Abstract
Background:
Intracerebral hemorrhage (ICH) stroke constitute up to 40% of incident strokes in Africa. While ICH patients are at high risk for atherosclerotic events, the risk-benefit of anti-atherosclerotic therapies in this patient population is uncertain.
Purpose:
To assess whether utility of statins and/ or antithrombotic agents after surviving an ICH correlates with atherosclerotic risk of an observational cohort.
Methods:
We analyzed data in a stroke registry prospectively collected on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, including diagnosis of ICH, co-morbidities, and key atherosclerotic risk reduction therapies (statins and anti-platelet drugs). We computed ischemic vascular risk using the Framingham Risk Score (FRS) to classify patients into low, intermediate and high vascular risk.
Results:
Of 1101 stroke survivors seen during the period, 244 (22.2%) had ICH. Vascular risk profiles were low (n=86; 35.2%), intermediate (n=71; 29.1%) and high (n=87; 35.7%). Utility of statin use was 76.7% (low risk), 84.5% (intermediaterisk), and 87.4% (high risk), p=0.16 while antiplatelet use trended with atherosclerotic risk being 9.3% (low risk), 25.4% (intermediate risk), and high risk (34.5%), p=0.0004. Independent factors associated with statin use were hypertension (OR 8.80; 95% CI: 2.34–33.11) and cigarette smoking (OR 0.29; 95% CI: 0.09–0.89) while antiplatelet drug use was associated with age (OR 1.43; 95% CI: 1.06–1.92) and time from index stroke (OR: 1.02; 95% CI: 1.01–1.02).
Conclusion:
Approximately two-thirds of ICH survivors in this African sample had intermediate to high risk of future atherosclerotic events. Clinical trials on the timing, safety, and efficacy of statins and antiplatelet drugs among ICH survivors could help better guide risk mitigation in this population.
Keywords: Intracerebral hemorrhage, atherosclerotic risk, Africa, statins
INTRODUCTION
Intracerebral hemorrhage (ICH), the more devastating stroke type, contributes approximately 10–15% of strokes in western high-income countries (HICs) and 20–40% in low-and-middle income countries (LMICs).1 Compared with HICs, the burden of ICH in sub-Saharan African (SSA) LMICs falls heavily on a young population leading to significant disability adjusted life years lost on the continent.2 A clustering of atherosclerotic cardio-metabolic risk factors such as hypertension, dyslipidemia and diabetes mellitus in an individual drives the occurrence of ICH akin to ischemic stroke.3–5 Furthermore, after surviving an ICH, arterial occlusive diseases such as ischemic strokes and myocardial infarctions are commoner cardiovascular events than recurrent ICH.6
Thus, secondary prevention of recurrent cardiovascular events among ICH survivors should hinge on assessing overall atherosclerotic event risk to guide treatment options. However, the use of statins for secondary prevention after ICH for instance is shrouded in controversy with clinical trial data suggesting potential harm7,8 versus a wealth of observational cohort data9 showing favorable impact. On the basis of a Markov decision model, it was recommended that statins should be avoided in patients with a history of ICH, particularly ICH with lobar location.10 Again, data on re-starting or stopping of Aspirin therapy among those on Aspirin who experience an acute ICH supports a re-start approach with lower rates of recurrent ICH in the Aspirin group as well as fewer occlusive arterial diseases.11
Although ICH is much commoner in Africa, there are no reports on risk reduction strategies for its survivors aside blood pressure control. We hypothesize that the utility of anti-atherosclerotic medications after an ICH will be guided by atherosclerotic risk of patients. In this report, we have analyzed data in a Ghanaian stroke registry to assess atherosclerotic risk reduction according to utilization of statins and/or anti-thrombotic therapy among ICH survivors.
METHODS
Study Design
This is a retrospective cross-sectional study from an ethically approved stroke registry data. The study was conducted at the Neurology Clinic of the Komfo Anokye Teaching Hospital in Kumasi, Ghana. Kumasi is the second largest city in Ghana with an estimated population of 4 million inhabitants.12 Since 2018, a stroke registry has been established to collect data among stroke survivors in a cross-sectional fashion. Data collected for the present analysis include age, gender, marital status, occupation, religion, type of stroke, and vascular risk factors as well as prescribed medications for secondary vascular risk reduction. For the present study, we probed the stroke registry data to capture information on ICH survivors, vascular risk factors and secondary prevention medications.
Diagnosis of Previous Stroke
Stroke diagnosis was based on the World Health Organization definition13, if participant had ever experienced sudden onset of weakness or sensory loss on one side of the body, sudden loss of vision, or sudden loss of speech.14–16 ICH was confirmed using CT scan.
Assessment of 10-year Atherosclerotic risk
The Framingham Risk Score (FRS)17 which incorporates gender, age, total cholesterol, HDL-cholesterol, systolic blood pressure, diabetes mellitus, cigarette smoking, prior cardiovascular disease, and use of antihypertensive medication was used to assess global CVD risk. Each participant was score using an on-line calculator into low-risk if score <10%, intermediate risk 10–20% and high risk if score >20%. Participants below 40 years were assigned an age of 40 years for risk calculation.
Statistical analysis
Baseline characteristics of ICH according to three categories of CVD risk namely low, intermediate and high were compared using Analysis of Variance (ANOVA) for continuous variables that followed parametric distribution and Kruskal Walis analysis for continuous variable that followed non-parametric distribution. Proportions were compared using the Chi-squared tests or Fisher’s exact test for proportions with subgroupings <5. Factors associated with either statin use or antiplatelet use were assessed using a multivariate logistic regression model with a p-value cut-off <0.10 considered for factor identification in bivariate analyses for inclusion into multivariate models. In all analyses, two-tailed p-values <0.05 were considered statistically significant. Statistical analysis was performed using GraphPad Prism version 7.
RESULTS
Demographic and Clinical characteristics of ICH survivors
Among 1101 stroke survivors in the registry, 244 (22.2%) had CT scan confirmed ICH. There was a male preponderance 146 (59.8%) with a mean ± SD age of ICH survivors at stroke onset being 51.3 ± 12.4 years. The age distribution of ICH survivors is shown in Figure 1 with a modal age range of 40–49 years. Using the Framingham Risk Score, 86 (35.2%) had low CVD risk, 71 (29.1%) had intermediate CVD risk and 87 (35.7%) had high CVD risk. A comparison of demographic and clinical characteristics of study participants according to CVD risk status is shown in Table 1. The age and sex distribution of global 10-year CVD risk among ICH survivors is depicted in Figure 2A–C.
Figure 1.
Age distribution of Intracerebral hemorrhagic stroke survivors in Ghana.
Table 1.
Comparison of demographic & clinical characteristics of Intracerebral hemorrhagic stroke survivors according to atherosclerotic risk
| Characteristic | Low risk N=86 | Intermediate risk N=71 | High risk N=87 | P-value |
|---|---|---|---|---|
| Age, mean ± SD | 41.2 ± 8.7 | 50.6 ± 7.5 | 61.9 ± 9.8 | <0.0001 |
| Male, n (%) | 39 (45.3) | 46 (64.8) | 61 (70.1) | 0.0024 |
| Location of residence | 0.84 | |||
| Rural | 9 (10.5) | 5 (7.1) | 10 (11.9) | |
| Semi-urban | 32 (37.2) | 30 (42.9) | 32 (38.1) | |
| Urban | 45 (52.3) | 35 (50.0) | 42 (50.0) | |
| Duration of stroke onset, median (IQR) | 13 (3–69) | 22 (5–72) | 36 (7–119) | 0.04 |
| Location of bleed | 0.15 | |||
| Non-lobar | 24 (27.9) | 23 (32.4) | 22 (25.3) | |
| Lobar | 7 (8.1) | 14 (19.7) | 11 (12.6) | |
| No data | 55 (64.0) | 34 (47.9) | 54 (62.1) | |
| Vascular Risk factors | ||||
| Hypertension, n (%) | 79 (91.9) | 68 (95.8) | 86 (98.9) | 0.09 |
| Diabetes mellitus, n (%) | 1 (1.2) | 5 (7.0) | 25 (28.7) | <0.0001 |
| Current smoker, n (%) | 1 (1.2) | 1 (1.4) | 9 (10.3) | 0.005 |
| Current alcohol use, n (%) | 22 | 24 | 30 | 0.38 |
| Total cholesterol | 4.9 ± 1.2 | 5.0 ± 1.7 | 5.5 ± 1.5 | 0.11 |
| LDL-cholesterol | 2.8 ± 1.0 | 3.1 ± 1.4 | 3.6 ± 1.4 | 0.01 |
| HDL-cholesterol | 1.7 : 1.1 | 1.4 ± 0.7 | 1.3 ± 0.4 | 0.02 |
| Triglycerides | 1.1 ± 0.5 | 1.3 ± 0.7 | 1.4 ± 0.6 | 0.11 |
| Secondary prevention medications | ||||
| Statins, n (%) | 66 (76.7) | 60 (84.5) | 76 (87.4) | 0.16 |
| Antiplatelet therapy, n (%) | 8 (9.3) | 18 (25.4) | 30 (34.5) | 0.0004 |
| Antihypertensives, mean ± SD | 2.7 ± 1.5 | 3.2 ± 1.2 | 3.2 ± 1.3 | 0.02 |
| ACE-inhibitor, n (%) | 29 (33.4) | 25 (35.2) | 39 (44.8) | 0.27 |
| Angiotensin receptor blocker, n (%) | 37 (43.0) | 39 (54.9) | 43 (49.4) | 0.33 |
| Beta-blocker, n (%) | 18 (20.9) | 26 (36.6) | 19 (21.8) | 0.05 |
| Calcium channel blocker, n (%) | 70 (81.4) | 64 (90.1) | 81 (93.1) | 0.05 |
| Diuretic, n (%) | 37 (43.0) | 40 (56.3) | 46 (52.9) | 0.21 |
| Mineralocorticoid receptor antagonist, n (%) | 9 (10.5) | 7 (9.9) | 14 (16.1) | 0.40 |
| Methyldopa, n (%) | 13 (15.1) | 9 (12.7) | 16 (18.4) | 0.61 |
| Hydralazine, n (%) | 20 (23.3) | 19 (26.8) | 20 (23.0) | 0.83 |
| Systolic BP, mean ± SD | 140.8 ± 25.2 | 153.3 ± 22.6 | 157.6 ± 21.3 | <0.0001 |
| Diastolic BP, mean ± SD | 91.5 ± 18.6 | 98.4 ± 15.2 | 92.8 ± 15.8 | 0.03 |
| eGFR, mean ± SD | 76.3 ± 20.1 | 72.9 ± 21.9 | 72.2 ± 22.2 | 0.46 |
| Fasting blood glucose, mean ± SD | 6.4 ± 1.6 | 6.8 ± 2.2 | 7.9 ± 3.4 | 0.01 |
Figure 2. Age- and sex distribution of 10-year atherosclerotic CVD risk among Ghanaian ICH survivors.
Proportions of males and females according to CVD risk (Fig. 2A), CVD risk according to age categories of <50 years, 50–64 years and 65+ years (Fig. 2B) and sex versus age distribution of CVD risk (Fig. 2C).
Use of Statins and Anti-platelet Medications before and after ICH occurrence
Before the occurrence of ICH, 17 (7.0%) subjects reported use of a statin, 11 (4.5%) reported using anti-platelet, none (0.0%) was on anticoagulant therapy while 134 (54.9%) subjects were on antihypertensive therapy. During hospitalization for ICH, 121 (49.6%) were commenced on a statin and 16 (6.6%) were commenced on an anti-platelet therapy.
At the time of enrollment into the registry at follow-up in the out-patient neurology clinic 202 (82.8%) were on statins. There was no significant difference in use of statins across the three atherosclerotic risk groups, being 76.7%, 84.5% and 87.4% from low to high risk, p=0.16. There were 55 (22.5%) on any antiplatelet in the registry with a graded utilization rate according to atherosclerotic risk being significantly higher among high CVD risk group at 34.5% versus 9.3% among low CVD risk group, p =0.0004. Furthermore, as shown in Figure 3, there was a progressive increase in the proportions on both an antiplatelet and a statin across the CVD risk categories being 9.3% in the low CVD risk group, 21.1% in the intermediate risk group and 29.9% in the high CVD risk group.
Figure 3.
Proportions of ICH survivors according to use of Antiplatelet and or statin therapy in relation to 10-year CVD atherosclerotic risk.
Factors associated with statin and anti-platelet use
The two independent factors associated with use of statins among ICH survivors were having hypertension with adjusted odds ratio of 8.80 (95% CI: 2.34–33.11) and cigarette smoking aOR of 0.29 (95% CI: 0.09–0.89) as shown in Table 2. Furthermore, the two independent factors associated with anti-platelet use were increasing age, aOR of 1.43 (95% CI: 1.06–1.92) and longer duration of stroke at enrollment into registry, aOR of 1.02 (95% CI: 1.01–1.02) for each month longer. (Table 3)
Table 2.
Factors associated with Statin use among ICH survivors in Ghana
| Factor | Unadjusted odds ratio (95% CI) | p-value | Adjusted odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Age, each 10-year rise | 1.32 (0.99–1.76) | 0.06 | 1.23 (0.92–1.66) | 0.17 |
| Male sex | 1.62 (0.83–3.17) | 0.16 | -- | -- |
| Hypertension | 9.90 (2.75–35.61) | 0.0004 | 8.80 (2.34–33.11) | 0.001 |
| Diabetes mellitus | 0.85 (0.32–2.21) | 0.74 | -- | -- |
| Alcohol use | 0.69 (0.34–1.37) | 0.29 | -- | -- |
| Cigarette use | 0.31 (0.11–0.91) | 0.03 | 0.29 (0.09–0.89) | 0.03 |
| Duration of stroke in months | 1.00 (0.99–1.01) | 0.79 | -- | -- |
Table 3.
Factors associated with Anti-platelet use among ICH survivors in Ghana
| Factor | Unadjusted odds ratio (95% CI) | p-value | Adjusted odds ratio (95% CI) | p-value |
|---|---|---|---|---|
| Age, each 10-year rise | 1.44 (1.13–1.84) | 0.004 | 1.43 (1.06–1.92) | 0.02 |
| Male sex | 1.23 (0.66–2.29) | 0.51 | -- | -- |
| Hypertension | 1.33 (0.28–6.32) | 0.72 | -- | -- |
| Diabetes mellitus | 2.50 (1.13–5.54) | 0.02 | 1.73 (0.66–4.49) | 0.26 |
| Alcohol use | 1.10 (0.58–2.09) | 0.77 | -- | -- |
| Cigarette use | 2.92 (1.03–8.23) | 0.04 | 1.75 (0.51–6.05) | 0.38 |
| Duration of stroke in months | 1.02 (1.01–1.02) | <0.0001 | 1.02 (1.01–1.02) | <0.0001 |
DISCUSSION
Among 244 ICH stroke survivors with an average age of 50 years, 35% had low, 29% had intermediate and 36% had high atherosclerotic event risk using the Framingham Risk calculator. While statin use did not trend with atherosclerotic risk as we hypothesized, antithrombotic use was significantly correlated with atherosclerotic risk. The heightened risks for 10-year atherosclerotic CVD risk were driven by increasing age and male gender with diabetes and cigarette smoking key as modifiable risk factors in this West African sample. Hypertension was ubiquitous as a risk factor present in nearly 95% of all study subjects. Of interest to atherosclerotic event risk reduction among ICH survivors, statins were prescribed for 77% in the low event risk group increasing up to 87% in the high atherosclerotic event risk group. The frequency of statin use after ICH in our study is substantially higher than data from nationwide stroke registers such as 749 out of 7583 (9.9%) in Taiwan18, 2258 out of 15,270 (14.8%) in Denmark 19, and 1276 out of 7696 (16.6%) in Sweden.20 Possible reasons for increased use of statins among ICH survivors in our case series could be the emerging evidence from meta-analysis of favorable outcomes for statin use after ICH9, and perhaps the fact that these middle-aged ICH survivors have several years of potential exposure to atherosclerotic event risk requiring mitigation.
In our cohort, having hypertension was strongly associated with use of statins while statin use was inversely associated with history of cigarette smoking. Of interest, only 7% of ICH survivors were on statin therapy at stroke onset, almost 50% were commenced lipid modulator therapy during acute phases of ICH and increased to 83% during follow-up at our out-patient clinic. While it has been recommended that statins should be avoided in patients with ICH, in particular those with lobar bleeds, our experience among nearly 850 West Africans with acute ICH shows that 77% were non-lobar in location.5 Furthermore dyslipidemia, hypertension and diabetes mellitus were significantly associated with occurrence of lobar ICH and would warrant the institution of use statins at some stage in their clinical care.5
Regarding antithrombotic therapy with antiplatelets, there was a graded increase in its usage from 9% in the low risk group, 25% in the intermediate and 35% in the high-risk groups which represent an overall low rate of utilization of this secondary preventative strategy in the present cohort. Compositely, 23% of ICH survivors were on any anti-platelets which is lower than 31.4% in ICH survivors in Denmark21 but marginally higher than 20% of 469 ICH survivors who re-started antithrombotic drugs in multinational cohort from France, United Kingdom, Netherlands and Scotland.22 The clinical conundrum of whether or not to initiate or re-start Aspirin among ICH cases has been partially addressed with reassuring data from RE-START trial where ICH survivors who re-started Aspirin compared with those who stopped Aspirin had a lower risk of recurrent ICH, adjusted HR of 0.51 (95% CI: 0.25–1.03); p=0.06 and lower risk of arterial occlusive diseases a composite of MI, stroke or death from vascular cause, adjusted HR of 0.65 (95% CI: 0.44–0.95); p=0.025.11 It should promptly be noted that up to 44% of ICH cases in the developed countries are on Aspirin at ICH occurrence22,23 compared with <5% reported aspirin use in our study. In our study, use of anti-platelets among ICH survivors was associated with increasing age with a 43% higher odds of antiplatelet use with each 10-year older and each month longer after ICH was associated with a 2% higher odds of antiplatelet use.
The optimal approach to atherosclerotic risk reduction after surviving an ICH still has several unanswered questions. For instance, what is the safety and efficacy of statin and or antiplatelet therapy after surviving an acute incident ICH? Should secondary preventative therapies using statins and or antithrombotic therapy be initiated on the balance of future atherosclerotic event risk versus potential harm from re-bleeding? As observed in the present study, clinicians managing ICH survivors do not have clinical trial evidence to base decision-making on secondary risk reduction beyond blood pressure control. Our recent studies have highlighted a high burden of resistant forms of hypertension among stroke survivors, in particular, those with ICH.24–26 Furthermore, control of blood pressure is poor among stroke survivors27–30 and use of statins among high atherosclerotic risk patients including stroke survivors has been reportedly low in Ghana.31–33 As the number of stroke survivors continues to rise on the African continent34, local data are needed to guide the development of clinical guidelines for secondary prevention after stroke.
A limitation of this study is that we have not provided any outcome measures on the atherosclerotic risk reduction and should be looked at in future studies from Africa. Information on location of ICH was not available for about 58% of the study sample due to missing information in their medical records for us to classify bleeds as either lobar or non-lobar. Furthermore, this is a single center study hence our findings are not readily generalizable to other medical settings.
In conclusion, approximately two-thirds of ICH survivors in this west African sample have intermediate to high atherosclerotic event risk. Clinical trials on the safety and efficacy of statins and anti-thrombotic therapy among ICH survivors are needed particularly in low-and-middle income countries where ICH burden is highest to guide clinicians resolve conundrums of secondary risk reduction approaches in this unique population.
Highlights.
ICH constitute up to 40% of strokes in Africa
ICH survivors are at heightened risk for future atherosclerotic events
In a Ghanaian stroke registry, 22% of stroke survivors had ICH
35% had low, 29% intermediate and 36% had high vascular risk using the Framingham Risk Score
83% of ICH survivors were on statin and 23% on anti-platelet therapy
Acknowledgements:
We are grateful to our Research Assistants Mr. Nathaniel Adusei-Mensah and Mr. Michael Ampofo for helping with data collection.
Source of Funding:
National Heart, Lung, and Blood Institute (R01HL152188)
Footnotes
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Disclosures: None
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