Gender-Related Differences in Diagnostic Evaluation and Outcome of Ischemic Stroke in Poland
Background and Purpose— We compared the diagnostic evaluation and outcome of ischemic stroke between men and women in large cohort of Polish patients.
Methods— Our study included 1488 consecutive patients (755 women and 733 men) with ischemic stroke, treated in a single stroke unit between January 2002 and August 2007. We analyzed demographic factors, major risk factors for stroke, severity of neurological deficit on admission, diagnostic work-up performed during the hospital stay, and outcome on discharge.
Results— Women were older than men (70.9±13.7 vs 66.2±12.7 years; P<0.001) and had greater neurological deficit on admission (median NIHSS score: 7 [3–13] vs 5 [3–10]; P<0.001). They were also less likely to obtain good recovery on discharge (39.2% vs 49.9%; P<0.001). Carotid ultrasound and echocardiography were performed more often in men (77.2% vs 68.7% and 52.4% vs 46.5%, respectively; P<0.05). Lesser neurological deficit on admission, younger age, and lack of history of myocardial infarction or previous stroke, but not gender, were independent predictors of full diagnostic work-up.
Conclusions— Gender does not influence the adequate diagnostic evaluation of ischemic stroke as an independent factor.
Epidemiological studies conducted in the United States and Western Europe revealed sex differences in the management of patients with stroke. Women were less likely to have any brain imaging, echocardiography, or carotid evaluation, even after adjustment for confounders.1–3 The reasons for this inequality are not fully understood.
Polish stroke patients present with more severe neurological deficit and with greater number of vascular risk factors when compared to the United States patients.4 We hypothesized that the gender-related differences in diagnostic evaluation of stroke patients are present also in Polish stroke patients. Therefore, we attempted to compare the diagnostic evaluation of ischemic stroke between men and women in large cohort of patients treated in our stroke unit.
Materials and Methods
This study enrolled all consecutive patients with ischemic stroke admitted to the stroke unit of our department between January 2002 and August 2007. During that period, 1927 patients were admitted with the diagnosis of acute cerebrovascular accident. Stroke was diagnosed according to the WHO criteria.5 Intracranial hemorrhage was excluded with the neuroimaging study made on admission. Ischemic stroke was diagnosed in 1488 (77.2%) patients and they were included in the study.
We have obtained the approval of the local bioethics committee to run the stroke registry. All patients or their relatives gave an informed consent to use patients’ data for the research purposes.
Demographic data and risk factors profile were collected as described previously.6
All the diagnostic studies related to the stroke evaluation were recorded. Full diagnostic work-up was defined as at least 1 neuroimaging study (CT or MRI), ECG, carotid ultrasound, and echocardiography.
Neurological deficit on admission was assessed in each patient with National Institutes of Health Stroke Scale (NIHSS). Outcome was assessed with the Glasgow Outcome Scale at discharge.
Variables that differ between patients with complete and incomplete diagnostic work-up in the univariate analysis (at P<0.2) entered the initial logistic regression model with the completeness of the diagnostic evaluation as a dependent variable. Subsequent models were created using stepwise method (backward selection). P<0.05 was considered statistically significant.
Baseline characteristics of studied patients is given in Table 1. Carotid ultrasound and echocardiography were performed more often in men. Male patients were also more likely to obtain the full diagnostic work-up during their hospital stay (Table 2) and to achieve good recovery on Glasgow Outcome Scale.
Male gender, younger age, presence of ischemic heart disease, hypercholesterolemia, smoking, lacking history of previous stroke, as well as lesser neurological deficit on admission were all associated with the greater probability of complete diagnostic work-up in univariate analysis (Table 3).
Multivariate analysis with the logistic regression modeling revealed that lesser neurological deficit on admission (P<0.00001; OR, 0.957; 95% CI, 0.941–0.974), younger age (P=0.00001; OR, 0.981; 95% CI, 0.973–0.989), and lack of history of myocardial infarction or previous stroke (P=0.003; OR, 0.676; 95% CI, 0.524–0.872 and P=0.02; OR, 0.739; 95% CI, 0.571–0.955, respectively), but not gender, were independent predictors of complete diagnostic work-up performed during the hospital stay.
Our study revealed that gender does not influence the completeness of diagnostic work-up in patients with ischemic stroke. Women are less likely to receive adequate work-up, but it can be explained by other characteristics related to the gender.
First, female stroke victims are, on average, older then men; this was shown previously1,3 and was also noted in our study. Younger patients were more likely to receive adequate evaluation of stroke and this group comprised fewer women than men. Second, women presented with greater neurological deficit, which was also reported in previous studies,3 and the smaller neurological deficit independently predicted completeness of diagnostic work-up.
Previous studies conducted in the United States,2 Canada,7 and West European countries1,3 showed the same difference between women and men regarding the use of diagnostic procedures in patients with acute stroke. It is worthy to note, however, that the sex differences remained significant in those studies even after the adjustment for potential confounders.
We recognize the hospital-based design as the important limitation of our study. It was, however, shown in community-based study in Warsaw, Poland,8 that 98% of patients with suspected stroke, who live in an urban area, are admitted to the hospital. The chance of having the complete diagnostic evaluation of stroke seems to be rather small in outpatients with acute stroke.
Sources of Funding
This study was supported by the State Committee for Scientific Research (Poland) grant 2 PO5 CO1226.
- Received June 11, 2008.
- Accepted June 24, 2008.
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