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Cerebrovascular Disease

Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic AttackSecondary Analysis of the POINT Randomized Clinical Trial

Educational Objective
To examine the association between black race and early ischemic stroke recurrence.
1 Credit CME
JAMA Neurology
May 1, 2020
Original Investigation
Hooman Kamel, MD1,2;
Cenai Zhang, MS1;
Dawn O. Kleindorfer, MD3;
Emily B. Levitan, ScD4;
Virginia J. Howard, PhD4;
George Howard, DrPH5;
Elsayed Z. Soliman, MD, MSc, MS6,7,8;
S. Claiborne Johnston, MD, PhD9
Author Affiliations
  • 1Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
  • 2Deputy Editor, JAMA Neurology
  • 3Department of Neurology, University of Cincinnati, Ohio
  • 4Department of Epidemiology, University of Alabama at Birmingham, Birmingham
  • 5Department of Biostatistics, University of Alabama at Birmingham, Birmingham
  • 6Epidemiological Cardiology Research Center, Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 7Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 8Department of Internal Medicine–Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 9Dell Medical School, Dean’s Office, University of Texas at Austin, Austin
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Key Points

Question  Do black patients in the United States face a higher risk of early ischemic stroke recurrence?

Findings  In this cohort study of 4044 US participants in the Platelet-Oriented Inhibition in New Transient Ischemic Attack or Minor Ischemic Stroke trial, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race.

Meaning  Among US participants in a randomized clinical trial focused on secondary prevention after minor ischemic stroke or transient ischemic attack, black individuals faced a higher risk of early ischemic stroke recurrence, even after adjustment for demographics, comorbidities, and medication adherence.

Abstract

Importance  Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective.

Objective  To examine the association between black race and early ischemic stroke recurrence.

Design, Setting, and Participants  This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data.

Main Outcomes and Measures  The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype.

Results  Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients.

Conclusions and Relevance  Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures.

Trial Registration  clinicaltrials.gov Identifier: NCT00991029

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Cerebrovascular Disease Health Disparities Neurology Stroke Cerebrovascular Infarction
Article Information

Accepted for Publication: December 18, 2019.

Corresponding Author: Hooman Kamel, MD, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 420 E 70th St, LH-413, New York, NY 10021 (hok9010@med.cornell.edu).

Published Online: February 24, 2020. doi:10.1001/jamaneurol.2020.0010

Author Contributions: Dr Kamel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kamel, Kleindorfer, Johnston.

Acquisition, analysis, or interpretation of data: Kamel, Zhang, Levitan, V. Howard, G. Howard, Soliman.

Drafting of the manuscript: Kamel.

Critical revision of the manuscript for important intellectual content: Zhang, Kleindorfer, Levitan, V. Howard, G. Howard, Soliman, Johnston.

Statistical analysis: Kamel, Zhang, Levitan.

Obtained funding: Kamel, Johnston.

Administrative, technical, or material support: Kamel, Johnston.

Supervision: Johnston.

Conflict of Interest Disclosures: Dr Kamel reported serving as coprincipal investigator for the National Institutes of Health (NIH)–funded ARCADIA trial, which receives an in-kind study drug from the BMS-Pfizer Alliance and in-kind study assays from Roche Diagnostics, a steering committee member of Medtronic's Stroke AF trial (uncompensated), an end point adjudication committee member for a trial of empagliflozin for Boehringer-Ingelheim, and an advisory board member for Roivant Sciences on the topic of Factor XI inhibition. Dr Levitan reported grants from Amgen and personal fees from Novartis outside the submitted work. Dr Johnston reported nonfinancial support from Sanofi and grants from the NIH/National Institute of Neurological Disorders and Stroke (NINDS) and AstraZeneca. No other disclosures were reported.

Funding/Support: The POINT trial was funded by NIH/NINDS (grants U01NS062835, U01NS056975, and U01NS059041). Dr Kamel is supported by the NIH (grants R01NS097443 and R01HL144541).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Kamel is a Deputy Editor of JAMA Neurology, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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