Sex Differences in Ischemic Stroke Outcomes in Patients with Pulmonary Hypertension

The relationship between systemic hypertension and cerebrovascular disease is well known. Despite pulmonary hypertension (PH) is being recognized as a risk factor for acute ischemic stroke, no study has evaluated the impact of PH on acute ischemic stroke (AIS) outcomes. Tiberiu A. Pana and colleague conducted a study titled “Sex Differences in Ischemic Stroke Outcomes in Patients with Pulmonary Hypertension” published in the journal of the American Heart Association. The summary of this study is given below:

Objective:

To determine the relationship between PH and adverse in-hospital outcomes post-acute ischemic stroke
To investigate whether sex differences affect this association.

Method:

A total of 1,106,045 admissions were included. Data from the US National Inpatient Sample were used for acute ischemic stroke admissions within October 2015 – December 2017. Logistic regressions were used after adjusting for demographics, comorbidities, and revascularization therapies to analyze the relationship between PH and outcomes (prolonged hospitalization >4 days, mortality, and routine home discharge). It also included interaction terms between PH and sex and age groups.

Findings:

The study reports that 76.7% of patients with AIS and PH had chronic lung disease, concomitant left heart disease, or both. These are patients in whom PH is likely secondary to their respiratory or cardiologic comorbidities. Additionally, there was no association between PH and in-hospital mortality. While PH is more prevalent in female patients, male patients with PH experience worse right ventricular function and generally worse outcomes than female patients with PH. As compared to female counterparts, male patients have a shorter life expectancy. Surprisingly, there was a lack of association between PH and AIS mortality. On the other hand, it is reported that even mild elevation in mean pulmonary artery pressure is directly related to adverse mortality outcomes. Furthermore, right ventricular failure and decreased cardiac functional reserve are more likely to develop in patients with PH. Thus, they may be more susceptible to cardiac complications and hemodynamic instability associated with acute stroke.
The study highlights PH as an independent risk factor for long hospitalization periods and discharges disability regardless of sex. Additionally, both genders may still have an overall worse prognosis after AIS. The study also highlights that age is an important factor to examine is the relationship between PH and AIS.

Limitation:

Authors acknowledge that investigators lack information regarding the severity of PH along with the World Health Organization classification of PH. Thus, they were unable to conduct stratification by the severity of PH or cause. Secondly, the study lacked information regarding stroke severity, such as the National Institutes of Health Stroke Scale along with stroke etiological classification. Lastly, there was a lack of medication data.

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