Hospitalization For Acute Ischemic Stroke Research Articles

Effectiveness and Safety of Clopidogrel vs Aspirin in Elderly Patients With Ischemic Stroke

ObjectiveTo evaluate the risks of recurrent stroke and major bleeding events with clopidogrel and aspirin use among patients aged 80 years or older. Patients and MethodsThis retrospective cohort study was conducted using the Full Population Data of the Health and Welfare Database in Taiwan. Patients aged 80 years or older who received monotherapy with clopidogrel or aspirin following hospitalization for primary acute ischemic stroke between January 1, 2009, and December 31, 2018, were included. Inverse probability of treatment weighting was used to balance measured covariates between clopidogrel and aspirin users. Measured outcomes included recurrent acute ischemic stroke, acute myocardial infarction, composite cardiovascular events (recurrent stroke or acute myocardial infarction), intracranial hemorrhage, major gastrointestinal tract bleeding, and composite major bleeding events (intracranial hemorrhage or major gastrointestinal tract bleeding). ResultsA total of 15,045 patients were included in the study, 1979 of whom used clopidogrel and 13,066 who used aspirin following hospitalization for primary acute ischemic stroke. Clopidogrel use was associated with significantly lower risk of recurrent acute ischemic stroke (hazard ratio [HR], 0.89; 95% CI, 0.83 to 0.96; P=.002), composite cardiovascular events (HR, 0.88; 95% CI, 0.82 to 0.95; P<.001), intracranial hemorrhage (HR, 0.71; 95% CI, 0.56 to 0.90; P=.005), and composite major bleeding events (HR, 0.89; 95% CI, 0.80 to 0.99; P=.04) compared with aspirin use. ConclusionIn patients aged 80 years or older with primary acute ischemic stroke, clopidogrel users had lower risks of recurrent stroke and the composite cardiovascular events compared with aspirin users. Clopidogrel users also had lower risks of intracranial hemorrhage and the composite major bleeding events compared with aspirin users.

US Surveillance of Acute Ischemic Stroke Patient Characteristics, Care Quality, and Outcomes for 2019.

The United States lacks a timely and accurate nationwide surveillance system for acute ischemic stroke (AIS). We use the Get With The Guidelines-Stroke registry to apply poststratification survey weights to generate national assessment of AIS epidemiology, hospital care quality, and in-hospital outcomes. Clinical data from the Get With The Guidelines-Stroke registry were weighted using a Bayesian interpolation method anchored to observations from the national inpatient sample. To generate a US stroke forecast for 2019, we linearized time trend estimates from the national inpatient sample to project anticipated AIS hospital volume, distribution, and race/ethnicity characteristics for the year 2019. Primary measures of AIS epidemiology and clinical care included patient and hospital characteristics, stroke severity, vital and laboratory measures, treatment interventions, performance measures, disposition, and clinical outcomes at discharge. We estimate 552 476 patients with AIS were admitted in 2019 to US hospitals. Median age was 71 (interquartile range, 60-81), 48.8% female. Atrial fibrillation was diagnosed in 22.6%, 30.2% had prior stroke/transient ischemic attack, and 36.4% had diabetes. At baseline, 46.4% of patients with AIS were taking antiplatelet agents, 19.2% anticoagulants, and 46.3% cholesterol-reducers. Mortality was 4.4%, and only 52.3% were able to ambulate independently at discharge. Performance nationally on AIS achievement measures were generally higher than 95% for all measures but the use of thrombolytics within 3 hours of early stroke presentations (81.9%). Additional quality measures had lower rates of receipt: dysphagia screening (84.9%), early thrombolytics by 4.5 hours (79.7%), and statin therapy (80.6%). We provide timely, reliable, and actionable US national AIS surveillance using Bayesian interpolation poststratification weights. These data may facilitate more targeted quality improvement efforts, resource allocation, and national policies to improve AIS care and outcomes.

Mechanical thrombectomy after acute ischemic stroke in patients with left ventricular assist devices: A nationwide analysis.

Left ventricular assist devices (LVADs) are an established, durable, and life-saving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population, but LVO trials largely excluded patients on mechanical circulatory support, and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Using the National Inpatient Sample, we identified all adult patients hospitalized with acute ischemic stroke (AIS) from 2005 to 2018. Regression models adjusting for patient demographics, hospital factors, and clinical severity were used to compare outcomes following MT in patients with and without LVAD. Subgroup analyses were also performed in LVAD patients experiencing stroke in the post-operative setting and stroke in the setting of pre-existing devices. Of the 1,633,234 AIS hospitalizations identified, 794 occurred in patients with LVADs. Around 61% were post-operative. Post-stroke in-hospital mortality was higher among patients with LVADs (23.3% vs 7.23%, P < 0.001). Among those receiving MT, mortality was also higher in the LVAD population (31.0% vs 14.1%, P = 0.009), though this was largely driven by the post-operative LVAD subgroup. In multivariable analysis, only post-operative LVAD patients experienced greater odds of in-hospital death after MT (adjusted odds ratio (aOR): 8.66, confidence interval (CI):1.46-51.3); patients with pre-existing LVADs demonstrated no difference in post-MT mortality (aOR: 1.06; 95% CI: 0.29-3.91) or in odds of discharge home after MT (aOR 0.63, CI: 0.17-2.32). Our data suggest MT is not a futile treatment approach in patients with pre-existing LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Outcomes of Patients With Type 2 Myocardial Infarction Complicating Acute Ischemic Stroke

ObjectiveTo study the patient profiles and the prognostic impact of type 2 myocardial infarction (MI) on outcomes of acute ischemic stroke (AIS). MethodsThe National Readmission Database 2018 was queried for patients with primary AIS hospitalizations with and without type 2 MI. Baseline characteristics, inpatient outcomes, and 30-day all-cause readmissions between cohorts were compared. ResultsOf 587,550 AIS hospitalizations included in the study, 4182 (0.71%) had type 2 MI. Patients with type 2 MI were older (73.6 years vs 70.1 years; P<.001) and more likely to be female (52% vs 49.7%; P<.001), and they had a higher prevalence of heart failure (32.6% vs 15.5%; P<.001), atrial fibrillation (38.5% vs 24.2%; P<.001), prior MI (8.8% vs 7.7%; P<.001), valvular heart disease (17% vs 9.8%; P<.001), peripheral vascular disease (12.2% vs 9.2%; P<.001), and chronic kidney disease (24.4% vs 16.7%; P<.001). Compared with patients without type 2 MI, AIS patients with type 2 MI had significantly higher in-hospital mortality (adjusted odds ratio [aOR], 1.96; 95% CI, 1.65 to 2.32), poor functional outcome (aOR, 1.80; 95% CI, 1.62 to 2.00), more hospital costs (adjusted parameter estimate, $5618; 95% CI, $4480 to $6755), higher rate of discharge to a facility (aOR, 1.70; 95% CI, 1.52 to 1.90), increased length of stay (adjusted parameter estimate, 2.22; 95% CI, 1.72 to 2.72), and higher rate of 30-day all-cause readmissions (aOR, 1.38; 95% CI, 1.18 to 1.60). ConclusionType 2 MI in patients hospitalized with AIS is associated with poor prognosis and higher resource utilization.

Changes in nationwide in-hospital stroke care during the first four waves of COVID-19 in Germany.

In the early stages of the global COVID-19 pandemic hospital admissions for acute ischemic stroke (AIS) decreased substantially. As health systems have become more experienced in dealing with the pandemic, and as the proportion of the population vaccinated rises, it is of interest to determine whether the prevalence of AIS hospitalization and outcomes from hospitalization have returned to normal. In this observational, retrospective cohort study, we compared the prevalence and outcomes of AIS during the first four waves of the pandemic to corresponding pre-pandemic periods in 2019 using administrative data collected from a nationwide network of 76 hospitals that manages 7% of all in-hospital cases in Germany. We included 25,821 AIS cases in the study period (2020/2021) and used 26,295 AIS cases as controls (2019). Compared to pre-pandemic numbers, mean daily AIS admissions decreased only during wave 1 (from 39.6 to 34.1; p < 0.01) and wave 2 (from 39.9 to 38.3; p = 0.03) and returned to normal levels during waves 3 and 4. AIS case fatality increased in wave 1 only (from 6.0% to 7.6%; p = 0.03). We observed a consistent decrease in the prevalences of arterial hypertension, diabetes, and obesity among AIS cases throughout the pandemic and no changes in rates of systemic thrombolysis, mechanical thrombectomy, or decompressive craniectomy. The rate of transfer to stroke units increased only during waves 2 (by 4.6%; p < 0.01) and 3 (by 3.0%; p < 0.01). The proportion of patients with coinciding SARS-CoV-2 and AIS was low, peaking at 3.4% in wave 2 and subsequently decreasing to 0.4% in wave 4. In Germany, the COVID-19 pandemic seems to have had a larger effect on nationwide in-hospital AIS care during the early pandemic stages, in which AIS case numbers decreased and case fatality rose. This may reflect a nationwide "learning curve" within health care systems in providing AIS care in times of a pandemic.

The impact of a comprehensive national policy on improving acute stroke patient care in Lithuania.

Introduction:Reperfusion therapy (RT) is a mainstay treatment for acute ischemic stroke (AIS). We aimed to evaluate the impact of a comprehensive national policy (CNP) to improve access to RT for AIS patients across Lithuania.Patients and methods:Aggregated anonymized data on AIS cases treated in Lithuanian hospitals between 2006 and 2019 were retrospectively obtained from the Institute of Hygiene and the Stroke Integrated Care Management Committee. Through an interrupted time series analysis, we examined the trends in AIS hospital admissions, RT, and in-hospital case fatality rates prior to the enactment of CNP in 2014, changes immediately after the intervention, and differences in trends between the pre- and post-intervention periods. Mean yearly door-to-needle times were calculated post-intervention.Results:114,436 cases were treated for AIS in Lithuanian hospitals before, and 65,084 after the government intervention. We observed a significant decreasing post-intervention trend change in AIS hospital admission rate per 100,000 population (regression coefficient ± standard error: β = –16.47 ± 3.95, p = 0.002) and an increasing trend change in the proportion of AIS patients who received reperfusion treatment: intravenous thrombolysis (β = 1.42 ± 0.96, p < 0.001) and endovascular therapy (β = 0.85 ± 0.05, p < 0.001). The proportion of patients treated in stroke centers increased immediately after the intervention (β = 4.95 ± 1.14, p = 0.001), but the long-term post-intervention trend did not change. In addition, there was a significant decreasing trend in all cause in-hospital case fatality rate within primary and comprehensive stroke centers after the intervention (β = –0.60 ± 0.18, p = 0.008) despite its prompt initial immediate increase (β = 1.68 ± 0.73, p = 0.043). The mean countrywide door-to-needle time decreased from 68 min in 2014 to 43 min in 2019.Conclusion:The comprehensive national stroke patient care policy could be associated with an immediate increase in stroke center treatment rate, increased access to RT, and improved stroke care performance measures.

Association of Postprocedural Left Atrial Volume and Reservoir Function with Outcomes in Patients with Atrial Fibrillation Undergoing Catheter Ablation

The value of left atrial (LA) volume and reservoir function (ResF) after ablation for atrial fibrillation for predicting overall outcomes needs further investigation, particularly in large cohorts. The aim of this study was to test the hypothesis that abnormal LA volume and ResF after ablation are associated with adverse outcomes. Patients who underwent primary atrial fibrillation ablation between 2007 and 2016 and had available measurements of maximum LA volume index (LAVImax) and minimum LA volume index (LAVImin) and LA ResF (LA emptying fraction and LA expansion index) at 3-month echocardiographic examination after ablation were included in this analysis. The primary endpoint was the composite of cardiac hospitalization for heart failure or acute ischemic events, stroke or transient ischemic attack, and all-cause death; secondary endpoints were cardiac hospitalization and all-cause death. A total of 792 patients were studied (mean age, 60±10years). Over a median of 7.5years (interquartile range, 3.0-9.7years) of follow-up, 96 patients experienced adverse events. After adjustment for several parameters, including age, comorbidities, and left ventricular structure and function, increased LA volumes and impaired ResF were each independently associated with the primary endpoint (LAVImax > 34mL/m2: adjusted hazard ratio [HR], 2.37 [95% CI, 1.49-3.76; P=.0003]; LAVImin ≥ 20.5mL/m2: adjusted HR, 3.21 [95% CI, 1.97-5.24; P<.0001]; LA emptying fraction < 40%: adjusted HR, 2.00 [95% CI, 1.29-3.10; P=.002]; LA expansion index < 66%: adjusted HR, 1.91 [95% CI, 1.22-2.98; P=.005]) as well as with the secondary endpoints of cardiac hospitalization (P<.05 for adjusted HR for all LA parameters) and all-cause death (P<.05 for adjusted HR for LAVImin, LA emptying fraction and LA expansion index). ResF measures were incremental to LAVImax (P<.05 for all), but not to LAVImin. In patients with normal LA (LAVImax ≤ 34mL/m2; n=403), those with higher LAVImin (≥17mL/m2) were at 4 times higher risk for primary endpoint events (age-adjusted HR, 4.32; 95% CI, 1.90-9.81; P=.0005). All these findings were independent of atrial tachyarrhythmia recurrence. Enlarged left atrium and impaired ResF at 3months after ablation for atrial fibrillation are strongly associated with long-term outcomes, independent of left ventricular function or cardiac rhythm at follow-up. LAVImin showed the strongest associations and even identified a high-risk subgroup among patients with nondilated left atria.

Acute ischemic stroke and COVID-19 pandemic in Brazil: a comparative study of frequency and risk factors before and during SARS-CoV-2 era.

Background COVID-19 pandemic directly impacted the request for hospital care and medical assistance for several diseases worldwide, as occurred with acute ischemic stroke. The present study sought to compare the incidence and severity of acute ischemic stroke (AIS), in addition to sociodemographic, clinical, and radiological characteristics of patients hospitalized in the prepandemic (2018–2019) and pandemic (2020–2021) eras.MethodsAn incidence case–control, observational, and analytical research was carried out in the Stroke Unit of Hospital Governador Celso Ramos, Florianopolis, Santa Catarina, Brazil, including 171 patients admitted with acute ischemic stroke from April 2018 to April 2019 (prepandemic era) and 148 patients between January 2020 and January 2021 (during pandemic).ResultsThe mean incidence of AIS hospital admissions was significantly lower in the pandemic period (CI 95%, 0.2 to 5.6; p = 0.04), being lower in the lockdown periods and when the incidence of new COVID-19 cases increased. Besides, referring to AIS severity, the mean areas of AIS were larger during the pandemic period (p < 0.01), especially in August, September, December, and January (p < 0.05). Sociodemographic and clinical variables did not show any difference between the two periods of the study.ConclusionsHospital admissions for AIS decreased in the COVID-19 pandemic, mostly during months of higher incidences of new COVID-19 cases. When the incidence of admissions diminished, an increase in the severity of AIS was observed, characterized by larger areas. These findings might contribute to other similar referral centers in managing public policies related to stroke.

COVID-19 and Risk of Acute Ischemic Stroke Among Medicare Beneficiaries Aged 65 Years or Older: Self-Controlled Case Series Study.

Findings of association between coronavirus disease 2019 (COVID-19) and stroke remain inconsistent, ranging from significant association to absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The current study examined the association between COVID-19 and risk of acute ischemic stroke (AIS). We included 37,379 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 from April 1, 2020, through February 28, 2021, and AIS hospitalization from January 1, 2019, through February 28, 2021. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incidence rate ratios (IRRs) by comparing incidence of AIS in risk periods (0-3, 4-7, 8-14, 15-28 days after diagnosis of COVID-19) vs control periods. Among 37,379 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.4 (interquartile range 73.5-87.1) years and 56.7% were women. When AIS at day of exposure (day = 0) was included in the risk periods, IRRs at 0-3, 4-7, 8-14, and 15-28 days following COVID-19 diagnosis were 10.3 (95% confidence interval 9.86-10.8), 1.61 (1.44-1.80), 1.44 (1.32-1.57), and 1.09 (1.02-1.18); when AIS at day 0 was excluded in the risk periods, the corresponding IRRs were 1.77 (1.57-2.01) (day 1-3), 1.60 (1.43-1.79), 1.43 (1.31-1.56), and 1.09 (1.01-1.17), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities. Risk of AIS among Medicare FFS beneficiaries was 10 times (day 0 cases in the risk period) as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65-74 years and those without prior history of stroke. This study provides Class IV evidence that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with increased risk of AIS in the first 3 days after diagnosis in Medicare FFS beneficiaries ≥65 years of age.

Abstract 134: Population-level Trends In Clinal Outcomes And Endovascular Stroke Therapy In Acute Ischemic Stroke

Intro &amp; Background: Following the publication of the randomized clinical trials in 2015 and 2018 on endovascular stroke therapy (EVT), procedural utilization has increased. The effect of EVT utilization on clinical outcomes in acute ischemic stroke (AIS) at the population-level, however, remains incompletely characterized. Methods &amp; Materials: We performed a retrospective cross-sectional analysis using the Texas Public Use Data File with records from January 2016 through the first quarter of 2020. This dataset includes full sample data on all patients hospital discharged from all state-licensed hospitals. AIS hospitalizations were identified as those with a primary diagnosis of AIS by ICD-10 diagnostic codes. Patients &lt;18 were excluded, as well as patients missing age data. EVT was defined using ICD-10 procedure codes. Excellent clinical outcome was defined as discharge to home. Trends for EVT and percentage of home discharge were assessed by quarter and the correlation between two trends were examined by cross-correlation. Results: Among 165,738 AIS cases, 61% were over 65 years old, 51% were female, 51% were White and 25% were Hispanic. Over the course of the study period, EVT utilization increased 0.25% per quarter [95% CI 0.23-0.27, P&lt;0.001]. Excellent clinical outcomes also increased over this time period, with a 0.21% quarterly increase in patients being discharged home [95% CI 0.16-0.25, p&lt;0.001] (Figure). At the population-level, we observed a positive correlation between increasing EVT utilization and excellent clinical outcomes (R=0.64, p&lt; 0.003). Conclusion: In this state-wide cohort, increasing usage of EVT was positively correlated with excellent clinical outcomes. These data provide evidence for population-level improvements in AIS care with improving EVT access and utilization.

Abstract TMP16: Covid-19 And Risk Of Acute Ischemic Stroke Among Medicare Beneficiaries: Self-controlled Case Series Study

Introduction: Findings of association between COVID-19 and stroke remain inconsistent, ranging from significant association, absence of association to less than expected ischemic stroke among hospitalized patients with COVID-19. The present study examined the association between COVID-19 and risk of acute ischemic stroke (AIS). Methods: We included 19,553 Medicare fee-for-service (FFS) beneficiaries aged ≥65 years diagnosed with COVID-19 between April 1 and November 30, 2020 and AIS hospitalization from January 1, 2019 through November 30, 2020. We used a self-controlled case series design to examine the association between COVID-19 and AIS and estimated the incident rate ratios (IRR) by comparing incidence of AIS in risk periods (0-3, 4-7, 8-14, 15-28 days after diagnosis of COVID-19) vs. control periods. Results: Among 19,553 Medicare FFS beneficiaries with COVID-19 and AIS, the median age at diagnosis of COVID-19 was 80.5 (interquartile range 73.6-87.3) years and 57.5% were women. IRRs at 0-3, 4-7, 8-14, and 15-28 days following COVID-19 diagnosis were 10.97 (95% confidence interval 10.30-11.68), 1.59 (1.35-1.87), 1.23 (1.07-1.41), and 1.06 (0.95-1.18), respectively. The association appeared to be stronger among younger beneficiaries and among beneficiaries without prior history of stroke but largely consistent across sex and race/ethnicities. Conclusions: Risk of AIS among Medicare FFS beneficiaries was ten times as high during the first 3 days after diagnosis of COVID-19 as during the control period and the risk associated with COVID-19 appeared to be stronger among those aged 65-74 years and those without prior history of stroke.

Abstract WMP53: Venous Thromboembolism Among Medicare Beneficiaries Hospitalized With Acute Ischemic Stroke With And Without History Of Covid-19

Introduction: Venous thromboembolism (VTE) is a common medical complication following acute ischemic stroke (AIS). Studies have suggested that VTE rates were higher among patients with a history of COVID-19. We examined the risk of VTE in AIS patients with and without a history of COVID-19 among Medicare beneficiaries. Methods: We identified Medicare fee-for-service (FFS) beneficiaries aged ≥65 years with AIS hospitalizations from 04/01/2020 to 06/30/2021. COVID-19 cases were identified by the first diagnosis of COVID-19 on a claim at any health care setting. We defined AIS with COVID-19 if the dates of COVID-19 diagnoses were earlier than AIS admission dates. To identify VTE for each AIS admission, we used the following secondary diagnoses codes: ICD-CM-10: I80, I81, I82, I26. We compared the prevalence ratio (PR) of VTE between AIS patients with and without a history of COVID-19. Results: Among 178,830 Medicare FFS beneficiaries with AIS admissions, 6.1% had a history of COVID-19 and 2.6% had VTE as a complication. VTE prevalence among AIS patients with a history of COVID-19 was 3.98% (95% confidence interval (CI), 3.62-4.36%) and 2.53% (95% CI, 2.46-2.61%) among patients without a history of COVID-19. The adjusted PR of VTE was 1.55 (95% CI, 1.40-1.70, p&lt;0.001) comparing AIS admissions with a history of COVID-19 and those without a history of COVID-19. Non-Hispanic Black patients had the highest VTE prevalence, 6.14% among those with a history of COVID-19 and 3.89% among those without a history of Covid-19, as compared to other race/ethnicity groups. Both Non-Hispanic White and non-Hispanic Black patients with a history of COVID-19 had &gt;50% increased risk of VTE than those without a history of COVID-19 (Adjusted PR, 1.59, 95% CI, 1.42-1.78 for Non-Hispanic White, 1.58, 95% CI, 1.28-1.94 for Non-Hispanic Black, p&lt;0.001). Conclusion: AIS patients with a history of COVID-19 had an increased risk of VTE compared with patients without COVID-19. Healthcare professionals should be aware of the increased risks of VTE among AIS patients with COVID-19 and implement protocols for early VTE prevention.

Abstract TP79: Palliative Care After Stroke In Patients With Left Ventricular Assist Devices: A Nationwide Analysis

Background: Stroke is a common cause of death in patients with left ventricular assist devices (LVADs) and there is wide variation around end-of-life care. Palliative care encounters (PCEs) are associated with 6% of all stroke-related hospitalizations in the US but little is known about the palliative care needs or practices of PCE after LVAD-related stroke. We sought to better understand current practices around PCE after LVAD-related stroke and its association with outcomes. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all LVAD-related acute ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) hospitalizations. Demographics, clinical variables, utilization of life-prolonging interventions (LPIs; e.g., percutaneous endoscopic gastrostomy and tracheostomy) and outcomes were compared using multivariable regression. Results: 952 LVAD-related strokes were identified (58% IS, 22% ICH, and 19% SAH); 30% occurred perioperatively. PCE was associated with 16.9% of strokes (in 11% of IS, 24% of ICH and 28% of SAH), a rate that remained stable over time (P=0.112 for trend). Women made up a smaller proportion of those receiving PCE (17% vs 25%, P = 0.05). PCE was associated with 6% of non-fatal strokes and 46% of strokes resulting in in-hospital death. Among patients who died, SAH had the highest rate of PCE (54%), followed by IS (44%), and ICH (40%). Among decedents, PCE was associated with less frequent use of LPIs in ICH and SAH but did not effect length of stay (Figure). Conclusion: Although PCE is utilized more frequently in LVAD-related stroke compared to rates in the general stroke population, many LVAD stroke patients die without PCE intervention. PCE is not consistently associated with less aggressive care or early death in LVAD patients dying of stroke. Further work is needed to increase patient and family awareness of PCE services aimed at directing goal-concordant care after devastating neurologic injuries.

Abstract WP158: Trends In Utilization Of IV Thrombolysis And Mechanical Thrombectomy In Patients With Stroke And Malignancy.

Background and Purpose: Existing data shows that IV thrombolysis (tPA) and mechanical thrombectomy (MT) use in acute ischemic stroke (AIS) patients and malignancy is &lt;2%. Our aim was to determine whether utilization of recanalization therapies has increased in AIS patients with cancer since publication of pivotal MT trials. Methods: All admissions with a primary diagnosis of AIS (weighted n=5,554,161) were identified from the 2007-2018 Nationwide Inpatient Sample. Cancer-associated strokes (CAS) were categorized into hematologic (hem), solid and metastatic (met) cancers. Joint point regression and multivariable-adjusted logistic regression models with interaction terms were used to evaluate rate of change in t-PA and MT use in CAS compared to non-CAS admissions. Results: Across this period, 4.0% of AIS admissions had comorbid CAS. The proportion of AIS hospitalizations with CAS increased from 3.8% in 2007 to 4.4% in 2018. Mean age of CAS was 72.9 (47.6% women) vs. 70.6 years (51.8% women) among non-CAS. CAS patients had fewer vascular risk factors. Highest t-PA usage was in non-CAS pts (7.8%) and lowest use in met-CAS pts (3.8%) and this difference was significant. In contrast MT usage was highest in met-CAS (2.0%) vs non-CAS (1.6%) and hem-CAS (1.2%). A race-by-time interaction revealed an increase in utilization of both therapies in all CAS groups. Pace of the increase was slower in met CAS (OR 0.97, 95%CI 0.95-0.99) per unit increase in year. MT use increased at a faster pace in met-CAS patients (OR 1.07, 95%CI 1.02-1.12) compared to non-CAS. Although overall mortality rates for patients with cancer has decreased for all cancer types, CAS had significantly higher in hospital mortality as compared to NCS (8.9% vs 4.4%, p &lt;0.001). Conclusions: Utilization of both t-PA and MT has increased over the last decade. Contrary to prior studies, the current frequency and pace of increase in MT use is greater in met-CAS admissions compared to non-CAS. Patients with CAS have fewer traditional vascular risk factors and significantly higher in hospital mortality. Future studies should address longer term outcomes in CAS versus non-cancer strokes.

Abstract TMP64: Outcomes After Mechanical Thrombectomy In Patients With Left Ventricular Assist Devices

Background: Left ventricular assist devices (LVADs) are an established durable and lifesaving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population but LVO trials largely excluded patients on mechanical circulatory support and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all adult patients hospitalized with acute ischemic stroke (AIS). The presence of LVAD, the use of MT, and additional covariates were extracted. Descriptive statistics and multivariable regression models were used to compare outcomes following MT in patients with and without LVADs. Results: Of the 798,059 AIS hospitalizations identified, 366 occurred in patients with LVADs. LVAD patients were younger (mean age 59.6 [13.2] vs 70.1 [14.3], p &lt;0.001), and were less often female (23.0% vs 50.9%, p &lt;0.001). In the general stroke population 2% were treated with MT vs 6% in LVAD-associated AIS. Post-stroke mortality was higher among LVAD patients (18.4% vs 6.22, p=0.000). However, among patients receiving MT, there was no significant difference in in-hospital mortality between LVAD and non-LVAD patients (23.1% vs 12.5%, p=0.104). In crude analysis and after adjusting for potential confounders there was no difference in odds of discharge to home after treatment with MT (Figure). Conclusion: Our data suggests MT is not a futile treatment approach in patients with LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Abstract WP74: An Automated, Electronic Health Record-based Algorithm To Classify Ischemic Stroke Etiology

Introduction: Determining acute ischemic stroke (AIS) etiology is central to secondary stroke prevention, but can be diagnostically challenging. We built a stroke etiology classification model using electronic health record (EHR) data from non-cryptogenic AIS hospitalization encounters. Methods: We studied discharge summaries of non-cryptogenic AIS patients hospitalized at 2 academic, Comprehensive Stroke Centers from 2015-2020. The outcome was stroke etiology encoded in each institution’s stroke registry, abstracted from the discharge attending’s impression. We engineered variables including 1) clinical features from Unified Medical Language System concepts identified by a text mining tool, MetaMap , and 2) neuroimaging, echocardiographic, and laboratory features by regular expression operations. XGBoost classifier models were generated (80% training set, 20% testing set). A grid search of 36 model parameter value combinations and 10-fold cross validation were performed. We assessed variable importance in the optimized algorithm by calculating each feature’s Shapley value, the absolute value of the variable’s mean impact in predicting each specific stroke etiology. Results: The cohort was comprised of 1,993 patients (mean age 69 years, 55% male). We engineered a total of 2,004 features. Mean cross-validated accuracies of the best model in the training and validation sets were: 73.0% and 65.5%, respectively. Validation precision, recall, and F1 weighted scores were 66.2%, 65.5%, and 64.1% (mean cross-validated). The top 20 features contributing to etiology prediction are in Figure 1. Conclusion: We developed an EHR-based, automated tool to replicate a discharging attending’s stroke etiology diagnosis in non-cyptogenic patients. With further training in representative cohorts of non-cryptogenic and cryptogenic patients with an eventually diagnosed etiology, this algorithm may aide stroke etiology diagnosis before hospital discharge.

Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm: Prevalence and Practice Patterns.

There are limited data about the epidemiology and secondary stroke prevention strategies used for patients with depressed left ventricular ejection fraction (LVEF) and sinus rhythm following an acute ischemic stroke (AIS). We sought to describe the prevalence of LVEF ≤40% and sinus rhythm among patients with AIS and antithrombotic treatment practice in a multi-center cohort from 2002 to 2018. This was a multi-center, retrospective cohort study comprised of patients with AIS hospitalized in the Greater Cincinnati Northern Kentucky Stroke Study and 4 academic, hospital-based cohorts in the United States. A 1-stage meta-analysis of proportions was undertaken to calculate a pooled prevalence. Univariate analyses and an adjusted multivariable logistic regression model were performed to identify demographic, clinical, and echocardiographic characteristics associated with being prescribed an anticoagulant upon AIS hospitalization discharge. Among 14 338 patients with AIS with documented LVEF during the stroke hospitalization, the weighted pooled prevalence of LVEF ≤40% and sinus rhythm was 5.0% (95% CI, 4.1-6.0%; I2, 84.4%). Of 524 patients with no cardiac thrombus and no prior indication for anticoagulant who survived postdischarge, 200 (38%) were discharged on anticoagulant, 289 (55%) were discharged on antiplatelet therapy only, and 35 (7%) on neither. There was heterogeneity by site in the proportion discharged with an anticoagulant (22% to 45%, P<0.0001). Cohort site and National Institutes of Health Stroke Severity scale >8 (odds ratio, 2.0 [95% CI, 1.1-3.8]) were significant, independent predictors of being discharged with an anticoagulant in an adjusted analysis. Nearly 5% of patients with AIS have a depressed LVEF and are in sinus rhythm. There is significant variation in the clinical practice of antithrombotic therapy prescription by site and stroke severity. Given this clinical equipoise, further study is needed to define optimal antithrombotic treatment regimens for secondary stroke prevention in this patient population.

Abstract 14012: Trends of Cannabis Use Disorder and Its Impact on Outcomes of Acute Ischemic Stroke: 2007-2018

Background: Cannabis is one of the most extensively cultivated illicit drugs internationally. Its legalization and decriminalization in some states of the U.S. has increased its usage. Despite its widespread use, cannabinoid-related cerebrovascular disease is underreported. There are contradicting studies regarding the risk of Acute Ischemic Stroke (AIS) and its outcomes among cannabis users. Hypothesis: Our analysis estimates concurrent Cannabis Usage Disorder (CUD) trends among AIS patients and its impact on AIS outcomes. Methods: Study cohort was derived from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. Hospitalizations due to AIS in the age group of 18-49 were identified using previously validated ICD-9-CM/ICD-10-CM codes. Cochran Armitage trend test and multivariable survey logistic regression modeling were then utilized to analyze temporal trends, predictors, and outcomes. Results: Out of a total 406,987 hospitalizations due to AIS from 2007-2018, 19,614 (4.82%) had concurrent CUD. AIS hospitalizations with concurrent CUD have increased from 3.3% in 2007 to 6.6% in 2018 with a yearly increase of 10% (OR 1.1; 95%CI 1.1-1.1; p&lt;0.01). In multivariable regression analysis, age group 18-34 (OR 2.5; 95% CI 2.3-2.7; p&lt; 0.01); male (OR 1.5; 95%CI 1.4-1.6; p&lt;0.01), African American (OR 2.1; 95% CI 1.9 -2.2, p&lt;0.01), lower socio-economic group (OR 1.3; 95% CI 1.2-1.5, p&lt;0.01), West region (OR 1.5; 95% CI 1.3-1.7, p&lt;0.01), Weight loss (OR 1.3; 95% CI 1.1-1.6, p=0.01), Depression (OR 1.2; 95% CI 1.1-1.3, p =0.001) and other psychiatric disorders were associated with concurrent CUD among AIS patients. After adjusting with confounding factors, CUD was not associated with higher in-hospital mortality (OR 1.0; 95% CI 0.9-1.1, p=0.21) and discharge to facility. Conclusion: Our results show that between 2007 and 2018, hospitalizations due to AIS with concurrent CUD has doubled. This association is significantly higher among 18-34 age group, males, African American, Western US and with concomitant psychiatric disorders. However, CUD was not associated with poor outcomes in AIS. Our study highlights underlying demographic trends and emphasizes the need for further studies to identify the causal association of cannabis use and AIS.

Effect of COVID‐19 on Acute Ischemic Stroke Hospitalizations and Treatments: Population‐Level Experience

Background Several studies have reported changes in the volume and type of acute ischemic stroke (AIS) hospitalizations during the early stage of the COVID‐19 pandemic. However, population‐based assessments, which include lower volume centers and more comprehensive geographic areas, are limited. Here, we evaluate an entire state‐level experience during the first peak COVID pandemic and compare against a 1‐year prior historical period. Methods We conducted a retrospective population‐based study using the Texas Inpatient Public Use Data File, capturing all discharges from hospitals in the State of Texas, except federal hospitals. AIS admission volumes, patient characteristics, proportions of large vessel occlusion (LVO), admission rates to comprehensive stroke centers, use of intravenous tissue plasminogen activator and endovascular treatment, and patient outcomes were compared between April 1, 2019 and June 30, 2019 (historical control period) and April 1, 2020 and June 30, 2020 (pandemic period). Results A total of 9277 hospitalized AIS cases were identified during the pandemic period, a decrease of 12% (10 524) compared with the control period. Cases without LVO dropped by 15%, whereas LVO cases dropped by only 5%. There were no significant differences in age or race and ethnicity of patients. While admission rates to comprehensive stroke centers (39.6% versus 39.4%, P =0.81) and endovascular treatment use in LVO (17.0% versus 16.3%, P =0.45) were not different between the 2 periods, the use of intravenous tissue plasminogen activator (15.0% versus 13.6%, relative risk [RR], 0.90; 95% CI, 0.84–0.97; P =0.004) decreased. The percentage of patients who died or were discharged to hospice increased from 7.2% to 8.25% (RR, 1.17; 95% CI. 1.06–1.29; P =0.001). Conclusions This study from a statewide population‐level analysis confirms smaller hospital‐based cohorts observing decreasing numbers of milder AIS admissions, and lower use of thrombolysis. Although LVO admissions and endovascular treatment use were largely unchanged, these findings suggest missed treatment opportunities for patients with AIS in the pandemic.

Differential prognostic value of resistin for cardiac death in patients with coronary artery disease according to the presence of metabolic syndrome.

Resistin is associated with atherosclerosis progression by affecting inflammation and insulin resistance. There are controversial data regarding the prognostic value of resistin in stable coronary artery disease (CAD) patients. We prospectively investigated the long-term prognostic value of resistin in patients with stable CAD. A total 741 consecutive patients with stable CAD were followed for a median of 5.5years. Serum resistin, lipids, high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) levels were measured at baseline. Primary endpoints were cardiac death and secondary hospitalizations for acute coronary syndrome, arrhythmic event or ischemic stroke. Follow-up data were obtained from 703 patients of whom 79 had a cardiac death (11.2%) and 205 (29.2%) met the secondary endpoints. Resistin was positively correlated with hsCRP (r = 0.159, p < 0.001) and IL-6 (r = 0.165, p = 0.002), and negatively with high-density lipoprotein-cholesterol (r = -0.176, p < 0.001). Resistin levels could not predict cardiac death [HR 1.044; 95% CI 0.994-1.096; p = 0.087] neither secondary endpoints [HR 1.025; 95% CI 0.983-1.068; p = 0.250). Among 298 patients (42.4%) with metabolic syndrome (MS) resistin levels were independently associated with cardiac death after adjustment for conventional risk factors [HR 1.121; 95% CI 1.045-1.204; p = 0.002). Further adjustment for ejection fraction of left ventricle(LVEF) did not change the association (HR 1.145; 95% CI 1.057-1.240; p = 0.001). Patients with resistin values ≥ 7.6ng/mL (median level) had 2.8 times higher risk of cardiac death compared to those with resistin levels < 7.6ng/mL after adjustment for traditional risk factors and LVEF (HR 2.882; 95% CI 1.311-6.336; p = 0.008). Resistin is independently associated with cardiac death in patients with stable CAD and MS.