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Barone V, Foschi M, Pavolucci L, Rondelli F, Rinaldi R, Nicodemo M, D’Angelo R, Favaretto E, Brusi C, Cosmi B, Degli Esposti D, D’Addato S, Bacchelli S, Giostra F, Pomata DP, Spinardi L, Faccioli L, Faggioli G, Donti A, Borghi C, Cortelli P, Guarino M. Enhancing stroke risk prediction in patients with transient ischemic attack: insights from a prospective cohort study implementing fast-track care. Front Neurol 2024; 15:1407598. [PMID: 38859972 PMCID: PMC11163114 DOI: 10.3389/fneur.2024.1407598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 04/29/2024] [Indexed: 06/12/2024] Open
Abstract
Background and aims Fast-track care have been proved to reduce the short-term risk of stroke after transient ischemic attack (TIA). We aimed to investigate stroke risk and to characterize short- and long-term stroke predictors in a large cohort of TIA patients undergoing fast-track management. Methods Prospective study, enrolling consecutive TIA patients admitted to a Northern Italy emergency department from August 2010 to December 2017. All patients underwent fast-track care within 24 h of admission. The primary outcome was defined as the first stroke recurrence at 90 days, 12 and 60 months after TIA. Stroke incidence with 95% confidence interval (CI) at each timepoint was calculated using Poisson regression. Predictors of stroke recurrence were evaluated with Cox regression analysis. The number needed to treat (NNT) of fast-track care in preventing 90-day stroke recurrence in respect to the estimates based on baseline ABCD2 score was also calculated. Results We enrolled 1,035 patients (54.2% males). Stroke incidence was low throughout the follow-up with rates of 2.2% [95% CI 1.4-3.3%] at 90 days, 2.9% [95% CI 1.9-4.2%] at 12 months and 7.1% [95% CI 5.4-9.0%] at 60 months. Multiple TIA, speech disturbances and presence of ischemic lesion at neuroimaging predicted stroke recurrence at each timepoint. Male sex and increasing age predicted 90-day and 60-month stroke risk, respectively. Hypertension was associated with higher 12-month and 60-month stroke risk. No specific TIA etiology predicted higher stroke risk throughout the follow-up. The NNT for fast-track care in preventing 90-day stroke was 14.5 [95% CI 11.3-20.4] in the overall cohort and 6.8 [95% CI 4.6-13.5] in patients with baseline ABCD2 of 6 to 7. Conclusion Our findings support the effectiveness of fast-track care in preventing both short- and long-term stroke recurrence after TIA. Particular effort should be made to identify and monitor patients with baseline predictors of higher stroke risk, which may vary according to follow-up duration.
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Affiliation(s)
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Lucia Pavolucci
- Department of Neuroscience, S. Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | | | - Rita Rinaldi
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | | | | | - Elisabetta Favaretto
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carlotta Brusi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Degli Esposti
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sergio D’Addato
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Stefano Bacchelli
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Fabrizio Giostra
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniela Paola Pomata
- Emergency Department, Medicina d’Urgenza e Pronto Soccorso, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Spinardi
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Faccioli
- Diagnostic and Interventional Neuroradiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gianluca Faggioli
- Department of Vascular Surgery, DIMEC – University of Bologna, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Heart Disease Program, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Borghi
- Department of Cardio-Thoracic Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
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Edlow JA, Bellolio F. Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness. Ann Emerg Med 2024:S0196-0644(24)00214-2. [PMID: 38795083 DOI: 10.1016/j.annemergmed.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/27/2024]
Abstract
Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.
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Affiliation(s)
- Jonathan A Edlow
- Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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3
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Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 PMCID: PMC11179775 DOI: 10.1161/jaha.123.032808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
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Affiliation(s)
- Paul M. Wechsler
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ankur Pandya
- Department of Health Policy and ManagementHarvard T.H. Chan School of Public HealthBostonMA
| | - Neal S. Parikh
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Junaid A. Razzak
- Department of Emergency MedicineWeill Cornell MedicineNew YorkNY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Babak B. Navi
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Ava L. Liberman
- Department of Neurology, Clinical and Translational Neuroscience UnitFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
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4
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Sinha T, Riaz A, Rawat A, Phoo CN, Nageye ME, Chaudhari SS, Wei CR, Amin A. Comparison of Effectiveness and Safety of Dual Antiplatelet Therapy (DAPT) With Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients With Mild-to-Moderate Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58909. [PMID: 38800328 PMCID: PMC11118889 DOI: 10.7759/cureus.58909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
The aim of this meta-analysis was to assess the effectiveness and safety of the combination of clopidogrel and aspirin in patients with mild ischemic stroke or transient ischemic attack (TIA). The methodologies employed in this meta-analysis strictly followed the commonly used reporting formats for systematic reviews and meta-analyses. The methodologies employed in this meta-analysis strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Until March 25, 2024, we conducted thorough searches on PubMed, EMBASE (Excerpta Medica Database), and the Cochrane Library to locate studies investigating the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with mild or moderate stroke or TIA. Outcomes assessed in this meta-analysis included stroke (including ischemic stroke and hemorrhagic stroke), myocardial infarction, all bleeding events, and moderate to severe bleeding events. A total of 12 studies were included in this meta-analysis. The total number of enrolled patients across these studies was 35,369, with 16,957 receiving DAPT and 18,412 receiving aspirin monotherapy. The risk of developing stroke was significantly lower in patients receiving the combination of clopidogrel and aspirin compared to the aspirin monotherapy group (relative risk (RR): 0.77, 95% confidence interval (CI): 0.72 to 0.83, p-value<0.0001). No significant differences were there in terms of all bleeding events (RR: 1.37, 95% CI: 0.92 to 2.04, p-value: 0.12) and moderate to severe bleeding events (RR: 1.18, 95% CI: 0.86 to 1.63, p-value: 0.30). These findings highlight the importance of carefully weighing the potential benefits against the risks, especially in clinical decision-making for patients with TIA or ischemic stroke. Further research is warranted to elucidate optimal strategies for balancing stroke prevention with bleeding risk mitigation in this patient population.
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Affiliation(s)
- Tanya Sinha
- Medical Education, Tribhuvan University, Kirtipur, NPL
| | - Areeba Riaz
- Medicine, Quiad-e-Azam Medical College, Bahawalpur, PAK
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Chaw N Phoo
- Internal Medicine, University of Medicine, Mandalay, Mandalay, MMR
| | - Maymona E Nageye
- Internal Medicine - Pediatrics, Avalon University School of Medicine, Willemstad, CUW
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
| | - Adil Amin
- Cardiology, Pakistan Navy Ship Shifa, Karachi, PAK
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5
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Zhang X, Zhong W, Xue R, Jin H, Gong X, Huang Y, Chen F, Chen M, Gu L, Ge Y, Ma X, Zhong B, Wang M, Hu H, Chen Z, Yan S, Chen Y, Wang X, Zhang X, Xu D, He Y, Lou M, Wang A, Zhang X, Ma L, Lu X, Wang J, Lou Q, Qian P, Xie G, Zhu X, He S, Hu J, Wen X, Liu Y, Wang Y, Fu J, Fan W, Liebeskind D, Yuan C, Lou M. Argatroban in Patients With Acute Ischemic Stroke With Early Neurological Deterioration: A Randomized Clinical Trial. JAMA Neurol 2024; 81:118-125. [PMID: 38190136 PMCID: PMC10775075 DOI: 10.1001/jamaneurol.2023.5093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/20/2023] [Indexed: 01/09/2024]
Abstract
Importance The effect of argatroban in patients with acute ischemic stroke (AIS) and early neurological deterioration (END) is unknown. Objective To assess the efficacy of argatroban for END in AIS. Design, Setting, and Participants This open-label, blinded-end point, randomized clinical trial was conducted from April 4, 2020, through July 31, 2022. The date of final follow-up was October 31, 2022. This was a multicenter trial. Eligible patients were adults with AIS who experienced END, which was defined as an increase of 2 or more points on the National Institutes of Health Stroke Scale within 48 hours from symptom onset. Patients who withdrew consent, experienced duplicate randomization, or were lost to follow-up were excluded from the study. Interventions Patients were randomly assigned to the argatroban group and control group within 48 hours of symptom onset. Both groups received standard therapy based on guidelines, including oral mono or dual antiplatelet therapy. The argatroban group received intravenous argatroban for 7 days (continuous infusion at a dose of 60 mg per day for 2 days, followed by 20 mg per day for 5 days) in addition to standard therapy. Main Outcome and Measure The primary end point was good functional outcome at 90 days, defined as a modified Rankin Scale score of 0 to 3. Results A total of 628 patients (mean [SD] age, 65 [11.9] years; 400 male [63.7%]) were included in this study (argatroban group, 314 [50%] and control group, 314 [50%]). Of these, 18 withdrew consent, 1 had duplicate randomization, and 8 were lost to follow-up. A total of 601 patients with stroke were included in the intention-to-treat analysis. Finally, 564 patients were included in the per-protocol analysis as 6 participants in the argatroban group and 31 participants in the control group did not follow the complete protocol. The number of patients with good functional outcome at 90 days was 240 (80.5%) in the argatroban group and 222 (73.3%) in the control group (risk difference, 7.2%; 95% CI, 0.6%-14.0%; risk ratio, 1.10; 95% CI, 1.01-1.20; P = .04). The proportion of symptomatic intracranial hemorrhage was 3 of 317 (0.9%) in the argatroban group and 2 of 272 (0.7%) in the control group (P = .78). Conclusions and Relevance Among patients with AIS with END, treatment with argatroban and antiplatelet therapy resulted in a better functional outcome at 90 days. This trial provided evidence to support the use of argatroban in reducing disability for patients with END. Trial Registration ClinicalTrials.gov Identifier: NCT04275180.
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Affiliation(s)
- Xuting Zhang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Rui Xue
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haidi Jin
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoxian Gong
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuhui Huang
- School of Public Health, Zhejiang University, Hangzhou, China
| | - Fujian Chen
- Department of Neurology, People’s Hospital of Anji, Huzhou, China
| | - Mozi Chen
- Department of Neurology, People’s Hospital of Anji, Huzhou, China
| | - Liqun Gu
- Department of Neurology, First Hospital of Ninghai County, Ningbo, China
| | - Yebo Ge
- Department of Neurology, The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Xiaodong Ma
- Department of Neurology, Haiyan People’s Hospital, Jiaxing, China
| | - Bifeng Zhong
- Department of Neurology, Putuo Hospital, Zhoushan, China
| | - Mengjie Wang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haitao Hu
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhicai Chen
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shenqiang Yan
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Chen
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Wang
- Department of Neurology, Yiwu Central Hospital, Yiwu, China
| | - Xiaoling Zhang
- Department of Neurology, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Dongjuan Xu
- Department of Neurology, Dongyang Affiliated Hospital of Wenzhou Medical University, Dongyang, China
| | - Yuping He
- Department of Neurology, Zhuji People’s Hospital, Zhuji, China
| | - Minfang Lou
- Department of Neurology, Quzhou Traditional Chinese Medicine Hospital, Quzhou, China
| | - Aiju Wang
- Department of Neurology, Xiangshan People’s Hospital, Xiangshan, China
| | - Xiong Zhang
- Department of Neurology, Institute of Geriatric Neurology, The Second Affiliated Hospital and Yuying Children’s Hospital, Wenzhou Medical University, Wenzhou, China
| | - Li Ma
- Department of Neurology, Shaoxing Second Hospital, Shaoxing, China
| | - Xiaodong Lu
- Department of Neurology, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Jianer Wang
- Department of Neurology, The Second People’s Hospital of Yuhang District, Hangzhou, China
| | - Qiong Lou
- Department of Neurology, The Affiliated Hospital of Medicine School, Ningbo University, Ningbo, China
| | - Ping’an Qian
- Department of Neurology, Ningbo Ninth Hospital, Ningbo, China
| | - Guomin Xie
- Department of Neurology, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Xiaofen Zhu
- Department of Neurology, Quzhou City Kecheng District People’s Hospital, Quzhou, China
| | - Songbin He
- Department of Neurology, Zhoushan Hospital, Wenzhou Medical University, Zhoushan, China
| | - Jin Hu
- Department of Neurology, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xiongjie Wen
- Department of Neurology, Tongxiang Hospital of Traditional Chinese Medicine, Jiaxing, China
| | - Yan Liu
- Department of Neurology, Zhenhai Longsai Hospital of Ningbo city, Ningbo, China
| | - Yanwen Wang
- Department of Neurology, Zhejiang Hospital, Hangzhou, China
| | - Jingjing Fu
- Department of Neurology, The 4th Affiliated Hospital of Zhejiang University, School of Medicine, Yiwu, China
| | - Weinv Fan
- Department of Neurology, Ningbo No.2 Hospital, Ningbo, China
| | - David Liebeskind
- David Geffen School of Medicine, Department of Neurology and Comprehensive Stroke Center, University of California, Los Angeles
| | - Changzheng Yuan
- School of Public Health, Zhejiang University, Hangzhou, China
- Department of Nutrition, Harvard T.H. School of Public Health, Boston, Massachusetts
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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7
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Jain U, Jain B, Brown J, Sultan IB, Thoma F, Anetakis KM, Balzer JR, Subramaniam K, Yousef S, Wang Y, Nogueira R, Thirumala PD. Outcomes after Perioperative Transient Ischemic Attack Following Cardiac Surgery. J Cardiovasc Dev Dis 2024; 11:27. [PMID: 38248897 PMCID: PMC10816235 DOI: 10.3390/jcdd11010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Perioperative transient ischemic attacks (PTIAs) are associated with significantly increased rates of postoperative complications such as low cardiac output, atrial fibrillation, and significantly higher mortality in cardiac procedures. The current literature on PTIAs is sparse and understudied. Therefore, we aim to understand the effects of PTIA on hospital utilization, readmission, and morbidity. Using data on all the cardiac procedures at the University of Pittsburgh Medical Center from 2011 to 2019, fine and gray analysis was performed to identify whether PTIAs and covariables correlate with increased hospital utilization, stroke, all-cause readmission, Major Adverse Cardiac and Cerebrovascular Events (MACCE), MI, and all-cause mortality. Logistic regression for longer hospitalization showed that PTIA (HR: 2.199 [95% CI: 1.416-3.416] increased utilization rates. Fine and gray modeling indicated that PTIA (HR: 1.444 [95% CI: 1.096-1.902], p < 0.01) increased the rates of follow-up all-cause readmission. However, PTIA (HR: 1.643 [95% CI: 0.913-2.956] was not statistically significant for stroke readmission modeling. Multivariate modeling for MACCE events within 30 days of surgery (HR: 0.524 [95% CI: 0.171-1.605], p > 0.25) and anytime during the follow-up period (HR: 1.116 [95% CI: 0.825-1.509], p > 0.45) showed no significant correlation with PTIA. As a result of PTIA's significant burden on the healthcare system due to increased utilization, it is critical to better define and recognize PTIA for timely management to improve perioperative outcomes.
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Affiliation(s)
- Urvish Jain
- School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA;
| | - Bhav Jain
- School of Medicine, Stanford University, Stanford, CA 94305, USA;
| | - James Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Ibrahim B. Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Floyd Thoma
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Katherine M. Anetakis
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
| | - Jeffrey R. Balzer
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Yisi Wang
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (J.B.); (S.Y.); (Y.W.)
| | - Raul Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Parthasarathy D. Thirumala
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (K.M.A.); (J.R.B.); (P.D.T.)
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
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8
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Kuzan A, Kozak-Sykała A, Fiedorowicz A, Kałas W, Strządała L, Gamian A. Advanced Glycation End-Products in Blood Serum-Novel Ischemic Stroke Risk Factors? Implication for Diabetic Patients. J Clin Med 2024; 13:443. [PMID: 38256577 PMCID: PMC10816329 DOI: 10.3390/jcm13020443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/03/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
New predictors of ischemic incidents are constantly sought since they raise the awareness of patients and their doctors of stroke occurrence. The goal was to verify whether Advanced Glycation End Products (AGEs), in particular AGE10, could be one of them. The AGE10 measurement was conducted using a non-commercial ELISA assay in the blood serum of neurological patients without cerebrovascular event (n = 24), those with transient brain attack (TIA) (n = 17), and severe ischemic stroke (n = 35). Twice as many of the people with TIA or severe stroke presented high AGE10 serum concentrations compared to the patients with other neurological conditions (χ2 = 8.2, p = 0.004; χ2 = 8.0, p = 0.005, respectively). The risk of ischemic incident was significantly risen in people with higher levels of AGE10 (OR = 6.5, CI95%: 1.7-24.8; OR = 4.7, CI95%: 1.5-14.5 for TIA and stroke subjects, respectively). We observed a positive correlation (r = 0.40) between high AGE10 levels and diabetes. Moreover, all the diabetic patients that had a high AGE10 content experienced either a severe ischemic stroke or TIA. The patients with high levels of AGE10 exhibited higher grades of disability assessed by the NIHSS scale (r = 0.35). AGE10 can be considered a new biomarker of ischemic stroke risk. Patients with diabetes presenting high AGE10 levels are particularly prone to the occurrence of cerebrovascular incidents.
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Affiliation(s)
- Aleksandra Kuzan
- Department of Biochemistry and Immunochemistry, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Anna Kozak-Sykała
- Neurology and Stroke Department, Independent Public Healthcare Centre, Jankowski Regional Hospital in Przeworsk, Szpitalna 16, 37-200 Przeworsk, Poland;
| | - Anna Fiedorowicz
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Wojciech Kałas
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Leon Strządała
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
| | - Andrzej Gamian
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, 53-114 Wroclaw, Poland (W.K.); (L.S.); (A.G.)
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Zaharia AL, Tutunaru D, Oprea VD, Tănase CE, Croitoru A, Stan B, Voinescu DC, Ionescu AM, Coadǎ CA, Lungu M. Thrombomodulin Serum Levels-A Predictable Biomarker for the Acute Onset of Ischemic Stroke. Curr Issues Mol Biol 2024; 46:677-688. [PMID: 38248346 PMCID: PMC10813863 DOI: 10.3390/cimb46010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/07/2024] [Accepted: 01/10/2024] [Indexed: 01/23/2024] Open
Abstract
The early diagnosis of acute ischemic stroke (AIS) can be challenging in cases presenting with a scarcity of clinical signs, normal cerebral imaging in early stages and a lack of specific serum markers. Thrombomodulin has been shown to be associated with cerebrovascular ischemic events and can be considered an important biomarker for the acute onset of ischemic stroke. In our study, we compared the serum levels of thrombomodulin (sTM) between a relevant patient group of 70 AIS patients and a control group of patients without AIS admitted into the neurology department between June 2022 and May 2023. sTM levels were measured at 24 h and 48 h after patients' admissions into the hospital. There was a significant difference between the two groups (AIS: 23.2 ± 9.17 ng/mL vs. controls: 3.64 ± 1.72 ng/mL; p-value < 0.001). sTM values were correlated with the score of neurological deficits, with gender and dyslipidemia. The association of sTM values with the acute onset of AIS as an end point was significant, which allows rapid therapeutic interventions, even in the absence of a well-defined clinical syndrome (AUC = 0.99). Reanalysis of the patients after propensity score matching increased the power of sTM as a biomarker (AUC = 1). sTM represents a potentially useful biomarker to diagnose the onset of an AIS, even in scarce clinical presentations, which makes thrombomodulin a valuable indicator for early treatment initiation.
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Affiliation(s)
- Andrei-Lucian Zaharia
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Dana Tutunaru
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Violeta Diana Oprea
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Claudiu Elisei Tănase
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
- “St. Joan” Pediatric Clinical Emergency Hospital Galati, 800487 Galati, Romania
| | - Ana Croitoru
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Bianca Stan
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Doina Carina Voinescu
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
| | - Ana-Maria Ionescu
- Faculty of Medicine and Pharmacy, Ovidius University of Constanța, 900470 Constanța, Romania;
| | - Camelia Alexandra Coadǎ
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Mihaiela Lungu
- “St. Apostle Andrei” Clinical Emergency County Hospital Galati, 800578 Galati, Romania; (A.-L.Z.); (A.C.); (B.S.); (D.C.V.); (M.L.)
- Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 800216 Galati, Romania;
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10
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Tanaka K, Coutts SB, Joundi RA, Singh N, Uehara T, Ohara T, Koga M, Koge J, Toyoda K, Penn AM, Balshaw RF, Bibok MMB, Votova K, Smith EE, Minematsu K, Demchuk AM. Presenting Symptoms and Diffusion-Weighted MRI Positivity by Time After Transient Neurologic Events: A Pooled Analysis of 3 Cohort Studies. Neurology 2024; 102:e207846. [PMID: 38165379 PMCID: PMC10834141 DOI: 10.1212/wnl.0000000000207846] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/27/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVE The association between focal vs nonfocal presenting symptom and diffusion-weighted imaging (DWI) positivity in relation to onset-to-imaging time in patients with transient neurologic events remains unclear. We hypothesize that episodes consisting of focal symptoms would have proportionally higher DWI-positive imaging at later onset-to-imaging times. METHODS Patients with transient neurologic symptoms and a normal neurologic examination who had DWI in the combined data set of 3 cohort studies were included. We used logistic regression models to evaluate the association between each type of presenting symptom (motor weakness, speech impairment, sensory symptoms, vision loss, diplopia, gait instability, dizziness, headache, presyncope, and amnesia) and DWI positivity after adjusting for clinical variables (age, sex, history of stroke, dyslipidemia, coronary artery disease, atrial fibrillation, symptoms duration [<10, 10-59, ≥60 minutes, or unclear], and study source). We stratified the results by onset-to-imaging time categories (<6 hours, 6-23 hours, and ≥24 hours). RESULTS Of the total 2,411 patients (1,345 male, median age 68 years), DWI-positive lesions were detected in 598 patients (24.8%). The prevalence of DWI positivity was highest in those with motor weakness (34.7%), followed by speech impairment (33.5%). In a multivariable analysis, the presence of motor weakness, speech impairment, and sensory symptoms was associated with DWI positivity, while vision loss and headache were associated with lower odds of DWI positivity, but nevertheless had 13.6% and 15.3% frequency of DWI positive. The odds of being DWI positive varied by onset-to-imaging time categories for motor weakness, with greater odds of being DWI positive at later imaging time (<6 hours: odds ratio [OR] 1.25, 95% confidence interval [CI] 0.84-1.87; 6-23 hours: OR 2.24, 95% CI 1.47-3.42; and ≥24 hours: OR 2.42, 95% CI 1.74-3.36; interaction p = 0.033). Associations of other symptoms with DWI positivity did not vary significantly by time categories. DISCUSSION We found that onset-to-imaging time influences the relationship between motor weakness and DWI positivity in patients with transient neurologic events. Compared with motor, speech, and sensory symptoms, visual or nonfocal symptoms carry a lower but still a substantive association with DWI positivity.
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Affiliation(s)
- Koji Tanaka
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Shelagh B Coutts
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Raed A Joundi
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Nishita Singh
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Tohiyuki Uehara
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Tomoyuki Ohara
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Masatoshi Koga
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Junpei Koge
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Kazunori Toyoda
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Andrew M Penn
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Robert F Balshaw
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Maximilian M B Bibok
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Kristine Votova
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Eric E Smith
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Kazuo Minematsu
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
| | - Andrew M Demchuk
- From the Department of Clinical Neurosciences (K. Tanaka, S.B.C., N.S., E.E.S., A.M.D.), Radiology (S.B.C., E.E.S., A.M.D), Community Health Sciences (S.B.C.), and Hotchikiss Brain Institute (S.B.C., E.E.S., A.M.D.), Cumming School of Medicine, University of Calgary, Calgary, Canada; Rady Faculty of Health Sciences (N.S.), University of Manitoba, Winnipeg, Canada; Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Canada; Department of Cerebrovascular Medicine (T.U., T.O., M.K., J.K., K. Toyoda, K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Stroke Rapid Assessment Unit (A.M.P.), Island Health, Victoria; George & Fay Yee Centre for Healthcare Innovation (R.F.B.), University of Manitoba, Winnipeg; Department of Research and Capacity Building (M.M.B.), Island Health, Victoria; Island Health Regional Health Authority, Division of Medical Sciences (K.V.), University of Victoria, Victoria, Canada
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11
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Sico JJ, Hu X, Myers LJ, Levine D, Bravata DM, Arling GW. Real-world analysis of two ischaemic stroke and TIA systolic blood pressure goals on 12-month mortality and recurrent vascular events. Stroke Vasc Neurol 2024:svn-2023-002759. [PMID: 38191185 DOI: 10.1136/svn-2023-002759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/12/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION Whether obtaining the more intensive goal systolic blood pressure (SBP) of <130 mm Hg, rather than a less intensive SBP goal of <140 mm Hg poststroke/transient ischaemic attack (TIA) is associated with incremental mortality and recurrent vascular event benefit is largely unexplored using real-world data. Lowering SBP excessively may result in poorer outcomes. METHODS This is a retrospective cohort study of 26 368 Veterans presenting to a Veterans Administration Medical Center (VAMC) with a stroke/TIA between October 2015 and July 2018. Patients were excluded from the study if they had missing or extreme BP values, receiving dialysis or palliative care, left against medical advice had a cancer diagnosis, were cared for in a VAMC enrolled in a stroke/TIA quality improvement initiative, died or had a cerebrovascular or cardiovascular event within 90 days after their index stroke/TIA. The analytical sample included 12 337 patients. Average SBP during 90 days after discharge was assessed in categories (≤105 mm Hg, 106-115 mm Hg, 116-130 mm Hg, 131-140 mm Hg and >140 mm Hg). Separate multivariable Cox proportional hazard regressions were used to examine the relationship between average SBP groups and time to: (1) mortality and (2) any recurrent vascular event, from 90 days to up to 365 days after discharge from the index emergency department visit or inpatient admission. RESULTS Compared with those with SBP>140 mm Hg, patients with SBP between 116 and 130 mm Hg had a significantly lower risk of recurrent stroke/TIA (HR 0.77, 95% CI 0.60 to 0.99) but not cardiovascular events. Patients with SBP lower than 105 mm Hg, compared with those with >140 mm Hg demonstrated a statistically significant higher risk of death (HR 2.07, 95% CI 1.43 to 3.00), but no statistical differences were found in other SBP groups. DISCUSSION Data support a more intensive SBP goal to prevent recurrent cerebrovascular events among stroke/TIA patients by 90 days poststroke/TIA compared with less intensive goal. Very low SBPs were associated with increased mortality risk.
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Affiliation(s)
- Jason J Sico
- Internal Medicine and Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Neurology, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Xin Hu
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Laura J Myers
- VA Health Services Research and Development (HSR&D) Center for Healthcare Informatics and Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Deborah Levine
- Departments of Medicine and Neurology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Dawn M Bravata
- Health Services Research and Development (HSR&D) Center for Healthcare Informatics and Communication and the HSR&D Stroke Quality Enhancement Research Initiative (QUERI); Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Greg W Arling
- Department of Veterans Affairs (VA), Health Services Research and Development (HSR&D) Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative (QUERI), Indianapolis, Indiana, USA
- Department of Nursing, Purdue University, West Lafayette, Indiana, USA
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12
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Shu C, Zheng C, Luo D, Song J, Jiang Z, Ge L. Acute ischemic stroke prediction and predictive factors analysis using hematological indicators in elderly hypertensives post-transient ischemic attack. Sci Rep 2024; 14:695. [PMID: 38184714 PMCID: PMC10771433 DOI: 10.1038/s41598-024-51402-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/04/2024] [Indexed: 01/08/2024] Open
Abstract
Elderly hypertensive patients diagnosed with transient ischemic attack (TIA) are at a heightened risk for developing acute ischemic stroke (AIS). This underscores the critical need for effective risk prediction and identification of predictive factors. In our study, we utilized patient data from peripheral blood tests and clinical profiles within hospital information systems. These patients were followed for a three-year period to document incident AIS. Our cohort of 11,056 individuals was randomly divided into training, validation, and testing sets in a 5:2:3 ratio. We developed an XGBoost model, developed using selected indicators, provides an effective and non-invasive method for predicting the risk of AIS in elderly hypertensive patients diagnosed with TIA. Impressively, this model achieved a balanced accuracy of 0.9022, a recall of 0.8688, and a PR-AUC of 0.9315. Notably, our model effectively encapsulates essential data variations involving mixed nonlinear interactions, providing competitive performance against more complex models that incorporate a wider range of variables. Further, we conducted an in-depth analysis of the importance and sensitivity of each selected indicator and their interactions. This research equips clinicians with the necessary tools for more precise identification of high-risk individuals, thereby paving the way for more effective stroke prevention and management strategies.
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Affiliation(s)
- Chang Shu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China.
| | - Chenguang Zheng
- Tianjin Key Laboratory of Brain Science and Neural Engineering, Tianjin University, Tianjin, China
| | - Da Luo
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China
| | - Jie Song
- Academy of Medical Engineering and Translational Medicine, Intelligent Medical Engineering, Tianjin University, Tianjin, China
| | - Zhengyi Jiang
- Academy of Medical Engineering and Translational Medicine, Intelligent Medical Engineering, Tianjin University, Tianjin, China
| | - Le Ge
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, 300350, China.
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Roy A, Sreekrishnan A, Camargo Faye E, Silverman S, Zachrison KS, Harriott AM, Matiello M, Manzano GS, Prasanna M, Nedelcu S, Singhal AB. Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke. Neurol Clin Pract 2023; 13:e200209. [PMID: 37829551 PMCID: PMC10567120 DOI: 10.1212/cpj.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
Background and Objectives Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. Methods As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. Results We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Discussion Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.
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Affiliation(s)
- Alexis Roy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anirudh Sreekrishnan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Erica Camargo Faye
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kori S Zachrison
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mrinalini Prasanna
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Simona Nedelcu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Suo Y, Jing J, Meng X, Li Z, Pan Y, Yan H, Jiang Y, Liu L, Zhao X, Wang Y, Li H, Wang Y. Intracranial arterial stenosis and recurrence in stroke patients with different risk stratifications by Essen stroke risk score. Neurol Res 2023; 45:1069-1078. [PMID: 37724803 DOI: 10.1080/01616412.2023.2257415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 07/29/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES We sought to investigate whether the prognostic value of intracranial arterial stenosis (ICAS) is consistent across different risk stratifications using the Essen Stroke Risk score (ESRS). METHODS We derived data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events trial. Patients without complete baseline brain imaging data were excluded. Participants were categorized into different risk groups based on ESRS (low risk, 0-2, and high risk ≥ 3). The main outcome was stroke recurrence within 3 and 12 months. Hazard ratios (HRs) and 95% confidence intervals (95%CIs) of ICAS, and other factors associated with stroke recurrence within 3 and 12 months were estimated using the Cox regression method. RESULTS During the 3-month follow-up, 54 patients (7.9%) had recurrent stroke in the low-risk group, and 39 patients (9.6%) had recurrent stroke in the high-risk group. ICAS was associated with a higher risk of stroke within 3 months (HR = 2.761; 95%CI = 1.538-4.957; P < 0.001) in the low-risk group, but not in the high-risk group (HR = 1.501; 95%CI = 0.701-3.213; P = 0.296). ICAS was independently associated with higher recurrent risk in the low-risk group (HR = 2.540; 95%CI = 1.472-4.381; P < 0.001), but not in the high-risk group (HR = 1.951; 95%CI = 0.977-3.893; P = 0.058) within 12 months. CONCLUSION ICAS was an independent predictor of both 3- and 12-month stroke recurrence in low-risk but not high-risk patients with minor ischemic stroke or transient ischemic attack according to ESRS stratification.
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Affiliation(s)
- Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Tiantan Neuroimaging Center of Excellence, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, China
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15
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Monden M, Murata N, Takahashi K, Fukamachi D, Okumura Y. Repeated Cerebral Infarction Immediately after Bypass Graft Angiography: A Case Report. Int J Angiol 2023; 32:250-252. [PMID: 37927833 PMCID: PMC10624535 DOI: 10.1055/s-0041-1725182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A cerebral infarction (CI) is a common complication of coronary angiography (CAG); however, repeated CIs in the immediate period after a CAG have not been reported yet. The patient in the present study experienced left upper quadrant blindness immediately after internal thoracic arteriography, and magnetic resonance imaging (MRI) showed a high-intensity area in the right occipital lobe. Despite the administration of antithrombotic therapy, the patient became transiently comatose for 6 hours. MRI showed a new high-intensity area in the left thalamus. A noninvasive assessment should be considered before internal thoracic arteriography to prevent the risk of complications.
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Affiliation(s)
- Masaki Monden
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Nobuhiro Murata
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kurara Takahashi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Daisuke Fukamachi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
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16
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Al Salman S, Al Sultan AA, Aldawood MA, Alradhi HK, AlMuhaish MA, Alsumaeel SA. Bridge to Better Care: Investigating Transient Ischemic Attack (TIA) Management Expertise Among Primary Healthcare Providers in Al-Ahsa, Saudi Arabia. Cureus 2023; 15:e50420. [PMID: 38222199 PMCID: PMC10784710 DOI: 10.7759/cureus.50420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Transient ischemic attacks (TIAs) are brief episodes of neurological impairment caused by reduced blood flow to the brain, spinal cord, or retina, typically lasting under an hour. Recent advances in neuroimaging suggest that some TIAs may actually be small strokes with resolved symptoms. This study focuses on assessing the knowledge and management of TIAs among primary care physicians and nurses in Al-Ahsa, Saudi Arabia. Methodology This is a cross-sectional study, conducted in Al-Ahsa, Saudi Arabia, during the period July to August 2023. Data were collected using an electronic questionnaire and was analyzed using IBM SPSS Statistics for Windows, version 27.0.1 (released 2020, IBM Corp., Armonk, New York, United States). Results Among the participants, 64.0% correctly identified TIA as an ischemic neurological deficit. However, only 20.2% provided correct responses for all TIA symptoms. Regarding diagnostic tests, 47.4% acknowledged the need for neuroimaging immediately after TIA, while 17.5% recognized the importance of ultrasonography of the supra-aortic trunks. In terms of TIA management, 38.6% preferred referral to the emergency service, and 41.2% correctly perceived the risk of TIA recurrence as similar to that of established cerebral ischemic stroke. Significant disparities were observed in the recognition of TIA symptoms, with physicians outperforming nurses, particularly in identifying motor deficits (82.4% vs. 65.2%) and speech alterations (86.8% vs. 76.1%, p = 0.004). However, nurses exhibited better knowledge in recognizing the need for a neuroimaging test (48.5% vs. 45.7%, p = 0.849) and the urgency of conducting a transcranial Doppler (TCD) (19.1% vs. 23.9%, p = 0.641). Conclusion A considerable proportion of healthcare providers demonstrate a good understanding of TIA definition and management. However, the lack of significant predictors for good knowledge and attitude suggests the need for more comprehensive strategies to enhance TIA management expertise across healthcare professionals.
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Liu X, Jiang J, Li D, Horrow J, Tamada H, Kahl A, Hariharan V, Avinav A, Li X. Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom. Cardiol Ther 2023; 12:675-687. [PMID: 37789237 DOI: 10.1007/s40119-023-00332-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/08/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA. METHODS This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported. RESULTS Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90 days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively. CONCLUSIONS In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.
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Affiliation(s)
- Xuejun Liu
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jenny Jiang
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Danshi Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jay Horrow
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Hiroshi Tamada
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Anja Kahl
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | | | | | - Xiaoyan Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA.
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18
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Naveed H, Akhtar N, Al-Jerdi S, Uy RT, Joseph S, Morgan D, Babu B, Shanthi S, Shuaib A. Appropriate use of antiplatelet medications following transient ischemic attacks and stroke: a 9-year study from the Middle East. Front Neurol 2023; 14:1269292. [PMID: 38020628 PMCID: PMC10666165 DOI: 10.3389/fneur.2023.1269292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose Guidelines recommend that patients with high-risk TIAs and minor strokes presenting within 1-3 days from onset should be offered dual antiplatelet therapy (DAPT). There are little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective database. Methods The Qatar Stroke Database began the enrollment of patients with TIAs and acute stroke in 2014 and currently has ~16,000 patients. For this study, we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with an ABCD2 score of 4, and a minor stroke was defined as an NIHSS of 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed. Results After excluding patients with ICH, mimics, and rare secondary causes, 8,082 patients were available for final analysis (TIAs: 1,357 and stroke: 6,725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor strokes, 1,207 of 3,572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) low-risk TIAs and 809 of 3,153 (25.7%) non-minor stroke patients. Conclusion This large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from the hospital. This requires urgent attention and further investigation.
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Affiliation(s)
- Hiba Naveed
- Department of Medical Education, Weill Cornell College of Medicine, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Salman Al-Jerdi
- Department of Medical Education, Weill Cornell College of Medicine, Doha, Qatar
| | - Ryan Ty Uy
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Blessy Babu
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Shobana Shanthi
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Chang RW, Pimentel N, Tucker LY, Rothenberg KA, Avins AL, Flint AC, Faruqi RM, Nguyen-Huynh MN, Neugebauer R. A comparative effectiveness study of carotid intervention for long-term stroke prevention in patients with severe asymptomatic stenosis from a large integrated health system. J Vasc Surg 2023; 78:1239-1247.e4. [PMID: 37406943 PMCID: PMC11020993 DOI: 10.1016/j.jvs.2023.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The results of current prospective trials comparing the effectiveness of carotid endarterectomy (CEA) vs standard medical therapy for long-term stroke prevention in patients with asymptomatic carotid stenosis (ACS) will not be available for several years. In this study, we compared the observed effectiveness of CEA and standard medical therapy vs standard medical therapy alone to prevent ipsilateral stroke in a contemporary cohort of patients with ACS. METHODS This cohort study was conducted in a large integrated health system in adult subjects with 70% to 99% ACS (no neurologic symptom within 6 months) with no prior ipsilateral carotid artery intervention. Causal inference methods were used to emulate a conceptual randomized trial using data from January 1, 2008, through December 31, 2017, for comparing the event-free survival over 96 months between two treatment strategies: (1) CEA within 12 months from cohort entry vs (2) no CEA (standard medical therapy alone). To account for both baseline and time-dependent confounding, inverse probability weighting estimation was used to derive adjusted hazard ratios, and cumulative risk differences were assessed based on two logistic marginal structural models for counterfactual hazards. Propensity scores were data-adaptively estimated using super learning. The primary outcome was ipsilateral anterior ischemic stroke. RESULTS The cohort included 3824 eligible patients with ACS (mean age: 73.7 years, 57.9% male, 12.3% active smokers), of whom 1467 underwent CEA in the first year, whereas 2297 never underwent CEA. The median follow-up was 68 months. A total of 1760 participants (46%) died, 445 (12%) were lost to follow-up, and 158 (4%) experienced ipsilateral stroke. The cumulative risk differences for each year of follow-up showed a protective effect of CEA starting in year 2 (risk difference = 1.1%, 95% confidence interval: 0.5%-1.6%) and persisting to year 8 (2.6%, 95% confidence interval: 0.3%-4.8%) compared with patients not receiving CEA. CONCLUSIONS In this contemporary cohort study of patients with ACS using rigorous analytic methodology, CEA appears to have a small but statistically significant effect on stroke prevention out to 8 years. Further study is needed to appropriately select the subset of patients most likely to benefit from intervention.
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Affiliation(s)
- Robert W Chang
- Department of Vascular Surgery, the Permanente Medical Group, South San Francisco, CA; Division of Research, Kaiser Permanente Northern California, Oakland, CA.
| | - Noel Pimentel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA
| | - Alexander C Flint
- Department of Neurology, The Permanente Medical Group, Redwood City, CA
| | - Rishad M Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, CA
| | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Neurology, The Permanente Medical Group, Walnut Creek, CA
| | - Romain Neugebauer
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Monday O, Rawat A, Isaak AK, Manzoor A, Jaiswal G, Saeed L, Kumari A, Amin A. Comparing the Effectiveness of Intravenous Tissue Plasminogen Activator and Dual Antiplatelet Therapy in Patients With Minor Stroke: A Meta-Analysis. Cureus 2023; 15:e46436. [PMID: 37927654 PMCID: PMC10624328 DOI: 10.7759/cureus.46436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 11/07/2023] Open
Abstract
The aim of this study was to compare the outcomes between dual antiplatelet therapy (DAPT) versus intravenous tissue plasminogen activator (IV t-PA) in patients with minor stroke. This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Two authors independently conducted online database searches using PubMed, Web of Science, and EMBASE to identify articles published in English language from inception to September 5, 2023. Outcomes assessed in this meta-analysis included all-cause mortality, stroke incidence, and functional outcomes (measured by modified ranking scale (mRS) scores of 0 to 1). A total of three studies fulfilled the eligibility criteria and included in the final analysis. Pooled analysis showed that the risk of all-cause mortality was not significantly different between the t-PA group and DAPT group (relative risk (RR): 1.14, 95% confidence interval (CI): 0.32-4.06). Compared with those treated with DAPT, there was no significant difference in t-PA in terms of the number of patients with a favorable functional outcome (defined as an mRS score of 0-1). The risk of stroke was not significantly different between the t-PA group and DAPT group (RR: 1.11, 95% CI: 0.68 to 1.82). The analysis, based on three studies, revealed no significant differences between t-PA and DAPT regarding all-cause mortality, stroke incidence, and functional outcomes.
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Affiliation(s)
- Obinna Monday
- Medicine, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Abraham K Isaak
- Telemetry, Sharp Memorial Hospital, San Diego, USA
- Internal Medicine, Orotta School of Medicine and Dentistry, Asmara, ERI
| | - Amima Manzoor
- Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Goldi Jaiswal
- Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Leena Saeed
- Internal Medicine, National Ribat University, Khartoum, SDN
| | - Ajanta Kumari
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Adil Amin
- Cardiology, Pakistan Navy Ship Shifa (PNS Shifa), Karachi, PAK
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21
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Han M, Jia W, Wu Y, Kuang J, Tu J, Yin S, Chen J, Zhang X, Li J, Chen Y, Wu B, Yi Y. Short-term efficacy and safety of personalized antiplatelet therapy for patients with acute ischaemic stroke or transient ischaemic attack: A randomized clinical trial. Br J Clin Pharmacol 2023; 89:2813-2824. [PMID: 37159861 DOI: 10.1111/bcp.15775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 04/07/2023] [Accepted: 04/22/2023] [Indexed: 05/11/2023] Open
Abstract
AIMS The aim of this study was to determine whether the testing strategy for clopidogrel and/or aspirin resistance using CYP2C19 genotyping or urinary 11-dhTxB2 testing has an impact on clinical outcomes. METHODS A multicentre, randomized, controlled trial was conducted at 14 centres in China from 2019 to 2021. For the intervention group, a specific antiplatelet strategy was assigned based on the CYP2C19 genotype and 11-dhTxB2, a urinary metabolite of aspirin, and the control group received nonguided (ie, standard of care) treatment. 11-dhTXB2 is a thromboxane A2 metabolite that can help quantify the effects of resistance to aspirin in individuals after ingestion. The primary efficacy outcome was new stroke, the secondary efficacy outcome was a poor functional prognosis (a modified Rankin scale score ≥3), and the primary safety outcome was bleeding, all within the 90-day follow-up period. RESULTS A total of 2815 patients were screened and 2663 patients were enrolled in the trial, with 1344 subjects assigned to the intervention group and 1319 subjects assigned to the control group. A total of 60.1% were carriers of the CYP2C19 loss-of-function allele (*2, *3) and 8.71% tested positive for urinary 11-dhTxB2- indicating aspirin resistance in the intervention group. The primary outcome was not different between the intervention and control groups (P = .842). A total of 200 patients (14.88%) in the intervention group and 240 patients (18.20%) in the control group had a poor functional prognosis (hazard ratio 0.77, 95% confidence interval [CI] 0.63 to 0.95, P = .012). Bleeding events occurred in 49 patients (3.65%) in the intervention group and 72 patients (5.46%) in the control group (hazard ratio 0.66, 95% CI 0.45 to 0.95, P = .025). CONCLUSIONS Personalized antiplatelet therapy based on the CYP2C19 genotype and 11-dhTxB2 levels was associated with favourable neurological function and reduced bleeding risk in acute ischaemic stroke and transient ischaemic attack patients. The results may help support the role of CYP2C19 genotyping and urinary 11-dhTxB2 testing in the provision of precise clinical treatment.
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Affiliation(s)
- Mengqi Han
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Weijie Jia
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yifan Wu
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jie Kuang
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Shujuan Yin
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jibiao Chen
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Xiaolin Zhang
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jingyi Li
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yongsen Chen
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Bin Wu
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yingping Yi
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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22
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Cao S, Zhao L, Pei L, Gao Y, Fang H, Liu K, Liu H, Yang S, Sun S, Wu J, Song B, Xu Y. ABCD2 score has equivalent stroke risk prediction for anterior circulation TIA and posterior circulation TIA. Sci Rep 2023; 13:13993. [PMID: 37634045 PMCID: PMC10460395 DOI: 10.1038/s41598-023-41260-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023] Open
Abstract
Transient ischemic attack (TIA) was clinically divided into anterior circulation (AC) or posterior circulation (PC). Previous study reported that ABCD2 score could predict the stroke risk after AC-TIA but might have limitation for PC-TIA. We aimed to classify TIA depending on neuroimaging and assess the value of ABCD2 score for predicting stroke risk in different territories. Research data was from TIA database of the First Affiliated Hospital of Zhengzhou University. TIA patients with acute infarction on diffuse weighted imaging [that is, transient symptoms with infarction (TSI)] were divided into anterior and posterior circulation groups according to the location of infarction. The outcome was recurrent stroke within 7 and 90 days. The predictive power of ABCD2 score was determined using area under receiver operator characteristic curve (AUC) analyses. Overall, 382 AC-TSI and 112 PC-TSI patients were included. There were 38 (9.9%) AC-TSI patients and 11(9.8%) PC-TSI patients who had recurrent stroke at 7 days, and 66 (17.3%) AC-TSI patients and 19 (17.0%) PC-TSI patients who had recurrent stroke within 90 days. At 7 days, the AUC for ABCD2 score was 0.637 (95% confidence interval CI 0.554-0.720) in anterior circulation and 0.683 (95% CI 0.522-0.845) in posterior circulation. The C statistics for ABCD2 score in the two groups were not statistically significant (Z = - 0.499; P = 0.62). Similar result was found when the outcome time-point was set at 90 days. ABCD2 score could predict the short-term risk of recurrent stroke after AC-TSI and PC-TSI, and had similar predictive abilities for AC-TSI and PC-TSI.
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Affiliation(s)
- Shuang Cao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Lu Zhao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Lulu Pei
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Yuan Gao
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Hui Fang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Kai Liu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Hao Liu
- Department of Magnetic Resonance, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shuxiang Yang
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Shilei Sun
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Jun Wu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China
| | - Bo Song
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China.
| | - Yuming Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052, Henan Province, People's Republic of China.
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23
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Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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24
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Paul M, Paul JW, Hinwood M, Hood RJ, Martin K, Abdolhoseini M, Johnson SJ, Pollack M, Nilsson M, Walker FR. Clopidogrel Administration Impairs Post-Stroke Learning and Memory Recovery in Mice. Int J Mol Sci 2023; 24:11706. [PMID: 37511466 PMCID: PMC10380815 DOI: 10.3390/ijms241411706] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Clopidogrel, which is one of the most prescribed antiplatelet medications in the world, is given to stroke survivors for the prevention of secondary cardiovascular events. Clopidogrel exerts its antiplatelet activity via antagonism of the P2Y12 receptor (P2RY12). Although not widely known or considered during the initial clinical trials for clopidogrel, P2RY12 is also expressed on microglia, which are the brain's immune cells, where the receptor facilitates chemotactic migration toward sites of cellular damage. If microglial P2RY12 is blocked, microglia lose the ability to migrate to damaged sites and carry out essential repair processes. We aimed to investigate whether administering clopidogrel to mice post-stroke was associated with (i) impaired motor skills and cognitive recovery; (ii) physiological changes, such as survival rate and body weight; (iii) changes in the neurovascular unit, including blood vessels, microglia, and neurons; and (iv) changes in immune cells. Photothrombotic stroke (or sham surgery) was induced in adult male mice. From 24 h post-stroke, mice were treated daily for 14 days with either clopidogrel or a control. Cognitive performance (memory and learning) was assessed using a mouse touchscreen platform (paired associated learning task), while motor impairment was assessed using the cylinder task for paw asymmetry. On day 15, the mice were euthanized and their brains were collected for immunohistochemistry analysis. Clopidogrel administration significantly impaired learning and memory recovery, reduced mouse survival rates, and reduced body weight post-stroke. Furthermore, clopidogrel significantly increased vascular leakage, significantly increased the number and appearance of microglia, and significantly reduced the number of T cells within the peri-infarct region post-stroke. These data suggest that clopidogrel hampers cognitive performance post-stroke. This effect is potentially mediated by an increase in vascular permeability post-stroke, providing a pathway for clopidogrel to access the central nervous system, and thus, interfere in repair and recovery processes.
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Affiliation(s)
- Marina Paul
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Jonathan W Paul
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Madeleine Hinwood
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Rebecca J Hood
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Discipline of Anatomy and Pathology, School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Kristy Martin
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
| | - Mahmoud Abdolhoseini
- School of Engineering, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Sarah J Johnson
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
- School of Engineering, College of Engineering, Science and Environment, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Michael Pollack
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Michael Nilsson
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden
- LKC School of Medicine, Nanyang Technological University, Singapore 639798, Singapore
| | - Frederick R Walker
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW 2308, Australia
- Hunter Medical Research Institute, 1 Kookaburra Circuit, New Lambton Heights, NSW 2305, Australia
- Centre for Rehab Innovations, University of Newcastle, Callaghan, NSW 2308, Australia
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25
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Cassidy T, Chapman L. Noise and transient ischaemic attacks - A challenge? J R Coll Physicians Edinb 2023; 53:132-134. [PMID: 36883336 DOI: 10.1177/14782715231161500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Consistency in medical decision-making is ideally expected. This includes consistency between different clinicians so that the same patient will receive the same diagnosis regardless of the assessing clinician. It also encompasses reliability as an individual clinician meaning at any given time or context, we apply the same process and principles to ensure the decisions we make do not deviate significantly from our peers or indeed our own past decisions. However, consistency in decision-making can be challenged when working within a busy healthcare system. We discuss the concept of 'noise' and explore how it affects decision-making in acute presentations of transient neurology where doctors can differ in terms of their diagnostic decisions.
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Affiliation(s)
- Tim Cassidy
- St. Vincent's University Hospital, Dublin, Ireland
| | - Lucy Chapman
- St. Vincent's University Hospital, Dublin, Ireland
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26
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Jeerakathil TJ, Yu AYX, Choi PMC, Fang S, Shuaib A, Majumdar SR, Demchuk AM, Butcher K, Watson TJ, Dean N, Gordon D, Hill MD, Edmond C, Coutts SB. Effects of a Province-wide Triaging System for TIA: The ASPIRE Intervention. Neurology 2023; 100:e2093-e2102. [PMID: 36977597 PMCID: PMC10186240 DOI: 10.1212/wnl.0000000000207201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 02/03/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Urgent transient ischemic attack (TIA) management to reduce stroke recurrence is challenging, particularly in rural and remote areas. In Alberta, Canada, despite an organized stroke system, data from 1999 to 2000 suggested that stroke recurrence after TIA was as high as 9.5% at 90 days. Our objective was to determine whether a multifaceted population-based intervention resulted in a reduction in recurrent stroke after TIA. METHODS In this quasi-experimental health services research intervention study, we implemented a TIA management algorithm across the entire province, centered around a 24-hour physician's TIA hotline and public and health provider education on TIA. From administrative databases, we linked emergency department discharge abstracts to hospital discharge abstracts to identify incident TIAs and recurrent strokes at 90 days across a single payer system with validation of recurrent stroke events. The primary outcome was recurrent stroke; with a secondary composite outcome of recurrent stroke, acute coronary syndrome, and all-cause death. We used an interrupted time series regression analysis of age-adjusted and sex-adjusted stroke recurrence rates after TIA, incorporating a 2-year preimplementation period (2007-2009), a 15-month implementation period, and a 2-year postimplementation period (2010-2012). Logistic regression was used to examine outcomes that did not fit the time series model. RESULTS We assessed 6,715 patients preimplementation and 6,956 patients postimplementation. The 90-day stroke recurrence rate in the pre-Alberta Stroke Prevention in TIA and mild Strokes (ASPIRE) period was 4.5% compared with 5.3% during the post-ASPIRE period. There was neither a step change (estimate 0.38; p = 0.65) nor slope change (parameter estimate 0.30; p = 0.12) in recurrent stroke rates associated with the ASPIRE intervention implementation period. Adjusted all-cause mortality (odds ratio 0.71, 95% CI 0.56-0.89) was significantly lower after the ASPIRE intervention. DISCUSSION The ASPIRE TIA triaging and management interventions did not further reduce stroke recurrence in the context of an organized stroke system. The apparent lower mortality postintervention may be related to improved surveillance after events identified as TIAs, but secular trends cannot be excluded. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that a standardized population-wide algorithmic triage system for patients with TIA did not reduce recurrent stroke rate.
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Affiliation(s)
- Thomas J Jeerakathil
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
| | - Amy Ying Xin Yu
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Philip M C Choi
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Shoufan Fang
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Ashfaq Shuaib
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Sumit R Majumdar
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Andrew M Demchuk
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Kenneth Butcher
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Tim J Watson
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Naeem Dean
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Deb Gordon
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Michael D Hill
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Cathy Edmond
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Shelagh B Coutts
- From the Department of Medicine (Neurology) (T.J.J., A.S.), and Division of General Internal Medicine (S.R.M., N.D.), University of Alberta (S.F), Edmonton; Alberta Health Services, Edmonton (T.J.J., A.S., D.G.) and Alberta Health Services, Calgary (C.E.); Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto, Ontario, Canada; Department of Neurosciences (P.M.C.C.), Monash University, Melbourne, Australia; Department of Clinical Neurosciences (A.M.D., T.J.W., M.D.H., S.B.C.), University of Calgary, Alberta, Canada; Neurology (K.B.), Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
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Micieli A, Singh N, Jahn B, Siebert U, Menon BK, Demchuk AM. Cost-effectiveness of testing for CYP2C19 loss-of-function carriers following transient ischemic attack/minor stroke: A Canadian perspective. Int J Stroke 2023; 18:416-425. [PMID: 35739635 DOI: 10.1177/17474930221111898] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The CHANCE-2 study compared 3 weeks of aspirin-ticagrelor to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers following a transient ischemic attack (TIA)/minor stroke and demonstrated a modestly lower risk of stroke recurrence with aspirin-ticagrelor. This stroke protection was largely for minor stroke and came at an increased risk of bleeding. The cost-effectiveness of implementing testing for LOF allele status to personalize antiplatelet regimen for secondary stroke prevention after a TIA/minor stroke in the Canadian health care context is unknown. METHODS Cost-effectiveness analysis using a decision-analytic Markov cohort model with a lifetime horizon was performed to determine the costs and health benefits of testing for LOF allele status compared with no testing (current standard of care). The population of interest was patients living in Canada who suffered a TIA/minor stroke. Outcomes of interest were life-years gained (LYG), quality-adjusted life years (QALY) gained, costs (reported in 2022 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). We adopted the perspective of the Federal, Provincial, and Territorial Ministries of Health and used a 1.5% annual discount rate. Sensitivity analyses were performed to assess uncertainty. RESULTS Compared to standard of care, LOF allele testing leads to 0.14 LYG (undiscounted), 0.12 QALYs gained (undiscounted), and additional lifetime costs of CAD$432 (discounted) per patient. The ICER of the LOF allele testing strategy is CAD$4310 per QALY gained compared with standard of care. The probabilistic sensitivity analyses demonstrated that LOF allele testing was cost-effective in more than 99.99% of simulations using a willingness-to-pay threshold of CAD$50,000 per QALY. CONCLUSION Based on available evidence, testing for LOF allele followed by short duration 3 weeks of aspirin-ticagrelor compared to standard-of-care aspirin-clopidogrel can lead to prolonged life and improved quality of life and can be considered very cost-effective when compared with other well-accepted technologies in health and medicine.
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Affiliation(s)
- Andrew Micieli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Beate Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Lavallée PC, Charles H, Albers GW, Caplan LR, Donnan GA, Ferro JM, Hennerici MG, Labreuche J, Molina C, Rothwell PM, Steg PG, Touboul PJ, Uchiyama S, Vicaut É, Wong LKS, Amarenco P. Effect of atherosclerosis on 5-year risk of major vascular events in patients with transient ischaemic attack or minor ischaemic stroke: an international prospective cohort study. Lancet Neurol 2023; 22:320-329. [PMID: 36931807 DOI: 10.1016/s1474-4422(23)00067-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The prevalence of atherosclerosis and the long-term risk of major vascular events in people who have had a transient ischaemic attack or minor ischaemic stroke, regardless of the causal relationship between the index event and atherosclerosis, are not well known. In this analysis, we applied the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other causes, and dissection) grading system to estimate the 5-year risk of major vascular events according to whether there was a causal relationship between atherosclerosis and the index event (ASCOD grade A1 and A2), no causal relationship (A3), and with or without a causal relationship (A1, A2, and A3). We also aimed to estimate the prevalence of different grades of atherosclerosis and identify associated risk factors. METHODS We analysed patient data from TIAregistry.org, which is an international, prospective, observational registry of patients with a recent (within the previous 7 days) transient ischaemic attack or minor ischaemic stroke (modified Rankin Scale score of 0-1) from 61 specialised centres in 21 countries in Europe, Asia, the Middle East, and Latin America. Using data from case report forms, we applied the ASCOD grading system to categorise the degree of atherosclerosis in our population (A0: no atherosclerosis; A1 or A2: atherosclerosis with stenosis ipsilateral to the cerebral ischaemic area; A3: atherosclerosis in vascular beds not related to the ischaemic area or ipsilateral plaques without stenosis; and A9: atherosclerosis not assessed). The primary outcome was a composite of non-fatal stroke, non-fatal acute coronary syndrome, or cardiovascular death within 5 years. FINDINGS Between June 1, 2009, and Dec 29, 2011, 4789 patients were enrolled to TIAregistry.org, of whom 3847 people from 42 centres participated in the 5-year follow-up; 3383 (87·9%) patients had a 5-year follow-up visit (median 92·3% [IQR 83·4-97·8] per centre). 1406 (36·5%) of 3847 patients had no atherosclerosis (ASCOD grade A0), 998 (25·9%) had causal atherosclerosis (grade A1 or A2), and 1108 (28·8%) had atherosclerosis that was unlikely to be causal (grade A3); in 335 (8·7%) patients, atherosclerosis was not assessed (grade A9). The 5-year event rate of the primary composite outcome was 7·7% (95% CI 6·3-9·2; 101 events) in patients categorised with grade A0 atherosclerosis, 19·8% (17·4-22·4; 189 events) in those with grade A1 or A2, and 13·8% (11·8-16·0; 144 events) in patients with grade A3. Compared with patients with grade A0 atherosclerosis, patients categorised as grade A1 or A2 had an increased risk of the primary composite outcome (hazard ratio 2·77, 95% CI 2·18-3·53; p<0·0001), as did patients with grade A3 (1·87, 1·45-2·42; p<0·0001). Except for age, male sex, and multiple infarctions on neuroimaging, most of the risk factors that were identified as being associated with grade A1 or A2 atherosclerosis were modifiable risk factors (ie, hypertension, dyslipidaemia, overweight, smoking cigarettes, and low physical activity; all p values <0·025). INTERPRETATION In patients with transient ischaemic attack or minor ischaemic stroke, those with atherosclerosis have a much higher risk of major vascular events within 5 years than do those without atherosclerosis. Preventive strategies addressing complications of atherosclerosis should focus on individuals with atherosclerosis rather than grouping together all people who have had a transient ischaemic attack or minor ischaemic stroke (including those without atherosclerosis). FUNDING AstraZeneca, Sanofi, Bristol Myers Squibb, SOS Attaque Cérébrale Association.
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Affiliation(s)
- Philippa C Lavallée
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Hugo Charles
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Louis R Caplan
- Cerebrovascular Disease Service, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Michael G Hennerici
- Department of Neurology, Universitäts Medizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julien Labreuche
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France; Department of Biostatistics, CHU Lille, Lille, France
| | - Carlos Molina
- Department of Neurology, Stroke Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Peter M Rothwell
- Nuffield Department of Clinical Neuroscience, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Philippe Gabriel Steg
- Department of Cardiology, APHP, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Université Paris Cité, Paris, France; Institut Universitaire de France, Paris, France
| | - Pierre-Jean Touboul
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Shinichiro Uchiyama
- Center for Brain and Cerebral Vessels, International University of Health and Welfare, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Éric Vicaut
- Department of Biostatistics, APHP, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, Paris, France
| | - Lawrence K S Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France; Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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Kumar M, Khurana D, Ahuja CK, Kumar A, Singh B, Mohanty M. Simple CaroTID-VasC score to predict one-year risk of stroke in symptomatic carotid stenosis patients. J Neurol Sci 2023; 446:120578. [PMID: 36739782 DOI: 10.1016/j.jns.2023.120578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/22/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND A subset of extracranial symptomatic carotid stenosis (ESCS) patients may fare well on current optimal medical therapy (OMT), and surgery may be avoided in these patients. Therefore, we aimed to develop and validate a stroke risk prediction model to stratify the risk among ESCS patients. METHODS Adult ESCS patients who denied revascularization procedures were enrolled prospectively and prescribed OMT. Patients were followed-up for twelve months after assessing the clinical, imaging, and hemodynamics-based risk predictors at baseline. Cox regression analysis was performed on predictors which were significant in univariate analysis. Beta coefficients of significant predictors in Cox regression were used to generate a numeric score. The model was internally validated using bootstrapping. RESULTS A total of 20 (20.2%) out of 99 patients had event recurrence during the follow-up. Transient ischemic attack index event (P = 0.014), diabetes mellitus (P = 0.018), contralateral significant stenosis (P = 0.007), echolucent plaque (P = 0.011), and impaired vasomotor reactivity (P = 0.006) were significant predictors in Cox regression analysis. A points score (0-6) was derived from regression coefficients of the significant predictors. The area under ROC was 0.884 for the developed model and 0.832 for the bootstrapped model. Youden's index divided the score into low-risk (2.2%) and high-risk (35.8%) groups, and the difference in risk was significant (P < 0.001). CONCLUSIONS Most ESCS patients benefited from OMT, and the CaroTID-VasC score was effective in stratifying patients for risk of endpoint occurrence. The developed model may help identify high-risk subgroups of ESCS patients and assist the decision-making of carotid interventions.
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Affiliation(s)
- Mukesh Kumar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Department of Industrial Engineering, Dalhousie University, Halifax, NS, Canada
| | - Dheeraj Khurana
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Chirag Kamal Ahuja
- Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok Kumar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Baljinder Singh
- Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manju Mohanty
- Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Amin HP, Madsen TE, Bravata DM, Wira CR, Johnston SC, Ashcraft S, Burrus TM, Panagos PD, Wintermark M, Esenwa C. Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke 2023; 54:e109-e121. [PMID: 36655570 DOI: 10.1161/str.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.
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Non-association of stroke risk with intracranial hemodynamic steal in patients with symptomatic internal carotid artery occlusions. J Stroke Cerebrovasc Dis 2023; 32:106797. [PMID: 36527943 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/18/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Paradoxical intracranial hemodynamic steal (IHS) is known in patients having persistent proximal arterial occlusions and is linked with early neurological worsening. However, stroke risk specific to symptomatic internal carotid artery occlusions (SICAO) having paradoxical IHS is unknown. Therefore, we aimed to investigate the association of paradoxical IHS in SICAO patients with stroke recurrence during a one-year follow-up. MATERIALS AND METHODS We prospectively enrolled adult patients having SICAO with a recent history of ischemic events. Steal magnitude (SM) to classify patients in IHS and non-IHS categories was evaluated by a breath-holding test using bilateral transcranial doppler (TCD). Patients were prescribed optimal medical therapy and followed up for one year for any ischemic stroke/TIA/cardiovascular death. RESULTS 36 SICAO patients, mean age of 56 years, were assessed using TCD at median 22.5 days (Interquartile range, IQR= 9-42), and 11 (30.6%) had paradoxical IHS with median SM 12% (IQR= 6%-18%). On follow-up, 7 (19.4%) patients had event recurrence and its association with IHS was non-significant (IHS vs non-IHS, 18.2% vs 20%; Log-rank statistics=0.006; P=0.940). On Cox regression analysis, event recurrence was independently associated with the presence of significant contralateral stenosis only (regression coefficient= 2.237; P= 0.012; 95% CI= 1.63-53.89). CONCLUSIONS IHS prevalence among SICAO is high. However, paradoxical IHS was not associated with an increased risk of stroke in SICAO. Therefore, the presence of paradoxical IHS in SICAO may be considered a transit state and does not necessarily imply an increased risk of stroke.
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Chiu YC, Tang SC, Tsai LK, Hsieh MJ, Chiang WC, Jeng JS, Ma MHM. Development and Validation of a Risk Score for Predicting Ischemic Stroke After Transient Ischemic Attack. J Emerg Med 2023; 64:167-174. [PMID: 36813643 DOI: 10.1016/j.jemermed.2022.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND A risk stratification scale is essential to identify high-risk patients who had transient ischemic attack (TIA) to prevent subsequent permanent disability caused by ischemic stroke. OBJECTIVE This study aimed to develop and validate a scoring system to predict acute ischemic stroke within 90 days after TIA in an emergency department (ED). METHODS We retrospectively analyzed the data of patients with TIA in a stroke registry between January 2011 and September 2018. Characteristics, medication history, electrocardiogram (ECG), and imaging findings were collected. Univariable and multivariable stepwise logistic regression analyses were performed to create an integer point system. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow (HL) test were used to examine discrimination and calibration. Youden's Index was also used to determine the best cutoff value. RESULTS A total of 557 patients were included, and the occurrence rate of acute ischemic stroke within 90 days after TIA was 5.03%. After multivariable analysis, a new integer point system was created-MESH (Medication Electrocardiogram Stenosis Hypodense) score-which contained medication history (antiplatelet medication taken before admission, 1 point), right bundle branch block on electrocardiogram (1 point), intracranial stenosis ≥ 50% (1 point), and size of the hypodense area on computed tomography (diameter ≥ 4 cm, 2 points). The MESH score showed adequate discrimination (AUC = 0.78) and calibration (HL test = 0.78). The best cutoff value was 2 points, with a sensitivity of 60.71% and specificity of 81.66%. CONCLUSIONS The MESH score indicated improved accuracy for TIA risk stratification in the ED setting.
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Affiliation(s)
- Yu-Chen Chiu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin County, Taiwan
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Joundi RA, Yu AYX, Smith EE, Zerna C, Penn AM, Balshaw RF, Votova K, Bibok MB, Penn M, Saly V, Hegedus J, Coutts SB, Yu AYX, Penn AM, Trivedi A, Cook J, Morrison J, Blackwood K, Richards K, Votova K, Nealis M, Bibok MB, Penn M, Beattyova P, Rosenberg P, Frost S, Grant C, Hedgedus J, Grant S, Watson T, Saly V, Sedgwick C, Lesperance ML, Croteau NS, Appireddy R, Balshaw RF, Field TS, Dubuc V, Demchuk AM, Jambula A, Le A, Menon BK, Calvert C, Kenney C, Zerna C, Nikneshan D, Smith EE, Klourfeld E, Wagner G, Klein G, Aram H, Desai J, Ryckborst K, Bilston L, Hill MD, Almekhlafi M, Godfrey N, Imoukheude O, Stys P, Barber PA, Couillard P, Eswaradas P, Rhandawa P, Coutts SB, Bal S, Peters S, Save S, Subramaniam S, Musuka T, Stewart T, Hong ZM. Association Between Duration of Transient Neurological Events and Diffusion-Weighted Brain Lesions. J Am Heart Assoc 2023; 12:e027861. [PMID: 36695298 PMCID: PMC9973650 DOI: 10.1161/jaha.122.027861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background The relationship between duration of transient neurological events and presence of diffusion-weighted lesions by symptom type is unclear. Methods and Results This was a substudy of SpecTRA (Spectrometry for Transient Ischemic Attack Rapid Assessment), a multicenter prospective cohort of patients with minor ischemic cerebrovascular events or stroke mimics at academic emergency departments in Canada. For this study we included patients with resolved symptoms and determined the presence of diffusion-weighted imaging (DWI) lesion on magnetic resonance imaging within 7 days. Using logistic regression, we evaluated the association between symptom duration and DWI lesion, assessing for interaction with symptom type (focal only versus nonfocal/mixed), and adjusting for age, sex, education, comorbidities, and systolic blood pressure. Of 658 patients included, a DWI lesion was present in 232 (35.1%). There was a significant interaction between symptom duration and symptom type. For those with focal-only symptoms, there was a continuous increase in DWI probability up to 24 hours in duration (ranging from ≈40% to 80% probability). In stratified analyses, the increase in probability of DWI lesion with increased duration of focal symptoms was seen in women but not men. For those with nonfocal or mixed symptoms, predicted probability of DWI lesion was ≈35% and was greater in men, but did not increase with longer duration. Conclusions Increased duration of neurological deficits is associated with greater probability of DWI lesion in those with focal symptoms only. For individuals with nonfocal or mixed symptoms, about one-third had DWI lesions, but the probability did not increase with duration. These results may be important to improve risk stratification of transient neurological events.
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Affiliation(s)
- Raed A. Joundi
- Division of Neurology, Hamilton Health SciencesMcMaster University & Population Health Research InstituteHamiltonOntarioCanada
| | - Amy Y. X. Yu
- Division of Neurology, Department of MedicineUniversity of Toronto, Sunnybrook Health Sciences CentreTorontoOntarioCanada
| | - Eric E. Smith
- Departments of Clinical Neurosciences and Community Health SciencesUniversity of CalgaryAlbertaCanada
| | - Charlotte Zerna
- Department of Clinical Neurosciences and Diagnostic ImagingUniversity of Calgary Cumming School of MedicineCalgaryAlbertaCanada
| | - Andrew M. Penn
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Robert F. Balshaw
- George & Fay Yee Centre for Healthcare InnovationUniversity of ManitobaWinnipegManitobaCanada
| | - Kristine Votova
- Island Health Regional Health Authority, Division of Medical SciencesUniversity of VictoriaVictoriaBritish ColumbiaCanada
| | - Maximilian B. Bibok
- Department of Research and Capacity Building, Island HealthVictoriaBritish ColumbiaCanada
| | - Melanie Penn
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Viera Saly
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Janka Hegedus
- Stroke Rapid Assessment Unit, Island HealthVictoriaBritish ColumbiaCanada
| | - Shelagh B. Coutts
- Departments of Clinical Neurosciences and Community Health SciencesUniversity of CalgaryAlbertaCanada
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Lang AE, de Havenon A, Mac Grory B, Henninger N, Shu L, Furie KL, Easton JD, Kim A, Johnston SC, Yaghi S. Subsequent ischemic stroke and tobacco smoking: A secondary analysis of the POINT trial. Eur Stroke J 2022; 8:328-333. [PMID: 37021190 PMCID: PMC10069178 DOI: 10.1177/23969873221148224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/12/2022] [Indexed: 12/30/2022] Open
Abstract
Background: The aim of this study was to determine the effect of smoking status on subsequent stroke risk in patients with minor ischemic stroke or TIA and to determine whether smoking modifies the effect of clopidogrel-based DAPT on subsequent stroke risk. Methods: This was a post-hoc analysis of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, which had a 90-day follow-up period. We used multivariable Cox regression and subgroup interaction analysis to determine the effect of smoking on the risk of subsequent ischemic stroke and major hemorrhage, respectively. Results: Data from 4877 participants enrolled in the POINT trial were analyzed. Among these, 1004 were current smokers and 3873 were non-smokers at the time of index event. Smoking was associated with a non-significant trend toward an increased risk of subsequent ischemic stroke during follow up (adjusted HR, 1.31 (95% CI, 0.97–1.78), p = 0.076). The effect of clopidogrel on ischemic stroke did not differ between non-smokers (HR, 0.74 (95% CI, 0.56–0.98), p = 0.03) and smokers (HR, 0.63 (95% CI, 0.37–1.05), p = 0.078), p for interaction = 0.572. Similarly, the effect of clopidogrel on major hemorrhage did not differ between non-smokers (hazard ratio, 1.67 (95% CI, 0.40–7.00), p = 0.481) and smokers (HR, 2.59 (95% CI, 1.08–6.21), p = 0.032), p for interaction = 0.613. Conclusions: In this post-hoc analysis of the POINT trial we found that the effect of clopidogrel on reducing subsequent ischemic stroke as well as risk of major hemorrhage did not depend on smoking status, indicating that smokers benefit to a similar degree from DAPT as non-smokers.
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Affiliation(s)
- Adam Edward Lang
- Department of Primary Care, McDonald Army Health Center, Fort Eustis, VA, USA
- Department of Family Medicine and Population Health, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Adam de Havenon
- Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA
| | - Liqi Shu
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Karen L. Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, Sandler Neurosciences Center, San Francisco, CA, USA
| | - Anthony Kim
- Department of Neurology, University of California, San Francisco, Sandler Neurosciences Center, San Francisco, CA, USA
| | | | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Lip GYH, Genaidy A, Estes C, McKay D, Falks T. Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort. Eur Stroke J 2022; 8:334-343. [PMID: 37021195 PMCID: PMC10069223 DOI: 10.1177/23969873221146044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called “stroke-heart syndrome.” We aimed to investigate the relation of TIAs to incident clinical events. Methods: Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke. Results: The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21–9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51–2.32). Age also provided strong associations with incident TIA events. Conclusions: Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.
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Affiliation(s)
- Gregory YH Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Fava-Felix PE, Bonome-Vanzelli SRC, Ribeiro FS, Santos FH. Systematic review on post-stroke computerized cognitive training: Unveiling the impact of confounding factors. Front Psychol 2022; 13:985438. [PMID: 36578681 PMCID: PMC9792177 DOI: 10.3389/fpsyg.2022.985438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022] Open
Abstract
Background Stroke is a highly incapacitating disease that can lead to disabilities due to cognitive impairment, physical, emotional, and social sequelae, and a decrease in the quality of life of those affected. Moreover, it has been suggested that cognitive reserve (patients' higher levels of education or having a skilled occupation), for instance, can promote faster cognitive recovery after a stroke. For this reason, this review aims to identify the cognitive, functional, and behavioral effects of computerized rehabilitation in patients aged 50 years or older who had a stroke, considering cognitive reserve proxies. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-PRISMA, and performed the search for peer-reviewed randomized controlled trials without a date restriction on CINAHL, LILACS, PubMed, Scopus, and Web of Science databases were chosen. Results We screened 780 papers and found 19 intervention studies, but only 4 met the inclusion criteria and shared data. These studies included computerized tools for motor and cognitive rehabilitation in the experimental groups. In all studies, computerized training was combined with other interventions, such as standard therapy, occupational therapy, and aerobic exercises. There were 104 participants affected by ischemic or hemorrhagic stroke, predominantly male (57.69%), and all with cognitive impairment. Conclusion Despite a limited number of studies, varied methods and insufficient information available, schooling as a CR proxy combined with high-intensity computerized cognitive training was key to mediating cognitive improvement. The systematic review also identified that the associated ischemic stroke and shorter time of onset for rehabilitation contribute to the cognitive evolution of patients. Findings do not support a greater benefit of computerized cognitive training compared to conventional cognitive therapies. Systematic review registration [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=296193], identifier [CRD42022296193].
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Affiliation(s)
| | | | - Fabiana S. Ribeiro
- Department of Social Sciences, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Flávia H. Santos
- School of Psychology, University College Dublin, Dublin, Ireland
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Lee YT, Tsai CF, Yen YC, Huang LK, Chao SP, Hu LY, Shen CC, Lee HC. Periodontitis is a potential risk factor for transient ischemic attack and minor ischemic stroke in young adults: A nationwide population-based cohort study. J Periodontol 2022; 93:1848-1856. [PMID: 35297043 DOI: 10.1002/jper.21-0528] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/26/2021] [Accepted: 01/09/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND This study aims to determine whether periodontitis is a risk factor for transient ischemic attack (TIA) in young adults. METHODS The National Health Insurance (NHI) Research Database in Taiwan was the source of the data used in this retrospective cohort study. Individuals aged 20 to 53 years with periodontitis in 2001 and 2002 (n = 792,426) and an age- and sex-matched control group (n = 792,426) were selected. All participants were followed up until TIA diagnosis, 55 years of age, removal from the NHI program, death, or December 31, 2016. The incidence density and hazard ratio (HR) of new-onset TIA were compared between individuals with periodontitis and controls. Periodontitis was defined by dentists according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 523.3-5 with concurrent antibiotic prescription or periodontal treatment excluding scaling performed by certified dentists. TIA was defined according to the ICD-9-CM code 435.x at hospital discharge. RESULTS After adjustment for confounding factors, the risk of developing TIA/minor ischemic stroke was calculated to be higher in participants with periodontitis (HR, 1.24; 95% confidence interval, 1.15-1.32; P <0.001) than in those without. The HR was slightly higher among people aged 20 to 40 years than among those aged 40 to 53 years. CONCLUSION Periodontitis is associated with an increased risk of developing TIA/minor ischemic stroke. Periodontitis might be a modifiable risk factor for stroke in young adults. Clinicians must devote greater attention to this potential association to develop new preventive and therapeutic strategies for stroke in young adults.
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Affiliation(s)
- Yao-Tung Lee
- Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Center of Dementia, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chia-Fen Tsai
- Department of Psychiatry, Neurological Institute, Veterans General Hospital, Taipei, Taiwan.,Division of Psychiatry, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Chun Yen
- Biostatistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Li-Kai Huang
- Center of Dementia, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Shu-Ping Chao
- Center of Dementia, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Li-Yu Hu
- Division of Psychiatry, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Che Shen
- Division of Psychiatry, National Yang-Ming University, Taipei, Taiwan.,Department of Psychiatry, Chiayi Branch, Taichung Veterans General Hospital, Chiayi, Taiwan
| | - Hsin-Chien Lee
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry & Sleep Center, Taipei Medical University Hospital, Taipei, Taiwan
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Kumar V, Agarwal S, Saboo B, Makkar B. RSSDI Guidelines for the management of hypertension in patients with diabetes mellitus. Int J Diabetes Dev Ctries 2022; 42:576-605. [PMID: 36536953 PMCID: PMC9750845 DOI: 10.1007/s13410-022-01143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022] Open
Abstract
Hypertension and diabetes mellitus (DM) are two of the leading lifestyle diseases in the Indian and South Asian populations that often co-exist due to overlapping pathophysiological factors. Obesity, insulin resistance, inflammation, and oxidative stress are thought to be some common pathways. Up to 50% of hypertensive cases in India are diagnosed with type 2 diabetes mellitus (T2DM), which defines the need for a comprehensive guideline for managing hypertension in diabetic patients. These RSSDI guidelines have been formulated based on consultation with expert endocrinologists in India and Southeast Asia, acknowledging the needs of the Indian population. Ambulatory blood pressure monitoring and office and home-based blood pressure (BP) monitoring are recommended for the early analysis of risks. Cardiovascular risks, end-organ damage, and renal disorders are the primary complications associated with diabetic hypertension that needs to be managed with the help of non-pharmacological and pharmacological interventions. The non-pharmacological interventions include the nutrition education of the patient to reduce the intake of salt, sodium, and trans fats and increase the consumption of nuts, fresh fruits, vegetables, and potassium-rich foods. It is also recommended to initiate 50 to 60 min of exercise three to four times a week since physical activity has shown to be more beneficial for hypertension control in Indian patients than dietary modulation. For the pharmacological management of hypertension in patients with T2DM, angiotensin II receptor blockers (ARBs) are recommended as the first line of therapy, demonstrating their superiority over other antihypertensive agents such as ACEi. However, most of the global hypertension guidelines recommend initiation with combination therapy to achieve better BP control in most patients and to reduce the risk of adverse events. For combination therapy, calcium channel blockers (CCBs) are recommended to be administered along with ARBs instead of beta-blockers or diuretics to avoid the risk of cardiovascular events and hyperglycaemia. Among the CCBs, novel molecules (e.g. cilnidipine) are recommended in combination with ARBs for better cardiovascular and reno-protection in diabetic hypertensive patients.
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Affiliation(s)
- Vasanth Kumar
- Apollo Hospitals, Hyderabad, India
- President. RSSDI, Prune, India
| | - Sanjay Agarwal
- Aegle Clinic-Diabetes Care, Pune, India
- Department of Medicine and Diabetes, Ruby Hall Clinic, Pune, India
- Secretary-General, RSSDI, Pune, India
| | - Banshi Saboo
- Immediate Past-President, RSSDI, Pune, India
- Dia-Care Hormone Clinic, Ahmedabad, India
| | - Brij Makkar
- President-Elect, RSSDI, Prune, India
- Dr Makkar’s Diabetes & Obesity Centre, A-5B/122, Paschim Vihar, New Delhi, 110063 India
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Yu AYX, Penn J, Austin PC, Lee DS, Porter J, Fang J, Redelmeier DA, Kapral MK. Telemedicine use and outcomes after transient ischemic attack and minor stroke during the COVID-19 pandemic: a population-based cohort study. CMAJ Open 2022; 10:E865-E871. [PMID: 36195342 PMCID: PMC9544239 DOI: 10.9778/cmajo.20220027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has led to an increase in telemedicine use. We compared care and outcomes in patients with transient ischemic attack (TIA) or minor ischemic stroke before and after the widespread adoption of telemedicine in Ontario, Canada, in 2020. METHODS In a population-based cohort study using linked administrative data, we identified patients with TIA or ischemic stroke discharged from any emergency department in Ontario before the widespread use of telemedicine (Apr. 1, 2015, to Mar. 31, 2020) and after (Apr. 1, 2020, to Mar. 31, 2021). We measured care, including visits with a physician, investigations and medication renewal. We compared 90-day death before and after 2020 using Cox proportional hazards models, and we compared 90-day admission using cause-specific hazard models. RESULTS We identified 47 601 patients (49.3% female; median age 73, interquartile range 62-82, yr) with TIA (n = 35 695, 75.0%) or ischemic stroke (n = 11 906, 25.0%). After 2020, 83.1% of patients had 1 or more telemedicine visit within 90 days of emergency department discharge, compared with 3.8% before. The overall access to outpatient visits within 90 days remained unchanged (92.9% before v. 94.0% after; risk difference 1.1, 95% confidence interval [CI] -1.3 to 3.5). Investigations and medication renewals were unchanged. Clinical outcomes were also similar before and after 2020; the adjusted hazard ratio was 0.97 (95% CI 0.91 to 1.04) for 90-day all-cause admission, 1.06 (95% CI 0.94 to 1.20) for stroke admission and 1.07 (95% CI 0.93 to 1.24) for death. INTERPRETATION Care and short-term outcomes after TIA or minor stroke remained stable after the widespread implementation of telemedicine during the COVID-19 pandemic. Our findings suggest that telemedicine is an effective method of health care delivery that can be complementary to in-person care for minor ischemic cerebrovascular events.
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Affiliation(s)
- Amy Y X Yu
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont.
| | - Jeremy Penn
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Peter C Austin
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Douglas S Lee
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Joan Porter
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Jiming Fang
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Donald A Redelmeier
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
| | - Moira K Kapral
- Division of Neurology (Yu, Penn), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; ICES Central (Yu, Austin, Lee, Porter, Fang, Kapral); Division of Cardiology (Lee), Department of Medicine, University of Toronto, University Health Network; Division of General Internal Medicine (Redelmeier), Department of Medicine, University of Toronto, Sunnybrook Health Sciences Centre; Division of General Internal Medicine (Kapral), Department of Medicine, University of Toronto, University Health Network, Toronto, Ont
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Rattray N, Damush TM, Myers L, Perkins AJ, Homoya B, Knefelkamp C, Fleming B, Kingsolver A, Boldt A, Ferguson J, Zillich A, Bravata DM. Pharmacy program to improve care for veterans with transient ischaemic attack: a pilot implementation evaluation. BMJ Open Qual 2022. [PMCID: PMC9462122 DOI: 10.1136/bmjoq-2022-001863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Early evaluation and effective communication to manage transient ischaemic attacks (TIA) may lead to a reduction of up to 70% in recurrent events for patients with TIA/minor stroke, along with reduced costs and lengths of hospital stay. Methods We conducted a single site pilot evaluation of a clinical pharmacy programme to improve medication management among TIA patients. The programme included a structured protocol, online identification tool, and a templated discharge checklist. Primary effectiveness measures were change in systolic blood pressure (SBP) 90 days post discharge and prescription of high/moderate potency statins. Contextual aspects and clinical perspectives on the implementation process were evaluated through prospective semistructured interviews with key informants. Results The analysis included 75 patients in the preimplementation group and 61 in the postimplementation group. The mean SBP at 90 days post discharge was significantly lower in the post implementation period (pre implementation, 133.3 mm Hg (SD 17.8) vs post implementation, 126.8 mm Hg (16.6); p=0.045). The change in SBP from discharge to 90 days post discharge was greater in the postimplementation period (15.8 mm Hg (20.5) vs 24.8 mm Hg (23.2); p=0.029). The prescription of high/moderate potency statins were similar across groups (pre implementation, 66.7% vs post implementation, 77.4%; p=0.229). Front-line clinicians involved in the pilot study reported positively on the acceptability, appropriateness and feasibility of implementing the protocol without additional cost and within current scope of practice. Conclusions Implementation of a clinical protocol outlining medication management and provider communication to ensure rapid postdischarge treatment of TIA patients was associated with SBP improvements. The pilot evaluation demonstrates how clinical pharmacists may play a role in treating low frequency, high stakes cerebrovascular events where early treatment and follow-up are critical.
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Affiliation(s)
- Nicholas Rattray
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Teresa M Damush
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
| | - Laura Myers
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Anthony J Perkins
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- Department of Biostatistics, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Barbara Homoya
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | | | - Breanne Fleming
- Pharmacy Department, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Andrea Kingsolver
- Pharmacy Department, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Amy Boldt
- Pharmacy Department, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Jared Ferguson
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Alan Zillich
- Department of Pharmacy Practice, Purdue University, West Lafayette, Indiana, USA
| | - Dawn M Bravata
- Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- VA HSR&D Precision Monitoring to Transform Care (PRISM) Quality Enhancement Research Initiative, Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
- William M. Tierney Center for Health Services Research, Regenstrief Institute, Inc, Indianapolis, Indiana, USA
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Jalilianhasanpour R, Huntley JH, Alvin MD, Hause S, Ali N, Urrutia V, Ghazi Sherbaf F, Johnson PT, Yousem DM, Yedavalli V. Value of acute neurovascular imaging in patients with suspected transient ischemic attack. Eur J Radiol 2022; 154:110427. [DOI: 10.1016/j.ejrad.2022.110427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
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Shah K, McCabe B, Mathews C, Nehamkin A, Desai SM, Jadhav AP. Expedited management of low-risk transient ischemic attack patients: The “Fast-Track” TIA protocol. J Stroke Cerebrovasc Dis 2022; 31:106522. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 10/18/2022] Open
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Wang XZ, Li S, Liu Y, Cui GY, Yan FL. Construction of circRNA-Mediated Immune-Related ceRNA Network and Identification of Circulating circRNAs as Diagnostic Biomarkers in Acute Ischemic Stroke. J Inflamm Res 2022; 15:4087-4104. [PMID: 35873383 PMCID: PMC9304636 DOI: 10.2147/jir.s368417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Accumulating evidence suggests that circular RNAs (circRNAs) are involved in immune and inflammatory processes after acute ischemic stroke (AIS). However, the roles of circRNA-mediated competing endogenous RNA (ceRNA) in modulating immune inflammation of AIS have not yet been determined. This study aimed to construct a circRNA-mediated immune-related ceRNA network and identify novel circRNAs in AIS. Methods Microarray data were downloaded from the GEO database and further analysed by R software. Then, we constructed a circRNA-mediated ceRNA network based on interaction information from the bioinformatics database. A topological property analysis of the ceRNA network was conducted to screen novel circRNAs. Finally, we further applied quantitative real-time polymerase chain reaction (qRT-PCR) to two independent sets. Results We constructed an AIS immune-related ceRNA (AISIRC) network containing immune-related genes (IRGs), miRNAs, and circRNAs. Additionally, we extracted the subnetwork from the AISIRC network and screened six immune-related circRNAs. After identification and validation, we finally confirmed that plasma levels of circPTP4A2 and circTLK2 were significantly increased in AIS patients compared with both healthy control subjects (HCs) and transient ischemic attack (TIA) patients. Logistic regression and receiver-operating characteristic (ROC) curve analyses demonstrated that these two circRNAs may function as predictive and discriminative biomarkers for AIS. We also confirmed that plasma levels of circPTP4A2 were elevated in TIA patients compared with HCs and might be an independent risk factor for predicting TIA. Longitudinal analysis of circRNA expression up to 90 days after AIS indicated that the ability of circPTP4A2 and circTLK2 to monitor AIS dynamics was highly desirable. Conclusion In summary, the circRNA-mediated immune-related ceRNA network was successfully constructed, and two circulating circRNAs (circPTP4A2 and circTLK2) improved sensitivity for the diagnosis of AIS and could be considered diagnostic biomarkers.
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Affiliation(s)
- Xing-Zhi Wang
- School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, People's Republic of China.,Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, People's Republic of China
| | - Shuo Li
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Yun Liu
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Gui-Yun Cui
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, 221006, People's Republic of China
| | - Fu-Ling Yan
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, 210009, People's Republic of China
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Purroy F, Vicente-Pascual M, Arque G, Begue R, Farre J, Gallego Y, Gil-Villar MP, Mauri G, Montalà N, Pereira C, Torres-Querol C, Vazquez-Justes D. Risk of New-Diagnosed Atrial Fibrillation After Transient Ischemic Attack. Front Neurol 2022; 13:905304. [PMID: 35911925 PMCID: PMC9331650 DOI: 10.3389/fneur.2022.905304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 06/07/2022] [Indexed: 12/05/2022] Open
Abstract
Background Transient ischemic attack (TIA) provides a unique opportunity to optimize secondary preventive treatments to avoid subsequent ischemic stroke (SIS). Although atrial fibrillation (AF) is the leading cause of cardioembolism in IS and anticoagulation prevents stroke recurrence (SR), limited data exists about the risk of new-diagnosed AF (NDAF) after TIA and the consequences of the diagnostic delay. The aim of our study was to determine this risk in a cohort of TIA patients with long-term follow-up. Methods We carried out a prospective cohort study of 723 consecutive TIA patients from January 2006 to June 2010. Median follow-up was 6.5 (5.0–9.6) years. In a subgroup of 204 (28.2%) consecutive patients, a panel of biomarkers was assessed during the first 24 h of the onset of symptoms. Multivariate analyses were performed to find out the associated factors of NDAF. Kaplan-Meier analysis was also performed to analyzed risk of SIS. Results NDAF was indentified in 116 (16.0%) patients: 42 (36.2%) during admission, 18 (15.5%) within first year, 29 (25%) between one and five years and 27 (23.3%) beyond 5 years. NDAF was associated with sex (female) [hazard ratio (HR) 1.61 (95% CI, 1.07- 2.41)], age [[HR 1.05 (95% CI, 1.03–1.07)], previous ischemic heart disease (IHD) [HR 1.84, (95% CI 1.15–2.97)] and cortical DWI pattern [HR 2.81 (95% CI, 1.87–4.21)]. In the Kaplan-Meier analysis, NT-proBNP ≥ 218.2 pg/ml (log-rank test P < 0.001) was associated with significant risk of NDAF during the first 5 years of follow-up. Patients with NDAF after admission and before 5 years of follow-up had the highest risk of SIS (P = 0.002). Conclusion The risk of NDAF after TIA is clinically relevant. We identified clinical and neuroimaging factors of NDAF. In addition, NT-proBNP was related to NDAF. Our results can be used to evaluate the benefit of long-term cardiac monitoring in selected patients.
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Affiliation(s)
- Francisco Purroy
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Mikel Vicente-Pascual
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gloria Arque
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Robert Begue
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Joan Farre
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Yhovany Gallego
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
| | - Maria Pilar Gil-Villar
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gerard Mauri
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Nuria Montalà
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
- Hospital Universitari Santa Maria de Lleida, Lleida, Spain
| | - Cristina Pereira
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Coral Torres-Querol
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Daniel Vazquez-Justes
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova de Lleida, Lleida, Spain
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
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Gologorsky RC, Lancaster E, Tucker LY, Nguyen-Huynh MN, Rothenberg KA, Avins AL, Kuang HC, Chang RW. Natural History of Asymptomatic Moderate Carotid Artery Stenosis in a Large Community-Based Cohort. Stroke 2022; 53:2838-2846. [DOI: 10.1161/strokeaha.121.038426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Moderate carotid artery stenosis is a poorly defined risk factor for ischemic stroke. As such, practice recommendations are lacking. In this study, we describe the long-term risk of stroke in patients with moderate asymptomatic stenosis in an integrated health care system.
Methods:
All adult patients with asymptomatic moderate (50%–69%) internal carotid artery stenosis between 2008 and 2012 were identified, with follow-up through 2017. The primary outcome was acute ischemic stroke attributed to the ipsilateral carotid artery. Stroke rates were calculated using competing risk analysis. Secondary outcomes included disease progression, ipsilateral intervention, and long-term survival.
Results:
Overall, 11 614 arteries with moderate stenosis in 9803 patients were identified. Mean age was 74.2±9.9 years with 51.4% women. Mean follow-up was 5.1±2.9 years. There were 180 ipsilateral ischemic strokes (1.6%) identified (crude annual risk, 0.31% [95% CI, 0.21%–0.41%]), of which thirty-one (17.2%) underwent subsequent intervention. Controlling for death and intervention as competing risks, the cumulative incidence of stroke was 1.2% (95% CI, 1.0%–1.4%) at 5 years and 2.0% (95% CI, 1.7%–2.4%) at 10 years. Of identified strokes, 50 (27.8%) arteries had progressed to severe stenosis or occlusion. During follow-up, there were 17 029 carotid studies performed in 5951 patients, revealing stenosis progression in 1674 (14.4%) arteries, including 1614 (13.9%) progressing to severe stenosis and 60 (0.5%) to occlusion. The mean time to stenosis progression was 2.6±2.1 years. Carotid intervention occurred in 708 arteries (6.1%). Of these, 66.1% (468/708) had progressed to severe stenosis. The overall mortality rate was 44.5%, with 10.5% of patients lost to follow-up.
Conclusions:
In this community-based sample of patients with asymptomatic moderate internal carotid artery stenosis followed for an average of 5 years, the cumulative incidence of stroke is low out to 10 years. Future research is needed to optimize management strategies for this population.
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Affiliation(s)
- Rebecca C. Gologorsky
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | | | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, Inc, Walnut Creek, CA (M.N.N.-H.,)
| | - Kara A. Rothenberg
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco (A.L.A.)
| | - Hui C. Kuang
- Department of Surgery, The Permanente Medical Group, San Francisco, CA (H.C.K.)
| | - Robert W. Chang
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, South San Francisco, CA (R.W.C.)
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Chang RW, Tucker LY, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, Flint AC, Avins AL, Nguyen-Huynh MN. Incidence of Ischemic Stroke in Patients With Asymptomatic Severe Carotid Stenosis Without Surgical Intervention. JAMA 2022; 327:1974-1982. [PMID: 35608581 PMCID: PMC9131743 DOI: 10.1001/jama.2022.4835] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Optimal management of patients with asymptomatic severe carotid stenosis is uncertain, due to advances in medical care and a lack of contemporary data comparing medical and surgical treatment. OBJECTIVE To estimate stroke outcomes among patients with medically treated asymptomatic severe carotid stenosis who did not undergo surgical intervention. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study that included 3737 adult participants with asymptomatic severe (70%-99%) carotid stenosis diagnosed between 2008 and 2012 and no prior intervention or ipsilateral neurologic event in the prior 6 months. Participants received follow-up through 2019, and all were members of an integrated US regional health system serving 4.5 million members. EXPOSURES Imaging diagnosis of asymptomatic carotid stenosis of 70% to 99%. MAIN OUTCOMES AND MEASURES Occurrence of ipsilateral carotid-related acute ischemic stroke. Censoring occurred with death, disenrollment, or ipsilateral intervention. RESULTS Among 94 822 patients with qualifying imaging studies, 4230 arteries in 3737 (mean age, 73.8 [SD 9.5 years]; 57.4% male) patients met selection criteria including 2539 arteries in 2314 patients who never received intervention. The mean follow-up in this cohort was 4.1 years (SD 3.6 years). Prior to any intervention, there were 133 ipsilateral strokes with a mean annual stroke rate of 0.9% (95% confidence interval [CI], 0.7%-1.2%). The Kaplan-Meier estimate of ipsilateral stroke by 5 years was 4.7% (95% CI, 3.9%-5.7%). CONCLUSIONS AND RELEVANCE In a community-based cohort of patients with asymptomatic severe carotid stenosis who did not undergo surgical intervention, the estimated rate of ipsilateral carotid-related acute ischemic stroke was 4.7% over 5 years. These findings may inform decision-making regarding surgical and medical treatment for patients with asymptomatic severe carotid artery stenosis.
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Affiliation(s)
- Robert W. Chang
- Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Kara A. Rothenberg
- Department of Surgery, University of California San Francisco - East Bay, Oakland
| | | | - Rishad M. Faruqi
- Department of Vascular Surgery, The Permanente Medical Group, Santa Clara, California
| | - Hui C. Kuang
- Department of Vascular Surgery, The Permanente Medical Group, San Francisco, California
| | - Alexander C. Flint
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Redwood City, California
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Medicine, University of California San Francisco
- Department of Epidemiology and Biostatistics, University of California San Francisco
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Neurology, The Permanente Medical Group, Walnut Creek, California
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Mills WA, Woo AM, Jiang S, Martin J, Surendran D, Bergstresser M, Kimbrough IF, Eyo UB, Sofroniew MV, Sontheimer H. Astrocyte plasticity in mice ensures continued endfoot coverage of cerebral blood vessels following injury and declines with age. Nat Commun 2022; 13:1794. [PMID: 35379828 PMCID: PMC8980042 DOI: 10.1038/s41467-022-29475-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 03/11/2022] [Indexed: 01/30/2023] Open
Abstract
Astrocytes extend endfeet that enwrap the vasculature, and disruptions to this association which may occur in disease coincide with breaches in blood-brain barrier (BBB) integrity. Here we investigate if focal ablation of astrocytes is sufficient to disrupt the BBB in mice. Targeted two-photon chemical apoptotic ablation of astrocytes induced a plasticity response whereby surrounding astrocytes extended processes to cover vascular vacancies. In young animals, replacement processes occur in advance of endfoot retraction, but this is delayed in aged animals. Stimulation of replacement astrocytes results in constriction of pre-capillary arterioles, suggesting that replacement astrocytes are functional. Pharmacological inhibition of pSTAT3, as well as astrocyte specific deletion of pSTAT3, reduces astrocyte replacement post-ablation, without perturbations to BBB integrity. Similar endfoot replacement occurs following astrocyte cell death due to reperfusion in a stroke model. Together, these studies uncover the ability of astrocytes to maintain cerebrovascular coverage via substitution from nearby cells.
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Affiliation(s)
- William A. Mills
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XRobert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.438526.e0000 0001 0694 4940Graduate Program in Translational Biology, Medicine, & Health, Virginia Polytechnic Institute and State University, Blacksburg, VA USA
| | - AnnaLin M. Woo
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Shan Jiang
- grid.168010.e0000000419368956Department of Material Science and Engineering, Stanford University, Stanford, CA USA ,grid.168010.e0000000419368956Wu Tsai Neurosciences Institute, Stanford University, Stanford, CA USA
| | - Joelle Martin
- grid.438526.e0000 0001 0694 4940Graduate Program in Translational Biology, Medicine, & Health, Virginia Polytechnic Institute and State University, Blacksburg, VA USA
| | - Dayana Surendran
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Matthew Bergstresser
- grid.438526.e0000 0001 0694 4940School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA USA
| | - Ian F. Kimbrough
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Ukpong B. Eyo
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XRobert M. Berne Cardiovascular Research Center, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Michael V. Sofroniew
- grid.19006.3e0000 0000 9632 6718Department of Neurobiology, University of California, Los Angeles, CA USA
| | - Harald Sontheimer
- grid.27755.320000 0000 9136 933XBrain, Immunology, and Glia Center, University of Virginia School of Medicine, Charlottesville, VA USA ,grid.27755.320000 0000 9136 933XDepartment of Neuroscience, University of Virginia School of Medicine, Charlottesville, VA USA
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Zhang K, Fang Y, Fan H, Ren J, Liu C, Liu T, Wang Y, Li Y, Li J, Meng J, Qian L, Li X, Wu X, Niu X. A nomogram for predicting the in-hospital risk of recurrence among patients with minor non-cardiac stroke. Curr Med Res Opin 2022; 38:487-499. [PMID: 35119325 DOI: 10.1080/03007995.2022.2038488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/17/2022] [Accepted: 02/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients with minor stroke suffer a substantial risk of further recurrences, especially in the first two weeks. We aimed to develop and validate a prognostic nomogram to predict in-hospital stroke recurrence among patients with acute minor stroke. METHODS A total of 1326 patients with minor non-cardiac stroke (NIHSS) ≤5) from three centers were divided into development cohort (1016 patients from two centers) and validation cohort (310 patients from another center). Recurrent stroke was defined as a new ischemic stroke. A logistic regression model was employed to develop the nomogram to predict in-hospital stroke recurrence in patients with minor stroke using demographic, medical and imaging information. We then validated the nomogram externally. The predictive discrimination and calibration of the nomogram were assessed in the development and validation cohorts by area under the curve (AUC) and calibration plots. RESULTS During a median length of stay of 12 days, stroke recurrence occurred in 34 patients (3.3%). Predictors of in-hospital recurrence included prior history of transient ischemic attack, baseline NIHSS score, multiple infarctions, and carotid stenosis. The clinical and imaging-based nomogram B demonstrated adequate calibration and discrimination (AUC = 0.777), which was validated among 273 patients in a separate validation cohort (AUC = 0.753). Our clinical-imaging based nomogram was determined to be superior to the clinical-based nomogram and the RRE90 score in terms of discrimination. CONCLUSION A prognostic nomogram that integrates clinical and imaging information to predict the in-hospital risk of stroke recurrence among patients after acute minor stroke was constructed and validated externally. The nomogram demonstrated adequate calibration and discrimination in both the development and validation cohort.
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Affiliation(s)
- Kaili Zhang
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
- Department of Neurology of Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yalan Fang
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Haimei Fan
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
- Department of Neurology of The General Hospital of TISCO Affiliated to Shanxi Medical University, Taiyuan, China
| | - Jing Ren
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Chang Liu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingting Liu
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yongle Wang
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yanan Li
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Juan Li
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jingwen Meng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Radiology of Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Lixia Qian
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Department of Radiology of Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
| | - Xinyi Li
- Department of Neurology of Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xuemei Wu
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyuan Niu
- Department of Neurology of The First Hospital of Shanxi Medical University, Taiyuan, China
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49
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Vodencarevic A, Weingärtner M, Caro JJ, Ukalovic D, Zimmermann-Rittereiser M, Schwab S, Kolominsky-Rabas P. Prediction of Recurrent Ischemic Stroke Using Registry Data and Machine Learning Methods: The Erlangen Stroke Registry. Stroke 2022; 53:2299-2306. [PMID: 35360927 DOI: 10.1161/strokeaha.121.036557] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There have been multiple efforts toward individual prediction of recurrent strokes based on structured clinical and imaging data using machine learning algorithms. Some of these efforts resulted in relatively accurate prediction models. However, acquiring clinical and imaging data is typically possible at provider sites only and is associated with additional costs. Therefore, we developed recurrent stroke prediction models based solely on data easily obtained from the patient at home. METHODS Data from 384 patients with ischemic stroke were obtained from the Erlangen Stroke Registry. Patients were followed at 3 and 12 months after first stroke and then annually, for about 2 years on average. Multiple machine learning algorithms were applied to train predictive models for estimating individual risk of recurrent stroke within 1 year. Double nested cross-validation was utilized for conservative performance estimation and models' learning capabilities were assessed by learning curves. Predicted probabilities were calibrated, and relative variable importance was assessed using explainable artificial intelligence techniques. RESULTS The best model achieved the area under the curve of 0.70 (95% CI, 0.64-0.76) and relatively good probability calibration. The most predictive factors included patient's family and housing circumstances, rehabilitative measures, age, high calorie diet, systolic and diastolic blood pressures, percutaneous endoscopic gastrotomy, number of family doctor's home visits, and patient's mental state. CONCLUSIONS Developing fairly accurate models for individual risk prediction of recurrent ischemic stroke within 1 year solely based on registry data is feasible. Such models could be applied in a home setting to provide an initial risk assessment and identify high-risk patients early.
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Affiliation(s)
| | - Michael Weingärtner
- Interdisciplinary Center for Health Technology Assessment (HTA) and Public Health, Friedrich-Alexander University Erlangen-Nürnberg, Germany (M.W.)
| | - J Jaime Caro
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada (J.J.C.).,Health Policy, London School of Economics, United Kingdom (J.J.C.)
| | - Dubravka Ukalovic
- Computed Tomography, Siemens Healthcare GmbH, Forchheim, Germany (D.U.)
| | | | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Germany (S.S.)
| | - Peter Kolominsky-Rabas
- Interdisciplinary Center for Health Technology Assessment and Public Health, Friedrich-Alexander University Erlangen-Nürnberg, Germany (P.K.-R.)
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50
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Isnard F, Termoz A, Haesebaert J, Viprey M, Tazarourte K, Bravant E, Perreton N, Cakmak S, Meyran S, Ossedat C, Ducreux B, Pidoux C, Bony T, Douplat M, Potinet V, Sigal A, Derex L, Nighoghossian N, Schott-Pethelaz AM, Mechtouff L. Temporal Trend of Transient Ischemic Attack Management over a 10-Year Period: Data from the Rhône County, France. Cerebrovasc Dis 2022; 51:517-524. [PMID: 35350011 DOI: 10.1159/000520840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Timely recognition and management of transient ischemic attack (TIA) offer the greatest opportunity to prevent subsequent stroke. But variability of TIA management quality exists across hospitals. Under the impetus of national plans, measures were adopted to improve TIA management, including a structured local pathway. Our objective was to compare TIA management between two periods over 10 years, before and after the implementation of these measures. METHODS A before-and-after study was conducted with two identical population-based cohort studies in 2006-2007 (AVC69) and 2015-2016 (STROKE69) including all patients with TIA diagnosis over a 7-month period in six public and private hospitals in the Rhône county in France. The primary outcome was the adequate TIA management defined as brain and vessel imaging within 24 h of admission and the prescription of antithrombotic treatment at discharge. RESULTS We identified 109 patients TIA patients in 2006-2007, and 458 over the same period in 2015-2016. A higher proportion of patients were adequately managed in 2015-2016 compared to 2006-2007 (14/96 [15%] in 2006-2007 vs. 306/452 [68%] in 2015-2016, p < 0.001). This difference was mainly driven by a marked increase of vessel imaging performed within 24 h of admission, most often by computed tomography angiography. Furthermore, patients called more often emergency medical dispatch before admission, were admitted with a shorter delay after symptom onset, and were more likely discharged to home in 2015-2016 compared to 2006-2007. CONCLUSION Our study demonstrated an increasing rate of adequate TIA management, mainly driven by a marked increase of vessel imaging within 24 h of admission, over a 10-year period in the Rhône county in France.
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Affiliation(s)
- Florent Isnard
- Emergency Department - HEH, Hospices Civils de Lyon, Lyon, France
| | - Anne Termoz
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Lyon, France
| | - Julie Haesebaert
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Lyon, France
| | - Marie Viprey
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Lyon, France
| | - Karim Tazarourte
- Emergency Department - HEH, Hospices Civils de Lyon, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France
| | - Estelle Bravant
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Lyon, France
| | | | - Serkan Cakmak
- Stroke Unit, Hôpital Nord Ouest, Villefranche-sur-Saône, France
| | - Sylvie Meyran
- Emergency Department, Hôpital St Joseph St Luc, Lyon, France
| | | | - Bruno Ducreux
- Emergency Department, Hôpital Nord Ouest, Villefranche-sur-Saône, France
| | - Christelle Pidoux
- Emergency Department, Hôpital Nord Ouest, Villefranche-sur-Saône, France
| | - Thomas Bony
- Emergency Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre Bénite, France
| | - Marion Douplat
- Emergency Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre Bénite, France
| | - Veronique Potinet
- Emergency Department, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre Bénite, France
| | - Alain Sigal
- Emergency Department, Hospices Civils de Lyon, Hôpital Croix Rousse, Lyon, France
| | - Laurent Derex
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Stroke Center, Hôpital Pierre Wertheimer, Bron, France
| | | | - Anne-Marie Schott-Pethelaz
- Université de Lyon, Université Claude Bernard Lyon 1 - HESPER EA 7425, Lyon, France.,Hospices Civils de Lyon, Pôle de Sante Publique, Lyon, France
| | - Laura Mechtouff
- Hospices Civils de Lyon, Stroke Center, Hôpital Pierre Wertheimer, Bron, France
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