Comparing Risk Factor Profiles between Intracerebral Hemorrhage and Ischemic Stroke in Chinese and White Populations: Systematic Review and Meta-Analysis

Abstract

Background: Chinese populations have a higher proportion of intracerebral hemorrhage (ICH) in total strokes. However, the reasons are not fully understood.

Methods: To assess the differences in frequency of major risk factors between ICH and ischemic stroke (IS) in Chinese versus white populations of European descent, we systematically sought studies conducted since 1990 that compared frequency of risk factors between ICH and IS in Chinese or white populations. For each risk factor, in Chinese and Whites separately, we calculated study-specific and random effects pooled prevalence and odds ratios (ORs) for ICH versus IS.

Results: Six studies among 36,190 Chinese, and seven among 52,100 white stroke patients studied hypertension, diabetes, atrial fibrillation (AF), ischemic heart disease (IHD), hypercholesterolemia, smoking and alcohol. Pooled prevalence of AF was significantly lower in Chinese. Pooled ORs for ICH versus IS were mostly similar in Chinese and Whites. However, in Chinese--but not Whites--mean age was lower (62 versus 69 years), while hypertension and alcohol were significantly more frequent in ICH than IS (ORs 1.38, 95% CI 1.18-1.62, and 1.46, 1.12-1.91). Hypercholesterolemia and smoking were significantly less frequent in ICH in Whites, but not Chinese, while IHD, AF and diabetes were less frequent in ICH in both.

Conclusions: Different risk factor distributions in ICH and IS raise interesting possibilities about variation in mechanisms underlying the different distributions of pathological types of stroke between Chinese and Whites. Further analyses in large, prospective studies, including adjustment for potential confounders, are needed to consolidate and extend these findings.

Fig 1. Selection of studies in Chinese populations.

a. excluding patients with cardiogenic emboli; excluding patients with cardiogenic emboli, arteriovenous malformation, or using anticoagulants; excluding patients with other major illness (e.g., cancer, anemia); data only in men; data only in diabetes; data only in patients aged 35–64 years. b. weather, circadian variation of stroke onset, and dietary pattern.

Fig 2. Selection of studies in white popuations.

a. excluding patients with cardiogenic emboli, or both lacunar and cortical infarcts; data only in men; data only in patients with atrial fibrillation.

Fig 3. Pooled prevalence of risk factors in Chinese and white intracerebral hemorrhage.

ICH = intracerebral hemorrhage; CI = confidence interval; Betw group het = between-group (ethnic) heterogeneity; C = Chinese; W = Whites; HTN = hypertension; DM = diabetes; AF = atrial fibrillation; IHD = ischemic heart disease; HC = hypercholesterolemia. Horizontal lines represent 95% CIs. Diamonds represent pooled proportions.

Fig 4. Pooled prevalence of risk factors in Chinese and white ischemic stroke.

IS = ischemic stroke; CI = confidence interval; Betw group het = between-group (ethnic) heterogeneity; C = Chinese; W = Whites; HTN = hypertension; DM = diabetes; AF = atrial fibrillation; IHD = ischemic heart disease; HC = hypercholesterolemia. Horizontal lines represent 95% CIs. Diamonds represent pooled proportions.

Fig 5. Risk factor meta-analyses for intracerebral hemorrhage versus ischemic stroke in Chinese and white populations.

ICH = intracerebral hemorrhage; IS = ischemic stroke; n = number of patients with risk factor; N = total number of patients; OR = odds ratio; CI = confidence interval; Betw group het = between-group (ethnic) heterogeneity; C = Chinese; W = Whites; HTN = hypertension; DM = diabetes; AF = atrial fibrillation; IHD = ischemic heart disease; HC = hypercholesterolemia. Diamonds represent pooled ORs. Horizontal lines represent 95% CIs.