C. Cantú-Brito et al.

Letters to the editor

with atrial fibrillation: full text: a report of the
American College of Cardiology/American
Heart Association Task Force on practice
guidelines and the European Society of Car-
diology Committee for Practice Guidelines.
Europace 2006; 8:651–745.
2 Page RL, Wilkinson WE, Clair WK,
McCarthy EA, Pritchett EL. Asymptomatic
arrhythmias in patients with symptomatic
paroxysmal atrial fibrillation and paroxysmal
supraventricular tachycardia. Circulation
1994; 89:224–7.
3 Hindricks G, Pokushalov E, Urban L et al.
Performance of a new leadless implantable
cardiac monitor in detecting and quantifying
atrial fibrillation. Results of the XPECT trial.
Circ Arrhythm Electrophysiol 2010; 3:141–7.
The first Mexican multicenter
register on ischaemic stroke
(The PREMIER Study):
demographics, risk factors
and outcome
The readers of the International Journal
of Stroke may be interested to know that
in Mexico, information on acute care
and long-term outcome of patients
with ischaemic stroke (IS) and transient
ischaemic attack (TIA) is still unknown.
The Mexican PREMIER registry, a multi-
centre first-step stroke surveillance sys-
tem, was designed to investigate on risk
factors, acute care, secondary prevention
strategies and long-term outcome of
patients with IS and TIA. Here, we
present information on acute care and
one-year outcome of the IS cohort.
A total of 1376 patients (52% women,
mean age 68
5-years) were registered
from January 2005 to June 2006. Of
these cases, 1246 (91%) corresponded
to IS (mean NIHSS at admission: 12
8
points) and 130 (9%) to TIA. Risk
factors, acute care practices, IS subtypes
and long-term management were re-
corded. Five visits were completed dur-
ing one-year of follow-up.
Main risk factors were hypertension
(65%), obesity (51%) and diabetes
(35%). IS mechanisms were registered
as follows (see Table 1): 8% large-artery
atherosclerosis, 20% cardioembolism,
20% lacunes, 5% miscellaneous mechan-
isms and 41% undetermined aetiology.
Only 0
6% patients received IV throm-
bolysis (23% arriving in o3 h after
stroke onset) and 1% endarterectomies
or stentings. The 30-day case fatality rate
in IS patients was 15%. One year after the
brain infarction, one-third of the pa-
tients had mRS 0–1 (functionally inde-
pendent), one-third had mRS 2–5
(dependent) and another third died.
The one-year recurrence rate (1183 acute
survivors) was 11%.
As shown here, largely modifiable
risk factors are responsible for IS in
Mexico (1). A quarter of IS patients
arrive on time for thrombolysis, but
o1% of patients receive this manage-
ment, a characteristic of developing
countries (2). We observed that most
IS cases are of undetermined aetiology,
which denounces a low use of diagnostic
resources. Knowledge is needed for ac-
tion; thus, multitask efforts are impera-
tive to change this scenario in low-
income countries (3).
Carlos Cantú-Brito1,
José L. Ruiz-Sandoval2,
Luis M. Murillo-Bonilla3,
Erwin Chiquete4, Carolina
León-Jiménez5, Antonio Arauz6,
Jorge Villarreal-Careaga7,
Fernando Barinagarrementeria8,
Alma Ramos-Moreno9,
and the PREMIER Investigators
1
Department of Neurology, Instituto Nacional
de Ciencias Medicas y Nutricion Salvador
Zubiran, Mexico City, México
2
Department of Neurology, Hospital Civil de
Guadalajara ‘Fray Antonio Alcalde’,
Guadalajara, México
3
Department of Neurology, Facultad de
Medicina, Universidad Autónoma de
Guadalajara, Guadalajara, México
4
Department of Internal Medicine, Hospital
Civil de Guadalajara ‘Fray Antonio Alcalde’,
Guadalajara, México
5
Department of Neurology, Hospital Valentı́n
Gomez Farı́as, Zapopan, México
6
Stroke Clinic, Instituto Nacional de Neurologı́a
y Neurocirugı́a, Mexico City, México

Table 1 Gender, stroke severity on admission and short-term clinical outcome by aetiological subtypes of ischaemic stroke patients (n 5 1246)

LAA Lacunar CE Mixed Other Undetermined

Total (n 5 105, (n 5 250, (n 5 246, (n 5 69, (n 5 63, (n 5 513, P
(n 5 1246) 8
4%) 20
1%) 19
7%) 5
5%) 5
1%) 41
2%) value

Gender (%)
Female 51
6 43
8 43
6 61
0 53
6 63
5 50
9
Male 48
4 56
2 56
4 39
0 46
4 36
5 49
1 0
001
Age, median 71 (58–80) 75 (66–78) 69 (59–76) 75 (62–83) 76 (67–85) 48 (34–65) 70 (58–80) o0
001
(interquartile range), years
NIHSS score (%) n 5 1223 n 5 105 n 5 240 n 5 242 n 5 68 n 5 59 n 5 509
r8 39
5 47
6 69
2 30
6 41
2 40
7 27
7
9–18 36
5 34
3 27
5 35
5 33
8 40
7 41
7 o0
001
418 24
0 18
1 3
3 33
9 25
0 18
6 30
6
30-day outcome (%)
mRS: 0–1 22
8 22
9 35
6 17
1 21
7 38
1 17
5
mRS: 2–3 31
1 35
2 52
8 26
0 37
7 25
4 21
8 o0
001
mRS: 4–5 31
0 33
3 7
6 35
8 31
9 25
4 40
2
Death 15
2 8
6 4
0 21
1 8
7 11
1 20
5 o0
001
Data were missing for 23 patients.CE, cardioembolism; LAA, large-artery atherosclerosis; NIHSS, National Institutes of Health stroke scale.

& 2011 The Authors.

International Journal of Stroke & 2011 World Stroke Organization Vol 6, February 2011, 90–94 93
 Letters to the editor
7
Department of Neurology, Hospital General de
Culiacán, Culiacan, México
8
Department of Neurology, Hospital Angeles de
Querétaro, Querétaro, México
9
Strategic Clinical Research, Mexico City, México
Correspondence: Carlos Cantú-Brito,
Department of Neurology, Instituto Nacional
de Ciencias Médicas y Nutrición Salvador
Zubirán, Vasco de Quiroga #15, Col. Sección
XVI, Tlalpan, Mexico City 14439, Mexico.
E-mail: carloscantu_brito@hotmail.com
94
DOI: 10.1111/j.1747-4949.2010.00549.x
References
1 Cantu-Brito C, Majersik JJ, Sánchez BN et al.
Hospitalized stroke surveillance in the com-
munity of Durango, Mexico: the brain attack
surveillance in Durango study. Stroke 2010;
41:878–84.
International Journal of Stroke & 2011 World Stroke Organization Vol 6, February 2011, 90–94
C. Cantú-Brito et al.
2 Durai Pandian J, Padma V, Vijaya P, Sylaja PN,
Murthy JM. Stroke and thrombolysis in
developing countries. Int J Stroke 2007; 2:
17–26.
3 Mendis S. Prevention and care of stroke in
low- and middle-income countries; the need
for a public health perspective. Int J Stroke
2010; 5:86–91.
& 2011 The Authors.