Heart failure in acute ischemic stroke

Stroke outcomes following cardiac and aortic surgery are improved by the involvement of a stroke team

OBJECTIVES

Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries.

METHODS

This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up.

RESULTS

A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001).

CONCLUSIONS

Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.

Beyond the silence: A comprehensive exploration of long non-coding RNAs as genetic whispers and their essential regulatory functions in cardiovascular disorders

Long non-coding RNAs (lncRNAs) are RNA molecules that regulate gene expression at several levels, including transcriptional, post-transcriptional, and translational. They have a length of more than 200 nucleotides and cannot code. Many human diseases have been linked to aberrant lncRNA expression, highlighting the need for a better knowledge of disease etiology to drive improvements in diagnostic, prognostic, and therapeutic methods. Cardiovascular diseases (CVDs) are one of the leading causes of death worldwide. LncRNAs play an essential role in the complex process of heart formation, and their abnormalities have been associated with several CVDs. This Review article looks at the roles and relationships of long non-coding RNAs (lncRNAs) in a wide range of CVDs, such as heart failure, myocardial infarction, atherosclerosis, and cardiac hypertrophy. In addition, the review delves into the possible uses of lncRNAs in diagnostics, prognosis, and clinical treatments of cardiovascular diseases. Additionally, it considers the field's future prospects while examining how lncRNAs might be altered and its clinical applications.

Clinical Significance of MicroRNAs, Long Non-Coding RNAs, and CircRNAs in Cardiovascular Diseases

Based on recent research, the non-coding genome is essential for controlling genes and genetic programming during development, as well as for health and cardiovascular diseases (CVDs). The microRNAs (miRNAs), lncRNAs (long ncRNAs), and circRNAs (circular RNAs) with significant regulatory and structural roles make up approximately 99% of the human genome, which does not contain proteins. Non-coding RNAs (ncRNA) have been discovered to be essential novel regulators of cardiovascular risk factors and cellular processes, making them significant prospects for advanced diagnostics and prognosis evaluation. Cases of CVDs are rising due to limitations in the current therapeutic approach; most of the treatment options are based on the coding transcripts that encode proteins. Recently, various investigations have shown the role of nc-RNA in the early diagnosis and treatment of CVDs. Furthermore, the development of novel diagnoses and treatments based on miRNAs, lncRNAs, and circRNAs could be more helpful in the clinical management of patients with CVDs. CVDs are classified into various types of heart diseases, including cardiac hypertrophy (CH), heart failure (HF), rheumatic heart disease (RHD), acute coronary syndrome (ACS), myocardial infarction (MI), atherosclerosis (AS), myocardial fibrosis (MF), arrhythmia (ARR), and pulmonary arterial hypertension (PAH). Here, we discuss the biological and clinical importance of miRNAs, lncRNAs, and circRNAs and their expression profiles and manipulation of non-coding transcripts in CVDs, which will deliver an in-depth knowledge of the role of ncRNAs in CVDs for progressing new clinical diagnosis and treatment.

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

(1) Background: Little is known about how left ventricular systolic dysfunction (LVSD) affects functional and clinical outcomes in acute ischemic stroke (AIS) patients undergoing thrombolysis; (2) Methods: A retrospective observational study conducted between 2006 and 2018 included 937 consecutive AIS patients undergoing thrombolysis. LVSD was defined as left ventricular ejection fraction (LVEF) < 50%. Univariate and multivariate binary logistic regression analysis was performed for demographic characteristics. Ordinal shift regression was used for functional modified Rankin Scale (mRS) outcome at 3 months. Survival analysis of mortality, heart failure (HF) admission, myocardial infarction (MI) and stroke/transient ischemic attack (TIA) was evaluated with a Cox-proportional hazards model; (3) Results: LVSD patients in comparison with LVEF ≥ 50% patients accounted for 190 and 747 patients, respectively. LVSD patients had more comorbidities including diabetes mellitus (100 (52.6%) vs. 280 (37.5%), p < 0.001), atrial fibrillation (69 (36.3%) vs. 212 (28.4%), p = 0.033), ischemic heart disease (130 (68.4%) vs. 145 (19.4%), p < 0.001) and HF (150 (78.9%) vs. 46 (6.2%), p < 0.001). LVSD was associated with worse functional mRS outcomes at 3 months (adjusted OR 1.41, 95% CI 1.03-1.92, p = 0.030). Survival analysis identified LVSD to significantly predict all-cause mortality (adjusted HR [aHR] 3.38, 95% CI 1.74-6.54, p < 0.001), subsequent HF admission (aHR 4.23, 95% CI 2.17-8.26, p < 0.001) and MI (aHR 2.49, 95% CI 1.44-4.32, p = 0.001). LVSD did not predict recurrent stroke/TIA (aHR 1.15, 95% CI 0.77-1.72, p = 0.496); (4) Conclusions: LVSD in AIS patients undergoing thrombolysis was associated with increased all-cause mortality, subsequent HF admission, subsequent MI and poorer functional outcomes, highlighting a need to optimize LVEF.

The Relationship between Diastolic Blood Pressure and the Event of the First Ischemic Stroke in Hypertension Patients

BACKGROUND: Stroke has been the second leading cause of death and the third cause of disability worldwide. A record of hypertension and an increase in diastolic blood pressure (DBP) after the first stroke were associated with an increased risk of a second stroke. DBP has historically been considered as the leading cause of cardiac arrest in adults with hypertension. In the previous studies, it was found a relationship between DBP with stroke and functional outcomes. AIM: This research was carried out to determine the relationship between DBP and the event of ischemic stroke for the 1st time in hypertension patients. METHODS: This research is a case–control that was selected using a consecutive sampling technique, where 47 hypertensive patients with ischemic stroke as the case group were matched with 47 hypertensive patients without stroke as the control group. The research was conducted at H. Adam Malik Hospital, Medan and a network hospital. RESULTS: In this research, most samples in the case and control groups were men with 30 subjects (63.8%) with a mean age value of 58.11 ± 10.85 years. At TDD ≥90 mmHg, 34 subjects (72.3%) had ischemic stroke and 21 subjects (44.7%) did not. At TDD <90 mmHg, the percentage of ischemic stroke was 13 subjects (27.7%) and 26 subjects (55.3%) were non-ischemic stroke with p = 0.006, OR = 3.02. CONCLUSION: There is a significantly close relationship between diastolic blood pressure and the event of ischemic stroke.

Simultaneous cardio-cerebral infarction: a meta-analysis

BACKGROUND/INTRODUCTION

Cardio-cerebral infarction (CCI), which involves the simultaneous occurrence of acute ischaemic stroke and acute myocardial infarction, has a reported incidence of 0.0009%. Treatment of CCI presents a dilemma to physicians as both conditions are time critical. Despite the need for standardized treatment protocols, published data are sparse.

AIM

We aimed to summarize the reported cardio-cerebral infarction cases in the literature.

DESIGN

Meta-analysis.

METHODS

Four databases, Pubmed, Embase, Scopus and Google Scholar were searched until 25 August 2020. A title and abstract sieve, full-text review and extraction of data were conducted independently by three authors.

RESULTS

A total of 44 cases of CCI were identified from 37 case reports and series; 15 patients (34.1%) were treated using percutaneous coronary intervention (PCI) with stent, 8 patients (18.2%) were treated with a PCI without stent, 10 patients (22.7%) were treated via a cerebral vessel thrombectomy and 8 patients (18.2%) were treated via a thrombectomy of a coronary vessel. For medications, 20 patients (45.5%) were treated with thrombolytics, 10 patients (22.7%) were treated with anticoagulants, 8 patients (18.2%) were treated with antiplatelets and 11 patients (25.0%) were treated with anticoagulants and antiplatelets. Of 44 patients, 10 patients died, and 9 of those were due to cardiac causes. Among the 44 patients, days to death was observed to be a median of 2.0 days (interquartile range (IQR): 1.5, 4.0). The modified Rankin Score was measured in nine patients, with a median score of 2.0 (IQR: 1.0, 2.5) being reported.

DISCUSSION/CONCLUSION

The condition of CCI has substantial morbidity and mortality, and further studies are needed to examine the optimal diagnostic and treatment strategies of these patients.

End-to-end sensor fusion and classification of atrial fibrillation using deep neural networks and smartphone mechanocardiography

OBJECTIVE

The purpose of this research is to develop a new deep learning framework for detecting atrial fibrillation (AFib), one of the most common heart arrhythmias, by analyzing the heart's mechanical functioning as reflected in seismocardiography (SCG) and gyrocardiography (GCG) signals. Jointly, SCG and GCG constitute the concept of mechanocardiography (MCG), a method used to measure precordial vibrations with the built-in inertial sensors of smartphones.

APPROACH

We present a modified deep residual neural network model for the classification of sinus rhythm (SR), AFib, and Noise categories from tri-axial SCG and GCG data derived from smartphones. In the model presented, pre-processing including automated early sensor fusion and spatial feature extraction are carried out using attention-based convolutional and residual blocks. Additionally, we use bidirectional long short-term memory layers on top of fully-connected layers to extract both spatial and spatiotemporal features of the multidimensional SCG and GCG signals. The dataset consisted of 728 short measurements recorded from 300 patients. Further, the measurements were divided into disjoint training, validation, and test sets, respectively, of 481 measurements, 140 measurements, and 107 measurements. Prior to ingestion by the model, measurements were split into 10-second segments with 75 percent overlap, pre-processed, and augmented.

MAIN RESULTS

On the unseen test set, the model delivered average micro- and macro-F1-score of 0.88 (0.87-0.89; 95% CI) and 0.83 (0.83-0.84; 95% CI) for the segment-wise classification as well as 0.95 (0.94-0.96; 95% CI) and 0.95 (0.94-0.96; 95% CI) for the measurement-wise classification, respectively.

SIGNIFICANCE

Our method not only can effectively fuse SCG and GCG signals but also can identify heart rhythms and abnormalities in the MCG signals with remarkable accuracy.

Acute Ischemic Stroke and Heart Failure: Stroke Risk Factors Associated with Exclusion from Thrombolytic Therapy

Objective: Acute ischemic stroke (AIS) patients with congestive heart failure (HF) that present with various risk factors are less likely to receive recombinant tissue plasminogen activator (rtPA). The risk factors associated with excluding AIS patients with congestive heart failure (AIS-HF) from rtPA therapy have not been fully established. Methods: Retrospective data for 5469 AIS patients comprised of 590 AIS patients with HF and 4879 AIS patients without HF were collected from a regional stroke registry between January 2010 and June 2016. Baseline risk factors were analyzed using logistic regression analysis to determine the risk factors associated with rtPA exclusion in AIS-HF patients. Results: In the adjusted analysis, AIS-HF patients that that did not receive rtPA were more likely to be older (OR = 0.982, 95% CI, 0.966-1, P = .020), presented with coronary artery disease (OR = 0.618, 95% CI, 0.391-0.98, P = .040), and with an elevated INR (OR = 0.326, 95% CI, 0.129-0.82, P = .018). AIS-HF patients that were included for rtPA therapy were more likely to show improvement in ambulatory status (OR = 1.69, 95% CI, 1.058-2.7, P = .028). The discriminating power of the model was strong with an area under the curve (AUROC) = 0.668 (95% CI, 0.611-0.724, P < .001). Conclusion: Our study establishes the associations between stroke risk factors and exclusion from rtPA therapy. This finding suggests the need to develop management strategies for older HF patients with carotid artery disease and an elevated INR to improve their eligibility for rtPA treatment following an acute ischemic stroke.

Ischemic and Non-ischemic Stroke in Young Adults - A Look at Risk Factors and Outcome in a Developing Country

Objective Stroke among young adults is the leading cause of disability worldwide. Efforts are being taken to control stroke in the general population, but in parallel, there is an increasing trend of stroke among the young population. These patients are often affected by physical disability, cognitive impairment, and loss of productivity, all of which have personal, social, and economic implications. The main aim of this study was to determine the risk factors associated with stroke among young patients admitted to a tertiary care rehabilitation center and determine the effect of rehabilitation on the outcome of their daily life activities. Materials and Methods A retrospective hospital-based cohort study was conducted between January 2015 to December 2019. Prevalence of stroke-related risk factors like hypertension, hyperlipidemia, diabetes, and cardiac disease was assessed. Results Out of 710 young stroke adults, 71.97% were described as ischemic, and 28.03% reported as non-ischemic. Mean age (SD) was found to be 44.54 ± 9.3. Univariate analysis demonstrated that hyperlipidemia, cardiac disease, and diabetes indicated a significantly higher risk for ischemic stroke with an OR (95% CI) at 2.5 (1.7-3.7), 2.11 (1.2-3.6), and 1.66 (1.2-2.3) respectively. A significant improvement was observed in their Functional Independence Measure (FIM0 score after their rehabilitation irrespective of age and gender. Conclusion Association of risk factors associated with stroke should be subjected to close follow-up and management, thus reducing the risk of developing long-lasting disabilities at a young age. The identification of risk factors for young stroke incidence is a step towards improving health in the young adult population.

Carotid artery structure and hemodynamics and their association with adverse vascular events in left ventricular assist device patients

Left ventricular assist devices (LVADs) are associated with major vascular complications including stroke and gastrointestinal bleeding (GIB). These adverse vascular events may be the result of widespread vascular dysfunction resulting from pre-LVAD abnormalities or continuous flow during LVAD therapy. We hypothesized that pre-existing large artery atherosclerosis and/or abnormal blood flow as measured in carotid arteries using ultrasonography are associated with a post-implantation composite adverse outcome including stroke, GIB, or death. We retrospectively studied 141 adult HeartMate II patients who had carotid ultrasound duplex exams performed before and/or after LVAD surgery. Structural parameters examined included plaque burden and stenosis. Hemodynamic parameters included peak-systolic, end-diastolic, and mean velocity as well as pulsatility index. We examined the association of these measures with the composite outcome as well as individual subcomponents such as stroke. After adjusting for established risk factors, the composite adverse outcome was associated with pre-operative moderate-to-severe carotid plaque (OR 5.08, 95% CI 1.67-15.52) as well as pre-operative internal carotid artery stenosis (OR 9.02, 95% CI 1.06-76.56). In contrast, altered hemodynamics during LVAD support were not associated with the composite outcome. Our findings suggest that pre-existing atherosclerosis possibly in combination with LVAD hemodynamics may be an important contributor to adverse vascular events during mechanical support. This encourages greater awareness of carotid morphology pre-operatively and further study of the interaction between hemodynamics, pulsatility, and structural arterial disease during LVAD support.

Echocardiographic parameters determining cardiovascular outcomes in patients after acute ischemic stroke

Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic markers in patients with acute ischemic stroke (AIS). A total of 900 patients with AIS who underwent transthoracic echocardiography (72.6 ± 12.0 years and 60% males) were retrospectively reviewed. Composite clinical events, including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization, were assessed during clinical follow-ups. During a median follow-up of 3.3 years (interquartile range 0.6-5.1 years), there were 151 (16.8%) composite events. In the multivariable analyses after controlling for potential confounders, left ventricular ejection fraction (LVEF) < 62% (hazard ratio [HR] 1.62; 95% confidence interval [CI] 1.14-2.30; p = 0.007) and AV sclerosis (AVs) (HR 1.56; 95% CI 1.10-2.21; p = 0.013) were independent prognostic factors associated with composite events. Multivariable analyses showed that HR for composite events gradually increased according to LVEF and AVs: HR was 2.6-fold higher in the highest-risk group than in the lowest group (p < 0.001). Compared with a clinical model (global chi-square = 69.6), LVEF, AVs, and both of them were significantly improved outcome prediction in sequential Cox model analysis (global chi-square = 75.6, 75.7, and 78.8, respectively; p < 0.05 for each) for each. In patients with AIS, LVEF < 62%, and the presence of AV sclerosis can predict future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention.

Incident Hospitalization with Major Cardiovascular Diseases and Subsequent Risk of ESKD: Implications for Cardiorenal Syndrome

BACKGROUND

Cardiorenal syndrome is a well known concept, bolstered by extensive investigations of CKD as a risk factor of cardiovascular disease. However, data on whether cardiovascular disease increases long-term risk of ESKD are sparse.

METHODS

We assessed the association of incident hospitalization with major cardiovascular diseases (heart failure, atrial fibrillation, coronary heart disease, and stroke) with subsequent risk of ESKD among individuals enrolled in the Atherosclerosis Risk in Communities study; the analysis included 9047 individuals without prevalent cardiovascular disease at their fourth study visit. Each relevant incident cardiovascular disease event was entered into multivariable Cox proportional hazard models as a time-varying exposure to estimate hazard ratios.

RESULTS

During a median follow-up of 17.5 years, there were 2598 cases of hospitalization with cardiovascular disease (heart failure, n=1269; atrial fibrillation, n=1337; coronary heart disease, n=696; and stroke, n=559) and 210 cases of incident ESKD. The incidence of major cardiovascular disease was associated with increased risk of ESKD, with the highest risk for heart failure (hazard ratio, 11.40; 95% confidence interval, 8.38 to 15.50), followed by coronary heart disease, atrial fibrillation, and stroke. When we analyzed heart failure with preserved ejection fraction and heart failure with reduced ejection fraction separately, the risk was nominally higher for heart failure with preserved ejection fraction.

CONCLUSIONS

Major incident cardiovascular disease events were associated with ESKD, independent of kidney risk factors. In particular, heart failure showed a very strong association with ESKD. Our findings highlight the importance of monitoring and managing kidney disease in patients with cardiovascular disease. The potentially distinct contribution to ESKD of heart failure with preserved versus reduced ejection fraction deserves future investigation.

Transcatheter versus surgical aortic valve replacement in low-risk patients: a meta-analysis of randomized trials

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has emerged as a treatment option for severe aortic stenosis in patients at intermediate or high surgical risk. However, until recently there was insufficient evidence regarding the outcomes of TAVR compared to surgical aortic valve replacement (SAVR) for patients at low risk.

METHODS

We conducted a meta-analysis and systematic review of all randomized trials comparing the efficacy and safety of TAVR versus SAVR in patients at low surgical risk. Risk ratios (RR) and 95% confidence intervals (CIs) were calculated, using fixed- or random-effects model.

RESULTS

Four trials were eligible for analysis and comprised a total of 2887 patients (1497 allocated to TAVR and 1390 allocated to SAVR group). TAVR was associated with a 39% relative risk reduction (RRR) of major adverse cardiac events (MACE) (absolute risk reduction ARR of 3.7%; RR 0.61; 95% CI 0.47-0.79); 39% RRR of overall mortality (ARR of 1.4%; RR 0.61; 95% CI 0.39-0.96) and 45% RRR of cardiovascular mortality (ARR of 1.3%; RR 0.55; 95% CI 0.33-0.90), 69% RRR of life threatening or disabling bleeding (ARR of 7.0%; RR 0.31; 95% CI 0.22-0.44), 73% RRR of new-onset atrial fibrillation (ARR of 29%; RR 0.27; 95% CI 0.20-0.35) and 73% RRR of acute kidney injury (ARR of 2.1%; RR 0.27; 95% CI 0.14-0.56) as compared with SAVR. In contrast, TAVR was associated with a 4.7-fold increased risk of new pacemaker (PM) implantation (RR 4.72; 95% CI 1.83-12.15), which was driven by use of self-expanding valves.

CONCLUSION

TAVR in low-risk patients is superior to SAVR for the majority of outcomes.

Patients with heart failure with and without a history of stroke in the Netherlands: a secondary analysis of psychosocial, behavioural and clinical outcomes up to three years from the COACH trial

OBJECTIVE

To identify differences in psychosocial, behavioural and clinical outcomes between patients with heart failure (HF) with and without stroke.

DESIGN AND PARTICIPANTS

A secondary analysis of 1023 patients with heart failure enrolled in the Coordinating study evaluating Outcomes of Advising and Counselling in Heart failure.

SETTING

Seventeen hospitals located across the Netherlands.

OUTCOMES MEASURES

Depressive symptoms (Centre for Epidemiological Studies Depression Scale), quality of life (Minnesota Living with Heart Failure Questionnaire, Ladder of Life Scale), self-care (European Heart Failure Self-Care Behaviour Scale), adherence to HF management (modified version of the Heart Failure Compliance Questionnaire) and readmission for HF, cardiovascular-cause and all-cause hospitalisations at 18 months, and all-cause mortality at 18 months and 3 years.

RESULTS

Compared with those without stroke, patients with HF with a stroke (10.3%; n=105) had twice the likelihood of severe depressive symptoms (OR 2.83, 95% CI 1.27 to 6.28, p=0.011; OR 2.24, 95% CI 1.03 to 4.88, p=0.043) at 12 and 18 months, poorer disease-specific and generic quality of life (OR 2.80, 95% CI 1.61 to 4.84, p<0.001; OR 2.00, 95% CI 1.09 to 3.50, p=0.019) at 12 months, poorer self-care (OR 1.80, 95% CI 1.05 to 3.11, p=0.034; OR 2.87, 95% CI 1.61 to 5.11, p<0.0011) and HF management adherence (OR 0.39, 95% CI 0.18 to 0.81, p=0.012; OR 0.35, 95% CI 0.17 to 0.72, p=0.004) at 12 and 18 months, higher rates of hospitalisations and mortality at 18 months and higher all-cause mortality (HR 1.43, 95% CI 1.07 to 1.91, p=0.016) at 3 years.

CONCLUSIONS

Patients with HF and stroke have worse psychosocial, behavioural and clinical outcomes, notably from 12 months, than those without stroke. To ameliorate these poor outcomes long-term, integrated disease management pathways are warranted.

Prediction of the Lethal Outcome of Acute Recurrent Cerebral Ischemic Hemispheric Stroke

Background and objectives. Stroke-induced mortality is the third most common cause of death in developed countries. Intense interest has focused on the recurrent ischemic stroke, which rate makes up 30% during first 5 years after first-ever stroke. This work aims to develop criteria for the prediction of acute recurrent cerebral ischemic hemispheric stroke (RCIHS) outcome on the basis of comprehensive baseline clinical, laboratory, and neuroimaging examinations. Materials and Methods. One hundred thirty-six patients (71 males and 65 females, median age 74 (65; 78)) with acute RCIHS were enrolled in the study. All patients underwent a detailed clinical and neurological examination using National Institutes of Health Stroke Scale (NIHSS), computed tomography of the brain, hematological, and biochemical investigations. In order to detect the dependent and independent risk factors of the lethal outcome of the acute period of RCIHS, univariable and multivariable regression analysis were conducted. A receiver operating characteristic (ROC) analysis with the calculation of sensitivity and specificity was performed to determine the prediction variables. Results. Twenty-five patients died. The independent predictors of the lethal outcome of acute RCIHS were: Baseline NIHSS score (OR 95% CІ 1.33 (1.08-1.64), p = 0.0003), septum pellucidum displacement (OR 95% CI 1.53 (1.17-2.00), p = 0.0021), glucose serum level (OR 95% CI 1.28 (1.09-1.50), p = 0.0022), neutrophil-to-lymphocyte ratio (OR 95% CI 1.11 (1.00-1.21), p = 0.0303). The mathematical model, which included these variables was developed and it could determine the prognosis of lethal outcome of the acute RCIHS with an accuracy of 86.8% (AUC = 0.88 ± 0.04 (0.88-0.93), p < 0.0001).

Impact of heart failure on stroke mortality and recurrence

Objective

We aimed to examine the impact of heart failure (HF) on stroke mortality (in-hospital and postdischarge) and recurrence in a national stroke cohort from Thailand.

Methods

We used a large, insurance-based database including all stroke admissions in the public health sector in Thailand between 2004 and 2015. Logistic and Royston-Parmar regressions were used to quantify the effect of HF on in-hospital and long-term outcomes, respectively. All models were adjusted for age, sex and comorbidities and stratified by stroke type: acute ischaemic stroke (AIS) or intracerebral haemorrhage (ICH). Multistate models were constructed using flexible survival techniques to predict the impact of HF on the disease course of a patient with stroke (baseline-[recurrence]-death). Only first-ever cases of AIS or ICH were included in the multistate analysis.

Results

608 890 patients (mean age 64.29±13.72 years, 55.07% men) were hospitalised (370 527 AIS, 173 236 ICH and 65 127 undetermined pathology). There were 398 663 patients with first-ever AIS and ICH. Patients were followed up for a median (95% CI) of 4.47 years (4.45 to 4.49). HF was associated with an increase in postdischarge mortality in AIS (HR [99% CI] 1.69 [1.64 to 1.74]) and ICH (2.59 [2.07 to 3.26]). HF was not associated with AIS recurrence, while ICH recurrence was only significantly increased within the first 3 years after discharge (1.79 [1.18 to 2.73]).

Conclusions

HF increases the risk of mortality in both AIS and ICH. We are the first to report on high-risk periods of stroke recurrence in patients with HF with ICH. Specific targeted risk reduction strategies may have significant clinical impact for mortality and recurrence in stroke.

The Correlation between Severity of Neurological Impairment and Left Ventricular Function in Patients after Acute Ischemic Stroke

Despite left ventricular (LV) dysfunction increases the risk of incidental acute ischemic stroke (AIS), the association between LV function and severity of neurological deficits after AIS remains unclear. Between November 2015 and October 1017, a total of 99 AIS patients were prospectively enrolled and categorized into two groups based on National Institute of Health Stroke Scale (NIHSS). The AIS patients with NIHSS <6 were allocated into Group 1 (n = 50) and those with NIHSS ≥6 were into Group 2 (n = 49). Echocardiography was performed within 5 days after AIS to assess chamber size, left ventricular ejection fraction (LVEF) and valvular regurgitation. Besides, two inflammatory biomarkers, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), were evaluated on admission. The results showed Group 2 had significantly higher value of NLR and PLR (all p-values < 0.01) but lower LVEF (p = 0.001) and frequency of mitral regurgitation (p = 0.021) than Group 1. The NIHSS and modified Rankin scale were significantly negatively correlated with LVEF, whereas both were significantly positively correlated with NLR and PLR (all p-values < 0.02). Multivariate analysis showed LVEF <65%, aging and inflammation were significantly associated with NIHSS ≥6 (all p-values < 0.01). In conclusion, the AIS patients with NIHSS ≥6 had lower LVEF but more clinically dominant mitral regurgitation and higher NLR and PLR compared to those with NIHSS <6.

Risk of thromboembolic complications in adult congenital heart disease: A literature review

Adult congenital heart disease (ACHD) is a constantly expanding population with challenging issues. Initial medical and surgical treatments are seldom curative, and the majority of patients still experience late sequelae and complications, especially thromboembolic events. These common and potentially life-threating adverse events are probably dramatically underdiagnosed. Better identification and understanding of thromboembolic risk factors are essential to prevent long-term related morbidities. In addition to specific situations associated with a high risk of thromboembolic events (Fontan circulation, cyanotic congenital heart disease), atrial arrhythmia has been recognized as an important risk factor for thromboembolic events in ACHD. Unlike in patients without ACHD, thromboembolic risk stratification scores, such as the CHA₂DS₂-VASc score, may not be applicable in ACHD. Overall, after a review of the scientific data published so far, it is clear that the complexity of the underlying congenital heart disease represents a major risk factor for thromboembolic events. As a consequence, prophylactic anticoagulation is indicated in patients with complex congenital heart disease and atrial arrhythmia, regardless of the other risk factors, as opposed to simple heart defects. The landscape of ACHD is an ongoing evolving process, and specific thromboembolic risk scores are needed, especially in the setting of simple heart defects; these should be coupled with specific trials or long-term follow-up of multicentre cohorts.

The Role of Ejection Fraction to Clinical Outcome of Acute Ischemic Stroke Patients

AIMS

The aim of the study was to determine the effect of left ventricular ejection fraction on clinical outcomes of acute ischemic stroke patients.

STUDY DESIGN

This study design was a prospective cohort observational study.

PLACE AND DURATION OF STUDY

This study was conducted at Stroke Unit, Neurology Ward, and Cardiology Ward at the Dr. Sardjito Hospital, Yogyakarta, Indonesia, between July and December 2016.

MATERIALS AND METHODS

Hospitalized acute ischemic stroke patients were recruited, with sample was taken by consecutive sampling until reaching amount fulfilling inclusion criterion was 62 persons. In this study, clinical outcomes were measured by National Institutes of Health Stroke Scale (NIHSS) scores as well as dependent variables and left ventricular ejection fraction as independent variables. Logistic regression analyses were performed to discover any potential independent variable that can influence the left ventricular ejection fraction role at the clinical outcomes with NIHSS scores.

RESULTS

Multivariate analyses revealed that several variables were significantly interacted with the influence of left ventricular ejection fraction at the clinical outcomes with NIHSS scores. These variables were the left ventricular ejection fraction <48% (95% confidence interval [CI]: 0.691-0.925; P = 0.001), left ventricular ejection fraction + low high-density lipoprotein (HDL) (95% CI: 0.73-0.949; P = 0,001), left ventricular ejection fraction + diabetes mellitus (DM) (95% CI: 0.799-0.962; P = 0,001), and left ventricular ejection fraction + low HDL + DM (95% CI: 0.841-0.98; P = 0,001).

CONCLUSION

The influence of the lower left ventricular ejection fraction to clinical outcome of ischemic stroke patients has a worsening of neurological deficit outcome by considering the combination of several independent variables including the DM and low HDL.

Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease

BACKGROUND AND OBJECTIVES

It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD).

METHODS

Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants.

RESULTS

The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality.

CONCLUSIONS

LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.

Heart-brain Interactions in Heart Failure

Heart failure (HF) is a complex disease with a growing incidence worldwide. HF is accompanied by a wide range of conditions which affect disease progression, functional performance and contribute to growing healthcare costs. The interactions between a failing myocardium and altered cerebral functions contribute to the symptoms experienced by patients with HF, affecting many comorbidities and causing a poor prognosis. This article provides a condensed version of the 2018 position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association. It addresses the reciprocal impact on HF of several pathological brain conditions, including acute and chronic low perfusion of the brain, and impairment of higher cortical and brain stem functions. Treatment-related interactions - medical, interventional and device-related - are also discussed.

Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association

Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys-)functions. Bi-directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co-morbidities of HF. Moreover, neuro-cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio-embolic) or chronic (haemodynamic failure) low perfusion being sub-categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over-activation, neuro-cardiac reflexes). Treatment-related interactions could be categorized as medical, interventional and device-related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture.

Ryanodine receptor modification and regulation by intracellular Ca2+ and Mg2+ in healthy and failing human hearts

RATIONALE

Heart failure is a multimodal disorder, of which disrupted Ca²⁺ homeostasis is a hallmark. Central to Ca²⁺ homeostasis is the major cardiac Ca²⁺ release channel - the ryanodine receptor (RyR2) - whose activity is influenced by associated proteins, covalent modification and by Ca²⁺ and Mg²⁺. That RyR2 is remodelled and its function disturbed in heart failure is well recognized, but poorly understood.

OBJECTIVE

To assess Ca²⁺ and Mg²⁺ regulation of RyR2 from left ventricles of healthy, cystic fibrosis and failing hearts, and to correlate these functional changes with RyR2 modifications and remodelling.

METHODS AND RESULTS

The function of RyR2 from left ventricular samples was assessed using lipid bilayer single-channel measurements, whilst RyR2 modification and protein:protein interactions were determined using Western Blots and co-immunoprecipitation. In all failing hearts there was an increase in RyR2 activity at end-diastolic cytoplasmic Ca²⁺ (100nM), a decreased cytoplasmic [Ca²⁺] required for half maximal activation (K_a) and a decrease in inhibition by cytoplasmic Mg²⁺. This was accompanied by significant hyperphosphorylation of RyR2 S²⁸⁰⁸ and S²⁸¹⁴, reduced free thiol content and a reduced interaction with FKBP12.0 and FKBP12.6. Either dephosphorylation of RyR2 using PP1 or thiol reduction using DTT eliminated any significant difference in the activity of RyR2 from healthy and failing hearts. We also report a subgroup of RyR2 in failing hearts that were not responsive to regulation by intracellular Ca²⁺ or Mg²⁺.

CONCLUSION

Despite different aetiologies, disrupted RyR2 Ca²⁺ sensitivity and biochemical modification of the channel are common constituents of failing heart RyR2 and may underlie the pathological disturbances in intracellular Ca²⁺ signalling.

[Dilated cardiomyopathy as a cause of ischemic stroke]

Dilated cardiomyopathy (DCMP) is a disease of the myocardium characterized by the dilatation of heart cavities with the development of systolic dysfunction but without a decrease in the thickness of the myocardium. DCMP is a frequent cause of cardioembolic syndrome, in particular cardioembolic ischemic stroke (CES). A case of a patient with DCMP after CES is presented.

Total Cerebral Blood Flow in Patients with Cardioembolic Stroke: Is It Clinically Meaningful?

Chronic hypoperfusion may hinder the washout of emboli coming from the heart and facilitate the formation of intra-cavitary thrombi. We investigated whether a decreased total cerebral blood flow (tCBF) resulted in recurrence of stroke and other vascular events in consecutive patients with cardioembolic stroke. We excluded patients with extra-cranial carotid or vertebral stenosis. The recorded tCBF was the sum of blood flow in both the carotid and vertebral extra-cranial arteries as measured with ultrasonography. Patients were followed up to assess stroke recurrence, vascular events and mortality. We also recorded demographic data, vascular risk factors, treatment data, echocardiographic variables and the C congestive heart failure history H Hypertension history A Age D Diabetes S Sex S2 Stroke/TIA/Thromboembolism history Vasc Vascular Disease history (CHA₂DS₂-VASc) score. We studied 79 patients (age 77.9 ± 8.4 y). Mean tCBF was 65.5 ± 15.7 mL/100 g/min. Cox regression analysis found that CHA₂ DS₂-VASc score and ejection fraction were associated with tCBF. After a mean follow-up of 22 ± 8.5 mo, 7.6% of patients experienced a recurrent stroke, 12.7% experienced a vascular event and 21.5% of patients died. Clinical outcomes were not predicted by tCBF.

The association between comorbid anxiety disorders and the risk of stroke among patients with diabetes: An 11-year population-based retrospective cohort study

BACKGROUND

Diabetes and anxiety disorders are independent risk factors for stroke. However, it remains unclear whether the risk of stroke is higher among diabetic patients with comorbid anxiety than without comorbid anxiety. Therefore, the purpose of this study was to investigate the association between comorbid anxiety and the risk of stroke among patients with diabetes.

METHODS

This is a retrospective cohort study. We used the National Health Insurance Research Database in Taiwan to identify a diabetes cohort with a new diagnosis of an anxiety disorder but without a history of stroke. The enrollment period was 2001-2006 with up to 11 years of follow-up data. Comorbid anxiety was defined by both a clinical diagnosis of the DSM-IV (ICD-9-CM) and prescriptions for anxiolytic medications. Propensity score matching was performed to balance the selected confounders between the anxiety-exposed group and anxiety non-exposed group. Cox-propositional hazard regression models were used to evaluate the association between comorbid anxiety and the risk of stroke.

RESULTS

Among patients with diabetes (N=40,846), an estimated 5.8% (N=2374) of patients had comorbid anxiety disorders. Diabetic patients with comorbid anxiety were significantly associated with a higher risk of stroke compared to patients without comorbid anxiety (hazard ratio: 1.33, 95% confidence interval: 1.02-1.72).

LIMITATIONS

The severity of anxiety or diabetes could not be measured from the claims data. Residual confounding may still exist.

CONCLUSION

A significantly elevated risk of stroke was observed in association with comorbid anxiety among patients with diabetes. Psychiatrists should consider routine screening for anxiety disorders to prevent a stroke event among patients with diabetes.

A comparison of risk factors and prognosis between intra and extracranial acute atherosclerotic stroke in the Turkish population: a prospective study

BACKGROUND

The aim of this study was to compare the differences in risk factors and prognosis between acute stroke caused by definitive intracranial atherosclerosis (ICAS) or extracranial atherosclerosis (ECAS) in the Turkısh population.

METHODS

This study was prospectively designed in a single centre and conducted with patients who were hospitalised due to acute ischaemic stroke. Inclusion criteria were the diagnosis of atherosclerotic ischaemic stroke, defined as more than 50% stenosis or occlusion in the arterial structure supplying the ischaemic area, having excluded other possible causes.

RESULTS

Information on 58 ICAS and 57 ECAS stroke patients was collected in a 13-month period. The ECAS patients had male gender predominance (p = 0.003). Ageing, stroke history and hyperlipidaemia were related with stroke severity in ECAS, and gender was associated with severity in ICAS. Hypertension and being female were related with poor prognosis in ICAS (p = 0.081 vs. 0.087). Congestive heart failure (p = 0.002) was associated with poor prognosis and alcohol with a favourable outcome (p = 0.087) in ECAS. Stroke severity was related with poor prognosis in both groups (p < 0.001).

CONCLUSIONS

The prevalence of risk factors differs between ICAS and ECAS, and their influence differs for stroke severity and prognosis.

Association between Left Ventricular Dysfunction and Functional Outcomes at Three Months in Acute Ischemic Stroke

BACKGROUND

Left ventricular dysfunction (LVD) was associated with stroke occurrence and mortality. However, few studies have published the impact of LVD on functional stroke outcomes in the acute stroke period.

METHODS

We enrolled 1554 patients who were admitted to Dong-A University Hospital between January 2011 and November 2014. To determine the functional outcomes, the modified Rankin Scale (mRS) score at 3 months after stroke was used. The severity of LVD was defined depending on ejection fraction (EF): (1) severe (EF ≤ 40%); (2) mild (40% < EF < 55%); and (3) normal (EF ≥ 55%). EF was measured using transthoracic two-dimensional echocardiography. The distribution of mRS scores at 3 months after stroke was presented using LVD. Multivariable analysis was performed to predict poor functional outcomes.

RESULTS

Of the 1554 patients, 1417 had normal LV function, 87 had mild LVD, and 50 had severe LVD. Patients with LVD were older and had a high incidence of diabetes mellitus, atrial fibrillation, coronary artery disease, and severe stroke symptoms. With respect to treatment, patients with LVD received more thrombolysis and more anticoagulation medication after stroke. Stroke-related disability at discharge and at 3 months was significantly associated with LVD. In the multivariable analyses, old age, diabetes mellitus, high initial National Institutes of Health Stroke Scale score, stroke mechanism, and LVD were independent predictors of poor functional outcomes at 3 months.

CONCLUSIONS

LVD is associated with poor functional outcomes after acute ischemic stroke.

Heart dysfunction in patients with acute ischemic stroke or TIA does not predict all-cause mortality at long-term follow-up

BACKGROUND

Despite heart failure being a substantial risk factor for stroke, few studies have evaluated the predictive value of heart dysfunction for all-cause mortality in patients with acute ischemic stroke, in particular in the elderly. The aim of this study was to investigate whether impaired heart function in elderly patients can predict all-cause mortality after acute ischemic stroke or transient ischemic attack (TIA).

METHODS

A prospective long-term follow-up analysis was performed on a hospital cohort consisting of n = 132 patients with mean age 73 ± 9 years, presenting with acute ischemic stroke or transient ischemic attack, without atrial fibrillation. All patients were examined by echocardiography during the hospital stay. Data about all-cause mortality were collected at the end of the follow-up period. The mean follow-up period was 56 ± 22 months.

RESULTS

In this cohort, 58% of patients with acute ischemic stroke or TIA had heart dysfunction. Survival analysis showed that heart dysfunction did not predict all-cause mortality in this cohort. Furthermore, in multivariate regression analysis age (HR 5.401, Cl 1.97-14.78, p < 0.01), smoking (HR 3.181, Cl 1.36-7.47, p < 0.01), myocardial infarction (HR 2.826, Cl 1.17-6.83, p < 0.05) were independent predictors of all-cause mortality.

CONCLUSION

In this population with acute ischemic stroke or TIA and without non-valvular atrial fibrillation, impaired heart function does not seem to be a significant predictor of all-cause mortality at long-term follow-up.

Acute cardioembolic cerebral infarction: answers to clinical questions

Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14-30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.

Stroke aetiology and predictors of outcome in patients with heart failure and acute stroke: a 10-year follow-up study

AIMS

The aim of this study was to investigate stroke aetiology and assess the predictors of early and late outcome in patients with heart failure (HF) and acute stroke.

METHODS AND RESULTS

A total of 2904 patients, admitted between 1993 and 2010, were regularly followed up at months 1, 3, and 6, and yearly thereafter up to 10 years. There were 283 (9.7%) stroke patients with HF; atrial fibrillation (AF) was present in 144 (50.9%) of them. Stroke aetiology in patients with HF and AF was mainly cardioembolism (82%) regardless of HF aetiology. In contrast, in the 139 non-AF patients with HF, the stroke mechanism was associated with the aetiology of HF: valvular heart disease and dilated cardiomyopathy were related to cardioembolism in 60% and 66.7% of patients, respectively, whereas HF due to coronary artery disease or hypertension was associated with atherosclerotic and lacunar stroke in 40.8% and 61.5%, respectively. In the overall population, HF was an independent predictor of 10-year mortality [hazard ratio = 1.54, 95% confidence interval (CI) 1.29-1.83; P < 0.001]. Probability of 10-year survival was 19.4% (95% CI 14.5-23.5) for HF patients and 44.1% (95% CI 41.4-46.8) for non-HF patients (P < 0.0001). Ten-year mortality in HF patients was associated with functional class of HF, age, diabetes, stroke severity, and in-hospital aspirin use. The presence of AF in HF stroke patients did not influence 10-year survival and composite cardiovascular events (P = 0.429 and P = 0.406, respectively).

CONCLUSIONS

In patients with HF, stroke aetiology is influenced by the presence of AF and the underlying cause of HF. Early and late stroke outcome is associated with HF severity but not with the presence of AF.