Risk factors and acute ischemic stroke subtypes

Obesity: the perfect storm for heart failure

Obesity condition causes morphological and functional alterations involving the cardiovascular system. These can represent the substrates for different cardiovascular diseases, such as atrial fibrillation, coronary artery disease, sudden cardiac death, and heart failure (HF) with both preserved ejection fraction (EF) and reduced EF. Different pathogenetic mechanisms may help to explain the association between obesity and HF including left ventricular remodelling and epicardial fat accumulation, endothelial dysfunction, and coronary microvascular dysfunction. Multi-imaging modalities are required for appropriate recognition of subclinical systolic dysfunction typically associated with obesity, with echocardiography being the most cost-effective technique. Therapeutic approach in patients with obesity and HF is challenging, particularly regarding patients with preserved EF in which few strategies with high level of evidence are available. Weight loss is of extreme importance in patients with obesity and HF, being a primary therapeutic intervention. Sodium-glucose co-transporter-2 inhibitors have been recently introduced as a novel tool in the management of HF patients. The present review aims at analysing the most recent studies supporting pathogenesis, diagnosis, and management in patients with obesity and HF.

Hypertension-mediated organ damage involving multiple sites is an independent risk factor for cardiovascular events

Aims

Chronic pressure overload determines functional and structural alterations, leading to hypertension-mediated organ damage (HMOD), affecting multiple districts. We aim at evaluating the prognostic impact of the absence vs. presence of HMOD in one or more sites and of blood pressure (BP) and metabolic control in hypertensive patients.

Methods and results

The study included 7237 hypertensive patients from the Campania Salute Network Registry, followed up for 5.3 ± 4.5 years. As HMOD, we analysed the presence of left ventricular hypertrophy, carotid plaques, and chronic kidney disease (CKD-EPI ≥3 stage) and evaluated the impact of zero vs. one vs. two vs. three sites of HMOD on the occurrence of major adverse cardiovascular events (MACEs). Blood pressure control and Metabolic Score for Insulin Resistance (METS-IR) were also considered. Optimal BP control was achieved in 57.3% patients. Major adverse cardiovascular events occurred in 351 (4.8%) patients. The MACE rate in patients without HMOD was 2.7%, whereas it was 4.7, 7.9, and 9.8% in patients with one, two, and three sites with HMOD, respectively. By using Cox multivariate models, adjusted for age, BP control, mean heart rate, mean METS-IR, number of HMOD sites, and drugs, MACE was found to be significantly associated with ageing, mean METS-IR, anti-platelet therapy, and multiple sites with HMOD, whereas a negative association was found with renin-angiotensin system inhibitor drugs.

Conclusion

In hypertensive patients, the risk of MACE increases with the incremental number of districts involved by HMOD, independent of BP control and despite the significant impact of metabolic dysregulation. Hypertension-mediated organ damage involving multiple sites is the deleterious consequence of hypertension and dysmetabolism but, when established, it represents an independent cardiovascular risk factor for MACE occurrence.

Advanced imaging tools for evaluating cardiac morphological and functional impairment in hypertensive disease

Arterial hypertension represents a systemic burden, and it is responsible of various morphological, functional and tissue modifications affecting the heart and the cardiovascular system. Advanced imaging techniques, such as speckle tracking and three-dimensional echocardiography, cardiac magnetic resonance, computed tomography and PET-computed tomography, are able to identify cardiovascular injury at different stages of arterial hypertension, from subclinical alterations and overt organ damage to possible complications related to pressure overload, thus giving a precious contribution for guiding timely and appropriate management and therapy, in order to improve diagnostic accuracy and prevent disease progression. The present review focuses on the peculiarity of different advanced imaging tools to provide information about different and multiple morphological and functional aspects involved in hypertensive cardiovascular injury. This evaluation emphasizes the usefulness of the emerging multiimaging approach for a comprehensive overview of arterial hypertension induced cardiovascular damage.

Biochemical markers as diagnostic/prognostic indicators for ischemic disease

Objective

The use of a biomarker was extremely useful in clinical emergencies such as stroke to aid in triage and early management of cases. The diagnostic accuracy of laboratory biomarkers is run to approve the identification of easy, cheap and fast tests associated with cerebral ischemia and intracranial hemorrhage. The present study was designed to screen serum enolase activity, activities of CK-BB, LDH and lipid profile in patients with ischemic or related diseases as good diagnostic/ prognostic indicator for ischemic diseases.

Methods

Sixty male subjects in the age range of (45 ±2years) were divided into four groups each with 15 participants: Group (I) normal . Group (II) patients recently diagnosed as ischemic disease; Group (III) hypertensive patients and Group (IV); diabetic patients enolase activity (p<0.001) and CK-BB (p<0.01) in ischemic and hypertensive patients compared with control and diabetic groups. LDH level was significantly elevated in ischemic, hypertensive and diabetic patients compared with controls (p<0.001). The cut -off value for serum enolase was 62.5 nmol/l showing 90% sensitivity and 93% specificity for differentiation of ischemic disease. Positive correlations were observed between serum enolase (r = 0.56), and CK-BB (r = 0.53).

Conclusion

Serum enolase can be considered as a more sensitive and specific marker and used as a sensitive diagnostic or prognostic marker for ischemic related diseases.

Rehabilitation in oldest-old stroke patients: a comparison within over 65 population

BACKGROUND

Considering the demographic trend, characterized by a marked aging due to the increase in life expectancy and the improvement in medical care, in the next future elderly patients will represent the majority of stroke victims with a strong impact on rehabilitative services.

AIM

To investigate and characterize differences in functional outcome in elderly patients after stroke.

DESIGN

Observational study.

SETTING

Post-acute inpatient rehabilitation.

POPULATION

Subjects aged ≥65 years with acute (i.e. within 30 days from onset) ischemic or hemorrhagic stroke.

METHODS

At admission, all patients underwent neurological and clinical examination, functional evaluation and laboratory assessment. Comorbidities and clinical complications during hospital stay were recorded. Functional status was evaluated by means of the Functional Independence Measure (FIM) administered at admission and discharge. All patients underwent neuromotor rehabilitation, and speech therapy in case of aphasia, once a day, six days per week.

RESULTS

The study enrolled 402 patients, who were stratified in three groups according to age: 145 patients in Group 1, the young-old (65-74.9 years, G1), 206 in Group 2, the middle-old (75-84.9 years, G2) and 51 in Group 3, the oldest-old (≥85 years, G3). At discharge, FIM total scores increased significantly for all the groups (P<0.001); however FIM gains, as well as the efficiency parameters derived from FIM were significantly lower in G3 when compared with G1 and G2. G3 showed a significantly higher rate of comorbidities and a higher presence of pressure sores; infections occurred mainly in G2 and G3. Hospitalization was significantly longer for G1 and G2 with respect to G3, while mortality rates were significantly higher in G2 and G3 with respect to G1. The variables that predicted functional outcome were age, previous stroke, stroke severity and functional status at admission.

CONCLUSIONS

Despite advancing age seems to be associated with a reduced effectiveness of the rehabilitation process and a greater number of complications, intensive rehabilitation can produce significant functional gains for all stroke survivors, regardless of age.

CLINICAL REHABILITATION IMPACT

Understanding the specificity of this population will offer older subjects targeted interventions and, for health systems, better allocation of resources and the development of more effective approaches.

Rac1 Modulates Endothelial Function and Platelet Aggregation in Diabetes Mellitus

Background

Vascular complications and abnormal platelet function contribute to morbidity and mortality in diabetes mellitus. We hypothesized that the Rho‐related GTPase protein, Rac1, can influence both endothelial and platelet function and might represent a potential novel therapeutic target in diabetes mellitus.

Methods and Results

We used both in vitro and ex vivo approaches to test the effects of pharmacological inhibition of Rac1 during hyperglycemic condition. We evaluated the effect of NSC23766, a pharmacological inhibitor of Rac1, on vascular function in diabetic mice and platelet aggregation in diabetic subjects. We demonstrated that the administration of NSC23766 protects from hyperglycemia‐induced endothelial dysfunction, restoring NO levels, and reduces oxidative stress generated by nicotinamide adenine dinucleotide phosphate oxidase. Mechanistically, we identified Rho‐associated coiled‐coil serine/threonine kinase‐1 as a downstream target of Rac1. Moreover, we reported that during hyperglycemic conditions, human platelets showed hyperactivation of Rac1 and impaired NO release, which were both partially restored after NSC23766 treatment. Finally, we characterized the antiplatelet effect of NSC23766 during hyperglycemic conditions, demonstrating the additional role of Rac1 inhibition in reducing platelet aggregation in diabetic patients treated with common antiplatelet drugs.

Conclusions

Our data suggest that the pharmacological inhibition of Rac1 could represent a novel therapeutic strategy to reduce endothelial dysfunction and platelet hyperaggregation in diabetes mellitus.

Association of Paroxysmal Supraventricular Tachycardia with Ischemic Stroke: A National Case-Control Study

BACKGROUND AND PURPOSE

Cardioembolic stroke accounts for approximately 15%-20% of all ischemic strokes. Atrial fibrillation constitutes one-half to two-thirds of all cardioembolic stroke events. The association of paroxysmal supraventricular tachycardia (PSVT) with ischemic stroke remains unclear. A national case-control study was conducted to identify the risk factors, including PSVT, for ischemic stroke in Taiwan.

METHODS

We designed a national case-control study comprising patients diagnosed with ischemic stroke (n = 5633) from 1997 to 2011; each patient from the case group was randomly matched with the control group (n = 30,895) in Taiwan. Data were retrospectively collected from Taiwan's National Health Insurance Research Database, which contains not only claims data on hospitalization, emergency room visits, and outpatient department visits, but also patient characteristics.

RESULTS

Logistic regression analysis was used to identify the risk factors for ischemic stroke. Independent risk factors for ischemic stroke included age (in 5-year intervals; odds ratio [OR], 1.76; 95% confidence interval [CI], 173-1.78), the male sex (versus the female sex; OR, 1.88; 95% CI, 1.74-2.01), chronic kidney disease (OR, 3.09; 95% CI, 2.67-3.57), PSVT (OR, 2.05; 95% CI, 1.30-3.19), and aspirin use (OR, .04; 95% CI, .03-0.05).

CONCLUSIONS

Our study is the first in Taiwan to identify PSVT as a significant risk factor for ischemic stroke. New antithrombotic regimens, including aspirin, can be recommended for the primary prevention of stroke and for reducing the burden of stroke for patients with PSVT.

Hypertensive emergencies: a new clinical approach

The expression 'hypertensive urgencies' includes many diseases. The unifying features of these diseases are a high level of arterial pressure and acute distress of one or more organs. The aim of the review was to define the idea of the 'acute hypertension' as a new concept, different from 'chronic hypertension'. Acute hypertension might be related to 'organ damage' because it is the cause, the consequence or an effect of the acute stress. We compounded a narrative review which has included analyses of 373 articles. The structure of the search strategy included a literature search of PubMed, MEDLINE, Cochrane Library and Google Scholar databases. We applied the following inclusion criteria: prospective double-blind randomised controlled trials, experimental animal work studies, case-control studies and recruiting patients representative of the general sick population. In this review, the diseases included in the term 'hypertensive emergencies' share 'acute' hypertension. This is a new idea that emphasises the suddenly increased arterial pressure, irrespective of the initial arterial pressure and independent of the goals of hypertension control. The 'hypertensive emergencies' have been grouped together in three subsets: (1) diseases that result from acute hypertension that is caused by faulty regulation of the peripheral circulation (acute primary hypertension), (2) diseases that produce hypertension (acute secondary hypertension) and 3) diseases that have hypertension as an effect of the acute stress caused by the principle disease (acute associated hypertension). This review highlights a novel idea: acute hypertension is a common sign of different diseases characterised by the sudden surge of arterial pressure, so overwhelming the difference between hypertensive emergencies and urgencies. The judgment of acute hypertension is independent of the initial arterial pressure, normotension or hypertension and is linked with the transient failure of the baroreflex. Hypertensive emergencies are grouped together because all of these diseases require prompt therapy to prevent the negative outcomes of acute hypertension.

PPARγ and IL-6 - 174G>C gene variants in Croatian patients with ischemic stroke

AIM

Etiology of ischemic stroke (IS) is multifactorial and includes interaction of genetic and environmental factors. Different genes, their polymorphisms, host susceptibility, and inflammation processes play a role in IS development. The aim of this study was to evaluate the effect of PPAR-γ and IL-6 gene variants on IS onset.

MATERIAL AND METHODS

A total of 301 subjects (144 males, 157 females) participated in the study, 114 patients with IS and 187 healthy controls.

RESULTS

Statistically significant predictors of IS were male gender (OR 7.13, 95% CI 2.92-17.39, p<0.001), hypertension (OR 7.82. 95% CI 2.53-24.19, p<0.001), lowered HDL cholesterol (OR 8.20, 95% CI 2.41-27.94, p=0.001), elevated C-reactive protein (OR 5.26, 95% CI 1.92-14.41) and IL-6 -174 GC (OR 2.44 95% CI 1.01-5.91, p=0.0048) genotype. Males, compared to females, had 7 times higher odds for stroke. IL6 -174G/C genotype increased the odds for IS for 2.4 times. PPARγ was not statistically significantly associated with stroke.

CONCLUSION

We can point to the IL-6 -174G>C polymorphisms as candidate gene marker and risk factor for the prediction of ischemic stroke.

Gender-related protection from or vulnerability to severe CNS diseases: gonado-structural and/or gonado-activational? A meta-analysis of relevant epidemiological studies

BACKGROUND

A vast scientific literature has dealt with gender-specific risk for brain disorder. That field is evolving toward a consensus to the effect that the estrogen hormone family is outstandingly and uniquely neuroprotective. However, the epidemiology relevant to this general outlook remains piecemeal.

METHOD

The present investigation strategically formats the relevant epidemiological findings around the world in order to quantitatively meta-analyze gender ratio of risk for a variety of relevant severe central nervous system (CNS) diseases at all three gonadal stages of the life cycle, pre pubertal, post adolescent/pre menopausal, and post menopausal.

RESULTS

The data quantitatively establish that (1) no single epidemiological study should be cited as evidence of gender-specific neuroprotection against the most common severe CNS diseases because the gender-specific risk ratios are contradictory from one study to the other; (2) risk for severe CNS disease is indeed significantly gender-specific, but either gender can be protected: it depends on the disease, not at all on the age bracket.

CONCLUSION

Our assay of gender-specific risk for severe brain disease around the world has not been able to support the idea according to which any one gender-prevalent gonadal steroid hormone dominates as a neuroprotective agent at natural concentrations.