Long-Term Treatment with Citicoline Prevents Cognitive Decline and Predicts a Better Quality of Life after a First Ischemic Stroke

Endogenous defense mechanism-based neuroprotection in large-vessel acute ischemic stroke: A hope for future

BACKGROUND

Stroke is a leading cause of morbidity and mortality worldwide and a leading cause of disability. None of the neuroprotective agents have been approved internationally except edaravone in Japanese guidelines in acute ischemic stroke. We here discuss that there are two types of endogenous defense mechanisms (EDMs) after acute stroke for neuromodulation and neuroregeneration, and if both can be activated simultaneously, then we can have better recovery in stroke.

AIMS AND OBJECTIVES

We aimed to study the effect of combination of neuroprotection therapies acting on the two wings of EDM in acute large-vessel middle cerebral artery (LMCA) ischemic stroke.

METHODS

Sixty patients of LMCA stroke were enrolled and randomized within 72 h into two groups of 30 patients each. The control group received standard medical care without any neuroprotective agents while the intervention group received standard medical care combined with oral citicoline with vinpocetine for 3 months with initial 1 week intravenous and edaravone and cerebrolysin injection, started within 72 h of onset of stroke. Patients were assessed on the basis of the National Institutes of Health Stroke Scale, Fugl-Meyer Assessment Score, Glasgow Coma Scale, and Mini-Mental Status Examination at admission, discharge, and after 90 days.

RESULTS

The intervention group showed significant and early improvements in motor as well as cognitive recovery.

CONCLUSION

Combination therapy for neuroprotection which is acting on two pathways of EDM can be useful in functional recovery after acute ischemic stroke.

Efficacy of citicoline as a supplement in glaucoma patients: A systematic review

PURPOSE

Glaucoma is a leading cause of irreversible blindness worldwide. Retinal ganglion cells (RGC), the neurons that connect the eyes to the brain, specifically die in glaucoma, leading to blindness. Elevated intraocular pressure (IOP) is the only modifiable risk factor, however, many patients progress despite excellent IOP control. Thus, alternative treatment strategies to prevent glaucoma progression are an unmet need. Citicoline has demonstrated neuroprotective properties in central neurodegenerative diseases. However, conclusive evidence of the effect of citicoline on glaucoma progression is missing. This systematic review investigates first-time the therapeutic potential of citicoline in glaucoma patients.

METHODS

The present study was conducted according to the PRISMA 2020 statement. PubMed, Web of Science, Google Scholar, and Embase were accessed in July 2023 to identify all clinical studies investigating the efficacy of citicoline on IOP, the mean deviation of the 24-2 visual field testing (MD 24-2), retinal nerve fibre layer (RNFL), and the pattern electroretinogram (PERG) P50-N95 amplitude in glaucoma patients. The risk of bias was assessed using the Review Manager 5.3 software (The Nordic Cochrane Collaboration, Copenhagen) and the Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool.

RESULTS

Ten studies were eligible for this systematic review, including 424 patients. The mean length of the follow-up was 12.1 ± 11.6 months. The overall risk of bias was low to moderate. The mean age of the patients was 56.7 years. There were no significant differences in the IOP, MD 24-2, RNFL, or PERG P50-N95 amplitude between patients receiving citicoline and the control group. There was no improvement from baseline to the last follow-up in IOP, MD 24-2, RNFL, or PERG P50-N95 amplitude.

CONCLUSION

There is a lack of sufficient evidence to support that citicoline slows the progression of glaucoma.

A systematic review and meta-analysis of health utility values among patients with ischemic stroke

Purpose

Ischemic stroke (IS) has a considerable impact on the health-related quality of life (HRQoL) of patients. A systematic review was conducted to summarize and synthesize the HRQoL reported from IS patients.

Methods

An electronic search was performed in PubMed, Web of Science, ScienceDirect, Embase, and Cochrane Library databases from inception to February 2022 for studies measuring utility values in IS patients. Basic information about the studies, patient characteristics, measurement of the utility values, and utility values were extracted and summarized. Utility values were pooled according to the time of evaluation, and disease severity was classified with modified Rankin Scale (mRS) scores. The quality of the studies was assessed according to key criteria recommended by the National Institute for Health and Care Excellence.

Results

A total of 39 studies comprising 30,853 participants were included in the study. Measured with EQ-5D-3L, the pooled utility values were 0.42 [95% confidential interval (CI): 0.13 to 0.71], 0.55 (95% CI: 0.43 to 0.68), 0.65 (95% CI: 0.52 to 0.78), 0.60 (95% CI: 0.43 to 0.78), and 0.67 (95% CI: 0.60 to 0.74) for patients diagnosed with IS within 1, 3, 6, 12, and 24 months or above among poststroke patients. Four studies reported utility values classified by mRS scores where synthesized estimates stratified by mRS scores ranged from 0.91 (95% CI: 0.85 to 0.97) for patients with an mRS score of 1 to-0.04 (95% CI:-0.18 to 0.11) for those with an mRS score of 5. As for the health dimension profiles, usual activity was the most impacted dimension, while self-care was the least impacted one.

Conclusion

This study indicated that the utility values in IS patients kept increasing from stroke onset and became relatively stabilized at 6 months poststroke. Health utility values decreased significantly as mRS scores increased. These results facilitate economic evaluations in utility retrieval and selection. Further exploration was required regarding the factors that affect the HRQoL of IS patients.

Citicoline May Prevent Cognitive Decline in Patients with Cerebrovascular Disease

Introduction

Neuroprotective drugs such as citicoline could improve cognitive performance and quality of life. We studied the effect of citicoline treatment and its association with Vascular Risk Factors (VRF) and APOE on cognition in patients with Subjective Cognitive Complaints (SCC) and Mild Cognitive Impairment (MCI).

Methods

This is an observational and prospective study with citicoline during 12 months follow-up. Eighty-one subjects who met criteria for SCC/MCI, aged 50-75 years with VRF were included and prescribed citicoline 1g/day. Subjects with previous cognitive impairment and any other central nervous system affection were excluded. Wilcoxon Signed Ranks test and paired samples t-test were used to analyze the change in neuropsychological performance.

Results

Mean age of the sample was 68.2 (SD 6.8) years and 26 (32.09%) were females. Fifteen subjects (24.6%) were APOE-ε4 carriers, fifty-six (76.7%) had hypertension, fifty-eight (79.5%) had dyslipidemia, twenty-one (28.8%) had diabetes mellitus and twenty-six (35.6%) had cardiopathy. Thirty-two (43.8%) subjects were diagnosed as SCC and forty-one (56.16%) as MCI. During the follow-up, Tweny-six patients (81.25%) in the group of SCC remained stable, six subjects (18.8%) converted to MCI. Twelve patients (29.9%) with MCI reverted to SCC and twenty-nine patients (70.7%) remained stable. At follow-up, SCC subjects had an improvement in the global language domain (p=0.03), naming (p<0.001), attention (p=0.01) and visuospatial abilities (p<0.01). MCI group showed an improvement in the screening test (p=0.03), delayed memory (p<0.01), global cognition (p=0.04) and in cognitive flexibility (p=0.03). Presence of APOE-ε4 had no impact on the above findings.

Discussion

SCC subjects showed an improvement in language and attention domains, while those with MCI performed better after 12 months in total scores of MoCA and RBANS domains, some converting back to SCC. This supports the idea that citicoline may prevent cognitive decline in patients with cognitive deficits.

An α7 nAChR approach for the baseline-dependent modulation of deviance detection in schizophrenia: A pilot study assessing the combined effect of CDP-choline and galantamine

BACKGROUND

Cognitive operations including pre-attentive sensory processing are markedly impaired in patients with schizophrenia (SCZ) but evidence significant interindividual heterogeneity, which moderates treatment response with nicotinic acetylcholine receptor (nAChR) agonists. Previous studies in healthy volunteers have shown baseline-dependency effects of the α7 nAChR agonist cytidine 5'-diphosphocholine (CDP-choline) administered alone and in combination with a nicotinic allosteric modulator (galantamine) on auditory deviance detection measured with the mismatch negativity (MMN) event-related potential (ERP).

AIM

The objective of this pilot study was to assess the acute effect of this combined α7 nAChR-targeted treatment (CDP-choline/galantamine) on speech MMN in patients with SCZ (N = 24) stratified by baseline MMN responses into low, medium, and high baseline auditory deviance detection subgroups.

METHODS

Patients with a stable diagnosis of SCZ attended two randomized, double-blind, placebo-controlled and counter-balanced testing sessions where they received a placebo or a CDP-choline (500 mg) and galantamine (16 mg) treatment. MMN ERPs were recorded during the presentation of a fast multi-feature speech MMN paradigm including five speech deviants. Clinical measures were acquired before and after treatment administration.

RESULTS

While no main treatment effect was observed, CDP-choline/galantamine significantly increased MMN amplitudes to frequency, duration, and vowel speech deviants in low group individuals. Individuals with higher positive and negative symptom scale negative, general, and total scores expressed the greatest MMN amplitude improvement following CDP-choline/galantamine.

CONCLUSIONS

These baseline-dependent nicotinic effects on early auditory information processing warrant different dosage and repeated administration assessments in patients with low baseline deviance detection levels.

Role of Citicoline in Patients With Mild Cognitive Impairment

The term mild cognitive impairment (MCI) defines an intermediate state between normal aging and dementia. Vascular cognitive impairment refers to a decline in cognitive function that is caused by or associated with vascular disease and comprises all the spectrum of cognitive impairments, from MCI of vascular origin to vascular dementia. One of the available treatments for cognitive impairment is cytidine diphosphate-choline (CDP-Choline), or citicoline. The objective of the present manuscript is to provide complete evidence about the efficacy of citicoline for MCI, especially of vascular origin, but also due to other neurodegenerative disorders. Citicoline is a pharmaceutical product constituted by the combination of 2 natural molecules (cytidine and choline) and is marketed as a food supplement. It has been proposed to provide neuroprotective effects through diverse mechanisms of action. Taking into account the available literature, citicoline has shown a consistent improvement in cognitive function in patients with MCI, especially of vascular origin. Moreover, it provides beneficial effects on vascular, Alzheimer, and mixed dementias, stroke sequelae, intracerebral hemorrhages, traumatic brain injuries, and neurodegenerative diseases. Long-term treatment with citicoline has also been demonstrated to be well-tolerated and has not been associated with severe adverse events. Citicoline is a safe, well-tolerated, and promising agent with evidenced neuroprotective properties.

The effect of citicoline oral solution on quality of life in patients with glaucoma: the results of an international, multicenter, randomized, placebo-controlled cross-over trial

PURPOSE

This study aims to evaluate whether the use of citicoline oral solution could improve quality of life in patients with chronic open-angle glaucoma (OAG).

DESIGN

Randomized, double-masked, placebo-controlled, cross-over study was used. Patients were randomized to one of the two sequences: either citicoline 500 mg/day oral solution-placebo or placebo-citicoline 500 mg/day oral solution. Switch of treatments was done after 3 months; patients were then followed for other 6 months. Follow-up included 3-month, 6-month, and 9-month visits.

OUTCOMES

The primary outcome was the mean change of "intra-patient" composite score of the Visual Function Questionnaire-25 (VFQ-25)^. after citicoline oral solution vs placebo at 6-month visit as compared with baseline.

METHODS

The trial was multicenter, conducted at 5 European Eye Clinics. OAG patients with bilateral visual field damage, a mean deviation (MD) ranging from - 5 to - 13 dB in the better eye, and controlled IOP were included. VFQ-25 and SF-36 questionnaires were administered at baseline and at 3-, 6-, and 9-month visits. A mixed effect model, with a random effect on the intercept, accounted for correlations among serial measurements on each subject.

RESULTS

The primary pre-specified outcome of the analysis reached statistical significance (p = 0.0413), showing greater improvement after citicoline oral solution. There was an increase in the composite score in both arms compared to baseline, but it was significant only for the placebo-citicoline arm (p = 0.0096, p = 0.0007, and p = 0.0006 for the three time-points compared to baseline). The effect of citicoline was stronger in patients with vision-related quality of life more affected by glaucoma at baseline.

CONCLUSIONS

This is the first placebo-controlled clinical study evaluating the effect of a medical treatment aiming at improving vision-related quality of life in glaucomatous patients.

Is Citicoline Effective in Preventing and Slowing Down Dementia?-A Systematic Review and a Meta-Analysis

BACKGROUND

Cognitive impairment is a staggering personal and societal burden; accordingly, there is a strong interest in potential strategies for its prevention and treatment. Nutritional supplements have been extensively investigated, and citicoline seems to be a promising agent; its role in clinical practice, however, has not been established. We systematically reviewed studies on the effect of citicoline on cognitive performance.

METHODS

We searched the PubMed and Cochrane Library databases for articles published between 2010 and 2022. Relevant information was extracted and presented following the PRISMA recommendations. Data were pooled using the inverse-variance method with random effects models.

RESULTS

We selected seven studies including patients with mild cognitive impairment, Alzheimer's disease or post-stroke dementia. All the studies showed a positive effect of citicoline on cognitive functions. Six studies could be included in the meta-analysis. Overall, citicoline improved cognitive status, with pooled standardized mean differences ranging from 0.56 (95% CI: 0.37-0.75) to 1.57 (95% CI: 0.77-2.37) in different sensitivity analyses. The overall quality of the studies was poor.

DISCUSSION

Available data indicate that citicoline has positive effects on cognitive function. The general quality of the studies, however, is poor with significant risk of bias in favor of the intervention. Other: PubMed and the Cochrane Library.

Citicoline: pharmacological and clinical review, 2022 update

This review is based on the previous one published in 2016 (Secades JJ. Citicoline: pharmacological and clinical review, 2016 update. Rev Neurol 2016; 63 (Supl 3): S1-S73), incorporating 176 new references, having all the information available in the same document to facilitate the access to the information in one document. This review is focused on the main indications of the drug, as acute stroke and its sequelae, including the cognitive impairment, and traumatic brain injury and its sequelae. There are retrieved the most important experimental and clinical data in both indications.

An Overview of Combination Treatment with Citicoline in Dementia

INTRODUCTION

The present article reports an overview of the studies about combination treatment with citicoline of Alzheimer's (AD) and mixed dementia (MD).

METHODS

A Medline search was carried out by using the keywords Alzheimer's dementia, mixed dementia, older people, treatment with citicoline, memantine, and acetylcholinesterase inhibitors (AchEIs).

RESULTS

Six studies were found to match the combination treatment of citicoline with AcheIs and/or memantine. The CITIRIVAD and CITICHOLINAGE studies were the first to report the potential benefits of adding citicoline to acetylcholinesterase inhibitors (AchEIs). Then, we added citicoline to memantine in the CITIMEM study, and finally, we demonstrated benefits in terms of delay in cognitive worsening with the triple therapy (citicoline + AchEIs + memantine). Other authors also reinforced our hypothesis through two further studies.

CONCLUSIONS

Open, prospective studies are advised to confirm the utility of combination therapy with citicoline for the treatment of AD and MD.

[Molecular and clinical aspects of the effect of cytidyndiphosphocholine on cognitive functions]

OBJECTIVE

Systematization of the array of publications on cytidyldiphosphocholine (CDP-choline).

MATERIAL AND METHODS

Systematic computer analysis of all currently available publications on CDP-choline (1750 publications in PUBMED) using the topological theory of big data analysis.

RESULTS

CDP-choline is essential for acetylcholine biosynthesis, phospholipid metabolism, and DNA methylation. The article describes the effects of CDP-choline on acetylcholinergic and other types of neurotransmission, anti-inflammatory, neuroprotective and neurotrophic effects of CDP-choline. Also, the paper presents the effects of the molecule on lipid metabolism and gene expression within the post-genomic paradigm (in particular, an increase in the expression of nicotinic and muscarinic acetylcholine receptors). The results of fundamental and clinical studies of CDP-choline in the treatment of cognitive impairments associated with cerebral ischemia and neurodegeneration are presented.

CONCLUSION

The pharmacological effects of CDP-choline are mediated through multiple molecular mechanisms that contribute to the nootropic action of this molecule.

Current view on post-stroke dementia

Dementia is one of the leading complications after stroke affecting about one third of survivors. Prevalence of post-stroke dementia (PSD) differs between studies due to variability in methodology, characteristics of included patients, type of stroke, diagnostic tools used to identify patients with dementia, or time when the assessment was performed. Patients diagnosed with PSD are at higher risk of mortality, disability, and institutionalization. Aetiology of PSD may include mixed overlapping processes such as vascular brain pathology or Alzheimer's disease. Several risk factors have been found to increase PSD incidence, involving demographics, vascular factors, stroke characteristics, abnormalities on neuroimaging, and stroke complications. However, the influence of some other factors still remains unclear. PSD may coexist with other neuropsychiatric disorders and its association with post-stroke depression seems to be the most significant. There is a strong need for further research on possible genetic, biological, and inflammatory biomarkers. Also, there are no unambiguously efficacious methods of management. Continuing to address these issues will help to find more effective interventions directly targeting prevention and treatment of PSD in the future.

Citicoline Modulates Glaucomatous Neurodegeneration Through Intraocular Pressure-Independent Control

Glaucoma is a neurodegenerative disease that causes progressive, irreversible vision loss. Currently, intraocular pressure (IOP) is the only modifiable risk factor for glaucoma. However, glaucomatous degeneration may continue despite adequate IOP control. Therefore, there exists a need for treatment that protects the visual system, independent of IOP. This study sought, first, to longitudinally examine the neurobehavioral effects of different magnitudes and durations of IOP elevation using multi-parametric magnetic resonance imaging (MRI), optokinetics and histology; and, second, to evaluate the effects of oral citicoline treatment as a neurotherapeutic in experimental glaucoma. Eighty-two adult Long Evans rats were divided into six groups: acute (mild or severe) IOP elevation, chronic (citicoline-treated or untreated) IOP elevation, and sham (acute or chronic) controls. We found that increasing magnitudes and durations of IOP elevation differentially altered structural and functional brain connectivity and visuomotor behavior, as indicated by decreases in fractional anisotropy in diffusion tensor MRI, magnetization transfer ratios in magnetization transfer MRI, T1-weighted MRI enhancement of anterograde manganese transport, resting-state functional connectivity, visual acuity, and neurofilament and myelin staining along the visual pathway. Furthermore, 3 weeks of oral citicoline treatment in the setting of chronic IOP elevation significantly reduced visual brain integrity loss and visual acuity decline without altering IOP. Such effects sustained after treatment was discontinued for another 3 weeks. These results not only illuminate the close interplay between eye, brain, and behavior in glaucomatous neurodegeneration, but also support a role for citicoline in protecting neural tissues and visual function in glaucoma beyond IOP control.

Citicoline Improves Human Vigilance and Visual Working Memory: The Role of Neuronal Activation and Oxidative Stress

Introduction:

Psychomotor performance task is used to assess the arousal and cognitive functions of the central nervous system. Alternatively, human visual working memory reflects the capability of the individual’s short-term memory. Psycho-mental stimuli are linked to the stimulation of Malondialdehyde (MDA) formations. Citicoline is a nootropic nucleotide agent with a favorable effect on the augmentation of human memory and cognitive function. Thus, the purpose of this study was to determine the effect of citicoline on human vigilance, visual working memory, and oxidative stress using healthy volunteers.

Methods:

40 healthy volunteers were enrolled and divided into two groups: group A: 20 volunteers received 500mg/day starch capsule for two weeks and group B: 20 volunteers received 500mg/day citicoline capsule for two weeks. Human vigilance, visual working memory, and oxidative stress markers of each volunteer were assessed before and after citicoline and placebo intake. The obtained data were analyzed by SPSS regarding P<0.05 as statistically significant.

Results:

Placebo had no significant effect on human vigilance and visual working memory after two weeks of therapy (P>0.05), whereas citicoline improved most variables of psychomotor performances and working memory (P<0.01). Placebo significantly increased serum MDA levels from 19.44±2.11 to 29.66±3.28 nmol/mL (P=0.0001), while citicoline significantly decreased MDA serum levels from 19.11±2.66 to 15.63±1.33 nmol/mL (P=0.0001).

Conclusion:

Citicoline improves human psychomotor vigilance, arousal, and visual working memory with significant amelioration of oxidative stress compared with placebo.

Application of Citicoline in Neurological Disorders: A Systematic Review

Citicoline is a chemical compound involved in the synthesis of cell membranes. It also has other, not yet explained functions. Research on the use of citicoline is conducted in neurology, ophthalmology, and psychiatry. Citicoline is widely available as a dietary supplement. It is often used to enhance cognitive functions. In our article, accessible databases were searched for articles regarding citicoline use in neurological diseases. This article has a systemic review form. After rejecting non-eligible reports, 47 remaining articles were reviewed. The review found that citicoline has been proven to be a useful compound in preventing dementia progression. It also enhances cognitive functions among healthy individuals and improves prognosis after stroke. In an animal model of nerve damage and neuropathy, citicoline stimulated regeneration and lessened pain. Among patients who underwent brain trauma, citicoline has an unclear clinical effect. Citicoline has a wide range of effects and could be an essential substance in the treatment of many neurological diseases. Its positive impact on learning and cognitive functions among the healthy population is also worth noting.

Experience with citicoline in patients with post-stroke cognitive impairment

Objective: to investigate the efficacy and safety of citicoline (Ceresil® Canon) in patients with post-stroke cognitive impairment.

Patients and methods. Examinations were made in 33 patients aged 45 years and older who had experienced primary ischemic hemispheric stroke with complaints of a decline in memory or other cognitive functions. The cognitive status was assessed using the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The presence of anxiety-depressive spectrum disorders was determined on the Hospital Anxiety and Depression Scale. All the patients received citicoline (Ceresil® Canon) oral solution at a dose of 1000 mg/day for 3 months.

Results and discussion. Citicoline administration showed a statistically significant reduction in the severity of cognitive impairment (p<0.001). The time course of positive changes in the cognitive status of patients was reflected by an increase in the median score on the MMSE from 26 [25; 27.5] to 28 [26.5; 29] and on MoCA from 23 [21; 25] to 25 [22; 26]. There was a decline in the number of patients with anxiety-depressive disorders. No adverse events or side effects were found in the patients.

Conclusion. The findings suggest that citicoline (Ceresil® Canon) produced as an oral solution is well tolerated and improves cognitive functions and affective sphere in patients in the recovery period of ischemic stroke.

The modern concept of neuroprotective therapy in the acute period of ischemic stroke

In recent years, significant successes have been achieved in the treatment of acute ischemic stroke. Given the trend towards an increase in the proportion of patients undergoing intravenous thrombolysis and / or mechanical thrombectomy, the question justifies: is there place for neuroprotective therapy (NT) in the era of active introduction of reperfusion treatment? The review discusses the main mechanisms of brain damage in ischemia / reperfusion and the leading neuroprotective strategies studied in clinical trials. Neuroprotective approaches to suppress excitotoxicity, oxidative and nitrosative stress are presented. The clinical efficacy of magnesium sulfate, uric acid, and edaravone is discussed. Non-pharmacological methods of neuroprotection have been characterized, including remote ischemic conditioning, therapeutic hypothermia and neurostimulation. NT in a situation of impossibility of cerebral reperfusion is discussed. The results of randomized clinical trials and meta-analyzes on citicoline (ceraxon) are analyzed. A clinical case is presented illustrating the management of a patient for whom reperfusion therapy was not feasible due to the course of the disease. In the era of the active development of reperfusion methods for the treatment of ischemic stroke, the goal-setting of NT has changed: it is intended to expand the possibilities of application and increase the effectiveness of intravenous thrombolysis and/or mechanical thrombectome, as well as neutralize their negative reperfusion effects. The main targets for NT remain excitotoxicity, oxidative and nitrosative stress. On the other hand, the real clinical situation associated with the low frequency of reperfusion technology in our country necessitates the use of neuroprotectors effective in this category of patients. In this regard, the administration of ceraxon increases the chances of achieving functional independence. The most effective use of the drug from the first day of the disease at a dose of 2000 mg per day intravenously for at least 4-6 weeks with further long-term oral administration at a dose of 1000 mg per day.

Implantable cardiac monitors to detect atrial fibrillation after cryptogenic stroke: a systematic review and economic evaluation

BACKGROUND

Cryptogenic stroke is a stroke for which no cause is identified after standard diagnostic tests. Long-term implantable cardiac monitors may be better at diagnosing atrial fibrillation and provide an opportunity to reduce the risk of stroke recurrence with anticoagulants.

OBJECTIVES

The objectives were to assess the diagnostic test accuracy, clinical effectiveness and cost-effectiveness of three implantable monitors [BioMonitor 2-AF™ (Biotronik SE & Co. KG, Berlin, Germany), Confirm Rx™ (Abbott Laboratories, Lake Bluff, IL, USA) and Reveal LINQ™ (Medtronic plc, Minneapolis, MN, USA)] in patients who have had a cryptogenic stroke and for whom no atrial fibrillation is detected after 24 hours of external electrocardiographic monitoring.

DATA SOURCES

MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effects and Health Technology Assessment databases were searched from inception until September 2018.

REVIEW METHODS

A systematic review was undertaken. Two reviewers agreed on studies for inclusion and performed quality assessment using the Cochrane Risk of Bias 2.0 tool. Results were discussed narratively because there were insufficient data for synthesis. A two-stage de novo economic model was developed: (1) a short-term patient flow model to identify cryptogenic stroke patients who have had atrial fibrillation detected and been prescribed anticoagulation treatment (rather than remaining on antiplatelet treatment) and (2) a long-term Markov model that captured the lifetime costs and benefits of patients on either anticoagulation or antiplatelet treatment.

RESULTS

One randomised controlled trial, Cryptogenic Stroke and underlying Atrial Fibrillation (CRYSTAL-AF) (Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014;370:2478-86), was identified, and no diagnostic test accuracy study was identified. The CRYSTAL-AF trial compared the Reveal™ XT (a Reveal LINQ predecessor) (Medtronic plc) monitor with standard of care monitoring. Twenty-six single-arm observational studies for the Reveal devices were also identified. The only data for BioMonitor 2-AF or Confirm Rx were from mixed population studies supplied by the companies. Atrial fibrillation detection in the CRYSTAL-AF trial was higher with the Reveal XT than with standard monitoring at all time points. By 36 months, atrial fibrillation was detected in 19% of patients with an implantable cardiac monitor and in 2.3% of patients receiving conventional follow-up. The 26 observational studies demonstrated that, even in a cryptogenic stroke population, atrial fibrillation detection rates are highly variable and most cases are asymptomatic; therefore, they probably would not have been picked up without an implantable cardiac monitor. Device-related adverse events, such as pain and infection, were low in all studies. The de novo economic model produced incremental cost effectiveness ratios comparing implantable cardiac monitors with standard of care monitoring to detect atrial fibrillation in cryptogenic stroke patients based on data for the Reveal XT device, which can be related to Reveal LINQ. The BioMonitor 2-AF and Confirm RX were included in the analysis by making a strong assumption of equivalence with Reveal LINQ. The results indicate that implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold. When each device is compared incrementally, BioMonitor 2-AF dominates Reveal LINQ and Confirm RX.

LIMITATIONS

The cost-effectiveness analysis for implantable cardiac monitors is based on a strong assumption of clinical equivalence and should be interpreted with caution.

CONCLUSIONS

All three implantable cardiac monitors could be considered cost-effective at a £20,000-30,000 threshold, compared with standard of care monitoring, for cryptogenic stroke patients with no atrial fibrillation detected after 24 hours of external electrocardiographic monitoring; however, further clinical studies are required to confirm their efficacy in cryptogenic stroke patients.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42018109216.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 5. See the NIHR Journals Library website for further project information.

Pharmacotherapy for Vascular Cognitive Impairment

Vascular cognitive impairment (VCI) is the second most common type of dementia after Alzheimer's disease (AD). Stroke and cardiovascular risk factors have been linked to both AD and VCI and potentially can affect cognitive function in mid and later life. Various pharmacological agents, including donepezil, galantamine, and memantine, approved for the treatment of AD have shown modest cognitive benefits in patients with vascular dementia (VaD). However, their functional and global benefits have been inconsistent. Donepezil has shown some cognitive benefit in patients with VaD only, and galantamine has shown some benefit in mixed dementia (AD/VaD). The benefits of other drugs such as rivastigmine, memantine, nimodipine, and piracetam are not clear. Some other supplements and herbal therapies, such as citicoline, actovegin, huperzine A, and vinpocetine, have also been studied in patients with VaD, but their beneficial effects are not well established. Non-drug therapies and lifestyle modifications such as diet, exercise, and vascular risk factor control are important in the management of VCI and should not be ignored. However, there is a need for more robust clinical trials focusing on executive function and other cognitive measures and incorporation of newer imaging modalities to provide additional evidence about the utility of these strategies in patients with VCI.