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Abuelazm M, Khildj Y, Ibrahim AA, Mahmoud A, Amin AM, Gowaily I, Khan U, Abdelazeem B, Brašić JR. Intensive Blood Pressure Control After Endovascular Thrombectomy for Acute Ischemic Stroke: a Systematic Review and Meta-Analysis. Clin Neuroradiol 2024; 34:563-575. [PMID: 38453701 DOI: 10.1007/s00062-024-01391-6] [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: 11/25/2023] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Optimal clinical outcome with successful recanalization from endovascular thrombectomy (EVT) requires optimal blood pressure (BP) management. We aimed to evaluate the efficacy and safety of the intensive BP target (< 140 mm Hg) versus the standard BP target (< 180 mm Hg) after EVT for acute ischemic stroke. METHODS We conducted a systematic review and meta-analysis synthesizing evidence from randomized controlled trials (RCTs) obtained from PubMed, Embase Cochrane, Scopus, and WOS until September 7th, 2023. We used the fixed-effect model to report dichotomous outcomes using risk ratio (RR) and continuous outcomes using mean difference (MD), with a 95% confidence interval (CI). PROSPERO ID CRD42023463206. RESULTS We included four RCTs with 1559 patients. There was no difference between intensive BP and standard BP targets regarding the National Institutes of Health Stroke Scale (NIHSS) change after 24 h [MD: 0.44 with 95% CI (0.0, 0.87), P = 0.05]. However, the intensive BP target was significantly associated with a decreased risk of excellent neurological recovery (mRS ≤ 1) [RR: 0.87 with 95% CI (0.76, 0.99), P = 0.03], functional independence (mRS ≤ 2) [RR: 0.81 with 95% CI (0.73, 0.90), P = 0.0001] and independent ambulation (mRS ≤ 3) [RR: 0.85 with 95% CI (0.79, 0.92), P < 0.0001]. CONCLUSIONS An intensive BP target after EVT is associated with worse neurological recovery and significantly decreased rates of functional independence and independent ambulation compared to the standard BP target. Therefore, the intensive BP target should be avoided after EVT for acute ischemic stroke.
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Affiliation(s)
| | - Yehya Khildj
- Faculty of Medicine, University of Algiers, Algiers, Algeria
| | | | | | | | | | - Ubaid Khan
- Faculty of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Basel Abdelazeem
- Department of Cardiology, West Virginia University, West Virginia, USA
| | - James Robert Brašić
- Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Behavioral Health, New York City Health and Hospitals/Bellevue, New York, NY, USA
- Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, USA
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Samuel S, Craver K, Miller C, Pelsue B, Gonzalez C, Allison TA, Gulbis B, Choi HA, Kim S. Reviving Decades-Old Wisdom: Longitudinal Analysis of Renin-Angiotensin System Inhibitors and Its Effects on Acute Ischemic Stroke to Improve Outcomes. Am J Hypertens 2024; 37:531-539. [PMID: 38501167 DOI: 10.1093/ajh/hpae033] [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: 01/29/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND While renin-angiotensin system (RAS) inhibitors have a longstanding history in blood pressure control, their suitability as first-line in-patient treatment may be limited due to prolonged half-life and kidney failure concerns. METHODS Using a cohort design, we assessed the impact of RAS inhibitors, either alone or in combination with beta-blockers, on mortality, while exploring interactions, including those related to end-stage renal disease and serum creatinine levels. Eligible subjects were Acute Ischemic Stroke (AIS) patients aged 18 or older with specific subtypes who received in-patient antihypertensive treatment. The primary outcome was mortality rates. Statistical analyses included cross-sectional and longitudinal approaches, employing generalized linear models, G-computation, and discrete-time survival analysis over a 20-day follow-up period. RESULTS In our study of 3,058 AIS patients, those using RAS inhibitors had significantly lower in-hospital mortality (2.2%) compared to non-users (12.1%), resulting in a relative risk (RR) of 0.18 (95% CI: 0.12-0.26). Further analysis using G-computation revealed a marked reduction in mortality risk associated with RAS inhibitors (0.0281 vs. 0.0913, risk difference [RD] of 6.31% or 0.0631, 95% CI: 0.046-0.079). Subgroup analysis demonstrated notable benefits, with individuals having creatinine levels below and above 1.3 mg/dl exhibiting statistically significant RD (RD -0.0510 vs. -0.0895), and a significant difference in paired comparison (-0.0385 or 3.85%, CI 0.023-0.054). Additionally, longitudinal analysis confirmed a consistent daily reduction of 0.93% in mortality risk associated with the intake of RAS inhibitors. CONCLUSIONS RAS inhibitors are associated with a significant reduction in in-hospital mortality in AIS patients, suggesting potential clinical benefits in improving patient outcomes.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Kyndol Craver
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Charles Miller
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
| | - Brittany Pelsue
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Catherine Gonzalez
- Department of Neurology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Teresa A Allison
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Brian Gulbis
- Department of Pharmacy, Memorial Hermann Hospital, Houston, Texas, USA
| | - Huimahn Alex Choi
- Department of Neurosurgery, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Seokhun Kim
- Institute of Clinical Research and Learning Health Care, UT Health Houston, Houston, Texas, USA
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3
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Papadimitriou D, Korompoki E, Ntaios G. The optimal management of arterial blood pressure in acute stroke: A never-ending conundrum. Eur J Intern Med 2024; 124:44-45. [PMID: 38734520 DOI: 10.1016/j.ejim.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Dimitra Papadimitriou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa 41110, Greece.
| | - Eleni Korompoki
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa 41110, Greece
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4
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Barra ME, Giulietti JM, DiCarlo JA, Erler KS, Krenz J, Roberts RJ, Lin DJ. Medication Profiles at Hospital Discharge Predict Poor Outcomes After Acute Ischemic Stroke. J Pharm Pract 2024; 37:600-606. [PMID: 36604314 DOI: 10.1177/08971900221150282] [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: 01/07/2023]
Abstract
Objectives: To examine the relationship between medications prescribed during the first 6-months post-stroke and functional outcome. Materials and Methods: A retrospective analysis of ischemic stroke survivors enrolled in an observational stroke recovery study from June-2017 to July-2019 was performed. Survivors with favorable outcomes (modified rankin scale (mRS) score 0-2) were compared to those with unfavorable outcomes (mRS ≥3) 6-months after stroke on the following: discharge medication classes prescribed, achievement of recommended targets for blood pressure control, glycemic control, and LDL ≤70 mg/dL, medication changes, medication interactions, and medication list discrepancies. Results: Unfavorable 6-month outcomes occurred in 36/78 (46.2%) of survivors. Survivors with unfavorable outcomes were more likely to be prescribed a central nervous system-acting agent (97.2% vs 71.4%; P = .0022) and/or an anti-hyperglycemic agent (25.0% vs 9.5%; P = .009) at discharge. After adjustment of baseline covariates, total number of medications prescribed was associated with unfavorable 6-month outcomes (OR 1.13, 95% CI 1.0-1.28). Secondary stroke prevention measures were not achieved in a high proportion of survivors. Medication changes during 6-month follow up were common and survivors with unfavorable outcomes were more likely to have clinically significant drug-drug interactions. Discussion: At 6-months, survivors with unfavorable outcomes were found to be prescribed more medications, particularly central nervous system-acting and anti-hyperglycemic agents. There were also more drug-drug interactions in the medications prescribed compared to those with favorable outcomes. Together, these data suggest the need for enhanced screening of high-risk stroke survivors focused on close monitoring of polypharmacy, drug-drug interactions, and adverse events with pharmacotherapy.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer M Giulietti
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- School of Pharmacy, Northeastern University, Boston, MA, USA
| | - Julie A DiCarlo
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly S Erler
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - James Krenz
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - David J Lin
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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5
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Medicherla C, Pashun R, Al-Mufti F. Review of Cerebral Collateral Circulation and Insight into Cardiovascular Strategies to Limit Collateral Damage in Ischemic Stroke. Cardiol Rev 2024; 32:188-193. [PMID: 37729598 DOI: 10.1097/crd.0000000000000614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Cerebral collateral circulation is a dynamic and adaptive process by which alternative vascular pathways supply perfusion to ischemic brain tissue in the event of an arterial occlusion. This complicated network of blood vessels that acts as a natural bypass plays a pivotal role in stroke pathophysiology and has become a key area of study given its significance in stroke treatment and patient outcomes. In this review, we will study the factors influencing the formation, recruitment, and endurance of collateral vessels; discuss imaging modalities for quantitative and qualitative assessment of this network; explore the role of collaterals in stroke management; and highlight several cardiovascular strategies to minimize damage to collaterals and optimize stroke outcomes.
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Affiliation(s)
| | - Raymond Pashun
- Department of Cardiology, New York University Langone Health, New York, NY
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, NY
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6
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Kakaletsis N, Ntaios G, Milionis H, Karagiannaki A, Chouvarda I, Dourliou V, Chytas A, Hatzitolios AI, Savopoulos C. Prognostic significance of 24-h blood pressure and variability indices in the outcome of acute ischaemic stroke. Intern Med J 2023; 53:1137-1146. [PMID: 35666577 DOI: 10.1111/imj.15834] [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: 12/08/2021] [Accepted: 05/29/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The association between blood pressure (BP) levels and BP variability (BPV) following acute ischaemic stroke (AIS) and outcome remains controversial. AIMS To investigate the predictive value of systolic BP (SBP) and diastolic BP (DBP) and BPV measured using 24-h ambulatory blood pressure monitoring (ABPM) methods during AIS regarding outcome. METHODS A total of 228 AIS patients (175 without prior disability) underwent ABPM every 20 min within 48 h from onset using an automated oscillometric device (TM 2430, A&D Company Ltd) during day time (7:00-22:59) and night time (23:00-6:59). Risk factors, stroke subtypes, clinical and laboratory findings were recorded. Mean BP parameters and several BPV indices were calculated. End-points were death and unfavourable functional outcome (disability/death) at 3 months. RESULTS A total of 61 (26.7%) patients eventually died. Multivariate logistic regression analysis revealed that only mean night-time DBP (hazard ratio (HR): 1.04; 95% confidence interval (CI): 1.00-1.07) was an independent prognostic factor of death. Of the 175 patients without prior disability, 79 (45.1%) finally met the end-point of unfavourable functional outcome. Mean 24-h SBP (HR: 1.03; 95% CI: 1.00-1.05), day-time SBP (HR: 1.02; 95% CI: 1.00-1.05) and night-time SBP (HR: 1.03; 95% CI: 1.01-1.05), SBP nocturnal decline (HR: 0.93; 95% CI: 0.88-0.99), mean 24-h DBP (HR: 1.08; 95% CI: 1.03-1.13), day-time DBP (HR: 1.07; 95% CI: 1.03-1.12) and night-time DBP (HR: 1.06; 95% CI: 1.02-1.10) were independent prognostic factors of an unfavourable functional outcome. CONCLUSIONS In contrast with BPV indices, ABPM-derived BP levels and lower or absence of BP nocturnal decline in the acute phase are prognostic factors of outcome in AIS patients.
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Affiliation(s)
- Nikolaos Kakaletsis
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Haralampos Milionis
- Department of Internal Medicine, Medical School, University of Ioannina, University Hospital of Ioannina, Ioannina, Greece
| | - Anastasia Karagiannaki
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioanna Chouvarda
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Dourliou
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Achileas Chytas
- Laboratory of Medical Informatics, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos I Hatzitolios
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Christos Savopoulos
- First Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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7
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Hao F, Yin S, Tang L, Zhang X, Zhang S. Nicardipine versus Labetalol for Hypertension during Acute Stroke: A Systematic Review and Meta-Analysis. Neurol India 2022; 70:1793-1799. [PMID: 36352567 DOI: 10.4103/0028-3886.359214] [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: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Current recommendations prescribe either nicardipine or labetalol as the first-line treatment for acute hypertension due to ease of use, availability, and low price. However, it is unclear if these drugs have different effectiveness and safety profiles. This systematic review and meta-analysis aimed to compare the efficacy and safety of labetalol and nicardipine in patients with acute stroke. MATERIALS AND METHODS MEDLINE via PubMed, Scopus, Embase, and Google Scholar databases were electronically searched for the eligible publications from inception until March 2022. All full-text journal papers in English which compared the efficacy of nicardipine with that of labetalol on lowering blood pressure (BP; or treating hypertension) in all subtypes of acute stroke were included. The Cochrane Collaboration tool was used to assess the risk of bias. Data were analyzed using specific statistical methods. RESULTS Following the abstract and full-text screening, this meta-analysis included five retrospective cohorts and one prospective pseudorandomized cohort. Nicardipine's effect on time at goal BP was significantly superior to that of labetalol in patients with acute stroke (0.275 standardized mean difference [SMD], 95% confidence interval [CI]: 0.112-0.438, P = 0.001). The incidence of adverse events was significantly higher in the nicardipine group than that in the labetalol group. The pooled odds ratio (OR) was 1.509 (95% CI: 1.077-2.113, I2 = 0.00%, P = 0.757). The quality of included studies was found to be low. CONCLUSION More prospective, comparative trials are needed to investigate the efficacy of BP management as well as clinical outcomes in acute stroke patients receiving continuous labetalol and nicardipine infusions.
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Affiliation(s)
- Fang Hao
- Department of Neurology, Liaocheng People's Hospital, Shandong Province, China
| | - Suna Yin
- Department of Operating Room, Liaocheng Veterans Hospital, Shandong Province, China
| | - Lina Tang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
| | - Xueguang Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
| | - Shubao Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Shandong Province, China
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8
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Bath PM, Song L, Silva GS, Mistry E, Petersen N, Tsivgoulis G, Mazighi M, Bang OY, Sandset EC. Blood Pressure Management for Ischemic Stroke in the First 24 Hours. Stroke 2022; 53:1074-1084. [PMID: 35291822 DOI: 10.1161/strokeaha.121.036143] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High blood pressure (BP) is common after ischemic stroke and associated with a poor functional outcome and increased mortality. The conundrum then arises on whether to lower BP to improve outcome or whether this will worsen cerebral perfusion due to aberrant cerebral autoregulation. A number of large trials of BP lowering have failed to change outcome whether treatment was started prehospital in the community or hospital. Hence, nuances on how to manage high BP are likely, including whether different interventions are needed for different causes, the type and timing of the drug, how quickly BP is lowered, and the collateral effects of the drug, including on cerebral perfusion and platelets. Specific scenarios are also important, including when to lower BP before, during, and after intravenous thrombolysis and endovascular therapy/thrombectomy, when it may be necessary to raise BP, and when antihypertensive drugs taken before stroke should be restarted. This narrative review addresses these and other questions. Although further large trials are ongoing, it is increasingly likely that there is no simple answer. Different subgroups of patients may need to have their BP lowered (eg, before or after thrombolysis), left alone, or elevated.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Lili Song
- The George Institute China at Peking University Health Science Center, Beijing (L.S.)
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Sydney, Australia (L.S.)
| | - Gisele S Silva
- Neurology, Federal University of São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, Brazil (G.S.S.)
| | - Eva Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH (E.M.)
| | - Nils Petersen
- Department of Neurology, Divisions of Vascular Neurology and Neurocritical Care, Yale School of Medicine, New Haven (N.P.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (G.T.)
| | - Mikael Mazighi
- Department of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris, INSERM 1148, FHU Neurovasc, France (M.M.)
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea (O.Y.B.)
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- The Norwegian Air Ambulance Foundation, Oslo (E.C.S.)
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9
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Yeh CF, Chin YC, Hung W, Huang PI, Lan MY. Vertebral artery stenosis predicts cerebrovascular diseases following radiotherapy for nasopharyngeal carcinoma. Support Care Cancer 2022; 30:5821-5830. [PMID: 35357575 DOI: 10.1007/s00520-022-07011-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/22/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE Radiotherapy for nasopharyngeal carcinoma (NPC) may induce cerebrovascular diseases including ischemic stroke and transient ischemic attack (TIA), which can cause severe disability. However, information on the incidence and predictors of cerebrovascular diseases is scarce. This study aimed to estimate the incidence of cerebrovascular diseases following NPC, and attempts to ascertain the predictors of cerebrovascular diseases to facilitate early prevention. METHODS We performed a retrospective cohort study on 655 NPC patients who received radiotherapy between 2006 and 2018 in a medical center. This study analyzed the incidence, clinical and imaging presentation of patients with cerebrovascular diseases. Cox proportional hazard model was used to identify risk factors associated with cerebrovascular diseases following radiotherapy. RESULTS There were 14 patients who developed an ischemic stroke, and 3 patients developed a TIA after a mean follow-up of 5.8 years. Most ischemic events were from large-artery atherosclerosis (76.5%), and the most common symptom of ischemic stroke was unilateral limb weakness (57.1%). The cumulative incidence of ischemic stroke or TIA 15 years after radiotherapy was 9.1% (95% confidence interval [CI] = 4.7-17.2%). Multivariate Cox regression identified vertebral artery stenosis (HR: 18.341; 95% CI = 3.907-86.100; P < 0.001), atrial fibrillation (HR: 13.314; 95% CI = 1.306-135.764; P = 0.029), and hypertension (HR: 7.511; 95% CI = 1.472-38.320; P = 0.015) as independent predictors of ischemic stroke or TIA. CONCLUSION Our study found that NPC patients with vertebral artery stenosis, atrial fibrillation, or hypertension carry a higher risk for ischemic stroke or TIA. Regular assessment of vertebral artery after radiotherapy was suggested.
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Affiliation(s)
- Chien-Fu Yeh
- Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 11217, Taiwan.,Department of Otorhinolaryngology, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, 11221, Taiwan
| | - Yu-Ching Chin
- Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 11217, Taiwan
| | - Wei Hung
- Department of Medical Education, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Taipei, 11217, Taiwan
| | - Pin-I Huang
- Division of Radiation Oncology, Department of Oncology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Taipei, 11217, Taiwan
| | - Ming-Ying Lan
- Department of Otorhinolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, No. 201, Sec. 2, Shipai Rd., Beitou District, Taipei City, 11217, Taiwan. .,Department of Otorhinolaryngology, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St., Taipei, 11221, Taiwan.
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10
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Strømsnes TA, Kaugerud Hagen TJ, Ouyang M, Wang X, Chen C, Rygg SE, Hewson D, Lenthall R, McConachie N, Izzath W, Bath PM, Dhillon PS, Podlasek A, England T, Sprigg N, Robinson TG, Advani R, Ihle-Hansen H, Sandset EC, Krishnan K. Pressor therapy in acute ischaemic stroke: an updated systematic review. Eur Stroke J 2022; 7:99-116. [PMID: 35647316 PMCID: PMC9134777 DOI: 10.1177/23969873221078136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/17/2022] [Indexed: 11/15/2022] Open
Abstract
Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.
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Affiliation(s)
- Torbjørn Austveg Strømsnes
- Department of Neurosurgery, Oslo University hospital, Norway
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Clinical Medicine, University of Bergen, Norway
| | - Truls Jørgen Kaugerud Hagen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - Menglu Ouyang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Xia Wang
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
| | - Chen Chen
- The George Institute for Global Health, Faulty of Medicine, University of New South Wales, Australia
- The George Institute for Global Health, Peking University Health Science Center, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Silje-Emilie Rygg
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Department of Geriatric Medicine, Oslo University hospital, Norway
| | - David Hewson
- Department of Anaesthesia, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rob Lenthall
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Norman McConachie
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Wazim Izzath
- Department of Neuroradiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Permesh Singh Dhillon
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Anna Podlasek
- Department of Neuroradiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Timothy England
- Department of Stroke Medicine, Royal Derby Hospital, Derby, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
| | - Thompson G Robinson
- College of Life Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Rajiv Advani
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Hege Ihle-Hansen
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
| | - Else Charlotte Sandset
- Stroke Unit Department of Neurology, Oslo University hospital, Norway
- Norwegian Air Ambulance Foundation, Norway
| | - Kailash Krishnan
- Stroke, Department of Acute Medicine, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Stroke Trials Unit, University of Nottingham, Queen’s Medical Centre campus, Nottingham, UK
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11
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Blood Pressure Control in Acute Stroke: Labetalol or Nicardipine? J Stroke Cerebrovasc Dis 2021; 30:105959. [PMID: 34217067 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/10/2021] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To assess the safety and efficacy of continuous infusion (CIV)-labetalol compared to -nicardipine in controlling blood pressure (BP) in the acute stroke setting. MATERIALS Patients were eligible if they had a diagnosis of an acute stroke and were administered either CIV-labetalol or CIV-nicardipine. Study outcomes were assessed within the first 24 h of the antihypertensive infusion. RESULTS A total of 3,093 patients were included with 3,008 patients in the CIV-nicardipine group and 85 in the CIV-labetalol group. No significant difference was observed in percent time at goal BP between the nicardipine (82%) and labetalol (85%) groups (p = 0.351). There was also no difference in BP variability between nicardipine (37%) and labetalol (39%) groups (p = 0.433). Labetalol was found to have a shorter time to goal BP as compared to nicardipine (24 min vs. 40 min; p = 0.021). While CIV-nicardipine did have a higher incidence of tachycardia compared to labetalol (17% vs. 4%; p <0.001), the incidence of hypotension (13% vs. 15%; p = 0.620) and bradycardia (24% vs. 22%; p = 0.797) were similar. CONCLUSIONS These results indicate that CIV-labetalol and CIV-nicardipine are comparable in safety and efficacy in controlling BP for patients with acute stroke.
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12
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Alotaibi SM, Alotaibi HM, Alolyani AM, Abu Dali FA, Alshammari AK, Alhwiesh AA, Gari DM, Khuda IKMQ, Vallabadoss CA. Assessment of the stroke-specific quality-of-life scale in KFHU, Khobar: A prospective cross-sectional study. ACTA ACUST UNITED AC 2021; 26:171-178. [PMID: 33814370 PMCID: PMC8024127 DOI: 10.17712/nsj.2021.2.20200126] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/07/2020] [Indexed: 11/20/2022]
Abstract
Objectives: To assess the overall and domain-specific quality of life (QOL) in post-stroke patients using the stroke-specific quality of life (SS-QOL) scale and to identify variables that may affect the QOL after stroke. Methods: A prospective cross-sectional study, included 80 stroke patients, was conducted in the Neurology department at King Fahad Hospital of the University (KFHU), Khobar, Saudi Arabia, from December 2019 to February 2020. Stroke patients were interviewed using the Arabic version of the SS-QOL questionnaire and modified Rankin scale (mRS). Results: The overall quality of life in the surveyed participants was at the level of 3.72 points, which is above the average recognized in the middle of the scale that ranges from 1 to 5. The overall quality of life was not significantly correlated with sex, age, type of stroke, recurrence of stroke, and time since stroke (p>0.05). Hypertension and atrial fibrillation were the only comorbidities that were determined to be significantly associated with the overall quality of life at the level of (3.53), and (2.97) respectively (p<0.05). There was a statistically significant correlation between the mRS score and the overall quality of life (p<0.05). Conclusion: Performing a comprehensive assessment of the overall QOL in post-stroke patients will result in better health outcomes, particularly in terms of quality of functioning in psycho-social aspects.
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Affiliation(s)
- Sarah M Alotaibi
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Horia M Alotaibi
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Amira M Alolyani
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Fawziah A Abu Dali
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Alaa K Alshammari
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Amani A Alhwiesh
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Danya M Gari
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Inam Khuda M Q Khuda
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Christopher A Vallabadoss
- From the College of Medicine (Alotaibi S, Alotaibi H, Alolyani, Abudalli, Alshammari, Alhwiesh), from the Department of Family Medicine (Gari); and from the Deanship for Quality and Development (Vallabadoss), Department of Neurology (Khuda), College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
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13
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Cantone M, Lanza G, Puglisi V, Vinciguerra L, Mandelli J, Fisicaro F, Pennisi M, Bella R, Ciurleo R, Bramanti A. Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021; 11:70. [PMID: 33430236 PMCID: PMC7825668 DOI: 10.3390/brainsci11010070] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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Affiliation(s)
- Mariagiovanna Cantone
- Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Giuseppe Lanza
- Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy
- Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy
| | - Valentina Puglisi
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Luisa Vinciguerra
- Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; (V.P.); (L.V.)
| | - Jaime Mandelli
- Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy;
| | - Francesco Fisicaro
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Manuela Pennisi
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; (F.F.); (M.P.)
| | - Rita Bella
- Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy;
| | - Rosella Ciurleo
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
| | - Alessia Bramanti
- IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; (R.C.); (A.B.)
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14
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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review. Brain Sci 2021. [PMID: 33430236 DOI: 10.3390/brainsci11010070.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and early target, among others. The strong relationship between arterial hypertension and cerebrovascular diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. However, despite the large amount of data on the preventive strategies and therapeutic measures that can be adopted, the management of high BP in patients with acute cerebrovascular diseases presenting at the emergency department is still an area of debate. Overall, the outcome of stroke patients with high blood pressure values basically depends on the occurrence of hypertensive emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients referred to the emergency department because of an acute cerebrovascular event. This will also focus greater attention on the management of certain stroke-related, time-dependent interventions, such as intravenous thrombolysis and mechanic thrombectomy.
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15
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Abstract
Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.
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Affiliation(s)
- Philip B Gorelick
- From the Division of Stroke and Neurocritical Care, Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University of Medicine, New Orleans, LA (P.K.W.)
| | - Farzaneh Sorond
- Davee Department of Neurology (F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, Dean Emeritus, School of Medicine, University of Virginia Health System, Charlottesville (R.M.C.)
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16
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Baig H, Ashraf MH, Ashraf MA, Khan MA, Mohamed Nazeer MN. An Unexpected Case of Posterior Reversible Encephalopathy Syndrome. Cureus 2020; 12:e10129. [PMID: 33005543 PMCID: PMC7524021 DOI: 10.7759/cureus.10129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
This study presents an 86-year-old gentleman who was admitted under the acute stroke team for a possible posterior cerebral infarct. Radiologic imaging revealed that the diagnosis was in fact posterior reversible encephalopathy syndrome (PRES). Through a process of elimination by means of investigations, the most likely cause was found to be mild hypertension on a background of vascular dementia causing a possible exacerbation of PRES symptoms. A multidisciplinary approach was found to be beneficial, providing safe and effective care for this patient, allowing a brief recovery period and restoration of baseline function and thus minimising permanent sequelae.
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Affiliation(s)
- Hassan Baig
- Department of General Surgery, Ninewells Hospital, Dundee, GBR.,Department of General Surgery, University of Dundee, Dundee, GBR
| | | | | | - Mujahid A Khan
- Department of Neurology, University of Glasgow, Glasgow, GBR
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17
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Zheng XY, Xu XJ, Liu YY, Xu YJ, Pan SX, Zeng XY, Yi Q, Xiao N, Lin LF. Age-standardized mortality, disability-adjusted life-years and healthy life expectancy in different cultural regions of Guangdong, China: a population-based study of 2005-2015. BMC Public Health 2020; 20:858. [PMID: 32503557 PMCID: PMC7275520 DOI: 10.1186/s12889-020-8420-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 02/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Guangdong province is dominated by three cultural regions: Canton, Hakka and Hoklo. However, little is known about the disease burden within these regions, particularly because different population,environmental and socioeconomic risk factors might cause different patterns of mortality, disability-adjusted life-years (DALY), life expectancy and healthy life expectancy (HALE). We aimed to compare the patterns of disease burden in Canton, Hakka and Hoklo regions between 2005 and 2015. METHOD We calculated the mortality, YLL, YLD for 116 diseases for different cultural regions between 2005 and 2015. We calculated the DALYs for 116 causes as the sum of YLLs and YLDs. We estimated the life expectancy and HALE by using sex-specific mortality rates and YLDs for the three cultural regions. RESULTS With a respective reduction of 22.3, 15.8 and 17.8% in 2015 compared with 2005, the age-standardized DALY rates in 2015 was 19,988.0, 14,396.5 and 20,436.6 in Hakka, Canton and Hoklo region. Canton region had a significantly lower mortality and DALYs in most diseases, followed by Hoklo and Hakka regions. The life expectancy and HALE at birth were highest in Canton region in both 2005 and 2015, than in Hoklo and Hakka region. CONCLUSIONS Our findings call for improved public health care via the refinement of policy and effective measures for disease prevention. Understanding the environmental and culture-related risk factors of diseases in Hoklo and Hakka regions may help inform public health sectors to reduce the disease burden and the between-region inequality.
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Affiliation(s)
- Xue-Yan Zheng
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
| | - Xiao-Jun Xu
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
| | - Yi-Yang Liu
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yan-Jun Xu
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
| | - Si-Xing Pan
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Xin-Ying Zeng
- National Center for Chronic and Non-Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Qian Yi
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, Guangzhou, China
| | - Ni Xiao
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China
| | - Li-Feng Lin
- Institute of Non-Communicable Disease Control and Prevention, Guangdong Provincial Center for Disease Control And Prevention, 160 Qunxian Road, Panyu District, Guangzhou, Guangdong, China.
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18
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Nasi LA, Martins SCO, Gus M, Weiss G, de Almeida AG, Brondani R, Rebello LC, DalPizzol A, Fuchs FD, Valença MJM, Wirth LF, Nunes G, Anderson CS. Early Manipulation of Arterial Blood Pressure in Acute Ischemic Stroke (MAPAS): Results of a Randomized Controlled Trial. Neurocrit Care 2020; 30:372-379. [PMID: 30460598 DOI: 10.1007/s12028-018-0642-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION There is uncertainty over the optimal level of systolic blood pressure (SBP) in the setting of acute ischemic stroke (AIS). The aim of this study was to determine the efficacy of the early manipulation of SBP in non-thrombolised patients. The key hypothesis under investigation was that clinical outcomes vary across ranges of SBP in AIS. METHODS 218 patients were randomized within 12 h of AIS to maintain the SBP during 24 h within three ranges: Group 1 140-160 mmHg, Group 2 161-180 mmHg or Group 3 181-200 mmHg. Vasoactive drugs and fluids were used to achieve these targets. Good outcome was defined as a modified Rankin score 0-2 at 90-days. RESULTS The median SBP in the three groups in 24 h was: 153 mmHg, 163 mmHg, and 178 mmHg, respectively, P < 0.0001. Good clinical outcome did not differ among the different groups (51% vs 52% vs 39%, P = 0.27). Symptomatic intracranial hemorrhage (SICH) was more frequent in the higher SBP range (1% vs 2.7% vs 9.1%, P = 0.048) with similar mortality rates. No patient had acute neurological deterioration related to the SBP reduction in the first 24 h. In our logistic regression analysis, the odds of having good clinical outcome was higher in Group 2 (OR 2.83) after adjusting for important confounders. Regardless of the assigned group, the probability of good outcome was 47% in patients who were manipulated to increase the BP, 42% to decrease and 62% in non-manipulated (P = 0.1). Adverse effects were limited to Group 2 (4%) and Group 3 (7.6%) and were associated with the use of norepinephrine (P = 0.05). CONCLUSIONS Good outcome in 90 days was not significantly different among the 3 blood pressure ranges. After logistic regression analysis, the odds of having good outcome was greater in Group 2 (SBP 161-180 mmHg). SICH occurred more frequently in Group 3 (181-200 mmHg).
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Affiliation(s)
- Luiz Antonio Nasi
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.
| | - Sheila Cristina Ouriques Martins
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Miguel Gus
- Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Gustavo Weiss
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Garcia de Almeida
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Rosane Brondani
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia Costa Rebello
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Angélica DalPizzol
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Flávio Danni Fuchs
- Hypertension Group, Cardiology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Maria Júlia Monteiro Valença
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil.,Stroke Division, Neurology Service, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Letícia F Wirth
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil
| | - Gerson Nunes
- Vascular Unit, Emergency Department, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Ramiro Barcelos 2350, Porto Alegre, RS, CEP 90 035-903, Brazil
| | - Craig S Anderson
- The George Institute for Global Health, Royal Prince Alfred Hospital, University of New South Wales, Sydney, Australia
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19
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He M, Panchangam S, Cruz B, Mukherjee D. Underutilization of Cardiac Therapies in Patients with Acute Ischemic Stroke and Elevated Troponin. Cardiovasc Hematol Agents Med Chem 2019; 17:144-151. [PMID: 31629400 DOI: 10.2174/1871525717666191019115338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/27/2019] [Accepted: 09/27/2019] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Recent findings have shown that in Acute Ischemic Stroke (AIS) patients, elevated troponin is associated with increased mortality. However, due to concerns of cerebral hypoperfusion and hemorrhagic transformation, current practice has been slow to apply proven cardiac therapies to these patients. This study aims to determine this rate of utilization. MATERIALS AND METHODS A single-center review of 83 patients with AIS and measured troponin was conducted. Patients were stratified based on elevated and non-elevated troponin. Between groups, we measured the utilization of evidence-based cardiac therapies and used a univariate logistic regression to compare outcomes of mortality, re-hospitalization, recurrent acute ischemic stroke, recurrent acute myocardial infarction, and a composite of these outcomes. RESULTS Of 83 patients, 25 had elevated troponin and 58 had non-elevated troponin. There was no statistical difference in the use of cardiac therapies between the two groups. Adenosine diphosphate P2Y12 antagonists were infrequently used in both elevated and non-elevated troponin groups at 32% vs. 24% (p = 0.64), as were Angiotensin-Converting Enzyme Inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) at 56% vs. 69% (p = 0.38). Those in the elevated troponin group encountered a statistically significant increase in composite endpoint 64% vs. 33% (Odds Ratio [OR] 7.28, 95% Confidence interval [CI] 2.19-28.88, p<0.01). CONCLUSION Cardiac therapies are underutilized in patients with acute ischemic stroke and elevated troponin levels. In turn, this low usage may explain the increase in morbidity and mortality seen in these patients and the use of such therapies should be considered when treating this subset of patients as the cardio protective nature of these therapies may outweigh the risks associated with them in AIS patients.
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Affiliation(s)
- Michael He
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Subhasree Panchangam
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Benjamin Cruz
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
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20
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Gorelick PB, Qureshi S, Farooq MU. Management of blood pressure in stroke. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2019; 3:100021. [PMID: 33447751 PMCID: PMC7803067 DOI: 10.1016/j.ijchy.2019.100021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 10/09/2019] [Indexed: 01/01/2023]
Abstract
Objective In this review and opinion piece, we discuss recent United States (US)-based guidance statements on the management of BP in stroke according to stroke type and stage of stroke. Methods We reviewed the most recent guidance statements on BP control from United States (US)-based organizations such as the American Heart Association/American Stroke Association (AHA/ASA) and American College of Cardiology (ACC), and articles available to the authors in their personal files. Results The key BP target before starting alteplase (t-PA) is < 185/110 mm Hg, and the maintenance BP after tPA administration is < 180/105 mm Hg. For IPH patients with systolic BP between 150 and 220 mm Hg and no contraindication to acute BP reduction therapy, acute lowering to 140 mm Hg systolic BP is safe. For persons with small vessel or lacunar cerebral ischemia, a reasonable BP lowering target is < 130 mm Hg systolic. For primary stroke prevention, the target BP for those with hypertension is < 140/90 mm Hg and self-measured BP is recommended to assist in BP control. Recent study and guidance suggest a BP target of <130/80 mm Hg for both primary and recurrent stroke prevention. BP control is reasonable for the prevention of cognitive decline or dementia. Conclusions BP targets for the proper management of stroke vary by chronological stage of stroke and by stroke subtype. Furthermore, consideration should be given to control of BP variability, especially in the acute phases of stroke, as it may play a role in conferring longer term outcomes. Stroke is an important cause of morbidity and mortality worldwide, and is well suited for prevention and acute treatment with proper BP management. BP targets in acute ischemic stroke vary whether intravenous alteplase is administered or an endovascular intervention is implemented or not. In acute intraparenchymal hemorrhage of the brain (IPH), it is reasonable to lower BP to a systolic level of 140–150 or up to 160 mm Hg. For both first and recurrent stroke prevention it is reasonable to aim for a BP target of <130/80 mm Hg based on the recent data. The revised BP target has been lowered to <130/80 mm Hg for prevention of major cardiovascular outcomes including stroke. Intensive BP control potentially preserves cognition, brain health, and brain structural integrity. Blood pressure variability is a new target for study in the acute treatment and prevention of stroke.
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Affiliation(s)
- Philip B Gorelick
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Translational Neuroscience, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Shakaib Qureshi
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
| | - Muhammad U Farooq
- Hauenstein Neurosciences, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
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Severin R, Wang E, Wielechowski A, Phillips SA. Outpatient Physical Therapist Attitudes Toward and Behaviors in Cardiovascular Disease Screening: A National Survey. Phys Ther 2019; 99:833-848. [PMID: 30883642 PMCID: PMC6602156 DOI: 10.1093/ptj/pzz042] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/14/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Screening the cardiovascular system is an important and necessary component of the physical therapist examination to ensure patient safety, appropriate referral, and timely medical management of cardiovascular disease (CVD) and risk factors. The most basic screening includes a measurement of resting blood pressure (BP) and heart rate (HR). Previous work demonstrated that rates of BP and HR screening and perceptions toward screening by physical therapists are inadequate. OBJECTIVE The purpose was to assess the current attitudes and behaviors of physical therapists in the United States regarding the screening of patients for CVD or risk factors in outpatient orthopedic practice. DESIGN This was a cross-sectional, online survey study. METHODS Data were collected from an anonymous adaptive online survey delivered via an email list. RESULTS A total of 1812 surveys were included in this analysis. A majority of respondents (n = 931; 51.38%) reported that at least half of their current caseload included patients either with diagnosed CVD or at moderate or greater risk of a future occurrence. A total of 14.8% of respondents measured BP and HR on the initial examination for each new patient. The most commonly self-reported barriers to screening were lack of time (37.44%) and lack of perceived importance (35.62%). The most commonly self-reported facilitators of routine screening were perceived importance (79.48%) and clinic policy (38.43%). Clinicians who managed caseloads with the highest CVD risk were the most likely to screen. LIMITATIONS Although the sampling population included was large and representative of the profession, only members of the American Physical Therapy Association Orthopaedic Section were included in this survey. CONCLUSIONS Despite the high prevalence of patients either diagnosed with or at risk for CVD, few physical therapists consistently included BP and HR on the initial examination. The results of this survey suggest that efforts to improve understanding of the importance of screening and modifications of clinic policy could be effective strategies for improving rates of HR and BP screening.
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Affiliation(s)
- Richard Severin
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, 1919 W. Taylor St, Room 506G, MC 898, Chicago, IL 60612 (USA)
| | - Edward Wang
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, (USA)
| | - Adam Wielechowski
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, (USA)
| | - Shane A Phillips
- Department of Physical Therapy, College of Applied Health Sciences, University of Illinois at Chicago, (USA)
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Abstract
How to cite this article: Jain V, Choudhary J, Pandit R. Blood Pressure Target in Acute Brain Injury. Indian J Crit Care Med 2019;23(Suppl 2):S136–S139.
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Affiliation(s)
- Vivek Jain
- Department of Critical Care Medicine, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
| | - Jitendra Choudhary
- Department of Critical Care Medicine, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
| | - Rahul Pandit
- Department of Critical Care Medicine, Fortis Hospital, Mulund, Mumbai, Maharashtra, India
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[Arterial hypertension in old age with the focus on 80]. Z Gerontol Geriatr 2018; 51:825-838. [PMID: 30402738 DOI: 10.1007/s00391-018-1454-0] [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: 06/20/2018] [Revised: 08/31/2018] [Accepted: 09/18/2018] [Indexed: 10/27/2022]
Abstract
Untreated high blood pressure in old age increases the risk of secondary diseases, especially stroke, coronary heart disease, myocardial infarction and heart failure and should be treated according to the guidelines. For slightly frail people up to the age of 80 years, a systolic blood pressure of 130-139 mm Hg (measured in the doctors surgery) should be the aim. According to the current European guidelines the same values are recommended for those over the age of 80 years but treatment should start at a systolic blood pressure of ≥160 mm Hg. In physically disabled and very frail older people an individually tailored approach is recommended, regardless of age. The authors recommend a target systolic value <150 mm Hg but not below 130/70 mm Hg. In the event of poor tolerance the treatment should be adapted further as necessary. Antihypertensive medication should be selected under the aspects of polypharmacy. In many cases arterial hypertension in old age can be treated in accordance with the guidelines, taking multimorbidity and the interaction of medications into consideration.
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Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage. Curr Opin Neurol 2018; 31:8-13. [DOI: 10.1097/wco.0000000000000508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Regenhardt RW, Das AS, Stapleton CJ, Chandra RV, Rabinov JD, Patel AB, Hirsch JA, Leslie-Mazwi TM. Blood Pressure and Penumbral Sustenance in Stroke from Large Vessel Occlusion. Front Neurol 2017; 8:317. [PMID: 28717354 PMCID: PMC5494536 DOI: 10.3389/fneur.2017.00317] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 12/11/2022] Open
Abstract
The global burden of stroke remains high, and of the various subtypes of stroke, large vessel occlusions (LVOs) account for the largest proportion of stroke-related death and disability. Several randomized controlled trials in 2015 changed the landscape of stroke care worldwide, with endovascular thrombectomy (ET) now the standard of care for all eligible patients. With the proven success of this therapy, there is a renewed focus on penumbral sustenance. In this review, we describe the ischemic penumbra, collateral circulation, autoregulation, and imaging assessment of the penumbra. Blood pressure goals in acute stroke remain controversial, and we review the current data and suggest an approach for induced hypertension in the acute treatment of patients with LVOs. Finally, in addition to reperfusion and enhanced perfusion, efforts focused on developing therapeutic targets that afford neuroprotection and augment neural repair will gain increasing importance. ET has revolutionized stroke care, and future emphasis will be placed on promoting penumbral sustenance, which will increase patient eligibility for this highly effective therapy and reduce overall stroke-related death and disability.
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Affiliation(s)
- Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Alvin S. Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Christopher J. Stapleton
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Ronil V. Chandra
- Interventional Neuroradiology, Monash Imaging, Monash Health, Monash University, Melbourne, VIC, Australia
| | - James D. Rabinov
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B. Patel
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua A. Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Thabele M. Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Neuroendovascular Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Zuin M, Rigatelli G, Picariello C, Carraro M, Zonzin P, Roncon L. Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean Arterial Pressure Index (AMAPI). Heart Vessels 2017. [PMID: 28642976 DOI: 10.1007/s00380-017-1012-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute pulmonary embolism (PE) is the third cause of cardiovascular (CV) mortality. We evaluated a new risk index, named Age-Mean Arterial Pressure Index (AMAPI), to predict 30-day CV mortality in patients with acute PE. Data of 209 patients (44.0% male and 56.0% female, mean age 70.58 ± 14.14 years) with confirmed acute PE were retrospectively analysed. AMAPI was calculated as the ratio between age and mean arterial pressure (MAP), which was defined as [systolic blood pressure + (2 × diastolic blood pressure)]/3. To test AMAPI accuracy, a comparison with shock index (SI) and simplified pulmonary embolism severity index (sPESI) was performed. Patients were divided in two groups according their hemodynamic stability, or not, at admission. 30-day mortality rate, in all cases for CV events, was 10.5% (n = 22). Hemodynamically unstable patients had a higher AMAPI compare to those without hypotension at admission (1.28 ± 0.39 vs 0.78 ± 0.27, p < 0.0001). Receiving operative curve analyses (ROC) found the optimal cut-off for AMAPI in hemodynamically stable and unstable patients ≥0.9 and ≥0.92, respectively. In both groups, patients with an AMAPI over the cut-off were significantly older, hypotensive (both systolic and diastolic blood pressure), with a higher SI and lower MAP. In hemodynamically stable patients, 30-day CV mortality risk prediction was improved adding AMAPI ≥0.9 to both SI and sPESI (net reclassification improvement-NRI-of 14.2%, p = 0.0006 and 11.5%, p = 0.0002, respectively). In hemodynamically unstable patients NRI was 19.2%, p = 0.006. Mantel-Cox analysis revealed a statistical significant difference in the distribution of survival between hemodynamically stable patients with an AMAPI index ≥0.9 compared to those with an AMAPI <0.89 [log rank (Mantel-Cox) p < 0.0001] and in hemodynamically unstable patients with an AMAPI ≥0.92 [log rank (Mantel-Cox) p = 0.001]. AMAPI ≥0.90 and ≥0.92 predict 30-day CV mortality in hemodynamically stable and unstable patients with acute PE.
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Affiliation(s)
- Marco Zuin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.,Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Gianluca Rigatelli
- Unit of Cardiovascular Diagnosis and Endoluminal Interventions, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Claudio Picariello
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Mauro Carraro
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Pietro Zonzin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy
| | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.
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Bucholz EM, Butala NM, Normand SLT, Wang Y, Krumholz HM. Association of Guideline-Based Admission Treatments and Life Expectancy After Myocardial Infarction in Elderly Medicare Beneficiaries. J Am Coll Cardiol 2017; 67:2378-2391. [PMID: 27199062 DOI: 10.1016/j.jacc.2016.03.507] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 02/29/2016] [Accepted: 03/08/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guideline-based admission therapies for acute myocardial infarction (AMI) significantly improve 30-day survival, but little is known about their association with long-term outcomes. OBJECTIVES This study evaluated the association of 5 AMI admission therapies (aspirin, beta-blockers, acute reperfusion therapy, door-to-balloon [D2B] time ≤90 min, and time to fibrinolysis ≤30 min) with life expectancy and years of life saved after AMI. METHODS We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI, with 17 years of follow-up. Life expectancy and years of life saved after AMI were calculated using Cox proportional hazards regression with extrapolation using exponential models. RESULTS Survival for recipients and non-recipients of the 5 guideline-based therapies diverged early after admission and continued to diverge during 17-year follow-up. Receipt of aspirin, beta-blockers, and acute reperfusion therapy on admission was associated with longer life expectancy of 0.78 (standard error [SE]: 0.05), 0.55 (SE: 0.06), and 1.03 (SE: 0.12) years, respectively. Patients receiving primary percutaneous coronary intervention (PCI) within 90 min lived 1.08 (SE: 0.49) years longer than patients with D2B times >90 min, and door-to-needle (D2N) times ≤30 min were associated with 0.55 (SE: 0.12) more years of life. A dose-response relationship was observed between longer D2B and D2N times and shorter life expectancy after AMI. CONCLUSIONS Guideline-based therapy for AMI admission is associated with both early and late survival benefits, and results in meaningful gains in life expectancy and large numbers of years of life saved in elderly patients.
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Affiliation(s)
- Emily M Bucholz
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Yale School of Medicine and Yale School of Public Health, New Haven, Connecticut
| | - Neel M Butala
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yun Wang
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Connecticut; Section of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut.
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Yeung SE, Loken Thornton W. "Do it-yourself": Home blood pressure as a predictor of traditional and everyday cognition in older adults. PLoS One 2017; 12:e0177424. [PMID: 28520751 PMCID: PMC5435167 DOI: 10.1371/journal.pone.0177424] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/27/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Hypertension guidelines recommend home blood pressure (HBP) monitoring in adjunct to office blood pressure (OBP) for its greater reproducibility and prognostic utility in the prevention of cardiovascular outcomes, especially stroke. To date, the relationship between HBP and cognitive function remains unexplored. METHODS We examined HBP as a cognitive predictor in a multi-ethnic group of community-dwelling adults aged 60 and over (N = 133) using neuropsychological measures and analyzed the data using multiple regression analyses. We also employed "everyday cognition" measures that have been found to have higher prognostic utility for real-world functioning than traditional cognitive tasks. RESULTS Good to perfect HBP monitoring compliance over seven days was achieved by 88.7% of the participants with superior reliability (ICC≥.96) to office readings. Higher home systolic BP and pulse pressure predicted worse processing speed, executive function, and everyday cognitive function, whereas lower home diastolic BP predicted worse everyday cognition. Office readings were similarly associated with everyday cognitive function but with no other cognitive measures. CONCLUSION Our findings are the first to validate HBP as a predictor of neuropsychological function in older adults beyond cognitive screening. Differential relationships among blood pressure variables and specific cognitive domains were observed. With proper standardization and training, we demonstrated that HBP can be obtained in a multi-ethnic community-dwelling older adult cohort. Our findings emphasize the importance of employing blood pressure and cognitive measures that are adequately sensitive to detect vascular-related cognitive impairment in a relatively healthy population. Implications regarding proper HBP measurement for hypertension management, cognitive health, and everyday function are discussed.
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Affiliation(s)
- Sophie E Yeung
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Wendy Loken Thornton
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
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Delays in door-to-needle time for acute ischemic stroke in the emergency department: A comprehensive stroke center experience. J Neurol Sci 2017; 376:102-105. [DOI: 10.1016/j.jns.2017.03.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 02/19/2017] [Accepted: 03/02/2017] [Indexed: 11/22/2022]
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Theofanidis D, Gibbon B. Nursing interventions in stroke care delivery: An evidence-based clinical review. JOURNAL OF VASCULAR NURSING 2016; 34:144-151. [DOI: 10.1016/j.jvn.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/02/2016] [Accepted: 07/06/2016] [Indexed: 10/20/2022]
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Abstract
This article discusses interesting vascular neurology cases including the management of intracranial stenosis, migraine headache and stroke risk, retinal artery occlusions associated with impaired hearing, intracranial occlusive disease, a heritable cause of stroke and vascular cognitive impairment, and an interesting clinico-neuroradiologic disorder associated with eclampsia.
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Affiliation(s)
- Muhammad U Farooq
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, 200 Jefferson Street Southeast, Grand Rapids, MI 49503, USA.
| | - Philip B Gorelick
- Department Translational Science & Molecular Medicine, Mercy Health Hauenstein Neurosciences, Michigan State University College of Human Medicine, 220 Cherry Street Southeast, Room H 3037, Grand Rapids, MI 49503, USA
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Xiong L, Lin W, Han J, Chen X, Leung T, Soo Y, Wong KS. Enhancing cerebral perfusion with external counterpulsation after ischaemic stroke: how long does it last? J Neurol Neurosurg Psychiatry 2016; 87:531-6. [PMID: 25934015 DOI: 10.1136/jnnp-2014-309842] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 04/13/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE External counterpulsation (ECP) is a non-invasive method used to augment cerebral perfusion in ischaemic stroke. We aimed to investigate time-course effects on blood pressure elevation and cerebral blood flow augmentation induced by ECP in ischaemic stroke. METHODS Patients with acute unilateral ischaemic stroke and large artery occlusive disease were recruited to receive 35 daily 1 h ECP treatment sessions. Serial transcranial Doppler monitoring of bilateral middle cerebral arteries was performed on days 3, 5, 7, 10, 14, 21, 28 and 35 after stroke onset. Flow velocity changes before, during and after ECP and continuous beat-to-beat blood pressure data were recorded. The cerebral augmentation index (CAI) is the increase in the percentage of the middle cerebral artery mean flow velocity during ECP compared with baseline. RESULTS The CAI in patients with stroke was significantly higher on the ipsilateral side and on the contralateral side on day 3 (ipsilateral CAI, 9.3%; contralateral CAI, 7.2%), day 5 (7.0%; 6.7%), day 7 (6.8%; 6.0%), day 10 (6.0%; 5.1%), day 14 (4.7%; 2.6%) and day 21 (4.1%; 2.2%) after stroke onset than that in controls (-2.0%) (all p<0.05). There was a significant trend of decreasing CAI on the ipsilateral and contralateral sides over time after a stroke. Differences in the percentage increase in the mean blood pressure did not change significantly over time in patients with stroke. CONCLUSIONS Blood pressure elevation persists throughout ECP treatment, which consists of 35 sessions. However, cerebral blood flow augmentation may last at least 3 weeks and then appears to return to baseline 1 month after acute stroke onset.
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Affiliation(s)
- Li Xiong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Wenhua Lin
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Jinghao Han
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Thomas Leung
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yannie Soo
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Ka Sing Wong
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
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Tian G, Xiong L, Lin W, Han J, Chen X, Leung TWH, Soo YOY, Wong LKS. External Counterpulsation Reduces Beat-to-Beat Blood Pressure Variability When Augmenting Blood Pressure and Cerebral Blood Flow in Ischemic Stroke. J Clin Neurol 2016; 12:308-15. [PMID: 27095525 PMCID: PMC4960215 DOI: 10.3988/jcn.2016.12.3.308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE External counterpulsation (ECP) is a noninvasive method used to enhance cerebral perfusion by elevating the blood pressure in ischemic stroke. However, the response of the beat-to-beat blood pressure variability (BPV) in ischemic stroke patients during ECP remains unknown. METHODS We enrolled recent ischemic stroke patients and healthy controls. Changes in the blood flow velocities in bilateral middle cerebral arteries and the continuous beat-to-beat blood pressure before, during, and after ECP were monitored. Power spectral analysis revealed that the BPV included oscillations at very low frequency (VLF; <0.04 Hz), low frequency (LF; 0.04-0.15 Hz), and high frequency (HF; 0.15-0.40 Hz), and the total power spectral density (TP; <0.40 Hz) and LF/HF ratio were calculated. RESULTS We found that ECP significantly increased the systolic and diastolic blood pressures in both stroke patients and controls. ECP decreased markedly the systolic and diastolic BPVs at VLF and LF and the TP, and the diastolic BPV at HF when compared with baseline. The decreases in diastolic and systolic BPV reached 37.56% and 23.20%, respectively, at VLF, 21.15% and 12.19% at LF, 8.76% and 16.59% at HF, and 31.92% and 23.62% for the total TP in stroke patients, which did not differ from those in healthy controls. The change in flow velocity on the contralateral side was positively correlated with the total TP systolic BPV change induced by ECP (r=0.312, p=0.035). CONCLUSIONS ECP reduces the beat-to-beat BPV when increasing the blood pressure and cerebral blood flow velocity in ischemic stroke patients. ECP might be able to improve the clinical outcome by decreasing the beat-to-beat BPV in stroke patients, and this should be explored further in future studies.
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Affiliation(s)
- Ge Tian
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wenhua Lin
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jinghao Han
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Xiangyan Chen
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Thomas Wai Hong Leung
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yannie Oi Yan Soo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Lawrence Ka Sing Wong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China.
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Zhou M, Wang H, Zhu J, Chen W, Wang L, Liu S, Li Y, Wang L, Liu Y, Yin P, Liu J, Yu S, Tan F, Barber RM, Coates MM, Dicker D, Fraser M, González-Medina D, Hamavid H, Hao Y, Hu G, Jiang G, Kan H, Lopez AD, Phillips MR, She J, Vos T, Wan X, Xu G, Yan LL, Yu C, Zhao Y, Zheng Y, Zou X, Naghavi M, Wang Y, Murray CJL, Yang G, Liang X. Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013. Lancet 2016; 387:251-72. [PMID: 26510778 DOI: 10.1016/s0140-6736(15)00551-6] [Citation(s) in RCA: 951] [Impact Index Per Article: 118.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China. METHODS Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013. FINDINGS All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990. INTERPRETATION Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems. FUNDING China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.
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Affiliation(s)
- Maigeng Zhou
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China; Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Haidong Wang
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Jun Zhu
- National Office of MCH Surveillance of China, Chengdu, China
| | - Wanqing Chen
- Cancer Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - Linhong Wang
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China
| | - Shiwei Liu
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China
| | - Yichong Li
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China
| | - Lijun Wang
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yunning Liu
- National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, China
| | - Peng Yin
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jiangmei Liu
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shicheng Yu
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Feng Tan
- National Institute of Occupational Health and Poison Control, Beijing, China
| | - Ryan M Barber
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Matthew M Coates
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Daniel Dicker
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Maya Fraser
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Diego González-Medina
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Hannah Hamavid
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Yuantao Hao
- School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Guoqing Hu
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, China
| | - Guohong Jiang
- Tianjin Centers for Disease Control and Prevention, Tianjin, China
| | | | - Alan D Lopez
- University of Melbourne, Melbourne, VIC, Australia
| | - Michael R Phillips
- School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Emory University, Atlanta, GA, USA
| | - Jun She
- Zhongshan Hospital, Shanghai, China
| | - Theo Vos
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Xia Wan
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Beijing, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | | | - Chuanhua Yu
- Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, China; Global Health Institute, Wuhan University, Wuhan, China
| | - Yong Zhao
- Chongqing Medical University, Chongqing, China
| | - Yingfeng Zheng
- Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiaonong Zou
- Cancer Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - Mohsen Naghavi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Yu Wang
- Chinese Center for Disease Control and Prevention, Beijing, China
| | - Christopher J L Murray
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | | | - Xiaofeng Liang
- Chinese Center for Disease Control and Prevention, Beijing, China.
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Abstract
Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and significant disability among survivors. The management of ICH has been influenced by the results of several major trials completed in the last decade. It is now recognized that hematoma expansion is a major cause of morbidity and mortality. However, efforts to improve clinical outcome through mitigation of hematoma expansion have so far been unsuccessful. Acute blood pressure management has recently been shown to be safe in the setting of acute ICH but there was no reduction in mortality with early blood pressure (BP) lowering. Two large trials of surgical evacuation of supratentorial ICH have not shown improvement in outcome with surgery, thus minimally invasive surgical strategies are currently being studied. Lastly, a better understanding of the pathophysiology of ICH has led to the identification of several new mechanisms of injury that could be potential therapeutic targets.
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Affiliation(s)
- Venkatesh Aiyagari
- a Department of Neurological Surgery and Neurology and Neurotherapeutics , University of Texas Southwestern Medical Center , Dallas , TX , USA
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Toth P, Csiszar A, Sosnowska D, Tucsek Z, Cseplo P, Springo Z, Tarantini S, Sonntag WE, Ungvari Z, Koller A. Treatment with the cytochrome P450 ω-hydroxylase inhibitor HET0016 attenuates cerebrovascular inflammation, oxidative stress and improves vasomotor function in spontaneously hypertensive rats. Br J Pharmacol 2015. [PMID: 23194285 DOI: 10.1111/bph.12079] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Hypertension increases cerebrovascular oxidative stress and inflammation and impairs vasomotor function. These pathological alterations lead to dysregulation of cerebral blood flow and exacerbate atherogenesis, increasing the morbidity of ischaemic cerebrovascular diseases and promoting vascular cognitive impairment. We aimed to test the hypothesis that increased production of the arachidonic acid metabolite 20-hydroxy-5,8,11,14-eicosatetraenoic acid (20-HETE) contributes to hypertension-induced cerebrovascular alterations. EXPERIMENTAL APPROACH We treated male spontaneously hypertensive rats (SHR) with HET0016 (N-hydroxy-N'-(4-butyl-2-methylphenyl)-formamidine), an inhibitor of 20-HETE synthesis. In middle cerebral arteries (MCAs) of SHRs, we focused on vasomotor responses and end points that are highly relevant for cellular reactive oxygen species (ROS) production, inflammatory cytokine expression and NF-κB activation. KEY RESULTS SHRs treated with HET0016 remained hypertensive (SHR + HET0016: 149 ± 8 mmHg, Wistar-Kyoto rat: 115 ± 4 mmHg; P < 0.05.), although their systolic blood pressure was decreased compared to untreated SHRs (191 ± 6 mmHg). In MCAs of SHRs, flow-induced constriction was increased, whereas ACh- and ATP-induced dilations were impaired. This functional impairment was reversed by treatment with HET0016. Treatment with HET0016 also significantly decreased oxidative stress in MCAs of SHRs (as shown by dihydroethidium staining and analysis of vascular 5-nitrotyrosine, 4-hydroxynonenal and carbonyl content) and inhibited cerebrovascular inflammation (shown by the reduced mRNA expression of TNFα, IL-1β and IL-6). Treatment of SHRs with HET0016 also attenuated vascular NF-κB activation. In vitro treatment with 20-HETE significantly increased vascular production of ROS and promoted NF-κB activation in cultured cerebromicrovascular endothelial cells. CONCLUSIONS AND IMPLICATIONS Taken together, treatment with HET0016 confers anti-oxidative and anti-inflammatory effects in the cerebral arteries of SHRs by disrupting 20-HETE-mediated autocrine/paracrine signalling pathways in the vascular wall. It is likely that HET0016-induced decreases in blood pressure also potentiate the cerebrovascular protective effects of the drug.
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Affiliation(s)
- Peter Toth
- Reynolds Oklahoma Center on Aging, Department of Geriatric Medicine, University of Oklahoma, Oklahoma City, OK 73104, USA
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Gorelick PB. Should blood pressure be lowered in acute ischemic stroke? The CATIS trial. ACTA ACUST UNITED AC 2015; 9:331-3. [PMID: 25979408 DOI: 10.1016/j.jash.2015.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Philip B Gorelick
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI; Hauenstein Neuroscience Center, Mercy Health, Grand Rapids, MI.
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Gorelick PB. Treatment: special conditions: co-existing vascular disease: stroke. ACTA ACUST UNITED AC 2015; 9:320-5; quiz 326-7. [PMID: 25817216 DOI: 10.1016/j.jash.2015.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Nicks B, Henley J, Mfinanga J, Manthey D. Neurologic emergencies in resource-limited settings: A review of stroke care considerations. Afr J Emerg Med 2015. [DOI: 10.1016/j.afjem.2014.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Abstract
Ischaemic stroke is a devastating condition that is the leading cause of disability in the USA. Over the last 2 decades, the focus of management has shifted from secondary stroke prevention to acute treatment. Coordinated care starts in the field with the emergency medical service providers and continues in the ambulance and the emergency department through to the intensive care unit. After diagnosis and stabilization, a major goal is reperfusion therapy with intravenous fibrinolytics. Neuroimaging research is focused on improving patient selection, expanding treatment windows, and increasing the safety of therapeutic intervention. The role of adjunctive intra-arterial and mechanical thrombectomy remains undefined, and methods to improve reperfusion using sonolysis and new-generation fibrinolytics are currently investigational. Treatment in the intensive care unit targets prevention of secondary brain injury through optimization of blood pressure, cerebral perfusion, glucose, and temperature management, ventilation, and oxygenation. The most feared complications include malignant cerebral edema and symptomatic hemorrhagic transformation. Decompressive craniectomy is life saving, but questions regarding patient selection and timing remain. Hyperosmolar agents are currently used to mitigate cerebral edema, but newer agents to prevent the formation of cerebral edema at the molecular level are being studied. We outline a practical approach to current emergency and intensive care management based on consensus guidelines and the best available evidence.
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Yu JM, Kong QY, Schoenhagen P, Shen T, He YS, Wang JW, Zhao YP, Shi DN, Zhong BL. The prognostic value of long-term visit-to-visit blood pressure variability on stroke in real-world practice: a dynamic cohort study in a large representative sample of Chinese hypertensive population. Int J Cardiol 2014; 177:995-1000. [PMID: 25449513 DOI: 10.1016/j.ijcard.2014.09.149] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/25/2014] [Accepted: 09/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The prognostic significance of long-term visit-to-visit blood pressure variability (BPV) has not yet been validated in "real world" hypertensive patients. The aim of the current study is to explore the prognostic value of BPV on stroke in hypertensive patients. METHODS This was a dynamic prospective cohort study based on electronic medical records in Shanghai, China. Hypertensive patients (N=122,636) without history of stroke at baseline, were followed up from 2005 to 2011. The cohort comprised of 4522 stroke patients and 118,114 non-stroke patients during a mean follow-up duration of 48 months. BPV was measured by standard deviation (SD) and the coefficient of variation (CV) of blood pressure. RESULTS The visit-to-visit variability of both systolic blood pressure (SBP) and diastolic blood pressure (DBP) was independently associated with the occurrence of stroke [SD: the hazard ratios (95% confidence intervals) of SBP and DBP were 1.042 (1.021 to 1.064) and 1.052 (1.040 to 1.065); CV: the hazard ratios (95% confidence intervals) of SBP and DBP were 1.183 (1.010 to 1.356) and 1.151 (1.005 to 1.317), respectively]. The hazard ratio values increased along with an increase of the BPV levels of SBP and DBP. The increment effect remained significant after controlling the blood pressure control status of subjects. CONCLUSIONS Increased BPV of both SBP and DBP, independent of the average blood pressure, is a predictor of stroke among community hypertensive patients in real-world clinical practice. The risk of stroke increased along with increased BPV. Stabilizing BPV might be a therapeutic target in hypertension.
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Affiliation(s)
- Jin-ming Yu
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China.
| | - Qun-yu Kong
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Paul Schoenhagen
- Cleveland Clinic, Imaging Institute and Heart & Vascular Institute, Cleveland, OH, USA
| | - Tian Shen
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Yu-song He
- Medical Affairs of Great China Region of Novartis, Beijing, China
| | - Ji-wei Wang
- Institute of Clinical Epidemiology, Key Laboratory of Public Health Safety, Ministry of Education, School of Public Health, Fudan University, Shanghai, China
| | - Yan-ping Zhao
- Shanghai Minhang Center for Disease Control and Prevention, Shanghai, China
| | - Dan-ni Shi
- Medical Affairs of Great China Region of Novartis, Beijing, China
| | - Bao-liang Zhong
- Department of Science and Education, Affiliated Mental Health Center, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Shih HM, Lin WC, Wang CH, Lin LC. Hypertensive Patients Using Thiazide Diuretics as Primary Stroke Prevention Make Better Functional Outcome after Ischemic Stroke. J Stroke Cerebrovasc Dis 2014; 23:2414-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.05.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 05/15/2014] [Accepted: 05/20/2014] [Indexed: 11/28/2022] Open
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Abstract
As per current recommendation, patients with acute ischemic stroke should be offered carotid endarterectomy (CEA) within 24-72 hours. The same applies to patients with recurrent transient ischemic attacks (TIA). This time is usually less for hemodynamic optimization of patients who’ve suffered acute ischemic stroke. Hence’ they are hemodynamically labile and can have accelerated hypertension on induction/extubation. This can have disastrous outcomes. It is a common practice among anesthesiologists to avoid angiotensin converting enzyme(ACE) inhibitors or angiotensin receptor blockers on the day of surgery. This also adds to hypertensive issues perioperatively. Dexmedetomidine is a wonderful drug which can be used during CEA. Due to its centrally mediated sympatholytic effect, it confers good hemodynamic control during induction, intraoperatively, and during extubation. We did a search on PubMed and Google for carotid endarterectomies done under general and locoregional anesthesia during which dexmedetomidine was used. The keywords used by us during the search were as follows: anesthesia, carotid endarterectomy, anesthesia. We also searched for use of dexmedetomidine infusion to attenuate hypertensive response to intubation and for providing stability in major surgeries like CABG, craniotomies, bariatric surgeries, and valve replacements.
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Affiliation(s)
- Abhijit S Nair
- Department of Anesthesia, Yashoda Hospitals, Somajiguda, Hyderabad, Andhra Pradesh, India
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Castilla-Guerra L, del Carmen Fernandez-Moreno M. Letter by Castilla-Guerra and Fernandez-Moreno regarding article, "Does abnormal circadian blood pressure pattern really matter in patients with transient ischemic attack or minor stroke?". Stroke 2014; 45:e130. [PMID: 24846874 DOI: 10.1161/strokeaha.114.005629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lee HR, Ham OK, Lee YW, Cho I, Oh HS, Rha JH. Knowledge, health-promoting behaviors, and biological risks of recurrent stroke among stroke patients in Korea. Jpn J Nurs Sci 2014; 11:112-20. [PMID: 24698647 DOI: 10.1111/jjns.12013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 01/11/2013] [Indexed: 11/27/2022]
Abstract
AIM The study was undertaken to explore stroke knowledge, health-promoting behaviors, and predictors for biological risk profiles of stroke recurrence among stroke patients in Korea. METHODS This study was a cross-sectional descriptive study. Seventy-five stroke patients were recruited from a university medical center. Stroke knowledge, physical functioning, health-promoting life profile (HPLP), and five biological risk factors for stroke recurrence (i.e. systolic and diastolic blood pressure, total cholesterol, blood glucose, and body mass index) were measured. RESULTS The results indicated that 70.0% of the patients selected correct answers in most of the knowledge questions. The mean score for HPLP was 3.08 ± 0.45 (range, 1-4). Twenty-seven percent of patients had their five biological risk factors under control. Education level of 9 years or less and duration of stroke diagnosis within a year were predictors for biological risk profiles of stroke recurrence (F=6.94, P<0.01). CONCLUSION Stroke patients exhibited appropriate stroke knowledge and performed moderate to high levels of health-promoting behaviors. However, 73.2% of patients had uncontrolled risk factor(s) in one or more of the five biological risk factors for stroke recurrence. Nurses should be aware that stroke patients seeking treatments from clinics and hospitals are still at risk of stroke recurrence.
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Affiliation(s)
- Hei Ryun Lee
- Department of Nursing, Inha University, Incheon, Korea
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Feldstein CA. Early treatment of hypertension in acute ischemic and intracerebral hemorrhagic stroke: Progress achieved, challenges, and perspectives. ACTA ACUST UNITED AC 2014; 8:192-202. [DOI: 10.1016/j.jash.2013.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 09/25/2013] [Accepted: 09/27/2013] [Indexed: 10/26/2022]
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Katz BS, Flemming KD. Antithrombotic selection and risk factor management in ischemic stroke and transient ischemic attack. Neurosurg Focus 2014; 36:E10. [PMID: 24380476 DOI: 10.3171/2013.10.focus13402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
In addition to appropriate antithrombotic therapy, the identification and treatment of modifiable ischemic stroke risk factors can reduce the likelihood of recurrent stroke. Neurosurgeons should be knowledgeable of the specific risk factors and general recommendations for ischemic stroke, as they may play a significant role in the management options for patients with intracranial and extracranial atherosclerotic disease. The authors of this article review the indications for and selection of antithrombotics in patients with cerebral ischemia. In addition, the identification and secondary prevention of select risk factors are discussed.
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Affiliation(s)
- Brian S Katz
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
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