Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association

The association between the ring finger protein 213 gene R4810K variant and intracranial major artery stenosis/occlusion in the Han Chinese population and high-resolution magnetic resonance imaging findings

BACKGROUND AND PURPOSE:

The ring finger protein 213 (RNF213) gene R4810K variant, a susceptibility locus for moyamoya disease (MMD), has recently been identified to be associated with intracranial major artery stenosis/occlusion (ICASO) without satisfying the diagnostic criteria of MMD in the Japanese population. However, further studies are needed to determine whether this variant is associated with ICASO in other populations and whether R4810K variant-related ICASO could be categorized as MMD. The aim of this study is to elucidate whether the R4810K variant was associated with ICASO among the Han Chinese population and potential histopathology of R4810K variant-related ICASO.

MATERIALS AND METHODS:

We conducted a case–control study to evaluate association and performed high-resolution (HR) magnetic resonance imaging (MRI) to investigate arterial wall feature of ICASO. The R4810K variant was genotyped in 114 ICASO patients and 268 controls. Then, patients with R4810K variant-related ICASO were subjected to HR MRI examination and presumptively diagnosed based on the characteristics thus observed.

STATISTICAL ANALYSIS:

The relationship between R4810K variant and ICASO was evaluated by Fisher's exact test with odds ratios (OR) and 95% confidence interval (CI).

RESULTS:

The R4810K variant was associated with ICASO and increased the risk for ICASO (P < 0.01; OR: 20.2; 95% CI: 2.5–163.11). Presumptive MMD was diagnosed in all female patients with R4810K variant. However, presumptive intracranial atherosclerotic stenosis was diagnosed in one of three males harboring this variant.

CONCLUSIONS:

The R4810K variant is a genetic risk factor for ICASO among the Han Chinese population and that R4810K variant-related ICASO should be identified as MMD in female but not uncertain in male patients.

Amount and Content of Sensorimotor Therapy Delivered in Three Stroke Rehabilitation Units in Quebec, Canada

Purpose: This study creates a baseline clinical portrait of sensorimotor rehabilitation in three stroke rehabilitation units (SRUs) as a first step in implementing a multi-centre clinical research platform. Method: Participants in this cross-sectional, descriptive study were the patients and rehabilitation teams in these SRUs. Prospective (recording of therapy time and content and a Web-based questionnaire) and retrospective (chart audit) methods were combined to characterize the practice of the rehabilitation professionals. Results: The 24- to 39-bed SRUs admitted 100-240 inpatients in the year audited. The mean combined duration of individual occupational and physical therapy was 6.3-7.5 hours/week/patient. When evening hours and the contributions of other professionals as well as group therapy and self-practice were included, the total amount of therapy was 13.0 (SD 3) hours/patient/week. Chart audit and questionnaire data revealed the Berg Balance Scale was the most often used outcome measure (98%-100%), and other outcome measure use varied. Clinicians favoured task-oriented therapy (35%-100%), and constraint-induced movement therapy (0%-15%), electrical stimulation of the tibialis anterior (0%-15%), and body weight-supported treadmill training (0%-1%) were less often used. Conclusions: This study is the first to provide objective data on therapy time and content of stroke rehabilitation in Quebec SRUs.

Transcatheter Closure of Patent Foramen Ovale versus Medical Therapy after Cryptogenic Stroke: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Patent foramen ovale (PFO) with atrial septal aneurysm is suggested as an important potential source for cryptogenic strokes. Percutaneous PFO closure to reduce the recurrence of stroke compared to medical therapy has been intensely debated. The aim of this study is to assess whether PFO closure in patients with cryptogenic stroke is safe and effective compared with medical therapy.

METHOD

A search of PubMed, Medline, and Cochrane Central Register from January 2000 through September 2017 for randomized controlled trails (RCT), which compared PFO closure to medical therapy in patients with cryptogenic stroke was conducted. We used the items "PFO or patent foramen ovale", "paradoxical embolism", "PFO closure" and "stroke". Data were pooled for the primary outcome measure using the random-effects model as pooled rate ratio (RR). The primary outcome was reduction in recurrent strokes.

RESULT

Among 282 studies, 5 were selected. Our analysis included 3,440 patients (mean age 45 years, 55% men, mean follow-up 2.9 years), 1,829 in the PFO closure group and 1,611 in the medical therapy group. The I2 heterogeneity test was found to be 48%. A random effects model combining the results of the included studies demonstrated a statistically significant risk reduction in risk of recurrent stroke in the PFO closure group when compared with medical therapy (RR 0.42; 95% CI 0.20-0.91, p = 0.03).

CONCLUSION

Pooled data from 5 large RCTs showed that PFO closure in patients with cryptogenic stroke is safe and effective intervention for prevention of stroke recurrence compared with medical therapy.

Risk of Stroke or Death Is Associated With the Timing of Carotid Artery Stenting for Symptomatic Carotid Stenosis: A Secondary Data Analysis of the German Statutory Quality Assurance Database

BACKGROUND

Subgroup analyses from randomized trials indicate that the time interval between the neurologic index event and carotid artery stenting is associated with periprocedural stroke and death rates in patients with symptomatic carotid stenosis. The aim of this article is to analyze whether this observation holds true under routine conditions in Germany.

METHODS AND RESULTS

Secondary data analysis was done on 4717 elective carotid artery stenting procedures that were performed for symptomatic carotid stenosis. The patient cohort was divided into 4 groups according to the time interval between the index event and intervention (group I 0-2, II 3-7, III 8-14, and IV 15-180 days). Primary outcome was any in-hospital stroke or death. For risk-adjusted analyses, a multilevel multivariable regression model was used. The in-hospital stroke or death rate was 3.7% in total and 6.0%, 4.4%, 2.4%, and 3.0% in groups I, II, III, and IV, respectively. Adjusted analysis showed a decreased risk for any stroke or death in group III, a decreased risk for any major stroke or death in groups III and IV, and a decreased risk for any death in groups II and III compared to the reference group I.

CONCLUSIONS

A short time interval between the neurologic index event and carotid artery stenting of up to 7 days is associated with an increased risk for stroke or death under routine conditions in Germany. Although results cannot prove causal relationships, carotid artery stenting may be accompanied by an increased risk of stroke or death during the early period after the index event.

Effect of fluoxetine on three-year recurrence in acute ischemic stroke: A randomized controlled clinical study

OBJECTIVE

To evaluate the effect of fluoxetine on three-year recurrence rate of acute ischemic stroke.

PATIENTS AND METHODS

404 enrolled patients with acute ischemic stroke were randomly divided into control and treatment groups, and underwent conventional secondary preventive therapy for ischemic stroke. In addition, the treatment group was administered fluoxetine (20 mg daily for 90 days). A three-year follow-up was performed, and indicators related to risk factors of stroke were assessed at day 90 of follow-up. The effect of fluoxetine on the three-year recurrence rate of acute ischemic stroke was evaluated by survival analysis, as well as multifactor Cox regression analysis.

RESULTS

The values of systolic blood pressure, blood total cholesterol, blood low density lipoprotein and glycosylated hemoglobin at day 90 of follow-up were significantly lower in treatment group than control group (P = 0.002, P = 0.002, P = 0.018, P = 0.011, respectively). The occurrence rates of epilepsy, gastrointestinal bleeding, syncope, allergic reactions, hemorrhagic infarction, and death were not significantly different between the two groups during the follow-up (P > 0.05). The recurrence-free survival rate of ischemic stroke was significantly lower in the treatment group than control group as assessed by the Kaplan-Meier test (85.1% Vs 75.7%, P = 0.016), as well as the recurrence-free survival rate after day 90 in the three-year follow-up (87.0% Vs 79.3%, P = 0.043). Multifactor Cox regression analysis demonstrated treatment with fluoxetine was an independent factor reducing three-year recurrence in acute ischemic stroke (HR = 0.594, 95% CI: 0.376-0.938).

CONCLUSION

Treatment with fluoxetine for 90 days after acute ischemic stroke significantly reduces the three-year recurrence rate of ischemic stroke.

Long-term trends in antithrombotic drug prescriptions among adults aged 80 years and over from primary care: a temporal trends analysis using electronic health records

PURPOSE

This study aimed to estimate trends in antithrombotic prescriptions from 2001 to 2015 among people aged 80 years and over within clinical indications.

METHODS

A prospective cohort study with 215,559 participants registered with the UK Clinical Practice Research Datalink from 2001 to 2015 was included in the analyses. The prevalence and incidence of antiplatelet and anticoagulant drugs were estimated for each year and by five clinical indications.

RESULTS

The prevalence rate of antithrombotic prescriptions among patients aged over 80 years and diagnosed with atrial fibrillation increased from 53% in 2001 to 77% in 2015 (P_trend <.001). Anticoagulant prescriptions rates also increased five-fold in older adults with atrial fibrillation from around 10% in 2001 to 46% in 2015 (P_trend <.001). Clopidogrel-prescribing rates in patients aged over 80 years and with venous thrombosis increased from 0.4% in 2001 to 10% in 2015 (P_trend <.001). Warfarin-prescribing rates in older patients with venous thrombosis increased from 13% in 2001 to 21% in 2015 (P_trend <.001).

CONCLUSIONS

The use of antithrombotic drugs increased from 2001 to 2015 in people aged 80 years and over across multiple clinical indications. Assessing the benefits and harms of antithrombotic drugs across different clinical indications in older people is a priority.

Feasibility study of a targeted self-management intervention for reducing stroke risk factors in a high-risk population in Uganda

INTRODUCTION

Stroke remains a global concern due to increasing lifespan, patterns of industrialization, adoption of harmful western diets, and an increasing prevalence of risk factors such as hypertension, obesity, and diabetes. We investigated an adopted novel self-management intervention, TargetEd mAnageMent Intervention (TEAM) to reduce modifiable stroke risk factors in Uganda.

METHODS

A six-month, uncontrolled, prospective pilot study to establish feasibility, acceptability and preliminary efficacy of TEAM in Ugandans at high risk for stroke was conducted. The primary outcome was change in systolic BP from baseline to 24-week follow-up. Secondary outcomes included change in diastolic BP, serum cholesterol, high and low density lipoprotein (HDL, LDL) and triglycerides.

RESULTS

Mean (SD) baseline systolic BP was 162.9 (±25.6) mmHg while mean (SD) baseline diastolic BP was 99.1 (±13.8) mmHg. There was a significant reduction in mean baseline blood pressure of 163/98.8mmHg to blood pressure of 147.8/88.0mmHg at 24weeks, P=0.023. There were also significant reductions in the serum total cholesterol levels at 24weeks with P=0.001.

CONCLUSION

Targeted training in self-management (TEAM) adapted to the Ugandan setting is feasible, highly acceptable to participants and appears to be associated with reduced blood pressure, improved lipid profiles and improved glucose control in diabetics.

Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART): study protocol for a randomized controlled trial

Background

There is an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA). Secondary prevention guidelines recommend that antihypertensive, statin and antiplatelet therapy be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular-risk reduction. However, these goals are seldom realized in routine clinical care settings in SSA due to logistical challenges.

We seek to assess whether a polypill containing fixed doses of three antihypertensive agents, a statin and antiplatelet therapy taken once daily per os for 12 months among recent stroke survivors would result in carotid intimal thickness regression compared with usual care (UC).

Methods

The Stroke Minimization through Additive Anti-atherosclerotic Agents in Routine Treatment (SMAART) trial is a phase 2, open-label, evaluator-blinded trial involving 120 Ghanaian recent-ischemic-stroke survivors. Using a computer-generated sequence, patients will be randomly allocated 1:1 into either the intervention arm or UC. Patients in the intervention arm will receive Polycap DS® (containing aspirin, 100 mg; atenolol, 50 mg; ramipril, 5 mg; thiazide, 12.5 mg; simvastatin, 20 mg) taken as two capsules once daily. Patients in the UC will receive separate, individual secondary preventive medications prescribed at the physician’s discretion. Both groups will be followed for 12 months to assess changes in carotid intimal thickness regression – a surrogate marker of atherosclerosis – as primary outcome measure. Secondary outcome measures include adherence to therapy, safety and tolerability, health-related quality of life, patient satisfaction, functional status, depression and cognitive dysfunction.

Discussion

An efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, parallel-group, randomized controlled trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in SSA.

Trial registration

ClinicalTrials.gov, ID: NCT03329599. Registered on 11 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2564-0) contains supplementary material, which is available to authorized users.

Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke.

METHODS

Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs.

RESULTS

In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt.

CONCLUSION

This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.

Assessment of anticoagulation treatments in non-valvular atrial fibrillation patients diagnosed in a basic health area

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia. To assess the need for anticoagulation is essential for its management. Our objective was to investigate whether the indication of anticoagulation was adequate in patients diagnosed with non-valvular AF, given the CHA2-DS2-VASc scale, measuring the International Normalizad Ratio range (INR) in patients treated with anti-vitamin K drugs.

METHODS

This is an observational and cross sectional study. 232 patients with atrial fibrillation were included. We analyzed demographic, the CHA2-DS2-VASc and HAS-BLED variables, the treatment and INR values for 6 consequentive months. The confrontation of variables was performed using chi-square and Mantel-Haenzel test.

RESULTS

The prevalence of AF was 1.05%. The 88.4% had CHA2-DS2-VASc ≥ 2. The 71.1% were taking anticoagulants, of which 58.2% were under antivitamin k. The 46.7% of patients taking antivitamin K, presented inadequate range of INR. There was a greater prescription of antivitamin k in patients with persistent or permanent AF compared to the paroxysmal form (62.8 vs. 37.2% p<.001). The use of drugs that increase bleeding was associated with a worse control of INR after adjustment for the main variables of clinical relevance (odds ratio 2.17 [1.02-4.59], p=.043).

CONCLUSIONS

The level of anticoagulation with antivitamin K was inadequate in our sample, despite a proper follow up and adherence to treatment. Patients with paroxysmal AF received less antivitamin K than those with persistent/permanent AF.

Effect of Non-vitamin K Antagonist Oral Anticoagulants in Atrial Fibrillation Patients with Newly Diagnosed Cancer

BACKGROUND AND OBJECTIVES

There are limited data on the use of non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients with cancer. We aimed to assess the efficacy and safety of NOACs in AF patients with cancer in this study.

METHODS

In 2,568 consecutive non-valvular AF patients with newly diagnosed cancer, we analyzed ischemic stroke/systemic embolism (SE), major bleeding, and all-cause death. Based on propensity score matching, 388 matched pairs were included in the NOAC and warfarin groups.

RESULTS

Patient baseline characteristics were comparable between the matched groups. During median follow-up of 1.8 years, the NOAC group had significantly lower incidences of ischemic stroke/SE (p<0.001), major bleeding (p<0.001), and all-cause death (p<0.001) than the warfarin group. Moreover, the incidence of major bleeding was significantly lower in the NOAC group than in the warfarin group with optimal international normalized ratio control (p=0.03). Especially, within 1 year after cancer diagnosis, the incidences of all clinical events were significantly lower in the NOAC group than in the warfarin group.

CONCLUSIONS

In AF patients with newly diagnosed cancer, NOACs showed lower incidences of ischemic stroke/SE, major bleeding, and all-cause death than warfarin, especially within 1 year after cancer diagnosis.

Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient's caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial

BACKGROUND

Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment, but necessary to prevent recurrence and improve patients' quality of life. To involve a referent nurse and a caregiver from the patient's social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family. The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up, and an interventional program directed to the patient and a caregiving member of their social circle, as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke.

METHODS/DESIGN

The design is a randomized, controlled, clinical trial conducted in the French Stroke Unit of the Strokavenir network. In total, 410 patients will be recruited and randomized in optimized follow up or usual follow up for 2 years. In both group, patients will be seen by a neurologist at 6, 12 and 24 months. The optimized follow up will include follow up by a nurse from the vascular neurology department, including therapeutic follow up, and a training program on secondary prevention directed to the patient and a caregiving member of their social circle. After discharge, a monthly telephone interview, in the first year and every 3 months in the second year, will be performed by the nurse. At 6, 12 and 24 month, the nurse will give the patient and caregiver another training session. Usual follow up is only done by the patient's general practitioner, after classical information on secondary prevention of risk factors during hospitalization. The primary outcome measure is blood pressure measured after the first year of follow up. Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been randomized. Secondary endpoints are associated mortality, morbidity, recurrence, drug side-effects and medico-economic analysis.

DISCUSSION

The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke, personalizing the role of the nurse and including the patient's caregiver.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT 02132364. Registered on 7 May 2014. EUDRACT, A 00473-40.

A Targeted Self-Management Approach for Reducing Stroke Risk Factors in African American Men Who Have Had a Stroke or Transient Ischemic Attack

PURPOSE

This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men.

DESIGN

Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months.

SETTING

Academic health center.

PARTICIPANTS

Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19).

INTERVENTION

Self-management training, delivered in 1 individual and 4 group sessions (over 3 months).

MEASURES

Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants.

ANALYSIS

T tests for paired differences and nonparametric tests. Thematic content qualitative analysis.

RESULTS

Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

Prescription of antihypertensive medication at discharge influences survival following stroke

OBJECTIVE

To investigate the risk of death from cardiovascular disease between patients who were and were not prescribed antihypertensive medication following stroke or TIA.

METHODS

This was a large cohort study using routinely collected prospective data from the Australian Stroke Clinical Registry. Patients registered between 2009 and 2013 who were discharged to the community or rehabilitation were included. Cases were linked to the National Death Index to determine the date and cause of death. Propensity score matching with stratification was utilized to compare between similar subgroups of patients. Multivariable competing risks regression, with noncardiovascular death as a competing risk, was conducted to investigate the association between the prescription of antihypertensive medications and cardiovascular death at 180 days after admission.

RESULTS

Among 12,198 patients from 40 hospitals, 70% were prescribed antihypertensive medications. Patients who were older, were treated in a stroke unit, and had better socioeconomic position were more often discharged from hospital with an antihypertensive medication. Including only patients within propensity score quintiles with acceptable levels of balance in covariates between groups (n = 8,786), prescription of antihypertensive medications was associated with a 23% greater reduction in the subhazard of cardiovascular death compared to those who were not prescribed these agents (subhazard ratio 0.77; 95% confidence interval 0.61 to 0.97).

CONCLUSIONS

People who are prescribed antihypertensive medications at discharge from hospital after a stroke or TIA demonstrate better cardiovascular and all-cause survival outcomes than those not prescribed these agents.

Influence of blood glucose level on the prognosis of patients with diabetes mellitus complicated with ischemic stroke

We carried out this meta-analysis for the aim of exploring the influence of diabetes mellitus (DM) on the prognosis of patients with ischemic stroke. Relevant studies were identified using computerized databases supplemented with manual search strategies. The included studies were strictly followed the inclusion and exclusion criteria. Case-control studies which related to the influence of DM on the prognosis of patients with ischemic stroke were selected. Statistical analyses were implemented with the STATA version 12.0 statistical software. Our current meta-analysis initially retrieved 253 studies (227 in Chinese and 26 in English), 13 studies (6 in English and 7 in Chinese) were eventually incorporated in this meta-analysis. These 13 case-control studies included 8463 patients altogether (3249 patients with DM complicated with ischemic stroke and 5214 patients with ischemic stroke). The results of this meta-analysis manifested that there was a significant difference of the blood glucose level at 48 h after stroke between patients with DM complicated with ischemic stroke and patients with ischemic stroke (standard mean difference [SMD] =1.27, 95% confidence interval [CI] =0.02–2.51, P = 0.047); however, the effectiveness, fatality, and the National Institutes of Health Stroke Scale (NIHSS) score in patients with DM complicated with ischemic stroke, and patients with ischemic stroke had no significant difference (effectiveness: risk ratio [RR] = 0.88, 95% CI = 0.75–1.03, P = 0.121; fatality: RR = 1.29, 95% CI = 0.97–1.71, P = 0.081; NIHSS score: SMD = −0.14, 95% CI = −1.56-1.28, P = 0.849). The current evidence suggests that there is statistical difference of the blood glucose level at 48 h after stroke between patients with DM complicated with ischemic stroke and patients with ischemic stroke, but there is no statistical difference of prognostic indicators between patients in two groups. Thus, our study provides certain clinical value.

Stroke: the critically neglected first year post-stroke

Purpose

Stroke is a leading cause of death and disability in the USA and worldwide. While stroke care has evolved dramatically, many new acute approaches to therapy focus only on the first 3-12 hours. Significant treatment opportunities beyond the first 12 hours can play a major role in improving outcomes for stroke patients. The purpose of this paper is to highlight the issues that affect stroke care delivery for patients and caregivers and describe an integrated care model that can improve care across the continuum.

Design/methodology/approach

This paper details evidence-based research that documents current stroke care and efforts to improve care delivery. Further, an innovative integrated care model is described, and its novel application to stroke care is highlighted.

Findings

Stroke patients and caregivers face fragmented and poorly coordinated care systems as they move through specific stroke nodes of care, from acute emergency and in-hospital stay through recovery post-discharge at a care facility or at home, and can be addressed by applying a comprehensive, technology-enabled Integrated Stroke Practice Unit (ISPU) Model of Care.

Originality/value

This paper documents specific issues that impact stroke care and the utilization of integrated care delivery models to address them. Evidence-based research results document difficulties of current care delivery methods for stroke and the impact of that care delivery on patients and caregivers across each node of care. It offers an innovative ISPU model and highlights specific tenets of that model for readers.

Consumer Wearable Devices for Activity Monitoring Among Individuals After a Stroke: A Prospective Comparison

Background

Activity monitoring is necessary to investigate sedentary behavior after a stroke. Consumer wearable devices are an attractive alternative to research-grade technology, but measurement properties have not been established.

Objective

The purpose of this study was to determine the accuracy of 2 wrist-worn fitness trackers: Fitbit Charge HR (FBT) and Garmin Vivosmart (GAR).

Methods

Adults attending in- or outpatient therapy for stroke (n=37) wore FBT and GAR each on 2 separate days, in addition to an X6 accelerometer and Actigraph chest strap monitor. Step counts and heart rate data were extracted, and the agreement between devices was determined using Pearson or Spearman correlation and paired t or Wilcoxon signed rank tests (one- and two-sided). Subgroup analyses were conducted.

Results

Step counts from FBT and GAR positively correlated with the X6 accelerometer (ρ=.78 and ρ=.65, P<.001, respectively) but were significantly lower (P<.01). For individuals using a rollator, there was no significant correlation between step counts from the X6 accelerometer and either FBT (ρ=.42, P=.12) or GAR (ρ=.30, P=.27). Heart rate from Actigraph, FBT, and GAR demonstrated responsiveness to changes in activity. Both FBT and GAR positively correlated with Actigraph for average heart rate (r=.53 and .75, P<.01, respectively) and time in target zone (ρ=.49 and .74, P<.01, respectively); these measures were not significantly different, but nonequivalence was found.

Conclusions

FBT and GAR had moderate to strong correlation with best available reference measures of walking activity in individuals with subacute stroke. Accuracy appears to be lower among rollator users and varies according to heart rhythm. Consumer wearables may be a viable option for large-scale studies of physical activity.

Efficacy and Safety of Individualized Coaching After Stroke: the LAST Study (Life After Stroke): A Pragmatic Randomized Controlled Trial

BACKGROUND AND PURPOSE

The evidence for interventions to prevent functional decline in the long term after stroke is lacking. The aim of this trial was to evaluate the efficacy and safety of an 18-month follow-up program of individualized regular coaching on physical activity and exercise.

METHODS

This was a multicentre, pragmatic, single-blinded, randomized controlled trial. Adults (age ≥18 years) with first-ever or recurrent stroke, community dwelling, with modified Rankin Scale <5, and no serious comorbidities were included 10 to 16 weeks poststroke. The intervention group received individualized regular coaching on physical activity and exercise every month for 18 consecutive months. The control group received standard care. Primary outcome was the Motor Assessment Scale at end of intervention (18-month follow-up). Secondary measures were Barthel index, modified Rankin Scale, item 14 from Berg Balance Scale, Timed Up and Go test, gait speed, 6-minute walk test, and Stroke Impact Scale. Other outcomes were adverse events and compliance to the intervention assessed by training diaries and the International Physical Activity Questionnaire.

RESULTS

Three hundred and eighty consenting participants were randomly assigned to individualized coaching (n=186) or standard care (n=194). The mean estimated difference on Motor Assessment Scale in favor of control group was -0.70 points (95% confidence interval, -2.80, 1.39), P=0.512. There were no differences between the groups on Barthel index, modified Rankin Scale, or Berg Balance Scale. The frequency of adverse events was low in both groups. Results from International Physical Activity Questionnaire and training diaries showed increased activity levels but low intensity of the exercise in the intervention group.

CONCLUSIONS

The regular individualized coaching did not improve maintenance of motor function or the secondary outcomes compared with standard care. The intervention should be regarded as safe. Despite the neutral results, the health costs related to the intervention should be investigated.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01467206.

Clinical significances and features of prompt brain CT scan after intracranial artery stenting: analysis of 501 cases

Cerebral hemorrhage is a serious complication of intracranial artery stenting that could be fatal without timely identification and treatment. Prompt brain CT scan would help to evaluate whether cerebral hemorrhage occurs, however, the diverse features of the CT scan immediately after stenting could influence the judgement sometimes. Therefore, we analyzed and summarized these features to help to determine the clinical significance of these CT features. The prompt CT features after stenting were classified into three types. Type I indicates that no high-density shadows. Type II indicates that high-density shadows scattered in the infarct areas and/or subarachnoid spaces without mass effect. Type III indicates high-density shadows scattered in and/or out of the infarct areas and/or subarachnoid space with obvious mass effects. Based on this classification, the patients in both Type I and II would continue the double anti-platelet treatment (DAPT) and anti-coagulation treatment, while the later need closer monitoring. However, patients in Type III must immediately withdraw the DAPT and anti-coagulation treatment with close monitoring and surgical intervention was needed when necessary. Nineteen (3.79%) patients were classified into Type III, and 5 (1.00%) of the 19 were accepted surgical intervention. Two of these patients died (0.40%). The prompt CT scan timely distinguishing the cerebral hemorrhage was necessary after intracranial artery stent angioplasty. Additionally, based on the different prompt CT features to take different therapeutic strategies after stenting would achieve better outcomes for ischemic stroke or transient ischemic stroke (TIA) patients underwent intracranial artery endovascular therapy.

Comparative Analysis on Low- and Standard-Dose Regimes of Alteplase Thrombolytic Therapy for Acute Ischemic Stroke: Efficacy and Safety

Objective: This study analyzed the efficacy and safety of low-dose and standard-dose alteplase intravenous thrombolytic therapy for acute ischemic stroke (AIS). Methods: Patients with AIS who underwent intravenous alteplase thrombolysis from July 2012 to December 2016 were retrospectively analyzed and correspondingly divided into low-dose (0.6–0.89 mg/kg) group and standard-dose group (0.9 mg/kg) according to alteplase dosage. The clinical outcome was evaluated by modified Rankin Scale (mRS) at 90 days after onset. The safety index was the mortality at 90 days after onset and the incidence of symptomatic intracranial hemorrhage (SICH) within 7 days. Results: A total of 1,486 patients were included (1,115 cases in low-dose group and 371 cases in standard-dose group). There were no significant differences in baseline data between the 2 groups. As mRS, good outcome rate as well as mortality rate in both groups had no significant difference (36.1 vs. 37.6%; χ2 = 10.882, p = 0.890; 5.5 vs. 7.3%; χ2 = 2.163, p = 0.076), but the incidence of SICH in low-dose group was significantly lower than that of the standard-dose group (2.2 vs. 5.9%; χ2 = 3.157, p = 0.001). Conclusion: The efficacy of low-dose alteplase intravenous thrombolytic therapy for AIS was equivalent to the standard-dose regimen but with higher safety.

Adhering to the principles of clinical pharmacology - the correct fixed combinations of antihypertensive drugs

INTRODUCTION

Hypertension is one of the primary modifiable risk factor for cardiac and renal diseases with the prevalence around 30-45% of the general population, with a steep increase with ageing. The administration of blood pressure-lowering drugs is to reduce the risk of major clinical cardiovascular outcomes. Hypertension guidelines recommend combination therapy in patients with high cardiovascular risk and with subclinical organ damage as well as when monotherapy fails. Areas covered: As the etiology of essential hypertension is multifactorial, combination therapy using different classes of antihypertensive agents have greater effect than each on its own (synergistic effect), may have better tolerability (two components minimizing each other's side effects) and lead to improved patient compliance. Several studies assess the hypotensive efficacy on drug combination; there are also studies on triple drug combination. Expert commentary: At present, dual and triple combination therapy is available to hypertensive patients with good clinical outcomes, compliance and low profile of side effects. It is critical as patients' adherence to the pharmacological therapy significantly decreases the risk of long-term adverse events including mortality. It appears that combinations not only of hypotensive drugs but also with statins (as well as antidiabetics) will be widely used.

Pivotal neuroinflammatory and therapeutic role of high mobility group box 1 in ischemic stroke

Stroke is a major cause of mortality and disability worldwide. Stroke is a frequent and severe neurovascular disorder. The main cause of stroke is atherosclerosis, and the most common risk factor for atherosclerosis is hypertension. Therefore, prevention and treatment of stroke are crucial issues in humans. High mobility group box 1 (HMGB1) is non-histone nuclear protein that is currently one of the crucial proinflammatory alarmins in ischemic stroke (IS). It is instantly released from necrotic cells in the ischemic core and activates an early inflammatory response. HMGB1 may signal via its putative receptors, such as receptor for advanced glycation end products (RAGE), toll-like receptors (TLRs) as well as matrix metalloproteinase (MMP) enzymes during IS. These receptors are expressed in brain cells. Additionally, brain-released HMGB1 can be redox modified in the circulation and activate peripheral immune cells. The role of HMGB1 may be more complex. HMGB1 possesses beneficial actions, such as endothelial activation, enhancement of neurite outgrowth, and neuronal survival. HMGB1 may also provide a novel link for brain-immune communication leading to post-stroke immunomodulation. Therefore, HMGB1 is new promising therapeutic intervention aimed at promoting neurovascular repair and remodeling after stroke. In this review, we look at the mechanisms of secretion of HMGB1, the role of receptors, MMP enzymes, hypoglycemia, atherosclerosis, edema, angiogenesis as well as neuroimmunological reactions and post-ischemic brain recovery in IS. We also outline therapeutic roles of HMGB1 in IS.

Impact of clopidogrel and potent P2Y12-inhibitors on mortality and stroke in patients with acute coronary syndrome or undergoing percutaneous coronary intervention

Administration of a P2Y12-receptor antagonist in addition to aspirin is mandatory in patients with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI) to reduce the occurrence of thrombotic events; however, their impact on mortality and stroke is unclear. We aimed to evaluate the influence of moderate (clopidogrel) or potent (prasugrel/ticagrelor) P2Y12-receptor inhibition on major cardiovascular outcomes among patients with ACS or undergoing PCI. Systematic literature search was performed to find randomised, controlled clinical trials comparing the clinical impact of clopidogrel with placebo or prasugrel/ticagrelor versus clopidogrel. Outcome measures included cardiovascular death, myocardial infarction (MI), total stroke and intracranial haemorrhage (ICH). Random-effects model with Mantel-Heanszel weighting was used to pool outcomes into a meta-analysis. Four studies comparing clopidogrel with placebo and five trials comparing clopidogrel with new P2Y12-receptor inhibitors were identified including a total of 107,473 patients. Compared to placebo, clopidogrel reduced the risk of cardiovascular death (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.87–0.99, p=0.02), MI (OR 0.80; 95%CI 0.74–0.88, p<0.00001) and stroke (OR 0.84; 95%CI 0.72–0.97, p=0.02), without influencing risk for ICH (OR 0.96;& 95%CI 0.69–1.33, p=0.79). Treatment with prasugrel/ticagrelor provided additional benefit over clopidogrel regarding cardiovascular mortality (OR 0.86; 95%CI 0.78–0.94, p=0.002) and MI (OR: 0.83; 95%CI 0.74–0.93, p<0.001), but no advantage in stroke (OR: 1.06; 95%CI 0.88–1.26, p=0.55) and in ICH (OR: 1.16; 95%CI 0.75–1.81; p=0.49) was observed. Increased potency of P2Y12-receptor inhibition is associated with decreased risk in cardiovascular death and MI; however, this association is not true in case of stroke, where potent P2Y12-receptor antagonists have no incremental benefit over clopidogrel.

Prescription of secondary preventive drugs after ischemic stroke: results from the Malaysian National Stroke Registry

BACKGROUND

Evaluation of secondary stroke prevention in low and middle-income countries remains limited. This study assessed the prescription of secondary preventive drugs among ischemic stroke patients upon hospital discharge in Malaysia and identified factors related to the prescribing decisions.

METHODS

From Malaysian National Stroke Registry, we included patients with non-fatal ischemic stroke. Prescriptions of antiplatelet, anticoagulants, antihypertensive drugs and lipid-lowering drugs were assessed. Multi-level logistic regressions were performed to determine the relation between potential factors and drug prescriptions.

RESULTS

Of 5292 patients, 48% received antihypertensive drugs, 88.9% antiplatelet and 88.7% lipid-lowering drugs upon discharge. Thirty-three percent of patients with an indication for anticoagulants (n = 391) received it. Compared to patients <=50 years, patients above 70 years were less likely to receive antiplatelet (OR: 0.72, 95% CI: 0.50-1.03), lipid-lowering drugs (OR: 0.66, 95% CI: 0.45-0.95) and anticoagulants (OR: 0.27, 95% CI: 0.09-0.83). Patients with moderate to severe disability upon discharge had less odds of receiving secondary preventive drugs; an odds ratio of 0.57 (95% CI: 0.45-0.71) for antiplatelet, 0.86 (95% CI: 0.75-0.98) for antihypertensive drugs and 0.78 (95% CI: 0.63-0.97) for lipid-lowering drugs in comparison to those with minor disability. Having prior specific comorbidities and drug prescriptions significantly increased the odds of receiving these drugs. No differences were found between sexes and ethnicities.

CONCLUSIONS

Prescription of antihypertensive drugs and anticoagulants among ischemic stroke patients in Malaysia were suboptimal. Efforts to initiate regular clinical audits to evaluate the uptake and effectiveness of secondary preventive strategies are timely in low and middle-income settings.

A Systematic Review and Meta-Analysis on Self-Management for Improving Risk Factor Control in Stroke Patients

PURPOSE

The aims of this review were to describe the self-management interventions used to improve risk factor control in stroke patients and quantitatively assess their effects on the following: 1) overall risk factor control from lifestyle behaviour (i.e. physical activity, diet and nutrition, stress management, smoking, alcohol, and medication adherence), and medical risk factors (i.e. blood pressure, cholesterol, blood glucose) and (2) individual risk factors.

METHOD

We systematically searched the PubMed, PsycINFO, CINAHL and Cochrane Database of Systematic Reviews databases to September 2015 to identify relevant randomized controlled trials investigating self-management to improve stroke risk factors. The self-management interventions were qualitatively described, and the data included in meta-analyses.

RESULTS

Fourteen studies were included for review. The model estimating an effect averaged across all stroke risk factors was not significant, but became significant when four low-quality studies were removed (SMD = 0.10 [95 % CI = 0.02 to 0.17], I ² = 0 %, p = 0.01). Subgroup analyses revealed a significant effect of self-management interventions on lifestyle behaviour risk factors (SMD = 0.15 [95 % CI = 0.04 to 0.25], I ² = 0 %, p = 0.007) but not medical risk factors. Medication adherence was the only individual risk factor that self-management interventions significantly improved (SMD = 0.31 [95 % CI = 0.07 to 0.56], I ² = 0 %, p = 0.01).

CONCLUSION

Self-management interventions appear to be effective at improving overall risk factor control; however, more high-quality research is needed to corroborate this observation. Self-management has a greater effect on lifestyle behaviour risk factors than medical risk factors, with the largest effect at improving medication adherence.

Independent Modular Filter for Embolic Protection in Carotid Stenting

BACKGROUND

Embolic protection during carotid artery stenting reduces the rate of thromboembolic events. The Wirion Embolic Protection System is used to deploy an independent distal filter using any 0.014″ guidewire. WISE study (Wirion Study Europe) evaluated the safety and performance of Wirion Embolic Protection System in patients undergoing carotid artery stenting.

METHODS AND RESULTS

A prospective, multicenter, nonrandomized, open-label, single-arm study of carotid artery stenting in high surgical risk patients was performed. The primary end point, a composite of death, stroke, and myocardial infarction at 30 days, was compared with performance goal derived from historical controls. Secondary end points were components of the primary end point and the device, angiographic, procedural, and clinical success rates. Preplanned interim analysis was performed on the first 120 patients. At interim analysis, the primary end point was significantly lower for the Wirion Embolic Protection System group, compared with historical data (3.3% versus 6.3%, respectively; P value =0.0008). Analysis of primary end point components in the WISE group, compared with the historical control group, shows numerically lower mortality (0% versus 1.7%, respectively; P=0.21), stroke (2.5% versus 4.6%, respectively; P=0.18), and myocardial infarction (0.8% versus 1.5%, respectively; P=0.50). Device, angiographic, procedural, and clinical success was achieved in 99.2%, 99.1%, 98.3%, and 96.6% of cases, respectively.

CONCLUSIONS

The data suggest that independent modular filter use in carotid artery stenting in high surgical risk patients is safe and effective. The outcomes suggest that use of an independent modular filter may be associated with a lower rate of embolic complications associated with carotid stent placement.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01783639.

Community Perceptions of Barriers to Stroke Recovery and Prevention in Greater Kampala, Uganda: Implications for Policy and Practice

OBJECTIVE

Stroke risk and stroke burden are increasing in Sub Saharan Africa. Qualitative analysis was used to assess perceived barriers to stroke recovery and prevention in an urban/suburban Ugandan population in order to refine and implement a promising nurse and peer-led self-management intervention previously conducted in the United States.

METHODS

In depth interviews and focus groups were conducted with 48 participants (stroke survivors, caretakers, and those at risk for stroke. All interviews and focus groups were audiotaped, transcribed verbatim, and analyzed using content analysis, with an emphasis on dominant themes.

RESULTS

Three major domains of perceived barriers to stroke recovery and prevention emerged from the data: (1) Individual barriers (PTSD, stress, resistance to seeking care, medication non-adherence, unhealthy lifestyles, functional impairment, and a paucity of stroke knowledge); (2) Family/community barriers (lack of family and community support and caretaker burden); and (3) Provider and healthcare system barriers (lack of access and inadequate follow-up). Importantly, participants in this study identified a pressing need for increasing stroke awareness in the community as part of recovery and prevention efforts.

CONCLUSIONS

Stroke risk reduction efforts implemented at the patient, community, and healthcare system levels are needed. These efforts could, perhaps, be modeled along the lines of a previous very successful public health initiative to reduce HIV burden in Uganda.

Stroke-Related Disease Comorbidity and Secondary Stroke Prevention Practices Among Young Stroke Survivors

BACKGROUND

Although ischemic stroke incidence has been in decline over the past 60 years, the same has not been observed among individuals younger than 55 years. Recent reports have shown a substantial increase in young stroke incidence, yet little is known about young stroke survivors.

OBJECTIVE

The aim of this study was to examine the disease comorbidity profile and secondary prevention practices in stroke survivors younger than 50 years.

METHODS

This study used a retrospective data analysis of secondary stroke prevention practices among young stroke survivors using data from the 2015 National Health Interview Survey.

RESULTS

Approximately 57% of the sample reported having hypertension; 33%, high cholesterol; 13%, diabetes; and 7%, heart disease. In the past 12 months, more than 60% had seen a general doctor, neurologist, or specialist, and more than 75% were following low-dose aspirin advice or taking prescribed medications for blood pressure or cholesterol. Similarly, 84% had their blood pressure checked, and 66% had their cholesterol checked, but only 50% had a fasting test for their blood sugar in the past 12 months.

CONCLUSIONS

Many young stroke survivors exhibit comorbid disease conditions that are similar to older stroke survivors. A large percentage are engaged in general chronic disease and secondary stroke prevention practices, yet less than two-thirds had seen a general doctor in the past 12 months. Primary care doctors and other health professionals are critical to the implementation of disease management strategies that consider their age, secondary stroke risk, expected life spans, and other issues that differ from older adult stroke survivors.

Is Metabolic Syndrome Associated with the Risk of Recurrent Stroke: A Meta-Analysis of Cohort Studies

BACKGROUND

The association between metabolic syndrome (MetS) and recurrence of stroke remains unknown. We summarized the evidence by a meta-analysis of prospective cohort studies.

METHODS

We searched the PubMed, EMBASE, and Google Scholar databases from their inception until July 2016 for cohort studies investigating this research question; relevant information was extracted by 2 independent investigators, and then aggregated using the random-effects meta-analysis approach.

RESULTS

We identified 5 studies, including 7752 stroke patients who had a history of stroke or transient ischemic attack. Compared with persons without MetS, persons with MetS have a significantly higher risk of recurrent stroke, and the pooled relative risk (RR) was 1.52 (95% confidence interval (CI): 1.17-1.97). The strength of this association is greater than individual MetS components such as elevated blood pressure (RR = 1.05, 95% CI: .72-1.52), elevated triglycerides (RR = 1.04, 95% CI: .84-1.29), low high-density lipoprotein cholesterol (RR = 1.16, 95% CI: .91-1.48), or obesity (RR = 1.12, 95% CI: .89-1.41). The risk of recurrent stroke was highest in the group with elevated glycemia (RR = 1.70, 95% CI: 1.12-2.56).

CONCLUSIONS

This meta-analysis suggests that MetS might be an important predictor of recurrent stroke. Among the 5 components of MetS, elevated glycemia was a stronger predictor for recurrent stroke.

Exercise and Older Adults

Regular exercise is essential for healthy aging and offers many health benefits, including reduced risk of all-cause mortality, chronic disease, and premature death. Because physical inactivity is prevalent, greater focus is needed on integrating exercise into care plans and counseling, and developing partnerships that support exercise opportunities. Older adults should be as physically active as their abilities and conditions allow. For substantial health benefits, older adults need to do aerobic, muscle-strengthening, and stretching exercises weekly, and balance activities as needed. Appropriate planning must take account of factors such as prescribed medications, nutrition, injuries, hip and knee arthroplasties, and chronic conditions.

Acupuncture lowering blood pressure for secondary prevention of stroke: a study protocol for a multicenter randomized controlled trial

Background

Stroke is the prime cause of morbidity and mortality in the general population, and hypertension will increase the recurrence and mortality of stroke. We report a protocol of a pragmatic randomized controlled trial (RCT) using blood pressure (BP)-lowering acupuncture add-on treatment to treat patients with hypertension and stroke.

Methods

This is a large-scale, multicenter, subject-, assessor- and analyst-blinded, pragmatic RCT. A total of 480 patients with hypertension and ischemic stroke will be randomly assigned to two groups: an experimental group and a control group. The experimental group will receive “HuoXueSanFeng” acupuncture combined with one antihypertensive medication in addition to routine ischemic stroke treatment. The control group will only receive one antihypertensive medication and basic treatments for ischemic stroke. HuoXueSanFeng acupuncture will be given for six sessions weekly for the first 6 weeks and three times weekly for the next 6 weeks. A 9-month follow-up will, thereafter, be conducted. Antihypertensive medication will be adjusted based on BP levels. The primary outcome will be the recurrence of stroke. The secondary outcomes including 24-h ambulatory BP, the TCM syndrome score, the Short Form 36-item Health Survey (SF-36), the National Institute of Health Stroke Scale (NIHSS), as well as the Barthel Index (BI) scale will be assessed at baseline, 6 weeks and 12 weeks post initiating treatments; cardiac ultrasound, carotid artery ultrasound, transcranial Doppler, and lower extremity ultrasound will be evaluated at baseline and 12 weeks after treatment. The safety of acupuncture will also be assessed.

Discussion

We aim to determine the clinical effects of controlling BP for secondary prevention of stroke with acupuncture add-on treatment.

Trial registration

ClinicalTrials.gov, ID: NCT02967484. Registered on 13 February 2017; last updated on 27 June 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2171-5) contains supplementary material, which is available to authorized users.

Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke

BACKGROUND

The efficacy of closure of a patent foramen ovale (PFO) in the prevention of recurrent stroke after cryptogenic stroke is uncertain. We investigated the effect of PFO closure combined with antiplatelet therapy versus antiplatelet therapy alone on the risks of recurrent stroke and new brain infarctions.

METHODS

In this multinational trial involving patients with a PFO who had had a cryptogenic stroke, we randomly assigned patients, in a 2:1 ratio, to undergo PFO closure plus antiplatelet therapy (PFO closure group) or to receive antiplatelet therapy alone (antiplatelet-only group). Imaging of the brain was performed at the baseline screening and at 24 months. The coprimary end points were freedom from clinical evidence of ischemic stroke (reported here as the percentage of patients who had a recurrence of stroke) through at least 24 months after randomization and the 24-month incidence of new brain infarction, which was a composite of clinical ischemic stroke or silent brain infarction detected on imaging.

RESULTS

We enrolled 664 patients (mean age, 45.2 years), of whom 81% had moderate or large interatrial shunts. During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 95% confidence interval [CI], 0.09 to 0.62; P=0.002). The incidence of new brain infarctions was significantly lower in the PFO closure group than in the antiplatelet-only group (22 patients [5.7%] vs. 20 patients [11.3%]; relative risk, 0.51; 95% CI, 0.29 to 0.91; P=0.04), but the incidence of silent brain infarction did not differ significantly between the study groups (P=0.97). Serious adverse events occurred in 23.1% of the patients in the PFO closure group and in 27.8% of the patients in the antiplatelet-only group (P=0.22). Serious device-related adverse events occurred in 6 patients (1.4%) in the PFO closure group, and atrial fibrillation occurred in 29 patients (6.6%) after PFO closure.

CONCLUSIONS

Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation. (Funded by W.L. Gore and Associates; Gore REDUCE ClinicalTrials.gov number, NCT00738894 .).

Efficacy and safety of a generic rosuvastatin in a real-world setting: prospective, observational clinical study in Lebanese patients

BACKGROUND

No published studies have assessed the efficacy and safety of rosuvastatin generics.

OBJECTIVES

Primary objective to assess the safety and efficacy of a generic rosuvastatin in reducing plasma low-density-lipoprotein cholesterol (LDL-C) in Lebanese dyslipidemic patients. Changes in high-density lipoprotein cholesterol, triglycerides and adverse effects were secondary objectives.

DESIGN

Prospective, observational, non-comparative.

SETTING

Multiple outpatient clinics in Lebanon.

PATIENTS AND METHODS

Dyslipidemic patients requiring statin therapy were followed for 2 months after prescription of a generic rosuvastatin at the physician's discretion. Efficacy and safety measurements were collected from medical records.

MAIN OUTCOME MEASURES

Efficacy was assessed based on the evaluation of mean and percent change in LDL-C between baseline and week 8 as well as the proportion of patients reaching target LDL-C levels. Safety was assessed based on the evaluation of the incidence of adverse events (AEs) during the study period.

RESULTS

Two months after initiation of generic rosuvastatin, LDL-C levels in the 313 eligible patients who completed the study significantly decreased from 4.3 (0.8) mmol/L (168.2 [31.3] mg/dL) at baseline to 2.7 (0.7) mmol/L (105.9 [25.5] mg/dL) (P < .001). The mean percent change in LDL-C level was highest in subjects receiving generic rosuvastatin at a dose of 40 mg/day (-47.4%), followed by 20 mg/day (-36.8%), and 10 mg/ day (-31.4%); 82.5% of patients reached the target LDL-C level as set by their physician at baseline. Thirteen patients (4%) reported six AEs during treatment: abdominal pain, headache, stomach ache, insomnia, musculoskeletal pain/myalgia and nausea. No clinically significant changes in serum creatinine, serum creatine kinase, or liver function tests were reported. One patient withdrew because of an adverse event.

CONCLUSIONS

Generic rosuvastatin was efficacious and safe in reducing LDL-C levels and helping the majority of patients achieve LDL-C targets after a short treatment period.

LIMITATIONS

The observational nature, and a control group, and the relatively short duration of follow-up limit the generalizability of results. The authors received fees for study activities at patient visits from an independent clinical research organization subcontracted by the sponsor.

Toll-like Receptor 2: A Novel Therapeutic Target for Ischemic White Matter Injury and Oligodendrocyte Death

Despite paramount clinical significance of white matter stroke, there is a paucity of researches on the pathomechanism of ischemic white matter damage and accompanying oligodendrocyte (OL) death. Therefore, a large gap exists between clinical needs and laboratory researches in this disease entity. Recent works have started to elucidate cellular and molecular basis of white matter injury under ischemic stress. In this paper, we briefly introduce white matter stroke from a clinical point of view and review pathophysiology of ischemic white matter injury characterized by OL death and demyelination. We present a series of evidence that Toll-like receptor 2 (TLR2), one of the membranous pattern recognition receptors, plays a cell-autonomous protective role in ischemic OL death and ensuing demyelination. Moreover, we also discuss our recent findings that its endogenous ligand, high-mobility group box 1 (HMGB1), is released from dying OLs and exerts autocrine trophic effects on OLs and myelin sheath under ischemic condition. We propose that modulation of TLR2 and its endogenous ligand HMGB1 can be a novel therapeutic target for ischemic white matter disease.

Uncertain Associations of Major Bleeding and Concurrent Use of Antiplatelet Agents and Chinese Medications: A Nested Case-Crossover Study

Despite the evidence that some commonly used Chinese medications (CMs) have antiplatelet/anticoagulant effects, many patients still used antiplatelets combined with CMs. We conducted a nested case-crossover study to examine the associations between the concomitant use of antiplatelets and CMs and major bleeding using population-based health database in Taiwan. Among the cohort of 79,463 outpatients prescribed antiplatelets (e.g., aspirin and clopidogrel) continuously, 1,209 patients hospitalized with new occurring bleeding in 2012 and 2013 were included. Those recruited patients served as their own controls to compare different times of exposure to prespecified CMs (e.g., Asian ginseng and dong quai) and antiplatelet agents. The periods of case, control 1, and control 2 were defined as 1–4 weeks, 6–9 weeks, and 13–16 weeks before hospitalization, respectively. Conditional logistic regression analyses found that concurrent use of antiplatelet drugs with any of the prespecified CMs in the case period might not significantly increase the risks of bleeding over that in the control periods (OR = 1.00, 95% CI 0.51 to 1.95 and OR = 1.13, 95% CI 0.65 to 1.97). The study showed no strong relationships between hospitalization for major bleeding events and concurrent use of antiplatelet drugs with the prespecified CMs.

Effects With and Without Clopidogrel Loading Treatment for Acute Ischemic Cerebrovascular Disease Patients: A Retrospective Cohort Study

OBJECTIVES

We investigated the effectiveness of clopidogrel loading (CL) treatment compared with usual clopidogrel non-loading (NL) treatment for acute ischemic cerebrovascular disease.

METHODS

We screened consecutive 1072 patients with ischemic cerebrovascular disease within 48 hours of symptom onset admitted to our hospital. Eligible patients were divided into the CL group (300 mg on day 1, followed by 50-75 mg once daily) and NL group (50-75 mg once daily). The incidence proportion of neurologic deterioration during hospitalization was compared between the 2 groups using logistic regression analysis.

RESULTS

A total of 224 patients, 39 in CL group and 185 in NL group, were enrolled. The frequency of neurologic deterioration did not significantly differ between the 2 groups (risk ratio [95% confidence interval]: 1.47 [.88-2.46]). On the preset subgroup analysis according to stroke subtype, the frequency of neurologic deterioration in CL group was significantly higher in branch atheromatous disease (risk ratio: 2.44 [1.67-3.55]) and was not different statistically in transient ischemic attack (risk ratio: 0). The analysis adjusted by several confounders showed that the incidence proportion of neurologic deterioration was not significantly different in large artery atherosclerosis (adjusted odds ratio: 1.06 [.23-4.84]) as crude analysis. The incidence proportion of adverse events was not significantly different between the 2 groups.

CONCLUSIONS

The effect of CL therapy differed by stroke subtypes in preventing neurologic deterioration. CL therapy appeared to be ineffective in branch atheromatous disease. Therefore, the choice of CL therapy should carefully be made according to stroke subtypes.