Vascular event rates in patients with atherosclerotic cerebrovascular disease

Assessing the Validity of the Criteria for the Extreme Risk Category of Atherosclerotic Cardiovascular Disease: A Nationwide Population-Based Study

Objective

To validate the criteria for the extreme risk category for atherosclerotic cardiovascular disease (ASCVD).

Methods

An observational cohort study of 35,464 individuals with established ASCVD was performed using the National Health Information Database. Incident myocardial infarction (MI), ischemic stroke, and death in patients with established ASCVD was investigated to validate the criteria for the extreme risk category of ASCVD defined as the presence of diabetes mellitus (DM), chronic kidney disease (CKD), and history of premature ASCVD.

Results

Among 35,464 patients, 77.97% of them were classified into the extreme risk group of ASCVD. A total of 28.10%, 39.61%, and 32.12% had DM, CKD, and a history of premature ASCVD, respectively. During a mean follow-up of 8.39 years, MI, ischemic stroke, and all-cause death were found in 3.87%, 8.51%, and 23.98% of participants, respectively. In multivariate analysis, patients with DM had higher risk for MI (hazard ratio [HR], 1.62; 95% confidence interval [CI], 1.45–1.81), ischemic stroke (HR, 1.39; 95% CI, 1.29–1.50), and all-cause death (HR, 1.52; 95% CI, 1.45–1.59) than those without DM. Patients with CKD had 1.56 times higher risk for MI, 1.12 times higher risk for ischemic stroke, and 1.34 times higher risk for death than those without CKD. However, the risk for MI, ischemic stroke, and all-cause death was not different between patients with and without a history of premature ASCVD.

Conclusion

DM and CKD, but not a history of premature ASCVD, could be considered as reasonable criteria of an extreme risk for ASCVD.

Secondary Stroke Prevention in Polish Adults: Results from the LIPIDOGRAM2015 Study

BACKGROUND

The purpose of the study was to evaluate secondary stroke prevention in Poland and its association with sociodemographic factors, place of residence, and concomitant cardiovascular risk factors.

MATERIAL AND METHODS

From all patients in LIPIDOGRAM2015 Study (n = 13,724), 268 subjects had a history of ischaemic stroke and were included.

RESULTS

165 subjects (61.6%) used at least one preventive medication. Oral antiplatelet and anticoagulation agents were used by 116 (43.3%) and 70 (26.1%) patients, respectively. Only 157 (58.6%) participants used lipid-lowering drugs, and 205 (76.5%) were treated with antihypertensive drugs. Coronary heart disease (CHD) and dyslipidaemia were associated with antiplatelet treatment (p = 0.047 and p = 0.012, respectively). A history of atrial fibrillation, CHD, and previous myocardial infarction correlated with anticoagulant treatment (p = 0.001, p = 0.011, and p < 0.0001, respectively). Age, gender, time from stroke onset, place of residence, and level of education were not associated with antiplatelet or anticoagulant treatment. Only 31.7% of patients were engaged in regular physical activity, 62% used appropriate diet, and 13.6% were current smokers.

CONCLUSIONS

In Poland drugs and lifestyle modification for secondary stroke prevention are not commonly adhered to. Educational programmes for physicians and patients should be developed to improve application of effective secondary prevention of stroke.

Cognition in the First Year After a Minor Stroke, Transient Ischemic Attack, or Mimic Event and the Role of Vascular Risk Factors

Background: Cognitive impairment following a minor stroke or transient ischemic attack (TIA) is common; however, due to diagnostic difficulties, the prevalence and underlying cause of impairment remain poorly defined. We compared cognition in patients after a minor stroke, TIA, or mimic event at three time points in the first year following the event. We examine whether cognitive impairment occurs following these events and whether this impairment differs based on the event type. Further, we measure whether these findings persist after controlling for age, education, and the presence of vascular risk factors and whether the presence of vascular risk factors, independent of event etiology, is associated with cognitive impairment. Lastly, we investigate whether increased stroke risk, as assessed by the ABCD2, is associated with reduced cognition.

Methods: Medical information, a cognitive screening test, and a measure of executive functioning were collected from 613 patients (123 minor stroke, 175 TIA, and 315 mimics) using phone interviews at three time points in the first year following the event. Linear mixed models were used to determine the effect of event type, vascular risk factors, and predicted stroke risk on cognitive performance while controlling for confounders.

Results: There was no relationship between event type and performance on either cognitive measure. When all confounders are controlled for, performance on the cognitive screening test was uniquely accounted for by the presence of heart failure, myocardial infarction, angina, and hypertension (all p < 0.047), whereas the measure of executive functioning was uniquely accounted for by the presence of hypertension and angina (all p < 0.032). Increased stroke risk also predicted performance on the cognitive screening test and the measure of executive functioning (all p < 0.002).

Conclusions: Our findings indicate that cognitive impairment following a minor stroke or TIA may be attributed to the high prevalence of chronic vascular risk factors in these patients. This highlights the importance of long-term management of vascular risk factors beyond event recovery to reduce the risk of cognitive impairment. Increased stroke risk (i.e., ABCD2 score) was also associated with reduced cognition, suggesting that it may be helpful in signaling the need for further cognitive evaluation and intervention post-event.

Extreme Atherosclerotic Cardiovascular Disease (ASCVD) Risk Recognition

PURPOSE OF REVIEW

To distinguish extreme and very high atherosclerotic cardiovascular disease (ASCVD) event risk based on prospective epidemiological studies and clinical trial results.

RECENT FINDINGS

Clinical practice guidelines have categorized patients with either a history of one or more "clinical ASCVD" events or "coronary heart disease (CHD) risk equivalency" to be at "very high risk" for a recurrence or a first event, respectively. A 20% or greater 10-year ASCVD risk for a composite 3-point "major" atherosclerotic cardiovascular event (MACE) of non-fatal myocardial infarction (MI), non-fatal stroke, or cardiovascular death can serve as an arbitrary definition of those at "very high risk." Exclusion of stroke may underestimate risk of "hard" endpoint 10-year ASCVD risk and addition of other potential endpoints, e.g., hospital admission for unstable angina or revascularization, a 5-point composite MACE, may overinflate the risk definitions and categorization. "Extreme" risk, a descriptor for even higher morbidity and mortality potential, defines a 30% or greater 10-year 3-point MACE (ASCVD) risk. In prospective, epidemiological studies and randomized clinical trial (RCT) participants with an initial acute coronary syndrome (ACS) within several months of entry into the study meet the inclusion criteria assignment for extreme risk. In survivors beyond the first year of an ASCVD event, "extreme" risk persists when one or more comorbidities are present, including diabetes, heart failure (HF), stage 3 or higher chronic kidney disease (CKD), familial hypercholesterolemia (FH), and poorly controlled major risk factors such as hypertension and persistent tobaccoism. "Extreme" risk particularly applies to those with progressive or multiple clinical ASCVD events in the same artery, same arterial bed, or polyvascular sites, including unstable angina and transient ischemic events. Identifying asymptomatic individuals with extensive subclinical ASCVD at "extreme" risk is a challenge, as risk engine assessment may not be adequate; individuals with genetic FH or those with diabetes and Agatston coronary artery calcification (CAC) scores greater than 1000 exemplify such threatening settings and opportunities for aggressive primary prevention. Heterogeneity exists among individuals at risk for clinical ASCVD events; identifying those at "extreme" risk, a more ominous ASCVD category, associated with greater morbidity and mortality, should prompt the most effective global cardiometabolic risk reduction.

THE POSSIBILITIES OF USING A NEW FIXED-DOSE COMBINATION OF ROSUVASTATIN AND ACETYLSALICYLIC ACID: FOCUS GROUPS OF PATIENTS

The review focuses on the impairment of the carotid, coronary arteries and lower-extremity arterial disease. Systemic involvement of various vascular beds in atherogenesis is emphasized. Epidemiological characteristics of morbidity and mortality from the main clinical manifestations of atherosclerosis - ischemic stroke, ischemic heart disease and lower-extremity arterial disease are given. The current principles of drug therapy are considered from the point of view of improving the prognosis and eliminating ischemia. The basic positions of International and Russian clinical recommendations on the management of patients with the presence of certain clinical manifestations of atherosclerosis are discussed. Detailed administration schemes and the preferred doses of statins and antiplatelet agents depending on the localization of atherosclerotic lesion and the severity of stenosis are described. The target blood lipids levels in the treatment with statins are given. The advantages of statins as drugs that reduce the risk of cardiovascular complications are presented. Current data on the pattern of antiplatelet use, including acetylsalicylic acid, in individuals with clinical manifestations of atherosclerosis are given. The principal tactic of dual antiplatelet therapy and schemes of its use in patients undergoing percutaneous coronary intervention, coronary artery bypass surgery and in individuals with a history of acute coronary disorders are considered.

Management of Acute Retinal Ischemia: Follow the Guidelines!

Acute retinal arterial ischemia, including vascular transient monocular vision loss (TMVL) and branch (BRAO) and central retinal arterial occlusions (CRAO), are ocular and systemic emergencies requiring immediate diagnosis and treatment. Guidelines recommend the combination of urgent brain magnetic resonance imaging with diffusion-weighted imaging, vascular imaging, and clinical assessment to identify TMVL, BRAO, and CRAO patients at highest risk for recurrent stroke, facilitating early preventive treatments to reduce the risk of subsequent stroke and cardiovascular events. Because the risk of stroke is maximum within the first few days after the onset of visual loss, prompt diagnosis and triage are mandatory. Eye care professionals must make a rapid and accurate diagnosis and recognize the need for timely expert intervention by immediately referring patients with acute retinal arterial ischemia to specialized stroke centers without attempting to perform any further testing themselves. The development of local networks prompting collaboration among optometrists, ophthalmologists, and stroke neurologists should facilitate such evaluations, whether in a rapid-access transient ischemic attack clinic, in an emergency department-observation unit, or with hospitalization, depending on local resources.

Transient monocular blindness: Vascular causes and differential diagnoses

Transient monocular blindness is an acute episode of ischemic origin in which one eye has profound visual loss, followed by full recovery within one hour. Transient monocular blindness most often occurs in the setting of retinal ischemia secondary to carotid embolism, but other mechanisms have been reported, including thrombosis (most often in the setting of giant cell arteritis), hemodynamic disorders (secondary to severe carotid stenosis), or vasospasm. Transient monocular blindness is considered a transient ischemic attack originating in the carotid arteries, and must be managed the same as transient ischemic attack involving the brain, in order to prevent a subsequent stroke.

Knowledge of peripheral arterial disease: Results of an intervention to measure and improve PAD knowledge in Toronto

Background

Prevalence of peripheral arterial disease (PAD) has dramatically increased in both developing, as well as developed countries. However, significant knowledge and practice gaps persist. In Canada, efforts to improve this knowledge level are lacking. In this study, we examine PAD knowledge in Toronto, and evaluate a pilot intervention to address the knowledge gaps.

Objectives

Measure PAD awareness in Toronto, and evaluate an intervention to improve PAD knowledge among the public.

Methods

In the context of a community-based awareness campaign, an interview-based survey was used to assess the PAD awareness among general public. A sample of participants was split into two arms: control (survey only) and intervention (survey and education pamphlet), the choice between assigning the site as case or control was random. A follow-up telephone and email-based survey was conducted after 6 weeks to assess the attained knowledge level of PAD.

Results

Two hundred thirty-seven participants completed the baseline survey. One hundred eighty-eight participants (78.7%) had never heard of PAD. The remaining “PAD-aware” cohort had low overall knowledge of the disease characteristics. Participants from each arm completed the follow-up survey. The level of education, age, and gender were not predictors of knowledge scores; however, age was a predictor of PAD awareness, while gender and level of education were not. Participants in the intervention group showed significant knowledge scores improvement in five PAD domains, while those from control group showed significant improvement in their preventative measures, treatment modalities, and total scores. The impact of the study intervention on average scores was borderline not significant ( p = 0.05).

Conclusion

PAD knowledge gap in the Canadian public is larger than what was previously reported. Educational campaigns are necessary to address this gap and improve the outcome of PAD patients through patients' activation. Our results are encouraging and warrant a next intervention to explore an educational program impact on PAD knowledge.

Secondary Stroke Prevention with Antiplatelet Drugs: Have We Reached the Ceiling?

Patients with transient ischemic attack (TIA) or ischemic stroke carry a risk of recurrent stroke of between 5% and 20% per year. In patients with TIA or ischemic stroke of non-cardiac origin, antiplatelet drugs are able to decrease the relative risk of stroke by 11–15% and the risk of stroke, myocardial infarction, and vascular death by 15–22%. Aspirin is the most widely used drug. It is affordable and effective. Low doses of 50–325 mg aspirin are as effective as high doses and cause less gastrointestinal side-effects. The combination of aspirin with slow-release dipyridamole is superior to aspirin alone for stroke prevention but not for the prevention of cardiac events. The risk of major bleeding complications is not increased with the combination, which suggests that dipyridamole might act in another way than as antiplatelet drug. Clopidogrel is not superior to aspirin in unselected stroke patients but is superior in patients at high risk of recurrence. The combination of aspirin plus clopidogrel is not more effective than clopidogrel alone, but carries a higher bleeding risk. The most effective antiplatelet drugs, the GP IIb/IIIa antagonists, are not superior to aspirin and carry a higher risk of bleeding. These results indicate that any antiplatelet therapy with a more potent drug than aspirin will only have a marginally higher efficacy, which might be offset by a higher bleeding rate. Therefore, selection of patients who might benefit from antiplatelet therapy other than aspirin is important.

Plasma L5 levels are elevated in ischemic stroke patients and enhance platelet aggregation

L5, the most electronegative and atherogenic subfraction of low-density lipoprotein (LDL), induces platelet activation. We hypothesized that plasma L5 levels are increased in acute ischemic stroke patients and examined whether lectin-like oxidized LDL receptor-1 (LOX-1), the receptor for L5 on endothelial cells and platelets, plays a critical role in stroke. Because amyloid β (Aβ) stimulates platelet aggregation, we studied whether L5 and Aβ function synergistically to induce prothrombotic pathways leading to stroke. Levels of plasma L5, serum Aβ, and platelet LOX-1 expression were significantly higher in acute ischemic stroke patients than in controls without metabolic syndrome (P < .01). In mice subjected to focal cerebral ischemia, L5 treatment resulted in larger infarction volumes than did phosphate-buffered saline treatment. Deficiency or neutralizing of LOX-1 reduced infarct volume up to threefold after focal cerebral ischemia in mice, illustrating the importance of LOX-1 in stroke injury. In human platelets, L5 but not L1 (the least electronegative LDL subfraction) induced Aβ release via IκB kinase 2 (IKK2). Furthermore, L5+Aβ synergistically induced glycoprotein IIb/IIIa receptor activation; phosphorylation of IKK2, IκBα, p65, and c-Jun N-terminal kinase 1; and platelet aggregation. These effects were blocked by inhibiting IKK2, LOX-1, or nuclear factor-κB (NF-κB). Injecting L5+Aβ shortened tail-bleeding time by 50% (n = 12; P < .05 vs L1-injected mice), which was prevented by the IKK2 inhibitor. Our findings suggest that, through LOX-1, atherogenic L5 potentiates Aβ-mediated platelet activation, platelet aggregation, and hemostasis via IKK2/NF-κB signaling. L5 elevation may be a risk factor for cerebral atherothrombosis, and downregulating LOX-1 and inhibiting IKK2 may be novel antithrombotic strategies.

Ophthalmic masquerades of the atherosclerotic carotids

Patients with carotid atherosclerosis can present with ophthalmic symptoms. These symptoms and signs can be due to retinal emboli, hypoperfusion of the retina and choroid, opening up of collateral channels, or chronic hypoperfusion of the globe (ocular ischemic syndrome). These pathological mechanisms can produce many interesting signs and a careful history can bring out important past symptoms pointing toward the carotid as the source of the patient's presenting symptom. Such patients are at high risk for an ischemic stroke, especially in the subsequent few days following their first acute symptom. It is important for clinicians to be familiar with these ophthalmic symptoms and signs caused by carotid atherosclerosis for making an early diagnosis and to take appropriate measures to prevent a stroke. This review elaborates the clinical features, importance, and implications of various ophthalmic symptoms and signs resulting from atherosclerotic carotid artery disease.

Risk factors and incidence for peripheral arterial disease in patients with typical lumbar spinal stenosis

OBJECTIVE

Intermittent claudication (IC) is a typical symptom of peripheral arterial disease (PAD) and lumbar spinal stenosis (LSS). In order to prevent misdiagnosis of vascular disease, it is important to know the incidence of and risk factors for PAD in patients with LSS. Therefore, the aim of our study was to evaluate the incidence of and risk factors for PAD in patients with typical and severe LSS who underwent spinal surgical treatment.

METHODS

The occurrence of PAD was examined retrospectively in 171 consecutive patients with LSS and severe IC who underwent surgical treatment at our hospital from June 2012 to June 2013. Data were collected on background characteristics (sex, age) and known risk factors for PAD, such as hypertension, diabetes mellitus, smoking, hyperlipidemia, stroke, and ischemic heart disease.

RESULTS

Of the 171 patients enrolled, 7 had an abnormal ankle-brachial index (ABI). Computed tomography angiography (CTA) was performed in these patients, and a final diagnosis of PAD was established for all 7 patients. The incidence of PAD in all patients with LSS was 4.1%(7 of 171). Stroke and ischemic heart disease were significantly more common in the LSSPAD group compared with the LSS group. Multiple logistic regression analyses with a forced-entry method revealed that age and stroke (p<0.05) were independent risk factors for PAD.

CONCLUSION

To prevent misdiagnosis of fatal PAD, we recommend ABI be assessed in patients with LSS and history of stroke.

Two cases of acute ischemic stroke associated with iron deficiency anemia due to bleeding from uterine fibroids in middle-aged women

We herein report two cases of acute ischemic stroke associated with iron deficiency anemia (IDA) due to bleeding from uterine fibroids. Anemia is not generally recognized as a risk factor for stroke. The physiological mechanisms that may factor in the development of ischemic stroke in patients with IDA include thrombocytosis, hypercoagulable state, and anemic hypoxia. In our two cases, IDA was considered to be the cause of ischemic stroke because all other known causes of stroke were ruled out. In patients with ischemic stroke due to anemia, early treatment of the anemia is important to prevent stroke recurrence.

European Stroke Prevention Study 2: A study of low-dose acetylsalicylic acid and of high dose dipyridamole in secondary prevention of cerebro-vascular accidents

In spite of some data being added to our knowledge of the effect of antiplatelets in secondary prevention of brain ischemic lesion in recent years, the main reasons to perform a second European Stroke Prevention Study (ESPS 2), which started in 1987-1988, were: (a) clarify the relative roles of aspirin (ASA) and dipyridamole (DP) alone or in combination; (b) confirm the efficacy of small doses of ASA and, so doing, decrease the number of drop-outs due to ASA side effects; (c) join information to the effect of antiplatelets in complete stroke. General characteristics of the sample of 6602 patients are presented and compared with other major trials and series. The patients in the four treatment arms (aspirin, dipyridamole, aspirin + dipyridamole and placebo) are compared. The more relevant features and risk factors known to influence long term prognosis are described and discussed. The small proportion of patients included with TIA (23.7%) and the comparability among treatment groups are stressed. No relevant differences have been found, among groups, on the sex or age distribution, prevalence of hypertension, diabetes, previous vascular events or atrial fibrillation, nor in the characteristics of the accident leading to the inclusion in trial.

Association of carotid plaque echogenicity with recurrence of ischemic stroke

BACKGROUND

Atherosclerosis is related to various cardiovascular and cerebrovascular events like cerebral infarction. Recurrence of ischemic stroke is specifically related to atherosclerotic load as determined by the presence of carotid atheromatous plaques and its echogenicity.

AIM

This study was to evaluate the association of recurrence of stroke with echogenic characteristics of carotid plaque in ischemic stroke patients.

MATERIALS AND METHODS

Carotid sonography using high-resolution 7.5 MHz along with gray-scale technique was done in each ischemic stroke patient to find the occurrence of plaque and its echogenicity according to Mannheim Carotid Intima-Media Thickness Consensus (2004-2006). Followup of patient done to know the recurrence of stroke during 6-month duration and its association with plaque echogenicity.

RESULTS

A significant association found between the presence of plaque and known cerebrovascular risk factors. Also significant association found between recurrence of stroke and echolucent character of carotid plaque in bivariate analysis (P = 0.0028).

CONCLUSIONS

Recurrence of stroke is related to advanced stage of atherosclerosis that is specified by carotid plaque and its characteristics. It will help us to identify groups of patients at different risk for stroke and planning better strategies to prevent such events.

Demographics of carotid atherosclerotic plaque features imaged by computed tomography

OBJECTIVES

This was a prospective, cross-sectional study to evaluate the risk factors and symptoms associated with specific carotid wall and atherosclerotic plaque features as seen on computed tomography-angiography (CTA) studies.

MATERIALS AND METHODS

A total of 120 consecutive consenting patients admitted to the emergency department with suspected cerebrovascular ischemia, and receiving standard-of-care CTA of the brain and neck on a 64-slice CT scanner, were prospectively enrolled in the study. The carotid wall features observed on CT were quantitatively analyzed with customized software using different radiodensities for contrast-phase acquisition of the carotids. Clinical datasets, including a complete medical history and examination, were obtained by research physicians or specially trained associates blinded to any findings on CT. Univariate and multivariate analyses were performed to assess the degree of association between clinical indicators and quantitative CT features of carotid atherosclerotic plaques.

RESULTS

Men tended to have increased carotid lumen (coefficient: 608.7; 95% CI: 356.9-860.6; P<0.001) and wall volumes (209.2; 54.5-364.0; P=0.008), and hypertension was associated with increased wall volume (260.6; 88.7-432.6; P=0.003). Advanced age was associated with increases in maximum wall thickness (0.02; 0.003-0.05; P=0.029), fibrous cap thickness (0.005; 0.001-0.008; P=0.016) and number of calcium voxels (2.7; 1.25-4.2; P<0.001), and the presence of a carotid bruit was associated with carotid stenosis length (21.0; 5.38-37.8; P=0.009). Exercise was inversely related to the number of calcium (-37.1; -71.5 - -2.7; P=0.035) and lipid (-7.9; -15.1 - -0.7; P=0.032) voxels. ACE inhibitor use was associated with fibrous cap thickness (0.1; 0.04-0.23; P=0.005).

CONCLUSION

Significant associations were found between clinical descriptors and carotid atherosclerotic plaque features as revealed by CT. Future studies are needed to validate our findings, and to continue investigations into whether CT features of carotid plaques can be used as biomarkers to quantify the impact of strategies aiming to correct vascular risk factors.

Clinical risk factors and CT imaging features of carotid atherosclerotic plaques as predictors of new incident carotid ischemic stroke: a retrospective cohort study

BACKGROUND AND PURPOSE

Parameters other than luminal narrowing are needed to predict the risk of stroke more reliably, particularly in patients with <70% stenosis. The goal of our study was to identify clinical risk factors and CT features of carotid atherosclerotic plaques, in a retrospective cohort of patients free of stroke at baseline, that are independent predictors of incident stroke on follow-up.

MATERIALS AND METHODS

We identified a retrospective cohort of patients admitted to our emergency department with suspected stroke between 2001-2007 who underwent a stroke work-up including a CTA of the carotid arteries that was subsequently negative for acute stroke. All patients also had to receive a follow-up brain study at least 2 weeks later. From a random sample, we reviewed charts and imaging studies of patients with subsequent new stroke on follow-up as well as those who remained stroke-free. All patients were classified either as "new carotid infarct patients" or "no-new carotid infarct patients" based on the Causative Classification for Stroke. Independently, the baseline CTA studies were processed using a custom, CT-based automated computer classifier algorithm that quantitatively assesses a set of carotid CT features (wall thickness, plaque ulcerations, fibrous cap thickness, lipid-rich necrotic core, and calcifications). Univariate and multivariate statistical analyses were used to identify any significant differences in CT features between the patient groups in the sample. Subsequent ROC analysis allowed comparison to the classic NASCET stenosis rule in identifying patients with incident stroke on follow-up.

RESULTS

We identified a total of 315 patients without a new carotid stroke between baseline and follow-up, and 14 with a new carotid stroke between baseline and follow-up, creating the main comparison groups for the study. Statistical analysis showed age and use of antihypertensive drugs to be the most significant clinical variables, and maximal carotid wall thickness was the most relevant imaging variable. The use of age ≥ 75 years, antihypertensive medication use, and a maximal carotid wall thickness of at least 4 mm was able to successfully identify 10 of the 14 patients who developed a new incident infarct on follow-up. ROC analysis showed an area under the ROC curve of 0.706 for prediction of new stroke with this new model.

CONCLUSIONS

Our new paradigm of using age ≥ 75 years, history of hypertension, and carotid maximal wall thickness of >4 mm identified most of the patients with subsequent new carotid stroke in our study. It is simple and may help clinicians choose the patients at greatest risk of developing a carotid infarct, warranting validation with a prospective observational study.

Atherosclerotic disease and risk factor modification in Saudi Arabia: a call to action

PURPOSE

Atherosclerotic disease (AD) is the leading cause of death worldwide and in Saudi Arabia. Intensive risk reduction therapy plays a major role in reducing adverse cardiovascular outcomes in patients with AD. The level of awareness of this important fact amongst physicians (family physicians, general internists, cardiologists and vascular surgeons) in managing these patients in Saudi Arabia is not currently known. This study was conducted to examine the perceptions and knowledge of risk reduction therapy in patients with AD amongst physicians in Saudi Arabia in two clinical presentations; coronary artery disease (CAD) and peripheral artery disease (PAD).

MATERIALS AND METHODS

We conducted a cross-sectional self-administered survey of 897 physicians at different hospitals in four provinces in Saudi Arabia.

RESULTS

The recommended targets of low density lipoprotein-cholesterol (LDL-C), blood glucose, and blood pressure in patients with CAD and PAD were known as 40% and 36%; 70% and 66%; and 32% and 28% of physicians, respectively. The initiation of antiplatelet medications, angiotensin converting enzyme (ACE) inhibitors, statins, and nicotine replacement therapy for smokers in patients with CAD and PAD were recommended by 98% and 97%; 52% and 34%; 61% and 56%; and 50% and 43% of physicians, respectively. Compared to other specialties, cardiologists had the lowest threshold for initiating risk reduction therapy, whereas vascular surgeons had the highest threshold.

CONCLUSION

The level of physician awareness of atherosclerosis risk reduction therapy across Saudi Arabia has revealed knowledge and action gaps. A call to action to implement effective strategies to encourage health professionals to use risk reduction therapy and increase public awareness is needed.

Validation of the Stroke Prognostic Instrument-II in a large, modern, community-based cohort of ischemic stroke survivors

BACKGROUND AND PURPOSE

The risk of recurrent stroke in the modern era of secondary stroke prevention is not well defined. Several prediction models, including the Stroke Prognostic Instrument-II (SPI-II), have been created to identify patients at highest risk, but their performance in modern populations has been infrequently tested. We aimed to assess the 1-year risk of recurrence after hospital discharge in a recent, large, community-based cohort of patients with ischemic stroke and to validate the SPI-II prediction model in this cohort.

METHODS

From 2004 through 2006, 5575 patients with acute ischemic stroke were prospectively identified and followed for recurrent events. Kaplan-Meier statistics were used to analyze the cumulative incidence of recurrent ischemic stroke. Harrell c-statistic was calculated to determine the performance of SPI-II in predicting stroke or death at 1 year, and the log-rank test was used to compare the differences among low-, middle-, and high-risk groups.

RESULTS

Among 5575 patients with ischemic stroke, recurrence was observed in 221 during the subsequent year. Kaplan-Meier estimates of cumulative rates of recurrent stroke were 2.5%, 3.6%, and 4.8% at 3, 6, and 12 months, respectively. Rates of stroke or death for SPI-II in the low-, middle-, and high-risk groups were 8.2%, 24.5%, and 35.6%, respectively (trend, P=0.001). The c-statistic for SPI-II was 0.62 (95% CI, 0.61-0.64).

CONCLUSIONS

The modern 1-year rate of recurrent stroke after hospital discharge is low but still substantial at 4.8%. SPI-II is a modestly effective tool in identifying patients with ischemic stroke at highest risk of developing recurrence or death.

An arterial pulse examination is not sufficient for diagnosis of peripheral arterial disease in lumbar spinal canal stenosis: a prospective multicenter study

STUDY DESIGN

Prospective, multicenter study.

OBJECTIVE

To conduct peripheral arterial disease (PAD) screening on intermittent claudication (IC) in patients with lumbar spinal canal stenosis (LSCS) to examine the relationships among combined LSCS and PAD, symptoms, and physical findings.

SUMMARY OF BACKGROUND DATA

IC occurs due to two underlying diseases, LSCS and PAD, and has an increasing prevalence with the aging of society. Reliable diagnosis of PAD is critical for appropriate conservative management of IC patients with LSCS in an Orthopedic Surgery Outpatient Department (OSOPD).

METHODS

PAD tests were prospectively conducted in 201 patients with IC and LSCS who initially visited an OSOPD at a hospital affiliated with the Nogoya Spine Group. Occurrence of PAD as a complication was assessed using ankle brachial pressure index (ABI) and toe brachial pressure index (TBI) tests. PAD was diagnosed in patients with ABI ≤ 0.9 or TBI ≤ 0.6, and the relationship of the occurrence of PAD with symptoms and physical findings such as abnormal arterial pulses was investigated.

RESULTS

Combined LSCS and PAD was found in 52 patients (26%), with 45 cases (22%) diagnosed on the basis of TBI test in patients with a normal ABI. Of the patients with PAD, many suffered from risk factors for PAD, with a significantly higher frequency of PAD in patients with hyperlipidemia (P < 0.05). PAD also occurred significantly more frequently in patients with abnormal pulses in the popliteal (P < 0.05), posterior tibial (P < 0.0001), and dorsal pedis (P < 0.0001) arteries; however, the sensitivity of these tests for PAD diagnosis was relatively low, at 34%, 60% and 68%, respectively.

CONCLUSION

The results of the prospective study define the rate of occurrence of combined LSCS and PAD using ABI and TBI tests for the first time, and the findings suggest that screening for PAD should be conducted in LSCS patients. ABI and TBI tests are necessary for PAD screening in outpatients, whereas observation of the arterial pulse in the lower extremities is necessary but not sufficient for PAD diagnosis.

Effects on duration of post-operative ischemia and patterns of blood flow recovery in different conditions of mouse hind limb ischemia

BACKGROUND

Current limitations to the experimentation on patients with peripheral arterial disease push the development of different preclinical strategies. We investigated both duration of ischemia and blood flow recovery in mouse models of partial femoral artery ligation.

METHODS

Male BALB/c mice were used. The ligation over needle method involved placing a suture needle over the femoral artery, ligating over it and then removing the needle. The transfixation method involved transfixing the approximate center of the femoral artery and then tying the suture. Laser Doppler Perfusion Imaging was used to assess perfusion every 3rd day until 42 days after the procedure.

RESULTS

Ligation over needle method: Immediately post procedure, mean perfusion was -71.87% ± 4.43. Then mean difference in perfusion remained below the base line reading on days 3, 6, 9, and 12. From day 15 on wards mean perfusion progressively improved remaining near base line. Transfixation Method: Immediately post procedure mean perfusion was -70.82% ± 4.73. Mean perfusion improved following the procedure on days 3 and 6; a plateau followed this on days 9, 12 and 15. From day 15 onwards perfusion progressively improved remaining well below base line until crossing it on day 36.

CONCLUSION

The currently described models do not pose major improvements over previously described methods.

Noninvasive carotid artery imaging with a focus on the vulnerable plaque

Currently carotid imaging has 2 main focuses: assessment of luminal stenosis and classification of atherosclerotic plaque characteristics. Measurement of the degree of stenosis is the main assessment used for current treatment decision making, but an evolving idea that is now driving imaging is the concept of vulnerable plaque, which is where plaque components are identified and used to define which plaques are at high risk of causing symptoms compared with those at low risk. This review article covers the methods used for noninvasive assessment of carotid luminal stenosis and the options available for plaque imaging.

Heart disease and stroke statistics--2011 update: a report from the American Heart Association

Each year, the American Heart Association (AHA), in conjunction with the Centers for Disease Control and Prevention, the National Institutes of Health, and other government agencies, brings together the most up-to-date statistics on heart disease, stroke, other vascular diseases, and their risk factors and presents them in its Heart Disease and Stroke Statistical Update. The Statistical Update is a valuable resource for researchers, clinicians, healthcare policy makers, media professionals, the lay public, and many others who seek the best national data available on disease morbidity and mortality and the risks, quality of care, medical procedures and operations, and costs associated with the management of these diseases in a single document. Indeed, since 1999, the Statistical Update has been cited more than 8700 times in the literature (including citations of all annual versions). In 2009 alone, the various Statistical Updates were cited ≈1600 times (data from ISI Web of Science). In recent years, the Statistical Update has undergone some major changes with the addition of new chapters and major updates across multiple areas. For this year’s edition, the Statistics Committee, which produces the document for the AHA, updated all of the current chapters with the most recent nationally representative data and inclusion of relevant articles from the literature over the past year and added a new chapter detailing how family history and genetics play a role in cardiovascular disease (CVD) risk. Also, the 2011 Statistical Update is a major source for monitoring both cardiovascular health and disease in the population, with a focus on progress toward achievement of the AHA’s 2020 Impact Goals. Below are a few highlights from this year’s Update.

Dual antiplatelet therapy in secondary prevention of ischemic stroke: a ghost from the past or a new frontier?

With majority of ischemic strokes attributable to atherothrombosis and many being predictable after transient ischemic attacks (TIA), the role of early secondary prevention with antiplatelet agents is under renewed investigation. Prior major clinical trials of various secondary stroke prevention regimens pointed to a greater efficacy of dual antiplatelet agents if initiated early from symptom onset. This paper examines data and rationale behind dual antiplatelet regimens across the completed clinical trials. The safety of dual antiplatelets approach is of concern, but it could be outweighed, at least in early management, by a greater reduction in recurrence of ischemic events since this risk is "front loaded" after minor stroke or TIA. Aspirin monotherapy, though considered standard of care, is compared to aspirin-extended release dipiridamole and its combination with clopidogrel in early-phase completed and efficacy-phase ongoing clinical trials.

Clinical characteristics of early and late recurrent ischaemic stroke

BACKGROUND AND PURPOSE

The aim of the study was to search for differences between clinical characteristics of recurrent ischaemic stroke which occurred within the fifth year after the first event or later, and early recurrence, i.e. within the first year after first-ever ischaemic stroke. We also tried to determine prognostic factors of late recurrent ischaemic episodes.

MATERIAL AND METHODS

The patients were divided into two groups: group I comprised 124 individuals with recurrence within the first year, and group II - 98 individuals in whom the recurrent episode appeared within the fifth year or later.

RESULTS

A significantly higher percentage of patients in group I demonstrated evident stenosis (70% or more) of internal carotid artery ipsilateral to stroke (p = 0.023). In this group more cardioembolic strokes were found compared to group II, while in the latter, predominantly lacunar strokes appeared (p = 0.046 and 0.0002, respectively). Group II patients significantly more frequently reported acetylsalicylic acid application, including systematic drug use (p = 0.001). No evident differences were found between groups considering other important non-modifiable and modifiable risk factors of stroke.

CONCLUSIONS

Small differences between risk factors of ischaemic stroke profiles in patients with early and late recurrent episodes do not allow us to distinguish unequivocally a group of patients with better prognosis regarding the time of recurrent stroke. Use of antiplatelet drugs, either systematic or non-systematic, and lacunar stroke are independent, positive prognostic factors of delay of potential recurrent stroke.

Predicting recurrent stroke after minor stroke and transient ischemic attack

The risk of a subsequent stroke following an acute transient ischemic attack or minor stroke is high, with 90-day risk at approximately 10%. Identification of those patients at the highest risk for recurrent stroke following a transient ischemic attack or minor stroke may allow risk-specific management strategies to be implemented, such as hospital admission with expedited work-up for those at high risk and emergency room discharge for those at low risk. Predictors of recurrent stroke, including the ABCD2 score, brain imaging and the stroke mechanism, are reviewed in this article, with a focus on recent literature. An emphasis is placed on the importance of early imaging of the brain parenchyma (diffusion-weighted imaging) and vascular imaging to identify patients at high risk for recurrence. The need for identification of the cause of the initial event, allowing therapies to be tailored to the individual patient, is discussed.

Carotid plaque, a subclinical precursor of vascular events: the Northern Manhattan Study

BACKGROUND

Carotid atherosclerosis is a known biomarker associated with future vascular disease. The risk associated with small, nonstenotic carotid plaques is less clear. The objective of this study was to examine the association between maximum carotid plaque thickness and risk of vascular events in an urban multiethnic cohort.

METHODS

As part of the population-based Northern Manhattan Study, carotid plaque was analyzed among 2,189 subjects. Maximum carotid plaque thickness was evaluated at the cutoff level of 1.9 mm, a prespecified value of the 75th percentile of the plaque thickness distribution. The primary outcome measure was combined vascular events (ischemic stroke, myocardial infarction, or vascular death).

RESULTS

Carotid plaque was present in 1,263 (58%) subjects. After a mean follow-up of 6.9 years, vascular events occurred among 319 subjects; 121 had fatal or nonfatal ischemic stroke, 118 had fatal or nonfatal myocardial infarction, and 166 died of vascular causes. Subjects with maximum carotid plaque thickness greater than 1.9 mm had a 2.8-fold increased risk of combined vascular events in comparison to the subjects without carotid plaque (hazard ratio, 2.80; 95% CI, 2.04-3.84). In fully adjusted models, this association was significant only among Hispanics. Approximately 44% of the low-risk individuals by Framingham risk score had a 10-year vascular risk of 18.3% if having carotid plaque.

CONCLUSIONS

Maximum carotid plaque thickness is a simple and noninvasive marker of subclinical atherosclerosis associated with increased risk of vascular outcomes in a multiethnic cohort. Maximum carotid plaque thickness may be a simple and nonexpensive tool to assist with vascular risk stratification in preventive strategies and a surrogate endpoint in clinical trials.

The Continued Promise of Neuroprotection for Acute Stroke Treatment

Stroke is the second leading cause of death. However, effective pharmocologic treatment options are still extremely limited and applicable to only a small fraction of patents. The translational failure in finding an effective neuroprotectant for ischemic strokes has generated an active discussion in this field. One focus has been on validating systems for testing neuroprotectants. This review discusses some fundamental issues in experimental stroke that are worthy of further exploration. We begin with a general review of the current status of experimental stroke research and then move on to a discussion of the determining factors and processes that control and differentiate the fate of ischemic ischemic cells and tissue. We propose several strategies of neuroprotection for ischemic strokes with an emphasis on manipulating cellular energy state.

Patients at high risk for ischemic stroke: identification and actions

Atherosclerosis is a disease of chronic inflammation. It is diffuse, multisystemic and affects the vascular, metabolic and immune systems. The traditional evaluation of risk is based on methods of clinical and biological assessments, and conventional imaging. The existence of symptomatic disease and the number of symptomatic sites of atherothrombosis are critical factors in predicting the recurrence of major vascular events. However, these methods are insufficient to predict near-future episodes, above all in the individual standard clinical practice. Active treatment of modifiable risk factors such as hypertension, dyslipidemia and atrial fibrillation can reduce the number of patients who develop a stroke. There is considerable evidence suggesting that a substantial proportion of the population with high blood pressure receives insufficient treatment. More active treatment of this condition is probably the most efficient single measure. Lifestyle factors such as smoking, diet, physical inactivity and obesity contribute to the relatively high incidence of stroke. There is a need to incorporate new systemic markers and new investigation techniques in the future so as to identify the individuals at risk in the population and to administer more individualized intervention therapies.

Stroke and its prevention in chronic kidney disease

This is a review of stroke mechanisms and management. The concept of stroke and transient ischemic attack and the recently proposed revision in definitions and controversies are discussed. We also discuss the use of antiplatelet and anticoagulant drugs for stroke due to carotid and cardiac disease.

Transient ischemic attack and risk of stroke recurrence: The Lehigh Valley Recurrent Stroke Study

We investigated the effect of transient ischemic attack occurring both before and after an initial stroke on risk of recurrent stroke in a population-based study. In the Lehigh Valley Recurrent Stroke Study, patients were enrolled between July 1987 and August 1989 and followed up regularly at about 6-month intervals for up to 4 years (mean, 2 years). In addition to history of transient ischemic attack before and after the initial stroke, information on comorbidities including hypertension, myocardial infarction, cardiac arrhythmia, and diabetes mellitus was collected at the baseline visit and at follow-up visits. The 621 patients with an initial ischemic stroke constituted the cohort analyzed in this report. A history of transient ischemic attack was present at enrollment in 114 (18.4%) patients. During follow-up, 20 patients experienced a transient ischemic attack, and 77 had a recurrent stroke. Using a Cox proportional hazards model taking comorbidities, sex, and age into account, we analyzed the relationship between transient ischemic attack and recurrent stroke in the 503 patients with at least one follow-up visit. History of transient ischemic attack before the initial stroke was associated with a decreased risk of recurrent stroke (Hazards ratio, 0.3; 95% confidence interval, 0.08 to 0.86; P=.03), whereas a new transient ischemic attack after the initial stroke was associated with an increased risk of recurrent stroke (Hazards ratio, 11.7; 95% C.I. confidence interval=3.45 to 39.83; P=.0001).

How to treat hypertension in patients with peripheral artery disease

The risk of peripheral artery disease is underestimated by many physicians; such risk is further augmented by the presence of hypertension. Detection of these conditions is essential to prevent cardiovascular accidents. This review deals with the management of peripheral artery disease as a risk factor, highlighting the need for triple therapy (antiplatelet drugs, angiotensin-converting enzyme inhibitors, and statins). Treatment of hypertension is approached by reviewing the essentials of the different antihypertensive drugs available, focusing on their peripheral circulatory effect. However, because individual antihypertensive drugs seem not to differ largely in this respect, attention is drawn to the message that the most important task in these patients is to control total cardiovascular risk rather than focusing on the choice of the individual antihypertensive drug.