Effects of low serum triglyceride on stroke mortality: A prospective follow-up study

Low-Density Lipoprotein Cholesterol to Triglyceride Ratio and Clinical Outcomes after Acute Ischaemic Stroke or Transient Ischaemic Attack

AIMS

Studies showed that low-density lipoprotein cholesterol (LDL-C) to triglyceride (TG) ratio could be used as a predictive parameter of low-density lipoprotein oxidation in vivo and the level of small dense LDL-C. However, whether LDL-C/TG ratio is associated with stroke prognosis remains unclear. We investigated the associations of LDL-C/TG ratio with outcomes in patients with acute ischaemic stroke (AIS) or transient ischaemic attacks (TIA) and explored whether it produced more predictive value than LDL-C and TG.

METHODS

Data were derived from the Third China National Stroke Registry (CNSR-III). Multivariable Cox regression for stroke recurrence, composite vascular events and all-cause death and logistic regression for the poor functional outcome (modified Rankin Scale score 3-6) were used.

RESULTS

A total of 14123 patients were included. After adjusting for confounding factors, quartile 4 of LDL-C/TG ratio was associated with an increased risk of recurrent stroke (hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.03-1.56), composite vascular events (HR,1.23; 95% CI, 1.00-1.52), death (HR,1.70; 95% CI, 1.13-2.54) and poor functional outcome (odds ratio, 1.34; 95% CI, 1.12-1.61) at 3 months follow-up compared with quartile 1. We also found that quartile 4 of LDL-C and TG was positively and negatively associated with poor functional outcome at 3 months, respectively. LDL-C/TG ratio performed better than LDL-C or TG in predicting clinical outcomes.

CONCLUSIONS

LDL-C/TG ratio was associated with the risk of stroke recurrence, composite vascular events, death and poor functional outcome in patients with AIS or TIA.

Association between the triglyceride-glucose index and all-cause and CVD mortality in the young population with diabetes

BACKGROUND

Although studies have demonstrated the value of the triglyceride-glucose (TyG) index for cardiovascular disease (CVD) and cardiovascular mortality, however, few studies have shown that the TyG index is associated with all-cause or CVD mortality in young patients with diabetes. This study aimed to investigate the association between the TyG index and all-cause and CVD mortality in young patients with diabetes in the United States.

METHODS

Our study recruited 2440 young patients with diabetes from the National Health and Nutrition Examination Survey (NHANES) 2001-2018. Mortality outcomes were determined by linking to National Death Index (NDI) records up to December 31, 2019. Cox regression modeling was used to investigate the association between TyG index and mortality in young patients with diabetes. The nonlinear association between TyG index and mortality was analyzed using restricted cubic splines (RCS), and a two-segment Cox proportional risk model was constructed for both sides of the inflection point.

RESULTS

During a median follow-up period of 8.2 years, 332 deaths from all causes and 82 deaths from cardiovascular disease were observed. Based on the RCS, the TyG index was found to have a U-shaped association with all-cause and CVD mortality in young patients with diabetes, with threshold values of 9.18 and 9.16, respectively. When the TyG index was below the threshold value (TyG index < 9.18 in all-cause mortality and < 9.16 in CVD mortality), its association with all-cause and CVD mortality was not significant. When the TyG index was above the threshold (TyG index ≥ 9.18 in all-cause mortality and ≥ 9.16 in CVD mortality), it showed a significant positive association with all-cause mortality and CVD mortality (HR 1.77, 95% CI 1.05-2.96 for all-cause mortality and HR 2.38, 95% CI 1.05-5.38 for CVD mortality).

CONCLUSION

Our results suggest a U-shaped association between TyG index and all-cause and CVD mortality among young patients with diabetes in the United States, with threshold values of 9.18 and 9.16 for CVD and all-cause mortality, respectively.

Association between serum triglycerides and stroke type, severity, and prognosis. Analysis in 6558 patients

BACKGROUND AND OBJECTIVES

Hypertriglyceridemia (HT) may increase the risk of stroke. Limited studies have shown that stroke severity and infarction size are smaller in patients with HT. We explored the relationship between triglyceride levels and stroke risk factors, severity and outcome in a large prospective database.

DESIGN

Prospective Cross-sectional study.

SETTING

We retrospectively interrogated the Qatar Stroke Database in all patients admitted between 2014-2022 with acute ischemic stroke and evaluated the relationship between triglyceride, diabetes, stroke severity (measured on NIHSS), stroke type (TOAST classification) and the short- (mRS at 90 days) and long-term outcomes (MACE at 1 year) in patients with HT.

PARTICIPANTS

Six thousand five hundred fifty-eight patients ≥20 years were included in this study RESULTS: Six thousand five hundred fifty-eight patients with ischemic stroke [mean age 54.6 ± 12. 9; male 82.1%) were included. Triglyceride levels upon admission were low-normal (≤1.1 mmol/L) in 2019 patients, high-normal (1.2-1.7 mmol/L) in 2142 patients, borderline-high (1.8-2.2 mmol/L) in 1072 patients and high (≥2.3 mmol/L) in 1325 patients. Higher triglyceride levels were associated with stroke and increased likelihood of having diabetes, obesity, active smoking, and small vessel/lacunar stroke type. An inverse relationship was noted whereby higher triglyceride levels were associated with lower stroke severity and reduced likelihood of poorer outcome (mRS 3-6) at discharge and 90 days. Long-term MACE events were less frequent in patients with higher triglyceride levels. After adjusting age, gender, diabetes, prior stroke, CAD, and obesity, multivariate analysis showed that hypertension and triglyceride levels were higher in mild ischemic strokes patients.

CONCLUSIONS

Increasing triglycerides are associated with higher risk of small vessel disease and requires further prospective cohort studies for confirmation.

Metabolic syndrome and ischaemic stroke in non-anticoagulated atrial fibrillation with low CHA2DS2-VASc scores

OBJECTIVE

Conflicting results have been reported on whether metabolic syndrome (MetS) confers an increased risk of ischaemic stroke in atrial fibrillation (AF). We investigated the risk of ischaemic stroke according to MetS in patients with AF who are not indicated for oral anticoagulants.

METHODS

A total of 76 015 oral anticoagulant-naïve patients with AF with low Congestive Heart Failure, Hypertension, Age ≥75 years (Doubled), Diabetes Mellitus, Stroke (Doubled), Vascular Disease, Age 65-74 years, Sex Category (Female) (CHA2DS2-VASc) score (0 and 1) were included from the National Health Information Database. The risk of ischaemic stroke was evaluated according to MetS, the number of MetS components (metabolic burden), and individual metabolic components defined by health examination data within 2 years of AF diagnosis.

RESULTS

MetS was prevalent among 21 570 (28.4%) of the entire study population (mean age 49.8±11.1 years, mean CHA2DS2-VASc score 0.7±0.5). During a mean follow-up of 5.1 years, ischaemic stroke occurred in 1395 (1.84%) patients. MetS was associated with a higher risk of ischaemic stroke (adjusted HR (aHR) 1.19, 95% CI 1.06 to 1.33, p=0.002). Patients with the highest number of MetS components (4 or 5) showed the greatest aHR of 1.38 (95% CI 1.13 to 1.69), whereas those with a single component had a marginal risk of ischaemic stroke (aHR 1.17, 95% CI 0.97 to 1.40). Elevated blood pressure and increased waist circumference were independent components associated with 1.48-fold and 1.15-fold higher risks of ischaemic stroke, respectively.

CONCLUSION

Among AF patients with CHA2DS2-VASc scores of 0 and 1 with no anticoagulation, MetS is associated with an increased risk of ischaemic stroke. Given the linear incremental association between metabolic burden and ischaemic stroke, the integrated management of metabolic derangements in AF is required.

A nomogram predicts early neurological deterioration after mechanical thrombectomy in patients with ischemic stroke

Introduction

Early neurological deterioration (END) is common in acute ischemic stroke and is directly associated with poor outcome after stroke. Our aim is to develop and validate a nomogram to predict the risk of END after mechanical thrombectomy (MT) in acute ischemic stroke patients with anterior circulation large-vessel occlusion.

Methods

We conducted a real-world, multi-center study in patients with stroke treated with mechanical thrombectomy. END was defined as a worsening by 2 or more NIHSS points within 72-hour after stroke onset compared to admission. Multivariable logistic regression was used to determine the independent predictors of END, and the discrimination of the scale was assessed using the C-index. Calibration curves were constructed to evaluate the calibration of the nomogram, and decision curves were used to describe the benefits of using the nomogram.

Results

A total of 1007 patients were included in our study. Multivariate logistic regression analysis found age, admission systolic blood pressure, initial NIHSS scores, history of hyperlipemia, and location of occlusion were independent predictors of END. We developed a nomogram that included these 6 factors, and it revealed a prognostic accuracy with a C-index of 0.678 in the derivation group and 0.650 in the validation group. The calibration curves showed that the nomogram provided a good fit to the data, and the decision curves demonstrated a large net benefit.

Discussion

Our study established and validated a nomogram to stratify the risk of END before mechanical embolectomy and identify high-risk patients, who should be more cautious when making clinical decisions.

Association between lipid levels and all-cause and cause-specific mortality in critically ill patients

Extremely low lipid levels are considered a sign of debilitation and illness. The association between lipid levels and the risk of mortality in critically ill patients has not been well investigated. This study was designed to evaluate the association between lipid levels and all-cause and cause-specific mortality in critically ill patients using a large collaborative research database known as the eICU database. In total, 27,316 individuals with low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) and triglyceride (TG) measurements were analyzed. A J-shaped association was observed between LDL-C, HDL-C, and TC levels and all-cause and noncardiovascular mortality, with low concentrations associated with higher risk. LDL-C, HDL-C and TC levels in the first quintile were associated with higher all-cause and noncardiovascular mortality but not with cardiovascular mortality compared to the reference quintile. There was a marked synergistic effect between low LDL-C combined with low HDL-C on the risk of mortality. Individuals with LDL-C ≤ 96 mg/dL and HDL-C ≤ 27 mg/dL had an increased risk of all-cause mortality (OR 1.52, 95% CI: 1.26-1.82), cardiovascular mortality (OR 1.07, 95% CI: 1.37-1.76) and noncardiovascular mortality (OR 1.82, 95% CI: 1.37-2.43). The results of this observational cohort showed that low LDL-C, HDL-C and TC levels were independently associated with higher all-cause and noncardiovascular mortality in critically ill patients.

Hypertriglyceridemia: A Neglected Risk Factor for Ischemic Stroke?

Hypertriglyceridemia is caused by defects in triglyceride metabolism and generally manifests as abnormally high plasma triglyceride levels. Although the role of hypertriglyceridemia may not draw as much attention as that of plasma cholesterol in stroke, plasma triglycerides, especially nonfasting triglycerides, are thought to be correlated with the risk of ischemic stroke. Hypertriglyceridemia may increase the risk of ischemic stroke by promoting atherosclerosis and thrombosis and increasing blood viscosity. Moreover, hypertriglyceridemia may have some protective effects in patients who have already suffered a stroke via unclear mechanisms. Therefore, further studies are needed to elucidate the role of hypertriglyceridemia in the development and prognosis of ischemic stroke.

Biomarkers Predictive of Long-Term Outcome After Ischemic Stroke: A Meta-Analysis

BACKGROUND AND PURPOSE

The goal of this study was to systematically review the utility of serum biomarkers in the setting of ischemic stroke (IS) to predict long-term outcome.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986-2018. All studies assessing long-term functional outcome (defined as 30 days or greater) following IS with respect to serum biomarkers were included. Data were extracted and pooled using a meta-analysis of odds ratios.

RESULTS

Of the total 2928 articles in the original literature search, 183 studies were ultimately selected. A total of 127 serum biomarkers were included. Biomarkers were grouped into several categories: inflammatory (32), peptide/enzymatic (30), oxidative/metabolic (28), hormone/steroid based (23), and hematologic/vascular (14). The most commonly studied biomarkers in each category were found to be CRP, S100β, albumin, copeptin, and D-dimer. With the exception of S100β, all were found to be statistically associated with >30-day outcome after ischemic stroke.

CONCLUSIONS

Serum-based biomarkers have the potential to predict functional outcome in IS patients. This meta-analysis has identified CRP, albumin, copeptin, and D-dimer to be significantly associated with long-term outcome after IS. These biomarkers have the potential to serve as a platform for prognosticating stroke outcomes after 30 days. These serum biomarkers, some of which are routinely ordered, can be combined with imaging biomarkers and used in artificial intelligence algorithms to provide refined predictive outcomes after injury. Ultimately these tools will assist physicians in providing guidance to families with regards to long-term independence of patients.

Relationship between serum lipid levels and ischemic stroke in patients with atrial fibrillation: a nested case-control study based on the China Atrial Fibrillation Registry

BACKGROUND

Atrial fibrillation (AF) is an important risk factor for acute ischemic stroke.

METHODS

A nested case-control study was conducted among patients diagnosed with AF, whose information was acquired from the prospective China Atrial Fibrillation Registry (China-AF), from August 2011 to December 2018.

RESULTS

This study compared patients with stroke group (n = 145) with a matched control group (n = 577). Demographic data were similar except for body mass index (BMI), diastolic blood pressure (DBP) which were higher, and new oral anticoagulant (NOAC) treatment rate which was lower in the stroke group (all P < 0.05). Baseline median [IQR] levels of including triglyceride (TG) were higher in the stroke group (21.96 [16.74, 21.52], mg/dL) than the control group (19.62 [14.76, 27.36], mg/dL) (P = 0.012), while the total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were similar between the two groups. Elevated TG and HDL-C were positively associated with ischemic stroke (OR 1.01, 95% CI 1.00-1.02, P = 0.032; OR 1.03, 95% CI 1.00-1.05, P = 0.025), after adjustment for BMI, systolic blood pressure, DBP, CHA₂DS₂-VASc score, HAS-BLED score, NOAC, LDL-C and HDL-C. However, NOAC (OR 0.20, 95% CI 0.05-0.84, P = 0.029) could decrease the likelihood of ischemic stroke in patients with AF. In subgroup analysis, higher TG level remained significantly associated with ischemic stroke for AF patients without a history of smoking (OR 1.26, 95% CI 1.02-1.55, P = 0.028).

CONCLUSION

Higher level of TG and HDL-C were positively associated with ischemic stroke in patients with AF.

Disparities in cardio metabolic risk between Black and White women with polycystic ovary syndrome: a systematic review and meta-analysis

OBJECTIVE

We conducted a systematic review and meta-analysis to summarize and quantitatively pool evidence on cardiometabolic health disparities between Black and White women with polycystic ovary syndrome in the United States in response to the call for further delineation of these disparities in the international evidence-based guideline for the assessment and management of polycystic ovary syndrome.

DATA SOURCES

Databases of MEDLINE, Web of Science, and Scopus were searched initially through March 05, 2020, and confirmed on September 11, 2020.

STUDY ELIGIBILITY CRITERIA

Observational studies documenting cardiometabolic risk profile (glucoregulatory, lipid profile, anthropometric, and blood pressure status) in Black and White women with polycystic ovary syndrome were included. Studies on children (<17 years old) and pregnant or menopausal-aged women (>50 years) were excluded. The primary outcome was fasting glucose. Furthermore, data on major cardiovascular events (stroke, coronary heart disease, heart failure) and mortality rate (cardiovascular death, total mortality) were evaluated.

METHODS

Data were pooled by random-effects models and expressed as mean differences and 95% confidence intervals. Studies were weighted based on the inverse of the variance. Heterogeneity was evaluated by Cochran Q and I2 statistics. Study methodologic quality was assessed by the Newcastle-Ottawa scale.

RESULTS

A total of 11 studies (N=2851 [652 Black and 2199 White]) evaluated cardiometabolic risk profile and all had high quality (Newcastle-Ottawa scale score of ≥8). No studies reported on cardiovascular events and mortality rate. Black women had comparable fasting glucose (-0.61 [-1.69 to 2.92] mg/dL; I2=62.5%), yet exhibited increased fasting insulin (6.76 [4.97-8.56] μIU/mL; I2=59.0%); homeostatic model assessment of insulin resistance (1.47 [0.86-2.08]; I2=83.2%); systolic blood pressure (3.32 [0.34-6.30] mm Hg; I2=52.0%); and decreased triglyceride (-32.56 [-54.69 to -10.42] mg/dL; I2=68.0%) compared with White women (all, P≤.03). Groups exhibited comparable total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and diastolic blood pressure (all, P≥.06).

CONCLUSIONS

Black women with polycystic ovary syndrome have a greater tendency for an adverse cardiometabolic risk profile (increased insulin, homeostatic model assessment of insulin resistance, and systolic blood pressure) despite lower triglycerides than White women. Our observations support the consideration of these disparities for diagnostic, monitoring, and management practices in Black women and for future guideline recommendations. Given the heterogeneity among studies, future research should address the relative contributions of biologic, environmental, socioeconomic, and healthcare factors to the observed disparities. Furthermore, longitudinal research is required to address patient-pressing complications, including cardiovascular events and mortality rate in Black women with polycystic ovary syndrome as a high-risk yet understudied population.

Relationship between non-fasting triglycerides and cardiovascular disease mortality in a 20-year follow-up study of a Japanese general population: NIPPON DATA90

Background

Non-fasting triglycerides (TG) are considered a better predictor of cardiovascular disease (CVD) than fasting TG. However, the effect of non-fasting TG on fatal CVD events remains unclear. In the present study, we aimed to explore the relationship between non-fasting TG and CVD mortality in a Japanese general population.

Methods

A total of 6,831 participants without a history of CVD, in which those who had a blood sampling over 8 hours or more after a meal were excluded, were followed for 18.0 years. We divided participants into seven groups according to non-fasting TG levels: ≤59 mg/dL, 60–89 mg/dL, 90–119 mg/dL, 120–149 mg/dL, 150–179 mg/dL, 180–209 mg/dL, and ≥210 mg/dL, and estimated the multivariable-adjusted hazard ratios (HRs) of each TG group for CVD mortality after adjusting for potential confounders, including high density lipoprotein cholesterol. Additionally, we performed analysis stratified by age <65 and ≥65 years.

Results

During the follow-up period, 433 deaths due to CVD were detected. Compared with a non-fasting TG of 150–179 mg/dL, non-fasting TG ≥210 mg/dL was significantly associated with increased risk for CVD mortality (HR 1.56: 95% CI, 1.01–2.41). Additionally, lower levels of non-fasting TG were also significantly associated with increased risk for fatal CVD. In participants aged ≥65 years, lower levels of non-fasting TG had a stronger impact on increased risk for CVD mortality, while higher levels of non-fasting TG had a stronger impact in those aged <65 years.

Conclusion

In a general Japanese population, we observed a U-shaped association between non-fasting TG and fatal CVD events.

Combined Utility of 25 Disease and Risk Factor Polygenic Risk Scores for Stratifying Risk of All-Cause Mortality

While genome-wide association studies have identified susceptibility variants for numerous traits, their combined utility for predicting broad measures of health, such as mortality, remains poorly understood. We used data from the UK Biobank to combine polygenic risk scores (PRS) for 13 diseases and 12 mortality risk factors into sex-specific composite PRS (cPRS). These cPRS were moderately associated with all-cause mortality in independent data within the UK Biobank: the estimated hazard ratios per standard deviation were 1.10 (95% confidence interval: 1.05, 1.16) and 1.15 (1.10, 1.19) for women and men, respectively. Differences in life expectancy between the top and bottom 5% of the cPRS were estimated to be 4.79 (1.76, 7.81) years and 6.75 (4.16, 9.35) years for women and men, respectively. These associations were substantially attenuated after adjusting for non-genetic mortality risk factors measured at study entry (i.e., middle age for most participants). The cPRS may be useful in counseling younger individuals at higher genetic risk of mortality on modification of non-genetic factors.

Temporal Trends in Cardiovascular Complications in People With or Without Type 2 Diabetes: The Fremantle Diabetes Study

CONTEXT

There is evidence that diabetes-related complications are declining but most data sources have limitations.

OBJECTIVE

To characterize temporal changes in incidence rates (IRs) of chronic complications and mortality in well-characterized, community-based Australians.

DESIGN

Longitudinal observational study.

SETTING

Urban population.

PARTICIPANTS

Participants with type 2 diabetes from the Fremantle Diabetes Study phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) age-, sex,- and ZIP code-matched 1:4 to people without diabetes.

MAIN OUTCOME MEASURES

First hospitalizations for/with myocardial infarction (MI), stroke, heart failure (HF), lower extremity amputation, and cardiovascular disease (CVD) and all-cause mortality. Five-year IRs, IR ratios for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated.

RESULTS

The 13,995 participants had a mean age of 64.8 years and 50.4% were males. There were lower IR ratios for MI, stroke, HF, and CVD death in FDS2 versus FDS1. IRDs for people with versus without type 2 diabetes had reduced by >50% between phases for MI, stroke, HF, lower extremity amputation, and CVD death, with no change in IRD for all-cause mortality. Within the pooled type 2 diabetes cohort, FDS2 versus FDS1 participation was an independent inverse predictor of stroke, HF, CVD death, and all-cause mortality after adjustment in Cox proportional hazards models.

CONCLUSIONS

Cardiovascular outcomes in Australians have improved since the 1990s, especially in type 2 diabetes. The difference in all-cause mortality between those with and without type 2 diabetes has persisted despite longer survival.

Potentially modifiable blood triglyceride levels by the control of conventional risk factors

Backgrounds

Triglyceride (TG) is known to be regulated by multiple lifestyle factors rather than genetic factors. This cross-sectional and community-based study (Healthy Twin study in Korea) aimed to estimate the “modifiable TG level” by identifying non-genetic risk factors of TG.

Methods

Participants were recruited between 2006 and 2011 who fulfilled health examinations and detail surveys: 3079 Korean adults including 949 monozygotic twins and 222 dizygotic twins. In order to investigate conventional risk factors, a mixed model accounting for family as a random effect was performed. In addition, we conducted a co-twin control analysis for 452 monozygotic twin (MZ) pairs, to examine non-genetic risk factors and potentially modifiable serum triglyceride levels.

Results

After excluding patients on dyslipidemia or diabetes medication, 2672 individuals (1029 men, with mean age of 43.9; and 1643 women with mean age of 43.3; 949 MZ pairs, 222 dizygotic twin pairs, and 1501sibling pairs) were analyzed. Fasting blood sugar (FBS), lipid panel, height, weight, waist (WC) and hip circumference, body mass index (BMI), amount of dietary intake and amount of physical activity was examined after adjusting for age and sex. For conventional analysis, WC, fat %, and BMI were identified as significant factors influencing serum triglyceride levels. Examination of non-genetic factors from the Co-twin control study revealed BMI (beta coefficient 9.94 with C.I. 3.42 to 16.46) and amount of alcohol intake (beta coefficient 0.08 with C.I. 0.02 to 0.14) as significant factors.

Conclusion

Our findings suggest that controlling body weight and alcohol intake might be effective to control TG; moderate weight control (BMI 1 reduction) and reducing alcohol consumption by 50 g/week (about two glassed of beer) might reduce TG level by 9.94 and 4.0 mg/dL.

The triglyceride paradox in the mortality of coronary artery disease

Background

The role of triglyceride (TG) in secondary prevention of patients with coronary artery disease (CAD) was debated. In the present study, we assessed the association between admission TG levels and long-term mortality risk in CAD patients.

Methods

A retrospective analysis was conducted from a single registered database. 3061 consecutive patients with CAD confirmed by coronary angiography were enrolled and were grouped into 3 categories by the tertiles of admission serum TG levels. The primary end point in this study was all-cause mortality and the secondary end point was cardiovascular mortality.

Results

The mean follow-up time was 26.9 ± 13.6 months and death events occurred in 258 cases and cardiovascular death events occurred in 146 cases. Cumulative survival curves indicated that the risk of all-cause death decreased with increasing TG level (Tertile 1 vs. Tertile 2 vs. Tertile 3 = 10.3% vs. 8.6% vs. 6.3%, log rank test for overall p = 0.001). Cox regression analysis showed an independent correlation between TG level and risk of all-cause mortality [hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.58–0.86] and cardiovascular mortality (HR 0.67, 95% CI 0.51–0.89) in total patients with CAD. Subgroup analysis found the similar results in patients with acute coronary syndrome and acute myocardial infarction.

Conclusions

This study found an inverse association between TG levels and mortality risk in CAD patients, which suggests that the “TG paradox” may exist in CAD patients.

Trial registration

ChiCTR, ChiCTR-OOC-17010433. Registered 17 February 2017 - Retrospectively registered.

Association of serum lipids with clinical outcome in acute ischaemic stroke: A systematic review and meta-analysis

Serum lipid levels have been investigated as prognostic markers in patients with acute ischaemic stroke. However, these results remain inconsistent. This study aimed at assessing the association between serum lipid and clinical outcomes in acute ischaemic stroke. Relevant data were obtained from Cochrane Library, PubMed and Web of Science databases. The heterogeneity of pooled results was determined by the Cochran's Q test and Higgins I-squared statistic. The random-effect model was performed to calculate the pooled results if P_H < 0.05 for Q-test, otherwise the fixed-effect model was applied. The primary results were death, and the secondary were recurrence, dependency, mRS score ≥3, and early neurological deterioration. A total of 21 full-text studies was included in the present study. For primary results, the pooled results from 5 studies with 4119 patients showed that triglyceride (TG) was a significant predictor for death (OR = 0.65, 95%CI = 0.43-0.98, P_H = 0.028). The pooled data from 11 studies with 12,486 patients for total cholesterol (TC), 4 studies with 7593 patients for low-density lipoprotein cholesterol (LDL-C), and 5 studies with 6933 patients for high-density lipoprotein cholesterol (HDL-C) suggested that TC (OR = 0.79, 95%CI = 0.56-1.13, P_H < 0.001), LDL-C (OR = 1.02, 95%CI = 0.66-1.57, P_H = 0.042), and HDL-C (OR = 1.18, 95%CI = 0.75-1.86, P_H = 0.003) were not associated with death in acute ischaemic stroke. For secondary results, the pooled results of 2 studies with 867 patients indicated that TG was positively associated with early neurological deterioration. This study suggested that serum TG was associated with death and early neurological deterioration in acute ischaemic stroke.

Lipid Paradox in Statin-Naïve Acute Ischemic Stroke But Not Hemorrhagic Stroke

Background: Low lipid level is associated with better cardiovascular outcome. However, lipid paradox indicating low lipid level having worse outcomes could be seen under acute injury in some diseases. The present study was designed to clarify the prognostic significance of acute-phase lipid levels within 1 day after admission for stroke on mortality in first-ever statin-naïve acute ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: This observational study was conducted using the data collected from Stroke Registry In Chang-Gung Healthcare System (SRICHS) between 2009 and 2012. Patients with recurrent stroke, onset of symptoms >1 day, and history of the use of lipid-lowering agents prior to index stroke were excluded. Stroke was classified into IS and hypertension-related HS. The primary outcomes were 30-day and 1-year mortality identified by linkage to national death registry for date and cause of death. Receiver operating characteristic (ROC) curve analysis and multivariate Cox proportional hazard models were used to examine the association of lipid profiles on admission with mortality. Results: Among the 18,268 admitted stroke patients, 3,746 IS and 465 HS patients were eligible for analysis. In IS, total cholesterol (TC) <163.5 mg/dL, triglyceride (TG) <94.5 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, non-high-density lipoprotein cholesterol (non-HDL-C) <130.5 mg/dL, and TC/HDL ratio <4.06 had significantly higher risk for 30-day/1-year mortality with hazard ratio (HR) of 2.05/1.37, 1.65/1.31, 1.68/1.38, 1.80/1.41, and 1.58/1.38, respectively, compared with high TC, TG, LDL, non-HDL-C, and TC/HDL ratio (p < 0.01 in all cases). In HS, lipid profiles were not associated with mortality, except HDL for 30-day mortality (p = 0.025) and high uric acid (UA) concentrations for 30-day and 1-year mortality (p = 0.002 and 0.012, respectively). High fasting glucose and high National Institute of Health Stroke Scale (NIHSS) score at admission were associated with higher 30-day and 1-year mortality in both IS and HS and low blood pressure only in IS (p < 0.05). Synergic effects on mortality were found when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score in IS (p < 0.05). Conclusions: Lipid paradox showing low acute-phase lipid levels with high mortality could be seen in statin-naïve acute IS but not in HS. The mortality in IS was increased when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score.

Dehydration is a strong predictor of long-term prognosis of thrombolysed patients with acute ischemic stroke

BACKGROUND AND PURPOSE

Dehydration was found to be involved in the poor prognosis of patients with acute ischemic stroke. It is unclear whether dehydration status before onset is related with prognosis of thrombolysed patients with acute ischemic stroke. If it is the case, quickly hydrating may improve the prognosis. The present study was designed to explore the issue.

METHODS

Eligible 294 patients with acute ischemic stroke after thrombolysis were enrolled in the present study according to inclusion/exclusion criteria. According to the modified Rankin scale (mRS) 90 days post stroke, the patients were divided into two groups: mRS 0-2 (n = 191) and mRS 3-6 (n = 103). In the present study, BUN/Cr ≥ 15 combined with USG > 1.010 or either of them were chosen as dehydration marker. Clinical data were analyzed between two groups. Univariate and multivariate statistical analyses were carried out.

RESULTS

Age, fibrinogen, blood glucose, BUN/Cr, NIHSS score at admission, the systolic blood pressure (SBP) before thrombolysis, dehydration status (BUN/Cr ≥ 15 plus USG > 1.010), hyperlipidemia, USG and D-dimer on admission day, and TOAST classification showed significant difference between two groups (p < .05). Further stratification analysis showed that BUN/Cr ≥ 15, NIHSS ≥ 6, blood glucose ≥8, and SBP > 150 were markedly associated with poor outcome (mRS 3-6, p < .05). After adjusting for age, fibrinogen, USG, D-dimer, dehydration status, NIHSS, blood glucose, SBP, hyperlipidemia, and BUN/Cr at admission, multivariate logistic regression showed that dehydration status, higher NIHSS, higher blood glucose, and higher SBP at admission were independent risk factors for predicting the long-term poor prognosis of thrombolysed patients.

CONCLUSIONS

The present findings suggest that BUN/Cr ≥ 15 combined with USG > 1.010 as a marker of dehydration status was an independent risk factor for long-term poor prognosis of thrombolysed patients with acute ischemic stroke.

High nonfasting triglyceride concentrations predict good outcome following acute ischaemic stroke

OBJECTIVES

A higher fasting triglyceride (TG) concentration has been associated with better functional outcomes after stroke. Recent observational studies have found that nonfasting TG concentrations predict incident stroke better than fasting concentrations. The aim of the study was to investigate the relationship between fasting and nonfasting serum TG concentrations versus 3-month functional activity and mortality among patients with acute ischaemic stroke.

METHODS

This was a retrospective study based on prospectively collected data. Blood samples were taken from acute ischaemic stroke patients at the time of hospital presentation to measure nonfasting TG concentrations and on the following morning to measure fasting TG concentrations. Fasting and nonfasting serum TG concentrations were collapsed into their respective three categories. All participants were assessed at 3 months after stroke using the modified Rankin Scale.

RESULTS

A total of 556 ischaemic stroke patients (67 ± 13 years; 57% male) were included in this study. Bivariately, the highest fasting and nonfasting TG category had more of a likelihood of good 3-month functional activity and less of a likelihood of being dead at 3 months compared to their respective lowest TG categories. The highest fasting TG (OR 2.93, 95% CI 1.67-5.14) and nonfasting TG (OR 2.66, 95% CI 1.51-4.67) categories had more of a likelihood of good 3-month functional activity compared to their respective lowest TG categories after adjustment for possible confounders.

DISCUSSION

Higher fasting and nonfasting serum TG concentrations predicted good poststroke outcome independently of other prognostic factors.

Triglyceride to high-density lipoprotein cholesterol ratio predicts worse outcomes after acute ischaemic stroke

BACKGROUND AND PURPOSE

The effect of the triglyceride (TG) to high-density lipoprotein cholesterol (HDL-C) ratio (TG/HDL-C) on clinical outcomes of acute ischaemic stroke (AIS) patients is unclear. This study sought to determine whether the TG/HDL-C ratio in AIS patients is associated with worse outcomes at 3 months.

METHODS

Acute ischaemic stroke patients who were admitted from 2011 to 2014 were enrolled in this study. TG, total cholesterol (TC), HDL-C and low-density lipoprotein cholesterol (LDL-C) were collected on admission. Three end-points were defined according to the modified Rankin scale (mRS) score at 3 months after symptom onset (excellent outcome, mRS 0-1; good outcome, mRS 0-2; and death, mRS 6).

RESULTS

In all, 1006 patients were included (median age 68.5 years; 58.2% male). Higher TG, non-HDL-C and TG/HDL-C were strongly associated with the three end-points after adjustments: excellent [odds ratio (OR) = 1.39, OR 1.89 and OR 2.34, respectively] and good (OR 1.48, OR 2.90 and OR 4.12) outcomes, and death (OR 0.59, OR 0.29 and OR 0.26). According to receiver operating characteristic (ROC) analysis, the best discriminating factor was a TG/HDL-C ≥ 0.87 for excellent outcomes [area under the ROC curve (AUC) 0.596; sensitivity 73.3%; specificity 42.7%] and non-death (AUC 0.674; sensitivity 67.8%; specificity 60.6%) as well as a TG/HDL-C ≥ 1.01 for a good outcome (AUC 0.652; sensitivity 61.6%; specificity 63.2%). Patients with a TG/HDL-C < 0.87 had a 2.94-fold increased risk of death (95% confidence interval 1.89-4.55) compared with patients with a TG/HDL-C ≥ 0.87.

CONCLUSIONS

A lower TG/HDL-C was independently associated with death and worse outcome at 3 months in AIS.

Elevated calcium after acute ischemic stroke: association with a poor short-term outcome and long-term mortality

BACKGROUND AND PURPOSE

An elevated intracellular calcium level is known to be a major initiator and activator of ischemic cell death pathway; however, in recent studies, elevated serum calcium levels have been associated with better clinical outcomes and smaller cerebral infarct volumes. The pathophysiological role played by calcium in ischemic stroke is largely unknown.

METHODS

Acute stroke patients from a prospective stroke registry, consecutively admitted during October 2002-September 2008, were included. Significant associations between the modified Rankin scale distribution at discharge and serum calcium or albumin-corrected calcium were identified using ordinal logistic regression analysis. Cox proportional hazard models were used for survival analysis.

RESULTS

Mean serum calcium and albumin-corrected calcium levels of the 1,915 participants on admission were 8.97±0.58 mg/dL and 9.07±0.49 mg/dL, respectively. Second [adjusted odds ratio 1.32 (95% confidence interval 1.07-1.61)] and third [1.24 (1.01-1.53)] tertiles of serum calcium level and the third [1.24 (1.01-1.53)] tertile of albumin-corrected calcium level were found to be independent risk factors for a poor discharge outcome. Significant relationships were observed with serum calcium [1.19 (1.03-1.38)] and albumin-corrected calcium [1.21(1.01-1.44)] as linear variables. However, only albumin-corrected calcium was associated with long-term mortality, third tertile [adjusted hazard ratio 1.40 (1.07-1.83)], and increase by 1 mg/dL [1.46 (1.16-1.84)].

CONCLUSIONS

Elevated albumin-corrected serum calcium levels are associated with a poorer short-term outcome and greater risk of long-term mortality after acute ischemic stroke.

The association baseline NIH Stroke Scale score with ABO blood-subtypes in young patients with acute ischemic stroke

OBJECTIVES

The presence of the A and B blood group antigens has been associated with risk of arterial thrombosis. The aim of the current study was to design a new simpler form of National Institutes of Health Stroke Scale (NIHSS) for use on admission, and assess the association of blood groups with NIHSS score in young stroke patients.

METHODS

We conducted this study in 1311 young Chinese adults with acute ischemic cerebral stroke. The outcome measures included a composite favorable outcome (defined as a modified Rankin Scale (mRS) of 0 or 2) and poor outcome (defined as a modified Rankin Scale score of 3 or 6) at discharge; a minor strokes (NIHSS scores 0-5) and severe strokes (NIHSS scores ≥6). Logistic regression analyses were used to determine the association between ABO blood groups and stroke severity.

RESULTS

Regression analysis confirmed in relative to patients with AB subtype, Oxfordshire community stroke project classification (OCSP) subtype and serum white blood cell (WBC) were the major predictors for stroke severity. Meanwhile, diabetes, serum triglyceride and uric acid levels were determined as independent indicators of stroke severity in A, B and O blood subtype respectively. The optimal cutoff score of the baseline NIHSS was ≤5 for patients with non-O subtype, the optimal cutoff score of the baseline NIHSS was ≤7 for patients with blood O subtype.

CONCLUSIONS

Our analysis provide compelling information regarding the ABO blood groups differences in predictors of stroke severity and the different validity of NIHSS scores in predicting prognosis at discharge between O subtype and non-O subtype.

The Triglyceride Paradox in Stroke Survivors: A Prospective Study

Objective. The purpose of our study was to understand the association between serum triglycerides and outcomes in acute ischemic stroke (AIS) patients. Methods. A cohort of all adult patients presenting to the Emergency Department (ED) with an AIS from March 2004 to December 2005 were selected. The lipid profile levels were measured within 24 hours of stroke onset. Demographics, admission stroke severity (NIHSS), functional outcome at discharge (modified Rankin Scale (mRS)), and mortality at 3 months were recorded. Results. The final cohort consisted of 334 subjects. A lower level of triglycerides at presentation was found to be significantly associated with worse National Institutes of Health Stroke Scale (NIHSS) (P = 0.004), worse mRS (P = 0.02), and death at 3 months (P = 0.0035). After adjusting for age and gender and NIHSS, the association between triglyceride and mortality at 3 months was not significant (P = 0.26). Conclusion. Lower triglyceride levels seem to be associated with a worse prognosis in AIS.

Impact of CHADS(2) Score on Neurological Severity and Long-Term Outcome in Atrial Fibrillation-Related Ischemic Stroke

Background and Purpose

The CHADS₂ (an acronym for congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack or thromboembolism) score is a widely used system for estimating the risk of stroke in patients with atrial fibrillation. However, how the CHADS₂ score is related to stroke severity and outcome in patients with strokes due to atrial fibrillation has not yet been elucidated.

Methods

We enrolled patients with atrial fibrillation who visited our stroke center within 7 days after the onset of acute ischemic stroke between October 2002 and September 2008. CHADS₂ scores were categorized into three groups: 0 points, low risk; 1 or 2 points, intermediate risk; and 3-6 points, high risk. Poor neurological state was defined as follows: a National Institutes of Health Stroke Scale (NIHSS) score of ≥2, and a modified Rankin Scale (mRS) score of ≥3 at discharge. Mortality information was ascertained as at December 2008.

Results

A cohort of 298 patients with atrial-fibrillation-related stroke was included in this study. A high-risk CHADS₂ score at admission was a powerful predictor of poor neurological outcome [for NIHSS: odds ratio (OR), 4.17; 95% confidence interval (CI), 1.76-9.87; for mRS: OR, 2.97; 95% CI, 1.23-7.16] after controlling for all possible confounders. In addition, a high-risk CHADS₂ score was an independent predictor of all causes of death during the follow-up [hazard ratio (HR), 3.01; 95% CI, 1.18-7.65] and vascular death (HR, 12.25; 95% CI, 1.50-99.90).

Conclusions

Although the CHADS₂ score was originally designed to distinguish patients with a future risk of stroke, our study shows that it may also be used to predict poor neurological outcome after atrial-fibrillation-related stroke.

Serum triglyceride level is an important predictor of early prognosis in patients with acute ischemic stroke

BACKGROUND

Some recent studies have shown that poor outcomes after acute ischemic stroke (AIS) were closely related to lower serum triglyceride (TG) levels, not hypertriglyceridemia. However, hypertriglyceridemia has been shown to be an independent predictor for poor outcome in patients with coronary artery disease. This study attempted to evaluate the association between serum TG levels and early prognosis of AIS.

METHODS

We enrolled 736 consecutive patients with AIS. Based on the TG level, patients were divided into 5 groups based on the guidelines of the National Cholesterol Education Program (NCEP). We defined early neurological deterioration (END) as a 4-point or greater deterioration of the NIH stroke scale (NIHSS) score and early clinical improvement (ECI) as a 4-point reduction of NIHSS within a week after symptom onset. We compared patients with END, ECI, and neither END nor ECI.

RESULTS

The risk of END was significantly higher in the hyperTG and hypoTG groups compared with the normal group. The percentages of ECI were significantly lower in the hypoTG, borderline, and hyperTG groups compared with the normal group. For END, the multivariable adjusted odds ratios were significantly higher in the hypoTG, borderline, and hyperTG groups compared with the low normal group (50 to 100mg/dl).

CONCLUSIONS

TG had a nonlinear, J-shaped association with poor outcome and a reverse J-shaped association with good outcome in AIS. This study suggests that both hyperTG and hypoTG can be risk factors for poor early outcome in AIS.

Higher on-admission serum triglycerides predict less severe disability and lower all-cause mortality after acute ischemic stroke

BACKGROUND

High(er) on-admission triglyceride (TG) levels have been suggested as an independent predictor of better outcomes of the acute ischemic stroke. Data regarding poststroke physical disabilities have been contradictory. We aimed to investigate the relationship between fasting on-admission TG and development of disability and all-cause mortality over a 2.5-year period.

METHODS

This prospective observational study included 83 acute ischemic stroke patients (29 cardioembolic; 41% men; median age 76 years) followed-up for 28 to 30 months and assessed for physical disability using the Modified Rankin scale (mRS) at 1 week and 3, 12, and 24 months poststroke. TGs were considered as a continuous and a binary variable (≤ 1.27 [n = 43] and >1.27 mmol/L [n = 43]).

RESULTS

Higher TGs (continuous or binary) were independently (default adjustments: stroke type, severity at presentation, age, atrial fibrillation, preindex event antiplatelet use, infarct volume, postindex event antiplatelet, statin and angiotensin-converting enzyme inhibitor use, on-admission fasting cholesterol, mean platelet volume, and glomerular filtration rate) were associated with: (1) higher odds of mRS 0 to 2 (none/mild disability) across the assessments (overall odds ratio [OR] 2.73 [95% confidence interval {CI} 1.15-6.38] and OR 3.57 [95% CI 1.04-12.3], respectively); (2) lower odds of mRS worsening between any 2 consecutive assessments (overall OR 0.44 [95% CI 0.20-0.96] and OR 0.35 [95% CI 0.16-0.77], respectively); (3) lower risk of all-cause mortality (hazard ratio 0.47 [95% CI 0.23-0.96] and hazard ratio 0.45 [95% CI 0.21-0.98], respectively).

CONCLUSIONS

These data suggest that higher fasting TGs on-admission predict less severe disability, reduced disability progression, and all-cause mortality in patients with acute ischemic stroke.

Pentraxin 3: a novel and independent prognostic marker in ischemic stroke

OBJECTIVE

Pentraxin 3 (PTX3) is one of the pattern-recognition receptors related to the initial step of the immune response with C-reactive protein, but the physiologic and pathologic functions are not fully understood. The purpose of the current study was to determine the impact of PTX3 levels on mortality after ischemic stroke.

METHODS

We consecutively enrolled 376 patients who had ischemic stroke between September 2004 and September 2006. The patients were divided into tertiles according to PTX3 levels. Cox regression analysis was used to determine hazard ratios (HRs) and 95% confidence intervals (CIs) of the PTX3 tertiles for all-cause mortality with adjustment for traditional risk factors and laboratory variables, including C-reactive protein.

RESULTS

During the follow-up, 19.4% of the patients were deceased. The median PTX3 levels were higher in the deceased patients (18.0 vs. 6.4 ng/mL, p<0.001). Based on Cox regression analysis, compared with the first tertile of PTX3, the adjusted HRs of the second and third tertiles for all-cause mortality were 1.24 (95% CI, 0.52-2.98) and 2.64 (95% CI, 1.19-5.85), respectively. When the log-transformed levels of PTX3 were incorporated as continuous variables, higher levels of PTX3 were also associated with an increased mortality (increase per log unit; HR, 1.60; 95% CI, 1.19-2.16).

CONCLUSIONS

We showed that higher levels of PTX3 are independently associated with increased mortality after ischemic stroke. Our results suggest that PTX3 may be used as a new powerful prognostic biomarker in patients with ischemic stroke.