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England TJ, Hedstrom A, O'Sullivan SE, Woodhouse L, Jackson B, Sprigg N, Bath PM. Remote Ischemic Conditioning After Stroke Trial 2: A Phase IIb Randomized Controlled Trial in Hyperacute Stroke. J Am Heart Assoc 2019; 8:e013572. [PMID: 31747864 PMCID: PMC6912955 DOI: 10.1161/jaha.119.013572] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 09/23/2019] [Indexed: 11/16/2022]
Abstract
Background Repeated episodes of limb ischemia and reperfusion (remote ischemic conditioning [RIC]) may protect the brain from ischemic reperfusion injury. Methods and Results We performed a phase IIb blinded dose-escalation sham-controlled trial in patients with hyperacute stroke, randomized 1:1 to receive RIC (four 5-minute cycles) or sham to the nonparetic upper limb, in 3 blocks of increasing dose, starting within 6 hours of ictus. The primary outcome was trial feasibility (recruitment, attrition). Secondary outcomes included adherence, tolerability, safety (serious adverse events), plasma biomarkers at days 1 and 4 (S100-ß protein, matrix metalloproteinase-9, and neuron-specific enolase), and functional outcome. Sixty participants were recruited from 2 centers (3 per month) with no loss to follow-up: time to randomization 4 hours 5 minutes (SD 72 minutes), age 72 years (12), men 60%, blood pressure 154/80 mm Hg (25/12), National Institutes of Health Stroke Scale 8.4 (6.9), and 55% thrombolyzed. RIC was well tolerated with adherence not differing between RIC and sham, falling in both groups on day 3 (P=0.001, repeated measures ANOVA) because of discharge or transfer. S100ß increased in the sham group (mean rise 111 pg/mL [302], P=0.041, repeated measures ANCOVA) but not the RIC group. There were no differences in matrix metalloproteinase-9, neuron-specific enolase, number with serious adverse events (RIC 10 versus sham 10, P=0.81), deaths (2 versus 4, P=0.36), or modified Rankin Scale score (2 [interquartile range 1-4], 2 [interquartile range, 1-3]; P=0.85). Conclusions RIC in hyperacute stroke is feasible when given twice daily for 2 days and appears safe in a small population with hyperacute stroke. A larger phase III trial is warranted. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02779712.
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Affiliation(s)
- Timothy J. England
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
- StrokeRoyal Derby HospitalUniversity Hospitals of Derby and BurtonNHS Foundation TrustDerbyUnited Kingdom
| | - Amanda Hedstrom
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
| | - Saoirse E. O'Sullivan
- Vascular MedicineDivision of Medical Sciences and GEMSchool of MedicineUniversity of NottinghamDerbyUnited Kingdom
| | - Lisa Woodhouse
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
| | - Ben Jackson
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
| | - Nikola Sprigg
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
- StrokeNottingham University Hospitals NHS TrustCity Hospital CampusNottinghamUnited Kingdom
| | - Philip M. Bath
- Stroke Trials UnitDivision of Clinical NeuroscienceCity Hospital CampusUniversity of NottinghamNottinghamUnited Kingdom
- StrokeNottingham University Hospitals NHS TrustCity Hospital CampusNottinghamUnited Kingdom
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102
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Pocock H, Thomson M, Taylor S, Deakin CD, England E. Optimising ambulance service contribution to clinical trials: a phenomenological exploration using focus groups. Br Paramed J 2019; 4:8-15. [PMID: 33447146 PMCID: PMC7783917 DOI: 10.29045/14784726.2019.12.4.3.8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Out-of-hospital cardiac arrest trials can prove challenging and there is a need to share learning from those that have recruited successfully. We have just completed three years of recruitment to PARAMEDIC2, a placebo-controlled trial of adrenaline in out-of-hospital cardiac arrest. This study was designed to describe the experience of operational ambulance staff involved in recruiting patients into PARAMEDIC2. Methods: Four focus groups involving trial paramedics and supporting members of the emergency care team were conducted across different geographical regions of a single UK ambulance service participating in the PARAMEDIC2 study. Data analysis was supported by NVivo 12 and themes were identified using a thematic analysis approach. Results: Forty-four participants contributed to the focus groups. Four overarching themes were identified: context for the research, ethical concerns, concerns at the patient’s side and ongoing trial support. Participants felt that research such as PARAMEDIC2 is important and necessary to drive medical progress. They valued the opportunity to be part of a large project. Due to the deferred consent model employed, public awareness of the trial was felt to be important. Most expressed equipoise regarding adrenaline, but some felt concerned about enrolling younger patients and there was discussion around what constitutes a successful outcome. Struggles with ethical concerns were overcome through training and one-to-one discussion with research paramedics. Participants valued feedback on their performance of trial tasks, but also wanted feedback on their resuscitation skills. Cardiac arrest places a high cognitive demand on paramedics; simplicity and reinforcement of trial processes were key to facilitating recruitment. Caring for relatives was a high priority for paramedics and some felt conflicted about not discussing the trial with them. Conclusions: This study has provided insights into paramedic experience of a large-scale pre-hospital trial. Investment in time and resource to provide face-to-face training and personalised feedback to paramedics can foster engagement and optimise performance.
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Affiliation(s)
- Helen Pocock
- South Central Ambulance Service NHS Foundation Trust: ORCID iD: http://orcid.org/0000-0001-7648-5313
| | | | - Sarah Taylor
- South Central Ambulance Service NHS Foundation Trust
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust: ORCID ID: https://orcid.org/0000-0002-2565-9771
| | - Ed England
- South Central Ambulance Service NHS Foundation Trust: ORCID iD: https://orcid.org/0000-0002-8009-2843
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103
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Blauenfeldt RA, Hjort N, Gude MF, Behrndtz AB, Fisher M, Valentin JB, Kirkegaard H, Johnsen SP, Hess DC, Andersen G. A multicentre, randomised, sham-controlled trial on REmote iSchemic conditioning In patients with acute STroke (RESIST) - Rationale and study design. Eur Stroke J 2019; 5:94-101. [PMID: 32232175 DOI: 10.1177/2396987319884408] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/03/2019] [Indexed: 12/20/2022] Open
Abstract
Rationale Remote ischaemic conditioning, applied in the prehospital setting and continued in-hospital, may improve functional outcome in patients with acute ischaemic stroke and intracerebral haemorrhage. Aims To evaluate whether combined remote ischaemic per- and postconditioning can improve long-term functional outcome in acute ischaemic stroke and intracerebral haemorrhage patients. Methods and design Danish multicentre, prospective, randomised, patient-assessor blinded, sham-controlled study. Adult patients with a putative stroke identified prehospital with symptom duration <4 h, who are independent in daily activities will be randomised 1:1 to remote ischaemic conditioning or Sham-remote ischaemic conditioning. The treatment protocol will be five cycles, each consisting of 5 min with a blood pressure cuff inflation and 5 min with a deflated cuff placed on the upper extremity. The cuff pressure for remote ischaemic conditioning will be 200 mmHg-285 mmHg according to the individual systolic blood pressure and 20 mmHg sham-remote ischaemic conditioning during inflation. The study is approved as an acute study and consent is waived in the acute phase.Sample size estimation: For a 7% increased odds for a beneficial shift on the modified Rankin Scale at a significance level of 5% and power of 90%, 1000 patients with a target diagnosis of acute ischaemic stroke and intracerebral haemorrhage and a total of 1500 patients with a prehospital presumed stroke will be included.Study outcomes: The primary outcome will be the modified Rankin Scale score measured at three-month follow-up (analysed using ordinal logistic regression). ClinicalTrials.gov Identifier: NCT03481777.
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Affiliation(s)
- Rolf A Blauenfeldt
- Neurology & Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Hjort
- Neurology & Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
| | - Martin F Gude
- Department of Research and Development, Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark
| | - Anne B Behrndtz
- Neurology & Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark.,Department of Neurology, Regional Hospital of West Jutland, Holstebro, Denmark
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jan B Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Hans Kirkegaard
- Department of Research and Development, Emergency Medical Services, Central Denmark Region and Aarhus University, Aarhus, Denmark
| | - Søren P Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - David C Hess
- Department of Neurology, Medical College Georgia & Augusta University, Augusta, GA, USA
| | - Grethe Andersen
- Neurology & Danish Stroke Center, Aarhus University Hospital, Aarhus, Denmark
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104
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Gorelick PB, Qureshi S, Farooq MU. Management of blood pressure in stroke. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2019; 3:100021. [PMID: 33447751 PMCID: PMC7803067 DOI: 10.1016/j.ijchy.2019.100021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/09/2019] [Indexed: 01/01/2023]
Abstract
Objective In this review and opinion piece, we discuss recent United States (US)-based guidance statements on the management of BP in stroke according to stroke type and stage of stroke. Methods We reviewed the most recent guidance statements on BP control from United States (US)-based organizations such as the American Heart Association/American Stroke Association (AHA/ASA) and American College of Cardiology (ACC), and articles available to the authors in their personal files. Results The key BP target before starting alteplase (t-PA) is < 185/110 mm Hg, and the maintenance BP after tPA administration is < 180/105 mm Hg. For IPH patients with systolic BP between 150 and 220 mm Hg and no contraindication to acute BP reduction therapy, acute lowering to 140 mm Hg systolic BP is safe. For persons with small vessel or lacunar cerebral ischemia, a reasonable BP lowering target is < 130 mm Hg systolic. For primary stroke prevention, the target BP for those with hypertension is < 140/90 mm Hg and self-measured BP is recommended to assist in BP control. Recent study and guidance suggest a BP target of <130/80 mm Hg for both primary and recurrent stroke prevention. BP control is reasonable for the prevention of cognitive decline or dementia. Conclusions BP targets for the proper management of stroke vary by chronological stage of stroke and by stroke subtype. Furthermore, consideration should be given to control of BP variability, especially in the acute phases of stroke, as it may play a role in conferring longer term outcomes. Stroke is an important cause of morbidity and mortality worldwide, and is well suited for prevention and acute treatment with proper BP management. BP targets in acute ischemic stroke vary whether intravenous alteplase is administered or an endovascular intervention is implemented or not. In acute intraparenchymal hemorrhage of the brain (IPH), it is reasonable to lower BP to a systolic level of 140–150 or up to 160 mm Hg. For both first and recurrent stroke prevention it is reasonable to aim for a BP target of <130/80 mm Hg based on the recent data. The revised BP target has been lowered to <130/80 mm Hg for prevention of major cardiovascular outcomes including stroke. Intensive BP control potentially preserves cognition, brain health, and brain structural integrity. Blood pressure variability is a new target for study in the acute treatment and prevention of stroke.
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Affiliation(s)
- Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Translational Neuroscience, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Shakaib Qureshi
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
| | - Muhammad U Farooq
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
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105
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Campbell BCV, De Silva DA, Macleod MR, Coutts SB, Schwamm LH, Davis SM, Donnan GA. Ischaemic stroke. Nat Rev Dis Primers 2019; 5:70. [PMID: 31601801 DOI: 10.1038/s41572-019-0118-8] [Citation(s) in RCA: 827] [Impact Index Per Article: 165.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Stroke is the second highest cause of death globally and a leading cause of disability, with an increasing incidence in developing countries. Ischaemic stroke caused by arterial occlusion is responsible for the majority of strokes. Management focuses on rapid reperfusion with intravenous thrombolysis and endovascular thrombectomy, which both reduce disability but are time-critical. Accordingly, improving the system of care to reduce treatment delays is key to maximizing the benefits of reperfusion therapies. Intravenous thrombolysis reduces disability when administered within 4.5 h of the onset of stroke. Thrombolysis also benefits selected patients with evidence from perfusion imaging of salvageable brain tissue for up to 9 h and in patients who awake with stroke symptoms. Endovascular thrombectomy reduces disability in a broad group of patients with large vessel occlusion when performed within 6 h of stroke onset and in patients selected by perfusion imaging up to 24 h following stroke onset. Secondary prevention of ischaemic stroke shares many common elements with cardiovascular risk management in other fields, including blood pressure control, cholesterol management and antithrombotic medications. Other preventative interventions are tailored to the mechanism of stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe symptomatic carotid artery stenosis.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia. .,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia.
| | - Deidre A De Silva
- Department of Neurology, Singapore General Hospital campus, National Neuroscience Institute, Singapore, Singapore
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
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106
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van Oosterhout WP, Schoonman GG, Saal DP, Thijs RD, Ferrari MD, van Dijk JG. Abnormal cardiovascular response to nitroglycerin in migraine. Cephalalgia 2019; 40:266-277. [PMID: 31594384 PMCID: PMC7066481 DOI: 10.1177/0333102419881657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Migraine and vasovagal syncope are comorbid conditions that may share part of their pathophysiology through autonomic control of the systemic circulation. Nitroglycerin can trigger both syncope and migraine attacks, suggesting enhanced systemic sensitivity in migraine. We aimed to determine the cardiovascular responses to nitroglycerin in migraine. Methods In 16 women with migraine without aura and 10 age- and gender-matched controls without headache, intravenous nitroglycerin (0.5 µg·kg−1·min−1) was administered. Finger photoplethysmography continuously assessed cardiovascular parameters (mean arterial pressure, heart rate, cardiac output, stroke volume and total peripheral resistance) before, during and after nitroglycerin infusion. Results Nitroglycerin provoked a migraine-like attack in 13/16 (81.2%) migraineurs but not in controls (p = .0001). No syncope was provoked. Migraineurs who later developed a migraine-like attack showed different responses in all parameters vs. controls (all p < .001): The decreases in cardiac output and stroke volume were more rapid and longer lasting, heart rate increased, mean arterial pressure and total peripheral resistance were higher and decreased steeply after an initial increase. Discussion Migraineurs who developed a migraine-like attack in response to nitroglycerin showed stronger systemic cardiovascular responses compared to non-headache controls. The stronger systemic cardiovascular responses in migraine suggest increased systemic sensitivity to vasodilators, possibly due to insufficient autonomic compensatory mechanisms.
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Affiliation(s)
- Willebrordus Pj van Oosterhout
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, OLVG Hospital, Amsterdam, the Netherlands
| | - Guus G Schoonman
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Elisabeth Tweesteden Hospital, Tilburg, the Netherlands
| | - Dirk P Saal
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Neurology, Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands
| | - Roland D Thijs
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Gert van Dijk
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.,Section of Clinical Neurophysiology, Leiden, University Medical Center, Leiden, the Netherlands
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107
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Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Hepburn T, Mair G, Montgomery AA, Phillips SJ, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Siriwardena AN, Venables G, Wardlaw JM, Sprigg N. Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial. Stroke 2019; 50:3064-3071. [PMID: 31587658 PMCID: PMC6824503 DOI: 10.1161/strokeaha.119.026389] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset.
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Affiliation(s)
- Philip M Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Lisa J Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Jason P Appleton
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Science Center, Beijing, China (C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, NSW, Australia (C.S.A.)
| | - Eivind Berge
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Department of Neurology (E.C.S.), Oslo University Hospital, Norway
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia (L.C.)
| | - Mark Dixon
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,East Midlands Ambulance Service NHS Trust, Nottingham, United Kingdom (M.D.)
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences, GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - Peter J Godolphin
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Grant Mair
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Stephen J Phillips
- Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Canada (S.J.P.)
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, United Kingdom (J.P.)
| | - Chris I Price
- Institute of Neuroscience, Newcastle University, United Kingdom (C.I.P.)
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, United Kingdom (M.R.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, United Kingdom (C.R.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.)
| | - Else C Sandset
- Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA (J.L.S.)
| | - A Niroshan Siriwardena
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Community and Health Research Unit, University of Lincoln, United Kingdom (A.N.S.)
| | - Graham Venables
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom (G.V.)
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
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108
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Moullaali TJ, Wang X, Martin RH, Shipes VB, Robinson TG, Chalmers J, Suarez JI, Qureshi AI, Palesch YY, Anderson CS. Blood pressure control and clinical outcomes in acute intracerebral haemorrhage: a preplanned pooled analysis of individual participant data. Lancet Neurol 2019; 18:857-864. [DOI: 10.1016/s1474-4422(19)30196-6] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 11/29/2022]
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109
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Anderson CS, Bath PM. Blood pressure reduction and intravenous thrombolysis - Authors' reply. Lancet 2019; 394:e25. [PMID: 31448746 DOI: 10.1016/s0140-6736(19)31413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 06/10/2019] [Indexed: 11/22/2022]
Affiliation(s)
- Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney 2050, Australia.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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110
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Kruyt ND, Roos YB, Nederkoorn PJ. Blood pressure reduction and intravenous thrombolysis. Lancet 2019; 394:e24. [PMID: 31448745 DOI: 10.1016/s0140-6736(19)31624-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden 2333ZA, Netherlands.
| | - Yvo B Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, Netherlands
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111
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Diener HC, Nitschmann S. [Optimal blood pressure control in patients with acute ischaemic stroke : ENCHANTED trial]. Internist (Berl) 2019; 60:1118-1120. [PMID: 31432198 DOI: 10.1007/s00108-019-00659-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- H-C Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät, Universität Duisburg-Essen, Hufelandstraße 55, 45147, Essen, Deutschland.
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Abstract
Significant advances in the acute treatment of patients with intracerebral hemorrhage (ICH) have been achieved in recent years. While many randomized trials have provided neutral results, important findings have been generated for the design of follow-up studies. Furthermore, a number of observational studies have been published, which in turn provide the basis for further methodologically stronger investigations. The focus is on avoidance of early bleeding progression, which can be influenced by blood pressure management and hemostasis. Furthermore, ICH surgery may experience a renaissance through minimally invasive techniques. In addition, perihemorrhagic edema and its pharmacological modulation are becoming increasingly more important. Optimal treatment of ventricular involvement is continuing to develop dynamically. Finally, long-term antithrombotic treatment has been intensely studied in observational analyses and is currently being investigated in randomized trials. This article addresses these most relevant topics in acute and long-term treatment of ICH patients and provides an overview of current debates in these areas of treatment.
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113
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van den Berg SA, Dippel DWJ, Hofmeijer J, Fransen PSS, Caminada K, Siegers A, Kruyt ND, Kerkhoff H, de Leeuw FE, Nederkoorn PJ, van der Worp HB. Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP): study protocol for a randomised controlled trial. Trials 2019; 20:383. [PMID: 31242931 PMCID: PMC6595565 DOI: 10.1186/s13063-019-3419-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 05/09/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Some studies have suggested that transdermal administration of glyceryl trinitrate (GTN; nitroglycerin) in the first few hours after symptom onset increases the chance of a favourable outcome after ischaemic stroke or intracerebral haemorrhage, possibly through an increase in intracranial collateral blood flow and a reduction in blood pressure. The Multicentre Randomised trial of Acute Stroke treatment in the Ambulance with a nitroglycerin Patch (MR ASAP) aims to assess the effect of transdermal GTN, started within 3 h after stroke onset in the prehospital setting, on functional outcome at 90 days in patients with acute ischaemic stroke or intracerebral haemorrhage. METHODS MR ASAP is a phase III, multicentre, randomised, open-label clinical trial with a blinded outcome assessment. A total of 1400 adult patients with suspected stroke and a systolic blood pressure ≥ 140 mmHg will be randomised to transdermal GTN (5 mg/day), administered as a transdermal patch by paramedics in the prehospital setting within 3 h of stroke onset and continued for 24 h or to standard care. The primary outcome is the score on the modified Rankin Scale (mRS) at 90 days, analysed with ordinal logistic regression. Secondary outcomes include blood pressure and collateral circulation at hospital admission, neurological deficit measured with the National Institutes of Health Stroke Scale at 24 h, and mortality and poor outcome (mRS score 3 to 6) at 90 days. This trial will be conducted in the Netherlands and will use a deferred consent procedure. The trial is part of the Collaboration for New Treatments of Acute Stroke (CONTRAST) programme. DISCUSSION MR ASAP will assess whether very early administration of GTN improves outcome after stroke in a setting where rates of intravenous thrombolysis and endovascular treatment for acute ischaemic stroke are high. The deferred consent procedure facilitates prompt GTN treatment and will prevent delay to revascularisation therapies. If early transdermal GTN treatment proves to be effective, this low-cost treatment can be readily implemented into daily clinical practice. TRIAL REGISTRATION ISRCTN Registry, ISRCTN99503308 . Registered on 2 January 2018.
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Affiliation(s)
- Sophie A. van den Berg
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Diederik W. J. Dippel
- Department of Neurology, Erasmus MC University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Puck S. S. Fransen
- Department of Neurology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Klaartje Caminada
- Regional Ambulance Service IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
- Department of Emergency Medicine, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Arjen Siegers
- Ambulance Amsterdam, Karperweg 19-25, 1075 LB Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Nyika D. Kruyt
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Paul J. Nederkoorn
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - H. Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - on behalf of the MR ASAP Investigators
- Department of Neurology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Neurology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
- Department of Neurology, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Regional Ambulance Service IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
- Department of Emergency Medicine, Isala, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Ambulance Amsterdam, Karperweg 19-25, 1075 LB Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Neurology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
- Department of Neurology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Bulwa Z, Gomez CR, Morales-Vidal S, Biller J. Management of Blood Pressure After Acute Ischemic Stroke. Curr Neurol Neurosci Rep 2019; 19:29. [PMID: 31037389 DOI: 10.1007/s11910-019-0941-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW The present manuscript examines the significance of blood pressure elevation in patients with acute ischemic stroke, the physiologic principles worthy of consideration during its treatment, and the recent empirical evidence that should guide management protocols. It also provides a sound and practical approach to treatment along the time continuum, with particular relevance to reperfusion strategies. RECENT FINDINGS The existing evidence shows that both insufficient and excessive blood pressures are detrimental to the outcome of patients with acute ischemic stroke. This "U-shaped" relation, however, relates to measurements at the time of presentation, and clinical studies lack detail and specificity relative to differential measurements along the time continuum, particularly prior to and following reperfusion. Extrapolating from recent series, it is possible to construct treatment protocols balanced for effectiveness and safety. The management of blood pressure after acute ischemic stroke is an important, complex, and challenging aspect of care, requiring a thorough understanding of cerebrovascular physiology. Along the time continuum, the therapeutic priorities start with the preservation of penumbral tissue prior to reperfusion and then follow with the limitation of the damaging effects of excessive blood pressure readings after reperfusion, optimizing the chances of improved outcomes.
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Affiliation(s)
- Zachary Bulwa
- Department of Neurology, Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Camilo R Gomez
- Department of Neurology, University of Missouri Columbia, Columbia, MO, USA.
| | - Sarkis Morales-Vidal
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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115
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Appleton JP, Woodhouse LJ, Belcher A, Bereczki D, Berge E, Caso V, Chang HM, Christensen HK, Collins R, Gommans J, Laska AC, Ntaios G, Ozturk S, Sare GM, Szatmari S, Wang Y, Wardlaw JM, Sprigg N, Bath PM. It is safe to use transdermal glyceryl trinitrate to lower blood pressure in patients with acute ischaemic stroke with carotid stenosis. Stroke Vasc Neurol 2019; 4:28-35. [PMID: 31105976 PMCID: PMC6475087 DOI: 10.1136/svn-2019-000232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background There is concern that blood pressure (BP) lowering in acute stroke may compromise cerebral perfusion and worsen outcome in the presence of carotid stenosis. We assessed the effect of glyceryl trinitrate (GTN) in patients with carotid stenosis using data from the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. Methods ENOS randomised 4011 patients with acute stroke and raised systolic BP (140-220 mm Hg) to transdermal GTN or no GTN within 48 hours of onset. Those on prestroke antihypertensives were also randomised to stop or continue their medication for 7 days. The primary outcome was the modified Rankin Scale (mRS) at day 90. Ipsilateral carotid stenosis was split: <30%; 30-<50%; 50-<70%; ≥70%. Data are ORs with 95% CIs adjusted for baseline prognostic factors. Results 2023 (60.5%) ischaemic stroke participants had carotid imaging. As compared with <30%, ≥70% ipsilateral stenosis was associated with an unfavourable shift in mRS (worse outcome) at 90 days (OR 1.88, 95% CI 1.44 to 2.44, p<0.001). Those with ≥70% stenosis who received GTN versus no GTN had a favourable shift in mRS (OR 0.56, 95% CI 0.34 to 0.93, p=0.024). In those with 50-<70% stenosis, continuing versus stopping prestroke antihypertensives was associated with worse disability, mood, quality of life and cognition at 90 days. Clinical outcomes did not differ across bilateral stenosis groups. Conclusions Following ischaemic stroke, severe ipsilateral carotid stenosis is associated with worse functional outcome at 90 days. GTN appears safe in ipsilateral or bilateral carotid stenosis, and might improve outcome in severe ipsilateral carotid stenosis.
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Affiliation(s)
- Jason P Appleton
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Andrew Belcher
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Hui Meng Chang
- Department of Neurology, Singapore General Hospital, Singapore, Singapore
| | | | - Ronan Collins
- Tallaght Hospital, Trinity College Dublin, Dublin, Ireland
| | - John Gommans
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Ann C Laska
- Department of Clinical Science, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Serefnur Ozturk
- Neurology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Gillian M Sare
- Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Szabolcs Szatmari
- Department of Neurology, Clinical County Emergency Hospital, Targu Mures, Romania
| | - Yongjun Wang
- Neurology, Beijing Tiantan Hospital, Beijing, China
| | | | - Nikola Sprigg
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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