious increased prevalence in males (as high as 59.2 % to 71.42%)19. A higher prevalence of stroke was found in men as compared to women in WHO Eastern Mediterranean countries as shown by Boutayeb et al20.

In the present study, male patients had mean age of 64.37+13.662 years and female patients had mean age of 61.44+14.256 years. In several studies from Pakistan, the mean age was reported from 57 to 62 years. Males had a mean age of 58.2 years and females had about 60 years. Different studies from Pakistan showed that stroke patients had a mean age of about 60+10 years. Consequently Pakistani population suffers stroke at a younger age (minimum 10 years sooner)19.

In our study the frequency of acute stroke was more (63%) in the elderly patients of age 60 years or above. The proportion of stroke comprised by elderly population is about17%21. They have a greater risk-adjusted mortality and morbidity as well as extended stay in hospital22,23.

There is a greater risk of stroke with growing age in both the gender, especially in women10,18,24. Ischemic stroke was more prevalent in patients below 80 years in males as compared to females. Age may influence risk of stroke in different genders10, as women have reduced stroke incidence than men when corrections for age applied.

Lofmark et al showed that at younger age (55 to 64 years), stroke was found less frequently in females as compared to males. But as the age advanced to 75 to 85 years, females were found to have a higher incidence than males25.

Yao et al showed that at stroke onset, female patients were significantly more aged as compared to males. Moreover, females had a considerably increased prevalence of AF, heart diseases and diabetes. In contrast, smoking (presently or in the past) and alcohol consumption were greatly prevalent in male patients. Both genders showed similar prevalence of hypertension18. These findings suggest that in young males a healthy lifestyle is of paramount significance to reduce incidence of stroke.

In the current study, the major risk factor was hypertension (62%), (males 40% vs. females 22%). Other studies from Pakistan showed the frequency of hypertension in stroke patients of about 50 to 82%19. Boutayeb et al showed that hypertension was found greater than 50% in 38 studies, DM greater than 25% in 36 studies, smoking greater than 15% in 26 studies and dyslipidemia greater than 25% in19 studies20.

In both gender groups, no significant difference was observed for hypertension. However its frequency differ significantly among the different age groups (p =0.001). Hypertension is considered key essential factor in the development of stroke. Hypertension was the commonest risk factor (66.2%) in an Iraqi study26.

Coronary Artery disease is particularly associated with a higher risk of stroke15. In our study, CAD was present in 33% of patients (males 26% vs. females 07%). In a study from Quetta, 12.2% of stroke patients were having CAD27; whereas in Karachi, 19.57% of stroke patients were having CAD28. Similarly, in Islamabad, 28.8% of stroke patients were found to have CAD29. Yao et al reported more prevalent heart disease in females from China18.

Diabetes is another significant contributor to stroke. Both the magnitude of ischemic infarct and the clinical outcome are considerably affected by hyperglycemia30. Several mechanisms (both direct and indirect) may result in advanced atherosclerosis and help explain the harmful effects of hyperglycemia on cardiovascular system31. Duration of diabetes is also considered to be related with higher stroke risk. A rise of about 3% of stroke risk is observed by every year of diabetes duration32.

In our study, DM was present in 28% of patients (males 14% vs. females 14%). In a meta-analysis by Khan et al, DM was found in 18-41.5% of patients with stroke19. In admitted stroke patients, diabetes as a risk factor was observed as 22.4% in men and 24.7% in women in the Minnesota Heart Survey33.

Female patients were found to have increased frequency of diabetes in studies conducted on Chinese and African American subjects18,34,35. But many scientific studies involving the European and White Americans showed the opposite results10,36. This disparity may be multi-factorial (genetic and life styles factors) but true explanation is unknown.

In the present study, hyperlipidemia was present in 24% of patients (males 13% vs. females 11%). In other studies, the prevalence of hyperlipidemia is shown to be 9.9% to 32%19. Dyslipidemias were found to be associated with a severe stroke and poor outcome in northern Pakistani population37.

Varbo et al showed that hypertriglyceridemia is significantly associated with stroke in both genders. Such high risk was not associated with hypercholesterolemia in females. However males with hypercholesterolemia were found to have elevated stroke risk38.

Atrial Fibrillation is strongly associated with stroke39. Prevalence of AF related stroke unduly rises in advanced age to about 23.5%40. In the present study, AF was present in 21% of patients (males 19% vs. females 02 %,) and increased significantly with increasing age (p=0.054). This is in conformity with the results of another study done in Karachi where AF was found in 41.48% of patients greater than 50 years with ischemic stroke (males 58.95% vs. females 41.05%)41.

On the other hand, some studies observed an increased incidence of AF in females as compared to males10,36. However, these studies also showed that AF was considerably more frequent in patients above 60years of age. High incidence of AF in the elderly may be due to the gradual loss of conduction tissue, proliferation of myofibroblasts and atrial fibrosis42.

In our study smoking was present in 47% of patients (males 46% vs. females 01%, p =0.000).This is in conformity with other studies from Pakistan, where smoking was found in 22-53% of patients. Similar results were obtained by Palm et al where smoking was more common in men43. In contrast to non-smokers or those who stopped smoking for more than 10 years, current smokers sustain stroke more frequently44,45.

CONCLUSION

This study showed that pattern of distribution of stroke risk factors is gender and age specific. Stroke risk factor profiles are different for male and female as well as for young and old patients. The most frequent modifiable risk factor for stroke was hypertension. Hypertension, diabetes mellitus and hyperlipidemia differ significantly among the three age groups. Smoking was significantly different in males and females. Depending on patient's gender and age, better stroke prevention strategies need to be developed..

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