Racial and Gender Differences in Stroke Severity, Outcomes, and Treatment in Patients with Acute Ischemic Stroke

Abstract

Background Previous research has indicated that women and Blacks have worse outcomes following acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis and functional outcome after AIS. Methods AIS patients who presented to two academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2 point increase in NIHSS), and functional outcome at discharge, measured by the modified Rankin Scale (mRS), were investigated. These outcomes were compared across race/gender groups. A sub-analysis was conducted to assess race/gender differences in exclusion criteria for tPA. Results Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS on admission (8) with White men had the lowest median NIHSS on admission (6). There were no differences in outcomes between Black men and White men. A smaller percentage of Black women than White women were treated with tPA (27.6% vs. 36.6%, p<0.0001), partially due to a greater proportion of White women presenting within 3 hours (51% vs. 45.5%, p =0.0005). Black women had decreased odds of poor functional outcome relative to White women (OR=0.85, 95%CI 0.72-1.00), but after adjustment for baseline differences in age, NIHSS and tPA use this association was no longer significant (OR=1.2, 95%CI 0.92-1.46, p=0.22). Black women with a NIHSS on admission of less than 7 were at lower odds of receiving tPA than the other race gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR 0.66, 95%CI 0.44-0.99, p=0.0433). Conclusion Race and gender were not significantly associated with short-term outcome, although Black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to Black women not arriving to the ED in time is of great importance.

Incidence, Management and Short-Term Outcome of Stroke in a General Population of 1.4 Million Japanese ― Shiga Stroke Registry ―

“…In previous population-based studies from Europe, casefatality rates at 30 days have been reported to be 20.6-21.6% for total stroke 22,23 and 31.6% for intracerebral hemorrhage. 22 In several recent hospital-based studies, the percentage of patients with death or dependency (mRS score 3 to 6) at discharge has been reported to be 43.4% in men and 49.6% in women for ischemic stroke in the USA, 24 and 30.9% in men and 39.8% in women for total stroke in Korea. 25 In a large-scale Japanese hospital-based registry, the frequency of death or dependency (mRS score 3-6) at discharge has been reported as 45.2% for large-artery infarction, 26.6% for lacunar infarction, 59.5% for cardioembolic infarction, and 67.4% for hypertensive intracerebral hemorrhage.…”

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

“…More recent studies demonstrated significant differences in delay to arrival within 3 hours22, 52, 58 that persist after adjusting for age, sex, stroke severity, and insurance status 26. Boehme et al found that black women, specifically, are more likely to arrive outside of the 3‐hour time window than white men, black men, or white women 59. In their analysis of >200 000 acute stroke cases in the Get With The Guidelines Stroke registry, Ekundayo et al found that minorities were less likely to use EMS,12 but in the Greater Cincinnati/Northern Kentucky Stroke Study there was no difference in EMS utilization between white and black patients 60.…”

Age, Sex, and Racial Differences in Neuroimaging Use in Acute Stroke: A Population-Based Study

“…Previous studies have shown compelling sex, racial, and socioeconomic disparities in the treatment and outcomes among patients with acute stroke. [5][6][7] Generally, racial minorities and women with acute stroke have lower quality hospital care, 5,[8][9][10][11][12][13] including the use of imaging. These disparities can contribute to inequality in stroke outcomes and are a top research priority of the National Institute of Neurologic Disorders and Stroke.…”