on June 26, 2003
Published online before print June 26, 2003, doi: 10.1161/01.STR.0000079818.08343.8C
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Submitted on March 4, 2003
From the Stroke Prevention Research Unit, Department of Clinical Neurology, University of Oxford, Oxford, UK. * To whom correspondence should be addressed. E-mail: peter.rothwell{at}clneuro.ox.ac.uk.
Background--To understand the mechanisms of stroke and to target prevention, we need to know how risk factors differ between etiological subtypes. Hospital-based studies may be biased because not all stroke patients are admitted. If risk factors differ between patients who are admitted and those who are not, then case-control studies will be biased. If the likelihood of admission also depends on stroke subtype, then case-case comparisons may also be biased. Methods--We compared risk factors and ischemic stroke subtypes (TOAST classification) in hospitalized and nonhospitalized patients in 2 population-based stroke incidence studies: the Oxford Vascular Study (OXVASC) and Oxfordshire Community Stroke Project (OCSP). We also performed a meta-analysis of risk factor-stroke subtype associations with other published population-based studies. Results--In OXVASC and OCSP, stroke subtypes differed between hospitalized (293 of 647) and nonhospitalized patients (P<0.0001), with more cardioembolic strokes (odds ratio [OR], 1.8; 95% CI, 1.3 to 2.6) and fewer lacunar strokes (OR, 0.4; 95% CI, 0.3 to 0.7). Premorbid blood pressure and cholesterol were higher in hospitalized patients (both P<0.0001). Risk factor-stroke subtype associations in hospitalized patients were consequently biased (P=0.001). Meta-analysis of data from all patients in OXVASC, OCSP, and 2 other studies demonstrated consistent risk factor-stroke subtype associations. However, contrary to previous hospital-based studies, there was only a weak (OR, 1.4; 95% CI, 1.1 to 1.8) and inconsistent (Pheterogeneity=0.01) association between small-vessel stroke and hypertension and no association with diabetes (OR, 1.0; 95% CI, 0.7 to 1.3). Conclusions--Prevalences of risk factors and stroke subtypes differ between hospitalized and nonhospitalized patients with ischemic stroke, which may bias hospital-based risk factor studies. Meta-analysis of population-based studies suggests that vascular risk factors differ between stroke subtypes.
Accepted on March 11, 2003
Differences in Vascular Risk Factors Between Etiological Subtypes of Ischemic Stroke. Importance of Population-Based Studies
U. G.R. Schulz MD, MRCP and P. M. Rothwell PhD, FRCP*
Key words: etiology • risk factors • stroke • stroke classification
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