The association between cerebral atherosclerosis and arterial stiffness in acute ischemic stroke

Arterial Stiffness Predicts the Outcome of Endovascular Treatment in Patients with Acute Ischemic Stroke

Background: The association between arterial stiffness and outcome after endovascular treatment (EVT) is unknown. This study investigated whether arterial stiffness predicts post-EVT outcome in patients with acute ischemic stroke. Methods: This retrospective and observational cohort study included consecutive patients treated with EVT for acute ischemic stroke from June 2020 to November 2022. Arterial stiffness was assessed by brachial-ankle pulse wave velocity. Poor functional outcome was defined as a modified Rankin Scale score ≥3 at 3 months. Results: The mean age of patients included in this study was 71.9 ± 11.8 years, and 57.3% were men. Poor functional outcome was present in 46.8%. Multivariable logistic regression analysis showed that arterial stiffness was independently associated with poor functional outcome (odds ratio 8.640, 95% confidence interval [CI] 1.581-47.228) after adjusting for age, initial stroke severity, hypertension, atrial fibrillation, device pass number, and successful recanalization. A nomogram based on the multivariable statistic model showed a better prediction of poor functional outcome compared to classic risk factor models without arterial stiffness (net reclassification improvement 0.529, 95% CI 0.186-0.873; integrated discrimination improvement 0.046, 95% CI 0.009-0.083). Conclusions: We found that arterial stiffness was an independent predictor of poor functional outcome in patients treated with EVT following acute ischemic stroke.

Risk of Ischemic Stroke in Relation to Helicobacter pylori Infection and Eradication Status: A Large-Scale Prospective Observational Cohort Study

Background/Aims

: A few studies have suggested the association between Helicobacter pylori (HP) infection and ischemic stroke. However, the impact of HP eradication on stroke risk has not been well evaluated. This study aimed to assess the influence of HP eradication on the incidence of ischemic stroke, considering the potential effect of sex.

Methods

: This prospective observational cohort study was conducted at Seoul National University Bundang Hospital, from May 2003 to February 2023, and involved gastroscopy-based HP testing. Propensity score (PS) matching was employed to ensure balanced groups by matching patients in the HP eradicated group (n=2,803) in a 3:1 ratio with patients in the HP non-eradicated group (n=960). Cox proportional hazard regression analysis was used to evaluate the risk of ischemic stroke.

Results

: Among 6,664 patients, multivariate analysis after PS matching indicated that HP eradication did not significantly alter the risk of ischemic stroke (hazard ratio, 0.531; 95% confidence interval, 0.221 to 1.270; p=0.157). Sex-specific subgroup analyses, both univariate and multivariate, did not yield statistically significant differences. However, Kaplan-Meier analysis revealed a potential trend: the females in the HP eradicated group exhibited a lower incidence of ischemic stroke than those in the HP non-eradicated group, although this did not reach statistical significance (p=0.057).

Conclusions

: This finding suggests that HP eradication might not impact the risk of ischemic stroke. However, there was a trend showing that females potentially had a lower risk of ischemic stroke following HP eradication, though further investigation is required to establish definitive evidence.

Can prolonged P-R interval predict clinical outcomes in non-ST elevation acute coronary syndrome patients?

BACKGROUND

The present study aimed to respond to clinical question, can prolonged P-R interval predict clinical outcomes in non-ST elevation acute coronary syndrome patients?

METHODS

This descriptive-analytical study was conducted on cardiac patients. All of the non-ST elevation acute coronary syndrome (NSTEACS) including non-ST elevation myocardial infarction (NSTEMI) and unstable angina patients included in the study. Then they divided into two groups: prolonged P-R interval and normal P-R interval. The patients who had a history of digoxin and calcium channel blocker use, using antiarrhythmic drugs, known valvular or congenital heart disease and connective tissue, unreadable P-R interval and cardiac block were excluded. Data were collected using the questionnaire consisted demographic data and clinical outcomes and a follow-up part was completed by one of the researchers.

RESULTS

Finally, 248 patients completed the study. The results showed both of the two groups had significant differences in terms of the history of myocardial infarction (MI) (p = 0.018), the level of high-density lipoprotein (HDL) (p = 0.004), heart rate (p = 0.042), inverted T wave (p = 0.017), anterior ST- segment depression (p = 0.008), normal report of coronary angiography (CAG) (p = 0.003), three vessels disease (p = 0.043), left main lesion (p = 0.045) and SYNTAX score (p = 0.032) based on the CAG report. The results of six-month follow-up showed although, the frequency of ischemic stroke, coronary artery disease (CAD) and cardiovascular death were higher in prolonged P-R interval groups. The chi-square test showed this difference was statistically non-significant (p > 0.05). The multivariate logistic regression model revealed non-significant relationships between prolonged P-R interval and SYNTAX score, significant CAD, three-vessel disease, inverted T wave, anterior ST depression, heart rate and HDL.

CONCLUSIONS

Based on the results of our study the six-month follow-up showed non-significant outcomes. Further studies are recommended to assess the long-term outcomes.

Central arterial stiffening and intracranial atherosclerosis: the atherosclerosis risk in communities neurocognitive study (ARIC-NCS): Aortic stiffness & intracranial atherosclerosis

OBJECTIVES

Previous studies suggest an association between central arterial stiffness (CAS) and intracranial atherosclerotic disease (ICAD) among Asian participants with stroke or hypertension; this association has not been evaluated in United States populations. We assessed the cross-sectional association of CAS with ICAD presence and burden in late-life, and differences in association by age, sex, and race.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of 1,285 Atherosclerosis Risk in Communities Study participants [mean age 75 (standard deviation: 5) years, 38 % male, 20  % Black] at Visit 5 (2011-2013). CAS was measured as carotid-femoral pulse wave velocity (cfPWV) using the Omron VP-1000 Plus. ICAD was assessed using high-resolution vessel wall MRI and MR angiography. We evaluated associations of a 1 standard deviation (SD) cfPWV (3.02 m/s) and high vs. non-high cfPWV (≥ 13.57 m/s vs. < 13.57 m/s) with presence of plaques (yes/no) and plaque number (0, 1-2, and >2) using multivariable logistic and ordinal logistic regression models adjusted for covariates.

RESULTS

Each one SD greater cfPWV was associated with higher odds of plaque presence (odds ratio (OR)=1.32, 95 % confidence interval (CI): 1.22, 1.43), and an incrementally higher odds of number of plaques (OR 1-2 vs. 0 plaques = 1.21, 95 % CI: 1.10, 1.33; OR >2 vs. 0 plaques = 1.51, 95 % CI: 1.33,1.71). Results suggested differences by race, with greater magnitude associations among Black participants.

CONCLUSIONS

CAS was positively associated with ICAD presence and burden; cfPWV may be a useful subclinical vascular measure for identification of individuals who are at high risk for cerebrovascular disease.

Impact of Excessive Increase in Systolic Blood Pressure after Exercise on Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction

OBJECTIVE

Although the clinical outcomes for patients with ST-elevation myocardial infarction (STEMI) have improved significantly, some patients still experience poor clinical outcomes. The available risk classifications focus on the short-term outcomes, and it remains important to find high-risk features among patients with STEMI. In Japan, the 200 m walk electrocardiogram (ECG) test is widely performed before discharge. The purpose of this study was to investigate the association between the excessive increase in systolic blood pressure (SBP) following a 200 m walk and the long-term clinical outcomes in patients with STEMI.

METHODS

We included 680 patients with STEMI and divided those into an excessive increase in SBP group (n = 144) and a non-excessive increase in SBP group (n = 536) according to the SBP increase after a 200 m walk ECG test. We defined an excessive increase in SBP as SBP ≥ 20 mmHg either just after or 3 min after a 200 m walk ECG test. The primary endpoint consisted of major cardiovascular events (MACE), defined as the composite of all-cause death, non-fatal myocardial infarction, readmission for heart failure, and ischemia-driven target vessel revascularization.

RESULTS

The median follow-up duration was 831 days. MACE was more frequently observed in the excessive increase in SBP group (24.3%) than in the non-excessive increase in SBP group (15.1%). Multivariate Cox hazard analysis revealed that the excessive increase in SBP was significantly associated with MACE (HR 1.509, 95% CI: 1.005-2.267, p = 0.047) after controlling for multiple confounding factors.

CONCLUSION

An excessive increase in SBP after the 200 m walk ECG test was significantly associated with MACE in patients with STEMI. The 200 m walk ECG test is simple and low-cost, but may help to identify high-risk patients with STEMI.

Quantitative Thermal Stimulation Using Therapeutic Ultrasound to Improve Cerebral Blood Flow and Reduce Vascular Stiffness

It is important to improve cerebrovascular health before the occurrence of cerebrovascular disease, as it has various aftereffects and a high recurrence rate, even with appropriate treatment. Various medical recommendations for preventing cerebrovascular diseases have been introduced, including smoking cessation, exercise, and diet. However, the effectiveness of these methods varies greatly from person to person, and their effects cannot be confirmed unless they are practiced over a long period. Therefore, there is a growing need to develop more quantitative methods that are applicable to the public to promote cerebrovascular health. Thus, in this study, we aimed to develop noninvasive and quantitative thermal stimulation techniques using ultrasound to improve cerebrovascular health and prevent cerebrovascular diseases. This study included 27 healthy adults in their 20s (14 males, 13 females). Thermal stimulation using therapeutic ultrasound at a frequency of 3 MHz was applied to the right sternocleidomastoid muscle in the supine posture for 2 min at four intensities (2.4, 5.1, 7.2, and 10.2 W/cm2). Diagnostic ultrasound was used to measure the peak systolic velocity (PSV), heart rate (HR), and pulse wave velocity (PWV) in the right common carotid artery (CCA), and the physiological changes were compared between intervention intensities. Compared to pre-intervention (preI), the PSV showed a significant increase during intervention (durI) at intensities of 7.2 W/cm2 and 10.2 W/cm2 (p = 0.010 and p = 0.021, respectively). Additionally, PWV showed a significant decrease for post-intervention (postI) at 7.2 W/cm2 and 10.2 W/cm2 (p = 0.036 and p = 0.035, respectively). However, the HR showed no significant differences at any of the intensities. The results demonstrate that an intervention at 3 MHz with an intensity of 7.2 W/cm2 or more can substantially increase cerebral blood flow and reduce arterial stiffness. Therefore, the use of therapeutic ultrasound of appropriate intensity is expected to improve the cerebral blood flow and reduce vascular stiffness to maintain cerebral blood flow at a certain level, which is closely related to the prevention and treatment of cerebrovascular diseases, thereby improving cerebrovascular health.

Aortic Stiffness Is Independently Associated with Intracranial Carotid Artery Calcification in Patients with Ischemic Stroke

INTRODUCTION

Intracranial carotid artery calcification (ICAC), as a strong contributor to the occurrence of ischemic stroke, might be present in the medial or intimal arterial layer. Traditional cardiovascular risk factors (CVRFs) are associated with ICAC; however, its association with new markers of vascular function is less understood. The paper aimed to evaluate the relationship between carotid-femoral pulse wave velocity (CF-PWV) and ICAC subtypes.

METHODS

We enrolled 65 patients with ischemic stroke. CF-PWV, systolic, diastolic, mean blood pressure, and pulse pressure were measured within 6 ± 2 days after stroke onset, and CT was performed within 24 h. ICAC on the stroke site was classified by two methods: volume and score based. Tertiles of ICAC volume were determined, and low-grade ICAC (T1) was regarded as a reference. According to the score-based method, (dominant) medial and (dominant) intimal ICAC subtypes were determined. Data were analyzed with multivariate logistic regression.

RESULTS

Medial and intimal ICAC subtypes were found in 34 (52%) and 24 (37%) patients, respectively. In 11% of patients, no ICAC calcifications were found. CF-PWV was higher in patients with high-grade ICAC (OR = 1.56, 95% CI = 1.03-2.35, p = 0.035). CF-PWV was higher in patients with the medial ICAC subtype (OR = 1.60, 95% CI = 1.00-2.55, p = 0.049) after adjustment for traditional CVRFs.

CONCLUSION

Our study demonstrates that among patients with ischemic stroke, aortic stiffness is independently associated with ICAC and that medial ICAC, compared with intimal ICAC, is accompanied by more advanced aortic stiffness.

Arterial stiffness and progression of white matter hyperintensities of presumed vascular origin in community-dwelling older adults of Amerindian ancestry: The Atahualpa Project Cohort

OBJECTIVE

Arterial stiffness - as measured by the aortic pulse wave velocity (aPWV) - has been associated with biomarkers of cerebral small vessel disease (cSVD), in particular with white matter hyperintensities (WMH) of presumed vascular origin. Most studies have been conducted in White and Asian populations, and information on this relationship in other ethnic groups is limited. We designed a longitudinal prospective study to assess the impact of aPWV on WMH progression in individuals of Amerindian ancestry.

PATIENTS AND METHODS

Participants of the Atahualpa Project Cohort were assessed at baseline with aPWV determinations, clinical interviews and brain MRIs. At the end of the study, brain MRIs were repeated in order to ascertain WMH progression. Poisson regression models adjusted for demographics and cardiovascular risk factors were fitted to assess WMH progression incidence rate by baseline levels of aPWV.

RESULTS

The study included 260 individuals aged ≥60 years (mean age: 65.6 ± 6.1 years; 57 % women). The mean aPWV was 9.9 ± 1.5 m/s. Follow-up MRIs revealed WMH progression in 102 (39 %) individuals after a mean follow-up of 6.5 ± 1.4 years. Unadjusted analysis showed a higher baseline aPWV among subjects that developed WMH progression compared with those who did not (p < 0.001). Multivariate Poisson regression models showed an increased WMH progression rate among individuals in the second (IRR: 2.06; 95 % C.I.: 1.09-3.88) and third (IRR: 2.75; 95 % C.I.: 1.29-5.87) tertiles of aPWV compared with those in the first tertile.

CONCLUSIONS

aPWV is associated with WMH progression, suggesting a link between atherosclerosis and cSVD in the study population.

Usefulness of the Atherosclerosis Risk Score for Patients With Acute Infarction in the Lenticulostriate Artery Region

Background and purpose

Internal carotid artery intima-media thickness (IMT) and pulse wave velocity (PWV) are risk factors of cerebrovascular disease and coronary artery disease. They are known as independent predictors of arteriosclerotic disease. It has been reported that IMT and PWV are useful factors for predicting stroke subtype and/or outcome.

Coronary artery disease onset is proportional to atherosclerosis progression, and the Framingham Risk Score (FRS) and Suita score (SS) are standard risk predictors. This study examined whether FRS and SS can be useful for patient outcomes with acute infarction in the lenticulostriate artery (LSA) region without special tests or invasive procedures while using IMT or PWV as predictive factors.

Methods

We screened 629 consecutive patients with ischemic stroke and reviewed 84 patients with acute infarction in the LSA region who were admitted between January 2018 and December 2020. An early deterioration (ED) group was defined. In addition, the clinical characteristics, FRS, SS, treatment therapy, and neurovascular findings were evaluated.

Results

FRS and SS (FRS: 11.6 vs. 8.3, p < 0.01, SS: 58.2 vs. 53.7, p = 0.01, respectively), pre-symptomatic modified Rankin Scale (mRS) (p = 0.03), mRS at discharge (p < 0.01), and deterioration of manual muscle test (MMT) (<0.01) were significantly higher in patients in the ED (34 patients) group than in the no-ED group (54 patients). FRS and SS were correlated with mRS deterioration (FRS: r = 0.47; p < 0.01, SS: r = 0.23; p = 0.03). Among the laboratory parameters, total cholesterol (TC) (p < 0.01) and low-density lipoprotein cholesterol (LDL-C) (p < 0.01) were significantly higher in the ED group, and no significant differences in any acute therapeutic interventions.

Conclusion

Atherosclerosis risk scores, such as FRS and SS, may be useful for predicting outcomes in patients with acute LSA-region infarctions within 48 hours of onset.

Brachial-ankle pulse wave velocity as a measurement for increased carotid intima-media thickness: A comparison with carotid-femoral pulse wave velocity in a Chinese community-based cohort

Carotid‐femoral pulse wave velocity (cfPWV) and brachial‐ankle pulse wave velocity (baPWV) act as two most frequently applied indicators to evaluate arterial stiffness. Limited studies have systematically compared the relationships between cfPWV/baPWV and increased carotid intima‐media thickness (cIMT). This study aimed to investigate the associations of the two PWV indices with cIMT in a Chinese community‐based population. A total of 6026 Chinese participants from an atherosclerosis cohort were included in our analysis. Increased cIMT was defined as the maximum of cIMT > 0.9 mm in end‐systolic period of carotid artery. Mean (SD) cfPWV and baPWV were 8.55±1.83  and 16.79±3.35 m/s, respectively. The prevalence of increased cIMT was 59.58%. In multivariable logistic regression, both PWVs were independently associated with increased cIMT after adjustment for various confounders (for 1 m/s increase of cfPWV: OR = 1.07, 95% CI: 1.02‐1.11; for 1 m/s increase of baPWV: OR = 1.03, 95% CI: 1.00‐1.05). The highest cfPWV and baPWV quartile groups had higher prevalence of increased cIMT when compared with the lowest quartile groups (for cfPWV: OR = 1.28, 95% CI: 1.06‐1.55; for baPWV: OR = 1.23, 95% CI: 1.00‐1.50). However, when both PWVs were added into multivariable model simultaneously, only cfPWV was associated with odds of increased cIMT. Subgroup analyses further showed cfPWV was more strongly associated with increased cIMT than baPWV in males, participants aged ≥65 years, and those with other cardiovascular risk factors. In conclusion, both cfPWV and baPWV are associated with increased cIMT in a Chinese community‐based population. Furthermore, cfPWV is more strongly correlated with increased cIMT compared to baPWV.

The relation between inter arm blood pressure difference and presence of cardiovascular disease: a review of current findings

Raised inter arm blood pressure difference (IABPD) is already well-known as a clinical sign of peripheral arterial diseases including aortic dissection and subclavian stenosis. However, there are several other diseases associated with high IABPD. Therefore, this study aimed to review the association between increased IABPD and the presence of lethal health conditions, the possible mechanisms behind this relationship, and its contributing risk factors. Significant IABPD has been observed in patients with atherosclerotic plaques, peripheral artery disease, coronary artery disease, and chronic kidney disease. Patients with high IABPD are also at more risk of left ventricular hypertrophy that may affect long-term cardiac function. Besides, brain injuries such as stroke, dementia, and Alzheimer's disease has been related to increased IABPD. Considering that raised IABPD is associated with multiple cardiovascular diseases and other organ damage, IABPD detection may be accurate for the early diagnosis and screening of these life-threatening diseases and help manage them better.

Variable fluid flow regimes alter human brain microvascular endothelial cell-cell junctions and cytoskeletal structure

The human brain microvasculature is constantly exposed to variable fluid flow regimes and their influence on the endothelium depends in part on the synchronous cooperative behavior between cell-cell junctions and the cytoskeleton. In this study, we exposed human cerebral microvascular endothelial cells to a low laminar flow (1 dyne⋅cm^-2 ), high laminar flow (10 dyne⋅cm^-2 ), low oscillatory flow (±1 dyne⋅cm^-2 ), or high oscillatory flow (±10 dyne⋅cm^-2 ) for 24 hr. After this time, endothelial cell-cell junction and cytoskeletal structural response was characterized through observation of zonula occludens-1 (ZO-1), claudin-5, junctional adhesion molecule-A (JAM-A), vascular endothelial cadherin (VE-Cad), and F-actin. In addition, we also characterized cell morphology through measurement of cell area and cell eccentricity. Our results revealed the greatest change in junctional structure reorganization for ZO-1 and JAM-A to be observed under low laminar flow conditions while claudin-5 exhibited the greatest change in structural reorganization under both low and high laminar flow conditions. However, VE-Cad displayed the greatest structural response under a high laminar flow, reflecting the unique responses each cell-cell junction protein had to each fluid flow regime. In addition, cell area and cell eccentricity displayed most significant changes under the high laminar flow and low oscillatory flow, respectively. We believe this study will be useful to the field of cell mechanics and mechanobiology.

A Mendelian randomization analysis of the relationship between cardioembolic risk factors and ischemic stroke

Observational studies have shown that several risk factors are associated with cardioembolic stroke. However, whether such associations reflect causality remains unknown. We aimed to determine whether established and provisional cardioembolic risk factors are causally associated with cardioembolic stroke. Genetic instruments for atrial fibrillation (AF), myocardial infarction (MI), electrocardiogram (ECG) indices and N-terminal pro-brain natriuretic peptide (NT-pro BNP) were obtained from large genetic consortiums. Summarized data of ischemic stroke and its subtypes were extracted from the MEGASTROKE consortium. Causal estimates were calculated by applying inverse-variance weighted analysis, weighted median analysis, simple median analysis and Mendelian randomization (MR)-Egger regression. Genetically predicted AF was significantly associated with higher odds of ischemic stroke (odds ratio (OR): 1.20, 95% confidence intervals (CI): 1.16-1.24, P = 6.53 × 10^-30) and cardioembolic stroke (OR: 1.95, 95% CI: 1.85-2.06, P = 8.81 × 10^-125). Suggestive associations were found between genetically determined resting heart rate and higher odds of ischemic stroke (OR: 1.01, 95% CI: 1.00-1.02, P = 0.005), large-artery atherosclerotic stroke (OR: 1.02, 95% CI: 1.00-1.04, P = 0.026) and cardioembolic stroke (OR: 1.02, 95% CI: 1.00-1.04, P = 0.028). There was no causal association of P-wave terminal force in the precordial lead V1 (PTFVI), P-wave duration (PWD), NT-pro BNP or PR interval with ischemic stroke or any subtype.

Red blood cell distribution width is associated with hypoperfusion in carotid endarterectomy under regional anesthesia

BACKGROUND

A subset of patients submitted to carotid endarterectomy under regional anesthesia develop intraoperative neurologic deficit during carotid artery crossclamping related to critical cerebral perfusion, which may be owing to low flow or embolic phenomena. This subgroup is deemed prone to worse outcomes, which highlights its clinical relevance. The main aim of this study was to identify clinical and hematological predictors for intraoperative neurologic deficit. The secondary aim was to evaluate the perioperative prognostic value of postcarotid artery crossclamping manifestations of cerebral ischemia.

METHODS

Between January 2012 to January 2020, patients submitted to carotid endarterectomy under regional anesthesia in a tertiary referral center who presented intraoperative neurologic deficit were prospectively and consecutively included. This group constituted 8% of the total carotid endarterectomy performed in the center during this timeframe. The control group of patients was the subsequent patient submitted to carotid endarterectomy without intraoperative neurologic deficit in a 1:1 ratio. Blood samples were collected before surgery (<2 weeks). Propensity score matching was used to identify well-matched pairs of patients.

RESULTS

A total of 180 patients were included, with 90 (50% of the cohort and 8% of total carotid endarterectomies) presenting intraoperative neurologic deficit associated to clamping. Mean age was 71.4 ± 9.27 years in the study group and 68.8 ± 8.36 years in the control group. The clinical variables presenting significance after multivariate analysis include: age (adjusted odds ratio: 1.04, 5-95% confidence interval, [1.003-1.078]; P = .034), obesity (adjusted odds ratio: 3.537 [1.445-8.658]; P = .006), lower ipsilateral carotid stenosis grade (adjusted odds ratio: 0.725 [0.525-0.997]; P = .049), and higher contralateral carotid stenosis grade (adjusted odds ratio: 1.266 [1.057-1.516]; P = .010). Red cell distribution width coefficient of variation demonstrated statistical significance in predicting intraoperative neurologic deficit with an adjusted odds ratio of 1.394 (1.076-1.805); P = .012. The 30-day stroke rate was significantly higher in the intraoperative neurologic deficit group, with an adjusted odds ratio of 5.13 (5-95% confidence interval [1.058-24.87]; P = .042) after propensity score matching. Postoperative complications (Clavien-Dindo ≥2) were also associated with intraoperative neurologic deficit (after propensity score matching adjusted odds ratio of 2.748 [5-95% confidence interval, 0.976-7.741]; P = .051).

CONCLUSION

In this study, increased red cell distribution width coefficient of variation demonstrated value to predict intraoperative neurologic deficit. Additionally, age, obesity, a lower degree of ipsilateral carotid stenosis, and a higher degree of contralateral carotid stenosis also demonstrated ability to predict intraoperative neurologic deficit. Moreover, intraoperative neurologic deficit was an independent risk factor for 30-day stroke and postoperative complications Clavien-Dindo ≥2.

The trends in nanomaterial-based biosensors for detecting critical biomarkers in stroke

Acute ischemic stroke (AIS), is the second global cause of death after cardiovascular diseases, accounts for 80-85% of cerebrovascular disease. Stroke diagnosis could be challenging in the acute phase. Detection of biomarkers for evaluating the prognosis of diseases is essential for improving personalized treatment and decreasing mortality. At the present time, the absence of a broadly existing and rapid diagnostic test is an important limitation in the evaluation and treatment of diseases. The use of a biomarker-based diagnostic attitude has confirmed very valuable in acute coronary syndromes, which has been promoted in acute stroke to help early management decisions. Over the past decade, different detection procedures have developed for the assessment of human cardiac troponins (cTnI). This review emphasizes on summarizing optical, and electrochemical biosensors for the detection of cTnI, brain natriuretic peptide (BNP), and neuron-specific enolase (NSE) as a critical biomarker in stroke.

Association of Fibroblast Growth Factor 23 With Ischemic Stroke and Its Subtypes: A Mendelian Randomization Study

Fibroblast growth factor 23 (FGF23), which is involved in the regulation of vitamin D, is an emerging independent risk factor for cardiovascular diseases. Previous studies have demonstrated a positive association between FGF23 and stroke. In this study, we aimed to assess the association of FGF23 with ischemic stroke and its subtypes by applying a Mendelian randomization (MR) framework. Five genetic variants obtained from a genome-wide association study involving 16,624 European subjects were used as valid instruments of circulating FGF23 levels. MR was applied to infer the causality of FGF23 levels and the risk of ischemic stroke using data from the MEGASTROKE consortium. Subsequently, several MR analyses, including inverse-variance weighted meta-analysis, MR-Egger, weighted median estimate (WME), MR Pleiotropy Residual Sum and Outlier were performed. The heterogeneity test analysis, including Cochran's Q, I 2 test and leave-one-out analysis were also applied. Furthermore, potential horizontal/vertical pleiotropy was assessed. Lastly, the power of MR analysis was tested. Three validated variants were found to be associated with circulating FGF23 levels and were used for further investigation. We found that high expression level of FGF23 was not associated with any ischemic stroke. However, a causal association between genetically predicted FGF23 levels and the risk of large-artery atherosclerotic stroke (LAS) was significant, with an odds ratio of 1.74 (95% confidence interval = 1.08-2.81) per standard deviation increase in circulating FGF23 levels. Our findings provide support for the causal association between FGF23 and LAS, and therefore, offer potential therapeutic targets for LAS. The specific roles of FGF23 in LAS and associated molecules require further investigation.

Short stature is associated with higher pulse wave velocity in subjects without overt cardiovascular disease

Short stature is reportedly associated with cardiovascular disease (CVD). However, the mechanism underlying this intriguing epidemiological finding is unclear. Pulse wave velocity (PWV), a marker of vascular stiffness, is a predictor of future CVD. Therefore, PWV may be affected by height even before overt CVD occurs. Here, we investigated the association between adult height and PWV in subjects without overt CVD.A total of 1019 subjects (48 ± 12 years old; 509 men, 21 with diabetes mellitus, 209 with hypertension) without overt CVD were enrolled, all of whom underwent brachial-ankle PWV (baPWV) measurements. The subjects were divided into 3 groups by height. A multiple regression model was used to estimate baPWV values among heights after the adjustment for confounders.Mean baPWV value was highest in the group with the shortest height for both sexes (both P < .001). Bivariate correlation analysis between height and baPWV showed significant correlations in men (r = -0.131, P = .003) and women (r = -0.180, P < .001). In the multiple regression analysis with adjustment for identified confounders, group height was a predictor of baPWV (P for trend = .003) in younger men (<50 years old) but not in older men, while group height was correlated with baPWV in older women (≥50 years old, P for trend = .014) but not in younger women.Height is inversely correlated with baPWV in subjects without overt CVD, especially in younger men and older women. This may explain the historical epidemiological observation of an inverse relationship between height and CVD.

Prognostic value of CHADS2 and CHA2DS2-VASc scores for post-discharge outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention

The CHADS2 and CHA2DS2-VASc scores were initially developed to assess the risk of stroke or systemic embolism in patients with atrial fibrillation (AF). Recently, these two scoring systems have been demonstrated to predict long- and short-term cardiovascular (CV) outcomes in many patient cohorts. However, to the best of our knowledge, their prognostic value has not been fully elucidated in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). This study aimed to investigate the association of CHADS2 and CHA2DS2-VASc scores with CV outcomes in such patients.We included a total of 915 ACS patients undergoing PCI in this study. CHADS2 and CHA2DS2-VASc scores were calculated from data collected before discharge. The primary endpoint was defined as a composite of major adverse CV events (MACE) including overall death, nonfatal stroke, nonfatal myocardial infarction (MI) and unplanned repeat revascularization. We assessed MACE's relationship to CHADS2 and CHA2DS2-VASc scores using Cox proportional-hazard regression analyses.Mean follow-up duration was 918 days. MACE occurred in 167 (18.3%) patients. A higher CHADS2 score was associated with reduced event-free survival (EFS) from MACE (logrank test, P = .007) with differences potentiated if stratified by CHA2DS2-VASc score (logrank test, P < .001). Univariate analysis showed that both CHADS2 and CHA2DS2-VASc scores were good predictors of MACE. In the multivariate Cox proportional-hazard regression analysis, CHA2DS2-VASc score (hazard ratio [HR], 1.15; 95% confidence interval [CI] 1.04-1.27; P = .007) remained a useful predictor of MACE; however, CHADS2 score was no longer associated with increased risk of MACE. C-statistics for CHA2DS2-VASc score, GRACE (Global Registry of Acute Coronary Events) hospital discharge risk score (GRACE Score) and SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) Score II (SS II) in predicting MACE were 0.614, 0.598, and 0.609, respectively.CHA2DS2-VASc score was an independent and significant predictor of MACE in ACS patients undergoing PCI, and its discriminatory performance was not inferior to those of GRACE Score and SS II.

Arterial Stiffness is Associated with Intracranial Arterial Stenosis other than Dolichoectasia in the General Population

Aims: The relationship between central arterial stiffness and aging-related intracranial arteriopathy is not well investigated in the general population. In a population-based study, we investigated arterial stiffness in relation to intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia.

Methods: This study was a cross-sectional analysis on 1,123 subjects (aged 56.0 ± 9.3 years, 37.9% men) of the population-based Shunyi study in China. Arterial stiffness was assessed by measuring brachial-ankle pulse wave velocity (baPWV). Intracranial atherosclerotic stenosis and intracranial arterial dolichoectasia were evaluated via brain magnetic resonance angiography. Multivariate regression models were constructed to investigate the association between baPWV and intracranial large artery diseases.

Results: Increased baPWV was significantly associated with higher prevalence of intracranial atherosclerotic stenosis (odds ratio for the highest quartile of baPWV compared with the lowest quartile, 3.66 [95% confidence interval, 1.57–8.54]), after adjustment for cardiovascular risk factors in multivariate analysis. BaPWV was not associated with the presence of basilar artery dolichoectasia and dilation of basilar artery and internal carotid artery. When the diameters of intracranial arteries were regarded as continuous variables, increased baPWV was inversely related to the internal carotid artery diameter in fully adjusted models (β ± SE, −0.083 ± 0.042, p = 0.047).

Conclusions: This population-based study demonstrates that arterial stiffness was more likely associated with intracranial stenotic arteriopathy other than intracranial dilative arteriopathy.

Plasma Fibroblast Growth Factor 23 Concentration Is Associated with Intracranial Cerebral Atherosclerosis in Acute Ischemic Stroke Patients

BACKGROUND AND PURPOSE

Fibroblast growth factor 23 (FGF23) is associated with atherosclerosis via nitric-oxide-associated endothelial dysfunction and calcium-phosphate-related bone mineralization. This study aimed to determine the association of the plasma FGF23 concentration with intracranial cerebral atherosclerosis (ICAS) and extracranial cerebral atherosclerosis (ECAS).

METHODS

We prospectively enrolled 262 first-ever ischemic stroke patients in whom brain magnetic resonance was performed and a blood sample acquired within 24 h after admission. Plasma FGF23 concentrations were measured using an enzyme-linked immunosorbent assay. The presence of ICAS or ECAS was defined as a ≥50% decrease in arterial diameter in magnetic resonance angiography. The burden of cerebral atherosclerosis was calculated by adding the total number of vessels defined as ICAS or ECAS.

RESULTS

Our study population included 152 (58.0%) males. The mean age was 64.7 years, and the plasma FGF23 concentration was 347.5±549.6 pg/mL (mean±SD). ICAS only, ECAS only, and both ICAS and ECAS were present in 31.2% (n=82), 4.9% (n=13), and 6.8% (n=18) of the subjects, respectively. In multivariate binary and ordinal logistic analyses, after adjusting for sex, age, and variables for which p<0.1 in the univariate analysis, the plasma FGF23 concentration (per 100 pg/mL) was positively correlated with the presence of ICAS [odds ratio (OR)=1.07, 95% CI=1.00-1.15, p=0.039], burden of ICAS (OR=1.09, 95% CI=1.04-1.15, p=0.001), and burden of ECAS (OR=1.06, 95% CI=1.00-1.12, p=0.038), but it was not significantly related to the presence of ECAS (OR=1.05, 95% CI=0.99-1.12, p=0.073).

CONCLUSIONS

The plasma FGF23 may be a potential biomarker for cerebral atherosclerosis, particularly the presence and burden of ICAS in stroke patients.

Predictive performance of aortic arch calcification for clinical outcomes in patients with acute coronary syndrome that undergo percutaneous coronary intervention: A prospective clinical study

Currently, little is known regarding the predictive utility of aortic arch calcification (AAC) for clinical outcomes in patients with acute coronary syndrome (ACS) who undergo percutaneous coronary intervention (PCI). The present study was designed to investigate the predictive performance of AAC as detected by chest x-ray for clinical outcomes among ACS patients undergoing PCI.A total of 912 patients who were diagnosed as ACS and treated with PCI were included in this prospective, cohort study. All study participants received chest x-rays on admission, and a semiquantitative 4-point scale was used to assess the extent of AAC. The primary end point was defined as a composite of major adverse cardiovascular events (MACE) comprising death, nonfatal stroke, nonfatal myocardial infarction, and unplanned repeat revascularization. The key secondary end point was the composite of cardiovascular death, nonfatal stroke, and nonfatal myocardial infarction. The prognostic values of AAC were assessed in multivariate Cox-proportional hazards regression analyses adjusted for major confounders.The mean follow-up duration was 917 days and, during the follow-up period, MACE occurred in 168 (18.4%) patients. Kaplan-Meier analyses revealed significantly higher incidences of the primary and key secondary end points in patients with higher AAC grades (log-rank test; all P < .001). Multivariate Cox-proportional hazards regression analyses showed that, in comparison to AAC grade 0, the hazard ratios of AAC grades 1, 2, and 3 for predicting MACE were 1.63 (95% confidence interval [CI] 0.99-2.67), 2.15 (95% CI 1.27-3.62), and 2.88 (95% CI 1.41-5.86), respectively. The C-index of the variables, including peripheral arterial disease and serum levels of triglyceride for predicting MACE, was 0.644 (95% CI 0.600-0.687) versus 0.677 (95% CI 0.635-0.719) when AAC grades were also included; the continuous net reclassification improvement was 16.5% (8.7%-23.4%; P < .001).The extent of AAC as detected by chest x-ray is an independent predictor of MACE among ACS patients undergoing PCI. Further research is warranted to evaluate whether specific treatment strategies that are established based on AAC extent are needed for optimal risk reduction in relevant patient populations.

Pulse Wave Velocity in Atherosclerosis

Early detection of subclinical atherosclerosis is important to reduce patients' cardiovascular risk. However, current diagnostic strategy focusing on traditional risk factors or using risk scoring is not satisfactory. Non-invasive imaging tools also have limitations such as cost, time, radiation hazard, renal toxicity, and requirement for specialized techniques or instruments. There is a close interaction between arterial stiffness and atherosclerosis. Increased luminal pressure and shear stress by arterial stiffening causes endothelial dysfunction, accelerates the formation of atheroma, and stimulates excessive collagen production and deposition in the arterial wall, leading to the progression of atherosclerosis. Pulse wave velocity (PWV), the most widely used measure of arterial stiffness, has emerged as a useful tool for the diagnosis and risk stratification of cardiovascular disease (CVD). The measurement of PWV is simple, non-invasive, and reproducible. There have been many clinical studies and meta-analyses showing the association between PWV and coronary/cerebral/carotid atherosclerosis. More importantly, longitudinal studies have shown that PWV is a significant risk factor for future CVD independent of well-known cardiovascular risk factors. The measurement of PWV may be a useful tool to select subjects at high risk of developing subclinical atherosclerosis or CVD especially in mass screening.

Pulse Wave Velocity in Atherosclerosis

Early detection of subclinical atherosclerosis is important to reduce patients' cardiovascular risk. However, current diagnostic strategy focusing on traditional risk factors or using risk scoring is not satisfactory. Non-invasive imaging tools also have limitations such as cost, time, radiation hazard, renal toxicity, and requirement for specialized techniques or instruments. There is a close interaction between arterial stiffness and atherosclerosis. Increased luminal pressure and shear stress by arterial stiffening causes endothelial dysfunction, accelerates the formation of atheroma, and stimulates excessive collagen production and deposition in the arterial wall, leading to the progression of atherosclerosis. Pulse wave velocity (PWV), the most widely used measure of arterial stiffness, has emerged as a useful tool for the diagnosis and risk stratification of cardiovascular disease (CVD). The measurement of PWV is simple, non-invasive, and reproducible. There have been many clinical studies and meta-analyses showing the association between PWV and coronary/cerebral/carotid atherosclerosis. More importantly, longitudinal studies have shown that PWV is a significant risk factor for future CVD independent of well-known cardiovascular risk factors. The measurement of PWV may be a useful tool to select subjects at high risk of developing subclinical atherosclerosis or CVD especially in mass screening.

Cerebral Arterial Stiffness as A New Marker of Early Stage Atherosclerosis of The Cerebral Large Artery in Acute Stroke

Aim: Carotid–cer ebral pulse wave velocity (ccPWV) reflects the segment (C-M segment) stiffness between the common carotid artery and ipsilateral middle cerebral artery. C-M segment atherosclerosis (CMSA) is regarded the most frequent cause of anterior circulation ischemic stroke. We aimed to evaluate the association of ccPWV with early stage CMSA in this study.

Methods: Eighty-one acute ischemic stroke (AIS) patients with 154 C-M segments who were successfully evaluated with digital subtraction angiography, ccPWV, carotid intima–media thickness (cIMT), and brachial–ankle pulse wave velocity were enrolled into this study. Patient demographics and clinical data were retrieved from our AIS databases.

Results: Multivariate analyses showed that CMSA was independently associated with higher systolic BP, ccPWV, and cIMT. ccPWV and cIMT presented good diagnostic values for evaluating early stage CMSA in the receiver operating characteristic curve analyses. The areas under the curve (AUCs) of ccPWV were significantly higher than that of cIMT (Z = 2.204, P = 0.007). The AUC, sensitivity, specificity, Youden index, and cutoff of ccPWV for detecting early stage CMSA were 0.815 (P < 0.001), 86%, 70.7%, 0.567, and 5.4 m/s, respectively. Furthermore, ccPWV was significantly correlated with the stenosis of CMSA at the early stage in Spearman's correlation analyses (r = 0.877, P < 0.001) and fractional polynomial plot with 95% confidence intervals.

Conclusions: Cerebral arterial stiffness has the potential to be a new marker of early stage atherosclerosis of the cerebral large artery. This finding may help us prevent the occurrence of stroke and decrease the burden of society from stroke patients.

Association between Cerebral Arterial Stiffness and Large Artery Atherosclerosis in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Carotid-cerebral pulse wave velocity (ccPWV) reflects the segment (C-M segment) stiffness between common carotid artery and ipsilateral middle cerebral artery. The C-M segment atherosclerosis (CMSA) is regarded as a most frequent cause of anterior circulation ischemic stroke. We therefore, attempted to investigate the relationship between cerebral arterial stiffness and CMSA, and provide reliable data for the early diagnosis of CMSA.

METHODS

Between June 2012 and August 2016, 81 acute ischemic stroke (AIS) patients with 154 C-M segments successfully evaluated with digital subtraction angiography and ccPWV were enrolled into this study. Patient demographics and clinical data were retrieved from our AIS databases.

RESULTS

Multivariate analyses showed that ccPWV was independently associated with CMSA (β = 39.6, P = .009) and Systolic blood pressure (β = 7.1, P < .001) in AIS patients. The values of ccPWV had a trend to be higher in the groups with more lesions (F = 45.9, P < .01) and severer stenosis (F = 102.6, P = .000), and was positively correlated with the number of lesions (r = .662, P = .000), and degree of stenosis (r = .858, P = .000) of CMSA. The fractional polynomial plots with 95% CIs also describe the close relationship between ccPWV and the number of lesions and degree of stenosis in CMSA.

CONCLUSIONS

Cerebral arterial stiffness is independently associated with the presence of CMSA, closely related to the vascular damage of C-M segment and reflects the vascular structure change of C-M segment in AIS patients. It may have the potential for assessment of CMSA in its initial stage.

Iatrogenic Removal of the Intima in the Middle Cerebral Artery by a Stent Retriever: A Report of Two Cases

BACKGROUND

Mechanical thrombectomy improves functional outcomes in patients with acute ischemic stroke. However, stent retrievers have the risk of vascular damage.

CASE DESCRIPTION

We present 2 cases of patients with acute internal carotid artery occlusion who experienced removal of the intima by a stent retriever. In both patients, a 6 × 30-mm Solitaire stent was fully deployed from the M2 portion and slowly withdrawn. White membranes were retrieved outside the strut in both patients. Histopathologic examination showed that one membrane consisted of thickened intima and internal elastic lamina and the other consisted of calcified intima and internal elastic lamina. One patient who suffered embolic stroke experienced recurrent infarction within 24 hours after operation, and the damaged vessel was occluded on magnetic resonance angiography 21 days after stroke. In another patient with carotid artery dissection, the damaged vessel showed asymptomatic stenosis on magnetic resonance angiography 90 days after stroke. Arteries with both atherosclerosis and vessel dissection may be vulnerable to high radial expansion force.

CONCLUSIONS

Full deployment of a relatively large-sized stent into a vulnerable vessel may cause vessel dissection after removal of the intima. Appropriate material selection and treatment strategy while considering stroke etiology and the occlusion site are important to prevent vessel damage.

Arterial Stiffness is Independently Associated with Severity of Carotid Siphon Calcifications in Community-Dwelling Older Adults: The Atahualpa Project

BACKGROUND

Knowledge on the association between arterial stiffness and intracranial atherosclerosis is limited. Here, we aimed to assess whether the aortic pulse wave velocity (PWV)-used as a surrogate of arterial stiffness-might independently predict severity of carotid siphon calcifications (CSCs), used as a marker of atherosclerosis.

METHODS

Of 437 Atahualpa residents aged 60 years or older, 300 (69%) underwent head computed tomography (CT) (for CSC assessment), brain magnetic resonance imaging (for identification of neuroimaging signatures of cerebral small vessel disease [SVD]), and aortic PWV determinations (for arterial stiffness estimation). Ordinal logistic regression models were constructed to predict severity of CSC (as the dependent variable) according to levels of aortic PWV after adjusting for demographics, cardiovascular risk factors, and neuroimaging signatures of SVD.

RESULTS

Grade 1 CSC were noticed in 120 (40%) subjects, grade 2 in 84 (28%), grade 3 in 73 (24%), and grade 4 in 23 (8%). The mean PWV was 10.4 ± 1.8 m/s, which increased from 9.8 ± 1.3 to 11.1 ± 2.1 m/s in individuals with grades 1 and 4 CSC, respectively (P <.001). The most parsimonious ordinal logistic regression model adjusted for relevant confounders showed a significant association between aortic PWV and severity of CSC. In this model, a change of 1 unit of aortic PWV increased the odds of CSC severity by 1.22 (95% confidence interval 1.07-1.39; P = .004).

CONCLUSIONS

The monotonically increased odds of aortic PWV among subjects with different grades of CSC, suggest that aortic PWV may be a marker for identifying candidates for CT screening in the search of CSC.

CHA2DS2-VASc Score Predict No-Reflow Phenomenon in Primary Percutaneous Coronary Intervention in Primary Percutaneous Coronary Intervention

Introduction: No-reflow is one of the major complications of primary PCI in patients with acute ST elevation myocardial infarction. This phenomenon is associated with adverse outcomes in these patients. In the current study, we evaluated the effectiveness of CHA2DS2-VASc score in predicting no-reflow phenomenon. CHA2DS2-VASc score is a risk stratification method to estimate the risk of thromboembolism in patients with atrial fibrillation. Methods: In total, 396 patients with ST elevation myocardial infarction who had undergone primary PCI were evaluated in our study. Based on post interventional TIMI flow rate results, the patients were divided into two groups: control group (294 patients) and no-reflow group (102 patients). The CHA2DS2-VASc score was calculated for each participant. Multivariate regression analysis was performed to determine the predictive value of this score. Results: Our findings showed that CHA2DS2-VASc score can predict no-reflow independently (odds ratio: 3.06, 95%, confidence interval: 2.23-4.21, P <0 .001). Moreover, lower systolic blood pressure, higher diastolic blood pressure, grade 0 initial TIMI flow rate and smaller stent size were other independent predictors of the no-reflow in our study. We also defined a cut off value of ≥ 2 for the CHA2DS2-VASc score in predicting the no-reflow with a sensitivity of 88% and specificity of 67%, area under curve: 0.83 with 95% CI (0.79-0.88). Conclusion: The CHA2DS2-VASc score could be used as a simple applicable tool in the prediction of no-reflow before primary PCI in the acute ST elevation myocardial infarction patients.

Interarm Systolic and Diastolic Blood Pressure Difference Is Diversely Associated With Cerebral Atherosclerosis in Noncardioembolic Stroke Patients

BACKGROUND

Interarm systolic and diastolic blood pressure differences (IASBD, IADBD) are not infrequent in various populations. Cerebral atherosclerosis, including extracranial cerebral atherosclerosis (ECAS) and intracranial cerebral atherosclerosis (ICAS), is an important risk factor for stroke. In this study, we aimed to investigate the relationship of IASBD, IADBD with presence and burden of ICAS and ECAS.

METHODS

This was a retrospective hospital-based cross-sectional study. In total, 1,063 consecutive noncardioembolic ischemic stroke patients, who were checked for bi-brachial blood pressures from ankle-brachial index and brain magnetic resonance angiographic images of cerebral arteries, were included. The IASBD and IADBD were defined as absolute value of the blood pressure difference in both arms.

RESULTS

In all included patients, patients with IASBD ≥10 and IADBD ≥10 were noted in 9.4% (100/1,063) and 5.3% (56/1,063). The patients with IASBD ≥10 mm Hg were more frequently burdened with ICAS (P = 0.001) and ECAS (P = 0.027) and patients with IADBD ≥10 mm Hg were more frequently burdened with ICAS (P = 0.042) but not ECAS (P = 0.187). Multivariate analysis after adjusting gender, age, and a P value <0.1 in univariate analysis showed IASBD ≥10 mm Hg was associated with the presence of both ECAS and ICAS [odds ratio (OR): 2.96, 95% confidence interval (CI): 1.65-5.31]. The IADBD ≥10 mm Hg was related with presence of ICAS only (OR: 1.87, 95% CI: 1.05-3.37) but not with ECAS only (OR: 1.50, 95% CI: 0.73-3.06).

CONCLUSIONS

Our study showed IASBD and IADBD were diversely associated with cerebral atherosclerosis. In noncardioembolic stroke patients with IASBD ≥10 or IADBD ≥10, the possibility of accompanying cerebral atherosclerosis should be considered.

PR interval prolongation in coronary patients or risk equivalent: excess risk of ischemic stroke and vascular pathophysiological insights

BACKGROUND

Whether PR prolongation independently predicts new-onset ischemic events of myocardial infarction and stroke was unclear. Underlying pathophysiological mechanisms of PR prolongation leading to adverse cardiovascular events were poorly understood. We investigated the role of PR prolongation in pathophysiologically-related adverse cardiovascular events and underlying mechanisms.

METHODS

We prospectively investigated 597 high-risk cardiovascular outpatients (mean age 66 ± 11 yrs.; male 67%; coronary disease 55%, stroke 22%, diabetes 52%) for new-onset ischemic stroke, myocardial infarction (MI), congestive heart failure (CHF), and cardiovascular death. Vascular phenotype was determined by carotid intima-media thickness (IMT).

RESULTS

PR prolongation >200 ms was present in 79 patients (13%) at baseline. PR prolongation >200 ms was associated with significantly higher mean carotid IMT (1.05 ± 0.37 mm vs 0.94 ± 0.28 mm, P = 0.010). After mean study period of 63 ± 11 months, increased PR interval significantly predicted new-onset ischemic stroke (P = 0.006), CHF (P = 0.040), cardiovascular death (P < 0.001), and combined cardiovascular endpoints (P < 0.001) at cut-off >200 ms. Using multivariable Cox regression, PR prolongation >200 ms independently predicted new-onset ischemic stroke (HR 8.6, 95% CI: 1.9-37.8, P = 0.005), cardiovascular death (HR 14.1, 95% CI: 3.8-51.4, P < 0.001) and combined cardiovascular endpoints (HR 2.4, 95% CI: 1.30-4.43, P = 0.005). PR interval predicts new-onset MI at the exploratory cut-off >162 ms (C-statistic 0.70, P = 0.001; HR: 8.0, 95% CI: 1.65-38.85, P = 0.010).

CONCLUSIONS

PR prolongation strongly predicts new-onset ischemic stroke, MI, cardiovascular death, and combined cardiovascular endpoint including CHF in coronary patients or risk equivalent. Adverse vascular function may implicate an intermediate pathophysiological phenotype or mediating mechanism.

Progression in acute ischemic stroke: Is widespread atherosclerotic background a risk factor?

OBJECTIVES

In this study, we aimed to investigate the causes and conditions related with progression and outcome of progressive acute ischemic stroke.

PATIENTS AND METHODS

In this prospective study, a total of 78 acute ischemic stroke patients (32 males, 46 females; mean age 70±12.8 years; range 34 to 95 years) were included between February 2006 and October 2010. The patients were classified into two groups as those with and without progression according to the National Institute of Health Stroke Scale (NIHSS). Risk factors for ischemic stroke, stroke subtypes, and radiological investigations and prognosis were compared between the progressive and non-progressive patients.

RESULTS

Neurological deterioration occurred in 12 patients (15%). Progressive acute ischemic stroke patients had carotid stenosis compared to non-progressive patients (50% vs 19%), and ischemic cardiac disease (33% vs 6%) more common in the patients with progression. Mortality during hospital stay and long term-outcomes were similar between the groups.

CONCLUSION

Our study results suggest that widespread atherosclerotic diseases may induce neurological progression.

Proteomic analysis and comparison of intra‑ and extracranial cerebral atherosclerosis responses to hyperlipidemia in rabbits

The present study aimed to investigate protein expression levels of intra‑ and extracranial atherosclerosis in rabbits following administration of a high‑fat diet. Rabbits were randomly divided into control (group A; n=9) and high‑fat diet (group B; n=9) groups. At week 12, tissues were sectioned from the common carotid artery (CCA) and middle cerebral artery (MCA). Pathological analysis was performed. Differential protein expression levels were examined by 2‑D gel electrophoresis (2‑DE) and mass spectrometry (MS) analysis and validated by western blotting. Serum lipid levels, the intima‑media thickness (IMT) and degree of atherosclerosis of the CCA and MCA were increased at week 12 in the high‑fat diet group compared with rabbits that received a normal diet. 2‑DE and MS analysis of the protein extracted from CCA and MCA detected >439 different proteins; the expression of 25 proteins was altered, and 8 proteins [albumin A chain, tropomyosin α‑1 chain (TPM1), heat shock protein 70 (HSP70), α‑smooth muscle actin, β‑galactose binding agglutinin, TPM4 isoform 2, cell keratin 9, single octylic acid glyceride β‑2) demonstrated significant alterations in expression levels. Due to limited antibody sources, only three differentially expressed proteins (TPM1, HSP70 and α‑smooth muscle actin) were examined by western blotting. The results of our previous study demonstrated that hyperlipidemia affected the IMT of intracranial and extracranial cerebral arteries. In the present study, protein expression levels of TPM1 and α‑smooth muscle actin from extracranial cerebral arteries were significantly increased compared with intracranial cerebral arteries; however, protein expression levels of HSP70 from intracranial cerebral arteries was increased compared with extracranial cerebral arteries. The differences may be closely associated with cell proliferation and metastasis, and oxidoreduction, in intra‑ and extracranial cerebral atherosclerosis. HSP70 may have protective properties against atherosclerosis via underlying anti‑inflammatory mechanisms, furthermore, differential protein expression levels (TPM1, HSP70 and α‑smooth muscle actin) between intra‑ and extracranial cerebral arteries may facilitate the identification of novel biological markers for the diagnosis and treatment of cerebral arteriosclerosis.

Brachial-ankle PWV for predicting clinical outcomes in patients with acute stroke

BACKGROUND

Although brachial-ankle pulse wave velocity (baPWV) is well-known for predicting the cardiovascular mortality and morbidity, its anticipated value is not demonstrated well concerning acute stroke.

METHODS

Total 1557 patients with acute stroke who performed baPWV were enrolled. We evaluated the prognostic value of baPWV predicting all-cause death and vascular death in patients with acute stroke Results: Highest quartile of baPWV was ≥23.64 m/s. All-caused deaths (including vascular death; 71) were 109 patients during follow-up periods (median 905 days). Multivariate Cox regression analysis revealed that patients with the highest quartile of baPWV had higher risk for vascular death when they are compared with patients with all other three quartiles of baPWV (Hazard ratio with 95% confidence interval [CI] 1.879 [1.022-3.456], p = .042 for vascular death).

CONCLUSION

High baPWV was a strong prognostic value of vascular death in patients with acute stroke.

Brachial-ankle pulse wave velocity is associated with 3-month functional prognosis after ischemic stroke

BACKGROUND AND AIMS

Brachial-ankle pulse wave velocity (baPWV) is a good measure of arterial stiffness and is associated with risk of future vascular events. The present study aimed to examine whether baPWV can also predict 3-month functional outcome after stroke.

METHODS

This hospital-based study included 327 consecutive patients with acute ischemic stroke and in whom baPWV was measured during hospitalization. We defined good and poor functional outcomes as a modified Rankin Scale score of <3 and ≥ 3 at 3 months, respectively, after initial stroke.

RESULTS

Patients with poor outcomes were significantly older (73.1 versus 66.3 years, p < 0.001) and more likely to have extracranial carotid arterial stenosis (29.5% versus 13.1%, p < 0.001), atrial fibrillation (21.0% versus 11.3%, p = 0.020), history of coronary artery disease (20.0% versus 11.7%, p = 0.042), and high baPWV value (22.84 versus 19.48 m/s, p < 0.001). Irrespective of patients' age, sex, baseline risk factors, initial stroke severity, and stroke etiology, baPWV was consistently higher in patients with poor outcome than those with good outcome. Multivariate analysis revealed that baPWV >23.11 m/s, calculated from the receiver-operating characteristic curve, had an independent predictive value for poor functional outcome (odds ratio, 1.51; 95% confidence interval, 1.08-2.11; p = 0.016).

CONCLUSIONS

BaPWV measured during the acute phase of stroke can independently predict 3-month functional prognosis. We suggest that baPWV should be performed as part of the early stroke work-up to identify patients suffering from severe stroke-related disability.

CHA2DS2-VASc Score is a Predictor of No-Reflow in Patients With ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Intervention

Thrombosis and distal embolization play crucial role in the etiology of no-reflow. CHA2DS2-VASc score is used to estimate the risk of thromboembolism in patients with atrial fibrillation. We tested the hypothesis that CHA2DS2-VASc can predict no-reflow among patients who underwent primary percutaneous coronary intervention (PCI). A total number of 2375 consecutive patients with ST-segment elevation myocardial infarction were assessed for the study. Patients were divided into 2 groups as no-reflow (n = 111) and control (n = 1670) groups according to post-PCI no-reflow status. CHA2DS2-VASc scores were calculated for all patients. CHA2DS2-VASc scores were significantly higher in the no-reflow group compared to the control group. After a multivariate regression analysis, CHA2DS2-VASc score remained as an independent predictor (odds ratio: 1.58, 95% confidence interval: 1.33-1,88, P < .001) of no-reflow. Receiver–operating characteristics analysis revealed the cutoff value of CHA2DS2-VASc score ≥2 as a predictor of no-reflow with a sensitivity of 66% and a specificity of 59%. Moreover, in-hospital mortality was also associated with significantly higher CHA2DS2-VASc scores. In conclusion, CHA2DS2-VASc score is associated with higher risk of no-reflow and in-hospital mortality rates in patients who underwent primary PCI.

Increased Epicardial Fat Thickness Correlates with Aortic Stiffness and N-Terminal Pro-Brain Natriuretic Peptide Levels in Acute Ischemic Stroke Patients

Epicardial fat, a metabolically active tissue, has emerged as a risk factor and active player in metabolic and cardiovascular diseases. We investigated epicardial fat thickness in patients who had sustained an acute ischemic stroke, and we evaluated the relationship of epicardial fat thickness with other prognostic factors. We enrolled 61 consecutive patients (age, ≥18 yr) who had sustained a first acute ischemic stroke and had been admitted to our hospital within 24 hours of the onset of stroke symptoms. The control group comprised 82 consecutive sex- and age-matched patients free of past or current stroke who had been admitted to our cardiology clinics. Blood samples were taken for measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels at admission. Aortic stiffness indices and epicardial fat thickness were measured by means of transthoracic echocardiography within the first 48 hours. In comparison with the control group, the patients with acute ischemic stroke had significantly higher epicardial fat thickness (4.8 ± 0.9 vs 3.8 ± 0.7 mm; P <0.001), lower aortic distensibility (2.5 ± 0.8 vs 3.4 ± 0.9 cm(2) ·dyn(-1); P <0.001) and lower aortic strain (5.5% ± 1.9% vs 6.4% ± 1.8%; P=0.003). We found a significant association between epicardial fat thickness, NT-proBNP levels, and arterial dysfunction in patients who had sustained acute ischemic stroke. Increased epicardial fat thickness might be a novel risk factor and might enable evaluation of subclinical target-organ damage in these patients.

Association of Brachial-Ankle Pulse Wave Velocity with Asymptomatic Intracranial Arterial Stenosis in Hypertension Patients

BACKGROUND

Intracranial arterial stenosis is a common cause of ischemic stroke in Asians. We therefore sought to explore the relationship of brachial-ankle pulse wave velocity and intracranial arterial stenosis in 834 stroke-free hypertensive patients.

METHODS

Intracranial arterial stenosis was evaluated through computerized tomographic angiography. Brachial-ankle pulse wave velocity was measured by an automated cuff device.

RESULTS

The top decile of brachial-ankle pulse wave velocity was significantly associated with intracranial arterial stenosis (P = .027, odds ratio = 1.82; 95% confidence interval: 1.07-3.10). The patients with the top decile of brachial-ankle pulse wave velocity showed 56% higher risk for the presence of intracranial arterial stenosis to the whole population, which was more significant in patients younger than 65 years old. We also found that brachial-ankle pulse wave velocity related to both intracranial arterial stenosis and homocysteine.

CONCLUSION

Our study showed the association of brachial-ankle pulse wave velocity with asymptomatic intracranial arterial stenosis in hypertension patients, especially in relative younger subjects. Brachial-ankle pulse wave velocity might be a relatively simple and repeatable measurement to detect hypertension patients in high risk of intracranial arterial stenosis.

A New Method for Cerebral Arterial Stiffness by Measuring Pulse Wave Velocity Using Transcranial Doppler

AIM

Pulse wave velocity (PWV) has been regarded as the "gold standard" measurement of arterial stiffness (AS), but it is still only used in the assessment of central and peripheral arteries. We constructed a new method to evaluate cerebral AS by measuring PWV using transcranial Doppler (TCD).

METHODS

In all, 90 healthy subjects who received annual health screening were consecutively enrolled in this study between January 2011 and June 2013. Data on clinical characteristics, brachium-ankle (ba) PWV, and carotid-cerebral (cc) PWV measured with our newly constructed method by two experienced operators were recorded. cc PWV was calculated as the distance between two points in the common carotid artery and proximal part of ipsilateral middle cerebral artery, which was divided by the pulse transit time between these two points where the pulse was measured using TCD.

RESULTS

The value of cc PWV was 499.3±78.6 cm/s. Correlation between cc PWV and ba PWV in the assessment of AS was r=0.794 (P＜0.001). The concordance between both the above mentioned methods was good. Interobserver and intraobserver reliability using interclass correlation for measuring cc PWV were 0.815 (P＜0.001) and 0.939 (P＜0.001), respectively. In multivariable analysis, older age (β=4.51, P＜0.001) and increased diastolic blood pressure (β=2.39, P＜0.001) were independently associated with higher cc PWV.

CONCLUSION

cc PWV measured using TCD may be a promising method for the assessment of human cerebral AS, which is independently associated with age and diastolic blood pressure.

Decreased circulating neopterin is associated with increased arterial elasticity: a beneficial role of periodontal treatment

BACKGROUND

The aim of this study was to evaluate the effect of periodontal treatment on arterial elasticity and circulating neopterin in patients with moderate to severe periodontitis in a Chinese population.

METHODS

One hundred and eight patients with moderate to severe periodontitis were eligible to take part in the study and were randomized into two groups. The treatment group received intensive periodontal treatment, while the control group received control periodontal treatment. All parameters, including brachial-ankle pulse wave velocity (baPWV), ankle brachial index (ABI), serum neopterin (NP), high-sensitivity C-reactive protein (hs-CRP), Interleukin-6 (IL-6), were evaluated before treatment and 1 month after treatment.

RESULTS

The parameters including NP, hs-CRP, IL-6 and baPWV decreased significantly after 1 month in the treatment group (p < 0.05 for all comparisons) but not in the control group (p > 0.05). There was no significant difference in the change of ABI between the two groups (p = 0.231). A positive correlation was found between the decreased circulating NP and increased arterial elasticity in the treatment group (r = 0.947, p < 0.001).

CONCLUSIONS

This study demonstrates for the first time that the fall in circulating NP induced by periodontal treatment contributes to increased arterial elasticity in patients with moderate and severe periodontitis.

Brachial-ankle pulse wave velocity and ankle-brachial index are complementary tools for transcranial Doppler ultrasonography in early diagnosis of intracranial arterial stenosis/occlusion in patients with acute ischemic stroke

The aim of this study was to explore whether brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) are suitable to serve as complementary tools for TCD in early diagnosis of intracranial arterial stenosis/occlusion in patients with acute ischemic stroke (AIS). A total of 52 patients with AIS onset and 52 age-matched healthy controls were included in this study. All participants received TCD detection, and baPWV and ABI were measured. Computed topography (CT)/magnetic resonance imaging (MRI) was applied to confirm diagnosis. TCD data from all participants was collected and reviewed to diagnose stenosis and occlusion of the major intracranial arteries. Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to assess and compare the diagnostic accuracy of the various diagnostic approaches. We found that a combination of TCD with either baPWV or ABI, or a combination of the three provided a significantly higher area under the curve (AUC) in detecting stenosis or occlusion in various intracranial arteries, excluding the anterior cerebral artery (ACA), when compared to TCD alone, thereby demonstrating that these combined approaches provide improved diagnostic accuracy. In conclusion, our findings suggest that both baPWV and ABI are suitable complementary tools for TCD in early diagnosis of intracranial arterial stenosis/occlusion in AIS patients and that these combinations may assist in facilitating the diagnostic process associated with this disease.

Prognostic Significance of Regional Arterial Stiffness for Stroke in Hypertension

BACKGROUND

Hypertension is strongly associated with cardiovascular disease. It has been reported that arterial stiffness is related to cardiovascular mortality and morbidity in hypertensive patients and that the physiological evaluation of arterial stiffness may assist clinicians in the early detection of atherosclerosis.

SUMMARY

It has been demonstrated that increased arterial stiffness is an independent predictor of cardiovascular disease, including stroke. Arterial stiffness is associated with structural changes in the brain. However, the stiffness responses of muscular arteries are different from those of elastic arteries, and so the impact of arterial stiffness and the conclusions to be drawn may be different depending on the region in which the measurement is taken.

KEY MESSAGES

In this review, we summarize the current literature describing the association between arterial stiffness, including carotid-femoral and brachial-ankle pulse wave velocity and cardio-ankle vascular index, and cardiovascular disease, specifically stroke. We discuss the utility and prognostic significance of regional arterial stiffness measurements.

Comparison of arteriosclerotic indicators in patients with ischemic stroke: ankle-brachial index, brachial-ankle pulse wave velocity and cardio-ankle vascular index

The ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV) and cardio-ankle vascular index (CAVI) are surrogate markers of arteriosclerosis. However, their roles in patients with acute ischemic stroke remain unclear. From October 2003 to September 2011, we enrolled patients with arteriosclerotic ischemic stroke (AIS) exhibiting large infarcts attributed to large-artery atherosclerosis (LAA) or deep subcortical infarcts (mainly lacunar infarcts) attributed to small-artery disease (SAD). Outpatients without a history of stroke served as controls (CTL). We divided the study period into two terms and assessed patients using two different oscillometric devices (Form PWV/ABI, Omron Colin; and VaSera VS-1500, Fukuda Denshi) in each term. One-way analysis of variance and age- and sex-adjusted analysis of covariance were used to compare the three groups. We analyzed 842 patients. The ABI was significantly lower in the LAA (n = 102) group than in the SAD (n = 280) and CTL (n = 460) groups. The baPWV was significantly higher in the LAA and SAD groups than in the CTL group. The CAVI gradually increased in the order of CTL, SAD and LAA. The cutoff values of baPWV and CAVI for detection of AIS were 18.3 m s(-1) (odds ratio (OR): 6.09, 95% confidence interval (CI): 3.97-9.62, P < 0.01) and 9.5 (OR: 1.44, 95% CI: 1.24-1.70, P < 0.001), respectively. Among the three indicators, a lower ABI indicated advanced atherosclerosis associated with LAA, and an increased baPWV more closely indicated AIS. An increased CAVI may indicate the degree of vessel stiffness due to arteriosclerosis.

Carotid endarterectomy versus stenting: Does the flow really change? An Echo-Color-Doppler analysis

To assess potential hemodynamic differences after carotid endarterectomy (CEA) and carotid artery stenting (CAS) and their eventual impact on clinical management. Between July 2012 and October 2013 two groups of 30 patients each referred for CEA or CAS were prospectively enrolled in two tertiary hospital care centers. Pre-procedural imaging assessment of carotid artery disease was performed with Echo-Color-Doppler (ECD) and computed tomography angiography (CTA). ECD was repeated within 24 h and 1, 6 and 12 months after surgical/endovascular procedures. Peak systolic velocity (PSV) and end diastolic velocity (EDV) were assessed at two standard sites: common carotid artery (CCA) and distal internal carotid artery (ICA). Twenty-four hours ECD findings highly differ between the two populations. CCA PSV in the CEA and CAS groups was respectively 44.88 ± 9.16 and 69.20 ± 20.04 cm/s (p = 0.002); CCA EDV was 16.11 ± 2.29 and 19.13 ± 6.42 cm/s (p = 0.065); ICA PSV was 46.11 ± 7.9 and 94.02 ± 57.7 cm/s (p = 0.0012); ICA EDV was 20.22 ± 4.33 and 30.47 ± 18.33 cm/s (p = 0.025). One month, 6 months and 1 year findings confirmed the different trend in the two cohorts; in particular, at 1 year: CCA PSV was 50.94 ± 12.44 and 60.59 ± 26.84 cm/s (p = 0.181); CCA EDV was 17.11 ± 3.46 and 19 ± 16.35 cm/s (p = 0.634); ICA PSV was 51.66 ± 10.1 and 70.86 ± 20.64 cm/s (p = 0.014); ICA EDV was 25.05 ± 8.65 and 32.66 ± 13 cm/s (p = 0.0609). ECD follow-up of patients undergone CEA or CAS may play a critical role in the clinical management. Strict surveillance of blood flow velocities allows reducing false positive re-stenosis diagnosis and choosing the best anti-aggregation therapies. Within the first month CEA patients benefit from a lower risk condition in comparison with CAS patients, due to a significantly faster PSV drop; moreover, long-term CCA PSV after CEA could be used as a surrogate marker of neointima formation.