Tachycardia burden in stroke unit is associated with functional outcome after ischemic stroke

Effect of heart rate on poor outcome in stroke patients treated with intra-arterial thrombectomy

BACKGROUND AND PURPOSE

The relationship between heart rate and the prognosis of patients with large vessel occlusion strokes treated with mechanical thrombectomy (MT) is not well established. This study aimed to evaluate the association of mean heart rate and heart rate variability (HRV) with the clinical outcomes after MT therapy.

METHODS

Acute ischemic stroke patients undergoing MT therapy were prospectively recruited from March 2020 to November 2022. Their heart rate was collected every hour for the initial 72 h after MT procedure, and the variability of heart rate was measured by standard deviation (SD) and coefficient of variation (CV). All-cause mortality and worsening of functional outcome (change in modified Rankin Scale (mRS) score) at 3-month were captured. Binary logistic regression was used to evaluate the association between heart rate indicators and all-cause mortality. Ordinal logistic regression was used to evaluate the association between heart rate indicators and worsening of functional outcome.

RESULTS

Among 191 MT-treated patients, 51(26.7%) patients died at 3-month after stroke. Increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were all associated with the increased risk of mortality (adjusted hazard ratio [aHR] with 95% CI: 1.29 [1.09-1.51], 1.19 [1.07-1.32], 1.14 [1.03-1.27]; respectively). Patients in the highest tertile of heart rate SD had an increased risk of mortality (4.62, 1.70-12.52). After using mRS as a continuous variable, we found increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were associated with the worsening of functional outcome (adjusted odds ratio [aOR] with 95% CI: 1.35 [1.11-1.64], 1.27 [1.05-1.53], 1.19 [1.02-1.40]; respectively). A linear relationship was observed between mean heart rate or heart rate SD and mortality; while all of the heart rate measures in this study showed a linear relationship with the worsening of functional outcome.

CONCLUSIONS

Higher mean heart rate and HRV were associated with the increased risk of 3-month all-cause mortality and worse functional outcome after MT therapy for AIS patients.

Heart-Rate-to-Blood-Pressure Ratios Correlate with Malignant Brain Edema and One-Month Death in Large Hemispheric Infarction: A Cohort Study

INTRODUCTION

Large hemispheric infarction (LHI) can lead to fatal complications such as malignant brain edema (MBE). We aimed to investigate the correlation between heart-rate-to-blood-pressure ratios and MBE or one-month death after LHI.

METHODS

We prospectively included LHI patients from a registered cohort. Hourly heart-rate-to-blood-pressure ratios were recorded as a variation of the traditional shock index (SI), SIs and SId (systolic and diastolic pressures, respectively), and calculated for mean and variability (standard deviation) in 24 h and two 12 h epochs (1-12 h and 13-24 h) after onset of symptoms. MBE was defined as neurological deterioration symptoms with imaging evidence of brain swelling. We employed a generalized estimating equation to compare the trend in longitudinal collected SIs and SId between patients with and without MBE. We used multivariate logistic regression to investigate the correlation between SIs, SId and outcomes.

RESULTS

Of the included 162 LHI patients, 28.4% (46/162) developed MBE and 25.3% (40/158) died within one month. SIs and SId increased over baseline in all patients, with a similar ascending profile during the first 12 h epoch and a more intensive increase in the MBE group during the second 12 h epoch (p < 0.05). During the overall 24 h, patients with greater SId variability had a significantly increased MBE risk after adjustment (OR 3.72, 95%CI 1.38-10.04). Additionally, during the second 12 h epoch (13-24 h after symptom onset), patients developing MBE had a significantly higher SId level (OR 1.18, 95%CI 1.00-1.39) and greater SId variability (OR 3.16, 95%CI 1.35-7.40). Higher SId and greater SId variability within 24 h independently correlated with one-month death (all p < 0.05). Within the second 12 h epoch, higher SIs, higher SId and greater SId variability independently correlated with one-month death (all p < 0.05). No significant correlation was observed in the first 12 h epoch.

CONCLUSIONS

Higher and more fluctuated heart-rate-to-blood-pressure ratios independently correlated with MBE development and one-month death in LHI patients, especially during the second 12 h (13-24 h) epoch after onset.

Exploring the Utility of Autonomic Nervous System Evaluation for Stroke Prognosis

Stroke is a major cause of functional disability and is increasing in frequency. Therefore, stroke prognosis must be both accurate and timely. Among other biomarkers, heart rate variability (HRV) is investigated in terms of prognostic accuracy within stroke patients. The literature research of two databases (MEDLINE and Scopus) is performed to trace all relevant studies published within the last decade addressing the potential utility of HRV for stroke prognosis. Only the full-text articles published in English are included. In total, forty-five articles have been traced and are included in the present review. The prognostic value of biomarkers of autonomic dysfunction (AD) in terms of mortality, neurological deterioration, and functional outcome appears to be within the range of known clinical variables, highlighting their utility as prognostic tools. Moreover, they may provide additional information regarding poststroke infections, depression, and cardiac adverse events. AD biomarkers have demonstrated their utility not only in the setting of acute ischemic stroke but also in transient ischemic attack, intracerebral hemorrhage, and traumatic brain injury, thus representing a promising prognostic tool whose clinical application may greatly facilitate individualized stroke care.

Tachycardia Changes Increase Neurological Deterioration in Patients with Acute Non-Cardioembolic Stroke: An ADS Post-Hoc Analysis

AIM

A previous randomized study showed that dual antiplatelet therapy (DAPT) with aspirin and cilostazol is not superior to aspirin monotherapy for patients with acute non-cardioembolic stroke; however, the reason for this remains uncertain. We focused on the unusual side effects of cilostazol, namely, tachycardia changes, and validated their influence on patients with acute non-cardioembolic stroke.

METHODS

This post-hoc study extracted data from the acute aspirin plus cilostazol dual therapy study (ADS) registry, a multicenter, prospective, randomized, open-label trial. Patients were randomly allocated to the dual group (aspirin plus cilostazol) and the aspirin monotherapy group (aspirin alone). Tachycardia changes were defined as ≥ 5% heart rate increase at 48 h after admission compared with that at admission. Baseline data and outcomes were validated with four divided groups: aspirin-non-tachycardia changes (AN), aspirin-tachycardia changes (AT), dual-non-tachycardia changes (DN), and dual-tachycardia changes (DT).

RESULTS

Finally, 1,188 patients were analyzed in this ADS post-hoc analysis (aspirin monotherapy group, 594; dual group, 594). The proportion of change in tachycardia was 19.2% in the aspirin monotherapy group and 38.2% in the dual group (p＜0.001^＊＊＊). Although the recurrences of symptomatic stroke and transient ischemic attack were not significantly different, the neurological deterioration was significantly different among the AN, AT, DN, and DT groups (p＜0.05^＊).

CONCLUSIONS

Tachycardia changes increase neurological deterioration even in patients with non-cardioembolic acute stroke. DAPT consisting of aspirin and cilostazol increases the proportion of tachycardia changes and is not superior to aspirin monotherapy.

Tricin attenuates cerebral ischemia/reperfusion injury through inhibiting nerve cell autophagy, apoptosis and inflammation by regulating the PI3K/Akt pathway

To elucidate the effect of tricin in cerebral ischemia/reperfusion (I/R) injury and examine its possible underlying mechanisms. Rats were randomly divided into Sham (exposed the right internal carotid arteries), I/R, and tricin (administered at various doses) groups. After the cerebral I/R injury model was established, a Morris water maze test and a tetrazolium chloride assay were performed. Apoptosis and autophagy were assessed in the nerve cells of hippocampus tissue, and the levels of inflammatory markers within animal serum were detected. Proteins related to apoptosis and the PI3K/Akt pathway were evaluated. To further investigate the mechanisms by which tricin affects brain damage, mouse neuroblastoma cells N2a were divided into control, oxygen-glucose deprivation and reoxygenation (OGD/R), tricin, PI3K/Akt activator, and tricin + PI3K/Akt inhibitor groups. The cell viability, apoptosis, inflammatory factors, and PI3K/Akt pathway related proteins in N2a cells were also detected. The results revealed that I/R-induced learning and memory dysfunction was improved by tricin treatment. The area of cerebral infarction, the levels of apoptosis and autophagy in nerve cells, and the serum inflammatory marker content were all decreased following tricin treatment. Additionally, the expression of Beclin-1 protein was downregulated, while the expression of Bcl-2 protein, p-PI3K/PI3K and p-Akt/Akt was upregulated after tricin treatment. Mechanistically, tricin or PI3K/Akt activator ameliorated OGD/R-induced apoptosis, autophagy, and inflammation. However, these effects were reversed following PI3K/Akt inhibitor treatment in OGD/R-induced N2a cells. In summary, this study suggested that tricin can against I/R-induced brain injury by inhibiting autophagy, apoptosis and inflammation, and activating the PI3K/Akt signaling pathway.

Initial in-hospital heart rate is associated with three-month functional outcomes after acute ischemic stroke

Background

Increased heart rate (HR) has been associated with stroke risk and outcomes.

Material and methods

We analyzed 1,420 patients from a hospital-based stroke registry with acute ischemic stroke (AIS). Mean initial in-hospital HR and the coefficient of variation of HR (HR-CV) were derived from the values recorded during the first 3 days of hospitalization. The study outcome was the 3-month functional outcome. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using multivariable logistic regression analysis.

Results

A higher mean HR level was significantly and continuously associated with a higher probability of unfavorable functional outcomes. Compared with the reference group (mean HR < 70 beats per minute), the multivariate-adjusted OR for an unfavorable outcome was 1.81 (95% CI, 1.25–2.61) for a mean HR ≥ 70 and < 80 beats per minute, 2.52 (95% CI, 1.66 − 3.52) for a mean HR ≥ 80 and < 90 beats per minute, and 3.88 (95% CI, 2.20–6.85) for mean HR ≥ 90 beats per minute. For stroke patients with a history of hypertension, the multivariate-adjusted OR for patients with a HR-CV ≥ 0.12 (versus patients with a HR-CV < 0.08 as a reference) was 1.73 (95% CI, 1.11–2.70) for an unfavorable outcome.

Conclusions

Our results indicated that a high initial in-hospital HR was significantly associated with unfavorable 3-month functional outcomes in patients with AIS. In addition, stroke patients with a HR-CV ≥ 0.12 also had unfavorable outcomes compared with those with a HR-CV < 0.08 if they had a history of hypertension.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02252-2.

Differentially expressed genes induced by β-caryophyllene in a rat model of cerebral ischemia-reperfusion injury

Experimental studies have shown that β-caryophyllene (BCP) improved neurological deficits of cerebral ischemia-reperfusion injury (CIRI) rats resulting from Middle Cerebral Artery Occlusion (MCAO). However, research on targets of BCP on CIRI has not been completed. In this study, the mRNA sequencing was used to distinguish various therapeutic multiple targets of BCP on CIRI. Differentially expressed genes (DEGs) were identified from RNA-seq analysis. CIRI induced up-regulated genes (CIRI vs. Sham) and BCP -induced down-regulated genes (BCP vs CIRI) were identified. Significant DEGs were identified only that expressed in each of all samples. Gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis of significant DEGs were determined by cluster Profiler. Protein interactive network (PPI) was analyzed using the String tool and Hub genes was identified by cytoHubba. Transcription factor (TF) regulatory network for the potential Hub genes was constructed. Western blot and ELISA were used to verified hub genes and relative inflammatory cytokines. After mRNA sequencing, a total of 411 DEGs were filtered based on the 2 series (CIRI vs. Sham and CIRI vs. BCP), with Pax1, Cxcl3 and Ccl20 are the most remarkable ones reversed by BCP. GO analysis was represented by DEGs involved in multiple biological process such as extra-cellular matrix organization, leukocyte migration, regulation of angiogenesis, reactive oxygen species metabolic process, etc. KEGG analysis showed that DEGs participated several signaling pathways including MAPK signaling pathway (rno04010), Cytokine-cytokine receptor interaction (rno04060), JAK-STAT signaling pathway (rno04630), and others. The protein-protein interaction (PPI) network consisted of 339 nodes and 1945 connections, and top ten Hub genes were identified by cytoHubba such as TIMP1, MMP-9, and STAT3. Subsequently, a TFs-miRNAs-targets regulatory network was established, involving 6 TFs, 5 miRNAs, and 10 hub genes, consisting of several regulated models such as Brd4 - rno-let-7e - Mmp9, Brd4 - rno-let-7i - Stat3, and Hnf4a- rno-let-7b -Timp1. Finally, western blot demonstrated that BCP could inhibit the increased TIMP1, MMP-9 and STAT3 expression in rat brains after I/R. ELISA represented that BCP could suppress inflammatory cytokines caused by CIRI and present anti-oxidative property. In conclusion, this study shows that the intervention of BCP can significantly reduce neurologic deficit, improve the cerebral ischemia, and a total of ten hub genes were found closely related to the treatment of BCP on CIRI. Prudent experimental validation suggests that the BCP might have the neuro-protective effects in CIRI by decreasing the expression of MMP-9 and TIMP-1, STAT3. In a sense, this study reveals that the MMP-9/TIMP-1 signaling pathway may be involved in the injury after CIRI and thus provides a new treatment strategy as well as a researching method for stroke.

Calycosin-7-O-β-D-glucoside Attenuates OGD/R-Induced Damage by Preventing Oxidative Stress and Neuronal Apoptosis via the SIRT1/FOXO1/PGC-1α Pathway in HT22 Cells

Neuronal apoptosis induced by oxidative stress is a major pathological process that occurs after cerebral ischemia-reperfusion. Calycosin-7-O-β-D-glucoside (CG) is a representative component of isoflavones in Radix Astragali (RA). Previous studies have shown that CG has potential neuroprotective effects. However, whether CG alleviates neuronal apoptosis through antioxidant stress after ischemia-reperfusion remains unknown. To investigate the positive effects of CG on oxidative stress and apoptosis of neurons, we simulated the ischemia-reperfusion process in vitro using an immortalized hippocampal neuron cell line (HT22) and oxygen-glucose deprivation/reperfusion (OGD/R) model. CG significantly improved cell viability and reduced oxidative stress and neuronal apoptosis. In addition, CG treatment upregulated the expression of SIRT1, FOXO1, PGC-1α, and Bcl-2 and downregulated the expression of Bax. In summary, our findings indicate that CG alleviates OGD/R-induced damage via the SIRT1/FOXO1/PGC-1α signaling pathway. Thus, CG maybe a promising therapeutic candidate for brain injury associated with ischemic stroke.

Effect of renal function status on the prognostic value of heart rate in acute ischemic stroke patients

BACKGROUND AND AIMS

The association between heart rate and prognosis of ischemic stroke remains debatable, and whether renal function status influences the relationship between them is still not elucidated.

METHODS

A total of 3923 ischemic stroke patients were included in this prospective multicenter study from the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS). The primary outcome was a combination of death and major disability (modified Rankin Scale score ≥3) at 3 months after stroke. Secondary outcomes were, separately, death and major disability.

RESULTS

The association between heart rate tertiles and primary outcome was appreciably modified by renal function status (p_interaction = 0.037). After multivariate adjustment, high heart rate was associated with increased risk of primary outcome in patients with abnormal renal function (odds ratio, 1.61; 95% confidence interval, 1.02-2.54; p_trend = 0.039) but not in patients with normal renal function (odds ratio, 0.96; 95% confidence interval, 0.75-1.23; p_trend = 0.741), when two extreme tertiles were compared. Each 10 bpm increase of heart rate was associated with 21% (95% CI: 1%-44%) increased risk of primary outcome, and a linear association between heart rate and risk of primary outcome was observed among patients with abnormal renal function (p for linearity = 0.002).

CONCLUSIONS

High heart rate may be merely a strong predictor of poor prognosis in acute ischemic stroke patients with abnormal renal function, suggesting that heart rate reduction should be applied to ischemic stroke patients with abnormal renal function to improve their prognosis.

Tachycardia as a Negative Prognostic Factor for Stroke Outcome

INTRODUCTION

The outcome of stroke, especially lethal one is significant, as in the hemorrhagic as well as in ischemic stroke.

GOAL

was to show the impact on the stroke outcome of tachycardia correlated with lesion localization.

MATERIAL AND METHODS

Material for our work was patients who were treated due to the stroke at the Neurology Clinic Sarajevo in the period from 31 March 2015 until 01 January 2016. A total of 544 stoke patients were treated in the reporting period, 221 (44.6%) died. There were 70.9% patients with ischemic and 29.1% with hemorrhagic stroke. Each patient underwent ECG, which registered tachycardia during admission and on third day of hospitalization.

RESULTS

In relation to the presence of tachycardia on admission there were statistically significant differences in the group of patients with hemorrhage and ischemia in relation to presence of tachycardia (p <0.01). In the group of patients with hemorrhage coma was more present (78.9%), while tachycardia was statistically more often in those with loss of consciousness than in the group with coma. Group of patients with ischemia has 52.75% of the patients with tachycardia without statistical correlation between the presence and absence of disorders of consciousness. Midline lesions were statistically more often associated with paroxysmal tachycardia in relation to the lateral lesions (p <0.01). Statistical analysis shows that there are statistically significant differences between observed groups χ2=35.576, p=0.0001. Lethal outcome of hemorrhagic stroke was 55.45%, 32.6% for ischemia. A significant statistical significance of ischemic and hemorrhagic stroke compared to the lethal outcome correlated with the registered tachycardia and medial lesion localization.

CONCLUSION

Tachycardia on admission in patients with stroke is a relevant negative predictor for stroke outcome. Medial localization of changes significantly affects the occurrence of tachycardia and lethal outcome of stroke which is statistically significantly more associated with hemorrhagic stroke.