Public and Private Hospital Care Disparities of Ischemic Stroke in Mexico: Results from the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) Study.

BACKGROUND AND AIMS: Mortality and bad outcome by stroke are higher in developing countries than in industrialized countries. Health-care system efficiency could explain these disparities. Our objective was to identify the impact on short- and middle-term outcomes of patients with acute ischemic stroke (AIS) among public and private Mexican medical care. METHODS: We analyzed data from patients with AIS included in the Primer Registro Mexicano de Isquemia Cerebral (PREMIER) study. Transient ischemic attacks (TIAs) and ambulatory patients were excluded. Mortality and good outcome were assessed by the modified Rankin Scale (mRS) and analyzed at 1, 3, and 12 months of follow-up. RESULTS: From 1246 patients with AIS included in the registry, 1123 were hospitalized, either in public (n = 881) or in private (n = 242) hospitals. There were no significant differences regarding age and gender. In private settings, patients had a higher educational level, a major frequency of dyslipidemia, a previous stroke and TIA, less overweight and obesity, a sedentary lifestyle, and diabetes; stroke severity, the rate of systemic complications, the length of stay, and in-hospital mortality were also lower; a major frequency of thrombolysis was observed when compared with public hospitals. Our study showed a better outcome (mRS score ≤2) in private scenarios and a higher mortality in patients treated in public hospitals at short- and middle-term follow-ups. CONCLUSIONS: A polarized medical practice was observed in the AIS care in this large multicenter cohort of Mexico. There is evidence of an advantage for private scenarios, possibly related with an optimal infrastructure or with a strong patient's economic status.

Serum uric acid and outcome after acute ischemic stroke: PREMIER study.

BACKGROUND: Current evidence shows that uric acid is a potent antioxidant whose serum concentration increases rapidly after acute ischemic stroke (AIS). Nevertheless, the relationship between serum uric acid (SUA) levels and AIS outcome remains debatable. We aimed to describe the prognostic significance of SUA in AIS. METHODS: We studied 463 patients (52% men, mean age 68 years, 13% with glomerular filtration rate <60 ml/min at hospital arrival) with AIS pertaining to the multicenter registry PREMIER, who had SUA measurements at hospital presentation. Multivariate models were constructed to analyze the association of SUA with functional outcome as assessed by the modified Rankin scale (mRS) at 30-day, 3-, 6- and 12-month follow-up. A mRS 0-1 was regarded as a very good outcome. RESULTS: Mean SUA concentration at hospital arrival was 6.1 ± 3.7 mg/dl (362.8 ± 220.0 µmol/l). Compared with cases with higher SUA levels at hospital admission, patients with ≤4.5 mg/dl (≤267.7 µmol/l; the lowest tertile of the sample) had more cases of a very good 30-day outcome (30.5 vs. 18.9%, respectively; p = 0.004). SUA was not associated with mortality or functional dependence (mRS >2) at 30 days, or with any outcome measure at 3, 6 or 12 months poststroke. After adjustment for age, gender, stroke type and severity (NIHSS <9), time since event onset, serum creatinine, hypertension, diabetes and smoking, a SUA ≤4.5 mg/dl (≤267.7 µmol/l) was positively associated with a very good short-term outcome (odds ratio: 1.76, 95% confidence interval: 1.05-2.95; negative predictive value: 81.1%), but not at 3, 6 or 12 months of follow-up. When NIHSS was entered in the multivariate model as a continuous variable, the independent association of SUA with outcome was lost. Compared with cases with higher levels, patients with SUA ≤4.5 mg/dl (≤267.7 µmol/l) were more frequently younger than 55 years, women, with mild strokes, with normal serum creatinine and fewer had hypertension. The time since event onset to hospital arrival was not significantly associated with AIS severity or SUA levels; nevertheless, a nonsignificant tendency was observed for patients with severe strokes and high SUA levels arriving in <24 h. CONCLUSIONS: A low SUA concentration is modestly associated with a very good short-term outcome. Our findings support the hypothesis that SUA is more a marker of the magnitude of the cerebral infarction than an independent predictor of stroke outcome.

[Obesity paradox and functional recovery in first-ever acute ischemic stroke survivors: the PREMIER study]. / Paradoja de la obesidad y recuperación funcional en sobrevivientes a un primer infarto cerebral: estudio PREMIER.

INTRODUCTION: The 'obesity paradox' is the decreasing risk of death after cardiovascular disease, with a high body mass index (BMI), even when BMI is a risk factor for vasculopathy, in the first place. Our aim was to analyze the influence of obesity on the functional recovery after ischemic stroke. PATIENTS AND METHODS: We studied 510 patients who survived a first-ever acute ischemic stroke, without cerebrovascular disease history, and without recurrence or death after 12 months of follow-up. We also studied 501 healthy subjects who received tetrapolar bioimpedance analysis to compare the waist-to-height ratio (WHtR), abdominal circumference and BMI, as adiposity indices, in order to apply them in stroke patients. RESULTS: In healthy individuals, WHtR performed better than BMI or abdominal circumference in predicting body fat. In a Cox proportional hazards model adjusted for multiple covariables, age (hazard ratio, HR = 1.11; 95% confidence interval, 95% CI = 1.08-1.14), NIHSS score (HR = 1.03; 95% CI = 1.01-1.05) and WHtR > 70 (HR = 2.44; 95% CI = 1.33-4.48) were associated with a high risk of attaining a modified Rankin scale more or equal than 3 at 12 months after stroke; whereas BMI > 35 (HR = 0.33; 95% CI = 0.11-0.98) was protector. CONCLUSION: As reflected by WHtR, the excess of adiposity increases the chance of severe disability after ischemic stroke. Since BMI reflects also total lean mass, it is risky to conclude that there is a protective effect of obesity alone in the functional recovery after stroke; nevertheless, it is possible that a certain magnitude of body mass is necessary to prevent severe disability in stroke survivors.

Paradoja de la obesidad y recuperación funcional en sobrevivientes a un primer infarto cerebral: estudio PREMIER / Obesity paradox and functional recovery in first-ever acute ischemic stroke survivors: the PREMIER study

Introducción. Se denomina 'paradoja de la obesidad' al descenso del riesgo de muerte por enfermedad cardiovascular, con un índice de masa corporal (IMC) alto, aun cuando este es un factor de riesgo para vasculopatía. Nuestro objetivo fue analizar la influencia de la obesidad en la recuperación funcional que sigue a un ictus isquémico. Pacientes y métodos. Analizamos 510 pacientes con un primer infarto cerebral, sin historia de ictus y sin recurrencia o muerte en 12 meses de seguimiento. A 501 sujetos sanos se les evaluó mediante bioimpedancia tetrapolar, para comparar el índice cintura/talla (ICT), perímetro abdominal e IMC en la discriminación de adiposidad, para aplicarlos a pacientes con ictus. Resultados. En individuos sanos, el ICT se desempeño notablemente mejor que el IMC o el perímetro abdominal para identificar adiposidad corporal. En un modelo de riesgos proporcionales de Cox ajustado por múltiples covariables, la edad (riesgo relativo, RR = 1,11; intervalo de confianza del 95%, IC 95% = 1,08-1,14), puntuación de la National Institutes of Health Stroke Scale (RR = 1,03; IC 95% = 1,01-1,05) e ICT > 70 (RR = 2,44; IC 95% = 1,33-4,48) se asociaron a mayor riesgo de alcanzar una puntuación mayor o igual a 3 en la escala de Rankin modificada a los 12 meses, mientras que un IMC > 35 (RR = 0,33; IC 95% = 0,11-0,98) fue protector. Conclusión. El exceso de adiposidad, según el ICT, aumenta la probabilidad de discapacidad grave después del ictus. Dado que el IMC refleja también masa magra, es arriesgado concluir que existe un efecto protector de la obesidad en la recuperación del ictus, pero es posible que cierta masa corporal sea necesaria para prevenir una discapacidad grave (AU)

Introduction. The 'obesity paradox' is the decreasing risk of death after cardiovascular disease, with a high body mass index (BMI), even when BMI is a risk factor for vasculopathy, in the first place. Our aim was to analyze the influence of obesity on the functional recovery after ischemic stroke. Patients and methods. We studied 510 patients who survived a first-ever acute ischemic stroke, without cerebrovascular disease history, and without recurrence or death after 12 months of follow-up. We also studied 501 healthy subjects who received tetrapolar bioimpedance analysis to compare the waist-to-height ratio (WHtR), abdominal circumference and BMI, as adiposity indices, in order to apply them in stroke patients (AU)

Manejo agudo y pronóstico a un año en pacientes mexicanos con un primer infarto cerebral: resultados del estudio multicéntrico PREMIER / Acute care and one-year outcome of Mexican patients with first-ever acute ischemic stroke: the PREMIER study

Introducción. Se carece de información sobre el cuidado agudo y pronóstico de mexicanos con infarto cerebral. El objetivo de este informe es proveer los resultados de un sistema multicéntrico de vigilancia hospitalaria en ictus isquémico agudo. Pacientes y métodos. En el estudio PREMIER se incluyeron 1.376 pacientes de 59 hospitales entre enero de 2005 y junio de 2006. De éstos, se analizaron 1.040 (52% mujeres; edad promedio: 67,5 años) con un primer infarto cerebral. Cinco visitas se completaron durante un año de seguimiento. Resultados. Los principales factores de riesgo fueron hipertensión (64%), obesidad (51%) y diabetes (35%). Un 19% de los pacientes se presentó con un síndrome de circulación anterior total, un 38% de circulación anterior parcial, un 26% lacunar y un 17% de circulación posterior. En el 8%, el mecanismo del ictus fue aterotrombosis de grandes arterias, el 18% fue cardioembólico, el 20% lacunar, el 6% misceláneo y el 42% indeterminado. Aunque un 17% de los pacientes llegó en menos de tres horas de ocurrido el ictus, sólo al 0,5% se le realizó trombólisis intravenosa. Se practicó endarterectomía o colocación de endoprótesis arterial en el 1%. La mortalidad a 30 días fue del 15%. Al año de seguimiento, un 47% tuvo una puntuación en la escala de Rankin modificada de 0-2 puntos (independiente), un 23% tuvo 2-5 puntos (dependiente) y un 29% falleció. La tasa anual de recurrencia fue del 8%. Conclusión. En México, una proporción significativa de pacientes llega a tiempo para trombólisis, pero muy pocos la reciben. Existe un bajo uso de recursos de diagnóstico para asignar la etiología del infarto cerebral. La tasa de fatalidad a 30 días se duplica un año después del ictus (AU)

Introduction. Information on acute care and outcome of Mexican patients with ischaemic stroke is lacking. The aim of this report is to provide results of a first step stroke surveillance system and outcome at one year of follow-up. Patients and methods. In the PREMIER study 1,376 patients from 59 Mexican hospitals were included from January 2005 to June 2006. Of these, 1,040 (52% women, mean age 67.5 years) with first-ever cerebral infarction are here analyzed. Five visits were completed during the one year follow-up. Results. Main risk factors were hypertension (64%), obesity (51%) and diabetes (35%). Total anterior circulation stroke syndrome occurred in 19% of patients, partial anterior in 38%, lacunar in 26% and posterior stroke syndrome in 17% cases. In 8% the stroke mechanism was large-artery atherosclerosis, in 18% cardioembolism, in 20% lacunar, in 6% miscellaneous mechanisms and in 42% the mechanism was undetermined, mainly due to a low use of diagnostic resources. Although 17% of patients arrived in < 3 h from stroke onset, only 0.5% had IV thrombolysis. Only 1% received endarterectomy or stenting. The 30-day case fatality rate was 15%. At one-year of follow-up, 47% had a modified Rankin score 0-2 (independent), 23% had 2-5 (dependent) and 29% died. One-year acute ischaemic stroke recurrence rate was 8%. Conclusion. In Mexico a significant proportion of patients arrive on time for thrombolysis, but very few receive this therapy. There is a low use of diagnostic resources to assign aetiology. Thirty-day case fatality rate doubles at 1-year after acute ischaemic stroke (AU)

Acute care and one-year outcome of Mexican patients with first-ever acute ischemic stroke: the PREMIER study.

INTRODUCTION: Information on acute care and outcome of Mexican patients with ischaemic stroke is lacking. The aim of this report is to provide results of a first step stroke surveillance system and outcome at one year of follow-up. PATIENTS AND METHODS: In the PREMIER study 1,376 patients from 59 Mexican hospitals were included from January 2005 to June 2006. Of these, 1,040 (52% women, mean age 67.5 years) with first-ever cerebral infarction are here analyzed. Five visits were completed during the one year follow-up. RESULTS: Main risk factors were hypertension (64%), obesity (51%) and diabetes (35%). Total anterior circulation stroke syndrome occurred in 19% of patients, partial anterior in 38%, lacunar in 26% and posterior stroke syndrome in 17% cases. In 8% the stroke mechanism was large-artery atherosclerosis, in 18% cardioembolism, in 20% lacunar, in 6% miscellaneous mechanisms and in 42% the mechanism was undetermined, mainly due to a low use of diagnostic resources. Although 17% of patients arrived in < 3 h from stroke onset, only 0.5% had IV thrombolysis. Only 1% received endarterectomy or stenting. The 30-day case fatality rate was 15%. At one-year of follow-up, 47% had a modified Rankin score 0-2 (independent), 23% had 2-5 (dependent) and 29% died. One-year acute ischaemic stroke recurrence rate was 8%. CONCLUSION: In Mexico a significant proportion of patients arrive on time for thrombolysis, but very few receive this therapy. There is a low use of diagnostic resources to assign aetiology. Thirty-day case fatality rate doubles at 1-year after acute ischaemic stroke.