Vol 5 No 1 full text edit.indd Althea Medical Journal. 2018;5(1) 32 AMJ March 2018 Demographic and Risk Factors of Intracerebral Hemorrhage Stroke Patients in Dr. Hasan Sadikin General Hospital Bandung in 2007–2016 Sabrina Putri Lofissa,1 Paulus Anam Ong,2 Nur Atik3 1Faculty of Medicine Universitas Padjadjaran, 2Department of Neurology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Basic Medicine Faculty of Medicine Universitas Padjadjaran Bandung, Indonesia Abstract Background: Intracerebral hemorrhage stroke is a type of stroke which is considered to have a higher mortality risk than ischemic stroke. Preventive programs are needed to minimize stroke cases by reducing the risk factors. This study aimed to identify the demographic and risk factors of intracerebral hemorrhage stroke patients in Dr. Hasan Sadikin General Hospital Bandung in 2007–2016. Methods: This was a descriptive cross sectional study. Data were obtained from Dr. Hasan Sadikin General Hospital medical resume January 2007- December 2016 by total sampling. Subjects of this study were intracerebral hemorrhage stroke patients hospitalized in Dr. Hasan Sadikin General Hospital. The period of study was from August 2016 until May 2017. Variables included in this study were gender, occupation, education level, age; risk factors such as hypertension, dyslipidemia, diabetes mellitus, hyperuricemia, and kidney disease. The collected data were presented in percentage. Results: The highest demographic prevalence in 10 years was in female, non-occupational person, elementary school graduate, and frequently found in the 50-59 age group. The highest risk factor was hypertension, but it slightly decreased from 78.8% in 2007-2008 to 55.3% in 2015-2016, followed by dyslipidemia, diabetes mellitus, hyperuricemia which increased in 2007-2008 and 2015-2016. (Dyslipidemia: from 8.1% to 23.8%; Hyperuricemia: from 2.5% to11.2%; Diabetes Mellitus: from 6.6% to 8.9%). Conclusions: The demographic of intracerebral hemorrhage stroke shows a high prevalence found in females, older age, non-occupational persons, and elementary school graduates. Among the risk factors, hypertension is most likely to happen in ten years. Keywords: Demography, intracerebral hemorrhage stroke, risk factors Correspondence: Sabrina Putri Lofissa, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Email: putrilofissa@gmail.com Introduction Intracerebral hemorrhage stroke is one type of stroke which is considered to have a higher mortality risk than ischemic stroke.1 According to the World Health Organization (WHO), stroke was defined as rapidly developed clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death, with no other apparent cause than cerebrovascular disease.2 Based on a Basic Health Research (Riset Kesehatan Dasar, Riskesdas), the national stroke prevalence showed an increased prevalence from 8.3 per 1000 population in 2007 to 12.1 per 1000 population in 2013.3 According to WHO, the stroke itself ranks first in the mortality rate in Indonesia about 328.000 in 2012.4 West Java Province has the highest estimated number of stroke patients around 238.001 people (7.4‰) and 533.895 people (16.6‰) based on health personnel (Tenaga kesehatan, Nakes) or based on diagnosis/symptoms.5 Intracerebral hemorrhagic are considered to have a higher mortality than ischemic stroke.1 The risk factors are divided into non-modifiable and modifiable risk factors. Some of modifiable risk factors are hypertension, obesity, smoking, diabetes mellitus, hyperuricemia, and heavy alcohol consumption, while the non-modifiable risk factors are age, race, sex, and genetics.6,7 Due to the lack of intracerebral hemorrhage stroke data in Indonesia, especially in West Java AMJ. 2018;5(1):32–7 ISSN 2337-4330 || doi: http://dx.doi.org/10.15850/amj.v5n1.1333 Althea Medical Journal. 2018;5(1) 33 Province which was known to have the most stroke patients in Indonesia, this study was carried out to identify the demography and risk factors among intracerebral hemorrhagic patients at Dr. Hasan Sadikin General Hospital as a referral hospital in West Java. Methods The method used in this study was a descriptive cross sectional design which was carried out at the Department of Neurology, Dr. Hasan Sadikin General Hospital from August 2016 to May 2017. The ethics approval has been obtained from Dr. Hasan Sadikin General Hospital and the Faculty of Medicine, Universitas Padjadjaran Health Research Ethics Committee before starting to collect data. The data involved were medical resumes from January 2007 to December 2016 by total sampling with 2259 sample size. The inclusion criteria subjects were intracerebral hemorrhage stroke patients diagnosed in the first admission approved by a computed tomography (CT) scan and hospitalized from 2007 to2016 at Dr. Hasan Sadikin General Hospital. Incomplete data or missing data of intracerebral hemorrhagic patients’ medical resume were excluded in this study. The variables of demography characteristics included in this study were age, gender, educational level, and occupation. The other variables based on risk factors were hypertension, dyslipidemia, hyperuricemia, diabetes mellitus, and kidney disease. Furthermore, data was processed by Microsoft Office Excel 2010 and presented in tables. Results Among 2259 intracerebral hemorrhagic patients at Dr. Hasan Sadikin General Hospital in the period of 2007-2016; only 1168 patients met the inclusion criteria (aged 14-86 years). The total inclusion subjects consisted of 514 male (aged 15-86 years) and 654 female (aged 14-86 years) (Table 1). The intracerebral hemorrhagic stroke increases with age. The highest age category was 50-59, while the lowest prevalence occurred at age <40 years with an increase in prevalence from 4% in 2007-2008 to 12.2% in 2015-2016 (Table 2). Moreover, non-occupation patients had the highest prevalence in 2007-2016. Among them were students, housewives, the unemployed and retiree, followed by blue collars and agricultural workers such as farmers, fishermen, and laborers. Meanwhile, employee and entrepreneur were the two jobs with the lowest prevalence, with an increased prevalence reaching 18.8% for employee and Sabrina Putri Lofissa, Paulus Anam Ong, Nur Atik: Demographic and Risk Factors of Intracerebral Hemorrhage Stroke Patients in Dr. Hasan Sadikin General Hospital Bandung in 2007-2016 Table 1 Demographic Characteristic based on Gender in 2007-2016 Gender 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % Male 119 47.0 103 36.3 99 42.7 97 48.0 96 48.7 Female 134 53.0 181 63.7 133 57.3 105 52.0 101 51.3 Total 253 100 284 100 232 100 202 100 197 100 Table 2 Demographic Characteristic based on Age Category in 2007-2016 Age Category (years 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % <40 10 4 11 3.9 25 10.8 14 7 24 12.2 40-49 51 20.2 57 20.1 45 19.3 37 18.3 53 27 50-59 78 30.8 112 39.4 61 26.3 73 36.1 61 30.9 60-69 73 28.8 63 22.2 60 25.9 41 20.3 41 20.8 ≥70 41 16.2 41 14.4 41 17.7 37 18.3 18 9.1 Total 253 100 284 100 232 100 202 100 197 100 Althea Medical Journal. 2018;5(1) 34 AMJ March 2018 14.2% for entrepreneur in 2015-2016 (Table 3). Based on the difference of educational level; patients who graduated from elementary school or less, were the highest prevalence within 10 years with a declining prevalence in 2015-2016. Meanwhile, a decrease in prevalence was shown at the higher educational level among diploma/college/ university graduate patients (Table 4). Moreover, based on risk factors, the subjects had one or more risk factors. Hypertension was the highest risk factor, with the decreasing prevalence from 78.8% in 2007-2008 to 55.3% in 2015-2016, followed by dyslipidemia, diabetes mellitus, and hyperuricemia with an increased prevalence in 2015-2016. Meanwhile, there were no significant changes of kidney disease from year to year (Table 5). Discussion A hospital based study showed that male predominated by 51% between the ages of 21- 78 and the mean age is 50 years. The female Table 3 Demographic Characteristic based on Occupation in 2007-2016 Occupation 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % Non-occupation 152 60.1 186 65.5 153 65.9 117 57.9 109 55.3 Occupation White collar worker Employee 39 15.4 19 6.7 10 4.3 17 8.4 37 18.8 Entrepreneur 5 2.0 23 8.1 35 15.1 23 11.4 28 14.2 Blue collar and agricultural Worker 57 22.5 56 19.7 34 14.7 45 22.3 23 11.7 Total 253 100.0 284 100.0 232 100.0 202 100.0 197 100.0 Table 4 Demographic Characteristic based on Education Level in 2007-2016 Education Level Graduates 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % Elementary school/ less 187 74 219 77.1 131 56.5 132 65.4 102 51.8 JHS 32 12.6 34 12 68 29.3 35 17.3 33 16.7 SHS 33 13.0 29 10.2 31 13.3 33 16.3 51 25.9 D/C/U graduates 1 0.4 2 0.7 2 0.9 2 1 11 5.6 Total 253 100 284 100 232 100 202 100 197 100 Note: JHS: Junior High School, SHS: Senior High School, D: Diploma, C: College, U: University Table 5 Modifiable Risk Factors in 2007-2016 Modifiable Risk Factor 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 n % n % n % n % n % Hypertension 252 78.8 283 65.1 228 71.7 200 62.7 193 55.3 Dislipidemia 26 8.1 95 21.8 47 14.8 68 21.3 83 23.8 Hyperuricemia 8 2.5 30 6.9 23 7.2 34 10.7 39 11.2 Diabetes Mellitus 21 6.6 25 5.7 20 6.3 14 4.4 31 8.9 Kidney Disease 13 4.1 2 0.5 0 0.0 3 0.9 3 0.9 Total 320 100.0 435 100.0 318 100.0 319 100.0 349 100.0 Althea Medical Journal. 2018;5(1) 35 is rather older with age ranging from 24-83 years with the mean age of 53 years.6 However, the results of this study showed female were greater in number than male within 10 years. Women in pregnancy or postpartum, the longer life expectancy, older age or over 75 years can be considered as the high prevalence found in female.7,8 In this study, the prevalence patient’ age of >70 years were greater in female with 51.1% in the recent two years (2015-2016). Stroke incidence increases with age and is expected to double in every decade between the ages of 45 to 85 years. It is most likely to occur between the ages of 55-64 years, while in the age below 40 years is still uncommon.6 The results of this study identified the highest prevalence was found in the age group 55-59 years and an increase of prevalence among age <40 in the last ten years. The increased prevalence among young adults (less than 40) in the recent years is associated with the increasing consumption of junk food and soda or sweet beverages which exceeds the recommended calories per day in young adults. Another factor is the prolong inactivity or less frequent physical activity increases the risk of cardiovascular disease.9 Based on a study conducted by the Korean Community Health Survey10 (KCHS) in 2010, 78.8% of the stroke patients are with no occupation. This study revealed those with no occupation within 10 years have the highest prevalence, followed by those who work as blue collar and agricultural workers, and least likely to occur among white collar workers who work as employees or entrepreneurs. The white collar workers tend to get adequate protection, supportive environmental conditions with lower physical demands, and were financially better, while those with no occupation and blue collar and agricultural workers are classified as a low socioeconomic group that have limited access to health facilities and tend to have minimal education. Other low socioeconomic groups such as laborers or other blue collar and agricultural workers are frequently affected by physical, chemical, and psychosocial exposure included noise and heat pollution and other environmental factors, thus increase the cardiovascular risk.10,11 However, in this study the low socioeconomic factor is still insufficient to conclude those with no occupation, and blue collar and agricultural workers have a high risk of stroke. The subjects with no occupations in this study were students, housewives, the unemployed and retired. This study showed that the prevalence of age above 50 years was greater than the age below 50, therefore the majority of the subjects might be considered as retired with old age. Based on the educational level, the result of this study showed that patients graduated from elementary school or less had the highest prevalence within 10 years and were 51.8% in the last two years, while those graduated from diploma/college/university had the lowest prevalence within 10 years, and were approximately 5.6% in the last two years. In agreement in this study, previous studies reported that educational attainment represents a form of health awareness and socioeconomic status. People with higher education also tend to have an urgency to understand the health consequences, while people with lower educational level are associated with cognitive impairment and unhealthy lifestyles.11,12 Based on the Interstroke study involving 22 countries reported that hypertension is the highest prevalence among intracerebral hemorrhagic patients with 83% (551/663), and stronger for intracerebral hemorrhagic than ischemic stroke.13 Chronic hypertension leads to vascular changes include fibroid necrosis (lipohyalinosis) of penetrating arteries and arterioles supplying the white matters, microaneurysm formation, luminal narrowing and microhemorrhage, all of which are susceptible to rupture.14,15 In this study, hypertension was the highest prevalence among intracerebral hemorrhagic patients and there was a decreasing hypertension prevalence from year to year. An increased awareness of people who have checked into health facilities could be a factor of decreasing hypertension prevalence.3 A study conducted by the Chongqin Center for Disease Control and Prevention in 2014 showed 37.4% dyslipidemia among stroke patients had hypertriglyceridemia and low High-density lipoprotein (HDL) cholesterol. This phenomenon is likely due to the high carbohydrates intake and high-fat-diets in recent decades, which affects the high serum triglyceride level.16 The result in this study is in agreement with the previous study that people with dyslipidemia were found in intracerebral hemorrhagic patients and 23.8% were in the last two years. Hyperuricemia was associated with cardiovascular disease and other risk factors such as hypertension, high triglyceride and cholesterol serum, and metabolic syndrome, though, the mechanism is poorly understood. However, the role of uric acid is Sabrina Putri Lofissa, Paulus Anam Ong, Nur Atik: Demographic and Risk Factors of Intracerebral Hemorrhage Stroke Patients in Dr. Hasan Sadikin General Hospital Bandung in 2007-2016 Althea Medical Journal. 2018;5(1) 36 AMJ March 2018 controversial since on the other hand uric acid has neuroprotective effects by acting as a free radical scavenger.17 In this study, the prevalence of hyperuricemia among intracerebral hemorrhagic patients increased from year to year, reaching 11.2% in recent two years. Furthermore, Interstroke study showed the prevalence of diabetes mellitus among intracerebral hemorrhagic patients were 10%.13 There is not much difference between the previous studies and ours since the recent prevalence in two years in this study were 8.6%. Diabetes mellitus is one of the cardiovascular risk that accelerates the atherosclerosis progression and damages microvasculature which leads to hypertension.2,6 In this study, kidney disease was the least likely to occur among intracerebral hemorrhagic patients and had no significant changes from year to year. Atherosclerosis Risk in Communities (ARIC) reported that a low creatinine clearance among Chronic Kidney Disease (CKD) and anemia were associated with the increase risk for stroke. A study in Japan18 revealed that CKD with macroalbuminuria are independent risk factors for stroke. However, a single kidney disease is still insufficient as an independent risk factor for stroke.18 In conclusion, the high prevalence among intracerebral hemorrhage stroke is frequently found in female, older age, non- occupation and low level of education person. Hypertension is the highest risk factor, followed by dyslipidemia, diabetes mellitus, and hyperuricemia with deleterious effect on microvasculature. Metabolic syndrome includes high cholesterol and plasma glucose level, high blood pressure, and hyperuricemia is associated with cardiovascular disease and diabetes mellitus type 2 which reflects the stroke patients. A bad lifestyle includes high intake calories from junk food, smoking and less physical activity are enough to explain the reason of increasing prevalence of diabetes mellitus, dyslipidemia, and hyperuricemia in the recent years in this study.17,19 This study had certain limitations. The cross-sectional design of this study was limited in analyzing the correlation between variables of intracerebral hemorrhagic stroke. Additionally, the retrospective study using medical resumes was also a limitation in this study since there were many missing data and unspecific information about the variables of this study. 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