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Predicting asymptomatic coronary artery stenosis by aortic arch plaque in acute ischemic cerebrovascular disease: beyond the cervicocephalic atherosclerosis? Chin Med J (Engl) 2019; 132:905-913. [PMID: 30958431 PMCID: PMC6595764 DOI: 10.1097/cm9.0000000000000174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Asymptomatic coronary artery stenosis (ACAS) ≥50% is common in patients with acute ischemic cerebrovascular disease (AICVD), which portends a poor cardiovascular and cerebrovascular prognosis. Identifying ACAS ≥50% early may optimize the clinical management and improve the outcomes of these high-risk AICVD patients. This study aimed to investigate whether aortic arch plaque (AAP), an early atherosclerotic manifestation of brain blood-supplying arteries, could be a predictor for ACAS ≥50% in AICVD. Methods: In this cross-sectional study, atherosclerosis of the coronary and brain blood-supplying arteries was simultaneously evaluated using one-step computed tomography angiography (CTA) in AICVD patients without coronary artery disease history. The patients were divided into ACAS ≥50% and non-ACAS ≥50% groups according to whether CTA showed stenosis ≥50% in at least one coronary arterial segment. The AAP characteristics of CTA were depicted from aspects of thickness, extent, and complexity. Results: Among 118 analyzed patients with AICVD, 29/118 (24.6%) patients had ACAS ≥50%, while AAPs were observed in 86/118 (72.9%) patients. Increased AAP thickness per millimeter (adjusted odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.18–2.05), severe-extent AAP (adjusted OR: 13.66, 95% CI: 2.33–80.15), and presence of complex AAP (adjusted OR: 7.27, 95% CI: 2.30–23.03) were associated with ACAS ≥50% among patients with AICVD, independently of clinical demographics and cervicocephalic atherosclerotic stenosis. The combination of AAP thickness, extent, and complexity predicted ACAS ≥50% with an area under the receiver-operating characteristic curve of 0.78 (95% CI: 0.70–0.85, P < 0.001). All three AAP characteristics provided additional predictive power beyond cervical and intracranial atherosclerotic stenosis for ACAS ≥50% in AICVD (all P < 0.05). Conclusions: Thicker, severe-extent, and complex AAP were significant markers of the concomitant ACAS ≥50% in AICVD, possibly superior to the indicative value of cervical and intracranial atherosclerotic stenosis. As an integral part of atherosclerosis of brain blood-supplying arteries, AAP should not be overlooked in predicting ACAS ≥50% for patients with AICVD.
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Olesen KKW, Steensig K, Madsen M, Thim T, Jensen LO, Raungaard B, Eikelboom J, Kristensen SD, Bøtker HE, Maeng M. Comparison of Frequency of Ischemic Stroke in Patients With Versus Without Coronary Heart Disease and Without Atrial Fibrillation. Am J Cardiol 2019; 123:153-158. [PMID: 30389089 DOI: 10.1016/j.amjcard.2018.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 11/18/2022]
Abstract
Recent trials of antithrombotic therapy in patients with coronary artery disease (CAD) have demonstrated substantial reductions in ischemic stroke. Our aim was to examine ischemic stroke risk in patients with CAD and to identify those at highest risk. We examined ischemic stroke risk in patients without atrial fibrillation who underwent coronary angiography between 2004 and 2012. Patients were stratified according to presence or absence of CAD and further stratified by extent of CAD (0 vessel disease [VD], 1 VD, 2 VD, 3 VD, and diffuse VD). End points were composites of ischemic stroke, transient ischemic attack (TIA), and systemic embolism, as well as major adverse cardiovascular and cerebrovascular events (MACCE) defined as cardiac death, myocardial infarction, plus ischemic stroke, TIA, and systemic embolism. Adjusted incidence rate ratios (IRRs) were estimated. A total of 68,829 patients were included, 25,032 had 0 VD, 4,736 had diffuse VD, 18,471 had 1 VD, 10,588 had 2 VD, and 10,002 had 3 VD. Median follow-up was 4.0 years. CAD extent was associated with an increased risk of stroke, TIA, and systemic embolism (1 VD: adjusted IRR 1.02, 95% confidence interval [CI] 0.90 to 1.16; diffuse VD: adjusted IRR 1.22, 95% CI 1.02 to 1.47; 2 VD: adjusted IRR 1.28, 95% CI 1.12 to 1.45; 3 VD: adjusted IRR 1.37, 95% CI 1.20 to 1.55) compared with patients with 0 VD. Presence and extent of CAD were also associated with MACCE. In conclusion, CAD is associated with an increased risk of stroke, TIA, and systemic embolism and MACCE in patients without atrial fibrillation, and patients with coronary multi-VD are at highest risk and may be candidates for treatment strategies aiming at reducing ischemic stroke incidence.
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Affiliation(s)
- Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
| | - Kamilla Steensig
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Madsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Bent Raungaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - John Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Pande SD, Lwin MT, Kyaw KM, Khine AA, Thant AA, Win MM, Morris J. Post-stroke seizure-Do the locations, types and managements of stroke matter? Epilepsia Open 2018; 3:392-398. [PMID: 30187010 PMCID: PMC6119755 DOI: 10.1002/epi4.12249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2018] [Indexed: 12/16/2022] Open
Abstract
Objective To determine the incidence of post‐stroke seizures and the associated risk factors in a government‐restructured hospital in Singapore. Methods This retrospective study included consecutive patients (age ≥21 years) admitted to the stroke rehabilitation facility at Changi General Hospital, Singapore, between June 2008 and May 2017, with a minimum post‐discharge follow‐up of 6 months. Patients with known epilepsy central nervous system infection or tumor, a history of neurosurgery and or missing data were excluded from study. To determine the incidence of seizures, the patients’ hospital records, including those for all initial and subsequent admissions and outpatient follow‐ups, were reviewed. All prescribed medications were checked and documented. Seizures were diagnosed on the basis of clinical examination with or without electroencephalography. Results In total, 722 patients (women, 38%) with a mean age of 64 years were included. Of these, 48 (6.64%) experienced post‐stroke seizures during a follow‐up period of 6–108 months. The incidence of seizures was significantly higher in patients with hemorrhagic stroke (42%, p = 0.010), those with ischemic partial anterior circulation stroke (PACS) (27%, p = 0.025), those who underwent a neurosurgical procedure after stroke (p < 0.001), those with a low activated partial thromboplastin time (APTT) at admission (mean, 25.6; p = 0.015), and those using levodopa (21%, p < 0.001). Neurosurgical intervention after stroke (odds ratio [OR] 6.2, 95% confidence interval [CI] 2.9–13.1; p < 0.001), APTT (per‐unit increase; OR 0.86, 95% CI 0.76–0.98; p = 0.028), and underlying ischemic heart disease (IHD; OR 2.2, 95% CI 1.08–4.60; p = 0.029) were found to be independent predictors of seizure occurrence after stroke. Significance Post‐stroke seizure incidence from our study is 6.64%, with a median follow‐up of 49 months. Among patients with stroke, those with underlying IHD, those who undergo a neurosurgical procedure, and those with a low APTT at admission need careful monitoring. Levodopa should be used with caution and withdrawn as soon as possible.
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Affiliation(s)
- Shrikant D Pande
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - May Thiri Lwin
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - Kaung Myat Kyaw
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - Aye Aye Khine
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - Aye Aye Thant
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - May Myat Win
- Department of Neurological Rehabilitation Changi General Hospital Singapore Singapore
| | - Julie Morris
- Department of Medical Statistics University Hospital of South Manchester Manchester United Kingdom
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Four birds with one stone? Reparative, neuroplastic, cardiorespiratory, and metabolic benefits of aerobic exercise poststroke. Curr Opin Neurol 2018; 29:684-692. [PMID: 27661010 DOI: 10.1097/wco.0000000000000383] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Converging evidence from animal models of stroke and clinical trials suggests that aerobic exercise has effects across multiple targets. RECENT FINDINGS The subacute phase is characterized by a period of heightened neuroplasticity when aerobic exercise has the potential to optimize recovery. In animals, low intensity aerobic exercise shrinks lesion size and reduces cell death and inflammation, beginning 24 h poststroke. Also in animals, aerobic exercise upregulates brain-derived neurotrophic factor near the lesion and improves learning. In terms of neuroplastic effects, clinical trial results are less convincing and have only examined effects in chronic stroke. Stroke patients demonstrate cardiorespiratory fitness levels below the threshold required to carry out daily activities. This may contribute to a 'neurorehabilitation ceiling' that limits capacity to practice at a high enough frequency and intensity to promote recovery. Aerobic exercise when delivered 2-5 days per week at moderate to high intensity beginning as early as 5 days poststroke improves cardiorespiratory fitness, dyslipidemia, and glucose tolerance. SUMMARY Based on the evidence discussed and applying principles of periodization commonly used to prepare athletes for competition, we have created a model of aerobic training in subacute stroke in which training is delivered in density blocks (duration × intensity) matched to recovery phases.
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Kijpaisalratana N, Chutinet A, Suwanwela NC. Hyperacute Simultaneous Cardiocerebral Infarction: Rescuing the Brain or the Heart First? Front Neurol 2017; 8:664. [PMID: 29270151 PMCID: PMC5725403 DOI: 10.3389/fneur.2017.00664] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/23/2017] [Indexed: 11/26/2022] Open
Abstract
Concurrent acute ischemic stroke and acute myocardial infarction is an uncommon medical emergency condition. The challenge for the physicians regarding the management of this situation is paramount since early management of one condition will inevitably delay the other. We present two illustrative cases of “hyperacute simultaneous cardiocerebral infarction” who presented with simultaneous cardiocerebral infarction and arrived at the hospital within the thrombolytic therapeutic window for acute ischemic stroke of 4.5 h. We propose an algorithm for managing the patient with hyperacute simultaneous cardiocerebral infarction based on hemodynamic status and suggest close cardiac monitoring based on the site of cerebral infarction.
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Affiliation(s)
| | - Aurauma Chutinet
- Chulalongkorn Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Faculty of Medicine, Department of Medicine, Division of Neurology, Chulalongkorn University, Bangkok, Thailand
| | - Nijasri C Suwanwela
- Chulalongkorn Stroke Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Faculty of Medicine, Department of Medicine, Division of Neurology, Chulalongkorn University, Bangkok, Thailand
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Widimsky P, Doehner W, Diener HC, Van Gelder IC, Halliday A, Mazighi M. The role of cardiologists in stroke prevention and treatment: position paper of the European Society of Cardiology Council on Stroke. Eur Heart J 2017; 39:1567-1573. [DOI: 10.1093/eurheartj/ehx478] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 08/01/2017] [Indexed: 02/03/2023] Open
Affiliation(s)
- Petr Widimsky
- Third Faculty of Medicine, Cardiocenter, Charles University, University Hospital Kralovske Vinohrady, Srobárova 50, 100 00 Prague, Czech Republic
| | - Wolfram Doehner
- Center for Stroke Research Berlin and Department of Cardiology, Campus Virchow, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
- Berlin-Brandenburg Center for Regenerative Therapies, Charite Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Hans Christoph Diener
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Isabelle C Van Gelder
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Mikael Mazighi
- Stroke Unit Lariboisière Hospital, Interventional Neuroradiology Fondation Rothschild, Denis Diderot University, 2 rue Ambroise Paré, Paris 75010, France
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Abstract
The heart and brain are constantly interacting under normal physiological conditions. This interaction is under the control of the autonomic nervous system with parasympathetic and sympathetic nerve fibers including the participating brain structures. Pathological conditions, such as epilepsy and ischemic cerebral stroke influence heart function, especially the frequency and may result in severe arrhythmia. An asymmetric influence of the left and right brain hemispheres on the heart rate is still under debate. Conversely, the influence of the heart in cases of acute cardiac arrest on brain function is equally relevant and a common clinical problem after resuscitation. We review the damaging cascade of global cerebral hypoxia and the value of different diagnostic procedures as well as the ethical problem of the point in time of termination of consciousness and the instruments for estimating the prognosis.
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Yang CJ, Chen PC, Lin CS, Tsai CL, Tsai SH. Thrombolytic therapy-associated acute myocardial infarction in patients with acute ischemic stroke: A treatment dilemma. Am J Emerg Med 2016; 35:804.e1-804.e3. [PMID: 27890301 DOI: 10.1016/j.ajem.2016.11.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/20/2016] [Accepted: 11/20/2016] [Indexed: 11/16/2022] Open
Abstract
Acute myocardial infarction (AMI) is uncommon in the acute phase of acute ischemic stroke (AIS) and occurs in approximately 1% of the population. Here, we report a paradoxical case of AMI during tissue plasminogen activator (t-PA) infusion for AIS. We review and analyze the previously reported cases. We found that only patients with AMI which occurred after thrombolytic therapy for AIS who received an adequate combination of anticoagulation plus percutaneous coronary intervention survived their events. Several mechanisms have been proposed for the development of AMI after thrombolytic therapy. These mechanisms include fragmented intra-cardiac thrombus, intensified platelet aggregation that may lead to an increased potential for intra-cardiac thrombus formation, and a reduction in clot-associated plasminogen that may lead to a paradoxical hypercoagulable state of the coronary arteries. Currently, there is no consensus regarding this specific scenario. We propose that the therapeutic benefit and the potential risk of hemorrhagic complications should be further investigated and individualized. In patients who receive thrombolytic therapy for AIS and who then develop post-thrombolytic AMI, we suggest that the maximum treatment for the subsequent AMI be instituted promptly to avoid short-term mortality.
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Affiliation(s)
- Chih-Jen Yang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Chuan Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Lin Tsai
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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