Abstract
Background
Stroke prevention is an important public health goal in Low-and-Middle Income countries (LMIC) due to its high mortality and morbidity in these settings. Epidemiological data from high-income countries have demonstrated a potent predictive association between self-reported stroke symptoms and risks of future strokes, incident cognitive impairment and all-cause mortality.
Objective
To utilize a pictographic version of the 8-item Questionnaire for Verifying Stroke Free Status (QVSFS) to screen for stroke symptoms and determine its predictors among hypertensive and diabetic patients in a rural hospital within a LMIC.
Methods
Between July and October 2016, 500 consecutive patients with hypertension and/or diabetes mellitus encountered in clinic at the Agogo Presbyterian Hospital, a district level health institution in Ghana were enrolled. A validated pictographic version of the QVSFS was administered by trained research assistants to all study participants and demographic and clinical information on hypertension and diabetes control were collected. The neurologist/ Specialist Physician examined all patients neurologically using a structured questionnaire and reviewed medical charts for objective documentary evidence of stroke. Predictors of stroke symptoms were assessed using a multivariate logistic regression model.
Results
Among the cohort, median (IQR) age was 58 (51–66) years, 399 (79.8%) were women, 388 (77.6%) had hypertension, 92 (18.4%) had diabetes and hypertension, and 20 (4.0%) had just diabetes. 30 (6.0%) patients had confirmed stroke/TIA after physician evaluation, 151 (30.6%) had at least one symptom of stroke (SS) without prior diagnosis of stroke/TIA and 319 (63.8%) reported no stroke symptoms. Independent predictors of reporting stroke symptoms were increasing age - aOR: 1.38 (1.16–1.64) for each 10 years older and HBA1C–OR: 1.74 (1.16–2.61) for each 2% increase. Subjects with previous Stroke/TIA diagnosis had significantly higher mean ± SD systolic blood pressure (148.0 ± 21.2mmHg vs. 136.0 ± 17.3mmHg vs. 138.3±19.7mmHg, p=0.009) and median (IQR) HBA1C (8.8% (6.7–10.2) vs. 8.2 (6.4–10.6) vs. 7.2 (6.3–8.0), p=0.05) compared with SS and asymptomatic groups.
Conclusion
One in three patients with hypertension and/ diabetes in rural Ghana report stroke-like symptoms. Routine use of the pictographic version of the QVSFS could assist in identifying patients with or at high risk for stroke who may benefit from appropriate prevention treatments.
Keywords: Stroke symptoms, prevention, risk factors, developing countries
Introduction
Stroke prevention is an important public health priority in Low- and Middle-Income Countries (LMICs) including sub-Saharan Africa where the already high burden of stroke is predicted to escalate over the coming decades.(1–3) High rates of hypertension, diabetes mellitus, dyslipidemia and obesity, underpinned by the adoption of western lifestyles combined with low health literacy rates on stroke have contributed to the upsurge of stroke in these settings.(4–7) Cost-effective primary and secondary preventive strategies, in particular tools for screening high-risk populations for stroke symptoms are urgently needed for targeted interventions to reverse the dire projected trends of stroke in developing countries.
The 8-item questionnaire for Verifying Stroke Free Status (QVSFS) is an accurate, reliable and easy-to-use questionnaire with excellent diagnostic features for ruling out stroke by assessing previous diagnosis of stroke/TIA and 6 cardinal stroke symptoms. (8) A spectrum of stroke has been described via use of the QVSFS in screening adult populations ranging from asymptomatic, Stroke symptoms without stroke diagnosis (SS), transient ischemic attacks (TIA) and strokes. Findings from the population based prospective REGARDS study9 in the US, where the QVSFS was used to screen enrolled participants, indicate a high prevalence of stroke symptoms among stroke-free individuals10 which is strongly predictive of prospective risks for strokes11,12, and cognitive impairment13. Indeed, self-reported stroke symptoms among stroke-free individuals have been identified as a potent risk factor for future stroke after adjustment for the traditional vascular risk factors of CVDs12. Furthermore, these investigators found graded associations between the spectrum of stroke and risk for future strokes and all-cause mortality.14 However, the prevalence of symptoms of stroke among individuals at high risk for cardiovascular disease such as diabetes and hypertension in resource-limited settings where the greatest burden of stroke resides remains unknown.
The prospects for the QVSFS to be used as a tool for screening for the presence of stroke and/or stroke symptoms among hypertensive and diabetic patients have hitherto not been explored. The performance of this instrument in resource-limited settings was recently assessed in a validation study in three commonly spoken West African languages with a modification that included the addition of pictographs of stroke symptoms and was found to be excellent. 15,16 Application of the questionnaire for the purposes of screening high CVD risk patients under routine care may enhance the detection of unreported stroke/TIA diagnosis or stroke symptoms by clinicians for the appropriate interventions to be implemented and could further offer an opportunity to educate patients on stroke symptoms during clinic visits or community screening programs. Our objectives for the present study are to assess rates and predictors of stroke symptoms among hypertensive and diabetic patients at high risk for cardiovascular disease (CVD) and assess the performance of the QVSFS in a rural Ghanaian hospital.
Methods
This cross-sectional study was ethically approved by the Committee on Human Research Publications and Ethics and was conducted at the Agogo Presbyterian hospital at the Ashanti Akim district in the Ashanti region of Ghana. The hospital serves predominantly a rural population of farmers and has a dedicated hypertension and diabetes clinics where subjects for the present study were recruited. 500 consecutive hypertensive and/or diabetic patients were enrolled into the study between July and October 2016 after obtaining informed consent. Basic demographic information were collected by 5 trained research assistants who then administered the 8-item QVSFS with pictures for question items 3 to 8 which assesses sudden onset hemiparesis, hemisensory loss, mono-/bi-ocular visual loss, hemi-anopsia, expressive or receptive aphasias. (Supplementary information 1). The questionnaire was translated into Akan language as previously described15,16 and administered in the local dialect and the answers recorded as yes, no, or don’t know for each question item. Participants were subsequently reviewed by a Specialist Physician, who being blinded to the responses of the QVSFS, reviewed the medical records of all participants for evidence of previously documented diagnosis of stroke/TIA, then examined the patient neurologically to elicit the presence of hemiparesis, hemianesthesia, visual field defects, and aphasia and adjudicate whether the patient has had a stroke/TIA as a gold standard. Clinic systolic and diastolic blood pressures (in mmHg) for the previous two clinic visits as well as the HBA1C (%) levels within the previous 3 months for diabetes mellitus patients were collected.
Statistical Analysis
Baseline demographic and clinical characteristics of participants were compared using the Chi-squared test (categorical variables), Mann Whitney U-test or Student’s t-test for medians or means respectively for paired continuous variables and ANOVA or Kruskal-Wallis tests for more than 2 group comparisons of continuous variables. Participants who scored 0 to 8 (no to all questions) were classified stroke free/asymptomatic; subjects who answered ‘Yes’ to any of the item numbers 3–8 but ‘No’ to Items 1 and 2 and were found not have objective clinical evidence of stroke by the attending Physician were classified as Stroke Symptoms without Stroke diagnosis (SS) and subjects were classified as having a stroke/TIA if the attending physician found objective evidence of stroke on review of medical chart, history and examination. We estimated the sensitivity, specificity, positive and negative predictive values of the QVSFS with their corresponding 95% confidence intervals based on a positive response any of the 8 items compared with physicians diagnosis of stroke as gold standard. We also assessed the demographic and clinical predictors of having at least one stroke symptom using a multivariable logistic regression analysis where stroke symptom was specified as the dependent variable and pre-specified independent variables were age, gender, educational status, domicile location, systolic blood pressure and HBA1C. In all analyses, statistical significance was attained if a 2-tailed p<0.05 was reached with no adjustments for multiple comparisons.
Results
Demographic characteristics
The 500 study participants comprised of 399 (79.8%) females and 101 (20.2%) males with an overall median (IQR) age of 58 (51–66) years. There were 388 (77.6%) hypertensive, 92 (18.4%) diabetic hypertensive, and 20 (4.0%) diabetic patients.
Frequency of stroke symptoms
169 (33.8%) subjects had experienced at least one symptom of stroke with 110, 40, 9, 7 and 3 individuals reporting 1, 2, 3, 4 and 5 out of the 6 possible symptoms respectively. 30 (6.0%) patients had confirmed stroke/TIA after physician evaluation, 151 (30.6%) had at least one symptom of stroke (SS) without prior diagnosis of stroke/TIA and 319 (63.8%) reported no stroke symptoms (Asymptomatic). Individual item responses to the QVSFS, duration of symptoms and frequency of clinically demonstrable neurologic deficits are as shown in table 1.
Table 1.
Frequencies & duration of symptoms in response to Items on the 8-item QVSFS.
| QUESTION | Self-reported Frequency, n (%) | Mean ± SD duration (years) | Frequency of deficits on clinical examination |
|---|---|---|---|
| Previous diagnosis of stroke | 18 (3.6%) | 4.5 ± 3.1 | |
| Previous diagnosis of ‘mild stroke’/TIA | 25 (5.0%) | 3.0 ± 2.8 | |
| Sudden painless weakness of half of body | 47 (9.4%) | 2.0 ± 2.6 | 5 (1.0%) |
| Sudden numbness or dead feeling on one side of body | 20 (4.0) | 2.9 ± 2.8 | 1 (0.2%) |
| Sudden painless loss of vision in one or both eyes | 66 (13.2%) | 3.5 ± 3.7 | 0 (0.0%) |
| Suddenly lost one half of your vision | 72 (14.4%) | 1.7 ± 2.2 | 1 (0.2%) |
| Loss of the ability to understand what people are saying | 39 (7.8%) | 3.3 ± 4.2 | 0 (0.0%) |
| Lost of ability to express verbally or in writing | 16 (3.2%) | 2.1 ± 2.4 | 1 (0.2%) |
Comparison of demographic and clinical features according stroke/TIA status
As shown in table 2, subjects with confirmed stroke/TIA and the SS groups are comparably older than those asymptomatic for stroke with a proportionally higher propensity for male than female subjects to have confirmed stroke/TIA. In a decreasing manner, the highest concentrations of HBA1C were observed among those with stroke/TIA followed by the SS group and the asymptomatic group whilst the highest systolic blood pressures were noted among stroke/TIA subjects with comparable levels among the SS and asymptomatic groups. The distribution of the stroke spectrum according to vascular risk factor status i.e. hypertension, hypertension plus diabetes and diabetes alone is depicted in Figure 1.
Table 2.
Comparison of subjects with Stroke/TIA, Stroke symptoms but no stroke, and no stroke symptoms High Risk CVD patients.
| Variable | Stroke/TIA n = 30 | Stroke symptoms but no stroke (SS) n = 151 | No stroke symptoms n = 319 | P-value |
|---|---|---|---|---|
| Age, mean ± SD | 59.7 ± 12.6 | 60.7 ± 10.2 | 56.5 ± 11.0 | 0.0005 |
| Female gender, n (%) | 14 (46.7) | 123 (81.5) | 264 (82.8) | <0.0001 |
| Educational status, n (%) | 0.32 | |||
| Primary/None | 14 (46.7) | 89 (58.9) | 169 (53.0) | |
| >Secondary | 16 (53.3) | 62 (41.1) | 150 (47.0) | |
| Location of domicile | 0.80 | |||
| Rural | 25 (83.3) | 122 (80.8) | 252 (79.0) | |
| Semi-urban/urban | 5 (16.7) | 29 (19.2) | 67 (21.0) | |
| Hypertension, n (%) | 29 (96.7) | 145 (96.0) | 304 (95.3) | 0.90 |
| Diabetes Mellitus, n (%) | 7 (23.3) | 40 (26.5) | 65 (20.7) | 0.34 |
| SBP (mmHg), mean ± SD | 148.0 ± 21.2 | 136.0 ± 17.3 | 138.3±19.7 | 0.009 |
| DBP (mmHg), mean ± SD | 82.6 ± 12.4 | 79.3 ± 10.9 | 79.4 ± 11.3 | 0.32 |
| HBA1C (%), median (IQR) | 8.8 (6.7– 10.2) | 8.2 (6.4–10.6) | 7.2 (6.3– 8.0) | 0.05 |
Figure 1.
Distribution of stroke spectrum (stroke/TIA, stroke symptoms without stroke, asymptomatic) according vascular risk factor profile.
Hemi-sensory loss and receptive dysphasia were significantly commoner among those with Stroke/TIA compared with the SS group whilst hemianopsia was more commonly reported among the SS groups compared with those with previous stroke/TIA (Table 3). Among 470 subjects without previous stroke/TIA diagnosis, 30.6% reported one or more stroke symptoms and the prevalence of each symptom is presented overall, and by age, sex, educational status, hypertensive or diabetic status in table 4. Hemianopsia was the commonest stroke symptom whilst receptive dysphasia was the least reported symptom. In general, speech and visual symptoms were significantly commoner above age 60 years while hemiparesis was commoner among diabetics than non-diabetics.
Table 3.
Comparison of Frequency of Stroke Symptoms by those with History of stroke/TIA compared with no History of stroke but stroke symptoms
| Stroke symptom | History of stroke/TIA (n=30) | No History of stroke (n=151) | P-value |
|---|---|---|---|
| Sudden weakness on one side | 8 (26.7%) | 39 (25.8%) | 0.92 |
| Sudden numbness on one side | 10 (33.3%) | 10 (6.6%) | <0.0001 |
| Painless loss of vision | 7 (23.3%) | 59 (39.1%) | 0.10 |
| Painless loss of vision one half of vision | 7 (23.3%) | 65 (43.0%) | 0.04 |
| Loss of ability to communicate | 9 (30.0%) | 30 (19.9%) | 0.21 |
| Loss of ability to understand | 7 (23.3%) | 9 (6.0%) | 0.002 |
Table 4.
Prevalence of individual stroke symptoms among Hypertensive and Diabetes Patients without History of Stroke/TIA diagnosis.
| SUB-GROUPS | Unilateral painless weakness (n=39) | Unilateral numbness (n = 10) | Painless loss of vision (n = 59) | Loss of one half of vision (n = 65) | Loss of ability to communicate (n = 30) | Loss of ability to understand (n = 9) |
|---|---|---|---|---|---|---|
| Overall | 8.3% | 2.1% | 12.6% | 13.8% | 6.4% | 1.9% |
| Age, years | P=0.91 | P=0.11 | P=0.0002 | P=0.49 | P=0.005 | P=0.05** |
| <60 (n=257) | 21 (8.2%) | 3 (1.2%) | 19 (7.4%) | 33 (12.8%) | 9 (3.5%) | 2 (0.8%) |
| >60 (n=213) | 18 (8.5%) | 7 (3.3%) | 40 (18.8%) | 32 (15.0%) | 21 (9.9%) | 7 (3.3%) |
| Sex | P=0.96 | P=0.84 | P=0.83 | P=0.22 | P=0.52 | P=0.60 |
| Male (n=83) | 7 (8.4%) | 2 (2.4%) | 11 (13.3%) | 15 (18.1%) | 4 (4.8%) | 1 (1.2%) |
| Female (n=387) | 32 (8.3%) | 8 (2.1%) | 48 (12.4%) | 50 (12.9%) | 26 (6.7%) | 8 (2.1%) |
| Education | P=0.12 | P=0.74 | P=0.31 | P=0.93 | P=0.04 | P=0.47 |
| No/Primary (n=258) | 26 (10.1%) | 6 (2.3%) | 36 (14.0%) | 36 (14.0%) | 22 (8.5%) | 6 (2.3%) |
| >Secondary (n=212) | 13 (6.1%) | 4 (1.9%) | 23 (10.8%) | 29 (13.7%) | 8 (3.8%) | 3 (1.4%) |
| Hypertension | P=0.40 | P=1.00 | P=0.67 | P=0.56 | P=0.13 | P=0.34 |
| Yes (n=449) | 36 (8.0%) | 10 (2.2%) | 57 (12.7%) | 63 (14.0%) | 27 (6.0%) | 8 (1.8%) |
| No (n=21) | 3 (14.2%) | 0 (0.0%) | 2 (9.5%) | 2 (9.5%) | 3 (14.3%) | 1 (4.8%) |
| Diabetes | P=0.001 | P=0.86 | P=0.95 | P=0.04 | P=0.30 | P=0.99 |
| Yes (n=105) | 20 (19.0%) | 2 (1.9%) | 13 (12.4%) | 21 (20.0%) | 9 (8.6%) | 2 (1.9%) |
| No (n=365) | 29 (7.9%) | 8 (2.2%) | 46 (12.6%) | 44 (12.1%) | 21 (5.8%) | 7 (1.9%) |
Note 30 patients with history of Stroke/TIA were excluded from this analysis.
Predictors of stroke symptoms
Increasing age, male gender and higher HBA1C levels were significantly associated with having stroke symptoms in unadjusted analysis. Upon adjustment for confounders, increasing age - OR: 1.38 (1.16–1.64) for each 10 years older and HBA1C–OR: 1.74 (1.16–2.61) for each 2% increase in HBA1C levels- were significantly associated with risk of having stroke symptoms.
Performance of the QVSFS questionnaire for stroke diagnosis
The QVSFS had a sensitivity, specificity, positive and negative predictive values of 0.93 (0.68–1.00), 0.66 (0.61–0.70), 0.08 (0.04–0.13) and 1.00 (0.98–1.00). Question item 1 had the highest sensitivity, specificity, PPV and NPV as shown in table 6.
Table 6.
QVSFS global score and Item-by-item performance for stroke diagnosis
| Question | Sensitivity | Specificity | Positive Predictive Value | Negative Predictive Value |
|---|---|---|---|---|
| 1–8 | 0.93 (0.68– 1.00) | 0.66 (0.61– 0.70) | 0.08 (0.04–0.13) | 1.00 (0.98–1.00) |
| 1 | 0.93 (0.68– 1.00) | 0.99 (0.98– 1.00) | 0.78 (0.52–0.94) | 1.00 (0.99–1.00) |
| 2 | 0.67 (0.38– 0.88) | 0.97 (0.95– 0.98) | 0.40 (0.21–0.61) | 0.99 (0.98–1.00) |
| 3 | 0.47 (0.21– 0.73) | 0.92 (0.89– 0.94) | 0.15 (0.06–0.28) | 0.98 (0.96–1.00) |
| 4 | 0.40 (0.16– 0.68) | 0.97 (0.95– 0.98) | 0.30 (0.12–0.54) | 0.98 (0.96–0.99) |
| 5 | 0.27 (0.08– 0.55) | 0.87 (0.84– 0.90) | 0.06 (0.02–0.15) | 0.97 (0.96–0.99) |
| 6 | 0.20 (0.04– 0.48) | 0.86 (0.82– 0.89) | 0.04 (0.01–0.12) | 0.97 (0.95–0.96) |
| 7 | 0.20 (0.04– 0.48) | 0.93 (0.90– 0.95) | 0.08 (0.02–0.21) | 0.97 (0.96–0.99) |
| 8 | 0.33 (0.12– 0.62) | 0.98 (0.96– 0.99) | 0.33 (0.12–0.62) | 0.98 (0.96–0.99) |
Gold standard for stroke diagnosis= Physician history taking, focused neurological examination and review of medical charts for previous documented diagnosis of stroke.
Discussion
We report a high frequency of stroke symptoms among hypertensive and diabetic patients attending a rural Ghanaian hospital in West Africa. Almost 34% of study participants reported at least one symptom of stroke with only 6% clinically diagnosed with stroke or transient ischemic attack. 31% had stroke-like symptoms without clinically diagnosed stroke/TIA. Independent predictors of reporting stroke symptoms were increasing age and poor glycemic control and stroke/TIA subjects had higher systolic BP and HBA1C compared with SS and asymptomatic groups indicating a poor control of these cardinal risk factors and heightened risk for recurrent stroke.
Among study participants without Stroke/TIA, stroke-like symptoms such as visual loss, expressive and receptive aphasias were commoner among subjects older than 60 years and diabetics were more likely to report hemiparesis and homonymous hemianopsia than non-diabetics. The high frequency of stroke-like symptoms among this study population could be due undiagnosed minor strokes from which subjects may have recovered, transient cerebral/retinal ischemia or stroke mimics such as hypoglycemia, hypertensive encephalopathy, neuropathy or hypertensive/diabetic retinopathy as previously suggested.17 It is likely that most of the symptoms elicited were of evanescent nature given that detailed neurological examination of study subjects for objective clinical evidence of these deficits often yielded negative findings and there was an overall low frequency of permanent neurological deficits. Again the mean duration of these symptoms ranged from a few months to several years. These caveats notwithstanding, there is a growing notion that self-reported stroke-like symptoms may represent an intermediate phenotype in the stroke spectrum between an asymptomatic stroke-free state and clinical TIA/Stroke state with adverse prognostic consequences. In the REGARDS cohort, 18% of the general population aged 45+ reported stroke-like symptoms in the absence of stroke or TIA at enrollment10. The investigators have prospectively identified associations between presence of stroke-like symptoms and higher Framingham Stroke Risk Score,10 increased risk of cognitive impairment13, lower quality of life18, incremental risk for future stroke based on number of stroke symptoms reported12 and most significantly an increased risk of all-cause mortality14. In the present study 3 in 10 had stroke-like symptoms without prior diagnosis of stroke/TIA.
We found that increasing age was an independent risk factor for self-reported stroke symptoms with a 38% increased odds for each 10-year increment after accounting for the moderating effects of other confounders. Furthermore the mean age of subjects with stroke/TIA was not significantly different from those with stroke-like symptoms without stroke. The salience of these observations is supported by the positive correlation between increasing age and the frequency of ‘silent infarcts’-evidence of vascular injury on neuroimaging without a clinical history of stroke. The frequency of asymptomatic cerebral ischemia noted among persons aged 55–64 years is 11%, progressively increasing to 43% for individuals >85 years of age.19, 20 We also noted that for each 2% increase in HBA1C level, odds of reporting stroke symptoms increased by 74% which is an interesting observation because diabetes mellitus is often associated with lacunar strokes 21 ,22 which may present with mild or transient stroke symptoms, however poorly controlled diabetes could also present with stroke mimics due to glycemic excursions. From a pathophysiologic viewpoint however, it has been amply demonstrated that subjects with diabetes and hypertension have a profound predisposition to atherosclerosis which is strongly linked to the pathogenesis of stroke via arterial inflammation and stiffness.23–25 Although males were more likely to experience stroke symptoms in unadjusted analysis, the effect of gender was lost on adjusted analysis. Thus the elderly and poorly controlled diabetics may require closer monitoring to ensure that targets for primary and secondary prevention of CVD are met to avert vascular events.
Conceptually, the QVSFS was designed to rule out stroke diagnosis to enable the identification of control subjects for epidemiological studies8 when such individuals responded negatively to all 8-items on the questionnaire. However the questionnaire could have wider applications beyond research settings, particularly in routine clinic care for identification of patients with vascular risk factors at high risk for adverse outcomes such as those with stroke/TIA and certainly those with stroke symptoms without a clinical diagnosis of stroke. Regarding the use of the QVSFS for detection of stroke/TIA in the present study, we found that it maintained a high sensitivity and negative predictive value of 93% and 100% respectively but a lower specificity of 66% and positive predictive value of 8% due probably to the diluting effect of the high frequency of stroke-like symptoms in the present cohort. Altogether, our observations suggest that there may be added value in routinely screening patients at high risk for CVD using the QVSFS given its excellent diagnostic qualities for stroke diagnosis, its predictive value for future vascular events and cognitive impairment, its low-cost and ease of use. The introduction of pictographs could enhance the utility of the instrument as an educational tool for use by health care workers evaluating hypertensive or diabetic patients in clinic or within the community.
Limitations of the present study include the cross-sectional nature which precludes causal associations from being drawn, recollection of stroke symptoms by study subjects which could be subject to recall bias and stroke diagnosis was confirmed in most instances on medical review and clinical examination without recourse to neuroimaging, the study being conducted in a rural setting without these resources. These limitations present potential avenues for designing prospective cohort studies for evaluation of the role of self-reported stroke symptoms on risks for strokes, dementia, and mortality particularly among patients at high risk for these events. A key sub-study would be the inclusion of neuroimaging to ascertain the prevalence of vascular insults in relation to purported stroke symptoms. Thus said, interventions such as stringent control of vascular risk factors among such patients would mitigate the dire outcomes predicted on the basis of the known associations poor risk factor control and vascular events25–27.
Conclusion
Nearly 3 out of 10 patients with hypertension and diabetes reports having stroke-like symptoms. The routine utilization of the pictographic version of the QVSFS in screening for stroke symptoms is recommended to help clinicians identify patients at high risk for adverse vascular outcomes for targeted interventions to mitigate this risk.
Table 5.
Predictors of having stroke symptoms among High CVD Risk Patients using multivariable logistic regression modeling.
| Predictor | Unadjusted OR (95% CI) | P-value | Adjusted OR (95% CI) | P-value |
|---|---|---|---|---|
| Age, each 10 years older | 1.39 (1.17– 1.65) | 0.0002 | 1.38 (1.16– 1.64) | 0.0003 |
| Gender | ||||
| Male | 1.56 (1.00– 2.44) | 0.05 | 1.47 (0.93– 2.32) | 0.10 |
| Female | 1.00 | |||
| Educational status | ||||
| Secondary or above | 0.87 (0.60– 1.25) | 0.45 | – | - |
| None/Primary | 1.00 | |||
| Domicile location | ||||
| Urban | 0.88 (0.56– 1.39) | 0.58 | - | - |
| Rural | 1.00 | |||
| Hypertension | ||||
| Yes | 1.22 (0.49– 3.04) | 0.68 | - | - |
| No | 1.00 | |||
| Diabetes Mellitus | ||||
| Yes | 1.32 (0.86– 2.03) | 0.21 | - | - |
| No | 1.00 | |||
| HBA1C, every 2% rise | 1.55 (1.09– 2.20) | 0.01 | 1.74 (1.16– 2.61) | 0.008 |
| Systolic BP | ||||
| >140mmHg | 0.90 (0.62– 1.32) | 0.60 | - | - |
| <140mmHg | 1.00 | |||
Highlights.
The 8-item QVSFS could be used to screen for stroke symptoms among high risk CVD subjects
500 Ghanaian hypertensive ± diabetic subjects were screened for stroke symptoms using a pictorial version of the QVSFS
6% of study population had previous strokes/TIA
3 in 10 had stroke-like symptoms without prior diagnosis of stroke with high risk for future CVD events and dementia
The QVSFS could assist in identifying patients to benefit from CVD preventive interventions in routine care settings
Acknowledgments
We are grateful to Ernest Oduro Acquah, Emmanuel Oppong, Bright Amoako Asiamah, Francis Agyei, and Edith Sai-Affreh for helping with data collection.
Source of funding: National Institute of Health- National Institute of Neurological Disorders & Stroke; R21 NS094033 and NHGRI, NIH-NINDS; U54 HG007479.
Footnotes
Conflict of Interest: None to declare
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