Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke

Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis

Raphae S. Barlas, Katie Honney, Yoon K. Loke, Stephen J. McCall, Joao H. Bettencourt-Silva, Allan B. Clark, Kristian M. Bowles, Anthony K. Metcalf, Mamas A. Mamas, John F. Potter, Phyo K. Myint

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Abstract

Background - The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence.

Methods and Results - We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57–2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23–1.74]).

Conclusions - Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.
Original languageEnglish
Article numbere003019
Pages (from-to)1-17
Number of pages17
JournalJournal of the American Heart Association
Volume5
Issue number8
DOIs
Publication statusPublished - 17 Aug 2016

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Registries
Anemia
Hemoglobins
Stroke
Mortality
Odds Ratio
Population
Cohort Studies
Databases

Keywords

  • hemoglobin
  • mortality
  • prognosis
  • stroke

Cite this

Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke : Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis. / Barlas, Raphae S.; Honney, Katie; Loke, Yoon K.; McCall, Stephen J.; Bettencourt-Silva, Joao H.; Clark, Allan B.; Bowles, Kristian M.; Metcalf, Anthony K.; Mamas, Mamas A.; Potter, John F.; Myint, Phyo K.

In: Journal of the American Heart Association, Vol. 5, No. 8, e003019, 17.08.2016, p. 1-17.

Research output: Contribution to journalArticle

Barlas, RS, Honney, K, Loke, YK, McCall, SJ, Bettencourt-Silva, JH, Clark, AB, Bowles, KM, Metcalf, AK, Mamas, MA, Potter, JF & Myint, PK 2016, 'Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke: Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis', Journal of the American Heart Association, vol. 5, no. 8, e003019, pp. 1-17. https://doi.org/10.1161/JAHA.115.003019
Barlas, Raphae S. ; Honney, Katie ; Loke, Yoon K. ; McCall, Stephen J. ; Bettencourt-Silva, Joao H. ; Clark, Allan B. ; Bowles, Kristian M. ; Metcalf, Anthony K. ; Mamas, Mamas A. ; Potter, John F. ; Myint, Phyo K. / Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke : Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis. In: Journal of the American Heart Association. 2016 ; Vol. 5, No. 8. pp. 1-17.
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abstract = "Background - The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence.Methods and Results - We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5{\%} of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95{\%} CI 1.57–2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95{\%} CI 1.23–1.74]).Conclusions - Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.",
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note = "Acknowledgments We thank the stroke data team for their contribution to maintain the Norfolk and Norwich University Hospital stroke & transient ischemic attack registers. Sources of Funding The Norfolk and Norwich University Hospital Stroke and Transient Ischemic Attack Register is maintained by the Norfolk and Norwich University Hospital National Health Service Foundation Trust Stroke Services and data management for this study is supported by the Norfolk and Norwich University Hospital Research and Development Department through Research Capability Funds.",
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TY - JOUR

T1 - Impact of Hemoglobin Levels and Anemia on Mortality in Acute Stroke

T2 - Analysis of UK Regional Registry Data, Systematic Review, and Meta‐Analysis

AU - Barlas, Raphae S.

AU - Honney, Katie

AU - Loke, Yoon K.

AU - McCall, Stephen J.

AU - Bettencourt-Silva, Joao H.

AU - Clark, Allan B.

AU - Bowles, Kristian M.

AU - Metcalf, Anthony K.

AU - Mamas, Mamas A.

AU - Potter, John F.

AU - Myint, Phyo K.

N1 - Acknowledgments We thank the stroke data team for their contribution to maintain the Norfolk and Norwich University Hospital stroke & transient ischemic attack registers. Sources of Funding The Norfolk and Norwich University Hospital Stroke and Transient Ischemic Attack Register is maintained by the Norfolk and Norwich University Hospital National Health Service Foundation Trust Stroke Services and data management for this study is supported by the Norfolk and Norwich University Hospital Research and Development Department through Research Capability Funds.

PY - 2016/8/17

Y1 - 2016/8/17

N2 - Background - The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence.Methods and Results - We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57–2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23–1.74]).Conclusions - Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.

AB - Background - The impact of hemoglobin levels and anemia on stroke mortality remains controversial. We aimed to systematically assess this association and quantify the evidence.Methods and Results - We analyzed data from a cohort of 8013 stroke patients (mean±SD, 77.81±11.83 years) consecutively admitted over 11 years (January 2003 to May 2015) using a UK Regional Stroke Register. The impact of hemoglobin levels and anemia on mortality was assessed by sex‐specific values at different time points (7 and 14 days; 1, 3, and 6 months; 1 year) using multiple regression models controlling for confounders. Anemia was present in 24.5% of the cohort on admission and was associated with increased odds of mortality at most of the time points examined up to 1 year following stroke. The association was less consistent for men with hemorrhagic stroke. Elevated hemoglobin was also associated with increased mortality, mainly within the first month. We then conducted a systematic review using the Embase and Medline databases. Twenty studies met the inclusion criteria. When combined with the cohort from the current study, the pooled population had 29 943 patients with stroke. The evidence base was quantified in a meta‐analysis. Anemia on admission was found to be associated with an increased risk of mortality in both ischemic stroke (8 studies; odds ratio 1.97 [95% CI 1.57–2.47]) and hemorrhagic stroke (4 studies; odds ratio 1.46 [95% CI 1.23–1.74]).Conclusions - Strong evidence suggests that patients with anemia have increased mortality with stroke. Targeted interventions in this patient population may improve outcomes and require further evaluation.

KW - hemoglobin

KW - mortality

KW - prognosis

KW - stroke

U2 - 10.1161/JAHA.115.003019

DO - 10.1161/JAHA.115.003019

M3 - Article

VL - 5

SP - 1

EP - 17

JO - Journal of the American Heart Association

JF - Journal of the American Heart Association

SN - 2047-9980

IS - 8

M1 - e003019

ER -