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Racial Disparities in Stroke Recurrence: A Population-Based Study
David Joseph Robinson1, Robert Stanton2, Heidi Sucharew2
1Department of Neurology and Rehabilitation Medicine (D.J.R., R.S.K.A., M.H., S.F., E.A.M., S.D., D.W., B.K.), University of Cincinnati; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Miami Neuroscience Institute (F.d.l.R.l.R.), Baptist Health South Florida; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (A.J.), Yale University, New Haven, CT; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (M.S.), Soroka Medical Center, Beersheva, Israel; Department of Neurology (S.S.), University of Kansas Medical Center Kansas City; Department of Emergency Medicine (K.W.), University of Cincinnati, OH; and Department of Neurology (D.O.K.), University of Michigan, Ann Arbor. drobinism@gmail.com.
Insights
Black individuals have a higher risk of recurrent stroke, but this difference significantly decreases when traditional stroke risk factors are considered. Addressing these factors may reduce stroke recurrence disparities.
Area of Science:
- Neurology
- Public Health
- Epidemiology
Background:
- Significant racial disparities exist in stroke incidence in the United States.
- Black individuals face a higher risk of initial stroke, even after accounting for known risk factors.
- The risk of recurrent stroke among Black individuals remains largely unexamined.
Purpose of the Study:
- To investigate the association between Black race and the risk of recurrent stroke.
- To determine if traditional stroke risk factors mediate the relationship between race and stroke recurrence.
- To identify potential targets for reducing racial disparities in stroke recurrence.
Main Methods:
- A cohort of 3,816 patients with index stroke or transient ischemic attack (TIA) was followed for 3 years.
- Multivariable survival analysis was used to assess the effect of Black race on stroke recurrence.
- Traditional stroke risk factors (hypertension, diabetes, smoking, age, left ventricular hypertrophy) were included as covariates.
Main Results:
- The 3-year stroke recurrence rate was 15.4% in the study population.
- Black individuals showed a higher age- and sex-adjusted risk of recurrent stroke (HR 1.34).
- After adjusting for traditional risk factors, the association between Black race and recurrence was attenuated and no longer significant (HR 1.1).
- The association was stronger at younger ages and may not be fully explained by traditional risk factors.
Conclusions:
- While recurrent stroke is more common in Black individuals, this disparity is substantially reduced when traditional risk factors are accounted for.
- Interventions focused on managing hypertension, diabetes, and other risk factors could help mitigate racial disparities in stroke recurrence.
- Further research is needed to understand the role of risk factors in younger Black individuals experiencing recurrent stroke.
Background And Objective:
There are significant racial disparities in stroke in the United States, with Black individuals having a higher risk of incident stroke even when adjusted for traditional stroke risk factors. It is unknown whether Black individuals are also at a higher risk of recurrent stroke.
Methods:
Over an 18-month period spanning 2014-2015, we ascertained index stroke cases within the Greater Cincinnati/Northern Kentucky population of 1.3 million. We then followed up all patients for 3 years and determined the risk of recurrence. Multivariable survival analysis was performed to determine the effect of Black race on recurrence.
Results:
There were 3,816 patients with index stroke/TIA events in our study period, and 476 patients had a recurrent event within 3 years. The Kaplan-Meier estimate of 3-year recurrence rate was 15.4%. Age-adjusted and sex-adjusted stroke recurrence rate was higher in Black individuals (HR 1.34, 95% CI 1.1-1.6; p = 0.003); however, when adjusted for traditional stroke risk factors including hypertension, diabetes, smoking status, age, and left ventricular hypertrophy, the association between Black race and recurrence was significantly attenuated and became nonsignificant (HR 1.1, 95% CI 0.9-1.36, p = 0.32). At younger ages, Black race was more strongly associated with recurrence, and this effect may not be fully attenuated by traditional stroke risk factors.
Discussion:
Recurrent stroke was more common among Black individuals, but the magnitude of the racial difference was substantially attenuated and became nonsignificant when adjusted for traditional stroke risk factors. Interventions targeting these risk factors could reduce disparities in stroke recurrence.
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