Risk factors for stroke and type of stroke in persons with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group

Preventability of ischemic stroke/transient ischemic attack in a tertiary care center in Argentina

INTRODUCTION

Cardiovascular disease remains a leading cause of morbidity and mortality worldwide, with many individuals presenting with acute ischemic stroke or transient ischemic attack (AIS/TIA) due to underlying vascular risk factors (VRF). While these patients typically undergo routine evaluations for acute treatment, the prevention of these conditions is often underestimated. This study reports the prevalence of non-optimized VRF and estimates their degree of avoidability in a cohort of patients treated in a tertiary care center following AIS/TIA.

METHODS

This retrospective study enrolled patients older than 18 years who experienced AIS/TIA over a two-year period. Preventability was defined as the degree to which an acute cerebrovascular event could have been prevented if the VRF had been appropriately treated. Using the variables determined at the onset of AIS or TIA, we developed a 10-point scale to classify the degree of preventability (not preventable [score of 0], low preventability [score of 1-3], and high preventability [score of 4 or higher]). We further defined sub-scores based on the effectiveness of treatment of high blood pressure [HBP] (0-2 points), dyslipidemia [DLP] (0-2 points), atrial fibrillation [AF] (1 point), active smoking [AS] (1 point), obesity (1 point), previous coronary heart disease [CHD] (1 point), and previous AIS/TIA (2 points). Demographic factors, etiologies, and imaging findings were evaluated, tabulated independently, and subsequently correlated with clinical findings extracted from the available patient records.

RESULTS

Of the 395 patients (334 with AIS and 61 with TIA), 376 (95.19 %) exhibited some degree of preventability, whereas 19 (4.81 %) presented with a nonpreventable event. In total, 296 (74.94 %) presented a low preventable event, and 80 (20.25 %) presented a high preventable event. Applying the Chi-square test of independence to stroke etiology highlighted cardio-aortic embolism and large artery atherosclerosis as groups with a significantly higher burden of risk factors necessitating intervention, while patients with stroke of other etiologies had more adequate control of VRF. In terms of stroke severity, as determined by the National Institutes of Health Stroke Scale (NIHSS), patients with NIHSS scores >5 were more likely to experience preventable events. According to the ABCD2 score, higher risk scores were significantly associated with a higher preventive factor burden; however, age, sex, vascular territory, and Canadian TIA scores were not related to the prevention of AIS/TIA.

CONCLUSIONS

The high percentage of preventable events reflects the need to study other factors that may contribute to unhealthy lifestyles in this population. Potential reasons for poor health include high levels of stress, sleep deprivation, working conditions and an unhealthy diet. Further studies are required to better understand these phenomena.

Pharmacological interventions for asymptomatic carotid stenosis

BACKGROUND

Carotid artery stenosis is narrowing of the carotid arteries. Asymptomatic carotid stenosis is when this narrowing occurs in people without a history or symptoms of this disease. It is caused by atherosclerosis; that is, the build-up of fats, cholesterol, and other substances in and on the artery walls. Atherosclerosis is more likely to occur in people with several risk factors, such as diabetes, hypertension, hyperlipidaemia, and smoking. As this damage can develop without symptoms, the first symptom can be a fatal or disabling stroke, known as ischaemic stroke. Carotid stenosis leading to ischaemic stroke is most common in men older than 70 years. Ischaemic stroke is a worldwide public health problem.

OBJECTIVES

To assess the effects of pharmacological interventions for the treatment of asymptomatic carotid stenosis in preventing neurological impairment, ipsilateral major or disabling stroke, death, major bleeding, and other outcomes.

SEARCH METHODS

We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and three trials registers from their inception to 9 August 2022. We also checked the reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs), irrespective of publication status and language, comparing a pharmacological intervention to placebo, no treatment, or another pharmacological intervention for asymptomatic carotid stenosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two review authors independently extracted the data and assessed the risk of bias of the trials. A third author resolved disagreements when necessary. We assessed the evidence certainty for key outcomes using GRADE.

MAIN RESULTS

We included 34 RCTs with 11,571 participants. Data for meta-analysis were available from only 22 studies with 6887 participants. The mean follow-up period was 2.5 years. None of the 34 included studies assessed neurological impairment and quality of life. Antiplatelet agent (acetylsalicylic acid) versus placebo Acetylsalicylic acid (1 study, 372 participants) may result in little to no difference in ipsilateral major or disabling stroke (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.47 to 2.47), stroke-related mortality (RR 1.40, 95% CI 0.54 to 3.59), progression of carotid stenosis (RR 1.16, 95% CI 0.79 to 1.71), and adverse events (RR 0.81, 95% CI 0.41 to 1.59), compared to placebo (all low-certainty evidence). The effect of acetylsalicylic acid on major bleeding is very uncertain (RR 0.98, 95% CI 0.06 to 15.53; very low-certainty evidence). The study did not measure neurological impairment or quality of life. Antihypertensive agents (metoprolol and chlorthalidone) versus placebo The antihypertensive agent, metoprolol, may result in no difference in ipsilateral major or disabling stroke (RR 0.14, 95% CI 0.02 to1.16; 1 study, 793 participants) and stroke-related mortality (RR 0.57, 95% CI 0.17 to 1.94; 1 study, 793 participants) compared to placebo (both low-certainty evidence). However, chlorthalidone may slow the progression of carotid stenosis (RR 0.45, 95% CI 0.23 to 0.91; 1 study, 129 participants; low-certainty evidence) compared to placebo. Neither study measured neurological impairment, major bleeding, adverse events, or quality of life. Anticoagulant agent (warfarin) versus placebo The evidence is very uncertain about the effects of warfarin (1 study, 919 participants) on major bleeding (RR 1.19, 95% CI 0.97 to 1.46; very low-certainty evidence), but it may reduce adverse events (RR 0.89, 95% CI 0.81 to 0.99; low-certainty evidence) compared to placebo. The study did not measure neurological impairment, ipsilateral major or disabling stroke, stroke-related mortality, progression of carotid stenosis, or quality of life. Lipid-lowering agents (atorvastatin, fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin) versus placebo or no treatment Lipid-lowering agents may result in little to no difference in ipsilateral major or disabling stroke (atorvastatin, lovastatin, pravastatin, and rosuvastatin; RR 0.36, 95% CI 0.09 to 1.53; 5 studies, 2235 participants) stroke-related mortality (lovastatin and pravastatin; RR 0.25, 95% CI 0.03 to 2.29; 2 studies, 1366 participants), and adverse events (fluvastatin, lovastatin, pravastatin, probucol, and rosuvastatin; RR 0.76, 95% CI 0.53 to1.10; 7 studies, 3726 participants) compared to placebo or no treatment (all low-certainty evidence). The studies did not measure neurological impairment, major bleeding, progression of carotid stenosis, or quality of life.

AUTHORS' CONCLUSIONS

Although there is no high-certainty evidence to support pharmacological intervention, this does not mean that pharmacological treatments are ineffective in preventing ischaemic cerebral events, morbidity, and mortality. High-quality RCTs are needed to better inform the best medical treatment that may reduce the burden of carotid stenosis. In the interim, clinicians will have to use other sources of information.

Can miRNAs Be Considered as Diagnostic and Therapeutic Molecules in Ischemic Stroke Pathogenesis?-Current Status

Ischemic stroke is one of the leading causes of death worldwide. Clinical manifestations of stroke are long-lasting and causing economic burden on the patients and society. Current therapeutic modalities to treat ischemic stroke (IS) are unsatisfactory due to the intricate pathophysiology and poor functional recovery of brain cellular compartment. MicroRNAs (miRNA) are endogenously expressed small non-coding RNA molecules, which can act as translation inhibitors and play a pivotal role in the pathophysiology associated with IS. Moreover, miRNAs may be used as potential diagnostic and therapeutic tools in clinical practice; yet, the complete role of miRNAs is enigmatic during IS. In this review, we explored the role of miRNAs in the regulation of stroke risk factors viz., arterial hypertension, metabolic disorders, and atherosclerosis. Furthermore, the role of miRNAs were reviewed during IS pathogenesis accompanied by excitotoxicity, oxidative stress, inflammation, apoptosis, angiogenesis, neurogenesis, and Alzheimer's disease. The functional role of miRNAs is a double-edged sword effect in cerebral ischemia as they could modulate pathological mechanisms associated with risk factors of IS. miRNAs pertaining to IS pathogenesis could be potential biomarkers for stroke; they could help researchers to identify a particular stroke type and enable medical professionals to evaluate the severity of brain injury. Thus, ascertaining the role of miRNAs may be useful in deciphering their diagnostic role consequently it is plausible to envisage a suitable therapeutic modality against IS.

Left Ventricular Hypertrophy and Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background and Purpose

Left ventricular hypertrophy (LVH) is associated with the risk of stroke and dementia independently of other vascular risk factors, but its association with cerebral small vessel disease (CSVD) remains unknown. Here, we employed a systematic review and meta-analysis to address this gap.

Methods

Following the MOOSE guidelines (PROSPERO protocol: CRD42018110305), we systematically searched the literature for studies exploring the association between LVH or left ventricular (LV) mass, with neuroimaging markers of CSVD (lacunes, white matter hyperintensities [WMHs], cerebral microbleeds [CMBs]). We evaluated risk of bias and pooled association estimates with random-effects meta-analyses.

Results

We identified 31 studies (n=25,562) meeting our eligibility criteria. In meta-analysis, LVH was associated with lacunes and extensive WMHs in studies of the general population (odds ratio [OR]_lacunes, 1.49; 95% confidence interval [CI], 1.12 to 2.00) (OR_WMH, 1.73; 95% CI, 1.38 to 2.17) and studies in high-risk populations (OR_lacunes: 2.39; 95% CI, 1.32 to 4.32) (OR_WMH, 2.01; 95% CI, 1.45 to 2.80). The results remained stable in general population studies adjusting for hypertension and other vascular risk factors, as well as in sub-analyses by LVH assessment method (echocardiography/electrocardiogram), study design (cross-sectional/cohort), and study quality. Across LV morphology patterns, we found gradually increasing ORs for concentric remodelling, eccentric hypertrophy, and concentric hypertrophy, as compared to normal LV geometry. LVH was further associated with CMBs in high-risk population studies.

Conclusions

LVH is associated with neuroimaging markers of CSVD independently of hypertension and other vascular risk factors. Our findings suggest LVH as a novel risk factor for CSVD and highlight the link between subclinical heart and brain damage.

Determinants of preventable stroke-Ankara ACROSS stroke preventability study

BACKGROUND

Unhealthy lifestyle and inadequate control of vascular risk factors are the major contributors of stroke burden. Failure in achieving the target levels in control of these factors, not only designate missed opportunities contributing to the preventability of an incident stroke, but also set the post-stroke treatment goals in a case wise basis. In this study, we analyzed pre-event clinical features that play a role in stroke preventability, and determined the cumulative burden of risk factors that necessitate optimization following the ischemic insult.

METHODS

Information about the pre-stroke optimal control of seven major modifiable risk factors (Life's Simple 7: hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, diet, and physical activity) was prospectively collected in ischemic stroke patients admitted to three tertiary academic centers in Ankara. Stroke preventability was evaluated by the overall number of factors requiring optimization with patients ≥4 risk factor conditions categorized as those suffering from a preventable stroke. Bivariate and multivariate analyzes were performed to uncover predictors of stroke preventability.

RESULTS

Among 787 patients, 386 (49.0%) had ≥4 risk factor conditions requiring optimization. Preventable stroke was more common in younger patients, and patients with small artery occlusion. Multivariate analyses taking into account the pre-stroke antithrombotic treatment regimen, have highlighted age (OR: 0.99, 95%CI 0.98-1.00), female gender (1.59, 95%CI 1.17-2.16), coronary artery disease (1.54, 95%CI 1.10-2.14), small artery occlusion (1.90, 95%CI 1.13-3.18), and cardio-aortic embolism (0.53, 95%CI 0.35-0.82) as significant factors associated with preventability.

CONCLUSIONS

Approximately half of the ischemic stroke patients have preventable stroke from the perspective of risk factor control. Extra care should be given to strategies directed to risk factor control and lifestyle interventions in certain high-risk groups for the prevention of future complications.

Blood pressure-lowering efficacy of reserpine for primary hypertension

BACKGROUND

Many antihypertensive agents exist today for the treatment of primary hypertension (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, or both). Randomised controlled trials (RCTs) have been carried out to investigate the evidence for these agents. There is, for example, strong RCT evidence that thiazides reduce mortality and morbidity. Some of those trials used reserpine as a second-line therapy. However, the dose-related blood pressure reduction with this agent is not known.

OBJECTIVES

The primary objective of this review was to quantify the dose-related efficacy of reserpine versus placebo or no treatment in reducing systolic blood pressure (SBP) or diastolic blood pressure (DBP), or both.We also aimed to evaluate the dose-related effects of reserpine on mean arterial blood pressure (MAP) and heart rate (HR), as well as the dose-related effects on withdrawals due to adverse events.

SEARCH METHODS

We searched the Cochrane Hypertension Group Specialised Register (January 1946 to October 2016), CENTRAL (2016, Issue 10), MEDLINE (January 1946 to October 2016), Embase (January 1974 to October 2016), and ClinicalTrials.gov (all dates to October 2016). We also traced citations in the reference sections of the retrieved studies.

SELECTION CRITERIA

Included studies were truly randomised controlled trials (RCTs) comparing reserpine monotherapy to placebo or no treatment in participants with primary hypertension.

DATA COLLECTION AND ANALYSIS

We assessed methods of randomisation and concealment. We extracted and analysed data on blood pressure reduction, heart rate, and withdrawal due to adverse effects.

MAIN RESULTS

We found four RCTs (with a total of 237 participants) that met the inclusion criteria, none of which we found through the 2016 update search. The overall pooled effect demonstrates a statistically significant systolic blood pressure (SBP) reduction in participants taking reserpine compared with placebo (weighted mean difference (WMD) -7.92, 95% confidence interval (CI) -14.05 to -1.78). Because of significant heterogeneity across the trials, a significant effect in diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) could not be found. A dose of reserpine 0.5 mg/day or greater achieved the SBP effects. However, we could not determine the dose-response pattern because of the small number of trials. We did not combine data from the trial that investigated Rauwiloid against placebo with reserpine data from the remaining three trials. This is because Rauwiloid is a different alkaloid extract of the plant Rauwolfia serpentina, and the dose used is not comparable to reserpine. None of the included trials reported withdrawals due to adverse effects.

AUTHORS' CONCLUSIONS

Reserpine is effective in reducing SBP roughly to the same degree as other first-line antihypertensive drugs. However, we could not make definite conclusions regarding the dose-response pattern because of the small number of included trials. More RCTs are needed to assess the effects of reserpine on blood pressure and to determine the dose-related safety profile before the role of this drug in the treatment of primary hypertension can be established.

Review: Lipids and stroke

Stroke is the third leading cause of death in adults. Although vascular disease is the prime contributor to its pathogenesis, dyslipidaemia is not unambiguously established as a risk factor for stroke in the same way that it is for coronary artery disease. Non-statin treatments of dyslipidaemia have not been shown clearly to help in preventing stroke. However, large clinical trials of treatment with statins over a number of years have demonstrated that these drugs decrease ischaemic stroke rates in persons at risk. Whether this reflects the efficacy of statins in lowering low density lipoprotein-cholesterol (LDL-c) concentrations alone or whether additional mechanisms may apply is not clear.

2D-1H proton magnetic resonance spectroscopic imaging study on brain metabolite alterations in patients with diabetic hypertension

The aim of the present study was to investigate the possible metabolic alterations in the frontal cortex and parietal white matter in patients with diabetic hypertension (DHT) using proton magnetic resonance (MR) spectroscopic imaging. A total of 33 DHT patients and 30 healthy control subjects aged between 45 and 75 were included in the present study. All subjects were right‑handed. The spectroscopy data were collected using a GE Healthcare 1.5T MR scanner. The multi‑voxels were located in the semioval center (repetition time/echo time=1,500 ms/35 ms). The area of interest was 8x10x2 cm in volume and contained the two sides of the frontal cortex and the parietal white matter. The spectra data were processed using SAGE software. The ratios of brain metabolite concentrations, particularly for N‑acetylaspartate (NAA)/creatine (Cr) and Choline (Cho)/Cr were calculated and analyzed. Statistical analyses were performed using SPSS 17.0. The NAA/Cr ratio of the bilateral prefrontal cortex of the DHT group was significantly lower than that of the control group (left t=‑7.854, P=0.000 and right t=‑5.787, P=0.000), The Cho/Cr ratio was also much lower than the control group (left t=2.422, P=0.024 and right t=2.920, P=0.007). NAA/Cr ratio of the left parietal white matter of the DHT group was extremely lower than that of the control group (t=‑4.199, P=0.000). Therefore, DHT may result in metabolic disorders in the frontal cortex and parietal white matter but the metabolic alterations are different in various regions of the brain. The alteration in cerebral metabolism is associated with diabetes and hypertension. The ratios of NAA/Cr and Cho/Cr are potential metabolic markers for the brain damage induced by DHT.

Activation of the ACE2/Ang-(1-7)/Mas pathway reduces oxygen-glucose deprivation-induced tissue swelling, ROS production, and cell death in mouse brain with angiotensin II overproduction

We previously demonstrated that mice which overexpress human renin and angiotensinogen (R+A+) show enhanced cerebral damage in both in vivo and in vitro experimental ischemia models. Angiotensin-converting enzyme 2 (ACE2) counteracts the effects of angiotensin (Ang-II) by transforming it into Ang-(1-7), thus reducing the ligand for the AT1 receptor and increasing stimulation of the Mas receptor. Triple transgenic mice, SARA, which specifically overexpress ACE2 in neurons of R+A+ mice were used to study the role of ACE2 in ischemic stroke using oxygen and glucose deprivation (OGD) of brain slices as an in vitro model. We examined tissue swelling, the production of reactive oxygen species (ROS), and cell death in the cerebral cortex (CX) and the hippocampal CA1 region during OGD. Expression levels of NADPH oxidase (Nox) isoforms, Nox2 and Nox4 were measured using western blots. Results show that SARA mice and R+A+ mice treated with the Mas receptor agonist Ang-(1-7) had less swelling, cell death, and ROS production in CX and CA1 areas compared to those in R+A+ animals. Treatment of slices from SARA mice with the Mas antagonist A779 eliminated this protection. Finally, western blots revealed less Nox2 and Nox4 expression in SARA mice compared with R+A+ mice both before and after OGD. We suggest that reduced brain swelling and cell death observed in SARA animals exposed to OGD result from diminished ROS production coupled with lower expression of Nox isoforms. Thus, the ACE2/Ang-(1-7)/Mas receptor pathway plays a protective role in brain ischemic damage by counteracting the detrimental effects of Ang-II-induced ROS production.

Clinical effectiveness of telmisartan alone or in combination therapy for controlling blood pressure and vascular risk in the elderly

Elderly patients (age ≥ 65 years) with hypertension are at high risk for vascular complications, especially when diabetes is present. Antihypertensive drugs that inhibit the renin-angiotensin system have been shown to be effective for controlling blood pressure in adult and elderly patients. Importantly, renin-angiotensin system inhibitors were shown to have benefits beyond their classic cardioprotective and vasculoprotective effects, including reducing the risk of new-onset diabetes and associated cardiovascular effects. The discovery that the renin-angiotensin system inhibitor and angiotensin II type 1 (AT(1)) receptor blocker (ARB), telmisartan, can selectively activate the peroxisome proliferator-activated receptor-γ (PPARγ, an established antidiabetic drug target) provides the unique opportunity to prevent and treat cardiovascular complications in high-risk elderly patients with hypertension and new-onset diabetes. Two large clinical trials, ONTARGET (Ongoing Telmisartan Alone in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized AssessmeNt Study in ACE-I iNtolerant subjects with cardiovascular disease) have assessed the cardioprotective and antidiabetic effects of telmisartan. The collective data suggest that telmisartan is a promising drug for controlling hypertension and reducing vascular risk in high-risk elderly patients with new-onset diabetes.

Associations of obesity measures with subtypes of ischemic stroke in the ARIC Study

BACKGROUND

Associations between obesity and lacunar, nonlacunar thrombotic, and cardioembolic stroke are not firmly established.

METHODS

Body mass index (BMI), waist circumference, and waist-to-hip ratio (WHR) were recorded at baseline between 1987 and 1989 in the Atherosclerosis Risk in Communities (ARIC) Study for 13 549 black and white adults who were aged from 45 to 64 years and had no history of cardiovascular disease or cancer. The incidence of ischemic stroke subtypes was ascertained from surveillance of hospital records over a median follow-up of 16.9 years. Cox proportional hazards regression analyses adjusted for age, sex, race, education, smoking status and cigarette years, usual ethanol intake, and leisure time sports index were used to estimate hazard ratios (HRs).

RESULTS

The ARIC sample at baseline was 43.8% men and 27.3% blacks; mean age was 53.9 years. Mean BMI, waist circumference, and WHR were 27.7 kg/m(2), 96.8 cm, and 0.92, respectively. The associations of lacunar (n = 138), nonlacunar (n = 338), and cardioembolic (n = 122) ischemic stroke incidence with obesity measures were all generally positive and linear. The HRs for the highest versus lowest quintile of the 3 obesity measures ranged from 1.43-2.21 for lacunar stroke, 1.90-2.16 for nonlacunar stroke, and 2.37-2.91 for cardioembolic stroke.

CONCLUSIONS

Although different pathophysiological mechanisms may exist, the incidences of lacunar, nonlacunar, and cardioembolic stroke were all significantly positively associated with the degree of obesity, regardless of the measure used.

Impact of blood pressure levels on different types of stroke: the Hisayama study

OBJECTIVE

Clinical uncertainty remains whether the blood pressure classification and risk stratifications recommended by the Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2009) are useful in predicting the risks of stroke and its subtypes in the general Japanese population.

METHODS

A total of 1621 stroke-free residents of a Japanese community aged at least 40 years were followed up for 32 years. Outcomes were total and cause-specific stroke (lacunar infarction, atherothrombotic infarction, cardioembolic infarction, cerebral haemorrhage and subarachnoid haemorrhage). Incidence was calculated by the pooling of repeated observations method.

RESULTS

The age-adjusted incidence of total stroke rose progressively with higher blood pressure levels in both sexes (both P for trend <0.0001). A similar pattern was observed for lacunar infarction in both sexes and for cerebral haemorrhage in men: the differences were significant between optimal blood pressure and grades 1-3 hypertension (all P < 0.05). The age-adjusted incidence of atherothrombotic infarction in either sex and that of cardioembolic infarction and subarachnoid haemorrhage in women significantly increased in grade 3 hypertension (all P < 0.05). These associations remained substantially unchanged even after adjustment for other risk factors. In regard to risk stratification, the age-adjusted incidence of stroke significantly increased with the level of risk in both sexes.

CONCLUSION

Our findings suggest that the blood pressure classification and risk stratifications recommended by the JSH 2009 guidelines are useful in predicting the risk of stroke in a general Japanese population, but the magnitude and patterns of the impact of blood pressure categories are different among stroke subtypes.

Lipid profile components and risk of ischemic stroke: the Northern Manhattan Study (NOMAS)

OBJECTIVE

To explore the relationship between lipid profile components and incident ischemic stroke in a stroke-free prospective cohort.

DESIGN

Population-based prospective cohort study.

SETTING

Northern Manhattan, New York.

PATIENTS

Stroke-free community residents. Intervention As part of the Northern Manhattan Study, baseline fasting blood samples were collected on stroke-free community residents followed up for a mean of 7.5 years.

MAIN OUTCOME MEASURES

Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals for lipid profile components and ischemic stroke after adjusting for demographic and risk factors. In secondary analyses, we used repeated lipid measures over 5 years from a 10% sample of the population to calculate the change per year of each of the lipid parameters and to impute time-dependent lipid parameters for the full cohort.

RESULTS

After excluding those with a history of myocardial infarction, 2940 participants were available for analysis. Baseline high-density lipoprotein cholesterol, triglyceride, and total cholesterol levels were not associated with risk of ischemic stroke. Low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol levels were associated with a paradoxical reduction in risk of stroke. There was an interaction with use of cholesterol-lowering medication on follow-up, such that LDL-C level was only associated with a reduction in stroke risk among those taking medications. An LDL-C level greater than 130 mg/dL as a time-dependent covariate showed an increased risk of ischemic stroke (adjusted hazard ratio, 3.81; 95% confidence interval, 1.53-9.51).

CONCLUSIONS

Baseline lipid panel components were not associated with an increased stroke risk in this cohort. Treatment with cholesterol-lowering medications and changes in LDL-C level over time may have attenuated the risk in this population, and lipid measurements at several points may be a better marker of stroke risk.

Blood pressure and stroke in heart failure in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study

BACKGROUND AND PURPOSE

The prevalence of stroke is increased in individuals with heart failure (HF). The stroke mechanism in HF may be cardiogenic embolism or cerebral hypoperfusion. Stroke risk increases with decreasing ejection fraction and low cardiac output is associated with hypotension and poor survival. We examine the relationship among blood pressure level, history of stroke/transient ischemic attack (TIA), and HF.

METHODS

We compared the prevalence of self-reported history of stroke or TIA in the REasons for Geographic And Racial Differences in Stroke (REGARDS) participants with HF (as defined by current digoxin use) and without HF. We excluded participants with atrial fibrillation or missing data. We examined the relationship between HF and history of stroke/TIA within tertiles of systolic blood pressure (SBP) adjusting for patient demographic and health characteristics.

RESULTS

Prevalent stroke/TIA were reported by 66 (26.3%) of 251 participants with and 1805 (8.5%) of 21 202 participants without HF (P<0.0001). Within each tertile of SBP, the unadjusted OR (95% CI) for prior stroke/TIA among those with HF compared with those without HF (the reference group) was, 4.0 (2.8 to 5.8) for SBP <119.5 mm Hg, 2.7 (1.8 to 3.9) for SBP >or=119.5 but <131.5 mm Hg, and 2.3 (1.6 to 3.2) for SBP >or=131.5 mm Hg. After adjustment, the relationship between prior stroke/TIA and HF remained significant only within the lowest tertile of SBP (<119.5 mm Hg; 3.0; 1.5 to 6.1).

CONCLUSIONS

The odds of prevalent self-reported stroke/TIA are increased in participants with HF and most markedly increased in participants with low SBP. Longitudinal data are needed to determine whether this reflects stroke/TIA secondary to thromboembolism from poor cardiac function or secondary to cerebral hypoperfusion.

Blood pressure lowering efficacy of reserpine for primary hypertension

BACKGROUND

Many antihypertensive agents exist today for the treatment of primary hypertension (systolic blood pressure >/=140 mmHg and/or diastolic blood pressure >/=90 mmHg). Randomised controlled trials have been carried out to investigate the evidence for these agents.There is, for example, strong RCT evidence that thiazides reduce mortality and morbidity. Reserpine has been used as a second-line therapy in some of those trials. However, the dose-related blood pressure reduction with this agent is not known.

OBJECTIVES

To investigate the dose-related effect of reserpine on blood pressure, heart rate and withdrawals due to adverse events.

SEARCH STRATEGY

The databases CENTRAL, EMBASE, and MEDLINE were searched. We also traced citations in the reference sections of the retrieved studies.

SELECTION CRITERIA

Included studies were truly randomised controlled trials comparing reserpine monotherapy to placebo or no treatment in patients with primary hypertension.

DATA COLLECTION AND ANALYSIS

Methods of randomization and concealment were assessed. Data on blood pressure reduction, heart rate,and withdrawal due to adverse effects were extracted and analysed.

MAIN RESULTS

Four RCTs (N =237) were found that met the inclusion criteria. The overall pooled effect demonstrates a statistically significant systolic blood pressure (SBP) reduction in patients taking reserpine compared to placebo (WMD -7.92, 95% CI -14.05, -1.78). Due to significant heterogeneity across trials, a significant effect in diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) could not be found. The SBP effects were achieved with 0.5 mg/day or greater. However, the dose-response pattern could not be determined because of the small number of trials. Data from the trial that investigated Rauwiloid against placebo was not combined with reserpine data from the remaining three trials. This is because Rauwiloid is a different alkaloid extract of the plant Rauwolfia serpentina and the dose used is not comparable to reserpine. None of the included trials reported withdrawals due to adverse effects.

AUTHORS' CONCLUSIONS

Reserpine is effective in reducing SBP roughly to the same degree as other first-line antihypertensive drugs. However, we could not make definite conclusions regarding the dose-response pattern because of the small number of included trials. More RCTs are needed to assess the effects of reserpine on blood pressure and to determine the dose-related safety profile before the role of this drug in the treatment of primary hypertension can be established.

Blood pressure-lowering treatment for primary and secondary prevention of different types of stroke

High blood pressure is the most important modifiable risk factor for stroke and accumulating evidence indicates that blood pressure levels are likely to be associated with all stroke subtypes. There is also evidence from randomized trials suggesting that blood pressure-lowering treatment provides protection against every stroke subtype in both primary and secondary prevention settings. Blood pressure lowering is likely to be one of the most effective and generalizable strategies across a variety of stroke subtypes.

Reducing emboli in cardiac surgery: does it make a difference?

Particulate embolization remains a serious complication of cardiac surgery. Adverse events associated with particulate embolization affect patient morbidity and long-term survival, and increase the length of hospital stay and the cost of health care. Today, atherosclerosis plays a role in at least two-thirds of all adverse events after coronary artery revascularization, and postoperative stroke is the second most common cause of operative mortality. Because many lower-risk patients now undergo interventional revascularization, higher-risk patients are now typically referred for surgical revascularization. These patients are older and sicker, and have multiple comorbidities, making them more susceptible to adverse events. For these high-risk patients, surgeons should be proactive in attempting to reduce the possibility of emboli. Patients must be carefully assessed before surgery to determine their risk, and if the risk is high, surgeons should consider using newer, innovative devices, and techniques in their operative strategy that have proven to be effective in mitigating some of the potential embolic adverse events. A multifaceted, preventive strategy can make a difference, not only in reducing particulate emboli, but also in reducing morbidity and in lowering the economic burden on the health-care system. This brief review will address three areas of focus that are important for the prevention of particulate embolization: (i) prevalence and morbidity of atherosclerotic disease; (ii) risk factors for adverse neurologic events; and (iii) prevention/mitigation of adverse events for patients undergoing cardiac surgery.

Serum lipids in patients with stroke--a cross-sectional case-control study

BACKGROUND

Vascular disease remains the prime contributor to the pathogenesis of stroke, but dyslipidemia has not been clearly established as a risk factor for stroke the same way it has been for coronary artery disease. There is no case-controlled study on the contribution of serum lipids to stroke in Nigerians. This study aimed at assessing the possibility of serum lipids as risk factor for stroke in Nigerian patients.

METHOD

The demography, blood pressure, fasting plasma glucose and fasting serum lipids of 87 consecutive patients with first-ever stroke managed at the University of Benin teaching hospital between January and December 2005 were analyzed and compared with those of age- and sex-matched controls.

RESULTS

Eighty-seven stroke patients (55 males and 32 females; mean age 61.25 +/- 14.77 years) were compared with age- and sex-matched controls. Ischemic stroke constituted 64.37%, while the rest had hemorrhagic stroke. There were no significant differences in the serum cholesterol, HDL-C and LDL-C levels of stroke patients and controls (p > 0.05), but the serum triglyceride level was higher among the stroke patients (p < 0.001) with a significant relative risk (RR = 1.77; p < 0.01).

CONCLUSION

In this cross-sectional case-control study, there is no significant difference in the serum lipids of Nigerian patients with stroke with the exception of serum triglyceride, which seems to confer significant stroke risk.

Incidence and risk factors for stroke in American Indians: the Strong Heart Study

BACKGROUND

There are few published data on the incidence of fatal and nonfatal stroke in American Indians. The aims of this observational study were to determine the incidence of stroke and to elucidate stroke risk factors among American Indians.

METHODS AND RESULTS

This report is based on 4549 participants aged 45 to 74 years at enrollment in the Strong Heart Study, the largest longitudinal, population-based study of cardiovascular disease and its risk factors in a diverse group of American Indians. At baseline examination in 1989 to 1992, 42 participants (age- and sex-adjusted prevalence proportion 1132/100 000, adjusted to the age and sex distribution of the US adult population in 1990) had prevalent stroke. Through December 2004, 306 (6.8%) of 4507 participants without prior stroke suffered a first stroke at a mean age of 66.5 years. The age- and sex-adjusted incidence was 679/100 000 person-years. Nonhemorrhagic cerebral infarction occurred in 86% of participants with incident strokes; 14% had hemorrhagic stroke. The overall age-adjusted 30-day case-fatality rate from first stroke was 18%, with a 1-year case-fatality rate of 32%. Age, diastolic blood pressure, fasting glucose, hemoglobin A(1c,) smoking, albuminuria, hypertension, prehypertension, and diabetes mellitus were risk factors for incident stroke.

CONCLUSIONS

Compared with US white and black populations, American Indians have a higher incidence of stroke. The case-fatality rate for first stroke is also higher in American Indians than in the US white or black population in the same age range. Our findings suggest that blood pressure and glucose control and smoking avoidance may be important avenues for stroke prevention in this population.

Transoesophageal echocardiographic findings in patients with ischemic lacunar and nonlacunar stroke

The aim of this study was to compare risk factors and concomitant potential cardioembolic sources detected by transthoracic (TTE) and transoesophageal echocardiography (TEE) in patients with lacunar and nonlacunar infarcts. Clinical data of 139 patients with a first episode of ischemic stroke who underwent both TTE and TEE were analysed. Patients were divided into two groups, lacunar (LACI=36), and nonlacunar infarcts (NLACI=103); then the latter group was divided into two subgroups, anterior (ACI=76) and posterior circulation infarct (POCI=27). Presence of hypertension and diabetes mellitus were not significantly different between LACI and NLACI groups. The rate of potential cardioembolic risk factors detected by echocardiography was similar in the NLACI groups. At least one potential cardiac source of embolism was identified in 44% (n=16) of LACI, 52.6% (n=40) of ACI and 55.5% (n=15) of POCI patients. Atrial fibrillation was significantly frequent in the ACI group. No significant differences were found between all groups regarding age, sex, hyperlipidemia, and smoking. Our findings demonstrate that hypertension and diabetes mellitus are equally important in the pathogenesis of both LACI and NLACI groups and there is a need for careful cardiac evaluation in cases even with lacunar infarct.

Risk of stroke with typical and atypical anti-psychotics: a retrospective cohort study including unexposed subjects

The purpose of the study was to investigate the risk of stroke with typical and atypical anti-psychotics in elderly subjects, weighting for a number of known risk factors, including dementia. Data were retrospectively drawn from the primary care setting from the Health Search Database, which stores information on about 1.5% of the total Italian population served by general practitioners. All elderly patients (65+ years) prescribed an anti-psychotic in monotherapy from January 2000 to June 2003 were selected for the study. A cohort of patients not exposed to anti-psychotics was taken from the same database. Subjects who had previously had a stroke were excluded. The main outcome measure was the incidence of first-ever stroke during exposure to an anti-psychotic.The sample included non-users (69,939), users of atypicals (599), butyrophenones (749), phenotiazines (907) and substituted benzamides (1,968). The crude incidence of stroke in subjects not exposed to anti-psychotics was 12.0/1000 person-years. Risk was significantly higher for those on butyrophenones (47.1/1000), phenotiazines (72.7/1000) and in the atypical anti-psychotic group (47.4/1000). Substituted benzamides had an almost significant higher risk (25.0/1000). Cox regression modelling, weighting for demographic and clinical variables with non-users as the reference group, showed that the risk for stroke was 5.79 times for phenotiazines, 3.55 times for butyrophenones, and 2.46 times for atypicals. Clinicians should be cautious in prescribing phenotiazines and butyrophenones in elderly patients, since the risk for stroke would seem comparable or even greater than with atypicals.

High-density lipoprotein-cholesterol and risk of stroke and carotid atherosclerosis: a systematic review

BACKGROUND AND PURPOSE

Epidemiological studies have found no relationship between total cholesterol and stroke risk, but little attention has been paid to high-density lipoprotein-cholesterol (HDL-C).

METHODS

We performed a systematic PubMed literature search for epidemiological studies that examined the association between HDL-C level and stroke or carotid intima-media thickness (IMT).

RESULTS

We identified 18 studies on the relationship between HDL-C and stroke risk and 37 on HDL-C and carotid IMT. Eight of ten prospective cohort studies (n=238,739) and three of eight case-control studies (n=3604 cases, 8220 controls) supported an association between elevated HDL-C level and decreased risk of stroke. Prospective cohort studies reporting on relative risk per unit increase in HDL-C showed an 11-15% decreased stroke risk per 10-mg/dl increase in HDL-C. Of 37 studies on carotid IMT, 31 reported cross-sectional, one longitudinal, and five both cross-sectional and longitudinal associations between HDL-C level and carotid IMT. Of 36 cross-sectional studies (n=51,288), 20 showed an inverse association between HDL-C level and carotid IMT. Of six longitudinal studies (n=20,065), three showed no association, one showed a weak association in a subgroup of white women and two showed a significant inverse relationship between HDL-C level and carotid IMT. Pooled estimates could not be calculated because of the variation in study designs and analysis.

CONCLUSIONS

The weight of evidence in the literature supports an inverse association between HDL-C level and stroke or carotid atherosclerosis, but more data are needed to firmly establish this protective effect.

Relation of serum total cholesterol and other factors to risk of cerebral infarction in Japanese men with hypercholesterolemia

BACKGROUND

Risk factors for cerebral infarction have not been well clarified, except for hypertension (HT), and few studies have examined the risk factors in the elderly.

METHODS AND RESULTS

Clinical and behavioral risk factors for cerebral infarction were examined in 4,349 Japanese men aged 45-74 years with a serum total cholesterol (TC) concentration of 220 mg/dl or greater who participated in the Kyushu Lipid Intervention Study. A total of 81 men developed definite cerebral infarction in a 5-year follow-up period. The Cox proportional hazards model was used with serum TC at baseline and during the follow-up, serum high-density lipoprotein-cholesterol (HDL-C), HT, diabetes mellitus (DM), and other factors as covariates. Serum TC during the follow-up, not at baseline, was positively associated with cerebral infarction, showing a stronger association in the elderly (>or=65 years old) than in the middle-aged (<65 years old). Statin use was related to a moderate decrease in the risk of cerebral infarction when follow-up TC was not considered, but the decrease was almost nullified after adjustment for follow-up TC. A low concentration of serum HDL-C, diabetes mellitus, hypertension, and angina pectoris were each related to an increased risk. No clear association was observed for body mass index, smoking or alcohol use.

CONCLUSIONS

Lowering cholesterol is important in the prevention of cerebral infarction in men with moderate hypercholesterolemia. A low concentration of HDL-C, DM, and HT are independent predictors of cerebral infarction.

Differences between hypertensive and non-hypertensive ischemic stroke

We compared risk factors, clinical features, neuroimaging data, and outcome between hypertensive and non-hypertensive ischemic stroke patients. Differential features of ischemic stroke patients with hypertension (n = 768) and without hypertension (n = 705) were assessed by bivariate analysis. Independent predictors of hypertensive ischemic stroke were determined by multivariate analysis. Atherothrombotic infarction and lacunar infarct were significantly more common in the hypertensive group, in which older age and a higher occurrence of previous cerebral infarction, hyperlipidemia, acute stroke onset, lacunar syndrome, and pons topography was also observed. Age of 85 years or older, valvular heart disease, and decreased consciousness were more common in non-hypertensive patients. After multivariate analysis, lacunar syndrome, female gender, and previous infarction were directly associated with hypertensive ischemic stroke. Age of 85 years or older and valvular heart disease were inversely associated with hypertensive ischemic stroke. Hypertension was the main cardiovascular risk factor only for lacunes and atherothrombotic infarction, that is, ischemic stroke associated with small- and large-artery disease.

High density lipoprotein cholesterol and the risk of stroke in elderly men: the Honolulu heart program

High density lipoprotein (HDL) cholesterol has been inversely associated with coronary heart disease. Associations with stroke are less clear, particularly among the elderly. In this study, the authors examined the relation between HDL cholesterol levels and the risk of stroke in elderly men. Levels of HDL cholesterol were measured in 2,444 Honolulu Heart Program men aged 71-93 years at the 1991-1993 examinations. The participants, who were free of prevalent stroke, coronary heart disease, and cancer at baseline, were followed to the end of 1998 for thromboembolic and hemorrhagic stroke. While HDL cholesterol was unrelated to hemorrhagic events, incidence of thromboembolic stroke declined consistently with increasing HDL cholesterol level (p = 0.003). There was a nearly threefold excess of thromboembolic stroke in men with low HDL cholesterol levels (<1.0 mmol/liter (<40 mg/dl)) compared with men with high levels (> or =1.6 mmol/liter (> or =60 mg/dl)) (10.6/1,000 person-years vs. 3.6/1,000 person-years; p = 0.001). Adjustment for other risk factors had little effect on these findings, although associations appeared strongest in elderly men with "desirable" total cholesterol levels, hypertension, or diabetes mellitus. These findings suggest that HDL cholesterol level is inversely related to the risk of thromboembolic stroke in elderly men. Whether HDL cholesterol alters the effect of other factors on stroke risk in elderly men warrants further study.

Predictors of stroke in patients undergoing coronary artery bypass grafting surgery: A prospective, nested, case-control study

The objective of the present study was to assess the risk factors for stroke in patients undergoing coronary artery bypass grafting (CABG) surgery. We conducted a nested case-control study from a 9-year, prospective hospitalization cohort (n = 6245). Inclusion in the cohort included CABG between October 1993 and June 2002. Exclusion criteria included any other simultaneously performed surgery. Cases were defined as patients who underwent CABG and experienced a stroke (171 cases, 2.7% of the total), and controls were patients who underwent CABG without a stroke. Cases were matched to controls at a ratio of 1:3 (513 controls). The 39 predictor variables were pump time, body surface area, creatinine, previous percutaneous transcoronary angioplasty (PTCA), clamp time, coronary perfusion time, previous cardiac surgeries, hypertension, race, sex, previous myocardial infarction, family history of coronary disease, history of cerebrovascular disease, preoperative neurologic disease, pulmonary hypertension, aortic disease, previous intervention within 30 days, angina history, bleeding history, previous vascular surgery, diabetes, age, myocardial findings, chronic obstructive pulmonary disease, New York Heart Association class, previous gastrointestinal disease, current vascular disease, systemic diseases, vessels at last PTCA, PTCA result, current smoking, tobacco history, dialysis, current anticoagulant therapy, character of operation, left ventricular hypertrophy, hypercholesterolemia, and chronic corticosteroid therapy. There were 13 significant predictors of stroke. Regression analysis revealed 3 independent predictors of stroke: age >70 years (odds ratio [OR], 4.61; 95% confidence interval [CI], 2.84-6.07), poor preoperative neurologic status (OR, 4.24; 95% CI, 2.02-5.79), and previous cardiac surgery (OR, 1.75; 95% CI, 1.05-2.91). We conclude that in patients undergoing CABG surgery, the independent predictors for stroke, in order of risk, are age >70 years, poor preoperative neurologic status, and previous cardiac surgery.

Trials in isolated systolic hypertension: an update

Isolated systolic hypertension (ISH) has proved to be a powerful predisposing factor for cardiovascular diseases in the elderly. Recent placebo-controlled interventional trials such as the Systolic Hypertension in the Elderly Program, the Systolic Hypertension in Europe, and the Systolic Hypertension in China showed that the lowering of systolic blood pressure using a diuretic- or a calcium antagonist-based treatment is associated with a decrease in cardiovascular events. Antihypertensive therapy was found especially effective in preventing stroke in the elderly with ISH. A slowing in the progression of dementia was observed in patients randomized to a calcium antagonist-based treatment. Patients at high cardiovascular risk such as those with diabetes benefited the most from treatment. In another trial performed in patients with left ventricular hypertrophy (Losartan Intervention For Endpoint Reduction), a subset of patients had ISH. In those patients, an angiotensin II antagonist-based treatment was superior to a b-blocker-based treatment in preventing cardiovascular complications. The experience accumulated in patients with ISH showed that combination therapy is often required to control blood pressure. Overall, the evidence available today indicates that pharmacologic treatment of ISH markedly improves the outcome of elderly patients.

Relationship Between Abdominal Visceral Fat and Lacunar Infarcts in Japanese Men

BACKGROUND

The relationship between abdominal visceral fat accumulation and lacunar infarcts has not been previously investigated in Japanese men.

METHODS AND RESULTS

The subjects were 637 middle-aged (40-64 years) and 222 elderly (65-79 years) men who participated in a health checkup program from 1999 to 2003. The association between lacunar infarcts identified by magnetic resonance imaging and cardiovascular risk factors, including abdominal visceral fat accumulation evaluated by computed tomography, was examined. The prevalence of lacunar infarcts was 4.9%. Hypertension was associated with lacunar infarcts among both the middle-aged men [age-adjusted odds ratio (OR)=2.9 (95% confidence interval (CI): 1.1-7.8)] and the elderly men [OR=5.1 (95%CI: 1.4-19.0)]. Abdominal visceral fat accumulation was slightly associated with lacunar infarcts among middle-aged men, but not among elderly men: OR in the highest (>or=117 cm(2)) vs lowest (<or=83 cm(2)) tertiles of fat area was 2.6 (95%CI: 0.9-7.6) for middle-aged men. Extreme accumulation of visceral fat (>or=143 cm(2)) was still slightly associated with lacunar infarcts after adjustment for age, hypertension, drinking and smoking among middle-aged men [OR=2.7 (95%CI: 0.8-9.1)].

CONCLUSIONS

This cross-sectional study suggests that abdominal visceral fat accumulation is a possible risk factor of lacunar infarcts, in addition to hypertension, in middle-aged Japanese men.

Use of Calcium Channel Antagonists for the Treatment of Hypertension in the Elderly

Systolic blood pressure and pulse pressure increase continuously throughout adult life and the prevalence of arterial hypertension rises accordingly, reaching 53-78% among those aged 65-74 years. Estimates of the prevalence of isolated systolic hypertension in the elderly range from 34-65%, with more women than men affected. It has been shown that within all age groups a difference in usual systolic blood pressure of 20 mm Hg or a difference in usual diastolic blood pressure of 10 mm Hg is associated with an approximately 2-fold difference in the risk of dying from stroke or ischaemic heart disease. Intervention trials using predominantly diuretics and/or beta-adrenoceptor antagonists have proven the efficacy and tolerability of antihypertensive treatment in elderly patients. For many years there have been ongoing discussions about the safety of calcium channel antagonists, especially in patients with diabetes mellitus. However, according to a recently published large prospective, randomised, double-blind, controlled clinical trial with more than 33,000 patients enrolled, no indications for increased total mortality, cancer rate or gastrointestinal bleeding for participants on amlodipine, a long-acting dihydropyridine calcium channel antagonist, were found. With calcium channel antagonists, protective effects against cardiovascular disease have been proven in large trials with elderly patients, particularly against stroke. There is good evidence to suggest that calcium channel antagonists may be superior to other antihypertensive agents in diabetic patients with isolated systolic hypertension. These agents are well tolerated and probably delay the progression of dementia. The lack of adverse metabolic effects that, in the case of a diuretic-based regimen, may have important long-term implications concerning cardiovascular risk, make calcium channel antagonists an attractive choice when antihypertensive treatment decisions need to be made in a predominantly overweight or obese elderly population.

Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study

The purpose of the study was to compare nutrient intakes among Chinese, Japanese, UK, and US INTERMAP samples, and assess possible relationships of dietary patterns to differential patterns of cardiovascular diseases between East Asian and Western countries. Based on a common Protocol and Manuals of Operations, high-quality dietary data were collected by four standardized 24-h dietary recalls and two 24-h urine collections from 17 population samples in China (three samples), Japan (four samples), UK (two samples), and USA (eight samples). There were about 260 men and women aged 40-59 years per sample--total N=4680. Quality of dietary interview and data entry were monitored and enhanced by extensive systematic ongoing quality control procedures at local, country, and international level. Four databases on nutrient composition of foods from the four countries were updated and enhanced (76 nutrients for all four countries) by the Nutrition Coordinating Center, University of Minnesota, in cooperation with Country Nutritionists. The mean body mass index was much higher for Western than East Asian samples. Macronutrient intakes differed markedly across these samples, with Western diet higher in total fat, saturated and trans fatty acids, and Keys dietary lipid score, lower in total carbohydrate and starch, higher in sugars. Based on extensive published data, it is a reasonable inference that this pattern relates to higher average levels of serum total cholesterol and higher mortality from coronary heart disease in Western than East Asian populations. The rural Chinese diet was lower in protein, especially animal protein, in calcium, phosphorus, selenium, and vitamin A. Dietary sodium was higher, potassium lower, hence Na/K ratio was higher in the Asian diet, especially for Chinese samples. This pattern is known to relate to risks of adverse blood pressure level and stroke. At the end of the 20th century, East Asian and Western diets remain significantly different in macro- and micronutrient composition. Both dietary patterns have aspects that can be regarded, respectively, as adverse and protective in relation to the major adult cardiovascular diseases. In both Asian and Western countries, public efforts should be targeted at overcoming adverse aspects and maintaining protective patterns for prevention and control of cardiovascular diseases.

Trials in isolated systolic hypertension: an update

Isolated systolic hypertension (ISH) has proved to be a powerful predisposing factor for cardiovascular diseases in the elderly. Recent placebo-controlled interventional trials such as the Systolic Hypertension in the Elderly Program (SHEP), the Systolic Hypertension in Europe (Syst-Eur), and the Systolic Hypertension in China (Syst-China) showed that the lowering of systolic blood pressure using a diuretic- or a calcium antagonist-based treatment is associated with a decrease in cardiovascular events. Antihypertensive therapy was found especially effective in preventing stroke in the elderly with ISH. A slowing in the progression of dementia was observed in patients randomized to a calcium antagonist-based treatment. Patients at high cardiovascular risk such as those with diabetes benefited the most from treatment. In another trial performed in patients with left ventricular hypertrophy (Losartan Intervention For Endpoint Reduction ), a subset of patients had ISH. In those patients, an angiotensin II antagonist-based treatment was superior to a b-blocker-based treatment in preventing cardiovascular complications. The experience accumulated in patients with ISH showed that combination therapy is often required to control blood pressure. Overall, the evidence available today indicates that pharmacologic treatment of ISH markedly improves the outcome of elderly patients.

The role of lipid profile in determining the risk of ischemic stroke in the elderly: a case-control study

In this study, we investigated the association of lipids with ischemic stroke and its different subtypes in elderly patients. In particular, lipid parameters not extensively investigated so far in previous case-control studies specifically focused in the old population, such as lipoprotein Lp (a) and Apoproteins AI (ApoAI) and B (ApoB), have been taken into account. Seventy nine patients (mean age 83 +/- 7.4, range 67-99), consecutively admitted to a Geriatric Ward between January 1998 and June 2000 with acute stroke (first event) were studied. A complete clinical and laboratory assessment, including neurological evaluation, head CT scan, carotid ultrasonography and ECG, was employed to define the clinical and etiologic stroke subtype, according to standardized criteria. Fasting blood samples were collected within 48 h from admission, for determination of total cholesterol (TC), triglycerides (TG), High Density Lipoprotein-cholesterol (HDL-C), Lp(a), ApoAI and ApoB; Low Density Lipoprotein-Cholesterol (LDL-C) was estimated by Friedwald formula. Eighty eight age and sex-matched outpatients, referred to the hospital for non-inflammatory disorders of joints and musculoskeletal system, served as controls. Patients showed HDL-C and HDL-C/ApoAI ratio significantly lower than controls, with higher LDL-C/HDL-C ratio. Analysis on quartiles of lipoprotein concentrations showed also a significant increase in odds of stroke for LDL-C concentrations over 100 mg/dl, in absence of a linear relationship between LDL-C levels and risk. Multiple logistic regression, adjusting for non-lipid risk factors for stroke, confirmed the independent association of low HDL-C and HDL-C/ApoAI with all strokes, as well as with each subtype. In conclusion, these data suggest that lipids give some contribution to stroke risk even in the elderly, with a more prevalent role for HDL than LDL, and that lipid profile assessment must be taken into account in estimating the individual risk of stroke.

Reduction in serum total cholesterol and risks of coronary events and cerebral infarction in Japanese men: the Kyushu Lipid Intervention Study

Lowering serum total cholesterol is shown to decrease the risk of coronary heart disease (CHD) in Western countries,but evidence is limited regarding cerebral infarction (CI). The present study used the Kyushu Lipid Intervention Study to examine the risks of CHD events and CI in relation to reduction in serum total cholesterol. Subjects were 4,615 men aged 45-74 years with serum total cholesterol of 220 mg/dl (5.68 mmol/L) or greater who had no history of CHD events or stroke. CHD events and CI numbered 125 and 92, respectively, in a 5-year follow-up. After adjustment for potential confounding factors, the relative risks of CHD events and CI for 15% or greater reduction in total cholesterol, compared with less than 5% reduction, were 0.78 (95% confidence limit [CL]0.46-1.32) and 0.39 (95% CL 0.22-0.69), respectively. As compared with on-treatment cholesterol levels of 240 mg/dl (6.20 mmol/L)or higher, the risk of CHD events was approximately 50% lower across 3 categories below 240 mg/dl (6.20 mmol/L), and that of CI was 70%lower at 2 categories below 220 mg/dl (5.68 mmol/L). Lowering serum total cholesterol below 220 mg/dl (5.68 mmol/L) seems desirable with regard to the prevention of CI.

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

BACKGROUND

Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population.

METHODS

Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible.

RESULTS

Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis.

CONCLUSIONS

Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.

Why do treated hypertensives suffer strokes? An internist's perspective

Despite widespread treatment of hypertension, stroke continues to be the third leading cause of death in the United States. Antihypertensive therapy is more effective in preventing hemorrhagic strokes than ischemic strokes. In order to understand the reasons why antihypertensive therapy is only partially successful in the eradication of ischemic strokes, differences in the pathogenesis and treatment of subtypes of stroke must be considered. There are three main stroke subtypes of ischemic strokes: small-vessel arteriopathic (lacunar), large-artery atherothrombotic, and cardioembolic. Hypertension is the major cause of lacunar strokes but plays a lesser role in the pathogenesis of atherothrombotic strokes. Antihypertensive therapy prevents the majority of lacunar strokes but may not have a major impact on the occurrence of atherothrombotic strokes. Due to impaired cerebral autoregulation, overtreatment of hypertension, especially in the elderly and in patients with previous strokes, may paradoxically lead to stroke (J-curve). Assuming that the majority of lacunar strokes are prevented by judicious antihypertensive therapy, future therapeutic efforts should concentrate on the prevention of atherothrombotic and cardioembolic strokes. In this regard, refinement of surgical techniques, pharmacologic approaches aimed at plaque stabilization, and the application of transesophageal echocardiography for the diagnosis of embolic strokes (and anticoagulation for a probable source) are promising. Besides the obvious reasons of noncompliance and inadequate therapy, overly aggressive treatment of hypertension in the elderly and stroke mechanisms unrelated to blood pressure may explain the occurrence of strokes despite our efforts to treat hypertension.

Isolated Systolic Hypertension in the Elderly

Isolated systolic hypertension (ISH) is the predominant form of hypertension in persons older than 50 years, who represent the majority of individuals with hypertension. Systolic blood pressure (SBP) determines Joint National Committee blood pressure stage, and therefore the need for therapy, far more often than diastolic blood pressure (DBP). SBP consistently is associated with greater risk for overall mortality, coronary heart disease, stroke, congestive heart failure, renal failure, and other end points. In addition, clinicians are far less aggressive and less successful at controlling SBP compared with DBP. Thus, SBP should be acknowledged as the major criterion that determines diagnosis, staging, and therapeutic management in older individuals. Several recent large, randomized, placebo-controlled trials of drug therapy targeting ISH in the elderly have shown dramatic reductions in cardiovascular end points and mortality. The treatment of patients with ISH must occur within the framework of the larger goals associated with treatment of hypertension generally. Lifestyle modification, including salt restriction and increasing physical activity, may contribute to improvements in arterial compliance and control of ISH in particular. In clinical trials, most antihypertensive agents decrease SBP more than DBP. However, certain drug classes, such as angiotensin-converting enzyme inhibitors and nitrates, have advantageous properties that may make them particularly useful for the treatment of ISH.

Minimizing perioperative adverse events in the elderly

Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly.

[Hypertension in the elderly and health global results with different pharmacological therapies]

OBJECTIVES

To describe the benefits of treatment for hypertension in the elderly, the most efficient drugs, those most widely used in clinical practice to reduce morbi-mortality taken from the literature.

DESIGN

Systematic review.

PARTICIPANTS

Review study in Medline and the Cochrane Collaboration database. The antihypertensive pharmacological treatment is described (diuretics high and low dosage, calcium channel blockers, ACE inhibitor, and beta-blockers) administered to elderly people and their outcomes in morbi-mortality.

MEASUREMENTS AND MAIN RESULTS

Reduction in coronary and cerebral morbidity and general, cardiovascular and cerebrovascular mortality.

RESULTS

There is evidence to suggest that treatment for hypertension is helpful in the elderly, although efficiency is doubtful in patients over 80 years old. For persons aged over 65 general mortality is RR = 0.84 (0.75-0.94) and coronary morbidity RR = 0.80 (0.70-0.92). For persons aged over 80 general mortality is RR = 1 (0.86-1.17) and cardiovascular mortality is RR = 0.94 (0.75-1.18). Not all pharmacological groups produce the same results in mortality and morbidity. Diuretics (low dosage) offer better results than the remaining treatments reducing cardiovascular mortality as well cerebrovascular morbidity.

CONCLUSIONS

Treatment with drugs in hypertense elderly people is beneficial in terms of mortality and morbidity. Treatment with low dose diuretics, with or without potassium savers, is the elective treatment for hypertension in elderly patients.

Long-term predictors of stroke in a cohort of people aged 70 years

This paper aims at studying the development and the risk factors for stroke prospectively during a 6-year follow-up in the Turku Elderly Study, Turku, Finland. The study cohort consisted of 1032 people aged 70 years at baseline. The stroke events (ICD-9 codes 430-434) were identified by computer linkage from the hospital discharge and death registers, and from a follow-up questionnaire. During the 6 years of follow-up, 71 patients (6.9%) suffered a stroke. Previous stroke (RR 5.82), history of transient ischemic attack (RR 4.14), diabetes mellitus (RR 2.50), poorly controlled hypertension (RR 2.42), smoking (RR 1.94) and male sex (RR 1.65) were independent risk factors for stroke. Atrial fibrillation, cardiac failure and previous myocardial infarction did not appear to be significant independent predictors of stroke in the elderly. The risk of stroke in the elderly population appears to be strongly related to the concomitant clinical disease, and this should be remembered when identifying persons at increased risk of stroke. Poorly controlled hypertension was associated with an increased risk of stroke. Thus, achieving a good control of blood pressure in elderly hypertensives receiving treatment has the potential to prevent strokes.

Is there a preferred antihypertensive therapy for isolated systolic hypertension and reduced arterial compliance?

Isolated systolic hypertension (ISH) is the most common type of hypertension and the most difficult type to control with antihypertensive therapy. ISH, by definition, is wide pulse pressure hypertension resulting largely from excessive large artery stiffness and representing an independent risk factor for cardiovascular disease in the older aged population. Two major intervention studies of ISH have shown significant benefit in reducing systolic blood pressure with active drug therapy, including thiazide diuretics and calcium receptor antagonists. The optimal treatment strategy is to maximize reduction in systolic blood pressure and to minimize reduction in diastolic blood pressure, thereby reducing pulse pressure. All classes of antihypertensive drugs reduce pulse pressure by means of lowering peripheral resistance, but certain drugs like nitrates, angiotensin converting enzyme inhibitors, and other drugs affecting the renin-angiotensin system have multiple actions that improve large artery stiffness and early wave reflection and are especially useful in treating ISH in the elderly.

The efficacy and tolerability of losartan versus atenolol in patients with isolated systolic hypertension. Losartan ISH Investigators Group

OBJECTIVE

To compare the efficacy and tolerability of angiotensin II (Ang II) antagonist losartan and the beta-blocker atenolol in the treatment of patients with isolated systolic hypertension (ISH) after 16 weeks of treatment.

METHODS

A double-blind, randomized, multi-country study was carried out in 273 patients with ISH. Patients with a sitting systolic blood pressure (SiSBP) of 160-205 mmHg, and a sitting diastolic blood pressure (SiDBP) < 90 mmHg at screening and at placebo baseline were subjected to a 4-week placebo period and then randomly grouped to receive 50 mg losartan or 50 mg atenolol once daily for 16 weeks. At 8 and 12 weeks, patients not controlled (SiDBP > or = 160 mmHg) were given additional treatment of 12.5 mg hydrochlorothiazide (HCTZ) once daily.

RESULTS

Similar significant reductions in SiSBPs (mean +/- SD) were obtained with 50 mg losartan and 50 mg atenolol, from 173.7 +/- 10.3 and 173.5 +/- 10.7 mmHg at baseline to 149.0 +/- 15.5 and 148.2 +/- 15.3 mmHg after 16 weeks of losartan or atenolol treatment respectively. Sixty-seven percent of the losartan-treated and 64% of the atenolol-treated patients remained on monotherapy throughout the study. Only 1.5% of the losartan-treated patients withdrew because of a clinical adverse event (CAE) compared with 7.2% in the atenolol-treatment group (P= 0.035). Drug-related CAEs were observed significantly more frequently with atenolol than with losartan treatment (20.3 versus 10.4%; P = 0.029).

CONCLUSION

It is concluded that 50 mg losartan and 50 mg atenolol produced comparable reductions in SiSBP in patients with ISH but losartan was better tolerated. This is the first demonstration of the therapeutic value of selective Ang II receptor blockade with losartan in the treatment of ISH.

Cholesterol, stroke risk, and stroke prevention

Serum cholesterol traditionally has been considered a poor predictor of total stroke risk; however, it is associated positively with ischemic stroke risk and associated negatively with hemorrhagic stroke risk. Although studies failed to demonstrate stroke reduction using older cholesterol-lowering medications, recent study of the statin class of medications shows both consistent stroke and other cardiovascular benefits. Ischemic stroke and coronary heart disease share similar underlying mechanisms, likely explaining much of the therapeutic benefit from statins. Current research is directed at further determining groups of patients most likely to benefit from lipid reduction in stroke prevention. In the interim, patients with established atherosclerosis should be treated with a statin to achieve a low-density lipoprotein cholesterol level less than 100 mg/dL.

Stroke in cardiac surgical patients: determinants and outcome

BACKGROUND

Despite improving outcomes in cardiac surgical patients, stroke continues to remain a major complication. Few prospective studies are available on postoperative stroke. The present study was conducted to elucidate the incidence and predictors of stroke in a large group of cardiac surgical patients.

METHODS AND RESULTS

Prospective data collected on 4,941 patients undergoing cardiac surgery were subjected to univariate and logistic regression analyses (98.4% men; 72% older than 60 years; 9.1% with history of prior stroke; 80.4% underwent isolated coronary artery bypass grafting). Stroke predictors include history of stroke and hypertension, older age, systolic hypertension, bronchodilator and diuretic use, high serum creatinine, surgical priority, great vessel repair, use of inotropic agents after cardiopulmonary bypass, and total cardiopulmonary bypass time (p < 0.05 for all comparisons). Median intensive care unit and hospital stays were longer, and hospital mortality and 6-month mortality were higher for patients with stroke (p < 0.001).

CONCLUSIONS

Stroke after cardiac surgical procedures is a morbid event. Identification of predictors and development of strategies to modify these factors should lead to a lower incidence of stroke.