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Management of the Stroke Patient with Patent Foramen Ovale: New Insights and Persistent Questions in the Wake of Recent Randomized Trials. Curr Atheroscler Rep 2013; 15:338. [DOI: 10.1007/s11883-013-0338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Jovanović ZB, Pavlović MA, Vujisić Tešić PB, Boričić Kostić VM, Cvitan ŽE, Pekmezović PT, Šternić Čovičković MN. The significance of the ultrasound diagnostics in evaluation of the emboligenic pathogenesis of transient ischemic attacks. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:597-603. [PMID: 23384465 DOI: 10.1016/j.ultrasmedbio.2012.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 09/29/2012] [Accepted: 10/28/2012] [Indexed: 06/01/2023]
Abstract
The objective of this study was to examine the possibilities of ultrasound diagnostics in the evaluation of emboligenic pathogenesis of transient ischemic attacks (TIAs) and the frequency of specific origins of embolism. A total of 150 adult patients with TIA and 50 control patients, were examined by neurosonologic, echocardiographic and venous ultrasound examination. Emboligenic pathogenesis of TIA was established in 36.6% of patients. Microembolic signals were detected in 22.7% of the whole group, and 61.8% in emboligenic TIA subgroup. Artery-to-artery embolism from ulcerated plaque of the carotid arteries was found in 12.6% of patients, from the aortic arch atheroma in 3.3% and cardioembolism in 12.6% (atrial fibrillation 7.3%, atrial septal aneurysm 2%, mitral valve prolapse 2%, mechanical heart valve 0.7%, left atrium thrombus 0.7%). Paradoxic embolism with the patent foramen ovale was established in 6% of patients, and with the pulmonary right-to-left shunt in 2%. Correlation with controls showed significantly higher frequency of the ulcerated carotid plaque and frequency of microembolic signals in the TIA group (p < 0.05). The patients with potential sources of embolism had a greater risk of developing TIA than those without these sources.
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Affiliation(s)
- Z B Jovanović
- Neurological Clinic, Clinical Center of Serbia, Dr. Subotica 6, 11 000 Belgrade, Serbia. E-mail:
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Meier B, Kalesan B, Mattle HP, Khattab AA, Hildick-Smith D, Dudek D, Andersen G, Ibrahim R, Schuler G, Walton AS, Wahl A, Windecker S, Jüni P. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368:1083-91. [PMID: 23514285 DOI: 10.1056/nejmoa1211716] [Citation(s) in RCA: 597] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The options for secondary prevention of cryptogenic embolism in patients with patent foramen ovale are administration of antithrombotic medications or percutaneous closure of the patent foramen ovale. We investigated whether closure is superior to medical therapy. METHODS We performed a multicenter, superiority trial in 29 centers in Europe, Canada, Brazil, and Australia in which the assessors of end points were unaware of the study-group assignments. Patients with a patent foramen ovale and ischemic stroke, transient ischemic attack (TIA), or a peripheral thromboembolic event were randomly assigned to undergo closure of the patent foramen ovale with the Amplatzer PFO Occluder or to receive medical therapy. The primary end point was a composite of death, nonfatal stroke, TIA, or peripheral embolism. Analysis was performed on data for the intention-to-treat population. RESULTS The mean duration of follow-up was 4.1 years in the closure group and 4.0 years in the medical-therapy group. The primary end point occurred in 7 of the 204 patients (3.4%) in the closure group and in 11 of the 210 patients (5.2%) in the medical-therapy group (hazard ratio for closure vs. medical therapy, 0.63; 95% confidence interval [CI], 0.24 to 1.62; P=0.34). Nonfatal stroke occurred in 1 patient (0.5%) in the closure group and 5 patients (2.4%) in the medical-therapy group (hazard ratio, 0.20; 95% CI, 0.02 to 1.72; P=0.14), and TIA occurred in 5 patients (2.5%) and 7 patients (3.3%), respectively (hazard ratio, 0.71; 95% CI, 0.23 to 2.24; P=0.56). CONCLUSIONS Closure of a patent foramen ovale for secondary prevention of cryptogenic embolism did not result in a significant reduction in the risk of recurrent embolic events or death as compared with medical therapy. (Funded by St. Jude Medical; ClinicalTrials.gov number, NCT00166257.).
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Affiliation(s)
- Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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Nam HS, Kim YD, Heo JH. Response to Letter by D’Anna et al Regarding Article, “Long-Term Mortality in Patients With Stroke of Undetermined Etiology”. Stroke 2013; 44:e4-5. [DOI: 10.1161/strokeaha.112.678391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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Sipola P, Hedman M, Onatsu J, Turpeinen A, Halinen M, Jäkälä P, Vanninen R. Computed Tomography and Echocardiography together Reveal More High-Risk Findings than Echocardiography Alone in the Diagnostics of Stroke Etiology. Cerebrovasc Dis 2013; 35:521-30. [DOI: 10.1159/000350734] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/05/2013] [Indexed: 11/19/2022] Open
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Affiliation(s)
- Gustavo Saposnik
- From the Stroke Outcomes Research Unit, Stroke Outcomes Research Canada (SORCan), Division of Neurology, Department of Medicine, St Michael’s Hospital, University of Toronto, Toronto, Canada; the Institute for Clinical Evaluative Sciences & Li Ka Shing Knowledge Institute, Toronto, Canada; and the Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Lee JM, Park JJ, Jung HW, Cho YS, Oh IY, Yoon CH, Suh JW, Chun EJ, Choi SI, Youn TJ, Lim C, Cho GY, Chae IH, Park KH, Choi DJ. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb 2012; 20:73-93. [PMID: 22986555 DOI: 10.5551/jat.13540] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
UNLABELLED Left ventricular (LV) thrombus is one of the risk factors for systemic thromboembolism. The aims of this study were to compare the long-term clinical outcomes of LV thrombus using current therapeutics, anticoagulation, operative treatment, and antiplatelet agents and to identify independent predictors of systemic thromboembolism. METHODS We screened 86,374 patients for intracardiac thrombus in the electronic medical records and imaging databases. Records of 62 patients with LV thrombus, diagnosed between May 2003 to November 2011, were comprehensively reviewed regarding baseline characteristics, imaging data and thrombus outcomes, thromboembolic events and treatment complications by treatment group. RESULTS The majority (80.6%) had ischemic etiology. Systemic thromboembolism developed in 18 patients; 8 (45%) were post-treatment thromboembolisms while 10 events occurred before treatment began. No post-treatment thromboembolism occurred in the operative treatment group; in contrast, 7 post-treatment thromboembolisms occurred in anticoagulation group (17%) (Log rank p= 0.175). Independent predictors of post-treatment thromboembolism were dilated cardiomyopathy (HR 61.30, p= 0.001), previous cerebrovascular events (HR 7.06, p= 0.042), female gender (HR 7.11, p= 0.031), and echocardiographic left ventricular end-diastolic diameter (HR 1.15, p= 0.047). CONCLUSIONS In this study, the rate of post-treatment thromboembolism was not significantly different among the treatment groups; however, operative treatment tended towards less post-treatment thromboembolism than other treatment groups.
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Affiliation(s)
- Joo Myung Lee
- Seoul National University Hospital, Seoul, South Korea
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Hoey ETD, Mankad K, Al-Chalabi H, Rosa S. The emerging role of cardiovascular MRI for suspected cardioembolic stroke. Clin Radiol 2012; 68:107-16. [PMID: 22939694 DOI: 10.1016/j.crad.2012.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 06/22/2012] [Accepted: 07/05/2012] [Indexed: 10/28/2022]
Abstract
Stroke is a leading cause of morbidity and long-term disability worldwide and is often the result of embolic material from the heart or proximal aorta. These are referred to as cardioembolic sources of stroke. The investigation of patients with suspected cardioembolic stroke has traditionally been the mainstay of echocardiography. Cardiac magnetic resonance imaging (MRI) is a powerful imaging technique that has rapidly evolved over the last decade and is playing an ever increasing role in clinical cardiovascular imaging. This review of the literature aims to furnish the reader with an understanding of the role of cardiac MRI across the spectrum of causes of cardioembolic sources of stroke by providing the reader with an overview of the indications, technical considerations, a proposed imaging algorithm, and capabilities of this technology with selected illustrated examples of disease entities.
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Affiliation(s)
- E T D Hoey
- Department of Radiology, Heart of England NHS Foundation Trust, Birmingham, UK
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Szabó KJ, Adány R, Balla J, Balogh Z, Boda Z, Edes I, Fekete I, Káplár M, Mátyus J, Oláh L, Olvasztó S, Paragh G, Páll D, Pfliegler G, Vajda G, Zeher M, Csiba L. [Advances in the prevention, diagnosis and therapy of vascular diseases]. Orv Hetil 2012; 153:483-98. [PMID: 22430004 DOI: 10.1556/oh.2012.29340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Atherosclerosis is a systemic disease affecting the coronary, carotid, intracerebral, renal and peripherial arteries. The early morphological and functional impairments could be detected in the second or third decades of life and their progression depend on the number and severity of risk factors and individual susceptility. Although the vascular risk factors (smoking, overweight, age, unhealthy diet, lack of physical exercise, hypertension, diabetes mellitus, chronic kidney disease and dyslipidemia) are the same and common in the different vascular diseases, the present clinical routine artificially classifies the diagnosis and therapy of different vascular diseases into different subfields of medicine with the negative impact of possible polypragmasia. Recently, worldwide health surveys (e.g. REACH registry) have proven the usefulness of a holistic approach in the diagnosis and therapy of multiorgan-affected vascular patients. This review summarizes the multidisciplinary advances and future perspective of vascular diseases.
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Affiliation(s)
- Katalin Judit Szabó
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum Neurológiai Klinika Debrecen Nagyerdei krt 98. 4032
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Ustrell X, Pellisé A. Cardiac workup of ischemic stroke. Curr Cardiol Rev 2011; 6:175-83. [PMID: 21804776 PMCID: PMC2994109 DOI: 10.2174/157340310791658721] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 04/10/2010] [Accepted: 05/25/2010] [Indexed: 12/31/2022] Open
Abstract
Stroke is the leading cause of disability in developed countries and the third cause of mortality. Up to 15-30% of ischemic strokes are caused by cardiac sources of emboli being associated with poor prognosis and high index of fatal recurrence. In order to establish an adequate preventive strategy it is crucial to identify the cause of the embolism. After a complete diagnostic workup up to 30% of strokes remain with an undetermined cause, and most of them are attributed to an embolic mechanism suggesting a cardiac origin.There is no consensus in the extent and optimal approach of cardiac workup of ischemic stroke. Clinical features along with brain imaging and the study of the cerebral vessels with ultrasonography or MRI/CT based angiography can identify other causes or lead to think about a possible cardioembolic origin.Atrial fibrillation is the most common cause of cardioembolic stroke. Identification of occult atrial fibrillation is essential. Baseline ECG, serial ECG('s), cardiac monitoring during the first 48 hours, and Holter monitoring have detection rates varying from 4 to 8% each separately. Extended cardiac monitoring with event loop recorders has shown higher rates of detection of paroxysmal atrial fibrillation.Cardiac imaging with echocardiography is necessary to identify structural sources of emboli. There is insufficient data to determine which is the optimal approach. Transthoracic echocardiography has an acceptable diagnostic yield in patients with heart disease but transesophageal echocardiography has a higher diagnostic yield and is necessary if no cardiac sources have been identified in patients with cryptogenic stroke with embolic mechanism.
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Affiliation(s)
- Xavier Ustrell
- Stroke Unit, Neurology Department, Joan XXIII University Hospital, Tarragona, Catalonia, Spain
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Hong YJ, Hur J, Kim YJ, Lee HJ, Nam JE, Kim HY, Choe KO, Choi BW. The usefulness of delayed contrast-enhanced cardiovascular magnetic resonance imaging in differentiating cardiac tumors from thrombi in stroke patients. Int J Cardiovasc Imaging 2011; 27 Suppl 1:89-95. [DOI: 10.1007/s10554-011-9961-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 10/07/2011] [Indexed: 10/17/2022]
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Kim YD, Hong HJ, Cha MJ, Nam CM, Nam HS, Heo JH. Determinants of infarction patterns in cardioembolic stroke. Eur Neurol 2011; 66:145-50. [PMID: 21876359 DOI: 10.1159/000330563] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 06/14/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Embolic infarctions from the heart are known to cause multiple scattered infarct lesions as well as single, large territorial infarctions. However, it remains unknown which factors contribute to these different infarction patterns in patients with potential cardiac sources of embolism (PCSE). METHODS We examined 388 ischemic stroke patients with a high-risk PCSE using diffusion-weighted imaging. Infarction patterns were categorized into a single large lesion, a single small lesion, confluent and additional lesions, or small scattered lesions. The relationships between infarction patterns and clinical and hematologic parameters were investigated. RESULTS Of the 388 patients, a single large lesion was detected in 139 (35.8%), a single small lesion in 29 (7.5%), confluent and additional lesions in 171 (44.1%), and small scattered lesions in 49 (12.7%). Prior use of antiplatelet agents and anticoagulant were associated with the pattern of small scattered lesions and a single small lesion, respectively. Additionally, higher white blood cell counts were associated with confluent and additional lesions. The type of high-risk PCSE was not related to a specific infarction pattern. CONCLUSIONS These results suggest that platelet function and inflammatory processes may directly affect the thrombus formation in the cardiac chamber.
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Affiliation(s)
- Young Dae Kim
- Department of Neurology, Severance Hospital Integrative Research Institute for Cerebral and Cardiovascular Diseases, Seoul, Korea
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Hubail Z, Lemler M, Ramaciotti C, Moore J, Ikemba C. Diagnosing a Patent Foramen Ovale in Children. Stroke 2011; 42:98-101. [DOI: 10.1161/strokeaha.110.595876] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background and Purpose—
Transesophageal echocardiography (TEE) is the gold standard for the diagnosis of a patent foramen ovale in adults. In children, acoustic windows on transthoracic echocardiography (TTE) are better than in adults; thus, an invasive TEE may not be necessary. Our goal was to assess the validity of TTE with agitated saline injection for the diagnosis of a patent foramen ovale in children using TEE as the gold standard.
Methods—
Fifty consecutive pediatric patients >1 year of age referred for TEE were prospectively enrolled. Imaging included 2-dimensional, color Doppler, and agitated saline contrast injections with and without Valsalva by TTE followed by TEE. Interpreters of the TTE were blinded to TEE results. Studies were categorized as “inconclusive” if the TTE images were inadequate for definitive diagnosis by the blinded interpreter.
Results—
TTE results were considered conclusive in 43 of 50 (86%) patients. Among the 43 conclusive studies, the 2 modalities disagreed in 1 patient. TTE had a positive predictive value of 100%, negative predictive value 97%, sensitivity of 88%, and specificity of 100% for detecting a patent foramen ovale.
Conclusions—
TTE with agitated saline injection is diagnostic for the assessment of atrial septal integrity in the majority of children.
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Affiliation(s)
- Zakariya Hubail
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Matthew Lemler
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Claudio Ramaciotti
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Jay Moore
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
| | - Catherine Ikemba
- From the Department of Pediatrics (Z.H., M.L., C.R., C.I.), Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Tex; and Children's Medical Center of Dallas (Z.H., M.L., C.R., J.M., C.I.), Dallas, Tex
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Kataoka H, Kumazawa M, Izumi T, Ueno S. Bihemispheric Subcortical Infarcts in the Middle Cerebral Artery Territory. CLINICAL MEDICINE INSIGHTS: CASE REPORTS 2011; 4:25-8. [PMID: 22084609 PMCID: PMC3201104 DOI: 10.4137/ccrep.s7121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and purpose: Previous studies have suggested embolic mechanisms for bihemispheric subcortical infarcts involving the anterior and posterior circulation. However, the mechanism of bihemispheric subcortical infarcts in middle cerebral artery (MCA) territories remains uncertain. We describe a patient with acute bihemispheric subcortical infarcts in restricted MCA territories suggesting an embolic mechanism. Case description: A 62-year-old woman with a history of hypertension and hyperlipidemia suddenly presented with left hemiplegia. Diffusion-weighted and T2-weighted magnetic resolution imaging of the brain showed multiple subcortical high intensity in the MCA territories. There were no acute infarctions in the cerebrum, brain stem, or cerebellum, including cortical lesions. The patient had no carotid, internal carotid artery, or MCA disease. Conclusion: Bihemispheric subcortical infarcts in the MCA territory are likely to have a proximal embolic source and such infarcts could be associated with multiple subcortical infarcts due to small vessel disease.
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Affiliation(s)
- Hiroshi Kataoka
- Department of Neurology, Nara Medical University, Kashihara, Nara, Japan
| | - Masahiro Kumazawa
- Department of Neurology, Heisei Memorial Hospital, Kashihara, Nara, Japan
| | - Tesseki Izumi
- Department of Neurology, Nara Medical University, Kashihara, Nara, Japan
| | - Satoshi Ueno
- Department of Neurology, Nara Medical University, Kashihara, Nara, Japan
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Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, Creager MA, Culebras A, Eckel RH, Hart RG, Hinchey JA, Howard VJ, Jauch EC, Levine SR, Meschia JF, Moore WS, Nixon JVI, Pearson TA. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010; 42:517-84. [PMID: 21127304 DOI: 10.1161/str.0b013e3181fcb238] [Citation(s) in RCA: 1030] [Impact Index Per Article: 73.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke. METHODS Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee. RESULTS Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed. CONCLUSIONS Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.
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Abstract
Patent foramen ovale is found in 24% of healthy adults and 38% of patients with cryptogenic stroke. This ratio and case reports indicate that patent foramen ovale and stroke are associated, probably because of paradoxical embolism. In healthy people with patent foramen ovale, embolic events are not more frequent than in controls, and therefore no primary prevention is needed. However, once ischaemic events occur, the risk of recurrence is substantial and prevention becomes an issue. Acetylsalicylic acid and warfarin reduce this risk to the same level as in patients without patent foramen ovale. Patent foramen ovale with a coinciding atrial septal aneurysm, spontaneous or large right-to-left shunt, or multiple ischaemic events potentiates the risk of recurrence. Transcatheter device closure has therefore become an intriguing addition to medical treatment, but its therapeutic value still needs to be confirmed by randomised-controlled trials.
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Affiliation(s)
| | - B. Meier
- Department of Cardiology, Inselspital, University of Bern, Bern, Switzerland
| | - K. Nedeltchev
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
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Calcific aortic valve and spontaneous embolic stroke: A review of literature. J Neurol Sci 2009; 287:32-5. [DOI: 10.1016/j.jns.2009.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 06/28/2009] [Accepted: 07/23/2009] [Indexed: 11/15/2022]
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Tanabe N, Iso H, Seki N, Suzuki H, Yatsuya H, Toyoshima H, Tamakoshi A. Daytime napping and mortality, with a special reference to cardiovascular disease: the JACC study. Int J Epidemiol 2009; 39:233-43. [DOI: 10.1093/ije/dyp327] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Ohki SI, Kubota I, Aizawa K, Misawa Y. Aortogenic cerebrovascular accident. Interact Cardiovasc Thorac Surg 2009; 9:899-900. [DOI: 10.1510/icvts.2009.212241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Yoo SH, Nah HW, Jo MW, Kang DW, Kim JS, Koh JY, Kwon SU. Age and body weight adjusted warfarin initiation program for ischaemic stroke patients. Eur J Neurol 2009; 16:1100-5. [DOI: 10.1111/j.1468-1331.2009.02745.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hur J, Kim YJ, Lee HJ, Ha JW, Heo JH, Choi EY, Shim CY, Kim TH, Nam JE, Choe KO, Choi BW. Cardiac Computed Tomographic Angiography for Detection of Cardiac Sources of Embolism in Stroke Patients. Stroke 2009; 40:2073-8. [DOI: 10.1161/strokeaha.108.537928] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jin Hur
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Jin Kim
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye-Jeong Lee
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong-Won Ha
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Eui-Young Choi
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi-Young Shim
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Tae Hoon Kim
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Eun Nam
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyu Ok Choe
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byoung Wook Choi
- From Department of Diagnostic Radiology (J.H., Y.J.K., H.-J.L., T.H.K., J.E.N., K.O.C., B.W.C.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Division of Cardiology (J.-W.H., E.-Y.C., C.-Y.S.), Yonsei Cardiovascular Center, Yonsei University College of Medicine, Seoul, South Korea; Department of Neurology (J.H.H.), Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Morris JG, Duffis EJ, Fisher M. Cardiac workup of ischemic stroke: can we improve our diagnostic yield? Stroke 2009; 40:2893-8. [PMID: 19478214 DOI: 10.1161/strokeaha.109.551226] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Discovering potential cardiac sources of stroke is an important part of the urgent evaluation of the ischemic stroke patient as it often impacts treatment decisions that are essential for determining secondary stroke prevention strategies, yet the optimal approach to the cardiac workup of an ischemic stroke patient is not known. METHODS A review of the literature concerning the utility of cardiac rhythm monitoring (ECG, telemetry, Holter monitors, and event recorders) and structural imaging (transthoracic and transesophageal echocardiography) was performed. RESULTS Data supporting a definitive, optimal, and cost-effective approach are lacking, though some data suggest that appropriate patient selection can improve the diagnostic and therapeutic yield of rhythm monitoring and echocardiography in the evaluation of stroke etiology. CONCLUSIONS Based on available data, an algorithmic approach for the evaluation of patients with acute ischemic cerebrovascular events that takes into account therapeutic and diagnostic yield as well as cost-efficiency is proposed.
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Affiliation(s)
- Jane G Morris
- Department of Neurology, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA 01655, USA.
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Ford MA, Reeder GS, Lennon RJ, Brown RD, Petty GW, Cabalka AK, Cetta F, Hagler DJ. Percutaneous Device Closure of Patent Foramen Ovale in Patients With Presumed Cryptogenic Stroke or Transient Ischemic Attack. JACC Cardiovasc Interv 2009; 2:404-11. [DOI: 10.1016/j.jcin.2008.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 12/21/2008] [Indexed: 10/20/2022]
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Ikonomidis I, Papadopoulos C, Flevari P, Paraskevaidis I, Lekakis J, Kremastinos DT. Left atrial thrombus after biventricular pacemaker implantation. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:582-4. [DOI: 10.1093/ejechocard/jep022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hussein A, Hilal D, Hamoui O, Hussein H, Abouzahr L, Kabbani S, Chammas E. Value of aortic arch analysis during routine transthoracic echocardiography in adults. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:625-9. [DOI: 10.1093/ejechocard/jep014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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