Prior History Of Stroke Research Articles

Abstract WMP42: Differences In Antihypertensive Prescribing And Smoking Cessation Counseling After Acute Ischemic Stroke 2003-2016: The National Regards Cohort Study

Background: Limited population-based evidence is available about risk factor management following stroke. We examined age, race, sex, and regional (Stroke Belt vs. other) differences in discharge antihypertensive prescribing and smoking cessation counseling after ischemic stroke using population level data from a national cohort study. Methods: Medical record data was abstracted from 1042 participants enrolled in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study who had an adjudicated ischemic stroke between 2003-2016. Participants with a history of prior stroke, in-hospital death, hospice discharge, incomplete records, and non-smokers for smoking cessation analyses were excluded resulting in 798 cases for discharge antihypertensive prescribing and 117 cases for smoking cessation counseling in the final analyses. Differences were assessed using modified Poisson regression adjusting for patient and hospital level factors. Results: Overall, 86% received discharge antihypertensives while 50% of current smokers received counseling at discharge. Participants who were older, female, had a greater number of CV risk factors, and higher BMIs were significantly more likely to receive discharge antihypertensives compared to younger participants, males, those with fewer risk factors and lower BMIs, respectively (age RR 1.05; 95% CI, 1.02-1.09; female sex RR 1.09; 95% CI, 1.03-1.16; total risk factors RR 1.07; 95% CI, 1.04-1.10; BMI RR 1.01; 95% CI, 1.00-1.01). There was an increasing trend in receipt of smoking cessation counseling over time (RR 1.12; 95% CI, 1.04-1.21). Conclusions: Discharge antihypertensive prescribing varies modestly by patient-level variables. There were no differences in smoking cessation counseling by age, sex, race, or study region. Smoking cessation counseling has improved over time, yet only half of smokers received cessation counseling.

Abstract WP90: Black Americans Have Worse Functional And Cognitive Outcomes Than White Americans After Stroke

Introduction: We studied racial differences in post-stroke outcomes using a prospective, population-based cohort of stroke survivors as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Methods: Neurologic (NIHSS, range of 0-42, higher scores are worse), functional (ADLs/IADLs, range 1-4, higher scores are worse), and cognitive (3MSE, range 0-100, higher scores are better) outcomes were measured 90 days after stroke. Cox proportional hazards and negative binomial linear regression models were used to examine the associations between race and 90-day all-cause mortality and NIHSS, respectively, whereas linear regression was used for ADLs/IADLs and 3MSE scores. Covariates included demographics, initial NIHSS, comorbidities, prior stroke history, tPA, pre-stroke disability, and pre-stroke cognition. The mortality model also adjusted for DNR status. Results: At 90 days post-stroke, Black Americans (BAs) (n=130) had a median (IQR) NIHSS of 2 (1,6) compared to NIHSS of 1 (0,3) in non-Hispanic white Americans (NHWs) (n=868). BAs had a median (IQR) ADL/IADL score of 2.4 (1.5, 3.4) compared to 2 (1.3, 3.0) in NHWs. BAs scored a median of 85.0 (75.0, 92.5) on the 3MSE compared to NHWs’ score of 92.0 (83.0, 96.0). Death occurred in 23 (11%) of BAs and 268 (19%) of NHWs within 90 days. After adjustment for covariates, functional outcomes at 90 days were worse in BAs compared to NHWs, with 14% (95% CI=4.9, 23) greater limitations in ADLs/IADLs and 47.9% (95% CI=16.3, 88.1) greater severity of stroke symptoms. Cognition at 90 days was 7% (95% CI=2.7, 11.3) lower in BAs compared to NHWs. BAs had a 25.2% lower (95% CI=-19.9, 53.3) hazard rate of mortality than NHWs (Figure). Conclusions: In this prospective, population-based community sample, BAs had worse functional and cognitive outcomes at 90 days compared to NHWs. Future research should investigate the cause of these racial disparities.

Abstract WMP38: One Year Medicare Spending On Beneficiaries In Atrial Fibrillation Not Being Treating With Long-term Anticoagulants Experiencing A Hospitalization For Ischemic Stroke

Background: It is well known that individuals in atrial fibrillation (AF) who are not using anticoagulants are at higher risk of Ischemic Stroke (IS). These hospitalizations result in the utilization of significant healthcare resources in addition to reducing patients’ quality of life. The purpose of this study is to estimate how much the Medicare program spends treating a Medicare beneficiary (MB) with AF who are not being anticoagulated with an IS hospitalization and the 12-months following discharge. Method: The study population consisted of all MBs in the fee-for-service program who had a hospitalization for IS and were discharged between January 1, 2018 to December 31, 2018. A total of 50,509 MBs met the study inclusion criteria and were not excluded due to prior history of stroke or on long-term anticoagulants. The study period for accumulating Medicare spending at healthcare facilities is for the index hospitalization and all facility claims that occurred within 12-months of the index hospital discharge date. Results: Average total Medicare spending per MB for the study population was $46,867±$49,212 resulting in total Medicare spending of nearly $2.5 billion during the study period. Highest average spending per MB was for hospital services $25,848 (of which $15,790± $20,984 occurred during the index hospitalization and $10,058±$21,956 during readmission during the follow-up period. The Medicare program also spent over $3,000 per study patient at skilled nursing facilities ($8,131±$14,979), rehabilitation facilities ($5,538±$12,739), and outpatient facilities or emergency departments ($3,056±$7,495). At least, 19% of MB died during the study period. Medicare spent $25,397±$30,259 on those MBs that died during their index hospitalization and $67,276±$65,021 on those MBs that survived their index IS hospitalization but died during the follow-up period. Conclusion: MBs with AF who are not being treated with anticoagulants and suffer an ischemic stroke result in one-year Medicare Part A program spending of approximately $47,000 per person compared to the average Medicare spending for all services of approximately $12,000 per beneficiary in 2018. Identification of MB in AF and treatment with anticoagulants would save CMS significant dollars.

Relationship between premature ventricular complexes and stroke mortality in the general population

ObjectivesPredictors for increased stroke mortality identify those who may need closer monitoring and better hospital care. While the link between premature ventricular complexes (PVCs) and incident ischemic stroke has been reported, studies on the association with fatal stroke are non-existent. Materials and methodsWe examined the association of PVCs with stroke mortality in 8047 participants (56.5 ± 0.39 years, 53% women, 80.9% Non-Hispanic Whites) without prior history of stroke from the Third National Health and Nutrition Examination Survey. National Death Index was used to identify the date and cause of death. PVCs were detected from 12‑lead standard electrocardiograms. Cox proportional hazard analysis was used to examine the association between any PVC with stroke mortality. ResultsApproximately 2.1% (n = 134) participants had PVCs at baseline. Over a median follow-up of 22 years, 337 fatal strokes occurred. More strokes occurred in participants with baseline PVCs compared to those without (unadjusted cumulative incidence of stroke 9.5% vs. 2.5% respectively, p-value 0.001). In a multivariable-adjusted model, the presence of PVC was associated with an increased risk of stroke mortality (HR (95%CI): 2.50 (1.15–5.43). This association was stronger in participants with coronary heart disease (CHD) than those without it (HR (95%CI): 5.98 (2.2–16.2) vs. 1.97 (0.75–5.1) respectively; interaction-p = 0.008). ConclusionsPVCs are associated with an increased risk of stroke mortality, especially among individuals with CHD. Whether improved hospital care or modifying PVCs could change outcomes should be examined in prospective studies.

Transient ischemic attack events and incident cardiovascular and non-cardiovascular complications: Observations from a large diversified multimorbid cohort.

Transient ischemic attack (TIA) is a strong signal prompting the incidence of future cardiovascular and non-cardiovascular complications, in light of recent debate on the so-called "stroke-heart syndrome." We aimed to investigate the relation of TIAs to incident clinical events. Patients were drawn from three health plans with a wide spectrum of age groups and a wide mix of socio-economic/disability status. Two TIA cohorts in a retrospective design were used to achieve the study specific aims: (i) to investigate the incidence of TIA and associated cardiovascular and non-cardiovascular complications within 30 and 90 days from the onset of incident TIA events; and (ii) to examine the potential risk factors for developing incident TIA events in the general population with/without a history of prior stroke. The incident TIA cohort consisted of 53,716 patients with an average age of 64.2 years (SD 15.2) and 46.1% male. Following TIA, the incidence proportions of ischemic stroke within 30 and 90 days were 2.7% and 3.8%, respectively, and for incident acute coronary syndrome being 0.94 and 1.84, respectively. Ventricular arrhythmia had proportions of 1.2 and 2.14, respectively within 30 and 90 days, with acute heart failure having values of 0.49 and 0.923. About 45% or more of the cardiovascular and non-cardiovascular complications occurred in the first 30 days following the incident TIA cases. About one-third of the recurrent TIA cases followed the incident TIA cases within a span of 30 days. Amongst comorbidities with stroke in the comorbid history, prior stroke provided the strongest risk factor in terms of odds ratio (OR = 8.34, 95% CI 7.21-9.66) for incident TIA events. Age was strongly associated with incident TIA events. Without a prior history of stroke (ischemic stroke/transient ischemic attack/thrombo-embolic events), valvular disease was the strongest risk factor from among the comorbidities (OR-1.87, 95% CI 1.51-2.32). Age also provided strong associations with incident TIA events. Following a TIA, there was a high risk of stroke, acute coronary syndrome, ventricular arrhythmia, acute heart failure, and non-cardiovascular complications.

Maybe asymptomatic carotid disease is not as benign as we think.

In this issue of JVS, Turner et al1Turner A.D. Zhu J. Rao A. Ting W. Han D. Tadros R. et al.Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.J Vasc Surg. 2022; 76: 1625-1632Google Scholar provide some additional insight into the impact of a remote history of cerebrovascular events as a marker for increased periprocedural adverse events after carotid stenting. The default definition of “asymptomatic” extracranial carotid disease is the absence of clinical signs and symptoms of a transient ischemic attack or stroke. As this report shows, although most asymptomatic patients are truly asymptomatic, a subset do indeed have a prior history of a neurologic event that occurred more than 180 days before an intervention but are still typically categorized as asymptomatic. This current report demonstrates that at least among patients treated with carotid stenting (transfemoral vs transcarotid), the periprocedural outcomes more closely resemble the symptomatic rather than the asymptomatic patient population. For years, we have tried a variety of imaging techniques to identify the unstable asymptomatic plaque including computed tomographic evaluation, magnetic resonance plaque characterization, ultrasound gray scale median, and transcranial Doppler.2Kakkos S.K. Griffin M.B. Nicolaides A.N. Kyriacou E. Sabetai M.M. Tegos T. et al.Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) study group. The size of juxtaluminal hypoechoic area in ultrasound images of asymptomatic carotid plaques predicts the occurrence of stroke.J Vasc Surg. 2013; 57 (discussion: 617-8): 609-618.e1Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar,3Saba L. Antignani P.L. Gupta A. Cau R. Paraskevas K.I. Poredos P. et al.International Union of Angiology (IUA) consensus paper on imaging strategies in atherosclerotic carotid artery imaging: from basic strategies to advanced approaches.Atherosclerosis. 2022; 354: 23-40Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Unfortunately, none are broadly recognized as an accurate predictor. In my institution, transcranial Doppler is used quite frequently by the stroke neurologists, yet it has not made a noticeable impact on the current treatment algorithm for most patients. Hopefully, upcoming prospective studies such as the Carotid Artery Multimodality imaging Prognostic study may provide more valuable insight of the unstable asymptomatic plaque with contemporary imaging techniques.4Gargani L. Baldini M. Berchiolli R. Bort I.R. Casolo G. Chiappino D. et al.Detecting the vulnerable carotid plaque: the Carotid Artery Multimodality imaging Prognostic study design.J Cardiovasc Med (Hagerstown). 2022; 23: 466-473Crossref Scopus (1) Google Scholar Although the current report demonstrates improved outcomes among the transcarotid treated patient population vs transfemoral stenting using the Vascular Quality Initiative database, some concerns exist in regard to the data quality and sample size. Important unknowns include adherence and implementation of currently accepted optimal medical therapy, operator expertise, and objective neurologic assessment before and after the procedure. Nevertheless, the important message is that asymptomatic patients with any prior history of a remote neurologic event tend to have less favorable outcomes as compared those with no prior history of a neurologic event, and this information should be taken into consideration as part of the treatment algorithm. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patientsJournal of Vascular SurgeryVol. 76Issue 6PreviewAsymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. Full-Text PDF

Carotid stenosis patients with a remote history of cerebrovascular events have increased risk of major adverse events over asymptomatic patients.

Asymptomatic patients with a remote history of transient ischemic attack (TIA) or stroke are not well studied as a separate population from asymptomatic patients with no prior history of TIA or stroke. We compared in-hospital outcomes after transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TFCAS) among symptomatic patients, patients with a remote history of neurologic symptoms, and asymptomatic patients. Data from patients in the Vascular Quality Initiative database who underwent TCAR (January 2017 to April 2020) or TFCAS (May 2005 to April 2020) were analyzed. Symptomatic status was defined as TIA and/or stroke occurring within 180days before the procedure. Asymptomatic status was divided into patients with no history of TIA/stroke (asymptomatic) and patients with a history of TIA/stroke occurring more than 180days before the procedure (remote history of neurologic symptoms). The Student t-test and Pearson χ2 test were used to compare baseline patient characteristics and outcomes. Multivariate logistic regression was used to adjust for significant between-group differences in baseline characteristics. There were 7158 patients who underwent TCAR (symptomatic: 2574, asymptomatic: 3689, and asymptomatic with a remote history of neurologic symptoms: 895) and 18,023 patients who underwent TFCAS (symptomatic: 6195, asymptomatic: 10,333, and asymptomatic with a remote history of neurologic symptoms: 1495). Regardless of symptom status, the mean patient age was 73years for TCAR and 69years for TFCAS. A total of 64% of patients in the study were male and 36% of patients were female. The mean long-term follow-up data ranged between 208 and 331days within the three patient groups. Carotid stenosis patients with a remote history of neurologic symptoms had higher rates of TIA, stroke, TIA/stroke, stroke/death, and stroke/death/myocardial infarction than asymptomatic patients, and these rates were similar to those of symptomatic patients. Comparing TCAR and TFCAS among patients with a remote history of neurologic symptoms, there were statistically significant reductions in the odds of stroke/death (odds ratio: 0.46, 95% confidence interval: 0.27-0.84, P= .011) and stroke/death/myocardial infarction (odds ratio: 0.51, 95% confidence interval: 0.30-0.87, P= .013) after TCAR. This was likely driven by the increased rate of death after TFCAS in patients with a remote history of neurologic symptoms (0.9%) compared with asymptomatic patients (0.6%). Asymptomatic patients with a remote history of TIA/stroke do not have the same outcomes as asymptomatic patients without a history of TIA/stroke and are at higher risk of adverse in-hospital events. Patients with a remote history of TIA/stroke have increased risk of in-hospital death after TFCAS and may benefit from TCAR.

Determinants of post-stroke depression among stroke survivors at University of Gondar Hospital, Northwest Ethiopia: a case-control study

BackgroundStroke is one of the most common causes of disability among adults. Post-stroke depression (PSD) is a frequent neuropsychiatric complication in stroke patients. Despite the increasing prevalence of stroke, there is a paucity of data on PSD and its determinants among stroke survivors in developing countries like Ethiopia. We aim to assess the factors associated with PSD in survivors of stroke.MethodA hospital-based unmatched case-control study was conducted during the period of February to July 2020 at University of Gondar Hospital among stroke survivors. Study subjects were recruited consecutively. Socio-demographic and clinical data were obtained from patients’ interviews and medical record reviews. A diagnosis of PSD was made using the Patient Health Questionnaire (PHQ-9). EpiData version 3.1 was used to enter data, and SPSS version 26 was used to analyze it. Bivariate and multivariate logistic regressions were fitted to identify associated variables. The adjusted odds ratio (AOR) with 95% confidence interval (CI) and p-value 0.05 were used to determine the significance of the association.ResultA total of 240 stroke survivors were included in the study (80 cases and 160 controls). The mean age was 60.8 years (SD ± 14.3) with an equal sex distribution. Variables statistically associated with PSD were male gender (AOR = 3.5, 95% CI: 1.64-7.46 C, P-value = 0.001), subcortical location of the largest lesion (AOR = 2.42, 95% CI: 1.06–5.56, p-value = 0.036), severity of the stroke (AOR = 52.34, 95% CI:10.64-256.87, p-value = 0.000), physical disability (AOR = 5.85. 95% CI:1.94–17.65, p-value = 0.002), previous history of stroke or transient ischemic attack (AOR = 5.90, 95% CI:2.04–17.10, p-value = 0.001) and ischemic heart disease (AOR = 9.97, 95% CI:3.4-29.22, p-value = 0.000).ConclusionImportant factors in the occurrence of PSD in this study include prior history of stroke, physical disability, severity of the stroke, subcortical location of the lesion, male gender, and ischemic heart disease. Stroke patients with such factors need routine screening for PSD, particularly in LMICs where there is uncoordinated post-stroke care, a shortage of neurologists and mental health practitioners.

Radiomics-Derived Brain Age Predicts Functional Outcome After Acute Ischemic Stroke.

While chronological age is one of the most influential determinants of poststroke outcomes, little is known of the impact of neuroimaging-derived biological "brain age." We hypothesized that radiomics analyses of T2-FLAIR images texture would provide brain age estimates and that advanced brain age of patients with stroke will be associated with cardiovascular risk factors and worse functional outcomes. We extracted radiomics from T2-FLAIR images acquired during acute stroke clinical evaluation. Brain age was determined from brain parenchyma radiomics using an ElasticNet linear regression model. Subsequently, relative brain age (RBA), which expresses brain age in comparison with chronological age-matched peers, was estimated. Finally, we built a linear regression model of RBA using clinical cardiovascular characteristics as inputs and a logistic regression model of favorable functional outcomes taking RBA as input. We reviewed 4,163 patients from a large multisite ischemic stroke cohort (mean age = 62.8 years, 42.0% female patients). T2-FLAIR radiomics predicted chronological ages (mean absolute error = 6.9 years, r = 0.81). After adjustment for covariates, RBA was higher and therefore described older-appearing brains in patients with hypertension, diabetes mellitus, a history of smoking, and a history of a prior stroke. In multivariate analyses, age, RBA, NIHSS, and a history of prior stroke were all significantly associated with functional outcome (respective adjusted odds ratios: 0.58, 0.76, 0.48, 0.55; all p-values < 0.001). Moreover, the negative effect of RBA on outcome was especially pronounced in minor strokes. T2-FLAIR radiomics can be used to predict brain age and derive RBA. Older-appearing brains, characterized by a higher RBA, reflect cardiovascular risk factor accumulation and are linked to worse outcomes after stroke.

Prevalence of Cerebrovascular Accidents Among the US Population With Substance Use Disorders: A Nationwide Study.

Introduction Globally, stroke is one of the top ten causes of death. The incidence of stroke in patients aged 44 years and younger was noted to have risen over the past three decades. This rise in stroke diagnosis among young adults could be attributed to multiple reasons, including the rising prevalence of comorbidities like diabetes, hypertension, substance use disorders (SUDs), etc. Aim & objectives This study's primary aim was to evaluate the prevalence of stroke in the US population and the prevalence of SUDs amongst patients with a prior history of stroke. The secondary aim was to evaluate the association between Stroke and SUDs. Methods Our population was obtained from the National Health and Nutrition Examination Survey (NHANES) between the years 2013 to 2018. We identified respondents diagnosed with stroke using the questionnaire and the history of various SUDs amongst this population. The data were analyzed using SAS software (Version 9.4). We performed univariate analysis using the chi-square and Mann-Whitney test, and a p-value of <0.05 was considered statistically significant. Results Two hundred sixty-four thousand seven hundred forty (264,740) respondents were included in this study, and 10435 (3.94%) respondents were noted to have a history of stroke. The population subset with a stroke diagnosis was older (68 years vs. 51 years). Higher prevalence was noted among the female sex (52.14% females vs. 47.86% males), Non-Hispanic white ethnicity, followed by Non-Hispanic black & then other Hispanics (47.56% vs.25.47% vs. 7.82%), and those belonging to a lower annual household income of $0-$25,000 and $25,000-$65,000 ( 46.61% vs. 35.93% ). (p<0.0001). After adjusting for socio-demographics and coexisting comorbidities, e-cigarette [OR: 2.03; 95% CI: 2.03-2.03], cocaine [OR: 1.54; 95%CI:1.54-1.54], heroin [OR: 1.83; 95%CI: 1.83-1.83], marijuana or hashish [OR: 1.01; 95% CI: 1.01-1.01], were observed to have an association with higher odds of stroke than the population without a history of using these illicit drugs. Conclusion Among respondents with a history of stroke, the use of cocaine was most prevalent, followed by marijuana/hashish, heroin, e-cigarettes, and injecting illegal drugs. The odds of having a stroke were two times higher in the population using an e-cigarette and higher among those using heroin, cocaine, and marijuana/ hashish. The Government should plan policy changes to treat SUDs in the USA, which could help reduce the stroke burden. Recall that bias and geographic variations in response rate by participants of the study were the limitations of our survey-based study.

Cognitive Screening in Adults with Sickle Cell Disease: Prospective Validation of the Rowland Universal Dementia Assessment Scale

Background: Adults with sickle cell disease (SCD) are at increased risk of early cognitive decline. The American Society of Hematology recommends surveillance for cognitive impairment. However, optimal screening strategies in this population have not been established. The RUDAS (Rowland Universal Dementia Assessment Scale) is a short screening questionnaire developed for use in culturally diverse patient populations. In adults with SCD, it is less biased by educational attainment than the Montreal Cognitive Assessment (MoCA). Hypothesis: We hypothesized that the RUDAS is a valid tool to predict neurocognitive disorder (NCD) in adults with SCD. Aims: 1. Describe trends in RUDAS scores during long-term cognitive surveillance; 2. Evaluate the ability of RUDAS scores to predict the diagnosis of NCD. Method: A retrospective study was conducted. All patients who had undergone cognitive screening with RUDAS in 2018 and repeat testing as part of routine surveillance in 2021-2022 were identified. Starting in 2021, all adults with SCD are assessed by a multidisciplinary team (neurologist, hematologist, neuropsychologist) for neurocognitive screening and assessment. RUDAS was administered and scored as previously described (Forté et al, JAMA Net Open 2021). A clinical diagnosis of NCD was established by a neurologist and/or neuropsychologist. Repeated measure t-test was performed to compare RUDAS trends over time. Standard t-test was used to compare RUDAS between a priori defined subgroups (with and without NCD). Positive predictive values (PPV) were calculated. Results: From an initial assessment of 92 patients, 28 adult SCD patients met the inclusion criteria. The median age was 39 years [range: 24-65], 16 (57%) were female and the median educational level was 14 years [range: 10-18]. Genotype distribution was 18 (64%) with the SS or Sβ0-thalassemia genotype and 10 (36%) with the SC or Sβ+-thalassemia genotype. None of the patients had an established diagnosis of NCD, and 5 (18%) had a prior history of stroke. The mean (±standard deviation (SD)) RUDAS scores were 26.7±2.0 in 2018 and 27.3±2.7 in 2021-2022. Overall, the scores did not significantly change over time (+0.6±2.8, paired t-test P=0.3). In table 1, we present the results of the subgroup analysis according to NCD diagnosis. In those in whom a diagnosis of NCD was established in 2021-2022, RUDAS score declined by -0.9±2.8 points (P=0.3). In those not meeting the criteria for NCD, the mean change was +1.7±2.4 (P=0.01). RUDAS scores differed significantly in those with and without NCD (25.5±2.8 and 28.6±1.5, P<0.001). RUDAS scores <28 and even more significantly those <23 were highly predictive of a diagnosis of NCD (PPV=86% and 100%, respectively, P<0.001, table 2). Conclusion: The results of our study suggest that lower RUDAS scores are associated with the diagnosis of neurocognitive disorder in adults with SCD. Prospective validation is ongoing with a larger sample size. In addition, patient characteristics will be explored as potential predictors of NCD. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Venous Thromboembolism Is Associated with Right-Sided Cardiac Dysfunction and Increased Mortality in Patients with Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is a hypercoagulable state. Approximately 11-12% of patients with SCD have a venous thromboembolism (VTE) by age 40 which portends a nearly three-fold increased mortality risk compared to those without VTE. Additionally, echocardiographic findings of right-sided cardiac dysfunction and pulmonary hypertension (PH) are also independent mortality predictors in SCD. In the general population, VTE is a risk factor for PH; however, the association in SCD is uncertain. We hypothesized that patients with SCD and VTE have a greater frequency of right-sided cardiac dysfunction by transthoracic echocardiogram (TTE) and associated mortality risk compared to those without VTE. Methods: We performed a retrospective chart review of 402 consecutive SCD patients who received care at our institution between 2003 and 2021. VTE was defined as deep vein thrombosis (DVT) and/or pulmonary embolism (PE) by diagnostic imaging. Demographics, clinical and laboratory data, VTE diagnostic imaging, and TTE results were obtained from each subject. For those with VTE, we recorded data pre-VTE and 5 years post-VTE. For those without VTE, we recorded data at entry into the database and 5 years later. The atrial and ventricular size, right and left ventricular function, valvular function, and tricuspid regurgitant jet velocity (TRV) were collected from each echocardiogram. Data were analyzed using Fisher's exact, Sign-ranked and McNemar's tests. Results: In our cohort, 251 subjects (62%) were HbSS/HbSβ0 and 227 (56%) were female. VTE occurred in 75 individuals (19%) with deep vein thrombosis in 35 (47%), pulmonary embolism in 50 (67%), and both observed in 9 (12%). Prior history of acute chest syndrome, avascular necrosis, stroke, and surgical splenectomy was associated with VTE (p<0.01 for all). History of VTE was associated with an increased mortality rate during our study period compared to those without VTE (13% vs 6%, p=0.04). Within our cohort, 183 patients had initial and follow-up echocardiography (77% of VTE group, 38% of non-VTE group). In the VTE group, there was a higher frequency of right atrial enlargement five years post-VTE compared to pre-VTE (p=0.03). There was a non-significant trend towards decreased right ventricular function over five years in the VTE group (p=0.08) Neither of these findings occurred in the non-VTE group. There was no significant change in TRV after five years of follow-up in either group; however, only 45% of echocardiograms had TRV ascertained. Conclusions: Sickle cell disease patients who sustained a VTE had an increased risk of prior complications and subsequent mortality compared to those without a VTE. The presence of increased right atrial size and a trend towards right ventricular dysfunction five years post-VTE suggest development of pulmonary hypertension despite lack of change in the TRV. These findings need to be explored by a deeper analysis of the echocardiography, and in the future, a prospective study.

Abstract 14102: The Joint Effect of Arterial Stiffness and High Central Blood Pressure on Risk of Stroke Among Hypertensive Adults

Introduction: The increases in arterial stiffness and central blood pressure (cBP) suggest significant status of vascular damages with different physio-pathological progress. However, the joint effect of them on risk of first stroke have remained uncertain. And the predictive value of CAP over peripheral blood pressure (bBP) is controversial. Hypothesis: This study aims to test the hypothesis that the combination of elevated arterial stiffness and central systolic blood pressure (cSBP) can predict first stroke and is associated with highest risks among hypertensive adults. Methods: A total of 7531 hypertensive adults without prior history of stroke were analyzed. cSBP was measured noninvasively using A-Pulse CASPro device. Arterial stiffness was measured by carotid-femoral pulse wave velocity using the noninvasive PulsePen device (WPP001-ET, DiaTecne s.r.l). Whole data was collected from July 2016 to December 2019. Increased arterial stiffness was defined as cfPWV ≥10 m/s. The primary outcome was first all-cause stroke. Results: Of the 7531 participants, mean age was 61.3 ± 9.3 years, 37.2% were male, the mean brachial blood pressure is the mean cfPWV was 9.4 ± 2.2 m/s, the mean cSBP is 131.3 ± 12.8 mmHg. During a mean follow-up time of 3.3 years, 432 (5.2%) participants developed stroke, of which 380 were ischemic strokes. Compared with the reference group (low cfPWV and cSBP), only the group with both high cfPWV and cSBP was significantly associated with risk of stroke after adjusted for covariates (HR: 1.51, 95% CI 1.10, 2.07). Similar result was found in Kaplan Meier Curve. Such association appears robust in different sub-group analysis. Conclusion: The combination of higher arterial stiffness and central systolic blood pressure is associated with highest risk of first stroke compared to other groups. The combined control of arterial stiffness and central blood pressure serves the purpose of primary prevention of first all-cause stroke among hypertensive population.

Abstract 14188: An Unexpected Cause of Anterior ST Segment Elevation After Coronary Intervention

Background: ST elevation (STE) in V1 to V3 is traditionally labeled as anteroseptal infarction due to occlusion of the LAD proximal to the septal branches. An important and uncommon cause for similar ECG findings is an isolated RV myocardial infarction due to occlusion of the proximal RCA and/or its branches. We present a case of anteroseptal ST elevation after jailing of a conus branch during percutaneous coronary intervention (PCI) to the RCA. CASE: 89-year-old female with history of moderate aortic stenosis (AS), hypertension, hypercholesterolemia, and prior stroke presented with progressive dyspnea on exertion and 3 days of chest tightness. Initial echocardiogram showed an EF of 64% and severe AS with peak velocity of 4.27 m/s, mean gradient of 45 mmHg and aortic valve area of 0.43 cm 2 . Coronary angiography showed severe stenosis of the proximal RCA successfully treated with intravascular lithotripsy and drug-eluting stent deployment with jailing of the conus branch. The LAD and LCX had mild nonobstructive disease. Patient developed chest pain after the procedure with new STE in V1 to V3. She was taken for emergent cardiac angiogram due to suspected occlusion of the LAD however this showed unchanged anatomy with patent stent in the RCA and no new severe stenosis or occlusion of the left coronary arteries. There was no flow in the jailed conus branch that was not intervened on due to small vessel size. A repeat echocardiogram showed new mild RV dilatation with unchanged EF and normal LV wall motion. Patient had resolution of the chest pain and STE within 2 hours and was discharged home in stable condition. Conclusion: Occlusion of a conus branch artery with associated isolated RV myocardial infarction is an uncommon cause of STE in anteroseptal leads. High index of suspicion is important to anticipate and manage potential complications like ventricular arrhythmias and RV failure.

Total atrial conduction time provides novel information in prediction for stroke in patients with sinus rhythm

The total atrial conduction time (TACT) measured by echocardiography predicts the risk of atrial fibrillation (AF). This study aimed to investigate whether adding the TACT to the revised Framingham stroke risk profile (rFSRP) improves the efficacy of predicting stroke incidence in patients without prior stroke or known AF. The TACT was measured in 376 consecutive patients > 18 years (58.5 ± 16.3 years; 46% male) receiving echocardiography without any prior history of stroke or AF. The primary endpoint was the occurrence of ischemic stroke, and the secondary endpoint was any documentation of AF during the 2 years of follow-up. During the follow-up period, ischemic strokes occurred in 10 patients (2.65%), and AF in 22 patients (5.85%). The TACT was significantly longer in those who later had a stroke compared with those who did not (169.4 vs. 142.7 ms, p < 0.001). Both rFSRP and TACT predicted the risk for stroke incidence. The univariate model showed that the TACT was a predictor of ischemic stroke incidence (p < 0.001; hazard ratio of 1.94 for every 10 ms; 95% confidence interval, 1.49–2.54). The addition of TACT to rFSRP significantly improved the area under the receiver operating characteristic curve (0.79 vs. 0.85, p = 0.001). Stroke risk prediction was significantly improved by the addition of TACT to rFSRP. The utility of the TACT should be further investigated in large-scale randomized clinical trials.

A 47-Year-Old Man Presenting With Seizures and Prior Stroke.

A 47-year-old man presented to his local hospital in Peru after a generalized tonic-clonic seizure. His family reported a history of prior stroke of unclear etiology. This case report discusses the approach to a first seizure (including in tropical regions like Peru), the relationship between stroke and seizures, the approach to stroke in the young, and how to diagnose rare diseases in resource-limited settings.

Association between early rhythm control and the risk of dementia in patients with atrial fibrillation and prior history of stroke: a nationwide population-based study

Abstract Background Patients with atrial fibrillation (AF) who experienced stroke before are at high risk for dementia. Although early rhythm control in patients with AF reduces the risk of stroke, there is a lack of evidence on whether early rhythm control reduces the risk of developing dementia in patients with new-onset AF and a history of prior stroke. Purpose To compare the risk of dementia between early rhythm control therapy and usual care in patients with new-onset AF and a history of prior stroke Methods Using the Korean nationwide claims database, we identified patients who were newly diagnosed as AF and had a history of prior stroke. Patients with prevalent dementia were excluded. Patients who received rhythm control therapy, including antiarrhythmic drug, direct current cardioversion, or AF catheter ablation, within 1 year after incident AF were defined as the early rhythm control group, otherwise as the usual care group. The inverse probability of treatment weighting method was used to balance baseline characteristics between the two groups. The incidence of all dementia, Alzheimer dementia, and vascular dementia were evaluated during follow-up. Results A total of 41,370 patients were included (mean age, 70±11 years; mean CHA2DS2-VASc score 5.3±1.6; 43% female); 10,213 were in the early rhythm control group and 31,157 in the usual care group. All patients received oral anticoagulants. During a median 2.7 years of follow-up, 6414 patients developed incident dementia (incidence rate, 4.9 per 100 person-years). Compared to usual care, early rhythm control was associated with lower risks of all dementia, Alzheimer dementia, and vascular dementia (weighted hazard ratio [95% confidence interval], 0.825 [0.776–0.876], 0.831 [0.774–0.893], and 0.800 [0.702–0.913], respectively, all p&amp;lt;0.001) (Figure 1). The beneficial effect of early rhythm control on the risk of dementia were consistent regardless of the characteristics of prior stroke, for example, recent stroke within 6-month from their enrollment, disabling stroke that required continuous rehabilitation therapy, and severe stroke causing intensive care unit admission. Conclusion Early rhythm control within 1 year after AF diagnosis might be beneficial to prevent dementia in patients with incident AF and a history of stroke. To prevent progression of further cognitive dysfunction, early rhythm control should be considered in these patients. Funding Acknowledgement Type of funding sources: None.

The relative importance of particle count, type, and size of ApoB-containing lipoproteins in risk of myocardial infarction

Abstract Background An accumulating body of evidence suggests that the number of apolipoprotein B-containing particles (ApoB-P) is more predictive of cardiovascular risk than their lipid content. However, it is unclear if this association is consistent across different lipoprotein types and sizes. Purpose We aimed to evaluate if particle type and size are associated with incident myocardial infarction (MI) beyond ApoB-P count. Moreover, we aimed to determine if the risk associated with lipoprotein(a) is additive to that of ApoB-P. Methods This prospective cohort study included 96,126 participants without prior history of stroke, coronary or peripheral artery disease or use of lipid-lowering medication from the UK Biobank. Count and size of VLDL, IDL, LDL, and HDL, as well as ApoB level and total ApoB-P count were measured in non-fasting plasma samples by nuclear magnetic resonance platform. Lipoprotein(a) was measured by immunoturbidimetric assay. We explored associations between these lipoprotein markers and incident MI using Cox proportional hazard models adjusted sequentially for clinical covariates, HDL count and size, and ApoB-P. Results Over a median follow-up of 12.1 years, 1702 participants had incident MI. In unadjusted models, 1-SD increases in ApoB-P count, ratio of VLDL to (LDL+IDL) particle counts, VLDL size and lipoprotein(a) were associated with a higher risk of MI, while LDL size was associated with a lower risk of MI (Table 1). When adjusting for clinical covariates and lipid parameters, only ApoB-P and lipoprotein(a) remained significantly associated with a higher risk of MI (HR: 1.40 [1.32; 1.48] and 1.20 [1.14; 1.27], respectively). Adjusted restricted cubic splines confirmed findings from linear trend Cox models (Figure 1). ApoB-P count was highly correlated with ApoB level (r=0.99), and replication of analyses replacing one for another revealed no change in results. Conclusion The risk of MI is independently associated with the total particle count of all ApoB-P, and not the size or type of these lipoproteins. ApoB level can be used as a very accurate surrogate of ApoB-P count in the clinical setting. Lipoprotein(a) is associated with MI risk independently of total particle count, and therefore, the combination of ApoB and lipoprotein(a) may provide the optimal clinical evaluation of lipid-mediated MI risk. Funding Acknowledgement Type of funding sources: None.

Pre-stroke dementia and in-hospital outcomes in the Chinese Stroke Center Alliance.

Little is known about the impact of prevalent dementia on in-hospital outcomes of patients with incident stroke in China. Using data from the Chinese Stroke Center Alliance (CSCA), we aim to quantify the prevalence of pre-stroke dementia and whether this group is at higher risk of adverse in-hospital outcomes compared to those without pre-stroke dementia. We used multivariable logistic regression models to assess the associations between pre-stroke dementia and ambulation by day 2, in-hospital mortality, in-hospital complications, and being discharged home. Covariates included age, sex, comorbidities [dyslipidemia, atrial fibrillation, peripheral vascular disease (PVD), smoking, and alcohol use], medication history (antiplatelet drugs or lipid-lowering drugs), stroke severity [measured by the National Institute of Health Stroke Scale (NIHSS)], administration of intravenous tissue plasminogen activator (IV tPA) within 4.5 hours of stroke onset, and receipt of deep vein thrombosis (DVT) prophylaxis if indicated. In the final analytic sample of 559,070 ischemic stroke patients with no prior stroke history enrolled across 1,476 hospitals, those with pre-stroke dementia (n=1,511; 0.3%) were older and more likely to be female. Despite having received similar treatment, patients with pre-stroke dementia had lower odds of ambulating by day 2 [odds ratio (OR) =0.69; 95% confidence interval (CI): 0.62-0.78], higher odds of in-hospital mortality (OR =2.01; 95% CI: 1.35-2.99) or complications (OR =2.17; 95% CI: 1.93-2.44), and lower odds of being discharged home compared to those without pre-stroke dementia (OR =0.71; 95% CI: 0.62-0.83). Worse in-hospital outcomes among patients with pre-stroke dementia may be explained by pre-existing cognitive impairment that limited their ability to advocate for care needs. Further research is needed to determine whether a different care pathway or additional attention from clinicians is necessary for patients with pre-stroke dementia.

Association of Data-Driven White Matter Hyperintensity Spatial Signatures With Distinct Cerebral Small Vessel Disease Etiologies.

Topographical distribution of white matter hyperintensities (WMH) are hypothesized to vary by cerebrovascular risk factors. We used an unbiased pattern discovery approach to identify distinct WMH spatial patterns and investigate their association with different WMH etiologies. We performed a cross-sectional study on participants of the Alzheimer's Disease Neuroimaging Initiative (ADNI) to identify spatially distinct WMH distribution patterns using voxel-based spectral clustering analysis of aligned WMH probability maps. We included all participants from the ADNI Grand Opportunity/ADNI 2 study with available baseline 2D-FLAIR MRI scans, without history of stroke or presence of infarction on imaging. We evaluated the associations of these WMH spatial patterns with vascular risk factors, amyloid-β PET, and imaging biomarkers of cerebral amyloid angiopathy (CAA), characterizing different forms of cerebral small vessel disease (CSVD) using multivariable regression. We also used linear regression models to investigate whether WMH spatial distribution influenced cognitive impairment. We analyzed MRI scans of 1,046 ADNI participants with mixed vascular and amyloid-related risk factors (mean age 72.9, 47.7% female, 31.4% hypertensive, 48.3% with abnormal amyloid PET). We observed unbiased partitioning of WMH into 5 unique spatial patterns: deep frontal, periventricular, juxtacortical, parietal, and posterior. Juxtacortical WMH were independently associated with probable CAA, deep frontal WMH were associated with risk factors for arteriolosclerosis (hypertension and diabetes), and parietal WMH were associated with brain amyloid accumulation, consistent with an Alzheimer disease (AD) phenotype. Juxtacortical, deep frontal, and parietal WMH spatial patterns were associated with cognitive impairment. Periventricular and posterior WMH spatial patterns were unrelated to any disease phenotype or cognitive decline. Data-driven WMH spatial patterns reflect discrete underlying etiologies including arteriolosclerosis, CAA, AD, and normal aging. Global measures of WMH volume may miss important spatial distinctions. WMH spatial signatures may serve as etiology-specific imaging markers, helping to resolve WMH heterogeneity, identify the dominant underlying pathologic process, and improve prediction of clinical-relevant trajectories that influence cognitive decline.