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Guman NAM, Becking AML, Weijers SS, Kraaijpoel N, Mulder FI, Carrier M, Jara-Palomares L, Di Nisio M, Ageno W, Beyer-Westendorf J, Klok FA, Vanassche T, Otten JMMB, Cosmi B, Peters MJL, Wolde MT, Delluc A, Sanchez-Lopez V, Porreca E, Bossuyt PMM, Gerdes VEA, Büller HR, van Es N, Kamphuisen PW. Risk assessment tools for bleeding in patients with unprovoked venous thromboembolism: an analysis of the PLATO-VTE study. J Thromb Haemost 2024; 22:2470-2481. [PMID: 38866248 DOI: 10.1016/j.jtha.2024.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/23/2024] [Accepted: 05/27/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Guidelines suggest indefinite anticoagulation after unprovoked venous thromboembolism (VTE) unless the bleeding risk is high, yet there is no consistent guidance on assessing bleeding risk. OBJECTIVES This study aimed to evaluate the performance of 5 bleeding risk tools (RIETE, VTE-BLEED, CHAP, VTE-PREDICT, and ABC-Bleeding). METHODS PLATO-VTE, a prospective cohort study, included patients aged ≥40 years with a first unprovoked VTE. Risk estimates were calculated at VTE diagnosis and after 3 months of treatment. Primary outcome was clinically relevant bleeding, as per International Society on Thrombosis and Haemostasis criteria, during 24-month follow-up. Discrimination was assessed by the area under the receiver operating characteristic curve (AUROC). Patients were classified as having a "high risk" and "non-high risk" of bleeding according to predefined thresholds; bleeding risk in both groups was compared by hazard ratios (HRs). RESULTS Of 514 patients, 38 (7.4%) had an on-treatment bleeding. AUROCs were 0.58 (95% CI, 0.48-0.68) for ABC-Bleeding, 0.56 (95% CI, 0.46-0.66) for RIETE, 0.53 (95% CI, 0.43-0.64) for CHAP, 0.50 (95% CI, 0.41-0.59) for VTE-BLEED, and 0.50 (95% CI, 0.40-0.60) for VTE-PREDICT. The proportion of high-risk patients ranged from 1.4% with RIETE to 36.9% with VTE-BLEED. The bleeding incidence in the high-risk groups ranged from 0% with RIETE to 13.0% with ABC-Bleeding, and in the non-high-risk groups, it varied from 7.7% with ABC-Bleeding to 9.6% with RIETE. HRs ranged from 0.93 (95% CI, 0.46-1.9) for VTE-BLEED to 1.67 (95% CI, 0.86-3.2) for ABC-Bleeding. Recalibration at 3-month follow-up did not alter the results. CONCLUSION In this cohort, discrimination of currently available bleeding risk tools was poor. These data do not support their use in patients with unprovoked VTE.
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Affiliation(s)
- Noori A M Guman
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands.
| | - Anne-Marie L Becking
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Suzanne S Weijers
- Department of Central Diagnostic Laboratory, Amsterdam University Medical Center location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Frits I Mulder
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Luis Jara-Palomares
- Department of Respiratory Diseases, Hospital Universitario Virgen del Rocio, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Gabriele D'Annunzio University, Chieti, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division "Thrombosis & Hemostasis" University Hospital "Carl Gustav Carus" Dresden, Germany
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Johannes M M B Otten
- Department of Internal Medicine, Meander Medisch Centrum, Amersfoort, the Netherlands
| | - Benilde Cosmi
- Department of Medical and Surgical Sciences, University of Bologna Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mike J L Peters
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marije Ten Wolde
- Department of Internal Medicine, Flevo Hospital, Almere, the Netherlands
| | - Aurélien Delluc
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Veronica Sanchez-Lopez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/Centro de Investigaciones Cientificas/Universidad de Sevilla, Seville, Spain
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, School of Medicine and Health Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Patrick M M Bossuyt
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Victor E A Gerdes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Spaarne Hospital, Hoofddorp, the Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Pieter W Kamphuisen
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Univesity Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands
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2
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Xiao X, Luo Z, Peng M, Yan H, Yi D, Du Z, Liu J. Expression profile of circulating miRNAs in patients with atrial fibrillation-dominated cardioembolic stroke: A systematic review and bioinformatics analysis. Heliyon 2024; 10:e35201. [PMID: 39166047 PMCID: PMC11334639 DOI: 10.1016/j.heliyon.2024.e35201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 07/23/2024] [Accepted: 07/24/2024] [Indexed: 08/22/2024] Open
Abstract
Background Cardioembolic stroke is a type of ischemic stroke with high disability and mortality, a high recurrence rate and poor prognosis. miRNAs have been explored as potential noninvasive biomarkers in atrial fibrillation and ischemic stroke, but their expression profile in cardioembolic stroke still needs to be explored. This study will explore the differences in miRNA expression between cardioembolic stroke patients and healthy people through meta-analysis and attempt to analyze the target genes by bioinformatics analysis. Methods Literature databases and gene expression databases were searched from the inception date to June 2022. The study reported the circulating miRNA expression profiles in cardioembolic stroke patients and healthy controls. miRNAs with significantly differential expression and their target genes were analyzed. Results Three articles and one gene expression dataset were included in the analysis. The results showed that miR-21-5p (SMD: 2.16; 95 % CI: 1.57, 2.75; p < 0.001), miR-943, miR-145-3p, and miR-3148 were upregulated in cardioembolic stroke patients compared with controls. The downregulated miRNAs included miR-3136-5p, miR-2277-5p, and miR-2277-3p. The area under the receiver operating characteristic curve of miR-21-5p for cardioembolic stroke was 0.975 (0.933-0.989). For the enrichment results, the target genes of upregulated miRNAs were enriched in the MAPK signaling pathway, Ras signaling pathway, etc. The target genes of downregulated miRNAs were also enriched in the Ras signaling pathway. Conclusions This study suggested that circulating miR-21-5p is upregulated in cardioembolic stroke patients compared to healthy controls. The Ras signaling pathway plays an important role in pathogenesis according to enrichment analysis.
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Affiliation(s)
- Xiangbin Xiao
- Corresponding author. No. 196, Hospital Road, Jianyang City, Sichuan Province, 641400, China.
| | | | - Minjian Peng
- Cardiovascular Department, The People's Hospital of Jianyang City, Chengdu, Sichuan Province, China
| | - Hui Yan
- Cardiovascular Department, The People's Hospital of Jianyang City, Chengdu, Sichuan Province, China
| | - Dengliang Yi
- Cardiovascular Department, The People's Hospital of Jianyang City, Chengdu, Sichuan Province, China
| | - Zigang Du
- Cardiovascular Department, The People's Hospital of Jianyang City, Chengdu, Sichuan Province, China
| | - Ji Liu
- Cardiovascular Department, The People's Hospital of Jianyang City, Chengdu, Sichuan Province, China
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3
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Veale EL. Pharmacy-Led Management of Atrial Fibrillation: Improving Treatment Adherence and Patient Outcomes. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2024; 13:101-114. [PMID: 39101005 PMCID: PMC11297543 DOI: 10.2147/iprp.s397844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/13/2024] [Indexed: 08/06/2024] Open
Abstract
The world's population is ageing, with the number of those over 60 years expected to represent a fifth of the total population by 2050. Increases in chronic long-term health conditions (LTCs) associated with ageing, and requiring regular but often avoidable medical intervention, are pressurising already overloaded, health and social care systems. Atrial fibrillation (AF) is an LTC, which is most frequently diagnosed in the elderly. An often, asymptomatic condition, AF is associated with a 3- to 5-fold increased risk of severe ischemic stroke. Stroke prevention, with risk-stratified oral anticoagulants (OACs) is the standard recommended care for patients with AF. Stroke avoidance is, however, dependent on persistent adherence to OAC medication, with an adherence rate of >80% considered necessary to achieve optimal health outcomes. Suboptimal adherence to OACs is common, with a third of all AF patients not taking their medication as prescribed. This combined with the short half-life of OACs can result in poor clinical outcomes for patients. Policy makers now consider improving adherence to prescribed medicines for LTCs, a public health priority, to ensure better health outcomes for patients, whilst minimising unnecessary health system costs. Prescribing medicines to treat LTCs, such as AF, is not enough, particularly when the patient may not experience any measurable benefit to the treatment and may instead, experience medication-associated adverse events, including a risk of bleeding. Pharmacists who are experts in medicines management are ideally placed to support medication adherence, to educate, and to improve health outcomes for patients with AF. In this review, I will consider the evidence for poor medication adherence in LTCs and in particular adherence to OACs in patients with AF and highlight the role that pharmacists can play in ensuring optimal adherence and showcase pharmacist-led interventions that effectively address this problem.
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Affiliation(s)
- Emma L Veale
- Medway School of Pharmacy, University of Kent and University of Greenwich, Chatham Maritime, Kent, UK
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4
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Yagi R, Mori Y, Goto S, Iwami T, Inoue K. Routine Electrocardiogram Screening and Cardiovascular Disease Events in Adults. JAMA Intern Med 2024:2820721. [PMID: 38949831 PMCID: PMC11217891 DOI: 10.1001/jamainternmed.2024.2270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 04/16/2024] [Indexed: 07/02/2024]
Abstract
Importance The resting electrocardiogram (ECG) is commonly performed for cardiovascular disease (CVD) screening purposes in Japan. However, evidence is limited regarding the prognostic significance of ECG in clinical practice settings. Objective To investigate the association between ECG abnormalities and CVD outcomes in a working-age population. Design, Setting, and Participants This nationwide cohort study included individuals aged 35 to 65 years from the Japan Health Insurance Association database, which covers approximately 40% (30 million) of the working-age population in Japan. Data from April 1, 2015, to March 31, 2022, were included, and analysis was conducted from October 1, 2022, to April 11, 2024. Exposures Baseline ECG status (normal, 1 minor abnormality, ≥2 minor abnormalities, or major abnormality). Main Outcomes and Measures The primary outcome was a composite of overall death and CVD hospital admission due to myocardial infarction, stroke, or heart failure. The secondary outcome was developing a new major ECG abnormality over the years of screening. Results Of 3 698 429 individuals enrolled in the nationwide annual health check program (mean [SD] age, 47.1 [8.5] years; 66.6% male), 623 073 (16.8%) had 1 minor ECG abnormality, 144 535 (3.9%) had 2 or more minor ECG abnormalities, and 56 921 (1.5%) had a major ECG abnormality. During a median follow-up of 5.5 (IQR, 3.4-5.7) years, baseline ECG abnormality was independently associated with an increased incidence of the composite end points of overall death and CVD admission compared with normal ECG (incidence rates per 10 000 person-years: 92.7 [95% CI, 92.2-93.2] for normal ECG, 128.5 [95% CI, 127.2-129.9] for 1 minor ECG abnormality, 159.7 [95% CI, 156.6-162.9] for ≥2 minor ECG abnormalities, and 266.3 [95% CI, 259.9-272.3] for a major ECG abnormality; adjusted hazard ratios: 1.19 [95% CI, 1.18-1.20] for 1 minor ECG abnormality, 1.37 [95% CI, 1.34-1.39] for ≥2 minor ECG abnormalities, and 1.96 [95% CI, 1.92-2.02] for a major ECG abnormality). Furthermore, the presence and number of minor ECG abnormalities were associated with an increased incidence of developing new major ECG abnormalities (incidence rates per 10 000 person-years: 85.1 [95% CI, 84.5-85.5] for normal ECG, 217.2 [95% CI, 215.5-219.0] for 1 minor ECG abnormality, and 306.4 [95% CI, 302.1-310.7] for ≥2 minor ECG abnormalities; and adjusted hazard ratios: 2.52 [95% CI, 2.49-2.55] for 1 minor ECG abnormality and 3.61 [95% CI, 3.55-3.67] for ≥2 minor ECG abnormalities). Associations were noted regardless of baseline CVD risk. Conclusions and Relevance The findings of this study suggest that the potential role of routine ECG screening for early prevention of CVD events, along with the optimal follow-up strategy, should be examined in future studies.
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Affiliation(s)
- Ryuichiro Yagi
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Yuichiro Mori
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shinichi Goto
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of General Internal Medicine & Family Medicine, Department of General and Acute Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Taku Iwami
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
| | - Kosuke Inoue
- Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan
- Hakubi Center for Advanced Research, Kyoto University, Kyoto, Japan
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5
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Boyi T, Richmond RL, Kayastha D, Manes RP, Rimmer R. Restarting Antithrombotic Therapies After Endoscopic Sinus Surgery: A Systematic Review. Ann Otol Rhinol Laryngol 2024; 133:633-638. [PMID: 38557289 DOI: 10.1177/00034894241245840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Antithrombotic therapies, comprised of both anticoagulant and antiplatelet agents, are routinely paused prior to endoscopic sinus surgery (ESS) to reduce the risk of perioperative hemorrhage. At present, no clear guidelines exist to guide otolaryngologists on when to resume these agents after ESS. Our goal was to systematically review the existing literature related to this topic. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically queried the PubMed, Embase, Ovid, Web of Science, Cochrane, and CINAHL databases to identify publications reporting on antithrombotic and antiplatelet therapy in the context of ESS. The primary outcomes we sought were recommendations on the timing of antithrombotic therapy resumption after ESS. RESULTS Of the 104 unique articles identified, all were screened for relevance by 2 independent reviewers based on title and abstract, 20 underwent full-text review, and 6 met inclusion criteria for analysis. Of these, 3 were literature reviews, 2 were case-control studies, and 1 was a cohort study. All publications discussed when to pause antithrombotic therapy prior to surgery while only 3 articles discussed resumption of these agents. Recommendations were mixed. CONCLUSION A paucity of literature exists on the resumption of antithrombotic therapies after ESS. As a major determining factor in patient morbidity, guideline-based resumption of these therapies is needed.
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Affiliation(s)
- Trinithas Boyi
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Rhys L Richmond
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Darpan Kayastha
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - R Peter Manes
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ryan Rimmer
- Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Yale School of Medicine, New Haven, CT, USA
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Jiang W, Jiang L, Zhao X, Liu Y, Sun H, Zhou X, Liu Y, Huang S. Bioinformatics Analysis Reveals HIST1H2BH as a Novel Diagnostic Biomarker for Atrial Fibrillation-Related Cardiogenic Thromboembolic Stroke. Mol Biotechnol 2024:10.1007/s12033-024-01187-6. [PMID: 38825608 DOI: 10.1007/s12033-024-01187-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/29/2024] [Indexed: 06/04/2024]
Abstract
Atrial fibrillation (AF) is a significant precursor to cerebral embolism. Our study sought to unearth new diagnostic biomarkers for atrial fibrillation-related cerebral embolism (AF-CE) by meticulously examining multiple GEO datasets and meta-analysis. The gene expression omnibus (GEO) database provided RNA sequencing data associated with AF and stroke. We began by pinpointing genes with varied expressions in AF-CE patient blood samples. A meta-analysis was subsequently undertaken using several RNA sequencing datasets to verify these genes. LASSO regression discerned key genes for AF-CE, with their diagnostic prowess verified through ROC curve examination. Active signaling pathways within stroke patients were discerned via GO and KEGG enrichment, with PPI interactions detailing gene interplay. Differential gene analysis revealed an upregulation of sixteen genes and a downregulation of four in stroke patient blood samples. Eight genes showcased varied expression in the meta-analysis. LASSO regression zeroed in on five of these, culminating in HIST1H2BH's identification as a characteristic gene. HIST1H2BH's prowess in predicting AF-CE was confirmed through ROC. Integrin signaling, platelet activation, ECM interactions, and the PI3K-Akt pathway were found active in stroke victims. HIST1H2BH's interaction with the notably upregulated ITGA2B was spotlighted by PPI. Additionally, HIST1H2BH exhibited links with NK cells and eosinophils. HIST1H2BH emerges as an insightful diagnostic beacon for AF-CE. Its presence, post AF, potentially modulates pathways, accentuating platelet activation and consequent thrombus generation, leading to cerebral embolism.
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Affiliation(s)
- Wenbing Jiang
- Department of Cardiology, Wenzhou Integrated Traditional Chinese and Western Medicine Hospital, No.75 Jinxiu Road, Lucheng District, Wenzhou, 325000, Zhejiang Province, People's Republic of China.
| | - Lelin Jiang
- Second Clinical College of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Xiaoli Zhao
- Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Yiying Liu
- Postgraduate Training Base Allianceof Wenzhou Medical University (Wenzhou Central Hosptial), Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Huanghui Sun
- The Dingli Clinical College of Wenzhou Medical University, Heart Function Examination Room, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Xinlang Zhou
- Department of Cardiology, Wenzhou Integrated Traditional Chinese and Western Medicine Hospital, No.75 Jinxiu Road, Lucheng District, Wenzhou, 325000, Zhejiang Province, People's Republic of China
| | - Yin Liu
- Department of Cardiology, Wenzhou Integrated Traditional Chinese and Western Medicine Hospital, No.75 Jinxiu Road, Lucheng District, Wenzhou, 325000, Zhejiang Province, People's Republic of China
| | - Shu'se Huang
- Department of Cardiology, Wenzhou Integrated Traditional Chinese and Western Medicine Hospital, No.75 Jinxiu Road, Lucheng District, Wenzhou, 325000, Zhejiang Province, People's Republic of China
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Otite FO, Patel SD, Aneni E, Lamikanra O, Wee C, Albright KC, Burke D, Latorre JG, Morris NA, Anikpezie N, Singla A, Sonig A, Kamel H, Khandelwal P, Chaturvedi S. Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020. Int J Stroke 2024; 19:547-558. [PMID: 38086764 DOI: 10.1177/17474930231222163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. METHODS We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. RESULTS Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period. CONCLUSION AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.
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Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Smit D Patel
- Department of Neurosurgery, University of Connecticut, Hartford, CT, USA
| | - Ehimen Aneni
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Claribel Wee
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Karen C Albright
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Devin Burke
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Julius Gene Latorre
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Nicholas Allen Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nnabuchi Anikpezie
- Department of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - Amit Singla
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Ashish Sonig
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | | | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Prisco D, Canfora M, Mazzetti M, Mattioli I, Bettiol A. Factor XI Inhibitors: perspectives in primary and secondary prevention of ischemic stroke. Intern Emerg Med 2024:10.1007/s11739-024-03611-w. [PMID: 38743127 DOI: 10.1007/s11739-024-03611-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024]
Abstract
Stroke is one of the most common causes of mortality and disability worldwide. Antithrombotic therapy represents the mainstay in primary and secondary prevention, both in cardioembolic and non-cardioembolic stroke. Particularly, direct oral anticoagulants play a crucial role in atrial fibrillation, the most common cause of cardioembolic stroke, whereas single or dual antiplatelet therapy is preferred in non-cardioembolic stroke. However, the limitations related to the residual risk of cardioembolic or cerebrovascular events, and the risk of major bleeding, still represent unmet medical needs. To overcome them, new drugs inhibiting Factor XI (FXI) and Factor XII have been proposed, with a selective inhibition of contact pathway of coagulation, delineating a new anticoagulant approach. This review provides a summary of the currently available evidence and future perspectives on FXI inhibitors, that can represent an additional therapeutic option in the primary and secondary prevention of cardioembolic and non-cardioembolic ischemic stroke, also in challenging therapeutic contexts.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Viale L.Go Giovanni Brambilla, 3, 50134, Florence, Italy
- Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Maria Canfora
- Department of Experimental and Clinical Medicine, University of Florence, Viale L.Go Giovanni Brambilla, 3, 50134, Florence, Italy.
| | - Matteo Mazzetti
- Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Irene Mattioli
- Department of Experimental and Clinical Medicine, University of Florence, Viale L.Go Giovanni Brambilla, 3, 50134, Florence, Italy
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Viale L.Go Giovanni Brambilla, 3, 50134, Florence, Italy
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Sandiford P, Poppe KK, Grey C, Doughty R, Chambers E, Kim KJ, Hill A, Bartholomew K. The Prevalence and Management of Atrial Fibrillation in New Zealand Māori Detected through an Abdominal Aortic Aneurysm Screening Program. Heart Lung Circ 2024; 33:304-309. [PMID: 38326133 DOI: 10.1016/j.hlc.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 09/22/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Atrial fibrillation (AF) screening was incorporated into an abdominal aortic aneurysm screening (AAA) program for New Zealand (NZ) Māori. METHODS AF screening was performed as an adjunct to AAA screening of Māori men aged 60-74 years and women aged 65-74 years registered with primary health care practices in Auckland, NZ. Pre-existing AF was determined through coded diagnoses or medications in the participant's primary care record. Subsequent audit of the record assessed accuracy of pre-screening coding, medication use and clinical follow-up. RESULTS Among 1,933 people successfully screened, the prevalence of AF was 144 (7.4%), of which 46 (2.4% of the cohort) were patients without AF coded in the medical record. More than half of these were revealed to be known AF but that was not coded. Thus, the true prevalence of newly detected AF was 1.1% (n=21). An additional 48 (2.5%) of the cohort had been coded as AF but were not in AF at the time of screening. Among the 19 at-risk screen-detected people with AF, 10 started appropriate anticoagulation therapy within 6 months. Of the nine patients who did not commence anticoagulation therapy, five had a subsequent adverse clinical outcome in the follow-up period, including one with ischaemic stroke; two had contraindications to anticoagulants. Among those with previously diagnosed AF, the proportion receiving anticoagulation therapy rose from 57% pre-screening to 83% at 6 months post-screening (p<0.0001); among newly diagnosed AF the proportion rose from 0% to 53% (p<0.01). CONCLUSIONS AF screening is a feasible low-cost adjunct to AAA screening with potential to reduce ethnic inequities in stroke incidence. However, effective measures are needed to ensure that high-risk newly diagnosed AF is managed according to best practice guidelines.
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Affiliation(s)
- Peter Sandiford
- Planning Funding and Outcomes, Auckland and Waitematā District Health Boards, Auckland, New Zealand.
| | - Katrina K Poppe
- Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Corina Grey
- Planning Funding and Outcomes, Auckland and Waitematā District Health Boards, Auckland, New Zealand
| | - Robert Doughty
- Faculty of Medicine, University of Auckland, Auckland, New Zealand
| | - Erin Chambers
- Planning Funding and Outcomes, Auckland and Waitematā District Health Boards, Auckland, New Zealand
| | - Kyu J Kim
- Planning Funding and Outcomes, Auckland and Waitematā District Health Boards, Auckland, New Zealand
| | - Andrew Hill
- Auckland City Hospital, Auckland, New Zealand
| | - Karen Bartholomew
- Planning Funding and Outcomes, Auckland and Waitematā District Health Boards, Auckland, New Zealand
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10
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Rus M, Ardelean AI, Crisan S, Marian P, Pobirci OL, Huplea V, Judea Pusta C, Osiceanu GA, Stanis CE, Andronie-Cioara FL. Optimizing Atrial Fibrillation Care: Comparative Assessment of Anticoagulant Therapies and Risk Factors. Clin Pract 2024; 14:344-360. [PMID: 38391413 PMCID: PMC10888395 DOI: 10.3390/clinpract14010027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/27/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation (AF) is a common arrhythmia associated with various risk factors and significant morbidity and mortality. MATERIALS AND METHODS This article presents findings from a study involving 345 patients with permanent AF. This study examined demographics, risk factors, associated pathologies, complications, and anticoagulant therapy over the course of a year. RESULTS The results showed a slight predominance of AF in males (55%), with the highest incidence in individuals aged 75 and older (49%). Common risk factors included arterial hypertension (54%), dyslipidemia, diabetes mellitus type 2 (19.13%), and obesity (15.65%). Comorbidities such as congestive heart failure (35.6%), mitral valve regurgitation (60%), and dilated cardiomyopathy (32%) were prevalent among the patients. Major complications included congestive heart failure (32%), stroke (17%), and myocardial infarction (5%). Thromboembolic and bleeding risk assessment using CHA2DS2-VASc and HAS-BLED scores demonstrated a high thromboembolic risk in all patients. The majority of patients were receiving novel oral anticoagulants (NOACs) before admission (73%), while NOACs were also the most prescribed antithrombotic therapy at discharge (61%). CONCLUSIONS This study highlights the importance of risk factor management and appropriate anticoagulant therapy in patients with AF, to reduce complications and improve outcomes. The results support the importance of tailored therapeutic schemes, for optimal care of patients with AF.
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Affiliation(s)
- Marius Rus
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Adriana Ioana Ardelean
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Simina Crisan
- Cardiology Department, "Victor Babes" University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Paula Marian
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Oana Lilliana Pobirci
- Department of Psycho Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Veronica Huplea
- Department of Psycho Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Claudia Judea Pusta
- Department of Morphological Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Gheorghe Adrian Osiceanu
- Department of Morphological Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | | | - Felicia Liana Andronie-Cioara
- Department of Psycho Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
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11
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Chen YY, Chang HC, Lin YJ, Chien KL, Hsieh YC, Chung FP, Lin CH, Lip GYH, Chen SA. The impact of sodium-glucose co-transporter-2 inhibitors on dementia and cardiovascular events in diabetic patients with atrial fibrillation. Diabetes Metab Res Rev 2024; 40:e3775. [PMID: 38340046 DOI: 10.1002/dmrr.3775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/28/2023] [Accepted: 12/12/2023] [Indexed: 02/12/2024]
Abstract
AIMS The effectiveness of sodium-glucose co-transporter-2 inhibitors (SGLT2i) on incident dementia in patients with diabetes and atrial fibrillation (AF) remains unknown. This study aimed to investigate the association between SGLT2i and the risk of incident dementia in diabetic patients with AF, and to explore the interactions with oral anticoagulants or dipeptidyl peptidase-4 inhibitors (DPP4i). MATERIALS AND METHODS We conducted a cohort study using Taiwan's National Health Insurance Research Database. Patients with diabetes and AFwithout a prior history of established cardiovascular diseases, were identified. Using propensity score matching, 810 patients receiving SGLT2i were matched with 1620 patients not receiving SGLT2i. The primary outcome was incident dementia, and secondary outcomes included composite cardiovascular events and mortality. RESULTS After up to 5 years of follow-up, SGLT2i use was associated with a significantly lower risk of incident dementia (hazard: 0.71, 95% confidence interval: 0.51-0.98), particularly vascular dementia (HR: 0.44, 95% CI: 0.24-0.82). SGLT2i was related to reduced risks of AF-related hospitalisation (HR: 0.72, 95% CI: 0.56-0.93), stroke (HR: 0.75, 95% CI: 0.60-0.94), and all-cause death (HR: 0.33, 95% CI: 0.24-0.44). The protective effects were consistent irrespective of the concurrent use of non-vitamin K antagonist oral anticoagulants (NOACs) or DPP4i. CONCLUSIONS In diabetic patients with AF, SGLT2i was associated with reduced risks of incident dementia, AF-related hospitalisation, stroke, and all-cause death. The protective effects were independent of either concurrent use of NOACs or DPP4i.
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Affiliation(s)
- Yun-Yu Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Post-Baccalaureate Medicine and College of Life Sciences, National Chung Hsing University, Taichung, Taiwan
| | - Hao-Chih Chang
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medicine, Taipei Veterans General Hospital Taoyuan Branch, Taoyuan, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Cheng Hsieh
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Shih-Ann Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
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12
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Zhen S, Chu F, Kodesh A, Kim J. Ischaemic stroke in a patient with non-valvular atrial fibrillation (NVAF) despite non-vitamin K oral anticoagulant (NOAC) therapy. BMJ Case Rep 2024; 17:e258761. [PMID: 38199668 PMCID: PMC10806926 DOI: 10.1136/bcr-2023-258761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Primary stroke prevention in non-valvular atrial fibrillation (NVAF) is primarily with non-vitamin K oral anticoagulant (NOAC) therapy. However, 20-36% of ischaemic strokes seem to occur in patients with atrial fibrillation while already on anticoagulation. We present a case of an ischaemic stroke in an elderly female in her 70s with medical history significant for hypertension and NVAF. She had a CHA2DS2-VASc score of 3 and was on apixaban for thromboprophylaxis. She presented with neurological deficits consistent with a left middle cerebral artery stroke, confirmed via head imaging; the most likely stroke aetiology was determined to be cardioembolic in the setting of NVAF. She was treated with continuation of her apixaban at the same dosage She displayed improved function, although with residual expressive aphasia at her 2-month neurology follow-up. Cardioembolic ischaemic stroke in NVAF despite current NOAC therapy does not have current management guidelines.
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Affiliation(s)
- Simon Zhen
- Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fion Chu
- Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Afek Kodesh
- Internal Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Jisoon Kim
- Internal Medicine, Montefiore Medical Center, Bronx, New York, USA
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13
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Algahtani H, Shirah B, Hachinski V. Primordial and Primary Prevention of Ischemic Stroke in Saudi Arabia: A Combination Approach and Evolving Concepts. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:1-9. [PMID: 38362089 PMCID: PMC10866385 DOI: 10.4103/sjmms.sjmms_62_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/18/2023] [Accepted: 09/20/2023] [Indexed: 02/17/2024]
Abstract
Ischemic stroke is a considerable public health hazard and a significant cause of disability and mortality in Saudi Arabia. Primary prevention strategies in the country are currently limited. With the health sector transformation program that depends on the principles of value-based care and applying the new model of care in disease prevention, aggressive and serious steps for primary stroke prevention are expected to be implemented. This article reviews primordial and primary prevention of ischemic stroke in Saudi Arabia and suggests a combination approach and framework for implementation. We provide a pragmatic solution to implement primordial and primary stroke prevention in Saudi Arabia and specify the roles of the government, health professionals, policymakers, and the entire population. Currently, there are several key priorities for primordial and primary stroke prevention in Saudi Arabia that should target people at different levels of risk. These include an emphasis on a comprehensive approach that includes both individual and population-based strategies and establishing partnerships across health-care providers to share responsibility for developing and implementing both strategies. This is an urgent call for action to initiate different strategies suggested by experts for primary stroke prevention in Saudi Arabia.
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Affiliation(s)
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Vladimir Hachinski
- Department of Clinical Neurological Sciences, Robarts Research Institute, Western University, London, Ontario, Canada
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14
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Suomalainen OP, Martinez-Majander N, Broman J, Mannismäki L, Aro A, Curtze S, Pakarinen S, Lehto M, Putaala J. Stroke in Patients with Atrial Fibrillation: Epidemiology, Screening, and Prognosis. J Clin Med 2023; 13:30. [PMID: 38202037 PMCID: PMC10779359 DOI: 10.3390/jcm13010030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained arrythmia and one of the strongest risk factors and causal mechanisms of ischemic stroke (IS). Acute IS due to AF tends to be more severe than with other etiology of IS and patients with treated AF have reported to experience worse outcomes after endovascular treatment compared with patients without AF. As cardioembolism accounts for more than a fifth of ISs and the risk of future stroke can be mitigated with effective anticoagulation, which has been shown to be effective and safe in patients with paroxysmal or sustained AF, the screening of patients with cryptogenic IS (CIS) for AF is paramount. Embolic stroke of undetermined source (ESUS) is a subtype of CIS with a high likelihood of cardioembolism. The European Stroke Organization and European Society of Cardiology guidelines recommend at least 72 h of screening when AF is suspected. The longer the screening and the earlier the time point after acute IS, the more likely the AF paroxysm is found. Several methods are available for short-term screening of AF, including in-hospital monitoring and wearable electrocardiogram recorders for home monitoring. Implantable loop monitors provide an effective long-term method to screen patients with high risk of AF after IS and artificial intelligence and convolutional neural networks may enhance the efficacy of AF screening in the future. Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists in both primary and secondary prevention of IS in AF patients. Recent data from the randomized controlled trials (RCT) also suggest that early initiation of DOAC treatment after acute IS is safe compared to later initiation. Anticoagulation treatment may still predispose for intracranial bleeding, particularly among patients with prior cerebrovascular events. Left atrial appendix closure offers an optional treatment choice for patients with prior intracranial hemorrhage and may offer an alternative to oral anticoagulation even for patients with IS, but these indications await validation in ongoing RCTs. There are still controversies related to the association of found AF paroxysms in CIS patients with prolonged screening, pertaining to the optimal duration of screening and screening strategies with prolonged monitoring techniques in patients with ESUS. In this review, we summarize the current knowledge of epidemiology, screening, and prognosis in AF patients with stroke.
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Affiliation(s)
- Olli Pekka Suomalainen
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Nicolas Martinez-Majander
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Jenna Broman
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Laura Mannismäki
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Aapo Aro
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Sami Curtze
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
| | - Sami Pakarinen
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Mika Lehto
- Departments of Cardiology, Helsinki University Hospital, University of Helsinki, 00290 Helsinki, Finland; (A.A.); (S.P.); (M.L.)
| | - Jukka Putaala
- Departments of Neurology, Helsinki University Hospital, University of Helsinki, Haartmaninkatu 4, P.O. Box 340, 00290 Helsinki, Finland; (N.M.-M.); (J.B.); (L.M.); (S.C.); (J.P.)
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15
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Behnoush AH, Khalaji A, Bahiraie P, Gupta R. Meta-analysis of outcomes following intravenous thrombolysis in patients with ischemic stroke on direct oral anticoagulants. BMC Neurol 2023; 23:440. [PMID: 38102548 PMCID: PMC10722877 DOI: 10.1186/s12883-023-03498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND There has been debate on the use of intravenous thrombolysis (IVT) in patients with ischemic stroke and the recent use of direct oral anticoagulants (DOACs). Studies have compared these patients with non-DOAC groups in terms of outcomes. Herein, we aimed to systematically investigate the association between DOAC use and IVT's efficacy and safety outcomes. RESULTS A comprehensive systematic search was performed in PubMed, Embase, Scopus, and the Web of Science for the identification of relevant studies. After screening and data extraction, a random-effect meta-analysis was performed to calculate the odds ratio (OR) and 95% confidence interval (CI) for comparison of outcomes between patients on DOAC and controls. Six studies were included in the final review. They investigated a total of 254,742 patients, among which 3,499 had recent use of DOACs. The most commonly used DOACs were rivaroxaban and apixaban. The patients on DOAC had significantly higher rates of atrial fibrillation, hypertension, diabetes, and smoking. Good functional outcome defined by modified Rankin Scale (mRS) 0-2 was significantly lower in patients who received DOACs (OR 0.71, 95% CI 0.62 to 0.81, P < 0.01). However, in the subgroup analysis of 90-day mRS 0-2, there was no significant difference between groups (OR 0.71, 95% 0.46 to 1.11, P = 0.14). All-cause mortality was not different between the groups (OR 1.02, 95% CI 0.68 to 1.52, P = 0.93). Similarly, there was no significant difference in either of the in-hospital and 90-day mortality subgroups. Regarding symptomatic intracranial hemorrhage (sICH), the previous DOAC use was not associated with an increased risk of bleeding (OR 0.98, 95% CI 0.69 to 1.39, P = 0.92). A similar finding was observed for the meta-analysis of any ICH (OR 1.15, 95% CI 0.94 to 1.40, P = 0.18). CONCLUSIONS Based on our findings, IVT could be considered as a treatment option in ischemic stroke patients with recent use of DOACs since it was not associated with an increased risk of sICH, as suggested by earlier studies. Further larger studies are needed to confirm these findings and establish the safety of IVT in patients on DOAC.
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Affiliation(s)
- Amir Hossein Behnoush
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- School of Medicine, Tehran University of Medical Sciences, Poursina St., Keshavarz Blvd, Tehran, 1417613151, Iran.
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Pegah Bahiraie
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rahul Gupta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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16
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Lai Y, He J, Gao X, Peng D, Zhou H, Xu Y, Luo X, Yang H, Zhang M, Deng C, Wu S, Xue Y, Zhou F, Rao F. Involvement of plasminogen activator inhibitor-1 in p300/p53-mediated age-related atrial fibrosis. PeerJ 2023; 11:e16545. [PMID: 38107584 PMCID: PMC10722982 DOI: 10.7717/peerj.16545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023] Open
Abstract
Plasminogen activator inhibitor-1 (PAI-1), a key regulator of the fibrinolytic system, is also intimately involved in the fibrosis. Although PAI-1 may be involved in the occurrence of atrial fibrillation (AF) and thrombosis in the elderly, but whether it participated in aging-related atrial fibrosis and the detailed mechanism is still unclear. We compared the transcriptomics data of young (passage 4) versus senescent (passage 14) human atrial fibroblasts and found that PAI-1 was closely related to aging-related fibrosis. Aged mice and senescent human and mouse atrial fibroblasts underwent electrophysiological and biochemical studies. We found that p300, p53, and PAI-1 protein expressions were increased in the atrial tissue of aged mice and senescent human and mouse atrial fibroblasts. Curcumin or C646 (p300 inhibitor), or p300 knockdown inhibited the expression of PAI-1 contributing to reduced atrial fibroblasts senescence, atrial fibrosis, and the AF inducibility. Furthermore, p53 knockdown decreased the protein expression of PAI-1 and p21 in senescent human and mouse atrial fibroblasts. Our results suggest that p300/p53/PAI-1 signaling pathway participates in the mechanism of atrial fibrosis induced by aging, which provides new sights into the treatment of elderly AF.
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Affiliation(s)
- Yingyu Lai
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Department of Pharmacy, The People’s Hospital of Hezhou, Hezhou, Guangxi, China
| | - Jintao He
- School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Xiaoyan Gao
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Dewei Peng
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Huishan Zhou
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yuwen Xu
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Xueshan Luo
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Hui Yang
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Mengzhen Zhang
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Chunyu Deng
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Shulin Wu
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Yumei Xue
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Feng Zhou
- Department of Neurology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, China
| | - Fang Rao
- Medical Research Institute, Guangdong Provincial Key Laboratory of Clinical Pharmacology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
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17
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Bangash AB, Li Y, Huang W, Zhong J, Zheng H, Zhang D, Zeng A, Wang R, Zhao W, Wang M, Zhao Y, Yu L, Liu Q, Jiang R, Jiang C, Zhang J. Left atrial appendage occlusion using the LAmbre device in atrial fibrillation patients with a history of ischemic stroke: 1-Year outcomes from a multicenter study in China. Pacing Clin Electrophysiol 2023; 46:1478-1483. [PMID: 37943004 DOI: 10.1111/pace.14866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/07/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patients with non-valvular atrial fibrillation (NVAF) and previous stroke have a significantly higher risk of stroke recurrence. This study aimed to examine the safety and efficacy of the LAmbre left atrial appendage occlusion device in NVAF patients with a history of stroke. METHODS We examined 103 consecutive NVAF patients in 11 Chinese medical centers who had a history of stroke or transient ischemic attacks (TIA) and underwent placement of the LAmbre device. Follow-up was conducted 1, 3, 6, and 12 months after the procedure. The primary endpoints were the incidence of new ischemic or hemorrhagic stroke, TIA, systemic embolism, or cardiac death. Secondary endpoints were serious perioperative or device-related complications and cerebral, gastrointestinal, or other bleeding events requiring transfusion of at least 2 units of packed red blood cells. RESULTS Mean patient age was 67.63 ± 7.14 years; mean CHA2DS2-VASc score was 4.72 ± 1.18 and mean HAS-BLED score was 1.90 ± 1.00. LAmbre device placement was successful in 101 patients (98.05%). Mean follow-up was 12.2 months. Five patients (4.95%) developed a new pericardial effusion after the procedure; none required treatment. Eighty-six patients (85.15%) exhibited no peri-device leak (PDL). However, 13 (12.8%) had a small (0-3 mm) PDL and two (2.3%) had a moderate PDL (3-5 mm). One recurrent stroke occurred during follow-up (1.1%). No other complications occurred. CONCLUSIONS This multicenter study shows the safety and efficacy of LAmbre left atrial appendage occlusion for NVAF patients with a history of stroke or TIA.
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Affiliation(s)
- Abdul Basit Bangash
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuechun Li
- Department of Cardiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jingquan Zhong
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Hongmei Zheng
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Dayong Zhang
- Department of Cardiology, Sichuan Mianyang 404 Hospital, Mianyang, Sichuan, China
| | - Anning Zeng
- Department of Cardiology, The People's Hospital of Qiannan, Duyun, Guizhou, China
| | - Rui Wang
- Department of Cardiology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenbiao Zhao
- Department of Cardiology, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Maojing Wang
- Department of Cardiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yu Zhao
- Department of Cardiology, Dongguan Tungwah Hospital, Dongguan, Guangdong, China
| | - Lu Yu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qiang Liu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ruhong Jiang
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jinhua Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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18
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Qiu K, Wei K, Jia ZY, Liu S. Design and Validation of a Novel Evaluation Scale to Predict Inpatient Large Vessel Occlusion Strokes: Clinical Assessment Stroke Severity for Inpatient Scale. J Comput Assist Tomogr 2023; 47:806-810. [PMID: 37707412 DOI: 10.1097/rct.0000000000001476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES A large quantity of ischemic stroke events occur in patients hospitalized for non-stroke-related reason. No scale has been developed to identify the large vessel occlusion (LVO) among inpatient stroke alerts. We aimed to develop a novel evaluation scale to predict LVO from in-hospital stroke alerts. METHODS Data from consecutive in-hospital stroke alerts were analyzed at a single high volume stroke center between January 2016 and October 2020. We developed a predictive scale based on the first half of patients (training group) using multivariate logistic regression and evaluated it in the remaining half of patients (validation group) adopting receiver operating curve. Receiver operating characteristics of the scale were analyzed to evaluate its value for the detection of LVO. RESULTS A total of 243 patients were enrolled for further study, among them, 94 (38.7%) had confirmed LVO. Three risk factors independently predicted the presence of LVO: recent cardiac or pulmonary procedure (1 point), neurological deficit scale (≥1: 2 points), and history of atrial fibrillation (1 point). The CAPS scale was generated based on predictive factors and demonstrated highly effective discrimination in identifying the presence of LVO in the training group (area under curve = 0.956) and the validation group (area under curve = 0.940). When the score ≥2, CAPS scale showed 97.9% sensitivity, 79.2% specificity, 74.8% positive predictive value, and 98.3% negative predictive value for discriminating LVO. CONCLUSIONS CAPS scale was developed for identifying LVO among inpatient stroke alerts with high sensitivity and specificity, which may help to quickly prompt responses by appropriate stroke teams.
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Affiliation(s)
- Kai Qiu
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Ke Wei
- Department of Stroke Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
| | - Zhen-Yu Jia
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Sheng Liu
- From the Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
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19
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Abstract
Cardioembolic stroke from atrial fibrillation causes substantial death and disability in the United States. Treatment with oral anticoagulants provides safe and effective stroke prevention for high-risk patients. This article reviews strategies for the use of anticoagulation and highlights the nurse's role in patient education.
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Affiliation(s)
- Carrie Palmer
- The University of North Carolina at Chapel Hill School of Nursing, 7460 Carrington Hall, Chapel Hill, NC 27599, USA.
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20
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Tang Y, Qi L, Xu L, Lin L, Cai J, Shen W, Liu Y, Li M. Atrial giant cell myocarditis with preserved left ventricular function: a case report and literature review. J Cardiothorac Surg 2023; 18:232. [PMID: 37452361 PMCID: PMC10347761 DOI: 10.1186/s13019-023-02316-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
Giant cell myocarditis (GCM) is a rare and fatal inflammatory disorder induced by T-lymphocytes, typically affecting young adults. Generally, this disease presents with a rapidly progressive course and a very poor prognosis. In recent years, atrial GCM (aGCM) has been recognized as a clinicopathological entity distinct from classical GCM. As described by retrievable case reports, although its histopathological manifestations are highly similar to those of classical GCM, this entity is characterized by preserved left ventricular function and atrial arrhythmias, without ventricular arrhythmias. aGCM tends to show benign disease progression with a better clinical prognosis compared with the rapid course and poor prognosis of vGCM. We report a patient with aGCM with a history of renal abscess whose persistent myocardial injury considered to be associated with a history of renal abscess. Infection could be a potential trigger for the development of aGCM in this patient. An extensive literature review was also performed and the following three aspects were summarized: (1) Epidemiology and histopathological characteristics of aGCM; (2) The role of imaging in the evaluation of aGCM; (3) Diagnostic points and therapeutic decisions in aGCM.
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Affiliation(s)
- Yilin Tang
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, No. 221 West Yanan Road, Shanghai, 200040, China
| | - Lin Qi
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, No. 221 West Yanan Road, Shanghai, 200040, China.
| | - Ling Xu
- Department of Cardiovascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Lei Lin
- Department of Cardiovascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Junfeng Cai
- Department of Cardiovascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Wei Shen
- Department of Cardiovascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Yang Liu
- Department of Cardiovascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Ming Li
- Department of Radiology, Huadong Hospital Affiliated to Fudan University, No. 221 West Yanan Road, Shanghai, 200040, China.
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21
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Platzbecker K, Müller-Fielitz H, Foraita R, Koepp MJ, Voss A, Pflock R, Linder R, Pigeot I, Schink T, Schwaninger M. In atrial fibrillation epilepsy risk differs between oral anticoagulants: active comparator, nested case-control study. Europace 2023; 25:euad087. [PMID: 37013704 PMCID: PMC10228540 DOI: 10.1093/europace/euad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is a risk factor for brain infarction, which can lead to epilepsy. We aimed to investigate whether treatment of AF with direct oral anticoagulants (DOACs) affects the risk of epilepsy in comparison to treatment with the vitamin K antagonist phenprocoumon (PPC). METHODS AND RESULTS We performed an active comparator, nested case-control study based on the German Pharmacoepidemiological Research Database that includes claims data from statutory health insurance providers of about 25 million persons since 2004. In 2011-17, 227 707 AF patients initiated treatment with a DOAC or PPC, of which 1828 cases developed epilepsy on current treatment with an oral anticoagulant. They were matched to 19 084 controls without epilepsy. Patients with DOAC treatment for AF had an overall higher risk of epilepsy with an odds ratio of 1.39, 95% CI (1.24; 1.55) compared to current PPC treatment. Cases had higher baseline CHA2DS2-VASc scores and more frequently a history of stroke than controls. After excluding patients with ischaemic stroke prior to the diagnosis of epilepsy, the risk of epilepsy was still higher on DOACs than on PPC. In contrast, within a cohort of patients with venous thromboembolism, the risk of epilepsy on treatment with DOACs was less elevated [adjusted odds ratio 1.15, 95% CI (0.98; 1.34)]. CONCLUSION In patients with AF initiating oral anticoagulation, treatment with a DOAC was associated with an increased risk of epilepsy compared to the vitamin K antagonist PPC. Covert brain infarction may explain the observed elevated risk of epilepsy.
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Affiliation(s)
- Katharina Platzbecker
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Helge Müller-Fielitz
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ronja Foraita
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, Queen Square, Box 29, London WC1N 3BG, United Kingdom
| | - Annemarie Voss
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - René Pflock
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Roland Linder
- Techniker Krankenkasse, Bramfelder Straße 140, 22305 Hamburg, Germany
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
- Faculty of Mathematics and Computer Science, University of Bremen, Bibliothekstraße 5, 28334 Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Markus Schwaninger
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
- DZHK (German Research Centre for Cardiovascular Research), Hamburg-Lübeck-Kiel, Germany
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22
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Jung M, Lee BJ, Lee S, Shin J. Clinical outcomes and predictors of a gap in direct-acting oral anticoagulant therapy in the elderly: A time-varying analysis of a nationwide cohort study. Thromb Res 2023; 226:61-68. [PMID: 37121013 DOI: 10.1016/j.thromres.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/03/2023] [Accepted: 04/20/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION As direct-acting oral anticoagulants (DOACs) have short half-lives of around 12 h, even a short gap in DOAC therapy may diminish anticoagulation effects, increasing risks of adverse clinical outcomes. We aimed to evaluate clinical consequences of a gap in DOAC therapy with atrial fibrillation (AF) and to identify its potential predictors. MATERIALS AND METHODS In this retrospective cohort study, we included DOAC users aged over 65 years with AF from the 2018 Korean nationwide claims database. We defined a gap in DOAC therapy as no claim for a DOAC one or more days after the due date of a refill prescription. We used a time-varying-analysis method. The primary outcome was a composite of death and thrombotic events including ischemic stroke/transient ischemic attack or systemic embolism. Potential predictors of a gap included sociodemographic and clinical factors. RESULTS AND CONCLUSIONS Among 11,042 DOAC users, 4857 (44.0 %) patients had at least one gap. Standard national health insurance, non-metropolitan locations of medical institutions, history of liver disease, chronic obstructive pulmonary disease, cancer, or dementia, and use of diuretics or non-oral agents were associated with increased risks of a gap. In contrast, history of hypertension, ischemic heart disease, or dyslipidemia were associated with a decreased risk of a gap. A short gap in DOAC therapy was significantly associated with a higher risk of the primary outcome compared to no gap (hazard ratio 4.04, 95 % confidence interval 2.95-5.52). The predictors could be utilized to identify at-risk patients to provide additional support to prevent a gap.
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Affiliation(s)
- Minji Jung
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, CA, United States
| | - Beom-Jin Lee
- Research Institute of Pharmaceutical Sciences and Technology, Ajou University, Suwon, Republic of Korea
| | - Sukhyang Lee
- Division of Clinical Pharmacy, College of Pharmacy, Ajou University, Suwon, Republic of Korea.
| | - Jaekyu Shin
- Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, CA, United States.
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23
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Chen Q, Toorop MMA, Tops LF, Lijfering WM, Cannegieter SC. Time Trends in Patient Characteristics, Anticoagulation Treatment, and Prognosis of Incident Nonvalvular Atrial Fibrillation in the Netherlands. JAMA Netw Open 2023; 6:e239973. [PMID: 37097630 PMCID: PMC10130953 DOI: 10.1001/jamanetworkopen.2023.9973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Importance The temporal trend in adverse events regarding stroke prevention for nonvalvular atrial fibrillation (NVAF) in the direct oral anticoagulant (DOAC) era was rarely investigated comprehensively, especially taking into account potential changes in patient characteristics and anticoagulation treatment. Objective To investigate time trends in patient characteristics, anticoagulation treatment, and prognosis of patients with incident NVAF in the Netherlands. Design, Setting, and Participants This retrospective cohort study assessed patients with incident NVAF initially recognized within a hospitalization between 2014 and 2018, using data from Statistics Netherlands. Participants were followed-up for 1 year from the hospital admission at which the incident NVAF diagnosis was made or until death, whichever occurred first. Data were analyzed from January 15, 2021, to March 8, 2023. Exposure Calendar year of the incident NVAF diagnosis, according to which the participants were categorized into 5 cohorts. Main Outcomes and Measures Outcomes of interest were baseline patient characteristics, anticoagulation treatment, and occurrence of ischemic stroke or major bleeding within the 1-year follow-up after incident NVAF. Results Between 2014 and 2018, 301 301 patients (mean [SD] age, 74.2 [11.9] years; 169 748 [56.3%] male patients) experienced incident NVAF in the Netherlands, each of whom was categorized into 1 of 5 cohorts by calendar year. Baseline patient characteristics were broadly the same between cohorts with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke [doubled], vascular disease, age 65 to 74 years, and sex category [female]) score of 2.9 (1.7). The median (IQR) proportion of days covered by OACs (ie, vitamin K antagonists or DOACs) within the 1-year follow-up increased from 56.99% (0%-86.30%) to 75.62% (0%-94.52%), and DOACs increased from 5102 patients (13.5%) to 32 314 patients (72.0%) among those who received OACs, gradually replacing VKAs as the first choice of OACs. Over the course of the study, there were statistically significant decreases in the 1-year cumulative incidence of ischemic stroke (from 1.63% [95% CI, 1.52%-1.73%] to 1.39% [95% CI, 1.30%-1.48%) and major bleeding (from 2.50% [95% CI, 2.37%-2.63%] to 2.07% [95% CI, 1.96%-2.19%]), and the association was consistent after adjusting for baseline patient characteristics and excluding those with preexisting chronic anticoagulation. Conclusions and Relevance This cohort study of patients with incident NVAF diagnosed between 2014 and 2018 in the Netherlands found similar baseline characteristics, increased OAC use with DOACs being favored over time, and improved 1-year prognosis. Comorbidity burden, potential underuse of anticoagulation medications, and specific subgroups of patients with NVAF remain directions for future investigations and further improvement.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Myrthe M A Toorop
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- The Knowledge Institute of the Federation of Medical Specialists, Utrecht, the Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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24
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Shakibajahromi B, Kasner SE, Schmitt C, Favilla CG. Anticoagulation under-utilization in atrial fibrillation patients is responsible for a large proportion of strokes requiring endovascular therapy. J Stroke Cerebrovasc Dis 2023; 32:106980. [PMID: 36634399 PMCID: PMC9928840 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES Atrial fibrillation (AF) is responsible for 30-50% of large strokes requiring endovascular thrombectomy (EVT). Anticoagulation (AC) underutilization is a common source of AF-related stroke. We compared antithrombotic medications among stroke patients with AF that did or did not undergo EVT to determine if AC underutilization disproportionately results in strokes requiring EVT, while quantifying the proportion of likely preventable thrombectomies. METHODS This retrospective single-center cohort included consecutive patients admitted with acute ischemic stroke between 2016 and 2021. Patients were categorized based on the presence of AF, and pre-admission antithrombotic medications were compared between those who underwent EVT and those who didn't. The reason for not being on AC was abstracted from the medical record, and patients were categorized as either AC eligible or AC contraindicated. RESULTS Of 3092 acute ischemic stroke patients, 644 had a history of AF, 213 of whom underwent EVT. Patients who required EVT were more likely to not be taking any antithrombotics prior to admission (34% vs 24%, p=0.007) or have subtherapeutic INR on admission if taking warfarin (83% vs 63%; p = 0.046). Among the AF-EVT patients, 44% were taking AC, and only 31% were adequately anticoagulated. Only 8% of AF-EVT patients who were not on pre-admission AC had a clear contraindication, and 94% were ultimately discharged on AC. CONCLUSIONS Lack of antithrombotic therapy in AF patients disproportionately contributes to strokes requiring EVT. A small minority of AF patients have contraindications to AC, so adequate anticoagulation can prevent a remarkable number of strokes requiring EVT.
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25
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De Caterina R, Prisco D, Eikelboom JW. Factor XI inhibitors: cardiovascular perspectives. Eur Heart J 2023; 44:280-292. [PMID: 36263776 DOI: 10.1093/eurheartj/ehac464] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Anticoagulants are the cornerstone for prevention and treatment of thrombosis but are not completely effective, and concerns about the risk of bleeding continue to limit their uptake. Animal studies and experience from patients with genetic coagulation factor XI deficiency suggesting that this factor is more important for thrombosis than for haemostasis raises the potential for drugs that target factor XI to provide safer anticoagulation. Multiple factor XI inhibitors are currently under evaluation in clinical trials, including parenterally administered antisense oligonucleotides, monoclonal antibodies, and orally active small-molecule inhibitors. Promising results of phase 2 trials in patients undergoing major orthopaedic surgery, and in those with end-stage kidney disease, atrial fibrillation and acute coronary syndromes have led to large phase 3 trials that are currently ongoing. We here review premises for the use of these agents, results so far accrued, ongoing studies, and perspectives for future patient care.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Domenico Prisco
- Chair of Internal Medicine, Department of Experimental and Clinical Medicine, University of Florence and Careggi University Hospital, Florence, Italy
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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26
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Meng Y, Zhang Y, Zhu C, Nie C, Liu P, Chang S, Wang S. Atrial high-rate episode burden and stroke risks for patients with device-detected subclinical atrial fibrillation: A systematic review and meta-analysis. Int J Cardiol 2023; 371:211-220. [PMID: 36243183 DOI: 10.1016/j.ijcard.2022.09.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/10/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial high-rate episode (AHRE) and stroke are related; however, the magnitude of the correlations between different AHRE burdens and stroke remains unknown. We analysed studies that evaluated this relationship. METHODS We searched for observational controlled studies that reported the associations of different AHRE burdens with stroke in populations with cardiac implantable electronic devices (CIEDs). The primary endpoint was stroke or thrombosis during follow-up. We performed subgroup analyses according to the classification criteria and research design of the included studies. RESULTS Of the 5985 studies identified, 9 met the eligibility criteria and included 42,958 patients. Patients with low and high AHRE burdens had a 1.2-fold risk of stroke (no heterogeneity) and a 2.52-fold risk of stroke (moderate heterogeneity), respectively. After excluding studies analysing the atrial fibrillation history, no significant difference in progressive stroke risk was observed for patients with a low AHRE burden (without significant heterogeneity). An increased likelihood of stroke was observed for patients with a high AHRE burden (decreased heterogeneity). Four of the nine studies classified high and low AHRE burdens using the longest AHRE time. Five studies classified high and low AHRE burdens based on the median of the total AHRE time as the cutoff value. Low and high AHRE burdens were more closely related to stroke when classified by the total AHRE duration than when classified by the single longest AHRE duration. CONCLUSIONS For populations with CIEDs without an atrial fibrillation history, a high AHRE burden was significantly associated with stroke.
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Affiliation(s)
- Yanhai Meng
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Surgical Intensive Care Unit, Fuwai Yunnan Cardiovascular Hospital, Kunming, China
| | - Yanbo Zhang
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Changsheng Zhu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changrong Nie
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Liu
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuo Chang
- Surgical Intensive Care Unit, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuiyun Wang
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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27
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Zhang D, Liu Z, Guo W, Lu Q, Zhang H, Lei Z, Liu P, Huang C, Wang J, Chang Q, Lin X, Wang F, Wu S. Serum homocysteine level is an independent risk factor for 1-year stroke recurrence in patients with acute ischemic stroke and H-type hypertension: results from the Xi'an stroke registry study of China. Front Neurol 2023; 14:1161318. [PMID: 37143996 PMCID: PMC10151713 DOI: 10.3389/fneur.2023.1161318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Background H-type hypertension has a high prevalence in China. However, the association of serum homocysteine levels with 1-year stroke recurrence in patients with acute ischemic stroke (AIS) and H-type hypertension has not been studied. Methods A prospective cohort study of patients with AIS admitted to hospitals between January and December 2015 in Xi'an, China, was conducted. Serum homocysteine levels, demographic data, and other relevant information were collected from all patients upon admission. Stroke recurrences were routinely tracked at 1, 3, 6, and 12 months after discharge. The blood homocysteine level was studied as a continuous variable and tertiles (T1-T3). A multivariable Cox proportional hazard model and a two-piecewise linear regression model were utilized to evaluate the association and ascertain the threshold effect regarding the serum homocysteine level and 1-year stroke recurrence in patients with AIS and H-type hypertension. Results Overall, 951 patients with AIS and H-type hypertension were enrolled, of whom 61.1% were male. After adjusting for confounders, patients in T3 had a significantly increased risk of recurrent stroke within 1 year, compared with those in T1 as the reference (hazard ratio = 2.24, 95% confidence interval: 1.01-4.97, p = 0.047). Curve fitting showed that serum homocysteine levels were positively curvilinearly correlated with 1-year stroke recurrence. Threshold effect analysis showed that an optimal threshold of serum homocysteine level <25 μmol/L was effective in reducing the risk of 1-year stroke recurrence in patients with AIS and H-type hypertension. Elevated homocysteine levels in patients with severe neurological deficits on admission significantly increased the risk of 1-year stroke recurrence (p for interaction = 0.041). Conclusions In patients with AIS and H-type hypertension, the serum homocysteine level was an independent risk factor for 1-year stroke recurrence. A serum homocysteine level of ≥25 μmol/L significantly increased the risk of 1-year stroke recurrence. These findings can inform the creation of a more precise homocysteine reference range for the prevention and treatment of 1-year stroke recurrence in patients with AIS and H-type hypertension and provide a theoretical foundation for the individualized prevention and treatment of stroke recurrence.
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Affiliation(s)
- Dandan Zhang
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Zhongzhong Liu
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Department of Epidemiology and Biostatistics, School of Public Health of Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Weiyan Guo
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Qingli Lu
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Huan Zhang
- College of Life Science, Northwest University, Xi'an, China
| | - Zhen Lei
- College of Life Science, Northwest University, Xi'an, China
| | - Pei Liu
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Congli Huang
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Department of Traditional Chinese Medicine, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Jing Wang
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Qiaoqiao Chang
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Xuemei Lin
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Fang Wang
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
| | - Songdi Wu
- Department of Neurology, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory for Innovation and Translation of Neuroimmunological Diseases, Xi'an No.1 Hospital, The First Affiliated Hospital of Northwest University, Xi'an, China
- College of Life Science, Northwest University, Xi'an, China
- *Correspondence: Songdi Wu
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Kanesamoorthy S, Sheron VA, Uruthirakumar P, Kodippily C, Kumarendran B, Gooden TE, Thomas GN, Nirantharakumar K, Lip GYH, Guruparan M, Haniffa R, Surenthirakumaran R, Beane A, Subaschandran K. Prevalence of atrial fibrillation in Northern Sri Lanka: a study protocol for a cross-sectional household survey. BMJ Open 2022; 12:e056480. [PMID: 36418134 PMCID: PMC9685242 DOI: 10.1136/bmjopen-2021-056480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is often underdiagnosed, particularly in low-income and middle-income countries (LMICs) where screening for AF is not always feasible or considered common practice in primary care settings. Epidemiological data on AF in LMICs is often incomplete particularly in vulnerable populations. This LMIC research collaborative aims to identify the prevalence of AF in the Northern Sri Lankan community. METHODS AND ANALYSIS A cross-sectional household survey piloted and codesigned through a series of community engagement events will be administered in all five districts in Northern Province, Sri Lanka. A multistage cluster sampling approach will be used starting at district level, then the Divisional Secretariats followed by Grama Niladhari divisions. Twenty households will be selected from each cluster. The study aims to recruit 10 000 participants aged 50 years or older, 1 participant per household. Demographic and socioeconomic characteristics, well-being and lifestyle and anthropometric measurements will be collected using a digital data platform (REDCap, Research Electronic Data Capture) by trained data collectors. Participants will be screened for AF using a fingertip single-lead ECG via a smartphone application (AliveCor) with rhythm strips reviewed by a consultant cardiologist. Prevalence of AF and risk factors will be established at province and district-levels. Adjusted ORs and population attributable fractions for AF risk factors will be determined. ETHICS AND DISSEMINATION This study was approved by the Ethics Review Committee of Faculty of Medicine at University of Jaffna. Written informed consent will be obtained from all participants. Findings will be disseminated through publication in a peer-reviewed journal and presentations at conferences. The findings will enable early treatment for new AF diagnoses and inform interventions to improve community-based management of AF in LMICs.
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Affiliation(s)
- Shribavan Kanesamoorthy
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Northern Province, Sri Lanka
| | | | - Powsiga Uruthirakumar
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Northern Province, Sri Lanka
| | - Chamira Kodippily
- National Intensive Care Surveillance-Mahidol Oxford Tropical Medicine Research Unit, Jaffna, Sri Lanka
| | - Balachandran Kumarendran
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Northern Province, Sri Lanka
| | - Tiffany E Gooden
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | - Graham Neil Thomas
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
| | | | - Gregory Y H Lip
- Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, Merseyside, UK
| | - Mahesan Guruparan
- Department of Cardiology, Jaffna Teaching Hospital, Jaffna, Sri Lanka
| | - Rashan Haniffa
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | | | - Abi Beane
- Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | - Kumaran Subaschandran
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Northern Province, Sri Lanka
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29
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Embolic infarct topology differs between atrial fibrillation subtypes and embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2022; 31:106782. [PMID: 36130470 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/07/2022] [Accepted: 09/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we sought to differentiate clinical and radiographic patterns of ESUS patients from patterns in patients with a highly probable cardioembolic source. MATERIALS & METHODS A prospective registry of consecutive adults with acute infarction on diffusion-weighted magnetic resonance imaging was queried. Patients with infarctions due to small vessel disease, large vessel disease, and other causes were excluded. Multivariable logistic regression was used to identify independent predictors of two potentially embolic patterns: (1) multifocal and (2) cortical lesions, comparing patients with ESUS against those with atrial fibrillation (AF). RESULTS Among 1243 screened patients, 343 (27.6%) experienced strokes due to ESUS or AF. Prior to the index stroke, patients with AF as compared to ESUS were older (median 75 vs. 65, p<0.01) and had more heart failure (25.9% vs. 8.4%, p<0.01). The odds of multifocal infarction were the same between patients with ESUS and both AF subtypes (p>0.05), however, cortical involvement was more associated with both AF versus ESUS (77.7% vs. 65.7%, P=0.02). A higher Fazekas grade of white matter disease was inversely associated with cortical infarction among included patients (aOR 0.77, 95% CI 0.62-0.96). CONCLUSION Cortical infarctions were twice as common among patients with AF versus ESUS. Subcortical infarct topography was strongly associated with chronic microvascular ischemic changes and therefore may not represent embolic phenomena. Larger-scale investigations are warranted to discern whether large or multifocal subcortical infarcts ought to be excluded from the ESUS designation.
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30
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Zhang X, Hou S, Liu W, Chen W, Chen F, Ma W, Wang J, Fan Y, Wang Y, Chang D, Fu H, Cai H, Zhang Y, Hou CR, Xu Y, Zhou D, Ge J. Percutaneous Left Atrial Appendage Closure With a Novel LAA Occluder for Stroke Prevention in Atrial Fibrillation. JACC. ASIA 2022; 2:547-556. [PMID: 36518725 PMCID: PMC9743450 DOI: 10.1016/j.jacasi.2022.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/29/2022] [Accepted: 04/25/2022] [Indexed: 01/11/2023]
Abstract
Background More than 90% of thromboses originate from the left atrial appendage (LAA) in patients with nonvalvular atrial fibrillation (NVAF). Objectives This study was designed to investigate the safety and efficacy of LAA closure with the Leftear device (Pulse Scientific) in NVAF patients. Methods A prospective, multicenter, registry-based study was conducted in 200 NVAF patients with CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack, vascular disease, female sex) scores ≥2. The primary safety endpoint was defined as any serious adverse events. Efficacy was assessed by a primary composite endpoint of hemorrhagic or ischemic stroke, systemic embolism, and cardiac or unexplained death at 1 year of follow-up. Results The device was implanted in 196 patients, with 1-stop LAA closure combined with atrial fibrillation ablation implemented in 133 patients. The immediate success rate was 100%. There were serious adverse events in 9 patients (4.5%; 95% CI: 1.6%-7.4%), which mainly occurred in 1-stop LAA closure. All pericardial tamponades occurred in 6 patients with 1-stop LAA closure. No patient experienced a major bleeding event or acute device-related thrombus. During the 12-month follow-up period, the risk of the primary composite endpoint was 1.6% (95% CI: 0.3%-4.5%), and statistical noninferiority was achieved (the upper bound of 95% CI: 4.5% < the prespecified maximum annual incidence of 8.0%). Ischemic stroke occurred in 1 patient, 3 patients had incomplete LAA sealing, and no delayed device-related thrombus was found. Conclusions LAA closure with the novel disc-like occluder shows high procedural success, satisfactory safety, and encouraging efficacy for stroke prevention in patients with NVAF. Compared with 1-stop LAA closure, single LAA closure may be more tolerable. (A multicenter, single-arm clinical trial to evaluate the efficacy and safety of left atrial appendage system for left atrial appendage occlusion in patients with non-valvular atrial fibrillation; ChiCTR1900023035).
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Affiliation(s)
- Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Shiqiang Hou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
| | - Weijing Liu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Wei Chen
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Fadong Chen
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, People’s Republic of China
| | - Jian’an Wang
- Department of Cardiology, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang, People’s Republic of China
| | - Youqi Fan
- Department of Cardiology, The Second Affiliated Hospital Zhejiang University School of Medicine, Zhejiang, People’s Republic of China
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital, Xiamen University, Fujian, People’s Republic of China
| | - Dong Chang
- Department of Cardiology, Xiamen Cardiovascular Hospital, Xiamen University, Fujian, People’s Republic of China
| | - Hua Fu
- Department of Cardiology, West China Hospital, Sichuan University, Sichuan, People’s Republic of China
| | - Heng Cai
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, People’s Republic of China
| | - Yushun Zhang
- Department of Cardiology, First Affiliated Hospital of Xi 'an Jiaotong University, Shaanxi, People’s Republic of China
| | - Cody R. Hou
- College of Biological Sciences, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
- Address for correspondence: Dr Yawei Xu, Department of Cardiology, Shanghai Tenth People's Hospital, No. 301 Yanchang Middle Road, Shanghai 200072, People’s Republic of China.
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
- Dr Daxin Zhou, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, No.180 Fenglin Road, Shanghai 200032, People's Republic of China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Disease, Shanghai, People’s Republic of China
- National Clinical Research Center for Interventional Medicine, Shanghai, People’s Republic of China
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31
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Polymeris AA, Meinel TR, Oehler H, Hölscher K, Zietz A, Scheitz JF, Nolte CH, Stretz C, Yaghi S, Stoll S, Wang R, Häusler KG, Hellwig S, Klammer MG, Litmeier S, Leon Guerrero CR, Moeini-Naghani I, Michel P, Strambo D, Salerno A, Bianco G, Cereda C, Uphaus T, Gröschel K, Katan M, Wegener S, Peters N, Engelter ST, Lyrer PA, Bonati LH, Grunder L, Ringleb PA, Fischer U, Kallmünzer B, Purrucker JC, Seiffge DJ. Aetiology, secondary prevention strategies and outcomes of ischaemic stroke despite oral anticoagulant therapy in patients with atrial fibrillation. J Neurol Neurosurg Psychiatry 2022; 93:588-598. [PMID: 35396339 PMCID: PMC9148984 DOI: 10.1136/jnnp-2021-328391] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/05/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the aetiology, subsequent preventive strategies and outcomes of stroke despite anticoagulation in patients with atrial fibrillation (AF). METHODS We analysed consecutive patients with AF with an index imaging-proven ischaemic stroke despite vitamin K-antagonist (VKA) or direct oral anticoagulant (DOAC) treatment across 11 stroke centres. We classified stroke aetiology as: (i) competing stroke mechanism other than AF-related cardioembolism; (ii) insufficient anticoagulation (non-adherence or low anticoagulant activity measured with drug-specific assays); or, (iii) AF-related cardioembolism despite sufficient anticoagulation. We investigated subsequent preventive strategies with regard to the primary (composite of recurrent ischaemic stroke, intracranial haemorrhage, death) and secondary endpoint (recurrent ischaemic stroke) within 3 months after index stroke. RESULTS Among 2946 patients (median age 81 years; 48% women; 43% VKA, 57% DOAC), stroke aetiology was competing mechanism in 713 patients (24%), insufficient anticoagulation in 934 (32%) and cardioembolism despite sufficient anticoagulation in 1299 (44%). We found high rates of the primary (27% of patients; completeness 91.6%) and secondary endpoint (4.6%; completeness 88.5%). Only DOAC (vs VKA) treatment after index stroke showed lower odds for both endpoints (primary: adjusted OR (aOR) (95% CI) 0.49 (0.32 to 0.73); secondary: 0.44 (0.24 to 0.80)), but not switching between different DOAC types. Adding antiplatelets showed higher odds for both endpoints (primary: aOR (95% CI) 1.99 (1.25 to 3.15); secondary: 2.66 (1.40 to 5.04)). Only few patients (1%) received left atrial appendage occlusion as additional preventive strategy. CONCLUSIONS Stroke despite anticoagulation comprises heterogeneous aetiologies and cardioembolism despite sufficient anticoagulation is most common. While DOAC were associated with better outcomes than VKA, adding antiplatelets was linked to worse outcomes in these high-risk patients. Our findings indicate that individualised and novel preventive strategies beyond the currently available anticoagulants are needed. TRIAL REGISTRATION NUMBER ISRCTN48292829.
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Affiliation(s)
- Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Hannah Oehler
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kyra Hölscher
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Annaelle Zietz
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Jan F Scheitz
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Stretz
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Svenja Stoll
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Karl Georg Häusler
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Simon Hellwig
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Markus G Klammer
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Litmeier
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Iman Moeini-Naghani
- Department of Neurology, The George Washington University, Washington, DC, USA
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexander Salerno
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Carlo Cereda
- Stroke Center, Neurology Department, Neurocenter of Southern Switzerland EOC, Lugano, Ticino, Switzerland
| | - Timo Uphaus
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Hospital Mainz, Mainz, Germany
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Nils Peters
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Stroke Center, Klinik Hirslanden Zurich, Zurich, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lorenz Grunder
- Department of Neuroradiology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | | | - Urs Fischer
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland.,Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Bernd Kallmünzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
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32
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Tsivgoulis G, Triantafyllou S, Palaiodimou L, Grory BM, Deftereos S, Köhrmann M, Dilaveris P, Ricci B, Tsioufis K, Cutting S, Magiorkinis G, Krogias C, Schellinger PD, Dardiotis E, Rodriguez-Campello A, Cuadrado-Godia E, Aguiar de Sousa D, Sharma M, Gladstone DJ, Sanna T, Wachter R, Furie KL, Alexandrov AV, Yaghi S, Katsanos AH. Prolonged Cardiac Monitoring and Stroke Recurrence: A Meta-analysis. Neurology 2022; 98:e1942-e1952. [PMID: 35264426 DOI: 10.1212/wnl.0000000000200227] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/01/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Prolonged poststroke cardiac rhythm monitoring (PCM) reveals a substantial proportion of patients with ischemic stroke (IS) with atrial fibrillation (AF) not detected by conventional rhythm monitoring strategies. We evaluated the association between PCM and the institution of stroke preventive strategies and stroke recurrence. METHODS We searched MEDLINE and SCOPUS databases to identify studies reporting stroke recurrence rates in patients with history of recent IS or TIA receiving PCM compared with patients receiving conventional cardiac rhythm monitoring. Pairwise meta-analyses were performed under the random effects model. To explore for differences between the monitoring strategies, we combined direct and indirect evidence for any given pair of monitoring devices assessed within a randomized controlled trial (RCT). RESULTS We included 8 studies (5 RCTs, 3 observational; 2,994 patients). Patients receiving PCM after their index event had a higher rate of AF detection and anticoagulant initiation in RCTs (risk ratio [RR] 3.91, 95% CI 2.54-6.03; RR 2.16, 95% CI 1.66-2.80, respectively) and observational studies (RR 2.06, 95% CI 1.57-2.70; RR 2.01, 95% CI 1.43-2.83, respectively). PCM was associated with a lower risk of recurrent stroke during follow-up in observational studies (RR 0.29, 95% CI 0.15-0.59), but not in RCTs (RR 0.72, 95% CI 0.49-1.07). In indirect analyses of RCTs, the likelihood of AF detection and anticoagulation initiation was higher for implantable loop recorders compared with Holter monitors and external loop recorders. DISCUSSION PCM after an IS or TIA can lead to higher rates of AF detection and anticoagulant initiation. There is no solid RCT evidence supporting that PCM may be associated with lower stroke recurrence risk.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Sokratis Triantafyllou
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Lina Palaiodimou
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Brian Mac Grory
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Spyridon Deftereos
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Martin Köhrmann
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Polychronis Dilaveris
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Brittany Ricci
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Konstantinos Tsioufis
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Shawna Cutting
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Gkikas Magiorkinis
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Christos Krogias
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Peter D Schellinger
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Efthymios Dardiotis
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Ana Rodriguez-Campello
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Elisa Cuadrado-Godia
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Diana Aguiar de Sousa
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Mukul Sharma
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - David J Gladstone
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Tommaso Sanna
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Rolf Wachter
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Karen L Furie
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Andrei V Alexandrov
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Shadi Yaghi
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
| | - Aristeidis H Katsanos
- From the Second Department of Neurology (G.T., S.T., L.P., A.H.K.) and Second Department of Cardiology (S.D.), School of Medicine, "Attikon" Hospital, First Department of Cardiology (P.D., K.T.), School of Medicine, Hippokration Hospital, and Hygiene, Epidemiology and Medical Statistics, Medical School (G.M.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.V.A.), University of Tennessee Health Science Center, Memphis; Duke University School of Medicine (B.M.G.), Durham, NC; Department of Neurology (M.K.), Universitätsklinikum Essen, Germany; Department of Neurology (B.R., S.C., K.L.F.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (C.K.), St. Josef-Hospital, Ruhr University, Bochum; Departments of Neurology and Neurogeriatry (P.D.S.), Johannes Wesling Medical Center, Ruhr University Bochum, Minden, Germany; Department of Neurology (E.D.), University of Thessaly, Larissa, Greece; Stroke Unit (A.R.-C., E.C.-G.), Department of Neurology, Group of Research on Neurovascular Diseases, Hospital Del Mar Medical Research Institute. DCEX, Universitat Pompeu Fabra, Universitat Autonoma de Barcelona, Spain; Department of Neurosciences (Neurology) (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal; Division of Neurology (M.S., A.H.K.), McMaster University and Population Health Research Institute, Hamilton; Sunnybrook Research Institute and Hurvitz Brain Sciences Program (D.J.G.), Sunnybrook Health Sciences Centre, and Department of Medicine, University of Toronto, Canada; Fondazione Policlinico Gemelli IRCCS (T.S.); Catholic University of the Sacred Heart (T.S.), Institute of Cardiology, Rome, Italy; Clinic and Policlinic for Cardiology (R.W.), University Hospital Leipzig, Germany; and Department of Neurology (S.Y.), New York University School of Medicine, NY
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Rubiera M, Aires A, Antonenko K, Lémeret S, Nolte CH, Putaala J, Schnabel RB, Tuladhar AM, Werring DJ, Zeraatkar D, Paciaroni M. European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin. Eur Stroke J 2022; 7:VI. [PMID: 36082257 PMCID: PMC9446336 DOI: 10.1177/23969873221099478] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG). Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.
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Affiliation(s)
- Marta Rubiera
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Kateryna Antonenko
- Department of Neurology, Bogomolets National Medical University, Kyiv, Ukraine
| | | | - Christian H. Nolte
- Klinik und Hochschulambulanz für Neurologie and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany; Freie Universität Berlin, Humboldt- Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Jukka Putaala
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Renate B. Schnabel
- Department of Cardiology University Heart and Vascular Center Hamburg, University Medical Center Hamburg Eppendorf Hamburg Germany
- German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck Germany
| | - Anil M Tuladhar
- Department of Neurology, Donders Center for Medical Neurosciences, Radboud
University Medical Center, Nijmegen, The Netherlands
| | - David J. Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Dena Zeraatkar
- Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Maurizio Paciaroni
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Bawadikji AA, Teh CH, Kader MABSA, Sulaiman SAS, Ibrahim B. Urine Metabolites as a Predictor of Warfarin Response Based on INR in Atrial Fibrillation. Curr Drug Metab 2022; 23:415-422. [PMID: 35422207 DOI: 10.2174/1389200223666220413112649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/24/2021] [Accepted: 01/26/2022] [Indexed: 11/22/2022]
Abstract
Background:
Warfarin is an anticoagulant with wide inter-individual variations in drug responses monitored based on the International Normalized Ratio (INR). It is commonly prescribed for atrial fibrillation (AF) and stroke. Oral anticoagulants (e.g., warfarin) reduce the risk of getting a stroke but increase the risk of hemorrhage. The proton nuclear magnetic resonance (1H-NMR) pharmacometabonomics technique is useful for determining drug responses. Furthermore, pharmacometabonomics analysis can help identify novel biomarkers of warfarin outcome/INR stability in urine.
Objectives:
The focus of this research was to determine if urine metabolites could predict the warfarin response based on INR in patients who were already taking warfarin (identification; phase I) and to determine if urine metabolites could distinguish between unstable and stable INR in patients who had just started taking warfarin (validation; phase II).
Methods:
A cross-sectional study was conducted. Ninety urine samples were collected for phase 1, with 49 having unstable INR and 41 having stable INR. In phase II, 21 urine samples were obtained, with 13 having an unstable INR and eight having a stable INR. The metabolites associated with unstable INR and stable INR could be determined using univariate and multivariate logistic regression analysis.
Results:
Multivariate logistic regression (MVLR) analysis showed that unstable INR was linked with seven regions.
Discussion:
The urine pharmacometabonomics technique utilized could differentiate between the urine metabolite profiles of the patients on warfarin for INR stability.
Conclusion:
1H-NMR-based pharmacometabonomics can help lead to a more individualized, controlled side effect for warfarin, thus minimizing undesirable effects in the future.
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Affiliation(s)
| | | | | | | | - Baharudin Ibrahim
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Malaysia
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Malaya
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Ma Z, Chu L, Liu CF, Liu W, Wei J. Construction of a Joint Prediction Model for the Occurrence of Ischemic Stroke and Acute Myocardial Infarction Based on Bioinformatic Analysis. DISEASE MARKERS 2022; 2022:5967131. [PMID: 35419117 PMCID: PMC9001103 DOI: 10.1155/2022/5967131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022]
Abstract
Ischemic stroke (IS) has imposed significant threat to both middle-aged and elderly people worldwide. Acute myocardial infarction (AMI) is a rare but serious complication following IS, which can further increase patient disability and mortality rates. With the development of intravenous thrombolysis and endovascular treatment, the prognosis of IS has been greatly improved. However, the pathogenesis of IS complicated with AMI is still unclear. To fill this gap, this work uses bioinformatic analysis, where IS and AMI datasets were combined for differential gene analysis, and then, a ROC prediction model for target gene analysis was constructed. It is found that OSM gene has the highest prediction accuracy (AUC = 0.793), followed by IL6ST, IL6, JAK1, IL6R, and JAK2 genes. Joint prediction model showed higher accuracy in predicting the outcome of control and case (AUC = 0.918). The etiology of ischemic stroke and acute myocardial infarction is complicated. Their cooccurring pathological mechanisms and the conversion between the two diseases could not be explained by a single gene. Therefore, the joint prediction model in this work can provide a better prediction accuracy for research purpose.
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Affiliation(s)
- Zhaolei Ma
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
- Department of Neurology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, China
| | - Lan Chu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
- Department of Neurology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, China
- Institute of Neuroscience, Soochow University, Suzhou, Jiangsu 215004, China
| | - Chun-Feng Liu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
- Institute of Neuroscience, Soochow University, Suzhou, Jiangsu 215004, China
| | - Wupeng Liu
- Department of Cardiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, China
| | - Jing Wei
- Department of Endocrinology, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550004, China
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36
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Liu Z, Lin X, Lin W, Lu Q, Liu P, Wang J, Liu Y, Chang Q, Wang Y, Song C, Wang F, Shi Y, Wang Q, Liu G, Tian Y, Wu S. A J-Shaped Curve Relationship Between Baseline Fasting Blood Glucose and 1-Year Stroke Recurrence in Non-diabetic Patients With Acute Cerebral Infarction in Xi'an, China: A Multicenter Observational Cohort Study. Front Neurol 2022; 12:698793. [PMID: 35126276 PMCID: PMC8810505 DOI: 10.3389/fneur.2021.698793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background The relationship between baseline fasting blood glucose (FBG) levels and 1-year stroke recurrence in non-diabetic patients with acute cerebral infarction (ACI) is unclear. We aimed to clarify this relationship in non-diabetic patients with ACI. Methods Baseline FBG levels and related information of the patients were collected at admission and the events of stroke recurrence were followed up 1, 3, 6, and 12 months after the patients were discharged. Baseline FBG levels were analyzed as continuous variables and quartiles (Q1–Q4). Multivariate Cox regression models and a two-piecewise linear regression model were used to investigate the relationship and determine the threshold effect between baseline FBG levels and 1-year stroke recurrence in non-diabetic patients with ACI. Results Overall, 1,634 non-diabetic patients with ACI were enrolled. After adjusting for potential confounding factors, the hazard is 2.24-fold higher in Q4 than those in Q2, being considered the reference in non-diabetic patients with ACI [hazard ratio (HR) = 2.24, 95%CI: 1.08–4.65, P = 0.031]. Plotting hazard ratios over baseline FBG levels suggested a J-shaped relationship for 1-year stroke recurrence. Further analysis revealed that the nadir value of baseline FBG levels is 4.6 mmol/L. The relationship was more significant in patients with atrial fibrillation than in those without (P for interaction = 0.009). Conclusion Lower and higher baseline FBG levels may lead to an increased risk of 1-year stroke recurrence in non-diabetic patients with ACI as shown by a J-shaped curve with a nadir value of 4.6 mmol/L.
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Affiliation(s)
- Zhongzhong Liu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Xuemei Lin
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Wenjuan Lin
- College of Life Science, Northwest University, Xi'an, China
| | - Qingli Lu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Pei Liu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Jing Wang
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Yan Liu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Qiaoqiao Chang
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Yan Wang
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Chensheng Song
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Fang Wang
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Yaling Shi
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Qing Wang
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Guozheng Liu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
| | - Ye Tian
- Department of Neurology, The Affiliated Hospital of Northwest University (Xi'an No.3 Hospital), Xi'an, China
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, The Affiliated Hospital of Northwest University (Xi'an No.3 Hospital), Xi'an, China
- *Correspondence: Ye Tian
| | - Songdi Wu
- Department of Neurology, The First Affiliated Hospital of Northwest University (Xi'an No.1 Hospital), Xi'an, China
- College of Life Science, Northwest University, Xi'an, China
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, The Affiliated Hospital of Northwest University (Xi'an No.3 Hospital), Xi'an, China
- Songdi Wu
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Ko D, Dai Q, Flynn DB, Bosch NA, Helm RH, Monahan KM, Andersson C, Anderson CD, Walkey AJ. Meta-Analysis of Randomized Clinical Trials Comparing the Impact of Implantable Loop Recorder Versus Usual Care After Ischemic Stroke for Detection of Atrial Fibrillation and Stroke Risk. Am J Cardiol 2022; 162:100-104. [PMID: 34756594 PMCID: PMC8678332 DOI: 10.1016/j.amjcard.2021.09.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/14/2021] [Accepted: 09/17/2021] [Indexed: 01/03/2023]
Abstract
Implantable loop recorder (ILR) is recommended to detect subclinical atrial fibrillation (AF) after cryptogenic stroke; however, the clinical outcomes of this practice is unclear. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate 12-month AF detection, change in oral anticoagulation (OAC), and recurrent stroke in ILR versus usual care after ischemic stroke. We searched Medline, Embase, Web of Science, Cochrane Library for randomized controlled trials comparing ILR with usual care after any ischemic stroke. Primary outcomes were cumulative AF detection and recurrent stroke (ischemic or hemorrhagic) or transient ischemic attack over 12 months. Secondary outcome was OAC initiation. Meta-analysis was performed with Mantel-Haenszel pooled odds ratios (ORs) and random effects models. Of 200 identified articles, 3 trials were included (1,233 participants). Cryptogenic stroke and underlying AF included cryptogenic stroke only, stroke of known cause and underlying-AF included small or large vessel stroke only, and post embolic rhythm detection with implantable vs external monitoring included all ischemic strokes. The 12-month AF detection was 13% in the ILR group and 2.4% in controls. ILR was more likely to detect AF compared with usual care (OR 5.8, 95% confidence interval 3.2 to 10.2). Stroke or transient ischemic attack occurred in 7% with ILR and 9% with usual care (OR 0.8, 95% confidence interval 0.5 to 1.2). In patients with detected AF, 97% and 100% were started on OAC in cryptogenic stroke and underlying AF and post embolic rhythm detection with implantable vs external monitoring, respectively, compared with 68% in stroke of known cause and underlying-AF. In conclusion, ILR was superior to usual care in AF detection, but the relative low incidence of AF and the nondifferential risk of stroke between the ILR and usual care arms may suggest that most patients do not benefit from ILR implantation. Further studies are warranted to understand if patient selection can be improved to increase the diagnostic yield of ILR.
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Affiliation(s)
- Darae Ko
- Section of Cardiovascular Medicine.
| | - Qiying Dai
- Cardiology Department, Saint Vincent Hospital, Worcester, Massachusetts
| | - David B Flynn
- Department of Medical Sciences & Education, Boston University School of Medicine, Boston, Massachusetts
| | | | | | | | | | - Christopher D Anderson
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts; McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts; Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Allan J Walkey
- The Pulmonary Center, Department of Medicine; Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, Massachusetts
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Plasma Anion Gap and Risk of In-Hospital Mortality in Patients with Acute Ischemic Stroke: Analysis from the MIMIC-IV Database. J Pers Med 2021; 11:jpm11101004. [PMID: 34683145 PMCID: PMC8541378 DOI: 10.3390/jpm11101004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 02/06/2023] Open
Abstract
We aimed to investigate the association between the plasma anion gap (AG) and in-hospital mortality among patients with acute ischemic stroke (AIS). In total, 1236 AIS patients were enrolled using the Medical Information Mart for Intensive Care Database IV. Primary outcome was in-hospital mortality. The patients were divided into four groups according to AG category. The mean age and Charlson comorbidity index increased as the AG category increased. The fourth AG category was most related to the in-hospital mortality (hazards ratio (HR), 95% confidence interval (CI): 2.77, 1.60-4.71), even after adjusting for possible confounding variables (Model 1: HR, 95% CI: 3.37, 1.81-6.09; Model 2: HR, 95% CI: 3.57, 1.91-6.69). Moreover, intensive care unit mortality (p = 0.008) was higher in the highest AG category, but the intracranial hemorrhage (p = 0.071) did not associate with the plasma AG. The plasma AG had a satisfactory predictive ability for in-hospital mortality among AIS patients (areas under the receiver operating characteristic curve: 0.631). The plasma AG is an independent risk factor that can satisfactorily predict the in-hospital mortality among AIS patients.
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Capodanno D, Angiolillo DJ. Oral antithrombotic therapy for the prevention of recurrent cerebrovascular events. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:383-391. [PMID: 34374741 DOI: 10.1093/ehjcvp/pvab062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/06/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022]
Abstract
Stroke is frequently a disabling and even life-threatening condition that has an ischemic cause in most cases. Transient ischemic attack (TIA) is a lower-risk condition that still exposes to the risk of future major cardiovascular events. The causes of stroke can be classified as cardioembolic disease, large vessel disease, small vessel disease, undetermined, or others. Cardioembolic disease and atherothrombosis of large arteries are the most common underlying processes of ischemic stroke and TIA. Therefore, antithrombotic therapy is a central strategy in the pharmacological management of these patients. However, because antithrombotic therapy provides ischemic protection at the price of increased bleeding, defining the fine balance between efficacy and safety is a clinical challenge. Numerous trials have recently defined the current indications to the use of anticoagulant and antiplatelet therapy in patients with various subtypes of ischemic stroke or TIA. In this review, we provide an updated appraisal of the currently available evidence on the use of various oral antithrombotic agents for prevention of recurrent events after an ischemic stroke or TIA.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Amoda O, A E, Uwagbale E. A Case of Failed Dual Antiplatelet Therapy With Oral Anticoagulant in the Prevention of Acute Ischemic Stroke. Cureus 2021; 13:e15915. [PMID: 34322355 PMCID: PMC8310612 DOI: 10.7759/cureus.15915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/17/2022] Open
Abstract
Cerebrovascular accidents (CVA) or strokes cause focal neurological deficits, which may be due to rupture or occlusion of blood vessels supplying areas of the brain. Atrial fibrillation (AF) is an independent and significant risk factor for ischemic CVA, mainly via the embolic pathway. This is evident as newly diagnosed patients with AF are typically started on anticoagulation therapy if their CHA2DS2-VASc score is equal to or greater than two. Furthermore, ischemic CVA may occur as a thrombotic phenomenon due to significant vessel atherosclerotic disease involving plaque ulceration and rupture. Such a phenomenon may be curtailed with antiplatelet therapy in at-risk patient populations, particularly as a form of secondary prevention. This case highlights the unfortunate incidence of an ischemic CVA in a patient using dual antiplatelet therapy (DAPT) and anticoagulation.
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Affiliation(s)
- Oluyemisi Amoda
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Elmarie A
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
| | - Ese Uwagbale
- Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, USA
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41
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Evaluating High-Functioning Young Stroke Survivors with Cognitive Complaints. Can J Neurol Sci 2021; 49:368-372. [PMID: 34134793 DOI: 10.1017/cjn.2021.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Montreal Cognitive Assessment (MoCA) is a commonly used cognitive outcome in stroke trials. However, it may be insufficiently sensitive to detect impairment in high-functioning stroke survivors. The National Institutes of Health (NIH) Toolbox Cognition Battery (NIHTB-CB), a 30-min comprehensive tablet-based cognitive assessment, may be a better choice to characterize cognitive issues in this cohort. METHODS We compared MoCA and NIHTB-CB performance in young stroke survivors (18-55 years) with excellent functional outcomes (modified Rankin Scale 0-1) reporting subjective cognitive complaints to that of age-matched healthy controls. We recruited 53 stroke survivors and 53 controls. We performed a sensitivity analysis in those participants with normal MoCA scores (≥26). RESULTS Median MoCA scores were not significantly different between stroke survivors (27.0 vs. 28.0) and healthy controls. Mean T scores for NIHTB-CB fluid (44.9 vs. 54.2), crystallized (53.8 vs. 60.0), and total cognition (49.1 vs. 58.4) components were significantly lower in stroke survivors compared to healthy controls (p < 0.001 for all). In participants scoring within normal range (≥26) on the MoCA, NIHTB-CB scores for all components remained significantly lower in stroke survivors. CONCLUSIONS In young stroke survivors with excellent functional outcomes and subjective cognitive complaints, the NIHTB-CB, but not the MoCA, was able to detect differences in cognitive performance between stroke survivors and healthy controls. The NIHTB-CB may be a suitable outcome measure for cognition in clinical trials examining higher-functioning young stroke survivors.
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42
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Cheng X, Dong Q. Towards individualised secondary prevention after intracerebral haemorrhage. Lancet Neurol 2021; 20:411-413. [PMID: 34022160 DOI: 10.1016/s1474-4422(21)00130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Xin Cheng
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China.
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
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43
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Greenberg SM. Cerebral microbleeds and prediction of intracranial haemorrhage. Lancet Neurol 2021; 20:252-254. [PMID: 33743229 DOI: 10.1016/s1474-4422(21)00065-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 01/09/2023]
Affiliation(s)
- Steven M Greenberg
- Stroke Research Center, Massachusetts General Hospital, Boston MA 02114, USA.
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44
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Affiliation(s)
- Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Ontario, Canada
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