贫困对卒中复发的影响：一项基于人群的研究。
Impact of Poverty on Stroke Recurrence: A Population-Based Study.
机构信息
From the Departments of Neurology (C.J.B., B.S., D.K.) and Emergency Medicine (R.R.), University of Michigan, Ann Arbor; Department of Biostatistics (H.S.), Cincinnati Children's Hospital Medical Center; Departments of Neurology and Rehabilitation Medicine (D.R., L.N., R.J.S., D.W., S.F., E.A.M., S.D., M.H., M.L.F., B.K.) and Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH; Department of Neurology (A.S.J.), Yale University, New Haven, CT; Miami Neuroscience Institute (F.D.L.R.L.R.), Baptist Health South Florida; Department of Neurology (J.M.), Indiana University School of Medicine, Indianapolis; Department of Neurology (E.C.), University of Chicago, IL; Department of Neurology (S.S.), University of Kansas Medical Center, Kansas City; Department of Neurology (M.S.), Soroka Medical Center, Beersheba, Israel; and National Neurology Program (S.R.M.), Veterans Health Administration and Department of Neurology, Baylor College of Medicine, Houston, TX.
出版信息
Neurology. 2024 Jun 11;102(11):e209423. doi: 10.1212/WNL.0000000000209423. Epub 2024 May 17.
BACKGROUND AND OBJECTIVES
Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear.
METHODS
In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke.
RESULTS
Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively ( < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models.
DISCUSSION
Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.
背景与目的
贫困与更高的中风发病率相关。贫困与中风复发之间的关系尚不清楚。
方法
在这项基于人群的研究中，在 2015 年的研究期间确定了大辛辛那提/北肯塔基地区的首发中风，并随访至 2018 年 12 月 31 日，以了解复发情况。主要暴露因素是邻里社会经济地位（nSES），以每个普查区内低于联邦贫困线的家庭比例（分为 4 类：≤5%、>5%-10%、>10%-25%、>25%）定义。泊松回归模型根据 2015 年 5 年美国社区调查的人口数据，为每 10 万居民提供了复发率估计值，调整了年龄、性别和种族因素。在二次分析中，Cox 模型允许在有首发中风的患者中，根据 nSES 将血管危险因素纳入复发风险评估中。
结果
在 2125 名首发中风患者中，245 名在研究期间发生了中风复发。nSES 越差，中风复发的风险越高，在低于贫困线比例分别为≤5%、>5%-10%、>10%-25%和>25%的普查区，复发率分别为 12.5、17.5、25.4 和 29.9/10 万（<0.01）。在调整 nSES 之前，黑人和白人之间复发性中风的相对风险（95%CI）为 2.54（1.91-3.37），调整后为 2.00（1.47-2.74），下降了 35.1%。在二次分析中，nSES 较差（最低 vs 最高类别，HR 1.74，95%CI 1.10-2.76）和黑人种族（HR 1.31，95%CI 1.01-1.70）均与复发风险独立相关，但在完全调整后均无统计学意义。在完全调整的模型中，年龄、糖尿病和左心室肥厚与复发风险增加相关。
讨论
居住在贫困社区的居民中风复发风险呈剂量依赖性增加，贫困社区的贫困程度约占黑人个体中风复发风险增加的三分之一。这些结果突出了贫困、种族以及二者相互作用作为中风复发的重要驱动因素的重要性。
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