Burden Of Vascular Risk Factors Research Articles

Abstract WP224: Trends In Self-reported Stroke And Myocardial Infarction Prevalence And Associated Modifiable Risk Factors Within Race/ethnicity Strata In The United States From 2011-2019

Background: Stroke and myocardial infarction (MI) prevalence varies by race/ethnicity, as do the risk factors. Methods: We included biyearly data from the 2011-2019 Behavioral Risk Factor Surveillance System (BRFSS) surveys of adults (age ≥18) in the United States. We describe survey-weighted prevalence of self-reported stroke and MI by race and ethnicity. We also describe the prevalence of modifiable vascular risk factors in patients with stroke and MI. Results: The weighted number of U.S. participants represented in BRFSS surveys increased from 237,404,549 in 2011 to 251,703,709 in 2019. Stroke prevalence increased from 2.9% in 2011 to 3.4% in 2019 (<0.001), while MI prevalence did not change over time (4.3% in 2011; 4.2% in 2019). The prevalence of stroke and MI was highest in American Indian/Alaskan Natives (AI/AN) at 5.6% and 7.5% in 2011 and 2019, respectively, compared to 3.2% and 4.8% for whites (p<0.001). Prevalence trends by race/ethnicity are in Figure 1. Modifiable risk factors are in Tables 1&2, which show that AI/AN consistently have the highest or second highest proportion with ≥4 risk factors. Conclusion: Prevalence of self-reported stroke, but not MI, is increasing in the United States. AI/AN consistently had the highest prevalence from 2011-2019 and the highest overall burden of modifiable vascular risk factors, rendering this group more vulnerable to a recurrent vascular event.

Abstract WMP102: Prevalence Of Genetic Mutations In 15 Mendelian Stroke Genes In Young Stroke Patients

Introduction: Although the heritability of stroke might be higher in young-age stroke population, it is even uncertain how many of them has monogenic causes of stroke. We aimed to estimate the prevalence and clinical characteristics of 15 monogenic disorders associated with stroke in a large, unselected young-age stroke population Methods: From a prospective, nationwide, multicenter, acute stroke registry of consecutive patients admitted to 15 academic or regional stroke centers in Korea, we enrolled all patients aged 55 years or younger except those who refuse to participate in this study. We performed genetic analysis using a customized targeted next-generation sequencing panel ( GLA, NOTCH3, HTRA1, RNF213, ACVRL1, ENG, CBS, TREX1, ABCC6, COL4A1, FBN1, NF1, COL3A1, MT-TL1, and APP ) to find clinically relevant genetic variants, and reviewed clinical information of the patients. Results: Genetic analysis was performed in 1,033 patients (male 70.7%, mean age 45.8±7.9). Twenty-eight clinically relevant genetic variants were identified in 131 (12.7%) patients, and were found most frequently in RNF213 (59, 5.7%) followed by ABCC6 (53, 5.1%) and NOTCH3 (15, 1.5%). Genetic variants were more commonly observed in younger group than older group (17.1% vs. 9.3%, p=0.021), but were not different according to vascular risk factor burden. Patients with premature (<60y) family history of stroke had genetic variants more frequently than those with family history at ≥60y (23.7% vs. 11.4%, p=0.047). Typical neuroimaging abnormalities were observed in only 25% of patients with RNF213 variants and 27% of those with NOTCH3 variants. Variants of uncertain significance were found in 15.4%. Conclusion: Clinically relevant genetic variants were not uncommon than expected. We might have opportunities to improve our daily practice by genetic counseling patients and their families to reduce the future stroke.

Incidental DWI Lesions in Patients with Recent Small Subcortical Infarctions

ObjectivesIncidental acute ischemic lesions distinct from the primary neurological insult are identified on diffusion-weighted imaging (DWI) in a number of conditions where cerebral microvascular pathology plays a central role. Another major manifestation of cerebral small vessel disease (CSVD) is ischemic stroke named as recent small subcortical infarction (RSSI). In this study, we sought to identify the prevalence and predictors of incidental DWI lesions in patients with RSSI. Materials and MethodsWe retrospectively analyzed a consecutive series of acute ischemic stroke patients with DWI evidence of acute lesions solely localized to perforator artery territories. Images were evaluated for the presence of additional acute or subacute subcortical DWI lesions, apart from the symptomatic lesion. Clinical features including vascular risk factor burden, together with imaging markers of chronic CSVD, were compared among patients with and without incidental acute or subacute lesions. ResultsAmong 396 patients with no alternate stroke etiology additional incidental subcortical DWI bright lesions were identified in 74 (19%) cases. These lesions were primarily localized in the corona radiata, or centrum semiovale. Patients with incidental DWI lesions were more likely to have a history of hypertension, a higher white matter hyperintensities burden in the periventricular and subcortical region, higher perivascular spaces burden in the basal ganglia, multiple cerebral microbleeds, and multiple chronic lacunes. Presence of multiple chronic lacunes (OR 5.98, 95% CI 3.18-11.24) and ≥2 vascular risk factors (OR 2.03, 95% CI 1.05-3.91) stood out as features significantly associated with incidental DWI lesions in multivariate analysis. ConclusionsOur study shows that acute or subacute ischemic lesions can be incidentally detected in approximately one-fifth of patients with RSSI. This observation suggests that the course of CSVD might be more active, temporally and spatially, in a distinct subgroup of RSSI patients, specifically those with a higher chronic lacune and vascular risk factor burden.

Association of tau pathology and vascular risk factor burden with longitudinal measures of plasma neurofilament light

AbstractBackgroundIn the context of Alzheimer’s disease (AD), tau pathology is a major driver of the neurodegenerative cascade that ultimately leads to loss of neurons and synapses. In fact, studies have shown that neurodegeneration is more strongly associated with tau pathology than amyloid‐β (Aβ) accumulation. Although plasma neurofilament light (NfL) is a neuroaxonal damage biomarker that currently is in the research spotlight, the factors influencing the association between its longitudinal trajectory and tau pathology remains unclear. Since vascular risk factors (VRFs) present an important role in AD etiology and progression, here we aimed to determine whether tau pathology, in combination with or independently of VRF burden, is associated with longitudinal plasma NfL trajectory.MethodWe assessed 901 participants [276 CU, 455 MCI and 170 AD] from ADNI with baseline plasma p‐tau181 and [18F]AV45 Aβ‐PET, as well as longitudinal plasma NfL measurements (up to 4 years). Baseline VRF burden was calculated considering the history for cardiovascular disease, hypertension, diabetes mellitus, hyperlipidemia, stroke or transient ischemic attack, smoking, atrial fibrillation and left ventricular hypertrophy. Individuals were dichotomized as following: elevated VRF burden if ≥2 VRFs (V+), tau positive if plasma p‐tau181 ≥ 17.7 pg/mL (T+) and amyloid positive if global Aβ‐PET SUVR ≥ 1.11 (A+). Subjects who were A‐T+ were excluded. Linear mixed‐effects models (LMMs) were performed to evaluate plasma NfL’s longitudinal trajectories.ResultThe LMMs demonstrated that tau positivity (T+) was significantly associated with a higher rate of longitudinal increase in plasma NfL levels in comparison to the tau‐negative group (Fig. 1). However, analysis dividing the groups both by tau and VRF burden status demonstrated that the rates of increase in plasma NfL were greater only in the presence of both VRF burden and tau positivity (T+V+; t‐value=2.54, p<0.05), when compared to the reference group (T‐V‐; Fig. 2). Moreover, specific slope‐contrast analyses confirmed that only the T+V+ group presented a clearly separate trajectory.ConclusionOur findings suggest that an elevated VRF burden influences the relation between tau pathology and neurodegeneration in AD.Therefore, tau‐mediated neurodegeneration seems to be most relevant in combination with vascular‐mediated neuroaxonal injury. These findings reinforce the pivotal contribution of vascular pathology to AD development.

Lower regional cerebrovascular reactivity relates to worse episodic memory among older adults

AbstractBackgroundCerebrovascular reactivity (CVR) measures the ability of the cerebrovasculature to respond to vasoactive stimuli. Decreased CVR in the default mode network (DMN) has been associated with increased vascular risk factor burden. DMN connectivity is fundamentally dependent on vascular compliance, which can be altered in MCI, and may impact episodic memory consolidation. This study cross‐sectionally evaluated whether the topography of CVR is associated with episodic memory performance.MethodVanderbilt Memory & Aging Project participants free of stroke were included (n=117, 76.0±7.3 years, 46% female). Participants underwent neuropsychological assessment and multimodal 3T brain MRI, including T1‐weighted imaging and T2*‐weighted blood‐oxygenation level‐dependent (BOLD‐fMRI) for quantifying CVR. During the BOLD‐fMRI acquisition, a hypercapnic normoxic respiratory challenge was administered by alternating normocapnic normoxia and hypercapnic normoxia (5% CO2/95%‐air) in 90s blocks. BOLD‐fMRI data were time‐delay processed, yielding whole‐brain mapping of the maximum correlation with the gas stimulus (CVRMAX) and time‐to‐max CVR (CVRDELAY). Mean CVR metrics were calculated in atlas‐derived DMN regions. Ordinary least squares regression models related DMN‐CVR to episodic memory performance adjusting for demographics, Framingham Stroke Risk Profile, and apolipoprotein E‐e4 status. Clusters were corrected using family‐wise‐error rate p<0.05.ResultDMN‐CVRMAX was related to episodic memory performance (b=1.0x10‐3, p=0.03) but DMN‐CVRDELAY was not (p=0.09). In voxelwise analysis relating CVRMAX to memory, seven clusters surviving correction were identified, all suggesting lower CVRMAX related to worse memory performance. The peak value of the top cluster was located in the middle temporal gyrus. In voxelwise analysis relating CVRDELAY to memory, 11 clusters surviving correction were identified, all indicating longer CVRDELAY related to worse memory performance. The peak value of the top cluster was located in postcentral gyrus.ConclusionAmong older adults, lower DMN‐CVRMAX is associated with worse episodic memory performance and this association is not confined to the DMN. Associations between regionally reduced vascular compliance and episodic memory may result from vascular impairment of large‐scale brain networks such as the DMN, though these associations should be further explored. T32‐AG058524, IIRG‐08‐88733, R01‐AG034962, R01‐NS100980, K24‐AG046373, P20‐AG068082

The Age-Dependent Association Between Vascular Risk Factors and Depressed Mood.

Cumulative burden of vascular risk factors (VRFs) has been linked to an increased risk of depressed mood. However, the role of age in this association is still unclear. Here, we investigated whether VRF burden is associated with levels and changes in depressed mood and whether these associations become stronger or weaker from mid- to later life. We used longitudinal data from 5,689 participants (52-89 years) of the English Longitudinal Study of Ageing. A composite score incorporated the presence of 5 VRFs: hypertension, diabetes, smoking, obesity, and hypercholesterolemia. Second-order latent growth models were used to test whether levels and changes of depressed mood differed as a function of baseline VRF burden, and whether these associations were moderated by age. Baseline VRF burden showed a small association with higher levels of depressed mood (estimate = 0.081; 95% CI: 0.024, 0.138, p = .005). This association varied with age, such that it was stronger in midlife compared to later life (estimate = -0.007; 95% CI: -0.013, -0.002, p = .017). There was no evidence that VRF burden was associated with changes in depressed mood. Our findings suggest that VRF burden in midlife, but less so in later life, predicts individual differences in depressed mood. These findings are consistent with reports on the importance of midlife VRFs and support the idea that promotion of vascular health in this age group or earlier in life may be critical to maintain mental health across adulthood.

Ischemic Stroke, Inflammation, and Endotheliopathy in COVID-19 Patients.

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May 2021 Stroke Highlights

May 2021 <i>Stroke</i> Highlights

Do Associations Between Vascular Risk and Mild Cognitive Impairment Vary by Race?

Objectives: Given prevalence differences of mild cognitive impairment (MCI) among Black and white older adults, this study aimed to examine whether overall vascular risk factor (VRF) burden and individual VRF associations with amnestic (aMCI) and nonamnestic (naMCI) MCI status varied by Black/white race. Methods: Participants included 2755 older adults without dementia from the ACTIVE study. Comprehensive neuropsychological criteria were used to classify cognitively normal, aMCI, and naMCI. VRFs were primarily defined using subjective report and medication data. Multinomial logistic regression was run predicting MCI subtype. Results: Greater overall VRF burden, high cholesterol, and obesity evinced greater odds of naMCI in Black participants than whites. Across participants, diabetes and hypertension were associated with increased odds of aMCI and naMCI, respectively. Discussion: Results may reflect known systemic inequities on dimensions of social determinants of health for Black older adults. Continued efforts toward examining underlying mechanisms contributing to these findings are critical.

White matter hyperintensity in middle-age adults (40–59 years) and risk factors for cerebrovascular disease

Introduction. White matter hyperintensity (WMH) is a neuroimaging age-related phenomenon associated with an increased cardiovascular risk in people with arterial hypertension (AH). The prevalence of WMH and its relationship with risk factors for cerebrovascular disease (CVD) in middle-age population requires clarification. Aim: to assess the prevalence of the WMH phenomenon in people of working age (40–59 years) and to establish cerebrovascular risk factors associated with its development. Material and methods. Study cohort (n = 376; 156 (41.5%) men and 220 (58.5%) women; mean age 49.7 ± 5.0 years) was formed by screening an open population (40–59 years of age). Using a questionnaire and clinical, laboratory and instrumental findings, including brain MRI (1T), the prevalence of cardiovascular and cerebrovascular risk factors was analyzed. The odds ratio (OR) of the event occurring and a 95% confidence interval were calculated. Results. High prevalence of risk factors was revealed in the age group of 40–59 years, including AH in 46.7%, increased body mass index (BMI) in 60.6%, dyslipidemia (up to 39%), metabolic syndrome in 21.5%, thickening of the intima-media complex in 57.2%, atherosclerotic plaques in 49.7% of all cases. WMH was identified in 32% (120/376) of the subjects examined. An association between presence, severity of WMH and age, presence and severity of AH, as well as total burden of vascular risk factors was established. The most significant factors associated with the development of WMH in people aged 40–59 were found to be AH (OR 3.35), atherosclerosis of the brachiocephalic arteries (OR 1.79), and hyperglycemia (OR 1.36). Conclusion. Thus, there is a high prevalence of risk factors for cardiovascular and cerebrovascular diseases in the working-age population of the megalopolis (Moscow) at the age of 40–59 years, which is associated with accelerated WMH formation. Significant factors that are associated with WMH are AH, atherosclerosis of the brachiocephalic arteries, hyperglycemia, as well as dyslipidemia and metabolic syndrome. Early detection and management of the listed modifiable risk factors are necessary to prevent the development and progression of cerebral injury.

Design of the Shunyi study on cardiovascular disease and age-related brain changes: a community-based, prospective, cohort study.

BackgroundRapid economic growth and increasing lifespan have contributed to an increasing burden of chronic non-communicable diseases in China. Population-based studies focusing on cardiovascular disease and age-related brain changes, with extensive clinical, genetic, and imaging data as well as a comprehensive evaluation of brain function are lacking in China. The Shunyi cohort study aimed to investigate the determinants and consequences of cardiovascular disease and age-related brain alterations among individuals residing in a rural area of Beijing.MethodsThis prospective, community-based study included individuals aged 35 years and older living in five villages in Shunyi, a rural district located 20 miles from urban Beijing. A total of 1,586 individuals were enrolled between June 2013 and September 2014. Biological samples and brain magnetic resonance images were collected along with baseline clinical data through face-to-face interviews. Whole exome sequencing and quantitative assessments of cognitive and motor function were performed.ResultsAmong the 1,586 participants included, 40% were men, and the mean age of the cohort was 56.7±10.0 years. This population had a relatively low education level. A heavy burden of vascular risk factors with a low control rate was observed in the Shunyi population. Since 2017, the cohort has been followed up annually. As of October 2019, we had failed to obtain the follow-up data of five participants.ConclusionsWith an extensive range of clinical, genetic, and imaging data, the Shunyi cohort study has the potential to contribute significantly towards identifying the causes and consequences of cardiovascular disease and age-related brain changes in older people in China.

Association of Low Systolic Blood Pressure with Postmortem Amyloid-β and Tau.

Vascular mechanisms may contribute to the accumulation of AD pathology. We examined whether the burden of vascular risk factors proximate to death is associated with amyloid-β and tau levels or modified their known association. We examined the brains of 1, 585 participants from two longitudinal community-based studies of older adults. Amyloid-β and tau were quantified by postmortem examination. The burden of vascular risk factors was summarized by calculating the Framingham general cardiovascular risk score (FRS) proximate to death. Using linear regressions, we examined the association of the FRS with the amyloid-β and tau levels and examined if the FRS modified the association of the amyloid-β with tau. On average, participants were nearly 90 years old and two-thirds were women. The FRS was not associated with amyloid-β (Spearman r = -0.00, p = 0.918) or tau (r = 0.01, p = 0.701). However, the FRS as a whole (estimate = -0.022, SE = 0.008, p = 0.009), and specifically the systolic blood pressure (SBP) component (estimate = -0.033, SE = 0.012, p = 0.009), modified the association of the amyloid-β with tau. Further analysis showed that the association between amyloid-β and tau was stronger at lower levels of SBP. Late-life vascular risk scores were not related to postmortem levels of amyloid-β or tau. However, lower levels of vascular risk scores and SBP were associated with a stronger association between amyloid-β and tau. These data suggest that vascular risk factors may modify the relation of AD pathology markers to one another.

The effect of vascular risk factor burden on the severity of COVID-19 illness, a retrospective cohort study

BackgroundPatients with cardiovascular comorbidities are at high risk of poor outcome from COVID-19. However, how the burden (number) of vascular risk factors influences the risk of severe COVID-19 disease remains unresolved. Our aim was to investigate the association of severe COVID-19 illness with vascular risk factor burden.MethodsWe included 164 (61.8 ± 13.6 years) patients with COVID-19 in this retrospective study. We compared the difference in clinical characteristics, laboratory findings and chest computed tomography (CT) findings between patients with severe and non-severe COVID-19 illness. We evaluated the association between the number of vascular risk factors and the development of severe COVID-19 disease, using a Cox regression model.ResultsSixteen (9.8%) patients had no vascular risk factors; 38 (23.2%) had 1; 58 (35.4%) had 2; 34 (20.7%) had 3; and 18 (10.9%) had ≥4 risk factors. Twenty-nine patients (17.7%) experienced severe COVID-19 disease with a median (14 [7–27] days) duration between onset to developing severe COVID-19 disease, an event rate of 4.47 per 1000-patient days (95%CI 3.10–6.43). Kaplan-Meier curves showed a gradual increase in the risk of severe COVID-19 illness (log-rank P < 0.001) stratified by the number of vascular risk factors. After adjustment for age, sex, and comorbidities as potential confounders, vascular risk factor burden remained associated with an increasing risk of severe COVID-19 illness.ConclusionsPatients with increasing vascular risk factor burden have an increasing risk of severe COVID-19 disease, and this population might benefit from specific COVID-19 prevention (e.g., self-isolation) and early hospital treatment measures.

Abstract 15: Trends in Atrial Fibrillation-related Cardiovascular Mortality Rates in The United States: 1999-2017

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia in adults and the prevalence is increasing due to the aging of the population and the growing burden of vascular risk factors. Although deaths due to cardiovascular disease (CVD) death have dramatically decreased in recent years, trends in AF-related CVD death has not been previously investigated. Purpose: We sought to quantify trends in AF-related CVD death rates in the United States. Methods: AF-related CVD death was ascertained using the CDC WONDER online database. AF-related CVD deaths were identified by listing CVD (I00-I78) as underlying cause of death and AF (I48) as contributing cause of death among persons aged 35 to 84 years. We calculated age-adjusted mortality rates (AAMR) per 100,000 population, and examined trends over time estimating average annual percent change (AAPC) using Joinpoint Regression Program (National Cancer Institute). Subgroup analyses were performed to compare AAMRs by sex-race (black and white men and women) and across two age groups (younger: 35-64 years, older 65-84 years). Results: A total of 522,104 AF-related CVD deaths were identified between 1999 and 2017. AAMR increased from 16.0 to 22.2 per 100,000 from 1999 to 2017 with an acceleration following an inflection point in 2009. AAPC before 2009 was significantly lower than that after 2009 [0.4% (95% CI, 0.0 - 0.7) vs 3.5% (95% CI, 3.1 - 3.9), p &lt; 0.001). The increase of AAMR was observed across black and white men and women overall and in both age groups (FIGURE), with a more pronounced increase in black men and white men. Black men had the highest AAMR among the younger decedents, whereas white men had the highest AAMR among the older decedents. Conclusion: This study revealed that death rate for AF-related CVD has increased over the last two decades and that there are greater black-white disparities in younger decedents (&lt;65 years). Targeting equitable risk factor reduction that predisposes to AF and CVD mortality is needed to reduce observed health inequities.

Author response: WMH and long-term outcomes in ischemic stroke: A systematic review and meta-analysis.

We thank Dr. Gupta for the interest in our article1 and for raising important issues about alternative causes of white matter hyperintensities (WMH) other than small vessel disease (SVD). Indeed, migraine, hypertensive encephalopathy, eclampsia, and therapy with immunomodulatory agents may cause temporary WMH lesions. Yet, the prevalence of WMH lesions in the general population increases substantially with age because of the increasing underlying burden of SVD.2,3 In our article, we refer to WMH in a specific population of patients with ischemic stroke. Given the relatively old age and the high burden of vascular risk factors of this population, we believe that most WMH lesions in the original studies entered our meta-analysis to represent manifestations of SVD.

Systematic development of structured semi-interactive stroke prevention package for secondary stroke prevention

Background:Lack of compliance to medication and uncontrolled risk factors are associated with increased risk of recurrent stroke and acute coronary syndrome in patients with recent stroke. Multimodal patient education may be a strategy to improve the compliance to medication and early adoption of nonpharmacological measures to reduce the vascular risk factor burden in patients with stroke. We thus aim to develop multilingual short messaging services (SMS), print, and audio-visual secondary stroke prevention patient education package. The efficacy of the package will be tested in a randomized control trial to prevent major cardiovascular and cerebrovascular events.Methods:In the formative stage, intervention materials (SMS, video, and workbook) were developed. In the acceptability stage, the package was independently assessed and modified by the stakeholders involved in the stroke patient care and local language experts. The modified stroke prevention package was tested for implementation issues (implementation stage).Results:Sixty-nine SMS, six videos, and workbook with 11 chapters with 15 activities were developed in English language with a mean ± SD SMOG index of 9.1 ± 0.4. A total of 355 stakeholders including patients (24.8%), caregivers (24.8%), doctors (10.4%), nurses (14.1%), local language experts (2.8%), physiotherapists (13.2%), and research coordinators (9.8%) participated in 10 acceptability stage meetings. The mean Patient Education Material Assessment Tool understandability score in all languages for SMS, video scripts, and workbook was 95.2 ± 2.6%, 95.2 ± 4.4%, and 95.3 ± 3.6%, respectively. The patients [n = 20, mean age of 70.3 ± 10.6 years and median interquartile range (IQR) baseline NIHSS 1 (0–3)] or the research coordinators (n = 2) noted no implementation issues at the end of 1 month.Conclusion:An implementable complex multilingual patient education material could be developed in a stepwise manner. The efficacy of the package to prevent major adverse cardiovascular events is being tested in the SPRINT INDIA study.

Mid-life and late-life vascular risk factor burden and neuropathology in old age.

ObjectiveTo determine whether vascular risk factor burden in mid‐ or late‐life associates with postmortem vascular and neurodegenerative pathologies in a community‐based sample.MethodsWe studied participants from the Framingham Heart Study who participated in our voluntary brain bank program. Overall vascular risk factor burden was calculated using the Framingham Stroke Risk Profile (FSRP). Mid‐life FSRP was measured at 50 to 60 years of age. Following death, brains were autopsied and semi‐quantitatively assessed by board‐certified neuropathologists for cerebrovascular outcomes (cortical infarcts, subcortical infarcts, atherosclerosis, arteriosclerosis) and Alzheimer’s disease pathology (Braak stage, cerebral amyloid angiopathy, and neuritic plaque score). We estimated adjusted odds ratios between vascular risk burden (at mid‐life and before death) and neuropathological outcomes using logistic and proportional‐odds logistic models.ResultsThe median time interval between FSRP and death was 33.4 years for mid‐life FSRP and 4.4 years for final FSRP measurement before death. Higher mid‐life vascular risk burden was associated with increased odds of all cerebrovascular pathology, even with adjustment for vascular risk burden before death. Late‐life vascular risk burden was associated with increased odds of cortical infarcts (OR [95% CI]: 1.04 [1.00, 1.08]) and arteriosclerosis stage (OR [95% CI]: 1.03 [1.00, 1.05]). Mid‐life vascular risk burden was not associated with Alzheimer’s disease pathology, though late‐life vascular risk burden was associated with increased odds of higher Braak stage (OR [95% CI]: 1.03 [1.01, 1.05]).InterpretationMid‐life vascular risk burden was predictive of cerebrovascular but not Alzheimer’s disease neuropathology, even after adjustment for vascular risk factors before death.

127 Modifiable Cardiovascular Risk Profile in People with Mild Cognitive Symptoms Attending a Memory Service - an Opportunity to Promote Brain Health

Abstract Background Current evidence strongly implicates the burden of vascular risk factors (VRF) in the development of stroke, cognitive decline and dementia. This effect is mediated through several mechanisms, including amyloidogenesis, chronic neuroinflamation, cerebral perfusion and white-matter changes. Vascular risk profiling is well-embedded in stroke and cardiac services, but less so in memory services. Methods A review of established modifiable VRF (hypercholesterolemia, Body Mass Index (BMI), hypertension, HbA1c, smoking and alcohol habits) of people with mild cognitive complaints (mild cognitive impairment and subjective memory decline) in a memory service was performed. Risk factors measured in clinic were classified as: systolic ≥140mmHg / diastolic ≥90mmHg hypertension; LDL cholesterol &gt;3mmol/l; HbA1c &gt;39mmol/mol; weekly alcohol &gt;21units; smoking and BMI &gt;24.9kg/m2. Data was recorded and analysed using Microsoft Excel. Results Thirty-seven people, including 16 females (mean age 71.4, range of 49-83 years), were reviewed. 13/37 (35%) were aged ≤69 years. A total of 91 VRFs were identified in the study population. 29/37 (78%) had ≥2 VRF present. 3/37 (8%) had five VRF. 18/37 (49%) had prior history of either stroke, vascular or heart disease. Five of thirty-seven, (13.5%) and 13/37 (35%) were current and ex-smokers respectively, 2/37 (5%) consumed excess alcohol, 24/37 (65%) had elevated BMI and 11/37 (30%) had elevated LDL cholesterol. 21/37 (57%) had hypertension. Of these, 11/21 were known but poorly-controlled and 10/21 were identified de novo. All of the 32% (12/37) who had hyperglycaemia were de novo. Conclusion This study highlights the high prevalence of unidentified or poorly controlled VRF in people with mild cognitive symptoms attending a memory service. Given its importance to brain health and mitigation of future cognitive decline, a structured focus on identifying and managing these VRF in this setting is necessary. Exercise-based lifestyle programs should be embedded in post-diagnostic services for this population.

Adults With Complex Congenital Heart Disease: Cerebrovascular Considerations for the Neurologist.

As infant and childhood mortality has decreased in congenital heart disease, this population is increasingly reaching adulthood. Adults with congenital heart disease (ACHD) represent a group with increased risk of stroke, silent brain infarcts, and vascular cognitive impairment. Cyanotic and other complex cardiac lesions confer the greatest risk of these cerebrovascular insults. ACHD patients, in addition to having an increased risk of stroke from structural cardiac issues and associated physiological changes, may have an accelerated burden of conventional vascular risk factors, including hypertension and impaired glucose metabolism. Adult neurologists should be aware of the risks of clinically evident and subclinical cerebrovascular disease in this population. We review the existing evidence on primary and secondary stroke prevention in individuals with complex congenital heart disease, and identify knowledge gaps in need of further research, including treatment of acute stroke in this population. Multisystemic genetic syndromes are outside the scope of this review.

Risk of Atrial Fibrillation in Black Versus White Medicare Beneficiaries With Implanted Cardiac Devices.

BackgroundBlack individuals in the United States experience higher rates of ischemic stroke than other racial groups but have lower rates of clinically apparent atrial fibrillation (AF). It is unclear whether blacks truly have less AF or simply more undiagnosed AF.Methods and ResultsWe performed a retrospective cohort study using inpatient and outpatient claims from 2009 to 2015 for a 5% nationally representative sample of Medicare beneficiaries. We included patients aged ≥66 years with at least 1 documented Current Procedural Terminology code for interrogation of an implantable pacemaker, cardioverter‐defibrillator, or loop recorder and no documented history of AF, atrial flutter, or stroke before their first device interrogation. Kaplan–Meier statistics and Cox proportional hazards models were used to examine the association between black race and the composite outcome of AF or atrial flutter while adjusting for age, sex, and vascular risk factors. Among 47 417 eligible patients, the annual incidence of AF/atrial flutter was 12.2 (95% CI, 11.5–13.1) per 100 person‐years among blacks and 17.6 (95% CI, 17.4–17.9) per 100 person‐years among non‐black beneficiaries. After adjustment for confounders, black beneficiaries faced a lower hazard of AF/atrial flutter than non‐black beneficiaries (hazard ratio, 0.75; 95% CI, 0.70–0.80). Despite the lower risk of AF, black patients faced a higher hazard of ischemic stroke (hazard ratio, 1.37; 95% CI, 1.22–1.53).ConclusionsAmong Medicare beneficiaries with implanted cardiac devices capable of detecting atrial rhythm, black patients had a lower incidence of AF despite a higher burden of vascular risk factors and a higher risk of stroke.