Biological and Social Determinants of Hypertension Severity Before vs After Intracerebral Hemorrhage

Abramson, Jessica R; Castello, Juan Pablo; Keins, Sophia; Kourkoulis, Christina; Rodriguez-Torres, Axana; Myserlis, Evangelos Pavlos; Alabsi, Haitham; Warren, Andrew; Henry, Jonathan J.; Gurol, M. Edip; Viswanathan, Anand; Greenberg, Steven M.; Towfighi, Amytis; Skolarus, Lesli E.; Anderson, Christopher; Rosand, Jonathan; Biffi, Alessandro

doi:10.1212/wnl.0000000000200003

Cited by 8 publications

(10 citation statements)

References 31 publications

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“…We used data from the prospectively collected Massachusetts General Hospital ICH cohort 10 . Inclusion criteria are age over 18 and admission to the MGH Neuroscience Intensive Care Unit from January 1994 until January 2020 with a clinical and radiographically confirmed diagnosis of primary ICH.…”

Section: Methodsmentioning

confidence: 99%

“…Despite increasingly standardized care for acute clinical management of intracerebral hemorrhage (ICH), disparate outcomes after ICH have been described [10][11][12][13][14][15][16] . Given prior literature suggesting a role for educational attainment impacting risk and recovery for stroke, we hypothesize that in addition to traditional clinical risk factors, such as hypertension, education will be associated with ICH severity and recovery.…”

Section: Introductionmentioning

confidence: 99%

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Educational attainment in hemorrhagic stroke severity and functional outcome

Yechoor

Rist

Ganbold

et al. 2023

Preprint

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Introduction: While stroke education is a hallmark of clinical care in primary stroke centers, the educational attainment of patients is rarely considered. The objective of this study is to determine whether educational attainment, in addition to traditional risk factors, is associated with intracerebral hemorrhage (ICH) severity and functional outcomes.<break><break>Methods: Subjects were enrolled in a prospectively ascertained cohort of patients with primary ICH from 1994 until 2020 at the Massachusetts General Hospital Neurosciences Intensive Care Unit. Data on social determinants of health (SDOH), past medical history for ICH risk factors, and ICH severity were obtained on admission. The primary outcome was stroke severity, calculated using the ICH score. The secondary outcome was 12-month modified Rankin Score (mRS). <break><break>Results: Of 2,539 patients eligible for analyses, 1,744 (69%) presented with mild ICH (ICH Score < 3) and 795 (31%) presented with severe ICH (ICH score 3). In a multivariable logistic regression analysis controlling for age, income, and a pre-stroke diagnosis of coronary artery disease, only educational attainment was associated with stroke severity, with patients with high school-only education more likely to present with a severe ICH compared to college diplomates (odds ratio 2.37, 95% CI 1.77, 3.19). Additionally, those with high school-only education were less likely to recover to a good functional outcome (mRS<4) after ICH when compared to college diplomates (odds ratio 0.43, 95% CI 0.19, 0.93) when controlling for stroke severity, and pre-stroke diagnoses of hypertension and dementia. <break><break>Discussion: Pre-stroke educational attainment is an independent predictor of ICH severity and subsequent functional outcomes at 12-month post-stroke. Given the association with recovery, tailoring inpatient stroke education to level of educational attainment may serve to reduce the disparity in outcomes after hemorrhagic stroke. Educational attainment may act as both a social and a biological determinant, and could represent a modifiable risk factor for ICH survivors.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Educational attainment in hemorrhagic stroke severity and functional outcome

Yechoor

Rist

Ganbold

et al. 2023

Preprint

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“…All relevant covariates displayed <5% missing values; these missing values were filled via random dataset-based imputation, as previously described. 21 Categorical variables were compared using Fisher exact test (2-sided) and continuous variables using the Mann-Whitney rank-sum or unpaired t test, as appropriate. We created separate longitudinal mixed effects models to investigate determinants of systolic and diastolic BP measurements during follow-up after ICH.…”

Section: Methodsmentioning

confidence: 99%

Association of Depression Onset and Treatment With Blood Pressure Control After Intracerebral Hemorrhage

Keins

Abramson

Mallick

et al. 2023

Stroke

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Background: Blood pressure (BP) control represents a crucial intervention to improve long-term outcomes following spontaneous intracerebral hemorrhage (ICH). However, fewer than half of ICH survivors achieve target treatment goals. ICH survivors are also at very high risk for poststroke depression, which may contribute to inadequate BP control. We, therefore, sought to determine whether depressive symptoms after ICH are associated with inadequate BP control. We also investigated whether associations between depression after ICH and BP measurements were mediated by treatment with selective serotonin reuptake inhibitors or norepinephrine-serotonin reuptake inhibitors antidepressants. Methods: We leveraged data from a single-center longitudinal study of ICH conducted at Massachusetts General Hospital (Boston, MA) between 2006 and 2018. We collected data from semiautomated review of electronic health records, baseline and follow-up interviews, and computed tomography imaging. Information on BP measurements, depression diagnoses, antidepressants medication use, and medical visits were collected longitudinally and analyzed using mixed effects models. Primary outcomes included systolic and diastolic BP measurements during long-term follow-up after ICH. Results: We included 1243 consecutive ICH patients without pre-stroke depression history. Of these, 721 (58%) were diagnosed with incident depression over a median follow-up time of 52.8 months (interquartile range, 42.1–60.5). Depression onset was associated with subsequent increase in systolic (+8.3 mm Hg, SE, 2.4 mm Hg, P =0.012) and diastolic (+4.4 mm Hg, SE, 1.2 mm Hg) BP measurements. Resolution of depressive symptoms was associated with subsequent decrease in systolic (−5.9 mm Hg, SE, 1.4 mm Hg, P =0.031) and diastolic (−3.4 mm Hg, SE, 1.1 mm Hg, P =0.041) BP measurements. We also found associations between higher systolic BP measurements and use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants, independent of whether depression symptoms were active or not (all P <0.05). Conclusions: ICH survivors displayed increasing BP values after receiving a diagnosis of depression, followed by decreasing values among those experiencing resolution of depressive symptoms. Use of selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor antidepressants was independently associated with higher systolic BP measurements. Clinicians ought to closely monitor BP for ICH survivors being treated for depression, especially using selective serotonin reuptake inhibitor and noradrenaline-serotonin reuptake inhibitor. Future studies will also be required to investigate the mechanisms underlying these associations.

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“…Despite increasingly standardised and accessible care for acute clinical management of intracerebral haemorrhage (ICH), the prevalence and incidence of ICH have increased and inequitable outcomes after ICH have been described11–18 suggesting factors apart from traditional clinical determinants impact the risk and recovery from stroke. Given prior literature suggests a role for educational attainment in impacting risk and recovery for stroke, we hypothesise that in addition to traditional clinical risk factors, such as hypertension (HTN), educational attainment will be associated with ICH severity and prognosis.…”

Section: Introductionmentioning

confidence: 99%

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage

Yechoor,

Rist,

Ganbold

et al. 2024

BMJ Neurol Open

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BackgroundEducational attainment is a critical social determinant of health that impacts the risk and severity of incident ischaemic stroke, but less is known of its impact on intracerebral haemorrhage (ICH). The objective of this study is to determine whether educational attainment is associated with ICH severity and short-term prognosis.MethodsSubjects were enrolled in a prospectively ascertained cohort with primary ICH from 1994 to 2020 at Massachusetts General Hospital. Educational attainment, medical history of ICH risk factors, ICH volume and ICH score were obtained on admission. The primary outcomes were ICH volume and the ICH score.ResultsOf 2539 eligible patients eligible, the median age of the sample was 74 (IQR 64–82) and 2159 (85%) had high school-only education. 1655 (65%) presented with an ICH volume less than or equal to 30 mL and 1744 (69%) presented with an ICH score less than 3. In multivariable logistic regression analyses controlling for age, income, employment history and prestroke diagnoses of hypertension and coronary artery disease, patients with high school-only education were more likely to have an ICH volume greater than 30 mL compared with college diplomates (OR 1.58, 95% CI 1.24 to 2.08) and more likely to have an ICH score of 3 or greater compared with college diplomates (OR 2.37, 95% CI 1.77 to 3.19).DiscussionPrestroke educational attainment is independently associated with ICH severity and short-term prognosis, with lower educational attainment associated with larger ICH volumes and higher ICH scores. Future studies should examine how educational attainment impacts exposure to traditional clinical risk factors.

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Biological and Social Determinants of Hypertension Severity Before vs After Intracerebral Hemorrhage

Cited by 8 publications

References 31 publications

Educational attainment in hemorrhagic stroke severity and functional outcome

Educational attainment in hemorrhagic stroke severity and functional outcome

Association of Depression Onset and Treatment With Blood Pressure Control After Intracerebral Hemorrhage

Educational attainment, severity and short-term prognosis of intracerebral haemorrhage

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