Associations between peripheral artery disease and ischemic stroke: implications for primary and secondary prevention

The link between impaired oxygen supply and cognitive decline in peripheral artery disease

Although peripheral artery disease (PAD) primarily affects large arteries outside the brain, PAD is also associated with elevated cerebral vulnerabilities, including greater risks for brain injury (such as stroke), cognitive decline and dementia. In the present review, we aim to evaluate recent literature and extract information on potential mechanisms linking PAD and consequences on the brain. Furthermore, we suggest novel therapeutic avenues to mitigate cognitive decline and reduce risk of brain injury in patients with PAD. Various interventions, notably exercise, directly or indirectly improve systemic blood flow and oxygen supply and are effective strategies in patients with PAD or cognitive decline. Moreover, triggering protective cellular and systemic mechanisms by modulating inspired oxygen concentrations are emerging as potential novel treatment strategies. While several genetic and pharmacological approaches to modulate adaptations to hypoxia showed promising results in preclinical models of PAD, no clear benefits have yet been clinically demonstrated. We argue that genetic/pharmacological regulation of the involved adaptive systems remains challenging but that therapeutic variation of inspired oxygen levels (e.g., hypoxia conditioning) are promising future interventions to mitigate associated cognitive decline in patients with PAD.

Cerebrovascular Events After Transcatheter Edge-to-Edge Repair and Guideline-Directed Medical Therapy in the COAPT Trial

BACKGROUND

Little is known regarding the risk of cerebrovascular events (CVE) in patients with heart failure and severe secondary mitral regurgitation treated with transcatheter edge-to-edge repair (TEER).

OBJECTIVES

The study sought to examine the incidence, predictors, timing, and prognostic impact of CVE (stroke or transient ischemic attack) in the COAPT (Cardiovascular Outcomes Assessment of the Mitraclip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial.

METHODS

A total of 614 patients with heart failure and severe secondary mitral regurgitation were randomized to TEER plus guideline-directed medical therapy (GDMT) vs GDMT alone.

RESULTS

At 4-year follow-up, 50 CVEs occurred in 48 (7.8%) of the 614 total patients enrolled in the COAPT trial; Kaplan-Meier event rates were 12.3% in the TEER group and 10.2 in the GDMT alone group (P = 0.91). Within 30 days of randomization, CVE occurred in 2 (0.7%) patients randomized to TEER and 0% randomized to GDMT (P = 0.15). Baseline renal dysfunction and diabetes were independently associated with increased risk of CVE, while baseline anticoagulation was associated with a reduction of CVE. A significant interaction was present between treatment group and anticoagulation such that TEER compared with GDMT alone was associated with a reduced risk of CVE among patients with anticoagulation (adjusted HR: 0.24; 95% CI: 0.08-0.73) compared with an increased risk of CVE in patients without anticoagulation (adjusted HR: 2.27; 95% CI: 1.08-4.81; P_interaction = 0.001). CVE was an independent predictor of death within 30 days after the event (HR: 14.37; 95% CI: 7.61, 27.14; P < 0.0001).

CONCLUSIONS

In the COAPT trial, the 4-year rate of CVE was similar after TEER or GDMT alone. CVE was strongly associated with mortality. Whether anticoagulation is effective at reducing CVE risk after TEER warrants further study. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] and COAPT CAS [COAPT); NCT01626079).

The Association between Ankle-Brachial Index/Pulse Wave Velocity and Cerebral Large and Small Vessel Diseases in Stroke Patients

(1) Background: The study investigated whether the ankle-brachial index (ABI) and pulse wave velocity (baPWV) could reflect the severity of small vessel disease (SVD) and large artery atherosclerosis (LAA). (2) Methods: A total of 956 consecutive patients diagnosed with ischemic stroke were prospectively enrolled from July 2016 to December 2017. SVD severity and LAA stenosis grades were evaluated via magnetic resonance imaging and carotid duplex ultrasonography. Correlation coefficients were calculated between the ABI/baPWV and measurement values. Multinomial logistic regression analysis was performed to determine predictive potential. (3) Results: Among the 820 patients included in the final analysis, the stenosis grade of extracranial and intracranial vessels was inversely correlated with the ABI (p < 0.001, respectively) and positively correlated with the baPWV (p < 0.001 and p = 0.004, respectively). Abnormal ABI, not baPWV, independently predicted the presence of moderate (adjusted odds ratio, aOR: 2.18, 95% CI: 1.31-3.63) to severe (aOR: 5.59, 95% CI: 2.21-14.13) extracranial vessel stenosis and intracranial vessel stenosis (aOR: 1.89, 95% CI: 1.15-3.11). Neither the ABI nor baPWV was independently associated with SVD severity. (4) Conclusions: ABI is better than baPWV in screening for and identifying the existence of cerebral large vessel disease, but neither test is a good predictor of cerebral SVD severity.

Can Sublingual Nitrate Improve Visualization of Lower Limb Arteries on Computed Tomography Angiography?

OBJECTIVE

The aim of the study is to evaluate the role of sublingual nitrate in improving vessel visualization on peripheral computed tomography angiography (CTA).

METHODS

Fifty patients clinically diagnosed with peripheral arterial disease of the lower limb were prospectively included in this study: Twenty-five underwent CTA after sublingual nitrate administration (nitrate group) and 25 without (non-nitrate group). Two blinded observers qualitatively and quantitatively assessed the data thus generated. The mean luminal diameter, intraluminal attenuation, site, and percentage of stenosis were evaluated in all segments. Assessment of collateral visualization at sites of significant stenosis was also done.

RESULTS

Patients in the nitrate and non-nitrate groups were similar in age and sex characteristics (P > 0.05).On subjective evaluation, there was significantly improved visualization of the femoropopliteal and tibioperoneal vasculature of the lower limb in the nitrate group compared with the non-nitrate group (P < 0.05). Quantitative evaluation showed a statistically significant difference in the measured arterial diameters for all evaluated segments in the nitrate group versus the non-nitrate group (P < 0.05). Intra-arterial attenuation was significantly greater for all segments in the nitrate group resulting in better contrast opacification in these studies. Collateral visualization around segments with more than 50% stenosis/occlusion was also better in the nitrate group.

CONCLUSIONS

Our study suggests that nitrate administration before peripheral vascular CTA can improve visualization, especially in the distal segments by increasing the vessel diameter and intraluminal attenuation along with better delineation of the collateral circulation around stenotic areas. It may also improve the number of evaluable segments of vasculature in these angiographic studies.

Therapeutic angiogenesis-based strategy for peripheral artery disease

Peripheral artery disease (PAD) poses a great challenge to society, with a growing prevalence in the upcoming years. Patients in the severe stages of PAD are prone to amputation and death, leading to poor quality of life and a great socioeconomic burden. Furthermore, PAD is one of the major complications of diabetic patients, who have higher risk to develop critical limb ischemia, the most severe manifestation of PAD, and thus have a poor prognosis. Hence, there is an urgent need to develop an effective therapeutic strategy to treat this disease. Therapeutic angiogenesis has raised concerns for more than two decades as a potential strategy for treating PAD, especially in patients without option for surgery-based therapies. Since the discovery of gene-based therapy for therapeutic angiogenesis, several approaches have been developed, including cell-, protein-, and small molecule drug-based therapeutic strategies, some of which have progressed into the clinical trial phase. Despite its promising potential, efforts are still needed to improve the efficacy of this strategy, reduce its cost, and promote its worldwide application. In this review, we highlight the current progress of therapeutic angiogenesis and the issues that need to be overcome prior to its clinical application.

Cardiac Rehabilitation and Mortality Risk Reduction in Peripheral Artery Disease at 6-Month Outcome

The management of patients with peripheral artery disease (PAD) is integrative and multidisciplinary, in which cardiac rehabilitation (CR) plays a prognostic role in terms of functional status, quality of life, and long-term impact on morbidity and mortality. We conducted a prospective cohort study on 97 patients with PAD admitted to a single tertiary referral center. Based on a prognostic index developed to stratify long-term mortality risk in PAD patients, we divided the cohort into two groups: low and low-intermediate risk group (45 cases) and high-intermediate and high risk group (52 cases). We analyzed demographics, clinical parameters, and paraclinical parameters in the two groups, as well as factors associated with cardiological reassessment prior to the established deadline of 6 months. Obesity (p = 0.048), renal dysfunction (p < 0.001), dyslipidemia (p < 0.001), tobacco use (p = 0.048), and diabetes mellitus (p < 0.001) are comorbidities with long-term prognostic value. Low-density lipoprotein cholesterol (p = 0.002), triglycerides (p = 0.032), fasting glucose (p = 0.011), peak oxygen uptake (p = 0.005), pain-free walking distance (p = 0.011), maximum walking time (p < 0.001), and maximum walking distance (p = 0.002) influence the outcome of PAD patients by being factors associated with clinical improvement at the 6-month follow-up. PAD patients benefit from enrollment in CR programs, improvement of clinical signs, lipid and carbohydrate profile, and weight loss and maintenance of blood pressure profile within normal limits, as well as increased exercise capacity being therapeutic targets.

Impact of Sarcopenia on Functional Outcomes Among Patients With Mild Acute Ischemic Stroke and Transient Ischemic Attack: A Retrospective Study

Introduction

Sarcopenia, a age-related disease characterized by loss of muscle mass accompanied by loss of function, is associated with nutrition imbalance, physical inactivity, insulin resistance, inflammation, metabolic syndrome, and atherosclerosis which are risk factors for cardiovascular disease. However, its association with outcomes after ischemic stroke has not been well-established. This study investigated whether functional outcomes of patients with acute ischemic stroke is associated with sarcopenia.

Methods

Data were collected from 568 consecutive patients with acute ischemic stroke with National Institute of Health Stroke Scale 0–5 or transient ischemic attack who underwent bioelectrical impedance analysis between March 2018 and March 2021. Sarcopenia was defined, as low muscle mass, as measured by bioelectrical impedance analysis, and low muscle strength, as indicated by the Medical Research Council score. Unfavorable functional outcome was defined as mRS score of 2–6 at 90 days after discharge. The relationship between functional outcomes and the presence of sarcopenia or its components was determined.

Results

Of the 568 patients included (mean age 65.5 ± 12.6 years, 64.6% male), sarcopenia was detected in 48 (8.5%). After adjusting for potential confounders, sarcopenia was independently and significantly associated with unfavorable functional outcome (odds ratio 2.37, 95% confidence interval 1.15–4.73 for unfavorable functional outcome, odds ratio 2.10, 95% confidence interval 1.18–3.71 for an increase in the mRS score). Each component of sarcopenia was also independently associated with unfavorable functional outcome (odds ratio 1.76, 95% confidence interval 1.05–2.95 with low muscle mass, odds ratio 2.64, 95% confidence interval 1.64–4.23 with low muscle strength). The impact of low muscle mass was larger in men than in women, and in patients with lower muscle mass of the lower extremities than in those with lower muscle mass of the upper extremities.

Conclusions

In this study, the prevalence of sarcopenia in patients with stroke was lower than most of previous studies and patients with sarcopenia showed higher likelihood for unfavorable functional outcomes at 90 days after acute ischemic stroke or TIA. Further investigation of the interventions for treating sarcopenia and its impact on the outcome of ischemic stroke patients is needed.

Low Toe-Brachial Index Is Associated With Stroke Outcome Despite Normal Ankle-Brachial Index

Introduction: We investigated whether the toe-brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle-brachial index (ABI). Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4. Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7-54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial-ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114-0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095-0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135-2.400], all-cause mortality (HR 2.105, 95% CI 1.343-3.298), and MACE (HR 1.838, 95% CI 1.396-2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080-2.618), all-cause mortality (HR 2.075, 95% CI 1.180-3.651), and MACE (HR 1.619, 95% CI 1.149-2.281) in patients with normal ABI. Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

Survival of Patients Following First Diagnosis of Diabetic Foot Complications: A Nationwide 15-Year Longitudinal Analysis

Background and Aims

The long-term survival in people with type 2 diabetes following first diagnosis of diabetic foot complications (FDDFC) is unclear. The object is to evaluate the mortality rate in subjects with type 2 diabetes following FDDFC and the impacts of the major cardiovascular comorbidities.

Methods

Nationwide data were analyzed for subjects with T2D and DFC between 2003 and 2017 according to ICD-9 coding. DFC was defined with the codes of ulcers, infections, or severe peripheral artery disease that required intervention (PAD) to mimic the real world diagnosis. Criteria of FDDFC were preceded by a period without any DFC for at least 5 years. Major cardiovascular comorbidities: established PAD and cardiovascular diseases (CVD: including coronary heart disease (CHD), stroke, or heart failure) before the index date as well as lower-extremity amputations (LEA) at the index episode were analyzed.

Results

Among 300,115 subjects with DFC, a total of 103,396 patients had FDDFC. The mean 5-year survival rate of these subjects was 81.05%. Using subjects without associated major cardiovascular comorbidity as baseline, the adjusted hazard ratios (aHR) were1.43 (95% confidence interval 1.38-1.49) in group PAD-/CVD+, followed by 1.70 (1.59-1.80) in PAD+/CVD- and 1.98 (1.89-2.08) in PAD+/CVD+. The aHR was further increased in patients with PAD who additionally had heart failure (3.77, 3.50-4.05), stroke (2.06, 1.95-2.18), or CHD (1.89, 1.79-2.00). Subjects with PAD rather than other CVD were associated with LEA at FDDFC. Patients with major LEA (above the ankle) at FDDFC episode had lower 5-year survival rate (65.01%) followed by those with minor LEA (72.24%) and without LEA (81.61%).

Conclusions

Cardiovascular comorbidity as well as LEA status at the event of FDDFCs were both associated with patient survival outcomes. Earlier identification of this large population could lead to higher survival rates.

Sex differences in predictors for cognitive decline and dementia in people with stroke or transient ischemic attack in the PROGRESS trial

BACKGROUND

Stroke and transient ischemic attack confer greater risk of cognitive decline and dementia.

AIMS

We used data from the Perindopril Protection Against Recurrent Stroke Study (PROGRESS), a blood pressure-lowering randomized controlled trial in stroke/transient ischemic attack. We evaluated overall and sex-specific differences in treatment effects for cognitive decline/dementia, as well as associations with vascular and stroke-specific predictors,considering death as a competing risk.

METHODS

Multinomial logistic regression was used to estimate overall and sex-specific odds ratios (OR) (95% confidence intervals (CI)) for treatment effects and predictors associated with the risk of cognitive decline/dementia, and the women-to-men ratio of odds ratio (RORs).

RESULTS

Over a median four years, 763 cognitive decline/dementia (30.9% women) were recorded in 5888 participants. Women had lower odds of cognitive decline/dementia than men (OR 0.78, 95%CI 0.63-0.95). Active treatment was associated with lower odds of cognitive decline/dementia (0.84, 0.72-0.98), with no evidence of sex difference. Higher education (0.96,0.94-0.98 (per year)) and baseline Mini-Mental State Examination (MMSE)) were associated with lower odds of cognitive decline/dementia (0.84,0.82-0.86 (per point higher)). Higher diastolic blood pressure (1.11,1.02-1.20 (per 10 mmHg)), low estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (1.27,1.03-1.58), and peripheral arterial disease (1.78,1.26-2.52) were associated with higher odds of cognitive decline/dementia. APOE ɛ4 was not associated with cognitive decline/dementia (1.05 (0.85-1.30)). Low eGFR was more strongly associated with cognitive decline/dementia in women than men (RORs, 1.60 (1.03-2.48)). Diabetes was more strongly associated with men than women.

CONCLUSIONS

Several risk factors were associated with cognitive decline/dementia in people with prior stroke/transient ischemic attack, with notable sex differences. Long-term cognitive sequelae of stroke should be considered to strengthen joint prevention strategies for stroke, cognitive decline, and dementia.Trial Registration: This trial was not registered because enrolment began before 1 July 2005.

Influence of Microalbuminuria on Long-Term Survival and Cardiovascular or Limb Events in Peripheral Arterial Disease

Objective: This study aimed to examine the relationship between microalbuminuria and long-term life expectancy or limb events in patients with peripheral arterial disease (PAD).

Materials and Methods: A prospective cohort study was performed in 714 patients with PAD. The primary outcomes were cardiovascular or cerebrovascular death (CCVD) and all-cause death (AD), and secondary outcomes were major adverse cardiovascular events (MACE) and cardiovascular and/or limb events (CVLE).

Results: The 5, 10, and 15 year survival rates were 82.4%, 53.1%, and 33.0%, respectively. The prevalence of patients with increased microalbuminuria was 39.2%. Higher microalbuminuria, age, C-reactive protein (CRP), lower serum albumin, estimated glomerular filtration rate (eGFR), ankle–brachial pressure index (ABI), diabetes, cerebral infarction, and coronary heart disease (CHD) were associated with CCVD; higher microalbuminuria, age, CRP, D-dimer, lower serum albumin, eGFR, and critical limb ischemia were related to AD; higher microalbuminuria, age, CRP, lower serum albumin, ABI, diabetes, and CHD were related to MACE; higher microalbuminuria, age, lower ABI, cerebral infarction, and CHD were related to CVLE in Cox multivariate analyses (p<0.05). Statins reduced CCVD, AD, MACE, and CVLE (p<0.001).

Conclusion: Higher microalbuminuria was a significant predictor for CCVD, AD, MACE, and CVLE in PAD patients.

Impact of brain natriuretic peptide for predicting long-term life expectancy and cardiovascular or limb events in peripheral arterial disease

BACKGROUND

Brain natriuretic peptide (BNP) is introduced as a predictor of the degree of ventricular dysfunction and is associated with mortality. There are limited reports on the relationship of BNP with long-term all-cause death (AD) and cardiovascular or limb events in peripheral artery disease (PAD). We examined the relationship between BNP level and these events in PAD patients.

METHODS

We performed a prospective cohort study in 938 PAD patients. The patients were divided into four groups based on BNP levels with median (interquartile range): Q1: ≤20.4; Q2: 20.5-42.8; Q3: 42.9-103.4; and Q4: ≥103.5 pg/mL. The endpoints were AD, freedom from major adverse cardiovascular events (MACE), and MACE plus limb events (MALE).

RESULTS

The median follow-up time was 65 months. There were 383 deaths (40.8%) during follow-up period. AD depended on BNP levels (p<0.01), with 5-year freedom from AD rates of Q1: 94%, Q2: 84%, Q3: 69%, and Q4: 55%. The Kaplan-Meier estimates of freedom from AD, MACE, and MALE had significant differences among Q1- Q4 groups (p< 0.001). In multiple regression analysis, BNP had significant negative correlations with eGFR, serum albumin, and BMI and positive correlations with diabetes (p<0.05). In Cox multivariate analysis, higher BNP, age, CRP, D-dimer, lower BMI, ABI, serum albumin, and eGFR were related to AD; and higher BNP, age, lower ABI, serum albumin, CAD, and DM were related to MACE and MALE (p<0.05). Statins improved AD, MACE, and MALE (p<0.01).

CONCLUSIONS

BNP was a promising biomarker for AD, MACE, and MALE in patients with PAD.

Exploring the Impact of Cerebrovascular Disease and Major Depression on Non-diseased Human Tissue Transcriptomes

Background

The development of complex diseases is contributed by the combination of multiple factors and complicated interactions between them. Inflammation has recently been associated with many complex diseases and may cause long-term damage to the human body. In this study, we examined whether two types of complex disease, cerebrovascular disease (CVD) or major depression (MD), systematically altered the transcriptomes of non-diseased human tissues and whether inflammation is linked to identifiable molecular signatures, using post-mortem samples from the Genotype-Tissue Expression (GTEx) project.

Results

Following a series of differential expression analyses, dozens to hundreds of differentially expressed genes (DEGs) were identified in multiple tissues between subjects with and without a history of CVD or MD. DEGs from these disease-associated tissues-the visceral adipose, tibial artery, caudate, and spinal cord for CVD; and the hypothalamus, putamen, and spinal cord for MD-were further analyzed for functional enrichment. Many pathways associated with immunological events were enriched in the upregulated DEGs of the CVD-associated tissues, as were the neurological and metabolic pathways in DEGs of the MD-associated tissues. Eight gene-tissue pairs were found to overlap with those prioritized by our transcriptome-wide association studies, indicating a potential genetic effect on gene expression for circulating cytokine phenotypes.

Conclusion

Cerebrovascular disease and major depression cause detectable changes in the gene expression of non-diseased tissues, suggesting that a possible long-term impact of diseases, lifestyles and environmental factors may together contribute to the appearance of "transcriptomic scars" on the human body. Furthermore, inflammation is probably one of the systemic and long-lasting effects of cerebrovascular events.

Accuracy of Peripheral Arterial Disease Registers in UK General Practice: Case-Control Study

Background:

Approximately 20% of the UK population aged 55 to 75 years have evidence of peripheral arterial disease (PAD). PAD affects quality of life and life expectancy if not appropriately diagnosed and managed. At risk patients require accurate diagnosis to ensure optimal treatment to slow disease progression and minimize adverse outcomes.

Aim:

To assess the accuracy of general practice (GP) registration of the diagnosis of peripheral arterial disease (PAD).

Design and Setting:

An observational analytic case-control study. As part of a National Institute for Health Research–funded (ISRCTN13301188) project assessing novel diagnostic methods set in GP practice.

Methods:

A total of 125 patients registered as having PAD and 125 age- and sex-matched controls were recruited from 15 general practices across North East England. The register was then assessed for accuracy of diagnosis. Duplex vascular ultrasound scanning (DUS) undertaken by vascular scientists was used as the gold standard reference for PAD.

Results:

The PAD register had a sensitivity of 86% (95% CI 77%-92%) and specificity of 74% (95% CI 67%-81%) when compared with DUS. The positive predictive value, however, was 69.6% (95% CI 63%-75%) and negative predictive value 88.8% (95% CI 82%-92%). The overall diagnostic effectiveness of the PAD register was 79.2% (95% CI 73%-84%).

Conclusion:

This analysis indicates that while PAD is detected with reasonable sensitivity in primary care, many patients registered with a diagnosis of PAD lacked DUS-proven disease. Improved approaches to the objective diagnosis of PAD may improve diagnosis and management of PAD in primary care.

Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization

OBJECTIVES

The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk.

METHODS

We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary ICD-9/10-CM discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using ICD-9/10-CM codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods.

RESULTS

Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18-2.31) and 180 days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days.

CONCLUSIONS

Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.

The Costs and Cardiovascular Benefits in Patients With Peripheral Artery Disease From a Fourth-Generation Synchronous Telehealth Program: Retrospective Cohort Study

BACKGROUND

Patients with peripheral artery disease (PAD) are at high risk for major cardiovascular events, including myocardial infarction, stroke, and hospitalization for heart failure. We have previously shown the clinical efficacy of a fourth-generation synchronous telehealth program for some patients, but the costs and cardiovascular benefits of the program for PAD patients remain unknown.

OBJECTIVE

The telehealth program is now widely used by higher-risk cardiovascular patients to prevent further cardiovascular events. This study investigated whether patients with PAD would also have better cardiovascular outcomes after participating in the fourth-generation synchronous telehealth program.

METHODS

This was a retrospective cohort study. We screened 5062 patients with cardiovascular diseases who were treated at National Taiwan University Hospital and then enrolled 391 patients with a diagnosis of PAD. Of these patients, 162 took part in the telehealth program, while 229 did not and thus served as control patients. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to mitigate possible selection bias. Follow-up outcomes included heart failure hospitalization, acute coronary syndrome, stroke, and all-cause readmission during the 1-year follow-up period and through the last follow-up.

RESULTS

The mean follow-up duration was 3.1 (SD 1.8) years for the patients who participated in the telehealth program and 3.2 (SD 1.8) for the control group. The telehealth program patients exhibited lower risk of ischemic stroke than did the control group in the first year after IPTW (0.9% vs 3.5%; hazard ratio [HR] 0.24; 95% CI 0.07-0.80). The 1-year composite endpoint of vascular accident, including acute coronary syndrome and stroke, was also significantly lower in the telehealth program group after IPTW (2.4% vs 5.2%; HR 0.46; 95% CI 0.21-0.997). At the end of the follow-up, the telehealth program group continued to exhibit a significantly lower rate of ischemic stroke than did the control group after IPTW (0.9% vs 3.5%; HR 0.52, 95% CI 0.28-0.93). Furthermore, the medical costs of the telehealth program patients were not higher than those of the control group, whether in terms of outpatient, emergency department, hospitalization, or total costs.

CONCLUSIONS

The PAD patients who participated in the fourth-generation synchronous telehealth program exhibited lower risk of ischemic stroke events over both mid- and long-term follow-up periods. However, larger-scale and prospective randomized clinical trials are needed to confirm our findings.

Features of Antithrombotic Therapy in Patients with Multifocal Arterial Disease

Multifocal arterial injury is common in patients with atherosclerotic cardiovascular diseases and is associated with increased risk of cardiovascular complications and death. Administration of more intensive antithrombotic therapy, particularly combinations of acetylsalicylic acid and a "vascular" dose of rivaroxaban, in patients with multifocal arterial injury is characterized by a beneficial ratio of efficiency and safety due to a pronounced decrease in the risk of cardiovascular complications. Detection of peripheral artery diseases in patients with ischemic heart disease and atherosclerotic cerebrovascular pathology makes it possible to improve the risk stratification, optimize the diagnostic tactics and clarify indications for more intensive antithrombotic therapy.

Abnormal vascular physiology in the lower extremities as a risk factor for ischemic stroke and mortality

CONTEXT

Peripheral artery disease (PAD) is highly prevalent in the general population, affecting up to 25% of patients 55 years of age or older. There is a known association with acute ischemic stroke, but limited large cohort studies exist pertaining to the relationship between PAD severity and incident ischemic stroke.

OBJECTIVES

To evaluate the risk of incident ischemic stroke and mortality along the spectrum of low and elevated ankle brachial index (ABI) measurement.

METHODS

We performed a retrospective extraction of ABI data of all adult patients who underwent lower extremity physiology study for any indication from January 1, 1996 to June 30, 2018 in the Mayo Clinic health system. PAD was categorized into severe, moderate, mild, and borderline based on ABI measurements and poorly compressible arteries (PCA). These were compared with normal ABI measurements. Associations of PAD/PCA with new ischemic stroke events and all cause mortality were analyzed. Hazard ratios (HR) were calculated using multivariable Cox proportional regression with 95% confidence intervals.

RESULTS

A total of 39,834 unique patients were included with a median follow up duration of 4.59 years. All abnormal ABI groups, except borderline PAD, were associated with increased risk of incident ischemic stroke after multivariate regression compared to normal ABI. A severity-dependent association was observed between PAD and ischemic stroke with moderate (HR, 1.22 [95% CI, 1.10-1.35]) and severe (HR, 1.19 [95% CI, 1.02-1.40]) categories conferring similar risk in comparison to normal ABI. Patients with PCA carried the greatest ischemic stroke risk (HR, 1.30 [95% CI, 1.15-1.46]). Similarly, abnormal ABI groups were associated with a significant risk for all cause mortality in a severity-dependent manner, with severe PAD conferring the greatest risk (HR, 3.07 [95% CI, 2.88-3.27]).

CONCLUSIONS

This study adds to the growing body of evidence that both PAD and PCA are independent risk factors for incident ischemic stroke and all cause mortality. The association of PAD severity and PCA with risk of ischemic stroke may help clinicians with risk stratification and determining treatment intensity.

Features of Risk Stratification, Diagnosis and Secondary Prevention in Patients with Multifocal Arterial Disease. Part 1: Risk Stratification and Diagnosis

Multifocal arterial disease is common in patients with atherosclerotic cardiovascular disease and is associated with an increased risk of cardiovascular complications and death. The possibility of improving the prognosis of patients with multifocal arterial disease is associated with a more efficient diagnosis of both the underlying disease and obstructive atherosclerotic lesions of other localizations and with a more intensive secondary prevention. According to observational studies, the presence of significant stenoses of the carotid arteries and, especially, lower extremities arterial disease can be predictorы of similar lesions in other vascular beds and their detection with screening methods available in clinical practice allows improvement of the diagnosis in patients with suspected coronary artery disease. On the other hand, screening of lower extremities artery diseases in patients with acute coronary syndrome can clarify indications for the use of invasive diagnostic and treatment strategy, in patients with chronic coronary artery disease it can justify more aggressive approaches to secondary prevention.

The protective effect of statins against pressure ulcers in stroke patients: A propensity-score matched study based on a real-world database

BACKGROUND AND AIMS

Limited information is available regarding the association between statins and pressure ulcers. The purpose of this study is to evaluate the beneficial effects of statins on pressure ulcers in stroke patients.

METHODS

Using the claims data of Taiwan's National Health Insurance, we conducted a retrospective cohort study and identified new-onset stroke patients in 2000-2004. The propensity-score matching procedure was used to select eligible stroke patients with (n = 49,919) and without (n = 49,919) the use of statins. These two groups were followed until the end of 2009 to track the occurrence of pressure ulcers. Multivariate Cox proportional hazard models were conducted to calculate adjusted hazard rations (HRs) and 95% confidence intervals (CIs) of pressure ulcer associated with the use of statins.

RESULTS

Stroke patients who used statins had a reduced risk of pressure ulcers during the follow-up period (HR 0.74, 95% CI 0.71-0.78). The association between statin use and a reduced risk of poststroke pressure ulcers was significant in men (HR 0.73, 95% CI 0.68-0.78), women (HR 0.75, 95% CI 0.71-0.80), and people aged more than 50 years. Use of lovastatin, pravastatin, rosuvastatin, atrovastatin, fluvastatin, and simvastatin was associated with reduced poststroke pressure ulcers. There was a dose-dependent decrease in the frequency of pressure ulcers with increasing quantities of statins used, from 1 prescription to ≥3 prescriptions.

CONCLUSION

We raised the possibility that use of statins was associated with reduced risk of pressure ulcers in stroke patients. However, the potential beneficial effect associated with statins requires further validation using randomized clinical trials.

The impact of left ventricular diastolic dysfunction for the prognosis in patients with lower extremity arterial disease

Aims

Lower extremity arterial disease (LEAD) and left ventricular diastolic dysfunction (LVDD) share many risk factors, but the characteristics of LVDD and its association with prognosis in patients with LEAD have not been fully examined.

Methods and results

We investigated the impact of LVDD on the clinical outcomes in LEAD patients. LVDD was classified according to the newest suggested classification by the American Society of Echocardiography. Survival analysis for mortality (primary endpoint) and major adverse cardiac events (MACE; secondary endpoint) was calculated with all clinical variables and adjusted by multivariate Cox regression. We consecutively enrolled 221 controls and 464 LEAD patients from outpatient clinics and hospitals. The prevalence of LVDD was proportional to the severity of LEAD defined by the Rutherford class. The difference of LVDD severity is significant when compared with the control and LEAD patients or LEAD patients who underwent endovascular therapy (EVT), and it is also proportional to the LEAD severity. The grade of LVDD was a significant factor in predicting MACE and mortality in LEAD patients after multivariate Cox regression analysis [hazard ratio (HR) = 2.11, 95% CI = 1.47–2.83, P = 0.026; HR = 1.47, 95% CI = 1.02–2.02, P = 0.041]. This impact remained significant in LEAD patients who underwent EVT.

Conclusions

The degree of LVDD may predict MACE and mortality in LEAD patients. Whether early identification of LVDD in LEAD patients is helpful warrants further large‐scale prospective randomized studies.

Clinical outcomes after TAVR with heparin or bivalirudin as periprocedural anticoagulation in patients with and without peripheral arterial disease: Results from the BRAVO-3 randomized trial

OBJECTIVES

This study sought to investigate the clinical outcomes of patients with and without peripheral artery disease (PAD) in the BRAVO-3 trial with respect to the effect of bivalirudin versus unfractionated heparin (UFH).

BACKGROUND

PAD is found frequently in patients undergoing transcatheter aortic valve replacement (TAVR) and is reported to confer an increased risk of adverse events. It is unknown whether patients with and without PAD may demonstrate a differential response to bivalirudin versus UFH.

METHODS

BRAVO-3 was a randomized multicenter trial comparing transfemoral TAVR with bivalirudin versus UFH (31 centers, n = 802). Major adverse cardiovascular events (MACE) were a composite of 30-day death, myocardial infarction, or cerebrovascular accidents (CVA). Net adverse cardiovascular events (NACE) were a composite of major bleeding or MACE.

RESULTS

The total cohort included 119 patients with PAD. Vascular complications occurred significantly more frequently in patients with PAD both in-hospital (25.2 vs. 16.7%; OR 1.68) and at 30 days (29.4 vs. 17.3%; OR 1.99). No significant differences were observed regarding mortality, NACE, MACE, major bleeding or CVA with bivalirudin versus UFH among patients with or without PAD. In patients with PAD, bivalirudin was associated with an increased risk of minor vascular complications at 30 days.

CONCLUSIONS

Patients with PAD undergoing transfemoral TAVR did not exhibit an increased risk of any major adverse events, according to the procedural anticoagulant randomization. However, patients treated with Bivalirudin had significantly higher rates of minor vascular complications.

The Geriatric Nutritional Risk Index Predicts Long-Term Survival and Cardiovascular or Limb Events in Peripheral Arterial Disease

Aim: The Geriatric Nutritional Risk Index (GNRI) was developed to assess the nutritional risk and is associated with mortality. However, there are limited reports on the relationship between the GNRI and overall survival (OS) in peripheral artery disease (PAD). Therefore, the purpose of this study was to examine the relationship between GNRI and OS and cardiovascular or limb events in patients with PAD.

Methods: A prospective cohort study was performed on 1,219 patients with PAD. The baseline GNRI was calculated from the serum albumin level and body mass index obtained at the first visit. The patients were divided into four groups according to the GNRI: G0 (> 98), G1 (92–98), G2 (82–91), and G3 (< 82). The endpoints were OS and freedom from major adverse cardiovascular events (MACE) and MACE plus limb events (MACLE).

Results: The median follow-up period was 73 months. There were 626 deaths (51.4%) during the follow-up. The rate of cardiovascular death was 51.3%. OS clearly depended on the GNRI (p < 0.01), with five-year OS rates of 80.8% for G0, 62.0% for G1, 40.0% for G2, and 23.3% for G3. In multivariate analyses, the GNRI, age, ankle–brachial pressure index (ABPI), critical limb ischemia, estimated glomerular filtration rate (eGFR), and C-reactive protein (CRP) were independent factors associated with OS, and GNRI, age, ABPI, coronary artery disease, diabetes mellitus, eGFR, and CRP were associated with MACE and MACLE (all p < 0.05). Statins were found to improve OS, MACE, and MACLE (p < 0.01).

Conclusions: GNRI is an independent predictor for OS, MACE, and MACLE in patients with PAD.

Prestroke Sarcopenia and Stroke Severity in Elderly Patients with Acute Stroke

OBJECTIVE

The association between prestroke sarcopenia and stroke severity has not been evaluated previously. The purpose of this study was to determine whether prestroke sarcopenia is associated with stroke severity in elderly patients with acute stroke.

METHODS

We assessed prestroke sarcopenia of elderly patients with acute stroke by using a questionnaire for sarcopenia (SARC-F). Patients were divided into groups according to their SARC-F score: SARC-F score less than 4 (nonsarcopenia) and SARC-F score ≥4 (prestroke sarcopenia). Stroke severity was assessed according to the National Institute of Health Stroke Scale. Logistic regression was used to derive crude and adjusted odds ratio for the presence of prestroke sarcopenia and stroke severity.

RESULTS

Among the 183 patients enrolled (age, median [interquartile range]: 75 [11] years; 103 men), the prevalence of prestroke sarcopenia was 15% (n = 27). Crude odds ratio for the presence of prestroke sarcopenia and moderate-to-severe stroke (National Institute of Health Stroke Scale score > 5) was 4.00 (95% confidence interval, 1.68-9.53; P = .002). After adjusting for confounding variables (age, sex, and stroke risk factors), the presence of prestroke sarcopenia remained an independent predictor of severe stroke, with an odds ratio of 3.54 (95% confidence interval, 1.32-9.49; P= .01).

CONCLUSIONS

Prestroke sarcopenia can predict moderate to severe stroke in elderly patients with acute stroke.

Peripheral artery disease and outcomes in patients with acute myocardial infarction

Aim

To describe the population of patients with previously diagnosed peripheral artery disease (PAD) experiencing a myocardial infarction (MI) and to investigate 1-year major adverse cardiac events (MACE: all-cause mortality, reinfarction, stroke and heart failure hospitalisation) following MI.

Background

MI patients with PAD constitute a high-risk population with adverse cardiac outcomes. Contemporary real-life data regarding the clinical characteristics of this patient population and clinical event rates following MI remain scarce.

Methods

This observational study included all MI patients presenting with ST-elevation MI or non-ST-elevation MI between 01 January 2005 and 31 December 2014 with (n=4213) and without (n=106 763) a concurrent PAD diagnosis, identified in the nationwide Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry and the National Patient Registry (PAD prevalence: 3.8%). Cox proportional hazard models were applied to compare the outcome between the two populations.

Results

MI patients with PAD were older and more often burdened with comorbidities, such as diabetes, hypertension and previous MI. After adjustments, PAD was significantly associated with higher rates of MACE (HR 1.35, 95% CI 1.27 to 1.44), mortality (HR 1.59, 95% CI 1.43 to 1.76), reinfarction (HR 1.48, 95% CI 1.32 to 1.66), stroke (HR 1.27, 95% CI 1.05 to 1.53), heart failure (HR 1.29, 95% CI 1.20 to 1.40) and bleeding (HR 1.26, 95% CI 1.09 to 1.47) at 1 year.

Conclusion

A concurrent PAD diagnosis was independently significantly associated with higher rates of adverse outcomes following MI in a nationwide real-life MI population. The low prevalence of PAD compared with previous studies suggests significant underdiagnosing. Future studies should investigate if PAD screening with ankle–brachial index may increase diagnosing and subsequently lead to improved treatment of polyvascular disease

Asymptomatic cerebral infarction is a predictor of long-term survival and vascular or limb events in peripheral arterial disease

Aims

The purpose of this study was to examine long-term life expectancy including cerebrovascular events (CVE) and fate of the leg in patients with peripheral arterial disease (PAD) with or without cerebral infarction (CI) detected by computed tomography (CT).

Methods and results

A prospective cohort study was performed in 932 patients with PAD. The endpoints were overall survival (OS), CVE, stroke-free survival (SFS), freedom from major adverse cardiovascular events (MACE), and freedom from major adverse cardiovascular and limb events (MACLE). The prevalence of CI on CT was 56.8%. There were 413 deaths (44.3%) during follow-up. The rate of cardiovascular deaths among those who died was 53.5%. The 3-, 5-, and 10-year OS rates were 82.0%, 76.9%, and 46.2%, respectively. In Cox multivariate analyses, age, ankle brachial pressure index (ABI), critical limb ischaemia (CLI), estimated glomerular filtration rate (eGFR), albumin level, and CI were independent factors associated with OS (P < 0.05); age, ABI, CLI, atrial fibrillation (AF), and CI were related to CVE (P < 0.05); age, ABI, CLI, diabetes, coronary heart disease (CHD), AF, eGFR, lower albumin, and CI were related to SFS (P < 0.05); age, ABI, CLI, diabetes, CHD, eGFR, lower albumin, and CI were associated with MACE (P < 0.05); and age, ABI, diabetes, CHD, eGFR, lower albumin and CI were related to MACLE (P < 0.05). Statins improved MACE and MACLE (P < 0.05), and AF increased MACLE (P < 0.05).

Conclusions

CI on CT was an independent predictor for mortality, CVE, SFS, MACE, and MACLE. Statins improved MACE and MACLE, but AF increased CVE and MACLE in patients with PAD.

Association between carotid artery stenosis and peripheral artery disease: Evaluation by screening carotid ultrasonography (cross-sectional study)

We aimed to investigate the association between carotid artery stenosis and peripheral artery disease (PAD) by screening carotid ultrasonography (CUS).From January 2012 to December 2015, 231 consecutive patients who had undergone preoperative CUS for PAD were included in this study. A radiologist assessed the degree of internal carotid artery (ICA) stenosis by using the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Severe (>70%) ICA stenosis was evaluated based on the type of vascular surgery, PAD lesion, and ankle-brachial index (ABI). Data were analyzed using multiple logistic regression analysis and the χ test.Among 231 PAD patients, multilevel lesions revealed significantly higher incidence of severe ICA stenosis than iliac and infrainguinal lesion (22.5% vs 9.4% vs 8%: P = .016). Age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.12: P = .035), chronic kidney disease (CKD, OR: 6.19, 95% CI: 2.04-45.04: P = .013), and cerebral vascular disease (CVD, OR: 4.08, 95% CI: 1.13-16.46: P = .037) were significant risk factors of severe ICA stenosis in multivariate analysis. Prevalence of severe ICA stenosis according to ABI in PAD was not significant.Preoperative screening by CUS provides valuable information onasymptomatic carotid artery stenosis (ACAS) that can identify severe ACAS patients who are at high risk of stroke and to consider more intensive management of carotid disease in PAD patients. CUS can be a useful noninvasive preoperative screening imaging tool for PAD patients with multilevel lesions, aged > 65 years old, with CKD and CVD.

Exploring Different Strategies of Assessing the Economic Impact of Multiple Diabetes-Associated Complications and Their Interactions: A Large Claims-Based Study in Germany

BACKGROUND

In the context of an aging population with increasing diabetes prevalence, people are living longer with diabetes, which leads to increased multimorbidity and economic burden.

OBJECTIVE

The primary aim was to explore different strategies that address the economic impact of multiple type 2 diabetes-related complications and their interactions.

METHODS

We used a generalized estimating equations approach based on nationwide statutory health insurance data from 316,220 patients with type 2 diabetes (baseline year 2012, 3 years of follow-up). We estimated annual total costs (in 2015 euros) for type 2 diabetes-related complications and, in addition, explored different strategies to assess diabetes-related multimorbidity: number of prevalent complications, co-occurrence of micro- and macrovascular complications, disease-disease interactions of prevalent complications, and interactions between prevalent/incident complications.

RESULTS

The increased number of complications was significantly associated with higher total costs. Further assessment of interactions showed that macrovascular complications (e.g., chronic heart failure) and high-cost complications (e.g., end-stage renal disease, amputation) led to significant positive effects of interactions on costs, whereas early microvascular complications (e.g., retinopathy) caused negative interactions. The chronology of the onset of these complications turned out to have an additional impact on the interactions and their effect on total costs.

CONCLUSIONS

Health economic diabetes models and evaluations of interventions in patients with diabetes-related complications should pay more attention to the economic effect of specific disease interactions. Politically, our findings support the development of more integrated diabetes care programs that take better account of multimorbidity. Further observational studies are needed to elucidate the shared pathogenic mechanisms of diabetes complications.

Peripheral Artery Disease and Transcatheter Aortic Valve Replacement Outcomes: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Therapy Registry

BACKGROUND

Peripheral artery disease (PAD) is associated with increased cardiovascular mortality, and PAD risk factors overlap with those for aortic stenosis. The prevalence and outcomes associated with PAD in a population undergoing transcatheter aortic valve replacement (TAVR) are unknown.

METHODS AND RESULTS

Using the Society of Thoracic Surgeons/Transcatheter Valve Therapy Registry linked to Medicare claims data, we identified patients ≥65 years old undergoing TAVR from 2011 to 2015. We calculated hazard ratios for 1-year adverse outcomes, including mortality, readmission, and bleeding, for patients with PAD compared with those without, adjusting for baseline characteristics and postprocedure medications. Analyses were performed separately by access site (transfemoral and nontransfemoral). Of 19 660 patients undergoing transfemoral TAVR, 4810 (24.5%) had PAD; 3730 (47.9%) of 7780 patients undergoing nontransfemoral TAVR had PAD. In both groups, patients with PAD were significantly more likely to have coronary and carotid artery diseases. At 1-year follow-up, patients with PAD undergoing TAVR via transfemoral access had a higher incidence of death (16.8% versus 14.4%; adjusted hazard ratio, 1.14; P=0.01), readmission (45.5% versus 42.1%; hazard ratio, 1.11; P<0.001), and bleeding (23.1% versus 19.7%; hazard ratio, 1.18; P<0.001) compared with patients without PAD. Patients with PAD undergoing TAVR via nontransfemoral access did not have significantly higher rates of 1-year mortality or readmission compared with patients without PAD.

CONCLUSIONS

PAD is common among patients undergoing commercial TAVR via transfemoral and nontransfemoral access. Among patients undergoing transfemoral TAVR, PAD is associated with a higher incidence of 1-year adverse outcomes compared with absence of PAD.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01737528.

Proteomic Analysis of Cerebral Cortex Extracts from Sus scrofa with Induced Hemorrhagic Stroke

Cerebrovascular diseases, including stroke and micro stroke, are the main causes of death in contemporary society. Hemorrhagic stroke is the fast emerging defficiency in the brain function resulting from disturbance of blood supply to the brain caused by the rapture of blood vessels (Lopez et al. in Proteomics Clin Appl 6:190-200, 2012). The influence of a model hemorrhagic stroke on white pigs with the change in the protein profile of their cortical samples 24 h and 2 months after the stroke was examined using mass-spectrometric analysis. Different proteins (n = 30) were identified, and their content was elevated. These proteins are involved in the mechanisms of neuroprotection, including compensation of oxidative stress (TXN, SNCA, PRDX6, ENO1), prevention of unwanted protein aggregation and apoptosis (PTMA, SNCA, SNCB), release of neurotransmitters (GAPDH, PEBP1) and assembly of the cytoskeleton (ACTA2, PTMA, TUBA4A, TUBA1D), etc. Also, a group of seven Ras family proteins involved in the regulation of cell proliferation and differentiation was found in the samples taken 24 h following the stroke. The relative concentrations of most of the proteins in the samples taken 2 months after the stroke demonstrate intermediate values between the control sample and the sample taken in 24 h, indicating the extinction of change in the protein profile with time. During the first 24 h after the stroke, there is an increase in protein fractions participating in exocytosis, synaptic plasticity/signaling, and support of neurotransmitter transport. Such shift in the weight of protein functional clusters can be attributed to activation of compensatory mechanisms in the body focused on neuroprotection.

The CHA2DS2-VASc score: Not as simple as it seems

The CHA₂DS₂-VASc score has been widely adopted as a risk stratification tool for strokes in patients with atrial fibrillation and to help in deciding when anticoagulation therapy for stroke prophylaxis may be beneficial. The score as a whole has been well validated and has been included in the current major practice guidelines. An advantage of the CHA₂DS₂-VASc score is its ease of use, allowing clinicians to quickly estimate risk based on a short set of criteria. However, the benefit of simplicity may also be a weakness. Studies on individual components of the score suggest that only a subset of patients deemed to be at risk based on the current definition are actually at risk for stroke. Thus, users of the score should be aware of the nuances based on available evidence and avoid over-generalization. Accurate assessment of stroke risk has important clinical implications as it influences decision-making on initiation of anticoagulation.

Association between modified CHA2DS2-VASc Score with Ankle-Brachial index < 0.9

The ankle-brachial index (ABI) is a reliable diagnostic examination for peripheral arterial occlusive disease (PAOD). We previously reported CHADS₂ score was significantly correlated with PAOD. However, the association between CHA₂DS₂-VASc score and ABI < 0.9 is not evaluated in the literature. The aim of the present study was to investigate whether CHA₂DS₂-VASc score has a strong association with PAOD. We enrolled 1482 patients in this study. PAOD was defined as ABI < 0.9 in either leg. Vascular disease in CHA₂DS₂-VASc score was modified as vascular disease except PAOD. Of the 1482 subjects, the prevalence of ABI < 0.9 was 5.6%. Multivariate analysis showed that the increased age, decreased estimated glomerular filtration rate and increased modified CHA₂DS₂-VASc score (OR, 1.764; p < 0.001) were independent associated with ABI < 0.9. In addition, the percentage of ABI < 0.9 in patients with modified CHA₂DS₂-VASc score of 0, 1, and <2 were 0%, 0.9%, and 0.7%, respectively (All < 1%). Our study demonstrated modified CHA₂DS₂-VASc score was significantly associated with ABI < 0.9. Calculation of modified CHA₂DS₂-VASc score might be useful in identifying patients with PAOD and in stratifying the risk of PAOD in non-AF patients.

Circulating Angiogenic Growth Factors in Diabetes Patients with Peripheral Arterial Disease and Exertional Leg Pain in Ghana

Objective

Peripheral arterial disease (PAD) is a common complication of diabetes, associated with impairment in angiogenesis. Angiogenesis is regulated by angiogenic growth factors such as angiopoietin 1 (Ang-1), Ang-2, and vascular endothelial growth factor (VEGF). We studied the association between angiogenic growth factors versus PAD and exertional leg symptoms in diabetes patients in Ghana.

Method

In this cross-sectional study, ankle-brachial index was measured with oscillometrically and exertional leg symptoms were screened with Edinburgh claudication questionnaire in 140 diabetes patients and 110 nondiabetes individuals. Circulating levels of Ang-1, Ang-2, and VEGF were measured with immunosorbent assay.

Results

The prevalence of PAD and exertional leg pain was 16.8% and 24.8%, respectively. Compared to non-PAD participants, PAD patients had higher VEGF levels [85.8 (37.5–154.5) versus 57.7 (16.6–161.1) p = 0.032] and lower Ang-1 levels [31.3 (24.8–42.6) versus 40.9 (28.2–62.1), p = 0.017]. In multivariable logistic regression, patients with exertional leg pain had increased the odds of plasma Ang-2 levels [OR (95% CI): 2.08 (1.08–6.41), p = 0.036].

Conclusion

Diabetes patients with PAD and exertional leg pain have imbalance in angiogenic growth factors, indicating impaired angiogenesis. In patients with exertional leg pains, Ang-2 may be an important biomarker.

Carotid plaque rather than intima-media thickness as a predictor of recurrent vascular events in patients with acute ischemic stroke

Background

To investigate the impacts of carotid plaque and intima-media thickness (IMT) on future vascular events (VEs) in the patients with acute ischemic stroke.

Methods

A total of 479 consecutive Korean patients with acute ischemic stroke were divided into 2 groups according to development of VEs; VE group (65.4 ± 10.9 years) vs no VE group (62.8 ± 13.2 years). VEs were defined as the development of recurrent stroke, coronary events, peripheral arterial disease, and death. Clinical, laboratory, and imaging findings were compared between the groups.

Results

During 105.5 ± 29.0 months of follow up, VEs were developed in 142 patients (29.6%). In univariate analysis, VEs were significantly associated with age, gender, diabetes, renal function, lipid levels, left ventricular function, carotid plaque or IMT. In multivariate analysis, the presence of carotid plaque, diabetes, renal function and male gender were independent predictors of future VEs in the patients with ischemic stroke, but carotid IMT was not a predictor of future VEs. Event free survival was significantly lower in patients with carotid plaque than without carotid plaque on Kaplan-Meier analysis (log rank p < 0.001).

Conclusion

The present study demonstrated that diabetes, impaired renal function, male gender, and the presence of carotid plaque rather than IMT were independent predictors of future VEs in Korean patients with acute ischemic stroke. Active medical management and careful monitoring for the development of recurrent VEs are strongly recommended in patients with acute ischemic stroke and carotid plaque.

Empirical anticoagulation for patients in sinus rhythm at high risk of ischaemic stroke: A review of current literature

Ischaemic stroke is one of the commonest causes of morbidity and mortality worldwide and around a fifth of events can be attributed to a cardioembolic source. This is typically due to atrial fibrillation (AF), the most common sustained cardiac arrhythmia. However, AF can, at times, be difficult to detect due to a relative lack of symptoms and the fact that it can be paroxysmal in nature. Studies have shown that diagnosis of AF improves as the length of cardiac monitoring increases. However, prolonged cardiac monitoring is not a cost-effective way of diagnosing AF. Therefore, an alternative approach may be to empirically anticoagulate individuals who are at high risk of stroke. This article summarises current evidence surrounding stroke risk prediction, the use of anticoagulation in the secondary prevention of stroke and its use in the primary prevention of stroke in high risk groups with the aim of determining whether empirical anticoagulation is a safe and effective strategy.

The Association between Residence Floor Level and Cardiovascular Disease: The Health and Environment in Oslo Study

Background. Increasingly more people live in tall buildings and on higher floor levels. Factors relating to floor level may protect against or cause cardiovascular disease (CVD). Only one previous study has investigated the association between floor level and CVD. Methods. We studied associations between floor of bedroom and self-reported history of stroke, venous thromboembolism (VTE), and intermittent claudication (IC) among 12.525 inhabitants in Oslo, Norway. We fitted multivariate logistic regression models and adjusted for sociodemographic variables, socioeconomic status (SES), and health behaviors. Additionally, we investigated block apartment residents (N = 5.374) separately. Results. Trend analyses showed that disease prevalence increased by floor level, for all three outcomes. When we investigated block apartment residents alone, the trends disappeared, but one association remained: higher odds of VTE history on 6th floor or higher, compared to basement and 1st floor (OR: 1.504; 95% CI: 1.007–2.247). Conclusion. Floor level is positively associated with CVD, in Oslo. The best-supported explanation may be residual confounding by building height and SES. Another explanation, about the impact of atmospheric electricity, is also presented. The results underline a need to better understand the associations between residence floor level and CVD and multistory housing and CVD.

Peripheral artery disease and exertional leg symptoms in diabetes patients in Ghana

Background

Peripheral arterial disease (PAD) is a major health problem in diabetes patients in high-income countries, but the PAD burden in sub-Saharan Africa is largely undetermined. We studied the prevalence of PAD and exertional leg symptoms in diabetes (DM) patients in a tertiary hospital in Ghana.

Methods

In a case control study design, 485 DM and 330 non-diabetes participants were recruited. PAD was diagnosed as Ankle Brachial Index (ABI) < 0.9. Edinburgh Claudication Questionnaire (ECQ) was used to assess exertional leg symptoms.

Results

The overall prevalence of classical intermittent claudication was 10.3 % and ABI-diagnosed PAD was 26.7 %, with 3.5 % of the participants having both classic intermittent claudication and ABI-diagnosed PAD. The prevalence of exertional leg symptoms were similar in diabetes patients with and without PAD. In non-diabetes participants, intermittent claudication and rest pain were higher in PAD patients than in non-PAD participants. In multivariable logistic regression, intermittent claudication [OR (95 % CI), 3.39 (1.14 – 8.1), p < 0.05] and rest pain [4.3 (1.58 – 9.67), p < 0.001] were independently associated with PAD in non-diabetes group, and rest pain [1.71 (1.13 – 2.17), p < 0.05] was associated with PAD in all participants.

Conclusions

There is high burden of PAD and exertional leg pains in DM patients in Ghana. PAD is expressed as intermittent claudication and rest pain in non-diabetes individuals.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-016-0247-x) contains supplementary material, which is available to authorized users.

CHADS2 Score and Risk of New-onset Peripheral Arterial Occlusive Disease in Patients without Atrial Fibrillation: A Nationwide Cohort Study in Taiwan

AIM

Although our recent cross-sectional study demonstrated that the CHADS2 score is associated with an ankle-brachial index of ＜ 0.9 in patients without atrial fibrillation (AF), the true cause-effect relationship between these parameters remains to be evaluated. Hence, the aim of this study was to investigate whether the CHADS2 score is a useful predictor of new-onset PAOD in non-AF patients.

METHODS

From January 1, 2000 to December 31, 2001, a total of 723,750 patients older than 18 years of age with no past history of PAOD, rheumatic heart disease or AF were surveyed from the "National Health Insurance Research Database." The CHADS2 score was calculated for each patient. Finally, 581,997 (score 0), 84,971 (score 1), 31,473 (score 2), 14,432 (score 3), 8,156 (score 4), 2,430 (score 5) and 291 (score 6) patients were studied and followed for the onset of PAOD. We further divided the study patients into four groups: group 1 (score 0), group 2 (score 1-2), group 3 (score 3-4) and group 4 (score 5-6).

RESULTS

During the follow-up period of 9.83 ± 0.01 years, 24,775 (3.4%) patients experienced new-onset PAOD. The overall incidence of PAOD was 0.6 per 1,000 patient-years. The rate of PAOD increased from 1.8% (group 1) to 18.7% (group 4) (p ＜ 0.001). According to a multivariate analysis, groups 2-4 were significantly associated with new-onset PAOD (all p ＜ 0.001). In addition, the hazard ratio of each two-point increment in the CHADS2 score for predicting PAOD was 2.51 (p ＜ 0.001).

CONCLUSIONS

The CHADS2 score is a useful predictor of new-onset PAOD in non-AF patients.

Prognostic implications of the Ankle Brachial Index in patients with acute ischemic stroke: A meta-analysis

BACKGROUND

The ankle brachial index (ABI) is recognized as a marker of atherosclerotic disease. The detection of ABI may improve the risk stratification.

METHODS

We systematically searched Pubmed and Embase (from the earliest date to October 2015) for studies evaluating the prognostic value of ABI in patients with acute ischemic stroke. Stroke or cardiovascular events, mortality and functional outcomes were analyzed.

RESULTS

Seventeen studies, containing 9404 patients, were included. The mean age of participants in each study ranged from 64 to 79 years. The prevalence of low ABI varied from 7.4% to 40.5%. In this quantitative analysis, we found that low ABI increased the risk of composite outcomes (myocardial infarction or stroke or mortality), disability and mortality.

CONCLUSION

The detection of ABI may help to identify high-risk patients for secondary stroke prevention.

Ankle-Brachial Index and Recurrent Stroke Risk: Meta-Analysis

BACKGROUND AND PURPOSE

The ankle-brachial index (ABI) is a fast, cheap, noninvasive indicator of atherosclerotic burden that may also be a predictor of stroke recurrence. In this systematic review and meta-analysis, we sought to explore ABI's merit as a marker for stroke recurrence and vascular risk by synthesizing the data currently available in stroke literature.

METHODS

We searched Embase, MEDLINE, and Pubmed databases for prospective cohort studies that included consecutive patients with stroke and transient ischemic attack, measured ABI at baseline, and performed a follow-up assessment at least 12 months after initial stroke or transient ischemic attack. The following end points were chosen for our analysis: recurrent stroke and combined vascular end point (recurrent vascular event or vascular death). Crude risk ratios and adjusted Cox proportional hazard ratios were combined separately using the random-effects model. Study-level characteristics (eg, percent of cohort with a history of hypertension, average cohort age, level of adjustment, and mean follow-up duration) were included as covariates in a metaregression analysis.

RESULTS

We identified 11 studies (5374 patients) that were not significantly heterogeneous. Pooling adjusted hazard ratios showed that low ABI was associated with both an increased hazard of recurrent stroke (hazard ratio, 1.70; 95% confidence interval, 1.10-2.64) and an increased risk of vascular events or vascular death (hazard ratio, 2.22; 95% confidence interval, 1.67-2.97).

CONCLUSION

Our results confirm the positive association between ABI and stroke recurrence. Further studies are needed to see whether inclusion of ABI will help improve the accuracy of prediction models and management of stroke patients.

[Sleep disorders and circadian rhythms in diseases of the cardiovascular system]

OBJECTIVE

To study disturbances of sleep and circadian rhythms in patients with cardiovascular diseases taking into account the level of melatonin secretion and to optimize a complex approach to their treatment.

MATERIALS AND METHODS

The study included patients with cardiovascular diseases with- (n=121) and without (n=105) cerebrovascular diseases (CVD). All patients received melaxen in dose 3 mg daily 30-40 min before sleep. Examination of patients included assessment of neurological status, psychometric scales, the definition of circadian rhythm of the heart and blood pressure, determination of 6-SOMT in daily urine.

RESULTS

Pathological changes in circadian rhythms affected sleep disturbances, emotional and cognitive disorders and were associated with a reduction in the level of 6-SOMT in the urine. These changes were most pronounced in patients with CVD and stroke. The inclusion of melaxen in the comprehensive regimen of treatment improved sleep, reduced mood disorders and normalized the circadian heart rate profile and blood pressure.

CONCLUSION

The data obtained allowed to consider melaxen as an effective tool in the complex therapy of patients with CVD.

The ARTICO study: identification of patients at high risk of vascular recurrence after a first non-cardioembolic stroke

BACKGROUND

About 20% of patients with a first ischaemic stroke will experience a new vascular event within the first year. The atherosclerotic burden, an indicator of the extension of atherosclerosis in a patient, has been associated with the risk of new cardiovascular events in the general population. However, no predictive models reliably identify groups at a high risk of recurrence. The ARTICO study prospectively analysed the predictive value for the risk of recurrence of specific atherosclerotic markers.

METHODS

The multicentre ARTICO study included 620 consecutive independent patients older than 60 years suffering from a first non-cardioembolic stroke. We analysed classical stroke risk factors; duplex study of supraaortic trunk including intima-media thickness (IMT) measurement; quantification of internal carotid (ICA) stenosis; number, morphology and surface characteristics of carotid plaques; ankle brachial index (ABI); and the presence of microalbuminuria. Patients were followed up at 6 and 12 months after inclusion. The primary end-point was death or major cardiovascular events.

RESULTS

Any vascular event or death at 12 months occurred in 78 (13.8%) patients. In 40 (7.1%) of these the vascular event was a stroke recurrence. Weight, history of diabetes mellitus, history of symptomatic PAD, ABI <0.9 and significant ICA stenosis (>50%) were associated with a higher risk of vascular events on follow-up in the bivariate analysis. In the final Cox regression analysis, body mass index (BMI), systolic blood pressure, history of diabetes mellitus, symptomatic PAD (HR, 2.76; 95% CI, 1.10-6.95; p=0.03), and particularly patients with both ICA stenosis >50% and PAD (HR 4.52; 95% CI, 2.14-9.53; p<0.001) were independently associated with an increased risk of vascular events. Neither isolated ICA stenosis >50% nor isolated abnormal ABI remained associated with an increased risk of recurrence in comparison with the whole population.

CONCLUSIONS

Symptomatic PAD identifies a high risk group of vascular recurrence after a first non-cardioembolic stroke. The associated increased risk was particularly high in patients with both ICA stenosis and either symptomatic or asymptomatic PAD. Neither asymptomatic PAD alone nor isolated ICA stenosis >50% were associated with an increased risk of recurrence in this particularly high-risk group of non-cardioembolic stroke.

Heart rate significantly influences the relationship between atrial fibrillation and ankle-brachial index

OBJECTIVES

Both atrial fibrillation (AF) and vascular disease share several risk factors and the two diseases often coexist. The patients with AF were reported to have a decreased ankle-brachial index (ABI). However, ABI was also reported to have an inverse relationship with heart rate (HR). Because AF patients often have a transiently or persistently rapid HR, this study aimed to assess whether AF was significantly associated with decreased ABI and whether HR could significantly influence the relationship between AF and ABI.

METHODS

We included 166 AF and 1336 non-AF patients from subjects undergoing echocardiographic examinations. ABI was measured using an ABI-form device.

RESULTS

Compared to non-AF patients, AF patients had a decreased ABI (p<0.001). In a multivariate model, including covariates of age, sex, blood pressures, etc., the presence of AF was significantly associated with low ABI (β=-0.069, p=0.026). However, further adjustment for HR made this association disappear (p=0.971).

CONCLUSION

This study demonstrated that the presence of AF was associated with decreased ABI, but this association became insignificant after further adjustment for HR, which suggested HR could significantly influence the relationship between AF and ABI.

Increased pulsatility of the intracranial blood flow spectral waveform on transcranial Doppler does not point to peripheral arterial disease in stroke patients

BACKGROUND

Peripheral arterial disease (PAD) is common in patients with acute cerebral ischemia. Indexes of resistance derived from the systolic and diastolic velocities are routinely used in diagnostic transcranial Doppler (TCD) to detect intracranial arterial disease. We sought to explore whether these indexes can predict the presence of PAD in acute cerebral ischemia.

METHODS

We prospectively evaluated consecutive patients with acute cerebral ischemia. On TCD, peak-systolic and end-diastolic velocities in both middle cerebral and basilar arteries were manually measured to calculate pulsatility index (PI) and resistance index (RI). Increased resistance was defined as PI equal to 1.2 or more and RI equal to .75 or more. Ankle-brachial index (ABI) measurements were performed and an ABI equal to .9 or more was considered predictive of definite PAD.

RESULTS

We included 95 patients (45 male, 50 female) aged 66 ± 9 years with a median National Institutes Health Stroke Scale score of 3 (interquartile range, 8) points. The ABI was abnormal and consistent with definite PAD in 24 of 95 (25.3%; 95% confidence interval [CI], 16.4-34.2) patients. Increased PI did not differ among patients with and without PAD (20.8% vs. 28.2%, P = .60). Only 1 patient with PAD had increased RI as opposed to 4 patients without PAD (4.2% vs. 5.6%, P = 1.0). Increased PI was not found to be an independent predictor of PAD (odds ratio [OR], .68; 95% CI, .22-2.12; P = .51). Increases in both PI and RI independently predicted arterial hypertension (OR, 1.62; 95% CI, 1.19-2.21; P = .002 and OR, 3.20; 95% CI, 1.51-6.77; P = .002, respectively).

CONCLUSIONS

Our findings indicate that PAD cannot be inferred from intracranial flow parameters predictive of arterial disease and risk factors such as hypertension among patients with acute cerebral ischemia.

Peripheral arterial disease and risk of atrial fibrillation and stroke: the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Peripheral arterial disease (PAD) shares several risk factors with atrial fibrillation (AF), and persons with PAD have an increased risk of stroke. It is unclear if PAD is associated with an increased risk for AF and whether this potential association explains the increased risk of stroke observed in those with PAD.

METHODS AND RESULTS

We examined the association between PAD, measured by ankle-brachial index (ABI), and incident AF and incident stroke, separately, in 6568 participants (mean age 62±10 years, 53% women, 62% nonwhite) from the Multi-Ethnic Study of Atherosclerosis (MESA). ABI values <1.0 or >1.4 defined PAD. AF was ascertained through review of hospital discharge records and from Medicare claims data until December 31, 2010. An independent adjudication committee ascertained stroke events. Cox regression was used to estimate hazard ratios and 95% CIs for the association between PAD and AF and stroke. Over a median follow-up of 8.5 years, 301 (4.6%) participants developed AF and 140 (2.1%) developed stroke. In a model adjusted for sociodemographics, cardiovascular risk factors, and potential confounders, PAD was associated with an increased risk of AF (hazard ratio 1.5, 95% CI 1.1 to 2.0). In a similar model, PAD was associated with incident stroke (hazard ratio 1.7, 95% CI 1.1 to 2.5), and the magnitude of risk was not different after inclusion of AF as a time-dependent covariate (hazard ratio 1.7, 95% CI 1.1 to 2.5).

CONCLUSIONS

PAD is associated with an increased risk of AF and stroke in MESA. Potentially, the relationship between PAD and stroke is not mediated by AF.

The efficacy and safety of cilostazol in ischemic stroke patients with peripheral arterial disease (SPAD): protocol of a randomized, double-blind, placebo-controlled multicenter trial

RATIONALE

It is not uncommon for patients with ischemic stroke to have peripheral arterial disease (PAD). Patients with polyvascular diseases carry greater burden of atherosclerosis and higher risks of developing vascular events and death. More effective regimens, such as dual antiplatelet agents, may be more effective for controlling progression of atherosclerosis in secondary prevention.

AIM

This study aims to evaluate whether cilostazol plus aspirin is more efficacious than aspirin alone for preventing progression of atherosclerosis in patients with ischemic stroke or transient ischemic attack (TIA) who also have peripheral arterial disease.

DESIGN

The Safety and Efficacy of Cilostazol in Ischemic Stroke Patients with Peripheral Arterial Disease (SPAD) study is a randomized double-blinded placebo-controlled trial. Patients with previous ischemic stroke or TIA who had been taking aspirin (100 mg per day), aged 50 years or older, with PAD in the lower limbs based on ankle-brachial index (ABI) <1·0 will be randomized into the treatment group with cilostazol (200 mg/day) or the placebo group on 1:1 basis.

STUDY OUTCOMES

Patients will be evaluated at 1, 3, 6, 9 and 12 months after randomization. The primary endpoint is difference in change in ABI between groups. The secondary and tertiary endpoints are the difference between groups in change in carotid intima-media thickness (IMT) and incidence rate of major cardiovascular events, including recurrent stroke, myocardial infarction, unstable angina, other vascular events, and death; and the safety measures, including major bleeding events, hemorrhagic stroke and death of any cause.

CONCLUSION

The SPAD trial is the first study to evaluate the safety and efficacy of dual antiplatelet agents, aspirin plus cilostazol, in comparison with aspirin alone in patients with both ischemic stroke or TIA and PAD. Results from this trial will provide important information on the merit of adding cilostazol to aspirin for slowing down progression of atherosclerosis in patients with ischemic stroke and PAD.