Differences in ischemic and hemorrhagic recurrence rates among race-ethnic groups in the PRoFESS secondary stroke prevention trial


  • Conrado J. Estol,

    Corresponding author
    • Correspondence: Conrado J. Estol, Neurology and Vascular Disease Prevention Unit, Av. Callao 1875, C1023, Buenos Aires, Argentina.

      E-mail: conrado.estol@stat-research.com

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  • Philip M. W. Bath,

  • Philip B. Gorelick,

  • Daniel Cotton,

  • Renee Hebert Martin,

  • PRoFESS Publications Committee and PRoFESS Investigators

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    • PRoFESS Publications Committee: H.-C. Diener (chair), P. Bath, G.A. Donnan, D. Cotton, C. Estol, L. Hilbrich, M. Humphreys, S. Ôunpuu, R. Roberts, P. Teal, D. Toni, R. Sacco, S. Yusuf.

  • Conflict of interest: Dr. Conrado J. Estol and Ms. Renee Hebert Martin have nothing to disclose. Dr. Philip M. W. Bath received consulting fees from Boehringer Ingelheim. Dr. Philip B. Gorelick received consulting fees from AstraZenica/Quintiles, Bayer, Janssen, Takeda, Roche/Parexel, Shire, Brainsgate, and D-Pharm, and lecture fees from Boehringer Ingelheim. Mr. Daniel Cotton is an employee of Boehringer Ingelheim.
  • The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors and were fully responsible for all content and editorial decisions, and were involved at all stages of manuscript development. The authors received no compensation related to the development of the manuscript. This work was supported by Boehringer Ingelheim Pharmaceuticals, Inc. (BIPI). BIPI was given the opportunity to check the data used in the manuscript for factual accuracy only.


Background and Aims

Epidemiological studies show that vascular risk factors are the same across the world but their effect vary between different race-ethnic groups. However, few studies have evaluated differences in recurrent stroke rates in various race-ethnicities. In >20 000 patients spanning 35 countries encompassing most race-ethnicities, we evaluated the incidence of ischemic and hemorrhagic strokes and myocardial infarction in patients within the context of the largest secondary stroke prevention trial (Prevention Regimen for Effectively Avoiding Secondary Strokes) to identify any significant differences.


There were 20 332 patients with a recent ischemic stroke randomized in a factorial design to receive the antiplatelet agent clopidogrel vs. aspirin plus extended-release dipyridamole, and 80 mg of the anthypertensive telmisartan vs. placebo. The primary outcome for the trial was the time to any recurrent stroke. Statistical analysis was used to detect race-ethnic differences in recurrent vascular events.


Mean patient age was 66 (±8·6) years and 36% were women. The study included 58% European/Caucasian, 33% Asians, 5% Latin/Hispanic, and 4% Black African. There were 74% of patients that were hypertensive, and average systolic and diastolic blood pressure was 144·1/83·8 mmHg. There was at least one significant difference in the overall test of all race-ethnic groups in myocardial infarction and symptomatic intracerebral hemorrhage occurrence. In the Kaplan–Meier hemorrhage and stroke-free survival curves, Asians showed a significantly higher recurrence of ischemic stroke risk in the 135–150 mmHg and greater than 150 mm Hg blood pressure groups, and a greater risk of hemorrhage recurrence in the greater than 150 mmHg blood pressure group.


We found a significant difference in myocardial infarction and symptomatic intracerebral hemorrhage recurrence among different race-ethnic groups. The risk of recurrent ischemic and hemorrhagic stroke was greater in Asians with high blood pressure.