Antithrombotic medication for cardioembolic stroke prevention

Integrative Analysis of MAPK14 as a Potential Biomarker for Cardioembolic Stroke

The aim of this study was to obtain the candidate genes and biomarkers that are significantly related to cardioembolic stroke (CS) by applying bioinformatics analysis. In accordance with the results of the weighted gene coexpression network analysis (WGCNA) in the GSE58294 dataset, 11 CS-related coexpression network modules were identified in this study. Correlation analysis showed that the black and pink modules are significantly associated with CS. A total of 18 core genes in the black module and one core gene in the pink module were determined. We then identified differentially expressed genes (DEGs) of CS at 3 h, 5 h, and 24 h postonset. After performing intersection, it was found that 311 genes were coexpressed at these three time points. These genes were majorly enriched in positive regulation of transferase activity and regulation of peptidase activity. The abovementioned coexpressed DEGs were subjected to protein-protein interaction analysis and subnetwork module analysis. Subsequently, we used cytoHubba to obtain 11 key genes from DEGs. The intersection of the core genes screened from WGCNA and the key genes selected from DEGs yielded the MAPK14 gene. The expression level of MAPK14 on the receiver operating characteristic (ROC) curves of CS at 3 h, 5 h, and 24 h showed that the area under the ROC curve (AUC) was 0.923, 0.934, and 0.941, respectively. In a nutshell, MAPK14 screened out by using WGCNA showed differential expression in CS. We conclude that MAPK14 can be used as a potential biological marker of CS and exhibits potential to predict the physiopathological condition of CS patients.

Clinical-evolutive particularities and a multimodal therapeutic-rehabilitative approach, as well as through connected care approach, in the case of hemiplegia after ischemic cardio-embolic stroke within a polypathological context – A case report

Introduction: Cardiac embolism is one of the most common causes of embolic CVA. The recovery of patients with cardio-embolic stroke is a complex process which requires taking into account all associated pathologies (e.g. diabetes mellitus) that can play a decisive role in the evolution of the patient. A multidisciplinary team is required for such a purpose. Material and methods: The paper presents the case of a 63-year old patient with hemiplegia after an ischemic cardio-embolic stroke within a poly-pathological context. In January 2019, the patient suffered from an ischemic stroke in the carotid region with an ataxic spastic hemiparesis and left facial paresis with cerebrasthenia and bradylalia and he was admitted to “St. Ioan” Clinical Emergency Hospital in Bucharest. After the patient was stabilized and received specialized treatment, following the investigations and the interdisciplinary consultations, he received indication of neuromuscular recovery and for this reason he was admitted to our clinic. The patient was clinically and functionally evaluated, according the standardized protocols implemented in our clinic, through the assessment scales (MMSE, GOS-E and Rankin, MoCA, FIM, FAC, QoL, Asworh and Penn) and also para-clinically, in order to evaluate his biological reserve and his bearing availability of the recovery program. Results: After a complex neuro-recovery program undertaken by a multidisciplinary team formed by doctors, kinesiotherapists, medium healthcare and paramedical personnel, the patient displayed a slowly favorable evolution (hardened by his multiple associated diseases due to the above-mentioned co-morbidities) from a functional point of view with the improvement of the walking program and the increase in the muscle force and self-autonomy. Conclusion: The recovery of patients with cardio-embolic stroke is a complex process, which requires taking into account all associated pathologies that can play a decisive role in the evolution of the patient. A multidisciplinary team is required for such purposes. Key words: stroke, hemiplegia, poly-pathologic, ischemic

Oral anticoagulant therapy and bleeding events with vitamin K antagonists in patients with atrial fibrillation in a Hungarian county hospital

Background

Vitamin K antagonists, despite their tight therapeutic spectrum and the fear of bleeding complications, were long the most important drugs used in anticoagulant therapy. The aim of this study was to evaluate the quality of anticoagulant therapy and its relation with bleedings in everyday clinical practice.

Material/Methods

We analyzed the data of 272 patients with non-valvular atrial fibrillation treated in our county hospital using retrospective data collection of the last 1008±384 days. The INR (International Normalized Ratio) values and the time in therapeutic range (TTR) were analyzed. We asked patients about bleeding complications and searched the medical records.

Results

The TTR proved to be 64% and there was no statistically significant difference between that of 252 (92.7%) patients taking acenocoumarol and 20 (7.3%) on warfarin. Analyzing various factors leading to TTR under 70%, we found that none of them have a significant impact. Significantly more bleeding events occurred in the first 3 months after the initiation of anticoagulant therapy and in patients with TTR under 70%, but the latter was not significant after adjustment for factors influencing bleeding (OR 1.607, CI 0.571–4.522, p=0.392).

Conclusions

Although the present study’s TTR values were similar to those found in the warfarin branch of various large-scale international trials and in real-life settings, further improvement of vitamin K antagonist therapy are necessary. As the possibilities for this are limited, we believe that the new type anticoagulant agents have a place in everyday clinical practice.

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.

Dosing practice of low molecular weight heparins and its efficacy and safety in cardiovascular inpatients: a retrospective study in a Chinese teaching hospital

Background

Low-molecular-weight heparins (LMWHs) are safe and effective anticoagulant options for cardiovascular patients when applied as body weight-adjusted doses. However, there are some barriers that make it difficult to implement weight-adjusted doses in clinical practice. Therefore, it is vital to learn the dosing practices of LMWH and its efficacy and safety in clinical practice.

Methods

A retrospective study was conducted in cardiovascular inpatients who had received at least one dose of LMWH during a 6-month period. Appropriateness of LMWH dosing was determined and major clinical outcomes (major adverse vascular events and major bleeding) during hospitalization were evaluated.

Results

A total of 376 admissions representing 364 patients received LMWH treatment. Of these, 17.0% (64/376) of admissions did not have body weight records. Of the 312 admissions included for the outcome study, only 34 cases (10.9%) received the recommended doses of LMWH, while 51 cases (16.3%) received mild underdoses, 223 cases (71.5%) received major underdoses and 4 (1.3%) received excess doses. There were 10 major adverse vascular events, which occurred more often in patients receiving excess doses of LMWH than in patients receiving recommended, mild or major underdoses (50%, 2.9%, 2.0% and 2.7%, respectively, P < 0.001). After multivariable analysis, severe renal insufficiency was an independent risk factor for major adverse vascular events [odds ratio (OR), 31.93; 95% confidence interval (CI), 5.99-170.30; P < 0.001]. No major bleeding was recorded.

Conclusions

Underdose of LMWH is commonly used in cardiovascular inpatients, which was suboptimal according to guidelines. Using LMWH at a fixed, low dose for treatment purposes in patients without severe renal insufficiency was not associated with a higher risk of adverse vascular events in the current study, though larger studies with extended follow-ups are required to fully assess the long-term consequences of LMWH underdosing.