1. Feb 2014 NHSymp_NAISDB_BK Ischemic Stroke: Results of NAISD National Acute Ischemic Stroke Database Bhojo A. Khealani Assistant Professor Neurology-Medicine Aga Khan University, Karachi, Pakistan

2. Team and Institutions Feb 2014 NHSymp_NAISDB_BK Bhojo A Khealani Maria Khan Safia Awan Mohammad Wasay Abdul Malik Muhammad Tariq Alam I Siddiqi

3. Background Stroke is the leading cause of disability and the second leading cause of mortality in the world. »WHO. Global status report on noncommunicable diseases 2010. Geneva: World Health Organization. 2011. »Mathers CD, Fat DM, Boerma JT. The global burden of disease: 2004 update. World Health Organization; 2008. Burden of stroke is expected to decrease in high income countries whereas it is expected to double in low and middle income countries »Feigin VL, Lawes CMM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. The Lancet Neurology. 2009;8(4):355-69. Feb 2014 NHSymp_NAISDB_BK

4. Background Exact Stroke burden in Pakistan is not Known Risk factors are prevalent Poor Preventive strategies »Khan FS et al. The burden of non-communicable disease in transition communities in an Asian megacity: baseline findings from a cohort study in Karachi, Pakistan. PloS one. 2013;8(2):e56008. »Hashmi M, Khan M, Wasay M. Growing burden of stroke in Pakistan: a review of progress and limitations. International Journal of Stroke. 2012. »Mehndiratta MM. Current Status of Trends in Ischemic and Hemorrhagic Strokes. Neuroepidemiology. 2012;39(1):43-4. »Chronic diseases. NHS of Pakistan;1990-94. Health profile of peoples of Pakistan. 1998:49-69 Feb 2014 NHSymp_NAISDB_BK

5. Background Community based research »Kamal AK et al. The burden of stroke and TIAs in Pakistan: a community based prevalence study. BMC Neurology 2009,9:58 doi:10.1186/1471- 2377-9-58 Hospital based research –Paucity –Single center based »Bhojo A Khealani, Wasay M.Burden of stroke in Pakistan. Int J Stroke. 2008 Nov;3(4):293-6. Feb 2014 NHSymp_NAISDB_BK

6. Objectives To establish a multicenter ischemic stroke registry –to provide insight Epidemiology Stroke subtypes Risk factors of ischemic strokes Acute outcome Feb 2014 NHSymp_NAISDB_BK

7. Feb 2014 NHSymp_NAISDB_BK Four academic centers (three urban and one rural) participated in this project. –Well established acute neurology services Trained Neurologists Imaging facilities Recruitment –January 1, 2007 to December 31, 2007 Evaluation –Clinical by trained Neurologist –Brain imaging Materials and Methods

8. Feb 2014 NHSymp_NAISDB_BK Inclusion criteria –Age>14years –ClinicalAcute neurological deficit suggestive of acute ischemic stroke –Imaging:Supported by imaging Exclusion Criteria –Refuse to give consent –ICH on brain imaging –Other cause that could explain the focal neurologic deficit Materials and Methods

9. Willing to participate –Written consent Questionnaire –Demographics –stroke severity »NIHSS » mRS –vascular risk factors –stroke workup »Brain and vascular imaging »Echocardiogram, electrocardiogram, holter »Other workup –stroke subtype »TOAST Feb 2014 NHSymp_NAISDB_BK

10. Feb 2014 NHSymp_NAISDB_BK SPSS 19.0 continuous variables –means along with standard deviations categorical data –frequencies and percentages are reported For gender comparison –chi square test of independence was used for categorical variables –student’s t-test for continuous variables Predictors of poor outcome –Binary logistic regression –P value of 0.05 was taken as significant. Materials and Methods

11. Results N874Mean Age 59.7 years Feb 2014 NHSymp_NAISDB_BK 60.5 39.5 18 19

12. Severe stroke(NIHSS 14 or more):266 Average hospital stay (days)5.93±5.147 Outcome at discharge was recorded for 697 subjects. –Mortality13.2% –favorable outcome (mRS of 2 or less)36% Feb 2014 NHSymp_NAISDB_BK

13. Results Risk factors N (%) Hypertension444 (50.8) Diabetes227 (26) Dyslipidemia204 (23.3) IHD135 (16.7) A-fib17 (2.1) Smoker Pack years 154/717 (17.6) 28.07 (14.57) (Range 1-60) Previous Stroke161 (18.4) Family History of Stroke68/833 (7.8) Feb 2014 NHSymp_NAISDB_BK HDL <40 (419)233 (55.6) HDL<35 (419)151 (36.0) LDL>100 (458)284 (32.5) Total Cholesterol >200(450)122 (14) Dyslipidemia (Chol>200, or LDL>100 or HDL<40( (443)368 (83.1)

14. Results: Imaging Feb 2014 NHSymp_NAISDB_BK 69% 31% 75 25 22% 43% 33% had old strokes

15. Results Performed:731 –Abnormal299 LVH13.5% Ischemia 10.5% Atrial fibrillation 5.9% Performed507 –LVH193 –LV WMAs114 –EF >35%35 –LV clot8 –RV clot2 –PFO3 –ASD1 Performed277 –Abnormal24 (8.7%) Feb 2014 NHSymp_NAISDB_BK

16. Results: Stroke Subtypes Feb 2014 NHSymp_NAISDB_BK

17. Results: ComplicationN (%) Pneumonia105 (13.0) UTI58 (7.2) GI Bleed13 (1.6) Stroke/TIA8 (1.0) MI/Angina14 (1.7) CCF/Cardiogenic shock28 (3.5) DVT3 (0.4) Phlebitis4(0.5) Feb 2014 NHSymp_NAISDB_BK Medications625 –Antiplatelets87% –Antocoagulation10% –Statins53% –Anti HTN31% –Anti DM meds16%

18. Male n=529Female n=345p-value Age Mean(SD)59.21 (13.76)59.36 (14.27)0.88 Systolic BP Mean(SD)146.88 (30.37)152.93 (31.74)0.006 Diastolic BP Mean(SD)86.24 (17.75)88.17 (18.0)0.12 RBS Mean(SD)168.13 (87.13)169.83 (83.38)0.79 Less than 45 n (%)440 (83.2)281 (81.4)0.52 TOAST Large vessel Small vessel Cardioembolic Unknown etiology 164 (31) 143 (27) 49 (9.3) 173 (32.7) 113 (32.8) 82 (23.8) 42 (12.2) 108 (31.3) 0.40 Risk Factors DM (RBS>200) HTN Dyslipidemia Smoker Carotid Stenosis>70% A-fib on ECG Severe LV dysfunction 98 (27.1) 199 (40.9) 236 (85.8) 135 (33.2) 19 (10.9) 20 (4.6) 25 (9.4) 74 (28.0) 159 (49.4) 132 (78.6) 12 (5.1) 5 (4.9) 23 (7.8) 9 (5.1) 0.81 0.02 0.048 <0.001 0.14 0.07 0.049 Investigations MRI Echocardiography ECG Carotid Doppler 137 (30.3) 273 (56.2) 474 (89.6) 250 (47.3) 81 (26.7) 186 (57.8) 315 (91.3) 129 (37.4) 0.29 0.66 0.48 0.004 Complications Pneumonia UTI 63 (13.0) 27 (5.6) 42 (13.0) 31 (9.6) 0.97 0.03 Stroke Severity NIHSS >14156 (33.8)110 (36.5)0.06 MRS at discharge 0-2 3-5 6 166 (37.8) 218 (49.7) 55 (12.5) 89 (30.9) 162 (56.3) 37 (12.8) 0.14 Hospital Stay Mean(SD)5.93 (5.12)5.94 (5.25)0.99 Feb 2014 NHSymp_NAISDB_BK

19. <45 years, n=153 >45 years, n=721 p-value Male n(%)89 (58.2)440 (61)0.52 Systolic BP Mean(SD)134.6 (28.4)150.3 (30.9)<0.001 Diastolic BP Mean(SD)84.1 (17.2)86.7 (17.4)0.20 RBS Mean(SD)143.8 (49.1)170.8 (91.0)<0.001 TOAST Large vessel Small vessel Cardioembolic Unknown/Other defined Stroke Severity NIHSS 47 (30.7) 22 (14.4) 24 (15.7) 60 (39.2) 12. (8.7) 230 (31.9) 203 (28.2) 67 (9.3) 221 (30.7) 12.7 (9.4) 0.001 0.89 Risk Factors DM HTN Current Smoker IHD Previous Stroke A-fib on ECG 8 (8.6) 35 (37.6) 17 (18.3) 7 (7.5) 6 (6.5) 4 (4.3) 90 (18.0) 230 (45.9) 72 (14.4) 93 (18.6) 101 (20.2) 31 (6.2) <0.025 0.14 0.33 0.01 0.002 0.48 Investigations MRI/CT Echocardiography ECG Carotid Doppler 90 (96.8) 63 (67.7) 86 (92.5) 42 (45.2) 485 (96.8) 309 (61.9) 462 (92.2) 231 (46.2) 0.99 0.29 0.93 0.85 In-hospital Complications Pneumonia UTI GI Bleed MI/Angina 10 (10.8) 3 (3.2) 1 (1.1) 0 (0.0) 77 (15.4) 27 (5.4) 10 (2.0) 12 (2.4) 0.25 0.38 0.55 0.13 MRS at discharge 0-2 3-6 42 (34.1) 81 (65.8) 213 (35.3) 391 (64.8) 0.75 Hospital Stay6.1 (4.4)5.1 (4.4)0.60 Feb 2014 NHSymp_NAISDB_BK

20. <70 years, n=711>70 years, n=163p-value Male n(%)436 (61.3)93 (57.1)0.32 Systolic BP Mean(SD)149.0 (31.13)146.9 (29.2)0.45 Diastolic BP Mean(SD)87.9 (18.2)83.4 (16.1)0.006 RBS Mean(SD)169.4 (86.8)153.1 (67.9)0.06 TOAST Large vessel Small vessel Cardioembolic Unknown etiology 230 (32.3) 177 (24.9) 73 (10.3) 231 (32.5) 47 (28.8) 48 (29.4) 18 (11) 50 (30.7) 0.59 Risk Factors DM (RBS>200) HTN Dyslipidemia Smoker Carotid Stenosis>70% A-fib on ECG Severe LV dysfunction 146 (28.6) 286 (43.8) 292 (84.6) 127 (24.5) 20 (8.8) 31 (5.2) 27 (7.7) 26 (22.6) 72 (46.5) 76 (77.6) 20 (16.3) 4 (7.8) 12 (9.0) 7 (7.6) 0.19 0.55 0.10 0.14 0.82 0.09 0.98 Investigations MRI Echocardiography ECG Carotid Doppler 186 (27.1) 405 (57) 648 (91.1) 312 (43.9) 52 (34) 102 (62.6) 141 (86.5) 64(41.1) 0.09 0.21 0.79 0.54 Complications Pneumonia UTI 72 (11.0) 40 (6.1) 33 (21.3) 18 (11.6) 0.001 0.02 Stroke Severity NIHSS >14211 (33.9)55 (39.0)0.38 MRS at discharge 0-2 3-5 6 220 (38.6) 285 (50.0) 65 (11.4) 31 (24.4) 69 (54.3) 27 (21.3) 0.001 Hospital Stay Mean(SD)5.97 (5.42)5.80 (3.98)0.74 Feb 2014 NHSymp_NAISDB_BK

21. Results: Outcome OR (95% CI) Poor outcome (mRS>3) Model 1 1.92 (1.24-2.98) Model 2: 1.75 (1.08-2.84) Model 3: 1.52 (0.92-2.51) In-hospital death Model 1 2.47 (1.43-4.27) Model 2: 2.13 (1.28-3.56) Model 3: 2.08 (1.16-3.75) Feb 2014 NHSymp_NAISDB_BK Model 1: Adjusted for gender Model 2: Adjusted for gender, hypertension, and TOAST Model 3: Adjusted for gender, hypertension, TOAST, Pneumonia and UTI

22. Conclusion Hypertension and dyslipidemia were the commonest risk factors Large vessel atherosclerosis was the commonest stroke etiology. Elderly patients were significantly –more likely to have in-hospital complications –to die during hospital stay –to have a higher modified Rankin score at discharge. Feb 2014 NHSymp_NAISDB_BK

23. Thanks Feb 2014 NHSymp_NAISDB_BK