Independent Predictor Of Stroke Research Articles

Cardio-Ankle Vascular Index Predicts Post-Discharge Stroke in Patients with Heart Failure.

Aim: We aimed to evaluate the significance of the cardio-ankle vascular index (CAVI) to predict stroke in patients with heart failure (HF). Methods: This was a prospective observational study, which recruited clinical data from a total of 557 patients who had been hospitalized for HF and undergone CAVI. According to the receiver operating characteristic curve analysis, the accurate cut-off value of CAVI in predicting post-discharge stroke was 9.64. We divided the patients into two groups: the high-CAVI group (HF patients with CAVI ≥ 9.64, n =111, 19.9%) and the low-CAVI group (HF patients with CAVI ＜9.64, n =446, 80.1%). We compared the patients’ characteristics and post-discharge prognosis. The primary endpoint was stroke. Results: The high-CAVI group was older (73.0 vs. 65.5 years old, P ＜0.001). Male sex (73.9% vs. 61.4%, P =0.015), coronary artery disease (47.7% vs. 36.1%, P =0.024), and diabetes mellitus (54.1% vs. 37.4%, P =0.001) were more prevalent in the high-CAVI group. In contrast, there was no difference in left ventricular ejection fraction, and prevalence of hypertension and dyslipidemia. The Kaplan-Meier analysis demonstrated that post-discharge stroke rate was higher in the high-CAVI group than in the low-CAVI group (log-rank P =0.005). In multivariate Cox proportional hazard analysis, high CAVI was found to be an independent predictor of stroke, with an adjusted hazard ratio of 3.599, compared to low CAVI. Conclusion: CAVI independently predicts stroke in patients with HF.

Impact of Left Atrial Appendage Closure on LAA Thrombus Formation and Thromboembolism After LAA Isolation.

This study sought to evaluate the safety and effectiveness of electrical isolation of the left atrial appendage (LAAEI) as well as the status of left atrial appendage closure (LAAC) in these patients. Catheter-based LAAEI is increasingly performed for treatment of symptomatic atrial fibrillation and pulmonary vein isolation nonresponders. Previous studies indicate an increased incidence of thromboembolic events after LAAEI despite effective oral anticoagulation. Interventional LAAC may prevent cardioembolic events after LAAEI but data regarding safety, feasibility, and efficacy of LAAC in this clinical setting are scarce. Consecutive patients who underwent LAAEI at 2 German tertiary care hospitals were analyzed. A total of 270 patients underwent LAAEI by radiofrequency ablation in 255 (94.4%), cryoballoon ablation in 12 (4.4%), and by a combination of both techniques in 3 cases (1.1%). Stroke or transient ischemic attack occurred in 24 of 244 (9.8%) individuals with available follow-up. LAA thrombus formation was found in 53 patients (19.6%). A total of 150 patients underwent LAAC after LAAEI. No LAA thrombus was documented in any patient who underwent LAAC. Of the patients who underwent LAAEI, 67.6% were in sinus rhythm after a mean of 682.7 ± 61.7days. LAA flow after LAAEI but not arrhythmia recurrence was identified as an independent predictor of stroke and/or transient ischemic attack or LAA thrombus (p<0.0001). Sinus rhythm was documented in about two-third of patients undergoing LAAEI as treatment of therapy refractory atrial arrhythmias. LAAC potentially prevents LAA thrombus formation and thromboembolism.

Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study.

BackgroundThere is an increased attention to stroke following SARS-CoV-2. The goal of this study was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.MethodsThis multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.FindingsWe received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke—123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1–3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4–4.7, p = 0.006) were predictive of stroke.InterpretationThe results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients.FundingNone.

Predictive Factors for 30-Day Stroke and Death Rate in a Contemporary Series of Carotid Endarterectomies Performed for Asymptomatic Stenosis of the Internal Carotid Artery

The objective was to retrospectively analyze the perioperative outcomes of carotid endarterectomy (CEA) performed for asymptomatic carotid stenosis in the last decade and to identify predictors of increased risk of stroke and death in a single-center experience. From January 2008 to December 2018, 2501 consecutive CEAs were performed in a single academic institution. Data concerning these interventions were prospectively collected in a dedicated database. A retrospective analysis of the database was performed, and 1956 interventions performed in asymptomatic patients were found. Univariate and multivariate (forward logistic regression) analyses were used to identify potentially significant predictors of stroke and death rate at 30 days and to calculate their weight in determining it. Thirty-day stroke and death rates were then assessed for each subgroup of different predictors. Overall, 30-day stroke and death rate was 0.9% (17 cases). On multivariate analysis, male sex, diabetes, and combined cardiac surgery and the need for selective shunting were identified as independent predictors of stroke and death at 30 days; 22.3% of patients did not have any predictor, whereas 51.3%, 23.1%, and 3.2% of the patients had one, two, or three predictors, respectively. No patient had four predictors. Thirty-day stroke and death rate for patients without any of the identified predictors was 0.2% (1 case/436 interventions), whereas the corresponding figures for patients with one, two, or three predictors were 0.7% (7 cases/1006 interventions; P = .7 in comparison with patients with no predictors), 1% (4 cases/451 interventions; P = .1 in comparison with patients with no predictors and P = .7 in comparison with patients with one predictor), and 8.5% (5 cases/63 interventions; P < .001 in comparison with patients with no predictor, one predictor, or two predictors). A subgroup of asymptomatic patients undergoing CEA with a prohibitive perioperative risk does exist, thus questioning the indication for surgery in such patients.

Stroke Prevention With the PCSK9 (Proprotein Convertase Subtilisin-Kexin Type 9) Inhibitor Evolocumab Added to Statin in High-Risk Patients With Stable Atherosclerosis.

Background and Purpose- The PCSK9 (proprotein convertase subtilisin-kexin type 9) monoclonal antibody evolocumab lowered LDL (low-density lipoprotein) cholesterol by 59% to 0.8 (0.5-1.2) mmol/L and significantly reduced major vascular events in the FOURIER trial (Further Cardiovascular Outcomes Research with PCSK9 Inhibition in Subjects with Elevated Risk). Herein, we report the results of a prespecified analysis of cerebrovascular events in the overall trial population and in patients stratified by prior stroke. Methods- FOURIER was a randomized, double-blind trial comparing evolocumab versus placebo in patients with established atherosclerosis, additional risk factors, and LDL cholesterol levels ≥1.8 (or non-HDL [high-density lipoprotein] ≥2.6 mmol/L) on statin therapy. The median follow-up was 2.2 years. We analyzed the efficacy of evolocumab to reduce overall stroke and stroke subtypes, as well as the primary cardiovascular composite end point by subgroups according to a history of stroke. Results- Among the 27 564 patients, 469 (1.7%) experienced a total of 503 strokes of which 421 (84%) were ischemic. Prior ischemic stroke, diabetes mellitus, elevated CRP (C-reactive protein), history of heart failure, older age, nonwhite race, peripheral arterial disease, and renal insufficiency were independent predictors of stroke. Evolocumab significantly reduced all stroke (1.5% versus 1.9%; hazard ratio, 0.79 [95% CI, 0.66-0.95]; P=0.01) and ischemic stroke (1.2% versus 1.6%; hazard ratio, 0.75 [95% CI, 0.62-0.92]; P=0.005), with no difference in hemorrhagic stroke (0.21% versus 0.18%; hazard ratio, 1.16 [95% CI, 0.68-1.98]; P=0.59). These findings were consistent across subgroups, including among the 5337 patients (19%) with prior ischemic stroke in whom the hazard ratios (95% CIs) were 0.85 (0.72-1.00) for the cardiovascular composite, 0.90 (0.68-1.19) for all stroke, and 0.92 (0.68-1.25) for ischemic stroke (P interactions, 0.91, 0.22, and 0.09, respectively, compared with patients without a prior ischemic stroke). Conclusions- Inhibition of PCSK9 with evolocumab added to statin in patients with established atherosclerosis reduced ischemic stroke and cardiovascular events in the total population and in key subgroups, including those with prior ischemic stroke. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT01764633.

Elevated Outpatient C-Reactive Protein Independently Predicts Stroke and Gastrointestinal Bleeding in LVAD Patients

Inflammation and congestion may contribute to stroke and gastrointestinal bleeding (GIB) in LVAD pts. C-Reactive Protein (CRP), erythrocyte sedimentation rate (ESR), and N-terminal-pro B-type natriuretic peptide (NT-proBNP) are established biomarkers of inflammation and congestion. We aimed to investigate the association of these biomarkers with stroke and GIB in LVAD pts who survived to their first outpt visit. Serum CRP, ESR and NT-proBNP were prospectively measured in consecutive LVAD pts at outpt visits. Pts with stroke or GIB prior to their first visit were excluded from the respective analysis. Biomarker levels were averaged to the date of the outcome of interest. ROC curves were constructed to identify the optimal biomarkers cut off points to predict stroke and GIB. Multivariable Cox proportional hazard models were built to assess the association of CRP with stroke and GIB after adjusting for age, gender, BMI, diabetes, INTERMACS profile, and NT-proBNP. 228 LVAD pts (105 HMII and 105 HM3, 18 others) were enrolled. 216 pts met inclusion for the GIB analysis (Cohort 1) and 223 for the stroke analysis (Cohort 2). The median follow-up was 829 [408-1196] and 857 [464-1209]d, respectively. 35 pts had a GIB and 24 had a stroke at a median follow up of 223 [120-695] and 415 [164-768]d. Median CRP, ESR and NT-proBNP were 14.6 [7.27-30.7] mg/L, 38.3 [25.8-55.5] mm/hr, and 1144 [655-2314] pg/mL in Cohort 1, and 22 [6.14-30.5] mg/L, 41.7 [25.1-53.0] mm/hr, and 1157 [662-2366] pg/mL in Cohort 2. The ROC curves identified significant cut offs only for CRP: 15.5 mg/L (AUC 0.66, p<0.01) for stroke (Fig 1a), and 8 mg/L (AUC 0.61, p<0.05) for GIB (Fig 1b). Multivariable Cox proportional Hazard models demonstrated that CRP >15.5 mg/L was an independent predictor of stroke (HR 4.2 95% CI 1.6-11.1, p=0.004) and CRP>8 mg/L was an independent predictor of GIB (HR 3.0 95% CI 1.0-8.6, p=0.04) CONCLUSION: Elevated outpt CRP is an independent predictor of stroke and GIB in LVAD recipients.

Prevalence and prognostic significance of device-detected subclinical atrial fibrillation in patients with heart failure and reduced ejection fraction

BackgroundCardiac implanted electronic devices (CIEDs) can detect short durations of previously unrecognised atrial fibrillation (AF). The prognostic significance of device-detected subclinical AF, in the context of contemporary heart failure (HF) therapy, is unclear. MethodsAmongst patients enrolled in the Remote Monitoring in HF with implanted devices (REM-HF) trial, three categories were defined based on total AF duration in the first year of follow-up: no AF, subclinical AF (≥6 min to ≤24 h), and AF >24 h. All-cause mortality, stroke, and cardiovascular hospitalisation were assessed. Results1561 patients (94.6%) had rhythm data: 71 (4.6%) had subclinical AF (median of 4 episodes, total duration 3.1 h) and 279 (17.9%) had AF >24 h. During 2.8 ± 0.8 years' follow-up, 39 (2.5%) patients had a stroke. Stroke rate was highest amongst patients with subclinical AF (2.0 per 100-person years) versus no AF or AF >24 h (0.8 and 1.0 per 100-person years, respectively). In the overall cohort, AF >24 h was not an independent predictor of stroke. However, amongst patients with no history of AF (n = 932), new-onset subclinical AF conferred a three-fold higher stroke risk (adjusted HR 3.35, 95%CI 1.15–9.77, p = 0.027). AF >24 h was associated with more frequent emergency cardiovascular hospitalisation (adjusted HR 1.46, 95%CI 1.19–1.79, p < 0.0005). Neither AF classification was associated with mortality. ConclusionsIn patients with HF and a CIED, subclinical AF was infrequent but, as a new finding, was associated with an increased risk of stroke. Anticoagulation remains an important consideration in this population, particularly when the clinical profile indicates a high stroke risk.

Identifying Gaps and Missed Opportunities for Intravenous Thrombolytic Treatment of Inpatient Stroke.

Background: Inpatient stroke-codes (ISC) have traditionally seen low treatment rates with IV-thrombolytic (IVT). The purpose of this study was to identify the predictors of true stroke, prevalent IVT-treatment gap and study the factors associated with such missed treatment opportunities (MTO).Methods: A retrospective chart review identified ISC from March 2017 to March 2018. Clinical, radiographic and demographic data were collected. Primary analysis was performed between stroke vs. non-stroke diagnoses. Dichotomous variables were analyzed using Chi-Square test of proportions and continuous variables with Wilcoxon-Ranked-Sum test. Significant factors were then tested in a multivariate logistic regression model for independence.Results: From 211 ISC, 36% (n = 76) had an acute stroke. Hemorrhagic stroke (HS) was present in 5.7% (n = 12). Of the remaining 199, 44% (n = 87) were IVT-eligible but only 3.4% (n = 3) were treated. Of the remaining 84 IVT-eligible-but-untreated patients, 69(82.1%) were mimics, while 15 (17.9%) had an ischemic stroke (IS), constituting a MTO of 1 in 6 IVT-eligible patients, with National Institutes of Health Stroke Scale (NIHSS) ≤4 being the commonest deterrent. Independent predictors of stroke were ejection fraction (EF) <30% (p = 0.030, OR = 3.06), post-operative status (p = 0.001, OR = 3.71), visual field-cut (p = 0.008, OR = 3.70), and facial droop (p = 0.010, OR = 2.59).Conclusion: In our study, one in three ISC were true strokes. IVT treatment rates were low with a MTO of 1 in 6 IVT-eligible patients. The most common reason for not treating was NIHSS ≤4. Knowing predictors of true stroke and the common barriers to IVT treatment can help narrow this treatment gap.

The Association Between Coronary Artery Calcification and Subclinical Cerebrovascular Diseases in Men: An Observational Study.

Aim: Coronary artery calcification (CAC) is an independent predictor of stroke and dementia, in which subclinical cerebrovascular diseases (SCVDs) play a vital pathogenetic role. However, few studies have described the association between CAC and SCVDs. Therefore, the aim of this study was to assess the clinical relationship between CAC and SCVDs in a healthy Japanese male population.Methods: In this observational study, 709 men, free of stroke, were sampled from a city in Japan from 2010 to 2014. CAC was scored using the Agatston method. The following SCVDs were assessed using magnetic resonance imaging: intracranial arterial stenosis (ICAS), lacunar infarction, deep and subcortical white matter hyperintensity (DSWMH), periventricular hyperintensity (PVH), and microbleeds. The participants were categorized according to CAC scores as follows: no CAC (0), mild CAC (1–100), and moderate-to-severe CAC (> 100). The adjusted odds ratios of prevalent SCVDs were computed in reference to the no-CAC group using logistic regression.Results: The mean (standard deviation) age of the participants was 68 (8.4) years. Participants in the moderate-to-severe CAC category showed significantly higher odds of prevalent lacunar infarction, DSWMH, and ICAS in age-adjusted and risk-factor-adjusted models. Microbleeds and PVH, in contrast, did not show any significant associations. The trends for CAC with lacunar infarction, DSWMH, and ICAS were also significant (all P-values for trend ≤ 0.02).Conclusions: Higher CAC scores were associated with higher odds of lacunar infarction, DSWMH, and ICAS. The presence and degree of CAC may be a useful indicator for SCVDs involving small and large vessels.

Cerebral collaterals and stroke in patients with isolated carotid artery dissections

To investigate potential association between collateral arterial supply and stroke in patients with isolated internal carotid artery dissection (iCeAD). We hypothesized a lower risk of stroke in patients with more robust collateral supply. This is a single-center, retrospective review of iCeAD patients between 1994 and 2018. iCeAD patients with sufficient neuroimaging data were included. Patients were categorized based on cerebral infarction (stroke) on neuroimaging. The collaterals score, ranging from 0 to 8 with higher scores indicating more robust collaterals, was assessed based on contributions from leptomeningeal arteries (0–2 points), anterior communicating artery (0–2 points) and anterior cerebral artery A1 segment (0–2 points), and posterior communicating artery (0–2 points). The study included 62 iCeAD patients, comprising 33 and 29 patients in the stroke and no stroke groups, respectively. Neurological motor deficit (p < 0.001) and internal carotid artery occlusion (p = 0.033) were independent predictors of stroke. More robust collaterals was associated with lower stroke risk (p = 0.032) in univariable analysis, but not after adjustment for baseline differences. The collaterals score performed poorly in receiver-operating characteristics (ROC) curve analysis, with area under the ROC (AUROC) curve of 0.640. A collaterals score of >4 had a sensitivity and specificity of 89.7% and 36.4% for no stroke, respectively. The covariate-adjusted AUROC curve was 0.514. Collateral circulation appeared to be a poor predictor of cerebral infarction in patients with isolated iCeAD. Future studies in larger, independent cohorts are needed to better understand the interaction of collaterals with stroke in cervical artery dissection.

Proteinuria as an independent predictor of stroke: Systematic review and meta-analysis.

BackgroundProteinuria has emerged as an important vascular risk factor for adverse cardiovascular events including stroke. Hypertension has been proposed as the principal confounder of this relationship but its role has not been systematically examined.AimWe aimed to determine if proteinuria remains an independent predictor of stroke after more complete adjustment for blood pressure.Summary of reviewWe performed a systematic review, searching MEDLINE and EMBASE (to February 2018) for cohort studies or randomized controlled trials that reported stroke incidence in adults according to baseline proteinuria ± glomerular filtration rate. Study and participant characteristics and relative risks were extracted. Estimates were combined using a random effects model. Heterogeneity was assessed by χ2 statistics and I2, and by subgroup strata and meta-regression, with a particular focus on the impact of more complete adjustment for blood pressure on the association. The quality of cohort studies and post hoc analyses was assessed using the Newcastle–Ottawa Scale. We identified 38 studies comprising 1,735,390 participants with 26,405 stroke events. Overall, the presence of any level of proteinuria was associated with greater stroke risk (18 studies; pooled crude relative risk 2.00, 95%CI 1.63–2.46; p < 0.001) even after adjustment for established cardiovascular risk factors (33 studies; pooled adjusted relative risk 1.72, 1.51–1.95; p < 0.001), albeit with considerable heterogeneity between studies (p < 0.001; I2 = 77.3%). Moreover, the association did not substantially attenuate with more thorough adjustment for hypertension: single baseline blood pressure measure (10 studies; pooled adjusted relative risk = 1.92, 1.39–2.66; p < 0.001); history or treated hypertension (four studies; pooled adjusted relative risk = 1.76, 1.13–2.75, p = 0.013); multiple blood pressure measurements over months to years (four studies; relative risk = 1.68, 1.33–2.14; p < 0.001).ConclusionsEven after extensive adjustment for hypertension, proteinuria is strongly and independently associated with incident stroke risk, possibly indicating a shared renal and cerebral susceptibility to vascular injury that is not fully explained by traditional vascular risk factors.

P263 Characterisation of patients with acute myocardial infarction complicated by left ventricular thrombus

Abstract Funding Acknowledgements None Background/Introduction Left ventricular (LV) thrombus is a widely recognized complication of acute myocardial infarction (AMI). Limited data are available from South East Asian patients with this post-infarction complication nor on whether patients with non-ST segment elevation myocardial infarction (NSTEMI) or STEMI with associated LV thrombosis exhibit differing clinical characteristics and/or outcomes. Left Ventricular Ejection Fraction (LVEF) ≤ 40% is a recognized predictor of LV thrombus formation, but there is limited data on LV thrombus patients with EF &amp;gt; 40% or in NSTEMI patients. Purpose This study aims to investigate and compare the clinical characteristics, treatment and outcomes of post-AMI patients with LV thrombus formation, with a particular emphasis on those with EF ≤ 40% and in NSTEMI patients. Methods Among 5829 consecutive echocardiogram results containing the keyword "thrombus" from August 2006 to September 2017, we identified 289 post-AMI patients with acute LV thrombus formation. Demographics, treatment and outcome measures were analysed. Results Cardiovascular risk factors such as dyslipidaemia (54.0%) and hypertension (50.5%) were commonly present in post-AMI patients with LV thrombus. Mean LVEF was 33.0 ± 10.4%. The majority (68.0%) of patients received triple therapy and 59.5% achieved thrombus resolution. NSTEMI patients had greater number of co-morbidities including heart failure (p &amp;lt; 0.01), documented history of ischaemic heart disease preceding the AMI leading to thrombus formation (p &amp;lt; 0.01) and lower LVEF (28.3 ± 9.3% vs. 34.8 ± 10.3% , p &amp;lt; 0.01) compared with STEMI cases. On multivariate analysis, having a lower EF was a significant independent predictor of stroke (HR 0.96, 95% CI 0.93-1.00, p = 0.03) and all-cause mortality (HR 0.95, 95% CI 0.92-0.99, p &amp;lt; 0.01). The categories of STEMI and NSTEMI did not predict thrombus resolution, stroke events or all-cause mortality after adjustment. Conclusion(s) Post-AMI LV thrombus patients with NSTEMI and STEMI differed in terms of their co-morbidities in their demographics and co-morbidities but it was a lower EF that was associated with an increased risk of stroke and all-cause mortality. Further studies on this topic are required.

P805Changes in arterial stiffness independently predict stroke in patients with essential hypertension: Data from a 8-year-follow-up study

Abstract Background/Introduction Although arterial stiffening is related to atherosclerosis progression, the prognostic role of its alterations in cerebrovascular events in hypertension is not fully elucidated. Purpose The aim of the present study was to assess the predictive role of changes inarterial stiffness for the incidence of stroke in a cohort of essential hypertensive patients. Methods We followed up 1082 essential hypertensives (mean age 55.9 years, 562 males, office blood pressure (BP)=145/91 mmHg) for a mean period of 8 years. All subjects had at least one annual visit and underwent blood sampling for assessment of metabolic profile, whilearterial stiffness was evaluated on the basis of carotid to femoral pulse wave velocity (PWV), by means of a computerized method at the initial and last visit. The distribution of baseline PWV was split by the median (8.2 m/sec) and accordingly subjects were classified into those with high (n=546) and low values (n=536). Stroke was defined as rapid onset of a new neurological deficit persisting at least 24 hours unless death supervened confirmed by computed tomography and magnetic resonance angiography and/or cerebrovascular angiography findings. Results The incidence of stroke over the follow-up period was 2.2%. Hypertensives who had stroke (n=24) compared to those without stroke at follow-up (n=1058) were older at baseline (65±9 vs 56±12 years, p=0.032), had higher office BP levels (155±13 vs 145±15mmHg, p=0.014) and prevalence of high PWV levels (67% vs 40%, p=0.021). No difference was observed between hypertensives with stroke and those without stroke with respect to baseline renal function and lipid levels (p=NS for all). By univariate Cox regression analysis it was revealed that changes in PWV levels between baseline and last visit predicted stroke (hazard ratio=1.352, p=0.004). Moreover, in multivariate Cox regression model, baseline age (hazard ratio=1.087, p=0.03), changes in PWV (hazard ratio=1.115, p=0.024) but not changes in office BP levels turned out to be independent predictors of stroke. Conclusions In essential hypertensive patients, changes in PWV predict future development of stroke, independently of established confounders, including BP. These findings support that PWV constitutes a potent prognosticator of cerebrovascular events and its estimation is essential in order to improve risk stratification in hypertension.

STROKE RISK PREDICTION IN PATIENTS WITH ATRIAL FIBRILLATION AND RHEUMATIC HEART DISEASE: RESULTS FROM THE RE-LY AF REGISTRY

Atrial fibrillation (AF) is associated with an increased risk for stroke. Since stroke risk varies according to associated risk factors, scores such as CHA2DS2-VASc are used to assess risk. Patients with AF and rheumatic heart disease (RHD), especially with mitral stenosis, have traditionally been considered to be at very high risk of future stroke, regardless of other factors. However, there are limited data to validate this assumption. The RE-LY AF registry enrolled 15,400 patients with AF from emergency departments across the world and followed them for 1 year. A total of 1,788 (11.6%) patients had RHD. We assessed the one-year risk of stroke in those with and without RHD and evaluated whether the CHA2DS2-VASc score predicted stroke risk in patients both with and without RHD. We also assessed if RHD and moderate-to-severe mitral stenosis were independent risk factors for stroke. Patients with RHD were younger (51.4±15.7 vs. 67.8±13.6 years), predominantly female (66.2% vs. 44.7%), and had a lower CHA2DS2-VASc score (2.1±1.7 vs. 3.7±2.2) as compared to patients without RHD (all p < 0.001). Echocardiographic validation of RHD patients showed that mitral stenosis was the most common valve lesion (69.4% of patients). The average mean transmitral gradient in patients with mitral stenosis was 11.5±6.5 mmHg. Patients with RHD had a higher baseline rate of anticoagulation use (60.5% vs. 45.3%, p < 0.001). Unadjusted annual rates of stroke were 2.8% and 4.1% for patients with and without RHD, respectively. The CHA2DS2-VASc score was predictive for stroke risk in patients with and without RHD (c-statistics: 0.69 and 0.63, respectively). In a multivariate logistic regression model excluding patients with mechanical heart valves, we found that age, gender, prior stroke or transient ischemic attack, congestive heart failure, tobacco and anticoagulation use were significant independent predictors for stroke. Neither RHD (adjusted odds ratio [OR] 1.34, 95% confidence interval [CI] 0.91-1.97, p=0.13) nor mitral stenosis in particular (adjusted OR 0.96, 95% CI 0.61-1.53, p=0.88) were independently associated with the risk for stroke. The CHA2DS2-VASc score is predictive for stroke risk in AF patients both with and without RHD. In AF patients, moderate-to-severe mitral stenosis is not an independent risk factor for stroke. These data indicate that it is reasonable to use a similar approach to risk stratification in AF patients with and without RHD.

Predictors of Stroke After Minimally Invasive Mitral Valve Surgery Without the Cross-Clamp

Minimally invasive mitral valve surgery (mini-MVS) with hypothermic fibrillatory arrest has been associated with an increased risk of stroke. We aim to investigate the incidence, predictors, and outcomes of stroke in a large cohort of patient who underwent clampless mini-MVS. Between January 2008 and June 2017, we performed 1247 mini-MVSs. The clinical, operative, and postoperative outcomes were analyzed. Univariable and multivariable regression analyses were used to identify predictors of postoperative stroke. The median follow-up was 5.2 years (interquartile range 2.6-7.5). The etiology of mitral valve (MV) disease was degenerative (60.4%, n = 753), functional (12.8%, n = 160), rheumatic (8.7%, n = 109), endocarditis (3.1%, n = 39), and reoperative MV surgery (14.9%, n = 186). The overall incidence of postoperative neurologic event was 2.5% (n = 31/1247). Univariable predictors of stroke were a higher Society of Thoracic Surgeons mortality risk (6.0 ± 11.8% vs 3.3 ± 5.2%, P < 0.001), advanced age, (69.6 ± 12.1 years vs 63.0 ± 13.6 years, P = 0.002), female gender (71.0% vs 46.3%, P = 0.007), and a history of a cerebrovascular accident (22.6% vs 8.7%, P = 0.008). Stroke patients had a higher 30-day mortality (22.6% vs 1.6%, P < 0.001) and a higher risk for long-term mortality (hazard ratio = 5.56, 95% confidence interval [CI] 3.2-9.6, P < 0.001). Advanced age (odds ratio [OR] 2.1; 95% CI 1.1-4.0; P = 0.02), female gender (OR 2.3; 95% CI 0.9-5.2; P = 0.05), and history of cerebrovascular accident (OR 3.1; 95% CI 0.98-10.1; P = 0.05) remained as independent predictors of stroke in the multivariable analysis. Our decade-long experience indicates that clampless mini-MVS is associated with a low incidence of postoperative stroke, and that the predictors of stroke are not specific to this approach.

Clot Lysis Time Predicts Stroke During Anticoagulant Therapy in Patients with Atrial Fibrillation

BackgroundFormation of dense fibrin clots has been reported in both atrial fibrillation (AF) and ischemic stroke. We have previously demonstrated that such clot properties can predict thromboembolism and major bleeding in AF patients treated with vitamin K antagonists (VKAs). In this longitudinal cohort study, we evaluated whether impaired fibrinolysis is associated with clinical outcomes in AF. MethodsIn 236 patients with AF receiving VKAs, we measured ex vivo plasma clot lysis time (CLT), a measure of global fibrinolysis along, with von Willebrand factor antigen (vWF), plasminogen activator inhibitor 1 antigen (PAI-1), and other fibrinolysis modulators. The primary outcome were ischemic cerebrovascular events. Secondary end points were death and major bleeding. ResultsDuring a median follow-up time of 4.3 (interquartile range 3.7-4.8) years, annual rates of death, ischemic cerebrovascular events, and major bleeding were 1.48%, 2.96%, and 3.45%, respectively. Patients with CLT in the fourth quartile (> 115 min) had 8-fold higher stroke or transient ischemic attack (TIA) rates compared with the other patients (8.67% vs 1.1%; P < 0.0001). CLT correlated with PAI-1 and vWF (r = 0.59; P < 0.0001 for both). In the multivariate Cox regression analysis adjusted for potential confounders, the independent predictors of stroke or TIA were CLT > 115 minutes (hazard ratio [HR] 7.67, 95% confidence interval [CI] 2.78-21.17; P < 0.0001), PAI-1 (HR 1.16, 95% 1.05-1.28; P = 0.003), and CHA2DS2-VASc score ≥3 (HR 5.18, 95% 1.76-15.29; P = 0.003). CLT was not associated with death or major and minor bleeding events. ConclusionsImpaired fibrinolysis may predict thromboembolic events in AF patients receiving VKA.

Both left upper lobectomy and left pneumonectomy are risk factors for postoperative stroke

Retrospective studies have found that left upper lobectomy (LUL) may be a new risk factor for stroke, and the potential mechanism is pulmonary vein thrombosis, which more likely develops in the left superior pulmonary vein (LSPV) stump. The LSPV remaining after left pneumonectomy is similar to that remaining after LUL. However, the association between left pneumonectomy, LUL, and postoperative stroke remains unclear. Thus, we sought to analyze whether both LUL and left pneumonectomy are risk factors for postoperative stroke. We prospectively included consecutive patients who underwent resection between November 2016 and March 2018 at our institution with 6 months of follow-up. Baseline demographic and clinical data were taken. A logistic regression model was used to determine independent predictors of postoperative stroke. In our study, 756 patients who underwent an isolated pulmonary lobectomy procedure were screened; of these, 637 patients who completed the 6-month follow-up were included in the analysis. Multivariable logistic regression analysis adjusted for common risk factors showed that the LUL and left pneumonectomy were independent predictors of stroke (odds ratio, 18.12; 95% confidence interval, 2.12–155.24; P = 0.008). Moreover, diabetes mellitus also was a predictor of postoperative stroke. In conclusion, both LUL and left pneumonectomy are significant risk factors for postoperative stroke.

GLUCOCORTICOIDS TREATMENT CAN WORSEN CEREBROVASCULAR REACTIVITY IN HYPERTENSIVE PATIENTS WITH RHEUMATOID ARTHRITIS

Objective: Hypertension (HTN) and rheumatoid arthritis (RA) are considered to be independent predictors of stroke. A long exposure to Glucocorticoids (GCs) (in years) is associated with a high CVD risk. A impaired cerebrovascular reactivity (CVR) is associated with increased risk of stroke. The aim of this study was to evaluate parameters of cerebrovascular reactivity in hyperoxia (O2CVR) in hypertensive patients combined with RA treated with GCs (1-st group) in comparison to matched subjects without GCs treatment (2-nd group). Design and method: The study involved 61 patients with HTN and RA (7 men and 54 women), mean age 59.8 ± 7.7 years, BP 148.9 ± 9.1/87.9 ± 5.1 mmHg. All patients were treated with methotrexate. Patients were divided into two groups matched by sex, age, grade of HTN, activity of RA. Group 1 included 12 patients treated with prednisolone 7.7 ± 4.9 mg per day for an average 3.5 years. Group 2 included 49 patients without GCs treatment. CVR was evaluated by bilateral transcranial Doppler sonography of the middle cerebral arteries (MCA) in hyperoxia. We measured MCA time average maximal blood flow velocity (TAMX), peak systolic velocity (Vps) at baseline, during 120 seconds inhalation of oxygen (O2) and during 3 min recovery phase. We used two parameters for CVR evaluation: index changes of flow velocity mean IFVm = (Vps2–Vps0)/Vps0*100% and speed modification of velocity SMFVm = (Vps2–Vps0)/120). Vps0 is starting parameter; Vps2 is the parameter during 2-nd minute of oxygen inhalation. Values are presented as Me [25; 75 percentiles]. Results: In general, a high and comparable in both groups frequency of impaired O2CVR was in 74% of patients. Most patients had an insufficient degree of decrease (less than 20%) of MCA blood flow velocities during oxygen inhalation. However, the values of IFVm and SMFVm were significantly higher in patients of 1-st group compared to patients of 2-nd group −4.4 [−14.1; 1,1] vs −15.3 [−21.1; −10.1] (P = 0.007) and −0.04 [−0.09; 0.01] vs 0.09 [−0.16; −0.05] (P = 0.032), respectively. Conclusions: Hypertensive patients with RA have a high frequency of impaired O2CVR. GCs treatment is associated with more severe impaired O2CVR.

Female Gender as a Risk Factor for Adverse Outcomes After Carotid Revascularization

We aim to identify gender differences in complications after carotid surgery. Our primary endpoint is the incidence of perioperative stroke, myocardial infarction, and mortality. Secondary endpoints include restenosis and reintervention rates. All patients undergoing carotid endarterectomy from July 2003 to May 2016 were reviewed. The Society for Vascular Surgery carotid reporting standards were used as a guideline for data collection. Over 13years, 9,585 patients with carotid disease were referred to our institution. A total of 690 procedures were performed (633 carotid endarterectomies, 54 carotid angioplasties and stenting, and 3 bypasses). Of these 633 carotid endarterectomy procedures, 31.8% (201) were in women and 68.2% (432) were in men. In the perioperative period, female gender was found to be an independent predictor of stroke (odds ratio [OR]: 8.597, 95% confidence interval [CI]: 0.967-76.429, P=0.041), restenosis (OR: 2.103, 95% CI: 1.445-3.060, P<0.001), and reintervention (OR: 6.448, 95% CI: 1.313-31.667, P=0.019). Mortality and cardiac morbidity did not significantly differ between genders. Ten-year stroke-free survival was 98.0% in women and 99.1% in men (logrank P=0.259). Ten-year restenosis-free survival was 77.6% (45 of 201) in women and 89.4% (45 of 425) in men (logrank P<0.001). Ten-year reintervention-free survival was 97.0% in women and 99.5% in men (logrank P=0.008). Female gender was not an independent predictor of myocardial infarction (P=0.713) and mortality (P=0.856), respectively. The mean follow-up time was 47.06±37.48months with a median follow-up time of 43months (interquartile range: 14.0-72.5). Female gender was an independent predictor of postoperative stroke, restenosis, and reintervention. Symptom status at the time of surgery and type of closure of the arteriotomy did not influence development of stroke in female patients.

Predictors of Recurrent Ischemic Stroke in Patients with Embolic Strokes of Undetermined Source and Effects of Rivaroxaban Versus Aspirin According to Risk Status: The NAVIGATE ESUS Trial

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.