A systematic review of closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and cryptogenic stroke or transient ischemic attack

The role of miRNA-29b1 on the hypoxia-induced apoptosis in mammalian cardiomyocytes

Cardiomyocyte apoptosis is a complex biological process involving the interaction of many factors and signaling pathways. In hypoxic environment, cardiomyocytes may trigger apoptosis due to insufficient energy supply, increased production of oxygen free radicals, and disturbance of intracellular calcium ion balance. The present research aimed to investigate the role of microRNA-29b1 (miR-29b1) in hypoxia-treated cardiomyocytes and its potential mechanism involved. We established an in vitro ischemia model using AC16 and H9C2 cardiomyocytes through hypoxia treatment (1% O2, 48 h). Cell apoptosis was evaluated by flow cytometry using Annexin V FITC-PI staining assay. Moreover, we used Western blot and immunofluorescence analysis to determine the expression of Bcl-2, Bax caspase-3 and Cx43 proteins. We found that miR-29b1 protected AC16 and H9C2 cells from hypoxia-induced injury as evidence that miR-29b1 attenuated the effects of hypoxia treatment on AC16 and H9C2 cell apoptosis after hypoxia treatment. In conclusion, our findings suggest that miR-29b1 may have potential cardiovascular protective effects during ischemia-related myocardial injury.

The efficacy of transitional care services in patients with transient ischemic attack: A retrospective cohort study

Transient ischemic attack (TIA) carries a particularly high short-term risk of stroke, which is associated with brain dysfunction caused by a regional reduction in blood flow. Transitional care services present benefits in improving ischemic neurological function and decreasing the recurrence in patients with TIA. The purpose of this study was to investigate the effects of transitional care on clinical outcomes in patients hospitalized for TIA. We retrospectively collected data about 1288 patients with TIA from May 2017 to June 2019. Patients were divided into mild (n = 438), moderate (n = 420) and severe group (n = 430) accessed by age, blood pressure, type of TIA, and duration (ABCD2) score. Participants were patients hospitalized due to TIA, assigned to transitional care (n = 643) or usual care (n = 645), and followed up for 24 months. Physical function of patients was evaluated using the 6-minute walk test. We evaluated patient reach, implementation using hospital quality measures, hospital-level sustainability physical function, ischemic neurological score, composite quality indicator score, and recurrence of TIA between transitional care or usual care group. TIA patients in transitional care group had better physical function and quality indicator score, lower ischemic neurological score and recurrence of TIA, and shorter hospital stay than patients in usual care group. Results demonstrated that transitional care significantly improved the patients' satisfaction compared to usual care. Patients in mild, moderate, and severe group presented more benefits than usual care clinical outcomes in patients hospitalized for TIA. Transitional care is associated with better functional status for patients with TIA.

LRG1 promotes hypoxia-induced cardiomyocyte apoptosis and autophagy by regulating hypoxia-inducible factor-1α

Cardiomyocyte apoptosis and autophagy play important roles in acute myocardial infarction (AMI), but the effect of leucine-rich alpha-2-glycoprotein 1 (LRG1) on the apoptosis and autophagy of H9c2 has not yet been reported. It was found through differential gene analysis and LASSO analysis that LRG1 was the key gene in AMI. In this study, western blot was applied to detect the protein expression of Bax, Bcl2, LC3, p62, LRG1 and hypoxia-inducible factor-1α (HIF-1α); CCK-8 assay was employed to detect cell viability; Annexin V-FITC/PI staining was adopted to evaluate apoptosis, and immunofluorescence assay was applied to detect autophagy. Under hypoxia conditions in H9c2 cells, LRG1 protein levels were increased, the cell activity was decreased, and apoptosis and autophagy were promoted; the downregulated LRG1 significantly enhanced cell viability but inhibited apoptosis and autophagy. When knocking down HIF-1α in the overexpressed LRG1 cells, the effects of LRG1 were reversed under hypoxia condition. In conclusion, LRG1/HIF-1α promoted H9c2 cell apoptosis and autophagy in hypoxia, potentially providing new ideas for the determination and treatment of AMI.

Abbreviation: LRG1: Leucine-rich alpha-2-glycoprotein 1; LRR: leucine-rich repeat; HIF-1α: Hypoxia-inducible factor-1α; AMI: acute myocardial infarction

Neuroprotective effects of SOX5 against ischemic stroke by regulating VEGF/PI3K/AKT pathway

Ischemic stroke is a common clinical cardiovascular disease and often accompanied by central nervous system injury. It often causes paralysis or loss of motor function after central nervous system injury and significantly reduces the patient's quality of life. At present, there is no effective treatment strategy for nerve damage caused by ischemic stroke. Therefore, it is urgently need to explore effective treatment targets. The protein expression of SOX5, VEGF and apoptosis related proteins were measured by western blot. The mRNA expression of SOX5 and VEGF were detected by RT-qPCR. The concentration of S100B and GFAP which are related to nerve damage were detected using ELISA assay. The transcriptional regulation of SOX5 on VEGF was detected using ChIP-PCR and dual luciferase reporter gene assays. The cell apoptosis was measured by TUNEL assay and cell viability was detected by CCK-8 assay. In our study, we found that the expression of SOX5 was significantly reduced when LPS induced apoptosis in PC-12 cells. Overexpression of SOX5 repaired LPS-induced apoptosis. SOX5 promotes VEGF expression as a transcription factor to activate the PI3K/AKT pathway. VEGF also repairs nerve injury and brain tissue injury caused by ischemic stroke. In conclusion, SOX5 transcription regulates the expression of VEGF to activate the PI3K/AKT pathway, which repaired nerve damage caused by ischemic stroke. Therefore, SOX5 could be a new targetto regulate VEGF which can repair nerve injury induced by ischemic stroke.

Transcatheter closure of patent foramen ovale following cryptogenic stroke: An updated meta-analysis of randomized controlled trials

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) after cryptogenic stroke has long been a contentious issue. Herein, we pool aggregate data examining safety and efficacy of transcatheter closure of PFO compared with medical therapy following initial cryptogenic stroke.

METHODS

We searched for randomized clinical trials (RCT) that compared device closure with medical management and reported on subsequent stroke and adverse events. Stroke was considered as the primary efficacy endpoint, whereas bleeding and atrial fibrillation were considered primary safety endpoints. Data were pooled by the random effects model and I2 was used to assess heterogeneity.

RESULTS

A total of 5 RCT investigating 3630 patients met inclusion criteria. Pooled analysis revealed that device closure compared to medical management was associated with a significant reduction in stroke (RR=0.3, 95% CI=0.02-0.57). There was, however, a significant increase in atrial arrhythmias with device therapy (RR=4.8, 95% CI=2.2-10.7). We found no increase in bleeding (RR=0.80, 95% CI=0.5-1.4), death (RR=0.76, 95% CI=0.3-1.99) or "any adverse events" (RR=1.02, 95% CI=0.85-1.23) with device therapy. Sub-group analysis revealed that device closure significantly reduced the incidence of the composite primary endpoint among patients who had moderate to large shunt sizes (RR=0.22, 95% CI=0.02-0.42).

CONCLUSIONS

Transcatheter closure is associated with a significant reduction in the risk of stroke compared to medical management at the expense of an increased risk of atrial arrhythmias.

Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis

BACKGROUND

Recent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention.

MATERIAL AND METHODS

Data sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke.

RESULTS

Five RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post-TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39-0.94, P = 0.03, I² = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53-1.19, P = 0.26, I² = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17-12.59, P = 0.0002, I² = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48-1.06, P = 0.09, I² = 0%).

CONCLUSIONS

TPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new-onset atrial fibrillation and a trend toward reduced neuropsychiatric events.

Serpentine thrombus in the heart: a rare case of trapped thrombus in patent foramen ovale

A 77-year-old Caucasian woman with recent abdominal surgery was diagnosed with multiple paradoxical systemic emboli in the mesenteric and renal circulation. Diagnosis was made by direct visualisation of a serpentine thrombus traversing both atria through patent foramen ovale (PFO) by transesophageal echocardiogram (TEE). Concomitantly, the patient was found to have deep venous thrombosis and pulmonary embolism. A decision was made to pursue cardiothoracic surgery preceded by inferior vena cava filter placement. She was started on intravenous anticoagulation. Repeat TEE was negative for thrombus and the patient did not present any new clinical signs of embolisation by this time. Consequently, the treatment plan was modified and the patient received oral systemic anticoagulation followed by PFO closure with the use of St. Jude Amplatzer Cribriform septal occluder device. During the outpatient follow-up the patient was asymptomatic and there was no significant flow through the device on transthoracic echocardiogram.

Meta-Analysis Comparing Patent Foramen Ovale Closure Versus Medical Therapy to Prevent Recurrent Cryptogenic Stroke

New evidence suggests that closure of a patent foramen ovale (PFO) plus medical therapy (MT; antiplatelet or anticoagulation) is superior to MT alone to prevent recurrent cryptogenic stroke. We performed a meta-analysis of randomized controlled trials that compared PFO closure plus MT with MT alone in patients with cryptogenic stroke. The efficacy end points were recurrent stroke, transient ischemia attack, and death. The safety end points were major bleeding and newly detected atrial fibrillation. Trials were pooled using random effects and fixed effects models. A trial sequential analysis was performed to assess if the current evidence is sufficient. Risk ratios (RR) were calculated for pooled estimates of risk. Five randomized controlled trials (3,440 patients) were included. Mean follow-up was 4.1 years. PFO closure reduced the risk of recurrent stroke by 58% (RR 0.42, 95% CI 0.20 to 0.91, p = 0.03). The number needed to treat was 38. The cumulative Z-line crossed the trial sequential boundary, suggesting there is adequate evidence to conclude that PFO closure reduces the risk of recurrent stroke by 60%. PFO closure did not reduce the risk of transient ischemia attack (RR 0.78, 95% CI 0.53 to 1.15, p = 0.21), mortality (RR 0.74, 95% CI 0.35 to 1.60, p = 0.45), or major bleeding (RR 0.96, 95% CI 0.42 to 2.20, p = 0.93); it did increase the risk of atrial fibrillation (RR 4.69, 95% CI 2.17 to 10.12, p <0.0001).

Identification of core pathways based on attractor and crosstalk in ischemic stroke

Ischemic stroke is a leading cause of mortality and disability around the world. It is an important task to identify dysregulated pathways which infer molecular and functional insights existing in high-throughput experimental data. Gene expression profile of E-GEOD-16561 was collected. Pathways were obtained from the database of Kyoto Encyclopedia of Genes and Genomes and Retrieval of Interacting Genes was used to download protein-protein interaction sets. Attractor and crosstalk approaches were applied to screen dysregulated pathways. A total of 20 differentially expressed genes were identified in ischemic stroke. Thirty-nine significant differential pathways were identified according to P<0.01 and 28 pathways were identified with RP<0.01 and 17 pathways were identified with impact factor >250. On the basis of the three criteria, 11 significant dysfunctional pathways were identified. Among them, Epstein-Barr virus infection was the most significant differential pathway. In conclusion, with the method based on attractor and crosstalk, significantly dysfunctional pathways were identified. These pathways are expected to provide molecular mechanism of ischemic stroke and represents a novel potential therapeutic target for ischemic stroke treatment.

Patent foramen ovale closure to prevent secondary neurologic events

In October of 2016 the United States Food and Drug Administration approved the Amplatzer Patent Foramen Ovale (PFO) occluder device for use in patients with cryptogenic stroke, to reduce the risk of recurrent stroke. This event followed 15years of off-label use of atrial septal occluder devices, 3 randomized trials, and enormous controversy over the efficacy of this procedure. While none of the trials reached the primary endpoint needed to prove the efficacy of PFO closure in preventing recurrent stroke, meta-analyses and 5-year follow-up of 1 trial suggest that PFO closure decreases the risk of recurrent stroke, especially in sub-groups with large shunts and atrial septal aneurysms, and especially when the Amplatzer device (rather than other devices) is used. While the relative reduction in stroke associated with PFO closure is large (about 50%), the absolute reduction is low (1-2%) and must be balanced against complications of the procedure (about 3%). Thus, PFO closure is restricted to patients with cryptogenic stroke, and depends heavily on patients' personal preferences. Uncertainties about the etiology of stroke in patients with PFO and the efficacy of PFO closure cause a difficult problem for the internal medicine specialist. At one extreme the internist may wonder if every patient with a documented PFO should be referred to a cardiologist. At the other extreme, supported by specialty society guidelines, internists may conclude that PFO closure is rarely necessary. In this paper we review the current status of PFO closure and suggest a rational strategy for this procedure.

Association of Rs2071410 on Furin with Transient Ischemic Attack Susceptibility and Prognosis in a Chinese Population

Background

Because genotype CG/GG of Furin rs2071410 can increase susceptibility to hypertension, this study investigated whether Furin rs2071410 is correlated with transient ischemic attack (TIA) susceptibility and prognosis.

Material/Methods

The odds ratios (ORs) and their 95% confidence intervals (95% CIs) were evaluated to assess the association of rs2071410 with TIA risk, and logistic regression was used to estimate the effects of various risk factors (e.g., diabetes, hypertension, and hyperlipidemia) on TIA.

Results

Compared with the homozygous genotype CC of rs2071410, the frequency of CG + GG genotype in the case group was significantly higher than in the control group (OR=1.47, 95% CI: 1.05–2.05, P<0.05). The CG + GG genotype carriers were observed to have worse 90-day prognosis after TIA treatment than patients carrying CC genotype (OR=12.86, 95% CI: 7.41–22.33, P<0.05). Moreover, logistic regression analysis found that age, diabetes, hypertension, and hyperlipidemia were associated with the onset of TIA (P<0.05, all). Of note, individuals with CG + GG genotype had 49.3% increased risk of TIA compared with individuals with CC genotype (OR=1.49, 95% CI: 1.05–2.12), and patients with CG + GG genotype had worse 90-day prognosis after TIA treatment than patients with CC genotype (OR=11.39, 95% CI: 6.29–20.62).

Conclusions

Furin rs2071410 was significantly correlated with TIA occurrence and prognosis in the Chinese population.

The relationship of patent foramen ovale location with severity of stroke: A new risk factor for paradoxical embolism

OBJECTIVE

Patent foramen ovale (PFO) is a common developmental anomaly and is well associated with paradoxical embolism and cryptogenic stroke. The aim of this study was to investigate the relationship of PFO location with severity of cryptogenic stroke.

MATERIALS AND METHODS

Fifty patients with cryptogenic stroke and echocardiographically proven PFO were classified according to the severity of stroke. In order to define the location of PFOs, an imaginary line dividing the length of interatrial septum vertically into two equal parts was drawn manually at axial plane on cardiac multidetector computed tomography. PFOs located at superior part of this imaginary line was defined as superiorly located PFO, while PFOs located at inferior part of this imaginary line was defined as inferiorly located PFO.

RESULTS

Fourteen patients (28%) revealed mild, 20 patients (40%) revealed moderate and 16 patients (32%) had severe stroke. Based on PFO location, there were 34 patients (68%) with superiorly (group 1), and 16 patients (32%) with inferiorly (group 2) located PFO. It was found that patients of group 1 had significantly higher frequency of moderate or severe stroke compared to those of group 2 (p < 0.005) CONCLUSION: In conclusion, the patients with superiorly located PFO had higher frequency of severe stroke compared to the patients with inferiorly located PFO. Since this is a preliminary study, clinical application and importance of this finding necessitates further large-scale interventional studies.

Disorganized Systematic Reviews and Meta-analyses: Time to Systematize the Conduct and Publication of These Study Overviews?

The number of meta-analyses published annually has increased more than 20-fold between 1994 (n = 386) and 2014 (n = 8203). In examining how much of this increase in meta-analysis publication has genuinely represented novel contributions to clinical medicine and public health, it became clear that there was an abundance of redundant and disorganized meta-analyses, creating confusion and generating considerable debate. Ironically, meta-analyses, which should prevent redundant research, have become a victim of it. Recently, 17 meta-analyses were published based on the results of only 3 randomized controlled trials that studied the role of transcatheter closure of patent foramen ovale for prevention of cryptogenic stroke. In our search of the published literature, we identified at least 10 topics that were the subject of 10 meta-analyses. In the context of overlapping meta-analyses, one questions what needs to be done to put this "runaway train" back on track. In this review we examine the practice of redundant meta-analyses and the reasons for its disturbing "popularity." The registration of systematic reviews should be mandatory in prospective registries, such as PROSPERO, and the PRISMA checklist should be updated to incorporate new evidence and mandate the reference of previously published reviews and rationale for any new study.

Identification of autophagy signaling network that contributes to stroke in the ischemic rodent brain via gene expression

Autophagy plays a vital role in cerebral ischemia and may be a potential target for developing novel therapy for stroke. In this study, we constructed an autophagy-related pathway network by analyzing the genes related to autophagy and ischemic stroke, and the risk genes were screened. Two autophagy-related modules were significantly up-regulated and clustered to influence cerebral ischemia. Besides, three key modular genes (NFKB1, RELA, and STAT3) were revealed. With 5-fold cross validation, the ROC curves of NFKB1, RELA, and STAT3 were 0.8256, 0.8462, and 0.8923. They formed a complex module and competitively mediated the activation of autophagy in cerebral ischemia. In conclusion, a module containing NFKB1, RELA, and STAT3 mediates autophagy, serving as a potential biomarker for the diagnosis and therapy of ischemic stroke.

PFO Closure for Cryptogenic Stroke

A patent foramen ovale (PFO) is a common finding in the general population and has been theorized to be a mechanism for ischemic stroke primarily due to a deep venous thrombus embolizing through the shunt into the arterial circulation. There has been much debate regarding the association between PFO and stroke, especially in the case of a cryptogenic stroke (i.e., stroke of unknown etiology) in a younger patient without other risk factors. Traditionally, when a PFO is detected, antithrombotic therapy to mitigate risk of a future ischemic event has been the mainstay of treatment. More recently, both surgical and transcatheter closure of a PFO have been widely utilized. However, there are only few randomized controlled trials assessing the efficacy of PFO closure for stroke prevention.