title: Chronic Obstructive Pulmonary Disease and the Risk of Stroke. The Rotterdam Study.
abstract: BACKGROUND
  Worldwide, chronic obstructive pulmonary disease (COPD) and stroke are leading causes of death. Increasing evidence suggests an association between both diseases, either caused by an increased atherosclerosis risk in patients with COPD or as a consequence of shared risk factors between stroke and COPD.
  
  
  OBJECTIVE
  To examine the associations between COPD and subtypes of stroke in the general population and to explore the role of cardiovascular risk factors and exacerbations on these associations.
  
  
  METHODS
  Within the prospective population-based Rotterdam Study, we followed 13,115 participants without history of stroke for occurrence of stroke. Follow up started in 1990 to 2008 and ended in 2012. COPD was related to stroke using a time-dependent Cox proportional hazard model.
  
  
  RESULTS
  COPD was diagnosed in 1,566 participants. During 126,347 person-years, 1,250 participants suffered a stroke, of which 701 were ischemic and 107 hemorrhagic. Adjusted for age, age squared, and sex, COPD was significantly associated with all stroke (hazard ratio [HR], 1.20; 95% confidence interval, 1.00-1.43), ischemic stroke (HR, 1.27; 1.02-1.59), and hemorrhagic stroke (HR, 1.70; 1.01-2.84). Adjusting for cardiovascular risk factors gave similar effect sizes. In contrast, additional adjusting for smoking attenuated the effect sizes: HR, 1.09 (0.91-1.31) for all stroke; HR, 1.13 (0.91-1.42) for ischemic stroke; and HR 1.53 (0.91-2.59) for hemorrhagic stroke. After an acute severe exacerbation, subjects with COPD had a 6.66-fold (2.42-18.20) increased risk of stroke.
  
  
  CONCLUSIONS
  Our cohort study demonstrated a higher risk of both ischemic and hemorrhagic stroke in subjects with COPD and revealed the importance of smoking as a shared risk factor.
authors.affiliation: 1 Department of Epidemiology.|2 Department of Neurology.
authors.forename: Marileen L P
authors.initials: ML
authors.lastname: Portegies
authors.affiliation: 1 Department of Epidemiology.|3 Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.
authors.forename: Lies
authors.initials: L
authors.lastname: Lahousse
authors.affiliation: 3 Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.
authors.forename: Guy F
authors.initials: GF
authors.lastname: Joos
authors.affiliation: 1 Department of Epidemiology.
authors.forename: Albert
authors.initials: A
authors.lastname: Hofman
authors.affiliation: 2 Department of Neurology.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Koudstaal
authors.affiliation: 1 Department of Epidemiology.|4 Department of Internal Medicine.
authors.forename: Bruno H
authors.initials: BH
authors.lastname: Stricker
authors.affiliation: 1 Department of Epidemiology.|5 Department of Respiratory Medicine, and.|3 Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.
authors.forename: Guy G
authors.initials: GG
authors.lastname: Brusselle
authors.affiliation: 1 Department of Epidemiology.|2 Department of Neurology.|6 Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands; and.
authors.forename: M Arfan
authors.initials: MA
authors.lastname: Ikram
mesh_terms: D000368:Aged; D001249:Asthma / Q000150:complications; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications*; D012307:Risk Factors; D020521:Stroke / Q000209:etiology*
keywords: cerebral infarction; chronic airflow obstruction; epidemiology; exacerbations; intracerebral hemorrhage