The Stroke in Italy and Related Impact on Outcome (SIRIO) study: design and baseline data

The Epidemiology of Atrial Fibrillation and Stroke

The burden of stroke is increasing due to aging population and unhealthy lifestyle habits. The considerable rise in atrial fibrillation (AF) is due to greater diffusion of risk factors and screening programs. The link between AF and ischemic stroke is strong. The subtype most commonly associated with AF is cardioembolic stroke, which is particularly severe and shows the highest rates of mortality and permanent disability. A trend toward a higher prevalence of cardioembolic stroke in high-income countries is probably due to the greater diffusion of AF and the control of atherosclerotic of risk factors.

Low awareness of stroke guidelines and preference for Chinese herbs in community physicians: a national survey in China

BACKGROUND

Physicians' adherence to stroke guidelines is becoming a critical part of public stroke care system. The objective of this national survey was to examine Chinese physicians' awareness of the guidelines in secondary stroke prevention.

METHODS

This is a non-commercial and no-incentive internet survey. Respondents were asked to perform a self-examination of 13 questions regarding their stroke practice. Their awareness of stroke guidelines, preference for Chinese traditional herbs (CTH), and patients' expense for stroke treatment were surveyed and compared between physicians from community and from tertiary hospitals using univariate analysis and logistic regression.

RESULTS

A total of 8,581 physicians (70.1% from community hospitals) responded to the survey. Only 32.1% physicians considered risk factors control necessary for stroke. For the treatments of symptomatic carotid stenosis, only 10.4% physicians selected carotid endarterectomy and anti-platelet plus controlling stroke risk factors. Only 21.45% physicians selected warfarin anticoagulation for stroke patients with atrial fibrillation. In contrast, a high percentage (64.56%) of physicians had positive attitude towards CTH. Compared with those from tertiary hospitals, community physicians were more likely unaware of the guidelines and preferred CTH. Those who prescribed CTH reported more patients' cost (P<0.001, OR 1.78, 95% CI, 1.55-2.04) than who didn't.

CONCLUSIONS

There is a very low awareness of stroke guidelines in Chinese community physicians. A well-organized continuing stroke-guidelines education should be an essential part of public stroke-care system in China. Also, more well-designed clinical trials are required to establish the safety and effectiveness of CTH.

Atherothrombotic burden and medium-term prognosis in patients with acute ischemic stroke: findings of the SIRIO study

BACKGROUND

Short- and medium-term mortality after acute stroke is related to the severity of the index event and the patient's age. However, recent studies have reassessed the prognostic value of the systemic atherothrombotic burden in these patients, not only in the long term. This post hoc analysis of the findings of the SIRIO trial (Stroke in Italy and Related Impact on Outcome) examined the prognostic impact of systemic atherothrombosis.

METHODS

SIRIO was a multicenter observational study enrolling patients during the acute phase of stroke of both ischemic and hemorrhagic origin. The present analysis, however, only covered patients with ischemic stroke. At baseline, the main personal and clinical details were recorded and patients were classified as having either polyvascular disease or single arterial disease on the basis of whether they had symptomatic atherothrombotic disease in other sites besides the cerebrovascular location. For all patients we calculated the Essen Stroke Risk Score (ESRS), dividing them into groups with scores of less than 3 or 3 and more. We recorded total mortality and nonfatal vascular events 12 months after enrolment. Multivariate logistic regression analysis was used to select predictors of medium-term mortality and nonfatal cardiovascular events. There were 2,561 patients with ischemic stroke, 823 of them classified as having polyvascular disease; 940 (out of 2,485) had an ESRS of less than 3 and 1,545 had a score of 3 or more.

RESULTS

The combined endpoint 'death (all causes) and nonfatal cardiovascular events within 12 months of hospital discharge' was significantly dependent on the following factors: ESRS, Rankin scale and National Institutes of Health Stroke Scale scores, and polyvascular disease. Polyvascular disease status significantly affected mortality and nonfatal cardio- and cerebrovascular events after discharge (OR = 1.44, 95% CI = 1.10-1.88). Age was also confirmed as a significant predictor of the combined endpoint.

CONCLUSIONS

Besides age and the clinical severity of the index event, symptomatic involvement of several vascular districts was also an important predictor of mortality and nonfatal cardiovascular events in the medium term in patients with ischemic stroke.

Identification and management of polyvascular disease in patients with noncardioembolic ischaemic stroke

Recent registry results have shown that polyvascular disease (PolyVD), usually manifested as coronary heart disease or peripheral arterial disease (PAD), is a marker of increased morbidity and mortality in patients with noncardioembolic ischaemic stroke, but is often inadequately assessed. This Personal View Paper advocates routine examination for PolyVD in such patients. Peripheral arterial disease can be readily detected in routine practice by measurement of the ankle-brachial index. This paper makes recommendations for risk stratification, discharge documentation and, where possible, management of ischaemic stroke patients with PolyVD.

Risk factors and treatment at recurrent stroke onset: results from the Recurrent Stroke Quality and Epidemiology (RESQUE) Study

BACKGROUND

Much effort has been made to study first-ever stroke patients. However, recurrent stroke has not been investigated as extensively. It is unclear which risk factors dominate, and whether adequate secondary prevention has been provided to patients who suffer from recurrent stroke. Also, the different types of recurrent stroke need further evaluation.

METHODS

The study included patients with recurrent stroke admitted to twenty-three Swedish stroke centers. The type of previous and recurrent stroke was determined, as well as evaluation (when applicable) of recurrent ischemic stroke according to the TOAST classification. Presence of vascular risk factors was registered and compared to the type of stroke. Also assessed was ongoing secondary prevention treatment at recurrent stroke onset.

RESULTS

A total of 889 patients with recurrent stroke (mean age 77) were included in the study. Of these, 805 (91%) had ischemic stroke, 78 (9%) had intracerebral hemorrhage and 6 (<1%) stroke of unknown origin. The most frequent vascular risk factors were hypertension (75%) and hyperlipidemia (56%). Among the 889 patients, 29% had atrial fibrillation. Of the patients in the ischemic group with cardiac embolism, only 21% were on anticoagulation treatment. The majority of the patients (75%) had their most recent previous stroke >12 months before admission.

CONCLUSIONS

Few patients had a recurrent stroke shortly after the previous stroke in this study. This indicates that it is meaningful to prevent a second event with an adequate long-term treatment strategy for secondary prevention after first-ever stroke. There also seems to be a clear potential for improving secondary prevention after stroke.