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Until July 31, 2012, we followed 2, 589 participants for an average of 9.2 years. Six participants were lost to follow-up. Thirty-four participants were excluded for missing ABSI or CRP data, and a total of 2, 549 people were ultimately included in the analysis. Among the 2, 549 participants, 76 ischemic stroke events were recorded during the follow-up period. The cumulative incidence rates of ischemic stroke were 2.98% and the incidence density was 323 per 100, 000 person-years.
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Our study included 1, 045 males and 1, 504 females. The mean age of the participants was 46.50 ± 12.38 years at baseline. Table 1 presents the baseline characteristics among the 4 groups. Conventional stroke risk factors, such as age, gender, cigarette smoking, alcohol drinking, family history of CVD, hypertension status, BMI, FPG, TG, TC, LDL-C, and HDL-C were significantly different among the 4 groups. Participants with the a high level of ABSI in either the low CRP level or the high CRP level group tended to be older, smokers, drinkers, hypertensive, and have higher TC levels; those with high CRP levels in either the low ABSI or the high ABSI level groups were prone to be male, have higher levels of BMI, TG, LDL-C, FPG, a family history of CVD, and lower levels of HDL-C.
Items Low ABSI/ Low CRP High ABSI/ Low CRP Low ABSI/ High CRP High ABSI/ High CRP PValue* Number of participants 1, 495 418 424 212 Age (years) 42.92 ± 10.78 55.47 ± 2.32 45.66 ± 11.23 55.70 ± 11.74 < 0.0001 Male (%) 590 (39.41) 155 (36.73) 209 (49.64) 91 (43.54) 0.0004 Cigarette smoking (%) 604 (40.35) 214 (50.71) 201 (47.74) 112 (53.59) < 0.0001 Alcohol drinking (%) 437 (29.19) 160 (37.91) 160 (38.00) 94 (44.98) < 0.0001 Family history of CVD (%) 144 (9.62) 49 (11.61) 87 (20.67) 50 (23.92) < 0.0001 Hypertension (%) 440 (29.39) 190 (45.02) 202 (47.98) 121 (57.89) < 0.0001 BMI (kg/m2) 22.05 ± 3.21 21.56 ± 3.56 23.40 ± 3.71 22.91 ± 4.01 < 0.0001 ABSI (m11/6/kg2/3) 0.0781 ± 0.0036 0.0875 ± 0.0040 0.0790 ± 0.0031 0.0878 ± 0.0038 < 0.0001 TG (mmol/L) 0.81 (0.58-1.14) 0.96 (0.70-1.35) 1.38 (0.96-2.01) 1.55 (1.08-2.46) < 0.0001 TC (mmol/L) 3.45 (2.83-4.07) 3.85 (3.23-4.60) 3.74 (3.13-4.78) 4.22 (3.38-5.04) < 0.0001 LDL-C (mmol/L) 2.04 (1.51-2.63) 2.36 (1.78-3.11) 2.36 (1.73-3.21) 2.61 (1.90-3.37) < 0.0001 HDL-C (mmol/L) 1.17 (0.98-1.38) 1.19 (1.01-1.43) 1.03 (0.86-1.27) 1.09 (0.92-1.30) < 0.0001 FPG (mmol/L) 4.7 (4.2-5.2) 4.6 (4.2-5.2) 5.3 (4.9-5.8) 5.6 (4.9-6.3) < 0.0001 logCRP (mg/L) 0.66 ± 0.24 0.70 ± 0.21 1.28 ± 0.17 1.33 ± 0.19 < 0.0001 Note.*CVD, cardiovascular disease; BMI, body mass index; ABSI, a body shape index; TG, triglyceride; TC, total cholesterol; LDL-C, low density lipoprotein cholesterol; HDL-C, high density lipoprotein cholesterol; FPG, fasting plasma glucose; CRP, C-reactive protein. Table 1. Baseline Characteristics of 4 Subgroups According to ABSI and CRP Levels among 2, 549 Participants
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Table 2 shows the multivariable adjusted HR for the association of ABSI and CRP levels with the risk of incident ischemic stroke. In crude models, high ABSI and high CRP levels were significantly associated with the risk of ischemic stroke with HRs (95% CI) of 3.67 (2.34-5.75) and 1.94 (1.22-3.08), respectively. After multivariate adjustments, HRs (95% CI) for ischemic stroke among the participants with high ABSI and high CRP levels were 1.46 (0.89-2.39) and 1.63 (0.95-2.79), respectively, compared to those with low ABSI or low CRP levels. Moreover, 1-SD increment of ABSI and logarithm CRP were 1.18 (0.94-1.47) and 1.18 (0.90-1.55), respectively.
Items Unadjusted Age and Gender Adjusted Multivariable Adjusted* HR 95% CI HR 95% CI HR 95% CI Low ABSI 1.00 reference 1.00 reference 1.00 Reference High ABSI 3.67 (2.34-5.75) 1.34 (0.82-2.19) 1.46 (0.89-2.39) ABSI (per 1 SD) 1.61 (1.41-1.83) 1.13 (0.90-1.42) 1.18 (0.94-1.47) Low CRP 1.00 reference 1.00 Reference 1.00 reference High CRP 1.94 (1.22-3.08) 1.61 (1.01-2.56) 1.63 (0.95-2.79) logCRP (per 1 SD) 1.30 (1.05-1.62) 1.17 (0.93-1.46) 1.18 (0.90-1.55) Note.*Adjusted for age, gender, alcohol drinking, cigarette smoking, hypertension, FPG, TG, HDL cholesterol, family history of CVD, CRP (only adjusted in models for ABSI) and BMI (only adjusted in models for CRP). Table 2. Hazard Ratios and 95% Confidence Intervals of Ischemic Stroke with ABSI and CRP
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Figure 1 presents the Kaplan-Meier curves for cumulative incidence rates of ischemic stroke among the 4 groups according to ABSI and CRP levels. During the average 9.2 years of follow-up, the cumulative incidence rates of ischemic stroke among the low ABSI/low CRP, low ABSI/high CRP, high ABSI/low CRP, and high ABSI/high CRP level groups were 1.83%, 2.18%, 4.89%, and 9.71%, respectively (P < 0.0001). The cumulative incidence of ischemic stroke was highest in the high ABSI/high CRP level group.
Table 3 presents the unadjusted and multivariate adjusted HRs (95% CI) for ischemic stroke for the different combinations of ABSI and CRP levels. Compared with the low ABSI/low CRP level group, the unadjusted HRs (95% CIs) for ischemic stroke in the low ABSI/high CRP, high ABSI/low CRP and high ABSI/high CRP level groups were 1.21 (0.57-2.58), 2.80 (1.57-4.99), and 5.82 (3.27-10.39), respectively. After adjusting for multivariate factors including age, gender, cigarette smoking, alcohol drinking, hypertension, FPG, family history of CVD, TG, and HDL-C, the HRs (95% CIs) for ischemic stroke for the low ABSI/high CRP, high ABSI/low CRP, and high ABSI/high CRP level groups were 1.04 (0.46-2.35), 1.06 (0.58-1.95), and 2.52 (1.27-5.00), respectively. The HR for the high ABSI/high CRP level group remained significant although it decreased. In addition, no significant interaction was observed between ABSI and CRP levels on ischemic stroke risk in the multivariable analysis (P = 0.110).
Items Events Person-years Unadjusted Age and Gender Adjusted Multivariable Adjusted* HR 95% CI HR 95% CI HR 95% CI Low ABSI/Low CRP 27 13948 1.00 (reference) 1.00 (reference) 1.00 (reference) Low ABSI/High CRP 9 4005 1.21 (0.57-2.58) 0.98 (0.46-2.09) 1.04 (0.46-2.35) High ABSI/Low CRP 20 3721 2.80 (1.57-4.99) 0.93 (0.50-1.71) 1.06 (0.58-1.95) High ABSI/High CRP 20 1860 5.82 (3.27-10.39) 2.12 (1.16-3.88) 2.52 (1.27-5.00) ABSI × CRP 1.72 (0.65-4.56) 2.34 (0.88-6.21) 2.30 (0.83-6.36) Note.*Adjusted for age, gender, alcohol drinking, cigarette smoking, hypertension, FPG, TG, HDL cholesterol, family history of CVD. FPG: fasting plasma glucose, TG: triglyceride, HDL: high density lipoprotein cholesterol. Table 3. Adjusted Hazard Ratios for Ischemic Stroke Incidence According to ABSI with CRP Level
ROC curves which demonstrated the predictive values of ABSI, BMI, WC, and CRP on the risk of ischemic stroke are shown in Figure 2. The AUCs (95% CIs) of ABSI, CRP, BMI, and WC were 0.706 (0.688-0.724), 0.585 (0.565-0.604), 0.537 (0.517 -0.556), and 0.572 (0.552-0.591), respectively. The AUC of ABSI was significantly higher than that of BMI (P = 0.0002), WC (P = 0.0001), and CRP (P = 0.0024).
Figure 2. Area under the curve for the prediction of ischemic stroke incidence according to the baseline ABSI, CRP, BMI, and WC levels. The AUCs of ABSI, BMI, WC, and CRP were 0.706 (0.688-0.724), 0.537 (0.517 -0.556), 0.572 (0.552-0.591), and 0.585 (0.565-0.604), respectively. The AUC of ABSI is significantly higher than that of BMI (P = 0.0002), WC (P = 0.0001) and CRP (P = 0.0024).