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Background: N-terminal pro-B-type natriuretic peptide (NT-pro-BNP), a commonly used marker of cardiac function, is associated with presence of stroke symptoms and is a strong risk factor for future atrial fibrillation, stroke and mortality. Little data are available on the association between NT-pro-BNP levels and stroke recurrence. Objective: We studied the relationship between NT-proBNP with the risk of future ischemic stroke across a spectrum of pre-existing cerebrovascular conditions, ranging from history of stroke symptoms, to prior transient ischemic attack (TIA), to prior stroke. Methods: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort enrolled 30 239 black and white Americans age 45 years and older in 2003-14. Among a case-cohort study sample including 1109 stroke cases and a 4311-person cohort random sample, we calculated hazard ratios of future ischemic stroke by baseline NT-proBNP stratified by presence of prior cerebrovascular conditions. Results: In the cohort sample, there were 3056 participants without any history of cerebrovascular disease, 738 with prior stroke symptoms, 196 with history of TIA and 338 with history of prior stroke. In a fully adjusted model, elevated NT-proBNP was associated with risk of stroke in participants without a pre-existing cerebrovascular condition (HR 2.32, 95% CI 1.84, 2.94), and in participants with a history of stroke symptoms (HR 1.67 95% CI 1.01, 2.78) or TIA (HR 2.66, 95% CI 1.00, 7.04), but not among those with prior stroke (HR 1.26, 95% CI 0.71, 2.21). Conclusions: These findings further support the potential for NT-proBNP testing to identify patients who are at highest risk for future stroke, although not in those with prior stroke.

Purpose: The safety of revascularization for asymptomatic carotid stenosis, and the efficacy of medical therapy for stroke prevention have improved. Therefore, results of prior randomized trials may not apply to current treatment decisions. The NINDS-funded CREST-2 will compare carotid endarterectomy and intensive medical therapy (IMT) versus IMT alone (n=1240), and carotid stenting and IMT versus IMT alone (n=1240) in asymptomatic patients with≥70% stenosis. Materials & Methods: CREST-2 consists of two parallel randomized clinical trials to be conducted at a target of ≈120 centers, including within NINDS StrokeNet. The composite primary outcome is stroke or death during the peri-procedural period or ipsilateral ischemic stroke thereafter up to 4 years. Blinded assessment of cognition will be done periodically. Centrally directed IMT includes tight control of blood pressure (systolic target Results: As of June 12, 2015, 94 centers have been approved by the Site Selection Committee. Credentialing is ongoing, with 198 approved surgeons and 64 approved interventionists; 124 additional conditionally approved interventionists will be able to submit additional cases for review under the CREST-2 Registry. The Centers for Medicare and Medicaid will offer CAS reimbursement for Registry enrollees. As of June 12, 2015, there are 39 actively enrolling centers, and 37 patients have been randomized. Conclusion: CREST-2 is designed to identify the best approach for asymptomatic carotid stenosis. The first patient was randomized in December, 2014. An update will be provided regarding the numbers of patients randomized, centers certified, as well as surgeons and interventionists fully approved. Registration: ClinicalTrials.gov Identifier: NCT02089217

Introduction: The association of DHEAS with coronary risk has been extensively studied, but little information is available on stroke risk. DHEAS levels are lower with stroke risk factors such as atrial fibrillation, arterial stiffness and atherosclerosis, but only one paper evaluated stroke risk and showed an inverse association of DHEAS and stroke risk in female nurses. Hypothesis: We assessed the hypothesis that lower DHEAS level is associated with increased ischemic stroke risk. Methods: REGARDS enrolled 30,239 US participants aged 45 and older in 2003-07 (41% black, 59% white, 55% living in the southeastern stroke belt). Baseline serum DHEAS was measured in 1,578 participants; 963 in a cohort random sample and 544 with first-time ischemic stroke during 5.4 years of follow up. Cox proportional hazard models with weights to account for the case cohort design were used to calculate hazard ratios (HR) of stroke by quartiles of DHEAS levels. Results: DHEAS was significantly lower with older age, white race, female sex, and history of heart disease. DHEAS in the first compared to the fourth quartile was associated with increased risk of stroke (HR 1.7, CI: 1.2-2.4), although this association was not present after adjusting for age (or other stroke risk factors: HR 1.0, CI: 0.7-1.6). These findings were similar in men and women. Stratifying on age, as shown in the table, in those 65 years (HR 0.8, CI: 0.5-1.4). Conclusion: There was no overall association of lower DHEAS and stroke risk in this bi-racial cohort of men and women from across the US, although a possible difference by age was observed. More research is needed to determine association of DHEAS with stroke risk.

Background: Recently, it has been shown that atrial fibrillation (AF) is an independent risk factor for end-stage renal disease (ESRD) among persons with chronic kidney disease (CKD). However, the association between AF and incident ESRD has not been examined in the general population. Methods: A total of 25,315 study participants (mean age 65 ± 9.0 years; 54% women; 40% blacks) from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study were included in this analysis. AF was identified in study participants at baseline (2003- 2007) by the study electrocardiogram and self-reported history of a physician diagnosis. Incident cases of ESRD were identified through linkage of REGARDS participants with the United States Renal Data System. Cox proportional-hazards regression was used to generate hazard ratios (HR) and 95% confidence intervals (95%CI) for the association between ESRD and AF. Results: A total of 2,190 (8.7%) participants had AF at baseline. Over a median follow-up of 7.7 years, 295 (1.2%) participants developed ESRD. In multivariable adjusted models, AF was associated with an increased risk of incident ESRD (Table 1). However, the association between AF and ESRD became non-significant after adjustment for baseline markers of CKD. Similar results were obtained when albumin-to-creatinine ratio was included in the model as a continuous variable (log-transformed). An interaction between AF and CKD was not detected. Conclusion: AF is associated with an increased risk of ESRD in the general population. However, this association potentially is explained by underlying CKD.

Background: The American Heart Association has developed Life’s Simple 7 (LS-7) as a measure of cardiovascular health. In a recent study, LS-7 showed a graded relationship with cardiovascular disease incidence. The association of LS-7 with incident stroke has not been reported previously. Methods: We analyzed data from REGARDS, a national population-based cohort of 30,239 blacks and whites, aged ≥ 45 years of age, sampled from US population between 2003 and 2007. Data for LS-7 was collected by telephone, mail questionnaires, and an in-home exam. Participants were contacted every 6 months for possible stroke, which was validated by physicians using medical record review. LS-7 components (blood pressure, cholesterol, glucose, BMI, smoking, physical activity, diet) were each coded as: poor (1 point), intermediate (2 points) and ideal (3 points). An overall LS-7 score, created by summing the 7 component scores (possible range: 7 to 21), was categorized as: highest (17–21), medium (12–16) and lowest (7–11) cardiovascular health. Cox regression was used to model LS-7 score categories with stroke events. Results: There were 22,914 participants with data on LS-7 and no previous CVD. Mean age was 65 years, 40% were black, and 55% female. Over 4.9 years of follow-up, there were 432 incident strokes. Mean (SD) LS-7 score was 13.5 (2.5). After adjustment for age and sex, mean LS-7 scores were lower for blacks (12.9 ± 0.02) than whites (14.3 ± 0.02). LS-7 categories were associated with incident stroke in a graded fashion (figure). After adjusting for age, race, sex, income, and education, each better health category was associated with a 25% lower risk of incident stroke (HR=0.75, 95% CI = 0.63, 0.90). In stratified analyses, HR was similar for blacks and whites (p-value = 0.55). Conclusion: Blacks had lower levels of cardiovascular health factors than whites. Better cardiovascular health based on LS-7 score was associated with a lower risk of stroke. Results suggest that efforts to improve the LS-7 score may be useful for stroke prevention.

National death certificate data suggest that racial disparities in acute coronary heart disease (CHD) mortality widened over the past decade for both men and women. To better understand this disparity, we examined black:white race-sex differences in overall, fatal and nonfatal acute CHD incidence in a large national biracial cohort. REGARDS is following 30,239 community-dwellers age ≥;45 years recruited between 2003-7 from 48 states. Recruitment was designed to balance race and sex; the final sample was 55% female and 41% black. Participants are telephoned every 6 months for CVD endpoints, with retrieval of medical records, death certificates, interviews with next-of-kin, and expert adjudication following national consensus recommendations. Acute CHD was defined as definite or probable myocardial infarction (MI) or acute CHD death. Among participants free of CHD at baseline, we examined black:white hazards for incident overall acute CHD, and, separately, fatal and nonfatal acute CHD for men and women through 2008, adjusting incrementally for sampling, sociodemographics and CHD risk factors. The study sample numbered 24,431 with mean age 64.1 (SD±9.3). Over a mean follow-up of 3.4 (maximum 5.9) years, 48.7% (55/113) of black men, 33.0% (38/115) of black women, 23.0% (46/200) of white men and 24.1% (21/87) of white women died at their presentation of acute CHD. Black:white hazard ratios for overall, fatal and nonfatal acute CHD from incrementally adjusted models stratified on sex are presented in the Table. Black men and women had over twice the age-adjusted hazard of incident fatal acute CHD compared to whites, not entirely explained by excess risk factor burden among blacks. Although socio-economic and CHD risk factors among blacks continue to be major contributors to fatal incident acute CHD, known risk factors did not fully explain the disparity between black and white men; causes of the elevated risk among black men need to be better understood if widening CHD mortality disparities are to be reversed.

Background: Self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) survey show higher prevalence of obesity in the south, particularly for the East South Central(ESC) states of LA, MS, and AL. Because obesity is associated with hypertension and diabetes, higher prevalence of obesity has been hypothesized as a primary contributor to the stroke belt, an area of high stroke mortality in the southeast. We assessed measured obesity from the National Health and Nutrition Examination Survey (NHANES) and REasons for Geographic and Racial Differences in Stroke (REGARDS), a national population-based cohort from 48 states, and compared geographic prevalence patterns across studies. Methods: Weighted obesity prevalence estimates (with 95% CIs) were calculated from NHANES (2003-2008; n = 6138), REGARDS (2003-2007; n = 30,183), and BRFSS (2003-2007; n = 67,742) in non-Hispanic black and white adults over 45 years of age in the census divisions. Obesity was defined as BMI >= 30 kg/m 2 . Results: There is a lack of concordance in the obesity prevalence (see Figure) between BRFSS and both REGARDS (top left) and NHANES (bottom right). In contrast, the comparison of REGARDS and NHANES (top right) shows good agreement in the estimated obesity prevalence for all divisions (including those containing the stroke belt states, shown in red). Conclusion: Our results indicate discordance in measured and self-reported obesity prevalence especially in the ESC division. The objectively measured obesity prevalence for both NHANES and REGARDS was high in the West North Central division including ND, SD, NE, KS, MN, IA, and MO. Factors other than obesity may contribute to the high prevalence of hypertension and diabetes, and high stroke mortality rates, in the stroke belt. Additionally, these data suggest that errors in self-reporting height and/or weight differ by region and may have distorted past estimates of obesity rates by region.

We wish to thank Drs Brian Eigel and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance. Summary Each year, the American Heart Association, in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in …

Appendix I: List of Statistical Fact Sheets. URL: http://www.americanheart.org/presenter.jhtml?identifier=2007 We wish to thank Drs Brian Eigel and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance. Disclosures View this table: View this table: View this table: # Summary {#article-title-2} Each year, the American Heart Association, in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease …

We thank Drs Robert Adams, Gary Friday, Philip Gorelick, and Sylvia Wasserthiel-Smoller, members of Stroke Statistics Subcommittee; Drs Joe Broderick, Brian Eigel, Kimberlee Gauveau, Jane Khoury, Jerry Potts, Jane Newburger, and Kathryn Taubert; and Sean Coady and Michael Wolz for their valuable comments and contributions. We acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance. View this table: Writing Group Disclosures # Summary {#article-title-2} Each year the American Heart Association, in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media, the lay public, and many others who seek the …

1. About These Statistics…e70 2. Cardiovascular Diseases…e72 3. Coronary Heart Disease, Acute Coronary Syndrome, and Angina Pectoris…e89 4. Stroke…e99 5. High Blood Pressure…e111 6. Congenital Cardiovascular Defects…e116 7. Heart Failure…e119 8. Other Cardiovascular Diseases…e122 9. Risk Factor: Smoking/Tobacco Use…e128 10. Risk Factor: High Blood Cholesterol and Other Lipids…e132 11. Risk Factor: Physical Inactivity…e136 12. Risk Factor: Overweight and Obesity…e139 13. Risk Factor: Diabetes Mellitus…e143 14. End-Stage Renal Disease and Chronic Kidney Disease…e149 15. Metabolic Syndrome…e151 16. Nutrition…e153 17. Quality of Care…e155 18. Medical Procedures…e159 19. Economic Cost of Cardiovascular Diseases…e162 20. At-a-Glance Summary Tables…e164 21. Glossary and Abbreviation Guide…e168 Writing Group Disclosures…e171 Appendix I: List of Statistical Fact Sheets: http://www.americanheart.org/presenter.jhtml?identifier=2007 We thank Drs Robert Adams, Philip Gorelick, Matt Wilson, and Philip Wolf (members of the Statistics Committee or Stroke Statistics Subcommittee); Brian Eigel; Gregg Fonarow; Kathy Jenkins; Gail Pearson; and Michael Wolz for their valuable comments and contributions. We would like to acknowledge Tim Anderson and Tom Schneider for their editorial contributions and Karen Modesitt for her administrative assistance. # 1. About These Statistics {#article-title-2} The American Heart Association (AHA) works with the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS); the National Heart, Lung, and Blood Institute (NHLBI); the National Institute of Neurological Disorders and Stroke (NINDS); and other government agencies to derive the annual statistics in this Update. This chapter describes the most important sources and the types of data we use from them. For more details and an alphabetical list of abbreviations, see Chapter 21 of this document, the Glossary and Abbreviation Guide. The surveys used are