Co-Designed Cardiac Rehabilitation for the Secondary Prevention of Stroke (CARESS): A Pilot Program Evaluation.

Structured health system-based programs, such as cardiac rehabilitation, may reduce the risk of recurrent stroke. This study aimed to co-design and evaluate a structured program of rehabilitation, developed based on insights from focus groups involving stroke survivors and health professionals. Conducted in Tasmania, Australia in 2019, the 7-week program comprised one hour of group exercise and one hour of education each week. Functional capacity (6 min walk test), fatigue, symptoms of depression (Patient Health Questionnaire), and lifestyle were assessed pre- and post-program, with a historical control group for comparison. Propensity score matching determined the average treatment effect (ATE) of the program. Key themes from the co-design focus groups included the need for coordinated care, improved psychosocial management, and including carers and peers in programs. Of the 23 people approached, 10 participants (70% men, mean age 67.4 ± 8.6 years) completed the program without adverse events. ATE analysis revealed improvements in functional capacity (139 m, 95% CI 44, 234) and fatigue (-5 units, 95% CI -9, -1), with a small improvement in symptoms of depression (-0.8 units, 95% CI -1.8, 0.2) compared to controls. The co-designed program demonstrated feasibility, acceptability, and positive outcomes, suggesting its potential to support stroke survivors.

Age and sex disparities in cardiovascular risk factor management prior to stroke: Linked registry and general practice data.

INTRODUCTION: There is limited evidence about the management of cardiovascular risk factors within 12 months before stroke/transient ischaemic attack (TIA) in Australian general practices. We evaluated whether age and sex disparities in cardiovascular risk factor management for primary prevention exist in general practice. METHODS: A retrospective cohort study using data from the Australian Stroke Clinical Registry (2014-2018) linked with general practice data from three primary health networks in Victoria, Australia. We included adults who had ≥2 encounters with a general practitioner within 12 months immediately before the first stroke/TIA. Cardiovascular risk factor management within 12 months before stroke/TIA was evaluated in terms of: assessment of risk factors (blood pressure [BP], serum lipids, blood glucose, body weight); prescription of prevention medications (BP, lipid-, glucose-lowering, antithrombotic agents); and attainment of risk factor targets. RESULTS: Of 2,880 patients included (median age 76.5 years, 48.4% women), 80.9% were assessed for BP, 49.9% serum lipids, 46.8% blood glucose, and 39.3% body weight. Compared to patients aged 65-84 years, those aged <65 or ≥85 years were less often assessed for risk factors, with women aged ≥85 years assessed for significantly fewer risk factors than their male counterparts. The most prescribed prevention medications were BP-lowering (64.9%) and lipid-lowering agents (42.0%). There were significant sex differences among those aged <65 years (34.7% women vs. 40.2% men) and ≥85 years (34.0% women vs. 44.3% men) for lipid-lowering agents. Risk factor target attainment was generally poorer in men than women, especially among those aged <65 years. CONCLUSION: Age-sex disparity exists in risk factor management for primary prevention in general practice, and this was more pronounced among younger patients and older women.

Low-Density-Lipoprotein Cholesterol and Mortality Outcomes Among Healthy Older Adults: A Post Hoc Analysis of ASPREE Trial.

BACKGROUND: The prognostic implication of cholesterol levels in older adults remains uncertain. This study aimed to examine the relationship between low-density-lipoprotein cholesterol (LDL-c) and mortality outcomes in older individuals. METHODS: This post hoc analysis examined the associations of LDL-c levels with mortality risks from all-cause, cardiovascular disease (CVD), cancer, and combined non-CVD/noncancer conditions in a cohort of individuals aged ≥65 years from the ASPirin in Reducing Events in the Elderly trial (NCT01038583). At baseline, participants had no diagnosed dementia, physical disability, or CVD, and were not taking lipid-lowering agents. Outcome analyses were performed using multivariable Cox models. RESULTS: We analyzed 12 334 participants (mean age: 75.2 years). Over a median 7-year follow-up, 1 250 died. Restricted cubic splines found a U-shaped relation for LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVE mortality (nadir: 3.3-3.4 mmol/L); the risk of CVD mortality was similar at LDL-c below 3.3 mmol/L and increased above 3.3 mmol/L. Similar trends were observed in analyses modeling LDL-c by quartiles. When modeling LDL-c as a continuous variable, the risk of all-cause mortality, cancer mortality, and noncancer/non-CVD mortality was decreased by 9%, 16%, and 18%, respectively, per 1-mmol/L higher LDL-c, and the risk of CVD mortality was increased by 19% per 1-mmol/L higher LDL-c. Reduced all-cause and non-CVD/noncancer mortality risks were only significant in males but not females (pinteraction < .05). CONCLUSIONS: There were U-shaped relationships between LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVD mortality in healthy older adults. Higher LDL-c levels were associated with an increased risk of CVD mortality. Future studies are warranted to confirm our results.

In Search of a Gold Standard Tool for Assessing Knowledge of Stroke: A Systematic Review.

BACKGROUND: Knowledge of stroke is essential to empower people to reduce their risk of these events. However, valid tools are required for accurate and reliable measurement of stroke knowledge. We aimed to systematically review contemporary stroke knowledge assessment tools and appraise their content validity, feasibility, and measurement properties. METHODS: The protocol was registered in PROSPERO (CRD42023403566). Electronic databases (MEDLINE, PsycInfo, CINAHL, Embase, Scopus, Web of Science) were searched to identify published articles (1 January 2015-1 March 2023), in which stroke knowledge was assessed using a validated tool. Two reviewers independently screened titles and abstracts prior to undertaking full-text review. COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methods guided the appraisal of content validity (relevance, comprehensiveness, comprehensibility), feasibility, and measurement properties. RESULTS: After removing duplicates, the titles and abstracts of 718 articles were screened; 323 reviewed in full; with 42 included (N = 23 unique stroke knowledge tools). For content validity, all tools were relevant, two were comprehensive, and seven were comprehensible. Validation metrics were reported for internal consistency (n = 20 tools), construct validity (n = 17 tools), cross-cultural validity (n = 15 tools), responsiveness (n = 9 tools), reliability (n = 7 tools), structural validity (n = 3 tools), and measurement error (n = 1 tool). The Stroke Knowledge Test met all content validity criteria, with validation data for six measurement properties (n = 3 rated "Sufficient"). CONCLUSION: Assessment of stroke knowledge is not standardised and many tools lacked validated content or measurement properties. The Stroke Knowledge Test was the most comprehensive but requires updating and further validation for endorsement as a gold standard.

Determining pathways of effect between correlates and outcomes of transport-related physical activity at differing timepoints across the lifecourse: A structural equation modelling approach.

Transport-related physical activity levels differ across the lifecourse; however, the nature of these differences is poorly understood. This study examined the relationship between correlates of transport-related physical activity and how they differ in strength, pathway, and direction across the lifecourse. Structural Equation Modelling assessed relationships between correlates (e.g., age, smoking, education) and transport-related physical activity (assessed via the International Physical Activity Questionnaire) at four timepoints of the Australian Childhood Determinants of Adult Health study: childhood (7-15y; n = 6302), early-adulthood (26-36y; n = 2700), early/mid-adulthood (31-41y; n = 1649), and mid-adulthood (36-49y; n = 1794). Several pathways were consistent across the lifecourse. Self-rated health directly associated with transport-related physical activity across all timepoints. During adulthood greater body mass index and smoking frequency were indirectly associated with lower levels of transport-related physical activity via self-rated health; similarly, lower educated adults, who smoked more frequently, and had poorer health, had lower transport-related physical activity. Urban residence was directly associated with greater transport-related physical activity in childhood and early-adulthood; having more children in early/mid- and mid-adulthood was directly associated with less transport-related physical activity. This is the first study to report pathways of direct and indirect association between correlates and transport-related physical activity at key lifecourse stages. The pathways highlighted can inform policy and practice to aid in the development of age-specific lifecourse interventions.

Socioeconomic status and health-related quality of life after stroke: a systematic review and meta-analysis.

BACKGROUND: Socioeconomic status (SES) is associated with stroke occurrence and survival following stroke but its association with health-related quality of life (HRQoL) following stroke remains uncertain. We performed a systematic review and meta-analysis to examine the association between SES and HRQoL after stroke. METHODS: PubMed, SCOPUS, EMBASE, and Web of Science were searched to identify relevant cohort and case-control studies between January 2000 and May 2022. Two authors screened titles, abstracts and full text articles. One author extracted data from all included studies. Meta-analyses were performed for studies with comparable measurements of SES and HRQoL. Random effects models were used to estimate pooled summary standardised mean differences in HRQoL by SES. RESULTS: Out of 1,876 citations, 39 studies incorporated measurement of overall HRQoL following stroke and were included in the systematic review, with 17 studies included in the meta-analyses. Overall, reports including education, income, occupation and work status effects on HRQoL after stroke were inconsistent among all included 39 studies. In the global meta-analysis of 17 studies, HRQoL among survivors of stroke was lower in the low SES group than in the high SES group (standardised mean difference (SMD) -0.36, 95% CI -0.52, -0.20, p < 0.0001). When using education and income indicators separately, summary effects were similar to those of the global analysis (low versus high education SMD -0.38, 95% CI -0.57, -0.18, p < 0.0001; low versus high income SMD -0.39, 95% CI -0.59, -0.19, p < 0.0001). CONCLUSIONS: Across all SES indicators, people with stroke who have lower SES have poorer overall HRQoL than those with higher SES. Accessibility and affordability of poststroke support services should be taken into consideration when planning and delivering services to people with low SES.

A Scoping Review of mHealth Interventions for Secondary Prevention of Stroke: Implications for Policy and Practice.

Secondary prevention is a major priority for those living with stroke and may be improved through the use of mobile Health (mHealth) interventions. While evidence for the effectiveness of mHealth interventions for secondary prevention of stroke is growing, little attention has been given to the translation of these interventions into real-world use. In this review, we aimed to provide an update on the effectiveness of mHealth interventions for secondary prevention of stroke, and investigate their translation into real-world use. Four electronic databases and the gray literature were searched for randomized controlled trials of mHealth interventions for secondary prevention of stroke published between 2010 and 2023. Qualitative and mixed-methods evaluations of the trials were also included. Data were extracted regarding study design, population, mHealth technology involved, the intervention, and outcomes. Principal researchers from these trials were also contacted to obtain further translational information. From 1151 records, 13 randomized controlled trials and 4 evaluations were identified; sample sizes varied widely (median, 56; range, 24-4298). Short message service messages (9/13) and smartphone applications (6/13) were the main technologies used to deliver interventions. Primary outcomes of feasibility of the intervention were achieved in 4 trials, and primary outcomes of changes in risk factors, lifestyle behaviors, and adherence to medication improved in 6 trials. Only 1 trial had a hard end point (ie, stroke recurrence) as a primary outcome, and no significant differences were observed between groups. There was evidence for only 1 intervention being successfully translated into real-world use. Further evidence is required on the clinical effectiveness of mHealth interventions for preventing recurrent stroke, and the associated delivery costs and cost-effectiveness, before adoption into real-world settings.

Association of body mass index from childhood to mid-adulthood with health-related quality of life in mid-adulthood.

PURPOSE: Most studies regarding the association of obesity with health-related quality of life (HRQoL) have assessed obesity at only one or two time points. We aimed to examine the associations of life course body mass index (BMI) from childhood with health-related quality of life (HRQoL) in mid-adulthood. METHODS: Data were from a cohort study of Australian children (n = 2254, mean baseline age 12.0 (2.0) years in 1985, 46.8% male). Weight and height were measured at baseline and measured or self-reported on average 20, 25, and 30 years later. Age and sex-standardised BMI-z score was calculated at each time point. Physical and mental HRQoL and health state utilities (HSUs) were measured by SF-12 and SF-6D at the last adult follow-up. Linear regression was used to examine the associations adjusting for age, sex, and childhood health status. RESULTS: Higher BMI-z score in childhood (ßadjusted - 1.39, 95% CI - 1.73 to - 1.05) and increasing BMI-z score from childhood to young adulthood (ßadjusted - 1.82, 95% CI - 2.17 to - 1.46) and from young to mid-adulthood (ßadjusted - 1.77, 95% CI - 2.28 to - 1.26) were associated with lower physical HRQoL in mid-adulthood. Similar results were found for mid-adulthood HSUs (ßadjusted ranged - 0.006 to - 0.014, all P < 0.05). Only increasing BMI-z score from young to mid-adulthood significantly related to poorer mental HRQoL (ßadjusted - 0.74, 95% CI - 1.29 to - 0.19) in mid-adulthood. CONCLUSION: High BMI from childhood to mid-adulthood had only modest associations with HRQoL and HSUs, with effects on physical HRQoL most apparent.

trips4health: a single-blinded randomised controlled trial incentivising adult public transport use for physical activity gain.

BACKGROUND: Public transport users tend to accumulate more physical activity than non-users; however, whether physical activity is increased by financially incentivising public transport use is unknown. The trips4health study aimed to determine the impact of an incentive-based public transport intervention on physical activity. METHODS: A single-blinded randomised control trial of a 16-week incentive-based intervention involved Australian adults who were infrequent bus users (≥ 18 years; used bus ≤ 2 times/week) split equally into intervention and control groups. The intervention group were sent weekly motivational text messages and awarded smartcard bus credit when targets were met. The intervention group and control group received physical activity guidelines. Accelerometer-measured steps/day (primary outcome), self-reported transport-related physical activity (walking and cycling for transport) and total physical activity (min/week and MET-min/week) outcomes were assessed at baseline and follow-up. RESULTS: Due to the COVID pandemic, the trial was abandoned prior to target sample size achievement and completion of all assessments (N = 110). Steps/day declined in both groups, but by less in the intervention group [-557.9 steps (-7.9%) vs.-1018.3 steps/week (-13.8%)]. In the intervention group, transport-related physical activity increased [80.0 min/week (133.3%); 264.0 MET-min/week (133.3%)] while total physical activity levels saw little change [35.0 min/week (5.5%); 25.5 MET-min/week (1.0%)]. Control group transport-related physical activity decreased [-20.0 min/week (-27.6%); -41.3 MET-min/week (-17.3%)], but total physical activity increased [260.0 min/week (54.5%); 734.3 MET-min/week (37.4%)]. CONCLUSION: This study found evidence that financial incentive-based intervention to increase public transport use is effective in increasing transport-related physical activity These results warrant future examination of physical activity incentives programs in a fully powered study with longer-term follow-up. TRIAL REGISTRATION: This trial was registered with the Australian and New Zealand Clinical Trials Registry August 14th, 2019: ACTRN12619001136190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377914&isReview=true.

Sex differences in the association between stroke risk factors and pre-clinical predictors of stroke in the childhood determinants of Adult Health study.

BACKGROUND AND AIMS: It is unclear why blood pressure (BP), metabolic markers and smoking increase stroke incidence in women more than men. We examined these associations with carotid artery structure and function in a prospective cohort study. METHODS: Participants in the Australian Childhood Determinants of Adult Health study at ages 26-36 years (2004-06) were followed-up at 39-49 years (2014-19). Baseline risk factors included smoking, fasting glucose, insulin, systolic and diastolic BP. Carotid artery plaques, intima-media thickness [IMT], lumen diameter and carotid distensibility [CD] were assessed at follow up. Log binomial and linear regression with risk factor × sex interactions predicted carotid measures. Sex-stratified models adjusting for confounders were fitted when significant interactions were identified. RESULTS: Among 779 participants (50% women), there were significant risk factor × sex interactions with baseline smoking, systolic BP and glucose associated with carotid measures in women only. Current smoking was associated with incidence of plaques (RRunadjusted 1.97 95% CI 1.4, 3.39), which reduced when adjusted for sociodemographics, depression, and diet (RRadjusted 1.82 95% CI 0.90, 3.66). Greater systolic BP was associated with lower CD adjusted for sociodemographics (ßadjusted -0.166 95% CI -0.233, -0.098) and hypertension with greater lumen diameter (ßunadjusted 0.131 95% CI 0.037, 0.225), which decreased when adjusted for sociodemographics, body composition and insulin (ßadjusted 0.063 95% CI -0.052, 0.178). Greater glucose (ßunadjusted -0.212 95% CI -0.397, -0.028) was associated with lower CD, which decreased when adjusted for sociodemographics, BP, depression and polycystic ovary syndrome (ßadjusted -0.023 95% CI -0.249, 0.201). CONCLUSIONS: Smoking, SBP and glucose affect carotid structure and function more in women than men with some of this risk due to co-occurring risk factors.

Distinct patterns of adult transport-related physical activity (TRPA) behaviour exist independent of the TRPA behaviours of childhood: the childhood determinants of adult health study.

BACKGROUND: Transport-related physical activity (TRPA) is recognised as a potential means of increasing total physical activity participation that may yield substantial health benefits. Public health campaigns focusing on promoting TRPA from a young age aim to develop life-long healthy habits. However, few studies have examined how TRPA changes across the lifecourse and whether childhood TRPA levels influence those observed later in life. METHODS: Using the Australian Childhood Determinants of Adult Health study (baseline, 1985), latent class growth mixture modelling with adjustment for time-varying covariates was performed using four timepoints (ranging from 7 to 49 years) to assess behavioural patterns and retention of TRPA across the lifecourse. As child and adult adjusted TRPA measures could not be harmonised, trajectories of adult TRPA (n = 702) were instead identified, and log-binomial regression analysis was performed to determine whether childhood levels of TRPA (high/medium/low) influenced these trajectories. RESULTS: Two stable groups of adult TRPA trajectories were identified: persistently low (n = 520; 74.2%), and increasingly high TRPA (n = 181; 25.8%). There was no significant relationship between childhood TRPA levels and patterns in adulthood (relative risk of high childhood TRPA yielding high adult TRPA trajectory membership = 1.06; 95% confidence interval = 0.95-1.09). CONCLUSION: This study found childhood TRPA levels were not associated with TRPA patterns in adulthood. These findings suggest that while TRPA in childhood may have health, social, and environmental benefits, it does not appear to impact adult TRPA directly. Therefore, further intervention is required beyond childhood to promote the implementation of healthy TRPA behaviours into adulthood.

Area-level and individual-level socio-economic differences in health-related quality of life trajectories: Results from a 10-year longitudinal stroke study.

BACKGROUND: We examined area-level (aSES) and individual-level (iSES) socio-economic status on trajectories of HRQoL to 10 years following stroke. METHODS: Participants with strokes between 1/5/1996 and 30/4/1999 completed the Assessment of Quality of Life instrument (AQoL, range: -0.04 [worse than death] to 0 [death] to 1 [full health]) at ≥one of 3month, 6-month, 1-year, 2-year, 3-year, 4-year, 5-year, 7-year and 10-year interviews after stroke. Sociodemographic and health information were collected at baseline. We derived aSES from postcode using the Australian Socio-Economic Indexes For Area (2006) (categories: high, medium, low), and iSES from lifetime occupation (categories: non-manual, manual). Multivariable linear mixed effects modelling was used to estimate trajectories of HRQoL over 10 years, by aSES and iSES, adjusting for age, sex, cardiovascular disease, smoking, diabetes, stroke severity, stroke type, and the time influence on age and health conditions. RESULTS: Of 1,686 participants enrolled, we excluded 239 with 'possible' stroke and 284 with missing iSES. Among the remaining 1,163 participants, 1,123 (96.6%) had AQoL assessed at ≥3 timepoints. In multivariable analysis, over time, people in the medium aSES group had mean 0.02 (95% CI -0.06, 0.02) greater reduction in AQoL score, and people in the low aSES group had mean 0.04 (95% CI, -0.07, -0.001) greater reduction, than those in the high aSES group. Manual workers had an average 0.04 (95% CI, -0.07, -0.01) greater reduction in AQoL score over time than non-manual workers. CONCLUSIONS: Over time, HRQoL declines in all people with stroke, declining most rapidly in lower SES groups.

Association Between Risk Factors in Childhood and Sex Differences in Prevalence of Carotid Artery Plaques and Intima-Media Thickness in Mid-Adulthood in the Childhood Determinants of Adult Health Study.

Background The origins of sex differences in cardiovascular diseases are not well understood. We examined the contribution of childhood risk factors to sex differences in adult carotid artery plaques and intima-media thickness (carotid IMT). Methods and Results Children in the 1985 Australian Schools Health and Fitness Survey were followed up when they were aged 36 to 49 years (2014-19, n=1085-1281). Log binomial and linear regression examined sex differences in adult carotid plaques (n=1089) or carotid IMT (n=1283). Childhood sociodemographic, psychosocial, and biomedical risk factors that might contribute to sex differences in carotid IMT/plaques were examined using purposeful model building with additional adjustment for equivalent adult risk factors in sensitivity analyses. Women less often had carotid plaques (10%) than men (17%). The sex difference in the prevalence of plaques (relative risk [RR] unadjusted 0.59 [95% CI, 0.43 to 0.80]) was reduced by adjustment for childhood school achievement and systolic blood pressure (RR adjusted 0.65 [95% CI, 0.47 to 0.90]). Additional adjustment for adult education and systolic blood pressure further reduced sex difference (RR adjusted 0.72 [95% CI, 0.49 to 1.06]). Women (mean±SD 0.61±0.07) had thinner carotid IMT than men (mean±SD 0.66±0.09). The sex difference in carotid IMT (ß unadjusted -0.051 [95% CI, -0.061 to -0.042]) reduced with adjustment for childhood waist circumference and systolic blood pressure (ß adjusted -0.047 [95% CI, -0.057 to -0.037]) and further reduced with adjustment for adult waist circumference and systolic blood pressure (ß adjusted -0.034 [95% CI, -0.048 to -0.019]). Conclusions Some childhood factors contributed to adult sex differences in plaques and carotid IMT. Prevention strategies across the life course are important to reduce adult sex differences in cardiovascular diseases.

Personalized knowledge to reduce the risk of stroke (PERKS-International): Protocol for a randomized controlled trial.

RATIONALE: Theoretically, most strokes could be prevented through the management of modifiable risk factors. The Stroke Riskometer™ mobile phone application (hereon "The App") uses an individual's data to provide personalized information and advice to reduce their risk of stroke. AIMS: To determine the effect of The App on a combined cardiovascular risk score (Life's Simple 7®, LS7) of modifiable risk factors at 6 months post-randomization. METHODS AND DESIGN: PERKS-International is a Phase III, multicentre, prospective, pragmatic, open-label, single-blinded endpoint, two-arm randomized controlled trial (RCT). Inclusion criteria are as follows: age ⩾ 35 and ⩽75 years; ⩾2 LS7 risk factors; smartphone ownership; no history of stroke/myocardial infarction/cognitive impairment/terminal illness. The intervention group (IG) will be provided with The App, and the usual care group (UCG) is provided with generic online information about risk factors, but not be informed about The App. Face-to-face assessments will be conducted at baseline and 6 months, and online at 3 and 12 months. The RCT includes a process and economic evaluation. STUDY OUTCOMES AND SAMPLE SIZE: The primary outcome is a difference in the mean change in LS7 (seven individual items: blood pressure, cholesterol, glucose, body mass index (BMI), smoking, physical activity, and diet) from baseline to 6 months post-randomization with intention-to-treat analysis. Secondary outcomes include: change in individual LS7 items, quality of life; stroke awareness, adverse events; health service use; and costs. Based on pilot data, 790 participants (395 IG, 395 UCG) will be required to provide 80% power (two-sided α = 0.05) to detect a mean difference in the LS7 of ⩾0.40 (SD 1.61) in IG compared to 0.01 (SD 1.44) in the UCG at 6 months post-randomization. DISCUSSION: Stroke is largely preventable. This study will provide evidence of the effectiveness of a mobile app to reduce stroke risk. TRIAL REGISTRATION: ACTRN12621000211864.

Echocardiographic detection of heart valve disease in a community cohort of asymptomatic Australians > 65 years with cardiovascular risk factors.

BACKGROUND: Valvular heart disease is becoming an increasingly prevalent with population ageing. We sought to define the current prevalence of valvular heart disease in Australia. METHODS: The TasELF and VicELF studies prospectively recruited 962 asymptomatic participants ≥65 years, with at least one cardiovascular risk factor, from the Tasmanian and Victorian communities. People were excluded if they had a previous diagnosis of heart failure, or a life expectancy <1 year. All underwent baseline echocardiography. Those with moderate or severe valvular disease were identified. The current prevalence of clinically significant valve disease was applied to the Australian Bureau of Statistics population projections. RESULTS: Echocardiograms were interpretable in 943 participants (98%). Clinically significant valve disease was present in 5% of the population, and mitral regurgitation was the most common overall valvular lesion, present in 36% of the population. The projected numbers of people with clinically significant valvular disease is expected to increase significantly across all age groups by the year 2060. CONCLUSIONS: Clinically significant yet asymptomatic valvular disease was prevalent in a large community cohort of participants with at least one risk factor. The total burden of valvular heart disease is expected to increase dramatically over the coming decades.

Antihypertensive Medication Adherence and the Risk of Vascular Events and Falls After Stroke: A Real-World Effectiveness Study Using Linked Registry Data.

BACKGROUND: Real-world evidence is limited on whether antihypertensive medications help avert major adverse cardiovascular events (MACE) after stroke without increasing the risk of falls. We investigated the association of adherence to antihypertensive medications on the incidence of MACE and falls requiring hospitalization after stroke. METHODS: A retrospective cohort study of adults who were newly dispensed antihypertensive medications after an acute stroke (Australian Stroke Clinical Registry 2012-2016; Queensland and Victoria). Pharmaceutical dispensing records were used to determine medication adherence according to the proportion of days covered in the first 6 months poststroke. Outcomes between 6 and 18 months postdischarge included: (i) MACE, a composite outcome of all-cause death, recurrent stroke or acute coronary syndrome; and (ii) falls requiring hospitalization. Estimates were derived using Cox models, adjusted for >30 confounders using inverse probability treatment weights. RESULTS: Among 4076 eligible participants (median age 68 years; 37% women), 55% had a proportion of days covered ≥80% within 6 months postdischarge. In the subsequent 12 months, 360 (9%) participants experienced a MACE and 337 (8%) experienced a fall requiring hospitalization. After achieving balance between groups, participants with a proportion of days covered ≥80% had a reduced risk of MACE (hazard ratio: 0.68; 95% CI: 0.54-0.84) and falls requiring hospitalization (subdistribution hazard ratio: 0.78; 95% CI: 0.62-0.98) than those with a proportion of days covered <80%. CONCLUSIONS: High adherence to antihypertensive medications within 6 months poststroke was associated with reduced risks of both MACE and falls requiring hospitalization. Patients should be encouraged to adhere to their antihypertensive medications to maximize poststroke outcomes.

Is sex a predictor for delayed cerebral ischaemia (DCI) and hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH)? A systematic review and meta-analysis.

OBJECTIVES: DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis. METHODS: A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies. RESULTS: There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11-1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27-2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78-1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99-1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57-1.33). CONCLUSIONS: Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.

Factors Contributing to Sex Differences in Health-Related Quality of Life After Ischemic Stroke: BASIC (Brain Attack Surveillance in Corpus Christi) Project.

Background Women have been reported to have worse health-related quality of life (HRQoL) following stroke than men, but uncertainty exists over the reasons for the sex difference. Methods and Results We included all ischemic strokes registered with the BASIC (Brain Attack Surveillance in Corpus Christi) project (May 2010-December 2016), a population-based stroke study, who completed a 90-day outcome interview. Information on baseline characteristics was obtained from medical records and in-person interviews. HRQoL was measured by the 12-item short-form Stroke Specific Quality of Life Scale. Multivariable Tobit regression was used to estimate the mean difference in overall HRQoL scores (range, 1-5; higher indicating better HRQoL) between sexes and to identify contributing factors to the differences. We included 1061 cases with complete data on HRQoL and covariates (median age, 67 years; 51% women). In unadjusted analyses, women had poorer overall HRQoL than men (mean difference, -0.26 [95% CI, -0.40 to -0.13]). Contributors to this difference included sociodemographic/prestroke factors (eg, age, race and ethnicity, prestroke function), risk factors/comorbidities (eg, history of stroke, Alzheimer disease/dementia), and initial stroke severity. Sociodemographic/prestroke factors explained 62% of the sex difference (mean difference, -0.08 [95% CI, -0.21 to 0.04]). In a fully adjusted model that included adjustment for all confounding factors, the sex difference was eliminated and became nonsignificant (mean difference, -0.03 [95% CI, -0.16 to 0.09]). Conclusions Poorer HRQoL in women compared with men was observed and explained by the combination of sociodemographic and prestroke factors, including physical function before stroke and stroke severity. The findings suggest potential subgroups of women who might benefit from more targeted interventions before and after stroke to improve HRQoL.

Correlates and determinants of transport-related physical activity among adults: an interdisciplinary systematic review.

INTRODUCTION: Transport-related physical activity (TRPA) has been identified as a way to increase physical activity due to its discretionary and habitual nature. Factors thought to influence TRPA span multiple disciplines and are rarely systematically considered in unison. This systematic review aimed to identify cross-sectional and longitudinal factors associated with adult TRPA across multiple research disciplines. METHODS: Using four electronic databases, a systematic search of English, peer-reviewed literature from 2010 - 2020 was performed. Studies quantitatively examining factors associated with the outcome of adult TRPA were eligible. RESULTS: Seventy-three studies (n = 66 cross-sectional; n = 7 longitudinal) were included, cumulatively reporting data from 1,278,632 observations. Thirty-six factors were examined for potential association with TRPA and presented in a social-ecological framework: individual (n = 15), social (n = 3), and environmental (n = 18). Seven factors were found to be consistently associated with higher adult TRPA: lower socio-economic status, higher self-efficacy, higher social normalization, lower distance of travel, higher destination concentration, more streetlighting, and higher public transportation frequency with a greater number of terminals near route start and endpoints. CONCLUSIONS: This is the first comprehensive compilation of the correlates and determinants of adult TRPA. Seven individual, social, and environmental factors demonstrated consistent associations with TRPA. Models formed using these factors may facilitate more effective promotion of TRPA. There is a lack of longitudinal studies as well as studies assessing cognitive/attitudinal and social factors, highlighting gaps for further research. Those developing policies and strategies targeting TRPA need to consider a range of factors at the individual, social, and environmental level to maximise the likelihood of effectiveness.

Longitudinal associations of childhood fitness and obesity profiles with midlife cognitive function: an Australian cohort study.

OBJECTIVES: Clusters of low fitness and high obesity in childhood are associated with poorer health outcomes in later life, however their relationship with cognition is unknown. Identifying such profiles may inform strategies to reduce risk of cognitive decline. This study examined whether specific profiles of childhood fitness and obesity were associated with midlife cognition. DESIGN: Prospective study. METHODS: In 1985, participants aged 7-15 years from the Australian Childhood Determinants of Adult Health study were assessed for fitness (cardiorespiratory, muscular power, muscular endurance) and anthropometry (waist-to-hip ratio). Participants were followed up between 2017 and 2019 (aged 39-50). Composites of psychomotor speed-attention, learning-working memory and global cognition were assessed using CogState computerised battery. Latent profile analysis was used to derive mutually exclusive profiles based on fitness and anthropometry. Linear regression analyses examined associations between childhood profile membership and midlife cognition adjusting for age, sex and education level. RESULTS: 1244 participants were included [age: 44.4 ±â€¯2.6 (mean ±â€¯SD) years, 53% female]. Compared to those with the highest levels of fitness and lowest waist-to-hip ratio, three different profiles characterised by combinations of poorer cardiorespiratory fitness, muscular endurance and power were associated with lower midlife psychomotor-attention [up to -1.09 (-1.92, -0.26) SD], and lower global cognition [up to -0.71 (-1.41, -0.01) SD]. No associations were detected with learning-working memory. CONCLUSIONS: Strategies that improve low fitness and decrease obesity levels in childhood could contribute to improvements in cognitive performance in midlife.