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Hollingworth M, Woodhouse LJ, Law ZK, Ali A, Krishnan K, Dineen RA, Christensen H, England TJ, Roffe C, Werring D, Peters N, Ciccone A, Robinson T, Członkowska A, Bereczki D, Egea-Guerrero JJ, Ozturk S, Bath PM, Sprigg N. The Effect of Tranexamic Acid on Neurosurgical Intervention in Spontaneous Intracerebral Hematoma: Data From 121 Surgically Treated Participants From the Tranexamic Acid in IntraCerebral Hemorrhage-2 Randomized Controlled Trial. Neurosurgery 2024:00006123-990000000-01177. [PMID: 38785451 DOI: 10.1227/neu.0000000000002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES An important proportion of patients with spontaneous intracerebral hemorrhage (ICH) undergo neurosurgical intervention to reduce mass effect from large hematomas and control the complications of bleeding, including hematoma expansion and hydrocephalus. The Tranexamic acid (TXA) for hyperacute primary IntraCerebral Hemorrhage (TICH-2) trial demonstrated that tranexamic acid (TXA) reduces the risk of hematoma expansion. We hypothesized that TXA would reduce the frequency of surgery (primary outcome) and improve functional outcome at 90 days in surgically treated patients in the TICH-2 data set. METHODS Participants enrolled in TICH-2 were randomized to placebo or TXA. Participants randomized to either TXA or placebo were analyzed for whether they received neurosurgery within 7 days and their characteristics, outcomes, hematoma volumes (HVs) were compared. Characteristics and outcomes of participants who received surgery were also compared with those who did not. RESULTS Neurosurgery was performed in 5.2% of participants (121/2325), including craniotomy (57%), hematoma drainage (33%), and external ventricular drainage (21%). The number of patients receiving surgery who received TXA vs placebo were similar at 4.9% (57/1153) and 5.5% (64/1163), respectively (odds ratio [OR] 0.893; 95% CI 0.619-1.289; P-value = .545). TXA did not improve outcome compared with placebo in either surgically treated participants (OR 0.79; 95% CI 0.30-2.09; P = .64) or those undergoing hematoma evacuation by drainage or craniotomy (OR 1.19 95% 0.51-2.78; P-value = .69). Postoperative HV was not reduced by TXA (mean difference -8.97 95% CI -23.77, 5.82; P-value = .45). CONCLUSION TXA was not associated with less neurosurgical intervention, reduced HV, or improved outcomes after surgery.
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Affiliation(s)
- Milo Hollingworth
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, UK
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhe K Law
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Azlinawati Ali
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Faculty of Health Sciences, School of Medical Imaging, University of Sultan Zainal Abidin, Kuala Nerus, Malaysia
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital, Bispebjerg, Denmark
| | - Timothy J England
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Royal Derby Hospital, University Hospitals of Derby and Burton, Derby, UK
| | - Christine Roffe
- Stroke Research, School of Medicine, Keele University, Newcastle under Lyme, UK
| | - David Werring
- Stroke Research Centre, Brain Repair & Rehabilitation, UCL Queen Square Institute of Neurology, London, UK
| | - Nils Peters
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alfonso Ciccone
- Azienda Socio Sanitaria Territoriale di Mantova, Mantova, Italy
| | | | | | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | | | - Serefnur Ozturk
- Department of Neurology, Neurointensive Care- Stroke Center, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Queen's Medical Centre, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Department of Acute Medicine, Nottingham University Hospitals, Nottingham, UK
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2
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Lim A, Ma H, Johnston SC, Singhal S, Muthusamy S, Wang Y, Pan Y, Coutts SB, Hill MD, Ois A, Kapral MK, Knoflach M, Woodhouse LJ, Bath PM, Phan TG. Ninety-Day Stroke Recurrence in Minor Stroke: Systematic Review and Meta-Analysis of Trials and Observational Studies. J Am Heart Assoc 2024; 13:e032471. [PMID: 38641856 DOI: 10.1161/jaha.123.032471] [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: 08/31/2023] [Accepted: 03/18/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5. METHODS AND RESULTS Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1; P=0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0). CONCLUSIONS The risk of recurrence after minor ischemic stroke is declining over time but remains important.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Emergency Medicine Monash Health Melbourne Victoria Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | | | - Shaloo Singhal
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Subramanian Muthusamy
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University Beijing China
- China National Clinical Research Centre for Neurological Diseases Beijing China
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, University of Calgary Alberta Canada
| | - Angel Ois
- Servicio de Neurologı'a, Hospital del Mar Barcelona Spain
| | - Moira K Kapral
- Department of Medicine University of Toronto Ontario Canada
| | - Michael Knoflach
- Department of Neurology Innsbruck Medical University Innsbruck Austria
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience University of Nottingham, Queen's Medical Centre Nottingham United Kingdom
| | - Thanh G Phan
- School of Clinical Sciences at Monash Health Monash University Melbourne Victoria Australia
- Department of Neurology Monash Health Melbourne Victoria Australia
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3
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Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [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: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
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Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Wang X, Yang J, Moullaali TJ, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw J, Anderson CS, Sakamoto Y, Bath PM, Chalmers J. Influence of Time to Achieve Target Systolic Blood Pressure on Outcome After Intracerebral Hemorrhage: The Blood Pressure in Acute Stroke Collaboration. Stroke 2024. [PMID: 38410986 DOI: 10.1161/strokeaha.123.044358] [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: 07/12/2023] [Accepted: 01/17/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To investigate whether an earlier time to achieving and maintaining systolic blood pressure (SBP) at 120 to 140 mm Hg is associated with favorable outcomes in a cohort of patients with acute intracerebral hemorrhage. METHODS We pooled individual patient data from randomized controlled trials registered in the Blood Pressure in Acute Stroke Collaboration. Time was defined as time form symptom onset plus the time (hour) to first achieve and subsequently maintain SBP at 120 to 140 mm Hg over 24 hours. The primary outcome was functional status measured by the modified Rankin Scale at 90 to 180 days. A generalized linear mixed models was used, with adjustment for covariables and trial as a random effect. RESULTS A total of 5761 patients (mean age, 64.0 [SD, 13.0], 2120 [36.8%] females) were included in analyses. Earlier SBP control was associated with better functional outcomes (modified Rankin Scale score, 3-6; odds ratio, 0.98 [95% CI, 0.97-0.99]) and a significant lower risk of hematoma expansion (0.98, 0.96-1.00). This association was stronger in patients with bigger baseline hematoma volume (>10 mL) compared with those with baseline hematoma volume ≤10 mL (0.006 for interaction). Earlier SBP control was not associated with cardiac or renal adverse events. CONCLUSIONS Our study confirms a clear time relation between early versus later SBP control (120-140 mm Hg) and outcomes in the one-third of patients with intracerebral hemorrhage who attained sustained SBP levels within this range. These data provide further support for the value of early recognition, rapid transport, and prompt initiation of treatment of patients with intracerebral hemorrhage.
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Affiliation(s)
- Xia Wang
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (J.Y.)
| | - Tom J Moullaali
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Norway (E.C.S.)
- Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Lisa J Woodhouse
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
- Neurology Unit, Department of Medicine, National University of Malaysia, Kuala Lumpur (Z.K.L.)
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Japan (H.A.)
| | - Kenneth S Butcher
- School of Clinical Medicine, University of New South Wales, Australia. (K.S.B.)
- Division of Neurology, University of Alberta, Edmonton, Canada (K.S.B.)
| | - Candice Delcourt
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D., C.S.A.)
| | - Leon Edwards
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, Australia (L.E.)
| | - Salil Gupta
- Department of Neurology, Army Hospital Research and Referral, New Delhi, India (S.G.)
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China (W.J.)
- The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China (W.J.)
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, United States (S.K.)
| | - John Potter
- Stroke Research Group, Norfolk and Norwich University Hospital, United Kingdom (J.P.)
- Norwich Medical School, University of East Anglia, UK (J.P.)
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia (A.I.Q.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles (J.L.S.)
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M., R.A.-S.S., J.W.)
| | - Craig S Anderson
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
- Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D., C.S.A.)
- The George Institute China, Beijing (C.S.A.)
| | - Yuki Sakamoto
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan (Y.S.)
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, United Kingdom (L.J.W., Z.K.L., N.S., P.M.B.)
- Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (Z.K.L., N.S., P.M.B.)
| | - John Chalmers
- Faculty of Medicine, George Institute for Global Health, University of New South Wales, Australia. (X.W., T.J.M., C.D., C.S.A., J.C.)
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5
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Appleton JP, Woodhouse LJ, Anderson CS, Ankolekar S, Cala L, Dixon M, England TJ, Krishnan K, Mair G, Muir KW, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Sandset EC, Saver JL, Shone A, Siriwardena AN, Wardlaw JM, Sprigg N, Bath PM. Prehospital transdermal glyceryl trinitrate for ultra-acute ischaemic stroke: data from the RIGHT-2 randomised sham-controlled ambulance trial. Stroke Vasc Neurol 2024; 9:38-49. [PMID: 37290930 PMCID: PMC10956104 DOI: 10.1136/svn-2022-001634] [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: 04/14/2022] [Accepted: 08/12/2022] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The effect of transdermal glyceryl trinitrate (GTN, a nitrovasodilator) on clinical outcome when administered before hospital admission in suspected stroke patients is unclear. Here, we assess the safety and efficacy of GTN in the prespecified subgroup of patients who had an ischaemic stroke within the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). METHODS RIGHT-2 was an ambulance-based multicentre sham-controlled blinded-endpoint study with patients randomised within 4 hours of onset. The primary outcome was a shift in scores on the modified Rankin scale (mRS) at day 90. Secondary outcomes included death; a global analysis (Wei-Lachin test) containing Barthel Index, EuroQol-5D, mRS, telephone interview for cognitive status-modified and Zung depression scale; and neuroimaging-determined 'brain frailty' markers. Data were reported as n (%), mean (SD), median [IQR], adjusted common OR (acOR), mean difference or Mann-Whitney difference (MWD) with 95% CI. RESULTS 597 of 1149 (52%) patients had a final diagnosis of ischaemic stroke; age 75 (12) years, premorbid mRS>2 107 (18%), Glasgow Coma Scale 14 (2) and time from onset to randomisation 67 [45, 108] min. Neuroimaging 'brain frailty' was common: median score 2 [2, 3] (range 0-3). At day 90, GTN did not influence the primary outcome (acOR for increased disability 1.15, 95% CI 0.85 to 1.54), death or global analysis (MWD 0.00, 95% CI -0.10 to 0.09). In subgroup analyses, there were non-significant interactions suggesting GTN may be associated with more death and dependency in participants randomised within 1 hour of symptom onset and in those with more severe stroke. CONCLUSIONS In patients who had an ischaemic stroke, ultra-acute administration of transdermal GTN in the ambulance did not improve clinical outcomes in a population with more clinical and radiological frailty than seen in previous in-hospital trials.
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Affiliation(s)
- Jason Philip Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Craig S Anderson
- Faculty of Medicine, The George Institute for Global Health, Sydney, New South Wales, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
- Neurology, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, New South Wales, Australia
| | - Sandeep Ankolekar
- Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Mark Dixon
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Grant Mair
- Centre for Clinical Brain Sciences, Dementia Research Institute, Univeristy of Edinburgh, Edinburgh, UK
| | - Keith W Muir
- Institute of Neurology and Psychology, University of Glasgow, Glasgow, UK
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Angela Shone
- Research and Graduate Services, University of Nottingham, Nottingham, UK
| | - Aloysius Niroshan Siriwardena
- East Midlands Ambulance Service NHS Trust, Nottingham, UK
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Dementia Research Institute, Univeristy of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Woodhouse LJ, Montgomery AA, Pocock S, James M, Ranta A, Bath PM. Optimising the analysis of vascular prevention trials: Re-Assessment of the TARDIS trial, the first prevention trial to adopt an ordinal primary outcome measure. Contemp Clin Trials Commun 2023; 35:101186. [PMID: 37745289 PMCID: PMC10517366 DOI: 10.1016/j.conctc.2023.101186] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/19/2023] [Accepted: 07/03/2023] [Indexed: 09/26/2023] Open
Abstract
Background Ordinalised vascular outcomes incorporating event severity are more informative than binary outcomes that just include event numbers. The TARDIS trial was the first vascular prevention study to use an ordinalised vascular outcome as its primary efficacy and safety measures and collected severity information for other vascular events. Methods TARDIS was an international prospective randomised open-label blinded-endpoint trial assessing one month of intensive versus guideline antiplatelet therapy in patients with acute non-cardioembolic stroke or TIA. Vascular events and their severity were recorded up to final follow-up at 90 days post randomisation. For each outcome, statistical techniques compared ordinal/continuous (10 models) and dichotomous (5 models) analyses; results were then ranked with the smallest p-value being given the smallest rank. Outcomes were also assessed within the pre-defined subgroup of participants with mild stroke (NIHSS≤3), or TIA recruited within 24 h. Results Ordinal versions of vascular event outcomes were created in 3096 participants for stroke, myocardial infarction, major cardiac events, bleeding events, serious adverse events and venous thromboembolism (VTE), with 32 outcomes being created overall (29 in the subgroup population due to the absence of VTE events). Overall, the tests run on ordinal outcomes tended to rank higher than tests performed on binary outcomes. 764 (24.7%) participants were recruited within 24 h of a mild stroke/TIA; again, tests run on ordinal outcomes ranked higher. Conclusions In TARDIS, tests performed on ordinal vascular outcomes tended to attain a higher rank than those performed on binary outcomes. Trial registration ISRCTN47823388.
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Affiliation(s)
- Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Stuart Pocock
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - Anna Ranta
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - for the TARDIS Investigators
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, D Floor South Block, Queen's Medical Centre, Nottingham, NG7 2UH, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
- London School of Hygiene & Tropical Medicine, Keppel St., London, WC1E 7HT, UK
- Department of Medicine, University of Otago Wellington, Wellington, 6242, New Zealand
- Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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Desborough MJR, Al-Shahi Salman R, Stanworth SJ, Havard D, Woodhouse LJ, Craig J, Krishnan K, Brennan PM, Dineen RA, Coats TJ, Hepburn T, Bath PM, Sprigg N. Desmopressin for patients with spontaneous intracerebral haemorrhage taking antiplatelet drugs (DASH): a UK-based, phase 2, randomised, placebo-controlled, multicentre feasibility trial. Lancet Neurol 2023; 22:557-567. [PMID: 37353276 PMCID: PMC10284719 DOI: 10.1016/s1474-4422(23)00157-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The risk of death from spontaneous intracerebral haemorrhage is increased for people taking antiplatelet drugs. We aimed to assess the feasibility of randomising patients on antiplatelet drug therapy with spontaneous intracerebral haemorrhage to desmopressin or placebo to reduce the antiplatelet drug effect. METHODS DASH was a phase 2, randomised, placebo-controlled, multicentre feasibility trial. Patients were recruited from ten acute stroke centres in the UK and were eligible if they had an intracerebral haemorrhage with stroke symptom onset within 24 h of randomisation, were aged 18 years or older, and were taking an antiplatelet drug. Participants were randomly assigned (1:1) to a single dose of intravenous desmopressin 20 μg or matching placebo. Treatment allocation was concealed from all staff and patients involved in the trial. The primary outcome was feasibility, which was measured as the number of eligible patients randomised and the proportion of eligible patients approached, and analysis was by intention to treat. The trial was prospectively registered with ISRCTN (reference ISRCTN67038373), and it is closed to recruitment. FINDINGS Between April 1, 2019, and March 31, 2022, 1380 potential participants were screened for eligibility. 176 (13%) participants were potentially eligible, of whom 57 (32%) were approached, and 54 (31%) consented and were subsequently recruited and randomly assigned to receive desmopressin (n=27) or placebo (n=27). The main reason for eligible patients not being recruited was the patient arriving out of hours (74 [61%] of 122 participants). The recruitment rate increased after the enrolment period was extended from 12 h to 24 h, but it was then impaired due to the COVID-19 pandemic. Of the 54 participants included in the analysis (mean age 76·4 years [SD 11·3]), most were male (36 [67%]) and White (50 [93%]). 53 (98%) of 54 participants received all of their allocated treatment (one participant assigned desmopressin only received part of the infusion). No participants were lost to follow-up or withdrew from the trial. Death or dependency on others for daily activities at day 90 (modified Rankin Scale score >4) occurred in six (22%) of 27 participants in the desmopressin group and ten (37%) of 27 participants in the placebo group. Serious adverse events occurred in 12 (44%) participants in the desmopressin group and 13 (48%) participants in the placebo group. The most common adverse events were expansion of the haemorrhagic stroke (four [15%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group) and pneumonia (one [4%] of 27 participants in the desmopressin group and six [22%] of 27 participants in the placebo group). INTERPRETATION Our results show it is feasible to randomise patients with spontaneous intracerebral haemorrhage who are taking antiplatelet drugs to desmopressin or placebo. Our findings support the need for a definitive trial to determine if desmopressin improves outcomes in patients with intracerebral haemorrhage on antiplatelet drug therapy. FUNDING National Institute for Health Research.
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Affiliation(s)
- Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | | | - Simon J Stanworth
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Diane Havard
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Jennifer Craig
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul M Brennan
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert A Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK; NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Tim J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Trish Hepburn
- Mental Health and Clinical Neurosciences, and Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK; Stroke, Medicine Division, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Woodhouse LJ, Appleton JP, Ankolekar S, England TJ, Mair G, Muir K, Price CI, Pocock S, Randall M, Robinson TG, Roffe C, Sandset EC, Saver JL, Siriwardena AN, Sprigg N, Wardlaw JM, Bath PM. Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial. BMJ Neurol Open 2023; 5:e000424. [PMID: 37564156 PMCID: PMC10410995 DOI: 10.1136/bmjno-2023-000424] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 05/11/2023] [Indexed: 08/12/2023] Open
Abstract
Background The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation. Methods RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS). Results 1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84). Conclusion At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH. Trial registration number ISRCTN26986053.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sandeep Ankolekar
- Department of Neurology, King's College Hospital NHS Trust, London, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and GEM, Royal Derby Hospital, Derby, UK
| | - Grant Mair
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Keith Muir
- Neurology, University of Glasgow, Glasgow, UK
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, and NIHR Biomedical Research Unit for Cardiovascular Diseases, University of Leicester, Leicester, UK
| | - Christine Roffe
- Institute for Science and Technology in Medicine, Keele University, Keele, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- UK Dementia Research Institute, The University of Edinburgh Centre for Clinical Brain Sciences, Edinburgh, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Wardlaw JM, Woodhouse LJ, Mhlanga II, Oatey K, Heye AK, Bamford J, Cvoro V, Doubal FN, England T, Hassan A, Montgomery A, O'Brien JT, Roffe C, Sprigg N, Werring DJ, Bath PM. Isosorbide Mononitrate and Cilostazol Treatment in Patients With Symptomatic Cerebral Small Vessel Disease: The Lacunar Intervention Trial-2 (LACI-2) Randomized Clinical Trial. JAMA Neurol 2023:2805321. [PMID: 37222252 DOI: 10.1001/jamaneurol.2023.1526] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Importance Cerebral small vessel disease (cSVD) is a common cause of stroke (lacunar stroke), is the most common cause of vascular cognitive impairment, and impairs mobility and mood but has no specific treatment. Objective To test the feasibility, drug tolerability, safety, and effects of 1-year isosorbide mononitrate (ISMN) and cilostazol treatment on vascular, functional, and cognitive outcomes in patients with lacunar stroke. Design, Setting, and Participants The Lacunar Intervention Trial-2 (LACI-2) was an investigator-initiated, open-label, blinded end-point, randomized clinical trial with a 2 × 2 factorial design. The trial aimed to recruit 400 participants from 26 UK hospital stroke centers between February 5, 2018, and May 31, 2021, with 12-month follow-up. Included participants had clinical lacunar ischemic stroke, were independent, were aged older than 30 years, had compatible brain imaging findings, had capacity to consent, and had no contraindications to (or indications for) the study drugs. Data analysis was performed on August 12, 2022. Interventions All patients received guideline stroke prevention treatment and were randomized to ISMN (40-60 mg/d), cilostazol (200 mg/d), ISMN-cilostazol (40-60 and 200 mg/d, respectively), or no study drug. Main Outcomes The primary outcome was recruitment feasibility, including retention at 12 months. Secondary outcomes were safety (death), efficacy (composite of vascular events, dependence, cognition, and death), drug adherence, tolerability, recurrent stroke, dependence, cognitive impairment, quality of life (QOL), and hemorrhage. Results Of the 400 participants planned for this trial, 363 (90.8%) were recruited. Their median age was 64 (IQR, 56.0-72.0) years; 251 (69.1%) were men. The median time between stroke and randomization was 79 (IQR, 27.0-244.0) days. A total of 358 patients (98.6%) were retained in the study at 12 months, with 257 of 272 (94.5%) taking 50% or more of the allocated drug. Compared with those participants not receiving that particular drug, neither ISMN (adjusted hazard ratio [aHR], 0.80 [95% CI, 0.59 to 1.09]; P = .16) nor cilostazol (aHR, 0.77 [95% CI, 0.57 to 1.05]; P = .10) alone reduced the composite outcome in 297 patients. Isosorbide mononitrate reduced recurrent stroke in 353 patients (adjusted odds ratio [aOR], 0.23 [95% CI, 0.07 to 0.74]; P = .01) and cognitive impairment in 308 patients (aOR, 0.55 [95% CI, 0.36 to 0.86]; P = .008). Cilostazol reduced dependence in 320 patients (aHR, 0.31 [95% CI, 0.14 to 0.72]; P = .006). Combination ISMN-cilostazol reduced the composite (aHR, 0.58 [95% CI, 0.36 to 0.92]; P = .02), dependence (aOR, 0.14 [95% CI, 0.03 to 0.59]; P = .008), and any cognitive impairment (aOR, 0.44 [95% CI, 0.23 to 0.85]; P = .02) and improved QOL (adjusted mean difference, 0.10 [95% CI, 0.03 to 0.17]; P = .005) in 153 patients. There were no safety concerns. Conclusions and Relevance These results show that the LACI-2 trial was feasible and ISMN and cilostazol were well tolerated and safe. These agents may reduce recurrent stroke, dependence, and cognitive impairment after lacunar stroke, and they could prevent other adverse outcomes in cSVD. Therefore, both agents should be tested in large phase 3 trials. Trial Registration ClinicalTrials.gov Identifier: NCT03451591.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Iris I Mhlanga
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Anna K Heye
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - John Bamford
- Department of Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Vera Cvoro
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
- Victoria Hospital, National Health Service Fife, Kirkcaldy, United Kingdom
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Timothy England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Ahamad Hassan
- Department of Neurology, Leeds General Infirmary, Leeds, United Kingdom
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Christine Roffe
- Stroke Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - David J Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, Russell Square House, London, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
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McDermott JH, Woodhouse LJ, Sen D, Smith CJ, Newman WG, Bath PM. Abstract WP173: Interaction Between CYP2C19 Allele Status And Outcome Following Ischemic Stroke In Patients Treated With Clopidogrel: A TARDIS Trial Substudy. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp173] [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:
Clopidogrel is routinely prescribed following ischaemic stroke (IS), or transient ischaemic attack (TIA), as secondary prevention. Conversion of clopidogrel to its active form involves several hepatic cytochrome P450 enzymes (CYP450), including P450-2C19 (CYP2C19). Previous evidence suggests that CYP2C19 loss of function (LoF) carriers prescribed clopidogrel are at increased risk of vascular events in comparison with non-carriers. We sought to test for interaction between CYP2C19 LoF status and treatment effects in the TARDIS trial.
Methods:
TARDIS was an international, randomised trial recruiting participants with acute IS/TIA. Participants were assigned to receive intensive antiplatelet therapy (aspirin, clopidogrel, and dipyridamole) or guideline therapy (clopidogrel alone or aspirin and dipyridamole). Blood samples for genotyping were taken from consented participants at a 70 of the 106 recruiting centres.
Results:
Of 3096 participants, 1361 (44%) had samples available for genotyping. Median age was 69.0 years and 65.1% were male. Of the 1361 with samples, 1071 (78.7%) were randomised to clopidogrel and 290 (21.3%) to aspirin plus dipyridamole. 387 (28.4%) participants were CYP2C19 LoF allele carriers. At 35 days, 64 participants (4.7%) had a further IS/TIA and the rate of major adverse cardiovascular events was 6.8%. In participants randomised to clopidogrel (monotherapy or intensive) the rates of further IS/TIA were 4.9% in LoF allele carriers and 4.2% in non-carriers. As for those taking clopidogrel monotherapy, the rates of further IS/TIA were 7.4% in LoF allele carriers compared to 3.8% in non-carriers, though this difference was non-significant (p=0.14). There were no significant differences, in outcome or bleeding risk, by treatment group and LoF carrier status.
Conclusions:
No significant interaction was found between CYP2C19 genotype and outcome following IS/TIA when prescribed clopidogrel, either as monotherapy or in combination with aspirin and dipyridamole. There was no observed interaction between LoF status, clinical outcome, and bleeding rates. A caveat is that this analysis was undertaken on a subgroup of TARDIS participants and so was underpowered to detect a difference in the monotherapy group.
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Affiliation(s)
- John H McDermott
- The Div of Evolution, Infection and Genomics, UNIVERSITY OF MANCHESTER, Manchester, United Kingdom
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, Univ of Nottingham, Nottingham, United Kingdom
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Cntr, Geoffrey Jefferson Brain Rsch Cntr, Salford, United Kingdom
| | | | - William G Newman
- The Div of Evolution, Infection and Genomics, UNIVERSITY OF MANCHESTER, Manchester, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neurosciences, UNIVERSITY OF NOTTINGHAM, Nottingham, United Kingdom
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Dixon M, Appleton JP, Scutt P, Woodhouse LJ, Haywood LJ, Havard D, Williams J, Siriwardena AN, Bath PM. Time intervals and distances travelled for prehospital ambulance stroke care: data from the randomised-controlled ambulance-based Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2). BMJ Open 2022; 12:e060211. [PMID: 36410799 PMCID: PMC9680177 DOI: 10.1136/bmjopen-2021-060211] [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] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Ambulances offer the first opportunity to evaluate hyperacute stroke treatments. In this study, we investigated the conduct of a hyperacute stroke study in the ambulance-based setting with a particular focus on timings and logistics of trial delivery. DESIGN Multicentre prospective, single-blind, parallel group randomised controlled trial. SETTING Eight National Health Service ambulance services in England and Wales; 54 acute stroke centres. PARTICIPANTS Paramedics enrolled 1149 patients assessed as likely to have a stroke, with Face, Arm, Speech and Time score (2 or 3), within 4 hours of symptom onset and systolic blood pressure >120 mm Hg. INTERVENTIONS Paramedics administered randomly assigned active transdermal glyceryl trinitrate or sham. PRIMARY AND SECONDARY OUTCOMES Modified Rankin scale at day 90. This paper focuses on response time intervals, distances travelled and baseline characteristics of patients, compared between ambulance services. RESULTS Paramedics enrolled 1149 patients between September 2015 and May 2018. FINAL DIAGNOSIS intracerebral haemorrhage 13%, ischaemic stroke 52%, transient ischaemic attack 9% and mimic 26%. Timings (min) were (median (25-75 centile)): onset to emergency call 19 (5-64); onset to randomisation 71 (45-116); total time at scene 33 (26-46); depart scene to hospital 15 (10-23); randomisation to hospital 24 (16-34) and onset to hospital 97 (71-141). Ambulances travelled (km) 10 (4-19) from scene to hospital. Timings and distances differed between ambulance service, for example, onset to randomisation (fastest 53 min, slowest 77 min; p<0.001), distance from scene to hospital (least 4 km, most 20 km; p<0.001). CONCLUSION We completed a large prehospital stroke trial involving a simple-to-administer intervention across multiple ambulance services. The time from onset to randomisation and modest distances travelled support the applicability of future large-scale paramedic-delivered ambulance-based stroke trials in urban and rural locations. TRIAL REGISTRATION NUMBER ISRCTN26986053.
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Affiliation(s)
- Mark Dixon
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
- Leicester, Leicestershire & Rutland Division, East Midlands Ambulance Service NHS Trust, Nottingham, UK
| | - Jason P Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Polly Scutt
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lisa J Woodhouse
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Lee J Haywood
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Diane Havard
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
| | - Julia Williams
- Division of Paramedic Science, School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | | | - Philip M Bath
- Division of Mental Health and Clinical Neuroscience, University of Nottingham Faculty of Medicine and Health Sciences, Nottingham, UK
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Krishnan K, Law ZK, Woodhouse LJ, Dineen RA, Sprigg N, Wardlaw JM, Bath PM. Measures of intracranial compartments in acute intracerebral haemorrhage: data from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial (RIGHT-2). Stroke Vasc Neurol 2022; 8:151-160. [PMID: 36202546 PMCID: PMC10176998 DOI: 10.1136/svn-2021-001375] [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: 10/17/2021] [Accepted: 05/11/2022] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Intracerebral haemorrhage volume (ICHV) is prognostically important but does not account for intracranial volume (ICV) and cerebral parenchymal volume (CPV). We assessed measures of intracranial compartments in acute ICH using computerised tomography scans and whether ICHV/ICV and ICHV/CPV predict functional outcomes. We also assessed if cistern effacement, midline shift, old infarcts, leukoaraiosis and brain atrophy were associated with outcomes. METHODS Data from 133 participants from the Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke-2 Trial trial were analysed. Measures included ICHV (using ABC/2) and ICV (XYZ/2) (by independent observers); ICHV, ICV and CPV (semiautomated segmentation, SAS); atrophy (intercaudate distance, ICD, Sylvian fissure ratio, SFR); midline shift; leukoaraiosis and cistern effacement (visual assessment). The effects of these measures on death at day 4 and poor functional outcome at day 90 (modified Rankin scale, mRS of >3) was assessed. RESULTS ICV was significantly different between XYZ and SAS: mean (SD) of 1357 (219) vs 1420 (196), mean difference (MD) 62 mL (p<0.001). There was no significant difference in ICHV between ABC/2 and SAS. There was very good agreement for ICV measured by SAS, CPV, ICD, SFR, leukoaraiosis and cistern score (all interclass correlations, n=10: interobserver 0.72-0.99, intraobserver 0.73-1.00). ICHV/ICV and ICHV/CPV were significantly associated with mRS at day 90, death at day 4 and acute neurological deterioration (all p<0.05), similar to ICHV. Midline shift and cistern effacement at baseline were associated with poor functional outcome but old infarcts, leukoaraiosis and brain atrophy were not. CONCLUSIONS Intracranial compartment measures and visual estimates are reproducible. ICHV adjusted for ICH and CPV could be useful to prognosticate in acute stroke. The presence of midline shift and cistern effacement may predict outcome but the mechanisms need validation in larger studies.
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Affiliation(s)
- Kailash Krishnan
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK .,Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Zhe Kang Law
- Department of Medicine, National University of Malaysia Faculty of Medicine, Kuala Lumpur, Malaysia
| | | | - Rob A Dineen
- Radiological Sciences Research Group, University of Nottingham, Nottingham, UK.,National Institute of Health Research Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, Chancellor's Building, University of Edinburgh, Edinburgh, UK
| | - Philip M Bath
- Stroke, Department of Acute Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Stroke Trials Unit, University of Nottingham, Nottingham, UK
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14
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Bath PM, Mhlanga I, Woodhouse LJ, Doubal F, Oatey K, Montgomery AA, Wardlaw JM. Cilostazol and isosorbide mononitrate for the prevention of progression of cerebral small vessel disease: baseline data and statistical analysis plan for the Lacunar Intervention Trial-2 (LACI-2) (ISRCTN14911850). Stroke Vasc Neurol 2022; 8:134-143. [PMID: 36219567 PMCID: PMC10176977 DOI: 10.1136/svn-2022-001816] [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: 06/29/2022] [Accepted: 08/16/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Cerebral small vessel disease (SVD) causes lacunar strokes (25% of all ischaemic strokes), physical frailty and cognitive impairment and vascular and mixed dementia. There is no specific treatment to prevent progression of SVD. METHODS The LACunar Intervention Trial-2 is an investigator-initiated prospective randomised open-label blinded-endpoint phase II feasibility study assessing cilostazol and isosorbide mononitrate for preventing SVD progression. We aimed to recruit 400 patients with clinically evident lacunar ischaemic stroke and randomised to cilostazol, isosorbide mononitrate, both or neither, in addition to guideline secondary ischaemic stroke prevention, in a partial factorial design. The primary outcome is feasibility of recruitment and adherence to medication; key secondary outcomes include: drug tolerability; recurrent vascular events, cognition and function at 1 year after randomisation; and safety (bleeding, falls, death). Data are number (%) and median (IQR). RESULTS The trial commenced on 5 February 2018 and ceased recruitment on 31 May 2021 with 363 patients randomised, with the following baseline characteristics: average age 64 (56.0, 72.0) years, female 112 (30.9%), stroke onset to randomisation 79.0 (27.0, 244.0) days, hypertension 267 (73.6%), median blood pressures 143.0 (130.0, 157.0)/83.0 (75.0, 90.0) mm Hg, current smokers 67 (18.5%), educationally achieved end of school examinations (A-level) or higher 118 (32.5%), modified Rankin scale 1.0 (0.0, 1.0), National Institutes Health stroke scale 1.0 (1.4), Montreal Cognitive Assessment 26.0 (23.0, 28.0) and total SVD score on brain imaging 1.0 (0.0, 2.0). This publication summarises the baseline data and presents the statistical analysis plan. SUMMARY The trial is currently in follow-up which will complete on 31 May 2022 with results expected in October 2022. TRIAL REGISTRATION NUMBER ISRCTN14911850.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, University of Edinburgh, Edinburgh, UK
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15
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Pszczolkowski S, Sprigg N, Woodhouse LJ, Gallagher R, Swienton D, Law ZK, Casado AM, Roberts I, Werring DJ, Al-Shahi Salman R, England TJ, Morgan PS, Bath PM, Dineen RA. Effect of Tranexamic Acid Administration on Remote Cerebral Ischemic Lesions in Acute Spontaneous Intracerebral Hemorrhage: A Substudy of a Randomized Clinical Trial. JAMA Neurol 2022; 79:468-477. [PMID: 35311937 PMCID: PMC8938900 DOI: 10.1001/jamaneurol.2022.0217] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Hyperintense foci on diffusion-weighted imaging (DWI) that are spatially remote from the acute hematoma occur in 20% of people with acute spontaneous intracerebral hemorrhage (ICH). Tranexamic acid, a hemostatic agent that is under investigation for treating acute ICH, might increase DWI hyperintense lesions (DWIHLs). Objective To establish whether tranexamic acid compared with placebo increased the prevalence or number of remote cerebral DWIHLs within 2 weeks of ICH onset. Design, Setting, and Participants This prospective nested magnetic resonance imaging (MRI) substudy of a randomized clinical trial (RCT) recruited participants from the multicenter, double-blind, placebo-controlled, phase 3 RCT (Tranexamic Acid for Hyperacute Primary Intracerebral Hemorrhage [TICH-2]) from July 1, 2015, to September 30, 2017, and conducted follow-up to 90 days after participants were randomized to either the tranexamic acid or placebo group. Participants had acute spontaneous ICH and included TICH-2 participants who provided consent to undergo additional MRI scans for the MRI substudy and those who had clinical MRI data that were compatible with the brain MRI protocol of the substudy. Data analyses were performed on an intention-to-treat basis on January 20, 2020. Interventions The tranexamic acid group received 1 g in 100-mL intravenous bolus loading dose, followed by 1 g in 250-mL infusion within 8 hours of ICH onset. The placebo group received 0.9% saline within 8 hours of ICH onset. Brain MRI scans, including DWI, were performed within 2 weeks. Main Outcomes and Measures Prevalence and number of remote DWIHLs were compared between the treatment groups using binary logistic regression adjusted for baseline covariates. Results A total of 219 participants (mean [SD] age, 65.1 [13.8] years; 126 men [57.5%]) who had brain MRI data were included. Of these participants, 96 (43.8%) were randomized to receive tranexamic acid and 123 (56.2%) were randomized to receive placebo. No baseline differences in demographic characteristics and clinical or imaging features were found between the groups. There was no increase for the tranexamic acid group compared with the placebo group in DWIHL prevalence (20 of 96 [20.8%] vs 28 of 123 [22.8%]; odds ratio [OR], 0.71; 95% CI, 0.33-1.53; P = .39) or mean (SD) number of DWIHLs (1.75 [1.45] vs 1.81 [1.71]; mean difference [MD], -0.08; 95% CI, -0.36 to 0.20; P = .59). In an exploratory analysis, participants who were randomized within 3 hours of ICH onset or those with chronic infarcts appeared less likely to have DWIHLs if they received tranexamic acid. Participants with probable cerebral amyloid angiopathy appeared more likely to have DWIHLs if they received tranexamic acid. Conclusions and Relevance This substudy of an RCT found no evidence of increased prevalence or number of remote DWIHLs after tranexamic acid treatment in acute ICH. These findings provide reassurance for ongoing and future trials that tranexamic acid for acute ICH is unlikely to induce cerebral ischemic events. Trial Registration isrctn.org Identifier: ISRCTN93732214.
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Affiliation(s)
- Stefan Pszczolkowski
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham, United Kingdom
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Rebecca Gallagher
- Imaging Department, Leicester Royal Infirmary, Leicester, United Kingdom
| | - David Swienton
- Imaging Department, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Zhe Kang Law
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Ana M Casado
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Ian Roberts
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David J Werring
- Stroke Research Centre, University College London Queen Square Institute of Neurology, London, United Kingdom
| | | | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Department of Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
| | - Paul S Morgan
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, Nottingham, United Kingdom
| | - Robert A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham, United Kingdom
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
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16
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Woodhouse LJ, Appleton JP, Scutt P, Everton L, Wilkinson G, Caso V, Czlonkowska A, Gommans J, Krishnan K, Laska AC, Ntaios G, Ozturk S, Phillips S, Pocock S, Prasad K, Szatmari S, Wardlaw JM, Sprigg N, Bath PM. Effect of continuing versus stopping pre-stroke antihypertensive agents within 12 h on outcome after stroke: A subgroup analysis of the efficacy of nitric oxide in stroke (ENOS) trial. EClinicalMedicine 2022; 44:101274. [PMID: 35112073 PMCID: PMC8790472 DOI: 10.1016/j.eclinm.2022.101274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/20/2021] [Accepted: 01/07/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND It is not known whether to continue or temporarily stop existing antihypertensive drugs in patients with acute stroke. METHODS We performed a prospective subgroup analysis of patients enrolled into the Efficacy of Nitric Oxide in Stroke (ENOS) trial who were randomised to continue vs stop prior antihypertensive therapy within 12 h of stroke onset. The primary outcome was functional outcome, assessed with the modified Rankin Scale at 90 days by observers blinded to treatment assignment, and analysed with ordinal logistic regression. FINDINGS Of 4011 patients recruited into ENOS from 2001 to 2014, 2097 patients were randomised to continue vs stop prior antihypertensive treatment, and 384 (18.3%, continue 185, stop 199) were enrolled within 12 h of ictus: mean (SD) age 71.8 (11.8) years, female 193 (50.3%), ischaemic stroke 342 (89.1%) and total anterior circulation syndrome 114 (29.7%). As compared with stopping, continuing treatment within 12 h of onset lowered blood pressure by 15.5/9.6 mmHg (p<0.001/<0.001) by 7 days, shifted the modified Rankin Scale to a worse outcome by day 90, adjusted common odds ratio (OR) 1.46 (95% CI 1.01-2.11), and was associated with an increased death rate by day 90 (hazard ratio 2.17, 95% CI 1.24-3.79). Other outcomes (disability - Barthel Index, quality of life - EQ-visual analogue scale, cognition - telephone mini-mental state examination, and mood - Zung depression scale) were also worse with continuing treatment. INTERPRETATION In this pre-specified subgroup analysis of the large ENOS trial, continuing prior antihypertensive therapy within 12 h of stroke onset in a predominantly ischaemic stroke population was unsafe with worse functional outcome, disability, cognition, mood, quality of life and increased death. Future studies assessing continuing or stopping prior antihypertensives in the context of thrombectomy are awaited.
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Affiliation(s)
- Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
| | - Jason P. Appleton
- Stroke, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham B15 2GW, UK
- Institute of Applied Health Research, College of Dental and Medical Sciences, University of Birmingham, Birmingham, UK
| | - Polly Scutt
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
| | - Lisa Everton
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Gwenllian Wilkinson
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Italy
| | | | - John Gommans
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Ann C. Laska
- Department of Clinical Science, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Greece
| | - Serefnur Ozturk
- Neurology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Kameshwar Prasad
- Rajendra Institute of Medical Sciences, Ranchi, Jharkhand 834009, India
| | - Szabolcs Szatmari
- Department of Neurology, Clinical County Emergency Hospital, Targu Mures, Romania
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK
- Corresponding author at: Stroke Trials Unit, Mental Health & Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, South Block D floor, Nottingham NG7 2UH UK.
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17
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Moullaali TJ, Wang X, Sandset EC, Woodhouse LJ, Law ZK, Arima H, Butcher KS, Chalmers J, Delcourt C, Edwards L, Gupta S, Jiang W, Koch S, Potter J, Qureshi AI, Robinson TG, Al-Shahi Salman R, Saver JL, Sprigg N, Wardlaw JM, Anderson CS, Bath PM. Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data. J Neurol Neurosurg Psychiatry 2022; 93:6-13. [PMID: 34732465 PMCID: PMC8685661 DOI: 10.1136/jnnp-2021-327195] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH). METHODS A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect. RESULTS Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (pinteraction=0.031) and agent (pinteraction<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth. INTERPRETATION Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent. PROSPERO REGISTRATION NUMBER CRD42019141136.
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Affiliation(s)
- Tom J Moullaali
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway.,Research and Development Department, The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lisa J Woodhouse
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.,National University of Malaysia, Kuala Lumpur, Malaysia
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Fukuoka University, Fukuoka, Japan
| | - Kenneth S Butcher
- Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - John Chalmers
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Candice Delcourt
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Leon Edwards
- Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Central Clinical School, the University of Sydney, Sydney, New South Wales, Australia
| | - Salil Gupta
- Department of Neurology, Army Hospital Research and Referral, New Delhi, India
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.,The Shaanxi Cerebrovascular Disease Clinical Research Center, Xi'an, China
| | - Sebastian Koch
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - John Potter
- Stroke Research Group, Norfolk and Norwich University Hospital, UK.,Norwich Medical School, University of East Anglia, UK
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Thompson G Robinson
- University of Leicester, Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Leicester, UK
| | | | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, UCLA, Los Angeles, California, USA
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia .,Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia.,Neurology Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,The George Institute China at Peking University Health Science Center, Beijing, PR China
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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18
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Bath PM, Skinner CJC, Bath CS, Woodhouse LJ, Korovesi AAK, Long H, Havard D, Coleman CM, England TJ, Leyland V, Lim WS, Montgomery AA, Royal S, Avery A, Webb AJ, Gordon AL. Dietary nitrate supplementation for preventing and reducing the severity of winter infections, including COVID-19, in care homes (BEET-Winter): a randomised placebo-controlled feasibility trial. Eur Geriatr Med 2022; 13:1343-1355. [PMID: 36385690 PMCID: PMC9668238 DOI: 10.1007/s41999-022-00714-5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/31/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE Infections cause considerable care home morbidity and mortality. Nitric oxide (NO) has broad-spectrum anti-viral, bacterial and yeast activity in vitro. We assessed the feasibility of supplementing dietary nitrate (NO substrate) intake in care home residents. METHODS We performed a cluster-randomised placebo-controlled trial in UK residential and nursing care home residents and compared nitrate containing (400 mg) versus free (0 mg daily) beetroot juice given for 60 days. Outcomes comprised feasibility of recruitment, adherence, salivary and urinary nitrate, and ordinal infection/clinical events. RESULTS Of 30 targeted care homes in late 2020, 16 expressed interest and only 6 participated. 49 residents were recruited (median 8 [interquartile range 7-12] per home), mean (standard deviation) age 82 (8) years, with proxy consent 41 (84%), advance directive for hospital non-admission 8 (16%) and ≥ 1 doses of COVID-19 vaccine 37 (82%). Background dietary nitrate was < 30% of acceptable daily intake. 34 (76%) residents received > 50% of juice. Residents randomised to nitrate vs placebo had higher urinary nitrate levels, median 50 [18-175] v 18 [10-50] mg/L, difference 25 [0-90]. Data paucity precluded clinical between-group comparisons; the outcome distribution was as follows: no infection 32 (67%), uncomplicated infection 0, infection requiring healthcare support 11 (23%), all-cause hospitalisation 5 (10%), all-cause mortality 0. Urinary tract infections were most common. CONCLUSIONS Recruiting UK care homes during the COVID-19 pandemic was partially successful. Supplemented dietary nitrate was tolerated and elevated urinary nitrate. Together, infections, hospitalisations and deaths occurred in 33% of residents over 60 days. A larger trial is now required. TRIAL REGISTRATION ISRCTN51124684. Application date 7/12/2020; assignment date 13/1/2021.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH Nottinghamshire UK
| | - Cameron J. C. Skinner
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Charlotte S. Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | | | - Hongjiang Long
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Diane Havard
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK
| | - Christopher M. Coleman
- Division of Infection, Immunity and Microbes, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Timothy J. England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, South Block D Floor, Nottingham, NG7 2UH UK ,Department of Stroke, University Hospitals of Derby and Burton, Derby, DE22 3NE UK
| | | | - Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, NG7 2RD UK
| | - Simon Royal
- University of Nottingham Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW UK
| | - Amanda Avery
- School of Biosciences, University of Nottingham, Sutton Bonington, LE12 5RD UK
| | - Andrew J. Webb
- Clinical Pharmacology, School of Cardiovascular Medicine and Sciences, Kings College London and British Heart Foundation Centre of Research Excellence, St Thomas’ Hospital, London, SE1 7EH UK
| | - Adam L. Gordon
- Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Derby, DE22 3NE Derbyshire UK ,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
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Woodhouse LJ, Montgomery AA, Mant J, Davis BR, Algra A, Mas JL, Staessen JA, Thijs L, Tonkin A, Kirby A, Pocock SJ, Chalmers J, Hankey GJ, Spence JD, Sandercock P, Diener HC, Uchiyama S, Sprigg N, Bath PM. Statistical reanalysis of vascular event outcomes in primary and secondary vascular prevention trials. BMC Med Res Methodol 2021; 21:218. [PMID: 34657596 PMCID: PMC8520648 DOI: 10.1186/s12874-021-01388-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular prevention trials typically use dichotomous event outcomes although this may be inefficient statistically and gives no indication of event severity. We assessed whether ordinal outcomes would be more efficient and how to best analyse them. METHODS Chief investigators of vascular prevention randomised controlled trials that showed evidence of either benefit or harm, or were included in a systematic review that overall showed benefit or harm, shared individual participant data from their trials. Ordered categorical versions of vascular event outcomes (such as stroke and myocardial infarction) were analysed using 15 statistical techniques and their results then ranked, with the result with the smallest p-value given the smallest rank. Friedman and Duncan's multiple range tests were performed to assess differences between tests by comparing the average ranks for each statistical test. RESULTS Data from 35 trials (254,223 participants) were shared with the collaboration. 13 trials had more than two treatment arms, resulting in 59 comparisons. Analysis approaches (Mann Whitney U, ordinal logistic regression, multiple regression, bootstrapping) that used ordinal outcome data had a smaller average rank and therefore appeared to be more efficient statistically than those that analysed the original binary outcomes. CONCLUSIONS Ordinal vascular outcome measures appear to be more efficient statistically than binary outcomes and provide information on the severity of event. We suggest a potential role for using ordinal outcomes in vascular prevention trials.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Barry R Davis
- The University of Texas Health Science Center at Houston, Houston, USA
| | - Ale Algra
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Louis Mas
- Hopital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Jan A Staessen
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Andrew Tonkin
- Chronic Disease & Aging Unit, Monash University, Clayton, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - John Chalmers
- George Institute for Global Health, Sydney, Australia
| | - Graeme J Hankey
- Department of Neurology, University of Western Australia, Crawley, Australia
| | | | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Nikola Sprigg
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK.
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20
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Appleton JP, Woodhouse LJ, Sprigg N, Wardlaw JM, Bath PM. Corrigendum: Intracranial Bleeding After Reperfusion Therapy in Acute Ischaemic Stroke Patients Randomized to Glyceryl Trinitrate vs. Control: An Individual Patient Data Meta-Analysis. Front Neurol 2020; 11:625572. [PMID: 33324341 PMCID: PMC7726315 DOI: 10.3389/fneur.2020.625572] [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: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/25/2022] Open
Abstract
[This corrects the article DOI: 10.3389/fneur.2020.584038.].
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Affiliation(s)
- Jason P. Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
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21
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Beishon L, Woodhouse LJ, Bereczki D, Christensen HK, Collins R, Gommans J, Kruuse C, Ntaios G, Ozturk S, Phillips S, Pocock S, Szatmari S, Wardlaw J, Sprigg N, Bath PM. Relationship between nitrate headache and outcome in patients with acute stroke: results from the efficacy of nitric oxide in stroke (ENOS) trial. Stroke Vasc Neurol 2020; 6:180-186. [PMID: 33154177 PMCID: PMC8258084 DOI: 10.1136/svn-2020-000498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/16/2020] [Accepted: 09/19/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Nitrate-induced headache is common and may signify responsive cerebral vasculature. We assessed the relationship between nitrate headache and outcome in patients with acute stroke. MATERIALS AND METHODS Patients were those randomised to glyceryl trinitrate (GTN) versus no GTN in the efficacy of nitric oxide in stroke trial. Development of headache by end of treatment (day 7), and functional outcome (modified Rankin Scale, primary outcome) at day 90, were assessed. Analyses are adjusted for baseline prognostic factors and give OR and mean difference (MD) with 95% CI. RESULTS In 4011 patients, headache was more common in GTN than control (360, 18.0% vs 170, 8.5%; p<0.001). Nitrate-related headache was associated with: younger age, female sex, higher diastolic blood pressure, non-total anterior circulation syndrome, milder stroke and absence of dysphasia (p<0.05). Nitrate headache was not associated with improved functional outcome (OR 0.90, 95% CI 0.73 to 1.10, p=0.30) or death (day 90) (HR 0.64, 95% CI 0.40 to 1.02, p=0.062), but reduced death or deterioration (day 7) (OR 0.45, 95% CI 0.25 to 0.82), death in hospital (OR 0.44, 95% CI 0.22 to 0.88) and improved activities of daily living (Barthel index, MD 3.7, 95% CI 0.3 to 7.1) and cognition (telephone interview cognitive screen, MD 2.0, 95% CI 0.7 to 3.3) (day 90). Non-nitrate headache was not associated with death, disability or cognition. DISCUSSION AND CONCLUSION Development of a nitrate headache by day 7 after stroke may be associated with improved activities of daily living and cognitive impairment at day 90, which was not seen with non-nitrate headache.
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Affiliation(s)
- Lucy Beishon
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Hanne K Christensen
- Bispebjerg Hospital and University of Copenhagen, University of Copenhagen, Copenhagen, Denmark
| | - Ronan Collins
- Department of Geriatric and Stroke Medicine, Adelaide and Meath Hospital, Dublin, Ireland
| | - John Gommans
- Department of Medicine, Hawke's Bay Hospital, Camberley, New Zealand
| | - Christina Kruuse
- Department of Neurology, Herlev Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - George Ntaios
- Department of Medicine, Larissa University Hospital, University of Thessaly, Volos, Greece
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Medical Faculty, Konya, Turkey
| | - Stephen Phillips
- Department of Neurology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Stuart Pocock
- Medical Statistics Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Szabolcs Szatmari
- Department of Neurology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Targu Mures, Romania
| | - Joanna Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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22
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Bath PM, Woodhouse LJ, Suntrup-Krueger S, Likar R, Koestenberger M, Warusevitane A, Herzog J, Schuttler M, Ragab S, Everton L, Ledl C, Walther E, Saltuari L, Pucks-Faes E, Bocksrucker C, Vosko M, de Broux J, Haase CG, Raginis-Zborowska A, Mistry S, Hamdy S, Dziewas R. Pharyngeal electrical stimulation for neurogenic dysphagia following stroke, traumatic brain injury or other causes: Main results from the PHADER cohort study. EClinicalMedicine 2020; 28:100608. [PMID: 33294818 PMCID: PMC7700977 DOI: 10.1016/j.eclinm.2020.100608] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 10/01/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Neurogenic dysphagia is common and has no definitive treatment. We assessed whether pharyngeal electrical stimulation (PES) is associated with reduced dysphagia. METHODS The PHAryngeal electrical stimulation for treatment of neurogenic Dysphagia European Registry (PHADER) was a prospective single-arm observational cohort study. Participants were recruited with neurogenic dysphagia (comprising five groups - stroke not needing ventilation; stroke needing ventilation; ventilation acquired; traumatic brain injury; other neurological causes). PES was administered once daily for three days. The primary outcome was the validated dysphagia severity rating scale (DSRS, score best-worst 0-12) at 3 months. FINDINGS Of 255 enrolled patients from 14 centres in Austria, Germany and UK, 10 failed screening. At baseline, mean (standard deviation) or median [interquartile range]: age 68 (14) years, male 71%, DSRS 11·4 (1·7), time from onset to treatment 32 [44] days; age, time and DSRS differed between diagnostic groups. Insertion of PES catheters was successfully inserted in 239/245 (98%) participants, and was typically easy taking 11·8 min. 9 participants withdrew before the end of treatment. DSRS improved significantly in all dysphagia groups, difference in means (95% confidence intervals, CI) from 0 to 3 months: stroke (n = 79) -6·7 (-7·8, -5·5), ventilated stroke (n = 98) -6·5 (-7·6, -5·5); ventilation acquired (n = 35) -6·6 (-8·4, -4·8); traumatic brain injury (n = 24) -4·5 (-6·6, -2·4). The results for DSRS were mirrored for instrumentally assessed penetration aspiration scale scores. DSRS improved in both supratentorial and infratentorial stroke, with no difference between them (p = 0·32). In previously ventilated participants with tracheotomy, DSRS improved more in participants who could be decannulated (n = 66) -7·5 (-8·6, -6·5) versus not decannulated (n = 33) -2·1 (-3·2, -1·0) (p<0·001). 74 serious adverse events (SAE) occurred in 60 participants with pneumonia (9·2%) the most frequent SAE. INTERPRETATION In patients with neurogenic dysphagia, PES was safe and associated with reduced measures of dysphagia and penetration/aspiration. FUNDING Phagenesis Ltd.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG5 1PB, United Kingdom
- Stroke, Nottingham University Hospital NHS Trust, Nottingham NG5 1PB, United Kingdom
- Corresponding author at: Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG5 1PB, United Kingdom.
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG5 1PB, United Kingdom
| | - Sonja Suntrup-Krueger
- Department of Neurology, University Hospital Münster, Building A1, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Klagenfurt am Wörthersee, Austria
| | - Markus Koestenberger
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Klagenfurt am Wörthersee, Klagenfurt am Wörthersee, Austria
| | - Anushka Warusevitane
- Stroke Research, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Parish Building, 1st Floor, Newcastle Road, Stoke-on-Trent, Staffordshire ST4 6QG, United Kingdom
| | - Juergen Herzog
- Clinic for Neurological Rehabilitation and Early Rehabilitation, Schön Klinik München-Schwabing, Parzivalplatz 4, 80804 Munich, Germany
| | - Michael Schuttler
- Centre of Neurology, Schön Klinik Bad Staffelstein, Am Kurpark 11, 96231 Bad Staffelstein, Germany
| | - Suzanne Ragab
- Department of Stroke, Philip Arnold Unit Ground Floor, Poole Hospital NHS Foundation Trust, Longfleet road, Poole BH15 2JB, United Kingdom
| | - Lisa Everton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham NG5 1PB, United Kingdom
- Speech and Language Therapy, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham NG3 6AA, United Kingdom
| | - Christian Ledl
- Specialist Clinic for Neurology, Neurological Rehabilitation and Alzheimer's Therapy, Schön Klinik Bad Aibling, Kolbermoorer Strasse 72, 83043 Bad Aibling, Germany
| | - Ernst Walther
- Clinic for Neurology and Neurorehabilitation, Schön Klinik Hamburg Eilbek, Hamburg, Germany
| | - Leopold Saltuari
- Department of Neurology, Ö. Landeskrankenhaus Hochzirl-Natters, Tiroler landesrankenanstalten GmbH. LkH Hochzirl, 6170 Zirl/Hochzirl, Austria
| | - Elke Pucks-Faes
- Department of Neurology, Ö. Landeskrankenhaus Hochzirl-Natters, Tiroler landesrankenanstalten GmbH. LkH Hochzirl, 6170 Zirl/Hochzirl, Austria
| | - Christof Bocksrucker
- Department of Neurology, Konventhospital Barmherzige Brúder Linz, Seilerstätte 2, 4021 Linz, Austria
| | - Milan Vosko
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Johanna de Broux
- Clinic for Neurology, Alexianer Krefeld GmbH, Dießemer Bruch 81, 47805 Krefeld, Germany
| | - Claus G. Haase
- Clinic for Neurology and Neurophysiology, Evangelische Kliniken Gelsenkirchen, Lehrkrankenhaus der Universität Essen-Duisburg, Munckelstr. 27, 45879 Gelsenkirchen, Germany
| | | | - Satish Mistry
- Department for Clinical Research, Phagenesis Limited, Manchester M15 6SE, United Kingdom
| | - Shaheen Hamdy
- Department for Clinical Research, Phagenesis Limited, Manchester M15 6SE, United Kingdom
- Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, University of Manchester and the Manchester Academic Health Sciences Centre, Manchester M6 8HD, United Kingdom
| | - Rainer Dziewas
- Department of Neurology, University Hospital Münster, Building A1, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
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23
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de Jonge JC, Woodhouse LJ, Reinink H, van der Worp HB, Bath PM. PRECIOUS: PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke-statistical analysis plan of a randomised, open, phase III, clinical trial with blinded outcome assessment. Trials 2020; 21:884. [PMID: 33106180 PMCID: PMC7586648 DOI: 10.1186/s13063-020-04717-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/31/2020] [Indexed: 12/01/2022] Open
Abstract
Rationale Aspiration, infections, and fever are common in the first days after stroke, especially in older patients. The occurrence of these complications has been associated with an increased risk of death or dependency. Aims and design PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke (PRECIOUS) is an international, multi-centre, 3 × 2 factorial, randomised, controlled, open-label clinical trial with blinded outcome assessment, which will assess whether prevention of aspiration, infections, or fever with metoclopramide, ceftriaxone, paracetamol, respectively, or any combination of these in the first 4 days after stroke onset improves functional outcome at 90 days in elderly patients with acute stroke. Discussion This statistical analysis plan provides a technical description of the statistical methodology and unpopulated tables and figures. The paper is written prior to data lock and unblinding of treatment allocation. Trial registration ISRCTN registry ISRCTN82217627. Registered on 22 September 2015. The trial was prospectively registered.
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Affiliation(s)
- Jeroen C de Jonge
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Hendrik Reinink
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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24
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Appleton JP, Woodhouse LJ, Sprigg N, Wardlaw JM, Bath PM. Intracranial Bleeding After Reperfusion Therapy in Acute Ischaemic Stroke Patients Randomized to Glyceryl Trinitrate vs. Control: An Individual Patient Data Meta-Analysis. Front Neurol 2020; 11:584038. [PMID: 33193044 PMCID: PMC7606455 DOI: 10.3389/fneur.2020.584038] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Thrombolysis, with or without thrombectomy, for acute ischaemic stroke is associated with an increased risk of intracranial bleeding. We assessed whether treatment with glyceryl trinitrate (GTN), a nitric oxide donor, may influence the associated bleeding risk. Methods: We searched for completed randomized controlled trials of GTN vs. no GTN in acute ischaemic stroke with data on reperfusion treatments (thrombolysis and/or thrombectomy). The primary efficacy outcome was functional status as assessed by the modified Rankin Scale (mRS) at day 90; the primary safety outcome was intracranial bleeding. Secondary safety outcomes included symptomatic intracranial hemorrhage and haemorrhagic transformation of infarction. Individual patient data were pooled and meta-analysis performed using ordinal or binary logistic regression with adjustment for trial and prognostic variables both overall and in those randomized within 6 h of symptom onset. Results: Three trials met the eligibility criteria. Of 715 patients with ischaemic stroke who underwent thrombolysis (709, >99%) or thrombectomy (24, 3.4%), 357 (49.9%) received GTN and 358 (50.1%) received no GTN. Overall, there was no difference in the distribution of the mRS at day 90 between GTN vs. no GTN (OR 0.94, 95% CI 0.72-1.23; p = 0.65); similarly, there was no difference in intracranial hemorrhage rates between treatment groups (OR 0.90, 95% CI 0.43-1.89; p = 0.77). In those randomized to GTN vs. no GTN within 6 h of symptom onset, there were numerically fewer bleeding events, but these analyses did not reach statistical significance. Conclusions: In ischaemic stroke patients treated predominantly with thrombolysis, transdermal GTN was safe, but did not influence functional outcome at 90 days.
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Affiliation(s)
- Jason P. Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
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25
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Scutt P, Woodhouse LJ, Montgomery AA, Bath PM. Data sharing: experience of accessing individual patient data from completed randomised controlled trials in vascular and cognitive medicine. BMJ Open 2020; 10:e038765. [PMID: 32912955 PMCID: PMC7482449 DOI: 10.1136/bmjopen-2020-038765] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/10/2020] [Accepted: 07/01/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Meta-analysis based on individual patient data (IPD) from randomised trials is superior to using published summary data since it facilitates subgroup and multiple variable analyses. Guidelines and funders expect that researchers share IPD for bona fide analyses, but in practice, this is done variably. Here, we report the experience of obtaining IPD for two collaborative analysis studies. SETTING Two linked studies required IPD from published randomised trials. The leading researchers for eligible trials were approached and asked to share IPD including trial characteristics, patient demographics, baseline clinical data and outcome measures. PARTICIPANTS Participants in eligible randomised controlled trials included patients with or at risk of cognitive decline/vascular events. PRIMARY AND SECONDARY OUTCOME MEASURES Numbers (%) of trials where the leading researcher responded favourably/negatively or did not respond. If negative, reasons behind the response were collected. If positive, methods used to share IPD were recorded. RESULTS Across the two studies, 391 completed trials were identified. Email addresses for researchers were found for 313 (80%) of the trials. One hundred and forty-eight (47%) researchers did not respond despite being sent multiple emails. Following contact, positive initial responses were received from 92 researchers, resulting in IPD being shared for 78 trials. Eighty-seven (28%) researchers declined to share data; justifications were recorded. The median time from first request to accessing data in one study was 241 (IQR 383.3) days. IPD sources included: direct from researcher, via academic trial funders repository and a website requiring remote analysis of commercial data. Where data were shared, a variety of methods were used to transfer data. CONCLUSION Sharing of IPD from trials is desirable and a requirement of many funding bodies. However, accessing IPD faces multiple challenges including refusals to share, delays in access to data and having to perform analyses on a remote website. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Polly Scutt
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Hearing Sciences, NIHR Nottingham Biomedical Research Centre, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Philip M Bath
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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26
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Godolphin PJ, Bath PM, Algra A, Berge E, Chalmers J, Eliasziw M, Hankey GJ, Hosomi N, Ranta A, Weimar C, Woodhouse LJ, Montgomery AA. Cost-benefit of outcome adjudication in nine randomised stroke trials. Clin Trials 2020; 17:576-580. [PMID: 32650688 DOI: 10.1177/1740774520939231] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Central adjudication of outcomes is common for randomised trials and should control for differential misclassification. However, few studies have estimated the cost of the adjudication process. METHODS We estimated the cost of adjudicating the primary outcome in nine randomised stroke trials (25,436 participants). The costs included adjudicators' time, direct payments to adjudicators, and co-ordinating centre costs (e.g. uploading cranial scans and general set-up costs). The number of events corrected after adjudication was our measure of benefit. We calculated cost per corrected event for each trial and in total. RESULTS The primary outcome in all nine trials was either stroke or a composite that included stroke. In total, the adjudication process associated with this primary outcome cost in excess of £100,000 for a third of the trials (3/9). Mean cost per event corrected by adjudication was £2295.10 (SD: £1482.42). CONCLUSIONS Central adjudication is a time-consuming and potentially costly process. These costs need to be considered when designing a trial and should be evaluated alongside the potential benefits adjudication brings to determine whether they outweigh this expense.
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Affiliation(s)
- Peter J Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK.,MRC Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Ale Algra
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - John Chalmers
- The George Institute for Global Health, University of NSW, Sydney, NSW, Australia
| | - Misha Eliasziw
- Department of Public Health and Community Medicine, Tufts University, Boston, MA, USA
| | - Graeme J Hankey
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | | | - Christian Weimar
- Universitätsklinikum Essen, Klinik für Neurologie, Hufelandstr, Essen, Germany
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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27
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Wardlaw J, Bath PMW, Doubal F, Heye A, Sprigg N, Woodhouse LJ, Blair G, Appleton J, Cvoro V, England T, Hassan A, John Werring D, Montgomery A. Protocol: The Lacunar Intervention Trial 2 (LACI-2). A trial of two repurposed licenced drugs to prevent progression of cerebral small vessel disease. Eur Stroke J 2020; 5:297-308. [PMID: 33072884 PMCID: PMC7538764 DOI: 10.1177/2396987320920110] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Background Small vessel disease causes a quarter of ischaemic strokes (lacunar subtype),
up to 45% of dementia either as vascular or mixed types, cognitive
impairment and physical frailty. However, there is no specific treatment to
prevent progression of small vessel disease. Aim We designed the LACunar Intervention Trial-2 (LACI-2) to test feasibility of
a large trial testing cilostazol and/or isosorbide mononitrate (ISMN) by
demonstrating adequate participant recruitment and retention in follow-up,
drug tolerability, safety and confirm outcome event rates required to power
a phase 3 trial. Methods and design LACI-2 is an investigator-initiated, prospective randomised open label
blinded endpoint (PROBE) trial aiming to recruit 400 patients with prior
lacunar syndrome due to a small subcortical infarct. We randomise
participants to cilostazol v no cilostazol and ISMN or no ISMN, minimising
on key prognostic factors. All patients receive guideline-based best medical
therapy. Patients commence trial drug at low dose, increment to full dose
over 2–4 weeks, continuing on full dose for a year. We follow-up
participants to one year for symptoms, tablet compliance, safety, recurrent
vascular events, cognition and functional outcomes, Trails B and brain MRI.
LACI-2 is registered ISRCTN 14911850, EudraCT 2016–002277-35. Trial outcome: Primary outcome is feasibility of recruitment and
compliance; secondary outcomes include safety (cerebral or systemic
bleeding, falls, death), efficacy (recurrent cerebral and cardiac vascular
events, cognition on TICS, Trails B) and tolerability. Summary LACI-2 will determine feasibility, tolerability and provide outcome rates to
power a large phase 3 trial to prevent progression of cerebral small vessel
disease.
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Affiliation(s)
| | - Philip M W Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | - Anna Heye
- The University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
| | | | | | | | - Vera Cvoro
- The University of Edinburgh, Edinburgh, UK
| | | | - Ahamad Hassan
- University College London Institute of Neurology, London, UK
| | | | - Alan Montgomery
- Stroke Trials Unit, Division of Clinical Neuroscience, The University of Nottingham, Nottingham, UK
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Bath PM, Woodhouse LJ, Suntrup-Krueger S, Hamdy S, Dziewas R. Abstract TMP40: Pharyngeal Electrical Stimulation for Early Decannulation in Tracheotomised Stroke Patients With Dysphagia: A Meta-analysis of Individual Patient Data From Randomised Controlled Trials. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp40] [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:
Dysphagia is common after stroke and associated with a poor outcome. Pharyngeal electrical stimulation (PES) increased decannulation rates in tracheotomised stroke patients with dysphagia following ventilation in two trials. We report the results of an individual patient data meta-analysis assessing PES in severely dysphagic tracheotomised stroke patients.
Methods:
We searched for randomised controlled trials of PES in dysphagic tracheotomised stroke patients and obtained individual patient data for demographic and clinical (stroke severity, NIHSS; functional oral intake scale, FOIS; decannulation) variables from trialists. Data are number (%), median [interquartile range], mean (standard deviation) and mean difference (MD) or odds ratio (OR) with 95% confidence intervals (CI).
Results:
Two completed trials were identified (n=30, PHAST-TRAC n=69 [funded by Phagenesis Ltd]), with data for 99 participants (PES 55, 56%; sham 44, 44%). Mean age 64 (13) years, female 40 (40%), NIHSS 18 [14-21], time from onset to randomisation 27 days [20-38], and FOIS=1 (nil by mouth). As compared with sham, PES was associated with an increased proportion of patients who were ready for early decannulation, 59% versus 11% (OR 11.4, 95% CI 3.86-33.33; p<0.001) and improved FOIS score at discharge (MD 1.13, 95% CI 0.25-2.00; p=0.011). Treated participants who were ready for decannulation tended to have a shorter hospital length of stay: 23 vs 41 days (p=0.070) than those who were not ready. No device-related serious adverse events were reported.
Conclusions:
PES was associated with an increased proportion of stroke patients who were ready for decannulation and less dysphagia, in two randomised trials.
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Affiliation(s)
| | - Lisa J Woodhouse
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | | | - Shaheen Hamdy
- Dept of Neurology, Univ of Manchester, Manchester, United Kingdom
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29
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Law ZK, England TJ, Mistri AK, Woodhouse LJ, Cala L, Dineen R, Ozturk S, Beridze M, Collins R, Bath PM, Sprigg N. Incidence and predictors of early seizures in intracerebral haemorrhage and the effect of tranexamic acid. Eur Stroke J 2020; 5:123-129. [PMID: 32637645 DOI: 10.1177/2396987320901391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 10/03/2019] [Accepted: 12/29/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Seizures are common after intracerebral haemorrhage. Tranexamic acid increases the risk of seizures in non-intracerebral haemorrhage population but its effect on post-intracerebral haemorrhage seizures is unknown. We explored the risk factors and outcomes of seizures after intracerebral haemorrhage and if tranexamic acid increased the risk of seizures in the Tranexamic acid for IntraCerebral Haemorrhage-2 trial. Patients and methods Seizures were reported prospectively up to day 90. Cox regression analyses were used to determine the predictors of seizures within 90 days and early seizures (≤7 days). We explored the effect of early seizures on day 90 outcomes. Results Of 2325 patients recruited, 193 (8.3%) had seizures including 163 (84.5%) early seizures and 30 (15.5%) late seizures (>7 days). Younger age (adjusted hazard ratio (aHR) 0.98 per year increase, 95% confidence interval (CI) 0.97-0.99; p = 0.008), lobar haematoma (aHR 5.84, 95%CI 3.58-9.52; p < 0.001), higher National Institute of Health Stroke Scale (aHR 1.03, 95%CI 1.01-1.06; p = 0.014) and previous stroke (aHR 1.66, 95%CI 1.11-2.47; p = 0.013) were associated with early seizures. Tranexamic acid did not increase the risk of seizure within 90 days. Early seizures were associated with worse modified Rankin Scale (adjusted odds ratio (aOR) 1.79, 95%CI 1.12-2.86, p = 0.015) and increased risk of death (aOR 3.26, 95%CI 1.98-5.39; p < 0.001) at day 90.Discussion and conclusion: Lobar haematoma was the strongest independent predictor of early seizures after intracerebral haemorrhage. Tranexamic acid did not increase the risk of post-intracerebral haemorrhage seizures in the first 90 days. Early seizures resulted in worse functional outcome and increased risk of death.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Timothy J England
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Vascular Medicine, Division of Medical Sciences and GEM, University of Nottingham, Nottingham, UK
| | - Amit K Mistri
- Stroke Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lesley Cala
- School of Medicine, University of Western Australia, Perth, Australia
| | - Rob Dineen
- Radiological Sciences, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Serefnur Ozturk
- Department of Neurology, Medical Faculty, Selcuk University, Konya, Turkey
| | - Maia Beridze
- The First University Clinic of Tbilisi State Medical University, Tbilisi, Georgia
| | - Ronan Collins
- Stroke Service, Adelaide and Meath Hospital, Tallaght, Ireland
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Department of Stroke, Division of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Department of Stroke, Division of Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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30
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Appleton JP, Woodhouse LJ, Adami A, Becker JL, Berge E, Cala LA, Casado AM, Caso V, Christensen HK, Dineen RA, Gommans J, Koumellis P, Szatmari S, Sprigg N, Bath PM, Wardlaw JM. Imaging markers of small vessel disease and brain frailty, and outcomes in acute stroke. Neurology 2019; 94:e439-e452. [PMID: 31882527 PMCID: PMC7080284 DOI: 10.1212/wnl.0000000000008881] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/16/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To assess the association of baseline imaging markers of cerebral small vessel disease (SVD) and brain frailty with clinical outcome after acute stroke in the Efficacy of Nitric Oxide in Stroke (ENOS) trial. METHODS ENOS randomized 4,011 patients with acute stroke (<48 hours of onset) to transdermal glyceryl trinitrate (GTN) or no GTN for 7 days. The primary outcome was functional outcome (modified Rankin Scale [mRS] score) at day 90. Cognition was assessed via telephone at day 90. Stroke syndrome was classified with the Oxfordshire Community Stroke Project classification. Brain imaging was adjudicated masked to clinical information and treatment and assessed SVD (leukoaraiosis, old lacunar infarcts/lacunes, atrophy) and brain frailty (leukoaraiosis, atrophy, old vascular lesions/infarcts). Analyses used ordinal logistic regression adjusted for prognostic variables. RESULTS In all participants and those with lacunar syndrome (LACS; 1,397, 34.8%), baseline CT imaging features of SVD and brain frailty were common and independently associated with unfavorable shifts in mRS score at day 90 (all participants: SVD score odds ratio [OR] 1.15, 95% confidence interval [CI] 1.07-1.24; brain frailty score OR 1.25, 95% CI 1.17-1.34; those with LACS: SVD score OR 1.30, 95% CI 1.15-1.47, brain frailty score OR 1.28, 95% CI 1.14-1.44). Brain frailty was associated with worse cognitive scores at 90 days in all participants and in those with LACS. CONCLUSIONS Baseline imaging features of SVD and brain frailty were common in lacunar stroke and all stroke, predicted worse prognosis after all acute stroke with a stronger effect in lacunar stroke, and may aid future clinical decision-making. IDENTIFIER ISRCTN99414122.
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Affiliation(s)
- Jason P Appleton
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Lisa J Woodhouse
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Alessandro Adami
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Jennifer L Becker
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Eivind Berge
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Lesley A Cala
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Ana M Casado
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Valeria Caso
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Hanne K Christensen
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Robert A Dineen
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - John Gommans
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Panos Koumellis
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Szabolcs Szatmari
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Nikola Sprigg
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
| | - Philip M Bath
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK.
| | - Joanna M Wardlaw
- From the Stroke Trials Unit (J.P.A., L.J.W., N.S., P.M.B.) and Radiological Sciences Research Group (R.A.D.), Division of Clinical Neurosciences, University of Nottingham; Stroke (J.P.A., N.S., P.M.B.), Nottingham University Hospitals NHS Trust, UK; Stroke Center (A.A.), IRCSS Sacro Cuore-Don Calabria Hospital, Negrar, Verona, Italy; Department of Medical Imaging (J.L.B.), College of Medicine, University of Arizona, Tucson; Department of Internal Medicine and Cardiology (E.B.), Oslo University Hospital, Norway; School of Medicine (L.A.C.), University of Western Australia, Crawley; Department of Neuroradiology (A.M.C.), Division of Clinical Neurosciences, Western General Hospital, Edinburgh, UK; Stroke Unit (V.C.), Santa Maria della Misericordia Hospital, University of Perugia, Italy; Neurology (H.K.C.), Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark; Department of Medicine (J.G.), Hawke's Bay District Health Board, Hastings, New Zealand; Department of Neuroradiology (P.K.), Nottingham University Hospitals, Queen's Medical Centre, UK; Department of Neurology (S.S.), Clinical County Emergency Hospital, Targu Mures, Romania; and Division of Neuroimaging Sciences (J.M.W.), Centre for Clinical Brain Sciences, Dementia Research Institute, University of Edinburgh, UK
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Godziuk K, Prado CM, Woodhouse LJ, Forhan M. Prevalence of sarcopenic obesity in adults with end-stage knee osteoarthritis. Osteoarthritis Cartilage 2019; 27:1735-1745. [PMID: 31276820 DOI: 10.1016/j.joca.2019.05.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/19/2018] [Revised: 04/16/2019] [Accepted: 05/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify the prevalence of sarcopenic obesity, a phenotype of low muscle mass and high adiposity, in adults with end-stage knee osteoarthritis (OA). Various diagnostic criteria, including assessment of muscle/fat mass, muscle strength and physical function, were used to identify patients with and without sarcopenic obesity, and to compare outcomes of pain, function and quality of life. DESIGN Cross-sectional clinical study including adults with a body mass index (BMI) ≥30 kg/m2 and knee OA. Body composition was measured by dual-energy X-ray absorptiometry (DXA). Assessments included gait speed, handgrip strength, six minute walk test, and self-reported pain, physical function, and health-related quality of life using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and EuroQol Foundation (EQ-5D). RESULTS 151 adults (59% female) aged 65.1 ± 7.9 years, mean BMI 37.1 ± 5.5 kg/m2, were included. Prevalence of sarcopenic obesity using diagnostic cut-offs of appendicular skeletal muscle mass (ASM) relevant to height2, weight and BMI varied from 1.3% (95% confidence interval (CI): 0.2-4.7%) to 14.6% (9.4-21.2%) and 27.2% (20.2-35%), respectively. A combined diagnostic approach including low ASM with either low strength or low function yielded a prevalence of 8.6% (4.7-14.3%). Sarcopenic obesity influenced walking speed, endurance, strength, and patient-reported difficulty with self-care activities, regardless of diagnostic approach. CONCLUSION Prevalence of sarcopenic obesity varied depending on diagnostic criteria. Given the impact of this condition and OA on physical function, we suggest a combined diagnostic approach be used to clarify expected prevalence and enable early clinical identification and management of sarcopenic obesity in patients with knee OA.
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Affiliation(s)
- K Godziuk
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.
| | - C M Prado
- Department of Agricultural, Food and Nutritional Science, Faculty of Agricultural, Life and Environmental Sciences, University of Alberta, Edmonton, AB, Canada.
| | - L J Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.
| | - M Forhan
- Department of Occupational Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.
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32
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Bath PM, Woodhouse LJ, Krishnan K, Appleton JP, Anderson CS, Berge E, Cala L, Dixon M, England TJ, Godolphin PJ, Hepburn T, Mair G, Montgomery AA, Phillips SJ, Potter J, Price CI, Randall M, Robinson TG, Roffe C, Rothwell PM, Sandset EC, Sanossian N, Saver JL, Siriwardena AN, Venables G, Wardlaw JM, Sprigg N. Prehospital Transdermal Glyceryl Trinitrate for Ultra-Acute Intracerebral Hemorrhage: Data From the RIGHT-2 Trial. Stroke 2019; 50:3064-3071. [PMID: 31587658 PMCID: PMC6824503 DOI: 10.1161/strokeaha.119.026389] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Pilot trials suggest that glyceryl trinitrate (GTN; nitroglycerin) may improve outcome when administered early after stroke onset.
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Affiliation(s)
- Philip M Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Lisa J Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Kailash Krishnan
- Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
| | - Jason P Appleton
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.)
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia (C.S.A.).,The George Institute China at Peking University Health Science Center, Beijing, China (C.S.A.).,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, NSW, Australia (C.S.A.)
| | - Eivind Berge
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Department of Neurology (E.C.S.), Oslo University Hospital, Norway
| | - Lesley Cala
- Faculty of Health and Medical Sciences, University of Western Australia (L.C.)
| | - Mark Dixon
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,East Midlands Ambulance Service NHS Trust, Nottingham, United Kingdom (M.D.)
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences, GEM, Royal Derby Hospital Centre (T.J.E.), University of Nottingham, United Kingdom
| | - Peter J Godolphin
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Grant Mair
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Queen's Medical Centre (P.J.G., T.H., A.A.M.), University of Nottingham, United Kingdom
| | - Stephen J Phillips
- Department of Medicine, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Canada (S.J.P.)
| | - John Potter
- Bob Champion Research and Education Building, University of East Anglia, Norwich, United Kingdom (J.P.)
| | - Chris I Price
- Institute of Neuroscience, Newcastle University, United Kingdom (C.I.P.)
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, United Kingdom (M.R.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, United Kingdom (T.G.R.)
| | - Christine Roffe
- Stroke Research in Stoke, Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, United Kingdom (C.R.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford, United Kingdom (P.M.R.)
| | - Else C Sandset
- Research and Development, The Norwegian Air Ambulance Foundation, Oslo, Norway (E.C.S.)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California Keck School of Medicine, Los Angeles (N.S.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at UCLA (J.L.S.)
| | - A Niroshan Siriwardena
- Department of Internal Medicine (E.B., A.N.S), Oslo University Hospital, Norway.,Community and Health Research Unit, University of Lincoln, United Kingdom (A.N.S.)
| | - Graham Venables
- Department of Neurology, Royal Hallamshire Hospital, Sheffield, United Kingdom (G.V.)
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, Edinburgh Imaging and UK Dementia Research Institute at the University of Edinburgh, Chancellor's Building (G.M., J.M.W.)
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B., L.J.W., J.P.A., M.D., N.S.).,Stroke, Nottingham University Hospitals National Health Service (NHS) Trust, City Hospital Campus, United Kingdom (P.M.B., K.K., N.S.)
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33
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Moullaali TJ, Wang X, Woodhouse LJ, Law ZK, Delcourt C, Sprigg N, Krishnan K, Robinson TG, Wardlaw JM, Al-Shahi Salman R, Berge E, Sandset EC, Anderson CS, Bath PM. Lowering blood pressure after acute intracerebral haemorrhage: protocol for a systematic review and meta-analysis using individual patient data from randomised controlled trials participating in the Blood Pressure in Acute Stroke Collaboration (BASC). BMJ Open 2019; 9:e030121. [PMID: 31315876 PMCID: PMC6661570 DOI: 10.1136/bmjopen-2019-030121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/02/2019] [Accepted: 06/14/2019] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Conflicting results from multiple randomised trials indicate that the methods and effects of blood pressure (BP) reduction after acute intracerebral haemorrhage (ICH) are complex. The Blood pressure in Acute Stroke Collaboration is an international collaboration, which aims to determine the optimal management of BP after acute stroke including ICH. METHODS AND ANALYSIS A systematic review will be undertaken according to the Preferred Reporting Items for Systematic review and Meta-Analysis of Individual Participant Data (IPD) guideline. A search of Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE from inception will be conducted to identify randomised controlled trials of BP management in adults with acute spontaneous (non-traumatic) ICH enrolled within the first 7 days of symptom onset. Authors of studies that meet the inclusion criteria will be invited to share their IPD. The primary outcome will be functional outcome according to the modified Rankin Scale. Safety outcomes will be early neurological deterioration, symptomatic hypotension and serious adverse events. Secondary outcomes will include death and neuroradiological and haemodynamic variables. Meta-analyses of pooled IPD using the intention-to-treat dataset of included trials, including subgroup analyses to assess modification of the effects of BP lowering by time to treatment, treatment strategy and patient's demographic, clinical and prestroke neuroradiological characteristics. ETHICS AND DISSEMINATION No new patient data will be collected nor is there any deviation from the original purposes of each study where ethical approvals were granted; therefore, further ethical approval is not required. Results will be reported in international peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42019141136.
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Affiliation(s)
- Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Xia Wang
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Zhe Kang Law
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
- National University of Malaysia, Bangi, Malaysia
| | - Candice Delcourt
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Neurology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Nikola Sprigg
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Else C Sandset
- Neurology Department, Oslo University Hospital, Oslo, Norway
- Research and Development, Norwegian Air Ambulance Foundation, Bodo, Norway
| | - Craig S Anderson
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Neurology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Philip M Bath
- Stroke Trials Unit, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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34
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Appleton JP, Blair GW, Flaherty K, Law ZK, May J, Woodhouse LJ, Doubal F, Sprigg N, Bath PM, Wardlaw JM. Effects of Isosorbide Mononitrate and/or Cilostazol on Hematological Markers, Platelet Function, and Hemodynamics in Patients With Lacunar Ischaemic Stroke: Safety Data From the Lacunar Intervention-1 (LACI-1) Trial. Front Neurol 2019; 10:723. [PMID: 31333572 PMCID: PMC6616057 DOI: 10.3389/fneur.2019.00723] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/18/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Cilostazol and isosorbide mononitrate (ISMN) are candidate treatments for cerebral small vessel disease and lacunar ischaemic stroke. As both drugs may influence hemoglobin and platelet count, and hemodynamics, we sought to assess their effects in the lacunar intervention-1 (LACI-1) trial. Methods: Fifty-seven lacunar ischaemic stroke patients were randomized to immediate ISMN, cilostazol, or their combination for 9 weeks in addition to guideline stroke prevention. A fourth group received both drugs with a delayed start. Full blood count, platelet function, peripheral blood pressure (BP), heart rate and central hemodynamics (Augmentation index, Buckberg index) were measured at baseline, and weeks 3 and 8. Differences were assessed by multiple linear regression adjusted for baseline and key prognostic variables. Registration ISRCTN 12580546. Results: At week 8, platelet count was higher with cilostazol vs. no cilostazol (mean difference, MD 35.73, 95% confidence intervals, 95% CI 2.81-68.66, p = 0.033), but no significant differences were noted for hemoglobin levels or platelet function. At week 8, BP did not differ between the treatment groups, whilst heart rate was higher in those taking cilostazol vs. no cilostazol (MD 6.42, 95% CI 1.17-11.68, p = 0.017). Buckberg index (subendocardial perfusion) was lower in those randomized to cilostazol vs. no cilostazol and in those randomized to both drugs vs. either drug. Whilst ISMN significantly increased unadjusted augmentation index (arterial stiffness, MD 21.19, 95% CI 9.08-33.31, p = 0.001), in isolation both drugs non-significantly reduced augmentation index adjusted for heart rate. Conclusions: Cilostazol increased heart rate and platelet count, and reduced Buckberg index, whilst both drugs may individually reduce arterial stiffness adjusted for heart rate. Neither drug had clinically significant effects on hemoglobin or platelet function over 8 weeks. Further assessment of the safety and efficacy of these medications following lacunar ischaemic stroke is warranted.
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Affiliation(s)
- Jason P. Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Gordon W. Blair
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, Edinburgh, United Kingdom
- Edinburgh Imaging, University of Edinburgh, Edinburgh, United Kingdom
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jane May
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Fergus Doubal
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, Edinburgh, United Kingdom
- Edinburgh Imaging, University of Edinburgh, Edinburgh, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Joanna M. Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Dementia Research Centre in the UK Dementia Research Initiative, Edinburgh, United Kingdom
- Edinburgh Imaging, University of Edinburgh, Edinburgh, United Kingdom
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35
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Flaherty K, Duley L, England TJ, Havard D, Heptinstall S, James M, Kasonde C, Krishnan K, Markus HS, Montgomery AA, Pocock S, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Triple versus guideline antiplatelet therapy to prevent recurrence after acute ischaemic stroke or transient ischaemic attack: the TARDIS RCT. Health Technol Assess 2019; 22:1-76. [PMID: 30179153 DOI: 10.3310/hta22480] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Two antiplatelet agents are better than one for preventing recurrent stroke after acute ischaemic stroke or transient ischaemic attack (TIA). Therefore, intensive treatment with three agents might be better still, providing it does not cause undue bleeding. OBJECTIVE To compare the safety and efficacy of intensive therapy with guideline antiplatelet therapy for acute ischaemic stroke and TIA. DESIGN International prospective randomised open-label blinded end-point parallel-group superiority clinical trial. SETTING Acute hospitals at 106 sites in four countries. PARTICIPANTS Patients > 50 years of age with acute non-cardioembolic ischaemic stroke or TIA within 48 hours of ictus (stroke). INTERVENTIONS Participants were allocated at random by computer to 1 month of intensive (combined aspirin, clopidogrel and dipyridamole) or guideline (combined aspirin and dipyridamole, or clopidogrel alone) antiplatelet agents, and followed for 90 days. MAIN OUTCOME MEASURES The primary outcome was the incidence and severity of any recurrent stroke (ischaemic, haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days by blinded telephone follow-up. Analysis using ordinal logistic regression was by intention to treat. Other outcomes included bleeding and its severity, death, myocardial infarction (MI), disability, mood, cognition and quality of life. RESULTS The trial was stopped early on the recommendation of the Data Monitoring Committee after recruitment of 3096 participants (intensive, n = 1556; guideline, n = 1540) from 106 hospitals in four countries between April 2009 and March 2016. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy in 3070 (99.2%) participants with data [93 vs. 105 stroke/TIA events; adjusted common odds ratio 0.90, 95% confidence interval (CI) 0.67 to 1.20; p = 0.47]. Major (encompassing fatal) bleeding was increased with intensive as compared with guideline therapy [39 vs. 17 participants; adjusted hazard ratio (aHR) 2.23, 95% CI 1.25 to 3.96; p = 0.006]. There were no differences between the treatment groups in all-cause mortality, or the composite of death, stroke, MI and major bleeding (aHR 1.02, 95% CI 0.77 to 1.35; p = 0.88). LIMITATIONS Patients and investigators were not blinded to treatment. The comparator group comprised two guideline strategies because of changes in national guidelines during the trial. The trial was stopped early, thereby reducing its statistical power. CONCLUSIONS The use of three antiplatelet agents is associated with increased bleeding without any significant reduction in recurrence of stroke or TIA. FUTURE WORK The safety and efficacy of dual antiplatelet therapy (combined aspirin and clopidogrel) versus aspirin remains to be defined. Further research is required on identifying individual patient response to antiplatelets, and the relationship between response and the subsequent risks of vascular recurrent events and bleeding complications. TRIAL REGISTRATION Current Controlled Trials ISRCTN47823388. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 48. See the NIHR Journal Library website for further project information. The Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) vanguard phase was funded by the British Heart Foundation (grant PG/08/083/25779, from 1 April 2009 to 30 September 2012) and indirect funding was provided by the Stroke Association through its funding of the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK. There was no commercial support for the trial and antiplatelet drugs were sourced locally at each site. The trial was sponsored by the University of Nottingham.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maia Beridze
- Department of Neurology, Hospital of War Veterans, Tbilisi, Georgia
| | - Hanne Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | | | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart Pocock
- Medical Statistics Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annamarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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36
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Appleton JP, Woodhouse LJ, Belcher A, Bereczki D, Berge E, Caso V, Chang HM, Christensen HK, Collins R, Gommans J, Laska AC, Ntaios G, Ozturk S, Sare GM, Szatmari S, Wang Y, Wardlaw JM, Sprigg N, Bath PM. It is safe to use transdermal glyceryl trinitrate to lower blood pressure in patients with acute ischaemic stroke with carotid stenosis. Stroke Vasc Neurol 2019; 4:28-35. [PMID: 31105976 PMCID: PMC6475087 DOI: 10.1136/svn-2019-000232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background There is concern that blood pressure (BP) lowering in acute stroke may compromise cerebral perfusion and worsen outcome in the presence of carotid stenosis. We assessed the effect of glyceryl trinitrate (GTN) in patients with carotid stenosis using data from the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. Methods ENOS randomised 4011 patients with acute stroke and raised systolic BP (140-220 mm Hg) to transdermal GTN or no GTN within 48 hours of onset. Those on prestroke antihypertensives were also randomised to stop or continue their medication for 7 days. The primary outcome was the modified Rankin Scale (mRS) at day 90. Ipsilateral carotid stenosis was split: <30%; 30-<50%; 50-<70%; ≥70%. Data are ORs with 95% CIs adjusted for baseline prognostic factors. Results 2023 (60.5%) ischaemic stroke participants had carotid imaging. As compared with <30%, ≥70% ipsilateral stenosis was associated with an unfavourable shift in mRS (worse outcome) at 90 days (OR 1.88, 95% CI 1.44 to 2.44, p<0.001). Those with ≥70% stenosis who received GTN versus no GTN had a favourable shift in mRS (OR 0.56, 95% CI 0.34 to 0.93, p=0.024). In those with 50-<70% stenosis, continuing versus stopping prestroke antihypertensives was associated with worse disability, mood, quality of life and cognition at 90 days. Clinical outcomes did not differ across bilateral stenosis groups. Conclusions Following ischaemic stroke, severe ipsilateral carotid stenosis is associated with worse functional outcome at 90 days. GTN appears safe in ipsilateral or bilateral carotid stenosis, and might improve outcome in severe ipsilateral carotid stenosis.
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Affiliation(s)
- Jason P Appleton
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Andrew Belcher
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Oslo, Norway
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Hui Meng Chang
- Department of Neurology, Singapore General Hospital, Singapore, Singapore
| | | | - Ronan Collins
- Tallaght Hospital, Trinity College Dublin, Dublin, Ireland
| | - John Gommans
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Ann C Laska
- Department of Clinical Science, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece
| | - Serefnur Ozturk
- Neurology, Selcuk University Faculty of Medicine, Konya, Turkey
| | - Gillian M Sare
- Neurology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Szabolcs Szatmari
- Department of Neurology, Clinical County Emergency Hospital, Targu Mures, Romania
| | - Yongjun Wang
- Neurology, Beijing Tiantan Hospital, Beijing, China
| | | | - Nikola Sprigg
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke, Division of Clinical Neurosciences, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Appleton JP, Scutt P, Dixon M, Howard H, Haywood L, Havard D, Hepburn T, England T, Sprigg N, Woodhouse LJ, Wardlaw JM, Montgomery AA, Pocock S, Bath PM. Ambulance-delivered transdermal glyceryl trinitrate versus sham for ultra-acute stroke: Rationale, design and protocol for the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) trial (ISRCTN26986053). Int J Stroke 2019; 14:191-206. [PMID: 28762896 DOI: 10.1177/1747493017724627] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Vascular nitric oxide levels are low in acute stroke and donors such as glyceryl trinitrate have shown promise when administered very early after stroke. Potential mechanisms of action include augmentation of cerebral reperfusion, thrombolysis and thrombectomy, lowering blood pressure, and cytoprotection. AIM To test the safety and efficacy of four days of transdermal glyceryl trinitrate (5 mg/day) versus sham in patients with ultra-acute presumed stroke who are recruited by paramedics prior to hospital presentation. SAMPLE SIZE ESTIMATES The sample size of 850 patients will allow a shift in the modified Rankin Scale with odds ratio 0.70 (glyceryl trinitrate versus sham, ordinal logistic regression) to be detected with 90% power at 5% significance (two-sided). DESIGN The Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) is a multicentre UK prospective randomized sham-controlled outcome-blinded parallel-group trial in 850 patients with ultra-acute (≤4 h of onset) FAST-positive presumed stroke and systolic blood pressure ≥120 mmHg who present to the ambulance service following a 999 emergency call. Data collection is performed via a secure internet site with real-time data validation. STUDY OUTCOMES The primary outcome is the modified Rankin Scale measured centrally by telephone at 90 days and masked to treatment. Secondary outcomes include: blood pressure, impairment, recurrence, dysphagia, neuroimaging markers of the acute lesion including vessel patency, discharge disposition, length of stay, death, cognition, quality of life, and mood. Neuroimaging and serious adverse events are adjudicated blinded to treatment. DISCUSSION RIGHT-2 has recruited more than 500 participants from seven UK ambulance services. STATUS Trial is ongoing. FUNDING British Heart Foundation. REGISTRATION ISRCTN26986053.
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Affiliation(s)
- Jason P Appleton
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Polly Scutt
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Mark Dixon
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Harriet Howard
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lee Haywood
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diane Havard
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Trish Hepburn
- 2 Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tim England
- 3 Division of Medical Sciences, University of Nottingham, Derby, UK
| | - Nikola Sprigg
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Alan A Montgomery
- 2 Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart Pocock
- 5 Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Philip M Bath
- 1 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Appleton JP, Woodhouse LJ, Bereczki D, Berge E, Christensen HK, Collins R, Gommans J, Ntaios G, Ozturk S, Szatmari S, Wardlaw JM, Sprigg N, Rothwell PM, Bath PM. Effect of Glyceryl Trinitrate on Hemodynamics in Acute Stroke. Stroke 2019; 50:405-412. [PMID: 30626285 PMCID: PMC6358219 DOI: 10.1161/strokeaha.118.023190] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/25/2018] [Accepted: 11/13/2018] [Indexed: 11/30/2022]
Abstract
Background and Purpose- Increased blood pressure (BP), heart rate, and their derivatives (variability, pulse pressure, rate-pressure product) are associated with poor clinical outcome in acute stroke. We assessed the effects of glyceryl trinitrate (GTN) on hemodynamic parameters and these on outcome in participants in the ENOS trial (Efficacy of Nitric Oxide in Stroke). Methods- Four thousand and eleven patients with acute stroke and raised BP were randomized within 48 hours of onset to transdermal GTN or no GTN for 7 days. Peripheral hemodynamics were measured at baseline (3 measures) and daily (2 measures) during treatment. Between-visit BP variability over days 1 to 7 (as SD) was assessed in quintiles. Functional outcome was assessed as modified Rankin Scale and cognition as telephone mini-mental state examination at day 90. Analyses were adjusted for baseline prognostic variables. Data are mean difference or odds ratios with 95% CI. Results- Increased baseline BP (diastolic, variability), heart rate, and rate-pressure product were each associated with unfavorable functional outcome at day 90. Increased between-visit systolic BP variability was associated with an unfavourable shift in modified Rankin Scale (highest quintile adjusted odds ratio, 1.65; 95% CI, 1.37-1.99), worse cognitive scores (telephone mini-mental state examination: highest quintile adjusted mean difference, -2.03; 95% CI, -2.84 to -1.22), and increased odds of death at day 90 (highest quintile adjusted odds ratio, 1.57; 95% CI, 1.12-2.19). GTN lowered BP and rate-pressure product and increased heart rate at day 1 and reduced between-visit systolic BP variability. Conclusions- Increased between-visit BP variability was associated with poor functional and cognitive outcomes and increased death 90 days after acute stroke. In addition to lowering BP and rate-pressure product, GTN reduced between-visit systolic BP variability. Agents that lower BP variability in acute stroke require further study.
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Affiliation(s)
- Jason P Appleton
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (J.P.A., L.J.W., N.S., P.M.B.)
- Department of Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (J.P.A., N.S., P.M.B.)
| | - Lisa J Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (J.P.A., L.J.W., N.S., P.M.B.)
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary (D.B.)
| | - Eivind Berge
- Department of Internal Medicine and Cardiology, Oslo University Hospital, Norway (E.B.)
| | - Hanne K Christensen
- Department of Neurology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark (H.K.C.)
| | - Rónán Collins
- Stroke Services, Trinity College Dublin, Tallaght Hospital, Ireland (R.C.)
| | - John Gommans
- Department of Medicine, Hawke's Bay District Health Board, Hastings, New Zealand (J.G.)
| | - George Ntaios
- Department of Medicine, University of Thessaly, Larissa, Greece (G.N.)
| | - Serefnur Ozturk
- Department of Neurology, Selcuk University Faculty of Medicine, Konya, Turkey (S.O.)
| | - Szabolcs Szatmari
- Department of Neurology, Clinical County Emergency Hospital, Targu Mures, Romania (S.S.)
| | - Joanna M Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, (J.M.W.)
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (J.P.A., L.J.W., N.S., P.M.B.)
- Department of Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (J.P.A., N.S., P.M.B.)
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, United Kingdom (P.M.R.)
| | - Philip M Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (J.P.A., L.J.W., N.S., P.M.B.)
- Department of Stroke, Nottingham University Hospitals NHS Trust, United Kingdom (J.P.A., N.S., P.M.B.)
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Steer KJD, Bostick GP, Woodhouse LJ, Nguyen TT, Schankath A, Lambert RGW, Jaremko JL. Can effusion-synovitis measured on ultrasound or MRI predict response to intra-articular steroid injection in hip osteoarthritis? Skeletal Radiol 2019; 48:227-237. [PMID: 29980827 DOI: 10.1007/s00256-018-3010-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 12/21/2017] [Revised: 06/11/2018] [Accepted: 06/17/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Intra-articular steroid injection (IASI) is an effective therapy for hip osteoarthritis (OA), but carries risks and provides significant pain relief to only two thirds of patients. We attempted to predict response to IASI in hip OA patients using baseline clinical, ultrasound, and MRI data. METHODS Observational study of 97 subjects with symptomatic hip OA presenting for IASI. At baseline and 8 weeks we obtained hip MRI, grayscale and Doppler ultrasound, clinical range of motion (ROM), timed-up and go test (TUG) scores, and self-reported Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain, stiffness, and function scores. Bone-capsule distance (BCD) measurements of inflammation on hip ultrasound and MRI were measured at three locations: the proximal-most uncovered portion of the femoral head, the superficial-most (apex) portion of the femoral head, and the largest fluid pocket at the femoral neck. RESULTS Ultrasound and MRI BCD correlated with each other significantly and strongly at the apex and neck. Power Doppler findings did not correlate significantly with any other imaging indices. Eight weeks post-injection, WOMAC pain, function, and stiffness scores significantly improved and TUG time improved nearly to the level of significance, but there were no significant changes in ultrasound, MRI, or Doppler indices. Baseline variables were not significantly different between responder and nonresponder WOMAC pain or TUG time cohorts. CONCLUSION Basic measures of inflammation on ultrasound and MRI are highly related to each other, but provide little insight into patient function and pain after IASI. Other mechanisms to explain improvement in patient status after IASI are likely at work.
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Affiliation(s)
- K J D Steer
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, 2A2.41 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada.
| | - G P Bostick
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
| | - L J Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada.,McCaig Institute for Bone and Joint Health, Calgary, AB, Canada
| | - T T Nguyen
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, 2A2.41 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada
| | - A Schankath
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, 2A2.41 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada
| | - R G W Lambert
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, 2A2.41 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada
| | - J L Jaremko
- Department of Radiology and Diagnostic Imaging, Faculty of Medicine, University of Alberta, 2A2.41 WMC, 8440-112 Street NW, Edmonton, AB, T6G 2B7, Canada
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Law ZK, Scutt P, Woodhouse LJ, Gray R, Appleton JP, Lysons C, Frowd N, Bath PM, Sprigg N. Abstract 16: The Tranexamic Acid for Intracerebral Haemorrhage-2 (TICH-2) Trial: Results of One Year Follow Up Data. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.16] [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:
The Tranexamic acid for IntraCerebral Haemorrhage-2 (TICH-2) trial reported no significant improvement in death and dependency at day 90 despite reduction in haematoma expansion and early neurological deterioration. However, significant recovery after stroke, particularly intracerebral haemorrhage may take more than 3 months. Here we will report the participant outcomes one year after stroke.
Methods:
TICH-2 was a prospective randomised controlled trial that tested the efficacy and safety of tranexamic acid in spontaneous intracerebral haemorrhage when given within 8 hours of onset. Centralised blinded telephone follow up was performed for patients from the United Kingdom at Day 365. Outcome assessments included modified Rankin Scale, Barthel index, Telephone Interview Cognitive Status-modified, EuroQoL-5D and Zung Depression Scale.
Results:
2325 patients were recruited into the trial (age 68.9 ±13.8 years; 1301 male, 56%). 1161 participants were assigned to tranexamic acid and 1164 participants to placebo. 1909 participants (82.1%) were recruited from the United Kingdom and eligible for day 365 follow up. 81 patients (4.2%) were lost to follow up. Of the 1800 patients with available outcome to date, 609 (33.8%) died while 1003 (55.6%) had poor functional outcome (modified Rankin Scale 4 to 6).
Conclusion:
This is a place-holding abstract for the results of the ongoing day 365 follow-up of TICH-2. To our knowledge this will be the largest long term follow-up of patients with intracerebral haemorrhage.
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Affiliation(s)
| | - Polly Scutt
- Univ of Nottingham, Nottingham, United Kingdom
| | | | - Robert Gray
- Univ of Nottingham, Nottingham, United Kingdom
| | | | | | - Nadia Frowd
- Univ of Nottingham, Nottingham, United Kingdom
| | | | - Nikola Sprigg
- Stroke, Univ of Nottingham, Nottingham, United Kingdom
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Bath PM, Scutt P, Appleton JP, Dixon M, Woodhouse LJ, Wardlaw JM, Sprigg N. Baseline characteristics of the 1149 patients recruited into the Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) randomized controlled trial. Int J Stroke 2018; 14:298-305. [DOI: 10.1177/1747493018816451] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background High blood pressure is common in acute stroke and associated with a worse functional outcome. Glyceryl trinitrate, a nitric oxide donor, lowers blood pressure in acute stroke and may improve outcome. Aims Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2) tested the feasibility of performing a UK multicenter ambulance-based stroke trial, and the safety and efficacy of glyceryl trinitrate when administered by paramedics before hospital admission. Methods Paramedic-led ambulance-based multicenter prospective randomized single-blind blinded-endpoint parallel-group controlled trial of transdermal glyceryl trinitrate (given for four days) versus sham in patients with ultra-acute (<4 h) presumed stroke. Data are number (%), median (interquartile range) or mean (standard deviation). Results Recruitment ran from October 2015 to 31 May 2018. A total 1149 patients were recruited from eight UK ambulance services and taken to 54 acute hospitals. Baseline characteristics include: mean age 73 (15) years; female 555 (48%); median time from stroke to randomization 70 (45, 115) min; face-arm-speech scale score 2.6 (0.5); and blood pressure 162 (25)/92 (18) mmHg. The final diagnosis was ischemic stroke 52%, hemorrhagic stroke 13%, Transient Ischemic Attack (TIA) 9%, and mimic 25%. The main trial results will be presented in quarter 4 2018. The results will also be included in updated Cochrane systematic reviews, and individual patient data meta-analyses of all relevant randomized controlled trials. Conclusion It was feasible to perform a multicenter ambulance-based ultra-acute stroke trial in the UK and to treat with glyceryl trinitrate versus sham. The relatively unselected cohort of stroke patients is broadly representative of those admitted to hospital in the UK. Trial registration ISRCTN26986053.
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Affiliation(s)
- Philip M Bath
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Polly Scutt
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Dixon
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Clinical Governance, Audit & Research, East Midlands Ambulance Service NHS Trust, Lincoln, UK
| | - Lisa J Woodhouse
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Brain Research Imaging Centre, University of Edinburgh, Edinburgh, UK
| | - Nikola Sprigg
- Stroke, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Godolphin PJ, Montgomery AA, Woodhouse LJ, Bereczki D, Berge E, Collins R, Díez-Tejedor E, Gommans J, Lees KR, Ozturk S, Phillips S, Pocock S, Prasad K, Szatmari S, Wang Y, Bath PM, Sprigg N. Central adjudication of serious adverse events did not affect trial's safety results: Data from the Efficacy of Nitric Oxide in Stroke (ENOS) trial. PLoS One 2018; 13:e0208142. [PMID: 30475912 PMCID: PMC6258247 DOI: 10.1371/journal.pone.0208142] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/02/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Central adjudication of serious adverse events (SAEs) can be undertaken in clinical trials, especially for open-label studies where outcome assessment may be at risk of bias. This study explored the effect of central adjudication of SAEs on the safety results of the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. METHODS ENOS assigned patients with acute stroke at random to receive either transdermal glyceryl trinitrate (GTN) or no GTN and to Stop or Continue previous antihypertensive treatment. SAEs were reported by local investigators who were not blinded to treatment allocation. Central adjudicators, blinded to treatment allocation, reviewed the investigators reports and used evidence available to confirm or re-categorise the classification of event, likely causality, diagnosis and expectedness of event. RESULTS Of 4011 patients enrolled in ENOS, 1473 SAEs were reported by local investigators; this was reduced to 1444 after the review by adjudicators, with 29 re-classified as not an SAE. There was fair agreement between investigators and adjudicators regarding likely causality, with 808 agreements and 644 disagreements (56% crude agreement, weighted kappa, κ = 0.31). Agreement increased upon dichotomisation of the causality categories, with 1432 agreements and 20 disagreements (99% crude agreement, kappa = 0.54). Repeating the main trial safety analysis with investigator reported events showed that adjudication had no effect on the main trial safety conclusions. CONCLUSIONS In a large trial, with many SAEs reported, central adjudication of these events did not affect trial conclusions. This suggests that adjudication of SAEs in a clinical trial where the intervention already has a well-established safety profile may not be necessary. Potential efficiency savings (financial, logistical) can be made through not adjudicating SAEs.
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Affiliation(s)
- Peter J. Godolphin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Daniel Bereczki
- Department of Neurology, Semmelweis University, Budapest, Hungary
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Exuperio Díez-Tejedor
- Department of Neurology, La Paz University Hospital–Autonoma University of Madrid, Madrid, Spain
| | | | | | | | - Stephen Phillips
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, Canada
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
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Sandset EC, Sanossian N, Woodhouse LJ, Anderson C, Berge E, Lees KR, Potter JF, Robinson TG, Sprigg N, Wardlaw JM, Bath PM. Protocol for a prospective collaborative systematic review and meta-analysis of individual patient data from randomized controlled trials of vasoactive drugs in acute stroke: The Blood pressure in Acute Stroke Collaboration, stage-3. Int J Stroke 2018; 13:759-765. [DOI: 10.1177/1747493018772733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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
Rationale Despite several large clinical trials assessing blood pressure lowering in acute stroke, equipoise remains particularly for ischemic stroke. The “Blood pressure in Acute Stroke Collaboration” commenced in the mid-1990s focussing on systematic reviews and meta-analysis of blood pressure lowering in acute stroke. From the start, Blood pressure in Acute Stroke Collaboration planned to assess safety and efficacy of blood pressure lowering in acute stroke using individual patient data. Aims To determine the optimal management of blood pressure in patients with acute stroke, including both intracerebral hemorrhage and ischemic stroke. Secondary aims are to assess which clinical and therapeutic factors may alter the optimal management of high blood pressure in patients with acute stroke and to assess the effect of vasoactive treatments on hemodynamic variables. Methods and design Individual patient data from randomized controlled trials of blood pressure management in participants with ischemic stroke and/or intracerebral hemorrhage enrolled during the ultra-acute (pre-hospital), hyper-acute (<6 h), acute (<48 h), and sub-acute (<168 h) phases of stroke. Study outcomes The primary effect variable will be functional outcome defined by the ordinal distribution of the modified Rankin Scale; analyses will also be carried out in pre-specified subgroups to assess the modifying effects of stroke-related and pre-stroke patient characteristics. Key secondary variables will include clinical, hemodynamic and neuroradiological variables; safety variables will comprise death and serious adverse events. Discussion Study questions will be addressed in stages, according to the protocol, before integrating these into a final overreaching analysis. We invite eligible trials to join the collaboration.
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Affiliation(s)
| | - Nerses Sanossian
- Department of Neurology, University of Southern California, Los Angeles, USA
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Craig Anderson
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Eivind Berge
- Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John F Potter
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences and UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Woodhouse LJ, Scutt P, Hamdy S, Smithard DG, Cohen DL, Roffe C, Bereczki D, Berge E, Bladin CF, Caso V, Christensen HK, Collins R, Czlonkowska A, de Silva A, Etribi A, Laska AC, Ntaios G, Ozturk S, Phillips SJ, Prasad K, Szatmari S, Sprigg N, Bath PM. Route of Feeding as a Proxy for Dysphagia After Stroke and the Effect of Transdermal Glyceryl Trinitrate: Data from the Efficacy of Nitric Oxide in Stroke Randomised Controlled Trial. Transl Stroke Res 2018; 9:120-129. [PMID: 28770403 PMCID: PMC5849635 DOI: 10.1007/s12975-017-0548-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 05/30/2017] [Accepted: 06/19/2017] [Indexed: 01/13/2023]
Abstract
Post-stroke dysphagia is common, associated with poor outcome and often requires non-oral feeding/fluids. The relationship between route of feeding and outcome, as well as treatment with glyceryl trinitrate (GTN), was studied prospectively. The Efficacy of Nitric Oxide in Stroke (ENOS) trial assessed transdermal GTN (5 mg versus none for 7 days) in 4011 patients with acute stroke and high blood pressure. Feeding route (oral = normal or soft diet; non-oral = nasogastric tube, percutaneous endoscopic gastrostomy tube, parenteral fluids, no fluids) was assessed at baseline and day 7. The primary outcome was the modified Rankin Scale (mRS) measured at day 90. At baseline, 1331 (33.2%) patients had non-oral feeding, were older, had more severe stroke and more were female, than 2680 (66.8%) patients with oral feeding. By day 7, 756 patients had improved from non-oral to oral feeding, and 119 had deteriorated. Non-oral feeding at baseline was associated with more impairment at day 7 (Scandinavian Stroke Scale 29.0 versus 43.7; 2p < 0.001), and worse mRS (4.0 versus 2.7; 2p < 0.001) and death (23.6 versus 6.8%; 2p = 0.014) at day 90. Although GTN did not modify route of feeding overall, randomisation ≤6 h of stroke was associated with a move to more oral feeding at day 7 (odds ratio = 0.61, 95% confidence intervals 0.38, 0.98; 2p = 0.040). As a proxy for dysphagia, non-oral feeding is present in 33% of patients with acute stroke and associated with more impairment, dependency and death. GTN moved feeding route towards oral intake if given very early after stroke. Clinical Trial Registration Clinical Trial Registration-URL: http://www.controlled-trials.com . Unique identifier: ISRCTN99414122.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Shaheen Hamdy
- Centre for Gastrointestinal Sciences, University of Manchester, Salford, UK
| | - David G Smithard
- Elderly Medicine, Princess Royal University Hospital, Orpington, UK
| | - David L Cohen
- Elderly Medicine, Northwick Park Hospital, Harrow, UK
| | - Christine Roffe
- Institute for Science and Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - Daniel Bereczki
- Neurology, Semmelweis University, Balassu, Budapest, Hungary
| | | | - Christopher F Bladin
- The Florey Institute of Neuroscience & Mental Health Melbourne Brain Centre-Austin Campus, Heidelberg, Australia
| | - Valeria Caso
- Stroke Unit, Ospedale Santa Maria della Misericordia di Perugia, Perugia, Italy
| | - Hanne K Christensen
- Neurology, Bispebjerg Hospital & University of Copenhagen, Copenhagen, Denmark
| | - Rónán Collins
- Stroke Service, Tallaght Hospital, Tallaght Dublin, Ireland
| | - Anna Czlonkowska
- Neurology 2, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Asita de Silva
- Clinical Trials Unit, University of Kelaniya, Ragama, Sri Lanka
| | | | | | | | | | | | - Kameshwar Prasad
- Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Hucknall Road, Nottingham, NG5 1PB, UK.
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK.
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Bath PM, Woodhouse LJ, Appleton JP, Beridze M, Christensen H, Dineen RA, Duley L, England TJ, Flaherty K, Havard D, Heptinstall S, James M, Krishnan K, Markus HS, Montgomery AA, Pocock SJ, Randall M, Ranta A, Robinson TG, Scutt P, Venables GS, Sprigg N. Antiplatelet therapy with aspirin, clopidogrel, and dipyridamole versus clopidogrel alone or aspirin and dipyridamole in patients with acute cerebral ischaemia (TARDIS): a randomised, open-label, phase 3 superiority trial. Lancet 2018; 391:850-859. [PMID: 29274727 PMCID: PMC5854459 DOI: 10.1016/s0140-6736(17)32849-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 09/23/2017] [Accepted: 11/02/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Intensive antiplatelet therapy with three agents might be more effective than guideline treatment for preventing recurrent events in patients with acute cerebral ischaemia. We aimed to compare the safety and efficacy of intensive antiplatelet therapy (combined aspirin, clopidogrel, and dipyridamole) with that of guideline-based antiplatelet therapy. METHODS We did an international, prospective, randomised, open-label, blinded-endpoint trial in adult participants with ischaemic stroke or transient ischaemic attack (TIA) within 48 h of onset. Participants were assigned in a 1:1 ratio using computer randomisation to receive loading doses and then 30 days of intensive antiplatelet therapy (combined aspirin 75 mg, clopidogrel 75 mg, and dipyridamole 200 mg twice daily) or guideline-based therapy (comprising either clopidogrel alone or combined aspirin and dipyridamole). Randomisation was stratified by country and index event, and minimised with prognostic baseline factors, medication use, time to randomisation, stroke-related factors, and thrombolysis. The ordinal primary outcome was the combined incidence and severity of any recurrent stroke (ischaemic or haemorrhagic; assessed using the modified Rankin Scale) or TIA within 90 days, as assessed by central telephone follow-up with masking to treatment assignment, and analysed by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN47823388. FINDINGS 3096 participants (1556 in the intensive antiplatelet therapy group, 1540 in the guideline antiplatelet therapy group) were recruited from 106 hospitals in four countries between April 7, 2009, and March 18, 2016. The trial was stopped early on the recommendation of the data monitoring committee. The incidence and severity of recurrent stroke or TIA did not differ between intensive and guideline therapy (93 [6%] participants vs 105 [7%]; adjusted common odds ratio [cOR] 0·90, 95% CI 0·67-1·20, p=0·47). By contrast, intensive antiplatelet therapy was associated with more, and more severe, bleeding (adjusted cOR 2·54, 95% CI 2·05-3·16, p<0·0001). INTERPRETATION Among patients with recent cerebral ischaemia, intensive antiplatelet therapy did not reduce the incidence and severity of recurrent stroke or TIA, but did significantly increase the risk of major bleeding. Triple antiplatelet therapy should not be used in routine clinical practice. FUNDING National Institutes of Health Research Health Technology Assessment Programme, British Heart Foundation.
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Affiliation(s)
- Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK.
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | | | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Neurology, Copenhagen, Denmark
| | - Robert A Dineen
- Radiological Sciences, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Timothy J England
- Vascular Medicine, Division of Medical Sciences & GEM, University of Nottingham, Nottingham, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Diane Havard
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Stan Heptinstall
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Marc Randall
- Department of Neurology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital and University of Otago, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Cardiovascular Research Centre, University of Leicester, Leicester, UK
| | - Polly Scutt
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Graham S Venables
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK; Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, UK
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Scutt P, Appleton JP, Dixon M, Woodhouse LJ, Sprigg N, Wardlaw JM, Montgomery AA, Pocock S, Bath PM. Statistical analysis plan for the 'Rapid Intervention with Glyceryl trinitrate in Hypertensive stroke Trial-2 (RIGHT-2)'. Eur Stroke J 2018; 3:193-196. [PMID: 31008350 DOI: 10.1177/2396987318756696] [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] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/03/2018] [Indexed: 11/16/2022] Open
Abstract
Rationale Glyceryl trinitrate, a nitric oxide donor, is a candidate treatment for acute stroke; it lowers blood pressure, does not alter cerebral blood flow or platelet function and is neuroprotective in experimental stroke. The ongoing rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial aims to assess the safety and efficacy of paramedic-delivered glyceryl trinitrate in patients with ultra-acute stroke.Aims and design: The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial is a multicentre UK-based prospective randomised sham-controlled outcome-blinded parallel-group trial in patients with presumed stroke who present to the ambulance service following a 999 emergency call. The primary outcome is the modified Rankin scale measured by central telephone follow-up at 90 days. Results This paper describes the statistical analysis plan for the rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial and was developed prior to unblinding to treatment allocation. The statistical analysis plan includes details of methods for analyses and unpopulated tables and figures to be included in the primary and other secondary publications. Discussion Statistical analysis plan details what analyses will be done prior to unblinding to treatment allocation to avoid bias in the findings. Rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial will determine whether glyceryl trinitrate administered ultra-acutely can improve outcome after stroke. The rapid intervention with glyceryl trinitrate in hypertensive stroke trial-2 trial is registered as ISRCTN26986053.
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Affiliation(s)
- Polly Scutt
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Jason P Appleton
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Mark Dixon
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Nikola Sprigg
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | | | - Stuart Pocock
- 4Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Philip M Bath
- 1Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Woodhouse LJ, Flaherty K, Havard D, Sprigg N, Bath PM. Abstract 103: Intensive versus Guideline Antiplatelet Therapy in Patients With Transient Ischaemic Attack: Data From the Triple Antiplatelets for Reducing Dependency in Ischaemic Stroke (TARDIS) Trial. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.103] [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 risk of recurrence following an ischaemic stroke (IS) or transient ischaemic attack (TIA) is high, especially immediately after the event. Intensive treatment might be more effective in preventing recurrence than guideline therapy providing bleeding does not become excessive. We tested this in a subgroup of patients enrolled with TIA into the TARDIS trial.
Methods:
TARDIS was an international multicentre prospective randomised open-label blinded-endpoint controlled trial. Patients with acute non-cardioembolic IS or TIA were randomised to intensive antiplatelet therapy (combined aspirin, clopidogrel and dipyridamole) or guideline antiplatelets (clopidogrel alone, or combined aspirin and dipyridamole) given for one month. The primary outcome was recurrent cerebral events and their severity (using modified Rankin Scale) at 3 months. Data are number (%), mean (standard deviation, SD) or odds ratio (OR) with 95% confidence interval (CI).
Results:
Of 3,096 patients, 953 (30.8%; intensive 480, guideline 473) were enrolled with TIA. At baseline: mean age 70 (SD 10); male 62%; onset to randomisation <12 hours 17%, <24 hours 48%. By day 90, no differences were present between the two treatment groups for the primary outcome, death or other functional outcomes. However, patients in the intensive arm were less likely to suffer a recurrent TIA than those on guideline treatment (OR 0.48, 95% CI 0.25-0.93).
Conclusion:
Patients with a qualifying event of TIA were less likely to suffer a recurrent TIA if they received intensive treatment rather than guideline. However, no differences were present for recurrent stroke events.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | - Katie Flaherty
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | - Diane Havard
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | - Philip M Bath
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
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Bath PM, May J, Flaherty K, Woodhouse LJ, Dovlatova N, Fox SC, England TJ, Krishnan K, Robinson TG, Sprigg N, Heptinstall S, Investigators TARDIS. Remote Assessment of Platelet Function in Patients with Acute Stroke or Transient Ischaemic Attack. Stroke Res Treat 2017; 2017:7365684. [PMID: 28630782 PMCID: PMC5463170 DOI: 10.1155/2017/7365684] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 03/03/2017] [Accepted: 03/30/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The TARDIS trial assessed the safety and efficacy of intensive versus guideline antiplatelet agents given for one month in patients with acute stroke or TIA. The aim of this substudy was to assess the effect of antiplatelet agents taken at baseline on platelet function reactivity and activation. METHODS Platelet function, assessed by remotely measured surface expression of P-selectin, was assessed in patients at their time of randomisation. Data are median fluorescence values. RESULTS The aspirin P-selectin test demonstrated that platelet expression was lower in 494 patients taking aspirin than in 162 patients not: mean 210 (SD 188) versus 570 (435), difference 360.3 (95% CI 312.2-408.4) (2p < 0.001). Aspirin did not suppress P-selectin levels below 500 units in 23 (4.7%) patients. The clopidogrel test showed that platelet reactivity was lower in 97 patients taking clopidogrel than in 585 patients not: 655 (296) versus 969 (315), difference 314.5 (95% CI 247.3-381.7) (2p < 0.001). Clopidogrel did not suppress P-selectin level below 860 units in 24 (24.7%) patients. CONCLUSIONS Aspirin and clopidogrel suppress stimulated platelet P-selectin, although one-quarter of patients on clopidogrel have high on-treatment platelet reactivity. Platelet function testing may be performed remotely in the context of a large multicentre trial. Trial registration ISRCTN47823388.
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Affiliation(s)
- Philip M. Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham NG5 1PB, UK
- Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham NG5 1PB, UK
| | - Jane May
- Platelet Solutions Ltd., Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
- Platelet Research Group/Stroke, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham NG5 1PB, UK
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham NG5 1PB, UK
| | - Natalia Dovlatova
- Platelet Solutions Ltd., Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
- Platelet Research Group/Stroke, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
| | - Sue C. Fox
- Platelet Solutions Ltd., Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
- Platelet Research Group/Stroke, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
| | - Timothy J. England
- Vascular Medicine, Division of Medical Sciences and GEM, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham NG5 1PB, UK
- Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham NG5 1PB, UK
| | - Thompson G. Robinson
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, City Hospital Campus, Nottingham NG5 1PB, UK
- Stroke, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham NG5 1PB, UK
| | - Stan Heptinstall
- Platelet Solutions Ltd., Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
- Platelet Research Group/Stroke, Division of Clinical Neuroscience, University of Nottingham, Queen's Medical Centre Campus, Nottingham NG7 2UH, UK
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Woodhouse LJ, Manning L, Potter JF, Berge E, Sprigg N, Wardlaw J, Lees KR, Bath PM, Robinson TG. Continuing or Temporarily Stopping Prestroke Antihypertensive Medication in Acute Stroke. Hypertension 2017; 69:933-941. [DOI: 10.1161/hypertensionaha.116.07982] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/25/2016] [Accepted: 02/07/2017] [Indexed: 11/16/2022]
Abstract
Over 50% of patients are already taking blood pressure–lowering therapy on hospital admission for acute stroke. An individual patient data meta-analysis from randomized controlled trials was undertaken to determine the effect of continuation versus temporarily stopping preexisting antihypertensive medication in acute stroke. Key databases were searched for trials against the following inclusion criteria: randomized design; stroke onset ≤48 hours; investigating the effect of continuation versus stopping prestroke antihypertensive medication; and follow-up of ≥2 weeks. Two randomized controlled trials were identified and included in this meta-analysis of individual patient data from 2860 patients with ≤48 hours of acute stroke. Risk of bias in each study was low. In adjusted logistic regression and multiple regression analyses (using random effects), we found no significant association between continuation of prestroke antihypertensive therapy (versus stopping) and risk of death or dependency at final follow-up: odds ratio 0.96 (95% confidence interval, 0.80–1.14). No significant associations were found between continuation (versus stopping) of therapy and secondary outcomes at final follow-up. Analyses for death and dependency in prespecified subgroups revealed no significant associations with continuation versus temporarily stopping therapy, with the exception of patients randomized ≤12 hours, in whom a difference favoring stopping treatment met statistical significance. We found no significant benefit with continuation of antihypertensive treatment in the acute stroke period. Therefore, there is no urgency to administer preexisting antihypertensive therapy in the first few hours or days after stroke, unless indicated for other comorbid conditions.
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Affiliation(s)
- Lisa J. Woodhouse
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Lisa Manning
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - John F. Potter
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Eivind Berge
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Nikola Sprigg
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Joanna Wardlaw
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Kennedy R. Lees
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Philip M. Bath
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
| | - Thompson G. Robinson
- From the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (L.J.W., N.S., P.M.B.); University Hospitals of Leicester NHS Trust, United Kingdom (L.M.); Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norfolk, United Kingdom (J.F.P.); Department of Internal Medicine, Oslo University Hospital, Norway (E.B.); Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (J.W.); Institute of
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Stodolak S, Woodhouse LJ, Sprigg N, Bereczki D, Bath PM. Abstract TP70: Incidence of Serious Adverse Events Following Acute Stroke: Data From the Efficacy of Nitric Oxide in Stroke (ENOS) Trial. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.tp70] [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:
Reporting of serious adverse events (SAEs) is an essential safety procedure in randomised controlled trials. Risk factors for SAEs post-stroke and the relationship of SAEs with outcome were studied in the ENOS trial.
Methods:
ENOS assessed glyceryl trinitrate (GTN, 5 mg) vs no GTN for 7 days in 4,011 patients with acute stroke and high blood pressure. Information on SAEs was collected up to day 90. SAEs were adjudicated centrally with blinding to treatment assignment.
Results:
SAEs were reported in 1022 (25.5%) patients, 43.8% of whom died. Patients who suffered SAEs were more likely to be older (mean age 74.2 vs. 69.0 years, p<0.001) and have a history of atrial fibrillation (AF) (relative risk [RR] 1.80, p<0.001). Patients with non-oral feeding at baseline were more vulnerable to SAEs (RR 2.14, p<0.001) and fatal SAEs (RR 3.77, p<0.001) as compared with those with oral feeding. Males were at less risk than females to suffer an SAE (RR 0.83, p<0.001), as were smokers (RR 0.73, p<0.001). Smokers also suffered fewer fatal SAEs (RR 0.55, p<0.001). GTN did not increase the incidence of SAEs. The most common type of SAE was pneumonia (6% incidence) with a high risk of death (RR 9.29, p<0.001).
Conclusions:
SAEs are associated with a range of risk factors that should be taken into account in clinical practice. AF and non-oral feeding status were associated with increased, and smoking with reduced, risk of of SAEs. Incidence of pneumonia was a common and life threatening issue amongst patients.
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Affiliation(s)
- Szymon Stodolak
- Sch of Life Sciences, Univ of Nottingham, Nottingham, United Kingdom
| | - Lisa J Woodhouse
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | - Nikola Sprigg
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
| | | | - Philip M Bath
- Stroke, Div of Clinical Neuroscience, Univ of Nottingham, Nottingham, United Kingdom
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