American Heart Research Articles

When is an implantable cardioverter-defibrillator controversial?

When is an implantable cardioverter-defibrillator controversial?

Correction to: An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

Correction to: An Updated Definition of Stroke for the 21st Century: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.

Efficacy of clopidogrel for stroke depends on CYP2C19 genotype and risk profile.

Dual antiplatelet therapy (DAT) with clopidogrel plus aspirin has been suggested by American Heart Association/American Stroke Association guidelines for minor stroke (MS) and transient ischemic attack (TIA) patients. The purpose of this study was to find the potential subgroups that benefit from DAT. We aimed to compare the efficacy of clopidogrel-aspirin therapy with that of aspirin therapy in MS/TIA patients stratified by CYP2C19 genotype and risk profiles. CYP2C19 loss-of-function allele (LoFA) carriers were defined as patients with LoFA of either *2 or *3. Low- and high-risk profile was defined as Essen Stroke Risk Score (ESRS) <3 and ≥3, respectively. Stroke recurrence at 1 year was considered primary outcome. Of a total 2,933 MS/TIA patients, there were 1,726 (58.8%) LoFA carriers and 1,068 (36.4%) patients at high risk (ESRS ≥3). No significant difference for stroke recurrence between the clopidogrel-aspirin group and aspirin alone group was found in LoFA carriers (11.2% vs 13.3%, hazard ratio [HR] = 0.83, 95% confidence interval [CI] = 0.64~1.09). In stratified analyses by CYP2C19 genotype and ESRS, HRs (95% CIs) of the clopidogrel-aspirin therapy for stroke recurrence were 1.00 (0.70~1.42), 0.63 (0.41~0.97), 0.62 (0.40~0.96), and 0.52 (0.31~0.88) among subgroups of LoFA carriers at low risk, LoFA carriers at high risk, LoFA noncarriers at low risk, and LoFA noncarriers at high risk, respectively, with p = 0.021 for interaction. Overall, LoFA carriers do not benefit from DAT, but there is significant benefit for LoFA carriers who are at high risk. The benefit of clopidogrel in Chinese MS/TIA patients depends on CYP2C19 genotype and risk profile. ANN NEUROL 2019;86:419-426.

Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke: Meta-Analysis of 5 Randomized Trials.

Background and Purpose- TNK (tenecteplase), a newer fibrinolytic agent, has practical delivery advantages over ALT (alteplase) that would make it a useful agent if noninferior in acute ischemic stroke treatment outcome. Accordingly, the most recent US American Heart Association/American Stroke Association acute ischemic stroke guideline recognized TNK as an alternative to ALT, but only based on informal consideration, rather than formal meta-analysis, of completed randomized control trials. Methods- Systematic literature search and formal meta-analysis were conducted per PRISMA guidelines (Preferred Reporting Items for Systemic Reviews and Meta-Analyses), adapted to noninferiority analysis. The primary outcome of freedom from disability (modified Rankin Scale score, 0-1) outcome at 3 m, and additional efficacy and safety outcomes, were analyzed. Results- Systematic search identified 5 trials enrolling 1585 patients (828 TNK, 757 ALT). Across all trials, mean age was 70.8, 58.5% male, baseline National Institutes of Health Stroke Scale mean 7.0, and time from last known well to treatment start mean 148 minutes. All ALT patients received standard 0.9 mg/kg dosing, while TNK dosing was 0.1 mg/kg in 6.8%, 0.25 mg/kg in 24.6%, and 0.4 mg/kg in 68.6%. For the primary end point, crude cumulative rates of disability-free (modified Rankin Scale score, 0-1) 3 m outcome were TNK 57.9% versus ALT 55.4%. Informal, random-effects meta-analysis, the risk difference was 4% (95% CI, -1% to 8%). The lower 95% CI bound fell well within the prespecified noninferiority margin. Similar results were seen for the additional efficacy end points: functional independence (modified Rankin Scale score, 0-2): crude TNK 71.9% versus ALT 70.5%, risk difference 2% (95% CI, -3% to 6%); and modified Rankin Scale shift analysis, common odds ratio 1.21 (95% CI, 0.93-1.57). For safety end points, lower event rates reduced power, but point estimates were also consistent with noninferiority Conclusions- Accumulated clinical trial data provides strong evidence that TNK is noninferior to ALT in the treatment of acute ischemic stroke. These findings provide formal support for the recent guideline recommendation to consider TNK an alternative to ALT.

Differential burden of peripheral artery disease

Differential burden of peripheral artery disease

The quality of medication optimization among patients with transient ischemic attack or minor stroke

AbstractObjectiveTo assess the quality of medication optimization for transient ischemic attack (TIA) and minor stroke patients across the Veterans Health Administration (VHA), and to identify characteristics predicting medication optimization for hypertension, hyperlipidemia, and diabetes. The scope of this study focuses on these three medication‐related conditions and defines optimization as medication changes or additions made within a guideline‐defined timeframe.MethodsWe constructed a retrospective cohort including all patients discharged with a TIA or minor stroke (index event) in any VHA Emergency Department (ED) or inpatient setting during fiscal year 2011. Inpatient and outpatient medical/pharmacy data were collected from a variety of electronic health sources for 1 year prior to and up to 90 days after discharge. Medication optimization for hypertension, hyperlipidemia, and diabetes was defined using relevant VHA and American Heart Association/American Stroke Association guidelines. For each of the three medication‐based outcomes, multivariable logistic regression models examined demographic, past medical history, and other clinical variables to identify predictors of optimization.ResultsAmong 8427 patients, 33.7% (n = 2837) were eligible for medication optimization for hypertension, 55.2% (n = 4655) for hyperlipidemia, and 7.2% (n = 606) for diabetes. Guideline‐concordant medication optimization occurred for 28% of eligible patients with hypertension, 28% of patients with hyperlipidemia, and 34% of patients with diabetes. Factors that were associated with medication optimization included younger age, inpatient stay (vs discharge from the ED), greater baseline disease severity (higher blood pressure, low‐density lipoprotein [LDL] cholesterol, or hemoglobin A1c [glycated hemoglobin]), and primary care follow‐up within 30 days after the index event.ConclusionOne‐third or fewer eligible patients with TIA or minor stroke had their medications optimized in a timely manner in concordance with evidence‐based guidelines. Interventions to improve timely medication optimization are needed to reduce the risk of recurrent vascular events in this high‐risk population.

The Prevalence of Cardiovascular Disease Risk Factors: An Age-matched Analysis from FiLWHEL (2014–2016), NNS (2008), KNHANES (2013–2015) and NHANES (2013–2016) Data (P18-088-19)

ObjectivesCardiovascular disease (CVD) is accountable for major cause of deaths among women worldwide. We aimed to assess the prevalence of CVD risk factors among Filipino women in Korea, Filipino women in the Philippines, Korean women in Korea and US women in the US. MethodsWe randomly selected a sample of 504 women from each study using a 1:1 age-matching analysis. Age range from 20–57 years old. We analyzed anthropometry, blood pressure and biomarkers data from the Filipino Women’s Health and Diet Study (FiLWHEL), the Philippine National Nutrition Survey (NNS), Korean National Health and Nutrition Examination Survey (KNHANES) and the US National Health and Nutrition Examination Survey (NHANES). We used the American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) criteria to categorize blood lipids. We assessed the prevalence of CVD risk factors using proportions, means and standard deviations. ResultsWe found that high BMI (≥25 kg/m²) and high waist circumference (WC: ≥85 cm) were prevalent in NHANES (65.6%, mean BMI = 29.48 ± 8.18 and 70.8%, mean WC = 96.16 ± 18.19, respectively) than in FiLWHEL (30.9%, 26.4% respectively), NNS (29.0%, 23.9% respectively) and KNHANES (19.8%, 12.0% respectively), p-value = <.0001. NHANES also exhibited higher prevalence for high cholesterol (≥200 mg/dL), high triglyceride (≥150 mg/dL) and high glucose (≥110 mg/dL) with 32.3%, 25.4% and 10.8% respectively. However, compared with NHANES (28.3%) and KNHANES (21.6%), NNS and FiLWHEL had higher prevalence of pre-hypertension and hypertension combined (47.6% and 43.8%, respectively), p-value = < .0001. Also, high prevalence of low HDL-c (<50 mg/dL) was striking in NNS (39.84 ± 5.75) than in FiLWHEL (58.19 ± 14.06), NHANES (57.44 ± 16.76) and KNHANES (56.97 ± 11.35). ConclusionsOur study suggest that the prevalence of risk factors for cardiovascular disease were different across Filipino women in Korea and in the Philippines, Korean women and US women. Funding SourcesHandok Pharmaceutical Co., Ltd.

Impact of pretransplant mitral annular calcification on the incidence of cardiac events after renal transplantation.

Mitral annular calcification (MAC) is associated with increased risk of major adverse cardiac events. We hypothesized that MAC, identified on a pretransplant transthoracic echocardiography (TTE), is predictive of cardiac events following renal transplantation (RT). In a retrospective cohort of consecutive RT recipients, pretransplant MAC presence and severity were determined on TTE performed within 1 year prior to transplant. MAC severity was quantified based on the circumferential MAC extension relative to the mitral valve annulus. Post-transplant cardiac risk was assessed using the sum of risk factors (range: 0-8) set forth by the American Heart Association/American College of Cardiology Foundation consensus statement on the assessment of RT candidates. Subjects underwent pretransplant stress single-photon emission computed tomography myocardial perfusion imaging and followed for post-transplant composite outcome of cardiac death or myocardial infarction (CD/MI). Among 336 subjects (60.5% men; mean age 52 ± 12 years), MAC was present in 78 (23%) patients. During a mean follow-up of 3.1 ± 1.9 years, a total of 70 events were observed. Patients with MAC had a higher event rate compared with those without MAC (34.6% versus 17.8%, log-rank P = 0.001). There was a stepwise increase in CD/MI risk with increasing MAC severity (P for trend = 0.002). MAC-associated risk remained significant after adjusting for sex, duration of dialysis, sum of risk factors, ejection fraction and perfusion abnormality burden, providing an incremental prognostic value to these parameters (Δχ2=4.63; P = 0.031). Among RT recipients, the burden of pretransplant MAC is an independent predictor of post-transplant risk of CD/MI. MAC should be considered in the preoperative assessment of RT candidates.

Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review protocol

Background and purposeCerebral venous thrombosis causes disability from venous infarct and hemorrhage and potential mortality. Anticoagulation improves survival and disability outcomes, yet direct oral anticoagulants are currently not indicated in cerebral venous thrombosis due to lack of evidence, despite being on the market for nearly a decade. This systematic review will collate evidence of reported safety and efficacy of direct oral anticoagulant therapy in cerebral venous thrombosis.MethodsA search strategy was developed with a research librarian and registered on a protocol database (PROSPERO CRD42017078398). All published studies from MEDLINE and EMBASE up to February 2019 containing patients diagnosed with cerebral venous thrombosis who were treated with a direct oral anticoagulant (dabigatran, rivaroxaban, apixaban, or edoxaban) will be included. A risk of bias analysis will be performed to evaluate quality of studies overall.DiscussionCurrent guidelines in the treatment of cerebral vein thrombosis dating back to 2011 from the American Heart Association/American Stroke Association endorse the utility of anticoagulation for the treatment of cerebral vein thrombosis; however, they did not support the use of direct oral anticoagulants. Updated guidelines from the European Stroke Organization, endorsed by the European Academy of Neurology in 2017, also refute utilization of direct oral anticoagulants due to a lack of evidence. There have been nearly 10 years of experience with direct oral anticoagulants in the treatment of venous thrombosis and prevention of stroke in patients with atrial fibrillation, with purported efficacy and safety in comparison with heparins and vitamin K antagonists. Our goal is to undertake a systematic review to assess the effectiveness and safety of direct oral anticoagulants in patients with cerebral vein thrombosis to help guide clinical decision-making for patients unable to take heparins or vitamin K antagonists and to direct future studies to contribute further to an area of certain evidence-based needs.Systematic review registrationPROSPERO CRD42017078398

MON-213 Evaluation of Type 2 Diabetes and Cardiovascular Disease Risk Factors in Reproductive-Age Women with Polycystic Ovary Syndrome (PCOS) Using the 2014 Androgen Excess and PCOS Society Criteria for the Polycystic Ovarian Morphology

Polycystic ovary syndrome (PCOS) is a complex and prevalent endocrine condition among reproductive-age women associated with adverse metabolic consequences. Metabolic syndrome (MetS) is a cluster of risk factors conferring an increased risk for type 2 diabetes (DM2) and cardiovascular disease (CVD). Research has been limited, in part, due to marked heterogeneity in criteria employed to determine MetS, retrospective data collection, and the use of older or less accurate criteria to diagnose PCOS and polycystic ovarian morphology (PCOM). We aimed to 1) examine the prevalence of MetS and evaluate DM2 and CVD risk factors in reproductive-age Canadian women with PCOS; and, 2) assess the relevance of MetS to clinical and biochemical features of PCOS using a prospective comprehensive approach and a rigorously-defined PCOS population. Baseline observations were evaluated in 237 women with PCOS (Androgen Excess and PCOS [AE-PCOS] Society 2006 criteria for PCOS and AE-PCOS Society 2014 recommendations to determine PCOM) and 42 healthy controls (18-36 years). Clinical and biochemical measures of MetS (International Diabetes Federation and the American Heart Association/National Heart, Lung, and Blood Institute 2009), DM2 (Diabetes Canada Clinical Practice Guidelines 2018), and CVD risk factors (AE-PCOS Society statement 2010) were assessed. The prevalence of MetS was 29.5% in women with PCOS; that is, approximately 6-fold higher than age-matched controls (P<0.001). Women with PCOS presented with higher glucose abnormality, acanthosis nigricans, total cholesterol to high-density lipoprotein cholesterol (TC/HDL-C) ratio, and lower sex-hormone binding globulin (SHBG) concentrations when compared with controls after accounting for differences in the body mass index (BMI; P<0.01). Women with both PCOS and MetS exhibited exacerbated insulin and glucose responses to a 75-gram glucose tolerance test, increased TC/HDL-C ratio, TC, and SHBG concentrations, as well as increased hirsutism and acanthosis nigricans when compared to women with PCOS without MetS after adjusting for BMI (P≤0.05). Canadian reproductive-age women with PCOS whose PCOM were characterized according to the AE-PCOS Society 2014 recommendations have a high prevalence of MetS and exhibit adverse cardiometabolic and DM2 risk profiles. MetS is associated with increased hyperandrogenism and hypercholesterolemia in women with PCOS attributed to inherent insulin resistance, hyperinsulinemia, and synergistic effects of concomitant obesity. Screening and regular monitoring for CVD and DM2 risk factors are reinforced for women with PCOS across the reproductive lifespan.

CD8 T cells exert a critical role in the transition from left heart failure to lung remodeling and right ventricular hypertrophy

BackgroundPatients with left ventricular (LV) failure or heart failure (HF) often progress to right ventricular (RV) hypertrophy and/or failure even with optimal medical care. Previously, we have shown a potential role for regulatory T cells (Tregs) in suppressing LV failure progression. However, the particular leukocyte subset(s) that promote the transition from LV failure to RV hypertrophy and failure are unknown. Here, we investigated the role of cytotoxic CD8+T cells in this progression.MethodsMice with LV failure produced by transverse aortic constriction (TAC) were randomized to depletion of cytotoxic CD8+T cells using specific blocking antibodies. The cardiac function, lung inflammation, fibrosis, vascular remodeling, and right ventricular remodeling were determined.ResultsLV failure caused lung inflammation and lung T cell activation involving both CD4+and CD8+T cell activation. Depletion of CD8+ T cells dramatically attenuated the increase of lung weight, lung inflammation, lung vascular remodeling, and RV hypertrophy in mice with existing LV failure.ConclusionsOur findings demonstrate that CD8+T cells play a critical role in promoting the transition from LV failure to lung remodeling and RV hypertrophy, indicating that modulation of CD8+T cell activity may represent a new approach to heart failure therapy.Support or Funding InformationThis study was supported by research grants 81470512 and 81570355 from Nature Science Foundation, and Grants HL098669, HL102597, R01HL105406 from the National Institutes of Health, and a grant in aid from American Heart Association.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Myeloid Derived miR‐21 Influences Coronary Collateral Growth in Metabolic Syndrome

Well‐developed coronary collaterals prove to be highly beneficial in salvaging ischemic myocardium, preserving cardiac function, and improving patient outcome post‐occlusion. However, this process is impaired in patients with metabolic syndrome. A more complete understanding of the underlying mechanism, cell types, and genes causing the impaired coronary collateral growth (CCG) response have yet to be elucidated. Better understanding of the process of CCG will lead to potential therapeutics to induce CCG and circumvent ischemic injury. MicroRNA‐21 (miR‐21) has been studied in cancer, with its central role in the down‐regulation of pro‐apoptotic genes leading to sustained cellular proliferation. However, miR‐21 has recently been reported to modulate inflammation after myocardial infarction (MI) and to play a role in the development of atherosclerosis. Furthermore, miR‐21 has been shown to be involved in macrophage polarization, where it generally serves to reduce inflammatory markers and promote anti‐inflammatory markers. In addition, miR‐21 dysregulation has been rooted in the diabetic population wherein lies a systemic inflammatory state. In this study, we investigated the role of miR‐21 during CCG in diabetes mellitus, which is a major risk factor for the development of cardiovascular disease. Our preliminary data suggested that down‐regulating miR‐21 rescues the impaired CCG in diet‐induced diabetic animals. Given that miR‐21 is highly abundant in immune cells, we sought to further study if miR‐21 regulates CCG by modulating the inflammatory response. While macrophages have been extensively studied during MI events or in atherosclerosis conditions, their roles during CCG are not well‐defined. Thus, we utilize a myeloid specific (Lyz2) miR‐21 knockout to investigate the impact of miR‐21 in macrophages on CCG within the context of diabetes. First, colony stimulating factor‐1 directed bone marrow derived macrophages from miR‐21 Lyz2‐knockout mice were subjected to high glucose (4.5 g/L) and / or hypoxia (3% oxygen) to mimic diabetic conditions. Interestingly, the knockout macrophages have differences in their spindle like projections even before beginning treatment. This possibly suggests greater baseline activation compared to the control. We also observe morphological differences after treatment. The expression profile will give more accurate results. In vivo, CCG is blunted in the miR‐21 Lyz2‐knockout animals subjected to the repetitive ischemia protocol. This suggests that miR‐21 in the myeloid lineage is critical for CCG in healthy non‐diabetic mice. Further studies of CCG in the miR‐21 Lyz2‐knockout mice fed high fat and high sugar diet will give us more insight into the mechanisms underlying impaired CCG in diabetes.Support or Funding InformationThe research is funded by National Institutes of Health grant 2R01HL103227‐05 (Zhang, Yin), 1R01HL135110‐01 (WMC, LY), 1 R01 HL137008‐01A1 (LY), 1R15HL115540‐01 (LY) and 14BGIA18770028 from American Heart Association.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Hypertension‐Induced Renal Injury is Associated with Impaired Glomerular Barrier Function Involving Podocyte Dysfunction

Dahl SS rats rapidly develop hypertension, proteinuria, and renal injury when challenged with a high‐salt diet. Previous studies revealed that a deficiency in the renal formation of 20‐HETE in SS rats impairs afferent arteriole myogenic response, autoregulation of renal blood flow, tubuloglomerular feedback and glomerular capillary pressure and enhances sodium transport in the thick ascending loop of Henle. However, the role of 20‐HETE in podocyte and glomerular barrier function is still unknown. The aim of this study is to investigate the role of 20‐HETE on the regulation of glomerular function and podocyte function using SS rats and CYP4A1 transgenic rats on a SS background. We found that the production of 20‐HETE was significantly higher in the isolated glomeruli of CYP4A1 compared to SS rats by using mass spectrometry. Immunoblot analysis demonstrated that the expression of α‐smooth muscle actin and vimentin was lower in the isolated glomeruli of CYP4A1 vs. SS rats, indicating reduced epithelial mesenchymal transition (EMT). After challenged with a 4% high‐salt diet, the mean arterial pressure increased to a similar extent in both strains as measured by radio telemetry. However, compared with SS rats, CYP4A1 rats developed lower proteinuria (127 ± 14 vs. 270 ± 23 mg/day, respectively), had unaltered glomerular permeability to albumin (Palb) by using a fluorescence dilution technique, and exhibited greater increases in Palb after treatment with HET0016, a 20‐HETE synthesis inhibitor. In addition, Masson's trichrome staining showed that the glomerular injury score was attenuated in hypertensive CYP4A1 transgenic vs. SS rats (1.3 ± 0.2 vs. 2.4 ± 0.2, respectively), and the area of renal interstitial fibrosis was significantly lower in CYP4A1 transgenic vs. SS rats (6% ± 1% vs. 18% ± 4%, respectively). Moreover, hypertensive CYP4A1 rats exhibited less podocyte foot process effacement and detachment than SS rats when examined by a transmission electron microscopy. These findings indicate that increased production of 20‐HETE has renoprotective effects in association with decreased EMT, preserved podocyte and glomerular barrier function. This study indicates that 20‐HETE is a potential novel pharmacological target and biomarker in hypertension and chronic kidney disease.Support or Funding InformationThis study was supported by grants HL36279 (RJR) and DK104184 (RJR), AG050049 (FF), P20GM104357 (RJR and FF) from the National Institutes of Health; 16GRNT31200036 (FF) from the American Heart Association.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq.

Background:Optimal prescribing of secondary prevention medications after acute coronary syndrome (ACS) events has been shown to reduce morbidity and mortality. However, it is unknown whether these medications are optimally prescribed at discharge from acute care in Iraq.Objective:To evaluate whether patients with ACS received optimal secondary prevention medications: antiplatelets, statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs), and beta-blockers at discharge from a cardiology unit, and to assess whether statins, ACEI/ARBs and beta-blockers were prescribed at target doses based on the American Heart Association/American College of Cardiology (AHA/ACC) guidelines.Methods:Observational retrospective cross-sectional study of patients with ACS admitted to a hospital in Baghdad and survived to discharge between May 2016 and January 2017. Patient-level data and secondary prevention medications at discharge were extracted from routine medical records. Optimal dosing was defined as ≥75%, moderate dosing as 50–74%, and low dosing as <50% of the target dose.Results:45.6% (200/439) of eligible patients were included in the study who were aged 25 to 90 years (mean 57.8 years) with 78.0% (156/200) being male. Of those included, 84.5% had a myocardial infarction and 15.5% unstable angina, and the length of hospital stay ranged from 1 to 29 days (median 4 days). In total, 53.5% of patients were prescribed all five secondary prevention medications at discharge, and after accounting for contraindications, 60.0% were treated according to AHA/ACC guidelines. The prescription rate of dual antiplatelet therapy, statins, ACEI/ARBs and beta-blockers was 92.5%, 94.5%, 69.5% and 87.0% respectively. Hypertension, diabetes mellitus and the prescription of oral nitrates were associated with the prescription of optimal secondary prevention therapy. Although 80.9% of patients were prescribed target doses of antiplatelets and statins, only 12.2% and 9.2% were prescribed target doses of ACEI/ARBs, and beta-blockers respectively.Conclusions:Approximately one in two patients received the recommended secondary prevention therapy. However, only a minority of patients were prescribed optimal doses of ACEI/ARBs and beta-blockers, in line with guidance. Quality improvement strategies should be implemented, which may include greater involvement of pharmacists within the cardiology multidisciplinary team.

THE OVERUSE OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN PATIENTS WITH CONFIRMED ISCHEMIC STROKE

The role of transesophageal echocardiography (TEE) in identifying ischemic stroke etiology is debated. In 2009, the American Heart Association/American Stroke Association issued a scientific statement for echocardiography, providing a class IIa recommendation. However, this recommendation came with

The association of metabolic syndrome components and diabetes mellitus: evidence from China National Stroke Screening and Prevention Project

BackgroundThe metabolic syndrome (MetS) is related with cardiovascular disease. However, its relationship with diabetes mellitus (DM) has not been examined in Chinese population with a larger sample. We aimed to assess the relationship between metabolic syndrome (MetS) and its components, and DM, and to determine the best one from the available definitions of Mets when assessing the risk of DM.MethodsThis was a cross-sectional survey in a nationally representative sample of 109,551 Chinese adults aged ≥40 years in 2014–15. MetS was defined according to three criteria including the updated International Diabetes Federation (IDF) criterion, the National Cholesterol Education Program Third Adult Treatment Panel (NCEP ATP III) criterion and American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) criterion. Logistic regression models were used to estimate the odds of DM.ResultsMetS as defined by three criteria including IDF, NCEP ATP III,and AHA/NHLBI all increased the prevalence of DM, and the adjusted ORs with 95% CI was more higher using NCEP ATP III (3.65, 3.52–3.79) than IDF (2.50, 2.41–2.60) and AHA/NHLBI (3.03, 2.92–3.24). The odds of DM was highest in hyperglycemia with cut-off glucose≥6.1 mmol/L (14.55, 13.97–15.16), and other components were also associated significantly with DM. There was heterogeneity for OR of DM associated with various trait combinations.ConclusionsThe NCEP ATPIII MetS definition may be more suitable for assessment of DM risk in Chinese population. Hyperglycemia, as previous study reported, are important risk factors of DM. Besides, other traits of Mets are also significantly associated with DM and should therefore be of greater concern.

American Heart Month - February 2019.

Heart disease is the leading cause of death for men and women in the United States, and heart attacks are a major category of heart disease; someone in the United States has a heart attack every 40 seconds (1). February is American Heart Month, an ideal time to remind all adults to focus on their hearts and encourage them, their families, friends, and communities to learn the important signs and symptoms of heart attack and how to respond. Recognizing that someone might be having a heart attack and calling emergency services (9-1-1) are crucial for optimizing access to lifesaving emergency cardiac care and receipt of advanced treatments and improving survival. Five common symptoms of a heart attack are 1) pain or discomfort in the jaw, neck, or back; 2) feeling weak, lightheaded, or faint; 3) chest pain or discomfort; 4) pain or discomfort in the arms or shoulder; and 5) shortness of breath. If someone is suspected to be having a heart attack, 9-1-1 should be called immediately.

Abstract TP343: Achieving Stroke Honor Role Elite Plus by Implementing a 24/7 Neuro-Hospitalist Program

Patients with acute ischemic stroke benefit most from intravenous tissue plasminogen activator (tPA) when given as fast as possible. The American Heart Association/American Stroke Association’s (AHA/ASA) highest target is the Stroke Honor Role Elite Plus. This is designed for programs that give IV tPA within 60 minutes in 75% of patients and within 45 minutes in 50% of patients. The current literature however is not clear on the benefit of a comprehensive 24/7 neurohospitalist model on the treatment times of acute ischemic stroke patients with IV tPA. The purpose of our study was to determine the impact of a 24/7 in-house neurohospitalist model on door-to-needle times (DTN) for patients with acute ischemic stroke presenting to the emergency department within 4.5 hours. There were 76 patients treated from 2016-2017 and 83 patients treated from 2017-2018, DTN times were compared before and after implementation of the neurohospitalist program in July 2017. The DTN in 2016-2017 (mean = 53.32 minutes, SD = 29, n =76) was greater than the DTN in 2017-2018 (mean = 44 minutes, SD = 20, n = 83). This difference was statistically significant with p = 0.010 (1 tail). In addition, the improvement in DTN allowed recognition of Stroke Honor Role Elite Plus by the AHA/ASA. Conclusion: Implementation of a 24/7 in-house neurohospitalist program is associated with faster DNT for IV tPA and ability to achieve target AHA/ASA’s Stroke Honor Role Elite Plus.

Abstract WP511: Using a Nurse Driven Protocol for Stroke Triage

Background: In 2013, the American Heart Association/American Stroke Association began a public awareness marketing campaign that included a tool; called F.A.S. T. The purpose was used to educate the public on stroke signs and symptoms and to go to the emergency department promptly for treatment. Prehospital personnel has stroke screening tools, such as Cincinnati Stroke Scale utilized locally. The health system stroke center utilized a nursing triage process using the acronym "FLASHED" to identify patients were exhibiting symptoms of stroke so that nurses would triage patients based on the acronym. F stands for facial asymmetry or droop; L is leg weakness or numbness. A is for arm weakness or numbness. S stands for speech deficits. H is for a severe headache without cause. E is for eyes; this includes all or part of the vision in one or both eyes. D stands for dizziness or loss of coordination if accompanied by any of the above symptoms. Purpose: The purpose of this study was to utilize a tool better suited for nursing for stroke identification in the ED setting. Identifying if patients that met the FLASHED criteria for stroke were appropriate for receiving an emergent evaluation for an acute stroke. Methods: A retrospective electronic record review of ED patients was used for this study. A content analysis included identification of symptom description and stroke one activations over a 24 month period. A patient arriving in the ED meeting FLASHED criteria resulted in stroke one activation with their last known well within 6 hours of arrival. Results: Over a 24 month period, nearly 500 Stroke One activations occurred. Of those activations, 3% did not meet the FLASHED criteria. 89.7% of all Stroke One Activations received a stroke workup by a neurologist. 56% of all activations resulted in the patient being discharged from either an inpatient or observation status with a stroke related diagnosis. Conclusion: Recognition of possible stroke patients based on symptoms upon arrival to the ED promptly is a priority for all EDs. A clear triage tool is essential to identify patients with stroke symptoms. While using FLASHED as this tool resulted in assessments, testing, and interventions further study is needed to determine the validity and reliability of the FLASHED tool.

Comparison of Clinical Care and In-Hospital Outcomes of Asian American and White Patients With Acute Ischemic Stroke

Although overall stroke incidence and mortality in the United States is improving, little is known about the characteristics and clinical outcomes of acute ischemic stroke in Asian American individuals. To compare the characteristics, care, and outcomes of Asian American and white patients with acute ischemic stroke. Retrospective analysis of Asian American and white patients admitted with a primary diagnosis of acute ischemic stroke to hospitals participating in the Get With The Guidelines-Stroke (GWTG-Stroke) program between April 1, 2004, and July 31, 2016. The GWTG-Stroke database is a prospectively collected stroke quality improvement registry sponsored by the American Heart Association/American Stroke Association. Multivariable logistic regression models assessed the association of Asian American race/ethnicity, clinical outcomes, and quality measures. The study population of 1 772 299 patients (mean [SD] age, 72.4 [14.2] years; 51.3% female) consisted of 64 337 Asian American patients (3.6%) and 1 707 962 white patients (96.4%) admitted to 2171 GWTG-Stroke hospitals with acute ischemic stroke. After adjustment for patient and hospital variables, Asian American patients were seen with greater stroke severity compared with white patients (National Institutes of Health Stroke Scale [NIHSS] score ≥16) (odds ratio [OR], 1.35; 95% CI, 1.30-1.40; P < .001), manifested higher in-hospital mortality (OR, 1.14; 95% CI, 1.09-1.19; P < .001), had longer length of stay (OR, 1.17; 95% CI, 1.14-1.20; P < .001), and were less likely to ambulate independently at discharge (OR, 0.84; 95% CI, 0.79-0.90; P < .001). Although Asian American patients had fewer intravenous tissue plasminogen activator (IV tPA) administrations than white patients (OR, 0.95; 95% CI, 0.91-0.98; P = .003), they had more symptomatic hemorrhage after tPA (OR, 1.36; 95% CI, 1.20-1.55; P < .001) and overall post-tPA complications (OR, 1.31; 95% CI, 1.18-1.46; P < .001). Asian American patients had better quality measure adherence overall than white patients, including rehabilitation (OR, 1.27; 95% CI, 1.18-1.36; P < .001), door to tPA within 60 minutes (OR, 1.14; 95% CI, 1.06-1.22; P < .001), and intensive statin therapy (OR, 1.14; 95% CI, 1.10-1.18; P < .001). After adjustment for stroke severity, Asian American patients had lower in-hospital mortality than white patients (OR, 0.95; 95% CI, 0.91-0.99; P = .008). Asian American patients manifested more severe ischemic strokes, were less likely to receive IV tPA, and had worse functional outcomes than white patients. These findings warrant additional research toward improving clinical outcomes for Asian American patients with acute ischemic stroke.