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Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, Jokinen H, Katsanos AH, Ornello R, Pantoni L, Pasi M, Pavlovic AM, Rudilosso S, Schmidt R, Staals J, Taylor-Rowan M, Hussain S, Lindgren AG. European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J 2024; 9:5-68. [PMID: 38380638 PMCID: PMC10916806 DOI: 10.1177/23969873231219416] [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: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/22/2024] Open
Abstract
A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hugues Chabriat
- CNVT and Department of Neurology, Hopital Lariboisière, Paris, France
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Stéphanie Debette
- Bordeaux Population Health Research Center; University of Bordeaux – Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, Edinburgh, UK
| | - Hanna Jokinen
- Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland
| | - Aristeidis H Katsanos
- Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - Raffaele Ornello
- Neurology/Department of Biotechnological ad Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Marco Pasi
- Department of Neurology, University of Tours, Tours, France
| | - Aleksandra M Pavlovic
- University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neurology, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Julie Staals
- Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands
| | - Martin Taylor-Rowan
- School of Health and Wellbeing; General Practice and Primary Care, Clarice Pears Building, University of Glasgow, Glasgow, UK
| | | | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Department of Neurology, Skåne University Hospital, Lund, Skånes Universitetssjukhus, Lund, Sweden
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2
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [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: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- 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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3
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Canonico ME, Piccolo R, Avvedimento M, Leone A, Esposito S, Franzone A, Giugliano G, Gargiulo G, Hess CN, Berkowitz SD, Hsia J, Cirillo P, Esposito G, Bonaca MP. Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions. J Cardiovasc Dev Dis 2023; 10:164. [PMID: 37103043 PMCID: PMC10144744 DOI: 10.3390/jcdd10040164] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023] Open
Abstract
Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.
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Affiliation(s)
- Mario Enrico Canonico
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V0A6, Canada
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Salvatore Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Connie N. Hess
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Scott D. Berkowitz
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Judith Hsia
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marc P. Bonaca
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
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4
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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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6
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Tekle WG, Hassan AE. Intracranial Atherosclerotic Disease: Current Concepts in Medical and Surgical Management. Neurology 2021; 97:S145-S157. [PMID: 34785613 DOI: 10.1212/wnl.0000000000012805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 03/05/2021] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article reviews the current concepts in intracranial atherosclerotic disease (ICAD) as a common etiology of ischemic stroke; pathophysiologic mechanisms of ischemic stroke; diagnostic evaluation; and therapeutic modalities, including maximal medical therapy (MMT), percutaneous transluminal angioplasty and stenting (PTAS), and bypass surgery. RECENT FINDINGS Data from recent studies demonstrate that proper patient selection and timing of procedure and standardized PTAS techniques by experienced operators resulted in acceptably low periprocedural adverse events for patients who failed MMT. SUMMARY ICAD is a common cause of ischemic stroke. Complex pathology and high rates of recurrent and disabling ischemic strokes despite currently available treatments make ICAD the most challenging to treat of all ischemic stroke etiologies. Randomized trials previously showed that MMT, which involves the use of combinations of antiplatelet medications, targeted control of hypertension and serum low-density lipoprotein cholesterol, and adequate management of body weight through lifestyle modification, was superior to PTAS in decreasing rates of recurrent ischemic strokes from symptomatic ICAD. MMT performed better than expected, while periprocedural complications were significantly higher than expected in PTAS. Meanwhile, high rates of recurrent ischemic stroke despite MMT remain a great challenge. New clinical evidence continues to emerge on a safer application of PTAS, which is currently offered to a subset of patients who present with recurrent ischemic strokes despite MMT.
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Affiliation(s)
- Wondwossen G Tekle
- From the University of Texas Rio Grande Valley (W.G.T., A.E.H.), Edinburg; and Valley Baptist Medical Center (W.G.T., A.E.H.), Harlingen, TX.
| | - Ameer E Hassan
- From the University of Texas Rio Grande Valley (W.G.T., A.E.H.), Edinburg; and Valley Baptist Medical Center (W.G.T., A.E.H.), Harlingen, TX
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7
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Hankey GJ. Evolution of Evidence-Based Medicine in Stroke. Cerebrovasc Dis 2021; 50:644-655. [PMID: 34315156 DOI: 10.1159/000517679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
The introduction and evolution of evidence-based stroke medicine has realized major advances in our knowledge about stroke, methods of medical research, and patient outcomes that continue to complement traditional individual patient care. It is humbling to recall the state of knowledge and scientific endeavour of our forebears who were unaware of what we know now and yet pursued the highest standards for evaluating and delivering effective stroke care. The science of stroke medicine has evolved from pathophysiological theory to empirical testing. Progress has been steady, despite inevitable disappointments and cul-de-sacs, and has occasionally been punctuated by sensational breakthroughs, such as the advent of reperfusion therapies guided by imaging.
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Affiliation(s)
- Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Washington, Australia.,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia
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8
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Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
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Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
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9
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AbuRahma AF, Avgerinos ED, Chang RW, Darling RC, Duncan AA, Forbes TL, Malas MB, Perler BA, Powell RJ, Rockman CB, Zhou W. The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease. J Vasc Surg 2021; 75:26S-98S. [PMID: 34153349 DOI: 10.1016/j.jvs.2021.04.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Ali F AbuRahma
- Department of Surgery, West Virginia University-Charleston Division, Charleston, WV.
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh School of Medicine, UPMC Hearrt & Vascular Institute, Pittsburgh, Pa
| | - Robert W Chang
- Vascular Surgery, Permanente Medical Group, San Francisco, Calif
| | | | - Audra A Duncan
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular & Endovascular Surgery, University of Western Ontario, London, Ontario, Canada
| | - Mahmoud B Malas
- Vascular & Endovascular Surgery, University of California San Diego, La Jolla, Calif
| | - Bruce Alan Perler
- Division of Vascular Surgery & Endovascular Therapy, Johns Hopkins, Baltimore, Md
| | | | - Caron B Rockman
- Division of Vascular Surgery, New York University Langone, New York, NY
| | - Wei Zhou
- Division of Vascular Surgery, University of Arizona, Tucson, Ariz
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10
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Danese A, Mugnai G, Prevedello F, Morra M, Bilato C. The role of echocardiography in the embolic stroke of undetermined source. J Cardiovasc Med (Hagerstown) 2021; 21:547-555. [PMID: 32628421 DOI: 10.2459/jcm.0000000000001023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Echocardiography plays an important role both in the diagnosis and the treatment/prevention of embolic stroke of undetermined source and should be performed as soon as possible for preventing ischemic stroke recurrencies, which occur more frequently during the first week after the first ischemic event. Early identification of the cause of a transient ischemic attack or stroke is indeed a primary goal for the neurologist in the Stroke Unit and requires specific diagnostic strategies. Echocardiography, together with other diagnostic tools such as carotid and transcranial ultrasounds, provides this information promptly. In particular, echocardiography might be able to detect the main sources of the embolic stroke, such as atrial fibrillation, ventricular akinesia, aortic atheroma plaques and/or cardiac shunts. The present review discusses the importance and the practical role of echocardiography as a crucial diagnostic tool for detecting the main source of emboli in the setting of the acute stroke.
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Affiliation(s)
| | - Giacomo Mugnai
- Division of Cardiology, West Vicenza General Hospitals, Vicenza, Italy
| | | | | | - Claudio Bilato
- Division of Cardiology, West Vicenza General Hospitals, Vicenza, Italy
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11
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Sagris D, Georgiopoulos G, Leventis I, Pateras K, Pearce LA, Korompoki E, Makaritsis K, Vemmos K, Milionis H, Ntaios G. Antithrombotic treatment in patients with stroke and supracardiac atherosclerosis. Neurology 2020; 95:e499-e507. [PMID: 32631920 DOI: 10.1212/wnl.0000000000009823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/09/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of oral anticoagulants vs antiplatelets in patients with stroke and atherosclerotic plaques in the aortic arch or cervical or intracranial arteries, collectively described as supracardiac atherosclerosis. METHODS We searched PubMed and Scopus until August 28, 2019, for randomized trials comparing oral anticoagulants vs antiplatelets in patients with stroke and supracardiac atherosclerosis using the terms "anticoagulant or anticoagulation" and "antiplatelet or aspirin" and "randomized controlled trial or RCT" and "stroke or cerebral ischemia" and "aortic or carotid or vertebrobasilar or intracranial or atherosclerosis or stenosis or arterial." Four outcomes were assessed: recurrent ischemic stroke, major ischemic event or death, major bleeding, and intracranial bleeding. Treatment effects (relative risk [RR] and 95% confidence interval [CI]) were estimated by meta-analysis using random-effects models. RESULTS Among 1,117 articles identified in the literature search, results from 10 randomized controlled trials involving 6,068 patients with stroke/TIA with supracardiac atherosclerosis were included in the meta-analysis. Recurrent ischemic stroke rates were 2.94 per 100 patient-years in the anticoagulant-assigned patients vs 3.30 per 100 patient-years in the antiplatelet-assigned patients (RR, 0.91; 95% CI, 0.70-1.18 for the SJ estimator, I2 = 26%). Major ischemic event or death rates were 4.39 per 100 patient-years in anticoagulant-assigned patients vs 4.32 in antiplatelet-assigned patients (RR, 1.03; 95% CI, 0.79-1.35; I2 = 54.5%). Major bleeding rates were 2.88 per 100 patient-years in anticoagulant-assigned patients vs 0.82 in antiplatelet-assigned patients (RR, 3.21; 95% CI, 1.96-5.24; I2 = 46%). CONCLUSION This systematic review and meta-analysis showed that anticoagulant-assigned patients with stroke and supracardiac atherosclerosis were not at different risk of ischemic stroke recurrence and increased risk of major bleeding compared to antiplatelet-assigned patients.
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Affiliation(s)
- Dimitrios Sagris
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Georgios Georgiopoulos
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Ioannis Leventis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Pateras
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Lesly A Pearce
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Eleni Korompoki
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Makaritsis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Vemmos
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Haralampos Milionis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - George Ntaios
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece.
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12
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Synthesis and antithrombotic activity of 1-benzyl-N'-benzylidenepiperidine-3-carbohydrazide derivatives. Blood Coagul Fibrinolysis 2020; 31:179-185. [PMID: 32271313 DOI: 10.1097/mbc.0000000000000877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
: Platelet aggregation inhibition and interfering with clot formation are essential tools for antithrombotic therapy and there is a need for discovering new antithrombotic agents. In this study, we synthesized a series of benzylidenepiperidine-3-carbohydrazide derivatives (1f-11f), bearing various selected substituents on both the piperidine ring nitrogen and the hydrazide nitrogen. The synthesized compounds were characterized by FTIR, HNMR spectroscopic techniques, CHN/O elemental analysis and electrospray ionization mass spectra. All new 1-benzyl-N'-benzylidenepiperidine-3-carbohydrazides were evaluated for their antiplatelet aggregation activities (against platelet aggregation induced by AA, ADP and collagen separately) and anticoagulant activities [protrombin time (PT) and partial thromboplastin time (PTT)]. Antiplatelet aggregation activity of the new derivatives was measured using human plasma on an APACT 4004 aggregometer. All the compounds were mainly effective on ADP pathway of platelet aggregation compared with collagen and AA pathways. The most potent compound on platelet aggregation induced by ADP is compound 2f with 87% aggregation inhibition activity at 0.5 mmol/l concentration. The synthesized compounds were further investigated for their anticoagulant action via the two PT and PTT models. They all showed higher PT and PTT values compared with the blank control sample. The most potent compounds are 5f, 6f, 7f and 1f. All compounds were obtained in good yield and further evaluated for their antiplatelet and anticoagulant activity.
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13
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Bertaglia E, Blank B, Blomström-Lundqvist C, Brandes A, Cabanelas N, Dan GA, Dichtl W, Goette A, de Groot JR, Lubinski A, Marijon E, Merkely B, Mont L, Piorkowski C, Sarkozy A, Sulke N, Vardas P, Velchev V, Wichterle D, Kirchhof P. Atrial high-rate episodes: prevalence, stroke risk, implications for management, and clinical gaps in evidence. Europace 2019; 21:1459-1467. [PMID: 31377792 PMCID: PMC6788209 DOI: 10.1093/europace/euz172] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/15/2019] [Indexed: 12/20/2022] Open
Abstract
Self-terminating atrial arrhythmias are commonly detected on continuous rhythm monitoring, e.g. by pacemakers or defibrillators. It is unclear whether the presence of these arrhythmias has therapeutic consequences. We sought to summarize evidence on the prevalence of atrial high-rate episodes (AHREs) and their impact on risk of stroke. We performed a comprehensive, tabulated review of published literature on the prevalence of AHRE. In patients with AHRE, but without atrial fibrillation (AF), we reviewed the stroke risk and the potential risk/benefit of oral anticoagulation. Atrial high-rate episodes are found in 10-30% of AF-free patients. Presence of AHRE slightly increases stroke risk (0.8% to 1%/year) compared with patients without AHRE. Atrial high-rate episode of longer duration (e.g. those >24 h) could be associated with a higher stroke risk. Oral anticoagulation has the potential to reduce stroke risk in patients with AHRE but is associated with a rate of major bleeding of 2%/year. Oral anticoagulation is not effective in patients with heart failure or survivors of a stroke without AF. It remains unclear whether anticoagulation is effective and safe in patients with AHRE. Atrial high-rate episodes are common and confer a slight increase in stroke risk. There is true equipoise on the best way to reduce stroke risk in patients with AHRE. Two ongoing trials (NOAH-AFNET 6 and ARTESiA) will provide much-needed information on the effectiveness and safety of oral anticoagulation using non-vitamin K antagonist oral anticoagulants in patients with AHRE.
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Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Vascular and Thoracic Sciences, Azienda Ospedaliera, Padua, Italy
| | | | | | - Axel Brandes
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Nuno Cabanelas
- Arrhythmias Unit of Cardiology Department, Hospital Prof. Dr. Fernando Fonseca, Amadora-Sintra, Portugal
| | - G -Andrei Dan
- Colentina University Hospital, Medicine University “Carol Davila”, Bucharest, Romania
| | - Wolfgang Dichtl
- University Hospital of Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- St. Vincenz Hospital Paderborn, Cardiology and Intensive Care Medicine, Paderborn, Germany
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrzej Lubinski
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University Budapest, Budapest, Hungary
| | - Lluis Mont
- Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Catalonia, Spain
| | | | | | - Neil Sulke
- Eastbourne District General Hospital, Eastbourne, UK
| | - Panos Vardas
- Heart Sector, Hygeia Group Hospitals, Athens, Greece
| | - Vasil Velchev
- Cardiology Clinic, St. Anna University Hospital, Medical University Sofia, Sofia, Bulgaria
| | - Dan Wichterle
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Paulus Kirchhof
- Atrial Fibrillation NETwork (AFNET), Muenster, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals NHS Trusts, IBR 126a, Wolfson Drive, Birmingham B15 2TT, UK
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14
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Köhrmann M, Kleinschnitz C. [Update on antithrombotic secondary prevention of ischemic stroke]. DER NERVENARZT 2019; 90:995-1004. [PMID: 31560112 DOI: 10.1007/s00115-019-00788-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Over the past decade innovations regarding antithrombotic treatment for secondary stroke prevention have been particularly dominated by the non-vitamin K dependent anticoagulants in patients with cardioembolic stroke; however, several studies investigating other important aspects have also recently been published. This update focuses on new trials on intensified antiplatelet therapy in the early phase of (mild) stroke and transient ischemic attacks (TIA) as well as studies on secondary prevention in patients with embolic stroke of undetermined source (ESUS). Data from these studies are critically reviewed to demonstrate strategies for clinical implementation.
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Affiliation(s)
- Martin Köhrmann
- Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Christoph Kleinschnitz
- Klinik für Neurologie, Universitätsklinikum Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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15
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Ntaios G, Swaminathan B, Berkowitz SD, Gagliardi RJ, Lang W, Siegler JE, Lavados P, Mundl H, Bornstein N, Meseguer E, Amarenco P, Cucchiara B, Camps-Renom P, Makaritsis K, Korompoki E, Papavasileiou V, Marti-Fabregas J, Milionis H, Vemmos K, Connolly SJ, Hart RG. Efficacy and Safety of Rivaroxaban Versus Aspirin in Embolic Stroke of Undetermined Source and Carotid Atherosclerosis. Stroke 2019; 50:2477-2485. [DOI: 10.1161/strokeaha.119.025168] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The sources of emboli in patients with embolic stroke of undetermined source (ESUS) are multiple and may not respond uniformly to anticoagulation. In this exploratory subgroup analysis of patients with carotid atherosclerosis in the NAVIGATE (New Approach Rivaroxaban Inhibition of Factor Xa in a Global Trial Versus ASA to Prevent Embolism)-ESUS trial, we assessed whether the treatment effect in this subgroup is consistent with the overall trial population and investigated the association of carotid atherosclerosis with recurrent ischemic stroke.
Methods—
Carotid atherosclerosis was analyzed either as the presence of mild (ie, 20%–49%) atherosclerotic stenosis or, separately, as the presence of carotid plaque. Primary efficacy outcome was ischemic stroke recurrence. Safety outcomes were major bleeding and symptomatic intracerebral bleeding.
Results—
Carotid plaque was present in 40% of participants and mild carotid stenosis in 11%. There was no significant difference in ischemic stroke recurrence between rivaroxaban- and aspirin-treated patients among 490 patients with carotid stenosis (5.0 versus 5.9/100 patient-years, respectively, hazard ratio [HR], 0.85; 95% CI, 0.39–1.87;
P
for interaction of treatment effect with patients without carotid stenosis 0.78) and among 2905 patients with carotid plaques (5.9 versus 4.9/100 patient-years, respectively, HR, 1.20; 95% CI, 0.86–1.68;
P
for interaction of treatment effect with patients without carotid stenosis 0.2). Among patients with carotid plaque, major bleeding was more frequent in rivaroxaban-treated patients compared with aspirin-treated (2.0 versus 0.5/100 patient-years, HR, 3.75; 95% CI, 1.63–8.65). Patients with carotid stenosis had similar rate of ischemic stroke recurrence compared with those without (5.4 versus 4.9/100 patient-years, respectively, HR, 1.11; 95% CI, 0.73–1.69), but there was a strong trend of higher rate of ischemic stroke recurrence in patients with carotid plaque compared with those without (5.4 versus 4.3/100 patient-years, respectively, HR, 1.23; 95% CI, 0.99–1.54).
Conclusions—
In ESUS patients with carotid atherosclerosis, we found no difference in efficacy between rivaroxaban and aspirin for prevention of recurrent stroke, but aspirin was safer, consistent with the overall trial results. Carotid plaque was much more often present ipsilateral to the qualifying ischemic stroke than contralateral, supporting an important etiological role of nonstenotic carotid disease in ESUS.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02313909.
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Affiliation(s)
- George Ntaios
- From the Department of Internal Medicine, University of Thessaly, Larissa, Greece (G.N., K.M.)
| | | | - Scott D. Berkowitz
- Bayer US LLC, Pharmaceuticals Clinical Development Thrombosis, NJ (S.D.B.)
| | | | - Wilfried Lang
- Hospital St John of God, Sigmund Freud Private University, Medical Faculty, Vienna, Austria (W.L.)
| | - James E. Siegler
- Department of Neurology, Hospital of the University of Pennsylvania (J.E.S., B.C.)
| | | | | | | | - Elena Meseguer
- Neurology Service, Bichat Hospital, Paris, France (E.M.)
| | - Pierre Amarenco
- APHP, Bichat hospital, Paris-Diderot, Sorbonne Paris Cité university, France (P.A.)
| | - Brett Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania (J.E.S., B.C.)
| | - Pol Camps-Renom
- Unitat de Malalties Vasculars Cerebrals, Servei de Neurologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (P.C.-R., J.M.-R.)
| | - Konstantinos Makaritsis
- From the Department of Internal Medicine, University of Thessaly, Larissa, Greece (G.N., K.M.)
| | - Eleni Korompoki
- Division of Brain Science, Imperial College London, Charing Cross Hospital, United Kingdom (E.K.)
- Department of Clinical Therapeutics, University Athens School of Medicine, Greece (E.K.)
| | - Vasileios Papavasileiou
- Stroke Medicine, Leeds Teaching Hospitals NHS Trust, School of Medicine, University of Leeds, West Yorkshire, United Kingdom (V.P.)
| | - Joan Marti-Fabregas
- Unitat de Malalties Vasculars Cerebrals, Servei de Neurologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (P.C.-R., J.M.-R.)
| | - Haralampos Milionis
- School of Health Sciences, Faculty of Medicine University of Ioannina, Greece (H.M.)
| | | | - Stuart J. Connolly
- Department of Medicine, (Cardiology) Population Health Research Institute, McMaster University, Hamilton, ON, Canada. (S.J.C.)
| | - Robert G. Hart
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University, Hamilton, ON, Canada. (R.G.H.)
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16
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Umemura T, Nishizawa S, Nakano Y, Saito T, Kitagawa T, Miyaoka R, Suzuki K, Yamamoto J. Importance of Finding Embolic Sources for Patients with Embolic Stroke of Undetermined Source. J Stroke Cerebrovasc Dis 2019; 28:1810-1815. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 03/27/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022] Open
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17
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Tsivgoulis G, Katsanos AH, Köhrmann M, Caso V, Lemmens R, Tsioufis K, Paraskevas GP, Bornstein NM, Schellinger PD, Alexandrov AV, Krogias C. Embolic strokes of undetermined source: theoretical construct or useful clinical tool? Ther Adv Neurol Disord 2019; 12:1756286419851381. [PMID: 31205494 PMCID: PMC6535711 DOI: 10.1177/1756286419851381] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 04/28/2019] [Indexed: 11/30/2022] Open
Abstract
In 2014, the definition of embolic strokes of undetermined source (ESUS) emerged as a new clinical construct to characterize cryptogenic stroke (CS) patients with complete vascular workup to determine nonlacunar, nonatherosclerotic strokes of presumable embolic origin. NAVIGATE ESUS, the first phase III randomized-controlled, clinical trial (RCT) comparing rivaroxaban (15 mg daily) with aspirin (100 mg daily), was prematurely terminated for lack of efficacy after enrollment of 7213 patients. Except for the lack of efficacy in the primary outcome, rivaroxaban was associated with increased risk of major bleeding and hemorrhagic stroke compared with aspirin. RE-SPECT ESUS was the second phase III RCT that compared the efficacy and safety of dabigatran (110 or 150 mg, twice daily) to aspirin (100 mg daily). The results of this trial have been recently presented and showed similar efficacy and safety outcomes between dabigatran and aspirin. Indirect analyses of these trials suggest similar efficacy on the risk of ischemic stroke (IS) prevention, but higher intracranial hemorrhage risk in ESUS patients receiving rivaroxaban compared to those receiving dabigatran (indirect HR = 6.63, 95% CI: 1.38-31.76). ESUS constitute a heterogeneous group of patients with embolic cerebral infarction. Occult AF represents the underlying mechanism of cerebral ischemia in the minority of ESUS patients. Other embolic mechanisms (paradoxical embolism via patent foramen ovale, aortic plaque, nonstenosing unstable carotid plaque, etc.) may represent alternative mechanisms of cerebral embolism in ESUS, and may mandate different management than oral anticoagulation. The potential clinical utility of ESUS may be challenged since the concept failed to identify patients who would benefit from anticoagulation therapy. Compared with the former diagnosis of CS, ESUS patients required thorough investigations; more comprehensive diagnostic work-up than is requested in current ESUS diagnostic criteria may assist clinicians in uncovering the source of brain embolism in CS patients and individualize treatment approaches.
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Affiliation(s)
- Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Aristeidis H. Katsanos
- Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
- Department of Neurology, St. Josef-Hospital, Ruhr University, Bochum, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Germany
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy
| | - Robin Lemmens
- Division of Experimental Neurology, Department of Neurosciences, Catholic University (KU) Leuven-University, Belgium, Flemish Institute for Biotechnology (VIB), Center for Brain and Disease Research, Laboratory of Neurobiology, Leuven, Belgium, and Department of Neurology, University Hospitals Leuven, Belgium
| | - Konstantinos Tsioufis
- First Cardiology Clinic, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Greece
| | - George P. Paraskevas
- First Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Natan M. Bornstein
- Shaare Zedek Medical Center, Jerusalem, and Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Peter D. Schellinger
- Departments of Neurology and Neurogeriatry, Johannes Wesling Medical Center, Ruhr University Bochum, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, USA
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Gudrunstr.56, Bochum, 44791, Germany
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18
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Tolias CM, Giamouriadis A, Hogg FRA, Ghimire P. Malignant MCA Syndrome. Neurosurgery 2019. [DOI: 10.1007/978-3-319-98234-2_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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19
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Abstract
Atherosclerotic cardiovascular (CV) disease represents one of leading cause of mortality and morbidity in Western countries. An increased risk of CV events was identified in patients with peripheral arterial diseases (PADs), which include all arterial diseases, other than coronary arteries and the aorta. In particular, lower extremity artery disease (LEAD) and/or carotid artery disease present growing incidence in general population and a consequent increase in mortality and morbidity. Medical treatment, including antiplatelet therapy, is a cornerstone in management of these patients, even when they are treated with endovascular or surgical procedures. Despite their clinical relevance, data on optimal antiplatelet treatment in this clinical setting are lacking and often derived from clinical trials on coronary artery disease and by subgroups analysis. The purpose of this review is to examine the available data from registries, randomized trials and meta-analysis on antiplatelet treatment in patients with LEAD and carotid stenosis with the aim to provide evidence to support clinical decision making.
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Affiliation(s)
- Rosetta Melfi
- Unit of Cardiovascular Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Elisabetta Ricottini
- Unit of Cardiovascular Sciences, Department of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
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20
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Mujaj B, Bos D, Muka T, van der Lugt A, Ikram MA, Vernooij MW, Stricker BH, Franco OH. Antithrombotic treatment is associated with intraplaque haemorrhage in the atherosclerotic carotid artery: a cross-sectional analysis of The Rotterdam Study. Eur Heart J 2018; 39:3369-3376. [PMID: 30060115 PMCID: PMC6148524 DOI: 10.1093/eurheartj/ehy433] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/13/2018] [Accepted: 07/11/2018] [Indexed: 12/24/2022] Open
Abstract
Aims Antithrombotic treatment plays a key role in stroke prevention, but their direct effects on the composition of carotid artery atherosclerotic plaques are unknown. To investigate the association of antithrombotic treatment with carotid artery plaque composition, with a specific focus on an intraplaque haemorrhage (IPH). Methods and results From the population-based Rotterdam Study, 1740 participants with carotid atherosclerosis on ultrasound (mean age 72.9 years, 46.0 women) underwent magnetic resonance imaging of the carotid arteries to assess plaque composition. Information on the use of oral anticoagulants [vitamin K antagonists (VKA)] and antiplatelet agents (salicylates), including duration of use and dosage, was obtained from pharmacy records for all participants. We used logistic regression models to assess the association between the use of anticoagulants and antiplatelet agents, and the different plaque components adjusting for confounders. Current and past use of VKA [adjusted odds ratio (OR): 1.88, 95% confidence interval (CI): 0.74-4.75 and OR 1.89, 95% CI: 0.91-3.93] and antiplatelet agents (OR: 1.22, 95% CI: 0.91-1.62), and (OR: 1.23, 95% CI: 0.86-1.75) showed positive trend with a higher presence of IPH. Also, a longer duration of use was associated with a higher frequency of IPH (OR: 3.15, 95% CI: 1.23-8.05) for the use of VKA, and longer duration of the use for antiplatelet agents showed a positive trend (OR: 1.21, 95% CI: 0.88-1.67). We also found that higher levels of international normalized ratio above 2.97 for VKA (OR: 1.48, 95% CI: 1.03-2.15) and higher daily defined dosage than 1.0 for antiplatelet agents (OR: 1.50, 95% CI: 1.21-1.87) were related to a higher frequency of IPH. We found no association with lipid core or calcification. Conclusions The use of antithrombotic treatment relates to a higher frequency of IPH in carotid atherosclerotic plaques.
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Affiliation(s)
- Blerim Mujaj
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
- Department of Cardiovascular Sciences, Research Unit Hypertension and Cardiovascular Epidemiology, Studies Coordinating Centre, KU Leuven, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Leuven, Belgium
| | - Daniel Bos
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, CA Rotterdam, the Netherlands
- Department of Epidemiology, Harvard TH Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA
| | - Taulant Muka
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, CA Rotterdam, the Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, CA Rotterdam, the Netherlands
- Department of Neurology, Erasmus MC, PO Box 2040, CA Rotterdam, the Netherlands
| | - Meike W Vernooij
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, CA Rotterdam, the Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus MC, Rm Na-2717, CA Rotterdam, the Netherlands
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21
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Jia X, Levine GN, Birnbaum Y. The CHA 2DS 2-VASc score: Not as simple as it seems. Int J Cardiol 2018; 257:92-96. [PMID: 29506745 DOI: 10.1016/j.ijcard.2017.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 11/29/2017] [Accepted: 12/11/2017] [Indexed: 01/31/2023]
Abstract
The CHA2DS2-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA2DS2-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke. Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.
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Affiliation(s)
- Xiaoming Jia
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States.
| | - Glenn N Levine
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States; Michael E. DeBakey VA Medical Center, Houston, TX, United States
| | - Yochai Birnbaum
- Department of Medicine, Baylor College of Medicine, Houston, TX, United States
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Ögren J, Irewall AL, Söderström L, Mooe T. Serious hemorrhages after ischemic stroke or TIA - Incidence, mortality, and predictors. PLoS One 2018; 13:e0195324. [PMID: 29621285 PMCID: PMC5886551 DOI: 10.1371/journal.pone.0195324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/20/2018] [Indexed: 11/26/2022] Open
Abstract
Background Data are lacking on the risk and impact of a serious hemorrhage on the prognosis after ischemic stroke (IS) or transient ischemic attack (TIA). We aimed to estimate the incidence of serious hemorrhage, analyze the impact on mortality, and identify predictors of hemorrhage after discharge from IS or TIA. Methods and findings All patients admitted to Östersund Hospital for an IS or TIA in 2010–2013 were included (n = 1528, mean age: 75.1 years). Serious hemorrhages were identified until 31st December 2015. Incidence rates were calculated. The impact on mortality (stratified by functional level) was determined with Kaplan-Meier analysis. Non-parametric estimation under the assumption of competing risk was performed to assess the cumulative incidence and predictors of serious hemorrhages. The incidence rates of serious (n = 113) and intracranial hemorrhages (n = 45) after discharge from IS and TIA were 2.48% and 0.96% per year at risk, respectively. Patients with modified Rankin Scale (mRS) scores of 3–5 exhibited 58.9% mortality during follow-up and those with mRS scores of 0–2 exhibited 18.4% mortality. A serious hemorrhage did not affect mortality in patients with impaired functional status, but it increased the risk of death in patients with mRS scores of 0–2. Hypertension was associated with increased risk of serious hemorrhage. Conclusions We found that, after discharge from an IS or TIA, serious hemorrhages were fairly common. Impairments in function were associated with high mortality, but serious hemorrhages only increased the risk of mortality in patients with no or slight disability. Improved hypertension treatment may decrease the risk of serious hemorrhage, but in patients with low functional status, poor survival makes secondary prevention challenging.
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Affiliation(s)
- Joachim Ögren
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
- * E-mail:
| | - Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
| | - Lars Söderström
- Unit of Research, Development and Education, Östersund, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden
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Amarenco P. Learning from TARDIS: time for more focused trials in stroke prevention. Lancet 2018; 391:819-821. [PMID: 29274728 DOI: 10.1016/s0140-6736(17)33309-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Pierre Amarenco
- Department of Neurology and Stroke Center, Bichat Hospital, Paris Diderot, Sorbonne Paris Cite University, Paris, 75018 Paris, France.
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Zhang JJ, Liu X. Aspirin plus dipyridamole has the highest surface under the cumulative ranking curves (SUCRA) values in terms of mortality, intracranial hemorrhage, and adverse event rate among 7 drug therapies in the treatment of cerebral infarction. Medicine (Baltimore) 2018; 97:e0123. [PMID: 29595635 PMCID: PMC5895377 DOI: 10.1097/md.0000000000010123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The standardization for the clinical use of drug therapy for cerebral infarction (CI) has not yet determined in some aspects. In this paper, we discussed the efficacies of different drug therapies (aspirin, aspirin plus dipyridamole, aspirin plus clopidogrel, aspirin plus warfarin, cilostazol, warfarin, and ticlopidine) for CI. METHODS We searched databases of PubMed and Cochrane Library from the inception to April, 2017, randomized controlled trials (RCTs) met the inclusion and exclusion criteria were enrolled in this study. The network meta-analysis integrated evidences of direct and indirect comparisons to assess odd ratios (OR) and surface under the cumulative ranking curves (SUCRA) value. RESULTS Thirteen eligible RCTs including 7 drug therapies were included into this network meta-analysis. The network meta-analysis results showed that CI patients who received aspirin plus dipyridamole presented lower mortality when compared with those received aspirin plus clopidogrel (OR = 0.46, 95% CI = 0.18-0.99), indicating aspirin plus dipyridamole therapy had better efficacy for CI. As for intracranial hemorrhage (ICH), stroke recurrence, and adverse event (AE) rate, there were no significant differences of efficacy among 7 drug therapies. Besides, SUCRA values demonstrated that in the 7 drug therapies, aspirin plus dipyridamole therapy was more effective than others (mortality: 80.67%; ICH: 76.6%; AE rate: 90.2%). CONCLUSIONS Our findings revealed that aspirin plus dipyridamole therapy might be the optimum one for patients with CI, which could help to improve the survival of CI patients.
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Eerenberg ES, Kampuisen PW, Levi M. Anticoagulants. Hamostaseologie 2017; 31:229-35. [DOI: 10.5482/ha-1153] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 06/06/2011] [Indexed: 11/05/2022] Open
Abstract
SummaryAnticoagulants are effective in the prevention and treatment of a variety of arterial and venous thrombotic disorders but are associated with an increased risk of serious bleeding complications. Based on well documented studies of patients using vitamin K antagonists the incidence of major bleeding is 0.5%/year and the incidence of intracranial bleeding is 0.2%/year, however, in real life practice this incidence may be even higher. Risk factors for bleeding are the intensity of anticoagulation, the management strategy to keep the anticoagulant effect in the desired range, and patient characteristics. Recently, a new generation of anticoagulants have been developed and is currently evaluated in clinical trials. Initial results show a similar or superior efficacy over conventional anticoagulant agents with a good safety profile. In case of serious bleeding complications in a patient who uses vitamin K antagonists, this anticoagulant treatment can be quickly reversed by administration of vitamin K or coagulation factor concentrates. For the newer anticoagulants, quick reversal strategies are more cumbersome, although some interventions, including prothrombin complex concentrates, show promising results in initial experimental studies.
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Goli RR, Contractor MM, Nathan A, Tuteja S, Kobayashi T, Giri J. Antiplatelet Therapy for Secondary Prevention of Vascular Disease Complications. Curr Atheroscler Rep 2017; 19:56. [DOI: 10.1007/s11883-017-0698-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Singh P, Harper Y, Oliphant CS, Morsy M, Skelton M, Askari R, Khouzam RN. Peripheral interventions and antiplatelet therapy: Role in current practice. World J Cardiol 2017; 9:583-593. [PMID: 28824788 PMCID: PMC5545142 DOI: 10.4330/wjc.v9.i7.583] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/13/2017] [Accepted: 04/24/2017] [Indexed: 02/06/2023] Open
Abstract
Peripheral arterial disease (PAD) is a common disorder associated with a high risk of cardiovascular mortality and continues to be under-recognized. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease. Management includes exercise program, pharmacologic therapy and revascularization including endovascular and surgical approach. The optimal revascularization strategy, endovascular or surgical intervention, is often debated due to the paucity of head to head randomized controlled studies. Despite significant advances in endovascular interventions resulting in increased utilization over surgical bypass, significant challenges still remain. Platelet activation and aggregation after percutaneous transluminal angioplasty of atherosclerotic arteries are important risk factors for re-occlusion/restenosis and life-threatening thrombosis following endovascular procedures. Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and death from cardiovascular causes in patients with PAD. Despite an abundance of data demonstrating efficacy of antiplatelet therapy in coronary artery disease and cerebrovascular disease, there is a paucity of clinical information, clinical guidelines and randomized controlled studies in the PAD population. Hence, data on antiplatelet therapy in coronary interventions is frequently extrapolated to peripheral interventions. The aim of this review article is to elucidate the current data on revascularization and the role and duration of antiplatelet and anticoagulant therapy in re-vascularized lower limb PAD patients.
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Amarenco P, Kim AS. Aspirin's Benefits Were Previously Underestimated and Are Primarily Accrued in the Acute Setting. Stroke 2017; 48:1438-1440. [PMID: 28411262 DOI: 10.1161/strokeaha.117.015061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/01/2017] [Accepted: 02/27/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Pierre Amarenco
- From the INSERM LVTS-U1148, AP-HP, Department of Neurology and Stroke Center, Bichat Hospital, DHU FIRE, Paris-Diderot University, Sorbonne-Paris Cité, France (P.A.); and Department of Neurology, University of California San Francisco (A.S.K.).
| | - Anthony S Kim
- From the INSERM LVTS-U1148, AP-HP, Department of Neurology and Stroke Center, Bichat Hospital, DHU FIRE, Paris-Diderot University, Sorbonne-Paris Cité, France (P.A.); and Department of Neurology, University of California San Francisco (A.S.K.)
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Lehtola H, Airaksinen KEJ, Hartikainen P, Hartikainen JEK, Palomäki A, Nuotio I, Ylitalo A, Kiviniemi T, Mustonen P. Stroke recurrence in patients with atrial fibrillation: concomitant carotid artery stenosis doubles the risk. Eur J Neurol 2017; 24:719-725. [DOI: 10.1111/ene.13280] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 02/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- H. Lehtola
- Department of Medicine; Keski-Suomi Central Hospital; Jyvaskyla Finland
| | | | - P. Hartikainen
- Neurology; NeuroCenter; Kuopio University Hospital; Kuopio Finland
| | | | - A. Palomäki
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
| | - I. Nuotio
- Department of Acute Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - A. Ylitalo
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
- Satakunta Central Hospital; Pori Finland
| | - T. Kiviniemi
- Heart Center; Turku University Hospital; University of Turku; Turku Finland
| | - P. Mustonen
- Department of Medicine; Keski-Suomi Central Hospital; Jyvaskyla Finland
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Cheng SF, Brown MM. Contemporary medical therapies of atherosclerotic carotid artery disease. Semin Vasc Surg 2017; 30:8-16. [DOI: 10.1053/j.semvascsurg.2017.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ambrosi P, Daumas A, Villani P, Giorgi R. Meta-analysis of major bleeding events on aspirin versus vitamin K antagonists in randomized trials. Int J Cardiol 2017; 230:572-576. [DOI: 10.1016/j.ijcard.2016.12.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 12/14/2016] [Accepted: 12/16/2016] [Indexed: 11/15/2022]
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Apixaban for treatment of embolic stroke of undetermined source (ATTICUS randomized trial): Rationale and study design. Int J Stroke 2016; 12:985-990. [DOI: 10.1177/1747493016681019] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rationale Optimal secondary prevention of embolic stroke of undetermined source is not established. The current standard in these patients is acetylsalicylic acid, despite high prevalence of yet undetected paroxysmal atrial fibrillation. Aim The ATTICUS randomized trial is designed to determine whether the factor Xa inhibitor apixaban administered within 7 days after embolic stroke of undetermined source, is superior to acetylsalicylic acid for prevention of new ischemic lesions documented by brain magnetic resonance imaging within 12 months after index stroke. Design Prospective, randomized, blinded, parallel-group, open-label, German multicenter phase III trial in approximately 500 patients with embolic stroke of undetermined source. A key inclusion criterion is the presence or the planned implantation of an insertable cardiac monitor. Patients are 1:1 randomized to apixaban or acetylsalicylic acid and treated for a 12-month period. It is an event-driven trial aiming for core-lab adjudicated primary outcome events. Study outcomes The primary outcome is the occurrence of at least one new ischemic lesion identified by axial T2-weighted FLAIR magnetic resonance imaging and/or axial DWI magnetic resonance imaging at 12 months when compared with the baseline magnetic resonance imaging. Key secondary outcomes are the combination of recurrent ischemic strokes, hemorrhagic strokes, systemic embolism; combination of MACE including recurrent stroke, myocardial infarction, and cardiovascular death and combination of major and clinically relevant non-major bleeding defined according to ISTH, and change of cognitive function and quality of life (EQ-5D, Stroke Impact Scale). Discussion Embolic stroke of undetermined source is caused by embolic disease and associated with a high risk of recurrent ischemic strokes and clinically silent cerebral ischemic lesions. ATTICUS will investigate the impact of atrial fibrillation detected by insertable cardiac monitor and the effects of early anticoagulation with apixaban compared with antiplatelet therapy with acetylsalicylic acid on the incidence of new ischemic lesion after embolic stroke of undetermined source.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to update the reader on current concepts of workup and secondary prevention in patients with stroke of undetermined cause. RECENT FINDINGS Clinical research in patients with cryptogenic stroke has been hampered by the lack of standardized, widely accepted diagnostic criteria. The new definition of 'Embolic stroke of undetermined etiology' postulates an embolic mechanism of ischemic stroke. It is based on the exclusion of lacunar infarction by brain imaging, arterial stenosis more than 50% or dissection of the respective brain-supplying artery by computed tomography/magnetic resonance-angiography or ultrasound, atrial fibrillation by at least 24 h EKG monitoring, as well as some rare etiologies such as vasculitis, drug abuse, or coagulopathies. However, it still comprises many patients with atherosclerotic etiologies (but <50% stenosis) as well as covert paroxysmal atrial fibrillation which can be detected by repeated Holter EKG or an implantable device. A patent foramen ovale can be found in up to 58% of cryptogenic stroke patients, but causality in an individual patient remains uncertain and can only be statistically inferred. SUMMARY The new concept of embolic stroke of undetermined etiology enabled three ongoing randomized controlled trials which investigate oral anticoagulation versus aspirin for secondary stroke prevention.
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Antiplatelet Therapy vs. Anticoagulation in Cervical Artery Dissection: Rationale and Design of the Cervical Artery Dissection in Stroke Study (CADISS). Int J Stroke 2016; 2:292-6. [PMID: 18705933 DOI: 10.1111/j.1747-4949.2007.00165.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Rationale Cervical artery dissection is an important cause of stroke in the young. It can present with local symptoms or stroke/transient ischaemic attacks. Following presentation there is a risk of stroke, particularly in the first month following presentation. The mechanism of stroke is believed to be thromboembolic in the majority of cases. Many clinicians anticoagulate patients with cervical dissection for 3–6 months. This is not evidence based and is supported by a paucity of data and no data from randomised control trials. Aims CADISS is a prospective multicentre randomised-con-trolled trial in acute (within 7 days of onset) carotid and vertebral artery dissection. Intracerebral artery dissection is excluded. Design Patients are randomised to antiplatelet therapy (aspirin, dipyridamole or clopidogrel alone or in dual combination) or anticoagulation therapy [heparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 2–3] for at least 3 months. Treatment is open-label. Study outcome The primary end-point is ipsilateral stroke or death within 3 months from randomisation. Secondary end-points include any TIA or stroke, major bleeding and presence of residual stenosis at 3 months (> 50%). All neuroimaging and serious adverse events will be adjudicated blinded to treatment. An initial feasibility phase of 250 subjects will allow us to determine whether there are sufficient clinical end-points to provide the power to determine a treatment effect and adequate numbers of patients can be recruited. The feasibility phase will be continued into a fully powered definitive treatment trial. Initial power calculations based on limited natural history data suggest a sample size of approximately 3000. Sample size calculations will be refined once the frequency of outcome events during the feasibility phase is known.
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Field TS, Castellanos M, Weksler BB, Benavente OR. Antiplatelet Therapy for Secondary Prevention of Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ntaios G, Papavasileiou V, Milionis H, Makaritsis K, Vemmou A, Koroboki E, Manios E, Spengos K, Michel P, Vemmos K. Embolic Strokes of Undetermined Source in the Athens Stroke Registry. Stroke 2015; 46:2087-93. [DOI: 10.1161/strokeaha.115.009334] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/09/2015] [Indexed: 12/21/2022]
Affiliation(s)
- George Ntaios
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Vasileios Papavasileiou
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Haralampos Milionis
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Konstantinos Makaritsis
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Anastasia Vemmou
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Eleni Koroboki
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Efstathios Manios
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Konstantinos Spengos
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Patrik Michel
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
| | - Konstantinos Vemmos
- From the Department of Medicine, Larissa University Hospital, School of Medicine, University of Thessaly, Larissa, Greece (G.N., V.P., K.M.); Comprehensive Stroke Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Sciences Centre, Salford Royal Foundation Trust, Manchester, UK (V.P.); Department of Medicine, Ioannina University Hospital, School of Medicine, University of Ioannina, Ioannina, Greece (H.M.); Department of Clinical Therapeutics, Medical School of Athens, Alexandra
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Zhang JT, Chen KP, Zhang S. Efficacy and safety of oral anticoagulants versus aspirin for patients with atrial fibrillation: a meta-analysis. Medicine (Baltimore) 2015; 94:e409. [PMID: 25634169 PMCID: PMC4602973 DOI: 10.1097/md.0000000000000409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The purpose of this study was to perform a meta-analysis comparing the effectiveness and safety of anticoagulation to antiplatelet therapy for the prevention of thromboembolic events in patients with atrial fibrillation (AF). MEDLINE, Cochrane, EMBASE, and Google Scholar databases were searched for studies published through May 31, 2014. Randomized controlled trials comparing anticoagulants (warfarin) and antiplatelet therapy in patients with AF were included. The primary outcomes were the rates of stroke and systemic embolism. Secondary outcomes included the rates of hemorrhage/major bleeding and death. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Nine reports of 8 trials that enrolled 4363 patients (2169 patients received anticoagulation and 2194 antiplatelet therapy) were included. All of the studies compared adjusted-dose warfarin or with aspirin, and the majority of the patients were >70 years of age. Anticoagulants were titrated to an international normalized ratio (INR) of 2.0 to 4.5, and aspirin was administered at a dosage of 75 to 325 mg/d. Death occurred in 206 participants treated with an anticoagulant and 229 participants treated with antiplatelet therapy. There was no significant difference in the overall stroke rate between the groups (OR = 0.667, 95% CI 0.426-1.045, P = 0.08); however, patients with nonrheumatic AF (NRAF) treated with an anticoagulant had a lower risk of stroke (OR = 0.557, 95% CI 0.411-0.753, P < 0.001). Anticoagulants were associated with a lower risk of embolism (OR = 0.616, 95% CI = 0.392-0.966, P = 0.04), and this finding persisted in patients with NRAF (OR = 0.581, 95% CI 0.359-0.941, P = 0.03). No significant difference in the rate of hemorrhage/major bleeding was noted (OR = 1.497, 95% CI 0.730-3.070, P = 0.27), and this finding persisted on subgroup analysis. Anticoagulants appear to be more effective than aspirin in preventing embolisms in patients with AF, as the risk of bleeding is not increased.
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Affiliation(s)
- Jing-Tao Zhang
- From the Cardiac Arrhythmia Center (J-TZ, K-PC, SZ), Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Road, Beijing 100037, China
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Albaladejo P, Deplanque D, Fossati F, Mahagne MH, Mismetti P, Nguyen P, Roy P, Touze E, Mourad JJ. [Proper use of apixaban: an outline for clinical practice]. ACTA ACUST UNITED AC 2014; 39:409-25. [PMID: 25451020 DOI: 10.1016/j.jmv.2014.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 09/10/2014] [Indexed: 12/18/2022]
Abstract
Apixaban is a direct inhibitor of coagulation factor Xa. Superior efficacy over aspirin and antivitamin K has been shown in the prevention of stroke and systemic embolism during non-valvular atrial fibrillation with a more favorable safety profile, even though the risk of hemorrhage cannot be ignored, considering its mechanism of action. The recommended dose is 5mg twice daily which can be reduced to 2.5mg depending on the individual risk. Apixaban is also indicated for the treatment of venous thromboembolism but reimbursement has not yet been accepted in France for this indication. As with all direct oral anticoagulants, no routine biological monitoring is required, nevertheless their use may have an impact on all coagulation tests, eventually hampering interpretation. In particular clinical circumstances where a measure of anticoagulant efficacy is deemed necessary, specific assay of anti-Xa activity is appropriate, the result being expressed as concentration of the anticoagulant used. It is therefore necessary to state the name of the medicine for which the assay is requested. With these new anticoagulants, management of hemorrhagic events can be more difficult due to the lack of a specific antidote. Pro-hemostatic substances have exhibited efficacy in animal models but results are still insufficiently documented in clinical practice. Local or locoregional hemostasis measurements, when possible, are an essential factor in the treatment of hemorrhagic events.
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Affiliation(s)
- P Albaladejo
- Service d'anesthésie-réanimation, CHU de Grenoble, BP 217, 38043 Grenoble cedex 09, France
| | - D Deplanque
- Laboratoire de pharmacologie, faculté de médecine, CHR de Lille, 1, place de Verdun, 59045 Lille, France
| | - F Fossati
- 12, rue de Condé, 59110 La Madeleine, France
| | - M H Mahagne
- Unité neurovasculaire, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Devoluy, BP 319, 06006 Nice cedex 1, France
| | - P Mismetti
- Service médecine et thérapeutique, hôpital Bellevue, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - P Nguyen
- Laboratoire central d'hématologie, hôpital Robert-Debré, CHU de Reims, avenue du Général-Koenig, 51092 Reims cedex, France
| | - P Roy
- Accueil et traitement urgences, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 9, France
| | - E Touze
- Service de neurologie, hôpital Sainte-Anne, 1, rue Cabanis, 75014 Paris, France
| | - J-J Mourad
- Unité médecine interne, HTA, hôpital Avicenne-AP-HP, 125, rue de Stalingrad, 93009 Bobigny cedex, France.
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Paciaroni M, Bogousslavsky J. Antithrombotic Therapy in Carotid Artery Stenosis: An Update. Eur Neurol 2014; 73:51-6. [DOI: 10.1159/000367988] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 08/31/2014] [Indexed: 11/19/2022]
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Affiliation(s)
- Ben J. Connolly
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
| | - Lesly A. Pearce
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
| | - Robert G. Hart
- From the Population Health Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada (B.J.C., R.G.H.); and Biostatistics Consultant, Minot, ND (L.A.P.)
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Hart RG, Diener HC, Coutts SB, Easton JD, Granger CB, O'Donnell MJ, Sacco RL, Connolly SJ. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13:429-38. [PMID: 24646875 DOI: 10.1016/s1474-4422(13)70310-7] [Citation(s) in RCA: 1078] [Impact Index Per Article: 107.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Cryptogenic (of unknown cause) ischaemic strokes are now thought to comprise about 25% of all ischaemic strokes. Advances in imaging techniques and improved understanding of stroke pathophysiology have prompted a reassessment of cryptogenic stroke. There is persuasive evidence that most cryptogenic strokes are thromboembolic. The thrombus is thought to originate from any of several well established potential embolic sources, including minor-risk or covert cardiac sources, veins via paradoxical embolism, and non-occlusive atherosclerotic plaques in the aortic arch, cervical, or cerebral arteries. Accordingly, we propose that embolic strokes of undetermined source are a therapeutically relevant entity, which are defined as a non-lacunar brain infarct without proximal arterial stenosis or cardioembolic sources, with a clear indication for anticoagulation. Because emboli consist mainly of thrombus, anticoagulants are likely to reduce recurrent brain ischaemia more effectively than are antiplatelet drugs. Randomised trials testing direct-acting oral anticoagulants for secondary prevention of embolic strokes of undetermined source are warranted.
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Affiliation(s)
- Robert G Hart
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada.
| | | | | | - J Donald Easton
- Department of Neurology, University of California San Francisco, San Francisco, USA
| | | | | | - Ralph L Sacco
- Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Stuart J Connolly
- McMaster University and Population Health Research Institute, Hamilton, ON, Canada
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Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, Fang MC, Fisher M, Furie KL, Heck DV, Johnston SCC, Kasner SE, Kittner SJ, Mitchell PH, Rich MW, Richardson D, Schwamm LH, Wilson JA. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160-236. [PMID: 24788967 DOI: 10.1161/str.0000000000000024] [Citation(s) in RCA: 2860] [Impact Index Per Article: 286.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.
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Fuentes B, Gállego J, Gil-Nuñez A, Morales A, Purroy F, Roquer J, Segura T, Tejada J, Lago A, Díez-Tejedor E, Alonso de Leciñana M, Álvarez-Sabin J, Arenillas J, Calleja S, Casado I, Castellanos M, Castillo J, Dávalos A, Díaz-Otero F, Egido J, López-Fernández J, Freijo M, García Pastor A, Gilo F, Irimia P, Maestre J, Masjuan J, Martí-Fábregas J, Martínez-Sánchez P, Martínez-Vila E, Molina C, Nombela F, Ribó M, Rodríguez-Yañez M, Rubio F, Serena J, Simal P, Vivancos J. Guía para el tratamiento preventivo del ictus isquémico y AIT (II). Recomendaciones según subtipo etiológico. Neurologia 2014; 29:168-83. [DOI: 10.1016/j.nrl.2011.06.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 06/29/2011] [Indexed: 11/28/2022] Open
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Guidelines for the preventive treatment of ischaemic stroke and TIA (II). Recommendations according to aetiological sub-type. NEUROLOGÍA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.nrleng.2011.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Atherosclerotic disease often involves the intracranial arteries including those encased by cranial bones and dura, and those located in the subarachnoid space. Age, hypertension, and diabetes mellitus are independent risk factors for intracranial atherosclerosis. Intracranial atherosclerosis can result in thromboembolism with or without hypoperfusion leading to transient or permanent cerebral ischaemic events. High rates of recurrent ischaemic stroke and other cardiovascular events mandate early diagnosis and treatment. Present treatment is based on a combination of antiplatelet drugs, optimisation of blood pressure and LDL cholesterol values, and intracranial angioplasty or stent placement, or both, in selected patients.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and CentraCare Health, St Cloud, MN, USA.
| | - Louis R Caplan
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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A randomized, double-blinded, placebo-controlled, multicenter trial, healing effect of rebamipide in patients with low-dose aspirin and/or non-steroidal anti-inflammatory drug induced small bowel injury. J Gastroenterol 2014; 49:239-44. [PMID: 23595613 DOI: 10.1007/s00535-013-0805-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 03/22/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND It is not clear what kind of drug is appropriate to heal NSAID-induced enteropathy. Several reports showed the preventive effect of prostaglandin analogue or inducer using healthy subjects who took NSAIDs. However there was no report for healing effect and for patients. The aim of this study was to evaluate the healing effect of rebamipide in patients with NSAIDs-induced enteropathy. In addition, we evaluated for nutritional parameter. METHODS This study was conducted as a randomized, double-blinded, placebo-controlled, multicenter trial. Study protocol was approved by each hospital's ethical committees. Patients with LDA and/or NSAID more than 3 months were enrolled. Patients with enteropathy were divided into the placebo and the rebamipide groups. Rebamipide 100 mg three times daily was administered during 4 weeks. Capsule endoscopies were performed at 0 and 4 week. The number of small intestinal ulcer and erosion were evaluated. Total protein was analyzed as nutritional parameter. RESULTS Sixty one participants were completed this study. Change in number of small intestinal erosion in the rebamipide group was -2.5 ± 3.4, and 2.1 ± 3.9 in the placebo group (P < 0.0001). Change in number of small intestinal ulcer in the rebamipide group was -0.5 ± 1.6, and 0.1 ± 0.7 in the placebo group (P = 0.024). Change in serum total protein levels in the rebamipide group was 0.06 ± 0.36, and -0.27 ± 0.34 in the placebo group (P = 0.0005). CONCLUSIONS Rebamipide has not only the healing effect for NSAIDs-induced enteropathy compared with placebo, but the improvement of nutritional condition. These results showed a tentative therapeutical strategy for chronic NSAIDs users.
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Weimar C, Weber R, Diener HC. Antithrombotic medication for stroke prevention. Expert Rev Cardiovasc Ther 2014; 7:1245-54. [DOI: 10.1586/erc.09.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Katz BS, Flemming KD. Antithrombotic selection and risk factor management in ischemic stroke and transient ischemic attack. Neurosurg Focus 2014; 36:E10. [PMID: 24380476 DOI: 10.3171/2013.10.focus13402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In addition to appropriate antithrombotic therapy, the identification and treatment of modifiable ischemic stroke risk factors can reduce the likelihood of recurrent stroke. Neurosurgeons should be knowledgeable of the specific risk factors and general recommendations for ischemic stroke, as they may play a significant role in the management options for patients with intracranial and extracranial atherosclerotic disease. The authors of this article review the indications for and selection of antithrombotics in patients with cerebral ischemia. In addition, the identification and secondary prevention of select risk factors are discussed.
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Affiliation(s)
- Brian S Katz
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
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50
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Schulz UG. Drug treatments in the secondary prevention of ischaemic stroke. Maturitas 2013; 76:267-71. [DOI: 10.1016/j.maturitas.2013.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 05/16/2013] [Indexed: 01/25/2023]
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