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Saeed D, Fuenmayor D, Niño Medina JA, Saleh I, Castiblanco Torres JD, Horn WL, Sosa Quintanilla MH, Leiva KE, Dannuncio V, Viteri M, Rivas M, Kumari N. Unraveling the Paradox: Can Anticoagulation Improve Outcomes in Patients With Heart Failure and Increased Bleeding Risk? Cureus 2024; 16:e57544. [PMID: 38707016 PMCID: PMC11068119 DOI: 10.7759/cureus.57544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/07/2024] Open
Abstract
Heart failure (HF) patients frequently present with comorbidities such as atrial fibrillation (AF) or other cardiovascular conditions, elevating their risk of thromboembolic events. Consequently, anticoagulation therapy is often considered for thromboprophylaxis, although its initiation in HF patients is complicated by concomitant bleeding risk factors. This review explores the paradoxical relationship between HF, increased bleeding risk, and the potential benefits of anticoagulation. Through an examination of existing evidence from clinical trials, observational studies, and meta-analyses, we aim to elucidate the role of anticoagulation in HF patients with increased bleeding risk. Despite guidelines recommending anticoagulation for certain HF patients with AF or other thromboembolic risk factors, uncertainty persists regarding the optimal management strategy for those at heightened risk of bleeding. The review discusses the pathophysiological mechanisms linking HF and thrombosis, challenges in bleeding risk assessment, and strategies to minimize bleeding risk while optimizing thromboprophylaxis. Shared decision-making between clinicians and patients is emphasized as essential for individualized treatment plans that balance the potential benefits of anticoagulation against the risk of bleeding complications. Furthermore, it examines emerging anticoagulant agents and their potential role in HF management, highlighting the need for further research to delineate optimal management strategies and inform evidence-based practice. In conclusion, while anticoagulation holds promise for improving outcomes in HF patients, careful consideration of patient-specific factors and ongoing research efforts are essential to optimize therapeutic strategies in this population.
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Affiliation(s)
- Danish Saeed
- Internal Medicine, Shaikh Zayed Medical Complex, Lahore, PAK
| | | | - Jose A Niño Medina
- Faculty of Legal and Political Sciences, Universidad de Carabobo, Valencia, VEN
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Inam Saleh
- Pediatrics, University of Kentucky College of Medicine, Lexington, USA
| | | | - Wendys L Horn
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | | | - Karen E Leiva
- General Medicine and Surgery, National Autonomous University of Honduras, Tegucigalpa, HND
| | | | - Maria Viteri
- Metabolic Syndrome Department, Hospital General Ambato, Ambato, ECU
| | - Miguel Rivas
- Faculty of Health Sciences, Universidad de Carabobo, Valencia, VEN
| | - Neelam Kumari
- Internal Medicine, Jinnah Medical & Dental College, Karachi, PAK
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He G, Wei L, Lu H, Deng J, Wang F, Zhu Y. Core overestimation of CT perfusion in patients with cardiac insufficiency who had a stroke is mediated by impaired collaterals. J Neurointerv Surg 2023; 16:31-37. [PMID: 36898828 DOI: 10.1136/jnis-2023-020096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 02/28/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND We hypothesized that left ventricular systolic dysfunction (LVSD) would lead to an ischemic core overestimation in patients with acute ischemic stroke (AIS), and impaired collateral status might partly mediate this effect. OBJECTIVE A pixel-based analysis of CT perfusion (CTP) and follow-up CT was undertaken to investigate the optimum CTP thresholds for the ischemic core if overestimation was found. METHODS A total of 208 consecutive patients with AIS with large vessel occlusion in the anterior circulation, who received initial CTP evaluation and successful reperfusion, were retrospectively analyzed and divided into an LVSD (left ventricular ejection fraction (LVEF) ratio <50%; n=40) and a normal cardiac function (LVEF≥50%; n=168) group. Ischemic core overestimation was considered when the CTP-derived core was larger than the final infarct volume. We investigated the relationship between cardiac function, probability for core overestimation, and collateral scores using mediation analysis. A pixel-based analysis was undertaken to define the optimum CTP thresholds for ischemic core. RESULTS LVSD was independently associated with impaired collaterals (aOR=4.28, 95% CI 2.01 to 9.80, P<0.001) and core overestimation (aOR=2.52, 95% CI 1.07 to 5.72, P=0.030). In mediation analysis, the total effect on core overestimation is composed of the direct effect of LVSD (+17%, P=0.034) and the mediated indirect effect of collateral status (+6%, P=0.020). Collaterals explained 26% of the effect of LVSD on core overestimation. Compared with relative cerebral blood flow (rCBF) thresholds of <35%, <30%, and <20%, a rCBF <25% cut-off point had the highest correlation (r=0.91) and best agreement (mean difference 3.2±7.3 mL) with the final infarct volume to determine the CTP-derived ischemic core in patients with LVSD. CONCLUSIONS LVSD increased the possibility of ischemic core overestimation on baseline CTP, partly due to impaired collateral status, and a stricter rCBF threshold should be considered.
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Affiliation(s)
- Guangchen He
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liming Wei
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haitao Lu
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiangshan Deng
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Doehner W, Böhm M, Boriani G, Christersson C, Coats AJS, Haeusler KG, Jones ID, Lip GYH, Metra M, Ntaios G, Savarese G, Shantsila E, Vilahur G, Rosano G. Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis. Eur J Heart Fail 2023; 25:2107-2129. [PMID: 37905380 DOI: 10.1002/ejhf.3071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow) and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Saarland University (Kardiologie, Angiologie und Internistische Intensivmedizin), Homburg, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | | | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Shantsila
- Department of Primary Care, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gemma Vilahur
- Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau and CIBERCV, Barcelona, Spain
| | - Giuseppe Rosano
- St George's University Hospital, London, UK, San Raffaele Cassino, Rome, Italy
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Chua SK, Huang PS, Chen JJ, Chiu FC, Hwang JJ, Tsai CT. Use of the CHA 2DS 2-VASc score to predict subsequent myocardial infarction in atrial fibrillation. Hellenic J Cardiol 2023:S1109-9666(23)00147-1. [PMID: 37633490 DOI: 10.1016/j.hjc.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND The risk of subsequent myocardial infarction (MI) varies widely in patients with atrial fibrillation (AF). No convenient scoring system currently exists to identify MI in AF. While each element of the CHA2DS2-VASc (congestive heart failure; hypertension; age ≥75 years [doubled]; type 2 diabetes; previous stroke or thromboembolism [doubled]; vascular disease; age 65-75 years; and sex category) score can increase the likelihood of MI, this retrospective longitudinal study aimed to determine the accuracy of the CHA2DS2-VASc score in predicting subsequent MI risk in AF. METHODS A total of 29,341 patients with AF were enrolled and followed up from January 2010 until the first occurrence of MI or until December 2020. The primary endpoint was the occurrence of subsequent MI. RESULTS The average age of the study population was 71 years, and 43.2% were male. The mean CHA2DS2-VASc score was found to be higher in patients with AF who had experienced an MI than in those who had not (3.56 ± 1.92 vs. 3.32 ± 1.81, p < 0.001). During the long-term follow-up, the risk of subsequent MI increased by 22% with every one-point increase in the CHA2DS2-VASc score (hazard ratio 1.22, 95% confidence interval 1.19-1.25; p < 0.001). Kaplan-Meier analysis revealed that high CHA2DS2-VASc scores were more likely to experience an MI than those with low CHA2DS2-VASc scores (log-rank p < 0.001). Furthermore, the CHA2DS2-VASc score was a significant predictor of MI in multivariate regression analysis. CONCLUSION The CHA2DS2-VASc score is a valuable predictor of subsequent MI risk in patients with AF.
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Affiliation(s)
- Su-Kiat Chua
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, ROC; Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan, ROC
| | - Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan, ROC
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan, ROC
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 100, Taiwan, ROC; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 100, Taiwan, ROC; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan, ROC.
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Yaghi S. Diagnosis and Management of Cardioembolic Stroke. Continuum (Minneap Minn) 2023; 29:462-485. [PMID: 37039405 DOI: 10.1212/con.0000000000001217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cardioembolic stroke accounts for nearly 30% of ischemic strokes. Prompt diagnosis of the underlying mechanism may improve secondary prevention strategies. This article reviews recent randomized trials, observational studies, case reports, and guidelines on the diagnosis and treatment of cardioembolic stroke. LATEST DEVELOPMENTS Several pathologies can lead to cardioembolic stroke, including atrial fibrillation, aortic arch atheroma, patent foramen ovale, left ventricular dysfunction, and many others. Secondary stroke prevention strategies differ across these heterogeneous mechanisms. In addition to medical treatment advances such as the use of direct oral anticoagulants in patients with atrial fibrillation, surgical treatments such as closure of patent foramen ovale have been shown to reduce the risk of recurrent stroke in select patients. Furthermore, left atrial appendage occlusion is a promising strategy for patients with atrial fibrillation who are candidates for short-term oral anticoagulation therapy but not long-term oral anticoagulation therapy. ESSENTIAL POINTS A thorough diagnostic evaluation is essential to determine cardioembolic causes of stroke. In addition to risk factor management and lifestyle modifications, identification and targeting of the underlying cardioembolic stroke mechanisms will lead to improved stroke prevention strategies in patients with cardioembolic stroke.
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6
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Yoshida Y, Jin Z, Russo C, Homma S, Nakanishi K, Ito K, Mannina C, Elkind MSV, Rundek T, Yoshita M, DeCarli C, Wright CB, Sacco RL, Di Tullio MR. Subclinical left ventricular systolic dysfunction and incident stroke in the elderly: long-term findings from Cardiovascular Abnormalities and Brain Lesions. Eur Heart J Cardiovasc Imaging 2023; 24:522-531. [PMID: 35900282 PMCID: PMC10226754 DOI: 10.1093/ehjci/jeac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Heart disease is associated with an increased risk for ischaemic stroke. However, the predictive value of reduced left ventricular ejection fraction (LVEF) for stroke is controversial and only observed in patients with severe reduction. LV global longitudinal strain (LV GLS) can detect subclinical LV systolic impairment when LVEF is normal. We investigated the prognostic role of LV GLS for incident stroke in a predominantly elderly cohort. METHODS AND RESULTS Two-dimensional echocardiography with speckle tracking was performed in the Cardiac Abnormalities and Brain Lesions (CABL) study. Among 708 stroke-free participants (mean age 71.4 ± 9.4 years, 60.9% women), abnormal LV GLS (>-14.7%: 95% percentile of the subgroup without risk factors) was detected in 133 (18.8%). During a mean follow-up of 10.8 ± 3.9 years, 47 participants (6.6%) experienced an ischaemic stroke (26 cardioembolic or cryptogenic, 21 other subtypes). The cumulative incidence of ischaemic stroke was significantly higher in participants with abnormal LV GLS than with normal LV GLS (P < 0.001). In multivariate stepwise logistic regression analysis, abnormal LV GLS was associated with ischaemic stroke independently of cardiovascular risk factors including LVEF, LV mass, left atrial volume, subclinical cerebrovascular disease at baseline, and incident atrial fibrillation [hazard ratio (HR): 2.69, 95% confidence interval (CI): 1.47-4.92; P = 0.001]. Abnormal LV GLS independently predicted cardioembolic or cryptogenic stroke (adjusted HR: 3.57, 95% CI: 1.51-8.43; P = 0.004) but not other subtypes. CONCLUSION LV GLS was a strong independent predictor of ischaemic stroke in a predominantly elderly stroke-free cohort. Our findings provide insights into the brain-heart interaction and may help improve stroke primary prevention strategies.
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Affiliation(s)
- Yuriko Yoshida
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Zhezhen Jin
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Cesare Russo
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Koki Nakanishi
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Kazato Ito
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Carlo Mannina
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitchell S V Elkind
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Tatjana Rundek
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Mitsuhiro Yoshita
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Charles DeCarli
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Clinton B Wright
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Ralph L Sacco
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
| | - Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia university Irving Medical Center, 630 W 168th St, New York, NY 10032, USA
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Patel P, Tiongson J, Chen A, Siegal T, Oak S, Golla A, Kamen S, Thon JM, Vigilante N, Rana A, Hester T, Siegler JE. Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke. Front Neurol 2022; 13:1041806. [PMID: 36588887 PMCID: PMC9797677 DOI: 10.3389/fneur.2022.1041806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. Methods We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Results Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. Conclusion In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.
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Affiliation(s)
- Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Justin Tiongson
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Austin Chen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Taylor Siegal
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Akhil Golla
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | | | - Ameena Rana
- Department of Neurology, Sinai Beth Israel Hospital, New York, NY, United States
| | - Taryn Hester
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - James E. Siegler
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States,*Correspondence: James E. Siegler
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Ng TP, Wong C, Leong ELE, Tan BY, Chan MYY, Yeo LL, Yeo TC, Wong RC, Leow AS, Ho JSY, Sia CH. Simultaneous cardio-cerebral infarction: a meta-analysis. QJM 2022; 115:374-380. [PMID: 34051098 DOI: 10.1093/qjmed/hcab158] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 05/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND/INTRODUCTION Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse. AIM We aimed to summarize the reported cardio-cerebral infarction cases in the literature. DESIGN Meta-analysis. METHODS Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors. RESULTS A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported. DISCUSSION/CONCLUSION The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.
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Affiliation(s)
- T P Ng
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - E L E Leong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10 , 119228, Singapore
| | - B Y Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road , NUHS Tower Block Level 10, 119228, Singapore
- Division of Neurology, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - M Y-Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road, 119074, Singapore
| | - L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Division of Neurology, University Medicine Cluster, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - T-C Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road, 119074, Singapore
| | - R C Wong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore, 5 Lower Kent Ridge Road , 119074, Singapore
| | - A S Leow
- Internal Medicine Residency, National University Health System, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
| | - J S-Y Ho
- Academic Foundation Programme, North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX, UK
| | - C-H Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore , 5 Lower Kent Ridge Road, 119074, Singapore
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Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
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Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
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10
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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11
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Ito K, Li S, Homma S, Thompson JLP, Buchsbaum R, Matsumoto K, Anker SD, Qian M, Di Tullio MR. Left ventricular dimensions and cardiovascular outcomes in systolic heart failure: the WARCEF trial. ESC Heart Fail 2021; 8:4997-5009. [PMID: 34545701 PMCID: PMC8712869 DOI: 10.1002/ehf2.13560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 04/23/2021] [Accepted: 08/03/2021] [Indexed: 11/16/2022] Open
Abstract
Aims There is limited information on the association between left ventricular (LV) dimensions and cardiovascular (CV) outcomes in patients with heart failure (HF) with reduced LV ejection fraction (HFrEF) receiving recommended HF treatment. We investigated the association between LV dimensions and CV outcomes in HFrEF patients receiving recommended HF treatment. Methods and results We investigated the association between LV echocardiographic dimensions and CV outcomes using conventional Cox models in 1138 HFrEF patients in sinus rhythm randomized to warfarin or aspirin treatment in the Warfarin vs. Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. LV enlargement, whether by diameter [LV end‐diastolic diameter index (LVEDDI) and LV end‐systolic diameter index (LVESDI)] or volume [LV end‐diastolic volume index (LVEDVI) and LV end‐systolic volume index (LVESVI)], was independently associated with all‐cause death [LVEDDI: hazard ratio (HR) per cm/m2 1.53, LVESDI: HR per cm/m2 1.65, LVEDVI: HR per 10 mL/m2 1.07, and LVESVI: HR per 10 mL/m2 1.10; all P values < 0.001], CV death (HR 1.68, 1.79, 1.09, and 1.12, respectively; all P values < 0.001), and HF hospitalization (HR 1.59, 1.79, 1.06, and 1.08, respectively; all P values < 0.001). No association was observed with myocardial infarction or stroke. The associations were independent of LV ejection fraction values, and incremental to them. LV volumes conferred additional predictive value over LV diameters. Conclusions Left ventricular enlargement is an independent predictor of CV events in patients with HFrEF and recommended HF treatment. LV dimensions should be considered in the risk assessment.
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Affiliation(s)
- Kazato Ito
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - Siyuan Li
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Shunichi Homma
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - John L P Thompson
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Richard Buchsbaum
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Kenji Matsumoto
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
| | - Stefan D Anker
- Department of Cardiology, Berlin Institute of Health Center for Regenerative Therapies, and German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Min Qian
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Marco R Di Tullio
- Department of Medicine, Columbia University Irving Medical Center, PH3-342, 622 West 168th Street, New York, NY, 10032, USA
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12
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Liu C, Chen S, Zhang H, Chen Y, Gao Q, Chen Z, Liu Z, Wang J. Bioinformatic analysis for potential biological processes and key targets of heart failure-related stroke. J Zhejiang Univ Sci B 2021; 22:718-732. [PMID: 34514752 DOI: 10.1631/jzus.b2000544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This study aimed to uncover underlying mechanisms and promising intervention targets of heart failure (HF)-related stroke. HF-related dataset GSE42955 and stroke-related dataset GSE58294 were obtained from the Gene Expression Omnibus (GEO) database. Weighted gene co-expression network analysis (WGCNA) was conducted to identify key modules and hub genes. Gene Ontology (GO) and pathway enrichment analyses were performed on genes in the key modules. Genes in HF- and stroke-related key modules were intersected to obtain common genes for HF-related stroke, which were further intersected with hub genes of stroke-related key modules to obtain key genes in HF-related stroke. Key genes were functionally annotated through GO in the Reactome and Cytoscape databases. Finally, key genes were validated in these two datasets and other datasets. HF- and stroke-related datasets each identified two key modules. Functional enrichment analysis indicated that protein ubiquitination, Wnt signaling, and exosomes were involved in both HF- and stroke-related key modules. Additionally, ten hub genes were identified in stroke-related key modules and 155 genes were identified as common genes in HF-related stroke. OTU deubiquitinase with linear linkage specificity(OTULIN) and nuclear factor interleukin 3-regulated(NFIL3) were determined to be the key genes in HF-related stroke. Through functional annotation, OTULIN was involved in protein ubiquitination and Wnt signaling, and NFIL3 was involved in DNA binding and transcription. Importantly, OTULIN and NFIL3 were also validated to be differentially expressed in all HF and stroke groups. Protein ubiquitination, Wnt signaling, and exosomes were involved in HF-related stroke. OTULIN and NFIL3 may play a key role in HF-related stroke through regulating these processes, and thus serve as promising intervention targets.
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Affiliation(s)
- Chiyu Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Sixu Chen
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China
| | - Haifeng Zhang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China
| | - Yangxin Chen
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China
| | - Qingyuan Gao
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China
| | - Zhiteng Chen
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China.,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China
| | - Zhaoyu Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510120, China.
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China. .,Laboratory of Cardiac Electrophysiology and Arrhythmia in Guangdong Province, Guangzhou 510120, China.
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13
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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14
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 958] [Impact Index Per Article: 319.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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15
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Sedaghat A, Vij V, Al-Kassou B, Gloekler S, Galea R, Fürholz M, Meier B, Valgimigli M, O'Hara G, Arzamendi D, Agudelo V, Asmarats L, Freixa X, Flores-Umanzor E, De Backer O, Søndergaard L, Nombela-Franco L, McInerney A, Korsholm K, Nielsen-Kudsk JE, Afzal S, Zeus T, Operhalski F, Schmidt B, Montalescot G, Guedeney P, Iriart X, Miton N, Saw J, Gilhofer T, Fauchier L, Veliqi E, Meincke F, Petri N, Nordbeck P, Rycerz S, Ognerubov D, Merkulov E, Cruz-González I, Gonzalez-Ferreiro R, Bhatt DL, Laricchia A, Mangieri A, Omran H, Schrickel JW, Rodes-Cabau J, Nickenig G. Device-Related Thrombus After Left Atrial Appendage Closure: Data on Thrombus Characteristics, Treatment Strategies, and Clinical Outcomes From the EUROC-DRT-Registry. Circ Cardiovasc Interv 2021; 14:e010195. [PMID: 34003661 DOI: 10.1161/circinterventions.120.010195] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
| | - Vivian Vij
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
| | - Baravan Al-Kassou
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
| | - Steffen Gloekler
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Roberto Galea
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Monika Fürholz
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Bernhard Meier
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Marco Valgimigli
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.).,Cardiocentro Ticino, Lugano, Switzerland (M.V.)
| | - Gilles O'Hara
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.)
| | - Dabit Arzamendi
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | - Victor Agudelo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | - Lluis Asmarats
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.).,Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | | | | | - Ole De Backer
- Rigshospitalet Copenhagen University Hospital, Denmark (O.D.B., L.S.)
| | - Lars Søndergaard
- Rigshospitalet Copenhagen University Hospital, Denmark (O.D.B., L.S.)
| | | | - Angela McInerney
- Hospital Clinico San Carlos Madrid, Spain (L.N.-F., A. McInerney)
| | | | | | - Shazia Afzal
- University Hospital Düsseldorf, Germany (S.A., T.Z.)
| | - Tobias Zeus
- University Hospital Düsseldorf, Germany (S.A., T.Z.)
| | - Felix Operhalski
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany (F.O., B.S.)
| | - Boris Schmidt
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany (F.O., B.S.)
| | - Gilles Montalescot
- Surbonne University Pitié-Salpêtrière Hospital (AP-HP) Paris, France (G.M., P.G.)
| | - Paul Guedeney
- Surbonne University Pitié-Salpêtrière Hospital (AP-HP) Paris, France (G.M., P.G.)
| | | | - Noelie Miton
- University Hospital Bordeaux, France (X.I., N.M.)
| | | | | | | | - Egzon Veliqi
- St. Georg Hospital Hamburg, Germany (E.V., F.M.)
| | | | - Nils Petri
- University Hospital Würzburg, Germany (N.P., P.N.)
| | | | - Szymon Rycerz
- Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany (S.R.)
| | - Dmitrii Ognerubov
- Russian Cardiology Research and Production Complex, Moscow (D.O., E.M.)
| | - Evgeny Merkulov
- Russian Cardiology Research and Production Complex, Moscow (D.O., E.M.)
| | | | | | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital Harvard Medical School, Boston (D.L.B.)
| | | | | | | | | | - Josep Rodes-Cabau
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.)
| | - Georg Nickenig
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
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16
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Baker AD, Sharma R. Cardiac Testing in Search for Occult Atrial Fibrillation after Ischemic Stroke. Curr Treat Options Cardio Med 2021; 23. [DOI: 10.1007/s11936-021-00908-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Barkhudaryan A, Doehner W, Scherbakov N. Ischemic Stroke and Heart Failure: Facts and Numbers. An Update. J Clin Med 2021; 10:jcm10051146. [PMID: 33803423 PMCID: PMC7967189 DOI: 10.3390/jcm10051146] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/26/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022] Open
Abstract
Heart failure (HF) is a severe clinical syndrome accompanied by a number of comorbidities. Ischemic stroke occurs frequently in patients with HF as a complication of the disease. In the present review, we aimed to summarize the current state of research on the role of cardio–cerebral interactions in the prevalence, etiology, and prognosis of both diseases. The main pathophysiological mechanisms underlying the development of stroke in HF and vice versa are discussed. In addition, we reviewed the results of recent clinical trials investigating the prevalence and prevention of stroke in patients with HF.
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Affiliation(s)
- Anush Barkhudaryan
- Department of Cardiology, Clinic of General and Invasive Cardiology, University Hospital No 1, Yerevan State Medical University, Yerevan 0025, Armenia;
- Cardiovascular Research Institute Basel, University Hospital Basel, 4056 Basel, Switzerland
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Department of Cardiology, Campus Virchow, Charité-Universitätsmedizin Berlin, DZHK (German Center for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Nadja Scherbakov
- BIH Center for Regenerative Therapies (BCRT), Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Department of Cardiology, Campus Virchow, Charité-Universitätsmedizin Berlin, DZHK (German Center for Cardiovascular Research), Partner Site Berlin, 13353 Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Correspondence:
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18
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Jiang R, Wang Y, Pang L, Sun X, Chu X, Wang F, Huang J. Feasibility of off-pump coronary artery grafting for patients with impaired left ventricular ejection fraction: A retrospective cohort study from a single institutional database. J Card Surg 2021; 36:1935-1942. [PMID: 33665893 DOI: 10.1111/jocs.15462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/05/2021] [Accepted: 02/14/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Despite substantial advances in surgical practice, the management of patients with impaired left ventricular ejection fraction (LVEF) remains challenging. Furthermore, evidence on the outcomes of off-pump coronary artery bypass (OPCAB) surgery in this population is inconsistent. We conducted the present study to compare the short- and long-term outcomes of OPCAB in patients with different ejection fractions. METHODS This retrospective cohort study used data from the Hua-Shan Cardiac Surgery and included consecutive patients aged ≥ 18 years who underwent OPCAB procedures during 2016-2019. The patients included in the study were followed up until death or the end of data collection. Patients with different ejection fractions were matched 1:2 using propensity score matching. Factors associated with short-term outcomes were determined using logistic regression, and Kaplan-Meier survival analyses for the differences in all-cause death were generated. RESULTS The two propensity score matched groups consisted of 40 left ventricular dysfunction (LVD) and 80 normal left ventricular function (NLVF) patients. No significant intergroup differences were observed in the postoperative outcomes for the occurrence of left heart failure (22.5% in LVD vs. 5.0% in NLVF, p = .009). Age (odds ratio = 1.11, 95% confidence interval = 1.04-1.18) but not the preoperative LVEF was shown to be a strong predictor of short-term events in logistic regression analyses. Kaplan-Meier curves displayed similar freedom from all-cause death (p = .119) or cardio-death (p = .092) between groups. CONCLUSION The immediate postoperative outcomes and long-term outcomes were similar between the groups, indicating that OPCAB is a safe and effective choice for patients with LVD.
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Affiliation(s)
- Rongrong Jiang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Yiqing Wang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Liewen Pang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xiaotian Sun
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Xianglin Chu
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Fangrui Wang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
| | - Jiechun Huang
- Department of Cardiothoracic Surgery, Huashan Hospital, Fudan University, Shanghai, PR China
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19
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Zhao TJ, Yang QK, Tan CY, Bi LD, Li J, Miao ZL. Prognostic value of D-dimer/fibrinogen ratio in the adverse outcomes of patients hospitalized for heart failure. Biomark Med 2020; 14:1733-1745. [PMID: 33174759 DOI: 10.2217/bmm-2020-0553] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: To evaluate the clinical value of plasma D-dimer/fibrinogen ratio (DFR) in patients hospitalized for heart failure (HF). Methods: Clinical data of 235 patients were retrospectively analyzed. Kaplan-Meier method and Cox regression analysis were used to identify significant prognosticators. Results: The Kaplan-Meier analysis showed that a higher DFR level was significantly associated with an increase in the end point outcomes, including HF readmission, thrombotic events and death (log-rank test: p < 0.001). The multivariate Cox regression analysis showed that the high tertile of DFR was significantly associated with the study end points (HR: 2.18; 95% CI: 1.31-3.62; p = 0.003), compared with the low tertile. Conclusion: DFR is a reliable prognostic indicator for patients hospitalized for HF.
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Affiliation(s)
- Tian-Jun Zhao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, 110016, China
| | - Qian-Kun Yang
- Department of Bone & Soft Tissue Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, 110042, China
| | - Chun-Yu Tan
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, 110016, China
| | - Li-Dan Bi
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, 110016, China
| | - Jie Li
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, 110016, China
| | - Zhi-Lin Miao
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, 110016, China
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20
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Lau K, Malik A, Foroutan F, Buchan TA, Daza JF, Sekercioglu N, Orchanian-Cheff A, Alba AC. Resting Heart Rate as an Important Predictor of Mortality and Morbidity in Ambulatory Patients With Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail 2020; 27:349-363. [PMID: 33171294 DOI: 10.1016/j.cardfail.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/30/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Resting heart rate is a risk factor of adverse heart failure outcomes; however, studies have shown controversial results. This meta-analysis evaluates the association of resting heart rate with mortality and hospitalization and identifies factors influencing its effect. METHODS AND RESULTS We systematically searched electronic databases in February 2019 for studies published in 2005 or before that evaluated the resting heart rate as a primary predictor or covariate of multivariable models of mortality and/or hospitalization in adult ambulatory patients with heart failure. Random effects inverse variance meta-analyses were performed to calculate pooled hazard ratios. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to assess evidence quality. Sixty-two studies on 163,445 patients proved eligible. Median population heart rate was 74 bpm (interquartile range 72-76 bpm). A 10-bpm increase was significantly associated with increased risk of all-cause mortality (hazard ratio 1.10, 95% confidence interval 1.08-1.13, high quality). Overall, subgroup analyses related to patient characteristics showed no changes to the effect estimate; however, there was a strongly positive interaction with age showing increasing risk of all-cause mortality per 10 bpm increase in heart rate. CONCLUSIONS High-quality evidence demonstrates increasing resting heart rate is a significant predictor of all-cause mortality in ambulatory patients with heart failure on optimal medical therapy, with consistent effect across most patient factors and an increased risk trending with older age.
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Affiliation(s)
- Kimberley Lau
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah Malik
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Farid Foroutan
- McMaster University, Hamilton, Ontario, Canada; Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | - Tayler A Buchan
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada
| | | | | | - Ani Orchanian-Cheff
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Ana C Alba
- Ted Rogers Centre for Heart Research, University Health Network, Toronto, Ontario, Canada.
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21
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Tai YH, Chang CC, Yeh CC, Sung LC, Hu CJ, Cherng YG, Chen TL, Liao CC. Long-Term Risk of Stroke and Poststroke Outcomes in Patients with Heart Failure: Two Nationwide Studies. Clin Epidemiol 2020; 12:1235-1244. [PMID: 33177880 PMCID: PMC7652062 DOI: 10.2147/clep.s261179] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/12/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To evaluate the long-term risk of stroke and poststroke adverse outcomes in patients with heart failure (HF). Methods We used research data from Taiwan’s National Health Insurance Program from 2000 to 2005 and identified 20,072 adults aged ≥30 years who were newly diagnosed with HF. Frequency matching based on age and sex was used to select a comparison cohort consisting of 80,288 adults without HF. Events of incident stroke were identified from medical claims during the 2000–2013 follow-up period. The adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of the association of stroke with HF were calculated with a multiple Cox proportional hazard model. Another nested stroke cohort study of 480,604 hospitalized stroke patients determined the adjusted odds ratios (ORs) and 95% CIs for adverse events after stroke in patients with and without HF between 2000 and 2009. Results Compared with the non-HF cohort, HF patients had an increased risk of stroke (HR 2.32, 95% CI 2.21–2.43), including ischemic stroke and hemorrhagic stroke. The association between HF and stroke was significant in both sexes and in patients in all age groups and with various medical conditions. Previous HF was associated with poststroke mortality (OR 1.40, 95% CI 1.31–1.50), pneumonia (OR 1.33, 95% CI 1.28–1.38), and septicemia (OR 1.30, 95% CI 1.23–1.37). Conclusion HF was associated with a higher risk of stroke, and patients with HF had more complications and greater mortality after stroke.
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Affiliation(s)
- Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chuen-Chau Chang
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan.,Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chieh Yeh
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Surgery, University of Illinois, Chicago, IL, USA
| | - Li-Chin Sung
- Division of Cardiology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yih-Giun Cherng
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ta-Liang Chen
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chien-Chang Liao
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Anesthesiology, Taipei Medical University Hospital, Taipei, Taiwan.,Anesthesiology and Health Policy Research Center, Taipei Medical University Hospital, Taipei, Taiwan.,Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
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22
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Yang G, Wang L, Sun J, Zhang D, Zhang R, Yuan C, Long M, Zhong Y, Li C, Wang X, Chen X, Zhou Q, Liu B, Jiang H, Lian A, Gareev I, Li L, Zhao S. Left ventricular ejection fraction as an independent predictor of poor outcome in acute intracerebral hemorrhage. Brain Behav 2020; 10:e01643. [PMID: 32515560 PMCID: PMC7375101 DOI: 10.1002/brb3.1643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/21/2020] [Accepted: 03/30/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Few studies of the effect of cardiac abnormalities on acute intracerebral hemorrhage (ICH) outcomes have been published. We sought to determine whether the left ventricular ejection fraction (LVEF) is associated with the functional outcome and mortality of acute ICH patients. METHODS We conducted a retrospective study on 364 acute ICH patients from January to December 2016. The primary outcome was defined by the modified Rankin Scale and mortality at 3 months. The associations between LVEF and outcome were investigated using univariable and multivariable logistic regression models. RESULTS Depressed LVEF was significantly associated with a poor functional outcome with an odds ratio [OR] of 0.966, 95% confidence interval (CI) 0.942-0.991, p = .008, and high mortality (OR 0.968 [95% CI 0.943-0.994], p = .015) at 3 months for acute ICH patients by univariate analysis. Multivariable logistic regression analysis indicated that LVEF was an independent predictor of a poor functional outcome (OR 0.961 [95% CI 0.935-0.988], p = .005) and mortality (OR 0.949 [95% CI 0.918-0.981], p = .002). The percentage of acute ICH patients with poor functional outcome (p = .005) and mortality (p = .002) was obviously higher in the group of patients with a LVEF of <50%. CONCLUSIONS LVEF is an independent predictor of functional outcome and mortality at 3 months for acute ICH patients. These findings could provide the evidence needed for prognosis prediction in acute ICH patients.
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Affiliation(s)
- Guang Yang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Lu Wang
- Department of Urology, The Fourth Hospital of Harbin Medical University, Harbin, China
| | - Jingxian Sun
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Daming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China.,Section of Surgical Outcomes and Epidemiology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Ruotian Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Chao Yuan
- Department of Urology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Meixin Long
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yingqiang Zhong
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Chunmei Li
- Department of Neurology, The Fourth Hospital of Harbin Medical University, Harbin, China
| | - Xiaoxiong Wang
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Xin Chen
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
| | - Qi Zhou
- Research Administration Office, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bo Liu
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongquan Jiang
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ailing Lian
- Operating Room, The First Hospital of Harbin Medical University, Harbin, China
| | | | - Lili Li
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shiguang Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China.,Institute of Brain Science, Harbin Medical University, Harbin, China
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23
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Gama F, Ferreira J, Carmo J, Costa FM, Carvalho S, Carmo P, Cavaco D, Morgado FB, Adragão P, Mendes M. Implantable Cardioverter-Defibrillators in Trials of Drug Therapy for Heart Failure: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e015177. [PMID: 32290732 PMCID: PMC7428541 DOI: 10.1161/jaha.119.015177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Medical therapy for heart failure with reduced ejection fraction evolved since trials validated the use of implantable cardioverter–defibrillators (ICDs). We sought to evaluate the performance of ICDs in reducing mortality in the era of modern medical therapy by means of a systematic review and meta‐analysis of contemporary randomized clinical trials of drug therapy for heart failure with reduced ejection fraction. METHODS AND RESULTS We systematically identified randomized clinical trials that evaluated drug therapy in patients with heart failure with reduced ejection fraction that reported mortality. Studies that enrolled <1000 patients, patients with left ventricular ejection fraction >40%, or patients in the acute phase of heart failure and study treatment with devices were excluded. We identified 8 randomized clinical trials, including 31 701 patients of whom 3631 (11.5%) had an ICD. ICDs were associated with a lower risk of all‐cause mortality (relative risk [RR], 0.85; 95% CI, 0.78–0.94) and sudden cardiac death (RR, 0.49; 95% CI, 0.40–0.61). Results were consistent among studies published before and after 2010. In meta‐regression analysis, the proportion of nonischemic etiology did not affect the associated benefit of ICD. CONCLUSIONS In our meta‐analysis of contemporary randomized trials of drug therapy for heart failure with reduced ejection fraction, the rate of ICD use was low and associated with a decreased risk in both all‐cause mortality and sudden cardiac death. This benefit was still present in trials with new medical therapy.
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Affiliation(s)
- Francisco Gama
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal
| | - Jorge Ferreira
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal
| | - João Carmo
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Francisco Moscoso Costa
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Salomé Carvalho
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Pedro Carmo
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Diogo Cavaco
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Francisco Belo Morgado
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital Lusíadas Lisbon Portugal
| | - Pedro Adragão
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal.,Hospital da Luz Lisbon Portugal
| | - Miguel Mendes
- Hospital Santa Cruz Centro Hospitalar Lisboa Ocidental Nova Medical School Faculdade de Ciências Médicas Lisbon Portugal
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24
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Lai GY, Devlin PJ, Kesavabhotla K, Rich JD, Pham DT, Potts MB, Jahromi BS. Management and outcome of intracranial hemorrhage in patients with left ventricular assist devices. J Neurosurg 2020; 132:1133-1139. [DOI: 10.3171/2018.12.jns182467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/04/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAs the use of left ventricular assist devices (LVADs) has expanded, cerebrovascular complications have become an increasing source of morbidity and mortality in this population. Intracranial hemorrhage (ICH) in particular remains a devastating complication in patients who undergo LVAD placement with no defined management guidelines. The authors therefore reviewed surgical and anticoagulation management and outcomes of patients with LVADs who presented to their institution with ICH.METHODSThis retrospective cohort study assessed outcomes of patients who underwent LVAD placement at a single institution between 2007 and 2016 and in whom imaging demonstrated ICH.RESULTSDuring the study period, 281 patients had a HeartMate II or HeartWare LVAD placed. There were 37 episodes of ICH (recurrent in 3 cases). ICHs were categorized as intraparenchymal hemorrhage (IPH; n = 22, 59%), subdural hemorrhage (SDH; n = 6, 16%), and subarachnoid hemorrhage (SAH; n = 9, 24%). Neurosurgical intervention was deemed necessary in 27.3%, 66.7%, and 0% of patients with IPH, SDH, and SAH, respectively; overall survival > 30 days for each type of hemorrhage was 41%, 83%, and 89%, respectively. No patients had LVAD thrombus as a result of reversal of anticoagulation. Combined with prior reports, good outcomes are seen more often following surgery for SDH than for IPH (57% vs 7%, p = 0.004) in patients who underwent VAD placement.CONCLUSIONSPatients with IPH who undergo LVAD placement have poor outcomes regardless of anticoagulation reversal or neurosurgical intervention, whereas those with SDH may have good outcomes with medical and surgical intervention, and those with SAH appear to do well without anticoagulation reversal or surgery. When needed, anticoagulation reversal was not associated with an increase in LVAD thrombosis in this series.
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Affiliation(s)
- Grace Y. Lai
- 1Department of Neurosurgery, Northwestern University Medical Center
| | - Paul J. Devlin
- 2Department of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University Medical Center
| | | | - Jonathan D. Rich
- 3Department of Medicine, Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern University Medical Center; and
| | - Duc T. Pham
- 2Department of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University Medical Center
| | - Matthew B. Potts
- 1Department of Neurosurgery, Northwestern University Medical Center
- 4Department of Radiology, Northwestern University Medical Center, Chicago, Illinois
| | - Babak S. Jahromi
- 1Department of Neurosurgery, Northwestern University Medical Center
- 4Department of Radiology, Northwestern University Medical Center, Chicago, Illinois
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25
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Kurzawski J, Janion-Sadowska A, Zandecki L, Piatek L, Koziel D, Sadowski M. Global peak left atrial longitudinal strain assessed by transthoracic echocardiography is a good predictor of left atrial appendage thrombus in patients in sinus rhythm with heart failure and very low ejection fraction - an observational study. Cardiovasc Ultrasound 2020; 18:7. [PMID: 32061249 PMCID: PMC7024551 DOI: 10.1186/s12947-020-00188-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Peak left atrial longitudinal strain (PALS) can help identify left atrial appendage thrombus (LAAT) in patients with atrial fibrillation. Nevertheless, few studies have been performed in patients in sinus rhythm without established indications for anticoagulation but with increased risk of LAAT, such as heart failure (HF) with severe left ventricular systolic dysfunction patients. The primary aim of this study was to identify clinical and transthoracic echocardiography predictors of LAAT in HF patients with very low left ventricular ejection fraction and sinus rhythm. The secondary objective was to analyze frequencies and predictors of a composite clinical endpoint of death or hospitalization for ischemic stroke. METHODS We included 63 patients with HF, left ventricular ejection fraction < 25%, sinus rhythm at presentation, no history of atrial fibrillation, and without any established indications for anticoagulation. We determined whether clinical and transthoracic echocardiography parameters, including left atrial strain analysis, predicted LAAT. Transesophageal echocardiography was performed in all patients. When LAAT was detected, anticoagulation was recommended. The participants were followed for a median of 28.6 months (range 4-40) to determine the composite endpoint. RESULTS LAAT was found in 20 (31.7%) patients. Global PALS was the best independent predictor of LAAT in univariate and multivariate logistic regression analyses (Gini coefficient 0.65, area under the receiver-operating characteristic curve 0.83). A global PALS value below 8% was a good discriminator of LAAT presence (odds ratio 30.4, 95% CI 7.2-128, p < 0.001). During follow-up, 18 subjects (28.6%) reached the composite clinical endpoint. CHA2DS2-VASc score, use of angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, and body surface area were significant predictors for the composite endpoint of death or hospitalization for ischemic stroke in the multivariate regression model. CONCLUSIONS LAAT was relatively common in our group of HF patients and PALS has shown prognostic potential in LAAT identification. Further research is needed to determine whether initiation of anticoagulation or additional screening supported by PALS measurements will improve clinical outcomes in these patients.
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Affiliation(s)
| | | | - Lukasz Zandecki
- The Jan Kochanowski University, ul. Stefana Zeromskiego 5, 25-001, Kielce, Poland.
| | - Lukasz Piatek
- The Jan Kochanowski University, ul. Stefana Zeromskiego 5, 25-001, Kielce, Poland
| | - Dorota Koziel
- The Jan Kochanowski University, ul. Stefana Zeromskiego 5, 25-001, Kielce, Poland
| | - Marcin Sadowski
- The Jan Kochanowski University, ul. Stefana Zeromskiego 5, 25-001, Kielce, Poland
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26
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Garcia-Esperon C, Spratt NJ, Gangadharan S, Miteff F, Bivard A, Lillicrap T, Tomari S, Levi CR, Parsons MW. Computed Tomography Perfusion Identifies Patients With Stroke With Impaired Cardiac Function. Stroke 2020; 51:498-503. [PMID: 31896345 DOI: 10.1161/strokeaha.119.027255] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background and Purpose- Low left ventricular ejection fraction (LVEF) leads to worse outcomes after stroke. We hypothesized that the arterial input function (AIF) variability on perfusion computed tomography, especially the time between scan onset and end of AIF (SO-EndAIF), would reflect reduction of cardiac output. Methods- Retrospective analysis of consecutive stroke patients, who underwent computed tomography between January 2013 and September 2018, was performed in 2 parts. (1) To determine the correlation between SO-EndAIF and LVEF, all patients with a transthoracic echocardiogram performed ±6 months from the time of stroke were included. LVEF was dichotomized as either normal (≥50%) or decreased (<50%). (2) AIF was compared with hypoperfusion volume, defined as delay time >3 seconds and with clinical outcome measured using 3-month modified Rankin Scale. Results- A total of 732 ischemic stroke patients underwent computed tomography, 231 with transthoracic echocardiogram were included in part (1), 393 with outcome data were included in part (2). In part (1), 193/231 (83.5%) had normal LVEF (median 61%) and 38/231 (16.5%) decreased LVEF (median 39%). The low-LVEF group had significantly prolonged SO-EndAIF compared with normal-LVEF group (mean of 39.7 versus 26 second; P<0.001), and larger hypoperfusion lesions (94.9 versus 37.6 mL; P<0.001). SO-EndAIF time was strongly associated with EF, with an area under the curve of 0.86. Twenty nine seconds was the best threshold to distinguish between normal and impaired EF (area under the curve, 0.77). In part (2), the SO-EndAIF ≥29 second group had larger hypoperfusion volumes (21.8 versus 89.7 mL; P<0.001) and infarct core (12.2 versus 2.3 mL; P<0.0001) and patients with SO-EndAIF ≥29 seconds had fewer excellent or good clinical outcomes (modified Rankin Scale score 0-1; 40% versus 22%; OR, 2.79; P<0.001, modified Rankin Scale score 0-2; 65% versus 35%; OR, 1.41; P=0.033). Conclusions- AIF width correlates with ejection fraction in acute ischemic stroke. A 29-second threshold from scan onset to end of AIF accurately predicts reduced LVEF and identifies patients more likely to have worse outcomes after stroke.
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Affiliation(s)
- Carlos Garcia-Esperon
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Neil J Spratt
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Shyam Gangadharan
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia
| | - Ferdinand Miteff
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Andrew Bivard
- Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.B., M.W.P.)
| | - Thomas Lillicrap
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Shinya Tomari
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Christopher R Levi
- From the Department of Neurology, John Hunter Hospital (C.G.-E., N.J.S., S.G., F.M., C.R.L.), University of Newcastle, Australia.,Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia
| | - Mark W Parsons
- Hunter Medical Research Institute (C.G.-E., N.J.S., F.M., T.L., S.T., C.R.L., M.W.P.), University of Newcastle, Australia.,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (A.B., M.W.P.)
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27
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Abstract
Background Associations between subtle changes in cardiac and cerebral structure and function are not well understood, with some studies suggesting that subclinical cardiac changes may be associated with markers of vascular brain insult. Methods and Results Data from the ARIC (Atherosclerosis Risk in Communities) Study (5th ARIC visit; 2011‐2013; N=1974) were used to explore relationships between abnormalities of cardiac structure/function and subclinical brain disease and to test specific associations between those cardiac and vascular brain changes that share a common mechanism. In adjusted models white matter hyperintensities were 0.66 cm3 greater (95% confidence interval [CI] 0.08‐1.25) for every 1‐mm increase in left ventricular LV wall thickness and 0.64 cm3 greater (95% CI 0.19‐1.08) for every 10 g/m2 increase in LV mass index, both markers of LV structure. Odds of brain infarction also increased with greater LV wall thickness (odds ratio 1.11, 95% CI 1.01‐1.23 per 1 mm) and larger LV mass (odds ratio 1.08, 95% CI 1.00‐1.17 per 10 g/m2). Higher ejection fraction (per 5%), a marker of systolic function, was significantly associated with decreased odds of overall infarct (odds ratio 0.85, 95% CI0.77‐0.95), but not with cortical infarction (odds ratio 0.92, 95% CI0.78‐1.08). Conclusions Among elderly participants in a large cohort study, subclinical markers of LV structure and LV systolic dysfunction were associated with increased odds of brain infarction and more white matter hyperintensities, independent of other vascular risk factors. This suggests end‐organ dysfunction occurs in the heart and brain in parallel, with further studies needed to determine causality.
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Chou YL, Liou JT, Cheng CC, Tsai MC, Lin WS, Cheng SM, Lin CL, Lin CS, Kao CH. The association of ischaemic stroke in patients with heart failure without atrial flutter/fibrillation. Heart 2019; 106:616-623. [DOI: 10.1136/heartjnl-2019-315646] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 11/03/2022] Open
Abstract
PurposeThis study evaluated the association between ischaemic stroke (IS) and heart failure (HF) in the absence of atrial fibrillation (AF) or atrial flutter (AFL) using a population-based nation-wide cohort database.MethodNewly diagnosed patients with HF without previous stroke and acute myocardial infarction (AMI) were enrolled. Based on the propensity scores matching age, sex and all comorbidities, our studies comprised 12 179 patients with HF and 12 179 patients without HF. Cox proportion hazard regression models and competing-risk regression models were used to evaluate the risk of IS among patients with HF without AF or AFL.ResultsIn the multivariable analysis, older age (adjusted HR (95% CI)=1.05 (1.04 to 1.05)), male sex (adjusted HR (95% CI)=1.36 (1.24 to 1.50)), diabetes (adjusted HR (95% CI)=2.22 (1.97 to 2.49)) and hypertension (adjusted HR (95% CI)=1.60 (1.41 to 1.82)) were markedly associated with IS in patients with HF. The HF group had a markedly higher risk of IS than did the non-HF group (subdistribution HR (SHR)=1.51, 95% CI: 1.37 to 1.66) and AMI (SHR=3.40, 95% CI: 2.71 to 4.28). Additionally, according to the Kaplan-Meier analysis, patients with HF were at a significantly higher risk of cumulative incidence of IS and AMI than did patients with non-HF (p value of log-rank test <0.001).ConclusionThis study indicated that HF is a strong independent risk factor for IS, even in the absence of AF or AFL. Clinical physicians should investigate IS through routine screening and careful monitoring of patients with HF.
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Pana TA, McLernon DJ, Mamas MA, Bettencourt-Silva JH, Metcalf AK, Potter JF, Myint PK. Individual and Combined Impact of Heart Failure and Atrial Fibrillation on Ischemic Stroke Outcomes. Stroke 2019; 50:1838-1845. [PMID: 31154943 DOI: 10.1161/strokeaha.119.025481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose- We aimed to determine individual and combined effects of atrial fibrillation (AF) and heart failure (HF) on acute ischemic stroke outcomes: in-hospital mortality, length-of-stay, and poststroke disability; long-term mortality and stroke recurrence. Methods- Prospective cohort study of patients with acute ischemic stroke admitted to a UK center with a catchment population of ≈900 000 between 2004 and 2016. Exposure groups were patients with neither AF nor HF (reference group), those with AF but without HF, those with HF but without AF, and those with AF+HF. Logistic and Cox regressions were used to model in-hospital and long-term outcomes, respectively. Results- A total of 10 816 patients with a mean age±SD =77.9±12.1 years, 48% male were included. Only 30 (4.9%) of the patients with HF but not AF were anticoagulated at discharge. Both AF (odds ratio, 1.24 [95% CI, 1.07-1.43]), HF (odds ratio, 1.40 [1.10-1.79]), and their combination (odds ratio, 2.23 [1.83-2.72]) were associated with increased odds of in-hospital mortality. All 3 exposure groups were associated with increased length-of-stay, while only AF predicted increased disability (1.36 [1.12-1.64]). Patients were followed for a median of 5.5 and 3.7 years for mortality and recurrence, respectively. Long-term mortality was associated with AF (hazard ratio, 1.45 [95% CI, 1.33-1.59]), HF (2.07 [1.83-2.36]), and their combination (2.20 [1.96-2.46]). Recurrent stroke was associated with AF 1.50 (1.26-1.78), HF (1.33 [1.01-1.75]), and AF with HF (1.62 [1.28-2.07]). Conclusions- The AF-associated excess risk of stroke recurrence was independent of comorbid HF. HF without AF was also associated with a significant risk of recurrence. Anticoagulation for secondary stroke prevention in patients with HF without AF may require further evaluation in a clinical trial setting.
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Affiliation(s)
- Tiberiu A Pana
- From the Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom (T.A.P., D.J.M., P.K.M.)
| | - David J McLernon
- From the Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom (T.A.P., D.J.M., P.K.M.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (M.A.M.)
| | - Joao H Bettencourt-Silva
- Norwich Medical School, University of East Anglia, United Kingdom (J.H.B.-S., A.K.M., J.F.P., P.K.M.).,Clinical Informatics, Department of Medicine, University of Cambridge, United Kingdom (J.H.B.-S.)
| | - Anthony K Metcalf
- Norwich Medical School, University of East Anglia, United Kingdom (J.H.B.-S., A.K.M., J.F.P., P.K.M.)
| | - John F Potter
- Norwich Medical School, University of East Anglia, United Kingdom (J.H.B.-S., A.K.M., J.F.P., P.K.M.).,Norfolk and Norwich University Hospital, United Kingdom (J.F.P., P.K.M.)
| | - Phyo K Myint
- From the Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom (T.A.P., D.J.M., P.K.M.).,Norwich Medical School, University of East Anglia, United Kingdom (J.H.B.-S., A.K.M., J.F.P., P.K.M.).,Norfolk and Norwich University Hospital, United Kingdom (J.F.P., P.K.M.).,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom (P.K.M.)
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Abstract
PURPOSE Ischemic stroke significantly contributes to morbidity and mortality in heart failure (HF). The risk of stroke increases significantly, with coexisting atrial fibrillation (AF). An aggravating factor could be asymptomatic paroxysms of AF (so-called silent AF), and therefore, the risk stratification in these patients remains difficult. This review provides an overview of stroke risk in HF, its risk stratification, and stroke prevention in these patients. RECENT FINDINGS Stroke risk stratification in HF patients remains an important issue. Recently, the CHA2DS2-VASc score, originally developed to predict stroke risk in AF patients, had been reported to be a predictive for strokes in HF patients regardless of AF being present. Furthermore, there are several independent risk factors (e.g., hypertension, diabetes mellitus, prior stroke) described. Based on the current evidence, HF should be considered as an independent risk factor for stroke. The CHA2DS2-VASc score might be useful to predict stroke risk in HF patients with or without AF in clinical routine. However, there is only a recommendation for the oral anticoagulation use in patients with concomitant HF and AF, while in patients with HF and no AF, individualized risk stratification is preferred. Current guidelines recommend to prefer non-vitamin Kantagonist anticoagulants over warfarin.
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Affiliation(s)
- Katja Schumacher
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.,Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Heart Center, Department of Electrophysiology, University of Leipzig, Leipzig, Germany.,Institute for Medical Informatics, Statistics and Epidemiology (IMISE), Leipzig University, Leipzig, Germany
| | - Eduard Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK.
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31
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Di Tullio MR, Qian M, Thompson JLP, Labovitz AJ, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Buchsbaum R, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Left atrial volume and cardiovascular outcomes in systolic heart failure: effect of antithrombotic treatment. ESC Heart Fail 2018; 5:800-808. [PMID: 30015405 PMCID: PMC6165930 DOI: 10.1002/ehf2.12331] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 05/24/2018] [Accepted: 06/14/2018] [Indexed: 01/20/2023] Open
Abstract
AIMS Left atrium (LA) dilation is associated with adverse cardiovascular (CV) outcomes. Blood stasis, thrombus formation and atrial fibrillation may occur, especially in heart failure (HF) patients. It is not known whether preventive antithrombotic treatment may decrease the incidence of CV events in HF patients with LA enlargement. We investigated the relationship between LA enlargement and CV outcomes in HF patients and the effect of different antithrombotic treatments. METHODS AND RESULTS Two-dimensional echocardiography with LA volume index (LAVi) measurement was performed in 1148 patients with systolic HF from the Warfarin versus Aspirin in Reduced Ejection Fraction (WARCEF) trial. Patients were randomized to warfarin or aspirin and followed for 3.4 ± 1.7 years. While the primary aim of the trial was a composite of ischaemic stroke, death, and intracerebral haemorrhage, the present report focuses on the individual CV events, whose incidence was compared across different LAVi and treatment subgroups. After adjustment for demographics and clinical covariates, moderate or severe LA enlargement was significantly associated with total death (hazard ratio 1.6 and 2.7, respectively), CV death (HR 1.7 and 3.3), and HF hospitalization (HR 2.3 and 2.6) but not myocardial infarction (HR 1.0 and 1.4) or ischaemic stroke (1.1 and 1.5). The increased risk was observed in both patients treated with warfarin or aspirin. In warfarin-treated patients, a time in therapeutic range >60% was associated with lower event rates, and an interaction between LAVi and time in therapeutic range was observed for death (P = 0.034). CONCLUSIONS In patients with systolic HF, moderate or severe LA enlargement is associated with death and HF hospitalization despite treatment with antithrombotic medications. The possibility that achieving a more consistent therapeutic level of anticoagulation may decrease the risk of death requires further investigation.
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Affiliation(s)
- Marco R Di Tullio
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Min Qian
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | | | | | | | | | | | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Susan Graham
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, Birmingham, UK
| | - Bruce Levin
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Jay P Mohr
- Department of Neurology, Columbia University Medical Center, New York, NY, USA
| | - Richard Buchsbaum
- Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Conrado J Estol
- Centro Neurológico de Tratamiento y Rehabilitación, Buenos Aires, Argentina
| | - Dirk J Lok
- Deventer Hospital, Deventer, The Netherlands
| | | | - Stefan D Anker
- Department of Innovative Clinical Trials, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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Streng KW, Nauta JF, Hillege HL, Anker SD, Cleland JG, Dickstein K, Filippatos G, Lang CC, Metra M, Ng LL, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zwinderman AH, Zannad F, Damman K, van der Meer P, Voors AA. Non-cardiac comorbidities in heart failure with reduced, mid-range and preserved ejection fraction. Int J Cardiol 2018; 271:132-139. [PMID: 30482453 DOI: 10.1016/j.ijcard.2018.04.001] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/19/2018] [Accepted: 04/02/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Comorbidities play a major role in heart failure. Whether prevalence and prognostic importance of comorbidities differ between heart failure with preserved ejection fraction (HFpEF), mid-range (HFmrEF) or reduced ejection fraction (HFrEF) is unknown. METHODS Patients from index (n = 2516) and validation cohort (n = 1738) of The BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT-CHF) were pooled. Eight non-cardiac comorbidities were assessed; diabetes mellitus, thyroid dysfunction, obesity, anaemia, chronic kidney disease (CKD, estimated glomerular filtration rate < 60 mL/min/1.73 m2), COPD, stroke and peripheral arterial disease. Patients were classified based on ejection fraction. The association of each comorbidity with quality of life (QoL), all-cause mortality and hospitalisation was evaluated. RESULTS Patients with complete comorbidity data were included (n = 3499). Most prevalent comorbidity was CKD (50%). All comorbidities showed the highest prevalence in HFpEF, except for stroke. Prevalences of HFmrEF were in between the other entities. COPD was the comorbidity associated with the greatest reduction in QoL. In HFrEF, almost all were associated with a significant reduction in QoL, while in HFpEF only CKD and obesity were associated with a reduction. Most comorbidities in HFrEF were associated with an increased mortality risk, while in HFpEF only CKD, anaemia and COPD were associated with higher mortality risks. CONCLUSIONS The highest prevalence of comorbidities was seen in patients with HFpEF. Overall, comorbidities were associated with a lower QoL, but this was more pronounced in patients with HFrEF. Most comorbidities were associated with higher mortality risks, although the associations with diabetes were only present in patients with HFrEF.
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Affiliation(s)
- Koen W Streng
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan F Nauta
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Hans L Hillege
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen (UMG), Göttingen, Germany
| | - John G Cleland
- National Heart & Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK
| | - Kenneth Dickstein
- University of Bergen, Bergen, Norway; Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Heart Failure Unit, Athens University Hospital Attikon, Athens, Greece
| | - Chim C Lang
- School of Medicine Centre for Cardiovascular and Lung Biology, Division of Medical Sciences, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland and Cardiology Department, Military Hospital, Wroclaw, Poland
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Dirk J van Veldhuisen
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Aeilko H Zwinderman
- Department of Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Faiez Zannad
- Inserm CIC 1433, Université de Lorrain, CHU de Nancy, Nancy, France
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter van der Meer
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
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33
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Siliste R, Antohi E, Pepoyan S, Nakou E, Vardas P. Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice. Eur J Heart Fail 2018; 20:978-988. [DOI: 10.1002/ejhf.1153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/31/2017] [Accepted: 01/15/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Elena‐Laura Antohi
- Department of Cardiology Emergency Cardiovascular Disease Institute ‘Prof. Dr. C.C. Iliescu’ Bucharest Romania
| | - Sergey Pepoyan
- Department of Cardiology Yerevan State Medical University (YSMU), University Clinical Hospital Yerevan Armenia
| | - Eleni Nakou
- Department of Cardiology Heraklion University Hospital Crete Greece
| | - Panos Vardas
- Department of Cardiology Heraklion University Hospital Crete Greece
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Abstract
Heart failure (HF) is one of the major causes of death worldwide. Despite the high incidence of stroke in patients with HF, there has been a controversy as to whether HF itself is a risk factor for stroke. Recently, there is a great deal of evidence that HF itself increases the risk of stroke. In previous studies, the benefit of warfarin for stroke prevention in patients with HF was offset by the risk of bleeding. In the era of non-vitamin K antagonist oral anticoagulants with low bleeding profiles, we can expect a more effective stroke prevention in patients with HF by selective anticoagulation. The purpose of this review is to describe the relationship between stroke and HF, which could be an unconventional risk factor and a potential intervention target for stroke prevention.
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Affiliation(s)
- Woohyeun Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eung Ju Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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35
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Lee JY, Sunwoo JS, Kwon KY, Roh H, Ahn MY, Lee MH, Park BW, Hyon MS, Lee KB. Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease. Korean Circ J 2018; 48:1148-1156. [PMID: 30403019 PMCID: PMC6221865 DOI: 10.4070/kcj.2018.0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/18/2018] [Accepted: 07/24/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD). METHODS Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants. RESULTS The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality. CONCLUSIONS LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.
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Affiliation(s)
- Jeong Yoon Lee
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Sang Sunwoo
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Kyum Yil Kwon
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Hakjae Roh
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Moo Young Ahn
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Min Ho Lee
- Department of Cardiology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Byoung Won Park
- Department of Cardiology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Min Su Hyon
- Department of Cardiology, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University School of Medicine, Seoul, Korea.
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36
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Chen C, Li D, Deng L. Letter by Chen et al Regarding Article, "Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial". Stroke 2016; 47:e272. [PMID: 27803389 DOI: 10.1161/strokeaha.116.015175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Chen Chen
- Department of Cardiology West China Hospital Sichuan University Chengdu, China
| | - Dongze Li
- Department of Emergency Medicine West China Hospital, Sichuan University Chengdu, China
| | - Lixia Deng
- Department of Cardiology West China Hospital, Sichuan University Chengdu, China
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Perlini S, Salinaro F, Grassi G. Ventricular-arterial coupling in the clinical evolution of acute ischemic stroke. J Hypertens 2016; 34:2335-6. [PMID: 27805914 DOI: 10.1097/HJH.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Di Tullio MR, Thompson JLP, Homma S. Response by Di Tullio et al to Letter Regarding Article, "Left Ventricular Ejection Fraction and Risk of Stroke and Cardiac Events in Heart Failure: Data From the Warfarin Versus Aspirin in Reduced Ejection Fraction Trial". Stroke 2016; 47:e273. [PMID: 27803390 DOI: 10.1161/strokeaha.116.015297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marco R Di Tullio
- Department of Medicine Division of Cardiology Columbia University Medical Center New York
| | - John L P Thompson
- Department of Biostatistics Mailman School of Public Health Columbia University Medical Center New York
| | - Shunichi Homma
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York
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Parikh NS, Cool J, Karas MG, Boehme AK, Kamel H. Stroke Risk and Mortality in Patients With Ventricular Assist Devices. Stroke 2016; 47:2702-2706. [PMID: 27650070 DOI: 10.1161/strokeaha.116.014049] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 08/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Ventricular assist devices (VADs) have advanced the management of end-stage heart failure. However, these devices are associated with hemorrhagic and thrombotic complications, including stroke. We assessed the incidence, risk factors, and outcomes of ischemic and hemorrhagic stroke after VAD placement. METHODS Using administrative claims data from acute care hospitals in California, Florida, and New York from 2005 to 2013, we identified patients who underwent VAD placement, defined by the International Classification of Diseases, Ninth Revision, Clinical Modification code 37.66. Ischemic and hemorrhagic strokes were identified by previously validated coding algorithms. We used survival statistics to determine the incidence rates and Cox proportional hazard analyses to examine the associations. RESULTS Among 1813 patients, we identified 201 ischemic strokes and 116 hemorrhagic strokes during 3.4 (±2.0) years of follow-up after implantation of a VAD. The incidence of stroke was 8.7% per year (95% confidence interval [CI], 7.7-9.7). The annual incidence of ischemic stroke (5.5%; 95% CI, 4.8-6.4) was nearly double that of hemorrhagic stroke (3.1%; 95% CI, 2.6-3.8). Women faced a higher hazard of stroke than men (hazard ratio, 1.6; 95% CI, 1.2-2.1), particularly hemorrhagic stroke (hazard ratio, 2.2; 95% CI, 1.4-3.4). Stroke was strongly associated with subsequent in-hospital mortality (hazard ratio, 6.1; 95% CI, 4.6-7.9). CONCLUSIONS The incidence of stroke after VAD implantation was 8.7% per year, and incident stroke was strongly associated with subsequent in-hospital mortality. Notably, ischemic stroke occurred at nearly twice the rate of hemorrhagic stroke. Women seemed to face a higher risk for hemorrhagic stroke than men.
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Affiliation(s)
- Neal S Parikh
- From the Department of Neurology (N.S.P., J.C., H.K.), Division of Cardiology (M.G.K.), and Feil Family Brain and Mind Research Institute (N.S.P., J.C., H.K.), Weill Cornell Medicine, NY; and Department of Neurology, Columbia College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (A.K.B.).
| | - Joséphine Cool
- From the Department of Neurology (N.S.P., J.C., H.K.), Division of Cardiology (M.G.K.), and Feil Family Brain and Mind Research Institute (N.S.P., J.C., H.K.), Weill Cornell Medicine, NY; and Department of Neurology, Columbia College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (A.K.B.)
| | - Maria G Karas
- From the Department of Neurology (N.S.P., J.C., H.K.), Division of Cardiology (M.G.K.), and Feil Family Brain and Mind Research Institute (N.S.P., J.C., H.K.), Weill Cornell Medicine, NY; and Department of Neurology, Columbia College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (A.K.B.)
| | - Amelia K Boehme
- From the Department of Neurology (N.S.P., J.C., H.K.), Division of Cardiology (M.G.K.), and Feil Family Brain and Mind Research Institute (N.S.P., J.C., H.K.), Weill Cornell Medicine, NY; and Department of Neurology, Columbia College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (A.K.B.)
| | - Hooman Kamel
- From the Department of Neurology (N.S.P., J.C., H.K.), Division of Cardiology (M.G.K.), and Feil Family Brain and Mind Research Institute (N.S.P., J.C., H.K.), Weill Cornell Medicine, NY; and Department of Neurology, Columbia College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (A.K.B.)
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