Disease In Stroke Patients Research Articles

The Prevalence of Peripheral Arteriopathy is Higher in Ischaemic Stroke as Compared with Transient Ischaemic Attack and Intracerebral Haemorrhage

There is little data on the association of peripheral arterial disease and stroke. We aimed to assess the prevalence of peripheral arterial disease in acute stroke and to identify the predisposing factors for peripheral arterial disease in a stroke cohort. We enrolled all consecutive patients who were admitted to our stroke- and neurocritical care units with the diagnosis of a transient ischaemic attack, ischaemic or haemorrhagic stroke over a period of 5 months. As controls, we analysed 50 nonvascular neurological patients who were matched to age. Upon admission, assessment of the ankle brachial index was performed in all patients. The only exclusion criteria was decompensated congestive heart failure. Altogether, we compared 374 stroke patients (95 transient ischaemic attack, 231 ischaemic, and 48 haemorrhagic strokes) and 50 nonstroke controls. The prevalence of peripheral arterial disease in the control group was 14%. There was a trend towards a higher prevalence of peripheral arterial disease in stroke patients (chi(2)-test: P=0.051; prevalence peripheral arterial disease in transient ischaemic attack: 16.8%, ischaemic stroke: 32%, and haemorrhagic stroke: 20.8%). A higher proportion of ischaemic stroke patients were peripheral arterial disease-positive, compared with transient ischaemic attack patients (P=0.005) and controls (P=0.011), respectively. Multivariate regression analyses identified the parameters age, arterial hypertension, current or former smokers and a history of cardiovascular events to be predisposing factors of peripheral arterial disease. This study represents the first systematic investigation of the prevalence of peripheral arterial disease in stroke. By now, it is clear that: * peripheral arterial disease is more commonly found in stroke than in nonstroke patients * ischaemic stroke patients show the highest prevalence of peripheral arterial disease, and * peripheral arterial disease in stroke is related to common vascular risk factors.

Quality of Care and Outcomes in Patients With Diabetes Hospitalized With Ischemic Stroke

Diabetes is a common comorbid disease in stroke patients and has a strong influence on stroke-related outcomes, including stroke recurrence. We sought to examine the quality of care and in-hospital outcomes in patients with diabetes in the Get With the Guidelines-Stroke (GWTG-Stroke) program. Data were obtained from 415 926 ischemic stroke patients from 1070 United States hospitals that participated in GWTG-Stroke between 2003 and 2008. We analyzed the relationships between diabetes and quality of care, in-hospital mortality, and discharge home using multivariable logistic regression. There were 130 817 (31%) ischemic stroke patients with diabetes. Quality of care received by patients with and without diabetes was similar except for intravenous recombinant tissue plasminogen activator (rt-PA) and cholesterol treatment. Fifty-four percent of patients with diabetes who arrived within 2 hours of onset received rt-PA compared to 60.8% of patients without diabetes (adjusted odds ratio [aOR], 0.83; 95% CI, 0.79-0.88). Almost 80% of patients with diabetes were discharged on cholesterol treatment compared to 71% of patients without diabetes (aOR, 1.40; 95% CI, 1.37-1.44). Diabetes patients were less likely to be discharged home (aOR, 0.80; 95% CI, 0.78-0.81) and had a higher risk of in-hospital death (aOR, 1.12; 95% CI, 1.08-1.15). Quality of care among patients with and without diabetes was similar except for rt-PA and cholesterol treatment. Diabetes was associated with worse stroke-related outcomes. Greater quality-improvement efforts to increase the use of rt-PA and other secondary prevention treatments in patients with diabetes are warranted.

Multimodality Stroke Prevention

Prevention harbors the greatest potential for reducing the societal burden from stroke. As evidence accumulates on the multifactorial pathogenesis of vascular disease and the impact of novel combination therapies targeted at reducing recurrent vascular events, a new paradigm is emerging, which is that of multimodality vascular prevention. Knowledge of the evidence behind this strategy and the effective means for implementing it could be useful to the practicing neurologist taking care of stroke patients. Our review presents the evidence behind the broadening therapeutic options for recurrent vascular event prevention in ischemic stroke patients whose underlying stroke pathophysiologic mechanism is either presumed to be due to atherosclerosis or who have prior evidence of systemic atherosclerosis. We elaborate on conventional and novel vascular risk factors, as well as risk factor prediction models. Therapies discussed include antithrombotics, statins, antihypertensives, surgical/endovascular treatments, and lifestyle modification. Basis for evidence (or the lack thereof), national guideline recommendations, areas of controversy, and avenues of future focus for these treatments are also discussed in this paper. Furthermore, the knowledge-treatment gap as it pertains to optimal vascular risk-factor control and appropriate initiation and maintenance of evidence-based preventive therapies is explored, and an effective hospital-based intervention involving the in-hospital initiation of these treatments prior to discharge, that may help bridge this gap, is detailed. Neurologists should be aware that a timely, systematic, evidence-based multimodal preventive approach to atherothrombotic disease in stroke patients that transcends the continuum of care across points of service will likely increase treatment rates and improve clinical outcomes.

Risk of Myocardial Infarction and Vascular Death After Transient Ischemic Attack and Ischemic Stroke

Whether stroke patients should be investigated for asymptomatic coronary artery disease remains matter of debate. Absolute risks of myocardial infarction (MI) and vascular death after a stroke have not been accurately assessed. We performed a systematic review and a meta-analysis to determine the risk of MI and nonstroke vascular death after transient ischemic attack (TIA) and ischemic stroke. Cohort studies of TIA or ischemic stroke patients were included if they were published between 1980 and March 2005, reported risk of MI and nonstroke vascular death, enrolled >100 patients, and had at least 1 year of follow-up. We included 39 studies in a total of 65,996 patients with mean follow-up of 3.5 years. Two reviewers independently carried out data extraction using a standardized form. Absolute annual risks were estimated through weighted meta-regressions with a random effect. To test the predictions of expected event rates derived from our analysis, we used individual patient data. The annual risks were 2.1% (CI 95%: 1.9 to 2.4) for nonstroke vascular death, 2.2% (1.7 to 2.7) for total MI, 0.9% (0.7 to 1.2) for nonfatal MI and 1.1% (0.8 to 1.5) for fatal MI. The time course of risk was linear. Estimated risks fitted well with observed risks at the individual level. There was no heterogeneity in the absolute risks according to baseline study characteristics. Patients with TIA or stroke have a relatively high risk of MI and nonstroke vascular death. Additional research is needed to identify the determinants of coronary artery disease in stroke patients.

Echocardiography in stroke and the prescription of new anticoagulation and cardiac medications: A pilot project

Previous research on echocardiography in patients with acute stroke has focused on identifying possible cardioembolic etiologies of the stroke, but physicians might also obtain echocardiography to guide the management of heart disease in stroke patients. The objectives of this study were to determine how frequently echocardiography is used in acute ischemic stroke patients, and to evaluate if receiving echocardiography is associated with new prescriptions for anticoagulant or cardiac medications. This secondary data analysis of a previous cohort study included medical records of acute ischemic stroke patients admitted to 1 of 10 acute-care hospitals in Connecticut from 1996 to 1998. A total of 58 of 119 (49%) acute ischemic stroke patients received echocardiography. Among these 58 patients, 43 (74%) received either a new prescription for anticoagulation or a new cardiac medication prescription (10 of 58 [17%] new anticoagulation only, 22 of 58 [38%] new cardiac medication only, and 11 of 58 [19%] both). New anticoagulant medications were prescribed more often in patients receiving echocardiography (21 of 58; 36%), than in patients not receiving echocardiography (10 of 61; 16%) (P = .014). In addition, new cardiac medications were prescribed more often in patients receiving echocardiography (34 of 58; 59%), than in patients not receiving echocardiography (24 of 61; 39%) (P = .035). Echocardiography is commonly obtained in patients with acute stroke, and its use is associated with both the prescription of new anticoagulation and new cardiac medications. Although previous research about the use of echocardiography in acute stroke has focused on its role in identifying stroke etiologies, future research should include an assessment of it use in treating concomitant heart disease.

Heart and carotid artery disease in stroke patients with intermittent claudication.

Much has been published on the natural history of intermittent claudication (IC), but little is known about the clinical features of stroke patients with IC. The purpose of this study was to examine clinical features and risk factors in stroke patients with or without IC, including heart disease and carotid artery disease. A hospital-based study was conducted of 3901 stroke patients, who were prospectively coded and entered into a computerized databank. Of these patients, 219 had symptoms of IC. Patients were subdivided by age into 10-year categories. There were at least 12 times more non-IC than IC patients in each category. An age-matched random sample was obtained containing 12 non-IC cases for each IC case, resulting in 219 cases of IC and 2628 non-IC cases. The prevalence of IC in the total stroke population was 5.6%. IC prevalence increased sharply with age until about 70 years. Cardiac ischaemia and internal carotid artery (ICA) disease were significantly more frequent in stroke with IC than without IC. IC patients also exhibited a higher prevalence of atherosclerotic disease as well as other risk factors such as smoking, hypercholesterolaemia, elevated haematocrit, and family history of stroke. Ischaemic heart disease and ICA disease are especially common in stroke with IC. IC, large artery disease and stroke share similar risk factors. IC symptoms in stroke patients may indicate extensive generalized atherosclerosis.

Cardiac arrhythmias in acute stroke.

Cardiac arrhythmias were more frequent (p less than 0.001) in 312 stroke patients admitted to an intensive care stroke unit, than in 92 patients admitted to the unit and subsequently found not to have strokes. This significant difference remained when a stroke subgroup and the non-stroke group were matched for age, sex and duration of stay in the unit (P less than 0.005). Hypertension and hypertensive cardiac disease were more common in the stroke than in the non-stroke patients (P less than 0.001). Ectopic beats and atrial fibrillation, as well as other arrhythmias, were most frequent in patients with cerebral hemisphere infarction, and patients with hemispheric lesions had significantly more arrhythmias than those with brain stem lesions (P less than 0.05). The arrhythmias were rarely (2%) responsible for hemodynamic ischemic cerebrovascular lesions, but may have been associated with cerebral embolism in up to 17% of cases. The cardiac arrhythmias appeared to have little influence on the course of the subsequent recovery from stroke. Although these arrhythmias frequently reflect the high incidence of cardiac disease in stroke patients, in some cases they are secondary to the acute cerebrovascular lesion itself.