OUP accepted manuscript

Stroke-heart syndrome: current progress and future outlook

Stroke can lead to cardiac complications such as arrhythmia, myocardial injury, and cardiac dysfunction, collectively termed stroke-heart syndrome (SHS). These cardiac alterations typically peak within 72 h of stroke onset and can have long-term effects on cardiac function. Post-stroke cardiac complications seriously affect prognosis and are the second most frequent cause of death in patients with stroke. Although traditional vascular risk factors contribute to SHS, other potential mechanisms indirectly induced by stroke have also been recognized. Accumulating clinical and experimental evidence has emphasized the role of central autonomic network disorders and inflammation as key pathophysiological mechanisms of SHS. Therefore, an assessment of post-stroke cardiac dysautonomia is necessary. Currently, the development of treatment strategies for SHS is a vital but challenging task. Identifying potential key mediators and signaling pathways of SHS is essential for developing therapeutic targets. Therapies targeting pathophysiological mechanisms may be promising. Remote ischemic conditioning exerts protective effects through humoral, nerve, and immune-inflammatory regulatory mechanisms, potentially preventing the development of SHS. In the future, well-designed trials are required to verify its clinical efficacy. This comprehensive review provides valuable insights for future research.

Regular Use of Aspirin and Statins Reduces the Risk of Cancer in Individuals with Systemic Inflammatory Diseases

Aspirin has shown potential for cancer prevention, but a recent large randomized controlled trial found no evidence for a reduction in cancer risk. Given the anti-inflammatory effects of aspirin, systemic inflammatory diseases (SID), such as osteoporosis, cardiovascular diseases, and metabolic diseases, could potentially modify the aspirin-cancer link. To investigate the impact of aspirin in people with SIDs, we conducted an observational study on a prospective cohort of 478,615 UK Biobank participants. Individuals with at least one of the 41 SIDs displayed a higher cancer risk than those without SIDs. Regular aspirin use showed protective effects exclusively in patients with SID, contrasting an elevated risk among their non-SID counterparts. Nonetheless, aspirin use demonstrated preventative potential only for 9 of 21 SID-associated cancer subtypes. Cholesterol emerged as another key mediator linking SIDs to cancer risk. Notably, regular statin use displayed protective properties in patients with SID but not in their non-SID counterparts. Concurrent use of aspirin and statins exhibited a stronger protective association in patients with SID, covering 14 common cancer subtypes. In summary, patients with SIDs may represent a population particularly responsive to regular aspirin and statin use. Promoting either combined or individual use of these medications within the context of SIDs could offer a promising chemoprevention strategy.

SIGNIFICANCE

Individuals with systemic inflammatory diseases derive chemoprotective benefits from aspirin and statins, providing a precision cancer prevention approach to address the personal and public challenges posed by cancer.

Exploring the Poststroke Experiences and Needs of South Asian Communities Living in High-Income Countries: Findings from a Scoping Review

Despite the high prevalence of stroke among South Asian communities in high-income countries, a comprehensive understanding of their unique experiences and needs after stroke is lacking. This study aimed to synthesize the literature examining the experiences and needs of South Asian community members impacted by stroke and their family caregivers residing in high-income countries. A scoping review methodology was utilized. Data for this review were identified from seven databases and hand-searching reference lists of included studies. Study characteristics, purpose, methods, participant characteristics, results, limitations, recommendations, and conclusions were extracted. Data were analyzed using descriptive qualitative analysis. In addition, a consultative focus group exercise with six South Asian community members who had experienced a stroke and a program facilitator was conducted to inform the review interpretations. A total of 26 articles met the inclusion criteria and were analyzed. Qualitative analysis identified four descriptive categories: (1) rationale for studying the South Asian stroke population (e.g., increasing South Asian population and stroke prevalence), (2) stroke-related experiences (e.g., managing community support versus stigma and caregiving expectations), (3) stroke service challenges (e.g., language barriers), and (4) stroke service recommendations to address stroke service needs (e.g., continuity of care). Several cultural factors impacted participant experiences, including cultural beliefs about illness and caregiving. Focus group participants from our consultation activity agreed with our review findings. The clinical and research recommendations identified in this review support the need for culturally appropriate services for South Asian communities across the stroke care continuum; however, more research is necessary to inform the design and structure of culturally appropriate stroke service delivery models.

Systolic blood pressure visit-to-visit variability and outcomes in Asian patients with atrial fibrillation

We aimed to assess the association between SBP-VVV and outcomes in Asian patients with atrial fibrillation (AF). AF patients in the COOL-AF registry with SBP measured at baseline, and at least two other visits were studied. We defined SBP-VVV using the standard deviation (SD) of average SBP. Patients were categorized according to the quartiles of SBP SD. The associations between SBP-VVV and outcomes were assessed in the adjusted Cox model. We studied 3172 patients (mean age 67.7 years; 41.8% female), with the prevalence of hypertension being 69%. Warfarin was used in 69% of patients, whereas 7% received non-vitamin K antagonist oral anticoagulants. The minimum and maximum SD of average SBP in the study population was 0.58 and 56.38 mmHg respectively. The cutoff of SD of average SBP for each quartile in our study were 9.09, 12.15, and 16.21 mmHg. The rates of all-cause mortality, ischemic stroke or systemic embolization (SSE), major bleeding, and intracranial hemorrhage (ICH) were 3.10, 1.42, 2.09, and 0.64 per 100 person-years, respectively. Compared with the first quartile, patients in the fourth quartile had a significantly higher risk of mortality (adjusted HR 1.60, 95%CI 1.13-2.25), bleeding (aHR 1.92, 95%CI 1.25-2.96) and ICH (aHR 3.51, 95%CI 1.40-8.76). The risk of SSE was not significantly different among the quartiles. SBP-VVV had a significant impact on the long-term outcomes of Asian patients with AF, particularly mortality and bleeding. Adequate SBP control and maintaining SBP stability over time may improve outcomes for AF patients.

Fibrinaloid Microclots and Atrial Fibrillation

Atrial fibrillation (AF) is a comorbidity of a variety of other chronic, inflammatory diseases for which fibrinaloid microclots are a known accompaniment (and in some cases, a cause, with a mechanistic basis). Clots are, of course, a well-known consequence of atrial fibrillation. We here ask the question whether the fibrinaloid microclots seen in plasma or serum may in fact also be a cause of (or contributor to) the development of AF. We consider known 'risk factors' for AF, and in particular, exogenous stimuli such as infection and air pollution by particulates, both of which are known to cause AF. The external accompaniments of both bacterial (lipopolysaccharide and lipoteichoic acids) and viral (SARS-CoV-2 spike protein) infections are known to stimulate fibrinaloid microclots when added in vitro, and fibrinaloid microclots, as with other amyloid proteins, can be cytotoxic, both by inducing hypoxia/reperfusion and by other means. Strokes and thromboembolisms are also common consequences of AF. Consequently, taking a systems approach, we review the considerable evidence in detail, which leads us to suggest that it is likely that microclots may well have an aetiological role in the development of AF. This has significant mechanistic and therapeutic implications.

Management of ischaemic stroke survivors in primary care setting: the road to holistic care

The management of ischaemic stroke survivors is multidisciplinary, necessitating the collaboration of numerous medical professionals and rehabilitation specialists. However, due to the lack of comprehensive and holistic follow-up, their post-discharge management may be suboptimal. Achieving this holistic, patient-centred follow-up requires coordination and interaction of subspecialties, which general practitioners can provide as the first point of contact in healthcare systems. This approach can improve the management of stroke survivors by preventing recurrent stroke through an integrated post-stroke care, including appropriate Antithrombotic therapy, assisting them to have a Better functional and physiological status, early recognition and intervention of Comorbidities, and lifestyles. For such work to succeed, close interdisciplinary collaboration between primary care physicians and other medical specialists is required in a holistic or integrated way.

Adherence to an integrated care pathway for stroke is associated with lower risk of major cardiovascular events: A report from the Athens Stroke Registry

BACKGROUND

A recent European Society of Cardiology (ESC) Council on Stroke position paper proposed a holistic integrated care management approach for stroke patients, to improve cardiovascular outcomes. The impact of implementing the ABCstroke pathway 'concept' on clinical outcomes has never been estimated before. In order to investigate the potential effect of ABCstroke pathway adherence to cardiovascular outcomes post stroke, we performed a post-hoc analysis from the Athens Stroke Registry.

METHODS AND RESULTS

This analysis was performed in the Athens Stroke Registry, which includes all consecutive patients with acute first-ever ischemic stroke. The Kaplan-Meier product limit was used to estimate the cumulative hazard of each outcome according to adherence with the ABCstroke pathway. We studied 2513 patients [median (IQR) age 71 (62-78) years; 37.7 % female] with ischemic stroke with median follow-up period of 30 (6-75) months. Full adherence to the ABC pathway was identified in 156 (6.2 %) of the patients, while 192 (7.6 %) did not adhere to any of the therapeutic pillars of ABCstroke. Full adherence to ABC treatment pathway was associated with significant reduction of stroke recurrence, compared to patients with no or partial adherence (aHR: 0.61; 95 %CI: 0.37-0.99), as well as a lower risk of MACE (HR: 0.59; 0.39-0.88) and death (aHR: 0.22; 95 %CI: 0.12-0.41).

CONCLUSION

Full adherence to the ABCstroke pathway based on the current guidelines was evident in only 6.2 % of our ischaemic stroke cohort but was independently associated with lower risks of stroke recurrence, major cardiovascular events and mortality. This highlights a potential opportunity to improve clinical outcomes post-stroke with a holistic or integrated care management approach.

Physiotherapy management focusing on proprioceptive impairment in a patient with gait and balance impairments following stroke: A case report

BACKGROUND

Proprioceptive impairment contributes to gait and balance impairments in patients with stroke. Diagnosis functional impairments and evaluation treatment efficacy require quantitative proprioception assessment. However, proprioception assessment has remained limited to ordinal scale measurement, with a lack of ratio scale measurements.

PURPOSE

This case report describes a physiotherapy management program focusing on proprioceptive impairment in patients with stroke using quantitative tests such as Threshold to Detect Passive Motion (TDPM) and Joint Position Sense (JPS).

CASE DESCRIPTION

A63-year-old male patient with an acute pontine lacunar infarction was admitted to our hospital. His muscle strength, selective movement, and trunk activity were preserved. However, the Berg Balance Scale (BBS) and Gait Assessment andIntervention Tool (GAIT) score were 42 and 9 points, observing balance impairment and the buckling knee pattern with hip ataxia during gait. Based on these, TDPM and JPS using image capture were performed. In physiotherapeuticdiagnosis, proprioceptive impairments in the hip and knee joints were the primary functional impairments related to balance and gait. To address these proprioceptive impairments, a 13-day treatment protocol incorporating transcutaneous electrical nerve stimulation (intensity: sensory threshold, frequency: 100 Hz) targeting the quadriceps femoris was performed.

OUTCOMES

The patient was discharged after achieving independent ambulation and improvement in BBS (56 points) and GAIT (2 points) scores, exceeding the minimum clinically important difference. Recovery of proprioceptive impairment corresponded withimproved balance and gait ability.

CONCLUSION

Quantitatively evaluating proprioceptive impairments may provide novel rehabilitation for patients with stroke who have proprioceptive impairments and contribute to clinical decision-making.

The optimal antithrombotic strategy for post-stroke patients with atrial fibrillation and extracranial artery stenosis-a nationwide cohort study

BACKGROUND

In post-stroke atrial fibrillation (AF) patients who have indications for both oral anticoagulant (OAC) and antiplatelet agent (AP), e.g., those with carotid artery stenosis, there is debate over the best antithrombotic strategy. We aimed to compare the risks of ischemic stroke, composite of ischemic stroke/major bleeding and composite of ischemic stroke/intracranial hemorrhage (ICH) between different antithrombotic strategies.

METHODS

This study included post-stroke AF patients with and without extracranial artery stenosis (ECAS) (n = 6390 and 28,093, respectively) identified from the Taiwan National Health Insurance Research Database. Risks of clinical outcomes and net clinical benefit (NCB) with different antithrombotic strategies were compared to AP alone.

RESULTS

The risk of recurrent ischemic stroke was higher for patients with ECAS than those without (12.72%/yr versus 10.60/yr; adjusted hazard ratio [aHR] 1.104, 95% confidence interval [CI] 1.052-1.158, p < 0.001). For patients with ECAS, when compared to AP only, non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy was associated with lower risks for ischaemic stroke (aHR 0.551, 95% CI 0.454-0.669), the composite of ischaemic stroke/major bleeding (aHR 0.626, 95% CI 0.529-0.741) and the composite of ischaemic stroke/ICH (aHR 0.577, 95% CI 0.478-0.697), with non-significant difference for major bleeding and ICH. When compared to AP only, warfarin monotherapy was associated with higher risks of major bleeding (aHR 1.521, 95% CI 1.231-1.880), ICH (aHR 2.045, 95% CI 1.329-3.148), and the composite of ischaemic stroke and major bleeding. With combination of AP plus warfarin, there was an increase in ischaemic stroke, major bleeding, and the composite outcomes, when compared to AP only. NOAC monotherapy was the only approach associated with a positive NCB, while all other options (warfarin, combination of AP-OAC) were associated with negative NCB.

CONCLUSIONS

For post-stroke AF patients with ECAS, NOAC monotherapy was associated with lower risks of adverse outcomes and a positive NCB. Combination of AP with NOAC or warfarin did not offer any benefit, but more bleeding especially with AP-warfarin combination therapy.

Investigating the Role of Brain Natriuretic Peptide (BNP) and N-Terminal-proBNP in Thrombosis and Acute Ischemic Stroke Etiology

The need for biomarkers for acute ischemic stroke (AIS) to understand the mechanisms implicated in pathological clot formation is critical. The levels of the brain natriuretic peptides known as brain natriuretic peptide (BNP) and NT-proBNP have been shown to be increased in patients suffering from heart failure and other heart conditions. We measured their expression in AIS clots of cardioembolic (CE) and large artery atherosclerosis (LAA) etiology, evaluating their location inside the clots, aiming to uncover their possible role in thrombosis. We analyzed 80 thrombi from 80 AIS patients in the RESTORE registry of AIS clots, 40 of which were of CE and 40 of LAA etiology. The localization of BNP and NT-BNP, quantified using immunohistochemistry and immunofluorescence, in AIS-associated white blood cell subtypes was also investigated. We found a statistically significant positive correlation between BNP and NT-proBNP expression levels (Spearman's rho = 0.668 p < 0.0001 *). We did not observe any statistically significant difference between LAA and CE clots in BNP expression (0.66 [0.13-3.54]% vs. 0.53 [0.14-3.07]%, p = 0.923) or in NT-proBNP expression (0.29 [0.11-0.58]% vs. 0.18 [0.05-0.51]%, p = 0.119), although there was a trend of higher NT-proBNP expression in the LAA clots. It was noticeable that BNP was distributed throughout the thrombus and especially within platelet-rich regions. However, NT-proBNP colocalized with neutrophils, macrophages, and T-lymphocytes, suggesting its association with the thrombo-inflammatory process.

Management of patent foramen ovale; findings from a nationwide survey

OBJECTIVES

Several clinical trials have provided evidence supporting the transcatheter closure of patent foramen ovale (PFO) in selected patients following a cryptogenic stroke. However, it remains unknown to what extent these guidelines have been implemented in everyday clinical practice and the familiarity of physicians from different specialties with PFO closure. The aim of our nationwide survey is to explore the implementation of transcatheter PFO occlusion in Greek clinical practice.

MATERIALS AND METHODS

Attending level cardiologists, internal medicine physicians and neurologists involved in the management of PFO-related strokes working in Greece were invited to complete an online questionnaire. The questionnaire consisted of 19 questions and was designed to obtain comprehensive data on provider demographics, PFO characteristics, and specific clinical scenarios.

RESULTS

A total of 51 physicians (56.9 % cardiologists, 25.5 % neurologists and 17.6 % internal medicine physicians) completed the survey, resulting in a response rate of 53 %. Cardiologists, internal medicine physicians and neurologists agree on several issues regarding PFO closure, such as PFO closure as first line treatment, management of patients with DVT or prior decompression sickness, and post-closure antithrombotic treatment, but different approaches were reported regarding closure in patients with thrombophilia treated with oral anticoagulation (p=0.012) and implantable loop recorder placement for atrial fibrillation exclusion (p=0.029 and p=0.020).

CONCLUSIONS

Our findings show that cardiologists, internal medicine physicians and neurologists agree in numerous issues, but share different views in the management of patients with thrombophilia and rhythm monitoring duration. These results highlight the significance of collaboration among physicians from different medical specialties for achieving optimal results.

Current Trends in Gait Rehabilitation for Stroke Survivors: A Scoping Review of Randomized Controlled Trials

BACKGROUND

Stroke stands as a significant global health concern, constituting a leading cause of disability worldwide. Rehabilitation interventions are crucial in aiding the recovery of stroke patients, contributing to an overall enhancement in their quality of life. This scoping review seeks to identify current trends in gait rehabilitation for stroke survivors.

METHODS

The review followed the methodological framework suggested by Arksey and O'Malley. Electronic databases, such as CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection, were systematically searched in November 2023. Inclusion criteria comprised papers published in either English or Portuguese from 2013 to 2023.

RESULTS

From the initial search, a total of 837 papers were identified; twenty-one papers were incorporated into this review. Thirteen distinct categories of gait rehabilitation interventions were identified, encompassing diverse approaches. These categories comprise conventional rehabilitation exercises, traditional gait training with integrated technology, and gait training supported by modern technologies.

CONCLUSIONS

Although traditional rehabilitation exercises have historically proven effective in aiding stroke survivors, a recent trend has emerged, emphasizing the development and integration of innovative therapeutic approaches that harness modern technologies.

Cost-Effectiveness of an Individualised Management Program after Stroke: A Trial-Based Economic Evaluation

INTRODUCTION

Evidence on the cost-effectiveness of comprehensive post-stroke programs is limited. We assessed the cost-effectiveness of an individualised management program (IMP) for stroke or transient ischaemic attack (TIA).

METHODS

A cost-utility analysis alongside a randomised controlled trial with a 24-month follow-up, from both societal and health system perspectives, was conducted. Adults with stroke/TIA discharged from hospitals were randomised by primary care practice to receive either usual care (UC) or an IMP in addition to UC (intervention). An IMP included stroke-specific nurse-led education and a specialist review of care plans at baseline, 3 months, and 12 months, and telephone reviews by nurses at 6 months and 18 months. Costs were expressed in 2021 Australian dollars (AUD). Costs and quality-adjusted life years (QALYs) beyond 12 months were discounted by 5%. The probability of cost-effectiveness of the intervention was determined by quantifying 10,000 bootstrapped iterations of incremental costs and QALYs below the threshold of AUD 50,000/QALY.

RESULTS

Among the 502 participants (65% male, median age 69 years), 251 (50%) were in the intervention group. From a health system perspective, the incremental cost per QALY gained was AUD 53,175 in the intervention compared to the UC group, and the intervention was cost-effective in 46.7% of iterations. From a societal perspective, the intervention was dominant in 52.7% of iterations, with mean per-person costs of AUD 49,045 and 1.352 QALYs compared to mean per-person costs of AUD 51,394 and 1.324 QALYs in the UC group. The probability of the cost-effectiveness of the intervention, from a societal perspective, was 60.5%.

CONCLUSIONS

Care for people with stroke/TIA using an IMP was cost-effective from a societal perspective over 24 months. Economic evaluations of prevention programs need sufficient time horizons and consideration of costs beyond direct healthcare utilisation to demonstrate their value to society.

Beyond antithrombotics: recent advances in pharmacological risk factor management for secondary stroke prevention

Patients with ischaemic stroke represent a diverse group with several cardiovascular risk factors and comorbidities, which classify them as patients at very high risk of stroke recurrence, cardiovascular adverse events or death. In addition to antithrombotic therapy, which is important for secondary stroke prevention in most patients with stroke, cardiovascular risk factor assessment and treatment also contribute significantly to the reduction of mortality and morbidity. Dyslipidaemia, diabetes mellitus and hypertension represent common and important modifiable cardiovascular risk factors among patients with stroke, while early recognition and treatment may have a significant impact on patients' future risk of major cardiovascular events. In recent years, there have been numerous advancements in pharmacological agents aimed at secondary cardiovascular prevention. These innovations, combined with enhanced awareness and interventions targeting adherence and persistence to treatment, as well as lifestyle modifications, have the potential to substantially alleviate the burden of cardiovascular disease, particularly in patients who have experienced ischaemic strokes. This review summarises the evidence on the contemporary advances on pharmacological treatment and future perspectives of secondary stroke prevention beyond antithrombotic treatment.

Needs Assessment Survey for Stroke Care Core Competency-Based Training for Neuroscience Nurses

BACKGROUND

Assessment of stroke care core competency for neuroscience nurses is crucial for developing training programs to improve the quality of care for patients who have a stroke. The goal of this study was to determine the priorities for competency-based training using an importance-performance analysis of stroke care core competency among neuroscience nurses.

METHOD

A cross-sectional descriptive survey was conducted using a convenience sample of 154 neuroscience nurses. Differences in importance and performance scores were analyzed with paired t tests. The training priority was determined using the importance-performance matrix.

RESULTS

The overall performance score was significantly lower than the importance score. The highest priority areas of training were (a) principles of stroke care and (b) cardiovascular and respiratory effects.

CONCLUSION

Competency-based continuing education is needed in implementing stroke best practices for neuroscience nurses to achieve optimal competency. [J Contin Educ Nurs. 2024;55(2):63-68.].

Stroke risk in rheumatoid arthritis patients: exploring connections and implications for patient care

Rheumatoid arthritis (RA) can independently increase the risk of stroke, affecting both young and adult RA patients. Recent attention has been drawn to the association between stroke and RA, supported by mounting evidence. Given that stroke is a significant and an urgent public health concern, this review aims to highlight the relationship between stroke and RA, covering mechanisms, underlying risk factors, early detection tools, and treatment implications. By uncovering the connection that links RA to stroke, we can pave the way for targeted healthcare practices and the development of preventive strategies for individuals with RA. Therefore, further research is imperative to deepen our understanding of this association and, ideally, guide treatment decisions for individuals at risk of both RA and stroke.

Cost-Effectiveness of a Government Policy to Incentivise Chronic Disease Management following Stroke: A Modelling Study

INTRODUCTION

Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). This paper aimed to estimate the potential cost-effectiveness of CDM policies over a lifetime for long-time survivors of stroke.

METHODS

A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n = 12,368, 42% female, median age 70 years, 45% had CDM claims) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n = 512, 34% female, median age 69.6 years, 52% had CDM claims) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty.

RESULTS

Per-person average total lifetime costs were AUD 142,939 and 8.97 QALYs for those with a claim, and AUD 103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM policies was 26.1%, at a willingness-to-pay threshold of AUD 50,000/QALY.

CONCLUSION

CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care cost-effectively is needed.

Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives

AIM(S)

To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting.

RESULTS

Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke.

CONCLUSION

Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway.

IMPACT

This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care.

REPORTING METHOD

We have adhered to relevant EQUATOR guidelines with the COREQ reporting method.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Atrial fibrillation and stroke: State-of-the-art and future directions

Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.

Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report

BACKGROUND

Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting.

RESEARCH QUESTION

What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19?

STUDY DESIGN AND METHODS

A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey.

RESULTS

The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19.

INTERPRETATION

The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.

Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

Heart failure and the heart-brain axis

In heart failure (HF) strong haemodynamic and neuronal signalling feedback interactions between the heart and the central nervous system (CNS) exist that are able to mutually provoke acute or chronic functional impairment. Cerebral injury secondary to HF may include acute stroke, cognitive decline and dementia and depressive disorders. Also brain stem functions are involved in the cardiac-cerebral interaction in HF as neurohormonal control and neuronal reflex circuits are known to be impaired or imbalanced in HF. In turn, impaired cerebral functions may account for direct and indirect myocardial injury and may contribute to symptomatic severity of HF, to disease progression and to increased mortality. Despite the clinical and pathophysiologic significance of the heart-CNS interaction, this relevant field of HF comorbidity is clinically under-recognized with regard to both diagnostic workup and treatment efforts. Here, principal aspects of pathophysiologic heart-CNS interactions related to HF are discussed such as stroke, effects on cognitive function, on depressive disorder and neurovegetative control and neuronal cardiovascular reflex regulation. Aspects of (limited) treatment options for cerebral functional interactions in HF are examined.

Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health

BACKGROUND

Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health.

METHODS

We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health.

RESULTS

The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731).

CONCLUSIONS

Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.

Risk Stratification Tools to Guide a Personalized Approach for Cardiac Monitoring in Embolic Stroke of Undetermined Source

Current recommendations support a personalized sequential approach for cardiac rhythm monitoring to detect atrial fibrillation after embolic stroke of undetermined source. Several risk stratification scores have been proposed to predict the likelihood of atrial fibrillation after embolic stroke of undetermined source. This systematic review aimed to provide a comprehensive overview of the field by identifying risk scores proposed for this purpose, assessing their characteristics and the cohorts in which they were developed and validated, and scrutinizing their predictive performance. We identified 11 risk scores, of which 4 were externally validated. The most frequent variables included were echocardiographic markers and demographics. The areas under the curve ranged between 0.70 and 0.94. The 3 scores with the highest area under the curve were the Decryptoring (0.94 [95% CI, 0.88-1.00]), newly diagnosed atrial fibrillation (0.87 [95% CI, 0.79-0.94]), and AF-ESUS (Atrial Fibrillation in Embolic Stroke of Undetermined Source) (0.85 [95% CI, 0.80-0.87]), of which only the latter was externally validated. Risk stratification scores can guide a personalized approach for cardiac rhythm monitoring after embolic stroke of undetermined source.

Guideline-Directed Low-Density Lipoprotein Cholesterol Management After Acute Ischemic Stroke: Findings from a National Health Care Service

Patients with ischemic stroke are at high risk for future cardiovascular events and should be treated intensively with lipid-modifying agents. Combination lipid-lowering therapies are often needed to achieve updated guideline-directed treatment goals. However, real-world data on intensification of lipid-lowering therapies and attainment of low-density lipoprotein cholesterol (LDL-C) targets early after ischemic stroke are limited. We extracted data from the largest healthcare provider in Israel on patients hospitalized with acute ischemic stroke between January 2020 and February 2022. Included were 3,027 patients surviving ≥1 year after stroke, with documented LDL-C levels and lipid-lowering medications at 2 time periods (0 to 3 months and 6 to 12 months after discharge). Participants were classified according to preexisting stroke and/or coronary artery disease. The use of combination lipid-lowering therapy (ezetimibe and/or proprotein convertase subtilisin/kexin type 9 [monoclonal antibodies] inhibitor plus statin) in the study population increased between the 2 timepoints from 3.6% to 5.1%, reaching 10.5% in those with previous coronary artery disease and stroke. LDL-C levels <70 and <55 mg/100 ml were attained by 42.3% and 22.9% of patients early after hospitalization, and in 49.5% and 27.1% during 6 to 12 months after hospitalization, respectively. Attainment of guideline-recommended LDL-C goals was higher in patients treated with combination lipid-lowering therapies and in those with preexisting cardiovascular disease. In conclusion, despite the advances in drug development and the availability of several mechanisms to lower cholesterol levels, the attainment of guideline-recommended LDL-C targets after acute ischemic stroke is suboptimal. Intensification of treatment with combination lipid-lowering therapies after hospitalization is uncommonly performed in clinical practice, even in those with preexisting cardiovascular disease.

Insertable cardiac monitoring results in higher rates of atrial fibrillation diagnosis and oral anticoagulation prescription after ischaemic stroke

AIMS

After an ischaemic stroke, atrial fibrillation (AF) detection allows for improved secondary prevention strategies. This study aimed to compare AF detection and oral anticoagulant (OAC) initiation in patients with an insertable cardiac monitor (ICM) vs. external cardiac monitor (ECM) after ischaemic stroke.

METHODS AND RESULTS

Medicare Fee-for-Service (FFS) insurance claims and Abbott Labs device registration data were used to identify patients hospitalized with an ischaemic stroke in 2017-2019 who received an ICM or ECM within 3 months. Patients with continuous Medicare FFS insurance and prescription drug enrolment in the prior year were included. Patients with prior AF, atrial flutter, cardiac devices, or OAC were excluded. Insertable cardiac monitor and ECM patients were propensity score matched 1:4 on demographics, comorbidities, and stroke hospitalization characteristics. The outcomes of interest were AF detection and OAC initiation evaluated with Kaplan-Meier and Cox proportional hazard regression analyses. A total of 5702 Medicare beneficiaries (ICM, n = 444; ECM, n = 5258) met inclusion criteria. The matched cohort consisted of 2210 Medicare beneficiaries (ICM, n = 442; ECM, n = 1768) with 53% female, mean age 75 years, and mean CHA₂DS₂-VASc score 4.6 (1.6). Insertable cardiac monitor use was associated with a higher probability of AF detection [(hazard ratio (HR) 2.88, 95% confidence interval (CI) (2.31, 3.59)] and OAC initiation [HR 2.91, CI (2.28, 3.72)] compared to patients monitored only with ECM.

CONCLUSION

Patients with an ischaemic stroke monitored with an ICM were almost three times more likely to be diagnosed with AF and to be prescribed OAC compared to patients who received ECM only.

Mobile health-technology integrated care in secondary prevention atrial fibrillation patients: a post-hoc analysis from the mAFA-II randomized clinical trial

AF patients with history of thromboembolic events are at higher risk of thromboembolic recurrences, despite appropriate antithrombotic treatment. We aimed to evaluate the effect of mobile health (mHealth) technology-implemented 'Atrial fibrillation Better Care' (ABC) pathway approach (mAFA intervention) in secondary prevention AF patients. The Mobile Health Technology for Improved Screening and Optimized Integrated Care in AF (mAFA-II) cluster randomized trial enrolled adult AF patients across 40 centers in China. The main outcome was the composite outcome of stroke or thromboembolism, all-cause death, and rehospitalization. Using Inverse Probability of Treatment Weighting (IPTW), we evaluated the effect of the mAFA intervention in patients with and without prior history of thromboembolic events (i.e., ischemic stroke or thromboembolism). Among the 3324 patients enrolled in the trial, 496 (14.9%, mean age: 75.1 ± 11.4 years, 35.9% females) had a previous episode of thromboembolic event. No significant interaction was observed for the effect of mAFA intervention in patients with vs. without history of thromboembolic events [Hazard ratio, (HR): 0.38, 95% confidence interval (CI):0.18-0.80 vs. HR 0.55, 95% CI 0.17-1.76, p for interaction = 0.587); however, a trend towards lower efficacy of mAFA intervention among AF patients in secondary prevention was observed for secondary outcomes, with significant interaction for bleeding events (p = 0.034) and the composite of cardiovascular events (p = 0.015). A mHealth-technology-implemented ABC pathway provided generally consistent reduction of the risk of primary outcome in both primary and secondary prevention AF patients. Secondary prevention patients may require further specific approaches to improve clinical outcomes such as bleeding and cardiovascular events.Trial registration: WHO International Clinical Trials Registry Platform (ICTRP) Registration number ChiCTR-OOC-17014138.

Cryptogenic stroke as a working diagnosis: the need for an early and comprehensive diagnostic work-up

In the Nordic Atrial Fibrillation and Stroke (NOR-FIB) study, the causes of ischemic stroke were identified in 43% of cryptogenic stroke patients monitored with implantable cardiac monitor (ICM), but one-third of these patients had non-cardioembolic causes. These results suggest the need for an early and comprehensive diagnostic work-up before inserting an ICM.

Post-stroke cardiovascular management: Current concepts, integrated care and future developments

After an ischaemic stroke patients often have cardiovascular complications known as stroke-heart syndrome. The cardiovascular management after stroke has a significant impact on life expectancy as well as the quality of life. The development and implementation of management pathways to improve outcomes for patients with stroke-heart syndrome requires a multidisciplinary involvement from health care professionals from primary, secondary and tertiary prevention levels. A holistic, integrated care approach could follow the ABC pathway: A) Appropriate antithrombotic therapy in all stroke/TIA patients in the acute phase as well as recommendations for the longer term treatment regimen are required to avoid recurrent stroke. B) For better functional and psychological status the assessment of post-stroke cognitive and physical impairment, depression, and anxiety as part of routine post-stroke work-up in every patient is necessary. C) Cardiovascular risk factors and comorbidities management further includes cardiovascular work-up, adapted drug therapy, but often also lifestyle changes that are central to the success of integrated care for stroke-heart syndrome. Greater patient and family/caregiver involvement in planning actions and the input and feedback on optimizing stroke care pathways is needed. Achieving integrated care is challenging and highly context dependent on different healthcare levels. A tailored approach will utilize a variety of enabling factors. In this narrative review, we summarize the current evidence and outline potential factors that will contribute to the successful implementation of integrated cardiovascular care for stroke-heart syndrome management.

Outcomes for patients hospitalized with acute myocardial infarction and cerebral infarction in the United States: insights from the National Inpatient Sample

This study aims to determine the frequency and impact of concomitant cerebral infarction and acute myocardial infarction (AMI) and association with in-hospital outcomes. We analyzed the nationally representative data from National Inpatient Sample between 2016 and 2019. We used multiple logistic regressions to determine the impact of sustaining a cerebral infarction or AMI on in-hospital mortality and linear regression to evaluate length of stay and hospitalization costs. A total of 2,396,450 admissions for cerebral infarction, 4,098,904 admissions for AMI and 130,635 admissions for both conditions were identified. The in-hospital mortality was 7.2% overall: 5.6% for patients with cerebral infarction, 7.7% for patients with AMI and 19.9% for patients with both conditions (p < 0.001). The median length of stay was 4 days, 3 days and 7 days for cerebral infarction, AMI and when both occurred together, respectively (p < 0.001). The median total healthcare cost for cerebral infarction, AMI and when both occurred was US$10,647, $15,735 and $23,290, respectively (p < 0.001). After adjustments for potential confounders, in-hospital mortality [adjusted odds ratio (aOR) 4.07, 95% CI 3.93-4.21], length of stay (aOR 3.95 95% CI 3.85-4.04), and hospitalization cost (regression coefficient 15,480 95% CI 15,135-15,825) were greater for patients with AMI and cerebral infarction compared to admission for cerebral infarction only. Cerebral infarction and AMI during the same hospitalization occurs in 5% of admissions with cerebral infarction and 3% of admission with AMI and is associated with significant increase in mortality, length of stay and cost compared to admissions with either condition alone.

Early Rhythm Control in Patients With Incident Atrial Fibrillation Who Had a Prior Stroke

BACKGROUND

There are limited data regarding the benefit of early rhythm control therapy for secondary prevention for stroke in patients with atrial fibrillation (AF).

OBJECTIVES

This study aimed to compare the risk of recurrent stroke between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke.

METHODS

Using the Korean nationwide claims database, the investigators identified patients who were newly diagnosed with AF and had a history of prior stroke. Patients who received rhythm control therapy, including antiarrhythmic drug, direct current cardioversion, or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, and the others were the usual care group. The propensity score weighting method was used to balance baseline characteristics between the 2 groups. Incident stroke was evaluated as a primary outcome.

RESULTS

A total of 53,509 patients were included (12,455 in the early rhythm control group and 41,054 in the usual care group). All patients were prescribed oral anticoagulants. During a median 2.6 years of follow-up, 4,382 patients had an incident stroke (incidence rate: 2.6 per 100 person-years). Early rhythm control was associated with a lower risk of recurrent stroke compared to the risk associated with usual care (weighted HR: 0.720; 95% CI: 0.666-0.779; P < 0.001).

CONCLUSIONS

Early rhythm control within 1 year after AF diagnosis might be beneficial to prevent recurrent stroke in patients with incident AF and a history of stroke. Integrated care, including optimal rhythm control with appropriate anticoagulation, should be considered in this population.

Atrial fibrillation and stroke

INTRODUCTION

Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified.

AREAS COVERED

This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract).

EXPERT OPINION

The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.

Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort

Background:

Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called “stroke-heart syndrome.” We aimed to investigate the relation of TIAs to incident clinical events.

Methods:

Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke.

Results:

The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21–9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51–2.32). Age also provided strong associations with incident TIA events.

Conclusions:

Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.

Acute ischaemic stroke: recent advances in reperfusion treatment

During the last 5–7 years, tremendous progress was achieved in the reperfusion treatment of acute ischaemic stroke during its first few hours from symptom onset. This review summarizes the latest evidence from randomized clinical trials and prospective registries with a focus on endovascular treatment using stent retrievers, aspiration catheters, thrombolytics, and (in selected patients) carotid stenting. Novel approaches in prehospital (mobile interventional stroke teams) and early hospital (direct transfer to angiography) management are described, and future perspectives (‘all-in-one’ laboratories with angiography and computed tomography integrated) are discussed. There is reasonable chance for patients with moderate-to-severe acute ischaemic stroke to survive without permanent sequelae when the large-vessel occlusion is removed by means of modern pharmaco-mechanic approach. Catheter thrombectomy is now the golden standard of acute stroke treatment. The role of cardiologists in stroke is expanding from diagnostic help (to reveal the cause of stroke) to acute therapy in those regions where such up-to-date Class I. A treatment is not yet available.

Should Audits Consider the Care Pathway Model? A New Approach to Benchmarking Real-World Activities

Clinical audit is a method to assess the quality of healthcare services based on whether standards are met or not met. This approach is limited because it fails to recognize how decisions that take place over time and the natural progression of disease has an impact on what happens to patients and the care they receive. The aim of this paper is to introduce the concept of care pathway and explain how care pathways can be audited to better understand care. The care pathway is defined by clinically relevant events that take place within one or more healthcare institutions. The process begins with defining an ideal care pathway which is created by considering local expertise and guidelines. It is then possible to audit against the extent to which this ideal care pathway is achieved. This care pathway audit can enable identification of patterns in real-world care which can help with the of design interventions to help shift patients from the less to more desirable pathways. We conclude that through the process of the care pathway audit cycle, it is possible to learn about real-world activities, better utilize resources, promote safer care, improve quality of care, and help develop more effective interventions.