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McEvoy JW, McCarthy CP, Bruno RM, Brouwers S, Canavan MD, Ceconi C, Christodorescu RM, Daskalopoulou SS, Ferro CJ, Gerdts E, Hanssen H, Harris J, Lauder L, McManus RJ, Molloy GJ, Rahimi K, Regitz-Zagrosek V, Rossi GP, Sandset EC, Scheenaerts B, Staessen JA, Uchmanowicz I, Volterrani M, Touyz RM. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J 2024; 45:3912-4018. [PMID: 39210715 DOI: 10.1093/eurheartj/ehae178] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Law ZK, Menon CS, Woodhouse LJ, Appleton JP, Al-Shahi Salman R, Robinson T, Werring D, Roffe C, Dineen RA, Bath PM, Sprigg N. Outcome 1 year after ICH: Data from the Tranexamic acid for IntraCerebral Haemorrhage 2 (TICH-2) trial. Eur Stroke J 2024:23969873241265939. [PMID: 39076020 DOI: 10.1177/23969873241265939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Abstract
INTRODUCTION The Tranexamic acid for IntraCerebral Haemorrhage-2 (TICH-2) trial reported no significant improvement in death and dependency at day 90 despite reductions in haematoma expansion, early neurological deterioration and early death. However, significant recovery after stroke, particularly intracerebral haemorrhage (ICH), may take more than 3 months. Here we report the participant outcomes at 1 year after stroke. PATIENTS AND METHODS TICH-2 was a prospective randomised controlled trial that tested the efficacy and safety of tranexamic acid in spontaneous ICH when given within 8 h of onset. Patients with ICH on anticoagulation were excluded. Centralised blinded telephone follow up was performed for patients from the United Kingdom at 1 year. The primary outcome was modified Rankin Scale at 1 year. Secondary outcomes included Barthel index, Telephone Interview Cognitive Status-modified, EuroQoL-5D and Zung Depression Scale. This was a prespecified secondary analysis of the TICH-2 trial. RESULTS About 2325 patients were recruited into the trial (age 68.9 ± 13.8 years; 1301 male, 56%). About 1910 participants (82.2%) were eligible for day 365 follow up. 57 patients (3.0%) were lost to follow up. Tranexamic acid did not reduce the risk of poor functional outcome at 1 year (adjusted OR 0.91 95% CI 0.77-1.09; p = 0.302). However, Cox proportional hazard analysis revealed significant survival benefit in the tranexamic acid group (adjusted HR 0.83, 95% CI 0.70-0.99; p = 0.038). CONCLUSION There was no difference in functional outcome at 1 year after ICH. Tranexamic acid may reduce mortality at 1 year without an increase in severely dependent survivors. But this should be interpreted with caution as this is a result of secondary analysis in a neutral trial.
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Affiliation(s)
- Zhe Kang Law
- Stroke Medicine, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | | | - Lisa J Woodhouse
- Stroke Medicine, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason Philip Appleton
- Stroke Medicine, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David Werring
- Institute of Neurology and National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | | | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Philip Michael Bath
- Stroke Medicine, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke Medicine, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
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Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Xiao M, Li L, Zhu W, Wu F, Wu B. Statin-related neurocognitive disorder: a real-world pharmacovigilance study based on the FDA adverse event reporting system. Expert Rev Clin Pharmacol 2024; 17:255-261. [PMID: 38275183 DOI: 10.1080/17512433.2024.2311875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/25/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Concerns regarding statin-related neurocognitive disorders have emerged in recent years. However, previous studies have reported inconsistent results. We evaluated the association between statins and neurocognitive disorders using the FDA Adverse Event Reporting System (FAERS). RESEARCH DESIGN AND METHODS Data from 2004 to 2022 were obtained from the FAERS database. After deduplication and standardization of drug names, we extracted neurocognitive disorder event (NCDE) cases reported with statins as the suspected drugs. The significant association between statins and NCDE was evaluated using the reporting odds ratio (ROR) and information component. RESULTS In total, 6,959 NCDE cases with statins as the primary suspected drugs were identified. Signals were detected in pravastatin (ROR, 1.49; 95% CI: 1.32-1.67), atorvastatin (ROR, 1.39; 95% CI: 1.34-1.44), and simvastatin (ROR, 1.31; 95% CI: 1.25-1.38). Age-stratified analysis showed that (1) in the population aged 65 years and older, signals were detected for atorvastatin, simvastatin, rosuvastatin, pravastatin, lovastatin, fluvastatin, and pitavastatin; and (2) in populations under 65 years of age, signals were detected for atorvastatin, simvastatin, rosuvastatin, pravastatin, and lovastatin. CONCLUSIONS This study suggests a significant association between the NCDE and statins, including atorvastatin, simvastatin, and pravastatin. The intensity of the association increased with age.
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Affiliation(s)
- Min Xiao
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Li Li
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Weiwei Zhu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Fengbo Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Wu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, China
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Hobden G, Tang EYH, Demeyere N. A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories. Neuropsychol Rehabil 2024:1-18. [PMID: 38367002 DOI: 10.1080/09602011.2024.2314882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/16/2024] [Indexed: 02/19/2024]
Abstract
Cognitive impairment is common early after stroke but trajectories over the long term are variable. Some stroke survivors make a full recovery, while others retain a stable impairment or decline. This study explored the perceived advantages and disadvantages of discussing potential cognitive trajectories with stroke survivors and their family members. Stroke survivors at least six-months post-stroke were purposively sampled from an existing pool of research volunteers recruited originally for the OCS-Recovery study. They were invited, alongside a family member, to participate in a semi-structured interview. Interviews were audio recorded, transcribed, and analyzed using reflexive thematic analysis. Twenty-six stroke survivors and eleven family members participated. We identified one overarching theme and three related subthemes. The overarching theme was: One size does not fit all. The subthemes were: (1) Hearing about potential cognitive trajectories helps to develop realistic expectations; (2) Discussions about cognitive trajectories may be motivating; (3) Cognitive decline and post-stroke dementia discussions may be anxiety-provoking and depressing. Healthcare professionals should adopt a person-centred approach to sharing information about post-stroke cognitive trajectories. Discussions should be tailored to individual needs and preferences, with dementia-related topics in particular addressed with the utmost selectivity and sensitivity.
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Affiliation(s)
- Georgina Hobden
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | | | - Nele Demeyere
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Schmidbauer M, Wischmann J, Dimitriadis K, Kellert L. [Secondary prophylaxis of ischemic stroke]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:1171-1183. [PMID: 37947810 DOI: 10.1007/s00108-023-01615-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/12/2023]
Abstract
The secondary prophylaxis of ischemic stroke provides an enormous therapeutic potential due to the high frequency of recurrent thrombembolic events and the exceptional importance of modifiable cardiovascular risk factors for the individual risk of stroke. In this respect, anti-thrombotic, interventional and surgical treatment options must be selected based on the respective etiology. Furthermore, meticulous optimization of risk factors is essential for effective long-term care. Close interdisciplinary and intersectoral collaboration is crucial, especially in the long-term treatment.
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Affiliation(s)
- Moritz Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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Stulberg EL, Sachdev PS, Murray AM, Cramer SC, Sorond FA, Lakshminarayan K, Sabayan B. Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review. J Clin Med 2023; 12:7413. [PMID: 38068464 PMCID: PMC10706919 DOI: 10.3390/jcm12237413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/10/2023] [Accepted: 11/21/2023] [Indexed: 01/22/2024] Open
Abstract
Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.
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Affiliation(s)
- Eric L. Stulberg
- Department of Neurology, University of Utah, Salt Lake City, UT 84112, USA;
| | - Perminder S. Sachdev
- Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Sydney, NSW 2052, Australia;
- Neuropsychiatric Institute, Prince of Wales Hospital, Sydney, NSW 2031, Australia
| | - Anne M. Murray
- Berman Center for Outcomes and Clinical Research, Minneapolis, MN 55415, USA;
- Department of Medicine, Geriatrics Division, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
| | - Steven C. Cramer
- Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095, USA;
- California Rehabilitation Institute, Los Angeles, CA 90067, USA
| | - Farzaneh A. Sorond
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA;
| | - Behnam Sabayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA;
- Department of Neurology, Hennepin Healthcare Research Institute, Minneapolis, MN 55404, USA
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Goldstein LB, Toth PP, Dearborn-Tomazos JL, Giugliano RP, Hirsh BJ, Peña JM, Selim MH, Woo D. Aggressive LDL-C Lowering and the Brain: Impact on Risk for Dementia and Hemorrhagic Stroke: A Scientific Statement From the American Heart Association. Arterioscler Thromb Vasc Biol 2023; 43:e404-e442. [PMID: 37706297 DOI: 10.1161/atv.0000000000000164] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The objective of this scientific statement is to evaluate contemporary evidence that either supports or refutes the conclusion that aggressive low-density lipoprotein cholesterol lowering or lipid lowering exerts toxic effects on the brain, leading to cognitive impairment or dementia or hemorrhagic stroke. The writing group used literature reviews, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion to summarize existing evidence and to identify gaps in current knowledge. Although some retrospective, case control, and prospective longitudinal studies suggest that statins and low-density lipoprotein cholesterol lowering are associated with cognitive impairment or dementia, the preponderance of observational studies and data from randomized trials do not support this conclusion. The risk of a hemorrhagic stroke associated with statin therapy in patients without a history of cerebrovascular disease is nonsignificant, and achieving very low levels of low-density lipoprotein cholesterol does not increase that risk. Data reflecting the risk of hemorrhagic stroke with lipid-lowering treatment among patients with a history of hemorrhagic stroke are not robust and require additional focused study.
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Zhou J, Wei Q, Hu H, Liu W, Guan X, Ma A, Wang L. A systematic review and meta-analysis of health utility values among patients with ischemic stroke. Front Neurol 2023; 14:1219679. [PMID: 37731850 PMCID: PMC10507900 DOI: 10.3389/fneur.2023.1219679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Purpose Ischemic stroke (IS) has a considerable impact on the health-related quality of life (HRQoL) of patients. A systematic review was conducted to summarize and synthesize the HRQoL reported from IS patients. Methods An electronic search was performed in PubMed, Web of Science, ScienceDirect, Embase, and Cochrane Library databases from inception to February 2022 for studies measuring utility values in IS patients. Basic information about the studies, patient characteristics, measurement of the utility values, and utility values were extracted and summarized. Utility values were pooled according to the time of evaluation, and disease severity was classified with modified Rankin Scale (mRS) scores. The quality of the studies was assessed according to key criteria recommended by the National Institute for Health and Care Excellence. Results A total of 39 studies comprising 30,853 participants were included in the study. Measured with EQ-5D-3L, the pooled utility values were 0.42 [95% confidential interval (CI): 0.13 to 0.71], 0.55 (95% CI: 0.43 to 0.68), 0.65 (95% CI: 0.52 to 0.78), 0.60 (95% CI: 0.43 to 0.78), and 0.67 (95% CI: 0.60 to 0.74) for patients diagnosed with IS within 1, 3, 6, 12, and 24 months or above among poststroke patients. Four studies reported utility values classified by mRS scores where synthesized estimates stratified by mRS scores ranged from 0.91 (95% CI: 0.85 to 0.97) for patients with an mRS score of 1 to-0.04 (95% CI:-0.18 to 0.11) for those with an mRS score of 5. As for the health dimension profiles, usual activity was the most impacted dimension, while self-care was the least impacted one. Conclusion This study indicated that the utility values in IS patients kept increasing from stroke onset and became relatively stabilized at 6 months poststroke. Health utility values decreased significantly as mRS scores increased. These results facilitate economic evaluations in utility retrieval and selection. Further exploration was required regarding the factors that affect the HRQoL of IS patients.
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Affiliation(s)
| | | | | | | | | | - Aixia Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Luying Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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Singh SS, Zhong S, Rogers KA, Hachinski VC, Frisbee SJ. Prevalence of dementia, heart disease and stroke in community-dwelling adults in Canada, 2016-2021: opportunities for joint prevention. Arch Public Health 2023; 81:158. [PMID: 37620877 PMCID: PMC10464200 DOI: 10.1186/s13690-023-01171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION This aim of this study is to provide updated estimates on the prevalence of dementia, heart disease, and stroke in Canadian communities. Targeting all three conditions together, at the community level, may be key to disease prevention and health aging in the Canadian population. METHODS Using nationwide health survey data, we calculated the age-standardized prevalence of self-reported dementia, heart disease and stroke in adults aged 18 years and over residing in Canadian communities from 2016 to 2021. Poisson regression models were used to detect statistically significant changes in the prevalence of all three conditions from 2016 to 2021. RESULTS Less than 1% (~ 175,000 individuals) of adults residing in Canadian communities reported dementia, 5% (~ 1.5 million individuals) reported heart disease, and more than 1% (~ 370,000 individuals) reported stroke annually from 2016 to 2021. Overall, the age-standardized prevalence for stroke decreased minimally from 2016 to 2021 (p = 0.0004). Although the age-standardized prevalence of heart disease and dementia decreased from 2016 to 2018, subsequent increases in prevalence from 2018 to 2021 led to a lack of overall statistically significant changes from 2016 to 2021 (p = 0.10 for heart disease and p = 0.37 for dementia). CONCLUSION Recent increases in the prevalence of dementia, heart disease and stroke in Canadian communities threaten to reverse any gains in vascular disease prevention over the past six years. Findings reveal the urgent need for intensified prevention efforts that are community-based with a focus on joint reduction in the shared risk factors contributing to all three diseases.
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Affiliation(s)
- Sarah S Singh
- Robarts Research Institute, University of Western Ontario, 100 Perth Dr, London, ON, N6A 5K8, Canada.
| | - Shiran Zhong
- Department of Geography, University of Western Ontario, London, ON, Canada
| | - Kem A Rogers
- Department of Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Vladimir C Hachinski
- Robarts Research Institute, University of Western Ontario, 100 Perth Dr, London, ON, N6A 5K8, Canada
- Department of Clinical Neurological Sciences, and Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
| | - Stephanie J Frisbee
- Department of Pathology & Laboratory Medicine, and Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
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Dopler B. Stroke Prevention. Dela J Public Health 2023; 9:6-10. [PMID: 37701472 PMCID: PMC10494800 DOI: 10.32481/djph.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
Stroke has three main subtypes - ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The most common stroke subtype is ischemic stroke, making up about 88% of strokes. Many of these strokes may be prevented by lifestyle modifications. These lifestyle modifications include engaging in physical activity, dietary changes such as the Mediterranean diet, smoking cessation, and avoiding substance abuse. Addressing medical conditions such as diabetes, hypertension, lipid management, sleep apnea, and atrial fibrillation will also have a major impact on stroke prevention. In addition to stroke prevention, these strategies help with overall brain health, which may also have an impact on neurological degenerative diseases such as Alzheimer's disease.
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Affiliation(s)
- Bruce Dopler
- Neurologist, Neurology Center of South Delaware; Tidal Health Nanticoke
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de Havenon A, Smith EE, Sharma R, Falcone GJ, Bangad A, Prabhakaran S, Sheth KN. Improvement in the Prediction of Cerebrovascular Events With White Matter Hyperintensity. J Am Heart Assoc 2023; 12:e029374. [PMID: 37345754 PMCID: PMC10356061 DOI: 10.1161/jaha.123.029374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 03/23/2023] [Indexed: 06/23/2023]
Abstract
Background It remains unclear if white matter hyperintensity (WMH) on magnetic resonance imaging adds relevant cerebrovascular prognostic information beyond vascular risk factors and demographics alone. Methods and Results We performed a post hoc analysis of hypertensive individuals in SPRINT-MIND (Systolic Blood Pressure Intervention Trial-Memory and Cognition in Decreased Hypertension). The primary outcome was incident stroke or cognitive impairment (mild cognitive impairment or dementia). We fit logistic regression models with the predictors of Atherosclerotic Cardiovascular Disease Risk Score, age, sex, race, education, current cigarette smoking, and the SPRINT-MIND randomization arm. WMH was subsequently included in the model to determine if it improved area under the receiver operating curve using the DeLong test. We used a structural equation model to determine the indirect effect on the primary outcome mediated through WMH. We included 727 individuals (mean age at baseline 67.7±8.4 years, 61.1% were men, 62.6% were non-Hispanic White, and mean years of follow-up was 3.6±0.9). Of the 727 individuals, 67 (9.2%) developed incident stroke or cognitive decline. The area under the receiver operating curve of the baseline model (without WMH) was 0.75 (95% CI, 0.70-0.81), and after the addition of WMH it increased to 0.81 (95% CI, 0.76-0.86) (P=0.004 for difference). The mediation analysis showed that 26.3% of the vascular risk's effect on the primary outcome is indirectly mediated through WMH. Conclusions In adult hypertensive individuals, we found that the addition of WMH to models predicting incident stroke or cognitive impairment improved the prognostic ability above vascular risk and demographics alone to a level consistent with excellent prediction. Registration Information REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology Yale University New Haven CT USA
- Center for Brain and Mind Health Yale University New Haven CT USA
| | - Eric E Smith
- Department of Clinical Neurosciences University of Calgary Alberta Canada
| | - Richa Sharma
- Department of Neurology Yale University New Haven CT USA
- Center for Brain and Mind Health Yale University New Haven CT USA
| | - Guido J Falcone
- Department of Neurology Yale University New Haven CT USA
- Center for Brain and Mind Health Yale University New Haven CT USA
| | - Aaron Bangad
- Department of Neurology Yale University New Haven CT USA
| | | | - Kevin N Sheth
- Department of Neurology Yale University New Haven CT USA
- Center for Brain and Mind Health Yale University New Haven CT USA
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Joseph J, Pajewski NM, Dolor RJ, Ann Sellers M, Perdue LH, Peeples SR, Henrie AM, Woolard N, Jones WS, Benziger CP, Orkaby AR, Mixon AS, VanWormer JJ, Shapiro MD, Kistler CE, Polonsky TS, Chatterjee R, Chamberlain AM, Forman DE, Knowlton KU, Gill TM, Newby LK, Hammill BG, Cicek MS, Williams NA, Decker JE, Ou J, Rubinstein J, Choudhary G, Gazmuri RJ, Schmader KE, Roumie CL, Vaughan CP, Effron MB, Cooper-DeHoff RM, Supiano MA, Shah RC, Whittle JC, Hernandez AF, Ambrosius WT, Williamson JD, Alexander KP. Pragmatic evaluation of events and benefits of lipid lowering in older adults (PREVENTABLE): Trial design and rationale. J Am Geriatr Soc 2023; 71:1701-1713. [PMID: 37082807 PMCID: PMC10258159 DOI: 10.1111/jgs.18312] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 04/22/2023]
Abstract
Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double-blind, placebo-controlled randomized pragmatic clinical trial, will compare high-intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community-dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site-reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co-secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.
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Affiliation(s)
| | | | - Rowena J. Dolor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Mary Ann Sellers
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Adam M. Henrie
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Albuquerque, NM
| | - Nancy Woolard
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - W. Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Ariela R. Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, and Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA
| | - Amanda S. Mixon
- Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
| | | | | | - Christine E. Kistler
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, NC
| | | | - Ranee Chatterjee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Daniel E. Forman
- Department of Medicine, Sections of Geriatrics and Cardiology, University of Pittsburgh; Pittsburgh GRECC, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | | | - L. Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Bradley G. Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Jake E. Decker
- Section of Primary Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jiafu Ou
- Cardiology Division, John Cochran VA Medical Center and Cardiology Division, Washington University School of Medicine, St. Louis, MO
| | - Jack Rubinstein
- Division of Cardiology, Cincinnati VAMC and Division of Cardiovascular Diseases, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH
| | - Gaurav Choudhary
- Providence VA Medical Center, and Lifespan Cardiovascular Institute, and Alpert Medical School of Brown University, Providence RI
| | - Raúl J. Gazmuri
- Captain James A. Lovell Federal Health Care Center and Rosalind Franklin University of Medicine and Science, Chicago, IL
| | | | - Christianne L. Roumie
- Vanderbilt University Medical Center and Geriatric Research Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
| | - Camille P. Vaughan
- Birmingham/Atlanta Geriatric Research Education and Clinical Center (GRECC), Department of Veterans Affairs, and Division of Geriatrics & Gerontology, Department of Medicine, Emory University, Atlanta, GA
| | - Mark B. Effron
- John Ochsner Heart and Vascular Institute, The University of Queensland Ochsner Clinical School, New Orleans, LA
| | | | | | - Raj C. Shah
- Family & Preventive Medicine and the Rush Alzheimer’s Disease Center, Rush University, Chicago, IL
| | | | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Karen P. Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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14
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Hsu CY, Saver JL, Ovbiagele B, Wu YL, Cheng CY, Lee M. Association Between Magnitude of Differential Blood Pressure Reduction and Secondary Stroke Prevention: A Meta-analysis and Meta-Regression. JAMA Neurol 2023; 80:506-515. [PMID: 36939729 PMCID: PMC10028545 DOI: 10.1001/jamaneurol.2023.0218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/06/2023] [Indexed: 03/21/2023]
Abstract
Importance The degree to which more intensive blood pressure reduction is better than less intensive for secondary stroke prevention has not been delineated. Objective To perform a standard meta-analysis and a meta-regression of randomized clinical trials to evaluate the association of magnitude of differential blood pressure reduction and recurrent stroke in patients with stroke or transient ischemic attack (TIA). Data Sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1980, to June 30, 2022. Study Selection Randomized clinical trials that compared more intensive vs less intensive blood pressure lowering and recorded the outcome of recurrent stroke in patients with stroke or TIA. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Risk ratio (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive blood pressure lowering with primary and secondary outcomes. The univariate meta-regression analyses were conducted to evaluate a possible moderating effect of magnitude of differential systolic blood pressure (SBP) and diastolic blood pressure (DBP) reduction on the recurrent stroke and major cardiovascular events. Main Outcomes and Measures The primary outcome was recurrent stroke and the lead secondary outcome was major cardiovascular events. Results Ten randomized clinical trials comprising 40 710 patients (13 752 women [34%]; mean age, 65 years) with stroke or TIA were included for analysis. The mean duration of follow-up was 2.8 years (range, 1-4 years). Pooled results showed that more intensive treatment compared with less intensive was associated with a reduced risk of recurrent stroke in patients with stroke or TIA (absolute risk, 8.4% vs 10.1%; RR, 0.83; 95% CI, 0.78-0.88). Meta-regression showed that the magnitude of differential SBP and DBP reduction was associated with a lower risk of recurrent stroke in patients with stroke or TIA in a log-linear fashion (SBP: regression slope, -0.06; 95% CI, -0.08 to -0.03; DBP: regression slope, -0.17; 95% CI, -0.26 to -0.08). Similar results were found in the association between differential blood pressure lowering and major cardiovascular events. Conclusions and Relevance More intensive blood pressure-lowering therapy might be associated with a reduced risk of recurrent stroke and major cardiovascular events. These results might support the use of more intensive blood pressure reduction for secondary prevention in patients with stroke or TIA.
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Affiliation(s)
- Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L. Saver
- UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, Los Angeles
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, Los Angeles
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Chun-Yu Cheng
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
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15
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Levine DA, Chen B, Galecki AT, Gross AL, Briceño EM, Whitney RT, Ploutz-Snyder RJ, Giordani BJ, Sussman JB, Burke JF, Lazar RM, Howard VJ, Aparicio HJ, Beiser AS, Elkind MSV, Gottesman RF, Koton S, Pendlebury ST, Sharma A, Springer MV, Seshadri S, Romero JR, Hayward RA. Associations Between Vascular Risk Factor Levels and Cognitive Decline Among Stroke Survivors. JAMA Netw Open 2023; 6:e2313879. [PMID: 37195662 PMCID: PMC10193182 DOI: 10.1001/jamanetworkopen.2023.13879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/30/2023] [Indexed: 05/18/2023] Open
Abstract
Importance Incident stroke is associated with accelerated cognitive decline. Whether poststroke vascular risk factor levels are associated with faster cognitive decline is uncertain. Objective To evaluate associations of poststroke systolic blood pressure (SBP), glucose, and low-density lipoprotein (LDL) cholesterol levels with cognitive decline. Design, Setting, and Participants Individual participant data meta-analysis of 4 US cohort studies (conducted 1971-2019). Linear mixed-effects models estimated changes in cognition after incident stroke. Median (IQR) follow-up was 4.7 (2.6-7.9) years. Analysis began August 2021 and was completed March 2023. Exposures Time-dependent cumulative mean poststroke SBP, glucose, and LDL cholesterol levels. Main Outcomes and Measures The primary outcome was change in global cognition. Secondary outcomes were change in executive function and memory. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition. Results A total of 1120 eligible dementia-free individuals with incident stroke were identified; 982 (87.7%) had available covariate data and 138 (12.3%) were excluded for missing covariate data. Of the 982, 480 (48.9%) were female individuals, and 289 (29.4%) were Black individuals. The median age at incident stroke was 74.6 (IQR, 69.1-79.8; range, 44.1-96.4) years. Cumulative mean poststroke SBP and LDL cholesterol levels were not associated with any cognitive outcome. However, after accounting for cumulative mean poststroke SBP and LDL cholesterol levels, higher cumulative mean poststroke glucose level was associated with faster decline in global cognition (-0.04 points/y faster per each 10-mg/dL increase [95% CI, -0.08 to -0.001 points/y]; P = .046) but not executive function or memory. After restricting to 798 participants with apolipoprotein E4 (APOE4) data and controlling for APOE4 and APOE4 × time, higher cumulative mean poststroke glucose level was associated with a faster decline in global cognition in models without and with adjustment for cumulative mean poststroke SBP and LDL cholesterol levels (-0.05 points/y faster per 10-mg/dL increase [95% CI, -0.09 to -0.01 points/y]; P = .01; -0.07 points/y faster per 10-mg/dL increase [95% CI, -0.11 to -0.03 points/y]; P = .002) but not executive function or memory declines. Conclusions and Relevance In this cohort study, higher poststroke glucose levels were associated with faster global cognitive decline. We found no evidence that poststroke LDL cholesterol and SBP levels were associated with cognitive decline.
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Affiliation(s)
- Deborah A. Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
- Department of Neurology and Stroke Program, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Bingxin Chen
- Department of Nursing, University of Michigan, Ann Arbor
| | - Andrzej T. Galecki
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Alden L. Gross
- Department of Epidemiology, Johns Hopkins Bloomberg School Public Health, Baltimore, Maryland
| | - Emily M. Briceño
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
| | - Rachael T. Whitney
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
| | | | - Bruno J. Giordani
- Department of Psychiatry and Michigan Alzheimer’s Disease Center, University of Michigan, Ann Arbor
| | - Jeremy B. Sussman
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - James F. Burke
- Department of Neurology, Ohio State University College of Medicine, Columbus
| | - Ronald M. Lazar
- Department of Neurology and Evelyn F. McKnight Brain Institute, Heersink School of Medicine, University of Alabama at Birmingham
| | - Virginia J. Howard
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health
| | - Hugo J. Aparicio
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, Massachusetts
| | - Alexa S. Beiser
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Rebecca F. Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Silvia Koton
- Department of Epidemiology, Johns Hopkins Bloomberg School Public Health, Baltimore, Maryland
- Department of Nursing, The Stanley Steyer School of Health Professions, Tel Aviv University, Tel Aviv, Israel
| | - Sarah T. Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- NIHR Biomedical Research Centre, Departments of Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Anu Sharma
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
| | - Mellanie V. Springer
- Department of Neurology and Stroke Program, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Sudha Seshadri
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, Massachusetts
- Department of Neurology and Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, Joe R. and Teresa Lozano Long School of Medicine, University of Texas San Antonio
| | - Jose R. Romero
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, Massachusetts
| | - Rodney A. Hayward
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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16
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Fan J, Bai J, Liu W, Cai J. Effects of intensive vs. standard blood pressure control on cognitive function: Post-hoc analysis of the STEP randomized controlled trial. Front Neurol 2023; 14:1042637. [PMID: 36816574 PMCID: PMC9930906 DOI: 10.3389/fneur.2023.1042637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
Background The STEP (Strategy of Blood Pressure Intervention in the older Hypertensive Patients) trial showed that intensive systolic blood pressure (SBP) control resulted in a lower incidence of cardiovascular events than standard treatment. This study analyzed the effects of intensive SBP lowering on cognitive function. Methods STEP was a multicenter, randomized controlled trial of hypertensive patients aged 60-80 years. Participants were randomly assigned (1:1) to SBP goals of 110-130 mmHg (intensive treatment) or 130-150 mmHg (standard treatment). Each individual was asked to complete a cognitive function test (Mini-Mental State Examination; MMSE) at baseline and during follow-up. The primary outcome for this study was the annual change in MMSE score. Subjects with a score less than education-specific cutoff point were categorized as cognitive decline. Results The analysis enrolled 6,501 participants (3,270 participants in the intensive-treatment and 3,231 participants in the standard-treatment groups). Median follow-up was 3.34 years. There was a minor change in MMSE score, with an annual change of -0.001 [95% confidence interval [CI] -0.020, 0.018] and 0.030 (95% CI 0.011, 0.049) in the intensive- and standard-treatment groups, respectively (p = 0.052). Cognitive decline occurred in 46/3,270 patients (1.4%) in the intensive-treatment group and 42/3,231 (1.3%) in the standard-treatment group (hazard ratio 0.005, 95% CI 0.654, 1.543, p = 0.983). Conclusions Compared with standard treatment, intensive SBP treatment did not result in a significant change in cognitive function test score. The impact of intensive blood pressure lowering was not evident using this global cognitive function test. Trial registration ClinicalTrials.gov. Unique identifier: NCT03015311.
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Affiliation(s)
- Jiali Fan
- Department of Hypertension, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jingjing Bai
- Department of Hypertension, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Liu
- Department of Cardiology, Beijing Jishuitan Hospital, Peking University Fourth Hospital, Beijing, China,Wei Liu ✉
| | - Jun Cai
- Department of Hypertension, National Center for Cardiovascular Diseases, Fuwai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China,*Correspondence: Jun Cai ✉
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17
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Gao Y, Li D, Lin J, Thomas AM, Miao J, Chen D, Li S, Chu C. Cerebral small vessel disease: Pathological mechanisms and potential therapeutic targets. Front Aging Neurosci 2022; 14:961661. [PMID: 36034144 PMCID: PMC9412755 DOI: 10.3389/fnagi.2022.961661] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Cerebral small vessel disease (CSVD) represents a diverse cluster of cerebrovascular diseases primarily affecting small arteries, capillaries, arterioles and venules. The diagnosis of CSVD relies on the identification of small subcortical infarcts, lacunes, white matter hyperintensities, perivascular spaces, and microbleeds using neuroimaging. CSVD is observed in 25% of strokes worldwide and is the most common pathology of cognitive decline and dementia in the elderly. Still, due to the poor understanding of pathophysiology in CSVD, there is not an effective preventative or therapeutic approach for CSVD. The most widely accepted approach to CSVD treatment is to mitigate vascular risk factors and adopt a healthier lifestyle. Thus, a deeper understanding of pathogenesis may foster more specific therapies. Here, we review the underlying mechanisms of pathological characteristics in CSVD development, with a focus on endothelial dysfunction, blood-brain barrier impairment and white matter change. We also describe inflammation in CSVD, whose role in contributing to CSVD pathology is gaining interest. Finally, we update the current treatments and preventative measures of CSVD, as well as discuss potential targets and novel strategies for CSVD treatment.
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Affiliation(s)
- Yue Gao
- Department of Neurointervention and Neurological Intensive Care, Dalian Municipal Central Hospital, Dalian, China
| | - Di Li
- Department of Neurointervention and Neurological Intensive Care, Dalian Municipal Central Hospital, Dalian, China
| | - Jianwen Lin
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, China
| | - Aline M. Thomas
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institution, Baltimore, MD, United States
| | - Jianyu Miao
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, China
| | - Dong Chen
- Department of Neurosurgery, Dalian Municipal Central Hospital, Dalian, China
| | - Shen Li
- Department of Neurology and Psychiatry, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Chengyan Chu
- Department of Neurology, Dalian Municipal Central Hospital, Dalian, China
- *Correspondence: Chengyan Chu,
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18
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Abstract
High blood pressure (BP) is detrimental to brain health. High BP contributes to cognitive impairment and dementia through pathways independent of clinical stroke. Emerging evidence shows that the deleterious effect of high BP on cognition occurs across the life span, increasing the risk for early-onset and late-life dementia. The term vascular cognitive impairment includes cognitive disorders associated with cerebrovascular disease, regardless of the pathogenesis. This focused report is a narrative review that aims to summarize the epidemiology of BP and vascular cognitive impairment, including differences by sex, race, and ethnicity, as well as the management and reversibility of BP and vascular cognitive impairment. It also discusses knowledge gaps and future directions.
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Affiliation(s)
- Deborah A. Levine
- Department of Internal Medicine and Cognitive Health Services Research Program, University of Michigan (U-M), Ann Arbor, MI
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI
| | - Mellanie V. Springer
- Department of Neurology and Stroke Program, U-M, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, U-M, Ann Arbor, MI
| | - Amy Brodtmann
- The Florey Institute of Neuroscience and Mental Health, Royal Melbourne Hospital, University of Melbourne, Australia
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19
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Sibbritt D, Hosseini M, Peng W, Bayes J, Adams J. The health care utilisation and out-of-pocket expenditure associated with Australian stroke survivors aged 55 and over. PLoS One 2022; 17:e0265907. [PMID: 35324963 PMCID: PMC8947389 DOI: 10.1371/journal.pone.0265907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/09/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Stroke is a major cause of mortality and disability worldwide. People with stroke have a number of options available to treat post-stroke related symptoms and challenges. The aim of this study was to assess the use of healthcare services, self-care practices and out-of-pocket expenses associated with post-stroke healthcare. Methods We retrospectively analysed data collected between April and October 2017 from a survey of 576 participants aged 55 to 96 from the 45 and Up Study, NSW (Australia), who had earlier reported a clinical diagnosis of stroke. Participants were asked about their use of health care services, including conventional medicine practitioners and medications, complementary medicine practitioners, practices and products and the respective associated out-of-pocket expenditure for each. Results Amongst the total of 576 individuals who participated in the study, 39% consulted a doctor, 18% consulted an allied health practitioner, and 8% consulted a complementary medicine practitioner in the previous year for their stroke. Participants’ average combined out-of-pocket expenditure for post-stroke related healthcare was AU$386.4 per annum. Extrapolated to all Australians with stroke, aged 55 years and over, the total out-of-pocket expenditure for post-stroke related healthcare is estimated to be AU$42 million per annum. Conclusions Post-stroke individuals used a wide range of health services and various self-care practices for stroke rehabilitation. Such healthcare utilisation is associated with significant annual out-of-pocket expenditure. Given the socioeconomic burden of stroke, further research is required to identify the barriers and facilitators of self-care among patients with stroke and explore the cost-effectiveness of the wide range of treatments(s) utilised for post-stroke care.
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Affiliation(s)
- David Sibbritt
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Mahdie Hosseini
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Wenbo Peng
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jessica Bayes
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
- * E-mail:
| | - Jon Adams
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
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20
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Yang Z, Toh S, Li X, Edwards D, Brayne C, Mant J. Statin use is associated with lower risk of dementia in stroke patients: a community-based cohort study with inverse probability weighted marginal structural model analysis. Eur J Epidemiol 2022; 37:615-627. [PMID: 35305172 PMCID: PMC9288375 DOI: 10.1007/s10654-022-00856-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 02/16/2022] [Indexed: 02/01/2023]
Abstract
Current evidence is inconclusive on cognitive benefits or harms of statins among stroke patients, who have high risk of dementia. This observational cohort study investigated the association between statin use and post-stroke dementia using data from the Clinical Practice Research Datalink. Patients without prior dementia who had an incident stroke but received no statins in the preceding year were followed for up to 10 years. We used inverse probability weighted marginal structural models to estimate observational analogues of intention-to-treat (ITT, statin initiation vs. no initiation) and per-protocol (PP, sustained statin use vs. no use) effects on the risk of dementia. To explore potential impact of unmeasured confounding, we examined the risks of coronary heart disease (CHD, positive control outcome), fracture and peptic ulcer (negative control outcomes). In 18,577 statin initiators and 14,613 non-initiators (mean follow-up of 4.2 years), the adjusted hazard ratio (aHR) for dementia was 0.70 (95% confidence interval [CI] 0.64–0.75) in ITT analysis and 0.55 (95% CI 0.50–0.62) in PP analysis. The corresponding aHRITT and aHRPP were 0.87 (95% CI 0.79–0.95) and 0.70 (95% CI 0.62–0.80) for CHD, 1.03 (95% CI 0.82–1.29) and 1.09 (95% CI 0.77–1.54) for peptic ulcer, and 0.88 (95% CI 0.80–0.96) and 0.86 (95% CI 0.75–0.98) for fracture. Statin initiation after stroke was associated with lower risk of dementia, with a potentially greater benefit in patients who persisted with statins over time. The observed association of statin use with post-stroke dementia may in part be overestimated due to unmeasured confounding shared with the association between statin use and fracture.
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Affiliation(s)
- Zhirong Yang
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School &, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Xiaojuan Li
- Department of Population Medicine, Harvard Medical School &, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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21
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McGurgan IJ, Kelly PJ, Turan TN, Rothwell PM. Long-Term Secondary Prevention: Management of Blood Pressure After a Transient Ischemic Attack or Stroke. Stroke 2022; 53:1085-1103. [PMID: 35291823 DOI: 10.1161/strokeaha.121.035851] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reducing blood pressure (BP) is a highly effective strategy for long-term stroke prevention. Despite overwhelmingly clear evidence from randomized trials that antihypertensive therapy substantially reduces the risk of stroke in primary prevention, uncertainty still surrounds the issue of BP lowering after cerebrovascular events, and the risk of recurrent stroke, coronary events, and vascular death remains significant. Important questions in a secondary prevention setting include should everyone be treated regardless of their poststroke BP, how soon after a stroke should BP-lowering treatment be commenced, how intensively should BP be lowered, what drugs are best, and how should long-term BP control be optimized and monitored. We review the evidence on BP control after a transient ischemic attack or stroke to address these unanswered questions and draw attention to some recent developments that hold promise to improve management of BP in current practice.
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Affiliation(s)
- Iain J McGurgan
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
| | - Peter J Kelly
- Neurovascular Clinical Science Unit, Stroke Service and Department of Neurology, Mater University Hospital, Dublin, Ireland (P.J.K.)
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston (T.N.T.)
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom (I.J.M., P.M.R.)
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22
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Kitagawa K, Arima H, Yamamoto Y, Ueda S, Rakugi H, Kohro T, Yonemoto K, Matsumoto M, Saruta T, Shimada K. Intensive or standard blood pressure control in patients with a history of ischemic stroke: RESPECT post hoc analysis. Hypertens Res 2022; 45:591-601. [PMID: 35241817 DOI: 10.1038/s41440-022-00862-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 11/09/2022]
Abstract
The Recurrent Stroke Prevention Clinical Outcome (RESPECT) Study and its pooled analysis showed that intensive blood pressure (BP) lowering reduced recurrent stroke risk by 22% in patients with a history of stroke. Here, we report the effect of intensive BP lowering on the risk of recurrent stroke subtypes in patients with a history of ischemic stroke. RESPECT was a randomized clinical trial among 1280 people with a history of cerebral infarction or intracerebral hemorrhage. Participants were assigned to the intensive blood pressure control group (blood pressure < 120/80 mmHg) or standard blood pressure control group (blood pressure < 140/90 mmHg). In this post hoc analysis, we analyzed 1074 patients with a history of cerebral infarction. The mean BP at baseline was 140.7/81.4 mmHg. Throughout the follow-up period, the mean BP was 133.4/77.5 (95% CI, 132.7-134.1/76.9-78.2) mmHg in the standard group and 126.7/74.1 (95% CI, 126.0-127.4/73.5-74.8) mmHg in the intensive group. During a mean follow-up of 3.9 years, 78 first recurrent strokes occurred. Intensive treatment tended to reduce overall annual stroke recurrence (1.74% in intensive vs. 2.17% in standard; P = 0.351 by log-rank test) and did not change the risk of ischemic stroke (1.74% vs. 1.75%, P = 0.999) but markedly reduced the risk of hemorrhagic stroke (0.00% vs. 0.39%, P = 0.005). Beneficial effects of intensive BP control were observed for the risk of hemorrhagic stroke in patients with a history of ischemic stroke. The findings of this study indicate the benefit of intensive BP control for patients with a history of ischemic stroke at high risk of hemorrhagic stroke.
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Affiliation(s)
- Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan.
| | - Hisatomi Arima
- Department of Prevented Medicine and Public Health, Faculty of Medicine, Fukuoka University, Jonan, Fukuoka, Japan
| | - Yasumasa Yamamoto
- Department of Stroke Center, Kyoto Katsura Hospital, Nishikyo, Kyoto, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology & Therapeutics, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takahide Kohro
- Department of Cardiovascular Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Koji Yonemoto
- Division of Biostatistics, School of Health Sciences, Faculty of Medicine, University of the Ryukyus, Nakagamigunn, Okinawa, Japan
| | | | - Takao Saruta
- Department of Internal Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazuyuki Shimada
- Cardiovascular Medicine, Shin-Oyama City Hospital, Oyama, Tochigi, Japan
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23
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Effect of immediate blood pressure reduction on post-stroke depression in ischemic stroke patients: A substudy of CATIS trial. J Affect Disord 2022; 300:195-202. [PMID: 34979180 DOI: 10.1016/j.jad.2021.12.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/27/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Several prospective studies have identified that hypertension is an important risk factor of post-stroke depression (PSD). However, the effect of immediate antihypertensive treatment on the risk of PSD in patients with acute ischemic stroke remains unknown. METHODS In this prespecified depression substudy of the China Antihypertensive Trial in Acute Ischemic Stroke (CATIS) randomized clinical trial, a total of 642 patients with acute ischemic stroke within 48 h of onset and elevated systolic BP at 7 sites of CATIS were included. Patients were randomly assigned to receive antihypertensive treatment (n = 318) or to control group (n = 324). The primary outcome was depression (Hamilton Rating Scale for Depression score≥8) at 3-month posttreatment follow-up. RESULTS At 24 h after randomization, the mean systolic BP was reduced by 21.6 mm Hg (12.5%) in the treatment group and 13.9 mm Hg (7.9%) in the control group (difference, -7.7 mm Hg [95% CI, -10.2 to -5.2]; P<0.001). The mean systolic BP levels at 7 days (P<0.001) and 14 days (P<0.001) after randomization in treatment group were also significantly lower than those in control group. At 3-month posttreatment follow-up, 122 patients (38.4%) in antihypertensive treatment group and 131 patients (40.4%) in control group developed PSD (odds ratio, 0.92 [95% CI, 0.67 to 1.26]; P = 0.59). LIMITATIONS All patients in the CATIS trial were Chinese, which might limit the generalizability of our findings to other populations. CONCLUSIONS Early antihypertensive treatment had no effect on the risk of PSD at 3 months among patients with acute ischemic stroke and elevated BP.
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24
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Lee M, Cheng CY, Wu YL, Lee JD, Hsu CY, Ovbiagele B. Association Between Intensity of Low-Density Lipoprotein Cholesterol Reduction With Statin-Based Therapies and Secondary Stroke Prevention: A Meta-analysis of Randomized Clinical Trials. JAMA Neurol 2022; 79:349-358. [PMID: 35188949 PMCID: PMC8861901 DOI: 10.1001/jamaneurol.2021.5578] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Importance The benefits and risks associated with intensive low-density lipoprotein cholesterol (LDL-C)-lowering statin-based therapies to lessen the risk of recurrent stroke have not been established. Objective To conduct a meta-analysis of randomized clinical trials to evaluate the association of more intensive vs less intensive LDL-C-lowering statin-based therapies with outcomes for patients with ischemic stroke. Data Sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched from January 1, 1970, to July 31, 2021. Study Selection This meta-analysis included randomized clinical trials that compared more intensive vs less intensive LDL-C-lowering statin-based therapies and recorded the outcome of recurrent stroke among patients with stroke. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used for abstracting data and assessing data quality and validity. Relative risk (RR) with 95% CI was used as a measure of the association of more intensive vs less intensive LDL-C lowering with primary and secondary outcomes. Main Outcomes and Measures The primary outcome was recurrent stroke, and the secondary outcomes were major cardiovascular events and hemorrhagic stroke. Results The final analysis included 11 randomized clinical trials with 20 163 patients (13 518 men [67.0%]; mean [SD] age, 64.9 [3.7] years) with stroke. The mean follow-up was 4 years (range, 1-6.1 years). Pooled results showed that more intensive LDL-C-lowering statin-based therapies were associated with a reduced risk of recurrent stroke compared with less intensive LDL-C-lowering statin-based therapies (absolute risk, 8.1% vs 9.3%; RR, 0.88; 95% CI, 0.80-0.96) and that the benefit associated with these LDL-C-lowering therapies was not different among LDL-C-lowering strategies (statins vs no statins: RR, 0.90; 95% CI, 0.81-1.01; more statins or ezetimibe vs less statins or ezetimibe: RR, 0.77; 95% CI, 0.62-0.96; and proprotein convertase subtilisin/kexin type 9 inhibitors plus statins vs placebo plus statins: RR, 0.90; 95% CI, 0.71-1.15; P = .42 for interaction). More intensive LDL-C-lowering statin-based therapies were associated with a reduced risk of major cardiovascular events, but with an increased risk of hemorrhagic stroke, compared with less intensive LDL-C-lowering statin-based therapies. More intensive LDL-C-lowering statin-based therapies were associated with a reduced risk of recurrent stroke in trials with all patients having evidence of atherosclerosis (RR, 0.79; 95% CI, 0.69-0.91), but not in trials with most patients not having evidence of atherosclerosis (RR, 0.95; 95% CI, 0.85-1.07; P = .04 for interaction), compared with less intensive LDL-C-lowering statin-based therapies. Conclusions and Relevance This study suggests that the benefits and risks of more intensive LDL-C-lowering statin-based therapies for recurrent stroke risk reduction might be more favorable than the benefits and risks of less intensive LDL-C-lowering statin-based therapies, especially for patients with evidence of atherosclerosis.
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Affiliation(s)
- Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chun-Yu Cheng
- Department of Neurosurgery, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Jiann-Der Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Yu Hsu
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco
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25
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Craig L, Hoo ZL, Yan TZ, Wardlaw J, Quinn TJ. Prevalence of dementia in ischaemic or mixed stroke populations: systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2022; 93:180-187. [PMID: 34782389 PMCID: PMC8784999 DOI: 10.1136/jnnp-2020-325796] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 08/30/2021] [Indexed: 12/24/2022]
Abstract
An understanding of the epidemiology of poststroke dementia (PSD) is necessary to inform research, practice and policy. With increasing primary studies, a contemporary review of PSD could allow for analyses of incidence and prevalence trends. Databases were searched using a prespecified search strategy. Eligible studies described an ischaemic or mixed stroke cohort with prospective clinical assessment for dementia. Pooled prevalence of dementia was calculated using random-effects models at any time after stroke (primary outcome) and at 1 year (range: 6-18 months), stratified for inclusion of prestroke dementia. Meta-regression explored the effect of year of study. Sensitivity analyses removed low-quality or outlier studies. Of 12 505 titles assessed, 44 studies were included in the quantitative analyses. At any time point after stroke, the prevalence of PSD was 16.5% (95% CI 10.4% to 25.1%) excluding prestroke dementia and 22.3% (95% CI 18.8% to 26.2%) including prestroke dementia. At 1 year, the prevalence of PSD was 18.4% (95% CI 7.4% to 38.7%) and 20.4% (95% CI 14.2% to 28.2%) with prestroke dementia included. In studies including prestroke dementia there was a negative association between dementia prevalence and year of study (slope coefficient=-0.05 (SD: 0.01), p<0.0001). Estimates were robust to sensitivity analyses. Dementia is common following stroke. At any point following stroke, more than one in five people will have dementia, although a proportion of this dementia predates the stroke. Declining prevalence of prestroke dementia may explain apparent reduction in PSD over time. Risk of dementia following stroke remains substantial and front-loaded, with high prevalence at 1 year post event.
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Affiliation(s)
- Louise Craig
- Institute of Cardiovascular and Medical Sciences, University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
| | - Zhi Liang Hoo
- Institute of Cardiovascular and Medical Sciences, University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
| | - Toh Zeng Yan
- Geriatric Medicine, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK
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26
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Yang Z, Edwards D, Burgess S, Brayne C, Mant J. Association of major blood lipids with post-stroke dementia: a community-based cohort study. Eur J Neurol 2021; 29:968-979. [PMID: 34918445 PMCID: PMC9303428 DOI: 10.1111/ene.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/07/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
Background and purpose The roles of blood low‐density lipoprotein cholesterol (LDL‐C), high‐density lipoprotein cholesterol (HDL‐C) and triglycerides in the development of post‐stroke dementia remain uncertain. This study was to investigate their potential associations. Methods A retrospective cohort study was conducted using the Clinical Practice Research Datalink. Patients with first‐ever stroke but no prior dementia were followed up for 10 years. Cox regression was used to examine the association of baseline LDL‐C, HDL‐C and triglycerides with post‐stroke dementia. Results Amongst 63,959 stroke patients, 15,879 had complete baseline data and were included in our main analysis. 10.8% developed dementia during a median of 4.6 years of follow‐up. The adjusted hazard ratio of dementia for LDL‐C (per log mmol/l increase) was 1.29 (95% confidence interval [CI] 1.14–1.47), with a linear increasing trend (p trend <0.001). The counterpart for triglycerides was 0.79 (95% CI 0.69–0.89), with a linear decreasing trend (p trend <0.001). For HDL‐C, there was no association with dementia (adjusted hazard ratio 0.89, 95% CI 0.74–1.08) or a linear trend (p trend = 0.22). Conclusions Blood lipids may affect the risk of post‐stroke dementia in different ways, with higher risk associated with LDL‐C, lower risk associated with triglycerides, and no association with HDL‐C.
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Affiliation(s)
- Zhirong Yang
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.,Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Duncan Edwards
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen Burgess
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK.,Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Carol Brayne
- Cambridge Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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27
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Dallaire-Théroux C, Quesnel-Olivo MH, Brochu K, Bergeron F, O’Connor S, Turgeon AF, Laforce RJ, Verreault S, Camden MC, Duchesne S. Evaluation of Intensive vs Standard Blood Pressure Reduction and Association With Cognitive Decline and Dementia: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2134553. [PMID: 34807261 PMCID: PMC8609411 DOI: 10.1001/jamanetworkopen.2021.34553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
IMPORTANCE Optimal blood pressure (BP) targets for the prevention of cognitive impairment remain uncertain. OBJECTIVE To explore the association of intensive (ie, lower than usual) BP reduction vs standard BP management with the incidence of cognitive decline and dementia in adults with hypertension. DATA SOURCES AND STUDY SELECTION A systematic review and meta-analysis of randomized clinical trials that evaluated the association of intensive systolic BP lowering on cognitive outcomes by searching MEDLINE, Embase, CENTRAL, Web of Science, CINAHL, PsycINFO, the International Clinical Trials Registry Platform, and ClinicalTrials.gov from database inception to October 27, 2020. DATA EXTRACTION AND SYNTHESIS Data screening and extraction were performed independently by 2 reviewers based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The risk of bias was assessed using the Cochrane risk of bias 2 tool. Random-effects models with the inverse variance method were used for pooled analyses. The presence of potential heterogeneity was evaluated with the I2 index. MAIN OUTCOMES AND MEASURES The primary outcome was cognitive decline. Secondary outcomes included the incidence of dementia, mild cognitive impairment (MCI), cerebrovascular events, serious adverse events, and all-cause mortality. RESULTS From 7755 citations, we identified 16 publications from 5 trials with 17 396 participants (mean age, 65.7 years [range, 63.0-80.5 years]; 10 562 [60.5%] men) and 2 additional ongoing trials. All 5 concluded trials included in quantitative analyses were considered at unclear to high risk of bias. The mean follow-up duration was 3.3 years (range, 2.0 to 4.7 years). Intensive BP reduction was not significantly associated with global cognitive performance (standardized mean difference, 0.01; 95% CI, -0.04 to 0.06; I2 = 0%; 4 trials; 5246 patients), incidence of dementia (risk ratio [RR], 1.09; 95% CI, 0.32 to 3.67; I2 = 27%; 2 trials; 9444 patients) or incidence of MCI (RR, 0.91; 95% CI, 0.73 to 1.14; I2 = 74%; 2 trials; 10 774 patients) when compared with standard treatment. However, a reduction of cerebrovascular events in the intensive group was found (RR, 0.79; 95% CI, 0.67 to 0.93; I2 = 0%; 5 trials; 17 396 patients) without an increased risk of serious adverse events or mortality. CONCLUSIONS AND RELEVANCE In this study, there was no significant association between BP reduction and lower risk of cognitive decline, dementia, or MCI. The certainty of this evidence was rated low because of the limited sample size, the risk of bias of included trials, and the observed statistical heterogeneity. Therefore, current available evidence does not justify the use of lower BP targets for the prevention of cognitive decline and dementia.
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Affiliation(s)
- Caroline Dallaire-Théroux
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
- CERVO Brain Research Center, Centre intégré universitaire de santé et services sociaux de la Capitale Nationale, Québec City, Québec, Canada
- Clinique Interdisciplinaire de Mémoire, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Marie-Hélène Quesnel-Olivo
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
| | - Karine Brochu
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
| | | | - Sarah O’Connor
- Faculty of Pharmacy, Institut universitaire de cardiologie et pneumologie de Québec (IUCPQ), Université Laval, Québec City, Québec, Canada
| | - Alexis F. Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada
- CHU de Québec–Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma–Emergency–Critical Care Medicine, Québec City, Québec, Canada
| | - Robert Jr Laforce
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
- Clinique Interdisciplinaire de Mémoire, CHU de Québec-Université Laval, Québec City, Québec, Canada
| | - Steve Verreault
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
| | - Marie-Christine Camden
- Division of Neuroscience, Hôpital de l’Enfant-Jésus, Centre Hospitalier Universitaire (CHU) de Québec-Université Laval, Québec City, Québec, Canada
| | - Simon Duchesne
- CERVO Brain Research Center, Centre intégré universitaire de santé et services sociaux de la Capitale Nationale, Québec City, Québec, Canada
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
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28
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Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O'Brien JT, Merriman N, Gillebert C, Huygelier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur J Neurol 2021; 28:3883-3920. [PMID: 34476868 DOI: 10.1111/ene.15068] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. METHODS Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. RESULTS There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. CONCLUSIONS These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Thomas Gattringer
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Hanne Huygelier
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology and Medical University of Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology Clinic, University Clinical Center of Serbia and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hugh S Markus
- Stroke Research group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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29
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Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O’Brien JT, Merriman N, Gillebert C, Huyglier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur Stroke J 2021; 6:I-XXXVIII. [PMID: 34746430 PMCID: PMC8564156 DOI: 10.1177/23969873211042192] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 01/14/2023] Open
Abstract
The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.
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Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders
Institute for Brain, Behaviour and Cognition, Radboud University Medical
Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical
Neurosciences and Preventive Medicine, Danube University Krems, der Donau, Austria
| | - Thomas Gattringer
- Department of Neurology and
Division of Neuroradiology, Vascular and Interventional Radiology, Department of
Radiology, Medical University of
Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O’Brien
- Department of Psychiatry, University of Cambridge School of
Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Deptartment of Health Psychology,
Division of Population Health Sciences, Royal College of Surgeons in
Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Hanne Huyglier
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and
Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and
Occupational Therapy, Bispebjerg and Frederiksberg
Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and
Geratology and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology
Clinic, University Clinical Center of Serbia
and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain
Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Hugh S Markus
- Stroke Research Group, Department
of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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30
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1217] [Impact Index Per Article: 405.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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31
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See AP, Charbel FT. Bypass for flow-augmentation in atherosclerotic carotid occlusion: a review of the literature and career experience. J Neurosurg Sci 2021; 65:305-321. [PMID: 33709658 DOI: 10.23736/s0390-5616.21.05094-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atherosclerosis of the internal carotid artery and intracranial vessels can compromise cerebral hemodynamics and cause stroke. Cerebral bypass has a half-century history in augmenting or replacing blood flow the brain. Several trials have investigated various applications of cerebral bypass in flow augmentation for atherosclerotic disease. This review discusses the clinical science of cerebrovascular atherosclerosis to provide the context in which cerebral bypass is currently applied. This includes prior clinical trials, ongoing clinical trials, and consensus guidelines, and is complemented by studies in the physiologic science of cerebrovascular flow. The scientific background is supplemented by the description of the technical art of bypass surgery based on a three-decade experience. Successful application of cerebral bypass to augment flow in atherosclerotic cerebrovascular disease requires correct diagnosis of compromised hemodynamic reserve refractory to medical optimization and an appropriate matching of bypass flow with cerebral demand.
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Hilkens NA, Klijn CJM, Richard E. Blood pressure, blood pressure variability and the risk of poststroke dementia. J Hypertens 2021; 39:1859-1864. [PMID: 33710171 DOI: 10.1097/hjh.0000000000002841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE High blood pressure and blood pressure variability are potential, modifiable risk factors of poststroke dementia. We aimed to investigate the association between achieved blood pressure, blood pressure variability and poststroke dementia. METHODS We studied 17 064 patients with noncardioembolic ischemic stroke included in the Prevention Regimen for Effectively avoiding Second Strokes (PRoFESS) trial. We analysed the data as a single observational cohort. We studied mean achieved SBP and DBP and blood pressure variability defined as coefficient of variation (SD/mean∗100). The association between blood pressure and dementia was investigated with logistic regression analysis, correcting for sociodemographic factors and cardiovascular risk factors. RESULTS During 39 818 person-years of follow-up, 817 patients were diagnosed with dementia (2.1 per 100 person-years). We found a significant nonlinear association between mean SBP and the risk of dementia, implying a U-shaped association between mean SBP and dementia. Mean SBP of 120-129 mmHg was associated with a significantly higher risk of dementia than 130-139 mmHg [odds ratio (OR) 1.28; 95% confidence interval (95% CI) 1.03-1.58]. There was no indication of a U-shaped association between mean DBP and dementia, and no significant association between mean DBP categories and dementia. Higher blood pressure variability was associated with an increased risk of dementia (OR 1.06 per point increase, 95% CI 1.02-1.04), independent of mean SBP. CONCLUSION Among patients with a recent noncardioembolic ischemic stroke, there appears to be a U-shaped association between achieved SBP and dementia. High blood pressure variability is associated with an increased risk of poststroke dementia.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Medical Center, Nijmegen, the Netherlands
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Toyoda K, Yamagami H, Kitagawa K, Kitazono T, Nagao T, Minematsu K, Uchiyama S, Tanahashi N, Matsumoto M, Nagata I, Nishikawa M, Nanto S, Shirai T, Abe K, Ikeda Y, Ogawa A. Blood Pressure Level and Variability During Long-Term Prasugrel or Clopidogrel Medication After Stroke: PRASTRO-I. Stroke 2021; 52:1234-1243. [PMID: 33563017 DOI: 10.1161/strokeaha.120.032824] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE High blood pressure increases bleeding risk during treatment with antithrombotic medication. The association between blood pressure levels and the risk of recurrent stroke during long-term secondary stroke prevention with thienopyridines (particularly prasugrel) has not been well studied. METHODS This was a post hoc analysis of the randomized, double-blind, multicenter PRASTRO-I trial (Comparison of Prasugrel and Clopidogrel in Japanese Patients With Ischemic Stroke-I). Patients with noncardioembolic stroke were randomly assigned (1:1) to receive prasugrel 3.75 mg/day or clopidogrel 75 mg/day for 96 to 104 weeks. Risks of any ischemic or hemorrhagic stroke, combined ischemic events, and combined bleeding events were determined based on the mean level and visit-to-visit variability, including successive variation, of systolic blood pressure (SBP) throughout the observational period. These risks were also compared between quartiles of mean SBP level and successive variation of SBP. RESULTS A total of 3747 patients (age 62.1±8.5 years, 797 women), with a median average SBP level during the observational period of 132.5 mm Hg, were studied. All the risks of any stroke (146 events; hazard ratio, 1.318 [95% CI, 1.094-1.583] per 10-mm Hg increase), ischemic stroke (133 events, 1.219 [1.010-1.466]), hemorrhagic stroke (13 events, 3.247 [1.660-6.296]), ischemic events (142 events, 1.219 [1.020-1.466]), and bleeding events (47 events, 1.629 [1.172-2.261]) correlated with increasing mean SBP overall. Similarly, an increased risk of these events correlated with increasing successive variation of SBP (hazard ratio, 3.078 [95% CI, 2.220-4.225] per 10-mm Hg increase; 3.051 [2.179-4.262]; 3.276 [1.172-9.092]; 2.865 [2.042-4.011]; 2.764 [1.524-5.016], respectively). Event rates did not differ between the clopidogrel and prasugrel groups within each quartile of SBP or successive variation of SBP. CONCLUSIONS Both high mean SBP level and high visit-to-visit variability in SBP were significantly associated with the risk of recurrent stroke during long-term medication with either prasugrel or clopidogrel after stroke. Control of hypertension would be important regardless of the type of antiplatelet drugs. Registration: URL: https://www.clinicaltrials.jp; Unique identifier: JapicCTI-111582.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T., K.M.)
| | - Hiroshi Yamagami
- Department of Stroke Neurology, Osaka National Hospital, Japan (H.Y.)
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University School of Medicine, Japan (K.K.)
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan (T.K.)
| | - Takehiko Nagao
- Department of Neurology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan (T.N.)
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K.T., K.M.)
| | - Shinichiro Uchiyama
- International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo, Japan (S.U.)
| | - Norio Tanahashi
- Department of Neurology, Saitama Medical University International Medical Center, Japan (N.T.)
| | | | - Izumi Nagata
- Department of Neurosurgery, Kokura Memorial Hospital, Fukuoka, Japan (I.N.)
| | | | - Shinsuke Nanto
- Nishinomiya Municipal Central Hospital, Hyogo, Japan (S.N.)
| | - Toshiaki Shirai
- Clinical Development Department (T.S.), R&D Division, Daiichi Sankyo Co, Ltd, Tokyo, Japan
| | - Kenji Abe
- Biostatistics & Data Management Department (K.A.), R&D Division, Daiichi Sankyo Co, Ltd, Tokyo, Japan
| | - Yasuo Ikeda
- Waseda University Faculty of Science and Engineering, Tokyo, Japan (Y.I.)
| | - Akira Ogawa
- Department of Neurosurgery, Iwate Medical University, Japan (A.O.)
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Abstract
PURPOSE OF REVIEW To review new evidence on links between poststroke dementia and inflammation. RECENT FINDINGS Although there are still no treatments for poststroke dementia, recent evidence has improved our understanding that stroke increases the risk of incident dementia and worsens cognitive trajectory for at least a decade afterwards. Within approximately the first year dementia onset is associated with stroke severity and location, whereas later absolute risk is associated with more traditional dementia risk factors, such as age and imaging findings. The molecular mechanisms that underlie increased risk of incident dementia in stroke survivors remain unproven; however new data in both human and animal studies suggests links between cognitive decline and inflammation. These point to a model where chronic brain inflammation, provoked by inefficient clearance of myelin debris and a prolonged innate and adaptive immune response, causes poststroke dementia. These localized immune events in the brain may themselves be influenced by the peripheral immune state at key times after stroke. SUMMARY This review recaps clinical evidence on poststroke dementia, new mechanistic links between the chronic inflammatory response to stroke and poststroke dementia, and proposes a model of immune-mediated neurodegeneration after stroke.
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D'Souza CE, Greenway MRF, Graff-Radford J, Meschia JF. Cognitive Impairment in Patients with Stroke. Semin Neurol 2021; 41:75-84. [PMID: 33418591 DOI: 10.1055/s-0040-1722217] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Despite substantial advances in stroke care, vascular cognitive impairment remains a prominent source of disability. Unlike sensorimotor impairments, cognition often continues to decline after stroke. An aging population will increase the prevalence of vascular cognitive impairment, with stroke playing an important role. Ten percent of patients presenting with stroke have pre-stroke dementia; an additional 10% will develop incident dementia with a first stroke, and 30% with a recurrent stroke. While stroke increases the risk of cognitive impairment, the presence of cognitive impairment also impacts acute stroke treatment and increases risk of poor outcome by nearly twofold. There is substantial overlap in the clinical and pathological aspects of vascular and degenerative dementias in many patients. How they relate to one another is controversial. The treatment of vascular cognitive impairment remains supportive, focusing on treating vascular risk factors. Cognitive rehabilitation after stroke is an area of active research, and existing pharmacologic treatments have limited benefit. Heightened awareness of cognitive impairment in the setting of stroke is imperative for prognostication and management, impetus for research and, ultimately, the discovery of efficacious treatments.
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Affiliation(s)
- Caitlin E D'Souza
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida.,Department of Neurology, Baptist Health, Jacksonville, Florida
| | | | | | - James F Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, Florida
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Secondary Stroke Prevention and Management for the Neuro-Ophthalmologist. J Neuroophthalmol 2020; 40:463-471. [DOI: 10.1097/wno.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.
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Affiliation(s)
- Philip B Gorelick
- From the Division of Stroke and Neurocritical Care, Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University of Medicine, New Orleans, LA (P.K.W.)
| | - Farzaneh Sorond
- Davee Department of Neurology (F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, Dean Emeritus, School of Medicine, University of Virginia Health System, Charlottesville (R.M.C.)
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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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Scutt P, Woodhouse LJ, Montgomery AA, Bath PM. Data sharing: experience of accessing individual patient data from completed randomised controlled trials in vascular and cognitive medicine. BMJ Open 2020; 10:e038765. [PMID: 32912955 PMCID: PMC7482449 DOI: 10.1136/bmjopen-2020-038765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Meta-analysis based on individual patient data (IPD) from randomised trials is superior to using published summary data since it facilitates subgroup and multiple variable analyses. Guidelines and funders expect that researchers share IPD for bona fide analyses, but in practice, this is done variably. Here, we report the experience of obtaining IPD for two collaborative analysis studies. SETTING Two linked studies required IPD from published randomised trials. The leading researchers for eligible trials were approached and asked to share IPD including trial characteristics, patient demographics, baseline clinical data and outcome measures. PARTICIPANTS Participants in eligible randomised controlled trials included patients with or at risk of cognitive decline/vascular events. PRIMARY AND SECONDARY OUTCOME MEASURES Numbers (%) of trials where the leading researcher responded favourably/negatively or did not respond. If negative, reasons behind the response were collected. If positive, methods used to share IPD were recorded. RESULTS Across the two studies, 391 completed trials were identified. Email addresses for researchers were found for 313 (80%) of the trials. One hundred and forty-eight (47%) researchers did not respond despite being sent multiple emails. Following contact, positive initial responses were received from 92 researchers, resulting in IPD being shared for 78 trials. Eighty-seven (28%) researchers declined to share data; justifications were recorded. The median time from first request to accessing data in one study was 241 (IQR 383.3) days. IPD sources included: direct from researcher, via academic trial funders repository and a website requiring remote analysis of commercial data. Where data were shared, a variety of methods were used to transfer data. CONCLUSION Sharing of IPD from trials is desirable and a requirement of many funding bodies. However, accessing IPD faces multiple challenges including refusals to share, delays in access to data and having to perform analyses on a remote website. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Polly Scutt
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Hearing Sciences, NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Philip M Bath
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Tang EYH, Robinson L, Exley C, Flynn D, Stephan BCM, Price C. Care priorities for stroke patients developing cognitive difficulties: a Delphi survey of UK professional views. BMC Health Serv Res 2020; 20:717. [PMID: 32758214 PMCID: PMC7404922 DOI: 10.1186/s12913-020-05558-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/20/2020] [Indexed: 11/30/2022] Open
Abstract
Background Post stroke cognitive difficulties are common but generally prioritised below other impairments. In the UK, clinical guidelines recommend a holistic review at six-months post-stroke including an assessment of cognitive function. In order to assist clinicians to provide better care for patients with post-stroke cognitive deficits and assist with service planning, our aim was to establish professional consensus on key actions at the six-month review. Methods An electronic Delphi survey was developed with ten potential actions for clinicians to prioritise across five different clinical scenarios describing patients with cognitive difficulties. Scenarios varied in terms of age of the stroke-survivor, stroke severity and use of dementia risk assessment. A panel of professional volunteers was obtained through the British Association of Stroke Physicians and the UK National Stroke Nursing Forum. Results Forty-five stroke clinicians completed round one, with 21 participants completing round two. Priorities consistently supported by professionals included access to psychological services, screening for a mood disorder and ensuring multi-professional input. Direct access to specialist memory services was not generally supported unless a dementia risk assessment tool indicated that the individual was at high risk of dementia. Conclusions Assessment of post-stroke cognitive deficits needs to be routinely considered during the six-month review. A formal risk assessment tool could be a way to streamline direct access to memory clinic services to ensure that individuals at-risk of dementia receive ongoing care.
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Affiliation(s)
- Eugene Y H Tang
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK.
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
| | - Darren Flynn
- Centre for Rehabilitation, Exercise and Sports Science, School of Health & Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK
| | - Blossom C M Stephan
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Innovation Park, Nottingham, NG7 2TU, UK
| | - Christopher Price
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
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Wardlaw J, Bath PMW, Doubal F, Heye A, Sprigg N, Woodhouse LJ, Blair G, Appleton J, Cvoro V, England T, Hassan A, John Werring D, Montgomery A. Protocol: The Lacunar Intervention Trial 2 (LACI-2). A trial of two repurposed licenced drugs to prevent progression of cerebral small vessel disease. Eur Stroke J 2020; 5:297-308. [PMID: 33072884 PMCID: PMC7538764 DOI: 10.1177/2396987320920110] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Small vessel disease causes a quarter of ischaemic strokes (lacunar subtype),
up to 45% of dementia either as vascular or mixed types, cognitive
impairment and physical frailty. However, there is no specific treatment to
prevent progression of small vessel disease. Aim We designed the LACunar Intervention Trial-2 (LACI-2) to test feasibility of
a large trial testing cilostazol and/or isosorbide mononitrate (ISMN) by
demonstrating adequate participant recruitment and retention in follow-up,
drug tolerability, safety and confirm outcome event rates required to power
a phase 3 trial. Methods and design LACI-2 is an investigator-initiated, prospective randomised open label
blinded endpoint (PROBE) trial aiming to recruit 400 patients with prior
lacunar syndrome due to a small subcortical infarct. We randomise
participants to cilostazol v no cilostazol and ISMN or no ISMN, minimising
on key prognostic factors. All patients receive guideline-based best medical
therapy. Patients commence trial drug at low dose, increment to full dose
over 2–4 weeks, continuing on full dose for a year. We follow-up
participants to one year for symptoms, tablet compliance, safety, recurrent
vascular events, cognition and functional outcomes, Trails B and brain MRI.
LACI-2 is registered ISRCTN 14911850, EudraCT 2016–002277-35. Trial outcome: Primary outcome is feasibility of recruitment and
compliance; secondary outcomes include safety (cerebral or systemic
bleeding, falls, death), efficacy (recurrent cerebral and cardiac vascular
events, cognition on TICS, Trails B) and tolerability. Summary LACI-2 will determine feasibility, tolerability and provide outcome rates to
power a large phase 3 trial to prevent progression of cerebral small vessel
disease.
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Affiliation(s)
| | - Philip M W Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | - Anna Heye
- The University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | | | | | - Vera Cvoro
- The University of Edinburgh, Edinburgh, UK
| | | | - Ahamad Hassan
- University College London Institute of Neurology, London, UK
| | | | - Alan Montgomery
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
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Effect of Combined Antihypertensive and Lipid-Lowering Therapies on Cognitive Function: A New Treatment Strategy? Cardiol Res Pract 2020; 2020:1484357. [PMID: 32351732 PMCID: PMC7178519 DOI: 10.1155/2020/1484357] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/03/2020] [Accepted: 03/19/2020] [Indexed: 01/06/2023] Open
Abstract
Risk factors for cardiovascular disease such as hypertension and hyperlipidemia are associated with cognitive decline. However, there is still no clear evidence that the use of antihypertensive or lipid-lowering therapy can prevent or delay cognitive decline or development of dementia. To provide a reference for clinical treatment, we analyzed the potential mechanisms of cognitive dysfunction induced by hypertension and hyperlipidemia, the clinical research and controversy of antihypertensive and lipid-lowering therapies on cognitive function, and the clinical value of combined antihypertensive and lipid-lowering therapy. It is currently believed that hypertension and elevated blood cholesterol levels in middle-aged people may be related to cognitive impairment or dementia in the elderly. Some studies suggest that intensive antihypertensive or lipid-lowering therapies are better than standard antihypertensive or lipid-lowering therapy, yet further tests are needed to confirm their effects on cognitive function. Actively controlling potential risk factors from middle age may be important for Alzheimer's disease (AD) prevention.
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Vu M, Schleiden LJ, Harlan ML, Thorpe CT. Hypertension Management in Nursing Homes: Review of Evidence and Considerations for Care. Curr Hypertens Rep 2020; 22:8. [PMID: 31938958 DOI: 10.1007/s11906-019-1012-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW We sought to summarize recent evidence regarding optimal blood pressure (BP) treatment targets and antihypertensive regimen intensity for nursing home (NH) residents and similar older, complex patients with hypertension. RECENT FINDINGS Recent trials have demonstrated cardiovascular benefits from more intensive BP targets among ambulatory, less complex older adults, but generalizability to NH residents is questionable. Other trials have demonstrated that de-intensifying antihypertensives in frail, older patients is feasible, with no or modest increases in BP, but most have not assessed effects on patient-centered outcomes. Observational studies with patients more representative of NH residents suggest harms associated with more intensive BP treatment and reduction in fall risk associated with deintensification, but findings and potential for bias vary across studies. Randomized trials and rigorous observational studies examining effects of deintensified BP management on patient-centered outcomes in complex, older populations are needed to inform improved guidelines and treatment for NH residents.
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Affiliation(s)
- Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Center for Medication Safety, Veterans Affairs Pharmacy Benefits Management, Hines, IL, USA
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Pharmacy & Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Michelle L Harlan
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Kerr Hall Suite 2204, Campus Box 7573, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.,Elon University, Elon, NC, USA
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA. .,Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Kerr Hall Suite 2204, Campus Box 7573, 301 Pharmacy Lane, Chapel Hill, NC, 27599, USA.
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Yang Z, Wang H, Edwards D, Ding C, Yan L, Brayne C, Mant J. Association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment after stroke: A systematic review and meta-analysis. Ageing Res Rev 2020; 57:100962. [PMID: 31505259 DOI: 10.1016/j.arr.2019.100962] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/20/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trial and observational evidence is conflicting in terms of the association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment in the general population. It is uncertain whether the associations occur in stroke patients, who are at known higher risk of cognitive decline. This systematic review was to synthesize the evidence for these associations among stroke patients. METHODS MEDLINE, EMBASE, the Cochrane Library and trial registries were searched. We included randomized controlled trials (RCTs) or observational cohort studies conducted among patients with stroke and reported on the association of blood lipids, atherosclerosis or statin use with dementia or cognitive impairment. Meta-analysis was conducted separately for crude and maximally adjusted odds ratios (ORs) and hazard ratios (HRs). RESULTS Of 18,026 records retrieved, 56 studies (one RCT and 55 cohort studies) comprising 38,423 stroke patients were included. For coronary heart disease, the pooled OR of dementia and cognitive impairment was 1.32 (95%CI 1.10-1.58, n = 15 studies, I2 = 0%) and 1.23 (95%CI 0.99-1.54, n = 14, I2 = 26.9%), respectively. Peripheral artery disease was associated with dementia (OR 3.59, 95%CI 1.47-8.76, n = 2, I2 = 0%) and cognitive impairment (OR 2.70, 95%CI 1.09-6.69, n = 1). For carotid stenosis, the pooled OR of dementia and cognitive impairment was 2.67 (95%CI 0.83-8.62, n = 3, I2 = 77.9%) and 3.34 (95%CI 0.79-14.1, n = 4, I2 = 96.6%), respectively. For post-stroke statin use, the pooled OR of dementia and cognitive impairment was 0.89 (95%CI 0.65-1.21, n = 1) and 0.56 (95%CI 0.46-0.69, n = 3, I2 = 0%), respectively. No association was observed for hypercholesterolemia. These results were mostly consistent with adjusted ORs or HRs, which were reported from limited evidence. CONCLUSION Atherosclerosis was associated with an increased risk of post-stroke dementia. Post-stroke statin use was associated with decreased risk of cognitive impairment. To confirm whether or not statins confer advantages in the post-stroke population in terms of preventing cognitive decline over and above their known effectiveness in reducing risk of further vascular events, further stroke trials including cognitive assessment and observational analyses adjusted for key confounders, focusing on key subgroups or statin use patterns are required.
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Kitagawa K, Yamamoto Y, Arima H, Maeda T, Sunami N, Kanzawa T, Eguchi K, Kamiyama K, Minematsu K, Ueda S, Rakugi H, Ohya Y, Kohro T, Yonemoto K, Okada Y, Higaki J, Tanahashi N, Kimura G, Umemura S, Matsumoto M, Shimamoto K, Ito S, Saruta T, Shimada K. Effect of Standard vs Intensive Blood Pressure Control on the Risk of Recurrent Stroke: A Randomized Clinical Trial and Meta-analysis. JAMA Neurol 2019; 76:1309-1318. [PMID: 31355878 DOI: 10.1001/jamaneurol.2019.2167] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance The Systolic Blood Pressure Intervention Trial (SPRINT) demonstrated that a systolic blood pressure (BP) target less than 120 mm Hg was superior to less than 140 mm Hg for preventing vascular events. This trial excluded patients with prior stroke; therefore, the ideal BP target for secondary stroke prevention remains unknown. Objective To assess whether intensive BP control would achieve fewer recurrent strokes vs standard BP control. Design, Setting, and Participants Randomized clinical trial (RCT) of standard vs intensive BP control in an intent-to-treat population of patients who had a history of stroke. Patients were enrolled between October 20, 2010, and December 7, 2016. For an updated meta-analysis, PubMed and the Cochrane Central Library database were searched through September 30, 2018, using the Medical Subject Headings and relevant search terms for cerebrovascular disease and for intensive BP lowering. This was a multicenter trial that included 140 hospitals in Japan; 1514 patients who had a history of stroke within the previous 3 years were approached, but 234 refused to give informed consent. Interventions In total, 1280 patients were randomized 1:1 to BP control to less than 140/90 mm Hg (standard treatment) (n = 640) or to less than 120/80 mm Hg (intensive treatment) (n = 640). However, 17 patients never received intervention; therefore, 1263 patients assigned to standard treatment (n = 630) or intensive treatment (n = 633) were analyzed. Main Outcomes and Measures The primary outcome was stroke recurrence. Results The trial was stopped early. Among 1263 analyzed patients (mean [SD] age, 67.2 [8.8] years; 69.4% male), 1257 of 1263 (99.5%) completed a mean (SD) of 3.9 (1.5) years of follow-up. The mean BP at baseline was 145.4/83.6 mm Hg. Throughout the overall follow-up period, the mean BP was 133.2/77.7 (95% CI, 132.5-133.8/77.1-78.4) mm Hg in the standard group and 126.7/77.4 (95% CI, 125.9-127.2/73.8-75.0) mm Hg in the intensive group. Ninety-one first recurrent strokes occurred. Nonsignificant rate reductions were seen for recurrent stroke in the intensive group compared with the standard group (hazard ratio [HR], 0.73; 95% CI, 0.49-1.11; P = .15). When this finding was pooled in 3 previous relevant RCTs in a meta-analysis, the risk ratio favored intensive BP control (relative risk, 0.78; 95% CI, 0.64-0.96; P = .02; absolute risk difference, -1.5%; 95% CI, -2.6% to -0.4%; number needed to treat, 67; 95% CI, 39-250). Conclusions and Relevance Intensive BP lowering tended to reduce stroke recurrence. The updated meta-analysis supports a target BP less than 130/80 mm Hg in secondary stroke prevention. Trial Registration ClinicalTrials.gov identifier: NCT01198496.
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Affiliation(s)
- Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Shinjuku, Tokyo, Japan
| | - Yasumasa Yamamoto
- Department of Neurology, Kyoto Katsura Hospital, Nishikyo, Kyoto, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University Faculty of Medicine, Jyonan, Fukuoka, Japan
| | - Toshiki Maeda
- Department of Preventive Medicine and Public Health, Fukuoka University Faculty of Medicine, Jyonan, Fukuoka, Japan
| | - Norio Sunami
- Department of Neurosurgery, Fukuzumi Hospital, Matsuyama, Ehime, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessel, Mihara Memorial Hospital, Isesaki, Gunnma, Japan
| | - Kazuo Eguchi
- Department of Internal Medicine, Hanyu General Hospital, Hanyu, Saitama, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Kazuo Minematsu
- General of the Hospital, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus School of Medicine, Nakagamigunn, Okinawa, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yusuke Ohya
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus School of Medicine, Nakagamigunn, Okinawa, Japan
| | - Takahide Kohro
- Department of Cerebrovascular Medicine, Jichi Medical School, Shimotsuke, Tochigi, Japan
| | - Koji Yonemoto
- Department of Environmental Health, University of the Ryukyus School of Medicine, Nakagamigunn, Okinawa, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center Clinical Research Institute, Chuo, Fukuoka, Japan
| | | | - Norio Tanahashi
- Department of Neurology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Genjiro Kimura
- Cardio-renal and Health Research Institute, Nagoya, Aichi, Japan
| | | | | | | | - Sadayoshi Ito
- Department of Nephrology Endocrinology and Vascular Medicine, Tohoku University School of Medicine, Sendai, Miyagi, Japan
| | - Takao Saruta
- Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Abstract
The notion of what qualifies as vascular dementia has varied greatly since the first mention of dementia after apoplexy in ancient literature. Current insight points towards a multifactorial cause of cognitive decline at old age, in which vascular components like atherosclerosis, arterio(lo)sclerosis, (micro)infarcts, and amyloid angiopathy play an important role alongside other markers of neurodegeneration. Cerebrovascular disease will be present in most individuals with dementia, but-just like other causes-rarely a cause on its own. The consequent limitations of nosology may be alleviated by addition of a vascular component to the recently introduced amyloid/tau/neurodegeneration etiological classification system for dementia. Meanwhile, risk of dementia is increased about 2-fold after stroke, and the prevention of (recurrent) stroke remains a cornerstone in the prevention of vascular dementia. Similarly, control of cardiovascular risk factors from middle age onwards is likely to have contributed to the reported decline in the age-specific incidence of dementia over the past decades. In conjunction with experimental studies, large-scale observational evidence from imaging, genomics, metabolomics, and alike will continue to improve our understanding of the underlying pathophysiological processes. To prevent ecological fallacies, such etiological studies in patients with dementia are best served by inclusion of subjects regardless of the presumed (single) cause of their disease.
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Affiliation(s)
- Frank J Wolters
- From the Department of Epidemiology (F.J.W., M.A.I.), Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (F.J.W.), Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Arfan Ikram
- From the Department of Epidemiology (F.J.W., M.A.I.), Erasmus University Medical Center, Rotterdam, the Netherlands
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Wardlaw JM, Smith C, Dichgans M. Small vessel disease: mechanisms and clinical implications. Lancet Neurol 2019; 18:684-696. [DOI: 10.1016/s1474-4422(19)30079-1] [Citation(s) in RCA: 500] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 02/06/2023]
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Lanctôt KL, Lindsay MP, Smith EE, Sahlas DJ, Foley N, Gubitz G, Austin M, Ball K, Bhogal S, Blake T, Herrmann N, Hogan D, Khan A, Longman S, King A, Leonard C, Shoniker T, Taylor T, Teed M, de Jong A, Mountain A, Casaubon LK, Dowlatshahi D, Swartz RH. Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019. Int J Stroke 2019; 15:668-688. [PMID: 31221036 DOI: 10.1177/1747493019847334] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.
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Affiliation(s)
- Krista L Lanctôt
- Sunnybrook Research Institute, Toronto, Canada.,University of Toronto Faculty of Medicine, Toronto, Canada
| | | | - Eric E Smith
- Calgary Stroke Program, Calgary, Canada.,Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, Alberta
| | - Demetrios J Sahlas
- Division of Neurology, Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada.,Department of Medicine (Neurology), Dalhousie University, Halifax, Canada.,Canadian Stroke Consortium, Ontario, Canada
| | - Melissa Austin
- Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | | | - Treena Blake
- GF Strong Rehabilitation Centre, Vancouver, Canada
| | - Nathan Herrmann
- Sunnybrook Research Institute, Toronto, Canada.,University of Toronto Faculty of Medicine, Toronto, Canada
| | - David Hogan
- University of Calgary Cumming School of Medicine, Calgary, Canada
| | - Aisha Khan
- Montreal University Health Center, Montreal, Canada
| | - Stewart Longman
- Calgary Stroke Program, Alberta Health Services, Calgary, Canada
| | - Andrea King
- Nova Scotia Health Authority, Halifax, Canada
| | - Carol Leonard
- Audiology and Speech-Language Pathology Program, University of Ottawa, Ottawa, Canada
| | | | - Trudy Taylor
- Carewest Dr. Vernon Fanning Centre, Calgary, Canada
| | - Moira Teed
- Heart and Stroke Foundation of Canada, Toronto, Canada
| | | | - Anita Mountain
- Dalhousie University Division of Physical Medicine and Rehabilitation, Halifax, Canada.,Nova Scotia Rehabilitation Centre Site, Halifax, Canada
| | - Leanne K Casaubon
- University of Toronto Faculty of Medicine, Toronto, Canada.,Canadian Stroke Consortium, Ontario, Canada.,Toronto Western Hospital, University Health Network, Toronto, Canada
| | | | - Richard H Swartz
- Sunnybrook Research Institute, Toronto, Canada.,University of Toronto Faculty of Medicine, Toronto, Canada
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Tang E, Exley C, Price C, Stephan B, Robinson L. The views of public and clinician stakeholders on risk assessment tools for post-stroke dementia: a qualitative study. BMJ Open 2019; 9:e025586. [PMID: 30918033 PMCID: PMC6475139 DOI: 10.1136/bmjopen-2018-025586] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Stroke-survivors are at increased risk of future dementia. Assessment to identify those at high risk of developing a disease using predictive scores has been utilised in different areas of medicine. A number of risk assessment scores for dementia have been developed but none has been recommended for use clinically. The aim of this qualitative study was to assess the acceptability and feasibility of using a risk assessment tool to predict post-stroke dementia. DESIGN Qualitative semi-structured interviews were conducted and analysed thematically. The patients and carers were offered interviews at around 6 (baseline) and 12 (follow-up) months post-stroke; clinicians were interviewed once. SETTING The study was conducted in the North-East of England with stroke patients, family carers and healthcare professionals in primary and secondary care. PARTICIPANTS Thirty-nine interviews were conducted (17 clinicians and 15 stroke patients and their carers at baseline. Twelve stroke patients and their carers were interviewed at follow-up, some interviews were conducted in pairs). RESULTS Barriers and facilitators to risk assessment were discussed. For the patients and carers the focus for facilitators were based on the outcomes of risk assessment for example assistance with preparation, diagnosis and for reassurance. For clinicians, facilitators were focused on the process that is, familiarity in primary care, resource availability in secondary care and collaborative care. For barriers, both groups focused on the outcome including for example, the anxiety generated from a potential diagnosis of dementia. For the patients/carers a further barrier included concerns about how it may affect their recovery. For clinicians there were concerns about limited interventions and how it would be different from standard care. CONCLUSIONS Risk assessment for dementia post-stroke presents challenges given the ramifications of a potential diagnosis of dementia. Attention needs to be given to how information is communicated and strategies developed to support the patients and carers if risk assessment is used.
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Affiliation(s)
- Eugene Tang
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christopher Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle, UK
| | - Blossom Stephan
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, Newcastle, UK
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