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Rivier CA, Acosta JN, Leasure AC, Forman R, Sharma R, de Havenon A, Spatz ES, Inzucchi SE, Kernan WN, Falcone GJ, Sheth KN. Secondary Prevention in Patients With Stroke Versus Myocardial Infarction: Analysis of 2 National Cohorts. J Am Heart Assoc 2024; 13:e033322. [PMID: 38639369 DOI: 10.1161/jaha.123.033322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND The implementation of preventive therapies among patients with stroke remains inadequately explored, especially when compared with patients with myocardial infarction (MI), despite sharing similar vascular risk profiles. We tested the hypothesis that participants with a history of stroke have a worse cardiovascular prevention profile in comparison to participants with MI. METHODS AND RESULTS In cross-sectional analyses within the UK Biobank and All of Us Research Program, involving 14 760 (9193 strokes, 5567 MIs) and 7315 (2948 strokes, 4367 MIs) participants, respectively, we evaluated cardiovascular prevention profiles assessing low-density lipoprotein (<100 mg/dL), blood pressure (systolic, <140 mm Hg; and diastolic, <90 mm Hg), statin and antiplatelet use, and a cardiovascular prevention score that required meeting at least 3 of these criteria. The results revealed that, within the UK Biobank, patients with stroke had significantly lower odds of meeting all the preventive criteria compared with patients with MI: low-density lipoprotein control (odds ratio [OR], 0.73 [95% CI, 0.68-0.78]; P<0.001), blood pressure control (OR, 0.63 [95% CI, 0.59-0.68]; P<0.001), statin use (OR, 0.45 [95% CI, 0.42-0.48]; P<0.001), antiplatelet therapy use (OR, 0.30 [95% CI, 0.27-0.32]; P<0.001), and cardiovascular prevention score (OR, 0.42 [95% CI, 0.39-0.45]; P<0.001). Similar patterns were observed in the All of Us Research Program, with significant differences across all comparisons (P<0.05), and further analysis suggested that the odds of having a good cardiovascular prevention score were influenced by race and ethnicity as well as neighborhood deprivation levels (interaction P<0.05 in both cases). CONCLUSIONS In 2 independent national cohorts, patients with stroke showed poorer cardiovascular prevention profiles and lower adherence to guideline-directed therapies compared with patients with MI. These findings underscore the need to explore the reasons behind the underuse of secondary prevention in vulnerable stroke survivors.
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Affiliation(s)
- Cyprien A Rivier
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | - Julian N Acosta
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | | | - Rachel Forman
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | - Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | - Erica S Spatz
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | | | - Walter N Kernan
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Guido J Falcone
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
| | - Kevin N Sheth
- Department of Neurology, Center for Brain and Mind Health Yale School of Medicine New Haven CT
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Kernan WN. The Primary Care Workforce Training Pipeline Has Two Ends. J Gen Intern Med 2024:10.1007/s11606-024-08682-1. [PMID: 38429483 DOI: 10.1007/s11606-024-08682-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
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Sharma R, de Havenon A, Rivier C, Payabvash S, Forman R, Krumholz H, Falcone GJ, Sheth KN, Kernan WN. Impaired mobility and MRI markers of vascular brain injury: Atherosclerosis Risk in Communities and UK Biobank studies. BMJ Neurol Open 2024; 6:e000501. [PMID: 38288313 PMCID: PMC10823923 DOI: 10.1136/bmjno-2023-000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 11/05/2023] [Indexed: 01/31/2024] Open
Abstract
Background Vascular brain injury (VBI) may be an under-recognised contributor to mobility impairment. We examined associations between MRI VBI biomarkers and impaired mobility. Methods We separately analysed Atherosclerosis Risk in Communities (ARIC) and UK Biobank (UKB) study cohorts. Inclusion criteria were no prevalent clinical stroke, and available brain MRI and balance and gait data. MRI VBI biomarkers were (ARIC: ventricular and white matter hyperintensity (WMH) volumes, non-lacunar and lacunar infarctions, microhaemorrhage; UKB: ventricular, brain and WMH volumes, fractional anisotropy (FA), mean diffusivity (MD), intracellular and isotropic free water volume fractions). Quantitative biomarkers were categorised into tertiles. Mobility impairment outcomes were imbalance and slow walk in ARIC and recent fall and slow walk in UKB. Adjusted multivariable logistic regression analyses were performed. Results We included 1626 ARIC (mean age 76.2 years; 23.4% imbalance, 25.0% slow walk) and 40 098 UKB (mean age 55 years; 15.8% falls, 2.8% slow walk) participants. In ARIC, imbalance associated with four of five VBI measures (all p values<0.05), most strongly with WMH (adjusted OR, aOR 1.64; 95% CI 1.18 to 2.29). Slow walk associated with four of five VBI measures, most strongly with WMH (aOR 2.32; 95% CI 1.66 to 3.24). In UKB, falls associated with all VBI measures except WMH, most strongly with FA (aOR 1.16; 95% CI 1.08 to 1.24). Slow walking associated with WMH, FA and MD, most strongly with FA (aOR 1.57; 95% CI 1.32 to 1.87). Conclusions VBI is associated with mobility impairment in community-dwelling, clinically stroke-free cohorts. Consequences of VBI may extend beyond clinically apparent stroke to include mobility.
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Affiliation(s)
- Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Cyprien Rivier
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Harlan Krumholz
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Ndumele CE, Neeland IJ, Tuttle KR, Chow SL, Mathew RO, Khan SS, Coresh J, Baker-Smith CM, Carnethon MR, Després JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV, Rangaswami J. A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1636-1664. [PMID: 37807920 DOI: 10.1161/cir.0000000000001186] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.
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Ndumele CE, Rangaswami J, Chow SL, Neeland IJ, Tuttle KR, Khan SS, Coresh J, Mathew RO, Baker-Smith CM, Carnethon MR, Despres JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation 2023; 148:1606-1635. [PMID: 37807924 DOI: 10.1161/cir.0000000000001184] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.
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Balasubramanian P, Kernan WN, Sheth KN, Ofstad AP, Rosenstock J, Wanner C, Zinman B, Mattheus M, Marx N, Inzucchi SE. Baseline Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes and Coronary Disease Versus Stroke: Secondary Analysis of Cardiovascular Outcome Trials. Stroke 2023; 54:2013-2021. [PMID: 37449424 PMCID: PMC10358436 DOI: 10.1161/strokeaha.122.042053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 06/02/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Patients with type 2 diabetes (T2D) and cardiovascular disease are at increased risk for recurrent ischemic events. Cardiovascular risk factor control is vital for secondary prevention, but how this compares among individuals with different T2D macrovascular complications is unknown. We aimed to determine if there might be differences in risk factor control in patients with T2D with previous stroke versus coronary artery disease (CAD). METHODS Cross-sectional analyses were performed on 12 856 patients with T2D with prior history of stroke with or without CAD from 3 diabetes cardiovascular outcome trials: CARMELINA (The Cardiovascular and Renal Microvascular Outcome Study With Linagliptin), EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), and CAROLINA (The Cardiovascular Outcome Study of Linagliptin vs Glimepiride in Type 2 Diabetes). Risk factors at baseline assessed included dyslipidemia, hypertension, smoking, and current antiplatelet/anticoagulant therapy. Control, respectively, was defined as LDL (low-density lipoprotein)-C <100 mg/dL or statin use, systolic blood pressure <140 and diastolic blood pressure <90 mm Hg, not currently smoking, and use of an antiplatelet/anticoagulant medication. The odds ratio of 3 to 4 (or good) versus 0 to 2 (or suboptimal) risk factors controlled was analyzed by logistic regression models. RESULTS The odds for good versus suboptimal risk factor control in patients with CAD alone was higher than in those with stroke alone across all 3 trials odds ratios (95% CI): CARMELINA, 2.05 (1.67-2.51), EMPA-REG OUTCOME, 2.50 (2.10-2.99), and CAROLINA, 1.63 (1.21-2.20). The respective odds ratios were lower (and rendered nonsignificant in CAROLINA) when cardiovascular risk factor control in patients with both CAD and stroke were compared with those with stroke alone: CARMELINA, 1.45 (1.13-1.87); EMPA-REG OUTCOME, 1.62 (1.25-2.08); and CAROLINA, 1.16 (0.74-1.83). CONCLUSIONS In contemporary populations of patients with T2D, there was significant discordance in control of cardiovascular risk factors between patients with stroke versus CAD, with the former having less optimal control. The intermediate results in patients with both CAD and stroke suggest that these differences could be related at least in part to clinician factors. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT01243424, NCT01131676, NCT01897532.
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Affiliation(s)
| | - Walter N. Kernan
- Section of General Internal Medicine, Department of Medicine (W.N.K), Yale School of Medicine, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology (K.N.S), Yale School of Medicine, New Haven, CT
| | - Anne Pernille Ofstad
- Boehringer Ingelheim Norway KS, Asker (A.P.O.)
- Oslo Diabetes Research Center, Norway (A.P.O.)
| | | | | | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, ON, Canada (B.Z.)
| | | | - Nikolaus Marx
- Department of Internal Medicine, University Hospital; RWTH Aachen University, Germany (N.M.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Department of Medicine (S.E.I), Yale School of Medicine, New Haven, CT
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Hassan SF, Viscoli CM, O'Connor PG, Dugdale LS, Sofair AN, Fitz MM, Richards B, Feiereisel KB, Lee SY, Ost SR, Swails JL, Fishman MB, Kernan WN. Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics. J Gen Intern Med 2023; 38:2318-2325. [PMID: 36800147 PMCID: PMC10406732 DOI: 10.1007/s11606-023-08066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/27/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.
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Affiliation(s)
- Samer F Hassan
- Brigham and Women's Hospital, Boston, MA, USA
- Yale School of Medicine, CT, New Haven, USA
| | | | | | - Lydia S Dugdale
- Yale School of Medicine, CT, New Haven, USA
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | | | - Matthew M Fitz
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Bradley Richards
- Brigham and Women's Hospital, Boston, MA, USA
- Division of Health Services, Connecticut Department of Social Services, Hartford, CT, USA
| | | | - Susan Y Lee
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Shelley R Ost
- University of Tennessee-Health Science Center College of Medicine, Memphis, TN, USA
| | - Jennifer L Swails
- McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Mary B Fishman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Dearborn Tomazos J, Viscoli C, Amin H, Lovelett LJ, Rivera J, Gull A, Kernan WN. Partial Meal Replacement for Weight Loss after Stroke: Results of a Pilot Clinical Trial. Cerebrovasc Dis 2023; 53:54-61. [PMID: 37231793 DOI: 10.1159/000530996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/02/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Over half of patients with acute ischemic stroke are overweight or obese as defined by a body mass index (BMI) ≥25 kg/m2. Professional and government agencies recommend weight management for these persons to improve risk factors for cardiovascular disease, including hypertension, dyslipidemia, vascular inflammation, and diabetes. However, approaches to weight loss have not been adequately tested specifically in patients with stroke. In anticipation of a larger trial with vascular or functional outcomes, we tested the feasibility and safety of a 12-week partial meal replacement (PMR) intervention for weight loss in overweight or obese patients with a recent ischemic stroke. METHODS This randomized open-label trial enrolled participants from December 2019 to February 2021 (with hiatus from March to August 2020 due to COVID-19 pandemic restrictions on research). Eligible patients had a recent ischemic stroke and BMI 27-49.9 kg/m2. Patients were randomized to a PMR diet (OPTAVIA® Optimal Weight 4 & 2 & 1 Plan®) plus standard care (SC) or SC alone. The PMR diet consisted of four meal replacements supplied to participants, two meals with lean protein and vegetables (self-prepared or supplied), and a healthy snack (also self-prepared or supplied). The PMR diet provided 1,100-1,300 calories per day. SC consisted of one instructional session on a healthy diet. Co-primary outcomes were ≥5% weight loss at 12 weeks and to identify barriers to successful weight loss among participants assigned to PMR. Safety outcomes included hospitalization, falls, pneumonia, or hypoglycemia requiring treatment by self or others. Due to the COVID-19 pandemic, study visits after August 2020 were by remote communication. RESULTS We enrolled 38 patients from two institutions. Two patients in each arm were lost and could not be included in outcome analyses. At 12 weeks, 9/17 patients in the PMR group and 2/17 patients in the SC group achieved ≥5% weight loss (52.9% vs. 11.9%; Fisher's exact p = 0.03). Mean percent weight change in the PMR group was -3.0% (SD 13.7) and -2.6% (SD 3.4) in the SC group (Wilcoxon rank-sum p = 0.17). No adverse events were attributed to study participation. Some participants had difficulty completing home monitoring of weight. In the PMR group, participants reported that food cravings and dislike for some food products were barriers to weight loss. CONCLUSION A PMR diet after ischemic stroke is feasible, safe, and effective for weight loss. In future trials, in-person or improved remote outcome monitoring may reduce anthropometric data variation.
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Affiliation(s)
| | - Catherine Viscoli
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Hardik Amin
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Laurel Jean Lovelett
- Department of Speech Language Pathology, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Jessica Rivera
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anum Gull
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Walter N Kernan
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Forman R, Viscoli CM, Meurer K, Sheth KN, Sansing LH, de Havenon A, Sharma R, Mariscal M, Kernan WN. Technical Dissonance in Home Blood Pressure Monitoring After Stroke: Having the Machine, but Not Using Correctly. Am J Hypertens 2023; 36:195-200. [PMID: 36520024 PMCID: PMC10016067 DOI: 10.1093/ajh/hpac129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/30/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In individuals with hypertension (HTN), lowering blood pressure (BP) after a stroke can lower the risk of stroke recurrence, but many patients do not reach the goal. Home blood pressure monitoring (HBPM) can help patients get to the goal, but rates of use and quality of technique have not been evaluated. METHODS We conducted a cross-sectional study of patients with stroke. Patients were eligible if they had a stroke within 2 years, had HTN, and lived at home. We classified patients as correctly performing HBPM if they used an arm cuff, sat ≥ 1 min before measurement, took ≥ 2 measurements, and use within 6 months. The primary outcome was the proportion of patients who had an HBPM and used it correctly, which we calculated according to race and ethnicity. We also asked patients what they would do if they found results outside the goal. RESULTS Among 150 participants, 120 (81%) possessed an HBPM and 29 (21%) used it correctly. We observed no significant disparity in rates of possession or correct use between non-Hispanic White participants and participants from underrepresented groups. Seventy percent of non-Hispanic White patients said they would contact their provider if their BP was above goal vs. 52% of underrepresented patients (P = 0.21). CONCLUSIONS Most patients after stroke have an HBPM, but only about 1 in 5 use it correctly. Approximately half of the patients from underrepresented racial or ethnic groups do not have a plan for responding to the values above goal. Our results indicate opportunities to improve the dissemination and correct use of HBPM.
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Affiliation(s)
- Rachel Forman
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Katherine Meurer
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Melissa Mariscal
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Walter N Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Abstract
Diabetes is a heterogeneous disease that affects 9% of the world's population (11% in the United States). The consequences of diabetes for the brain are severe; it nearly doubles a person's risk of stroke and is a major contributor to risk for cerebral small vessel disease and dementia. These effects on the brain are in addition to peripheral neuropathy, retinopathy, nephropathy, and coronary heart disease. In this article, we explain the treatments that can prevent or mitigate its harmful effects and propose a role for neurologists and other neurology clinicians in managing patients during routine care.
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Sharma R, De Havenon AH, Rivier C, Payabvash S, Forman R, Krumholz HM, Falcone GJ, Sheth KN, Kernan WN. Abstract 131: Brain Mri Biomarkers Of Impaired Balance And Slow Walk Speed: Atherosclerosis Risk In Communities And UK Biobank Studies. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background and Objectives:
Vascular brain injury (VBI) may contribute to imbalance and slow walk speed, but this is uncertain. We hypothesize that MRI biomarkers of VBI associate with impaired balance and slow walk speed.
Methods:
We performed separate, cross-sectional analyses in the Atherosclerosis Risk in Communities (ARIC) and UK Biobank (UKB) studies. Eligible participants had no prior clinical stroke and underwent a brain MRI and balance and walk speed ascertainment. MRI biomarkers of VBI analyzed were: ventricular volume, white matter hyperintensity volume (WMH), non-lacunar infarction, lacunar infarction, microhemorrhage in ARIC; ventricular volume, brain volume, WMH, fractional anisotropy (FA), mean diffusivity (MD), intra-cellular volume fraction, isotropic free water volume fraction in UKB. Quantitative biomarker levels were classified into tertiles, the unhealthiest tertile designated as the exposure. Our outcomes were poor balance and slow walk speed. We constructed multivariable logistic regression models to examine the associations between each MRI biomarker and the outcomes, adjusting for demographics and clinical history.
Results:
We included 1,626 ARIC participants (mean age 76.2 years; 23.4% impaired balance, 25.0% slow walk speed) and 40,098 UKB participants (mean age 55 years; 15.8% impaired balance, 2.8% slow walk speed). In ARIC, impaired balance was associated with 4 of 5 MRI measures of VBI in adjusted analysis (all p-values <0.05). The strongest association was with WMH (OR 1.36; 95% C.I. 1.04-1.76). Slow walk speed in ARIC was significantly associated with 4 of 5 MRI measures; the strongest association was with silent lacunar infarcts (OR 2.17; 95% C.I. 1.61-2.93). In UKB, poor balance was associated with all MRI biomarkers except WMH. The strongest association was with FA (OR 1.16; 95% C.I. 1.08-1.24). Slow walking speed was associated with WMH, FA, and MD. The strongest association was with FA (OR 1.42; 95% C.I. 1.21-1.67).
Conclusions:
We demonstrate that MRI measures of VBI are independently associated with impaired balance and slow walk speed in two studies of community-dwelling adults with no history of clinical stroke. Consequences of VBI may extend beyond clinically apparent stroke to also include mobility.
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de Havenon A, Sharma R, Sarpong D, Forman R, Prabhakaran S, Spatz ES, Krumholz HM, Fernandes C, Roy B, Sheth KN, Kernan WN. Abstract TMP25: Major Adverse Brain Events: Incidence Rates Of A Novel Composite Vascular Neurologic Outcome. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
The classical 3-point composite outcome MACE (major adverse cardiovascular events) includes incident stroke, myocardial infarction, and cardiovascular death. Conventional use of MACE may fail to account for important neurological consequences of vascular risk factors. We sought to report incidence rates of a novel composite neurologic outcome called major adverse brain events (MABE), comprised of incident stroke, dementia, and impaired balance in individuals with the vascular risk factor of hypertension.
Methods:
We analyzed TriNetX, the Health and Retirement Study (HRS), and Atherosclerosis Risk in Communities (ARIC), three longitudinal, publicly available datasets. We ascertained MABE as well as MACE and MACABE (MABE & MACE) as comparators by applying distinct adjudication methodologies in each dataset. We also evaluated the effect of good vascular health (maintenance of systolic blood pressure <140mm Hg and moderate or high physical activity, GVH) on rates of MABE and MACE in HRS through odds ratios (OR) adjusted for age, sex, and race/ethnicity.
Results:
We included 10,496,366 hypertensive individuals aged ≥40 years in the TriNetX sample with up to 4 years of follow-up, 2,251 hypertensive individuals aged ≥60 years in HRS with 4 years of follow-up, and 1,409 hypertensive individuals in ARIC with a mean of 4.9 years of follow-up. The incidence of MABE was 10.5% in TriNetX (Figure 1), 35.9% in HRS, and 33.3% in ARIC, of MACE was 17.5%, 40.8% and 12.9%, and of MACABE was 21.2%, 56.3%, and 39.9%, respectively. MABE incidence was highest in older, female, and Black individuals. In HRS, the adjusted OR in those with GVH was 0.50 (95% CI 0.34-0.73) for MABE, 0.71 (95% CI 0.51-0.99) for MACE, and 0.59 (95% CI 0.43-0.82) for MACABE.
Conclusions:
These data suggest that MABE is common among patients with hypertension, even in administrative datasets which are expected to have lower event rates. MABE may be useful for interventions that target brain health.
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Forman R, Viscoli CM, Bath PM, Furie KL, Guarino P, Inzucchi SE, Young L, Kernan WN. Central vs site outcome adjudication in the IRIS trial. J Stroke Cerebrovasc Dis 2022; 31:106667. [PMID: 35901589 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 06/22/2022] [Accepted: 07/17/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Central adjudication of outcome events is the standard in clinical trial research. We examine the benefit of central adjudication in the Insulin Resistance Intervention after Stroke (IRIS) trial and show how the benefit is influenced by outcome definition and features of the adjudicated events. METHODS IRIS tested pioglitazone for prevention of stroke and myocardial infarction in patients with a recent transient ischemic attack or ischemic stroke. We compared the hazard ratios for study outcomes classified by site and central adjudication. We repeated the analysis for an updated stroke definition. RESULTS The hazard ratios for the primary outcome were identical (0.76) and statistically significant regardless of adjudicator. The hazard ratios for stroke alone were nearly identical with site and central adjudication, but only reached significance with site adjudication (HR, 0.80; p = 0.049 vs. HR, 0.82; p = 0.09). Using the updated stroke definition, all hazard ratios were lower than with the original IRIS definition and statistically significant regardless of adjudication method. Agreement was higher when stroke type was certain, subtype was large vessel or cardioembolic, signs or symptoms lasted > 24 h, imaging showed a stroke, and when NIHSS was ≥3. DISCUSSION Central stroke adjudication caused the hazard ratio for a main secondary outcome in IRIS (stroke alone) to be higher and lose statistical significant compared with site review. The estimate of treatment effects were larger with the updated stroke definition. There may be benefit of central adjudication for events with specific features, such as shorter symptom duration or normal brain imaging.
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Affiliation(s)
- Rachel Forman
- Yale School of Medicine, 100 York St. Suite 1N, New Haven, CT 06511, United States.
| | - Catherine M Viscoli
- Yale School of Medicine, 100 York St. Suite 1N, New Haven, CT 06511, United States
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham NG7 2UH, UK
| | - Karen L Furie
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Peter Guarino
- Fred Hutchinson Cancer Research Center, Seattle, WA, United States; Yale School of Public Health, New Haven, CT, United States
| | - Silvio E Inzucchi
- Yale School of Medicine, 100 York St. Suite 1N, New Haven, CT 06511, United States
| | - Lawrence Young
- Yale School of Medicine, 100 York St. Suite 1N, New Haven, CT 06511, United States
| | - Walter N Kernan
- Yale School of Medicine, 100 York St. Suite 1N, New Haven, CT 06511, United States
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Spence JD, Viscoli C, Kernan WN, Young LH, Furie K, DeFronzo R, Abdul-Ghani M, Dandona P, Inzucchi SE. Efficacy of lower doses of pioglitazone after stroke or transient ischaemic attack in patients with insulin resistance. Diabetes Obes Metab 2022; 24:1150-1158. [PMID: 35253334 DOI: 10.1111/dom.14687] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 12/30/2022]
Abstract
AIMS Pioglitazone is a potent insulin-sensitizing drug with anti-atherosclerotic properties, but adverse effects have limited its use. We assessed the benefits and risks of lower versus higher doses of pioglitazone taken by participants in the Insulin Resistance Intervention in Stroke Trial. MATERIALS AND METHODS Efficacy [myocardial infarction (MI) or recurrent stroke] new-onset diabetes) and adverse outcomes (oedema, weight gain, heart failure and bone fracture) were examined for subjects assigned to pioglitazone or placebo within strata defined by mode dose of study drug taken (i.e. the dose taken on most days in the study). RESULTS Among the 1938 patients randomized to pioglitazone, the mode dose was <15 mg/day in 546 participants, 15 mg/day in 128, 30 mg/day in 89, and 45 mg/day in 1175. There was no significant effect on stroke/MI or new-onset diabetes with <15 mg/day. For 15 mg/30 mg/day pooled, the adjusted hazard ratios (95% CI) for stroke/MI were 0.48 (0.30, 0.76; p = .002) and 0.74 (0.69, 0.94) for 45 mg/day. For new-onset diabetes, the adjusted hazard ratios were 0.34 (0.15, 0.81; p = .001) and 0.31 (0.59, 0.94; p = .001) respectively. For oedema, weight gain and heart failure, the risk estimates for pioglitazone were lower for subjects taking <45 mg daily. For fractures, the increased risk with pioglitazone was similar across all dose strata. CONCLUSIONS Lower doses of pioglitazone appear to confer much of the benefit with less adverse effects than the full dose. Further study is needed to confirm these findings so that clinicians may optimize dosing of this secondary prevention strategy in patients with stroke.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - Catherine Viscoli
- Section of General Medicine Yale School of Medicine, New Haven, Connecticut, USA
| | - Walter N Kernan
- Section of General Medicine Yale School of Medicine, New Haven, Connecticut, USA
| | - Lawrence H Young
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Karen Furie
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Ralph DeFronzo
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Muhammad Abdul-Ghani
- Diabetes Division, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Paresh Dandona
- Diabetes Center, Millard Fillmore Hospital, Buffalo, New York, USA
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
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Nouh A, Amin-Hanjani S, Furie KL, Kernan WN, Olson DM, Testai FD, Alberts MJ, Hussain MA, Cumbler EU. Identifying Best Practices to Improve Evaluation and Management of In-Hospital Stroke: A Scientific Statement From the American Heart Association. Stroke 2022; 53:e165-e175. [PMID: 35137601 DOI: 10.1161/str.0000000000000402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This scientific statement describes a path to optimizing care for patients who experience an in-hospital stroke. Although these patients are in a monitored environment, their evaluation and treatment are often delayed compared with patients presenting to the emergency department, contributing to higher rates of morbidity and mortality. Reducing delays and optimizing treatment for patients with in-hospital stroke could improve outcomes. This scientific statement calls for the development of hospital systems of care and targeted quality improvement for in-hospital stroke. We propose 5 core elements to optimize in-hospital stroke care: 1. Deliver stroke training to all hospital staff, including how to activate in-hospital stroke alerts. 2. Create rapid response teams with dedicated stroke training and immediate access to neurological expertise. 3. Standardize the evaluation of patients with potential in-hospital stroke with physical assessment and imaging. 4. Address barriers to treatment potentially, including interfacility transfer to advanced stroke treatment. 5. Establish an in-hospital stroke quality oversight program delivering data-driven performance feedback and driving targeted quality improvement efforts. Additional research is needed to better understand how to reduce the incidence, morbidity, and mortality of in-hospital stroke.
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Dearborn-Tomazos JL, viscoli C, Rivera J, Gull A, Lovelett L, Amin H, Kernan WN. Abstract 156: Main Results Of The Take Off Pounds After Stroke Trial. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
To test the effectiveness of a 12-week partial meal replacement (PMR) intervention for achieving meaningful weight loss in overweight or obese patients with a recent ischemic stroke.
Methods:
Take Off Pounds After Stroke (TOPS) was a prospective randomized open blinded endpoint trial. Eligible patients had an ischemic stroke within the past 90 days, were ≥18 years of age, with BMI 27 to 49.9 kg/m
2
, maximum weight ≤350 pounds (limit of home scale we provided), and were able to stand on a scale unassisted, meet all nutritional needs by oral intake, and ready to undergo behavioral change. Patients were excluded if they required dialysis, had a contra-indication to a weight loss diet, had lost ≥12 lbs in the prior 3 months, were allergic to soy, did not speak English or were pregnant, breast feeding, or desired to become pregnant. Patients were randomized to a PMR (OPTAVIA® Optimal Weight 4&2&1 Plan™) or enhanced standard care (SC). The PMR program is commercially available and consists of daily intake of four meal replacements, two “lean and green” meals and one healthy snack (1,100 to 1,300 calories per day). Enhanced standard care consisted of one instructional session on a healthy diet advocated by the US Department of Agriculture (and provision of a manual). The primary outcome was achievement of at least 5% weight loss at 12 weeks.
Results:
From 1 2/2019 to 2/2021, a total of 38 patients were enrolled from two sites. Two patients in each arm did not complete the study. At 12 weeks, 9 of 17 patients in the PMR group and 2 of 17 patients in the SC group achieved at least 5% weight loss (52.9% v. 11.9%; Fisher’s exact p=.02). Mean percent weight loss in the PMR group was 3.0% (SD 13.7) compared with 2.6% (SD 3.4) in the SC group (Wilcoxon rank sum p=.17). Patients in the PMR group had a mean change in waist circumference of -5.0 cms (SD 9.8) compared to -4.7 cms (SD 6.3) in the standard advice group (ANOVA p=.94). Changes in blood pressure and modified Rankin Scale did not differ between groups. No adverse outcomes were associated with the study intervention.
Conclusion:
A dietary intervention for weight loss implemented soon after ischemic stroke is feasible, safe and effective for weight loss.
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Affiliation(s)
| | | | | | - Anum Gull
- Beth Israel Deaconess Med Cente, Boston, MA
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Kernan WN. Eating Well to Prevent Stroke: Peanuts Are on the Plate. Stroke 2021; 52:3551-3554. [PMID: 34496614 DOI: 10.1161/strokeaha.121.036172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT
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Kernan WN, Viera AJ, Billinger SA, Bravata DM, Stark SL, Kasner SE, Kuritzky L, Towfighi A. Primary Care of Adult Patients After Stroke: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2021; 52:e558-e571. [PMID: 34261351 DOI: 10.1161/str.0000000000000382] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Primary care teams provide the majority of poststroke care. When optimally configured, these teams provide patient-centered care to prevent recurrent stroke, maximize function, prevent late complications, and optimize quality of life. Patient-centered primary care after stroke begins with establishing the foundation for poststroke management while engaging caregivers and family members in support of the patient. Screening for complications (eg, depression, cognitive impairment, and fall risk) and unmet needs is both a short-term and long-term component of poststroke care. Patients with ongoing functional impairments may benefit from referral to appropriate services. Ongoing care consists of managing risk factors such as high blood pressure, atrial fibrillation, diabetes, carotid stenosis, and dyslipidemia. Recommendations to reduce risk of recurrent stroke also include lifestyle modifications such as healthy diet and exercise. At the system level, primary care practices can use quality improvement strategies and available resources to enhance the delivery of evidence-based care and optimize outcomes.
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 958] [Impact Index Per Article: 319.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Lazar RM, Howard VJ, Kernan WN, Aparicio HJ, Levine DA, Viera AJ, Jordan LC, Nyenhuis DL, Possin KL, Sorond FA, White CL. A Primary Care Agenda for Brain Health: A Scientific Statement From the American Heart Association. Stroke 2021; 52:e295-e308. [PMID: 33719523 DOI: 10.1161/str.0000000000000367] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A healthy brain is critical for living a longer and fuller life. The projected aging of the population, however, raises new challenges in maintaining quality of life. As we age, there is increasing compromise of neuronal activity that affects functions such as cognition, also making the brain vulnerable to disease. Once pathology-induced decline begins, few therapeutic options are available. Prevention is therefore paramount, and primary care can play a critical role. The purpose of this American Heart Association scientific statement is to provide an up-to-date summary for primary care providers in the assessment and modification of risk factors at the individual level that maintain brain health and prevent cognitive impairment. Building on the 2017 American Heart Association/American Stroke Association presidential advisory on defining brain health that included "Life's Simple 7," we describe here modifiable risk factors for cognitive decline, including depression, hypertension, physical inactivity, diabetes, obesity, hyperlipidemia, poor diet, smoking, social isolation, excessive alcohol use, sleep disorders, and hearing loss. These risk factors include behaviors, conditions, and lifestyles that can emerge before adulthood and can be routinely identified and managed by primary care clinicians.
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Kiran A, Viscoli CM, Furie KL, Gorman M, Kernan WN. Adherence to study drug in a stroke prevention trial"?>. J Stroke Cerebrovasc Dis 2020; 29:105048. [PMID: 32912514 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Standards for reporting and analyzing adherence to medical therapy have recently improved due to international consensus efforts. If applied to clinical trial research in patients with stroke, these improvements have the potential to identify when in the sequence of trial operations participants are at risk for non-adherence and opportunities to safeguard adherence. METHODS We analyzed three phases of adherence according to the European Society for Patient Adherence, COMpliance, and Persistence (ESPACOMP) Medication Adherence Reporting Guideline (EMERGE) taxonomy in the Insulin Resistance Intervention after Stroke (IRIS) trial: initiation (did patient start drug), implementation (did patient take a drug holiday, defined as temporary cessation lasting ≥14 days), and persistence (did patient prematurely and permanently discontinue drug). IRIS was a randomized, placebo controlled, double-blind trial testing pioglitazone to prevent stroke or myocardial infarction in patients with a recent ischemic stroke or transient ischemic attack. Adherence was classified by self-report. Researchers used coaching algorithms to seek adherence recovery if participants went off drug. RESULTS During 2005-2013, 3876 participants were enrolled from 179 sites in seven countries and followed for a mean of 4.8 years. Less than 1% of participants in each group did not initiate study drug. 20% of patients assigned to pioglitazone and 17% assigned to placebo took at least one drug holiday. 36% and 30%, respectively, discontinued the study drug prematurely with or without a prior holiday. The risk for stopping the study drug (temporarily or permanently) in the first year after randomization was twice the risk in each of the subsequent four years. This was true both for patients assigned to active therapy and placebo. More participants assigned to pioglitazone, compared to placebo, took a drug holiday or permanently stopped study drug, but the difference in rates of discontinuation was only evident in year one. In years two through five, rates of discontinuation were similar in the two treatment groups. The difference in rates during year one was the result of adverse effects related to the active study drug, pioglitazone. During the remainder of the trial, the attribution of discontinuations to adverse effects potentially related to pioglitazone was reduced but still higher in those assigned to active drug. Other reasons for discontinuation were similar between treatment groups and were largely unrelated to pharmacodynamic effects of the study drug. Rates of discontinuation varied widely among research sites. CONCLUSION Patients in a drug trial for stroke prevention are at greatest risk for premature drug discontinuation early after randomization. Reasons for discontinuation change over time. Variable discontinuation rates among sites suggests that adherence can be improved by using best practices from high-performing sites.
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Affiliation(s)
| | | | - Karen L Furie
- Alpert Medical School of Brown University, Providence, RI, United States.
| | - Mark Gorman
- Maine Medical Center, Portland, ME, United States
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Endres M, Kernan WN. LDL (Low-Density Lipoprotein) Cholesterol Below 70. Stroke 2020; 51:2276-2278. [DOI: 10.1161/strokeaha.120.029429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthias Endres
- Klinik für Neurologie, Charité–Universitätsmedizin Berlin, Germany (M.E.)
| | - Walter N. Kernan
- Klinik für Neurologie, Charité–Universitätsmedizin Berlin, Germany (M.E.)
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Spence JD, Viscoli CM, Inzucchi SE, Dearborn-Tomazos J, Ford GA, Gorman M, Furie KL, Lovejoy AM, Young LH, Kernan WN. Pioglitazone Therapy in Patients With Stroke and Prediabetes: A Post Hoc Analysis of the IRIS Randomized Clinical Trial. JAMA Neurol 2020; 76:526-535. [PMID: 30734043 DOI: 10.1001/jamaneurol.2019.0079] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance In the Insulin Resistance Intervention After Stroke (IRIS) randomized clinical trial, pioglitazone, an insulin-sensitizing agent, reduced the risk for recurrent stroke or myocardial infarction (MI) among patients with insulin resistance. However, insulin resistance is not commonly measured in clinical practice. Objective To analyze the effects of pioglitazone in patients with good adherence as well as intention-to-treat effects of pioglitazone in patients with prediabetes in the IRIS trial. Design, Setting, and Participants The IRIS trial was a randomized multicenter clinical trial in patients with prior stroke or transient ischemic attack as well as insulin resistance but not diabetes. Patients were enrolled from February 2005 to January 2013, and the median follow-up was 4.8 years. The post hoc analyses reported here were performed from June to September 2018. Per American Diabetes Association criteria, prediabetes was defined as having a hemoglobin A1c level of 5.7% to 6.4% or fasting plasma glucose level of 100 mg/dL to 125 mg/dL (to convert to mmol/L, multiply by 0.0555). Good adherence was defined as taking 80% or more of the protocol dose. Fasting glucose and hemoglobin A1c, used to define prediabetes, and adherence of 80% or higher, stipulated in the protocol as defining good adherence, were prespecified subgroups in the analysis plan. Interventions Participants were randomized to 15 mg of pioglitazone, with dose titrated to target of 45 mg daily, or matching placebo. Main Outcomes and Measures The primary outcome was recurrent stroke or MI. Secondary outcomes included stroke, acute coronary syndrome, stroke/MI/hospitalization for heart failure, and progression to diabetes. Results Among 3876 participants analyzed in the IRIS trial, 2885 were included in this analysis (1456 in the pioglitazone cohort and 1429 in the placebo cohort). The mean (SD) age of patients was 64 (11) years, and 974 (66.9%) and 908 (63.5%) of patients were men in the pioglitazone and placebo cohort, respectively. In the prediabetic population with good adherence (644 of 1456 individuals [44.2%] in the pioglitazone group and 810 of 1429 [56.7%] in the placebo group), the hazard ratios (95% CI) were 0.57 (0.39-0.84) for stroke/MI, 0.64 (0.42-0.99) for stroke, 0.47 (0.26-0.85) for acute coronary syndrome, 0.61 (0.42-0.88) for stroke/MI/hospitalization for heart failure, and 0.18 (0.10-0.33) for progression to diabetes. There was a nonsignificant reduction in overall mortality, cancer, and hospitalization, a slight increase in serious bone fractures, and an increase in weight gain and edema. Intention-to-treat results also showed significant reduction of events but to a lesser degree. Hazard ratios (95% CI) were 0.70 (0.56-0.88) for stroke/MI, 0.72 (0.56-0.92) for stroke, 0.72 (0.52-1.00) for acute coronary syndrome, 0.78 (0.63-0.96), for stroke/MI/hospitalization for heart failure, and 0.46 (0.35 to 0.61) for progression to diabetes. Conclusions and Relevance Pioglitazone may be effective for secondary prevention in patients with stroke/transient ischemic attack and with prediabetes, particularly in those with good adherence. Trial Registration ClinicalTrials.gov identifier: NCT00091949.
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Affiliation(s)
- J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | | | - Silvio E Inzucchi
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Gary A Ford
- Radcliffe Department of Medicine, University of Oxford, United Kingdom
| | - Mark Gorman
- Department of Neurology, Maine Medical Center, Portland, Maine
| | - Karen L Furie
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Anne M Lovejoy
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Lawrence H Young
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Dearborn JL, Viscoli CM, Young LH, Gorman MJ, Furie KL, Kernan WN. Achievement of Guideline-Recommended Weight Loss Among Patients With Ischemic Stroke and Obesity. Stroke 2019; 50:713-717. [PMID: 30786849 DOI: 10.1161/strokeaha.118.024008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background and Purpose- The proportion of patients with acute ischemic stroke or transient ischemic attack (TIA) and obesity who successfully achieve goals for weight reduction recommended by major professional organizations is unknown. Methods- We examined the experience of participants in the placebo group of the IRIS trial (Insulin Resistance Intervention after Stroke) with a body mass index ≥30 kg/m2 at entry. Patients were of age ≥40 years, with a qualifying stroke or TIA within 180 days of randomization and documented insulin resistance without diabetes mellitus. Weights at baseline and at years 1 and 2 after entry were analyzed to determine the proportion of patients achieving a 5% weight loss and achievement of body mass index <27 kg/m2. Results- Of 1937 subjects assigned to placebo, 855 (44%) had obesity at entry. Median age of these 855 subjects was 60 years (interquartile range, 53-68), 41% were women, and median time from stroke/TIA to trial entry was 79 days. Among 788 subjects in the trial at 1 year, 166 (21%) had lost at least 5% of their starting weight and 12 (2%) had achieved a body mass index <27 kg/m2. One hundred nine (14%) participants gained at least 5% of their baseline weight at 1 year. Among 744 subjects in the trial at 2 years, 185 (25%) had lost at least 5% of their baseline weight and 23 (3%) had achieved a body mass index <27 kg/m2. One hundred forty (19%) participants gained at least 5% of their starting weight at 2 years. Conclusions- Only one quarter of obese patients with a recent ischemic stroke or TIA lost a clinically significant amount of weight after their vascular event. Many patients gained weight. Enhancing weight loss after ischemic stroke or TIA may help improve functional outcome and reduce risk for future vascular events, but clinical trials are needed to test and confirm these potential benefits.
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Affiliation(s)
- Jennifer L Dearborn
- From the Department of Neurology (J.L.D.), Yale School of Medicine, New Haven, CT.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (J.L.D.)
| | - Catherine M Viscoli
- Department of Internal Medicine (C.M.V., L.H.Y., W.N.K.), Yale School of Medicine, New Haven, CT
| | - Lawrence H Young
- Department of Internal Medicine (C.M.V., L.H.Y., W.N.K.), Yale School of Medicine, New Haven, CT
| | - Mark J Gorman
- Department of Neurology, Maine Medical Center, Portland, ME (M.J.G.)
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (K.L.F.)
| | - Walter N Kernan
- Department of Internal Medicine (C.M.V., L.H.Y., W.N.K.), Yale School of Medicine, New Haven, CT
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Affiliation(s)
- Silvio E Inzucchi
- Section of Endocrinology/Fitkin 106, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06520-8020, USA.
| | | | - Lawrence H Young
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Walter N Kernan
- Section of General Medicine, Yale School of Medicine, New Haven, CT, USA
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27
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Dearborn JL, Khera T, Peterson M, Shahab Z, Kernan WN. Diet quality in patients with stroke. Stroke Vasc Neurol 2019; 4:154-157. [PMID: 31709122 PMCID: PMC6812639 DOI: 10.1136/svn-2018-000224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/27/2019] [Accepted: 03/11/2019] [Indexed: 11/04/2022] Open
Abstract
Objective A healthy diet is associated with reduced risk for stroke, myocardial infarction, cancer and death. We examined the prevalence of a healthy diet in patients with a recent stroke or transient ischaemic attack (TIA). Methods We recruited a convenience sample of 95 patients with a recent ischaemic stroke or TIA. Using information from a 125-item Food Frequency Questionnaire, we calculated dietary quality and the percentage of patients meeting recommended daily intake (RDI) for common macronutrients and elements. Results The mean age of patients was 66 years (SD: 16) and 46% were women. 39 patients (41%) were classified as having a healthy diet (35% of men and 48% of women). The majority of patients were within the RDI for carbohydrates (56.8%), total fat (61.1%), long-chain n-3 fats (68.4%), polyunsaturated fats (79.0%) and protein (96.8%). Very few patients consumed the recommended intake for sodium (25.3%), and even fewer consumed the RDI for potassium (4.2%), with the majority of patients consuming too much sodium and too little potassium. Conclusion We found that most patients with recent stroke or TIA were not following a healthy diet before their stroke event. For most patients, sodium intake was much above and potassium intake was much below RDI.
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Affiliation(s)
- Jennifer L Dearborn
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Tehmina Khera
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Meghan Peterson
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Zartashia Shahab
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Walter N Kernan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Correction to: Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2019; 62:873. [PMID: 30899969 DOI: 10.1007/s00125-019-4845-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The affiliation details for Geltrude Mingrone are corrected below.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK.
- Leicester Diabetes Centre, Leicester General Hospital, Leicester, LE5 4PW, UK.
| | - David A D'Alessio
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Judith Fradkin
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
- Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Deborah J Wexler
- Department of Medicine and Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Young LH, Viscoli CM, Inzucchi SE, Kernan WN. Response by Young et al to Letters Regarding Article, "Cardiac Outcomes After Ischemic Stroke or Transient Ischemic Attack: Effects of Pioglitazone in Patients With Insulin Resistance Without Diabetes Mellitus". Circulation 2019; 136:1567-1568. [PMID: 29038213 DOI: 10.1161/circulationaha.117.030513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lawrence H Young
- From Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., S.E.I., W.N.K.); and Yale Cardiovascular Research Center, New Haven, CT (L.H.Y.)
| | - Catherine M Viscoli
- From Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., S.E.I., W.N.K.); and Yale Cardiovascular Research Center, New Haven, CT (L.H.Y.)
| | - Silvio E Inzucchi
- From Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., S.E.I., W.N.K.); and Yale Cardiovascular Research Center, New Haven, CT (L.H.Y.)
| | - Walter N Kernan
- From Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., S.E.I., W.N.K.); and Yale Cardiovascular Research Center, New Haven, CT (L.H.Y.)
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30
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Kernan WN, Viscoli C, Young L, Gorman M. Abstract WP525: Adherence and Adherence Recovery in a Stroke Trial. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Standards for reporting and analyzing adherence to medical therapy have recently improved due to international consensus efforts. We report adherence in a stroke trial using the EMERGE guidelines and demonstrate how support of patients can lead to adherence recovery during therapy implementation.
Methods:
We analyzed 3 phases of adherence according to current taxonomy in the Insulin Resistance Intervention after Stroke (IRIS) trial: initiation (did patient start drug), implementation (did patient take a drug holiday, defined as temporary cessation lasting ≥14 days), and persistence (did patient permanently and prematurely discontinue drug). IRIS was a randomized, placebo controlled trial testing pioglitazone to prevent stroke or MI in patients with ischemic stroke/TIA and insulin resistance. Adherence was classified by self-report. Researchers used coaching algorithms to seek adherence recovery if participants went off drug.
Results:
During 2005-2013, 3876 participants were enrolled from 179 sites in 7 countries. Mean age was 63.5 years; 65% were male, 11% Black race, and 4% Hispanic ethnicity. A total of 26 patients (<1%) did not start study drug. During implementation, 706 (18%) patients took a drug holiday: 587 took 1 holiday, 97 took 2, and 22 took ≥3. Study drug was discontinued early in 1275 (33%). Major reasons for holidays and discontinuations are shown below by treatment.
Conclusion:
For the first time in a stroke trial, we report adherence according to internationally recommended guidelines. Results show that holidays are common, but participants will resume drug with coaching. Among reasons for drug cessation, only those secondary to study protocol were unavoidable and misattributions of AEs to study drug were common as seen in the placebo group. Our findings have implications for trials that require high drug adherence to successfully answer scientific hypotheses.
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Viscoli CM, Kent DM, Conwit R, Dearborn JL, Furie KL, Gorman M, Guarino PD, Inzucchi SE, Stuart A, Young LH, Kernan WN. Scoring System to Optimize Pioglitazone Therapy After Stroke Based on Fracture Risk. Stroke 2019; 50:95-100. [PMID: 30580725 PMCID: PMC6557695 DOI: 10.1161/strokeaha.118.022745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background and Purpose- The insulin sensitizer, pioglitazone, reduces cardiovascular risk in patients after an ischemic stroke or transient ischemic attack but increases bone fracture risk. We conducted a secondary analysis of the IRIS trial (Insulin Resistance Intervention After Stroke) to assess the effect of pretreatment risk for fracture on the net benefits of pioglitazone therapy. Methods- IRIS was a randomized placebo-controlled trial of pioglitazone that enrolled patients with insulin resistance but without diabetes mellitus within 180 days of an ischemic stroke or transient ischemic attack. Participants were recruited at 179 international centers from February 2005 to January 2013 and followed for a median of 4.8 years. Fracture risk models were developed from patient characteristics at entry. Within fracture risk strata, we quantified the effects of pioglitazone compared with placebo by estimating the relative risks and absolute 5-year risk differences for fracture and stroke or myocardial infarction. Results- The fracture risk model included points for age, race-ethnicity, sex, body mass index, disability, and medications. The relative increment in fracture risk with pioglitazone was similar in the lower (
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Affiliation(s)
| | | | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, MD
| | | | - Karen L. Furie
- Alpert Medical School of Brown University, Providence, RI
| | | | | | | | - Amber Stuart
- University of Connecticut School of Medicine, Farmington, CT
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32
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Dearborn JL, Viscoli CM, Inzucchi SE, Young LH, Kernan WN. Metabolic syndrome identifies normal weight insulin-resistant stroke patients at risk for recurrent vascular disease. Int J Stroke 2018; 14:639-645. [PMID: 30507360 DOI: 10.1177/1747493018816425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The obesity paradox refers to the finding in observational studies that patients with obesity have a better prognosis after stroke than normal weight patients. AIM To test the hypothesis that there might be important heterogeneity within the obese stroke population, such that those with metabolic syndrome would be at higher risk for stroke or myocardial infarction and all-cause mortality compared to patients without metabolic syndrome. METHODS The Insulin Resistance Intervention after Stroke trial enrolled non-diabetic patients with a recent ischemic stroke or transient ischemic attack and insulin resistance. We examined the association between metabolic syndrome and outcome risk in patients with normal weight at entry (body mass index (BMI) = 18.5-24.9 kg/m2), overweight (BMI = 25-29.9 kg/m2), or obesity (BMI ≥ 30 kg/m2). Analyses were adjusted for demographic features, treatment assignment, smoking, and major comorbid conditions. RESULTS Metabolic syndrome was not associated with greater risk for stroke or myocardial infarction among 1536 patients who were overweight (adjusted hazard ratio (HR), 0.95; 95% confidence interval (CI): 0.69-1.31) or 1626 obese patients (adjusted HR, 1.00; 95% CI: 0.70-1.41). However, among 567 patients with a normal BMI, metabolic syndrome was associated with increased risk for stroke or myocardial infarction (adjusted HR, 2.05; 95% CI: 1.25-3.37), and all-cause mortality (adjusted HR, 1.70; 95% CI: 1.03-2.81) compared to patients without metabolic syndrome. CONCLUSIONS The presence of metabolic syndrome identified normal weight patients with insulin resistance but no diabetes who have a higher risk of adverse cardiovascular outcomes, compared with patients without metabolic syndrome.
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Affiliation(s)
- Jennifer L Dearborn
- 1 Beth Israel Deaconess Medical Center, Boston MA.,2 Yale School of Medicine, New Haven, CT, USA.,3 Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
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33
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Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018; 61:2461-2498. [PMID: 30288571 DOI: 10.1007/s00125-018-4729-5] [Citation(s) in RCA: 739] [Impact Index Per Article: 123.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK.
- Leicester Diabetes Centre, Leicester General Hospital, Leicester,, LE5 4PW, UK.
| | - David A D'Alessio
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Judith Fradkin
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy
- Diabetes and Nutritional Sciences, King's College London, London, UK
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Deborah J Wexler
- Department of Medicine and Diabetes Unit, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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34
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Davies MJ, D'Alessio DA, Fradkin J, Kernan WN, Mathieu C, Mingrone G, Rossing P, Tsapas A, Wexler DJ, Buse JB. Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018; 41:2669-2701. [PMID: 30291106 PMCID: PMC6245208 DOI: 10.2337/dci18-0033] [Citation(s) in RCA: 1651] [Impact Index Per Article: 275.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.
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Affiliation(s)
- Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, U.K.,Leicester Diabetes Centre, Leicester General Hospital, Leicester, U.K
| | - David A D'Alessio
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Judith Fradkin
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Walter N Kernan
- Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy.,Diabetes and Nutritional Sciences, King's College London, London, U.K
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - Apostolos Tsapas
- Second Medical Department, Aristotle University Thessaloniki, Thessaloniki, Greece
| | - Deborah J Wexler
- Department of Medicine and Diabetes Unit, Massachusetts General Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
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35
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Kernan WN, Viscoli CM, Horwitz RI. An Error in An Old Paper Illustrates the Need for Data/Code Archives - Author response. J Clin Epidemiol 2018; 107:129. [PMID: 30465873 DOI: 10.1016/j.jclinepi.2018.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Walter N Kernan
- Professor of Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Ralph I Horwitz
- Professor of Medicine, Temple University School of Medicine, Philadelphia, PA
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Young LH, Viscoli CM, Schwartz GG, Inzucchi SE, Curtis JP, Gorman MJ, Furie KL, Conwit R, Spatz E, Lovejoy A, Abbott JD, Jacoby DL, Kolansky DM, Ling FS, Pfau SE, Kernan WN. Heart Failure After Ischemic Stroke or Transient Ischemic Attack in Insulin-Resistant Patients Without Diabetes Mellitus Treated With Pioglitazone. Circulation 2018; 138:1210-1220. [PMID: 29934374 PMCID: PMC6202153 DOI: 10.1161/circulationaha.118.034763] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The IRIS trial (Insulin Resistance Intervention After Stroke) demonstrated that pioglitazone reduced the risk for both cardiovascular events and diabetes mellitus in insulin-resistant patients. However, concern remains that pioglitazone may increase the risk for heart failure (HF) in susceptible individuals. METHODS In IRIS, patients with insulin resistance but without diabetes mellitus were randomized to pioglitazone or placebo (1:1) within 180 days of an ischemic stroke or transient ischemic attack and followed for ≤5 years. To identify patients at higher HF risk with pioglitazone, we performed a secondary analysis of IRIS participants without HF history at entry. HF episodes were adjudicated by an external review, and treatment effects were analyzed using time-to-event methods. A baseline HF risk score was constructed from a Cox model estimated using stepwise selection. Baseline patient features (individually and summarized in risk score) and postrandomization events were examined as possible modifiers of the effect of pioglitazone. Net cardiovascular benefit was estimated for the composite of stroke, myocardial infarction, and hospitalized HF. RESULTS Among 3851 patients, the mean age was 63 years, and 65% were male. The 5-year HF risk did not differ by treatment (4.1% pioglitazone, 4.2% placebo). Risk for hospitalized HF was low and not significantly greater in pioglitazone compared with placebo groups (2.9% versus 2.3%, P=0.36). Older age, atrial fibrillation, hypertension, obesity, edema, high C-reactive protein, and smoking were risk factors for HF. However, the effect of pioglitazone did not differ across levels of baseline HF risk (hazard ratio [95% CI] for pioglitazone versus placebo for patients at low, moderate, and high risk: 1.03 [0.61-1.73], 1.10 [0.56-2.15], and 1.08 [0.58-2.01]; interaction P value=0.98). HF risk was increased in patients with versus those without incident myocardial infarction in both groups (pioglitazone: 31.4% versus 2.7%; placebo: 25.7% versus 2.4%; P<0.0001). Edema, dyspnea, and weight gain in the trial did not predict HF hospitalization but led to more study drug dose reduction with a lower mean dose of pioglitazone versus placebo (29±17 mg versus 33±15 mg, P<0.0001). Pioglitazone reduced the composite outcome of stroke, myocardial infarction, or hospitalized HF (hazard ratio, 0.78; P=0.007). CONCLUSIONS In IRIS, with surveillance and dose adjustments, pioglitazone did not increase the risk of HF and conferred net cardiovascular benefit in patients with insulin resistance and cerebrovascular disease. The risk of HF with pioglitazone was not modified by baseline HF risk. The IRIS experience may be instructive for maximizing the net benefit of this therapy. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00091949.
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Affiliation(s)
| | | | | | | | | | | | - Karen L. Furie
- Alpert Medical School of Brown University, Providence, RI
| | - Robin Conwit
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Erica Spatz
- Yale University School of Medicine, New Haven, CT
| | - Anne Lovejoy
- Yale University School of Medicine, New Haven, CT
| | - J. Dawn Abbott
- Alpert Medical School of Brown University, Providence, RI
| | | | - Daniel M. Kolansky
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frederick S. Ling
- University of Rochester School of Medicine and Dentistry, Rochester, NY
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Kernan WN. Keeping Faith With Patients After Stroke or Transient Ischemic Attack. JAMA Neurol 2018; 75:404-405. [DOI: 10.1001/jamaneurol.2017.4027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Walter N. Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Leira EC, Viscoli CM, Polgreen LA, Gorman M, Kernan WN. Distance from Home to Research Center: A Barrier to In-Person Visits but Not Treatment Adherence in a Stroke Trial. Neuroepidemiology 2018; 50:137-143. [PMID: 29587267 DOI: 10.1159/000486315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Accepted: 12/13/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Clinical trials often seek to enroll patients from both urban and rural areas to safeguard the generalizability of results. However, maintaining contact with patients who live away from a recruitment site, including rural areas, can be challenging. In this research we examine the effect of distance between patient and study centers on treatment adherence and retention. METHODS Secondary analysis of 2,466 participants in the Insulin Resistance Intervention after Stroke trial who were enrolled from research sites in the United States. Driving distance between the zipcodes of patient's reported place of residence and the study center was calculated. Outcome measures were loss to follow-up, completion of annual in-person visits, adherence to preventive therapy, and adherence to study drug in the first 3 years of participation. Logistic regression models were used to adjust for confounders. RESULTS Distance from residence to research center was not associated with loss to follow-up, adherence to study drug, or adherence to preventive therapy (p > 0.05 for each). However, patients who lived farther from the research center (>120 miles), compared to patients who lived closer (<60 miles), were less likely to complete the second annual in-person visit (62 vs. 81%; adjusted OR 0.48; 95% CI 0.31-0.75) and third visit (53 vs. 75%; adjusted OR 0.44; 95% CI 0.29-0.67). CONCLUSIONS Distance between patient and study center was an independent predictor of missed in-person visits but not with adherence to study treatment or preventive care.
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Affiliation(s)
- Enrique C Leira
- Colleges of Medicine, Iowa City, Iowa, USA.,Public Health, Iowa City, Iowa, USA
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Dearborn JL, Viscoli CM, Kernan WN. Abstract TP389: Achievement of Healthy Weight Loss Among Patients With Recent Ischemic Stroke or TIA and Obesity. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Approximately 30% of patients with a recent ischemic stroke or TIA are obese as defined by a body mass index (BMI) ≥30 kgs/m
2
. Guidelines from professional and governmental organizations recommend that patients with obesity lose weight to improve cardiovascular risk factors including glucose control, diabetes risk, blood pressure, and lipid metabolism. In this study, we examined the proportion of patients with a recent ischemic stroke or TIA who achieve these recommendations and meet two common goals for weight reduction within two years: 1) reduction of weight by 5% from baseline and reduction to a BMI <27 kgs/m
2
.
Methods:
Participants were men and women assigned to placebo treatment in the Insulin Resistance Intervention after Stroke (IRIS) Trial who were obese at the time of enrollment. The IRIS trial was a randomized trial that examined the effectiveness of pioglitazone compared with placebo for prevention of stroke or MI among non-diabetic patients with a recent ischemic stroke or TIA and insulin resistance. The trial enrolled participants from 2005 to 2012. Participants were followed for a minimum of 28 months and were seen in-person and weighed annually.
Results:
Of the 1937 participants in the placebo arm of IRIS, 855 (44%) had BMI≥30 kgs/m
2
at entry. Mean age was 61 years (standard deviation, 10) and 59% were male. At one year, 788 patients with obesity at baseline remained in the trial with weight measured (10 died, 14 dropped-out, and 43 were missing weight). Among these patients, 133 (17%) had lost 5% of their body weight and 12 (2%) had achieved a BMI < 27 kgs/m
2
at 12 months. Two years from randomization, 22% had lost 5% of their body weight and 3% had achieved a BMI <27 kgs/m
2
.
Conclusion:
In this cohort of patients with ischemic stroke or TIA and obesity, less than a quarter achieved even modest goals for weight loss after one or two years. Clinical trials will be required to determine if failure to lose weight represents a lost opportunity for secondary stroke prevention. Trials can determine 1) if weight loss is effective for preventing recurrent stroke, cardiovascular disease and diabetes and for improving function after ischemic stroke or TIA and 2) the amount of weight loss that must be achieved to realize meaningful benefit.
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Yaghi S, Furie K, Viscoli CM, Kamel H, Gorman M, Dearborn J, Young LH, Inzucchi SE, Lovejoy AM, Kasner SE, Conwit R, Kernan WN. Abstract 101: Pioglitazone Prevents Stroke in Patients With a Recent TIA or Ischemic Stroke: a Secondary Analysis of the IRIS Trial. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The Insulin Resistance Intervention after Stroke (IRIS) trial demonstrated that pioglitazone reduced risk for the composite outcome of stroke or myocardial infarction among non-diabetic patients with insulin resistance and a recent ischemic stroke or TIA. The drug also reduced risk for stroke alone, but the finding did not reach statistical significance. During the trial, the Data & Safety Monitoring Board approved a secondary analysis using updated 2013 consensus criteria for ischemic stroke. Our objective is to examine the effect of pioglitazone, compared with placebo, on risk for stroke alone defined by the 2013 criteria.
Methods:
Participants were randomized to pioglitazone (45 mg per day target dose) or placebo and followed for a maximum of 5 years. An independent committee, blinded to treatment assignments, adjudicated all potential stroke outcomes. The primary outcome was any stroke, but we also examined type of stroke (ischemic or hemorrhagic), and ischemic stroke subtype.
Results:
Among 3876 IRIS participants (mean age 63 years, 65% male), 377 stroke events were observed in 319 participants over a median follow-up of 4.8 years (329 stroke events by the original trial criteria plus 48 new events identified by applying the 2013 stroke criteria). Pioglitazone was associated with a 25% risk reduction for any stroke (8.0% compared to 10.7%; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.60 to 0.94) and a 28% reduction for ischemic stroke (HR, 0.72; 95% CI, 0.57 to 0.9) but not hemorrhagic stroke (HR, 1.00; 95% CI, 0.50-2.00). Pioglitazone was associated with fewer numbers of all subtypes of ischemic stroke, but the difference from placebo reached or approached significance only for lacunar (HR, 0·46; 95% CI, 0·22-0·93; p=0·03) and large vessel (HR, 0·59; 95% CI, 0·33-1·04; p=0·07) strokes.
Conclusion:
Pioglitazone prevents recurrent ischemic stroke among non-diabetic patients with insulin resistance.
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Furie KL, Viscoli CM, Gorman M, Ford GA, Young LH, Inzucchi SE, Guarino PD, Lovejoy AM, Conwit R, Tanne D, Kernan WN. Effects of pioglitazone on cognitive function in patients with a recent ischaemic stroke or TIA: a report from the IRIS trial. J Neurol Neurosurg Psychiatry 2018; 89:21-27. [PMID: 28939682 DOI: 10.1136/jnnp-2017-316361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Patients with cerebrovascular disease are at increased risk for cognitive dysfunction. Modification of vascular risk factors, including insulin resistance, could improve poststroke cognitive function. METHODS In the Insulin Resistance Intervention after Stroke (IRIS) trial, patients with a recent ischaemic stroke or transient ischaemic attack (TIA) were randomised to pioglitazone (target 45 mg daily) or placebo. All patients were insulin resistant based on a Homeostasis Model Assessment-Insulin Resistance score >3.0. For this preplanned analysis of cognitive function, we examined the Modified Mini-Mental State Examination (3MS) score (maximum score, 100) during follow-up. Patients were tested at baseline and annually for up to 5 years. Longitudinal mixed model methods were used to compare changes in the 3MS over time. RESULTS Of the 3876 IRIS participants, 3398 had a 3MS score at baseline and at least once during follow-up and were included in the analysis. Median 3MS score at baseline was 97 (IQR 93-99). The average overall least squared mean 3MS score increased by 0.27 in the pioglitazone group and by 0.29 in the placebo group (mean difference between treatment groups -0.02; 95% CI -0.33 to 0.28, p=0.88). CONCLUSIONS Among insulin-resistant patients with a recent ischaemic stroke or TIA, pioglitazone did not affect cognitive function, as measured by the 3MS, over 5 years. TRIAL REGISTRATION ClinicalTrials.gov NCT00091949; Results.
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Affiliation(s)
- Karen L Furie
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mark Gorman
- Department of Neurology, Maine Medical Center, Portland, Maine, USA
| | - Gary A Ford
- Radcliffe Department of Medicine, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lawrence H Young
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Peter D Guarino
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Anne M Lovejoy
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robin Conwit
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - David Tanne
- Sackler Faculty of Medicine, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Walter N Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Kernan WN, Viscoli CM, Dearborn JL, Kent DM, Conwit R, Fayad P, Furie KL, Gorman M, Guarino PD, Inzucchi SE, Stuart A, Young LH. Targeting Pioglitazone Hydrochloride Therapy After Stroke or Transient Ischemic Attack According to Pretreatment Risk for Stroke or Myocardial Infarction. JAMA Neurol 2017; 74:1319-1327. [PMID: 28975241 DOI: 10.1001/jamaneurol.2017.2136] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance There is growing recognition that patients may respond differently to therapy and that the average treatment effect from a clinical trial may not apply equally to all candidates for a therapy. Objective To determine whether, among patients with an ischemic stroke or transient ischemic attack and insulin resistance, those at higher risk for future stroke or myocardial infarction (MI) derive more benefit from the insulin-sensitizing drug pioglitazone hydrochloride compared with patients at lower risk. Design, Setting, and Participants A secondary analysis was conducted of the Insulin Resistance Intervention After Stroke trial, a double-blind, placebo-controlled trial of pioglitazone for secondary prevention. Patients were enrolled from 179 research sites in 7 countries from February 7, 2005, to January 15, 2013, and were followed up for a mean of 4.1 years through the study's end on July 28, 2015. Eligible participants had a qualifying ischemic stroke or transient ischemic attack within 180 days of entry and insulin resistance without type 1 or type 2 diabetes. Interventions Pioglitazone or matching placebo. Main Outcomes and Measures A Cox proportional hazards regression model was created using baseline features to stratify patients above or below the median risk for stroke or MI within 5 years. Within each stratum, the efficacy of pioglitazone for preventing stroke or MI was calculated. Safety outcomes were death, heart failure, weight gain, and bone fracture. Results Among 3876 participants (1338 women and 2538 men; mean [SD] age, 63 [11] years), the 5-year risk for stroke or MI was 6.0% in the pioglitazone group among patients at lower baseline risk compared with 7.9% in the placebo group (absolute risk difference, -1.9% [95% CI, -4.4% to 0.6%]). Among patients at higher risk, the risk was 14.7% in the pioglitazone group vs 19.6% for placebo (absolute risk difference, -4.9% [95% CI, -8.6% to 1.2%]). Hazard ratios were similar for patients below or above the median risk (0.77 vs 0.75; P = .92). Pioglitazone increased weight less among patients at higher risk but increased the risk for fracture more. Conclusions and Relevance After an ischemic stroke or transient ischemic attack, patients at higher risk for stroke or MI derive a greater absolute benefit from pioglitazone compared with patients at lower risk. However, the risk for fracture is also higher. Trial Registration clinicaltrials.gov Identifier: NCT00091949.
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Affiliation(s)
- Walter N Kernan
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Pierre Fayad
- Department of Neurological Sciences, University of Nebraska Medical School, Omaha
| | - Karen L Furie
- Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Peter D Guarino
- Statistical Center for HIV/AIDS Research Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amber Stuart
- University of Connecticut School of Medicine, Farmington
| | - Lawrence H Young
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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Yaghi S, Furie KL, Viscoli CM, Kamel H, Gorman M, Dearborn J, Young LH, Inzucchi SE, Lovejoy AM, Kasner SE, Conwit R, Kernan WN. Pioglitazone Prevents Stroke in Patients With a Recent Transient Ischemic Attack or Ischemic Stroke: A Planned Secondary Analysis of the IRIS Trial (Insulin Resistance Intervention After Stroke). Circulation 2017; 137:455-463. [PMID: 29084736 DOI: 10.1161/circulationaha.117.030458] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 10/04/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The IRIS trial (Insulin Resistance Intervention after Stroke) demonstrated that pioglitazone reduced the risk for a composite outcome of stroke or myocardial infarction among nondiabetic patients with insulin resistance and a recent stroke or transient ischemic attack. The current planned secondary analysis uses updated 2013 consensus criteria for ischemic stroke to examine the effect of pioglitazone on stroke outcomes. METHODS Participants were randomly assigned to receive pioglitazone (45 mg/d target dose) or placebo within 180 days of a qualifying ischemic stroke or transient ischemic attack and were followed for a maximum of 5 years. An independent committee, blinded to treatment assignments, adjudicated all potential stroke outcomes. Time to first stroke event was compared by treatment group, overall and by type of event (ischemic or hemorrhagic), using survival analyses and Cox proportional hazards models. RESULTS Among 3876 IRIS participants (mean age, 63 years; 65% male), 377 stroke events were observed in 319 participants over a median follow-up of 4.8 years. Pioglitazone was associated with a reduced risk for any stroke at 5 years (8.0% in comparison with 10.7% for the placebo group; hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.60-0.94; log-rank P=0.01). Pioglitazone reduced risk for ischemic strokes (HR, 0.72; 95% CI, 0.57-0.91; P=0.005) but had no effect on risk for hemorrhagic events (HR, 1.00; 95% CI, 0.50-2.00; P=1.00). CONCLUSIONS Pioglitazone was effective for secondary prevention of ischemic stroke in nondiabetic patients with insulin resistance. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00091949.
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Affiliation(s)
- Shadi Yaghi
- Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.)
| | - Karen L Furie
- Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F.)
| | - Catherine M Viscoli
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
| | - Hooman Kamel
- Weill Cornell Medical College, New York, NY (H.K.)
| | | | - Jennifer Dearborn
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
| | - Lawrence H Young
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
| | - Silvio E Inzucchi
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
| | - Anne M Lovejoy
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
| | | | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.)
| | - Walter N Kernan
- Yale School of Medicine, New Haven, CT (C.M.V., J.D., L.H.Y., S.E.I., A.M.L., W.N.K.)
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Epstein KA, Viscoli CM, Spence JD, Young LH, Inzucchi SE, Gorman M, Gerstenhaber B, Guarino PD, Dixit A, Furie KL, Kernan WN. Smoking cessation and outcome after ischemic stroke or TIA. Neurology 2017; 89:1723-1729. [PMID: 28887378 DOI: 10.1212/wnl.0000000000004524] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 07/14/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To assess whether smoking cessation after an ischemic stroke or TIA improves outcomes compared to continued smoking. METHODS We conducted a prospective observational cohort study of 3,876 nondiabetic men and women enrolled in the Insulin Resistance Intervention After Stroke (IRIS) trial who were randomized to pioglitazone or placebo within 180 days of a qualifying stroke or TIA and followed up for a median of 4.8 years. A tobacco use history was obtained at baseline and updated during annual interviews. The primary outcome, which was not prespecified in the IRIS protocol, was recurrent stroke, myocardial infarction (MI), or death. Cox regression models were used to assess the differences in stroke, MI, and death after 4.8 years, with correction for adjustment variables prespecified in the IRIS trial: age, sex, stroke (vs TIA) as index event, history of stroke, history of hypertension, history of coronary artery disease, and systolic and diastolic blood pressures. RESULTS At the time of their index event, 1,072 (28%) patients were current smokers. By the time of randomization, 450 (42%) patients had quit smoking. Among quitters, the 5-year risk of stroke, MI, or death was 15.7% compared to 22.6% for patients who continued to smoke (adjusted hazard ratio 0.66, 95% confidence interval 0.48-0.90). CONCLUSION Cessation of cigarette smoking after an ischemic stroke or TIA was associated with significant health benefits over 4.8 years in the IRIS trial cohort.
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Affiliation(s)
- Katherine A Epstein
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Catherine M Viscoli
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - J David Spence
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Lawrence H Young
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Silvio E Inzucchi
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Mark Gorman
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Brett Gerstenhaber
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Peter D Guarino
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Anand Dixit
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Karen L Furie
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI
| | - Walter N Kernan
- From the Yale School of Medicine (K.A.E., C.M.V., L.H.Y., S.E.I., B.G., W.N.K.), New Haven, CT; University of Western Ontario (J.D.S.), London, Canada; Maine Medical Center (M.G.), Portland; Fred Hutchinson Cancer Research Center (P.D.G.), Seattle, WA; University of Newcastle Upon Tyne (A.D.), Newcastle, UK; and Alpert Medical School of Brown University (K.L.F.), Providence, RI.
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Inzucchi SE, Viscoli CM, Young LH, Furie KL, Gorman M, Lovejoy AM, Dagogo-Jack S, Ismail-Beigi F, Korytkowski MT, Pratley RE, Schwartz GG, Kernan WN. Response to Comment on Inzucchi et al. Pioglitazone Prevents Diabetes in Patients With Insulin Resistance and Cerebrovascular Disease. Diabetes Care 2016;39:1684-1692. Diabetes Care 2017; 40:e47-e48. [PMID: 28325804 PMCID: PMC5360290 DOI: 10.2337/dci16-0048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
| | | | | | - Karen L Furie
- Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | - Gregory G Schwartz
- VA Medical Center and University of Colorado School of Medicine, Denver, CO
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Viscoli CM, Inzucchi SE, Young LH, Insogna KL, Conwit R, Furie KL, Gorman M, Kelly MA, Lovejoy AM, Kernan WN. Pioglitazone and Risk for Bone Fracture: Safety Data From a Randomized Clinical Trial. J Clin Endocrinol Metab 2017; 102:914-922. [PMID: 27935736 PMCID: PMC5460686 DOI: 10.1210/jc.2016-3237] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 12/08/2016] [Indexed: 01/27/2023]
Abstract
CONTEXT Pioglitazone reduces cardiovascular risk in nondiabetic patients after an ischemic stroke or transient ischemic attack (TIA) but is associated with increased risk for bone fracture. OBJECTIVE To characterize fractures associated with pioglitazone by location, mechanism, severity, timing, and sex. DESIGN, SETTING, AND PATIENTS Patients were 3876 nondiabetic participants in the Insulin Resistance Intervention after Stroke trial randomized to pioglitazone or placebo and followed for a median of 4.8 years. Fractures were identified through quarterly interviews. RESULTS At 5 years, the increment in fracture risk between pioglitazone and placebo groups was 4.9% [13.6% vs 8.8%; hazard ratio (HR), 1.53; 95% confidence interval (CI), 1.24 to 1.89). In each group, ∼80% of fractures were low energy (i.e., resulted from fall) and 45% were serious (i.e., required surgery or hospitalization). For serious fractures most likely to be related to pioglitazone (low energy, nonpathological), the risk increment was 1.6% (4.7% vs 3.1%; HR, 1.47; 95% CI, 1.03 to 2.09). Increased risk for any fracture was observed in men (9.4% vs 5.2%; HR, 1.83; 95% CI, 1.36 to 2.48) and women (14.9% vs 11.6%; HR, 1.32; 95% CI, 0.98 to 1.78; interaction P = 0.13). CONCLUSIONS Fractures affected 8.8% of placebo-treated patients within 5 years after an ischemic stroke or TIA. Pioglitazone increased the absolute fracture risk by 1.6% to 4.9% and the relative risk by 47% to 60%, depending on fracture classification. Our analysis suggests that treatments to improve bone health and prevent falls may help optimize the risk/benefit ratio for pioglitazone.
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Affiliation(s)
| | | | | | | | - Robin Conwit
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland 20892;
| | - Karen L. Furie
- Alpert Medical School of Brown University, Providence, Rhode Island 02903;
| | - Mark Gorman
- Maine Medical Center, Portland, Maine 04102; and
| | - Michael A. Kelly
- Division of Neurology, Cook County Health and Hospitals System, Chicago, Illinois 60612
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Young LH, Viscoli CM, Curtis JP, Inzucchi SE, Schwartz GG, Lovejoy AM, Furie KL, Gorman MJ, Conwit R, Abbott JD, Jacoby DL, Kolansky DM, Pfau SE, Ling FS, Kernan WN. Cardiac Outcomes After Ischemic Stroke or Transient Ischemic Attack: Effects of Pioglitazone in Patients With Insulin Resistance Without Diabetes Mellitus. Circulation 2017; 135:1882-1893. [PMID: 28246237 DOI: 10.1161/circulationaha.116.024863] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Insulin resistance is highly prevalent among patients with atherosclerosis and is associated with an increased risk for myocardial infarction (MI) and stroke. The IRIS trial (Insulin Resistance Intervention after Stroke) demonstrated that pioglitazone decreased the composite risk for fatal or nonfatal stroke and MI in patients with insulin resistance without diabetes mellitus, after a recent ischemic stroke or transient ischemic attack. The type and severity of cardiac events in this population and the impact of pioglitazone on these events have not been described. METHODS We performed a secondary analysis of the effects of pioglitazone, in comparison with placebo, on acute coronary syndromes (MI and unstable angina) among IRIS participants. All potential acute coronary syndrome episodes were adjudicated in a blinded fashion by an independent clinical events committee. RESULTS The study cohort was composed of 3876 IRIS participants, mean age 63 years, 65% male, 89% white race, and 12% with a history of coronary artery disease. Over a median follow-up of 4.8 years, there were 225 acute coronary syndrome events, including 141 MIs and 84 episodes of unstable angina. The MIs included 28 (19%) with ST-segment elevation. The majority of MIs were type 1 (94, 65%), followed by type 2 (45, 32%). Serum troponin was 10× to 100× upper limit of normal in 49 (35%) and >100× upper limit of normal in 39 (28%). Pioglitazone reduced the risk of acute coronary syndrome (hazard ratio, 0.71; 95% confidence interval, 0.54-0.94; P=0.02). Pioglitazone also reduced the risk of type 1 MI (hazard ratio, 0.62; 95% confidence interval, 0.40-0.96; log-rank P=0.03), but not type 2 MI (hazard ratio, 1.05; 95% confidence interval, 0.58-1.91; P=0.87). Similarly, pioglitazone reduced the risk of large MIs with serum troponin >100× upper limit of normal (hazard ratio, 0.44; 95% confidence interval, 0.22-0.87; P=0.02), but not smaller MIs. CONCLUSIONS Among patients with insulin resistance without diabetes mellitus, pioglitazone reduced the risk for acute coronary syndromes after a recent cerebrovascular event. Pioglitazone appeared to have its most prominent effect in preventing spontaneous type 1 MIs. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00091949.
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Affiliation(s)
- Lawrence H Young
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.).
| | - Catherine M Viscoli
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Jeptha P Curtis
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Silvio E Inzucchi
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Gregory G Schwartz
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Anne M Lovejoy
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Karen L Furie
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Mark J Gorman
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Robin Conwit
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - J Dawn Abbott
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Daniel L Jacoby
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Daniel M Kolansky
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Steven E Pfau
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Frederick S Ling
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
| | - Walter N Kernan
- From Yale University School of Medicine, New Haven, CT (L.H.Y., C.M.V., J.P.C., S.E.I., A.M.L., D.L.J., S.E.P., W.N.K.); Denver VA Medical Center and University of Colorado School of Medicine (G.G.S., J.D.A.); Alpert Medical School of Brown University, Providence, RI (K.L.F., J.D.A.); Maine Medical Center, Portland (M.J.G.); National Institutes of Health/National Institute of Neurological Disorders and Stroke, Bethesda, MD (R.C.); University of Pennsylvania Perelman School of Medicine, Philadelphia (D.M.K.); and University of Rochester School of Medicine and Dentistry, NY (F.S.L.)
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Dearborn JL, Viscoli CM, Inzucchi SE, Young LH, Kernan WN. Abstract 74: Obesity and the Risk of Recurrent Vascular Events in Patients with Ischemic Stroke: Insights from the Insulin Resistance Intervention after Stroke (IRIS) Trial. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In epidemiologic research, patients with obesity have, on average, a lower risk for recurrent cardiovascular events after ischemic stroke compared with non-obese patients. Despite this “obesity paradox,” we hypothesized that clinical features associated with more severe metabolic disease would identify overweight and obese stroke patients at high risk for recurrent vascular events.
Methods:
The
IRIS
trial examined the efficacy of pioglitazone compared with placebo, for prevention of stroke/ myocardial infarction (MI) among non-diabetic insulin resistant patients with a recent ischemic stroke or TIA. Patients were followed for a median of 4.8 years. Among 3,707 participants, we first examined risk of recurrent stroke/MI by obesity status at baseline (overweight or obese [BMI ≥25] vs <25) using Cox proportional hazards models with and without adjustment for sociodemographic factors, smoking and vascular disease history. Next, for 3,142 participants with BMI ≥ 25, a Cox model including 7 baseline features (systolic blood pressure, C-reactive protein, HOMA-IR, hemoglobin A1C, waist circumference, triglycerides and high density lipoprotein) was used to stratify patients into tertiles of “metabolic risk”. The hazard of stroke/MI was then calculated across risk tertiles(T).
Results:
Overweight and obese participants had a lower incidence of stroke or MI compared with non-obese patients (10.1% vs.12.6%; hazard ratio [HR] 0.77, [0.59-0.99]) and the difference was attenuated after adjustment (HR 0.85 [0.66-1.11]). Among overweight and obese patients, a metabolic risk score identified patients at higher risk of stroke or MI (T3 12.2%, T2 9.2%, T1 9.0%; T3 vs. T1 HR 1.40 [1.08, 1.83]). This association remained significant after adjustments (HR 1.33 [1.02, 1.75]).
Conclusion:
Although overweight and obese patients may on average have lower risk of recurrent stroke or MI after an ischemic stroke or TIA compared with non-obese individuals, those with advanced metabolic impairment also have a high absolute risk of recurrence.
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Stuart AC, Sico JJ, Viscoli CM, Tayal AH, Inzucchi SE, Ford GA, Furie KL, Cote R, Spence JD, Tanne D, Kernan WN. Taking care of volunteers in a stroke trial: a new assisted-management strategy. Stroke Vasc Neurol 2016; 1:108-114. [PMID: 28959471 PMCID: PMC5435205 DOI: 10.1136/svn-2016-000029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 08/22/2016] [Accepted: 08/25/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AND PURPOSE Providing participants with evidence-based care for secondary prevention is an ethical and scientific priority for trials in stroke therapy. The optimal strategy, however, is uncertain. We report the performance of a new approach for delivering preventive care to trial participants. METHODS Participants were enrolled in the Insulin Resistance Intervention after Stroke trial, which examined the insulin sensitiser, pioglitazone versus placebo for prevention of stroke and myocardial infarction after ischaemic stroke or transient ischaemic attack. Preventive care was the responsibility of the participants' personal healthcare providers, but investigators monitored care and provided feedback annually. We studied achievement of 8 prevention goals at baseline and 3 annual visits, with a focus on 3 priority goals: blood pressure <140/90 mm Hg, low-density lipoprotein (LDL) cholesterol <2.59 mmol/L and antithrombotic therapy. RESULTS The proportion of participants achieving the priority goals was highest for antithrombotic use (96-99% in each year) and similar for blood pressure (66-72% in each year) and LDL (68-70% in each year). All 3 priority goals were achieved by 47-52% of participants in any given year. However, only 22% of participants achieved all 3 goals in each year. CONCLUSIONS A strategy of monitoring care and providing feedback was associated with high average yearly achievement of 3 priority secondary prevention goals, but the majority of trial participants did not persist in being at goal over time. TRIAL REGISTRATION NUMBER NCT00091949.
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Affiliation(s)
- Amber C Stuart
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jason J Sico
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Department of Neurology Service, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Catherine M Viscoli
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ashis H Tayal
- Neuroscience Institute, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Silvio E Inzucchi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary A Ford
- Division of Medical Sciences, Oxford University, Oxford, UK
| | - Karen L Furie
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Robert Cote
- Department of Neurology, Neurosurgery and Medicine, McGill University, Montreal, Quebec, Canada
| | | | - David Tanne
- Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Walter N Kernan
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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50
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Inzucchi SE, Viscoli CM, Young LH, Furie KL, Gorman M, Lovejoy AM, Dagogo-Jack S, Ismail-Beigi F, Korytkowski MT, Pratley RE, Schwartz GG, Kernan WN. Pioglitazone Prevents Diabetes in Patients With Insulin Resistance and Cerebrovascular Disease. Diabetes Care 2016; 39:1684-92. [PMID: 27465265 PMCID: PMC5033078 DOI: 10.2337/dc16-0798] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/04/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Insulin Resistance Intervention after Stroke (IRIS) trial recently found that pioglitazone reduced risk for stroke and myocardial infarction in patients with insulin resistance but without diabetes who had had a recent ischemic stroke or transient ischemic attack (TIA). This report provides detailed results on the metabolic effects of pioglitazone and the trial's prespecified secondary aim of diabetes prevention. RESEARCH DESIGN AND METHODS A total of 3,876 patients with recent ischemic stroke or TIA, no history of diabetes, fasting plasma glucose (FPG) <126 mg/dL, and insulin resistance by homeostasis model assessment of insulin resistance (HOMA-IR) score >3.0 were randomly assigned to pioglitazone or placebo. Surveillance for diabetes onset during the trial was accomplished by periodic interviews and annual FPG testing. RESULTS At baseline, the mean FPG, HbA1c, insulin, and HOMA-IR were 98.2 mg/dL (5.46 mmol/L), 5.8% (40 mmol/mol), 22.4 μIU/mL, and 5.4, respectively. After 1 year, mean HOMA-IR and FPG decreased to 4.1 and 95.1 mg/dL (5.28 mmol/L) in the pioglitazone group and rose to 5.7 and 99.7 mg/dL (5.54 mmol/L), in the placebo group (all P < 0.0001). Over a median follow-up of 4.8 years, diabetes developed in 73 (3.8%) participants assigned to pioglitazone compared with 149 (7.7%) assigned to placebo (hazard ratio [HR] 0.48 [95% CI 0.33-0.69]; P < 0.0001). This effect was predominately driven by those with initial impaired fasting glucose (FPG >100 mg/dL [5.6 mmol/L]; HR 0.41 [95% CI 0.30-0.57]) or elevated HbA1c (>5.7% [39 mmol/mol]; HR 0.46 [0.34-0.62]). CONCLUSIONS Among patients with insulin resistance but without diabetes who had had a recent ischemic stroke or TIA, pioglitazone decreased the risk of diabetes while also reducing the risk of subsequent ischemic events. Pioglitazone is the first medication shown to prevent both progression to diabetes and major cardiovascular events as prespecified outcomes in a single trial.
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Affiliation(s)
| | | | | | - Karen L Furie
- Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | - Gregory G Schwartz
- VA Medical Center and University of Colorado School of Medicine, Denver, CO
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