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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Obstetric and perinatal outcomes in women with cerebrovascular accident vs. transient ischemic attack: an evaluation of a population database. Arch Gynecol Obstet 2024:10.1007/s00404-024-07627-7. [PMID: 39009865 DOI: 10.1007/s00404-024-07627-7] [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: 11/21/2023] [Accepted: 07/01/2024] [Indexed: 07/17/2024]
Abstract
PURPOSE Cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs) are uncommon neurologic events in women of childbearing age. We aimed to compare pregnancy, delivery, and neonatal outcomes between women who suffered from a CVA and those who experienced a TIA. METHODS A retrospective population-based cohort study was performed using the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample. Included were all pregnant women who delivered or had a maternal death in the US between 2004 and 2014. We compared women with an ICD-9 diagnosis of a CVA before or during pregnancy to those diagnosed with a TIA before, during the pregnancy, or during the delivery admission. Pregnancy and perinatal outcomes were compared between the two groups, using multivariate logistic regression to control for confounders. RESULTS Among 9,096,788 women in the database, 898 met the inclusion criteria. Of them, 706 women (7.7/100,000) had a CVA diagnosis, and 192 (2.1/100,000) had a TIA diagnosis. Women with a CVA, compared to those with a TIA, had a higher rate of pregnancy-induced hypertension (aOR 3.82,95%CI 2.14-6.81, p < 0.001); preeclampsia (aOR 2.6,95%CI 1.3-5.2, p = 0.007), eclampsia (aOR 13.78,95% CI 1.84-103.41, p < 0.001); postpartum hemorrhage (aOR 4.52,95%CI 1.31-15.56, p = 0.017), blood transfusion (aOR 5.57,95%CI 1.65-18.72, p = 0.006), and maternal death (54 vs. 0 cases, 7.6% vs. 0%), with comparable neonatal outcomes. CONCLUSION Women diagnosed with a CVA before or during pregnancy had a higher incidence of myriad maternal complications, including hypertensive disorders of pregnancy, postpartum hemorrhage, and death, compared to women with a TIA diagnosis, with comparable neonatal outcomes, stressing the different prognoses of these two conditions, and the importance of these patients' diligent follow-up and care.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada.
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, 845 Rue Sherbrooke, O, Montreal, QC, 3HA 0G4, Canada
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Taylor RS, Bentley A, Metcalfe K, Lobo MD, Kirtane AJ, Azizi M, Clark C, Murphy K, Boer JH, van Keep M, Ta AT, Barman NC, Schwab G, Akehurst R, Schmieder RE. Cost Effectiveness of Endovascular Ultrasound Renal Denervation in Patients with Resistant Hypertension. PHARMACOECONOMICS - OPEN 2024; 8:525-537. [PMID: 38289517 PMCID: PMC11252101 DOI: 10.1007/s41669-024-00472-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/07/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND Resistant hypertension (rHTN) is defined as blood pressure (BP) of ≥ 140/90 mmHg despite treatment with at least three antihypertensive medications, including a diuretic. Endovascular ultrasound renal denervation (uRDN) aims to control BP alongside conventional BP treatment with antihypertensive medication. This analysis assesses the cost effectiveness of the addition of the Paradise uRDN System compared with standard of care alone in patients with rHTN from the perspective of the United Kingdom (UK) health care system. METHODS Using RADIANCE-HTN TRIO trial data, we developed a state-transition model. Baseline risk was calculated using Framingham and Prospective Cardiovascular Münster (PROCAM) risk equations to estimate the long-term cardiovascular risks in patients treated with the Paradise uRDN System, based on the observed systolic BP (SBP) reduction following uRDN. Relative risks sourced from a meta-analysis of randomised controlled trials were then used to project cardiovascular events in patients with baseline SBP ('control' patients); utility and mortality inputs and costs were derived from UK data. Costs and outcomes were discounted at 3.5% per annum. Modelled outcomes were validated against trial meta-analyses and the QRISK3 algorithm and real-world evidence of RDN effectiveness. One-way and probabilistic sensitivity analyses were conducted to assess the uncertainty surrounding the model inputs and sensitivity of the model results to changes in parameter inputs. Results were reported as incremental cost-effectiveness ratios (ICERs). RESULTS A mean reduction in office SBP of 8.5 mmHg with uRDN resulted in an average improvement in both absolute life-years (LYs) and quality-adjusted life-years (QALYs) gained compared with standard of care alone (0.73 LYs and 0.67 QALYs). The overall base-case ICER with uRDN was estimated at £5600 (€6500) per QALY gained (95% confidence interval £5463-£5739 [€6341-€6661]); modelling demonstrated > 99% probability that the ICER is below the £20,000-£30,000 (€23,214-€34,821) per QALYs gained willingness-to-pay threshold in the UK. Results were consistent across sensitivity analyses and validation checks. CONCLUSIONS Endovascular ultrasound RDN with the Paradise system offers patients with rHTN, clinicians, and healthcare systems a cost-effective treatment option alongside antihypertensive medication.
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Affiliation(s)
- Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit and Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, 90 Byres Rd, Glasgow, G12 8TB, UK.
| | | | | | - Melvin D Lobo
- Barts NIHR Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Michel Azizi
- Université de Paris, Paris, France
- Hypertension Department and DMU CARTE, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
- INSERM, CIC1418, Paris, France
| | - Christopher Clark
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | | | | | | | - An Thu Ta
- BresMed Netherlands, Utrecht, The Netherlands
| | | | | | - Ron Akehurst
- BresMed Health Solutions, Sheffield, UK
- University of Sheffield, Sheffield, UK
| | - Roland E Schmieder
- Nephrology and Hypertension, University Hospital Erlangen, Friedrich Alexander University, Erlangen, Germany
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Amikam U, Badeghiesh A, Baghlaf H, Brown R, Dahan MH. Transient ischemic attack and pregnancy, delivery and neonatal outcomes-An evaluation of a population database. Int J Gynaecol Obstet 2024; 166:412-418. [PMID: 38311958 DOI: 10.1002/ijgo.15387] [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: 12/15/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE Transient ischemic attack (TIA) is rare in women of reproductive age. We aimed to compare perinatal outcomes between women who suffered from a TIA to those who did not. METHODS A retrospective population-based cohort study utilizing the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample (HCUP-NIS). All women who delivered or had a maternal death in the US (2004-2014) were included in the study. Pregnancy, delivery, and neonatal outcomes were compared between women with an ICD-9 diagnosis of a TIA to those without. RESULTS Overall, 9 096 788 women met the inclusion criteria. Of these, 203 women (2.2/100000) had a TIA (either before or during pregnancy). Women with TIA, compared to those without, were more likely to be older than 35 years of age, white, in the highest income quartile, be insured by private insurance and suffer from obesity and chronic hypertension. Patients in the TIA group, compared to those without, had a higher rate of pregnancy-induced hypertension (aOR 2.5, 95% CI: 1.55-4.05, P < 0.001), pre-eclampsia (aOR 3.77, 95% CI: 2.15-6.62, P < 0.001), eclampsia (aOR 28.05, 95% CI: 6.91-113.95, P < 0.001), preterm delivery (aOR 1.78, 95% CI: 1.03-3.07, P = 0.039), and maternal complications such as deep vein thrombosis (aOR 33.3, 95% CI: 8.07-137.42, P < 0.001). Regarding neonatal outcomes, patients with a TIA, compared to those without, had a higher rate of congenital anomalies (aOR 7.04, 95% CI: 2.86-17.32, P < 0.001). CONCLUSION Women with a TIA diagnosis before or during pregnancy had a higher rate of maternal complications, including hypertensive disorders of pregnancy and venous thromboembolism, as well as an increased risk of congenital anomalies.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ahmad Badeghiesh
- Department of Obstetrics and Gynecology, King Abdulaziz University, Rabigh Branch, Rabigh, Saudi Arabia
| | - Haitham Baghlaf
- Department of Obstetrics and Gynecology, University of Tabuk, Tabuk, Saudi Arabia
| | - Richard Brown
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
| | - Michael H Dahan
- Department of Obstetrics and Gynecology, McGill University, Montréal, Quebec, Canada
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Schmidt J, Düvel JA, Elkenkamp S, Greiner W. Comparing the EQ-5D-5L and stroke impact scale 2.0 in stroke patients: an analysis of measurement properties. Health Qual Life Outcomes 2024; 22:45. [PMID: 38835023 DOI: 10.1186/s12955-024-02252-z] [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: 10/10/2023] [Accepted: 04/20/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Stroke has evolved to become a chronic disease and a major public health challenge. To adequately capture the full disease burden of stroke patients, the assessment of health-related quality of life (HRQoL) and thus the performance of respective measures is increasingly relevant. The aim of this analysis was to compare the measurement properties of two self-report instruments, the EQ-5D-5L and the Stroke Impact Scale 2.0. METHODS The data used for the analysis was derived from a quasi-experimental case management study for mildly to moderately affected incident stroke and transient ischemic attack (TIA) patients aged ≥ 18 in Germany. Data was collected patient-individually at 3, 6 and 12 months after initial stroke. The EQ-5D-5L and SIS 2.0 were compared in terms of feasibility, ceiling and floor effects, responsiveness and known-groups validity (Kruskal-Wallis H and Wilcoxon rank-sum test). RESULTS A response for all three follow-ups is available for n = 855 patients. The feasibility of the EQ-5D-5L is determined as good (completion rate: 96.4-96.6%, ≥ one item missing: 3.2 - 3.3%), whereas the SIS 2.0 is moderately feasible (overall completion rate: 44.9-46.1%, ≥ one item missing in domains: 4.7 - 28.7%). The SIS 2.0 shows substantial ceiling effects in comparable domains (physical function: 10.4 - 13%, others: 3.5-31.3%) which are mainly larger than ceiling effects in the EQ-5D-5L index (17.1-21.5%). In terms of responsiveness, the EQ-5D-5L shows small to moderate change while the SIS 2.0 presents with moderate to large responsiveness. The EQ-5D-5L index, mobility, usual activities and Visual Analogue Scale show known-groups validity (p < 0.05). Content-related domains of the SIS 2.0 show known-groups validity as well (p < 0.05). However, it is compromised in the emotion domain in both measures (p > 0.05). CONCLUSIONS The EQ-5D-5L seems to be slightly more suitable for this cohort. Nonetheless, the results of both measures indicate limited suitability for TIA patients. Large-scale studies concerning responsiveness and known-groups validity are encouraged. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register, retrospective registration on 21.09.2022. REGISTRATION ID DRKS00030297.
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Affiliation(s)
- Juliana Schmidt
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany.
| | - Juliane Andrea Düvel
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Svenja Elkenkamp
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
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Khan F, Coutts SB, Hill MD. Letter by Khan et al Regarding Article, "Long-Term Incidence of Ischemic Stroke After Transient Ischemic Attack: A Nationwide Study from 2014 to 2020". Circulation 2024; 149:797-798. [PMID: 38437480 DOI: 10.1161/circulationaha.123.067840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Faizan Khan
- Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, AB, Canada (F.K., S.B.C., M.D.H.)
- Public Health Agency of Canada, Ottawa, ON (F.K.)
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, AB, Canada (F.K., S.B.C., M.D.H.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Radiology and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, AB, Canada (F.K., S.B.C., M.D.H.)
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Vinding NE, Fosbøl EL. Response by Vinding and Fosbøl to Letter Regarding Article, "Long-Term Incidence of Ischemic Stroke After Transient Ischemic Attack: A Nationwide Study from 2014 to 2020". Circulation 2024; 149:799. [PMID: 38437475 DOI: 10.1161/circulationaha.123.068241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Naja Emborg Vinding
- Department of Cardiology, Rigshospitalet, University Hospital Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, University Hospital Copenhagen, Denmark
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Hafeez A, Cipriano LE, Kim RB, Zaric GS, Schwarz UI, Sarma S. Cost-Effectiveness Analysis of Pharmacogenomics (PGx)-Based Warfarin, Apixaban, and Rivaroxaban Versus Standard Warfarin for the Management of Atrial Fibrillation in Ontario, Canada. PHARMACOECONOMICS 2024; 42:69-90. [PMID: 37596504 DOI: 10.1007/s40273-023-01309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE To assess the cost-effectiveness of pharmacogenomics (PGx)-based warfarin (i.e., warfarin dosing following genetic testing), apixaban, and rivaroxaban oral anticoagulation versus standard warfarin for the treatment of newly diagnosed patients with nonvalvular atrial fibrillation (AF) aged ≥ 65 years. METHODS We developed a Markov decision-analytic model to compare costs [2017 Canadian dollars (C$)] and quality-adjusted life years (QALYs) from the Ontario health care payer perspective over a life-time horizon. The parameters used in the model were derived from the published literature, the Ontario health care administrative database, and expert opinion. To account for the uncertainty of model parameters, we conducted extensive deterministic and probabilistic sensitivity analyses. The results were summarized using incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves. RESULTS We found that PGx-based warfarin had an ICER of C$17,584/QALY compared with standard warfarin, and apixaban had an ICER of C$64,590/QALY compared with PGx-based warfarin in our base-case analysis. Rivaroxaban was extendedly dominated by PGx-based warfarin and apixaban. The probabilistic sensitivity analysis showed that apixaban, rivaroxaban, PGx-based warfarin, and standard warfarin were cost-effective at some willingness-to-pay (WTP) thresholds. PGx-based warfarin had a higher probability of being cost-effective than apixaban (51.3% versus 14.3%) at a WTP threshold of C$50,000/QALY. At a WTP threshold of C$100,000/QALY, apixaban had a higher probability of being cost-effective than PGx-based warfarin (54.6% versus 22.6%). CONCLUSION We found that PGx-based warfarin for patients with AF is cost-effective at a WTP threshold of C$50,000/QALY. Apixaban had a higher probability of being cost-effective (> 50%) at a WTP threshold of C$93,000/QALY.
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Affiliation(s)
- Aneeka Hafeez
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Lauren E Cipriano
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Ivey Business School, Western University, London, ON, Canada
| | - Richard B Kim
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Ivey Business School, Western University, London, ON, Canada
| | - Ute I Schwarz
- Division of Clinical Pharmacology, Department of Medicine, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
- ICES (formerly the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada.
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Hunter S, Vogel K, O’Leary S, Blennerhassett JM. Evaluating Feasibility of a Secondary Stroke Prevention Program. Healthcare (Basel) 2023; 11:2673. [PMID: 37830710 PMCID: PMC10573005 DOI: 10.3390/healthcare11192673] [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: 09/01/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Abstract
Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre-post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for 'relevance' (100%), 'felt safe to exercise' (96%) and 'intend to continue' (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD -2.1 cm, 95%CI -3.9 cm to -1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.
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Affiliation(s)
- Stephanie Hunter
- Austin Health, Health Independence Program, Community Rehabilitation Service, Melbourne, VIC 3084, Australia
| | - Kimberley Vogel
- Austin Health, Health Independence Program, Community Rehabilitation Service, Melbourne, VIC 3084, Australia
| | - Shane O’Leary
- Austin Health, Health Independence Program, Community Rehabilitation Service, Melbourne, VIC 3084, Australia
- Austin Health, Spinal Community Integration Service, Melbourne, VIC 3101, Australia
| | - Jannette Maree Blennerhassett
- Austin Health, Health Independence Program, Community Rehabilitation Service, Melbourne, VIC 3084, Australia
- Austin Health, Physiotherapy Department, Melbourne, VIC 3084, Australia
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Hung SH, Tierney C, Klassen TD, Schneeberg A, Bayley MT, Dukelow SP, Hill MD, Krassioukov A, Pooyania S, Poulin MJ, Yao J, Eng JJ. Blood pressure trajectory of inpatient stroke rehabilitation patients from the Determining Optimal Post-Stroke Exercise (DOSE) trial over the first 12 months post-stroke. Front Neurol 2023; 14:1245881. [PMID: 37794879 PMCID: PMC10546336 DOI: 10.3389/fneur.2023.1245881] [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: 07/04/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023] Open
Abstract
Background High blood pressure (BP) is the primary risk factor for recurrent strokes. Despite established clinical guidelines, some stroke survivors exhibit uncontrolled BP over the first 12 months post-stroke. Furthermore, research on BP trajectories in stroke survivors admitted to inpatient rehabilitation hospitals is limited. Exercise is recommended to reduce BP after stroke. However, the effect of high repetition gait training at aerobic intensities (>40% heart rate reserve; HRR) during inpatient rehabilitation on BP is unclear. We aimed to determine the effect of an aerobic gait training intervention on BP trajectory over the first 12 months post-stroke. Methods This is a secondary analysis of the Determining Optimal Post-Stroke Exercise (DOSE) trial. Participants with stroke admitted to inpatient rehabilitation hospitals were recruited and randomized to usual care (n = 24), DOSE1 (n = 25; >2,000 steps, 40-60% HRR for >30 min/session, 20 sessions over 4 weeks), or DOSE2 (n = 25; additional DOSE1 session/day) groups. Resting BP [systolic (SBP) and diastolic (DBP)] was measured at baseline (inpatient rehabilitation admission), post-intervention (near inpatient discharge), 6- and 12-month post-stroke. Linear mixed-effects models were used to examine the effects of group and time (weeks post-stroke) on SBP, DBP and hypertension (≥140/90 mmHg; ≥130/80 mmHg, if diabetic), controlling for age, stroke type, and baseline history of hypertension. Results No effect of intervention group on SBP, DBP, or hypertension was observed. BP increased from baseline to 12-month post-stroke for SBP (from [mean ± standard deviation] 121.8 ± 15.0 to 131.8 ± 17.8 mmHg) and for DBP (74.4 ± 9.8 to 78.5 ± 10.1 mmHg). The proportion of hypertensive participants increased from 20.8% (n = 15/72) to 32.8% (n = 19/58). These increases in BP were statistically significant: an effect [estimation (95%CI), value of p] of time was observed on SBP [0.19 (0.12-0.26) mmHg/week, p < 0.001], DBP [0.09 (0.05-0.14) mmHg/week, p < 0.001], and hypertension [OR (95%CI): 1.03 (1.01-1.05), p = 0.010]. A baseline history of hypertension was associated with higher SBP by 13.45 (8.73-18.17) mmHg, higher DBP by 5.57 (2.02-9.12) mmHg, and 42.22 (6.60-270.08) times the odds of being hypertensive at each timepoint, compared to those without. Conclusion Blood pressure increased after inpatient rehabilitation over the first 12 months post-stroke, especially among those with a history of hypertension. The 4-week aerobic gait training intervention did not influence this trajectory.
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Affiliation(s)
- Stanley H. Hung
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
- Rehabilitation Research Program, Center for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | | | - Tara D. Klassen
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Amy Schneeberg
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
| | - Mark T. Bayley
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sean P. Dukelow
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Andrei Krassioukov
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sepideh Pooyania
- Division of Physical Medicine and Rehabilitation, University of Manitoba, Winnipeg, MB, Canada
| | - Marc J. Poulin
- Department of Physiology and Pharmacology and Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Jennifer Yao
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Janice J. Eng
- Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada
- Rehabilitation Research Program, Center for Aging SMART, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Carlsson A, Irewall AL, Graipe A, Ulvenstam A, Mooe T, Ögren J. Long-term risk of major adverse cardiovascular events following ischemic stroke or TIA. Sci Rep 2023; 13:8333. [PMID: 37221291 PMCID: PMC10206105 DOI: 10.1038/s41598-023-35601-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 05/20/2023] [Indexed: 05/25/2023] Open
Abstract
Data are scarce on long-term outcomes after ischemic stroke (IS) or transient ischemic attack (TIA). In this prospective cohort study, we examined the cumulative incidence of major adverse cardiovascular events (MACE) after IS and TIA using a competing risk model and factors associated with new events using a Cox-proportional hazard regression model. All patients discharged alive from Östersund Hospital with IS or TIA between 2010 and 2013 (n = 1535) were followed until 31 December 2017. The primary endpoint was a composite of IS, type 1 acute myocardial infarction (AMI), and cardiovascular (CV) death. Secondary endpoints were the individual components of the primary endpoint, in all patients and separated in IS and TIA subgroups. The cumulative incidence of MACE (median follow-up: 4.4 years) was 12.8% (95% CI: 11.2-14.6) within 1 year after discharge and 35.6% (95% CI: 31.8-39.4) by the end of follow-up. The risk of MACE and CV death was significantly increased in IS compared to TIA (p-values < 0.05), but not the risk of IS or type 1 AMI. Age, kidney failure, prior IS, prior AMI, congestive heart failure, atrial fibrillation, and impaired functional status, were associated with an increased risk of MACE. The risk of recurring events after IS and TIA is high. IS patients have a higher risk of MACE and CV death than TIA patients.
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Affiliation(s)
- Andreas Carlsson
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Anna-Lotta Irewall
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Anna Graipe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Anders Ulvenstam
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Thomas Mooe
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Joachim Ögren
- Department of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden.
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Amin HP, Madsen TE, Bravata DM, Wira CR, Johnston SC, Ashcraft S, Burrus TM, Panagos PD, Wintermark M, Esenwa C. Diagnosis, Workup, Risk Reduction of Transient Ischemic Attack in the Emergency Department Setting: A Scientific Statement From the American Heart Association. Stroke 2023; 54:e109-e121. [PMID: 36655570 DOI: 10.1161/str.0000000000000418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
At least 240 000 individuals experience a transient ischemic attack each year in the United States. Transient ischemic attack is a strong predictor of subsequent stroke. The 90-day stroke risk after transient ischemic attack can be as high as 17.8%, with almost half occurring within 2 days of the index event. Diagnosing transient ischemic attack can also be challenging given the transitory nature of symptoms, often reassuring neurological examination at the time of evaluation, and lack of confirmatory testing. Limited resources, such as imaging availability and access to specialists, can further exacerbate this challenge. This scientific statement focuses on the correct clinical diagnosis, risk assessment, and management decisions of patients with suspected transient ischemic attack. Identification of high-risk patients can be achieved through use of comprehensive protocols incorporating acute phase imaging of both the brain and cerebral vasculature, thoughtful use of risk stratification scales, and ancillary testing with the ultimate goal of determining who can be safely discharged home from the emergency department versus admitted to the hospital. We discuss various methods for rapid yet comprehensive evaluations, keeping resource-limited sites in mind. In addition, we discuss strategies for secondary prevention of future cerebrovascular events using maximal medical therapy and patient education.
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Koeppel L, Dittrich S, Brenner Miguel S, Carmona S, Ongarello S, Vetter B, Cohn JE, Baernighausen T, Geldsetzer P, Denkinger CM. Addressing the diagnostic gap in hypertension through possible interventions and scale-up: A microsimulation study. PLoS Med 2022; 19:e1004111. [PMID: 36472973 PMCID: PMC9725126 DOI: 10.1371/journal.pmed.1004111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 09/15/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are the leading cause of mortality globally with almost a third of all annual deaths worldwide. Low- and middle-income countries (LMICs) are disproportionately highly affected covering 80% of these deaths. For CVD, hypertension (HTN) is the leading modifiable risk factor. The comparative impact of diagnostic interventions that improve either the accuracy, the reach, or the completion of HTN screening in comparison to the current standard of care has not been estimated. METHODS AND FINDINGS This microsimulation study estimated the impact on HTN-induced morbidity and mortality in LMICs for four different scenarios: (S1) lower HTN diagnostic accuracy; (S2) improved HTN diagnostic accuracy; (S3) better implementation strategies to reach more persons with existing tools; and, lastly, (S4) the wider use of easy-to-use tools, such as validated, automated digital blood pressure measurement devices to enhance screening completion, in comparison to the current standard of care (S0). Our hypothetical population was parametrized using nationally representative, individual-level HPACC data and the global burden of disease data. The prevalence of HTN in the population was 31% out of which 60% remained undiagnosed. We investigated how the alteration of a yearly blood pressure screening event impacts morbidity and mortality in the population over a period of 10 years. The study showed that while improving test accuracy avoids 0.6% of HTN-induced deaths over 10 years (13,856,507 [9,382,742; 17,395,833]), almost 40 million (39,650,363 [31,34,233, 49,298,921], i.e., 12.7% [9.9, 15.8]) of the HTN-induced deaths could be prevented by increasing coverage and completion of a screening event in the same time frame. Doubling the coverage only would still prevent 3,304,212 million ([2,274,664; 4,164,180], 12.1% [8.3, 15.2]) CVD events 10 years after the rollout of the program. Our study is limited by the scarce data available on HTN and CVD from LMICs. We had to pool some parameters across stratification groups, and additional information, such as dietary habits, lifestyle choice, or the blood pressure evolution, could not be considered. Nevertheless, the microsimulation enabled us to include substantial heterogeneity and stochasticity toward the different income groups and personal CVD risk scores in the model. CONCLUSIONS While it is important to consider investing in newer diagnostics for blood pressure testing to continuously improve ease of use and accuracy, more emphasis should be placed on screening completion.
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Affiliation(s)
- Lisa Koeppel
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Sabine Dittrich
- FIND, Geneva, Switzerland
- Nuffield Department of Medicine, Faculty of Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | | | | | | | - Jennifer Elizabeth Cohn
- Division of Infectious Diseases, University of Pennsylvania Perelman School of Medicine, Philadelphia, Philadelphia, United States of America
| | - Till Baernighausen
- Heidelberg Institute of Global Health (HIGH), Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
- Africa Health Research Institute, Somkhele, South Africa
- Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, California, United States of America
- Chan Zuckerberg Biohub, San Francisco, California, United States of America
| | - Claudia M. Denkinger
- Division of Infectious Diseases and Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), partner site Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
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13
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Long term survival after a first transient ischaemic attack in England: A retrospective matched cohort study. J Stroke Cerebrovasc Dis 2022; 31:106663. [PMID: 35907306 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106663] [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: 04/20/2022] [Revised: 07/03/2022] [Accepted: 07/17/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Transient ischaemic attacks (TIA) serve as warning signs for future stroke, and the impact of TIA on long term survival is uncertain. We assessed the long-term hazards of all-cause mortality following a first episode of a transient ischaemic attack (TIA). DESIGN Retrospective matched cohort study. METHODS Cohort study using electronic primary health care records from The Health Improvement Network (THIN) database in the United Kingdom. Cases born in or before 1960, resident in England, with a first diagnosis of TIA between January 1986 and January 2017 were matched to three controls on age, sex and general practice. The primary outcome was all-cause mortality. The hazards of all-cause mortality were estimated using a time-varying Double-Cox Weibull survival model with a random frailty effect of general practice, while adjusting for different socio-demographic factors, medical therapies, and comorbidities. RESULTS 20,633 cases and 58,634 controls were included. During the study period, 24,176 participants died comprising of 7,745 (37.5%) cases and 16,431(28.0%) controls. In terms of hazards of mortality, cases aged 39 to 60 years at the first TIA event had the highest hazard ratio (HR) of mortality compared to their 39-60 years matched controls (HR = 3.04 (2.91 - 3.18)). The HR for cases aged 61-70 years, 71-76 years and 77+ years were 1.98 (1.55 - 2.30), 1.79 (1.20 - 2.07) and 1.52 (1.15 - 1.97) compared to their same-aged matched controls. Cases aged 39-60 at TIA onset who were prescribed aspirin were associated with reduced HR of 0.93 (0.84 - 1.01), 0.90 (0.82 - 0.98) and 0.88 (0.80 - 0.96) at 5, 10 and 15 years respectively, compared to the same aged cases who were not prescribed any antiplatelet. Statistically significant reductions in hazard ratios were observed with aspirin at 10 and 15 years in all age groups. Hazard ratio point estimates for other antiplatelets (dipyridamole or clopidogrel) and dual antiplatelet therapy were very similar to aspirin at 5, 10 and 15 years but with wider confidence intervals that included 1. There was no survival benefit associated with antiplatelet prescription in controls. CONCLUSIONS The overall risk of death was considerably elevated in all age groups after a first-ever TIA event. Aspirin prescription was associated with a reduced risk. These findings support the use of aspirin in secondary prevention for people with a TIA. The results do not support the use of antiplatelet medication in people without TIA.
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Paras S, Mina A, Crammond DJ, Visweswaran S, Anetakis KM, Balzer JR, Shandal V, Thirumala PD. Cardiovascular-related mortality after intraoperative neurophysiologic monitoring changes during carotid endarterectomy. Clin Neurophysiol 2022; 139:43-48. [DOI: 10.1016/j.clinph.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 04/10/2022] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
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15
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Vinding NE, Butt JH, Olesen JB, Xian Y, Kristensen SL, Rørth R, Bonde AN, Gundlund A, Yafasova A, Weeke PE, Gislason GH, Torp-Pedersen C, Køber L, Fosbøl EL. Association Between Inappropriately Dosed Anticoagulation Therapy With Stroke Severity and Outcomes in Patients With Atrial Fibrillation. J Am Heart Assoc 2022; 11:e024402. [PMID: 35229642 PMCID: PMC9075280 DOI: 10.1161/jaha.121.024402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Oral anticoagulation (OAC) is effective for stroke prevention in patients with atrial fibrillation. However, some patients experience stroke despite OAC therapy, and knowledge about the impact of prior treatment quality is lacking. Methods and Results Patients with atrial fibrillation on OAC therapy who had a first‐time ischemic stroke were identified in the Danish Stroke Registry (2005–2018). Patients treated with vitamin K antagonist (VKA) therapy were compared according to the international normalized ratio just before stroke (international normalized ratio <2 [subtherapeutic], international normalized ratio 2–3 [therapeutic], international normalized ratio >3 [supratherapeutic]), and patients on underdosed, appropriately dosed, and overdosed direct OAC (DOAC) therapy were compared. Stroke severity was determined using the Scandinavia Stroke Scale (0–58 points), and the risk of very severe stroke (0–14 points) was analyzed by multivariable logistic regression. One‐year mortality was determined using multivariable Cox regression. A total of 2319 patients with atrial fibrillation and stroke were included; 1196 were taking a VKA (subtherapeutic [46%], therapeutic [43%], supratherapeutic [11%]), and 1123 were taking DOAC (underdosed [23%], appropriately dosed [60%], and overdosed [17%]). Subtherapeutic and supratherapeutic VKA therapy (compared with therapeutic) and underdosed DOAC therapy (compared with appropriate and underdosed DOAC) patients were older, more often women, and more comorbid. Subtherapeutic VKA therapy was associated with very severe stroke (odds ratio [OR], 2.06 [95% CI, 1.28–3.31]), whereas supratherapeutic VKA therapy was not (OR, 1.24 [95% CI, 0.60–2.57]) compared with therapeutic VKA therapy. Patients on subtherapeutic and supratherapeutic VKA therapy had a higher 1‐year mortality (hazard ratio [HR], 1.66 [95% CI, 1.29–2.13]); HR, 1.55 [95% CI, 1.08–2.22], respectively) than those on therapeutic VKA therapy. Treatment with underdosed or overdosed DOAC therapy was not associated with very severe stroke (OR, 1.27 [95% CI, 0.76–2.15]; OR, 0.73 [95% CI, 0.37–1.43], respectively) and was not associated with 1‐year mortality (HR, 1.09 [95% CI, 0.83–1.44]; HR, 0.82 [95% CI, 0.57–1.18], respectively) than appropriate DOAC. Conclusions Half of the patients with atrial fibrillation with stroke were on inappropriate OAC therapy. Subtherapeutic VKA was associated with worse stroke severity and higher mortality rate than therapeutic VKA therapy. Neither underdosed nor overdosed DOAC was associated with worse outcomes in adjusted models compared with appropriately dosed DOAC. This study supports DOAC as a first‐line therapy over VKA.
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Affiliation(s)
- Naja E Vinding
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jawad H Butt
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Jonas B Olesen
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Ying Xian
- Department of Neurology University of Texas Southwestern Medical Center Dallas TX
| | - Søren Lund Kristensen
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Rasmus Rørth
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Anders Nissen Bonde
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Anna Gundlund
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark.,Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark
| | - Adelina Yafasova
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Peter E Weeke
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Gunnar H Gislason
- Department of Cardiology Copenhagen University Hospital, Herlev and Gentofte Hospital Gentofte Denmark.,The Danish Heart Foundation Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation Nordsjællands Hospital Hillerød Denmark.,Department of Cardiology Aalborg University Hospital Aalborg Denmark.,Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
| | - Emil L Fosbøl
- Department of Cardiology Copenhagen University Hospital, Rigshospitalet Copenhagen Denmark
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Marilyn ML, Gordon G, Stephen P, Nicholas G, Wanda F, Kara T, Chris T, Howard W, Sharon S, David M, Gail E, Fiona P, Chris B, Judy D. Program of Rehabilitative Exercise and Education to Avert Vascular Events After Non-Disabling Stroke or Transient Ischemic Attack (PREVENT Trial): A Randomized Controlled Trial. Neurorehabil Neural Repair 2021; 36:119-130. [PMID: 34788569 PMCID: PMC9066689 DOI: 10.1177/15459683211060345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Non-disabling stroke (NDS) and transient ischemic attack (TIA) herald the possibility of future, more debilitating vascular events. Evidence is conflicting about potency of exercise and education in reducing risk factors for second stroke. Methods Three-site, single-blinded, randomized controlled trial with 184 participants <3 months of NDS or TIA (mean age, 65 years; 66% male) randomized to usual care (UC) or UC + 12-week program of exercise and education (PREVENT). Primary (resting systolic blood pressure) and secondary outcomes (diastolic blood pressure [DBPrest], high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], TC/HDL, triglycerides, fasting glucose, and body mass index) were assessed at baseline, post-intervention, and 6- and 12-month follow-up. Peak oxygen consumption (VO2peak) was measured at baseline, post-intervention, 12-month assessments. Results Significant between-group differences at post-intervention favored PREVENT group over UC: DBPrest (mean difference [MD]: −3.2 mmHg, 95% confidence interval [CI]: −6.3, −.2, P = .04) and LDL-C (MD: −.31 mmol/L, 95% CI: −.42, −.20, P = .02). Trends of improvement in PREVENT group were noted in several variables between baseline and 6-month follow-up but not sustained at 12-month follow-up. Of note, VO2 peak did not change over time in either group. Conclusion Impact of PREVENT on vascular risk factor reduction was more modest than anticipated, possibly because several outcome variables approximated normative values at baseline and training intensity may have been sub-optimal. Further investigation is warranted to determine when exercise and education programs are viable adjuncts to pharmaceutical management for reduction of risk factors for second stroke. Clinical Trial Registration-URL:http://www.clinicaltrials.gov. Unique identifier: #NCT00885456
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Affiliation(s)
- MacKay-Lyons Marilyn
- School of Physiotherapy, 3688Dalhousie University, Halifax, NS, Canada.,Physical Medicine, Nova Scotia Health Authority, 3688Dalhousie University, Halifax, NS, Canada
| | - Gubitz Gordon
- Neurology, 3688Dalhousie University, Halifax, NS, Canada
| | | | - Giacomantonio Nicholas
- QEII Health Sciences Centre, Halifax, NS, Canada.,Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Firth Wanda
- Cardiac Rehabilitation, QEII Community Cardiovascular Hearts-in-Motion, Halifax, NS, Canada
| | - Thompson Kara
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Theriault Chris
- Nova Scotia Health, Research Methods Unit, Halifax, NS, Canada
| | - Wightman Howard
- Cardiology Associates, Valley Regional Hospital, Kentville, NS, Canada
| | - Slipp Sharon
- Cardiac Rehabilitation, Valley Regional Hospital, Kentville, NS, Canada
| | - Marsters David
- Internal Medicine, Valley Regional Hospital, Kentville, NS, Canada
| | - Eskes Gail
- Physical Medicine, Nova Scotia Health Authority, Halifax, NS, Canada.,Psychiatry, 3688Dalhousie University, Halifax, NS, Canada.,Medicine, Nova Scotia Health, Halifax, NS, Canada
| | - Peacock Fiona
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
| | | | - Dewolfe Judy
- Cardiac Specialty Clinic, Valley Regional Hospital, Kentville, Canada
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Abreu P, Magalhães R, Baptista D, Azevedo E, Correia M. Admission and Readmission/Death Patterns in Hospitalized and Non-hospitalized First-Ever-in-a-Lifetime Stroke Patients During the First Year: A Population-Based Incidence Study. Front Neurol 2021; 12:685821. [PMID: 34566836 PMCID: PMC8455946 DOI: 10.3389/fneur.2021.685821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Hospitalization and readmission rates after a first-ever-in-a-lifetime stroke (FELS) are considered measures of quality of care and, importantly, may give valuable information to better allocate health-related resources. We aimed to investigate the hospitalization pattern and the unplanned readmissions or death of hospitalized (HospS) and non-hospitalized stroke (NHospS) patients 1 year after a FELS, based on a community register. Methods: Data about hospitalization and unplanned readmissions and case fatality 1 year after a FELS were retrieved from the population-based register undertaken in Northern Portugal (ACIN2), comprising all FELS in 2009–2011. We used the Kaplan–Meier method to estimate 1-year readmission/death-free survival and Cox proportional hazard models to identify independent factors for readmission/death. Results: Of the 720 FELS, 35.7% were not hospitalized. Unplanned readmission/death within 1 year occurred in 33.0 and 24.9% of HospS and NHospS patients, respectively. The leading causes of readmission were infections, recurrent stroke, and cardiovascular events. Stroke-related readmissions were observed in more than half of the patients in both groups. Male sex, age, pre- and post-stroke functional status, and diabetes were independent factors of readmission/death within 1 year. Conclusion: About one-third of stroke patients were not hospitalized, and the readmission/death rate was higher in HospS patients. Still, that readmission/death rate difference was likely due to other factors than hospitalization itself. Our research provides novel information that may help implement targeted health-related policies to reduce the burden of stroke and its complications.
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Affiliation(s)
- Pedro Abreu
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Rui Magalhães
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
| | - Diana Baptista
- Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Clinical Neurosciences and Mental Health, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Manuel Correia
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,Department of Neurology, Hospital Santo António - Centro Hospitalar Universitário do Porto, Porto, Portugal
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Patel UK, Dave M, Lekshminarayanan A, Malik P, DeMasi M, Chandramohan S, Pillai S, Tirupathi R, Shah S, Jani VB, Dhamoon MS. Risk Factors and Incidence of Acute Ischemic Stroke: A Comparative Study Between Young Adults and Older Adults. Cureus 2021; 13:e14670. [PMID: 34055518 PMCID: PMC8148619 DOI: 10.7759/cureus.14670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/24/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction Approximately 5-10% of strokes occur in adults of less than 45 years of age. The rising prevalence of stroke risk factors may increase stroke rates in young adults (YA). We aimed to compare risk factors and outcomes of acute ischemic stroke (AIS) among YA. Methods Adult hospitalizations for AIS and concurrent risk factors were found in the Nationwide Inpatient Sample database. Weighted analysis using chi-square and multivariable survey logistic regression was performed to evaluate AIS-related outcomes and risk factors among YA (18-45 years) and older patients. Results A total of 4,224,924 AIS hospitalizations were identified from 2003 to 2014, out of which 198,378 (4.7%) were YA. Prevalence trend of YA with AIS showed incremental pattern over time (2003: 4.36% to 2014: 4.7%; pTrend<0.0001). In regression analysis, the risk factors associated with AIS in YA were obesity (adjusted odds ratio {aOR}: 2.26; p<0.0001), drug abuse (aOR: 2.56; p<0.0001), history of smoking (aOR: 1.20; p<0.0001), infective endocarditis (aOR: 2.08; p<0.0001), cardiomyopathy (aOR: 2.11; p<0.0001), rheumatic fever (aOR: 4.27; p=0.0014), atrial septal disease (aOR: 2.46; p<0.0001), ventricular septal disease (aOR: 4.99; p<0.0001), HIV infection (aOR: 4.36; p<0.0001), brain tumors (aOR: 7.89; p<0.0001), epilepsy (aOR: 1.43; p<0.0001), end stage renal disease (aOR: 2.19; p<0.0001), systemic lupus erythematous (aOR: 3.76; p<0.0001), polymyositis (aOR: 2.72; p=0.0105), ankylosis spondylosis (aOR: 2.42; p=0.0082), hypercoagulable state (aOR: 4.03; p<0.0001), polyarteritis nodosa (aOR: 5.65; p=0.0004), and fibromuscular dysplasia (aOR: 2.83; p<0.0001). Conclusion There is an increasing trend in AIS prevalence over time among YA. Both traditional and non-traditional risk factors suggest that greater awareness is needed, with prevention strategies for AIS among young adults.
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Affiliation(s)
- Urvish K Patel
- Public Health and Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mihir Dave
- Internal Medicine, University of Nevada Reno, School of Medicine, Reno, USA
| | - Anusha Lekshminarayanan
- Internal Medicine, Richmond University Medical Center, Staten Island, USA
- Rehabilitation Medicine, New York Medical College and Metropolitan Hospital Center, New York, USA
| | - Preeti Malik
- Public Health, Icahn School of Medicine at Mount Sinai, New York, USA
- Neurology, Massachusetts General Hospital, Boston, USA
| | - Matthew DeMasi
- Internal Medicine, Albert Einstein College of Medicine, Bronx, USA
| | | | | | | | - Shamik Shah
- Neurology, Stormont Vail Health, Topeka, USA
| | - Vishal B Jani
- Neurology, Creighton University School of Medicine, Omaha, USA
| | - Mandip S Dhamoon
- Neurology, Icahn School of Medicine at Mount Sinai, New York, USA
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Discriminative Utility of Transcranial Magnetic Stimulation-Derived Markers of Cortical Excitability for Transient Ischemic Attack. Can J Neurol Sci 2021; 49:218-224. [PMID: 33843526 DOI: 10.1017/cjn.2021.62] [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: 11/07/2022]
Abstract
BACKGROUND Several guidelines currently recommend acute diffusion weighted imaging (DWI) for the detection of ischemia in transient ischemic attack (TIA). However, DWI hyperintensities resolve early and only 30%-50% with clinically defined TIA show acute DWI positivity. A recent meta-analysis reported an unexplained 7-fold variation in DWI positivity in TIA across studies, concluding that DWI does not provide a consistent basis for defining ischemia. Intracortical excitability, measured using transcranial magnetic stimulation (TMS), has previously been shown to be altered after TIA and associated with ABCD2 scores; however, whether altered cortical excitability is associated with clinical and DWI-based definitions of TIA remains unclear. METHODS Individuals with TIA symptoms (N = 23; mean age = 61 ± 12) were prospectively recruited and underwent DWI and paired-pulse TMS. Multivariate linear regression was used to estimate associations between TMS-derived excitability thresholds, and clinical TIA diagnosis, and imaging-based evidence of cerebral ischemia (DWI positivity). Area under the curve (AUC) analyses was used to compare the discriminability of TMS-derived thresholds and clinical TIA diagnoses. RESULTS Thresholds for intracortical inhibition in the TIA-unaffected hemisphere were significantly associated with the clinical diagnosis of TIA. No associations between TMS-derived thresholds and DWI positivity were observed. TMS thresholds showed low-moderate discriminability and values differed by age (65+) and sex. CONCLUSIONS In this small sample, TMS-derived markers of intracortical excitability were associated with clinical TIA diagnoses but not DWI positivity. Our results provide preliminary evidence for the potential discriminative utility of TMS for the diagnosis of TIA and highlight the need for future work in larger cohorts.
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Chong WFW, Ng LH, Ho RMH, Koh GCH, Hoenig H, Matchar DB, Yap P, Venketasubramanian N, Tan KB, Ning C, Menon E, Chang HM, De Silva DA, Lee KE, Tan BY, Young SHY, Ng YS, Tu TM, Ang YH, Yeo TT, Merchant RA, Kong KH, Singh R, Ng YL, Cheong A. Stroke Rehabilitation Use and Caregiver Psychosocial Health Profiles in Singapore: A Latent Profile Transition Analysis. J Am Med Dir Assoc 2021; 22:2350-2357.e2. [PMID: 33812841 DOI: 10.1016/j.jamda.2021.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/12/2021] [Accepted: 02/21/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To identify and describe caregiver profiles based on their psychosocial health characteristics over a 12-month period and transitions among these profiles, to determine if stroke rehabilitation use at 12 months post-stroke differed by caregiver profile transition patterns, and to investigate if caregiver profiles at 3 months post-stroke moderate the association of stroke rehabilitation use at 3 months and 12 months post-stroke after accounting for covariates. DESIGN Latent profile transition analysis of caregiver psychosocial health with stroke rehabilitation use at 12 month post-stroke as outcome. SETTING AND PARTICIPANTS A total of 149 stroke patient-caregiver dyads from the Singapore Stroke Study. METHODS Cross-sectional latent profile analyses were conducted on caregiver psychosocial health indicators of burden, depression, health status, quality of relationship with patient, and social support. Changes in latent profile classification over 3 time points (baseline, 3 months, and 12 months post-stroke) were analyzed using latent transition analysis. A transition model with stroke rehabilitation use at 12 months post-stroke as the outcome was tested after accounting for covariates. RESULTS Two distinct caregiver psychosocial health latent profiles were found across time: nondistressed and distressed. Most caregivers were classified as nondistressed and remained nondistressed over time. Distressed caregivers at baseline were 76% likely to become nondistressed at 12 month post-stroke. Regardless of profile transition patterns, nondistressed caregivers at 12 months post-stroke tended to have cared for stroke rehabilitation nonusers at 12 months post-stroke. Patient depression explained profile classification at 3 months and 12 months post-stroke. After accounting for covariates, rehabilitation users at 3 months post-stroke tended to continue using rehabilitation at 12 months post-stroke only when they had nondistressed caregivers at 3 months post-stroke. CONCLUSIONS AND IMPLICATIONS Whether caregiver adaptation explains the associations between the latent profile transition patterns and rehabilitation use at 12 months post-stroke should be examined. Early psychosocial health assessment and sustained support should be made available to stroke caregivers to enhance their well-being and subsequent patient rehabilitation participation.
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Affiliation(s)
- Wayne F W Chong
- School of Social Sciences, Nanyang Technological University, Singapore, Singapore, Singapore; GeroPsych Consultants Pte Ltd, Singapore, Singapore, Singapore.
| | - Leong Hwee Ng
- GeroPsych Consultants Pte Ltd, Singapore, Singapore, Singapore
| | - Ringo M-H Ho
- School of Social Sciences, Nanyang Technological University, Singapore, Singapore, Singapore
| | - Gerald C H Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore, Singapore; Office of Healthcare Transformation, Ministry of Health, Singapore, Singapore, Singapore
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Science, Durham Veterans Administration Medical Center, Durham, NC, USA; Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - David B Matchar
- Department of Medicine (General Internal Medicine), Duke University Medical Center, Durham, NC, USA; Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore, Singapore; Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore, Singapore
| | - Philip Yap
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore, Singapore
| | | | - Kelvin B Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore, Singapore; InfoComm, Technology and Data Group, Ministry of Health, Singapore, Singapore, Singapore
| | - Chou Ning
- CHOU Neuroscience Clinic, Farrer Park Hospital, Singapore, Singapore, Singapore; Chou Neurosurgery Pte Ltd, Gleneagles Hospital, Singapore, Singapore, Singapore
| | - Edward Menon
- Medical Services, St Andrew's Community Hospital, Singapore, Singapore, Singapore
| | - Hui Meng Chang
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore, Singapore
| | - Deidre A De Silva
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore, Singapore
| | - Kim En Lee
- Lee Kim En Neurology Pte Ltd, Singapore, Singapore, Singapore
| | | | - Sherry H Y Young
- Department of Rehabilitation Medicine, Changi General Hospital, Singapore, Singapore, Singapore
| | - Yee Sien Ng
- Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore, Singapore
| | - Yan Hoon Ang
- Geriatric Medicine, Khoo Teck Puat Hospital, Singapore, Singapore, Singapore
| | - Tseng Tsai Yeo
- Division of Neurosurgery, University Surgical Cluster, National University of Singapore, Singapore, Singapore, Singapore
| | - Reshma A Merchant
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore, Singapore; Department of Medicine (Division of Geriatric Medicine), National University Hospital, Singapore, Singapore, Singapore
| | - Keng He Kong
- Department of Rehabilitation Medicine, Tan Tock Seng Hospital, Singapore, Singapore, Singapore
| | - Rajinder Singh
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore, Singapore
| | - Yu Li Ng
- Manpower Planning and Strategy, Ministry of Health, Singapore, Singapore, Singapore
| | - Angela Cheong
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore, Singapore
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21
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Hill J, Hare M. Statins used for secondary prevention in patients with stroke reduce the risk of further ischaemic strokes and cardiovascular events. Evid Based Nurs 2021; 24:24. [PMID: 31874941 DOI: 10.1136/ebnurs-2019-103136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2019] [Indexed: 06/10/2023]
Affiliation(s)
- James Hill
- Evidence Synthesis, University of Central Lancashire, Preston, Lancashire, UK
| | - Marianne Hare
- NIHR Lancashire Clinical Research Facility, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
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22
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Chew DS, Rennert-May E, Quinn FR, Buck B, Hill MD, Spackman E, Manns BJ, Exner DV. Economic evaluation of extended electrocardiogram monitoring for atrial fibrillation in patients with cryptogenic stroke. Int J Stroke 2020; 16:809-817. [PMID: 33232196 DOI: 10.1177/1747493020974561] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timely identification of occult atrial fibrillation following cryptogenic stroke facilitates consideration of oral anticoagulation therapy. Extended electrocardiography monitoring beyond 24 to 48 h Holter monitoring improves atrial fibrillation detection rates, yet uncertainty remains due to upfront costs and the projected long-term benefit. We sought to determine the cost-effectiveness of three electrocardiography monitoring strategies in detecting atrial fibrillation after cryptogenic stroke. METHODS A decision-analytic Markov model was used to project the costs and outcomes of three different electrocardiography monitoring strategies (i.e. 30-day electrocardiography monitoring, three-year implantable loop recorder monitoring, and conventional Holter monitoring) in acute stroke survivors without previously documented atrial fibrillation. RESULTS The lifetime discounted costs and quality-adjusted life years were $206,385 and 7.77 quality-adjusted life years for conventional monitoring, $207,080 and 7.79 quality-adjusted life years for 30-day extended electrocardiography monitoring, and $210,728 and 7.88 quality-adjusted life years for the implantable loop recorder strategy. Additional quality-adjusted life years could be attained at a more favorable incremental cost per quality-adjusted life year with the implantable loop recorder strategy, compared with the 30-day electrocardiography monitoring strategy, thereby eliminating the 30-day strategy by extended dominance. The implantable loop recorder strategy was associated with an incremental cost per quality-adjusted life year gained of $40,796 compared with conventional monitoring. One-way sensitivity analyses indicated that the model was most sensitive to the rate of recurrent ischemic stroke. CONCLUSIONS An implantable loop recorder strategy for detection of occult atrial fibrillation in patients with cryptogenic stroke is more economically attractive than 30-day electrocardiography monitoring compared to conventional monitoring and is associated with a cost per quality-adjusted life year gained in the range of other publicly funded therapies. The value proposition is improved when considering patients at the highest risk of recurrent ischemic stroke. However, the implantable loop recorder strategy is associated with increased health care costs, and the opportunity cost of wide scale implementation must be considered.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.,Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Elissa Rennert-May
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada.,Snyder Institute for Chronic Diseases, University of Calgary, Alberta, Canada.,Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Alberta, Canada
| | - F Russell Quinn
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Eldon Spackman
- Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Braden J Manns
- Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Derek V Exner
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Alberta, Canada
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23
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Kate MP, Verma SJ, Arora D, Sylaja PN, Padma MV, Bhatia R, Khurana D, Sharma A, Ojha PK, Renjith V, Kulkarni GB, Sadiq M, Jabeen S, Borah NC, Ray BK, Sharma M, Pandian JD. Systematic Development of Structured Semi-interactive Stroke Prevention Package for Secondary Stroke Prevention. Ann Indian Acad Neurol 2020; 23:681-686. [PMID: 33623271 PMCID: PMC7887475 DOI: 10.4103/aian.aian_639_19] [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: 12/03/2020] [Revised: 12/10/2020] [Accepted: 01/26/2020] [Indexed: 11/05/2022] Open
Abstract
Background: Lack of compliance to medication and uncontrolled risk factors are associated with increased risk of recurrent stroke and acute coronary syndrome in patients with recent stroke. Multimodal patient education may be a strategy to improve the compliance to medication and early adoption of nonpharmacological measures to reduce the vascular risk factor burden in patients with stroke. We thus aim to develop multilingual short messaging services (SMS), print, and audio-visual secondary stroke prevention patient education package. The efficacy of the package will be tested in a randomized control trial to prevent major cardiovascular and cerebrovascular events. Methods: In the formative stage, intervention materials (SMS, video, and workbook) were developed. In the acceptability stage, the package was independently assessed and modified by the stakeholders involved in the stroke patient care and local language experts. The modified stroke prevention package was tested for implementation issues (implementation stage). Results: Sixty-nine SMS, six videos, and workbook with 11 chapters with 15 activities were developed in English language with a mean ± SD SMOG index of 9.1 ± 0.4. A total of 355 stakeholders including patients (24.8%), caregivers (24.8%), doctors (10.4%), nurses (14.1%), local language experts (2.8%), physiotherapists (13.2%), and research coordinators (9.8%) participated in 10 acceptability stage meetings. The mean Patient Education Material Assessment Tool understandability score in all languages for SMS, video scripts, and workbook was 95.2 ± 2.6%, 95.2 ± 4.4%, and 95.3 ± 3.6%, respectively. The patients [n = 20, mean age of 70.3 ± 10.6 years and median interquartile range (IQR) baseline NIHSS 1 (0–3)] or the research coordinators (n = 2) noted no implementation issues at the end of 1 month. Conclusion: An implementable complex multilingual patient education material could be developed in a stepwise manner. The efficacy of the package to prevent major adverse cardiovascular events is being tested in the SPRINT INDIA study.
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Affiliation(s)
- Mahesh Pundlik Kate
- Department of Clinical Neurosciences, Alberta Health Services, Edmonton, Canada
| | - Shweta Jain Verma
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - M V Padma
- Department of Neuroscience, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neuroscience, All India Institute of Medical Sciences, New Delhi, India
| | - Dheeraj Khurana
- Department of Neurology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arvind Sharma
- Department of Neurology, Zydus Hospital, Ahmedabad, Gujarat, India
| | - Pawan Kumar Ojha
- Department of Neurology, Grant Government Medical College, Mumbai, Maharashtra, India
| | - Vishnu Renjith
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Girish Baburao Kulkarni
- Department of Neurology, National Institute of Mental Health and Neuro-Sciences, Bangalore, Karnataka, India
| | - Mohammad Sadiq
- Department of Neurology, Christian Medical College, Vellore, Tamil Nadu, India
| | - S Jabeen
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N C Borah
- Department of Neurology, Guwahati Neurological Research Centre, Dispur, Assam, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurosciences, Kolkata, West Bengal, India
| | - Meenakshi Sharma
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India
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24
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Hill J, Harrison J, Raj S, Gregary B, Timoroksa AM, Gibson J. Mediators, confounders and effectiveness of interventions for medication adherence after stroke. BRITISH JOURNAL OF NEUROSCIENCE NURSING 2020; 16:S18-S24. [PMID: 38737446 PMCID: PMC7615945 DOI: 10.12968/bjnn.2020.16.sup5.s18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Abstract
After a stroke, people are left with an increased risk of recurrence. One of the primary methods of prevention is the use of a range of medications, but adherence to these is often low. This article evaluates and summarises three systematic reviews that investigate possible underlying reasons for this and how to overcome these barriers.
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Affiliation(s)
- James Hill
- Health Technology Assessment Group, University of Central Lancashire
| | - Joanna Harrison
- Health Technology Assessment Group, University of Central Lancashire
| | - Sonia Raj
- NIHR Lancashire Clinical Research Facility, Royal Preston Hospital
| | - Bindu Gregary
- NIHR Lancashire Clinical Research Facility, Royal Preston Hospital
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25
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Kauw F, Greving JP, Takx RAP, de Jong HWAM, Schonewille WJ, Vos JA, Wermer MJH, van Walderveen MAA, Kappelle LJ, Velthuis BK, Dankbaar JW. Prediction of long-term recurrent ischemic stroke: the added value of non-contrast CT, CT perfusion, and CT angiography. Neuroradiology 2020; 63:483-490. [PMID: 32857214 PMCID: PMC7966192 DOI: 10.1007/s00234-020-02526-5] [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: 06/17/2020] [Accepted: 08/16/2020] [Indexed: 11/30/2022]
Abstract
Purpose The aim of this study was to evaluate whether the addition of brain CT imaging data to a model incorporating clinical risk factors improves prediction of ischemic stroke recurrence over 5 years of follow-up. Methods A total of 638 patients with ischemic stroke from three centers were selected from the Dutch acute stroke study (DUST). CT-derived candidate predictors included findings on non-contrast CT, CT perfusion, and CT angiography. Five-year follow-up data were extracted from medical records. We developed a multivariable Cox regression model containing clinical predictors and an extended model including CT-derived predictors by applying backward elimination. We calculated net reclassification improvement and integrated discrimination improvement indices. Discrimination was evaluated with the optimism-corrected c-statistic and calibration with a calibration plot. Results During 5 years of follow-up, 56 patients (9%) had a recurrence. The c-statistic of the clinical model, which contained male sex, history of hyperlipidemia, and history of stroke or transient ischemic attack, was 0.61. Compared with the clinical model, the extended model, which contained previous cerebral infarcts on non-contrast CT and Alberta Stroke Program Early CT score greater than 7 on mean transit time maps derived from CT perfusion, had higher discriminative performance (c-statistic 0.65, P = 0.01). Inclusion of these CT variables led to a significant improvement in reclassification measures, by using the net reclassification improvement and integrated discrimination improvement indices. Conclusion Data from CT imaging significantly improved the discriminatory performance and reclassification in predicting ischemic stroke recurrence beyond a model incorporating clinical risk factors only. Electronic supplementary material The online version of this article (10.1007/s00234-020-02526-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard A P Takx
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Jan A Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - L Jaap Kappelle
- Brain Center, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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26
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Roberts PS, Krishnan S, Burns SP, Ouellette D, Pappadis MR. Inconsistent Classification of Mild Stroke and Implications on Health Services Delivery. Arch Phys Med Rehabil 2020; 101:1243-1259. [PMID: 32001257 PMCID: PMC7311258 DOI: 10.1016/j.apmr.2019.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/24/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To conduct a scoping review on classifications of mild stroke based on stroke severity assessments and/or clinical signs and symptoms reported in the literature. DATA SOURCES Electronic searches of PubMed, PsycINFO (Ovid), and Cumulative Index to Nursing and Allied Health (CINAHL-EBSCO) databases included keyword combinations of mild stroke, minor stroke, mini stroke, mild cerebrovascular, minor cerebrovascular, transient ischemic attack, or TIA. STUDY SELECTION Inclusion criteria were limited to articles published between January 2003 and February 2018. Inclusion criteria included studies (1) with a definition of either mild or minor stroke, (2) written in English, and (3) with participants aged 18 years and older. Animal studies, reviews, dissertations, blogs, editorials, commentaries, case reports, newsletters, drug trials, and presentation abstracts were excluded. DATA EXTRACTION Five reviewers independently screened titles and abstracts for inclusion and exclusion criteria. Two reviewers independently screened each full-text article for eligibility. The 5 reviewers checked the quality of the included full-text articles for accuracy. Data were extracted by 2 reviewers and verified by a third reviewer. DATA SYNTHESIS Sixty-two studies were included in the final review. Ten unique definitions of mild stroke using stroke severity assessments were discovered, and 10 different cutoff points were used. The National Institutes of Health Stroke Scale was the most widely used measure to classify stroke severity. Synthesis also revealed variations in classification of mild stroke across publication years, time since stroke, settings, and medical factors including imaging, medical indicators, and clinical signs and symptoms. CONCLUSIONS Inconsistencies in the classification of mild stroke are evident with varying use of stroke severity assessments, measurement cutoff scores, imaging tools, and clinical or functional outcomes. Continued work is necessary to develop a consensus definition of mild stroke, which directly affects treatment receipt, referral for services, and health service delivery.
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Affiliation(s)
| | - Shilpa Krishnan
- Department of Rehabilitation Medicine, Division of Physical Therapy, Emory University, Atlanta, Georgia
| | | | - Debra Ouellette
- Casa Colina Hospital and Centers for Healthcare, Pomona, California
| | - Monique R Pappadis
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas
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27
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Simpson DB, Breslin M, Cumming T, de Zoete SA, Gall SL, Schmidt M, English C, Callisaya ML. Sedentary time and activity behaviors after stroke rehabilitation: Changes in the first 3 months home. Top Stroke Rehabil 2020; 28:42-51. [PMID: 32578523 DOI: 10.1080/10749357.2020.1783917] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Sedentary time is prevalent following stroke, limiting functional improvement, and increasing cardiovascular risk. At discharge we examined: 1) change in sedentary time and activity over the following 3 months' and 2) physical, psychological or cognitive factors predicting any change. A secondary aim examined cross-sectional associations between factors and activity at 3 months. METHODS People with stroke (n = 34) were recruited from two rehabilitation units. An activity monitor (ActivPAL3) was worn for 7 days during the first week home and 3 months later. Factors examined included physical, psychological, and cognitive function. Linear mixed models (adjusted for waking hours) were used to examine changes in sedentary time, walking, and step count over time. Interaction terms between time and each factor were added to the model to determine if they modified change over time. Linear regression was performed to determine factors cross-sectionally associated with 3-month activity. RESULTS ActivPAL data were available at both time points for 28 (82%) participants (mean age 69 [SD 12] years). At 3 months, participants spent 39 fewer minutes sedentary (95%CI -70,-8 p = .01), 21 minutes more walking (95%CI 2,22 p = .02) and completed 1112 additional steps/day (95%CI 268,1956 p = .01), compared to the first week home. No factors predicted change in activity. At 3 months, greater depression (β 22 mins (95%CI 8,36) p = .004) and slower gait speed (β - 43 mins 95%CI -59,-27 p ≤ 0.001) were associated with more sedentary time and less walking activity, respectively. CONCLUSIONS Sedentary time reduced and walking activity increased between discharge home and 3 months later. Interventions targeting mood and physical function may warrant testing to reduce sedentary behavior 3 months following discharge.
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Affiliation(s)
- Dawn B Simpson
- Menzies Institute of Medical Research, University of Tasmania , Hobart, Australia.,Physiotherapy Department, Royal Hobart Hospital, Tasmanian Health Service - South , Hobart, Australia
| | - Monique Breslin
- Menzies Institute of Medical Research, University of Tasmania , Hobart, Australia
| | - Toby Cumming
- Stroke Division, Florey Institute of Neurosciences and Mental Health , Heidleberg, Australia
| | - Sam A de Zoete
- Physiotherapy Department, Royal Hobart Hospital, Tasmanian Health Service - South , Hobart, Australia
| | - Seana L Gall
- Menzies Institute of Medical Research, University of Tasmania , Hobart, Australia
| | - Matthew Schmidt
- School of Health Sciences, University of Tasmania , Hobart, Australia
| | - Coralie English
- School of Health Sciences and Priority Research Centre for Stroke and Brain Injury, University of Newcastle , Newcastle, Australia.,Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery, University of Newcastle and Hunter Medical Research Institute , New Lambton Heights, Australia.,School of Health Sciences and Alliance for Research in Exercise, Nutrition and Activity, University of South Australia , Adelaide, Australia
| | - Michele L Callisaya
- Menzies Institute of Medical Research, University of Tasmania , Hobart, Australia.,Peninsula Clinical School, Central Clinical School, Monash University , Melbourne, Australia
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28
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Boettiger DC, Newall AT, Chattranukulchai P, Chaiwarith R, Khusuwan S, Avihingsanon A, Phillips A, Bendavid E, Law MG, Kahn JG, Ross J, Bautista‐Arredondo S, Kiertiburanakul S. Statins for atherosclerotic cardiovascular disease prevention in people living with HIV in Thailand: a cost-effectiveness analysis. J Int AIDS Soc 2020; 23 Suppl 1:e25494. [PMID: 32562359 PMCID: PMC7305414 DOI: 10.1002/jia2.25494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/20/2020] [Accepted: 03/31/2020] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION People living with HIV (PLHIV) have an elevated risk of atherosclerotic cardiovascular disease (CVD) compared to their HIV-negative peers. Expanding statin use may help alleviate this burden. However, the choice of statin in the context of antiretroviral therapy is challenging. Pravastatin and pitavastatin improve cholesterol levels in PLHIV without interacting substantially with antiretroviral therapy. They are also more expensive than most statins. We evaluated the cost-effectiveness of pravastatin and pitavastatin for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy. METHODS We developed a discrete-state microsimulation model that randomly selected (with replacement) individuals from the TREAT Asia HIV Observational Database cohort who were aged 40 to 75 years, receiving antiretroviral therapy in Thailand, and not using lipid-lowering therapy. The model simulated each individual's probability of experiencing CVD. We evaluated: (1) treating no one with statins; (2) treating everyone with pravastatin 20mg/day (drug cost 7568 Thai Baht ($US243)/year) and (3) treating everyone with pitavastatin 2 mg/day (drug cost 8182 Baht ($US263)/year). Direct medical costs and quality-adjusted life-years (QALYs) were assigned in annual cycles over a 20-year time horizon and discounted at 3% per year. We assumed the Thai healthcare sector perspective. RESULTS Pravastatin was estimated to be less effective and less cost-effective than pitavastatin and was therefore dominated (extended) by pitavastatin. Patients receiving pitavastatin accumulated 0.042 additional QALYs compared with those not using a statin, at an extra cost of 96,442 Baht ($US3095), giving an incremental cost-effectiveness ratio of 2,300,000 Baht ($US73,812)/QALY gained. These findings were sensitive to statin costs and statin efficacy, pill burden, and targeting of PLHIV based on CVD risk. At a willingness-to-pay threshold of 160,000 Baht ($US5135)/QALY gained, we estimated that pravastatin would become cost-effective at an annual cost of 415 Baht ($US13.30)/year and pitavastatin would become cost-effective at an annual cost of 600 Baht ($US19.30)/year. CONCLUSIONS Neither pravastatin nor pitavastatin were projected to be cost-effective for the primary prevention of CVD among PLHIV in Thailand who are not currently using lipid-lowering therapy. We do not recommend expanding current use of these drugs among PLHIV in Thailand without substantial price reduction.
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Affiliation(s)
- David C Boettiger
- Kirby InstituteUNSW SydneySydneyNSWAustralia
- Institute for Health Policy StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Anthony T Newall
- The School of Public Health and Community MedicineUNSW SydneySydneyNSWAustralia
| | | | - Romanee Chaiwarith
- Research Institute for Health SciencesChiang Mai UniversityChiang MaiThailand
| | | | - Anchalee Avihingsanon
- The Thai Red Cross AIDS Research Centre and Faculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Andrew Phillips
- Institute for Global HealthUniversity College LondonUnited Kingdom
| | - Eran Bendavid
- Center for Health Policy and the Center for Primary Care and Outcomes ResearchStanford UniversityStanfordCAUSA
| | | | - James G Kahn
- Institute for Health Policy StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Jeremy Ross
- TREAT Asia/amfAR–Foundation for AIDS ResearchBangkokThailand
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29
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Feldman PH, McDonald MV, Trachtenberg M, Trifilio M, Onorato N, Sridharan S, Silver S, Eimicke J, Teresi J. Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial. Am J Hypertens 2020; 33:362-370. [PMID: 31541606 PMCID: PMC7109355 DOI: 10.1093/ajh/hpz148] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/18/2019] [Accepted: 09/11/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Uncontrolled hypertension (HTN) is a leading modifiable stroke risk factor contributing to global stroke disparities. This study is unique in testing a transitional care model aimed at controlling HTN in black and Hispanic poststroke, home health patients, an understudied group. METHODS A 3-arm randomized controlled trial design compared (i) usual home care (UHC), with (ii) UHC plus a 30-day nurse practitioner transitional care program, or (iii) UHC plus nurse practitioner plus a 60-day health coach program. The trial enrolled 495 black and Hispanic, English- and Spanish- speaking adults with uncontrolled systolic blood pressure (SBP ≥ 140 mm Hg) who had experienced a first-time or recurrent stroke or transient ischemic attack. The primary outcome was change in SBP from baseline to 3 and 12 months. RESULTS Mean participant age was 67; 57.0% were female; 69.7% were black, non-Hispanic; and 30.3% were Hispanic. Three-month follow-up retention was 87%; 12-month retention was 81%. SBP declined 9-10 mm Hg from baseline to 12 months across all groups; the greatest decrease occurred between baseline and 3 months. The interventions demonstrated no relative advantage compared to UHC. CONCLUSION The significant across-the-board SBP decreases suggest that UHC nurse/patient/physician interactions were the central component of SBP reduction and that additional efforts to lower recurrent stroke risk should test incremental improvements in usual care, not resource-intensive transitional care interventions. They also suggest the potential value of pragmatic home care programs as part of a broader strategy to overcome HTN treatment barriers and improve secondary stroke prevention globally. CLINICAL TRIALS REGISTRATION Trial Number NCT01918891.
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Affiliation(s)
- Penny H Feldman
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Margaret V McDonald
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Melissa Trachtenberg
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Marygrace Trifilio
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Nicole Onorato
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Sridevi Sridharan
- Center for Home Care Policy & Research, Visiting Nurse Service of New York, New York, USA
| | - Stephanie Silver
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | - Joseph Eimicke
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
| | - Jeanne Teresi
- Research Division, Hebrew Home at Riverdale, RiverSpring Health, Bronx, New York, USA
- Columbia University Stroud Center at New York State Psychiatric Institute, New York, USA
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Edwards JD, Kapral MK, Lindsay MP, Fang J, Swartz RH. Young Stroke Survivors With No Early Recurrence at High Long-Term Risk of Adverse Outcomes. J Am Heart Assoc 2020; 8:e010370. [PMID: 30563428 PMCID: PMC6405707 DOI: 10.1161/jaha.118.010370] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Approximately 8% to 21% of strokes affect adults aged <45 years. Although early stroke recurrence conveys the largest risk, long‐term risks for young survivors with no early complications are unclear. Methods and Results Longitudinal matched case‐control study (2003–2013). Consecutive patients with ischemic stroke or transient ischemic attack (young, ≤44 years) discharged from emergency or regional stroke centers in Ontario, Canada, with no death, recurrent stroke/transient ischemic attack, myocardial infarction, all‐cause hospitalization, or admission to a long‐term or continuing care facility (≤90 days) were matched 10:1 to general population controls on age (±1 year), sex, income, geography, and case date (±50 days). The primary outcome was a composite of death, stroke, myocardial infarction, and long‐term or continuing care facility admission at 1, 3, and 5 years. Absolute event rates for young stroke/transient ischemic attack patients were lower than for older patients at 1 (2.2% versus 9.9%), 3 (4.7% versus 24.6%), and 5 (7.1% versus 37.2%) years. However, piecewise constant hazard modeling revealed that, even after adjustment for vascular comorbidities, young patients showed a 7‐fold increased hazard of the composite outcome compared with young controls at 1 year (hazard ratio, 7.3; 95% CI, 4.0–13.6). Adjusted 5‐year piecewise hazard also remained >5× that of young controls (hazard ratio, 5.2; 95% CI, 2.8–9.4), compared with a 30% increase at 5 years for older patients (hazard ratio, 1.3; 95% CI, 1.3–1.4). Conclusions Young stable stroke/transient ischemic attack survivors show a higher long‐term hazard of adverse outcomes compared with matched controls than older patients. Findings support the need for long‐term follow‐up and aggressive risk reduction in young survivors and suggest secondary prevention guidelines for these patients are required.
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Affiliation(s)
- Jodi D Edwards
- 1 University of Ottawa Heart Institute Ottawa Ontario Canada.,2 School of Epidemiology and Public Health University of Ottawa Ottawa Ontario Canada.,3 ICES Toronto Ontario Canada
| | - Moira K Kapral
- 3 ICES Toronto Ontario Canada.,4 Department of Medicine and Institute of Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada.,5 Division of General Internal Medicine and Women's Health Program University Health Network Toronto Ontario Canada
| | | | | | - Richard H Swartz
- 7 Department of Medicine (Neurology) University of Toronto Toronto Ontario Canada.,8 Sunnybrook Research Institute Toronto Ontario Canada
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Kate MP, Arora D, Verma SJ, Sylaja PN, Renjith V, Sharma M, Pandian JD. Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) study protocol. Int J Stroke 2020; 15:109-115. [PMID: 31852411 DOI: 10.1177/1747493019895653] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
RATIONALE Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15-20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes. HYPOTHESIS We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year. DESIGN Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18-85 years, mRS <5, showing recent stroke in imaging are included. Participants or caregivers able to read and complete tasks suggested in a stroke prevention workbook and have a cellular device for receiving short message service and watching videos. A total of 5830 stroke patients speaking 11 different languages are being randomized to intervention or control arm. Patients in the intervention arm are receiving a stroke prevention workbook, regular educational short messages, and videos. All patients in the control arm are receiving standard of care management. SUMMARY Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke. TRIAL REGISTRATION This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).
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Affiliation(s)
| | - Deepti Arora
- Department of Neurology, Christian Medical College, Ludhiana, India
| | | | - P N Sylaja
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, India
| | - Vishnu Renjith
- Department of Neurology, Sri Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, India
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Bray EP, McMahon NE, Bangee M, Al-Khalidi AH, Benedetto V, Chauhan U, Clegg AJ, Georgiou RF, Gibson J, Lane DA, Lip GYH, Lightbody E, Sekhar A, Chatterjee K, Watkins CL. Etiologic workup in cases of cryptogenic stroke: protocol for a systematic review and comparison of international clinical practice guidelines. Syst Rev 2019; 8:331. [PMID: 31847884 PMCID: PMC6918649 DOI: 10.1186/s13643-019-1247-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of death and disability worldwide. Identifying the aetiology of ischaemic stroke is essential in order to initiate appropriate and timely secondary prevention measures to reduce the risk of recurrence. For the majority of ischaemic strokes, the aetiology can be readily identified, but in at least 30% of cases, the exact aetiology cannot be determined using existing investigative protocols. Such strokes are classed as 'cryptogenic' or as a stroke of unknown origin. However, there exists substantial variation in clinical practice when investigating cases of seemingly cryptogenic stroke, often reflecting local service availability and the preferences of treating clinicians. This variation in practice is compounded by the lack of international consensus as to the optimum level and timing of investigations required following a stroke. To address this gap, we aim to systematically review and compare recommendations in evidence-based clinical practice guidelines (CPGs) that relate to the assessment and investigation of the aetiology of ischaemic stroke, and any subsequent diagnosis of cryptogenic stroke. METHOD We will search for CPGs using electronic databases (MEDLINE, Health Management Information Consortium (HMIC), EMBASE, and CINAHL), relevant websites and search engines (e.g. guideline specific websites, governmental, charitable, and professional practice organisations) and hand-searching of bibliographies and reference lists. Two reviewers will independently screen titles, abstracts and CPGs using a pre-defined relevance criteria form. From each included CPG, we will extract definitions and terms for cryptogenic stroke; recommendations related to assessment and investigation of the aetiology of stroke, including the grade of recommendations and underpinning evidence. The quality of the included CPGs will be assessed using the AGREE II (Appraisal of Guidelines for Research and Evaluation) tool. Recommendations across the CPGs will be summarised descriptively highlighting areas of convergence and divergence between CPGs. DISCUSSION To our knowledge, this will be the first review to systematically compare recommendations of international CPGs on investigating the aetiology of ischaemic stroke. The findings will allow for a better understanding of international perspectives on the optimum level of investigations required following a stroke and thus contribute to achieving greater international consensus on best practice in this important and complex area. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019127822.
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Affiliation(s)
- Emma P. Bray
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Naoimh E. McMahon
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Munirah Bangee
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - A. Hakam Al-Khalidi
- Medtronic Limited, Building 9, Croxley Park, Hatters Lane, Watford, WD18 8WW UK
| | - Valerio Benedetto
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Umesh Chauhan
- Faculty of Clinical and Biomedical Sciences, University of Central Lancashire, Preston, PR1 2HE UK
| | - Andrew J. Clegg
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Rachel F. Georgiou
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Josephine Gibson
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Deirdre A. Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Elizabeth Lightbody
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
| | - Alakendu Sekhar
- The Walton Centre NHS Foundation Trust, Liverpool, L9 7LJ UK
| | | | - Caroline L. Watkins
- Faculty of Health and Wellbeing, University of Central Lancashire, Preston, PR1 2HE UK
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Jacob L, Tanislav C, Kostev K. Long-term risk of stroke and its predictors in transient ischaemic attack patients in Germany. Eur J Neurol 2019; 27:723-728. [PMID: 31811788 DOI: 10.1111/ene.14136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/03/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Little is known about the long-term association between transient ischaemic attack (TIA) and stroke. Therefore, the goal of this study was to analyze the long-term risk of stroke and associated predictors in a large cohort of TIA patients followed in general practices in Germany. METHODS This study included patients with an initial TIA diagnosis and subsequently followed up in one of 1262 general practices in Germany between January 2007 and December 2016 (N = 19 824 patients). The primary outcome of the study was the risk of ischaemic stroke within 10 years of the initial diagnosis of TIA. The secondary outcome was the identification of demographic, clinical and pharmaceutical variables significantly associated with stroke in TIA patients. RESULTS Within 10 years of the initial TIA diagnosis, 18.3% of individuals were diagnosed with stroke. Age was positively associated with stroke, with hazard ratios ranging from 1.88 in patients aged 51-60 years to 4.00 in those aged >80 years (reference group: patients aged ≤50 years). Furthermore, male sex, hypertension, diabetes mellitus, atrial fibrillation and ischaemic heart diseases had an additional impact on the risk of stroke. Finally, new oral anticoagulants, heparins, diuretics, angiotensin II receptor blockers and platelet aggregation inhibitors were identified as protective factors. CONCLUSIONS In a cohort of almost 20 000 TIA patients, 18.3% were diagnosed with stroke within 10 years after the TIA index event. Several demographic, clinical and pharmaceutical variables significantly predicted the long-term risk of stroke in TIA patients.
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Affiliation(s)
- L Jacob
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux, France.,Research and Development Unit, Parc Sanitari Sant Joan de Déu, CIBERSAM, Barcelona, Spain
| | - C Tanislav
- Department of Neurology, University Hospital Giessen and Marburg, Giessen, Germany
| | - K Kostev
- Epidemiology, IQVIA, Frankfurt, Germany
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Kate M, Brar S, George U, Rathore S, Butcher K, Pandian J, Hess D. Self- or caregiver-delivered manual remote ischemic conditioning therapy in acute ischemic stroke is feasible: the Early Remote Ischemic Conditioning in Stroke (ERICS) trial. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15490.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Infarct growth and recurrent stroke may be responsible for early morbidity and mortality in patients with acute ischemic stroke. Remote ischemic conditioning (RIC) may reduce infarct growth and prevent recurrent stroke; however, the exact dose remains to be investigated. We hypothesized that self- or caregiver-delivered six cycles of RIC intervention in acute ischaemic stroke for the first 12 weeks is feasible and safe compared to the four cycles RIC intervention. Methods: Adult ischemic stroke patients presenting within the first 48 h of symptom onset were screened. Patients with magnetic resonance imaging (MRI) evidence of acute infarct were randomized (1:1) to receive either four or six cycles of RIC therapy sessions two times daily in both arms for 12 weeks. All patients underwent MRI for infarct volume assessment and endothelial-dependent flow-mediated dilation (EDFMD) testing at baseline, 7 days and 12 weeks. Results: A total of 57 patients with mean±SD age of 59.4±12.4 years and median National Institute of Stroke Scale, 4 (IQR, 3-7) were randomised at a median of 23 h 30 min (IQR, 10 h 20 min to 30 h) after symptom onset to either the four-cycle (n=27) or six-cycle group (n=30). A total of 18 (66%) patients completed ≥50% sessions in 12 weeks in the four-cycles group; 21 (69.7%) patients completed ≥50% sessions in 12 weeks in the six-cycle group (p=0.4). There was no between-group differences in infarct growth, early neurological deterioration, recurrent stroke, and EDFMD at 7 days and 90 days. Conclusion: Both four and six cycles of short-term self- or caregiver-delivered RIC therapy is safe and may be feasible in acute ischaemic stroke patients. Randomised clinical trials are needed to assess efficacy to decrease infarct growth and prevent early neurological deterioration. Registration: Clinical Trial Registry - India: CTRI/2016/11/007495; registered on 25/11/2016.
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Fernandez DM, Rahman AH, Fernandez NF, Chudnovskiy A, Amir EAD, Amadori L, Khan NS, Wong CK, Shamailova R, Hill CA, Wang Z, Remark R, Li JR, Pina C, Faries C, Awad AJ, Moss N, Bjorkegren JLM, Kim-Schulze S, Gnjatic S, Ma'ayan A, Mocco J, Faries P, Merad M, Giannarelli C. Single-cell immune landscape of human atherosclerotic plaques. Nat Med 2019; 25:1576-1588. [PMID: 31591603 PMCID: PMC7318784 DOI: 10.1038/s41591-019-0590-4] [Citation(s) in RCA: 503] [Impact Index Per Article: 100.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 08/16/2019] [Indexed: 12/29/2022]
Abstract
Atherosclerosis is driven by multifaceted contributions of the immune system within the circulation and at vascular focal sites. However, specific characteristics of dysregulated immune cells within atherosclerotic lesions that lead to clinical events such as ischemic stroke or myocardial infarction are poorly understood. Here, using single-cell proteomic and transcriptomic analyses, we uncovered distinct features of both T cells and macrophages in carotid artery plaques of patients with clinically symptomatic disease (recent stroke or transient ischemic attack) compared to asymptomatic disease (no recent stroke). Plaques from symptomatic patients were characterized by a distinct subset of CD4+ T cells and by T cells that were activated and differentiated. Moreover, some T cell subsets in these plaques presented markers of T cell exhaustion. Additionally, macrophages from these plaques contained alternatively activated phenotypes, including subsets associated with plaque vulnerability. In plaques from asymptomatic patients, T cells and macrophages were activated and displayed evidence of interleukin-1β signaling. The identification of specific features of innate and adaptive immune cells in plaques that are associated with cerebrovascular events may enable the design of more precisely tailored cardiovascular immunotherapies.
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Affiliation(s)
- Dawn M Fernandez
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adeeb H Rahman
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicolas F Fernandez
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aleksey Chudnovskiy
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - El-Ad David Amir
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Letizia Amadori
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nayaab S Khan
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christine K Wong
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roza Shamailova
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher A Hill
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zichen Wang
- Mount Sinai Center for Bioinformatics, Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Romain Remark
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Innate Pharma, Marseille, France
| | - Jennifer R Li
- Department of Surgery, Vascular Division, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christian Pina
- Department of Surgery, Vascular Division, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Faries
- Department of Surgery, Vascular Division, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed J Awad
- Cerebrovascular Center, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Noah Moss
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johan L M Bjorkegren
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Integrated Cardio MetabolicCentre, Department of Medicine, Karolinska Institutet, Karolinska Universitetssjukhuset, Huddinge, Sweden
| | - Seunghee Kim-Schulze
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Hematology and Medical Oncology Division, The Tish Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sacha Gnjatic
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Avi Ma'ayan
- Mount Sinai Center for Bioinformatics, Department of Pharmacological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Mocco
- Cerebrovascular Center, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Faries
- Department of Surgery, Vascular Division, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miriam Merad
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Human Immune Monitoring Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Oncological Sciences, The Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chiara Giannarelli
- Cardiovascular Research Center, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- The Precision Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Pana TA, Wood AD, Mamas MA, Clark AB, Bettencourt‐Silva JH, McLernon DJ, Potter JF, Myint PK, Metcalfe AK, Bowles KM. Myocardial infarction after acute ischaemic stroke: Incidence, mortality and risk factors. Acta Neurol Scand 2019; 140:219-228. [PMID: 31140583 DOI: 10.1111/ane.13135] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/16/2019] [Accepted: 05/25/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To determine the risk factor profiles associated with post-acute ischaemic stroke (AIS) myocardial infarction (MI) over long-term follow-up. METHODS This observational study includes prospectively identified AIS patients (n = 9840) admitted to a UK regional centre between January 2003 and December 2016 (median follow-up: 4.72 years). Predictors of post-stroke MI during follow-up were examined using logistic and Cox regression models for in-hospital and post-discharge events, respectively. MI incidence was determined using a competing risk non-parametric estimator. The influence of post-stroke MI on mortality was examined using Cox regressions. RESULTS Mean age (SD) of study participants was 77.3 (12.2) years (48% males). Factors associated with in-hospital MI (OR [95% CI]) were increasing blood glucose (1.80 [1.17-2.77] per 10 mmol/L), total leucocyte count (1.25 [1.01-1.54] per 10 × 109 /L) and CRP (1.05 [1.02-1.08] per 10 mg/L increase). Age (HR [95% CI] = 1.03 [1.01-1.06]), coronary heart disease (1.59 [1.01-2.50]), chronic kidney disease (2.58 [1.44-4.63]) and cancers (1.76 [1.08-2.89]) were associated with incident MI between discharge and one-year follow-up. Age (1.02 [1.00-1.03]), diabetes (1.96 [1.38-2.65]), congestive heart failure (2.07 [1.44-2.99]), coronary heart disease (1.81 [1.31-2.50]), hypertension [1.86 (1.24-2.79)] and peripheral vascular disease (2.25 [1.40-3.63]) were associated with incident MI between 1 and 5 years after discharge. Diabetes (2.01 [1.09-3.72]), hypertension (3.69 [1.44-9.45]) and peripheral vascular disease (2.46 [1.02-5.98]) were associated with incident MI between 5 and 10 years after discharge. Cumulative MI incidence over 10 years was 5.4%. MI during all follow-up periods (discharge-1, 1-5, 5-10 years) was associated with increased risk of death (respective HR [95% CI] = 3.26 [2.51-4.15], 1.96 [1.58-2.42] and 1.92 [1.26-2.93]). CONCLUSIONS In conclusion, prognosis is poor in post-stroke MI. We highlight a range of potential areas to focus preventative efforts.
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Affiliation(s)
- Tiberiu A. Pana
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition University of Aberdeen Aberdeen UK
| | - Adrian D. Wood
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition University of Aberdeen Aberdeen UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences Keele University Stoke‐on‐Trent UK
| | - Allan B. Clark
- Norwich Medical School University of East Anglia Norwich UK
| | - Joao H. Bettencourt‐Silva
- Department of Medicine, Clinical Informatics University of Cambridge Cambridge UK
- Norfolk and Norwich University Hospital Norwich UK
| | - David J. McLernon
- Medical Statistics Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition University of Aberdeen Aberdeen UK
| | - John F. Potter
- Norfolk and Norwich University Hospital Norwich UK
- Norwich Cardiovascular Research Group, Norwich Medical School University of East Anglia Norwich UK
| | - Phyo K. Myint
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences & Nutrition University of Aberdeen Aberdeen UK
- Norwich Medical School University of East Anglia Norwich UK
- Norwich Cardiovascular Research Group, Norwich Medical School University of East Anglia Norwich UK
- Aberdeen Royal Infirmary NHS Grampian Aberdeen UK
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Li S, Tian Q, Fan J, Shi Z, Guo B, Chen H, Li Y, Shi S. Hospital use in survivors of transient ischaemic attack compared with survivors of stroke in central China: a nested case-control study. BMJ Open 2019; 9:e024052. [PMID: 31292173 PMCID: PMC6624025 DOI: 10.1136/bmjopen-2018-024052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES There is a lack of knowledge regarding post-discharge hospitalisation utilisation after transient ischaemic attack (TIA) in China. The aim of this study is to quantify rehospitalisation use in survivors of TIA compared with their own previous hospital use and matched survivors of stroke. DESIGN Nested case-control study of electronic medical records datasets. SETTING 958 hospitals in Henan, China, from July 2012 to December 2015. PARTICIPANTS In total, 4823 survivors of stroke were matched to the TIA cohort (average age: 64.5 years; proportion of men: 48.4%) at a 1:1 ratio. All subjects with an onset of stroke/TIA were recorded with a 1-year look-back and follow-up. OUTCOME MEASURES Adjusted difference-in-differences (DID) values in 1-year hospital lengths of stay (LOSs) and readmission within 7, 30 and 90 days. RESULTS There was an increase in hospital admissions in survivors of TIA in the year after the index hospitalisation compared with the prior year. Of the 2449 rehospitalisation events that occurred during the first year after TIA, stroke (20.6%) was the most common reason for rehospitalisation. There was no difference in the stroke-specific readmission rates between the TIA and stroke cohorts (p=0.198). The TIA cohort had fewer readmissions within 30 days and 90 days after all-cause discharge compared with the controls. The corresponding covariate-adjusted DID values were -3.5 percentage points (95% CI -5.3 to -1.8) and -4.5 (95% CI -6.5 to -2.4), respectively. A similar trend was observed in the 1-year LOS. In the stratified analysis, the DID reductions were not significant in patients with more comorbidities or in rural patients. CONCLUSIONS Compared with survivors of stroke, survivors of TIA use fewer hospital resources up to 1 year post-discharge. Greater attention to TIAs among patients with more comorbidities and rural patients may provide an opportunity to reduce hospital use.
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Affiliation(s)
- Sangsang Li
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Qingfeng Tian
- Department of Social Medicine, Zhengzhou University, Zhengzhou, China
| | - Junxing Fan
- Statistical Information Center, Health and Family Planning Commission of Henan Province, Zhengzhou, China
| | - Zhan Shi
- Department of Pharmacy, Zhengzhou People’s Hospital, Zhengzhou, UK
| | - Bingxin Guo
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Huanan Chen
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
| | - Yapeng Li
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, UK
| | - Songhe Shi
- Department of Epidemiology and Biostatistics, Zhengzhou University, Zhengzhou, China
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Effect of Kinesio Taping on the Walking Ability of Patients with Foot Drop after Stroke. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:2459852. [PMID: 31223327 PMCID: PMC6541939 DOI: 10.1155/2019/2459852] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 04/15/2019] [Indexed: 11/17/2022]
Abstract
Objective The purpose of this study was to investigate the effect of kinesio taping on the walking ability in patients with foot drop after stroke. Methods Sixty patients were randomly divided into the experimental group (with kinesio taping) and the control group (without kinesio taping). The 10-Meter Walking Test (10MWT), Timed Up and Go Test (TUGT), stride length, stance phase, swing phase, and foot rotation of the involved side were measured with the German ZEBRIS gait running platform analysis system and were used to evaluate and compare the immediate effects of kinesio taping. All the measurements were made in duplicate for each patient. Results The demographic variables of patients in both groups were comparable before the treatment (p>0.05). After kinesio taping treatment, significant improvement was found in the 10MWT and the TUGT for patients in the experimental group (p<0.05). There were significant differences in the 10MWT and TUGT between the experimental and control groups after treatment (p<0.05). In terms of gait, we found significant improvement in stride length (p<0.001), stance phase (p<0.001), swing phase (p<0.001), and foot rotation (p<0.001) of the involved side in experimental group after treatment compared with those before treatment. Further, the functional outcomes and gait ability were significantly improved in the experimental group after treatment (p<0.05), compared to the control group. Conclusion Kinesio taping can immediately improve the walking function of patients with foot drop after stroke.
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Hagberg G, Fure B, Sandset EC, Thommessen B, Ihle-Hansen H, Øksengård AR, Nygård S, Wyller TB, Ihle-Hansen H. Long-term effects on survival after a 1-year multifactorial vascular risk factor intervention after stroke or TIA: secondary analysis of a randomized controlled trial, a 7-year follow-up study. Vasc Health Risk Manag 2019; 15:11-18. [PMID: 30799926 PMCID: PMC6369929 DOI: 10.2147/vhrm.s191873] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Stroke and coronary heart disease share the same risk factors, and a multifactorial intervention after stroke may potentially result in the same reduction in cardiovascular mortality as seen after coronary events. We aimed to evaluate the effect on survival 7 years after a 1-year multifactorial risk factor intervention, and identify clinical predictors for long-term survival in a hospital-based cohort of patients with first-ever stroke or transient ischemic attack (TIA). Materials and methods We performed a secondary analysis of a randomized controlled trial including patients between February 2007 and July 2008 comparing an intensive risk factor intervention vs usual care the first year poststroke to prevent cognitive impairment. From February 2014 to July 2016, all patients were invited to a follow-up. For patients dying throughout the follow-up period, date of death was obtained from the medical record. Examination at baseline and 1-year follow-up included extensive assessment of vascular risk factors and cognitive assessments. Results A total of 195 patients were randomized. Mean (SD) age was 71.6 (12.5) years, 53.3% were male, mean (SD) body mass index (BMI) was 25.6 (4.1) kg/m2. During follow-up, 35 patients in the intervention group and 41 in the control group died. Kaplan–Meier survival estimates show no significant difference in intention-to-treat (ITT) population or complete case (CC) population (log-rank P=0.29 vs log-rank P=0.07). In multivariable Cox proportional hazards regression analyses, lower age and higher BMI was independently associated with long-term survival, adjusted HR (95% CI) 1.08 (1.05–1.11) per year and 0.91 (0.85–0.97) per kg/m2. Conclusion In this post hoc analysis, we found no significant effect on survival after 7 years of a multifactorial risk factor program given during the first year after first-ever stroke or TIA. Higher BMI was an independent predictor for long-term survival in this cohort.
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Affiliation(s)
- Guri Hagberg
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway, .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
| | - Brynjar Fure
- Department of Internal Medicine, Karlstad Central Hospital and Institute of Public Health, University of Tromsoe, Tromsoe, Norway
| | | | - Bente Thommessen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway, .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
| | - Anne Rita Øksengård
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway,
| | - Ståle Nygård
- Department of Informatics, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Torgeir B Wyller
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway, .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Hege Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Drammen, Norway, .,Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
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Abstract
AbstractBackgroundIn 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.MethodsAll new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.ResultsThree hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.ConclusionsOur study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.
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Remote Monitoring of Implantable Cardioverter-Defibrillators, Cardiac Resynchronization Therapy and Permanent Pacemakers: A Health Technology Assessment. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2018; 18:1-199. [PMID: 30443279 PMCID: PMC6235077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Under usual care, people with an implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy with or without a defibrillator (CRT-D and CRT-P, respectively), or a permanent pacemaker have follow-up in-person clinic visits. Remote monitoring of these devices allows the transfer of the information stored in the device so that it can be accessed by the clinic personnel via a secured website. METHODS We completed a health technology assessment, which included an evaluation of clinical benefits and harms, value for money, and patient preferences for remote monitoring of ICDs, CRTs, and permanent pacemakers plus clinic visits compared with clinic visits alone. This is an update of a 2012 health technology assessment. In addition to the eligible randomized controlled trials (RCTs) from the 2012 publication, we included RCTs identified through a systematic literature search on June 1, 2017. We assessed the risk of bias of each study using the Cochrane risk of bias tool and the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We conducted an economic evaluation to determine the cost-effectiveness of remote monitoring blended with in-clinic follow-up compared to in-clinic follow-up alone in patients with an ICD, a CRT-D, or a pacemaker. We determined the budget impact of blended remote monitoring in patients implanted with ICD, CRT-D, CRT-P, or pacemaker devices from the perspective of the Ontario Ministry of Health and Long-Term Care. To understand patient experiences with remote monitoring, we interviewed 16 patients and family members. RESULTS Based on 15 RCTs in patients with implanted ICDs or CRT-Ds, remote monitoring plus clinic visits resulted in fewer patients with inappropriate ICD shocks within 12 to 37 months of follow-up (moderate quality evidence; absolute risk difference -0.04 [95% confidence interval -0.07 to -0.01]), fewer total clinic visits (moderate quality evidence), and a shorter time to detection and treatment of events (moderate quality evidence) compared with clinic visits alone. There was a similar risk of major adverse events (moderate quality evidence).Based on 6 RCTs in patients with pacemakers, remote monitoring plus clinic visits reduced the arrhythmia burden (high quality evidence), the time to detection and treatment of arrhythmias (high quality evidence), and the number of clinic visits (moderate quality evidence]) compared with clinic visits alone. Here again, there was a similar risk of major adverse events (high quality evidence).Results from the economic evaluation showed that among ICD and CRT-D recipients, blended remote monitoring (remote monitoring plus in-clinic follow ups) was more costly (incremental value of $4,354 per person) and more effective, providing higher quality-adjusted life years (incremental value of 0.19), compared to in-clinic follow-up alone. Among pacemaker recipients, blended remote monitoring was less costly (with an incremental saving of $2,370 per person) and more effective (with an incremental value of 0.12 quality-adjusted life years) than with in-clinic follow-up alone. We estimated that publicly funding remote monitoring could result in cost savings of $14 million over the first five years.Participants using remote monitoring reported that these devices provide important medical and safety benefits in managing their heart condition. Remote cardiac monitoring provides patients and their family members with an increased freedom. Their belief that the device will help with earlier detection of technical or clinical problems reduces the amount of stress and distraction their condition causes in their lives. CONCLUSIONS Remote monitoring of ICDs, CRT-Ds, and pacemakers plus clinic visits resulted in improved outcomes without increasing the risk of major adverse events compared with clinic visits alone. Remote monitoring is a cost-effective option for patients implanted with cardiac electronic devices. Patients reported positive experiences using remote monitoring, and perceived that the device provided important medical and safety benefits.
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Chang TH, Chiu PF, Tsai CC, Chang CH, Wu CL, Kor CT, Li JR, Kuo CL, Huang CS, Chu CC, Lin CM, Chang CC. Favourable renal outcomes after intravenous thrombolytic therapy for acute ischemic stroke: Clinical implication of kidney-brain axis. Nephrology (Carlton) 2018; 24:896-903. [PMID: 30334303 DOI: 10.1111/nep.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 11/28/2022]
Abstract
AIM Recombinant tissue plasminogen activator (rt-PA) administration is the most prevalent treatment for acute ischemic within golden time. However, the effects of rt-PA on the kidney function in such patients remain unknown. This study determined long-term renal outcomes in patients with acute ischemic stroke receiving systemic rt-PA. METHODS We enroled patients who were hospitalized for acute ischemic stroke from January 2001 to January 2017. We applied 1:2 propensity score matching to eliminate various confounding variables. We defined surrogate renal outcomes as declining of estimated glomerular filtration rate (eGFR) greater than 30% and 50%, and chronic kidney disease (CKD) with eGFR less than 60 mL/min. We then compared the 1-year eGFR with paired t-test in patients treated with or without rt-PA. RESULTS Overall, 343 of 1739 patients received rt-PA within golden time. After 1:2 propensity score matching, their baseline characteristics were grouped as treated with rt-PA (n = 235) or not (n = 394). rt-PA-treated patients exhibited slower renal progression, including the risk of eGFR declining greater than 30% (hazard ratio (HR), 0.72; P = 0.03), risk of declining eGFR greater than 50% (HR, 0.63; P = 0.046) and risk of CKD (HR, 0.61; P = 0.005). After 1-year cohort, the rt-PA group exhibited an improved renal outcome by the paired t-test (propensity match: ΔGFR = 9.1 (95% confidence interval: 6.3, 11.8), P < 0.001 in rt-PA group; ΔGFR = -1.1 (95% confidence interval: -2.9, 0.7), P = 0.23 in non-rt-PA group). In patients with eGFR less than 45 mL/min (n = 34), intracerebral haemorrhage was not reported. CONCLUSION Patients receiving rt-PA for acute ischemic stroke exhibit favourable renal outcomes, and no increased incidence of intracerebral haemorrhage occurs in rt-PA patients with advanced CKD.
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Affiliation(s)
- Teng-Hsiang Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Ping-Fang Chiu
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Center of General Education, Tunghai University, Taichung, Taiwan.,Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Chun-Chieh Tsai
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chin-Hua Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chia-Lin Wu
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chew-Teng Kor
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Jhao-Rong Li
- Internal Medicine Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Ling Kuo
- Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Ching-Shan Huang
- Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Chung Chu
- Department of computer science, Tunghai University, Taichung, Taiwan
| | - Chih-Ming Lin
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.,Department of Social Work and Child Welfare, Providence University, Taichung, Taiwan.,Department of Medicinal Botanicals and Health Applications, Da-Yeh University, Changhua, Taiwan
| | - Chia-Chu Chang
- Nephrology Division, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Vascular & Genomic Research Center, Changhua Christian Hospital, Changhua, Taiwan.,Nephrology Division, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan.,Department of Nutrition, Hungkuang University, Taichung, Taiwan
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Carrasquillo O, Young B, Dang S, Fontan O, Ferras N, Romano JG, Dong C, Kenya S. Hispanic Secondary Stroke Prevention Initiative Design: Study Protocol and Rationale for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e11083. [PMID: 30341050 PMCID: PMC6231896 DOI: 10.2196/11083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 11/30/2022] Open
Abstract
Background Hispanic-Latino populations face a disproportionate stroke burden and are less likely to have sufficient control over stroke risk factors in comparison with other ethnic populations. A promising approach to improving chronic health outcomes has been the use of community health workers (CHWs). Objective The objective of this randomized controlled trial is to evaluate the effectiveness of a CHW intervention among Latino patients at risk of recurrent stroke. Methods The Hispanic Secondary Stroke Prevention Initiative (HiSSPI) is a randomized clinical trial of 300 Latino participants from South Florida who have experienced a stroke within the last 5 years. Participants randomized into the CHW intervention arm receive health education and assistance with health care navigation and social services through home visits and phone calls. The intervention also includes a mHealth component in which participants also receive daily text messages (short message service). The primary outcome is change in systolic blood pressure at 12 months. Other secondary outcomes include changes in low-density lipoprotein, glycated hemoglobin, and medication adherence. Results Study enrollment began in 2015 and will be completed by the end of 2018. The first results are expected to be submitted for publication in 2020. Conclusions HiSSPI is one of the first randomized controlled trials to examine CHW-facilitated stroke prevention and will provide rigorous evidence on the impact of CHWs on secondary stroke risk factors among Latino individuals who have had a stroke. Trial Registration ClinicalTrials.gov NCT02251834; https://clinicaltrials.gov/ct2/show/NCT02251834 (Archived by WebCite at http://www.webcitation.org/72DgMqftq) International Registered Report Identifier (IRRID) RR1-10.2196/11083
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Affiliation(s)
- Olveen Carrasquillo
- Division of General Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - BreAnne Young
- Division of General Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Stuti Dang
- Division of Geriatrics, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Orieta Fontan
- Division of General Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Natalie Ferras
- Division of General Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Jose G Romano
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Chuanhui Dong
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Sonjia Kenya
- Division of General Medicine, Miller School of Medicine, University of Miami, Miami, FL, United States
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Singh RJ, Chen S, Ganesh A, Hill MD. Long-term neurological, vascular, and mortality outcomes after stroke. Int J Stroke 2018; 13:787-796. [DOI: 10.1177/1747493018798526] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Despite improved survival and short-term (90-day) outcomes of ischemic stroke patients, only sparse data exist describing the sustained benefits of acute stroke care interventions and long-term prognosis of stroke survivors. Aim We review the contemporary literature assessing long-term (5 years or more) outcomes after stroke and acute stroke treatment. Summary of review Acute stroke unit care and intravenous thrombolysis have sustained benefits over longer follow-up, but few data exist on the long-term outcome after endovascular thrombectomy (EVT). A large proportion of stroke survivors face challenges of residual disability and neuropsychiatric sequelae (especially affective disorders and epilepsy) which affects their quality of life and is associated with poorer prognosis due to increase in stroke recurrences/mortality. Nearly, a quarter of stroke survivors have a recurrent stroke at 5 years, and nearly double that at 10 years. Mortality after recurrent stroke is high, and half of the stroke survivors are deceased at 5 years after stroke and three fourth at 10 years. Long-term all-cause mortality is largely due to conditions other than stroke. Both stroke recurrence and long-term mortality are affected by several modifiable risk factors, and thus amenable to secondary prevention strategies. Conclusions There is a need for studies reporting longer term effects of acute interventions, especially EVT. Better preventive strategies are warranted to reduce the vascular and non-vascular mortality long after stroke.
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Affiliation(s)
- Ravinder-Jeet Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Shuo Chen
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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Yu A, Coutts S. Role of Brain and Vessel Imaging for the Evaluation of Transient Ischemic Attack and Minor Stroke. Stroke 2018; 49:1791-1795. [DOI: 10.1161/strokeaha.118.016618] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/03/2018] [Accepted: 05/17/2018] [Indexed: 11/16/2022]
Affiliation(s)
- A.Y.X. Yu
- From the Division of Neurology, Department of Medicine, Sunnybrook Research Institute, University of Toronto, Ontario, Canada (A.Y.X.Y.)
| | - S.B. Coutts
- Department of Clinical Neurosciences (S.B.C.) and Department of Radiology (S.B.C.), Community Health Sciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
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Raluy-Callado M, Cox A, MacLachlan S, Bakheit AM, Moore AP, Dinet J, Gabriel S. A retrospective study to assess resource utilization and costs in patients with post-stroke spasticity in the United Kingdom. Curr Med Res Opin 2018; 34:1317-1324. [PMID: 29490512 DOI: 10.1080/03007995.2018.1447449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Post-stroke spasticity (PSS) is a common complication following stroke. This study describes the differences in healthcare resource utilization between patients who do and do not develop PSS in the UK. METHODS Adults registered in The Health Improvement Network database with a recorded stroke between 2007 and 2011 were included. PSS was identified through Read codes; machine learning was used to retrospectively identify unrecorded PSS events. Patients with diagnosed or predicted PSS in the 12 months after stroke were matched to those with no PSS on age, sex, number of strokes, socioeconomic status, and comorbidities using the nearest neighbor algorithm. Utilization and costs associated with general practitioner visits, nurse visits, hospitalizations, referrals to specialists, laboratory tests, and medications in the 12 months after stroke were compared. RESULTS Overall, 2,951 PSS cases were matched to 37,753 controls. During the first year, more PSS cases visited a physiotherapist (19% vs 7%) and occupational therapist (12% vs 5%) compared to controls. A greater proportion of cases were also referred to specialists (76% vs 64%) and hospitalized (33% vs 9%) compared to controls. Medication for spasticity was, on average, 14.68 prescriptions for cases and 5.64 for controls. Total mean costs per patient were £1,270 (standard deviation [SD] = 772) and £635 (SD = 273) for cases and controls, respectively. CONCLUSION Costs after stroke for patients developing PSS are twice as high compared to patients who do not develop it, with the major driver being the number of hospital admissions. This highlights the need for better recording and closer management of PSS.
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Affiliation(s)
| | | | | | | | - A Peter Moore
- c The Walton Centre NHS Foundation Trust , Liverpool , UK
| | - Jerome Dinet
- d Ipsen Pharma SAS , Boulogne-Billancourt , France
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Wein T, Lindsay MP, Côté R, Foley N, Berlingieri J, Bhogal S, Bourgoin A, Buck BH, Cox J, Davidson D, Dowlatshahi D, Douketis J, Falconer J, Field T, Gioia L, Gubitz G, Habert J, Jaspers S, Lum C, McNamara Morse D, Pageau P, Rafay M, Rodgerson A, Semchuk B, Sharma M, Shoamanesh A, Tamayo A, Smitko E, Gladstone DJ. Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke 2017; 13:420-443. [DOI: 10.1177/1747493017743062] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.
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Affiliation(s)
- Theodore Wein
- McGill University, Canada
- Montreal General Hospital, Canada
| | | | - Robert Côté
- McGill University, Canada
- Montreal General Hospital, Canada
| | - Norine Foley
- Western University, Canada
- workHORSE Consulting, London
| | | | | | | | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Canada
| | - Jafna Cox
- Department of Medicine, Dalhousie University, Canada
| | | | | | - Jim Douketis
- Divisions of General Internal Medicine, Hematology and Thromboembolism, McMaster University Department of Medicine, Canada
- Thrombosis Canada, Canada
| | | | - Thalia Field
- Faculty of Medicine, University of British Columbia, Canada
| | - Laura Gioia
- Department of Neurosciences, CHUM-Centre Hospitalier de l’Université de Montréal, Hôpital Notre Dame, Canada
| | - Gord Gubitz
- Department of Medicine, Dalhousie University, Canada
- Queen Elizabeth II Stroke Program, Nova Scotia, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Canada
| | | | - Cheemun Lum
- Stroke Program, Ottawa Civic Hospital, Canada
| | | | - Paul Pageau
- Department of Emergency Medicine, The University of Ottawa, Canada
| | - Mubeen Rafay
- Winnipeg Children’s Hospital, Canada
- University of Manitoba, Canada
| | | | | | - Mukul Sharma
- Population Health Research Institute, McMaster University, Canada
| | | | | | | | - David J Gladstone
- Sunnybrook Health Sciences Centre, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Canada
- University of Toronto Department of Medicine, Toronto, Canada
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Affiliation(s)
- Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, and Hotchkiss Brain Institute, Calgary, Alta.
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