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Katsanos AH, Shoamanesh A. Colchicine for the prevention of vascular events after non-cardioembolic stroke. Lancet 2024; 404:96-98. [PMID: 38857610 DOI: 10.1016/s0140-6736(24)01096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 05/23/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Aristeidis H Katsanos
- Department of Medicine (Neurology), McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON L8L2X2, Canada.
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON L8L2X2, Canada
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2
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Sarfo FS, Voeks J, Adamu S, Agyei BA, Agbenorku M, Adu-Darko N, Oteng MA, Obese V, Gyamfi RA, Mensah NA, Tagge R, Ampofo M, Kontoh SA, Nguah SB, Ovbiagele B. A cardiovascular polypill for secondary stroke prevention in a tertiary centre in Ghana (SMAART): a phase 2 randomised clinical trial. Lancet Glob Health 2023; 11:e1619-e1628. [PMID: 37734804 PMCID: PMC10576526 DOI: 10.1016/s2214-109x(23)00347-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND A cardiovascular polypill containing generic drugs might facilitate sustained implementation of and adherence to evidence-based treatments, especially in resource-limited settings. However, the impact of a cardiovascular polypill in mitigating atherosclerotic risk among stroke survivors has not been assessed. We aimed to compare a polypill regimen with usual care on carotid intima-media thickness (CIMT) regression after ischaemic stroke. METHODS In SMAART, a phase 2 parallel, open-label, assessor-masked, randomised clinical trial, we randomly allocated individuals (aged ≥18 years) who had an ischaemic stroke within the previous 2 months, using a computer-generated randomisation sequence (1:1), to either a polypill or usual care group at a tertiary centre in Ghana. The polypill regimen was a fixed-dose pill containing 5 mg ramipril, 50 mg atenolol, 12·5 mg hydrochlorothiazide, 20 mg simvastatin, and 100 mg aspirin administered as two capsules once per day for 12 months. Usual care was tailored guideline-recommended secondary prevention medications. The primary outcome was the change in CIMT over 12 months with adjustment for baseline values, compared using ANCOVA in all participants with complete data at month 12. Safety was analysed in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, NCT03329599, and is completed. FINDINGS Between Feb 12, 2019, and Dec 4, 2020, we randomly assigned 148 participants (74 to the usual care group and 74 to the polypill group), 74 (50%) of whom were male and 74 (50%) female. CIMT was assessed in 62 (84%) of 74 participants in the usual care group and 59 (80%) of 74 participants in the polypill group; the main reason for loss to follow-up was participants not completing the study. The mean CIMT change at month 12 was -0·092 mm (95% CI -0·130 to -0·051) in the usual care group versus -0·017 mm (-0·067 to 0·034) in the polypill group, with an adjusted mean difference of 0·049 (-0·008 to 0·109; p=0·11). Serious adverse events occurred among two (3%) participants in the usual care group, and eight (11%) participants in the polypill group (p=0·049). INTERPRETATION The polypill regimen resulted in similar regression in subclinical atherosclerosis and many secondary and tertiary outcome measures as the tailored drug regimen, but with more serious adverse events. Larger, longer-term, event-based studies, including patients with stroke in primary care settings, are warranted. FUNDING US National Institutes of Health. TRANSLATION For the Akan (Twi) translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Jenifer Voeks
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | | | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Raelle Tagge
- Northern Californian Institute of Research and Education, San Francisco, CA, USA
| | | | | | - Samuel Blay Nguah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Bruce Ovbiagele
- University of California San Francisco, San Francisco, CA, USA
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Li J, Qiu Y, Zhang C, Wang H, Bi R, Wei Y, Li Y, Hu B. The role of protein glycosylation in the occurrence and outcome of acute ischemic stroke. Pharmacol Res 2023; 191:106726. [PMID: 36907285 DOI: 10.1016/j.phrs.2023.106726] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/03/2023] [Accepted: 03/09/2023] [Indexed: 03/12/2023]
Abstract
Acute ischemic stroke (AIS) is a serious and life-threatening disease worldwide. Despite thrombolysis or endovascular thrombectomy, a sizeable fraction of patients with AIS have adverse clinical outcomes. In addition, existing secondary prevention strategies with antiplatelet and anticoagulant drugs therapy are not able to adequately decrease the risk of ischemic stroke recurrence. Thus, exploring novel mechanisms for doing so represents an urgent need for the prevention and treatment of AIS. Recent studies have discovered that protein glycosylation plays a critical role in the occurrence and outcome of AIS. As a common co- and post-translational modification, protein glycosylation participates in a wide variety of physiological and pathological processes by regulating the activity and function of proteins or enzymes. Protein glycosylation is involved in two causes of cerebral emboli in ischemic stroke: atherosclerosis and atrial fibrillation. Following ischemic stroke, the level of brain protein glycosylation becomes dynamically regulated, which significantly affects stroke outcome through influencing inflammatory response, excitotoxicity, neuronal apoptosis, and blood-brain barrier disruption. Drugs targeting glycosylation in the occurrence and progression of stroke may represent a novel therapeutic idea. In this review, we focus on possible perspectives about how glycosylation affects the occurrence and outcome of AIS. We then propose the potential of glycosylation as a therapeutic drug target and prognostic marker for AIS patients in the future.
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Affiliation(s)
- Jianzhuang Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanmei Qiu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunlin Zhang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hailing Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rentang Bi
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanhao Wei
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanan Li
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Bo Hu
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Cadel L, Cimino SR, Bradley-Ridout G, Hitzig SL, Patel T, Ho CH, Packer TL, Lofters AK, Hahn-Goldberg S, McCarthy LM, Guilcher SJT. Medication self-management interventions for persons with stroke: A scoping review. PLoS One 2023; 18:e0285483. [PMID: 37200316 DOI: 10.1371/journal.pone.0285483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/25/2023] [Indexed: 05/20/2023] Open
Abstract
The use of multiple medications is common following a stroke for secondary prevention and management of co-occurring chronic conditions. Given the use of multiple medications post-stroke, optimizing medication self-management for this population is important. The objective of this scoping review was to identify and summarize what has been reported in the literature on interventions related to medication self-management for adults (aged 18+) with stroke. Electronic databases (Ovid Medline, Ovid Embase, EBSCO CINAHL, Ovid PsycINFO, Web of Science) and grey literature were searched to identify relevant articles. For inclusion, articles were required to include an adult population with stroke undergoing an intervention aimed at modifying or improving medication management that incorporated a component of self-management. Two independent reviewers screened the articles for inclusion. Data were extracted and summarized using descriptive content analysis. Of the 56 articles that met the inclusion criteria, the focus of most interventions was on improvement of secondary stroke prevention through risk factor management and lifestyle modifications. The majority of studies included medication self-management as a component of a broader intervention. Most interventions used both face-to-face interactions and technology for delivery. Behavioural outcomes, specifically medication adherence, were the most commonly targeted outcomes across the interventions. However, the majority of interventions did not specifically or holistically target medication self-management. There is an opportunity to better support medication self-management post-stroke by ensuring interventions are delivered across sectors or in the community, developing an understanding of the optimal frequency and duration of delivery, and qualitatively exploring experiences with the interventions to ensure ongoing improvement.
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Affiliation(s)
- Lauren Cadel
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Stephanie R Cimino
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Sander L Hitzig
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tejal Patel
- University of Waterloo School of Pharmacy, Kitchener, ON, Canada
- Schlegel-University of Waterloo Research Institute of Aging, Waterloo, ON, Canada
| | - Chester H Ho
- Division of Physical Medicine & Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Tanya L Packer
- Schools of Occupational Therapy and Health Administration, Dalhousie University, Halifax, NS, Canada
- Department of Rehabilitation, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Aisha K Lofters
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Research Institute, Toronto, ON, Canada
| | - Shoshana Hahn-Goldberg
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- OpenLab, University Health Network, Toronto, ON, Canada
| | - Lisa M McCarthy
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Sara J T Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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5
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Kilkenny MF, Olaiya MT, Dalli LL, Kim J, Andrew NE, Sanfilippo FM, Thrift AG, Nelson M, Pearce C, Sanders L, Dewey H, Clissold B, Grimley R, Cadilhac DA. Treatment with Multiple Therapeutic Classes of Medication is Associated with Survival after Stroke. Neuroepidemiology 2021; 56:66-74. [PMID: 34758474 DOI: 10.1159/000520823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/31/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Treatment with several therapeutic classes of medication is recommended for secondary prevention of stroke. We analysed the associations between the number of classes of prevention medications supplied within 90 days post-discharge for ischemic stroke (IS)/transient ischemic attack (TIA) and survival. PATIENTS AND METHODS Retrospective cohort study of adults with first-ever IS/TIA (2010-2014) from the Australian Stroke Clinical Registry individually linked with data from national pharmaceutical and Medicare claims. Exposure was the number of classes of recommended medications, i.e. blood pressure-lowering, antithrombotic or lipid-lowering agents, supplied to patients within 90 days post-discharge for IS/TIA. The longitudinal association between the number of classes of medications and survival was evaluated with Cox proportional hazards regression models using the landmark approach. A landmark date of 90 days post-hospital discharge was used to separate exposure and outcome periods and only patients who survived until this date were included. RESULTS Of 8,429 patients (43% female, median age 74 years, 80% IS), 607 (7%) died in the year following 90 days post-discharge. Overall, 56% of patients were supplied all three classes of medications, 28% two classes of medications, 11% one class of medications, and 5% no class of medications. Compared to patients supplied all three medication classes, adjusted hazard ratios for all-cause mortality ranged from 1.43 (95% confidence interval [CI]: 1.18-1.72) in those supplied two medication classes to 2.04 (CI: 1.44-2.88) in those supplied with no medication class. CONCLUSION Treatment with all three classes of guideline-recommended medications within 90 days post-discharge was associated with better survival. Ongoing efforts are required to ensure optimal pharmacological intervention for secondary prevention of stroke.
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Affiliation(s)
- Monique F Kilkenny
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Muideen T Olaiya
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Lachlan L Dalli
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Joosup Kim
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Washington, Australia
| | - Amanda G Thrift
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Mark Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Lauren Sanders
- Department of Neurosciences, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Helen Dewey
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Benjamin Clissold
- Neurosciences Department, Monash Health, Clayton, Victoria, Australia
- Neurosciences Department, Barwon Health, Geelong, Victoria, Australia
| | - Rohan Grimley
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- School of Medicine, Griffith University, Birtinya, Queensland, Australia
| | - Dominique A Cadilhac
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
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Hasan TF, Hasan H, Kelley RE. Overview of Acute Ischemic Stroke Evaluation and Management. Biomedicines 2021; 9:1486. [PMID: 34680603 PMCID: PMC8533104 DOI: 10.3390/biomedicines9101486] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/05/2021] [Accepted: 10/13/2021] [Indexed: 01/19/2023] Open
Abstract
Stroke is a major contributor to death and disability worldwide. Prior to modern therapy, post-stroke mortality was approximately 10% in the acute period, with nearly one-half of the patients developing moderate-to-severe disability. The most fundamental aspect of acute stroke management is "time is brain". In acute ischemic stroke, the primary therapeutic goal of reperfusion therapy, including intravenous recombinant tissue plasminogen activator (IV TPA) and/or endovascular thrombectomy, is the rapid restoration of cerebral blood flow to the salvageable ischemic brain tissue at risk for cerebral infarction. Several landmark endovascular thrombectomy trials were found to be of benefit in select patients with acute stroke caused by occlusion of the proximal anterior circulation, which has led to a paradigm shift in the management of acute ischemic strokes. In this modern era of acute stroke care, more patients will survive with varying degrees of disability post-stroke. A comprehensive stroke rehabilitation program is critical to optimize post-stroke outcomes. Understanding the natural history of stroke recovery, and adapting a multidisciplinary approach, will lead to improved chances for successful rehabilitation. In this article, we provide an overview on the evaluation and the current advances in the management of acute ischemic stroke, starting in the prehospital setting and in the emergency department, followed by post-acute stroke hospital management and rehabilitation.
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Affiliation(s)
- Tasneem F. Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
| | - Hunaid Hasan
- Hasan & Hasan Neurology Group, Lapeer, MI 48446, USA;
| | - Roger E. Kelley
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, LA 71103, USA;
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7
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Xu J, Zhou Y, Yan C, Wang X, Lou J, Luo Y, Gao S, Wang J, Wu L, Gao X, Shao A. Neurosteroids: A novel promise for the treatment of stroke and post-stroke complications. J Neurochem 2021; 160:113-127. [PMID: 34482541 DOI: 10.1111/jnc.15503] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 01/14/2023]
Abstract
Stroke is the primary reason for death and disability worldwide, with few treatment strategies to date. Neurosteroids, which are natural molecules in the brain, have aroused great interest in the field of stroke. Neurosteroids are a kind of steroid that acts on the nervous system, and are synthesized in the mitochondria of neurons or glial cells using cholesterol or other steroidal precursors. Neurosteroids mainly include estrogen, progesterone (PROG), allopregnanolone, dehydroepiandrosterone (DHEA), and vitamin D (VD). Most of the preclinical studies have confirmed that neurosteroids can decrease the risk of stroke, and improve stroke outcomes. In the meantime, neurosteroids have been shown to have a positive therapeutic significance in some post-stroke complications, such as epilepsy, depression, anxiety, cardiac complications, movement disorders, and post-stroke pain. In this review, we report the historical background, modulatory mechanisms of neurosteroids in stroke and post-stroke complications, and emphasize on the application prospect of neurosteroids in stroke therapy.
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Affiliation(s)
- Jiawei Xu
- The First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yunxiang Zhou
- Department of Surgical Oncology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Caochong Yan
- The Key Laboratory of Reproductive Genetics, Ministry of Education, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianyao Lou
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yi Luo
- The Second Affiliated Hospital of Zhejiang University School of Medicine (Changxing Branch), Changxing, Huzhou, Zhejiang, China
| | - Shiqi Gao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Junjie Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Liang Wu
- Department of Pathology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiangfu Gao
- The First Affiliated Hospital of Zhejiang, Chinese Medical University, Hangzhou, Zhejiang, China
| | - Anwen Shao
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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8
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Venketasubramanian N, Anderson C, Ay H, Aybek S, Brinjikji W, de Freitas GR, Del Brutto OH, Fassbender K, Fujimura M, Goldstein LB, Haberl RL, Hankey GJ, Heiss WD, Lestro Henriques I, Kase CS, Kim JS, Koga M, Kokubo Y, Kuroda S, Lee K, Lee TH, Liebeskind DS, Lip GYH, Meairs S, Medvedev R, Mehndiratta MM, Mohr JP, Nagayama M, Pantoni L, Papanagiotou P, Parrilla G, Pastori D, Pendlebury ST, Pettigrew LC, Renjen PN, Rundek T, Schminke U, Shinohara Y, Tang WK, Toyoda K, Wartenberg KE, Wasay M, Hennerici MG. Stroke Care during the COVID-19 Pandemic: International Expert Panel Review. Cerebrovasc Dis 2021; 50:245-261. [PMID: 33756459 PMCID: PMC8089455 DOI: 10.1159/000514155] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has placed a tremendous strain on healthcare services. This study, prepared by a large international panel of stroke experts, assesses the rapidly growing research and personal experience with COVID-19 stroke and offers recommendations for stroke management in this challenging new setting: modifications needed for prehospital emergency rescue and hyperacute care; inpatient intensive or stroke units; posthospitalization rehabilitation; follow-up including at-risk family and community; and multispecialty departmental developments in the allied professions. SUMMARY The severe acute respiratory syndrome coronavirus 2 uses spike proteins binding to tissue angiotensin-converting enzyme (ACE)-2 receptors, most often through the respiratory system by virus inhalation and thence to other susceptible organ systems, leading to COVID-19. Clinicians facing the many etiologies for stroke have been sobered by the unusual incidence of combined etiologies and presentations, prominent among them are vasculitis, cardiomyopathy, hypercoagulable state, and endothelial dysfunction. International standards of acute stroke management remain in force, but COVID-19 adds the burdens of personal protections for the patient, rescue, and hospital staff and for some even into the postdischarge phase. For pending COVID-19 determination and also for those shown to be COVID-19 affected, strict infection control is needed at all times to reduce spread of infection and to protect healthcare staff, using the wealth of well-described methods. For COVID-19 patients with stroke, thrombolysis and thrombectomy should be continued, and the usual early management of hypertension applies, save that recent work suggests continuing ACE inhibitors and ARBs. Prothrombotic states, some acute and severe, encourage prophylactic LMWH unless bleeding risk is high. COVID-19-related cardiomyopathy adds risk of cardioembolic stroke, where heparin or warfarin may be preferable, with experience accumulating with DOACs. As ever, arteritis can prove a difficult diagnosis, especially if not obvious on the acute angiogram done for clot extraction. This field is under rapid development and may generate management recommendations which are as yet unsettled, even undiscovered. Beyond the acute management phase, COVID-19-related stroke also forces rehabilitation services to use protective precautions. As with all stroke patients, health workers should be aware of symptoms of depression, anxiety, insomnia, and/or distress developing in their patients and caregivers. Postdischarge outpatient care currently includes continued secondary prevention measures. Although hoping a COVID-19 stroke patient can be considered cured of the virus, those concerned for contact safety can take comfort in the increasing use of telemedicine, which is itself a growing source of patient-physician contacts. Many online resources are available to patients and physicians. Like prior challenges, stroke care teams will also overcome this one. Key Messages: Evidence-based stroke management should continue to be provided throughout the patient care journey, while strict infection control measures are enforced.
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Affiliation(s)
| | - Craig Anderson
- The George Institute for Global Health, Camperdown, Washington, Australia
| | - Hakan Ay
- Departments of Neurology and Radiology, Massachusetts General Hospital, Harvard School of Medicine, Boston, Massachusetts, USA
- Takeda Pharmaceutical Co. Limited, Cambridge, Massachusetts, USA
| | - Selma Aybek
- Department of Neurology, University Hospital Inselspital, Bern University, Bern, Switzerland
| | - Waleed Brinjikji
- Department of Radiology, Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Gabriel R de Freitas
- Instituto D'Or de Pesquisa e Ensino (IDOR), Rio de Janeiro, Brazil
- Department of Neurology, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Oscar H Del Brutto
- School of Medicine, Universidad Espiritu Santo-Ecuador, Samborondón, Ecuador
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Centre, Homburg, Germany
| | - Miki Fujimura
- Department of Neurosurgery, Kohnan Hospital, Sendai, Japan
- Division of Advanced Cerebrovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
| | - Larry B Goldstein
- Department of Neurology, University of Kentucky, Lexington, Kentucky, USA
| | - Roman L Haberl
- Department of Neurology and Neurological Intensive Medicine, Munich Clinic gGmbH, Academic Teaching Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, Washington, Australia
| | | | - Isabel Lestro Henriques
- Department of Neurosciences, Neurology Service, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jong S Kim
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Kokubo
- Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan
| | - Kiwon Lee
- Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Stephen Meairs
- Department of Neurology, Universitätsmedizin Mannheim, Mannheim, Germany
| | - Roman Medvedev
- Research Center of Neurology, Moscow, Russian Federation
| | | | - Jay P Mohr
- Tananbaum Stroke Center, New York, New York, USA
| | - Masao Nagayama
- Department of Neurology, International University of Health and Welfare(IUHW), Graduate School of Medicine, Tokyo, Japan
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte, Germany
- Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Guillermo Parrilla
- Department of Neurology, Interventional Neuroradiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Sarah T Pendlebury
- Departments of Internal Medicine and Geratology, John Radcliffe Hospital, Oxford, United Kingdom
- Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | | | | | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Ulf Schminke
- Department of Neurology, University Medicine, Greifswald, Germany
| | | | - Wai Kwong Tang
- Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Mohammad Wasay
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Michael G Hennerici
- Department of Neurology, Medical Faculty, Mannheim University of Heidelberg, Mannheim, Germany
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Ma TT, Wong ICK, Whittlesea C, Man KKC, Lau W, Wang Z, Brauer R, MacDonald TM, Mackenzie IS, Wei L. Impact of multiple cardiovascular medications on mortality after an incidence of ischemic stroke or transient ischemic attack. BMC Med 2021; 19:24. [PMID: 33530992 PMCID: PMC7856718 DOI: 10.1186/s12916-021-01900-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To manage the risk factors and to improve clinical outcomes, patients with stroke commonly receive multiple cardiovascular medications. However, there is a lack of evidence on the optimum combination of medication therapy in the primary care setting after ischemic stroke. Therefore, this study aimed to investigate the effect of multiple cardiovascular medications on long-term survival after an incident stroke event (ischemic stroke or transient ischemic attack (TIA)). METHODS This study consisted of 52,619 patients aged 45 and above with an incident stroke event between 2007 and 2016 in The Health Improvement Network database. We estimated the risk of all-cause mortality in patients with multiple cardiovascular medications versus monotherapy using a marginal structural model. RESULTS During an average follow-up of 3.6 years, there were 9230 deaths (7635 in multiple cardiovascular medication groups and 1595 in the monotherapy group). Compared with patients prescribed monotherapy only, the HRs of mortality were 0.82 (95% CI 0.75-0.89) for two medications, 0.65 (0.59-0.70) for three medications, 0.61 (0.56-0.67) for four medications, 0.60 (0.54-0.66) for five medications and 0.66 (0.59-0.74) for ≥ six medications. Patients with any four classes of antiplatelet agents (APAs), lipid-regulating medications (LRMs), angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers, diuretics and calcium channel blockers (CCBs) had the lowest risk of mortality (HR 0.51, 95% CI 0.46-0.57) versus any one class. The combination containing APAs, LRMs, ACEIs/ARBs and CCBs was associated with a 61% (95% CI 53-68%) lower risk of mortality compared with APAs alone. CONCLUSION Our results suggested that combination therapy of four or five cardiovascular medications may be optimal to improve long-term survival after incident ischemic stroke or TIA. APAs, LRMs, ACEIs/ARBs and CCBs were the optimal constituents of combination therapy in the present study.
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Affiliation(s)
- Tian-Tian Ma
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Ian C K Wong
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Cate Whittlesea
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Kenneth K C Man
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Wallis Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Zixuan Wang
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Ruth Brauer
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit (MEMO Research) and Hypertension Research Centre, University of Dundee, Dundee, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit (MEMO Research) and Hypertension Research Centre, University of Dundee, Dundee, UK
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK.
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10
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Zhang L, Shi J, Pan Y, Li Z, Yan H, Liu C, Lv W, Meng X, Wang Y. Secondary prevention medication persistence and prognosis of acute ischaemic stroke or transient ischaemic attack. Stroke Vasc Neurol 2021; 6:376-383. [PMID: 33526631 PMCID: PMC8485245 DOI: 10.1136/svn-2020-000471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 12/08/2020] [Accepted: 01/02/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction The risk of disability and mortality is high among recurrent stroke, which highlights the importance of secondary prevention measures. We aim to evaluate medication persistence for secondary prevention and the prognosis of acute ischaemic stroke or transient ischaemic attack (TIA) in China. Methods Patients with acute ischaemic stroke or TIA from the China National Stroke Registry II were divided into 3 groups based on the percentage of persistence in secondary prevention medication classes from discharge to 3 months after onset (level I: persistence=0%, level II: 0%<persistence<100%, level III: persistence=100%). The primary outcome was recurrent stroke. The secondary outcomes included composite events (stroke, myocardial infarction or death from cardiovascular cause), all-cause death and disability (modified Rankin Scale score=3–5) from 3 months to 1 year after onset. Recurrent stroke, composite events and all-cause death were performed using Cox regression model, and disability was identified through logistic regression model using the generalised estimating equation method. Results 18 344 patients with acute ischaemic stroke or TIA were included, 315 (1.7%) of whom experienced recurrent strokes. Compared with level I, the adjusted HR of recurrent stroke for level II was 0.41 (95% CI 0.31 to 0.54) and level III 0.37 (0.28 to 0.48); composite events for level II 0.41 (0.32 to 0.53) and level III 0.38 (0.30 to 0.49); all-cause death for level II 0.28 (0.23 to 0.35) and level III 0.20 (0.16–0.24). Compared with level I, the adjusted OR of disability for level II was 0.89 (0.77 to 1.03) and level III 0.82 (0.72 to 0.93). Conclusions Persistence in secondary prevention medications, especially in all classes of medications prescribed by the physician, was associated with lower hazard of recurrent stroke, composite events, all-cause death and lower odds of disability in patients with acute ischaemic stroke or TIA.
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Affiliation(s)
- Lei Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Changping District Hospital, Beijing, China
| | - Junfeng Shi
- Yixing People's Hospital, Jiangsu Province, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chelsea Liu
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Wei Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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11
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Katsanos AH, Hart RG. New Horizons in Pharmacologic Therapy for Secondary Stroke Prevention. JAMA Neurol 2020; 77:1308-1317. [DOI: 10.1001/jamaneurol.2020.2494] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Aristeidis H. Katsanos
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Robert G. Hart
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
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12
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Jang DE, Zuñiga JA. Factors associated with medication persistence among ischemic stroke patients: a systematic review. Neurol Res 2020; 42:537-546. [PMID: 32321382 DOI: 10.1080/01616412.2020.1754640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE An investigation of the prevalence of medication persistence and associated factors in order to inform effective strategies for improving medication persistence. METHODS A systematic review of the literature from 2010 to the present was performed, using the PRISMA protocol. Primary and empirical observational studies of adult ischemic stroke or transient ischemic attack patients were included. PubMed, CINAHL, Web of Science, Cochrane Library, and PsycInfo databases were searched using the key terms stroke, ischemic stroke, medication persistence, medication adherence, and patient compliance. RESULTS Of four hundred twenty-eight journal articles retrieved, a final 18 articles were included. Short-term medication persistence was 46.2-96.7%, and long-term medication persistence was 41.7-93.0%. Identified hospital-related factors for medication persistence were stroke unit care, in-hospital medical complications, and early follow-up visit. Demographic factors for medication persistence were older age, and high/adequate financial status; disease-related factors were disease history, stroke subtype, and symptom severity. Age less than 75, female sex, comorbidity, antiplatelet medication switch, and polypharmacy were identified as factors of medication nonpersistence. CONCLUSIONS Stroke patients' medication persistence decreases over time, and persistence on antiplatelets, anticoagulants, and statin was poor. Several factors were associated with medication persistence, and these factors should be considered in future secondary preventative strategies.
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Affiliation(s)
- Dong Eun Jang
- School of Nursing, The University of Texas at Austin , Austin, TX, USA
| | - Julie Ann Zuñiga
- School of Nursing, The University of Texas at Austin , Austin, TX, USA
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13
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Xia S, Du X, Guo L, Du J, Arnott C, Lam CSP, Huffman MD, Arima H, Yuan Y, Zheng Y, Wu S, Guang X, Zhou X, Lin H, Cheng X, Anderson CS, Dong J, Ma C. Sex Differences in Primary and Secondary Prevention of Cardiovascular Disease in China. Circulation 2020; 141:530-539. [PMID: 32065775 DOI: 10.1161/circulationaha.119.043731] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite improvements in diagnostic and therapeutic interventions to combat cardiovascular disease (CVD) in recent decades, there are significant ongoing access gaps and sex disparities in prevention that have not been adequately quantified in China. METHODS A representative, cross-sectional, community-based survey of adults (aged ≥45 years) was conducted in 7 geographic regions of China between 2014 and 2016. Logistic regression models were used to determine sex differences in primary and secondary CVD prevention, and any interaction by age, education level, and area of residence. Data are presented as adjusted odds ratios (ORs) and 95% CIs. RESULTS Of 47 841 participants (61.3% women), 5454 (57.2% women) had established CVD and 9532 (70.5% women) had a high estimated 10-year CVD risk (≥10%). Only 48.5% and 48.6% of women and 39.3% and 59.8% of men were on any kind of blood pressure (BP)-lowering medication, lipid-lowering medication, or antiplatelet therapy for primary and secondary prevention, respectively. Women with established CVD were significantly less likely than men to receive BP-lowering medications (OR, 0.79 [95% CI, 0.65-0.95]), lipid-lowering medications (OR, 0.69 [95% CI, 0.56-0.84]), antiplatelets (OR, 0.53 [95% CI, 0.45-0.62]), or any CVD prevention medication (OR, 0.62 [95% CI, 0.52-0.73]). Women with established CVD, however, had better BP control (OR, 1.31 [95% CI, 1.14-1.50]) but less well-controlled low-density lipoprotein cholesterol (OR, 0.66 [95% CI, 0.57-0.76]), and were less likely to smoke (OR, 13.89 [95% CI, 11.24-17.15]) and achieve physical activity targets (OR, 1.92 [95% CI, 1.61-2.29]). Conversely, women with high CVD risk were less likely than men to have their BP, low-density lipoprotein cholesterol, and bodyweight controlled (OR, 0.46 [95% CI, 0.38-0.55]; OR, 0.60 [95% CI, 0.52-0.69]; OR, 0.55 [95% CI, 0.48-0.63], respectively), despite a higher use of BP-lowering medications (OR, 1.21 [95% CI, 1.01-1.45]). Younger patients (<65 years) with established CVD were less likely to be taking CVD preventive medications, but there were no sex differences by area of residence or education level. CONCLUSIONS Large and variable gaps in primary and secondary CVD prevention exist in China, particularly for women. Effective CVD prevention requires an improved overall nationwide strategy and a special emphasis on women with established CVD, who have the greatest disparity and the most to benefit.
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Affiliation(s)
- Shijun Xia
- Beijing Anzhen Hospital, Capital Medical University, China (S.X., X.D., L.G., J. Dong, C.M.)
| | - Xin Du
- Beijing Anzhen Hospital, Capital Medical University, China (S.X., X.D., L.G., J. Dong, C.M.).,Heart Health Research Centre, Beijing, China (X.D., C.S.A.).,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.D., C.A., C.S.P.L., M.D.H., C.S.A.)
| | - Lizhu Guo
- Beijing Anzhen Hospital, Capital Medical University, China (S.X., X.D., L.G., J. Dong, C.M.)
| | - Jing Du
- Beijing Centre for Disease Prevention and Control, China (J. Du)
| | - Clare Arnott
- Heart Health Research Centre, Beijing, China (X.D., C.S.A.).,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.D., C.A., C.S.P.L., M.D.H., C.S.A.).,Cardiology Department (C.A.), Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Australia (C.A.)
| | - Carolyn S P Lam
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.D., C.A., C.S.P.L., M.D.H., C.S.A.).,National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.).,University Medical Centre Groningen, The Netherlands (C.S.P.L.)
| | - Mark D Huffman
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.D., C.A., C.S.P.L., M.D.H., C.S.A.).,Northwestern University Feinberg School of Medicine, Chicago, IL (M.D.H.)
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Japan (H.A.)
| | - Yiqiang Yuan
- The Seventh People's Hospital of Zhengzhou, Henan Province, China (Y.Y.)
| | - Yang Zheng
- Department of Cardiology, The First Hospital of Jilin University, Changchun, China (Y.Z.)
| | - Shulin Wu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China (S.W.)
| | - Xuefeng Guang
- Department of Cardiology, Yanan Hospital of Kunming, Kunming, Yunnan Province, China (X.G.)
| | - Xianhui Zhou
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumchi, Xinjiang Uyghur Autonomous Region, China (X.Z.)
| | - Hongbo Lin
- Yinzhou District Centre for Disease Control and Prevention, Ningbo, Zhejiang Province, China (H.L.)
| | - Xiaoshu Cheng
- Cardiovascular Department, The Second Affiliated Hospital of Nanchang University, Jiangxi Province, China (X.C.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (X.D., C.A., C.S.P.L., M.D.H., C.S.A.).,Neurology Department (C.S.A.), Royal Prince Alfred Hospital, Sydney, Australia.,The George Institute China at Peking University Health Science Centre, China (C.S.A.)
| | - Jianzeng Dong
- Beijing Anzhen Hospital, Capital Medical University, China (S.X., X.D., L.G., J. Dong, C.M.).,The First Affiliated Hospital of Zhengzhou University, Henan Province, China (J. Dong)
| | - Changsheng Ma
- Beijing Anzhen Hospital, Capital Medical University, China (S.X., X.D., L.G., J. Dong, C.M.)
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14
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Myers J, Bravata DM, Sico J, Myers L, Chaturvedi S, Cheng E, Baye F, Zillich AJ. The quality of medication optimization among patients with transient ischemic attack or minor stroke. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jaclyn Myers
- Department of Pharmacy Practice Purdue University College of Pharmacy Indianapolis Indiana
| | - Dawn M. Bravata
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | - Jason Sico
- Departments of Internal Medicine and Neurology Yale University School of Medicine New Haven Connecticut
| | - Laura Myers
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | | | - Eric Cheng
- Department of Neurology VA Greater Los Angeles Healthcare System Los Angeles California
| | - Fitsum Baye
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | - Alan J. Zillich
- Department of Pharmacy Practice Purdue University College of Pharmacy Indianapolis Indiana
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
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15
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Khandkar C, Vaidya K, Patel S. Colchicine for Stroke Prevention: A Systematic Review and Meta-analysis. Clin Ther 2019; 41:582-590.e3. [DOI: 10.1016/j.clinthera.2019.02.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/30/2019] [Accepted: 02/04/2019] [Indexed: 12/17/2022]
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16
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Ma TT, Wong ICK, Man KKC, Chen Y, Crake T, Ozkor MA, Ding LQ, Wang ZX, Zhang L, Wei L. Effect of evidence-based therapy for secondary prevention of cardiovascular disease: Systematic review and meta-analysis. PLoS One 2019; 14:e0210988. [PMID: 30657781 PMCID: PMC6338367 DOI: 10.1371/journal.pone.0210988] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The combination pharmacotherapy of antiplatelet agents, lipid-modifiers, ACE inhibitors/ARBs and beta-blockers are recommended by international guidelines. However, data on effectiveness of the evidence-based combination pharmacotherapy (EBCP) is limited. OBJECTIVES To determine the effect of EBCP on mortality and Cardiovascular events in patients with Coronary Heart Disease (CHD) or cerebrovascular disease. METHODS Publications in EMBASE and Medline up to October 2018 were searched for cohort and case-control studies on EBCP for the secondary prevention of cardiovascular disease. The main outcomes were all-cause mortality and major cardiovascular events. Meta-analyses were performed based on random effects models. RESULTS 21 studies were included. Comparing EBCP to either monotherapy or no therapy, the pooled risk ratios were 0.60 (95% confidence interval 0.55 to 0.66) for all-cause mortality, 0.70 (0.62 to 0.79) for vascular mortality, 0.73 (0.64 to 0.83) for myocardial infarction and 0.79 (0.68 to 0.91) for cerebrovascular events. Optimal EBCP (all 4 classes of drug prescribed) had a risk ratio for all-cause mortality of 0.50 (0.40 to 0.64). This benefit became more dilute as the number of different classes of drug comprising EBCP was decreased-for 3 classes of drug prescribed the risk ratio was 0.58 (0.49 to 0.69) and for 2 classes, the risk ratio was 0.67 (0.60 to 0.76). CONCLUSIONS EBCP reduces the risk of all-cause mortality and cardiovascular events in patients with CHD or cerebrovascular disease. The different classes of drugs comprising EBCP work in an additive manner, with optimal EBCP conferring the greatest benefit.
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Affiliation(s)
- Tian-Tian Ma
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
| | - Ian C. K. Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yang Chen
- UCL Institute of Cardiovascular Science, Univeristy College London, London, United Kingdom
| | - Thomas Crake
- Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Muhiddin A. Ozkor
- Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Ling-Qing Ding
- Department of Pharmacy, The Affiliated Cardiovascular Hospital of Xiamen University, Xiamen, China
| | - Zi-Xuan Wang
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
| | - Lin Zhang
- Intensive Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Li Wei
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
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17
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Kelly PJ, Murphy S, Coveney S, Purroy F, Lemmens R, Tsivgoulis G, Price C. Anti-inflammatory approaches to ischaemic stroke prevention. J Neurol Neurosurg Psychiatry 2018; 89:211-218. [PMID: 28935831 DOI: 10.1136/jnnp-2016-314817] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 07/24/2017] [Accepted: 08/08/2017] [Indexed: 12/19/2022]
Abstract
Stroke is a major cause of neurological morbidity and mortality. Atherosclerosis is a major contributor to first and recurrent stroke. A growing evidence base indicates that inflammation is a key process in the pathogenesis of atherosclerosis, leading to thromboembolic events. In this review, we summarise the evidence linking inflammation to stroke risk and discuss clinical trials addressing the 'inflammation hypothesis' in coronary disease and stroke. Trial registration number CONVINCE trial ClinicalTrials.gov number; NCT 02898610; Pre-results.
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Affiliation(s)
- Peter J Kelly
- Health Research Board Irish Stroke Clinical Trials Network and Mater University Hospital/University College Dublin, Dublin, Ireland
| | - Sean Murphy
- Royal College of Surgeons Ireland, Dublin, Ireland.,Mater University Hospital/University College Dublin, Dublin, Ireland
| | - Sarah Coveney
- Health Research Board Irish Stroke Clinical Trials Network and Mater University Hospital/University College Dublin, Dublin, Ireland
| | - Francisco Purroy
- Stroke Unit, Department of Neurology, Hospitalt Universitari Arnau de Vilanova de Lleida and Universitat de Lleida, Biomedical Research Institute of Lleida, Universitat de Lleida, Spain, Dublin, Ireland
| | - Robin Lemmens
- Department of Neurosciences, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), KU Leuven - University of Leuven, Leuven, Belgium.,Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,VIB Center for Brain and Disease Research, Laboratory of Neurobiology, Leuven, Belgium
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, University of Athens, School of Medicine, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Chris Price
- Institute of Neuroscience, Newcastle University, Newcastle, UK
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18
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Khoumri C, Bailly H, Delpont B, Daubail B, Blanc C, Chazalon C, Durier J, Hervieu-Bègue M, Osseby GV, Rouaud O, Giroud M, Vergely C, Béjot Y. Temporal trends in the premorbid use of preventive treatments in patients with acute ischemic cerebrovascular events and a history of vascular disease: The Dijon Stroke Registry (1985–2010). Presse Med 2017; 46:e259-e267. [DOI: 10.1016/j.lpm.2017.01.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/09/2016] [Accepted: 01/05/2017] [Indexed: 11/25/2022] Open
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19
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Latorre JGS, Flanagan S, Phipps MS, Shenoy AM, Bennett A, Seidenwurm D. Quality improvement in neurology. Neurology 2017; 89:1619-1626. [DOI: 10.1212/wnl.0000000000004486] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
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20
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Albright KC, Howard VJ, Howard G, Muntner P, Bittner V, Safford MM, Boehme AK, Rhodes JD, Beasley TM, Judd SE, McClure LA, Limdi N, Blackburn J. Age and Sex Disparities in Discharge Statin Prescribing in the Stroke Belt: Evidence From the Reasons for Geographic and Racial Differences in Stroke Study. J Am Heart Assoc 2017; 6:e005523. [PMID: 28768644 PMCID: PMC5586419 DOI: 10.1161/jaha.117.005523] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 06/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is a costly and debilitating disease that disproportionately affects blacks. Despite the efficacy of statins, evidence suggests racial disparities may exist in statin prescribing. METHODS AND RESULTS We analyzed discharge medications for participants hospitalized for an ischemic stroke during follow-up of the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study. Medications on admission and discharge were abstracted from medical records. Among the 666 eligible incident strokes (2003-2013), analyses were restricted to 323 participants who were not statin users at the time of admission and had no history of atrial fibrillation. Overall, 48.7% were prescribed a statin on discharge. In the Stroke Belt, participants aged 65 years and older were 47% less likely to be discharged on a statin compared with those younger than 65 years (relative risk [RR], 0.53; 95% CI, 0.38-0.74). This association was not observed in non-Stroke Belt residents. Outside the Stroke Belt, blacks were more likely than whites to be discharged on a statin (RR, 1.42; 95% CI, 1.04-1.94), while no black:white association was present among Stroke Belt residents (RR, 0.93; 95% CI, 0.69-1.26; P for interaction=0.228). Compared with women, men in the Stroke Belt were 31% less likely to be discharged on a statin (RR, 0.69; 95% CI, 0.50-0.94) while men outside the Stroke Belt were more likely to be discharged on a statin (RR, 1.38; 95% CI, 0.99-1.92; P for interaction=0.004). CONCLUSIONS Statin discharge prescribing may differ among Stroke Belt and non-Stroke Belt residents, particularly in older Americans and men.
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Affiliation(s)
- Karen C Albright
- Geriatric Research, Education and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, AL
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | | | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, AL
| | - Vera Bittner
- Department of Medicine, University of Alabama at Birmingham, AL
| | | | | | - J David Rhodes
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - T Mark Beasley
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Leslie A McClure
- Department of Biostatistics, University of Alabama at Birmingham, AL
| | - Nita Limdi
- Department of Neurology, University of Alabama at Birmingham, AL
| | - Justin Blackburn
- Department of Health Care Organization & Policy, University of Alabama at Birmingham, AL
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21
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Park JH, Lee J, Ovbiagele B. Association of Optimal Combination Drug Treatment with Obesity Status among Recent Ischemic Stroke Patients: Results of the Vitamin Intervention for Stroke Prevention (VISP) Trial. J Stroke 2017; 19:213-221. [PMID: 28592783 PMCID: PMC5466287 DOI: 10.5853/jos.2016.01347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/13/2017] [Accepted: 04/18/2017] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose One explanation for the ‘obesity paradox’, where obese patients seem to have better cardiovascular outcomes than lean patients, is that obese patients display an identifiable high cardiovascular risk phenotype that may lead to receiving or seeking earlier/more aggressive treatment.
Methods We analyzed a clinical trial dataset comprising 3643 recent (<120 days) ischemic stroke patients followed up for 2 years. Subjects were categorized as lean (body mass index [BMI], <25 kg/m2, n=1,006), overweight (25-29.9 kg/m2, n=1,493), or obese (≥30 kg/m2, n=1,144). Subjects were classified as level 0 to III depending on the number of secondary prevention prescriptions divided by the number of potentially indicated drugs (0=none of the indicated medications and III=all indicated medications as optimal combination drug treatment [OCT]). Independent associations between each BMI category and stroke/myocardial infarction/vascular death (major vascular events [MVEs]) and all-cause death were assessed.
Results MVEs occurred in 17.4% of lean, 16.1% of overweight, and 17.1% of obese patients; death occurred in 7.3%, 5.5%, and 5.1%, respectively. Individuals with a higher BMI status received more OCT (45.8%, 51.7%, and 55.3%, respectively; P<0.001). In the lean patient group, multivariable adjusted Cox analyses, showed that compared with levels 0-I, level II and level III were linked to lower risk of MVEs (hazard ratio [HR] 0.55; 95% confidence interval [CI]: 0.32–0.95 and HR 0.48; 95% CI: 0.28−0.83, respectively) and death (0.44; 0.21–0.96 and 0.23; 0.10−0.54, respectively).
Conclusions OCT for secondary prevention after an ischemic stroke is less frequent in lean (vs. obese) subjects, but when implemented is related to significantly better clinical outcomes.
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Affiliation(s)
- Jong-Ho Park
- Department of Neurologry, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Korea
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
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22
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Tan Y, Pan Y, Liu L, Wang Y, Zhao X, Wang Y. One-year outcomes and secondary prevention in patients after acute minor stroke: results from the China National Stroke Registry. Neurol Res 2017; 39:484-491. [PMID: 28476094 DOI: 10.1080/01616412.2017.1322804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ying Tan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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23
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Sarfo FS, Ovbiagele B. Stroke minimization through additive anti-atherosclerotic agents in routine treatment (SMAART): A pilot trial concept for improving stroke outcomes in sub-Saharan Africa. J Neurol Sci 2017; 377:167-173. [PMID: 28477689 DOI: 10.1016/j.jns.2017.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/09/2017] [Accepted: 04/10/2017] [Indexed: 01/24/2023]
Abstract
There has been an unprecedented rise in the prevalence of stroke in sub-Saharan Africa (SSA), which when compared to stroke profiles in high-income countries (HIC) is characterized by a younger age of onset, higher case fatality rates, and more severe disability among survivors. Stroke survivors in SSA (vs. HIC) are especially at high risk for recurrent vascular events or death due to undiagnosed or under-controlled vascular risk factors, logistical challenges, low health literacy, and lack of care affordability. While international expert consensus secondary prevention guidelines recommend that antihypertensive, statin and anti-platelet therapy, be initiated promptly after ischemic stroke and adhered to in a persistent fashion to achieve optimal vascular risk reduction, these goals are seldom realized in routine clinical care settings in SSA. A relatively simple, low-cost, evidence-based strategy that could be largely applied in a uniform manner to stroke survivors in low-to-middle income countries (LMICs), including the nations of SSA, is sorely needed. Fixed-dose combination pills, also known "polypills", containing generic drugs, i.e. Aspirin, a statin, and blood pressure (BP) lowering medication(s) may be a viable avenue to improve medication adherence and consequently reduce risk of further disability or death on a large scale among stroke survivors encountered in resource-constrained regions. In this conceptual article, we review the data supporting the rationale for a polypill to improve stroke outcomes in SSA and propose the conduct of a Stroke Minimization through Additive Anti-atherosclerotic Agent in Routine Treatment (SMAART) pilot study to determine the impact of a polypill such as the Polycap DS® in reducing future vascular risk compared to usual care in recent stroke in SSA. A preliminarily feasible and efficacy-suggesting SMAART trial could inform the future design of a multi-center, double-blinded, placebo-controlled, randomized trial comparing the clinical efficacy of the polypill strategy for vascular risk moderation among stroke survivors in LMICs.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Bruce Ovbiagele
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
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24
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Sarfo FS, Ovbiagele B, Akassi J, Kyem G. Baseline Prescription and One-Year Persistence of Secondary Prevention Drugs after an index Stroke in Central Ghana. eNeurologicalSci 2017; 6:68-73. [PMID: 28920085 PMCID: PMC5597054 DOI: 10.1016/j.ensci.2016.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 12/17/2016] [Accepted: 12/26/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND PURPOSE There is a paucity of data on persistence of secondary prevention medications among stroke survivors in resource-limited settings where stroke is on a rapid upward trajectory and its management severely challenged. To avert new cardiovascular events after stroke, preventive medications should be promptly instituted and used continuously. We report 1-year rates and determinants of persistent utilization of secondary prevention therapies after stroke in Ghana. METHODS A retrospective observational study involving 418 stroke survivors enrolled into a Neurology clinic in a tertiary institution in central Ghana between January 2011 and December 2013. Data on demography, stroke type, risk factor profile and five secondary risk prevention medication classes namely antihypertensive, antiplatelet, statins, antidiabetic and anticoagulants were collected from patient charts. Persistence within first year after stroke was defined as continuation of all secondary preventive medications prescribed at enrollment to the Neurology clinic and it excluded 126 (≈30%) patients who could not complete 12 month follow up. Data was closed for analysis in June 2015 to allow for at least 12 months of follow-up. RESULTS Rates of utilization of secondary preventive medications and its intensity were influenced by stroke type and prevailing vascular risk factors. In decreasing order, antihypertensive, lipid-modifying, anti-platelet, anti-diabetic medications and anti-coagulants were prescribed at frequencies (%) of 394 (94.3%), 303 (72.5%), 274 (65.6%), 61 (14.6%) and 2 (0.5%) respectively at enrollment into the Neurology clinic (n=418). Overall, 92.1% of subjects (n=292) under follow-up for 1 year were persistent on secondary prevention medications initiated at enrollment into the neurology clinic with medication class specific rates of 97.5% for antihypertensive, 94.8% for anti-platelets, 94.1% for statins, 85.7% for anti-diabetic and 50% for anticoagulants. Abuse of alcohol was significantly associated with non-persistence, adjusted OR (95% CI) of 3.08 (1.13-8.38). CONCLUSION Persistence of secondary preventive medications among stroke survivors in this resource-limited setting is excellent and comparable to those in resource-replete countries. There is however the need to investigate the causes of high attrition rates from care.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - John Akassi
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Gloria Kyem
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
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25
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Kerschen P, Planté-Bordeneuve V. Current and Future Treatment Approaches in Transthyretin Familial Amyloid Polyneuropathy. Curr Treat Options Neurol 2016; 18:53. [PMID: 27873215 DOI: 10.1007/s11940-016-0436-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OPINION STATEMENT Treatment of transthyretin familial amyloid polyneuropathy (TTR FAP) must be tailored to disease stage. Patients with early stage disease (i.e., without major impairment in walking ability), especially younger patients, should be referred as soon as possible for liver transplantation (LT) in the absence of major comorbid conditions. LT remains the most effective treatment option to date and should be offered to these patients as early as possible. Bridging therapy with an oral TTR stabilizer (tafamidis or diflunisal, according to local access to these treatments) should be started as soon as the diagnosis of TTR FAP is established. Early stage patients who do not wish to or have contraindications to LT should be treated with an oral TTR stabilizer or get access to the newly developed therapeutic options (IONIS TTR-Rx, patisiran, doxycycline/TUDCA). Late stage patients (presenting with significant walking impairment) are usually older and notoriously difficult to treat. They should be offered an oral TTR stabilizer but are not candidates for LT due to a significant rate of perioperative complications and increased risk of progressive neurological and especially cardiac disease despite LT. Access to the different therapies in development should also be considered depending on respective inclusion and exclusion criteria. The abovementioned treatment options were mostly validated in Val30Met mutation patients, but should also be offered to non-Val30Met patients, although mortality rates after LT are higher in these patients. Treatment decisions should be made on an individual basis. Screening for heart, eye, and renal involvement is mandatory for every patient at disease diagnosis and regularly thereafter, even in transplanted patients. Symptomatic treatment should be offered as needed, as well as genetic counseling to at-risk family members. Asymptomatic mutation carriers should benefit from regular screening for early symptoms of disease. Current therapeutic management of TTR FAP will hopefully be changed in the near future with data from the ongoing phase 2/3 studies testing the TTR gene silencing agents. In the longer term, it is likely that combined therapeutic approaches will be necessary to reverse the disease process.
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Affiliation(s)
- Philippe Kerschen
- Service de Neurologie, Centre Hospitalier de Luxembourg, 4 rue Barblé, L-1210, Luxembourg, Luxembourg
| | - Violaine Planté-Bordeneuve
- Service de Neurologie, CHU Henri Mondor, 51 avenue de Lattre de Tassigny, 94000, Créteil, France. .,Groupe de Recherche Clinique Amylose, Université Paris-Est-Créteil, 94000, Créteil, France.
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Callaly E, Ni Chroinin D, Hannon N, Marnane M, Akijian L, Sheehan O, Merwick A, Hayden D, Horgan G, Duggan J, Murphy S, O’Rourke K, Dolan E, Williams D, Kyne L, Kelly PJ. Rates, Predictors, and Outcomes of Early and Late Recurrence After Stroke. Stroke 2016; 47:244-6. [DOI: 10.1161/strokeaha.115.011248] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 09/28/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Few recent studies have investigated the rates and predictors of early and late stroke recurrence using prospective population–based methodology. We investigated recurrent stroke at 2 years in the North Dublin Population Stroke Study (NDPSS).
Methods—
Patients were ascertained from December 2005 to 2006 from overlapping community and hospital sources using hot and cold pursuit. Stroke recurrence, survival, and functional outcome were ascertained at 72 hours, 7 days, 28 days, 90 days, 1 year, and 2 years.
Results—
Of 567 patients, cumulative 2-year stroke recurrence rate was 10.8% and case fatality was 38.6%. Recurrence subtype was associated with initial stroke subtype (
P
<0.001). On multivariable Cox regression, hyperlipidemia (adjusted hazard ratio, 3.32;
P
=0.005) and prior stroke (adjusted hazard ratio, 2.92;
P
=0.01) were independent predictors of 2-year recurrence in 28-day survivors.
Conclusions—
Despite rigorous ascertainment, recurrent stroke rates were lower in current study than in earlier studies. Our data suggest that large sample sizes may be needed for future secondary prevention trials in patients treated with modern preventive medications.
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Affiliation(s)
- Elizabeth Callaly
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Danielle Ni Chroinin
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Niamh Hannon
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Michael Marnane
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Layan Akijian
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Orla Sheehan
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Aine Merwick
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Derek Hayden
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Gillian Horgan
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Joseph Duggan
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Sean Murphy
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Killian O’Rourke
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Eamon Dolan
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - David Williams
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Lorraine Kyne
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
| | - Peter J. Kelly
- From the Neurovascular Unit for Applied Research, Mater University Hospital, University College Dublin, Dublin, Ireland (E.C., D.N.C., N.H., M.M., L.A., O.S., A.M., D.H., G.H., J.D., S.M., K.O’R., L.K., P.J.K.); Departments of Geriatric and Stroke Medicine, Connolly Hospital, Dublin, Ireland (E.D.); Beaumont Hospital, Dublin, Ireland (D.W.); and Royal College of Surgeons, Dublin, Ireland (S.M., D.W.)
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Park JH, Ovbiagele B. Relationship of functional disability after a recent stroke with recurrent stroke risk. Eur J Neurol 2015; 23:361-7. [PMID: 26493027 DOI: 10.1111/ene.12837] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 08/04/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Post-stroke disability status is primarily focused on recovery prognostication but the influence of post-stroke disability on future vascular risk is unknown. The relationship between functional disability after an index stroke and risk of recurrent vascular events was examined. METHODS A cohort analysis of 3680 recent non-cardioembolic, non-to-moderate disabled [modified Rankin Scale (mRS) ≤3] stroke patients aged ≥35 years and followed for 2 years was reviewed. The mRS measured at a median of 35 days after the index stroke was analyzed as a dichotomous variable (mRS 3 vs. ≤2) and in a stepwise manner. Independent associations of post-stroke disability by mRS score with ischaemic stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome) and all-cause death (tertiary outcome) were analyzed. RESULTS Amongst study participants, 435 (11.8%) had an mRS of 3. Compared with mRS ≤2 as no/slight disability, mRS 3 as moderate disability was associated with a higher risk of stroke (adjusted hazard ratio 1.45, 95% confidence interval 1.06-1.99). Compared with mRS 0, there was a progressively higher independent risk for each of the study outcomes: stroke, mRS 1 (1.42, 0.97-2.08), mRS 2 (1.46, 0.97-2.20), mRS 3 (1.89, 1.20-2.97); major vascular events, mRS 1 (1.31, 1.01-1.70), mRS 2 (1.31, 0.99-1.74), mRS 3 (1.46, 1.06-2.01); and all-cause death, mRS 1 (1.75, 1.03-2.98), mRS 2 (2.49, 1.44-4.31), mRS 3 (2.72, 1.43-5.19). CONCLUSION Compared with no/slight disability, moderate disability after a recent stroke is linked to a higher risk of recurrent stroke.
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Affiliation(s)
- J-H Park
- Department of Neurology, Seonam University Myongji Hospital, Goyang, South Korea.,Department of Neurosciences, Medical University of South Carolina, Charleston, SC, USA
| | - B Ovbiagele
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, USA
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28
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Optimal combination treatment and vascular outcomes in recent ischemic stroke patients by premorbid risk level. J Neurol Sci 2015; 355:90-3. [PMID: 26044963 DOI: 10.1016/j.jns.2015.05.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 04/28/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Optimal combination of secondary stroke prevention treatment including antihypertensives, antithrombotic agents, and lipid modifiers is associated with reduced recurrent vascular risk including stroke. It is unclear whether optimal combination treatment has a differential impact on stroke patients based on level of vascular risk. METHODS We analyzed a clinical trial dataset comprising 3680 recent non-cardioembolic stroke patients aged ≥35 years and followed for 2 years. Patients were categorized by appropriateness levels 0 to III depending on the number of the drugs prescribed divided by the number of drugs potentially indicated for each patient (0=none of the indicated medications prescribed and III=all indicated medications prescribed [optimal combination treatment]). High-risk was defined as having a history of stroke or coronary heart disease (CHD) prior to the index stroke event. Independent associations of medication appropriateness level with a major vascular event (stroke, CHD, or vascular death), ischemic stroke, and all-cause death were analyzed. RESULTS Compared with level 0, for major vascular events, the HR of level III in the low-risk group was 0.51 (95% CI: 0.20-1.28) and 0.32 (0.14-0.70) in the high-risk group; for stroke, the HR of level III in the low-risk group was 0.54 (0.16-1.77) and 0.25 (0.08-0.85) in the high-risk group; and for all-cause death, the HR of level III in the low-risk group was 0.66 (0.09-5.00) and 0.22 (0.06-0.78) in the high-risk group. CONCLUSION Optimal combination treatment is related to a significantly lower risk of future vascular events and death among high-risk patients after a recent non-cardioembolic stroke.
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