Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association

The Cost Effectiveness of LAA Exclusion

Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention in lieu of oral anticoagulants. Reductions in bleeding risk and long-term compliance issues bundled with comparable stroke prevention benefits have made these interventions increasingly attractive. Unfortunately, healthcare funding remains limited. Comparative cost economic analyses are therefore critical in optimizing resource allocation. In this review we seek to discourse the cost economics analysis of LAA exclusion over available therapeutic alternatives (warfarin and the new oral anticoagulants (NOACs)). .

DASH (Dietary Approaches to Stop Hypertension) Diet and Risk of Subsequent Kidney Disease

BACKGROUND

There are established guidelines for recommended dietary intake for hypertension treatment and cardiovascular disease prevention. Evidence is lacking for effective dietary patterns for kidney disease prevention.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

Atherosclerosis Risk in Communities (ARIC) Study participants with baseline estimated glomerular filtration rate (eGFR) ≥ 60mL/min/1.73m2 (N=14,882).

PREDICTOR

The Dietary Approaches to Stop Hypertension (DASH) diet score was calculated based on self-reported dietary intake of red and processed meat, sweetened beverages, sodium, fruits, vegetables, whole grains, nuts and legumes, and low-fat dairy products, averaged over 2 visits.

OUTCOMES

Cases were ascertained based on the development of eGFRs<60mL/min/1.73m2 accompanied by ≥25% eGFR decline from baseline, an International Classification of Diseases, Ninth/Tenth Revision code for a kidney disease-related hospitalization or death, or end-stage renal disease from baseline through 2012.

RESULTS

3,720 participants developed kidney disease during a median follow-up of 23 years. Participants with a DASH diet score in the lowest tertile were 16% more likely to develop kidney disease than those with the highest score tertile (HR, 1.16; 95% CI, 1.07-1.26; P for trend < 0.001), after adjusting for sociodemographics, smoking status, physical activity, total caloric intake, baseline eGFR, overweight/obese status, diabetes status, hypertension status, systolic blood pressure, and antihypertensive medication use. Of the individual components of the DASH diet score, high red and processed meat intake was adversely associated with kidney disease and high nuts, legumes, and low-fat dairy products intake was associated with reduced risk for kidney disease.

LIMITATIONS

Potential measurement error due to self-reported dietary intake and lack of data for albuminuria.

CONCLUSIONS

Consuming a DASH-style diet was associated with lower risk for kidney disease independent of demographic characteristics, established kidney risk factors, and baseline kidney function. Healthful dietary patterns such as the DASH diet may be beneficial for kidney disease prevention.

Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient: Role of a Novel NQO1*2 Polymorphism

Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results-including coagulation parameters-were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient's warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient's international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S) polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care.

Safety of hormonal contraceptives among women with migraine: A systematic review

BACKGROUND

Migraine is common among women of reproductive age and is associated with an increased risk of ischemic stroke. Combined oral contraceptives (COCs) are also associated with an increased risk of ischemic stroke. Use of hormonal contraception among women with migraine might further elevate the risk of stroke among women of reproductive age.

OBJECTIVE

To identify evidence regarding the risk of arterial thromboembolism (stroke or myocardial infarction) among women with migraine who use hormonal contraceptives.

METHODS

We searched the PubMed database for all articles published from database inception through January 2016. We included studies that examined women with migraine overall or separated by subtype (with or without aura). Hormonal contraceptives of interest included combined hormonal methods (COCs, patch and ring) and progestin-only methods (progestin-only pills, injectables, implants and progestin intrauterine devices).

RESULTS

Seven articles met inclusion criteria. All were case-control studies of fair to poor quality reporting on use of COCs or oral contraceptives (OCs) not further described and all reported stroke outcomes. Four studies demonstrated that, among women with migraine (not separated by subtype), COC use was associated with approximately two to four times the risk of stroke compared with nonuse. The only study to examine specific migraine subtypes found an elevated risk of stroke among women with migraine with aura, and this risk was similar regardless of OC use, although these odds ratios were not reported. Two studies did not report risks among women with migraine and COC use combined, but both found increased risks of stroke with migraine and COC use independently. No evidence was found on other hormonal contraceptives or on risk of myocardial infarction.

CONCLUSION

Limited evidence suggests a two- to fourfold increased risk of stroke among women with migraine who use COCs compared with nonuse. Additional study is needed on the risks of hormonal contraceptives, including combined and progestin-only methods, among women with different migraine subtypes.

Combination Therapies for Smoking Cessation: A Hierarchical Bayesian Meta-Analysis

CONTEXT

Treatment guidelines recommend the use of combination therapies for smoking cessation, particularly behavioral therapy (BT) as an adjunct to pharmacotherapy. However, these guidelines rely on previous reviews with important limitations. This study's objective was to evaluate the efficacy of combination therapies compared with monotherapies, using the most rigorous data available.

EVIDENCE ACQUISITION

A systematic review and meta-analysis of RCTs of pharmacotherapies, BTs, or both were conducted. The Cochrane Library, Embase, PsycINFO, and PubMed databases were systematically searched from inception to July 2015. Inclusion was restricted to RCTs reporting biochemically validated abstinence at 12 months. Direct and indirect comparisons were made in 2015 between therapies using hierarchical Bayesian models.

EVIDENCE SYNTHESIS

The search identified 123 RCTs meeting inclusion criteria (60,774 participants), and data from 115 (57,851 participants) were meta-analyzed. Varenicline with BT increased abstinence more than other combinations of a pharmacotherapy with BT (varenicline versus bupropion: OR=1.56, 95% credible interval [CrI]=1.07, 2.34; varenicline versus nicotine patch: OR=1.65, 95% CrI=1.10, 2.51; varenicline versus short-acting nicotine-replacement therapies: OR=1.68, 95% CrI=1.15, 2.53). Adding BT to any pharmacotherapy compared with pharmacotherapy alone was inconclusive, owing to wide CrIs (OR=1.17, CrI=0.60, 2.12). Nicotine patch with short-acting nicotine-replacement therapy appears safe and increases abstinence versus nicotine-replacement monotherapy (OR=1.63, CrI=1.06, 3.03). Data are limited concerning other pharmacotherapy combinations and their safety and tolerability.

CONCLUSIONS

Evidence suggests that combination therapy benefits may be less than previously thought. Combined with BT, varenicline increases abstinence more than other pharmacotherapy with BT combinations.

The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis

Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.

Evaluating the Primary Prevention of Ischemic Stroke of Oral Antithrombotic Therapy in Head and Neck Cancer Patients with Radiation Therapy

Although previous studies demonstrated the risk of ischemic stroke (IS) in patients with head and neck cancer (HNC), the impact of oral antithrombotic therapy (OAT) on this risk has not yet been assessed. We aimed to evaluate the effectiveness and safety of OAT in patients with HNC treated with RT. This retrospective cohort study was performed using the National Health Insurance Research Database of Taiwan. A total of 37,638 patients diagnosed with HNC included in the study were classified as users and nonusers of OAT. Primary outcome was IS or transient ischemic attack (TIA), and secondary outcomes were death and major bleeding. The Cox proportional hazards model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). There was no significant difference in the risk of IS or TIA between patients on continuous OAT and nonusers (adjusted HR, 0.812; 95% CI, 0.199-3.309). The risk of major bleeding was not significantly different between the groups. From a national population database, we did not find an association between OAT and decreasing risk of ischemic stroke/TIA or increasing hazard of major bleeding.

Internal Carotid Artery Stenosis Presenting with Limb Shaking TIA

Internal carotid artery (ICA) stenosis may lead to a wide range of clinical symptoms. We describe the case of a 66-year-old female who experienced a transient ischemic attack (TIA) with episodes of limb shaking caused by ICA stenosis. After epilepsy had been suspected and ruled out, studies of her left ICA showed extensive blockage as a result of atherosclerosis. Magnetic resonance angiography (MRA) revealed total occlusion of the left ICA and the patient was eventually medically managed due to the strong possibility of surgical complications. We reported this patient's clinical course to shed light on a rare manifestation of carotid stenosis that may be confused with other diagnoses if not closely scrutinized.

Triglyceride to high-density lipoprotein cholesterol ratio predicts worse outcomes after acute ischaemic stroke

BACKGROUND AND PURPOSE

The effect of the triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C) on clinical outcomes of acute ischaemic stroke (AIS) patients is unclear. This study sought to determine whether the TG/HDL-C ratio in AIS patients is associated with worse outcomes at 3 months.

METHODS

Acute ischaemic stroke patients who were admitted from 2011 to 2014 were enrolled in this study. TG, total cholesterol (TC), HDL-C and low-density lipoprotein cholesterol (LDL-C) were collected on admission. Three end-points were defined according to the modified Rankin scale (mRS) score at 3 months after symptom onset (excellent outcome, mRS 0-1; good outcome, mRS 0-2; and death, mRS 6).

RESULTS

In all, 1006 patients were included (median age 68.5 years; 58.2% male). Higher TG, non-HDL-C and TG/HDL-C were strongly associated with the three end-points after adjustments: excellent [odds ratio (OR) = 1.39, OR 1.89 and OR 2.34, respectively] and good (OR 1.48, OR 2.90 and OR 4.12) outcomes, and death (OR 0.59, OR 0.29 and OR 0.26). According to receiver operating characteristic (ROC) analysis, the best discriminating factor was a TG/HDL-C ≥ 0.87 for excellent outcomes [area under the ROC curve (AUC) 0.596; sensitivity 73.3%; specificity 42.7%] and non-death (AUC 0.674; sensitivity 67.8%; specificity 60.6%) as well as a TG/HDL-C ≥ 1.01 for a good outcome (AUC 0.652; sensitivity 61.6%; specificity 63.2%). Patients with a TG/HDL-C < 0.87 had a 2.94-fold increased risk of death (95% confidence interval 1.89-4.55) compared with patients with a TG/HDL-C ≥ 0.87.

CONCLUSIONS

A lower TG/HDL-C was independently associated with death and worse outcome at 3 months in AIS.

Is CHA2DS2-VASc appropriate for hyperthyroid patients with atrial fibrillation? Implications of adding a transesophageal echocardiography evaluation

BACKGROUND

Anticoagulation remains a controversial issue among hyperthyroid patients with atrial fibrillation (AF). We aimed to evaluate the prevalence of the thrombogenic milieu (TM), detected using transesophageal echocardiography (TEE), among patients with AF related to hyperthyroidism, and to correlate these findings with the clinical embolic risk classification (CHA₂DS₂-VASc).

METHODS

CHA₂DS₂-VASc score, thyroid hormonal status, time since hyperthyroidism diagnosis, transthoracic echocardiography (TTE) and TEE were assessed in 47 consecutive patients aged between 18 and 65years with AF related to hyperthyroidism. The following TEE parameters defined TM: dense spontaneous echo contrast, thrombi, or left atrial appendage (LAA) blood flow velocities <0.20m/s. Non-classic TM was defined as non-dense SEC plus LAA flow velocity 0.20-0.40m/s.

RESULTS

Pulmonary hypertension was present in 39/47 (81.4%) and TM in 22/47 (46.8%) patients. Despite a low CHA₂DS₂-VASc score of 0/1, 10 of 19 (52.6%) patients had a TM, whereas 16 of 28 (57.1%) patients with score ≥2 had none. The probability of having a TM did not correlate with CHA₂DS₂-VASc scores. On regression binary analysis, hyperthyroidism diagnosed more than 12months previous was independently associated with non-classic TM (p=0.031).

CONCLUSION

Among patients younger than 65years of age with AF related to hyperthyroidism, pulmonary hypertension and TM on TEE were highly prevalent. There was no association between CHA₂DS₂-VASc with TEE markers of TM. Thyroid status, especially longer duration of hyperthyroidism might influence thrombogenic abnormalities. TEE adds useful information that may change antithrombotic therapy if otherwise guided solely by clinical risk classification.

Extracranial carotid artery stenosis and outcomes of patients undergoing transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is an alternative to open cardiac surgery in selected patients with severe aortic stenosis (AS). Carotid artery stenosis (CAS) has been associated with an increased risk of stroke following cardiac surgery, although the association between CAS and outcomes following TAVR is unclear. We therefore sought to study the prognostic impact of CAS on outcomes of patients undergoing TAVR.

METHODS

Consecutive patients (n=312) with severe symptomatic AS who underwent a carotid Doppler study immediately prior to TAVR were followed prospectively. Major adverse cardiovascular event (MACE) rates were stratified by the presence of CAS, defined in accordance with current practice guidelines.

RESULTS

Carotid atherosclerosis (CA, defined as any carotid plaque) was present in 301 (96.5%) of patients and CAS (peak systolic velocity [PSV]≥125cm/s; ≥50% diameter stenosis) in 97 (31.1%) patients. Severe CAS (PSV≥230cm/s; ≥70% stenosis, or near occlusion) was found in 20 (6.4%) patients. At long-term follow-up (248±205days), composite (20.9% vs. 19.6%, p=0.50) and individual (all-cause mortality, stroke, myocardial infarction, readmission for heart failure [19.5%% vs. 14.4%%, p=0.24; 3.3% vs. 2.1%, p=0.47; 1.4% vs. 0%, p=0.22; and 7.9% vs. 8.2%, p=0.84 respectively]) MACE rates did not differ significantly between patients without versus those with CAS. By multivariate analysis, CAS was not independently predictive of late MACE rates (HR=0.85, [95%CI 0.50-1.78], p=0.85).

CONCLUSIONS

CAS was not associated with worse outcomes following TAVR. The relative prognostic significance of CAS in patients considered for either surgical or transcatheter valve replacement merits further research.

Knowledge of Stroke Risk Factors among Stroke Survivors in Nigeria

Background. Knowledge of stroke risk factors is expected to reduce the incidence of stroke—whether first-ever or recurrent. This study examined knowledge of stroke risk factors and its determinants among stroke survivors. Methods. A cross-sectional survey of consenting stroke survivors at two physiotherapy facilities in Nigeria was carried out. Sociodemographic and clinical data were obtained and knowledge of stroke risk factors (defined as the ability to mention at least one correct risk factor) was assessed using open-ended questionnaire. Data were treated with descriptive statistics and logistic regression analysis. Results. Sixty-nine stroke survivors (male = 72.5%; mean ± SD age = 49.7 ± 10.6 years) participated in the study. Thirty-four (49.4%) participants had knowledge of stroke risk factors. Only educational level was significantly associated with knowledge and participants with tertiary educational qualification were about 48 times (odds ratio = 48.5; CI = 7.6–309.8; P < 0.0001) more likely to be knowledgeable than those with no education. Conclusion. Less than half of the participants had knowledge of stroke risk factors. Participants with tertiary education were significantly more knowledgeable than those with lower educational qualifications. Effective means of educating stroke survivors on stroke risk factors should be identified and adopted.

Higher Stroke Risk with Lower Blood Pressure in Hemodynamic Vertebrobasilar Disease: Analysis from the VERiTAS Study

BACKGROUND

Despite concerns regarding hypoperfusion in patients with large-artery occlusive disease, strict blood pressure (BP) control has become adopted as a safe strategy for risk reduction of stroke. We examined the relationship between BP control, blood flow, and risk of subsequent stroke in the prospective Vertebrobasilar Flow Evaluation and Risk of Transient Ischemic Attack and Stroke (VERiTAS) study.

METHODS

The VERiTAS study enrolled patients with recent vertebrobasilar (VB) transient ischemic attack or stroke and ≥50% atherosclerotic stenosis or occlusion of vertebral or basilar arteries. Hemodynamic status was designated as low or normal based on quantitative magnetic resonance angiography. Patients underwent standard medical management and follow-up for primary outcome event of VB territory stroke. Mean BP during follow-up (<140/90 versus ≥140/90 mm Hg) and flow status were examined relative to subsequent stroke risk using Cox proportional hazards analysis.

RESULTS

The 72 subjects had an average of 3.8 ± 1.2 BP recordings over 20 ± 8 months of follow-up; 39 (54%) had mean BP of<140/90 mm Hg. The BP groups were largely comparable for baseline demographics, risk factors, and stenosis severity. Comparing subgroups stratified by BP and hemodynamic status, we found that patients with both low flow and BP <140/90 mm Hg (n = 10) had the highest risk of subsequent stroke, with hazard ratio of 4.5 (confidence interval 1.3-16.0, P = .02), compared with the other subgroups combined.

CONCLUSIONS

Among a subgroup of patients with VB disease and low flow, strict BP control (BP <140/90) may increase the risk of subsequent stroke.

Multimodality ultrasound imaging in stroke: current concepts and future focus

INTRODUCTION

Stroke is a leading cause of disability and mortality worldwide. Ultrasound is a real-time imaging technique that is inexpensive, portable, non-invasive, and safe, with high diagnostic accuracy. Ultrasonic imaging can provide useful direct and indirect information about the characteristics of various vessels in the both intracranial and extracranial segments. Areas covered: In this review, we will discuss multimodal applications of ultrasonic imaging in stroke prevention and management including checking carotid intima-media thickness progression, evaluating the plaque morphology, calibrating the degree of stenosis, detecting the presence of patent foramen ovale, monitoring microembolization, and screening for stroke risk in patients with sickle cell disease. We present the conventional ultrasonography as well as the novel ultrasound techniques including gray scale median, 3-dementional ultrasound, elastography, intravascular ultrasound, and contrast-enhanced ultrasound. Expert commentary: Ultrasonography is a non-invasive, low-cost, safe, fast, and real-time imaging technology for stroke risk assessment. Each modality has its own advantage as well as limitation. Future research should be focused on developing new technologies that can improve the quality of imaging and accuracy of diagnosis.

A role for autophagy in carotid atherosclerosis

Purpose

Autophagy has emerged in recent years as a critical cellular survival mechanism for cell homeostasis and may play a protective role in atherosclerosis. We aimed to review here the role autophagy plays in different cell types present in carotid atherosclerotic plaques and that may be associated with the development of unstable carotid atheroma plaque.

Methods

We performed a thorough literature exploration in this area of research covering the three main cell types present in carotid atheroma plaques.

Findings

Reviewed reports indicate that the role of autophagy in stable or unstable carotid atherosclerotic plaques depends on the different cell types and phenotypes, the stage and morphology of the plaque and the specific autophagy factor/s involved.

Discussion

Although defective autophagy could be one of the causes for carotid atheroma plaques to become unstable, it is important to take into account that autophagic players can act differentially in different cell types and different stages of the developed plaque.

Conclusion

This review provides an overview of the role of autophagy in the main cell types in carotid atherosclerosis (i.e. macrophages, endothelial cells and smooth muscle cells).

Folic Acid Therapy Reduces the First Stroke Risk Associated With Hypercholesterolemia Among Hypertensive Patients

BACKGROUND AND PURPOSE

We sought to determine whether folic acid supplementation can independently reduce the risk of first stroke associated with elevated total cholesterol levels in a subanalysis using data from the CSPPT (China Stroke Primary Prevention Trial), a double-blind, randomized controlled trial.

METHODS

A total of 20 702 hypertensive adults without a history of major cardiovascular disease were randomly assigned to a double-blind daily treatment of an enalapril 10-mg and a folic acid 0.8-mg tablet or an enalapril 10-mg tablet alone. The primary outcome was first stroke.

RESULTS

The median treatment duration was 4.5 years. For participants not receiving folic acid treatment (enalapril-only group), high total cholesterol (≥200 mg/dL) was an independent predictor of first stroke when compared with low total cholesterol (<200 mg/dL; 4.0% versus 2.6%; hazard ratio, 1.52; 95% confidence interval, 1.18-1.97; P=0.001). Folic acid supplementation significantly reduced the risk of first stroke among participants with high total cholesterol (4.0% in the enalapril-only group versus 2.7% in the enalapril-folic acid group; hazard ratio, 0.69; 95% confidence interval, 0.56-0.84; P<0.001; number needed to treat, 78; 95% confidence interval, 52-158), independent of baseline folate levels and other important covariates. By contrast, among participants with low total cholesterol, the risk of stroke was 2.6% in the enalapril-only group versus 2.5% in the enalapril-folic acid group (hazard ratio, 1.00; 95% confidence interval, 0.75-1.30; P=0.982). The effect was greater among participants with elevated total cholesterol (P for interaction=0.024).

CONCLUSIONS

Elevated total cholesterol levels may modify the benefits of folic acid therapy on first stroke. Folic acid supplementation reduced the risk of first stroke associated with elevated total cholesterol by 31% among hypertensive adults without a history of major cardiovascular diseases.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794885.

Interaction Between Low-Dose Methotrexate and Nonsteroidal Anti-inflammatory Drugs, Penicillins, and Proton Pump Inhibitors

Objective: To review the potential drug interactions between low-dose methotrexate (LD-MTX) and nonsteroidal anti-inflammatory drugs (NSAIDs), penicillins, and proton-pump inhibitors (PPIs) given the disparity between interactions reported for high-dose and low-dose MTX to help guide clinicians. Data Sources: A literature search was performed in MEDLINE (1946 to September 2016), EMBASE (1974 to September 2016), and International Pharmaceutical Abstracts (1970 to January 2015) to identify reports describing potential drug interactions between LD-MTX and NSAIDS, penicillins, or PPIs. Reference lists of included articles were reviewed to find additional eligible articles. Study Selection and Data Extraction: All English-language observational, randomized, and pharmacokinetic (PK) studies assessing LD-MTX interactions in humans were analyzed to determine clinical relevance in making recommendations to clinicians. Clinical case reports were assigned a Drug Interaction Probability Scale score. Data Synthesis: A total of 32 articles were included (28 with NSAIDs, 3 with penicillins, and 2 with PPIs [1 including both PPI and NSAID]). Although there are some PK data to describe increased LD-MTX concentrations when NSAIDs are used concomitantly, the clinical relevance remains unclear. Based on the limited data on LD-MTX with penicillins and PPIs, no clinically meaningful interaction was identified. Conclusion: Given the available evidence, the clinical importance of the interaction between LD-MTX and NSAIDs, penicillins, and PPIs cannot be substantiated. Health care providers should assess the benefit and risk of LD-MTX regardless of concomitant drug use, including factors known to predispose patients to MTX toxicity, and continue to monitor clinical and laboratory parameters per guideline recommendations.

Heterogeneity of B Cell Functions in Stroke-Related Risk, Prevention, Injury, and Repair

It is well established that post-stroke inflammation contributes to neurovascular injury, blood-brain barrier disruption, and poor functional recovery in both animal and clinical studies. However, recent studies also suggest that several leukocyte subsets, activated during the post-stroke immune response, can exhibit both pro-injury and pro-recovery phenotypes. In accordance with these findings, B lymphocytes, or B cells, play a heterogeneous role in the adaptive immune response to stroke. This review highlights what is currently understood about the various roles of B cells, with an emphasis on stroke risk factors, as well as post-stroke injury and repair. This includes an overview of B cell functions, such as antibody production, cytokine secretion, and contribution to the immune response as antigen presenting cells. Next, evidence for B cell-mediated mechanisms in stroke-related risk factors, including hypertension, diabetes, and atherosclerosis, is outlined, followed by studies that focus on B cells during endogenous protection from stroke. Subsequently, animal studies that investigate the role of B cells in post-stroke injury and repair are summarized, and the final section describes current B cell-related clinical trials for stroke, as well as other central nervous system diseases. This review reveals the complex role of B cells in stroke, with a focus on areas for potential clinical intervention for a disease that affects millions of people globally each year.

Higher Risk of Ischemic Events in Secondary Prevention for Patients With Persistent Than Those With Paroxysmal Atrial Fibrillation

Background and Purpose—

The discrimination between paroxysmal and sustained (persistent or permanent) atrial fibrillation (AF) has not been considered in the approach to secondary stroke prevention. We aimed to assess the differences in clinical outcomes between mostly anticoagulated patients with sustained and paroxysmal AF who had previous ischemic stroke or transient ischemic attack.

Methods—

Using data from 1192 nonvalvular AF patients with acute ischemic stroke or transient ischemic attack who were registered in the SAMURAI-NVAF study (Stroke Management With Urgent Risk-Factor Assessment and Improvement-Nonvalvular AF; a prospective, multicenter, observational study), we divided patients into those with paroxysmal AF and those with sustained AF. We compared clinical outcomes between the 2 groups.

Results—

The median follow-up period was 1.8 (interquartile range, 0.93–2.0) years. Of the 1192 patients, 758 (336 women; 77.9±9.9 years old) and 434 (191 women; 77.3±10.0 years old) were assigned to the sustained AF group and paroxysmal AF groups, respectively. After adjusting for sex, age, previous anticoagulation, and initial National Institutes of Health Stroke Scale score, sustained AF was negatively associated with 3-month independence (multivariable-adjusted odds ratio, 0.61; 95% confidence interval, 0.43–0.87; P =0.006). The annual rate of stroke or systemic embolism was 8.3 and 4.6 per 100 person-years, respectively (multivariable-adjusted hazard ratio, 1.95; 95% confidence interval, 1.26–3.14) and that of major bleeding events was 3.4 and 3.1, respectively (hazard ratio, 1.13; 95% confidence interval, 0.63–2.08).

Conclusions—

Among patients with previous ischemic stroke or transient ischemic attack, those with sustained AF had a higher risk of stroke or systemic embolism compared with those with paroxysmal AF.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01581502.

Determinants and Time Trends for Ischaemic and Haemorrhagic Stroke in a Large Chinese Population

Background

The clinical epidemiology of stroke has been widely investigated in Caucasian populations, but the changes over time in the proportion of ischaemic to haemorrhagic strokes is less clear, especially in the Chinese population.

Aims

Our objective was to study the determinants and time trends for ischaemic and haemorrhagic stroke, in relation to age, in a large Chinese population cohort.

Methods

Using a medical insurance database in the southwest of China from 2001 to 2012, time trends in age-adjusted ischaemic and haemorrhagic stroke incidence and the contributing risk factors associated with age were investigated.

Results

Among 425,901 individuals without prior stroke (52.4% male, median age 54), the rate of ischaemic stroke (per 1000 patient-years) decreased between 2002–2007, then remained broadly similar between 2008–2012. The rate of haemorrhagic stroke showed a similar trend, being approximately 1.3–1.9 from 2008–2012. Compared to patients age<65, ischaemic and haemorrhagic stroke incidences (rate, 95% confidential interval, CI) were higher in the elderly population (age <65 versus age ≥65: ischaemic: 3.64, 3.33–4.00, vs 14.33, 14.01–14.60; haemorrhagic: 1.09, 1.00–1.10 vs 2.52,2.40–2.70, respectively, both p<0.001). There were no significant differences in haemorrhagic stroke rates between the elderly and the very elderly population. Ischaemic and haemorrhagic stroke shared similar risk factors (age, hypertension, coronary artery disease (CAD), vascular disease, and diabetes mellitus) (all p<0.05). In subjects age<75 years, CAD (7.17, 4.14–12.37) and diabetes mellitus (3.27, 2.42–4.42) contributed most to the developing of haemorrhagic stroke (all p<0.001). Amongst the very elderly, vascular disease (2.24, 1.49–3.37) was an additional major risk factor for haemorrhagic stroke, together with CAD and diabetes mellitus (all p<0.001).

Conclusion

In this large Chinese cohort, there was an increased risk of ischaemic stroke compared to haemorrhagic stroke with ageing. CAD, vascular disease, diabetes mellitus, and hypertension were major contributors to the development of hemorrhagic stroke in the very elderly Chinese population.

Current Practices in the Management of Antithrombotic Therapy During the Periendoscopic Period for Patients With Cardiovascular Disease

The management of antithrombotics during the periendoscopic period is traditionally represented as a doubleedged sword for cardiologists and endoscopists. Appropriate administration prevents thromboembolic events, whereas excessive administration provokes bleeding events. Therefore, cardiologists and endoscopists must consider the risks of bleeding and thromboembolism in individual cases, before deciding whether to continue antithrombotic use. Several guidelines exist concerning antithrombotic management in Asian and Western countries. These guidelines generally classify procedural bleeding risk and thromboembolic risk into high risk and low risk groups and recommend that the two risks be weighed when managing a given patient. Moreover, they generally do not recommend interrupting antithrombotics during the periendoscopic period unless absolutely necessary; however, the details surrounding this point differ among the guidelines after several revisions. In this review, we describe the present state, problems, and future perspectives concerning the management of antithrombotics in patients with cardiovascular disease undergoing gastrointestinal endoscopy.

Lifestyle modification for stroke prevention: facts and fiction

PURPOSE OF REVIEW

The purpose is to summarize recent evidence on lifestyle modifications and first or recurrent stroke risk.

RECENT FINDINGS

Weight reduction, low-risk diet, regular physical activity, smoking cessation, and low-to-moderate alcohol consumption may reduce stroke risk up to 50% or more, but level one evidence is still lacking for several interventions. Appropriate food ingredients can significantly decrease stroke risk as recently confirmed for Mediterranean diet. The optimal intensity and amount of physical exercise is still not well established before and after stroke, although modest levels of activity already show benefits. Passive smoking represents an important health hazard. The impact of tobacco withdrawal using e-cigarette is currently uncertain. Alcohol and stroke risk relation is probably J-shaped for ischaemic stroke and linear for intracranial haemorrhage. Coffee consumption is J-shaped for overall stroke. Several interventions have failed to show significant effects, including regular intake of 'healthy' forms of fatty acids, various vitamin supplements, and other antioxidants. Both individualized and public educational programmes are likely needed on a repetitive basis to induce and maintain a healthy lifestyle before or after a stroke.

Overweight and Obesity in Young Adulthood and the Risk of Stroke: a Meta-analysis

BACKGROUND

A systematic review assessing the association between overweight and obesity in young adulthood and stroke risk is lacking. Therefore, we conducted a meta-analysis to evaluate the association between overweight and obesity in young adulthood and stroke risk.

METHODS

We systematically searched PubMed and Embase databases for related studies of human subjects in the English language. Two investigators independently selected original studies in a 2-step process. Fixed- and random-effects models were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Subgroup analyses were also performed.

RESULTS

Eight studies met the inclusion criteria. The pooled adjusted RR of stroke was 1.36 (95% CI: 1.28-1.44) for overweight in young adulthood and 1.81 (95% CI: 1.45-2.25) for obesity in young adulthood. In subgroup analyses, overweight and obesity in young adulthood increased the risk of stroke in most groups, except for the group of stroke subtype. For ischemic stroke, the adjusted RR was 1.40 (95% CI: 1.24-1.58) for overweight in young adulthood and 1.78 (95% CI: 1.003-3.16) for obesity in young adulthood, whereas adjusted RR for hemorrhagic stroke was 1.25 (95% CI: .83-1.90) for overweight in young adulthood and 1.80 (95% CI: .97-3.35) for obesity in young adulthood.

CONCLUSIONS

Overweight and obesity in young adulthood are associated with an increased risk of stroke, probably, independent of other cardiovascular risk factors. The risk effect gradually increases with increasing body weight.

Plaque Imaging to Decide on Optimal Treatment: Medical Versus Carotid Endarterectomy Versus Carotid Artery Stenting

Many of the current guidelines for the management of carotid atherosclerosis are based on clinical trial findings published more than 2 decades ago. The lack of plaque information in clinical decision making represents a major shortcoming and highlights the need for contemporary trials based on characteristics of the atherosclerotic lesion itself, rather than luminal stenosis alone. This article summarizes the major dilemmas clinicians face in current practice, and discusses the rationale and evidence that plaque imaging may help to address these challenges and optimize the clinical management of carotid artery disease in the future.

Risk of seizure associated with use of acid-suppressive drugs: An observational cohort study

OBJECTIVES

Previous, large, prescription-event monitoring studies in patients receiving PPI therapy recorded instances of convulsion or seizure. The objective of this study was to quantify the relative risk of seizure associated with the use of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) in a general population, overall and stratified by epilepsy status, and to determine the effects of demographics and comorbidities.

METHODS

In this observational study (NCT01744301), patients aged 20-84years in the study period from 1 January 2005 to 31 December 2011 were identified from The Health Improvement Network. In a nested case-control analysis, 8605 patients with seizure were matched to 40000 controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using logistic regression.

RESULTS

After adjustment, there were no associations between current PPI use and seizure risk in the overall population (OR: 1.05; 95% CI: 0.87-1.27), the subcohort with epilepsy (OR: 0.87; 95% CI: 0.49-1.53), and the subcohort without epilepsy (OR: 1.05; 95% CI: 0.87-1.28). There were no associations between current H2RA use and seizure risk in the overall population (OR: 1.16; 95% CI: 0.62-2.18) and the subcohort without epilepsy (OR: 1.02; 95% CI: 0.51-2.01). Seizures were less frequent in women than in men. Dementia/psychosis, anxiety, depression, and use of anxiolytics, antidepressants, and paracetamol were associated with an increased seizure risk.

CONCLUSIONS

Our study revealed that the use of PPIs and the use of H2RAs were not associated with an increased risk of seizures in the overall population or in the cohorts stratified by epilepsy status.

Exercise Preconditioning Regulates the Toll-Like Receptor 4/Nuclear Factor-κB Signaling Pathway and Reduces Cerebral Ischemia/Reperfusion Inflammatory Injury: A Study in Rats

OBJECTIVE

To explore the influence of exercise preconditioning (EP) on the activity of the toll-like receptor (TLR)4/nuclear factor (NF)-κB signaling pathway in a rat model of cerebral ischemia/reperfusion (I/R) inflammatory injury.

METHODS

Ischemia was induced in rats using transient middle cerebral artery occlusion (tMCAO) after 3 weeks of EP. Fifty-four rats were divided into sham, MCAO, and EP+MCAO groups. Following the induction of cerebral I/R injury, rats were scored for neurological deficits. Various techniques were used to evaluate ischemic infarct volume and explore pathological changes in tissue morphology after cerebral I/R injury, wherein the levels of TLR4 and NF-κB were analyzed. In addition, enzyme-linked immunosorbent assays were used to detect the levels of tumor necrosis factor (TNF)-α and interleukin (IL)-1β in peripheral serum.

RESULTS

Twenty-four hours after cerebral I/R injury, the neurological deficit scores decreased and ischemic cortical damage alleviated in EP+MCAO group; the number of TLR4- and NF-κB-positive cells, the expression of TLR4 and NF-κB in the ischemic side, and the concentrations of TNF-α and IL-1β in the peripheral serum were lower in EP+MCAO group than those in the MCAO group (P <.05).

CONCLUSIONS

The present study indicates that EP can improve cerebral I/R-induced neurological deficits in rats, reduce infarct volume, mitigate pathological damage in the ischemic cortex, and exert neuroprotective effects. The mechanism underlying these effects might involve the regulation of the TLR4/NF-κB signaling pathway and the inhibition of central and peripheral inflammatory cascades during cerebral I/R injury.

First-ever ischemic stroke in elderly patients: predictors of functional outcome following carotid artery stenting

Age is an important risk factor for stroke, and carotid artery stenosis is the primary cause of first-ever ischemic stroke. Timely intervention with stenting procedures can effectively prevent secondary stroke; however, the impact of stenting on various periprocedural physical functionalities has never been thoroughly investigated. The primary aim of this study was to investigate whether prestenting characteristics were associated with long-term functional outcomes in patients presenting with first-ever ischemic stroke. The secondary aim was to investigate whether patient age was an important factor in outcomes following stenting, measured by the modified Rankin scale (mRS). In total, 144 consecutive patients with first-ever ischemic stroke who underwent carotid artery stenting from January 2010 to November 2014 were included. Clinical data were obtained by review of medical records. The Barthel index (BI) and mRS were used to assess disability before stenting and at 12-month follow-up. In total, 72/144 patients showed improvement (mRS[+]), 71 showed stationary and one showed deterioration in condition (mRS[-]). The prestenting parameters, ratio of cerebral blood volume (1.41 vs 1.2 for mRS[-] vs mRS[+]), BI (75 vs 85), and high-sensitivity C-reactive protein (hsCRP 5.0 vs 3.99), differed significantly between the two outcome groups (P<0.05). The internal carotid artery/common carotid artery ratio (P=0.011), BI (P=0.019), ipsilateral internal carotid artery resistance index (P=0.003), and HbA1c (P=0.039) were all factors significantly associated with patient age group. There was no significant association between age and poststenting outcome measured by mRS with 57% of patients in the ≥75 years age group showing mRS(-) and 43% showing mRS(+) (P=0.371). Our findings indicate that in our elderly patient series, carotid artery stenting may benefit a significant proportion of carotid stenotic patients regardless of age. Ratio of cerebral blood volume, BI, and admission hsCRP could serve as important predictors of mRS improvement and may facilitate differentiation of patients at baseline.

Metabolic syndrome and cardiovascular disease following hematopoietic cell transplantation: screening and preventive practice recommendations from CIBMTR and EBMT

Metabolic syndrome (MetS) is a constellation of cardiovascular risk factors that increases the risk of cardiovascular disease, diabetes mellitus and all cause mortality. Long-term survivors of hematopoietic cell transplantation (HCT) have a substantial risk of developing MetS and cardiovascular disease, with the estimated prevalence of MetS being 31-49% among HCT recipients. Although MetS has not yet been proven to impact cardiovascular risk after HCT, an understanding of the incidence and risk factors for MetS in HCT recipients can provide the foundation to evaluate screening guidelines and develop interventions that may mitigate cardiovascular-related mortality. A working group was established through the Center for International Blood and Marrow Transplant Research and the European Group for Blood and Marrow Transplantation with the goal of reviewing literature and recommend practices appropriate to HCT recipients. Here we deliver consensus recommendations to help clinicians provide screening and preventive care for MetS and cardiovascular disease among HCT recipients. All HCT survivors should be advised of the risks of MetS and encouraged to undergo recommended screening based on their predisposition and ongoing risk factors.

Bleeding Risk with Long-Term Low-Dose Aspirin: A Systematic Review of Observational Studies

BACKGROUND

Low-dose aspirin has proven effectiveness in secondary and primary prevention of cardiovascular events, but is also associated with an increased risk of major bleeding events. For primary prevention, this absolute risk must be carefully weighed against the benefits of aspirin; such assessments are currently limited by a lack of data from general populations.

METHODS

Systematic searches of Medline and Embase were conducted to identify observational studies published between 1946 and 4 March 2015 that reported the risks of gastrointestinal (GI) bleeding or intracranial hemorrhage (ICH) with long-term, low-dose aspirin (75-325 mg/day). Pooled estimates of the relative risk (RR) for bleeding events with aspirin versus non-use were calculated using random-effects models, based on reported estimates of RR (including odds ratios, hazard ratios, incidence rate ratios and standardized incidence ratios) in 39 articles.

FINDINGS

The incidence of GI bleeding with low-dose aspirin was 0.48-3.64 cases per 1000 person-years, and the overall pooled estimate of the RR with low-dose aspirin was 1.4 (95% confidence interval [CI]: 1.2-1.7). For upper and lower GI bleeding, the RRs with low-dose aspirin were 2.3 (2.0-2.6) and 1.8 (1.1-3.0), respectively. Neither aspirin dose nor duration of use had consistent effects on RRs for upper GI bleeding. The estimated RR for ICH with low-dose aspirin was 1.4 (1.2-1.7) overall. Aspirin was associated with increased bleeding risks when combined with non-steroidal anti-inflammatory drugs, clopidogrel and selective serotonin reuptake inhibitors compared with monotherapy. By contrast, concomitant use of proton pump inhibitors decreased upper GI bleeding risks relative to aspirin monotherapy.

CONCLUSIONS

The risks of major bleeding with low-dose aspirin in real-world settings are of a similar magnitude to those reported in randomized trials. These data will help inform clinical judgements regarding the use of low-dose aspirin in prevention of cardiovascular events.

Risk Factors for Stroke among Young-Old and Old-Old Community-Dwelling Adults in Japan: The Ohasama Study

AIM

Few studies have addressed stroke risk factors in older populations, particularly among the old-old. We examined differences in traditional risk factors for stroke among the old-old compared with the young-old in community-dwelling Japanese adults.

METHODS

We followed 2,065 residents aged ≥ 60 years who had no history of stroke. Traditional risk factors for stroke were obtained from a self-administered questionnaire at baseline. We classified participants into two age categories, 60-74 years (n=1,502) and ≥ 75 years (n=563), and assessed whether traditional risk factors were differentially associated with stroke incidence according to age category. Hazard ratios were calculated by the Cox proportional hazards model, adjusting for confounding factors and competing risk of death.

RESULTS

During a median follow-up of 12.8 and 7.9 years, 163 and 111 participants aged 60-74 and ≥ 75 years, respectively, developed a first stroke. Hypertension was consistently associated with increased risk of stroke, regardless of age category. Diabetes mellitus was associated with increased risk of stroke in those aged 60-74 years (hazard ratio, 1.50; 95% confidence interval, 1.00-2.25), but not in those aged ≥ 75 years (hazard ratio, 0.65; 95% confidence interval, 0.33-1.29), with significant interaction by age (P=0.035). No traditional risk factor other than hypertension was associated with stroke among those aged ≥ 75 years.

CONCLUSION

Those with hypertension had significantly higher stroke risk among old people, while diabetes mellitus was differentially associated with stroke according to age category. Our findings indicate the importance of different prevention strategies for stroke incidence according to age category.

Homocysteine lowering for stroke prevention: Unravelling the complexity of the evidence

Elevated levels of total homocysteine impair endothelial dysfunction and increase thrombosis. Homocysteine is causal in animal models, and in human studies, elevated total homocysteine is significantly associated with carotid atherosclerosis, lacunar infarction, and markedly increased risk of stroke in atrial fibrillation. Because two of the early large trials of B vitamin therapy (Vitamin Intervention for Stroke Prevention and the Norwegian Vitamin Study) did not show any reduction of stroke, and the Heart Outcomes Prevention Evaluation 2 trial was mistakenly interpreted as not showing a reduction of stroke (because the authors could not think of a biological difference between stroke and myocardial infarction), there has been widespread pessimism regarding treatment to lower total homocysteine for stroke prevention. However, the Heart Outcomes Prevention Evaluation 2 trial, the French trial of folic acid and omega three oils, the Vitamins to Prevent Stroke subgroup excluding antiplatelet therapy all showed a significant reduction of stroke. Reasons why the Vitamin Intervention for Stroke Prevention trial were negative included folate fortification in North America, provision of injections of B12 to patients with low baseline serum B12, and as it turns out, harm from cyanide in cyanocobalamin among participants with impaired renal function. In the Diabetic Intervention with Vitamins in Nephropathy trial, B vitamins including cyanocobalamin were harmful, and in a Vitamin Intervention for Stroke Prevention subgroup excluding participants who received B12 injections and those with impaired renal function, there was a statistically significant reduction of stroke/myocardial infarction/vascular death. In 2015, the China Stroke Primary Prevention Trial (CSPPT), in over 20,000 participants followed for 5 years, showed a significant reduction of stroke with folic acid in a setting where folate fortification has not been implemented. In the setting of folate fortification, the main causes of elevated total homocysteine are renal failure and metabolic B12 deficiency; the latter is very common among stroke patients (30% over age 71), and frequently missed. Serum B12 and total homocysteine should be checked routinely in stroke patients and elevated total homocysteine should be treated.

Clinician time used for decision making: a best case workflow study using cardiovascular risk assessments and Ask Mayo Expert algorithmic care process models

Background

Risk calculation is increasingly used in lipid management, congestive heart failure, and atrial fibrillation. The risk scores are then used for decisions about statin use, anticoagulation, and implantable defibrillator use. Calculating risks for patients and making decisions based on these risks is often done at the point of care and is an additional time burden for clinicians that can be decreased by automating the tasks and using clinical decision-making support.

Methods

Using Morae Recorder software, we timed 30 healthcare providers tasked with calculating the overall risk of cardiovascular events, sudden death in heart failure, and thrombotic event risk in atrial fibrillation. Risk calculators used were the American College of Cardiology Atherosclerotic Cardiovascular Disease risk calculator (AHA-ASCVD risk), Seattle Heart Failure Model (SHFM risk), and CHA₂DS₂VASc. We also timed the 30 providers using Ask Mayo Expert care process models for lipid management, heart failure management, and atrial fibrillation management based on the calculated risk scores. We used the Mayo Clinic primary care panel to estimate time for calculating an entire panel risk.

Results

Mean provider times to complete the CHA₂DS₂VASc, AHA-ASCVD risk, and SHFM were 36, 45, and 171 s respectively. For decision making about atrial fibrillation, lipids, and heart failure, the mean times (including risk calculations) were 85, 110, and 347 s respectively.

Conclusion

Even under best case circumstances, providers take a significant amount of time to complete risk assessments. For a complete panel of patients this can lead to hours of time required to make decisions about prescribing statins, use of anticoagulation, and medications for heart failure. Informatics solutions are needed to capture data in the medical record and serve up automatically calculated risk assessments to physicians and other providers at the point of care.

Nontyphoidal Salmonellosis, Human Immunodeficiency Virus Infection, and Ischemic Stroke

Nontyphoidal Salmonella infection and stroke are major causes of morbidity and mortality worldwide, with increased risk in the human immunodeficiency virus (HIV)-infected population. We report a rare case of ischemic stroke associated with Salmonella enteritidis subdural empyema in an older HIV-infected patient with multimorbidity, despite surgery and treatment with susceptible antimicrobial drugs.

Hypertension and Stroke in Patients with Left Ventricular Assist Devices (LVADs)

Stroke is one of the most dreaded complications of left ventricular assist device therapy in patients with end-stage congestive heart failure. There is strong evidence linking anticoagulation and infection with ischemic and hemorrhagic strokes, though recent data has emerged regarding the importance of elevated blood pressure. In the recently completed Heartware Ventricular Assist Device studies, a mean arterial pressure greater than 90 mmHg was associated with greater stroke risk, particularly the hemorrhagic subtype. In this review, we discuss recent evidence regarding deleterious effects of uncontrolled hypertension in patients with left ventricular devices, and propose measurement and management strategies.

Where to Focus Efforts to Reduce the Black-White Disparity in Stroke Mortality: Incidence Versus Case Fatality?

BACKGROUND AND PURPOSE

At age 45 years, blacks have a stroke mortality ≈3× greater than their white counterparts, with a declining disparity at older ages. We assess whether this black-white disparity in stroke mortality is attributable to a black-white disparity in stroke incidence versus a disparity in case fatality.

METHODS

We first assess if black-white differences in stroke mortality within 29 681 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort reflect national black-white differences in stroke mortality and then assess the degree to which black-white differences in stroke incidence or 30-day case fatality after stroke contribute to the disparities in stroke mortality.

RESULTS

The pattern of stroke mortality within the study mirrors the national pattern, with the black-to-white hazard ratio of ≈4.0 at age 45 years decreasing to ≈1.0 at age 85 years. The pattern of black-to-white disparities in stroke incidence shows a similar pattern but no evidence of a corresponding disparity in stroke case fatality.

CONCLUSIONS

These findings show that the black-white differences in stroke mortality are largely driven by differences in stroke incidence, with case fatality playing at most a minor role. Therefore, to reduce the black-white disparity in stroke mortality, interventions need to focus on prevention of stroke in blacks.

Design, methods and demographics from phase I of Alberta's Tomorrow Project cohort: a prospective cohort profile

BACKGROUND

Prospective cohorts have the potential to support multifactorial, health-related research, particularly if they are drawn from the general population, incorporate active and passive follow-up and permission is obtained to allow access by researchers to data repositories. This paper describes Phase I of the Alberta's Tomorrow Project cohort, a broad-based research platform designed to support investigations into factors that influence cancer and chronic disease risk.

METHODS

Adults aged 35-69 years living in Alberta, Canada, with no previous cancer diagnosis other than nonmelanoma skin cancer were recruited to the project by telephone-based random digit dialling. Participants were enrolled if they returned a Health and Lifestyle Questionnaire. Past year diet and physical activity questionnaires were mailed 3 months after enrolment. Consent was sought for active follow-up and linkage with administrative databases. Depending on enrolment date, participants were invited to complete up to 2 follow-up questionnaires (2004 and 2008).

RESULTS

Between 2001 and 2009, 31 072 (39% men) participants (mean age 50.2 [± 9.2] yr) were enrolled and 99% consented to linkage with administrative databases. Participants reported a wide range of educational attainment and household income. Compared with provincial surveillance data from the Canadian Community Health Survey, Alberta's Tomorrow Project participants had higher body mass index, lower prevalence of smoking and similar distribution of chronic health conditions. Follow-up questionnaires were completed by 83% and 72% of participants in 2004 and 2008, respectively. Robust quality control measures resulted in low frequencies of missing data.

INTERPRETATION

Alberta's Tomorrow Project provides a robust platform, based on a prospective cohort design, to support research into risk factors for cancer and chronic disease.

CHADS2 and CHA2DS2-VASc Scores Predict the Risk of Ischemic Stroke Outcome in Patients with Interatrial Block without Atrial Fibrillation

Aim: To evaluate the role of CHADS₂ and CHA₂DS₂-VASc scores in predicting the risk of ischemic stroke or transient ischemic attack (TIA) outcomes in patients with interatrial block (IAB) without a history of atrial fibrillation (AF).

Methods: A retrospective study was conducted, including 1,046 non-anticoagulated inpatients (612 males, 434 females; mean age: 63 ± 10 years) with IAB and without AF. IAB was defined as P-wave duration > 120 ms using a 12-lead electrocardiogram. CHADS₂ and CHA₂DS₂-VASc scores were retrospectively calculated. The primary outcomes evaluated were ischemic stroke or TIA.

Results: During the mean follow-up period of 4.9 ± 0.7 years, 55 (5.3%) patients had an ischemic stroke or TIA. Receiver operating characteristic (ROC) curve analysis showed that the CHADS₂ score [area under the curve (AUC), 0.638; 95% confidence interval (CI), 0.562–0.715; P = 0.001] and the CHA₂DS₂-VASc score (AUC, 0.671; 95% CI, 0.599–0.744; P <0.001) were predictive of ischemic strokes or TIA. Cut-off point analysis showed that a CHADS₂ score ≥ 3 (sensitivity = 0.455 and specificity = 0.747) and a CHA₂DS₂-VASc score ≥ 4 (sensitivity = 0.564 and specificity = 0.700) provided the highest predictive value for ischemic stroke or TIA. The multivariate Cox regression analysis showed that CHADS₂ [hazard ratio (HR), 1.442; 95% CI, 1.171–1.774; P = 0.001] and CHA₂DS₂-VASc (HR, 1.420; 95% CI, 1.203–1.677; P <0.001) scores were independently associated with ischemic stroke or TIA following adjustment for smoking, left atrial diameter, antiplatelet agents, angiotensin inhibitors, and statins.

Conclusions: CHADS₂ and CHA₂DS₂-VASc scores may be predictors of risk of ischemic stroke or TIA in patients with IAB without AF.

Detecting nonvalvular atrial fibrillation and anticoagulant therapy in cardioembolic ischemic stroke

Nonvalvular Atrial fibrillation (NVAF) is the most common cardiac arrhythmia associated with an increase in risk of stroke and systemic thromboembolism. Strokes related to AF are associated with higher mortality, greater disability, longer hospital stays, and lower chance of being discharged home. The present review will focus on the current status of detecting NVAF and stroke prevention when there is AF. The CHA2DS2-VASc risk stratification scheme is discussed for the identification of patients who are at risk for thromboembolic stroke related to NVAF. Patient with a CHA2DS2-VASc score of 2 or greater are candidates for warfarin or a novel oral anticoagulant, irrespective of whether the strategy is for rate or rhythm control. Finally, guidelines and landmark clinical trials in NVAF patients with primary or secondary stroke prevention are discussed.

Stroke and Chronic Kidney Disease: Epidemiology, Pathogenesis, and Management Across Kidney Disease Stages

Cerebrovascular disease and stroke are very common at all stages of chronic kidney disease (CKD), likely representing both shared risk factors as well as synergy among risk factors. More subtle ischemic brain lesions may be particularly common in the CKD population, with subtle manifestations including cognitive impairment. For individuals with nondialysis CKD, the prevention, approach to, diagnosis, and management of stroke is similar to the general, non-CKD population. For individuals with end-stage renal disease, far less is known regarding strategies to prevent stroke. Stroke prophylaxis using warfarin in dialysis patients with atrial fibrillation in particular remains of uncertain benefit. End-stage renal disease patients can be managed aggressively in the setting of acute stroke. Outcomes after stroke at all stages of CKD are poor, and improving these outcomes should be the subject of future clinical trials.

Assessment of Vascular Disease Prevention Practices in Urban Women

BACKGROUND

Women suffer higher rates of death due to stroke compared to men. In addition, previous studies suggest that women are treated less aggressively for vascular risk factors compared to men. We assessed the quality of primary and secondary vascular prevention at multiple primary care sites within a single region.

METHODS

Women more than age of 40 years were eligible for the study. Data from the electronic medical record at multiple primary care locations (internal medicine, family medicine, and geriatrics) were analyzed to assess quality of vascular preventative care. Specific attention was devoted to use of antithrombotic agents, statins, and estrogen.

RESULTS

1,815 women with a mean age of 61 years were reviewed. Seventy-five percent were African American. Patients in the urban practices had higher rates of vascular risk factors and existing vascular disease (heart disease or stroke) compared to the suburban locations. Seventy-one percent of patients with diabetes were receiving statins. For patients with previous stroke/transient ischemic attack (TIA), the use of antiplatelet agents or statins was <70%. Patients >70 years were more likely to receive antiplatelet agents (51% vs. 30%, p < 0.0001) and statins (p < 0.001).

CONCLUSIONS

Urban women have higher rates of vascular risk factors and overt vascular disease compared to suburban women. The use of proven secondary prevention medications for patients with prior stroke/TIA was suboptimal. Both primary and secondary prevention should be intensified for urban women.

Association between television viewing time and risk of incident stroke in a general population: Results from the REGARDS study

OBJECTIVES

The purpose of this study was to explore the relationship between TV/video viewing, as a measure of sedentary behavior, and risk of incident stroke in a large prospective cohort of men and women.

METHODS

This analysis involved 22,257 participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study who reported at baseline the amount of time spent watching TV/video daily. Suspected stroke events were identified at six-monthly telephone calls and were physician-adjudicated. Cox proportional hazards models were used to examine risk of stroke at follow-up.

RESULTS

During 7.1years of follow-up, 727 incident strokes occurred. After adjusting for demographic factors, watching TV/video ≥4h/day (30% of the sample) was associated with a hazard ratio of 1.37 increased risk of all stroke (95% confidence interval (CI), 1.10-1.71) and incident ischemic stroke (hazard ratio 1.35, CI 1.06-1.72). This association was attenuated by socioeconomic factors such as employment status, education and income.

CONCLUSIONS

These results suggest that while TV/video viewing is associated with increased stroke risk, the effect of TV/video viewing on stroke risk may be explained through other risk factors.