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Zhang S, Zhou Y, Wang J, Fu Q, Shen T, Pan G, Luo R, Yang X, Jiang L, Hu H. The Association of High Lipoprotein(a) Concentration and Risk of Ischaemic Stroke in Atrial Fibrillation Patients. Int J Gen Med 2024; 17:2001-2009. [PMID: 38736672 PMCID: PMC11088835 DOI: 10.2147/ijgm.s449400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/10/2024] [Indexed: 05/14/2024] Open
Abstract
Background Lipoprotein(a) [Lp(a)] is a well-established risk factor for ischaemic stroke (IS). It is unclear whether Lp(a) is associated with IS in patients with atrial fibrillation (AF). The aim of this study is to explore the association between the concentration of Lp(a) and the risk of IS in AF patients, hope to find the potential risk factor for the IS in AF patients. Methods This study is a retrospective cohort study. The screened AF patients between January 2017 and July 2021 were matched at 1:1 by the propensity score matching (PSM) method in the Second Affiliated Hospital of Nanchang University. Associations between Lp(a) and ischaemic stroke were analysed using logistic regression models, stratified analysis and sensitivity analysis. Statistical analyses were conducted using IBM SPSS software. Results The number of enrolled participates is 2258, which contains 1129 non-AF patients and 1129 AF patients. Among IS patients, the median Lp(a) concentration was higher than that of controls (17.03 vs. 15.36 mg/dL, P = 0.032). The Spearman rank-order correlation coefficients revealed significant positive relationships between IS and Lp(a) (P = 0.032). In addition, a significant increase in IS risk was associated with Lp(a) levels >30.00 mg/dL in unadjusted model [OR:1.263, 95% CI(1.046-1.523), P = 0.015], model 1 [OR:1.284, 95% CI(1.062,1.552), P = 0.010], model 2 [OR: 1.297, 95% CI(1.07,1.573). P = 0.008], and model 3 [OR: 1.290, 95% CI (1.064, 1.562). P = 0.009]. The stratified analysis indicated that this correlation was not affected by female sex [1.484 (1.117, 1.972), P = 0.006], age ≤ 60 [1.864 (1.067-3.254), P=0.029], hypertension [1.359 (1.074, 1.721), P = 0.011], or non-coronary heart disease (CHD) [1.388 (1.108, 1.738), P = 0.004]. Conclusion High levels of Lp(a) were significantly related to IS in AF patients and may be a potential risk factor in the onset of an IS in AF patients.
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Affiliation(s)
- Siyi Zhang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
- Department of Clinical Medicine, Queen Mary School of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Yue Zhou
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Jinghui Wang
- Department of Clinical Medicine, Queen Mary School of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Qingan Fu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Tianzhou Shen
- Department of Clinical Medicine, Queen Mary School of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Guanrui Pan
- Department of Clinical Medicine, Queen Mary School of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Renfei Luo
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Xinlei Yang
- Department of Biobank Center, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Long Jiang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
| | - Hui Hu
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People’s Republic of China
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Liljehult J, Molsted S, Møller T, Overgaard D, Christensen T. Lifestyle counselling as secondary prevention in patients with minor stroke or transient ischemic attack: a randomized controlled pilot study. Pilot Feasibility Stud 2024; 10:50. [PMID: 38519983 PMCID: PMC10958836 DOI: 10.1186/s40814-024-01478-4] [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: 08/17/2023] [Accepted: 03/12/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Patients with minor stroke or transient ischemic attacks have an increased risk of future strokes. These patients are often discharged home with limited specialized follow-up, although close to half of them experience cognitive deficits. Simple encouragements to avoid smoking, be physically active, and to take preventive medication are often insufficient to ensure adherence and more comprehensive interventions are needed to support the patients in adapting healthy behaviour. The aim of this study was to test the feasibility and potential effect of an early initiated, patient-centred intervention to patients with minor stroke or transient ischemic attacks targeting smoking, physical activity, and medication adherence, in a randomized, controlled pilot trial. METHODS Hospitalized patients were randomized to usual care or an intervention consisting of health behavioural counselling based on the 5A's model, telephone follow-up (4 and 8 weeks), and monitoring of physical activity. Follow-up time was 12 weeks. Feasibility was on the following domains: eligibility, acceptance, demand and practicality, adherence, attrition, and implementation and integration. RESULTS Forty patients of 84 potentially eligible were randomized to the two treatment arms (20 intervention/20 usual care). Thirty-two completed the 12-week follow-up, while 8 were either excluded or lost to follow-up. With few changes, the intervention was feasible and possible to deliver according to the protocol. CONCLUSION It was possible to identify relevant patients who could potentially benefit from a behavioural intervention, recruit and randomize them early after admission and retain most participants in the study until follow-up and derive statistical estimates to guide the design of large-scale randomized controlled trials. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03648957 . Registered 28 August 2018.
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Affiliation(s)
- Jacob Liljehult
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, Hillerød, 3400, Denmark.
- Department 9701, The University Hospitals Centre for Health Research (UCSF), Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark.
- Faculty of Health and Technology, Department of Nursing and Nutrition, Copenhagen University College, Tagensvej 86, Copenhagen N, 2200, Denmark.
| | - Stig Molsted
- Department of Clinical Research, Nordsjællands Hospital, Dyrehavevej 29, Hillerød, 3400, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3, Copenhagen N, 2200, Denmark
| | - Tom Møller
- Department 9701, The University Hospitals Centre for Health Research (UCSF), Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, Copenhagen, 2100, Denmark
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Copenhagen K, 1353, Denmark
| | - Dorthe Overgaard
- Faculty of Health and Technology, Department of Nursing and Nutrition, Copenhagen University College, Tagensvej 86, Copenhagen N, 2200, Denmark
| | - Thomas Christensen
- Department of Neurology, Nordsjællands Hospital, Dyrehavevej 29, Hillerød, 3400, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3, Copenhagen N, 2200, Denmark
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3
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Salmasi S, Safari A, De Vera MA, Högg T, Lynd LD, Koehoorn M, Barry AR, Andrade JG, Deyell MW, Rush KL, Zhao Y, Loewen P. Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study. J Thromb Thrombolysis 2024; 57:437-444. [PMID: 38103148 PMCID: PMC10961264 DOI: 10.1007/s11239-023-02921-8] [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] [Accepted: 11/01/2023] [Indexed: 12/17/2023]
Abstract
Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.
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Affiliation(s)
- Shahrzad Salmasi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Abdollah Safari
- Department of Mathematics, Statistics, and Computer Science, University of Tehran, Tehran, Iran
- Department of Data Analytics, Statistics and Informatics, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Tanja Högg
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mieke Koehoorn
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jason G Andrade
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada
| | - Marc W Deyell
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kathy L Rush
- School of Nursing, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Yinshan Zhao
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada.
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Ansari U, Brachmann J, Lewalter T, Zeymer U, Sievert H, Ledwoch J, Geist V, Hochadel M, Schneider S, Senges J, Akin I, Fastner C. LAA occlusion is effective and safe in very high-risk atrial fibrillation patients with prior stroke: results from the multicentre German LAARGE registry. Clin Res Cardiol 2024:10.1007/s00392-024-02376-8. [PMID: 38294498 DOI: 10.1007/s00392-024-02376-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Interventional left atrial appendage occlusion (LAAO) mitigates the risk of thromboembolic events in nonvalvular atrial fibrillation (AF) patients with contraindication for long-term oral anticoagulation (OAC). Patients with prior stroke have a relevantly increased risk of recurrent stroke, so the effectiveness of LAAO could be reduced in this specific very high-risk patient group. AIM This sub-study of the LAARGE registry investigates the effectiveness and safety of LAAO for secondary prevention in nonvalvular AF patients with a history of stroke. METHODS LAARGE is a prospective, non-randomised registry on the clinical reality of LAAO. The current sub-study employs data from index procedure and 1-year follow-up. Effectiveness and safety were assessed by documentation of all-cause mortality, non-fatal thromboembolism, procedure-related complications, and bleeding events. RESULTS A total of 638 patients were consecutively included from 38 hospitals in Germany and divided into two groups: 137 patients with a history of stroke (21.5%) and 501 patients without. Successful implantation was consistent between both groups (98.5% vs. 97.4%, p = NS), while peri-procedural MACCE and other complications were rare (0% vs. 0.6% and 4.4% vs. 4.0%, respectively; each p = NS). Kaplan-Meier estimate showed no significant difference in primary effectiveness outcome measure (freedom from all-cause death or non-fatal stroke) between both groups at follow-up (87.8% vs. 87.7%, p = NS). The incidence of transient ischemic attack or systemic embolism at follow-up was low (0% vs. 0.5% and 0.9% vs. 0%, respectively; each p = NS). Severe bleeding events after hospital discharge were rare (0% vs. 0.7%, p = NS). CONCLUSIONS Patients with prior stroke demonstrated similar effectiveness and safety profile for LAAO as compared to patients without prior stroke. LAAO could serve as a feasible alternative to OAC for secondary stroke prevention in this selected group of nonvalvular AF patients. CLINICALTRIALS GOV IDENTIFIER NCT02230748.
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Affiliation(s)
- Uzair Ansari
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Johannes Brachmann
- Department of Cardiology, Angiology, and Pneumology, Second Medical Clinic, Coburg Hospital, Coburg, Germany
- University of Split School of Medicine, Split, Croatia
| | - Thorsten Lewalter
- Department of Medicine, Cardiology, and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Uwe Zeymer
- Medizinische Klinik B, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt am Main, Germany
| | - Jakob Ledwoch
- Isar Herz Zentrum München, ISAR Klinikum, Munich, Germany
- Klinik für Kardiologie, Pneumologie und Internistische Intensivmedizin, München Klinik Neuperlach, Munich, Germany
| | - Volker Geist
- Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim (UMM), Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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5
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Kim KS, Hong S, Han K, Park CY. Clinical Characteristics of Patients With Statin Discontinuation in Korea: A Nationwide Population-Based Study. J Lipid Atheroscler 2024; 13:41-52. [PMID: 38299165 PMCID: PMC10825567 DOI: 10.12997/jla.2024.13.1.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 10/05/2023] [Accepted: 11/06/2023] [Indexed: 02/02/2024] Open
Abstract
Objective To investigate the clinical characteristics of patients with statin discontinuation in Korea, using a nationwide database. Methods We analyzed 1,308,390 patients treated with statin for the first time in their life between 2016 and 2017 using the Korean National Health Information Database. The patients participated in the Korean National Health Screening Program within two years before taking statin. Patients with statin discontinuation were defined as those who were not prescribed statin between 365 days and 730 days after the initial statin prescription. Results The overall prevalence of statin discontinuation was 39.44%. Patients with statin discontinuation were younger, had lower body mass index (BMI), included a higher number of smokers and drinkers, did not exercise regularly, with fewer cases of hypertension and diabetes mellitus than those without statin discontinuation (p<0.001). Compared with patients aged 20-29 years, the risk of statin discontinuation showed a U-shaped relationship with age (odds ratios [ORs]: 0.619 in 30-39 years; 0.454 in 40-49 years; 0.345 in 50-59 years; 0.307 in 60-69 years; 0.324 in 70-79 years; and 0.415 in ≥80 years). In addition, increased BMI was associated with decreased risk of statin discontinuation (ORs: 0.969 with 25.0-29.9 kg/m2, and 0.890 with ≥30.0 kg/m2). Patients with hypertension and diabetes mellitus were at a lower risk of statin discontinuation (OR: 0.414 for hypertension; 0.416 for diabetes mellitus). Conclusion The prevalence of patients with statin discontinuation in Korea was 39.44% at 1 to 2 years after initial statin treatment.
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Affiliation(s)
- Kyung-Soo Kim
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sangmo Hong
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Cheol-Young Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Gunkel S, Schötzau A, Fluri F. Burden of cerebral small vessel disease and changes of diastolic blood pressure affect clinical outcome after acute ischemic stroke. Sci Rep 2023; 13:22070. [PMID: 38086878 PMCID: PMC10716411 DOI: 10.1038/s41598-023-49502-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 12/08/2023] [Indexed: 12/18/2023] Open
Abstract
Elevated and low blood pressure (BP) may lead to poor functional outcome after ischemic stroke, which is conflicting. Hence, there must be another factor-such as cerebral small vessel disease (cSVD) -interacting with BP and thus, affecting outcome. Here, we investigate the relationship between BP and cSVD regarding outcome after stroke. Data of 423/503 stroke patients were prospectively analyzed. Diastolic (DBP) and systolic BP (SBP) were collected on hospital admission (BPad) and over the first 72 h (BP72h). cSVD-burden was determined on MR-scans. Good functional outcome was defined as a modified Rankin Scale score ≤ 2 at hospital discharge and 12 months thereafter. cSVD was a predictor of poor outcome (OR 2.8; p < 0.001). SBPad, DBPad and SBP72h were not significantly associated with outcome at any time. A significant relationship was found between DBP72h, (p < 0.01), cSVD (p = 0.013) and outcome at discharge. At 12 months, we found a relationship between outcome and DBP72h (p = 0.018) and a statistical tendency regarding cSVD (p = 0.08). Changes in DBP72h were significantly related with outcome. There was a U-shaped relationship between DBP72h and outcome at discharge. Our results suggest an individualized stroke care by either lowering or elevating DBP depending on cSVD-burden in order to influence functional outcome.
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Affiliation(s)
- Sarah Gunkel
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080, Würzburg, Germany
| | - Andreas Schötzau
- Eudox Statistics, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Felix Fluri
- Department of Neurology, University Hospital Würzburg, Josef-Schneider Strasse 11, 97080, Würzburg, Germany.
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Thalmann I, Preiss D, Schlackow I, Gray A, Mihaylova B. Quality of care for secondary cardiovascular disease prevention in 2009-2017: population-wide cohort study of antiplatelet therapy use in Scotland. BMJ Qual Saf 2023:bmjqs-2023-016520. [PMID: 37775268 DOI: 10.1136/bmjqs-2023-016520] [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: 07/11/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Antiplatelet therapy (APT) can substantially reduce the risk of further vascular events in individuals with established atherosclerotic cardiovascular disease (ASCVD). However, knowledge regarding the extent and determinants of APT use is limited. OBJECTIVES Estimate the extent and identify patient groups at risk of suboptimal APT use at different stages of the treatment pathway. METHODS Retrospective cohort study using linked NHS Scotland administrative data of all adults hospitalised for an acute ASCVD event (n=150 728) from 2009 to 2017. Proportions of patients initiating, adhering to, discontinuing and re-initiating APT were calculated overall and separately for myocardial infarction (MI), ischaemic stroke and peripheral arterial disease (PAD). Multivariable logistic regression and Cox proportional hazards models were used to assess the contribution of patient characteristics in initiating and discontinuing APT. RESULTS Of patients hospitalised with ASCVD, 84% initiated APT: 94% following an MI, 83% following an ischaemic stroke and 68% following a PAD event. Characteristics associated with lower odds of initiation included female sex (22% less likely than men), age below 50 years or above 70 years (aged <50 years 26% less likely, and aged 70-79, 80-89 and ≥90 years 21%, 39% and 51% less likely, respectively, than those aged 60-69 years) and history of mental health-related hospitalisation (45% less likely). Of all APT-treated individuals, 22% discontinued treatment. Characteristics associated with discontinuation were similar to those related to non-initiation. CONCLUSIONS APT use remains suboptimal for the secondary prevention of ASCVD, particularly among women and older patients, and following ischaemic stroke and PAD hospitalisations.
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Affiliation(s)
- Inna Thalmann
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Camm AJ. Leap or lag: left atrial appendage closure and guidelines. Europace 2023; 25:euad067. [PMID: 37012659 PMCID: PMC10227666 DOI: 10.1093/europace/euad067] [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: 01/19/2023] [Accepted: 02/28/2023] [Indexed: 04/05/2023] Open
Abstract
Atrial fibrillation (AF) is associated with life-threatening thromboembolism. Most emboli stem from thrombosis in the left atrial appendage (LAA). The current treatment of choice is oral anticoagulants (OACs), but a small proportion of patients cannot take OACs predominantly because of the so-called unacceptable bleeding risks. However, many who initially accept OACs subsequently stop therapy or reduce the OAC treatment to a potentially non-effective dose leaving them exposed to thromboembolic risk. A relatively simple alternative therapy involves the catheter-based insertion of a LAA closure (LAAC) device to prevent thromboembolism from the LAA. There is a considerable evidence base for this therapy consisting of clinical trials and observational data which suggests comparable therapeutic efficacy with a possible small excess of ischaemic strokes. Although LAAC has been very closely examined by regulators and approved for market release, guidelines from most professional societies give only weak recommendations for use of this device which may be the only known effective therapy available to some at-risk AF patients. Guidance materials from the same societies more enthusiastically endorse LAAC. Clinical practice is running well ahead of the guidelines because equipoise has been lost by physicians faced with patients for whom they have no other effective therapy. Guideline writers are correct in providing recommendations which are less strong for LAAC than for OACs, for those who are able and willing to take OAC treatment, but for those who are not, a stronger recommendation is needed. But, should the guidelines lag behind or leap ahead of the available evidence?
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Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace, London SW17 0RE, UK
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10
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Oikarinen A, Engblom J, Paukkonen L, Kääriäinen M, Kaakinen P, Kähkönen O. Effects of a lifestyle counselling intervention on adherence to lifestyle changes 7 years after stroke - A quasi-experimental study. Scand J Caring Sci 2023; 37:163-172. [PMID: 35766254 DOI: 10.1111/scs.13101] [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: 12/10/2021] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Adherence to medication and healthy lifestyle is crucial for preventing secondary strokes and other vascular events. However, there is not enough evidence on the long-term effects of hospital-initiated lifestyle counselling. AIM To determine the effects of The Risk Factor Targeted Lifestyle Counselling Intervention, which is implemented during acute hospitalisation, on adherence to lifestyle changes 7 years after stroke or TIA. METHODS Quasi-experimental design with 7-year follow-up period. Baseline data (n = 150) were gathered from a neurology unit in Finland between 2010 and 2011. Patients received either the studied intervention (n = 75) or the prevailing form of counselling at the time (n = 75). Data concerning lifestyle and clinical values were measured at the baseline time point, while adherence to lifestyle changes was assessed 7 years later (2017-2018). Analysis of covariance and multivariate ordinal logistic regression were used to describe the mean differences between the intervention and control groups. RESULTS Several between-group differences were detected, namely, members of the intervention group reported consuming less alcohol and having lost more weight during hospitalisation relative to the control group. No between-group differences in the prevalence of smokers were found, but the intervention group reported a greater number of daily cigarettes than the control group. Adherence to medication, importance of adherence to a healthy lifestyle, support from family and friends, and support from nurses were all significantly higher in the intervention group than in the control group. CONCLUSIONS The results suggest that the lifestyle counselling intervention was effective in decreasing alcohol use and weight, as well as increasing factors that are known to support adherence to a healthy lifestyle. RELEVANCE TO CLINICAL PRACTICE The results indicate that the adherence process already begins during acute phase counselling. To ensure long-lasting lifestyle changes, counselling should be started at the hospital, after which it can be provided by friends and family members.
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Affiliation(s)
- Anne Oikarinen
- Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Janne Engblom
- Quantitative Methods in Management, Turku School of Economics University of Turku, Turku, Finland
| | - Leila Paukkonen
- Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland.,Northern Ostrobothnia Hospital District, Oulu, Finland
| | - Maria Kääriäinen
- Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland.,Northern Ostrobothnia Hospital District, Oulu, Finland
| | - Pirjo Kaakinen
- Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland
| | - Outi Kähkönen
- Research Unit of Nursing Science and Health Management, Faculty of Medicine, University of Oulu, Oulu, Finland
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11
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Thalmann I, Preiss D, Schlackow I, Gray A, Mihaylova B. Population-wide cohort study of statin use for the secondary cardiovascular disease prevention in Scotland in 2009-2017. Heart 2023; 109:388-395. [PMID: 36192149 PMCID: PMC9985707 DOI: 10.1136/heartjnl-2022-321452] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/09/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the extent of suboptimal statin use for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD) at different stages of the treatment pathway and identify patient groups at risk of suboptimal treatment. METHODS National retrospective cohort study using linked National Health Service Scotland administrative data of adults hospitalised for an ASCVD event (n=167 978) from 2009 to 2017. Proportions of patients initiating, adhering to, discontinuing and reinitiating statins were calculated. We separately examined treatment following myocardial infarction (MI), ischaemic stroke and peripheral arterial disease (PAD) hospitalisations. Multivariable logistic regression and Cox proportional hazards models were used to assess the roles of patient characteristics in the likelihood of initiating and discontinuing statins. RESULTS Of patients hospitalised with ASCVD, only 81% initiated statin therapy, 40% of whom used high-intensity statin. Characteristics associated with lower odds of initiation included female sex (28% less likely than men), age below 50 years or above 70 years (<50 year-olds 26% less likely, and 70-79, 80-89 and ≥90 year-olds 22%, 49% and 77% less likely, respectively, than 60-69 year-olds), living in the most deprived areas and history of mental health-related hospital admission. Following MI, 88% of patients initiated therapy compared with 81% following ischaemic stroke and 75% following PAD events. Of statin-treated individuals, 24% discontinued treatment. Characteristics associated with discontinuation were similar to those related to non-initiation. CONCLUSIONS Statin use remains suboptimal for the secondary ASCVD prevention, particularly in women and older patients, and following ischaemic stroke and PAD hospitalisations. Improving this would offer substantial benefits to population health at low cost.
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Affiliation(s)
- Inna Thalmann
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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12
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The Use of Teach Back at Hospital Discharge to Support Self-Management of Prescribed Medication for Secondary Prevention after Stroke-Findings from A Feasibility Study. Healthcare (Basel) 2023; 11:healthcare11030391. [PMID: 36766966 PMCID: PMC9914903 DOI: 10.3390/healthcare11030391] [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: 12/11/2022] [Revised: 01/09/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023] Open
Abstract
The study aimed to investigate whether a structured discharge letter and the use of the person-centred communication method Teach Back for sharing information at hospital discharge could support perceived understanding and knowledge of and adherence to prescribed medication for secondary prevention after stroke. Data from a feasibility study of a codesigned care transition support for people with stroke was used. Patients who at discharge received both a structured discharge letter and participated in the person-centred communication method Teach Back (n = 17) were compared with patients receiving standard discharge procedures (n = 21). Questionnaires were used to compare the groups regarding perceived understanding of information about medical treatment, knowledge of information about medical treatment and medication adherence at 1 week and 3 months. There was a statistically significant difference in perceived understanding of information about medical treatment (p > 0.01) between the groups in favour of those who participated in Teach Back at the discharge encounter. No differences between groups were found regarding understanding health information about medical treatment and medication adherence. The results indicate that the use of Teach Back at the discharge encounter positively impacts perceived understanding of information about medical treatment in people with stroke. However, considering the nonrandomised study design and the small sample size, a large-scale trial is needed.
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Eriksson M, Grundberg A, Inge E, von Euler M. Stroke Recurrence Following 28 Days After First Stroke in Men and Women 2012 to 2020: Observations From the Swedish Stroke Register. J Am Heart Assoc 2023; 12:e028222. [PMID: 36688356 PMCID: PMC9973638 DOI: 10.1161/jaha.122.028222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background Stroke incidence, care, and survival show continuous improvements in Sweden, including no or decreasing disparities between men and women. In this study, we aimed to estimate and compare the risk of stroke recurrence in men and women over time, accounting for the competing risk of death. Methods and Results We included adult patients with first-time stroke (ischemic or intracerebral hemorrhage) registered in Riksstroke (the Swedish Stroke Register), 2012 to 2020, and followed until December 2020. Stroke recurrences included new events registered in Riksstroke from 28 days after stroke. To account for the competing risk of death, we used the cumulative incidence function to estimate crude incidences, and multivariable Cox regression to estimate cause-specific hazard ratios (HRs) adjusting for differences in patients' risk factor profiles. The study included 72 148 (53.5%) men and 62 689 (46.5%) women. We observed 10 925 stroke recurrences and 81 811 deaths following the initial 28 days after the first stroke. The cumulative incidence of stroke recurrence was 3.7% (95% CI, 3.6-3.8) after 1 year, 7.0 (95% CI, 6.8-7.1) after 3 years, and 9.1% (95% CI, 8.9-9.3) after 5 years. The incidence decreased substantially during the study period (HR, 2019-2020 versus 2012, 0.824 [95% CI, 0.759-0.894]). Overall, men had a lower risk of stroke recurrence. After adjustments for differences in patient characteristics, men had a slightly higher risk of recurrence (of any type) after an ischemic stroke (HR, 1.090 [95% CI, 1.045-1.138]) and a lower risk after hemorrhagic stroke (HR, 0.880 [95% CI, 0.781-0.991]) compared with women. Conclusions The risk of stroke recurrence has decreased in both men and women. Women's higher age and other differences in risk factors partly explain their higher risk of stroke recurrence compared with men.
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Affiliation(s)
| | | | - Erik Inge
- Department of Statistics, USBEUmeå UniversityUmeåSweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, Faculty of Medicine and HealthÖrebro UniversityÖrebroSweden
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14
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Yoo SH, Kim GG, Kim SR, Park MS, Kim JT, Choi KH, Park HY, Yi SH, Cha JK, Kim DH, Nah HW. Predictors of long-term medication adherence in stroke survivors: A multicentre, prospective, longitudinal study. J Clin Nurs 2023; 32:58-70. [PMID: 35922959 DOI: 10.1111/jocn.16472] [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: 02/23/2022] [Revised: 06/04/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although the optimal use of prescribed medications for stroke survivors is critical for preventing secondary stroke, longitudinal observations of the natural course of medication persistence and adherence in Korean stroke survivors are rare. Furthermore, studies are needed to identify strong predictors influencing medication adherence and to determine whether these predictors change over time. AIMS AND OBJECTIVES To evaluate the longitudinal medication persistence and adherence at 3 months and 1 year after discharge in all stroke patients and to identify predictors of long-term medication adherence in patients who can self-medicate. DESIGN A multicentre, prospective, longitudinal descriptive study. METHODS A total of 600 consecutive ischaemic stroke patients were recruited from three stroke centres across Korea, from 1 September, 2017 to 28 February, 2019. Various factors related to medication adherence suggested by the World Health Organisation were investigated through face-to-face interviews at each centre during hospitalisation. Medication persistence and adherence were assessed at 3 months and 1 year after discharge using the eight-item Morisky Medication Adherence Scale through telephone interviews. RESULTS Of 537 survivors at 3 months, 526 (98.0%) were persistent and 472 (89.7%) were adherent. Of 493 survivors at 1 year, 477 (96.8%) were persistent and 392 (82.2%) were adherent. Medication belief, income and health literacy were statistically significant predictors of three-month medication adherence, which predicted one-year medication adherence with older age and low income. CONCLUSIONS Among Korean stroke survivors, three-month and one-year medication persistence and adherence were relatively good. Medication beliefs and three-month medication adherence were important and modifiable factors predicting three-month adherence and one-year adherence, respectively. RELEVANCE TO CLINICAL PRACTICE To increase long-term adherence to medication, various strategies are needed to improve beliefs about medication, taking into account the patient's age and level of knowledge. These interventions need to be initiated during hospitalisation to form early medication habits after discharge.
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Affiliation(s)
- Sung-Hee Yoo
- College of Nursing, Chonnam National University, Gwangju, Korea
| | - Gye-Gyoung Kim
- College of Nursing, Chonnam National University, Gwangju, Korea
| | | | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital Medical School, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital Medical School, Gwangju, Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital Medical School, Gwangju, Korea
| | - Hyun-Young Park
- Department of Neurology, Wonkwang University Hospital, Iksan, Korea
| | - Sang-Hak Yi
- Department of Neurology, Wonkwang University Hospital, Iksan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, Korea
| | - Hyun-Wook Nah
- Department of Neurology, Chungnam National University Sejong Hospital, Sejong, Korea
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15
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Tobore TO. On stimulus persistence and human behavior: the stimulus persistence unification theory. Commun Integr Biol 2022; 15:240-252. [DOI: 10.1080/19420889.2022.2141954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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16
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Wolf M, Hasselström JK, Carlsson A, Euler MV, Hasselström J. Identifying factors explaining practice variation in secondary stroke prevention in primary care: a cohort study based on all patients with ischaemic stroke in the Stockholm region. BMJ Open 2022; 12:e064277. [PMID: 36410815 PMCID: PMC9680155 DOI: 10.1136/bmjopen-2022-064277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the practice variation in dispensation of secondary stroke preventive drugs among patients at different primary care centres (PCCs) in Stockholm region and to identify factors that may explain the variation. DESIGN Cohort study using administrative data from the Stockholm region. SETTING Stockholm Health Care Region, Sweden, serving a population of 2.3 million inhabitants, hospital and PCC data. PARTICIPANTS All patients (n=9761) with ischaemic stroke treated in hospital from 1 July 2009 to 30 June 2014 were included. Of these, 7562 patients registered with 187 PCCs were analysed. Exclusion criteria were; deceased patients, age <18, haemorrhagic stroke and/or switching PCC. PRIMARY AND SECONDARY OUTCOME MEASURES As primary outcome the impact of PCC organisation variables and patient characteristics on the dispensation of statins, antiplatelets, antihypertensives and anticoagulants were analysed. Secondarily, the unadjusted practice variation of preventive drug dispensation of 187 PCCs is described. RESULTS There was up to fourfold practice variation in dispensation of all secondary preventive drugs. Factors associated with a lower level of dispensed statins were privately run PCCs (OR 0.91 (95% CI 0.82 to 1.00)) and the patient being woman. Increased statin use was associated with a higher number of specialists in family medicine (OR 1.03 (95% CI 1.01 to 1.05)) and a higher proportion of patients registered with a specific physician (OR 1.37 (95% CI 1.11 to 1.68)). Women had on average a lower number of dispensed antihypertensives. CONCLUSIONS A high practice variation for dispensation of all secondary preventive drugs was observed. Patient and PCC level factors indicating good continuity of care and high level of general practitioner education were associated with higher use of statins. Findings are of importance to policymakers as well as individual providers of care, and more research and actions are needed to minimise inequality in healthcare.
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Affiliation(s)
- Maria Wolf
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Jakob K Hasselström
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Axel Carlsson
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
| | - Mia von Euler
- Department of Neurology and Rehabilitation, Örebro universitet Fakulteten för medicin och hälsa, Orebro, Sweden
| | - Jan Hasselström
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
- Academic Primary Health Care Centre, Stockholm, Sweden
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17
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Echouffo-Tcheugui JB, Turchin A, Rosenson RS, Fonarow GC, Goyal A, de Lemos JA, Arnold SV. Quality of Care Among Patients with Diabetes and Cerebrovascular Disease. Insights from The Diabetes Collaborative Registry. Am J Med 2022; 135:1336-1341. [PMID: 35872090 DOI: 10.1016/j.amjmed.2022.06.016] [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: 05/25/2022] [Revised: 06/25/2022] [Accepted: 06/26/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although secondary cardiovascular prevention is a focus among patients with type 2 diabetes (T2D) and coronary artery disease (CAD) or peripheral artery disease (PAD), the application of guideline-recommended therapy in T2D patients and isolated cerebrovascular disease (CeVD) remains unknown. METHODS In a US outpatient registry, T2D patients with established cardiovascular disease from 2014-2018 were categorized as: isolated CeVD, CeVD plus CAD or PAD, or isolated CAD/PAD. In each group, we determined the proportion with optimal secondary prevention (hemoglobin [Hb]A1C <8%, blood pressure <130/80 mm Hg, use of antithrombotics, use of statins, non-smoking/cessation counseling, and use of glucose-lowering medications with cardioprotective effects (sodium-glucose cotransporter [SGLT]-2 inhibitors, glucagon-like peptide [GLP]-1 receptor agonists, thiazolidinediones [TZDs]). Hierarchical Poisson regression was used to estimate relative rate of achieving each target across groups, adjusted for age and chronic kidney disease (where relevant). RESULTS Our study included 727,467 T2D outpatients with cardiovascular disease (isolated CeVD [n = 99,777], CeVD plus CAD/PAD [n = 158,361], isolated CAD/PAD [n = 469,329]). Compared with isolated CAD/PAD patients, isolated CeVD patients more often had an HbA1c <8% (adjusted relative risk [aRR] 1.10; 95% confidence interval [CI], 1.08-1.11) but less often had a blood pressure of ≤130/80 mm Hg (aRR 0.93; 95% CI, 0.92-0.94) or were prescribed antithrombotics (0.84; 95% CI, 0.83-0.85), statins (0.86; 95% CI, 0.85-0.87), GLP-1 agonists (0.75; 95% CI, 0.73-0.78), SGLT2 inhibitors (0.73; 95% CI, 0.71-0.76), and TZDs (aRR 0.76; 95% CI, 0.73-0.78). CONCLUSION Among T2D patients, those with isolated CeVD had the lowest rates of secondary cardiovascular prevention goals attainment. More focus is needed on secondary prevention in patients with CeVD.
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Affiliation(s)
| | - Alexander Turchin
- Division of Endocrinology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Robert S Rosenson
- Division of Cardiology, Icahn School of Medicine at Mount Sinai; Mount Sinai Heart, New York, NY
| | - Gregg C Fonarow
- Ahmanson-UCLA Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Abhinav Goyal
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - James A de Lemos
- Division of Cardiology, UT Southwestern School of Medicine, Dallas, TX
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute & University of Missouri-Kansas City, Kansas City, MO
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Perrier J, Olié V, Gabet A, Tzourio C, Bezin J. Antihypertensive and lipid‐lowering drugs usage after primary stroke in a large representative sample of the French population. Fundam Clin Pharmacol 2022; 36:742-749. [DOI: 10.1111/fcp.12756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 12/09/2021] [Accepted: 01/05/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Julia Perrier
- Inserm, Bordeaux Population Health Research Center U1219 University of Bordeaux Bordeaux France
| | - Valérie Olié
- Santé Publique France, The French Public Health Agency Paris France
| | - Amélie Gabet
- Santé Publique France, The French Public Health Agency Paris France
| | - Christophe Tzourio
- Inserm, Bordeaux Population Health Research Center U1219 University of Bordeaux Bordeaux France
| | - Julien Bezin
- Inserm, Bordeaux Population Health Research Center U1219 University of Bordeaux Bordeaux France
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Bassand C, Villois A, Gianola L, Laue G, Ramazani F, Riebesehl B, Sanchez-Felix M, Sedo K, Ullrich T, Duvnjak Romic M. Smart design of patient centric long-acting products: from preclinical to marketed pipeline trends and opportunities. Expert Opin Drug Deliv 2022; 19:1265-1283. [PMID: 35877189 DOI: 10.1080/17425247.2022.2106213] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION We see a development in the field of long-acting products to serve patients with chronic diseases by providing benefits in adherence, efficacy and safety of the treatment. This review investigates features of long-acting products on the market/pipeline to understand which drug substance (DS) and drug product (DP) characteristics likely enable a successful patient-centric, low-dosing frequency product. AREAS COVERED This review evaluates marketed/pipeline long-acting products with greater than one week release of small molecules and peptides by oral and injectable route of administration (RoA), with particular focus on patient centricity, adherence impact, health outcomes, market trends, and the match of DS/DP technologies which lead to market success. EXPERT OPINION Emerging trends are expected to change the field of long-acting products in the upcoming years by increasing capability in engineered molecules (low solubility, long half-life, high potency, etc.), directly developing DP as long-acting oral/injectable, increasing the proportion of products for local drug delivery, and a direction towards more subcutaneous, self-administered products. Among long-acting injectable products, nanosuspensions show a superiority in dose per administration and dosing interval, overwhelming the field of infectious diseases with the recently marketed products.
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Affiliation(s)
- Céline Bassand
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Alessia Villois
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Lucas Gianola
- Novartis Institute for Biomedical Research, Novartis Pharma AG, Basel 4002, Switzerland
| | - Grit Laue
- Novartis Institute for Biomedical Research, Novartis Pharma AG, Basel 4002, Switzerland
| | - Farshad Ramazani
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Bernd Riebesehl
- Technical Research and Development, Novartis Pharma AG, Basel 4002, Switzerland
| | - Manuel Sanchez-Felix
- Novartis Institutes for BioMedical Research, 700 Main Street, Cambridge, MA 02139, USA
| | - Kurt Sedo
- PharmaCircle LLC, Sunny Isles Beach, FL, USA
| | - Thomas Ullrich
- Novartis Institute for Biomedical Research, Novartis Pharma AG, Basel 4002, Switzerland
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Mastering health following minor stroke-A qualitative explorative study. J Stroke Cerebrovasc Dis 2022; 31:106607. [PMID: 35753094 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106607] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients with minor stroke or transient ischemic attack are encouraged to adopt a healthy lifestyle to prevent recurrent stroke. After discharge health behaviour is performed in an individual everyday context and must be properly understood within this context, including which aspects act as facilitators or barriers for healthy behaviour. OBJECTIVES To explore the experience of daily life in patients discharged home after minor stroke or transient ischemic attack, focusing on perceived health and reflection on health behaviour, and how this is associated with their overall experience of returning to their everyday context in relation to potential sequelae of stroke. METHODS Semi-structured qualitative interviews were conducted 3 - 13 months after discharge with sixteen patients discharged home after minor stroke or transient ischemic attack. Inductive thematic analysis was performed to analyse the interviews. RESULTS Participants associated their health and behaviour within a lens of worrying for future life prospect and triggered by perceived intrusive changes in their life condition. Even though some found it possible to resume participation in everyday life within weeks, they became increasingly aware that minor cognitive deficits, difficulties with planning, multi-tasking, memory, and fatigue influenced their health believes and behavioural patterns. The need for social and professional support had to be balanced against a wish for independence. CONCLUSION Patients with minor stroke or transient ischemic attacks experience changes as both being concrete in the form of persisting symptoms and abstract in the form of worries and uncertainty about the future. Perceived health was associated with a new sense of vulnerability due to realisations about the risk of recurrent stroke. Worries were anchored within the individual to handle, but for some they serve as a motivator to regulate their behaviour in order to master health.
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21
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Hinwood M, Nyberg J, Leigh L, Gustavsson S, Attia J, Oldmeadow C, Ilicic M, Linden T, Åberg ND, Levi C, Spratt N, Carey LM, Pollack M, Johnson SJ, Kuhn GH, Walker FR, Nilsson M. Do P2Y12 receptor inhibitors prescribed poststroke modify the risk of cognitive disorder or dementia? Protocol for a target trial using multiple national Swedish registries. BMJ Open 2022; 12:e058244. [PMID: 35534077 PMCID: PMC9086614 DOI: 10.1136/bmjopen-2021-058244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The target of a class of antiplatelet medicines, P2Y12R inhibitors, exists both on platelets and on brain immune cells (microglia). This protocol aims to describe a causal (based on a counterfactual model) approach for analysing whether P2Y12R inhibitors prescribed for secondary prevention poststroke may increase the risk of cognitive disorder or dementia via their actions on microglia, using real-world evidence. METHODS AND ANALYSIS This will be a cohort study nested within the Swedish National Health and Medical Registers, including all people with incident stroke from 2006 to 2016. We developed directed acyclic graphs to operationalise the causal research question considering potential time-independent and time-dependent confounding, using input from several experts. We developed a study protocol following the components of the target trial approach described by Hernan et al and describe the data structure that would be required in order to make a causal inference. We also describe the statistical approach required to derive the causal estimand associated with this important clinical question; that is, a time-to-event analysis for the development of cognitive disorder or dementia at 1, 2 and 5-year follow-up, based on approaches for competing events to account for the risk of all-cause mortality. Causal effect estimates and the precision in these estimates will be quantified. ETHICS AND DISSEMINATION This study has been approved by the Ethics Committee of the University of Gothenburg and Confidentiality Clearance at Statistics Sweden with Dnr 937-18, and an approved addendum with Dnr 2019-0157. The analysis and interpretation of the results will be heavily reliant on the structure, quality and potential for bias of the databases used. When we implement the protocol, we will consider and document any biases specific to the dataset and conduct appropriate sensitivity analyses. Findings will be disseminated to local stakeholders via conferences, and published in appropriate scientific journals.
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Affiliation(s)
- Madeleine Hinwood
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Jenny Nyberg
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
| | - Lucy Leigh
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Sara Gustavsson
- Department of Forensic Genetics, Forensic Toxicology National Board of Forensic Medicine, Linköping, Sweden
| | - John Attia
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Christopher Oldmeadow
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Marina Ilicic
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Thomas Linden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Neurorehabilitation and Recovery, Florey Neuroscience Institutes, Parkville, Victoria, Australia
| | - N David Åberg
- Department of Internal Medicine and Clinical Nutrition, University of Gothenburg, Goteborg, Sweden
- Department of Acute Medicine and Geriatrics, Sahlgrenska University Hospital, Goteborg, Region Västra Götaland, Sweden
| | - Chris Levi
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Neil Spratt
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Leeanne M Carey
- Neurorehabilitation and Recovery, Florey Neuroscience Institutes, Parkville, Victoria, Australia
- School of Allied Health, Human Services and Sport, La Trobe University - Melbourne Campus, Melbourne, Victoria, Australia
| | - Michael Pollack
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Sarah J Johnson
- School of Engineering, College of Engineering, Science and Environment, The University of Newcastle, Callaghan, New South Wales, Australia
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
| | - Georg Hans Kuhn
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Institute for Public Health, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frederick R Walker
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, New South Wales, Australia
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
| | - Michael Nilsson
- School of Medicine and Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Centre for Brain Repair and Rehabilitation, Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Center for Human and Health Sciences, Centre for Rehab Innovations, Callaghan, New South Wales, Australia
- LKC School of Medicine, Nanyang Technological University, Singapore
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22
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Patorno E, Schneeweiss S, George MG, Tong X, Franklin JM, Pawar A, Mogun H, Moura LMVR, Schwamm LH. Linking the Paul Coverdell National Acute Stroke Program to commercial claims to establish a framework for real-world longitudinal stroke research. Stroke Vasc Neurol 2022; 7:114-123. [PMID: 34750282 PMCID: PMC9067267 DOI: 10.1136/svn-2021-001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/12/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Non-interventional large-scale research on real-world patients who had a stroke requires the use of multiple data sources ensuring access to longitudinal data from large populations with clinically-detailed information. We sought to establish a framework for longitudinal research on patients hospitalised with stroke by linking information-rich, deidentified inpatient data from the Paul Coverdell National Acute Stroke Program (PCNASP) to commercial and Medicare Advantage longitudinal claims data. METHODS All stroke admissions in PCNASP between 2008 and 2015 were evaluated for linkage to longitudinal claims from a commercial insurer using an algorithm based on six available common data fields (patient age, gender, admission date, discharge date, discharge diagnosis and state) and a hospital match. We evaluated the linkage quality (via the percentage of unique records in the linked dataset) and the representativeness of the linked population. We also described medical history, stroke severity and patterns of medication use among the PCNASP-claims linked cohort. RESULTS The linkage produced uniqueness equal to 99.1%. We identified 5644 linked and 98 896 unlinked patients who had an ischaemic stroke hospitalisation in claims data. Linked patients were younger than unlinked (69.7 vs 72.5 years), but otherwise similar by medical history, prestroke medication use or lab values. Stroke severity was mild and most patients were discharged home. Prestroke and discharge use of antihypertensive and statins in the PCNASP were greater than their use as measured by filled prescriptions in claims. CONCLUSIONS High-quality linkage between the PCNASP and commercial claims data is feasible. This linkage identified differences between reported or recommended versus actual out-of-hospital medication utilisation, highlighting the importance of longitudinal data availability for research aimed to improve the care of patients who had a stroke.
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Affiliation(s)
- Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary G George
- Division for Heart Disease and Stroke Prevention, NCCDPHP, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Xin Tong
- Division for Heart Disease and Stroke Prevention, NCCDPHP, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajinkya Pawar
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lidia M V R Moura
- Epilepsy and Neurophysiology Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Fireman Vascular Center and Stroke Division, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Abumayyaleh M, Demmer J, Krack C, Pilsinger C, El-Battrawy I, Behnes M, Aweimer A, Mügge A, Lang S, Akin I. Hemodynamic Effects of Sacubitril/Valsartan in Patients with Reduced Left Ventricular Ejection Fraction Over 24 Months: A Retrospective Study. Am J Cardiovasc Drugs 2022; 22:535-544. [PMID: 35353351 PMCID: PMC9468101 DOI: 10.1007/s40256-022-00525-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 12/11/2022]
Abstract
Background The effects of sacubitril/valsartan in patients with chronic heart failure with reduced ejection fraction (HFrEF) were recently reported. However, the hemodynamic impact of this well-established treatment in patients with HFrEF has been poorly systematically researched. Aim We aimed to investigate the hemodynamic effects of sacubitril/valsartan among patients with HFrEF. Methods Between 2016 and 2020, we retrospectively collected data for patients with HFrEF treated at the University Medical Center Mannheim, Germany. Data for 240 patients with HFrEF were available. We systematically analyzed echocardiographic parameters, all-cause hospitalization, and congestion rate. Results The left ventricular ejection fraction (LVEF) improved from a median (minimum; maximum) of 28% (3; 65) before initiation of sacubitril/valsartan to a median of 34% (13; 64) at 24-month follow-up (p < 0.001). Systolic pulmonary atrial pressure (PAPsys) decreased from a median of 30 mmHg (13; 115) to 25 mmHg (20; 80) at 24-month follow-up (p = 0.005). The median (minimum; maximum) tricuspid annular plane systolic excursion improved from 17 mm (3; 31) at baseline to 20 mm (9; 30) at 12-month follow-up (p = 0.007). The incidence of severe and moderate mitral, tricuspid, and aortic valvular insufficiency improved after treatment. Hospitalization and congestion rates reduced at 24-month follow-up. The mortality rate in echocardiographic and functional nonresponders was higher than in responders (12.1 vs. 5.2%; p = 0.1 and 11.3 vs. 3.1%; p = 0.01, respectively). Conclusion Follow-up 24 months after starting treatment with sacubitril/valsartan revealed sustained improvements in echocardiographic parameters, including LVEF, PAPsys, and cardiac valvular insufficiency. Rates of all-cause hospitalization and congestion had decreased significantly at follow-up. The mortality rate was higher in echocardiographic and functional nonresponders. Supplementary Information The online version contains supplementary material available at 10.1007/s40256-022-00525-w.
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24
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McGurgan IJ, Kelly PJ, Turan TN, Rothwell PM. Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke. Stroke 2022; 53:1085-1103. [PMID: 35291823 DOI: 10.1161/strokeaha.121.035851] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
| | - Peter J Kelly
- Neurovascular Clinical Science Unit, Stroke Service and Department of Neurology, Mater University Hospital, Dublin, Ireland (P.J.K.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
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Pharmacist Interventions for Medication Adherence: Community Guide Economic Reviews for Cardiovascular Disease. Am J Prev Med 2022; 62:e202-e222. [PMID: 34876318 PMCID: PMC8863641 DOI: 10.1016/j.amepre.2021.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Adherence to medications for cardiovascular disease and its risk factors is less than optimal, although greater adherence to medication has been shown to reduce the risk factors for cardiovascular disease. This paper examines the economics of tailored pharmacy interventions to improve medication adherence for cardiovascular disease prevention and management. METHODS Literature from inception of databases to May 2019 was searched, yielding 29 studies for cardiovascular disease prevention and 9 studies for cardiovascular disease management. Analyses were done from June 2019 through May 2020. All monetary values are in 2019 U.S. dollars. RESULTS The median intervention cost per patient per year was $246 for cardiovascular disease prevention and $292 for cardiovascular disease management. The median change in healthcare cost per person per year due to the intervention was -$355 for cardiovascular disease prevention and -$2,430 for cardiovascular disease management. The median total cost per person per year was -$89 for cardiovascular disease prevention, with a median return on investment of 0.01. The median total cost per person per year for cardiovascular disease management was -$1,080, with a median return on investment of 7.52, and 6 of 7 estimates indicating reduced healthcare cost averted exceeded intervention cost. For cardiovascular disease prevention, the median cost per quality-adjusted life year gained was $11,298. There were no cost effectiveness studies for cardiovascular disease management. DISCUSSION The evidence shows that tailored pharmacy-based interventions to improve medication adherence are cost effective for cardiovascular disease prevention. For cardiovascular disease management, healthcare cost averted exceeds the cost of implementation for a favorable return on investment from a healthcare systems perspective.
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26
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Ladwig S, Werheid K. Determinants of Antidepressant Treatment and Outpatient Rehabilitation Within the First Year After Stroke. J Geriatr Psychiatry Neurol 2022; 35:135-144. [PMID: 33233997 DOI: 10.1177/0891988720973749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study aims to identify individual determinants of antidepressant treatment and outpatient rehabilitation after stroke. People with ischemic stroke (N = 303) recruited at 2 inpatient rehabilitation clinics were included into a prospective longitudinal study with follow-up telephone interviews 6 and 12 months later. Participants reported on their use of antidepressant medication and psychotherapy as well as physical, occupational, speech, and neuropsychological therapy. The use of antidepressants at discharge (n = 65, 23.8%) was predicted by the severity of depressive symptoms, severity of stroke, history of depression, and use of antidepressants at admission (all p < .05, R2= .55). The number of outpatient rehabilitation services used at follow-ups was predicted by higher functional and cognitive impairment, higher education, younger age, severity of depressive symptoms, and lower self-efficacy (all p < .05; R26M = .24, R212M = .49). The relevance of identified determinants for the improvement of treatment rates after stroke is discussed.
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Affiliation(s)
- Simon Ladwig
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany.,Clinic of Neurology, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Katja Werheid
- Department of Psychology, Humboldt-Universität zu Berlin, Berlin, Germany.,Clinic of Neurology, Hospital Ernst von Bergmann, Potsdam, Germany
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27
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Westberg A, Sjölander M, Glader EL, Gustafsson M. Primary Non-Adherence to Preventive Drugs and Associations with Beliefs About Medicines in Stroke Survivors. Patient Prefer Adherence 2022; 16:343-352. [PMID: 35177898 PMCID: PMC8844454 DOI: 10.2147/ppa.s351001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Medication non-adherence is a common problem in clinical practice. Little is known about stroke survivors' primary non-adherence to preventive drugs, and we hypothesised that their beliefs about medicines are associated with primary non-adherence. The objective was to describe primary non-adherence among stroke survivors and to assess associations between primary non-adherence to preventive drugs and beliefs about medicines. METHODS Questionnaires were sent to 797 individuals 3 months after stroke to assess beliefs about medicines through the Beliefs about Medicines Questionnaire (BMQ). All participants were registered in the Swedish Stroke Register (Riksstroke), and prescriptions for new preventive drugs during the hospital stay were identified through data from Riksstroke. Primary non-adherers were those who failed to fill one or more new prescriptions within 1 month of hospital discharge based on data from the Swedish Prescribed Drug Register. Differences between primary non-adherers and adherers were assessed by 2 tests and associations between the BMQ subscales and primary non-adherence were analysed using independent two-sample t-tests and multivariable logistic regression models. RESULTS A total of 594 individuals responded to the survey, of which 452 received new prescriptions of preventive drugs. Overall, 53 (12%) participants were classified as primary non-adherent. Primary non-adherers were more often dependent on help or support from next of kin (p=0.032) and had difficulties with memory more often (p=0.002) than the primary adherent individuals. No statistically significant differences in BMQ subscale-scores were found between the two groups (p>0.05). CONCLUSION Primary non-adherence to preventive drugs was low, and no associations were found between primary non-adherence and beliefs about medicines. Associations with cognitive impairments such as difficulties with memory and need for help from next of kin suggest that more effort is needed to help stroke survivors to start important preventive drug treatments after discharge from hospital.
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Affiliation(s)
- Annica Westberg
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
| | - Maria Sjölander
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, 901 87, Sweden
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, Umeå, 901 87, Sweden
- Correspondence: Maria Gustafsson, Department of Integrative Medical Biology, Umeå University, Umeå, SE-901 87, Sweden, Email
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28
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Beltai A, Combe B, Coffy A, Gaujoux-Viala C, Lukas C, Saraux A, Dougados M, Daurès JP, Hua C. Impact of multimorbidity on disease modifying anti-rheumatic drug therapy in early rheumatoid arthritis: data from the Espoir cohort. Joint Bone Spine 2021; 89:105326. [PMID: 34906696 DOI: 10.1016/j.jbspin.2021.105326] [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: 07/27/2021] [Revised: 11/19/2021] [Accepted: 12/01/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Multimorbidity is frequent in rheumatoid arthritis (RA) and could interfere with the therapeutic response. The aim of this study was to evaluate multimorbidity in the French cohort of early arthritis, the ESPOIR cohort, and its possible impact on the therapeutic response. METHODS We included patients fulfilling 2010 ACR/EULAR criteria for RA. An adapted MultiMorbidity Index (aMMI) was developed. Each patient was assigned scores of binary aMMI (0= no comorbidity, 1= at least 1 comorbidity) and counted and weighted aMMI. The primary endpoint was achievement of Clinical Disease Activity Index (CDAI) low disease activity after initiation of a first disease-modifying anti-rheumatic drug (DMARD) according to the aMMI. We collected data from the visit preceding the first DMARD initiation and the visit after at least 3 months of treatment. The impact of aMMI on therapeutic maintenance at 1, 3, 5 and 10 years was evaluated. RESULTS Analyses involved 472 patients: 302 (64%) had at least 1 comorbidity. Overall, 45.3% and 44.7% with binary aMMI= 0 or 1, respectively (non significant), achieved CDAI low disease activity. Similar results were found with counted and weighted aMMI. Therapeutic maintenance was significantly better with binary aMMI = 1 than binary aMMI = 0 (OR at 10 years= 14.0 [CI 95% 3.3-59.4]). Increased counted aMMI was associated with increased probability of still being on the first initiated DMARD at each time point. CONCLUSION In the ESPOIR cohort, therapeutic response to a first DMARD was not affected by multimorbidity but therapeutic maintenance was better in multimorbid patients.
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Affiliation(s)
- Aurélie Beltai
- Department of Rheumatology, CHU Montpellier, University of Montpellier, 371 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Bernard Combe
- Department of Rheumatology, CHU Montpellier, University of Montpellier, 371 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Amandine Coffy
- Biostatistiques, Nouvelles Technologies, 641 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Cécile Gaujoux-Viala
- Department of Rheumatology, CHU Nîmes, Place du Professeur Robert Debré, 30000 Nîmes, France; Institut Desbrest d'Epidémiologie et de Santé Publique UMR INSERM - University of Montpellier, 641 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Cédric Lukas
- Department of Rheumatology, CHU Montpellier, University of Montpellier, 371 Av. du Doyen Gaston Giraud, 34090 Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique UMR INSERM - University of Montpellier, 641 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Alain Saraux
- Department of Rheumatology, CHU de Brest, INSERM UMR 1227, University of Brest, 2 Avenue Foch, 29200 Brest, France
| | - Maxime Dougados
- Department of Rheumatology, CHU Cochin, University of Paris 5, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Jean Pierre Daurès
- Biostatistiques, Nouvelles Technologies, 641 Av. du Doyen Gaston Giraud, 34090 Montpellier, France
| | - Charlotte Hua
- Department of Rheumatology, CHU Nîmes, Place du Professeur Robert Debré, 30000 Nîmes, France; Institut Desbrest d'Epidémiologie et de Santé Publique UMR INSERM - University of Montpellier, 641 Av. du Doyen Gaston Giraud, 34090 Montpellier, France.
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Wakayama K, Shimamura M, Yoshida S, Hayashi H, Ju N, Nakagami H, Morishita R. Prevention of vascular dementia via immunotherapeutic blockade of renin-angiotensin system in a rat model. Brain Res 2021; 1772:147667. [PMID: 34587500 DOI: 10.1016/j.brainres.2021.147667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/15/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION As several clinical trials have revealed that angiotensin-converting enzyme inhibitors and angiotensin II (Ang II) receptor blockers may be efficient in treating vascular dementia (VaD), the long-acting blockade of the renin-angiotensin system (RAS) would be useful considering the poor adherence of antihypertensive drugs. Accordingly, we continuously blocked RAS via vaccination and examined the effectiveness of the VaD model in rats. METHODS Male Wistar rats were exposed to two-vessel occlusions (2VO) after three injections of Ang II peptide vaccine. The effects of the vaccine were evaluated in the novel object recognition test, brain RAS components, and markers for oligodendrocytes. RESULTS In the vaccinated rats, anti-Ang II antibody titer level was increased in serum until Day 168, but not in cerebral parenchyma. Vaccinated rats showed better object recognition memory with inhibited demyelination in the corpus callosum and activation of astrocytes and microglia. Also, levels of BrdU/GSTπ-positive cells and the phosphorylation of cAMP response element binding protein was increased in vaccinated rats, indicating that the differentiation of oligodendrocyte progenitor cells to mature oligodendrocytes was accelerated. Vaccinated rats showed increased expression of fibroblast growth factor-2 (FGF2), which was observed in endothelial cells. Angiotensinogen mRNA was decreased at 7 days after 2VO but increased at 14 and 28 days. CONCLUSION Ang II vaccine might have promoted oligodendrocyte differentiation and inhibited astrocytic and microglial activation by stimulating FGF2 signaling in the endothelial cells-oligodendrocyte/astrocyte/microglia coupling. These data indicate the feasibility of Ang II vaccine for preventing progression of vascular dementia.
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Affiliation(s)
- Kouji Wakayama
- Department of Advanced Clinical Science and Therapeutics, Graduate School of Medicine, The University of Tokyo, Japan
| | - Munehisa Shimamura
- Department of Neurology, Osaka University, Graduate School of Medicine, Japan; Department of Health Development and Medicine, Osaka University, Graduate School of Medicine, Japan.
| | - Shota Yoshida
- Department of Health Development and Medicine, Osaka University, Graduate School of Medicine, Japan
| | - Hiroki Hayashi
- Department of Health Development and Medicine, Osaka University, Graduate School of Medicine, Japan
| | - Nan Ju
- Department of Health Development and Medicine, Osaka University, Graduate School of Medicine, Japan
| | - Hironori Nakagami
- Department of Health Development and Medicine, Osaka University, Graduate School of Medicine, Japan
| | - Ryuichi Morishita
- Department of Clinical Gene Therapy, Osaka University, Graduate School of Medicine, Japan.
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30
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[Atrial fibrillation and the limits of oral anticoagulation: for whom are left atrial appendage occluders suitable?]. Internist (Berl) 2021; 63:230-237. [PMID: 34762155 DOI: 10.1007/s00108-021-01206-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with atrial fibrillation are at a significantly increased risk of thromboembolic events, especially ischemic strokes. Oral anticoagulation reduces this risk, but cannot be used in some patients for various reasons and is associated with a relevantly increased risk of bleeding. As an alternative for prophylaxis of thromboembolic events in patients with atrial fibrillation, there are different options of left atrial appendage closure. AIM This article explains the possibilities of interventional atrial occlusion as well as the suitable patient clientele using an overview of the currently available systems for atrial occlusion, a guideline for patient selection and a summary of the current scientific data. CONCLUSION AND AVAILABLE SCIENTIFIC DATA In carefully selected patients suffering from atrial fibrillation with relative or absolute contraindications for oral anticoagulation, interventional closure of the atrial appendage is a safe alternative for prophylaxis against thromboembolic events. The currently available scientific evidence from randomized controlled trials is sparse. Nevertheless, extensive amounts of registry study data suggest a benefit, while the results of several large randomized controlled trials are expected in the coming years.
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Sommer RJ, Kim JH, Szerlip M, Chandhok S, Sugeng L, Cain C, Kaplan AV, Gray WA. Conformal Left Atrial Appendage Seal Device for Left Atrial Appendage Closure: First Clinical Use. JACC Cardiovasc Interv 2021; 14:2368-2374. [PMID: 34736735 DOI: 10.1016/j.jcin.2021.08.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 07/27/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The authors report the first clinical experience with the Conformal Left Atrial Appendage Seal (CLAAS) device. BACKGROUND The CLAAS device was designed to address the limitations of first-generation left atrial appendage closure (LAAC) devices by providing an implant that is minimally traumatic, can be deployed in a noncoaxial fashion, and does not require postprocedural oral anticoagulation. METHODS Patients with atrial fibrillation at high stroke risk (CHA2DS2-VASc score ≥2) were recruited using standard selection criteria. The LAAC procedure was guided by transesophageal echocardiography with patients under general anesthesia. The CLAAS device is composed of a foam cup, with a Nitinol endoskeleton with an expanded polytetrafluoroethylene cover, delivered with a standard delivery system using a tether for full recapture. All patients received dual-antiplatelet therapy for 6 months, followed by aspirin alone. Transesophageal echocardiographic follow-up was scheduled for 45 days and 1 year. RESULTS Twenty-two patients (63.7% with CHA2DS2-VASc scores ≥3, 76.2% with HAS-BLED scores ≥3) were enrolled. The device was successfully implanted in 18 patients and unsuccessfully in 4 patients. There were no serious procedural complications. On transesophageal echocardiography performed at 45 days, 1 significant leak (≥5 mm) was seen, which was due to a large posterior lobe not appreciated at the time of implantation, and 1 device-related thrombus was noted, which resolved on oral anticoagulation. There were no periprocedural strokes, major pericardial effusions, or systemic or device embolization. CONCLUSIONS This first-in-human study demonstrates the clinical feasibility of the CLAAS device for LAAC.
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Affiliation(s)
| | - Jamie H Kim
- Catholic Medical Center, Manchester, New Hampshire, USA
| | | | | | - Lissa Sugeng
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Aaron V Kaplan
- Conformal Medical, Nashua, New Hampshire, USA; Heart & Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Association between Cerebral Infarction Risk and Medication Adherence in Atrial Fibrillation Patients Taking Direct Oral Anticoagulants. Healthcare (Basel) 2021; 9:healthcare9101313. [PMID: 34682992 PMCID: PMC8544438 DOI: 10.3390/healthcare9101313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/25/2021] [Accepted: 09/28/2021] [Indexed: 11/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are available for nonvalvular atrial fibrillation patients. The advantage of DOACs is that regular anticoagulation monitoring is not required. However, adherence to the recommended regimen is essential. We investigated the association between medication adherence and the risk of cerebral infarction in patients taking DOACs. Patients admitted to any of the participating hospitals for cerebral infarction from September 2018 to February 2020 and prescribed DOACs before admission were defined as the case group, and patients hospitalized for diseases other than cerebral infarction, except for bleeding disorders, and prescribed DOACs before admission were defined as the control group. A nested case–control study was adapted, and 58 and 232 patients were included in the case and control groups, respectively. Medication adherence was assessed by the pharmacists through standardized interviewing. The adjusted odds ratio for the risk of cerebral infarction for low-adherence patients (<80% adherence rate) against good-adherence patients (100% adherence rate) was 9.69 (95% confidence interval, 3.86–24.3; p < 0.001). The patients’ age and other background characteristics were not found to be risk factors for cerebral infarction. In conclusion, low adherence is a risk factor for cerebral infarction in patients taking DOACs. Pharmacists should focus on maintaining ≥80% adherence to DOAC therapy to prevent cerebral infarction.
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Labuz-Roszak B, Banach M, Skrzypek M, Windak A, Tomasik T, Mastej M, Tomaszewski M, Mikhailidis DP, Toth PP, Catapano A, Ray KK, Howard G, Lip GYH, Charchar FJ, Sattar N, Williams B, MacDonald TM, Penson P, Jozwiak JJ. Secondary Stroke Prevention in Polish Adults: Results from the LIPIDOGRAM2015 Study. J Clin Med 2021; 10:4472. [PMID: 34640490 PMCID: PMC8509736 DOI: 10.3390/jcm10194472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/12/2021] [Accepted: 09/21/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The purpose of the study was to evaluate secondary stroke prevention in Poland and its association with sociodemographic factors, place of residence, and concomitant cardiovascular risk factors. MATERIAL AND METHODS From all patients in LIPIDOGRAM2015 Study (n = 13,724), 268 subjects had a history of ischaemic stroke and were included. RESULTS 165 subjects (61.6%) used at least one preventive medication. Oral antiplatelet and anticoagulation agents were used by 116 (43.3%) and 70 (26.1%) patients, respectively. Only 157 (58.6%) participants used lipid-lowering drugs, and 205 (76.5%) were treated with antihypertensive drugs. Coronary heart disease (CHD) and dyslipidaemia were associated with antiplatelet treatment (p = 0.047 and p = 0.012, respectively). A history of atrial fibrillation, CHD, and previous myocardial infarction correlated with anticoagulant treatment (p = 0.001, p = 0.011, and p < 0.0001, respectively). Age, gender, time from stroke onset, place of residence, and level of education were not associated with antiplatelet or anticoagulant treatment. Only 31.7% of patients were engaged in regular physical activity, 62% used appropriate diet, and 13.6% were current smokers. CONCLUSIONS In Poland drugs and lifestyle modification for secondary stroke prevention are not commonly adhered to. Educational programmes for physicians and patients should be developed to improve application of effective secondary prevention of stroke.
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Affiliation(s)
- Beata Labuz-Roszak
- Department of Neurology, Institute of Medical Sciences, University of Opole, 45-052 Opole, Poland
| | - Maciej Banach
- Polish Mothers Memorial Hospital Research Institute, 93-338 Lodz, Poland;
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, 93-338 Lodz, Poland
- Cardiovascular Research Centre, University of Zielona Gora, 65-046 Zielona Gora, Poland
| | - Michal Skrzypek
- Department of Biostatistics, Faculty of Health Sciences in Bytom, Medical University of Silesia in Katowice, 41-902 Bytom, Poland;
| | - Adam Windak
- Department of Family Medicine, Jagiellonian University Medical College, 31-061 Krakow, Poland; (A.W.); (T.T.)
| | - Tomasz Tomasik
- Department of Family Medicine, Jagiellonian University Medical College, 31-061 Krakow, Poland; (A.W.); (T.T.)
| | | | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PT, UK;
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital, University College London, London NW3 2QG, UK;
| | - Peter P. Toth
- Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
- CGH Medical Center, Sterling, IL 61081, USA
| | - Alberico Catapano
- Department of Pharmacological Sciences, University of Milano and Multimedica IRCCS, 20099 Milano, Italy;
| | - Kausik K. Ray
- Department of Primary Care and Public Health, Imperial Centre for Cardiovascular Disease Prevention, Imperial College, Kensington, London W6 8RP, UK;
| | - George Howard
- Department of Biostatistics, School of Public Health of Alabama at Birmingham, Birmingham B15 2TT, UK;
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK;
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Fadi J. Charchar
- School of Health and Life Sciences, Federation University Australia, Ballarat, VIC 3350, Australia;
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow G12 8TA, UK;
| | - Bryan Williams
- NIHR University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK;
| | - Thomas M. MacDonald
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK;
| | - Peter Penson
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L2 2QP, UK;
- Liverpool Centre for Cardiovascular Science, Liverpool L69 7TX, UK
| | - Jacek J. Jozwiak
- Department of Family Medicine and Public Health, Institute of Medical Sciences, University of Opole, 45-052 Opole, Poland;
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Safouris A, Magoufis G, Tsivgoulis G. Emerging agents for the treatment and prevention of stroke: progress in clinical trials. Expert Opin Investig Drugs 2021; 30:1025-1035. [PMID: 34555978 DOI: 10.1080/13543784.2021.1985463] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recent years have witnessed unprecedented progress in stroke care, but unmet needs persist regarding the efficacy of acute treatment and secondary prevention. Novel approaches are being tested to enhance the efficacy of thrombolysis or provide neuroprotection in non-thrombolized patients. AREAS COVERED The current review highlights pharmaceutical agents under evaluation in clinical trials concerning the acute, subacute, and chronic phase post-stroke. We examine the evidence in favor of tenecteplase as an alternative thrombolytic drug to alteplase, nerinetide as a promising neuroprotective agent, and glibenclamide for reducing edema in malignant hemispheric infarction. We discuss the use of ticagrelor and the promising novel category of factor XI inhibitors in the subacute phase after stroke. We offer our insights on combined rivaroxaban and antiplatelet therapy, PCSK-9 inhibitors, and other non-statin hypolipidemic agents, as well as novel antidiabetic agents that have been shown to reduce cardiovascular events in the long-term. EXPERT OPINION Current approaches in stroke treatment and stroke prevention have already transformed stroke care from a linear one-for-all treatment paradigm to a more individualized approach that targets specific patient subgroups with novel pharmaceutical agents. This tendency enriches the therapeutic armamentarium with novel agents developed for specific stroke subgroups. ABBREVIATIONS IVT: intravenous thrombolysis; RCTs: randomized-controlled clinical trials; TNK: Tenecteplase; COVID-19: Coronavirus 2019 Disease; EXTEND-IA TNK: The Tenecteplase versus Alteplase Before Endovascular Therapy for Ischemic Stroke trial; AIS: acute ischemic stroke; NNT: number needed to treat; MT: mechanical thrombectomy; sICH: symptomatic intracranial hemorrhage; mRS: modified Rankin Scale; AHA/ASA: American Heart Association/American Stroke Association; ESO: European Stroke Organization; NA-1: Nerinetide; ENACT: Evaluating Neuroprotection in Aneurysm Coiling Therapy; CTA: CT angiography; TIA: transient ischemic attack; CHANCE: Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events; LOF: loss-of-function; PRINCE: Platelet Reactivity in Acute Nondisabling Cerebrovascular Events; THALES: Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and ASA [acetylsalicylic acid] for Prevention of Stroke and Death; CHANCE-2: Clopidogrel With Aspirin in High-risk Patients With Acute Non-disabling Cerebrovascular Events II; FXI: Factor XI; PACIFIC-STROKE: Program of Anticoagulation via Inhibition of FXIa by the Oral Compound BAY 2433334-NonCardioembolic Stroke study; COMPASS: Cardiovascular Outcomes for People Using Anticoagulation Strategies; CANTOS-ICAD: Combination Antithrombotic Treatment for Prevention of Recurrent Ischemic Stroke in Intracranial Atherosclerotic Disease; SAMMPRIS: Stenting and Aggressive Medical Therapy for Preventing Recurrent Stroke in Intracranial Stenosis; WASID: Warfarin-Aspirin Symptomatic Intracranial Disease; SPARCL: Stroke Prevention by Aggressive Reduction in Cholesterol Levels; LDL-C: low-density lipoprotein cholesterol; TST: Treat Stroke to Target; IMPROVE-IT: Improved Reduction of Outcomes: Vytorin Efficacy International Trial; PCSK9: proprotein convertase subtilisin-kexin type 9; FOURIER: Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk; CLEAR: Cholesterol Lowering via Bempedoic acid, an ACL-inhibiting Regimen; REDUCE-IT: Reduction of Cardiovascular Events With EPA Intervention Trial; STRENGTH: Outcomes Study to Assess STatin Residual Risk Reduction With EpaNova in HiGh CV Risk PatienTs With Hypertriglyceridemia; ACCORD: Action to Control Cardiovascular Risk in Diabetes; ADVANCE: Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; VADT: Veterans Affairs Diabetes Trial; GLP-1R: Glucagon-like peptide-1 receptor; SGLT2: sodium-glucose cotransporter 2; CONVINCE: COlchicine for preventioN of Vascular Inflammation in Non-CardioEmbolic stroke; PROBE: Prospective Randomized Open-label Blinded Endpoint assessment.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece.,Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Athens, Greece.,Department of Neurology, The University of Tennessee Health Science Center, Memphis, USA
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Kanthasamy V, Finlay M. Left atrial appendage occlusion: a niche procedure for a niche cohort? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:429-430. [PMID: 34313730 DOI: 10.1093/ehjqcco/qcab049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Malcolm Finlay
- Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK.,William Harvey Heart Centre, Queen Mary University of London, Charterhouse Square, London EC1A 6BQ, UK
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B, Yoon DH. Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study. BMC Neurol 2021; 21:349. [PMID: 34507550 PMCID: PMC8431917 DOI: 10.1186/s12883-021-02384-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data. METHODS Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months. RESULTS Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months. CONCLUSIONS The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.
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Affiliation(s)
- Seung Jae Kim
- International Healthcare Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | | | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea.
- Nuvizen, Palo Alto, California, 94303, USA.
| | - Eung-Joon Lee
- Institute of Public Health and Medical Care, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
- Department of Neurology, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Dae Hyun Yoon
- Department of Psychiatry, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea
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Eriksson M, Åsberg S, Sunnerhagen KS, von Euler M. Sex Differences in Stroke Care and Outcome 2005-2018: Observations From the Swedish Stroke Register. Stroke 2021; 52:3233-3242. [PMID: 34187179 DOI: 10.1161/strokeaha.120.033893] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies of stroke management and outcome in Sweden have revealed differences between men and women. We aimed to analyze if differences in stroke incidence, care, and outcome have altered over time. METHODS All stroke events registered in the Swedish Stroke Register 2005 to 2018 were included. Background variables and treatment were collected during the acute hospital stay. Survival data were obtained from the national cause of death register by individual linkage. We used unadjusted proportions and estimated age-adjusted marginal means, using a generalized linear model, to present outcome. RESULTS We identified 335 183 stroke events and a decreasing incidence in men and women 2005 to 2018. Men were on average younger than women (73.3 versus 78.1 years) at stroke onset. The age-adjusted proportion of reperfusion therapy 2005 to 2018 increased more rapidly in women than in men (2.3%-15.1% in men versus 1.4%-16.9% in women), but in 2018, women still had a lower probability of receiving thrombolysis within 30 minutes. Among patients with atrial fibrillation, oral anticoagulants at discharge increased more rapidly in women (31.2%-78.6% in men versus 26.7%-81.9% in women). Statins remained higher in men (36.9%-83.7% in men versus 32.3%-81.2% in women). Men had better functional outcome and survival after stroke. After adjustment for women's higher age, more severe strokes, and background characteristics, the absolute difference in functional outcome was <1% and survival did not differ. CONCLUSIONS Stroke incidence, care, and outcome show continuous improvements in Sweden, and previously reported differences between men and women become less evident. More severe strokes and older age in women at stroke onset are explanations to persisting differences.
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Affiliation(s)
- Marie Eriksson
- Department of Statistics, USBE, Umeå University, Sweden (M.E.)
| | - Signild Åsberg
- Department of Neuroscience, Uppsala University, Sweden (S.A.)
| | | | - Mia von Euler
- School of Medicine, Örebro University, Sweden (M.v.E.)
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Srithumsuk W, Chaleoykitti S, Jaipong S, Pattayakorn P, Podimuang K. Association between depression and medication adherence in stroke survivor older adults. Jpn J Nurs Sci 2021; 18:e12434. [PMID: 34137175 DOI: 10.1111/jjns.12434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/29/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
AIM This study aimed to investigate the association between depression score and medication adherence in stroke survivor older adults. METHODS The participants were 102 stroke survivor older adults. The outcome was medication adherence during a 6-month follow-up. The independent variable was the depression score which was assessed by the Patient Health Questionnaire-9 (PHQ-9). The confounding factors included sociodemographic data, clinical characteristics, number of comorbidities, and number of medications. We analyzed the association between depression and medication adherence using multiple linear regression analyses. RESULTS The PHQ-9 score of stroke survivor older adults at the baseline was 1.11±2.03, and at the 6-month follow-up was increased to 5.06±3.91. The medication adherence mean score at the outcome was 4.15±1.83. After full adjustment, the PHQ-9 scores at baseline and 6-month follow-up were significantly associated with medication adherence (β = -.315, 95% CI = -.483 to -.086, p = 0.006 and β = -.270, 95% CI = -.238 to -.020, p = 0.021, respectively). Other variables that affect medication adherence during a 6-month follow-up included living with others and a lower number of medications. CONCLUSION This study revealed that lower depression scores were associated with high medication adherence in post-stroke older adults. Additionally, living with others and a lower number of medications were associated with medication adherence. Therefore, stroke survivor older adults should be assessed for depression and given medication, and education should be used to improve mediation adherence, especially for the ones who live alone and have polypharmacy to prevent recurrent stroke.
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Affiliation(s)
- Werayuth Srithumsuk
- Faculty of Nursing Science and Allied Health, Phetchaburi Rajabhat University, Phetchaburi, Thailand
| | | | - Saitip Jaipong
- Stroke Unit, Phrachomklao Hospital, Phetchaburi, Thailand
| | - Pinthusorn Pattayakorn
- Department of Nursing, College of Natural Science, California State University San Bernardino, San Bernardino, California, USA.,Stroke Unit, Eisenhower Health, Rancho Mirage, California, USA
| | - Kattiya Podimuang
- Annenberg 3 South Telemetry Unit, Eisenhower Medical Center, Rancho Mirage, California, USA
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Loikas D, Linnér L, Sundström A, Wettermark B, von Euler M. Post-stroke epilepsy and antiepileptic drug use in men and women. Basic Clin Pharmacol Toxicol 2021; 129:148-157. [PMID: 34021701 DOI: 10.1111/bcpt.13617] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
Evidence-based recommendations for choice of antiepileptic drug (AED) in post-stroke epilepsy (PSE) are lacking. The aim of this study was to describe the use and persistence of AEDs when initiating treatment in men and women with PSE. An observational study based on individual-level patient data from a regional healthcare register in Stockholm, Sweden, was conducted. Adults (≥18 years) with a stroke diagnosis 2012-2016, a dispensed prescription of any AED within two years after the stroke, and with an epilepsy-related diagnosis were identified. Multinomial logistic regression and logistic regression were used to identify factors associated with choice of AED and discontinuation within 90 days, respectively. Of 9652 men and 9844 women with a stroke diagnosis, 287 men and 273 women had PSE and were dispensed AED. More than 60% of both men and women with PSE were treated with levetiracetam. Carbamazepine was the second most common drug followed by lamotrigine and valproic acid. There were significant differences in AED choice depending on for instance sex, age and renal impairment. Levetiracetam had the highest persistence in both men and women. Choice of AED, oral anticoagulant use and percutaneous endoscopic gastrostomy (PEG) showed an association with the persistence to therapy. We conclude that in both men and women with PSE, levetiracetam was the most used AED for initiation of treatment and also had the highest persistence.
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Affiliation(s)
- Desirée Loikas
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.,Region Stockholm, Health and Medical Care Administration, Stockholm, Sweden
| | - Love Linnér
- Region Stockholm, Health and Medical Care Administration, Stockholm, Sweden
| | - Anders Sundström
- Department of Pharmacy, Faculty of Pharmacy, Disciplinary Domain of Medicine and Pharmacy, Uppsala university, Uppsala, Sweden
| | - Björn Wettermark
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.,Department of Pharmacy, Faculty of Pharmacy, Disciplinary Domain of Medicine and Pharmacy, Uppsala university, Uppsala, Sweden
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
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Preclinical Assessment of a Novel Conformable Foam-Based Left Atrial Appendage Closure Device. BIOMED RESEARCH INTERNATIONAL 2021; 2021:4556400. [PMID: 34222469 PMCID: PMC8213491 DOI: 10.1155/2021/4556400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/10/2021] [Accepted: 05/20/2021] [Indexed: 11/17/2022]
Abstract
Background Left atrial appendage (LAA) occlusion has been established as an alternative to systemic anticoagulation for stroke prevention in patients with atrial fibrillation; however, limitations of current devices have slowed adoption. We present preclinical evaluations of a novel device, the Conformal Left Atrial Appendage Seal (CLAAS). Methods An in vitro assessment of conformability was conducted to evaluate the two CLAAS devices (regular 27 mm and large 35 mm) and a Watchman 2.5 (27 mm). Devices were placed within silicone tubes and compressed in a vise submerged in a water bath at 37°C. Changes in device diameter and visual seal were noted. Acute (n = 1) and chronic 60-day (n = 6) canine studies with gross and histologic assessment were performed. Results Conformability bench tests demonstrated that the regular CLAAS implant was able to seal oval orifices from 20 × 30 mm to 15 × 33 mm and the large from 30 × 35 mm to 20 × 40 mm. As the CLAAS implant was compressed in the minor diameter, it increased in the major diameter, thereby filling the oval space, whereas the Watchman 2.5 showed gaps and maintained its round configuration when compressed in one direction. Seven devices were successfully implanted in the canine model with complete seal without thrombus. Histologic examination showed complete neointima covering with minimal inflammation at 60 days. Conclusions Preclinical testing demonstrated the conformability of the CLAAS implant and its ability to seal the LAA. Clinical studies are ongoing to characterize the utility of the CLAAS implant in the treatment of patients with atrial fibrillation.
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Development of anti-thrombotic vaccine against human S100A9 in rhesus monkey. Sci Rep 2021; 11:11472. [PMID: 34075153 PMCID: PMC8169762 DOI: 10.1038/s41598-021-91153-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/24/2021] [Indexed: 02/08/2023] Open
Abstract
In post-stroke patients, a decreased adherence to antiplatelet drugs is a major challenge in the prevention of recurrent stroke. Previously, we reported an antiplatelet vaccine against S100A9 in mice, but the use of Freund’s adjuvant and the difference in amino acid sequences in epitopes between mice and humans were problematic for clinical use. Here, we redesigned the S100A9 vaccine for the common sequence in both humans and monkeys and examined its effects in cynomolgus monkeys with Alum adjuvant. First, we assessed several candidate epitopes and selected 102 to 112 amino acids as the suitable epitope, which could produce antibodies. When this peptide vaccine was intradermally injected into 4 cynomolgus monkeys with Alum, the antibody against human S100A9 was successfully produced. Anti-thrombotic effects were shown in two monkeys in a mixture of vaccinated serum and fresh whole blood from another cynomolgus monkey. Additionally, the anti-thrombotic effects were partially inhibited by the epitope peptide, indicating the feasibility of neutralizing anti-thrombotic effects of produced antibodies. Prolongation of bleeding time was not observed in vaccinated monkeys. Although further studies on increasing the effect of vaccine and safety are necessary, this vaccine will be a promising approach to improve adherence to antiplatelet drugs in clinical settings.
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Haeusler KG, Kirchhof P, Kunze C, Tütüncü S, Fiessler C, Malsch C, Olma MC, Jawad-Ul-Qamar M, Krämer M, Wachter R, Michalski D, Kraft A, Rizos T, Gröschel K, Thomalla G, Nabavi DG, Röther J, Laufs U, Veltkamp R, Heuschmann PU, Endres M. Systematic monitoring for detection of atrial fibrillation in patients with acute ischaemic stroke (MonDAFIS): a randomised, open-label, multicentre study. Lancet Neurol 2021; 20:426-436. [PMID: 34022169 DOI: 10.1016/s1474-4422(21)00067-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/12/2021] [Accepted: 02/18/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Systematic electrocardiogram (ECG) monitoring improves detection of covert atrial fibrillation in stroke survivors but the effect on secondary prevention is unknown. We aimed to assess the effect of systematic ECG monitoring of patients in hospital on the rate of oral anticoagulant use after 12 months. METHODS In this investigator-initiated, randomised, open-label, parallel-group multicentre study with masked endpoint adjudication, we recruited patients aged at least 18 years with acute ischaemic stroke or transient ischaemic attack without known atrial fibrillation in 38 certified stroke units in Germany. Patients were randomly assigned (1:1) to usual diagnostic procedures for atrial fibrillation detection (control group) or additional Holter-ECG recording for up to 7 days in hospital (intervention group). Patients were stratified by centre using a random permuted block design. The primary outcome was the proportion of patients on oral anticoagulants at 12 months after the index event in the intention-to-treat population. Secondary outcomes included the number of patients with newly diagnosed atrial fibrillation in hospital and the composite of recurrent stroke, major bleeding, myocardial infarction, or death after 6 months, 12 months, and 24 months. This trial was registered with ClinicalTrials.gov, NCT02204267, and is completed and closed for participants. FINDINGS Between Dec 9, 2014, and Sept 11, 2017, 3465 patients were randomly assigned, 1735 (50·1%) to the intervention group and 1730 (49·9%) to the control group. Oral anticoagulation status was available in 2920 (84·3%) patients at 12 months (1484 [50·8%] in the intervention group and 1436 [49·2%] in the control group). For the primary outcome, at 12 months, 203 (13·7%) of 1484 patients in the intervention group versus 169 (11·8%) of 1436 in the control group were on oral anticoagulants (odds ratio [OR] 1·2 [95% CI 0·9-1·5]; p=0·13). Atrial fibrillation was newly detected in patients in hospital in 97 (5·8%) of 1714 in the intervention group versus 68 (4·0%) of 1717 in the control group (hazard ratio [HR] 1·4 [95% CI 1·0-2·0]; p=0·024). The composite of cardiovascular outcomes and death did not differ between patients randomly assigned to the intervention group versus the control group at 24 months (232 [13·5%] of 1714 vs 249 [14·5%] of 1717; HR 0·9 [0·8-1·1]; p=0·43). Skin reactions due to study ECG electrodes were reported in 56 (3·3%) patients in the intervention group. All-cause death occured in 73 (4·3%) patients in the intervention group and in 103 (6·0%) patients in the control group (OR 0·7 [0·5-0·9]). INTERPRETATION Systematic core centrally reviewed ECG monitoring is feasible and increases the detection rate of atrial fibrillation in unselected patients hospitalised with acute ischaemic stroke or transient ischaemic attack, if added to usual diagnostic care in certified German stroke units. However, we found no effect of systematic ECG monitoring on the rate of oral anticoagulant use after 12 months and further efforts are needed to improve secondary stroke prevention. FUNDING Bayer Vital. TRANSLATION For the German translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany; Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany; German Atrial Fibrillation Network (AFNET), Münster, Germany
| | - Paulus Kirchhof
- German Atrial Fibrillation Network (AFNET), Münster, Germany; Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, UK; Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Department of Cardiology, Sandwell and West Birmingham NHS Trust, Birmingham, UK; University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Claudia Kunze
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Serdar Tütüncü
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Cornelia Fiessler
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Carolin Malsch
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Manuel C Olma
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie mit Abteilung für Experimentelle Neurologie, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Muhammad Jawad-Ul-Qamar
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Birmingham, UK; Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Department of Cardiology, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Michael Krämer
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany; Klinik für Kardiologie und Pneumologie, Universitätsmedizin Göttingen, Germany; German Centre of Cardiovascular Research, Göttingen, Germany
| | | | - Andrea Kraft
- Klinik für Neurologie, Krankenhaus Martha-Maria Halle, Halle, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Darius G Nabavi
- Department of Neurology, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Roland Veltkamp
- Department of Neurology, Alfried Krupp Krankenhaus, Essen, Germany; Department of Brain Sciences, Imperial College London, London UK
| | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany; Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité, Universitätsmedizin Berlin, Berlin, Germany; Klinik und Hochschulambulanz für Neurologie mit Abteilung für Experimentelle Neurologie, Charité, Universitätsmedizin Berlin, Berlin, Germany; German Center for Neurodegenerative Diseases (DZNE), Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany; Excellence Cluster NeuroCure, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany.
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Park J, Hong BY, Kim JS, Park JG, Jung J, Lim SH. Could DOAC Be a Better Choice Than Warfarin in Low Compliance Patients with Fontan Procedure? ACTA ACUST UNITED AC 2021; 57:medicina57050465. [PMID: 34068569 PMCID: PMC8151865 DOI: 10.3390/medicina57050465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: After the Fontan procedure, thromboembolic events need to be prevented. We present a young patient with a history of Fontan procedure and poor adherence to warfarin who developed systemic thromboembolism. He was changed to maintenance dabigatran, which is one of the available direct oral anticoagulants (DOACs). Case presentation: A 20-year-old man was diagnosed with cerebral infarct, pulmonary thromboembolism (PTE), and renal infarcts. He was prescribed warfarin to prevent thromboembolic events after the Fontan procedure. Based on his poor adherence to warfarin, we decided to change the anticoagulant therapy from warfarin to dabigatran 150 mg bid. One month later, his pulmonary thromboembolism regressed. Conclusion: Our case report showed a young adult with low compliance to warfarin who developed cerebral, pulmonary, and renal thromboembolic events. Thus, in our opinion, the change from warfarin to a DOAC was necessary for further prevention and treatment of PTE. A change from warfarin to a DOAC should be considered in patients with poor compliance who are at high risk of thromboembolic events, for example, after the Fontan procedure.
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Affiliation(s)
| | | | | | | | | | - Seong-Hoon Lim
- Correspondence: ; Tel.: +82-(31)-249-7650; Fax: +82-(31)-251-4481
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Shani SD, Sylaja PN, Sankara Sarma P, Raman Kutty V. Facilitators and barriers to medication adherence among stroke survivors in India. J Clin Neurosci 2021; 88:185-190. [PMID: 33992182 DOI: 10.1016/j.jocn.2021.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/21/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
Strict compliance with medication and life style modification are integral to secondary stroke prevention. This study was undertaken to find out medication adherence among stroke survivors and factors associated with it. Cross sectional survey among stroke survivors was conducted. Interview based self-reported medication adherence was defined as consumption at least >80% of their medications for last two weeks, based on last prescription. Structured interview using pretested interview schedule was done to collect other data. Sequential step wise logistic regression analysis was done to find out the facilitators and barriers to medication adherence. Two hundred and forty stroke survivors (mean age 58.64 ± 10.96 years; 25.4% females) with a mean post-stroke period of 6.65 ± 3.36 months were participated. Overall medication adherence was 43.8% (n = 105). Medication adherence was 34.3% (n = 134), 52.6% (n = 190) and 56.7% (n = 224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio (OR) = 4.85; 95% Confidence Interval (CI) 2.12-11.08, Hypertension: OR = 3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR = 3.88; 95% CI 1.96-4.04). Having daily routine (OR = 2.82; 95% CI 1.52-5.25), perceived need of medication (OR = 2.33; 95% CI 1.04-5.2) and perceived poor state of health (OR = 2.65; 95% CI 1.30-5.40) were facilitators. Memory issues (OR = 0.34; 95% CI 0.16-0.71), side effects (OR = 0.24; 95% CI 0.11-0.42) and financial constraints (OR = 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Establishing daily routines, periodic reminders, financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.
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Affiliation(s)
- S D Shani
- Achutha Menon Centre for Health Sciences Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India
| | - P N Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala 695 011, India.
| | - P Sankara Sarma
- Achutha Menon Centre for Health Sciences Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Thiruvananthapuram, Kerala, India
| | - V Raman Kutty
- Research Director, Amala Cancer Research Centre, Thrissur 680555, India
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Kim BJ, Cho YJ, Hong KS, Lee J, Kim JT, Choi KH, Park TH, Park SS, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi JC, Kim WJ, Shin DI, Sohn SI, Hong JH, Lee JS, Lee J, Han MK, Gorelick PB, Bae HJ. Treatment Intensification for Elevated Blood Pressure and Risk of Recurrent Stroke. J Am Heart Assoc 2021; 10:e019457. [PMID: 33787300 PMCID: PMC8174371 DOI: 10.1161/jaha.120.019457] [Citation(s) in RCA: 3] [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: 02/01/2023]
Abstract
Background It remains unclear whether physicians' attitudes toward timely management of elevated blood pressure affect the risk of stroke recurrence. Methods and Results From a multicenter stroke registry database, we identified 2933 patients with acute ischemic stroke who were admitted to participating centers in 2011, survived at the 1‐year follow‐up period, and returned to outpatient clinics ≥2 times after discharge. As a surrogate measure of physicians' attitude, individual treatment intensification (TI) scores were calculated by dividing the difference between the frequencies of observed and expected medication changes by the frequency of clinic visits and categorizing them into 5 groups. The association between TI groups and the recurrence of stroke within 1 year was analyzed using hierarchical frailty models, with adjustment for clustering within each hospital and relevant covariates. Mean±SD of the TI score was −0.13±0.28. The TI score groups were significantly associated with increased risk of recurrent stroke compared with Group 3 (TI score range, −0.25 to 0); Group 1 (range, −1 to −0.5), adjusted hazard ratio (HR) 13.43 (95% CI, 5.95–30.35); Group 2 (range, −0.5 to −0.25), adjusted HR 4.59 (95% CI, 2.01–10.46); and Group 4 (TI score 0), adjusted HR 6.60 (95% CI, 3.02–14.45); but not with Group 5 (range, 0–1), adjusted HR 1.68 (95% CI, 0.62–4.56). This elevated risk in the lowest TI score groups persisted when confining analysis to those with hypertension, history of blood pressure‐lowering medication, no atrial fibrillation, and regular clinic visits and stratifying the subjects by functional capacity at discharge. Conclusions A low TI score, which implies physicians' therapeutic inertia in blood pressure management, was associated with a higher risk of recurrent stroke. The TI score may be a useful performance indicator in the outpatient clinic setting to prevent recurrent stroke.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Yong-Jin Cho
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Keun-Sik Hong
- Department of Neurology Ilsan Paik HospitalInje University Goyang Republic of Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Kang Ho Choi
- Department of Neurology Chonnam National University Medical School and Hospital Gwangju Republic of Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Sang-Soon Park
- Department of Neurology Seoul Medical Center Seoul Republic of Korea
| | - Jong-Moo Park
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Kyusik Kang
- Department of Neurology Eulji General Hospital Eulji University Seoul Republic of Korea
| | - Soo Joo Lee
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae Guk Kim
- Department of Neurology Eulji University HospitalEulji University Daejeon Republic of Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Dae-Hyun Kim
- Department of Neurology Dong-A University College of Medicine Busan Republic of Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Kyung-Ho Yu
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Republic of Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Wi-Sun Ryu
- Department of Neurology Dongguk University Ilsan Hospital Goyang Republic of Korea
| | - Jay Chol Choi
- Department of Neurology Jeju National University Jeju Republic of Korea
| | - Wook-Joo Kim
- Department of Neurology Ulsan University HospitalUniversity of Ulsan College of Medicine Ulsan Republic of Korea
| | - Dong-Ick Shin
- Department of Neurology Chungbuk National University Hospital Cheongju Republic of Korea
| | - Sung Il Sohn
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Jeong-Ho Hong
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Republic of Korea
| | - Ji Sung Lee
- Clinical Research Center Asan Medical Center Seoul Republic of Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul Republic of Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
| | - Philip B Gorelick
- Davee Department of Neurology Northwestern University Feinberg School of Medicine Chicago IL
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center Seoul National University Bundang HospitalSeoul National University College of Medicine Seongnam Republic of Korea
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Gynnild MN, Aakerøy R, Spigset O, Askim T, Beyer MK, Ihle-Hansen H, Munthe-Kaas R, Knapskog AB, Lydersen S, Naess H, Røsstad TG, Seljeseth YM, Thingstad P, Saltvedt I, Ellekjaer H. Vascular risk factor control and adherence to secondary preventive medication after ischaemic stroke. J Intern Med 2021; 289:355-368. [PMID: 32743852 DOI: 10.1111/joim.13161] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/22/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Studies regarding adequacy of secondary stroke prevention are limited. We report medication adherence, risk factor control and factors influencing vascular risk profile following ischaemic stroke. METHODS A total of 664 home-dwelling participants in the Norwegian Cognitive Impairment After Stroke study, a multicenter observational study, were evaluated 3 and 18 months poststroke. We assessed medication adherence by self-reporting (4-item Morisky Medication Adherence Scale) and medication persistence (defined as continuation of medication(s) prescribed at discharge), achievement of guideline-defined targets of blood pressure (BP) (<140/90 mmHg), low-density lipoprotein cholesterol (LDL-C) (<2.0 mmol L-1 ) and haemoglobin A1c (HbA1c) (≤53 mmol mol-1 ) and determinants of risk factor control. RESULTS At discharge, 97% were prescribed antithrombotics, 88% lipid-lowering drugs, 68% antihypertensives and 12% antidiabetic drugs. Persistence of users declined to 99%, 88%, 93% and 95%, respectively, at 18 months. After 3 and 18 months, 80% and 73% reported high adherence. After 3 and 18 months, 40.7% and 47.0% gained BP control, 48.4% and 44.6% achieved LDL-C control, and 69.2% and 69.5% of diabetic patients achieved HbA1c control. Advanced age was associated with increased LDL-C control (OR 1.03, 95% CI 1.01 to 1.06) and reduced BP control (OR 0.98, 0.96 to 0.99). Women had poorer LDL-C control (OR 0.60, 0.37 to 0.98). Polypharmacy was associated with increased LDL-C control (OR 1.29, 1.18 to 1.41) and reduced HbA1c control (OR 0.76, 0.60 to 0.98). CONCLUSION Risk factor control is suboptimal despite high medication persistence and adherence. Improved understanding of this complex clinical setting is needed for optimization of secondary preventive strategies.
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Affiliation(s)
- M N Gynnild
- From the, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Stroke Unit, Department of Internal Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - R Aakerøy
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - O Spigset
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - T Askim
- From the, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - M K Beyer
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - H Ihle-Hansen
- Department of Medicine, Vestre Viken Hospital Trust, Baerum Hospital, Drammen, Norway.,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - R Munthe-Kaas
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Medicine, Vestre Viken Hospital Trust, Baerum Hospital, Drammen, Norway
| | - A B Knapskog
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - S Lydersen
- Department of Mental Health, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - H Naess
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Centre for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - T G Røsstad
- Department of Health and Welfare Services, City of Trondheim, Trondheim, Norway
| | - Y M Seljeseth
- Medical Department, Ålesund Hospital, Møre and Romsdal Health Trust, Ålesund, Norway
| | - P Thingstad
- From the, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - I Saltvedt
- From the, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Department of Geriatric Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - H Ellekjaer
- From the, Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Science, NTNU - Norwegian University of Science and Technology, Trondheim, Norway.,Stroke Unit, Department of Internal Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B. Non-persistence with anti-platelet therapy and long-term mortality after ischemic stroke: A nationwide study. PLoS One 2021; 16:e0244718. [PMID: 33561124 PMCID: PMC7872250 DOI: 10.1371/journal.pone.0244718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022] Open
Abstract
Background We tried to investigate the effect of non-persistence with antiplatelets after ischemic stroke on long-term all-cause mortality (ACM). Methods and findings We selected newly diagnosed ischemic stroke patients aged ≥20years who were newly treated with aspirin or clopidogrel from 2003–2010 Korean National Health Insurance Service-National Sample Cohort, a random sample of 2.2% of total population. Subjects were divided into two pairs of groups according to persistence with antiplatelets at 6 and 12 months: those who discontinued antiplatelets within 6 months (DA6M) and those who continued them for 6 or months or more (CA6M); and those who discontinued antiplatelets within 12 months (DA12M) and those who continued them for 12 months or more (CA12M). Those who died within 6 months among DA6M and those who died within 12 months among DA12M were excluded along with those with medication possession ratio<80% among CA6M and CA12M. Subjects were followed-up until death or December 31, 2013. Among 3,559 total subjects, DA6M were 1,080 and CA6M were 2,479 while, out of 3,628 total patients, DA12M were 1,434 and CA12M were 2,194. The risks of ACM [adjusted hazard ratio (aHR), 2.25; 95% confidence interval (CI), 1.94–2.61], cerebro-cardiovascular disease (CVD) death (aHR, 2.52; 95% CI, 1.96–3.24) and non-CVD death (aHR, 2.11; 95% CI, 1.76–2.64) of DA6M were all significantly increased compared to CA6M. DA12M also had significantly higher risks of ACM (aHR, 1.93; 95% CI, 1.65–2.25), CVD mortality (aHR, 2.13; 95% CI; 1.63–2.77) and non-CVD mortality (aHR, 1.83;95% CI 1.51–2.22) than DA12M but aHRs were lower than that between DA6M and CA6M. The difference rates of ACM, CVD death, and non-CVD death between non-persistent and persistent groups all continuously widened over time but the degree of difference was gradually decreased. Conclusions Maintaining antiplatelets for the first 12 months after ischemic stroke reduces long-term risks of both CVD death and non-CVD death.
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Affiliation(s)
- Seung Jae Kim
- Department of Family Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Oh Deog Kwon
- Republic of Korea Navy 2nd Fleet Medical Corps, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, Republic of Korea
- Nuvizen, Palo Alto, CA, United States of America
- * E-mail: (HCC); (EJL)
| | - Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- * E-mail: (HCC); (EJL)
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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Zhang L, Shi J, Pan Y, Li Z, Yan H, Liu C, Lv W, Meng X, Wang Y. Secondary prevention medication persistence and prognosis of acute ischaemic stroke or transient ischaemic attack. Stroke Vasc Neurol 2021; 6:376-383. [PMID: 33526631 PMCID: PMC8485245 DOI: 10.1136/svn-2020-000471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 12/08/2020] [Accepted: 01/02/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction The risk of disability and mortality is high among recurrent stroke, which highlights the importance of secondary prevention measures. We aim to evaluate medication persistence for secondary prevention and the prognosis of acute ischaemic stroke or transient ischaemic attack (TIA) in China. Methods Patients with acute ischaemic stroke or TIA from the China National Stroke Registry II were divided into 3 groups based on the percentage of persistence in secondary prevention medication classes from discharge to 3 months after onset (level I: persistence=0%, level II: 0%<persistence<100%, level III: persistence=100%). The primary outcome was recurrent stroke. The secondary outcomes included composite events (stroke, myocardial infarction or death from cardiovascular cause), all-cause death and disability (modified Rankin Scale score=3–5) from 3 months to 1 year after onset. Recurrent stroke, composite events and all-cause death were performed using Cox regression model, and disability was identified through logistic regression model using the generalised estimating equation method. Results 18 344 patients with acute ischaemic stroke or TIA were included, 315 (1.7%) of whom experienced recurrent strokes. Compared with level I, the adjusted HR of recurrent stroke for level II was 0.41 (95% CI 0.31 to 0.54) and level III 0.37 (0.28 to 0.48); composite events for level II 0.41 (0.32 to 0.53) and level III 0.38 (0.30 to 0.49); all-cause death for level II 0.28 (0.23 to 0.35) and level III 0.20 (0.16–0.24). Compared with level I, the adjusted OR of disability for level II was 0.89 (0.77 to 1.03) and level III 0.82 (0.72 to 0.93). Conclusions Persistence in secondary prevention medications, especially in all classes of medications prescribed by the physician, was associated with lower hazard of recurrent stroke, composite events, all-cause death and lower odds of disability in patients with acute ischaemic stroke or TIA.
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Affiliation(s)
- Lei Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Changping District Hospital, Beijing, China
| | - Junfeng Shi
- Yixing People's Hospital, Jiangsu Province, China
| | - Yuesong Pan
- 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
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chelsea Liu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wei Lv
- 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
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Wu W, Wang W, Yuan Y, Lin L, Tan Y, Yang J, Dai L, Wang Y. Knowledge, attitude and practice concerning healthcare-associated infections among healthcare workers in Wuhan, China: cross-sectional study. BMJ Open 2021; 11:e042333. [PMID: 33402407 PMCID: PMC7786794 DOI: 10.1136/bmjopen-2020-042333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES To assess the knowledge, attitude and practice (KAP) concerning healthcare-associated infections (HAIs) among healthcare givers and to identify the factors influencing KAP. DESIGN This was a hospital-based, cross-sectional study. SETTING Two public hospitals in Wuhan, central China. PARTICIPANTS Participants were recruited among healthcare workers (HCWs) of one general hospital and one children's hospital in Wuhan city between 1 June and 30 September 2019. PRIMARY AND SECONDARY OUTCOME MEASURES The outcomes were KAPs concerning HAIs. RESULTS Data from 455 HCWs were included in the final data analysis. The mean scores of KAP and total KAP were 15.67±3.32, 25.00±2.75, 43.44±5.15 and 84.76±6.72, respectively. The following factors were significantly associated with the total KAP score concerning HAIs, explaining 61% of the variance (p<0.001): gender (β=2.36, 95% CI 1.11 to 4.40), age (β=6.65, 95% CI 5.07 to 7.74), position (β=7.02, 95% CI 3.88 to 8.45), type of employment (β=-1.08, 95% CI -2.08 to -0.07), with HAI education within last year (β=-2.98, 95% CI -4.23 to -1.72), with invasive operation authority (β=-4.22, 95% CI -5.46 to -2.99), antibacterial drug training (β=-4.38, 95% CI -5.45 to -3.31) and with antibacterial drug training and clinical consultation (β=-4.35, 95% CI -5.38 to -3.32). CONCLUSION The controllable factors identified in this study can be used by hospital managers to implement measures that improve KAP among HCWs. Moreover, these measures should be customised, based on uncontrollable factors to suit the specific characteristics of medical staff and to improve KAP. Training programmes should be designed for medical workers to increase their awareness of HAIs and to foster positive attitudes and practices.
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Affiliation(s)
- Wenwen Wu
- School of Public Health and Management, Hubei University of Medicine, Shiyan, Hubei, China
| | - Wenru Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yufeng Yuan
- Department of Nosocomial Infection Management, Wuhan University Zhongnan Hospital, Wuhan, Hubei, China
| | - Likai Lin
- Institute of Hospital Management, Wuhan University, Wuhan, Hubei, China
| | - Yibin Tan
- Department of Nosocomial Infection Management, Wuhan University Zhongnan Hospital, Wuhan, Hubei, China
| | - Jinru Yang
- School of Medicine, Wuhan University of Science and Technology, Wuhan, Hubei, China
| | - Li Dai
- Department of Cardiovascular Medicine, Affiliated Dongfeng Hospital, Hubei University of Medicine, Shiyan, Hubei, China
| | - Ying Wang
- Department of Nosocomial Infection Management, Wuhan University Zhongnan Hospital, Wuhan, Hubei, China
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50
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Stroke patients' support: evaluation of knowledge, practices and training needs of French community pharmacists. Int J Clin Pharm 2021; 43:980-989. [PMID: 33387187 DOI: 10.1007/s11096-020-01204-z] [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: 12/18/2019] [Accepted: 11/16/2020] [Indexed: 10/22/2022]
Abstract
Background Stroke represents a major Public Health issue in industrialized countries because of its frequency and severity. In secondary stroke prevention, treatment efficacy is correlated to medication adherence. However, it remains suboptimal in stroke patients. Community pharmacists, in light of their positioning in the care pathway and proximity to patients, can play an essential role in patient support and improving treatment adherence. However, it is currently unknown whether pharmacists are ready to perform this task. Objective Evaluate knowledge, practices and training needs for community pharmacists in therapeutic stroke management to improve long term care for stroke patients. Setting Community pharmacies in the Rhone Alpes region (France). Method We conducted a cross sectional study via a standardized self-assessment questionnaire consisting of 40 questions divided into three parts. The latter was designed by a multidisciplinary team and distributed electronically to community pharmacists of the Rhône-Alpes region (France). Main outcome measure (a) global knowledge score on the pathology, risk factors and clinical care management, (b) description of the support practices for stroke patients, (c) training needs for pharmacists. Results The 104 participants presented a moderate level of knowledge (global score: 12/20 ± 3). Topics best mastered were: pathophysiology, target blood pressure and place of antiplatelets in the therapeutic strategy. Knowledge items that needed improvement were: warning signs correctly identified by 44% of participants, time delay for thrombolysis for which 14% answered correctly, target glycated hemoglobin levels were correct for 41%, and the 3 recommended antihypertensive drug classes were only identified by 5% of participants. Patient education received from pharmacists concerned dosage (89%), treatment adherence (88%), benefits (66%) and administration modalities of medicines (64%), management of risk factors (75% for diet, 73% for physical activity, 70% for smoking and 53% for alcohol). All pharmacists wanted additional training on risk factors and clinical management guidelines. Conclusion Based on this small study, the fragmented knowledge and varied practices promote the need for further training for pharmacists to optimize support of stroke patients. This study promotes the elaboration of training systems adapted to pharmacists' needs. This will help support the development of a targeted pharmaceutical care approach for stroke patients.
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