Racial and gender differences in stroke severity, outcomes, and treatment in patients with acute ischemic stroke.
BACKGROUND
Previous research has indicated that women and blacks have worse outcomes after acute ischemic stroke (AIS). Little research has been done to investigate the combined influence of race and gender in the presentation, treatment, and outcome of patients with AIS. We sought to determine the association of race and gender on initial stroke severity, thrombolysis, and functional outcome after AIS.


METHODS
AIS patients who presented to 2 academic medical centers in the United States (2004-2011) were identified through prospective registries. In-hospital strokes were excluded. Stroke severity, measured by admission National Institutes of Health Stroke Scale (NIHSS) scores, treatment with tissue plasminogen activator (tPA), neurologic deterioration (defined by a ≥2-point increase in NIHSS score), and functional outcome at discharge, measured by the modified Rankin Scale, were investigated. These outcomes were compared across race/gender groups. A subanalysis was conducted to assess race/gender differences in exclusion criteria for tPA.


RESULTS
Of the 4925 patients included in this study, 2346 (47.6%) were women and 2310 (46.9%) were black. White women had the highest median NIHSS score on admission (8), whereas white men had the lowest median NIHSS score on admission (6). There were no differences in outcomes between black men and white men. A smaller percentage of black women than white women were treated with tPA (27.6% versus 36.6%, P < .0001), partially because of a greater proportion of white women presenting within 3 hours (51% versus 45.5%, P = .0005). Black women had decreased odds of poor functional outcome relative to white women (odds ratio [OR] = .85, 95% confidence interval [CI] .72-1.00), but after adjustment for baseline differences in age, NIHSS, and tPA use, this association was no longer significant (OR = 1.2, 95% CI .92-1.46, P = .22). Black women with an NIHSS score less than 7 on admission were at lower odds of receiving tPA than the other race/gender groups, even after adjusting for arriving within 3 hours and admission glucose (OR = .66, 95% CI .44-.99, P = .0433).


CONCLUSIONS
Race and gender were not significantly associated with short-term outcome, although black women were significantly less likely to be treated with tPA. Black women had more tPA exclusions than any other group. The primary reason for tPA exclusion in this study was not arriving within 3 hours of stroke symptom onset. Given the growth in incident strokes projected in minority groups in the next 4 decades, identifying factors that contribute to black women not arriving to the emergency department in time are of great importance.
Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Amelia K
AK
Boehme
Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, Louisiana.
James E
JE
Siegler
Department of Neurology, University of Pennsylvania, Philadelphia, Pennysylvania.
Michael T
MT
Mullen
Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, Birmingham, Alabama; Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities Minority Health and Health Disparities Research Center, Birmingham, Alabama.
Karen C
KC
Albright
Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
Michael J
MJ
Lyerly
Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, Louisiana.
Dominique J
DJ
Monlezun
Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, Louisiana.
Erica M
EM
Jones
Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama.
Rikki
R
Tanner
Department of Neurology, University of Texas Medical School-Houston, Houston, Texas.
Nicole R
NR
Gonzales
Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama.
T Mark
TM
Beasley
Department of Neurology, University of Texas Medical School-Houston, Houston, Texas.
James C
JC
Grotta
Department of Neurology, University of Texas Medical School-Houston, Houston, Texas.
Sean I
SI
Savitz
Stroke Program, Department of Neurology, Tulane University Hospital, New Orleans, Louisiana. Electronic address: smartin2@tulane.edu.
Sheryl
S
Martin-Schild
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044383:Black People / Q000706:statistics & numerical data; D002545:Brain Ischemia / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D015331:Cohort Studies; D005006:Ethnicity; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D020127:Recovery of Function; D012189:Retrospective Studies; D017678:Sex Distribution; D020521:Stroke / Q000453:epidemiology* / Q000401:mortality / Q000628:therapy; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data; D055815:Young Adult; D001741:Black or African American
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
Acute stroke; ethnic disparities; ischemic stroke; treatment disparities