Cerebrovascular risk factors and their time-dependent effects on stroke survival in the EMMA cohort study.

To investigate the time-dependent effects of traditional risk factors on functional disability in all-cause mortality post-stroke, we evaluated data from a long-term stroke cohort. Baseline cerebrovascular risk factors (CVRF) and functionality at 1 and 6 months were evaluated in survivors from a prospective stroke cohort using the modified Rankin scale (m-RS), which classifies participants as improvement of disability, unchanged disability (at least moderate), and worsening disability. Cox regression models considering baseline risk factors, medication use, and functionality 6 months after stroke were fitted to identify their time-dependent effects up to 12 years of follow-up. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) are presented. Among 632 survivors (median age 68, 54% male, 71% first-ever episode), age and functional disability (unchanged and worsening) 6 months after ischemic stroke had time-dependent effects on all-cause mortality risk up to 12 years of follow-up. The most impacting risk factors were unchanged (at least moderate) (HR, 2.99; 95%CI: 1.98-4.52) and worsening disability (HR, 2.85; 95%CI: 1.26-6.44), particularly in the first two years after a stroke event (Time 1: ≥6 mo to <2.5 y). Worsening disability also impacted mortality in the period from ≥2.5 to <7.5 years (Time 2) of follow-up (HR, 2.43 (95%CI: 1.03-5.73). Other baseline factors had a fixed high-risk effect on mortality during follow-up. Post-stroke and continuous medication use had a fixed protective effect on mortality. Functional disability was the main contributor with differential risks of mortality up to 12 years of follow-up.

Cerebrovascular risk factors and their time-dependent effects on stroke survival in the EMMA cohort study

To investigate the time-dependent effects of traditional risk factors on functional disability in all-cause mortality post-stroke, we evaluated data from a long-term stroke cohort. Baseline cerebrovascular risk factors (CVRF) and functionality at 1 and 6 months were evaluated in survivors from a prospective stroke cohort using the modified Rankin scale (m-RS), which classifies participants as improvement of disability, unchanged disability (at least moderate), and worsening disability. Cox regression models considering baseline risk factors, medication use, and functionality 6 months after stroke were fitted to identify their time-dependent effects up to 12 years of follow-up. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) are presented. Among 632 survivors (median age 68, 54% male, 71% first-ever episode), age and functional disability (unchanged and worsening) 6 months after ischemic stroke had time-dependent effects on all-cause mortality risk up to 12 years of follow-up. The most impacting risk factors were unchanged (at least moderate) (HR, 2.99; 95%CI: 1.98-4.52) and worsening disability (HR, 2.85; 95%CI: 1.26-6.44), particularly in the first two years after a stroke event (Time 1: ≥6 mo to <2.5 y). Worsening disability also impacted mortality in the period from ≥2.5 to <7.5 years (Time 2) of follow-up (HR, 2.43 (95%CI: 1.03-5.73). Other baseline factors had a fixed high-risk effect on mortality during follow-up. Post-stroke and continuous medication use had a fixed protective effect on mortality. Functional disability was the main contributor with differential risks of mortality up to 12 years of follow-up.

Patient and Public Involvement and Engagement (PPIE): first steps in the process of the engagement in research projects in Brazil.

Patient and Public Involvement and Engagement (PPIE) - sometimes called Community Engagement and Involvement (CEI) - comes as a big challenge but one that can be very helpful for health care professionals and stakeholders in planning better health policies for attending to the main needs of the community. PPIE involves three pillars: public involvement, public engagement, and participation. Public involvement occurs when members of the general population are actively involved in developing the research question, designing, and conducting the research. Public engagement tells people about new studies, why they are important, the impact of results, the possible implication of the main findings for the community, and the possible impact of these new findings in society, as well as, in the dissemination of knowledge to the general population. Participation is being a volunteer in the study. Our experience with PPIE, to the best of our knowledge the first initiative in Brazil, is a partnership with the University of Birmingham, the University of Liverpool, and the NIHR Global Health Group on Atrial Fibrillation (AF) Management focusing on the AF care pathway exploring the important aspects of diagnosis and treatment in the primary care system from a low-middle income area in São Paulo. The involvement of patients/public in the research represents a new step in the process of inclusion of all segments of our society based on patient illness and the gaps in knowledge aiming to open new horizons for continuous improvement and better acceptance of research projects.

Patient and Public Involvement and Engagement (PPIE): first steps in the process of the engagement in research projects in Brazil

Patient and Public Involvement and Engagement (PPIE) - sometimes called Community Engagement and Involvement (CEI) - comes as a big challenge but one that can be very helpful for health care professionals and stakeholders in planning better health policies for attending to the main needs of the community. PPIE involves three pillars: public involvement, public engagement, and participation. Public involvement occurs when members of the general population are actively involved in developing the research question, designing, and conducting the research. Public engagement tells people about new studies, why they are important, the impact of results, the possible implication of the main findings for the community, and the possible impact of these new findings in society, as well as, in the dissemination of knowledge to the general population. Participation is being a volunteer in the study. Our experience with PPIE, to the best of our knowledge the first initiative in Brazil, is a partnership with the University of Birmingham, the University of Liverpool, and the NIHR Global Health Group on Atrial Fibrillation (AF) Management focusing on the AF care pathway exploring the important aspects of diagnosis and treatment in the primary care system from a low-middle income area in São Paulo. The involvement of patients/public in the research represents a new step in the process of inclusion of all segments of our society based on patient illness and the gaps in knowledge aiming to open new horizons for continuous improvement and better acceptance of research projects.

Hemostatic cardiovascular risk factors, common carotid-intima medial thickness and peripheral arterial disease in South Asians and African Caribbeans: a substudy to the Ethnic-Echocardiographic Heart of England Screening (E-ECHOES) study.

OBJECTIVE: To determine whether ethnic differences exist in inflammatory (interleukin-6 and C-reactive protein) and hemostatic biomarkers (soluble P-selectin [sP-sel], von Willebrand factor [VWF], and fibrin D-dimer) between South Asian (people originating from India, Pakistan, and Bangladesh) and African Caribbean (Black Caribbean and Black African) groups, the two largest minority ethnic groups in the UK; and to determine associations between these biomarkers and common carotid intima-media thickness and peripheral artery disease (PAD). PATIENTS AND METHODS: We recruited 572 subjects (356 South Asian and 216 Black) aged ≥ 45 years as a substudy to a community screening project, the Ethnic-Echocardiographic Heart of England Screening (E-ECHOES) study. All subjects completed an interviewer-led questionnaire, anthropometric measurements were taken, and blood sampling was performed if consent was granted. Ankle brachial pressure index (ABPI) was calculated, and the common carotid intima-media thickness (CCIMT) was measured. PAD was defined as ABPI < 0.9. ELISA was used to quantify inflammatory and hemostatic biomarkers. RESULTS: The incidence of hypertension (> 70%) and diabetes (> 27%) was high, but non-significantly different between the two ethnic groups. South Asians had higher platelet count and sP-sel levels than African Caribbeans (P < 0.0001 for both), despite there being no significant difference in antiplatelet medication. African Caribbeans had higher D-dimer levels (P = 0.0052). Among South Asians, VWF correlated with ABPI (P = 0.047) and mean (P = 0.002) and maximum CCIMT (P = 0.011) on univariate analysis, and remained an independent predictor of mean and maximum CCIMT on multivariate analysis with traditional cardiovascular risk factors (P = 0.034 and P = 0.046, respectively). In African Caribbeans, D-dimer levels were was higher in PAD than in normal ABPI participants (P = 0.04), and was associated with ABPI in both univariate analysis (P = 0.014) and multivariate analysis (P < 0.0001) with traditional cardiovascular risk factors. CONCLUSION: Ethnic differences are evident in inflammatory and hemostatic factors, as well as in their associations with CCIMT and PAD. These may reflect differences in cardiovascular risk factors or pathophysiologic processes that characterize each ethnic group.

Ethnic differences in patient perceptions of heart failure and treatment: the West Birmingham heart failure project.

OBJECTIVE: To investigate further the hypothesis that ethnic groups would have different levels of knowledge and perceptions of congestive heart failure (CHF) and treatments for this condition, a cross sectional survey was conducted of patients who were attending the heart failure clinics in two teaching hospitals of Birmingham, UK, that serve a multiethnic population. METHODS: 103 patients with CHF (66 men, 37 women) were surveyed by standard questionnaire: 42 were white, 34 Indo-Asian, 22 Afro-Caribbean, and 5 Oriental. RESULTS: When asked about their beliefs about control of one's health, 22 (64.7%) of Indo-Asians felt that God/fate controlled their health. The majority of white patients tended to believe that the greatest factor influencing their health was the doctor (15 (35.7%)). Of the total study cohort, only 68 (66%) of patients were aware of their primary diagnosis of heart failure; the majority of Indo-Asians (21 (61.8%)) were not aware of their diagnosis. Half of Indo-Asians (17 (50%)) felt that heart failure was not severe, in contrast to 40.9% (n = 9) of Afro-Caribbeans and only 19.1% (n = 8) of white patients. Of the study cohort, 38 (36.9%) were taking their drugs because their doctor told them to, a response most common among the Indo-Asians. The majority of Indo-Asians (22 (64.7%)) and Afro-Caribbeans (14 (63.6%)) stated that they did not have, or did not know whether they had enough, information about their drug. The corresponding figure for white patients was 21.4% (n = 9). When asked whether they took their medication regularly as prescribed, 7 (31.8%) of Afro-Caribbeans reported that they did not take their drugs regularly. CONCLUSIONS: Our study has highlighted deficiencies in the knowledge of CHF among patients from ethnic minority groups, as well as deficiencies in the information being given to these patients. There is a clear need to invest more in patient education for CHF, with special emphasis on certain high risk subgroups.

Ethnicity and peripheral vascular disease.

There are well-documented differences in the prevalence of coronary artery disease and carotid disease between caucasians, Afro-Caribbeans and Indo-Asians. Very little data are available on ethnic differences in peripheral vascular disease (PVD). To investigate this further, we surveyed 200 consecutive patients attending the vascular surgery service at a city centre hospital serving a multiethnic patient catchment population. All patients had proven PVD, with an ankle brachial pressure index of less than 0.8. Within this cohort, Afro-Caribbeans presented more frequently with PVD compared with the proportion of this ethnic group in the local population (p = 0.013), with a greater proportion with diabetes mellitus than in the other two ethnic groups. There did not appear to be a significant difference between the ethnic groups in any of the other established risk factors or associations (i.e. treated hypertension, smoking, previous history of ischaemic heart disease, atrial fibrillation, previous history of cerebrovascular accident or transient ischaemic attack) with PVD. As with coronary artery disease and carotid disease, there are ethnic differences in the prevalence of PVD, and the underlying risk factors, between caucasians, Afro-Caribbeans and Indo-Asians. Furthermore, patients of Afro-Caribbean origin present more frequently with symptomatic PVD than do either caucasians or Indo-Asians.

Ethnic differences in peripheral vascular disease.

The wide variation in the way coronary artery disease (CAD) affects different ethnic groups and the associated risk factor profiles of these groups have been extensively studied, but ethnic differences in the clinical manifestations of peripheral vascular disease (PVD) have been relatively neglected. The aim of the present review is to provide an overview of PVD in different ethnic groups and to explore possible pathophysiological factors accounting for these differences. Atherosclerotic PVD is generally less prevalent in Indo-Asians and Afro-Caribbeans than in caucasians, despite the 'classical' risk factors being as prevalent, if not more so, suggesting the possibility of as yet unidentified risk factors in these groups. Angiographic and microscopic evidence suggests that patients of African or Afro-Caribbean origin suffer from a different pattern of PVD, which primarily affects the distal arteries. In contrast, Indo-Asians tend to suffer from thromboangiitis obliterans (Buerger's disease) far more frequently than other ethnic groups; thus, their arterial disease appears to present much earlier and with greater severity. However, if this sub-category of patient is excluded, they seem to suffer much less from 'simple' atherosclerotic disease than their caucasian counterparts. Despite a higher prevalence of diabetes among Indo-Asians, the prevalence of intermittent claudication is considerably less in this ethnic group.