PROGRESS: Prevention of Recurrent Stroke

Adherence to secondary stroke prevention medications in Singapore: a single center study

OBJECTIVES

Recurrent strokes are associated with greater disability and mortality than first-time strokes. However, adherence to secondary stroke prevention medications has been reported to be suboptimal. We assessed medication adherence to antihypertensives, antiplatelets, and statins after acute ischemic stroke and identified factors associated with non-adherence behavior to each drug class.

METHODS

This single center study is an extension of a larger prospective cohort study of ischemic stroke patients assessed at an outpatient post stroke clinic. Medication adherence behavior and medication knowledge was determined by direct questioning, and perceptions towards medications via the Beliefs about Medicines Questionnaire. Factors associated with non-adherence in each drug class were determined using logistic regression.

RESULTS

Rates of adherence differed between antihypertensives (77.9%), antiplatelets (80.3%), and statins (64.7%) (p < 0.001) amongst the 193 patients surveyed. Non-adherence to antihypertensives was associated with living alone, taking < 5 medications, and stronger beliefs that medications are harmful. For antiplatelets, non-diabetic patients and patients with stronger beliefs that medications are harmful were more likely to be non-adherent. Patients non-adherent to statins were more likely to have a longer time since ischemic event and have a transient ischemic attack as the index event.

CONCLUSIONS

Overall, medication adherence behavior to secondary stroke prevention medications was poor, with statins the least adhered to. Factors associated with non-adherence to each drug class could guide the development of tailored interventions to improve adherence to secondary stroke prevention medications.

Daily blood pressure profile and blood-brain barrier permeability in patients with cerebral small vessel disease

Cerebral small vessel disease (CSVD) plays an important role in cognitive impairment, stroke, disability, and death. Hypertension is the main risk factor for CSVD. The use of antihypertensive therapy has not resulted in the expected decrease in CSVD complications, which may be related to the underestimation of significance of daily blood pressure profile for blood–brain barrier (BBB) permeability. 53 patients with CSVD of varying severity (mean age 60.08 ± 6.8 years, 69.8% women, subjects with treated long-standing hypertension vs. normotensive subjects − 84.8% vs. 15.2%) and 17 healthy volunteers underwent ambulatory blood pressure monitoring (ABPM) and MRI, including T1-weighted dynamic contrast-enhanced magnetic resonance imaging for assessing BBB permeability. Most of ABPM parameters in CSVD patients did not differ from controls, but were associated with the severity of white matter hyperintensity (WMH) and the total CSVD score. BBB permeability in normal-appearing white matter (NAWM) and grey matter (GM) was significantly higher in CSVD patients, and the severity of BBB permeability remained similar in patients with different stages of WMH. Among BBB permeability parameters, the area under the curve, corresponding to an increase in the contrast transit time in NAWM, had the greatest number of correlations with deviations of ABPM parameters. BBB permeability in CSVD is a universal mechanism of NAWM and GM damage associated with a slight increase in ABPM parameters. It is obvious that the treatment of hypertension in patients with not severe WMH should be more aggressive and carried out under the control of ABPM.

Applying Machine Learning to Carotid Sonographic Features for Recurrent Stroke in Patients With Acute Stroke

BACKGROUND

Although carotid sonographic features have been used as predictors of recurrent stroke, few large-scale studies have explored the use of machine learning analysis of carotid sonographic features for the prediction of recurrent stroke.

METHODS

We retrospectively collected electronic medical records of enrolled patients from the data warehouse of China Medical University Hospital, a tertiary medical center in central Taiwan, from January 2012 to November 2018. We included patients who underwent a documented carotid ultrasound within 30 days of experiencing an acute first stroke during the study period. We classified these participants into two groups: those with non-recurrent stroke (those who has not been diagnosed with acute stroke again during the study period) and those with recurrent stoke (those who has been diagnosed with acute stroke during the study period). A total of 1,235 carotid sonographic parameters were analyzed. Data on the patients' demographic characteristics and comorbidities were also collected. Python 3.7 was used as the programming language, and the scikit-learn toolkit was used to complete the derivation and verification of the machine learning methods.

RESULTS

In total, 2,411 patients were enrolled in this study, of whom 1,896 and 515 had non-recurrent and recurrent stroke, respectively. After extraction, 43 features of carotid sonography (36 carotid sonographic parameters and seven transcranial color Doppler sonographic parameter) were analyzed. For predicting recurrent stroke, CatBoost achieved the highest area under the curve (0.844, CIs 95% 0.824-0.868), followed by the Light Gradient Boosting Machine (0.832, CIs 95% 0.813-0.851), random forest (0.819, CIs 95% 0.802-0.846), support-vector machine (0.759, CIs 95% 0.739-0.781), logistic regression (0.781, CIs 95% 0.764-0.800), and decision tree (0.735, CIs 95% 0.717-0.755) models.

CONCLUSION

When using the CatBoost model, the top three features for predicting recurrent stroke were determined to be the use of anticoagulation medications, the use of NSAID medications, and the resistive index of the left subclavian artery. The CatBoost model demonstrated efficiency and achieved optimal performance in the predictive classification of non-recurrent and recurrent stroke.

PRESERVE: Randomized Trial of Intensive Versus Standard Blood Pressure Control in Small Vessel Disease

[Figure: see text].

Sex Differences of Combined Effects Between Hypertension and General or Central Obesity on Ischemic Stroke in a Middle-Aged and Elderly Population

Background

Hypertension and obesity are recognized as modifiable risk factors for stroke, but their combined effects are unknown. This study aimed to explore the combined effects of hypertension and general or central obesity on the risk of ischemic stroke in a middle-aged and elderly population.

Methods

The data of 11,731 participants (53.5 ± 10.5 years old) were analyzed from the Northeast China Rural Cardiovascular Health Study, 2012–2013. General obesity (GO) was defined by body mass index (BMI); central obesity (CO) was measured by waist circumference (WC), waist-to-height ratio (WHtR) and waist-to-hip ratio (WHpR).

Results

The overall prevalence of ischemic stroke was 3.1%. After adjusting for age and sex, the odds ratios for having ischemic stroke were 4.31 (3.14–5.91) among subjects with hypertension, 1.79 (1.40–2.30) with GO, 1.94 (1.54–2.43), 1.98 (1.54–2.53), and 1.65 (1.33–2.06) with CO measured by WC, WHtR and WHpR, respectively. After full adjustment for potential confounders, the combinations of hypertension and obesity indices (including BMI, WC, WHtR and WHpR) were associated with the highest risk of ischemic stroke, especially in women, which were respectively 7.3-fold, 9.3-fold, 9.9-fold and 7.6-fold higher than that of individuals without both conditions.

Conclusion

Our study results suggest that women with both hypertension and obesity, no matter defined by BMI, WC, WHtR or WHpR, were more likely to have ischemic stroke. A better understanding of the combined effects of these risk factors can help promote primary prevention in susceptible subgroups.

Comparisons of Stroke Knowledge and Health Behaviors in Patients With Hypertensive Stroke at Different Recurrence Risk Strata: The Comprehensive Reminder System Based on the Health Belief Model Study

BACKGROUND

Risk factor management via behavioral change contributes substantially to secondary stroke prevention. The health belief model identified self-perceived risk as a significant factor in behavior change. In previous studies, people have tended to incorrectly estimate their risk of stroke. Little is known about the differences in stroke knowledge and health behaviors in patients who have had a stroke with different risks of stroke recurrence in China.

OBJECTIVE

The aims of this study were to determine the accuracy of self-perceived risk of stroke recurrence and to compare stroke knowledge and health behaviors in patients with hypertensive stroke at different recurrence risk strata.

METHODS

Baseline data from 174 patients in the Comprehensive Reminder System based on the Health Belief Model (CRS-HBM) study were used. Self-perceived risk was assessed via the susceptibility subcategory of the Short-Form Health Belief Model Scale, and actual risk was stratified using the Essen Stroke Risk Score.

RESULTS

Only 27.0% of the patients estimated their risks of stroke recurrence accurately. Patients who perceived themselves to be at higher risk had better knowledge of warning signs. Compared with patients who underestimated their risk of stroke recurrence, those who accurately estimated or overestimated their risk less likely to smoke.

CONCLUSIONS

Most patients incorrectly estimated their risk of stroke recurrence. Communicating with patients about their future risk of recurrent stroke may help improve their stroke knowledge and health behaviors. Implementation of the Comprehensive Reminder System based on the Health Belief Model focusing on risk education aimed at prevention of stroke recurrence is warranted in China.

Neurological complications of systemic hypertension

Systemic hypertension is the most common, most easily diagnosed, and one of the most reversible risk factors for neurologic pathology. Acute severe hypertension above a mean arterial pressure of approximately 150mmHg exceeds the brain's autoregulatory capacity and results in increased cerebral blood flow leading to hypertensive encephalopathy. Chronic hypertension predisposes to cerebral vasculature atherosclerosis, medial hypertrophy, luminal narrowing, endothelial dysfunction, impaired arterial relaxation, and decreased ability to augment cerebral blood flow at low blood pressures. The pathologic effects of hypertension increase stroke risk by three- to fivefold. With three-fourths of strokes incident events, primary prevention is essential. Multiple studies have demonstrated the benefit of blood pressure lowering in reducing incident and recurrent strokes. Even more, hypertension is a risk factor for cognitive impairment and dementia through multifactorial mechanisms including vascular compromise, cerebral small vessel disease, white matter disease (leukoaraiosis), cerebral microbleeds, cerebral atrophy, amyloid plaque deposition, and neurofibrillary tangles. In patients without hypotension, treatment with antihypertensives slows progression and assuages the degree of cognitive decline. While the choice of antihypertensive did not make a significant difference in most cognitive outcome studies, some large meta-analyses have pointed to angiotensin receptor blockers as the favored agent. Because of the well-documented morbidity and mortality associated with unchecked hypertension, treating and preventing hypertension are universally critical pillars in healthcare.

Hypertension Among Hemorrhagic Stroke Patients in Northeast China: A Population-Based Study 2017-2019

BACKGROUND We aimed to profile the current epidemiology of hypertension among the survivors of hemorrhagic stroke in northeast China. MATERIAL AND METHODS Our cross-sectional study included 18 796 adults aged 40 years or older and residing in northeast China. Hemorrhagic stroke was identified according to the CT and/or MRI results. Hypertension was defined based on the Chinese hypertension guidelines. RESULTS We identified 208 patients with previous hemorrhagic stroke in this population-based study. The overall prevalence of hypertension in the studied population was 88%. Out of all the survivors of hemorrhagic stroke, 80.9% were aware of their hypertensive condition, 70.5% of the patients were in antihypertensive medications treatment, and only 12% of the patients had their blood pressure under control. Furthermore, only 17.10% of the patients who took hypertensive medications achieved appropriate blood pressure. Calcium channel blockers were more commonly used than other medications. Patients with controlled hypertension had significantly higher percentages of comorbidities when compared to those with uncontrolled hypertension. In our patient sample, the rates of stage 2 and stage 3 hypertension in the hemorrhagic stroke population were 28.8% and 15.9%, respectively, and women had a significantly higher prevalence of stage 3 hypertension when compared with men (21.3% vs. 10.0%, P=0.026). CONCLUSIONS The high prevalence of uncontrolled hypertension and high rates of blood pressure at stages 2 and 3 in patients with prior hemorrhagic stroke indicated a considerable stroke burden in northeast China. Therefore, effective and long-time management of hypertension in stroke survivors should be a priority.

Arterial Hypertension and Risk of Recurrent Event in Young Ischemic Stroke Patients

INTRODUCTION

In young patients, the cause of ischemic stroke (IS) remains often cryptogenic despite presence of traditional vascular risk factors (VRFs). Since arterial hypertension (AH) is considered the most important one, we aimed to evaluate the impact of AH and blood pressure (BP) levels after discharge on risk of recurrent IS (RIS) in young patients.

METHODS

The study set consisted of acute IS patients < 50 years of age enrolled in the prospective Heart and Ischemic STrOke Relationship studY registered on ClinicalTrials.gov (NCT01541163). Cause of IS was assessed according to the ASCOD classification.

RESULTS

Out of 319 enrolled patients <50 years of age (179 males, mean age 41.1 ± 7.8 years), AH was present in 120 (37.6%) of them. No difference was found in the rates of etiological subtypes of IS between patients with and without AH. Patients with AH were older, had more VRF, used more frequently antiplatelets prior IS, and had more RIS (10 vs. 1%, p = 0.002) during a follow-up (FUP) with median of 25 months. Multivariate logistic regression stepwise model showed the prior use of antiplatelets as only predictor of RIS (p = 0.011, OR: 6.125; 95% CI: 1.510-24.837). Patients with elevated BP levels on BP Holter 1 month after discharge did not have increased rate of RIS during FUP (3.8 vs. 1.7%, p = 1.000).

CONCLUSION

AH occurred in 37.6% of young IS patients. Patients with AH had more frequently RIS. Prior use of antiplatelets was found only predictor of RIS in young IS patients with AH.

[Arterial hypertension, cognitive disorders and dementia: a view of a cardiologist]

This article presents a review of Russian and foreign literature about the impact of arterial hypertension (AH) on the risk of cognitive impairment and dementia. Large studies have demonstrated the effect of blood pressure (BP) on the risk of vascular dementia and Alzheimer's disease (AD) in elderly and oldest old people as well as a role of antihypertensive therapy. There is evidence of a negative effect of hypertension in middle age on cognitive functions in late-life. Observational studies as a whole have shown the positive effect of antihypertensive therapy on the prevention of cognitive function and dementia. However, there are a number of limitations that dictate the need for further research on this issue. The importance of the interdisciplinary approach to treatment of cognitive impairment by cardiologists and/or therapists, together with neurologists, as well as complex treatment regimens, including correction of risk factors and neuroprotective therapy, is highlighted.

Use of antihypertensive medication after ischemic stroke in young adults and its association with long-term outcome

BACKGROUND

Knowledge on the use of secondary preventive medication in young adults is limited.

METHODS

We included 936 first-ever ischemic stroke 30-day survivors aged 15-49, enrolled in the Helsinki Young Stroke Registry, 1994-2007. Follow-up data until 2012 came from Finnish Care Register, Statistics Finland, and Social Insurance Institution of Finland. Usage thresholds were defined as non-users, low (prescription coverage <30%), intermediate (30-80%) and high users (>80%). Adjusted Cox regression allowed assessing the association of usage with all-cause mortality and recurrent vascular events.

RESULTS

Of our patients, 40.5% were non-users, 7.8% had low usage, 11.8% intermediate usage and 40.0% high usage. Median follow-up was 8.3 years. Compared to non-users, risk of mortality and recurrent stroke or TIA was lower for patients with low-intermediate (HR 0.40, 95% CI 0.22-0.65; HR 0.31, 95% CI 0.18-0.53) and high usage (HR 0.25, 95% CI 0.15-0.42; HR 0.30, 95% CI 0.19-0.46), after adjustment for confounders.

CONCLUSIONS

Use of antihypertensives was suboptimal in one-third of patients in whom antihypertensives were initially prescribed. Users were at lower risk of mortality and recurrent stroke or TIA compared to non-users. Key Messages The use of antihypertensive medication is suboptimal in one-third of patients in whom antihypertensive medication was initially prescribed after ischemic stroke at young age. The risk of mortality and recurrent stroke or TIA is lower for users of antihypertensive medication after ischemic stroke at young age compared to non-users, after adjustment for relevant confounders including pre-existing hypertension and prior use of antihypertensive medication. Specific guidelines on antihypertensive medication use after ischemic stroke at young age are lacking. However, our results may motivate doctors and patients in gaining better usage of antihypertensive medication, since better usage was associated with more favorable outcome in this study.

Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality

OBJECTIVE

To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults.

METHODS

We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate.

RESULTS

Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93).

CONCLUSION

The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

Effect of Standard vs Intensive Blood Pressure Control on Cerebral Blood Flow in Small Vessel Disease: The PRESERVE Randomized Clinical Trial

Importance

Blood pressure (BP) lowering is considered neuroprotective in patients with cerebral small vessel disease; however, more intensive regimens may increase cerebral hypoperfusion. This study examined the effect of standard vs intensive BP treatment on cerebral perfusion in patients with severe small vessel disease.

Objective

To investigate whether standard vs intensive BP lowering over 3 months causes decreased cerebral perfusion in small vessel disease.

Design, Setting, and Participants

This randomized clinical trial took place at 2 English university medical centers. Patients were randomized via a central online system (in a 1:1 ratio). Seventy patients with hypertension and with magnetic resonance imaging-confirmed symptomatic lacunar infarct and confluent white matter hyperintensities were recruited between February 29, 2012, and October 21, 2015, and randomized (36 in the standard group and 34 in the intensive group). Analyzable data were available in 62 patients, 33 in the standard group and 29 in the intensive group, for intent-to-treat analysis. This experiment examines the 3-month follow-up period.

Interventions

Patients were randomized to standard (systolic, 130-140 mm Hg) or intensive (systolic, <125 mm Hg) BP targets, to be achieved through medication changes.

Main Outcomes and Measures

Cerebral perfusion was measured using arterial spin labeling; the primary end point was change in global perfusion between baseline and 3 months, compared between treatment groups by analysis of variance. Linear regression compared change in perfusion against change in BP. Magnetic resonance imaging scan analysis was masked to treatment group.

Results

Among 62 analyzable patients, the mean age was 69.3 years, and 60% (n = 37) were male. The mean (SD) systolic BP decreased by 8 (12) mm Hg in the standard group and by 27 (17) mm Hg in the intensive group (P < .001), with mean (SD) achieved pressures of 141 (13) and 126 (10) mm Hg, respectively. Change in global perfusion did not differ between treatment groups: the mean (SD) change was -0.5 (9.4) mL/min/100 g in the standard group vs 0.7 (8.6) mL/min/100 g in the intensive group (partial η2, 0.004; 95% CI, -3.551 to 5.818; P = .63). No differences were observed when the analysis examined gray or white matter only or was confined to those achieving target BP. The number of adverse events did not differ between treatment groups, with a mean (SD) of 0.21 (0.65) for the standard group and 0.32 (0.75) for the intensive group (P = .44).

Conclusions and Relevance

Intensive BP lowering did not reduce cerebral perfusion in severe small vessel disease.

Trial Registration

isrctn.org Identifier: ISRCTN37694103.

Post-stroke hypertension control and receipt of health care services among veterans

Many ischemic stroke patients do not achieve goal blood pressure (BP < 140/90 mm Hg). To identify barriers to post-stroke hypertension management, we examined healthcare utilization and BP control in the year after index ischemic stroke admission. This retrospective cohort study included patients admitted for acute ischemic stroke to a VA hospital in fiscal year 2011 and who were discharged with a BP ≥ 140/90 mm Hg. One-year post-discharge, BP trajectories, utilization of primary care, specialty and ancillary services were studied. Among 265 patients, 246 (92.8%) were seen by primary care (PC) during the 1-year post-discharge; a median time to the first PC visit was 32 days (interquartile range: 53). Among N = 245 patients with post-discharge BP data, 103 (42.0%) achieved a mean BP < 140/90 mm Hg in the year post-discharge. Provider follow-ups were: neurology (51.7%), cardiology (14.0%), nephrology (7.2%), endocrinology (3.8%), and geriatrics (2.6%) and ancillary services (BP monitor [30.6%], pharmacy [20.0%], nutrition [8.3%], and telehealth [8%]). Non-adherence to medications was documented in 21.9% of patients and was observed more commonly among patients with uncontrolled compared with controlled BP (28.7% vs 15.5%; P = .02). The recurrent stroke rate did not differ among patients with uncontrolled (4.2%) compared with controlled BP (3.8%; P = .89). Few patients achieved goal BP in the year post-stroke. Visits to primary care were not timely. Underuse of specialty as well as ancillary services and provider perception of medication non-adherence were common. Future intervention studies seeking to improve post-stroke hypertension management should address these observed gaps in care.

Telemedical strategies for the improvement of secondary prevention in patients with cerebrovascular events—A systematic review and meta-analysis

Background

Data from European countries consistently show that guideline-conform secondary prevention after stroke/transient ischemic attack is being realized in only 50–80% of patients. Use of telemedicine to support long-term secondary prevention has been effective in other cardiovascular diseases.

Aims

We reviewed current evidence for telemedical-supported strategies for the improvement of secondary prevention after stroke/transient ischemic attack. A systematic review was performed in accordance with the PRISMA statement searching MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 18 May 2016. Randomized controlled trials and observational studies were included if they analyzed the effect of a telemedical strategy for supporting secondary prevention after stroke/transient ischemic attack compared to usual care and reported primary (behavior according to guidelines, e.g., medication adherence) or surrogate outcomes (consequences of primary outcome, e.g., blood pressure).

Summary of review

The review included 13 of 100 identified studies involving 2672 patients. Telemedical support mainly comprised telephone interventions, predominantly done by nurses. Outcomes were heterogeneous: medication adherence did not differ in one randomized controlled trial (p = 0.089). Mortality was reported in one study and was significantly (p < 0.001) higher in patients non-participating in a web-based intervention. Four studies assessed blood pressure in a comparable way that allowed calculation of a meta-analysis. In that, telemedical intervention had a significant blood-pressure lowering effect compared to the control group (mean difference −6.14 (95% confidence interval −10.41, −1.87), p = 0.005).

Conclusions

Telemedical-supported secondary prevention in cerebrovascular diseases might be effective but larger trials with standardized interventions and outcome measures including clinical endpoints are needed.

Calcium-Channel Blockers and Dementia Risk in Older Adults - National Health Insurance Service - Senior Cohort (2002-2013)

BACKGROUND

Some disagreements surround the effects of calcium-channel blockers (CCBs) on the risk of dementia. The purpose of this study was to investigate the protective effects of CCBs on dementia among elderly hypertensive Koreans.

METHODS AND RESULTS

We conducted a large population-based cohort study using the senior cohort database of the Korean National Health Insurance Service (2002-2013). Subjects were elderly hypertensive Koreans older than 60 years of age. A total of 18,423 patients (CCB user group: 13,692 patients; non-CCB antihypertensive user group: 4,731 patients) were statistically analyzed using the Cox proportional hazard regression model to estimate the adjusted hazard ratio (aHR) and confidence intervals (CIs) of dementia associated with CCB use. There were 2,881 cases (21.0%) of dementia in the CCB user group and 1,124 cases (23.8%) in the non-user group. CCB use significantly reduced the risk of total dementia (aHR 0.81, 95% CI 0.75-0.87, P<0.0001), Alzheimer's dementia (aHR 0.80, 95% CI 0.72-0.88, P<0.0001), and vascular dementia (aHR 0.81, 95% CI 0.70-0.94, P=0.0067).

CONCLUSIONS

CCB use had a protective effect on the risk of dementia among elderly hypertensive Koreans. (Circ J 2016; 80: 2336-2342).

Predictors of aneurysmal rebleed before definitive surgical or endovascular management

BACKGROUND

Aneurysmal rebleed is the most dreaded complication following subarachnoid hemorrhage. Being a cause of devastating outcome, the stratification of risk factors can be used to prioritize patients, especially at high volume centers.

METHOD

A total of 99 patients with aneurysmal rebleed were analyzed in this study both prospectively and retrospectively from August 2010 to July 2014. In the control group, 100 patients were selected randomly from the patient registry. A total of 25 variables from the demographic, historical, clinical and radiological data were compared and analyzed by univariate and multivariate logistic regression analysis.

RESULTS

Significant independent predictors of aneurysm rebleed were the presence of known hypertension (p = 0.023), diastolic blood pressure of >90 mmHg on admission (p = 0.008); presence of loss of consciousness (p = 0.013) or seizures (p = 0.002) at first ictus; history of warning headaches (p = 0.005); higher Fisher grade (p < 0.001); presence of multiple aneurysms (p = 0.021); irregular aneurysm surface (0.002).

CONCLUSIONS

Identification of high risk factors can help in stratifying patients in the high risk group. The risk stratification strategy with early intervention can prevent rebleeds. This in turn may translate into better outcomes of patients with intracranial aneurysms.

Chronic Management of Hypertension after Stroke: The Role of Ambulatory Blood Pressure Monitoring

Hypertension is the most important potentially reversible risk factor for stroke in all age groups; high blood pressure (BP) is also associated with increased risk of recurrent stroke in patients who have already had an ischemic or hemorrhagic event. Twenty-four hour ambulatory BP monitoring (ABPM) has become an important tool for improving the diagnosis and management of hypertension, and is increasingly used to assess patients with hypertension. Nevertheless, although ABPM devices are increasingly used for assessment of hypertension, their value in the chronic management of hypertension in patients with stroke has not been systematically studied. In fact, among large-scale randomized trials for secondary stroke prevention, only the Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention trial included 24-hour ABPM. ABPM has demonstrated chronic disruption of the circadian rhythm of BP after acute phase of stroke and has shown higher sensitivity compared to office BP in evaluating the effectiveness of antihypertensive treatment among stroke survivors. High 24-hour BP is an independent predictor for cerebrovascular events, brain microbleeds, and subsequent development of dementia. Nevertheless, although stroke care guidelines endorse the importance of hypertension management, the specific role of ABPM among stroke survivors after the acute phase of disease has not been established. Further studies are needed to clarify whether routine application of ABPM among these patients should be recommended.

Post-exercise hypotensive responses following an acute bout of aquatic and overground treadmill walking in people post-stroke: a pilot study

BACKGROUND

The purpose of this study is to investigate the effects of a single-bout of aquatic treadmill walking (ATW) and overground treadmill walking (OTW) on the magnitude and duration of post-exercise ambulatory blood pressure (BP) in people post-stroke.

METHODS

Seven people post-stroke participated in a cross-sectional comparative study. BP was monitored for up to 9 hours after a 15-minute bout of ATW and OTW at approximately 70% of maximal oxygen consumption (VO2max), performed on separate days. Mean systolic and diastolic BP values were compared between both exercise conditions and a day without exercise (control).

RESULTS

Three hours after OTW, mean SBP increased by 9% from pre-exercise baseline compared to a 3% decrease during the control day (P < 0.05). A similar trend was observed after the third hour of ATW (P = 0.06). However, ATW demonstrated a 3% overall decline in DBP after exercise compared to a 1% DBP increase of the control day (P < 0.05). Additionally, ATW showed a 6% reduction in mean systolic BP at the ninth hour post-exercise (P < 0.05) compared to baseline.

CONCLUSION

Our results indicate people post-stroke can sustain sufficient walking intensities necessary to reduce BP following cardiovascular exercise. Also, these data suggest that ATW can elicit clinically meaningful reductions in DBP and night-time SBP. Thus, it is recommended for clinicians to consider ATW as a non-pharmaceutical means to regulate DBP and promote nighttime dipping of SBP in people post-stroke. However, caution is advised during the immediate hours after exercise, a period of possible BP inflation.

Degree of blood pressure reduction and recurrent stroke: the PROGRESS trial

OBJECTIVE

There is ongoing controversy regarding a 'J-curve' phenomenon such that low and high blood pressure (BP) levels are associated with increased risks of recurrent stroke. We aimed to determine whether large treatment-related BP reductions are associated with increased risks of recurrent stroke.

DESIGN

Data are from the PROGRESS trial, where 6105 patients with cerebrovascular disease were randomly assigned to either active treatment (perindopril ± indapamide) or placebo(s). There were no BP criteria for entry. BP was measured at every visit, and participant groups defined by reduction in systolic BP (SBP) from baseline were used for the analyses. Outcome was recurrent stroke.

RESULTS

During a mean follow-up of 3.9 years, 727 recurrent strokes were observed. There were clear associations between the magnitude of SBP reduction and the risk of recurrent stroke. After adjustment for cardiovascular risk factors and randomised treatment, annual incidence was 2.08%, 2.10%, 2.31% and 2.96% for participant groups defined by SBP reductions of ≥ 20, 10-19, 0-9 and <0 mm Hg, respectively (p=0.0006 for trend).

CONCLUSIONS

The present analysis provided no evidence of an increase in recurrent stroke associated with larger reductions in SBP produced by treatment among patients with cerebrovascular disease.

Glycated hemoglobin independently predicts stroke recurrence within one year after acute first-ever non-cardioembolic strokes onset in A Chinese cohort study

Objective

Hyperglycemia is related to stroke. Glycated hemoglobin (HbA1c) can reflect pre-stroke glycaemia status. However, the information on the direct association between HbA1c and recurrence after non-cardioembolic acute ischemic strokes is rare and there is no consistent conclusion.

Methods

The ACROSS-China database comprised of 2186 consecutive first-ever acute ischemic stroke patients with baseline HbA1c values. After excluding patients who died from non-stroke recurrence and patients lost to follow up, 1817 and 1540 were eligible for 3-month and 1-year analyses, respectively. Multivariate Cox regression was performed to evaluate the associations between HbA1c and 3-month and 1-year stroke recurrence.

Results

The HbA1c values at admission were divided into 4 levels by quartiles: Q1 (<5.5%); Q2 (5.5 to <6.1%); Q3 (6.1% to <7.2%); and Q4 (≥7.2%). The cumulative recurrence rates were 8.3% and 11.0% for 3 months and 1 year, respectively. In multivariate analyses, when compared with Q1, the adjusted hazard ratios (AHRs) were 2.83 (95% confidence interval (CI) 1.28-6.26) in Q3 and 3.71(95% CI 1.68-8.21) in Q4 for 3-month stroke recurrence; 3.30 (95% CI 1.31-8.34) in Q3 and 3.35 (95% CI 1.36-8.21) in Q4 for 1-year stroke recurrence. Adding fasting plasma glucose in the multivariate analyses did not modify the association: AHRs were 2.75 (95% CI 1.24-6.11) in Q3 and 3.67 (95% CI 1.59-8.53) in Q4 for 3-month analysis; AHRs were 3.08 (95% CI 1.10-8.64) in Q3 and 3.31(95% CI 1.35-8.14) in Q4 for 1-year analysis.

Conclusions

A higher “normal” HbA1c level reflecting pre-stroke glycaemia status independently predicts stroke recurrence within one year after non-cardioembolic acute ischemic stroke onset. HbA1c is recommended as a routine test in acute ischemic stroke patients.

Trends in vascular risk factor treatment and control in US stroke survivors: the National Health and Nutrition Examination Surveys (1999-2010)

BACKGROUND

Treatment and control of vascular risk factors reduce the likelihood of recurrent stroke. Present nationally representative data are sparse regarding secondary prevention treatment and control rates.

METHODS AND RESULTS

We evaluated sex- and race-stratified blood pressure, cholesterol, and hemoglobin A1c levels and treatment and control rates in 1154 self-reported stroke survivors from the National Health and Nutrition Examination Surveys 1999 to 2010. We used weighted linear regression to estimate time trends. Participants were 54% to 61% women, 70% to 76% white, and had a mean age of 63 to 66 years. For blood pressure, treatment rates remained unchanged in men, but in women, treatment rates increased from 41% in 1999 to 2000 to 65% in 2009 to 2010 (P=0.03), and control rates increased from 23% to 79% (P=0.03). Treatment rates remained unchanged in non-Hispanic whites, non-Hispanic blacks, and Mexican Americans, although control rates increased in non-Hispanic whites from 50% in 1999 to 2002 to 69% in 2007 to 2010 (P=0.04). For cholesterol, treatment rates increased from 30% to 40% in men (P=0.02) and from 28% to 36% (P<0.01) in women, but control rates increased only in men, from 62% to 87% (P<0.01). Cholesterol treatment rates increased only in non-Hispanic blacks, from 18% to 37% (P=0.02). By sex and race, there was no change in dysglycemia treatment and control.

CONCLUSIONS

Despite improvements in blood pressure treatment and control and cholesterol treatment for women and cholesterol treatment and control for men, stroke secondary prevention through treatment and control of vascular risk factors remains suboptimal. Urgent action is needed to improve secondary prevention to reduce stroke morbidity and mortality in this high-risk group.

Angiotensin II AT(1) receptor blockers as treatments for inflammatory brain disorders

The effects of brain AngII (angiotensin II) depend on AT(1) receptor (AngII type 1 receptor) stimulation and include regulation of cerebrovascular flow, autonomic and hormonal systems, stress, innate immune response and behaviour. Excessive brain AT(1) receptor activity associates with hypertension and heart failure, brain ischaemia, abnormal stress responses, blood-brain barrier breakdown and inflammation. These are risk factors leading to neuronal injury, the incidence and progression of neurodegerative, mood and traumatic brain disorders, and cognitive decline. In rodents, ARBs (AT(1) receptor blockers) ameliorate stress-induced disorders, anxiety and depression, protect cerebral blood flow during stroke, decrease brain inflammation and amyloid-β neurotoxicity and reduce traumatic brain injury. Direct anti-inflammatory protective effects, demonstrated in cultured microglia, cerebrovascular endothelial cells, neurons and human circulating monocytes, may result not only in AT(1) receptor blockade, but also from PPARγ (peroxisome-proliferator-activated receptor γ) stimulation. Controlled clinical studies indicate that ARBs protect cognition after stroke and during aging, and cohort analyses reveal that these compounds significantly reduce the incidence and progression of Alzheimer's disease. ARBs are commonly used for the therapy of hypertension, diabetes and stroke, but have not been studied in the context of neurodegenerative, mood or traumatic brain disorders, conditions lacking effective therapy. These compounds are well-tolerated pleiotropic neuroprotective agents with additional beneficial cardiovascular and metabolic profiles, and their use in central nervous system disorders offers a novel therapeutic approach of immediate translational value. ARBs should be tested for the prevention and therapy of neurodegenerative disorders, in particular Alzheimer's disease, affective disorders, such as co-morbid cardiovascular disease and depression, and traumatic brain injury.