Better outcome after stroke with higher serum cholesterol levels

Association between blood triglycerides and stroke-associated pneumonia: a prospective cohort study

BACKGROUND

Cerebral infarction requires the reduction of blood lipids, but low triglycerides are associated with poor prognosis. stroke-associated pneumonia (SAP) can also lead to poor prognosis. Therefore, the purpose of this study is to investigate the correlation between triglycerides (TG) and SAP.

METHODS

This prospective cohort study was conducted at the First Affiliated Hospital of Soochow University and enrolled consecutive patients with acute ischemic stroke admitted between March 2019 and March 2021. Univariate analysis, Multivariable logistic regression analysis, subgroup analysis, curve fitting, inflection point analysis, stratified and interaction analyses was performed to examine the relationship between blood TG and SAP.

RESULTS

The study included 240 patients with acute ischemic stroke (92 females, mean age 68 years), of whom 94 developed SAP. Multivariate logistic regression analysis demonstrated that TG levels were independently associated with SAP. The fitting curve shows a linear relationship between TG level and SAP incidence, with a decrease in SAP incidence as TG increases. The inflection point value is TG = 2.6mmol/L.

CONCLUSIONS

The findings suggest that TG levels may be inversely associated with the risk of SAP in elderly patients with acute ischemic stroke.

Developing a nomogram model for 3-month prognosis in patients who had an acute ischaemic stroke after intravenous thrombolysis: a multifactor logistic regression model approach

OBJECTIVES

This study is to establish a nomination graph model for individualised early prediction of the 3-month prognosis of patients who had an acute ischaemic stroke (AIS) receiving intravenous thrombolysis with recombinant tissue plasminogen activator.

DESIGN

For the period from January 2016 through August 2022, 991 patients who had an acute stroke eligible for intravenous thrombolysis were included in the retrospective analysis study. The study was based on multifactor logistic regression.

PARTICIPANTS

Patients who received treatment from January 2016 to February 2021 were included in the training cohort, and those who received treatment from March 2021 to August 2022 were included in the testing cohort.

INTERVENTIONS

Each patient received intravenous thrombolysis within 4.5 hours of onset, with treatment doses divided into standard doses (0.9 mg/kg).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was a 3-month adverse outcome (modified Rankin Scale 3-6).

RESULTS

The National Institutes of Health Stroke Scale Score after thrombolysis (OR=1.18; 95% CI: 1.04 to 1.36; p = 0.015), door-to-needle time (OR=1.01; 95% CI: 1.00 to 1.02; p = 0.003), baseline blood glucose (OR=1.08; 95% CI: 1.00 to 1.16; p=0.042), blood homocysteine (OR=7.14; 95% CI: 4.12 to 12.71; p<0.001), monocytes (OR=0.05; 95% CI: 0.01 to 0.043; p=0.005) and monocytes/high-density lipoprotein (OR=62.93; 95% CI: 16.51 to 283.08; p<0.001) were independent predictors of adverse outcomes 3 months after intravenous thrombolysis, and the above six factors were included in the nominated DGHM2N nomogram. The area under the receiver operating characteristic curve value of the training cohort was 0.870 (95% CI: 0.841 to 0.899) and in the testing cohort was 0.822 (95% CI: 0.769 to 0.875).

CONCLUSIONS

A reliable nomogram model (DGHM2N model) was developed and validated in this study. This nomogram could individually predict the adverse outcome of patients who had an AIS receiving intravenous thrombolysis with alteplase for 3 months.

Predictive value of the BDH2-MN2 nomogram model for prognosis at 3 months after receiving intravenous thrombolysis in patients with acute ischemic stroke

Introduction

The present study focused on developing a nomogram model to predict the 3-month survival of patients with acute ischemic stroke (AIS) receiving intravenous thrombolysis with tissue plasminogen activator (tPA).

Material and methods

A total of 709 patients were enrolled in the present study, including 496 patients in the training set and 213 patients in the validation set. All data were statistically analyzed using R software. We applied LASSO regression analysis to construct nomograms by screening statistically significant predictors from all variables.The model discrimination was evaluated based on the area under the receiver operating characteristic curve (AUC-ROC).

Results

LASSO regression analysis was conducted for all variables, which revealed BNP, DNT, HCY, HDL, MHR, NHR and post-thrombolysis NIHSS as independent predictors of adverse outcomes at 3 months after intravenous thrombolysis. Accordingly, these seven factors were incorporated in the nominated BDH2-MN2 nomogram. The resulting AUC-ROC values determined for the training and validation sets were 0.937 (95% CI: 0.822-0.954) and 0.898 (95% CI: 0.748-0.921), respectively.

Conclusions

A robust BDH2-MN2 (BNP, DNT, HCY, HDL, MHR, NHR and post-thrombolysis NIHSS) nomogram model was successfully developed and validated. The developed nomogram enables prediction of adverse outcomes of individual AIS patients receiving intravenous thrombolysis with alteplase for 3 months.

Prognosis of patients with coexisting obesity and malnutrition after ischemic stroke: A cohort study

BACKGROUND

The double burden of malnutrition, defined as the coexistence of obesity and malnutrition, is an increasing global health concern and is unclear in patients after ischemic stroke. The current study explored the combined impacts of obesity and malnutrition on patients with ischemic stroke.

METHODS

We conducted a single-center prospective cohort study with patients with ischemic stroke enrolled in Minhang Hospital in China between January 2018 and December 2022. Patients were stratified into four categories based on their obesity (defined by body mass index) and nutritional status (classified according to the Controlling Nutritional Status score): (1) nourished nonobese, (2) malnourished nonobese, (3) nourished obese, and (4) malnourished obese. The primary end points were poor outcomes and all-cause mortality at 3 months.

RESULTS

A total of 3160 participants with ischemic stroke were included in our study, of which 64.7% were male and the mean age was 69 years. Over 50% of patients were malnourished. At 3-month follow-up, the malnourished nonobese had the worst outcomes (34.4%), followed by the malnourished obese (33.2%), nourished nonobese (25.1%), and nourished obese (21.8%; P < 0.001). In multivariable analyses, with nourished nonobese group as the reference, the malnourished nonobese group displayed poorer outcomes (odds ratio [OR], 1.395 [95% CI, 1.169-1.664], P < 0.001) and higher all-cause mortality (OR, 1.541 [95% CI, 1.054-2.253], P = 0.026), but only a nonsignificant increase in poor prognosis rate (33.2% vs. 25.1%, P = 0.102) and mortality (4.2% vs. 3.6%, P = 0.902) were observed in the malnourished obese group.

CONCLUSION

A high prevalence of malnutrition is observed in the large population suffering from ischemic attack, even in the obese. Malnourished patients have the worst prognosis particularly in those with severe nutritional status regardless of obesity, while the best functional outcomes and the lowest mortality are demonstrated in nourished obese participants.

Endovascular recanalization in patients with severely disabling non-acute ischemic stroke

BACKGROUND

It is unclear whether patients with severely disabling ischemic stroke (SDIS-that is, modified Rankin scale (mRS) scores of 3-5) benefit from non-acute endovascular recanalization (ER).

OBJECTIVE

To determine the effect of non-acute ER or medical treatment in severely disabled patients with non-acute ischemic stroke (mRS scores of 3-5).

METHODS

Between January 2018 and August 2021, non-acute patients with SDIS and large vessel occlusion were collected from two regional stroke centers. Patients who met the inclusion and exclusion criteria were assigned to two groups based on whether they underwent ER (ER group) or not (medical group). The primary functional outcome was the mRS score at 90 days. The primary safety outcomes were the recurrence of stroke and mortality.

RESULTS

Of the 325 patients with hypoperfusion cerebral infarction caused by large vessel occlusion, 63 met the inclusion criteria (32 patients in the ER group, 31 patients in the medical group). A favorable outcome (mRS score ≤2) occurred more often in the ER group than in the medical group (59.4% vs 22.6%, respectively; OR=0.12, 95% CI 0.02 to 0.58; P<0.01). There were no significant differences in new-onset ischemic stroke (6.3% vs 3.2%, respectively; P=1.000), symptomatic intracerebral hemorrhage (12.5% vs 0%, respectively; P=0.113), or mortality within 90 days (6.3% vs 6.5%, respectively; P=1.000) between the two groups. Preoperative mRS scores (OR=7.34, 95% CI 1.56 to 34.5; P=0.02) and ER (OR=0.12, 95% CI 0.02 to 0.58; P<0.01) were significantly associated with outcome.

CONCLUSION

Our data suggest that patients with SDIS (mRS score 3-5) with smaller infarct cores and better collateral circulation can benefit from non-acute ER, with no additional perioperative complications or mortality.

Admission LDL-cholesterol, statin pretreatment and early outcomes in acute ischemic stroke

BACKGROUND

Lipid paradox of low LDL-C may cause physicians to be reluctant to use statins in acute ischemic stroke (AIS) patients with low LDL-C levels at admission.

OBJECTIVE

This study investigated the association between LDL-C levels and early vascular outcomes and assessed the potential interaction effect between LDL-C and statin pretreatment on early outcomes.

PATIENTS AND METHODS

This was a study of a prospective, multicenter, registry of AIS patients with admission LDL-C. The subjects were divided into 3 groups according to LDL-C levels: low LDL-C (≤100 mg/dL); intermediate LDL-C (>100, <130 mg/dL); and high LDL-C (≥130 mg/dL). The primary early vascular outcome was a composite of stroke (ischemic or hemorrhagic), myocardial infarction and all-cause mortality within 3 months. The associations of LDL-C levels as a continuous variable and the risks of primary outcome using Cox proportional hazards models with restricted cubic splines were explored.

RESULTS

A total of 32,505 patients (age, 69 ± 12; male, 58.6%) were analyzed. The 3 groups showed significant differences in the 3-month primary outcome, with highest events in the low LDL-C group; after adjustment, no significant associations with the 3-month primary outcome remained. U-shaped nonlinear relationships of LDL-C levels with the 3-month primary outcome were observed (Pnon-linearity<0.001), with substantial relationships in the no pretreatment subgroup.

CONCLUSIONS

The relationships between admission LDL-C levels and early outcomes are complex but appear to be paradoxical in patients with low LDL-C and no statin pretreatment. The results suggest that statin pretreatment might offset the paradoxical response of low LDL-C on early vascular outcomes. Further study would be warranted.

Nuclear Magnetic Resonance-Based Metabolomics to Predict Early and Late Adverse Outcomes in Ischemic Stroke Treated with Intravenous Thrombolysis

Metabolic perturbations and inflammatory mediators play a fundamental role in both early and late adverse post-acute ischemic stroke outcomes. Using data from the observational MAGIC (MArker bioloGici nell'Ictus Cerebrale) study, we evaluated the effect of 130 serum metabolic features, using a nuclear magnetic spectroscopy approach, on the following outcomes: hemorrhagic transformation at 24 h after stroke, non-response to intravenous thrombolytic treatment with the recombinant tissue plasminogen activator (rt-PA), and the 3 month functional outcome. Blood circulating metabolites, lipoproteins, and inflammatory markers were assessed at the baseline and 24 h after rt-PA treatment. Adjusting for the major determinants for unfavorable outcomes (i.e., age, sex, time onset-to-treatment, etc.), we found that acetone and 3-hydroxybutyrate were associated with symptomatic hemorrhagic transformation and with non-response to rt-PA; while 24 h after rt-PA, levels of triglycerides high-density lipoprotein (HDL) and triglycerides low-density lipoprotein (LDL) were associated with 3 month mortality. Cholesterol and phospholipids levels, mainly related to smaller and denser very low-density lipoprotein (VLDL) and LDL subfractions were associated with 3 month poor functional outcomes. We also reported associations between baseline 24 h relative variation (Δ) in VLDL subfractions and ΔC-reactive protein, Δinterleukin-10 levels with hemorrhagic transformation. All observed metabolic changes reflect a general condition of energy failure, oxidative stress, and systemic inflammation that characterize the development of adverse outcomes.

Short-Term Prognostic Predictive Evaluation in Female Patients With Ischemic Stroke: A Retrospective Cross-Sectional Study

Introduction and Aim

Stroke is a disease with high mortality and morbidity. Although studies are generally performed on all patients with stroke, it is known that gender has an effect on etiology and prognosis. This study aimed to determine the importance of clinical stroke scales and laboratory markers in determining the short-term prognosis of female patients with ischemic stroke of anterior circulation.

Materials and Methods

The study was planned as a retrospective and cross-sectional study. SEDAN score, the National Institutes of Health stroke scale (NIHSS), the Modified Rankin Scale (mRS), the Glasgow Coma Scale (GCS), and THRIVE score applied to the patients at the time of admission were recorded. Admission blood glucose, hemoglobin, leukocyte, urea, albumin, and blood lipid levels were evaluated. The relationship of all these parameters with in-hospital prognosis, mortality, and disability at discharge was examined. The relationship between groups and data was analyzed using the SPSS package program after the normality analysis.

Results

In this study, there were 733 female patients with stroke with a mean age of 69.53 ± 14.51 years and 858 male patients with stroke with a mean age of 64.27 ± 13.29 years. Hospitalization time, length of stay in the intensive care unit, ventilation need rate, mortality, and dependency rate were higher in female patients (p = 0.001). The NIHSS, SEDAN, and THRIVE scores were higher in female patients who had in-hospital mortality, had a poor prognosis, and who were discharged as dependent (p = 0.001). GCS was lower in this patient group (p = 0.001). Blood glucose, creatinine, leukocytes, urea, and CRP levels were higher; the albumin and hemoglobin levels was lower in female patients who had fatal outcomes (p = 0.009, 0.001, 0.001, 0.001, 0.001, and 0.020; respectively). In female patients who were dependent at discharge, blood urea, glucose, and CRP levels were higher and the albumin levels were lower than those in female patients who achieved functional independence (p = 0.001, 0.016, 0.002, and 0.001, respectively).

Conclusion

Our study showed that the short-term prognosis is worse in female patients who had an ischemic stroke of anterior circulation. It also revealed some clinical and laboratory parameters that could predict this situation. More intensive monitoring may be needed to improve prognosis in female patients.

The prognostic significance of the lipid profile after an ischemic stroke

BACKGROUND

The role that cholesterol levels play in stroke is still uncertain, especially in secondary prevention. The aim was to determine how a comprehensive analysis of the lipid profile can be associated with post-stroke outcomes.

Consecutive patients diagnosed with ischemic stroke were included in our cohort and followed up for 24months. Baseline clinical and demographic data were collected as well as a complete lipid profile 6-months after the index stroke. Lipid variables were analyzed quantitatively and qualitatively. Clinical outcomes included stroke recurrence, major cardiovascular events, and functional performance (assessed with the modified Rankin scale).

RESULTS

The study included 588 patients with an average age of 58.3 years. There were 148 (25.2%) patients with high total cholesterol, 260 (44.2%) with low HDL, 180 (30.6%) with high LDL, and 204 (34.7%) with high triglycerides. There were 164 (27.9%) patients with no abnormalities in the lipid profile. After the follow-up, 108 (18.3%) had another stroke, 32 (5.4%) had major cardiovascular events, and 360 (61.2%) presented good functional outcomes. A higher LDL-C/HDL-C ratio and a low HDL-C level were significantly associated with worse cardiovascular outcomes. The detection of LDL-C > 70 mg/dL was an independent predictor of a higher risk of stroke recurrence and worse functional performance. The greater the number of altered lipid variables, the greater the chance of developing an unfavorable composite outcome and presenting cardiovascular events after the stroke.

CONCLUSIONS

The complete analysis of the lipid panel allows the determination of the prognosis of patients who suffered a stroke.

Relevance of cerebral small vessel disease load scores in first-ever lacunar infarction

AIM

To reveal the correlation between total cerebrovascular disease load and primary lacunar infarction.

BACKGROUND

Cerebral small vessel disease (CSVD) is the lack of specific clinical manifestations, whose clinical diagnoses are highly dependent on neuroimaging results. Total CSVD load scores may be more suitable for the assessment of overall brain function damage caused by CSVD. Little is known about whether the association between imaging markers of CSVD and CSVD total load scores at the time of first-ever lacunar infarction (LI).

METHODS

clinical data of 396 patients hospitalised from September 2016 to May 2018 due to a first-ever LI (case group), along with patients diagnosed with CSVD based on imaging alone and those with no abnormalities (control group) based on magnetic resonance imaging (MRI). Binary logistic regression and multiple ordered logistic regression were used to analyse the characteristics of imaging markers of CSVD in patients with first-ever LI, including different total score burden and distribution, and the relationship between different markers.

RESULTS

In 396 patients, smoking, cholesterol level and total small vessel disease (SVD) score were all significantly associated with the first-ever LI. There were more LI, cerebral microbleeds (CMB), white matter hyperintensities (WMH), and moderate to severe enlarged perivascular spaces (EPVS) in the first-ever LI group, relative to controls (p < 0.01). The Fazekas scores for periventricular WMH, deep WMH, and total Fazekas score were all significantly higher in patients with first-ever LI relative to those with no cerebral abnormalities (p < 0.01). An analysis of various imaging markers of CSVD revealed a significant correlation between the presence and degree of any marker and the severity of other markers, even after adjusting for the presence of other markers (p < 0.05).

CONCLUSIONS

The first-ever LI group exhibited higher total CSVD score loads, a greater number of lacunae, CMB, severe WMH and moderate to severe EPVS. Smoking is an independent risk factor in patients with first-ever LI.

Early prediction of the 3-month outcome for individual acute ischemic stroke patients who received intravenous thrombolysis using the N2H3 nomogram model

Background:

The aim of this study was to establish a nomogram model for individualized early prediction of the 3-month prognosis in patients with acute ischemic stroke (AIS) who were treated with intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis.

Methods:

A total of 691 patients were included in this study; 564 patients were included in the training cohort, while 127 patients were included in the test cohort. The main outcome measure was a 3-month unfavorable outcome (modified Rankin Scale 3–6). To construct the nomogram model, stepwise logistic regression analysis was applied to select the significant predictors of the outcome. The discriminative performance of the model was assessed by calculating the area under the receiver operating characteristic curve (AUC-ROC). A decision curve analysis was used to evaluate prognostic value of the model.

Results:

The initial National Institutes of Health Stroke Scale [NIHSS, odds ratio (OR), 1.35; 95% confidence interval (CI), 1.28–1.44; p < 0.001], delta NIHSS (changes in the NIHSS score from baseline to 24 h, OR, 0.75; 95% CI, 0.70–0.79; p < 0.001), hypertension (OR, 2.07; 95% CI, 1.32–3.31; p = 0.002), hyperhomocysteinemia (Hhcy, OR, 2.18; 95% CI, 1.20–4.11; p = 0.013), and the ratio of high-density lipoprotein cholesterol (HDL-C) to low-density lipoprotein cholesterol (LDL-C) (HDL-C/LDL-C, OR, 3.29; 95% CI, 1.00–10.89; p = 0.049) (N2H3) were found to be independent predictors of a 3-month unfavorable outcome from multivariate logistic regression analysis and were incorporated in the N2H3 nomogram model. The AUC-ROC of the training cohort was 0.872 (95% CI, 0.841–0.902), and the AUC-ROC of the test cohort was 0.900 (95% CI, 0.848–0.953).

Conclusion:

The study presented the N2H3 nomogram model, with initial NIHSS score, delta NIHSS, hypertension, Hhcy, and HDL-C/LDL-C as predictors. It therefore provides an individualized early prediction of the 3-month unfavorable outcome in AIS patients treated with intravenous rt-PA thrombolysis.

Impact of triglyceride playing on stroke severity correlated to bilirubin

Major lipids making effects on the occurrence of acute ischemic stroke (AIS) is well recognized, but their roles on stroke severity remain uncertain. To explore the exact roles of lipids playing on stroke severity and the possible mechanism, we conduct this observational study.Data was collected from patients with AIS from February 2008 to May 2012. The level of major lipids was compared among AIS groups with different severity and investigated the correlation. Also, the relationship existed between major lipids and bilirubin. Mechanism of major lipids playing on stroke severity was researched to determine if oxidative stress reflected by bilirubin.Lower triglyceride (TG) and higher high density lipoprotein cholesterol (HDL-C) were observed in severe stroke, and obvious correlation existed between TG and stroke severity or HDL-C and stroke severity. TG was associated negatively with direct bilirubin (DBIL) and total bilirubin (TBIL), and lower level of DBIL and TBIL were related to higher quartiles of TG. There was no obvious difference of DBIL and TBIL among the groups of quartiles of HDL-C. TG was the influence factor of stroke severity in severe stroke through multiple univariable logistic regression. But it was not the independent influence factor after multivariable logistic regression adjusted by DBIL or TBIL. However, HDL-C was the influence factor of stroke severity through both univariable and multivariable logistic regression.Lower TG or higher HDL-C predicted severer stroke. The effect of TG on stroke severity was mediated by bilirubin, not HDL-C.

Small dense low-density lipoprotein cholesterol is strongly associated with NIHSS score and intracranial arterial calcification in acute ischemic stroke subjects

Intracranial artery calcification (IAC) is an important risk factor for cerebral infarction and a key biomarker for intracranial artery stenosis. Small dense low-density lipoprotein cholesterol (sd-LDL-c) was independently associated with increased cardiovascular events and coronary calcification. Our study assessed whether sd-LDL-c is an independent factor for IAC in acute ischemic stroke (AIS) patients. This cross-sectional study involved a total of 754 patients with AIS (mean age: 65 ± 13.2 years). All the patients had received brain computed tomography angiography (CTA) examination to evaluate IAC. Serum sd-LDL-c levels and other biochemical parameters were analyzed. Admission NIHSS score and mRS score at discharge were collected. After 60-days 85 patients died during hospitalization and follow-up. Partial correlation analysis showed that serum sd-LDL-c levels were associated with admission NIHSS score and IAC score after adjusted age and gender. Logistic regression analysis showed that serum sd-LDL-c levels independently predicted NIHSS scores (β = 1.537, 95%CI: 0.134-2.878, p = 0.042) and IAC scores (β = 1.355, 95%CI: 0.319-2.446, p = 0.015). The average level of sd-LDL-c in patients who died was also significantly increased compared to survival patients (1.04 ± 0.59 vs 0.88 ± 0.44 mmol/L, p = 0.017). However, multivariate logistic regression analysis showed serum sd-LDL-c levels could not predict all-cause mortality and prognosis in AIS patients. Our study found that sd-LDL-c as a strong atherogenic lipid particle can independently predict admission NIHSS scores and the severity of cerebral artery calcification in AIS patients. However, its prognostic value in AIS patients still needs further study in the future.

Low density lipoprotein cholesterol values and outcome of stroke patients: influence of previous aspirin therapy

Background: The link between low-density lipoprotein cholesterol (LDL-C) and stroke risk remains controversial and few studies have evaluated the effect of LDL-C after stroke survival.Aims: We assessed the hypothesis proposing the effect of LDL-C on the outcome of stroke patients under the influence of previous Aspirin Therapy.Methods: Associations between LDL-C and outcomes. The effect of LDL cholesterol on stoke outcome was evaluated using Kaplan-Meier methodology, log-rank test, Cox proportional hazard models and Bootstrap Analysis.Results: In a cohort of 342 cases, we observed that among stroke patients with no record of previous aspirin therapy LDL-C levels within recommended range (nLDL-C) are associated to a poor overall survival on (p < 0.001, log-rank test) leading to a 4-fold increased mortality risk in both timeframes of 12 (HR 4.45, 95% CI 1.55-12.71; p = 0.004) or 24 months (HR 4.13, 95%CI 1.62-10.50;p = 0.003) after the first event of stroke. Moreover, modelling the risk of a second event after the first stroke in the timeframe of 24 months demonstrated a predictive capacity for nLDL-C plasmatic levels (HR 3.94, 95%CI 1.55-10.05; p = 0.004) confirmed by Bootstrap analysis (p = 0.003; 1000 replications). In a further step, the inclusion of LDL-C in simulating models equations to predict the risk of a second event in the timeframe of 12 months increased nearly 20% the predictive ability (c-index from 0.763 to 0.956).Conclusion: A worse outcome was seen in stroke patients with normal levels of LDLC, but this finding was restricted to patients not under previous aspirin therapy.

Effects of cholesterol levels on outcomes of out-of-hospital cardiac arrest: a cross-sectional study

Objective

High cholesterol level is a risk factor for coronary artery disease, and coronary artery disease is a major risk factor for out-of-hospital cardiac arrest (OHCA). However, the effect of cholesterol level on outcomes of OHCA has been poorly studied. This study aimed to determine the effect of cholesterol level on outcomes of OHCA.

Methods

This cross-sectional study used the CAPTURES (Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance) project database in Korea. Multivariable conditional logistic regression analysis was performed to estimate the effect of cholesterol level on outcomes in OHCA.

Results

In all, 584 cases of OHCA were analyzed; those with cholesterol levels <120 mg/dL were classified as having low total cholesterol (TC) (n=197), those with levels ranging from 120–199 mg/dL as middle TC (n=322), and those with ≥200 mg/dL as high TC (n=65). Compared to low TC, more patients with middle TC and high TC survived to discharge (9.1% vs. 22.0% and 26.2%, respectively, P=0.001). The good cerebral performance category also increased in that order (4.1 % vs. 14.6% and 23.1%, respectively, P≤0.001). Comparing middle TC and high TC with low TC, adjusted odds ratios (95% confidence intervals) were 1.97 (1.06 to 3.64) and 2.53 (1.08 to 5.92) for survival to discharge, respectively, and 2.53 (1.07 to 5.98) and 4.73 (1.63 to 13.71) for good neurological recovery, respectively.

Conclusion

Higher cholesterol is associated with better outcomes in OHCA; cholesterol level is a good predictor of outcomes of OHCA.

The Lipid Paradox Among Acute Ischemic Stroke Patients-A Retrospective Study of Outcomes and Complications

Background and objectives: The Studies have suggested hypercholesterolemia is a risk factor for cerebrovascular disease. However, few of the studies with a small number of patients had tested the effect of hypercholesterolemia on the outcomes and complications among acute ischemic stroke (AIS) patients. We hypothesized that lipid disorders (LDs), though risk factors for AIS, were associated with better outcomes and fewer post-stroke complications. Materials and Method: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2003–2014) in adult hospitalizations for AIS to determine the outcomes and complications associated with LDs, using ICD-9-CM codes. In 2014, we also aimed to estimate adjusted odds of AIS in patients with LDs compared to patients without LDs. The multivariable survey logistic regression models, weighted to account for sampling strategy, were fitted to evaluate relationship of LDs with AIS among 2014 hospitalizations, and outcomes and complications amongst AIS patients from 2003–2014. Results and Conclusions: In 2014, there were 28,212,820 (2.02% AIS and 5.50% LDs) hospitalizations. LDs patients had higher prevalence and odds of having AIS compared with non-LDs. Between 2003–2014, of the total 4,224,924 AIS hospitalizations, 451,645 (10.69%) had LDs. Patients with LDs had lower percentages and odds of mortality, risk of death, major/extreme disability, discharge to nursing facility, and complications including epilepsy, stroke-associated pneumonia, GI-bleeding and hemorrhagic-transformation compared to non-LDs. Although LDs are risk factors for AIS, concurrent LDs in AIS is not only associated with lower mortality and disability but also lower post-stroke complications and higher chance of discharge to home.

Association of demographic and socioeconomic characteristics with body mass index of outpatient diabetic adults attending a tertiary health facility in Enugu, Nigeria

BACKGROUND/OBJECTIVE

Recently, demographic and socioeconomic characteristics have been emphasized in dealing with chronic diseases of which Type 2 diabetes (T2D) is one. This present study was conducted to correlate the demographic and socioeconomic characteristics of out-patient type 2 diabetic adults with their body mass index (BMI).

METHODOLOGY

This cross-sectional study was conducted in the Out-patients Diabetic clinic of University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu Nigeria. A total of 370 subjects were purposively selected from the 2888 annual average attendances and examined with questionnaire and anthropometry. Information on their demographic and socioeconomic characteristics was correlated with their body mass index.

RESULT

The results indicated that there were more (59%) urban diabetics than rural (25.7%) diabetics, many (65.7%) were within the age range of 41-60years, more (64.9%) females than males (35.1%), mainly (86.2%) married and of Christian religion (94.1%) and Igbo ethnicity (95.9%). The majority (91.1%) were of a monogamous family type with 55.4% from average sized (4-6persons) families. More than 1/3 (34.1%) had tertiary education, mainly (43%) civil servants, and 45.1% earning above 137.21 US Dollar per month. Most (69%) of the diabetics were over-weight, a trend of both under-nutrition (1.1%), and over-nutrition (68.7%) with mean BMI value of 27.19 kg/m² was also observed. BMI had slight negative association with age, sex, and occupation and positive association with religion, ethnicity, marital status and level of education.

CONCLUSION

There is a weak negative association of age, sex and occupation with BMI.

Functional Outcome and Safety of Intracranial Thrombectomy After Emergent Extracranial Stenting in Acute Ischemic Stroke Due to Tandem Occlusions

Background and Purpose: Various endovascular approaches to treat acute ischemic stroke caused by extra- intracranial tandem occlusions (TO) exist: percutaneous transluminal angioplasty with or without emergent extracranial carotid stenting (ECS) due to high-grade stenosis preceded or followed by intracranial mechanical and/or aspiration thrombectomy (MT). Which treatment strategy to use is still a matter of debate.

Methods: From our ongoing prospective stroke registry we retrospectively analyzed 1,071 patients with anterior circulation stroke getting endovascular treatment within 6 h of symptom onset. ECS prior to intracranial MT for TO (n = 222) was compared to MT as standard of care (control group; acute intracranial vessel occlusion without concomitant ipsilateral ICA-occlusion or high-grade stenosis [C; n = 849]). Good functional outcome (mRS ≤ 2 at 3 months), mortality rates, frequencies of symptomatic intracranial hemorrhage (sICH) and successful recanalization (Thrombolysis in Cerebral Infarction Score [TICI] 2b or 3) were assessed. In subgroup analyses we tried to detect possible influences of stroke etiology, dual inhibition of platelet aggregation (IPA; clopidogrel [CLO]: n = 83; ticagrelor [TIC]: n = 137; in combination with Aspirin) and intravenous thrombolysis (IVT).

Results: Functional outcome was superior in TO (mRS 0–2: 44.6%) when compared with controls (36.0%; OR [95% CI]: 3.49 [1.59–7.67]; p = 0.002). There was no difference in all-cause mortality at 3 months (TO: 21.6%; C: 27.7%; 0.78 [0.47–1.29]; p = 0.324), in-hospital mortality (0.76 [0.45–1.30]; p = 0.324), sICH (TO: 3.2%; C: 5.0%; 0.70 [0.30–1.59]; p = 0.389), and TICI 2b/3 (TO: 89.1%; C: 88.3%; p = 0.813). In subgroup-analysis, TIC and CLO did not differ in functional outcome (TIC: 45.3%; CLO: 44.6%; 1.04 [0.51–2.09]; p = 0.920) and mortality rates (all-cause mortality: TIC: 23.4%; CLO: 16.9%; 0.75 [0.27–2.13]; p = 0.594). sICH was more frequent in TIC (n = 7 [5.1%]) vs. CLO (n = 0; p = 0.048).

Conclusion: In our pre-selected cohort, ECS prior to intracranial MT in TO allowed for a good functional outcome that was superior compared to a control population. Mortality rates did not differ. Despite a dual IPA in TO, there was no increase in sICH. CLO and TIC for dual IPA did not differ in terms out outcome and mortality rates. A significant increase in sICH was observed after initial loading with TIC.

Contribution of Serum Lipid Profiles to Outcome After Endovascular Thrombectomy for Anterior Circulation Ischemic Stroke

The contribution of lipids, including low- and high-density lipoprotein cholesterol (LDL-C and HDL-C, respectively) and triglycerides (TG), to stroke outcomes is still debated. We sought to determine the impact of LDL-C concentrations on the outcome of patients with ischemic stroke in the anterior circulation who received treatment with endovascular thrombectomy (EVT). We performed a retrospective analysis of consecutive patients with acute ischemic stroke treated at a tertiary center between 2012 and 2016. Patients treated with EVT for large artery occlusion in the anterior circulation were selected. The primary endpoint was functional outcome at 3 months as measured with the modified Rankin Scale (mRS). Secondary outcome measures included hospital death and final infarct volume (FIV). Blood lipid levels were determined in a fasting state, 1 day after admission. We studied a total of 174 patients (44.8% men) with a median age of 74 years (interquartile range [IQR] 61–82) and median National Institutes of Health Stroke Scale at admission of 18 (14–22). Bridging therapy with intravenous tissue-plasminogen activator (t-PA) was administered in 122 (70.5%). The median LDL-C was 90 mg/dl (72–115). LDL-C demonstrated a U-type relationship with FIV (p = 0.036). Eighty-three (50.0%) patients had an mRS of 0–2 at 3 months. This favorable outcome was independently associated with younger age (OR 0.944, 95% CI 0.90–0.99, p = 0.012), thrombolysis in cerebral infarction 2b-3 reperfusion (OR 5.12, 95% CI 1.01–25.80, p = 0.015), smaller FIV (0.97 per cm³, 95% CI 0.97–0.99, p < 0.001), good leptomeningeal collaterals (OR 5.29, 95% CI 1.48–18.9, p = 0.011), and LDL-C more than 77 mg/dl (OR 0.179, 95% CI 0.04–0.74, p = 0.018). A higher LDL-C concentration early in the course of a stroke caused by large artery occlusion in the anterior circulation is independently associated with a favorable clinical outcome at 3 months. Further studies into the pathophysiological mechanisms underlying this observation are warranted.

Association of serum lipids with clinical outcome in acute ischaemic stroke: A systematic review and meta-analysis

Serum lipid levels have been investigated as prognostic markers in patients with acute ischaemic stroke. However, these results remain inconsistent. This study aimed at assessing the association between serum lipid and clinical outcomes in acute ischaemic stroke. Relevant data were obtained from Cochrane Library, PubMed and Web of Science databases. The heterogeneity of pooled results was determined by the Cochran's Q test and Higgins I-squared statistic. The random-effect model was performed to calculate the pooled results if P_H < 0.05 for Q-test, otherwise the fixed-effect model was applied. The primary results were death, and the secondary were recurrence, dependency, mRS score ≥3, and early neurological deterioration. A total of 21 full-text studies was included in the present study. For primary results, the pooled results from 5 studies with 4119 patients showed that triglyceride (TG) was a significant predictor for death (OR = 0.65, 95%CI = 0.43-0.98, P_H = 0.028). The pooled data from 11 studies with 12,486 patients for total cholesterol (TC), 4 studies with 7593 patients for low-density lipoprotein cholesterol (LDL-C), and 5 studies with 6933 patients for high-density lipoprotein cholesterol (HDL-C) suggested that TC (OR = 0.79, 95%CI = 0.56-1.13, P_H < 0.001), LDL-C (OR = 1.02, 95%CI = 0.66-1.57, P_H = 0.042), and HDL-C (OR = 1.18, 95%CI = 0.75-1.86, P_H = 0.003) were not associated with death in acute ischaemic stroke. For secondary results, the pooled results of 2 studies with 867 patients indicated that TG was positively associated with early neurological deterioration. This study suggested that serum TG was associated with death and early neurological deterioration in acute ischaemic stroke.

High nonfasting triglyceride concentrations predict good outcome following acute ischaemic stroke

OBJECTIVES

A higher fasting triglyceride (TG) concentration has been associated with better functional outcomes after stroke. Recent observational studies have found that nonfasting TG concentrations predict incident stroke better than fasting concentrations. The aim of the study was to investigate the relationship between fasting and nonfasting serum TG concentrations versus 3-month functional activity and mortality among patients with acute ischaemic stroke.

METHODS

This was a retrospective study based on prospectively collected data. Blood samples were taken from acute ischaemic stroke patients at the time of hospital presentation to measure nonfasting TG concentrations and on the following morning to measure fasting TG concentrations. Fasting and nonfasting serum TG concentrations were collapsed into their respective three categories. All participants were assessed at 3 months after stroke using the modified Rankin Scale.

RESULTS

A total of 556 ischaemic stroke patients (67 ± 13 years; 57% male) were included in this study. Bivariately, the highest fasting and nonfasting TG category had more of a likelihood of good 3-month functional activity and less of a likelihood of being dead at 3 months compared to their respective lowest TG categories. The highest fasting TG (OR 2.93, 95% CI 1.67-5.14) and nonfasting TG (OR 2.66, 95% CI 1.51-4.67) categories had more of a likelihood of good 3-month functional activity compared to their respective lowest TG categories after adjustment for possible confounders.

DISCUSSION

Higher fasting and nonfasting serum TG concentrations predicted good poststroke outcome independently of other prognostic factors.

Pravastatin But Not Simvastatin Improves Survival and Neurofunctional Outcome After Cardiac Arrest and Cardiopulmonary Resuscitation

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In a murine model of CA and CPR, intravenous application of hydrophilic pravastatin resulted in increased survival and neurofunctional outcome.

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In contrast, intravenous application of lipophilic simvastatin did not improve survival or neurofunction following CA/CPR.

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Pravastatin, but not simvastatin, treatment reduced post-resuscitation pulmonary edema and augmented pulmonary function.

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In vitro, pravastatin augmented endothelial cell function, whereas simvastatin induced endothelial cell apoptosis.

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This study supports previous requests for an intravenous formulation of hydrophilic statins for clinical use.

Cardiac arrest (CA) followed by cardiopulmonary resuscitation (CPR) is associated with high mortality and poor neurological outcome. We compared the effects of pravastatin and simvastatin on survival and neurofunction in a murine model of CA/CPR. Pravastatin, a hydrophilic statin, increased survival and neurofunction during a 28-day follow-up period. This therapy was associated with improved pulmonary function, reduced pulmonary edema, and increased endothelial cell function in vitro. In contrast, lipophilic simvastatin did not modulate survival but increased pulmonary edema and impaired endothelial cell function. Although pravastatin may display a therapeutic option for post-CA syndrome, the application of simvastatin may require re-evaluation.

Prognostic significance of major lipids in patients with acute ischemic stroke

Although dyslipidemia increases the risk for ischemic stroke, previous studies reported conflicting data regarding the association between lipid levels and stroke severity and outcome. To evaluate the predictive value of major lipids in patients with acute ischemic stroke. We prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0 % males, age 79.4 ± 6.8 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Moderate/severe stroke was defined as NIHSS ≥5. The outcome was assessed with dependency rates at discharge (modified Rankin scale between 2 and 5) and with in-hospital mortality. Independent predictors of moderate/severe stroke were age (relative risk (RR) 1.05, 95 % confidence interval (CI) 1.02-1.08, p < 0.001), atrial fibrillation (RR 1.71, 95 % CI 1.19-2.47, p < 0.005), heart rate (RR 1.02, 95 % CI 1.01-1.04, p < 0.001), log-triglyceride (TG) levels (RR 0.24, 95 % CI 0.08-0.68, p < 0.01) and high-density lipoprotein cholesterol (HDL-C) levels (RR 0.97, 95 % CI 0.95-0.98, p < 0.001). Major lipids did not predict dependency at discharge. Independent predictors of in-hospital mortality were atrial fibrillation (RR 2.35, 95 % CI 1.09-5.04, p < 0.05), diastolic blood pressure (RR 1.05, 95 % CI 1.02-1.08, p < 0.001), log-TG levels (RR 0.09, 95 % CI 0.01-0.87, p < 0.05) and NIHSS at admission (RR 1.19, 95 % CI 1.14-1.24, p < 0.001). Low-density lipoprotein cholesterol levels were not associated with stroke severity or outcome. Lower TG and HDL-C levels are associated with more severe stroke. Lower TG levels also appear to predict in-hospital mortality in patients with acute ischemic stroke.

Cholesterol Levels Are Associated with 30-day Mortality from Ischemic Stroke in Dialysis Patients

BACKGROUND

We investigated the impact of serum cholesterol levels on 30-day mortality after ischemic stroke in dialysis patients.

METHODS

From the Taiwan Stroke Registry data, we identified 46,770 ischemic stroke cases, including 1101 dialysis patients and 45,669 nondialysis patients from 2006 to 2013.

RESULTS

Overall, the 30-day mortality was 1.46-fold greater in the dialysis group than in the nondialysis group (1.75 versus 1.20 per 1000 person-days). The mortality rates were 1.64, .62, 2.82, and 2.23 per 1000 person-days in dialysis patients with serum total cholesterol levels of <120 mg/dL, 120-159 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. Compared to dialysis patients with serum total cholesterol levels of 120-159 mg/dL, the corresponding adjusted hazard ratios of mortality were 4.20 (95% confidence interval [CI] = 1.01-17.4), 8.06 (95% CI = 2.02-32.2), and 6.89 (95% CI = 1.59-29.8) for those with cholesterol levels of <120 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively.

CONCLUSIONS

Dialysis patients with serum total cholesterol levels of ≥160 mg/dL or <120 mg/dL on admission are at an elevated hazard of 30-day mortality after ischemic stroke.

Effect of using fluoxetine at different time windows on neurological functional prognosis after ischemic stroke

PURPOSE

To evaluate the effect of using fluoxetine at different time intervals after ischemic stroke on neurological functional prognosis in China.

METHODS

The patients enrolled were randomly allocated to three groups. Group A received fluoxetine 20 mg/day immediately; group B received fluoxetine 20 mg/day 7 days after enrollment; and group C did not receive fluoxetine. The therapeutic duration of fluoxetine was 90 days and the follow-up period was 180 days.

RESULTS

The mean NIHSS score at day 90 was significantly lower in group A than group C (P = 0.005), while at day 180, the mean score in group A was significantly lower than groups B and C (P = 0.035, P = 0.000), respectively. The mean BI score at day 90 was significantly higher in group A than group C (P = 0.001), while at day 180, the mean score in group A was significantly higher than groups B and C (P = 0.036, P = 0.000), respectively. Regression analysis indicated that lower NIHSS score and higher BI score at day 180 were attributed to the early administration of fluoxetine.

CONCLUSIONS

In patients with ischemic stroke, early administration of fluoxetine may improve the neurological functional prognosis.

Sex differences in outcomes after stroke among patients with low total cholesterol levels: a large hospital-based prospective study

Background

Previous studies have shown that total cholesterol (TC) levels are associated with stroke outcomes, but sex differences in the association between TC levels, especially a low TC level, and ischemic stroke outcomes are unknown. We aimed to assess the sex differences in stroke outcomes among patients with atherothrombotic infarctions and low TC levels in China.

Methods

This study recruited patients with atherothrombotic infarctions from Tianjin, China, between May 2005 and September 2014. Patients with low TC levels (defined as TC <4.22 mmol/L) were analyzed in this study. Sex differences in stroke subtypes, severity, risk factors, and outcomes at 3 and 12 months after stroke were compared.

Results

Overall, 1587 patients with low TC levels were recruited to this study from among 6407 patients with atherothrombotic infarctions listed in a stroke registry. Women were more likely than men to have posterior circulation infarcts, severe stroke, hypertension, and obesity but less likely to be current smokers or to consume alcohol. There were no sex differences in stroke outcomes. Older age and severe stroke were common risk factors for poor outcomes after stroke in this study. The presence of diabetes mellitus was an independent predictor of low mortality at 12 months after stroke, possibly because a drug commonly used to treat diabetes, metformin, enhances angiogenesis. Obesity was the determinant of the recurrence and dependency rates at 12 months after stroke.

Conclusions

These findings suggest that patients (both men and women) with atherothrombotic infarction who have low TC levels would not benefit from receiving statin treatment. Therefore, it is crucial to explore the impact of statin treatment on outcomes in Asian patients, especially Chinese patients with atherothrombotic and low TC levels, in order to improve outcomes after stroke and reduce the disease burden.

Stroke severity may predict causes of readmission within one year in patients with first ischemic stroke event

INTRODUCTION

Readmissions after stroke are costly. Risk assessment using information available upon admission could identify high-risk patients for potential interventions to reduce readmissions. Baseline stroke severity has been suspected to be a factor in readmission; however, the exact nature of the impact has not been adequately understood.

METHODS

Hospitalized adult patients with first-ever ischemic stroke were identified from a nationwide administrative database. Stroke severity was assessed using a validated claims-based stroke severity index. Cox proportional hazards models were used to investigate the relationship between stroke severity and first readmission within one year.

RESULTS

Of the 10,877 patients, 4295 (39.5%) were readmitted in one year. The cumulative risk of readmission was 34.1%, 44.7%, and 62.9% in patients with mild, moderate, and severe stroke, respectively. Patients with greater stroke severity had a significantly higher adjusted risk of first readmission for infection, metabolic disorders, neurological sequelae, and pulmonary diseases, whereas those with lesser stroke severity were prone to first readmission due to accidents. Stroke severity did not affect the risk of first readmission for recurrent stroke/transient ischemic attack, other cardiovascular events, malignancy, ulcers/upper gastrointestinal bleeding, kidney diseases, and others.

CONCLUSIONS

Stroke severity in patients with first-ever ischemic stroke not only predicts readmission but also relates to the cause of readmission. Our results might provide important information for tailoring discharge planning to prevent readmissions.

Hyperlipidemia is associated with lower risk of poststroke mortality independent of statin use: A population-based study

Background Although statin therapy is associated with reduced stroke and mortality risk, some studies report that higher lipid levels are associated with improved outcomes following ischemic stroke. Aims We examined the association of hyperlipidemia (HLD) combined with statin therapy on all-cause mortality in stroke patients. Methods All stroke patients in the Greater Cincinnati Northern Kentucky region of ∼1.3 million were identified using ICD-9 discharge codes in 2005 and 2010. Stroke patients with and without HLD were categorized based on their reported statin use at baseline or discharge into three groups: no-HLD/no-statins, HLD/no-statins, and HLD/on-statins. Cox proportional hazards model was used to estimate the risk of mortality at 30 days, 1 year, and 3 years poststroke. Results Overall, 77% (2953) of the 3813 ischemic stroke patients were diagnosed with HLD and 72% ( n = 2123) of those patients were on statin medications. The mean age was 70.0 ± 14.6 years, 56% were women, and 21% were black. In adjusted analyses, the HLD/no-statins group showed 35% (adjusted hazard ratio (aHR) = 0.65, 95% CI: 0.46-0.92), 27% (aHR = 0.73, 95% CI: 0.59-0.90), and 17% (aHR = 0.83, 95% CI: 0.70-0.97) reduced risk of mortality at 30 days, 1 year, and 3 years, respectively, poststroke, compared with no-HLD/no-statins group. The HLD/on-statins group showed an additional 17% significant survival benefit at 3 years poststroke compared with HLD/no-statins group. Conclusions A diagnosis of HLD in ischemic stroke patients is associated with reduced short- and long-term mortality, irrespective of statin use. Statin therapy is associated with significant, additional long-term survival benefit.

Low total cholesterol level is the independent predictor of poor outcomes in patients with acute ischemic stroke: a hospital-based prospective study

BACKGROUND

Total cholesterol is a well-documented risk factor for coronary disease. Previous studies have shown that high total cholesterol level is associated with better stroke outcomes, but the association of low total cholesterol levels and ischemic stroke outcomes is rare. Therefore, we aimed to assess the association of low total cholesterol levels and stroke outcomes among acute ischemic stroke patients in China.

METHODS

This study recruited 6407 atherothrombotic infarction patients from Tianjin, China, between May 2005 and September 2014. All patients were categorized into five groups according to TC level quintiles at admission. Differences in subtypes, severity, risk factors, and outcomes at 3, 12, and 36 months after stroke were compared between these groups.

RESULTS

In total, 1256 (19.6%) patients had low cholesterol levels, with a higher prevalence in men than in women (23.7% vs. 11.2%, P < 0.001). Compared with higher cholesterol levels, the lowest cholesterol level quintile (TC, <4.07 mmol/L) was associated with older age (64.7 years, P = 0.033), anterior circulation infarct (22.8%), atrial fibrillation (4.9%), current smoking (41.1%), and alcohol consumption (21.1%) and lower frequencies of hypertension (72.9%), diabetes (30.7%), and obesity (9.9%). Dependency and recurrence rates were significantly higher at 36 months in patients in the lowest TC level quintile than in those with higher cholesterol levels (dependency rates, 51.2% vs 45.2%; P = 0.007 and recurrence rates, 46.3% vs 37.3%, P = 0.001). Moreover, these differences remained after adjustment for age, sex, stroke severity, and Oxfordshire Community Stroke Project classification (odds ratios [ORs] for dependency rate, 1.41; 95% confidence interval [CI], 1.11, 1.79; P = 0.005 and recurrence rate, 1.50; 95% CI, 1.19, 1.89; P = 0.001). However, mortality rates after stroke were not significantly different between the groups.

CONCLUSIONS

These findings suggest that statin treatment for patients with atherothrombotic infarction and low cholesterol levels increase long-term dependency and recurrence rates, but do not increase mortality rates. It is crucial to highlight the different impact of statin treatment on patients with atherothrombotic infarction and lower cholesterol levels for secondary stroke prevention in China.

Clinical factors associated with statins prescription in acute ischemic stroke patients: findings from the Lombardia Stroke Registry

BACKGROUND

Statins, due to their well-established pleiotropic effects, have noteworthy benefits in stroke prevention. Despite this, a significant proportion of high-risk patients still do not receive the recommended therapeutic regimens, and many others discontinue treatment after being started on them. The causes of non-adherence to current guidelines are multifactorial, and depend on both physicians and patients. The aim of this study is to identify the factors influencing statin prescription at Stroke Unit (SU) discharge.

METHODS

This study included 12,750 patients enrolled on the web-based Lombardia Stroke Registry (LRS) from July 2009 to April 2012 and discharged alive, with a diagnosis of ischemic stroke or transient ischemic attack (TIA) and without contra-indication to statin therapy. By logistic regression analysis and classification trees, we evaluated the impact of demographic data, risk factors, tPA treatment, in-hospital procedures and complications on statin prescription rate at discharge.

RESULTS

We observed a slight increase in statins prescription during the study period (from 39.1 to 43.9%). Lower age, lower stroke severity and prestroke disability, the presence of atherothrombotic/lacunar risk factors, a diagnosis of non-cardioembolic stroke, tPA treatment, the absence of in-hospital complications, with the sole exception of hypertensive fits and hyperglycemia, were the patient-related predictors of adherence to guidelines by physicians. Overall, dyslipidemia appears as the leading factor, while TOAST classification does not reach statistical significance.

CONCLUSIONS

In our region, Lombardia, adherence to guidelines in statin prescription at Stroke Unit discharge is very different from international goals. The presence of dyslipidemia remains the main factor influencing statin prescription, while the presence of well-defined atherosclerotic etiopathogenesis of stroke does not enhance statin prescription. Some uncertainties about the risk/benefit of statin therapy in stroke etiology subtypes (cardioembolism, other or undetermined causes) may partially justify the underuse of statin in ischemic stroke. The differences that exist between current international guidelines may prevent a more widespread use of statin and should be clarified in a consensus.

Predictors of early mortality in patients with ischemic stroke

Accurate predictors of early outcome in stroke patients have a number of important applications, such as introducing secondary prevention strategies, supporting treatment decisions or designing randomized clinical trials. Surprisingly, a generally accepted, reliable and well-validated mortality-prediction model is still unavailable. This review outlines the most important predictors of in-hospital mortality that could be assessed at admission to hospital emergency room within 24 h of ischemic stroke onset. A number of factors are discussed such as nonmodifiable factors (e.g., age, gender and genetic factors); type of stroke and its severity - measured by different clinical score scales; predictive models; laboratory markers; special neuroradiological and neurophysiological tests; and comorbid conditions at admission and quality of hospital care.

A study of serum apolipoprotein A1, apolipoprotein B and lipid profile in stroke

BACKGROUND

Role of Serum Lipids, Lipoproteins and Lipoprotein related variables in the prediction of Stroke is less clear. Abnormalities in plasma Lipoproteins are the most firmly established and best understood risk factors for Atherosclerosis and they are probable risk factors for Ischaemic stroke, largely by their link to Atherosclerosis. Apo B reflects the concentration of potentially atherogenic particles (LDL), and Apo A1 reflects the corresponding concentration of anti- atherogenic particles (HDL), represent additional lipoprotein related variables that may indicate the vascular risk.

AIM

To study serum concentration of Apolipoprotein A1, Apolipoprotein B, Apo B/Apo A1 ratio and Lipid profile in Stroke Cases and to compare with healthy controls.

DESIGN

A total number of 100 subjects within 30 - 70 years were considered for the study. 50 subjects with Stroke (both clinically as well as Computed tomographically proven cases) and 50 age and sex matched healthy individuals were taken for the study.

MATERIAL AND METHODS

Total cholesterol, HDL cholesterol and Triglycerides are estimated by Enzymatic method using Semiautoanalyser. LDL cholesterol is estimated by Friedewald formula. Apo B and Apo A1 are estimated by Immunoturbidimetric method using Semiautoanalyser.

STATISTICAL ANALYSIS

Student 't' test was used to compare the data between cases and controls. Diagnostic validity tests were conducted to assess the Diagnostic efficiency of Apo A1, Apo B and Apo B/Apo A1 ratio.

RESULTS

Total cholesterol, LDL cholesterol and Triglycerides are significantly increased in Cases compared to Controls. HDL - cholesterol is significantly decreased in Cases compared to Controls. Apo B and Apo B/Apo A1 ratio are significantly increased and Apo A1 is significantly decreased in Cases compared to Controls. Diagnostic validity tests showed that, Apo B , Apo A1 and Apo B /Apo A1 ratio have highest Sensitivity, Specificity and Diagnostic efficiency.

CONCLUSION

Apo B , Apo A1 and Apo B / Apo A1 ratio can be used as predictors of stroke along with traditional lipid profile components.

Impact of polyunsaturated fatty acid consumption prior to ischemic stroke

OBJECTIVE

The Japanese have higher levels of n-3 polyunsaturated fatty acids (PUFAs) such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in their diets. These facts may contribute to the lower rates of atherosclerosis in Japanese. The purposes of this study were to assess the PUFA levels in patients with subtypes of acute ischemic stroke and to assess the relationship between severity and PUFA levels.

MATERIAL AND METHODS

We studied 75 patients with lacunar infarction (LI; n = 25), atherothrombotic infarction (AT; n = 32), and cardiogenic embolism (CE; n = 18). The patients underwent blood examinations in a fasting state next morning of hospitalization, including examination of low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL), triglyceride (TG), blood glucose, hemoglobin A1c (HbA1c), uric acid, and fatty acid fractions of EPA, DHA, dihomo-γ-linolenic acid (DGLA), and arachidonic acid (AA). We used the modified Rankin Scale (mRS) to assess clinical severity at discharge.

RESULTS

There was no significant difference in the EPA/AA and DHA/AA ratio among the three stroke subgroups, although the DGLA/AA ratio was significantly higher in patients with LI than in patients with CE. Considering the confounding factors, the mRS was negatively correlated with EPA/AA and positively correlated with age, DHA/AA, and blood glucose.

CONCLUSIONS

High EPA/AA ratio was associated with good outcome in ischemic stroke. Our paper suggests that prestroke dietary habits affect the severity in patients with ischemic stroke.

Functional outcome in young adult ischemic stroke: impact of lipoproteins

AIM

To determine the functional outcome in a cohort of young adults with ischemic stroke patients, focusing on components of lipid profile.

METHODS

In our registry including consecutive patients with first-ever ischemic stroke aged 15-49 from 1994 to 2007, we analyzed predictors of 3-month functional outcome (modified Rankin Scale, mRS). Infarct size fell into small, medium, large posterior, or large anterior. Stroke severity was assessed with NIH Stroke Scale (NIHSS). Serum lipids were measured within 72 h after admission. Binary, multinomial ordinal, and Poisson regressions allowed revealing factors associated with size of infarct, stroke severity, and unfavorable outcome or death (mRS, 2-6) or mRS as an ordinal measure.

RESULTS

In the 968 patients included (mean age, 41.3 ± 7.6; 62.6% men; 49.5% with mRS 0-1), factors associated with unfavorable outcome after multivariable analysis were increasing age (odds ratio, 1.03 per year; 95% confidence interval, 1.01-1.05), higher NIHSS score (1.23 per point, 1.17-1.29), large anterior (4.37, 2.26-8.42) or posterior (1.73, 1.05-2.85) infarcts, bilateral lesions (2.28, 1.30-3.98), internal carotid artery dissection (ICAD) (3.65, 1.41-9.47), and inversely high-density lipoprotein (HDL) levels (0.58 per unit increase, 0.38-0.86). Increasing HDL associated with smaller infarct size (0.71, 0.51-0.98). Both higher total and HDL cholesterol associated with lower NIHSS score (0.96, 0.93-0.98 for total cholesterol and 0.82, 0.75-0.88 for HDL) and lower 3-month mRS (0.87, 0.78-0.97 for total cholesterol and 0.65, 0.47-0.90 for HDL).

CONCLUSION

In addition to known prognosticators, ICAD and lower HDL levels were independently associated with adverse clinical outcomes in our young adult stroke cohort.

Biomarkers and functional outcomes from ischaemic cerebral events in women: a prospective cohort study

BACKGROUND AND PURPOSE

Several biomarkers have been associated with an increased risk of ischaemic stroke. However, the association between these biomarkers and functional outcome from cerebral ischaemic events is unclear. We aimed to assess the patterns of association between cardiovascular disease biomarkers and functional outcomes after incident ischaemic cerebral events in women.

METHODS

Prospective cohort study of 27,728 women enrolled in the Women's Health Study who provided information on blood samples and were free of stroke or transient ischaemic attack (TIA) at baseline. Multinomial logistic regression was used to determine the association between elevated biomarker levels and functional outcomes from ischaemic cerebral events. Possible functional outcomes included TIA and ischaemic stroke with modified Rankin Scale (mRS) score of 0-1, 2-3, or 4-6.

RESULTS

After a mean follow-up of 15.1 years, 461 TIAs and 380 ischaemic strokes occurred. Elevated levels of total cholesterol were associated with the highest risk of poor functional outcome (mRS 4-6) after incident cerebral ischaemic events (relative risk = 2.02, 95% CI = 1.18-3.46). We observed significant associations between elevated levels of total cholesterol, Lp(a), C-reactive protein, and triglycerides, and mild or moderate functional outcomes after ischaemic cerebral events. Elevations in all other biomarkers were not significantly associated with functional outcomes.

CONCLUSIONS

Whilst total cholesterol level was associated with highest risks of poor functional outcome after stroke, we overall observed an inconsistent pattern of association between biomarkers linked with an increased risk of vascular events and more impaired functional outcomes from stroke.

Effect of previous statin therapy on severity and outcome in ischemic stroke patients: a population-based study

Although statin therapy has been shown to be effective in the prevention of ischemic stroke, its effect on stroke severity and early outcome is still controversial. We aimed to evaluate the association between statin use before onset and both initial severity and functional outcome in ischemic stroke patients. All cases of first-ever ischemic stroke that occurred in Dijon, France (151,000 inhabitants) between 2006 and 2011 were prospectively identified from the Dijon Stroke Registry. Vascular risk factors, clinical severity at onset assessed by the NIHSS score, stroke subtypes, prestroke statin use, and lipid profile were collected. Functional outcome was defined by a six-level categorical outcome using the modified Rankin scale. Analyses were performed using ordinal logistic regression models. Among the 953 patients with first-ever ischemic stroke, 127 (13.3 %) had previously been treated with statins. Initial stroke severity did not differ between statin users and non-users [median NIHSS score (interquartile range) 4.0 (7.0) versus 4.0 (9.0) p = 0.104]. In unadjusted analysis, statin use was associated with a lower risk of an unfavorable functional outcome at discharge (OR 0.69; 95 % CI 0.49-0.96; p = 0.026) that was no longer significant in multivariate analyses (OR 0.76; 95 % CI 0.53-1.09; p = 0.134). After adjustment for admission plasma LDL cholesterol levels, the non-significant association was still observed (OR 0.76; 95 % CI 0.49-1.18; p = 0.221). This population-based study showed that prestroke statin therapy did not affect initial clinical severity but was associated with a non-significant better early functional outcome after ischemic stroke.

The Influence of Stroke Risk Factors and Comorbidities on Assessment of Stroke Therapies in Humans and Animals

The main driving force behind the assessment of novel pharmacological agents in animal models of stroke is to deliver new drugs to treat the human disease rather than to increase knowledge of stroke pathophysiology. There are numerous animal models of the ischaemic process and it appears that the same processes operate in humans. Yet, despite these similarities, the drugs that appear effective in animal models have not worked in clinical trials. To date, tissue plasminogen activator is the only drug that has been successfully used at the bedside in hyperacute stroke management. Several reasons have been put forth to explain this, but the failure to consider comorbidities and risk factors common in older people is an important one. In this article, we review the impact of the risk factors most studied in animal models of acute stroke and highlight the parallels with human stroke, and, where possible, their influence on evaluation of therapeutic strategies.

Are higher total serum cholesterol levels associated with better long-term motor function after ischemic stroke?

OBJECTIVES

The objective of the study was to investigate the prognostic role of total cholesterol (TC) level on the long-term motor function after ischemic stroke.

METHODS

One hundred and fourteen patients with ischemic stroke were included and divided into high total cholesterol (HTC; TC ≧5.18 mmol/l or ≧200 mg/dl) and low total cholesterol (LTC; TC <5.18 mmol/l or <200 mg/dl) groups. The motor outcome was evaluated using the motor score of the Fugl-Meyer assessment (MFMA) at 2 weeks (baseline), 1, 3, 6, and 12 months after stroke. Prognostic factors on the repeated measurements of the MFMA were investigated using the linear mixed regression model.

RESULTS

The TC, basal ganglion lesion, baseline MFMA, first-time stroke, and follow-up time were identified as significant predictors for serial MFMA scores. The HTC group had higher MFMA scores than the LTC group by 2.72 units (95% confidence interval (CI): 0.17, 5.27, P = 0.037). An elevation of one unit of baseline MFMA led to a 0.86 increase (95% CI: 0.82, 0.90, P < 0.001) of subsequent MFMA scores. Subjects with basal ganglion lesions had lower MFMA scores by -3.55 (95% CI: -5.97, -1.14, P = 0.004).

DISCUSSION

Higher total cholesterol at the acute phase of ischemic stroke is a favorable prognostic factor for long-term motor function.

Association of total serum cholesterol with functional outcome following home care rehabilitation in Italian patients with stroke

BACKGROUND

Stroke is a disabling disease. In elderly populations, stroke is the third leading cause of death and the primary cause of reduction in or loss of functional ability and personal autonomy. Possible associations between levels of total serum cholesterol (TC) and both incidence of stroke and functional outcomes after rehabilitation are still under study.

OBJECTIVE

To detect positive and negative prognostic factors associated with functional outcomes in first-time stroke patients admitted to an integrated home care rehabilitative program.

METHODS

This study enrolled 141 patients with a first-time stroke who were admitted to a home care rehabilitation program. Primary outcome measures were the Barthel activities of daily living (ADL) and mobility indices at the beginning and end of the rehabilitative treatment. The impact of TC and other demographic and clinical variables was analyzed using bivariate and multivariate logistic regression analyses.

RESULTS

Age and Short Portable Mental Status Questionnaire (SPMSQ) score were negatively associated with functional outcome. In contrast, elevated TC was positively associated with a better home rehabilitative treatment outcome. Barthel index score at admission was negatively associated with outcomes assessed by the Barthel ADL index and age with outcomes assessed by the Barthel mobility index. In a multivariate logistic regression analysis, SPMSQ score and elevated TC were significantly associated with outcome. Specifically, higher SPMSQ scores were negatively associated with better rehabilitative treatment outcomes, whereas elevated TC was positively associated.

CONCLUSIONS

Elevated TC seems to be associated with better functional outcomes in patients with first-time stroke.

Clinical outcomes after PCI for acute coronary syndrome in unprotected left main coronary artery disease: insights from the Swiss Acute Left Main Coronary Vessel Percutaneous Management (SALVage) study

AIMS

Unprotected left main (ULM) coronary artery disease is encountered in 3%-10% of coronary angiograms and is associated with high mortality. The survival of patients with ULM disease presenting with acute coronary syndromes (ACS) depends on different variables and is lowest in those with cardiogenic shock (CS). The aim of the present study was to estimate the impact of baseline characteristics on the subsequent clinical outcome in patients treated by percutaneous coronary intervention (PCI) of ULM for ACS.

METHODS AND RESULTS

One hundred and thirty-four patients were retrieved from our database and followed by phone or physician visit. Patients were classified into two groups according to their presentation (CS/STEMI group: patients presenting with CS or ST-elevation myocardial infarction; NSTEMI/UA group: patients with non-STEMI or unstable angina). Data collected were baseline characteristics, procedural information, and clinical outcome. The primary endpoint was all-cause mortality at 6-month follow-up. The secondary end point was a composite of cardiac death, myocardial infarction, and any repeat revascularisation, i.e., major adverse cardiac events (MACE). Kaplan-Meier curves were computed for survival. Logistic regression determined that hypercholesterolaemia (OR 6.22, p=0.03), high pre-procedural TIMI score (OR 3.89, p=0.01), preserved left ventricular ejection fraction (OR 1.07, p=0.01) and LM as culprit lesion (OR 8.57, p=0.01) protected against development of CS. Primary outcome occurred in 44% of patients in the CS/STEMI group compared to 6% in the NSTEMI/UA group (p<0.001). MACE were observed in 30 patients (48%) of the CS/STEMI group and in 12 patients (19%) of the NSTEMI/UA group (p=0.001).

CONCLUSIONS

Acute coronary syndrome due to critical ULM stenosis is associated with high mortality even after successful PCI. Patients presenting with CS or STEMI are at particular risk.