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Li XY, Lv JJ, Zhao Y, Zhang YJ, Yang XT, Zhang RH, Guo ZL, Wang ZW, Cheng ZH. Global Burden of Stroke Attributable to Low Physical Activity/High Body Mass Index Among People Aged 55 Years and Older. Stroke 2024; 55:2075-2085. [PMID: 38920043 DOI: 10.1161/strokeaha.123.046180] [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: 12/12/2023] [Accepted: 06/06/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND This study aimed to quantify the global stroke burden attributable to low physical activity and high body mass index in adults aged ≥55 years using data from the Global Burden of Disease 2019 study. METHODS We extracted data on stroke mortality, disability-adjusted life years, and risk factor exposure from the Global Burden of Disease 2019 study for people aged ≥55 years. We calculated the population-attributable fraction and absolute number of stroke cases and disability-adjusted life years attributable to low physical activity and high body mass index by location, age group, sex, and year. RESULTS Globally, body mass index and physical inactivity-attributable stroke burden have declined modestly since 1990, but with diverging escalatory regional trajectories. Population growth and aging drive this rising burden. CONCLUSIONS Multidimensional, context-specific strategies focused on modifiable lifestyle risks are imperative to address the modest declines and escalatory regional trajectories in body mass index and physical inactivity-attributable stroke burden.
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Affiliation(s)
- Xin-Yu Li
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
- Department of Plastic and Reconstructive Surgery (X.-Y.L., R.-H.Z.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Jia-Jie Lv
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Yan Zhao
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
- Department of Nursing (Y.Z.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Yuan-Jie Zhang
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Xi-Tao Yang
- Department of Interventional Therapy, Multidisciplinary Team of Vascular Anomalies (X.-T.Y.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Ru-Hong Zhang
- Department of Plastic and Reconstructive Surgery (X.-Y.L., R.-H.Z.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Zhi-Lin Guo
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
| | - Zhao-Wei Wang
- Department of Neurology, Qianjiang Central Hospital of Hubei Province, PR China (Z.-W.W.)
| | - Zhi-Hua Cheng
- Department of Neurosurgery (X.-Y.L., J.-J.L., Y.Z., Y.-J.Z., Z.-L.G., Z.-H.C.), Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, PR China
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Zhang X, Jing J, Wang A, Xie X, Johnston SC, Li H, Bath PM, Xu Q, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Chen W, Gong X, Li J, Han X, Meng X, Wang Y. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a subgroup analysis of the CHANCE-2 trial. Stroke Vasc Neurol 2024:svn-2023-002450. [PMID: 38286485 DOI: 10.1136/svn-2023-002450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 12/16/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVES Evidence of the optimal antiplatelet therapy for elderly patients who had a stroke is limited, especially those elder than 80 years. This study aimed to explore the efficacy and safety of dual antiplatelet therapy (DAPT) in old-old patients compared with younger patients in the ticagrelor or Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events-II (CHANCE-2) trial. METHODS CHANCE-2 was a randomised, double-blind, placebo-controlled trial in China involving patients with high-risk transient ischaemic attack or minor stroke with CYP2C19 loss-of-function alleles. In our substudy, all enrolled patients were stratified by age: old-old (≥80 years), young-old (65-80 years) and younger (<65 years). The primary outcomes were stroke recurrence and moderate to severe bleeding within 90 days, respectively. RESULTS Of all the 6412 patients, 406 (6.3%) were old-old, 2755 (43.0%) were young-old and 3251 (50.7%) were younger. Old-old patients were associated with higher composite vascular events (HR 1.41, 95% CI 1.00 to 1.98, p=0.048), disabling stroke (OR 2.43, 95% CI 1.52 to 3.88, p=0.0002), severe or moderate bleeding (HR 8.40, 95% CI 1.95 to 36.21, p=0.004) and mortality (HR 7.56, 95% CI 2.23 to 25.70, p=0.001) within 90 days. Ticagrelor-aspirin group was associated with lower risks of stroke recurrence within 90 days in younger patients (HR 0.68, 95% CI 0.51 to 0.91, p=0.008), which was no differences in old-old patients. CONCLUSION Elderly patients aged over 80 in CHANCE-2 trial had higher risks of composite vascular events, disabling stroke, severe or moderate bleeding and mortality within 90 days. Genotype-guided DAPT might not be as effective in old-old patients as in younger ones. TRIAL REGISTRATION NUMBER NCT04078737.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weifeng Chen
- Department of Neurology, Xingyang People's Hospital, Henan, China
| | - Xuhai Gong
- Daqing Oilfield General Hospital, Daqing, Heilongjiang, China
| | - Jianhua Li
- The First Hospital of Fangshan District, Beijing, China
| | | | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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Bonkhoff AK, Grefkes C. Precision medicine in stroke: towards personalized outcome predictions using artificial intelligence. Brain 2022; 145:457-475. [PMID: 34918041 PMCID: PMC9014757 DOI: 10.1093/brain/awab439] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 11/02/2021] [Accepted: 11/21/2021] [Indexed: 11/16/2022] Open
Abstract
Stroke ranks among the leading causes for morbidity and mortality worldwide. New and continuously improving treatment options such as thrombolysis and thrombectomy have revolutionized acute stroke treatment in recent years. Following modern rhythms, the next revolution might well be the strategic use of the steadily increasing amounts of patient-related data for generating models enabling individualized outcome predictions. Milestones have already been achieved in several health care domains, as big data and artificial intelligence have entered everyday life. The aim of this review is to synoptically illustrate and discuss how artificial intelligence approaches may help to compute single-patient predictions in stroke outcome research in the acute, subacute and chronic stage. We will present approaches considering demographic, clinical and electrophysiological data, as well as data originating from various imaging modalities and combinations thereof. We will outline their advantages, disadvantages, their potential pitfalls and the promises they hold with a special focus on a clinical audience. Throughout the review we will highlight methodological aspects of novel machine-learning approaches as they are particularly crucial to realize precision medicine. We will finally provide an outlook on how artificial intelligence approaches might contribute to enhancing favourable outcomes after stroke.
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Affiliation(s)
- Anna K Bonkhoff
- J. Philip Kistler Stroke Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian Grefkes
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Juelich, Juelich, Germany
- Department of Neurology, University Hospital Cologne, Cologne, Germany
- Medical Faculty, University of Cologne, Cologne, Germany
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Pan Y, Shi G. Silver Jubilee of Stroke Thrombolysis With Alteplase: Evolution of the Therapeutic Window. Front Neurol 2021; 12:593887. [PMID: 33732203 PMCID: PMC7956989 DOI: 10.3389/fneur.2021.593887] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/01/2021] [Indexed: 01/01/2023] Open
Abstract
In 1995, the results of a landmark clinical trial by National Institute of Neurological Disorders and Stroke (NINDS) made a paradigm shift in managing acute cerebral ischemic stroke (AIS) patients at critical care centers. The study demonstrated the efficacy of tissue-type plasminogen activator (tPA), alteplase in improving neurological and functional outcome in AIS patients when administered within 3 h of stroke onset. After about 12 years of efforts and the results of the ECASS-III trial, it was possible to expand the therapeutic window to 4.5 h, which still represents a major logistic issue, depriving many AIS patients from the benefits of tPA therapy. Constant efforts in this regards are directed toward either speeding up the patient recruitment for tPA therapy or expanding the current tPA window. Efficient protocols to reduce the door-to-needle time and advanced technologies like telestroke services and mobile stroke units are being deployed for early management of AIS patients. Studies have demonstrated benefit of thrombolysis guided by perfusion imaging in AIS patients at up to 9 h of stroke onset, signifying “tissue window.” Several promising pharmacological and non-pharmacological approaches are being explored to mitigate the adverse effects of delayed tPA therapy, thus hoping to further expand the current tPA therapeutic window without compromising safety. With accumulation of scientific data, stroke organizations across the world are amending/updating the clinical recommendations of tPA, the only US-FDA approved drug for managing AIS patients. Alteplase has been a part of our neurocritical care and we intend to celebrate its silver jubilee by dedicating this review article discussing its journey so far and possible future evolution.
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Affiliation(s)
- Yuanmei Pan
- Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guowen Shi
- Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Lee MK, Hsu PC, Tsai WC, Chen YC, Lee HH, Lee WH, Chu CY, Lee CS, Yen HW, Lin TH, Voon WC, Lai WT, Sheu SH, Su HM. Gender differences in major adverse cardiovascular outcomes among aged over 60 year-old patients with atherosclerotic cardiovascular disease: A population-based longitudinal study in Taiwan. Medicine (Baltimore) 2020; 99:e19912. [PMID: 32384435 PMCID: PMC7220184 DOI: 10.1097/md.0000000000019912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Atherosclerotic cardiovascular disease (ASCVD) including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contributes to the major causes of death in the world. Although several studies have evaluated the association between gender and major adverse cardiovascular outcomes in old ASCVD patients, the result is not consistent. Hence, we need a large-scale study to address this issue.This retrospective cohort study included aged over 60 year-old patients with a diagnosis of ASCVD, including CVD, CAD, or PAD, from the database contained in the Taiwan National Health Insurance Bureau during 2001 to 2004. The matched cohort was matched by age, comorbidities, and medical therapies at a 1:1 ratio. A total of 9696 patients were enrolled in this study, that is, there were 4848 and 4848 patients in the matched male and female groups, respectively. The study endpoints included acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, in-hospital mortality, and so on. In multivariate Cox regression analysis in matched cohort, the adjusted hazard ratios (HRs) for female group in predicting acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality were 0.67 (P < .001), 0.73 (P = .0015), 0.78 (P < .001), 0.59 (P < .001), and 0.77 (P = .0007), respectively.In this population-based propensity matched cohort study, age over 60 year-old female patients with ASCVD were associated with lower rates of acute myocardial infarction, hemorrhagic stroke, ischemic stroke, vascular procedures, and in-hospital mortality than male patients. Further prospective studies may be investigated in Taiwan.
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Affiliation(s)
- Meng-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Wei-Chung Tsai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ying-Chih Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
| | - Hung-Hao Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
| | - Wen-Hsien Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chee-Siong Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Wen-Chol Voon
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Wen-Ter Lai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Sheng-Hsiung Sheu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
| | - Ho-Ming Su
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan ROC
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Late Cerebrovascular Events Following Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020; 13:872-881. [DOI: 10.1016/j.jcin.2019.11.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 11/23/2022]
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Cai J, Zhu M, Zhou X. Letter by Cai et al Regarding Article, "One-Year Home-Time and Mortality After Thrombolysis Compared With Nontreated Patients in a Propensity-Matched Analysis". Stroke 2019; 51:e17. [PMID: 31771462 DOI: 10.1161/strokeaha.119.028010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jun Cai
- Department of Neurology, The Second Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Mingguang Zhu
- Department of Neurology, The Second Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Xuemei Zhou
- Department of Neurology, The Second Affiliated Hospital of Gannan Medical University, Ganzhou, China
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Prevention and Treatment of Acute Stroke in the Nonagenarians and Beyond: Medical and Ethical Issues. Curr Treat Options Neurol 2019; 21:27. [PMID: 31065827 DOI: 10.1007/s11940-019-0567-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW As one of the fastest growing portions of the population, nonagenarians will constitute a significant percentage of the stroke patient population in the near future. Nonagenarians are nevertheless not specifically targeted by most clinical guidelines. In this review, we aimed to summarise the available evidence guiding stroke prevention and treatment in this age group. RECENT FINDINGS Several recent observational studies have shown that the benefits of anticoagulation for the oldest old patients with atrial fibrillation may outweigh the bleeding risk. A sub-analysis of the IST-3 trial has shown for the first time that thrombolysis treatment in acute ischaemic stroke may be beneficial and safe even in octogenarian patients and older. Several recent observational studies have assessed thrombolysis in nonagenarians. The latest of these has shown better disability outcomes without increased rates of symptomatic intracerebral haemorrhage with thrombolysis. Nonagenarian stroke patients may benefit from similar preventative and therapeutic strategies as their younger counterparts. A few important exceptions include primary prevention using aspirin or statins. Patient selection is nevertheless essential given the increased adverse event rates. Patient preference should play a key role in the decision-making process. Clinical trials including more nonagenarian patients are required to yield more robust evidence.
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Abstract
Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.
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Affiliation(s)
- Anjail Sharrief
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, United States
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, United States.
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Jönsson AC, Delavaran H, Lövkvist H, Baturova M, Iwarsson S, Ståhl A, Norrving B, Lindgren A. Secondary prevention and lifestyle indices after stroke in a long-term perspective. Acta Neurol Scand 2018; 138:227-234. [PMID: 29671868 DOI: 10.1111/ane.12944] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the long-term perspective regarding prevalence of risk factors, secondary stroke prevention, and lifestyle indices after stroke. METHODS From a population-based one-year cohort (n = 416), we performed an observational study of 145 survivors at 16 months and 10 years after stroke (age 27-97 years) regarding secondary prevention including reaching acceptable treatment goals; nutritional status with focus on underweight; and the lifestyle indices: living situation, level of dependence, and self-assessed health condition. RESULTS Ten years after stroke, 50% of the subjects with hypertension diagnosis and 55% of those without hypertension diagnosis were within the blood pressure goal <140/90 compared with 32% (P = .008) and 37% (N.S.) at 16 months. Acceptable HbA1c levels among subjects with diabetes mellitus diagnosis increased from 35% to 45% (N.S.). Among those without diabetes diagnosis, satisfactory HbA1c levels decreased from 98% to 79% (P < .001). Underweight increased from 9% to 17% (P = .019). Among patients with cerebral infarction, the prevalence of atrial fibrillation increased from 22% to 29% (P = .004), and treatment with oral anticoagulants from 75% to 78% (N.S.). Acceptable LDL cholesterol levels increased from 59% to 80% (P = .033) among subjects on lipid lowering treatment, and from 18% to 40% among untreated (P = .010). At 10 years, 90% still lived in their own home. Health condition was reported as good/very good/excellent by 65%. Age, female sex, and living situation were associated with intensity of secondary prevention measures and underweight. CONCLUSIONS The proportion of individuals within treatment goals improved over time, but secondary prevention still needed additional consideration 10 years after stroke.
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Affiliation(s)
- A. C. Jönsson
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
- Department of Neurology and Rehabilitation Medicine; Skåne University Hospital; Lund Sweden
| | - H. Delavaran
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
- Department of Neurology and Rehabilitation Medicine; Skåne University Hospital; Lund Sweden
| | - H. Lövkvist
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
- Unit for Medical Statistics and Epidemiology; Skåne University Hospital, Clinical Studies Sweden - Forum South; Lund Sweden
| | - M. Baturova
- Department of Clinical Sciences, Cardiology; Lund University; Lund Sweden
- University Clinic, St. Petersburg State University; St. Petersburg Russia
| | - S. Iwarsson
- Department of Health Sciences; Lund University; Lund Sweden
| | - A. Ståhl
- Department of Technology and Society; Faculty of Engineering; Lund University; Lund Sweden
| | - B. Norrving
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
- Department of Neurology and Rehabilitation Medicine; Skåne University Hospital; Lund Sweden
| | - A. Lindgren
- Department of Clinical Sciences Lund, Neurology; Lund University; Lund Sweden
- Department of Neurology and Rehabilitation Medicine; Skåne University Hospital; Lund Sweden
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Zucchella C, Consilvio M, Iacoviello L, Intiso D, Tamburin S, Casale R, Bartolo M. Rehabilitation in oldest-old stroke patients: a comparison within over 65 population. Eur J Phys Rehabil Med 2018; 55:148-155. [PMID: 30160435 DOI: 10.23736/s1973-9087.18.05297-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Considering the demographic trend, characterized by a marked aging due to the increase in life expectancy and the improvement in medical care, in the next future elderly patients will represent the majority of stroke victims with a strong impact on rehabilitative services. AIM To investigate and characterize differences in functional outcome in elderly patients after stroke. DESIGN Observational study. SETTING Post-acute inpatient rehabilitation. POPULATION Subjects aged ≥65 years with acute (i.e. within 30 days from onset) ischemic or hemorrhagic stroke. METHODS At admission, all patients underwent neurological and clinical examination, functional evaluation and laboratory assessment. Comorbidities and clinical complications during hospital stay were recorded. Functional status was evaluated by means of the Functional Independence Measure (FIM) administered at admission and discharge. All patients underwent neuromotor rehabilitation, and speech therapy in case of aphasia, once a day, six days per week. RESULTS The study enrolled 402 patients, who were stratified in three groups according to age: 145 patients in Group 1, the young-old (65-74.9 years, G1), 206 in Group 2, the middle-old (75-84.9 years, G2) and 51 in Group 3, the oldest-old (≥85 years, G3). At discharge, FIM total scores increased significantly for all the groups (P<0.001); however FIM gains, as well as the efficiency parameters derived from FIM were significantly lower in G3 when compared with G1 and G2. G3 showed a significantly higher rate of comorbidities and a higher presence of pressure sores; infections occurred mainly in G2 and G3. Hospitalization was significantly longer for G1 and G2 with respect to G3, while mortality rates were significantly higher in G2 and G3 with respect to G1. The variables that predicted functional outcome were age, previous stroke, stroke severity and functional status at admission. CONCLUSIONS Despite advancing age seems to be associated with a reduced effectiveness of the rehabilitation process and a greater number of complications, intensive rehabilitation can produce significant functional gains for all stroke survivors, regardless of age. CLINICAL REHABILITATION IMPACT Understanding the specificity of this population will offer older subjects targeted interventions and, for health systems, better allocation of resources and the development of more effective approaches.
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Affiliation(s)
| | - Marco Consilvio
- Division of Neurologic, Cardiologic, and Pneumological Rehabilitation, European Institute of Rehabilitation, Isernia, Italy
| | - Licia Iacoviello
- Department of Epidemiology and Prevention, NEUROMED Mediterranean Neurological Institute for Research and Care, Pozzilli, Isernia, Italy.,Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Domenico Intiso
- Unit of Physical Medicine and Neurorehabilitation, Casa Sollievo della Sofferenza Institute for Research and Care, San Giovanni Rotondo, Foggia, Italy
| | - Stefano Tamburin
- Unit of Neurology, University Hospital of Verona, Verona, Italy.,Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Roberto Casale
- Scientific Direction, HABILITA, Zingonia di Ciserano, Bergamo, Italy
| | - Michelangelo Bartolo
- Unit of Neurorehabilitation, Department of Rehabilitation, HABILITA, Zingonia di Ciserano, Bergamo, Italy -
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Du YZ, Gao XX, Wang CT, Zheng HZ, Lei Y, Wu MH, Shi XM, Ban HP, Gu WL, Meng XG, Wei MT, Hu CX. Acupuncture lowering blood pressure for secondary prevention of stroke: a study protocol for a multicenter randomized controlled trial. Trials 2017; 18:428. [PMID: 28915826 PMCID: PMC5603044 DOI: 10.1186/s13063-017-2171-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 07/03/2017] [Indexed: 01/19/2023] Open
Abstract
Background Stroke is the prime cause of morbidity and mortality in the general population, and hypertension will increase the recurrence and mortality of stroke. We report a protocol of a pragmatic randomized controlled trial (RCT) using blood pressure (BP)-lowering acupuncture add-on treatment to treat patients with hypertension and stroke. Methods This is a large-scale, multicenter, subject-, assessor- and analyst-blinded, pragmatic RCT. A total of 480 patients with hypertension and ischemic stroke will be randomly assigned to two groups: an experimental group and a control group. The experimental group will receive “HuoXueSanFeng” acupuncture combined with one antihypertensive medication in addition to routine ischemic stroke treatment. The control group will only receive one antihypertensive medication and basic treatments for ischemic stroke. HuoXueSanFeng acupuncture will be given for six sessions weekly for the first 6 weeks and three times weekly for the next 6 weeks. A 9-month follow-up will, thereafter, be conducted. Antihypertensive medication will be adjusted based on BP levels. The primary outcome will be the recurrence of stroke. The secondary outcomes including 24-h ambulatory BP, the TCM syndrome score, the Short Form 36-item Health Survey (SF-36), the National Institute of Health Stroke Scale (NIHSS), as well as the Barthel Index (BI) scale will be assessed at baseline, 6 weeks and 12 weeks post initiating treatments; cardiac ultrasound, carotid artery ultrasound, transcranial Doppler, and lower extremity ultrasound will be evaluated at baseline and 12 weeks after treatment. The safety of acupuncture will also be assessed. Discussion We aim to determine the clinical effects of controlling BP for secondary prevention of stroke with acupuncture add-on treatment. Trial registration ClinicalTrials.gov, ID: NCT02967484. Registered on 13 February 2017; last updated on 27 June 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2171-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yu-Zheng Du
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China.
| | - Xin-Xin Gao
- Emergency Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Cheng-Ting Wang
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China.,Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hai-Zhen Zheng
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China.,Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yun Lei
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Meng-Han Wu
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xue-Min Shi
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China
| | - Hai-Peng Ban
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China
| | - Wen-Long Gu
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China
| | - Xiang-Gang Meng
- Acupuncture and Moxibustion Department, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88, Changling Road, Xiqing District, Tianjin, 300000, China
| | - Mao-Ti Wei
- Department of Epidemiology, Logistics College of Chinese People's Armed Police Forces, Tianjin, China
| | - Chun-Xiao Hu
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
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13
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Subic A, Cermakova P, Norrving B, Winblad B, von Euler M, Kramberger MG, Eriksdotter M, Garcia-Ptacek S. Management of acute ischaemic stroke in patients with dementia. J Intern Med 2017; 281:348-364. [PMID: 28150348 DOI: 10.1111/joim.12588] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
An estimated 10% of stroke patients have an underlying dementia. As a consequence, health professionals often face the challenge of managing patients with dementia presenting with an acute stroke. Patients with dementia are less likely to receive thrombolysis (0.56-10% vs. 1-16% thrombolysis rates in the general population), be admitted to a stroke unit or receive some types of care. Anticoagulation for secondary stroke prevention is sometimes withheld, despite dementia not being listed as an exclusion criterion in current guidelines. Studies in this population are scarce, and results have been contradictory. Three observational studies have examined intravenous thrombolysis for treatment of acute ischaemic stroke in patients with dementia. In the two largest matched case-control studies, there were no significant differences between patients with and without dementia in the risks of intracerebral haemorrhage or mortality. The risk of intracerebral haemorrhage ranged between 14% and 19% for patients with dementia. Studies of other interventions for stroke are lacking for this population. Patients with dementia are less likely to be discharged home compared with controls (19% vs. 41%) and more likely to be disabled (64% vs. 59%) or die during hospitalization (22% vs. 11%). The aim of this review was to summarize current knowledge about the management of ischaemic stroke in patients with pre-existing dementia, including organizational aspects of stroke care, intravenous thrombolysis, access to stroke unit care and use of supportive treatment. Evidence to support anticoagulation for secondary prevention of stroke in patients with atrial fibrillation and antiplatelet therapy in nonembolic stroke will be discussed, as well as rehabilitation and how these factors influence patient outcomes. Finally, ethical issues, knowledge gaps and pathways for future research will be considered.
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Affiliation(s)
- A Subic
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden.,Department of Neurology, University Medical Center, Ljubljana, Slovenia
| | - P Cermakova
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden.,International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - B Norrving
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - B Winblad
- Division of Neurogeriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - M von Euler
- Department of Clinical Science and Education, Södersjukhuset, Stockholm, Sweden.,Karolinska University Hospital, Department of Clinical Pharmacology, Stockholm, Sweden
| | - M G Kramberger
- Department of Neurology, University Medical Center, Ljubljana, Slovenia
| | - M Eriksdotter
- Department of Geriatric Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
| | - S Garcia-Ptacek
- Department of Geriatric Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.,Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Stockholm, Sweden
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14
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Saldina IY, Klochikhina OA, Shprakh VV, Stakhovskaya LV. [Epidemiology of stroke in Irkutsk: the data of the territorial population register (2009-2013)]. Zh Nevrol Psikhiatr Im S S Korsakova 2016; 116:4-8. [PMID: 27905381 DOI: 10.17116/jnevro2016116824-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To study the changes in the main epidemiological induces of stroke in Irkutsk over 2009-2013. MATERIAL AND METHODS To obtain significant epidemiological data, a unified method of territorial/population register was used. Stroke morbidity and mortality among persons aged over 25 years is presented. RESULTS The highest indices of morbidity among men (5,6 per 1000 population) were recorded in 2010, among women (3,9 per 1000 population) in 2009. Stroke morbidity decreased by 28% in women of Irkutsk over the 5-year period. Indices of morbidity among men did not change during the period of the study and were higher compared to nationwide RESULTS: Mortality indices demonstrated a trend to a reduction: the mortality from stroke decreased by 2-fold over the 5 years. CONCLUSION The decrease in stroke mortality among men and women (both in Irkutsk and Russia in whole) is a logical consequence of a complex approach to the problem as well as opening of specialized vascular centers and secondary prevention of stroke.
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Affiliation(s)
- I Yu Saldina
- Irkutsk State Medical Academy of Post-Graduate Education, Irkutsk, Russia
| | - O A Klochikhina
- Pirogov Russian National Research Medical University, Moscow, Russia ,Research Institute of Cerebrovaskular Pathology and Stroke, Moscow, Russia
| | - V V Shprakh
- Irkutsk State Medical Academy of Post-Graduate Education, Irkutsk, Russia
| | - L V Stakhovskaya
- Pirogov Russian National Research Medical University, Moscow, Russia ,Research Institute of Cerebrovaskular Pathology and Stroke, Moscow, Russia
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15
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Lindley RI. Inclusion of Older People in Trials. Stroke 2016; 47:2679-2680. [DOI: 10.1161/strokeaha.116.014940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Richard I. Lindley
- From the Westmead Hospital Clinical School (C24) and George Institute for Global Health, University of Sydney, New South Wales, Australia
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16
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Sanossian N, Apibunyopas KC, Liebeskind DS, Starkman S, Burgos AM, Conwit R, Eckstein M, Pratt F, Stratton S, Hamilton S, Saver JL. Characteristics and Outcomes of Very Elderly Enrolled in a Prehospital Stroke Research Study. Stroke 2016; 47:2737-2741. [PMID: 27679533 DOI: 10.1161/strokeaha.116.013318] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 07/19/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND AND PURPOSE Greater numbers of individuals aged ≥80 years enjoy a high quality of life, yet historically stroke trials have excluded this population. We aimed to describe a population of very elderly successfully enrolled into an acute stroke trial and compare their characteristics and outcomes with the younger cohort. METHODS We analyzed consecutive patients enrolled <2 hours of symptom onset in a prehospital stroke treatment trial, the FAST-MAG clinical trial (Field Administration of Stroke Therapy-Magnesium). We gathered demographic, treatment, and outcome data for nonelderly (<80 years old), very elderly (≥80 years old), and extreme elderly (≥90 years old). We describe key differences in the population of elderly and the impact of their inclusion on the clinical trial. RESULTS Of 1700 participants in FAST-MAG, there were 1210 nonelderly, 490 very elderly, and 60 extreme elderly subjects. Very elderly stroke patients successfully enrolled in a research study were more likely to be women, white, and have an ischemic mechanism rather than an intracerebral hemorrhage. Although the very elderly had generally poorer outcomes, 4 in 10 were functionally independent at 90 days. CONCLUSIONS Inclusion of the very elderly population in acute stroke clinical trials would both significantly increase study participation and generalizability of future acute stroke clinical trials. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.
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Affiliation(s)
- Nerses Sanossian
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.).
| | - Kathleen C Apibunyopas
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - David S Liebeskind
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Sidney Starkman
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Adrian M Burgos
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Robin Conwit
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Marc Eckstein
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Frank Pratt
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Sam Stratton
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Scott Hamilton
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
| | - Jeffrey L Saver
- From the Department of Neurology, Roxanna Todd Hodges Comprehensive Stroke Clinic (N.S., K.C.A., A.M.B.), and Department of Emergency Medicine (M.E.), University of Southern California, Los Angeles; Department of Neurology, Stroke Center (D.S.L., S. Starkman, J.L.S.) and Neurovascular Imaging Core Laboratory (D.S.L.) and School of Public Health (S. Stratton), University of California, Los Angeles; National Institutes of Neurological Disorders and Stroke, Bethesda, MD (R.C.); Department of Emergency Medicine, Torrance Memorial Medical Center, Torrance, CA (F.P.); Department of Neurology, Stanford University, CA (S.H.)
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17
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Saldina IY, Klochihina OA, Shprakh VV, Stahovskaya LV. [Stroke epidemiology in Irkutsk according to the territorial population register]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:15-19. [PMID: 26525929 DOI: 10.17116/jnevro20151159215-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study the dynamics of main epidemiological indices of stroke in Irkutsk in 2009-2013 and to compare the results with those in Russia. MATERIAL AND METHODS The study was based on the data of the clinical/epidemiological analysis of stroke in open population of men and women in Irkutsk, the data analysis was performed using SAS 8.0. RESULTS The territorial population register showed changes in disease and death rates for all stroke cases in the group of 25-74 years old both in men and women. The morbidity in men did not significantly exceed that in Russia. In the period of 5 years, the morbidity in women decreased by 28%. The stable trend towards the decrease in deaths from stroke in men and women was observed. During the observational period it decreased two-fold.
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Affiliation(s)
- I Yu Saldina
- Irkutsk State Medical Academy of Post-Graduate Education, Irkutsk
| | - O A Klochihina
- Pirogov Russian National Research Medical University, Research Institute of Cerebrovaskular Pathology and Stroke, Moscow
| | - V V Shprakh
- Irkutsk State Medical Academy of Post-Graduate Education, Irkutsk
| | - L V Stahovskaya
- Pirogov Russian National Research Medical University, Research Institute of Cerebrovaskular Pathology and Stroke, Moscow
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18
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Choi JC, Lee JS, Park TH, Park SS, Cho YJ, Park JM, Kang K, Lee KB, Lee SJ, Ko Y, Kim JG, Lee J, Cho KH, Kim JT, Yu KH, Lee BC, Oh MS, Cha JK, Kim DH, Nah HW, Kim DE, Ryu WS, Kim BJ, Bae HJ, Kim WJ, Shin DI, Yeo MJ, Sohn SI, Hong JH, Lee J, Hong KS. Intravenous Tissue Plasminogen Activator Improves the Outcome in Very Elderly Korean Patients with Acute Ischemic Stroke. J Stroke 2015; 17:327-35. [PMID: 26437998 PMCID: PMC4635722 DOI: 10.5853/jos.2015.17.3.327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/20/2015] [Accepted: 04/29/2015] [Indexed: 01/25/2023] Open
Abstract
Background and Purpose In a recent pooled analysis of randomized clinical trials (RCTs), intravenous tissue plasminogen activator (TPA) improves the outcome in patients aged ≥80 years. However, it is uncertain whether the findings are applicable to clinical practice in Asian populations. Methods From a multicenter stroke registry database of Korea, we identified patients with acute ischemic stroke who were aged ≥ 80 years. Using multivariable analysis and propensity score (PS)-matched analyses, we assessed the effectiveness and safety of intravenous TPA within 4.5 hours. Results Among 2,334 patients who met the eligible criteria, 236 were treated with intravenous TPA (mean age, 83±5; median NIHSS, 13 [IQR, 8-17]). At discharge, the TPA group compared to the no-TPA group had a favorable shift on the modified Rankin Scale (mRS) score (multivariable analysis, OR [95% CI], 1.51 [1.17-1.96], P=0.002; PS-matched analysis, 1.54 [1.17-2.04], P=0.002) and was more likely to achieve mRS 0-1 outcome (multivariable analysis, 2.00 [1.32-3.03], P=0.001; PS-matched analysis, 1.59 [1.04-2.42], P=0.032). TPA treatment was associated with an increased risk of symptomatic intracranial hemorrhage (multivariable analysis, 5.45 [2.80-10.59], P<0.001; PS-matched analysis, 4.52 [2.24-9.13], P<0.001), but did not increase the in-hospital mortality (multivariable analysis, 0.86 [0.50-1.48], P=0.58; PS-matched analysis, 0.88 [0.52-1.47], P=0.61). Conclusions In the setting of clinical practice, intravenous TPA within 4.5 hours improved the functional outcome despite an increased risk of symptomatic intracranial hemorrhage in very elderly Korean patients. The findings, consistent with those from pooled analysis of RCTs, strongly support the use of TPA for this population.
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Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Jong-Moo Park
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Kyusik Kang
- Department of Neurology, Eulji General Hospital, Eulji University, Seoul, Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Soo-Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Youngchai Ko
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Hospital, Daegu, Korea
| | - Ki-Hyun Cho
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Hyun-Wook Nah
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Min-Ju Yeo
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Sung Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
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19
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Hubbard RE, Peel NM, Scott IA, Martin JH, Smith A, Pillans PI, Poudel A, Gray LC. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202:373-7. [PMID: 25877120 DOI: 10.5694/mja13.00172] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 10/22/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate medication changes for older patients admitted to hospital and to explore associations between patient characteristics and polypharmacy. DESIGN Prospective cohort study. PARTICIPANTS AND SETTING Patients aged 70 years or older admitted to general medical units of 11 acute care hospitals in two Australian states between July 2005 and May 2010. All patients were assessed using the interRAI assessment system for acute care. MAIN OUTCOME MEASURES Measures of physical, cognitive and psychosocial functioning; and number of regular prescribed medications categorised into three groups: non-polypharmacy (0-4 drugs), polypharmacy (5-9 drugs) and hyperpolypharmacy (≥ 10 drugs). RESULTS Of 1220 patients who were recruited for the study, medication records at admission were available for 1216. Mean age was 81.3 years (SD, 6.8 years), and 659 patients (54.2%) were women. For the 1187 patients with complete medication records on admission and discharge, there was a small but statistically significant increase in mean number of regular medications per day between admission and discharge (7.1 v 7.6), while the prevalence of medications such as statins (459 [38.7%] v 457 [38.5%] patients), opioid analgesics (155 [13.1%] v 166 [14.0%] patients), antipsychotics (59 [5.0%] v 65 [5.5%] patients) and benzodiazepines (122 [10.3%] v 135 [11.4%] patients) did not change significantly. Being in a higher polypharmacy category was significantly associated with increase in comorbidities (odds ratio [OR], 1.27; 95% CI, 1.20-1.34), presence of pain (OR, 1.31; 1.05-1.64), dyspnoea (OR, 1.64; 1.30-2.07) and dependence in terms of instrumental activities of daily living (OR, 1.70; 1.20-2.41). Hyperpolypharmacy was observed in 290/1216 patients (23.8%) at admission and 336/1187 patients (28.3%) on discharge, and the proportion of preventive medication in the hyperpolypharmacy category at both points in time remained high (1209/3371 [35.9%] at admission v 1508/4117 [36.6%] at discharge). CONCLUSIONS Polypharmacy is common among older people admitted to general medical units of Australian hospitals, with no clinically meaningful change to the number or classification (symptom control, prevention or both) of drugs made by treating physicians.
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Affiliation(s)
| | | | - Ian A Scott
- University of Queensland, Brisbane, QLD, Australia
| | | | - Alesha Smith
- University of Queensland, Brisbane, QLD, Australia
| | | | - Arjun Poudel
- University of Queensland, Brisbane, QLD, Australia
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White CL, Szychowski JM, Pergola PE, Field TS, Talbert R, Lau H, Peri K, Benavente OR. Can blood pressure be lowered safely in older adults with lacunar stroke? The Secondary Prevention of Small Subcortical Strokes study experience. J Am Geriatr Soc 2015; 63:722-9. [PMID: 25850462 DOI: 10.1111/jgs.13349] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine safety and tolerability of lowering blood pressure in older adults with lacunar stroke. DESIGN Cohort study. SETTING The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial, which compared the efficacy of two systolic blood pressure (SBP) targets (<130 mmHg and 130-149 mmHg) for secondary stroke prevention. PARTICIPANTS Of 3,020 SPS3 participants, 494 aged 75 and older at baseline were used in these analyses. MEASUREMENTS Rates of side effects related to lowering SBP and clinical outcomes, including stroke recurrence and vascular death, were examined. RESULTS Older participants achieved SBP levels similar to those of younger participants (mean SBP of 125 mmHg and 137 mmHg in lower and higher SBP target groups, respectively). At least once during the approximately 3.5 years of follow-up, 21% reported dizziness, and 15% reported lightheadedness when standing; the only significant difference between the younger and older groups was unsteadiness when standing (23% vs 32% respectively, P < .001). There was no difference according to treatment group. In younger adults, recurrent stroke was less likely in the lower than the higher SBP group (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.59-1.01) but not in older participants (HR = 1.01, 95% CI = 0.59-1.73), although the interaction was not significant (P = .39). The lower SBP target was associated with a significant reduction in vascular death in older participants (HR = 0.42, 95% CI = 0.18-0.98), with a significant interaction between age and SBP group (P = .049). CONCLUSION Except for unsteadiness when standing, there was no difference according to age in individuals with lacunar stroke with respect to side effects potentially related to lowering blood pressure. Although the lower SBP target was not associated with lower likelihood of recurrent stroke, these exploratory analyses suggested a possible benefit related to vascular death.
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Affiliation(s)
- Carole L White
- School of Nursing, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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Triasunova МA, Agafonov KI, Nehaeva KA, Miloserdov MA, Maslova NN, Rakov AM, Agulina NA. [An analysis of the work of vascular service in Smolensk from 2009 to 2014]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:78-83. [PMID: 26525941 DOI: 10.17116/jnevro20151159278-83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
MATERIAL AND METHODS Report of the regional vascular service center of Smolensk work and work of vascular service of Smolensk region were analyzed. The aim of the study is to analyze work of the vascular service in Smolensk and Smolensk region in 2009-2014. RESULTS AND CONCLUSION Mortality and morbidity in patients with cardio-vascular diseases in Smolensk Region are higher than in other regions of Russia. Recently a number of patients hospitalized to vascular service centers are increased. Infectious complications (pneumonia, bedsores, pyoderma) take lead place in mortality. Nowadays it's very important to solve the problem with prophylaxis of infectious complications in patients with acute ischemic stroke, also to solve problem with rehabilitation in patients with mild and severe motor disorders and disorders of praxis, gnosis. Continuous training of doctors and nurses in regional vascular service centers is needed. It will increase quality of medical service and improve rehabilitation prognosis in patients with ischemic stroke.
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Affiliation(s)
| | | | | | | | | | - A M Rakov
- Smolensk State Medical University, Smolensk
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22
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Sun MC, Lai TB, Jeng JS, Sung SF, Sung PS, Tang SC, Chen WL, Chen CH. Safety of intravenous thrombolysis for ischaemic stroke in Asian octogenarians and nonagenarians. Age Ageing 2015; 44:158-61. [PMID: 25355619 DOI: 10.1093/ageing/afu172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND symptomatic intracerebral haemorrhage (ICH) is a major concern of intravenous thrombolysis (IVT) for ischaemic stroke. Asians are considered more vulnerable to ICH than non-Asians. Reports on safety of IVT for Asian octogenarians and nonagenarians are limited. AIMS the aims of our study were to compare the safety of IVT between octogenarians and nonagenarians and between Asian and Western patients. METHODS patients receiving IVT for ischaemic stroke were prospectively registered from four hospitals in Taiwan. Octogenarians and nonagenarians were recruited for analysis. The primary safety outcome measure was symptomatic ICH. The secondary outcome measure was 3-month mortality. We searched the literature on IVT for ischaemic stroke for comparison. RESULTS from January 2007 to December 2012, a total of 186 (18.3%) ischaemic stroke patients aged 80 and older, including 166 octogenarians and 20 nonagenarians, were recruited from 1,018 patients receiving IVT. Nine (4.8%) of recruited patients had symptomatic ICH, all in the octogenarian group (5.4%). Three-month mortality was 14.1% in recruited patients and without difference between the two age groups (P = 0.558). The results were comparable with reports on Western octogenarians and nonagenarians in the literature. CONCLUSION octogenarians and nonagenarians receiving IVT have a similar safety outcome. Asian octogenarians and nonagenarians receiving IVT for ischaemic stroke are not at higher risk of symptomatic ICH and mortality than Western patients.
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Affiliation(s)
- Mu-Chien Sun
- Stroke Center, Changhua Christian Hospital, Changhua, Taiwan Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Tien-Bao Lai
- Stroke Center, Changhua Christian Hospital, Changhua, Taiwan Department of Emergency Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Pi-Shan Sung
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Liang Chen
- Stroke Center, Changhua Christian Hospital, Changhua, Taiwan Department of Radiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Chih-Hung Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Abstract
PURPOSE OF REVIEW The third International Stroke Trial (IST-3) was a randomized controlled trial of thrombolysis with intravenous recombinant tissue plasminogen activator in patients with acute ischemic stroke within 6 h of onset. It sought to determine whether a wider variety of patients might benefit from treatment than were eligible under the prevailing European Union approval for the drug, especially among those aged over 80 years. RECENT FINDINGS The entry criteria were broad, and there was no upper age limit for inclusion; over half the 3035 patients were aged over 80 years. For the types of patient recruited in IST-3, despite the early hazards (chiefly of fatal intracerebral hemorrhage), thrombolysis within 6 h did not affect longer-term survival and improved functional outcome. Benefit was greatest among patients treated within 3 h, and benefit did not appear to be diminished among elderly patients or those with severe stroke. SUMMARY These results should, therefore, encourage clinicians to: consider thrombolytic treatment for a wider variety of patients (particularly those aged over 80 years); treat those with more severe strokes; reinforce their efforts to increase the proportion of ischemic strokes treated within 3 h; and, have greater confidence that mortality is not increased by treatment. VIDEO ABSTRACT http://links.lww.com/CONR/A23.
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Quality indicators in acute stroke care: a prospective observational survey in 13 Italian regions. Aging Clin Exp Res 2014; 26:279-86. [PMID: 24293350 DOI: 10.1007/s40520-013-0171-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 11/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Quality monitoring has great relevance in stroke care. The Project "How to guarantee adherence to effective interventions in stroke care" aimed to estimate adherence to acute-phase guidelines in stroke care in Italy. METHODS A prospective observational study was performed in 27 hospitals of 13 Italian Regions. Adherence to 15 process indicators was evaluated, comparing also stroke units (SU) with conventional wards. An overall score of care, defined as the sum of achieved indicators, was calculated. A multilevel hierarchical model described performance at patient, hospital and regional level. RESULTS Overall, 484 consecutive stroke patients (mean age, 73.4 years; 52.7 % males) were included. Total score ranged from 2 to 15 (mean 8.5 ± 2.4). SU patients were more often evaluated with the National Institutes of Health Stroke Scale (NIHSS) within 24 h, had more frequently an assessment of pre- and post-stroke disability, and a CT scan the same or the day after admission. Regional-hospital- and patient-level variability explained, respectively, 25, 34, and 41 % of total score variance. In multivariate models, patients >80 years vs. younger showed a change in total score of -0.45 (95 % CI -0.79 to -0.12), and those with NIHSS ≥14 vs. ≤5 of -0.92 (95 % CI -1.53 to -0.30). A negative change means a worse adjusted average adherence to process indicators. SU admission increased total score of 1.55 (95 % CI 0.52-2.58). CONCLUSIONS Our data confirm the need of quality monitoring in stroke care. Although SU patients showed a better adherence to quality indicators, overall compliance was unsatisfactory.
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Velders MA, James SK, Libungan B, Sarno G, Fröbert O, Carlsson J, Schalij MJ, Albertsson P, Lagerqvist B. Prognosis of elderly patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention in 2001 to 2011: A report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) registry. Am Heart J 2014; 167:666-73. [PMID: 24766976 DOI: 10.1016/j.ahj.2014.01.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 01/30/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Elderly patients constitute a growing part of the population presenting with ST-elevation myocardial infarction (STEMI). The use of primary percutaneous coronary intervention (PCI) in this high-risk population remains poorly investigated. METHODS Using the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we identified consecutive patients with STEMI 80 years or older undergoing primary PCI during a 10-year period. Temporal trends in care and 1-year prognosis were investigated, and long-term outcome was compared with a reference group of patients with STEMI aged 70 to 79 years. Relative survival was calculated by dividing the observed survival rate with the expected survival rate of the general population. Adjusted end points were calculated using Cox regression. RESULTS In total, 4,876 elderly patients with STEMI were included. During the study period, average age and presence of comorbidity increased, as well as the use of antithrombotic therapy. Procedural success remained constant. One-year mortality was exclusively reduced between the most recent vs the earliest cohort, whereas the risk of reinfarction, heart failure, stroke, and bleeding remained similar. The risk of death was higher for elderly patients early after PCI, after which the prognosis was slightly better compared with the general population. Long-term risk of adverse events increased markedly with age. CONCLUSIONS The prognosis of patients older than 80 years treated with primary PCI for STEMI was relatively unchanged during the 10-year inclusion period, despite changes in patient characteristics and treatment. Advanced age increased the risk of adverse events, but survivors of the early phase after PCI had a slightly improved prognosis compared with the general population.
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Zhang D, Zou X, Sy C, Qin H, Wang Y, Liao X, Liu L. Thrombolysis and reperfusion: advanced understanding of early management strategies in acute ischemic stroke. Neurol Res 2014; 36:391-6. [PMID: 24661072 DOI: 10.1179/1743132814y.0000000349] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Currently, intravenous (IV) thrombolysis within 3 hours from stroke onset is the only approved treatment in acute ischemic stroke (AIS). Although effective, the definition of therapeutic time window and appropriate patient selection still remains controversial. Notably, early endovascular treatment strategies may serve as an adjunct therapy for time window extension in AIS. In this article, we review the safety and efficacy of IV thrombolysis in AIS as it pertains to the optimal time window, the selection of eligible patients, and in combination with endovascular treatment. Combined clinical application of IV thrombolysis and endovascular therapy may improve the therapeutic outcomes for AIS patients.
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27
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Frank B, Fulton RL, Lees KR. The effect of time to treatment on outcome in very elderly thrombolysed stroke patients. Int J Stroke 2014; 9:591-6. [PMID: 24588833 DOI: 10.1111/ijs.12249] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 11/17/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Intravenous thrombolysis is beneficial in, even very elderly, acute ischemic stroke patients. However, while the relation between treatment benefit and treatment delay (onset time to treatment) in patients younger than 80 years is well known, it is uncertain in the very elderly. AIMS This analysis aims at examining this relationship in the elderly, and to provide a comparison with the derived relationship in younger patients as a check of validity. METHODS We assessed the interaction between age, onset time to treatment, and thrombolysis exposure by analyzing the modified Rankin scale score distribution or mortality rate at 90 days, among patients registered in a trials archive. We established whether the effect of alteplase changes with onset time to treatment, by treating onset time to treatment as a continuum in a multivariate logistic regression model. RESULTS Data were available for 3063 patients, of whom 2341 were thrombolysed. Five hundred ninety-seven patients were aged >80, of whom 352 were thrombolysed. Among patients aged >80, no significant interaction of outcome with onset time to treatment was observed (P = 0·4650), but the estimated slope of the decay in benefit with onset time to treatment was comparable with that established for younger patients. Analyzing the entire dataset, there was an interaction between onset time to treatment and alteplase treatment (P = 0·0159), but neither between age and onset time to treatment (P = 0·7098) nor between age and alteplase treatment (P = 0·0755). CONCLUSIONS In this nonrandomized comparison, the relationship of benefit and safety with thrombolysis across onset time to treatment in very elderly stroke patients was comparable with that in their younger counterparts. Across the investigated time span of 3·5 h, we can safely treat with the same time window as we use for younger patients.
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Affiliation(s)
- Benedikt Frank
- Department of Medicine and Therapeutics, Faculty of Medicine, University of Glasgow, Western Infirmary, Glasgow, UK; Department of Neurology, University of Duisburg-Essen, Essen, Germany
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Eissa A, Krass I, Bajorek BV. Use of medications for secondary prevention in stroke patients at hospital discharge in Australia. Int J Clin Pharm 2014; 36:384-93. [DOI: 10.1007/s11096-013-9908-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 12/26/2013] [Indexed: 10/25/2022]
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Berg BI, Juergens P, Soerensen Y, Savic M, Zeilhofer HF, Schwenzer-Zimmerer K. Traumatology of the facial skeleton in octogenarian patients: a retrospective analysis of 96 cases. J Craniomaxillofac Surg 2014; 42:870-3. [PMID: 24513308 DOI: 10.1016/j.jcms.2013.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 09/11/2013] [Accepted: 12/27/2013] [Indexed: 11/25/2022] Open
Abstract
AIM The aim of this retrospective study was to evaluate the frequency and distribution of maxillofacial trauma patients over 80 years, with regard to type and environment of accidents as well as treatment and complications. PATIENTS AND METHODS Data for 94 patients (96 cases; aged 80-94 years) with maxillofacial fractures were retrospectively analysed. RESULTS Data of 30 male and 64 female patients with an average age of 85 years were analysed. In 90% of the study population, the cause of fractures was a fall, followed by traffic accidents (9%) and assault (1%). Seventy-two patients had fractures of the midface, 10 had factures of the mandible, 9 had fractures of both the midface and mandible and 5 had fractures of the neurocranium and midface. Surgical intervention was required in 57% of the patients. Post-operative complications were: four cases of diplopia, two cases of infected plates, four cases of lower eyelid ectropion and in one case a retrobulbar haematoma. CONCLUSION Facial trauma in the elderly can often be treated conservatively unless the patient complains of functional problems. Due to co-morbidities, special attention should be paid to hypertension, anticoagulant agents and the surgical approach.
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Affiliation(s)
- B-I Berg
- Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland; Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland.
| | - P Juergens
- Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland; Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland
| | - Y Soerensen
- Krankenhaus Reinbek, Dept. of Surgery (Head: Prof. Dr. T. Strate), Hamburg, Germany
| | - M Savic
- Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland; Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland
| | - H-F Zeilhofer
- Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland; Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland
| | - K Schwenzer-Zimmerer
- Dept. of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University Hospital Basel, Basel, Switzerland; Hightech Research Center of Cranio-Maxillofacial Surgery (Head: Prof. Dr. Dr. H.-F. Zeilhofer), University of Basel, Basel, Switzerland
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Bates BE, Kwong PL, Xie D, Valimahomed A, Ripley DC, Kurichi JE, Stineman MG. Factors Influencing Receipt of Early Rehabilitation After Stroke. Arch Phys Med Rehabil 2013; 94:2349-2356. [PMID: 23924439 DOI: 10.1016/j.apmr.2013.07.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 07/18/2013] [Accepted: 07/22/2013] [Indexed: 10/26/2022]
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Leslie-Mazwi TM, Chandra RV, Simonsen CZ, Yoo AJ. Elderly patients and intra-arterial stroke therapy. Expert Rev Cardiovasc Ther 2013; 11:1713-23. [PMID: 24195443 DOI: 10.1586/14779072.2013.839219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.
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Affiliation(s)
- Thabele M Leslie-Mazwi
- Neuroendovascular, Neurologic Critical Care, Massachusetts General Hospital, Boston, USA
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Tanaka AFD, Scheicher ME. Relação entre depressão e desequilíbrio postural em idosos que sofreram acidente vascular encefálico. FISIOTERAPIA EM MOVIMENTO 2013. [DOI: 10.1590/s0103-51502013000200008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: A incidência de Acidente Vascular Encefálico (AVE) aumenta com o envelhecimento e duplica a cada década de vida a partir dos 55 anos de idade. Entre as complicações decorrentes de um AVE estão o desequilíbrio postural e a depressão. OBJETIVOS: Avaliar e correlacionar equilíbrio postural e depressão em idosos com e sem AVE. MATERIAIS E MÉTODOS: Foram avaliados 38 sujeitos (19 com AVE e 19 sem AVE). O equilíbrio foi avaliado pela Escala de Equilíbrio de Berg e a depressão pela Escala de Depressão de Yesavage. RESULTADOS: Idosos com AVE apresentaram depressão quando comparados com idosos sem a doença (p < 0,0001). O risco de cair em idosos com AVE foi 102 vezes maior do que em idosos sem AVE. Houve correlação entre depressão e equilíbrio (r = -0,55; p = 0,01). CONCLUSÃO: Pacientes idosos com sequelas de AVE apresentam maior desequilíbrio e maior depressão, quando comparados com idosos de mesma faixa etária sem a doença.
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Sarikaya H. Safety and Efficacy of Thrombolysis with Intravenous Alteplase in Older Stroke Patients. Drugs Aging 2013; 30:227-34. [DOI: 10.1007/s40266-013-0052-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ferguson C, Inglis SC, Newton PJ, Middleton S, Macdonald PS, Davidson PM. Atrial fibrillation and thromboprophylaxis in heart failure: the need for patient-centered approaches to address adherence. Vasc Health Risk Manag 2013; 9:3-11. [PMID: 23345982 PMCID: PMC3551455 DOI: 10.2147/vhrm.s39571] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Atrial fibrillation is a common arrhythmia in heart failure and a risk factor for stroke. Risk assessment tools can assist clinicians with decision making in the allocation of thromboprophylaxis. This review provides an overview of current validated risk assessment tools for atrial fibrillation and emphasizes the importance of tailoring individual risk and the importance of weighing the benefits of treatment. Further, this review provides details of innovative and patient-centered methods for ensuring optimal adherence to prescribed therapy. Prior to initiating oral anticoagulant therapy, a comprehensive risk assessment should include evaluation of associated cardiogeriatric conditions, potential for adherence to prescribed therapy, frailty, and functional and cognitive ability.
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Affiliation(s)
- Caleb Ferguson
- Center for Cardiovascular and Chronic Care, University of Technology, Sydney, Australia.
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Sanossian N, Djabiras C, Mack WJ, Ovbiagele B. Trends in cancer diagnoses among inpatients hospitalized with stroke. J Stroke Cerebrovasc Dis 2012; 22:1146-50. [PMID: 23246193 DOI: 10.1016/j.jstrokecerebrovasdis.2012.11.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 10/30/2012] [Accepted: 11/19/2012] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cancer, by conferring a hypercoagulable state, may lead to an ischemic stroke. Relatively little is known about the prevalence and evolution of cancer among stroke patients over the last decade. METHODS We used the Nationwide Inpatient Sample to identify discharges with any InternationalClassification of Diseases, Ninth Revision, diagnosis code for cancer and ischemic stroke from 1997 to 2006. We then calculated age-adjusted yearly acute ischemic stroke hospitalization rates among adult populations with and without cancer. RESULTS Prevalence of cancer among hospitalized stroke patients increased from 1997 to 2006 (N = 31,075 [9.1% of all ischemic stroke hospitalizations] to 34,138 [10.6%], P < .0001). The most common types of cancer among hospitalized stroke patients in 1997 and 2006 were prostate (21% versus 19%), breast (19% versus 19%), gastrointestinal (16% versus 13%), and colorectal (13% versus 13%). Over the decade there was a significant decrease in the prevalence of stroke hospitalizations (slope -3.02, 95% confidence interval -3.69 to -2.34), but not among cancer patients (slope 1.35, 95% confidence interval -0.88 to 3.58). CONCLUSION About 1 in 10 hospitalized ischemic stroke patients in the United States has comorbid cancer, and there has been a slight rise in this rate over the last decade. This is likely due to enhanced survival from better cancer treatments, but further study is warranted.
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Affiliation(s)
- Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles, California.
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Rafael RI, Rafael RS. Prevención cardiovascular en el adulto mayor. REVISTA MÉDICA CLÍNICA LAS CONDES 2012. [DOI: 10.1016/s0716-8640(12)70374-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A. The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial. Lancet 2012; 379:2352-63. [PMID: 22632908 PMCID: PMC3386495 DOI: 10.1016/s0140-6736(12)60768-5] [Citation(s) in RCA: 832] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Thrombolysis is of net benefit in patients with acute ischaemic stroke, who are younger than 80 years of age and are treated within 4·5 h of onset. The third International Stroke Trial (IST-3) sought to determine whether a wider range of patients might benefit up to 6 h from stroke onset. METHODS In this international, multicentre, randomised, open-treatment trial, patients were allocated to 0·9 mg/kg intravenous recombinant tissue plasminogen activator (rt-PA) or to control. The primary analysis was of the proportion of patients alive and independent, as defined by an Oxford Handicap Score (OHS) of 0-2 at 6 months. The study is registered, ISRCTN25765518. FINDINGS 3035 patients were enrolled by 156 hospitals in 12 countries. All of these patients were included in the analyses (1515 in the rt-PA group vs 1520 in the control group), of whom 1617 (53%) were older than 80 years of age. At 6 months, 554 (37%) patients in the rt-PA group versus 534 (35%) in the control group were alive and independent (OHS 0-2; adjusted odds ratio [OR] 1·13, 95% CI 0·95-1·35, p=0·181; a non-significant absolute increase of 14/1000, 95% CI -20 to 48). An ordinal analysis showed a significant shift in OHS scores; common OR 1·27 (95% CI 1·10-1·47, p=0·001). Fatal or non-fatal symptomatic intracranial haemorrhage within 7 days occurred in 104 (7%) patients in the rt-PA group versus 16 (1%) in the control group (adjusted OR 6·94, 95% CI 4·07-11·8; absolute excess 58/1000, 95% CI 44-72). More deaths occurred within 7 days in the rt-PA group (163 [11%]) than in the control group (107 [7%], adjusted OR 1·60, 95% CI 1·22-2·08, p=0·001; absolute increase 37/1000, 95% CI 17-57), but between 7 days and 6 months there were fewer deaths in the rt-PA group than in the control group, so that by 6 months, similar numbers, in total, had died (408 [27%] in the rt-PA group vs 407 [27%] in the control group). INTERPRETATION For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 h improved functional outcome. Benefit did not seem to be diminished in elderly patients. FUNDING UK Medical Research Council, Health Foundation UK, Stroke Association UK, Research Council of Norway, Arbetsmarknadens Partners Forsakringsbolag (AFA) Insurances Sweden, Swedish Heart Lung Fund, The Foundation of Marianne and Marcus Wallenberg, Polish Ministry of Science and Education, the Australian Heart Foundation, Australian National Health and Medical Research Council (NHMRC), Swiss National Research Foundation, Swiss Heart Foundation, Assessorato alla Sanita, Regione dell'Umbria, Italy, and Danube University.
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Kim WJ, Kwon OK, Oh CW, Jung C, Lee JS, Lee J, Park JH, Ko Y, Jang MS, Yang MH, Han MK, Bae HJ. Effectiveness and Safety of Thrombolysis in Ischemic Stroke Patients Aged 80 Years or Older. ACTA ACUST UNITED AC 2012. [DOI: 10.5853/kjs.2012.14.1.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - O-Ki Kwon
- Department of Neurosurgery, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Cheolkyu Jung
- Department of Radiology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Sung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
| | - Jung Hyun Park
- Department of Neurology, Dongguk University Gyeongju Hospital, Gyeongju, Korea
| | - Youngchai Ko
- Department of Neurology, Eulji University Hospital, Eulji University School of Medicine, Daejeon, Korea
| | - Myung Suk Jang
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Hwa Yang
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee-Joon Bae
- Department of Neurology, Stroke Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Intravenous thrombolysis for acute cerebral ischaemia in old stroke patients ≥80 years of age. J Neurol 2011; 259:1461-7. [DOI: 10.1007/s00415-011-6359-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 12/02/2011] [Accepted: 12/08/2011] [Indexed: 10/14/2022]
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Sandercock P, Lindley R, Wardlaw J, Dennis M, Innes K, Cohen G, Whiteley W, Perry D, Soosay V, Buchanan D, Venables G, Czlonkowska A, Kobayashi A, Berge E, Slot KB, Murray V, Peeters A, Hankey GJ, Matz K, Brainin M, Ricci S, Cantisani TA, Gubitz G, Phillips SJ, Antonio A, Correia M, Lyrer P, Kane I, Lundstrom E. Update on the third international stroke trial (IST-3) of thrombolysis for acute ischaemic stroke and baseline features of the 3035 patients recruited. Trials 2011; 12:252. [PMID: 22129158 PMCID: PMC3286387 DOI: 10.1186/1745-6215-12-252] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 11/30/2011] [Indexed: 11/11/2022] Open
Abstract
Background Intravenous recombinant tissue plasminogen activator (rtPA) is approved in Europe for use in patients with acute ischaemic stroke who meet strictly defined criteria. IST-3 sought to improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of rtPA in acute ischaemic stroke, and to determine whether a wider range of patients might benefit. Design International, multi-centre, prospective, randomized, open, blinded endpoint (PROBE) trial of intravenous rtPA in acute ischaemic stroke. Suitable patients had to be assessed and able to start treatment within 6 hours of developing symptoms, and brain imaging must have excluded intracranial haemorrhage and stroke mimics. Results The initial pilot phase was double blind and then, on 01/08/2003, changed to an open design. Recruitment began on 05/05/2000 and closed on 31/07/2011, by which time 3035 patients had been included, only 61 (2%) of whom met the criteria for the 2003 European approval for thrombolysis. 1617 patients were aged over 80 years at trial entry. The analysis plan will be finalised, without reference to the unblinded data, and published before the trial data are unblinded in early 2012. The main trial results will be presented at the European Stroke Conference in Lisbon in May 2012 with the aim to publish simultaneously in a peer-reviewed journal. The trial result will be presented in the context of an updated Cochrane systematic review. We also intend to include the trial data in an individual patient data meta-analysis of all the relevant randomised trials. Conclusion The data from the trial will: improve the external validity and precision of the estimates of the overall treatment effects (efficacy and safety) of iv rtPA in acute ischaemic stroke; provide: new evidence on the balance of risk and benefit of intravenous rtPA among types of patients who do not clearly meet the terms of the current EU approval; and, provide the first large-scale randomised evidence on effects in patients over 80, an age group which had largely been excluded from previous acute stroke trials. Trial registration ISRCTN25765518
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Affiliation(s)
- Peter Sandercock
- The IST-3 Co-ordinating Centre, Neurosciences Trial Unit, Bramwell Dott Building, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK.
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Auriel E, Gur A, Uralev O, Brill S, Shopin L, Karni A, Shenhar Tsarfaty S, Bornstein N. Characteristics of first ever ischemic stroke in the very elderly: Profile of vascular risk factors and clinical outcome. Clin Neurol Neurosurg 2011; 113:654-7. [DOI: 10.1016/j.clineuro.2011.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 03/27/2011] [Accepted: 05/15/2011] [Indexed: 11/29/2022]
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Luker JA, Bernhardt J, Grimmer-Somers KA. Demographic and stroke-related factors as predictors of quality of acute stroke care provided by allied health professionals. J Multidiscip Healthc 2011; 4:247-59. [PMID: 21847347 PMCID: PMC3155855 DOI: 10.2147/jmdh.s22569] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Indexed: 11/25/2022] Open
Abstract
Background: We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals. Methods: Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality. Results: Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care. Conclusion: Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia
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Luker JA, Bernhardt J, Grimmer-Somers KA. Age and gender as predictors of allied health quality stroke care. J Multidiscip Healthc 2011; 4:239-45. [PMID: 21847346 PMCID: PMC3155854 DOI: 10.2147/jmdh.s21559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background: Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown. Aims: Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals. Methods: A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model. Results: No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality. Conclusion: Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia Adelaide, South Australia, Australia
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Luker JA, Wall K, Bernhardt J, Edwards I, Grimmer-Somers KA. Patients' age as a determinant of care received following acute stroke: a systematic review. BMC Health Serv Res 2011; 11:161. [PMID: 21729329 PMCID: PMC3150246 DOI: 10.1186/1472-6963-11-161] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 07/06/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients.Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes. METHODS We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity. RESULTS Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies. CONCLUSION Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia.
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Niewada M, Sandercock PAG, Lindley RI, Członkowska A. Planning trials in older patients with stroke: data from the International Stroke Trial. Age Ageing 2011; 40:395-8. [PMID: 21447486 DOI: 10.1093/ageing/afr030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Maciej Niewada
- Department of Clinical and Experimental Pharmacology, Warsaw Medical University, Krakowskie Przedmieście 26/28, Warsaw 00-927, Poland.
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Sandercock PAG, Niewada M, Członkowska A. The International Stroke Trial database. Trials 2011; 12:101. [PMID: 21510853 PMCID: PMC3104487 DOI: 10.1186/1745-6215-12-101] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 04/21/2011] [Indexed: 12/05/2022] Open
Abstract
Background We aimed to make individual patient data from the International Stroke Trial (IST), one of the largest randomised trials ever conducted in acute stroke, available for public use, to facilitate the planning of future trials and to permit additional secondary analyses. Methods For each randomised patient, we have extracted data on the variables assessed at randomisation, at the early outcome point (14-days after randomisation or prior discharge) and at 6-months and provide them as an analysable database. Results The IST dataset includes data on 19 435 patients with acute stroke, with 99% complete follow-up. Over 26.4% patients were aged over 80 years at study entry. Background stroke care was limited and none of the patients received thrombolytic therapy. Conclusions The IST dataset provides a source of primary data which could be used for planning further trials, for sample size calculations and for novel secondary analyses. Given the age distribution and nature of the background treatment given, the data may be of value in planning trials in older patients and in resource-poor settings.
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Affiliation(s)
- Peter A G Sandercock
- Department of Clinical Neurosciences, University of Edinburgh, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK.
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Ovbiagele B, Markovic D, Towfighi A. Recent age- and gender-specific trends in mortality during stroke hospitalization in the United States. Int J Stroke 2011; 6:379-87. [PMID: 21609416 DOI: 10.1111/j.1747-4949.2011.00590.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Advancements in diagnosis and treatment have resulted in better clinical outcomes after stroke; however, the influence of age and gender on recent trends in death during stroke hospitalization has not been specifically investigated. We assessed the impact of age and gender on nationwide patterns of in-hospital mortality after stroke. METHODS Data were obtained from all US states that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 1998 (n=1 351 293) and 2005 and 2006 (n=1 202 449), with a discharge diagnosis of stroke (identified by the International Classification of Diseases, Ninth Revision procedure codes), were included. Time trends for in-hospital mortality after stroke were evaluated by gender and age group based on 10-year age increments (<55, 55-64, 65-74, 75-84, >84) using multivariable logistic regression. RESULTS Between 1997 and 2006, in-hospital mortality rates decreased across time in all sub-groups (all P<0·01), except in men >84 years. In unadjusted analysis, men aged >84 years in 1997-1998 had poorer mortality outcomes than similarly aged women (odds ratio 0·93, 95% confidence interval=0·88-0·98). This disparity worsened by 2005-2006 (odds ratio 0·88, 95% confidence interval=0·84-0·93). After adjusting for confounders, compared with similarly aged women, the mortality outcomes among men aged >84 years were poorer in 1997-1998 (odds ratio 0·97, 95% confidence interval=0·92-1·02) and were poorer in 2005-2006 (odds ratio 0·92, 95% confidence interval=0·87-0·96), P=0·04, for gender × time trend. CONCLUSIONS Over the last decade, in-hospital mortality rates after stroke in the United States have declined for every age/gender group, except men aged >84 years. Given the rapidly ageing US population, avenues for boosting in-hospital survival among very elderly men with stroke need to be explored.
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Affiliation(s)
- Bruce Ovbiagele
- Stroke Center and Department of Neurology, University of California, Los Angeles, CA, USA
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Sandercock P, Wardlaw J, Lindley R. ‘Where are we Now with Intravenous Thrombolysis for Acute Ischaemic Stroke’? Int J Stroke 2010; 5:381-2. [DOI: 10.1111/j.1747-4949.2010.00465.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The publication of the updated individual patient data meta-analysis of the larger randomised trials of intravenous rt-PA for acute ischaemic stroke has re-opened the debate about how the treatment should be used in routine practice, and what information can be expected to emerge in the next 2-3 years from the ongoing trials [the largest of which is the Third International Stroke Trial (IST-3)].
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Abstract
Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6-24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD.
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Affiliation(s)
- Johan Lökk
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden.
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