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Xie Y, Liu S, Wang X, Huang H, Wang M, Qu W, Yu Z, Wang W, Luo X. Lipids, Apolipoproteins, Lipid-Lowering Drugs, and the Risk of Cerebral Small Vessel Disease: A Mendelian Randomization Study. J Am Heart Assoc 2024; 13:e032409. [PMID: 39158561 DOI: 10.1161/jaha.123.032409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 07/16/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Serum lipids are causally involved in the occurrence of atherosclerosis, but their roles in cerebral small vessel disease remain unclear. This study aimed to investigate the causal roles of lipid or apolipoprotein traits in cerebral small vessel disease and to determine the effects of lipid-lowering interventions on this disease. METHODS AND RESULTS Data on genetic instruments of lipids/apolipoproteins, as well as characteristic cerebral small vessel disease manifestations, including small vessel stroke (SVS) and white matter hyperintensity (WMH), were obtained from publicly genome-wide association studies. Through 2-sample Mendelian randomization analyses, it was found that decreased levels of high-density lipoprotein cholesterol (odds ratio [OR], 0.85, P=0.007) and apolipoprotein A-I (OR, 0.83, P=0.005), as well as increased level of triglycerides (OR, 1.16, P=0.025) were associated with a higher risk of SVS. A low level of high-density lipoprotein cholesterol (OR, 0.93, P=0.032) was associated with larger WMH volume. Specifically, the genetically determined expressions of lipid fractions in various size-defined lipoprotein particles were more closely related to the risk of SVS than WMH. Moreover, it was found that the hypertension trait ranked at the top in mediating the causal effect of hyperlipidemia on SVS and WMH by using Mendelian randomization-based mediation analysis. For drug-target Mendelian randomization, the low-density lipoprotein cholesterol-reducing genetic variation alleles at HMGCR and NL1CL1 genes and the high-density lipoprotein cholesterol-raising genetic variation alleles at the CETP gene were predicted to decrease the risk of SVS. CONCLUSIONS The present Mendelian randomization study indicates that genetically determined hyperlipidemia is closely associated with a higher risk of cerebral small vessel disease, especially SVS. Lipid-lowering drugs could be potentially considered for the therapies and preventions of SVS rather than WMH.
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Affiliation(s)
- Yi Xie
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Shuai Liu
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College Huazhong University of Science and Technology Wuhan China
| | - Xinyue Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Hao Huang
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Minghuan Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Wensheng Qu
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Zhiyuan Yu
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
- Key Laboratory of Neurological Diseases of the Chinese Ministry of Education, School of Basic Medicine, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Hubei Key Laboratory of Neural Injury and Functional Reconstruction Huazhong University of Science and Technology Wuhan China
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Wang X, Zheng J, Chen Y, You C, Ma L. Low-density Lipoprotein Cholesterol Reduction Therapies for Secondary Prevention in Patients with Stroke: A Network Meta-analysis. Curr Neuropharmacol 2023; 22:CN-EPUB-135397. [PMID: 37881090 PMCID: PMC11333788 DOI: 10.2174/1570159x22666231020093035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/14/2023] [Accepted: 05/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Patients with previous strokes are at a higher risk of stroke recurrence. Current guidelines recommend a range of low-density lipoprotein cholesterol (LDL-C)-lowering treatments to reduce the risk of recurrent stroke. However, the optimal agent for decreasing LDL-C to lower the risk of recurrent stroke remains unclear. This study aimed to assess the relative effects of various LDL-C -lowering agents for secondary stroke prevention. METHODS Several databases were searched from inception up to 2022. Only randomized controlled trials that compared different LDL-C-lowering agents in adult patients with previous strokes were included. The primary endpoint was a recurrent stroke. The surface under the cumulative ranking curve (SUCRA) was also applied to estimate the overall ranking probability of the treatment agents for each outcome. RESULTS Overall, nine trials comprising 17,226 patients were included. Ezetimibe plus statins (RR: 0.56, 95% CrI: 0.35-0.87) and statins alone (RR: 0.90, 95% CrI: 0.81-1.00) reduced the risk of stroke recurrence. Ezetimibe plus statins was superior to statins alone in decreasing the incidence of recurrent stroke (RR: 0.62, 95% CrI: 0.39-0.95). However, treatment with statins was related to an increased risk of hemorrhagic stroke compared to placebo (RR: 1.57, 95% CrI: 1.13-2.21). All agents were related to a decreased incidence of major adverse cardiovascular events. CONCLUSION Treatment with ezetimibe plus statins was suggested as the most efficacious in decreasing the incidence of recurrent stroke. The analysis also revealed that statin monotherapy was related to an increased risk of hemorrhagic stroke.
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Affiliation(s)
- Xing Wang
- West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Jun Zheng
- West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Yuqi Chen
- West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Chao You
- West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
- West China Brain Research Centre, Sichuan University, Chengdu, Sichuan 610041, PR China
| | - Lu Ma
- West China Hospital, Sichuan University, Chengdu, Sichuan 610041, PR China
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Dugré N. Lipid-lowering therapies for cardiovascular disease prevention and management in primary care: PEER umbrella systematic review of systematic reviews. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:701-711. [PMID: 37833094 PMCID: PMC10575662 DOI: 10.46747/cfp.6910701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
OBJECTIVE To assess the benefits and harms of lipid-lowering therapies used to prevent or manage cardiovascular disease including bile acid sequestrants (BAS), ezetimibe, fibrates, niacin, omega-3 supplements, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, and statins. DATA SOURCES MEDLINE, the Cochrane Database of Systematic Reviews, and a grey literature search. STUDY SELECTION Systematic reviews of randomized controlled trials published between January 2017 and March 2022 looking at statins, ezetimibe, PCSK9 inhibitors, fibrates, BAS, niacin, and omega-3 supplements for preventing cardiovascular outcomes were selected. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, and adverse events. SYNTHESIS A total of 76 systematic reviews were included. Four randomized controlled trials were also included for BAS because no efficacy systematic review was identified. Statins significantly reduced MACE (6 systematic reviews; median risk ratio [RR]=0.74; interquartile range [IQR]=0.71 to 0.76), cardiovascular mortality (7 systematic reviews; median RR=0.85, IQR=0.83 to 0.86), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.88 to 0.92). Major adverse cardiovascular events were also significantly reduced by ezetimibe (3 systematic reviews; median RR=0.93, IQR=0.93 to 0.94), PCSK9 inhibitors (14 systematic reviews; median RR=0.84, IQR=0.83 to 0.87), and fibrates (2 systematic reviews; mean RR=0.86), but these interventions had no effect on cardiovascular or all-cause mortality. Fibrates had no effect on any cardiovascular outcomes when added to a statin. Omega-3 combination supplements had no effect on MACE or all-cause mortality but significantly reduced cardiovascular mortality (5 systematic reviews; median RR=0.93, IQR=0.93 to 0.94). Eicosapentaenoic acid ethyl ester alone significantly reduced MACE (1 systematic review, RR=0.78) and cardiovascular mortality (2 systematic reviews; RRs of 0.82 and 0.82). In primary cardiovascular prevention, only statins showed consistent benefits on MACE (6 systematic reviews; median RR=0.75, IQR=0.73 to 0.78), cardiovascularall-cause mortality (7 systematic reviews, median RR=0.83, IQR=0.81 to 0.90), and all-cause mortality (8 systematic reviews; median RR=0.91, IQR=0.87 to 0.91). CONCLUSION Statins have the most consistent evidence for the prevention of cardiovascular complications with a relative risk reduction of about 25% for MACE and 10% to 15% for mortality. The addition of ezetimibe, a PCSK9 inhibitor, or eicosapentaenoic acid ethyl ester to a statin provides additional MACE risk reduction but has no effect on all-cause mortality.
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Affiliation(s)
- Nicolas Dugré
- Pharmacist at the CIUSSS du Nord-de-l’Île-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montréal in Quebec
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Goldstein LB, Toth PP, Dearborn-Tomazos JL, Giugliano RP, Hirsh BJ, Peña JM, Selim MH, Woo D. Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2023; 43:e404-e442. [PMID: 37706297 DOI: 10.1161/atv.0000000000000164] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The objective of this scientific statement is to evaluate contemporary evidence that either supports or refutes the conclusion that aggressive low-density lipoprotein cholesterol lowering or lipid lowering exerts toxic effects on the brain, leading to cognitive impairment or dementia or hemorrhagic stroke. The writing group used literature reviews, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion to summarize existing evidence and to identify gaps in current knowledge. Although some retrospective, case control, and prospective longitudinal studies suggest that statins and low-density lipoprotein cholesterol lowering are associated with cognitive impairment or dementia, the preponderance of observational studies and data from randomized trials do not support this conclusion. The risk of a hemorrhagic stroke associated with statin therapy in patients without a history of cerebrovascular disease is nonsignificant, and achieving very low levels of low-density lipoprotein cholesterol does not increase that risk. Data reflecting the risk of hemorrhagic stroke with lipid-lowering treatment among patients with a history of hemorrhagic stroke are not robust and require additional focused study.
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Guo W, Liu Z, Liu P, Lu Q, Chang Q, Zhang M, Huo Y, Lin X, Peng L, Liu T, Yan Y, Lei Z, Wang Y, Huang C, Zhang D, Wang F, Wu S. Association between Triglyceride-Glucose Index and 1-Year Recurrent Stroke after Acute Ischemic Stroke: Results from the Xi'an Stroke Registry Study of China. Cerebrovasc Dis 2023; 53:391-402. [PMID: 37757755 DOI: 10.1159/000534240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION The triglyceride-glucose (TyG) index is reported to be related to poor functional outcomes and all-cause mortality post-stroke. However, the association between TyG index and recurrent stroke after acute ischemic stroke (AIS) has not been well described. We aimed to identify whether the TyG index was associated with 1-year recurrent stroke after AIS. METHODS Baseline patient information was collected at admission, and the TyG index was calculated. Recurrent stroke events were followed up at 1, 3, 6, and 12 months after diagnosis. We then examined the association between the TyG index and risk of 1-year recurrent stroke using multivariable Cox regression models and restricted cubic spline analyses. RESULTS Among 2,288 participants, the mean TyG index was 8.8 ± 0.7. Those in the fourth quartile (Q4) demonstrated higher recurrent stroke risk than those in Q1 (adjusted hazard ratio [HR] = 1.63; 95% confidence interval [CI], 0.98-2.72; p = 0.059). Subgroup analysis revealed a sex-specific association between TyG index and recurrent stroke (p for interaction = 0.022). Additionally, restricted cubic splines analyses showed a nonlinear association between the TyG index and 1-year recurrent stroke. In females, patients in the Q4 had a 2.95-fold increased recurrent stroke risk than did patients in the Q1 (adjusted HR = 2.95; 95% CI: 1.09-7.94; p = 0.032); the risk increased when the TyG index was >8.73. However, no significant correlation was observed in males. CONCLUSION A nonlinear association was found between the TyG index and 1-year recurrent stroke risk. Subsequently, a high TyG index could predict an increased 1-year recurrent stroke risk in female AIS patients.
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Affiliation(s)
- Weiyan Guo
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Zhongzhong Liu
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
- Department of Epidemiology and Biostatistics, School of Public Health of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Pei Liu
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Qingli Lu
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Qiaoqiao Chang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Mi Zhang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Yan Huo
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Xuemei Lin
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Linna Peng
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- College of Life Science, Northwest University, Xi'an, China
| | - Tong Liu
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Yinfang Yan
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Zhen Lei
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Yuanji Wang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Congli Huang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Dandan Zhang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Fang Wang
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
| | - Songdi Wu
- Department of Neurology, Xi'an No. 1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Innovation and Transformation of Neuroimmunological Diseases, Xi'an, China
- College of Life Science, Northwest University, Xi'an, China
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Ye Z, Cao Y, Miao C, Liu W, Dong L, Lv Z, Iheozor-Ejiofor Z, Li C. Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis. Cochrane Database Syst Rev 2022; 10:CD009197. [PMID: 36194420 PMCID: PMC9531722 DOI: 10.1002/14651858.cd009197.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
BACKGROUND There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the third update of a review originally published in 2014, and most recently updated in 2019. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system. OBJECTIVES To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis. SEARCH METHODS An information specialist searched five bibliographic databases up to 17 November 2021 and additional search methods were used to identify published, unpublished, and ongoing studies. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies). DATA COLLECTION AND ANALYSIS Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence. MAIN RESULTS There are no new completed RCTs on this topic since we published our last update in 2019. We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD. AUTHORS' CONCLUSIONS For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.
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Affiliation(s)
- Zelin Ye
- Department of Imaging, West China School of Stomatology, Chengdu, China
| | - Yubin Cao
- Department of Head and Neck Oncology, State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Cheng Miao
- Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Wei Liu
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Li Dong
- Department of Cardiovascular Medicine, Hospital of Traditional Chinese Medicine Affiliated to Southwest Medical University, Luzhou, China
| | - Zongkai Lv
- Department of Stomatology, Nan Chong Central Hospital, Second Clinical Medical College of Chuan Bei Medical College, Nanchong, China
| | | | - Chunjie Li
- State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral Diseases, Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, Chengdu, China
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Wechjakwen N, Aroonnual A, Prangthip P, Soonthornworasiri N, Phienluphon PP, Lainampetch J, Kwanbunjan K. Associations between the rs5498 (A > G) and rs281432 (C > G) polymorphisms of the ICAM1 gene and atherosclerotic cardiovascular disease risk, including hypercholesterolemia. PeerJ 2022; 10:e12972. [PMID: 35282277 PMCID: PMC8916030 DOI: 10.7717/peerj.12972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/30/2022] [Indexed: 01/11/2023] Open
Abstract
Background Atherosclerotic cardiovascular disease (ASCVD) originates from complex risk factors, including age, gender, dyslipidemia, obesity, race, genetic and genetic variation. ICAM1 gene polymorphisms are a significant risk factor for ASCVD. However, the impact of the rs5498 and rs281432 polymorphisms on the prevalence of hypercholesterolemia (HCL) has not been reported. Therefore, we determine the relationships between single nucleotide polymorphisms (SNPs), including rs5498 and rs281432 on Intercellular adhesion molecule 1 gene (ICAM1) and ASCVD susceptibility in patients with HCL. Methods The clinical characteristics of 278 participants were assessed, and classified to groups having HCL and without HCL. ICAM1 SNPs genotyping was performed by DNA sequencing, and ICAM1 expression was measured using real-time PCR. Results Positive dominant model rs5498 participants had twice the risk of HCL (95% confidence interval (CI): [1.24-3.23], P = 0.005). The frequency of the G allele in rs5498 was 1.69 times higher in participants with HCL than in controls (95% CI [1.15-2.47], P = 0.007). Participants with the rs5498 AG or GG variants and high ICAM1 mRNA expression (≥3.12) had 2.49 times the risk (95% CI [1.42-4.38], P = 0.001), and those with a high LDL-C concentration (≥3.36 mmol/L) had 2.09 times the risk (95% CI [1.19-3.66], P = 0.010) of developing ASCVD compared with those with low ICAM1 mRNA and LDL-C levels. Interestingly, participants carrying the rs5498 AG or GG variants who had tachycardia (resting heart rates (RHRs) >100 beats/min) had a 5.02-times higher risk than those with a lower RHR (95% CI [1.35-18.63], P = 0.016). Conclusions It may consider the G allele in ICAM1 rs5498 is associated with a higher risk of ASCVD in Thai people with HCL, and is also positively associated with ICAM1 mRNA expression, LDL-C concentration, and RHR.
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Affiliation(s)
- Naruemon Wechjakwen
- Department of Tropical Nutrition and Food Science, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Amornrat Aroonnual
- Department of Tropical Nutrition and Food Science, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Pattaneeya Prangthip
- Department of Tropical Nutrition and Food Science, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Jirayu Lainampetch
- Department of Nutrition, Faculty of Public health, Mahidol University, Bangkok, Thailand
| | - Karunee Kwanbunjan
- Department of Tropical Nutrition and Food Science, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Yan L, Wang X, Wang T, Shu L, Li Y, Dmytriw AA, Yang K, Xu R, Bai X, Yang B, Lu X, Ma Y, Jiao L. Statins for people with intracerebral hemorrhage. Hippokratia 2022. [DOI: 10.1002/14651858.cd014929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Lin Yan
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xue Wang
- Medical Library of Xuanwu Hospital; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Tao Wang
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Liqi Shu
- Department of Neurology; The Warren Alpert Medical School of Brown University; Providence Rhode Island USA
| | - Ye Li
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Adam A Dmytriw
- Department of Medical Imaging; University of Toronto; Toronto Canada
| | - Kun Yang
- Department of Evidence-based Medicine; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Ran Xu
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xuesong Bai
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Bin Yang
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Xia Lu
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Yan Ma
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
| | - Liqun Jiao
- Department of Neurosurgery; Xuanwu Hospital, Capital Medical University; Beijing China
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Higher dose statins after stroke. Aust Prescr 2021; 44:146-147. [PMID: 34728878 PMCID: PMC8542487 DOI: 10.18773/austprescr.2021.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Woodhouse LJ, Montgomery AA, Mant J, Davis BR, Algra A, Mas JL, Staessen JA, Thijs L, Tonkin A, Kirby A, Pocock SJ, Chalmers J, Hankey GJ, Spence JD, Sandercock P, Diener HC, Uchiyama S, Sprigg N, Bath PM. Statistical reanalysis of vascular event outcomes in primary and secondary vascular prevention trials. BMC Med Res Methodol 2021; 21:218. [PMID: 34657596 PMCID: PMC8520648 DOI: 10.1186/s12874-021-01388-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular prevention trials typically use dichotomous event outcomes although this may be inefficient statistically and gives no indication of event severity. We assessed whether ordinal outcomes would be more efficient and how to best analyse them. METHODS Chief investigators of vascular prevention randomised controlled trials that showed evidence of either benefit or harm, or were included in a systematic review that overall showed benefit or harm, shared individual participant data from their trials. Ordered categorical versions of vascular event outcomes (such as stroke and myocardial infarction) were analysed using 15 statistical techniques and their results then ranked, with the result with the smallest p-value given the smallest rank. Friedman and Duncan's multiple range tests were performed to assess differences between tests by comparing the average ranks for each statistical test. RESULTS Data from 35 trials (254,223 participants) were shared with the collaboration. 13 trials had more than two treatment arms, resulting in 59 comparisons. Analysis approaches (Mann Whitney U, ordinal logistic regression, multiple regression, bootstrapping) that used ordinal outcome data had a smaller average rank and therefore appeared to be more efficient statistically than those that analysed the original binary outcomes. CONCLUSIONS Ordinal vascular outcome measures appear to be more efficient statistically than binary outcomes and provide information on the severity of event. We suggest a potential role for using ordinal outcomes in vascular prevention trials.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Barry R Davis
- The University of Texas Health Science Center at Houston, Houston, USA
| | - Ale Algra
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Louis Mas
- Hopital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Jan A Staessen
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Andrew Tonkin
- Chronic Disease & Aging Unit, Monash University, Clayton, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - John Chalmers
- George Institute for Global Health, Sydney, Australia
| | - Graeme J Hankey
- Department of Neurology, University of Western Australia, Crawley, Australia
| | | | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Nikola Sprigg
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK.
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11
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Abstract
After an ischaemic stroke or transient ischaemic attack, patients have a high risk of having another stroke. Secondary stroke prevention includes antiplatelet therapy, statins and antihypertensives Aspirin, clopidogrel, or a combination of aspirin with dipyridamole are first-line options for secondary stroke prevention in the absence of atrial fibrillation Dual antiplatelet therapy has a benefit in the first three weeks after stroke, but patients should change to a single antiplatelet drug after this time Anticoagulants are indicated if the patient has atrial fibrillation. Avoid combinations of anticoagulants and antiplatelet drugs Patients should be started on statins after an ischaemic stroke. High doses are recommended even if cholesterol concentrations are normal Antihypertensive drugs are recommended for all patients with systolic blood pressures greater than 140/90 mmHg. ACE inhibitors, calcium channel blockers and diuretics are first-line options
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12
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Bruning T, Al-Khaled M. Do statins reduce the mortality rate in stroke patients treated with systemic thrombolysis in a 5-year. Neural Regen Res 2021; 16:1807-1812. [PMID: 33510087 PMCID: PMC8328772 DOI: 10.4103/1673-5374.306088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The present study investigated the association between pre-treatment with a cholesterol-lowering drug (statin) or new setting hereon and the effect on the mortality rate in patients with acute ischemic stroke who received intravenous systemic thrombolysis. During a 5-year period (starting in October 2008), 542 consecutive stroke patients who received intravenous systemic thrombolysis with recombinant tissue plasminogen activator (rt-PA) at the Department of Neurology, University Hospital Schleswig-Holstein, Campus Lübeck, Germany, were included. Patients were characterized according to statins. The primary endpoint was mortality; it was assessed twice: in hospital and 3 months after discharge. The secondary outcome was the rate of symptomatic intracerebral hemorrhage. Of the 542 stroke patients examined (mean age 72 ± 13 years; 51% women, mean National Institutes of Health Stroke Scale (NIHSS) score 11), 138 patients (25.5%) had been pre-treated with statin, while in 190 patients (35.1%) statin therapy was initiated during their stay in hospital, whereas 193 (35.6%) never received statins. Patients pre-treated with statin were older and more frequently had previous illnesses (arterial hypertension, diabetes mellitus and previous cerebral infarctions), but were comparably similarly affected by the stroke (NIHSS 11 vs. 11; P = 0.76) compared to patients who were not on statin treatment at the time of cerebral infarction. Patients pretreated with statin did not differ in 3-month mortality from those newly treated to a statin (7.6% vs. 8%; P = 0.9). Interestingly, the group of patients pretreated with statin showed a lower rate of in hospital mortality (6.6% vs. 17.0; P = 0.005) and 3-month mortality (10.7% vs. 23.7%; P = 0.005) than the group of patients who had no statin treatment at all. The same effect was seen for patients newly adjusted to a statin during the hospital stay compared to patients who did not receive statins (3-month mortality: 7.1% vs. 23.7%; P < 0.001). With a good functional outcome (mRS ≤ 2), 60% of patients were discharged, the majority (69.6%; P < 0.001) of whom received a statin at discharge. The rate of symptomatic intracerebral hemorrhages in the course of cranial computed tomography was independent of whether the patients were pretreated with a statin or not (8.8% vs. 8.7%, P = 0.96). Pre-treatment with statin as well as new adjustment could reveal positive effect on prognosis of intravenous thrombolyzed stroke patients. Further investigations are required. The study was approved by the Ethic Committee of the University of Lübeck (approval No. 4-147).
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Affiliation(s)
- Toralf Bruning
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Mohamed Al-Khaled
- Department of Neurology, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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13
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Georgakis MK, Malik R, Anderson CD, Parhofer KG, Hopewell JC, Dichgans M. Genetic determinants of blood lipids and cerebral small vessel disease: role of high-density lipoprotein cholesterol. Brain 2020; 143:597-610. [PMID: 31968102 DOI: 10.1093/brain/awz413] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 10/26/2019] [Accepted: 11/19/2019] [Indexed: 01/14/2023] Open
Abstract
Blood lipids are causally involved in the pathogenesis of atherosclerosis, but their role in cerebral small vessel disease remains largely elusive. Here, we explored associations of genetic determinants of blood lipid levels, lipoprotein particle components, and targets for lipid-modifying drugs with small vessel disease phenotypes. We selected genetic instruments for blood levels of high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides, for cholesterol and triglycerides components of size-defined lipoprotein particles, and for lipid-modifying drug targets based on published genome-wide association studies (up to 617 303 individuals). Applying two-sample Mendelian randomization approaches we investigated associations with ischaemic and haemorrhagic manifestations of small vessel disease [small vessel stroke: 11 710 cases, 287 067 controls; white matter hyperintensities (WMH): 10 597 individuals; intracerebral haemorrhage: 1545 cases, 1481 controls]. We applied the inverse-variance weighted method and multivariable Mendelian randomization as our main analytical approaches. Genetic predisposition to higher HDL-C levels was associated with lower risk of small vessel stroke [odds ratio (OR) per standard deviation = 0.85, 95% confidence interval (CI) = 0.78-0.92] and lower WMH volume (β = -0.07, 95% CI = -0.12 to -0.02), which in multivariable Mendelian randomization remained stable after adjustments for LDL-C and triglycerides. In analyses of lipoprotein particle components by size, we found these effects to be specific for cholesterol concentration in medium-sized high-density lipoprotein, and not large or extra-large high-density lipoprotein particles. Association estimates for intracerebral haemorrhage were negatively correlated with those for small vessel stroke and WMH volume across all lipid traits and lipoprotein particle components. HDL-C raising genetic variants in the gene locus of the target of CETP inhibitors were associated with lower risk of small vessel stroke (OR: 0.82, 95% CI = 0.75-0.89) and lower WMH volume (β = -0.08, 95% CI = -0.13 to -0.02), but a higher risk of intracerebral haemorrhage (OR: 1.64, 95% CI = 1.26-2.13). Genetic predisposition to higher HDL-C, specifically to cholesterol in medium-sized high-density lipoprotein particles, is associated with both a lower risk of small vessel stroke and lower WMH volume. These analyses indicate that HDL-C raising strategies could be considered for the prevention of ischaemic small vessel disease but the net benefit of such an approach would need to be tested in a randomized controlled trial.
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Affiliation(s)
- Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany.,Graduate School for Systemic Neurosciences (GSN), Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Rainer Malik
- Institute for Stroke and Dementia Research (ISD), University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Christopher D Anderson
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.,Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Program in Medical and Population Genetics, Broad Institute, Cambridge, MA, USA.,Henry and Allison McCance Center for Brain Health, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Klaus G Parhofer
- Department of Internal Medicine IV, University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Jemma C Hopewell
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital of Ludwig-Maximilians-University (LMU), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,German Centre for Neurodegenerative Diseases (DZNE), Munich, Germany
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14
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Liu W, Cao Y, Dong L, Zhu Y, Wu Y, Lv Z, Iheozor‐Ejiofor Z, Li C. Periodontal therapy for primary or secondary prevention of cardiovascular disease in people with periodontitis. Cochrane Database Syst Rev 2019; 12:CD009197. [PMID: 31887786 PMCID: PMC6953391 DOI: 10.1002/14651858.cd009197.pub4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND There may be an association between periodontitis and cardiovascular disease (CVD); however, the evidence so far has been uncertain about whether periodontal therapy can help prevent CVD in people diagnosed with chronic periodontitis. This is the second update of a review originally published in 2014, and first updated in 2017. Although there is a new multidimensional staging and grading system for periodontitis, we have retained the label 'chronic periodontitis' in this version of the review since available studies are based on the previous classification system. OBJECTIVES To investigate the effects of periodontal therapy for primary or secondary prevention of CVD in people with chronic periodontitis. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, two trials registries, and the grey literature to September 2019. We placed no restrictions on the language or date of publication. We also searched the Chinese BioMedical Literature Database, the China National Knowledge Infrastructure, the VIP database, and Sciencepaper Online to August 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared active periodontal therapy to no periodontal treatment or a different periodontal treatment. We included studies of participants with a diagnosis of chronic periodontitis, either with CVD (secondary prevention studies) or without CVD (primary prevention studies). DATA COLLECTION AND ANALYSIS Two review authors carried out the study identification, data extraction, and 'Risk of bias' assessment independently and in duplicate. They resolved any discrepancies by discussion, or with a third review author. We adopted a formal pilot-tested data extraction form, and used the Cochrane tool to assess the risk of bias in the studies. We used GRADE criteria to assess the certainty of the evidence. MAIN RESULTS We included two RCTs in the review. One study focused on the primary prevention of CVD, and the other addressed secondary prevention. We evaluated both as being at high risk of bias. Our primary outcomes of interest were death (all-cause and CVD-related) and all cardiovascular events, measured at one-year follow-up or longer. For primary prevention of CVD in participants with periodontitis and metabolic syndrome, one study (165 participants) provided very low-certainty evidence. There was only one death in the study; we were unable to determine whether scaling and root planning plus amoxicillin and metronidazole could reduce incidence of all-cause death (Peto odds ratio (OR) 7.48, 95% confidence interval (CI) 0.15 to 376.98), or all CVD-related death (Peto OR 7.48, 95% CI 0.15 to 376.98). We could not exclude the possibility that scaling and root planning plus amoxicillin and metronidazole could increase cardiovascular events (Peto OR 7.77, 95% CI 1.07 to 56.1) compared with supragingival scaling measured at 12-month follow-up. For secondary prevention of CVD, one pilot study randomised 303 participants to receive scaling and root planning plus oral hygiene instruction (periodontal treatment) or oral hygiene instruction plus a copy of radiographs and recommendation to follow-up with a dentist (community care). As cardiovascular events had been measured for different time periods of between 6 and 25 months, and only 37 participants were available with at least one-year follow-up, we did not consider the data to be sufficiently robust for inclusion in this review. The study did not evaluate all-cause death and all CVD-related death. We are unable to draw any conclusions about the effects of periodontal therapy on secondary prevention of CVD. AUTHORS' CONCLUSIONS For primary prevention of cardiovascular disease (CVD) in people diagnosed with periodontitis and metabolic syndrome, very low-certainty evidence was inconclusive about the effects of scaling and root planning plus antibiotics compared to supragingival scaling. There is no reliable evidence available regarding secondary prevention of CVD in people diagnosed with chronic periodontitis and CVD. Further trials are needed to reach conclusions about whether treatment for periodontal disease can help prevent occurrence or recurrence of CVD.
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Affiliation(s)
- Wei Liu
- West China Hospital of Stomatology, Sichuan UniversityState Key Laboratory of Oral DiseasesNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Yubin Cao
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Li Dong
- Hospital of Traditional Chinese Medicine Affiliated to Southwest Medical UniversityDepartment of Cardiovascular MedicineNo 11, South Jiangyang RoadLuzhouSichuanChina646000
| | - Ye Zhu
- West China Hospital, Sichuan UniversityDepartment of Cardiovascular DiseaseNo 37, Guo Xue XiangChengduSichuanChina610041
| | - Yafei Wu
- West China Hospital of Stomatology, Sichuan University, State Key Laboratory of Oral DiseasesDepartment of PeriodontologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
| | - Zongkai Lv
- Nan Chong Central Hospital, Second Clinical Medical College of Chuan Bei Medical CollegeDepartment of StomatologyNo. 66 , Da Bei Jie RoadNanchongSichuanChina637000
| | | | - Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduSichuanChina610041
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15
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Nezu T, Hosomi N, Kitagawa K, Nagai Y, Nakagawa Y, Aoki S, Kagimura T, Maruyama H, Origasa H, Minematsu K, Uchiyama S, Matsumoto M. Effect of Statin on Stroke Recurrence Prevention at Different Infarction Locations: A Post Hoc Analysis of The J-STARS Study. J Atheroscler Thromb 2019; 27:524-533. [PMID: 31554765 PMCID: PMC7355099 DOI: 10.5551/jat.51391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Aim: Posterior circulation stroke (PCS) has different clinical features and prognosis compared with anterior circulation stroke (ACS), and whether the effect of statin therapy on stroke prevention differs according to infarction location remains unclear. This post hoc analysis of the J-STARS study aimed to compare the usefulness of statin at different infarction locations (i.e., ACS and PCS). Methods: In the J-STARS study, 1578 patients were randomly assigned to the pravastatin or control group. The subjects were divided into two subgroups (ACS and PCS groups) based on the arteries responsible for the infarction. Cox proportional hazards models were used to investigate whether the all stroke recurrence rate was different between the ACS and PCS groups. Results: The PCS group (n = 499) had a significantly higher prevalence of diabetes than the ACS group (n = 1022) (30.7% vs. 19.8%, P < 0.001). During the follow-up (4.9 ± 1.4 years), the incidence of all stroke was significantly lower in the pravastatin group than in the control group among patients with PCS (adjusted hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.25–0.83, P = 0.009); however, the stroke recurrence rates were not significantly different between both groups among patients with ACS (adjusted HR 1.32, 95% CI 0.93–1.88, P = 0.123). A significant interaction between the ACS and PCS groups in terms of pravastatin effects was noted (P = 0.003 for interaction). Conclusions: Pravastatin significantly reduced the recurrence rate of all stroke among patients with PCS. Thus, the effect of statin on the recurrence of stroke may differ according to infarction location.
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Affiliation(s)
- Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine
| | - Yoji Nagai
- Center for Clinical Research, Kobe University Hospital
| | - Yoko Nakagawa
- Division of Medical Statistics, Translational Research Informatics Center, Foundation for Biomedical Research and Innovation
| | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Tatsuo Kagimura
- Division of Medical Statistics, Translational Research Informatics Center, Foundation for Biomedical Research and Innovation
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences
| | | | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center
| | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences.,Sakai City Medical Center, Sakai City Hospital Organization
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16
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Yang Z, Edwards D, Massou E, Saunders CL, Brayne C, Mant J. Statin use and high-dose statin use after ischemic stroke in the UK: a retrospective cohort study. Clin Epidemiol 2019; 11:495-508. [PMID: 31388316 PMCID: PMC6607979 DOI: 10.2147/clep.s201983] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/29/2019] [Indexed: 12/26/2022] Open
Abstract
Background: Trial evidence supports statin use after ischemic stroke and recent American, European and British guidelines recommend high-intensity statins for this indication. Limited data are available describing current statin use among these patients in unselected settings. We conducted a cohort study to examine secular trends and factors associated with statin use and dose following ischemic stroke. Methods: A retrospective cohort study of patients with first ischemic stroke between 2000 and 2014 was conducted using the Clinical Practice Research Datalink (CPRD). Proportions of statin users and high-intensity statin users within 2 years after stroke were estimated for each calendar year. We used Cox regression models to explore potential factors associated with statin use and Poisson regression models to calculate risk ratios for the use of a high-intensity statin. Results: A total of 80,442 patients with first stroke were analyzed. The proportion using statins within 2 years after stroke increased from 25% in 2000 to 70% in 2006 and remained at about 75% through 2014. Among post-stroke statin users, high-intensity use accounted for approximately 15% between 2004 and 2011 and then increased to almost 35% in 2014. Older patients (aged ≥75 years), younger patients (<45 years), patients with no prior statin treatment, dementia, underweight, or absence of cardiovascular factors (coronary heart disease, smoking, obesity, diabetes, hypertension, or transient ischemic attack) were less likely to use statins and less likely to receive a high-intensity statin. Conclusion: There has been an increase over time in both statin use and dose, but many patients with ischemic stroke continue to be under-treated. Clinical trials and policy interventions to improve appropriate post-stroke statin use should focus on younger and older patients, patients with no pre-stroke statin treatment, and patients without additional cardiovascular risk factors.
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Affiliation(s)
- Zhirong Yang
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Efthalia Massou
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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17
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Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues. Curr Treat Options Neurol 2019; 21:27. [PMID: 31065827 DOI: 10.1007/s11940-019-0567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group. RECENT FINDINGS Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.
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18
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Tramacere I, Boncoraglio GB, Banzi R, Del Giovane C, Kwag KH, Squizzato A, Moja L. Comparison of statins for secondary prevention in patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis. BMC Med 2019; 17:67. [PMID: 30914063 PMCID: PMC6436237 DOI: 10.1186/s12916-019-1298-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 03/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Statins may prevent recurrent ischemic events after ischemic stroke. Determining which statin to use remains controversial. We aimed to summarize the evidence for the use of statins in secondary prevention for patients with ischemic stroke by comparing benefits and harms of various statins. METHODS We searched for randomized controlled trials (RCTs) assessing statins in patients with ischemic stroke or transient ischemic attack (TIA) in MEDLINE, EMBASE, and CENTRAL up to July 2017. Two authors extracted data and appraised risks of bias. We performed pairwise meta-analyses and trial sequential analyses (TSA) to compare statins versus placebo/no statin, and network meta-analyses using frequentist random-effects models to compare statins through indirect evidence. We used GRADE to rate the overall certainty of evidence. Primary outcomes were all-cause mortality and all strokes. Secondary outcomes were different types of strokes, cardiovascular events, and adverse events. RESULTS We identified nine trials (10,741 patients). No head-to-head RCTs were found. The median follow-up period was 2.5 years. Statins did not seem to modify all stroke and all-cause mortality outcomes; they were associated with a decreased risk of ischemic stroke (odds ratio, OR, 0.81 [95% CI, 0.70 to 0.93]; absolute risk difference, ARD, - 1.6% [95% CI, - 2.6 to - 0.6%]), ischemic stroke or TIA (OR, 0.75 [95% CI, 0.64 to 0.87]; ARD, - 4.2% [95% CI, - 6.2 to - 2.1%]), and cardiovascular event (OR, 0.75 [95% CI, 0.69 to 0.83]; ARD, - 5.4% [95% CI, - 6.8 to - 3.6%]), and did not seem to modify rhabdomyolysis, myalgia, or rise in creatine kinase. In the comparison of different statins, moderate- to high-quality evidence indicated that differences between pharmaceutical products seemed modest, with high doses (e.g., atorvastatin 80 mg/day and simvastatin 40 mg/day) associated with the greatest benefits. TSA excluded random error as a cause of the findings for ischemic stroke and cardiovascular event outcomes. Evidence for increased risk of hemorrhagic stroke was sensitive to the exclusion of the SPARCL trial. CONCLUSIONS Evidence strongly suggests that statins are associated with a reduction in the absolute risk of ischemic strokes and cardiovascular events. Differences in effects among statins were modest, signaling potential therapeutic equivalence. TRIAL REGISTRATION PROSPERO CRD42018079112.
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Affiliation(s)
- Irene Tramacere
- Department of Research and Clinical Development, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133, Milan, Italy.
| | - Giorgio B Boncoraglio
- Department of Cerebrovascular Disease, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Rita Banzi
- Center for Drug Regulatory Policies, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Koren H Kwag
- Medical School for International Health, Ben Gurion University, Beersheba, Israel
| | | | - Lorenzo Moja
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Unit of Clinical Epidemiology, IRCCS Galeazzi Orthopedic Institute, Milan, Italy
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19
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Statin Use and the Risk of Dementia in Patients with Stroke: A Nationwide Population-Based Cohort Study. J Stroke Cerebrovasc Dis 2018; 27:3001-3007. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.06.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/27/2018] [Accepted: 06/24/2018] [Indexed: 11/21/2022] Open
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20
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Li C, Lv Z, Shi Z, Zhu Y, Wu Y, Li L, Iheozor‐Ejiofor Z. Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis. Cochrane Database Syst Rev 2017; 11:CD009197. [PMID: 29112241 PMCID: PMC6486158 DOI: 10.1002/14651858.cd009197.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an association between chronic periodontitis and cardiovascular disease (CVD). However, it is not known whether periodontal therapy could prevent or manage CVD in patients with chronic periodontitis. OBJECTIVES The objective of this systematic review was to investigate the effects of periodontal therapy in preventing the occurrence of, and management or recurrence of, CVD in patients with chronic periodontitis. SEARCH METHODS Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 31 August 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 7), MEDLINE Ovid (1946 to 31 August 2017), Embase Ovid (1980 to 31 August 2017) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL EBSCO) (1937 to 31 August 2017) . The US National Institutes of Health Trials Registry (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform and Open Grey were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.We also searched the Chinese BioMedical Literature Database (1978 to 27 August 2017), the China National Knowledge Infrastructure (1994 to 27 August 2017), the VIP database (1989 to 27 August 2017) and Sciencepaper Online (2003 to 27 August 2017). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs were considered eligible. Studies were selected if they included patients with a diagnosis of chronic periodontitis and previous CVD (secondary prevention studies) or no CVD (primary prevention studies); patients in the intervention group received active periodontal therapy compared to maintenance therapy, no periodontal treatment or another kind of periodontal treatment in the control group. DATA COLLECTION AND ANALYSIS Two review authors carried out the study identification, data extraction and risk of bias assessment independently and in duplicate. Any discrepancies between the two authors were resolved by discussion or with a third review author. A formal pilot-tested data extraction form was adopted for the data extraction, and the Cochrane tool for risk of bias assessment was used for the critical appraisal of the literature. MAIN RESULTS No studies were identified that assessed primary prevention of CVD in people with periodontitis. One study involving 303 participants with ≥ 50% blockage of one coronary artery or a coronary event within three years, but not the three months prior, was included. The study was at high risk of bias due to deviation from the protocol treatment allocation and lack of follow-up data. The trial compared scaling and root planing (SRP) with community care for a follow-up period of six to 25 months. No data on deaths (all-cause or CVD-related) were reported. There was insufficient evidence to determine the effect of SRP and community care in reducing the risk of CVD recurrence in patients with chronic periodontitis (risk ratio (RR) 0.72; 95% confidence interval (CI) 0.23 to 2.22; very low quality evidence). The effects of SRP compared with community care on high-sensitivity C-reactive protein (hs-CRP) (mean difference (MD) 0.62; -1.45 to 2.69), the number of patients with high hs-CRP (RR 0.77; 95% CI 0.32 to 1.85) and adverse events (RR 9.06; 95% CI 0.49 to 166.82) were also not statistically significant. The study did not assess modifiable cardiovascular risk factors, other blood test results, heart function parameters or revascularisation procedures. AUTHORS' CONCLUSIONS We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.
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Affiliation(s)
- Chunjie Li
- State Key Laboratory of Oral Diseases, West China Hospital of Stomatology, Sichuan UniversityDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduChina610041
| | - Zongkai Lv
- Nan Chong Central Hospital, Second Clinical Medical College of Chuan Bei Medical CollegeDepartment of StomatologyNo. 66 , Da Bei Jie RoadNanchongChina637000
| | - Zongdao Shi
- West China Hospital of Stomatology, Sichuan University, State Key Laboratory of Oral DiseasesDepartment of Oral and Maxillofacial SurgeryNo. 14, Section Three, Ren Min Nan RoadChengduChina610041
| | - Ye Zhu
- West China Hospital, Sichuan UniversityDepartment of Cardiovascular DiseaseNo 37, Guo Xue XiangChengduChina610041
| | - Yafei Wu
- West China Hospital of Stomatology, Sichuan University, State Key Laboratory of Oral DiseasesDepartment of PeriodontologyNo. 14, Section Three, Ren Min Nan RoadChengduChina610041
| | - Longjiang Li
- West China Hospital of Stomatology, Sichuan University, State Key Laboratory of Oral DiseasesDepartment of Head and Neck OncologyNo. 14, Section Three, Ren Min Nan RoadChengduChina610041
| | - Zipporah Iheozor‐Ejiofor
- The University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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21
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Albright KC, Howard VJ, Howard G, Muntner P, Bittner V, Safford MM, Boehme AK, Rhodes JD, Beasley TM, Judd SE, McClure LA, Limdi N, Blackburn J. Age and Sex Disparities in Discharge Statin Prescribing in the Stroke Belt: Evidence From the Reasons for Geographic and Racial Differences in Stroke Study. J Am Heart Assoc 2017; 6:e005523. [PMID: 28768644 PMCID: PMC5586419 DOI: 10.1161/jaha.117.005523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is a costly and debilitating disease that disproportionately affects blacks. Despite the efficacy of statins, evidence suggests racial disparities may exist in statin prescribing. METHODS AND RESULTS We analyzed discharge medications for participants hospitalized for an ischemic stroke during follow-up of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Medications on admission and discharge were abstracted from medical records. Among the 666 eligible incident strokes (2003-2013), analyses were restricted to 323 participants who were not statin users at the time of admission and had no history of atrial fibrillation. Overall, 48.7% were prescribed a statin on discharge. In the Stroke Belt, participants aged 65 years and older were 47% less likely to be discharged on a statin compared with those younger than 65 years (relative risk [RR], 0.53; 95% CI, 0.38-0.74). This association was not observed in non-Stroke Belt residents. Outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin (RR, 1.42; 95% CI, 1.04-1.94), while no black:white association was present among Stroke Belt residents (RR, 0.93; 95% CI, 0.69-1.26; P for interaction=0.228). Compared with women, men in the Stroke Belt were 31% less likely to be discharged on a statin (RR, 0.69; 95% CI, 0.50-0.94) while men outside the Stroke Belt were more likely to be discharged on a statin (RR, 1.38; 95% CI, 0.99-1.92; P for interaction=0.004). CONCLUSIONS Statin discharge prescribing may differ among Stroke Belt and non-Stroke Belt residents, particularly in older Americans and men.
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Affiliation(s)
- Karen C Albright
- Geriatric Research, Education and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, AL
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | | | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | - Vera Bittner
- Department of Medicine, University of Alabama at Birmingham, AL
| | | | | | - J David Rhodes
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - T Mark Beasley
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Leslie A McClure
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Nita Limdi
- Department of Neurology, University of Alabama at Birmingham, AL
| | - Justin Blackburn
- Department of Health Care Organization & Policy, University of Alabama at Birmingham, AL
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22
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Bordet R, Ihl R, Korczyn AD, Lanza G, Jansa J, Hoerr R, Guekht A. Towards the concept of disease-modifier in post-stroke or vascular cognitive impairment: a consensus report. BMC Med 2017; 15:107. [PMID: 28539119 PMCID: PMC5444106 DOI: 10.1186/s12916-017-0869-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/06/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Vascular cognitive impairment (VCI) is a complex spectrum encompassing post-stroke cognitive impairment (PSCI) and small vessel disease-related cognitive impairment. Despite the growing health, social, and economic burden of VCI, to date, no specific treatment is available, prompting the introduction of the concept of a disease modifier. CONSENSUS AND SUGGESTIONS Within this clinical spectrum, VCI and PSCI remain advancing conditions as neurodegenerative diseases with progression of both vascular and degenerative lesions accounting for cognitive decline. Disease-modifying strategies should integrate both pharmacological and non-pharmacological multimodal approaches, with pleiotropic effects targeting (1) endothelial and brain-blood barrier dysfunction; (2) neuronal death and axonal loss; (3) cerebral plasticity and compensatory mechanisms; and (4) degenerative-related protein misfolding. Moreover, pharmacological and non-pharmacological treatment in PSCI or VCI requires valid study designs clearly stating the definition of basic methodological issues, such as the instruments that should be used to measure eventual changes, the biomarker-based stratification of participants to be investigated, and statistical tests, as well as the inclusion and exclusion criteria that should be applied. CONCLUSION A consensus emerged to propose the development of a disease-modifying strategy in VCI and PSCI based on pleiotropic pharmacological and non-pharmacological approaches.
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Affiliation(s)
- Régis Bordet
- University of Lille, Inserm, CHU, U1171 'Degenerative and vascular cognitive disorders', Lille, France.
- Département de Pharmacologie Médicale, Faculté de Médecine, 1 place Verdun, 59045, Lille Cedex, France.
| | - Ralf Ihl
- University of Duesseldorf, Alexian Research Center, Krefeld, Germany
| | - Amos D Korczyn
- Department of Neurology, Tel Aviv University, Ramat Aviv, Israel
| | - Giuseppe Lanza
- Department of Neurology IC, Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
| | - Jelka Jansa
- University Medical Centre Ljubljana, Neurologic Hospital, Neurorehabilitation Unit, Ljubljana, Slovenia
| | - Robert Hoerr
- Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany
| | - Alla Guekht
- Department of Neurology, Neurosurgery and Genetics, Russian National Research Medical University, Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
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23
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Mijajlović MD, Pavlović A, Brainin M, Heiss WD, Quinn TJ, Ihle-Hansen HB, Hermann DM, Assayag EB, Richard E, Thiel A, Kliper E, Shin YI, Kim YH, Choi S, Jung S, Lee YB, Sinanović O, Levine DA, Schlesinger I, Mead G, Milošević V, Leys D, Hagberg G, Ursin MH, Teuschl Y, Prokopenko S, Mozheyko E, Bezdenezhnykh A, Matz K, Aleksić V, Muresanu D, Korczyn AD, Bornstein NM. Post-stroke dementia - a comprehensive review. BMC Med 2017; 15:11. [PMID: 28095900 PMCID: PMC5241961 DOI: 10.1186/s12916-017-0779-7] [Citation(s) in RCA: 377] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 01/03/2017] [Indexed: 12/11/2022] Open
Abstract
Post-stroke dementia (PSD) or post-stroke cognitive impairment (PSCI) may affect up to one third of stroke survivors. Various definitions of PSCI and PSD have been described. We propose PSD as a label for any dementia following stroke in temporal relation. Various tools are available to screen and assess cognition, with few PSD-specific instruments. Choice will depend on purpose of assessment, with differing instruments needed for brief screening (e.g., Montreal Cognitive Assessment) or diagnostic formulation (e.g., NINDS VCI battery). A comprehensive evaluation should include assessment of pre-stroke cognition (e.g., using Informant Questionnaire for Cognitive Decline in the Elderly), mood (e.g., using Hospital Anxiety and Depression Scale), and functional consequences of cognitive impairments (e.g., using modified Rankin Scale). A large number of biomarkers for PSD, including indicators for genetic polymorphisms, biomarkers in the cerebrospinal fluid and in the serum, inflammatory mediators, and peripheral microRNA profiles have been proposed. Currently, no specific biomarkers have been proven to robustly discriminate vulnerable patients ('at risk brains') from those with better prognosis or to discriminate Alzheimer's disease dementia from PSD. Further, neuroimaging is an important diagnostic tool in PSD. The role of computerized tomography is limited to demonstrating type and location of the underlying primary lesion and indicating atrophy and severe white matter changes. Magnetic resonance imaging is the key neuroimaging modality and has high sensitivity and specificity for detecting pathological changes, including small vessel disease. Advanced multi-modal imaging includes diffusion tensor imaging for fiber tracking, by which changes in networks can be detected. Quantitative imaging of cerebral blood flow and metabolism by positron emission tomography can differentiate between vascular dementia and degenerative dementia and show the interaction between vascular and metabolic changes. Additionally, inflammatory changes after ischemia in the brain can be detected, which may play a role together with amyloid deposition in the development of PSD. Prevention of PSD can be achieved by prevention of stroke. As treatment strategies to inhibit the development and mitigate the course of PSD, lowering of blood pressure, statins, neuroprotective drugs, and anti-inflammatory agents have all been studied without convincing evidence of efficacy. Lifestyle interventions, physical activity, and cognitive training have been recently tested, but large controlled trials are still missing.
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Affiliation(s)
- Milija D Mijajlović
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Dr Subotica 6, 11000, Belgrade, Serbia.
| | - Aleksandra Pavlović
- Neurology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Dr Subotica 6, 11000, Belgrade, Serbia
| | - Michael Brainin
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | | | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hege B Ihle-Hansen
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Dirk M Hermann
- Department of Neurology, University Hospital Essen, Essen, Germany
| | - Einor Ben Assayag
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Edo Richard
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Alexander Thiel
- Department of Neurology and Neurosurgery, McGill University at SMBD Jewish General Hospital and Lady Davis Institute for Medical Research, Montreal, Québec, Canada
| | - Efrat Kliper
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yong-Il Shin
- Department of Rehabilitation Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Yun-Hee Kim
- Department of Physical and Rehabilitation Medicine, Sungkyunkwan University School of Medicine, Center for Prevention and Rehabilitation, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - SeongHye Choi
- Department of Neurology, Inha University School of Medicine, Incheon, South Korea
| | - San Jung
- Hallym University Medical Center, Kang Nam Sacred Heart Hospital, Seoul, South Korea
| | - Yeong-Bae Lee
- Department of Neurology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Osman Sinanović
- Department of Neurology, University Clinical Center Tuzla, School of Medicine University of Tuzla, 75000, Tuzla, Bosnia and Herzegovina
| | - Deborah A Levine
- Department of Internal Medicine, University of Michigan and the VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ilana Schlesinger
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Technion Faculty of Medicine, Haifa, Israel
| | - Gillian Mead
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Vuk Milošević
- Clinic of Neurology, Clinical Center Nis, Nis, Serbia
| | - Didier Leys
- U1171-Department of Neurology, University of Lille, Inserm, Faculty of Medicine, Lille University Hospital, Lille, France
| | - Guri Hagberg
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Marie Helene Ursin
- Department of internal medicine, Oslo University Hospital, Ullevål and Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Yvonne Teuschl
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Semyon Prokopenko
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Elena Mozheyko
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Anna Bezdenezhnykh
- Department of Neurology and Medical Rehabilitation, Krasnoyarsk State Medical University named after Professor V.F. Voyno-Yasenetsky, Krasnoyarsk, Russia
| | - Karl Matz
- Department of Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Vuk Aleksić
- Department of Neurosurgery, Clinical Hospital CenterZemun, Belgrade, Serbia
| | - DafinFior Muresanu
- Department of Clinical Neurosciences, "Iuliu Hatieganu" University of Medicine, Clij-Napoca, Romania
| | - Amos D Korczyn
- Department of Neurology, Tel Aviv University, Ramat Aviv, 69978, Israel
| | - Natan M Bornstein
- Stroke Unit, Department of Neurology, Tel-Aviv Sorasky Medical Center, Tel-Aviv, Israel
- Shaare Zedek Medical Center, Jerusalem, Israel
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24
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Riemsma R, Corro Ramos I, Birnie R, Büyükkaramikli N, Armstrong N, Ryder S, Duffy S, Worthy G, Al M, Severens J, Kleijnen J. Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation. Health Technol Assess 2016; 20:v-xxxi, 1-251. [PMID: 26933827 DOI: 10.3310/hta20170] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease. OBJECTIVE The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children. DATA SOURCES A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible. METHODS A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression. RESULTS Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women. CONCLUSIONS The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling. STUDY REGISTRATION PROSPERO Registration Number CRD42014013764. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Nasuh Büyükkaramikli
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | | | | | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK.,School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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25
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Pandit AK, Kumar P, Kumar A, Chakravarty K, Misra S, Prasad K. High-dose statin therapy and risk of intracerebral hemorrhage: a meta-analysis. Acta Neurol Scand 2016; 134:22-8. [PMID: 26647879 DOI: 10.1111/ane.12540] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 11/30/2022]
Abstract
Statin plays a major role in the primary and secondary prevention of cardiovascular disease (CVD). Inconsistent findings in the studies have been observed toward the risk of intracerebral hemorrhage (ICH) using higher dose of statin. To examine this issue, we performed a meta-analysis of randomized controlled trials (RCTs) to assess the association between higher dose of various statins and risk of ICH among patients with CVD. Literature was searched for studies published before June 10, 2015, using electronic database 'PubMed', 'EMBASE', and 'Google Scholar' as well as from many trial databases. The following search terms were used: 'Statin therapy' AND 'Cardiovascular Disease', AND 'Dose' AND 'Intracerebral hemorrhage', AND 'Randomized Controlled Trials' AND 'High Dose Statin'. High dose of statins was defined as atorvastatin 80 mg, simvastatin 80 mg, pravastatin 40 mg, rosuvastatin 20 mg per day. Fixed-effect model was used to estimate the risk ratio (RR) and 95% confidence interval (CI) if heterogeneity was <50%; otherwise, random-effect model was used. Begg's funnel plot was used to assess the publication bias. Seven RCTs involving 31,099 subjects receiving high-dose statin and 31,105 subjects receiving placebo were analyzed in our meta-analysis. A significant risk of ICH was observed in subjects with higher dose of statin (RR = 1.53; 95% CI: 1.16-2.01; P = 0.002). There was no difference in all-cause mortality between the two groups (RR = 0.95; 95% CI: 0.86-1.06; P = 0.36). No publication bias was observed through Begg's funnel plot. Higher dose of statins was found to be associated with the risk of ICH. Future studies are needed to confirm these findings.
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Affiliation(s)
- A. K. Pandit
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - P. Kumar
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - A. Kumar
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - K. Chakravarty
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - S. Misra
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
| | - K. Prasad
- Department of Neurology; All India Institute of Medical Sciences; New Delhi India
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26
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Jhuo SJ, Tsai WC, Lin TH, Voon WC, Lai WT, Sheu SH. Statin Dose and the Risk of Intracerebral Hemorrhage: A Population-Based Longitudinal Study in Taiwan. ACTA CARDIOLOGICA SINICA 2016; 32:23-30. [PMID: 27122928 DOI: 10.6515/acs20150204c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND In the last 15 years, there has been considerable interest in statin use as a means to reduce the likelihood of vascular events. Several clinical trials have shown that high-dose statin (HDS) treatment could reduce vascular events. In high-risk populations, lipid treatment guidelines have generally suggested prescribing statin up to the highest recommended dosage. However, there remains concern about the risk of intracerebral hemorrhage (ICH) with HDS treatment. METHODS This was a national population-based cohort study from the National Health Insurance Research Database of Taiwan extending from July 2001 to December 2008. Patients with cerebrovascular or cardiovascular disease were enrolled. The HDS group was defined as those patients receiving more than 420 mg per year of atorvastatin or an equivalent potency statin. Moderate dose statin group (MDS) was defined as those patients receiving atorvastatin in amounts between 196-420 mg per year or an equivalent potency statin. Low dose statin (LDS) group was defined as those receiving less than 196 mg per year of atorvastatin or an equivalent statin. The primary endpoint is ICH. The secondary endpoints are myocardial infarction (MI), ischemic stroke (IS) and new-onset DM (NDM). RESULTS A total of 5459 patients were enrolled in our study, with study participant ages ranging from 62.91 ± 11.85 years and a mean follow-up time of 2039 ± 6 days. After adjusting for age, gender, diabetes and hypertension, Cox regression analysis found ICH risk was lower in HDS and MDS groups compared with LDS (HR 0.49, 95% CI 0.26-0.91, p = 0.0246 and HR 0.45, 95% CI 0.24-0.86, p = 0.0157). The risk of IS is lower in patients with HDS treatment (HR 0.68, 95% CI 0.55-0.83, p < 0.01). However, the risk of MI and NDM incidence are not statistically significant between the different dose groups. CONCLUSIONS In the real-world data provided by Taiwan's National Health Insurance research database, it was shown that patients who received a higher dose of statin had a reduced and not elevated risk of intracerebral hemorrhage. KEY WORDS High-dose statin; Hyperlipidemia; Intracerebral hemorrhage; Ischemic stroke; New-onset DM.
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Affiliation(s)
- Shih-Jie Jhuo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Wei-Chung Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chol Voon
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Hsiung Sheu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital; ; Department of Internal Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Yaghi S, Elkind MSV. Lipid Control and Beyond: Current and Future Indications for Statin Therapy in Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:27. [PMID: 26920158 DOI: 10.1007/s11936-016-0448-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OPINION STATEMENT Statins are a group of lipid-lowering agents that are competitive inhibitors of the enzyme 3-hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase that have been used to reduce cholesterol levels and prevent cardiovascular events. Statins have been also shown to reduce the risk of stroke. In this review, we cover the role of statins in cerebrovascular disease through lipid-lowering mechanisms and other "pleiotropic" effects that provide protection against cerebrovascular events and potentially contribute to improve functional outcome after stroke.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, Division of Stroke and Cerebrovascular Disease, The Warren Alpert Medical School of Brown University, 593 Eddy St. APC 530, Providence, RI, 02903, USA.
| | - Mitchell S V Elkind
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Kim J, Thrift AG, Nelson MR, Bladin CF, Cadilhac DA. Personalized medicine and stroke prevention: where are we? Vasc Health Risk Manag 2015; 11:601-11. [PMID: 26664130 PMCID: PMC4671759 DOI: 10.2147/vhrm.s77571] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
There are many recommended pharmacological and non-pharmacological therapies for the prevention of stroke, and an ongoing challenge is to improve their uptake. Personalized medicine is seen as a possible solution to this challenge. Although the use of genetic information to guide health care could be considered as the apex of personalized medicine, genetics is not yet routinely used to guide prevention of stroke. Currently personalized aspects of prevention of stroke include tailoring interventions based on global risk, the utilization of individualized management plans within a model of organized care, and patient education. In this review we discuss the progress made in these aspects of prevention of stroke and present a case study to illustrate the issues faced by health care providers and patients with stroke that could be overcome with a personalized approach to the prevention of stroke.
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Affiliation(s)
- Joosup Kim
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia ; Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Mark R Nelson
- Discipline of General Practice, School of Medicine, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Christopher F Bladin
- Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia ; Eastern Health Clinical School, Monash University, Clayton, VIC, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia ; Public Health, Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
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Scutt P, Blackburn D, Krishnan K, Ballard C, Burns A, Ford GA, Mant J, Passmore P, Pocock S, Reckless J, Sprigg N, Stewart R, Wardlaw JM, Bath PM. Baseline characteristics, analysis plan and report on feasibility for the Prevention Of Decline in Cognition After Stroke Trial (PODCAST). Trials 2015; 16:509. [PMID: 26545986 PMCID: PMC4636808 DOI: 10.1186/s13063-015-1033-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 10/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A common complication after stroke is development of cognitive impairment and dementia. However, effective strategies for reducing the risk of developing these problems remain undefined. Potential strategies include intensive lowering of blood pressure (BP) and/or lipids. This paper summarises the baseline characteristics, statistical analysis plan and feasibility of a randomised control trial of blood pressure and lipid lowering in patients post-stroke with the primary objective of reducing cognitive impairment and dementia. METHODS The Prevention Of Decline in Cognition After Stroke Trial (PODCAST) was a multi-centre prospective randomised open-label blinded-endpoint controlled partial-factorial internal pilot trial running in secondary and primary care. Participants without dementia were enrolled 3-7 months post ischaemic stroke or spontaneous intracerebral haemorrhage, and randomised to intensive versus guideline BP lowering (target systolic BP <125 mmHg versus <140 mmHg); patients with ischaemic stroke were also randomised to intensive or guideline lipid lowering (target LDL cholesterol <1.4 mmol/L versus <3 mmol/L). The primary outcome was the Addenbrooke's Cognitive Examination-Revised; a key secondary outcome was to assess feasibility of performing a large trial of one or both interventions. Data are number (%) or mean (standard deviation). The trial was planned to last for 8 years with follow-up between 1 and 8 years. The plan for reporting the main results is included as Additional file 2. RESULTS 83 patients (of a planned 600) were recruited from 19 UK sites between 7 October 2010 and 31 January 2014. Delays, due to difficulties in the provision of excess treatment costs and to complexity of follow-up, led to few centres taking part and a much lower recruitment rate than planned. Patient characteristics at baseline were: age 74 (SD 7) years, male 64 (77 %), index stroke ischaemic 77 (93 %), stroke onset to randomisation 4.5 [SD 1.3] months, Addenbrooke's Cognitive Examination-Revised 86 (of 100, SD 8), Montreal Cognitive Assessment 24 (of 30, SD 3), BP 147/82 (SD 19/11) mmHg, total cholesterol 4.0 (SD 0.8) mmol/L and LDL cholesterol 2.0 (SD 0.7) mmol/L, modified Rankin Scale 1.1 (SD 0.8). CONCLUSION Limited recruitment suggests that a large trial is not feasible using the current protocol. The effects of the interventions on BP, lipids, and cognition will be reported in the main publication. TRIAL REGISTRATION ISRCTN85562386 registered on 23 September 2009.
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Affiliation(s)
- Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital campus, Hucknall Road, Nottingham, NG5 1 PB, UK.
| | - Dan Blackburn
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385A Glossop Road, Sheffield, S10 2HQ, UK.
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital campus, Hucknall Road, Nottingham, NG5 1 PB, UK.
| | - Clive Ballard
- Wolfson Center for Age-Related Diseases, Wolfson Wing, Hodgkin Building, King's College London, Guy's Campus, London, SE1 1UL, UK.
| | - Alistair Burns
- Faculty of Medical and Human Sciences, Institute of Brain, Behavior and Mental Health, University of Manchester, Grafton Street, Manchester, M13 9NT, UK.
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
| | - Jonathan Mant
- General Practice & Primary Care Research Unit, University of Cambridge, Addenbrooke's Hospital, Forvie Site, Cambridge, CB2 0SR, UK.
| | - Peter Passmore
- Institute of Clinical Sciences, Queens University, Belfast, Royal Victoria Hospital, Block B, Belfast, BT12 6BA, UK.
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - John Reckless
- Department of Endocrinology, Royal United Hospital, Combe Park, Bath, BA1 3NG, UK.
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital campus, Hucknall Road, Nottingham, NG5 1 PB, UK.
| | - Rob Stewart
- King's College London (Institute of Psychiatry, Psychology and Neuroscience), Department of Psychological Medicine (Box 63), De Crespigny Park, London, SE5 8AF, UK.
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Western General Hospital, Crewe Rd, Edinburgh, EH4 2XU, UK.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital campus, Hucknall Road, Nottingham, NG5 1 PB, UK.
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Hosomi N, Nagai Y, Kohriyama T, Ohtsuki T, Aoki S, Nezu T, Maruyama H, Sunami N, Yokota C, Kitagawa K, Terayama Y, Takagi M, Ibayashi S, Nakamura M, Origasa H, Fukushima M, Mori E, Minematsu K, Uchiyama S, Shinohara Y, Yamaguchi T, Matsumoto M. The Japan Statin Treatment Against Recurrent Stroke (J-STARS): A Multicenter, Randomized, Open-label, Parallel-group Study. EBioMedicine 2015; 2:1071-8. [PMID: 26501105 PMCID: PMC4588424 DOI: 10.1016/j.ebiom.2015.08.006] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 08/04/2015] [Accepted: 08/04/2015] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although statin therapy is beneficial for the prevention of initial stroke, the benefit for recurrent stroke and its subtypes remains to be determined in Asian, in whom stroke profiles are different from Caucasian. This study examined whether treatment with low-dose pravastatin prevents stroke recurrence in ischemic stroke patients. METHODS This is a multicenter, randomized, open-label, blinded-endpoint, parallel-group study of patients who experienced non-cardioembolic ischemic stroke. All patients had a total cholesterol level between 4.65 and 6.21 mmol/L at enrollment, without the use of statins. The pravastatin group patients received 10 mg of pravastatin/day; the control group patients received no statins. The primary endpoint was the occurrence of stroke and transient ischemic attack (TIA), with the onset of each stroke subtype set to be one of the secondary endpoints. FINDING Although 3000 patients were targeted, 1578 patients (491 female, age 66.2 years) were recruited and randomly assigned to pravastatin group or control group. During the follow-up of 4.9 ± 1.4 years, although total stroke and TIA similarly occurred in both groups (2.56 vs. 2.65%/year), onset of atherothrombotic infarction was less frequent in pravastatin group (0.21 vs. 0.64%/year, p = 0.0047, adjusted hazard ratio 0.33 [95%CI 0.15 to 0.74]). No significant intergroup difference was found for the onset of other stroke subtypes, and for the occurrence of adverse events. INTERPRETATION Although whether low-dose pravastatin prevents recurrence of total stroke or TIA still needs to be examined in Asian, this study has generated a hypothesis that it may reduce occurrence of stroke due to larger artery atherosclerosis. FUNDING This study was initially supported by a grant from the Ministry of Health, Labour and Welfare, Japan. After the governmental support expired, it was conducted in collaboration between Hiroshima University and the Foundation for Biomedical Research and Innovation.
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Affiliation(s)
- Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yoji Nagai
- Foundation for Biomedical Research and Innovation Translational Research Informatics Center, Kobe, Japan
| | | | | | - Shiro Aoki
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Tomohisa Nezu
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hirofumi Maruyama
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Norio Sunami
- Department of Neurological Surgery, Matsuyama Shimin Hospital, Matsuyama, Japan
| | - Chiaki Yokota
- National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Yasuo Terayama
- Department of Neurology, Iwate Medical University, Morioka, Japan
| | - Makoto Takagi
- Department of Neurology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | | | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Masanori Fukushima
- Foundation for Biomedical Research and Innovation Translational Research Informatics Center, Kobe, Japan
| | - Etsuro Mori
- Department of Behavioral Neurology and Cognitive Neuroscience, Tohoku University Graduate School of Medicine, Sendai, Japan
| | | | - Shinichiro Uchiyama
- Clinical Research Center, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Yukito Shinohara
- Federation of National Public Service Personnel Mutual Aid Associations Tachikawa Hospital, Tokyo, Japan
| | | | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Múñoz O, García ÁA, Fernández DG, Higuera AM, Ruiz ÁJ, Aschner P, Toro JM, Arteaga JM, Merchán A, Sánchez Vallejo G, Villalba Y. Guía de práctica clínica para la prevención, detección temprana, diagnóstico, tratamiento y seguimiento de las dislipidemias: tratamiento farmacológico con estatinas. REVISTA COLOMBIANA DE CARDIOLOGÍA 2015. [DOI: 10.1016/j.rccar.2015.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Li C, Lv Z, Shi Z, Zhu Y, Wu Y, Li L, Iheozor-Ejiofor Z. Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis. Cochrane Database Syst Rev 2014:CD009197. [PMID: 25123257 DOI: 10.1002/14651858.cd009197.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an association between chronic periodontitis and cardiovascular disease (CVD). However, it is not known whether periodontal therapy could prevent or manage CVD in patients with chronic periodontitis. OBJECTIVES The objective of this systematic review was to investigate the effects of periodontal therapy in preventing the occurrence of, and management or recurrence of, CVD in patients with chronic periodontitis. SEARCH METHODS The electronic databases that were searched were the Cochrane Oral Health Group's Trials Register (to 7 April 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 3), MEDLINE via OVID (1946 to 7 April 2014), EMBASE via OVID (1980 to 7 April 2014), CINAHL via EBSCO (1937 to 7 April 2014), OpenGrey (to 7 April 2014), the Chinese BioMedical Literature Database (1978 to April 2014), the China National Knowledge Infrastructure (1994 to April 2014) and the VIP database (1989 to April 2014). We searched the US National Institutes of Health Trials Register, the World Health Organization (WHO) Clinical Trials Registry Platform and Sciencepaper Online for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs were considered eligible. Studies were selected if they included patients with a diagnosis of chronic periodontitis and previous CVD (secondary prevention studies) or no CVD (primary prevention studies); patients in the intervention group received active periodontal therapy compared to maintenance therapy, no periodontal treatment or another kind of periodontal treatment in the control group. DATA COLLECTION AND ANALYSIS Two review authors carried out the study identification, data extraction and risk of bias assessment independently and in duplicate. Any discrepancies between the two authors were resolved by discussion or with a third review author. A formal pilot-tested data extraction form was adopted for the data extraction, and the Cochrane Collaboration's tool for risk of bias assessment was used for the critical appraisal of the literature. MAIN RESULTS No studies were identified that assessed primary prevention of CVD in people with periodontitis. One study involving 303 participants with ≥ 50% blockage of one coronary artery or a coronary event within three years, but not the three months prior, was included. The study was at high risk of bias due to deviation from the protocol treatment allocation and lack of follow-up data. The trial compared scaling and root planing (SRP) with community care for a follow-up period of six to 25 months. No data on deaths (all-cause or CVD-related) were reported. There was insufficient evidence to determine the effect of SRP and community care in reducing the risk of CVD recurrence in patients with chronic periodontitis (risk ratio (RR) 0.72; 95% confidence interval (CI) 0.23 to 2.22; very low quality evidence). The effects of SRP compared with community care on high-sensitivity C-reactive protein (hs-CRP) (mean difference (MD) 0.62; -1.45 to 2.69), the number of patients with high hs-CRP (RR 0.77; 95% CI 0.32 to 1.85) and adverse events (RR 9.06; 95% CI 0.49 to 166.82) were also not statistically significant. The study did not assess modifiable cardiovascular risk factors, other blood test results, heart function parameters or revascularisation procedures. AUTHORS' CONCLUSIONS We found very low quality evidence that was insufficient to support or refute whether periodontal therapy can prevent the recurrence of CVD in the long term in patients with chronic periodontitis. No evidence on primary prevention was found.
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Affiliation(s)
- Chunjie Li
- Department of Head and Neck Oncology, West China Hospital of Stomatology, Sichuan University, State Key Laboratory of Oral Diseases, No. 14, Section Three, Ren Min Nan Road, Chengdu, Sichuan, China, 610041
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Lager KE, Mistri AK, Khunti K, Haunton VJ, Sett AK, Wilson AD. Interventions for improving modifiable risk factor control in the secondary prevention of stroke. Cochrane Database Syst Rev 2014:CD009103. [PMID: 24789063 DOI: 10.1002/14651858.cd009103.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved. OBJECTIVES To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (April 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. We located further studies by searching reference lists of articles and contacting authors of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention. DATA COLLECTION AND ANALYSIS Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists. MAIN RESULTS This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m(2); 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions. AUTHORS' CONCLUSIONS Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.
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Affiliation(s)
- Kate E Lager
- Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, UK, LE1 6TP
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Johansen ME, Green LA, Sen A, Kircher S, Richardson CR. Cardiovascular risk and statin use in the United States. Ann Fam Med 2014; 12:215-23. [PMID: 24821892 PMCID: PMC4018369 DOI: 10.1370/afm.1641] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Statins reduce the risk of mortality and coronary artery disease in individuals at high cardiovascular risk. Using nationally representative data, we examined the relationships between statin use and cardiovascular risk, diagnosis of hyperlipidemia, and other risk factors. METHODS We analyzed data from the 2010 Medical Expenditure Panel Survey, a nationally representative survey of the U.S. civilian noninstitutionalized population. The study sample had a total of 16,712 individuals aged 30 to 79 years. Those who reported filling at least 2 statin prescriptions were classified as statin users. We created multiple logistic regression models for statin use as the dependent variable, with cardiovascular risk factors and sociodemographic factors as independent variables. RESULTS Overall, 58.2% (95% CI, 54.6%-61.7%) of individuals with coronary artery disease and 52.0% (95% CI, 49.4%-54.6%) of individuals with diabetes aged older than 40 years were statin users. After adjusting for cardiovascular risk factors and sociodemographic factors, the probability of being on a statin was significantly higher among individuals with both hyperlipidemia and coronary artery disease, at 0.44 (95% CI, 0.40-0.48), or hyperlipidemia only, at 0.32 (95% CI, 0.30-0.33), than among those with coronary artery disease only, at 0.11 (95% CI, 0.07-0.15). A similar pattern was seen in people with diabetes. CONCLUSIONS In this nationally representative sample, many people at high risk for cardiovascular events, including those with coronary artery disease, diabetes, or both, were not receiving statins despite evidence that these agents reduce adverse events. This undertreatment appears to be related to placing too much emphasis on hyperlipidemia and not enough on cardiovascular risk. Recently released guidelines from the American College of Cardiology and the American Heart Association offer an opportunity to improve statin use by focusing on cardiovascular risk instead of lipid levels.
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Lackland DT, Roccella EJ, Deutsch AF, Fornage M, George MG, Howard G, Kissela BM, Kittner SJ, Lichtman JH, Lisabeth LD, Schwamm LH, Smith EE, Towfighi A. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45:315-53. [PMID: 24309587 PMCID: PMC5995123 DOI: 10.1161/01.str.0000437068.30550.cf] [Citation(s) in RCA: 559] [Impact Index Per Article: 55.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden. METHODS Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions. CONCLUSIONS The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.
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Nagai Y, Kohriyama T, Origasa H, Minematsu K, Yokota C, Uchiyama S, Ibayashi S, Terayama Y, Takagi M, Kitagawa K, Nomura E, Hosomi N, Ohtsuki T, Yamawaki T, Matsubara Y, Nakamura M, Yamasaki Y, Mori E, Fukushima M, Kobayashi S, Shinohara Y, Yamaguchi T, Matsumoto M. Rationale, design, and baseline features of a randomized controlled trial to assess the effects of statin for the secondary prevention of stroke: the Japan Statin Treatment Against Recurrent Stroke (J-STARS). Int J Stroke 2013; 9:232-9. [PMID: 24015915 PMCID: PMC4283729 DOI: 10.1111/ijs.12099] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although statin therapy is beneficial for preventing first strokes, the benefit for recurrent stroke and its sub-types remains unknown in Asian populations. The aim of this study is to examine the role of pravastatin in the secondary prevention of stroke in Japanese patients. METHODS This is a multicenter, randomized, open-label, parallel group study of patients with noncardioembolic ischemic stroke (atherothrombotic infarction, lacunar infarction, and infarction of undetermined etiology). All patients were diagnosed with hyperlipidemia and with a total cholesterol level between 180 and 240 mg/dl at enrollment. Patients in the treatment group receive 10 mg/day of pravastatin, and those in the control group receive no statin treatment. The primary end-point is the recurrence of stroke, including transient ischemic attack. The secondary end-points include the onset of respective stroke sub-types and functional outcomes related to stroke. The patients were enrolled for five-years and will be followed up for five-years. RESULTS A total of 1578 eligible patients (age: 66·2 years, men: 68·8%), including 64·2% with lacunar infarction, 25·4% with atherothrombotic infarction, and 10·4% with infarction of undetermined etiology were included in this study. Lipid levels were generally well controlled (total cholesterol: 210·0 mg/dl, low density lipoprotein cholesterol: 129·5 mg/dl) at baseline. In addition, the disability of patients was relatively mild, and cognitive function was preserved in the majority of patients. CONCLUSION This article reports the rationale, design, and baseline features of a randomized controlled trial to assess the effects of statin for the secondary prevention of stroke. Follow-ups of patients are in progress and will end in 2014.
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Affiliation(s)
- Yoji Nagai
- Foundation for Biomedical Research and Innovation Translational Research Informatics Center, Kobe, Japan
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Edwards D, Fletcher K, Deller R, McManus R, Lasserson D, Giles M, Sims D, Norrie J, McGuire G, Cohn S, Whittle F, Hobbs V, Weir C, Mant J. RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial. Trials 2013; 14:194. [PMID: 23819476 PMCID: PMC3716929 DOI: 10.1186/1745-6215-14-194] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 06/14/2013] [Indexed: 11/23/2022] Open
Abstract
Background People who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist – that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist? Methods/Design This is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard. Discussion This pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA. Trial registration ISRCTN62019087
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Affiliation(s)
- Duncan Edwards
- General Practice and Primary Care Research Unit, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK
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Boyd CM, Vollenweider D, Puhan MA. Informing evidence-based decision-making for patients with comorbidity: availability of necessary information in clinical trials for chronic diseases. PLoS One 2012; 7:e41601. [PMID: 22870234 PMCID: PMC3411714 DOI: 10.1371/journal.pone.0041601] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 06/22/2012] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The population with multiple chronic conditions is growing. Prior studies indicate that patients with comorbidities are frequently excluded from trials but do not address whether information is available in trials to draw conclusions about treatment effects for these patients. METHODS AND FINDINGS We conducted a literature survey of trials from 11 Cochrane Reviews for four chronic diseases (diabetes, heart failure, chronic obstructive pulmonary disease, and stroke). The Cochrane Reviews systematically identified and summarized trials on the effectiveness of diuretics, metformin, anticoagulants, longacting beta-agonists alone or in combination with inhaled corticosteroids, lipid lowering agents, exercise and diet. Eligible studies were reports of trials included in the Cochrane reviews and additional papers that described the methods of these trials. We assessed the exclusion and inclusion of people with comorbidities, the reporting of comorbidities, and whether comorbidities were considered as potential modifiers of treatment effects. Overall, the replicability of both the inclusion criteria (mean [standard deviation (SD)]: 6.0 (2.1), range (min-max): 1-9.5) and exclusion criteria (mean(SD): 5.3 (2.1), range: 1-9.5) was only moderate. Trials excluded patients with many common comorbidities. The proportion of exclusions for comorbidities ranged from 0-42 percent for heart failure, 0-55 percent for COPD, 0-44 percent for diabetes, and 0-39 percent for stroke. Seventy of the 161 trials (43.5%) described the prevalence of any comorbidity among participants with the index disease. The reporting of comorbidities in trials was very limited, in terms of reporting an operational definition and method of ascertainment for the presence of comorbidity and treatments for the comorbidity. It was even less common that the trials assessed whether comorbidities were potential modifiers of treatment effects. CONCLUSIONS Comorbidities receive little attention in chronic disease trials. Given the public health importance of people with multiple chronic conditions, trials should better report on comorbidities and assess the effect comorbidities have on treatment outcomes.
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Affiliation(s)
- Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America.
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Abstract
Although evidence from epidemiological studies examining a relationship between cholesterol level and stroke is less than definitive, there is a compelling evidence from the clinical therapy trials primarily designed to examine the coronary benefits of statins that statin therapy also causes a reduction in the risk of stroke. Even though a stroke does not have the same exact pathophysiology as a heart attack, specific trials in stroke patients confirm advantages and risks of statin therapy in this kind of population. In primary prevention, statins are effective both when low-density lipoprotein (LDL) is raised and when hs-CRP is elevated. In secondary prevention, an absolute reduction of recurrent stroke can be obtained with statins, with a number needed to treat at 5 years of 45.
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Affiliation(s)
- Ugo Paliani
- Division of Internal Medicine, ASL 1 Umbria, via Engels-Voc.Chioccolo, 06012 Città di Castello (Perugia), Italy.
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Zirpoli H, Caputo M, Carraturo A, Torino G, Fazio A, Attya M, Rastrelli L, Tecce MF. Selective action of human sera differing in fatty acids and cholesterol content on in vitro gene expression. J Cell Biochem 2012; 113:815-23. [PMID: 22021027 DOI: 10.1002/jcb.23409] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Serum constituents might directly affect metabolic diseases pathogenesis and are commonly used as diagnostic tool. The aim of this study was to investigate the human serum effect on in vitro gene expression, related to nutrients action and involved in lipid metabolism. In detail, 40 human sera were firstly analyzed in fatty acids profile by gas-chromatography. Then samples were tested through direct addition within culture medium on Hep G2 human hepatoma cells, comparing samples from hypercholesterolemic (average 273 mg/dl) versus normocholesterolemic male subjects (average 155 mg/dl), since this condition is a relevant disease risk factor and is typically consequent to nutritional style. Hypercholesterolemic sera produced a 0.4-fold reduction of sterol regulatory element binding protein 1c (SREBP-1c) mRNA (P < 0.05) and a 1.5-fold increase of UDP-glucuronosyltransferase 1A1 (UGT1A1) mRNA (P < 0.01). Samples with higher concentrations of n-6 fatty acids produced a higher expression of UGT1A1 mRNA. Total fatty acids [docosahexaenoic, eicosopentanoic, arachidonic, linolenic, and linoleic acid (DHA, EPA, AA, LNA, and LA, respectively)] in each serum resulted roughly inverse with trend of SREBP-1c mRNA expression. Serum AA, LA, and trans fatty acids were more abundant in hypercholesterolemic subjects (P < 0.01) while DHA as quota of detected fatty acids was significantly higher in normocholesterolemic subjects (P < 0.05). While it is not possible to indicate which component was responsible for the observed gene modulations, our data indicate that sera differing in lipid profiles, mainly associated with dietary behavior, differentially affect gene expression known to be involved in metabolic and nutritional related conditions.
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Affiliation(s)
- Hylde Zirpoli
- Department of Pharmaceutical and Biomedical Sciences, University of Salerno, via Ponte Don Melillo, 84084 Fisciano, Salerno, Italy
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Cataldo MC, Calcara ML, Caputo G, Mammina C. Association of total serum cholesterol with functional outcome following home care rehabilitation in Italian patients with stroke. Disabil Health J 2012; 5:111-6. [PMID: 22429545 DOI: 10.1016/j.dhjo.2011.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Revised: 11/04/2011] [Accepted: 11/17/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stroke is a disabling disease. In elderly populations, stroke is the third leading cause of death and the primary cause of reduction in or loss of functional ability and personal autonomy. Possible associations between levels of total serum cholesterol (TC) and both incidence of stroke and functional outcomes after rehabilitation are still under study. OBJECTIVE To detect positive and negative prognostic factors associated with functional outcomes in first-time stroke patients admitted to an integrated home care rehabilitative program. METHODS This study enrolled 141 patients with a first-time stroke who were admitted to a home care rehabilitation program. Primary outcome measures were the Barthel activities of daily living (ADL) and mobility indices at the beginning and end of the rehabilitative treatment. The impact of TC and other demographic and clinical variables was analyzed using bivariate and multivariate logistic regression analyses. RESULTS Age and Short Portable Mental Status Questionnaire (SPMSQ) score were negatively associated with functional outcome. In contrast, elevated TC was positively associated with a better home rehabilitative treatment outcome. Barthel index score at admission was negatively associated with outcomes assessed by the Barthel ADL index and age with outcomes assessed by the Barthel mobility index. In a multivariate logistic regression analysis, SPMSQ score and elevated TC were significantly associated with outcome. Specifically, higher SPMSQ scores were negatively associated with better rehabilitative treatment outcomes, whereas elevated TC was positively associated. CONCLUSIONS Elevated TC seems to be associated with better functional outcomes in patients with first-time stroke.
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Affiliation(s)
- Maria Concetta Cataldo
- Geriatric Assessment and Integrated Home Care Unit, District 10, Regional Health Agency 6, Palermo, Italy
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Li C, Lv Z, Shi Z, Zhu Y, Wu Y, Li L. Periodontal therapy for the management of cardiovascular disease in patients with chronic periodontitis. Cochrane Database Syst Rev 2011. [DOI: 10.1002/14651858.cd009197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Vollenweider D, Boyd CM, Puhan MA. High prevalence of potential biases threatens the interpretation of trials in patients with chronic disease. BMC Med 2011; 9:73. [PMID: 21663701 PMCID: PMC3141538 DOI: 10.1186/1741-7015-9-73] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 06/13/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The complexity of chronic diseases is a challenge for investigators conducting randomized trials. The causes for this include the often difficult control for confounding, the selection of outcomes from many potentially important outcomes, the risk of missing data with long follow-up and the detection of heterogeneity of treatment effects. Our aim was to assess such aspects of trial design and analysis for four prevalent chronic diseases. METHODS We included 161 randomized trials on drug and non-drug treatments for chronic obstructive pulmonary disease, type 2 diabetes mellitus, stroke and heart failure, which were included in current Cochrane reviews. We assessed whether these trials defined a single outcome or several primary outcomes, statistically compared baseline characteristics to assess comparability of treatment groups, reported on between-group comparisons, and we also assessed how they handled missing data and whether appropriate methods for subgroups effects were used. RESULTS We found that only 21% of all chronic disease trials had a single primary outcome, whereas 33% reported one or more primary outcomes. Two of the fifty-one trials that tested for statistical significance of baseline characteristics adjusted the comparison for a characteristic that was significantly different. Of the 161 trials, 10% reported a within-group comparison only; 17% (n = 28) of trials reported how missing data were handled (50% (n = 14) carried forward last values, 27% (n = 8) performed a complete case analysis, 13% (n = 4) used a fixed value imputation and 10% (n = 3) used more advanced methods); and 27% of trials performed a subgroup analysis but only 23% of them (n = 10) reported an interaction test. Drug trials, trials published after wide adoption of the CONSORT (CONsolidated Standards of Reporting Trials) statement (2001 or later) and trials in journals with higher impact factors were more likely to report on some of these aspects of trial design and analysis. CONCLUSION Our survey showed that an alarmingly large proportion of chronic disease trials do not define a primary outcome, do not use appropriate methods for subgroup analyses, or use naïve methods to handle missing data, if at all. As a consequence, biases are likely to be introduced in many trials on widely prescribed treatments for patients with chronic disease.
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Affiliation(s)
- Daniela Vollenweider
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Feher A, Pusch G, Koltai K, Tibold A, Gasztonyi B, Szapary L, Feher G. Statintherapy in the primary and the secondary prevention of ischaemic cerebrovascular diseases. Int J Cardiol 2010; 148:131-8. [PMID: 20843571 DOI: 10.1016/j.ijcard.2010.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 05/14/2010] [Accepted: 08/08/2010] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Stroke is a major public health problem. It is the third leading cause of death worldwide and results in hospital admissions, morbidity, and long-term disability. Despite the inconsistent or weak association between cholesterol and stroke, statins can reduce the incidence of stroke in high-risk populations and in patients with a stroke or transient ischaemic attack. METHODS The aim of our study was to review the efficacy of statin therapy in both primary and secondary stroke prevention. We also reviewed the effectiveness and cost-effectiveness among different statins and we also reviewed the possible effect of treatment added to statin monotherapy. RESULTS There is evidence that statin therapy in both primary and secondary prevention significantly reduces subsequent major coronary events but only marginally reduces the risk of stroke recurrence. There is no clear evidence of beneficial effect from statins in those with previous haemorrhagic stroke and it is unclear whether statins should be started immediately post stroke or later. There is a pressing need for direct evidence, from head-to-head trials, to determine whether individual statins provide differing protection from clinically important events in stroke prevention. It is possible that combinations of lipid-lowering agents did not improve clinical outcomes more than high-dose statin monotherapy, although clinical trials are still ongoing.
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Affiliation(s)
- Andrea Feher
- Department of Neurology, University of Pecs, School of Medicine, Pecs, Hungary
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Abstract
Cardiovascular risk factors have been associated with 2 common manifestation of unhealthy brain in older people, cognitive impairment and depression. The evidence for these effects is almost entirely observational, but links hypertension, smoking, hypercholesterolemia, diabetes mellitus, and hyperhomocysteinemia with cognitive impairment and depression. Unfortunately randomized trials evaluating interventions for these risk factors on the outcomes of cognition or mood have either been inconclusive or negative. However, as there are considerable other health benefits from targeting cardiovascular risk factors, these interventions should be more widely adopted, which would also probably result in positive outcomes for the brain.
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The Cochrane Database of Systematic Reviews--issue 3 2009. J Evid Based Med 2009; 2:205-6. [PMID: 21349014 DOI: 10.1111/j.1756-5391.2009.01036.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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