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Long B, Koyfman A. Best Clinical Practice: Controversies in Transient Ischemic Attack Evaluation and Disposition in the Emergency Department. J Emerg Med 2017; 52:299-310. [DOI: 10.1016/j.jemermed.2016.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 02/07/2023]
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Evans BA, Ali K, Bulger J, Ford GA, Jones M, Moore C, Porter A, Pryce AD, Quinn T, Seagrove AC, Snooks H, Whitman S, Rees N. Referral pathways for patients with TIA avoiding hospital admission: a scoping review. BMJ Open 2017; 7:e013443. [PMID: 28196949 PMCID: PMC5318551 DOI: 10.1136/bmjopen-2016-013443] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To identify the features and effects of a pathway for emergency assessment and referral of patients with suspected transient ischaemic attack (TIA) in order to avoid admission to hospital. DESIGN Scoping review. DATA SOURCES PubMed, CINAHL Web of Science, Scopus. STUDY SELECTION Reports of primary research on referral of patients with suspected TIA directly to specialist outpatient services. DATA EXTRACTION We screened studies for eligibility and extracted data from relevant studies. Data were analysed to describe setting, assessment and referral processes, treatment, implementation and outcomes. RESULTS 8 international studies were identified, mostly cohort designs. 4 pathways were used by family doctors and 3 pathways by emergency department physicians. No pathways used by paramedics were found. Referrals were made to specialist clinic either directly or via a 24-hour helpline. Practitioners identified TIA symptoms and risk of further events using a checklist including the ABCD2 tool or clinical assessment. Antiplatelet medication was often given, usually aspirin unless contraindicated. Some patients underwent tests before referral and discharge. 5 studies reported reduced incident of stroke at 90 days, from 6-10% predicted rate to 1.3-2.1% actual rate. Between 44% and 83% of suspected TIA cases in these studies were referred through the pathways. CONCLUSIONS Research literature has focused on assessment and referral by family doctors and ED physicians to reduce hospitalisation of patients with TIA. No pathways for paramedical use were reported. We will use results of this scoping review to inform development of a paramedical referral pathway to be tested in a feasibility trial. TRIAL REGISTRATION NUMBER ISRCTN85516498. Stage: pre-results.
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Affiliation(s)
| | - Khalid Ali
- Brighton and Sussex Medical School, Brighton, UK
| | | | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Chris Moore
- Welsh Ambulance Service NHS Trust, Swansea, UK
| | | | - Alan David Pryce
- Lay Contributor c/o Swansea University Medical School, Swansea, UK
| | - Tom Quinn
- Kingston University and St George's, University of London, London, UK
| | | | | | - Shirley Whitman
- Lay Contributor c/o Swansea University Medical School, Swansea, UK
| | - Nigel Rees
- Welsh Ambulance Service NHS Trust, Swansea, UK
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Abstract
Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients."
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Affiliation(s)
- Lauren M Nentwich
- Department of Emergency Medicine, Boston Medical Center, Dowling 1 South, 1 Boston Medical Center Place, Boston, MA 02143, USA.
| | - Benjamin Grimmnitz
- Department of Emergency Medicine, Boston Medical Center, Dowling 1 South, 1 Boston Medical Center Place, Boston, MA 02143, USA
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Estimating cardiovascular disease incidence from prevalence: a spreadsheet based model. BMC Med Res Methodol 2017; 17:9. [PMID: 28114890 PMCID: PMC5259888 DOI: 10.1186/s12874-016-0288-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/26/2016] [Indexed: 12/02/2022] Open
Abstract
Background Disease incidence and prevalence are both core indicators of population health. Incidence is generally not as readily accessible as prevalence. Cohort studies and electronic health record systems are two major way to estimate disease incidence. The former is time-consuming and expensive; the latter is not available in most developing countries. Alternatively, mathematical models could be used to estimate disease incidence from prevalence. Methods We proposed and validated a method to estimate the age-standardized incidence of cardiovascular disease (CVD), with prevalence data from successive surveys and mortality data from empirical studies. Hallett’s method designed for estimating HIV infections in Africa was modified to estimate the incidence of myocardial infarction (MI) in the U.S. population and incidence of heart disease in the Canadian population. Results Model-derived estimates were in close agreement with observed incidence from cohort studies and population surveillance systems. This method correctly captured the trend in incidence given sufficient waves of cross-sectional surveys. The estimated MI declining rate in the U.S. population was in accordance with the literature. This method was superior to closed cohort, in terms of the estimating trend of population cardiovascular disease incidence. Conclusion It is possible to estimate CVD incidence accurately at the population level from cross-sectional prevalence data. This method has the potential to be used for age- and sex- specific incidence estimates, or to be expanded to other chronic conditions.
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Wang Y, Lin Y, Meng X, Chen W, Chen G, Wang Z, Wu J, Wang D, Li J, Cao Y, Xu Y, Zhang G, Li X, Pan Y, Li H, Liu L, Zhao X, Wang Y. Effect of ticagrelor with clopidogrel on high on-treatment platelet reactivity in acute stroke or transient ischemic attack (PRINCE) trial: Rationale and design. Int J Stroke 2017; 12:321-325. [PMID: 28381198 DOI: 10.1177/1747493017694390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale and aim Little is known about the safety and efficacy of the combination of ticagrelor and aspirin in acute ischemic stroke. This study aimed to evaluate whether the combination of ticagrelor and aspirin was superior to that of clopidogrel and aspirin in reducing the 90-day high on-treatment platelet reactivity for acute minor stroke or transient ischemic attack, especially for carriers of cytochrome P450 2C19 loss-of-function allele. Sample size and design This study was designed as a prospective, multicenter, randomized, open-label, active-controlled, and blind-endpoint, phase II b trial. The required sample size was 952 patients. It was registered with ClinicalTrials.gov (NCT02506140). Study outcomes The primary outcome was the proportion of patients with high on-treatment platelet reactivity at 90 days. High on-treatment platelet reactivity is defined as the P2Y12 reaction unit >208 measured using the VerifyNow P2Y12 assay. Conclusion The Platelet Reactivity in Acute Non-disabling Cerebrovascular Events study explored whether ticagrelor combined with aspirin could reduce further the proportion of patients with high on-treatment platelet reactivity at 90 days after acute minor stroke or transient ischemic attack compared with clopidogrel and aspirin.
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Affiliation(s)
- Yilong Wang
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Lin
- 5 Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xia Meng
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Weiqi Chen
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Guohua Chen
- 6 Department of Neurology, Wuhan No.1 Hospital, Wuhan, China
| | - Zhimin Wang
- 7 Department of Neurology, Taizhou First People's Hospital, Huangyan Hospital of Wenzhou Medical University, Taizhou, China
| | - Jialing Wu
- 8 Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Dali Wang
- 9 Department of Neurology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Jianhua Li
- 10 Department of Neurology, The First Hospital of Fangshan District, Beijing, China
| | - Yibin Cao
- 11 Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Yuming Xu
- 12 Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guohua Zhang
- 13 Department of Neurology, the Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaobo Li
- 14 Department of Neurology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, Yangzhou, China
| | - Yuesong Pan
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- 1 Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,2 China National Clinical Research Center for Neurological Diseases, Beijing, China.,3 Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,4 Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Appelros P, Háls Berglund M, Ström JO. Long-Term Risk of Stroke after Transient Ischemic Attack. Cerebrovasc Dis 2016; 43:25-30. [DOI: 10.1159/000451061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 09/15/2016] [Indexed: 11/19/2022] Open
Abstract
Background: In the absence of active management, the stroke risk after a transient ischemic attack (TIA) may be high. Almost 10 years ago, the results of the EXPRESS and SOS-TIA studies called for a more rapid management of TIA patients. The purpose of this study was to investigate the other stroke risks in the longer term, after the implementation of a more active approach to TIA. We also wanted to assess the predictive value of the ABCD2 score in this context. Methods: Riksstroke is the national stroke registry in Sweden. Data from Riksstroke's TIA module, and the national cause-of-death register, for the years 2011 and 2012 were used in this study. Stroke occurrence was monitored via Riksstroke. Cox's regression was used for risk evaluation. The predictive value of the ABCD2 score was assessed by calculating the area under the receiver operating characteristics curve. Results: A total of 15,068 TIA episodes occurred in 14,102 patients. The follow-up time varied between 0 and 819 days, with an average of 417 days. The mortality for all TIA patients during the follow-up time was 7.1%. Of the unique patients, 545 had one or more strokes (3.9%), corresponding to 34 events per 1,000 person years. Significant risk factors for stroke were: age, previous TIA, atrial fibrillation (AF), oral anticoagulant (OAC) treatment, hypertension treatment, and the ABCD2 items speech impairment, unilateral weakness, and diabetes mellitus. The ABCD2 score correlated with a subsequent stroke, but its predictive value was low. Conclusion: The risk of stroke is low after the acute phase of a TIA, probably lower than in previous studies. This may be due to better secondary prevention in recent years. Several risk factors predict stroke, notably hypertensive treatment, which may be inadequate; and AF, where OACs may be under-used. It is difficult to identify the role of the ABCD2 score in clinical practice.
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Ramirez L, Kim-Tenser MA, Sanossian N, Cen S, Wen G, He S, Mack WJ, Towfighi A. Trends in Transient Ischemic Attack Hospitalizations in the United States. J Am Heart Assoc 2016; 5:JAHA.116.004026. [PMID: 27664805 PMCID: PMC5079046 DOI: 10.1161/jaha.116.004026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Transient ischemic attack (TIA) is a major predictor of subsequent stroke. No study has assessed nation‐wide trends in hospitalization for TIA in the United States. Methods and Results Temporal trends in hospitalization for TIA (International Classification of Diseases, Ninth Revision code 435.0–435.9) from 2000 to 2010 were assessed among adults aged ≥25 years using the Nationwide Inpatient Sample. Age‐, sex‐, and race/ethnic‐specific TIA hospitalization rates were calculated using the weighted number of hospitalizations as the numerator and the US population as the denominator. Age‐adjusted rates were standardized to the 2000 US Census population. From 2000 to 2010, age‐adjusted TIA hospitalization rates decreased from 118 to 83 per 100 000 (overall rate reduction, −29.7%). Age‐specific TIA hospitalization rates increased for individuals aged 24 to 44 years (10–11 per 100 000), but decreased for individuals aged 45 to 64 (74 to 65 per 100 000), 65 to 84 (398 to 245 per 100 000), and ≥85 years (900 to 619 per 100 000). Blacks had the highest age‐adjusted yearly hospitalization rates, followed by Hispanics and whites (124, 82, and 67 per 100 000 in 2010). Rates slightly increased for blacks, but decreased for Hispanics and whites. Compared to women, age‐adjusted TIA hospitalization rates were lower and declined more steeply in men (132 to 89 per 100 000 versus 134 to 97 per 100 000). Conclusions Although overall TIA hospitalizations have decreased in the United States, the reduction has been more pronounced among older individuals, men, whites, and Hispanics. These findings highlight the need to target risk‐factor control among women, blacks, and individuals aged <45 years.
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Affiliation(s)
- Lucas Ramirez
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA
| | - May A Kim-Tenser
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Nerses Sanossian
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
| | - Steven Cen
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Ge Wen
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shuhan He
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - William J Mack
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurosurgery, University of Southern California, Los Angeles, CA Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California, Los Angeles, CA
| | - Amytis Towfighi
- Keck School of Medicine, University of Southern California, Los Angeles, CA Department of Neurology, University of Southern California, Los Angeles, CA Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA
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108
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O'Brien EC, Zhao X, Fonarow GC, Schulte PJ, Dai D, Smith EE, Schwamm LH, Bhatt DL, Xian Y, Saver JL, Reeves MJ, Peterson ED, Hernandez AF. Quality of Care and Ischemic Stroke Risk After Hospitalization for Transient Ischemic Attack: Findings From Get With The Guidelines-Stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S117-24. [PMID: 26515199 DOI: 10.1161/circoutcomes.115.002048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with transient ischemic attack (TIA) are at increased risk for ischemic stroke. We derived a prediction rule for 1-year ischemic stroke risk post-TIA, examining estimated risk, receipt of inpatient quality of care measures for TIA, and the presence or absence of stroke at 1 year post discharge. METHODS AND RESULTS We linked 67 892 TIA Get With The Guidelines-Stroke patients >65 years (2003-2008) to Medicare inpatient claims to obtain longitudinal outcomes. Using Cox proportional hazards modeling in a split sample, we identified baseline demographics and clinical characteristics associated with ischemic stroke admission during the year post-TIA, and developed a Get With The Guidelines Ischemic Stroke after TIA Risk Score; performance was examined in the validation sample. Quality of care was estimated by a global defect-free care measure, and individual performance measures within estimated risk score quintiles. The overall hospital admission rate for ischemic stroke during the year post-TIA was 5.7%. Patients with ischemic stroke were more likely to be older, black, and have higher rates of smoking, previous stroke, diabetes mellitus, previous myocardial infarction, heart failure, and atrial fibrillation. The Risk Score showed moderate discriminative performance (c-statistic=0.606); highest quintile patients were less likely to receive statins, smoking cessation counseling, and defect-free care. Although not associated with 1-year ischemic stroke, DCF was associated with a significantly lower risk of all-cause mortality. CONCLUSIONS TIA patients with high estimated ischemic stroke risk are less likely to receive defect-free care than low-risk patients. Standardized risk assessment and delivery of optimal inpatient care are needed to reduce this risk-treatment mismatch.
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Affiliation(s)
- Emily C O'Brien
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.).
| | - Xin Zhao
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C Fonarow
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - David Dai
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric E Smith
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Lee H Schwamm
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Ying Xian
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Jeffrey L Saver
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Mathew J Reeves
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
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Capodanno D, Alberts M, Angiolillo DJ. Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease. NATURE REVIEWS. CARDIOLOGY 2016. [PMID: 27489191 DOI: 10.1038/nrcardio.2016.111.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk-benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.
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Affiliation(s)
- Davide Capodanno
- Ferrarotto Hospital, University of Catania, Via Salvatore Citelli 6, 95124 Catania CT, Italy
| | - Mark Alberts
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390, USA
| | - Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, 653 West 8th Street, Jacksonville, Florida 32209, USA
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Antithrombotic therapy for secondary prevention of atherothrombotic events in cerebrovascular disease. Nat Rev Cardiol 2016; 13:609-22. [PMID: 27489191 DOI: 10.1038/nrcardio.2016.111] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Atherothrombosis is the common underlying process for numerous progressive manifestations of cardiovascular disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD). Antiplatelet therapy is the cornerstone of pharmacological management in patients with atherothrombosis. Over the past 20 years, major advances in antiplatelet pharmacotherapy have been made, particularly for the treatment of patients with CAD. The treatment of patients with concomitant CAD and CVD is complex, owing to their increased risk of both ischaemia and bleeding. When CVD arises from large artery atherosclerosis, antithrombotic therapies are essential to prevent stroke or transient ischaemic attack (TIA). However, the use of antithrombotic medications in patients with CVD can put them at high risk of intracranial haemorrhage. As such, the risk-benefit profile of various combinations of antiplatelet agents in patients with both CAD and CVD is uncertain. This Review provides a state-of-the-art account of the available evidence on antithrombotic therapies for the secondary prevention of atherothrombotic events in patients with concomitant CAD and CVD, particularly those with a history of noncardioembolic stroke or TIA.
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111
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Bates ER, Babb JD, Casey DE, Cates CU, Duckwiler GR, Feldman TE, Gray WA, Ouriel K, Peterson ED, Rosenfield K, Rundback JH, Safian RD, Sloan MA, White CJ. ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert Consensus Document on Carotid Stenting. Vasc Med 2016; 12:35-83. [PMID: 17451093 DOI: 10.1177/1358863x06076103] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Li J, Zhao X, Meng X, Lin J, Liu L, Wang C, Wang A, Wang Y, Wang Y. High-Sensitive C-Reactive Protein Predicts Recurrent Stroke and Poor Functional Outcome: Subanalysis of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events Trial. Stroke 2016; 47:2025-30. [PMID: 27328699 DOI: 10.1161/strokeaha.116.012901] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 05/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Minor stroke and transient ischemic attack are common disorders with high rate of subsequent disabling stroke. We aim to investigate the role of high-sensitive C-reactive protein (hsCRP) in predicting recurrent stroke and poor functional outcome. METHODS In the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial, 3044 (59%) consecutive patients from 73 (64%) prespecified centers had hsCRP levels measured. The primary outcome was any stroke within 90 days. The secondary outcome included combined vascular events and dependence or death defined as modified Rankin Scale score of 2 to 6 at 90 days and a new vascular event during 1-year follow-up. The associations of hsCRP with recurrent stroke and functional outcome were analyzed by using Cox proportional hazards and logistic regression models. RESULTS Elevated hsCRP (>3.0 mg/L) was observed in 32% of the study population. Patients with hsCRP >3 mg/L had an increased risk of recurrent stroke (adjusted hazard ratio, 1.46; 95% confidence interval, 1.08-1.98; P=0.039), ischemic stroke and combined vascular events, and poor functional outcome (adjusted odds ratio, 1.68; 95% confidence interval, 1.22-2.32; P=0.002) compared with those with hsCRP <1 mg/L within 90-day follow-up period. High hsCRP levels also independently predicted recurrent stroke during 1-year follow-up. There was no interaction of hsCRP levels with randomized antiplatelet therapy. CONCLUSIONS High hsCRP levels predict recurrent stroke and poor functional outcome in acute patients with minor stroke or transient ischemic attack. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979589.
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Affiliation(s)
- Jiejie Li
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Chunxue Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Anxin Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China.
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China; and Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, China.
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113
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Blood Biomarkers in Minor Stroke and Transient Ischemic Attack. Neurosci Bull 2016; 32:463-8. [PMID: 27250628 DOI: 10.1007/s12264-016-0038-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/05/2016] [Indexed: 01/11/2023] Open
Abstract
Minor stroke and transient ischemic attack (TIA) are common disorders with a high rate of subsequent disabling stroke, so the early recognition and management of minor stroke and TIA is of great importance. At the moment, the diagnosis of these disorders is based on neurologic deficits in a stroke-clinician's examination of the patient, supplemented by the results of acute brain imaging. However, high variability in TIA diagnosis has been reported between physicians, even trained vascular neurologists, and image-based diagnostic confirmation is not always readily available. Some patients still have ischemic events despite sustained standard secondary preventive therapy. Blood biomarkers are promising to aid in the diagnosis, risk stratification, and individual treatment of minor stroke and TIA. Some studies are being conducted in this field. This mini-review aims to highlight potential biomarkers for diagnosis and those helpful in predicting the risk of future stroke and the selection of treatment.
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Tibæk M, Dehlendorff C, Jørgensen HS, Forchhammer HB, Johnsen SP, Kammersgaard LP. Increasing Incidence of Hospitalization for Stroke and Transient Ischemic Attack in Young Adults: A Registry-Based Study. J Am Heart Assoc 2016; 5:JAHA.115.003158. [PMID: 27169547 PMCID: PMC4889186 DOI: 10.1161/jaha.115.003158] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Studies have reported increasing incidence of ischemic stroke in adults younger than 50 to 55 years. Information on temporal trends of other stroke subtypes and transient ischemic attack (TIA) is sparse. The aim of this study was to investigate temporal trends of the incidence of hospitalizations for TIA and stroke including sex‐ and subtype‐specific trends in young adults aged 15 to 30 years. Methods and Results From the Danish National Patient Register, we identified all cases of first‐ever stroke and TIA (age 15–30 years) in Denmark, who were hospitalized during the study period of 1994 to 2012. Incidence rates and estimated annual percentage changes (EAPCs) were estimated by using Poisson regression. During the study period, 4156 cases of first‐ever hospitalization for stroke/TIA were identified. The age‐standardized incidence rates of hospitalizations for stroke increased significantly (EAPC 1.83% [95% CI 1.11–2.55%]) from 11.97/100 000 person‐years (PY) in 1994 to 16.77/100 000 PY in 2012. TIA hospitalizations increased from 1.93/100 000 PY in 1994 to 5.81/100 000 PY in 2012 and after 2006 more markedly in men than in women (EAPC 16.61% [95% CI 10.45–23.12%]). The incidence of hospitalizations for ischemic stroke was markedly lower among men, but increased significantly from 2006 (EAPC 14.60% [95% CI 6.22–23.63%]). The incidences of hospitalizations for intracerebral hemorrhage and subarachnoid hemorrhage remained stable during the study period. Conclusions The incidence rates of first‐time hospitalizations for ischemic stroke and TIA in young Danish adults have increased substantially since the mid 1990s. The increase was particularly prominent in the most recent years.
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Affiliation(s)
- Maiken Tibæk
- Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | - Christian Dehlendorff
- Statistics, Bioinformatics and Registry, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Henrik S Jørgensen
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), TBI Unit, Department of Neurorehabilitation, Rigshospitalet, University of Copenhagen, Denmark
| | | | - Søren P Johnsen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Lars P Kammersgaard
- Research Unit on Brain Injury Rehabilitation Copenhagen (RUBRIC), TBI Unit, Department of Neurorehabilitation, Rigshospitalet, University of Copenhagen, Denmark
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115
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Abstract
Transient ischemic attack (TIA) is a transient episode of neurologic dysfunction caused due to loss of blood flow to the brain or spinal cord without acute infarction. Depending on the area of the brain involved, symptoms of TIA vary widely from patient to patient. Since the blockage period in TIA is very short-lived, there is no permanent damage. Risk factors for TIA include family history of stroke or TIA, age above 55 years or older, higher risk of TIA in males than females, high blood pressure, diabetes mellitus, and tobacco smoking. Genetics, race, and imbalance in lipid profile are other risk factors of TIA. TIA is usually diagnosed after taking a thorough history and a physical examination. Several radiological tests such as computed tomography and magnetic resonance imaging are useful in the evaluation of patients who have had a TIA. Ultrasound of the neck and an echocardiogram of the heart are other tests useful in the diagnosis and evaluation of the attack. The treatment following acute recovery from a TIA depends on the underlying cause. Patients who have more than 70% stenosis of the carotid artery, removal of atherosclerotic plaque is usually done by carotid endarterectomy surgery. One-third of the people with TIA can later have recurrent TIAs and one-third can have a stroke because of permanent nerve cell loss. Having a TIA is a risk factor for eventually having a stroke. Educating the patients and inculcating lifestyle modifications in them are initial steps to minimize the prevalence of transient ischemic attack.
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Affiliation(s)
- Supreet Khare
- Armed Forces Medical College, Pune, Maharashtra, India
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116
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Kernan WN, Viscoli CM, Furie KL, Young LH, Inzucchi SE, Gorman M, Guarino PD, Lovejoy AM, Peduzzi PN, Conwit R, Brass LM, Schwartz GG, Adams HP, Berger L, Carolei A, Clark W, Coull B, Ford GA, Kleindorfer D, O'Leary JR, Parsons MW, Ringleb P, Sen S, Spence JD, Tanne D, Wang D, Winder TR. Pioglitazone after Ischemic Stroke or Transient Ischemic Attack. N Engl J Med 2016; 374:1321-31. [PMID: 26886418 PMCID: PMC4887756 DOI: 10.1056/nejmoa1506930] [Citation(s) in RCA: 732] [Impact Index Per Article: 91.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. METHODS In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction. RESULTS By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003). CONCLUSIONS In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).
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Affiliation(s)
- Walter N Kernan
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Catherine M Viscoli
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Karen L Furie
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Lawrence H Young
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Silvio E Inzucchi
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Mark Gorman
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter D Guarino
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Anne M Lovejoy
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter N Peduzzi
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Robin Conwit
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Lawrence M Brass
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Gregory G Schwartz
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Harold P Adams
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Leo Berger
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Antonio Carolei
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Wayne Clark
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Bruce Coull
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Gary A Ford
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Dawn Kleindorfer
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - John R O'Leary
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Mark W Parsons
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Peter Ringleb
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Souvik Sen
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - J David Spence
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - David Tanne
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - David Wang
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
| | - Toni R Winder
- From the School of Medicine (W.N.K., C.M.V., L.H.Y., S.E.I., A.M.L., L.M.B., J.R.O.) and the School of Public Health (P.D.G., P.N.P., J.R.O.), Yale University, New Haven, and the Cooperative Studies Program Coordinating Center, Veteran Affairs (VA) Connecticut HealthCare System, West Haven (P.D.G., P.N.P.) - all in Connecticut; Alpert Medical School, Brown University, Providence, RI (K.L.F.); Vermont College of Medicine, Burlington (M.G.); the National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); the VA Medical Center and the University of Colorado School of Medicine, Denver (G.G.S.); the University of Iowa, Iowa City (H.P.A.); Hôpital Charles LeMoyne, Greenfield Park, QC (L.B.), the University of Western Ontario, London (J.D.S.), and the Center for Neurological Research, Lethbridge, AB (T.R.W.) - all in Canada; University of L'Aquila, L'Aquila, Italy (A.C.); Oregon Health Sciences University, Portland (W.C.); the University of Arizona, Tucson (B.C.); the University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxfordshire, United Kingdom (G.A.F.); the University of Cincinnati, Cincinnati (D.K.); John Hunter Hospital, University of Newcastle, New Lambton Heights, NSW, Australia (M.W.P.); the University of Heidelberg, Heidelberg, Germany (P.R.); the University of South Carolina School of Medicine, Columbia (S.S.); Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel (D.T.); and the Illinois Neurological Institute-OSF Saint Francis Medical Center and the Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria (D.W.)
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Wang A, Wu L, Wang X, Zhao X, Wang C, Liu L, Zheng H, Cao Y, Wang Y, Wang Y. Effect of recurrent stroke on poor functional outcome in transient ischemic attack or minor stroke. Int J Stroke 2016; 11:NP80. [PMID: 27012273 DOI: 10.1177/1747493016641954] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Lingyun Wu
- Graduate School, North China University of Science and Technology, Tangshan, China
| | - Xianwei Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Huaguang Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yibin Cao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China China National Clinical Research Center for Neurological Diseases, Beijing, China Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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118
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The long-term effect of exercise on vascular risk factors and aerobic fitness in those with transient ischaemic attack: a randomized controlled trial. J Hypertens 2016; 32:2064-70. [PMID: 25023152 DOI: 10.1097/hjh.0000000000000283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Exercise has beneficial effects on vascular risk factors in transient ischaemic attack (TIA) patients within the sub-acute phase. This study examined whether TIA patients randomized to an early exercise and education programme within 2 weeks of TIA diagnosis would demonstrate improvements in cardiovascular risk factors and aerobic fitness 12 months post-diagnosis compared with control patients. METHODS A single-centre, randomized, parallel-group clinical trial. Sixty TIA patients (69 ± 11 years) completed a vascular risk stratification baseline assessment and a physical fitness examination. Individuals were randomized to either an 8-week early exercise and education group or control group. Fifty-one patients attended post-intervention assessments that were completed immediately (post-intervention) and 12 months after (12PI). RESULTS A significantly greater improvement in resting SBP was observed between baseline and post-intervention for EX than for CON (-11 mmHg cf. -1 mmHg, respectively; P < 0.05). The improvement in SBP was maintained between post-intervention and 12PI (P > 0.05). Similar findings were demonstrated for BMI, bodyweight and peak oxygen uptake (P < 0.05). Exercise blood pressure, pulse pressure and double product (SBP x heart rate; an indication of myocardial workload) were significantly lower at post-intervention and 12PI for EX than for CON (all P < 0.05). CONCLUSION An 8-week exercise programme soon after TIA resulted in beneficial changes in resting and exercise blood pressure that were maintained for 12 months. CLINICAL TRIAL REGISTRATION http://www.anzctr.org.au/ TRIAL REGISTRATION NUMBER ACTRN12611000630910.
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Yuan K, Kim AS. When a Single Antiplatelet Agent for Stroke Prevention Is Not Enough: Current Evidence and Future Applications of Dual Antiplatelet Therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:26. [DOI: 10.1007/s11936-016-0449-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Computed tomography perfusion imaging may predict cognitive impairment in patients with first-time anterior circulation transient ischemic attack. Int J Cardiovasc Imaging 2016; 32:671-7. [PMID: 26721459 DOI: 10.1007/s10554-015-0828-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
To determine whether computed tomography perfusion imaging (CTPI)-derived parameters are associated with vascular cognitive impairment (VCI) in patients with transient ischemic attack (TIA). Patients with first-time anterior circulation TIA (diagnosed within 24 h of onset) and normal cognition, treated between August 2009 and August 2014 at the Department of Neurology of Chengdu Military General Hospital, China, were analyzed retrospectively. Patients underwent whole-brain CTPI within 1 week of TIA to detect cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT) and time to peak (TTP) in the ischemic region. Based on cognitive function assessment 4 weeks after TIA, using the Montreal cognitive assessment (MoCA) and mini mental state examination, the patients were divided into control and VCI groups. CTPI parameters and other clinical data were compared between groups, and Spearman's correlation analysis used to identify associations between cognitive scores and CTPI parameters in the VCI group. 50 patients (25 per group; aged 55-72 years) were included. Patient age, gender, smoking status, alcohol consumption, educational level, time from TIA onset to admission, time from TIA onset to CTPI, and prevalence of hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation and hyperhomocysteinemia did not differ between groups. Both groups showed TTP and MTT prolongation, CBF reduction, but no change in CBV in the ischemic region; these changes were significantly larger in the VCI group (P < 0.05). MTT correlated negatively with MoCA score (r = -0.51, P = 0.009). CTPI could facilitate early diagnosis of VCI in patients with anterior circulation TIA.
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Cocho D, Monell J, Planells G, Ricciardi A, Pons J, Boltes A, Espinosa J, Ayats M, Garcia N, Otermin P. Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Cereda CW, George PM, Inoue M, Vora N, Olivot JM, Schwartz N, Lansberg MG, Kemp S, Mlynash M, Albers GW. Inter-rater agreement analysis of the Precise Diagnostic Score for suspected transient ischemic attack. Int J Stroke 2015; 11:85-92. [DOI: 10.1177/1747493015607507] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background No definitive criteria are available to confirm the diagnosis of transient ischemic attack. Inter-rater agreement between physicians regarding the diagnosis of transient ischemic attack is low, even among vascular neurologists. We developed the Precise Diagnostic Score, a diagnostic score that consists of discrete and well-defined clinical and imaging parameters, and investigated inter-rater agreement in patients with suspected transient ischemic attack. Methods Fellowship-trained vascular neurologists, blinded to final diagnosis, independently reviewed retrospectively identical history, physical examination, routine diagnostic studies, and brain magnetic resonance imaging (diffusion and perfusion images) from consecutive patients with suspected transient ischemic attack. Each patient was rated using the 8-point Precise Diagnostic Score score, composed of a clinical score (0–4 points) and an imaging score (0–4 points). The composite Precise Diagnostic Score determines a Precise Diagnostic Score Likelihood of Brain Ischemia Scale: 0–1 = unlikely, 2 = possible, 3 = probable, 4–8 = very likely. Results Three raters reviewed data from 114 patients. Using Precise Diagnostic Score, all three raters scored a similar percentage of the clinical events as being “probable” or “very likely” caused by brain ischemia: 57, 55, and 58%. Agreement was high for both total Precise Diagnostic Score (intraclass correlation coefficient of 0.94) and for the Likelihood of Brain Ischemia Scale (agreement coefficient of 0.84). Conclusions Compared with prior studies, inter-rater agreement for the diagnosis of transient brain ischemia appears substantially improved with the Precise Diagnostic Score scoring system. This score is the first to include specific criteria to assess the clinical relevance of diffusion-weighted imaging and perfusion lesions and supports the added value of magnetic resonance imaging for assessing patients with suspected transient ischemic attack.
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Affiliation(s)
- Carlo W Cereda
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
- Stroke Center, Neurocentre (EOC) of Southern Switzerland, Lugano, Switzerland
| | - Paul M George
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Manabu Inoue
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Nirali Vora
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Jean-Marc Olivot
- Department of Neurology, Stroke Center, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Neil Schwartz
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Maarten G Lansberg
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Stephanie Kemp
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Michael Mlynash
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
| | - Gregory W Albers
- Department of Neurology & Neurologic Sciences, Stanford Stroke Center, Stanford University, Stanford, USA
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation 2015; 133:e38-360. [PMID: 26673558 DOI: 10.1161/cir.0000000000000350] [Citation(s) in RCA: 3735] [Impact Index Per Article: 415.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Lehman LL, Watson CG, Kapur K, Danehy AR, Rivkin MJ. Predictors of Stroke After Transient Ischemic Attack in Children. Stroke 2015; 47:88-93. [PMID: 26556823 DOI: 10.1161/strokeaha.115.009904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/14/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Transient ischemic attack (TIA) in children has received far less attention compared with TIA in adults. The risk factors of stroke after TIA in children are relatively unknown. We aimed to determine the percentage of children who have stroke after TIA and the risk factors associated with stroke after TIA. METHODS We searched the medical records at Boston Children's Hospital for the year 2010 to find children who were evaluated for TIA to determine associated risk factors of stroke after TIA. We included children who were evaluated in 2009 through 2010 for TIA and had magnetic resonance imaging. We examined follow-up imaging through August 2014 for subsequent stroke. Logistic regression was used to calculate odds ratios for factors in our cohort who are associated with stroke after presentation with TIA. RESULTS We identified 63 children who experienced a TIA. The mean time of imaging follow-up was 4.5 years after TIA presentation. Of the 63 children, 10 (16%) developed radiological evidence of ischemic cerebral injury within the follow-up period. Four of the 10 (6%) demonstrated diffusion abnormalities on magnetic resonance imaging at TIA presentation, whereas 8 (13%) had a stroke after their TIA. Arteriopathy, female sex, and autoimmune disorders were significantly associated with stroke after TIA. CONCLUSIONS In our cohort of children, stroke occurred after TIA at a rate similar to that seen in adults, but the risk factors for stroke after TIA in children are different.
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Affiliation(s)
- Laura L Lehman
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA.
| | - Christopher G Watson
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Kush Kapur
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Amy R Danehy
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
| | - Michael J Rivkin
- From the Departments of Neurology (L.L.L., C.G.W., K.K., M.J.R.), Psychiatry (M.J.R.), and Radiology (A.R.D., M.J. R.), Boston Children's Hospital, MA; and Departments of Radiology (A.R.D.) and Neurology (L.L.L., M.J.R.), Harvard Medical School, Boston, MA
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Perry JJ, Losier JH, Stiell IG, Sharma M, Abdulaziz K. National Survey of Neurologists for Transient Ischemic Attack Risk Stratification Consensus and Appropriate Treatment for a Given Level of Risks. J Stroke Cerebrovasc Dis 2015; 24:2514-20. [PMID: 26419528 DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 06/19/2015] [Accepted: 06/26/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Patients with a new transient ischemic attack (TIA) have a 5% subsequent stroke risk within 7 days. The Canadian TIA Score accurately determines the risk of subsequent stroke risk; however, it is unclear if physicians will use this new scale or how it will be used. Our objectives were to assess: (1) anticipated use; (2) component face validity; (3) risk strata for stroke within 7 days; and (4) actions required, for a given risk for subsequent stroke based on the proposed Canadian TIA Score. METHODS After a rigorous development process (sample selection, key informant interviews, development of questionnaire following Dillman Tailored Design technique, cognitive interviews, and pilot-testing), a survey questionnaire was administered to a random sample of 300 neurologists selected from all neurologists listed in a national medical directory. The surveys were distributed using a modified Dillman technique. RESULTS From a total of 265 eligible surveys, we received 140 (52.8%) completed surveys; 7 of 13 components comprising the Canadian TIA Score were rated as "very important" or "important" by survey respondents. Risk categories for subsequent stroke were defined as: minimal risk: less than 1%; low risk: 2%-4.9%; high risk: 5%-10%; critical risk: more than 10% risk of subsequent stroke within 7 days. Most (87.1%) of the neurologists would use a validated Canadian TIA Score. CONCLUSIONS Neurologists appear ready to use a validated Canadian TIA Score in their clinical practice. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk.
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Affiliation(s)
- Jeffrey J Perry
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada.
| | - Justin H Losier
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mukul Sharma
- Department of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Kasim Abdulaziz
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Brandler ES, Sharma M. Early dual antiplatelet therapy in stroke: should we take the CHANCE? ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:177. [PMID: 26366394 DOI: 10.3978/j.issn.2305-5839.2015.07.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Ethan S Brandler
- 1 Department of Emergency Medicine, Associate Director, Emergency Medical Services, State University of New York at Stony Brook, NY, USA ; 2 Department of Community Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar 143001, India
| | - Mohit Sharma
- 1 Department of Emergency Medicine, Associate Director, Emergency Medical Services, State University of New York at Stony Brook, NY, USA ; 2 Department of Community Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar 143001, India
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Wang X, Zhao X, Johnston SC, Xian Y, Hu B, Wang C, Wang D, Liu L, Li H, Fang J, Meng X, Wang A, Wang Y, Wang Y. Effect of clopidogrel with aspirin on functional outcome in TIA or minor stroke: CHANCE substudy. Neurology 2015; 85:573-9. [PMID: 26283758 PMCID: PMC4548281 DOI: 10.1212/wnl.0000000000001844] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 04/16/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We compared the effect of clopidogrel plus aspirin vs aspirin alone on functional outcome and quality of life in the Clopidogrel in High-risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial of aspirin-clopidogrel vs aspirin alone after acute minor stroke or TIA. METHODS Participants were assessed at 90 days for functional outcome using the modified Rankin Scale (mRS) and quality of life using the EuroQol-5 Dimension (EQ-5D). Poor functional outcome was defined as mRS score of 2-6 at 90 days and poor quality of life as EQ-5D index score of 0.5 or less. RESULTS Poor functional outcome occurred in 254 patients (9.9%) in the clopidogrel-aspirin group, as compared with 299 (11.6%) in the aspirin group (p = 0.046). Poor quality of life occurred in 142 (5.5%) in the clopidogrel-aspirin group and in 175 (6.8%) in the aspirin group (p = 0.06). Disabling stroke at 90 days occurred in 166 (6.5%) in the clopidogrel-aspirin group and in 219 (8.5%) in the aspirin group (p = 0.01). In stratified analysis by subsequent stroke, there was no difference in 90-day functional outcome and quality of life between the 2 groups. CONCLUSIONS In patients with minor stroke or TIA, the combination of clopidogrel and aspirin appears to be superior to aspirin alone in improving the 90-day functional outcome, and this is consistent with a reduction in the rate of disabling stroke in the dual antiplatelet arm. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with acute minor stroke or TIA, clopidogrel plus aspirin compared to aspirin alone improves 90-day functional outcome (absolute reduction of poor outcome 1.70%, 95% confidence interval 0.03%-3.42%).
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Affiliation(s)
- Xianwei Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Xingquan Zhao
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - S Claiborne Johnston
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Ying Xian
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Bo Hu
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Chunxue Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - David Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Liping Liu
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Hao Li
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Jiming Fang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Xia Meng
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Anxin Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Yongjun Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada
| | - Yilong Wang
- From the Department of Neurology (X.W., X.Z., C.W., L.L., H.L., X.M., A.W., Yongjun Wang, Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; the Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; Duke Clinical Research Institute (DCRI) (Y.X.), Duke University, Durham, NC; the Department of Quantitative Health Sciences (B.H.), Cleveland Clinic, OH; INI Stroke Network (D.W.), OSF Healthcare System, University of Illinois College of Medicine, Peoria; and Institute for Clinical Evaluative Sciences (J.F.), Toronto, Canada.
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National survey of emergency physicians for transient ischemic attack (TIA) risk stratification consensus and appropriate treatment for a given level of risk. CAN J EMERG MED 2015; 18:10-8. [PMID: 26226855 DOI: 10.1017/cem.2015.57] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Five percent of transient ischemic attack (TIA) patients have a subsequent stroke within 7 days. The Canadian TIA Score uses clinical findings to calculate the subsequent stroke risk within 7 days. Our objectives were to assess 1) anticipated use; 2) component face validity; 3) risk strata for stroke within 7 days; and 4) actions required, for a given risk for subsequent stroke. METHODS After a rigorous development process, a survey questionnaire was administered to a random sample of 300 emergency physicians selected from those registered in a national medical directory. The surveys were distributed using a modified Dillman technique. RESULTS From a total of 271 eligible surveys, we received 131 (48.3%) completed surveys; 96.2% of emergency physicians would use a validated Canadian TIA Score; 8 of 13 components comprising the Canadian TIA Score were rated as Very Important or Important by survey respondents. Risk categories for subsequent stroke were defined as minimal-risk: 10% risk of subsequent stroke within 7 days. CONCLUSION A validated Canadian TIA Score will likely be used by emergency physicians. Most components of the TIA Score have high face validity. Risk strata are definable, which may allow physicians to determine immediate actions, based on subsequent stroke risk, in the emergency department.
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Palomeras Soler E, Fossas Felip P, Cano Orgaz A, Sanz Cartagena P, Casado Ruiz V, Muriana Batista D. Evaluación rápida del ataque isquémico transitorio en un hospital sin guardias de neurología. Neurologia 2015; 30:325-30. [DOI: 10.1016/j.nrl.2013.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 10/24/2013] [Accepted: 12/29/2013] [Indexed: 01/08/2023] Open
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Palomeras Soler E, Fossas Felip P, Cano Orgaz A, Sanz Cartagena P, Casado Ruiz V, Muriana Batista D. Rapid assessment of transient ischaemic attack in a hospital with no on-call neurologist. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2015.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Secondary stroke prevention in the elderly in many cases requires the use of drug therapy to maximize risk factor control. However, the elderly (≥65 years) are most likely to receive care that is not evidence-based, because of concerns for adverse events. In this review, we provide evidence to the practitioner in support of the value of blood pressure control with drug therapy to decrease recurrent stroke risk. This review also highlights evidence for the importance of statin therapy in stroke prevention among the elderly. Finally, the appropriate use of antiplatelet therapy and oral anticoagulation is addressed.
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132
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Perry JJ, Kerr J, Symington C, Sutherland J. How do we manage emergency department patients diagnosed with transient ischemic attack? CAN J EMERG MED 2015; 14:20-4. [DOI: 10.2310/8000.2011.110533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTIntroduction:Multiple studies have demonstrated low rates of antithrombotic use, low neuroimaging rates, and high subsequent risk of stroke at 90 days following an emergency department (ED) diagnosis of transient ischemic attack (TIA). This study assessed the use of antithrombotic medications, neuroimaging, and subsequent 90-day stroke rate for patients in a more recent cohort of ED patients discharged home with TIA.Methods:We conducted a 1-year historical cohort study of all patients discharged with a TIA at a tertiary care ED (census 60,000 visits/year), which was one of the four sites participating in one of the aforementioned studies. Data were extracted from paper and electronic records onto standardized data extraction forms. Clinical findings, medications, and tests were recorded.Results:A total of 211 patients were enrolled in the study. The patients had the following characteristics: the mean age was 71.2 years (SD 13.8 years), 56.9% were female, 53.1% had a history of hypertension, 26.5% had a history of ischemic heart disease, and 17.1% had a previous stroke. The most frequent neurologic deficit was unilateral weakness (53.6%), and most deficits lasted for more than 60 minutes (71.6%). Antithrombotic medications were used for 96.7% of patients at ED discharge. Neuroimaging was conducted in 94.3% of patients while in the ED. Our cohort had a 90-day stroke rate of 1.9%.Conclusions:This study established that most TIA patients receive neuroimaging in the ED and are started on or maintained on antithrombotic agents. Clinicians are encouraged to ensure that electrocardiography is done routinely and to involve Neurology in follow-up care.
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Wang Y, Zhao X, Jiang Y, Li H, Wang L, Johnston SC, Liu L, Wong KSL, Wang C, Pan Y, Jing J, Xu J, Meng X, Zhang M, Li Y, Zhou Y, Zhao W, Wang Y. Prevalence, knowledge, and treatment of transient ischemic attacks in China. Neurology 2015; 84:2354-61. [PMID: 25957333 DOI: 10.1212/wnl.0000000000001665] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 02/25/2015] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To investigate the prevalence, knowledge, and treatment of TIA in a Chinese adult population. METHODS We conducted a complex, multistage, probability sampling-designed, cross-sectional, nationwide survey of 98,658 Chinese adults in 2010. Possible TIA cases were first identified by symptoms recall or self-reported history of TIA through face-to-face interviews, and the final diagnosis was then made by expert neurologists through phone interviews or record review. RESULTS The age-standardized prevalence of TIA was 2.27%. Clinically, only 16.0% of the participants were diagnosed before the study. The prevalence of TIA was higher in women and in patients who were older, had less education, were current smokers, lived in rural or undeveloped areas, and had a history of stroke, hypertension, myocardial infarction, dyslipidemia, or diabetes. Based on the survey responses, approximately 3.08% of Chinese adults had knowledge of TIA. Among patients with TIA, only 5.02% received treatment and 4.07% received guideline-recommended therapy. CONCLUSIONS TIA is prevalent and an estimated 23.9 million people in China may have experienced a TIA. Public knowledge on TIA is very limited. TIA appears to be largely undiagnosed and untreated in China. There is an urgent need to develop strategies to improve the identification and appropriate management of TIA.
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Affiliation(s)
- Yilong Wang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
| | - Xingquan Zhao
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yong Jiang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Hao Li
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Limin Wang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - S Claiborne Johnston
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Liping Liu
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Ka Sing Lawrence Wong
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Chunxue Wang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yuesong Pan
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Jing Jing
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Jie Xu
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Xia Meng
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Mei Zhang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yichong Li
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yong Zhou
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Wenhua Zhao
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Yongjun Wang
- From the Department of Neurology (Yilong Wang, X.Z., Y.J., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing; China National Clinical Research Center for Neurological Diseases (Yilong Wang, X.Z., H.L., L.L., C.W., Y.P., J.J., J.X., X.M., Y.Z., Yongjun Wang), Beijing; National Center for Chronic and Non-communicable Disease Control and Prevention (Y.J., L.W., M.Z., Y.L.), Chinese Center for Disease Control and Prevention (W.Z.), Beijing, China; Departments of Neurology and Epidemiology (S.C.J.), University of California, San Francisco; and Division of Neurology (K.S.L.W.), Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China.
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134
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Dutta D, Bowen E, Foy C. Four-Year Follow-Up of Transient Ischemic Attacks, Strokes, and Mimics. Stroke 2015; 46:1227-32. [DOI: 10.1161/strokeaha.114.008632] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There is limited information on outcomes from rapid access transient ischemic attack (TIA) clinics. We present 4-year outcomes of TIAs, strokes, and mimics from a UK TIA clinic database.
Methods—
All patients referred between April 2010 and May 2012 were retrospectively identified and outcomes determined. End points were stroke, myocardial infarction, any vascular event (TIA, stroke, or myocardial infarction), and all-cause death. Data were analyzed by survival analysis.
Results—
Of 1067 patients, 31.6% were TIAs, 18% strokes, and 50.4% mimics. Median assessment time was 4.5 days from onset and follow-up was for 34.9 months. Subsequent strokes occurred in 7.1% of patients with TIA, 10.9% of patients with stroke, and 2.0% of mimics at the end of follow-up. Stroke risk at 90 days was 1.3% for patients diagnosed as TIA or stroke. Compared with mimics, hazard ratios for subsequent stroke were 3.88 (1.90–7.91) for TIA and 5.84 (2.81–12.11) for stroke. Hazard ratio for any subsequent vascular event was 2.91 (1.97–4.30) for TIA and 2.83 (1.81–4.41) for stroke. Hazard ratio for death was 1.68 (1.10–2.56) for TIA and 2.19 (1.38–3.46) for stroke.
Conclusions—
Our results show a lower 90-day stroke incidence after TIA or minor stroke than in earlier studies, suggesting that rapid access daily TIA clinics may be having a significant effect on reducing strokes.
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Affiliation(s)
- Dipankar Dutta
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
| | - Emily Bowen
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
| | - Chris Foy
- From the Stroke Service (D.D., E.B.) and Research Design Service (C.F.), Gloucestershire Royal Hospital, Gloucester, UK
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135
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Ovbiagele B. Tackling the growing diabetes burden in Sub-Saharan Africa: a framework for enhancing outcomes in stroke patients. J Neurol Sci 2015; 348:136-41. [PMID: 25475149 PMCID: PMC4298457 DOI: 10.1016/j.jns.2014.11.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/08/2014] [Accepted: 11/17/2014] [Indexed: 12/24/2022]
Abstract
According to the World Health Organization (WHO), more than 80% of worldwide diabetes (DM)-related deaths presently occur in low- and middle-income countries (LMIC), and left unchecked these DM-related deaths will likely double over the next 20 years. Cardiovascular disease (CVD) is the most prevalent and detrimental complication of DM: doubling the risk of CVD events (including stroke) and accounting for up to 80% of DM-related deaths. Given the aforementioned, interventions targeted at reducing CVD risk among people with DM are integral to limiting DM-related morbidity and mortality in LMIC, a majority of which are located in Sub-Saharan Africa (SSA). However, SSA is contextually unique: socioeconomic obstacles, cultural barriers, under-diagnosis, uncoordinated care, and shortage of physicians currently limit the capacity of SSA countries to implement CVD prevention among people with DM in a timely and sustainable manner. This article proposes a theory-based framework for conceptualizing integrated protocol-driven risk factor patient self-management interventions that could be adopted or adapted in future studies among hospitalized stroke patients with DM encountered in SSA. These interventions include systematic health education at hospital discharge, use of post-discharge trained community lay navigators, implementation of nurse-led group clinics and administration of health technology (personalized phone text messaging and home tele-monitoring), all aimed at increasing patient self-efficacy and intrinsic motivation for sustained adherence to therapies proven to reduce CVD event risk.
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Affiliation(s)
- Bruce Ovbiagele
- Department of Neurology and Neurosurgery, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 301, MSC 606, Charleston, SC 29425, United States.
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136
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Wasserman JK, Perry JJ, Sivilotti ML, Sutherland J, Worster A, Émond M, Jin AY, Oczkowski WJ, Sahlas DJ, Murray H, MacKey A, Verreault S, Wells GA, Dowlatshahi D, Stotts G, Stiell IG, Sharma M. Computed Tomography Identifies Patients at High Risk for Stroke After Transient Ischemic Attack/Nondisabling Stroke. Stroke 2015; 46:114-9. [DOI: 10.1161/strokeaha.114.006768] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Ischemia on computed tomography (CT) is associated with subsequent stroke after transient ischemic attack. This study assessed CT findings of acute ischemia, chronic ischemia, or microangiopathy for predicting subsequent stroke after transient ischemic attack.
Methods—
This prospective cohort study enrolled patients with transient ischemic attack or nondisabling stroke that had CT scanning within 24 hours. Primary outcome was subsequent stroke within 90 days. Secondary outcomes were stroke at ≤2 or >2 days. CT findings were classified as ischemia present or absent and acute or chronic or microangiopathy. Analysis used Fisher exact test and multivariate logistic regression.
Results—
A total of 2028 patients were included; 814 had ischemic changes on CT. Subsequent stroke rate was 3.4% at 90 days and 1.5% at ≤2 days. Stroke risk was greater if baseline CT showed acute ischemia alone (10.6%;
P
=0.002), acute+chronic ischemia (17.4%;
P
=0.007), acute ischemia+microangiopathy (17.6%;
P
=0.019), or acute+chronic ischemia+microangiopathy (25.0%;
P
=0.029). Logistic regression found acute ischemia alone (odds ratio [OR], 2.61; 95% confidence interval [CI[, 1.22–5.57), acute+chronic ischemia (OR, 5.35; 95% CI, 1.71–16.70), acute ischemia+microangiopathy (OR, 4.90; 95% CI, 1.33–18.07), or acute+chronic ischemia+microangiopathy (OR, 8.04; 95% CI, 1.52–42.63) was associated with a greater risk at 90 days, whereas acute+chronic ischemia (OR, 10.78; 95% CI, 2.93–36.68), acute ischemia+microangiopathy (OR, 8.90; 95% CI, 1.90–41.60), and acute+chronic ischemia+microangiopathy (OR, 23.66; 95% CI, 4.34–129.03) had greater risk at ≤2 days. Only acute ischemia (OR, 2.70; 95% CI, 1.01–7.18;
P
=0.047) was associated with a greater risk at >2 days.
Conclusions—
In patients with transient ischemic attack/nondisabling stroke, CT evidence of acute ischemia alone or acute ischemia with chronic ischemia or microangiopathy was associated with increased subsequent stroke risk within 90 days.
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Affiliation(s)
- Jason K. Wasserman
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Jeffrey J. Perry
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Marco L.A. Sivilotti
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Jane Sutherland
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Andrew Worster
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Marcel Émond
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Albert Y. Jin
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Wieslaw J. Oczkowski
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Demetrios J. Sahlas
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Heather Murray
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Ariane MacKey
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Steve Verreault
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - George A. Wells
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Dar Dowlatshahi
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Grant Stotts
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Ian G. Stiell
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
| | - Mukul Sharma
- From the Department of Pathology and Laboratory Medicine (J.K.W.), Ottawa Hospital Health Research Institute (J.K.W., J.J.P., D.D., I.G.S.), Department of Emergency Medicine (J.J.P., I.G.S.), Department of Epidemiology and Community Medicine (G.A.W.), and Division of Neurology (D.D., G.S.), University of Ottawa, Ottawa, Ontario, Canada; Department of Emergency Medicine and of Pharmacology and Toxicology (M.L.A.S.), Department of Neurology (A.Y.J.), and Department of Emergency Medicine (H.M.),
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137
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Eric Dyken M, Bin Im K, B. Richerson G. Sleep and Stroke. Sleep Med 2015. [DOI: 10.1007/978-1-4939-2089-1_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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138
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Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Judd SE, Kissela BM, Lackland DT, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Matchar DB, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Willey JZ, Woo D, Yeh RW, Turner MB. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation 2014; 131:e29-322. [PMID: 25520374 DOI: 10.1161/cir.0000000000000152] [Citation(s) in RCA: 4462] [Impact Index Per Article: 446.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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139
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Wardlaw J, Brazzelli M, Miranda H, Chappell F, McNamee P, Scotland G, Quayyum Z, Martin D, Shuler K, Sandercock P, Dennis M. An assessment of the cost-effectiveness of magnetic resonance, including diffusion-weighted imaging, in patients with transient ischaemic attack and minor stroke: a systematic review, meta-analysis and economic evaluation. Health Technol Assess 2014; 18:1-368, v-vi. [PMID: 24791949 DOI: 10.3310/hta18270] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Patients with transient ischaemic attack (TIA) or minor stroke need rapid treatment of risk factors to prevent recurrent stroke. ABCD2 score or magnetic resonance diffusion-weighted brain imaging (MR DWI) may help assessment and treatment. OBJECTIVES Is MR with DWI cost-effective in stroke prevention compared with computed tomography (CT) brain scanning in all patients, in specific subgroups or as 'one-stop' brain-carotid imaging? What is the current UK availability of services for stroke prevention? DATA SOURCES Published literature; stroke registries, audit and randomised clinical trials; national databases; survey of UK clinical and imaging services for stroke; expert opinion. REVIEW METHODS Systematic reviews and meta-analyses of published/unpublished data. Decision-analytic model of stroke prevention including on a 20-year time horizon including nine representative imaging scenarios. RESULTS The pooled recurrent stroke rate after TIA (53 studies, 30,558 patients) is 5.2% [95% confidence interval (CI) 3.9% to 5.9%] by 7 days, and 6.7% (5.2% to 8.7%) at 90 days. ABCD2 score does not identify patients with key stroke causes or identify mimics: 66% of specialist-diagnosed true TIAs and 35-41% of mimics had an ABCD2 score of ≥ 4; 20% of true TIAs with ABCD2 score of < 4 had key risk factors. MR DWI (45 studies, 9078 patients) showed an acute ischaemic lesion in 34.3% (95% CI 30.5% to 38.4%) of TIA, 69% of minor stroke patients, i.e. two-thirds of TIA patients are DWI negative. TIA mimics (16 studies, 14,542 patients) make up 40-45% of patients attending clinics. UK survey (45% response) showed most secondary prevention started prior to clinic, 85% of primary brain imaging was same-day CT; 51-54% of patients had MR, mostly additional to CT, on average 1 week later; 55% omitted blood-sensitive MR sequences. Compared with 'CT scan all patients' MR was more expensive and no more cost-effective, except for patients presenting at > 1 week after symptoms to diagnose haemorrhage; strategies that triaged patients with low ABCD2 scores for slow investigation or treated DWI-negative patients as non-TIA/minor stroke prevented fewer strokes and increased costs. 'One-stop' CT/MR angiographic-plus-brain imaging was not cost-effective. LIMITATIONS Data on sensitivity/specificity of MR in TIA/minor stroke, stroke costs, prognosis of TIA mimics and accuracy of ABCD2 score by non-specialists are sparse or absent; all analysis had substantial heterogeneity. CONCLUSIONS Magnetic resonance with DWI is not cost-effective for secondary stroke prevention. MR was most helpful in patients presenting at > 1 week after symptoms if blood-sensitive sequences were used. ABCD2 score is unlikely to facilitate patient triage by non-stroke specialists. Rapid specialist assessment, CT brain scanning and identification of serious underlying stroke causes is the most cost-effective stroke prevention strategy. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Miriam Brazzelli
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hector Miranda
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Francesca Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Zahid Quayyum
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Duncan Martin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsten Shuler
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin Dennis
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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140
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Peacock F, Beckley P, Clark C, Disch M, Hewins K, Hunn D, Kontos MC, Levy P, Mace S, Melching KS, Ordonez E, Osborne A, Suri P, Sun B, Wheatley M. Recommendations for the evaluation and management of observation services: a consensus white paper: the Society of Cardiovascular Patient Care. Crit Pathw Cardiol 2014; 13:163-198. [PMID: 25396295 DOI: 10.1097/hpc.0000000000000033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Observation Services (OS) was founded by emergency physicians in an attempt to manage "boarding" issues faced by emergency departments throughout the United States. As a result, OS have proven to be an effective strategy in reducing costs and decreasing lengths of stay while improving patient outcomes. When OS are appropriately leveraged for maximum efficiency, patients presenting to emergency departments with common disease processes can be effectively treated in a timely manner. A well-structured observation program will help hospitals reduce the number of inappropriate, costly inpatient admissions while avoiding the potential of inappropriate discharges. Observation medicine is a complicated multidimensional issue that has generated much confusion. This service is designed to provide the best possible patient care in a value-based purchasing environment where quality, cost, and patient satisfaction must continually be addressed. Observation medicine is a service not a status. Therefore, patients are admitted to the service as outpatients no matter whether they are placed in a virtual or dedicated observation unit. The key to a successful observation program is to determine how to maximize efficiencies. This white paper provides the reader with the foundational guidance for observational services. It defines how to set up an observational service program, which diagnoses are most appropriate for admission, and what the future holds. The goal is to help care providers from any hospital deliver the most appropriate level of treatment, to the most appropriate patient, in the most appropriate location while controlling costs.
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Affiliation(s)
- Frank Peacock
- From the *Baylor College of Medicine, Ben Taub Hospital, Houston, TX; †Society of Cardiovascular Patient Care, Dublin, OH; ‡Beaumont Health System, Royal Oaks, MI; §Virginia Commonwealth University Medical Center, Richmond, VA; ¶Wayne State University School of Medicine, Detroit, MI; ‖Cleveland Clinic, Cleveland, OH; **Emory University School of Medicine, Atlanta, GA; and ††Oregon Health & Science University, Portland, OR
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141
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Kronish IM, Goldfinger JZ, Negron R, Fei K, Tuhrim S, Arniella G, Horowitz CR. Effect of peer education on stroke prevention: the prevent recurrence of all inner-city strokes through education randomized controlled trial. Stroke 2014; 45:3330-6. [PMID: 25248910 PMCID: PMC4213208 DOI: 10.1161/strokeaha.114.006623] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/27/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success. We aimed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors. METHODS Between 2009 and 2012, we enrolled 600 stroke or transient ischemic attack survivors from diverse, low-income communities in New York City into a 2-arm randomized clinical trial that compared a 6 week (1 session/week), peer-led, community-based, stroke prevention self-management group workshop (N=301) to a wait-list control group (N=299). The primary outcome was the proportion with a composite of controlled blood pressure (<140/90 mm Hg), low-density lipoprotein cholesterol <100 mg/dL, and use of antithrombotic medications at 6 months. Secondary outcomes included control of the individual stroke risk factors. All analyses were by intent-to-treat. RESULTS There was no difference in the proportion of intervention and control group participants achieving the composite outcome (34% versus 34%; P=0.98). The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group (76% versus 67%; P=0.02). This corresponded to a greater change in systolic blood pressure in the intervention versus control group (-3.63 SD, 19.81 mm Hg versus +0.34 SD, 23.76 mm Hg; P=0.04). There were no group differences in the control of cholesterol or use of antithrombotics. CONCLUSIONS A low-cost peer education self-management workshop modestly improved blood pressure, but not low-density lipoprotein cholesterol or antithrombotic use, among stroke and transient ischemic attack survivors from vulnerable, predominantly minority urban communities. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov/show/NCT0102727. Unique identifier: NCT01027273.
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Affiliation(s)
- Ian M Kronish
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.).
| | - Judith Z Goldfinger
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
| | - Rennie Negron
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
| | - Kezhen Fei
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
| | - Stanley Tuhrim
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
| | - Guedy Arniella
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
| | - Carol R Horowitz
- From the Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University Medical Center, New York, NY (I.M.K.); Departments of Medicine (J.Z.G., C.R.H.), Health Evidence and Policy (R.N., K.F., C.R.H.), and Neurology (S.T.), Icahn School of Medicine at Mount Sinai, New York, NY; and Department of Family Medicine, Institute for Family Health, New York, NY (G.A.)
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142
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Cocho D, Monell J, Planells G, Ricciardi AC, Pons J, Boltes A, Espinosa J, Ayats M, Garcia N, Otermin P. Rapid diagnosis and treatment of TIA results in low rates of stroke, myocardial infarction and vascular death. Neurologia 2014; 31:18-23. [PMID: 25261166 DOI: 10.1016/j.nrl.2014.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/25/2014] [Accepted: 05/29/2014] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The 90-day risk of cerebral infarction in patients with transient ischaemic attack (TIA) is estimated at between 8% and 20%. There is little consensus as to which diagnostic strategy is most effective. This study evaluates the benefits of early transthoracic echocardiography (TTE) with carotid and transcranial Doppler ultrasound in patients with TIA. METHODS Prospective study of patients with TIA in an emergency department setting. Demographic data, vascular risk factors, and ABCD(2) score were analysed. TIA aetiology was classified according to TOAST criteria. All patients underwent early vascular studies (<72hours), including TTE, carotid ultrasound, and transcranial Doppler. Primary endpoints were recurrence of stroke or TIA, myocardial infarction (MI), or vascular death during the first year. RESULTS We evaluated 92 patients enrolled over 24 months. Mean age was 68.3±13 years and 61% were male. The mean ABCD(2) score was 3 points (≥5 in 30%). The distribution of TIA subtypes was as follows: 12% large-artery atherosclerosis; 30% cardioembolism; 10% small-vessel occlusion; 40% undetermined cause; and 8% rare causes. Findings from the early TTE led to a change in treatment strategy in 6 patients (6.5%) who displayed normal physical examination and ECG findings. At one year of follow-up, 3 patients had experienced stroke (3.2%) and 1 patient experienced MI (1%); no vascular deaths were identified. CONCLUSIONS In our TIA patients, early vascular study and detecting patients with silent cardiomyopathy may have contributed to the low rate of vascular disease recurrence.
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Affiliation(s)
- D Cocho
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España.
| | - J Monell
- Servicio de Cardiología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - G Planells
- Servicio de Urgencias Médicas, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - A C Ricciardi
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - J Pons
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - A Boltes
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - J Espinosa
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - M Ayats
- Servicio de Cardiología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - N Garcia
- Servicio de Urgencias Médicas, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
| | - P Otermin
- Servicio de Neurología, Hospital General de Granollers, Universitat Internacional de Catalunya, Barcelona, España
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143
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Braun CMJ, Roberge C. Gender-related protection from or vulnerability to severe CNS diseases: gonado-structural and/or gonado-activational? A meta-analysis of relevant epidemiological studies. Int J Dev Neurosci 2014; 38:36-51. [PMID: 25109841 DOI: 10.1016/j.ijdevneu.2014.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A vast scientific literature has dealt with gender-specific risk for brain disorder. That field is evolving toward a consensus to the effect that the estrogen hormone family is outstandingly and uniquely neuroprotective. However, the epidemiology relevant to this general outlook remains piecemeal. METHOD The present investigation strategically formats the relevant epidemiological findings around the world in order to quantitatively meta-analyze gender ratio of risk for a variety of relevant severe central nervous system (CNS) diseases at all three gonadal stages of the life cycle, pre pubertal, post adolescent/pre menopausal, and post menopausal. RESULTS The data quantitatively establish that (1) no single epidemiological study should be cited as evidence of gender-specific neuroprotection against the most common severe CNS diseases because the gender-specific risk ratios are contradictory from one study to the other; (2) risk for severe CNS disease is indeed significantly gender-specific, but either gender can be protected: it depends on the disease, not at all on the age bracket. CONCLUSION Our assay of gender-specific risk for severe brain disease around the world has not been able to support the idea according to which any one gender-prevalent gonadal steroid hormone dominates as a neuroprotective agent at natural concentrations.
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Affiliation(s)
- Claude M J Braun
- Department of Psychology, Université du Québec à Montréal, Canada.
| | - Carl Roberge
- Department of Psychology, Université du Québec à Montréal, Canada
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144
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Kellett N, Drummond AER, Palmer T, Munshi S, Lincoln NB. Impact of transient ischaemic attack and minor stroke on daily life. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2014. [DOI: 10.12968/ijtr.2014.21.7.318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Naomi Kellett
- MSc student in rehabilitation psychology at the Institute of Work, Health and Organisations, University of Nottingham, Nottingham
| | - Avril ER Drummond
- Professor of Healthcare Research at the School of Health Sciences, University of Nottingham, Nottingham
| | - Tracy Palmer
- Nurse at the Stroke Service, Nottingham University Hospitals NHS Trust, Nottingham
| | - Sunil Munshi
- Consultant Stroke Physician at the Stroke Service, Nottingham University Hospitals NHS Trust, Nottingham
| | - Nadina B Lincoln
- Professor of Clinical Psychology at the Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
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145
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Wang J, Wu J, Liu R, Gao F, Hu H, Yin X. The ABCD2score is better for stroke risk prediction after anterior circulation TIA compared to posterior circulation TIA. Int J Neurosci 2014; 125:50-5. [DOI: 10.3109/00207454.2014.905777] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Junjun Wang
- 1Department of Neurology, Zhejiang Hospital, Hangzhou, China
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146
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Sobolewski P, Brola W, Wiszniewska M, Szczuchniak W, Fudala M, Domagalski M, Śledzińska-Dźwigał M. Intravenous thrombolysis with rt-PA for acute ischemic stroke within 24h of a transient ischemic attack. J Neurol Sci 2014; 340:44-9. [DOI: 10.1016/j.jns.2014.02.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 01/19/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
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147
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Affiliation(s)
- Elaine T. Miller
- From the University of Cincinnati, College of Nursing, OH (E.T.M.); and Saint Luke’s Hospital of Kansas City, MO (D.S.)
| | - Debbie Summers
- From the University of Cincinnati, College of Nursing, OH (E.T.M.); and Saint Luke’s Hospital of Kansas City, MO (D.S.)
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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2860] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
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149
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Patel RAG. State of the art in carotid artery stenting: trial data, technical aspects, and limitations. J Cardiovasc Transl Res 2014; 7:446-57. [PMID: 24771314 DOI: 10.1007/s12265-014-9567-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 04/13/2014] [Indexed: 10/25/2022]
Abstract
The volume of carotid artery stenting (CAS) safety and efficacy data has grown exponentially over the last decade. Recent comparative data with carotid endarterectomy, the utility of embolic protection devices, peri-procedural medications, basic technical aspects of CAS, developments in carotid stent design, potential complications of CAS, and complication risk factors are discussed in this review.
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Affiliation(s)
- Rajan A G Patel
- John Ochsner Heart & Vascular Institute, Ochsner Medical Center, 1514 Jefferson Hwy., New Orleans, LA, 70121, USA,
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150
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Johnston SC, Easton JD, Farrant M, Barsan W, Battenhouse H, Conwit R, Dillon C, Elm J, Lindblad A, Morgenstern L, Poisson SN, Palesch Y. Platelet-oriented inhibition in new TIA and minor ischemic stroke (POINT) trial: rationale and design. Int J Stroke 2014; 8:479-83. [PMID: 23879752 DOI: 10.1111/ijs.12129] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ischemic stroke and other vascular outcomes occur in 10-20% of patients in the three-months following a transient ischemic attack or minor ischemic stroke, and many are disabling. The highest risk period for these outcomes is the early hours and days immediately following the ischemic event. Aspirin is the most common antithrombotic treatment used for these patients. AIM The aim of POINT is to determine whether clopidogrel plus aspirin taken <12 h after transient ischemic attack or minor ischemic stroke symptom onset is more effective in preventing major ischemic vascular events at 90 days in the high-risk, and acceptably safe, compared with aspirin alone. DESIGN POINT is a prospective, randomized, double-blind, multicenter trial in patients with transient ischemic attack or minor ischemic stroke. Subjects are randomized to clopidogrel (600 mg loading dose followed by 75 mg/day) or matching placebo, and all will receive open-label aspirin 50-325 mg/day, with a dose of 162 mg daily for five-days followed by 81 mg daily strongly recommended. STUDY OUTCOMES The primary efficacy outcome is the composite of new ischemic vascular events - ischemic stroke, myocardial infarction, or ischemic vascular death - by 90 days. The primary safety outcome is major hemorrhage, which includes symptomatic intracranial hemorrhage. DISCUSSION Aspirin is the most common antithrombotic given to patients with a stroke or transient ischemic attack, as it reduces the risk of subsequent stroke. This trial expects to determine whether more aggressive antithrombotic therapy with clopidogrel plus aspirin, initiated acutely, is more effective than aspirin alone.
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