1-year Stroke Research Articles

Refining Prediction of Atrial Fibrillation-Related Stroke Using the P2-CHA2DS2-VASc Score.

In people with atrial fibrillation (AF), periods of sinus rhythm present an opportunity to detect prothrombotic atrial remodeling through measurement of P-wave indices (PWIs)-prolonged P-wave duration, abnormal P-wave axis, advanced interatrial block, and abnormal P-wave terminal force in lead V1. We hypothesized that the addition of PWIs to the CHA2DS2-VASc score would improve its ability to predict AF-related ischemic stroke. We included 2229 participants from the ARIC study (Atherosclerosis Risk in Communities) and 700 participants from MESA (Multi-Ethnic Study of Atherosclerosis) with incident AF who were not on anticoagulants within 1 year of AF diagnosis. PWIs were obtained from study visit ECGs before development of AF. AF was ascertained using study visit ECGs and hospital records. Ischemic stroke cases were based on physician adjudication of hospital records. We used Cox proportional hazards models to estimate hazard ratios and 95% CIs of PWIs for ischemic stroke. Improvement in 1-year stroke prediction was assessed by C-statistic, categorical net reclassification improvement, and relative integrated discrimination improvement. Abnormal P-wave axis was the only PWI associated with increased ischemic stroke risk (hazard ratio, 1.84; 95% CI, 1.33-2.55) independent of CHA2DS2-VASc variables, and that resulted in meaningful improvement in stroke prediction. The β estimate was approximately twice that of the CHA2DS2-VASc variables, and thus abnormal P-wave axis was assigned 2 points to create the P2-CHA2DS2-VASc score. This improved the C-statistic (95% CI) from 0.60 (0.51-0.69) to 0.67 (0.60-0.75) in ARIC and 0.68 (0.52-0.84) to 0.75 (0.60-0.91) in MESA (validation cohort). In ARIC and MESA, the categorical net reclassification improvements (95% CI) were 0.25 (0.13-0.39) and 0.51 (0.18-0.86), respectively, and the relative integrated discrimination improvement (95% CI) were 1.19 (0.96-1.44) and 0.82 (0.36-1.39), respectively. Abnormal P-wave axis-an ECG correlate of left atrial abnormality- improves ischemic stroke prediction in AF. Compared with CHA2DS2-VASc, the P2-CHA2DS2-VASc is a better prediction tool for AF-related ischemic stroke.

Balloon Predilation in Transcatheter Aortic Valve Replacement with Self-expanding Valves

ABSTRACT Introduction: The utility of routine balloon predilation in transcatheter aortic valve replacement (TAVR) with self-expanding valves is not established. Clinical outcomes at 30 days and 1 year post TAVR, deploying the “no balloon predilation” strategy have not been systematically described. Methods: Between October 2011 and September 2016, all patients who underwent TAVR with self-expanding valves (CoreValve®, Medtronic, Inc., Minneapolis, MN, USA) were stratified into predilation and no predilation groups. Of the 564 patients in the study, predilation was performed in 410 (72.7%) patients. Results: The need for postdilation was less when predilation was performed (30.2%), compared with no predilation (39.0%; adjusted odds ratio [aOR]:0.741, 95% confidence interval [CI]: 0.493–1.114). “Clinically significant” paravalvular leak (PVL) was similar in the predilation (5.9%) and no predilation (6.8%) groups (aOR: 0.886, 95% CI: 0.398–1.971). Permanent pacemaker implantation was higher following predilation (25.1%), compared with no predilation (15.6%; aOR:3.086, 95% CI:1.413–6.738). There were no differences in 30-day myocardial infarction, or 30-day and 1-year stroke and death. When patients undergoing predilation were further stratified into conservative predilation (predilation balloon size ≤ minimum annulus diameter) and aggressive predilation (predilation balloon size > minimum annulus) groups, need for postdilation was lowest with aggressive predilation. PVL, 30-day and 1-year stroke rates were similar in the aggressive, conservative and no predilation groups. Conclusion: Balloon predilation in TAVR with a self-expanding prosthesis was associated with a significant decrease in the need for balloon postdilation, and a significant increase in the need for a permanent pacemaker. There was no difference in PVL, and 30-day and 1-year stroke and death rates between the two groups.

Evidence-Based Performance Measures and Outcomes in Patients With Acute Ischemic Stroke.

Stroke is the leading cause of death in China. Despite the wide dissemination of evidence-based guidelines, data about adherence to these in routine clinical practice are scarce. We conducted a study using a nationwide registry to evaluate the implementation of evidence-based stroke performance indicators and associated guidelines, for patients with an ischemic stroke in China. The China National Stroke Registry is a prospective cohort study, including 12 416 patients diagnosed with acute ischemic stroke from 132 hospitals across China, for 1 year beginning September 2007. Twelve performance indicators were selected to evaluate the quality of stroke care. Multivariable Cox models were used to determine the association between optimal compliance and clinical outcomes. Conformity with performance measures ranged from a median of 6.5% for the use of intravenous tPA (tissue-type plasminogen activator) to 81.8% for early use of antithrombotics. The optimal compliance with all in-hospital measures was associated with 1-year death after admission (hazard ratio, 0.66; 95% CI, 0.55-0.79). The optimal compliance with all discharge measures was associated with the 1-year death after discharge (hazard ratio, 0.55; 95% CI, 0.44-0.69), 1-year stroke recurrence (hazard ratio, 0.81; 95% CI, 0.70-0.93), and favorable functional outcomes (defined as modified Rankin Scale score of ≤2) (hazard ratio, 1.10; 95% CI, 1.04-1.16). Adherence to evidence-based ischemic stroke care measures in China revealed substantial gaps, and select measures were associated with improved outcomes. These findings support the need for ongoing quality measurement and improvement in stroke care in China.

Submaximal primary angioplasty for symptomatic intracranial atherosclerosis: peri-procedural complications and long-term outcomes.

The aim of our study is to report the peri-procedural complications and long-term stroke recurrent rate of symptomatic intracranial atherosclerosis (ICAS) patients who underwent submaximal primary angioplasty. This is a retrospective analysis of consecutive patients in a single center who underwent submaximal primary angioplasty between January 1, 2012 and December 31, 2015. The peri-procedural complications and long-term outcomes are reported. Primary angioplasty was successfully performed in 129 patients (97.0%). The mean degree of pre-procedural stenosis was 81.9 ± 10.2%, and the degree of residual stenosis was 40.7 ± 19.1%. There were nine (6.8%) peri-procedural complications within 30days, including seven ischemic strokes, one subarachnoid hemorrhage, and one asymptomatic intracerebral hemorrhage. None of them resulted in death. One-year follow-up was available in 122 patients (91.7%). Three more ischemic strokes (2.3%) which were in the territory of the treated artery occurred between 30days and 1year. The 1-year stroke and death rate was 9.0%, including peri-procedural stroke. Kaplan-Meier analysis showed a 3-year stroke-free survival of 87.2%. Submaximal primary angioplasty can be performed with a low peri-procedural complication rate and relatively good clinical outcome at long-term follow-up for symptomatic ICAS patients.

Retinal Vasculature Reactivity During Flicker Light Provocation, Cardiac Stress and Stroke Risk in Africans: The SABPA Study.

Structural and functional similarities exist between the retinal, cerebral and, as previously suggested, the coronary microvasculature. Retinal microvascular structure and functionality (in response to flicker-light-induced-provocation (FLIP)) may relate to coronary artery disease risk and possible stroke risk. We investigated associations between retinal vessel structure, functionality and cardiac stress markers (cardiac troponin T [cTnT], amino-terminal B-type natriuretic peptide [NT-proBNP]) to translate these retina-heart relationships to stroke risk. We included 317 African and Caucasian teachers' (aged 23-68years), who participated in the Sympathetic Activity and Ambulatory Blood Pressure in Africans (SABPA) study. Fasting plasma and serum samples for cTnT and NT-proBNP were collected. Retinal vascular calibres were quantified from fundus images and dynamic retinal vessel calibre responses during FLIP. The University of California stroke risk score was applied to assess sub-clinical 10-year stroke risk. cTnT levels were similar in Africans and Caucasians, whereas NT-proBNP levels were lower in Africans. In Africans, a reduced arteriolar calibre and attenuated arteriolar dilation during FLIP was associated with higher cTnT (p < 0.01). Their larger retinal-venular calibre (p < 0.02) and attenuated arteriolar dilation during FLIP (p < 0.05) were associated with lower NT-proBNP. Again, exclusively in Africans, increased cardiac stress, wider venular calibres and retinal arteriovenous nicking predicted an increased 10-year stroke risk with odds ratios of 1.57 (95% CI, 1.34; 1.68, p = 0.031), 1.51 (95% CI, 1.26; 1.59, p = 0.002), 1.10 (95% CI, 0.94; 2.85, p = 0.002) and 1.06 (95% CI 0.83; 1.56, p = 0.052), respectively. None of these associations were evident in the Caucasian group. Investigating the retinal vasculature may serve as a tool to approximate sub-clinical coronary and cerebral microvasculature damage or dysfunction. These cardiac stress-retinal associations additionally predicted a greater stroke risk in the SABPA African cohort. Observable changes in the retinal vasculature may serve as markers for the identification and prediction of cardio-systemic and cerebral vascular morbidities and risks, thereby establishing a brain-heart link. Graphical Abstract Proposed series of events during which sustained high pressure and increased cardiac stress may alter retinal reactivity and link to increased stroke risk.

Abstract 17138: Are Patients With Diabetes Mellitus at Increased Risk for Adverse Outcomes After Left Ventricular Assist Device Implantation? A Systematic Review and Meta-Analysis

Background: Patients with diabetes mellitus (DM) are known to have reduced life expectancy and be at increased risk for multiple morbidities including serious infection. However, published data on DM outcomes after left ventricular assist device (LVAD) implantation are sparse, inconsistent and individual studies are small with limited power. We conducted a systematic review and meta-analysis to compare survival and adverse events post-LVAD in DM versus non-DM (NDM) patients. Methods: Medline, Scopus and Cochrane Central databases were searched for studies comparing outcomes in DM and NDM patients undergoing LVAD implantation for advanced heart failure (HF) from inception-February 2018. Outcomes included all-cause mortality (30-day and one-year), device-related infection, ischemic stroke, hemorrhagic stroke and major bleeding. Results were reported as random effect risk ratios (RR) with 95 % confidence intervals. Results: We identified 5 retrospective cohort studies, at low risk of bias, reporting on 1,351 patients (n=488 DM). There was a borderline significant, increased 30-day mortality (RR: 1.57 [1.00, 2.47]; p=0.05; I 2 =0%) among DM vs. NDM. The DM and NDM groups did not differ significantly in terms of 1-year mortality (RR: 1.15 [0.98, 1.35]; p=0.08; I 2 =39%), device-related infection (RR: 1.05 [0.92, 1.19]; p=0.88; I 2 =0%), ischemic stroke (RR: 1.29 [0.91, 1.83]; p=0.69; I 2 =0%), hemorrhagic stroke (RR: 1.10 [0.42, 2.83]; p=0.85; I 2 =69%), and bleeding (RR: 1.06 [0.80, 1.40]; p=0.70; I 2 =27%). Conclusion: Following LVAD implantation, patients with DM, versus patients without, have a modestly elevated 30-day mortality rate. However, 1-year mortality rates, device related infection, and bleeding rates were not different.

Focal Cerebral Arteriopathy of Childhood: Novel Severity Score and Natural History.

Background and Purpose- Focal cerebral arteriopathy (FCA)-a common cause of arterial ischemic stroke in previously healthy children-often progresses over days to weeks, increasing the risk of recurrent stroke. We developed a novel severity scoring system designed to quantify FCA progression and correlate with clinical outcomes. Methods- The VIPS study (Vascular Effects of Infection in Pediatric Stroke) prospectively enrolled 355 children with arterial ischemic stroke (2010-2014), including 41 with centrally confirmed FCA. Two neuroradiologists independently reviewed FCA cerebrovascular imaging, assigning a graded severity score of zero (no involvement) to 4 (occlusion) to individual arterial segments. The FCA severity score (FCASS) was the unweighted sum. In an iterative process, we modeled scores derived from different combinations of arterial segments to identify the model that optimized correlation with clinical outcome, simplicity, and reliability. Results- The optimal FCASS summed scores from 5 arterial segments: supraclinoid internal carotid artery, A1, A2, M1, and M2. The median (interquartile range) baseline FCASS was 4 (2-6). Of 33 children with follow-up imaging, the maximum FCASS (at any time point) was 7 (5-9). Twenty-four (73%) had FCA progression on follow-up with their maximum FCASS at a median of 8 (5-35.5) days poststroke; their median FCASS increase was 4 (2.5-6). FCASS did not correlate with recurrent arterial ischemic stroke. Maximum (but not baseline) FCASS correlated with 1-year pediatric stroke outcome measures ( P=0.037). Conclusions- Our novel scoring system for FCA severity correlates with neurological outcomes in the VIPS cohort and provides a tool for FCA treatment trials under development.

Transfemoral Carotid Artery Stents Should Be Used with Caution in Patients with Asymptomatic Carotid Artery Stenosis

Significant national variation exists in defining the degree of stenosis that requires intervention in patients with asymptomatic carotid artery stenosis (ACAS). We aimed to evaluate the risk of perioperative and 2-year stroke and death in ACAS patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for severe versus very severe stenosis in a contemporary population. All patients undergoing CEA or transfemoral CAS for ACAS in the Vascular Quality Initiative (2005-2017) were included. Degree of stenosis was defined as the highest recorded on any imaging method. Univariable and multivariate logistic regression analyses were performed to assess risk of stroke, stroke/death, and major adverse cardiac events (MACE) at 30 days; and Cox proportional hazard, life tables, and Kaplan-Meier estimates were implemented to evaluate ipsilateral stroke and stroke/death at 2 years postoperatively in patients undergoing CEA versus CAS for severe (60-79%) and very severe (≥80%) stenosis adjusting for baseline characteristics. A total of 53,337 ACAS patients were examined (severe stenosis=17,586; 33.%), of which 11.5% (n=6,127) underwent CAS. The crude incidence of 30-day stroke/death was significantly higher for CAS versus CEA in the very severe stenosis group (2.0% vs. 1.2%, P<0.001), but not in the severe stenosis group (1.7% vs. 1.3%, P=0.17). MACE was not significantly different for CAS versus CEA in either group (P≥0.64). On multivariable analysis, CAS was associated with a persistently higher risk of 30-day stroke or death compared to CEAin patients with very severe stenosis (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.26-2.13). The 30-day composite stroke/death risk for patients undergoing CEA was similar for severe versus very severe stenosis (OR 1.07, 95% CI 0.89-1.28), but there was a trend toward higher risk of perioperative stroke in the severe stenosis group (OR 1.23, 95% CI 0.97-1.56). Two-year outcomes were similar; the crude annualized incidence rates of stroke and stroke/death were higher for CAS versus CEA in both the severe (stroke: incidence rate ratio [IRR] 1.62, 95% CI 1.00-2.55; stroke/death: IRR 1.53, 95% CI 1.11-1.64) and very severe stenosis (stroke: IRR 1.97, 95% CI 1.44-2.65; stroke/death: IRR 1.51, 95% CI 1.34-1.68) groups (all, P≤0.04). On multivariable Cox proportional hazards analysis, CAS was associated with a higher risk of stroke or death compared to CEA in patients with both severe (hazard ratio [HR] 1.40, 95% CI 1.15-1.70) and very severe stenosis (HR 1.62, 95% CI 1.37-1.90). More than one-third of patients undergoing carotid revascularization for ACAS had 60-79% stenosis. Having lower degree of stenosis is not protective against stroke and death for either CEA or CAS at either 30 days or 2 years postoperatively. We believe that optimal medical management should be the first line in stroke prevention for asymptomatic patients with severe (60-79%) carotid stenosis.

Racial differences in recurrent ischemic stroke risk and recurrent stroke case fatality.

To determine black-white differences in 1-year recurrent stroke and 30-day case fatality after a recurrent stroke in older US adults. We conducted a retrospective cohort study using a 5% random sample of Medicare beneficiaries with fee-for-service health insurance coverage who were hospitalized for ischemic stroke between 1999 and 2013. Hazard ratios for recurrent ischemic stroke and risk ratios for 30-day case fatality comparing blacks to whites were calculated with adjustment for demographics, risk factors, and competing risk of death when appropriate. Among 128,789 Medicare beneficiaries having an ischemic stroke (mean age 80 years [SD 8 years], 60.4% male), 11.1% were black. The incidence rate of recurrent ischemic stroke per 1,000 person-years for whites and blacks was 108 (95% confidence interval [CI], 106-111) and 154 (95% CI 147-162) , respectively. The multivariable-adjusted hazard ratio for recurrent stroke among blacks compared with whites was 1.36 (95% CI 1.29-1.44). The case fatality after recurrent stroke for blacks and whites was 21% (95% CI 21%-22%) and 16% (95% CI 15%-18%), respectively. The multivariable-adjusted relative risk for mortality within 30 days of a recurrent stroke among blacks compared with whites was 0.82 (95% CI 0.73-0.93). The risk of stroke recurrence among older Americans hospitalized for ischemic stroke is higher for blacks compared to whites, while 30-day case fatality after recurrent stroke remains lower for blacks.

Transcatheter Aortic Valve Replacement With a Repositionable Self-Expanding Prosthesis: The PORTICO-I Trial 1-Year Outcomes

BackgroundThe new self-expanding, repositionable transcatheter heart valve (THV) system was designed for treatment of severe, symptomatic aortic stenosis in patients with high surgical risk. ObjectivesThe purpose of this study was to report 1-year outcomes of transcatheter aortic valve replacement with the new THV system. MethodsThis ongoing, international, multicenter study evaluated patients with severe, symptomatic aortic stenosis implanted with the THV via transfemoral access and follow-up at 30 days, 1 year, and annually through 5 years. The primary endpoint is all-cause mortality at 1 year; secondary endpoints include clinical outcomes and echocardiographic measurements, both adjudicated. ResultsA total of 941 patients (82.4 ± 5.9 years; 65.7% female; Society of Thoracic Surgeons Predicted Risk of Operative Mortality score: 5.8%) were enrolled and underwent an implant at 61 sites in Europe, Australia, and Canada. At 1 year, Kaplan-Meier estimates for all-cause mortality, cardiovascular mortality, disabling stroke rates, and myocardial infarction were 12.1%, 6.6%, 2.2%, and 2.5%, respectively. Mean aortic transvalvular gradient and aortic valve area were 8.66 mm Hg and 1.75 cm2, respectively. Paravalvular leakage was moderate or higher in 2.6% of patients with no severe leakage. New pacemaker rates were 18.7% and 21.3% for pacemaker naïve patients at 30 days and 1 year, respectively. Functional class, exercise capacity, and quality of life improved significantly from baseline to 1 year. ConclusionsTranscatheter aortic valve replacement with the new THV in patients who are at increased surgical risk is associated with low 1-year mortality and stroke rates. Favorable hemodynamic results at 1 year are observed with low transvalvular pressure gradient and incidence of significant paravalvular leakage. (5 Year Observation of Patients With PORTICO Valves [PORTICO-I]; NCT01802788)

Incidence, Management, and Associated Clinical Outcomes of New-Onset Atrial Fibrillation Following Transcatheter Aortic Valve Replacement: An Analysis From the STS/ACC TVT Registry

ObjectivesThe aim of this study was to evaluate incidence, care patterns, and clinical outcomes in patients developing new-onset atrial fibrillation (AF) following transcatheter aortic valve replacement (TAVR). BackgroundPre-procedural AF has been associated with adverse outcomes in patients undergoing TAVR, but the incidence of new-onset AF, associated anticoagulant management, and subsequent clinical outcomes are unclear. MethodsUsing the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry linked with Medicare claims, patients undergoing TAVR from 2011 to 2015 who developed post-procedural AF were evaluated. Patients with known AF prior to TAVR were excluded. Outcomes of interest included in-hospital mortality and stroke and all-cause mortality, stroke, and bleeding at 12 months. Multivariate adjustment was then performed to determine differences in 1-year outcomes among those with and without new post-procedural AF, stratified by anticoagulation status. ResultsWe identified 1,138 of 13,556 patients (8.4%) who developed new onset AF (4.4% of transfemoral [TF]–access patients, 16.5% of non-TF-access patients). Patients developing AF were older, more likely female, had higher Society of Thoracic Surgeons risk scores, and were often treated using non-TF access. Despite having a median CHA2DS2-VASc score of 5 (25th and 75th percentile: 5 to 6), only 28.9% of patients with new AF were discharged on oral anticoagulation. In-hospital mortality (7.8% vs. 3.4%; p < 0.01) and stroke (4.7% vs. 2.0%; p < 0.01) were higher among patients who developed post-procedural AF compared with those who did not. At 1 year, rates of death (adjusted hazard ratio [HR]: 1.37; 95% confidence interval [CI]: 1.19 to 1.59), stroke (adjusted HR: 1.50; 95% CI: 1.14 to 1.98), and bleeding (adjusted HR: 1.24; 95% CI: 1.10 to 1.40) were higher among patients with new-onset AF. One-year mortality rates were highest among patients who developed new-onset AF but were not discharged on anticoagulation. ConclusionsPost-TAVR AF occurred in 8.4% of patients (4.4% with TF access, 16.5% with non-TF access), with fewer than one-third of patients receiving anticoagulation at discharge, and was associated with increased risk for in-hospital and 1-year mortality and stroke. Given the clinical significance of post-TAVR AF, additional studies are necessary to delineate the optimal management strategy in this high-risk population.

Stroke recurrence and mortality in northeastern Greece: the Evros Stroke Registry.

Up to date there is no population-based study from Greece providing long-term data on incidence of both all-cause mortality and stroke recurrence for patients with first ever stroke (FES). Adult patients with FES were registered during a 24-month period (2010-2012) and followed-up for 12months. We calculated cumulative incidences of stroke mortality and recurrence. Univariable and multivariable Cox proportional hazards regression analyses were used to identify independent determinants of 1-year mortality and 1-year stroke recurrence. We prospectively documented 703 first ever stroke cases (mean age 75 ± 12 years; 52.8% males; ischemic stroke 80.8%, intracerebral hemorrhage 11.8%, subarachnoid hemorrhage 4.4%, undefined 3.0%) with a total follow-up time of 119,805 person-years. The cumulative incidence rates of mortality of all FES patients at 28 days, 3 months and 1 year were 21.3% (95% CI 18.5-24.5%), 26% (95% CI 22.9-29.4%) and 34.7% (95% CI 31.3-38.3%), respectively. The risk of 1-year mortality was independently (p < 0.05) associated with advancing age, history of hypertension, increased stroke severity on admission, and hemorrhagic FES type. Cumulative 1-year stroke mortality differed according to both index FES type (ischemic vs. hemorrhage; p < 0.001), but also across different ischemic stroke subtypes (p = 0.025). The cumulative incidence rates of recurrent stroke at 28 days, 3 months and 1 year were 2.0% (95% CI 1.2-3.6%), 4.2% (2.8-6.2%) and 6.7% (5.1-8.8%), respectively. Comparable to other population-based surveys, our study reports 1-year mortality and stroke recurrence rates in patients with FES. These findings highlight the need for effective secondary prevention strategies in a border region of southeastern Europe, which exhibits very high FES incidence rates.

The Impact of Gender on Atrial Fibrillation Incidence and Progression to Dementia

There are a paucity of data regarding the role of gender and atrial fibrillation (AF) on cognitive decline and incidence of dementia. Such data may provide insight into the disproportionate incidence of dementia in women and may help identify high-risk characteristics to target for prevention. We examined patients who underwent coronary angiography at an Intermountain Healthcare Medical Center and enrolled in a prospective cardiovascular database. To be included, patients could not have a previous diagnosis of AF or dementia and had to have 5years of follow-up. Endpoints included incident AF and dementia. Study cohort consisted of 35,608 patients without a previous history of AF or dementia, with 14,377 (40.4%) being woman. Women had lower rates of hypertension, diabetes, coronary artery disease, and prior myocardial infarction, but higher rates of prior stroke. Men had a higher incidence of 5-year and long-term AF. However, women trended toward a higher incidence of 5-year and long-term dementia and stroke compared with men. In all groups of patients with and without AF, prior stroke predicted cognitive decline. In patients without a history of or development of AF, diabetes significantly increased risk of dementia. Women have higher rates of dementia over time than men, driven by higher baseline stroke rates and nontraditional cardiovascular risk factors. The higher dementia rates were in the setting of lower AF rates. However, in both men and women who develop AF, dementia rates are increased and do not show gender-based differences in risk.

Renal dysfunction increases the risk of recurrent stroke in patients with acute ischemic stroke

Background and aimsThis study investigated risks of short-term (1 and 3 months) and long-term (1-year) recurrent stroke associated with glomerular filtration rate (eGFR) in patients with acute ischemic stroke. MethodsFrom the Taiwan Stroke Registry data, we identified 45,876 acute ischemic stroke patients from April 2006 to April 2014 and classified them into 4 groups based on the eGFR at admission: ≥ 90, 60–89, 30–59, and <30 mL/min/1.73 m2 or on dialysis. The risks of 1-month, 3-month and 1-year recurrent stroke related to the eGFR levels were investigated. ResultsBoth the risks of short-term and long-term recurrent stroke increased as the eGFR levels declined. The 1-month recurrent incidence rates increased steadily from 0.54 to 0.59, 0.84 and 0.89 per 1000 person-days, as the eGFR declined from ≥90 to 60–89, 30–59, and <30 mL/min/1.73 m2 or on dialysis, respectively. Compared to patients with eGFR ≥90 mL/min/1.73 m2, the adjusted subhazard ratio of 1-month recurrent stroke decreased from 1.69 (95% confidence interval (CI) = 1.24–2.31) for patients with eGFR < 30 mL/min/1.73 m2 or on dialysis to 1.14 (95% CI = 0.91–1.43) for patients with eGFRs of 60–89 mL/min/1.73 m2, considering the competing risk of deaths. Similar patterns were also observed for the adjusted HRs of 3-month and 1-year recurrent stroke, but with reduced hazard values, by the corresponding eGFR levels. ConclusionsThere is an independent graded association between an increased risk of recurrent stroke and declining eGFR levels in patients with acute ischemic stroke.

Secondary stroke prevention and guideline adherent antithrombotic treatment in patients with atrial fibrillation: Insights from the Gulf Survey of atrial fibrillation events (Gulf SAFE)

BackgroundAnticoagulation therapy in patients with atrial fibrillation (AF) is well established as effective thromboprophylaxis. However, AF patients with prior stroke are often treated with suboptimal antithrombotic treatment (ATT). In the present study, we investigated clinical characteristics and outcomes in AF patients with versus without prior stoke, in relation to guideline adherence in ATT. MethodsWe used data from the Gulf SAFE registry, which included patients with AF who presented to hospitals in Gulf countries of the Middle East. Adherence to guideline recommended ATT was assessed against the European Society of Cardiology guidelines. ResultsOf 1860 patients, 15.4% had a history of stroke (secondary stroke prevention). For secondary stroke prevention, 62.0% of patients were prescribed oral anticoagulants, while 27.9% were still prescribed antiplatelet therapy alone and 10.1% received no ATT. Overall, 49.0% were treated with guideline adherent ATT, 25.5% were undertreated, and 25.4% were overtreated. On multivariable logistic regression analysis, undertreatment (OR; 2.763, 95% CI; 1.426–5.352, p = 0.003) was significantly associated with an increased risk of 1-year stroke. On the other hand, overtreatment was significantly associated with an increased risk of 1-year bleeding (OR; 3.294, 95% CI; 1.517–7.152, p = 0.003). ConclusionsOnly half of the AF patients received optimal ATT for stroke prevention if we apply guideline recommendations. Guideline adherent ATT significantly reduced the risk of stroke and bleeding compared with non-guideline adherent ATT.

Meta-Analysis Comparing the Frequency of Stroke After Transcatheter Versus Surgical Aortic Valve Replacement

Stroke is one of the most feared complications of aortic valve replacement. Although the outcomes of transcatheter aortic valve implantation (TAVI) improved substantially over time, concerns remained about a potentially higher incidence of stroke with TAVI compared with surgical replacement (SAVR). However, comparative data are sparse. We performed a meta-analysis comparing the incidence of stroke among patients undergoing TAVI versus SAVR. Of the 5067 studies screened, 28 eligible studies (22 propensity-score matched studies and 6 randomized trials) were analyzed. Primary endpoints were 30-day stroke and disabling stroke. Secondary endpoints were 1-year stroke and disabling stroke. A total of 23,587 patients were included, of whom 47.27% underwent TAVI and 52.72% underwent SAVR. For each endpoint, pooled estimates of odds ratio (OR) with 95% confidence interval (CI) were calculated. The pooled estimates for stroke (2.7% vs 3.1%, OR 0.86; 95% CI 0.72 to 1.02; p=0.08) and disabling stroke (2.5% vs 2.9%, OR 0.96; 95% CI 0.57 to 1.62; p=0.89) were comparable following TAVI versus SAVR at 30 days. Similarly, the pooled estimates for stroke (5.0% vs 4.6%, OR 1.01; 95% CI 0.79 to 1.28; p=0.96) and disabling stroke (4.1% vs 4.5%, OR 0.92; 95% CI 0.92 to 1.39; p=0.71) were similar at 1 year. A sensitivity analysis including only RCTs yielded similar results. Our meta-analysis documents comparable rates of strokes and disabling strokes following TAVI or SAVR both at 30 days and 1 year.

Insurance status and 1-year outcomes of stroke and transient ischaemic attack: a registry-based cohort study in China

ObjectiveAlthough more than 95% of the population is insured by urban or rural insurance programmes in China, little research has been done on insurance-related outcome disparities for patients with acute...

Stroke Rates Following Surgical Versus Percutaneous Coronary Revascularization

BackgroundCoronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are used for coronary revascularization in patients with multivessel and left main coronary artery disease. Stroke is among the most feared complications of revascularization. Due to its infrequency, studies with large numbers of patients are required to detect differences in stroke rates between CABG and PCI. ObjectivesThis study sought to compare rates of stroke after CABG and PCI and the impact of procedural stroke on long-term mortality. MethodsWe performed a collaborative individual patient-data pooled analysis of 11 randomized clinical trials comparing CABG with PCI using stents; ERACI II (Argentine Randomized Study: Coronary Angioplasty With Stenting Versus Coronary Bypass Surgery in Patients With Multiple Vessel Disease) (n = 450), ARTS (Arterial Revascularization Therapy Study) (n = 1,205), MASS II (Medicine, Angioplasty, or Surgery Study) (n = 408), SoS (Stent or Surgery) trial (n = 988), SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial (n = 1,800), PRECOMBAT (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease) trial (n = 600), FREEDOM (Comparison of Two Treatments for Multivessel Coronary Artery Disease in Individuals With Diabetes) trial (n = 1,900), VA CARDS (Coronary Artery Revascularization in Diabetes) (n = 198), BEST (Bypass Surgery Versus Everolimus-Eluting Stent Implantation for Multivessel Coronary Artery Disease) (n = 880), NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trial (n = 1,184), and EXCEL (Evaluation of Xience Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial (n = 1,905). The 30-day and 5-year stroke rates were compared between CABG and PCI using a random effects Cox proportional hazards model, stratified by trial. The impact of stroke on 5-year mortality was explored. ResultsThe analysis included 11,518 patients randomly assigned to PCI (n = 5,753) or CABG (n = 5,765) with a mean follow-up of 3.8 ± 1.4 years during which a total of 293 strokes occurred. At 30 days, the rate of stroke was 0.4% after PCI and 1.1% after CABG (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.20 to 0.53; p < 0.001). At 5-year follow-up, stroke remained significantly lower after PCI than after CABG (2.6% vs. 3.2%; HR: 0.77; 95% CI: 0.61 to 0.97; p = 0.027). Rates of stroke between 31 days and 5 years were comparable: 2.2% after PCI versus 2.1% after CABG (HR: 1.05; 95% CI: 0.80 to 1.38; p = 0.72). No significant interactions between treatment and baseline clinical or angiographic variables for the 5-year rate of stroke were present, except for diabetic patients (PCI: 2.6% vs. CABG: 4.9%) and nondiabetic patients (PCI: 2.6% vs. CABG: 2.4%) (p for interaction = 0.004). Patients who experienced a stroke within 30 days of the procedure had significantly higher 5-year mortality versus those without a stroke, both after PCI (45.7% vs. 11.1%, p < 0.001) and CABG (41.5% vs. 8.9%, p < 0.001). ConclusionsThis individual patient-data pooled analysis demonstrates that 5-year stroke rates are significantly lower after PCI compared with CABG, driven by a reduced risk of stroke in the 30-day post-procedural period but a similar risk of stroke between 31 days and 5 years. The greater risk of stroke after CABG compared with PCI was confined to patients with multivessel disease and diabetes. Five-year mortality was markedly higher for patients experiencing a stroke within 30 days after revascularization.

Incorporating Cardioprotective Effects of Once-Weekly Semaglutide in Estimates of Health Benefits for Patients with Type 2 Diabetes

Economic modeling of type 2 diabetes (T2D) relies on sets of risk equations (e.g., UKPDS 68) to predict cardiovascular (CV) events and mortality as mediated through changes in risk factors (e.g., HbA1c). Recent CV outcomes trials (CVOTs) have shown significant benefits in events over a short time period (between 2-4 years), along with beneficial changes in risk factors such as blood pressure, HbA1c, and weight. The contributions of these changes to the observed outcomes within these CVOTs are unclear. In patients with high CV risk, the SUSTAIN 6 trial of once-weekly semaglutide+standard of care (SoC) reported a statistically significant reduction in stroke (HR=0.61) after 104 weeks vs. placebo+SoC. We sought to establish the contribution of risk factor changes to this observed outcome, by evaluating the performance of traditional risk equations in predicting outcome benefits seen with once-weekly semaglutide. As a secondary objective, the impact of incorporating the stroke benefit on estimated long term health benefits was assessed. The IQVIA Core Diabetes Model was used to assess predictive accuracy of the UKPDS 68 risk equations on the observed stroke benefit. Secondly, the model was calibrated to preserve the ratio of the observed cumulative incidence of stroke between treatment arms. Finally, results were extrapolated over 50 years. The UKPDS 68 equations were able to predict 64% of the observed 2-year stroke risk reduction, suggesting a drug-mechanistic effect other than changes in risk factors. Calibration results indicate that a relative risk of stroke of 0.83 (17% reduction) applied to once-weekly semaglutide was required to preserve the cumulative incidence ratio. Results of extrapolation increased quality-adjusted life-years by 0.18 and life-years by 0.29 vs. placebo+SoC. Results of this analysis may have implications on future approaches assessing the long term economic impact of new therapies in T2D in this era of multiple CVOTs. Disclosure M. Evans: Advisory Panel; Self; Novo Nordisk A/S. Consultant; Self; Novartis AG, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc., Merck Sharp &amp; Dohme Corp. P. Johansen: Consultant; Self; Janssen Global Services, LLC.. Employee; Self; Novo Nordisk A/S. H. Vrazic: Employee; Self; Novo Nordisk A/S.

Stroke and Cardiovascular Outcomes in Patients With Carotid Disease Undergoing Transcatheter Aortic Valve Replacement.

Stroke is a serious complication of both transcatheter aortic valve replacement (TAVR) and carotid artery disease (CD). The implications of CD in patients undergoing TAVR are unclear. The Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapies Registry, consisting of data from consecutive US TAVR cases during the years 2013 to 2015, was linked to Medicare claims data to ascertain 30-day and 1-year cumulative incidence rates of stroke and all-cause mortality. We compared 30-day and 1-year stroke and mortality outcomes between patients with no-CD and patients with moderate, severe, and occlusive CD and adjusted for baseline covariates using proportional hazards models. Among 29 143 patients undergoing TAVR across 390 US sites, 22% had CD. Patients with CD had higher rates of prior hypertension, diabetes mellitus, stroke, and myocardial infarction. Observed in-hospital stroke rates were 2.0% among no-CD, 2.5% among moderate CD, 3.0% among severe CD, and 2.6% among occlusive CD. There was no association between the presence of CD and 30-day stroke (adjusted hazard ratio, 1.16; 95% confidence interval, 0.94-1.43) or mortality (adjusted hazard ratio, 1.10; 95% confidence interval, 0.95-1.28). There was no association between CD and 1-year stroke (adjusted hazard ratio, 1.03; 95% confidence interval, 0.86-1.24) or mortality (adjusted hazard ratio, 1.02; 95% confidence interval, 0.93-1.12). Furthermore, there was no significant risk-adjusted association between severity of CD and 30-day or 1-year stroke or mortality. CD is common among TAVR patients, present in 1 of 5. CD was not associated with an increased risk of stroke or mortality at 30 day or 1 year. Post-TAVR stroke seems to be because of mechanisms other than CD.