Panorama Burden of stroke in Puerto Rico Juan Zevallos1*, Fernando Santiago2, Juan González3, Abiezer Rodríguez2, Luis Pericchi4, Rafael Rodríguez-Mercado5, and Ulises Nobo6 Stroke is the fifth leading cause of death and the first cause of long-term disability in Puerto Rico. Trained staff reviewed and independently validated the medical records of patients who had been hospitalized with possible stroke at any of the 20 largest hospitals located in Puerto Rico during 2007, 2009, and 2011. The mean age of the 5005 newly diagnosed stroke patients (51·2% female) was 70 years. At the time of hospitalization, women were 41⁄2 years older, were less likely to be married (60·2% vs. 39·9%, P < 0·001), smoked less (5·8% vs. 13·4%, P < 0·001), and had significantly higher proportion of diabetes (56·0% vs. 54·8%), hypertension (89·1% vs. 85·0%), and low density lipoprotein-cholesterol (LDL-Chol) > 100 mg/dL (65·7% vs. 57·5%) P < 0·05. Ischemic stroke represented 75% of all types of strokes. Atrial fibrillation was mentioned in 7·9% of the medical records. The risk for dying before discharge was similar for both genders, but was 40% higher for women than for men at one-year followup: age-adjusted odds ratio = 1·4 (95% confidence interval = 1·2–1·5). Key words: countries, epidemiology, stroke, stroke prevalence, stroke subtypes, tPA
Puerto Rico is a commonwealth of the United States and it is located in the Caribbean, east of the Dominican Republic. Its 3·7 million people are 99% Hispanic and span over 9104 km2 with a population density of 406·4/km2 (1). The proportion of residents over the age of 65 has increased from 11·2% in 2000 to 15·2% in 2011 (2). Stroke is a leading cause of death and disability in Puerto Rico, and the Puerto Rico Stroke Registry is the first island-wide stroke registry that collects ongoing, standardized, and reliable data on incidental, consecutive strokes. The registry was established in 2007 to obtain information on demographics, stroke subtype, medical and stroke severity measures, diagnostic evaluation, revascularization, in-hospital management, discharge disposition, in-hospital mortality and follow-up survival, and quality of care indicators from the 20 largest adult, nonmilitary medical centers in Puerto Rico with emergency care facilities. This Correspondence: Juan C Zevallos*, Florida International University, FIU Herbert Wertheim College of Medicine, BBC Academic Center 1, Suite 237, Miami, Florida 33181, USA. E-mail: [email protected] 1 FIU Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA 2 Neurology, University of Puerto Rico, San Juan, Puerto Rico 3 Emergency Medicine, University of Puerto Rico, San Juan, Puerto Rico 4 Mathematics, University of Puerto Rico, San Juan, Puerto Rico 5 Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico 6 Neurology, HIMA-San Pablo Hospital, Caguas, Puerto Rico Received: 12 May 2014; Accepted: 30 June 2014; Published online 20 August 2014 Conflict of interest: None declared. DOI: 10.1111/ijs.12350 © 2014 World Stroke Organization
manuscript focuses on the demographic profile; the distribution for known comorbidities for stroke including atrial fibrillation, diabetes, hypercholesterolemia, hypertension, and current smoking; the distribution of stroke type; and the in-hospital and long-term mortality among Puerto Ricans. Trained physicians and nurses obtained information on age, sex, and marital status, and independently validated the medical records of patients who had been hospitalized with possible stroke International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes 430–438, but without transient ischemic attacks (TIAs), i.e., ICD-9-CM code 435) at any of the 20 participating hospitals (all of which had emergency room capability) during study years 2007, 2009, and 2011. Since we were interested in documenting the incidence rates of newly diagnosed strokes, we restricted our study sample to patients hospitalized with an initial stroke. Patients initially hospitalized in one hospital and then transferred to another during the same event were counted only once. Each case was validated using the computed tomography or magnetic resonance imaging report provided in the medical record and classified as ischemic or hemorrhagic type. The detailed data collection and validation methodologies have been described elsewhere (3). Patients were classified as having diabetes and hypertension whenever these comorbidities were mentioned in the medical record, or if they were treated with hypoglycemic or antihypertensive agents, respectively. Patients treated with cholesterol-lowering drugs and/or documented low density lipoprotein (LDL) >100 mg/dL were considered having hyperlipidemia. Current smoking refers to the proportion of those who smoke at the time of hospitalization. The mortality rate during hospitalization was directly abstracted from the medical records, whereas the one-year survival status after discharge was obtained from the National Death Index and/or the Puerto Rico Department of Health vital statistics databases. The geographic distribution of the 20 participating hospitals is shown in Fig. 1. A total of 5005 incidental acute stroke cases (mean age was 70 years and 51·2% female) were registered during 2007, 2009, and 2011 (Table 1). The proportion of strokes reached a peak at age 75–84 years and then declined in both genders. Atrial fibrillation was mentioned in the medical records in 7·9% of all cases. Women were less likely to be married than men (39·9% vs. 60·2% P < 0·001), showed smaller BMI (25·9 ± 6·3 vs. 28·3 ± 5·6, P < 0·001), and to be current smokers (5·8% vs. 13·4%, P < 0·001). Out of 10 stroke patients, approximately 5 had diabetes, 8 had hypertension, 3 had hyperlipidemia, and 1 was a current smoker. Women were more likely than men to have hypertension (89·1% vs. 81%, P = 0·010) and higher levels of low density lipoprotein-cholesterol (LDL-Chol) > 100 mg/dL (65·7% vs. 57·5%, P = 0·018). Although overall ischemic strokes (74·5%) accounted for the majority of stroke subtypes, women were more Vol 10, January 2015, 117–119
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Fig. 1 Geographic location of participating hospitals: the Puerto Rico stroke registry. Table 1 Demographics, comorbidities, and mortality, by gender: the Puerto Rico stroke registry, 2007, 2009, and 2011 Characteristic
All N = 5005 n (%)
Women N = 2563 n (%)
Men N = 2442 n (%)
*P-value (two-tailed)
Age (years), mean ± SD Age group (years) 84 Married BMI (kg/m2), mean ± SD Atrial fibrillation Hyperlipidemia LDL-Chol (>100 mg/dL) Hypertension Diabetes mellitus Current smoker status In-hospital mortality Alive at follow-up**
70·4 ± 13·7
73·2 ± 13·4
68·6 ± 13·1
Puerto Rico is a commonwealth of the United States and it is located in the Caribbean, east of the Dominican Republic. Its 3·7 million people are 99% Hispanic and span over 9104 km2 with a population density of 406·4/km2 (1). The proportion of residents over the age of 65 has increased from 11·2% in 2000 to 15·2% in 2011 (2). Stroke is a leading cause of death and disability in Puerto Rico, and the Puerto Rico Stroke Registry is the first island-wide stroke registry that collects ongoing, standardized, and reliable data on incidental, consecutive strokes. The registry was established in 2007 to obtain information on demographics, stroke subtype, medical and stroke severity measures, diagnostic evaluation, revascularization, in-hospital management, discharge disposition, in-hospital mortality and follow-up survival, and quality of care indicators from the 20 largest adult, nonmilitary medical centers in Puerto Rico with emergency care facilities. This Correspondence: Juan C Zevallos*, Florida International University, FIU Herbert Wertheim College of Medicine, BBC Academic Center 1, Suite 237, Miami, Florida 33181, USA. E-mail: [email protected] 1 FIU Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA 2 Neurology, University of Puerto Rico, San Juan, Puerto Rico 3 Emergency Medicine, University of Puerto Rico, San Juan, Puerto Rico 4 Mathematics, University of Puerto Rico, San Juan, Puerto Rico 5 Neurosurgery, University of Puerto Rico, San Juan, Puerto Rico 6 Neurology, HIMA-San Pablo Hospital, Caguas, Puerto Rico Received: 12 May 2014; Accepted: 30 June 2014; Published online 20 August 2014 Conflict of interest: None declared. DOI: 10.1111/ijs.12350 © 2014 World Stroke Organization
manuscript focuses on the demographic profile; the distribution for known comorbidities for stroke including atrial fibrillation, diabetes, hypercholesterolemia, hypertension, and current smoking; the distribution of stroke type; and the in-hospital and long-term mortality among Puerto Ricans. Trained physicians and nurses obtained information on age, sex, and marital status, and independently validated the medical records of patients who had been hospitalized with possible stroke International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) codes 430–438, but without transient ischemic attacks (TIAs), i.e., ICD-9-CM code 435) at any of the 20 participating hospitals (all of which had emergency room capability) during study years 2007, 2009, and 2011. Since we were interested in documenting the incidence rates of newly diagnosed strokes, we restricted our study sample to patients hospitalized with an initial stroke. Patients initially hospitalized in one hospital and then transferred to another during the same event were counted only once. Each case was validated using the computed tomography or magnetic resonance imaging report provided in the medical record and classified as ischemic or hemorrhagic type. The detailed data collection and validation methodologies have been described elsewhere (3). Patients were classified as having diabetes and hypertension whenever these comorbidities were mentioned in the medical record, or if they were treated with hypoglycemic or antihypertensive agents, respectively. Patients treated with cholesterol-lowering drugs and/or documented low density lipoprotein (LDL) >100 mg/dL were considered having hyperlipidemia. Current smoking refers to the proportion of those who smoke at the time of hospitalization. The mortality rate during hospitalization was directly abstracted from the medical records, whereas the one-year survival status after discharge was obtained from the National Death Index and/or the Puerto Rico Department of Health vital statistics databases. The geographic distribution of the 20 participating hospitals is shown in Fig. 1. A total of 5005 incidental acute stroke cases (mean age was 70 years and 51·2% female) were registered during 2007, 2009, and 2011 (Table 1). The proportion of strokes reached a peak at age 75–84 years and then declined in both genders. Atrial fibrillation was mentioned in the medical records in 7·9% of all cases. Women were less likely to be married than men (39·9% vs. 60·2% P < 0·001), showed smaller BMI (25·9 ± 6·3 vs. 28·3 ± 5·6, P < 0·001), and to be current smokers (5·8% vs. 13·4%, P < 0·001). Out of 10 stroke patients, approximately 5 had diabetes, 8 had hypertension, 3 had hyperlipidemia, and 1 was a current smoker. Women were more likely than men to have hypertension (89·1% vs. 81%, P = 0·010) and higher levels of low density lipoprotein-cholesterol (LDL-Chol) > 100 mg/dL (65·7% vs. 57·5%, P = 0·018). Although overall ischemic strokes (74·5%) accounted for the majority of stroke subtypes, women were more Vol 10, January 2015, 117–119
117
Panorama
J. Zevallos et al.
Fig. 1 Geographic location of participating hospitals: the Puerto Rico stroke registry. Table 1 Demographics, comorbidities, and mortality, by gender: the Puerto Rico stroke registry, 2007, 2009, and 2011 Characteristic
All N = 5005 n (%)
Women N = 2563 n (%)
Men N = 2442 n (%)
*P-value (two-tailed)
Age (years), mean ± SD Age group (years) 84 Married BMI (kg/m2), mean ± SD Atrial fibrillation Hyperlipidemia LDL-Chol (>100 mg/dL) Hypertension Diabetes mellitus Current smoker status In-hospital mortality Alive at follow-up**
70·4 ± 13·7
73·2 ± 13·4
68·6 ± 13·1
