@article {741, title = {C-reactive protein, carotid intima-media thickness, and incidence of ischemic stroke in the elderly: the Cardiovascular Health Study.}, journal = {Circulation}, volume = {108}, year = {2003}, month = {2003 Jul 15}, pages = {166-70}, abstract = {

BACKGROUND: Increased carotid artery intima-media thickness (IMT) and elevated C-reactive protein (CRP) are both associated with the occurrence of stroke. We investigated whether elevated CRP is a risk factor for ischemic stroke independent of carotid IMT and studied the interaction between CRP and IMT.

METHODS AND RESULTS: We studied 5417 participants aged 65 years or older without preexisting stroke or chronic atrial fibrillation who were participants in the Cardiovascular Health Study. The hazard ratio of incident ischemic stroke was estimated by Cox proportional hazards regression. During 10.2 years of follow-up, 469 incident ischemic strokes occurred. The adjusted hazard ratios for ischemic stroke in the 2nd to 4th quartiles of baseline CRP, relative to the 1st quartile, were 1.19 (95\% CI 0.92 to 1.53), 1.05 (95\% CI 0.81 to 1.37), and 1.60 (95\% CI 1.23 to 2.08), respectively. With additional adjustment for carotid IMT, there was little confounding. The association of CRP with stroke was significantly different depending on IMT (P<0.02), with no association of CRP with stroke among those in the lowest IMT tertile and a significant association among those with higher levels of IMT.

CONCLUSIONS: We conclude that elevated CRP is a risk factor for ischemic stroke, independent of atherosclerosis severity as measured by carotid IMT. The association of CRP with stroke is more apparent in the presence of a higher carotid IMT. CRP and carotid IMT may each be independent integrals in determining the risk of ischemic stroke.

}, keywords = {Aged, Brain Ischemia, C-Reactive Protein, California, Carotid Arteries, Cohort Studies, Comorbidity, Female, Follow-Up Studies, Humans, Incidence, Longitudinal Studies, Male, Maryland, North Carolina, Odds Ratio, Pennsylvania, Proportional Hazards Models, Risk Assessment, Risk Factors, Stroke, Tunica Intima, Tunica Media, Ultrasonography}, issn = {1524-4539}, doi = {10.1161/01.CIR.0000079160.07364.6A}, author = {Cao, Jie J and Thach, Chau and Manolio, Teri A and Psaty, Bruce M and Kuller, Lewis H and Chaves, Paulo H M and Polak, Joseph F and Sutton-Tyrrell, Kim and Herrington, David M and Price, Thomas R and Cushman, Mary} } @article {864, title = {A prospective study of anemia status, hemoglobin concentration, and mortality in an elderly cohort: the Cardiovascular Health Study.}, journal = {Arch Intern Med}, volume = {165}, year = {2005}, month = {2005 Oct 24}, pages = {2214-20}, abstract = {

BACKGROUND: Anemia is viewed as a negative prognostic factor in the elderly population; its independent impact on survival is unclear.

METHODS: Baseline hemoglobin quintiles and anemia, as defined by the World Health Organization criteria, were assessed in relation to mortality in the Cardiovascular Health Study, a prospective cohort study with 11.2 years of follow-up of 5888 community-dwelling men and women 65 years or older, enrolled in 1989-1990 or 1992-1993 in 4 US communities.

RESULTS: A total of 1205 participants were in the lowest hemoglobin quintile (<13.7 g/dL for men; <12.6 g/dL for women), and 498 (8.5\%) were anemic (<13 g/dL for men; <12 g/dL for women). A reverse J-shaped relationship with mortality was observed; age-, sex-, and race-adjusted hazard ratios (95\% confidence interval [CI]) in the first and fifth quintiles, compared with the fourth quintile, were 1.42 (95\% CI, 1.25-1.62) and 1.24 (95\% CI, 1.09-1.42). After multivariate adjustment, these hazard ratios were 1.33 (95\% CI, 1.15-1.54) and 1.17 (95\% CI, 1.01-1.36). The demographic- and fully-adjusted hazard ratios of anemia for mortality were 1.57 (95\% CI, 1.38-1.78) and 1.38 (95\% CI, 1.19-1.54). Adjustment for causes and consequences of anemia (renal function, inflammation, or frailty) did not reduce associations.

CONCLUSIONS: Lower and higher hemoglobin concentrations and anemia by World Health Organization criteria were independently associated with increased mortality. The World Health Organization criteria did not identify risk as well as a lower hemoglobin value. Additional study is needed on the clinically valid definition for and causes of anemia in the elderly and on the increased mortality at the extremes of hemoglobin concentrations.

}, keywords = {Age Factors, Aged, Anemia, California, Female, Follow-Up Studies, Health Status, Hemoglobins, Humans, Male, Maryland, Multivariate Analysis, North Carolina, Observation, Pennsylvania, Prospective Studies, Risk Factors, Severity of Illness Index, Survival Rate}, issn = {0003-9926}, doi = {10.1001/archinte.165.19.2214}, author = {Zakai, Neil A and Katz, Ronit and Hirsch, Calvin and Shlipak, Michael G and Chaves, Paulo H M and Newman, Anne B and Cushman, Mary} } @article {900, title = {Factors associated with geographic variations in stroke incidence among older populations in four US communities.}, journal = {Stroke}, volume = {37}, year = {2006}, month = {2006 Aug}, pages = {1980-5}, abstract = {

BACKGROUND AND PURPOSE: In the Cardiovascular Health Study (CHS), we previously observed lower stroke incidence in Allegheny County, PA compared with the other 3 study sites. The purpose of this study was to study possible reasons for the lower stroke incidence in Allegheny County.

METHODS: CHS participants 65 years or older who were stroke-free at baseline (n=5639) were followed between 1989 to 1990 and 2000 for the development of stroke. Risk factors at baseline and their subsequent control were compared among both groups. Site-specific hazard ratios for stroke incidence were calculated using Cox regression models.

RESULTS: The unadjusted hazard ratio for total stroke incidence in Forsyth County, NC; Sacramento County, CA; and Washington County, MD combined compared with Allegheny County, PA was 1.74 (95\% CI: 1.42, 2.14). After adjustment for age and other traditional risk factors, there was modest reduction of the excess hazard in non-Allegheny sites compared with Allegheny County (hazard ratio=1.52, 95\% CI: 1.17, 1.98). Between baseline and the seventh-year visits, control of hypertension, diabetes, lipids, smoking, atrial fibrillation and transient ischemic attack were similar across sites. White matter grade > or = 3 on the baseline brain MRI was less common in Allegheny County (25.8\% versus 36.3\%, respectively; P<0.001) and accounted for 25\% of the excess hazard in non-Allegheny sites compared with Allegheny County.

CONCLUSIONS: Site differences in stroke risk factors at baseline and subsequent control only partially explain site differences in stroke incidence. White matter grade as a possible integrated measure of exposure and control of risk factors may help in explaining geographic variations in stroke incidence.

}, keywords = {Aged, Brain, California, Female, Humans, Incidence, Magnetic Resonance Imaging, Male, Maryland, North Carolina, Pennsylvania, Proportional Hazards Models, Risk Assessment, Risk Factors, Stroke}, issn = {1524-4628}, doi = {10.1161/01.STR.0000231454.77745.d9}, author = {El-Saed, Aiman and Kuller, Lewis H and Newman, Anne B and Lopez, Oscar and Costantino, Joseph and McTigue, Kathleen and Cushman, Mary and Kronmal, Richard} } @article {901, title = {Geographic variations in stroke incidence and mortality among older populations in four US communities.}, journal = {Stroke}, volume = {37}, year = {2006}, month = {2006 Aug}, pages = {1975-9}, abstract = {

BACKGROUND AND PURPOSE: Stroke is a leading cause of death and disability in the US. There is limited data on geographic variations in stroke incidence among older US populations who experience the majority of stroke burden. The purpose of this study was to compare stroke incidence and mortality rates in 4 US communities.

METHODS: Participants in the Cardiovascular Health Study (CHS) who had no history of stroke at baseline (n=5639) were followed for 10 or 7 years in predominantly white (n=5002) and black (n=637) participants, respectively. Incident stroke was validated by a stroke adjudication committee after ascertainment at annual visits, interim telephone contacts, and review of Medicare hospitalization data.

RESULTS: The 2000 US population age and sex standardized total stroke incidence rate for all CHS participants was 17.7 per 1000 person-years (95\% CI: 15.9, 19.5). The rate was significantly lower in Allegheny County, Pennsylvania 9.6/1000 person-years (95\% CI: 7.7, 11.5) than Forsyth County, North Carolina 19.2/1000 person-years (95\% CI: 15.6, 22.8), Sacramento County, California 20.7/1000 person-years (95\% CI: 16.9, 24.5), and Washington County, Maryland 19.8/1000 person-years (95\% CI: 16.1, 23.5). The lower stroke incidence rate in Allegheny County was consistent in gender, race, and age groups. Though not statistically significant, stroke mortality was also lower in Allegheny County than other 3 sites. The 1-month case fatality rate was similar in the 4 sites for all strokes, and by stroke types.

CONCLUSIONS: Understanding geographic variations in stroke incidence may be an important step in improving preventive practices of stroke.

}, keywords = {Aged, Aged, 80 and over, California, Female, Humans, Incidence, Male, Maryland, North Carolina, Pennsylvania, Stroke}, issn = {1524-4628}, doi = {10.1161/01.STR.0000231453.98473.67}, author = {El-Saed, Aiman and Kuller, Lewis H and Newman, Anne B and Lopez, Oscar and Costantino, Joseph and McTigue, Kathleen and Cushman, Mary and Kronmal, Richard} }