Neurologic complications of congenital heart disease in adults

Congenital heart disease (CHD) is a heterogeneous group of structural abnormalities of the cardiovascular system that are present at birth. Advances in childhood medical and surgical treatment have led to increasing numbers of adults with CHD. Neurological complications of CHD in adults are varied and can include an increased risk of stroke not only related to the underlying congenital defect and its surgical management but also due to atherosclerotic disease associated with advancing age. In addition to cerebrovascular events, CHD in adults is also associated with an increased risk of neurodevelopmental disorders, cognitive impairment, psychiatric disease, and epilepsy. Collaborative multidisciplinary care with contributions from neurologists and cardiologists with expertise in adult CHD is necessary to provide optimal long-term care for this complex and rapidly evolving population.

The association of circulating amylin with β-amyloid in familial Alzheimer's disease

INTRODUCTION

This study assessed the hypothesis that circulating human amylin (amyloid-forming) cross-seeds with amyloid beta (Aβ) in early Alzheimer's disease (AD).

METHODS

Evidence of amylin-AD pathology interaction was tested in brains of 31 familial AD mutation carriers and 20 cognitively unaffected individuals, in cerebrospinal fluid (CSF) (98 diseased and 117 control samples) and in genetic databases. For functional testing, we genetically manipulated amylin secretion in APP/PS1 and non-APP/PS1 rats.

RESULTS

Amylin-Aβ cross-seeding was identified in AD brains. High CSF amylin levels were associated with decreased CSF Aβ₄₂ concentrations. AD risk and amylin gene are not correlated. Suppressed amylin secretion protected APP/PS1 rats against AD-associated effects. In contrast, hypersecretion or intravenous injection of human amylin in APP/PS1 rats exacerbated AD-like pathology through disruption of CSF-brain Aβ exchange and amylin-Aβ cross-seeding.

DISCUSSION

These findings strengthened the hypothesis of circulating amylin-AD interaction and suggest that modulation of blood amylin levels may alter Aβ-related pathology/symptoms.

Preserving stroke care during the COVID-19 pandemic: Potential issues and solutions

The coronavirus 2019 (COVID-19) pandemic requires drastic changes in allocation of resources, which can affect the delivery of stroke care, and many providers are seeking guidance. As caregivers, we are guided by 3 distinct principles that will occasionally conflict during the pandemic: (1) we must ensure the best care for those stricken with COVID-19, (2) we must provide excellent care and advocacy for patients with cerebrovascular disease and their families, and (3) we must advocate for the safety of health care personnel managing patients with stroke, with particular attention to those most vulnerable, including trainees. This descriptive review by a diverse group of experts in stroke care aims to provide advice by specifically addressing the potential impact of this pandemic on (1) the quality of the stroke care delivered, (2) ethical considerations in stroke care, (3) safety and logistic issues for providers of patients with stroke, and (4) stroke research. Our recommendations on these issues represent our best opinions given the available information, but are subject to revision as the situation related to the COVID-19 pandemic continues to evolve. We expect that ongoing emergent research will offer additional insights that will provide evidence that could prompt the modification or removal of some of these recommendations.

Polypill Trials for Stroke Prevention-Main Results, Critical Appraisal, and Implications for US Population

PURPOSE OF REVIEW

The polypill, referring to a variety of combinations of low-cost cardiovascular and stroke preventive medications combined in a single tablet, has been evaluated as a population-based approach for cardiovascular disease prevention in several trials. This review summarizes the scope of the problem, main trial results, and their potential applicability to the US population.

RECENT FINDINGS

Initial trials demonstrated the efficacy of the polypill approach. The most recent, the PolyIran study, showed the effectiveness of one form of a polypill for cardiovascular disease prevention, high medication adherence, and low adverse event rates. None of published polypill trials focused on stroke as the primary outcome and most were conducted in developing countries, limiting generalization to the US population. A US-based randomized trial with stroke as the primary outcome is needed to assess the usefulness of this approach for stroke prevention in the USA.

Funds flow in academic neurology

Funds flow arrangements define the financial relationships between departments, medical centers, and university entities within a coordinated academic health system. Although these funds flow frameworks differ, common themes emerge including those that are unique in their influence on academic departments of neurology. Here, we review various funds flow models and their application. Four typical models are described, highlighting the advantages and disadvantages of each for neurology, keeping in mind that most academic health systems use a hybrid model. Several considerations are important when neurology departmental leadership participates in crafting or revising of these funds flow agreements, including choice of benchmarking targets, planning and funding for future growth, demonstrating value, and supporting nonclinical missions including education and research. The American Academy of Neurology Academic Initiative aims to continue to help academic departments nationally understand these issues and define funds flow arrangements that incorporate the unique characteristics of our specialty and allow us to provide outstanding care for patients while supporting the broad missions of neurology departments.

Water Pipe (Hookah) Smoking and Cardiovascular Disease Risk: A Scientific Statement From the American Heart Association

Tobacco smoking with a water pipe or hookah is increasing globally. There are millions of water pipe tobacco smokers worldwide, and in the United States, water pipe use is more common among youth and young adults than among adults. The spread of water pipe tobacco smoking has been abetted by the marketing of flavored tobacco, a social media environment that promotes water pipe smoking, and misperceptions about the addictive potential and potential adverse health effects of this form of tobacco use. There is growing evidence that water pipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term. Long-term water pipe use is associated with increased risk of coronary artery disease. Several harmful or potentially harmful substances present in cigarette smoke are also present in water pipe smoke, often at levels exceeding those found in cigarette smoke. Water pipe tobacco smokers have a higher risk of initiation of cigarette smoking than never smokers. Future studies that focus on the long-term adverse health effects of intermittent water pipe tobacco use are critical to strengthen the evidence base and to inform the regulation of water pipe products and use. The objectives of this statement are to describe the design and operation of water pipes and their use patterns, to identify harmful and potentially harmful constituents in water pipe smoke, to document the cardiovascular risks of water pipe use, to review current approaches to water pipe smoking cessation, and to offer guidance to healthcare providers for the identification and treatment of individuals who smoke tobacco using water pipes.

Vascular Cellular Adhesion Molecule-1 (VCAM-1) and Memory Impairment in African-Americans after Small Vessel-Type Stroke

BACKGROUND

African-Americans (AA) are 3 times more likely to have small-vessel-type ischemic strokes (SVS) than Whites. Small vessel strokes are associated with cognitive impairment, a relationship incompletely explained by white matter hyperintensity (WMH) burden. We examined whether inflammatory/endothelial dysfunction biomarkers are associated with cognition after SVS in AAs.

METHODS

Biomarkers were obtained in 24 subjects (median age 56.5 years, 54% women, median 12 years education). Cognition was assessed more than 6 weeks poststroke using the memory composite score (MCS), which was generated using recall from the Hopkins Verbal Learning Test-II and Brief Visuospatial Memory Test-Revised. A semi-automated, volumetric protocol was used to quantify WMH volume (WMHv) on clinical MRI scans. Potential biomarkers including vascular cell adhesion molecule-1 (VCAM-1), interleukin-1 receptor antagonist, interleukin-6, interleukin-8, interleukin-10, interferon gamma, and thrombin-antithrombin (TAT) were log-transformed and correlated with MCS with adjustment for potential confounders.

RESULTS

Among serum biomarkers, only VCAM-1-correlated with poorer memory based on the MCS (r = -.659; P = .0006). VCAM-1 (r = .554; P = .005) and age (r = .479; P = .018) correlated with WMHv; VCAM-1 was independently associated with MCS after adjustment for WMHv, age, and education (P = .023).

CONCLUSIONS

The findings of this exploratory analysis suggest that endothelial dysfunction and inflammation as reflected by VCAM-1 levels may play a role in poststroke cognitive impairment. Additional studies are needed to validate this observation and to evaluate this relationship in non-AAs and with other stroke types and compare this finding to cognitive impairment in nonstroke populations.

Hierarchical Clustering Analyses of Plasma Proteins in Subjects With Cardiovascular Risk Factors Identify Informative Subsets Based on Differential Levels of Angiogenic and Inflammatory Biomarkers

Agglomerative hierarchical clustering analysis (HCA) is a commonly used unsupervised machine learning approach for identifying informative natural clusters of observations. HCA is performed by calculating a pairwise dissimilarity matrix and then clustering similar observations until all observations are grouped within a cluster. Verifying the empirical clusters produced by HCA is complex and not well studied in biomedical applications. Here, we demonstrate the comparability of a novel HCA technique with one that was used in previous biomedical applications while applying both techniques to plasma angiogenic (FGF, FLT, PIGF, Tie-2, VEGF, VEGF-D) and inflammatory (MMP1, MMP3, MMP9, IL8, TNFα) protein data to identify informative subsets of individuals. Study subjects were diagnosed with mild cognitive impairment due to cerebrovascular disease (MCI-CVD). Through comparison of the two HCA techniques, we were able to identify subsets of individuals, based on differences in VEGF (p < 0.001), MMP1 (p < 0.001), and IL8 (p < 0.001) levels. These profiles provide novel insights into angiogenic and inflammatory pathologies that may contribute to VCID.

Abstract 86: Increasing World-Wide Stroke Burden, 2010-2017

Introduction: Although stroke-related mortality decreased over the last 3- decades, there is concern that morbidity and death rates may have increased over recent years.

Methods: World-wide data available from the Institute for Health Metrics Evaluation’s Global Health Data Exchange (ghdx.healthdata.org/gbd) was analyzed to determine changes in stroke incidence, prevalence, death rates and associated disability adjusted life years (DALYs) between 2010-2017.

Results: Over the 7-year period, global stroke incidence increased by 5.3% (148, 95% Uncertainty Interval, 140-157 to 156, 95% UI 146-168 per 100,000), prevalence by 19.3% (1,143, 95% UI 1,099-1,192 to 1,364, 95% UI 1,289-1,441 per 100,000), mortality by 5.3% (79, 95% UI 78-80 to 81, 95% UI 79-83 per 100,000) and DALYs by 2.7% (1,683, 95% UI 1,626-1,739 to 1,728, 95% UI 1,656-1,798 per 100,000). The Figure gives global trends for each metric between 1990-2017 (+/- 95% UI) and shows an increase in incidence and prevalence over the entire period with initial declines in mortality and DALYs that leveled off between about 2005-2013 and subsequently increased.

Conclusion: The global burden of stroke is increasing. As other data suggest that most of the previous decline in stroke-related mortality was related to improvements in risk factor control, these data indicate that population level programs to reduce risk may need to be reinforced.

Abstract WP257: Therapeutic Anti Coagulation and Ischemic Stroke Mechanism in Atrial Fibrillation Exploring Risk Factors

Background: Ischemic stroke occurs in setting of AF despite adequate treatment because of both cardiac and non-cardiac causes. We hypothesized that certain clinical , and cardiac characteristics would increase the likelihood of cardio -embolic stroke(CES) in therapeutically anticoagulated patients with AF

Methods: We reviewed the records of all adults who were adequately anticoagulated with warfarin or a DOAC(if information was available), and admitted to either the University of Kentucky or University of Massachusetts medical School with a diagnosis of ischemic stroke or transient ischemic attack between 01/01/2011 -06/30/2016. Stroke mechanism (CES vs non CES) using ASCOD criteria was determined by a vascular neurologist masked to the echocardiographic results. Categorical variables were analyzed with Chi square or Fisher exact test as appropriate. Continuous variables were analyzed using t test. P value <.05 was considered significant. Stepwise logistic regression was used to identify variable independently associated with CES

Results: 110 patients (68 patients with CES and 42 with non- CES ) were identified. In univariable analyses, CHF was more common in CES group (45% vs 23.8%, p=0.026) , EF was lower in CES group (49% vs 60% , p .00008) , history of PAD or Carotid disease were more common in non CES group (78% vs 50%, p .01) , also total cholesterol on admission was higher in the non CES group (158.5 vs 132.3 mg/dl, p .002) .other variables did not reach statistical significance ( see table) on multiple logistic regression only EF , total cholesterol and history of PAD/Carotid disease maintained statistical significance (.043, 0.013, and 0.022, respectively).

Conclusion: Patients with CES despite therapeutic anticoagulation had lower EF, were less likely to have extensive atherosclerotic disease , and had lower total cholesterol compared to those with non- CES. Larger prospective studies are required to confirm these findings

Abstract TMP52: The Hidden Burden of Ischemic Stroke, Transient Ischemic Attack, and Atrial Fibrillation Hospitalizations Among Elderly Women

Background: US women have a greater lifetime risk of stroke than men. Risk factors such as pregnancy and hormones influence sex differences in stroke at younger ages, but less is known about hospitalization rates and the proportion of hospitalizations for ischemic stroke (IS), transient ischemic attack (TIA), and atrial fibrillation (AF) by sex in different age groups. We assessed IS, TIA, and AF hospitalizations by sex and age.

Methods: IS (ICD-9 433, 434, 436), TIA (435), and AF (427.31) hospitalizations were identified in the 2014 National Inpatient Sample (NIS). Hospitalization rates per 100,000 population aged ≥18y were calculated using age- and sex-specific Census population denominators and NIS sampling weights to obtain national estimates. We also determined the proportions of condition-specific hospitalizations by sex.

Results: There were 338,654 (49.8% women) patients hospitalized for IS, 90,812 (58.0% women) for TIA, and 284,770 (49.9% women) for AF. For IS, TIA, and AF, respectively, the mean ages for women were 72.7y, 71.4y, and 74.0y vs 68.8y, 69.1y, and 66.2y for men. Hospitalization rates were higher for men than women at most ages for IS and AF; however, AF rates were higher in women beginning with age 80-84y (figure). Women represented a greater proportion of hospitalizations among those aged ≥75y for all 3 conditions (58% of IS, 62.5% of TIA, and 64.7% of AF events). The proportion of women hospitalized for TIA was higher in most age groups, but for IS and AF, the proportions of women exceeded those of men beginning at ages 75-80y and 70-75y, respectively.

Conclusion: Women were older when hospitalized for IS, TIA, and AF, and women aged ≥75y comprised the majority of these hospitalizations. This highlights the need for early detection of AF and IS risk in elderly women and underscores the importance of treating modifiable conditions to decrease the burden of vascular illness in women. This is critical given the overrepresentation of women among the very elderly.

Diabetic microcirculatory disturbances and pathologic erythropoiesis are provoked by deposition of amyloid-forming amylin in red blood cells and capillaries

In the setting of type-2 diabetes, there are declines of structural stability and functionality of blood capillaries and red blood cells (RBCs), increasing the risk for microcirculatory disturbances. Correcting hyperglycemia is not entirely effective at reestablishing normal cellular metabolism and function. Therefore, identification of pathological changes occurring before the development of overt hyperglycemia may lead to novel therapeutic targets for reducing the risk of microvascular dysfunction. Here we determine whether RBC-capillary interactions are altered by prediabetic hypersecretion of amylin, an amyloid forming hormone co-synthesized with insulin, and is reversed by endothelial cell-secreted epoxyeicosatrienoic acids. In patients, we found amylin deposition in RBCs in association with type-2 diabetes, heart failure, cancer and stroke. Amylin-coated RBCs have altered shape and reduced functional (non-glycated) hemoglobin. Amylin-coated RBCs administered intravenously in control rats upregulated erythropoietin and renal arginase expression and activity. We also found that diabetic rats expressing amyloid-forming human amylin in the pancreas (the HIP rat model) have increased tissue levels of hypoxia-inducible transcription factors, compared to diabetic rats that express non-amyloid forming rat amylin (the UCD rat model). Upregulation of erythropoietin correlated with lower hematocrit in the HIP model indicating pathologic erythropoiesis. In the HIP model, pharmacological upregulation of endogenous epoxyeicosatrienoic acids protected the renal microvasculature against amylin deposition and also reduced renal accumulation of HIFs. Thus, prediabetes induces dysregulation of amylin homeostasis and promotes amylin deposition in RBCs and the microvasculature altering RBC-capillary interaction leading to activation of hypoxia signaling pathways and pathologic erythropoiesis. Hence, dysregulation of amylin homeostasis could be a therapeutic target for ameliorating diabetic vascular complications.

Stroke in young cannabis users (18-49 years): National trends in hospitalizations and outcomes

BACKGROUND

Recent legalization of therapeutic and recreational cannabis use makes it imperative to have an insight into odds and trends in young-onset stroke-related hospitalizations among cannabis users (18-49 years).

METHODS

The National Inpatient Sample dataset (2007-2014) was utilized to assess national trends, odds of young-onset stroke-related hospitalizations, and outcomes among cannabis users vs. nonusers using provided discharge weights, strata, and cluster design. The rates are described per 100,000 hospitalizations among cannabis users and non-users.

RESULTS

A total of 3,307,310 hospitalizations were identified among young adults with current or previous cannabis use. Of these, 34,857 (1.1%) were related to young-onset stroke. A relative increase of 13.92% (553 in 2007 to 630 in 2014; p_trend < 0.001) in young-onset stroke admissions was reported among cannabis users. The odds of any stroke (OR 1.16, 95% CI 1.14-1.19, p < 0.001) and acute ischemic stroke (OR 1.41, 95% CI 1.31-1.51, p < 0.001) hospitalizations were considerably higher among cannabis users as compared to nonusers. In-hospital mortality rates were increasing (3.7% to 4.3%) among cannabis users whereas decreasing (7.7% to 5.9%) in nonusers from 2007 to 2014 (p_trend < 0.001). The mean length of stay and the hospitalization charges showed increasing trends in cannabis-related young-onset stroke admissions. There was an increasing trend in young-onset stroke admissions among male cannabis users (578 to 701; p_trend < 0.001) but not among females (516 to 457; p_trend = 0.14). The maximum rise in the young-onset stroke-related admissions was seen in African Americans (743 to 996; p_trend < 0.001).

CONCLUSIONS

We identified rising trends and higher risk (16% higher of overall young-onset stroke, 41% higher of acute ischemic stroke) of stroke-related hospitalizations and worse outcomes among cannabis users aged 18-49 years from 2007 to 2014.

Statin Safety and Associated Adverse Events: A Scientific Statement From the American Heart Association

One in 4 Americans >40 years of age takes a statin to reduce the risk of myocardial infarction, ischemic stroke, and other complications of atherosclerotic disease. The most effective statins produce a mean reduction in low-density lipoprotein cholesterol of 55% to 60% at the maximum dosage, and 6 of the 7 marketed statins are available in generic form, which makes them affordable for most patients. Primarily using data from randomized controlled trials, supplemented with observational data where necessary, this scientific statement provides a comprehensive review of statin safety and tolerability. The review covers the general patient population, as well as demographic subgroups, including the elderly, children, pregnant women, East Asians, and patients with specific conditions such as chronic disease of the kidney and liver, human immunodeficiency viral infection, and organ transplants. The risk of statin-induced serious muscle injury, including rhabdomyolysis, is <0.1%, and the risk of serious hepatotoxicity is ≈0.001%. The risk of statin-induced newly diagnosed diabetes mellitus is ≈0.2% per year of treatment, depending on the underlying risk of diabetes mellitus in the population studied. In patients with cerebrovascular disease, statins possibly increase the risk of hemorrhagic stroke; however, they clearly produce a greater reduction in the risk of atherothrombotic stroke and thus total stroke, as well as other cardiovascular events. There is no convincing evidence for a causal relationship between statins and cancer, cataracts, cognitive dysfunction, peripheral neuropathy, erectile dysfunction, or tendonitis. In US clinical practices, roughly 10% of patients stop taking a statin because of subjective complaints, most commonly muscle symptoms without raised creatine kinase. In contrast, in randomized clinical trials, the difference in the incidence of muscle symptoms without significantly raised creatinine kinase in statin-treated compared with placebo-treated participants is <1%, and it is even smaller (0.1%) for patients who discontinued treatment because of such muscle symptoms. This suggests that muscle symptoms are usually not caused by pharmacological effects of the statin. Restarting statin therapy in these patients can be challenging, but it is important, especially in patients at high risk of cardiovascular events, for whom prevention of these events is a priority. Overall, in patients for whom statin treatment is recommended by current guidelines, the benefits greatly outweigh the risks.

Distinct White Matter Changes Associated with Cerebrospinal Fluid Amyloid-β1-42 and Hypertension

BACKGROUND

Alzheimer's disease (AD) pathology and hypertension (HTN) are risk factors for development of white matter (WM) alterations and might be independently associated with these alterations in older adults.

OBJECTIVE

To evaluate the independent and synergistic effects of HTN and AD pathology on WM alterations.

METHODS

Clinical measures of cerebrovascular disease risk were collected from 62 participants in University of Kentucky Alzheimer's Disease Center studies who also had cerebrospinal fluid (CSF) sampling and MRI brain scans. CSF Aβ1-42 levels were measured as a marker of AD, and fluid-attenuated inversion recovery imaging and diffusion tensor imaging were obtained to assess WM macro- and microstructural properties. Linear regression analyses were used to assess the relationships among WM alterations, cerebrovascular disease risk, and AD pathology. Voxelwise analyses were performed to examine spatial patterns of WM alteration associated with each pathology.

RESULTS

HTN and CSF Aβ1-42 levels were each associated with white matter hyperintensities (WMH). Also, CSF Aβ1-42 levels were associated with alterations in normal appearing white matter fractional anisotropy (NAWM-FA), whereas HTN was marginally associated with alterations in NAWM-FA. Linear regression analyses demonstrated significant main effects of HTN and CSF Aβ1-42 on WMH volume, but no significant HTN×CSF Aβ1-42 interaction. Furthermore, voxelwise analyses showed unique patterns of WM alteration associated with hypertension and CSF Aβ1-42.

CONCLUSION

Associations of HTN and lower CSF Aβ1-42 with WM alteration were statistically and spatially distinct, suggesting independent rather than synergistic effects. Considering such spatial distributions may improve diagnostic accuracy to address each underlying pathology.

Association of Kidney Function With 30-Day and 1-Year Poststroke Mortality and Hospital Readmission

Background and Purpose- Kidney dysfunction is common among patients hospitalized for ischemic stroke. Understanding the association of kidney disease with poststroke outcomes is important to properly adjust for case mix in outcome studies, payment models and risk-standardized hospital readmission rates. Methods- In this cohort study of fee-for-service Medicare patients admitted with ischemic stroke to 1579 Get With The Guidelines-Stroke participating hospitals between 2009 and 2014, adjusted multivariable Cox proportional hazards models were used to determine the independent associations of estimated glomerular filtration rate (eGFR) and dialysis status with 30-day and 1-year postdischarge mortality and rehospitalizations. Results- Of 204 652 patients discharged alive (median age [25th-75th percentile] 80 years [73.0-86.0], 57.6% women, 79.8% white), 48.8% had an eGFR ≥60, 26.5% an eGFR 45 to 59, 16.3% an eGFR 30 to 44, 5.1% an eGFR 15 to 29, 0.6% an eGFR <15 without dialysis, and 2.8% were receiving dialysis. Compared with eGFR ≥60, and after adjusting for relevant variables, eGFR <45 was associated with increased 30-day mortality with the risk highest among those with eGFR <15 without dialysis (hazard ratio [HR], 2.09; 95% CI, 1.66-2.63). An eGFR <60 was associated with increased 1-year poststroke mortality that was highest among patients on dialysis (HR, 2.65; 95% CI, 2.49-2.81). Dialysis was also associated with the highest 30-day and 1-year rehospitalization rates (HR, 2.10; 95% CI, 1.95-2.26 and HR, 2.55; 95% CI, 2.44-2.66, respectively) and 30-day and 1-year composite of mortality and rehospitalization (HR, 2.04; 95% CI, 1.90-2.18 and HR, 2.46; 95% CI, 2.36-2.56, respectively). Conclusions- Within the first year after index hospitalization for ischemic stroke, eGFR and dialysis status on admission are associated with poststroke mortality and hospital readmissions. Kidney function should be included in risk-stratification models for poststroke outcomes.