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Zhang D, Ma H, Liu C, Li Y. Relationship between morning blood pressure variability and cerebral microbleed burden in patients with hypertension. J Clin Hypertens (Greenwich) 2024; 26:665-673. [PMID: 38775194 PMCID: PMC11180696 DOI: 10.1111/jch.14831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 03/26/2024] [Accepted: 04/26/2024] [Indexed: 06/18/2024]
Abstract
Cerebral microbleeds (CMBs) can be understood as a type of target organ damage caused by hypertension. We aimed to explore the association of the CMB burden with morning blood pressure (BP) variability in patients with hypertension. We divided patients with hypertension into two groups: a group with 1-10 CMBs and a group with more than 10 CMBs. The duration, grade, medication, and control of hypertension were recorded in all patients. Morning home BP measurements were performed every 3 days for a month. A total of 791 patients were recruited. Full factor model analysis showed that higher morning home diastolic BP variability (standard deviation [SD], OR = 1.080, 95% CI: 1.024-1.140, P = .005; coefficient of variation [CV], OR = 1.076, 95% CI: 1.028-1.128, P = .002) was associated with more than 10 CMBs. Morning home systolic and diastolic blood pressure variability (SD, CV, average real variability) in more than 10 non-lobar CMBs group was significantly higher than that in 1-10 non-lobar CMBs group (P < .05).The multivariate analysis showed higher morning home diastolic blood pressure variability (SD, OR = 1.124, 95% CI: 1.031-1.224, P = .008; CV, OR = 1.099, 95% CI: 1.019-1.186, P = .015; average real variability, OR = 1.055, 95% CI: 0.995-1.120, P = .075) was associated with more than 10 non-lobar CMBs. There was no significant relationship between morning home systolic blood pressure variability and more than 10 non-lobar CMBs (P > .05). Higher morning home diastolic blood pressure variability was associated with more than 10 CMBs and more than 10 non-lobar CMBs.
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Affiliation(s)
- Dongsen Zhang
- Department of NeurologyTangshan GongRen HospitalTangshanChina
| | - Hongying Ma
- Department of NeurologyTangshan GongRen HospitalTangshanChina
| | - Chunqin Liu
- Department of NeurologyTangshan GongRen HospitalTangshanChina
| | - Yongqiu Li
- Department of NeurologyTangshan GongRen HospitalTangshanChina
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2
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Liuzzo G, Patrono C. Weekly journal scan: it takes two for acute stroke. Eur Heart J 2024; 45:1781-1782. [PMID: 38568212 DOI: 10.1093/eurheartj/ehae166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Affiliation(s)
- Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Carlo Patrono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
- Center of Excellence on Ageing, CAST, 'G. d'Annunzio' University School of Medicine, Chieti, Italy
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Gao F, Ge S, Cui W, Zhao J, Yang Y, Guo W, Bai H, Wang B, Yang C, Mu S, Wang L, Zhao T, Qu Y, Cai Y. Risk factors for hemorrhage in patients with long-term aspirin therapy undergoing emergency external ventricular drainage/intracranial pressure probe placement. Heliyon 2024; 10:e26854. [PMID: 38463769 PMCID: PMC10920161 DOI: 10.1016/j.heliyon.2024.e26854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024] Open
Abstract
Background Studies have been inconclusive on the risk for hemorrhage in patients with a history of aspirin use who underwent emergency external ventricular drainage (EVD)/intracranial pressure (ICP) probe placement. The aim of this study was to explore hemorrhage-related risk factors in order to reduce the risk for hemorrhage in these patients. Methods Between July 2014 and July 2020, patients were retrospectively divided into EVD/ICP-related hemorrhage and non-hemorrhage groups. The collected data included age, gender, major diagnosis, medical history, imaging examinations, conventional coagulation test data, thromboelastography with platelet mapping (TEG-PM), surgical procedures and discharge conditions. Results In total 94 patients, 21 in the hemorrhage group (15 males, 6 females) and 73 in the non-hemorrhage group (52 males, 21 females) were included. The majority of hemorrhages were recorded in EVD patients (19/21; 90.5%). Platelet AA pathway inhibition rate of ≥75% (sensitivity: 79.45% specificity: 52.38%) (P = 0.014) and SBP ≥125 mmHg (P = 0.006) were significantly related to hemorrhage. When the platelet AA pathway inhibition rate was ≥75% and the during-procedure SBP was ≥125 mmHg, the hemorrhage rate was significantly higher (83.3%) than with SBP <125 mmHg (6.7%) (P < 0.001). When the inhibition rate was <75%, there were no significant differences in the hemorrhage rates between the during-procedure SBP ≥125 mmHg group (17.2%) and the SBP <125 mmHg group (13.2%) (P > 0.05). Multivariate logistic regression analysis revealed that a platelet AA pathway inhibition rate ≥75% (OR = 5.183, 95% CI: 1.683-15.960) and during-procedure SBP ≥125 mmHg (OR = 4.609, 95% CI: 1.466-14.484) were independent risk factors for EVD/ICP-related hemorrhage. Conclusion Patients with long-term aspirin therapy, a platelet AA pathway inhibition rate ≥75% and during-procedure SBP ≥125 mmHg had a significantly higher risk of hemorrhage, which could be reduced by adjusting the SBP to <125 mmHg.
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Affiliation(s)
- Fei Gao
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
- Department of Neurosurgery, The 986 Hospital of PLAAF, Xi'an, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Wenxing Cui
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Jingya Zhao
- Department of Blood Transfusion, Tangdu Hospital, Xi'an, China
| | - Yang Yang
- Department of Emergency, Tangdu Hospital, Xi'an, China
| | - Wei Guo
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Hao Bai
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Bao Wang
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Chen Yang
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Shijie Mu
- Department of Blood Transfusion, Tangdu Hospital, Xi'an, China
| | - Liang Wang
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Yaning Cai
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [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: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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Yamada T, Tanaka E, Kishitani T, Kojima Y, Nakashima D, Kitaoji T, Teramukai S, Nagakane Y. Effects of preceding antiplatelet agents on severity of ischemic stroke in patients with a history of stroke. J Neurol Sci 2024; 456:122857. [PMID: 38154249 DOI: 10.1016/j.jns.2023.122857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Antiplatelet agents are effective for secondary prevention of ischemic stroke and can reduce the severity of first-ever ischemic stroke. However, it is uncertain if prophylactic antiplatelet therapy reduces the severity of recurrent ischemic stroke. The aim of this study was to determine the effect of preceding antiplatelet treatment on the severity of thrombotic stroke (TS) in patients with a prior history of stroke. METHODS From a prospective hospital registry of 1338 consecutive patients with acute ischemic stroke, we identified patients with a prior history of stroke who were admitted for cardioembolic stroke (CE); TS including large-artery atherosclerosis, small vessel occlusion, and branch atheromatous disease; or other cause or cryptogenic stroke (OCS). Cases in each subtype were categorized based on preceding medication: antiplatelet agents (AP) and none (N). Severity of stroke (National Institutes of Health Stroke Scale: NIHSS) on admission was compared between AP and N cases. RESULTS The total cohort of 252 patients included 83 with CE, 102 with TS, and 67 with OCS. After excluding those with prior anticoagulants, the median NIHSS on admission was lower in AP cases than in N cases (3 vs. 5, p = 0.002). In multivariate analysis, preceding AP treatment was independently associated with minor stroke (NIHSS ≤4) on admission in CE group (OR 8.48, 95% CI 1.71-62.9, p = 0.008) and TS group (OR 4.24, 95% CI 1.44-13.4, p = 0.009). CONCLUSION Preceding antiplatelet treatment in patients with a prior history of stroke may reduce the severity of subsequent thrombotic and cardiogenic stroke.
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Affiliation(s)
- Takehiro Yamada
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan.
| | - Eijirou Tanaka
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Toru Kishitani
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Yuta Kojima
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Daisuke Nakashima
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Takamasa Kitaoji
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Yoshinari Nagakane
- Department of Neurology, Kyoto Second Red Cross Hospital, 355-5 Haruobi-cho, Kamigyo-ku, Kyoto 602-8026, Japan
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6
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Kim AS. Extending Dual Antiplatelet Therapy for TIA or Stroke. N Engl J Med 2023; 389:2478-2479. [PMID: 38157504 DOI: 10.1056/nejme2311961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Anthony S Kim
- From the UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco
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Yoon H, Park C. Effectiveness of Proprioceptive Body Vibration Rehabilitation on Motor Function and Activities of Daily Living in Stroke Patients with Impaired Sensory Function. Healthcare (Basel) 2023; 12:35. [PMID: 38200941 PMCID: PMC10779045 DOI: 10.3390/healthcare12010035] [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: 11/18/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024] Open
Abstract
Stroke patients experience impaired sensory and motor functions, which impact their activities of daily living (ADL). The current study was designed to determine the best neurorehabilitation method to improve clinical outcomes, including the trunk-impairment scale (TIS), Berg balance scale (BBS), Fugl-Meyer assessment (FMA), and modified Barthel index (MBI), in stroke patients with impaired sensory function. Forty-four stroke survivors consistently underwent proprioceptive body vibration rehabilitation training (PBVT) or conventional physical therapy (CPT) for 30 min/session, 5 days a week for 8 weeks. Four clinical outcome variables-the FMA, TIS, BBS, and MBI-were examined pre- and post-intervention. We observed significant differences in the FMA, BBS, and MBI scores between the PBVT and CPT groups. PBVT and CPT showed significant improvements in FMA, BBS, TIS, and MBI scores. However, PVBT elicited more favorable results than CPT in patients with stroke and impaired sensory function. Collectively, this study provides the first clinical evidence of optimal neurorehabilitation in stroke patients with impaired sensory function.
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Affiliation(s)
- Hyunsik Yoon
- Chungnam National University Hospital, Daejeon 35015, Republic of Korea;
- Department of Physical Therapy, Yonsei University, Wonju 26493, Republic of Korea
| | - Chanhee Park
- Department of Physical Therapy, Yonsei University, Wonju 26493, Republic of Korea
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8
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Brorson JR, Giurcanu M, Prabhakaran S, Johnston SC. Vulnerable and Stabilized States After Cerebral Ischemic Events: Implications of Kinetic Modeling in the SOCRATES, POINT, and THALES Trials. Neurology 2023; 101:e2205-e2214. [PMID: 37857494 PMCID: PMC10727217 DOI: 10.1212/wnl.0000000000207904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/15/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Trials of acute secondary prevention after minor stroke or transient ischemic attack (TIA), such as SOCRATES, POINT, and THALES, demonstrate a high initial rate of recurrence after ischemic events that drop quickly to a lower rate, suggesting a transient vulnerable clinical state, which may call for different treatments than the subsequent stabilized state. A kinetic model incorporating vulnerable and stabilized states provides estimates of the distinct kinetic rates reflecting the temporal features of underlying stroke mechanisms. We aimed to compare these kinetic rates between treatments and across trials, asking whether these features point to common pathophysiologic processes underlying stroke recurrence, and inform the targeting and timing of enhanced antiplatelet therapy in recurrent stroke prevention. METHODS Kaplan-Meier recurrence-free survival curves in the SOCRATES, POINT, and THALES trials were estimated for each treatment group and fitted by nonlinear regression to the 2-state kinetic model, producing estimates of kinetic parameters, with standard errors estimated using the nonparametric bootstrap with repetitive resampling. RESULTS For each trial, the 2-state kinetic model fit the survival curves better than did the null (single-state) kinetic model or the Weibull model (p < 0.05). Recurrence rates in the vulnerable state (k 1 ) were 100-fold higher than in the stabilized state (k 2 ). Transition rates from the vulnerable to stabilized state (k 0 ) were still more rapid. Kinetic parameters were consistent across the trials, without significant differences between the trials. Enhanced antiplatelet regimens produced significant reductions in k 1 (aspirin alone: 0.030 ± 0.004 d-1; active treatment: 0.016 ± 0.003 d-1; p < 0.01) but did not affect k 0 or k 2 , suggesting that active treatment only affected risk in the vulnerable state. Modeling based on these kinetic parameters suggests that most of the benefit of active treatment occurred within 3 days. DISCUSSION Across multiple trials of acute secondary prevention after minor stroke or TIA, recurrence of stroke is well-described by a 2-state kinetic model postulating vulnerable and stabilized states, with similar kinetic parameters across trials. Enhanced antiplatelet regimens only affected the recurrence rates in the vulnerable state, over a brief period. This analysis suggests that 2 distinct states follow acute cerebral ischemic events, subject to differential impact of immediate or delayed therapies.
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Affiliation(s)
- James R Brorson
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX.
| | - Mihai Giurcanu
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
| | - Shyam Prabhakaran
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
| | - S Claiborne Johnston
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
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Nakata H, Shelby T, Wang JC, Bouz GJ, Mayfield CK, Oakes DA, Lieberman JR, Christ AB, Heckmann ND. Postoperative Complications Associated with Non-Steroidal Anti-Inflammatory Combinations Used Status-Post Total Hip and Knee Arthroplasty. J Clin Med 2023; 12:6969. [PMID: 38002584 PMCID: PMC10672686 DOI: 10.3390/jcm12226969] [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: 09/27/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in multimodal pain control following total joint arthroplasty (TJA). However, few studies have assessed the complications associated with the combinations of NSAIDs in this population despite the known risks associated with this class of medications. The Premier Healthcare Database was queried to identify adults who underwent primary total hip or knee arthroplasty from 2005-2014. The following most common inpatient combinations of NSAIDs were chosen for analysis: aspirin + celecoxib (A + C), toradol + aspirin (T + A), toradol + ibuprofen (T + I), celecoxib + ibuprofen (C + I), ibuprofen + aspirin (I + A), and toradol + celecoxib (T + C). Primary outcomes included acute kidney injury (AKI), gastrointestinal bleed, and stroke. Secondary outcomes included periprosthetic joint infection (PJI), deep vein thrombosis, and pulmonary embolism. Univariate and multivariate regression analyses were used to compare differences and address confounds. Overall, 195,833 patients were identified. After controlling for confounds, increased odds of AKI was associated with A + C (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.09-1.34, p < 0.001) and decreased odds was associated with T + A (aOR 0.76, 95% CI: 0.69-0.83, p < 0.001). Increased odds of stroke was associated with A + C (aOR: 1.80, 95% CI: 1.15-2.84, p = 0.011); T + I (aOR 3.48, 95% CI: 1.25-9.73, p = 0.017); and I + A (aOR 4.29, 95% CI: 1.06-17.9, p = 0.046). Increased odds of PJI was associated with C + I (aOR: 10.3, 95% CI: 1.35-78.3, p = 0.024). In the TJA patient population, NSAID pairings should be regarded as distinct entities. Our results suggest that combinations including A + C, T + I, I + A, and C + I should be used cautiously. With this knowledge, providers should consider tailoring NSAID prescriptions appropriately.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Nathanael D. Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA 90033, USA; (H.N.); (T.S.); (J.C.W.); (G.J.B.); (C.K.M.); (D.A.O.); (J.R.L.); (A.B.C.)
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10
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Timpone VM, Reid M, Jensen A, Poisson SN, Callen AL, Costa B, Trivedi PS. Association of Incomplete Neurovascular Imaging After Emergency Department Encounters for Transient Ischemic Attack and Odds of Subsequent Stroke: A National Medicare Analysis. AJR Am J Roentgenol 2023; 221:673-686. [PMID: 37255044 DOI: 10.2214/ajr.23.29352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND. Multisociety guidelines recommend urgent brain and neurovascular imaging for patients with transient ischemic attack (TIA), to identify and treat modifiable stroke risk factors. Prior research suggests that most patients with TIA who present to the emergency department (ED) do not receive prompt neurovascular imaging. OBJECTIVE. The purpose of this study was to evaluate the association between incomplete neurovascular imaging workup during ED encounters for TIA and the odds of subsequent stroke. METHODS. This retrospective study obtained data from the Medicare Standard Analytical Files for calendar years 2016 and 2017; these files contain 100% samples of claims for Medicare beneficiaries. Information was extracted using ICD 10th revision (ICD-10) and CPT codes. Those patients who were discharged from an ED encounter with a TIA diagnosis and who underwent brain CT or brain MRI during or within 2 days of the encounter were identified. Patients were considered to have complete neurovascular imaging if they underwent cross-sectional vascular imaging of both the brain (brain CTA or brain MRA) and neck (neck CTA, neck MRA, or carotid ultrasound) during or within 2 days of the encounter. The association between incomplete neurovascular imaging and a new stroke diagnosis within the subsequent 90 days was tested by multivariable logistic regression analysis. RESULTS. The sample included 111,417 patients (47,370 men, 64,047 women; 26.0% older than 84 years) who had TIA ED encounters. A total of 37.3% of patients (41,592) had an incomplete neurovascular imaging workup. A new stroke diagnosis within 90 days of the TIA ED encounter occurred in 4.4% (3040/69,825) of patients with complete neurovascular imaging versus 7.0% (2898/41,592) of patients with incomplete neurovascular imaging. Incomplete neurovascular imaging was associated with increased likelihood of stroke within 90 days (OR, 1.30 [95% CI, 1.23-1.38]) after adjustment for patient characteristics (age, sex, race and ethnicity, high-risk comorbidities, median county household income) and hospital characteristics (region, rurality, number of beds, major teaching hospital designation). CONCLUSION. TIA ED encounters with incomplete neurovascular imaging were associated with higher odds of subsequent stroke occurring within 90 days. CLINICAL IMPACT. Increased access to urgent neurovascular imaging for patients with TIA may represent a target that could facilitate detection and treatment of modifiable stroke risk factors.
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Affiliation(s)
- Vincent M Timpone
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Margaret Reid
- Department of Health Systems, Management & Policy, Colorado School of Public Health, Aurora, CO
| | - Alexandria Jensen
- Department of Biostatistics & Informatics, Stanford School of Medicine, Palo Alto, CA
| | - Sharon N Poisson
- Department of Neurology, University of Colorado Hospital, Aurora, CO
| | - Andrew L Callen
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Bernardo Costa
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
| | - Premal S Trivedi
- Department of Radiology, University of Colorado Hospital, 12401 E 17th Ave, Aurora, CO 80045
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11
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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Edlmann E, Maripi H, Whitfield P. Systematic review on traumatic intracranial haemorrhage in patients on anti-thrombotic medications; haemorrhage progression, thrombosis, and anti-thrombotic recommencement. Neurosurg Rev 2023; 46:166. [PMID: 37410188 DOI: 10.1007/s10143-023-02075-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/22/2023] [Accepted: 06/20/2023] [Indexed: 07/07/2023]
Abstract
A large number of patients who sustain a traumatic intracranial haemorrhage (tICH) are taking anti-thrombotic (AT) medications at the time of injury. These are stopped acutely, but there is uncertainty about safe timing for recommencement. This review aimed to understand the rate of new/progressive haemorrhage, thrombosis, and death in tICH patients on ATs and the rate and timing of AT recommencement. A systematic review of OVID Medline and EMBASE from 2000 to 2021 including adult patients with tICH on ATs with reported outcomes was performed. A total of 59 observational studies (20,421 patients) were included. Most patients were elderly (mean age 74), suffering falls (78%), and had a mild head injury. The mean new/progressive haemorrhage rate during admission was 26%, mostly diagnosed on routine imaging performed within 72 h of injury, with only 8% clinically significant. Thrombotic events were reported in 17 studies; mean rate of 3% during admission, 4-9% at 30 days and 3-11% at 6 months. AT recommencement rate and timing were only reported in six studies and varied widely, with some studies demonstrating reduced thrombotic events and mortality with earlier AT recommencement. Current data is observational and sparse in relation to haemorrhage, thrombosis, and AT recommencement. There is some suggestion that early recommencement, within 7-14 days, may be beneficial but higher quality studies with more consistent data are urgently required.
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Affiliation(s)
- Ellie Edlmann
- Peninsula Medical School, Faculty of Health, University of Plymouth, PL6 8BX, Plymouth, UK.
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK.
| | - Haritha Maripi
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK
| | - Peter Whitfield
- Department of Neurosurgery, South West Neurosurgical CentreDepartment of Neurosurgery, Southwest Neurosurgical Centre, Derriford Hospital, PL6 8DH, Plymouth, UK
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Cloud GC, Williamson JD, Thao LTP, Tran C, Eaton CB, Wolfe R, Nelson MR, Reid CM, Newman AB, Lockery J, Fitzgerald SM, Murray AM, Shah RC, Woods RL, Donnan GA, McNeil JJ. Low-Dose Aspirin and the Risk of Stroke and Intracerebral Bleeding in Healthy Older People: Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2325803. [PMID: 37494038 PMCID: PMC10372701 DOI: 10.1001/jamanetworkopen.2023.25803] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/31/2023] [Indexed: 07/27/2023] Open
Abstract
Importance Low-dose aspirin has been widely used for primary and secondary prevention of stroke. The balance between potential reduction of ischemic stroke events and increased intracranial bleeding has not been established in older individuals. Objective To establish the risks of ischemic stroke and intracranial bleeding among healthy older people receiving daily low-dose aspirin. Design, Setting, and Participants This secondary analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized, double-blind, placebo-controlled trial of daily low-dose aspirin was conducted among community-dwelling people living in Australia or the US. Participants were older adults free of symptomatic cardiovascular disease. Recruitment took place between 2010 and 2014, and participants were followed up for a median (IQR) of 4.7 (3.6-5.7) years. This analysis was completed from August 2021 to March 2023. Interventions Daily 100-mg enteric-coated aspirin or matching placebo. Main Outcomes and Measures Stroke and stroke etiology were predetermined secondary outcomes and are presented with a focus on prevention of initial stroke or intracranial bleeding event. Outcomes were assessed by review of medical records. Results Among 19 114 older adults (10 782 females [56.4%]; median [IQR] age, 74 [71.6-77.7] years), 9525 individuals received aspirin and 9589 individuals received placebo. Aspirin did not produce a statistically significant reduction in the incidence of ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.71-1.11). However, a statistically significant increase in intracranial bleeding was observed among individuals assigned to aspirin (108 individuals [1.1%]) compared with those receiving placebo (79 individuals [0.8%]; HR, 1.38; 95% CI, 1.03-1.84). This occurred by an increase in a combination of subdural, extradural, and subarachnoid bleeding with aspirin compared with placebo (59 individuals [0.6%] vs 41 individuals [0.4%]; HR, 1.45; 95% CI, 0.98-2.16). Hemorrhagic stroke was recorded in 49 individuals (0.5%) assigned to aspirin compared with 37 individuals (0.4%) in the placebo group (HR, 1.33; 95% CI, 0.87-2.04). Conclusions and Relevance This study found a significant increase in intracranial bleeding with daily low-dose aspirin but no significant reduction of ischemic stroke. These findings may have particular relevance to older individuals prone to developing intracranial bleeding after head trauma. Trial Registration ISRCTN.org Identifier: ISRCTN83772183.
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Affiliation(s)
- Geoffrey C. Cloud
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Jeff D. Williamson
- Sticht Center for Healthy Aging and Alzheimer’s Prevention, Department of Internal Medicine, Section on Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cammie Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Charles B. Eaton
- Center for Primary Care and Prevention, Brown University School of Public Health, Pawtucket, Rhode Island
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark R. Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Christopher M. Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Anne B. Newman
- Department of Epidemiology Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jessica Lockery
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sharyn M. Fitzgerald
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Anne M. Murray
- Department of Medicine, Geriatrics Division, Hennepin HealthCare and Berman Center for Clinical Research, Hennepin HealthCare Research Institute, Minneapolis, Minnesota
| | - Raj C. Shah
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, Illinois
| | - Robyn L. Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
| | - John J. McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Bilski AE, Aparicio HJ, Gutierrez J, de Leeuw FE, Hilkens N. Antiplatelet Therapy or Not for Asymptomatic/Incidental Lacunar Infarction. Stroke 2023; 54:1954-1959. [PMID: 37191009 PMCID: PMC10421561 DOI: 10.1161/strokeaha.122.040444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Amanda E Bilski
- Department of Neurology, New York Presbyterian Hospital/ Columbia University Irving Medical Center
| | - Hugo J. Aparicio
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine
- Boston Medical Center
| | - Jose Gutierrez
- Department of Neurology, New York Presbyterian Hospital/ Columbia University Irving Medical Center
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Nina Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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15
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Iluţ S, Vesa ŞC, Văcăraș V, Mureșanu DF. Predictors of Short-Term Mortality in Patients with Ischemic Stroke. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1142. [PMID: 37374346 DOI: 10.3390/medicina59061142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: The purpose of this study is to investigate the predictive factors for intrahospital mortality in ischemic stroke patients. We will examine the association between a range of clinical and demographic factors and intrahospital mortality, including age, sex, comorbidities, laboratory values, and medication use. Materials and Methods: This retrospective, longitudinal, analytic, observational cohort study included 243 patients over 18 years old with a new ischemic stroke diagnosis who were hospitalized in Cluj-Napoca Emergency County Hospital. Data collected included the patient demographics, baseline characteristics at hospital admission, medication use, carotid artery Doppler ultrasound, as well as cardiology exam, and intrahospital death. Results: Multivariate logistic regression was used to determine which variables were independently associated with intrahospital death. An NIHSS score > 9 (OR-17.4; p < 0.001) and a lesion volume > 22.3 mL (OR-5.8; p = 0.003) were found to be associated with the highest risk of death. In contrast antiplatelet treatment (OR-0.349; p = 0.04) was associated with lower mortality rates. Conclusions: Our study identified a high NIHSS score and large lesion volume as independent risk factors for intrahospital mortality in ischemic stroke patients. Antiplatelet therapy was associated with lower mortality rates. Further studies are needed to explore the potential mechanisms underlying these associations and to develop targeted interventions to improve patient outcomes.
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Affiliation(s)
- Silvina Iluţ
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
| | - Ştefan Cristian Vesa
- Department of Pharmacology, Toxicology and Clinical Pharmacology, "Iuliu Haţieganu" University of Medicine and Pharmacy, 23 Gheorghe Marinescu Street, 400337 Cluj-Napoca, Romania
| | - Vitalie Văcăraș
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
| | - Dafin-Fior Mureșanu
- Department of Neurosciences, "Iuliu Haţieganu" University of Medicine and Pharmacy, 8 Victor Babeş Street, 400012 Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, 37 Mircea Eliade Street, 400364 Cluj-Napoca, Romania
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16
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Pan Y, Meng X, Yuan B, Johnston SC, Li H, Bath PM, Dong Q, Xu A, Jing J, Lin J, Jiang Y, Xie X, Jin A, Suo Y, Yang H, Feng Y, Zhou Y, Liu Q, Li X, Liu B, Zhu H, Zhao J, Huang X, Li H, Xiong Y, Li Z, Wang Y, Zhao X, Liu L, Wang Y. Indobufen versus aspirin in patients with acute ischaemic stroke in China (INSURE): a randomised, double-blind, double-dummy, active control, non-inferiority trial. Lancet Neurol 2023; 22:485-493. [PMID: 37121237 DOI: 10.1016/s1474-4422(23)00113-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 02/26/2023] [Accepted: 03/10/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Aspirin is recommended for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke but can lead to gastrointestinal intolerance and bleeding. Indobufen is used as an alternative antiplatelet agent in some countries, despite an absence of large-scale clinical trials for this indication. We tested the hypothesis that indobufen is non-inferior to aspirin in reducing the risk of new stroke at 90 days in patients with moderate-to-severe ischaemic stroke. METHODS We conducted a randomised, double-blind, double-dummy, active control, non-inferiority trial at 163 tertiary and district general hospitals in China. Eligible participants were aged 18-80 years with acute moderate-to-severe ischaemic stroke (National Institutes of Health Stroke Scale score 4-18). We randomly assigned (1:1) participants within 72 h of the onset of symptoms to receive either indobufen (100 mg tablet twice per day) or aspirin (100 mg tablet once per day) for 90 days. The randomisation sequence was computer generated centrally and stratified by local participating centres. Masked local investigators assigned the random code to patients in ascending order and provided a treatment kit corresponding to the random code. The primary efficacy outcome was new stroke and the primary safety outcome was severe or moderate bleeding, both within 90 days. This primary efficacy outcome was assessed in all randomly assigned and consenting patients and in a per-protocol group (ie, all patients finishing the treatment without major violation of the trial protocol). Safety analyses were done in the safety-analysis population (ie, all patients who received at least one dose of the study drug and had a safety assessment available). We assessed the non-inferiority of indobufen versus aspirin using the one-sided upper limit of the 95% CI of the hazard ratio (HR) with a prespecified non-inferiority margin of 1·25. This trial is registered with ClinicalTrials.gov (NCT03871517). FINDINGS This trial took place between June 2, 2019, and Nov 28, 2021. Of 84 093 patients screened, 5438 patients were randomly assigned to receive either indobufen (n=2715) or aspirin (n=2723), all of whom were included in the primary analyses. Median age was 64·2 years (IQR 56·1-70·6); 1921 (35·3%) were women and 3517 (64·7%) were men. Stroke occurred within 90 days in 213 (7·9%) patients in the indobufen group versus 175 (6·4%) in the aspirin group (HR 1·23, 95% CI 1·01-1·50; pnon-inferiority=0·44). Moderate or severe bleeding occurred in 18 (0·7%) patients in the indobufen group and in 28 (1·0%) in the aspirin group (0·63, 95% CI 0·35 to 1·15; p=0·13). Adverse events within 90 days occurred in 666 (24·5%) patients in the indobufen group and 679 (24·9%) patients in the aspirin group (p=0·73). INTERPRETATION In patients with acute moderate-to-severe ischaemic stroke, indobufen was not non-inferior to aspirin because the upper limit of the 95% CI was greater than 1·25. Furthermore, indobufen seemed to be inferior to aspirin in reducing the risk of recurrent stroke at 90 days because the lower limit of the 95% CI was greater than 1·00. Although moderate or severe bleeding did not differ between groups, these findings do not support the use of indobufen for secondary stroke prevention in patients with moderate-to-severe ischaemic stroke. FUNDING Hangzhou Zhongmei Huadong Pharmaceutical and Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Baoshi Yuan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Anding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aoming Jin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yue Suo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqin Yang
- Department of Neurology, Jiyuan Hospital of Traditional Chinese Medicine, Jiyuan, China
| | - Yefang Feng
- Department of Neurology, The Second People's Hospital of Huludao, Huludao, China
| | - Yanhua Zhou
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Qing Liu
- Department of Neurology, The Second People's Hospital of Guiyang, Guiyang, China
| | - Xueli Li
- Department of Neurology, Liaocheng Hospital, Shandong First Medical University, Liaocheng, China
| | - Bin Liu
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan, China
| | - Hui Zhu
- Department of Neurology, Lequn Branch, The First Hospital of Jilin University, Changchun, China
| | - Jinguo Zhao
- Department of Neurology, Weihai Wendeng District People's Hospital, Weihai, China
| | - Xuerong Huang
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Haitao Li
- Department of Neurology, Qihe County People's Hospital, Dezhou, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
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Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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18
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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Abstract
Cerebral small vessel disease (CSVD) has emerged as a common factor driving age-dependent diseases, including stroke and dementia. CSVD-related dementia will affect a growing fraction of the aging population, requiring improved recognition, understanding, and treatments. This review describes evolving criteria and imaging biomarkers for the diagnosis of CSVD-related dementia. We describe diagnostic challenges, particularly in the context of mixed pathologies and the absence of highly effective biomarkers for CSVD-related dementia. We review evidence regarding CSVD as a risk factor for developing neurodegenerative disease and potential mechanisms by which CSVD leads to progressive brain injury. Finally, we summarize recent studies on the effects of major classes of cardiovascular medicines relevant to CSVD-related cognitive impairment. Although many key questions remain, the increased attention to CSVD has resulted in a sharper vision for what will be needed to meet the upcoming challenges imposed by this disease.
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Affiliation(s)
- Fanny M. Elahi
- Departments of Neurology and Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY
- Neurology Service, VA Bronx Healthcare System, Bronx, NY
| | - Michael M. Wang
- Departments of Neurology and Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI
- Neurology Service, VA Ann Arbor Healthcare System, Ann Arbor, MI
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20
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Hanalioglu D, Oncel I, Hanalioglu S, Cebeci D, Kurt F, Gunes A, Gurkas E. Interplay between carotid artery dissection and thrombophilia leading to ischaemic stroke after minor head trauma in an adolescent: a case report. Paediatr Int Child Health 2023; 43:13-18. [PMID: 37849317 DOI: 10.1080/20469047.2023.2269362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023]
Abstract
Stroke in children is more common than is often realised; there are numerous potential causes, including carotid artery injury resulting from minor head or neck trauma, as well as genetic conditions associated with thrombophilia. A 13-year-old boy suffered an arterial ischaemic stroke (AIS) secondary to dissection of the left internal carotid artery (ICA) after he headed the ball during a game of football. He presented with generalised tonic-clonic seizure, loss of consciousness, right-sided hemiplegia and aphasia. Neuroradiological imaging showed left caudate, putaminal and posterior insular ischaemic infarct secondary to complete occlusion of the left ICA and accompanying partial left middle cerebral artery occlusion. He was treated with anticoagulant and anti-aggregant agents. Rarely, minor head trauma can result in internal carotid artery dissection, thrombus formation and arterial occlusion, leading to arterial ischaemic stroke. Prompt diagnosis and management are crucial to achieve a good neurological outcome.Abbreviations: AIS: arterial ischaemic stroke; ANA: anti-nuclear antibody; APA: anti-phospholipid antibody; APTT: activated partial thromboplastin time; CAD: carotid artery dissection; CCAD: cranio-cervical artery dissection; CRP: C-reactive protein; CT: computed tomography; CTA: computed tomography angiography; dsDNA: double-stranded DNA; ESR: erythrocyte sedimentation rate; ICA: internal carotid artery; LA: lupus anticoagulant; MCA: middle cerebral artery; MRA: magnetic resonance angiography; MRI: magnetic resonance imaging; MTHFR: methylenetetrahydrofolate reductase; PT INR: prothrombin time international normalised ratio.
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Affiliation(s)
- Damla Hanalioglu
- Department of Paediatrics, Division of Paediatric Emergency Medicine, University of Health Sciences, Ankara, Turkey
- Department of Paediatrics, Division of Paediatric Emergency Medicine, Hacettepe University Ihsan Dogramaci Children's Hospital, Ankara, Turkey
| | - Ibrahim Oncel
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
| | - Sahin Hanalioglu
- Department of Neurosurgery, University of Health Sciences, Ankara, Turkey
| | - Dilek Cebeci
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
| | - Funda Kurt
- Department of Paediatrics, Division of Paediatric Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Altan Gunes
- Department of Radiology, University of Health Sciences, Ankara, Turkey
| | - Esra Gurkas
- Department of Paediatrics, Division of Paediatric Neurology, University of Health Sciences, Ankara, Turkey
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Are Factor Xa Inhibitors Efficacious for Ischemic Stroke Prevention in Patients Without Atrial Fibrillation? Evidence From Randomized Clinical Trials. Can J Cardiol 2023; 39:187-197. [PMID: 36179950 DOI: 10.1016/j.cjca.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinical trials provide conflicting evidence regarding oral factor Xa inhibitors for prevention of ischemic stroke in patients without a history of atrial fibrillation (AF). METHODS We performed a critical appraisal of randomized clinical trials that tested oral factor Xa inhibitors in patients without AF that reported ischemic stroke. RESULTS Considering the 11 trials that reported > 10 ischemic strokes during follow-up (97,578 participants, 1195 ischemic strokes), 1 tested apixaban (57 strokes), 1 betrixaban (52 strokes), and 9 rivaroxaban (1086 strokes). In 7 trials with placebo comparisons, numerically fewer ischemic strokes occurred among those assigned factor Xa inhibitors in 7 of 8 randomized comparisons (range of hazard ratios [HRs], 0.89-0.51), including statistically significant reductions in 2 trials that compared rivaroxaban 2.5 mg twice daily vs placebo on a background of aspirin in patients with cardiovascular disease, COMPASS (HR, 0.51; 95% confidence interval [CI], 0.38-0.68) and COMMANDER-HF (HR, 0.64; 95% CI, 0.43-0.95). Compared with aspirin in 4 trials, oral factor Xa inhibitors were associated with fewer ischemic strokes in 2, with statistically significant reduction in 1 (rivaroxaban 5 mg twice daily in COMPASS; HR, 0.69; 95% CI, 0.53-0.90). Major bleeding was increased by oral factor Xa inhibitors in all 7 placebo-controlled trials (HR range, 1.42-4.08), with statistically significant increases reported in 5 trials, and in all 4 aspirin-controlled trials (all statistically significant increases; HR range, 1.52-2.72). CONCLUSIONS Aggregate evidence on the basis of placebo comparisons from randomized trials supports the potential for oral factor Xa inhibitors to reduce ischemic stroke in patients without AF, but major bleeding is increased.
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Yan X, Wang B, Xia P, Lan C, Wang Q, Ge W, Zhou Y, Jiang C. Efficacy and Safety of Anticoagulant Therapy Versus Antiplatelet Therapy in Acute Ischemic Stroke Patients with Atrial Fibrillation. Clin Appl Thromb Hemost 2023; 29:10760296231213070. [PMID: 37956462 PMCID: PMC10644758 DOI: 10.1177/10760296231213070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
The efficacy and safety of anticoagulant therapy in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF) remain uncertain. This study enrolled 431 AIS and AF patients from Nanjing Drum Tower Hospital between January 2019 and December 2021 and followed for 365 days to determine the associations between anticoagulants and clinical outcomes by assessing modified Rankin Scale (mRS) score, recurrent ischemic stroke/systemic embolism (IS/SE), all-cause mortality, intracranial hemorrhage (ICH) and major bleeding. Final analysis included 400 eligible patients and divided them into antiplatelet group (n = 191) and anticoagulant group (n = 209). Anticoagulant therapy was associated with excellent (mRS 0-1; adjusted odds ratio (aOR), 2.63; 95% confidence interval (CI), 1.61-4.30) and favorable functional outcomes (mRS 0-2; aOR, 2.82; 95% CI, 1.69-4.70) and lower risk of all-cause mortality (adjusted hazard ratio (aHR), 0.35; 95% CI, 0.21-0.57), ICH (aHR, 0.45; 95% CI, 0.23-0.87) and major bleeding (aHR, 0.51; 95% CI, 0.28-0.94), without increasing the risk of recurrent IS/SE (aHR, 0.75; 95% CI, 0.45-1.24). In conclusion, anticoagulant therapy may be a more effective and safer option than antiplatelet therapy for AIS patients with AF.
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Affiliation(s)
- Xiaodi Yan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Baoyan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Peng Xia
- Department of Pharmacy, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chen Lan
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Qian Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Yujie Zhou
- Department of Respiratory Critical Care Medicine, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Chenxiao Jiang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
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23
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[Retinal arterial occlusions (RAV) : S2e guidelines of the German Society of Ophthalmology (DOG), the German Retina Society (RG) and the German Professional Association of Ophthalmologists (BVA). Version: 7 October 2022]. DIE OPHTHALMOLOGIE 2023; 120:15-29. [PMID: 36525048 DOI: 10.1007/s00347-022-01780-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 12/23/2022]
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24
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Shirokov EA. [Modern strategies for the management of patients who have suffered ischemic stroke or transient ischemic attack]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:61-67. [PMID: 38148699 DOI: 10.17116/jnevro202312312261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
Modern strategies for secondary prevention of ischemic stroke (IS) are based on long-term use of drugs from three main pharmaceutical groups (antihypertensive, lipid-lowering and antithrombotic drugs). In practical terms, the most difficult thing for a practitioner is the choice of antithrombotic therapy with anticoagulants or antiplatelet agents. Antithrombotic therapy for patients with acute cerebrovascular accidents has changed significantly in recent years. Clinical guidelines mention traditional and new oral anticoagulants, and the family of antiplatelet agents that can be used in clinical practice has expanded. The possibilities of differentiated antithrombotic therapy depending on the pathogenetic subtype of IS have expanded. The concept of early secondary prevention, new in angioneurology, suggests the possibility of more aggressive management of patients using a combination of antithrombotic drugs. In connection with the increase in life expectancy of patients who have suffered a IS, the issues of choosing drugs with good efficacy and a better safety profile have become relevant. The article discusses the practical aspects of managing patients in the acute period of the disease, during the period of early secondary prevention (90 days), if long-term use of basic treatment strategies is necessary (years).
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Affiliation(s)
- E A Shirokov
- Russian New University, Moscow, Russia
- Center for Innovative Medicine, Moscow, Russia
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25
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Marcucci R, Berteotti M, Gragnano F, Galli M, Cavallari I, Renda G, Capranzano P, Santilli F, Capodanno D, Angiolillo DJ, Cirillo P, Calabrò P, Patti G, De Caterina R. Monitoring antiplatelet therapy: where are we now? J Cardiovasc Med (Hagerstown) 2022; 24:e24-e35. [PMID: 36729588 DOI: 10.2459/jcm.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.
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Affiliation(s)
- Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Martina Berteotti
- Department of Clinical and Experimental Medicine, University of Florence, Florence
| | - Felice Gragnano
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Mattia Galli
- Catholic University of the Sacred Heart, Rome.,Maria Cecilia Hospital, GVM Care & Research, Cotignola
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara
| | - Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Francesca Santilli
- Department of Medicine and Aging, and Center for Advanced Studies and Technology (CAST), G. d'Annunzio University Chieti-Pescara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples
| | - Paolo Calabrò
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale 'Sant'Anna e San Sebastiano', Caserta.,Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples
| | - Giuseppe Patti
- Maggiore della Carità Hospital, University of Eastern Piedmont, Novara
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa.,Division of Cardiology, Azienda Ospedaliero-Universitaria Pisana, Pisa.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo-Pescara, Pescara, Italy
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26
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Hu X, Hu Y, Sun X, Li Y, Zhu Y. Effect of aspirin in patients with established asymptomatic carotid atherosclerosis: A systematic review and meta-analysis. Front Pharmacol 2022; 13:1041400. [PMID: 36569309 PMCID: PMC9768439 DOI: 10.3389/fphar.2022.1041400] [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: 09/10/2022] [Accepted: 11/24/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Aspirin is widely used as an antiplatelet agent for secondary prevention in patients with atherosclerotic cardiovascular disease. However, it remains unclear whether aspirin can prevent the progression of carotid atherosclerosis or reduce vascular events and all-cause death. Methods: We performed a meta-analysis of the effect of aspirin in asymptomatic carotid atherosclerotic patients. Electronic databases including Pubmed, EMBase, ISI Web, Medline, Cochrane, and clinicaltrial.gov were searched for relevant randomized controlled trials. A total of five studies (841 individuals, 2,145 person-years) were included in this study. Two reviewers independently performed the study assessment and data extraction. Forest plots were used to assess the efficacy of aspirin. Egger's test was used to evaluate publication bias. Results: Aspirin did not alleviate the progression of carotid intima-media thickness (cIMT) compared with control patients (WMD: -0.05 mm, 95% confidence interval 95%CI: -0.12, 0.03). In subset analysis, aspirin was only associated with regression of cIMT when compared with the empty/placebo group (WMD: -0.10 mm, 95%CI: -0.18, -0.02). In type 2 diabetes mellitus, there were no statistical significance between groups (WMD: 0.10 mm, 95%CI: -0.31, 0.50). For the main vascular events and all-cause death, there were no differences between the aspirin group (RR: 0.73, 95%CI: 0.41, 1.31) and the control group (RR: 0.88, 95%CI: 0.41, 1.90). For outcome events, similar results were observed when patients were classified by different cIMT value (p > 0.05). The risk of gastrointestinal bleeding was similar between participants receiving and not receiving aspirin therapy (RR: 1.04, 95%CI: 0.07, 16.46). Conclusion: In patients with asymptomatic carotid atherosclerosis, low-dose aspirin may slightly alleviate the progression of cIMT, but does not reduce vascular events and all-cause death. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/, identifier PROSPERO.
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Affiliation(s)
- Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yao Hu
- Department of Traditional Chinese Medicine, Xiang He Community Healthcare Center, Chengdu, Sichuan, China
| | - Xiankun Sun
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Ying Li
- Department of Cardiology, West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Ye Zhu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China,*Correspondence: Ye Zhu,
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27
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The Use of Aspirin Increases the Risk of Major Adverse Cardiac and Cerebrovascular Events in Hypertensive Patients with Obstructive Sleep Apnea for the Primary Prevention of Cardiovascular Disease: A Real-World Cohort Study. J Clin Med 2022; 11:jcm11237066. [PMID: 36498638 PMCID: PMC9737230 DOI: 10.3390/jcm11237066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Background: Hypertensive patients with obstructive sleep apnea (OSA) are at high risk for cardiovascular diseases (CVDs), and the utility of aspirin for primary cardiovascular prevention in this population remains uncertain. (2) Methods: In this retrospective cohort study using data from the Urumchi Hypertension Database (UHDATA), hypertensive patients older than 18 years old with a first-time diagnosis of OSA were divided into three groups depending on aspirin history. Major adverse cardiac and cerebrovascular events (MACCE) were the primary outcome. Secondary outcomes included MACCE components, ischemic events, cardiac events, cerebrovascular events, and gastrointestinal bleeding risk. The inverse probability of treatment weighting (IPTW) method was used to balance the confounding factors among the groups, and the Cox proportional hazards model was used to calculate the hazard ratio (HR) and 95% confidence interval (CI). (3) Results: In persistent aspirin users, the risk of MACCE events (HR 2.11, 95%CI 1.23-3.63), ischemic events (HR 2.58, 95%CI 1.42-4.69), cerebrovascular events (HR 2.55, 95%CI 1.44-4.51), and non-fatal cerebral infarction (HR 3.14, 95%CI 1.69-5.84) was significantly elevated. (4) Conclusions: Continuous aspirin use increases the incidence of cardiovascular adverse events in hypertensive patients with OSA receiving aspirin for primary prevention of cardiovascular disease.
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28
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Genetic Association Study and Machine Learning to Investigate Differences in Platelet Reactivity in Patients with Acute Ischemic Stroke Treated with Aspirin. Biomedicines 2022; 10:biomedicines10102564. [PMID: 36289824 PMCID: PMC9599820 DOI: 10.3390/biomedicines10102564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/04/2022] [Accepted: 10/08/2022] [Indexed: 11/17/2022] Open
Abstract
Aspirin resistance (AR) is a pressing problem in current ischemic stroke care. Although the role of genetic variations is widely considered, the data still remain controversial. Our aim was to investigate the contribution of genetic features to laboratory AR measured through platelet aggregation with arachidonic acid (AA) and adenosine diphosphate (ADP) in ischemic stroke patients. A total of 461 patients were enrolled. Platelet aggregation was measured via light transmission aggregometry. Eighteen single-nucleotide polymorphisms (SNPs) in ITGB3, GPIBA, TBXA2R, ITGA2, PLA2G7, HMOX1, PTGS1, PTGS2, ADRA2A, ABCB1 and PEAR1 genes and the intergenic 9p21.3 region were determined using low-density biochips. We found an association of rs1330344 in the PTGS1 gene with AR and AA-induced platelet aggregation. Rs4311994 in ADRA2A gene also affected AA-induced aggregation, and rs4523 in the TBXA2R gene and rs12041331 in the PEAR1 gene influenced ADP-induced aggregation. Furthermore, the effect of rs1062535 in the ITGA2 gene on NIHSS dynamics during 10 days of treatment was found. The best machine learning (ML) model for AR based on clinical and genetic factors was characterized by AUC = 0.665 and F1-score = 0.628. In conclusion, the association study showed that PTGS1, ADRA2A, TBXA2R and PEAR1 polymorphisms may affect laboratory AR. However, the ML model demonstrated the predominant influence of clinical features.
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29
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Diener HC, Rothwell PM. Antithrombotic drugs in secondary stroke prevention: still some way to go. Lancet 2022; 400:974-975. [PMID: 36063822 DOI: 10.1016/s0140-6736(22)01703-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 08/31/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Hans Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Medical Faculty of the University Duisburg-Essen, 45147 Essen, Germany.
| | - Peter M Rothwell
- Department of Neurology, Nuffield Department of Clinical Neurosciences, Oxford, UK; Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford UK
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30
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Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, Mavilakandy A, England TJ, Eveson D, Mistri A, Dawson J, Appleton JP. Antiplatelet treatment for acute secondary prevention of non-cardioembolic minor stroke / transient ischaemic attack: an update for the acute physician. Clin Med (Lond) 2022; 22:449-454. [PMID: 38589066 PMCID: PMC9595021 DOI: 10.7861/clinmed.2021-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
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Affiliation(s)
| | - Zhe Kang Law
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jatinder S Minhas
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | - Thompson G Robinson
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | | | - Timothy J England
- Queen's Medical Centre, Nottingham, UK and Royal Derby Hospital, Derby, UK
| | | | | | - Jesse Dawson
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK and Queen Elizabeth University Hospital, Glasgow, UK
| | - Jason P Appleton
- Queen Elizabeth Hospital, Birmingham, UK and University of Birmingham College of Dental and Medical Sciences, Birmingham, UK
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31
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Dawson J, Béjot Y, Christensen LM, De Marchis GM, Dichgans M, Hagberg G, Heldner MR, Milionis H, Li L, Pezzella FR, Taylor Rowan M, Tiu C, Webb A. European Stroke Organisation (ESO) guideline on pharmacological interventions for long-term secondary prevention after ischaemic stroke or transient ischaemic attack. Eur Stroke J 2022; 7:I-II. [PMID: 36082250 PMCID: PMC9446324 DOI: 10.1177/23969873221100032] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Recurrent stroke affects 9% to 15% of people within 1 year. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations on pharmacological management of blood pressure (BP), diabetes mellitus, lipid levels and antiplatelet therapy for the prevention of recurrent stroke and other important outcomes in people with ischaemic stroke or transient ischaemic attack (TIA). It does not cover interventions for specific causes of stroke, including anticoagulation for cardioembolic stroke, which are addressed in other guidelines. This guideline was developed through ESO standard operating procedures and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified clinical questions, selected outcomes, performed systematic reviews, with meta-analyses where appropriate, and made evidence-based recommendations, with expert consensus statements where evidence was insufficient to support a recommendation. To reduce the long-term risk of recurrent stroke or other important outcomes after ischaemic stroke or TIA, we recommend: BP lowering treatment to a target of <130/80 mmHg, except in subgroups at increased risk of harm; HMGCoA-reductase inhibitors (statins) and targeting a low density lipoprotein level of <1.8 mmol/l (70 mg/dl); avoidance of dual antiplatelet therapy with aspirin and clopidogrel after the first 90 days; to not give direct oral anticoagulant drugs (DOACs) for embolic stroke of undetermined source and to consider pioglitazone in people with diabetes or insulin resistance, after careful consideration of potential risks. In addition to the evidence-based recommendations, all or the majority of working group members supported: out-of-office BP monitoring; use of combination treatment for BP control; consideration of ezetimibe or PCSK9 inhibitors when lipid targets are not achieved; consideration of use of low-dose DOACs in addition to an antiplatelet in selected groups of people with coronary or peripheral artery disease and aiming for an HbA1c level of <53 mmol/mol (7%) in people with diabetes mellitus. These guidelines aim to standardise long-term pharmacological treatment to reduce the burden of recurrent stroke in Europe.
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Affiliation(s)
- Jesse Dawson
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
- Jesse Dawson, Institute of Cardiovascular
and Medical Sciences, College of Medical, Veterinary and Life Sciences,
University of Glasgow, Queen Elizabeth University Hospital, Glasgow G12 9QQ, UK.
| | - Yannick Béjot
- Dijon Stroke Registry, Department of
Neurology, University Hospital of Dijon, Dijon, France
- Pathophysiology and Epidemiology of
Cardio-Cerebrovascular disease (PEC2), University of Burgundy, Dijon, France
| | - Louisa M Christensen
- Dept of Neurology, Copenhagen
University Hospital Bispebjerg, Kobenhavn, Denmark
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research (ISD), University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
| | - Guri Hagberg
- Oslo Stroke Unit, Department of
Neurology, Oslo University Hospital, Ullevål, Norway
- Department of medical research, Bærum
Hospital Vestre Viken Hospital Trust, Drammen, Norway
| | - Mirjam R Heldner
- Stroke Research Center Bern,
Department of Neurology, University and University Hospital Bern, Bern,
Switzerland
| | - Haralampos Milionis
- Department of Internal Medicine,
School of Health Sciences, Faculty of Medicine, University of Ioannina, Ioannina,
Greece
| | - Linxin Li
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical
Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow,
Glasgow, UK
| | - Cristina Tiu
- Department of Clinical Neurosciences,
University of Medicine and Pharmacy ‘Carol Davila’, Bucuresti, Romania
- Department of Neurology, University
Hospital Bucharest, Bucharest, Romania
| | - Alastair Webb
- Wolfson Centre for Prevention of
Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
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32
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Scalia L, Calderone D, Capodanno D. Antiplatelet therapy after acute ischemic stroke or transient ischemic attack. Expert Rev Clin Pharmacol 2022; 15:1027-1038. [DOI: 10.1080/17512433.2022.2118713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
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33
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Mathieu F, Malhotra AK, Ku JC, Zeiler FA, Wilson JR, Pirouzmand F, Scales DC. Pre-Injury Antiplatelet Therapy and Risk of Adverse Outcomes after Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neurotrauma Rep 2022; 3:308-320. [PMID: 36060453 PMCID: PMC9438446 DOI: 10.1089/neur.2022.0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There is an increasing number of trauma patients presenting on pre-injury antiplatelet (AP) agents attributable to an aging population and expanding cardio- or cerebrovascular indications for antithrombotic therapy. The effects of different AP regimens on outcomes after traumatic brain injury (TBI) have yet to be elucidated, despite the implications on patient/family counseling and the potential need for better reversal strategies. The goal of this systematic review and meta-analysis was to assess the impact of different pre-injury AP regimens on outcomes after TBI. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the OVID Medline, Embase, BIOSIS, Scopus, and Cochrane databases were searched from inception to February 2022 using a combination of terms pertaining to TBI and use of AP agents. Baseline demographics and study characteristics as well as outcome data pertaining to intracerebral hematoma (ICH) progression, need for neurosurgical intervention, hospital length of stay, mortality, and functional outcome were extracted. Pooled odds ratios (ORs) and mean differences comparing groups were calculated using random-effects models. Thirteen observational studies, totaling 1244 patients receiving single AP therapy with acetylsalicylic acid or clopidogrel, 413 patients on dual AP therapy, and 3027 non-AP users were included. No randomized controlled trials were identified. There were significant associations between dual AP use and ICH progression (OR, 2.81; 95% confidence interval [CI], 1.19–6.61; I2, 85%; p = 0.02) and need for neurosurgical intervention post-TBI (OR, 1.61; 95% CI, 1.15–2.28; I2, 15%; p = 0.006) compared to non-users, but not between single AP therapy and non-users. There were no associations between AP use and hospital length of stay or mortality after trauma. Pre-injury dual AP use, but not single AP use, is associated with higher rates of ICH progression and neurosurgical intervention post-TBI. However, the overall quality of studies was low, and this association should be further investigated in larger studies.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Address correspondence to: François Mathieu, MD, MPhil, FRCSC, Division of Neurosurgery, Department of Surgery, University of Toronto, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8.
| | - Armaan K. Malhotra
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jerry C. Ku
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Department of Surgery, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Long term survival after a first transient ischaemic attack in England: A retrospective matched cohort study. J Stroke Cerebrovasc Dis 2022; 31:106663. [PMID: 35907306 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106663] [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: 04/20/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Transient ischaemic attacks (TIA) serve as warning signs for future stroke, and the impact of TIA on long term survival is uncertain. We assessed the long-term hazards of all-cause mortality following a first episode of a transient ischaemic attack (TIA). DESIGN Retrospective matched cohort study. METHODS Cohort study using electronic primary health care records from The Health Improvement Network (THIN) database in the United Kingdom. Cases born in or before 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Double-Cox Weibull survival model with a random frailty effect of general practice, while adjusting for different socio-demographic factors, medical therapies, and comorbidities. RESULTS 20,633 cases and 58,634 controls were included. During the study period, 24,176 participants died comprising of 7,745 (37.5%) cases and 16,431(28.0%) controls. In terms of hazards of mortality, cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to their 39-60 years matched controls (HR = 3.04 (2.91 - 3.18)). The HR for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to their same-aged matched controls. Cases aged 39-60 at TIA onset who were prescribed aspirin were associated with reduced HR of 0.93 (0.84 - 1.01), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5, 10 and 15 years respectively, compared to the same aged cases who were not prescribed any antiplatelet. Statistically significant reductions in hazard ratios were observed with aspirin at 10 and 15 years in all age groups. Hazard ratio point estimates for other antiplatelets (dipyridamole or clopidogrel) and dual antiplatelet therapy were very similar to aspirin at 5, 10 and 15 years but with wider confidence intervals that included 1. There was no survival benefit associated with antiplatelet prescription in controls. CONCLUSIONS The overall risk of death was considerably elevated in all age groups after a first-ever TIA event. Aspirin prescription was associated with a reduced risk. These findings support the use of aspirin in secondary prevention for people with a TIA. The results do not support the use of antiplatelet medication in people without TIA.
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Deng Y, Zhang L, Zhang R, Duan J, Huang J, Qiu D. Clinical Features Differ Between Patients With Vertigo Attack Only and Weakness Attack Accompanying Vertigo Before Vertebrobasilar Stroke: A Retrospective Study. Front Neurol 2022; 13:928902. [PMID: 35968280 PMCID: PMC9363826 DOI: 10.3389/fneur.2022.928902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/22/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the different clinical features of patients with vertigo attacks alone and of those with weakness accompanying vertigo attacks before the vertebrobasilar ischemic stroke. Methods In this 4-year retrospective study, we manually screened the medical records of 209 patients, hospitalized with vertigo attack as the main complaint who were finally diagnosed with acute vertebrobasilar ischemic stroke. Patients were divided into two groups according to their symptoms: patients who only experienced vertigo attacks prior to the vertebrobasilar stroke (VO group) and patients who had both vertigo and weakness attacks (VW group) prior to the stroke. Clinical parameters, such as infarction site and volume, relative risk factors, ABCD2 score, and medical intervention, were compared between the two groups. Results The prevalence of hypertension was higher in the Vertigo attacks only (VO) group (42.2 vs. 29.0%, p < 0.05). The total cerebral infarction volume in the VO group was larger than the Vertigo and weakness attacks (VW) group (4.44 vs. 2.12 cm3, p < 0.05). Additionally, the cerebellum was more likely to be affected in the VO group. In contrast, patients in the VW group had higher carotid stenosis (14.2 vs. 27.2%, p < 0.05) and ABCD2 score (2.1 ± 1.2 vs. 3.6 ± 1.5, p = 0.02). The percentage of patients with medullary infarctions also increased in the VW group. Vertigo attack events occurred more frequently in the VW group (median 2.4 vs. 4.3, p < 0.04). We also found that the patients in the VW group were more likely to seek medical intervention after vertigo. Conclusions Clinical parameters, such as infarction location, relative risk factors, and ABCD2 score, differed between patients with vertigo symptoms with or without weakness attacks. These findings highlight the different clinical features of patients with vertigo attack only and those with weakness attacks accompanying vertigo prior to vertebrobasilar ischemic stroke.
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Affiliation(s)
- Yalan Deng
- Department of Oncology, NHC Key Laboratory of Cancer Proteomics, Laboratory of Structural Biology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Lei Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Rongsen Zhang
- Department of Ultrasonography, Second Xiangya Hospital, Central South University, Changsha, China
| | - Jingfeng Duan
- Department of Neurology, Third Hospital of Changsha, Changsha, China
| | - Jiabing Huang
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Jiabing Huang
| | - Dongxu Qiu
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
- Dongxu Qiu
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Mingming L, Peng P, Lichen Z, Shaohua L, Fei Y, Hongtao Z, Shitong L, Yao H, Xihai Z, Jianming C. Predictors of Progression in Intraplaque Hemorrhage Volume in Patients With Carotid Atherosclerosis: A Serial Magnetic Resonance Imaging Study. Front Neurol 2022; 13:815150. [PMID: 35911916 PMCID: PMC9334903 DOI: 10.3389/fneur.2022.815150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeThis study aimed to investigate the arterial disease risk factors for the progression of intraplaque hemorrhage (IPH) in patients with carotid atherosclerosis using serial high-resolution magnetic resonance (MR) imaging.MethodsConsecutive symptomatic patients who had MRI evidence of intraplaque hemorrhage present in the ipsilateral carotid artery with respect to the side of the brain affected by stroke or TIA were recruited in the study. All the patients underwent follow-up MR imaging at least 6 months after baseline. The annual change in IPH and other carotid plaque morphology was calculated, and a tertile method was used to classify the plaques as progressed or not with respect to IPH volume using the software CASCADE. Logistic regression and receiver operating characteristic (ROC) curve were conducted to evaluate the risk factors for the progression of IPH.ResultsA total of thirty-four symptomatic patients (mean age: 67.1 years, standard deviation [SD]: 9.8 years, 27 men) were eligible for the final analysis, and contralateral plaques containing IPH were seen in 11 of these patients (making 45 plaques with IPH in total). During mean 16.6-month (SD: 11.0 months) follow-up, the overall annual change in IPH volume in 45 plaques with IPH was mean −10.9 mm3 (SD: 49.1 mm3). Carotid plaques were significantly more likely to be classified in progressed IPH group if the patient was taking antiplatelet agent at baseline (OR: 9.76; 95%CI: 1.05 to 90.56; p = 0.045), had a baseline history of current or past smoking (OR: 9.28; 95%CI: 1.26 to 68.31; p = 0.029), or had a larger baseline carotid plaque-containing vessel wall volume (OR: 1.36 per 10 mm3; 95%CI: 1.02 to 1.81; p = 0.032) after adjustments for confounding factors. ROC analysis indicated that the combination of these three risk factors in the final model produced good discriminatory value for the progressed IPH group (area under the curve: 0.887).ConclusionsTaking an antiplatelet agent at baseline, a baseline history of current or past smoking and larger baseline carotid plaque-containing vessel wall volume were independently predictive of plaques being in the progressed IPH group. Our findings indicate that awareness and management of such risk factors may reduce the risk of intraplaque hemorrhage progression.
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Affiliation(s)
- Lu Mingming
- Department of Radiology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Peng Peng
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Zhang Lichen
- Department of Radiology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Liu Shaohua
- State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, The Second Medical Center of PLA General Hospital, Institute of Geriatrics, Beijing, China
| | - Yuan Fei
- Department of Radiology, Pingjin Hospital, Characteristic Medical Center of Chinese People's Armed Police Force, Tianjin, China
| | - Zhang Hongtao
- Department of Radiology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Liu Shitong
- Department of Radiology, The Fifth Medical Center of PLA General Hospital, Beijing, China
| | - He Yao
- State Key Laboratory of Kidney Disease, Beijing Key Laboratory of Aging and Geriatrics, The Second Medical Center of PLA General Hospital, Institute of Geriatrics, Beijing, China
- He Yao
| | - Zhao Xihai
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, China
- Zhao Xihai
| | - Cai Jianming
- Department of Radiology, The Fifth Medical Center of PLA General Hospital, Beijing, China
- *Correspondence: Cai Jianming
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Posti JP, Ruuskanen JO, Sipilä JOT, Luoto TM, Rautava P, Kytö V. Effect of Oral Anticoagulation and Adenosine Diphosphate Inhibitor Therapies on Short-term Outcome of Traumatic Brain Injury. Neurology 2022; 99:e1122-e1130. [PMID: 35764401 DOI: 10.1212/wnl.0000000000200834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Usage of oral anticoagulants (OAC) or adenosine diphosphate inhibitors (ADPi) is known to increase the risk of bleeding. We aimed to investigate the impact of OAC and ADPi therapies on short-term outcomes after traumatic brain injury (TBI). METHODS All adult patients hospitalized for TBI in Finland during 2005-2018 were retrospectively studied using a combination of national registries. Usage of pharmacy-purchased OACs and ADPis at the time of TBI was analyzed with the pill-counting method (Social Insurance Institution of Finland). The primary outcome was 30-day case-fatality (Finnish Cause of Death Registry). The secondary outcomes were acute neurosurgical operation (ANO) and admission duration (Finnish Care Register for Health Care). Baseline characteristics were adjusted with multivariable regression including age, sex, comorbidities, skull or facial fracture, OAC/ADPi treatment, initial admission location, and the year of TBI admission. RESULTS The study population included 57,056 persons (mean age 66 years) of whom 0.9% used direct oral anticoagulants (DOAC), 7.1% Vitamin K antagonists (VKA), and 2.3% ADPis. Patients with VKAs had higher case-fatality than patients without OAC (15.4% vs. 7.1%; adjHR 1.35, CI 1.23-1.48; p<0.0001). Case-fatality was lower with DOACs (8.4%) than with VKAs (adjHR 0.62, CI 0.44-0.87; p=0.005) and was not different from patients without OACs (adjHR 0.93, CI 0.69-1.26; p=0.634). VKA usage was associated with higher neurosurgical operation rate compared to non-OAC patients (9.1% vs. 8.3%; adjOR 1.33, CI 1.17-1.52; p<0.0001). There was no difference in operation rate between DOAC and VKA. ADPi was not associated with case-fatality or operation rate in the adjusted analyses. VKAs and DOACs were not associated with longer admission length compared with the non-OAC group, whereas the admissions were longer in the ADPi group compared with the non-ADPi group. CONCLUSION Preinjury use of VKA is associated with increases in short-term mortality and in need for ANOs after TBI. DOACs are associated with lower fatality than VKAs after TBI. ADPis were not independently associated with the outcomes studied. These results point to relative safety of DOACs or ADPis in patients at risk of head trauma and encourage to choose DOACs when oral anticoagulation is required. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that among adults with TBI, mortality was significantly increased in those using VKAs but not in those using DOACs or ADPis.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, Finland
| | - Jori O Ruuskanen
- Neurocenter, Department of Neurology, Turku University Hospital and University of Turku, Finland
| | - Jussi O T Sipilä
- Clinical neurosciences, University of Turku, Turku, Finland; Department of Neurology, Siun sote, North Karelia Central Hospital, Joensuu, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland.,Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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Li D, Ling X, Li X, Wei H, Zhao Z, Li X, Ma N. Association between GNAQ Gene DNA Methylation and Vascular Recurrence in Patients with Acute Ischemic Stroke or Transient Ischemic Attack. Cerebrovasc Dis 2022; 51:712-721. [PMID: 35764070 DOI: 10.1159/000524416] [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: 12/31/2021] [Accepted: 03/09/2022] [Indexed: 01/31/2023] Open
Abstract
PURPOSE We aimed to assess whether the aberrant methylation of GNAQ gene, which may involve in the clopidogrel resistance (CR), was associated with a higher risk of recurrent ischemic events in clopidogrel-treated acute ischemic stroke or transient ischemic attack (TIA) patients. METHODS This is a nested case-control study, 152 clopidogrel-treated acute ischemic stroke or TIA patients that were propensity-matched were included in the final analysis, including 36 patients with vascular recurrence set as cases. Methylation levels of GNAQ gene were identified with MassARRAY EpiTYPER assays. Univariate and multivariate logistic regression analyses were conducted to explore the predictive value of CpG units for recurrent ischemic events within 1 year.Mediation analysis was performed to assess the role of CR in describing the effect of GNAQ methylation on recurrent ischemic events. RESULTS A total of 16 differentially methylated CpG units were identified. Multivariate logistic analysis indicated that the average methylation of CpG 32-39 of GNAQ was associated with a significantly higher risk of ischemic events (p < 0.001). When transformed into dichotomous variables with the receiver operating characteristic curve, hypomethylation (<0.31) of CpG 32-39 of GNAQ significantly increased the risk of vascular recurrence (odds ratio 73.82, 95% confidence interval 20.33-268.01). The mediation effect of CR for recurrent ischemic events was not identified. CONCLUSIONS Hypomethylation of CpG 32-39 of GANQ gene was associated with a higher risk of ischemic events for clopidogrel-treated acute ischemic stroke or TIA patients. Further studies were warranted to explain the possible mechanism.
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Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xi Ling
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoqing Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongtao Wei
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhigang Zhao
- Department of Pharmacy, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Abbott AL. Extra-Cranial Carotid Artery Stenosis: An Objective Analysis of the Available Evidence. Front Neurol 2022; 13:739999. [PMID: 35800089 PMCID: PMC9253595 DOI: 10.3389/fneur.2022.739999] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/24/2022] [Indexed: 12/26/2022] Open
Abstract
Background and Purpose Carotid stenosis is arterial disease narrowing of the origin of the internal carotid artery (main brain artery). Knowing how to best manage this is imperative because it is common in older people and an important cause of stroke. Inappropriately high expectations have grown regarding the value of carotid artery procedures, such as surgery (endarterectomy) and stenting, for lowering the stroke risk associated with carotid stenosis. Meanwhile, the improving and predominant value of medical intervention (lifestyle coaching and medication) continues to be underappreciated. Methods and Results This article aims to be an objective presentation and discussion of the scientific literature critical for decision making when the primary goal is to optimize patient outcome. This compilation follows from many years of author scrutiny to separate fact from fiction. Common sense conclusions are drawn from factual statements backed by original citations. Detailed research methodology is given in cited papers. This article has been written in plain language given the importance of the general public understanding this topic. Issues covered include key terminology and the economic impact of carotid stenosis. There is a summary of the evidence-base regarding the efficacy and safety of procedural and medical (non-invasive) interventions for both asymptomatic and symptomatic patients. Conclusions are drawn with respect to current best management and research priorities. Several "furphies" (misconceptions) are exposed that are commonly used to make carotid stenting and endarterectomy outcomes appear similar. Ongoing randomized trials are mentioned and why they are unlikely to identify a routine practice indication for carotid artery procedures. There is a discussion of relevant worldwide guidelines regarding carotid artery procedures, including how they should be improved. There is an outline of systematic changes that are resulting in better application of the evidence-base. Conclusion The cornerstone of stroke prevention is medical intervention given it is non-invasive and protects against all arterial disease complications in all at risk. The "big" question is, does a carotid artery procedure add patient benefit in the modern era and, if so, for whom?
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Affiliation(s)
- Anne L. Abbott
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Neurology Private Practice, Knox Private Hospital, Wantirna, VIC, Australia
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40
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Phan TG, Clissold B, Ma H. Time to antithrombotic therapy after transient ischaemic attack and ischaemic stroke. Med J Aust 2022; 216:495-497. [DOI: 10.5694/mja2.51532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
| | - Benjamin Clissold
- Monash Health Melbourne VIC
- Stroke and Ageing Research Group Monash University Melbourne VIC
| | - Henry Ma
- Monash Health Melbourne VIC
- Monash University Melbourne VIC
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Pomero F, Galli E, Bellesini M, Maroni L, Squizzato A. P2Y12 inhibitors plus aspirin for acute treatment and secondary prevention in minor stroke and high-risk transient ischemic attack: A systematic review and meta-analysis. Eur J Intern Med 2022; 100:46-55. [PMID: 35331593 DOI: 10.1016/j.ejim.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging. OBJECTIVE This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA. METHODS A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach. RESULTS Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis. CONCLUSIONS Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy
| | - Eleonora Galli
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
| | - Marta Bellesini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Lorenzo Maroni
- Department of General Medicine, Hypertension Dyslipidemia and Cardiovascular Risk Clinic, ASST Valle Olona, Sant'Antonio Abate Hospital, Via Eusebio Pastori, 21013 Gallarate, VA, Italy; Ospedale di Circolo, Via Arnaldo da Brescia 1, 21052 Busto Arsizio, VA, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
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Jourdi G, Marquis-Gravel G, Martin AC, Lordkipanidzé M, Godier A, Gaussem P. Antiplatelet Therapy in Atherothrombotic Diseases: Similarities and Differences Across Guidelines. Front Pharmacol 2022; 13:878416. [PMID: 35571090 PMCID: PMC9092185 DOI: 10.3389/fphar.2022.878416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/29/2022] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet therapy, mainly consisting of aspirin and P2Y12 receptor antagonists, is the cornerstone of the pharmacological treatment and prevention of atherothrombotic diseases. Its use, especially in secondary cardiovascular prevention, has significantly improved patient clinical outcomes in the last decades. Primary safety endpoint (i.e., bleeding complications) remain a major drawback of antiplatelet drugs. National and international societies have published and regularly updated guidelines for antiplatelet therapy aiming to provide clinicians with practical recommendations for a better handling of these drugs in various clinical settings. Many recommendations find common ground between international guidelines, but certain strategies vary across the countries, particularly with regard to the choice of molecules, dosage, and treatment duration. In this review, we detail and discuss the main antiplatelet therapy indications in the light of the different published guidelines and the significant number of recently published clinical trials and meta-analyses and highlight the areas that deserve further investigation in order to improve antiplatelet therapy in patients with atherothrombotic diseases.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Anne-Céline Martin
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service de Cardiologie, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Anne Godier
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Anesthésie Réanimation, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Pascale Gaussem
- Université Paris Cité, INSERM, Innovative Therapies in Haemostasis, Paris, France.,Service d'Hématologie Biologique, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Zhang L, Kamen S, Niles J, Goss J, Heslin ME, Vigilante N, Thau L, Edwards C, Marden KR, Thon JM, Yeager T, Siegler JE. Resident-Driven Dysphagia Screening Protocol for Expedited Antithrombotic Delivery in Acute Ischemic Stroke. Neurohospitalist 2022; 12:467-475. [DOI: 10.1177/19418744221098384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background We implemented a multi-disciplinary process improvement intervention at our Comprehensive Stroke Center with speech/language pathologists to expedite oral medication delivery in stroke patients. Following a failed nursing dysphagia screen, trained neurology physicians screened dysphagia further to approve use of oral medications. We analyzed the safety and efficacy of this intervention. Methods We analyzed retrospectively collected data for hospital course, timing of first screen, first oral medication use, and complications (e.g., aspiration pneumonia) in consecutive ischemic stroke patients (9/2019-07/2021). Patients were included if they passed a dysphagia assessment by physicians (Ph), nurses (RN), or speech/language pathologists (SLP). Arrival-to-dysphagia screen and arrival-to-antithrombotic were assessed using restricted mean survival time (RMST). Results Of the 789 included patients, 673 were passed by RN, 104 by SLP, and 12 by Ph. Compared to patients passed by SLP, those passed by Ph were younger and had less severe deficits ( P < .01 for both). Patients were screened more quickly by Ph than RN or SLP (median 38 vs 182 vs 1330-min post-arrival, P = .0001; 299-min RMST difference vs RN [95%CI 22-575, P = .03]; 470-min RMST difference vs SLP [95%CI 175-765, P = .002]). This translated to faster oral antithrombotic use for Ph-passed patients (138-min RMST difference vs RN [95%CI 59-216]; 332-min RMST difference vs SLP [95%CI 253-411]). No patients passed by Ph experienced aspiration pneumonia (0%). Conclusions We safely conducted a physician-driven dysphagia screening paradigm which led to faster oral antithrombotic delivery without signal of patient harm. Physician availability to complete dysphagia screens in acute stroke patients was a limitation.
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Affiliation(s)
| | | | - Jennifer Niles
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jessica Goss
- Department of Speech and Language Pathology, Cooper University Hospital, Camden, NJ, USA
| | | | | | | | | | - Kyle R. Marden
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Terri Yeager
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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Rothwell PM. 20 years of improvement in stroke care: the rewards from finally funding more research. Lancet Neurol 2022; 21:402-404. [DOI: 10.1016/s1474-4422(22)00138-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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46
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Shao B, Hoover C, Shi H, Kondo Y, Lee RH, Chen J, Shan X, Song J, McDaniel JM, Zhou M, McGee S, Vanhoorelbeke K, Bergmeier W, López JA, George JN, Xia L. Deletion of platelet CLEC-2 decreases GPIbα-mediated integrin αIIbβ3 activation and decreases thrombosis in TTP. Blood 2022; 139:2523-2533. [PMID: 35157766 PMCID: PMC9029097 DOI: 10.1182/blood.2021012896] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/31/2022] [Indexed: 11/20/2022] Open
Abstract
Microvascular thrombosis in patients with thrombotic thrombocytopenic purpura (TTP) is initiated by GPIbα-mediated platelet binding to von Willebrand factor (VWF). Binding of VWF to GPIbα causes activation of the platelet surface integrin αIIbβ3. However, the mechanism of GPIbα-initiated activation of αIIbβ3 and its clinical importance for microvascular thrombosis remain elusive. Deletion of platelet C-type lectin-like receptor 2 (CLEC-2) did not prevent VWF binding to platelets but specifically inhibited platelet aggregation induced by VWF binding in mice. Deletion of platelet CLEC-2 also inhibited αIIbβ3 activation induced by the binding of VWF to GPIbα. Using a mouse model of TTP, which was created by infusion of anti-mouse ADAMTS13 monoclonal antibodies followed by infusion of VWF, we found that deletion of platelet CLEC-2 decreased pulmonary arterial thrombosis and the severity of thrombocytopenia. Importantly, prophylactic oral administration of aspirin, an inhibitor of platelet activation, and therapeutic treatment of the TTP mice with eptifibatide, an integrin αIIbβ3 antagonist, reduced pulmonary arterial thrombosis in the TTP mouse model. Our observations demonstrate that GPIbα-mediated activation of integrin αIIbβ3 plays an important role in the formation of thrombosis in TTP. These observations suggest that prevention of platelet activation with aspirin may reduce the risk for thrombosis in patients with TTP.
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Affiliation(s)
- Bojing Shao
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Christopher Hoover
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Huiping Shi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Yuji Kondo
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Robert H Lee
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Xindi Shan
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Jianhua Song
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - J Michael McDaniel
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Meixiang Zhou
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Samuel McGee
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, Katholieke Universiteit Leuven Campus Kulak Kortrijk, Kortrijk, Belgium; and
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - James N George
- Hematology-Oncology Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Lijun Xia
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Pan Y, Meng X, Chen W, Jing J, Lin J, Jiang Y, Johnston SC, Bath PM, Dong Q, Xu AD, Li H, Wang Y. Indobufen versus aspirin in acute ischaemic stroke (INSURE): rationale and design of a multicentre randomised trial. Stroke Vasc Neurol 2022; 7:457-461. [PMID: 35393360 PMCID: PMC9614137 DOI: 10.1136/svn-2021-001480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/02/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Indobufen can reversibly inhibit platelet aggregation and showed to be effective in the treatment of ischaemic heart and peripheral vascular diseases. However, it is unclear whether indobufen is an alternative antiplatelet agent for treatment of patients with ischaemic stroke. AIM To test whether indobufen is non-inferior to aspirin in reducing the risk of new stroke at 3 months in patients with moderate to severe ischaemic stroke. DESIGN The Indobufen vs Aspirin in Acute Ischaemic Stroke (INSURE) is a randomised, double-blind, double-dummy, positive drug control, non-inferior multicentre clinical trial conducted in 200 hospitals in China. Participants will be randomised at a 1:1 ratio to receive either 100 mg indofufen two times daily or 100 mg aspirin once daily within 72 hours of the onset of symptoms from day 1 to 3 months. STUDY OUTCOMES The primary efficacy outcome is a new stroke (ischaemic or haemorrhagic) within 3 months and the primary safety outcome is a severe or moderate bleeding event within 3 months. DISCUSSION The INSURE trial will evaluate whether indobufen is non-inferior to aspirin in reducing the risk of new stroke at 3 months in patients with moderate to severe ischaemic stroke. TRIAL REGISTRATION NUMBER NCT03871517.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - An-Ding Xu
- Department of Neurology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China.,Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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48
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Low-dose aspirin for the prevention of atherothrombosis across the cardiovascular risk continuum. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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49
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McGurgan IJ, Kelly PJ, Turan TN, Rothwell PM. Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke. Stroke 2022; 53:1085-1103. [PMID: 35291823 DOI: 10.1161/strokeaha.121.035851] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
| | - Peter J Kelly
- Neurovascular Clinical Science Unit, Stroke Service and Department of Neurology, Mater University Hospital, Dublin, Ireland (P.J.K.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
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50
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Hohlfeld T, Twarock S. Thrombozytenfunktionshemmer im Notfall. Notf Rett Med 2022. [DOI: 10.1007/s10049-020-00823-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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