Three-year survival after first-ever ischemic stroke is predicted by initial stroke severity: A hospital-based study

Impact of stroke history on procedural cerebrovascular insult probability and long-term outcome after TAVI

BACKGROUND

In TAVI procedural stroke is one of the most feared complications and for this reason also extensively studied. But there is a lack of data concerning the impact of previous stroke on procedural stroke and on long-term survival. The aim of this registry-based cohort study is to evaluate the prevalence of previous stroke in TAVI patients and its impact on procedural stroke risk as well as long-term outcome.

METHODS

We included all patients treated with TAVI between January 2007 and December 2020 and investigated concerning previous stroke in their medical history. Among 958 patients, 55 patients had previous stroke and were included in the present analysis.

RESULTS

The salient finding of the present study is that previous stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI. This is also observed after adjusting for confounders like EuroSCORE II (European system for cardiac operative risk evaluation) and AF (atrial fibrillation) as one of the main underlying diseases for cerebrovascular insult (CVI). However, previous stroke is not associated with higher rates of procedural CVI.

CONCLUSION

A history of stroke is significantly associated with higher all-cause mortality and has established itself as a predictor for poor outcome after TAVI without higher rates of procedural stroke.

Cost-effectiveness and potential budget impact of non-pharmacological interventions for early management in prehypertensive people: an economic evaluation for China

BACKGROUND

Non-pharmacological interventions (NPIs) could be considered in the early management of prehypertensive population. This study aimed to evaluate the potential cost-effectiveness of NPIs and the budget impact of implementing NPIs on prehypertensive population in China and provide evidence of chronic disease management innovation for decision-makers.

METHODS

Five NPIs including usual care, lifestyle, strengthen exercise, relaxation, and diet therapy were selected based on the practice of hypertension management in China. A nine-state Markov model was constructed to evaluate the lifetime costs and health outcomes of five NPIs and a non-intervention group from the perspective of Chinese healthcare system. The effectiveness of NPIs was obtained from a published study. Parameters including transition probabilities, costs and utilities were extracted or calculated from published literature and open-access databases. Sensitivity analyses were conducted to test the uncertainty of all parameters. The impact of duration of intervention was considered in scenario analyses. A budget impact analysis (BIA) was conducted to evaluate the total cost and the medical cost saving of a hypothetical nationwide implementation of potential cost-effective NPI in prehypertensive people. Management strategies including focusing on patients with specific ages or different CVE risk levels, and different duration of implementation were taken into consideration.

RESULTS

Strengthen exercise was the most cost-effective intervention with a probability of 78.1% under the given WTP threshold. Our results were sensitive to the cost of interventions, and the utility of prehypertension and hypertension. The duration of implementation had limited impact on the results. BIA results showed that the program cost was hefty and far more than the medical cost saving with the course of simulation time. Applying management strategies which focused on individual characteristics could largely reduce the program cost despite it remained higher than medical cost saving.

CONCLUSIONS

Strengthen exercise was a potential NPI that can be considered in priority for early management in prehypertensive population. Although early management can acquire medical cost saving, the related program cost can be quite hefty. Precise strategies which may help reduce the cost of early management should be taken into consideration in program design.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm³ and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm³. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm³ (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Cost Effectiveness of the First-in-Class ARNI (Sacubitril/Valsartan) for the Treatment of Essential Hypertension in a Chinese Setting

OBJECTIVE

The aim of this study was to model the potential long-term disease progression and pharmacoeconomic value of sacubitril/valsartan for the treatment of essential hypertension from a Chinese healthcare system perspective.

METHODS

A Markov cohort model with five health states was constructed to simulate the incidence of acute cardiovascular events and cost per quality-adjusted life-year (QALY) gained with sacubitril/valsartan compared with allisartan isoproxil and valsartan over a lifetime horizon with an annual cycle. Multivariable risk regression models derived from China-PAR data accompanied by hazard ratios were used to transform the dual mechanism of sacubitril/valsartan to lower blood pressure and left ventricular mass index into long-term fatal and non-fatal cardiovascular risks. Efficacy data were calculated using a network meta-analysis integrated by the results of clinical trials. Healthcare costs were determined from a real-world study and published literature, supplemented by expert opinion. Utilities were derived from literature. Both costs and health outcomes were discounted at 5.0% annually, and prices corresponded to 2021. Model validation, deterministic and probabilistic sensitivity analyses were conducted to test the robustness of results.

RESULTS

For simulated patients with hypertension, sacubitril/valsartan reduced the rates of myocardial infarction by 6.67% and 6.39%, stroke by 9.38% and 8.98%, and heart failure hospitalization by 9.92% and 9.62% relative to allisartan isoproxil and valsartan, respectively. It was also associated with gains in life expectancy among hypertensive individuals of 0.362-0.382 years. Eventually, lifetime costs per patient were CN¥59,272 (US$9187) for sacubitril/valsartan, CN¥54,783 (US$8492) for allisartan isoproxil, and CN¥56,714 (US$8791) for valsartan; total QALYs were 11.38, 11.24, and 11.25, respectively. The incremental cost-effectiveness ratio was CN¥31,805/QALY (US$4930/QALY) compared with allisartan isoproxil, and CN¥19,247/QALY (US$2983/QALY) compared with valsartan, both of which are below the one time per-capita GDP of CN¥80,976/QALY (US$12,551/QALY) in China. Similar results were obtained in various extensive sensitivity analysis scenarios.

CONCLUSIONS

This was the first study to evaluate the cost effectiveness of sacubitril/valsartan in the treatment of hypertension. Sacubitril/valsartan compares favorably with allisartan isoproxil and valsartan in the Chinese setting, which is mainly due to its higher efficacy resulting in fewer cardiovascular events and ultimately less related mortality over time. The results could inform deliberations regarding reimbursement and access to this treatment in China and may provide reference for facilitating more reasonable and efficient allocation of limited resources in such low- and middle-income countries.

Carotid intima media thickness measurements coupled with stroke severity strongly predict short-term outcome in patients with acute ischemic stroke: a machine learning study

Acute ischemic stroke (IS) is one of the leading causes of morbidity, functional disability and mortality worldwide. The objective was to evaluate IS risk factors and imaging variables as predictors of short-term disability and mortality in IS. Consecutive 106 IS patients were enrolled. We examined the accuracy of IS severity using the National Institutes of Health Stroke Scale (NIHSS), carotid intima-media thickness (cIMT) and carotid stenosis (both assessed using ultrasonography with doppler) predicting IS outcome assessed with the modified Rankin scale (mRS) three months after hospital admission. Poor prognosis (mRS ≥ 3) at three months was predicted by carotid stenosis (≥ 50%), type 2 diabetes mellitus and NIHSS with an accuracy of 85.2% (sensitivity: 90.2%; specificity: 81.8%). The mRS score at three months was strongly predicted by NIHSS (β = 0.709, p < 0.001). Short-term mortality was strongly predicted using a neural network model with cIMT (≥ 1.0 mm versus < 1.0 mm), NIHSS and age, yielding an area under the receiving operator characteristic curve of 0.977 and an accuracy of 94.7% (sensitivity: 100.0%; specificity: 90.9%). High NIHSS (≥ 15) and cIMT (≥ 1.0 mm) increased the probability of dying with hazard ratios of 7.62 and 3.23, respectively. Baseline NIHSS was significantly predicted by the combined effects of age, large artery atherosclerosis stroke, sex, cIMT, body mass index, and smoking. In conclusion, high values of cIMT and NIHSS at admission strongly predict short-term functional impairment as well as mortality three months after IS, underscoring the importance of those measurements to predict clinical IS outcome.

Cost-effectiveness analysis of combining traditional Chinese medicine in the treatment of hypertension: compound Apocynum tablets combined with Nifedipine sustained-release tablets vs Nifedipine sustained-release tablets alone

Background

We evaluated the long-term cost-effectiveness of antihypertensive traditional Chinese medicines (TCMs) and to compare the cost-effectiveness of a combined treatment consisting of compound Apocynum tablets and Nifedipine sustained-release tablets with the cost-effectiveness of treatment with Nifedipine sustained-release tablets alone.

Methods

A Markov model was used to simulate the potential incremental cost-effectiveness per quality-adjusted life year (QALY) to be gained from compound Apocynum tablets and Nifedipine sustained-release tablets compared with Nifedipine sustained-release tablets alone. Model parameter estimates were informed by previously published studies. The direct medical costs of outpatients with hypertension were estimated from the health care provider’s perspective. A 5% annual discount rate was applied to both costs and QALYs.

Results

TCMs combined with Nifedipine sustained-release tablets group generated a total 20-year cost of 11,517.94 RMB (US $1739.87), whereas Nifedipine sustained-release tablets alone group resulted in a 20-year cost of 7253.71 RMB (US $1095.73). TCMs combined with Nifedipine sustained-release tablets group resulted in a generation of 12.69 QALYs, whereas Nifedipine sustained-release tablets alone group resulted in 12.50. The incremental cost-utility ratio was 22,443.32 RMB (US $3390.23) per QALY. Considering the threshold of 1 GDP per capita in China in 2018 (US $9764.95), the combination of compound Apocynum tablets and Nifedipine sustained-release tablets was a cost-effective strategy. One-way and probabilistic sensitivity analysis showed unchanged results over an acceptable range.

Conclusions

Combining Traditional Chinese Medicines with chemical medicines is more cost-effective strategy in the treatment of hypertension.

The Relationship between Diffusion-Weighted Magnetic Resonance Imaging Lesions and 24-Hour Rhythm Holter Findings in Patients with Cryptogenic Stroke

BACKGROUND AND OBJECTIVES

Cranial magnetic resonance imaging findings of patients considered to be cryptogenic stroke may be useful in determining the clinical and prognostic significance of arrhythmias, such as atrial premature beats and atrial run attacks, that are frequently encountered in rhythm Holter analysis. This study was conducted to investigate the relationship between short atrial runs and frequent premature atrial contractions detected in Holter monitors and infarct distributions in cranial magnetic resonance imaging of patients diagnosed with cryptogenic stroke.

MATERIALS AND METHODS

We enrolled the patients with acute ischemic stroke whose etiology were undetermined. We divided the patients in two groups according to diffusion-weighted magnetic resonance imaging as single or multiple vascular territory acute infarcts. The demographic, clinical, laboratory, echocardiographic, and rhythm Holter analyses were compared.

RESULTS

The study investigated 106 patients diagnosed with cryptogenic stroke. Acute cerebral infarctions were detected in 31% of the investigated patients in multiple territories and in 69% in a single territory. In multivariate logistic regression analysis, the total premature atrial contraction count (OR = 1.002, 95% CI: 1.001⁻1.004, p = 0.001) and short atrial run count (OR = 1.086, 95% CI: 1.021⁻1.155, p = 0.008) were found as independent variables that could distinguish between infarctions in a single or in multiple vascular territories.

CONCLUSIONS

Rhythm Holter monitoring of patients with infarcts detected in multiple vascular territories showed significantly higher premature atrial contractions and short atrial run attacks. More effort should be devoted to the identification of cardioembolic etiology in cryptogenic stroke patients with concurrent acute infarcts in the multiple vascular territories of the brain.

Factors associated with long-term mortality for stroke unit patients in Latvia

AIM

The aim of this study was to evaluate how pre-stroke risk factors, neurological symptoms, and the level of disability shortly after stroke are associated with poststroke mortality during a 7-year period after stroke, for persons treated in a stroke unit.

METHODS

The data of 231 patients were included in the study. Patients who were treated in the stroke unit at the Riga East University Hospital between February 1, 2009, and July 20, 2009, were included in this study. Three stepwise Cox proportional hazard analyses were performed to analyze mortality in the 7 years following stroke. Pre-stroke risk factors (type of stroke, arterial hypertension, diabetes mellitus, atrial fibrillation, smoking, alcohol abuse, obesity, recurrent stroke, age, gender), neurological symptoms (motor deficit, sensory disturbance, aphasia, poststroke urinary incontinence (PSUI), mental status), and limitations of activity (feeding, bathing, grooming, dressing, toilet use, transfers, mobility, stairs) were evaluated as factors associated with mortality after stroke.

RESULTS

A total of 145 (62.8%) patients died during the study period. The final model for each group of factors included only one of the factors used for the analysis. Patients who had alcohol abuse were 40% more likely to die earlier. The hazard for those with PSUI is 1.72 times higher than those without PSUI. The independence in grooming showed a 39% lower likelihood of dying earlier.

CONCLUSION

Alcohol abuse as a pre-stroke risk factor, poststroke urinary incontinence as a neurological symptom, and dependence in grooming as a factor of disability were associated with earlier mortality in the first seven years after stroke.

Short-term and long-term survival probabilities among first-ever ischaemic and haemorrhagic stroke patients at a hospital in the suburban east coast of Peninsular Malaysia

AIM

This study aimed to determine the 28-day, 1-year, and 5-year survival probabilities in first-ever stroke patients in a relatively understudied setting: a suburban hospital that serves a predominantly rural population in the east coast of Peninsular Malaysia.

METHODS AND RESULTS

A retrospective record review was conducted among 432 first-ever stroke patients admitted to the Hospital Universiti Sains Malaysia, Kelantan, Malaysia. Data from between January 1, 2005 and December 31, 2011, were extracted from the medical records. The Kaplan-Meier product limit estimator was applied to determine the 28-day, 1-year, and 5-year survival probabilities. Log-rank test was used to test the equality of survival time between different groups. A total of 101 patients died during the study period. The 28-day, 1-year, and 5-year survival probabilities were 78.0% (95% confidence interval [CI]: 73.5-81.9), 74.2% (95% CI: 69.4-78.4), and 70.9% (95% CI: 65.1-75.9), respectively. There were significant differences in the survival time based on the types of stroke, Glasgow Coma Scale, hyperlipidaemia, atrial fibrillation, fasting blood glucose, and diastolic blood pressure.

CONCLUSION

This study, though retrospective, highlights several clinical parameters that influenced the survival probabilities among first-ever stroke patients managed in a suburban setting in Malaysia, and compared them to those reported in more urban regions. Our data emphasise the need for wider establishment of specialized stroke units and teams, as well as for prospective multi-centre studies on first-ever stroke patients to better inform the development of stroke care provision in Malaysia.

Predictors of in-hospital mortality and dependence at discharge in patients with MCA stroke with intravenous thrombolysis

Early risk stratification of mortality and dependence is important for guiding medical decision-making in stroke care. The study aim is to evaluate whether there are any differences between risk factors for in-hospital mortality and dependence at discharge in patients with first-episode ischemic stroke in the middle cerebral artery (MCA) receiving intravenous thrombolysis (IVT) treatment. The study comprised a single-center cohort of patients admitted consecutively for first-episode MCA ischemic stroke. A logistic regression analysis was performed to determine the variables associated with in-hospital mortality and dependence at discharge. We included 169 patients (50.9% women) with a mean age of 64.1 ± 12.9 years and a median National Institute of Health Stroke Scale (NIHSS) score of 13 (range 3-26) at admission. Nineteen patients (11.2%) died as inpatients [the main cause of death was found to be infection (47.4%)]. The independent predictors for in-hospital mortality were: age (OR 1.09, 95% CI 1.03-1.15, p = 0.004) and NIHSS score (>17) at admission (OR 1.17, 95% CI 1.05-1.30, p = 0.004). Two other crude models used to analyze in-hospital mortality (age and symptoms-to-needle time, and age and symptomatic intracerebral hemorrhage) were significant. NIHSS score (>11) at admission (OR 1.29, 95% CI 1.17-1.42, p < 0.001) and large artery atherosclerosis stroke (OR 3.10, 95% CI 1.10-8.76, p = 0.031) were independently associated with dependence at discharge. Overall, the predictors for mortality and dependence in patients with first-episode MCA ischemic stroke treated with IVT were different. This knowledge might help to improve the management of this devastating disease.

Factors Related to Cardioembolism as Major Predictors of Poor Survival after First-Ever Middle Cerebral Artery Stroke Treated with Thrombolysis

<b><i>Background and Purpose:</i></b> Prognostic factors related to mortality rates after stroke have been reported; however, most studies included different treatments and did not focus solely on ischemic stroke. The study aimed to report the short- and long-term survival and predictors of death in patients with first-ever ischemic stroke in the middle cerebral artery (MCA) territory, submitted to intravenous thrombolysis (IVT). <b><i>Methods:</i></b> A prospective observational cohort study of patients with first-ever ischemic stroke in the MCA territory treated with IVT from March 2010 to February 2015 was conducted, and patients were followed up until May 2015. The Kaplan-Meier method was used to estimate the cumulative case fatality rates. The potential prognostic factors were identified using Cox proportional hazards regression analysis. <b><i>Results:</i></b> A total of 169 patients, 51% women of mean age of 64.1 ± 12.9 years were followed up for a median time of 23.6 (8.1-36.2) months. At the end of the study, 53 (31.4%) patients had died. The estimated cumulative case fatality rate was 41.8% for 5 years. Chronic heart failure (hazards ratio [HR] 2.89, 95% CI 1.43-5.84, <i>p</i> = 0.003), atrial fibrillation (HR 3.88, 95% CI 1.30-11.57, <i>p</i> = 0.015), and symptomatic intracerebral hemorrhage (SICH; HR 7.83, 95% CI 3.43-17.92, <i>p</i> < 0.001) were significant unfavorable independent outcome predictors. The most frequent cause of death was infection (46%). <b><i>Conclusions:</i></b> Stroke in the MCA territory has a high mortality rate, even in patients treated with IVT. SICH, atrial fibrillation, and chronic heart failure are modifiable factors related to cardioembolism that need to be aggressively targeted for improved outcomes after stroke.

A comparison of risk factors and prognosis between intra and extracranial acute atherosclerotic stroke in the Turkish population: a prospective study

BACKGROUND

The aim of this study was to compare the differences in risk factors and prognosis between acute stroke caused by definitive intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS) in the Turkısh population.

METHODS

This study was prospectively designed in a single centre and conducted with patients who were hospitalised due to acute ischaemic stroke. Inclusion criteria were the diagnosis of atherosclerotic ischaemic stroke, defined as more than 50% stenosis or occlusion in the arterial structure supplying the ischaemic area, having excluded other possible causes.

RESULTS

Information on 58 ICAS and 57 ECAS stroke patients was collected in a 13-month period. The ECAS patients had male gender predominance (p = 0.003). Ageing, stroke history and hyperlipidaemia were related with stroke severity in ECAS, and gender was associated with severity in ICAS. Hypertension and being female were related with poor prognosis in ICAS (p = 0.081 vs. 0.087). Congestive heart failure (p = 0.002) was associated with poor prognosis and alcohol with a favourable outcome (p = 0.087) in ECAS. Stroke severity was related with poor prognosis in both groups (p < 0.001).

CONCLUSIONS

The prevalence of risk factors differs between ICAS and ECAS, and their influence differs for stroke severity and prognosis.

Risk factors for lung infection in stroke patients: a meta-analysis of observational studies

BACKGROUND

The aims of this meta-analysis were to evaluate the risk factors associated with lung infections in stroke patients and to provide evidence for prevention decisions.

METHODS

We searched the Embase, PubMed, EBSCO and Web of Science databases to collect studies from January 2000 to July 2015.

RESULTS

The meta-analysis identified 23 risk factors for lung infections in stroke patients, and the top 5, ranked by order according to odds ratio values (95% confidence interval), were as follows: multiple vertebrobasilar stroke, 22.99 (4.04, 130.83); National Institutes of Health Stroke Scale score >15 points, 14.63 (8.54, 25.08); mechanical ventilation, 10.20 (7.15, 14.57); nasogastric tube use, 9.87 (6.21, 15.70); and dysphagia, 7.50 (2.60, 21.65).

CONCLUSION

Preventive measures should be taken against these risk factors to reduce the incidence of lung infection.

Cost-effectiveness of amlodipine compared with valsartan in preventing stroke and myocardial infarction among hypertensive patients in Taiwan

Hypertension is a major risk factor for strokes and myocardial infarction (MI). Given its effectiveness and safety profile, the calcium channel blocker amlodipine is among the most frequently prescribed antihypertensive drugs. This analysis was conducted to determine the costs and quality-adjusted life years (QALYs) associated with the use of amlodipine and valsartan, an angiotensin II receptor blocker, in preventing stroke and MI in Taiwanese hypertensive patients. A state transition (Markov) model was developed to compare the 5-year costs and QALYs for amlodipine and valsartan. Effectiveness data were based on the NAGOYA HEART Study, local studies, and a published meta-analysis. Utility data and costs of MI and stroke were retrieved from the published literature. Medical costs were based on the literature and inflated to 2011 prices; drug costs were based on National Health Insurance prices in 2014. A 3% discount rate was used for costs and QALYs and a third-party payer perspective adopted. One-way sensitivity and scenario analyses were conducted. Compared with valsartan, amlodipine was associated with cost savings of New Taiwan Dollars (NTD) 2,251 per patient per year: costs were NTD 4,296 and NTD 6,547 per patient per year for amlodipine and valsartan users, respectively. Fewer cardiovascular events were reported in patients receiving amlodipine versus valsartan (342 vs 413 per 10,000 patients over 5 years, respectively). Amlodipine had a net gain of 58 QALYs versus valsartan per 10,000 patients over 5 years. Sensitivity analyses showed that the discount rate and cohort age had a larger effect on total cost and cost difference than on QALYs. However, amlodipine results were more favorable than valsartan irrespective of discount rate or cohort age. When administered to Taiwanese patients for hypertension control, amlodipine was associated with lower cost and more QALYs compared with valsartan due to a lower risk of stroke and MI events.

Chinese Herbal Medicines Might Improve the Long-Term Clinical Outcomes in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: Results of a Decision-Analytic Markov Model

Aims. The priority of Chinese herbal medicines (CHMs) plus conventional treatment over conventional treatment alone for acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI) was documented in the 5C trial (chictr.org number: ChiCTR-TRC-07000021). The study was designed to evaluate the 10-year effectiveness of CHMs plus conventional treatment versus conventional treatment alone with decision-analytic model for ACS after PCI. Methods and Results. We constructed a decision-analytic Markov model to compare additional CHMs for 6 months plus conventional treatment versus conventional treatment alone for ACS patients after PCI. Sources of data came from 5C trial and published reports. Outcomes were expressed in terms of quality-adjusted life years (QALYs). Sensitivity analyses were performed to test the robustness of the model. The model predicted that over the 10-year horizon the survival probability was 77.49% in patients with CHMs plus conventional treatment versus 77.29% in patients with conventional treatment alone. In combination with conventional treatment, 6-month CHMs might be associated with a gained 0.20% survival probability and 0.111 accumulated QALYs, respectively. Conclusions. The model suggested that treatment with CHMs, as an adjunctive therapy, in combination with conventional treatment for 6 months might improve the long-term clinical outcome in ACS patients after PCI.

Association between renal dysfunction and 3-year mortality in patients with acute first-ever ischemic stroke

OBJECTIVE

The influence of renal dysfunction on the clinical presentation and outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of renal dysfunction on the outcomes of patients with acute first-ever ischemic stroke.

METHODS

Nine-hundred thirty-four patients with acute first-ever ischemic stroke were enrolled and followed for 3 years. Renal function was assessed using the equation of the Modification Diet for Renal Disease for estimated glomerular filtration rate (eGFR). Serum creatinine levels were obtained within 3 days of acute stroke onset. Reduced eGFR was defined as eGFR<60ml/min/1.73m(2). Clinical presentation, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded.

RESULTS

Total 264 patients (28.3%) had a reduced eGFR. The prevalence of older age, hypertension, and atrial fibrillation was significantly higher in patients with a reduced eGFR. Total anterior circulation syndrome occurred more frequently among patients with a reduced eGFR (P=0.010). Multivariate Cox regression revealed that a reduced eGFR is a significant predictor of 3-year mortality (HR=1.67, 95% CI=1.06-2.62, P=0.026).

CONCLUSION

Reduced eGFR during the acute stroke stage is associated with increased risk of 3-year mortality. Furthermore, risk of acute complications and poor functional outcomes following discharge was significantly higher in patients with a reduced eGFR.

Long-term mortality according to the characteristics of early neurological deterioration in ischemic stroke patients

PURPOSE

Although early neurological deterioration (END) during the acute stroke period is known to be associated with poor functional outcomes, there is little data regarding the impact of END on long-term outcomes according to the characteristics of END. The aim of this study was to investigate whether there are differences in long-term mortality according to the characteristics of END among acute ischemic stroke or transient ischemic attack patients.

MATERIALS AND METHODS

END was defined as any increase (≥1) in National Institute of Health Stroke Scale score within 7 days after admission. We assessed the characteristics of END, such as the etiology and severity of END, as well as recovery after END. The relationship between 30-day or long-term mortality and each characteristic of END was investigated using multiple logistic analysis or Cox regression model.

RESULTS

Among 2820 patients, END was observed in 344 patients (12.2%). After adjustment for age, sex, underlying cardiovascular diseases, stroke severity, and stroke subtypes, END was associated with long-term mortality, whether it was mild or severe and whether or not it was followed by recovery. However, 30-day mortality was strongly related to the severity of END or the absence of recovery after END. Among the causes of END, recurrent stroke and medical illness were related to 30-day mortality, as well as long-term mortality, while brain herniation and intracranial hemorrhagic complications were only associated with 30-day mortality.

CONCLUSION

The results of the present study demonstrated that END is associated with higher mortality and the effects of END on short-term and long-term mortality depend on END characteristics.

Acceptance of disability and its predictors among stroke patients in Taiwan

BACKGROUND

Modern medicine has increased the survival rate for stroke patients; however, the patient's psychosocial adaptation after stroke onset may be related to the clinical outcomes. This study aimed to investigate patients' acceptance of disability (AOD) and its predictors in stroke patients.

METHODS

This cross-sectional study used a purposive sampling method to recruit 175 stroke patients from a hospital in southern Taiwan. A structured questionnaire gathered data on respondent demographics and disease characteristics, and included the Chinese version of the AOD Scale-Revised. Factors associated with AOD were examined by a multiple linear regression analysis.

RESULTS

The mean AOD score was 71.72, which indicated a lower level of disease acceptance (range, 32-128). Our findings showed that patients who reported no religious beliefs, shorter disease duration, recurrent stroke episodes, and poorer physical functioning also reported lower levels of disability acceptance. These factors accounted for 38.2% of the variance in AOD among participants.

CONCLUSIONS

The findings are beneficial to healthcare providers by identifying those stroke patients with predisposition of having lower disability acceptance, which could then facilitate the provision of appropriate rehabilitation interventions within six months after the diagnosis of stroke to support their adaptation process.

Infectious disease is the most common cause of death among stroke patients: two-years of follow-up

Stroke represents the second common cause of death in adults. Objective It was to evaluate the incidence and causes of mortality after 30 days in a group of patients with an atherothrombotic ischemic stroke who were followed-up for a period of up to two years. Methods We analyzed retrospectively the medical records of patients with ischemic stroke, who did not undergo thrombolysis, of the Santa Marcelina Hospital. We applied a research protocol to obtain information about risk factors and the etiology of death. Results They were followed 337: mean age was 66.6 years (SD 9.05) and 43.9% were females. The mortality rate was 11.9% with most deaths (37.5%) occurring due to infectious causes. The age was correlated with the risk of death, which was five times higher in patients older than 80. Conclusion The most important cause of death after 30 days was infectious disease, and advanced age was predictor of mortality among patients with an atherothrombotic stroke etiology.

Association of plasma osteoprotegerin levels with stroke severity and functional outcome in acute ischaemic stroke patients

Osteoprotegerin (OPG) is known to regulate processes involved in vascular injury and inflammation. We investigated the relationship between plasma OPG levels and stroke subtype, stroke severity at admission and functional outcome at 3 months in 172 patients with acute ischaemic stroke. Patients with large artery atherosclerosis and those with multiple causes had higher plasma OPG levels than patients with lacune. Increased plasma OPG levels were independently associated with more severe stroke and poor functional outcome. These results suggest pleiotropic roles of OPG in mediating atherosclerosis and ischaemic brain injury. OPG is a potential biomarker for predicting neurologic outcome in stroke.

Acute ischemic stroke in the very elderly Chinese: risk factors, hospital management and one-year outcome

BACKGROUND

Little information is available on Asian patients over 80 years with stroke. We aimed to investigate characteristics of the very elderly ischemic stroke hospitalized patients in China.

METHODS

We prospectively enrolled consecutive patients with acute ischemic stroke from March, 2002 to October, 2008 into the analysis. Patients were divided into two groups: <80 years versus ≥80 years and risk factors, hospital management and one-year outcome were compared.

RESULTS

Of the 2619 cases included, 302 (11.5%) patients were 80 years or older. Compared with patients <80 years, patients over 80 years old had higher rates of hypertension (66.2% versus 56.1%, p=0.001), atrial fibrillation (23.5% versus 14.5%, p=0.000), and coronary heart disease (13.6% versus 5.7%, p=0.000). In addition, they were less likely to have received transthoracic echocardiography (45.4% versus 55.4%, p=0.001), color Doppler of extracranial vessels (54.0% versus 61.2%, p=0.015), antiplatelet agents (80.8% versus 86.8%, p=0.004), or anticoagulants (4.0% versus 9.0%, p=0.003). After adjusting for sex and stroke severity on admission, the very elderly patients had higher case-fatality and disability rates at one year (33.8% versus 13.2%, p=0.000; 37.8% versus 20.9%, p=0.000; respectively).

CONCLUSIONS

In China, the proportion of the very elderly in hospitalized stroke population is lower than that in western countries whereas the most common risk factors seem similar. The hospital management for these patients is relatively insufficient and the long-term outcome is generally unfavorable compared with patients under 80 years old.