History Of Prior Ischemic Stroke Research Articles

Clinical characteristics and outcome of amaurosis fugax due to transient retinal ischemia: Results from a contemporary cohort

BackgroundWhether presenting an episode of amaurosis fugax (AFx) increases the risk of ischemic stroke is controversial and there is a lack of consensus in the following management. We aimed to describe the clinical characteristics and prognosis of patients with AFx due to suspected transient retinal ischemia. MethodsObservational, retrospective study of patients admitted in a Comprehensive Stroke Center with diagnosis of AFx due to suspected transient retinal ischemia between 2015 and 2020. Clinical characteristics and diagnostic-therapeutic data were collected, as well as recurrences (new episodes of amaurosis and/or ischemic strokes). Multivariable Cox regression analyses were performed to study factors associated with the risk of recurrence. ResultsWe included 91 patients with a mean age of 67.9±14.8 years, 43(47.3%) were women. After the diagnostic workup 14(15.4%) AFx were attributed to an atherothrombotic etiology, 4(4.4%) cardioembolic source, 10(11%) other determined cause (TOAST-OC) and 63(69,2%) indeterminate etiology. 71(78%) patients started antiplatelet therapy and 2(2.2%) anticoagulant therapy. After a median follow-up of 3.5 years (IQR 1.8-5.2), at least one recurrence was recorded in eight (8.8%) patients (four new AFx and four cerebral infarctions). TOAST-OC (HR=9.66, 95% CI 2.41-38.70; p=0.001) and prior history of ischemic stroke (HR=4.21. 95% CI 1.01-17.66; p=0.049) were both independently associated with the risk of recurrence. ConclusionsIn two out of three patients, AFx due to transient retinal ischemia was of undetermined cause. The risk of stroke recurrence after a first episode of AFx in our cohort was 8.8%. Patients with TOAST-OC etiology identified were at highest risk of recurrence.

Association of Statin Use With Risk of Stroke Recurrence After Intracerebral Hemorrhage.

Survivors of spontaneous intracerebral hemorrhage (ICH) may have indications for statin therapy. The effect of statins on the risk of subsequent hemorrhagic and ischemic stroke (IS) in this setting is uncertain. We sought to determine the risk of any stroke (ischemic stroke, IS or recurrent-ICH), IS and recurrent-ICH associated with statin use among ICH-survivors. Using the Danish Stroke Registry, we identified all patients admitted to a hospital in Denmark (population 5.8 million) with a first-ever ICH between January 2003-to-December 2021 who were age ≥50-years and survived >30-days. Patients were followed until August 2022. Within this cohort, we conducted three nested case-control analyses for any stroke, IS, and recurrent-ICH. We matched controls for age, sex, time since first-ever ICH, and history of prior IS. The primary exposure was statin use before or on the date of subsequent stroke or the equivalent date in matched controls. Using conditional logistic regression, we calculated adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) for any stroke, IS, and recurrent-ICH associated with statin exposure. We identified 1,959 patients with any stroke (women 45.3%; mean [SD] age, 72.6 [9.7] years) who were matched to 7,400 controls; 1,073 patients with IS (women 42.0%; mean [SD] age, 72.4 [10.0] years) who were matched to 4,035 controls, and 984 patients with recurrent-ICH (women 48.7%; mean [SD] age, 72.7 [9.2] years) who were matched to 3,755 controls. Statin exposure was associated with a lower risk of both any stroke (cases 38.6%, controls 41.1%; (aOR 0.88; 95%CI, 0.78-0.99) and IS (cases 39.8%, controls 41.8%, aOR 0.79; 95%CI, 0.67-0.92), but was not associated with recurrent-ICH risk (cases 39.1%, controls 40.8%, aOR 1.05; 95%CI, 0.88-1.24). Exposure to statins was not associated with an increased risk of recurrent-ICH but was associated with lower risk of any stroke, largely due to a lower risk of IS. Confirmation of these findings in randomized trials is needed. This study provides class III evidence that statin use in ICH patients is associated with a lower risk of any stroke and IS and not with increased risk of recurrent-ICH.

Predictors of Radiographic and Symptomatic Hemorrhagic Conversion Following Endovascular Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion.

BackgroundEndovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices.MethodologyThis is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion.ResultsA total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of <6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008).ConclusionsHistory of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.

Association of atrial 18F-fluorodeoxyglucose uptake and prior ischemic stroke in non-atrial fibrillation patients

BackgroundAtrial cardiomyopathy has gained increasing attention in the field of ischemic stroke due to its prothrombotic substrate. Timely identification of high-risk individuals without atrial fibrillation (AF) is essential in secondary prevention. We sought to explore the feasibility of atrial 18F-fluorodeoxyglucose (FDG) imaging in detecting diseased atrial substrate and in identifying ischemic stroke in a non-AF population. Methods1444 non-AF inpatients were initially identified. Among them, 196 patients had enhanced atrial FDG uptake, while 392 patients without atrial activity were selected as controls. Atrial activity, the history of ischemic stroke, and atrial cardiomyopathy were analyzed. ResultsPatients with atrial cardiomyopathy had a higher prevalence of enhanced atrial activity (47.1% vs 26.0%, P < .001), and patients with increased atrial activity had a higher prevalence of a prior history of ischemic stroke (12.2% vs 3.3%, P < .001). Multivariate regression analysis demonstrated that atrial activity was independently related to ischemic stroke after adjustment for risk factors (OR 4.02, 95% CI 1.97–8.19, P < .001) and atrial cardiomyopathy (OR 3.63, 95% CI 1.51–8.74, P = .004). ConclusionsThis study identified an association between atrial FDG activity and a history of ischemic stroke and atrial cardiomyopathy in non-AF individuals. Further longitudinal study is warranted to demonstrate their causal relationship.

A clinical study of 288 patients with anterior cerebral artery infarction

Acute ischemic stroke in the territory of anterior cerebral artery (ACA) is uncommon. Therefore, large population studies evaluating ACA infarction are scarce. We sought to evaluate epidemiological and etiological characteristics of ACA infarction compared to other territorial infarctions. We analyzed a prospectively collected stroke registry of all acute ischemic stroke patients for 19years at two tertiary hospitals. We included patients with acute ischemic stroke caused by large vessel stenosis or occlusion including ACA, middle cerebral artery (MCA), posterior cerebral artery (PCA), and vertebrobasilar artery (VBA). A total of 4171 patients were enrolled. Patients with ACA infarction (N = 288) were significantly older with more females than those with MCA, PCA, or VBA infarction. There were more patients with history of prior ischemic stroke in the ACA infarction group than in other groups. The etiology of the ACA infarction was similar to those of the MCA, PCA and also the total population (66.7-71.8% of LAA and 17.9-20.9% of CE). When patients had prior ischemic stroke history, ACA infarction was more likely to be caused by LAA than MCA or PCA infarction (OR = 6.2, 95% CI 2.0-19.2, p = 0.002 and OR = 4.0, 95% CI 1.1-14.6, p = 0.038, respectively). Patients with ACA infarction had significantly more prior ischemic stroke than those with MCA, PCA, or VBA infarction. The etiology of ACA infarction in patients with prior ischemic stroke showed significantly more LAA than that of MCA or PCA infarction.

A Population Cohort Study to Evaluate the Risk of Ischemic Stroke Among Individuals with a New Diagnosis of Cancer Compared to Matched Cancer-Free Controls: Impact of Prior Stroke History

▪Cancer is a risk factor for thrombosis, but unlike venous thrombosis, its association with ischemic stroke, and its impact on stroke management and post-stroke outcomes are not well characterized. The primary objective of this study was to measure and compare the risk of ischemic stroke in individuals with a new diagnosis of cancer and those without a history of cancer in two separate matched cohorts based on the absence (Matched Cohort 1) or presence (Matched Cohort 2) of a prior diagnosis of ischemic stroke (Figure 1).Methods: We conducted a population-based matched cohort study of adults ≥18 years using linked clinical and administrative health databases in Ontario, Canada (2010 to 2019). Individuals with a new diagnosis of cancer were matched (1:1) to cancer-free controls by age and sex. Cancer diagnoses were determined using ICD-O-3 diagnostic codes (basal and squamous cell carcinoma and primary central nervous system tumors were excluded). For cancer patients, the index date was the diagnosis date and a corresponding dummy index date was assigned to the matched cancer-free control. The primary outcome was the incidence of ischemic stroke (time to ischemic stroke following index) determined using validated ICD-9 or -10 diagnostic codes from hospitalizations or emergency department visits. Analyses were conducted separately, in parallel, for each cohort. Standardized differences were used to compare the distributions of baseline characteristics. Cumulative incidence function (CIF) curves were generated for ischemic stroke and all-cause mortality. Competing risk methods were used to calculate sub-distribution adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for ischemic stroke, where death was treated as a competing event. Interactions with the timeline at 1.5 years after index were incorporated to assess if the hazard ratio for the main exposure (cancer vs cancer-free) varied before and after the 1.5-year mark. Regression analyses were adjusted using baseline characteristics for which there was imbalance between groups.Results: Matched Cohort 1 included 620,647 individuals with cancer and 620,647 controls. Matched Cohort 2 included 13,924 individuals with cancer and 13,924 controls. Baseline characteristics were generally well balanced (Table 1). Use of antithrombotic medications (prior to index) among individuals ≥66 years was similar between the groups (data not shown). CIF curves for ischemic stroke and mortality are shown in Figure 2.In Matched Cohort 1 (no history of stroke), the risk of ischemic stroke was increased in cancer patients compared to cancer-free controls 1.5 years post-index (aHR 1.40, 95%CI 1.34-1.47). From 1.5 years to 5 years, the risk of ischemic stroke was lower in cancer patients compared to controls (aHR 0.72, 95%CI 0.69-0.74). In Matched Cohort 2 (prior history of ischemic stroke), the risk of ischemic stroke was similar at 1.5 years after the index date in individuals with and without cancer (aHR 1.00, 95%CI 0.88-1.14). From 1.5 to 5 years, the risk of ischemic stroke was reduced (aHR 0.53, 95%CI 0.46-0.62) in cancer patients compared to controls.Conclusions:Compared to cancer-free controls, the risk of ischemic stroke among individuals with a new cancer diagnosis depended on the presence or absence of prior history of ischemic stroke, a novel finding not previously reported. In individuals without a prior history of stroke, those with cancer had a 1.5-fold higher risk of ischemic stroke at 1.5 years compared to controls. In individuals with a prior history of stroke, those with cancer had a similar risk of stroke compared to controls. At 5 years post-index, the risk of ischemic stroke was lower in cancer patients in both cohorts which may reflect high early mortality rates and lower stroke risk among long-term survivors of cancer. The risk of death among cancer patients was highest during the first 1.5 years after the index date in both cohorts. However, the magnitude of the risk increase was higher in individuals without a prior history of stroke (10-fold) compared to those with a prior history of cancer (5-fold). Limitations include unknown causes of death and unavailability of some covariates (e.g. smoking and antithrombotic use in individuals aged <65 years). Future analyses will explore risk of ischemic stroke within common cancer subtypes (breast, prostate, colon, pancreas, lymphoma), and assess stroke risk factors, treatments and outcomes. [Display omitted] DisclosuresSiegal: BMS-Pfizer: Honoraria; Leo Pharma: Honoraria; Novartis: Honoraria; Portola: Honoraria; Servier: Honoraria. Carrier: Pfizer: Honoraria, Research Funding; BMS: Honoraria, Research Funding; Servier: Honoraria; Leo Pharma: Honoraria, Research Funding; Bayer: Honoraria; Sanofi: Honoraria. Gross: Valeo: Honoraria; Leo Pharma: Honoraria; Bayer: Honoraria; BMS-Pfizer: Honoraria.

Risk of Ischemic Stroke in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Prior Stroke

It has not been well studied whether transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) have lower risk of ischemic stroke (IS) in those with prior history of IS. From the Nationwide Readmission Database from October 2015 to November 2017, TAVI and SAVR above age 50 were identified with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System codes. Transapical TAVI and SAVR with concomitant bypass, mitral, or tricuspid surgery were excluded. The primary outcome was in-hospital IS. A total of 92,435 TAVI (13,292 with prior stroke) and 68,651 SAVR (5,365 with prior stroke) were identified. In-hospital IS was significantly lower in TAVI compared with SAVR (3.7% vs 8.0%, adjusted odds ratio 0.65, 95% confidence interval 0.47 to 0.89, p <0.01) with prior stroke whereas it was similar between TAVI and SAVR (1.7% vs 2.1%, adjusted odds ratio 0.97, 95% confidence interval 0.78 to 1.19, p=0.75) in those without prior stroke (P interaction < 0.001). In-hospital mortality, acute kidney injury, and bleeding were lower in TAVI compared with SAVR in patients with and without prior stroke (P interaction > 0.05 for all). This analysis of a national claims database showed that TAVI was associated with a lower risk of in-hospital IS compared with SAVR among patients with prior stroke.

Abstract P595: Incidentally-Discovered Asymptomatic Ischemic Lesions Identified Using Natural Language Processing Are Strong Risk Factors for Dementia

Background: White matter disease (WMD) and silent brain infarction (SBI) are known to be risk markers for dementia. Nevertheless, the effects of incidentally-discovered WMD and SBI on routinely-obtained neuroimages is unknown. Methods: In the retrospective cohort study, Kaiser Permanente-Southern California (KPSC) health plan enrollees aged ≥ 50 years old with a brain cross-sectional image (CT or MRI) between 2009-2019 and without a prior history of ischemic stroke, transient ischemic attack, or dementia were identified. Natural language processing (NLP) was used to identify patients with SBI and WMD on the first qualifying neuroimaging report. Cox proportional hazards regression model was applied to estimate the effects of WMD and SBI on dementia, controlling for major cardiovascular risk factors. Results: Among 262,875 individuals receiving brain neuroimaging, 13,154 (5.0%) and 78,330 (29.8%) had SBI and WMD, respectively. The table below summarizes the crude dementia incidence rates. The crude hazard ratio (HR) was 3.69 (95% CI 3.58-3.80) for WMD and 2.80 (95% CI 2.68-2.93) for SBI. In the multivariable model controlling for all major cardiovascular risk factors, the effect of WMD on dementia risk was found to be stronger in younger compared to older patients and for CT- compared to MRI-discovered lesions. With CT, the adjusted HR was 3.08 (95% CI 2.84-3.34) for those &lt; age 70 and 1.90 (95% CI 1.83-1.97) for those ≥ age 70. With MRI, the adjusted HR was 2.58 (95% CI 2.31-2.87) for those &lt; age 70 and 1.59 (95% CI 1.45-1.75) for those ≥ age 70. The adjusted HR associated with a finding of SBI was 2.01 (95% CI 1.78-2.32) for patients age &lt;70 and 1.26 (95% CI 1.20-1.32) for patients age ≥70, and was not modified by imaging modality. Conclusion: Incidentally-discovered WMD and SBI are common in patients ≥ age 50 and are associated with substantial increase in the risk of subsequent dementia. The findings may represent an opportunity for dementia prevention.

Abstract P604: Incidentally-Discovered Asymptomatic Ischemic Lesions Identified Using Natural Language Processing Are Strong Risk Markers for Future Ischemic Stroke

Background: White matter disease (WMD) and silent brain infarction (SBI) are known to be risk markers for stroke. Nevertheless, the predictive value of these changes when seen incidentally on routinely-obtained neuroimages is unknown. Methods: In this retrospective cohort study, Kaiser Permanente-Southern California health plan enrollees aged ≥ 50 years old with a brain CT or MRI scan between 2009-2019 and without a prior history of ischemic stroke, transient ischemic attack, or dementia were identified. Natural language processing (NLP) was used to identify patients with SBI and WMD on the index neuroimaging report. We used Cox proportional hazards to estimate the risk of future ischemic stroke associated with the presence of SBI and of WMD, controlling for major stroke risk factors. Results: Among 262,875 individuals receiving brain neuroimaging, 13,154 (5.0%) and 78,330 (29.8%) had SBI and WMD, respectively. The Table below summarizes the crude stroke incidence rates. The crude hazard ratio (HR) was 3.40 (95% CI 3.25-3.56) for SBI and 2.63 (95% CI 2.54-2.71) for WMD. In the multivariable model controlling for all major stroke risk factors, the effect of SBI was found to be stronger in younger versus older patients and for MRI- versus CT-discovered lesions. With MRI, the average adjusted HR over time was 2.95 (95% CI 2.53-3.44) for those &lt; age 65 and 2.15 (95% CI 1.91-2.41) for those ≥ age 65. With CT scan, the average adjusted HR over time was 2.48 (95%CI 2.19-2.81) for those &lt; age 65 and 1.81 (95% CI 1.71-1.91) for those ≥ age 65. The adjusted HR associated with a finding of WMD was 1.76 (95% CI 1.69-1.82) and was not modified by age or imaging modality. The effect of SBI decreased gradually over time, while the effect of WMD remained constant. Conclusion: Incidentally-discovered SBI and WMD are common in patients ≥ age 50 and are associated with substantial increases in the risk of subsequent symptomatic stroke. The findings may represent an opportunity for stroke prevention.

Incidentally-Discovered Silent Cerebrovascular Disease Identified Using Natural Language Processing Are Strong Risk Markers for Future Ischemic Stroke

Background: White matter disease (WMD) and silent brain infarction (SBI) are known risk markers for stroke. Nevertheless, the predictive value of these changes when seen incidentally on routinely-obtained neuroimages is unknown. Methods: We included patients age ≥ 50 in the Kaiser Permanente Southern California (KPSC) health system scanned between 2009-2019 with a head CT or MRI and no prior history of ischemic stroke, transient ischemic attack, or dementia. We used natural language processing (NLP) to identify patients with SBI and WMD from the corresponding report of the index neuroimage. We used Cox proportional hazards to estimate the risk of future ischemic stroke associated with the presence of SBI and of WMD, controlling for major stroke risk factors. Results: Among 262,875 individuals receiving neuroimaging, NLP identified 13,154 (5·0%) with SBI and 78,330 (29·8%) with WMD. The incidence rate of future stroke was 32·5 (95% CI 31·1, 33·9) per 1,000 patient-years for patients with SBI; 19·3 (95% CI 18·9, 19·8) for patients with WMD and 6.8 (95% CI 6·7, 7·0) for patients without silent cerebrovascular disease. The crude HR associated with SBI was 3.40 (95% CI 3·25 to 3·56); and for WMD was 2·63 (95% CI 2·54 to 2·71). Adjusted for major stroke risk factors, the effect of incidentally-discovered SBI was found to be stronger in younger compared to older patients and for MRI- compared to CT-discovered lesions. With MRI, the adjusted HR was 2·95 (95% CI 2·53 to 3·44) for those = age 65. The adjusted HR associated with a finding of WMD was 1·76 (95% CI 1·69 to 1·82) and was not modified by age or imaging modality. Conclusion: Incidentally-discovered SBI and WMD are common in patients > age 50 and are associated with substantial increases in the risk of subsequent symptomatic stroke. These findings present an opportunity for stroke prevention. Funding Statement: This work was funded by a National Institutes of Health (NIH) grant (R01-NS102233). Declaration of Interests: None to declare. Ethics Approval Statement: The study protocol was approved by Tufts Medical Center’s and KPSC’s Institutional Review Board.

Impact of atrial fibrillation on the risk of ischemic stroke in patients on hemodialysis: BOREAS-HD3 Study.

Atrial fibrillation (AF) is an established risk factor for ischemic stroke in a general population. However, its impact in patients on hemodialysis (HD), a group with a high risk for stroke, is still controversial. Here we examined this issue in a Japanese cohort. This study was designed as a multicenter cohort study. HD patients (n = 1,067) were enrolled from 22 institutes in January 2009 and followed up for 3years. Patients with missing data (n = 196) or kidney transplantation (n = 4) were excluded, and 867 patients contributed to the analysis of the risk of new-onset of ischemic stroke. At baseline, AF was observed in 123 patients (14.2%, AF group) and not in the others (n = 744: 85.8%, non-AF group). During a follow-up period of 31.3months, the cumulative incidence rate for ischemic stroke was significantly higher in the AF group than in the non-AF group (6.5% vs. 2.9%, p < 0.05). In Cox regression analysis, AF was a significant independent risk factor for new-onset of ischemic stroke after adjustment for age, sex, prior history of ischemic stroke, use of warfarin, dialysis vintage, comorbidity of diabetic nephropathy, and interdialytic weight gain (hazard ratio 2.17-2.68). Present analyses using comprehensive adjustment for multiple confounders, including prior history of ischemic stroke, indicated that AF independently increases the risk of new-onset of ischemic stroke by more than twofold in Japanese HD patients.

Abstract TMP57: The Influence of Telomere Length on Ischemic Stroke Risk and Phenotype

Background: Telomeres are specific nucleotide repeats that play a central role in control of DNA damage related to cell division and aging. The degree of telomere shortening that occurs as part of aging is associated with age-related non-cancer diseases like hypertension, diabetes mellitus and coronary artery disease. Although a number of studies have highlighted that a similar relationship might exist with ischemic stroke, contradictory reports are also present in the literature. In this study we investigated the association between telomere length and ischemic stroke, not only in terms of stroke risk in general, but also from the perspective of stroke etiology and severity. Methods: In a Caucasian cohort, telomere length was determined by Southern blot from peripheral blood leukocytes in 163 consecutive ischemic stroke patients, and 210 controls without any prior history of ischemic stroke. Univariate and multivariate analyses were performed to determine the contribution of telomere length to stroke risk, stroke etiology, admission NIHSS score and DWI lesion volume. Results: The median (interquartile range) telomere length was 7.0 (5.5-9.0) kb in the overall population. Expectedly, telomere length was negatively correlated with aging (r=-0.23; p&lt;0.001). A short telomere length (i.e. lowest quartile; ≤5.5 kb) was significantly associated with ischemic stroke (OR 3.0, 95%CI 1.8-5.1) when adjusted for age, gender and cardiovascular risk factors. This significant relationship persisted for all stroke etiologies, except for other rare causes of stroke. There was no significant relationship between admission lesion volume and telomere length; however, patients with short telomeres presented with more severe strokes (NIHSS score ≥16) when adjusted for age, risk factors, stroke etiology and infarct volume (OR 7.0; 95%CI 1.7-28.7). Conclusion: Almost all etiologic subtypes of ischemic stroke are related to shortened telomere length, irrespective of the age of the subject. Furthermore, presence of short telomeres negatively influences the tolerance of brain to ischemia, thereby causing more severe clinical phenotypes in these patients in the setting of ischemic stroke.

P1879Characterization of cardiac diagnostic care pathways by indication and physician specialty in a real-world dataset of 314,554 patients

Abstract Background A variety of modalities exist for diagnosing cardiac arrhythmias via ambulatory ECG recording. These can range from short-term (i.e. ≤48 hours) holter monitoring, medium-term external monitoring for up to 30 days, and long-term monitoring via an implantable cardiovascular monitor (ICM). Purpose To quantify the prevalence of different diagnostic care pathways for cardiac arrhythmias in a large, real-world dataset. Methods A de-identified database of aggregated EHR data from 2015–2017 was used to identify patients with any procedure or service received for an ambulatory cardiac diagnostic monitor. Three categories of diagnostic monitoring technologies were identified: (1) Holter monitoring for up to 48 hours, (2) External ECG and event monitoring for up to 30 days via external loop recorder, mobile cardiac telemetry (MCT), or other external ECG recording device, and (3) ICMs. Patients with their first monitor in 2015 or later were selected. The number of patients that had their initial monitor in each of the different categories were quantified, as well as the number that followed a care pathway progression from shorter-term to longer-term monitoring. Patients were grouped by clinical history (syncope or ischemic stroke diagnosis codes in the 6 months prior) as well as by whether they had a clinical interaction with an electrophysiologist (EP) at any point in their care pathway. Results A total of 314,554 patients were identified with a mean follow-up duration of 340.1±232.5 days. The initial monitor type used across all patients was 68.8% holter, 27.7% extended holter/MCT/external loop recorder, and 3.5% ICMs. 5.1% of all patients received multiple categories of monitoring. 50,812 patients had a prior history of syncope, 46.4% of which were seen by an EP. 28,374 patients had a prior history of ischemic stroke, with 50.9% seen by an EP. The figure shows that patients seen by an EP are more likely to receive ICMs than those not seen by an EP (20.6% vs. 3.8% for syncope; 25.3% vs. 5.7% for stroke; both p&lt;0.001). Patients seen by an EP are also more likely to receive multiple categories of progressively-longer monitoring than those not seen by an EP (10.4% vs. 4.6% for syncope; 8.3% vs. 4.0% for stroke; both p&lt;0.001). Conclusion Cardiac diagnostic care pathways for syncope and ischemic stroke are significantly different between those patients that are seen by an EP versus those that are not. Relatively few patients overall received multiple types of cardiac diagnostic monitoring. Acknowledgement/Funding Medtronic

High Risk of One-year Stroke Recurrence in Patients with Younger Age and Prior History of Ischemic Stroke.

Recurrent ischemic strokes increase the risk of disability and mortality. The role of conventional risk factors in recurrent strokes may change due to increased awareness of prevention strategies. The aim of this study was to explore the potential risk factors besides conventional ones which may help to affect the advances in future preventive concepts associated with one-year stroke recurrence (OSR). We analyzed 6,632 adult patients with ischemic stroke. Differences in clinical characteristics between patients with and without OSR were analyzed using multivariate logistic regression and classification and regression tree (CART) analyses. Among the study population, 525 patients (7.9%) had OSR. Multivariate logistic regression analysis revealed that male sex (OR 1.243, 95% CI 1.025 - 1.506), age (OR 1.015, 95% CI 1.007 - 1.023), and a prior history of ischemic stroke (OR 1.331, 95% CI 1.096 - 1.615) were major factors associated with OSR. CART analysis further identified age and a prior history of ischemic stroke were important factors for OSR when classified the patients into three subgroups (with risks of OSR of 8.8%, 3.8%, and 12.5% for patients aged > 57.5 years, ≤ 57.5 years/with no prior history of ischemic stroke, and ≤ 57.5 years/with a prior history of ischemic stroke, respectively). Male sex, age, and a prior history of ischemic stroke could increase the risk of OSR by multivariate logistic regression analysis, and CART analysis further demonstrated that patients with a younger age (≤ 57.5 years) and a prior history of ischemic stroke had the highest risk of OSR.

Elevated anticardiolipin titer as a stroke factor in young patients in kirkuk city

Background: Stroke is a common cause of morbidity and mortality worldwide, and it is the third leading cause of medical death in developed countries. Stroke can be classified into ischemic disease (80%) and hemorrhagic disease (20).&#x0D; Subject and methods: A case-control study done in the period extending from November 2013 to April 2014 in neuro medicine department in Azadi teaching hospital in Kirkuk city in Iraq. This study involving 2 study groups, each one of them, including 50 patients. The first group (cases) included 50 patients diagnosed as having an ischemic stroke by neurologist their ages were less than 45 years .in another group (control), 50 patients involved admitted to the same hospital with no history of prior ischemic stroke.&#x0D; Results: Fifty patients with stroke of ischemic orgin and 50 controls included in the study. Table 1 summarize demographic and clinical characteristics of patients and control groups, control was older than ischemic stroke patient with no significant correlation (P-value=0.33). Gender distribution showing a significant correlation in regarding female sex in both groups (P-value=0.001). Ischemic stroke according to our findings is more prevalent in those patients with Hypertension with 66% of patients in comparison to 42% of control patients with P-value of 0.0001, diabetic patients with double percentage (72%) to those in control group (36%) with P-value of 0.0001,coronary arterial disease ,valvular heart disease and rhythm disease such as atrial fibrillation seen to be more popular in those patients with ischemic stroke with no significant value in regarding to patients having coronary and valvular heart disease (P-value=0.11,0.21) and strongly associated with those patient presented with atrial fibrillation (P-value=0.0001).&#x0D; Conclusion: Elevated anticardiolipin antibodies are seen to be as an independent risk factor for ischemic stroke.

The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms.

Cerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes. This was a retrospective cohort study using the National Health Insurance Service-National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed. A total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14-0.85). Consistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

Abstract 35: Safety and Outcomes of Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke Patients With Recent Stroke: Findings From Get With the Guidelines-Stroke

Introduction: Guidelines recommend against use of Intravenous tissue Plasminogen Activator (IV tPA) in acute ischemic stroke (IS) patients with prior IS within past 3 months. However, there are limited data on the safety of IV tPA in this population. Methods: Using American Heart Association Get With the Guideline-Stroke between February 2009 and December 2015 we identified 1399 acute IS patients otherwise eligible for IV tPA but with IS within prior 3 months. Of these, 293 were treated with IV tPA. We compared them with 30,655 acute IS patients treated with IV tPA but with no prior IS history. Multivariable logistic regression models were used to evaluate association between recent prior IS (within 90 days, 1-14 days, 15-30 days, 31-90 days) with symptomatic intracranial hemorrhage (sICH) and discharge outcomes after IV tPA. Results: Age (median 80, IQR 74-87) and stroke severity as measured by NIHSS (median 11, IQR 6-18) were similar for acute IS patients treated with IV tPA with or without recent IS. However, patients with recent IS were more likely to have higher prevalence of cardiovascular risk factors. In unadjusted analysis, patients with recent IS within prior 90 days were more likely to experience sICH and in-hospital mortality and less likely to have good functional outcomes (modified Rankin Scale score, 0-1) than those with no history of IS (Table 1). On multivariate analysis, risk for sICH and in-hospital mortality was not significantly different but good functional outcomes at discharge occurred less often among patients with history of IS within prior 90 days. In a prespecified subgroup analysis, the increased risk for sICH appeared to concentrate in those with recent IS within 14 days of the acute index IS but not in later time window. Conclusions: Recent IS within 90 days is associated with increased risk of worse outcomes in acute IS patients treated with tPA. In our study, the risk of sICH after tPA was highest among those with a history of prior IS within the past 14 days.

Utilization and safety of extracranial-intracranial bypass surgery in symptomatic steno-occlusive disorders.

OBJECTIVE:The objective of this study was to investigate patterns of utilization and safety of extracranial–intracranial (EC-IC) bypass in patients with symptomatic cerebrovascular steno-occlusive disorders.METHODS:Patients with one of the steno-occlusive conditions (defined as symptomatic intracranial stenosis, extracranial stenosis, and moyamoya disease) were identified using all nonfederal hospitalizations in New York (2005–2014) and Florida (2005–2015). EC-IC bypass surgery was defined using the corresponding procedure codes. Patients were included if there was a prior history of ischemic stroke or transient ischemic attack. Patients were excluded for any preceding diagnosis of cerebral hemorrhage, aneurysm, or trauma. The primary outcome was perioperative ischemic stroke, cerebral hemorrhage, or mortality occurring within 30 days of surgery. We also determined yearly trends for the volume of EC-IC bypass procedures in the study period.RESULTS:Among 346 patients with steno-occlusive disease treated with EC-IC bypass, median age was 52.5 years and 52.5% were female. Rates of EC-IC bypass surgery procedure increased until 2011 and then decreased coinciding with the publication of the Carotid Occlusion Surgery Study trial. Thirty-day event rates of stroke, hemorrhage, or death decreased in patients treated with EC-IC bypass (odds ratio: 0.2, confidence interval: 0.0.4–0.99; P = 0.03) over the 10-year study period.CONCLUSIONS:Overall utilization of EC-IC bypass procedure is relatively low, whereas the 30-day complication rates for patients with steno-occlusive conditions appear to be relatively low and improving. Further research is needed to confirm these findings and to determine the subset of patients who would most likely benefit from this intervention.

Risk of ischemic stroke and the use of individual non-steroidal anti-inflammatory drugs: A multi-country European database study within the SOS Project

Background and purposeA multi-country European study using data from six healthcare databases from four countries was performed to evaluate in a large study population (>32 million) the risk of ischemic stroke (IS) associated with individual NSAIDs and to assess the impact of risk factors of IS and co-medication.MethodsCase-control study nested in a cohort of new NSAID users. For each case, up to 100 sex- and age-matched controls were selected and confounder-adjusted odds ratios for current use of individual NSAIDs compared to past use calculated.Results49,170 cases of IS were observed among 4,593,778 new NSAID users. Use of coxibs (odds ratio 1.08, 95%-confidence interval 1.02–1.15) and use of traditional NSAIDs (1.16, 1.12–1.19) were associated with an increased risk of IS. Among 32 individual NSAIDs evaluated, the highest significant risk of IS was observed for ketorolac (1.46, 1.19–1.78), but significantly increased risks (in decreasing order) were also found for diclofenac, indomethacin, rofecoxib, ibuprofen, nimesulide, diclofenac with misoprostol, and piroxicam. IS risk associated with NSAID use was generally higher in persons of younger age, males, and those with a prior history of IS.ConclusionsRisk of IS differs between individual NSAIDs and appears to be higher in patients with a prior history of IS or transient ischemic attack (TIA), in younger or male patients. Co-medication with aspirin, other antiplatelets or anticoagulants might mitigate this risk. The small to moderate observed risk increase (by 13–46%) associated with NSAIDs use represents a public health concern due to widespread NSAID usage.

Ticagrelor for stroke prevention in patients with vascular risk factors: A systematic review and meta-analysis

BackgroundEven though ticagrelor was beneficial in prior cardiovascular trials, its efficacy in stroke prevention was inconclusive in recent randomized-controlled clinical trials (RCTs). We sought to consolidate the evidence for efficacy and safety of ticagrelor for stroke prevention. MethodsWe conducted a systematic review and meta-analysis of RCTs in major databases reporting following efficacy and safety outcomes among patients with cerebral or cardiovascular risk factors treated with ticagrelor (vs. control): ischemic stroke (IS), combined ischemic and hemorrhagic stroke, myocardial infarction (MI), cardiovascular death (CVD), all-cause mortality, and major bleeding events. We pooled risk ratios (RR) and adjusted hazard ratios (HRadjusted) from each trial using random-effect models, and assessed the heterogeneity using Cochran Q and I2 statistics. ResultsWe identified 13 RCTs, comprising 64,360 patients. In comparison to control group, ticagrelor reduced the risk of IS (RR = 0.86; 95%CI = 0.78–0.95, p = .003; I2 = 0%), combined ischemic and hemorrhagic strokes (risk ratio: 0.90; 95%CI: 0.81–1.00, p = .05; I2 = 0%), and composite stroke/MI/CVD (RR = 0.90; 95%CI = 0.81–0.99, p = .03; I2 = 47%). Ticagrelor was not associated with increased risk of mortality (RR: 0.95; 95%CI: 0.84–1.07; p = .40) or major bleeding events (RR: 1.18; 95%CI: 0.92–1.50; p = .19). Additional analyses demonstrated that ticagrelor reduced the risk of incident strokes (HRadjusted = 0.87; 95%CI = 0.76–0.98; p = .03) and composite stroke/MI/CVD (HRadjusted = 0.88; 95%CI = 0.78–0.98; p = .02) among patients with prior history of IS or transient ischemic attack. ConclusionsTicagrelor seems to be a beneficial option for primary and secondary stroke prevention in patients with cerebral or cardiovascular risk factors. Further RCTs are needed to evaluate the role of ticagrelor in secondary stroke prevention.