Chronic high-altitude exposure and the epidemiology of ischaemic stroke: a systematic review

Abstract

Introduction: About 5.7% of the world population resides above 1500 m. It has been hypothesised that acute exposure to high-altitude locations can increase stroke risk, while chronic hypoxia can reduce stroke-related mortality.

Objective: This review aims to provide an overview of the available evidence on the association between long-term high-altitude exposure and ischaemic stroke.

Design: A systematic review was performed from 1 January 1960 to 1 December 2021 to assess the possible link between high-altitude exposure and ischaemic stroke. The AMED, EMBASE, Cochrane Library, PubMed, MEDLINE, the Europe PubMed Central and the Latin-American bibliographic database Scielo were accessed using the University of Southampton library tool Delphis. In this review, we included population and individual-based observational studies, including cross-sectional and longitudinal studies except for those merely descriptive individual-based case reports. Studies were limited to humans living or visiting high-altitude locations for at least 28 days as a cut-off point for chronic exposure.

Results: We reviewed a total of 1890 abstracts retrieved during the first step of the literature review process. The authors acquired in full text as potentially relevant 204 studies. Only 17 documents met the inclusion criteria and were finally included. Ten studies clearly suggest that living at high altitudes may be associated with an increased risk of stroke; however, five studies suggest that altitude may act as a protective factor for the development of stroke, while two studies report ambiguous results.

Conclusions: This review suggests that the most robust studies are more likely to find that prolonged living at higher altitudes reduces the risk of developing stroke or dying from it. Increased irrigation due to angiogenesis and increased vascular perfusion might be the reason behind improved survival profiles among those living within this altitude range. In contrast, residing above 3500 m seems to be associated with an apparent increased risk of developing stroke, probably linked to the presence of polycythaemia and other associated factors such as increased blood viscosity.

Keywords: angiogenesis; high altitude; hypoxia; review; stroke; thrombosis.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) chart diagram for reporting literature review search and meta-analysis.

Figure 2

Proposed mechanisms and hypothesised physiopathology at low altitude (<2500 m), high altitude (2500–3500 m) and very high altitude (>3500 m). O₂ is the oxygen availability in relationship to sea level. FiO₂: angiogenesis occurs at different elevations above sea level but during the hypoxic beneficial window, polycythaemia and red cell as well as platelet adhesiveness are not significant as above 3500 m, thus the protective effect reaches its maximum. Above 3500 m, although angiogenesis is present, the significantly high haematocrit and polycythaemia increase the risk of blood stasis and thrombogenesis. BP, barometric pressure.