LOS ANGELES – A large survey of Asian Americans suggests that the group experiences more severe ischemic strokes and is less likely to receive intravenous tissue plasminogen activator (tPA) than do white patients, among other discrepancies. The research found that whites had declining stroke severity between 2004 and 2016, but there was no change in Asian Americans.
The research encompasses all self-identified Asian Americans in the Get-with-the-Guidelines, which is a voluntary stroke quality improvement program begun by the American Heart Association in 2003. The analysis included 64,337 Asian Americans and 1,707,962 white Americans at 2,171 hospitals nationwide that participated in the program during 2004-2016.
“I think the most important finding is that they’re not getting as much tPA and having more tPA complications, such as bleeding more. I think it gives it an urgency that maybe was lacking, an urgency that we really need to address this issue by finding innovative ways to reach Asian Americans, to educate them about stroke. We need to find culturally appropriate ways to reach out to Asian populations,” said Dr. Song, who is a vascular neurologist at Rush Medical College, Chicago.
Dr. Song is working on small-scale interventions that are culturally tailored for Asian populations. “I think the way to approach any insular community is to work from within, so that’s my goal,” Dr. Song said.
One particular finding suggested a need for better education among Asian American communities. Asian Americans were less likely than whites to report a clinical history of having heightened levels of low-density lipoproteins. “They didn’t know that they had high cholesterol, but they had a higher LDL [cholesterol levels] than Caucasians on average,” said Dr. Song. The mean LDL cholesterol value was 101 mg/dL in Asian Americans, compared with 95 mg/dL in whites, which was statistically significant.
White patients had higher rates of atrial fibrillation (21.2% vs. 16.0%), coronary artery disease (27.8% vs. 17.5%), and stenosis (4.7% vs. 2.0%), while Asian Americans were more prone to diabetes (38.0% vs. 29.2%).
Severe strokes (National Institutes of Health stroke score of 16 or greater) were more common among Asian Americans (odds ratio, 1.35; P less than .0001). After adjustment for stroke severity, the researchers found that Asian Americans were less likely to receive tPA (OR, 0.90; P less than .0001) and more likely to experience symptomatic intracerebral hemorrhage within 36 hours of receiving tPA (OR, 1.23; P = .003). “I think that may have something to do with the pathophysiology of Asian stroke that we don’t quite understand yet, but we can see there is a problem,” Dr. Song said.
Although in-hospital mortality was initially higher among Asian Americans, this trend switched after researchers corrected for stroke severity, leading to a better outcome for Asian Americans (OR, 0.95; P = .008). Some quality of care measures also favored Asian Americans, including receipt of stroke education (OR, 1.08; P = .02), receipt of IV tPA within 60 minutes of arrival (OR, 1.14; P = .0006), LDL cholesterol documentation (OR, 1.19; P less than .0001), and receipt of intensive statin therapy (OR, 1.15; P less than .0001). However, Asian Americans were less likely to receive a CT scan within 25 minutes of arrival (OR, 0.92; P less than .0001).
Between 2004 and 2016, both groups benefited from similar improvements, but there were differences. In 2016, a stroke in a white patient was less likely to be severe than in 2004 (OR, 0.97; P less than .0001), while there was no change in Asian Americans (OR, 1.00; P = .95).
The study is limited by the fact that the database is voluntary, which could lead to selection bias, and all Asian Americans are combined into one group. “One can argue that South Asian stroke is not the same as Japanese stroke or stroke in the Philippines,” Dr. Song said. Still, the findings suggest problems that need to be addressed. “I think it highlights the problem that Asian ischemic stroke patients don’t do as well, they bleed more, and they receive less tPA. I think that’s a big deal.”
The study received no specific funding. Dr. Song reported having no financial disclosures.