Acute Cerebrovascular Events Research Articles

395 Is Lower Extremity Venography Necessary in Pulmonary Embolism CT Imaging?

Study Objective: Pulmonary thromboembolism (PTE) is the third most mortal disease after acute myocardial infarction and cerebrovascular events. Ten percent of patients with pulmonary embolism also have deep venous thrombosis (DVT). Point-of-care compression ultrasound (PoCUS) is performed in the emergency room to detect the DVT of the patients, and doppler ultrasonography is performed by the radiology physicians. In addition to pulmonary computerized tomography (CT) angiography, lower extremity venography is also performed.

Impact of Intracoronary Imaging-Guided Percutaneous Coronary Intervention on Procedural Outcomes Among Complex Patient Groups.

Background Intracoronary imaging (ICI) has been shown to improve survival after percutaneous coronary intervention (PCI). Whether this prognostic benefit is sustained across different indications remains unclear. Methods and Results All PCI procedures performed in England and Wales between April, 2014 and March 31, 2020, were retrospectively analyzed. The association between ICI use and in-hospital major acute cardiovascular and cerebrovascular events; composite of all-cause mortality, stroke, and reinfarction and mortality was examined using multivariable logistic regression analysis for different imaging-recommended indications as set by European Association for Percutaneous Cardiovascular Interventions consensus. Of 555 398 PCI procedures, 10.8% (n=59 752) were ICI-guided. ICI use doubled between 2014 (7.8%) and 2020 (17.5%) and was highest in left main PCI (41.2%) and lowest in acute coronary syndrome (9%). Only specific European Association for Percutaneous Cardiovascular Interventions imaging-recommended indications were associated with reduced major acute cardiovascular and cerebrovascular events and mortality, including left main PCI (odds ratio [OR], 0.45 [95% CI, 0.39-0.52] and 0.41 [95% CI, 0.35-0.48], respectively), acute coronary syndrome (OR, 0.76 [95% CI, 0.70-0.82] and 0.70 [95% CI, 0.63-0.77]), and stent length >60 mm (OR, 0.75 [95% CI, 0.59-0.94] and 0.72 [95% CI, 0.54-0.95]). Stent thrombosis and renal failure were associated with lower mortality (OR, 0.69 [95% CI, 0.52-0.91]) and major acute cardiovascular and cerebrovascular events (OR, 0.77 [95% CI, 0.60-0.99]), respectively. Conclusions ICI use has more than doubled over a 7-year period at a national level but remains low, with <1 in 5 procedures performed under ICI guidance. In-hospital survival was better with ICI-guided than angiography-guided PCI, albeit only for specific indications.

Remodeling of the Neurovascular Unit Following Cerebral Ischemia and Hemorrhage.

Formulated as a group effort of the stroke community, the transforming concept of the neurovascular unit (NVU) depicts the structural and functional relationship between brain cells and the vascular structure. Composed of both neural and vascular elements, the NVU forms the blood–brain barrier that regulates cerebral blood flow to meet the oxygen demand of the brain in normal physiology and maintain brain homeostasis. Conversely, the dysregulation and dysfunction of the NVU is an essential pathological feature that underlies neurological disorders spanning from chronic neurodegeneration to acute cerebrovascular events such as ischemic stroke and cerebral hemorrhage, which were the focus of this review. We also discussed how common vascular risk factors of stroke predispose the NVU to pathological changes. We synthesized existing literature and first provided an overview of the basic structure and function of NVU, followed by knowledge of how these components remodel in response to ischemic stroke and brain hemorrhage. A greater understanding of the NVU dysfunction and remodeling will enable the design of targeted therapies and provide a valuable foundation for relevant research in this area.

Adhesion Molecules and Vulnerable Plaques – Promoters of Acute Coronary Syndromes

Abstract Biological factors that characterize extrinsic plaque vulnerability include various pro- and anti-inflammatory cytokines that contribute to the development and progression of atherosclerosis. Adhesion molecules are among the initiators of the atherosclerotic process, by mediation of endothelial inflammation. The soluble forms of these adhesion molecules have been identified in the circulatory blood, with an increased level in case of subjects with atherosclerotic lesions and higher levels in patients with acute coronary syndromes or vulnerable plaques. In addition, several authors have found a significant predictive capacity of these molecules in case of patients presenting with acute coronary and cerebrovascular events. The aim of this manuscript is to provide a short description of the role of adhesion molecules in the development and progression of atherosclerotic lesions towards acute coronary syndromes, as well as their capacity for predicting major adverse cardiovascular events in vulnerable cardiovascular patients.

Personalized Critical Care Medicine (Review)

Personalized medicine (PM) is a major trend in health care development in the 21st century. This area includes studying risk factors for disease development (prediction), interventions for preventing diseases (prophylaxis), individualization of diagnosis and treatment (personalization), informing the patient on disease prevention and treatment (participation). In the recent years, an intense research to introduce the personalized medicine principles into the management of critically ill patients, has been under way. This includes identification of patient groups based on genomic research, development of diagnostic tests using molecular markers, creation of novel classes of drugs based on individual patient characteristics.The aim of the review is to summarize the available data on the implementation of the principles of PM in the routine practice of critical care institutions.We analyzed more than 300 sources of literature from the Pubmed and Scopus databases, as well as the RSCI database. Eighty five most relevant sources were selected for the review. The paper reports data on the organization and results of implementation of PM principles and advanced technologies, such as Emergency Medicine Sample Bank (EMSB), in the daily activity of clinics providing emergency critical care. The formation of the novel PM concept focused on the treatment of critically ill patients has been discussed. The review contains detailed data on the patterns of development of specific critical illnesses such as acute cerebrovascular events, acute respiratory distress syndrome, traumatic brain injury, shock, myocardial infarction, cardiac rhythm and conduction disturbances. Medication efficacy in view of individual genetic patient characteristics has also been highlighted. No research limitations on the subject were identified.Conclusion. The analysis of literature has demonstrated positive results of implementing PM principles in prevention, diagnosis and treatment of critically ill patients. Creation of Biobanks, development of training programs and regulatory documentation, advancing the scientific research, introduction of new methods of diagnosis and treatment will contribute to the implementation of PM principles in practical healthcare.

Factors, associated with major adverse events in rural males with arterial hypertension at long-term follow-up

Background and Aims : To study the factors, associated with major adverse events (MAEs) in rural males with uncomplicated arterial hypertension (HTN) at long-term follow-up.Methods: The prospective study enrolled 160 rural males with uncomplicated primary HTN (mean age 50 ± 6 years). We analyzed clinical and instrumental data. High-to-very high SCORE cardiovascular risk was identified in 102 (63,7%) patients. Blood pressure visit-to-visit variability (VVV) was assessed by standard deviation and coefficient of variation (CV) (derived from the four consecutive visits). Left ventricular (LV) hypertrophy (by echo) was detected in 129 (80,6%) patients. The median of follow-up was 27 months (interquartile range 24-30 months). During the follow-up period, 14 (8,8%) patients presented with MAEs (totally, 17 events): acute cerebrovascular event (n=9); myocardial infarction (n=2); first-onset atrial fibrillation (AF) (n=2); AF transition in permanent pattern (n=2); and relative LV ejection fraction decline >10% (n=2).Results: At multivariable analysis, the factors, associated with MAEs at long-term follow-up, were as follows: SCORE cardiovascular risk (per 1 % increase: HR 1,09 (95% CI 1,01-1,17); р=0,034); mean arterial pressure (MAP) (per 1 mm Hg increase: HR 1,23 (95% CI 1,07-1,41); р=0,003); CV (MAP) (per 1% increase: HR 1,41 (95% CI 1,08-1,83); р=0,012); and LV myocardial mass, indexed by height2,7 (per 1 g/m2,7 increase: HR 1,07 (95% CI 1,03-1,11); р=0,001).Conclusions: Long-term MAEs in rural HTN males were associated with SCORE cardiovascular risk, MAP, MAP VVV (by CV) and LV myocardial mass index (by height2,7). These factors should be taken into account while MAEs risk stratification in rural males with uncomplicated HTN. Background and Aims : To study the factors, associated with major adverse events (MAEs) in rural males with uncomplicated arterial hypertension (HTN) at long-term follow-up. Methods: The prospective study enrolled 160 rural males with uncomplicated primary HTN (mean age 50 ± 6 years). We analyzed clinical and instrumental data. High-to-very high SCORE cardiovascular risk was identified in 102 (63,7%) patients. Blood pressure visit-to-visit variability (VVV) was assessed by standard deviation and coefficient of variation (CV) (derived from the four consecutive visits). Left ventricular (LV) hypertrophy (by echo) was detected in 129 (80,6%) patients. The median of follow-up was 27 months (interquartile range 24-30 months). During the follow-up period, 14 (8,8%) patients presented with MAEs (totally, 17 events): acute cerebrovascular event (n=9); myocardial infarction (n=2); first-onset atrial fibrillation (AF) (n=2); AF transition in permanent pattern (n=2); and relative LV ejection fraction decline >10% (n=2). Results: At multivariable analysis, the factors, associated with MAEs at long-term follow-up, were as follows: SCORE cardiovascular risk (per 1 % increase: HR 1,09 (95% CI 1,01-1,17); р=0,034); mean arterial pressure (MAP) (per 1 mm Hg increase: HR 1,23 (95% CI 1,07-1,41); р=0,003); CV (MAP) (per 1% increase: HR 1,41 (95% CI 1,08-1,83); р=0,012); and LV myocardial mass, indexed by height2,7 (per 1 g/m2,7 increase: HR 1,07 (95% CI 1,03-1,11); р=0,001). Conclusions: Long-term MAEs in rural HTN males were associated with SCORE cardiovascular risk, MAP, MAP VVV (by CV) and LV myocardial mass index (by height2,7). These factors should be taken into account while MAEs risk stratification in rural males with uncomplicated HTN.

Coronary artery bypass grafting in patients with concomitant diabetes mellitus: Perioperative profile and early postoperative complications

Background and Aims : To evaluate perioperative profile and early postoperative complications (EPOCs) in patients with stable coronary artery disease (SCAD) and diabetes mellitus (DM), undergoing isolated coronary artery bypass grafting (CABG).Methods: We enrolled 600 consecutive SCAD patients (mean age 61±9 years, 511 (85,2%) males), undergoing isolated CABG. DM type 2 was diagnosed in 212 (35,3%) patients. We analyzed perioperative clinical and instrumental data, and EPOCs cases. Totally, EPOCs were registered in 112 (18,7%) patients.Results: The DM group, as compared to SCAD patients without DM, was characterized by the higher prevalence of females (21,7% vs. 11,1%, respectively; p<0,001) and moderate-to-severe obesity cases (15,6% vs. 4,9%, respectively; p<0,001), as well as the higher frequency of patients with 3-vessel disease (87,7% vs. 73,7%, respectively; p<0,001). EPOCs were more prevalent in DM group (vs. no-DM: 32,1% and 11,3%, respectively; p<0,001), namely due to the higher frequency of acute kidney injury, acute heart failure and acute cerebrovascular events cases. Consequently, the perioperative profile of DM patients, as opposed to no-DM patients, included longer inotropic support and intensive care.Conclusions: The concomitant DM worsens coronary atherosclerosis burden and perioperative profile in patients undergoing isolated CABG, namely by the higher frequency of EPOCs, requiring longer intensive care. Further investigations aimed at the EPOCs risk reduction are needed for SCAD patients with concomitant DM, undergoing surgical revascularization. Background and Aims : To evaluate perioperative profile and early postoperative complications (EPOCs) in patients with stable coronary artery disease (SCAD) and diabetes mellitus (DM), undergoing isolated coronary artery bypass grafting (CABG). Methods: We enrolled 600 consecutive SCAD patients (mean age 61±9 years, 511 (85,2%) males), undergoing isolated CABG. DM type 2 was diagnosed in 212 (35,3%) patients. We analyzed perioperative clinical and instrumental data, and EPOCs cases. Totally, EPOCs were registered in 112 (18,7%) patients. Results: The DM group, as compared to SCAD patients without DM, was characterized by the higher prevalence of females (21,7% vs. 11,1%, respectively; p<0,001) and moderate-to-severe obesity cases (15,6% vs. 4,9%, respectively; p<0,001), as well as the higher frequency of patients with 3-vessel disease (87,7% vs. 73,7%, respectively; p<0,001). EPOCs were more prevalent in DM group (vs. no-DM: 32,1% and 11,3%, respectively; p<0,001), namely due to the higher frequency of acute kidney injury, acute heart failure and acute cerebrovascular events cases. Consequently, the perioperative profile of DM patients, as opposed to no-DM patients, included longer inotropic support and intensive care. Conclusions: The concomitant DM worsens coronary atherosclerosis burden and perioperative profile in patients undergoing isolated CABG, namely by the higher frequency of EPOCs, requiring longer intensive care. Further investigations aimed at the EPOCs risk reduction are needed for SCAD patients with concomitant DM, undergoing surgical revascularization.

Analysis of Prescriptions for Dual Antiplatelet Therapy After Acute Ischemic Stroke

After the publication of the CHANCE (Clopidogrel in High Risk Patients With Acute Nondisabling Cerebrovascular Events) and POINT (Platelet-Oriented Inhibition in New Transient Ischemic Attack and Minor Ischemic Stroke) clinical trials, the American Heart Association/American Stroke Association (AHA/ASA) issued a new class 1, level of evidence A, recommendation for dual antiplatelet therapy (DAPT; aspirin plus clopidogrel) for secondary prevention in patients with minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤3). The extent to which variations in DAPT prescribing patterns remain and the extent to which practice patterns in the US are consistent with evidence-based guidelines are unknown. To evaluate the discharge DAPT prescribing patterns after publication of the new AHA/ASA guidelines and assess the extent of hospital-level variation in the use of DAPT for secondary prevention in patients with minor stroke (NIHSS score ≤3), as indicated by guidelines, and in patients with nonminor stroke (NIHSS score >3), for whom the risks and benefits of DAPT have not been fully established. This multicenter retrospective cohort study involved 132 817 patients from 1890 hospitals participating in the AHA/ASA Get With The Guidelines-Stroke program. Patients who were hospitalized for acute ischemic stroke and prescribed antiplatelet therapy at discharge between October 1, 2019, and June 30, 2020, were included. Minor ischemic stroke (NIHSS score ≤3) vs nonminor ischemic stroke (NIHSS score >3). The primary outcome was DAPT prescription at discharge. The extent to which variations in DAPT use were explained at the hospital level was assessed by calculating the median odds ratio (OR), which was derived using multivariable logistic regression analysis and compared the likelihood that 2 patients with identical clinical features admitted to 2 randomly selected hospitals (1 with higher propensity and 1 with lower propensity for DAPT use) would receive DAPT at discharge. Associations between hospital-level DAPT use among patients with minor vs nonminor stroke were evaluated using Pearson ρ correlation coefficients. Among 132 817 patients (median [IQR] age, 68 [59-78] years; 68 768 men [51.8%]), 4282 (3.2%) were Asian, 11 254 (8.5%) were Hispanic, 27 221 (20.5%) were non-Hispanic Black, 84 468 (63.6%) were non-Hispanic White, and 5592 (4.2%) were of other races and/or ethnicities (including American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and unable to determine). Overall, 86 551 patients (65.2%) presented with minor ischemic stroke, and 46 266 patients (34.8%) presented with nonminor ischemic stroke. After the 2019 AHA/ASA guideline updates, 40 661 patients (47.0%) with minor stroke (NIHSS median [IQR] score, 1 [0-2]) and 19 703 patients (42.6%) with nonminor stroke (NIHSS median [IQR] score, 6 [5-9]) received DAPT at discharge. Despite guideline recommendations, 45 890 patients (53.0%) with minor stroke did not receive DAPT. After accounting for patient characteristics, substantial hospital-level variations were found in the use of DAPT in those with minor stroke (median [IQR] hospital-level DAPT prescription rate, 44.8% [33.7%-57.7%]; range, 0%-91.7%; median OR, 2.03 [95% CI, 1.97-2.09]) when comparing 2 patients with identical risk factors discharged from 2 randomly selected hospitals, 1 with higher propensity and 1 with lower propensity for DAPT use. The use of DAPT in patients with nonminor stroke also varied significantly (median [IQR] hospital-level DAPT prescription rate, 41.4% [30.0%-53.8%]; range, 0%-100%; median OR, 1.90 [95% CI, 1.83-1.97]). Overall, hospitals that were more likely to prescribe DAPT for minor strokes were also more likely to prescribe DAPT for nonminor strokes (Pearson ρ = 0.72; P < .001). This cohort study found that despite updated AHA/ASA guidelines, more than 50% of patients with minor acute ischemic stroke did not receive DAPT at discharge. In contrast, more than 40% of patients with nonminor stroke received DAPT despite lack of evidence in this setting. These findings suggest that enhancing adherence to evidence-based DAPT practice guidelines may be a target for quality improvement in the treatment of patients with ischemic stroke.

Incidence and Outcomes of Acute Cerebrovascular Events: Methodology of the Population-Based Normandy Stroke Study

Background: The number of strokes has been steadily increasing due to the aging of the population, and its management has changed dramatically in recent years. Nevertheless, there are few unbiased epidemiological studies to investigate the incidence of strokes and their long-term prognosis. Methods: The Normandy Stroke Study (NSS) is a prospective population-based study of all strokes and transient ischemic attacks in a large urban, suburban, and rural area in the Northwest of France. It was designed to meet the current gold standard in stroke epidemiological study by using multiple overlapping sources for case identification. It also aimed to assess the impact of socioeconomic disparities and long-term prognosis of stroke through an additional follow-up up to 3 years after the event to better understand the functional and cognitive prognostic of stroke as well as the quality of life in patients after stroke. Conclusion: NSS will provide important data on the epidemiology and long-term consequences of stroke at the population level and will help care providers adapt resource allocation.

Cardiac Function Assessment By Echocardiography In Ischemic Stroke/Non Hemorrhagic Cerebral Infarction

Background: Every year, more than half a million people in the world suffer from acute cerebrovascular events, including ischemic stroke, intracerebral and subarachnoid hemorrhage, giving a mortality of nearly 20%. Acute strokes, especially subarachnoid hemorrhage is frequently accompanied by a variety of electrocardiographic (ECG) abnormalities. Objective: To find out the cardiac function assessment by echocardiography in ischemic stroke/non hemorrhagic cerebral infarction. Material and Methods: An observational study was conducted in Department of Medicine and Cardiology, Sher-E-Bangla Medical College Hospital, Bangladesh from July to December-2019. 51 patients of ischemic stroke were taken and 2D transthoracic echocardiography was done to find potential cardioembolic abnormalities. Results: 74.5% of patients had echocardiographic abnormalities and 41.1% had potential cardioembolic abnormalities, out of which most common were ventricular wall hypokinesia, calcific aortic valve, rheumatic heart disease and dilated cardiomyopathy. The prevalence was almost similar in different age groups and both the sexes. Conclusion: Prevalence of potential cardioembolic abnormalities is high (41.1%) in ischemic stroke patients and 2D echocardiography is therefore recommended in the management and secondary prevention of cardioembolicstroke, which has a higher mortality and more chances of recurrence than atherothrombotic type of ischemicstroke.

Stroke-associated in-hospital mortality

In this article, we narrated the epidemiological indicators of stroke in the world and in Kyrgyzstan as well. The data on morbidity, mortality and hospital mortality in acute cerebrovascular events, such as ischemic, hemorrhagic strokes, were shared.

Risks and preventive strategy of periodontal treatments for patients with cardiovascular and cerebrovascular diseases

The prevalence and mortality of the patients who suffer cardiovascular and cerebrovascular diseases are rising in China, and the number of periodontitis patients with cardiovascular and cerebrovascular diseases is growing. Certain principles should be followed during periodontal treatments for these patients due to their particular health conditions. Stomatologists should cooperate with cardiovascular physicians to evaluate the risks and benefits of periodontal treatments in advance, and to select reasonable treatment timings and plans. During treatments, the heart rates, blood pressures and other vital indicators are monitored in real time to avoid acute cardiovascular and cerebrovascular events. The application, discontinuation and adjustment of specific cardiovascular drugs are determined by cardiovascular physicians.

Risk Stratification Models for Stroke in Patients Hospitalized with COVID-19 Infection

ObjectivesTo derive models that identify patients with COVID-19 at high risk for stroke. Materials and MethodsWe used data from the AHA's Get With The Guidelines® COVID-19 Cardiovascular Disease Registry to generate models for predicting stroke risk among adults hospitalized with COVID-19 at 122 centers from March 2020-March 2021. To build our models, we used data on demographics, comorbidities, medications, and vital sign and laboratory values at admission. The outcome was a cerebrovascular event (stroke, TIA, or cerebral vein thrombosis). First, we used Cox regression with cross validation techniques to identify factors associated with the outcome in both univariable and multivariable analyses. Then, we assigned points for each variable based on corresponding coefficients to create a prediction score. Second, we used machine learning techniques to create risk estimators using all available covariates. ResultsAmong 21,420 patients hospitalized with COVID-19, 312 (1.5%) had a cerebrovascular event. Using traditional Cox regression, we created/validated a COVID-19 stroke risk score with a C-statistic of 0.66 (95% CI, 0.60–0.72). The CANDLE score assigns 1 point each for prior cerebrovascular disease, afebrile temperature, no prior pulmonary disease, history of hypertension, leukocytosis, and elevated systolic blood pressure. CANDLE stratified risk of an acute cerebrovascular event according to low- (0–1: 0.2% risk), medium- (2–3: 1.1% risk), and high-risk (4–6: 2.1–3.0% risk) groups. Machine learning estimators had similar discriminatory performance as CANDLE: C-statistics, 0.63–0.69. ConclusionsWe developed a practical clinical score, with similar performance to machine learning estimators, to help stratify stroke risk among patients hospitalized with COVID-19.

Palliative care among metastatic breast cancer patients in the end-of-life period in the U.S.

e13002 Background: Research has shown that palliative care improves the quality of end of life care, and lowers associated costs for cancer patients. The purpose of this study was to determine utilization of palliative care consult (PCC) on or after date of metastasis to date of death, the association of emergency department (ED), intensive care unit (ICU) and chemotherapies among metastatic breast cancer (MBC) patients in the United States. Methods: We conducted a retrospective study using the de-identified electronic medical record data from a national healthcare informatics provider and insurer between January 1, 2000 and December 31, 2018. The MBC patients (age ≥ 18 years) who were diagnosed with a secondary neoplasm after the index diagnosis of breast cancer and deceased in the period of data capture were included. The cohort was split into the PCC groups, patients who had received at least one PCC on or after the date of metastasis through date of death; and the non-PCC group. The ED, ICU and chemotherapy encounters since metastasis were defined by ICD-9/10, HCPCS or CPT codes per encounter records. We quantified the ED and ICU visits within two months of death; and the antineoplastic chemotherapies within one and two months of death. Time from metastasis to death and utilization of services were compared between the PCC and the non-PCC groups using Whitney U-test and Chi-squared test. Results: 979 deceased MBC patients had at least one PCC and 1,636 did not at all. Overall, average patient age at the last admission was 68.7+/-12.9 years. The median time from metastasis to death was 9 (2 – 24) years. More than half of them were Caucasian (79.8%) and nearly half from the Midwest region (47.1%). Between the two groups, age distribution was not significantly different, but the PCC patients were more likely to have shorter time to death (8 vs 10 years), be African American (12.8% vs 9.8%), reside in Midwest (52.9% vs 43.7%) and have experienced complications since metastasis except for acute cerebrovascular events. Compared to the non-PCC patients, the PCC patients were more likely to use ED (52.2% vs 22.2%), ICU (12.5% vs 13.4%) within two months of death, and to receive chemotherapy within one and two months of death (17.7% vs 13.9% and 12.9% vs 6.0%, respectively). Conclusions: Our study found that only 38% of BC patients received at least one PCC following date of metastatic diagnosis. Findings highlight the need to increase PCC among MBC patients immediately following diagnosis to ensure appropriate care is provided and utilized. Furthermore, educational and informational interventions will need to be developed to boost PCC utilization among MBC patients.

Leveraging cluster analysis of weather and pollution features to predict acute cardiac or cerebrovascular events

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Despite mounting evidence, the impact of the interplay between weather and pollution features on the risk of acute cardiac and cerebrovascular events has not been entirely appraised. Purpose We aimed to perform a comprehensive cluster analysis of weather and pollution features in a large metropolitan area, and their association with acute cardiac and cerebrovascular events. Methods Anonymized data on acute myocardial infarction (AMI) and acute cerebrovascular events were obtained from 3 tertiary care center from a single large metropolitan area. Weather and pollution data were obtained averaging measurements from several city measurement stations managed by the competent regional agency for enviromental protection, and from the Metereologic Center of Italian Military Aviation. Unsupervised machine learning was performed with hierarchical clustering to identify specific days with distinct weather and pollution features. Clusters were then compared for rate of acute cardiac and cerebrovascular events with Poisson models. Results As expected, significant pairwise correlations were found between weather and pollution features. Building upon these correlations, hierarchical clustering, from a total of 1169 days, generated 4 separate clusters: mostly winter days with low temperatures and high ozone concentrations (cluster 1, n=60, 5.1%), days with moderately high temperatures and low pollutants concentrations (cluster 2, n=419, 35.8%), mostly summer and spring days with high temperatures and high ozone concentrations (cluster 3, n=673, 57.6%), and mostly winter days with low temperatures and low ozone concentrations (cluster 4, n=17, 1.5%). Overall cluster-wise comparisons showed significant overall differences in adverse cardiac and cerebrovascular events (p&amp;lt;0.001), as well as in cerebrovascular events (p&amp;lt;0.001) and strokes (p=0.001). Between-cluster comparisons showed that Cluster 1 was associated with an increased risk of any event, cerebrovascular events, and strokes in comparison to Cluster 2, Cluster 3 and Cluster 4 (all p&amp;lt;0.05), as well as AMI in comparison to Cluster 3 (p=0.047). In addition, Cluster 2 was associated with a higher risk of strokes in comparison to Cluster 4 (p=0.030). Analysis adjusting for season confirmed the increased risk of any event, cerebrovascular events and strokes for Cluster 1 and Cluster 2. Conclusions Unsupervised machine learning can be leveraged to identify specific days with a unique clustering of adverse weather and pollution features which are associated with an increases risk of acute cardiovascular events, especially cerebrovascular events. These findings may improve collective and individual risk prediction and prevention.

Secondary prevention of acute coronary syndrome by reducing depression and anxiety

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Cardiovascular disease is expected to reach an annual mortality rate of 23 million individuals by 2030, primarily due to acute coronary syndrome (ACS) and cerebrovascular events. Simply stating the mortality associated with cardiovascular disease underrepresents its true burden considering the associated disability, healthcare expenditure, and loss of quality of life. Specifically, there has been increasing interest in the prevalence of depression and anxiety post-ACS as depressive and anxious symptoms are seen in up to 45% and 30% of patients, respectfully. These symptoms are associated with increased morbidity and mortality as well as decreased quality of life. Thus, it is crucial that secondary prevention be prioritized in this population with a specific focus on psychological wellbeing. Purpose The purpose of the present systematic review is to summarize the current literature on secondary prevention following ACS via interventions aimed at reducing depression and anxiety. Methods A systematic review was conducted of the databases PubMed, EMBASE, Web of Science, ClinicalTrials.gov, and Cochrane for studies which implemented an intervention to improve depression or anxiety in patients following ACS. Results The initial literature search identified 6,536 studies, of which 97 were added for inclusion with a total of 23,965 participants. Study design comprised 83 randomized control trials, two quasi-experimental studies, and 12 non-randomized experimental studies. The majority of interventions which significantly reduced symptoms of post-ACS anxiety involved modified cardiac rehabilitation programs (20%), aromatherapy (13%), and initiation of a new therapeutic (11%). Conversely, the majority of post-ACS interventions which significantly improved depressive symptoms involved therapy (24%), modified cardiac rehabilitation (24%), and initiation of a new therapeutic (20%). Notably, all aromatherapy (n=6), arts-based (n=3), exercise (n=7), meditation (n=3), and nature therapy (n=1) intervention studies extracted reported significant improvement in either depression or anxiety scores. Conclusions Depressive and anxious symptoms following ACS are associated with increased risk of death, rehospitalization, and poor quality of life. Programs which involve modified cardiac rehabilitation programs, aromatherapy, therapeutic agents, and therapy may increase secondary prevention of ACS by improving symptoms of depression and anxiety. Due to the heterogeneity of the programs identified, significant differences in sample size across studies, and the variety of depression/anxiety scales used, a large-scale randomized control trial comparing intervention efficacy is needed. Such a trial, as well as the present systematic review, may improve secondary prevention of ACS by identifying strategies to reduce depression and anxiety in this population.

Recurrent Ischemic Stroke and Bleeding in Patients With Atrial Fibrillation Who Suffered an Acute Stroke While on Treatment With Nonvitamin K Antagonist Oral Anticoagulants: The RENO-EXTEND Study.

In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA2DS2-VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0-1.3] for each point increase; P=0.05) and hypertension (OR, 2.3 [95% CI, 1.0-5.1]; P=0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0-1.2] for each year increase; P=0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4-14.2]; P=0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4-5.5]; P=0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8-1.7]). Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding.

Cerebrovascular Events in Suspected Sepsis: Retrospective Prevalence Study in Critically Ill Patients Undergoing Full-Body Computed Tomography.

PurposeThis study aimed at retrospectively evaluating full-body computed tomography (CT) examinations for the prevalence of cerebrovascular events in patients with suspected sepsis treated in the intensive care unit (ICU).MethodsAll full-body CT examinations, i.e., both cranial CT (cCT) and body CT including chest, abdomen and pelvis, for focus search in septic patients over a 12-months period were identified from three ICUs, using full-text search. From this retrospective cohort, we fully analyzed 278 cCT examinations for the occurrence of acute cerebral findings. All acute cerebrovascular events were independently reviewed by two blinded readers. Clinical and laboratory findings were extracted. The data were statistically analyzed using contingency tests.ResultsIn our population of patients with suspected sepsis, 10.8% (n = 30/278) were identified to have major cerebral events, including 7.2% (n = 20/278) major cerebrovascular events and 4.3% (n = 12/278) generalized parenchymal damage. 13.4% (n = 22/163) of patients with a severe coma as compared with non-severe coma, 4.4% (n = 3/68), showed a major cerebral event (p = 0.04). Patients referred from the cardiology/nephrology ICU ward showed major cerebral events in 16.3% (n = 22/135), as compared with 4.9% (n = 3/61) in patients from pulmonary ICU and 6.1% (n = 5/82) major cerebral events with surgical referral (p = 0.02).ConclusionOur study provides further evidence that septic patients may suffer from cerebral events with relevance to their prognosis. Severe coma and the referring ward were associated with acute cerebral conditions. Full-body CT has the advantage of both detecting of septic foci and possibly identifying ischemic or hemorrhagic stroke in this vulnerable patient population.

May Literature Synopsis

May Literature Synopsis

Predictive values of baseline matrix metalloproteinase 9 levels in peripheral blood on 3-month outcomes of high-risk patients with minor stroke or transient ischemic attack.

To explore the relationship between baseline levels of matrix metalloproteinase 9 (MMP9) in peripheral blood and the outcomes in patients with acute minor stroke and transient ischemic attack (TIA). We assessed data from patients with acute minor ischemic stroke or TIA who were included in the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial. Baseline level of MMP9 in peripheral blood is classified into five quintiles. We assessed the relationship between the baseline MMP9 and outcomes of stroke recurrence, composite vascular events, and poor functional outcomes within 90days after stroke onset. Of the 3014 patients included, 295 (9.79%) had recurrent stroke, 289 (9.59%) had recurrent ischemic stroke, 297 (9.85%) had combined vascular events, and 199 (6.64%) had poor functional outcomes within 90days. We used MMP9 concentrations near hazard ratio (HR)=1 (Q3) in restricted cubic splines as the reference. The result showed that, compared to patients in the Q3group, patients in the highest quintile (Q5group) had an increased risk of poor functional outcomes at 90days after adjusting the risk factors and confounders (p=0.030), which may be associated with an increased risk of combined vascular events (p=0.052). Using Cox regression models or logistic regression models with restricted cubic spline, we also observed that higher MMP9 ratios were associated with an increased risk of stroke recurrence, combined events, and poor functional outcomes at a range of concentrations. For patients with acute minor stroke or TIA, higher baseline MMP9level was associated with an increased risk of poor functional outcomes, which might be related to stroke recurrence and combined vascular events.