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Smoking and mortality in stroke survivors: can we eliminate the paradox?

ABSTRACT: Many studies have suggested that smoking does not increase mortality in stroke survivors. Index event bias, a sample selection bias, potentially explains this paradoxical finding. Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality by cigarette smoking status among stroke survivors using methods to account for index event bias.Among 5797 stroke survivors of 45 years or older who responded to the National Health Interview Survey years 1997-2004, an annual, population-based survey of community-dwelling US adults, linked to the National Death Index, we estimated all-cause, CVD, and cancer mortality by smoking status using Cox proportional regression and propensity score analysis to account for demographic, socioeconomic, and clinical factors. Mean follow-up was 4.5 years.From 1997 to 2004, 18.7% of stroke survivors smoked. There were 1988 deaths in this stroke survivor cohort, with 50% of deaths because of CVD and 15% because of cancer. Current smokers had an increased risk of all-cause mortality (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.14-1.63) and cancer mortality (HR, 3.83; 95% CI, 2.48-5.91) compared with never smokers, after controlling for demographic, socioeconomic, and clinical factors. Current smokers had an increased risk of CVD mortality controlling for age and sex (HR, 1.29; 95% CI, 1.01-1.64), but this risk did not persist after controlling for socioeconomic and clinical factors (HR, 1.15; 95% CI, .88-1.50).Stroke survivors who smoke have an increased risk of all-cause mortality, which is largely because of cancer mortality. Socioeconomic and clinical factors explain stroke survivors' higher risk of CVD mortality associated with smoking.

SUBMITTER: Levine DA

PROVIDER: S-EPMC4058406 | biostudies-literature | 2014 Jul

REPOSITORIES: biostudies-literature

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Smoking and mortality in stroke survivors: can we eliminate the paradox?

Levine Deborah A DA Walter James M JM Karve Sudeep J SJ Skolarus Lesli E LE Levine Steven R SR Mulhorn Kristine A KA

Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association 20140115 6

<h4>Background</h4>Many studies have suggested that smoking does not increase mortality in stroke survivors. Index event bias, a sample selection bias, potentially explains this paradoxical finding. Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality by cigarette smoking status among stroke survivors using methods to account for index event bias.<h4>Methods</h4>Among 5797 stroke survivors of 45 years or older who responded to the National Health Interview Survey ...[more]

PMID: 24439131

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Project description:BackgroundContinued smoking after stroke is associated with a high risk of stroke recurrence and other cardiovascular disease. We sought to comprehensively understand the epidemiology of smoking cessation in stroke survivors in the United States. Furthermore, we compared smoking cessation in stroke and cancer survivors because cancer is another smoking-related condition in which smoking cessation is prioritized.MethodsWe performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Using pooled data from 2013 to 2019, we identified stroke and cancer survivors with a history of smoking. We used survey procedures to estimate frequencies and summarize quit ratios with attention to demographic and geographic (state-wise and rural-urban) factors for stroke survivors. The quit ratio is conventionally defined as the proportion of ever smokers who have quit. Then, we used multivariable logistic regression to compare quit ratios in stroke and cancer survivors while adjusting for demographics and smoking-related comorbidities.ResultsAmong 4 434 604 Americans with a history of stroke and smoking, the median age was 68 years (interquartile range, 59-76), and 45.4% were women. The overall quit ratio was 60.8% (95% CI, 60.1%-61.6%). Quit ratios varied by age group, sex, race and ethnicity, and several geographic factors. There was marked geographic variation in quit ratios, ranging from 48.3% in Kentucky to 71.5% in California. Furthermore, compared with cancer survivors, stroke survivors were less likely to have quit smoking (odds ratio, 0.72 [95% CI, 0.67-0.79]) after accounting for differences in demographics and smoking-related comorbidities.ConclusionsThere were considerable demographic and geographic disparities in smoking quit ratios in stroke survivors, who were less likely to have quit smoking than cancer survivors. A targeted initiative is needed to improve smoking cessation for stroke survivors.

Project description:Importance:The population of cancer survivors is rapidly growing in the US. Tobacco smoking is associated with many cancers; however, whether cigarette smoking behaviors among cancer survivors vary according to cancer type-that is, smoking-related cancers (SRCs) vs non-smoking-related cancers (NSRCs)-remains unclear. Objectives:To examine cigarette smoking prevalence and behaviors (ie, continuing or quitting smoking) among cancer survivors and to compare them between survivors of SRCs and NSRCs. Design, Setting, and Participants:This study was a cross-sectional analysis of the 2017 National Health Interview Survey, a household survey of civilian US residents who were aged 18 years or older. The National Health Interview Survey is population based and is representative of the US population. Data analysis was performed from June to October 2019. Main Outcomes and Measures:The primary outcomes were prevalence of current cigarette smoking among cancer survivors and prevalence of continuing smoking and quitting smoking after a cancer diagnosis. Secondary outcomes included factors associated with continued smoking vs quitting smoking after a cancer diagnosis. Results:A total of 26?742 respondents (mean [SD] age, 50.97 [18.61] years; 14?646 women [51.76%]) to the 2017 National Health Interview Survey were included in this study. Of the 3068 individuals (9.42%) in the study population who had cancer, 589 (19.96%) were SRC survivors, 2297 (74.50%) were NSRC survivors, 168 (4.96%) were survivors of both SRC and NSRC, and the remaining 14 (0.58%) had missing information about the type of cancer. Four hundred forty-nine SRC survivors (54.08%) were women, compared with 1412 NSRC survivors (54.30%). Ninety-six SRC survivors (15.69%) and 151 NSRC survivors (7.99%) were younger than 45 years. Overall, 372 cancer survivors (13.16%) were current smokers. Current smoking prevalence was higher among survivors of SRCs (145 survivors [19.78%]) compared with NSRC survivors (251 survivors [10.63%]). Among cancer survivors, 309 current smokers at cancer diagnosis (43.96%) reported having successfully quit smoking and 372 (56.04%) reported continuing smoking. Among the continuing smokers, 176 (56.49%) reported an unsuccessful quit attempt in the last 12 months. After cancer diagnosis, SRC survivors had higher odds of continued smoking compared with NSRC survivors (odds ratio [OR], 2.10; 95% CI, 1.12-3.93; P?=?.02). Men (OR, 1.93; 95% CI, 1.05-3.57; P?=?.04), those with angina pectoris (OR, 5.40; 95% CI, 1.33-21.91; P?=?.02), and those with chronic bronchitis (OR, 2.55; 95% CI, 1.05-6.19; P?=?.04) had higher odds of continued smoking, whereas Hispanic participants (compared with non-Hispanic white participants: OR, 0.18; 95% CI, 0.05-0.68; P?=?.01) and married participants (compared with never married participants: OR, 0.33; 95% CI, 0.12-0.96; P?=?.04) had lower odds of continued smoking. Conclusions and Relevance:These findings suggest that compared with NSRC survivors, SRC survivors may be at higher risk of being cigarette smokers at cancer diagnosis and of continuing smoking afterward. Although smoking cessation interventions are critically important for all cancer survivors, special efforts should target survivors of SRCs.

Project description:Background: Low lipid level is associated with better cardiovascular outcome. However, lipid paradox indicating low lipid level having worse outcomes could be seen under acute injury in some diseases. The present study was designed to clarify the prognostic significance of acute-phase lipid levels within 1 day after admission for stroke on mortality in first-ever statin-naïve acute ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: This observational study was conducted using the data collected from Stroke Registry In Chang-Gung Healthcare System (SRICHS) between 2009 and 2012. Patients with recurrent stroke, onset of symptoms >1 day, and history of the use of lipid-lowering agents prior to index stroke were excluded. Stroke was classified into IS and hypertension-related HS. The primary outcomes were 30-day and 1-year mortality identified by linkage to national death registry for date and cause of death. Receiver operating characteristic (ROC) curve analysis and multivariate Cox proportional hazard models were used to examine the association of lipid profiles on admission with mortality. Results: Among the 18,268 admitted stroke patients, 3,746 IS and 465 HS patients were eligible for analysis. In IS, total cholesterol (TC) <163.5 mg/dL, triglyceride (TG) <94.5 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, non-high-density lipoprotein cholesterol (non-HDL-C) <130.5 mg/dL, and TC/HDL ratio <4.06 had significantly higher risk for 30-day/1-year mortality with hazard ratio (HR) of 2.05/1.37, 1.65/1.31, 1.68/1.38, 1.80/1.41, and 1.58/1.38, respectively, compared with high TC, TG, LDL, non-HDL-C, and TC/HDL ratio (p < 0.01 in all cases). In HS, lipid profiles were not associated with mortality, except HDL for 30-day mortality (p = 0.025) and high uric acid (UA) concentrations for 30-day and 1-year mortality (p = 0.002 and 0.012, respectively). High fasting glucose and high National Institute of Health Stroke Scale (NIHSS) score at admission were associated with higher 30-day and 1-year mortality in both IS and HS and low blood pressure only in IS (p < 0.05). Synergic effects on mortality were found when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score in IS (p < 0.05). Conclusions: Lipid paradox showing low acute-phase lipid levels with high mortality could be seen in statin-naïve acute IS but not in HS. The mortality in IS was increased when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score.

Project description:Background and Purpose- The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics. Methods- We included patients from the MR CLEAN registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke) with an initial target occlusion on computed tomography angiography located in the intracranial internal carotid artery, M1, or M2. The conventional angiography target occlusion was defined during endovascular treatment. Thrombus dynamics were classified as growth, stability, migration, and resolution. The primary outcome was functional outcome at 90 days (modified Rankin Scale). The secondary outcomes were successful and complete reperfusion (extended treatment in cerebral infarction scores of 2b-3 and 3, respectively). Results- The analysis included 1349 patients. Thrombus migration occurred in 302 (22%) patients, thrombus growth in 87 (6%), and thrombus resolution in 39 (3%). Intravenous treatment with alteplase was associated with more thrombus migration (adjusted odds ratio, 2.01; CI, 1.29-3.11) and thrombus resolution (adjusted odds ratio, 1.85; CI, 1.22-2.80). Thrombus migration was associated with a lower chance of complete reperfusion (adjusted odds ratio, 0.57; CI, 0.42-0.78) and successful reperfusion (adjusted odds ratio, 0.74; CI, 0.55-0.99). In the subgroup of patients with M1 initial target occlusion, thrombus migration was associated with better functional outcome (adjusted common odds ratio, 1.49; CI, 1.02-2.17), and there was a trend towards better functional outcome in patients with thrombus resolution (adjusted common odds ratio, 2.23; CI, 0.93-5.37). Conclusions- In patients with acute ischemic stroke, thrombus location regularly changes between computed tomography angiography and digital subtraction angiography. Administration of intravenous alteplase increases the chance of thrombus migration and resolution. Thrombus migration is associated with better functional outcome but reduces the rate of complete reperfusion.

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Smoking and mortality in stroke survivors: can we eliminate the paradox?

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Smoking and mortality in stroke survivors: can we eliminate the paradox?

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