Difference In Stroke Rate Research Articles

Abstract 20031: Transcatheter Aortic Valve Replacement Using Transfemoral vs Transapical Approach: A comprehensive Meta-analysis Comparing 30-day & 1-year Cerebrovascular Event Rates

Background: Transcatheter Aortic valve replacement (TAVR) has emerged as new technique for the management of patient with severe Aortic Stenosis (AS). Stroke is a potential complication associated with the procedure, when performed via both transfemoral (TF) and transapical approach (TA). Due to limited data, we performed a comprehensive meta-analysis comparing 30-day and 1-year stroke rates with TAVR performed using TF vs TA approach. Methods: We searched SCOPUS since inception to July 2014 using pre-defined criteria. The cerebrovascular event rates and type were estimated at different time points using standard random effects model. Results: 5 studies, with total 1956 valves placed, reported 30-day stroke rates with TA approach, and 9 studies, with 1146 valves, reported stroke rates with TF approach. No significant difference (p=0.313) was noted with TA vs TF approach with stroke rates 1.74 (0.61-2.87), 1.52 (0.71-2.33) respectively (Figure 1, Panel A). Similarly, 4 studies, with total 1657 valves, reported 1-year stroke rates with TA approach, and 8 studies, with 1034 valves, reported stroke using TF approach. Again, no significant difference (p=0.161) was noted with TA vs TF approach with adjusted stroke rates 3.78 (1.72-5.85), 3.11 (1.49-4.74) respectively (Figure 1, Panel B). Conclusion: We did not observe any difference in stroke rates when TAVR is performed using transapical versus transfemoral approach.

Transcatheter aortic valve implantation: emerging role in poor left ventricular function severe aortic stenosis?

Surgical aortic valve replacement (AVR) has long been recognized as the gold standard treatment for symptomatic severe aortic stenosis improving symptoms, survival and functional class. Recently, transcatheter aortic valve implantation (TAVI) has also become an established procedure for the treatment of higher risk patients with symptomatic severe aortic stenosis.1 These include the frail, elderly patient with multiple co-morbidities and disabilities. TAVI has been shown to successfully reduce aortic valve gradients to a similar degree as conventional AVR but the incidence of paravalvular aortic regurgitation (AR) is significantly higher.2, 3 Compared to conventional AVR, TAVI has a shorter recovery period, avoids a sternotomy and cardiopulmonary bypass, and has a lower risk of bleeding, acute kidney injury, atrial fibrillation and early mortality, but the risk of vascular complications, pacemaker implantations and cardiac perforations are higher.1, 3 Stroke rates were initially reported to be higher following TAVI compared to conventional AVR but recent studies suggest no difference in stroke rates.3

The influence of the breathing action on net drag force production in front crawl swimming.

20 elite swimmers completed a total of 6 randomized net drag force trials in 2 conditions (i) 3 breathing and (ii) 3 non-breathing. Net drag force was measured using an assisted motorized dynamometer device mounted upon a Kistler force-platform. The male participants demonstrated no statistical differences in stroke rates between breathing and non-breathing trials. Female participants, however, demonstrated a statistical difference stroke rate. The male participants demonstrated that the breathing action caused a greater (26%) net drag force compared to the females (16%). To further understand the influence of breathing on swimming technique, each stroke was analyzed and comparisons were made between the breathing and non-breathing conditions. The male participants demonstrated a similar minimum net drag force when comparing the breathing and non-breathing conditions. Analysis showed that minimum net drag force and maximum net drag force for the males changed when integrating the breathing action, while female participants demonstrated similar swimming technique, regardless of condition or stroke.

Abstract 9273: Meta-Analysis of Stroke After Transradial Versus Transfemoral Artery Catheterization

Objectives: To assess the risk of stroke after transradial (TR) versus transfemoral (TF) artery cardiac catheterization. Background: TR catheterization is gaining popularity due to its association with lower bleeding and access site complications, improved patient comfort, and lower costs compared to TF catheterization; however, there is concern that TR catheterization may be associated with an increased risk of neurological complications. Methods: We conducted a meta-analysis of randomized studies published until 2013 reporting risk of stroke in TR vs. TF catheterization. Results: Data from 11,273 patients in 13 studies were collated. The majority of patients were men, and 8,987 (79.7%) were enrolled in acute coronary syndrome trials. Very few patients had a history of prior coronary artery bypass grafting, and approximately 2/3 of patients underwent percutaneous coronary intervention. Stroke occurred in 25 of 5,659 patients in the TR group, vs. 24 of 5,614 patients in the TF group. There was no difference in stroke rates between the TR and TF groups ( Figure , risk difference 0.00%, 95% confidence interval -0.29% - 0.25%, p=0.88). This finding was consistent in a number of sensitivity analyses (excluding non-ST elevation acute coronary syndrome (ACS) trials, non-ACS trials, trials reporting in-hospital events or 30-day events, trials requiring radial expertise). Conclusions: TR catheterization is not associated with a significant increase in stroke compared to TF catheterization.

The FREEDOM trial: a definitive answer to coronary artery bypass grafting or stents in patients with diabetes and multivessel coronary artery disease

For the last two decades, there has been intense debate between cardiologists and surgeons regarding what the most effective mode is, of revascularization in patients with diabetes already receiving optimal medical therapy, who additionally require invasive coronary artery intervention on symptomatic and/or prognostic grounds. The debate began in earnest with the original interim analyses of the BARI trial, suggesting a survival advantage for the subset of patients with diabetes receiving coronary artery bypass grafting (CABG) rather than angioplasty [1], and was confirmed in the final 10-year follow-up with respective survival rates of 58 vs 46% (P=0.025) [2]. Since then, the recent publications of the 5-year outcomes of the SYNTAX Trial [3] and the ASCERT registry [4 ]h ave provided strong evidence that CABG, in comparison with percutaneous coronary intervention (PCI), offers a strong survival benefi ta s well as a marked reduction in myocardial infarction (MI) and repeat revascularization in patients with intermediate and more severe coronary artery disease (CAD) as judged by SYNTAX scores of >22. Because of the perception that patients with diabetes often have more severe and aggressive forms of CAD, intuitively there is an impression that they are also therefore likely to derive greater clinical benefit from CABG than from PCI. Others have argued, however, that significant advances in both medical therapy and stent technology would have eliminated the former—if any— benefit of CABG over PCI. Consequently, until the recent publication of the FREEDOM Trial [5], the relative merits of both interventions in patients with diabetes have also been fiercely debated. The main reason for the controversy was that, until the FREEDOM Trial, there was not a single trial in patients with diabetes, adequately powered, to give a definitive answer regarding whether CABG offered a survival or any other clinical benefit over PCI. It is therefore informative not only to examine the results of the FREEDOM trial, but also in the context of whether its findings are consistent with other evidence. The FREEDOM trial randomized 1900 patients with diabetes and multivessel CAD, already receiving aggressive medical therapy, to CABG or PCI with drug-eluting stents. This trial therefore included more patients with diabetes than the total from all the subgroups from the other randomized trials. The primary 5-year composite outcome of death from any cause, non-fatal MI or stroke, occurred in 26.6% of the PCI group and 18.7% of the CABG group (P=0.005). The benefit of CABG was driven by superior outcomes in both rates of death from any cause (10.6 vs 14.9%; P= 0.049) and MI (6.0 vs 13.9%; P< 0.001), but at the cost of a higher risk of stroke in the CABG group (5.2 vs 2.4%; P=0.03). And it is important to appreciate that this benefit of CABG over PCI was still evident although all patients were receiving aggressive medical therapy. It is alsoworth noting the relative risk of non-fatal stroke between CABG and PCI was 2.41 at 1 year, narrowing to 1.72 at 5 years [5]. The absolute clinical difference in stroke rates between CABG and PCI was actually small, being 2.1% (30 of 1444) and 0.82% (12 of 1471), respectively, at 1 year and 4.8% (65 of 1344) and 2.8% (42 of 1500) at 5 years. The early difference in stroke is almost certainly a consequence of the very well-recognized perioperative risk of stroke with CABG, with subsequent rates being more similar between the interventions. The same phenomenon was observed in the SYNTAX trial with CABG patients receiving less in the way of single and dual anti-platelet medication in the postoperative period [5]. Are the results of the FREEDOM trial consistent with other evidence? The answer is overwhelmingly, yes, from several other sources. Probably, the second-most definitive piece of evidence regarding the relative benefits of interventions in patients with diabetes is a subset analysis of the collaborative analysis of individual patient data from 7812 patients from 10 trials, of whom 1243 had diabetes, by Hlatky and co-workers. At a median follow-up of 5.9 years, mortality was substantially lower in the CABG group than in the PCI group (hazard ratio [HR]: 0.70, 95% confidence interval [CI]: 0.56–0.87) [6]. Since this analysis, several other pieces of data have emerged supporting the use of CABG rather than PCI in patients with diabetes. In the BARI 2D trial, 2368 patients with both type 2 diabetes and CAD were randomized to intensive medical therapy alone or to additionally undergo either prompt revascularization with PCI or CABG, according to the preference of the treating physician [7]. At 5 years, there was no significant difference in the composite primary end point between the PCI and medical therapy groups. In contrast, in the CABG group, the rate of major cardiovascular

Application of STREAM trial in management of acute myocardial infarction in real world practice

Primary PCI has been consistently superior to thrombolytic therapy within 3 h of onset of ST-segment elevation myocardial infarction (STEMI). However, primary PCI is beset with several problems. There is issue of lack of availability of cath lab enabled centers with huge delays in transfers of these patients to such centers. This issue is especially relevant in developing countries with limited accessibility to cath labs. Further, there is an issue of off-hours emergency PCI which seems to have a worse outcome than daytime procedures. Last but not the least, many physicians feel rushed with need to do primary PCI and would love to get some breathing space to consider other options, such as CABG and medical therapy. Facilitated PCI (PCI after thrombolysis) was supposed to address several of these issues particularly time delays with PCI but the results from several trials were rather disappointing (particularly related to high bleeding risks with this approach).1 On the other hand, pharmacoinvasive PCI is a strategy wherein patients are transferred to the major PCI center without the decision being made for automatic immediate PCI on arrival. TRANSFER AMI trial showed that this kind of therapy (dual thrombolytic and PVI strategy) could be effective and bleeding risks significantly reduced if PCI was performed at least 3 h after administration of thrombolysis.2 In the current article on the Strategic Reperfusion Early after Myocardial Infarction (STREAM) study, Armstrong et al describe a strategy of pre-hospital thrombolysis coupled with coronary angiography and primary PCI in patients with STEMI who presented within 3 h after symptom onset and who could not undergo PCI within 1 h after the first medical contact.3 They demonstrate that this strategy is at least as effective as that undertaking primary PCI on arrival to a cath lab enabled center (without thrombolysis). When patients on tenecteplase reached a major medical center, 36% needed urgent PCI (decided by lack of ST resolution on ECG) and received it just over 2 h after randomization. The other 64% of patients did not need urgent PCI and received an angiogram in an average of 17 h after arrival and, based on the results, received PCI or CABG under elective circumstances. This gave more time to plan an elective procedure and also consider other options. PCI at some point was performed in 90% of the PCI group vs. 80% of the thrombolysis group. CABG was performed in more patients in the thrombolysis group (4.7% vs. 2.1%). The primary endpoint (a composite of all-cause mortality, shock, congestive heart failure, and subsequent heart attack at 30 days) occurred in 12.4% in the thrombolysis group vs. 14.3% in the primary PCI group (relative risk in the thrombolysis group, 0.86; 95% confidence interval, 0.68–1.09; p = 0.21). The end-point reduction in the pharmacoinvasive group was driven largely by heart failure and shock, and it also enabled more patients to get bypass surgery, which might impact long-term mortality. Another interesting finding was that patients with inferior MIs seemed to do better in the pharmacoinvasive arm, which perhaps is reflective of the fact that lytic therapy is more efficacious in recanalizing the right than the left coronary artery. The only downside of pharmacoinvasive arm was rate of intracranial bleeding in the thrombolysis group was five times that in the primary PCI group (1.0% vs. 0.2%, p = 0.04). This fact was apparent early on the trial and led to a reduction in the dose of tenecteplase in elderly. After that amendment, which was made after 20% of planned recruitment, these rates declined to (0.5% vs. 0.3%), respectively, after the protocol amendment, with no difference in stroke rates. The conclusion of Armstrong and colleagues is controversial, since there was a similar risk of the primary end point in the two study groups and a significantly higher risk of intracranial bleeding with early thrombolysis. Thus primary PCI remains the treatment of choice in such patients who have close access to cath lab centers. However, there may be a cost advantage with the avoidance of an urgent invasive procedure in about two-thirds of these patients which may offset the extra cost of the thrombolytic agent. Less shock and heart failure in the thrombolysis group, coupled with the promising long-term outcomes reported in studies of pharmaco-invasive therapy reported previously certainly indicates that pharmacoinvasive therapy may provide a useful and reasonable option for many patients who cannot undergo timely PCI. It is especially useful in situations where PCI related delays such as occur in real-world situations, a greater clinical benefit would be anticipated for early pharmacoinvasive therapy. Major delays are prevalent in remote and urban regions. Further, although primary PCI in patients with STEMI is preferred, it is often unachievable.

Meta-analysis of stroke after transradial versus transfemoral artery catheterization

BackgroundTransradial (TR) catheterization is gaining popularity due to its association with lower bleeding and access site complications, improved patient comfort, and lower costs compared to transfemoral (TF) catheterization; however, there is concern that TR catheterization may be associated with an increased risk of neurological complications. New randomized data has emerged since the publication of the last meta-analysis evaluating the risk of stroke between TR and TF catheterization in 2009. MethodsWe conducted a meta-analysis of randomized studies published until 2013 reporting risk of stroke in TR vs. TF catheterization. ResultsData from 11,273 patients in 13 studies were collated. The majority of patients were men, and 8987 (79.7%) were enrolled in acute coronary syndrome trials. Very few patients had a history of prior coronary artery bypass grafting, and approximately 2/3 of patients underwent percutaneous coronary intervention. Stroke occurred in 25 of 5659 patients in the TR group, vs. 24 of 5614 patients in the TF group. There was no difference in stroke rates between the TR and TF groups (risk difference 0.00%, 95% confidence interval −0.29%–0.25%, p=0.88). ConclusionsTR catheterization is not associated with a significant increase in stroke compared to TF catheterization.

Intra-Abdominal Pressure during Swimming

The present study aimed to determine the intra-abdominal pressure during front crawl swimming at different velocities in competitive swimmers and to clarify the relationships between stroke indices and changes in intra-abdominal pressure. The subjects were 7 highly trained competitive collegiate male swimmers. Intra-abdominal pressure was measured during front crawl swimming at 1.0, 1.2 and 1.4 m · s(-1) and during the Valsalva maneuver. Intra-abdominal pressure was taken as the difference between minimum and maximum values, and the mean of 6 stable front crawl stroke cycles was used. Stroke rate and stroke length were also measured as stroke indices. There were significant differences in stroke rate among all velocities (P < 0.05). However, there was no significant difference in stroke length by velocity. Significant within-subject correlations between intra-abdominal pressure and stroke rate or stroke length (P < 0.01) were observed, although there were no significant correlations between intra-abdominal pressure and stroke indices when controlling for swimming velocity. These findings do not appear to support the effectiveness of trunk training performed by competitive swimmers aimed at increasing intra-abdominal pressure.

Abstract 245: Metabolic Syndrome and Common Carotid Artery Remodeling: Study of Women’s Health Across the Nation

Objective The metabolic syndrome (MetS) is linked to a higher risk of cardiovascular disease (CVD) events, including stroke. Measures of maladaptive carotid artery remodeling such as greater common carotid artery (CCA) intima-media thickness (IMT), and wider adventitial diameter (AD) are more prevalent among older women, varies by race/ethnicity and is predictive of stroke, however, data are lacking in women during the menopausal transition. Thus, we hypothesized more maladaptive carotid remodeling among MetS than those without MetS by race/ethnicity. Methods Study of Women’s Health Across the Nation (SWAN) participants, free of clinical CVD and with IMT and AD data at the 12th annual visit were evaluated. Lumen diameter (LD), circumferential wall stress (CWS) and circumferential wall tension (CWT) were calculated. Multivariable linear regressions were used to investigate the relationship between MetS and CCA parameters in all women and by race/ethnicity. Covariates included were age, height, site, LDL-c, education, medication use, menopause status and smoking. Results A total of 1183 women (41.3% MetS; 96.9% Postmenopausal; 52.1% Caucasian, 27.6% African American, 14.6% Chinese, 5.8% Hispanic) from 6 sites across the USA, aged 60.1±2.7 years old at visit 12 were included. MetS was associated with a larger LD (β(SE)): 0.222(0.033) mm, P &lt;0.0001; AD (0.317(0.038)) mm, P &lt;.0001; IMT(0.047(0.006)) mm, P &lt;.0001; CWS (2.51(0.938)) kPa, P &lt;.0077; CWT (5.53(0.637) kPa, P &lt;.0001), after adjusting for covariates. Compared to Caucasians, LD was greater in both African American and Chinese ( (0.130 (0.040) mm, P &lt;.0001; 0.292(0.064) mm, P&lt;.0001, respectively), AD was greater in African American ((0.236(0.046) mm, P &lt;.0001) and Chinese ((0.331(0.073) mm, P &lt;.0001), a thicker IMT((0.053(0.008) mm, P &lt;.0001), CWT was greater for African American and Chinese ((4.83(0.776) kPa, P &lt;.0001; 3.18(1.22) kPa, P =0.0093). Conclusion MetS is associated with maladaptive remodeling of the CCA, as evidenced by larger AD, LD, IMT and CWT. Importantly, the association between MetS and CCA remodeling varies between race/ethnicity, which could partially explain differences in stroke rates by race.

Gender and the risk of stroke in atrial fibrillation: impact of old and new anticoagulation regimens

Atrial fibrillation (AF) is the most common sustained arrhythmia. Thromboembolic events related to AF result in significant morbidity and mortality. An individual’s risk of thromboembolism in the setting of AF varies significantly based on clinical and demographic characteristics. The risk of stroke appears to be greater among women with AF than men. Warfarin provides sufficient protection against stroke, but does not eliminate gender differences in stroke rates. New oral anticoagulants demonstrated similar or superior efficacy compared to warfarin; however rates of stroke in women on new agents remain higher than those observed in men. In the present article, we review the reported gender-related differences in stroke rates in both anticoagulated and nonanticoagulated patient populations. We also focus on differences in stroke and bleeding rates among men and women treated with new oral anticoagulants. Finally, we explore potential sex-based differences in the efficacy and safety of new oral anticoagulants as reflected in the results of the landmark phase III trials.

THE INFLUENCE OF PERSONAL ANXIETY ON RISK OF MYOCARDIAL INFARCTION AND STROKE DURING 16 YEARS (1995–2010) IN WOMEN AGED 25–64 IN CONDITION OF WESTERN SIBERIA MEGAPOLIS (NOVOSIBIRSK)

ObjectivesTo study the influence of personal anxiety (PA) on relative risk of myocardial infarction (MI) and stroke in women aged of 25–64 years during 16 years of follow up in...

The prognostic impact of the stroke unit concept after transient ischemic attack

Background and purposeTransient ischemic attack (TIA) is associated with high short-term risk of stroke, especially in the early phase following the event. Data about the impact of the early hospitalization in a stroke unit on patients with TIA are sparse. This study compares the prognostic impact of the stroke unit concept with conventional care on patients with TIA. MethodsDuring a 30-month period (beginning April 2005), 878 patients (mean age, 70±12years; 44.3% female) with TIA admitted within 24h of symptom onset were prospectively evaluated. The adjusted logistic regression analyses were used to estimate the odds ratio for the stroke risk during hospitalization and the 90-day mortality. ResultsOf 878 patients, 591 (67.3%) were treated in the stroke unit, and 287 (32.7%) underwent conventional care. Patients receiving stroke-unit care had significantly higher rates of cranial computed tomography (96.3% vs. 88.1%; P<.001) and brain-supplying artery ultrasound (97.1% vs. 91.3%; P<.001) investigations. The stroke risk during hospitalization was 1.7% in patients treated in stroke unit and 2.4% in patients received a conventional care. A relevant difference between the groups was not found (1.7% vs. 2.4%; P=.45). The 90-day mortality rate was 1.7% in the stroke unit group compared to 2.2% in the conventional care group (1.7% vs. 2.2%; P=.66). The adjusted logistic regression analyses revealed no difference in stroke rates (odds ratio, 0.68; 95% confidence interval, 0.24–1.9) and in the 90-day mortality (odds ratio, 0.63; 95% confidence interval, 0.2–1.96) between the stroke unit concept and conventional care. ConclusionThe prognostic impact of the stroke unit care for patients with transient ischemic attack appears to be similar to that of the conventional care. Further randomized studies are needed to investigate the impact of stroke-unit care on patients with transient ischemic attack.

Risk of stroke after transcatheter aortic valve implantation (TAVI): a meta-analysis of 10,037 published patients

Transcatheter aortic valve implantation (TAVI) represents a novel treatment option for inoperable or high surgical risk patients with severe symptomatic aortic valve disease. Recent randomised studies have raised major safety concerns because of increased stroke/transient ischemic attack (TIA) rates with TAVI compared to medical treatment and conventional aortic valve replacement. We aimed to review all currently published literature and estimate the incidence of periprocedural stroke and outcomes in patients undergoing TAVI. Fifty-three studies including a total of 10,037 patients undergoing transfemoral, transapical or trans-subclavian TAVI for native aortic valve stenosis published between 01/2004 and 11/2011 were identified and included in a meta-analysis. Patients were 81.5 ± 1.8-years-old and had a mean logistic EuroSCORE of 24.77 ± 5.60%. Procedural stroke (<24 h) occurred in 1.5 ± 1.4%. The overall 30-day stroke/TIA was 3.3 ± 1.8%, with the majority being major strokes (2.9 ± 1.8%). During the first year after TAVI, stroke/TIA increased up to 5.2 ± 3.4%. Differences in stroke rates were associated with different approaches and valve prostheses used with lowest stroke rates after transapical TAVI (2.7 ± 1.4%). Average 30-day mortality was more than 3.5-fold higher in patients with compared to those without stroke (25.5 ± 21.9% vs. 6.9 ± 4.2%). TAVI was associated with average 30-day stroke/TIA rate of 3.3 ± 1.8% (range 0-6%). Most of these strokes were major strokes and were associated with increased mortality within in the first 30 days.

Abstract P285: Pattern of Atrial Fibrillation and Risk of Outcomes: The Loire Valley Atrial Fibrillation Project

Background: The risk of stroke and thromboembolism (TE) in patients with non-valvular atrial fibrillation (NVAF) can be classified in commonly-used stroke risk stratification scores. The role of the pattern of atrial fibrillation in risk prediction is unclear in contemporary ‘real world’ cohorts. Methods: Patients diagnosed with NVAF in a four-hospital-institution between 2000 and 2010 were identified and included. Event rates of stroke/TE were calculated according to pattern of AF, i.e. paroxysmal, persistent and permanent, defined by consensus guidelines. Independent risk factors of stroke/TE were investigated by Cox regression. Results: Among 7156 patients with NVAF, 4176 (58.4%) patients with paroxysmal, 376 (5.3%) with persistent and 2604 (36.3%) with permanent NVAF patterns were included. In non-anticoagulated patients, the overall stroke/TE event rate per 100 person-years was 1.29 (95% CI 1.13–1.47). Paroxysmal NVAF patients were more likely to be female (p&lt;0.001). Persistent NVAF patients were less likely to have prior history of stroke (p–0.002) and vascular disease (p&lt;0.001), and more likely to have hypertension (p&lt;0.001) and vitamin K antagonist therapy (p&lt;0.001). Permanent NVAF patients were more likely to have diabetes (p&lt;0.001), heart failure therapy (p&lt;0.001) and less likely to have dyslipidaemia (p&lt;0.001). Compared with paroxysmal NVAF, rates of stroke/TE (p=0.001), bleeding (p&lt;0.001) and all-cause mortality (p&lt;0.001) were significantly higher in permanent NVAF patients but not in persistent NVAF patients. In multivariate analyses, only previous stroke (hazard ratio, HR 2.58, 95% CI 2.08–3.21), vascular disease (HR 1.34,1.12–1.61), heart failure (HR 1.20,1.00–1.44), age≥75 years (HR 2.75, 2.16–3.50) and age 65–74 years (HR 1.60,1.22–2.09) increased stroke/TE risk, but persistent (HR1.13, 0.76–1.70) and permanent (HR 1.44,0.96–2.16) patterns of NVAF did not. Conclusion: In this large ‘real world’ cohort of NVAF patients, there were significant differences in rates of stroke, TE, death and bleeding between patterns of NVAF, however only previous stroke, age, heart failure and vascular disease (not pattern of NVAF) independently increased the risk of stroke/TE, death and bleeding in multivariate analyses. Therefore, the risk of stroke is similar across all patterns of NVAF and antithrombotic therapy should be based on clinical risk factors not NVAF pattern.

Ejection fraction and outcomes in patients with atrial fibrillation and heart failure: the Loire Valley Atrial Fibrillation Project

Heart failure (HF) increases the risk of stroke and thrombo-embolism (TE) in non-valvular atrial fibrillation (NVAF), and is incorporated in stroke risk stratification scores. We aimed to establish the role of ejection fraction (EF) in risk prediction in patients with NVAF and HF. Patients with NVAF, history of HF, and measured EF were included in a retrospective analysis. Patients with HF and preserved ejection fraction (HFPEF) were defined as those with clinical HF and EF ≥50% in this study. Among 7156 patients with NVAF, 1276 (17.8%) patients with HF and measured EF were included. Of these, 747/1276 (58.5%) patients were on vitamin K antagonists. The stroke/TE event rate per 100 person-years was 1.05 [95% confidence interval (CI) 0.87-1.25]. Patients with HFPEF were more likely to be female (P < 0.001), older (P < 0.001), and hypertensive (P < 0.001), and less likely to have prior vascular disease (P < 0.001). There were no differences in rates of stroke (P = 0.17) and stroke/TE (P = 0.11) between patients with HFPEF and those with HF and reduced EF. There were no significant differences in rates of all-cause mortality when patients were stratified by EF. In multivariate analyses, only previous stroke (hazard ratio 2.36, 95% CI 1.45-3.86) and vascular disease (1.57, 1.07-2.30) increased the risk of stroke/TE amongst NVAF patients with HF, but EF <35% did not (0.75, 0.44-1.30). In NVAF patients with HF, there were no differences in rates of stroke, TE, or death between EF categories. Only previous stroke and vascular disease (and not decreased EF) independently increased risk of stroke/TE in multivariate analyses.

Point of no return in diving emperor penguins: is the timing of the decision to return limited by the number of strokes?

At some point in a dive, breath-hold divers must decide to return to the surface to breathe. The issue of when to end a dive has been discussed intensively in terms of foraging ecology and behavioral physiology, using dive duration as a temporal parameter. Inevitably, however, a time lag exists between the decision of animals to start returning to the surface and the end of the dive, especially in deep dives. In the present study, we examined the decision time in emperor penguins under two different conditions: during foraging trips at sea and during dives at an artificial isolated dive hole. It was found that there was an upper limit for the decision-to-return time irrespective of dive depth in birds diving at sea. However, in a large proportion of dives at the isolated dive hole, the decision-to-return time exceeded the upper limit at sea. This difference between the decision times in dives at sea versus the isolated dive hole was accounted for by a difference in stroke rate. The stroke rates were much lower in dives at the isolated hole and were inversely correlated with the upper limit of decision times in individual birds. Unlike the decision time to start returning, the cumulative number of strokes at the decision time fell within a similar range in the two experiments. This finding suggests that the number of strokes, but not elapsed time, constrained the decision of emperor penguins to return to the surface. While the decision to return and to end a dive may be determined by a variety of ecological, behavioral and physiological factors, the upper limit to that decision time may be related to cumulative muscle workload.

Pharmacogenetic Effect of the Stromelysin (MMP3) Polymorphism on Stroke Risk in Relation to Antihypertensive Treatment

Background and Purpose— Atherothrombotic diseases including stroke share a common etiology of atherosclerosis, and susceptibility to atherosclerosis has a genetic component. Stromelysin-1 (matrix metalloproteinase-3 [MMP3]) regulates arterial matrix composition and is a candidate gene for atherothrombosis. A common polymorphism of MMP3 alters expression levels and affects atherosclerotic progression and plaque stability. As part of the Genetics of Hypertension Associated Treatment study, ancillary to the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial, we evaluated the 5A/6A polymorphism in MMP3 to determine its association with stroke and determine whether it modifies clinical outcome response to blood pressure–lowering drugs. Methods— The effect of the MMP3 5A/6A polymorphism on stroke rates was examined by using multivariate-adjusted Cox regression models, including a test for interactions between genotype and antihypertensive drug class. Results— Compared with participants treated with chlorthalidone with the 6A/6A genotype, individuals with the 6A/6A genotype randomized to lisinopril had higher stroke rates (hazard ratio=1.32; 95% CI, 1.08 to 1.61; P =0.007) and 5A/6A individuals taking lisinopril had lower stroke rates (hazard ratio interaction =0.74; 95% CI, 0.53 to 1.04; P interaction =0.08), whereas 5A/5A individuals taking lisinopril had the lowest stroke rate (hazard ratio interaction =0.51; 95% CI, 0.31 to 0.85; P interaction =0.009). There were no pharmacogenetic differences in stroke rate by genotype in patients taking amlodipine or doxazosin vs chlorthalidone. Conclusions— The MMP3 6A/6A genotype is associated with an increased risk of stroke in hypertensive subjects taking lisinopril compared with patients treated with chlorthalidone, whereas a protective effect was found for 5A/5A individuals treated with lisinopril. Genetic screening for the MMP3 5A/6A genotype might be a useful tool to select optimal antihypertensive therapy if this finding is replicated. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00563901.

Anticoagulation after Anterior Myocardial Infarction and the Risk of Stroke

BackgroundSurvivors of anterior MI are at increased risk for stroke with predilection to form ventricular thrombus. Commonly patients are discharged on dual antiplatelet therapy. Given the frequency of early coronary reperfusion and risk of bleeding, it remains uncertain whether anticoagulation offers additional utility. We examined the effectiveness of anticoagulation therapy for the prevention of stroke after anterior MI.Methods and FindingsWe performed a population-based cohort analysis of 10,383 patients who survived hospitalization for an acute MI in Ontario, Canada from April 1, 1999 to March 31, 2001. The primary outcome was four-year ischemic stroke rates compared between anterior and non-anterior MI patients. Risk factors for stroke were assessed by multivariate Cox proportional-hazards analysis. Warfarin use was determined at discharge and followed for 90 days among a subset of patients aged 66 and older (n = 1483). Among the 10,383 patients studied, 2,942 patients survived hospitalization for an anterior MI and 20% were discharged on anticoagulation therapy. Within 4 years, 169 patients (5.7%) were admitted with an ischemic stroke, half of which occurred within 1-year post-MI. There was no significant difference in stroke rate between anterior and non-anterior MI patients. The use of warfarin up to 90 days was not associated with stroke protection after anterior MI (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.37–1.26). The use of angiotensin-converting-enzyme inhibitors (HR, 0.65; 95% CI, 0.44–0.95) and beta-blockers (HR, 0.60; 95% CI, 0.41–0.87) were associated with a significant decrease in stroke risk. There was no significant difference in bleeding-related hospitalizations in patients who used warfarin for up to 90 days post-MI.ConclusionMany practitioners still consider a large anterior-wall MI as high risk for potential LV thrombus formation and stroke. Among a cohort of elderly patients who survived an anterior MI there was no benefit from the use of warfarin up to 90 days post-MI to prevent ischemic stroke. Our data suggests that routine anticoagulation of patients with anterior-wall MI may not be indicated. Prospective randomized trials are needed to determine the optimal antithrombin strategy for preventing this common and serious adverse outcome.

Stroke risk in AF: do AF patterns matter?

Stroke risk in AF: do AF patterns matter?

Endovascular versus open repair for descending thoracic aortic rupture: institutional experience and meta-analysis

Rupture of thoracic aneurysm, acute type B dissection, blunt thoracic trauma, and penetrating aortic ulcer can present with a similar clinical profile of thoracic aortic rupture. We report a meta-analysis of comparative studies evaluating endoluminal graft versus open repair of these lesions as well as the early experience from our institution. We searched the following databases for reports of endovascular versus open repair of acute descending thoracic aortic rupture: Medline/PubMed, OVID, EMBASE, CINAHL, ClinicalTrials.gov, the Cochrane central register of controlled trials and the Cochrane database of systematic reviews. We used the random-effects model to calculate the odds ratio (OR) and 95% confidence intervals (CI) for mortality, paraplegia/paraparesis and stroke rates. Also, the medical records of the patients treated in our institution with this technique from 2000 to 2008 were reviewed. Demographics, comorbidities and operative procedure information were retrieved. Outcomes examined were mortality, paraplegia and stroke. Meta-analysis indicates that endoluminal graft repair is accompanied by lower procedure related mortality (OR 0.46, 95% CI 0.26-0.78, p=0.005) and paraplegia rates (OR 0.23, 95% CI 0.08-0.65, p=0.005), as compared to open repair. There was no difference in stroke rate between the two methods (OR 0.86, 95% CI 0.26-2.8, p=0.8). We have treated 13 patients with endoluminal stent-grafts. No conversion to open repair was necessary. Stroke rate was 15%, no patient died as a result of the stent-graft placement, one patient died as a result of massive head injury (overall 30-day mortality: 7.5%). There were no spinal cord ischemic complications. Our experience and meta-analysis indicate that thoracic endograft repair has low mortality and spinal cord complication rates for treatment of acute thoracic aortic rupture. If this method proves to be durable, it could replace open repair as the treatment of choice for these critically ill patients.