Independent Predictor Of Stroke Research Articles

Prediction of cerebrovascular event risk following myocardial infarction

IntroductionPatients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI). Methodswe analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]). ResultsDuring follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60ml/min/m2 (p=0.029, OR 2.65, 95% CI 1.07–6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6–month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7mmol/l (OR 4.09; p=0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916). Discussion/ConclusionsIn patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.

Predição do risco de evento cerebrovascular após um enfarte agudo do miocárdio

Introduction Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI). Methods We analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]). Results During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60 ml/min/m 2 (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42 ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7 mmol/l (OR 4.09; p=0.017) that fi tted the data well (Hosmer-Lemeshow: p=0.916). Discussion/conclusions In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.

Blood C-Reactive Protein Concentration with ABCD2 Is a Better Prognostic Tool than ABCD2 Alone

Background: Increased C-reactive protein (CRP) is a known predictor of vascular events in asymptomatic individuals and stroke patients. Only a few studies included transient ischaemic attack (TIA) patients. We assessed CRP levels in addition to traditional risk factors in a cohort of patients with TIA to examine the relationship of these parameters to the occurrence of ischaemic stroke. Methods: This is a prospective, longitudinal clinical evaluation of the efficacy of CRP as a prognostic indicator. CRP levels were measured in 194 TIA patients and in 1,024 asymptomatic individuals (recruited from a project on stroke prevention, the PrATO, which was ongoing at the same time in the Aosta Valley). A clinical risk score was determined using the ABCD² score in TIA patients. The area under the receiver operating characteristic curve (AUC) was used to evaluate the significance of the markers as predictors. Two models were evaluated: model 1 used the ABCD² score and model 2 used serum CRP levels in addition to the ABCD² score. The primary outcome was an ischaemic stroke. Results: Within 2 years ischaemic strokes occurred in 33/194 patients. The Cox proportional hazards models, after adjustments for conventional risk factors, identified CRP levels ≧3 mg/l and ABCD² scores ≧4 as independent predictors of stroke. The corresponding AUCs were 0.565 and 0.636, based on model 1 and model 2, respectively; this represented a statistically significant difference (p = 0.043). The absolute integrated discrimination improvement was 0.0249 (p = 0.007) and the relative integrated discrimination improvement was 2.3710. The net benefit became significant from a predicted probability ≧10% and was 0.077 when based on model 1 and 0.087 when based on model 2. Conclusions: Routine CRP measurements in the acute phase might be a useful tool for identifying TIA patients who are at a higher risk of ischaemic stroke. The additional use of CRP levels for the risk assessment in TIA patients improves risk definition in terms of the ABCD² score alone.

Synergistic effect of chronic kidney disease and high circulatory norepinephrine level on stroke risk in Japanese hypertensive patients

ObjectiveEvidence is now available about the association between chronic kidney disease (CKD) and stroke. However, less is known about the underlying mechanisms, and there is currently no reliable marker for identifying stroke-prone high-risk patients among CKD patients. MethodsA total of 514 hypertensive patients aged >50 years (mean, 72.3 years; 37% men) underwent 24-h BP monitoring and measurement of circulatory high-sensitivity C-reactive protein (hs-CRP) and norepinephrine at baseline. CKD was defined as eGFR<60ml/min/1.73m2 using the Cockcroft–Gault equation. Results and conclusionDuring an average of 41 months (1751 person-years), there were 43 stroke events. Compared with hypertensive patients without CKD, those with CKD (n=225) had higher levels of sleep systolic BP (SBP) (125mmHg vs. 129mmHg), circulatory hs-CRP (0.12mg/L vs. 0.20mg/L) and norepinephrine (332.2pg/ml vs. 372.8pg/ml; all P<0.05). On multivariable analysis, the hazard ratio (HR) (95% CI) for stroke in CKD vs. non-CKD was 2.7 (1.2–6.9) (P<0.05). CKD, as well as the baseline presence of silent cerebral infarction, sleep SBP increase, and high hs-CRP level (highest quartile: ≥0.42mg/L) were independently and additively associated with stroke events; above all, there was a synergistic effect of CKD and high norepinephrine level (highest quartile: ≥538pg/ml) on stroke risk (all P<0.05). Among hypertensive patients with CKD, those within the highest quartiles of norepinephrine had a greater stroke risk compared to those who were in the lower quartiles of norepinephrine (HR (95% CI): 2.2 (1.0–4.5); P=0.045).In conclusion, CKD is an independent predictor of stroke in Japanese hypertensive patients; in particular, hypertensive patients with CKD and a high norepinephrine level have a synergistically augmented stroke risk.

Perioperative Stroke and Associated Mortality after Noncardiac, Nonneurologic Surgery

Stroke is a leading cause of morbidity and mortality in the United States and occurs in the perioperative period. The authors studied the incidence, predictors, and outcomes of perioperative stroke using the American College of Surgeons National Surgical Quality Improvement Program. Data on 523,059 noncardiac, nonneurologic patients in the American College of Surgeons National Surgical Quality Improvement Program database were analyzed for the current study. The incidence of perioperative stroke was identified. Logistic regression was applied to a derivation cohort of 350,031 patients to generate independent predictors of stroke and develop a risk model. The risk model was subsequently applied to a validation cohort of 173,028 patients. The role of perioperative stroke in 30-day mortality was also assessed. The incidence of perioperative stroke in both the derivation and validation cohorts was 0.1%. Multivariate analysis revealed the following independent predictors of stroke in the derivation cohort: age ≥ 62 yr, history of myocardial infarction within 6 months before surgery, acute renal failure, history of stroke, dialysis, hypertension, history of transient ischemic attack, chronic obstructive pulmonary disease, current tobacco use, and body mass index 35-40 kg/m² (protective). These risk factors were confirmed in the validation cohort. Surgical procedure also influenced the incidence of stroke. Perioperative stroke was associated with an 8-fold increase in perioperative mortality within 30 days (95% CI, 4.6-12.6). Noncardiac, nonneurologic surgery carries a risk of perioperative stroke, which is associated with higher mortality. The models developed in this study may be informative for clinicians and patients regarding risk and prevention of this complication.

Independent and Joint Associations of Physical Activity and Fitness on Stroke in Men

Introduction: Recent studies have demonstrated that physical activity (PA) and cardiorespiratory fitness (CRF) are independent predictors of stroke in men. The combined associations of these 2 factors are not well established. Objective: To investigate the independent and joint associations of PA and CRF with fatal, nonfatal, and total stroke in a group of men. Methods: The current analyses included 45 689 men aged 18 to 100 years who completed baseline sessions between 1970 and 2001. All participants had no known myocardial infarction, stroke, or cancer. Physical activity was measured by questionnaire, and CRF was assessed from a maximal treadmill exercise test. The National Death Index for fatal stroke and mail-back surveys for nonfatal stroke were used to ascertain cases. Cox regression analyses were used to estimate the risk of stroke outcomes. Results: There were 619 cases over 800 582 person-years of observation. Significant inverse associations were observed between CRF and fatal, nonfatal, and total strokes after adjustment for age and examination year (P for trend < 0.05 for each). No associations were found between PA and any of the 3 outcomes after adjusting for other covariates and CRF. Joint associations of 9 PA fitness groups showed less risk for total stroke in the moderate and high fitness categories. Conclusion: These findings suggest that CRF is an independent predictor of incident stroke in asymptomatic men.

The Link between Atrial Fibrillation and Stroke in Women

Atrial fibrillation (AF) is the most common clinically significant cardiac arrhythmia. The most serious complication of AF is thromboembolic stroke. The individual risk of stroke in the setting of AF varies. Several clinical factors have been identified as independent predictors of stroke in AF, including prior stroke, age, hypertension and diabetes. The bulk of available data identifies female gender as another independent predictor of stroke risk in AF. In this article, we review the link between AF and an elevated stroke risk in women, explore the potential pathophysiologic basis for this association and examine the data regarding the effectiveness of anticoagulation in reducing this risk.

E112 Parenting a deaf child and coping with stress

Background: Embolic stroke of undetermined source (ESUS) identifies patients with cryptogenic ischemic stroke presumed due to embolism from several unidentified sources. Among patients with recent ESUS, we sought to determine independent predictors of recurrent ischemic stroke during treatment with aspirin or rivaroxaban and to assess the relative effects of these treatments according to risk. Methods: Exploratory analyses of 7213 participants in the NAVIGATE ESUS international trial who were randomized to aspirin 100 mg/day or rivaroxaban 15 mg/day and followed for a median of 11 months, during which time there were 309 first recurrent ischemic strokes (4.6% per year). Baseline features were correlated with recurrent stroke by multivariate analysis. Results: The 7 independent predictors of recurrent stroke were stroke or transient ischemic attack (TIA) prior to the qualifying stroke (hazard ratio [HR] 2.03 95% confidence internal [CI] 1.58-2.60), current tobacco user (HR 1.62, 95% CI 1.24-2.12), age (HR 1.02 per year increase, 95%CI 1.01-1.03), diabetes (HR 1.28, 95% CI 1.01-1.64), multiple acute infarcts on neuroimaging (HR 1.49, 95% CI 1.09-2.02), aspirin use prior to qualifying stroke (HR 1.34, 95% CI 1.02-1.70), and time from qualifying stroke to randomization (HR .98, 95% CI .97-.99). The rate of recurrent stroke rate was 2.6% per year for participants without any of these risk factors, and increased by an average of 45% for each independent predictor (P < .001). There were no significant interactions between treatment effects and independent stroke predictors or stroke risk status. Conclusions: In this large cohort of ESUS patients, several features including prior stroke or TIA, advanced age, current tobacco user, multiple acute infarcts on neuroimaging, and diabetes independently identified those with an increased risk of ischemic stroke recurrence. The relative effects of rivaroxaban and aspirin were similar across the spectrum of independent stroke predictors and recurrent stroke risk status.

Adiponectin Level as a Consequence of Genetic Variation, but Not Leptin Level or Leptin

The adipocytokines adiponectin and leptin have been suggested as risk factors for cardiovascular disease, including stroke, acting through atherosclerosis. However, studies have provided conflicting results in underpowered cohorts with some suggesting that the leptin:adiponectin ratio is a better predictor of risk. We examined these associations with carotid intima-media thickness (IMT), a marker of early atherosclerosis and arterial remodeling and an independent predictor of stroke. We also examined association between genetic variants in the leptin and adiponectin genes and IMT. Adiponectin and leptin levels were determined in 990 individuals from the community Carotid Atherosclerosis Progression Study. Five variants in the gene encoding adiponectin and 7 in the gene encoding leptin were genotyped and their effects on circulating levels assessed. Both were then correlated with IMT. Adiponectin levels negatively correlated with IMT (-0.079, P=0.013). There was no correlation between leptin levels or leptin:adiponectin ratio and IMT. Two variants in the ADIPOQ gene encoding adiponectin were associated with altered adiponectin levels, 1 of which (rs266729) was associated with IMT. There was also an interaction with body mass index (P=0.019) with the association being present in obese subjects (P=0.02). Our results support a causal role for adiponectin in early carotid IMT and suggest it may act through interaction with obesity. In contrast, we found no evidence of a role for leptin and no evidence that leptin:adiponectin ratio is a better predictor of risk that adiponectin levels alone.

Anesthesia Literature Review

Anesthesia Literature Review

Persistent Sex Disparity in Midlife Stroke Prevalence in the United States

Background: A recent study found that US women aged 45–54 years in 1999–2004 were twice as likely as men to report previous stroke. The aim of this study was to evaluate the validity of this finding by assessing the sex-specific midlife stroke prevalence in the most recent nationally representative, cross-sectional sample of US individuals. Methods: Sex-specific stroke prevalence, sex-specific vascular risk factor prevalence and sex-specific independent predictors of stroke were assessed among 35- to 64-year olds who participated in the National Health and Nutrition Examination Surveys in 2005–2006 (n = 2,274). Results: Women aged 35–64 years were almost 3 times more likely than men to report prior stroke (2.90 vs. 1.07%; p < 0.001). This disparity was driven by the 45- to 54-year age group, where women had thrice the odds of prior stroke compared with men (OR 3.12, 95% CI 1.30–7.50). Among 45- to 54-year olds, men were more likely than women to have a history of smoking, elevated homocysteine and elevated triglyceride levels, but less likely to be abdominally obese (p < 0.001). Independent stroke risk factors among women aged 35–64 years were a homocysteine level >8.5 µmol/l (OR 6.19, 95% CI 2.57–14.93), a history of myocardial infarction (OR 5.35, 95% CI 1.09–26.27) and diabetes mellitus (OR 6.63, 95% CI 2.47–17.81). Conclusion: The midlife sex disparity in US stroke prevalence persists. Greater emphasis on prompt recognition and treatment of cardiovascular risk factors among young and middle-aged women may ameliorate this worrisome trend.

Larger Left Atrial Appendage Is an Independent Predictor of Stroke in Patients with Atrial Fibrillation

Background: Left atrial appendage (LAA) is an important source of thromboembolism in patients with atrial fibrillation (AF). This study evaluated the features of LAA associated with stroke in patients with AF.Methods: We compared the size of LAA using computed tomography (CT) between 224 AF patients with non-hemorrhagic stroke (Group 1, 71 women, age 67±10 years) and 365 AF patients without stroke (Group 2, 77 women, age 56±11 years).Results: Group 1 included more female patients (31.7% vs. 21.1%, p=0.004), and was older than group 2 (p<0.001). There was no difference in the type of AF between two groups. CHADS2 score (3.2±0.8, vs. 0.6±0.7, p<0.001) and LA dimension (4.76±0.82 vs. 4.12±0.59 cm, p<0.001) were significantly lager in group 1 than group 2. The orifice size (3.85±1.66 vs. 2.57±0.93 cm2, p<0.001) and depth of LAA (3.18±0.67 vs. 2.67±0.57 cm, p<0.001) were significantly larger in group 1 than group 2. In multivariate analysis, age (OR 2.08 per decade increase, 95% CI 1.59–2.71, p<0.001), LA size (OR 1.89, 95% CI 1.29–2.76, p=0.001), the orifice size (OR 1.58, 95% CI 1.26–1.99, p<0.001) and the depth of LAA (OR 1.91, 95% CI 1.24–2.95, p=0.004) were independent predictors of stroke.Conclusion: In patients with non-valvular atrial fibrillation, the larger orifice size and depth of LAA were independent predictors of stroke with advanced age and LA enlargement.

The effects of size and period of administration of gold nanoparticles on rheological parameters of blood plasma of rats over a wide range of shear rates: In vivo

BackgroundBlood viscosity appears to be independent predictor of stroke, carotid intima-media thickening, atherosclerosis and most cardiovascular diseases. In an attempt to understand the toxicity and the potential threat of GNPs therapeutic and diagnostic use, an array of rheological parameters were performed to quantify the blood plasma response to different sizes and administration periods of GNPs over a wide range of shear rates.MethodsHealthy, thirty male Wistar-Kyoto rats, 8-12 weeks old (approximately 250 g body weight) were divided into control group (NG: n = 10), group 1 (G1A: intraperitoneal infusion of 10 nm GNPs for 3 days, n = 5 and G1B: intraperitoneal infusion of 10 nm GNPs for 7 days, n = 5), group 2 (G2A: intraperitoneal infusion of 50 nm GNPs for 3 days, n = 5 and G2B: intraperitoneal infusion of 50 nm GNPs for 7 days, n = 5). Dose of 100 μl of GNPs was administered to the animals via intraperitoneal injection. Blood samples of nearly 1 ml were obtained from each rat. Various rheological parameters such as torque, shear stress, shear rate, viscosity, plastic velocity, yield stress, consistency index (k) and flow index (n) were measured in the blood plasma of rats after the intraperitoneal administration of 10 and 50 nm GNP for 3 and 7 days using Brookfield LVDV-III Programmable rheometer.ResultsThe relationship between shear stress and shear rate for control, G1A, G1B, G2A and G2B was linearly related. The plastic viscosity and the yield stress values for G1A, G1B, G2A and G2B significantly (p < 0.05) decreased compared with the control. The n and k values calculated from equation (1). The k values for G1A, G1B and G2B decreased compared with the control; however the means were not significantly different. While G2A indicates no significant change compared with the control. The values of the flow behaviour index (n) were equal ≤ 1 for all the different GNPs sizes. The viscosity values measured for 10 and 50 nm GNPs (G1A, G1B, G2A and G2B) decreased compared with the control; however the means were not significantly different. The decrease in blood plasma viscosity values observed with all GNPs is particle size and administration period independent.ConclusionsAt these particular shear rates, the estimated rheological parameters are not influenced by GNPs size and shape, number of NPs, surface area and administration period of GNPs. This study demonstrates that the highly decrease in blood plasma viscosity was accompanied with the smaller 10 nm GNPs compared with the 50 nm GNPs. The decrease in blood plasma viscosity induced with 10 and 50 nm GNPs may be attributed to decrease in hematocrit and haemoglobin concentration in addition to erythrocyte deformability. This study suggests that histomorphologcal, histochemical and ultrastrucural investigations are needed to evaluate the inflammations and tissue injuries, in relation to the application of GNPs as a therapeutic and diagnostic tool.

National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007

This study compared, at a national level, trends in utilization, mortality, and stroke after carotid angioplasty and stenting (CAS) and carotid endarterectomy (CEA) from 2005 to 2007. The Nationwide Inpatient Sample (NIS) was queried for patient discharges with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for CAS and CEA. The primary outcomes were in-hospital mortality, stroke, hospital charges, and discharge disposition. Subgroup analyses were performed to evaluate these outcomes by neurologic presentation using χ(2) and multivariable logistic regression. Of the 404,256 discharges for carotid revascularization, CAS utilization was 66% higher in 2006 than in 2005 (9.3% vs 14%, P = .0004). Crude mortality, stroke, and median charges remained higher for CAS than for CEA; discharge to home was more common after CEA. Results improved from 2005 to 2007. By logistic regression of the total cohort from 2005 to 2006, CAS was independently predictive of mortality (odds ratio [OR], 1.47; 95% confidence interval [CI], 1.08-2.00; P < .0001). Independent predictors of stroke included CAS (OR, 1.43; 95% CI, 1.18-1.73; P < .0001) and symptomatic disease (OR, 2.4; 95% CI, 2.06-2.93;P < .0001). Among subgroups based on neurological presentation, regression showed that CAS significantly increased the odds of stroke in asymptomatic patients (OR, 1.6; 95% CI, 1.2-2.0; P = .0003). Among symptomatic patients, CAS increased the odds of in-hospital death (OR, 3.0; 95% CI, 1.7-5.1, P < .0001) and trended toward significance for stroke (OR, 1.7; 95% CI, 1.0-2.8; P = .0569). Utilization of CAS has increased from the years 2005 to 2007 with some improvements in the outcome. Despite improvements in outcome, resource utilization remains significantly higher for CAS than CEA.

Carotid Intima-Media Thickness is Greater but Carotid Plaque Prevalence is Lower in Black Compared with White Subjects

Carotid IMT is widely used as a surrogate marker for atherosclerosis. Prospective studies in largely white populations demonstrate that it is strongly associated with carotid plaque and is an independent predictor of stroke. There are few data from black populations. In a previous study, we showed that carotid IMT is increased in black individuals in the UK. The purpose of this study was to confirm this with a larger sample size and to establish whether raised IMT in black stroke-free individuals is associated with increased carotid plaque. High-resolution sonography was used to measure the CCA-, BIF-, and ICA-IMT and plaque in 306 black and 281 white healthy individuals recruited by random community sampling from London, U.K. Mean CCA-IMT was determined by using a semiautomated computer program that detects the blood/intima borderline and the media/adventitia borderline with the use of a gray-value algorithm. CCA-IMT was higher in black compared with white individuals after controlling for cardiovascular risk factors and socioeconomic status (β = 0.050; 95%CI, 0.024-0.076; P < .001). BIF- and ICA-IMT were also increased in black subjects. In contrast, carotid plaque was more common in white individuals (OR, 2.90; 95%CI, 1.41-5.96; P = .004). The lack of correlation between increased IMT and carotid plaque in black individuals implies that IMT should not currently be used as a surrogate marker of atherosclerosis in black populations. It suggests that the increased IMT seen in black individuals may not represent early atherosclerosis.

Aortic stiffness and pulse wave reflection in young subjects with migraine

Migraine has been associated with an increased risk for ischemic stroke and other cardiovascular (CV) events, including angina, myocardial infarction, and CV death, but the mechanisms that link migraine to CV disease remain uncertain. We hypothesized that aortic pulse wave velocity (PWV), a direct measure of aortic stiffness and an independent predictor of stroke and CV disease, may be increased in young migraineurs with no overt CV disease or major CV risk factors. We studied 60 subjects with migraine (age 33 ± 8 years, 85% women, blood pressure 119/74 ± 11/9 mm Hg) and 60 age-, sex-, and blood pressure-matched healthy control subjects. In all participants, carotid-femoral PWV and aortic augmentation index were determined by applanation tonometry. Cases and controls were free from overt CV disease, diabetes, and major CV risk factors. Subjects with migraine had a higher aortic PWV (7.6 ± 1.2 vs 6.4 ± 1.1 m × s(-1), p < 0.001) and aortic augmentation (heart rate-adjusted augmentation index, 0.17 ± 0.13 vs 0.08 ± 0.15, p < 0.001) than matched control subjects. Migraine patients with aura (n = 17) had higher aortic PWV than those without aura (n = 43; 8.2 ± 1.2 vs 7.4 ± 1.1 m × s(-1), p = 0.027). Age, mean arterial pressure as a measure of distending pressure, and migraine (all p < 0.05) independently predicted aortic PWV when a consistent number of CV risk factors was simultaneously controlled for. Migraine is independently associated with increased aortic stiffness and enhanced pressure wave reflection. This finding, obtained in young subjects without major CV risk factors, may represent one possible mechanism underlying the increased CV risk in migraine patients.

045 Predicting risk of stroke following TIA: a systematic review of the validation of ABCD2 clinical prediction rule

IntroductionStroke is a leading cause of death and acquired disability in every society in which it has been studied. Stroke and transient ischaemic attack (TIA) arise from identical aetiologies and...

Impaired Cerebrovascular Reactivity With Steal Phenomenon Is Associated With Increased Diffusion in White Matter of Patients With Moyamoya Disease

Reduced cerebrovascular reactivity (CVR) with steal phenomenon is an independent predictor for stroke and may indicate tissue exposed to episodic low-grade ischemia. The apparent diffusion coefficient (ADC) calculated using diffusion-weighted MRI is effective in characterizing focal brain ischemia and subtle structural changes in normal-appearing white matter (WM). We hypothesized that regions of steal phenomenon are associated with increased ADC in normal-appearing WM of patients with Moyamoya disease. Twenty-two patients with unilateral CVR impairment secondary to Moyamoya disease and 12 healthy control subjects underwent diffusion-weighted MRI and functional MRI mapping of the cerebrovascular response to hypercapnia. Parametric maps of ADC and CVR were calculated, coregistered, and segmented using automated image processing methods. ADC of normal-appearing WM was compared between hemispheres, and between WM with negative CVR (ie, steal phenomenon) and WM with positive CVR. In patients, ADC of normal-appearing WM was elevated in the hemisphere ipsilateral to the CVR impairment compared with the contralateral hemisphere (P<0.005) and in WM with negative CVR compared with WM with positive CVR (P<0.001). WM in regions of steal phenomenon within the affected hemisphere had higher ADC than homologous contralateral WM (P<0.005). In control subjects, negative CVR in WM was not associated with elevated ADC. Regions of steal phenomenon are spatially correlated with elevated ADC in normal-appearing WM of patients with Moyamoya disease. This structural abnormality may reflect low-grade ischemic injury after exhaustion of the cerebrovascular reserve capacity.

PULSE WAVE VELOCITY IS A PREDICTOR OF OUTCOME IN PATIENTS AFTER ISCHEMIC STROKE: PP.4.134

Objective: Increased aortic pulse wave velocity (PWV) has been shown to be an independent predictor of stroke in general population and of fatal stroke in essential hypertension. Augmentation index (Aix), derived from pulse wave analysis (PWA) independently predicted all-cause mortality and cardiovascular events in coronary patients. Whether PWV and PWA may predict outcome after ischemic stroke is unknown. Design and Methods: We enrolled 68 patients (49 males, age 63.5 ± 12.4 years, mean ± SD) with acute ischemic stroke. Patients were admitted during the first 48 hours of the disease onset (NIHSS at admission 6.1 ± 7.0). Carotid-femoral (CF) PWV, aortic systolic pressure (AoSBP) and augmentation index (AIx) were measured (Sphygmocor) one week after stroke onset. The outcome measures included NIHSS and modified Rankin score (mRS) at admission, and mRS 90 days after stroke. The end point was 90 - day favourable functional outcome (mRS 0 or 1). Data were analysed with multivariate logistic regression. Results: In patients with favourable outcome, the mean PWV-CF was lower than that in patients with non-favourable outcome (9.3 ± 1.7 vs. 12.4 ± 4.0 m/s, P < 0.001). Age, peripheral SBP and PWV-CF, but not AIx, predicted stroke outcome in univariate analysis (data not shown). Three different logistic regressions demonstrated that a low PWV-CF predicted a favourable outcome of stroke, independently of other CV risk factors, including age, peripheral SBP, and aortic SBP (Table).Conclusion: Our findings suggest that PWV is an independent predictor of stroke outcome.

Peripheral Arterial Disease as an Independent Predictor for Excess Stroke Morbidity and Mortality in Primary-Care Patients: 5-Year Results of the getABI Study

Background:There is controversial evidence with regard to the significance of peripheral arterial disease (PAD) as an indicator for future stroke risk. We aimed to quantify the risk increase for mortality and morbidity associated with PAD. Methods:In an open, prospective, noninterventional cohort study in the primary care setting, a total of 6,880 unselected patients ≧65 years were categorized according to the presence or absence of PAD and followed up for vascular events or deaths over 5 years. PAD was defined as ankle-brachial index (ABI) <0.9 or history of previous peripheral revascularization and/or limb amputation and/or intermittent claudication. Associations between known cardiovascular risk factors including PAD and cerebrovascular mortality/events were analyzed in a multivariate Cox regression model. Results:During the 5-year follow-up [29,915 patient-years (PY)], 183 patients had a stroke (incidence per 1,000 PY: 6.1 cases). In patients with PAD (n = 1,429) compared to those without PAD (n = 5,392), the incidence of all stroke types standardized per 1,000 PY, with the exception of hemorrhagic stroke, was about doubled (for fatal stroke tripled). The corresponding adjusted hazard ratios were 1.6 (95% confidence interval, CI, 1.1–2.2) for total stroke, 1.7 (95% CI 1.2–2.5) for ischemic stroke, 0.7 (95% CI 0.2–2.2) for hemorrhagic stroke, 2.5 (95% CI 1.2–5.2) for fatal stroke and 1.4 (95% CI 0.9–2.1) for nonfatal stroke. Lower ABI categories were associated with higher stroke rates. Besides high age, previous stroke and diabetes mellitus, PAD was a significant independent predictor for ischemic stroke. Conclusions:The risk of stroke is substantially increased in PAD patients, and PAD is a strong independent predictor for stroke.