Higher Risk Of Stroke Research Articles

Measuring only sitting blood pressure without considering supine blood pressure underestimates cardiovascular risk in the elderly

Abstract Background and Objective Elderly individuals exhibit greater variability in blood pressure (BP) readings between sitting and supine positions. Nocturnal hypertension (supine position) is closely associated with cardiovascular diseases and mortality. However, the relationship between supine BP and cardiovascular risk remains unclear. This study aims to investigate the association between the occurrence of major adverse cardiovascular events (MACEs) with BP in sitting and supine positions. Methodologies A total of 3363 participants aged 65 years or older from the Northern Shanghai Study were included. Each participant is given 3 consecutive sitting SBP readings (SBP1, SBP2, SBP3) at 2-minute intervals, we then calculated the SBP1-2 (average of SBP1 and SBP2), SBP2-3 (average of SBP2 and SBP3), SBP1-2-3 (average of SBP1, SBP2 and SBP3). we also collected two supine BP readings (S-SBP1, S-SBP2). Kaplan-Meier and Cox proportional hazard regression were used to investigate the association of sitting and supine BP with MACEs (composite of nonfatal myocardial infarction, nonfatal stroke, or death). Results The mean age of participants was 71.5 years, and 1467(43.6%) were men. After a median of 6.4-year follow-up, a total of 362 events were recorded. Among 3 successive BP readings, SBP2-3 had strongest association with MACEs incidence (hazard ratio, 1.12 [1.00-1.26] per SD). Multiple cox proportional hazard regression showed supine BP had significant value in predicting MACEs, acute myocardial infarction (AMI) and mortality compared to sitting BP. Kaplan-Meier revealed significant differences in MACEs rates among participants without hypertension (HTN) in both sitting and supine positions, with HTN in both positions, or those with HTN in either position (Log rank P < 0.01). Compared to participants without HTN in both sitting and supine positions, those with HTN in both positions had a 1.4-fold (hazard ratio,1.40[1.08-1.82]) higher risk of MACEs and 2-fold (hazard ratio,2.01[1.24-3.26]) higher risk of stroke. Conclusion Supine BP measurements are more valuable than sitting BP in predicting MACEs in elderly individuals. Hypertension in both positions significantly increases the risk of MACEs. Taken together, supine BP may also need to be emphasized in the elderly.central illustration

Inflammation and long-term outcomes after first-time direct current cardioversion for atrial fibrillation: a nationwide register study

Abstract Background Emerging evidence suggests that the pathogenesis of atrial fibrillation (AF) is affected by inflammatory processes which contribute to structural and electrical remodeling of the atria, creating a substrate for arrythmia. Aim To assess whether inflammation measured by C-reactive protein (CRP) is associated with readmission for direct current (DC) cardioversion, ablation, heart failure or stroke after discharge from 1st time DC cardioversion. Methods This nationwide retrospective cohort study included patients undergoing 1st DC cardioversion between 2011 and 2018. Exclusion criteria were death within one day of cardioversion and no available CRP at baseline. Primary outcome was readmission for DC cardioversion of AF. Secondary outcomes were AF ablation, new admission of stroke, new admission of heart failure (HF), and all-cause death. Absolute risk rates (ARR) of outcomes were calculated for patients with available 1-year follow-up data. CRP 20 mg/L was chosen as cutoff to establish a clinically relevant borderline for inflammation. The association between baseline CRP and outcome was assessed in Cox proportional hazards regression models with a follow-up period starting from 1st DC cardioversion, ending no later than 31st of December 2018, for the entire study population (n=9,977). Results After exclusion criteria the study population consisted of 9,977 patients Mean age for CRP > 20mg/L: 66.8 (IQR: 60.5-74.2). Mean age for CRP < 20mg/L 68.9 (IQR: 62.9-75.9)(p<0.001). In total, 68.9% were male and the most frequent comorbidities included hypertension (57.3%), ischemic heart disease (25.1%), HF (20.6%), and history of stroke (7.1%). Patients with available CRP measurement and 1yr follow up was 7,764. Compared to patients with low CRP (<20 mg/L), patients with elevated CRP (>20mg/L) had a higher 1-year ARR of HF, and all cause death (p<0.001). Compared to patients with low CRP, patients with elevated CRP had a lower 1-year ARR of all-ablation and new DC cardioversion (p<0.001), (Table 1). CRP > 20mg/L was associated with lower risk for new DC cardioversion (HR 0.72, 95% CI: 0.64-0.82, p<0.001). However, in patients <75 years of age with CRP > 20mg/L at baseline had an increased risk of stroke after multivariable adjustments (HR 1.92, 95% CI: 1.10-3.35; p = 0.02) (Fig.1), while CRP > 20 mg/L was not associated with an increased risk of stroke in patients > 75yrs of age (Cox regressions estimates) (p for interaction = 0.03). Conclusion However, elevated CRP was associated with an increased risk of stroke in patients <75 years of age, even after multivariable adjustments. These results suggest that CRP may not be a reliable predictor of readmission for DC-cardioversion, especially in older individuals, but might be a potential risk stratification tool in identifying AF patients at higher risk of stroke in young individuals. We suspect this is due to the population with elevated CRP has more comorbidities and are older.

Sex differences in outcomes of percutaneous left atrial appendage closure

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia in adults and is associated with an increased risk of embolic stroke. In a previous survey, 91% of nonrheumatic AF-related left atrial thrombi was originated in the left atrial appendage (LAA). Percutaneous left atrial appendage closure (LAAC) with the Watchman device has been shown to be noninferior to anticoagulation therapy in clinical trials for stroke prevention in nonrheumatic AF. It has been used in Japan since September 2019 only for patients who are at the high risk of bleeding events. The WATCHMAN family is the only left atrial appendage closure (LAAC) device in Japan. Since long time ago, sex differences have been attracting attention in the cardiology. Due to the cardiovascular protective effects of endogenous estrogens, premenopausal women are thought to be less likely to develop cardiovascular disease. Whereas, in area of AF, Female with AF have higher stroke risk and female with AF have severe after effect. However, there are few studies on sex differences in LAAC implantation outcomes. Purpose We aimed to identify the sex differences of outcomes of LAAC in Japanese patients. Methods A total of 118 consecutive patients who underwent LAAC at our hospital from January 2020 to August 2023 were prospectively analyzed. Various patient characteristics, comorbidities, and outcomes were identified and compared between male and female. Results Results are shown in Table. Female were older (79 vs. 73 years, p = 0.0009), thinner (Body mass index 22 vs. 24 kg/m2, p = 0.0326), and less likely to have had diabetes (19 vs. 40%, p = 0.0340). Pulmonary embolism was significantly more common in female after LAAC. If anticoagulants are discontinued after LAAC, women’s susceptibility to coagulation may become apparent. Conclusions LAAC was feasible and safe for Japanese patients of both genders. However, these results could have a relevant impact on the antithrombotic management of patients who are at the high risk of embolic considering sex difference. Especially, we should pay great attention when discontinuing anticoagulants after LAAC in female.

Circadian rhythm in atrial fibrillation detected by implantable loop recorder: a post-hoc analysis of a randomized clinical trial

Abstract Introduction Previous studies suggest the existence of circadian, weekly, and seasonal rhythms in the occurrence of atrial fibrillation (AF), which may be utilized to improve the yield of screening. The heterogeneity of AF natural history also necessitates better phenotyping to overcome the challenges of identifying candidates for screening and treatment. Purpose To explore the potential circadian rhythm in AF occurrence in persons without known arrhythmia but at high risk of AF and stroke. Methods Post-hoc analysis of the LOOP study (Atrial Fibrillation Detected by Continuous Electrocardiogram Monitoring Using Implantable Loop Recorder to Prevent Stroke in High-Risk Individuals), which randomized 6004 AF naïve participants (≥70 years old with additional stroke risk factors) 1:3 to receive implantable loop recorder screening or usual care. All loop recorder data was extracted to obtain the date and time of AF episode onset, AF duration, mean and max heart rate (HR) during AF, and symptom annotations. New-onset AF episodes lasting ≥6 minutes were adjudicated, and all subsequent episodes were included in the analysis. Results A total of 41,713 AF episodes (median duration 18 (8-64) minutes) were identified among 430 participants (Table 1). The median number of episodes for each participant with AF was 21 (4-82) and the median AF burden was 0.17% (0.04%-0.83%) of time from debut to end of monitoring. The most and least frequent days of AF onset were Sunday (15.3%) and Friday (13.6%), respectively, while AF occurred slightly more often during spring (26%) than in other seasons. The median time of onset was 09:57:15 AM (05:15:30 AM – 03:33:00 PM). The most frequent time of onset was at 09:00 AM (rounded to the nearest hour), which was two times more likely than at 09:00 PM, and 22% of all episodes occurred between 08:00 and 11:00 AM (Figure 1). A total of 25,329 (61%) episodes occurred between midnight and noon (AM). Nocturnal episodes, defined as episodes with onset between 10:00 PM and 07:00 AM, occurred in 368 (86%) AF participants and constituted a median of 40% of all episodes and 37% (14%-63%) of each participant’s episodes. The median duration of nocturnal episodes was 28 (10-104) minutes compared to 14 (8-44) minutes for daytime episodes. The averaged heart rate during AF was 81 (71-96) beats per minute (BPM), while 330 (77%) participants had AF episodes with heart rates equal to or above 100 BPM, and the duration of these episodes was 50 (15-201) minutes compared to 30 (21-85) minutes for slower episodes (below 100 BPM). Conclusion A circadian pattern was observed for screening-detected AF. AF onset occurred predominantly between 08:00 and 11:00 AM, representing more than one in five episodes. Nocturnal AF occurred in most participants with AF and accounted for almost half of all episodes, while these episodes also lasted longer than daytime episodes. This may warrant future studies investigating the timing of AF screening.

Assessing stroke and mortality risk in heart failure: the CHA2DS2-VASc score's prognostic value in patients with and without atrial fibrillation - a systematic review and meta analysis

Abstract Background Heart failure (HF) is a common cardiovascular disorder that is linked to substantial morbidity and mortality. The CHA2DS2-VASc score, originally designed to assess the risk of stroke in patients with atrial fibrillation, has demonstrated potential as a prognostic indicator for adverse outcomes in patients with heart failure. This systematic review and meta-analysis aimed to assess the predictive accuracy of the CHA2DS2-VASc score in determining the occurrence of stroke and increased mortality rates in patients with heart failure. Methods A thorough search of electronic databases, such as PubMed, EMBASE, and the Cochrane Library, was performed to find pertinent papers published until the search cutoff date. Included studies examined the correlation between the CHA2DS2-VASc score and the likelihood of stroke or death in patients with heart failure. The assessment of the quality of the included studies was conducted using recognized criteria, and data were collected for quantitative synthesis. Findings The meta-analysis encompassed four studies (45864 patients), revealing a consistent and substantial correlation between elevated CHA2DS2-VASc scores and heightened risks of both stroke and mortality in heart failure patients. More precisely, patients with CHA2DS2-VASc scores ≥4 had a greater risk of stroke compared to those with scores <4 (odds ratio 0.38, 95% confidence interval 0.33-0.43, p-value < 0.00001). The combined data showed homogeneity (p-value = 0.24, I2 = 29%). Similarly, patients with CHA2DS2-VASc scores ≥4 had a higher risk of mortality compared to those with scores <4 (OR 0.49, 95% CI 0.30-0.80, P = 0.05). However, the combined data showed significant heterogeneity (P < 0.00001, I2 = 96%). Conclusion The CHA2DS2-VASc score is a useful predictive tool for identifying heart failure patients who are hospitalized and at a high risk of both stroke and high mortality. The results of this study provide evidence for the practicality of using the CHA2DS2-VASc score for risk stratification in patients with heart failure. Additional investigation is necessary to confirm these findings and examine the incorporation of the CHA2DS2-VASc score into risk assessment algorithms for tailored patient management.Figure:Risk of strokeFigure:Risk of mortality

Benefits of prophylactic carotid revascularization in patients with asymptomatic carotid artery stenosis undergoing coronary artery bypass surgery: A narrative review.

Patients undergoing coronary artery bypass grafting (CABG) are at increased risk of perioperative stroke. Carotid atherosclerosis has been identified as an independent risk factor for stroke during and in the early postoperative period of cardiac surgery. However, the pathogenesis of peri-CABG stroke is multifactorial and frequently involves other noncarotid causes, such as cardiac emboli and aortic atheroma. Therefore, routine population-wide screening of carotid stenosis is not recommended, but target screening of patients at high risk of carotid-related perioperative stroke can have benefits. Carotid duplex sonography is recommended as an initial screening tool. Elimination of carotid stenosis before cardiac surgery is indicated in patients in whom carotid atherosclerosis is suspected to be the primary contributor to perioperative stroke. In patients with advanced carotid atherosclerosis, an individualized revascularization approach, including simultaneous or staged procedures, is advocated. The prevailing consensus is that synchronous surgery is safer than staged procedures. Carotid artery stenting represents a less invasive alternative, but its role in high-risk patients requires further investigation. In conclusion, the risk of perioperative stroke in patients undergoing CABG involves different factors, and carotid artery stenosis is involved in its pathogenesis only in some patients. Therefore, individualized approaches and careful consideration of patient risk factors are essential in determining the need for carotid screening and revascularization before CABG.

Obstructive sleep apnea and genotype rs6843082 as a risk factor for cerebrovascular accident

NO previous studies have examined the simultaneous effects of obstructive sleep apnea (OSA), hypertension, and the SNP rs68430822 on stroke. We aimed to explore whether these elements together, play a role as risk factors for stroke. Data was obtained from the Taiwan Biobank and the National Health Insurance database. We used logistic regression analysis to investigate the effect of OSA and hypertension as a risk factor for stroke in different genotypes. We found that OSA and hypertension was associated with stroke in those with the rs6843082 genotype. People with OSA and hypertension together with the rs6843082 genotype (GA + AA) showed a statistically significant difference as a risk for stroke (OR,2.57; 95% CI,1.53 to 4.33). However, there was no statistically significant difference in those people with OSA but without hypertension (OR, 0.53; 95% CI,0.13 to 2.25). After further stratification by combination of OSA and hypertension, those with genotype rs6843082 (GG) had higher risk odds than those with OSA and those with hypertension alone (OR,5.46, 95% CI,3.46 to 8.60). Individuals with genotype rs6843082(GA + AA), OSA and hypertension together had the highest risk for stroke (OR,6.25, 95% CI,3.63 to 10.76) and those with OSA and no hypertension (OR,0.57, 95% CI,0.14 to 2.36) had no significant risk. Our findings showed that people with genotype rs6843082 (GG), with or without hypertension had OSA as a risk factor for stroke. For individuals with the genotype rs6843082 (GA + AA), those with hypertension, OSA is a risk factor for stroke, and for those without hypertension, OSA is not associated with stroke.

Hypertensive disorders of pregnancy and stroke: a univariate and multivariate Mendelian randomization study.

Hypertensive disorders of pregnancy (HDP) are associated with an increased risk of stroke later in life in multiparous women. However, causality of these associations remains unclear. This study employed 2-sample univariate and multivariate Mendelian randomization (MR) to assess the causal connection between HDP and stroke. Genetic variants for HDP and two subtypes were identified from recent large-scale genome-wide association studies and the FinnGen consortium. Stroke summary data were obtained from the MEGASTROKE consortium. The primary analytical approach for univariate MR was the inverse variance weighting method. Sensitivity analyses incorporated methods such as MR-Egger regression, weighted median, and maximum likelihood to ascertain the robustness of the results. Additionally, multivariable MR analyses were conducted to account for potential associative effects of hypertension and type 2 diabetes. Genetically predicted HDP was associated with a high risk of large artery atherosclerosis (odds ratio [OR]=1.50, 95% confidence interval [CI]: 1.17-1.91, P=1.13×10-3) and small vessel stroke (OR=1.29, 95% CI: 1.20-1.50, P=1.52×10-3). HDP may also correlate with ischemic stroke (OR=1.13, 95% CI: 1.04-1.23, P=4.99×10-3) and stroke (OR=1.11, 95% CI: 1.03-1.20, P=8.85×10-3). An elevated risk of small vessel stroke (OR=1.20, 95% CI: 1.01-1.43, P=3.74×10-2) and large artery atherosclerosis (OR=1.22, 95% CI: 1.01-1.47, P=4.07×10-2) may be related with genetically predicted susceptibility to gestational hypertension. Genetically predicted susceptibility to preeclampsia or eclampsia may be associated with an increased risk of stroke (OR = 1.10, 95% CI: 1.02-1.19, P = 1.16×10-2) and ischemic stroke (OR = 1.10, 95% CI: 1.02-1.20, P = 1.84×10-2). Type 2 diabetes mellitus and hypertension were identified as significant factors contributing to the association between HDP and stroke. This study provides genetic evidence supporting an association between HDP and increased stroke risk bolstering HDP as a cerebrovascular risk factor.

Correlations Between Plasma BNP Level and Risk of Thrombotic-Hemorrhagic Events After Left Atrial Appendage Closure.

Background: Percutaneous left atrial appendage closure (LAAC) reduces the incidence of stroke/bleeding events in patients with non-valvular atrial fibrillation, high risk of stroke, and contraindication in continuing anticoagulation therapy. Of them, patients with heart failure may remain at high risk of these events after LAAC. Method: Patients who underwent LAAC and were listed for the multi-center, prospectively collected OCEAN-LAAC registry, were eligible. Of them, individuals without baseline plasma B-type natriuretic peptide (BNP) levels and those dependent on hemodialysis were excluded. The prognostic impact of baseline plasma BNP levels on the incidence of death or stroke/bleeding events after LAAC was evaluated. Results: A total of 937 patients (median 78 years, 596 men) were included. The LAAC device was successfully implanted in 934 (98%) patients. Over the 366 (251, 436) days after the LAAC, 148 patients encountered a primary outcome. The common logarithm of baseline plasma BNP was independently associated with the primary outcome with an adjusted hazard ratio of 1.46 (95% confidence interval 1.06-2.18, p = 0.043). A calculated cutoff of 2.12 (equivalent to 133 pg/mL of plasma BNP level) significantly stratified the cumulative incidence of the primary outcome (29% vs. 21% for 2 years, p = 0.004). Conclusions: Using prospectively collected large-scale multi-center Japanese registry data, we demonstrated that a baseline higher plasma BNP level was independently associated with a higher incidence of stroke/bleeding events and mortality after LAAC. Further studies are warranted to understand the optimal therapeutic strategy for LAAC candidates with elevated baseline plasma BNP levels.

Perbedaan Perubahan Tekanan Darah Antara yang Diberikan Jus Mentimun (Cucumis Sativus Linn) dengan Jus Pepaya (Carica Papaya) Terhadap Penderita Hipertensi Primer di Wilayah Kerja Puskesmas Ampenan

Hypertension is the leading cause of death in Indonesia and has a high risk of heart failure, stroke, kidney failure and myocardial infarction. Management of hypertension includes lifestyle changes, diet, stress management and others. In addition, giving cucumber juice and papaya juice is also recommended as a nursing management to lower blood pressure because the content of potassium, magnesium, phosphorus can treat hypertension. The purpose of this study was to determine the difference in blood pressure changes between those given cucumber juice (cucumis sativus linn) and papaya juice (carica papaya) for patients with primary hypertension in the Ampenan Health Center work area. The research method used was a Quasy Experimental study with a pretest-posttest control group design with a quantitative approach in the cucumber juice group and the papaya juice group with a control group without treatment. Random sampling technique was used to obtain 30 respondents divided into 3 groups. The results of the study showed that the results of the dependent t test showed a p value = <0.05 so that there was a difference in blood pressure reduction between those given cucumber juice and those given papaya juice in patients with hypertension.

Long-Term Outcome of Patients with Atrial Fibrillation and High Risk of Stroke Treated with Oral Anticoagulation or Left Atrial Appendage Occlusion: A Cardinality Matched Analysis

Introduction: Atrial fibrillation (AF) poses a significant risk of stroke. Left atrial appendage occlusion (LAAO) is an alternative for patients with contraindications to oral anticoagulation (OAC) or with high risk of bleeding. This study aims to compare the outcomes of LAAO versus conventional stroke prevention in high-risk AF-patients. Methods: This secondary analysis incorporates data from the prospective Swiss-AF and Beat-AF cohorts, and the Zurich LAAO Registry. Cardinality matching was performed to create two comparable cohorts: conventional treatment (92% OAC) and LAAO. The primary endpoint was a composite of stroke, cardiovascular (CV) death, and clinically relevant bleeding. Kaplan-Meier method with competing risk analysis was used. Results: Each group included 468 patients (age 76.4 [70.5, 82.0] years, 33% female). The LAAO group exhibited higher baseline bleeding risk (HAS BLED 2.0 [1.0–3.0] versus 3.0 [3.0–4.0]; p < 0.001). Median follow-up time: 6.0 (4.7–7.0) years in conventional treatment group and 4.0 (1.5–6.1) in LAAO group. No significant difference in the primary composite endpoint (HR 0.87, 95% CI: 0.72–1.06, p = 0.18), stroke risk (HR 1.14, 95% CI: 0.66–1.97, p = 0.64), or CV mortality (HR 1.08, 95% CI: 0.82–1.42, p = 0.60) was observed between groups. LAAO correlated with a significantly lower risk of clinically relevant bleeding (HR 0.61, 95% CI: 0.47–0.80, p < 0.001). Conclusion: In this cardinality matched analysis with long-term follow-up, LAAO showed similar stroke and CV death rates but lower clinically relevant bleeding risk compared to conventional therapy in high-risk AF-patients.

Low body mass index patients have worse outcomes after mechanical thrombectomy

BackgroundThere is evidence that frailty is an independent predictor of worse outcomes after stroke. Similarly, although obesity is associated with a higher risk for stroke, there are multiple reports describing...

Insulin resistance and sarcopenia: a prognostic longitudinal link to stroke risk in middle-aged and elderly Chinese population

BackgroundStroke is the leading cause of death in middle-aged and elderly people in China. Insulin resistance (IR) and sarcopenia are both closely associated with metabolic diseases. However, the relationship between these two indicators and stroke has not been fully investigated. The aim of this study was to investigate the relationship between IR and sarcopenia and the risk of new-onset stroke.MethodsUsing longitudinal data from the China Health and Retirement Longitudinal Study (CHARLS) from 2011 to 2018, Cox proportional hazards models were used to determine the association between IR surrogate indicators and sarcopenia status with stroke incidence.ResultsIn the present study, during a median 7 years of follow-up, we included 7009 middle-aged and elderly residents, of whom 515 presented with stroke incidence. After adjustment for potential confounders, both baseline IR surrogates and sarcopenia independently predicted stroke risk. In addition, co-morbidities had a higher risk of stroke than other groups. The positive association between TyG-WC and sarcopenia on stroke risk was particularly significant [HR (95% CI): 2.03 (1.52, 2.70)]. In subgroups of different ages and sexes, the combination of IR and sarcopenia is associated with the highest risk of stroke.ConclusionsWe found that IR and sarcopenia synergistically increase the incidence of stroke in older adults. This finding provides new perspectives for stroke detection and intervention and highlights the importance of early detection and management of IR and sarcopenia in older adults.

Pre-hospital delay intention and its associated factors in the high-risk population of stroke: A latent profile analysis.

To explore the possible latent classifications of pre-hospital delayed intention at high risk of stroke and to analyze the characteristics of different profiles. A cross-sectional study was conducted in one community in Shanghai, China. 470 individuals at high risk of stroke were recruited, and self-reported questionnaires (including socio-demographic, stroke knowledge, health belief, and pre-hospital delay behavior intention scale) were distributed between April and June 2023. A latent profile analysis was employed to identify the delay intention clusters, and multinomial logistic regression was utilized to ascertain the factors influencing the latent classes of delay intention. 457 high-risk populations with a response rate of 97.23% were finally enrolled in this study. Four distinct classes were identified: High warning signs-Low delay intention (26.3%), Low warning signs-Low delay intention (17.7%), moderate level of delay intention (37.3%), and high level of delay intention (18.7%). The influencing factors included stroke knowledge, health belief, age, education background, the nearest distance to the medical institution, and household income. The pre-hospital delay intention among high-risk populations of stroke was classified into four distinct classes. It is crucial for individuals at high risk to remain vigilant towards stroke symptoms and to take prompt action. Health promotion education may be explored as a strategy to bridge the gap between the recognition of stroke symptoms and the low pre-hospital delay intention.

Moderate hypothermia circulatory arrest as a brain-protective strategy for type A aortic dissection.

Brain-protective strategies for acute type A aortic dissection (TAAD) remain controversial. Moderate hypothermia circulatory arrest (MHCA) without cerebral perfusion is not commonly used. However, we aimed to assess its safety and efficacy in 358 patients who underwent hemiarch replacement with MHCA for acute type A aortic dissection at our institution from August 2012 to August 2022. Clinical outcomes were compared according to circulatory arrest time [≤15 min (S group, n = 52) vs ≥16 min (L group, n = 306)]. The primary outcome was postoperative stroke. The S group had more older patients (72.5 vs 68.8 years; P = 0.04), a greater incidence of carotid artery malperfusion (21% vs 11%; P = 0.043) and a lower body mass index (21.7 vs 23.6 kg/m2; P < 0.01) and hemodynamic instability (3.8% vs 16%; P = 0.02) than the L group. The incidence of postoperative stroke (7.7% vs 12%; P = 0.33) and the rate of 30-day mortality (5.8% vs 6.5%; P = 0.83) did not significantly differ between groups. After adjusting for all potential confounding factors pre- and intraoperatively, there was no significant difference in postoperative outcomes between groups. MHCA alone for TAAD had comparable postoperative outcomes with circulatory arrest times under and over 15 min. However, longer arrest times were associated with a higher risk of stroke.

The left atrial appendage exclusion for prophylactic stroke reduction (leaaps) trial: rationale and design

IntroductionLeft atrial appendage exclusion (LAAE) has been shown in randomized trials to reduce ischemic stroke risk in patients undergoing cardiac surgery with known atrial fibrillation (AF). Many patients undergoing cardiac surgery without pre-existing AF are at risk of stroke and may benefit from LAAE. MethodsLeft Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) is an international, prospective, randomized, multicenter, blinded trial evaluating the effectiveness of LAAE in preventing ischemic stroke or systemic embolism in patients undergoing cardiac surgery at increased risk of AF and ischemic stroke. The trial will enroll 6500 patients at increased risk of stroke in whom a cardiac surgery is planned at 250 sites worldwide. Eligible patients are ≥18 years old, have no pre-existing AF but are at increased risk for AF and stroke (based on age, CHA2DS2-VASc score, left atrium size or brain natriuretic peptide). Patients are randomized 1:1 to receive either LAAE with AtriClip or no LAAE during cardiac surgery. Healthcare providers outside of the operating room and the patient will be blinded to allocation. The primary effectiveness endpoint is the first occurrence of ischemic stroke, systemic arterial embolism, or surgical or endovascular LAA closure. The powered secondary effectiveness endpoint is ischemic stroke or systemic arterial embolism. The primary safety endpoint is the occurrence of one of the following events (through 30 days): pericardial effusion requiring percutaneous or surgical treatment, peri-operative major bleeding, deep sternal wound infection, or myocardial infarction. Other endpoints include mortality, rehospitalizations, clinically diagnosed AF, transient ischemic attack, and cognitive and quality of life assessments. Follow-up is every 6 months for a minimum of 5 years; primary analysis occurs when 469 patients have had an ischemic stroke or systemic embolism. ConclusionThe results of the LeAAPS trial will demonstrate whether LAAE with AtriClip at the time of other routine cardiac surgery reduces stroke or systemic arterial embolism during long-term follow-up in patients at high risk of stroke without pre-existing AF. Trial RegistrationClinicalTrials.gov, Identifier: NCT05478304, https://clinicaltrials.gov/study/NCT05478304?term=%20NCT05478304&rank=1

Association of Walking Pace and Risk of Stroke: A Two- Sample Mendelian Randomization Study in a European Ancestry Cohort.

Walking pace (WP), a simple physiological indicator, has been found to be strongly associated with a variety of health outcomes in recent years. Among them, the relationship between walking pace and stroke is of particular interest. Given the high morbidity, disability and mortality associated with stroke, identifying modifiable indicators of health, such as walking pace, could help in stroke prevention strategies. However, the causal relationship between WP and stroke risk remains unclear. This study aims to determine the causal relationship between walking pace and risk of stroke using a two-sample Mendelian randomization approach in a European-ancestry population. In order to evaluate the potential for a causal relationship between WP and stroke in people of European heritage, a two-sample Mendelian randomization (MR) study was carried out. Statistics about the association of single nucleotide polymorphisms (SNPs) with stroke were taken from FinnGen (R8) (n = 284,040), while the UK Biobank genome-wide association studies (GWAS) provided the summary data on the association of SNPs with WP (n = 459,915). The inverse-variance weighted (IVW) method was utilised as the primary strategy to examine the causal connection between WP and stroke. Additionally, complementary analyses were conducted using the MR-Egger and weighted median. In order to identify the potential directional pleiotropy and heterogeneity, the MR-Egger intercept test, the MR-PRESSO test, and Cochran's Q statistic were all carried out. This connection was evaluated using OR with 95% confidence intervals (CIs). A total of 48 SNPs were identified as valid instrumental variables in our two-sample MR analysis. The result showed that a slower walking pace is associated with a higher risk of stroke (OR = 0.573; 95% CI, 0.383-0.858, P = 0.007). The "leave-one-out" analysis demonstrated that the absence of a single SNP did not affect the robustness of our results. The MR-Egger intercept test indicated that genetic pleiotropy did not introduce bias into the results [intercept = -2.9E-03, SE = 0.008, P = 0.719] and Cochran's Q test revealed no heterogeneity. Therefore, the sensitivity analyses yielded comparable results. Consequently, the results of the sensitivity analyses were consistent. Our MR study revealed that WP is inversely associated with risk of stroke. These results provided evidence that slower WP causally increased the risk of stroke, recommending that patients with lower WP should have a prompt physical examination and targeted interventions to reduce their risk of stroke and enhance their quality of life.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio: Presented as a full length oral plenary presentation at the Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, June 19, 2024.

Higher stroke risk after carotid endarterectomy and transcarotid artery revascularization is associated with relative surgeon volume ratio: Presented as a full length oral plenary presentation at the Vascular Annual Meeting of the Society for Vascular Surgery, Chicago, Ill, June 19, 2024.

Association of the Triglyceride-Glucose Index and Related Metabolites with sICAS of the Posterior Circulation

ObjectiveThe triglyceride-glucose index (TyG), a reliable marker of insulin resistance (IR), has an unclear association with symptomatic intracranial atherosclerotic stenosis in the posterior circulation (POC-sICAS). This study aimed to investigate the association between the TyG index, associated metabolites, and POC-sICAS. MethodsA total of 106 patients with POC-sICAS and 81 with asymptomatic intracranial atherosclerotic stenosis of the posterior circulation (POC-aICAS) were retrospectively enrolled. The TyG index was calculated using the formula: ln [fasting triglyceride (mg/dL) × fasting blood glucose (mg/dL)/2]. Logistic regression analysis evaluated the correlation between the TyG index and POC-sICAS. Differential metabolic markers were identified using liquid chromatography-tandem mass spectrometry. The predictive value of the TyG index and differential metabolites for POC-sICAS was assessed through receiver operating characteristic (ROC) curve analysis. ResultsPatients with POC-sICAS had a significantly higher TyG index than those with POC-aICAS (9.25 [interquartile range {IQR} 8.79-9.92] vs 8.87 [IQR 8.83-9.26]; P<0.001). The TyG index was an independent risk factor for POC-sICAS (adjusted odds ratio [OR]: 2.20, 95% confidence interval [CI]: 1.09-4.42, P=0.027), particularly in patients with diabetes mellitus (adjusted OR: 14.39, 95% CI: 2.37-87.36, P=0.004). The association was stronger in patients younger than 65 years with a high TyG index (≥8.99) (adjusted OR: 4.35, 95% CI: 1.12-16.94, P=0.034). The TyG index positively correlated with 90-day poor prognosis in those with POC-sICAS (R=0.4042, P=0003), especially in those with diabetes mellitus (R=6405, P<00001) and those younger than 65 years (R=0.4628, P=0002). Moreover, 11 differential metabolites were significantly related to the TyG index. The TyG index combined with pregnanediol showed significant discrimination between patients with POC-sICAS and POC-aICAS (area under the curve [AUC]=1, 95% CI 1.000-1.000; P<0.001). ConclusionsThe TyG index and pregnanediol could help identify patients with a high risk of ischemic stroke in POC-ICAS. Moreover, the TyG index was associated with a poor 90-day prognosis in patients with POC-sICAS.

Long-term Risk of Stroke After New-Onset Atrial Fibrillation in Sepsis Survivors: A 2-Year Follow-Up Study.

Background: Cardiovascular complications such as new-onset atrial fibrillation (NOAF) are common in sepsis and are known to increase the risk of in-hospital mortality and stroke. However, only a handful of studies have evaluated the long-term risk of stroke after NOAF in sepsis survivors. As part of our efforts to address this issue, we conducted the first-ever follow-up study in a developing country evaluating the long-term risk of stroke for sepsis survivors following NOAF. Methods: This retrospective study evaluated all adult patients admitted at the Aga Khan University Hospital between July 2019 and December 2019 with the diagnosis of sepsis. Data was collected from medical records of the included patients. Outcome measures included in-hospital mortality and ischemic stroke within 2 years. Results: Seven hundred thirty patients were included in the study; 415 (57%) were males and 315 (43%) females; mean age was 59.4 ± 18 years. 59 (8%) patients developed NOAF. The risk of stroke within 2 years in sepsis survivors was 3.5%. Six out of 30 (20%) patients in the atrial fibrillation (AF) group developed stroke, whereas 11 out of 448 (2%) patients in the non-AF group developed stroke. NOAF was associated with an increased risk of ischemic stroke within 2 years (OR = 6.6; 95% CI, 2.3-12.8; P = <.001). Conclusion: We conclude that AF occurred frequently in sepsis patients and was also associated with a 6-fold increase in the risk of ischemic stroke within 2 years. Reliable interventions for identifying high-risk patients for ischemic stroke are still poorly characterized, and this study may serve as a basis for more extensive multicenter studies to identify patients at high risk for ischemic stroke in the aftermath of septic AF and develop precise interventions for preventing it.