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Original Paper

Neuroepidemiology 2017;48:72–78 Received: December 14, 2016


Accepted: April 10, 2017
DOI: 10.1159/000475667
Published online: May 13, 2017

Comparisons of Risk Factors for


Intracerebral Hemorrhage versus
Ischemic Stroke in Chinese Patients
Chung-Fen Tsai a Jiann-Shing Jeng b Niall Anderson c Cathie L.M. Sudlow d, e
a
Department of Neurology, Cardinal Tien Hospital, Fu Jen Catholic University, and b Stroke Center and Department
of Neurology, National Taiwan University Hospital, Taipei, Taiwan; c Centre for Population Health Sciences,
d
Centre for Clinical Brain Sciences, and e Institute of Genetics and Molecular Medicine, University of Edinburgh,
Edinburgh, UK

Keywords (OR 1.44, 95% CI 1.16–1.77) had significantly stronger asso-


Risk factor · Intracerebral hemorrhage · Ischemic stroke · ciations with ICH than IS, whereas diabetes, atrial fibrillation,
Chinese ischemic heart disease, hyperlipidemia, smoking, and tran-
sient ischemic attack were less associated with ICH than IS.
In subgroup analyses, the association of hypertension with
Abstract ICH vs. IS was more marked in younger patients. Conclusion:
Background: Chinese populations have a higher stroke inci- Hypertension and alcohol intake are more strongly associ-
dence, a higher proportion of intracerebral hemorrhage ated with ICH than IS in Chinese stroke patients, especially in
(ICH), and a lower proportion of ischemic stroke (IS) as com- younger patients. © 2017 S. Karger AG, Basel
pared with white populations. The reasons are not fully un-
derstood. Methods: To evaluate the differences of major risk
factors between ICH and IS in Chinese stroke patients, we
analysed acute ICH and IS patients consecutively recruited in Introduction
National Taiwan University Hospital Stroke Registry from
2006 to 2011. We used multiple logistic regression models to Stroke remains one of the leading causes of death world-
examine the associations of risk factors with ICH vs. IS. Also, wide, and intracerebral hemorrhage (ICH) is the most dev-
we conducted subgroup analyses when a strongly signifi- astating pathological type of stroke accounting for 10–20%
cant interaction was detected. Results: We included a total of total strokes among western populations [1]. The inci-
of 1,373 ICH and 4,953 IS patients. ICH patients were young- dence of ICH is much higher among Asians, including
er than IS patients (mean age 61 vs. 68 years, p < 0.001), but Chinese [2]. Although knowledge of stroke, availability of
there was no significant difference in gender (males 62 vs. brain imaging, medical care, and mortality have improved
59%, p = 0.064). A logistic regression model adjusted for age, in recent years, the incidence of ICH has not decreased and
gender, and other major risk factors showed that both hy- the functional outcome in survivors remains poor, leading
pertension (OR 2.23, 95% CI 1.74–2.87) and alcohol intake to an alarming situation worldwide [3, 4].
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Univ. of California San Diego

© 2017 S. Karger AG, Basel Prof. Cathie Sudlow


Centre for Clinical Brain Sciences
University of Edinburgh, 49 Little France Crescent
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E-Mail karger@karger.com
Edinburgh, EH16 4SB (UK)
www.karger.com/ned
E-Mail cathie.sudlow @ ed.ac.uk
In a systematic review, we have reported that Chinese Major Risk Factor Definitions
populations had a higher stroke incidence and a 2-fold Vascular risk factor information was obtained from the pa-
tients, family, and medical records. Hypertension was defined
proportion of ICH among all strokes, as compared with as history along with antihypertensive treatment or blood pres-
white populations [5]. The reasons for the prevalence of sure ≥140/90 mm Hg 7 days after stroke; diabetes was defined
this trend are not clear but could include differences in as history along with anti-diabetic treatment or fasting plasma
genetic and environmental exposures, and differences in glucose >126 mg/dL. Atrial fibrillation (AF) and ischemic heart
risk factor associations between ICH and ischemic stroke disease (IHD) were defined as history or electrocardiographic
evidence. Hyperlipidemia was recorded if patients had history
(IS) [6–8]. Our recent meta-analysis of major risk factors along with anti-hyperlipidemic treatment, hypercholesterol-
found that hypertension and alcohol intake were signifi- emia, or hypertriglyceridemia (≥200 mg/dL). Smoking included
cantly more frequent in ICH than IS in Chinese stroke current or previous smoking history. Alcohol intake was de-
patients, but not in white stroke patients [9]. However, fined as habitual drinking more than once per week. We also
these findings could be confounded by age, gender, and recorded previous stroke and history of transient ischemic at-
tack (TIA).
other risk factors.
To explore this further, we performed individual Statistical Analyses
Chinese patient data analyses using data from the For ICH vs. IS, we used Student t test to compare the mean age,
National Taiwan University Hospital (NTUH) Stroke and Pearson’s chi-square test to compare the proportions of male
Registry, comparing major risk factors between ICH gender, risk factors and 1-month case fatality between groups.
Since it was not assumed to contribute a linear change in odds of
and IS, and adjusting for potential confounders. We ICH vs. IS, we divided age into 5 equal-sized categories. First, we
aimed to test the hypothesis that risk factor prevalence calculated crude ORs with 95% CIs for each risk factor. Then we
and associations vary between ICH and IS in Chinese fitted a logistic regression model for the relevant risk factor, adjust-
stroke patients. As Chinese populations are aging rap- ing for age and gender, obtaining adjusted ORs (OR I). We devel-
idly and make up around one-fifth of the world’s popu- oped a second logistic regression model to adjust simultaneously
for all other major risk factors along with age and gender. In the
lation, a better understanding of the reasons for a high- second model, we used stepwise selection and analysis of variance
er incidence and proportion of ICH in Chinese could to incorporate the strongly significant 2-way interactions among
lead to more efficient stroke-prevention strategies, variables (p < 0.001), and to choose the best fitting model. From
thereby reducing the burden of the impending stroke [5, the parameters of this model, we obtained further adjusted ORs
10]. (OR II).
In addition, we conducted subgroup analyses to examine risk
factor associations with ICH vs. IS in different subgroups where
there was a strongly significant interaction. All statistical hypoth-
Methods esis tests were 2-sided, and p values <0.05 were considered signifi-
cant. Statistical analyses were performed with R statistical software
Subjects (http://www.R-project.org/) [16].
The NTUH Stroke Registry is a large hospital-based registry
initiated in 1995, prospectively recruiting consecutive acute
stroke patients [11–13]. Patients who had acute stroke within 10
days were included. A neurologist assessed each patient upon ar- Results
rival, recorded demographic information and clinical features,
reviewed medical records, arranged timely brain imaging, and Characteristics of ICH and IS Patients
discussed the imaging findings with a neuroradiologist. The In-
stitutional Review Board of NTUH approved the stroke registry, From January 1, 2006 to December 31, 2011, we in-
and informed consent was given by the patients. In this study, we cluded 1,373 spontaneous ICH patients and 4,953 adult
conducted analyses for first-ever or recurrent spontaneous ICH IS patients for analyses. For patients with more than one
and IS adult patients recruited between January 2006 and stroke during the study period, analyses were based only
December 2011. on the first stroke episode. All patients had brain CT im-
Diagnosis of Stroke and Its Types aging and 50% had additional brain MR and MR angiog-
The diagnosis of stroke was based on clinical features: acute raphy.
neurologic dysfunction of vascular origin lasting for more than ICH patients were younger than IS patients (mean age
24 h [14], along with brain CT or MRI findings. Strokes were clas- 61.4 vs. 68.1 years, p < 0.001), while there was no signifi-
sified as IS, ICH, or subarachnoid hemorrhage (SAH) according to cant difference in gender between groups (males 61.9% in
standard definitions [15]. Patients with traumatic ICH, postin-
farct hemorrhagic transformation, subdural/epidural/SAH, tumor ICH and 59.1% in IS, p = 0.064). Patients with ICH had a
bleeding, no brain imaging, or non-cerebrovascular causes were much higher 1-month case fatality than those with IS
excluded. (19.3 vs. 5.5%, p < 0.001).
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Univ. of California San Diego

Comparisons of Risk Factors for Stroke in Neuroepidemiology 2017;48:72–78 73


Chinese Patients DOI: 10.1159/000475667
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Table 1. Characteristics and risk factor distributions in ICH and IS among Chinese patients

ICH (n = 1,373) IS (n = 4,953) ICH vs. IS,


p value
n % 95% CI n % 95% CI

Age, years, mean ± SD 61.4±15.7 68.1±13.8 <0.0001**


Gender, male 850 61.9 59.2–64.5 2,929 59.1 57.8–60.5 0.064*
Hypertension 1,058 77.1 74.7–79.2 3,809 76.9 75.7–78.7 0.904*
Diabetes 310 22.6 20.4–24.9 1,838 37.1 35.8–38.4 <0.001*
AF 125 9.1 7.6–10.8 1,180 23.8 22.6–25.0 <0.001*
Ischemic heart 102 7.4 6.1–8.9 759 15.3 14.3–16.4 <0.001*
Hyperlipidemia 238 17.3 15.3–19.4 1,744 35.2 33.9–36.6 <0.001*
Smoking 327 23.8 21.6–26.1 1,455 29.4 28.1–30.7 <0.001*
Alcohol 221 16.1 14.2–18.1 689 13.9 13.0–14.9 0.041*
Previous stroke 282 20.5 18.4–22.8 1,175 23.7 22.5–24.9 0.013*
TIA 11 0.8 0.4–1.4 193 3.9 3.4–4.5 <0.001*
1-month case fatality 265 19.3 17.2–21.5 272 5.5 4.9–6.2 <0.001*

ICH, intracerebral hemorrhage; IS, ischemic stroke; NTUH, National Taiwan University Hospital; AF, atrial fibrillation; TIA,
transient ischemic attack. ** Based on Student t test; * based on Pearson’s chi-square test.

Risk Factor Comparisons for ICH vs. IS Subgroup Analysis of Hypertension in Different
The clinical characteristics and risk factor distribu- Age Groups
tions for ICH and IS are shown in Table 1. In unadjusted We found a strongly significant interaction between
comparisons, ICH patients had a significantly lower prev- age and hypertension (p < 0.001), implying a significant
alence of diabetes, AF, IHD, hyperlipidemia, smoking, difference in the association across different age groups
previous stroke and TIA than IS patients. Alcohol intake for hypertension, but not other risk factors. We, therefore,
was slightly more common in ICH vs. IS (crude OR 1.19, examined the association of hypertension with ICH vs. IS
95% CI 1.00–1.40), while hypertension did not differ sig- among 5 equal-sized age groups (18–55, 56–64, 65–72, 73–
nificantly between these 2 types (Fig. 1). 80, 81–106 years). Compared with older stroke patients,
After adjusting for age and gender, the association of hypertension had a stronger association with ICH vs. IS in
hypertension with ICH vs. IS became significantly younger stroke patients (Fig. 2). The fully adjusted results
stronger (OR I 1.25, 95% CI 1.07–1.45), while the re- showed that hypertension was significantly associated
sults for other risk factors remained similar except that with ICH vs. IS in patients aged <73 years (18–55 years OR
associations with alcohol and previous stroke became II 2.33, 95% CI 1.79–3.05; 56–64 years OR II 2.33, 95% CI
nonsignificant. After further adjusting for all risk fac- 1.58–3.48; 65–72 years OR II 1.84, 95% CI 1.22–2.87) but
tors but before including significant interactions, hy- not in those aged ≥73 years (73–80 years OR II 0.81, 95%
pertension and alcohol intake were significantly more CI 0.56–1.18; 81–106 years OR II 0.96, 95% CI 0.63–1.50).
associated with ICH than IS (hypertension OR II with-
out interactions 1.60, 95% CI 1.42–1.95; alcohol OR II
without interactions 1.45, 95% CI 1.16–1.79). For hy- Discussion
pertension, the association became yet stronger when
strongly significant interactions were included (hyper- In our study, we showed that ICH patients had a much
tension OR II with interactions 2.23, 95% CI 1.74–2.87; higher case fatality and a younger age of onset than IS pa-
Fig.  1). Fully adjusted analyses yielded similar but tients, but no significant difference in gender. In terms of
somewhat stronger negative associations than in unad- risk factor comparisons between ICH and IS, unadjusted
justed analyses for AF, hyperlipidemia, and smoking, and adjusted analyses were qualitatively similar, though
while results were changed only in a very negligible they varied to a certain extent in terms of the size of esti-
manner following adjustment for diabetes, TIA, and mates and significance. Both hypertension and alcohol
previous stroke. intake had stronger associations with ICH than IS after
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74 Neuroepidemiology 2017;48:72–78 Tsai/Jeng/Anderson/Sudlow


DOI: 10.1159/000475667
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Risk factor OR 95% CI
Hypertension CR 1.01 (0.87, 1.17)
OR I 1.25 (1.07, 1.45)
OR II 2.23 (1.74, 2.87)

Diabetes CR 0.49 (0.43, 0.57)


OR I 0.53 (0.46, 0.61)
OR II 0.48 (0.41, 0.56)

Atrial fibrillation CR 0.32 (0.26, 0.39)


OR I 0.40 (0.33, 0.49)
OR II 0.23 (0.17, 0.30)

Ischemic heart CR 0.44 (0.35, 0.55)


OR I 0.53 (0.42, 0.65)
OR II 0.67 (0.52, 0.82)

Hyperlipidemia CR 0.39 (0.33, 0.45)


OR I 0.35 (0.30, 0.41)
OR II 0.30 (0.26, 0.36)

Smoking CR 0.75 (0.65, 0.86)


OR I 0.56 (0.48, 0.66)
OR II 0.49 (0.41, 0.59)

Alcohol CR 1.19 (1.00, 1.41)


OR I 0.98 (0.82, 1.17)
OR II 1.44 (1.16, 1.77)

Previous stroke CR 0.83 (0.72, 0.96)


OR I 0.97 (0.83, 1.13)
OR II 1.04 (0.89, 1.22)

TIA CR 0.20 (0.10, 0.37)


Fig. 1. Risk factor analyses for ICH vs. IS in OR I 0.19 (0.10, 0.34)
Chinese patients. ICH, intracerebral hem-
OR II 0.21 (0.10, 0.37)
orrhage; IS, ischemic stroke; TIA, transient
ischemic attack; CR, crude odds ratio; OR 0.1 0.2 0.5 1.0 2.0 5.0
I, adjusted odds ratio I; OR II, adjusted Risk factor more frequent Risk factor more frequent
odds ratio II. Horizontal lines represent in IS in ICH
95% CIs. Diamonds represent pooled ORs.

adjusting for confounders, whereas diabetes, AF, IHD, tients are limited. Our results are in line with our meta-
hyperlipidemia, smoking, and TIA were less frequent in analyses after adjusting for confounding factors – hyper-
ICH vs. IS. Furthermore, the association of hypertension tension and alcohol intake had stronger associations with
with ICH vs. IS differed across different age groups, being ICH than IS in Chinese [9]. They may be responsible – at
more marked in younger stroke patients. Although least in part – for a higher incidence and proportion of
Chinese are reported to have a much higher ICH inci- ICH in Chinese populations.
dence than white populations, the reasons are still not Few large-scale studies or systematic reviews have di-
clear [17, 18]. Risk factor analyses for ICH vs. IS using rectly compared risk factors between ICH and IS. An ear-
robust methods based on a large number of Chinese pa- lier systematic review in mainly white populations re-
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Comparisons of Risk Factors for Stroke in Neuroepidemiology 2017;48:72–78 75


Chinese Patients DOI: 10.1159/000475667
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Hypertension OR 95% CI

OR II 18–55 years 2.33 (1.79, 3.05)

OR II 56–64 years 2.33 (1.58, 3.48)

OR II 65–72 years 1.84 (1.22, 2.87)

OR II 73–80 years 0.81 (0.56, 1.18)

OR II 84–106 years 0.96 (0.63, 1.50)


Fig. 2. Subgroup analyses of hypertension
for ICH vs. IS in different age groups. ICH, 0.5 1.0 2.0 5.0
intracerebral hemorrhage; IS, ischemic
Hypertension more Hypertension more frequent
stroke; OR II, adjusted odds ratio II. Hori- frequent in IS in ICH
zontal lines represent 95% CIs. Diamonds
represent pooled ORs.

ported that increased age, male gender, hypertension, and consolidate this finding that hypertension is a stronger
alcohol intake were risk factors for ICH, whereas hyper- risk factor for ICH vs. IS in Chinese patients [9, 22].
cholesterolemia was associated with a lower risk of ICH The reasons for a higher incidence of total strokes and
[19]. Recently, INTERSTROKE study conducted risk fac- ICH, and the greater association with hypertension for ICH
tor analyses for all strokes, IS, and ICH among 3,000 vs. IS in Chinese populations are not fully understood. The
stroke cases and controls from 22 countries (around one preference of high salt intake, inadequate treatment of hy-
third from Southeast Asia) [8]. Hypertension, smoking, pertension, and a higher proportion of deep ICH in Chinese
waist-to-hip ratio, diet, and alcohol intake were signifi- (predominantly associated with hypertension) may all con-
cant risk factors for ICH. Hypertension was more strong- tribute to these findings [23–25]. In the INTERMAP study
ly associated with ICH than IS, whereas the association among British, American, Japanese and Chinese popula-
with smoking appeared stronger with IS than ICH. How- tions, the Chinese were found to have the highest daily so-
ever, risk factor associations for ICH and IS were not pro- dium intake, which was known to lead to high blood pres-
vided solely in Chinese populations. sure and increased risk of stroke [23]. Also, the proportion
Hypertension is one of the most important risk factors of awareness, treatment, and control rates are relatively low-
for ICH, and its association with ICH probably differs er among the Chinese people. In mainland China, only 45%
among ethnic groups [20, 21]. Research from Asia Pacific were aware of high blood pressure, 28% took antihyperten-
Cohort study suggested a stronger association of increased sive medication, and 8% achieved control target (<140/90
blood pressure with hemorrhagic stroke among eastern mm Hg) [24]. In Taiwan, despite improvements in medical
Asians than White populations [20, 21]. However, these care after the implementation of the National Health Insur-
studies were conducted for all hemorrhagic strokes, in- ance scheme, the proportions of people with hypertension
cluding ICH and SAH together, while their causes were receiving treatment or achieving good control are still low,
somewhat different. No separate analysis for ICH was re- particularly in stroke patients less than 65 years old [26].
ported. Our recent systematic review and meta-analyses This may be one of the important reasons accounting for the
showed a higher incidence of stroke along with a higher stronger association with ICH vs. IS in younger stroke pa-
proportion of ICH in Chinese, and hypertension had a tients, and highlight the need to enhance education and
stronger association with ICH vs. IS as compared with treatment in this group.
white populations [5, 9]. Current analyses from individu- With regard to lipids, increased total cholesterol is as-
al patient data after controlling for confounders further sociated with the risk of IS but not hemorrhagic stroke
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76 Neuroepidemiology 2017;48:72–78 Tsai/Jeng/Anderson/Sudlow


DOI: 10.1159/000475667
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[27]. Recent research has also shown that low serum tri- strokes in Chinese populations. Also, information of
glyceride is associated with increased risk of ICH, but the some risk factors was collected from medical records, pa-
exact mechanism is not clear [28]. In our study, there tients, and families. We could not totally exclude the pos-
seemed to be a positive association of increased lipid with sibility of recall bias from a few patients.
IS but a negative association with ICH. Although there is a decreasing trend of ICH incidence
Although the effects of alcohol may be mediated in some populations, the incidence or proportion of ICH
through elevated blood pressure or other causes [29, 30], in all strokes is still much higher among the Chinese and
in our study, alcohol intake was still a significant indepen- other Asians [3, 5, 8, 32]. ICH is a multifactorial disease
dent risk factor for ICH vs. IS after adjusting for con- caused by several risk factors and interactions. In our
founders including hypertension. Previous meta-analy- analyses, hypertension and alcohol intake are important,
ses and large case–control studies have shown that alco- modifiable risk factors for ICH vs. IS among the Chinese,
hol has a dose-dependent relationship with hemorrhagic especially in younger stroke patients. A better under-
stroke and with ICH, whereas it has a curvilinear relation- standing of the underlying reasons could help shed light
ship with IS – a protective effect for low to moderate in- on different stroke mechanisms, guide further well-de-
take and increased risk for high consumption [8, 31]. signed research in this area, and provide potential targets
Our results provide important information on risk fac- to make effective strategies of stroke prevention.
tor comparisons for ICH vs. IS in Chinese populations, in
whom there is a higher incidence of total strokes and ICH.
Our study has several strengths. First, we recruited a con- Acknowledgments and Funding
siderable number of patients from the well-established
The authors wish to thank all the staff and participants in
NTUH Stroke Registry, with comprehensive records of
NTUH for their help in data collection. The study was sup-
essential information including risk factors. Second, the ported  partly by the Cardinal Tien Hospital Research Grant
inclusion of acute stroke patients was based on a standard (CTH106A-2A13).
definition of stroke, having stroke within 10 days, early
specialist assessment, and reliable classification of its
pathological types (100% brain CT or MRI rate). Third, Disclosure Statement
we used multiple logistic regression modeling to adjust
for confounding factors, and incorporated interactions The authors had no conflicts of interest to disclose.
among variables. Furthermore, we carried out subgroup
analyses to examine the association of hypertension with
ICH vs. IS in different age groups. Author Contributors
However, there are some limitations. The NTUH Study concept and design: All. Acquisition of data: C.-F.T. and
stroke registry is a large hospital-based registry in Taiwan, J.-S.J. Statistical analysis: C.-F.T. and N.A. Interpretation of data:
which may not be fully representative of all types of All. Manuscript drafting: C.-F.T. Critical revision: All.

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78 Neuroepidemiology 2017;48:72–78 Tsai/Jeng/Anderson/Sudlow


DOI: 10.1159/000475667
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