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Original Investigation
February 24, 2020

Association of Black Race With Early Recurrence After Minor Ischemic Stroke or Transient Ischemic Attack: Secondary Analysis of the POINT Randomized Clinical Trial

Author Affiliations
  • 1Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
  • 2Deputy Editor, JAMA Neurology
  • 3Department of Neurology, University of Cincinnati, Ohio
  • 4Department of Epidemiology, University of Alabama at Birmingham, Birmingham
  • 5Department of Biostatistics, University of Alabama at Birmingham, Birmingham
  • 6Epidemiological Cardiology Research Center, Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 7Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 8Department of Internal Medicine–Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 9Dell Medical School, Dean’s Office, University of Texas at Austin, Austin
JAMA Neurol. Published online February 24, 2020. doi:10.1001/jamaneurol.2020.0010
Key Points

Question  Do black patients in the United States face a higher risk of early ischemic stroke recurrence?

Findings  In this cohort study of 4044 US participants in the Platelet-Oriented Inhibition in New Transient Ischemic Attack or Minor Ischemic Stroke trial, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race.

Meaning  Among US participants in a randomized clinical trial focused on secondary prevention after minor ischemic stroke or transient ischemic attack, black individuals faced a higher risk of early ischemic stroke recurrence, even after adjustment for demographics, comorbidities, and medication adherence.

Abstract

Importance  Stroke incidence is higher among black than white individuals in the United States. It is unclear whether black individuals have a higher risk of stroke recurrence after a minor ischemic stroke or transient ischemic attack (TIA), a high-risk setting in which focused preventive efforts can be effective.

Objective  To examine the association between black race and early ischemic stroke recurrence.

Design, Setting, and Participants  This cohort study analyzed data from the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial conducted at 269 sites from May 28, 2010, to December 19, 2017. The trial enrolled 4881 adults within 12 hours of onset of a minor ischemic stroke (National Institutes of Health Stroke Scale score, 0-3) or high-risk TIA (ABCD2 score, ≥4). For this analysis, we excluded 598 patients enrolled outside the United States and 239 US patients with missing race/ethnicity data.

Main Outcomes and Measures  The primary outcome for this analysis was ischemic stroke within 90 days after randomization. Covariates included age, sex, Hispanic ethnicity, study assignment to take clopidogrel vs placebo, index stroke vs TIA, vascular risk factors, statin use, study drug adherence, and index event etiological subtype.

Results  Among 4044 patients included in the analysis, 918 (22.7%) were black. In an adjusted Cox model, black race was associated with a higher risk of recurrence compared with white race (hazard ratio, 1.6; 95% CI, 1.1-2.3). Findings were similar in subgroup analyses and in analyses limited to sites that enrolled black patients.

Conclusions and Relevance  Among US participants in the POINT trial, black individuals faced a higher risk of early stroke recurrence after a minor ischemic stroke or TIA. Our findings support research into black-white racial differences in the underlying mechanisms of recurrent stroke. In the meantime, extra effort should be made to ensure that black patients have access to proven secondary prevention measures.

Trial Registration  clinicaltrials.gov Identifier: NCT00991029

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