Arthritis is a chronic inflammatory condition commonly associated with mobility restriction and reduced activity. To date, the extent to which arthritis is an independent risk factor for stroke is unclear, and important, in light of an aging population. The purpose of this study was to (i) quantify the cross-sectional association between stroke and arthritis and (ii) to determine whether the relationship differed in physically active and inactivemiddle-aged and older adults. Data was derived from the 2010 Canadian Community Health Survey ( ≥30？y). Multivariable logistic regression was used to estimate the association between arthritis and stroke in models adjusted for age, physical activity (PA), and demographic factors. Overall, individuals with arthritis were 4 times more likely to report a history of stroke ( , 95% CI = 3.06–4.68), whereas those who were engaged in at least moderate PA (≥？1.5？kcal/kg/day) were less than half as likely (0.45, 0.92？0.62). This effect was moderated by age, as younger (30–65？y: 3.27, 2.22–4.83) but not older adults (>65？y: 1.04, 0.8–1.35) with arthritis had elevated odds of stroke. Both physical inactivity and arthritis are associated with higher odds of stroke, effects of which are the strongest amongst 30–65 year olds. 1. Introduction Stroke is a serious medical emergency and is the third leading cause of death in Canada [1]. Amongst the many known stroke risk factors, the INTERSTROKE study [2] identified 10 factors (including hypertension, smoking, alcohol intake, physical activity, diabetes, and cardiac causes) that are associated with 90% of all cases. While the stroke literature is extensive, few studies have examined the relationship of stroke to chronic diseases such as arthritis. Current estimates project that nearly 4 million Canadians are living with arthritis and that, by 2026, this number is expected to increase to over 6 million [3]. Subsequently, the direct and indirect healthcare burden of arthritis is considerable, particularly when estimates of work-related disability are included [4]. Given that older adults represent a large and growing proportion of the Canadian population [5], the issue of complex chronicity, such as the co-occurrence and interrelation of conditions such as arthritis and stroke, must be given greater attention. To date, research on the relationship between stroke and arthritis has been largely derived from studies of cardiovascular mortality [6]. A recent meta-analysis by Meune et al. [7] found that stroke was more commonly seen amongst individuals with rheumatoid arthritis (RA) (OR
References
[1]
Mortality, Summary List of Causes, Statistics Canada, 2009, http://www.statcan.gc.ca/pub/84f0209x/84f0209x2008000-eng.pdf.
[2]
M. J. O'Donnell, D. Xavier, L. Liu et al., “Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study,” The Lancet, vol. 376, no. 9735, pp. 112–123, 2010.
[3]
C. Lagacé, A. Perruccio, M. DesMeules, and E. Badley, “The impact of arthritis on canadians,” in Health Canada. Arthritis in Canada: An Ongoing Challenge, E. M. Badley and M. DesMeules, Eds., vol. 2, pp. 7–34, 2003.
[4]
W. Zhang and A. H. Anis, “The economic burden of rheumatoid arthritis: beyond health care costs,” Clinical Rheumatology, vol. 30, supplement 1, pp. S25–S32, 2011.
[5]
S. O'Donnell, C. Lagacé, L. McRae, and C. Bancej, “Life with arthritis in canada: a personal and public health challenge,” Chronic Diseases in Canada, vol. 31, no. 3, pp. 135–136, 2011.
[6]
L. Lévy, B. Fautrel, T. Barnetche, and T. Schaeverbeke, “Incidence and risk of fatal myocardial infarction and stroke events in rheumatoid arthritis patients. A systematic review of the literature,” Clinical and Experimental Rheumatology, vol. 26, no. 4, pp. 673–679, 2008.
[7]
C. Meune, E. Touzé, L. Trinquart, and Y. Allanore, “High risk of clinical cardiovascular events in rheumatoid arthritis: levels of associations of myocardial infarction and stroke through a systematic review and meta-analysis,” Archives of Cardiovascular Diseases, vol. 103, no. 4, pp. 253–261, 2010.
[8]
A. McEntegart, H. A. Capell, D. Creran, A. Rumley, M. Woodward, and G. D. O. Lowe, “Cardiovascular risk factors, including thrombotic variables, in a population with rheumatoid arthritis,” Rheumatology, vol. 40, no. 6, pp. 640–644, 2001.
[9]
D. H. Solomon, E. W. Karlson, E. B. Rimm et al., “Cardiovascular morbidity and mortality in women diagnosed with rheumatoid arthritis,” Circulation, vol. 107, no. 9, pp. 1303–1307, 2003.
[10]
C. D. Lee, A. R. Folsom, and S. N. Blair, “Physical activity and stroke risk: a meta-analysis,” Stroke, vol. 34, no. 10, pp. 2475–2481, 2003.
[11]
Canadian Community Health Survey—Annual Component (CCHS), Statistics Canada, 2012, http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226.
[12]
Tracking Heart Disease and Stroke in Canada. Public Health Agency of Canada, 2009, http://www.phac-aspc.gc.ca/publicat/2009/cvd-avc/pdf/cvd-avs-2009-eng.pdf.
[13]
M. Hollander, P. J. Koudstaal, M. L. Bots, D. E. Grobbee, A. Hofman, and M. M. B. Breteler, “Incidence, risk, and case fatality of first ever stroke in the elderly population. The Rotterdam Study,” Journal of Neurology Neurosurgery and Psychiatry, vol. 74, no. 3, pp. 317–321, 2003.
[14]
G. Falcone and J. Y. Chong, “Gender differences in stroke among older adults,” Geriatrics and Aging, vol. 10, no. 8, pp. 497–500, 2007.
[15]
Z. Nadareishvili, K. Michaud, J. M. Hallenbeck, and F. Wolfe, “Cardiovascular, rheumatologic, and pharmacologic predictors of stroke in patients with rheumatoid arthritis: a nested, case-control study,” Arthritis Care and Research, vol. 59, no. 8, pp. 1090–1096, 2008.
[16]
D. H. Solomon, N. J. Goodson, J. N. Katz et al., “Patterns of cardiovascular risk in rheumatoid arthritis,” Annals of the Rheumatic Diseases, vol. 65, no. 12, pp. 1608–1612, 2006.
[17]
A. K. Bacani, S. E. Gabriel, C. S. Crowson, J. A. Heit, and E. L. Matteson, “Noncardiac vascular disease in rheumatoid arthritis: increase in venous thromboembolic events?” Arthritis and Rheumatism, vol. 64, no. 1, pp. 53–61, 2012.
[18]
J. Lindhardsen, O. Ahlehoff, G. H. Gislason et al., “Risk of atrial fibrillation and stroke in rheumatoid arthritis: danish nationwide cohort study,” British Medical Journal, vol. 344, Article ID e1257, 2012.
[19]
I. Rincón, K. Williams, M. P. Stern, G. L. Freeman, D. H. O'Leary, and A. Escalantel, “Association between carotid atherosclerosis and markers of inflammation in rheumatoid arthritis patients and healthy subjects,” Arthritis and Rheumatism, vol. 48, no. 7, pp. 1833–1840, 2003.
[20]
F. Wolfe and K. Michaud, “Heart failure in rheumatoid arthritis: rates, predictors, and the effect of anti-tumor necrosis factor therapy,” American Journal of Medicine, vol. 116, no. 5, pp. 305–311, 2004.
[21]
C. L. Roumie, E. F. Mitchel, L. Kaltenbach, P. G. Arbogast, P. Gideon, and M. R. Griffin, “Nonaspirin NSAIDs, cyclooxygenase 2 inhibitors, and the risk for stroke,” Stroke, vol. 39, no. 7, pp. 2037–2045, 2008.
[22]
C. F. Christiansen, S. Christensen, F. Mehnert, S. R. Cummings, R. D. Chapurlat, and H. T. S？rensen, “Glucocorticoid use and risk of atrial fibrillation or flutter: a population-based, case-control study,” Archives of Internal Medicine, vol. 169, no. 18, pp. 1677–1683, 2009.
[23]
C.-H. Chang, W.-Y. Shau, C.-W. Kuo, S.-T. Chen, and M.-S. Lai, “Increased risk of stroke associated with nonsteroidal anti-inflammatory drugs: a nationwide case-crossover study,” Stroke, vol. 41, no. 9, pp. 1884–1890, 2010.
R. L. Sacco, “Identifying patient populations at high risk for stroke,” Neurology, vol. 51, supplement 3, pp. S27–S30, 1998.
[26]
G. Hu, C. Sarti, P. Jousilahti, K. Silventoinen, N. C. Barengo, and J. Tuomilehto, “Leisure time, occupational, and commuting physical activity and the risk of stroke,” Stroke, vol. 36, no. 9, pp. 1994–1999, 2005.
[27]
J. Bolen, L. Murphy, K. Greenlund, et al., “Arthritis as a potential barrier to physical activity among adults with heart disease—United States, 2005 and 2007,” Morbidity and Mortality Weekly Report, vol. 58, no. 7, pp. 165–169, 2009.
[28]
T. Kurth, J. M. Gaziano, K. Berger et al., “Body mass index and the risk of stroke in men,” Archives of Internal Medicine, vol. 162, no. 22, pp. 2557–2562, 2002.
[29]
J.-H. Chen, S.-Y. Chuang, H.-J. Chen, Y. E. H. Wen-Ting, and P. A. N. Wen-Harn, “Serum uric acid level as an independent risk factor for all-cause, cardiovascular, and ischemic stroke mortality: a chinese cohort study,” Arthritis Care and Research, vol. 61, no. 2, pp. 225–232, 2009.
[30]
C. J. Weir, S. W. Muir, M. R. Walters, and K. R. Lees, “Serum urate as an independent predictor of poor outcome and future vascular events after acute stroke,” Stroke, vol. 34, no. 8, pp. 1951–1956, 2003.
[31]
M.-C. Aubry, H. Maradit-Kremers, M. S. Reinalda, C. S. Crowson, W. D. Edwards, and S. E. Gabriel, “Differences in atherosclerotic coronary heart disease between subjects with and without rheumatoid arthritis,” Journal of Rheumatology, vol. 34, no. 5, pp. 937–942, 2007.
[32]
S. V. Ramagopalan, C. J. Wotton, A. E. Handel, D. Yeates, and M. J. Goldacre, “Risk of subarachnoid haemorrhage in people admitted to hospital with selected immune-mediated diseases: record-linkage studies,” BMC Neurology, vol. 13, no. 1, article 176, 2011.
[33]
K. A. Taubert, “Can patients with cardiovascular disease take nonsteroidal antiinflammatory drugs?” Circulation, vol. 117, no. 17, pp. e322–e324, 2008.
[34]
R. Madhok, O. Wu, G. McKellar, and G. Singh, “Non-steroidal anti-inflammatory drugs—changes in prescribing may be warranted,” Rheumatology, vol. 45, no. 12, pp. 1458–1460, 2006.
