Association of Socioeconomic Status and Infarct Volume With Functional Outcome in Patients With Ischemic Stroke.
Association of Socioeconomic Status and Infarct Volume With Functional Outcome in Patients With Ischemic Stroke.
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DOI：
10.1001/jamanetworkopen.2022.9178
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发表时间：
2022-04-01
影响因子：
13.8
通讯作者：
Tawakol, Ahmed
中科院分区：
文献类型：
--
作者：
Ghoneem, Ahmed;Osborne, Michael T.;Abohashem, Shady;Naddaf, Nicki;Patrich, Tomas;Dar, Tawseef;Abdelbaky, Amr;Al-Quthami, Adeeb;Wasfy, Jason H.;Armstrong, Katrina A.;Ay, Hakan;Tawakol, Ahmed
缺血性脑卒中患者的社会经济地位（SES）是否与梗死面积、临床严重程度和长期功能结局独立相关？在这项纳入1098例连续缺血性卒中患者的单中心队列研究中，采用脑磁共振成像和临床指标评估卒中初始严重程度。社会经济地位（以社区收入中位数和区域剥夺指数衡量）与初始卒中严重程度的影像学和临床测量独立相关，这反过来又占SES与长期功能结局之间关联的64%。这些发现表明，低社会经济地位的个体有更差的长期功能结果，主要是因为低社会经济地位与更大的梗死和更严重的临床中风有关，即使在调整了危险因素和治疗方法的差异之后也是如此。这项单中心队列研究评估了急性缺血性卒中患者的社会经济地位（SES）和梗死体积之间的关系，并探讨了梗死体积在社会经济地位和长期残疾之间的潜在中介作用。脑卒中后长期残疾与社会经济地位（SES）有关。然而，造成这种结果差异的原因尚不清楚。评估较低的SES是否与较大的入院梗死体积相关，以及初始梗死体积是否与SES和长期残疾之间的关联有关。这项队列研究是在前瞻性、连续人群（n = 1256）中进行的，这些患者在入院24小时内接受了磁共振成像（MRI）检查。患者于2009年5月31日至2011年12月31日在波士顿马萨诸塞州总医院招募。数据分析时间为2019年5月1日至2020年6月30日。使用临床（美国国立卫生研究院卒中量表[NIHSS]）和影像学（通过弥散加权MRI测量梗死体积）测量确定初始卒中严重程度（出现24小时内）。使用缺血性卒中的病因分类算法确定卒中的病因亚型。长期脑卒中残疾采用改良Rankin量表进行测量。社会经济地位的估计使用邮政编码衍生的家庭收入中位数和人口普查街区群体衍生的区域剥夺指数（ADI）。进行回归分析和中介分析。共有1098例患者有影像学和SES资料（平均[SD]年龄68.1[15.7]岁；男性607例[55.3%]）。收入与初始梗死体积呈负相关(标准化β， - 0.074 [95% CI, - 0.127至- 0.020]；007)，初始NIHSS（标准化β， - 0.113 [95% CI, - 0.171至- 0.054],P < .001）和长期残疾(标准化β， - 0.092 [95% CI, - 0.149至- 0.035],P =。001)，在多变量调整后仍然显著。初始卒中严重程度占SES与长期残疾之间关联的64%（标准化β， - 0.063 [95% CI, - 0.095至- 0.029];P < 0.05）。当使用ADI替代评估SES时，结果相似。这项队列研究的结果表明，较低的社会经济地位与出现时较大的梗死体积有关。在这项研究中，这些与ses相关的初始卒中严重程度差异是随后长期残疾差异的主要原因。这些发现将卒中后残疾的ses相关差异的责任从卒中后因素转移到发病前的因素。
Is socioeconomic status (SES) independently associated with infarct size, clinical severity, and long-term functional outcomes in patients with ischemic stroke? In this single-center cohort study of 1098 consecutive patients with ischemic stroke, initial stroke severity was assessed using magnetic resonance imaging of the brain and clinical indexes. Socioeconomic status (measured as median neighborhood income and area deprivation index) was independently associated with imaging and clinical measures of initial stroke severity, which in turn accounted for 64% of the association between SES and long-term functional outcome. These findings suggest that individuals with lower SES have worse long-term functional outcomes, primarily because lower SES is associated with larger infarcts and more clinically severe strokes on presentation, even after adjusting for differences in risk factors and therapies. This single-center cohort study assesses the association between socioeconomic status (SES) and infarct volume in patients presenting with with acute ischemic stroke and investigates the potential mediating role of infarct volume in the association between SES and long-term disbility. Long-term disability after stroke is associated with socioeconomic status (SES). However, the reasons for such disparities in outcomes remain unclear. To assess whether lower SES is associated with larger admission infarct volume and whether initial infarct volume accounts for the association between SES and long-term disability. This cohort study was conducted in a prospective, consecutive population (n = 1256) presenting with acute ischemic stroke who underwent magnetic resonance imaging (MRI) within 24 hours of admission. Patients were recruited in Massachusetts General Hospital, Boston, from May 31, 2009, to December 31, 2011. Data were analyzed from May 1, 2019, until June 30, 2020. Initial stroke severity (within 24 hours of presentation) was determined using clinical (National Institutes of Health Stroke Scale [NIHSS]) and imaging (infarct volume by diffusion-weighted MRI) measures. Stroke etiologic subtypes were determined using the Causative Classification of Ischemic Stroke algorithm. Long-term stroke disability was measured using the modified Rankin Scale. Socioeconomic status was estimated using zip code–derived median household income and census block group–derived area deprivation index (ADI). Regression and mediation analyses were performed. A total of 1098 patients had imaging and SES data available (mean [SD] age, 68.1 [15.7] years; 607 men [55.3%]). Income was inversely associated with initial infarct volume (standardized β, −0.074 [95% CI, −0.127 to −0.020]; P = .007), initial NIHSS (standardized β, −0.113 [95% CI, −0.171 to −0.054]; P < .001), and long-term disability (standardized β, −0.092 [95% CI, −0.149 to −0.035]; P = .001), which remained significant after multivariable adjustments. Initial stroke severity accounted for 64% of the association between SES and long-term disability (standardized β, −0.063 [95% CI, −0.095 to −0.029]; P < .05). Findings were similar when SES was alternatively assessed using ADI. The findings of this cohort study suggest that lower SES is associated with larger infarct volumes on presentation. These SES-associated differences in initial stroke severity accounted for most of the subsequent disparities in long-term disability in this study. These findings shift the culpability for SES-associated disparities in poststroke disability from poststroke factors to those that precede presentation.
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