Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association

Racial disparities in post-stroke functional outcomes in young patients with ischemic stroke

BACKGROUND AND PURPOSE

Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients.

METHODS

Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal-Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS).

RESULTS

Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65-3.15), CHF (OR 2.17, 1.06-4.46), and DM II 1.92 (1.25-2.94) while HIS had higher odds of DM II (OR 2.52, 1.55-4.10) and lower odds of smoking (OR 0.56, 0.35-0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31-0.78)) and HIS (OR 0.37 CI (0.21-0.67)) were less likely to have good functional outcome (mRS <2) at day 7 in adjusted analyses.

CONCLUSIONS

In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.

The Role of Physical Therapy in Multiple Risk Factor Management Poststroke: A Scoping Review

BACKGROUND AND PURPOSE

Individuals after stroke often have multiple chronic conditions, such as hypertension, diabetes, dyslipidemia, obesity, and tobacco use. These comorbidities not only are commonly found in individuals with stroke, but also negatively affect functional outcomes and increase risk for hospital readmission and overall mortality. It is important for physical therapists to address the whole person during treatment after stroke, including comorbidities, not just the problems resulting from the stroke itself. However, it is unclear how common it is for physical therapists to address multiple diagnoses at once using a wellness model. Therefore, the purpose of this scoping review was to examine current evidence regarding the role of physical therapy in addressing modifiable risk factors for individuals after stroke, to identify gaps in research associated with physical therapy management of related comorbid diagnoses during treatment for stroke.

METHODS

A scoping review methodology was utilized searching PubMed and CINAHL databases to identify interventional research studies specifically addressing multiple modifiable risk factors utilizing physical therapy for individuals after stroke.

RESULTS

The initial search yielded 5358 articles and 12 articles met full inclusion criteria. Only 2 studies included participants with significant mobility impairments, and none included individuals with communication impairments. Only 4 of the 12 studies provided education in their design. Eight studies did not include any patient-reported outcome measures. Only 3 studies included long-term follow-up assessments.

DISCUSSION

Secondary stroke risk factors can be positively addressed using physical therapy interventions; however, more research is needed regarding individuals with moderate to severe mobility or communication deficits. Opportunities for physical therapy research to address stroke risk factors in this complex population include expanding follow-up periods, improving educational interventions, and including caregivers in study design.

CONCLUSIONS

This review highlights the need for better integration of clinical considerations into stroke rehabilitation research as a whole, along with the need for additional research regarding the role physical therapy can play in addressing multimorbidity in individuals with stroke.

Impact of the Dedicated Neurointensivists on the Outcome in Patients with Ischemic Stroke Based on the Linked Big Data for Stroke in Korea

BACKGROUND

Neurocritical care by dedicated neurointensivists may improve outcomes of critically ill patients with severe brain injury. In this study, we aimed to validate whether neurointensive care could improve the outcome in patients with critically ill acute ischemic stroke using the linked big dataset on stroke in Korea.

METHODS

We included 1,405 acute ischemic stroke patients with mechanical ventilator support in the intensive care unit after an index stroke. Patients were retrieved from linking the Clinical Research Center for Stroke Registry and the Health Insurance Review and Assessment Service data from the period between January 2007 and December 2014. The outcomes were mortality at discharge and at 3 months after an index stroke. The main outcomes were compared between the centers with and without dedicated neurointensivists.

RESULTS

Among the included patients, 303 (21.6%) were admitted to the centers with dedicated neurointensivists. The patients treated by dedicated neurointensivists had significantly lower in-hospital mortality (18.3% vs. 26.8%, P = 0.002) as well as lower mortality at 3-month (38.0% vs. 49.1%, P < 0.001) than those who were treated without neurointensivists. After adjusting for confounders, a treatment without neurointensivists was independently associated with higher in-hospital mortality (odds ratio [OR], 1.59; 95% confidence intervals [CIs], 1.13-2.25; P = 0.008) and 3-month mortality (OR, 1.48; 95% CIs, 1.12-1.95; P = 0.005).

CONCLUSION

Treatment by dedicated neurointensivists is associated with lower in-hospital and 3-month mortality using the linked big datasets for stroke in Korea. This finding stresses the importance of neurointensivists in treating patients with severe ischemic stroke.

Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study

Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.

Assessment of acute treatment of hypertension in ischemic stroke patients

OBJECTIVES

Stroke, the most common neurologic disorder and the major cause of disability and death after heart disease causing 11.8% of the total deaths worldwide, is defined as a rapidly developing clinical signs of focal disturbance of cerebral function lasting more than 24 h. This study aims to assess appropriateness of hypertension treatment in acute stroke and its adherence with the choice of medications tailored according to blood pressure readings.

PATIENTS AND METHODS

This was a pilot study performed in Lebanese hospitals where medical records of ischemic stroke patients were used to collect required data. The study enrolled ischemic stroke patients older than 18 years of age, admitted to intensive care unit or internal medicine department. Patients with hemorrhagic stroke were excluded. Statistical analysis was done using IBM Statistical Package for the Social Science software. The significance level is p-value ≤ 0.05.

RESULTS

A total of 146 patients (56.8% females; mean age 76.6 ± 11.9) were included in the analysis. At baseline, patients had a mean ± standard deviation (SD) SBP of 160.6 (±31.3) and a mean DBP of 85.5. Labetalol and amlodipine were administered to patients with significantly higher baseline blood pressure (p < 0.001). Change in SBP from baseline after 2 h of drug administration was significantly higher with labetalol (p = 0.028 for patients eligible for reperfusion), amlodipine (p = 0.014), and nitroglycerine (p = 0.044). As for the change in SBP after 24 h, it was significantly higher with labetalol just for patients not eligible for reperfusion (p < 0.001), and amlodipine (p = 0.006). As for the change in DBP, it was significantly lower after 24 h on labetalol administration for patients not eligible for reperfusion (p < 0.001) and it was also lower 2 h after administration of ramipril (p = 0.001) and 24 h (p = 0.021).

CONCLUSION

This study reveals the gap between American Stroke Association guideline recommendations and the clinical practice and states the impact of such a difference on patients' health.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

30-day and 60-day rates and predictors of mortality among adult stroke patients: Prospective cohort study

Stroke is one of the most common medical emergencies and the leading cause of preventable death and long-term disability worldwide. A prospective cohort study was conducted at the stroke unit of Jimma university medical center for four consecutive months (from March 10 to July 10, 2017). Of the total 116 study patients, 60 (51.7%) had an ischemic stroke. At 30-day follow-up, 81 (69.8%) patients were alive, 34 (29.3%) were died, and one patient (0.9%) was lost to follow-up. Elevated alanine aminotransferase (ALT) level (AHR: 3.77, 95% CI: 1.34-10.57), diagnosis of stroke clinically alone (AHR: 3.90, 95 CI: 1.49-10.26), brain edema (AHR: 4.28, 95% CI: 1.61-11.37), and National Institute of Health Stroke Scale (NIHSS) ≥ 13 during hospital arrival (AHR: 6.49, 95% CI: 1.90-22.22) were the independent predictors of 30-day mortality. At 60-day follow-up, 68 (58.6%) patients were alive, 46 (39.7%) were died, and 2 (1.7%) were lost to follow-up. Discharge against medical advice (AHR: 6.40, 95% CI: 2.31-17.73) and severe modified Rankin score/mRS (4-5) at discharge (AHR: 3.64, 95% CI: 1.01-13.16) were the independent predictors of 60-day mortality. The median (IQR) length of survival after hospital admission for patients died within 30 and 60 days were 4.65 (2.34-11.80) and 9.3 (3.93-33) days, respectively. Stroke significantly affects the morbidity and mortality in Ethiopia. There is a need to provide better care and future planning for stroke patients as an emergency diagnosis and treatment to minimize mortality and disability.

Mindfulness with paced breathing reduces blood pressure

Elevated blood pressure (BP) is a major avoidable cause of premature morbidity and mortality in the United States (US) and worldwide, due primarily to increased risks of stroke as well as myocardial infarction. While there are therapeutic lifestyle changes and adjunctive pharmacologic medications of proven benefit, recent interest has increasingly focused on Complementary and Alternative Medicine, in particular, Mind-Body Interventions. With respect to BP, it is tempting to speculate that mindfulness with paced breathing will have beneficial effects in the short run that may translate into lowered risks of stroke in the long run. Paced breathing is deep diaphragmatic breathing with typical rates equal to or less than 5-7 breaths per minute compared with the usual rate of 12-14. One plausible mechanism of benefit is that paced breathing stimulates the parasympathetic nervous system which alters neuronal function in specific areas of the brain and reduces stress chemicals. The hypothesis that mindfulness with paced slow breathing reduces BP could be directly tested in randomized trials designed a priori to do so. Subsequently, a finding that mindfulness with paced breathing reduces BP would also lead to direct tests in randomized trials of reductions of carotid atherosclerosis and, if so, a larger scale trial to test whether there is a direct impact of mindfulness with paced breathing on reducing the risks of stroke and MI. If rigorous testing of this medical hypothesis led to positive results this would have large and important clinical and policy implications in the US and worldwide.

Polypill Trials for Stroke Prevention-Main Results, Critical Appraisal, and Implications for US Population

PURPOSE OF REVIEW

The polypill, referring to a variety of combinations of low-cost cardiovascular and stroke preventive medications combined in a single tablet, has been evaluated as a population-based approach for cardiovascular disease prevention in several trials. This review summarizes the scope of the problem, main trial results, and their potential applicability to the US population.

RECENT FINDINGS

Initial trials demonstrated the efficacy of the polypill approach. The most recent, the PolyIran study, showed the effectiveness of one form of a polypill for cardiovascular disease prevention, high medication adherence, and low adverse event rates. None of published polypill trials focused on stroke as the primary outcome and most were conducted in developing countries, limiting generalization to the US population. A US-based randomized trial with stroke as the primary outcome is needed to assess the usefulness of this approach for stroke prevention in the USA.

Trends in Mortality Rates from Cardiovascular Disease and Cancer between 2000 and 2015 in the Most Populous Capital Cities of the Five Regions of Brazil

Background

In many cities around the world, the mortality rate from cancer (CA) has exceeded that from disease of the circulatory system (DCS).

Objectives

To compare the mortality curves from DCS and CA in the most populous capital cities of the five regions of Brazil.

Methods

Data of mortality rates from DCS and CA between 2000 and 2015 were collected from the Mortality Information System of Manaus, Salvador, Goiania, Sao Paulo and Curitiba, and categorized by age range into early (30-69 years) and late (≥ 70 years), and by gender of the individuals. Chapters II and IX of the International Classification of Diseases-10 were used for the analysis of causes of deaths. The Joinpoint regression model was used to assess the tendency of the estimated annual percentage change of mortality rate, and the Monte Carlo permutation test was used to detect when changes occurred. Statistical significance was set at 5%.

Results

There was a consistent decrease in early and late mortality from DCS in both genders in the cities studied, except for late mortality in men in Manaus. There was a tendency of decrease of mortality rates from CA in São Paulo and Curitiba, and of increase in the rates from CA in Goiania. In Salvador, there was a decrease in early mortality from CA in men and women and an increase in late mortality in both genders.

Conclusion

There was a progressive and marked decrease in the mortality rate from DCS and a maintenance or slight increase in CA mortality in the five capital cities studied. These phenomena may lead to the intersection of the curves, with predominance of mortality from CA (old and new cases).

The Role of Selected Pro-Inflammatory Cytokines in Pathogenesis of Ischemic Stroke

Stroke is currently one of the most common causes of death and disability in the world, and its pathophysiology is a complex process, involving the oxidative stress and inflammatory reaction. Unfortunately, no biochemical factors useful in the diagnostics and treatment of stroke have been clearly established to date. Therefore, researchers are increasingly interested in the inflammatory response triggered by cerebral ischemia and its role in the development of cerebral infarction. This article gives an overview of the available literature data concerning the role of pro-inflammatory cytokines in acute stroke. Detailed analysis of their role in cerebral circulation disturbances can also suggest certain immune response regulatory mechanisms aimed to reduce damage to the nervous tissue in the course of stroke.

Global Stroke Statistics 2019

BACKGROUND

Data on stroke epidemiology and availability of hospital-based stroke services around the world are important for guiding policy decisions and healthcare planning.

AIMS

To provide the most current incidence, mortality and case-fatality data on stroke and describe current availability of stroke units around the world by country.

METHODS

We searched multiple databases (based on our existing search strategy) to identify new original manuscripts and review articles published between 1 June 2016 and 31 October 2018 that met the ideal criteria for data on stroke incidence and case-fatality. For data on the availability of hospital-based stroke services, we searched PubMed for all literature published up until 31 June 2018. We further screened reference lists, citation history of manuscripts and gray literature for this information. Mortality codes for International Classification of Diseases-9 and International Classification of Diseases-10 were extracted from the World Health Organization mortality database for each country providing these data. Population denominators were obtained from the World Health Organization, and when these were unavailable within a two-year period of mortality data, population denominators within a two-year period were obtained from the United Nations. Using country-specific population denominators and the most recent years of mortality data available for each country, we calculated both the crude mortality from stroke and mortality adjusted to the World Health Organization world population.

RESULTS

Since our last report in 2017, there were two countries with new incidence studies, China (n = 1) and India (n = 2) that met the ideal criteria. New data on case-fatality were found for Estonia and India. The most current mortality data were available for the year 2015 (39 countries), 2016 (43 countries), and 2017 (7 countries). No new data on mortality were available for six countries. Availability of stroke units was noted for 63 countries, and the proportion of patients treated in stroke units was reported for 35/63 countries.

CONCLUSION

Up-to-date data on stroke incidence, case-fatality, and mortality statistics provide evidence of variation among countries and changing magnitudes of burden among high and low-middle income countries. Reporting of hospital-based stroke units remains limited and should be encouraged.

[Analysis of comorbidities in hospitalized patients for ischemic stroke and their effects on lethality]

OBJECTIVES

The aim of the study consists of analyzing the comorbidities of acute ischemic stroke and those influencing its hospital lethality.

METHODS

We considered patients from Wallonia aged 25 years or more and admitted to a Belgian hospital for an acute ischemic stroke in 2013 and 2014. The analyzed medico-administrative data are taken from the Minimum Hospital Summary. A factorial correspondence analysis (FCA) was used to demonstrate the comorbidities profiles. A logistic regression was used to analyse the comorbidities influencing hospital lethality by ischemic stroke.

RESULTS

The stroke risk factors vary according to the age. Cardiac problems are more common in older people aged 85 years or more. High blood pressure, hypercholesterolemia and diabetes are more present between 65- and 84-year-olds. Overweight is more present between 55 and 74-year-olds. People who are addicted to alcohol or tobacco are often 65 years or younger. The logistic regression showed that age and heart problems are the risk factors that increase lethality. However there is a lethality diminution in the presence of high blood pressure, hypercholesterolemia, overweight and addiction to alcohol or tobacco.

CONCLUSION

This study demonstrates that medico-administrative databases and factorial statistical methods are perfectly adapted to confirm the ischemic stroke risk factors. This type of study will allow to target with more precision the secondary and tertiary prevention actions of stroke.

Atrial fibrillation in the elderly general population: a 30-year follow-up from 70 to 100 years of age

Objectives. There is limited knowledge of atrial fibrillation (AF) incidence among the very old. Data from longitudinal cohort studies may give us a better insight. The aim of the study was to investigate the incidence rate and prevalence of AF, as well as the impact of AF on mortality, in the general population, from 70 to 100 years of age. Design. This was a population-based prospective cohort study where three representative samples of 70-year-old men and women (n = 2,629) from the Gerontological and Geriatric Populations Studies in Gothenburg (H-70) were included between 1971 and 1982. The participants were examined at age 70 years and were re-examined repeatedly until 100 years of age. AF was diagnosed according to a 12-lead electrocardiogram (ECG) recording at baseline and follow-up examinations, from the Swedish National Patient Register (NPR), or from the Cause of Death Register. Results. The cumulative incidence of AF from 70 to 100 years of age was 65.6% for men and 52.8% for women. Mortality was significantly higher in participants with AF compared with those without, rate ratio (RR) 1.92 (95% CI 1.73-2.14). In a subgroup analysis comprising only participants with AF diagnosed by ECG at screening, the RR for death was 1.29 (95% C.I: 1.03-1.63). Conclusions. Among persons surviving to age 70, the cumulative incidence of AF was over 50% during follow-up. Mortality rate was twice as high in participants with AF compared to participants without AF. Among participants with AF first recorded at a screening examination, the increased risk was only 29%.

[Prognostic factors for mortality due to acute arterial stroke in a North African population]

Introduction

cerebrovascular accident (stroke) constitutes a major public health problem due to the number of people affected and to its medical social and economic consequences. This study aims to identify poor vital prognostic factors for survival in patients with acute arterial stroke.

Methods

we conducted a prospective study of patients with symptoms suggestive of stroke at the two University Hospitals of Sfax, Tunisia over a period of 4 months. Patients were followed-up for a period of 1 month.

Results

we collected data from 200 patients. After one month of follow-up, mortality was 19.9%. Poor prognostic factors were: male sex, consumption of tobacco, a history of stroke, low Glasgow score, high NIHSS, headaches, acute symptomatic epileptic seizures, Babinski's sign, mydriasis, aphasia, combined deviation of the head and the eyes, high PAS, PAD and PAM, hyperthermia, hyperglycaemia, leukocytosis, high concentration of CRP, creatinine, urea and troponin T, haemorrhagic stroke, perilesional oedema, a mass effect, commitment, total middle cerebral artery topography of ischemia, early signs of ischemia, meningeal hemorrhage, ventricular flood, hydrocephalus, the recourse to respiratory support, to anti-edematous treatment and to antihypertensive therapy, hemorrhagic transformation, vascular epilepsy, infectious, metabolic complications, complications of bed sores.

Conclusion

the identification of the predictive factors for survival allows for optimisation of therapeutic procedures and better implementation of patient' management. A comparative study will be considered to measure the impact of the corrective measures.

Impact of Diabetes on Complications, Long Term Mortality and Recurrence in 608,890 Hospitalised Patients with Stroke

Background:

Patients with diabetes mellitus (DM) have been found to be at an increased risk of suffering a stroke. However, research on the impact of DM on stroke outcomes is limited.

Objectives:

We aimed to examine the influence of DM on outcomes in ischaemic (IS) and haemorrhagic stroke (HS) patients.

Methods:

We included 608,890 consecutive stroke patients from the Thailand national insurance registry. In-hospital mortality, sepsis, pneumonia, acute kidney injury (AKI), urinary tract infection (UTI) and cardiovascular events were evaluated using logistic regressions. Long-term analysis was performed on first-stroke patients with a determined pathology (n = 398,663) using Royston-Parmar models. Median follow-ups were 4.21 and 4.78 years for IS and HS, respectively. All analyses were stratified by stroke sub-type.

Results:

Mean age (SD) was 64.3 (13.7) years, 44.9% were female with 61% IS, 28% HS and 11% undetermined strokes. DM was associated with in-hospital death, pneumonia, sepsis, AKI and cardiovascular events (odds ratios ranging from 1.13–1.78, p < 0.01) in both stroke types. In IS, DM was associated with long-term mortality and recurrence throughout the follow-up: HR_max (99% CI) at t = 4108 days: 1.54 (1.27, 1.86) and HR (99% CI) = 1.27(1.23,1.32), respectively. In HS, HR_max (t = 4108 days) for long-term mortality was 2.10 (1.87, 2.37), significant after day 14 post-discharge. HR_max (t = 455) for long-term recurrence of HS was 1.29 (1.09, 1.53), significant after day 116 post-discharge.

Conclusions:

Regardless of stroke type, DM was associated with in-hospital death and complications, long-term mortality and stroke recurrence.

Pathophysiological and clinical considerations in the perioperative care of patients with a previous ischaemic stroke: a multidisciplinary narrative review

With an ageing population and increasing incidence of cerebrovascular disease, an increasing number of patients presenting for routine and emergency surgery have a prior history of stroke. This presents a challenge for pre-, intra-, and postoperative management as the neurological risk is considerably higher. Evidence is lacking around anaesthetic practice for patients with vascular neurological vulnerability. Through understanding the pathophysiological changes that occur after stroke, insight into the susceptibilities of the cerebral vasculature to intrinsic and extrinsic factors can be developed. Increasing understanding of post-stroke systemic and cerebral haemodynamics has provided improved outcomes from stroke and more robust secondary prevention, although this knowledge has yet to be applied to our delivery of anaesthesia in those with prior stroke. This review describes the key pathophysiological and clinical considerations that inform clinicians providing perioperative care for patients with a prior diagnosis of stroke.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Kang Le Xin Reduces Blood Pressure Through Inducing Endothelial-Dependent Vasodilation by Activating the AMPK-eNOS Pathway

Hypertension is a major risk factor for stroke and cardiovascular events in clinic, which is accompanied by the abnormality of vascular tone and endothelial dysfunction of small artery. Here we report that Kang Le Xin (KLX), a novel anthraquinones compound, could reduce blood pressure and the underlying mechanisms involves that KLX induces endothelium-dependent vasodilation. KLX significantly decreases the arterial blood pressure of spontaneous hypertensive rats (SHR), decreases the contractile reactivity of superior mesenteric artery to phenylephrine and increases the vasodilatory reactivity of superior mesenteric artery to carbachol in a dose-dependent manner. Besides, KLX reduces vascular tension of endothelium-intact mesenteric artery pre-constricted with phenylephrine in a dose-dependent manner, while this effect is inhibited by depriving vascular endothelium or pretreating vascular rings with L-NAME (endothelial nitric oxide synthase inhibitor) or compound C (AMP-activated protein kinase inhibitor). Moreover, KLX increases nitric oxide (NO) generation, endothelial nitric oxide synthase (eNOS), AKT and AMP-activated protein kinase (AMPK) phosphorylation in cultured human umbilical vein endothelial cells (HUVECs), while these effects are inhibited by pretreating cells with compound C. In conclusion, KLX is a new compound with the pharmacological action of reducing arterial blood pressure. The underlying mechanism involves KLX induces endothelium-dependent vasodilation through activating AMPK-AKT-eNOS signaling pathway.

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

BACKGROUND

Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment.

METHODS

We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics.

RESULTS

746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001).

CONCLUSIONS

Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

Sociodemographic Disparities in Long-Term Mortality Among Stroke Survivors in the United States

Background and Purpose- It is unclear whether disparities in mortality among stroke survivors exist long term. Therefore, the purpose of the current study is to describe rates of longer term mortality among stroke survivors (ie, beyond 30 days) and to determine whether socioeconomic disparities exist. Methods- This analysis included 1329 black and white participants, aged ≥45 years, enrolled between 2003 and 2007 in the REGARDS study (Reasons for Geographic and Racial Differences in Stroke) who suffered a first stroke and survived at least 30 days after the event. Long-term mortality among stroke survivors was defined in person-years as time from 30 days after a first stroke to date of death or censoring. Mortality rate ratios (MRRs) were used to compare rates of poststroke mortality by demographic and socioeconomic characteristics. Results- Among adults who survived ≥30 days poststroke, the age-adjusted rate of mortality was 82.3 per 1000 person-years (95% CI, 75.4-89.2). Long-term mortality among stroke survivors was higher in older individuals (MRR for 75+ versus <65, 3.2; 95% CI, 2.6-4.1) and among men than women (MRR, 1.3; 95% CI, 1.1-1.6). It was also higher among those with less educational attainment (MRR for less than high-school versus college graduate, 1.5; 95% CI, 1.1-1.9), lower income (MRR for <$20k versus >50k, 1.4; 95% CI, 1.1-1.9), and lower neighborhood socioeconomic status (SES; MRR for low versus high neighborhood SES, 1.4; 95% CI, 1.1-1.7). There were no differences in age-adjusted rates of long-term poststroke mortality by race, rurality, or US region. Conclusions- Rates of long-term mortality among stroke survivors were higher among individuals with lower SES and among those residing in neighborhoods of lower SES. These results emphasize the need for improvements in long-term care poststroke, especially among individuals of lower SES.

Brain Cleanup as a Potential Target for Poststroke Recovery: The Role of RXR (Retinoic X Receptor) in Phagocytes

Background and Purpose- Phagocytic cells, such as microglia and blood-derived macrophages, are a key biological modality responsible for phagocytosis-mediated clearance of damaged, dead, or displaced cells that are compromised during senescence or pathological processes, including after stroke. This process of clearance is essential to eliminate the source of inflammation and to allow for optimal brain repair and functional recovery. Transcription factor, RXR (retinoic-X-receptor) is strongly implicated in phagocytic functions regulation, and as such could represent a novel target for brain recovery after stroke. Methods- Primary cultured microglia and bone marrow macrophages were used for phagocytic study. Mice with deleted RXR-α in myeloid phagocytes (Mac-RXR-α^-/-) were subjected to transient middle cerebral artery occlusion to mimic ischemic stroke and then treated with RXR agonist bexarotene. RNA-sequencing and long-term recovery were evaluated. Results- Using cultured microglia, we demonstrated that the RXR-α promotes the phagocytic functions of microglia toward apoptotic neurons. Using mice with deleted RXR-α in myeloid phagocytes (Mac-RXR-α^-/-), we have shown that despite behaving similarly to the control at early time points (up to 3 days, damage established histologically and behaviorally), these Mac-RXR-α^-/- mice demonstrated worsened late functional recovery and developed brain atrophy that was larger in size than that seen in control mice. The RXR-α deficiency was associated with reduced expression of genes known to be under control of the prominent transcriptional RXR partner, PPAR (peroxisome proliferator-activated receptor)-γ, as well as genes encoding for scavenger receptors and genes that signify microglia/macrophages polarization to a reparative phenotype. Finally, we demonstrated that the RXR agonist, bexarotene, administered as late as 1 day after middle cerebral artery occlusion, improved neurological recovery, and reduced the atrophy volume as assessed 28 days after stroke. Bexarotene did not improve outcome in Mac-RXR-α^-/- mice. Conclusions- Altogether, these data suggest that phagocytic cells control poststroke recovery and that RXR in these cells represents an attractive target with exceptionally long therapeutic window.

Young Stroke Survivors With No Early Recurrence at High Long-Term Risk of Adverse Outcomes

Background

Approximately 8% to 21% of strokes affect adults aged <45 years. Although early stroke recurrence conveys the largest risk, long‐term risks for young survivors with no early complications are unclear.

Methods and Results

Longitudinal matched case‐control study (2003–2013). Consecutive patients with ischemic stroke or transient ischemic attack (young, ≤44 years) discharged from emergency or regional stroke centers in Ontario, Canada, with no death, recurrent stroke/transient ischemic attack, myocardial infarction, all‐cause hospitalization, or admission to a long‐term or continuing care facility (≤90 days) were matched 10:1 to general population controls on age (±1 year), sex, income, geography, and case date (±50 days). The primary outcome was a composite of death, stroke, myocardial infarction, and long‐term or continuing care facility admission at 1, 3, and 5 years. Absolute event rates for young stroke/transient ischemic attack patients were lower than for older patients at 1 (2.2% versus 9.9%), 3 (4.7% versus 24.6%), and 5 (7.1% versus 37.2%) years. However, piecewise constant hazard modeling revealed that, even after adjustment for vascular comorbidities, young patients showed a 7‐fold increased hazard of the composite outcome compared with young controls at 1 year (hazard ratio, 7.3; 95% CI, 4.0–13.6). Adjusted 5‐year piecewise hazard also remained >5× that of young controls (hazard ratio, 5.2; 95% CI, 2.8–9.4), compared with a 30% increase at 5 years for older patients (hazard ratio, 1.3; 95% CI, 1.3–1.4).

Conclusions

Young stable stroke/transient ischemic attack survivors show a higher long‐term hazard of adverse outcomes compared with matched controls than older patients. Findings support the need for long‐term follow‐up and aggressive risk reduction in young survivors and suggest secondary prevention guidelines for these patients are required.

miR-130a alleviates neuronal apoptosis and changes in expression of Bcl-2/Bax and caspase-3 in cerebral infarction rats through PTEN/PI3K/Akt signaling pathway

Effect of micro ribonucleic acid (miR)-130a on neuronal apoptosis in rats with cerebral infarction (CI) was studied to explore whether phosphatase and tensin homolog deleted on chromosome ten (PTEN)/phosphatidylinositol 3-hydroxy kinase (PI3K)/protein kinase B (Akt) is involved in the regulation of neuronal apoptosis. Thirty-six Sprague-Dawley (SD) rats were randomly divided into blank control group, model group and miR-130a low-expression group. miR-130a was determined by quantitative polymerase chain reaction (qPCR), the content of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and IL-10 was detected using the enzyme-linked immunosorbent assay (ELISA) kits, and the neuronal apoptosis level in each group was determined through terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining. The neurobehavioral score was significantly lower in model group than that in blank control group (P<0.01), while it was significantly higher in miR-130a low-expression group than that in model group (P<0.01). Compared with blank control group, the model group had obviously increased content of TNF-α and IL-6 (P<0.01), decreased content of IL-10 (P<0.01), more apoptotic neurons (P<0.01), higher expression of caspase-3 (P<0.01), and obviously lower Bcl-2/Bax (P<0.01). Moreover, expression of phosphorylated (p)-PTEN, PI3K and p-Akt in brain tissues was remarkably lower in the model group than those in the blank control group (P<0.01). The expression level of miR-130a in brain tissues of CI rats is significantly increased. miR-130a promotes the release of inflammatory factors and facilitates neuronal apoptosis through suppressing the PTEN/PI3K/Akt signaling pathway.

Effects of neural stem cell-derived extracellular vesicles on neuronal protection and functional recovery in the rat model of middle cerebral artery occlusion

Stroke imposes a long-term neurological disability with limited effective treatments available for neuronal recovery. Transplantation of neural stem cells (NSCs) is reported to improve functional outcomes in the animal models of brain ischemia. However, the use of cell therapy is accompanied by adverse effects, so research is growing to use cell-free extracts such as extracellular vesicles (EVs) for targeting brain diseases. In the current study, male Wistar albino rats (20 months old) were subjected to middle cerebral artery occlusion (MCAO). Then, EVs (30 μg) were injected at 2 hours after stroke onset via an intracerebroventricular (ICV) route. Measurements were done at day 7 post-MCAO. EVs administration reduced lesion volume and steadily improved spontaneous locomotor activity. EVs administration also reduced microgliosis (ionized calcium-binding adaptor molecule 1 (Iba1)⁺ cells) and apoptotic (terminal-deoxynucleotidyl transferase mediated nick end labelling [TUNEL]) positive cells and increased neuronal survival (neuronal nuclear (NeuN)⁺ cells) in the ischemic boundary zone (IBZ). However, it had no effect on neurogenesis within the sub-ventricular zone (SVZ) but decreased cellular migration toward the IBZ (doublecortin (DCX)⁺ cells). The results of this study showed neuroprotective and restorative mechanisms of NSC-EVs administration, which may offer new avenues for therapeutic intervention of brain ischemia. SIGNIFICANCE OF THE STUDY: Based on our results, EVs administration can effectively reduce microglial density and neuronal apoptosis, thereby steadily improves functional recovery after MCAO. These findings provide the beneficial effect of NSC-EVs as a new biological treatment for stroke.

Pharmacological management of post-stroke depression

Introduction: Post-stroke depression (PSD) is a common clinical problem affecting approximately one-third of stroke survivors. PSD is associated with poor functional outcome and higher morbidity and mortality rates. Currently, uncertainty remains regarding optimal pharmacological strategies for its prevention and treatment.Areas covered: This article reviews the state of the current literature on pharmacologic intervention strategies for PSD, providing a summary of the most recent evidence to support pharmacological treatment in PSD.Expert opinion: Experimental and clinical research have increased our knowledge on PSD, although unanswered questions still remain regarding the best time to begin treatment, the effect of the antidepressants in areas other than emotion, or their capability to reduce mortality in stroke patients, among others.Currently, though numerous trials and meta-analyses suggest that antidepressants are effective in treating PSD and guidelines recommend their use for PSD, in the daily clinical practice, only a minority of patients are properly assessed and treated. Therefore, though further evidence is needed to clarify the real role of antidepressants in patients with stroke, physicians and other healthcare professionals must be familiar with the pharmacological treatment of PSD, in order to improve the outcome and increase the quality of life of this vulnerable group of patients.

Stroke impact on mortality and psychologic morbidity within the Childhood Cancer Survivor Study

BACKGROUND

Poor socioeconomic and health-related quality of life (HRQOL) outcomes in survivors of childhood cancer can lead to distress and overall negatively impact the lives of these individuals. The current report has highlighted the impact of stroke and stroke recurrence on mortality, psychological HRQOL, and socioeconomic outcomes within the Childhood Cancer Survivor Study (CCSS).

METHODS

The CCSS is a retrospective cohort study with longitudinal follow-up concerning survivors of pediatric cancer who were diagnosed between 1970 and 1986. Mortality rates per 100 person-years were calculated across 3 periods: 1) prior to stroke; 2) after first stroke and before recurrent stroke; and 3) after recurrent stroke. Socioeconomic outcomes, the standardized Brief Symptoms Inventory-18, the Medical Outcomes Study 36-Item Short Form Health Survey, and the CCSS-Neurocognitive Questionnaire also were assessed.

RESULTS

Among 14,358 participants (median age, 39.7 years), 224 had a stroke after their cancer diagnosis (single stroke in 161 patients and recurrent stroke in 63 patients). Based on 2636 deaths, all-cause late mortality rates were 0.70 (95% CI, 0.68-0.73) prior to stroke, 1.03 (95% CI, 0.73-1.46) after the first stroke, and 2.42 (95% CI, 1.48-3.94) after the recurrent stroke. Among 7304 survivors, those with stroke were more likely to live with a caregiver (single stroke odds ratio [OR], 2.3 [95% CI, 1.4-3.8]; and recurrent stroke OR, 5.3 [95% CI, 1.7-16.8]) compared with stroke-free survivors. Stroke negatively impacted task efficiency (single stroke OR, 2.4 [95% CI, 1.4-4.1] and recurrent stroke OR, 3.3 [95% CI, 1.1-10.3]) and memory (single stroke OR, 2.1 [95% CI, 1.2-3.7]; and recurrent stroke OR, 3.5 [95% CI, 1.1-10.5]).

CONCLUSIONS

Stroke and stroke recurrence are associated with increased mortality and negatively impact HRQOL measures in survivors of pediatric cancer.

Down-regulation of miR-3068-3p enhances kcnip4-regulated A-type potassium current to protect against glutamate-induced excitotoxicity

The main cause of excitotoxic neuronal death in ischemic stroke is the massive release of glutamate. Recently, microRNAs (miRNAs) have been found to play an essential role in stroke pathology, although the molecular mechanisms remain to be investigated. Here, to identify potential candidate miRNAs involved in excitotoxicity, we treated rat primary cortical neurons with glutamate and found that miR-3068-3p, a novel miRNA, was up-regulated. We hypothesized that restoring miR-3068-3p expression might influence the neuronal injury outcomes. The inhibition of miR-3068-3p, using tough decoy lentiviruses, significantly attenuated the effects of glutamate on neuronal viability and intracellular calcium overload. To unravel the mechanisms, we employed bioinformatics analysis and RNA sequencing to identify downstream target genes. Additional luciferase assays and western blots validated kcnip4, a Kv4-mediated A-type potassium current (I_A ) regulator, as a direct target of miR-3068-3p. The inhibition of miR-3068-3p increased kcnip4 expression and vice versa. In addition, the knockdown of kcnip4 by shRNA abolished the protective effect of miR-3068-3p, and over-expressing kcnip4 alone was sufficient to play a neuroprotective role in excitotoxicity. Moreover the inhibition of miR-3068-3p enhanced the I_A density, and the pharmacological inhibition of I_A abrogated the protective role of miR-3068-3p inhibition and kcnip4 over-expression. Therefore, we conclude that inhibition of miR-3068-3p protects against excitotoxicity via its target gene, kcnip4, and kcnip4-regulated I_A . Our data suggest that the miR-3068-3p/kcnip4 axis may serve as a novel target for the treatment of ischemic stroke.

Weisheng-Tang Ameliorates Acute Ischemic Brain Damage in Mice by Maintaining Blood-Brain Barrier Integrity

Stroke is one of the major causes of death and long-term disability worldwide; the associated breakdown of the blood-brain barrier (BBB) aggravates ischemic brain damage. Accordingly, many medicinal herbs and formulas have been used to treat stroke-related symptoms. In this study, we selected two Korean herbal medicine formulas, Weisheng-tang and Tongxuewan, through Dongeuibogam text-mining analysis, and evaluated their protective effect on BBB disruption and brain damage in stroke. Ischemic brain damage was induced in mice by photothrombotic cortical ischemia. The infarct volume, brain edema, neurological deficits, and motor function 24 h after ischemic injury were analyzed. We investigated BBB breakdown by measuring Evans blue extravasation in addition to endothelial cells, tight junction proteins, protease-activated receptor-1 (PAR-1), and matrix metalloproteinase-9 (MMP-9) using immunofluorescence staining and confocal microscopy. Pretreatment with Weisheng-tang significantly reduced infarct volume and edema and improved neurological and motor functions; however, Tongxuewan did not. In addition, Weisheng-tang decreased brain infarction and edema and recovered neurological and motor deficit in a dose-dependent manner (30, 100, and 300 mg/kg). Weisheng-tang pretreatment resulted in significantly less BBB damage and higher brain microvasculature after focal cerebral ischemia. Tight junction proteins, such as zonula occludens-1 (ZO-1) and claudin-5, were preserved in Weisheng-tang-pretreated mice. Moreover, the ischemic brain in these mice showed suppressed PAR-1 and MMP-9 expression. In conclusion, our findings show that Weisheng-tang, which was selected through literature analysis but has not previously been used as a stroke remedy, exerts protective effects against ischemic brain damage and suggest its possible application for potential stroke patients, especially in the elderly.

The outcomes of statin therapy in patients with acute ischemic stroke in Taiwan: a nationwide epidemiologic study

BACKGROUND

Acute stroke is the third leading cause of death in Taiwan. Although statin therapy is widely recommended for stroke prevention, little is known about the epidemiology of statin therapy after acute ischemic stroke (AIS) in Taiwan. To investigate the effects of statin therapy on recurrent stroke, intracranial hemorrhage (ICH), coronary artery disease (CAD), cost of hospitalization and mortality, we conducted a nationwide population-based epidemiologic study.

METHODS

Cases of AIS were identified from the annual hospitalization discharge diagnoses of the National Health Insurance Research Database with the corresponding International Classification of Diseases, ninth revision codes from January 2001 to December 2010. We divided the AIS patients into three groups: non-statin, pre-stroke statin and post-stroke statin.

RESULTS

A total of 422 671 patients with AIS (including 365 419 cases in the non-statin group, 22 716 cases in the pre-stroke statin group and 34 536 cases in the post-stroke statin group) were identified. When compared to the non-statin group, both statin groups had a lower recurrent stroke risk [pre-stroke statin: odds ratio (OR) = 0.84; 95% confidence interval (CI) = 0.82-0.87; P < 0.0001; post-stroke statin: OR = 0.89; 95% CI = 0.86-0.91; P < 0.0001], lower ICH risk (pre-statin: OR = 0.75; 95% CI = 0.69-0.82; P < 0.0001; post-stroke statin: OR = 0.75; 95% CI = 0.71-0.81; P < 0.0001), and a lower mortality rate (pre-stroke statin: OR = 0.56; 95% CI = 0.53-0.59; P < 0.0001; post-stroke statin: OR = 0.51; 95% CI = 0.48-0.53; P < 0.0001). In terms of CAD, only the post-statin group had a lower risk (OR = 0.81; 95% CI = 0.79-0.84; P < 0.0001) than the non-statin group. The post-statin group had the lowest 1-year medical costs after index discharge among the three groups.

CONCLUSIONS

Statin therapy reduced the risks of recurrent stroke, CAD, ICH and the first year mortality in patients after AIS. Treatment with statin therapy after AIS is a cost-effective strategy in Taiwan.

Efficacy of a Discharge Educational Strategy vs Standard Discharge Care on Reduction of Vascular Risk in Patients With Stroke and Transient Ischemic Attack: The DESERVE Randomized Clinical Trial

Importance

Despite secondary prevention strategies with proven efficacy, recurrent stroke rates remain high, particularly in racial/ethnic minority populations who are disproportionately affected by stroke.

Objective

To determine the efficacy of a culturally tailored skills-based educational intervention with telephone follow-up compared with standard discharge care on systolic blood pressure reduction in a multiethnic cohort of patients with mild/moderate stroke/transient ischemic attack.

Design, Setting, and Participants

Randomized clinical trial with 1-year follow-up. Participants were white, black, and Hispanic patients with mild/moderate stroke/transient ischemic attack prospectively enrolled from 4 New York City, New York, medical centers during hospitalization or emergency department visit between August 2012 and May 2016. Through screening of stroke admissions and emergency department notifications, 1083 eligible patients were identified, of whom 256 declined to participate and 275 were excluded for other reasons. Analyses were intention to treat.

Interventions

The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention is a skills-based, culturally tailored discharge program with follow-up calls delivered by a community health coordinator. This intervention was developed using a community engagement approach.

Main Outcomes and Measures

The primary outcome was systolic blood pressure reduction at 12 months postdischarge.

Results

A total of 552 participants were randomized to receive intervention or usual care (281 women [51%]; mean [SD] age, 64.61 [2.9] years; 180 Hispanic [33%], 151 non-Hispanic white [27%], and 183 non-Hispanic black [33%]). At 1-year follow-up, no significant difference in systolic blood pressure reduction was observed between intervention and usual care groups (β = 2.5 mm Hg; 95% CI, -1.9 to 6.9). Although not powered for subgroup analysis, we found that among Hispanic individuals, the intervention arm had a clinically and statically significant 9.9 mm Hg-greater mean systolic blood pressure reduction compared with usual care (95% CI, 1.8-18.0). There were no significant differences between arms among non-Hispanic white (β = 3.3; 95% CI, -4.1 to 10.7) and non-Hispanic black participants (β = -1.6; 95% CI, -10.1 to 6.8).

Conclusions and Relevance

Few behavioral intervention studies in individuals who have had stroke have reported clinically meaningful reductions in blood pressure at 12 months, and fewer have focused on a skills-based approach. Results of secondary analyses suggest that culturally tailored, skills-based strategies may be an important alternative to knowledge-focused approaches in achieving sustained vascular risk reduction and addressing racial/ethnic stroke disparities; however, these findings should be tested in future studies.

Trial Registration

ClinicalTrials.gov identifier: NCT01836354.

Management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center, Southwest Ethiopia: Prospective observational study

Objectives

The number of stroke patients receiving recombinant tissue plasminogen activator (r-tPA) in developing world is extremely low. Pre-hospital delay, financial constraints and lack of infrastructure are the main barriers. Additionally, various medical, neurological and psychological complications are allied to stroke patients after the acute attack. Hence, the study was aimed to identify management protocols and encountered complications among stroke patients admitted to stroke unit of Jimma university medical center (JUMC).

Patients and methods

Prospective observational study was conducted at stroke unit of JUMC from March 10 to July 10, 2017. All eligible consecutive stroke patients of ≥18 years were included. Data was entered to Epi data version 3.1 and analyzed using SPSS version 20.

Results

A total of 116 eligible stroke patients were followed with mean age of 55.14 ± 14.04 years and males comprised of 62.9%. Using world health organization (WHO) criteria, 60 (51.7%) patients had ischemic while 56 (48.3%) had hemorrhagic stroke. During admission, 93 (80.2%) patients had developed at least one complication. The most complication was brain edema (increased intracranial pressure) detected in about one third of the patients (30.2%) followed by urinary incontinence (28.4%) and aspiration pneumonia (19.8%). Almost half of the patients (52.5%) had at least one past medication history. During hospitalization, 111(95.7%) of patients had received at least one medication and the median start time of the medications after hospital arrival was 15 h. The most common medication given for the patients during hospitalization were antiplatelets and statins for 63 (54.3%) patients. During discharge, about 78 (67.2%) patients had received medications and antihypertensives were the prominent medications prescribed for half of the discharged patients.

Conclusion

Both neurologic and medical complications were common in majority of stroke patients. But the management protocol for stroke patients was sub-optimal and lagging behind the recommended guidelines due to lack of skilled personnel, appropriate treatment and diagnostic agents. The clinical team involved in the care of stroke patients should make preparations to take preventive measures that will save a lot of lives.

Hand strengthening exercises in chronic stroke patients: Dose-response evaluation using electromyography

STUDY DESIGN

Cross-sectional.

PURPOSE OF THE STUDY

This study evaluates finger flexion and extension strengthening exercises using elastic resistance in chronic stroke patients.

METHODS

Eighteen stroke patients (mean age: 56.8 ± 7.6 years) with hemiparesis performed 3 consecutive repetitions of finger flexion and extension, using 3 different elastic resistance levels (easy, moderate, and hard). Surface electromyography was recorded from the flexor digitorum superficialis (FDS) and extensor digitorum (ED) muscles and normalized to the maximal electromyography of the non-paretic arm.

RESULTS

Maximal grip strength was 39.2 (standard deviation: 12.5) and 7.8 kg (standard deviation: 9.4) in the nonparetic and paretic hand, respectively. For the paretic hand, muscle activity was higher during finger flexion exercise than during finger extension exercise for both ED (30% [95% confidence interval {CI}: 19-40] vs 15% [95% CI: 5-25] and FDS (37% [95% CI: 27-48] vs 24% [95% CI: 13-35]). For the musculature of both the FDS and ED, no dose-response association was observed for resistance and muscle activity during the flexion exercise (P > .05).

CONCLUSION

The finger flexion exercise showed higher muscle activity in both the flexor and extensor musculature of the forearm than the finger extension exercise. Furthermore, greater resistance did not result in higher muscle activity during the finger flexion exercise. The present results suggest that the finger flexion exercise should be the preferred strengthening exercise to achieve high levels of muscle activity in both flexor and extensor forearm muscles in chronic stroke patients. The finger extension exercise may be performed with emphasis on improving neuromuscular control.

LEVEL OF EVIDENCE

4b.

Emergency department telemedicine consults decrease time to interpret computed tomography of the head in a multi-network cohort

INTRODUCTION

Telemedicine can improve access to emergency stroke care in rural areas, but the benefit of telemedicine across different types and models of telemedicine networks is unknown. The objectives of this study were to (a) identify the impact of telemedicine on emergency department (ED) stroke care, (b) identify if telemedicine impact varied by network and (c) describe the variation in process outcomes by telemedicine across EDs.

METHODS

A prospective cohort study identified stroke patients in four telemedicine networks between November 2015 and December 2017. Primary exposure was telemedicine consultation during ED evaluation. Outcomes included: (a) interpretation of computed tomography (CT) of the head within 45 minutes and (b) time to administer tissue plasminogen activator (tPA). An interaction term tested for differences in telemedicine effect on stroke care by network and hospital.

RESULTS

Of the 932 stroke subjects, 36% received telemedicine consults. For subjects with a last known well time within two hours of ED arrival (27.9%), recommended CT interpretation within 45 minutes was met for 66.8%. Telemedicine was associated with higher odds of timely head CT interpretation (adjusted odds ratio = 3.03; 95% confidence interval (CI) 1.69-5.46). The magnitude of the association between telemedicine and time to interpret a CT of the head differed between telemedicine networks (interaction term p = 0.033). Among eligible patients, telemedicine was associated with faster time to administer tPA (adjusted hazard ratio = 1.81; 95% CI 1.31-2.50).

DISCUSSION

Telemedicine consultation during the ED encounter decreased the time to interpret at CT of the head among stroke patients, with differing magnitudes of benefit across telemedicine networks. The effect of heterogeneity of telestroke affects across different networks should be explored in future analyses.

Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.

Cardiovascular Risk Factor Burden in Veterans and Non-Veterans with Parkinson Disease

BACKGROUND

Medical comorbidities, including cardiovascular risk factors such as hypertension and diabetes, influence disease progression in Parkinson disease (PD) and may be variably present in different clinical populations.

OBJECTIVE/METHODS

We conducted a retrospective nested case-control study of 29 Veterans with PD and 29 non-Veteran PD controls. The groups were matched for age, gender, and disease duration. Both groups underwent clinical and imaging testing as part of their participation in a larger cross-sectional PD observational study at our research center. Veterans were recruited primarily from movement disorders neurology clinics at the Ann Arbor Veterans Affairs (VA) Health System. Non-Veterans were recruited primarily from analogous clinics at the University of Michigan Health System. We explored differences in cardiovascular risks factor burden between the groups.

RESULTS

Veterans with PD showed higher scores on the simplified Framingham 10-year general cardiovascular disease risk calculator (FR score; 27.3% (11.5) vs. 20.7% (6.8); t = -2.66, p = 0.011) and fewer years of self-reported education (14.5 (2.5) vs. 16.7 (2.6); t = 3.33, p = 0.002). After adjusting for age, disease duration, education, and the use of antihypertensive medications, Veterans showed higher FR scores (t = 2.95, p = 0.005) and a higher intra-subject ratio of FR score to age-and-gender normalized FR score (t = 2.49, p = 0.016), representing an elevated component of modifiable cardiovascular risk factor burden.

CONCLUSION

Cardiovascular comorbidities are common in Veterans with PD and may be more severe than in non-Veteran PD populations. These findings merit replication in other representative cohorts. Veterans may be a preferred population for clinical trials evaluating cardiovascular risk factor management on PD progression.

Stroke as a Cause of Death in Death Certificates of Patients with Dementia: A Cohort Study from the Swedish Dementia Registry

Introduction:

Patients with dementia may be at a higher risk for death from stroke. We aimed to describe characteristics of dementia patients that died from ischemic stroke (IS) in Sweden.

Methods:

A retrospective longitudinal analysis of prospectively collected data of patients registered into the Swedish Dementia Registry was conducted. Data on causes of death, drugs and comorbidities were acquired from the Swedish nationwide health registers. Deaths were attributed to stroke if the death certificate contained stroke as a cause of death and the patient had a stroke registered in Riksstroke, the Swedish Stroke Register, in the year preceding death. Demographic data at the time of dementia diagnosis was compared between patients dying from IS and registered in Riksstroke, patients dying from IS without being registered in Riksstroke and those dying from other causes.

Results:

Out of 49823 patients diagnosed with dementia between 2007 and 2014 in primary care or specialist clinics, 14170 (28.4%) had died by the end of 2014. Of these 1180 (8.3%) had IS in their death certificate, of which 459 (38.9%) had been registered in Riksstroke. In patients who died of IS the most common type of dementia was vascular dementia while those died from other causes were most often diagnosed with Alzheimer’s dementia (AD). Patients who died from IS and were registered in Riksstroke had higher MMSE score compared to other groups. Patients who died from IS took more cardiovascular medications. There were no differences in the use of antipsychotics, antidepressants, acetylcholinesterase inhibitors, memantine, anxiolytics, or hypnotics between the groups.

Conclusions:

There was a relatively high number of patients who died from IS as shown in their death certificate but had not been registered in Riksstroke in the year before death. This creates concerns on the accuracy of death certificate stroke diagnoses, particularly for deaths taking place outside hospitals.

Health Equity and Implementation Science in Heart, Lung, Blood, and Sleep-Related Research: Emerging Themes From the 2018 Saunders-Watkins Leadership Workshop

Disparities in health outcomes for heart, lung, blood, and sleep-related health conditions are pervasive in the United States, with an unequal burden experienced among structurally disadvantaged populations. One reason for this disparity is that despite the existence of effective interventions that promote health equity, few have been translated and implemented consistently in the healthcare system. To achieve health equity, there is a dire need to implement and disseminate effective evidence-based interventions that account for the complex and multilayered social determinants of health among marginalized groups across healthcare settings. To that end, the National Heart, Lung, and Blood Institute's Center for Translation Research and Implementation Science invited early stage investigators to participate in the inaugural Saunders-Watkins Leadership Workshop in May of 2018 at the National Institutes of Health. The goals of the workshop were to: (1) present an overview of health equity research, including areas which require ongoing investigation; (2) review how the fields of health equity and implementation science are related; (3) demonstrate how implementation science could be utilized to advance health equity; and (4) foster early stage investigator career success in heart, lung, blood, and sleep-related research. Herein, we highlight key themes from the 2-day workshop and offer recommendations for the future direction of health equity and implementation science research in the context of heart, lung, blood, and sleep-related health conditions.

Effects of Tai Chi on Cerebral Hemodynamics and Health-Related Outcomes in Older Community Adults at Risk of Ischemic Stroke: A Randomized Controlled Trial

This study investigated the effects of Tai Chi compared with no exercise control on the cerebral hemodynamic parameters and other health-related factors in community older adults at risk of ischemic stroke. A total of 170 eligible participants were randomly allocated to Tai Chi or control group. The cerebral hemodynamic parameters and physical fitness risk factors of cardiovascular disease were measured at baseline, 12 weeks, and 24 weeks. After the 12-week intervention, Tai Chi significantly improved the minimum of blood flow velocity (BFVmin); BFVmean; pulsatility index and resistance index of the right anterior cerebral artery; and BFVmax, BFVmin, and BFVmeanparameters of the right middle cerebral artery. Tai Chi training also decreased triglyceride, fasting blood glucose, and homocysteine levels, and improved balance ability. Therefore, the supervised 12-week Tai Chi exercise had potential beneficial effects on cerebral hemodynamics, plasma risk factors, and balance ability in older community adults at risk of ischemic stroke.

12/15 Lipoxygenase as a Therapeutic Target in Brain Disorders

Lipoxygenases are a family of lipid-oxidizing enzymes, which generate eicosanoids and related compounds from arachidonic acid and other polyunsaturated fatty acids. These metabolites play important roles in physiology and pathogenesis of host defense mechanisms, cardiovascular diseases, cancer, inflammatory, allergic and neurodegenerative diseases. The 12/15-lipoxygenase (LOX) is special in that it can directly oxidize lipid membranes containing polyunsaturated fatty acids, without the preceding action of a phospholipase, leading to the direct attack on membranous organelles, such as mitochondria. The cytotoxic activity of human 12/15-LOX is up-regulated in neurons and endothelial cells especially after a stroke and thought to contribute to both neuronal cell death and blood-brain barrier leakage. The discovery of inhibitors that selectively target recombinant 12/15-LOX in vitro, as well as possessing activity against the murine orthologous ex vivo, could potentially support a novel therapeutic strategy for the treatment of stroke and other brain disorders related to 12/15-LOX. Here we reviewed 12/15-LOX chemistry shortly, and the diseases in which 12/15-LOX has a role in their pathophysiology and recent advances of 12/15-LOX inhibitors as a treatment option for neurological diseases.

The post-stroke upper limb improvement effort survey (IMPETUS): a survey of individuals with chronic stroke

BACKGROUND

There is a considerable literature on arm/hand dysfunction post stroke, but little information on the participants' opinions about perceived and desired arm/hand strength, recovery, and function.

OBJECTIVE

The objective of this study was to examine the perceptions of individuals with stroke about arm/hand function and training devices.

METHODS

A 69-item survey was developed addressing: activity before and after stroke, involved arm/hand function, willingness to use a training device, and important device characteristics. The survey included items from the Hand Function and Strength Subscales of the Stroke Impact Scale (SIS). Face validity was established by physical therapists and individuals with stroke. The survey was administered via phone and online.

RESULTS

852 registry participants were recruited. Ninety-seven responded; 83 completed the survey. Subjects were 51 males, 31 females; mean age: 65 (25-95); meantime since stroke: 13 years (1-34; SD 6.678). There was a statistically significant difference between perceived and desired arm/hand strength, recovery, and function p<0.0001. Impairment factors, such as weakness and spasticity were greater barriers to recovery than socio-economic ones. Most participants (94%) were willing to use a device; functional gains during/following use were the most important characteristics.

LIMITATIONS

Participants had greater arm impairment and were more chronic than other studies.

CONCLUSIONS

Participants desired more arm/hand strength, function, and recovery that they perceived they had achieved. Impairment - level factors posed more barriers to arm recovery than socioeconomic ones. Most participants were interested in using arm/hand training devices; the most important device characteristic is functional gain.

Mortality and trends in stroke patients with seizures: A contemporary nationwide analysis

OBJECTIVE

Seizures are frequent among stroke patients. The goal of this study was to provide updated trends in seizures prevalence and mortality among hospitalized stroke patients.

METHODS

Data from the National Inpatient Sample was used to estimate trends in seizures prevalence among stroke patients as well as mortality by seizures status, between 2006 and 2014. We used a logistic regression model to examine the association between seizures and mortality, accounting for extraneous factors.

RESULTS

Overall 372,957 patients (6%) stroke patients had a secondary diagnosis of seizures. We found 29% higher odds of in-hospital death among stroke patients with a secondary diagnosis of seizures. The prevalence of seizures was more than two times higher among patients with hemorrhagic stroke (11.4%) compared to those with ischemic strokes (4.8%). The prevalence of seizures among stroke patients was 6.6% and 6.2% for all strokes, 12.6% and 12% for hemorrhagic strokes, and 5.3% and 5% for ischemic strokes respectively in 2006 and 2014. Although there was a steady decline in both groups, mortality rate among hospitalized stroke patients with seizures was consistently higher than in those without seizures for all strokes, ischemic strokes, and hemorrhagic strokes. Compared to patients with ischemic stroke and seizures, mortality rate was higher among patients with hemorrhagic stroke and seizures.

SIGNIFICANCE

Seizures were present in nearly one out of 15 patients hospitalized for stroke and were more frequent among those with hemorrhagic stroke. There was a decline in mortality among stroke patients during the study period, which remained significantly higher in patients with seizures than in patients without seizures, and in those with hemorrhagic stroke compared to those with ischemic stroke.