Disparities in Awareness of Myocardial Infarction and Stroke Symptoms and Response Among United States– and Foreign‐Born Adults in the National Health Interview Survey

Background Atherosclerotic cardiovascular disease, defined as nonfatal myocardial infarction (MI), coronary heart disease death, or fatal or nonfatal stroke, is the leading cause of death in the United States. MI and stroke symptom awareness and response reduce delays in hospitalization and mortality. Methods and Results We analyzed cross‐sectional data from the 2014 and 2017 National Health Interview Surveys on US‐ and foreign‐born adults from 9 regions of birth (Europe, South America, Mexico/Central America/Caribbean, Russia, Africa, Middle East, Indian subcontinent, Asia, and Southeast Asia). The outcomes were recommended MI and stroke knowledge, defined as knowing all 5 symptoms of MI or stroke, respectively, and choosing “call 9‐1‐1” as the best response. We included 63 059 participants, with a mean age 49.4 years; 54.1% were women, and 38.5% had a high school education or less. Recommended MI and stroke knowledge were highest in US‐born people. In both 2014 and 2017, MI knowledge was lowest in individuals born in Asia (23.9%±2.5% and 32.1%±3.3%, respectively), and stroke knowledge lowest for the Indian subcontinent (44.4%±2.4% and 46.0%±3.2%, respectively). Among foreign‐born adults, people from Russia and Europe had the highest prevalence of recommended MI knowledge in 2014 (37.4%±5.4%) and 2017 (43.5%±2.5%), respectively, and recommended stroke knowledge was highest in people from Europe (61.0%±2.6% and 67.2%±2.5%). Improvement in knowledge was not significant in all groups between 2014 and 2017. Conclusions These findings suggest a disparity in MI and stroke symptom awareness and response among immigrants in the United States. Culturally tailored public health education and health literacy initiatives are needed to help reduce these disparities in awareness.

Community Intent to Activate Emergency Medical Services May Be Associated with Regional tPA Treatment

<b><i>Introduction:</i></b> Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment. <b><i>Methods:</i></b> The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics. <b><i>Results:</i></b> The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81–90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2–4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA’s intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (<i>p</i> = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (<i>p</i> = 0.05). <b><i>Conclusions:</i></b> There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.

Time Evolution of the Stroke Symptom-Herb Networks Based on TCM Prescriptions

Traditional Chinese Medicine (TCM) has its origins in distant antiquity and has piled up over a long time with much knowledge about diseases, especially stroke. Different combinations of symptom variables yield different combinations of herbs to form a myriad of prescriptions, and they have undergone repeated confirmation and are worthy objects of excavation and analysis. Herbal studies on stroke have developed from genomics to transcriptomics, proteomics and metabolomics, yet more thought is needed on putting time in a wider perspective of the symptoms and herbs for stroke in Chinese medicine.Due to this, we studied the dynamic structure of TCM prescriptions on stroke, using over 270 TCM prescription books containing 2231 prescriptions related to stroke recorded from 341 to 2000 CE. We labeled the functions of the prescriptions with the symptoms based on subject terms in MESH Neurologic Manifestations, then standardized the herbs in the prescriptions, and finally connected the co-occurring symptoms and herbs in the prescriptions to build an undirected complex network. The Stroke Symptom-Herb Networks (SSHNs) can be seen from its network characteristics that it is not a random network and has small-world characteristics. It has experienced two peaks in its nearly 1700-year history, during the Song dynasty, the Ming and Qing dynasties. From 600 years onwards, the core herb cluster has been initially formed. The comparison of sub-network similarities allowed us to identify several symptoms with similar herb clusters.We divided the community based on modularity, and by analyzing the community evolution, we found a more fixed historical evolutionary trend with Hemiplegia and Sialorrhea nodes and their associated symptom and herb nodes. In the time series analysis, we found many symptom-herb combinations that were consistently closely related to historic time depends on assessing the similarity between the symptoms and the herbs. The complex network provides a distinctive perspective for understanding the symptom-herb relationships embedded in TCM prescriptions in remote antiquity.

Knowledge of Stroke in a Sub-urban Slum Community in Plateau State, North Central Nigeria

Background: Despite stroke being a prominent cause of morbidity and mortality in north central Nigeria, there is no information on community perception and knowledge of stroke symptoms. This study was designed to assess the knowledge of stroke in a suburban community. Methods: This was community-based cross sectional observational study conducted at Kabong in Tudun Wada/Kabong ward of Jos North Local Government Area of Plateau State in north central Nigeria. A multi-stage sampling technique was used to select Kabong Community and all adults 18 years and above in the community were invited to participate in the study. The knowledge of stroke symptoms was assessed using an interviewer-administered questionnaire. The main outcome measure was the ability to identify stroke symptoms. Results: There were 196 respondents with a mean age (± standard deviation) of 46.4 (± 16.7) years; their ages ranging from 18 – 84 years. Fifty-four percent could identify only one stroke symptom and this was “sudden weakness or numbness of face, arm or leg especially on one side of the body.” On multivariate logistic regression analysis, previous stroke education (Odds Ratio = 0.034, 95% CI = 0.008 – 0.147, p < 0.001) emerged as the independent predictor of ability to identify this stroke symptom. Conclusion: Knowledge of stroke was poor among participants. Efforts should be made to improve stroke knowledge through deliberate health education of stroke patients, their relatives and the community by health care providers.

Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment

Introduction: Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions. Methods: We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume). Results: There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05). Conclusions: Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.

Abstract P515: Early Neurological Deterioration in Minor Stroke Symptom Large Vessel Occlusion Patients

Background: 30% of minor stroke symptom (MSS) patients (NIHSS=<5) have underlying large vessel occlusions (LVO). MSS patients are less likely to receive endovascular therapy (EVT) and thrombolytic therapy. 20-25% of patients with LVO suffer early neurological deterioration (END), ≥ 4 points decrease on NIHSS, which is associated with worse outcomes. The predictability of END is currently unclear and there is need for elucidation on the factors which precipitate rapid decline. Methods: Retrospective review of MSS-LVO patients across two multi-hospital centers from June 2015 thru June 2018 was conducted. Patients who underwent immediate EVT without signs of deterioration were excluded. Baseline characteristics, management, and outcomes were compared with t-tests, Mann-Whitney U, Chi-square, Fisher’s exact test, and Fisher-Freeman-Halton test for continuous and categorical variables, as appropriate using SPSS Software. Results: Of the 45 MSS-LVO patients who were included, 12 suffered END. Demographics and baseline characteristics were not significantly different across groups. Weakness was more often a presenting symptom in the No-END cohort (84.8% vs 41.7% in END group, p=0.01). The END group showed a lower diastolic BP at the time of the highest NIHSS (86mmHg vs 72mmHg in END group, p= 0.03). The highest BP was comparable across groups (180/84 in the No END group vs 182/91 in END group, p>0.05); although in the END group, the high BP correlated with a higher NIHSS (3 vs 0 in No END group, p=0.01). Patients in the END group were more likely to receive tpA (58.3% vs 15.2% in No END group, p=0.01). The 24-hour NIHSS was greater in the END group (2.5 vs. 0, p=0.02). 84.4% of patients in the No END group had good functional outcome at 3-5 days (mRS 0-2), compared to 45.5% of the END patients (p=0.02). 25% of the END group had in-hospital mortality, while there were no deaths in the No END group. Fewer patients were discharged home (72.7% in No END vs 58.3% in END group, p=0.04). Conclusion: END in MSS patients is associated with worse outcomes at 3-5 days and higher in-hospital mortality. Presenting symptoms and BP fluctuations may be factors in predicting END. Further studies are needed to elucidate the risk factors associated with END in MSS-LVO patients.