Prior History Of Stroke Research Articles

Abstract 4119094: Claims-Based versus Registry-Reported Stroke Events in the NCDR Left Atrial Appendage Occlusion Registry

Background: Administrative claims data are increasingly used for post-marketing surveillance of drugs and medical devices, though data reliability remains uncertain. Given their associated morbidity and mortality, stroke events are particularly important to monitor for cardiovascular therapies such as transcatheter left atrial appendage occlusion (LAAO). However, there are limited data comparing stroke events in contemporary claims data to events reported in large nationwide registries with comprehensive data collection. Aim: To compare stroke events in Medicare claims data with adjudicated registry-reported events in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion (LAAO) Registry. Methods: LAAO Registry data were linked with 2016-2022 Medicare inpatient claims. Primary diagnosis ICD-10 codes from inpatient hospitalizations were compared to adjudicated registry-reported ischemic and hemorrhagic stroke events occurring after discharge with up to two years of follow-up. In multiple secondary analyses, primary and secondary diagnosis codes were counted as events in claims data and patients with prior history of stroke were also excluded. Results: The cohort included 71,043 adults ≥65 years old in the LAAO Registry with inpatient Medicare data. Following LAAO hospitalization discharge, there were 1405 claims-based and 1308 registry-reported total stroke events. Sensitivity and positive predictive value (PPV) of claims for identifying registry-reported events were 60.8% and 50.5% for ischemic stroke (kappa statistic 0.55), 42.7% and 50.5% for hemorrhagic stroke (kappa 0.46), and 58.1% and 54.1% for all stroke (kappa 0.55), respectively. Inclusion of secondary diagnosis codes improved sensitivity of claims (70.3% for ischemic stroke, 53.9% for hemorrhagic stroke and 67.0% for all stroke), but PPV decreased (44.8% for ischemic stroke, 34.8% for hemorrhagic stroke and 47.8% for all stroke). Specificity and negative predictive values of claims data were >98% for all stroke types. Findings were similar after excluding patients with prior history of stroke ( Table ). Conclusions: Among Medicare patients in the LAAO Registry, administrative claims data had moderate agreement with adjudicated registry-reported stroke events. Claims data may not reliably capture all stroke events in real-world practice, and additional event ascertainment methods may be needed to ensure accurate assessment of stroke in post-marketing surveillance efforts.

Abstract 4134345: Diastolic Dysfunction And The Risk Of Stroke And Major Bleeding

Background: Diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident ischemic stroke/transient ischemic attack (TIA) and with bleeding events is not well established. Aims: To examine the association of presence and severity of DD with the risk of incident ischemic stroke/TIA and major bleeding. Methods: A total of 219,667 patients who underwent at least one echocardiogram between 2010 and 2022 at a large academic institution and were followed for at least 3 months were included. Patients with prior history of stroke or TIA (n=21,505, 10%) were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups, based on the most severe DD assessment: Normal (n=113,265), grade I (n=21,981), grade II (n=7,215), and grade III (n=1,627). Patients in whom the presence of DD could not be determined (n=54,074) were excluded. The final study cohort (n=144,088) was followed to the endpoint of hospital admission for ischemic stroke/TIA or for major bleeding. Results: Over a median follow-up of 3.4 years, 3482 (2.4%) patients were hospitalized for stroke/TIA and 6994 (4.9%) for major bleeding. After adjusting for several confounding variables (Table), DD remained a strong predictor of incident stroke/TIA (hazard ratio (HR)=1.34 per grade increase in DD, p<0.001, Figure) and of major bleeding (HR=1.32 per grade increase in DD, p<0.001, Figure). These results were similar in patients with (n=11,508, 8%) or without prior history of atrial fibrillation. Conclusions: Patients with DD have a heightened risk of ischemic cerebrovascular accidents and major bleeding independent of the presence of atrial fibrillation. These risks escalate with the severity of DD. DD should be considered when counseling patients regarding their risk profile and management options.

Abstract 4137914: Eligibility for Semaglutide in US Adults with Diabetes and Potentially Preventable Cardiovascular Events Projected from the SUSTAIN-6 Trial

Background: The Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects with Type 2 Diabetes (SUSTAIN-6) trial showed cardiovascular disease (CVD) benefits of semaglutide therapy in patients with type 2 diabetes mellitus (T2DM). Purpose: To estimate the number of US adults with T2DM that may be eligible for semaglutide based on SUSTAIN-6 eligibility criteria and the number of preventable CVD events from semaglutide treatment based on observed CVD event reductions in SUSTAIN-6. Methods: We included US adults with T2DM from the National Health and Nutrition Examination Survey (NHANES) 2011– 2020 who had eligibility criteria from SUSTAIN-6. This included an HbA1c>7.0%, age > 50 with established CVD, heart failure, or chronic kidney disease or an age > 60 with at least one CVD risk factor. We estimated the number of primary composite and secondary CVD endpoints that would occur based on SUSTAIN-6 treated and placebo published event rates, with the difference indicating the number of preventable events (and annualized based on median 2.1 year follow-up time). Results: Among 5002 (projected to 34.0 million [M]) adults we identified with T2DM, we estimated 1,132 (6.9 million) (20.3%) to fit SUSTAIN-6 eligibility criteria. Compared to SUSTAIN-6 trial participants, our sample was slightly older, had a higher proportion of Black participants, shorter duration of diabetes, lower HbA1c and diastolic blood pressure, but similar body mass index and systolic blood pressure. Prior history of ischemic heart disease, myocardial infarction, and stroke were also less common in our NHANES sample. From SUSTAIN-6 semaglutide and placebo primary composite CVD event rates of 6.6% and 8.9%, respectively, we estimated 456,060 and 614,990 events would occur, respectively, for a total of 159,930 preventable CVD events, or 75,681 on an annualized basis. We similarly estimated annualized preventable events for secondary outcomes as shown in the Figure. Conclusion: Semaglutide may prevent many fatal and non-fatal CVD events if provided to US adults meeting SUSTAIN-6 eligibility criteria. More efforts are needed to educate the healthcare providers on the CVD benefits from newer diabetes therapies, including semaglutide.

Diastolic Dysfunction and the Risk of Stroke and Major Bleeding.

Left ventricular diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes including atrial fibrillation. Whether DD is independently associated with incident stroke and transient ischemic attack (TIA) and with bleeding events is not known. We performed this observational cohort analysis to examine the impact of DD on the risk of stroke/TIA and major bleeding. Patients who underwent at least 1 cardiac echocardiogram and were followed for at least 3 months were included in this study. Patients with a prior history of stroke, TIA, or major bleeding, as determined by International Classifications of Diseases codes, were excluded. Smart key-phrase search was applied to echocardiographic reports to classify patients into 4 groups based on the most severe DD assessment. Patients in whom the presence of DD could not be determined were excluded. The final study cohort was followed to the end point of hospital admission for stroke/TIA and major bleeding, and independent predictors of these events were evaluated using the multivariable Cox proportional hazards method. The final study cohort (age, 56±18 years; 56% women) had 96 702 patients with no DD and 18 164, 5881, and 1340 patients with DD grades I, II, and III, respectively. Over a median follow-up of 3.4 years, 2938 (2.4%) patients were hospitalized for stroke/TIA and 5567 (4.6%) for major bleeding. After adjusting for age, the CHA2DS2-VASc score, chronic kidney disease, use of antiplatelet agents, use of anticoagulation agents, the year of echocardiographic testing, household income, and history of atrial fibrillation, DD remained a strong predictor of incident stroke/TIA (hazard ratio, 1.22 per grade increase in DD [95% CI, 1.16-1.29]; P<0.001) and major bleeding (hazard ratio, 1.20 per grade increase in DD [95% CI, 1.16-1.25]; P<0.001). DD is independently associated with a higher risk of cerebrovascular accidents and major bleeding. DD should be considered when counseling patients regarding their risk profile and management options.

Iterative random forest-based identification of a novel population with high risk of complications post non-cardiac surgery

Assessing the risk of postoperative cardiovascular events before performing non-cardiac surgery is clinically important. The current risk score systems for preoperative evaluation may not adequately represent a small subset of high-risk populations. Accordingly, this study aimed at applying iterative random forest to analyze combinations of factors that could potentially be clinically valuable in identifying these high-risk populations. To this end, we used the Japan Medical Data Center database, which includes claims data from Japan between January 2005 and April 2021, and employed iterative random forests to extract factor combinations that influence outcomes. The analysis demonstrated that a combination of a prior history of stroke and extremely low LDL-C levels was associated with a high non-cardiac postoperative risk. The incidence of major adverse cardiovascular events in the population characterized by the incidence of previous stroke and extremely low LDL-C levels was 15.43 events per 100 person-30 days [95% confidence interval, 6.66–30.41] in the test data. At this stage, the results only show correlation rather than causation; however, these findings may offer valuable insights for preoperative risk assessment in non-cardiac surgery.

Cardiac amyloidosis and left atrial appendage closure: a multicenter retrospective study

Abstract Background Thromboembolic stroke risk remains a clinical challenge in cardiac amyloidosis (CA) patients with atrial fibrillation because of the increased prevalence of left atrial appendage thrombi irrespective of CHA2DS2-VASc score and a higher prevalence of factors that increase the risk of bleeding with anticoagulation. Left atrial appendage closure (LAAC) is an effective option in patients with atrial fibrillation and high bleeding risk; however, data describing a LAAC strategy for stroke prevention in patients with CA is limited. Among non-CA patients, procedural success and serious complication rates are around 98% and 3% respectively. Purpose In this multicenter retrospective study, we aimed to investigate whether left atrial appendage closure (LAAC) could reduce the risk of bleeding complications and ischemic cerebrovascular events in patients with CA. Methods In an international multi-center retrospective study, patients with CA that underwent LAAC were included. The diagnosis of CA was established on the basis of histologic confirmation or advanced multimodality cardiac imaging as per current consensus statements. Results A total of 28 patients (93% male; 87% ATTR-CA; 13% AL-CA; mean age 80 years) met inclusion criteria. At baseline, mean CHA2DS2-VASc and HAS-BLED scores were 4 and 3 respectively, mean left ventricular ejection fraction was 50%, and mean indexed left atrial volume was 58 mL/m2. 21% of patients had a prior history of ischemic stroke, 14% prior history of hemorrhagic stroke, 7% prior transient ischemic attack, and 54% had a prior history of major or minor bleeding. Procedural success was achieved in 26 patients (93%) with procedural complications occurring in 2 patients (vascular access site bleeding and cardiac tamponade). Regarding in-hospital and follow-up complications, 0% ischemic stroke, 0% hemorrhagic stroke, and major or minor bleeding in 4% of patients. During follow up, device thrombosis occurred in only 1 patient. Conclusion LAAC is a feasible and effective alternative to anticoagulation in patients with CA and excessive bleeding risk, with procedural success and complication rates similar to reported studies of non-CA patients.

Implantable cardioverter defibrillators among elderly survivors of out-of-hospital cardiac arrest

Abstract Background Survivors of out-of-hospital cardiac arrest (OHCA) with a shockable rhythm are at increased risk of cardiac arrest, and clinical practice guidelines recommend placement of an implantable cardioverter defibrillator (ICD) in the absence of a reversible cause and an expected meaningful survival of at least one year. Contemporary data on the prevalence of secondary prevention ICD placement among OHCA survivors remain limited. Purpose Examine patterns of secondary prevention ICD implantation in survivors of OHCA due to a shockable rhythm in a large national registry. Methods Using 2013-2019 data from the Cardiac Arrest Registry to Enhance Survival (CARES) linked to Medicare files, we identified 3,226 patients aged &amp;gt;65 years who survived to discharge following OHCA due to an initial shockable rhythm from January 1, 2013 to December 31, 2019. Patients with severe neurological disability, prior history of cancer, and those discharged to hospice were excluded. We calculated cumulative prevalence of ICD implantation at discharge, 90 days, and 6 months post cardiac arrest. Multivariable hierarchical regression models with random hospital effects were used to determine the adjusted association of patient characteristics with ICD implantation and quantify the extent of variation in ICD implantation across sites, using a median odds ratio (OR) and 95% confidence interval (CI). Results Patients’ mean age was 72.2 years; 23.5% were women, 10% were Black and 4% Hispanic. Among 3,226 OHCA patients, 997 (30.9%) received an ICD before discharge; 1,266 (39.2%) received an ICD within 90 days of cardiac arrest, and 1,287 (39.9%) received an ICD by 6 months. After adjusting for differences in demographics and co-morbidities, the odds of receiving an ICD at discharge were significantly lower in patients aged 85 years and older, women, patients with prior history of stroke or diabetes, patients who presented with acute myocardial infarction (P&amp;lt;0.05 for all). There was no significant difference in ICD implantation by race and ethnicity (P=0.94) (Table 1). Even after adjusting for patient demographics, co-morbidities, and presentation with acute myocardial infarction, there was large variation in hospital rate of ICD implantation at discharge, with a median odds ratio of 1.65 (95% CI 1.41-1.86). Conclusion Fewer than 1 in 3 patients with OHCA due to a shockable rhythm are discharged with a secondary prevention ICD. Although implantation of ICD was associated with patient variables, there was no difference in ICD implantation by race and ethnicity. There was large variation across hospitals in ICD implantation even after adjusting for patient variables highlighting an opportunity for improving post-arrest management of cardiac arrest survivors.

Is the incidence of cerebral embolic events underestimated in Takotsubo cardiomyopathy?

Abstract Introduction Although initially considered a benign cause of transient left ventricular dysfunction, Takotsubo cardiomyopathy (TCM or stress cardiomyopathy) has become an increasingly recognized cause of cerebral embolic events. Prior case series have suggested a 0.9% to 3% risk of ischemic stroke following the diagnosis of TCM. With the growing number of cases of stress cardiomyopathy reported since the COVID pandemic, we want to evaluate if the risk of stroke in the literature has been underestimated. Purpose In our study, we want to evaluate the risk of ischemic stroke one year following the diagnosis of Takotsubo cardiomyopathy in our university health centre. We also want to evaluate the time interval between the incidence of stroke and the initial diagnosis of TCM. Methods In this retrospective single-centre observational study, we collected data from 267 consecutive patients hospitalized for a diagnosis of Takotsubo cardiomyopathy (confirmed by echocardiography and cardiac catheterization) between May 2008 and December 2017 at our medical centre in Sherbrooke. All patients were followed for a minimum of one year. We excluded 14 patients with a prior history of stroke or a diagnosis of atrial fibrillation in the year following the diagnosis of TCM. We used a descriptive statistical analysis to evaluate the rate and time to event up to 1 year after the diagnosis. Results 253 patients were included in the study. The cohort was composed of 220 females (88% of the population), and the mean age was 69 years (SD: 11.8 years). Among this population, we identified 15 patients presenting with a stroke within a year after the diagnosis of stress cardiomyopathy, with a crude incidence of 5.9%. The median time interval between the incidence of stroke and the initial diagnosis of TCM was 17 days (2 to 298 days; an inter-quartile range of 3 to 105 days). The proportion of patients that reached the primary endpoint in the first 30 days was 67%. Conclusion According to our study, the risk of stroke in the year following the diagnosis of TCM is significantly higher than what is currently described in the literature. The fact that 10 of the 15 events occurred in the first 30 days may suggest a therappy design to lower the risk during that critical period could be explored. However, further studies are needed to address this issue.

The effect of oral anticoagulants on the incidence of dementia in patients with atrial fibrillation: a systematic review and meta-analysis

Abstract Background Atrial fibrillation (AF) is a common cardiac arrhythmia, with dementia being an increasingly recognised complication of this. Treatment with oral anticoagulant (OAC) therapy may be protective in developing this complication. Purpose This meta-analysis aims to investigate the validity of this hypothesis, whilst additionally exploring the effect of specific OAC medication subtypes on the incidence of dementia. Methods A comprehensive search of MEDLINE and Embase for relevant studies reporting the efficacy of OAC therapy for the incidence of dementia in patients with AF was conducted from its inception until March 2023. This included observational studies that reported odds ratio, risk ratio and hazard ratio for adult AF patients. Studies including patients with prior OAC use or prior history of dementia were excluded. Statistical analysis was performed using a random-effects model to calculate the pooled hazard ratio and their corresponding 95% confidence interval for all outcomes. Subgroup analyses were also performed according to the study design, presence of observational window, and prior history of stroke in patients. Results A total of 13 studies were included in the study. Although the heterogeneity was high in all comparisons, we demonstrated that OAC usage lowered the risk of developing dementia in AF patients when compared to the non-OAC cohort. Looking more specifically at medication subtypes, direct oral anticoagulants (DOACs) and vitamin K agonists (VKA) were both effective in reducing the likelihood of AF patients developing dementia when compared to non-OAC treatments. Conclusion Our meta-analysis confirms that administration of OAC and its subtypes (VKA and DOAC) are effective pharmacotherapies in managing dementia in patients with AF. These findings have important clinical implications for the management of AF patients and highlight the need for further investigation of the protective effects of OAC therapy on cognitive decline. Future research should explore the long-term effects of OAC therapy on cognitive function in AF patients.

Clinical impact of combined assessment of the CHADS2 score and geriatric nutritional risk index on clinical outcomes in patients with lower extremity artery disease without atrial fibrillation

Abstract Background The CHADS2 score is a well-known risk score for ischemic stroke in atrial fibrillation (AF) patients. Recently, it has been reported that the CHADS2 score was associated with an increased risk of new-onset lower extremity artery disease (LEAD) in patients without AF, the association between the CHADS2 score and clinical outcomes in patients with LEAD undergoing endovascular treatment (EVT) without AF remains unclear. Furthermore, malnutrition assessed by the geriatric nutritional risk index (GNRI) has been reported to be predictive of clinical outcomes in patients with LEAD. However, there are limited studies regarding the association of combined assessment of the GNRI and CHADS2 score and clinical outcomes in patients with LEAD without AF. Purpose The purpose of this study was to investigate the association between the combined assessment of GNRI and CHADS2 score, and mortality of LEAD patients undergoing EVT without AF. Methods This retrospective study investigated 236 consecutive LEAD patients who underwent EVT without AF. CHADS2 scores were calculated by assigning one point for heart failure, hypertension, age ≥75 years, and diabetes; and assigning 2 points for a prior history of stroke or transient ischemic attack. The GNRI on admission was calculated as follows: [14.89 × albumin (g/dL)] + [41.7 × (body weight/ideal body weight)], and the CHADS2 score and GNRI were calculated for each patient. We scored GNRI by assigning 2 points to low GNRI (GNRI &amp;lt;82) and 1 point to intermediate GNRI (GNRI =82 to &amp;lt;92). We then calculated the CHADS2 plus GNRI score for each patient and then patients were divided into the high CHADS2 plus GNRI scoregroup (CHADS2 plus GNRI score&amp;gt; 2, n = 123) and the low CHADS2plus GNRI score group (CHADS2 plus GNRI score≤ 2, n = 113) according to the median CHADS2 plus GNRI score. We investigated the associations between all-cause mortality in patients with LEAD who underwent EVT and the CHADS2 plus GNRI score. Results The mean age was 71.9±10.4 years, and 66.9% were men. During the median follow-up of 752 (283–1472) days, 50 patients died. Kaplan-Meier curves revealed that the cumulative incidence of all-cause death was significantly higher in the high CHADS2 plus GNRI score group than in the low CHADS2 plus GNRI score group (log-rank p = 0.003). Furthermore, even in the multivariate analysis,after adjusting for other risk factors including hemodialysis and clinical frailty scale, CHADS2 plus GNRI score was independently associated with all-cause death (per one score increase, hazard ratio: 1.26, 95% confidence interval (CI) 1.01-1.56, P=0.038). Conclusions In LEAD patients who underwent EVT without AF, a higher CHADS2 plus GNRI score was associated with an increased risk of all-cause death. A Combined CHADS2 plus GNRI score assessment may be a useful prognostic marker in patients with LEAD without AF.

Association between weight-adjusted waist index with incident stroke in the elderly with hypertension: a cohort study

The objective of this study was to ascertain the relationship between the weight-adjusted waist index (WWI) and the risk of stroke in an elderly hypertensive population, a relationship that has not been previously elucidated. The Cox regression model was employed to assess the correlation between baseline WWI measurements and the incidence of stroke. To further elucidate the shape of the association between baseline WWI and stroke, restricted cubic splines were employed. Furthermore, subgroup analyses and interaction tests were carried out to investigate potential heterogeneities. Our study cohort comprised 4962 hypertensive individuals aged 60 years or older with no prior history of stroke. Over a median follow-up of 3.2 years, we found 547 new-onset stroke cases. After adjusting for confounding variables, the Cox regression analysis revealed a positive association between baseline WWI and the risk of stroke, with hazard ratios (HRs) escalating progressively as WWI values increased. When compared to the lowest quartile of WWI, the highest quartile demonstrated an HR of 1.87 (95% CI, 1.44–2.42) for stroke. Subgroup analyses confirmed the consistency of this relationship across different demographic and clinical strata. The study findings indicate that an elevated WWI is significantly related with a higher risk of new-onset stroke among elderly patients with hypertension. These results underscore the importance of WWI as a potential risk stratification tool. To confirm these results and explore the causal mechanisms behind the observed correlation, more study is necessary.

Redo surgical aortic valve replacement for bioprosthetic structural valve deterioration.

To compare isolated primary bioprosthetic surgical aortic valve replacement (SAVR) with isolated redo surgical aortic valve replacement (rSAVR) due to structural valve deterioration (SVD). Clinical data of consecutive patients who underwent primary isolated SAVR and isolated rSAVR due to SVD between 1 January 2011 and 31 December 2022, at Leipzig Heart Center were retrospectively compared with regard to the primary outcome of all-cause mortality or stroke during hospitalization. Secondary outcomes of interest included myocardial infarction, re-exploration for bleeding, and permanent pacemaker implantation. A total of 2620 patients, 39.5% females, with a median EuroSCORE II of 1.7 [interquartile range (IQR) 1.1-2.7] were identified, of which rSAVR was performed in 174 patients (6.6%). Patients undergoing primary SAVR were older (69 vs 67 years of age, P = 0.001) and were less likely to have a history of prior stroke (0.9% vs 4.0%, P = 0.003). Although both all-cause death and death or stroke occurred less often following primary SAVR (0.5% vs 5.8%, and 2.2% vs 6.9%, respectively; P < 0.001), prior surgery was not associated with adverse clinical outcome in multivariable analysis. In a matched comparison of 322 patients, rates of death or stroke did not differ between groups (4.8% for both rSAVR and SAVR, P = 1.0). Although redo surgery for SVD is associated with increased rates of early mortality and stroke by univariate analysis, much of this increased risk can be accounted for by comorbidities. Patients undergoing rSAVR on an elective basis can expect an outcome similar to that of primary SAVR.

Scrambler therapy for treatment of poststroke pain.

Strokes involving sensory pathways can result in contralesional pain syndromes often refractory to pharmacologic interventions. Scrambler therapy (ST) is a noninvasive electroanalgesia device used to treat pain caused by peripheral neuropathy; however, data are scarce regarding its use in conditions secondary to central nervous system pathology. We evaluate the efficacy of ST to treat poststroke pain. Twenty patients with a history of prior stroke resulting in contralesional pain were randomized to receive ST or Sham as an adjunct to their stable medication regimen. Participants underwent 5 consecutive daily 40-min sessions. The study was blinded to patient and assessor. Pain scores (0-10) were recorded at baseline, pre- and postsession, and 4 weeks after final treatment. Student's t-tests compared differences in the mean change in pain score between groups immediately post-treatment #5, and at 4-weeks. The chi-squared analysis compared the proportion of patients in each group with >50% pain reduction. Participants randomized to ST had a mean change in pain score of -3.73 (SD 2.85) postintervention and -2.57 (SD 2.07) at 4 weeks, while the Sham group had a mean change in score of -0.94 (SD 1.36) and -0.25 (SD 0.84) (p between groups = 0.012, 0.004, respectively). Significantly more participants treated with ST reported a >50% reduction in pain immediately postintervention compared to Sham (70% vs. 10%, p = 0.006), but not at follow-up (30% vs. 10%, p = ns). ST may effectively decrease poststroke pain compared to Sham. Larger studies are needed to evaluate confounders such as stroke location, time from stroke, and concomitant treatment with medications.

Stroke after heart valve surgery: a single center institution report

IntroductionStroke is a potentially debilitating complication of heart valve replacement surgery, with rates ranging from 1 to 10%. Despite advancements in surgical techniques, the incidence of postoperative stroke remains a significant concern, impacting patient outcomes and healthcare resources. This study aims to investigate the incidence, risk factors, and outcomes of in-hospital adverse neurologic events, particularly stroke, following valve replacement. The analysis focuses on identifying patient characteristics and procedural factors associated with increased stroke risk.MethodsThis retrospective study involves a review of 417 consecutive patients who underwent SVR between January 2004 and December 2022. The study cohort was extracted from a prospectively recorded cardiac intensive care unit database. Preoperative and perioperative data were collected, and subjects with specific exclusion criteria were omitted from the analysis. The analysis includes demographic information, preoperative risk factors, and perioperative variables.ResultsThe study identified a 4.3% incidence of postoperative stroke among SVR patients. Risk factors associated with increased stroke susceptibility included prolonged cardiopulmonary bypass time, aortic cross-clamp duration exceeding 90 min, prior stroke history, diabetes mellitus, and mitral valve annulus calcification. Patients undergoing combined procedures, such as aortic valve replacement with mitral valve replacement or coronary artery bypass grafting with AVR and MVR, (OR = 10.74, CI:2.65–43.44, p-value = < 0.001) and (OR = 11.66, CI:1.02–132.70, p-value = 0.048) respectively, exhibited elevated risks. Internal carotid artery stenosis (< 75%) and requiring prolonged inotropic support were also associated with increased stroke risk(OR = 3.04, CI:1.13–8.12, P-value = 0.026). The occurrence of stroke correlated with extended intensive care unit stay (OR = 1.12, CI: 1.04–1.20, P-value = 0.002) and heightened in-hospital mortality.ConclusionIn conclusion, our study identifies key risk factors and underscores the importance of proactive measures to reduce postoperative stroke incidence in surgical valve replacement patients.

Clinical Impact of Self-Recognition of Recurrent Acute Myocardial Infarction: From KRMI-RCC.

Background/Objectives: Self-recognition of recurrent myocardial infarction (re-MI) may be essential for reducing prehospital time contrast to awareness of re-MI symptoms. However, data on the current status and clinical impact of self-recognition of re-MI are limited in the contemporary period. Thus, this study aimed to increase this body of knowledge. Methods: We enrolled 1018 patients with re-MI using data from the Korean Registry of Acute Myocardial Infarction for Regional Cardiocerebrovascular Centres. The patients were classified into self-recognised MI and unrecognised MI groups, and the differences between them were compared. Results: The rate of self-recognition among the patients with previous experience of MI was only 52.4%. Among the patients with re-MI, factors associated with self-recognition included recent first MI within 3 years, prior dyslipidaemia, two or more MI symptoms, and the male gender (p < 0.05). Factors associated with a lack of recognition were older age (≥70 years), prior stroke, and cancer history (p < 0.05). The proportion of symptoms-to-emergency room arrival time within 90 min among the patients with ST-elevation MI was significantly higher in the self-recognised group than in the unrecognised group (52.6% vs. 31.6%, p < 0.001). The self-recognised group showed a lower in-hospital mortality rate (1.5% vs. 6.2%, p < 0.001), and this benefit was maintained even after 1 year (hazard ratio: 0.53; p < 0.001). Conclusions: Only half of the patients who previously experienced a MI recognised a re-MI when it occurred. This recognition reduced prehospital delay and led to higher survival rates, which highlights the importance of patient education as well as objective monitoring devices, irrespective of individual recognition ability for immediate response.

Small-Vessel Disease and Intracranial Large Artery Disease in Brain MRI Predict Dementia and Acute Coronary Syndrome, Respectively: A Prospective, Observational Study in the Population at High Vascular Risk.

We aimed to clarify the predictive value of cerebral small-vessel disease and intracranial large artery disease (LAD) observed in magnetic resonance imaging of the brain and magnetic resonance angiography on future vascular events and cognitive impairment. Data were derived from a Japanese cohort with evidence of cerebral vessel disease on magnetic resonance imaging. This study included 862 participants who underwent magnetic resonance angiography after excluding patients with a modified Rankin Scale score >1 and Mini-Mental State Examination score <24. We evaluated small-vessel disease such as white matter hyperintensities and lacunes in magnetic resonance imaging and LAD with magnetic resonance angiography. Outcomes were incident stroke, dementia, acute coronary syndrome,and all-cause death. Over a median follow-up period of 4.5 years, 54 incident stroke, 39 cases of dementia, and 27 cases of acute coronary syndrome were documented. Both small-vessel disease (white matter hyperintensities and lacunes) and LAD were associated with stroke; however, only white matter hyperintensities were related to dementia. In contrast, only LAD was associated with acute coronary syndrome. Among the 357 patients with no prior history of stroke, coronary or peripheral artery disease, or atrial fibrillation, white matter hyperintensities emerged as the sole predictor of future stroke and dementia, while LAD was the sole predictor of acute coronary syndrome. Among cerebral vessels, small-vessel disease could underlie the cognitive impairment while LAD was associated with coronary artery disease as atherosclerotic vessel disease.

THE OUTCOME OF COGNITIVE THERAPY IN PATIENTS WITH FIRST-EVER STROKE AND RECURRENT STROKE

Background: Vascular dementia (VaD) is the second most prevalent type of dementia that impacts elderly adults, succeeding Alzheimer's disease. In contrast to Alzheimer's disease, Vascular Dementia (VaD) presents a wide range of cognitive changes, which are greatly influenced by the specific neural regions that are impacted by vascular pathology. The incidence of dementia in adults with a prior history of stroke is 30%, demonstrating a frequency that is 3-5 times more than those without any discernible stroke-related impairments. In addition, the intensity or frequency of strokes may contribute to a decrease in cognitive reserve in persons with vascular dementia. Case Report: We presented two cases of VaD. The first case was a 62-year-old man with a history of ischemic stroke without sequelae a year before the complaints of frequent forgetfulness and cognitive impairment. Neuropsychological examination showed neurocognitive disturbances in orientation, attention, memory, and visuospatial domain with impaired daily activities function. The MRI result showed senile brain atrophy with chronic infarction on the right temporoparietooccipital lobe, left side mesencephalon, right side pons accompanied by cortical laminar necrosis on the right frontal lobe and left temporoparietal lobe. The second case was a 79-year-old man with history of recurrent ischemic stroke (three times since 2021-2022) with sequelae of left hemiparesis and complaints of frequent forgetfulness and cognitive impairment in the last 1 year. Neuropsychological examination showed neurocognitive disturbances in orientation, attention, and visuospatial domain with impaired daily activities function. The MRI result showed subacute multiple lacunar infarctions in right insular cortex, right frontotemporal lobe cortex, right corona radiata, with multiple chronic infarcts on the right frontotemporoparietal lobe, right corona radiata, right internal genu capsule, right lateral periventricular anterior horn, pons, right left cerebellum, also senile brain atrophy. Both patients were diagnosed as VaD and given donepezil 1x10mg and memantine 1x5mg to treat the cognitive impairment. Both cases showed improvements after 6 months of therapy with MMSE from 17 to 28, MoCA-INA from 12 to 22 and MMSE from 19 to 23, MoCA-INA from 14 to 21 respectively. Discussion: The probability of acquiring vascular dementia (VaD) was strongly associated with the incidence and frequency of strokes. The prevalence of newly developed dementia after the initial stroke is approximately 10%, which increases to 30% with recurrent strokes. The likelihood of experiencing cognitive impairment and dementia after a stroke is primarily determined by the specific attributes of the stroke. While pharmacological therapy largely focuses on cognitive impairment, other factors, such as the stroke's characteristics, might contribute to neuronal and molecular abnormalities that result in cognitive loss. Two instances were shown, both demonstrating enhancements, with the initial instance, involving primary strokes, exhibiting a superior outcome compared to the subsequent instance with recurring strokes. A more profound or recurring stroke has the potential to reduce cognitive reserve, hence potentially heightening vulnerability to neurodegenerative disorders, either directly or by means of modifications in social contacts or lifestyle, which can subsequently affect cognitive performance. Conclusion: Recurrent stroke plays a role in reducing cognitive reserve and increasing the risk of dementia. Patients with VaD have shorter life expectancy, thus the severity of VaD is best managed by providing optimum acute stroke care and recurrent stroke prevention.

Demographic Characteristics and Functional Outcome in Posterior Circulation Strokes.

The constantly increasing incidence of stroke in Saudi Arabia substantiates an urgent need to elucidate underlying risk factors and etiologies. In terms of improving outcomes, the predictors of functional outcomes need to be identified as well. As posterior circulation strokes (PCS) have not been studied in detail, the current study aimed to identify the risk factors, etiology, and predictors of outcome in PCS. This retrospective study included the data for 138 patients with PCS. Demographics, risk factors, clinical signs/symptoms, etiology, and outcome at discharge and 3-month follow-up were recorded. Factors associated with outcomes were identified, and the difference was ascertained using Chi-square, odds ratios, and 95% confidence intervals. The mean participant age was 58 ± 14.8 years with 73% being males. The mean arrival time was 26.5 ± 31.6 h; with a mean National Institute of Health Stroke scale (NIHSS) score of 7.2 ± 5.6. Motor deficit and dysarthria were the most common presentations. Twenty percent of patients received intravenous recombinant tissue plasminogen activator, whereas endovascular thrombectomy was performed in 9 (6.5%). Follow-up outcome at 3 months was available in 113 (81.8%). Male sex, baseline modified Rankin scale of <2, low baseline NIHSS, and stable or improvement in baseline NIHSS during 24 h of admission were documented as predictors of a good outcome, whereas history of atrial fibrillation and prior stroke, high NIHSS at admission and worsening of symptoms during 24 h of admission, as well as bilateral body involvement were associated with poor outcome. The functional outcomes and the predictors of functional outcomes did not differ from the previously published literature; however, significant differences were observed in the risk factors and etiological profile in our population. These differences are of potential interest to the researchers and clinicians, as they carry important therapeutic and prognostic implications and need to be verified through large prospective studies.

Bariatric Metabolic Surgery vs Glucagon-Like Peptide-1 Receptor Agonists and Mortality

ImportanceEvidence regarding the relative effectiveness of bariatric metabolic surgery (BMS) and glucagon-like peptide-1 receptor agonists (GLP-1RAs) in reducing mortality and major adverse cardiovascular events (MACEs) is limited.ObjectiveTo compare all-cause mortality and nonfatal MACEs associated with BMS vs GLP-1RAs for adults with obesity and diabetes and without known cardiovascular disease.Design, Setting, and ParticipantsThis observational, retrospective cohort study was based on data obtained from the electronic medical records of Clalit Health Services (Clalit), the largest health care organization in Israel. The study included 6070 members aged 24 years or older, who had diabetes and obesity and no prior history of ischemic heart disease, ischemic stroke, or congestive heart failure. Patients who underwent BMS and patients who received GLP-1RAs from January 1, 2008, through December 31, 2021, were matched 1:1 by age, sex, and clinical characteristics. Follow-up ended December 31, 2022.ExposuresInitiation of BMS or GLP-1RAs.Main Outcomes and MeasuresThe primary outcome was all-cause mortality, assessed by multivariate Cox proportional hazards regression models. The secondary outcome was nonfatal MACEs, assessed by multivariate competing risk models.ResultsThe study included 3035 matched pairs of patients (total, 6070; mean [SD] age, 51.0 [9.5] years; 3938 women [64.9%]), who were followed up for a median of 6.8 years (IQR, 4.1-9.4 years). Among those with a diabetes duration of 10 years or less (2371 pairs), mortality was lower for those who underwent BMS than for those treated with GLP-1RAs (hazard ratio [HR], 0.38; 95% CI, 0.25-0.58). This association became nonsignificant when weight loss during the follow-up period was also included in the model (HR, 0.79; 95% CI, 0.43-1.48). Among patients with a duration of diabetes longer than 10 years (664 pairs), no survival advantage was demonstrated for BMS over GLP-1RA (HR, 0.65; 95% CI, 0.39-1.08). The risk for nonfatal MACEs did not differ between the treatment groups (HR, 0.74; 95% CI, 0.49-1.10 among patients with a diabetes duration of ≤10 years; HR, 1.21; 95% CI, 0.80-1.85 among patients with a diabetes duration of &amp;amp;gt;10 years).Conclusions and RelevanceIn this cohort study, BMS was associated with greater reduced mortality compared with first-generation GLP-1RAs among individuals with a diabetes duration of 10 years or less, mediated via greater weight loss. No differences in the risk for mortality were observed between the treatment modalities among individuals with a longer duration of diabetes, nor in the occurrence of nonfatal MACEs among all patients.

Spontaneous Ruptured Brain Arteriovenous Malformation In Adolescent Patient: Case Report

Introduction: Brain arteriovenous malformations (bAVMs) are one of the most common causes of intracranial hemorrhage in the adolescent. AVMs are relatively rare as congenital intracranial abnormalities but these lesions are becoming frequently reported. AVMs generally has no any symptoms and only recognized after intracranial or subarachnoid hemorrhage occurs. This disease usually gives symptoms of headaches and seizures without cause. However, along with the development of medical technology, arteriovenous malformation lesions are common. Case report: This 24 year old woman in unconscious with right hemiparesis and atypical chronic progressive headache with vas 8-9, without aura. Previously the patient had a seizure with a duration of 5 minutes, rigid all over body. The patient had no prior history of trauma, infection, hypertension, diabetes or stroke. GCS E2M5Vaphasia with motoric aphasia, motoric and sensory deficits in the form of right hemiparesis, paresis of N. VII, increased physiological reflexes, and positive Babinsky reflex. CT-Scan Angiography imaging of the head showed intraparenchymal bleeding in the left temporoparietal lobe with perifocal edema, AVM in the left temporalis region with a nidus with a feeding artery from the left MCA and a draining vein from the left transverse sinus. The patient was referred for further vascular intervention. Discuss: AVMs was previously considered a congenital malformation with risk of bleeding in anomalous tissue or nidus occurring within the brain parenchyma. Rupture of the artery and discharge into the subarachnoid space causes a sudden increase in ICP, cerebral vascular vasospasm resulting in global and focal brain dysfunction. In addition, with the increasing use of non-invasive intracranial imaging, AVMs can be detected directly.