1-year Stroke Research Articles

Carotid Artery Surgery to Reduce Long-Term Stroke Rates: Individual Patient Data Meta-Analysis of the Randomised Trials in Asymptomatic Patients

Background: Among patients with severe carotid artery stenosis but no recent symptoms from it, carotid surgery involves hazards, but then reduces long-term stroke rates. Triple-drug therapy (statin, anti-thrombotic, anti-hypertensive) also reduces long-term stroke rates in these asymptomatic patients. Past trials of carotid endarterectomy (CEA) can help assess the proportional reduction by carotid surgery in long-term stroke rates before and since triple-drug therapy became common. Methods: Intention-to-treat analyses used individual data from all 3 properly randomised trials among asymptomatic patients of immediate CEA vs deferral of any CEA until definitely indicated. Analyses of long-term stroke rates, censored at non-stroke death, used Kaplan-Meier life-tables and logrank methods. Findings: 2599 patients were allocated immediate CEA vs 2627 allocated deferral, with 89% vs 7% operated on within 1 year. Non-perioperative stroke rates were halved by allocation to immediate CEA (10-year stroke rate ratio [RR]=0.54, 95%CI 0.46-0.65, p<0.0001; 5.8% vs 11.7% by year 5); for fatal/disabling strokes, RR=0.55 (0.40-0.77, p<0.0001). Proportional reductions depended little on gender, or other patient characteristics. Ipsilateral and contralateral strokes were both reduced. In analyses restricted to strokes occurring on triple-drug therapy, absolute hazards and long-term stroke rates were lower than in the overall findings, but allocation to immediate CEA still halved long-term stroke rates (RR=0.56, 0.41-0.76; p=0.0002; 3.5% vs 7.0% by year 5). Of all CEAs undertaken, 3.1% involved perioperative stroke/death (71/3348; 40 dead/disabled, 31 not). Interpretation: Successful CEA halves long-term stroke rates. Net benefits will depend on surgical risks, long-term stroke rates without surgery, and life expectancy. Trial Registration: The trial is registered with the ISRCTN registry, ISRCTN21144362. Funding: MRC. Declaration of Interest: None to declare.

Intracranial Atherosclerosis Coexisting With White Matter Hyperintensities May Predict Unfavorable Functional Outcome in Patients With Acute Cerebral Ischemia.

Background and Purpose: This study aimed to assess the effect of baseline white matter hyperintensities (WMH) on 1-year stroke recurrence and the functional outcome for patients with intracranial atherosclerosis (ICAS).Methods: We analyzed 2,076 patients who were enrolled in the Chinese IntraCranial AtheroSclerosis (CICAS) study. ICAS and WMH were diagnosed by baseline magnetic resonance angiography. The primary outcomes were stroke recurrence and unfavorable functional outcome (modified Rankin Scale score 3–6) at 1 year.Results: Of the 2,076 patients included in this study, 1,370 (65.99%) were men, and the mean age was 61.70 years. In total, 224 (10.79%) patients had no WMH and no ICAS, 922 (44.41%) patients had WMH and no ICAS, 157 (7.56%) patients had ICAS and no WMH, and 773 (37.24%) had both WMH and ICAS. During the follow-up period, 87 patients had a recurrent stroke and 333 had unfavorable outcomes at 1 year. Compared to WMH (–) ICAS (–) group, the adjusted odd ratios and 95% confidence interval for unfavorable functional outcome were 0.791 (0.470–1.332; p = 0.3779) in the WMH (+) ICAS (–) group, 1.920 (1.024–3.600; p = 0.0421) in the WMH (–) ICAS (+) group, and 2.046 (1.230–3.403; p = 0.0058) in the WMH (+) ICAS (+) group. There was no significant difference in stroke recurrence risk among the four groups.Conclusion: ICAS coexisting with WMH may predict an unfavorable functional outcome at 1 year, but not stroke recurrence.

Association between acute heart failure and major cardiovascular events in atrial fibrillation patients presenting at the emergency department: an EMERG-AF ancillary study.

There is little evidence concerning the impact of acute heart failure (AHF) on the prognosis of atrial fibrillation patients attending the emergency department (ED). To know the influence of AHF on adverse long-term outcomes in patients presenting with atrial fibrillation in ED. Secondary analysis of a prospective, multicenter, observational cohort of consecutive atrial fibrillation patients, performed in 62 Spanish EDs. Patients presenting with atrial fibrillation in ED were divided by the presence or absence of AHF at arrival. Primary outcome: combination of 1-year all-cause mortality, major bleeding, stroke and other major cardiovascular events (MACE). Secondary outcomes: each of these events analyzed separately. Cox and logistic regression were used to investigate adjusted significant associations between AHF and outcomes. Totally, 1107 consecutive ED patients with atrial fibrillation attending ED were analyzed, 262 (23.7%) with AHF. The primary outcome occurred in 433 patients (39.1%), 1-year all-cause mortality in 151 patients (13.6%), major bleeding in 47 patients (4.2 %), stroke in 31 patients (2.8 %) and other MACE in 333 patients (30.1%). AHF was independently related to the primary outcome [odds ratio (OR), 1.422; 95% confidence interval (CI), 1.020-1.981; P = 0.037)] and 1-year MACE (OR, 1.797; 95% CI, 1.285-2.512; P = 0.001), but not to 1-year all-cause mortality, stroke or bleeding. The coexistence of AHF in patients presenting with atrial fibrillation in ED is associated to a worse 1-year outcome mainly due to MACE, but does not impact in overall mortality.

Performance of Atrial Fibrillation Risk Prediction Models in Over 4 Million Individuals.

Atrial fibrillation (AF) is associated with increased risks of stroke and heart failure. Electronic health record (EHR)-based AF risk prediction may facilitate efficient deployment of interventions to diagnose or prevent AF altogether. We externally validated an electronic health record AF (EHR-AF) score in IBM Explorys Life Sciences, a multi-institutional dataset containing statistically deidentified EHR data for over 21 million individuals (Explorys Dataset). We included individuals with complete AF risk data, ≥2 office visits within 2 years, and no prevalent AF. We compared EHR-AF to existing scores including CHARGE-AF (Cohorts for Heart and Aging Research in Genomic Epidemiology Atrial Fibrillation), C2HEST (coronary artery disease or chronic obstructive pulmonary disease, hypertension, elderly, systolic heart failure, thyroid disease), and CHA2DS2-VASc. We assessed association between AF risk scores and 5-year incident AF, stroke, and heart failure using Cox proportional hazards modeling, 5-year AF discrimination using C indices, and calibration of predicted AF risk to observed AF incidence. Of 21 825 853 individuals in the Explorys Dataset, 4 508 180 comprised the analysis (age 62.5, 56.3% female). AF risk scores were strongly associated with 5-year incident AF (hazard ratio per SD increase 1.85 using CHA2DS2-VASc to 2.88 using EHR-AF), stroke (1.61 using C2HEST to 1.92 using CHARGE-AF), and heart failure (1.91 using CHA2DS2-VASc to 2.58 using EHR-AF). EHR-AF (C index, 0.808 [95% CI, 0.807-0.809]) demonstrated favorable AF discrimination compared to CHARGE-AF (0.806 [95% CI, 0.805-0.807]), C2HEST (0.683 [95% CI, 0.682-0.684]), and CHA2DS2-VASc (0.720 [95% CI, 0.719-0.722]). Of the scores, EHR-AF demonstrated the best calibration to incident AF (calibration slope, 1.002 [95% CI, 0.997-1.007]). In subgroup analyses, AF discrimination using EHR-AF was lower in individuals with stroke (C index, 0.696 [95% CI, 0.692-0.700]) and heart failure (0.621 [95% CI, 0.617-0.625]). EHR-AF demonstrates predictive accuracy for incident AF using readily ascertained EHR data. AF risk is associated with incident stroke and heart failure. Use of such risk scores may facilitate decision support and population health management efforts focused on minimizing AF-related morbidity.

Transcatheter aortic valve replacement for bicuspid aortic valve stenosis with first- and new-generation bioprostheses: a systematic review and meta-analysis

Abstract Background Subjects with bicuspid aortic valve (BAV) have been excluded from transcatheter aortic valve re- placement (TAVR) randomized trials. Methods With this meta-analysis of observational studies we first compared TAVR outcomes of BAV vs. tricuspid aortic valve (TAV) patients, stratifying the results by device generation. Then, we looked for differences between balloon-expandable (BE) and self-expandable (SE) bioprostheses in BAV patients. Primary outcome was 30-day mortality. Secondary outcomes were 30-day stroke, moderate-severe paravalvular leakage, new pacemaker im- plantation, vascular complications and 1-year mortality. Results Thirteen studies (11,032 patients, 7291 TAV and 3741 BAV) and seven studies (706 patients, 367 treated with BE, 339 with SE valve) met inclusion criteria. Thirty-day (OR=1.13; 95% CI: 0.88–1.46, p=0.33) and 1-year mortality (OR=1.02; 95% CI: 0.77–1.37, p=0.87) were similar between patients receiving TAVR for BAV or TAV. Subjects treated for BAV were at higher risk of conversion to conventional surgery (OR=2.35; 95% CI: 1.30–4.23, p=0.005), implantation of a second valve (OR=2.06; 95% CI: 1.31–3.25; p=0.002), moderate/severe paravalvular leakage (PVL) (OR=1.67; 95% CI: 1.29–2.17; p=0.0001) and device failure (OR=1.26; 95% CI: 1.02–1.56; p=0.04). Rates of adverse events decreased significantly with the use of new-generation devices, but outcome differences remained consistent. BAV patients treated with BE vs. SE valves had similar 30-day and 1-year mortality, stroke and moderate-severe PVL. Balloon-expandable valves were associated with lower rates of a second valve and new pacemaker implantation but carried higher risk of annular rupture. Conclusions BAV patients treated with TAVR had similar 30-day and 1-year mortality as well as stroke and new pacemaker implantation rates compared to TAV subjects, but carried higher risk of moderate/severe PVL, conver- sion to surgery and device failure. Event rates significantly decreased with the use of new-generation devices, but TAVR still showed better procedural results in TAV compared to BAV. Funding Acknowledgement Type of funding source: None

Stroke and mortality rates after valve-in-valve TAVR and comparison with data from redo SAVR

Abstract Background and purpose Early registry data described a potentially increased risk for cerebrovascular events and mortality in patients undergoing transcatheter aortic valve replacement (TAVR) as valve-in-valve (viv) procedures. Further data of small patient cohorts described divergent results for cerebrovascular events and mortality in patients undergoing TAVR as viv procedures for failed surgical bioprotheses in comparison with patients on redo surgical aortic valve replacement (SAVR). We performed a meta-analysis of stroke rates and mortality for viv TAVR procedures basing on the current literature. Methods We included all case series (≥10 patients), case-control studies and randomized controlled trials comparing viv TAVR and redo SAVR procedures with respect to cerebrovascular events and mortality rates. Additionally, we included all case series and registries with patients undergoing viv TAVR. After a structured literature research, 17 studies were eligible. For statistical analysis risk ratios and confidence intervals using Mantel-Haenszel test and the I-statistic to quantify possible heterogeneity were calculated. A P-value &amp;lt;0.05 was defined as statistical significant difference. Results Eleven case series and registries reporting on stroke and mortality in 8,509 patients undergoing viv TAVR were eligible for analysis. The quantitative analysis of non-comparative studies showed a calculated 30-day stroke rate of 2.2% and 30-day mortality rate of 4.2% after viv TAVR. Data on the 1-year rates were sporadically reported, therefore meta analysis was not appropriately feasible. Six studies reporting on 498 participants undergoing viv TAVR (N=254) and redo SAVR (N=244) were eligible. The median age ranged from 72.3 to 80.2 years for viv TAVR and from 66.2 to 78.8 years for redo SAVR patients. The STS score was 7.2–7.4% (viv TAVR) and 5.8–7.7% (redo SAVR), respectively. A total of 3/226 participants treated with viv TAVR and 4/214 patients undergoing redo SAVR experienced a stroke during the first 30 postoperative days (N=4 trials, RR 0.86, 95% CI 0.20 to 3.59, p=0.83, I2 = 0%). None of the studies reported sufficient data on the 1-year stroke incidence. The 30-day mortality was 4.3% for viv TAVR and 4.5% for redo SAVR patients. This difference was not significantly different (N=6 trials, RR 0.90, 95% CI 0.40 to 2.05, p=0.80, I2 = 0%). The 1-year mortality rates were 13.3% and 13.6%, respectively (N=2 trials, RR 0.98, 95% CI 0.49 to 1.94, p=0.94, I2 = 0%). Conclusion In the current literature favorable stroke and mortality rates at 30 days for patients undergoing viv TAVR are documented. Similar stroke and mortality rates comparing viv TAVR and redo SAVR patients at 30 days were found as well as similar 1-year mortality. A selection bias for the viv TAVR and redo SAVR patients may exist, but cannot be dissolved with this registry analysis, only showing a trend of younger and lower risk patients receiving a redo SAVR procedure. Funding Acknowledgement Type of funding source: None

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Abstract Background Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE). Purpose This study is to investigate the prognosis of patients with LAA thrombus and their cause of death. Methods Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed. Results Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P&amp;lt;0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P&amp;lt;0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P&amp;lt;0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P&amp;lt;0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P&amp;lt;0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P&amp;lt;0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively. Conclusions The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy. Figure 1 Funding Acknowledgement Type of funding source: None

Validation of 10-Year Stroke Prediction Scores in a Community-Based Cohort of Chinese Older Adults.

A stroke prediction model based on the Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project was developed. We compared its predictive ability with the revised Framingham Stroke Risk Score (R-FSRS) for 5-year stroke incidence in a community cohort of Chinese adults, namely the Beijing Longitudinal Study of Aging (BLSA). Calibration, discrimination, and recalibration were used to compare the predictive ability between the two prediction models. Category-less net reclassification improvement (NRI) and integrated discrimination improvement (IDI) values were also assessed. During a mean follow-up duration of 5.1 years, 106 incidents of fatal or non-fatal strokes occurred among 1,203 participants aged 55–84 years. The R-FSRS applied to our cohort underestimated the 5-year risk for stroke in men and women. China-PAR performed better than the R-FSRS in terms of calibration (men, R-FSRS: χ2-value 144.2 [P < 0.001], China-PAR: 10.4 [P = 0.238]; women, R-FSRS: 280.1 [P < 0.001], China-PAR: 12.5 [P = 0.129]). In terms of discrimination, R-FSRS and China-PAR models performed modestly in our cohort (C-statistic 0.603 [95% CI: 0.560–0.644] for men using China-PAR and 0.568 [95% CI: 0.524–0.610] using the R-FSRS; the corresponding numbers for women were 0.602 [95% CI: 0.564–0.639] and 0.575 [95% CI: 0.537–0.613). The recalibrated China-PAR model significantly improved the discrimination in C statistics and produced higher category-less NRI and IDI for stroke incidence than the R-FSRS. Although China-PAR fairly estimated stroke risk in our cohort, it did not sufficiently identify adults at high risk of stroke. Caution would be exercised by practitioners in applying the original China-PAR to Chinese older adults. Further studies are needed to develop an adequate prediction model based on the recalibrated China-PAR or to find new risk markers which could upgrade this model.

High-dimensional propensity scores improved the control of indication bias in surgical comparative effectiveness studies

ObjectivesThe objective of the study is to evaluate the performance of high-dimensional propensity scores (hdPSs) for controlling indication bias as compared with propensity scores (PSs) in surgical comparative effectiveness studies. Study Design and SettingPatients who underwent interventional transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) between 2013 and 2017 were included from the French nationwide hospitals. At each hospital level, matched pairs of patients who underwent TAVI and SAVR were formed using PSs, considering 20 patient baseline characteristics, and hdPSs, considering the same patient characteristics and 300 additional variables from procedure and diagnosis codes the year before surgery. We compared death, reoperation, and stroke up to 3 years between TAVI and SAVR using Cox or Fine and Gray models. ResultsBefore matching, 12 of 20 patient characteristics were imbalanced between the included patients who underwent TAVI and SAVR. No significant imbalance persisted after matching with both methods. Hazard ratio of 1-year death, reoperation, and stroke was 1.3 [1.1; 1.4], 1.6 [1.1; 2.4], and 1.4 [1.2; 1.7] for TAVI relative to SAVR with PSs (n = 9,498 pairs) and 1.1 [1.0; 1.3], 1.3 [0.8; 2.0], and 1.3 [1.0; 1.6] with hdPSs (n = 7,157). ConclusionHdPS estimations were more consistent with results seen in randomized controlled trials. The HdPS is a promising alternative for the PS to control indication bias in comparative studies of surgical procedures.

Development and validation of a 2-year new-onset stroke risk prediction model for people over age 45 in China.

Multiple factors, including increasing incidence, poor knowledge of stroke and lack of effective, noninvasive and convenient stroke risk prediction tools, make it more difficult for precautions against stroke in China. Effective prediction models for stroke may assist to establish better risk awareness and management, healthier lifestyle, and lower stroke incidence for people.The China Health and Retirement Longitudinal Survey was the development cohort. Logistic regression was applied to model's development, in which the candidate variables with statistically significant coefficient were included in the prediction model. The area under receiver operating characteristic curve (AUC) and 10-times cross-validation were used for internal validation. Cutoff point of high-risk group was measured by Youden index. The China Health and Nutrition Survey was the validation cohort.The development cohort and the validation cohort included 16557 and 5065 participants, and the incidence density was 358.207/100,000 person-year and 350.701/100,000 person-year, respectively. The model for 2-year new-onset stroke risk prediction included age, hypertension, diabetes, heart disease, and smoking. The AUC and cross-validation AUC were 0.707 (95% confidence interval[CI]: 0.664, 0.750) and the 0.710 (95% CI: 0.650, 0.736). The sensitivity, specificity and accuracy of the cutoff point were 0.774, 0.545, and 0.319. The AUC and cross-validation AUC were 0.800 (95% CI: 0.744, 0.856) and 0.811(95% CI:0.714, 0.847), and the sensitivity, specificity and accuracy of cutoff point being 0.857,0.569, and 0.426 in external validation.A simple prediction tool using 5 noninvasive and easily accessible factors can assist in 2-year new-onset stroke risk prediction in Chinese people over 45 years old, which is believed to be applicable in identifying high-risk individuals and health management in China.

Reduction in Stroke After Transient Ischemic Attack in a Province-Wide Cohort Between 2003 and 2015.

Improvements in management of transient ischemic attack (TIA) have decreased stroke and mortality post-TIA. Studies examining trends over time on a provincial level are limited. We analyzed whether efforts to improve management have decreased the rate of stroke and mortality after TIA from 2003 to 2015 across an entire province. Using administrative data from the Canadian Institute for Health Information's (CIHI) databases from 2003 to 2015, we identified a cohort of patients with a diagnosis of TIA upon discharge from the emergency department (ED). We examined stroke rates at Day 1, 2, 7, 30, 90, 180, and 365 post-TIA and 1-year mortality rates and compared trends over time between 2003 and 2015. From 2003 to 2015 in Ontario, there were 61,710 patients with an ED diagnosis of TIA. Linear regressions of stroke after the index TIA showed a significant decline between 2003 and 2015, decreasing by 25% at Day 180 and 32% at 1 year (p < 0.01). The 1-year stroke rate decreased from 6.0% in 2003 to 3.4% in 2015. Early (within 48 h) stroke after TIA continued to represent approximately half of the 1-year event rates. The 1-year mortality rate after ED discharge following a TIA decreased from 1.3% in 2003 to 0.3% in 2015 (p < 0.001). At a province-wide level, 1-year rates of stroke and mortality after TIA have declined significantly between 2003 and 2015, suggesting that efforts to improve management may have contributed toward the decline in long-term risk of stroke and mortality. Continued efforts are needed to further reduce the immediate risk of stroke following a TIA.

Association of elevated hs-CRP and multiple infarctions with outcomes of minor stroke or TIA: subgroup analysis of CHANCE randomised clinical trial

Background and purposeThe relationship of high-sensitive C-reactive protein (hs-CRP) levels and infarction numbers with the prognosis of stroke is uncertain. This study evaluated the association of different hs-CRP levels and...

Japanese and Non-Japanese Patients with Transient Ischemic Attack or Minor Stroke: A Five-Year Risk Analysis of Stroke and Vascular Events.

Aims: We have previously reported 5-year follow-up data on the TIAregistry.org, an international prospective cohort in patients with transient ischemic attack (TIA) or minor stroke. We conducted a Japanese subgroup analysis because outcomes and predictors might differ according to ethnicities and regions. In this study, we compared the baseline and 5-year follow-up data of Japanese and non-Japanese patients with TIA or minor stroke. Methods: Patients with TIA or minor ischemic stroke within 7 days after the onset were classified into two groups based on ethnicity, Japanese ( n =345) and non-Japanese ( n =3502); further, 5-year event rates were compared between the two groups. We also determined predictors of 5-year stroke for both groups. Results: Vascular death and death from any cause were identified to be less prevalent, unlike stroke and intracranial hemorrhage, which was determined to be more prevalent in Japanese than in non-Japanese patients. Five-year rate of stroke was significantly higher in Japanese patients. Cumulative stroke and major cardiovascular event rates did not decline but instead linearly increased from 1 to 5 years in both groups. Baseline risk factors for 5-year stroke were as follows: age, diabetes, history of stroke or TIA, and congestive heart failure in Japanese patients. Independent predictors of 5-year stroke were large artery atherosclerosis, congestive heart failure, diabetes, and age in Japanese patients. Conclusions: Recurrent stroke and intracranial hemorrhage were determined to be more prevalent at 5 years after TIA or minor stroke in Japanese patients than in non-Japanese patients. Strategies to mitigate the long-term risks of stroke, aside from adherence to current guidelines, should take Japanese-patient-specific residual risks into account.

Trends in cardiovascular outcomes after acute coronary syndrome in New Zealand 2006–2016

ObjectivesCharacterisation of trends in acute coronary syndrome (ACS) outcomes are critical to informing clinical practice and quality improvement, but there are few recent population studies for ACS. We reviewed the...

A comparison of the Society for Vascular Surgery and the European Society for Vascular Surgery guidelines to identify which asymptomatic carotid patients should be offered a carotid endarterectomy

The management of patients with asymptomatic carotid stenosis (ACS) remains enduringly controversial and is the subject of extensive debate. Three landmark randomized controlled trials (RCTs) showed that carotid endarterectomy (CEA) conferred an approximately 50% relative risk reduction in the 5-year stroke risk compared with best medical therapy (BMT) alone.1-3 Based on these results, national and international guidelines recommended CEA for patients with ACS to reduce the risk of a future cerebrovascular event.

Concurrent intracranial and extracranial artery stenosis and the prognosis of transient ischaemic symptoms or imaging-negative ischaemic stroke

Background and purposeTransient ischaemic attack (TIA), transient symptoms with infarction (TSI) and diffusion-weighted imaging (DWI)-negative acute ischaemic stroke (AIS) share similar aetiologies but are considered to have a rather benign...

August 2020 Highlights.

August 2020 Highlights.

Serum and CSF Metabolites in Stroke-Free Patients Are Associated With Vascular Risk Factors and Cognitive Performance.

Background and purpose: The aggregation of vascular risk factors (VRFs) can aggravate cognitive impairment in stroke-free patients. Metabolites in serum and cerebrospinal fluid (CSF) may irreversibly reflect early functional deterioration. This study evaluated small-molecule metabolites (<1,000 Da) in the serum and CSF of patients with different degrees of cerebrovascular burden and investigated the correlation between metabolism and cognitive performance associated with VRFs.Methods: The subjects were divided into a low-risk group (10-year stroke risk ≤ 5%), a middle-risk group (10-year stroke risk >5% and <15%), and a high-risk group (10 years stroke risk ≥ 15%) according to the Framingham stroke risk profile (FSRP) score, which was used to quantify VRFs. We assess the cognitive function of the participants. We semiquantitatively quantified the small molecules using liquid chromatography–tandem mass spectrometry (LC-MS/MS). The correlation between the small molecules and cognitive function, along with VRFs, was investigated to identify key small molecules and possible underlying metabolic pathways.Results: When the FSRP scores increased, the cognitive performances of the subjects decreased, specifically the performance regarding the tasks of immediate memory, delayed recall, and executive function. Seven metabolites (2-aminobutyric acid, Asp Asp Ser, Asp Thr Arg, Ile Cys Arg, 1-methyluric acid, 3-tert-butyladipic acid, and 5α-dihydrotestosterone glucuronide) in serum and three metabolites [Asp His, 13-HOTrE(r), and 2,5-di-tert-Butylhydroquinone] in CSF were significantly increased, and one metabolite (arachidonoyl PAF C-16) in serum was significantly decreased in high-risk group subjects. Among these metabolites, 1-methyluric acid, 3-tert-butyladipic, acid and Ile Cys Arg in serum and 13-HOTrE(r), 2,5-di-tert-butylhydroquinone, and Asp His in CSF were found to be negatively related with cognitive performance in the high-risk group. Arachidonoyl PAF C-16 in serum was found to be associated with better cognitive performance. Caffeine metabolism and the tricarboxylic acid cycle (TCA cycle) were identified as key pathways.Conclusions: 1-Methyluric acid, 3-tert-butyladipic acid, arachidonoyl PAF C-16, and Ile Cys Arg in serum and 13-HOTrE(r), 2,5-di-tert-butylhydroquinone, and Asp His in CSF were identified as potential biomarkers of vascular cognitive impairment (VCI) at the early stage. Caffeine metabolism and the TCA cycle may play important roles in the pathophysiology of VRF-associated cognitive impairment.

Assessment of the CHA2DS2-VASc Score in Predicting Mortality and Adverse Cardiovascular Outcomes of Patients on Hemodialysis

Background: Patients with end-stage renal disease (ESRD) undergoing chronic hemodialysis are at high mortality and cardiovascular risk. This study was aimed to assess whether the CHA₂DS₂-VASc score may be used for risk stratification of this population. Methods: Included were patients undergoing chronic hemodialysis at Meir Medical Center. The CHA₂DS₂-VASc score was calculated for each patient at the initiation of hemodialysis. Patients were classified into 3 groups according to the CHA₂DS₂-VASc score: 0–3 (low), 4–5 (intermediate), and ≥6 (high). The primary endpoint was the composite of all-cause mortality, myocardial infarction, and stroke during the first year of hemodialysis. Results: Of the 457 patients with ESRD, 181 (40%) had low, 193 (42%) intermediate, and 83 (18%) high CHA₂DS₂-VASc scores. During the first year of hemodialysis, 109 (23.8%) patients died, 17 (3.7%) had a stroke, and 28 (6.1%) had a myocardial infarction. Compared to patients in the low CHA₂DS₂-VASc score group, those in the intermediate and high score groups had higher risk for the composite endpoint (OR: 2.6, 95% CI: 1.6–4.2, p < 0.01 and OR: 4.2, 95% CI: 2.3–7.5, p < 0.01, respectively). Each 1-point increase in CHA₂DS₂-VASc score was associated with a 38% increased risk for the composite endpoint, a 19% increased risk for 1-year myocardial infarction, and a 29% increased risk for 1-year stroke. Conclusions: Patients with ESRD are at an extremely high mortality and cardiovascular risk within the first year of hemodialysis. The CHA₂DS₂-VASc score was strongly associated with adverse outcomes and may be used for risk stratification of these patients.

Use of Dual-Layered Stents for Carotid Artery Angioplasty: 1-Year Results of a Patient-Based Meta-Analysis

ObjectivesThis study sought to evaluate 1-year safety and efficacy of dual-layered mesh-covered carotid stent systems (DLS) for carotid artery stenting (CAS). BackgroundSmall clinical studies evaluating 1-year outcomes of CAS performed with 2 available DLS, Roadsaver (RS) (Terumo Corp., Tokyo, Japan) and CGuard (CG) (InspireMD, Boston, Massachusetts), have been published. MethodsThe authors performed an individual patient–level meta-analysis including studies enrolling more than 100 CAS with DLS. The primary endpoint was the death and stroke rate; secondary endpoints were restenosis and in-stent thrombosis rates at 1 year. ResultsPatients were divided into 2 groups according to DLS (RS n = 250; CG n = 306). At 1 year, 11 patients died (1.97%), 7 patients in the group RS (2.8%) and 4 patients in the CG one (1.31%); and 10 strokes occurred, 4 in the group RS (1.6%) and 6 in the CG one (1.96%). Overall death and stroke rate was 3.77% (n = 21), 11 events in the group RS group (4.4%) and 10 in the CG group (3.27%). Symptomatic status was the only predictor of death and or stroke. At 1 year, restenosis occurred in 12 patients (2.1%), 10 in the group RS (4%) and 2 in the CG one (0.65%) (p = 0.007). In-stent thrombosis occurred in 1 patient (0.18%) in the CG group (0.32%). RS use was the only independent predictor of restenosis. ConclusionsThis study suggests that DLS use for CAS is associated with a low 1-year death and stroke rate, and the specific DLS stent used could affect the restenosis rate.