Low serum albumin levels predict poor outcome in patients with acute ischaemic stroke or transient ischaemic attack

Development and validation of a novel nomogram model predicting the unfavorable outcome based on NAR and collaterals status for patients with AIS

INTRODUCTION

Stroke is a leading cause of disability and mortality globally. This study aimed to develop a prognostic nomogram based on neutrophil-to-albumin ratio (NAR) and collateral status in acute ischemic stroke (AIS) patients with anterior large vessel occlusion (LVO).

MATERIAL & METHOD

590 AIS patients with LVO assessed for regional leptomeningeal collateral (rLMC) were retrospectively enrolled, and randomly divided into a training set (n = 414) and a testing set (n = 176). Unfavorable functional outcome was defined as a modified Rankin scale (mRS) score of 3 to 6 at 3 months. We assessed the accuracy and clinical utility of the nomogram using calibration plots, area under the curve (AUC), decision curve analysis (DCA), net reclassification index (NRI), and integrated discrimination improvement (IDI).

RESULTS

Both NAR and rLMC were independently associated with unfavorable outcome at 3 months (OR=8.96, p=0.0341; OR=0.89, p=0.0002, respectively). The developed nomogram (akaike information criterion (AIC)=398.77), which included NAR, rLMC and other factors, showed good performance (the AUC for the development and validation cohorts was 0.848 and 0.840 respectively) and improved the predictive value compared to a model without NAR and rLMC, according to an overall NRI of 3.27% (p=0.2401), overall IDI of 3.27% (p=0.2414), and a higher AUC (0.848 vs 0.831).

CONCLUSIONS

NAR can serve as an independent predictor in AIS patients with anterior LVO, and the nomogram incorporating NAR and rLMC is reliable in predicting unfavorable outcome. Further studies with larger sample sizes are needed to validate and extend these findings.

A High Fibrinogen-to-Albumin Ratio on Admission is Associated with Early Neurological Deterioration Following Intravenous Thrombolysis in Patients with Acute Ischemic Stroke

Purpose

The fibrinogen-to-albumin ratio (FAR) is a novel inflammation marker associated with various diseases. This study aimed to investigate the correlation between FAR and early neurological deterioration (END) after intravenous thrombolysis (IVT) in patients with acute ischemic stroke (AIS).

Patients and Methods

From September 1, 2021, to March 31, 2023, continuously recruited AIS patients who received IVT within 4.5 hours were included in the study. Blood samples were collected in the emergency room before IVT. The National Institutes of Health Stroke Scale (NIHSS) score was assessed upon admission and after thrombolysis within the first 24 hours. END was defined as an increase in the NIHSS score by ≥ 4 points within 24 hours after thrombolysis. Multivariate logistic regression analysis was conducted to explore the relationship between FAR and END, and a receiver operating characteristic (ROC) curve was used to evaluate the predictive ability of FAR for END.

Results

343 participants were recruited, and 59 (17.2%) experienced END. Patients with END had higher FAR levels than those without END (P<0.001). Multivariate logistic regression analysis showed that FAR was independently associated with END, both as a continuous variable and as a tertile variable (P<0.005). After excluding patients with hemorrhagic transformation (HT), FAR remained independently associated with END (P<0.005). The area under the curve (AUC) of FAR for predicting END was 0.650 (95% CI=0.571-0.729, P<0.001), with an optimal cutoff of 72.367 mg/g, a sensitivity of 61.6%, and a specificity of 62.6%.

Conclusion

FAR upon admission was independently associated with END after IVT and can be an effective predictor.

Which one predicts mortality better in acute ischemic stroke: negative vs positive acute-phase reactants

AIM

The aim of the study is to investigate the relationship between negative acute-phase reactants and positive acute-phase reactants with in-hospital mortality in patients diagnosed with acute ischemic stroke (AIS) in the emergency department (ED).

METHODS AND MATERIALS

Patients aged 18 and older who presented to the ED of a tertiary hospital with AIS were included in the study. Demographic and clinical characteristics, laboratory parameters, acute-phase reactants, National Institutes of Health Stroke Scale (NIHSS), and outcome data of the included patients were recorded on a standard data form.

RESULTS

A total of 588 patients were included in the study. When the in-hospital mortality of patients was examined, the mortality rate was 17.7%. In the analysis for predicting mortality, it was determined that albumin had the highest predictive power between the area under the curve (AUC) and the determined predictive values (AUC: 0.759, 95% CI 0.707-0.810, p < 0.001). The analyses of the study data revealed that albumin (<0.001) and TF (p = 0.049), which are negative acute-phase reactants, were independent predictors of mortality. According to our study data, in patients with AIS, for each unit decrease in albumin level at the time of ED admission, the risk of mortality increased by 0.868 times, and for each unit decrease in TF level, the risk of mortality increased by 0.593 times.

CONCLUSION

According to the study data, albumin and TF levels, which are negative acute-phase reactants, are independent determinants of in-hospital mortality in patients with acute ischemic stroke in the emergency department.

Serum Albumin and Post-Stroke Outcomes: Analysis of UK Regional Registry Data, Systematic Review, and Meta-Analysis

Hypoalbuminemia associates with poor acute ischemic stroke (AIS) outcomes. We hypothesised a non-linear relationship and aimed to systematically assess this association using prospective stroke data from the Norfolk and Norwich Stroke and TIA Register. Consecutive AIS patients aged ≥40 years admitted December 2003-December 2016 were included. Outcomes: In-hospital mortality, poor discharge, functional outcome (modified Rankin score 3-6), prolonged length of stay (PLoS) > 4 days, and long-term mortality. Restricted cubic spline regressions investigated the albumin-outcome relationship. We updated a systematic review (PubMed, Scopus, and Embase databases, January 2020-June 2023) and undertook a meta-analysis. A total of 9979 patients were included; mean age (standard deviation) = 78.3 (11.2) years; mean serum albumin 36.69 g/L (5.38). Compared to the cohort median, albumin < 37 g/L associated with up to two-fold higher long-term mortality (HRmax; 95% CI = 2.01; 1.61-2.49) and in-hospital mortality (RRmax; 95% CI = 1.48; 1.21-1.80). Albumin > 44 g/L associated with up to 12% higher long-term mortality (HRmax1.12; 1.06-1.19). Nine studies met our inclusion criteria totalling 23,597 patients. Low albumin associated with increased risk of long-term mortality (two studies; relative risk 1.57 (95% CI 1.11-2.22; I2 = 81.28)), as did low-normal albumin (RR 1.10 (95% CI 1.01-1.20; I2 = 0.00)). Strong evidence indicates increased long-term mortality in AIS patients with low or low-normal albumin on admission.

Ischemic Stroke Outcome Predicted by Serum Albumin Levels

OBJECTIVE AND AIM

 This research aims to assess the predictive importance of serum albumin levels in individuals who have recently experienced an acute ischemic stroke and to establish a correlation between these two variables.

MATERIALS AND METHODS

A prospective hospital-based investigation with 50 participants was conducted after receiving ethical approval from Sunshine Hospital, Hyderabad, India. Patients older than 18 years old who had radiological or clinical evidence of having suffered an acute ischemic stroke were considered for participation in the research.

RESULTS

 Albumin levels in the blood are typically about 3.6 g/dL. One patient between the ages of 46 and 55 had low serum albumin levels. Many people in both groups had albumin levels of about 4.4. Serum albumin concentration was measured using the modified Rankin Scale (mRS). After one week and three months, 32 patients had mRS values of less than three, whereas 16 had mRS values of greater than three-one; the individual presented with an mRS value over 3, as well as a blood albumin level below 3.5. The p-value ended up being 0.428. No link could be supported by the statistical evidence identified. P = 0.249 indicated no association between serum albumin and National Institutes of Health Stroke Scale (NIHSS) scores. According to the findings of this inquiry, there is no correlation between the amounts of albumin in the blood and the NIHSS scores.

CONCLUSION

This study did not find a correlation between higher blood albumin levels and a worse outcome after an ischemic stroke. It contradicts the corpus of current knowledge.

Serum albumin and cardiovascular disease: a Mendelian randomization study

BACKGROUND

An increasing body of evidence suggests that serum albumin levels play a role in cardiovascular diseases. However, the specific causal relationship between serum albumin levels and cardiovascular disease remains partially unknown.

METHODS

Mendelian randomization (MR) was employed in this study to examine potential causal relationships between instrumental variables and cardiovascular diseases. Specifically, we utilized genetic variants of serum albumin levels within the reference range as our instrumental variables. To acquire data on genetic associations with cardiovascular diseases, we sourced information from renowned genome-wide association studies such as UK BioBank, EMBL-EBI, and FinnGen. Notably, our study leveraged summary statistics from large cohorts that have been previously described.

RESULTS

We explored the association between serum albumin levels and various conditions, including heart failure (HF), venous thromboembolism (VTE), stroke, atrial fibrillation (AF), coronary artery disease (CAD), type 2 diabetes (T2DM), and pulmonary heart disease (PHD). Genetically predicted serum albumin levels were associated with PHD (odds ratio = 0.737, 95% CI = 0.622 - 0.874, P < 0.001), AF (odds ratio = 0.922, 95% CI = 0.870 - 0.977, P = 0.006), VTE (odds ratio = 0.993, 95% CI = 0.991 - 0.995, P < 0.001), and Stroke (odds ratio = 0.997, 95% CI = 0.995 - 0.999, P = 0.002). However, genetically predicted serum albumin level traits were not associated with HF, CAD and T2DM.

CONCLUSION

Our study demonstrates a significant association between serum albumin levels and cardiovascular disease, underscoring the crucial role of low serum albumin as a predictive factor in patients with cardiovascular disease.

The systemic inflammation score is a prognostic factor for patients with ischemic stroke who have not undergone intravenous thrombolysis or endovascular thrombectomy therapy

BACKGROUND

The systemic inflammation score (SIS) has been utilised as a representative biomarker for evaluating nutritional and inflammation status. However, the predictive value of SIS has not been reported in patients with acute ischemic stroke (AIS). We aimed to evaluate whether SIS is associated with prognosis in stroke.

METHODS

A total of 4801 patients with AIS were included in the study. The primary outcome was a modified Rankin Scale score>2 at the 3-month follow-up. A total of 4801 patients were randomly allocated into training (n=3361) and validation cohorts (n=1440) at a ratio of 7:3. Model performance was validated using the receiver operating characteristic (ROC) curve and calibration curve. Additionally, a comparison was made between the nomogram and the THRIVE score in regards to their respective predictive capabilities.

RESULTS

Overall, 1091(32.5%) patients in the training cohort and 446 (31.0%) patients in the validation cohort experienced an unfavorable outcome. The multivariate logistic regression analysis revealed that a high SIS, age, NIHSS, diabetes and prior stroke were associated with unfavorable outcome. Our nomogram was developed based on the variables mentioned above. The area under the curve (AUC) of the training set and the validation set are 0.702 and 0.708, respectively, indicating that the model has modest agreement and discrimination. The results of AUC, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) showed that nomogram had significantly higher predictive value than THRIVE scores (all P<0.001). However, unlike the THRIVE publication, all patients who had undergone intravenous thrombolysis or endovascular thrombectomy therapy were excluded in our study. In consequence, our derived THRIVE scores cannot be compared to those in the original THRIVE study.

CONCLUSION

The SIS exhibits potential as a simple prognostic biomarker, and the nomogram, which utilizes the SIS, may serve as a valuable tool for clinicians in the early identification of patients at heightened risk for unfavorable outcomes.

Albumin Levels and Risk of Early Cardiovascular Complications After Ischemic Stroke: A Propensity-Matched Analysis of a Global Federated Health Network

BACKGROUND

No studies have investigated the association between albumin levels and the risk of early cardiovascular complications in patients with ischemic stroke.

METHODS

Retrospective analysis with a federated research network (TriNetX) based on electronic medical records (International Classification of Diseases-Tenth Revision-Clinical Modification and logical observation identifiers names and codes) mainly reported between 2000 and 2023, from 80 health care organizations in the United States. Based on albumin levels measured at admission to the hospital, patients with ischemic stroke were categorized into 2 groups: (1) reduced (≤3.4 g/dL) and (2) normal (≥3.5 g/dL) albumin levels. The primary outcome was a composite of all-cause death, heart failure, atrial fibrillation, ventricular arrhythmias, myocardial infarction, and Takotsubo cardiomyopathy 30 days from the stroke. Secondary outcomes were the risk for each component of the primary outcome. Cox regression analyses were used to calculate hazard ratios (HRs) and 95% CIs following propensity score matching.

RESULTS

Overall, 320 111 patients with stroke had normal albumin levels (70.9±14.7 years; 48.9% females) and 183 729 (57.4%) had reduced albumin levels (72.9±14.3 years; 50.3% females). After propensity score matching, the primary outcomes occurred in 36.0% of patients with reduced and 26.1% with normal albumin levels (HR, 1.48 [95% CI, 1.46-1.50]). The higher risk in patients with reduced albumin levels was consistent also for all-cause death (HR, 2.77 [95% CI, 2.70-2.84]), heart failure (HR, 1.31 [95% CI, 1.29-1.34]), atrial fibrillation (HR, 1.11 [95% CI, 1.09-1.13]), ventricular arrhythmias (HR, 1.38 [95% CI, 1.30-1.46]), myocardial infarction (HR, 1.60 [95% CI, 1.54-1.65]), and Takotsubo cardiomyopathy (HR, 1.51 [95% CI, 1.26-1.82]). The association between albumin levels and the risk of cardiovascular events was independent of advanced age, sex, multimorbidity, and other causes of hypoalbuminemia. A progressively increased risk of adverse events was found in patients with mild and severe reduced compared to normal albumin levels.

CONCLUSIONS

Albumin levels are associated with the risk of early cardiovascular events and death in patients with ischemic stroke. The potential pathophysiological or therapeutic roles of albumin in patients with stroke warrant further investigation.

Combined Prognostic Impact of Low Muscle Mass and Hypoalbuminemia in Patients Hospitalized for Heart Failure: A Retrospective Cohort Study

BACKGROUND

Sarcopenia and hypoalbuminemia have been identified as independent predictors of increased adverse outcomes, including mortality and readmissions, in hospitalized older adults with acute decompensated heart failure (ADHF). However, the impact of coexisting sarcopenia and hypoalbuminemia on morbidity and death in adults with ADHF has not yet been investigated. We aimed to investigate the combined effects of lower muscle mass (LMM) as a surrogate for sarcopenia and hypoalbuminemia on in-hospital and postdischarge outcomes of patients hospitalized for ADHF.

METHODS AND RESULTS

A total of 385 patients admitted for ADHF between 2017 and 2020 at a single institution were retrospectively identified. Demographic and clinical data were collected, including serum albumin levels at admission and discharge. Skeletal muscle indices were derived from semi-automated segmentation software analysis on axial chest computed tomography at the twelfth vertebral level. Our analysis revealed that patients who had LMM with admission hypoalbuminemia experienced increased diagnoses of infection and delirium with longer hospital length of stay and more frequent discharge to a facility. Upon discharge, 27.9% of patients had higher muscle mass without discharge hypoalbuminemia (reference group), 9.7% had LMM without discharge hypoalbuminemia, 38.4% had higher muscle mass with discharge hypoalbuminemia, and 24.0% had LMM with discharge hypoalbuminemia; mortality rates were 37.6%, 51.4%, 48.9%, and 63.2%, respectively. 1- and 3-year mortality risks were highest in those with LMM and discharge hypoalbuminemia; this relationship remained significant over a median 23.6 (3.1-33.8) months follow-up time despite multivariable adjustments (hazard ratio, 2.03 [95% CI, 1.31-3.16]; P=0.002).

CONCLUSIONS

Hospitalization with ADHF, LMM, and hypoalbuminemia portend heightened mortality risk.

Fibrinogen-to-Albumin Ratio and Clinical Outcomes in Patients With Large Artery Atherosclerosis Stroke

BACKGROUND

A high fibrinogen-to-albumin ratio (FAR), a novel inflammatory marker, is considered to be a prognostic marker in vascular diseases. However, the association of FAR with large artery atherosclerosis (LAA) stroke is still unknown. This study was conducted to evaluate the association between FAR levels and clinical outcomes in patients with acute LAA stroke.

METHODS AND RESULTS

A total of 809 patients within 72 hours of LAA stroke were included and followed up to 1 year. FAR was calculated as fibrinogen (g/L)/albumin (g/L). The associations of FAR with clinical outcomes were assessed by multivariate Cox regression or logistic regression analysis. Clinical outcomes included stroke recurrence, all-cause death, poor functional outcome (modified Rankin Scale score 3-6), and dependence (modified Rankin Scale score 3-5). Among the 809 patients with acute LAA stroke, the median FAR was 0.075 (interquartile range, 0.064-0.087). At 1 year, 103 (12.7%) patients had stroke recurrence, 105 (13.0%) had poor functional outcome, 76 (9.8%) had dependence, and 29 (3.6%) had died. After adjusting for all confounding risk factors, a high FAR level was associated with stroke recurrence (hazard ratio, 2.57 [95% CI, 1.32-5.02]), poor functional outcome (odds ratio, 3.30 [95% CI, 1.57-6.94]), and dependence (odds ratio, 3.49 [95% CI, 1.49-8.19]).

CONCLUSIONS

A high FAR level was associated with an increased risk of stroke recurrence, poor functional outcome, and dependence in patients with acute LAA stroke.

Association between lactate/albumin ratio and 28-day all-cause mortality in ischemic stroke patients without reperfusion therapy: a retrospective analysis of the MIMIC-IV database

Objective

The lactate/albumin ratio (LAR) has been used as a novel prognostic indicator for aneurysmal subarachnoid hemorrhage, traumatic brain injury, sepsis, heart failure, and acute respiratory failure. However, its potential in predicting all-cause mortality in patients with ischemic stroke (IS) has not been evaluated. Therefore, this study aimed to elucidate the correlation between LAR and 28-day all-cause mortality in IS patients without reperfusion therapy.

Methods

This retrospective cohort study used data from the Medical Information Mart for Intensive Care (MIMIC-IV) (v2.0) database. It included 568 IS adult patients admitted to the intensive care unit (ICU). The correlation between LAR and ICU 28-day all-cause mortality rate was analyzed using multiple COX regression analysis and Kaplan-Meier survival analysis. Restricted cubic spline (RCS) curves were used to assess the relationship between LAR and 28-day mortality. In addition, a subgroup analysis was performed to investigate the impact of other influencing factors on outcomes. The primary outcome was the ability of LAR to predict 28-day mortality in IS patients.

Results

Among the 568 patients with IS, 370 survived (survival group) and 198 died (non-survival group) within 28 days of admission (mortality rate: 34.9%). A multivariate COX regression analysis indicated that LAR was an independent predictor of all-cause mortality within 28 days after admission for patients with IS (hazard ratio: 1.32; 95% confidence interval: 1.03-1.68; P = 0.025). We constructed a model that included LAR, age, race, sex, white blood cell count, Sequential Organ Failure Assessment (SOFA) score, and anion gap (AG) and established a prediction model with an area under the curve (AUC) value of 71.5% (95% confidence interval: 67.1%-75.8%). The optimal cutoff value of LAR that separated the survival group and the non-survival group based on the Youden index was 0.55. The Kaplan-Meier survival curves plotted using this critical value showed that patients with LAR ≥ 0.55 had a significantly higher 28-day all-cause mortality rate than patients with LAR < 0.55 (P = 0.0083).

Conclusion

LAR can serve as an independent predictor of all-cause mortality within 28 days after admission for patients with IS.

Serum Globulin to Albumin Ratio as a Novel Predictor of Adverse Clinical Outcomes in Coronary Artery Disease Patients Who Underwent PCI

Background

Coronary heart disease is one of the main causes of Mortality. Many biological indicators have been used to predict the prognosis of patients with coronary heart disease. The ratio of serum globulin to albumin (GAR) has been used to predict the prognosis of patients with various cancers. It has been proven that GAR is related to the prognosis of patients with stroke. However, GAR's role in cardiovascular disease remains unclear. Our purpose was to investigate the predictive value of GAR on clinical outcomes in post-percutaneous coronary intervention (PCI) patients with coronary artery disease (CAD).

Methods

From Dec. 2016 to Oct. 2021, a total of 14,994 patients undergoing PCI patients admitted to the First Affiliated Hospital of Xinjiang Medical University were divided into high GAR group (GAR ≥ 0.76, n = 4087) and low GAR group (GAR < 0.76, n = 10,907). The incidence of adverse outcomes including all-cause mortality (ACM), cardiovascular mortality (CM), major adverse cardiovascular events (MACE) and major adverse cardiovascular and cerebrovascular events (MACCE) was compared between the two groups. Multivariate Cox regression was used to adjust for the effects of confounding factors, while hazard ratios (HRs) and 95% confidence intervals (95% CI) were calculated. Median follow-up time was 24 months.

Results

Compared with the low GAR group, the high GAR group had significantly higher incidence of ACM (6.5% vs. 1.7%, p < 0.001); CM (4.9% vs. 1.2%, p < 0.001), MACE (10.5% vs. 6.7%, p < 0.001), and MACCE (11.3% vs. 7.5%, p < 0.001). Cox regression analysis showed the patients in the high GAR group had a 1.62-fold increased risk for ACM (HR = 2.622, 95% CI: 2.130-3.228, p < 0.01), a 1.782-fold increased risk for CM (HR = 2.782, 95% CI: 2.180-3.550, p < 0.01). There was a 37.2% increased risk for MACE (HR = 1.372, 95% CI: 1.204-1.564, p < 0.01), and 32.4% increased risk for MACCE (HR = 1.324, 95% CI: 1.169-1.500, p < 0.01), compared to the patients in the low GAR group.

Conclusions

The present study suggested that post-PCI CAD patients with higher GAR presented significantly increased mortality and adverse events GAR level at admission may 296 be considered as part of risk stratification when PCI is possible in patients with coronary heart disease.

Clinical Trial Registration

The detailed information of the PRACTICE study has been registered on http://Clinicaltrials.gov (Identifier: NCT05174143).

Serum Albumin Levels: A Biomarker to Be Repurposed in Different Disease Settings in Clinical Practice

Serum albumin (ALB), one of the most important proteins in human physiology, has the main functions of maintaining plasma oncotic pressure and plasma volume, transporting hormones, vitamins, oligominerals and drugs, and exerting a powerful antioxidant-anti-inflammatory role. Its prognostic value in liver and malabsorption syndromes is well known. In this narrative review, an analysis of the most important studies evaluating the prognostic significance of low serum ALB levels in hospitalized patients was performed. Specifically, the risk in emergency medicine, cardiovascular diseases, Coronavirus Disease 19 (COVID-19) infection, nephrology, oncology, and autoimmune rheumatic diseases has been examined to fully explore its clinical value. ALB is a negative acute-phase reactant and the reduction in its serum levels represents a threatening parameter for long-term survival in several clinical settings, and a strong biomarker for a poor prognosis in most diseases. Therefore, clinicians should consider serum ALB as a valuable tool to assess the efficacy of specific therapies, both in hospitalized patients and in chronic follow-up.

Association of serum albumin levels and stroke risk in adults over 40 years: A population-based study

This study assessed the relationship between serum albumin levels and adult stroke risk. From the 2009 to 2018 National Health and Nutrition Examination Survey, we performed a cross-sectional study with 17,303 participants who were 40 years of age or higher. A multivariate logistic regression model investigated serum albumin levels and stroke. To investigate apparent nonlinear connections, smoothed curve fitting was used. When a nonlinear relationship was discovered, the inflection point was determined using a recursive method. Serum albumin levels were significantly and inversely linked with the risk of stroke after controlling for possible variables [odds ratio 0.02, 95% confidence interval (0.00, 0.18), P = .0003]. An examination of subgroups revealed that the inverse relationship between serum albumin levels and risk of stroke was statistically significant in men, participants under 60 years old, non-diabetic participants, and hypertensive participants. Serum albumin levels and the risk of stroke were negatively correlated. An increased risk of stroke was linked to lower serum albumin levels.

Biomarkers associated with functional improvement after stroke rehabilitation: a systematic review and meta-analysis of randomized controlled trials

Objective

This study aims to identify blood and cerebrospinal fluid biomarkers that are correlated to the functional improvement of stroke patients after rehabilitation therapy, and provide ideas for the treatment and evaluation of stroke patients.

Methods

The PubMed, Web of Science, and Embase databases were searched for articles published in the English language, from inception to December 8, 2022.

Results

A total of 9,810 independent records generated 50 high-quality randomized controlled trials on 119 biomarkers. Among these records, 37 articles were included for the meta-analysis (with a total of 2,567 stroke patients), and 101 peripheral blood and cerebrospinal fluid biomarkers were included for the qualitative analysis. The quantitative analysis results revealed a moderate quality evidence that stroke rehabilitation significantly increased the level of brain-derived neurotrophic factor (BDNF) in serum. Furthermore, the low-quality evidence revealed that stroke rehabilitation significantly increased the concentration of serum noradrenaline (NE), peripheral blood superoxide dismutase (SOD), peripheral blood albumin (ALB), peripheral blood hemoglobin (HB), and peripheral blood catalase (CAT), but significantly decreased the concentration of serum endothelin (ET) and glutamate. In addition, the changes in concentration of these biomarkers were associated with significant improvements in post-stroke function. The serum BNDF suggests that this can be used as a biomarker for non-invasive brain stimulation (NIBS) therapy, and to predict the improvement of stroke patients.

Conclusion

The concentration of serum BNDF, NE, ET and glutamate, and peripheral blood SOD, ALB, HB and CAT may suggest the function improvement of stroke patients.

Association of albumin levels with the risk of intracranial atherosclerosis

OBJECTIVE

Intracranial artery stenosis from atherosclerosis is one of the etiologies of ischemic stroke. There is a correlation between serum albumin level and atherosclerosis. We aimed to investigate whether serum albumin level is related to intracranial atherosclerosis and its significance.

METHODS

A retrospective analysis of 150 individuals who underwent cervical cerebral angiography after admission, including clinical data, imaging data, and laboratory data. Since atherosclerosis cannot be used as a good quantitative indicator, we choose the degree of arterial stenosis to reflect atherosclerosis. SPSS 24 software was used for data analysis, and P < .05 was considered statistically significant.

RESULTS

Univariate analysis showed that age, diabetes, and serum albumin level were risk factors for intracranial atherosclerosis (P < .05). Multivariate analysis showed that diabetes and serum albumin levels were independent risk factors for intracranial atherosclerosis (P< 0.05). The average serum albumin level in the non-severe group was 39.80 g/L, and the average serum albumin level in the severe group was 37.60 g/L. The area under the ROC curve of serum albumin was 0.667 (95%CI 0.576-0.758, P = .001), the cutoff value was 0.332176, the sensitivity was 75.9%, and the specificity was 57.3%.

CONCLUSION

Serum albumin level is an independent risk factor for intracranial atherosclerosis, and provides a new direction for clinical prevention and treatment.

Effects of obesity on short-term mortality in patients with acute heart failure under different nutritional status

BACKGROUND

Increased body mass index (BMI) is associated with better survival in patients with acute heart failure (AHF), which is a paradoxical phenomenon. However, it is unclear whether different nutritional status affects this association.

METHODS

1325 patients with AHF from the Medical Information Mart for Intensive Care III database were retrospectively included. Nutritional status was assessed by serum albumin (SA) and prognostic nutritional index (PNI). Patients were divided into High-SA (≥ 3.5 g/dL) and Low-SA groups (< 3.5 g/dL), and they also were divided into High-PNI (≥ 38) and Low-PNI groups (< 38). Propensity-score matching (PSM) was used to control for the effect of baseline confounding factors, multifactor regression model was adopted to assess the association of nutritional status, BMI, and outcomes in AHF patients.

RESULTS

Of the 1325 patients (mean age 72.4 ± 13.1 years), 52.1% (n = 690) were male, 13.1% (n = 173) died in hospital and 23.5% (n = 311) died within 90 days. Before PSM, after adjusting for potential confounders, in the High-SA population, compared with the under/normal BMI group, overweight and obesity were negatively correlated with 90-day mortality, with adjusted hazard ratios (HR) of 0.47, 95% confidence interval (CI) (0.30-0.74), P = 0.001; HR 0.45, 95%CI (0.28-0.72), P = 0.001, respectively. However, this correlation was much attenuated in the Low-SA group (overweight BMI: HR 1.06, 95%CI 0.75-1.50, P = 0.744; obese BMI: HR 0.86, 95%CI 0.59-1.24, P = 0.413). After PSM, those who were overweight or obese in the High-SA group had a 50-58% reduction in 90-day risk of death, while the protective effect disappeared in the Low-SA group (HR 1.09, 95% CI 0.70-1.71; HR 1.02, 95%CI 0.66 - 0.59). Similarly, results were similar in analyses using PNI as a nutritional assessment criterion.

CONCLUSION

Overweight or Obesity was associated with lower short-term mortality in well-nourished AHF patients, whereas this association was significantly attenuated or even disappeared in malnourished patients. Therefore, further research is needed for weight loss recommendations for malnourished obese patients with AHF.

Association of serum albumin to globulin ratio with outcomes in acute ischemic stroke

BACKGROUND

Serum albumin to globulin ratio (A/G) has been widely used as a representative biomarker for assessing inflammation and nutrition status. However, in patients with acute ischemic stroke (AIS), the predictive value of serum A/G has rarely been reported. We aimed to evaluate whether serum A/G is associated with prognosis in stroke.

METHODS

We analyzed data from the Third China National Stroke Registry. The patients were categorized into quartile groups according to the serum A/G at admission. Clinical outcomes included poor functional outcomes (modified Rankin Scale [mRS] score of 3-6 or 2-6) and all-cause mortality at 3 months and1 year. Multivariable logistic regressions and Cox proportional hazards regressions were used to evaluate the association of serum A/G with the risk of poor functional outcomes and all-cause mortality.

RESULTS

A total of 11, 298 patients were included in this study. After adjustment for confounding factors, patients in the highest serum A/G quartile had a lower proportion of mRS score 2-6 (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.76-1.00) and mRS score 3-6 (OR, 0.87; 95% CI, 0.73-1.03) at 3 months follow-up. At 1 year follow-up, there was a significant association between higher serum A/G and mRS score 3-6 (OR, 0.68; 95% CI, 0.57-0.81). We also found that the highest serum A/G was related to decreased risk of all-cause mortality (hazard ratio [HR], 0.58; 95% CI, 0.36-0.94) at 3 months follow-up. Similar results were found at 1-year follow-up.

CONCLUSIONS

Lower serum A/G levels were associated with poor functional outcomes and all-cause mortality at 3 months and 1-year follow-up in patients with acute ischemic stroke.

Association between the geriatric nutritional risk index and the risk of stroke in elderly patients with hypertension: A longitudinal and cohort study

Objective

We aimed to investigate the association between the GNRI and the risk of stroke in elderly patients with hypertension.

Methods

A total of 5312 elderly hypertensive patients free of history of stroke were included. Multivariate Cox models were used to calculate hazard ratios (HRs) and their 95% confidence intervals (CIs) for stroke and its subtypes.

Results

The average time of follow-up was 3.8 years, and the median time was 3.2 years. We identified 640 individuals with stroke, of whom 526 had an ischemic stroke (IS) and 114 had a hemorrhagic stroke (HS). After adjusting for confounding variables, compared with participants in the lowest quartile of the GNRI, those in the third and fourth quartiles were associated with a decreased risk of stroke (adjusted HR 0.72, 95% CI 0.58-0.90, and adjusted HR 0.58, 95% CI 0.46-0.74, respectively, P for trend < 0.001). Similar results were found for IS and HS. Moreover, there were L-shaped associations of GNRI with new-onset HS (P for non-linearity = 0.034). Multiple sensitivity analyses and stratified analyses did not materially change the results.

Conclusions

In summary, we found that a lower GNRI was associated with a higher risk of incident stroke in elderly hypertensive patients. Additional prospective data collection is required to confirm our findings.

J-shaped association between serum albumin levels and long-term mortality of cardiovascular disease: Experience in National Health and Nutrition Examination Survey (2011-2014)

BACKGROUND

Cardiovascular disease (CVD) is a constellation of heart, brain, and peripheral vascular diseases with common soil hypothesis of etiology, and its subtypes have been well-established in terms of the albumin-mortality association. However, the association between albumin and the mortality of CVD as a whole remains poorly understood, especially the non-linear association. We aimed to investigate the association of albumin levels with long-term mortality of CVD as a whole.

MATERIALS AND METHODS

This study included all CVD patients who participated in the National Health and Nutrition Examination Survey (NHANES 2011-2014). CVD was defined as coronary heart disease, stroke, heart failure, or any combination of these two or three diseases. Serum albumin was tertile partitioned: tertile 1, <4.1; tertile 2, 4.1-4.3; and tertile 3, >4.3 g/dl. COX proportional hazards model was used to assess the association between the serum albumin levels and CVD mortality. Restricted cubic spline (RCS) curves were used to explore the non-linear relationship.

RESULTS

A total of 1,070 patients with CVD were included in the analysis, of which 156 deaths occurred during a median 34 months of follow-up. On a continuous scale, per 1 g/dl albumin decrease was associated with an adjusted HR (95% CI) of 3.85 (2.38-6.25). On a categorical scale, as compared with tertile 3, the multivariable adjusted hazard ratio (95% CI) was 1.42 (0.74-2.71) for the tertile 2, and 2.24 (1.20-4.16) for the tertile 1, respectively, with respect to mortality. RCS curve analysis revealed a J-shaped association between albumin and CVD mortality.

CONCLUSION

A J-shaped association between low serum albumin levels and increased long-term mortality of CVD has been revealed. This J-shaped association's implications for CVD prevention and treatment are deserving of being further studied.

Malnutrition Defined by Geriatric Nutritional Risk Index Predicts Outcomes in Severe Stroke Patients: A Propensity Score-Matched Analysis

Background: Malnutrition’s prognostic impact in patients with severe stroke requiring ICU admission is not well known. This study aimed to assess the nutritional status of severe stroke patients using the geriatric nutritional risk index (GNRI) and examine the association of GNRI with mortality in that population. Methods: We identified 1145 severe stroke patients requiring ICU admission from the Medical Information Mart for Intensive Care (MIMIC-III) database and divided them into low GNRI (≤98) or high GNRI (>98) groups. We used a propensity score matching (PSM) method to reduce confounding. Cox proportional hazards regression and restricted cubic splines were used to elucidate the association between GNRI and mortality. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Results: A total of 397 (35%) patients were in the low GNRI group (at risk of malnutrition). After PSM, patients in the low GNRI group still suffered higher mortality compared with the high GNRI group at 28 days (27.9 vs. 20.8%), 90 days (35.5 vs. 25.7%), and 1 year (43.4 vs. 30.9%) (p < 0.05). A low GNRI was significantly associated with an increased mortality (HR: 1.38, 95% CI 1.03−1.86 in 28 days; HR: 1.45, 95% CI 1.11−1.89 in 90 days; HR: 1.51, 95% CI 1.19−1.92 in 1 year). Sensitivity analyses yielded consistent results. Restricted cubic splines showed a progressively decreasing risk of mortality with increasing GNRI scores up to 110, approximately. Conclusion: Severe stroke patients with malnutrition experienced an increased risk of death compared to those without malnutrition. GNRI, as a simple and practical nutritional screening tool, can be used as a routine approach to the nutritional status of stroke patients.

The Association between Serum Albumin and Post-Operative Outcomes among Patients Undergoing Common Surgical Procedures: An Analysis of a Multi-Specialty Surgical Cohort from the National Surgical Quality Improvement Program (NSQIP)

While studies have demonstrated an association between preoperative hypoalbuminemia and adverse clinical outcomes, the optimal serum albumin threshold for risk-stratification in the broader surgical population remains poorly defined. We sought define the optimal threshold of preoperative serum albumin concentration for risk-stratification of adverse post-operative outcomes. Using the American College of Surgeons National Surgical Quality Improvement Program Database, we identified 842,672 patients that had undergone a common surgical procedure in one of eight surgical specialties. An optimal serum albumin concentration threshold for risk-stratification was determined using receiver-operating characteristic analysis. Multivariable logistic regression analysis was used to evaluate the odds of adverse surgical events; a priori defined subgroup analyses were performed. A serum albumin threshold of 3.4 g/dL optimally predicted adverse surgical outcomes in the broader cohort. After multivariable analysis, patients with hypoalbuminemia had increased odds of death within 30 days of surgery (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.94–2.08). Hypoalbuminemia was associated with greater odds of primary adverse events among patients with disseminated cancer (OR 2.03, 95% CI 1.88–2.20) compared to patients without disseminated cancer (OR 1.47, 95% CI 1.44–1.51). The standard clinical threshold for hypoalbuminemia is the optimal threshold for preoperative risk assessment.

[Association of nutritional status with clinical outcomes of stroke patients with acute anterior circulation large vessel occlusion after emergency endovascular treatment]

OBJECTIVE

To explore the influence of nutritional status on 90-day functional outcomes of stroke patients with acute large vessel occlusion in the anterior circulation after endovascular treatment (EVT).

METHODS

We retrospectively analyzed the baseline, laboratory, surgical and 90-day follow-up data of patients with stroke resulting from acute large vessel occlusion in the anterior circulation, who underwent emergency endovascular treatment in our hospital from July, 2015 to December, 2020. A favorable outcome was defined as a modified Rankin scale score ≤2 at 90 days. Univariate and multivariate regression analyses were performed to explore the relationship between nutritional status and 90-day functional outcomes of the patients.

RESULTS

A total of 459 patients (mean age of 68.29±11.21 years, including 260 males) were enrolled in this study. According to their prognostic nutritional index (PNI), the patients were divided into normal nutrition group (392 cases, 85.4%), moderate malnutrition group (44 cases, 9.6%), and severe malnutrition group (23 cases, 5.0%). Univariate analysis showed that the patients with good clinical outcomes had a lower proportion of malnutrition with a younger age, a lower rate of diabetes, lower baseline blood pressure, lower baseline NIHSS score, higher baseline ASPECT score, and higher rates of good collateral circulation and complete vascular recanalization. Multivariate analysis showed that in addition to age, diabetes, baseline systolic blood pressure, successful recanalization, baseline ASPECT score, baseline NIHSS score and collateral circulation, a greater PNI was a protective factor for a good 90-day outcome of patients after EVT (moderate vs severe: OR=0.245, 95% CI: 0.066-0.908, P=0.035; normal vs severe: OR=0.185, 95% CI: 0.059-0.581, P=0.004).

CONCLUSION

Nutritional status an important factor affecting the 90-day outcomes after EVT of stroke patients with acute large vessel occlusion in the anterior circulation.

Low serum albumin: A neglected predictor in patients with cardiovascular disease

Albumin, the most abundant circulating protein in blood, is an essential protein which binds and transports various drugs and substances, maintains the oncotic pressure of blood and influences the physiological function of the circulatory system. Albumin also has anti-inflammatory, antioxidant, and antithrombotic properties. Evidence supports albumin's role as a strong predictor of cardiovascular (CV) risk in several patient groups. Its protective role extends to those with coronary artery disease, heart failure, hypertension, atrial fibrillation, peripheral artery disease or ischemic stroke, as well as those undergoing revascularization procedures or with aortic stenosis undergoing transcatheter aortic valve replacement, and patients with congenital heart disease and/or endocarditis. Hypoalbuminemia is a strong prognosticator of increased all-cause and CV mortality according to several cohort studies and meta-analyses in hospitalized and non-hospitalized patients with or without comorbidities. Normalization of albumin levels before discharge lowers mortality risk, compared with hypoalbuminemia before discharge. Modified forms of albumin, such as ischemia modified albumin, also has prognostic value in patients with coronary or peripheral artery disease. When albumin is combined with other risk factors, such as uric acid or C-reactive protein, the prognostic value is enhanced. Although albumin supplementation may be a plausible approach, its efficacy has not been established and in patients with hypoalbuminemia, priority is focused on diagnosing and managing the underlying condition. The CV effects of hypoalbuminemia and relevant issues are considered in this review. Large cohort studies and meta-analyses are tabulated and the physiologic effects of albumin and the deleterious effects of low albumin are pictorially illustrated.

Stroke Proteomics: From Discovery to Diagnostic and Therapeutic Applications

Stroke remains a leading cause of death and disability, with limited therapeutic options and suboptimal tools for diagnosis and prognosis. High throughput technologies such as proteomics generate large volumes of experimental data at once, thus providing an advanced opportunity to improve the status quo by facilitating identification of novel therapeutic targets and molecular biomarkers. Proteomics studies in animals are largely designed to decipher molecular pathways and targets altered in brain tissue after stroke, whereas studies in human patients primarily focus on biomarker discovery in biofluids and, more recently, in thrombi and extracellular vesicles. Here, we offer a comprehensive review of stroke proteomics studies conducted in both animal and human specimen and present our view on limitations, challenges, and future perspectives in the field. In addition, as a unique resource for the scientific community, we provide extensive lists of all proteins identified in proteomic studies as altered by stroke and perform postanalysis of animal data to reveal stroke-related cellular processes and pathways.

High Neutrophil Percentage-To-Albumin Ratio Can Predict Occurrence of Stroke-Associated Infection

Purpose: Stroke-associated infection (SAI) is associated with adverse outcomes in patients with acute ischemic stroke (AIS). In this study, we aimed to evaluate the association between neutrophil percentage-to-albumin ratio (NPAR) and SAI occurrence in patients with AIS. Methods: We retrospectively analyzed all AIS patients who were admitted to the Neurology ward of The Second Hospital of Tianjin Medical University from November 2018 to October 2020. The relationship between NPAR and SAI was analyzed by multivariable analysis. The receiver operating characteristic (ROC) curve was used to compare the predicted value of albumin, neutrophil percentage, neutrophil-to-lymphocyte ratio (NLR), and NPAR. Results: We included 379 AIS patients out of which 51 (13.5%) developed SAI. The NPAR was independently associated with increased risk of SAI adjusting for confounders [adjusted odds ratio (aOR) = 10.52; 95% confidence interval (CI), 3.33-33.28; P <0.001]. The optimal cutoff value of NPAR for predicting SAI incidence was 1.64, with sensitivity and specificity of 90.2 and 55.8%, respectively. The area under the curve (AUC) value of NPAR [0.771 (0.725-0.812)] was higher than that of albumin [0.640 (0.590-0.689)], neutrophil percentage [0.747 (0.700-0.790)], and NLR [0.736 (0.689-0.780)], though the statistical significance appeared only between NPAR and albumin. Conclusions: We demonstrated that a higher NPAR could predict the occurrence of SAI. Thus, NPAR might be a more effective biomarker to predict SAI compared with albumin, neutrophil percentage, and NLR.