Brachial-ankle pulse wave velocity for predicting functional outcomes in patients with cryptogenic stroke

Aortic stiffness: an age-related prognostic marker?

Aortic stiffness, a consequence of vascular aging, is an independent predictor of cardiovascular morbidity and mortality. However, the impact of age and sex on its predictive performance remains unclear. We have included 6046 individuals from the population-based Rotterdam study. Survival analyses were performed to investigate the impact of age and sex on the link between aortic stiffness and outcomes, including coronary heart disease (CHD), stroke, cardiovascular disease (CVD), cardiovascular and all-cause mortality. The added predictive value of aortic stiffness across age categories and by sex was assessed by using explained variation, Harrell's C index and Integrated Discrimination Improvement (IDI). Aortic stiffness was independently associated with all outcomes [hazard ratio (95% confidence interval; CI): 1.16 (1.04-1.22) for CHD, 1.09 (1.00-1.19) for stroke, 1.11 (1.05-1.18) for CVD, 1.14 (1.05-1.23) for cardiovascular mortality, 1.08 (1.03-1.13) for all-cause mortality]. The strength of the association between aortic stiffness and stroke, cardiovascular and all-cause mortality decreased significantly by advancing age. The variance of the outcome (R2) explained by aortic stiffness alone was noticeable in individuals younger than 60 years and negligible in the other age categories. The association of aortic stiffness and CHD was stronger in women than in men. Similarly, the difference in R2 between women and men was greater for CHD than for the other considered outcomes. Our findings suggest that the gain in explained variation caused by aortic stiffness for CVD and mortality might be limited to individuals younger than 60 years.

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

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

Prognostic value of central blood pressure on the outcomes of embolic stroke of undetermined source

We investigated the prognostic impact of central blood pressure (BP) on outcomes in patients with embolic stroke of undetermined source (ESUS). The prognostic value of central BP according to ESUS subtype was also evaluated. We recruited patients with ESUS and data on their central BP parameters (central systolic BP [SBP], central diastolic BP [DBP], central pulse pressure [PP], augmentation pressure [AP], and augmentation index [AIx]) during admission. ESUS subtype classification was arteriogenic embolism, minor cardioembolism, two or more causes, and no cause. Major adverse cardiovascular event (MACE) was defined as recurrent stroke, acute coronary syndrome, hospitalization for heart failure, or death. Over a median of 45.8 months, 746 patients with ESUS were enrolled and followed up. Patients had a mean age of 62.8 years, and 62.2% were male. Multivariable Cox regression analysis showed that central SBP and PP were associated with MACE. All-cause mortality was independently associated with AIx. In patients with no cause ESUS, central SBP and PP, AP, and AIx were independently associated with MACE. AP and AIx were independently associated with all-cause mortality (all p < 0.05). We demonstrated that central BP can predict poor long-term prognosis in patients with ESUS, especially those with the no cause ESUS subtype.

The role of non-stenosing carotid artery plaques in embolic stroke of undetermined source, is it a silent offender? A review of literature

PURPOSE

Atherosclerotic cervical internal carotid artery disease is one of the major causes of ischemic stroke and transient ischemic attacks. The risk of stroke from mild to moderate stenoses (i.e. <50% stenosis) might be underestimated. There is increasing evidence that plaque morphological features reflect plaque instability that may harbor high risk for embolization. In this narrative review, we will review the literature on plaque features that predict vulnerability beyond the degree of stenosis, discuss the clinical association with stroke, and evaluate the evidence that these lesions serve as a source for embolic stroke of unknown source (ESUS).

METHODS

We performed a literature search using PubMed, EMBASE, and Web of Science. The terms "embolic stroke of undetermined source" and "plaque morphology" were used either alone or in combination with "non-flow limiting stenosis," "non-stenosing plaques," "high-risk plaque features" or "internal carotid artery plaque." Data on plaque morphology and ESUS were mainly taken from review articles, observational studies including retrospective cohort and cross-sectional studies, meta-analyses, and systematic reviews.

CONCLUSION

Nonstenosing carotid artery plaques with high-risk features carry a remarkable risk for stroke occurrence and randomized clinical trials are warranted for further evaluation of using carotid artery stenting or carotid endarterectomy to mitigate the risk of stroke.

Impact of interankle blood pressure difference on major adverse cardiovascular events in cryptogenic stroke patients without peripheral artery disease: a retrospective cohort study

OBJECTIVE

We investigated whether interankle blood pressure difference (IAND) can predict major adverse cardiovascular events (MACEs) in patients with cryptogenic stroke (CS) without peripheral artery disease (PAD).

DESIGN

A retrospective cohort study.

SETTING

Retrospective medical record data of patients with first-ever acute cerebral infarction who were admitted between 1 January 2007 and 31 July 2013.

PARTICIPANTS

CS patients admitted within 7 days of symptom onset were included.

OUTCOME MEASURES

MACEs were defined as stroke recurrence, myocardial infarction occurrence, or death. Survival analyses were conducted using the Kaplan-Meier method and Cox regression analysis.

METHODS

Consecutive CS patients without PAD who underwent ankle-brachial index (ABI) measurements were enrolled. PAD was defined if a patient had an ABI of <0.90 or a history of angiographically confirmed PAD. Systolic and diastolic IANDs were calculated as follows: right ankle blood pressure-left ankle blood pressure.

RESULTS

A total of 612 patients were enrolled and followed up for a median 2.6 (interquartile range, 1.0-4.3) years. In the Cox regression analysis, systolic and diastolic IANDs ≥15 mm Hg were independently associated with MACEs in CS patients without PAD (hazard ratio (HR) 2.115, 95% confidence interval (CI) 1.230 to 3.635 and HR 2.523, 95% CI 1.086 to 5.863, respectively). In the subgroup analysis, systolic IAND ≥15 mm Hg was independently associated with MACEs in older patients (age ≥65 years) (HR 2.242, 95% CI 1.170 to 4.298) but not in younger patients (age <65 years).

CONCLUSIONS

Large IAND is independently associated with the long-term occurrence of MACEs in patients with CS without PAD. In particular, the association between IAND and MACEs is only valid in elderly patients.

Low Toe-Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle-Brachial Index

Introduction: We investigated whether the toe-brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle-brachial index (ABI). Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4. Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7-54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial-ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114-0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095-0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135-2.400], all-cause mortality (HR 2.105, 95% CI 1.343-3.298), and MACE (HR 1.838, 95% CI 1.396-2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080-2.618), all-cause mortality (HR 2.075, 95% CI 1.180-3.651), and MACE (HR 1.619, 95% CI 1.149-2.281) in patients with normal ABI. Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

Mediation effect of arterial stiffness on ideal cardiovascular health and stroke

BACKGROUND AND AIMS

Ideal cardiovascular health (CVH) metrics was associated with stroke, but the causal pathway was poorly investigated. Arterial stiffness was a major factor associated with both ideal CVH metrics and stroke. This study aimed to investigate whether the effect of ideal CVH metrics on stroke was mediated and enhanced by arterial stiffness.

METHODS AND RESULTS

A total of 15,297 participants were included in current study. Arterial stiffness was measured by brachial-ankle pulse wave velocity (baPWV). Causal mediation analyses were used to separate the overall effects of ideal CVH metrics on stroke into indirect effects (mediated by arterial stiffness) and direct effects (mediated through pathways other than arterial stiffness). After a median follow-up of 5.88 years, 324 total stroke events (292 ischemic stroke and 31 hemorrhagic stroke) occurred. Mediation analysis showed 23.94% of the relation between ideal CVH and total stroke was mediated by baPWV (95% confidence interval [CI] of the indirect effect: 0.93-0.95). Further analysis showed the ideal CVH < median combined with baPWV ≥1400 cm/s was associated with the highest risk of total stroke (hazard ratio: 5.62; 95% CI, 3.53-8.96), compared with CVH ≥ median combined with baPWV < 1400 cm/s. Similar results were observed for ischemic stroke, but not for hemorrhagic stroke.

CONCLUSIONS

Arterial stiffness played a mediating role in the associations between ideal CVH metrics and risk of total and ischemic stroke. Combined ideal CVH metrics and baPWV is a reasonable and useful tool for the assessment and prevention of stroke.

Effect of Brachial-Ankle Pulse Wave Velocity Combined with Waist-to-Hip Ratio on Cardiac and Cerebrovascular Events

BACKGROUND

Abdominal obesity and brachial-ankle pulse wave velocity (baPWV) are indicators of atherosclerosis. But few studies have shown the relationship between baPWV combined with waist-hip ratio (WHR) and cardiac-cerebrovascular events (CCVEs).

METHODS

A total of 18944 subjects from Kailuan study were enrolled in this study. Follow-up was conducted three times over 4.82±1.92 years. All the participants were divided into 4 groups according to baPWV and WHR status on baseline: Q1 (normal baPWV, normal WHR), Q2 (normal baPWV, increased WHR), Q3 (increased baPWV, normal WHR) and Q4 (increased baPWV, increased WHR). The incidence and risk factors and further analysis of hypertension subgroups were analyzed.

RESULTS

During follow-up, 88 myocardial infarctions (MI), 278 cerebral ischemic strokes (CI), 285 strokes and 371 CCVEs occurred, with the cumulative incidence of 0.46%, 1.47%, 1.50%, and 1.96%, respectively. Multivariate Cox regression analysis revealed the risk of CI, stroke and CCVEs was higher in patients with increased baPWV and increased WHR than in the other three groups, followed by the Q3 group (increased baPWV, normal WHR) and Q2 group (normal baPWV, increased WHR) group (all adjusted P<0.01). Further hypertension subgroups analysis showed similar results, but differences were more significant among hypertensive patients. Accordingly, the combination of baPWV and WHR increased the risk of total CCVEs, especially in hypertensive patients.

CONCLUSIONS

BaPWV and WHR were important risk factors for CCVEs and had synergistic effects. When baPWV increased, WHR may contribute more to the risk of CCVEs in hypertensive patients.

Association of Brachial Ankle Pulse Wave Velocity With New Onset Stroke in Hypertensive Patients Aged Less Than 65 With Normal Fasting Glucose Among Chinese Community-Based Population

BACKGROUND

Previous studies have shown an association of stroke and brachial ankle pulse wave velocity (baPWV). However, due to limitations on total population size and small numbers of stroke cases, lack of power has prevented further detection among subgroups such as age and laboratory testing.

METHODS

A total of 19217 participants including 660 incident stroke patients were pooled in the present study. Participants were divided to 2 groups, aged less than 65 years [56.0 (50.0, 61.0)] and aged 65 years or more [70.0 (67.0, 74.0)].

RESULTS

After adjustment for demographic, anthropometric, and laboratory parameters, the incident stroke was positively associated to baPWV in the group aged less than 65 years (OR, 1.16; 95% CI, 1.05-1.28), but not in the older group aged 65 or more. When baPWV was assigned as quartiles, a significant, increased risk of new-onset stroke was found in quartiles 3-4 compared with quartile 1. In addition, the predictive value of baPWV for incident stroke was modified by fasting glucose in participants aged less than 65 years (P-interaction = 0.010). An increase in baPWV was strongly, positively associated to new-onset stroke in the subgroup of normal fasting glucose (< 5.6 mmol/L) (OR, 1.34; 95% CI, 1.15 - 1.57), but no effect was seen in the impaired fasting glucose (5.6-7.0 mmol/L) or diabetic fasting glucose (> 7.0 mmol/L) subgroups.

CONCLUSIONS

Increased baPWV was significantly associated with new-onset stroke in a hypertensive population aged less than 65 years. Particularly, it is of great importance to monitor baPWV for predicting incident stroke in "relatively healthy" hypertensive patients, i.e. aged less than 65 years with normal fasting glucose.

Non-stenosing Carotid Atherosclerosis and Arterial Stiffness in Embolic Stroke of Undetermined Source

Background and Purpose: Recent findings suggested that non-stenosing atherosclerosis (NSA) may play an important pathogenic role, especially in cryptogenic strokes. Furthermore, arterial stiffness has been suggested to be a useful tool in identifying patients with embolic stroke of undetermined source (ESUS) with poor neurological prognosis. In this view, the aim of our study was to assess the association between carotid NSA and arterial stiffness in ESUS patients, in order to better define the cardiovascular risk profile of this subgroup of patients.

Methods: We enrolled 100 patients with ESUS (52 males, 48 females) and 48 patients with ischemic stroke from atherosclerosis. All patients underwent clinical and neuroimaging examination. A 24-h heart rate and blood pressure monitoring was performed in order to evaluate systolic, diastolic and mean blood pressure, pulse pressure, and arterial stiffness index (ASI).

Results: NSA was present in 48 patients. In comparison with non-NSA-ESUS, in NSA-ESUS the mean age was higher, neurological deficit was more severe, hypertension, and diabetes were more common; systolic blood pressure, pulse pressure, and ASI were higher. In particular NSA-ESUS had ASI levels similar to strokes due to atherosclerosis.

Conclusions: Our findings shed light on specific cardiovascular risk profiles underlying different subtypes of ESUS, suggesting the presence of increased arterial stiffness in NSA-ESUS patients with a risk factors profile similar to strokes due to atherosclerosis.

State of the Art Review: Brachial-Ankle PWV

The brachial-ankle pulse wave velocity (brachial-ankle PWV), which is measured simply by wrapping pressure cuffs around the four extremities, is a simple marker to assess the stiffness of the medium- to large- sized arteries. The accuracy and reproducibility of its measurement have been confirmed to be acceptable. Risk factors for cardiovascular disease, especially advanced age and high blood pressure, are reported to be associated with an increase of the arterial stiffness. Furthermore, arterial stiffness might be involved in a vicious cycle with the development/progression of hypertension, diabetes mellitus and chronic kidney disease. Increase in the arterial stiffness is thought to contribute to the development of cardiovascular disease via pathophysiological abnormalities induced in the heart, brain, kidney, and also the arteries themselves. A recent independent participant data meta-analysis conducted in Japan demonstrated that the brachial-ankle PWV is a useful marker to predict future cardiovascular events in Japanese subjects without a previous history of cardiovascular disease, independent of the conventional model for the risk assessment. The cutoff point may be 16.0 m/s in individuals with a low risk of cardiovascular disease (CVD), and 18.0 m/s in individuals with a high risk of CVD and subjects with hypertension. In addition, the method of measurement of the brachial-ankle PWV can also be used to calculate the inter-arm systolic blood pressure difference and ankle-brachial pressure index, which are also useful markers for cardiovascular risk assessment.

Predicting Stroke Outcomes Using Ankle-Brachial Index and Inter-Ankle Blood Pressure Difference

Background: This study investigated the association of high ankle-brachial index difference (ABID) and systolic inter-ankle blood pressure difference (IAND) with short- and long-term outcomes in acute ischemic stroke patients without peripheral artery disease (PAD). Methods: Consecutive patients with acute ischemic stroke who underwent ankle-brachial index (ABI) measurement were enrolled. ABID was calculated as |right ABI-left ABI|. IAND and systolic inter-arm blood pressure difference (IAD) were calculated as |right systolic blood pressure – left systolic blood pressure|. Poor functional outcome was defined as modified Rankin Scale score ≥3 at 3 months. Major adverse cardiovascular events (MACEs) were defined as stroke recurrence, myocardial infarction, or death. Results: A total of 2901 patients were enrolled and followed up for a median of 3.1 (interquartile range, 1.6–4.7) years. Among them, 2643 (84.9%) patients did not have PAD. In the logistic regression analysis, ABID ≥ 0.15 and IAND ≥ 15 mmHg were independently associated with poor functional outcome (odds ratio (OR), 1.970, 95% confidence interval (CI), 1.175‒3.302; OR, 1.665, 95% CI, 1.188‒2.334, respectively). In Cox regression analysis, ABID ≥0.15 and IAND ≥ 15 mmHg were independently associated with MACEs (hazard ratio (HR), 1.514, 95% CI, 1.058‒2.166; HR, 1.343, 95% CI, 1.051‒1.716, respectively) and all-cause mortality (HR, 1.524, 95% CI, 1.039‒2.235; HR, 1.516, 95% CI, 1.164‒1.973, respectively) in patients without PAD. Conclusion: High ABID and IAND are associated with poor short-term outcomes, long-term MACE occurrence, and all-cause mortality in acute ischemic stroke without PAD.