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Abstract

Background

Stroke and transient ischemic attack confer greater risk of cognitive decline and dementia.

Aims

We used data from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), a blood pressure-lowering randomized controlled trial in stroke/transient ischemic attack. We evaluated overall and sex-specific differences in treatment effects for cognitive decline/dementia, as well as associations with vascular and stroke-specific predictors,considering death as a competing risk.

Methods

Multinomial logistic regression was used to estimate overall and sex-specific odds ratios (OR) (95% confidence intervals (CI)) for treatment effects and predictors associated with the risk of cognitive decline/dementia, and the women-to-men ratio of odds ratio (RORs).

Results

Over a median four years, 763 cognitive decline/dementia (30.9% women) were recorded in 5888 participants. Women had lower odds of cognitive decline/dementia than men (OR 0.78, 95%CI 0.63–0.95). Active treatment was associated with lower odds of cognitive decline/dementia (0.84, 0.72–0.98), with no evidence of sex difference. Higher education (0.96,0.94–0.98 (per year)) and baseline Mini-Mental State Examination (MMSE)) were associated with lower odds of cognitive decline/dementia (0.84,0.82–0.86 (per point higher)). Higher diastolic blood pressure (1.11,1.02–1.20 (per 10 mmHg)), low estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² (1.27,1.03–1.58), and peripheral arterial disease (1.78,1.26–2.52) were associated with higher odds of cognitive decline/dementia. APOE ɛ4 was not associated with cognitive decline/dementia (1.05 (0.85–1.30)). Low eGFR was more strongly associated with cognitive decline/dementia in women than men (RORs, 1.60 (1.03–2.48)). Diabetes was more strongly associated with men than women.

Conclusions

Several risk factors were associated with cognitive decline/dementia in people with prior stroke/transient ischemic attack, with notable sex differences. Long-term cognitive sequelae of stroke should be considered to strengthen joint prevention strategies for stroke, cognitive decline, and dementia.

Trial Registration: This trial was not registered because enrolment began before 1 July 2005.

Keywords

Stroke dementia cognitive decline sex difference competing risk

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References

Hachinski V, Einhäupl K, Ganten D, et al. Preventing dementia by preventing stroke: The Berlin Manifesto. Alzheimer's Dement 2019;15: 961–984.

Brainin

Feigin

Norrving

Martins

SCO

Hankey

Hachinski

. Global prevention of stroke and dementia: the WSO Declaration. Lancet Neurol 2020; 19: 487–488.

Lo JW, Crawford JD, Desmond DW, et al. Profile of and risk factors for poststroke cognitive impairment in diverse ethnoregional groups. Neurology 2019; 93: e2257–e2271.

Gorelick

Scuteri

Black

, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011; 42: 2672–2713.

Tzourio C, Anderson C, Chapman N, for the PROGRESS Collaborative Group. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med 2003; 163: 1069–1075.

Pendlebury ST, Rothwell PM, for the Oxford Vascular Study. Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based Oxford Vascular Study. Lancet Neurol 2019; 18: 248–258.

Guo X, Östling S, Kern S, Johansson L and Skoog I. Increased risk for dementia both before and after stroke: a population-based study in women followed over 44 years. Alzheimer's Dement 2018;14: 1253–1260.

Hachinski V. Brain health – curbing stroke, heart disease, and dementia: The 2020 Wartenberg Lecture. Neurology 2021;97273–279.

Dichgans

. Dementia risk after transient ischaemic attack and stroke. Lancet Neurol 2019; 18: 223–225.

10.

Mauvais-Jarvis F, Merz NB, Barnes PJ, et al. Sex and gender: modifiers of health, disease, and medicine. Lancet 2020; 396: 565–582.

11.

Peters SAE, Carcel C, Millett ERC and Woodward M. Sex differences in the association between major risk factors and the risk of stroke in the UK Biobank cohort study. Neurology 2020; 95: e2715–e2726.

12.

MacMahon S, Neal B, Tzourio C, for the PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack. Lancet 2001; 358: 1033–1041.

13.

Neal B and MacMahon S. The PROGRESS study: rationale and design. J Hypertens 1995; 13: 1869.

14.

Inker LA, Eneanya ND, Coresh J, et al. New creatinine- and cystatin Cbased equations to estimate GFR without race. New England Journal of Medicine 2021; 385: 1737–1749.

15.

Delgado C, Baweja M, Crews DC, et al. A Unifying Approach for GFR Estimation: Recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022; 79: 268-288.e1. .

16.

Folstein MF, Folstein SE and McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12: 189–198.

17.

Mahoney FI and Barthel D. Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. Maryland State Med J 1965; 41: 61–65.

18.

Lindley RI, Waddell F, Livingstone M, et al. Can simple questions assess outcome after stroke? Cerbrovasc Dis 1994; 4: 314–324.

19.

Tzourio C, Arima H, Harrap S, et al. APOE genotype, ethnicity, and the risk of cerebral hemorrhage. Neurology 2008; 70: 1322–1328.

20.

Woodward

. Rationale and tutorial for analysing and reporting sex differences in cardiovascular associations. Heart 2019; 105: 1701–1708.

21.

Rist PM, Chalmers J, Arima H, et al. Baseline cognitive function, recurrent stroke, and risk of dementia in patients with stroke. Stroke 2013; 44: 1790–1795.

22.

Peters R and Anderson CS. Advancing dementia prevention through effective blood pressure control. Lancet Neurol 2020; 19: 25–27.

23.

Pearce LA, McClure LA, Anderson DC, et al. Effects of long-term blood pressure lowering and dual antiplatelet treatment on cognitive function in patients with recent lacunar stroke: a secondary analysis from the SPS3 randomised trial. Lancet Neurol 2014; 13: 1177–1185.

24.

Hornslien AG, Sandset EC, Bath PM, et al. Effects of candesartan in acute stroke on cognitive function and quality of life: results from the Scandinavian Candesartan Acute Stroke Trial. Stroke 2013; 44: 2022–2024.

25.

Diener H-C, Sacco RL, Yusuf S, et al. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebo-controlled study. Lancet Neurol 2008; 7: 875–884.

26.

Ihle-Hansen H, Thommessen B, Fagerland MW, et al. Blood pressure control to prevent decline in cognition after stroke. Vasc Health Risk Manage 2015; 11: 311.

27.

Emdin CA, Rothwell PM, Salimi-Khorshidi G, et al. Blood pressure and risk of vascular dementia: evidence from a primary care registry and a cohort study of transient ischemic attack and stroke. Stroke 2016; 47: 1429–1435.

28.

Yang Z, Edwards D, Burgess S, Brayne C and Mant J. Association of Prior Atherosclerotic Cardiovascular Disease with Dementia After Stroke: a retrospective cohort study. J Alzheimer's Dis 2020; 77: 1157–1167.

29.

Guerchet M, Aboyans V, Nubukpo P, Lacroix P, Clément J-P and Preux P-M. Ankle-brachial index as a marker of cognitive impairment and dementia in general population. A systematic review. Atherosclerosis 2011; 216: 251–257.

30.

Banerjee A, Fowkes FG and Rothwell PM. Associations between peripheral artery disease and ischemic stroke: implications for primary and secondary prevention. Stroke 2010; 41: 2102–2107.

31.

Deckers K, Camerino I, van Boxtel MP, et al. Dementia risk in renal dysfunction: a systematic review and meta-analysis of prospective studies. Neurology 2017; 88: 198–208.

32.

Bress AP, Tanner RM, Hess R, et al. Prevalence of eligibility criteria for the Systolic Blood Pressure Intervention Trial in US adults among excluded groups: age< 50 years, diabetes mellitus, or a history of stroke. J Am Heart Assoc 2016; 5: e003547.

33.

Tamura MK, Gaussoin SA, Pajewski NM, et al. Kidney disease, intensive hypertension treatment, and risk for dementia and mild cognitive impairment: The systolic blood pressure intervention trial. J Am Soc Nephrol 2020; 31: 2122–2132.

34.

Zheng D, Sato S, Arima H, et al. Estimated GFR and the effect of intensive blood pressure lowering after acute intracerebral hemorrhage. Am J Kid Dis 2016; 68: 94–102.

35.

Kelly D and Rothwell PM. Disentangling the multiple links between renal dysfunction and cerebrovascular disease. J Neurol Neurosurg Psychiatry 2020; 91: 88–97.

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Sex differences in predictors for cognitive decline and dementia in people with stroke or transient ischemic attack in the PROGRESS trial