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Stroke Risk in Poliomyelitis Survivors: A Nationwide Population-Based Study

      Abstract

      Wu C-H, Liou T-H, Chen H-H, Sun T-Y, Chen K-H, Chang K-H. Stroke risk in poliomyelitis survivors: a nationwide population-based study.

      Objectives

      To assess the prevalence and risk of stroke among adults with polio and controls.

      Design

      A prospective, probability-sampling, 6-year population-based cohort study.

      Setting

      A National Health Insurance Research Database consisting of 316,355 randomly selected enrollees. The database is related to a National Health Insurance program with more than 22 million participants.

      Participants

      After excluding patients under 40 years of age, polio patients (N=212) (mean age ± SD, 54.0±10.2y; 57.1% men) were identified from the database from January 1, 2003 to December 31, 2008. For each polio patient, 2 age- and sex-matched patients were recruited as controls. Control patients did not have any neuromuscular diseases commonly found in childhood. The frequencies of patients with potential risk factors for stroke were assessed.

      Intervention

      None.

      Main Outcome Measure

      The prevalence and the adjusted odds ratio of ischemic stroke among polio patients and the controls were estimated.

      Results

      Polio patients had a higher prevalence of stroke (10.8% vs 2.4%, P<.001) than the controls. Polio patients with hypertension had a much higher prevalence of stroke (23.0%). The risk of stroke was higher for polio patients compared with the controls, yielding an adjusted odds ratio of 4.17 (95% confidence interval, 1.84–9.45, P<.001). Polio was a significant risk factor for stroke independent from hypertension, diabetes mellitus, hyperlipidemia, and cardiac diseases.

      Conclusions

      Adults with polio had a high prevalence of ischemic stroke. Polio was an additional risk factor for stroke. Polio patients with hypertension might potentiate the risk of stroke. Developing a health promotion program, suitable for polio patients, to increase participation in activities and exercises may be essential, especially for polio patients with hypertension.

      Key Words

      List of Abbreviations:

      CVD (cardiovascular disease), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), NHI (National Health Insurance), NHIRD (National Health Insurance Research Database)
      STROKE IS A MAJOR CAUSE of adult disability worldwide.
      • Donnan G.A.
      • Fisher M.
      • Macleod M.
      • Davis S.M.
      Stroke.
      Differing in other cardiovascular disease (CVD) victims, stroke patients are often left with some neurologic impairments, such as altered consciousness or cognition, motor weakness or incoordination, sensory impairment, and sphincter dysfunction. All or part of these distinctive features can make stroke patients dependent on activities of daily living. One third of the stroke patients or half of the stroke survivors thus have a major disability in their life after stroke.
      • Grysiewicz R.A.
      • Thomas K.
      • Pandey D.K.
      Epidemiology of ischemic and hemorrhagic stroke: incidence, prevalence, mortality, and risk factors.
      Being restrained from participating in physical exercise, adults who are disabled since childhood are more likely to have premature CVDs. Adults with previous poliomyelitis (polio) tend to experience hypertension and coronary heart disease,
      • Nielsen N.
      • Rostgaard K.
      • Askgaard D.
      • Skinhøj P.
      • Aaby P.
      Life-long morbidity among Danes with poliomyelitis.
      • Gawne A.C.
      • Wells K.R.
      • Wilson K.S.
      Cardiac risk factors in polio survivors.
      and the mean ages of polio patients studied in those published articles were younger than 65 years. To our knowledge, articles in the literature describing stroke in polio survivors were scarce. This issue might be important because the combined loss of function in stroke patients with preexisting polio might mutually potentiate rather than simply add up each individual functional loss and could further compromise their participation in activities of daily living.
      Polio was a common cause of physical disability in children in Taiwan in the 1950s and 1960s. Most polio patients are now 50 years or older. The prevalence of polio was estimated to be 1.17 to 1.63 per 1000 patients in Taipei.
      • Chen C.J.
      • Wang L.J.
      • Tay S.C.
      • Lim C.B.
      • Chang C.C.
      • Wang K.F.
      Prevalence of poliomyelitis among Taipei City school children.
      In Taiwan, polio patients often experienced the onset of polio before the age of 3 years. Most survivors had the spinal form of polio with muscular atrophy and weakness of the legs.
      • Chang C.W.
      • Huang S.F.
      Varied clinical patterns, physical activities, muscle enzymes, electromyographic and histologic findings in patients with post-polio syndrome in Taiwan.
      Many of them had a job and lived a life of mild to moderate level of physical activity.
      • Tsai H.C.
      • Hung T.H.
      • Chen C.C.
      • et al.
      Prevalence and risk factors for upper extremity entrapment neuropathies in polio survivors.
      One third of ambulatory men with polio had regular exercise weekly.
      • Chang K.H.
      • Lai C.H.
      • Chen S.C.
      • et al.
      Femoral neck bone mineral density in ambulatory men with poliomyelitis.
      We hypothesized that adults with previous polio would be more likely to have stroke. To conduct a nationwide sampling study, the Taiwan National Health Insurance Research Database (NHIRD) was used to test our hypothesis. The aims of this study were to assess the prevalence and risk of stroke among adults with polio and age- and sex-matched controls.

      Methods

      Taiwan NHIRD

      The National Health Insurance (NHI) program is a mandatory comprehensive medical care program with more than 22 million (99% of Taiwan's population) participants. One million enrollees in the NHI program in Taiwan in the year 2005 were randomly selected into the NHIRD (fig 1).
      National Health Insurance Research Database Data subsets.
      Every person in Taiwan has an equal chance to be sampled into the database. All of the health record data, including longitudinal medical claims for each selected enrollee, from January 1, 2003 to December 31, 2008, were compiled. The NHIRD thus consists of all the information on diagnosis and medical service, including ambulatory care and hospital inpatient care, of 1 million randomly selected enrollees for 6 years. For public purchase, data of those 1 million enrollees was equally divided into 25 data subsets with random numbers. Therefore, every data subset contains 40,000 enrollees' medical information from January 1, 2003 to December 31, 2008. With 8 data subsets of the Taiwan NHIRD, a nationwide population-based cohort study was conducted to evaluate the prevalence of ischemic stroke among adults with previous polio.
      Figure thumbnail gr1
      Fig 1Summary of the construction of the Taiwan NHIRD and the processes of recruitment of polio and control patients in the study.

      Selections of Participants

      Data of 316,355 patients of those 8 data subsets randomly selected from the Taiwan NHIRD from January 1, 2003 to December 31, 2008 were used in this study (see fig 1). Personal identification data of the NHIRD were delinked information for public purchase. Therefore, this study was exempt from full review by the institutional review board. The data of the patients with previous polio, including an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 138,
      Centers for Disease Control and Prevention
      International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).
      were extracted from those 8 data subsets of the NHIRD with an electronic search. For each patient with polio (polio group), 2 age- and sex-matched patients were recruited as controls (control group). The birthday of each control patient was no more than 7 days of age before or after that of the matched polio patient. Control patients did not have cerebral palsy, intellectual disability, and any other neuromuscular diseases commonly found in childhood. Starting from January 1, 2003 forward, a research assistant searched manually and selected the 2 matched patients first met in the database into the control group. These data, other than sex and birthday of each control patient, were not examined in the recruitment processes. For each polio patient, the searching processes stopped when the 2 matched control patients had been met. The date of each participant's first medical claim in the database was used to calculate his or her age using the formula: (the date of having first medical claim – birthday)/365. Excluded were those under 40 years of age.
      Patients who had had an ischemic stroke (ICD-9-CM code of 433 or 434)
      • Wu C.H.
      • Liou T.H.
      • Hsiao P.L.
      • Lin Y.C.
      • Chang K.H.
      Contribution of ischemic stroke to hip fracture risk and the influence of gender difference.
      in both the polio and control groups were identified. For each patient, the end date of the study coincided with the recorded date of stroke in the database. For patients without a stroke during the study period, the end date of the study for both groups was December 31, 2008. The frequencies of patients with risk factors for stroke,
      • Grysiewicz R.A.
      • Thomas K.
      • Pandey D.K.
      Epidemiology of ischemic and hemorrhagic stroke: incidence, prevalence, mortality, and risk factors.
      • Kelly-Hayes M.
      Influence of age and health behaviors on stroke risk: lessons from longitudinal studies.
      including hypertension (ICD-9-CM codes of 401-402), diabetes mellitus (250), hyperlipidemia (272), gout (274), atrial fibrillation (427.31),
      • Iwahana H.
      • Ishikawa S.
      • Ishikawa J.
      • et al.
      Atrial fibrillation is a major risk factor for stroke, especially in women: the Jichi medical school cohort study.
      myocardial infarction (410, 412), valvular heart disease (394-398), bronchitis (490-491),
      • Grau A.J.
      • Preusch M.R.
      • Palm F.
      • Lichy C.
      • Becher H.
      • Buggle F.
      Association of symptoms of chronic bronchitis and frequent flu-like illnesses with stroke.
      periodontal disease (523),
      • Pradeep A.R.
      • Hadge P.
      • Arjun Raju P.
      • Shetty S.R.
      • Shareef K.
      • Guruprasad C.N.
      Periodontitis as a risk factor for cerebrovascular accident: a case-control study in the Indian population.
      • Wu T.
      • Trevisan M.
      • Genco R.J.
      • Dorn J.P.
      • Falkner K.L.
      • Sempos C.T.
      Periodontal disease and risk of cerebrovascular disease: the first national health and nutrition examination survey and its follow-up study.
      and obesity (278)
      • Suk S.H.
      • Sacco R.L.
      • Boden-Albala B.
      • et al.
      Abdominal obesity and risk of ischemic stroke: the Northern Manhattan Stroke Study.
      were calculated. Stroke severity was assessed with the frequencies of the common complications after stroke,
      • Chung D.M.
      • Niewczyk P.
      • DiVita M.
      • Markello S.
      • Granger C.
      Predictors of discharge to acute care after inpatient rehabilitation in severely affected stroke patients.
      including dysphagia (787.2), speech disturbance (784.5), visual field defects (368.4), neurologic neglect syndrome (781.8), abnormality of gait (781.2), and hemiplegia (342.9).

      Data Analyses

      The differences in clinical characteristics between the polio and control groups were compared with a Pearson chi-square test or a Fisher exact test. Logistic regression analyses with enter method were used to assess potential risk factors of having stroke. Those variables found to have significant association with stroke in the univariate analyses were entered into the model with a stepwise method. The data were analyzed with SAS software version 9.1.a The differences between the 2 groups were considered significant if P values were smaller than .05.

      Results

      A random sample of 212 polio patients (mean age ± SD, 54.0±10.2y; 57.1% men) between January 1, 2003 and December 31, 2008 were identified from the 8 data subsets (including 316,355 randomly selected patients) of the Taiwan NHIRD. The control group (n=424) had the same distribution of age and sex as the polio group. Table 1 compares the clinical characteristics of patients with polio and the matched controls. Polio patients experienced more frequencies of stroke (10.8% vs 2.4%, χ2=20.71, P<.001) and hypertension (χ2=14.06, P<.001) than the controls.
      Table 1Comparison of Clinical Characteristics Between Patients With Poliomyelitis and the Matched Controls
      VariablesPoliomyelitis (n=212)Matched Control (n=424)
      Ischemic stroke23 (10.8)
      P<.001 (vs controls; Pearson chi-square test).
      10 (2.4)
      Hypertension87 (41.0)
      P<.001 (vs controls; Pearson chi-square test).
      112 (26.4)
      Diabetes mellitus43 (20.3)65 (15.3)
      Hyperlipidemia69 (32.5)110 (25.9)
      Gout29 (13.7)76 (17.9)
      Atrial fibrillation5 (2.4)5 (1.2)
      Myocardial infarction10 (4.7)12 (2.8)
      Valvular heart disease9 (4.2)9 (2.1)
      Bronchitis59 (27.8)
      P<.001 (vs controls; Pearson chi-square test).
      68 (16.0)
      Periodontal disease147 (69.3)290 (68.4)
      Obesity1 (0.5)0 (0)
      NOTE. Values are number (%).
      low asterisk P<.001 (vs controls; Pearson chi-square test).
      Hemiplegia (n=3), dysphagia (n=1), and speech disturbance (n=1) were found only in polio patients having stroke. Moreover, polio patients with hypertension had much higher prevalence of stroke (20 of 87) than the controls (6 of 112) with hypertension (23.0% vs 5.4%) (fig 2). The prevalence for those without hypertension in both the polio (3 of 125) and control (4 of 312) groups (2.4% vs 1.3%) were not significantly different (Fisher exact test, P=.414). The hypertensive to normotensive ratio of the prevalence of stroke was 9.58 for polio patients and 4.19 for controls (χ2=16.90, P<.001).
      Figure thumbnail gr2
      Fig 2Comparison of the prevalence of ischemic stroke among polio and control patients with and without hypertension. The prevalence of stroke for polio with hypertension was 4-fold that of controls with hypertension (χ2=13.40, P<.001), 10-fold that of polio without hypertension (χ2=22.48, P<.001), and 18-fold that of controls without hypertension. *P<.05 (Fisher exact test), ***P<.001 (Pearson χ2 test).
      Using univariate analyses, the associations between each clinical characteristic and stroke were shown in table 2. Table 2 is constructed by the simple logistic regression for each individual variable. Table 3 is the results of the stepwise method for model building. We have poliomyelitis, hypertension, atrial fibrillation, and myocardial infarction in the final model. The risk of stroke was higher for polio patients compared with controls, yielding an adjusted odds ratio of 4.17 (95% confidence interval, 1.84–9.45, P<.001) (see table 3). The logistic regression model had a good fit (Hosmer-Lemeshow test, χ2=2.22, P=.33). The interaction of hypertension by polio was not significant (β=1.02, P=.263) after adding it into the logistic regression model. The interaction of atrial fibrillation by polio was also insignificant (β=41.05, P=.999).
      Table 2Univariate Analyses of Risk Factors for Stroke
      VariablesIschemic StrokeOdds Ratio (95% confidence interval)
      Yes (n=33)No (n=603)
      Male sex19 (57.6)344 (57.0)1.02 (0.50–2.08)
      Poliomyelitis23 (69.7)
      P<.001;
      189 (31.3)5.04 (2.35–10.80)
      Hypertension26 (78.8)
      P<.001;
      173 (28.7)9.23 (3.93–21.67)
      Diabetes mellitus14 (42.4)
      P<.001;
      94 (15.6)3.99 (1.93–8.23)
      Hyperlipidemia17 (51.5)
      P<.01. (vs patients without stroke; Pearson chi-square test).
      162 (26.9)2.89 (1.43–5.86)
      Gout8 (24.2)97 (16.1)1.67 (0.73–3.81)
      Atrial fibrillation5 (15.2)
      P<.001;
      5 (0.8)21.36 (5.84–78.07)
      Myocardial infarction7 (21.2)
      P<.001;
      15 (2.5)10.55 (3.96–28.10)
      Valvular heart disease4 (12.1)
      P<.001;
      14 (2.3)5.80 (1.80–18.74)
      Bronchitis9 (27.3)118 (19.6)1.54 (0.70–3.40)
      Periodontal disease18 (54.5)419 (69.5)0.53 (0.26–1.07)
      Obesity0 (0)1 (0.2)0.99 (0.99–1.00)
      NOTE. Values are number (%) or as otherwise indicated.
      low asterisk P<.001;
      P<.01. (vs patients without stroke; Pearson chi-square test).
      Table 3Logistic Regression Analysis
      Variables entered included diabetes mellitus, hyperlipidemia, and valvular heart disease.
      of Potential Risk Factors of Ischemic Stroke for Patients Over Age 40 (n=636)
      Variable, Valueβ ± SE
      Standardized regression coefficient ± standard error.
      WaldAdjusted Odds Ratio (95% confidence interval)
      Poliomyelitis, yes
      Categorical variables (yes=1, no=0).
      1.43±0.42
      P<.001;
      11.694.17 (1.84–9.45)
      Hypertension, yes1.80±0.45
      P<.001;
      15.846.07 (2.50–14.77)
      Atrial fibrillation, yes2.13±0.82
      P<.005;
      6.728.39 (1.68–41.94)
      Myocardial infarction, yes1.35±0.62
      P<.05.
      4.803.86 (1.15–12.93)
      NOTE. Hosmer-Lemeshow test for goodness of fit, χ2=2.22, P=.33.
      low asterisk Variables entered included diabetes mellitus, hyperlipidemia, and valvular heart disease.
      Standardized regression coefficient ± standard error.
      Categorical variables (yes=1, no=0).
      § P<.001;
      P<.005;
      P<.05.

      Discussion

      With this probability sampling database, we found that polio patients had a higher prevalence and an excess risk of experiencing stroke than the age- and sex-matched controls. Polio was a significant risk factor for stroke, independent of hypertension, diabetes mellitus, hyperlipidemia, and cardiac diseases. In addition, polio patients with hypertension might potentiate the risk of stroke.
      Compared with the prevalence range of stroke of 1.3% to 2.6% among American Asians from 2003 to 2008,
      • Thom T.
      • Haase N.
      • Rosamond W.
      • et al.
      Heart disease and stroke statistics–2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Rosamond W.
      • Flegal K.
      • Friday G.
      • et al.
      Heart disease and stroke statistics–2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Rosamond W.
      • Flegal K.
      • Furie K.
      • et al.
      Heart disease and stroke statistics–2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Lloyd-Jones D.
      • Adams R.
      • Carnethon M.
      • et al.
      Heart disease and stroke statistics–2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Lloyd-Jones D.
      • Adams R.J.
      • Brown T.M.
      • et al.
      Heart disease and stroke statistics–2010 update: a report from the American Heart Association.
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics–2011 update: a report from the American Heart Association.
      we found that our control patients had a similar prevalence (see table 1). All these figures were lower than the prevalence of stroke of 10.8% among polio patients in this study. The occurrence of stroke in polio survivors may result in an additional loss of arm function, which is often normal in polio survivors in Taiwan,
      • Chang C.W.
      • Huang S.F.
      Varied clinical patterns, physical activities, muscle enzymes, electromyographic and histologic findings in patients with post-polio syndrome in Taiwan.
      and leads to difficulty in walking with crutches. Besides, ambulatory function after stroke is related to leg strength and lean tissue mass,
      • Patterson S.L.
      • Forrester L.W.
      • Rodgers M.M.
      • et al.
      Determinants of walking function after stroke: differences by deficit severity.
      both of which are decreased among polio patients.
      • Chang C.W.
      • Huang S.F.
      Varied clinical patterns, physical activities, muscle enzymes, electromyographic and histologic findings in patients with post-polio syndrome in Taiwan.
      • Chang K.H.
      • Lai C.H.
      • Chen S.C.
      • Hsiao W.T.
      • Liou T.H.
      • Lee C.M.
      Body composition assessment in Taiwanese individuals with poliomyelitis.
      Thus, polio survivors with a stroke might have an unfavorable walking outcome.
      Being that the mean age of our polio participants was 54.0 years, the finding that 10.8% of these younger polio patients had a stroke may suggest that stroke developed early among polio patients. In addition, polio patients had an excess risk for stroke independent from hypertension (see table 3). Polio patients with hypertension had a much higher prevalence of stroke (see fig 2). The combined effect of preexisting polio and having hypertension on the risk of stroke thus might potentiate rather than add up each individual risk factor for stroke.
      Obesity is common among persons with physical disability,
      • McGuire L.C.
      • Strine T.W.
      • Okoro C.A.
      • Ahluwalia I.B.
      • Ford E.S.
      Healthy lifestyle behaviors among older U.S. adults with and without disabilities, Behavioral Risk Factor Surveillance System, 2003.
      • Fitzmaurice C.
      • Kanarek N.
      • Fitzgerald S.
      Primary prevention among working age USA adults with and without disabilities.
      and is highly related to an increase in the prevalence of having metabolic syndrome and CVDs.
      • Guh D.P.
      • Zhang W.
      • Bansback N.
      • Amarsi Z.
      • Birmingham C.L.
      • Anis A.H.
      The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis.
      • Flegal K.M.
      • Graubard B.I.
      • Williamson D.F.
      • Gail M.H.
      Cause-specific excess deaths associated with underweight, overweight, and obesity.
      • Grundy S.M.
      Obesity, metabolic syndrome, and coronary atherosclerosis.
      Polio patients also have a high prevalence of obesity.
      • Chang K.H.
      • Lai C.H.
      • Chen S.C.
      • Hsiao W.T.
      • Liou T.H.
      • Lee C.M.
      Body composition assessment in Taiwanese individuals with poliomyelitis.
      Because obesity is a risk factor for ischemic stroke in the general population,
      • Suk S.H.
      • Sacco R.L.
      • Boden-Albala B.
      • et al.
      Abdominal obesity and risk of ischemic stroke: the Northern Manhattan Stroke Study.
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics–2011 update: a report from the American Heart Association.
      obesity may also be an important risk factor for stroke among polio patients. In contrast, the frequency of CVDs as a factor does not increase among adults with cerebral palsy.
      • Liptak G.S.
      Health and well being of adults with cerebral palsy.
      Bax et al
      • Bax M.C.
      • Smyth D.P.
      • Thomas A.P.
      Health care of physically handicapped young adults.
      reported that less than 5% of adults with cerebral palsy are obese and more than 15% of them are underweight. This anthropometric feature may be one of the reasons why adults with cerebral palsy do not have an increased prevalence of CVDs,
      • Wang K.Y.
      • Hsieh K.
      • Heller T.
      • Davidson P.W.
      • Janicki M.P.
      Carer reports of health status among adults with intellectual/developmental disabilities in Taiwan living at home and in institutions.
      as seen in adults with polio.
      • Gawne A.C.
      • Wells K.R.
      • Wilson K.S.
      Cardiac risk factors in polio survivors.
      Therefore, an active program, suitable for polio patients, in order to increase participation in physical exercise and to reduce body weight, might be clinically important in preventing stroke among polio patients.

      Study Limitations

      This study has 3 limitations. First, the ICD-9-CM coding may be inaccurate when using the existing data from a large database such as NHIRD. But the Taiwan NHIRD is constructed of medical claims for payment in the NHI program. The authority of the NHI program audits those medical claims regularly. Therefore, the data accuracy of the Taiwan NHIRD might be acceptable. However, the coding not related to medical claims, such as the coding for disease severity, might be lacking under the fee-for-service payment mode in the NHI program. Second, probably because the medical service for obesity is not fully covered by the NHI program, obesity might not be well recognized in this study database. Those patients with lifestyle-related risk factors for stroke, such as smoking, physical inactivity, and an unhealthy diet, could not be recognized either. But the frequency of hypertension, diabetes mellitus, and hyperlipidemia is often influenced by those lifestyle-related factors. The associations between stroke and each clinical characteristic of hypertension, diabetes mellitus, and hyperlipidemia were analyzed in this study. Further studies are needed to evaluate the contribution of obesity and lifestyle-related factors to stroke among polio patients. And third, the genetic factor may account for up to 40% of the risk for stroke,
      • Donnan G.A.
      • Fisher M.
      • Macleod M.
      • Davis S.M.
      Stroke.
      and the prevalence for stroke varies greatly in the general population between countries.
      • Feigin V.L.
      • Lawes C.M.
      • Bennett D.A.
      • Anderson C.S.
      Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century.
      The prevalence of stroke of 2.4% among our control patients was close to the range of 1.3% to 2.6% among American Asians from 2003 to 2008.
      • Thom T.
      • Haase N.
      • Rosamond W.
      • et al.
      Heart disease and stroke statistics–2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Rosamond W.
      • Flegal K.
      • Friday G.
      • et al.
      Heart disease and stroke statistics–2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Rosamond W.
      • Flegal K.
      • Furie K.
      • et al.
      Heart disease and stroke statistics–2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Lloyd-Jones D.
      • Adams R.
      • Carnethon M.
      • et al.
      Heart disease and stroke statistics–2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.
      • Lloyd-Jones D.
      • Adams R.J.
      • Brown T.M.
      • et al.
      Heart disease and stroke statistics–2010 update: a report from the American Heart Association.
      • Roger V.L.
      • Go A.S.
      • Lloyd-Jones D.M.
      • et al.
      Heart disease and stroke statistics–2011 update: a report from the American Heart Association.
      But to use the findings of this study globally, the influence of racial and socioeconomic differences on the occurrence of stroke needs to be evaluated.

      Conclusions

      Adults with polio had high prevalence of ischemic stroke. Polio was an additional risk factor for stroke, independent of hypertension. Therefore, developing a health promotion program, suitable for polio patients, in order to increase participation in activities and exercises may be essential, especially for polio patients with hypertension.
      • a
        SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513.

      Acknowledgment

      We thank Professor Winston W. Shen, MD for valuable editing comments on an earlier version of this manuscript.

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