Risk Of Ischemic Stroke In Patients Research Articles

Time in Therapeutic Range and Percentage of International Normalized Ratio in the Therapeutic Range as a Measure of Quality of Anticoagulation Control in Patients With Atrial Fibrillation

BackgroundTime in therapeutic range (TTR), albeit the standard measure of quality of anticoagulation control for warfarin, is underused in everyday clinical practice because of its tedious calculation. In contrast, the percentage of international normalized ratio measurements in range (PINRR) is a convenient alternative. Our objective was to investigate the correlation between PINRR and TTR and whether PINRR has clinical utility for prediction of ischemic stroke and intracranial hemorrhage in a “real-world” atrial fibrillation (AF) cohort. MethodsThis is an observational study based on a hospital-based AF registry. ResultsAmong 1428 Chinese patients with AF who were taking warfarin (76.2 ± 8.7 years; mean CHA2DS2-VASc, 4.2 ± 1.6 and HAS-BLED, 2.3 ± 0.9), mean and median TTR values were 38.2% ± 24.4% and 38.8% (interquartile range, 17.9% and 56.2%), respectively. Patients with TTR ≥ 65% (14.8%) had a lower annual risk of ischemic stroke (3.04% per year) than did those with TTR < 65% (5.35% per year). Mean and median PINRR were 34.3% ± 17.1% and 34.2% (interquartile range, 22.7% and 46.0%), respectively. TTR significantly correlated with PINRR in a linear fashion (r = 0.81; P < 0.0001). A cutoff of PINRR ≤ 56.1% was a good discriminator of TTR < 65%, with a high sensitivity (98.3%) and positive predictive value (91.9%). The annual ischemic stroke risk in patients with PINRR > 56.1% was 2.56% per year, lower than those with TTR ≥ 65% (3.04% per year). Patients with PINRR > 56.1% had an annual incidence of intracranial hemorrhage comparable to those with TTR ≥ 65% (0.49% per year vs 0.68% per year). ConclusionsAmong patients with AF who are taking warfarin, the PINRR is a user-friendly alternative to TTR, having a high sensitivity and positive predictive value in predicting TTR. As with TTR, PINRR is associated with clinical adverse events, ie, ischemic stroke and intracranial hemorrhage.

Risk of ischemic stroke in patients with systemic sclerosis: A systematic review and meta-analysis

Background. Several chronic inflammatory disorders, such as rheumatoid arthritis and idiopathic inflammatory myositis, have been shown to increase risk of ischemic stroke but the data on systemic sclerosis (SSc) remains unclear.Methods. We conducted a systematic review and meta-analysis of observational studies that reported odds ratio, relative risk, hazard ratio, or standardized incidence ratio comparing risk of ischemic stroke in patients with SSc versus non-SSc participants. Pooled risk ratio and 95% confidence intervals (CIs) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.Results. Four retrospective cohort studies were identified and included in our data analysis. We found a statistically significant elevated ischemic stroke risk in patients with SSc with a pooled risk ratio of 1.68 (95% CI, 1.26–2.24). The statistical heterogeneity was moderate with an I2 of 69%.Conclusions. Our study demonstrated a statistically significant increased ischemic stroke risk among patients with SSc.

Predicting postoperative atrial fibrillation using CHA2DS2-VASc scores

BackgroundPostoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery and is associated with increased morbidity and mortality. Pharmacologic prophylaxis is the main method of preventing POAF but needs to be targeted to patients at high risk of developing POAF. The CHA2DS2-VASc scoring system is a clinical guideline for assessing ischemic stroke risk in patients with atrial fibrillation. The present study evaluated the utility of this scoring system in predicting the risk of developing de novo POAF in cardiac surgery patients. Materials and methodsA total of 2385 patients undergoing cardiac surgery at our institution from 2008–2014 were identified for analysis. Each patient was assigned a CHA2DS2-VASc score and placed into a low- (score of 0), intermediate- (1), or high-risk (≥2) group. A multivariate regression model was created to control for known risk factors of atrial fibrillation. ResultsPOAF occurred in 380 of 2385 patients (15.9%). Mean CHA2DS2-VASc scores among patients with POAF and without POAF were 3.6 ± 1.7 and 2.8 ± 1.7, respectively (P < 0.0001). Using multivariate analysis, as a patient's CHA2DS2-VASc score rose from 0–9, the risk of developing POAF increased from 8.2%–42.3%. Each point increase was associated with higher odds of developing POAF (adjusted odds ratio, 1.27; 95% confidence interval, 1.18–1.36, P < 0.0001). Compared with low-risk patients, patients in the high-risk group were 5.21 times more likely to develop POAF (P < 0.0001). ConclusionsThe CHA2DS2-VASc algorithm is a simple risk-stratification tool that could be used to direct pharmacologic prophylaxis toward patients most likely to experience POAF.

Abstract 271: Anti-coagulation and Ischemic Stroke Risk in Patients with Chronic Kidney Disease and Atrial Fibrillation: Insights from the Kaiser Permanente Colorado Atrial Fibrillation Registry

Background: There is uncertainty about the benefits of anticoagulation therapy for stroke reduction in CKD patients with atrial fibrillation. Accordingly, we assessed the association between anticoagulation use and stroke risk in CKD patients with atrial fibrillation. Methods: The Kaiser Permanente Colorado Atrial Fibrillation Registry is comprised of patients with incident atrial fibrillation between January 1, 2006 and June 30, 2012 from Kaiser Permanente Colorado. Incident atrial fibrillation was defined by ICD-9 codes 427.31 (Atrial Fibrillation) or 427.32 (Atrial Flutter) and without a diagnosis in the prior year. Patients with mitral valve replacement, renal transplant, or use of anticoagulants other than warfarin were excluded. CKD status was determined by ICD-9 codes or by two consecutive outpatient laboratory results with estimated glomerular filtration rate &lt; 60 ml/min/1.73m2 by the CKD-EPI equation. The primary outcome was ischemic stroke identified by ICD-9 codes and validated by chart review. We assessed the association between warfarin use and ischemic stroke in patients with and without CKD using Cox proportional hazards models adjusted for CHA2DS2-VASc score and an interaction for warfarin use and CKD. Results: Of 5,728 patients with incident atrial fibrillation, 2,070 (36.1%) had CKD. Patients with CKD were older, more likely to be female, had a higher CHA2DS2-VASc score, and were more likely to receive warfarin than those without CKD (see Table). During a mean follow up of 2.6 years (SD 1.8 years), stroke occurred in 49 (2.4%) patients with CKD and 83 (2.3%) patients without CKD. In multivariable analysis adjusting for CHA2DS2-VASc score, warfarin use was associated with lower hazard of stroke (HR 0.36; 95% CI 0.24 - 0.53). When stratified by CKD status, warfarin use remained associated with lower hazard of stroke in CKD (HR 0.35; 95% CI 0.18 - 0.66) and non CKD (HR 0.36; 95% CI 0.22 - 0.60) patients. Conclusion: 1 in 3 patients with atrial fibrillation have CKD. There were similar reductions in the risk of stroke associated with warfarin use for CKD and non-CKD patients. These findings reinforce current clinical practice guidelines, which recommend warfarin use based on thromboembolic risk without consideration for CKD status.

Risk-Prediction Model for Ischemic Stroke in Patients Hospitalized With an Acute Coronary Syndrome (from the Global Registry of Acute Coronary Events [GRACE

The risk of stroke in patients hospitalized with an acute coronary syndrome (ACS) ranges from <1% to ≥ 2.5%. The aim of this study was to develop a simple predictive tool for bedside risk estimation of in-hospital ischemic stroke in patients with ACS to help guide clinicians in the acute management of these high-risk patients. Data were obtained from 63,118 patients enrolled from April 1999 to December 2007 in the Global Registry of Acute Coronary Events (GRACE), a multinational registry involving 126 hospitals in 14 countries. A regression model was developed to predict the occurrence of in-hospital ischemic stroke in patients hospitalized with an ACS. The main study outcome was the development of ischemic stroke during the index hospitalization for an ACS. Eight risk factors for stroke were identified: older age, atrial fibrillation on index electrocardiogram, positive initial cardiac biomarkers, presenting systolic blood pressure ≥ 160 mm Hg, ST-segment change on index electrocardiogram, no history of smoking, higher Killip class, and lower body weight (c-statistic 0.7). The addition of coronary artery bypass graft surgery and percutaneous coronary intervention into the model increased the prediction of stroke risk. In conclusion, the GRACE stroke risk score is a simple tool for predicting in-hospital ischemic stroke risk in patients admitted for the entire spectrum of ACS, which is widely applicable to patients in various hospital settings and will assist in the management of high-risk patients with ACS.

Stratification with CHA2DS2-VASc Score is Better than CHADS2 Score in Reducing Ischemic Stroke Risk in Patients with Atrial Fibrillation

Stratification with CHA2DS2-VASc Score is Better than CHADS2 Score in Reducing Ischemic Stroke Risk in Patients with Atrial Fibrillation

Procalcitonin Levels in Migraine Patients

Migraine is a risk factor for ischemic stroke. Sterile vascular inflammation may develop during migraine attacks. This study aims to investigate procalcitonin (PCT) levels amongst migraine patients as they are important markers for infection and sepsis, but can also be found at elevated levels in various cases of inflammation. Eighty adult migraine patients participated in our study. Patients were initially separated into two main groups; Group-1 consisted of 34 patients who had migraines during the attack period. Group-2 consisted of 46 patients during the period in-between attacks. Afterwards, patients were further divided into four subgroups based on their aura status; Group-1a Migraine without aura, 27 patients during attack period, Group-1b Migraine with aura, 7 patients during attack period, Group-2a Migraine without aura, 40 patients during the period in-between attacks, Group-2b Migraine with aura, 6 patients during the period in-between attacks. Average PCT levels in patients during attack periods were found to be higher than the average PCT levels of patients during the period in-between attacks. These elevated levels were determined to be statistically significant(p<0.01). Serum PCT levels of the patients with migraine without aura during the attack period were significantly higher than those of patients during the period in-between attacks(p<0.01). Based on significantly high levels of PCT, our results support the idea that sterile inflammation plays a role in migraine pathogenesis. Further studies are necessary to understand whether PCT is a marker for ischemic stroke risk in patients who go through frequent migraine attacks.

Higher risk of ischaemic stroke associated with factor XI levels in dyslipidaemic patients

Ischaemic stroke (IS) is a complex disease that involves genetic and environmental factors. The role of factor XI (FXI) in arterial thrombosis is unclear. We have investigated the risk of IS related to FXI levels in a case-control study. We studied 445 individuals: 218 diagnosed with IS and 227 age-gender-ethnic matched control subjects. We measured factor VIIIc, fibrinogen and factor XIc levels. FXI < 144% was taken as the reference group in the statistical analysis. There were 104 women and 114 men in the IS group and 108 women and 119 men in the control group. The crude odds ratio (OR) of IS in dyslipidaemic patients with high levels of FXI was 4.2 [95% confidence interval (CI): 1.2-14.8] compared with dyslipidaemic controls and low levels of FXI, but the OR in the non-dyslipidaemic with high levels of FXI subgroup was 1.2 (95% CI: 0.4-3.2). The adjusted OR of IS in dyslipidaemic patients with high levels of FXI was 6.4 (95% CI: 1.6-26.1) compared with dyslipidaemic controls, but the OR in non-dyslipidaemic subgroup with high levels of FXI was 0.6 (95% CI: 0.2-2.1). We found almost a sixfold higher risk of IS in patients with dyslipidaemia and high levels of FXI. Further studies should elucidate the role of FXI in IS and therapeutic approaches should become apparent for patients with dyslipidaemia and high-FXI plasma levels.

Higher Risk of Ischemic Stroke Associated with Factor XI Levels in Dyslipidemic Patients.

Ischemic stroke (IS) is a complex disease that involves genetic and environmental factors. The role of Factor XI in arterial thrombosis including IS is unclear. We have investigated the risk of IS related to Factor XI levels in a case-control study. We studied 445 individuals: 218 diagnosed with IS and 227 age-gender-ethnic control subjects. We measured Factor VIIIc, fibrinogen and Factor XIc levels. Factor XI<144% was taken as the reference group in the statistical analysis. Basic characteristic of patients and controls are summarized in the Table 1.When we analyzed the OR in all population, we observed an interaction between dyslipidemia and high FXI levels. So, we analyzed the data in 2 subgroups, dyslipidemic and non-dyslipidemic. The crude OR of IS in dyslipidemic patients with high levels of FXI was 4.2 (95% CI:1.2–14.8) compared with dyslipidemic controls and low levels of FXI, but the OR in the non-dyslipidemic with high levels of FXI subgroup was 1.2 (95% CI: 0.4–3.2). The adjusted OR of IS in dyslipidemic patients with high levels of FXI was 6.4 (95%CI: 1.6–26.1) compared with dyslipidemic controls, but the OR in non-dyslipidemic subgroup with high levels of FXI was 0.6 (95%CI: 0.2–2.1). In conclusion, we found almost a six-fold higher risk of IS in patients with dyslipidemia and high levels of FXI. Further studies should elucidate the role of Factor XI in IS and therapeutical approaches should become apparent in regard to patients with dyslipidemia and high Factor XI plasma levels.Table 1.IS (n=218)n (% )Controls (n=227)n (% )Unadjusted OR (95% CI)Sex (F/M)104/114108/119NSAge (years, mean, range)57 (23–80)55(21–80)NSSmoking94(45)75(40)1.6(1.1–2.3)*Dyslipidemia91(42)40(18)3.4(2.2–5.2)*Family History of arterial thrombosis112(51.7)39(19)5.1(3.3–7.8)*Hypertension96(43.9)39(17.3)3.7(2.4–5.8)*Morbid Obesity12(4.4)6(2.6)2.6(0.9–7.5)Alcohol Intake20(9.2)11(4.8)1.9(0.9–4.2)Diabetes Mellitus41(19)12(5)4.2(2.1–8.2)*Factor VIIIc(%, mean, range)187.3(62–516)157.1(48–360)p<0.0001Fibrinogen (g/l)(mean, range)3.7(1.9–8.4)3.5(2.1–7.8)p<0.002*Difference statistically significant (p<0.059 after adjustment by sex and age