Heart Disease and Stroke Statistics-2019 Update: A Report From the American Heart Association

Spatiotemporal and Demographic Trends and Disparities in Cardiovascular Disease Among Older Adults in the United States Based on 181 Million Hospitalization Records

Background

The US population is aging, with concurrent increases in cardiovascular disease (CVD) burdens; however, spatiotemporal and demographic trends in CVD incidence in the US elderly have not been investigated in detail. This study aims to characterize trends from 1991 to 2014 in CVD hospitalizations among US Medicare beneficiaries, aged 65+ years, by single year of age/sex/race/state using records from the US Centers for Medicare & Medicaid, covering 98% of older Americans.

Methods and Results

We abstracted 181 202 758 US Centers for Medicare & Medicaid hospitalization records indicating CVD in any of 10 diagnosis codes; tabulated total cases of CVD by sex, age, race, state, and calendar year (1991–2014); and normalized hospitalization counts to standardize over data batches. Stratum‐specific hospitalization rates were calculated using US Centers for Medicare & Medicaid records and US Census population counts; a cubic polynomial function was fit to year‐specific distributions of rates by single year of age. Nationwide, CVD‐related hospitalization rates increased from 1991 to 2014. Differences between hospitalization rates at age 65 and 66 years, representing magnitude of healthcare deferral until Medicare onset, increased by 7.49 per 100 people 1991 to 2006 overall, and were largest among blacks and Native Americans. Rates of CVD hospitalizations were consistently highest in the Midwest/Deep South. Evidence of misclassification of race/ethnicity in US Centers for Medicare & Medicaid hospitalization records in the 1990s was noted.

Conclusions

Trends in CVD‐related hospitalization rates among older Americans highlight the essential need for targeted policies to reduce CVD burdens, to improve reporting of race/ethnicity in large administrative databases, and to enhance access to affordable healthcare.

Serum Uric Acid - Risk Factor for Acute Ischemic Stroke and Poor Outcomes

Over the last decades several studies among the adult population have attempted to establish a correlation between the risk of stroke incidence and serum uric acid (SUA) concentration, and how these levels influence the patient’s neurological outcome after a stroke. But, to date, the results are conflicting. In this review, an extensive literature search was performed through PubMed for articles published until May 2019 to review the association. The study selection was narrowed by searching PubMed database using the Medical Subject Headings (MesH) and associated keywords. Only articles conducted in English and on human subjects were included. We considered an article for this review if it had statistics on either the incidence, stroke mortality or post-stroke functional outcomes along with serum uric acid levels in adults.

This review includes 21 articles with data of 33,580 cases of stroke and 1,100,888 participants. We can divide the articles reviewed into two separate cohorts of studies. One relates serum uric acid levels to stroke frequency and mortality, while the other is associated with serum uric acid and outcomes for stroke survivors. Based on our review, no significant relationship is observed with uric acid exhibiting protective effects on stroke outcome. Large clinical trials are advised to provide well-defined solutions to further assess the benefits of uric acid level lowering treatment in patients of vascular events, such as a stroke. However, we confidently report that increasing uric acid levels poses a higher risk for incidence of stroke.

Corticospinal Tract Injury Estimated From Acute Stroke Imaging Predicts Upper Extremity Motor Recovery After Stroke

Background and Purpose- Injury to the corticospinal tract (CST) has been shown to have a major effect on upper extremity motor recovery after stroke. This study aimed to examine how well CST injury, measured from neuroimaging acquired during the acute stroke workup, predicts upper extremity motor recovery. Methods- Patients with upper extremity weakness after ischemic stroke were assessed using the upper extremity Fugl-Meyer during the acute stroke hospitalization and again at 3-month follow-up. CST injury was quantified and compared, using 4 different methods, from images obtained as part of the stroke standard-of-care workup. Logistic and linear regression were performed using CST injury to predict ΔFugl-Meyer. Injury to primary motor and premotor cortices were included as potential modifiers of the effect of CST injury on recovery. Results- N=48 patients were enrolled 4.2±2.7 days poststroke and completed 3-month follow-up (median 90-day modified Rankin Scale score, 3; interquartile range, 1.5). CST injury distinguished patients who reached their recovery potential (as predicted from initial impairment) from those who did not, with area under the curve values ranging from 0.70 to 0.8. In addition, CST injury explained ≈20% of the variance in the magnitude of upper extremity recovery, even after controlling for the severity of initial impairment. Results were consistent when comparing 4 different methods of measuring CST injury. Extent of injury to primary motor and premotor cortices did not significantly influence the predictive value that CST injury had for recovery. Conclusions- Structural injury to the CST, as estimated from standard-of-care imaging available during the acute stroke hospitalization, is a robust way to distinguish patients who achieve their predicted recovery potential and explains a significant amount of the variance in poststroke upper extremity motor recovery.

Complex Evolution of Epidemiology of Vascular Diseases, Including Increased Disease Burden: From 2000 to 2015

BACKGROUND

Vascular diseases, encompassing coronary heart disease (CHD), cerebrovascular disease (CVD), and peripheral artery disease (PAD), are leading causes of the global mortality and morbidity burdens. Our objective was to evaluate the temporal trends in the burden of vascular diseases in the province of Quebec from 2000 to 2015.

METHODS

We identified subjects aged ≥ 20 years with vascular diseases in the Quebec Integrated Chronic Disease Surveillance System (a combination of 5 provincial health administrative datasets). We identified Quebecers with CHD, CVD, or PAD by tracking codes identifying vascular diseases (and interventions for CHD) in the hospitalization datasets. We used the 2011 Quebec standard population for age standardization.

RESULTS

In 2015, the crude prevalence of vascular diseases was 7.3% (n = 473,305), and the all-cause crude mortality rate was 6.6% (n = 31,320). Age-standardized prevalence of vascular diseases increased relatively by 21.4% between 2000 (5.6%; 99% confidence interval [CI], 5.5-5.6) and 2015 (6.8%; 99% CI, 6.7-6.8), whereas the age-standardized incidence and mortality rates showed relative decreases of 46.2% and 32.6%, respectively. PAD and CVD had lower prevalence and incidence but higher mortality than CHD. Most patients with CHD only had this vascular disease in contrast to patients with PAD who generally had diseases involving more than 1 vascular bed. CHD only and CHD with PAD ranked first and second, respectively, in mortality burdens.

CONCLUSIONS

During the last decade, the age-standardized incidence and mortality rate of vascular diseases declined, but their prevalence increased with the overall burden of vascular diseases remaining substantial in Quebec, Canada.

Migraine headache: Is it only a neurological disorder? Links between migraine and cardiovascular disorders

Migraine headache (MH) is a common disorder affecting millions of people in the United States. MH is substantially more prevalent in women compared to men. An association between migraine with or without aura and risk of cardiovascular disease (CVD) has been extensively reported. There are several proposed theories that may explain the pathophysiologic relationship between MH and CVD. This review will summarize the recent literature on this topic and provide an evidence-based perspective regarding the current knowledge and controversies regarding association of MH and CVD.

Clinical Validation of Nursing Diagnoses Related to Self-Care Deficits in Patients with Stroke

To clinically validate the defining characteristics of nursing diagnoses related to self-care deficits in feeding, bathing, toileting, and dressing in patients with stroke. A diagnostic accuracy study was conducted with a sample of 135 patients with stroke. Sensitivity and specificity were calculated based on the latent class analysis method using the random effects model. The prevalence of diagnoses was 23.5% for Bathing self-care deficit, 18.5% for Dressing self-care deficit, 13.3% for Toileting self-care deficit, and 7.5% for Feeding self-care deficit. Fourteen defining characteristics were sensitive, and 17 were specific. Hemorrhagic stroke and note 4 on the Rankin scale was associated with self-care deficits. Of the 37 defining characteristics of the four diagnoses studied, 19 were clinically validated according to the latent class analysis model. These most accurate clinical indicators contribute to the development of the care plan for patients with stroke.

Wearable Technology To Reduce Sedentary Behavior And CVD Risk In Older Adults: A Pilot Randomized Clinical Trial

Background

Physical exercise is associated with decreased cardiovascular disease (CVD) risk, but recent large-scale trials suggest that exercise alone is insufficient to reduce CVD events in high-risk older adults.

Purpose

This pilot randomized clinical trial aimed to collect critical data on feasibility, safety, and protocol integrity necessary to design a fully powered randomized controlled trial (RCT) and evaluate the impact of combining structured exercise with an intervention designed to enhance non-exercise physical activity (EX+NEPA) compared to EX alone.

Methods

Forty participants aged ≥60 years with moderate-to-high risk of coronary heart disease events were randomly assigned to either the EX+NEPA or EX groups and followed for 20 weeks. Both groups underwent a twice-weekly, 8-week center-based exercise intervention with aerobic and resistance exercises. EX+NEPA group also received a wearable activity tracking device along with behavioral monitoring and feedback throughout the study. Study outcomes were evaluated at 8 and 20 weeks.

Results

Data are presented as adjusted mean change of the differences over time with 95% confidence intervals at 20 weeks. Relative to EX, the change in steps/day at 20 weeks was 1994 (-40.27, 4028) higher for EX+NEPA. For sedentary time at close-out, the EX+NEPA group was -6.8 (-45.2, 31.6) min/day relative to EX. The between-group differences for systolic and diastolic blood pressure were -9.9 (-19.6, -0.3) and -1.8 (-6.9, 3.3) mmHg, respectively.

Conclusion

The addition of wearable technology intervention appeared to positively influence daily activity patterns and changes in blood pressure - potentially improving risk factors for CVD. A fully powered randomized trial is needed to ultimately test this hypothesis.

Reduced striatal activation in response to rewarding motor performance feedback after stroke

INTRODUCTION

Motor skill learning can help stroke survivors to cope with motor function deficits but requires many repetitions. One factor that keeps patients motivated is obtaining reward upon successfully completing a motor task. It has been suggested that stroke survivors have deficits in reward processing which may negatively impact skill learning.

OBJECTIVE

To test the hypothesis that stroke survivors have deficient reward processing during motor skill learning evident in reduced activation in the striatum and its subdivisions in functional magnetic resonance imaging as compared with healthy, age-matched control subjects.

METHODS

Striatal activity in response to performance dependent feedback and monetary reward was measured in 28 subacute stroke patients and 18 age-matched healthy control subjects during the training of visuomotor tracking an arc-shaped trajectory using the wrist (unimpaired side in patients, dominant side in controls) in an fMRI scanner.

RESULTS

Despite comparable monetary rewards, stroke patients showed reduced activation in the ventral part (p < 0.01), but not in the dorsal part of the striatum (p = 0.11). 14 patients had their lesion extending into the striatum. The nucleus accumbens as part of the ventral striatum was unlesioned in all participants and still showed a marked hypoactivation in stroke patients as compared with controls (p < 0.001), a finding that could not be explained by motivational differences between the groups.

CONCLUSION

Striatal hypoactivation in stroke survivors may cause impaired consolidation of motor skills. Stronger rewarding stimuli or drug-mediated enhancement may be needed to normalize reward processing after stroke with positive effects on recovery.

Is Stem Cell Therapy an Answer to Heart Failure: A Literature Search

The heart is one of the most industrious organs in the human body. It starts beating in the first few weeks of embryonic life and keeps pumping blood till death. This organ can host a range of diseases as well. Some can hamper the vasculature, while others can affect its electrical activity, the heart valves, etc. All these conditions can lead to end-stage failure where it can no longer meet the requirements of the body’s milieu. This imbalance between supply and demand leads to an array of symptoms. Medical management can reduce these clinical effects and possibly prolong the life expectancy in such patients. However, prescription medications can also have their own adverse effects. This necessitates that each line of treatment should be assessed on a risk vs benefit basis. The conventional approach has been to try and slow down the progression of heart failure (HF). However, the inception of stem cells in the management of HF has the potential for reversal of this pathology. Keeping this in view, many studies and trials are under process. To turn the clock back on the HF, before complications set in or get out of control, is the main focus of the time. This article attempts to evaluate various studies about stem cell therapy (SCT) and highlight the important aspects of this novel modality in changing patients' lives.

Screening and Initiating Supportive Care in Patients With Heart Failure

Background: Patients with heart failure (HF) experience a major symptom burden and an overall reduction of quality of life. However, supportive care (SC) remains an under-utilized resource for these patients. Among the many existing barriers to integrating SC into routine care, identifying patients with SC needs remains challenging. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is an important predictor of SC needs in patients with HF.

Methods and Results: We used the shortened version KCCQ-12 as a screening tool for SC need in our ambulatory HF patient population using a KCCQ-12 summary score of <29 as the cut-off. Of the 456 patients who completed the KCCQ-12, 41 (9%) were predicted to have SC needs. Demographics, medical history, biochemical parameters, echocardiographic assessment and medical treatment were similar between the two groups of patients. However, patients with KCCQ-12 <29 were more symptomatic based on both New York Heart Association (NYHA) classification and American Heart Association (AHA) staging with a higher prevalence of depression. We established a multidisciplinary SC clinic and the profile and outcomes of patients with SC needs that were referred and followed at our SC clinic were also evaluated. Twenty-three patients were referred to our SC clinic: 2 died before being seen, 1 refused SC and 20 received SC. Of these 20 patients, 11 died and 9 are currently being followed. Median survival after starting the SC clinic is 3 months. In the original SC cohort of 23, 17 patients had available KCCQ-12 summary scores. However, only 6 out of 17 (35%) had KCCQ-12 scores <29, indicating the need for additional assessment tools in this patient population.

Conclusions: The magnitude of unmet supportive care needs in patients with HF is significant. While the KCCQ-12 questionnaire is a useful tool to identify patients with SC, serial clinical evaluation, establishment of a SC clinic and prompt referral are essential for patients needing supportive care.

Music Interventions in Percutaneous Coronary Procedures: A Meta-Analysis

To clarify the effectiveness of music intervention for improving the well-being of patients undergoing coronary procedures for coronary heart disease, we conducted full-text searches of various databases (MEDLINE, Cochrane Library, CINAHL, ProQuest, and Airiti Library; 1966-2019) to identify randomized controlled trials and quasi-experimental studies of music intervention in recipients of angiography or percutaneous coronary intervention. Outcome measures included anxiety, discomfort, pain, heart rate, and blood pressure. The Cochrane methodology, Jadad Quality Score, and ROBINS-I were employed to evaluate evidence from 10 studies. Music intervention reduced anxiety (effect size: Z = 2.15, p = .03; six studies) and discomfort of lying (Z = 2.40, p = .02; two studies), but did not affect pain (Z = 0.94; two studies), heart rate (Z = 0.94; five studies), or blood pressure (systolic, Z = 1.27; diastolic, Z = 1.32; four studies) (all p > .05). The heterogeneity among studies was high. Large-scale, transcultural, high-quality trials are warranted to confirm the benefit of music intervention in patients undergoing coronary procedures.

Participation in Younger and Older Adults Post-stroke: Frequency, Importance, and Desirability of Engagement in Activities

Purpose: To characterize and compare frequency and subjective dimensions of post-stroke participation in younger (<65) and older adults (>age 65), in social, productivity and leisure activities, 6 months post-inpatient rehabilitation. Secondary aims included exploration of demographic and clinical factors influencing desire for increased participation and comparison of two measures of participation. Methods: A prospective cohort study of people with stroke (n = 99) who were identified during their inpatient rehabilitation stay and followed-up 6 months post-discharge with telephone interviews using two self-report participation measures. The Stroke Impact Participation subscale (SIS-P) measured the frequency of perceived limitations in social, leisure, productive activities and extent of stroke recovery. The Community Participation Indicators (CPI) examined activity frequency, importance, and desire for increased activity engagement. Descriptive statistics were used to summarize demographic variables and characterize SIS-P and CPI items. Differences between age groups on individual items were examined. Associations between measures and demographic variables were explored. Results: Both groups reported a wide variation in participation restrictions that was not associated with stroke severity and weakly associated with discharge functional status (rho = 0.20-0.35). There were no significant differences between age groups in CPI frequency (for 18/19 items), or the SIS-P. However, there was a trend toward more participation restrictions on the SIS-P among those <65 (p = 0.07). Younger adults (n = 46; median age = 53) were significantly more likely to indicate that they were not doing selected activities enough on the CPI, compared with older adults (n = 56; median age = 76). While age and ethnicity were independently associated with some activities, it was not associated with other activities. The CPI and SIS-P were moderately related at a correlation of rho = 0.54, p < 0.001. Conclusion: The CPI demonstrated value and utility in examining subjective perspectives of activity importance and desire for change for people who are 6 months post-stroke. Although the CPI and SIS-P are moderately related, subjective appraisal of participation in selected individual activities (CPI) better distinguished between age groups and provided unique and distinct information from the SIS-P.

Implementation of a Low-Dose, High-Frequency Cardiac Resuscitation Quality Improvement Program in a Community Hospital

BACKGROUND

In 2015 the American Heart Association launched the Resuscitation Quality Improvement^Ⓡ (RQI^Ⓡ) Program to address the urgent need to improve in-hospital cardiac arrest survival through a novel competency-based model for health care provider (HCP) cardiopulmonary resuscitation (CPR) training. This innovation differs from the traditional Basic Life Support (BLS) training model by providing self-directed, low-dose, high-frequency CPR skill activities with the objectives of skills mastery and retention. A program implementation study was conducted at the first hospital in the state of Illinois to adopt RQI in 2016.

METHODS

The study was designed to evaluate implementation of the RQI program, CPR performance during RQI simulation sessions, and participant impressions at a community hospital. Quantitative data were evaluated based on psychomotor compression and ventilation performance. Quantitative and qualitative data were evaluated based on a perceptual CPR confidence and program satisfaction survey.

RESULTS

Statistical analysis demonstrates significant improvement in HCPs' quarterly psychomotor CPR skill performance over a one-year period in first compression score, and first and highest ventilation score per quarterly session. The number of attempts to pass the ventilation skill session decreased between the first and fourth quarter. Survey results of HCPs' program perceptions 30 months post-RQI implementation indicate satisfaction with the RQI program and an increase in CPR skill confidence.

CONCLUSION

Findings demonstrate that the RQI program for ongoing verification of BLS skill and knowledge provides improvements in HCPs' CPR psychomotor competence and confidence/satisfaction using an efficient and sustainable method at a community hospital.

Using the epidemiology of critical limb ischemia to estimate the number of patients amenable to endovascular therapy

Critical limb ischemia represents the advanced stage of peripheral artery disease, a health problem with increasing prevalence. Critical limb ischemia is associated with significant mortality, limb loss, pain, and diminished health-related quality of life. Public awareness and early diagnosis are necessary for an effective treatment with early risk factor modification, smoking cessation, and exercise therapy. Herein, we present an overview of the epidemiology as well as the clinical stages of the disease, and estimate that there are 6.5 million patients with critical limb ischemia in the US, Europe, and Japan based on global population-based studies. At least 75% of these patients, accounting for approximately 4.8 million patients, are amenable to endovascular therapy.

Biomimetic and bioinspired strategies for oral drug delivery

Oral drug delivery remains the most preferred approach due to its multiple advantages. Recently there has been increasing interest in the development of advanced vehicles for oral delivery of different therapeutics. Among them, biomimetic and bioinspired strategies are emerging as novel approaches that are promising for addressing biological barriers encountered by traditional drug delivery systems. Herein we provide a state-of-the-art review on the current progress of biomimetic particulate oral delivery systems. Different biomimetic nanoparticles used for oral drug delivery are first discussed, mainly including ligand/antibody-functionalized nanoparticles, transporter-mediated nanoplatforms, and nanoscale extracellular vesicles. Then we describe bacteria-derived biomimetic systems, with respect to oral delivery of therapeutic proteins or antigens. Subsequently, yeast-derived oral delivery systems, based on either chemical engineering or bioengineering approaches are discussed, with emphasis on the treatment of inflammatory diseases and cancer as well as oral vaccination. Finally, bioengineered plant cells are introduced for oral delivery of biological agents. A future perspective is also provided to highlight the existing challenges and possible resolution toward clinical translation of currently developed biomimetic oral therapies.

Effect of functional electrical stimulation plus body weight-supported treadmill training for gait rehabilitation in patients with poststroke: a retrospective case-matched study

BACKGROUND

Functional electrical stimulation (FES) plus body weight-supported treadmill training (BWSTT) provide effective gait training for poststroke patients with abnormal gait. These features promote a successful active motor relearning of ambulation in stroke survivors.

AIM

This is a retrospective study to assess the effect of FES plus BWSTT for gait rehabilitation in patients poststroke.

DESIGN

A retrospective case-matched study.

SETTING

Participants were recruited from a rehabilitation department in an acute university-affiliated hospital POPULATION: Ninety patients poststroke from Yue Bei People's Hospital underwent BWSTT (A: control group) were compared to an equal number of cross-matched patients who received FES plus BWSTT (B: FES plus BWSTT group).

METHODS

While B group received FES for 45 minutes plus BSWTT for 30 minutes in the program, group A received time-matched BWSTT alone. The walking speed, step length, step cadence, Fugl-Meyer Lower-Limb Scale (LL-FMA), composite spasticity scale (CSS), 10-Meter Walk Test (10MWT), Tinetti Balance Test (TBT) and nerve physiology testing were collected before and after intervention.

RESULTS

One hundred and eighty patients with poststroke abnormal gait were chosen. There were significant differences in walking speed, step length, step cadence, LL-FMA, CSS, TBT, and 10MWT between baseline and postintervention (P<0.05). There were significant differences in walking speed, step length, step cadence, LL-FMA, CSS, TBT, and 10MWT between two groups at the end of the eighth week (P<0.05), but not at baseline (P>0.05). In comparison with group A, the peak of somatosensory evoked potential (SEP) and motor evoked potential (MEP) amplitude increased, the latency was shortened, and the conduction velocity of sensory nerve (SCV) and motor nerve (MCV) was significantly increased in the group B (P<0.05). No adverse events occurred during the study.

CONCLUSIONS

This study suggests that FES plus BWSTT could be more effective than BWSTT alone in the improvement of gait, balance, spasticity, and function of the lower limb in patients poststroke.

CLINICAL REHABILITATION IMPACT

Introduce effective rehabilitation strategies for poststroke patients with abnormal gait.

Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes

BACKGROUND

The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain.

METHODS

In this multicenter, randomized, open-label trial, we randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary end point (the safety end point) was bleeding.

RESULTS

A total of 4018 patients underwent randomization. A primary end-point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P = 0.006). The respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively. Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P = 0.46).

CONCLUSIONS

Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups. (Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München; ISAR-REACT 5 ClinicalTrials.gov number, NCT01944800.).

A Cross-Sectional Analysis of Differences in Physical Activity Levels between Stroke Belt and Non-Stroke Belt US Adults

BACKGROUND

The Stroke Belt is a region of the United States with elevated stroke incidence and prevalence of stroke risk factors. Physical inactivity is an important stroke risk factor, but little is known about whether current physical activity levels differ between Stroke Belt and non-Stroke Belt states. In this nationally representative study, we determined whether unadjusted and adjusted physical activity levels differ between the Stroke Belt region and the rest of the United States.

METHODS

Using 2017 Behavioral Risk Factor Surveillance System data, we conducted bivariate analyses to obtain unadjusted physical activity levels in Stroke Belt and non-Stroke Belt states. Logistic regressions that controlled for sociodemographic and stroke risk factors were created to estimate adjusted associations between Stroke Belt residence and physical activity.

RESULTS

A higher percentage of Stroke Belt residents were inactive (Stroke Belt: 35.3%, non-Stroke Belt: 29.4%) and failed to meet physical activity guidelines (Stroke Belt: 53.7%, non-Stroke Belt: 47.8%) compared to non-Stroke Belt residents. Stroke Belt residence was significantly associated with lower odds of meeting physical activity guidelines in a model that adjusted for sociodemographic factors only (odds ratio [OR]: 0.85, 95% confidence interval [CI]: 0.78-0.91) and one that adjusted for both sociodemographic and stroke risk factors (OR: 0.87, 95% CI: 0.81-0.93).

CONCLUSIONS

The considerably lower physical activity levels and likelihood of meeting physical activity guidelines in Stroke Belt residents compared to their non-Stroke Belt counterparts demonstrates a need for clinician attention and public health interventions to increase regular physical activity as part of a stroke reduction strategy in this region.

Probabilistic Graphical Modeling for Estimating Risk of Coronary Artery Disease: Applications of a Flexible Machine-Learning Method

Objectives. Coronary artery disease (CAD) is the leading cause of death and disease burden worldwide, causing 1 in 7 deaths in the United States alone. Risk prediction models that can learn the complex causal relationships that give rise to CAD from data, instead of merely predicting the risk of disease, have the potential to improve transparency and efficacy of personalized CAD diagnosis and therapy selection for physicians, patients, and other decision makers. Methods. We use Bayesian networks (BNs) to model the risk of CAD using the Z-Alizadehsani data set-a published real-world observational data set of 303 Iranian patients at risk for CAD. We also describe how BNs can be used for incorporation of background knowledge, individual risk prediction, handling missing observations, and adaptive decision making under uncertainty. Results. BNs performed on par with machine-learning classifiers at predicting CAD and showed better probability calibration. They achieved a mean 10-fold area under the receiver-operating characteristic curve (AUC) of 0.93 ± 0.04, which was comparable with the performance of logistic regression with L1 or L2 regularization (AUC: 0.92 ± 0.06), support vector machine (AUC: 0.92 ± 0.06), and artificial neural network (AUC: 0.91 ± 0.05). We describe the use of BNs to predict with missing data and to adaptively calculate prognostic values of individual variables under uncertainty. Conclusion. BNs are powerful and versatile tools for risk prediction and health outcomes research that can complement traditional statistical techniques and are particularly useful in domains in which information is uncertain or incomplete and in which interpretability is important, such as medicine.

Cilostazol Mono and Combination Treatments in Ischemic Stroke: An Updated Systematic Review and Meta-Analysis

Background and Purpose- We performed a systematic review and meta-analysis to explore the efficacy and safety of cilostazol as a mono or combination (plus aspirin or clopidogrel) treatments compared to conventional single antiplatelet therapy (SAPT, mainly aspirin) for secondary stroke prevention. Methods- Randomized controlled trial studies were searched across multiple comprehensive databases (MEDLINE, EMBASE, and Cochrane) for review. The primary outcome was recurrent stroke comprising ischemic and hemorrhagic stroke. Secondary outcomes included ischemic stroke, hemorrhagic stroke, myocardial infarction, and composite outcomes. We performed an updated systematic review and meta-analysis of the identified reports, including 2 recently published randomized controlled trials. In addition, network meta-analysis was performed to compare the relative effects of mono versus combination cilostazol treatments. Results- Ten studies were included in this review, 5 of which were assigned to the cilostazol mono group (n=5429) and the other 5 to the combination group (n=2456). The relative risks of recurrent stroke, ischemic stroke, and composite outcomes with cilostazol mono as well as combination treatments were significantly lower than with SAPT without any significant heterogeneity. An indirect comparison of these 3 outcomes revealed the cilostazol combination approach to be superior. The cilostazol mono treatment diminished hemorrhagic stroke more significantly than SAPT and the cilostazol combination did not increase hemorrhagic stroke compared to SAPT. The outcomes from the 2 cilostazol regimens were comparable to SAPT in the case of myocardial infarction. Conclusions- Cilostazol is a more effective and safer treatment option than SAPT approaches using mainly aspirin. Cilostazol regimens can also be modified to clinical situations as this drug reduces recurrent and ischemic stroke more efficiently as a combination therapy but is more beneficial for hemorrhagic stroke as a monotherapy.

Sodium Intake from Foods Exceeds Recommended Limits in the Spanish Population: The ANIBES Study

Excessive sodium consumption is associated with adverse health effects. An elevated dietary intake of salt (sodium chloride) has been related to high blood pressure or hypertension, a major but modifiable risk factor for cardiovascular disease, as well as to other ill health conditions. In the present work, our aim was to describe the contribution of foods to sodium consumption within the Spanish population in a representative sample from the "anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles in Spain" (ANIBES) study (9-75 years), to identify high consumer groups, as well as the major food groups that contribute to sodium intake in the Spanish diet. Intakes were assessed by 3-day food records collected on a tablet device. Sodium intakes across the ANIBES study population exceeded recommendations, as total intakes reached 2025 ± 805 mg of sodium per day, that is approximately 5.06 g/day of salt (excluding discretionary salt, added at the table or during cooking). Sodium intakes were higher in males than in females and within the youngest groups. Main dietary sources of sodium were meat and meat products (27%), cereals and grains (26%), milk and dairy products (14%) and ready-to-eat meals (13%). Given the established health benefits of dietary salt reduction, it would be advisable to continue and even improve the current national initiatives of awareness and educational campaigns and particularly food reformulation to decrease overall salt intakes across the Spanish population.

Cardiometabolic and Inflammatory Benefits of Sympathetic Down-Regulation with Zamicastat in Aged Spontaneously Hypertensive Rats

The hyperactivity of the sympathetic nervous system (SNS) plays a major role in the development and progression of several cardiovascular diseases. One strategy to mitigate the SNS overdrive is by restricting the biosynthesis of norepinephrine via the inhibition of dopamine β-hydroxylase (DBH). Zamicastat is a new DBH inhibitor that decreases norepinephrine and increases dopamine levels in peripherally sympathetic-innervated tissues. The cardiometabolic and inflammatory effects of sympathetic down-regulation were evaluated in 50 week old male spontaneously hypertensive rats (SHRs) receiving zamicastat (30 mg/kg/day) for 9 weeks. After 8 weeks of treatment, the blood pressure (BP) and heart rate (HR) were assessed by tail cuff plethysmography. At the end of the study, 24 h urine, plasma, heart, and kidney were collected for biochemical and morphometric analyses. Zamicastat-induced sympathetic down-regulation decreased the high BP in SHRs, with no observed effect on HR. The heart-to-body weight ratio was lower in SHRs treated with zamicastat, whereas the body weight and kidney-to-body weight ratio were similar between both SHR cohorts. Zamicastat-treated SHRs showed reduced 24 h urine output, but the urinary amount of protein excreted and creatinine clearance rate remained unchanged. Zamicastat treatment significantly decreased plasma triglycerides, free fatty acids, and aspartate aminotransferase levels. Aged SHRs showed higher plasma levels of inflammatory markers as compared with age-matched normotensive Wistar-Kyoto rats. The inflammatory benefits attained with DBH inhibition were expressed by a decrease in CRP, MCP-1, IL-5, IL-17α, GRO/KC, MIP-1α, and RANTES plasma levels as compared with untreated SHRs. In conclusion, DBH inhibition decreased norepinephrine levels, reduced end-organ damage, and improved cardiometabolic and inflammatory biomarkers in aged male SHRs.

Outcomes and safety of electronic consult use in vascular surgery

OBJECTIVE

The objective of this study was to determine how electronic consults (eConsults) are used in vascular surgery in a veterans health care setting and whether their use is safe for patients.

METHODS

A retrospective review was performed of all eConsults completed by the vascular surgery service at the Ann Arbor Veterans Affairs Healthcare System between October 10, 2012 and November 15, 2013. Patients' demographics and comorbidities were collected. eConsult recommendations and patient and provider compliance with recommendations were collected. Data on adverse outcomes up to 1 year after consultation and data on all-cause mortality at 1 year and 5 years were collected.

RESULTS

Between October 10, 2012 and November 15, 2013, of 350 eConsults completed, 123 (35%) were for peripheral artery disease, 93 (27%) for carotid stenosis, and 57 (16%) for abdominal aortic aneurysm. Unique recommendations were made for 291 consults (83%). Medication recommendations were made in 140 consults (40%). The most commonly recommended medication was cilostazol. Compliance with medication recommendations ranged from 30% to 61%. Noninvasive imaging was recommended in 220 consults (60.3%). Procedures overall were recommended in only six consults (1.7%). Five-year all-cause mortality for categorized diagnoses ranged from 8.3% for nonabdominal aneurysm to 28.1% for abdominal aortic aneurysm.

CONCLUSIONS

Within the Veterans Affairs vascular surgery service, eConsults provide a safe and effective means of triaging and providing recommendations for patients with vascular disease. eConsults used to augment traditional consultations may provide an important means of reducing clinic congestion for providers and reducing time and cost for patients.

Impact of Pharmacist Involvement in Heart Failure Transition of Care

Background: Heart failure (HF) transition of care (TOC) programs may improve continuity of care and coordination and decrease hospital readmissions. Objective: This study evaluated the impact of pharmacy-led HF TOC on HF readmission rate. Methods: This was a single-center, pre-post quasi-experimental study. Pharmacy TOC comprised admission and discharge medication reconciliations and patient education. Patients were included if they had a primary HF diagnosis. Patients were excluded if they were admitted for a non-HF diagnosis, admitted for <24 hours, had a stage IV cancer or dementia diagnosis, or were transferred to hospice care. The primary outcome was HF 30-day readmission rate. Results: A total of 663 patients were included in the study: 330 in the control group and 333 in the intervention group. The average age for both groups was 67 ± 16 years; 48.1% were female; 56.9% were African American; and 51.4% of patients had an ejection fraction ≤40%. In the control group, 57 (17.3%) patients had a HF 30-day readmission compared with 35 (10.5%) patients in the intervention group. After adjusting for age, the intervention group continued to show a difference in readmission (odds ratio = 0.578; 95% CI = 0.367-0.911; P = 0.018). The most common interventions were medication addition (11%), dose titration (7.5%), medication discontinuation (6.6%), and duplication avoidance (2.7%). Conclusion and Relevance: Pharmacy-led HF TOC, as a component of a targeted hospital-based initiative, significantly decreased HF 30-day readmission rate. Results from this study warrant further research to explore which interventions in TOC are most effective.

Sodium, hypertension, and the gut: does the gut microbiota go salty?

Recent evidence suggests that the gut microbiota contributes to the pathogenesis of hypertension (HTN). The gut microbiota is a highly dynamic organ mediating numerous physiological functions, which can be influenced by external factors such as diet. In particular, a major modifiable risk factor for HTN is dietary sodium intake. Sodium consumption in the United States is significantly greater than that recommended by the federal government and organizations such as the American Heart Association. Because of the emerging connection between the gut microbiota and HTN, the interaction between dietary sodium and gut microbiota has sparked interest. High-sodium diets promote local and systemic tissue inflammation and impair intestinal anatomy compared with low sodium intake in both human and animal studies. It is biologically plausible that the gut microbiota mediates the inflammatory response, as it is in constant interaction with the immune system and is necessary for proper maturation of immune cells. Recent rodent data demonstrate that dietary sodium disrupts gut microbial homeostasis as gut microbiota composition shifts with dietary sodium manipulation. In this review, we will focus on gut microbiota activity in HTN and the influence of high dietary sodium intake with an emphasis on the immune system, bacterial metabolites, and the circadian clock.

Biomarkers in diagnosing and treatment of acute heart failure

Acute heart failure (AHF) is a complex disorder involving different pathophysiological pathways. In recent years, there is an increased focus on biomarkers that help with diagnosis, risk stratification and disease monitoring of AHF. Finding a reliable set of biomarkers not only improves morbidity and mortality but it can also potentially reveal the new targets of therapy. In this paper, we have reviewed the biomarkers found useful for the diagnosis as well as for risk stratification and prognostication in patients with AHF. We have discussed the established biomarkers for AHF including cardiac troponins and natriuretic peptides and emerging biomarkers including adiponectin, mi-RNA, sST2, Gal-3, MR-proADM, OPG, CT-proAVP and H-FABP for the purposes of making diagnosis, their use as a guide of therapy or for determination of prognosis.

Molecular mechanisms of heart regeneration

The adult mammalian heart is incapable of clinically relevant regeneration. The regenerative deficit in adult mammalian heart contrasts with the fetal and neonatal heart, which demonstrate substantial regenerative capacity after injury. This deficiency in adult mammals is attributable to the lack of resident stem cells after birth, combined with an inability of pre-existing cardiomyocytes to complete cytokinesis. Studies of neonatal heart regeneration in mammals suggest that latent regenerative potential can be re-activated. Dissecting the cellular and molecular mechanisms that promote cardiomyocyte proliferation is key to stimulating true regeneration in adult humans. Here, we review recent advances in our understanding of cardiomyocyte proliferation that suggest molecular approaches to heart regeneration.

Cardiomyocyte Homeodomain-Interacting Protein Kinase 2 Maintains Basal Cardiac Function via Extracellular Signal-Regulated Kinase Signaling

BACKGROUND

Cardiac kinases play a critical role in the development of heart failure, and represent potential tractable therapeutic targets. However, only a very small fraction of the cardiac kinome has been investigated. To identify novel cardiac kinases involved in heart failure, we used an integrated transcriptomics and bioinformatics analysis and identified Homeodomain-Interacting Protein Kinase 2 (HIPK2) as a novel candidate kinase. The role of HIPK2 in cardiac biology is unknown.

METHODS

We used the Expression2Kinase algorithm for the screening of kinase targets. To determine the role of HIPK2 in the heart, we generated cardiomyocyte (CM)-specific HIPK2 knockout and heterozygous mice. Heart function was examined by echocardiography, and related cellular and molecular mechanisms were examined. Adeno-associated virus serotype 9 carrying cardiac-specific constitutively active MEK1 (TnT-MEK1-CA) was administrated to rescue cardiac dysfunction in CM-HIPK2 knockout mice.

RESULTS

To our knowledge, this is the first study to define the role of HIPK2 in cardiac biology. Using multiple HIPK2 loss-of-function mouse models, we demonstrated that reduction of HIPK2 in CMs leads to cardiac dysfunction, suggesting a causal role in heart failure. It is important to note that cardiac dysfunction in HIPK2 knockout mice developed with advancing age, but not during development. In addition, CM-HIPK2 knockout mice and CM-HIPK2 heterozygous mice exhibited a gene dose-response relationship of CM-HIPK2 on heart function. HIPK2 expression in the heart was significantly reduced in human end-stage ischemic cardiomyopathy in comparison to nonfailing myocardium, suggesting a clinical relevance of HIPK2 in cardiac biology. In vitro studies with neonatal rat ventricular CMscorroborated the in vivo findings. Specifically, adenovirus-mediated overexpression of HIPK2 suppressed the expression of heart failure markers, NPPA and NPPB, at basal condition and abolished phenylephrine-induced pathological gene expression. An array of mechanistic studies revealed impaired extracellular signal-regulated kinase 1/2 signaling in HIPK2-deficient hearts. An in vivo rescue experiment with adeno-associated virus serotype 9 TnT-MEK1-CA nearly abolished the detrimental phenotype of knockout mice, suggesting that impaired extracellular signal-regulated kinase signaling mediated apoptosis as the key factor driving the detrimental phenotype in CM-HIPK2 knockout mice hearts.

CONCLUSIONS

Taken together, these findings suggest that CM-HIPK2 is required to maintain normal cardiac function via extracellular signal-regulated kinase signaling.

Clinical Outcomes of Mortality, Readmissions, and Ischemic Stroke Among Medicare Patients Undergoing Left Atrial Appendage Closure via Implanted Device

IMPORTANCE

Left atrial appendage closure (LAAC) has emerged as a nonpharmacological alternative for stroke prevention in patients with nonvalvular atrial fibrillation. Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure are limited.

OBJECTIVE

To determine the characteristics, postprocedural mortality rate, and rates of readmission and ischemic stroke among Medicare beneficiaries who underwent LAAC via implanted device.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used Medicare inpatient claims from January 2015 to December 2017 for 13 627 patients aged older than 65 years with a diagnosis of atrial fibrillation who underwent LAAC with an implanted device from January 2015 to November 2017. Data analyses were conducted from January through August 2019.

EXPOSURE

Left atrial appendage closure.

MAIN OUTCOMES AND MEASURES

Mortality rates during the index admission and for 1 year after LAAC were assessed. The 30-day readmission rate and the primary reasons for readmission were also examined. In addition, the likelihood of hospitalization for ischemic stroke within 180 days among 9231 patients for whom 6 months of follow-up data were available was evaluated.

RESULTS

Among the 13 627 patients undergoing LAAC, the mean (SD) age was 78.0 (6.3) years, 9406 (69.0%) were older than 75 years, 11 980 (87.9%) were white, and 5630 (41.3%) were women. The mean (SD) CHA2DS2-VASc score was 4.3 (1.4). Twenty-eight patients (0.2%) died during the index admission. Mortality rates were 0.6% (80 patients) at 30 days, 1.9% (262 patients) at 90 days, 4.0% (547 patients) at 180 days, and 7.5% (1027 patients) at 365 days. The 30-day readmission rate among 13 599 patients discharged alive was 9.4% (1284 patients). Among 9231 patients with 6 months of follow-up data, 111 (1.2%) experienced readmission for ischemic stroke or transient ischemic attack within 180 days of discharge.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients older than 65 years with atrial fibrillation who underwent LAAC with an implanted device, readmission rates for ischemic strokes over the course of 6 months were lower than expected given the patients' CHA2DS2-VASc scores in the absence of anticoagulation therapy. Mortality at 1 year was higher than that reported in previous randomized clinical trials, likely because the patients in the present study were older, had a higher number of comorbidities, and were ineligible to receive warfarin.

Heart disease prevention in women: The NP's role

More women die from heart disease than any other illness. This article focuses on risk factors and their prevalence in women along with strategies for preventing this disease. Armed with this information, the NP can play a major role in preventing cardiovascular deaths in women.

Heart Failure in the Era of Precision Medicine: A Scientific Statement From the American Heart Association

One of 5 people will develop heart failure over his or her lifetime. Early diagnosis and better understanding of the pathophysiology of this disease are critical to optimal treatment. The "omics"-genomics, pharmacogenomics, epigenomics, proteomics, metabolomics, and microbiomics- of heart failure represent rapidly expanding fields of science that have, to date, not been integrated into a single body of work. The goals of this statement are to provide a comprehensive overview of the current state of these omics as they relate to the development and progression of heart failure and to consider the current and potential future applications of these data for precision medicine with respect to prevention, diagnosis, and therapy.

Chronic kidney disease in the pathogenesis of acute ischemic stroke

Chronic kidney disease has a graded and independent inverse impact on cerebrovascular health. Both thrombotic and hemorrhagic complications are highly prevalent in chronic kidney disease patients. Growing evidence suggests that in chronic kidney disease patients, ischemic strokes are more common than hemorrhagic strokes. Chronic kidney disease is asymptomatic until an advanced stage, but mild to moderate chronic kidney disease incites various pathogenic mechanisms such as inflammation, oxidative stress, neurohormonal imbalance, formation of uremic toxins and vascular calcification which damage the endothelium and blood vessels. Cognitive dysfunction, dementia, transient infarcts, and white matter lesions are widespread in mild to moderate chronic kidney disease patients. Uremic toxins produced after chronic kidney disease can pass through the blood-brain barrier and mediate cognitive dysfunction and neurodegeneration. Furthermore, chronic kidney disease precipitates vascular risk factors that can lead to atherosclerosis, hypertension, atrial fibrillation, and diabetes. Chronic kidney disease also exacerbates stroke pathogenesis, worsens recovery outcomes, and limits the eligibility of stroke patients to receive available stroke therapeutics. This review highlights the mechanisms involved in the advancement of chronic kidney disease and its possible association with stroke.

Automated accurate lumen segmentation using L-mode interpolation for three-dimensional intravascular optical coherence tomography

Intravascular optical coherence tomography (IVOCT) lumen-based computational flow dynamics (CFD) enables physiologic evaluations such as of the fractional flow reserve (FFR) and wall sheer stress. In this study, we developed an accurate, time-efficient method for extracting lumen contours of the coronary artery. The contours of cross-sectional images containing wide intimal discontinuities due to guide wire shadowing and large bifurcations were delineated by utilizing the natural longitudinal lumen continuity of the arteries. Our algorithm was applied to 5931 pre-intervention OCT images acquired from 40 patients. For a quantitative comparison, the images were also processed through manual segmentation (the reference standard) and automated ones utilizing cross-sectional and longitudinal continuities. The results showed that the proposed algorithm outperforms other schemes, exhibiting a strong correlation (R = 0.988) and overlapping and non-overlapping area ratios of 0.931 and 0.101, respectively. To examine the accuracy of the OCT-derived FFR calculated using the proposed scheme, a CFD simulation of a three-dimensional coronary geometry was performed. The strong correlation with a manual lumen-derived FFR (R = 0.978) further demonstrated the reliability and accuracy of our algorithm with potential applications in clinical settings.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

Childhood Tobacco Smoke Exposure and Risk of Atrial Fibrillation in Adulthood

BACKGROUND

Cigarette smoking is known to increase the risk of atrial fibrillation (AF), and a recent cross-sectional analysis suggested that parental smoking may be an AF risk factor.

OBJECTIVES

The purpose of this study was to assess if parental smoking predicts offspring AF in the Framingham Heart Study.

METHODS

This study analyzed Framingham Offspring cohort participants with parents in the Original cohort with known smoking status during the offspring's childhood. Framingham participants were evaluated every 2 to 8 years and were under routine surveillance for incident AF. The authors assessed AF incidence among Offspring participants exposed to parental smoking through age 18 years and performed a mediation analysis to determine the extent to which offspring smoking might explain observed associations.

RESULTS

Of 2,816 Offspring cohort participants with at least 1 parent in the Original cohort, 82% were exposed to parental smoking. For every pack/day increase in parental smoking, there was an 18% increase in offspring AF incidence (adjusted hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 1.00 to 1.39; p = 0.04). Additionally, parental smoking was a risk factor for offspring smoking (adjusted odds ratio [OR]: 1.34; 95% CI: 1.17 to 1.54; p < 0.001). Offspring smoking mediated 17% (95% CI: 1.5% to 103.3%) of the relationship between parental smoking and offspring AF.

CONCLUSIONS

Childhood secondhand smoke exposure predicted increased risk for adulthood AF after adjustment for AF risk factors. Some of this relationship may be mediated by a greater propensity among offspring of smoking parents to smoke themselves. These findings highlight potential new pathways for AF risk that begin during childhood, offering new evidence to motivate smoking avoidance and cessation.

Stroke Prevents Exercise-induced Gains in Bone Microstructure But Not Composition in Mice

Ischemic stroke induces rapid loss in bone mineral density up to 13 times greater than during normal aging, leading to markedly increased risk of fracture. Little is known about skeletal changes following stroke beyond density loss. In this study we use a mild-moderate middle cerebral artery occlusion model to determine the effects of ischemic stroke without bedrest on bone microstructure, dynamic bone formation, and tissue composition. Twenty-seven 12-week-old male C57Bl/6J mice received either a stroke or sham surgery and then either received daily treadmill exercise or remained sedentary for four weeks. All mice were ambulatory immediately following stroke, and limb coordination during treadmill exercise was unaffected by stroke, indicating similar mechanical loading across limbs for surgery groups. Stroke did not directly detriment microstructure, but exercise only stimulated adaptation in sham group, not stroke group, with increased bone volume fraction and trabecular thickness in the sham distal femoral metaphysis. Stroke differentially decreased cortical area in the affected limb relative to the unaffected limb of the distal femoral metaphysis, and endosteal bone formation rate in the affected tibial diaphysis. Although exercise failed to improve bone microstructure following stroke, exercise increased mineral-to-matrix content in stroke but not sham. Together, these results show that stroke inhibits exercise-induced changes to femoral microstructure but not tibial composition, even without changes to gait. Similarly, affected-unaffected limb differences in cortical bone structure and bone formation rate in ambulatory mice show that stroke affects bone health even without bedrest.