BNR - Cardiovascular Disease Report

List of Tables

Table 1.1. Summary statistics for the Barbados National Registry for Chronic Non- communicable Disease (the BNR) in 2020 (Population, 287,371)......................................................................................................7

Table 1.2. Trends in age-standardised incidence rates of men and women with acute MI or sudden cardiac death by year in Barbados, 2011 - 2020 11

Table 1.3. Main presenting symptoms for acute MI patients in Barbados, Jan–Dec 2020 (N=291) ..........13

Table 1.4. Prevalence of known risk factors among hospitalised acute MI patients, 2020(N=311) ..........14

Table 1.5. Mortality statistics for MI patients in Barbados, 2011-2020 15

Table 1.6. Number of STEMI cases and proportion reperfused by gender ...............................................17

Table 1.7. ‘Door to needle’ times for hospitalized patients .......................................................................18

Table 1.8. Proportion of patients receiving echocardiogram, 2020 ...........................................................19

Table 1.9. Proportion of patients receiving antithrombotic therapy at discharge 19

Table 2.1 Age-standardised incidence and mortality rates of stroke per 100,000 population by gender, Barbados .....................................................................................................................................................22

Table 2.2. Stroke subtypes in Barbados, 2018, 2019 & 2020 (N=550, N=622 & N=563 respectively) 24

Stroke Category...........................................................................................................................................24

Table 2.3. Main presenting symptoms for stroke patients in Barbados, Jan–Dec 2020 (N=563) ..............24

Table 2.4. Prevalence of known risk factors among hospitalised stroke patients, 2020 (N=622) 25

Table 2.5. Mortality statistics for stroke patients in Barbados, 2011-2020 26

Table 2.6. Proportion of persons with acute ischaemic events receiving anti- thrombotic therapy by year 28

Table 2.7. Proportion of ischaemic stroke cases receiving appropriate medications at discharge 28

List of Figures

Figure 1.1. Number of men and women with acute MI by year in Barbados. 2011 - 2020 9

Figure 1.2. Crude incidence rate of men and women per 100,000 population with acute MI by year in Barbados. 2011 - 2020 ................................................................................................................................10

Figure 1.3. Trends in age-standardised incidence rates of men and women with acute MI or sudden cardiac death by year in Barbados, 2011 - 2020.........................................................................................11

Figure 1.4a. Age and gender stratified incidence rate per 100,000 population of acute MI, Barbados, 2020 (N=547) 12

Figure 1.4b. Age and gender stratified incidence rate per 100,000 population of acute MI, Barbados, 2019 (N=547) ..............................................................................................................................................12

Figure 1.5. Flow-chart of vital status of acute MI patients admitted to the Queen Elizabeth Hospital in Barbados, 2020 16

Figure 2.1. Number of men and women with stroke by year in Barbados. 2011 - 2020............................20

Figure 2.2. Crude incidence rate of men and women with stroke by year in Barbados. 2011 – 2020 21

Figure 2.3 Trends in age-standardised incidence and mortality rates of stroke per 100,000 population by gender, Barbados........................................................................................................................................21

Figure 2.4a. Incidence rate of stroke per 100,000 population by age‐group and gender, Barbados, 2020 (N=700) 23

Figure 2.4b. Incidence rate of stroke per 100,000 population by age‐group and gender, Barbados, 2019 (N=758) .......................................................................................................................................................23

Figure 2.5. Flow-chart of vital status of stroke patients admitted to the Queen Elizabeth Hospital in Barbados, 2020 ...........................................................................................................................................26

Executive Summary

What is in this report. The Barbados National Registry for Chronic Non-communicable diseases (BNR) has previously reported the number of new cases (incidence), the number of deaths (mortality), and the length of time people survive after a heart attack or stroke (survival) for the years 2009-2019. This report provides new national incidence, mortality, and survival data for the year 2020 Additionally, we report morbidity associated with the cardiovascular events and the proportion of cases which received management in accordance with international treatment guidelines.

Definition. Cardiovascular diseases (CVD) are the leading causes of death globally 1 The Global Burden of Disease Study (GBD) categorises cardiovascular disease in the following manner: ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic and other stroke, atrial fibrillation, peripheral arterial disease (PAD), aortic aneurysm, cardiomyopathy and myocarditis, hypertensive heart disease, endocarditis, rheumatic heart disease (RHD), and a category for other CVD conditions 2 Acute myocardial infarction (AMI, acute MI or more commonly heart attack) is one of the categories of ischaemic heart disease (IHD). The BNR collects data on acute myocardial infarction (heart attacks) and stroke.

Background. Cardiovascular disease rates in the Caribbean are higher than other countries in the Americas and continue to be the largest contributor to deaths in the region. Studies suggest that prevalence is increasing.

Heart Attacks in Barbados. In 2020, the BNR registered 547 people with myocardial infarction (MI or heart attack), exactly matching the registrations for 2019. This included confirmed hospital diagnoses and cases identified after death, using death certification records. Overall, age standardised incidence rates (ASIRs) in 2020 were 99.7 per 100,000 (95%UI 90.9 - 109.2 per 100,000); in women 77.3 per 100,000 (95% UI 67.4 - 88.7 per 100,000) and in men 124.2 per 100,000 (95% *UI 109.7 - 140.4 per 100,000). Cases stratified by age and sex also showed increased cases in younger men. In-hospital case fatality rates (CFR) remained stable, the average rate for the past five years was 22%. There is a suggested disparity in the prescription of fibrinolysis in men compared to women in Barbados.

Strokes in Barbados. There were 700 stroke cases registered in 2020. This included confirmed hospital diagnoses and cases only identified after death, using death certification records. There continued to be a rise in strokes in younger men, with the peak age for strokes in the 65 – 74 age range. This trend is in line with a global shift towards strokes in younger men in LMICs.3 In-hospital case fatality for all stroke was stable and stands at 31% in 2020 and the case fatality at 28-days was 43%. Reperfusion in stroke patients remained at 2-3%, in comparison to 12% on the UK.4

1 Roth, Gregory A., et al. ‘Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015.’ Journal of the American College of Cardiology, vol. 70, no. 1, (2017), pp. 1–25. DOI.org (Crossref), doi:10.1016/j.jacc.2017.04.052.

2 GBD 2017 Causes of Death Collaborators (2018) ‘Global, regional and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study’ (2017) Lancet 392:1736–178

3 Katan M, Luft A. Global Burden of Stroke. Semin Neurol. 2018 Apr;38(2):208-211. doi: 10.1055/s-0038-1649503. Epub 2018 May 23. PMID: 29791947.

4 Stanley K, Dr Bhalla A, Professor James M, Dr Muruet W, and Durante N. The Sixth SSNAP Annual Report, Stroke care received for patients admitted to hospital between April 2018 to March 2019, https://www.strokeaudit.org/Documents/National/Clinical/Apr2018Mar2019/Apr2018Mar2019-AnnualReport.aspx

*95% UI – These stand for 95% uncertainty intervals and indicates the level of random error we expect around or estimates. These intervals indicate that even though our best estimate for is stated, the actual rate will fall between the listed range. For example, if the ASIR for 2010 is 77, we are 95% confident that the ASI rates for 2010 fall between 69.0 and 86.4.

Key messages

• Shift in peak age range for heart attacks from men 65-74 years old to in younger men 55-64 years continues from 2019 in 2020

• Strokes in younger men were more prevalent in the 65-74 age group in 2020 (for all stroke types)

• Age-standardised incidence rates (ASIRs) for heart attacks in men in Barbados continued to rise, with a slight increase in ASMRs in heart attack seen in both sexes

• The increase in ASIRs for stroke increased over the past ten years, coupled with no significant increase in ASMRs, may lead to increasing prevalence and increasing burden of care.

• There has been a gradual increase in proportion of STEMI cases reperfused from 2017-2020. Reperfusion with fibrinolysis in women with heart attacks remained low compared to men.

• Documentation of risk factors and medications in clinical notes continued to be a challenge, not meeting expectations

Summary Statistics

Table 1.1. Summary statistics for the Barbados National Registry for Chronic Noncommunicable Disease (the BNR) in 2020 (Population, 287,371)5

Myocardial Infarction Stroke (all) First ever Strokes

Number of registrations1 547 700 264

Hospital admissions (percentage admitted)2 338 (62%) 632 (90%) 264 (100%)

Rate per population3 0.19 0.24 0.09 In-hospital case fatality rate (cases with full information4 , n (%) 68 (23%) 177 (31%) .

Death Certificate Only (DCO)5 256 (47%) 137 (20%) n/a

Median (range) length of hospital stay (days)6 5 (1 - 145) 9 (1 - 148) 7 (1 - 148)

5 (1) Total numbers of persons who had events registered or entered in the BNR database; (2) Total number of hospital admissions as a proportion of registrations; (3) Total number of registrations as a proportion of the population; (4) Case fatality rate in hospital and post discharge for hospitalised patients; (5) Total number of deaths collected from death registry as a proportion of registrations; (6) Median and range of length of hospital stay (in days).

Introduction

The Barbadian population has had increasing numbers of non-communicable diseases (NCDs) and NCDrelated deaths.6 The COVID-19 pandemic, which started in Barbados on 17th March 2020, interrupted the availability of care through: the postponement of chronic care and outpatient clinics, clinic staff reallocation, reduced health seeking behaviour of patients with NCDs and availability of rehabilitative care.7 It also interrupted BNR’s ability to collect surveillance data during periods of nationally mandated lockdown

The data collected by the BNR provides no evidence of a direct impact on case numbers in 2020, neither was there any indication of excess stroke or heart attack deaths due to the COVID-19 pandemic for the reported year The COVID-19 pandemic however re-emphasized the need for accurate and robust health data for decision making, the impact surveillance can have on care and planning, and the need for an integrated Health Information System.

Methods

The BNR collected data from both hospital and community sources The Queen Elizabeth Hospital (QEH) is Barbados’ only public tertiary care institution and as such, a large proportion of individuals who present with stroke and acute myocardial infarction (AMI) are managed in this facility. It is standard practice for cardiovascular events managed initially at other healthcare facilities to be transported by ambulance to the QEH for additional care.

The methodology of data collection was modified due to the COVID-19 protocols at the Queen Elizabeth Hospital, which restricted the data abstractors’ access to the hospital wards. In 2020, data abstractors collected information from three sources within the Queen Elizabeth Hospital:

a. Accident and Emergency Records

b. Death Records

c. Medical Records

Data abstraction in the hospital specifically included the collection of additional information on the symptoms, treatment, vital status, risk factors and associated morbidities for anyone diagnosed with a heart attack or stroke. Information regarding the case history of individuals admitted to hospital was also obtained from chart review.

Out-of-hospital deaths and in-hospital deaths within 24 hours were identified through the national vital registration department by checking all death certificate diagnoses that list any form of ischemic heart disease (IHD) as the main cause of death. Deaths were validated by autopsy reports, chart review and clinical information from the last treating physician.

We calculated incidence rates using the United Nations World Population estimates for 2020 as the denominator and performed age-standardisation to the WHO World 2000 population

6 The Ministry of Health and Wellness. Barbados Health Report 2019. https://www.barbadosparliament.com/uploads/sittings/attachments/0c85813fd4d9746f1558af6c13239fca.pdf

7 Rapid Assessment of service delivery for NCDs during the COVID-19 pandemic in the Americas, 4 June 2020, https://iris.paho.org/handle/10665.2/52250

HEART ATTACKS

Burden - Number of cases, incidence, mortality, gender differences and comparison with previous years

Number of cases and crude incidence rates

Hospital capacity planning is an important issue in many developed and developing countries due to the increasing costs of inpatient care, constrained resources, and the growing demand for hospital care.8 The Queen Elizabeth Hospital (QEH) currently has a bed-capacity of 519 beds, with 6 beds dedicated to the cardiac unit. In November 2020, the QEH reported a delay in services due to full capacity9 . With a myocardial infarction patient’s hospital length of stay (LOS) averaging 5 days in 2020 along with case numbers and the burden of heart attacks can all provide data for future capacity planning. A recent study suggested that “in the post-pandemic period, essential health services will require significant scaling up, with access especially for NCD care ”10

Figure 1.1. Number of men and women with acute MI by year in Barbados. 20112020

8 Ravaghi, H., Alidoost, S., Mannion, R. et al. Models and methods for determining the optimal number of beds in hospitals and regions: a systematic scoping review. BMC Health Serv Res 20, 186 (2020). https://doi.org/10.1186/s12913-020-5023-z

9 QEH. QEH Connect. https://www.qehconnect.com/qeh-at-maximum-bed-capacity. November 1, 2020. Accessed June 2020.

10 Hennis AJM, Coates A, Del Pino S, et al. COVID-19 and inequities in the Americas: lessons learned and implications for essential health services. Rev Panam Salud Publica. 2021;45:e130. Published 2021 Dec 28. doi:10.26633/RPSP.2021.130

The number of cases registered in 2020, exactly matched those of 2019 (547 cases). However, the distribution of the cases returned to previous norms, with men recording slightly more cases than women (285 cases, men versus 262 cases, women). Despite case numbers being the same as 2019, the moving average of crude incidence indicated that the trend in cases of MI is increasing.

Figure 1.2. Crude incidence rate of men and women per 100,000 population with acute MI by year in Barbados. 2011 - 2020

Age-standardised Incidence and Mortality Rates (ASIR, ASMR)

Age-standardised incidence rates were comparable in 2019 (101.3 per 100, 000 (95% UI 92.5 - 110.9)) and 2020 (99.7 per 100, 000 in 2020 (95% UI 90.9 - 109.2)).

Likewise, age-standardised mortality rates for MI in 2020 (55 per 100,000) were similar to 2019 (52.8 per 100, 000). According to PAHO’s Cardiovascular Risk Burden, 11 ASMR in 2019 places Barbados in quartile 1 of CVD related deaths due to ischemic heart attacks compared to countries in the 4th quartile like Guyana with ASMRs of 157.6 per 100, 000. Like ASIRs, while comparably not high, Barbados and the Eastern Caribbean are showing increasing trends in ASMRs, rather than the decreasing trends that are needed to achieve the WHO SDG targets of a 1/3 reduction pre-mature mortality from NCDs by 2030.12

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8713468/

11 PAHO ENLACE. Data Portal on Noncommunicable Diseases, Mental Health, and External Causes: Cardiovascular disease burden https://www.paho.org/en/enlace/cardiovascular-disease-burden. Accessed June 2022.

12 UN Sustainable Development Goals. https://www.un.org/sustainabledevelopment/health/. Accessed July 2022.

Figure 1.3. Trends in age-standardised incidence rates of men and women with acute MI or sudden cardiac death by year in Barbados, 2011 - 2020

Table 1.2. Trends in age-standardised incidence and mortality rates of men and women with acute MI or sudden cardiac death by year in Barbados, 2011 - 2020

Men

Years Number % ASIR 95% UI ASMR 95%UI

2011 168 57.1 88.2 75.0 - 103.1 50 40.4 - 61.3 2012 203 50.2 103.3 89.1 - 119.2 59.5 48.9 - 71.7 2013 191 54.3 93.4 80.2 - 108.3 56 46. 0 - 67.7 2014 220 53.7 105.4 91.6 - 121.0 58.9 48.8 - 70.6 2015 169 52.2 83.5 71.1 - 97.7 35.3 27.6 - 44.6 2016 250 56.9 120.2 105.4 - 136.6 66.4 55.8 - 78.5 2017 253 54.2 115.4 101.2 - 131.1 58.5 48.7 - 69.8 2018 269 55.7 122.5 107.8 - 138.7 66 55.5 - 78.0 2019 271 49.5 120.3 105.8 - 136.3 61.2 51.2 - 72.8 2020 285 52.1 124.2 109.7 - 140.4 66 55.5 - 78.0

Women

Years Number % ASIR 95% UI ASMR 95%UI

2011 126 42.9 43.2 35.3 - 52.6 25.8 20.1 - 33.0 2012 201 49.8 70.8 60.6 - 82.3 40.3 33.0 - 49.1 2013 161 45.7 56.7 27.7 - 67.2 38.4 31.2 – 47.0 2014 190 46.3 61.3 52.1 - 71.9 33.7 27.3 - 41-6 2015 155 47.8 53.5 44.8 - 63.6 24 18.5 - 30.9 2016 188 42.9 61.6 52.4 - 72.1 32.8 26.6 - 40.3 2017 214 45.8 70.6 60.7 - 81.9 31 24.9 - 38.5 2018 213 44.1 66.7 57.4 - 77.37 40 33.0 - 48.3 2019 276 50.5 83.4 73.1 - 95.1 44.9 37.6 - 53.5 2020 262 47.9 77.3 67.4 - 88.7 45 37.6 - 53.7

Age and Gender Stratified Incidence Rates

Age stratified incidence rates in women continued to have the expected increase with increasing age Men of young age groups had greater incidence of heart attacks than those in the e 65-74 range in 2020. This trend has been noted elsewhere, with one study indicating that acute coronary syndromes (ACS), ST-elevation myocardial infarction (STEMI), or NSTEMI (Non-STEMI) occurs three to four times more often in men than in women below age 60, but after 75 years, women represent most patients.13

Figure 1.4a. Age and gender stratified incidence rate per 100,000 population of acute MI, Barbados, 2020 (N=547)

Figure 1.4b. Age and gender stratified incidence rate per 100,000 population of acute MI, Barbados, 2019 (N=547)

13

37, Issue 1, 1 January 2016, Pages 24–34, https://doi.org/10.1093/eurheartj/ehv598

The EUGenMed, Cardiovascular Clinical Study Group, Vera Regitz-Zagrosek, Sabine Oertelt-Prigione, Eva Prescott, Flavia Franconi, Eva Gerdts, Anna Foryst-Ludwig, Angela H.E.M. Maas, Alexandra Kautzky-Willer, Dorit Knappe-Wegner, Ulrich Kintscher, Karl Heinz Ladwig, Karin Schenck-Gustafsson, Verena Stangl, Gender in cardiovascular diseases: impact on clinical manifestations, management, and outcomes, European Heart Journal, Volume

Symptoms and Risk Factors of Acute MI

The American Heart Association (AHA)/American Stroke Association (ASA) describes chest pain due to ischemic heart disease primarily as central, pressure, squeezing, gripping, heaviness, tightness, exertional/stress related or retrosternal.14 Table 1.3 shows the main presenting symptoms and signs of Acute MI in men and women.

Table 1.3. Main presenting symptoms and signs of acute MI patients in Barbados, Jan–Dec 2020 (N=291)

2020

Symptom/Signs

Women (125) Men (166) Total (291) Number % Number % Number %

Chest pain 84 67 113 68 197 68

Shortness of breath 63 50 78 47 141 48 Sweating 56 45 72 43 128 44 Sudden vomiting 42 34 43 26 85 29

Women - The number and percentage of women with a given symptom as a % of the number of women with information for a specific year.

Men –The number and percentage of men with a given symptom as a % of the number of men with information for a specific year.

Totals –The total number and percentage of patients (men & women) with a given symptoms as a % of all patients with information for a specific year.

Light-headedness, nausea/malaise 29 23 36 22 65 22 Palpitations  30 24 30 18 60 21 Sudden dizziness/vertigo 21 17 32 19 53 18 Loss of consciousness 18 14 19 11 37 13 14 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,2021. Circulation e368-e454,144,22.doi:10.1161/CIR.0000000000001029. https://www.ahajournals.org/doi/abs/10.1161/CIR.0000000000001029

Risk Factors associated with AMI

Known risk factors associated with myocardial infarction include biological and social determinants. Cardiovascular disease risk (CVD risk) scores are now commonly being incorporated in the treatment of persons with CVD. This score is determined by the existence of cardiovascular risks including hypertension, diabetes mellitus (DM), smoking, family history of CVD, family history of high cholesterol, chronic kidney disease, obesity, as well as age.

CVD risk is used a prognostic and decision-making tool. The Health of the Nation Study suggests that there is a large prevalence of biological risks in the Barbados population, much of which are undiagnosed.15 Diabetics, for example, are at 2 – 4 times greater risk for heart attack. The presence of COVID-19 also adds an additional risk as studies are suggesting an increasing risk of diabetes after having COVID-19.16

Table 1.4. Prevalence of known risk factors among hospitalised acute MI patients, 2020(N=311)

Risk factor type

Prior CVD event/disease

Current co-morbidity

2020 Risk factor Number % n1

Prior acute MI 47 16 290

Prior stroke 34 19 179

Hypertension 205 86 237 Diabetes 132 75 176

Lifestyle-related Alcohol use 49 20 246 Smoking 25 11 220

n1 = denominator (i.e., total number reporting information about that risk factor).

15 Unwin N, Rose AMC, George KS, Hambleton IR, Howitt C. The Barbados Health of the Nation Survey: Core Findings. Chronic Disease Research Centre, The University of the West Indies and the Barbados Ministry of Health: St Michael, Barbados, January 2015; 48 pp 16 Xie Y, Al-Aly Z. Risks and burdens of incident diabetes in long COVID: a cohort study. Lancet Diabetes Endocrinol. 2022 May;10(5):311-321. doi: 10.1016/S2213-8587(22)00044-4. Epub 2022 Mar 21. PMID: 35325624; PMCID: PMC8937253.

Mortality

Secular trends in case fatality rates for AMI

Each case of myocardial infarction is followed to determine vital status (death) at discharge, 28 days and one year. In addition, registry personnel visit the death registry to collect data on all sudden cardiac and AMI deaths. The 28-day or 30-day case fatality/mortality rate is considered a quality indicator. In the US, the AHA reports a 30-day post-discharge mortality rate of 12%, as compared to a 28-day post-discharge mortality of 27% in Barbados in 2020.17

Table 1.5. Mortality statistics for MI patients in Barbados, 2011-2020

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Number of BNR Registrations 294 404 352 410 324 439 467 483 547 547

Number of hospitalised cases 158 239 178 255 232 249 301 288 342 338

Number of cases with full information* 119 187 153 234 209 217 278 257 311 291

In-hospital CFR (Clinical)*, n (%) 14 (12%) 30 (16%) 38 (25%) 72 (31%) 42 (20%) 38 (18%) 57 (21%) 62 (24%) 72 (23%) 68 (23%)

Total hospitalised deaths, n (%) 53 (34%) 82 (34%) 63 (35%) 93 (36%) 65 (28%) 70 (28%) 80 (27%) 93 (32%) 103 (30%) 115 (34%)

Case fatality rate at 28 days** 47% 45% 43% 43% 35% 32% 31% 39% 35% 27%

*Cases where the patient note was seen and the BNR team was able to summarise all the data needed (a full abstract)

** Cases which followed the clinical definition of an MI (see Appendix)

***Case fatality rate in hospital and post discharge for hospitalised patients

17 Heart Disease and Stroke Statistics 2020 Update: A Report From the American Heart Association, Salim S. Virani, MD, PhD, FAHA, Chair, Alvaro Alonso, MD, PhD, FAHA, Emelia J. Benjamin, MD, ScM, FAHA, Marcio S. Bittencourt, MD, PhD, MPH et al. On behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee https://www.ahajournals.org/doi/10.1161/CIR.0000000000000757

Focus on acute MI in-hospital outcomes

We calculated in-hospital case fatality rates using patients with abstracted data (291) and “death record only” reports where the patient has had a post-mortem (6 patients; note that there were no patients with unknown outcome in 2020).

Figure 1.5. Flow-chart of vital status of acute MI patients admitted to the Queen Elizabeth Hospital in Barbados, 2020

Performance measures for Acute Coronary syndrome (ACS), 2020

The American College of Cardiology (ACC)/ AHA has developed a set of key performance indicators that capture important aspects of quality of care including timeliness, effectiveness, efficiency, and patientcenteredness. In 2017, the ACC/AHA identified seventeen reporting measures that hospitals may use to assess their performance as it relates to the management of ST- elevation myocardial infarction (STEMI) and Non-ST elevation myocardial infarction (NSTEMI). Based on the data collected by the Barbados National Registry, we report on six of these performance measures for the hospital cases which had full information below.

The first three performance measures (PM) focus on management in the acute phase (first 24 hours), while the remaining three focus on management at discharge.

Performance measures for acute care

PM 1: Documented aspirin use within the first 24 hours

Typically, the AHA Get with the Guidelines Program (GWGT) recognises performance of 85% or greater compliance on each performance measure.18 Standards of care suggest that patients with acute myocardial infarction receive aspirin within the first 24 hours of arrival at hospital or first onset of symptoms (see Appendix B- Descriptions) In Barbados, in 2020, 55% of patients received aspirin within 24 hours. Poor documentation is the likely cause of such low rates given that an additional 40% of patients were given aspirin but no time of administration was documented in the notes.

PM 2: Proportion of STEMI patients who received reperfusion via fibrinolysis

Of the 338 hospitalised cases with full information in 2020, 103 persons were diagnosed with a STEMI. Of these, 48 (47%) received reperfusion (enzymes to restore blood flow, see Appendix B – Descriptions). Fibrinolytic drugs are used for reperfusion in Barbados since Primary Percutaneous Intervention was not routinely available up to and including 2020. Of the STEMI cases occurring in women in 2020, (12) 36% received fibrinolysis compared to 36 (51%) of men (Table 1.6). There is a recognised disparity in use of fibrinolysis in men versus women diagnosed with STEMI. One study, which adjusted for age and comorbidities, suggested that there is no correlation between age or existing disease presentation that should account for the disparity, and further suggested sex- and age-stratified monitoring of quality indicators and care pathways to standardize management for both sexes should be implemented in routine clinical practice 19

Table 1.6. Number of STEMI cases and proportion reperfused by gender

18 Heidenreich, P., Lewis, W. R, LaBresh, K.A, Schwamm, L.H., Fonarow G.C., ‘Hospital performance recognition with the Get With The Guidelines Program and mortality for acute myocardial infarction and heart failure’ American Heart Journal, volume 158,4 (2009): https://doi.org/10.1016/j.ahj.2009.07.031

19 Johnston N, Bornefalk-Hermansson A, Schenck-Gustafsson K, et al. Do clinical factors explain persistent sex disparities in the use of acute reperfusion therapy in STEMI in Sweden and Canada?. Eur Heart J Acute Cardiovasc Care. 2013;2(4):350-358. doi:10.1177/2048872613496940, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3821828/

PM 3: Median time to reperfusion for STEMI

“Door-to-needle” time was available for patients who received thrombolysis (to restore normal blood flow, see Appendix B – Descriptions). Time to fibrinolysis is typically recommended to be 30 minutes from first medical contact.20 In 2020 there was an increase in time to fibrinolysis from onset, however there was a reduction in time from admission. Time to first ECG is considered critical in the assessment and categorisation of events as either N-STEMI or STEMI, and therefore affects treatment recommendations. The suggested time to first ECG is less than 10 minutes21 . Here the median time from admission to first ECG increased significantly from 46 minutes in 2019 to 63 minutes in 2020

Table

1.7. ‘Door to needle’ times for hospitalized patients

2018 2019 2020

Median time from scene to arrival at A&E 19 minutes 20 minutes 20 minutes

Median time from admission to first ECG 53 minutes 46 minutes 63 minutes or 1 hour 3 minutes

Median time from admission to fibrinolysis

107.5 minutes or 1 hour 48 minutes 143 minutes or 2 hours and 23 minutes 102 minutes or 1 hour 42 minutes

Median time from onset to fibrinolysis 279 minutes or 4 hours 39 minutes 311 minutes or 5 hours 11 minutes 318 minutes or 5 hours 18 minutes

Performance measures related to discharge

PM 4: Proportion of patients receiving an echocardiogram before discharge

The ACC/AHA recommends that patients receive an evaluation of left ventricular ejection fraction (LVF) after a myocardial infarction. The BNR assessed this by reviewing the proportion of patients who received an echocardiogram (see Appendix B – Descriptions) before discharge. Registry records indicate that in 2020, of the patients alive at discharge, 33% had received an echocardiogram before leaving

20 Chris Wilkinson, Clive Weston, Adam Timmis, Tom Quinn, Alan Keys, Chris P Gale, The Myocardial Ischaemia National Audit Project (MINAP), European Heart Journal - Quality of Care and Clinical Outcomes, Volume 6, Issue 1, January 2020, Pages 19–22, https://doi.org/10.1093/ehjqcco/qcz052

21 Aho, K., Harmsen, P., Hatano, S., Marquardsen, J., Smirnov, V.E., Strasser, T., ‘Cerebrovascular disease in the community: results of a WHO collaborative study.’ Bull World Health Organ. (1980); 58: 113-130

hospital (compared to 24% in 2019) while an additional 30% had been referred for the procedure as an outpatient. Men were more likely to have an echocardiogram in 2020.

Table 1.8. Proportion of patients receiving echocardiogram, 2020

Year Timing Women Men Total Number % Number % Number % 20 20

Before discharge 25 29 62 71 87 33

Referred to receive after discharge 37 46 43 54 80 30

PM 5: Documented aspirin prescribed at discharge

Aspirin which is critical for secondary prevention was prescribed to 83% of patients in 2020 at discharge, slightly increased from 2019 (76%). Data to account for persons discharged on antiplatelets and chronic users of aspirin has been used to recalculate what is believed to be a more accurate representation of this metric in Table 1.9 below.

Table 1.9. Proportion of patients receiving antithrombotic therapy at discharge

Year Aspirin at Discharge Patient Receiving any Antiplatelets

Total Alive Percentage Receiving Therapy

2018 159 187 194 96% 2019 180 221 234 94% 2020 184 193 222 87%

PM 6: Documented statins prescribed at discharge

There were 82% of patients discharged home on a statin in 2020 (up from 71% in 2019). ACC/AHA recommends that patients be discharged home with a high intensity statin, but the dose and frequency were not collected by the registry and thus the proportion of these which were high intensity could not be evaluated

STROKE Burden - Number of cases, incidence, mortality, gender differences and comparison with previous years

Number of cases and crude incidence rates

Our strokes cases are defined according to the World Health Organisation (WHO) criteria as rapidly developing clinical signs of focal (at times global) disturbance of cerebral function lasting more than 24 hours or leading to death with no apparent cause other than that of vascular origin 22 There were 700 cases of stroke registered in 2020. Numbers and crude incidence rates were slightly higher for women for all years in which data was collected. Figure 2.1 shows the numbers of men and women who experienced a stoke, and Figure 2.2 shows the gradual increase in crude incidence by gender.

Figure 2.1. Number of men and women with stroke by year in Barbados. 20112020

22 Thygesen, K., Alpert J.S., Jaffe, A.S., Chaitman, B.R., Bax, J.J , Morrow, D.A., White, H.D.: the Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. ‘Fourth universal definition of myocardial infarction (2018)’. Circulation. 2018;138:e618–e651. DOI: 10.1161/CIR.0000000000000617.

Figure 2.2. Crude incidence rate of men and women with stroke by year in Barbados. 2011 – 2020

Age-standardised

Incidence and Mortality Rates (ASIR, ASMR)

The age-standardised rate of stroke was calculated as 135.2 per 100,000 (95% UI 124.7 - 146.5) in 2020. Table 2.1 lists the rates by gender for the year 2011 – 2020 There was a reduction in ASMRs in 2020, 44.2 per 100,000 versus 60.1 per 100,000 in 2019. There has been only a small non-significant rise in age-standardised incidence of strokes indicating that most of the increase seen in crude incidence is due to Barbados’ aging population.

Figure 2.3 Trends in age-standardised incidence and mortality rates of stroke per 100,000 population by gender, Barbados

Table 2.1 Age-standardised incidence and mortality rates of stroke per 100,000 population by gender, Barbados

Men

Years Number % ASIR 95% UI ASMR 95%UI

2011 261 46.4 136.6 120.1 - 154-8 61.3 50.5 - 73.9 2012 257 44.5 129.2 113.4 - 146.6 59.9 49.7 - 71.8 2013 327 47.1 161.8 144.2 - 181.0 66.2 55.5 - 78.4 2014 268 45.9 127.4 112.2 - 144.4 45.1 36.4 - 55.2 2015 267 45.6 128.0 112.7 - 144.9 49.5 40.5 - 60.2 2016 329 45.6 153.7 137.2 - 171.9 64.8 54.6 - 76.65 2017 301 46.5 137.3 121.7 - 154.4 51.6 42.5 - 62.3 2018 327 47.9 150.7 134.3 - 168.8 49.4 40.5 - 59.9 2019 362 47.8 157.2 141 - 175.0 67.3 57.2 - 78.9 2020 335 47.9 148.6 132.5 - 166.2 42.8 34.7 - 52.6

Women

Years Number % ASIR 95% UI ASMR 95%UI

2011 302 53.6 107.3 94.4 - 121.5 44.9 37.3 - 53.9 2012 321 55.5 107.7 95.2 - 121.5 50.6 42.9 - 59.6 2013 368 52.9 131.9 117.7 - 147.5 53.7 45.2 - 63.6 2014 316 54.1 111.1 98.1 - 125.5 36.4 29.8 - 44.4 2015 319 54.4 109.6 96.9 - 123.8 42.7 35.3 - 51.4 2016 392 54.4 135.1 120.7 - 150.9 59.9 51.1 - 70.0 2017 347 53.5 119.1 105.8 - 133.8 46.9 39.1 - 56.2 2018 355 52.1 120.1 106.7 - 134.9 48.8 41.1 - 57.9 2019 396 52.2 127.2 114.0 - 141.9 53.4 45.7 - 62.4 2020 365 52.1 122.8 109.2 - 137.8 45.2 37.3 - 54.6

Age and Gender Stratified Incidence Rates

The age stratified incidence rates remained typical in women, with incidence increasing with age. However, as seen in MI, the peak age for strokes is occurring in younger men, in the 65–74-year-old range. The percentage of persons under age 70 experiencing stroke in Barbados is 45% as compared to 60% globally23, which indicates the burden of stroke is largely in the most elderly in the population

Figure 2.4a. Incidence rate of stroke per 100,000 population by age‐group and gender, Barbados, 2020 (N=700)

Figure 2.4b. Incidence rate of stroke per 100,000 population by age‐group and gender, Barbados, 2019 (N=758)

*Updated from 2019 report

Stroke category

https://www.world-stroke.org/assets/downloads/WSO_Fact-sheet_15.01.2020.pdf

Of cases fully abstracted by the BNR in 2020 (563), ischaemic stroke remained the largest category, with 84% cases (244 women and 229 men). Less than 5% of strokes were subarachnoid haemorrhages or unclassified. A CT scan is recommended at presentation of symptoms and signs suggestive of stroke to determine whether the patient is eligible for reperfusion, 97% of stroke patients received a CT scan in 2020.

Table 2.2. Stroke subtypes in Barbados, 2018, 2019 & 2020 (N=550, N=622 & N=563 respectively)

Symptoms, Signs and Risk Factors of Stroke

Table 2.3 displays the proportion of patients who displayed the more common presenting signs and symptoms associated with stroke. Diminished responsiveness is used to characterise any drowsiness or temporary loss of consciousness or coma.

Table 2.3. Main presenting symptoms for stroke patients in Barbados, Jan–Dec 2020 (N=563)

Women - The number and percentage of women with a given symptom as a % of the number of women with information for a specific year. Men - The number and percentage of men with a given symptom as a % of the number of men with information for a specific year.

Totals –The total number and percentage of patients (men & women) with a given symptom as a % of all patients with information for a specific year.

Risk Factors

Overall, there was a reduction in documentation of risk factors in 2020 in the clinical notes A greater percentage of alcohol use was noted in 2020 (26% compared to 18% in 2019). The rate of smoking remained low (9% of cases with information recorded). Based on the available data hypertension, diabetes and prior stroke or TIA are the most common risk factors of stroke in Barbados.

Globally, greater concentration is being placed on the contribution of diet, physical activity, cholesterol and environmental exposures to stroke incidence and death. This data is not routinely collected at the Primary Care level, however, future efforts to improve documentation, the routine collection of obesity through BMI, and other risk factors may elucidate other significant risk factors.

Table 2.4. Prevalence of known risk factors among hospitalised stroke patients, 2020 (N=622)

Risk factor type

2020 Risk factor Number % n1

Prior stroke or TIA 133 24 561

Prior CVD event/disease

Current co-morbidity

Prior/current IHD/CVD/PVD/acute MI 32 10 320

Hypertension 410 90 456 Diabetes 228 77 296

Lifestyle-related Alcohol use 126 26 482 Smoking 37 9 432

Family history of stroke Mother, father, or sibling 34 6 557

n1 = denominator (i.e., total number reporting information about that risk factor). NR –Numbers too small for adequate representation

Mortality

Secular trends in Stroke Mortality

In-hospital case fatality rates (all cases) was recalculated for all years, 2011-2020. The average inhospital cases fatality (all cases) over the 10 years was 34%. The cases fatality rate at 28 days increased to 43%.

Table 2.5. Mortality statistics for stroke patients in Barbados, 2011-2020

2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Cases 563 578 695 584 586 723 650 682 758 700

Cases with full information 385 397 544 481 484 563 544 550 622 563

In-hospital CFR (of cases with full information) 25% 33% 31% 27% 31% 35% 31% 28% 37% 31%

In-hospital CFR (all cases) 25% 36% 31% 27% 33% 41% 35% 35% 41% 39%

Case fatality rates at 28 days* 45% 47% 36% 30% 43% 28% 32% 25% 32% 43%

*Case fatality rate in hospital and post discharge for hospitalised patients

Focus on stroke in-hospital outcomes

While the overall QEH in-hospital case fatality rate (CFR) for stroke in 2020 is 39% (246/632 with known outcome); this estimate should be interpreted with caution, a conservative estimate calculated based on cases with full information is (246/563) 31%.

Figure 2.5. Flow-chart of vital status of stroke patients admitted to the Queen Elizabeth Hospital in Barbados, 2020

Performance measures for stroke, 2020

The American Heart Association’s collaborative performance improvement programme has developed a set of measures to help hospitals managing stroke patients to assess the extent to which they adhere to evidenced-based approaches and thus promote changes that improve patient outcomes. The data collected by the BNR is suitable for the assessment of acute ischaemic strokes which constitute approximately 84% of strokes registered. The management of ischaemic stroke involves multiple dimensions of care (including acute treatment, prevention of recurrence, prevention and treatment of common medical complications, rehabilitation, and patient education and counseling) that cut across multiple healthcare disciplines (e.g., physicians, nurses, therapists, and others) and across multiple healthcare settings (e.g., outpatient, acute care hospital, and inpatient rehabilitation).

Below we use data from the registry to report on measures in both the acute and discharge phases of management, the recommendation is that hospital achieve 85% compliance with each performance measure24 .

Performance measures for acute care

PM 1: Proportion of patients receiving reperfusion

With the opening of the Stroke Unit in 2015, the Queen Elizabeth Hospital was able to offer IV TPA (a “clot busting” drug – see Appendix B) to patients arriving within 2 hours of onset of symptoms. An average of 11 people received reperfusion over the past four years was (2017-2020). This number represented less than 2.5% of cases annually.

PM 2: Proportion of patients with ischaemic stroke who receive antithrombotic therapy while in hospital

We calculated the proportion of persons with ischaemic stroke who received anti-thrombotics (see Appendix B for definition, e.g., warfarin, aspirin or clopidogrel) before leaving hospital. The proportion of persons receiving anti-thrombotics while in hospital was approximately 77% in both men and women in 2020, which was similar to previous years.

24

Get With The Guidelines® - Stroke Recognition Criteria, Achievement Awardshttps://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke/get-withthe-guidelines-stroke-recognition-criteria

Table 2.6. Proportion of persons with acute ischaemic events receiving antithrombotic therapy by year

2019 2020

Men Women Men Women

Number % Number % Number % Number %

Antithrombotics 183 74 182 68 188 77 178 78

Performance measures related to discharge

PM 3: Percent of patients with an ischaemic stroke prescribed antithrombotic therapy at discharge

There was a slight reduction in women who received anti-thrombotic therapy (see Appendix BDescriptions) at discharge (Table 2.7) (78% in 2020 compared to 83% in 2019), while the percentage of men remained the same (80% in 2019 & 2020)

PM 4: Statin Prescribed at Discharge: Percent of ischaemic stroke who are discharged on Statin medication

Statins are also recommended as effective secondary prevention treatment in patients who have had an ischaemic stroke. There was a reduction in statins prescribed to women from 73% in 2019 to 69% in 2020, while a greater percentage of men were prescribed statins 65% in 2019 compared to 77% in 2020 (Table 2.7).

Table 2.7. Proportion of ischaemic stroke cases receiving appropriate medications at discharge 2019 2020

Women Men Women Men

Number % Number % Number % Number %

BNR Professional and Public Engagement

Update on the professional and public engagement events which the BNR hosted in 2020.

Poster from BNR Seminar 2020, 2. Nation News Article (Hardcopy) October 30, 2020, 3. Nation News Article (Facebook), 4. Barbados Today Article (Online), October 30, 2020, 5. Post from BNR Facebook page -Health Recipes from BNR Staff

Appendices

Appendix A— Acknowledgements

This report was prepared by the Barbados National Registry for Chronic Non-communicable Disease (BNR), headquartered at the George Alleyne Chronic Disease Research Centre (GA-CDRC), The University of the West Indies. The BNR is a Ministry of Health and Wellness initiative, providing surveillance of the three principal causes of ill-health and death among Barbadians: stroke, myocardial infarction (heart attacks) and cancer. The National Commission for Non-communicable Disease provides oversight of the BNR.

We gratefully acknowledge all patients with myocardial infarction and strokes and their families who have contributed to the BNR-CVD. This surveillance system is made possible by the physicians, nursing staff, administrative staff and ancillary personnel of the Queen Elizabeth Hospital, Bayview Hospital, parish polyclinics, geriatric, and district hospitals, as well as private physicians, diagnostic establishments, and emergency clinics across the island. Their essential collaboration helps to bring ongoing improvements in stroke and myocardial infarction surveillance.

Contributors: BNR-CVD Surveillance Team (2020)

Dr Natasha Sobers, Head of NCD Surveillance, GA-CDRC (2018 - present)

Mrs. Abigail Robinson, Data abstractor, BNR-CVD

Ms Nicolette Roachford, Data abstractor, BNR-CVD

Mrs Martinette Forde, Follow-up nurse, BNR-CVD

Mrs Karen Whittaker, Steno Clerk, BNR

Ms. Jacqueline Campbell, Quality Control Coordinator, BNR

Ms Ashley Henry, Assistant Quality Control Coordinator, BNR

Dr Rudolph Delice, Clinical Director, BNR-Heart

Prof. David Corbin, Clinical Director, BNR-Stroke

Prof. Ian R Hambleton, Statistician, GA-CDRC

Prof. Simon G Anderson, Director, GA-CDRC (2019 – present)

Special Thanks

Prof. Sir Trevor Hassell, Chairman, National Chronic Non-communicable Disease Commission

Ms. Nicolai Ifill, Medical Records Dept., Queen Elizabeth Hospital

Mr. Andrew Yearwood, Medical Records Dept., Queen Elizabeth Hospital

Ms. Natalie Lynch, Medical Records Dept., Queen Elizabeth Hospital

Ms. Maria Phillips, Medical Records Dept., Queen Elizabeth Hospital

Mr. Curtis Nurse, Medical Records Dept., Queen Elizabeth Hospital

Mr. Stephen Barrow, Medical Records Dept., Queen Elizabeth Hospital

Ms Marsha Corbin, Medical Records Dept., Queen Elizabeth Hospital

Clerical officers of the A&E Department

Ms Cheryl Knight and the staff of the Registration Department

The Professional Advisory Board of the BNR (2020)

Name Affiliation

Prof. Sir Trevor Hassell (Chair) Chairman of the National Commission for Chronic NCDs

Prof. Simon Anderson Current Director, GA-CDRC

Dr Patrice Lawrence Williams Representative, PAHO/WHO

Dr Kenneth George Chief Medical Officer, Ag. Ministry of Health and Wellness

Dr E Arthur Phillips Senior Medical Officer of Health, Ministry of Health and Wellness

Mrs. Bynoe-Sutherland Executive Chair, QEH (ex officio represented by Ms. Lee-Ann Salandy)

Dr Natasha Sobers Principal Investigator, BNR

Dr Richard Ishmael Consultant cardiologist, QEH

Dr RK Shenoy Consultant radiotherapist, QEH

Prof. David Corbin Consultant Neurologist, QEH; Clinical Director, BNR–Stroke

Dr Rudolph Delice Head of Dept. of Medicine, QEH; Clinical Director, BNR–Heart

Prof. Patsy Prussia Honorary Consultant Pathologist, QEH; Clinical Director, BNR–Cancer

Dr David Gaskin Consultant Pathologist, QEH

Dr Natalie Greaves Lecturer, Coordinator, MPhil/PhD Program in Public Health (UWI)

Dr Cheryl Alexis Senior Lecturer in Clinical Haematology, FMS, UWI; Consultant, QEH

Dr Dawn Scantlebury Consultant Interventional Cardiologist, QEH

Mrs Tanya Martelly Research Manager, GA-CDRC

Mrs Shelly-Ann Forde Registrar, BNR

Appendix B Descriptions

BNR - Heart

The working definition for acute MI in Barbados is based on the current universal and epidemiological definitions.20 The elevated cardiac troponin values (cTn) with at least one value above the 99th percentile upper reference limit (URL). The myocardial injury is considered acute if there is a rise and/or fall of cTn values.

A definite acute MI is defined as:

Acute myocardial injury with clinical evidence of acute myocardial ischaemia and with detection of a rise and/or fall of cTn values with at least one value above the 99th percentile URL and at least one of the following:

• Symptoms of myocardial ischaemia;

• New ischaemic ECG changes;

• Development of pathological Q waves;

• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic etiology;

• Identification of a coronary thrombus by angiography or autopsy (not for types 2 or 3 MIs).

Postmortem demonstration of acute atherothrombosis in the artery supplying the infarcted myocardium meets criteria for type 1 MI. Evidence of an imbalance between myocardial oxygen supply and demand unrelated to acute atherothrombosis meets criteria for type 2 MI. Cardiac death in patients with symptoms suggestive of myocardial ischaemia and presumed new ischaemic ECG changes before cTn values become available or abnormal meets criteria for type 3 MI.

Treatment guidelines (acute MI)

Current best practice25 suggests five oral medications are often given to patients during hospitalization and following discharge with an acute myocardial infarction diagnosis; all with the aim of decreasing mortality and protecting heart muscle:

• Aspirin – to prevent the constricted artery from becoming completely blocked and to lower the risk of another event

• Reperfusion – to open the artery as quickly as possible to restore normal blood flow through fibrinolysis – “clot busting” medications or angioplasty.

• Additional blood thinners (e.g., Clopidrogel), to lower the risk of another event and to prevent clots from building up on stents

• Statins –to lower cholesterol and the risk of another myocardial infarction

25 World Health Organisation. ‘WHO STEPS Stroke Manual: The WHO STEPwise approach to stroke surveillance.’ 2006: Geneva, World Health Organisation

BNR-Stroke

The BNR uses the WHO stroke definition of a focal or global neurological impairment of sudden onset, lasting more than 24 hours (or leading to death), and of presumed vascular origin.26

Global impairment refers to patients with depressed consciousness or coma. The definition excludes coma of systemic vascular origin, transient ischaemic attacks (TIA), subdural haemorrhage, epidural haemorrhage, poisoning, and symptoms of trauma.

Treatment guidelines (stroke)

Current best practice for ischaemic stroke treatment20, 27suggests two main medications to be given during hospitalization with the aim of decreasing mortality.

• Thrombolysis is a “clot-busting” drug for urgent clot lysis, within 4.5 hours of symptom onset, to reperfuse – return blood flow to the tissue.

• Anti-thrombotic/ Anti-platelet therapy – to lower risk of a recurrent event: aspirin, or (if intolerant to aspirin) clopidogrel or dipyridamole

• Anti-coagulants/VTE Prophylaxis – used to prevent recurrent embolic stroke, atrial fibrillation, deep vein thrombosis or pulmonary embolus

• Statins – to lower cholesterol and the risk of recurrence: not routine, but recommended if patient already on statins or once not contra- indicated

26 National Institute for Health and Clinical Excellence, ‘Stroke: Diagnosis and immediate management of acute stroke and transient ischaemic attack.’ (2008) High Holborn: London.

27 Adams, H.P. Jr., del Zoppo, G., Alberts, M.J., Bhatt, D.L., Brass, L., Furlan, et al. Guidelines for the early management of adults with ischemic stroke : A guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Athero- sclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Interdisciplinary Working Groups: The American Academy of Neurology affirms the research value of this guideline as an educational tool for neurologists. Stroke. (2007) (38):1655-1711

Appendix C

Glossary of Terms

Age and sex stratified incidence rates: national surveillance data are described by age and gender groupings to give a clinical picture of the distribution of the disease in a country. Review of this information may provide clinically relevant, but not always statistically significant differences.

An age-adjusted rate is a weighted average of the age-specific rates, where the weights are the proportions of persons in the corresponding age groups of a standard population.

Crude and age-standardised incidence rates: to objectively measure the frequency of the disease within the population – incidence is used. It allows the report to state the numbers per a certain amount of the population. Given the significant time that has passed since the national census, we chose to use the United Nation population estimates for the years 2011-2020 for Barbados.

CT (computerised tomography) and MRI (magnetic resonance imaging) refer to two of the most common tests which may be used to diagnose a stroke event, and to classify its sub- type.

Incidence rate: An incidence rate is the number of new disease events occurring in a specified population during a year, usually expressed as the number of events per 100,000 population at risk. That is, Incidence rate = (New events / Population) × 100,000

The numerator of the incidence rate is the number of new disease events; the denominator is the size of the population. The number of new events may include multiple events occurring in one patient. In general, the incidence rate would not include recurrences (where recurrence is defined as a presentation to the healthcare system within a certain period of the initiating event).

Intracerebral haemorrhage: Stroke symptoms which may arise from the bleeding from intracerebral arteries.

Ischaemic stroke: Stroke symptoms which are known to originate from an occlusion (blockage) of cerebral arteries.

Subarachnoid haemorrhage: Stroke symptoms which arise from bleeding from intra-cranial arteries, resulting in blood arising between the two membranes which surround the brain.

Mortality rate: A mortality rate is the number of deaths, with the disease (stroke or AMI) as the underlying cause of death, occurring in a specified population during a year. Mortality is usually expressed as the number of deaths due to the disease per 100,000 population. That is, Mortality rate = (Disease Deaths/Population) × 100,000

The numerator of the mortality rate is the number of deaths; the denominator is the size of the population.

Number of cases: the overall number of events reported in a country. It can be used to inform the resources required by the health system.

Subarachnoid haemorrhage: Stroke symptoms which arise from bleeding from intra-cranial arteries, resulting in blood arising between the two membranes which surround the brain.

Published and printed by:

The Barbados National Registry for Chronic Non-Communicable Disease (BNR) George Alleyne Chronic Disease Research Centre, The University of the West Indies Jemmott’s Lane St Michael BB 11115 Barbados

Telephone: +246 426 6416 +246 256 4267

Email: bnr@cavehill.uwi.edu Website: www.bnr.org.bb

This report should be cited as:

Sobers N, Campbell JM, Forde SA, Henry A, Corbin D, Delice R, Anderson, SA, Hambleton I, Cardiovascular Disease in Barbados: Report of the BNR-Cancer. The George Alleyne Chronic Disease Research Centre, The University of the West Indies, St Michael, Barbados, November 2022