Ischemic CVA Research Articles

Routine HbA1c screening identifies de novo (pre)diabetes mellitus in 37% of ACS patients which comes with an even higher ischemic risk compared to known diabetes mellitus

Abstract Background Diabetes is a prominent risk factor for coronary artery disease (CAD). By exacerbating the progression of CAD, it puts these patients at increased risk of acute coronary syndrome (ACS) and recurrent ischemic events. It is therefore important to identify hyperglycaemic individuals and to treat them accordingly. However, in daily practice it is seen that a subsequent proportion of people with diabetes is undiagnosed. Purpose The aim of this research is to gain insight in the prevalence of patients with de novo (pre)diabetes, the treatment, and the risk of major adverse cardiac and cerebrovascular events (MACCE) compared to patients with known diabetes in an ACS cohort treated by percutaneous coronary intervention (PCI). Methods The Southeast Netherlands Heart Registry (ZON-HR) is an ongoing, multicentre registry collecting data of patients who underwent a PCI procedure. Of this cohort, patients presenting with ACS and measured HbA1c concentrations (on admission) were selected (N=1507). Patients with diagnosed diabetes are considered well-regulated when HbA1c <53 mmol/mol. Patients undiagnosed with diabetes were divided into three groups: HbA1c concentration <42 mmol/mol (normal), HbA1c 42-47 mmol/mol (pre-diabetes) and HbA1c ≥48 mmol/mol (diabetes). The rates of 30-day repeated myocardial infarction (MI), unplanned revascularisation, ischemic CVA, stent thrombosis, and cardiovascular mortality were determined, separately and combined as MACCE in patients with known diabetes compared to prediabetes and diabetes de novo. Results In the selected population, 28.5% of the patients were previously diagnosed with diabetes, which was well-regulated in only 30.2% of these patients. Of the patients not previously diagnosed, 23.1% and 14.4% had pre-diabetic and diabetic HbA1c concentrations, respectively. In 56.1% of patients with de novo diabetes, no glucose-lowering medication was prescribed at discharge (Table 1). At 30-day follow-up, de novo diabetes patients had increased rates of MACCE compared to patients with known diabetes (HR: 3.51, 95%CI 1.48-8.52) after multivariate analysis which corrected for differences at baseline (Figure 1). In addition, a significant increase in unplanned revascularisation (p=.014) and MI (p=.037) was found between de novo diabetes and known diabetes patients. Conclusions Almost half of the ACS patients in this cohort had either poorly regulated diabetes (305 patients) or was undiagnosed with (pre)diabetes while having an increased HbA1c concentration on admission (401 patients). Despite routine HbA1c screening, a subsequent part of these patients is not adequately treated for (pre)diabetes, especially the de novo diabetes patients. By this group, an even larger rate of MACCE was found, compared to the already established risk of diabetes in ACS. Therefore, active screening and treatment (as recommended in the guidelines) should get more attention to improve outcomes in these high-risk patients.Table 1:ACS population based on HbA1cFigure 1:Survival curves of 30D MACCE

Optimal anticoagulation strategy for left ventricular assist device patients undergoing thoracentesis: a retrospective study

Abstract Background Left ventricular assist devices (LVADs) are associated with thromboembolic risks necessitating anticoagulation, yet balancing these risks with bleeding concerns remains challenging. Current practice involves warfarin with a target INR of 2-3 alongside anti-platelet therapy. However, consensus on anticoagulation management is lacking, particularly during sub-therapeutic INR or procedural settings. Common strategies include bridging anticoagulation with heparin or enoxaparin, temporary cessation of anticoagulation during the procedure or uninterrupted anticoagulation. Purpose To evaluate and compare the incidence of bleeding and thromboembolic events in LVAD patients undergoing thoracentesis, with a focus on determining the optimal anticoagulation strategy during procedures. Methods Retrospective data was collected over one year from LVAD patients undergoing thoracentesis at a large academic center. Patients were categorized into ‘bridge’ (received intravenous heparin for bridging during thoracentesis) and ‘no-bridge’ (did not receive bridging anticoagulation) groups. Warfarin was paused before procedure and resumed after procedure in both groups. Baseline characteristics, including age, sex, race, BMI, LVAD type, and INTERMACS profile, were recorded. Primary outcomes were major bleeding and thromboembolic events within 30 days of warfarin cessation. Statistical analysis used t-test/Wilcoxon for continuous variables and Chi-square/Fisher exact test for categorical variables. A p-value <0.05 was considered significant. Results During the study, twenty LVAD patients underwent thirty-two thoracenteses (nineteen bridge, thirteen no-bridge). The demographics were similar among the two groups. Warfarin was held for an average of 5.5 ± 4.6 days before and resumed 4.1 ± 4.6 days after the procedure in the bridge group and 3.8± 3.2 days before and 1.7 ± 2.5 days after in the no-bridge group. Major bleeding occurred in 73.7% of bridge group cases versus 30.8% of no-bridge group cases (p=0.059). 63.2% of bridge group patients had a bloody pleural effusion on thoracentesis compared to 46.2% of no-bridge group patients (p value= 0.34). Average transfusion requirements were 2.8 units and 2 units in the bridge and the no-bridge groups respectively (p=0.658). Thromboembolic events included a 10.5% ischemic CVA rate in the bridge group, with none in the no-bridge group. No other arterial thromboembolic events, pump thrombosis or DVT/PE were observed in either group. Conclusion In LVAD patients undergoing thoracentesis, a non-bridging strategy does not appear to elevate the risk of thrombosis compared to a bridging approach. Moreover, the incidence of bleeding, while not statistically significant, trended higher in the bridging group.

Role of Prophylactic Antibiotics in Preventing Stroke-Associated Pneumonia in Patients with Ischemic Stroke

Objective: To compare the frequency of stroke-associated pneumonia in patients given prophylactic antibiotics versus those not given prophylactic antibiotics.Study Design: Comparative Cross-sectional study.Place and Duration of Study: The study was carried out at the Department of Internal Medicine, Combined st st Military Hospital (CMH), Peshawar, Pakistan from 1 August 2022 to 31 January 2023.Methods: We included 250 ischemic stroke patients and divided them into groups A, “Prophylactic group,” and B, “no prophylactic antibiotics group.” Patients were assessed at 7 days after admission for presence of “stroke associated pneumonia (SAP)” through clinical examination and chest X-rays. Data were analyzed using a statistical package for social sciences 22. For qualitative variables, frequency and percentages were used, whereas for quantitative data, the median (IQR) was used as the data were not normally distributed and contained outliers; using the median and IQR can be more appropriate for describing the central tendency and spread of the data compared to the mean and standard deviation.Results: In our study, the median age of the patients was 68(46-83) years. 61 (24.40%) of the patients were male while 189(75.60%) were female. The median BMI was 31 (19-44) kg/m2. Diabetes was present in 123 (49.20%) patients and 96(38.40%) had hypertension. We found that in the the “prophylactic antibiotics” group (A), 9 (7.20%) patients developed SAP, while in the “no prophylactic antibiotics” group (B) frequency of SAP was 34 (27.20%) (p< 0.001).Conclusion: Prophylactic antibiotics used in “ischemic stroke” patients provide better outcomes by reducing the incidence of “stroke-associated pneumonia”. Therefore, it should be given to all patients admitted to the hospital with ischemic CVA.
 How to cite this: Aslam MJ, Amir M, Sayed TM, Hashmat A, Hussain M, Fatima M.Role of Prophylactic Antibiotics in Preventing Stroke Associated Pneumonia in Patients with Ischemic Stroke. Life and Science. 2024; 5(1): 82-88. doi: http://doi.org/10.37185/LnS.1.1.465

Abstract 17748: Lipoprotein(a) and Oxidized Phospholipids on Lipoproteins and Cardiovascular Outcomes in Patients With Chronic Coronary Syndrome Treated With Colchicine

Introduction: Lipoproteins carrying pro-inflammatory oxidized phospholipids (OxPL), exemplified by lipoprotein(a) [Lp(a)], contribute to residual risk for major adverse cardiovascular events (MACE) in patients with chronic coronary syndrome (CCS) despite optimal medical treatment. Hypothesis: Anti-inflammatory colchicine therapy modifies MACE in patients with elevated Lp(a), OxPL on apo(a) [OxPL-apo(a)], and OxPL on apoB containing lipoproteins (OxPL-apoB). Aims To study the relationship of Lp(a), OxPL-apo(a) and OxPL-apoB with MACE in 1777 LoDoCo2 trial participants with CCS randomized to colchicine or placebo. Methods: End of study but not baseline samples were available. Because Lp(a), OxPL-apo(a) and OxPL-apoB levels are strongly genetically determined, we assumed that end of study values would reflect baseline values. The primary endpoint was a composite of MI, ischemic CVA or ischemia driven coronary revascularization. Cox regression was used to compare the incidence of the primary endpoint by Lp(a) dichotomized at 125 nmol/L and OxPL-apo(a) and OxPL-apoB in tertiles. Results: At study end, median (IQR) on-colchicine Lp(a), OxPL-apo(a), and OxPL-apoB levels in nmol/L were 22.4 (7.2-102.7), 7.8 (2.0-34.5) and 3.1 (1.3-6.3), similar to on-placebo levels of 23.9 (9.9-95.7), 8.8 (2.7-34.0), and 3.1 (1.4-5.9), respectively (p = 0.20, 0.98 and 0.18). MACE reduction with colchicine was independent of Lp(a) and OxPL-apo(a) (P interaction = 0.92 and 0.66 respectively). However, the largest MACE reduction was present in the highest vs lowest OxPL-apoB tertile ( Figure , P interaction < 0.05). Conclusions: The benefit of colchicine in reducing MACE was highest in subjects with elevated OxPL-apoB, suggesting colchicine may be most effective in subjects with heightened oxidation-driven inflammation. These findings may be hypothesis-generating and require validation in larger trials with baseline biomarker assessment including CRP and IL-6.

Mortality and morbidity following initiation of anticoagulant or antiplatelet treatment for blunt cerebrovascular injury

ObjectiveCerebrovascular accidents (CVA) are potential sequelae of blunt cerebrovascular injuries (BCVI). To minimize their risk, medical therapy is used commonly. It is unclear if anticoagulant or antiplatelet medications are superior for decreasing CVA risk. It is also unclear as to which confer fewer undesirable side effects specifically in patients with BCVI. The aim of this study was to compare outcomes between nonsurgical patients with BCVI with hospital admission records who were treated with anticoagulant medications and those who were treated with antiplatelet medications. MethodsWe performed a 5-year (2016-2020) analysis of the Nationwide Readmission Database. We identified all adult trauma patients who were diagnosed with BCVI and treated with either anticoagulant or antiplatelet agents. Patients who were diagnosed with index admission CVA, intracranial injury, hypercoagulable states, atrial fibrillation, and or moderate to severe liver disease were excluded. Those who underwent vascular procedures (open and/or endovascular approaches) and or neurosurgical treatment were also excluded. Propensity score matching (1:2 ratio) was performed to control for demographics, injury parameters, and comorbidities. Index admission and 6-month readmission outcomes were examined. ResultsWe identified 2133 patients with BCVI who were treated with medical therapy; 1091 patients remained after applying the exclusion criteria. A matched cohort of 461 patients (anticoagulant, 159; antiplatelet, 302) was obtained. The median patient age was 72 years (interquartile range [IQR], 56-82 years), 46.2% of patients were female, falls were the mechanism of injury in 57.2% of cases, and the median New Injury Severity Scale score was 21 (IQR, 9-34). Index outcomes with respect to (1) anticoagulant treatments followed by (2) antiplatelet treatments and (3) P values are as follows: mortality (1.3%, 2.6%, 0.51), median length of stay (6 days, 5 days; P < .001), and median total charge (109,736 USD, 80,280 USD, 0.12). The 6-month readmission outcomes are as follows: readmission (25.8%, 16.2%, <0.05), mortality (4.4%, 4.6%, 0.91), ischemic CVA (4.9%, 4.1%, P = not significant [NS]), gastrointestinal hemorrhage (4.9%, 10.2%, 0.45), hemorrhagic CVA (0%, 0.41%, P = NS), and blood loss anemia (19.5%, 12.2%, P = NS). ConclusionsAnticoagulants are associated with a significantly increased readmission rate within 6 months. Neither medical therapy is superior to one another in the reduction of the following: index mortality, 6-month mortality, and 6-month readmission with CVA. Notably, antiplatelet agents seem to be associated with increased hemorrhagic CVA and gastrointestinal hemorrhage on readmission, although neither association is statistically significant. Still, these associations underscore the need for further prospective studies of large sample sizes to investigate the optimal medical therapy for nonsurgical patients with BCVI with hospital admission records.

The Incidence of Cardiovascular Events in Small Versus Large Ischemic Stroke; A Three-Year Cohort Study.

Cerebral ischemia and coronary artery disease (CAD), the major leading causes of mortality and morbidity worldwide, are pathophysiologically interrelated. Cerebral ischemic events are categorized as large or small vessels disease. The current study compares the factors related to CAD events incidence following ischemic large versus small disease CVA. The current cohort study was conducted on 225 patients with ischemic stroke in two groups of large (n=75) and small (n=150) vessel disease during 2018-19. The patients' demographic, medical, and clinical characteristics were recruited. They were followed for three years regarding the incidence of CAD events, including ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), unstable angina (UA), and sudden cardiac death (SCD). Data about the coronary angiography, computed tomography angiography (CTA), Single Photon Emission Computed Tomography (SPECT), and the therapeutic approach were gathered. There were insignificant differences between the patients with small versus large vessels CVA in terms of ACS incidence (P-value=0.105), type of the events (P-value=0.836), angiographic (P-value=0.671), SPECT (P-value=0.99) and CTA findings (P-value>0.99) and approached CAD (P-value=0.728). Cox regression assessments revealed an increased risk of CAD events due to large versus small vessels disease after adjustments for hypertension, diabetes mellitus, dyslipidemia, re-stroke, and the previous history of IHD (HR=2.005, 95%CI: 1.093-2.988, P-value=0.021). According to the findings of this study, large-vessel involvement in an ischemic stroke was associated with more than a two-fold increase in the three-year probability of ischemic heart disease incidencet.

CORRELATION OF NIHSS WITH SHORT TERM COMPLICATIONS OF ACUTE ISCHEMIC CVA PATIENT RECEIVING THROMBOLYSIS

Stroke is characterized as a neurological decit attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral haemorrhage (ICH) and subarachnoid hemorrhage. Thrombolysis is associated with its own complication and side effects and also have its own contraindication which should be kept in mind when thrombolysis is planned for the patient. Of all thrombolysis- related complications, intracerebral haemorrhage causes the most signicant morbidity and mortality. A prospective, longitudinal observational study was done, in which 47 consecutive cases of ischemic CVA, were included from march 2020 to October 2021. The demographics, risk factors, biochemical parameters and outcomes (mortality and complications) were assessed, until discharge or in-hospital death. After 24 hours of thrombolysis, 7 patients had NIHSS between 0-4 (1 patient on arrival),19 patient had NIHSS of 5-15 (15 patients on arrival), 6 patients had NIHSS of 16-20 (11 patients on arrival) and 15 patients had NIHSS of 21-42 (20 patients on arrival). Intra cranial bleed was signicantly more among subjects with NIHSS score (after 24 hours) of 21-42 with 4 out of 7 patients in that group followed by 2 patients with NIHSS of 16-20. Deterioration of power was seen in 3 patients with 2patients of NIHSS of 21-42. Seizure occurred in 2 patients with single patient in NIHSS of 16-20 and 21-42 group respectively. NIHSS at admission and 24hrs after admission is clinical score which could be assessed bedside and helps in assessing prognosis for the patients.

CORRELATION BETWEEN MODIFIED RANKIN SCORE AND TERITORY OF STROKE IN PATIENTS THROMBOLYSED AT A TERTIARY CARE CENTER

Prognosis of functional outcome after ischemic stroke is inuenced by a variety of factors already assessable in the acute phase and within the rst days after symptom onset. In clinical trials, stroke outcome is most commonly rated by the modied Rankin Scale (mRS)1 because of the validity and rapid application of this rating scale and its ability to discriminate clinically relevant levels of disability and recovery. A prospective observational study was done, in which 47 cases of acute ischemic stroke, thrombolysed after ruling out any bleed were included from March 2020 to October 2021. The demographics, risk factors, biochemical parameters and outcomes (mortality and complications) were assessed, until discharge or in-hospital death. Most common complication was Intra-cranial bleed that occurred in 7 (14.9%) patients following which was deterioration of power in 3 (6.4%) patients. Seizure and sepsis were reported in 2 (4.3%) patients each. Systemic hemorrhage was reported in 1 (2.1%) case. No patient reported thromboembolism. Favorable outcome according to Modied rankin scoring is 0-2 and out of 47 patients 29 patient showed favorable outcome in which 21 patients were anterior territory ischemic CVA while 8 were posterior territory. Total 3 patients out of 47 showed worst score of 6 i.e., death and 2 of them belonging to posterior territory.

Abstract P053: Causes And Predictors Of Readmission In Hypertensive Emergency - A Nationwide Inpatient Analysis

Introduction: Hypertensive emergency (HE) is a common medical emergency requiring inpatient admission. Our aim was to characterize HE patient demographics and analyze the factors that increases the likelihood for HE readmissions. Methods: This was a retrospective cohort study using the 2019 Nationwide Readmissions Database to identify admissions in adults with a diagnosis HE. Regression models were used. Primary outcome was all-cause 30-day readmission rate, mortality rate, causes and predictors for readmission. Results: Out of a total of 56,648 admissions with HE, 7,753 were readmitted, with a readmission rate of 13.72%. The most common causes for readmissions were CHF exacerbation in setting of CKD stage 1-5 11.51% (892 of 7753), hypertensive emergency 11.48% (890 of 7753), hypertensive urgency 7.92% (614 of 7753), AKI 4.67% (362 of 7753), Sepsis 3.12% (241 of 7753), NSTEMI 2.44% (189 of 7753), and ischemic CVA 1.79% (139 of 7753). Compared to index admissions, readmissions had higher mortality rate (1.39% vs 0.35%), LOS (5.13 days vs 3.65 days), and total charge ($58,172.50 vs $42,273.43). See table 1 for index admission group demographics. The top predictors for readmissions were, reported in odds ratio, ESRD 3.43, hypertension 2.30, discharged AMA 2.29, diabetes mellitus 1.92, transfer to nursing facility 1.5, drug abuse 1.40, depression 1.28. Conclusion: HE has a high readmission rate of 13.72% with the most common cause for readmission being CHF exacerbation, followed by recurrence of HE, AKI, sepsis, NSTEMI, and ischemic CVA. The best predictor for HE readmission was ESRD, followed by hypertension, discharged AMA, and diabetes mellitus.

Abstract P322: 2-year Morbidity And Mortality Due To Hypertensive Crisis In A Predominantly African American Population

Title: 2-Year Morbidity and Mortality due to Hypertensive Crisis in a Predominantly African American Population Hypertensive crisis (HTNC) is a complication of Hypertension with a prevalence of 1-2%. HTNC is defined by a sudden and unpredictable increase in systolic blood pressure of ≥180 mmHg or diastolic blood pressure of ≥120 mmHg. HTNC may present as hypertensive urgency (HTNU) if asymptomatic, or hypertensive emergency (HTNE) if there are signs of end organ damage (EOD) eg: stroke (CVA), congestive heart failure (CHF), acute kidney injury (AKI), acute myocardial infarction (AMI) and death. A 2y retrospective cohort study of 1100 participants: 550 cases and 550 hypertensive controls BP &gt;140/90) but &lt; 200/120, matched for race, sex, and age, was conducted to determine the incidence of EOD, and the 2year mortality. The population was: Blacks 481/550 (87.4%), White 18/550 (3.3%), Asian 2/550 (0.4%) and other 49 /550 (8.9%). The mean SBP for cases was SBP 209.7 (SD=23.1), controls 147.8(SD=22.8) p=0.239; DBP cases 115.5 (SD=22.4), controls 84.2 (SD=14.1) p&lt;.001. The incidence of new EOD for CHF: HTNE=39/440 (9.8%), HTNU=8/150 (5.3%), controls=6/550 (1.1%), p&lt;.001; AKI HTNE=27/400 (6.8%), HTNU=5/150 (6.7 %), controls=17/550 (3.1%) p&lt;0.001; AMI HTNE=6.5% and HTNU=2.7% controls=6/550 (1.1%) p&lt;.001. There was no significant difference in the incidence of hemorrhagic and ischemic CVA, but the trend was higher in HTNE and HTNC for ischemic CVA: HTNE=4/400 (1%), HTNU=1/150 (0.7%), controls=(0.2%) p=.234. The 2y mortality for HTNE=82/400 (20.5%), HTNU=16/150 (10.6%), controls= 36/550 (6.5 %). The odds of dying was 3.5 times greater in the HTNU (OR 3.5, 95% CI 1.78-6.98), p&lt;.001) and 4.3 times in the HTNE population (OR 4.3, 95% CI 2.65-7.01), p&lt;.001). The study reveals a high morbidity and mortality associated with hypertensive crisis, with 1/5 of the population of HTNE dying in two years, mostly from related cardiovascular disease and renal failure.

Analysis of Haematological Parameters in Cerebrovascular Accidents: a Retrospective Study in Tertiary Care Centre

Aim: To analyse hematological parameters in Cerebrovascular disease&#x0D; Study design :A retrospective study&#x0D; Place of Study: The study was carried out in Saveetha Medical College and Hospital, Tamil Nadu, India.&#x0D; Methodology: This is a retrospective study conducted in Saveetha medical college and hospital during the period of December 2020 and May 2021. The study includes 260 cases, of which 130 CVA patients and 130 control group was taken. Haematological parameters were obtained using Sysmex Automated Analyzer XN-1000.&#x0D; Statistical analysis was done by SPSS software version 23, with descriptive and independent t test. The level of significance was taken as p value&lt;0.05&#x0D; Results: CVA are due to two main causes, ischaemic (63.84%) and haemorrhagic infarct (36.15%) The age ranges from 47-69 among stroke subjects. The mean age of control(38.80±12.40years) and CVA group(58.177±11.78years). Both ischaemic and haemorrhagic infarcts are more common among male. On haematological parameters study, analysis showed platelet was increased in CVA than control group. RBC, PCV, MCV, MCHC, TC, neutrophil, lymphocyte, eosinophil, basophil are significant. Haemoglobin, MCH, RDW and monocyte revealed no significance.&#x0D; Conclusion: In this study, haematological parameters of ischemic CVA patients were greatly altered. The presence of persistently altered status of haematological parameters cerebral ischemic event indicate that these parameters can be considered a simple inflammatory indicator during the development of ischemic damage.

PO-716-08 REAL WORLD CLINICAL OUTCOMES OF LEFT ATRIAL APPENDAGE OCCLUSION DEVICE IN THE OCTOGENARIAN AND NONAGENARIAN PATIENTS

Few trials evaluated real world clinical outcomes in patients with atrial fibrillation receiving the Watchman device for left atrial appendage closure. In the recent Ewolution trial, mean age of patients was 73.4 + 8 years. Although few patients > 80 years were included, the safety and efficacy in terms of clinical outcomes of stroke, bleeding and mortality in the octogenarian and nonagenarian population specifically has not been reported in real world setting. To examine peri-procedure outcomes and short-term outcomes at 6 weeks and 3-6 months in terms of stroke, bleeding, peri-device leaks, device related thrombosis and mortality. We conducted a retrospective chart review of all patients that were greater than or equal to 80 years old at the time of Watchman device implantation from January 1, 2018 through October 31st 2021 at the University of Texas Health SA and Methodist Hospital of San Antonio. We examined the history and procedural data, 6 week, 3-month and 6-month outcomes. Primary outcomes were ischemic CVA, major bleeding, and all-cause mortality. Secondary outcomes were device leaks and device related thrombus. We examined a cohort of 40 patients with a mean age of 87+ 3.5 years. Females comprised 78% with 50% Caucasians, 37.5% Hispanics, and 12.5% African Americans. The average CHA2DS2Vasc Score was 5.15 + 1.1 and the average HAS-BLED Score was 3.7+ 1.1. Mean EF was 56 + 11.6%. Ninety percent of patients were on direct oral anticoagulant pre-procedure. The most common indications for implantation were fall risk (37.5%) and bleeding risk (37.5%). Two patients had peri-device leak < 5mm immediately post procedure. There was one groin hematoma. One case was aborted due to anatomy of the appendage. There were no other peri-procedural complications. All patients were on a DOAC post implant for 6 weeks. TEE performed at 6 weeks revealed that one patient had a new small leak and one patient had a device related thrombus. At 6 weeks and at 3-6 months, there was no incidence of CVA. One patient died of unrelated cause and one patient was placed on hospice for cancer at 6 months. Left atrial appendage occlusion with Watchman device seems to be safe and effective in octogenarian and nonagenarian population.

Abstract 11868: A Reduced Anticoagulation Strategy Among Patients Supported With Ventricular Assist Device is Not Associated With Increased Mortality

Introduction: Patients with left ventricular assist device (VAD) are typically treated with aspirin and warfarin. However, some patients are unable to tolerate full anticoagulation (AC). There is limited information available regarding intermediate-term outcomes in patients on reduced or no anticoagulation. Methods: Patients who underwent VAD implantation at California Pacific Medical Center from January 2015 to January 2020 were studied retrospectively. Patients received aspirin 81 mg daily and warfarin with a target INR of 2-3, and anticoagulation was gradually de-intensified or withdrawn in response to recurrent mucosal bleeding. Pre-implantation characteristics, thrombolytic events (hemolysis, pump thrombosis requiring exchange, TIA, or ischemic CVA), and survival post-implant were compared among patients treated with full AC vs. reduced or no AC. We performed nonparametric survival analysis to obtain Kaplan-Meier survival estimates as of 9/15/2020. Cox proportional hazards regression was used to adjust for confounders measured at baseline. Results: 91 patients underwent VAD implant (80 HeartMate 3 and 11 HeartMate II). The median age was 65, and the majority of patients (79%) were treated as destination therapy. Reduced AC was used in 43 patients (47%), including no anticoagulation (12 patients), aspirin monotherapy (2 patients), warfarin monotherapy (16), warfarin monotherapy with a reduced INR target (10), and aspirin plus warfarin with a reduced INR target (3). During a median follow-up of 22 months, 15 thrombotic events were observed (12 in the reduced AC group and 3 in the full AC group, P=0.19). Two patients underwent pump exchange. 67% of thrombotic events and both pump exchanges occurred in HMII recipients. Survival was similar in both groups (Figure). Conclusions: The use of a reduced or no anticoagulation strategy after VAD implant is not uncommon and is associated with acceptable outcomes, particularly among HeartMate 3 recipients.

Results of Carotid Endarterectomy for Free-Floating Thrombus of the Carotid Artery

<h3>Introduction and Objective</h3> Free-floating thrombus (FFT) of the carotid artery is an uncommon occurrence with little published data. The etiology likely involves atherosclerotic plaque forming a nidus for thrombus formation. However, evidence suggests other conditions may be involved, including more recently Covid-19. Clinical management is debated, and it remains unclear whether surgical, endovascular intervention, or anticoagulation alone is superior. The purpose of this study is to report our recent experience with FFT treated by carotid endarterectomy (CEA). <h3>Methods</h3> We retrospectively reviewed the medical records and imaging studies of patients who underwent CEA for FFT at a single community hospital. Patient demographics, diagnostic methods, clinical presentation, past medical histories, and surgical outcomes were analyzed. <h3>Results</h3> Between November 2014 and June 2020, 312 carotid endarterectomies (CEA) were performed. A total of 6 CEA's was performed for FFT identified by CTA, duplex U/S, or both. The 5 women (83%) and 1 man (17%) had an average age of 59.9 years (range 39 to 76.5 years). Atherosclerosis risk factors included: smoking 4 (66%), diabetes 2 (33%), HTN 6 (100%), dyslipidemia 6 (100%). Two patients had an additional thrombotic or autoimmune condition. The FFT originated in the CCA in 2 cases (33%) and the proximal ICA in the remaining 4 cases (66%). The degree of carotid stenosis varied from 0 to 90%. All six patients presented with an ischemic stroke with an average NIH stroke scale of 4.7 (range, 1 – 10). Urgent CEA was performed in 5 patients with no worsening of their neurological symptoms. One patient with the FFT extending to the skull base was treated with apixaban, had complete resolution of the thrombus at six weeks, and subsequently underwent an uncomplicated elective CEA. The average length of stay was 5.8 days (range 2 to 17 days). Mean length of follow up was 4.2 years (range 2.7 to 6 years). During follow up, one patient required a repeat CEA for an early symptomatic recurrent stenosis. As compared to patients undergoing CEA without FFT, patients with FFT were younger (P=.02), more likely to be women (p=.01), and more likely to present with ischemic CVA (p<.001).Fig. 1Duplex scan, CTA and intraoperative photograph of FFT of the carotid artery.Fig 1 <h3>Conclusion</h3> In our series, FFT of the carotid artery always presented as an acute ischemic stroke and was more common in women. Although recommendations cannot be made based on this small retrospective study, our experience suggests that prompt CEA is a safe treatment option. Anticoagulation resulting in thrombus resolution has been previously reported and deserves further study.

Interaction between stroke severity and quality indicators of acute stroke care: a single-center retrospective analysis.

Ischemic stroke leads to substantial mortality and morbidity worldwide. Door-to-CT time, door-to-needle time (DNT), and door-to-groin time (DGT) are important quality indicators of stroke care. However, patient characteristics remain important determinants of outcome as well. In this single-center study, we investigated the interaction between these quality indicators and stroke severity regarding long-term functional outcome. All consecutive stroke patients treated at the ZOL stroke center, Genk, Belgium, between 2017 and 2020 were included in this retrospective observational study. Stroke severity was graded as "mild" if National Institutes of Health Stroke Scale (NIHSS) was equal to or lower than 8, "moderate" if NIHSS was between 9 and 15, and "severe" if NIHSS was higher than 16. Modified Rankin Scale (mRS) scores were collected before and 3months after stroke. Ordinal regression analysis with correction for patient characteristics of functional outcome was done. A total of 1255 patients were included, of which 84% suffered an ischemic CVA (n = 1052) and 16% a TIA (n = 203). The proportion of patients treated conservatively or with thrombolysis, thrombectomy, or the combination of both differed according to stroke severity (p < 0.0001). Door-to-CT time was longer in mild and moderate stroke (p < 0.0001). Median DNT also differed between stroke categories: 46 (IQR 31-70) min for mild vs. 36 (25-56) min for moderate vs. 30 (21-45) min for severe stroke (p = 0.0002). Median DGT did not differ between stroke severity categories (p = 0.15). NIHSS on admission and pre-stroke mRS were independently associated with mRS at 90days. Operational performance, reflected in door-to-CT time and DNT, was worse in patients with mild and moderate stroke severity. DNT was also associated with functional outcome in our center, along with pre-stroke mRS, NIHSS on admission and age.

Stroke patients presenting to the emergency department of a tertiary care hospital

Introduction: Stroke is one of the most common causes of morbidity and mortality in Nepal. It is the 3rd most common cause of death worldwide. In Nepal Non-communicable diseases in Nepal(NCDs) states that stroke accounts for 42% of all deaths and is estimated to reach about 66.3% of all deaths by 2030. Method: A retrospective cross-sectional study of all stroke patients seen in Patan Hospital Emergency Department for a period of 1 y. Demographic data, presenting complaint, time of onset of symptoms, time presenting to the Emergency, patient’s risk factors for stroke, head CT findings (hemorrhagic or ischemic stroke) were analyzed descriptively. Ethical approval was taken. Result: Total 170 patients (96 males i.e.56.5% and 74 females i.e. 43.5%) were analyzed. 130(76.5%) were ischemic CVA and 40 (23.5%) were hemorrhagic CVA. The most common presenting symptoms was hemiparesis and speech changes. Conclusion: Stroke is a common disease seen in Nepal, with higher percentages of hemorrhagic stroke.

Ischemic CVA as a Complication of COVID-19: A Case Report

COVID-19 is typically a respiratory or lung infection however the SARS-CoV-2 virus has been found to cause blood clots leading to stroke. The World Stroke Organization reported a 5% risk for an ischemic stroke in the setting of COVID-19

Investigating the relationship between interleukin-6 serum levels and outcome in acute ischemic CVA.

IntroductionInterleukin‐6 (IL‐6) is among the inflammatory mediators exhibiting elevated levels in ischemic stroke (IS) patients. The present study set out to evaluate the relationship between serum levels of interleukin‐6 with long‐term and at‐hospital outcomes of acute ischemic stroke in patients hospitalized at Imam Khomeini Hospital, Urmia, Iran, from 2017 to 2018.Method and materialsThis cross‐sectional descriptive study enrolled 29 and 31 acute stroke patients for long‐term and at‐hospital observation, respectively. Evaluation of stroke severity was performed using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) on days 1, 5, and 90. Serum IL‐6 level was measured via enzyme‐linked immunosorbent assay (ELISA) on days one and five.ResultsIn the present cohort study, the following population were enrolled: for long‐term evaluation, 11 (38%) men and 18 (63%) women with a mean age of 64.5 ± 14.9 years, and for at‐hospital evaluation: 11 (37.5%) men and 20 (64.5%) with a mean age of 65.25 ± 14.37 years. A significant positive correlation was observed between IL‐6 levels with NIHSS and mRS scores of the patients from time of admission until the end of the follow‐up period (long‐term: p < .001; at‐hospital: 0.022).ConclusionThe evidence from the present study suggests that IL‐6 contributes to the determination of the severity of ischemic strokes and may be useful in predicting prognosis. However, larger scale studies are required to further establish these finds.

MON-915 Acute Abdominal Pain and the Pheochromocytoma

Background:Pheochromocytomas are neuroendocrine tumors that release large amounts of metanephrines and catecholamines, resulting in a wide array of symptoms including hypertension, diaphoresis, and headaches. If left unrecognized they can lead to serious morbidity including ischemic or hemorrhagic CVA, encephalopathy, MI, Aortic Dissection, and renal injury.Clinical Case:A 62-year-old male began having difficulties with his blood pressure over the past year. He was first hospitalized for an acute ischemic CVA with hypertensive urgency. His blood pressure was generally controlled throughout the admission but he continued to have intermittent elevations. After transferring to an inpatient rehabilitation unit he had an episode of acute nausea, severe lower abdominal pain, and emesis following dinner. He was tachycardic and hypertensive up to 190/115. Acute abdominal imaging revealed constipation but no obstruction. His symptoms resolved, returning a few hours later with another episode of acute nausea, vomiting, and severe lower abdominal pain, with blood pressure 210/126 and tachycardia. IV Metoprolol, Hydralazine and pain medications did not significantly improve his blood pressure, he was subsequently started on a Nitroglycerin drip. Abdominal workup was unremarkable, he was stabilized and discharged back to rehabilitation on increased oral medications. He continued to have blood pressure spikes up to 200/124 with nausea, vomiting, and severe abdominal pain until a Clonidine patch was started, after which his blood pressure was better controlled. He was discharged home with continued outpatient therapies.A few weeks later he returned to the ER with nausea and severe abdominal pain, blood pressure at home was 254/185. On exam he was diaphoretic, tachycardic, and tachypneic. A CTA scan was obtained without signs of dissection. A Nitro drip with IV push Hydralazine were not effective at controlling his blood pressure, and so Lisinopril, Amlodipine, and a Clonidine patch were added. Over the next few days he had progressively fewer hypertensive elevations and his symptoms were only present during hypertensive episodes. An extensive workup for secondary hypertension was started. 24-hour plasma and urine Metanephrines were within normal limits. Urine Normetanephrine was elevated to 1266 ug/24h (Ref 88-444). Urine Norepinephrine was elevated to 124 ug/24h (Ref 15-80), Urine Dopamine was elevated to 578 ug/24h (Ref 65-400), and total Catecholamines were elevated to 133 ug/24h (Ref 15-100).Conclusion:This case illustrates the variance in presentations for Pheochromocytoma and the importance of maintaining a high index of suspicion for secondary causes in patients with intractable hypertension. While commonly reported symptoms include nausea and hypertension, the presentation of acute abdominal pain as the primary complaint is also an important feature of this disease.

A Study of Prevalence and Predictors of Acute Ischemic CVA Patients Admitted to Manipal Teaching Hospital, Pokhara, Nepal

Background: According to the World Health Organization (WHO), 15 million people suffer stroke worldwide each year. Of these, 5 million die, and another 5 million are left permanently disabled.&#x0D; Materials and methods: A retrospective hospital based observational study was carried out in patients with ischemic CVA. Modified Ranking Scale (MRS) on the follow up on 30 days after discharge was obtained. MRS 0-2 was categorized and good outcome and MRS 3-6 was categorized as poor outcome.&#x0D; Results: Out of 56 patients studied 33.9 % were less than 60 years of age and 63.1% were greater than 60 years of age. Male to female ratio was 1.55. MCA territory infarct was the most common with the frequency of 76.8%. There was significant association of HTN, DM, coronary artery disease and other factors as well with the outcome of the patients.&#x0D; Conclusion: On regards to clinic-social demographic parameters there was statistical significance between the gender of the patient, history of systemic hypertension, history of diabetes mellitus and coronary artery disease and outcome of the patient in 30 days follow up.