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Leache L, Gutiérrez-Valencia M, Finizola RM, Infante E, Finizola B, Pardo Pardo J, Flores Y, Granero R, Arai KJ. Pharmacotherapy for hypertension-induced left ventricular hypertrophy. Cochrane Database Syst Rev 2021; 10:CD012039. [PMID: 34628642 PMCID: PMC8502530 DOI: 10.1002/14651858.cd012039.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.
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Affiliation(s)
- Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | | | - Rosa M Finizola
- Unit of Special Projects, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Elizabeth Infante
- Unit of Systems, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Bartolome Finizola
- General Coordination, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Yris Flores
- Echocardiography Department and Cardiac Tomography Department, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | | | - Kaduo J Arai
- Coronary Care Unit, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
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Boncoraglio GB, Del Giovane C, Tramacere I. Antihypertensive Drugs for Secondary Prevention After Ischemic Stroke or Transient Ischemic Attack: A Systematic Review and Meta-Analysis. Stroke 2021; 52:1974-1982. [PMID: 33902303 DOI: 10.1161/strokeaha.120.031945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Approximately 30% of ischemic strokes occur after a previous stroke or transient ischemic attack. Arterial hypertension is one of the best established risk factors for first and recurrent stroke, both ischemic and hemorrhagic. Guidelines for the secondary prevention of ischemic stroke support the use of blood pressure (BP)-lowering drugs in most patients. However, the evidence for these recommendations comes from meta-analyses that included both ischemic and hemorrhagic stroke patients, whereas these 2 conditions differ quantitatively in several aspects. With this systematic review and meta-analysis, we aimed at summarizing the current evidence on BP-lowering drugs for secondary prevention in patients with ischemic stroke or transient ischemic attack. METHODS We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to January 31, 2020. We included randomized controlled trials comparing any specific BP-lowering drug, as monotherapy or combination, with either a control or another BP-lowering drug. RESULTS Eight studies that enrolled 33 774 patients with ischemic stroke or transient ischemic attack were included in the meta-analysis. Mean follow-up was 25 months (range, 3-48). Moderate-quality evidence indicated that a subsequent stroke occurred in 7.9% (ischemic in 7.4% or hemorrhagic in 0.6%) of patients taking any type of BP-lowering drug compared with 9.7% of patients taking placebo (odds ratio, 0.79 [95% CI, 0.66-0.94]; absolute risk difference, -1.9% [95% CI, -3.1% to -0.5%]). Moderate-quality evidence indicated that mortality occurred similarly in patients taking any type of BP-lowering treatment compared with placebo, with an absolute risk of 7.3% and 7.9%, respectively (odds ratio, 1.01 [95% CI, 0.92-1.10]; absolute risk difference, 0.1% [95% CI, -0.6% to 0.7%]). CONCLUSIONS The use of BP-lowering drugs in patients with ischemic stroke or transient ischemic attack is associated with a 1.9% risk reduction of stroke but does not affect the all-cause mortality risk.
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Affiliation(s)
- Giorgio B Boncoraglio
- Departments of Cerebrovascular Disease (G.B.B.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland (C.D.G.)
| | - Irene Tramacere
- Research and Clinical Development (I.T.), Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
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Copland E, Canoy D, Nazarzadeh M, Bidel Z, Ramakrishnan R, Woodward M, Chalmers J, Teo KK, Pepine CJ, Davis BR, Kjeldsen S, Sundström J, Rahimi K. Antihypertensive treatment and risk of cancer: an individual participant data meta-analysis. Lancet Oncol 2021; 22:558-570. [PMID: 33794209 PMCID: PMC8024901 DOI: 10.1016/s1470-2045(21)00033-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Some studies have suggested a link between antihypertensive medication and cancer, but the evidence is so far inconclusive. Thus, we aimed to investigate this association in a large individual patient data meta-analysis of randomised clinical trials. METHODS We searched PubMed, MEDLINE, The Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from Jan 1, 1966, to Sept 1, 2019, to identify potentially eligible randomised controlled trials. Eligible studies were randomised controlled trials comparing one blood pressure lowering drug class with a placebo, inactive control, or other blood pressure lowering drug. We also required that trials had at least 1000 participant years of follow-up in each treatment group. Trials without cancer event information were excluded. We requested individual participant data from the authors of eligible trials. We pooled individual participant-level data from eligible trials and assessed the effects of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), β blockers, calcium channel blockers, and thiazide diuretics on cancer risk in one-stage individual participant data and network meta-analyses. Cause-specific fixed-effects Cox regression models, stratified by trial, were used to calculate hazard ratios (HRs). The primary outcome was any cancer event, defined as the first occurrence of any cancer diagnosed after randomisation. This study is registered with PROSPERO (CRD42018099283). FINDINGS 33 trials met the inclusion criteria, and included 260 447 participants with 15 012 cancer events. Median follow-up of included participants was 4·2 years (IQR 3·0-5·0). In the individual participant data meta-analysis comparing each drug class with all other comparators, no associations were identified between any antihypertensive drug class and risk of any cancer (HR 0·99 [95% CI 0·95-1·04] for ACEIs; 0·96 [0·92-1·01] for ARBs; 0·98 [0·89-1·07] for β blockers; 1·01 [0·95-1·07] for thiazides), with the exception of calcium channel blockers (1·06 [1·01-1·11]). In the network meta-analysis comparing drug classes against placebo, we found no excess cancer risk with any drug class (HR 1·00 [95% CI 0·93-1·09] for ACEIs; 0·99 [0·92-1·06] for ARBs; 0·99 [0·89-1·11] for β blockers; 1·04 [0·96-1·13] for calcium channel blockers; 1·00 [0·90-1·10] for thiazides). INTERPRETATION We found no consistent evidence that antihypertensive medication use had any effect on cancer risk. Although such findings are reassuring, evidence for some comparisons was insufficient to entirely rule out excess risk, in particular for calcium channel blockers. FUNDING British Heart Foundation, National Institute for Health Research, Oxford Martin School.
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Affiliation(s)
- Emma Copland
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dexter Canoy
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Milad Nazarzadeh
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Zeinab Bidel
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rema Ramakrishnan
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Epidemiology and Biostatistics, The George Institute for Global Health, Imperial College London, London, UK; Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Koon K Teo
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Carl J Pepine
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Barry R Davis
- School of Public Health, University of Texas, Houston, TX, USA
| | - Sverre Kjeldsen
- Department of Cardiology, University of Oslo, Ullevaal Hospital, Oslo, Norway
| | - Johan Sundström
- Department of Medical Sciences, Clinical Epidemiology, Uppsala University, Uppsala, Sweden
| | - Kazem Rahimi
- Deep Medicine, Oxford Martin School, University of Oxford, Oxford, UK; Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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Hilkens NA, Klijn CJM, Richard E. Blood pressure, blood pressure variability and the risk of poststroke dementia. J Hypertens 2021; 39:1859-1864. [PMID: 33710171 DOI: 10.1097/hjh.0000000000002841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE High blood pressure and blood pressure variability are potential, modifiable risk factors of poststroke dementia. We aimed to investigate the association between achieved blood pressure, blood pressure variability and poststroke dementia. METHODS We studied 17 064 patients with noncardioembolic ischemic stroke included in the Prevention Regimen for Effectively avoiding Second Strokes (PRoFESS) trial. We analysed the data as a single observational cohort. We studied mean achieved SBP and DBP and blood pressure variability defined as coefficient of variation (SD/mean∗100). The association between blood pressure and dementia was investigated with logistic regression analysis, correcting for sociodemographic factors and cardiovascular risk factors. RESULTS During 39 818 person-years of follow-up, 817 patients were diagnosed with dementia (2.1 per 100 person-years). We found a significant nonlinear association between mean SBP and the risk of dementia, implying a U-shaped association between mean SBP and dementia. Mean SBP of 120-129 mmHg was associated with a significantly higher risk of dementia than 130-139 mmHg [odds ratio (OR) 1.28; 95% confidence interval (95% CI) 1.03-1.58]. There was no indication of a U-shaped association between mean DBP and dementia, and no significant association between mean DBP categories and dementia. Higher blood pressure variability was associated with an increased risk of dementia (OR 1.06 per point increase, 95% CI 1.02-1.04), independent of mean SBP. CONCLUSION Among patients with a recent noncardioembolic ischemic stroke, there appears to be a U-shaped association between achieved SBP and dementia. High blood pressure variability is associated with an increased risk of poststroke dementia.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
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Edgar CJ, Brooker H. Professor Keith Andrew Wesnes (1950 to 2020). ALZHEIMER'S & DEMENTIA: DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2020; 12:e12086. [PMID: 32995463 PMCID: PMC7507086 DOI: 10.1002/dad2.12086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Determining the Joint Effect of Obesity and Diabetes on All-Cause Mortality and Cardiovascular-Related Mortality following an Ischemic Stroke. Stroke Res Treat 2018; 2018:4812712. [PMID: 30174819 PMCID: PMC6106950 DOI: 10.1155/2018/4812712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/25/2018] [Indexed: 11/17/2022] Open
Abstract
Although obesity and diabetes mellitus, or diabetes, are independently associated with mortality-related events (e.g., all-cause mortality and cardiovascular-related mortality) following an ischemic stroke, little is known about the joint effect of obesity and diabetes on mortality-related events following an ischemic stroke. The aim of this study is to evaluate the joint effect of obesity and diabetes on mortality-related events in subjects with a recent ischemic stroke. Data from the multicenter Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial was analyzed for this study. The joint effect of obesity and diabetes on mortality-related events was estimated via Cox proportional hazards regression models. No difference in the hazard of all-cause mortality following an ischemic stroke was observed between obese subjects with diabetes and underweight/normal-weight subjects without diabetes. In contrast, obese subjects with diabetes had an increased hazard of cardiovascular-related mortality following an ischemic stroke compared with underweight/normal-weight subjects without diabetes. Additionally, there was evidence of an attributable proportion due to interaction as well as evidence of a highly statistically significant interaction on the multiplicative scale for cardiovascular-related mortality. In this clinical trial cohort of ischemic stroke survivors, obesity and diabetes synergistically interacted to increase the hazard of cardiovascular-related mortality.
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Zonneveld TP, Richard E, Vergouwen MDI, Nederkoorn PJ, de Haan RJ, Roos YBWEM, Kruyt ND. Blood pressure-lowering treatment for preventing recurrent stroke, major vascular events, and dementia in patients with a history of stroke or transient ischaemic attack. Cochrane Database Syst Rev 2018; 7:CD007858. [PMID: 30024023 PMCID: PMC6513249 DOI: 10.1002/14651858.cd007858.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Stroke is an important cause of death and disability worldwide. Since high blood pressure is an important risk factor for stroke and stroke recurrence, drugs that lower blood pressure might play an important role in secondary stroke prevention. OBJECTIVES To investigate whether blood pressure-lowering drugs (BPLDs) started at least 48 hours after the index event are effective for the prevention of recurrent stroke, major vascular events, and dementia in people with stroke or transient ischaemic attack (TIA). Secondary objectives were to identify subgroups of people in which BPLDs are effective, and to investigate the optimum systolic blood pressure target after stroke or TIA for preventing recurrent stroke, major vascular events, and dementia. SEARCH METHODS In August 2017, we searched the Trials Registers of the Cochrane Stroke Group and the Cochrane Hypertension Group, the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE Ovid (1946 to August 2017), Embase Ovid (1974 to August 2017), ClinicalTrials.gov, the ISRCTN Registry, Stroke Trials Registry, Trials Central, and the World Health Organization (WHO) International Clinical Trials Registry Platform Portal. SELECTION CRITERIA Randomised controlled trials (RCTs) of BPLDs started at least 48 hours after stroke or TIA. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts, selected eligible trials, extracted the data, assessed risk of bias, and used GRADE to assess the quality of the evidence. If necessary, we contacted the principal investigators or corresponding authors for additional data. MAIN RESULTS We included 11 studies involving a total of 38,742 participants: eight studies compared BPLDs versus placebo or no treatment (35,110 participants), and three studies compared different systolic blood pressure targets (3632 participants). The risk of bias varied greatly between included studies. The pooled risk ratios (RRs) of BPLDs were 0.81 (95% confidence interval (CI) 0.70 to 0.93; 8 RCTs; 35,110 participants; moderate-quality evidence), 0.90 (95% CI 0.78 to 1.04; 4 RCTs; 28,630 participants; high-quality evidence) for major vascular event, and 0.88 (95% CI 0.73 to 1.06; 2 RCTs; 6671 participants; high-quality evidence) for dementia. We mainly observed a reduced risk of recurrent stroke in the subgroup of participants using an angiotensin-converting enzyme (ACE) inhibitor or a diuretic (I2 statistic for subgroup differences 72.1%; P = 0.006). The pooled RRs of intensive blood pressure-lowering were 0.80 (95% CI 0.63 to 1.00) for recurrent stroke and 0.58 (95% CI 0.23 to 1.46) for major vascular event. AUTHORS' CONCLUSIONS Our results support the use of BPLDs in people with stroke or TIA for reducing the risk of recurrent stroke. Current evidence is primarily derived from trials studying an ACE inhibitor or a diuretic. No definite conclusions can be drawn from current evidence regarding an optimal systolic blood pressure target after stroke or TIA.
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Affiliation(s)
- Thomas P Zonneveld
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Edo Richard
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
- Radboud University Nijmegen Medical CenterDepartment of Neurology, Donders Institute for Brain, Behaviour and CognitionNijmegenNetherlands
| | - Mervyn DI Vergouwen
- University Medical Center UtrechtBrain Center Rudolf Magnus, Department of Neurology and NeurosurgeryUtrechtNetherlands
| | - Paul J Nederkoorn
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Rob J de Haan
- Amsterdam UMC, University of AmsterdamClinical Research UnitAmsterdamNetherlands
| | - Yvo BWEM Roos
- Amsterdam UMC, University of AmsterdamDepartment of NeurologyMeibergdreef 9AmsterdamNetherlands
| | - Nyika D Kruyt
- Leiden University Medical CenterDepartment of NeurologyLeidenNetherlands
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Rijkmans M, de Jong G, van den Berg JSP. Non-persistence in ischaemic stroke: Risk of recurrent vascular events. Acta Neurol Scand 2018; 137:288-292. [PMID: 29218700 DOI: 10.1111/ane.12813] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Ischaemic stroke is one of the leading causes of death and disability worldwide. Although the secondary preventive medication should be continued for life, its use commonly declines in time. This may lead to recurrent vascular events. In this study, we investigated if during a long follow-up period discontinuation of medication (non-persistence) in real life ischaemic stroke patients increased the risk of recurrent vascular events. MATERIALS AND METHODS This was a retrospective cohort study with the data retrieved from a database and the original patient records. The occurrence of new vascular events was determined from the electronic medical record. Medication use at time of follow-up was ascertained using the pharmacy-link in the electronic medical file and through a telephone interview. Primary endpoint was recurrent vascular events. Patients with two or more vascular risk factors were considered as having a high-risk profile. RESULTS A total of 286 patients (persistent n = 182 and non-persistent n = 104) were included. After median follow-up period of 5½ years in the persistent group 14.8% had a recurrent vascular event, vs 23.1% in the non-persistent group (P = .801). In the patients with a high-risk profile, the persistent group had significantly less recurrent vascular events than the non-persistent group (23.5% against 46.4% P = .021). CONCLUSION After a long follow-up period, ischaemic stroke patients with a high vascular risk profile who stopped taking their secondary preventive medication had an increased risk of a recurrent vascular events.
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Affiliation(s)
- M. Rijkmans
- Department of Neurology; Isala; Zwolle The Netherlands
| | - G. de Jong
- Department of Neurology; Isala; Zwolle The Netherlands
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Zhang B, Gu J, Qian M, Niu L, Ghista D. Study of correlation between wall shear stress and elasticity in atherosclerotic carotid arteries. Biomed Eng Online 2018; 17:5. [PMID: 29338745 PMCID: PMC5771221 DOI: 10.1186/s12938-017-0431-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/23/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This paper presents the use of the texture matching method to measure the rabbit carotid artery elasticity value of the experimental group and control group respectively. It compares the experimental rabbits, when they are prompted by pathological histology to be at the period of carotid atherosclerosis fatty streaks and fiber plaques, with the control group. METHODS We have used ultrasound linear array probe for scanning the rabbit carotid arteries. This allows us to obtain the wall shear stress (WSS) and the elasticity values in the atherosclerotic arteries. Using statistical analysis, we are able to clarify whether the texture matching method can diagnose atherosclerosis at the early stage. We also analyze the rabbit carotid artery elasticity and WSS values to make sure whether there is a correlation between both. Combining the texture matching method with the WSS quantitative analysis in the future can enable better prediction of the occurrence and development of atherosclerosis by using noninvasive medical imaging techniques. RESULTS This study has confirmed that from the 2nd to the 10th week, with the development of atherosclerosis, the arterial WSS reduction has a negative correlation with the increasing of artery wall elasticity, which means that as the arterial WSS decreases the arterial wall becomes less elastic. Correlating shear stress with atherosclerosis can clarify that WSS can be used as one of the effective parameters of early diagnosis of atherosclerosis. CONCLUSION In summary, we have found that the elasticity value can reflect the degree of atherosclerosis more objectively. Therefore, by using noninvasive imaging, the quantitative analysis of shear stress and combined with texture matching method can assist in the early diagnosis of atherosclerosis.
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Affiliation(s)
- Bo Zhang
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
| | - Junyi Gu
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Ming Qian
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Lili Niu
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Dhanjoo Ghista
- University 2020 Foundation, Northborough, MA, 01532, USA
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Effects of anti-hypertensive treatment on major cardiovascular events in populations within prehypertensive levels: a systematic review and meta-analysis. J Hum Hypertens 2018; 32:94-104. [PMID: 29317741 DOI: 10.1038/s41371-017-0026-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/07/2017] [Accepted: 11/16/2017] [Indexed: 02/06/2023]
Abstract
Uncertainties still remain in terms of the efficacy of anti-hypertensive treatment on the risk of major cardiovascular (CV) events within prehypertensive levels. This review aims to assess the efficacy and safety of anti-hypertensives on the CV risks in populations within prehypertensive levels. Randomized controlled trials (RCTs) concerning active treatment vs placebo in populations within prehypertensive levels were identified through electronic database and manual search. Outcomes included the first co-primary outcomes, stroke, heart failure (HF), myocardial infarction (MI), all-cause mortality, and cardiovascular mortality. The first co-primary outcomes were defined as composite cardiovascular disease (CVD) events in the included studies. A total of 29 RCTs involving 127,641 participants were identified. Pooled analysis showed active treatment was associated with a significant 7% reduction in risk of the first co-primary outcomes, 14% in stroke, and 10% in HF as compared to placebo (0.86, 0.77-0.96; 0.93, 0.89-0.98; and 0.90, 0.83-0.97). However, there were no significant reductions in risk of MI, all-cause mortality, and cardiovascular mortality. A significant reduction in risk of the first co-primary outcomes was observed in subpopulations with systolic blood pressure (SBP) 130-139 mmHg (0.94, 0.89-0.99) or prior CVDs (0.88, 0.82-0.94). Meta-regression analyses showed no significant relative risk reductions proportional to the magnitude of the mean baseline BP, mean on-treatment BP, the mean absolute change in BP, the proportion of patients with hypertension, and mean age. In summary, anti-hypertensive treatment has beneficial cardiovascular effects in populations within prehypertensive levels, especially in subpopulations with SBP 130-139 mmHg or prior CVDs.
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Zhang B, Gu J, Qian M, Niu L, Zhou H, Ghista D. Correlation between quantitative analysis of wall shear stress and intima-media thickness in atherosclerosis development in carotid arteries. Biomed Eng Online 2017; 16:137. [PMID: 29208019 PMCID: PMC5718157 DOI: 10.1186/s12938-017-0425-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/11/2017] [Indexed: 01/17/2023] Open
Abstract
Background This paper presents quantitative analysis of blood flow shear stress by measuring the carotid arterial wall shear stress (WSS) and the intima-media thickness (IMT) of experimental rabbits fed with high-fat feedstuff on a weekly basis in order to cause atherosclerosis. Methods This study is based on establishing an atherosclerosis model of high-fat rabbits, and measuring the rabbits’ common carotid arterial WSS of the experimental group and control group on a weekly basis. Detailed analysis was performed by using WSS quantification. Results We have demonstrated small significant difference of rabbit carotid artery WSS between the experimental group and the control group (P<0.01) from the 1st week onwards, while the IMT of experimental group had larger differences from 5th week compared with the control group (P<0.05). Next, we have shown that with increasing blood lipids, the rabbit carotid artery shear stress decreases and the rabbit carotid artery IMT goes up. The decrease of shear stress appears before the start of IMT growth. Furthermore, our receiver operator characteristic (ROC) curve analysis showed that when the mean value of shear stress is 1.198 dyne/cm2, the rabbit common carotid atherosclerosis fatty streaks sensitivity is 89.8%, and the specificity is 81.3%. The area under the ROC curve is 0.9283. Conclusions All these data goes to show that WSS decreasing to 1.198 dyne/cm2 can be used as an indicator that rabbit common carotid artery comes into the period of fibrous plaques. In conclusion, our study is able to find and confirm that the decrease of the arterial WSS can predict the occurrence of atherosclerosis earlier, and offer help for positive clinical intervention.
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Affiliation(s)
- Bo Zhang
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
| | - Junyi Gu
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Ming Qian
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Lili Niu
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Hui Zhou
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Dhanjoo Ghista
- University 2020 Foundation, Northborough, MA, 01532, USA
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12
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Amarenco P, Sissani L, Labreuche J, Vicaut E, Bousser MG, Chamorro A, Fisher M, Ford I, Fox KM, Hennerici MG, Mattle H, Rothwell PM, Steg PG, Diener HC, Sacco RL, Greving JP, Algra A. The Intracranial-B2LEED3S Score and the Risk of Intracranial Hemorrhage in Ischemic Stroke Patients Under Antiplatelet Treatment. Cerebrovasc Dis 2017; 43:145-151. [PMID: 28088798 DOI: 10.1159/000453459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic antiplatelet therapy in the post-acute phase of non-cardioembolic ischemic stroke is limited by the risk of intracranial hemorrhage (ICH) complications. METHODS We developed an ICH risk score based on the PERFORM trial cohort (n = 19,100), which included patients with a non-cardioembolic ischemic stroke or transient ischemic attack, and externally validated this score in one contemporary trial of very similar size and inclusion criteria, the PRoFESS trial (n = 20,332 patients). Outcome was ICH over 2 years. A Cox proportional-hazard regression analysis identified risk factors. Discrimination was quantified with c-statistics and calibration was assessed by comparing predicted and observed ICH risk in PERFORM and PRoFESS. RESULTS ICH occurred within 2 years in 263 (1.4%) patients in PERFORM trial and in 246 (1.2%) patients in PRoFESS trial. A 13-point score based on 9 items (Intracranial-B2LEED3S score - low body mass index, blood pressure, lacune, elderly, Asian ethnicity, coronary artery or cerebrovascular disease history, dual antithrombotic agent or oral anticoagulant, gender) was derived from the PERFORM trial. In PERFORM, the observed 2-year ICH risk varied from 0.75% in low-risk (score ≤2) to 2.44% in high-risk patients (score ≥5) with an acceptable calibration but a low discrimination both in PERFORM (c-statistic 0.64, 95% CI 0.61-0.68) and on external validation in PRoFESS (0.58, 95% CI 0.55-0.62). CONCLUSION The Intracranial-B2LEED3S score helps identify patients who are at a high risk of bleeding. However, other variables need to be identified to improve the score (e.g., microbleeds) (Clinical Trial Registration Information ISRCTN66157730). URL: http://www.isrctn.com/ISRCTN66157730?totalResults=5&pageSize=10&page=1&searchType=basic-search&offset=3&q=&filters=conditionCategory%3ACirculatory+System%2CrecruitmentCountry%3ATaiwan%2CrecruitmentCountry%3AAustria&sort=.
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13
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Hilkens NA, Greving JP, Algra A, Klijn CJ. Blood pressure levels and the risk of intracerebral hemorrhage after ischemic stroke. Neurology 2016; 88:177-181. [DOI: 10.1212/wnl.0000000000003489] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 10/04/2016] [Indexed: 11/15/2022] Open
Abstract
Objective:To investigate the association between blood pressure (BP) levels and risk of intracerebral hemorrhage (ICH) after ischemic stroke.Methods:We performed a post hoc analysis of data from the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial, a randomized clinical trial including 20,332 patients with recent noncardioembolic ischemic stroke. BP measurements were divided into predefined categories. We calculated incidence rates per BP category and performed multivariable Cox regression analysis with systolic blood pressure (SBP) and diastolic blood pressure (DBP) categories as time-dependent covariables.Results:One hundred thirty-three ICHs occurred during 50,778 person-years of follow-up, resulting in an incidence rate of 2.6 per 1,000 person-years. The incidence rate of ICH increased with increasing SBP and DBP categories. Risk of ICH was significantly higher in patients with SBP ≥160 mm Hg (hazard ratio 2.27, 95% confidence interval 1.34–3.86) compared with those with SBP of 130–<140 mm Hg and in patients with DBP ≥100 mm Hg (hazard ratio 3.08, 95% confidence interval 1.78–5.34) compared with those with DBP of 80–<90 mm Hg. The association between SBP or DBP and ICH did not differ by ischemic stroke subtype (p = 0.55 and 0.93).Conclusions:Among patients with recent noncardioembolic ischemic stroke, the risk of ICH is high. High SBP and DBP are associated with an increased risk of ICH. The association between BP and ICH is not dependent on ischemic stroke subtype.
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14
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Stuart AC, Sico JJ, Viscoli CM, Tayal AH, Inzucchi SE, Ford GA, Furie KL, Cote R, Spence JD, Tanne D, Kernan WN. Taking care of volunteers in a stroke trial: a new assisted-management strategy. Stroke Vasc Neurol 2016; 1:108-114. [PMID: 28959471 PMCID: PMC5435205 DOI: 10.1136/svn-2016-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND PURPOSE Providing participants with evidence-based care for secondary prevention is an ethical and scientific priority for trials in stroke therapy. The optimal strategy, however, is uncertain. We report the performance of a new approach for delivering preventive care to trial participants. METHODS Participants were enrolled in the Insulin Resistance Intervention after Stroke trial, which examined the insulin sensitiser, pioglitazone versus placebo for prevention of stroke and myocardial infarction after ischaemic stroke or transient ischaemic attack. Preventive care was the responsibility of the participants' personal healthcare providers, but investigators monitored care and provided feedback annually. We studied achievement of 8 prevention goals at baseline and 3 annual visits, with a focus on 3 priority goals: blood pressure <140/90 mm Hg, low-density lipoprotein (LDL) cholesterol <2.59 mmol/L and antithrombotic therapy. RESULTS The proportion of participants achieving the priority goals was highest for antithrombotic use (96-99% in each year) and similar for blood pressure (66-72% in each year) and LDL (68-70% in each year). All 3 priority goals were achieved by 47-52% of participants in any given year. However, only 22% of participants achieved all 3 goals in each year. CONCLUSIONS A strategy of monitoring care and providing feedback was associated with high average yearly achievement of 3 priority secondary prevention goals, but the majority of trial participants did not persist in being at goal over time. TRIAL REGISTRATION NUMBER NCT00091949.
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Affiliation(s)
- Amber C Stuart
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ashis H Tayal
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary A Ford
- Division of Medical Sciences, Oxford University, Oxford, UK
| | - Karen L Furie
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Robert Cote
- Department of Neurology, Neurosurgery and Medicine, McGill University, Montreal, Quebec, Canada
| | | | - David Tanne
- Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Walter N Kernan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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15
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Bernard TJ, Beslow LA, Manco-Johnson MJ, Armstrong-Wells J, Boada R, Weitzenkamp D, Hollatz A, Poisson S, Amlie-Lefond C, Lo W, deVeber G, Goldenberg NA, Dowling MM, Roach ES, Fullerton HJ, Benseler SM, Jordan LC, Kirton A, Ichord RN. Inter-Rater Reliability of the CASCADE Criteria: Challenges in Classifying Arteriopathies. Stroke 2016; 47:2443-9. [PMID: 27633024 DOI: 10.1161/strokeaha.116.013544] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/16/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE There are limited data about the reliability of subtype classification in childhood arterial ischemic stroke, an issue that prompted the IPSS (International Pediatric Stroke Study) to develop the CASCADE criteria (Childhood AIS Standardized Classification and Diagnostic Evaluation). Our purpose was to determine the CASCADE criteria's reliability in a population of children with stroke. METHODS Eight raters from the IPSS reviewed neuroimaging and clinical records of 64 cases (16 cases each) randomly selected from a prospectively collected cohort of 113 children with arterial ischemic stroke and classified them using the CASCADE criteria. Clinical data abstracted included history of present illness, risk factors, and acute imaging. Agreement among raters was measured by unweighted κ statistic. RESULTS The CASCADE criteria demonstrated a moderate inter-rater reliability, with an overall κ statistic of 0.53 (95% confidence interval [CI]=0.39-0.67). Cardioembolic and bilateral cerebral arteriopathy subtypes had much higher agreement (κ=0.84; 95% CI=0.70-0.99; and κ=0.90; 95% CI=0.71-1.00, respectively) than cases of aortic/cervical arteriopathy (κ=0.36; 95% CI=0.01-0.71), unilateral focal cerebral arteriopathy of childhood (FCA; κ=0.49; 95% CI=0.23-0.76), and small vessel arteriopathy of childhood (κ=-0.012; 95% CI=-0.04 to 0.01). CONCLUSIONS The CASCADE criteria have moderate reliability when used by trained and experienced raters, which suggests that it can be used for classification in multicenter pediatric stroke studies. However, the moderate reliability of the arteriopathic subtypes suggests that further refinement is needed for defining subtypes. Such revisions may reduce the variability in the literature describing risk factors, recurrence, and outcomes associated with childhood arteriopathy.
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Affiliation(s)
- Timothy J Bernard
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.).
| | - Lauren A Beslow
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Marilyn J Manco-Johnson
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Jennifer Armstrong-Wells
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Richard Boada
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - David Weitzenkamp
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Amanda Hollatz
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Sharon Poisson
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Catherine Amlie-Lefond
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Warren Lo
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Gabrielle deVeber
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Neil A Goldenberg
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Michael M Dowling
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - E Steve Roach
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Heather J Fullerton
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Susanne M Benseler
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Lori C Jordan
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Adam Kirton
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
| | - Rebecca N Ichord
- From the Section of Child Neurology (T.J.B., J.A.-W., R.B.), Section of Hematology/Oncology/BMT (M.J.M.-J.), Hemophilia and Thrombosis Center, Department of Pediatrics (T.J.B., M.J.M.-J., J.A.-W., A.H.), Department of Pediatrics (T.J.B, M.J.M-J, J.A-W., R.B.), Department of Biostatistics and Informatics, School of Public Health (D.W.), and Department of Neurology (S.P.), University of Colorado, Aurora; Division of Child Neurology (L.A.B.), Department of Pediatrics (L.A.B.), and Department of Neurology (L.A.B.), Yale School of Medicine, New Haven, CT; University of Washington (C.A.L.); Department of Pediatrics (W.L., E.S.R.) and Department of Neurology (W.L., E.S.R.), The Ohio State University and Nationwide Children's Hospital, Columbus; Hospital for Sick Children, University of Toronto, Ontario, Canada (G.d.V.); Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (N.A.G.); All Children's Research Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL (N.A.G.); Division of Pediatric Neurology, Department of Pediatrics (M.M.D.) and Department of Neurology and Neurotherapeutics (M.M.D.), UT Southwestern Medical Center, Dallas, TX; Division of Neurology, University of California, San Francisco (H.J.F.); Rheumatology Clinic, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Canada (S.M.B.); Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center (L.C.J.); Calgary Pediatric Stroke Program, Division of Neurology, Alberta Children's Hospital, University of Calgary, Canada (A.K.); and Department Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine (R.N.I.)
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Serebruany VL. Redesigning TRACER trial after TRITON. Int J Cardiol 2015; 197:44-7. [DOI: 10.1016/j.ijcard.2015.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 06/13/2015] [Accepted: 06/16/2015] [Indexed: 12/01/2022]
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Abstract
OPINION STATEMENT Cerebrovascular disease (CVD) is an important cause of cognitive dysfunction and dementia. The term vascular cognitive impairment (VCI) is used to describe the entire spectrum of cognitive dysfunction-ranging from mild impairment to dementia-attributable to all forms of cerebrovascular disease. Accurate assessment and management of vascular risk factors are a top priority in the treatment of VCI, particularly early in the disease when prevention strategies may prove to be more effective. There are limited treatment options to improve cognition and function in VCI. Several acetylcholinesterase inhibitors and the NMDA receptor antagonist memantine have been studied in large, well-designed trials. These agents are safe and provide modest cognitive benefits in vascular dementia (VaD) but have demonstrated inconsistent efficacy on functional measures. Other therapies, such as aspirin, calcium channel blockers, and vitamin supplementation, have less evidence to support their use in improving cognition in VCI. Although primary prevention trials suggest that treatment of hypertension, adherence to a Mediterranean diet, physical activity, and smoking cessation may reduce the risk of cognitive decline, there is limited evidence regarding these interventions in helping improve cognition in VCI. The pathophysiology and treatment of cerebral autosomal dominant arteriopathy with subcortical infarcts (CADASIL), cerebral amyloid angiopathy (CAA), and subcortical white matter disease (SWMD) deserves special consideration.
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Affiliation(s)
- Aaron Ritter
- Department of Neurology, Lou Ruvo Center for Brain Health, Cleveland Clinic, 888 West Bonneville Avenue, Las Vegas, NV, 89106, USA,
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Abstract
Whether there are any benefits without harm from early lowering of blood pressure (BP) in the setting of acute ischemic stroke (AIS) has been a longstanding controversy in medicine. Whilst most studies have consistently shown associations between elevated BP, particularly systolic BP, and poor outcome, some also report that very low BP (systolic <130 mmHg) and large reductions in systolic BP are associated with poor outcomes in AIS. However, despite these associations, the observed U- or J-shaped relationship between BP and outcome in these patients may not be causally related. Patients with more severe strokes may have a more prominent autonomic response and later lower BP as their condition worsens, often pre-terminally. Fortunately, substantial progress has been made in recent years with new evidence arising from well-conducted randomized trials. This review outlines new evidence and recommendations for clinical practice over BP management in AIS.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Sydney, Australia
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Feldstein CA. Lowering blood pressure to prevent stroke recurrence: a systematic review of long-term randomized trials. ACTA ACUST UNITED AC 2014; 8:503-13. [PMID: 25064772 DOI: 10.1016/j.jash.2014.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 05/03/2014] [Accepted: 05/03/2014] [Indexed: 10/25/2022]
Abstract
Albeit hypertension is a leading risk factor for an initial stroke, the role of blood pressure (BP) lowering to prevent a subsequent stroke is controversial. The present systematic review searched randomized trials published from January 1990 to January 2014 with the aim to assess antihypertensive treatment effects on recurrent stroke prevention. Seven randomized placebo-controlled trials enrolling 49,518 patients, two randomized trials not placebo controlled comparing antihypertensive drugs, and one randomized trial that compared the effects of intensive systolic BP lowering with a more conservative systolic BP management, were identified. The placebo-controlled trials had substantial methodological differences, explaining the difficulties to compare their results. An important obstacle arises from the large dispersion in the window's time between the qualifying stroke and randomization. Another barrier is the variation among studies in the recruited patient's stroke subtypes. Differences between trials could not be attributed to disparity in lowering BP or to different degrees of no adherence. The American Heart Association/American Stroke Association stated that although an absolute target of BP level has not been clearly defined, a reduction in recurrent stroke has been associated with an average lowering of 10/5 mm Hg. It should be taken into account that it is not advisable to reduce BP levels to <120/80 mm Hg. It should carry out an individualized selection, based on demographic characteristics and comorbidities (cardiovascular disease, diabetes mellitus, and chronic disease) among diuretics, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, or calcium channel blockers.
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Affiliation(s)
- Carlos A Feldstein
- Department of Internal Medicine, Hypertension Program, Hospital de Clínicas José de San Martín, University of Buenos Aires, Buenos Aires, Argentina.
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Estol CJ, Bath PMW, Gorelick PB, Cotton D, Martin RH. Differences in ischemic and hemorrhagic recurrence rates among race-ethnic groups in the PRoFESS secondary stroke prevention trial. Int J Stroke 2014; 9 Suppl A100:43-7. [PMID: 24636673 DOI: 10.1111/ijs.12269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 02/02/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Epidemiological studies show that vascular risk factors are the same across the world but their effect vary between different race-ethnic groups. However, few studies have evaluated differences in recurrent stroke rates in various race-ethnicities. In >20 000 patients spanning 35 countries encompassing most race-ethnicities, we evaluated the incidence of ischemic and hemorrhagic strokes and myocardial infarction in patients within the context of the largest secondary stroke prevention trial (Prevention Regimen for Effectively Avoiding Secondary Strokes) to identify any significant differences. METHODS There were 20 332 patients with a recent ischemic stroke randomized in a factorial design to receive the antiplatelet agent clopidogrel vs. aspirin plus extended-release dipyridamole, and 80 mg of the anthypertensive telmisartan vs. placebo. The primary outcome for the trial was the time to any recurrent stroke. Statistical analysis was used to detect race-ethnic differences in recurrent vascular events. RESULTS Mean patient age was 66 (±8·6) years and 36% were women. The study included 58% European/Caucasian, 33% Asians, 5% Latin/Hispanic, and 4% Black African. There were 74% of patients that were hypertensive, and average systolic and diastolic blood pressure was 144·1/83·8 mmHg. There was at least one significant difference in the overall test of all race-ethnic groups in myocardial infarction and symptomatic intracerebral hemorrhage occurrence. In the Kaplan-Meier hemorrhage and stroke-free survival curves, Asians showed a significantly higher recurrence of ischemic stroke risk in the 135-150 mmHg and greater than 150 mm Hg blood pressure groups, and a greater risk of hemorrhage recurrence in the greater than 150 mmHg blood pressure group. CONCLUSIONS We found a significant difference in myocardial infarction and symptomatic intracerebral hemorrhage recurrence among different race-ethnic groups. The risk of recurrent ischemic and hemorrhagic stroke was greater in Asians with high blood pressure.
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Banerjee A, Fauchier L, Bernard-Brunet A, Clementy N, Lip GYH. Composite risk scores and composite endpoints in the risk prediction of outcomes in anticoagulated patients with atrial fibrillation. The Loire Valley Atrial Fibrillation Project. Thromb Haemost 2014; 111:549-56. [PMID: 24452108 DOI: 10.1160/th13-12-1033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/19/2014] [Indexed: 11/05/2022]
Abstract
Several validated risk stratification schemes for prediction of ischaemic stroke (IS)/thromboembolism (TE) and major bleeding are available for patients with non-valvular atrial fibrillation (NVAF). On the basis for multiple common risk factors for IS/TE and bleeding, it has been suggested that composite risk prediction scores may be more practical and user-friendly than separate scores for bleeding and IS/TE. In a long-term prospective hospital registry of anticoagulated patients with newly diagnosed AF, we compared the predictive value of existing risk prediction scores as well as composite risk scores, and also compared these risk scoring systems using composite endpoints. Endpoint 1 was the simple composite of IS and major bleeds. Endpoint 2 was based on a composite of IS plus intracerebral haemorrhage (ICH). Endpoint 3 was based on weighted coefficients for IS/TE and ICH. Endpoint 4 was a composite of stroke, cardiovascular death, TE and major bleeding. The incremental predictive value of these scores over CHADS2 (as reference) for composite endpoints was assessed using c-statistic, net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Of 8,962 eligible individuals, 3,607 (40.2%) had NVAF and were on OAC at baseline. There were no statistically significant differences between the c-statistics of the various risk scores, compared with the CHADS2 score, regardless of the endpoint. For the various risk scores and various endpoints, NRI and IDI did not show significant improvement (≥1%), compared with the CHADS2 score. In conclusion, composite risk scores did not significantly improve risk prediction of endpoints in patients with NVAF, regardless of how endpoints were defined. This would support individualised prediction of IS/TE and bleeding separately using different separate risk prediction tools, and not the use of composite scores or endpoints for everyday 'real world' clinical practice, to guide decisions on thromboprophylaxis.
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Affiliation(s)
| | | | | | | | - G Y H Lip
- Prof. G. Y. H. Lip, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham B18 7QH, UK, E-mail:
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Abstract
Patients with transient ischemic attack and ischemic stroke have a high risk of recurrent stroke and death. While aspirin is accepted as standard therapy in these patients, recent trials demonstrate that a combination of aspirin and extended-release dipyridamole or clopidogrel is superior to aspirin monotherapy. Blockade of the renin-angiotensin system with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers may also reduce recurrent stroke. The ongoing Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial is designed to evaluate whether extended-release dipyridamole plus aspirin compared with clopidogrel, and whether telmisartan in addition to usual care, in individuals after a stroke, will reduce the risk of further strokes. PRoFESS is a multicenter, randomized, double-blind trial involving 695 sites from 35 countries or regions. The primary outcome for the trial is recurrent stroke, using a time-to-event analysis. Safety is evaluated by assessing the risk of major hemorrhagic and other serious adverse events. With over 20,000 patients randomized, and utilizing a 2 x 2 factorial design, PRoFESS is the largest stroke trial to investigate the prevention of recurrent stroke.
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Affiliation(s)
- Hans-Christoph Diener
- University Duisburg-Essen, Department of Neurology, Hufelandstrasse 55, 45122 Essen, Germany.
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Malloy RJ, Kanaan AO, Silva MA, Donovan JL. Evaluation of Antiplatelet Agents for Secondary Prevention of Stroke Using Mixed Treatment Comparison Meta-analysis. Clin Ther 2013; 35:1490-1500.e7. [DOI: 10.1016/j.clinthera.2013.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 08/20/2013] [Accepted: 09/06/2013] [Indexed: 10/26/2022]
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Ntalas IV, Milionis HJ, Kei AA, Kalantzi KI, Goudevenos JA. Antiplatelet Treatment in the Secondary Prevention of Coronary and Cerebrovascular Disease. Angiology 2013; 65:473-90. [DOI: 10.1177/0003319713499609] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ischemic heart disease and cerebrovascular disease remain major health problems with associated mortality and quality-of-life consequences. Antiplatelet agents, including thienopyridines and the new P2Y12 inhibitors, have been shown to improve survival in the secondary prevention setting. We review the available evidence on the effectiveness and safety of previous established as well as novel antithrombotic agents in the secondary prevention of cardiovascular disease with a special focus on cerebrovascular disease.
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Affiliation(s)
- Ioannis V. Ntalas
- Department of Cardiology, University of Ioannina, Medical School, Ioannina, Greece
| | - Haralampos J. Milionis
- Department of Internal Medicine, University of Ioannina, Medical School, Ioannina, Greece
| | - Anastazia A. Kei
- Department of Internal Medicine, University of Ioannina, Medical School, Ioannina, Greece
| | | | - John A. Goudevenos
- Department of Cardiology, University of Ioannina, Medical School, Ioannina, Greece
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25
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O’Donnell MJ, Diener HC, Sacco RL, Panju AA, Vinisko R, Yusuf S. Chronic Pain Syndromes After Ischemic Stroke. Stroke 2013; 44:1238-43. [DOI: 10.1161/strokeaha.111.671008] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Chronic pain syndromes are reported to be common after stroke, but most previous epidemiological studies have generally included small cohorts of patients with relatively short-term follow-up. In a large cohort with ischemic stroke (Prevention Regimen for Effectively avoiding Second Stroke [PRoFESS] trial), we determined the prevalence, risk factors, and clinical consequence of new poststroke pain syndromes.
Methods—
Within the PRoFESS trial (mean follow-up 2.5 years), a standardized chronic pain questionnaire was administered (at the penultimate follow-up visit) to all participants who reported chronic pain since their stroke and did not have a history of chronic pain before their index stroke. Multivariable logistic regression analyses were used to determine risk factors for poststroke pain (and pain subtypes), and the association between poststroke pain and cognitive (≥3 reduction in Mini-Mental State Examination score) and functional decline (≥1 increase in m-Rankin).
Results—
In total, 15 754 participants were included; of which 1665 participants (10.6%) reported new chronic poststroke pain, and included 431 participants (2.7%) with central poststroke pain, 238 (1.5%) with peripheral neuropathic pain, 208 (1.3%) with pain from spasticity, and 136 participants (0.9%) with pain from shoulder subluxation. More than 1 pain subtype was reported in 86 participants (0.6%). Predictors of poststroke pain included increased stroke severity, female sex, alcohol intake, statin use, depressive symptoms, diabetes mellitus, antithrombotic regimen, and peripheral vascular disease. A new chronic pain syndrome was associated with greater dependence (odds ratio, 2.16; 95% confidence interval, 1.82–2.56). Peripheral neuropathy and pain from spasticity/shoulder subluxation were associated with cognitive decline.
Conclusions—
Chronic pain syndromes are common after ischemic stroke and are associated with increased functional dependence and cognitive decline.
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Affiliation(s)
- Martin J. O’Donnell
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
| | - Hans-Christoph Diener
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
| | - Ralph L. Sacco
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
| | - Akbar A. Panju
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
| | - Richard Vinisko
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
| | - Salim Yusuf
- From the Population Health Research Group, McMaster University, Hamilton, Ontario, Canada (M.J.O'D., S.Y.); HRB-Clinical Research Facility, NUI Galway, Galway, Ireland (M.J.O’D.); Department of Neurology, University Hospital, Essen, Germany (H.-C.D.); Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Hamilton Health Sciences (A.A.P.) McMaster University, Hamilton, Ontario, Canada; Biostatistics Group (D.C.), Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (R.V.)
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26
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Weimar C, Cotton D, Sha N, Sacco RL, Bath PM, Weber R, Diener HC. Discontinuation of Antiplatelet Study Medication and Risk of Recurrent Stroke and Cardiovascular Events: Results from the PRoFESS Study. Cerebrovasc Dis 2013; 35:538-43. [DOI: 10.1159/000351144] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/25/2013] [Indexed: 11/19/2022] Open
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Valentine N, Van de Laar FA, van Driel ML. Adenosine-diphosphate (ADP) receptor antagonists for the prevention of cardiovascular disease in type 2 diabetes mellitus. Cochrane Database Syst Rev 2012; 11:CD005449. [PMID: 23152231 PMCID: PMC11285295 DOI: 10.1002/14651858.cd005449.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most prevalent complication of type 2 diabetes with an estimated 65% of people with type 2 diabetes dying from a cause related to atherosclerosis. Adenosine-diphosphate (ADP) receptor antagonists like clopidogrel, ticlopidine, prasugrel and ticagrelor impair platelet aggregation and fibrinogen-mediated platelet cross-linking and may be effective in preventing CVD. OBJECTIVES To assess the effects of adenosine-diphosphate (ADP) receptor antagonists for the prevention of cardiovascular disease in type 2 diabetes mellitus. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (issue 2, 2011), MEDLINE (until April 2011) and EMBASE (until May 2011). We also performed a manual search, checking references of original articles and pertinent reviews to identify additional studies. SELECTION CRITERIA Randomised controlled trials comparing an ADP receptor antagonist with another antiplatelet agent or placebo for a minimum of 12 months in patients with diabetes. In particular, we looked for trials assessing clinical cardiovascular outcomes. DATA COLLECTION AND ANALYSIS Two review authors extracted data for studies which fulfilled the inclusion criteria, using standard data extraction templates. We sought additional unpublished information and data from the principal investigators of all included studies. MAIN RESULTS Eight studies with a total of 21,379 patients with diabetes were included. Three included studies investigated ticlopidine compared to aspirin or placebo. Five included studies investigated clopidogrel compared to aspirin or a combination of aspirin and dipyridamole, or compared clopidogrel in combination with aspirin to aspirin alone. All trials included patients with previous CVD except the CHARISMA trial which included patients with multiple risk factors for coronary artery disease. Overall the risk of bias of the trials was low. The mean duration of follow-up ranged from 365 days to 913 days.Data for diabetes patients on all-cause mortality, vascular mortality and myocardial infarction were only available for one trial (355 patients). This trial compared ticlopidine to placebo and did not demonstrate any statistically significant differences for all-cause mortality, vascular mortality or myocardial infarction. Diabetes outcome data for stroke were available in three trials (31% of total diabetes participants). Overall pooling of two (statistically heterogeneous) studies showed no statistically significant reduction in the combination of fatal and non-fatal stroke (359/3194 (11.2%) versus 356/3146 (11.3%), random effects odds ratio (OR) 0.81; 95% confidence interval (CI) 0.44 to 1.49) for ADP receptor antagonists versus other antiplatelet drugs. There were no data available from any of the trials on peripheral vascular disease, health-related quality of life, adverse events specifically for patients with diabetes, or costs. AUTHORS' CONCLUSIONS The available evidence for ADP receptor antagonists in patients with diabetes mellitus is limited and most trials do not report outcomes for patients with diabetes separately. Therefore, recommendations for the use of ADP receptor antagonists for the prevention of CVD in patients with diabetes are based on available evidence from trials including patients with and without diabetes. Trials with diabetes patients and subgroup analyses of patients with diabetes in trials with combined populations are needed to provide a more robust evidence base to guide clinical management in patients with diabetes.
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Affiliation(s)
- Nyoli Valentine
- Bond UniversityDepartment of General PracticeGold CoastQueenslandAustralia4229
| | - Floris A Van de Laar
- Radboud University Nijmegen Medical CenterDepartment of Primary and Community Care, 117 ELGPO Box 9101NijmegenNetherlands6500 HB
| | - Mieke L van Driel
- The University of QueenslandDiscipline of General Practice, School of MedicineBrisbaneQueenslandAustralia4006
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Di Legge S, Koch G, Diomedi M, Stanzione P, Sallustio F. Stroke prevention: managing modifiable risk factors. Stroke Res Treat 2012; 2012:391538. [PMID: 23213626 PMCID: PMC3504482 DOI: 10.1155/2012/391538] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/08/2012] [Indexed: 12/12/2022] Open
Abstract
Prevention plays a crucial role in counteracting morbidity and mortality related to ischemic stroke. It has been estimated that 50% of stroke are preventable through control of modifiable risk factors and lifestyle changes. Antihypertensive treatment is recommended for both prevention of recurrent stroke and other vascular events. The use of antiplatelets and statins has been shown to reduce the risk of recurrent stroke and other vascular events. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are indicated in stroke prevention because they also promote vascular health. Effective secondary-prevention strategies for selected patients include carotid revascularization for high-grade carotid stenosis and vitamin K antagonist treatment for atrial fibrillation. The results of recent clinical trials investigating new anticoagulants (factor Xa inhibitors and direct thrombin inhibitors) clearly indicate alternative strategies in stroke prevention for patients with atrial fibrillation. This paper describes the current landscape and developments in stroke prevention with special reference to medical treatment in secondary prevention of ischemic stroke.
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Affiliation(s)
- Silvia Di Legge
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Giacomo Koch
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Paolo Stanzione
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
| | - Fabrizio Sallustio
- Stroke Unit, Department of Neuroscience, University of Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
- Santa Lucia Foundation, IRCCS, Viale Ardeatina 306, 00134 Rome, Italy
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Böhm M, Cotton D, Foster L, Custodis F, Laufs U, Sacco R, Bath PMW, Yusuf S, Diener HC. Impact of resting heart rate on mortality, disability and cognitive decline in patients after ischaemic stroke. Eur Heart J 2012; 33:2804-12. [PMID: 22922507 DOI: 10.1093/eurheartj/ehs250] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024] Open
Abstract
AIMS Recurrent stroke is a frequent and disabling event. A high heart rate is associated with cardiovascular outcomes. We investigated the effects of the resting heart rate on cardiovascular and neurological outcomes after recurrent stroke in the high-risk population of the PRoFESS study. METHODS AND RESULTS A total of 20,165 patients after ischaemic stroke (mean age 66.1, SD 8.6 years) assigned to the treatment arms of the PRoFESS trial were pooled divided by quintiles of the baseline heart rate and analysed according to cardiovascular and functional outcomes after stroke: recurrent stroke and major cardiovascular outcomes such as stroke, myocardial infarction, and worsening or new-onset heart failure as well as death from cardiovascular and non-cardiovascular causes. Pre-defined endpoints were disability after a recurrent stroke, assessed with the modified Rankin scale (mRS) and the Barthel index at 3 months, and cognitive function, assessed with the Mini-Mental State Examination (MMSE) score at 4 weeks after randomization and at the penultimate visit. Patients in the two highest quintiles of heart rate (77-82 and >82 b.p.m.) were at a higher risk for total death [hazard ratio (HR) 1.42, 95% CI 1.19-1.69 and HR 1.74, 95% CI 1.48-2.06, P < 0.0001] compared with the lowest quintile. Similar results were observed for vascular death [71-≤76 b.p.m., HR 1.39 (1.11-1.74), P < 0.0001] and non-vascular death [from >82 b.p.m., HR 1.66 (1.29-2.13), P = 0.0016]. Myocardial infarction (P = 0.7084) and recurrent stroke (P = 0.1379) were not significantly associated with the baseline heart rate. Hazard ratios were adjusted to multiple confounders including the baseline blood pressure. In the group of patients with a recurrent stroke, an association of a lower heart rate to better outcomes was measured with the Barthel index across all heart rate groups. In addition, there was a significant association of the baseline heart rate to the occurrence of significant cognitive decline according to an MMSE score ≤24 points at 1 month and at the penultimate visit or a decline of ≥2 points between these two time periods. Better independence score at a low heart rate were observed. CONCLUSION The heart rate is a risk indicator for mortality in patients with stroke and, importantly, a low heart rate is associated with a better functional outcome and less cognitive decline after an ischaemic stroke. TRIAL REGISTRATION ClinicalTrials.gov, number NTC00153062.
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Affiliation(s)
- Michael Böhm
- Universitätskliniken des Saarlandes, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Kirrberger Str. 1, D 66424 Homburg/Saar, Germany.
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Ukena C, Böhm M, Schirmer SH. Hot topics in cardiology: data from IABP-SHOCK II, TRILOGY-ACS, WOEST, ALTIDUDE, FAME II and more. Clin Res Cardiol 2012; 101:861-74. [PMID: 23064855 DOI: 10.1007/s00392-012-0511-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Accepted: 09/18/2012] [Indexed: 10/27/2022]
Abstract
This summary article provides an update on novel clinical trials in the field of cardiovascular medicine which were presented at the annual meeting of the European Cardiac Society, held in Munich, Germany, in August 2012. The data were presented by leading experts in the field with relevant positions in the trials and registries. Unpublished reports should be considered as preliminary data as the analysis may change in the final publications. This article provides the reader with comprehensive summaries of the most recent diagnostic and therapeutic developments in cardiovascular medicine as previously reported (Walenta et al. in Clin Res Cardiol 100:955-971, 2011; Schirmer et al. in Clin Res Cardiol 98:691-699, 2009).
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Affiliation(s)
- Christian Ukena
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Strasse, 66421 Homburg/Saar, Germany.
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31
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Turan TN, Lynn MJ, Nizam A, Lane B, Egan BM, Le NA, Lopes-Virella MF, Hermayer KL, Benavente O, White CL, Brown WV, Caskey MF, Steiner MR, Vilardo N, Stufflebean A, Derdeyn CP, Fiorella D, Janis S, Chimowitz MI. Rationale, design, and implementation of aggressive risk factor management in the Stenting and Aggressive Medical Management for Prevention of Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. Circ Cardiovasc Qual Outcomes 2012; 5:e51-60. [PMID: 22991350 PMCID: PMC3500085 DOI: 10.1161/circoutcomes.112.966911] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tanya N Turan
- Medical University of South Carolina, Charleston, SC 29425, USA.
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32
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Weber R, Weimar C, Blatchford J, Hermansson K, Wanke I, Möller-Hartmann C, Gizewski ER, Forsting M, Demchuk AM, Sacco RL, Saver JL, Warach S, Diener HC, Diehl A. Telmisartan on Top of Antihypertensive Treatment Does Not Prevent Progression of Cerebral White Matter Lesions in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) MRI Substudy. Stroke 2012; 43:2336-42. [DOI: 10.1161/strokeaha.111.648576] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ralph Weber
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Christian Weimar
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Jon Blatchford
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Karin Hermansson
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Isabel Wanke
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Claudia Möller-Hartmann
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Elke R. Gizewski
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Michael Forsting
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Andrew M. Demchuk
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Ralph L. Sacco
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Jeffrey L. Saver
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Steven Warach
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Hans-Christoph Diener
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
| | - Anke Diehl
- From the Departments of Neurology (R.W., C.W., H.C.D.) and Neuroradiology (I.W., C.M.-H., E.R.G., M.F., A.D.), University of Duisburg-Essen, Essen, Germany; Boehringer Ingelheim–Ltd, Bracknell, UK (J.B.); Boehringer Ingelheim AB, Stockholm, Sweden (K.H.); Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (A.M.D.); Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL (R.L.S.); Los Angeles Stroke Center, University of California, Los
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Dewilde S, Hawkins N. Investigating incoherence gives insight: clopidogrel is equivalent to extended-release dipyridamole plus aspirin in secondary stroke prevention. J Clin Epidemiol 2012; 65:835-45. [DOI: 10.1016/j.jclinepi.2012.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 01/19/2012] [Accepted: 01/22/2012] [Indexed: 10/28/2022]
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Destro M, Cagnoni F, Dognini GP, Galimberti V, Taietti C, Cavalleri C, Galli E. Telmisartan: just an antihypertensive agent? A literature review. Expert Opin Pharmacother 2012; 12:2719-35. [PMID: 22077832 DOI: 10.1517/14656566.2011.632367] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The modulation of the renin angiotensin aldosterone system (RAAS) is an important pathway in managing high blood pressure, and its overexpression plays a key role in target end-organ damage. Telmisartan is an angiotensin II receptor blocker (ARB) with unique pharmacologic properties, including the longest half-life among all ARBs; this leads to a significant and 24-h sustained reduction of blood pressure. Telmisartan has well-known antihypertensive properties, but there is also strong clinical evidence that it reduces left ventricular hypertrophy, arterial stiffness and the recurrence of atrial fibrillation, and confers renoprotection. AREAS COVERED This paper reviews telmisartan's pharmacological properties in terms of efficacy for hypertension control and, importantly, focuses on its new therapeutic indications and their clinical implications. EXPERT OPINION ONTARGET (ongoing telmisartan alone and in combination with ramipril global endpoint trial) demonstrated, that telmisartan confers cardiovascular protective effects similar to those of ramipril, but with a better tolerability. Moreover, recent investigations focused on the capability of telmisartan to modulate the peroxisome proliferator-activated receptor-gamma (PPAR-γ), an established target in the treatment of insulin resistance, diabetes and metabolic syndrome, whose activation is also correlated to anti-inflammatory and, finally, anti-atherosclerotic properties. Telmisartan shows peculiar features that go beyond blood pressure control. It presents promising and unique protective properties against target end-organ damage, potentially able to open a scenario of new therapeutic approaches to cardiovascular disease.
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Affiliation(s)
- Maurizio Destro
- General Medicine Unit, Treviglio-Caravaggio Hospital, Medical Department, A.O. Treviglio, 24047 Treviglio (BG), Italy.
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Jaturapatporn D, Isaac MGEKN, McCleery J, Tabet N. Aspirin, steroidal and non-steroidal anti-inflammatory drugs for the treatment of Alzheimer's disease. Cochrane Database Syst Rev 2012; 2012:CD006378. [PMID: 22336816 PMCID: PMC11337172 DOI: 10.1002/14651858.cd006378.pub2] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) is the most common form of dementia. The incidence of AD rises exponentially with age and its prevalence will increase significantly worldwide in the next few decades. Inflammatory processes have been suspected in the pathogenesis of the disease. OBJECTIVES To review the efficacy and side effects of aspirin, steroidal and non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of AD, compared to placebo. SEARCH METHODS We searched ALOIS: the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 12 April 2011 using the terms: aspirin OR "cyclooxygenase 2 inhibitor" OR aceclofenac OR acemetacin OR betamethasone OR celecoxib OR cortisone OR deflazacort OR dexamethasone OR dexibruprofen OR dexketoprofen OR diclofenac sodium OR diflunisal OR diflusinal OR etodolac OR etoricoxib OR fenbufen OR fenoprofen OR flurbiprofen OR hydrocortisone OR ibuprofen OR indometacin OR indomethacin OR ketoprofen OR lumiracoxib OR mefenamic OR meloxicam OR methylprednisolone OR nabumetone OR naproxen OR nimesulide OR "anti-inflammatory" OR prednisone OR piroxicam OR sulindac OR tenoxicam OR tiaprofenic acid OR triamcinolone OR NSAIDS OR NSAID. ALOIS contains records of clinical trials identified from monthly searches of a number of major healthcare databases (including MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS), numerous trial registries (including national, international and pharmacuetical registries) and grey literature sources. SELECTION CRITERIA All randomised controlled trials assessing the efficacy of aspirin, steroidal and non-steroidal anti-inflammatory drugs in AD. DATA COLLECTION AND ANALYSIS One author assessed risk of bias of each study and extracted data. A second author verified data selection. MAIN RESULTS Our search identified 604 potentially relevant studies. Of these, 14 studies (15 interventions) were RCTs and met our inclusion criteria. The numbers of participants were 352, 138 and 1745 for aspirin, steroid and NSAIDs groups, respectively. One selected study comprised two separate interventions. Interventions assessed in these studies were grouped into four categories: aspirin (three interventions), steroids (one intervention), traditional NSAIDs (six interventions), and selective cyclooxygenase-2 (COX-2) inhibitors (five interventions). All studies were evaluated for internal validity using a risk of bias assessment tool. The risk of bias was low for five studies, high for seven studies, and unclear for two studies.There was no significant improvement in cognitive decline for aspirin, steroid, traditional NSAIDs and selective COX-2 inhibitors. Compared to controls, patients receiving aspirin experienced more bleeding while patients receiving steroid experienced more hyperglycaemia, abnormal lab results and face edema. Patients receiving NSAIDs experienced nausea, vomiting, elevated creatinine, elevated LFT and hypertension. A trend towards higher death rates was observed among patients treated with NSAIDS compared with placebo and this was somewhat higher for selective COX-2 inhibitors than for traditional NSAIDs. AUTHORS' CONCLUSIONS Based on the studies carried out so far, the efficacy of aspirin, steroid and NSAIDs (traditional NSAIDs and COX-2 inhibitors) is not proven. Therefore, these drugs cannot be recommended for the treatment of AD.
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Affiliation(s)
- Darin Jaturapatporn
- Department of Family Medicine, Ramathibodi Hospital, Mahidol University, Bangkok and Baycrest Centre for Geriatric Care,University of Toronto, Toronto, Canada.
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Wang Y, Zhang S, Zhang L, Wang C. Chinese guidelines for the secondary prevention of ischemic stroke and transient ischemic attack 2010. CNS Neurosci Ther 2012; 18:93-101. [PMID: 22313945 PMCID: PMC6493434 DOI: 10.1111/j.1755-5949.2011.00290.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Yong‐Jun Wang
- Neurology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Su‐Ming Zhang
- Neurology Department, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liqun Zhang
- Neurology Department, St George's Hospital, London, UK
| | - Chun‐Xue Wang
- Neurology Department, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Weber R, Weimar C, Wanke I, Möller-Hartmann C, Gizewski ER, Blatchford J, Hermansson K, Demchuk AM, Forsting M, Sacco RL, Saver JL, Warach S, Diener HC, Diehl A. Risk of recurrent stroke in patients with silent brain infarction in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) imaging substudy. Stroke 2012; 43:350-5. [PMID: 22267825 DOI: 10.1161/strokeaha.111.631739] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Silent brain infarctions are associated with an increased risk of stroke in healthy individuals. Risk of recurrent stroke in patients with both symptomatic and silent brain infarction (SBI) has only been investigated in patients with cardioembolic stroke in the European Atrial Fibrillation Trial. We assessed whether patients with recent noncardioembolic stroke and SBI detected on MRI are at increased risk for recurrent stroke, other cardiovascular events, and mortality. METHODS The prevalence of SBI detected on MRI was assessed in 1014 patients enrolled in the imaging substudy of the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial. The primary outcome was first recurrence of stroke in patients with both symptomatic stroke and SBI in comparison with age- and sex-matched patients with stroke without SBI. Secondary outcomes were a combined vascular end point, other vascular events, and mortality. The 2 groups were compared using conditional logistic regression. RESULTS Silent brain infarction was detected in 207 (20.4%) of the 1014 patients. Twenty-seven (13.0%) patients with SBI and 19 (9.2%) without SBI had a recurrent stroke (OR, 1.42; 95% CI, 0.79-2.56; P=0.24) during a mean follow-up of 2.5 years. Similarly, there was no statistically significant difference for all secondary outcome parameters between patients with SBI and matched patients without SBI. CONCLUSIONS The presence of SBI in patients with recent mild noncardioembolic ischemic stroke could not be shown to be an independent risk factor for recurrent stroke, other vascular events, or a higher mortality rate. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00153062.
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Affiliation(s)
- Ralph Weber
- Department of Neurology, University Duisburg-Essen, Essen, Germany
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Bernard TJ, Manco-Johnson MJ, Lo W, MacKay MT, Ganesan V, DeVeber G, Goldenberg NA, Armstrong-Wells J, Dowling MM, Roach ES, Tripputi M, Fullerton HJ, Furie KL, Benseler SM, Jordan LC, Kirton A, Ichord R. Towards a consensus-based classification of childhood arterial ischemic stroke. Stroke 2011; 43:371-7. [PMID: 22156694 DOI: 10.1161/strokeaha.111.624585] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The implementation of uniform nomenclature and classification in adult arterial ischemic stroke (AIS) has been critical for defining outcomes and recurrence risks according to etiology and in developing risk-stratified treatments. In contrast, current classification and nomenclature in childhood AIS are often overlapping or contradictory. Our purpose was to develop a comprehensive consensus-based classification system for childhood AIS. METHODS Using a modified-Delphi method, members of the International Pediatric Stroke Study (IPSS) developed the Childhood AIS Standardized Classification And Diagnostic Evaluation (CASCADE) criteria. Two groups of pediatric stroke specialists from the IPSS classified 7 test cases using 2 methods each: (1) classification typical of the individual clinician's current clinical practice; and (2) classification based on the CASCADE criteria. Group 1 underwent in-person training in the utilization of the CASCADE criteria. Group 2 classified the same cases via an online survey, including definitions but without training. Inter-rater reliability (IRR) was assessed via multi-rater unweighted κ-statistic. RESULTS In Group 1 (with training), IRR was improved using CASCADE criteria (κ=0.78, 95% CI=[0.49, 0.94]), compared with typical clinical practice (κ=0.40, 95% CI=[0.11, 0.60]). In Group 2 (without training), IRR was lower than among trained raters (κ=0.61, 95% CI=[0.29, 0.77]), but higher than current practice (κ=0.23, 95% CI=[0.03, 0.36]). CONCLUSIONS A new, consensus-based classification system for childhood AIS, the CASCADE criteria, can be used to classify cases with good IRR. These preliminary findings suggest that the CASCADE criteria may be particularity useful in the setting of prospective multicenter studies in childhood-onset AIS, where standardized training of investigators is feasible.
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Affiliation(s)
- Timothy J Bernard
- Sections of Child Neurology and Hemophilia and Thrombosis Center, Department of Pediatrics, School of Public Health, University of Colorado, Aurora, CO, USA.
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Ovbiagele B, Bath PM, Cotton D, Vinisko R, Diener HC. Obesity and Recurrent Vascular Risk After a Recent Ischemic Stroke. Stroke 2011; 42:3397-402. [DOI: 10.1161/strokeaha.111.624957] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background and Purpose—
Although obesity is an established risk factor for the occurrence of a primary stroke, little is known about the impact of baseline obesity on recurrent vascular risk among patients with recently symptomatic cerebrovascular disease. We evaluated the association of obesity with future vascular risk in patients with a recent history of stroke.
Methods—
We analyzed the database of a multicenter trial involving 20 332 patients with recent ischemic stroke followed for 2.5 years. Subjects were divided into 3 groups according to recognized body mass index categories representing lean, overweight, and obese. Primary outcome was time to first recurrent stroke and secondary outcome time to stroke, myocardial infarction, or vascular death. The independent association of obesity with outcome was assessed by controlling for other known risk factors.
Results—
Of 20 246 eligible subjects, 4805 (24%) were obese. After adjusting for confounders, compared with the lean group, being overweight (hazard ratio, 0.95; 95% CI, 0.85–1.06) or obese (hazard ratio, 0.95; 95% CI, 0.83–1.08) was not associated with increased recurrent stroke risk, but being overweight (hazard ratio, 0.84; 95% CI, 0.77–0.92) or obese (hazard ratio, 0.86; 95% CI, 0.77–0.96) was associated with lower risk of a major vascular event.
Conclusions—
Obesity is not related to recurrent stroke risk, but obese patients with stroke are at lower overall vascular risk than their leaner counterparts, supporting the widely held notion of the existence of a cardiovascular “obesity paradox.”
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Affiliation(s)
- Bruce Ovbiagele
- From the Department of Neurosciences (B.O.), University of California at San Diego, San Diego, CA; the Stroke Trials Unit (P.M.B.), University of Nottingham, Nottingham, UK; Boehringer Ingelheim Pharmaceuticals, Inc (D.C., R.V.), Ridgefield, CT; and the Department of Neurology (H.-C.D.), University of Duisburg-Essen, Duisburg-Essen, Germany
| | - Philip M. Bath
- From the Department of Neurosciences (B.O.), University of California at San Diego, San Diego, CA; the Stroke Trials Unit (P.M.B.), University of Nottingham, Nottingham, UK; Boehringer Ingelheim Pharmaceuticals, Inc (D.C., R.V.), Ridgefield, CT; and the Department of Neurology (H.-C.D.), University of Duisburg-Essen, Duisburg-Essen, Germany
| | - Daniel Cotton
- From the Department of Neurosciences (B.O.), University of California at San Diego, San Diego, CA; the Stroke Trials Unit (P.M.B.), University of Nottingham, Nottingham, UK; Boehringer Ingelheim Pharmaceuticals, Inc (D.C., R.V.), Ridgefield, CT; and the Department of Neurology (H.-C.D.), University of Duisburg-Essen, Duisburg-Essen, Germany
| | - Richard Vinisko
- From the Department of Neurosciences (B.O.), University of California at San Diego, San Diego, CA; the Stroke Trials Unit (P.M.B.), University of Nottingham, Nottingham, UK; Boehringer Ingelheim Pharmaceuticals, Inc (D.C., R.V.), Ridgefield, CT; and the Department of Neurology (H.-C.D.), University of Duisburg-Essen, Duisburg-Essen, Germany
| | - Hans-Christoph Diener
- From the Department of Neurosciences (B.O.), University of California at San Diego, San Diego, CA; the Stroke Trials Unit (P.M.B.), University of Nottingham, Nottingham, UK; Boehringer Ingelheim Pharmaceuticals, Inc (D.C., R.V.), Ridgefield, CT; and the Department of Neurology (H.-C.D.), University of Duisburg-Essen, Duisburg-Essen, Germany
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Suksomboon N, Poolsup N, Prasit T. Systematic review of the effect of telmisartan on insulin sensitivity in hypertensive patients with insulin resistance or diabetes. J Clin Pharm Ther 2011; 37:319-27. [DOI: 10.1111/j.1365-2710.2011.01295.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Understanding the PRoFESS Study for Secondary Stroke Prevention. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 11:221-31. [PMID: 19433017 DOI: 10.1007/s11936-009-0023-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial is the largest secondary stroke prevention study completed to date. It compared extended-release dipyridamole plus aspirin (eDYP-ASA) versus clopidogrel and telmisartan versus antihypertensive regimens excluding angiotensin receptor blockers (ARBs). No statistical differences were found in either arm for the primary outcome of fatal or nonfatal stroke or prespecified secondary end points. eDYP-ASA also was associated with increases in major hemorrhagic events but not with statistical increases in combined rates of stroke recurrence or hemorrhage. Despite PRoFESS, the role of ARBs post stroke remains unclear, as concomitant angiotensin-converting enzyme inhibitor use in PRoFESS obscured whether just blood pressure lowering or renin-angiotensin system blockade is important. The resulting interpretation that eDYP-ASA is "not noninferior" has raised questions about how to interpret noninferiority analyses. Also, although the PRoFESS editorialists suggested that aspirin, the historical bystander control, was the "winner," a review of prior antiplatelet studies suggests that the benefits of aspirin, either as combination or monotherapy, are outweighed by its bleeding hazards. The benefits of clopidogrel or eDYP-ASA, compared with aspirin, are small but real, and both remain preferred agents in secondary stroke prevention.
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Thompson AM, Hu T, Eshelbrenner CL, Reynolds K, He J, Bazzano LA. Antihypertensive treatment and secondary prevention of cardiovascular disease events among persons without hypertension: a meta-analysis. JAMA 2011; 305:913-22. [PMID: 21364140 PMCID: PMC4313888 DOI: 10.1001/jama.2011.250] [Citation(s) in RCA: 165] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
CONTEXT Cardiovascular disease (CVD) risk increases beginning at systolic blood pressure levels of 115 mm Hg. Use of antihypertensive medications among patients with a history of CVD or diabetes and without hypertension has been debated. OBJECTIVE To evaluate the effect of antihypertensive treatment on secondary prevention of CVD events and all-cause mortality among persons without clinically defined hypertension. DATA SOURCES Meta-analysis with systematic search of MEDLINE (1950 to week 3 of January 2011), EMBASE, and the Cochrane Collaboration Central Register of Controlled Clinical Trials and manual examination of references in selected articles and studies. STUDY SELECTION From 874 potentially relevant publications, 25 trials that fulfilled the predetermined inclusion and exclusion criteria were included in the meta-analysis. DATA EXTRACTION Information on participant characteristics, trial design and duration, treatment drug, dose, control, and clinical events were extracted using a standardized protocol. Outcomes included stroke, myocardial infarction (MI), congestive heart failure (CHF), composite CVD outcomes, CVD mortality, and all-cause mortality. RESULTS Compared with controls, participants receiving antihypertensive medications had a pooled relative risk of 0.77 (95% confidence interval [CI], 0.61 to 0.98) for stroke, 0.80 (95% CI, 0.69 to 0.93) for MI, 0.71 (95% CI, 0.65 to 0.77) for CHF, 0.85 (95% CI, 0.80 to 0.90) for composite CVD events, 0.83 (95% CI, 0.69 to 0.99) for CVD mortality, and 0.87 (95% CI, 0.80 to 0.95) for all-cause mortality from random-effects models. The corresponding absolute risk reductions per 1000 persons were -7.7 (95% CI, -15.2 to -0.3) for stroke, -13.3 (95% CI, -28.4 to 1.7) for MI, -43.6 (95% CI, -65.2 to -22.0) for CHF events, -27.1 (95% CI, -40.3 to -13.9) for composite CVD events, -15.4 (95% CI, -32.5 to 1.7) for CVD mortality, and -13.7 (95% CI, -24.6 to -2.8) for all-cause mortality. Results did not differ according to trial characteristics or subgroups defined by clinical history. CONCLUSIONS Among patients with clinical history of CVD but without hypertension, antihypertensive treatment was associated with decreased risk of stroke, CHF, composite CVD events, and all-cause mortality. Additional randomized trial data are necessary to assess these outcomes in patients without CVD clinical recommendations.
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Affiliation(s)
- Angela M Thompson
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St, New Orleans, LA 70112-2715, USA
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Kral M, Herzig R, Sanak D, Skoloudik D, Vlachova I, Bartkova A, Hlustik P, Kovacik M, Kanovsky P. Oral antiplatelet therapy in stroke prevention. Minireview. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2011; 154:203-10. [PMID: 21048805 DOI: 10.5507/bp.2010.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Antiplatelet therapy plays a crucial role in the primary and secondary prevention of noncardioembolic ischemic stroke / transient ischemic attacks (IS/TIA). Several antiplatelet agents are available. This review deals with the characteristics of particular antiplatelet agents as well as choice of antiplatelet treatment in various situations, based on the evidence and international recommendations. METHODS PubMed and Stroke Trials Registry on-line databases and the European Stroke Organisation Guidelines for Management of IS/TIA 2008 and update of the recommendations of the American Heart Association / American Stroke Association Council 2008 on Stroke were used. RESULTS Acetylsalicylic acid (ASA) is the only antiplatelet drug used in primary prevention, mainly to reduce the risk of myocardial infarction (MI), but also in women aged 45 years or more and in some patients with non-valvular atrial fibrillation to reduce risk of IS/TIA. In the secondary prevention of noncardioembolic IS/TIA, ASA in combination with long release dipyridamole (DIP) and clopidogrel (CLOP) alone are considered first choice therapies. The choice of the particular antiplatelet agent should be individualized according to the patient risk factor profiles and treatment tolerance. ASA alone or triflusal can be used alternatively in patients who cannot be treated with either ASA+DIP or CLOP. The use of indobufen should be considered only in patients in need of temporary interruption of the antiplatelet therapy. Ticlopidine (TIC) should not be newly introduced into the treatment. Currently, insufficient data are available on the use of cilostazol in IS/TIA prevention.
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Affiliation(s)
- Michal Kral
- Stroke Center, Department of Neurology, Palacky University and University Hospital, Olomouc, Czech Republic.
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Dawson J, Quinn T, Lees KR, Walters MR. Microembolic Signals and Aspirin Resistance in Patients with Carotid Stenosis. Cardiovasc Ther 2011; 30:234-9. [DOI: 10.1111/j.1755-5922.2010.00259.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Franks ZG, Campbell RA, Weyrich AS, Rondina MT. Platelet-leukocyte interactions link inflammatory and thromboembolic events in ischemic stroke. Ann N Y Acad Sci 2010; 1207:11-7. [PMID: 20955420 DOI: 10.1111/j.1749-6632.2010.05733.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Stroke is a common and often fatal event, and, in survivors, it is accompanied by a high risk of recurrence. Ischemic stroke is associated with abnormal platelet activity and thrombus formation. In addition to their roles in the development of acute thrombi, platelets serve as a bridge for leukocytes within the vasculature. Myeloid leukocytes are critical mediators of atherosclerosis and atherothrombosis. Interactions between platelets and leukocytes foster an inflammatory and thrombotic milieu that influences lesion progression, facilitates plaque rupture, and triggers thrombus formation and embolization. Accordingly, antiplatelet agents, including aspirin, dipyridamole, and clopidogrel, are recommended therapies for most patients with a history of stroke. In addition to mitigating thrombosis, antiplatelet drugs have direct and indirect effects on inflammation, which may translate to enhanced clinical efficacy.
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Affiliation(s)
- Zechariah G Franks
- Program in Molecular Medicine, University of Utah, Salt Lake City, Utah, USA
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Gebel JM. Heterogeneity of Efficacy and Safety of Antiplatelet Therapy in Cardiovascular and Cerebrovascular Disease. Am J Cardiovasc Drugs 2010; 10:115-24. [DOI: 10.2165/11319580-000000000-00000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Galzerano D, Capogrosso C, Di Michele S, Galzerano A, Paparello P, Lama D, Gaudio C. New standards in hypertension and cardiovascular risk management: focus on telmisartan. Vasc Health Risk Manag 2010; 6:113-33. [PMID: 20448797 PMCID: PMC2860444 DOI: 10.2147/vhrm.s7857] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Indexed: 12/21/2022] Open
Abstract
Blockade of the renin–angiotensin system is an important approach in managing high blood pressure, and has increasingly been shown to affect cardiovascular disease processes mediated by angiotensin II throughout the cardiovascular and renal continua. Telmisartan is an angiotensin II receptor blocker (ARB) displaying unique pharmacologic properties, including a longer half life than any other ARB, that result in large and sustained reductions of blood pressure. In patients with mild-to-moderate hypertension, telmisartan has proved superior to other antihypertensive agents (valsartan, losartan, ramipril, perindopril, and atenolol) in controlling blood pressure particularly towards the end of the dosing interval. There is also clinical evidence that telmisartan reduces left ventricular hypertrophy, reduces arterial stiffness and the recurrence of atrial fibrillation, and confers renoprotection. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET®) study has demonstrated that telmisartan has similar cardiovascular protective effects to ramipril in a large, high-risk patient population but was better tolerated. The powerful and sustained blood pressure control apparent in clinical trials, together with cardiovascular protection and tolerability demonstrated in ONTARGET® means that telmisartan may be a preferred option for patients with hypertension.
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Staessen JA, Richart T, Wang Z, Thijs L. Implications of recently published trials of blood pressure-lowering drugs in hypertensive or high-risk patients. Hypertension 2010; 55:819-31. [PMID: 20212274 DOI: 10.1161/hypertensionaha.108.122879] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We reviewed 6 recent outcome trials of blood pressure (BP)-lowering drugs in 74,524 randomized hypertensive or high-risk patients. Over interpretation of nonsignificant or marginal probability values in large trials with overlapping end points, exclusion of patients not tolerating or not adhering to experimental treatments, labeling nonsignificant treatment effects as modest, and insufficient information on the quality of the BP measurements or on the BP changes early after randomization raise concern. From a clinical viewpoint, results should not be extrapolated to patients with characteristics dissimilar from those randomized. The benefit beyond BP lowering in cardiovascular prevention is tiny. Dual inhibition of the renin system should only be used in patients at high risk, in whom all drug combinations have been tried and who cannot be controlled by a single renin system inhibitor. Current evidence does not support BP lowering in normotensive patients or the use of renin system inhibitors for prevention of stroke recurrence. Because angiotensin-receptor blockers might offer less protection against myocardial infarction than angiotensin-converting enzyme inhibitors, the latter should remain the preferred renin system inhibitor for cardiovascular prevention in angiotensin-converting enzyme inhibitor-tolerant patients. In 2 trials, in which new-onset diabetes was a predefined end point, 1000 patients had to be treated for 1 year with an angiotensin-receptor blocker instead of placebo to prevent just 2 cases. From a design viewpoint, the time has come to revise the concept of large simple trials and to pursue research questions that serve patient interests more than showing noninferiority or highlight the ancillary qualities of marketable antihypertensive drugs.
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Affiliation(s)
- Jan A Staessen
- Studies Coordinating Centre, Division of Hypertension and Cardiovascular Rehabilitation, Department of Cardiovascular Diseases, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Block d, Level 00, Box 7001, B-3000 Leuven, Belgium.
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Bath PMW, Cotton D, Martin RH, Palesch Y, Yusuf S, Sacco R, Diener HC, Estol C, Roberts R. Effect of combined aspirin and extended-release dipyridamole versus clopidogrel on functional outcome and recurrence in acute, mild ischemic stroke: PRoFESS subgroup analysis. Stroke 2010; 41:732-8. [PMID: 20181679 DOI: 10.1161/strokeaha.109.564906] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Long-term antiplatelet therapy is effective at reducing recurrence after ischemic stroke. However, the relative safety and efficacy of combined aspirin-dipyridamole or clopidogrel are not known in patients with acute ischemic stroke. METHODS The factorial PRoFESS secondary prevention trial assessed antiplatelet and blood pressure-lowering strategies in 20,332 patients, 1360 of whom were randomized within 72 hours of ischemic stroke to combined aspirin (Asp; 25 mg BID) and extended-release dipyridamole (ER-DP; 200 mg BID, n=672) or clopidogrel (75 mg/d, n=688). The primary outcome for this post hoc subgroup analysis was functional outcome at 30 days; secondary outcomes included recurrence and death by 90 days. Analyses were adjusted for baseline prognostic variables and blood pressure treatment assignment. RESULTS Patients were representative of the whole trial (age 67 years, National Institutes of Health Stroke Scale score 3, small-artery occlusion 59%), and baseline variables were similar between treatment groups. The mean time from stroke to recruitment was 58 hours. By 90 days, treatment was no longer being taken in 121 (18%) patients randomized to Asp/ER-DP and in 86 (12.5%) assigned to clopidogrel (P=0.006). Combined death or dependency (shift analysis of modified Rankin Scale score at day 30) did not differ between treatment groups (odds ratio [OR]=0.97; 95% CI, 0.79 to 1.19). Nonsignificant trends to reduced recurrence (OR=0.56; 95% CI, 0.26 to 1.18) and vascular events (OR=0.71; 95% CI, 0.36 to 1.37) were present with Asp/ER-DP. Rates of death, major bleeding, and serious adverse events did not differ between treatment groups. CONCLUSIONS Treatment with combined Asp/ER-DP vs clopidogrel in 1360 patients with acute, mild ischemic stroke did not differ in terms of effects on functional outcome, recurrence, death, bleeding, or serious adverse events. Both treatments were practical to administer.
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Affiliation(s)
- Philip M W Bath
- Stroke Trials Unit, Division of Stroke Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK.
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