Thursday, February 02, 2023

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Lifestyle biomarker linked to high blood pressure, increased stroke risk among Black adults


American Stroke Association International Stroke Conference 2023, Abstract 83

Reports and Proceedings

AMERICAN HEART ASSOCIATION

Research Highlights:

  • Researchers have identified a lifestyle-related biomarker called gluconic acid that may be a target to reduce stroke risk in Black adults.
  • Higher levels of gluconic acid in the blood were associated with high blood pressure and increased risk of ischemic stroke among Black adults when compared to white adults.
  • Among Black adults, a higher level of gluconic acid was associated with a Southern diet (foods high in added fats, fried foods, processed meats and sugary drinks), a lower level of education and a lack of exercise.

Embargoed until 4 a.m. CT/5 a.m. ET, Thursday, Feb. 2, 2023

DALLAS, Feb. 2, 2023 — Researchers have identified a lifestyle-related metabolite biomarker called gluconic acid that is associated with high blood pressure, increased risk of ischemic stroke, eating a Southern diet, lower level of education and lack of exercise, among Black adults, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

According to the American Stroke Association, a division of the American Heart Association, stroke is one of the leading causes of death and disability in the U.S., and African Americans have long experienced a higher rate of stroke. Currently, researchers are investigating new risk factors such as variations in blood levels of metabolites that might explain these differences. Metabolites are substances in the blood produced while exercising or in the breakdown of food and medications during metabolism.

“We have identified a biomarker called gluconic acid that we believe is a lifestyle-related biomarker, providing a direct link to diet and exercise,” said Naruchorn Kijpaisalratana, M.D., Ph.D., lead study author and a research fellow in neurology at Massachusetts General Hospital in Boston. “Gluconic acid may be considered as a dietary-related oxidative stress marker due to its availability in food, potentially produced by the gut microbiome, and related to diseases with oxidative stress. We think that this biomarker may provide a pathway to improve diet and exercise habits to help prevent a future stroke.“

The study analyzed health data for more than 2,000 people participating in the Reasons for Geographic and Racial Difference in Stroke (REGARDS) study. The ongoing REGARDS study has enrolled more than 30,000 Black and white adults since 2003 from the Southeastern U.S., known as the “stroke belt,” and other states across the country. The aim of REGARDS is to investigate the reasons for the high rate of stroke among African Americans.

This new analysis included 1,075 ischemic stroke survivors during a mean follow-up period of 7 years. Of those, 439 were Black adults and 636 were white adults (mean age of 70 years; 50% female). A random comparison group drawn from study participants consisted of nearly 1,000 Black adults and white adults who had not had a stroke (mean age of 65 years; 55% female).

The samples used in this study were collected from REGARDS participants over a 4-year period of enrollment (from 2003 to 2007). Using the samples, researchers extracted and measured levels of 162 metabolites in the blood of the participants. The data analysis examining the association between these metabolite levels and high blood pressure and future risk of ischemic stroke in both the Black and white adults was performed in 2021-2022.

The study found:

  • Of the 162 metabolites that were measured, elevated levels of the metabolite gluconic acid were found in Black adults who had high blood pressure but not their white peers with high blood pressure.
  • Black adults with the highest gluconic acid levels were 86% more likely to have high blood pressure.
  • Black adults with the highest gluconic acid levels had a 53% increased risk of ischemic stroke. No such association was found for white participants.
  • Gluconic acid accounted for 25% of the association between high blood pressure and stroke among Black adults.
  • In Black adults, after adjusting for multiple factors, a higher level of gluconic acid was associated with a Southern diet (foods high in added fats, fried foods, processed meats and sugary drinks), a lower level of education and a lack of exercise.

The researchers suggest that a blood test measuring metabolites may be able to determine if diet and exercise are working to lower stroke risk. “In the future, we envision that a metabolite like gluconic acid may be used as a biomarker to inform health care professionals whether the patient is eating healthy enough or exercising enough,” Kijpaisalratana said. “A biomarker like gluconic acid may point individuals toward more targeted guidance for stroke prevention.”

A limitation of the study was that the participants had high blood pressure at the beginning of the study, so researchers were not able to track the condition as it developed.

“Given the longstanding, higher risk of stroke among Black versus white adults in the United States — which is still not fully explained by a higher frequency of traditional stroke risk factors — the discovery of a new, potential prognostic marker or therapeutic target is very important,” said Bruce Ovbiagele, M.D., M.Sc., M.A.S., M.B.A., M.L.S., FAHA, American Heart Association expert volunteer and associate dean and professor of neurology at the University of California, San Francisco and chief of staff at the San Francisco Veteran Affairs Health Care System. “Since previous studies have found that culturally tailored lifestyle educational approaches may help to improve blood pressure control in Black adults, gluconic acid might serve as an objective measure to inform health care professionals about how well their patients are doing reducing hypertension and stroke risk and may also be helpful to motivate Black patients to modify their lifestyles as appropriate to prevent stroke.”

Ovbiagele, who was not involved in this study, also noted that future studies will need to examine the relationship between gluconic acid and the known social determinants of cerebrovascular health, including psychosocial stress and stroke risk, among Black adults compared to their white counterparts. Additional research will also need to explore whether this relationship holds true for recurrent stroke risk, too, since about one out of four strokes is a recurrent stroke.

Co-authors are Zsuzsanna Ament, Ph.D.; Amit Patki M.D.; Varun Mahesh Bhave, M.D.-candidate; Ana-Lucia Garcia Guarniz, M.D.; Suzanne E. Judd, Ph.D.; Mary Cushman, M.D., M.Sc.; Leann Long, Ph.D.; Marguerite M. Irvin, Ph.D.; and W. Taylor Kimberly, M.D., Ph.D. Authors’ disclosures are listed in the abstract.

The study was funded by the National Institutes of Health and the American Heart Association.

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.

The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

Additional Resources:

The American Stroke Association’s International Stroke Conference (ISC) is the world’s premier meeting dedicated to the science and treatment of cerebrovascular disease. ISC 2023 will be held in person in Dallas and virtually, Feb. 8-10, 2023. The three-day conference will feature more than a thousand compelling presentations in categories that emphasize basic, clinical and translational sciences as research evolves toward a better understanding of stroke pathophysiology with the goal of developing more effective therapies. Engage in the International Stroke Conference on social media via #ISC23.


Black and Hispanic people in U.S. less likely to get treatment for stroke complications

American Stroke Association International Stroke Conference 2023, Abstract 146

Reports and Proceedings

AMERICAN HEART ASSOCIATION

Research Highlights:

  • Analysis of 20 years of data found Black and Hispanic adults in the U.S. were less likely to be treated for certain complications, such as depression and muscle stiffness, after a stroke compared to their white peers.
  • The greatest difference in the treatment of complications among Black and Hispanic stroke survivors occurred mainly within two weeks after a stroke.

Embargoed until 4 a.m. CT/5 a.m. ET, Thursday, Feb. 2, 2023

DALLAS, Feb. 2, 2023 — Analysis of 20 years of electronic health records across the U.S. finds Black and Hispanic stroke survivors were less likely than white stroke survivors to receive treatment for common complications during the first year after their stroke, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

Despite increases in recent decades in the overall stroke survival rates in the U.S., Black and Hispanic adults in the U.S. still consistently fare worse in their recovery from a stroke when compared to their peers who are white. According to a new study, differences in the treatment of complications immediately after a stroke may possibly explain these persistent health disparities.

“A constellation of symptoms may manifest after a stroke; however, not all complications are life-threatening events. Some complications may be more subtle and go undetected by the medical community and, as a result, people from different racial or ethnic groups may not receive equitable treatment,” said lead study author “Stroke may have a devastating impact on an individual’s quality of life, and I think we owe it to our patients to do what we can to improve their level of function and quality of life after a stroke.”

In this study, Using electronic medical records from 65 large health care centers across the U.S., the analysis included patients hospitalized with stroke between August 2002 and July 2022. The records were divided into three patient groups (Black, non-Hispanic white and Hispanic): 80,564 Black stroke survivors were matched to 80,564 non-Hispanic white stroke survivors; and 28,375 non-Hispanic white stroke survivors were matched to 28,375 Hispanic stroke survivors. All participants were older than 18 years with an average age of 64 and 54% were male.

Stroke survivors were matched based on 41 factors that may affect recovery, including age, sex and other health conditions, such as hypertension and diabetes (Type 1 and 2). After matching there were no significant group differences for any of 41 factors. For the analysis, researchers reviewed medications prescribed for six common stroke complications: central nervous system arousal/fatigue (foggy brain function); mood irregularities (depression/anxiety); spasticity (muscle stiffness); sleep problems; bladder incontinence; and seizure. They then compared the differences in the treatment of these conditions after a stroke among the people who had these complications at three points in time: 14 days, 90 days and 365 days after the stroke.

The analysis revealed:

  • Black stroke survivors were significantly less likely to be treated for any complications except seizure, compared to stroke survivors who were white. The largest difference was seen in the treatment of arousal/fatigue, spasticity, and mood at the 14-day mark. Compared to stroke survivors who were white adults, those who were Black adults were 30% less likely to be treated for central nervous system arousal, 27% less likely to be treated for spasticity and 17% less likely to be treated for mood irregularities.
  • In the comparison of Hispanic vs. non-Hispanic white stroke survivors at the 14-day mark, Hispanics survivors were 20% less likely to receive treatment for central nervous system arousal; 19% less likely to receive treatment for spasticity; and 16% less likely to receive treatment for mood irregularities.
  • Little to no differences in the treatment of seizure were seen between the three patient groups at all three time periods.

“When a patient is having a seizure, the physical manifestations are often clear and demand urgent treatment. However, for other symptoms like foggy brain function or depression, health care professionals must dig a little deeper to assess for these signs or symptoms and determine if treatment is warranted. This difference between seizures and the other more subtle symptoms is the important take away,” Simmonds said. ”We found that the disparities among different population groups narrowed a little over time, and this likely shows that some of these conditions are being recognized and treated. However, even at the one-year mark, the overall treatment disparities remain for the treatment of nearly all post-stroke complications.”

The main limitation of this analysis is that a large database review like this can identify racial disparities in stroke care, however, it is less attuned to identify the specific factors driving them. “These differences are real and persistent, so it’s a matter of finding them, one by one, and filling these gaps,” Simmonds said.

The research team plans to test various intervention strategies that may help stroke survivors who are Black or Hispanic achieve a better functional recovery after their stroke.

“Communication moving forward is important. Many people survive their stroke, so health care professionals need to ask patients about these other subtle symptoms that may indicate additional complications, in addition to traditional risk factors such as blood glucose levels or blood pressure. These other domains have an important impact on our patients’ post-stroke, day-to-day quality of life.”

“It is very important for stroke survivors to receive treatment for subsequent complications. Successful recovery and quality of life depend upon the identification and management of post stroke complications,” said American Stroke Association, a division of the American Heart Association, volunteer expert Karen L. Furie, M.D., M.P.H., FAHA, vice chair of the Association Stroke Brain Health Science Subcommittee and professor and chair of neurology at the Warren Alpert Medical School of Brown University in Providence, Rhode Island. “Understanding the factors that contribute to these differences in treatment will empower clinicians to deliver high-quality, equitable care to stroke patients.” Dr. Furie was not involved in this study.

Co-authors are Folefac D. Atem, Ph.D.; Babu G. Welch, M.D.; and Nneka L. Ifejika, M.D., M.P.H. Authors’ disclosures are listed in the abstract.

No funding was reported for this study.

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.

The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

Additional Resources:


Study finds Mexican American stroke survivors were less likely to receive intensive rehab


American Stroke Association International Stroke Conference 2023, Abstract WMP28

Reports and Proceedings

AMERICAN HEART ASSOCIATION

Research Highlights:

  • While previous research has indicated Mexican Americans have worse stroke outcomes, this study found they were more likely to have less intensive rehabilitation, such as home health and outpatient services, during the three months after their stroke compared to their non-Hispanic white peers.
  • Nearly one-third of all stroke survivors in the South Texas study, which included Mexican American adults, did not receive any type of rehabilitation within 90 days of their stroke.

DALLAS, Feb. 2, 2023 — Mexican American stroke survivors in a South Texas study, were more likely to use less intensive forms of rehabilitation services than their non-Hispanic white peers, and nearly one-third of all the stroke survivors did not receive any rehabilitation within 90 days of their stroke, according to preliminary research to be presented at the American Stroke Association’s International Stroke Conference 2023. The meeting, to be held in person in Dallas and virtually Feb. 8-10, 2023, is a world premier meeting for researchers and clinicians dedicated to the science of stroke and brain health.

Even though stroke death rates among Mexican Americans are lower than their non-Hispanic white peers, previous research has shown that they often have worse outcomes and suffer greater disability after their stroke. One factor contributing to how well stroke survivors recover is the type of rehabilitation they receive in the window of time after the stroke, explained lead study author Lynda Lisabeth, Ph.D., M.P.H., a professor of epidemiology at the University of Michigan in Ann Arbor.

“The more intensive forms of stroke rehabilitation that are provided at inpatient or skilled nursing facilities have better outcomes than less intensive forms of rehabilitation,” Lisabeth said. “Our objective was to identify what factors may impact the type of rehabilitation a person gets. We want to know if there are barriers to getting the most intensive level of rehabilitation, then we can develop interventions that target those barriers, which will help to maximize rehabilitation across the board and potentially reduce these disparities.”

Researchers examined the link between ethnicity and the use and type of rehabilitation accessed by stroke survivors during the first 90 days after a stroke. They enrolled 554 participants from a South Texas community in the Brain Attack Surveillance in Corpus Christi Project (BASIC) soon after their stroke. Two-thirds of the participants were Mexican American adults (66%), and one third were non-Hispanic white adults. Nearly half were women, and the median age was 66 years.

The study was conducted between 2019 and 2021. During this period researchers conducted telephone interviews to determine the type of rehabilitation the stroke survivors received after hospital discharge, such as: outpatient, home health, inpatient or a skilled nursing facility. Participants were called every two weeks for three months and asked about their care. Based on in-person and telephone interviews, assessments were made of functional ability and depression at 90 days, along with information about the type of post-discharge care received.

The study found:

  • One-third of all study participants did not receive any type of rehabilitation during the three months after their stroke.
  • Two thirds (67%) of Mexican American stroke survivors, compared to just over half (56%) of non-Hispanic white peers, received some form of post stroke rehabilitation.
  • Mexican American stroke survivors were younger (median age of 65 vs. 70 for non-Hispanic whites), had lower levels of education and income, more health problems, higher average body mass index, and worse functional outcome and depression at 90 days compared to non-Hispanic white peers in this study.
  • After accounting for multiple factors such as age, income and other health conditions, Mexican American stroke survivors had almost two times higher odds of using any rehabilitation than non-Hispanic white stroke survivors.
  • Mexican American stroke survivors were more likely to use outpatient (11% vs. 5%, respectively) and home health rehabilitation (38% vs. 30%, respectively) when compared to their non-Hispanic white peers.
  • There were no major differences in the use of inpatient rehabilitation and skilled nursing facilities between the Hispanic and non-Hispanic white groups.

“There are many factors that drive the type of rehabilitation stroke survivors receive or if they can access rehabilitation. We want to better understand the barriers and preferences of Mexican American stroke survivors, so we may help develop culturally sensitive interventions that may increase the chances of stroke survivors going to inpatient rehabilitation, which contributes to better recovery,” Lisabeth said.

The study is limited by its small size and its focus on one community in South Texas (Nueces County, Texas), which suggests these results may not apply to other communities across the country. “This community has a higher proportion of Mexican American people in an urban setting with a unique availability of rehabilitation. The study also took place over a period of time that overlapped with the COVID-19 pandemic,” Lisabeth said.

The researchers note future studies focused on barriers and facilitators to intensive rehabilitation, especially among Mexican American stroke survivors, may be a way to reduce disparities and make substantial improvements in recovery.

The American Heart Association/American Stroke Association’s 2021 Clinical Performance Measures for Stroke Rehabilitation: Performance Measures were developed to focus on key aspects of stroke rehabilitation that are important to maintaining quality of care for stroke patients. They cover various aspects of stroke rehabilitation in the acute, post-acute inpatient, outpatient and home settings.

According to those measures, stroke is among the most common causes of acquired disability among adults in the United States, with more than 7 million Americans over 20 years of age having experienced a stroke in the past and almost 2.5% of Americans reporting that they are disabled as a result of stroke. People in the U.S. discharged from the hospital after stroke received their rehabilitation care at either an inpatient rehabilitation facility (19%), skilled nursing facility (25%) or through home care services (12%).

“Rehabilitation after a stroke is a key factor in recovery and the return to independent functioning,” said Joel Stein, M.D., FAHA, chair of the writing group for the American Heart Association/American Stroke Association clinical performance measures and the Simon Baruch Professor and chair of the department of rehabilitation and regenerative medicine at Columbia University’s Vagelos College of Physicians and Surgeons; professor and chair of the department of rehabilitation medicine at Weill Cornell Medicine; and physiatrist-in-chief at NewYork-Presbyterian Hospital. “Exploring differences in care and disparities is an essential method of understanding gaps in care and improving systems of care for stroke survivors. Many factors may influence the delivery of rehabilitation care post-stroke. Stroke survivors with substantial impairments who have fewer financial resources and less social support may struggle with direct discharge from the hospital to home.” Dr. Stein was not involved in this study.

Co-authors are Madeline Kwicklis, M.S.; Elizabeth Almendarez, Ph.D.; Janet Prvu-Bettger, Sc.D., FAHA; and Lewis B. Morgenstern, M.D., FAHA. Authors’ disclosures are listed in the abstract.

The study was funded by the National Institutes of Health.

Statements and conclusions of studies that are presented at the American Heart Association’s scientific meetings are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. Abstracts presented at the Association’s scientific meetings are not peer-reviewed, rather, they are curated by independent review panels and are considered based on the potential to add to the diversity of scientific issues and views discussed at the meeting. The findings are considered preliminary until published as a full manuscript in a peer-reviewed scientific journal.

The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

Additional Resources:

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