Statins after recent stroke reduces recurrence and improves survival in an aging Mediterranean population without known coronary heart disease

Stroke health management: Novel strategies for the prevention of recurrent ischemic stroke

Objectives

The aim of the study was to assess the effect of the stroke health management model on the prognosis and recurrence of mild to moderate ischemic stroke, guided by the stroke health manager based on the patients' needs. In addition, up-to-date evidence of healthcare resource allocation, planning, and optimization is provided.

Methods

The current research was a retrospective, observational, single-center, history-controlled study with patients divided into two groups, namely, the intervention group and the control group, following the guidance of the stroke health manager. The control group patients received standard medical care during hospitalization, which consisted of advice on healthy lifestyle choices carried out by the bed nurse, but no structured education, WeChat group, or clinical consultation was included. The intervention group patients, in addition to the standard medical care, received health management and health education from the stroke health manager, and after hospital discharge, the patients were followed up over the telephone by the health manager to see if there was any recurrence or readmission.

Results

From 1 January 2018 to 31 December 2020, 382 patients with acute ischemic stroke were enrolled in this study. Through the univariate regression analysis, we found that SHM intervention was associated with a significantly lower risk of recurrence (HR = 0.459). We constructed a nomogram based on the significant variables from the regression analysis and also analyzed the association between the control group and the SHM intervention group among all subgroups using the Cox proportional hazards model to assess the effect of the stroke health management model. Most patients in this study had a total risk point between 170 and 270. The C-index value was 0.76, and the time-dependent AUC for predicting recurrence was >0.7.

Conclusion

The stroke health manager-guided management model based on patients' needs can better control the risk factors of stroke and significantly reduce the recurrence rate of mild to moderate ischemic stroke within 1 year.

Long term clinical outcomes of patients with ischemic stroke in primary care - a 9-year retrospective study

Background

We aim to document the long-term outcomes of ischemic stroke patients and explore the potential risk factors for recurrent cardiovascular events and all-cause mortality in primary care.

Methods

A retrospective cohort study performed at two general out-patient clinics (GOPCs) under Hospital Authority (HA) in Hong Kong (HK). Ischemic stroke patients with at least two consecutive follow-up visits during the recruitment period (1/1–30/6/2010) were included. Patients were followed up regularly till the date of recurrent stroke, cardiovascular event, death or 31/12/2018. The primary outcome was the occurrence of recurrent cerebrovascular event including transient ischemic stroke (TIA), ischemic stroke or hemorrhagic stroke. The secondary outcomes were all-cause mortality and coronary artery disease (CAD). We fit cox proportional hazard model adjusting death as competing risk factor to estimate the cause-specific hazard ratio (csHR).

Results

A total of 466 patients (mean age, 71.5 years) were included. During a median follow-up period of 8.7 years, 158 patients (33.9%) died. Eighty patients (17.2%) had recurrent stroke and 57 (12.2%) patients developed CAD. Age was an independent risk factor for recurrent stroke, CAD and death. Statin therapy at baseline had a protective effect for recurrent stroke (csHR = 0.476; 95% confidence interval [CI] 0.285–0.796, P = 0.005) after adjusting death as a competing risk factor and all-cause mortality (HR = 0.693, 95% CI 0.486–0.968, P = 0.043). In addition, female sex, antiplatelet and a higher diastolic blood pressure (DBP) at baseline were also independent predictors for survival.

Conclusions

Long term prognosis of ischemic stroke patients in primary care is favorable. Use of statin was associated with a significant decrease in stroke recurrence and mortality. Patients who died had a significant lower DBP at baseline, highlighted the need to consider both systolic and diastolic blood pressure in our daily practice.

Expression and short-term prognostic value of miR-126 and miR-182 in patients with acute stroke

Expression and short-term prognostic value of miR-126 and miR-182 in patients with acute stroke were investigated. In total, 153 patients with acute stroke admitted to the Second Affiliated Hospital of Soochow University from February 2016 to February 2018 were enrolled into the observation group as group A [88 patients with acute cerebral infarction (AIS)] or group B [65 patients with cerebral hemorrhage (ICH)]. Furthermore, 69 healthy people receiving physical examinations in the hospital were enrolled into the control group. The relative expression of miR-126 and miR-182 in all subjects were measured and their correlation with the National Institute of Health stroke scale (NIHSS) and activities of daily living (ADL) scores was analyzed. After 3 months of follow-up, the correlation of miR-126 and miR-182 with the Modified Rankin Scale (MRS) score of patients was investigated. The receiver operating characteristic (ROC) curve was employed to explore the value of miR-126 and miR-182, alone or in combination, in predicting the prognosis of acute stroke patients. Subjects in the control group had markedly higher miR-126 expression and lower miR-182 expression than those in group A and group B in the observation group (P<0.05). Pearson's correlation analysis suggested a notable correlation of miR-126 and miR-182 with NIHSS and ADL scores. Patients with a mild condition or good prognosis had higher miR-126 expression and lower miR-182 expression than patients with a severe condition or poor prognosis (P<0.05). Both miR-126 and miR-182 predicted the prognosis of acute stroke, and the combination of miR-126 and miR-182 presented better accuracy. The expression levels of miR-126 and miR-182 are associated with the neurological function, self-care ability, and prognosis in patients with acute stroke is highly valuable for predicting the prognosis of patients.

Real-world cardiovascular disease burden in patients with atherosclerotic cardiovascular disease: a comprehensive systematic literature review

OBJECTIVE

Based on randomized controlled trials (RCTs), non-fatal myocardial infarction (MI) rates range between 9 and 15 events per 1000 person-years, ischemic stroke between 4 and 6 per 1000 person-years, CHD death rates between 5 and 7 events per 1000 person-years, and any major vascular event between 28 and 53 per 1000 person-years in patients with atherosclerotic cardiovascular disease (ASCVD). We reviewed global literature on the topic to determine whether the real-world burden of secondary major adverse cardiovascular events (MACEs) is higher among ASCVD patients.

METHODS

We searched PubMed and Embase using MeSH/keywords including cardiovascular disease, secondary prevention and observational studies. Studies published in the last 5 years, in English, with ≥50 subjects with elevated low-density lipoprotein cholesterol (LDL-C) or on statins, and reporting secondary MACEs were included. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of each included study.

RESULTS

Of 4663 identified articles, 14 studies that reported MACE incidence rates per 1000 person-years were included in the review (NOS grades ranged from 8 to 9; 2 were prospective and 12 were retrospective studies). Reported incidence rates per 1000 person-years had a range (median) of 12.01-39.9 (26.8) for MI, 13.8-57.2 (41.5) for ischemic stroke, 1.0-94.5 (21.1) for CV-related mortality and 9.7-486 (52.6) for all-cause mortality. Rates were 25.8-211 (81.1) for composite of MACEs. Multiple event rates had a range (median) of 60-391 (183) events per 1000 person-years.

CONCLUSIONS

Our review indicates that MACE rates observed in real-world studies are substantially higher than those reported in RCTs, suggesting that the secondary MACE burden and potential benefits of effective CVD management in ASCVD patients may be underestimated if real-world data are not taken into consideration.

Comparative effects of more versus less aggressive treatment with statins on the long-term outcome of patients with acute ischemic stroke

BACKGROUND AND AIMS

There are no studies that compared the effects of different intensities of statin treatment on the long-term outcome of patients with recent ischemic stroke. We aimed to evaluate these effects.

METHODS

We prospectively studied 436 consecutive patients who were discharged after acute ischemic stroke (39.2% males, age 78.6 ± 6.7 years). Statin treatment was categorized in equipotent doses of atorvastatin. One year after discharge, the functional status was assessed with the modified Rankin scale (mRS). Adverse outcome was defined as mRS between 2 and 6. The occurrence of ischemic stroke, myocardial infarction and death was recorded.

RESULT

Adverse outcome rates were lower in patients treated with atorvastatin 20 mg/day or more potent doses of statins than in patients treated with atorvastatin 10 mg/day (63.5, 38.2 and 48.2%, respectively; p = 0.004). In binary logistic regression analysis, independent predictors of adverse outcome were the mRS at discharge (relative risk (RR) 2.33, 95% confidence interval (CI) 1.77-3.07, p < 0.001) whereas more aggressive treatment with statins independently predicted favorable outcome (atorvastatin 20 vs. 10 mg/day, RR 0.30, 95% CI 0.11-0.87, p = 0.026; atorvastatin 40 mg/day or more potent dose of statins vs. atorvastatin 10 mg/day, RR 1.66, 95% CI 0.62-4.44, p = NS). The incidence of cardiovascular events and all-cause mortality showed a trend for being lower in patients treated with atorvastatin 40-80 mg/day or rosuvastatin 10-40 mg/day than in those treated with less potent doses of statins.

CONCLUSION

More aggressive statin treatment improves the long-term functional outcome of patients with acute ischemic stroke more than less aggressive treatment.

Pathophysiology and Treatments of Oxidative Injury in Ischemic Stroke: Focus on the Phagocytic NADPH Oxidase 2

SIGNIFICANCE

Phagocytes play a key role in promoting the oxidative stress after ischemic stroke occurrence. The phagocytic NADPH oxidase (NOX) 2 is a membrane-bound enzyme complex involved in the antimicrobial respiratory burst and free radical production in these cells.

RECENT ADVANCES

Different oxidants have been shown to induce opposite effects on neuronal homeostasis after a stroke. However, several experimental models support the detrimental effects of NOX activity (especially the phagocytic isoform) on brain recovery after stroke. Therapeutic strategies selectively targeting the neurotoxic ROS and increasing neuroprotective oxidants have recently produced promising results.

CRITICAL ISSUES

NOX2 might promote carotid plaque rupture and stroke occurrence. In addition, NOX2-derived reactive oxygen species (ROS) released by resident and recruited phagocytes enhance cerebral ischemic injury, activating the inflammatory apoptotic pathways. The aim of this review is to update evidence on phagocyte-related oxidative stress, focusing on the role of NOX2 as a potential therapeutic target to reduce ROS-related cerebral injury after stroke.

FUTURE DIRECTIONS

Radical scavenger compounds (such as Ebselen and Edaravone) are under clinical investigation as a therapeutic approach against stroke. On the other hand, NOX inhibition might represent a promising strategy to prevent the stroke-related injury. Although selective NOX inhibitors are not yet available, nonselective compounds (such as apocynin and fasudil) provided encouraging results in preclinical studies. Whereas additional studies are needed to better evaluate this therapeutic potential in human beings, the development of specific NOX inhibitors (such as monoclonal antibodies, small-molecule inhibitors, or aptamers) might further improve brain recovery after stroke.

Statins and the risks of stroke recurrence and death after ischemic stroke: the Fukuoka Stroke Registry

BACKGROUND AND PURPOSE

The findings of recent clinical trials suggest that treatment with high-dose statins reduces the risk of stroke recurrence. However, the doses approved in Japan are much lower than those in the previous studies. This study aimed to elucidate whether prescribed doses of statins reduce the risks of cerebrovascular events (CVEs: stroke recurrence or transient ischemic attack) and all-cause mortality in a cohort of Japanese patients with first-ever ischemic stroke.

METHODS

The 2822 eligible patients registered in the Fukuoka Stroke Registry with first-ever acute ischemic stroke from June 2007 to February 2011 were classified into statin users (n = 993) and non-users (n = 1829) at discharge, and followed up until March 2012. We assessed the cumulative risks of CVE and all-cause mortality by the Kaplan-Meier method, and calculated hazard ratios (HRs) and 95% confidential intervals (CIs) using the Cox proportional hazards model.

RESULTS

During the follow-up time (median, 2.0 years), 305 patients had CVEs and 345 died. The cumulative risks of CVE and death after 4 years were significantly lower in statin users than in non-users (13.8% versus 19.5%, P = 0.005 for CVE; 11.8% versus 21.7%, P < 0.001 for death). After adjusting for multiple confounding factors, statin treatment significantly reduced the risks of CVE (HR, 0.70; 95% CI, 0.53 to 0.92; P = 0.011) and all-cause mortality (HR, 0.67; 95% CI, 0.50 to 0.89; P = 0.006).

CONCLUSIONS

Our findings suggest that low-dose statin may reduce the risks of CVE and death in Japanese patients with acute ischemic stroke.