Stroke risk factors and outcomes in Trinidad and Tobago: the START study

This study aimed to assess the risk factors, associations and outcomes of stroke at an academic tertiary medical center in Trinidad and Tobago.

This cross-sectional observational study with longitudinal follow-up evaluated 546 patients admitted with stroke at the Eric Williams Medical Sciences Complex (EWMSC) from January 2023 to January 2024. Patients' comorbidities, medications, and neuroimaging findings were recorded. Disability and survival outcomes utilizing the modified Rankin Scale (mRS) were assessed during their inpatient status and at three months post-hospitalization.

The average age represented was 65 years, with 56% males. Of a total of 546 patients who presented with acute neurologic deficits, 410 were diagnosed with a stroke, with the remaining 136 (25%) with a transient ischemic attack (TIA). Of the stroke cases, 328 (80%) were ischemic, 78 (19%) were hemorrhagic, and 5 (1%) were with ischemic lesions complicated by hemorrhagic transformation. The overall inpatient mortality rate was 16%, and the 3-month mortality rate was 26%. Gender was associated with an increased odds of having a stroke compared to a transient ischemic attack (p-value 0.036). Chronic kidney disease (CKD) was associated with an increased odds ratio (OR) of hemorrhagic stroke (OR = 11.10; 95% confidence interval (CI) 3.39-36.36, p-value 0.020). Diabetes mellitus (DM) (OR 1.72, 95% CI 1.08-2.73, p-value 0.02; OR 1.51, 95% CI 1.03-2.21; p-value 0.037), subarachnoid hemorrhage (SAH) (OR 5.45, 95% CI 1.72-17.32, p-value 0.004; OR 4.14, 95% CI 1.29-13.25, p-value 0.017), intraparenchymal hemorrhage (IPH) (OR 4.83, 95% CI 2.76-8.48, p-value < 0.001; OR 3.17, 95% CI 1.87-5.37, p-value < 0.001) and middle cerebral artery (MCA) infarct (OR 3.02, 95% CI 1.87-4.89, p-value < 0.001; OR 2.34, 95% CI 1.54-3.57, p-value < 0.001) were associated with in-hospital and 3-month mortality respectively. Atrial fibrillation (AF) (OR 2.47, 95% CI 1.08-5.64, p-value 0.031) was associated with in-hospital mortality. Age (OR 1.02, 95% CI 1.01-1.04, p-value 0.004), heart failure with reduced ejection fraction (HFrEF) (OR 4.88, 95% CI 1.15-20.68, p-value 0.032) and anterior cerebral artery (ACA) infarct (OR 2.27, 95% CI 1.13-4.56, p-value 0.022) were associated with 3-month mortality. Age was positively correlated with mRS (p-value 0.013). Ischemic stroke had a median mRS of 3, while hemorrhagic stroke had a median mRS of 5 (p-value < 0.001).

This study demonstrated high-risk subgroups, disability and mortality outcomes in patients with stroke in Trinidad. Conventional risk factors such as age, CKD, DM, AF, and HFrEF with specific neuroradiologic findings (SAH, IPH, MCA and ACA infarcts) were all negatively associated with adverse outcomes in stroke patients in Trinidad. This information may be clinically pertinent in devising comprehensive strategies to attenuate stroke burden. Further, large-scale prospective studies are required to confirm these epidemiologic results.

NCT05256550. This study was prospectively registered on 02/15/2022 on clinicaltrials.gov.