Awareness of Risk Factors for Cerebrovascular Diseases among Acute Ischemic Stroke Patients in Shenzhen, China

  

    
 
    
Hypertension
    
Diabetes
    
Dyslipidemia
    
Atrial    fibrillation
  
  

    
Covariates
    
Univariate1

      OR (95% CI)
    
Multivariable2

      OR (95% CI)
    
Univariate1

      OR (95% CI)
    
Multivariable2

      OR (95% CI)
    
Univariate1

      OR (95% CI)
    
Multivariable2

      OR (95% CI)
    
Univariate1

      OR (95% CI)
    
Multivariable2

      OR (95% CI)
  
  

    
Age (ref= age=60)
    
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 
  
  

    
<45
    
0.43 (0.35-0.53)
    
0.50 (0.40-0.63)
    
0.25 (0.16-0.38)
    
0.28 (0.18-0.45)
    
0.43 (0.27-0.68)
    
0.48 (0.29-0.80)
    
0.17 (0.07-0.45)
    
0.21 (0.08-0.57)
  
  

    
45-59
    
0.73 (0.64-0.84)
    
0.81 (0.70-0.94)
    
0.48 (0.37-0.61)
    
0.53 (0.41-0.69)
    
0.60 (0.45-0.79)
    
0.59 (0.43-0.82)
    
0.37 (0.21-0.66)
    
0.39 (0.21-0.72)
  
  

    
Male sex
    
0.72 (0.62-0.83)
    
0.75 (0.63-0.89)
    
0.73 (0.56-0.94)
    
0.85 (0.63-1.15)
    
0.99 (0.70-1.18)
    
0.96 (0.68-1.36)
    
0.56 (0.36-0.87)
    
0.57 (0.34-0.94)
  
  

    
BMI (ref= BMI=16)
    
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 
  
  

    
16.01-24.99
    
1.64 (0.71-3.81)
    
2.04 (0.86-4.85)
    
0.58 (0.07-4.84)
    
1.11 (0.12-10.14)
    
0.79 (0.51-4.08)
    
1.44 (0.24-8.53)
    
2.22 (0.20-24.74)
    
2.62 (0.20-34.78)
  
  

    
=25
    
1.75 (0.75-4.01)
    
2.44 (1.02-5.84)
    
0.44 (0.05-3.72)
    
0.95 (0.10-8.74)
    
0.82 (0.16-4.27)
    
1.85 (0.31-11.06)
    
2.65 (0.23-30.31)
    
3.71 (0.27-50.94)
  
  

    
Medical insurance
    
1.26 (1.11-1.44)
    
1.30 (1.13-1.49)
    
1.34 (1.06-1.70)
    
1.45 (1.13-1.85)
    
1.67 (1.27-2.20)
    
2.03 (1.50-2.74)
    
1.09 (0.69-1.70)
    
1.28 (0.80-2.07)
  
  

    
Smoking status (ref=never smoke)
    
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 
  
  

    
Current
    
0.76 (0.65-0.88)
    
0.94 (0.79-1.10)
    
0.73 (0.56-0.94)
    
0.98 (0.73-1.32)
    
1.02 (0.76-1.34)
    
1.36 (0.95-1.95)
    
0.64 (0.32-1.26)
    
1.27 (0.58-2.79)
  
  

    
Ever
    
1.54 (1.22-1.96)
    
1.68 (1.31-2.15)
    
1.30 (0.88-1.92)
    
1.35 (0.89-2.04)
    
1.09 (0.72-1.64)
    
1.12 (0.70-1.79)
    
1.02 (0.51-2.02)
    
1.24 (0.59-2.63)
  
  

    
Comorbidity
    
 
    
 
    
 
    
 
    
 
    
 
    
 
    
 
  
  

    
Stroke
    
2.42 (1.97-2.97)
    
2.24 (1.82-2.76)
    
3.53 (2.45-5.09)
    
3.07 (2.12-4.46)
    
5.86 (4.38-7.84)
    
5.92 (4.36-8.03)
    
2.36 (1.35-4.12)
    
2.38 (1.31-4.33)
  
  

    
MI
    
1.75 (1.01-3.02)
    
1.55 (0.89-2.71)
    
2.88 (1.14-7.31)
    
2.27 (0.88-5.86)
    
4.40 (2.22-8.70)
    
3.64 (1.72-7.73)
    
0.95 (0.41-2.21)
    
0.71 (0.27-1.82)
  
  

    
TIA
    
1.16 (0.77-1.74)
    
1.19 (0.79-1.80)
    
1.07 (0.56-2.06)
    
0.95 (0.48-1.87)
    
1.72 (0.90-3.25)
    
1.47 (0.70-3.06)
    
1.55 (0.44-5.39)
    
1.34 (0.35-5.11)
  
  

    
1Univariate column of the table is the isolated    association of the specific factor with the awareness of hypertension,    diabetes, dyslipidemia and atrial fibrillation, respectively.

      2Multivariable column is the association of the specific    factor with the awareness of those modifiable risk factors after adjustment    for all other factors shown in the table.

      Statistic values of P=0.05 are indicated in bold. 
  

Table 3: Factors respectively associated with the awareness of hypertension, diabetes, dyslipidemia and atrial fibrillation.

Discussions

The overall prevalence of hypertension (84.9%) in our study was similar to the data from National Epidemiological Survey of Stroke (NESS) in China 2013 (84.2%), but much higher than the data from CNSR III (63.0%) [8]. As for the awareness, there were 71.6% patients known their blood pressure issues, which was slightly higher than overall Chinese people but still lower than individuals from western countries [10,15]. We indicated that males were more likely to ignore their preexisting hypertension, which was consistent with the characteristics of U.S. adults but not for eastern Chinese, even though the prevalence of hypertension might be higher in males based on previous studies [10,15-18]. In keeping with earlier findings, younger patients in our study showed higher risk of being unaware of their hypertension [19,20]. Meanwhile, patients without medical insurance were supposed to be unaware of the existence of hypertension, which mainly caused by the economic concerns. Former studies also demonstrated that lower income was associated with lower awareness of hypertension [20-22].

Positive past history of stroke or MI might increase the awareness of hypertension in our analysis, but the association of MI became insignificant after adjusting confounders, stayed the same with previous researches [23]. Besides, patients quitting smoke and obesity were more likely aware of their existing hypertension. Since measurement of blood pressure is a kind of easy and noninvasive procedure. Thus, the hypertension was easier to be detected than other CVDs risk factors as long as improving the personal motivation. Nevertheless, the blood pressure showed no clinical significant different in patients no matter they knew their own hypertensive issue or not. In addition, the blood serum glucose levels were even higher in patients with awareness of presence of hypertension. Hence, awareness of the disease was the first but not the only step, patients also need to pay more attention to the blood pressure control.

The prevalence of diabetes in our AIS patients was about 31% slightly higher than the data from CNSR III [8]. While the awareness rate of diabetes was about 76.2%, which was lower than several other studies but still in line with the range of most previous researches [24-27]. Among patients who were unaware of their diabetic status, there were more younger individuals, males as well as individuals without medical insurance. In consistent with a recent study conducted in Dubai, females and individuals with health insurance and higher monthly income showed better knowledge of the diabetes [26]. Although female gender was associated with decreased awareness of diabetes in Malaysia [27]. Different from hypertensive patients, the blood glucose control was kind of well in patients known their diabetic issues, since their serum blood glucose levels were lower than those without awareness. Additionally, the mean blood pressure (both SBP and DBP), serum LDL level as well as BMI were also lower in patients presented with awareness of diabetes. This might kind of due to well knowledge of their healthy promoted good control of glucose as well as other metabolism issues, since hyperglycemia was one of the most critical issues in the metabolic syndrome [29,30].

Overall, 1333 patients (25.9%) were identified as dyslipidemia based on the serum level of LDL, which was much slightly lower than general Chinese people from NESS but much higher than acute ischemic stroke patients from CNSR III [8]. There were only 24.2% patients knew their dyslipidemic status, which was close to the previous data [31]. In keeping with other studies, more younger patients and patients without medical insurance were likely to be unaware of the existence of dyslipidemia [32,33]. Patients with stroke and MI history might have increased awareness of their lipid dysbolism, the same phenomenon were also found in previous research [34]. But the association between MI history and risk factors awareness became insignificant after adjusting other confounders. Patients controlled the lipids more effectively if they knew their lipids issues. The blood pressure levels were also slightly lower in patients who were aware of their dysilipidemia, although the mean blood pressure was still not ideal for the stroke prevention. Different from the awareness of other risk factors in our study, there was no significant gender difference between patients who were aware or unaware of their dyslipidemic problems. The gender difference was also negative in in northeast China as well as Switzerland, which might be due to the increased risk of dyslipidemia in menopause women [34,35].

The prevalence of AF in our study was aligned with the prevalence among AIS patients in CNSR III [8]. Up to 53.4% patients were aware of their abnormal heart rhythm.The awareness condition seemed to be better than elderly people in Ireland but still lag behind individuals in Estonia [15,36]. Older and females patients were more prominent in patients who were aware of the AF condition the same as elderly Irish population [36]. Patients with increased Charlson Comorbidity Index was associated with higher awareness of AF in ATRIA-CVRN study [37]. Similarly, among patients with well understanding of their abnormal heart rhythm, there were more patients combined with past history of stroke in the present study.

Additionally, older patients showed better awareness of their CVDs risk factors in our study, among which patients younger than 45 years old demonstrated lowest awareness of their hypertension, diabetes, dyslipidemia as well as AF. Actually, young patients throughout the world are found to be less aware of their existing stroke factors, even though the incidence rate of stroke in young people is still increasing at present [32,38,39]. Furthermore, based on our study, the treatment conditions of hypertension (61.6%), diabetes (71.1%), dyslipidemia (35.4%) and AF (63.9%) were also suboptimal, which would be another important issue need to be settled while improving the awareness of CVDs risk factors.

There are several limitations of our study. Firstly, there might be underestimated dyslipidemia condition, since we diagnose the dyslipidemia only based on serum LDL level. Actually, LDL is one of the most issues factors need to be well controlled for the secondary prevention of stroke, and the serum LDL level change align with serum cholesterol in most cases. Secondly, the blood pressure level as well as the blood glucose level might be transitory increased because of the stress reaction. Therefore, we measured three times a day and calculated mean value to assess the admission mean blood pressure. The blood glucose was assessed by the fasting biochemical profiles on the second morning after admission to minimize the effect of stress reaction caused by the acute ischemic stroke. Thirdly, this is a cross sectional study aimed to describe the status of CVDs risk factors awareness among AIS patients in Shenzhen. And some key factors is missing in our present study, such as education level that might also influence the awareness of CVDs risk factors, although this effect might be less in young population. The results of our study is not sufficient to identify the cause-and-effect conclusions, and we are conducting the prospective cohort to evaluate the potential contributing factors as well as the compliance of the treatment of each risk factor.

Conclusion

The overall awareness of the CVDs risk factors was suboptimal among AIS patients in Shenzhen, especially for the existing dyslipidemia. We indicated that males and younger patients and patients lacking of medical insurance, past illness history of stroke or MI were more likely to be unaware of their existing modifiable CVDs risk factors. The overall control of blood glucose and lipids as well as blood pressure were still need to be improved in patients with acute ischemic stroke, especially for those who knew less about their own health issues. More importantly, we should pay more attention to the improvement of the awareness of CVDs risk factors in people younger than 45 years old in Shenzhen, since the stroke screening program of China are mainly at the service of patients older than this age threshold.

Author Statements

Acknowledgments

This work was supported by the Shenzhen Quality Control Center for Management of Cerebrovascular Diseases, involving 29 hospitals of Shenzhen. We thank these participants in the study and express our gratitude for the nurses and doctors who were involved in the data collections.

Authors' Contributions

Lijie Ren and Yang Wang conceived and designed the study. Zhihao Lei and Shiyu Hu performed the data collection. Tao Lan and Shiyu Hu performed the statistical analysis and paper writing. Lijie Ren and Yang Wang reviewed and edited the manuscript. All authors read and approved the manuscript.

Availability of Data and Materials

The datasets analysed during the current study available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

All methods were carried out in accordance with relevant guidelines and regulations. All patients or their guardians were informed consent to participate in this medical quality control program. The data was public for application and de-identified. All experimental protocols were approved by the ethics committee of Shenzhen Second People’s Hospital.

Funding

This work was supported by the Scientific Research Items of Shenzhen Science and Technology Innovation Committee (No. SGLH20180628161804465 and GJHZ20200731095602009) and clinical research projects of Shenzhen Second People’s Hospital (No. 20203357015).

Competing Interests

No potential conflict of interest was reported by the authors.

References

1. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014; 383: 245-54.
2. Li X, Zhang X. Annual data set on national mortality surveillance 2018. Beijing: China Science and Technology Press. 2019.
3. Wang W, Jiang B, Sun H, Ru X, Sun D, Wang L, et al. Prevalence, incidence, and mortality of stroke in China: results from a nationwide population-based survey of 480 687 adults. Circulation. 2017; 135: 759-71.
4. Feigin VL, Nguyen G, Cercy K, Johnson CO, Alam T, Parmar PG, et al. Global, regional, and country-specific lifetime risks of stroke, 1990 and 2016. N Engl J Med. 2018; 379: 2429-37.
5. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014; 383: 245-54.
6. Shenzhen Municipal Bureau of Statistics, Gender Statistics report of Shenzhen in 2017 (in Chinese). Aug; 2019.
7. Lei L, Zhou HB, Peng K, et al. Analysis on the prevalence of stroke in Shenzhen residents during 2008-2013 (in Chinese). China Chronic Dis Prev Control. 2014: 564-6.
8. Wang Y-J, Li Z-X, Gu H-Q, Zhai Y, Jiang Y, Zhao X, et al. China Stroke Statistics 2019: A Report from the National Center for Healthcare Quality Management in Neurological Diseases, China National Clinical Research Center for Neurological Diseases, the Chinese Stroke Association, National Center for Chronic and non-communicable disease Control and Prevention, Chinese Center for Disease Control and Prevention and Institute for Global Neuroscience and Stroke Collaborations. Stroke Vasc Neurol. 2020; 5: 211-39.
9. Shenzhen Science and Technology Innovation Committee, Shenzhen Life Science and Biotechnology Association. Study on cardiovascular and cerebrovascular diseases in Shenzhen. 2016; 2015.
10. Lu Y, Wang P, Zhou T, Lu J, Spatz ES, Nasir K, et al. Comparison of prevalence, awareness, treatment, and control of cardiovascular risk factors in China and the United States. J Am Heart Assoc. 2018; 7: e007462.
11. Wang Z, Chen Z, Zhang L, Wang X, Hao G, Zhang Z, et al. Status of hypertension in China: results from the China hypertension survey, 2012-2015. Circulation. 2018; 137: 2344-56.
12. Carey RM, Whelton PK, 2017 ACC/AHA Hypertension Guideline Writing Committee. Prevention, detection, evaluation, and management of high blood pressure in adults: synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline. Ann Intern Med. 2018; 168: 351-8.
13. Chamberlain JJ, Rhinehart AS, Shaefer CF Jr, Neuman A. Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association standards of medical care in diabetes. Ann Intern Med. 2016; 164: 542-52.
14. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002; 106: 3143-421.
15. Soomann M, Vibo R, Kõrv J. Do stroke patients know their risk factors? J Stroke Cerebrovasc Dis. 2016; 25: 523-6.
16. Yan XF, Yang JW, Bai XK, Wang HR, Feng F, Hou LL, et al. Awareness, treatment and control of hypertension in 640 000 adults in eastern China. Zhonghua Liu Xing Bing Xue Za Zhi. 2020; 41: 68-73.
17. Huang XB, Zhang Y, Wang TD, Liu JX, Yi YJ, Liu Y, et al. Prevalence, awareness, treatment, and control of hypertension in southwestern China. Sci Rep. 2019; 9: 19098.
18. Das Gupta R, Shabab Haider S, Sutradhar I, Hasan M, Joshi H, Rifat Haider M, et al. Gender differences in hypertension awareness, antihypertensive use and blood pressure control in Nepalese adults: findings from a nationwide cross-sectional survey. J Biosoc Sci. 2020; 52: 412-38.
19. Fenech G, Vallée A, Cherfan M, Kab S, Goldberg M, Zins M, et al. Poor awareness of hypertension in France: the CONSTANCES population-based study. Am J Hypertens. 2020; 33: 543-51.
20. Felix C, Baldeon ME, Zertuche F, Fornasini M, Paucar MJ, Ponce L, et al. Low levels of awareness, treatment, and control of hypertension in Andean communities of Ecuador. J Clin Hypertens (Greenwich). 2020; 22: 1530-7.
21. Ahmed AAA, Al-Shami AM, Jamshed S, Zawiah M, Elnaem MH, Mohamed Ibrahim MI. Awareness of the risk factors for heart attack among the General Public in Pahang, Malaysia: A cross-sectional study. Risk Manag Healthc Policy. 2020; 13: 3089-102.
22. Bersamin A, Stafford RS, Winkleby MA. Predictors of hypertension awareness, treatment, and control among Mexican American women and men. J Gen Intern Med. 2009; 24: 521-7.
23. Gee ME, Janssen I, Pickett W, McAlister FA, Bancej CM, Joffres M, et al. Prevalence, awareness, treatment, and control of hypertension among Canadian adults with diabetes, 2007 to 2009. Can J Cardiol. 2012; 28: 367-74.
24. Alkerwi A, Pagny S, Lair ML, Delagardelle C, Beissel J. Level of unawareness and management of diabetes, hypertension, and dyslipidemia among adults in Luxembourg: findings from ORISCAV-LUX study. PLOS ONE. 2013; 8: e57920.
25. Sims M, Diez Roux AV, Boykin S, Sarpong D, Gebreab SY, Wyatt SB, et al. The socioeconomic gradient of diabetes prevalence, awareness, treatment, and control among African Americans in the Jackson Heart Study. Ann Epidemiol. 2011; 21: 892-8.
26. Abdulrahman M, Husain ZSM, Abdouli KA, Kazim MN, Sayed Mahdi Ahmad F, et al. Association between knowledge, awareness, and practice of patients with type 2 diabetes with socio-economic status, adherence to medication and disease complications. Diabetes Res Clin Pract. 2020; 163: 108124.
27. Bikbov MM, Fayzrakhmanov RR, Kazakbaeva GM, Zainullin RM, Arslangareeva II, Gilmanshin TR, et al. Prevalence, awareness and control of diabetes in Russia: the Ural Eye and Medical Study on adults aged 40+ years. PLOS ONE. 2019; 14: e0215636.
28. Ahmed AAA, Al-Shami AM, Jamshed S, Zawiah M, Elnaem MH, Mohamed Ibrahim MI. Awareness of the risk factors for heart attack among the General Public in Pahang, Malaysia: A cross-sectional study. Risk Manag Healthc Policy. 2020; 13: 3089-102.
29. Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome. Lancet. 2005; 365: 1415-28.
30. Diabetes Canada Clinical Practice Guidelines Expert Committee, Punthakee Z, Goldenberg R, Katz P. Definition, classification and diagnosis of diabetes, prediabetes and metabolic syndrome. Can J Diabetes. 2018; 42: S10-5.
31. Boo S, Yoon YJ, Oh H. Evaluating the prevalence, awareness, and control of hypertension, diabetes, and dyslipidemia in Korea using the NHIS-NSC database: A cross-sectional analysis. Med (Baltim). 2018; 97: e13713.
32. Yen ST, Tan AKG, Mustapha FI. Awareness of diabetes, hypertension, and hypercholesterolemia in Malaysia. J Diabetes. 2017; 9: 874-83.
33. Bucholz EM, Rodday AM, Kolor K, Khoury MJ, de Ferranti SD. Prevalence and predictors of cholesterol screening, awareness, and statin treatment among US adults with familial hypercholesterolemia or other forms of severe dyslipidemia (1999-2014). Circulation. 2018; 137: 2218-30.
34. Zhang FL, Xing YQ, Wu YH, Liu HY, Luo Y, Sun MS, et al. The prevalence, awareness, treatment, and control of dyslipidemia in northeast China: a population-based cross-sectional survey. Lipids Health Dis. 2017; 16: 61.
35. Croquelois A, Bogousslavsky J. Risk awareness and knowledge of patients with stroke: results of a questionnaire survey 3 months after stroke. J Neurol Neurosurg Psychiatry. 2006; 77: 726-8.
36. Frewen J, Finucane C, Cronin H, Rice C, Kearney PM, Harbison J, et al. Factors that influence awareness and treatment of atrial fibrillation in older adults. Q J Med. 2013; 106: 415-24.
37. Reading SR, Go AS, Fang MC, Singer DE, Liu IA, Black MH, et al. Health literacy and awareness of atrial fibrillation. J Am Heart Assoc. 2017; 6: e005128.
38. Bucholz EM, Gooding HC, de Ferranti SD. Awareness of cardiovascular risk factors in U.S. Young adults aged 18-39 years. Am J Prev Med. 2018; 54: e67-77.
39. Ekker MS, Boot EM, Singhal AB, Tan KS, Debette S, Tuladhar AM, et al. Epidemiology, aetiology, and management of ischaemic stroke in young adults. Lancet Neurol. 2018; 17: 790-801.