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Wang X, Xie X, Xu X, Tan L. Relationship between enteral nutrition timing and 28-day mortality in critically ill stroke patients in the MIMIC-IV database. Front Neurol 2024; 15:1411906. [PMID: 39165266 PMCID: PMC11333364 DOI: 10.3389/fneur.2024.1411906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/15/2024] [Indexed: 08/22/2024] Open
Abstract
Background The ideal timing for commencing enteral nutrition (EN) in critically ill stroke patients in the intensive care unit (ICU) remains a subject of debate, with ongoing controversy regarding the impact of early EN (EEN) initiation. In this study, we investigated the association between the timing of EN initiation and 28-day mortality using data from the MIMIC-IV database. Methods This study employed a retrospective cohort design using the MIMIC-IV database to identify stroke patients who received EN during their hospital stay. The main focus of this investigation was to examine 28-day mortality among these patients following hospital admission. Various demographic, clinical, laboratory, and intervention variables were considered as covariates. The Cox regression analysis was employed to assess the correlation between the timing of EN initiation and 28-day mortality, and restricted cubic splines (RCS) analysis was used to test for non-linear correlation. Patients were then stratified into two cohorts depending on the timing of EN initiation: within 2 days (n = 564) and beyond 2 days (n = 433). A multivariate Cox regression analysis was used to investigate the difference in 28-day mortality between the groups. Results A total of 997 participants were included in this study, with 318 (31.9%) dying within 28 days. We observed that the timing of EN initiation correlated with 28-day mortality, but this correlation was not significant after adjusting for covariates (crude HR: 0.94, 95% CI: 0.88-1, p = 0.044; adjusted HR: 0.96, 95% CI: 0.9-1.02, p = 0.178). The RCS analysis showed that the correlation was not non-linear. Notably, in the multivariate regression models, early EN initiation was associated with a higher mortality rate compared to late EN initiation [odds ratio (OR) = 1.34, 95% CI: 1.06-1.67, p = 0.012]. After adjusting for various confounding factors in the multivariate Cox regression models, we identified that patients in the early EN group had a 28% higher risk of mortality than those in the reference group (OR = 1.27, 95% CI: 1-1.61, p = 0.048). These associations remained consistent across various patient characteristics, as revealed through stratified analyses. Conclusions Early commencement of EN in critically ill stroke patients may be linked to a higher risk of 28-day mortality, highlighting the need for further investigation and a more nuanced consideration of the optimal timing for commencing EN in this patient population.
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Affiliation(s)
- Xiaoliang Wang
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong, China
| | - Xiuling Xie
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong, China
| | - Xin Xu
- Neurology Department of Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Lan Tan
- Neurology Department of Qingdao Municipal Hospital, Nanjing Medical University, Qingdao, Shandong, China
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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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3
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Patel J, Bhaskar SMM. Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis. Neurol Int 2023; 15:1014-1043. [PMID: 37755356 PMCID: PMC10537209 DOI: 10.3390/neurolint15030065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney, Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
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Wu H, Liu Y, Miao G, Ge J, You S, Zhang X, Liu H, Zhou Y, Lu T, Cao Y, Shi J. Effect of the interaction between atrial fibrillation and rt-PA dose on the prognosis of acute ischaemic stroke with intravenous thrombolysis. Postgrad Med J 2023; 99:588-594. [PMID: 37319158 DOI: 10.1136/postgradmedj-2022-141710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/09/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The association between atrial fibrillation (AF) and the prognosis of acute ischaemic stroke (AIS) remains controversial; whether the recombinant tissue plasminogen activator dose influences this association remains poorly understood. METHODS Patients who had an AIS were enrolled from eight stroke centres in China. According to the recombinant tissue plasminogen activator dose, patients treated with intravenous recombinant tissue plasminogen activator within 4.5 hours after symptom onset were divided into a low-dose group (recombinant tissue plasminogen activator <0.85 mg/kg) and a standard-dose group (recombinant tissue plasminogen activator ≥0.85 mg/kg). Patients who had an AIS in the low-dose group and the standard dose group were divided into whether or not they had AF. The main outcomes were major disability (modified Rankin scale (mRS) score 3-5), mortality and vascular events occurring within 3 months. RESULTS The study included 630 patients who received recombinant tissue plasminogen activator after AIS, including 391 males and 239 females, with a mean age of 65.8 years. Of these patients, 305 (48.4%) received low-dose recombinant tissue plasminogen activator and 325 (51.6%) received standard dose recombinant tissue plasminogen activator. The recombinant tissue plasminogen activator dose significantly influenced the association between AF and death or major disability (p-interaction=0.036). After multivariate adjustment, AF was associated with an increased risk of death or major disability (OR 2.90, 95% CI 1.47 to 5.72, p=0.002), major disability (OR 1.93, 95% CI 1.04 to 3.59, p=0.038) and vascular events (HR 5.01, 95% CI 2.25 to 11.14, p<0.001) within 3 months in patients with standard-dose recombinant tissue plasminogen activator. No significant association was found between AF and any clinical outcome in patients with low-dose recombinant tissue plasminogen activator (all p>0.05). With AF, the mRS score distribution showed a significantly worse shift in patients with standard-dose recombinant tissue plasminogen activator (p=0.016) than in those with low-dose recombinant tissue plasminogen activator (p=0.874). CONCLUSIONS AF may be a strong predictor of poor prognosis in patients who had an AIS receiving standard-dose recombinant tissue plasminogen activator, suggesting that low-dose recombinant tissue plasminogen activator should be administered to patients who had a stroke with AF to improve their prognosis. WHAT IS ALREADY KNOWN ON THIS TOPIC WHAT THIS STUDY ADDS HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
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Affiliation(s)
- Huan Wu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Neurology, Huangshan City People's Hospital, Huangshan, Anhui, China
| | - Yuanyuan Liu
- Department of Electrocardiography, The Affiliated Guangji Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Guihua Miao
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Jian Ge
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xia Zhang
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Huihui Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Zhou
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Taosheng Lu
- Department of Neurology, The First People's Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Yongjun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jijun Shi
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Wang X, You S, Zhou Z, Delcourt C, Wardlaw J, Mair G, Robinson T, Chen X, Yoshimura S, Torii-Yoshimura T, Carcel C, Malavera A, Anderson C, Lindley RI. Baseline brain imaging signs in patients with ischaemic stroke by the presence of atrial fibrillation: the ENCHANTED trial. J Neurol 2023; 270:2567-2575. [PMID: 36939933 PMCID: PMC10130001 DOI: 10.1007/s00415-023-11580-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/18/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND We aimed to assess the association of atrial fibrillation (AF) on outcomes in a post hoc analysis of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study) and how this association is modified by baseline imaging features. METHODS Inverse probability of treatment weight was used to remove baseline imbalances between those with and without AF. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. Secondary outcomes were symptomatic intracerebral haemorrhage (sICH), early neurological deterioration or death within 24 h, and death at 90 days. The logistic regression model was used to determine the associations. RESULTS Of the 3285 patients included in this analysis, 636 (19%) had AF at baseline. Compared with non-AF, AF was not significantly associated with an unfavourable shift of mRS (odds ratio 1.09; 95% confidence interval, 0.96-1.24), but with sICH (2.82; 1.78-4.48; IST-3 criteria), early neurological deterioration or death within 24 h (1.31; 1.01-1.70), and death (1.42; 1.12-1.79). Among patients with acute ischaemic signs (presence, extent, swelling and attenuation of acute lesions), AF was associated with the increased risk of all the poor outcomes (all P < 0.04 for interaction). CONCLUSIONS We found AF increased risk of sICH, early neurological deterioration or death and death, but not unfavourable functional recovery at day 90 after thrombolysis in patients with AIS. The presence of acute ischaemic brain imaging signs at stroke presentation could be used to improve risk stratification in the presence of AF. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (NCT01422616).
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Affiliation(s)
- Xia Wang
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Shoujiang You
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zien Zhou
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Joanna Wardlaw
- Edinburgh Imaging, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Grant Mair
- Edinburgh Imaging, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
| | - Sohei Yoshimura
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takako Torii-Yoshimura
- Division of Neurology, Department of Stroke and Cerebrovascular Diseases, National Cerebral and Cardiovascular Center, Osaka, Japan
- Department of Neurology and Neuroscience, Nagoya City University Graduate School of Medical Science, Nagoya, Japan
| | - Cheryl Carcel
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences,, Macquarie University, Sydney, Australia
| | - Alejandra Malavera
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Craig Anderson
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richard I Lindley
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia.
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Norata D, Lattanzi S, Broggi S, Rocchi C, Bartolini M, Silvestrini M. Liver fibrosis-4 score predicts outcome of patients with ischemic stroke undergoing intravenous thrombolysis. Front Neurol 2023; 14:1103063. [PMID: 36908601 PMCID: PMC9999710 DOI: 10.3389/fneur.2023.1103063] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 02/13/2023] [Indexed: 02/26/2023] Open
Abstract
Some evidence suggests a possible influence of liver disease on stroke prognosis. We investigated the association between fibrosis-4 (FIB-4) score, a marker of liver disease, and the 3-month outcome in patients with ischemic stroke undergoing intravenous thrombolysis. We also evaluated the rate of symptomatic intracranial hemorrhage after thrombolysis. In this prospective cohort study, we enrolled consecutive patients with ischemic stroke treated with thrombolysis who had a 3-month follow-up. The FIB-4 score was calculated and the validated cut-off values were used to indicate high/low risk of advanced liver fibrosis. The primary outcome was 3-month poor prognosis estimated as a modified Rankin scale score ≥3. Of the 264 included patients, 131 (49.62%) had a 3-month mRS ≥3, with a significantly higher FIB-4 score, compared to those with a mRS <3 score (adjp <0.001). When adjusted for possible confounders by multivariate logistic regression, FIB-4 score remained a significant predictor of poor outcome (OR 1.894, p = 0.011), along with history of atrial fibrillation (OR 3.488, p = 0.017), admission NIHSS score (OR 1.305, p < 0.001), and low values of hemoglobin (OR 0.730, p < 0.001). Mechanical thrombectomy had a favorable effect on patients' outcome (OR 0.201, p = 0.005). The risk of poor 3-month outcome was significantly higher among the 32 patients (12.1%) with high risk of severe fibrosis (p = 0.007). FIB-4 score values were also related to symptomatic intracranial hemorrhage (p = 0.004), specifically among patients with high probability of advanced hepatic fibrosis (p = 0.037). FIB-4 score can be considered as a promising independent predictor of poor prognosis in patients with acute ischemic stroke undergoing intravenous thrombolysis.
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Affiliation(s)
- Davide Norata
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Simona Lattanzi
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Serena Broggi
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Chiara Rocchi
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Marco Bartolini
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic and Stroke Unit, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Zhao J, Yuan F, Song C, Yin R, Chang M, Zhang W, Zhang B, Yu L, Jia Y, Ma Y, Song Y, Wang C, Song C, Wang X, Shang L, Yang F, Jiang W, Jiang W, Yang F, Zhao J, Yuan F, Song C, Sun L, Zhao Y, Wei J, Liu L, Hu M, Wang X, Zhang J, Shi X, Hui B, Chen R, Ren X, Du F, Yin R, Wei Y, Li Y, Chang MC, Zhang X, Yin Y, Zhang W, Guo J, Guo P, Lu J, Li C, Shen J, Bai M, Zhang M, Zhang B, Zhang S, Bai Y, Bai Y, Fan W, Wang L, Yu F, Ru Y, Wei W, Ma Y, Wang W, Hu R, Li Y, Ma X, Lv T, Yu L, Zhu H, Yang L, Wu Y, Cao J, Jia Y, Wu T, Zhang H, Liu S, Ning B, Song C, Zhao H, Li Z, Zhang H, Wang M, Song Y, Zhu Y, Wang C, Chen S, Ren Q, Lu S, Wang X, You Q, Liu Z, Jiang Y, Xiong J, Wang X, Zhao R, Huo K, Chen C, Qu Y, Ma L, Yang X, Liu Y, Wang X. Safety and efficacy of three enteral feeding strategies in patients with severe stroke in China (OPENS): a multicentre, prospective, randomised, open-label, blinded-endpoint trial. Lancet Neurol 2022; 21:319-328. [DOI: 10.1016/s1474-4422(22)00010-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
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Tsalta-Mladenov ME, Andonova SP. Quality of life after ischaemic stroke—accent on patients with thrombolytic therapy. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00418-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous thrombolysis is a widely approved treatment method for acute ischemic stroke (AIS). Nevertheless, there is a growing interest in its impact on functional outcomes and Health-related Quality of life (HR-QoL). We aimed to evaluate and compare the HR-QoL in patients receiving intravenous thrombolysis (IVT) and in those without thrombolytic therapy during the first 3-month post-stroke in a defined Bulgarian population.
Results
Patients treated with IVT have simillar functional outcomes and HR-QoL on the third month as the group with conservative treatment, besides their higher NIHSS on admission. Patients with IVT had better self-assessed recovery after the AIS. The higher NIHSS and mRS scores and the lower HR-QoL on discharge are reliable predictors for a poor functional outcome on the third month. A door-to-needle of 60 min or less, and the absence of pathological neuroimaging findings 24-h post IVT predict more beneficial HR-QoL outcome.
Conclusion
There were no significant differences in HR-QoL and functional outcomes between the groups. Nevertheless, IVT is a treatment option with great importance for improving the clinical outcomes after ischemic stroke, which should be performed in well selected patients.
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The prognostic significance of large vessel occlusion in stroke patients treated by intravenous thrombolysis. Pol J Radiol 2021; 86:e344-e352. [PMID: 34322183 PMCID: PMC8297478 DOI: 10.5114/pjr.2021.107065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/26/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose According to guidelines, to shorten the treatment window, acute ischaemic stroke (AIS) treatment by intravenous thrombolysis (IVT) can be done based on the results of head computed tomography (CT) without contrast. The impact of large vessel occlusion (LVO) on computed tomography angiography (CTA) in stroke prognosis in patients treated IVT or IVT and mechanical thrombectomy (MT), where indicated, has not yet been studied systematically. We investigated the influence of LVO in consecutive AIS patients on haemorrhagic transformation (HT) on CT 24 h after treatment, mRS < 2 on discharge (unfavourable outcome), and in-hospital mortality. Material and methods We analysed several parameters within 24 h after AIS: demographics, risk factors, mRS score pre-stroke, NIHSS upon admission and 24 h later, several clinical and biochemical parameters, and chronic treatment. Results We registered 1209 patients, of whom 362 (29.9%) received IVT and 108 had MT, where indicated. Admission CTA showed LVO in 197 patients (54.4%). Multivariate regression analysis showed that the presence of LVO and lower delta NIHSS (NIHSS on admission minus NIHSS 24 hours later) were independent parameters affecting HT risk. Multivariate analysis showed that the presence LVO and also older age, female sex, lower delta NIHSS, HT, stroke-associated infection, CRP levels ≥ 10 mg/L, and higher WBC count affected unfavourable outcome on discharge. LVO did not affect in-hospital mortality. Conclusions LVO in AIS patients treated by IVT or IVT and MT affects the risk of HT and unfavourable short-term outcome but not in-hospital mortality.
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10
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Hu Y, Ji C. Efficacy and safety of thrombolysis for acute ischemic stroke with atrial fibrillation: a meta-analysis. BMC Neurol 2021; 21:66. [PMID: 33573619 PMCID: PMC7877096 DOI: 10.1186/s12883-021-02095-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 02/04/2021] [Indexed: 12/28/2022] Open
Abstract
Background The efficacy and safety of intravenous thrombolysis (IVT) for acute ischemic stroke with atrial fibrillation (AF) is still controversial. Methods We conducted a meta-analysis of all relevant studies, retrieved through systematic search of PubMed, Embase, and Cochrane databases up to December 31, 2019. Modified Rankin Scale (mRS) scores of 0–1 at 90 days, mRS of 0–2 at 90 days, overall mortality, and incidence of symptomatic intracranial hemorrhage (sICH) were collected as outcome measures. Fixed- and random-effects meta-analytical models were applied, and between-study heterogeneity was assessed. Results A total of 8509 patients were enrolled in 18 studies. A comparison of IVT treatment in AF versus non-AF patients showed that AF was associated with a significantly lower proportion of patients with mRS of 0–1 (24.1% vs. 34.5%; OR 0.59; 95% CI 0.43–0.81; P < 0.001), mRS of 0–2 (33.6% vs. 47.8%; OR 0.55; 95% CI 0.43–0.70; P < 0.001), as well as significantly higher mortality (19.4% vs. 11.5%; OR 2.05; 95% CI 1.79–2.36; P < 0.001) and higher incidence of sICH (6.4% vs. 4.1%; OR 1.60; 95% CI 1.27–2.01; P < 0.001). A comparison of AF patients who were subjected or not to IVT showed that thrombolysis carried a higher risk of sICH (5.7% vs. 1.6%; OR 3.44; 95% CI 2.04–5.82; P < 0.001) and was not associated with a better prognosis. Subgroup analysis in prospective studies also suggested a poorer functional prognosis and higher mortality in AF patients treated with IVT compared with those who did not receive IVT. Some heterogeneity was present in this meta-analysis. Conclusions Acute IS patients with AF had worse outcomes than those without AF after thrombolytic therapy, and had a higher incidence of sICH after thrombolysis than those without thrombolysis. Thrombolysis in ischemic stroke patients with AF should be carefully considered based on clinical factors such as NIHSS score, age, and the type of AF.
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Affiliation(s)
- Yunzhen Hu
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
| | - Chunmei Ji
- Research Division of Clinical Pharmacology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Derbisz J, Nowak K, Wnuk M, Pulyk R, Jagiella J, Slowik J, Dziedzic T, Slowik A. Prognostic Significance of Stroke-Associated Infection and other Readily Available Parameters in Acute Ischemic Stroke Treated by Intravenous Thrombolysis. J Stroke Cerebrovasc Dis 2020; 30:105525. [PMID: 33338755 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105525] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/15/2020] [Accepted: 11/29/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The impact of contracting stroke-associate infection (SAI) that requires antibiotic treatment after an acute ischemic stroke (AIS) treated with alteplase remains unclear. We studied the profiles of SAI in patients with AIS treated with alteplase toward identifying predictive factors and prognostic implications at 90 days post-stroke. METHODS We analyzed 33 parameters readily available within 24 hours after AIS: demographics, risk factors, and several clinical and biochemical parameters. Outcome measures were mRS ≤ 2 and mortality 90 days post-stroke. RESULTS 83 (23.6%) of 352 patients developed SAI. Multivariate logistic regression analysis showed that atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS (the difference between NIHSS score measured upon admission and 24 hours after later), CRP≥10 mg/L, and elevated WBC count affected SAI risk (model including CRP levels and WBC count) and atrial fibrillation, mRS above 0 pre-stroke, lower delta NIHSS, HT, and elevated fibrinogen levels affected SAI risk (model excluding CRP levels and WBC count). 231 patients (74.1%) had mRS ≤ 2 at day 90. Multivariate logistic regression analysis showed that younger age, no hypertension, mRS=0 pre-stroke, higher delta NIHSS, no HT, no SAI, and CRP<10 mg/L, were associated with mRS≤2 at day 90. 54 (15.3%) patients died within 90 days. Multivariate logistic regression analysis showed that pre-stroke mRS>0, lower delta NIHSS, HT, CRP≥10 mg/L, lower triglyceride levels affected the risk of death within 90 days. CONCLUSIONS Several markers available within 24 hours post-stroke were predictive of SAI that requires antibiotic treatment. SAI affects long-term outcome but not mortality.
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Affiliation(s)
- Justyna Derbisz
- Department of Neurology, University Hospital, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Klaudia Nowak
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Marcin Wnuk
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Roman Pulyk
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Jeremiasz Jagiella
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Joanna Slowik
- Department of Dental Prophylaxis and Experimental Dentistry, Jagiellonian University Medical College, Montelupich 4 Str., 31-155 Krakow, Poland
| | - Tomasz Dziedzic
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Jakubowskiego 2 Str., 30-688 Krakow, Poland.
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Outcome predictors of intravenous thrombolytic therapy in acute ischemic stroke patients: an Egyptian center experiences. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00229-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Intravenous thrombolytic therapy remains the guideline-recommended treatment to improve outcomes after acute ischemic stroke. However, the functional outcome among patients with acute ischemic stroke after receiving intravenous thrombolytic therapy is influenced by huge variety of factors, and this was the aim of our study to evaluate the outcome predictors of intravenous thrombolytic therapy in a sample of Egyptian patients with acute ischemic stroke.
Methods
We enrolled 183 acute ischemic stroke patients who were treated with intravenous recombinant tissue plasminogen activator (IV rtPA) according to the last updated guidelines of American Heart Association and American Stroke Association (AHA/ASA) from February 2018 to February 2020; however, only 150 patients of them completed our study plan till the end. Data of study variables were collected, analyzed statistically and correlated with the functional outcome 3 months after receiving IV rtPA using the modified Rankin Scale (mRS).
Results
Good functional outcome was seen in 98 (65.3%) patients and poor functional outcome was seen in 52 (34.7%) patients. Multivariate analysis of the study variables was done to detect the significant independent predictors of the functional outcome. Atrial fibrillation (AF) (P value < 0.001*OR 6.28* (95% C.I)), hypertension (P value 0.001*OR 3.65*(95% C.I)), diabetes mellitus (DM) (P value 0.009*OR 2.805*(95% C.I)), increased National Institute of Health Stroke Scale (NIHSS) score 24 h after receiving IV rtPA (P value 0.003* OR 8.039* (95% C.I)), increased pulsatility index (PI) value in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of poor functional outcome. On the other hand decreased NIHSS score 24 h after receiving IV rtPA (P value 0.003* OR 0.124*(95% C.I)), Normal value of PI in cerebral vessels at the same side of stroke lesion (P value 0.038* OR 42.48*(95% C.I)) were the significant independent predictors of good functional outcome.
Conclusion
Intravenous thrombolytic therapy improves the functional outcome of acute ischemic stroke patients. Also, AF, hypertension, DM, NIHSS 24 h after receiving IV rtPA and PI could be used as independent predictors of the functional outcome.
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Pana TA, Mohamed MO, Clark AB, Fahy E, Mamas MA, Myint PK. Revascularisation therapies improve the outcomes of ischemic stroke patients with atrial fibrillation and heart failure. Int J Cardiol 2020; 324:205-213. [PMID: 33022289 DOI: 10.1016/j.ijcard.2020.09.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/28/2020] [Accepted: 09/30/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and heart failure (HF) carry a poor prognosis in acute ischaemic stroke (AIS). The impact of revascularisation therapies on outcomes in these patients is not fully understood. METHOD National Inpatient Sample (NIS) AIS admissions (January 2004-September 2015) were included (n = 4,597,428). Logistic regressions analysed the relationship between exposures (neither AF nor HF-reference, AF-only, HF-only, AF + HF) and outcomes (in-hospital mortality, length-of-stay >median and moderate-to-severe disability on discharge), stratifying by receipt of intravenous thrombolysis (IVT) or endovascular thrombectomy (ET). RESULTS 69.2% patients had neither AF nor HF, 16.5% had AF-only, 7.5% had HF-only and 6.7% had AF + HF. 5.04% and 0.72% patients underwent IVT and/or ET, respectively. AF-only and HF-only were each associated with 75-85% increase in the odds of in-hospital mortality. AF + HF was associated with greater than two-fold increase in mortality. Patients with AF-only, HF-only or AF + HF undergoing IVT had better or at least similar in-hospital outcomes compared to their counterparts not undergoing IVT, except for prolonged hospitalisation. Patients undergoing ET with AF-only, HF-only or AF + HF had better (in-hospital mortality, discharge disability, all-cause bleeding) or at least similar (length-of-stay) outcomes to their counterparts not undergoing ET. Compared to AIS patients without AF, AF patients had approximately 50% and more than two-fold increases in the likelihood of receiving IVT or ET, respectively. CONCLUSIONS We confirmed the combined and individual impact of co-existing AF or HF on important patient-related outcomes. Revascularisation therapies improve these outcomes significantly in patients with these comorbidities.
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Affiliation(s)
- Tiberiu A Pana
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom
| | - Mohamed O Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Eoin Fahy
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Phyo K Myint
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom; Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, United Kingdom; Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
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Nonatrial Fibrillation was Associated With Early Neurological Improvement After Intravenous Thrombolysis With rt-PA in Patients With Acute Ischemic Stroke. Neurologist 2020; 25:28-32. [PMID: 32132497 DOI: 10.1097/nrl.0000000000000261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intravenous thrombolysis is the only approved pharmacological treatment for acute ischemic stroke (AIS) patients, but the immediate response to thrombolysis varies by patient. OBJECTIVE To investigate the factors associated with early neurological improvement (ENI) after the administration of intravenous recombinant tissue plasminogen activator (rt-PA) treatment to AIS patients within 4.5 hours of onset. METHODS Demographics, onset to treatment time, risk factors, and clinical and laboratory data of 209 AIS patients undergoing intravenous rt-PA therapy at a Chinese hospital between January 2013 and August 2016 were retrospectively analyzed. The National Institutes of Health Stroke Scale (NIHSS) score was recorded before thrombolytic therapy, 24 hours after the treatment, and 7 days after the treatment to evaluate the recovery of neurological function. ENI was defined as a ≥4-point decrease in NIHSS score compared with baseline or a score of 0 or 1 at 24 hours and 7 days. A multivariate logistic regression analysis was performed to assess the outcomes. RESULTS Of the 209 AIS patients treated by intravenous thrombolysis with rt-PA, low-density lipoprotein (LDL) levels were significantly lower (P<0.05) in patients with ENI. The multivariable analysis showed that non-atrial fibrillation (AF) was independently associated with ENI at 24 hours and 7 days after thrombolysis. An overall 40.3% non-AF patients had ENI 24 hours after thrombolysis (odds ratio=2.501, 95% confidence interval: 1.204-5.198; P=0.014), and 65.9% non-AF patients had ENI 7 days after thrombolysis (odds ratio=2.953, 95% confidence interval: 1.434-6.081; P=0.003). Onset to treatment time was an independent predictor (P<0.05) for ENI at 7 days after thrombolysis. The NIHSS score and diastolic blood pressure on admission were associated with symptomatic intracerebral hemorrhagic transformation. CONCLUSIONS Non-AF was independently associated with ENI after intravenous thrombolysis in AIS patients, but non-AF was not associated with the occurrence of symptomatic intracerebral hemorrhage. Onset to treatment time was an independent predictor of ENI at 7 days after thrombolysis in AIS patients.
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15
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Wu HM, Chung CP, Lin YY. Similar thrombolysis outcomes in acute stroke patients with and without atrial fibrillation if pre-stroke CHA2DS2-VASc score is low: A retrospective study. Medicine (Baltimore) 2020; 99:e18680. [PMID: 31914063 PMCID: PMC6959866 DOI: 10.1097/md.0000000000018680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.
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Affiliation(s)
- Hung-Ming Wu
- Institute of Brain Science
- Department of Neurology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Chih-Ping Chung
- Brain Research Center
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yung-Yang Lin
- Institute of Brain Science
- Brain Research Center
- Institute of Clinical Medicine
- Department of Critical Care Medicine
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital
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16
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Yang Y, Sun W, Li D, Li XY, Wang XT, Li SC, Zhao HJ, Zhang JB. Multimode Computed-Tomography-Guided Thrombolysis under a Prolonged Time Window in Acute Ischemic Stroke Patients with Atrial Fibrillation. Int Heart J 2019; 60:822-829. [PMID: 31257338 DOI: 10.1536/ihj.18-636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.
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Affiliation(s)
- Ying Yang
- The Third Peoples Hospital of Dalian
| | - Wei Sun
- The Third Peoples Hospital of Dalian
| | - Dan Li
- Chongqing Changshou District Hospital of Traditional Chinese Medicine
| | | | | | | | | | - Jing-Bo Zhang
- The Third Peoples Hospital of Dalian.,Affiliated Brain Hospital of Shanghai Tongji University
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Yuan F, Yang F, Zhang W, Jia Y, Ma Y, Qu Y, Wang X, Huo K, Wang C, Yuan X, Song C, Zhang B, Jiang W. Optimizing early enteral nutrition in severe stroke (OPENS): protocol for a multicentre randomized controlled trial. BMC Neurol 2019; 19:24. [PMID: 30755171 PMCID: PMC6371599 DOI: 10.1186/s12883-019-1253-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 02/04/2019] [Indexed: 12/26/2022] Open
Abstract
Background Malnutrition is one of the crucial factors associated with poor prognosis in critical ill patients, yet a significant evidence gap surrounds the management of initial enteral feeding in severe stroke. The Optimizing Early Enteral Nutrition in Severe Stroke (OPENS) trial will compare a strategy of modified full enteral nutrition (EN) (standard full EN in conjunction with prokinetic drug) and a strategy of permissive underfeeding (40 to 60% of estimated caloric requirements) with standard full EN (advancement to target nutrition goals) in patients with severe stroke. Methods The OPENS trial is a multicenter randomized controlled study. A total of 600 adult patients with severe stroke will be enrolled in 12 study sites in China, and randomized to standard full EN, modified full EN, or permissive underfeeding. The primary outcome measurement is the proportion of participants with a poor outcome (modified Rankin Scale ≥3) at day 90 of enrollment. Secondary outcomes include incidence rates of complications during hospitalization, disability at hospital discharge, and the ability of activities of daily living at day 90 of enrollment. The relationship between intervention and the primary outcome will be analyzed using multivariate logistic regression adjusted for study site, demographics, and baseline characteristics. Discussion The OPENS trial will explore the optimum initial feeding strategy for acute severe stroke. This trial is, therefore, an important step in bridging the evidence gap surrounding the enteral feeding for patients with severe stroke during the first week of hospitalization. Trial registration ClinicalTrials.gov Identifier: NCT02982668; First Posted: December 5, 2016.
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Affiliation(s)
- Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China.
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China.
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Yi Jia
- Department of Neurology, Xi'an Gaoxing Hospital, Xi'an, 710075, China
| | - Yaling Ma
- Department of Neurology, Yulin No.1 Hospital, Yulin, 719000, China
| | - Yongcai Qu
- Department of Neurology, Yan'an University Affiliated Hospital, Yanan, 716000, China
| | - Xinglai Wang
- Department of Neurology, Xi'an Central Hospital, Xi'an, 710003, China
| | - Kang Huo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Chengkai Wang
- Department of Neurology, Tongchuan People's Hospital, Tongchuan, 727000, China
| | - Xiangjun Yuan
- Department of Neurology, Weinan Central Hospital, Weinan, 714000, China
| | - Chaohui Song
- Department of Neurology, Tongchuan Mining Bureau Hospital, Tongchuan, 727000, China
| | - Bei Zhang
- Department of Neurology, The First Affiliated Hospital of Xi'an Medical University, Xi'an, 710077, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China. .,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, 710032, China.
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Hsieh CY, Lee CH, Sung SF. Stroke occurrence while on antiplatelet therapy may predict atrial fibrillation detected after stroke. Atherosclerosis 2019; 283:13-18. [PMID: 30771556 DOI: 10.1016/j.atherosclerosis.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 11/20/2018] [Accepted: 01/10/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Stroke occurrence while on antiplatelet therapy, i.e., a breakthrough stroke, is often conveniently attributed to antiplatelet resistance. However, undetected paroxysmal atrial fibrillation (AF) may underlie breakthrough strokes. We hypothesized that a breakthrough stroke may be a clinical marker for patients at risk of having AF detected after stroke (AFDAS). METHODS Consecutive patients without known AF hospitalized for ischemic stroke between 2000 and 2013 were identified from nationwide claims data. The independent variable of interest was continued use of antiplatelet therapy within 30 days before stroke. The diagnosis of AF and comorbidities were ascertained using validated algorithms. Stroke severity (National Institutes of Health Stroke Scale [NIHSS]) was estimated using a validated claims-based method. Univariable and multivariable Cox regression analyses were used to determine the effect of breakthrough strokes on the occurrence of AFDAS separately in patients with mild and severe stroke (estimated NIHSS ≤10 versus >10). RESULTS Among 17,076 patients (40% female, mean age 69 years), 3314 (19%) were on antiplatelet therapy before stroke. In patients with mild stroke, prior antiplatelet use was significantly associated with the occurrence of AFDAS (adjusted hazards ratio, 1.26; 95% confidence interval, 1.08-1.48). In contrast, no association existed between prior antiplatelet use and the risk of AFDAS in those with severe stroke. CONCLUSIONS Patients with a breakthrough stroke of mild severity while on antiplatelet therapy carried an increased risk of AFDAS compared to those not on antiplatelet therapy. Our findings may help prioritize patients for advanced cardiac monitoring in daily practice.
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Affiliation(s)
- Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi City, Taiwan; Department of Information Management and Institute of Healthcare Information Management, National Chung Cheng University, Chiayi County, Taiwan.
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Yuan F, Yang F, Xue C, Wang K, Liu Q, Zhou J, Fu F, Wang X, Zhang W, Liu Y, Huo K, Lv H, Jiang W. Controlling Hypertension After Severe Cerebrovascular Event (CHASE): study protocol for a randomized controlled trial. Trials 2018; 19:130. [PMID: 29467025 PMCID: PMC5822484 DOI: 10.1186/s13063-018-2530-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/10/2018] [Indexed: 01/02/2023] Open
Abstract
Background No ideal blood pressure (BP) range has been scientifically determined for acute stroke, and no studies on BP management have been carried out for patients with severe stroke. This trial aims to investigate whether individualized lowering of elevated BP would improve the outcome in patients with severe stroke. Methods/design The CHASE trial is a multicenter, randomized, controlled study. A total of 500 adult patients with acute severe stroke will be enrolled in 18 study sites in China and randomized to individualized BP lowering (10–15% reduction from admission level) or guideline-recommended BP lowering. The primary outcome measurement is the proportion of participants with a poor outcome (modified Rankin Scale ≥ 3) at day 90 of enrollment. Secondary outcomes include disability at hospital discharge and the ability of activities of daily living at day 90 of enrollment. The relationship between intervention and the primary outcome will be analyzed using multivariate logistic regression adjusted for study site, demographics, and baseline characteristics. Discussion The CHASE trial will be the first study to explore the optimum BP management for acute severe stroke. This trial potentially offers a strong argument for individualized target for lowering elevated BP in patients with severe stroke. Trial registration ClinicalTrials.gov, NCT02982655. Registered on 30 November 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2530-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Fang Yuan
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Changhu Xue
- Department of Neurology, Xianyang Central Hospital, Xianyang, 712000, China
| | - Kangjun Wang
- Department of Neurology, Hanzhong Central Hospital, Hanzhong, 723000, China
| | - Qiuwu Liu
- Department of Neurology, Xi'an 141 Hospital, Xi'an, 710000, China
| | - Jun Zhou
- Department of Neurology, Shangluo Central Hospital, Shangluo, 726000, China
| | - Feng Fu
- Department of Neurology, 215 Hospital of Shaanxi NI, Xianyang, 712021, China
| | - Xiaocheng Wang
- Department of Neurology, Yulin No.2 Hospital, Yulin, 719000, China
| | - Wei Zhang
- Department of Neurology, Tangdu Hospital, Fourth Military Medical University, Xi'an, 710038, China
| | - Yi Liu
- Department of Neurology, Ankang Central Hospital, Ankang, 725000, China
| | - Kang Huo
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Hua Lv
- Department of Neurology, Shaanxi Provincial People's Hospital, Xi'an, 710068, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China. .,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, 710032, China.
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Yue R, Li D, Yu J, Li S, Ma Y, Huang S, Zeng Z, Zeng R, Sun X. Atrial Fibrillation is Associated With Poor Outcomes in Thrombolyzed Patients With Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3054. [PMID: 26962831 PMCID: PMC4998912 DOI: 10.1097/md.0000000000003054] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The influence of atrial fibrillation (AF) on the clinical outcomes of patients with ischemic stroke (IS) has not been completely determined. We aimed to perform a systematic review and meta-analysis to assess the relationship between AF and adverse events in patients with acute IS treated with thrombolysis.PubMed, EMBASE, and the Cochrane Library were searched for relevant studies regarding the association between AF and the outcomes of patients with IS treated with thrombolysis. Random and fixed effect models were used for pooling data.Twelve cohort studies involving 14,801 patients with acute IS were included. Meta-analysis revealed that patients with AF were more likely to die within 90 days after thrombolysis (odds ratio [OR], 2.13; 95% confidence interval [CI]: 1.68-2.70, P < 0.001), whereas this association was not observed in hospitalized patients (OR, 1.50; 95% CI, 0.86-2.60; P = 0.150). AF was associated with a reduced incidence of favorable outcomes (modified Rankin Scale ≤ 2) (OR, 1.95; 95% CI: 1.33-2.85, P = 0.001) and an increased risk of symptomatic intracerebral hemorrhage (OR, 1.28; 95% CI: 1.08-1.52, P = 0.006). No evident publication bias was found by Begg's test or Egger's test.Comorbidity of AF may increase the risk of adverse outcomes for patients with IS undergoing thrombolysis. Further well-designed trials are warranted to confirm this association.
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Affiliation(s)
- Rongzheng Yue
- From the Department of Nephrology (RY, SH); Department of Cardiology (DL, JY, ZZ, XS, RZ), West China Hospital, Sichuan University, Chengdu; Department of Cardiology (SL), First Affiliated Hospital of Xinjiang Medical University; and School of Public Health (YM), Xinjiang Medical University, Urumqi, China
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Hsieh CY, Lin HJ, Sung SF, Yang YHK, Lai ECC, Hsieh HC, Chen CH. Does Renal Dysfunction Modify the Effect of Intravenous Thrombolysis for Acute Ischemic Stroke within 4.5 Hours of Onset? A Multicenter Observational Study. J Stroke Cerebrovasc Dis 2015; 24:673-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 11/12/2014] [Indexed: 11/28/2022] Open
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Kongbunkiat K, Kasemsap N, Travanichakul S, Thepsuthammarat K, Tiamkao S, Sawanyawisuth K. Hospital mortality from atrial fibrillation associated with ischemic stroke: a national data report. Int J Neurosci 2014; 125:924-8. [PMID: 25387068 DOI: 10.3109/00207454.2014.986266] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To study factors associated with poor outcomes in acute ischemic stroke patients with atrial fibrillation (AF) by using a national database. MATERIALS AND METHODS This study was a retrospective analytical study by retrieving data from the Thailand national database system for universal coverage (UC) health insurance system. All adult patients aged over 18 years who were admitted with acute ischemic stroke during the fiscal years 2004-2012 by the appropriate ICD codes were searched. Eligible patients with AF were categorized as alive or dead during hospital stay. The mortality rate and factors associated with in-hospital mortality were studied. RESULTS There were 522,699 patients diagnosed as acute stroke; 277,291 patients (53.1%) had acute ischemic stroke. Of those with ischemic stroke, 25,319 patients (9.1%) had AF. The mortality rates of acute ischemic stroke with AF were 14.1% and without AF were 6.2%, (p < 0.001). Significant factors associated with mortality in acute stroke patients with AF by multivariate logistic regression were female gender (adjusted odds ratio; AOR 1.28), co-morbid diseases such as diabetes (AOR 1.28), hypertension (AOR 1.26), rt-PA treatment (AOR 0.55), and stroke complications, such as pneumonia (AOR 2.60), septicemia (AOR 6.50), or gastrointestinal bleeding (AOR 2.16). CONCLUSIONS At the national level, AF caused a higher mortality rate in acute ischemic stroke than in non-AF patients. Gender, co-morbid diseases, rt-PA treatment, and stroke complications were associated with mortality in acute ischemic stroke with AF.
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Affiliation(s)
- Kannikar Kongbunkiat
- a Department of Medicine, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand.,c North-eastern Stroke Research Group, Khon Kaen University
| | - Narongrit Kasemsap
- a Department of Medicine, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand.,c North-eastern Stroke Research Group, Khon Kaen University
| | - Suporn Travanichakul
- a Department of Medicine, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand.,c North-eastern Stroke Research Group, Khon Kaen University
| | - Kaewjai Thepsuthammarat
- b Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand
| | - Somsak Tiamkao
- a Department of Medicine, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand.,c North-eastern Stroke Research Group, Khon Kaen University
| | - Kittisak Sawanyawisuth
- a Department of Medicine, Faculty of Medicine, Khon Kaen University , Khon Kaen , Thailand.,d Research Center in Back, Neck, Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University , Khon Kaen , Thailand
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Padjen V, Bodenant M, Jovanovic DR, Ponchelle-Dequatre N, Novakovic N, Cordonnier C, Beslac-Bumbasirevic L, Leys D. Outcome of patients with atrial fibrillation after intravenous thrombolysis for cerebral ischaemia. J Neurol 2013; 260:3049-54. [DOI: 10.1007/s00415-013-7119-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 09/13/2013] [Accepted: 09/14/2013] [Indexed: 11/24/2022]
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Age Predicts Functional Outcome in Acute Stroke Patients with rt-PA Treatment. ISRN NEUROLOGY 2013; 2013:710681. [PMID: 24171121 PMCID: PMC3793585 DOI: 10.1155/2013/710681] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 08/18/2013] [Indexed: 11/18/2022]
Abstract
The standard treatment for acute ischemic stroke is thrombolytic therapy. There is limited data on prognostic factors of acute stroke with thrombolytic therapy particularly in Asian population. Acute ischemic stroke patients who were treated with thrombolytic therapy at Srinagarind Hospital between May 2008 and July 2010 were included. Factors associated with Barthel index more than 80 were studied by multiple logistic regression analysis. There were 75 patients included in the study. The mean NIHSS scores before treatment and at 3 months were 9.16 ± 4.82 and 3.83 ± 4.00, respectively, and median Barthel index at 3 months was 86. Only significant predictor for having Barthel index more than 80 points at 3 months was age (adjusted odds ratio 0.929, 95% confidence interval 0.874, 0.988). Four patients developed intracranial hemorrhage after the treatment (5%), and two died (2.6%). In conclusion, age predicts Barthel index in acute stroke patients with rt-PA treatment.
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