Modifiable etiological factors and the burden of stroke from the Rotterdam study: a population-based cohort study.
Modifiable etiological factors and the burden of stroke from the Rotterdam study: a population-based cohort study.
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DOI：
10.1371/journal.pmed.1001634
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发表时间：
2014-04
期刊：
影响因子：
15.8
通讯作者：
Ikram MA
中科院分区：
文献类型：
--
作者：
Bos MJ;Koudstaal PJ;Hofman A;Ikram MA
利用鹿特丹研究的数据，迈克尔·博斯和他的同事们估计了中风可归因于已确定的可改变的中风病因的比例。请参见文章后面的编辑总结，预防中风需要对其病因进行有效治疗。中风的许多病因已被确定，但由于缺乏队列研究的数据，就实际预防中风的数量而言，对这些因素进行有效干预的潜在收益仍不清楚。我们评估了目前已知的潜在可改变的病因因素对卒中发生的影响。这项基于人群的队列研究基于鹿特丹研究的6844名参与者，他们年龄≥55岁，基线时无卒中（1990-1993）。我们计算了个体风险因素和综合风险因素的人群归因风险（PARs），以估计理论上可以通过消除人群中的病因因素来预防的中风比例。基线时平均年龄69.4岁（标准差6.3岁）。在随访期间（平均随访12.9年，标准差6.3年），发生1020例卒中。对于任何脑卒中，经年龄和性别调整的高血压前期/高血压、吸烟、糖尿病、心房颤动、冠状动脉疾病和超重/肥胖的联合PAR为0.51 (95% CI 0.41-0.62)；高血压和吸烟是最重要的病因。c反应蛋白、水果和蔬菜的摄入量以及颈动脉内膜-中膜厚度的组合使总PAR提高0.06。缺血性卒中的PAR为0.55 (95% CI 0.41-0.68)，出血性卒中的PAR为0.70 （95% CI 0.45-0.87）。本研究的主要局限性在于，我们的研究人群几乎全部是生活在中高收入地区的高加索人，并且研究队列中的风险因素意识高于一般人群。大约一半的中风可归因于既定的因果关系和可改变的因素。这一发现不仅鼓励对已确定的病因进行干预，而且鼓励对不太确定的因素进行进一步研究。每年，全世界有1500万人中风。其中约600万人在数小时内死亡，另有500万人残疾。当大脑中的血管被血栓阻塞（缺血性中风）或破裂（出血性中风）时，大脑的血液供应突然中断，就会发生中风。失去了通常由血液输送给它们的氧气，靠近堵塞的脑细胞就会死亡。中风的症状取决于大脑的哪个部分受损，但包括身体一侧突然无力或瘫痪，一只或两只眼睛失明，说话或理解语言困难。任何出现这些症状的人都应该立即就医，因为及时治疗可以限制对大脑的损害。从长远来看，中风后的康复可以帮助克服中风引起的残疾，各种药物和行为咨询可以降低第二次中风的风险。50年前，人们发现治疗高血压可以降低严重高血压患者中风的风险。这一发现促使研究人员寻找其他可能改变的中风病因（导致中风的危险因素）。目前已确定的病因除高血压外，还包括吸烟、糖尿病、心房颤动（一种心律不齐）、心脏病、超重/肥胖。但是，这些致病风险因素的改变能预防多少中风呢？在这项以人群为基础的队列研究中，研究人员计算了这些已确定的病因的个体和联合人群归因风险（par），以估计理论上可以通过已知病因的最佳治疗来预防中风的比例。一项以人群为基础的队列研究招募了一组人，确定了他们在基线时的特征，并对他们进行跟踪，以了解特定特征是否与特定结果相关。一种疾病病因的PAR表明，如果没有这种危险因素，这种疾病在人口中所占的比例就不会发生。研究人员使用了鹿特丹研究中6844名参与者的数据，该研究旨在调查老年人长期致残疾病的原因和后果。在基线时，所有的参与者都超过55岁，没有中风。在随访期间，参与者中发生了1020次中风。研究人员利用基线暴露于各种中风病因的数据，计算出单个因素的par，并使用一种特殊的统计技术来计算这些因素的综合par。高血压前期/高血压、吸烟、糖尿病、心房颤动、心脏病和超重/肥胖的综合PAR为0.51。也就是说，在研究人群中，大约一半的中风可归因于这些病因因素的组合。高血压和吸烟是最重要的个体因素（par分别为0.36和0.16）。值得注意的是，包括几个不太确定的病因因素（血液中c反应蛋白水平升高，水果和蔬菜摄入量低，动脉内膜增厚）只使任何中风的总PAR提高了0.06。这些发现表明，研究队列中大约一半的中风可归因于已确定的可改变的病因，理论上可以通过从人群中消除这些危险因素来预防。先前的研究估计，通过消除已知的病因，可以预防更大比例的中风。研究人员承认，他们研究的某些方面可能导致了对中风归因于既定病因的比例的低估，并指出他们的发现可能不适用于贫困或种族多样化的人群。然而，他们认为，先前的研究可能高估了中风的PAR，因为它们是基于病例对照研究（在病例和对照个体中风发生后，而不是像基于人群的队列研究那样在中风发生之前，评估接触病因因素），并且通常没有使用最佳的统计技术来计算总PAR。这些新发现强调了以减少吸烟和高血压为目标的干预措施的重要性，并支持了对中风其他病因的研究。请通过本摘要的在线版本（http://dx.doi.org/10.1371/journal.pmed.1001634）访问这些网站。美国国家神经疾病和中风研究所提供有关中风各方面的信息（英文和西班牙文）；“了解中风”网站提供有关中风预防、治疗和康复的教育材料，包括个人故事（英语和西班牙语）；美国国家卫生研究院高级健康网站有更多关于中风的信息，互联网中风中心为患者、家属和卫生专业人员提供有关中风的详细信息（英语和西班牙语），英国国家健康服务选择网站也为患者及其家属提供有关中风的信息，包括个人故事MedlinePlus有关于中风的其他资源的链接（英语和西班牙语）鹿特丹研究的信息是可用的英国非营利网站Healthtalkonline提供了关于中风的个人故事
Using data from the Rotterdam study, Michiel Bos and colleagues estimate the proportion of strokes that are attributable to established modifiable etiological factors for stroke. Please see later in the article for the Editors' Summary Stroke prevention requires effective treatment of its causes. Many etiological factors for stroke have been identified, but the potential gain of effective intervention on these factors in terms of numbers of actually prevented strokes remains unclear because of the lack of data from cohort studies. We assessed the impact of currently known potentially modifiable etiological factors on the occurrence of stroke. This population-based cohort study was based on 6,844 participants of the Rotterdam Study who were aged ≥55 y and free from stroke at baseline (1990–1993). We computed population attributable risks (PARs) for individual risk factors and for risk factors in combination to estimate the proportion of strokes that could theoretically be prevented by the elimination of etiological factors from the population. The mean age at baseline was 69.4 y (standard deviation 6.3 y). During follow-up (mean follow-up 12.9 y, standard deviation 6.3 y), 1,020 strokes occurred. The age- and sex-adjusted combined PAR of prehypertension/hypertension, smoking, diabetes mellitus, atrial fibrillation, coronary disease, and overweight/obesity was 0.51 (95% CI 0.41–0.62) for any stroke; hypertension and smoking were the most important etiological factors. C-reactive protein, fruit and vegetable consumption, and carotid intima-media thickness in combination raised the total PAR by 0.06. The PAR was 0.55 (95% CI 0.41–0.68) for ischemic stroke and 0.70 (95% CI 0.45–0.87) for hemorrhagic stroke. The main limitations of our study are that our study population comprises almost exclusively Caucasians who live in a middle and high income area, and that risk factor awareness is higher in a study cohort than in the general population. About half of all strokes are attributable to established causal and modifiable factors. This finding encourages not only intervention on established etiological factors, but also further study of less well established factors. Please see later in the article for the Editors' Summary Every year, 15 million people worldwide have a stroke. About 6 million of these people die within hours, and another 5 million are left disabled. Stroke occurs when the brain's blood supply is suddenly interrupted by a blood vessel in the brain being blocked by a blood clot (ischemic stroke) or bursting (hemorrhagic stroke). Deprived of the oxygen normally carried to them by the blood, the brain cells near the blockage die. The symptoms of stroke depend on which part of the brain is damaged but include sudden weakness or paralysis along one side of the body, vision loss in one or both eyes, and trouble speaking or understanding speech. Anyone experiencing these symptoms should seek immediate medical attention because prompt treatment can limit the damage to the brain. In the longer term, post-stroke rehabilitation can help overcome the disabilities caused by stroke, and various drugs alongside behavioral counselling can reduce the risk of a second stroke. Fifty years ago, it was discovered that treatment of high blood pressure (hypertension) reduces the risk of stroke among people with severe hypertension. This discovery led researchers to search for other potentially modifiable etiological factors for stroke (risk factors that cause stroke). The list of established etiological factors now includes smoking, diabetes, atrial fibrillation (an irregular heartbeat), heart disease, and overweight/obesity, in addition to hypertension. But how many strokes would modification of these causal risk factors prevent? In this population-based cohort study, the researchers calculate the individual and combined population attributable risks (PARs) for these established etiological factors to provide an estimate of what proportion of strokes could theoretically be prevented by optimal treatment of known etiological factors. A population-based cohort study enrolls a group of people, determines their characteristics at baseline, and follows them to see whether specific characteristics are associated with specific outcomes. A PAR of an etiological factor for a disease indicates the proportion of that disease in the population that would not occur in the absence of the risk factor. The researchers used data from 6,844 participants in the Rotterdam Study, which was designed to investigate the causes and consequences of long-term and disabling diseases in the elderly. At baseline, all of the participants were over 55 years old and free from stroke. During follow-up, 1,020 strokes occurred among the participants. Using data on exposure at baseline to various etiological factors for stroke, the researchers calculated PARs for individual factors and used a special statistical technique to calculate PARs for the factors in combination. The combined PAR of prehypertension/hypertension, smoking, diabetes, atrial fibrillation, heart disease, and overweight/obesity was 0.51 for any stroke. That is, about half of the strokes in the study population were attributable to this combination of etiological factors. Hypertension and smoking were the most important individual factors (PARs of 0.36 and 0.16, respectively). Notably, the inclusion of several less well established etiological factors (increased blood levels of C-reactive protein, low fruit and vegetable consumption, and thickening of the lining of arteries) only raised the total PAR for any stroke by 0.06. These findings indicate that about half of the strokes in the study cohort were attributable to established modifiable etiological factors and could theoretically be prevented by eliminating these risk factors from the population. Previous studies have estimated that a larger proportion of strokes could be prevented by eliminating known etiological factors. The researchers acknowledge that some aspects of their study may have led to an underestimation of the proportion of stroke attributable to established etiological factors and note that their findings may not be generalizable to underprivileged or racially diverse populations. Nevertheless, they argue that previous studies are likely to have overestimated the PARs for stroke because they were based on case–control studies (in which exposure to etiological factors was assessed after a stroke had occurred in cases and control individuals, rather than before a stroke as in a population-based cohort study) and often did not use optimal statistical techniques to calculate the total PAR. Importantly, these new findings underscore the importance of interventions targeted at reducing smoking and hypertension and support the search for additional etiological factors for stroke. Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001634. The US National Institute of Neurological Disorders and Stroke provides information about all aspects of stroke (in English and Spanish); its Know Stroke site provides educational materials about stroke prevention, treatment, and rehabilitation including personal stories (in English and Spanish); the US National Institutes of Health SeniorHealth website has additional information about stroke The Internet Stroke Center provides detailed information about stroke for patients, families, and health professionals (in English and Spanish) The UK National Health Service Choices website also provides information about stroke for patients and their families, including personal stories MedlinePlus has links to additional resources about stroke (in English and Spanish) Information about the Rotterdam Study is available The UK not-for-profit website Healthtalkonline provides personal stories about stroke
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影响因子：
8.3
作者：
Bos, Michiel J.;Koudstaal, Peter J.;Breteler, Monique M. B.
通讯作者：
Breteler, Monique M. B.
影响因子：
8.3
作者：
Goldstein, Larry B.;Bushnell, Chair Cheryl D.;Pearson, Thomas A.
通讯作者：
Pearson, Thomas A.
影响因子：
13.6
作者：
Hofman, Albert;Murad, Sarwa Darwish;Vernooij, Meike W.
通讯作者：
Vernooij, Meike W.
DOI：
10.1001/jama.1967.03130240070013
发表时间：
1967-01-01
影响因子：
--
作者：
通讯作者：
--
影响因子：
29
作者：
Bos, Daniel;Portegies, Marileen L. P.;Ikram, M. Arfan
通讯作者：
Ikram, M. Arfan