Risk Factors for Ischemic Stroke and its Subtypes in Chinese vs. Caucasians: Systematic Review and Meta-Analysis

Abstract

Background

Chinese populations are reported to have a different distribution of ischemic stroke subtypes compared with Caucasians.

Aims

To understand this better, we aimed to evaluate the differences in prevalence of risk factors in ischemic stroke and their distributions among ischemic stroke subtypes in Chinese vs. Caucasians.

Summary or review

We systematically sought studies conducted since 1990 with data on frequency of risk factors among ischemic stroke subtypes in Chinese or Caucasians. For each risk factor, we calculated study-specific and random effects pooled estimates in Chinese and Caucasians separately for: prevalence among ischemic stroke; odds ratios, comparing prevalence for each ischemic stroke subtype vs. all others. We included seven studies among 16 199 Chinese, and eleven among 16 189 Caucasian ischemic stroke patients. Risk factors studied were hypertension, diabetes, atrial fibrillation, ischemic heart disease, hypercholesterolemia, smoking and alcohol. Chinese ischemic stroke patients had younger onset of stroke than Caucasians, similar prevalence of hypertension, diabetes, smoking and alcohol, and significantly lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia. Risk factor associations with ischemic stroke subtypes were mostly similar among Chinese and Caucasian ischemic stroke patients. Compared with all other ischemic subtypes, diabetes was more common in large artery stroke, atrial fibrillation and ischemic heart disease in cardioembolic stroke, and hypertension and diabetes in lacunar stroke.

Conclusion

Our study showed a lower prevalence of atrial fibrillation, ischemic heart disease and hypercholesterolemia in Chinese, and mostly similar risk factor associations in Chinese and Caucasian ischemic stroke patients. Further analyses of individual patient data to allow adjustment for confounders are needed to confirm and extend these findings.

Keywords

Chinese ischemic stroke risk factor subtype Whites

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References

Tsai

Thomas

Sudlow

. Epidemiology of stroke and its subtypes in Chinese versus White populations: a systematic review. Neurology 2013; 81:264–72.

Fang

Wang

Zhang

. Incidence and survival of symptomatic lacunar infarction in a Beijing populations: a 6-year prospective study. Eur J Neurol 2012; 19:1114–20.

Liu

Wang

Lee

Zhang

Kong

. Stroke in China: epidemiology, prevention and management strategies. Lancet Neurol 2007; 6:456–64.

Schulz

UGR

Rothwell

. Differences in vascular risk factors between etiological subtypes of ischemic stroke. Stroke 2003; 34:2050–9.

Jackson

Sudlow

. Are lacunar strokes really different? A systematic review of differences in risk factor profiles between lacunar and non-lacunar infarcts. Stroke 2005; 36:891–904.

Hatano

. Experience from a multicentre stroke register: a preliminary report. Bull World Health Organ 1976; 54:541–53.

Whisnant

Basford

Bernstein

. National Institute of Neurological Disorders and Stroke Ad Hoc Committee: classification of cerebrovascular diseases III. Stroke 1990; 21:637–76.

Adams

Jr Bendixen

Kappelle

. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST Trial of Org 10172 in Acute Ischemic Stroke. Stroke 1993; 24:35–41.

Bamford

Sandercock

Dennis

Burn

Warlow

. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337:1521–6.

10.

Higgins

Thompson

Deeks

Altman

. Measuring inconsistence in meta-analysis. BMJ 2003; 327:557–60.

11.

Borenstein

Hedges

Higgins

JPT

Rothstein

. Introduction to Meta-Analysis. Chichester, UK, John Wiley & Sons, 2009.

12.

Petitti

. Approaches to heterogeneity in meta-analysis. Stat Med 2001; 20:3625–33.

13.

Yip

Jeng

Lee

. Subtypes of ischaemic stroke. A hospital-based stroke registry in Taiwan (SCAN-IV). Stroke 1997; 28:2507–12.

14.

Lin

Kuo

Chang

. Stroke registry in Kaohsiung Veterans General Hospital. Chin Med J (Taipei) 2002; 65:307–13.

15.

Liu

Zhang

Yin

Zhu

. Subtypes and one-year survival of first-ever stroke in Chinese patients: the Nanjing Stroke Registry. Cerebrovasc Dis 2006; 22:130–6.

16.

Wang

Zhao

. Association of Hypertension with stroke recurrence depends on ischaemic stroke subtype. Stroke 2013; 44:1232–7.

17.

Wang

Kay

. Relationship between the Oxfordshire Community Stroke Project classification and vascular abnormalities in patients with predominantly intracranial atherosclerosis. J Neurol Sci 2003; 207:65–9.

18.

Liu

Feng

. Clinical characteristics and long-term prognosis of patients with ischemic and hemorrhagic stroke. Natl Med J China. 2008; 88:892–7.

19.

Jia

Zhao

Wang

. Diabetes and poor outcomes within 6 months after acute ischaemic stroke. The China National Stroke Registry. Stroke 2011; 42:2758–62.

20.

Yang

Jiang

Shao

Shi

. Relationship between the Oxfordshire Community Stroke Project classification and the risk factors for stroke in patients with ischaemic stroke. Chin J Cerebrovasc Dis 2011; 8:225–9.

21.

Marti-Vilalta

Arboix

. The Barcelona stroke registry. Eur Neurol 1999; 41:135–42.

22.

Vemmos

Takis

Georgilis

. The Athens stroke registry: results of a five-year hospital-based study. Cerebrovasc Dis 2000; 10:133–41.

23.

Kolominsky-Rabas

Weber

Gefeller

Neundoerfer

Heuschmann

. Epidemiology of ischaemic stroke subtypes according to TOAST criteria. Incidence, recurrence, and long-term survival in ischaemic stroke subtypes: a population-based study. Stroke 2001; 32:2735–40.

24.

Grau

Weimar

Buggle

. Risk factors, outcome, and treatment in subtypes of ischaemic stroke. The German Stroke Dada Bank. Stroke 2001; 32:2559–66.

25.

Silvestrelli

Paciaroni

Caso

. Risk factors and stroke subtypes: results of five consecutive years of the Perugia stroke registry. Clin Exp Hypertens 2006; 28:279–86.

26.

Hajat

Heuschmann

Coshall

. Incidence of aetiological subtypes of stroke in a multi-ethnic population based study: the South London Stroke Register. J Neurol Neurosurg Psychiatry 2011; 82:527–33.

27.

Bejot

Caillier

Salem

. Ischaemic stroke subtypes and associated risk factors: a French population based study. J Neurol Neurosurg Psychiatry 2008; 79:1344–8.

28.

Lindgren

Roijer

Norrving

Wallin

Eskilsson

Johansson

. Carotid artery and heart disease in subtypes of cerebral infarction. Stroke 1994; 25:2356–62.

29.

Carlo

Lamassa

Baldereschi

. Risk factors and outcome of subtypes of ischaemic stroke. Data from a multicentre multinational hospital-based registry. The European Community Stroke Project. J Neurol Sci 2006; 244:143–50.

30.

Hajat

Dundas

Stewart

. Cerebrovascular risk factors and stroke subtypes. Differences between ethnic groups. Stroke 2001; 32:37–42.

31.

Zhang

Attia

D'Este

. Prevalence and magnitude of classical risk factors for stroke in a cohort of 5092 Chinese steelworkers over 13.5 years of follow-up. Stroke 2004; 35:1052–6.

32.

Zhou

. An epidemiological study on the prevalence of atrial fibrillation in the Chinese population of mainland China. J Epidemiol 2008; 18:209–16.

33.

Yao

Zhao

. Sino-MONICA project. A collaborative study on trends and determinants in cardiovascular diseases in China, part I: morbidity and mortality monitoring. Circulation 2001; 103:462–8.

34.

Yang

Liu

. Prevalence of cardiovascular disease risk factor in the Chinese population: the 2007–2008 China National Diabetes and Metabolic Disorders Study. Eur Heart J 2012; 33:213–20.

35.

Rincon

Sacco

Kranwinkel

. Incidence and risk factors of intracranial atherosclerotic stroke: the Northern Manhattan Stroke Study. Cerebrovasc Dis 2009; 28:65–71.

36.

Arenillas

Molina

Chacón

. High lipoprotein (a), diabetes, and the extent of symptomatic intracranial atherosclerosis. Neurology 2004; 63:27–32.