Transient Ischemic Attack Stroke Research Articles

Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom.

Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA. This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported. Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively. In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.

Tips and Advice on Preparing a Research Manuscript for Submission and Publication in a Peer-Reviewed Stroke Journal

HomeStrokeAhead of PrintTips and Advice on Preparing a Research Manuscript for Submission and Publication in a Peer-Reviewed Stroke Journal Free AccessResearch ArticlePDF/EPUBAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBTips and Advice on Preparing a Research Manuscript for Submission and Publication in a Peer-Reviewed Stroke Journal Andrea Lendaris and Charles Esenwa Andrea LendarisAndrea Lendaris Correspondence to: Andrea Lendaris, MD, MS, Montefiore Medical Center, 3316 Rochambeau Ave, 4th floor, Bronx, NY 10467. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7522-1703 Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, The Bronx, NY. Search for more papers by this author and Charles EsenwaCharles Esenwa https://orcid.org/0000-0002-1455-9345 Department of Neurology, Montefiore Medical Center/Albert Einstein College of Medicine, The Bronx, NY. Search for more papers by this author Originally published3 Apr 2023https://doi.org/10.1161/STROKEAHA.122.037872Stroke. 2023;0FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Sources of Funding and Disclosures, see page xxx.Correspondence to: Andrea Lendaris, MD, MS, Montefiore Medical Center, 3316 Rochambeau Ave, 4th floor, Bronx, NY 10467. Email [email protected]org Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.122.037872PMID: 37009744 Originally publishedApril 3, 2023 Keywordspublicationpeer reviewplagiarismgoalsneurologyPDF download Advertisement SubjectsCerebrovascular Disease/StrokeIschemic StrokeTransient Ischemic Attack (TIA)

Comparison of Presentation and Prognosis of Takayasu Arteritis with or without Stroke or Transient Ischemic Attack-A Retrospective Cohort Study.

Takayasu arteritis (TAK) could cause a stroke or transient ischemic attack (TIA) in young individuals due to inflammatory vascular occlusion or intracerebral hemorrhage. We compared the clinical presentation, angiographic features, longitudinal patterns of disease activity, medical treatments, and survival in 34 TAK patients with stroke/TIA and 157 without stroke/TIA from a single-center retrospective cohort. TAK patients with stroke/TIA were older (p = 0.044) with a greater proportion of males (p = 0.022), more frequent vision loss (odds ratio (OR) for stroke/TIA vs. without stroke TIA 5.21, 95% CI 1.42-19.14), and less frequent pulse or blood pressure inequality (OR 0.43, 95% CI 0.19-0.96) than TAK patients without stroke/TIA. Hata's angiographic type IIa was more common in TAK patients with stroke/TIA (OR 11.00, 95%CI 2.60-46.58) and type V in TAK patients without stroke/TIA (OR 0.27, 95% CI 0.12-0.58). Cyclophosphamide was used more often in TAK patients with stroke/TIA (p = 0.018). Disease activity at baseline, 6, 12, and 24 months of follow-up was mostly similar for both groups. Risk of mortality was similar in TAK patients with or without stroke/TIA (hazard ratio unadjusted 0.76, 95% CI 0.15-3.99; adjusted for gender, age of disease onset, delay to diagnosis, baseline disease activity, and the number of conventional or biologic/targeted synthetic immunosuppressants used 1.38, 95% CI 0.19-10.20) even after propensity score-matched analyses. Stroke or TIA does not appear to affect survival in TAK patients adversely.

Abstract C086: The effect of length of residence in the US on risk of developing chronic disease in West African male immigrants

Abstract Background African immigrants represent one of the fastest growing groups of immigrants in the US, resulting in increased diversity of Blacks in the US. Therefore, there is a growing need to assess the healthcare needs and practices of this population. The main public health concern has been on infectious disease but priority should also focus on chronic disease. Specifically, the literature has yet to provide consistent results regarding the “healthy immigrant effect”, specifically that immigrants are in relatively better health on arrival before their health converges with native-born levels after time. Using the data collected by the Prostate Cancer Transatlantic Consortium (CaPTC), this study explores chronic disease history and healthy behaviors of male immigrants from West Africa with length of residence in the US. Methods A study questionnaire was used to collect data on West African (WA) Black men residing in Nigeria, Cameroon, and the United States. Data from 709 respondents, Black men between the ages of 35-70 years, recruited from community settings, was collected. Variables analyzed included age, education level, income, smoking and alcohol use, weight, height, physical activity levels, country of birth, country of residence, years since immigration, chronic disease history, and health insurance status. Descriptive analysis was used to determine the frequency of each condition among participants. Results There were 37 respondents, WA males, residing in the US; 26 born in Cameroon, 10 born in Nigeria, 1 born in Sierra Leone, 1 born in Ghana. The average age was 46.2 years and the average length of residency was 13.9 years. Participants were placed in two groups: length of residence in the US of less than or equal to 10 years (LT10Y) and greater than 10 years (GT10Y). This study focused on the most common chronic diseases in the US: high blood pressure (HB), high cholesterol (HC), diabetes (D), stroke/transient ischemic attack (ST), COPD, Alzheimer’s (AZ), and arthritis (AT). Although there was no statistical significant differences between participants who lived greater than 10 years in the US compared to those who resided 10 years or less, there was practical differences. For example, 39% in the LT10Y group had been diagnosed with HBP versus 42% in the GT10Y group. With larger sample size, it is likely that there may be statistical differences. There was statistical significant differences in HC diagnosis with 5% in LT10Y and 22.2% in GT10Y. The GT10Y group showed decreased alcohol use, increased frequency of physical activity, and frequent annual physician visits and had higher income and education level. Conclusion Based on our results, we found length of stay of WA Black males in the US to impact HC diagnosis, alcohol use, physical activity, and physician visits. The “healthy immigrant” phenomenon is likely to be moderated by several factors and need to be studied more among African immigrants. Citation Format: Adaora Ezeani, Ernest Kaninjing, Folakemi Odedina, Catherine Badejo, Anthonia Sowunmi, Omolara Fatiregun, Ayo Salako, A. A. Popoola, Mohammed Faruk, Emeka Iweala, Iya Bassey, Chidiebere Ogo, O. P. Oluwole, H. A Nggada, Paul Jibrin, Oluwole Kukoyi, Ifeoma Okoye, Abidemi Omonisi, Iheanyi Okpala, Lasebikan Nwamaka, A. Adeniji, Nissa Askins, Ruth Agaba, Oluwaseyi Adeniji. The effect of length of residence in the US on risk of developing chronic disease in West African male immigrants [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C086.

Abstract TP302: Health Insurance-Related Disparities in Management Patterns and In-Hospital Outcomes for Ischemic Cerebrovascular Disease: A Nationwide Trends Analysis of 2005-2015

Background and Purpose: China has made an impressive achievement in both the scale of coverage and the speed of expansion of its health insurance system, yet data regarding health insurance-related disparities in managements patents and in-hospital outcomes for ischemic stroke/transient ischemic attack (IS/TIA) are still limited. Methods: We used a two-stage random sampling method to create a nationally representative sample of patients in China hospitalized with IS/TIA in 2005, 2010, and 2015. Health insurance was limited in Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI), New Rural Cooperative Medical Scheme (NRCMS), and self-payment. We used three composite measures to summarize the treatment and management for assessment tests, in-hospital treatments, and medication at discharge. In-hospital outcomes, including death, discharge against medical advice (DAMA), and a composite outcome of death or DAMA, were assessed. Results: Of the 23,389 analyzed patients, the percentage of self-payment patients decreased from 56.3% in 2005 to 9.4% in 2015. Composite measures showed no significant difference between insurance status for in-hospital treatments and medication at discharge, except for assessment tests. Compared to UEBMI, other insurance groups had a higher risk of DAMA and in-hospital mortality or DAMA. Nevertheless, the discrepancies become smaller from 2005 to 2015 (P for interaction < 0.0001) (Figure 1). Conclusions: Health insurance-related disparities exist in management patterns and in-hospital outcomes for ischemic cerebrovascular disease, nevertheless, the discrepancies become improved to some degree from 2005 to 2010.

Antiplatelet Agents in Secondary Stroke Prevention: Selection, Timing, and Dose.

This narrative review critically evaluated the published studies regarding the systematic use of antiplatelet agents for secondary stroke prevention. Stroke is a leading cause of morbidity and mortality around the world. Multimodal prevention is the most viable strategy for reducing the societal burden of stroke recurrence. For secondary stroke prevention, antiplatelet therapy is at the core of effective long-term vascular risk reduction among survivors of an ischemic stroke or transient ischemic attack (TIA). In addition to aspirin, there are several antiplatelet agents proven to be efficacious in averting recurrent vascular events after an index ischemic stroke or TIA. However, beyond the challenges of keeping up with recent advances in antiplatelet drug options for secondary stroke prevention, questions linger about the most appropriate selection, timing, and dosing of antiplatelet treatment for a given patient. We narratively summarized the pharmacological properties of key antiplatelet drugs; discussed the evidence regarding efficacy, selection, timing, and dosing of various antiplatelet treatment regimens; and highlighted ongoing clinical trials identifying novel therapies with more favorable risk-benefit profiles than currently available antiplatelet agents for patients with a recent history of ischemic or TIA stroke. Finally, we reviewed published data on antiplatelet therapies that could potentially be applied in the management of commonly encountered challenging clinical scenarios.

Thromboembolism and Mortality in the Tasmanian Atrial Fibrillation Study.

Although utilization of anticoagulation in patients with atrial fibrillation (AF) has increased in recent years, contemporary data regarding thromboembolism and mortality incidence rates are limited outside of clinical trials. This study aimed to investigate the impact of the direct oral anticoagulants (DOACs) on the clinical outcomes of patients with AF included in the Tasmanian Atrial Fibrillation Study. The medical records of all patients with a primary or secondary diagnosis of AF who presented to public hospitals in Tasmania, Australia, between 2011 and 2015, were retrospectively reviewed. We investigated overall thromboembolic events (TEs), ischemic stroke/transient ischemic attack (IS/TIA), and mortality incidence rates in patients admitted to the Royal Hobart Hospital, the main teaching hospital in the state. We compared outcomes in 2 time periods: prior to the availability of DOACs (pre-DOAC; 2011 to mid-2013) and following their general availability after government subsidization (post-DOAC; mid-2013 to 2015). Of the 2390 patients with AF admitted during the overall study period, 942 patients newly prescribed an antithrombotic medication (465 and 477 from the pre-DOAC and post-DOAC time periods, respectively) were followed. We observed a significant decrease in the incidence rates of overall TE (3.2 vs 1.7 per 100 patient-years [PY]; P < .001) and IS/TIA (2.1 vs 1.3 per 100 PY; P = .022) in the post-DOAC compared to the pre-DOAC period. All-cause mortality was significantly lower in the post-DOAC period (2.9 vs 2.2 per 100 PY, P = .028). Increasing age, prior stroke, and admission in the pre-DOAC era were all risk factors for TE, IS/TIA, and mortality in this study population. The risk of IS/TIA was more than doubled (hazard ratio: 2.54; 95% confidence interval: 1.17-5.52) in current smokers compared to ex- and nonsmokers. Thromboembolic event and all-cause mortality rates were lower following the widespread availability of DOACs in this population.

Atrial fibrillation and treatment changes in cryptogenic stroke patients with an implantable loop recorder for continuous cardiac rhythm monitoring

Introduction: This interim analysis evaluates the risk profile and incidence of atrial fibrillation (AF) in patients who underwent continuous monitoring with an implantable loop recorder (ILR) for cryptogenic (unexplained) stroke or transient ischemic attack (TIA). Methods: The observational INSIGHT XT study prospectively enrolled patients who received an ILR with dedicated diagnostics for atrial fibrillation, irrespective of the clinical indication. Of 1002 patients enrolled in the study between Aug 2008 and Jan 2012, 121 received the ILR to evaluate cryptogenic stroke or TIA. The definition of cryptogenic stroke/TIA was at the investigators' appraisal and no unified approach to patient work-up was required. This analysis includes 74 patients with cryptogenic stroke or TIA for whom at least one follow-up visit was available at the time of interim analysis. Results: The mean age was 63±12 (50% female). Stroke was the index event in 46 of 74 (62%) of patients. 61% had hypertension, 14% diabetes, and none had heart failure. The mean CHADS2 score was 3.0±0.8 and the mean CHA2DS2VASc score 4.0±1.2. Most patients (72%) had no prior symptoms or cardiac rhythm disturbances, whereas 18% had a history of prior palpitations. Sixty-seven patients were taking antiplatelet medication and four were on oral anticoagulation (OAC) at enrollment. During a median follow up of 12 months (IQR 7 to 18) AF was reported in 17 patients (23%) and two patients were started on OAC and 10 patients were converted from antiplatelets to OAC. Five patients experienced a stroke or TIA (median time to event 1.2 months), of which one patient died. Three of the patients with stroke or TIA had AF detected prior to the recurrent event. Conclusion: Continuous monitoring with an ILR in patients with cryptogenic stroke of TIA detects a high proportion of AF; this can be attributed to longer continuous monitoring in this study. These patients have high CHADS2/CHA2DS2VASc scores; documenting AF in these cases may therefore be clinically relevant in order to decide appropriate treatment.

Clinical Update on the Management of Atrial Fibrillation

Atrial fibrillation (AF) is a cardiac arrhythmia associated with significant morbidity and mortality, affecting more than 3 million people in the United States and 1-2% of the population worldwide. Its estimated prevalence is expected to double within the next 50years. During the past decade, there have been significant advances in the treatment of AF. Studies have demonstrated that a rate control strategy, with a target resting heart rate between 80 and 100beats/minute, is recommended over rhythm control in the vast majority of patients. The CHA2 DS2 ≥ (congestive heart failure, hypertension, age ≥ 65 yrs, diabetes mellitus, stroke or transient ischemic attack, vascular disease, female gender) scoring system is a potentially useful stroke risk stratification tool that incorporates additional risk factors to the commonly used CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke transient ischemic attack) scoring tool. Similarly, a convenient scheme, termed HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), to assess bleeding risk has emerged that may be useful in select patients. Furthermore, new antithrombotic strategies have been developed as potential alternatives to warfarin, including dual-antiplatelet therapy with clopidogrel plus aspirin and the development of new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban. Vernakalant has emerged as another potential option for pharmacologic conversion of AF, whereas recent trials have better defined the role of dronedarone in the maintenance of sinus rhythm. Finally, catheter ablation represents another alternative to manage AF, whereas upstream therapy with inhibitors of the renin-angiotensin-aldosterone system, statins, and polyunsaturated fatty acids could potentially prevent the occurrence of AF. Despite substantial progress in the management of AF, significant uncertainty surrounds the optimal treatment of this condition.

What are the patient-held illness beliefs after a transient ischaemic attack, and do they determine secondary prevention activities: an exploratory study in a North London General Practice

A transient ischaemic attack (TIA) is a strong predictor of future stroke. Stroke is the most common cause of mortality in the United Kingdom. Management of risk factors can reduce the possibility of future strokes; however, these are often difficult to achieve optimally. Current evidence suggests that beliefs about causal attributions, severity and perceived risk of stroke may influence uptake of secondary prevention activities amongst this patient group. To explore the illness beliefs of patients about TIAs and future risk of stroke, and to determine whether these beliefs determine secondary stroke prevention activities. A qualitative study comprising face-to-face, semi-structured interviews conducted in the homes of participants. Sampling was purposive and drawn from a single North London General Practice. A thematic framework analysis method was followed. Eleven participants took part in the study (aged 46-86 years, three female participants and eight male participants). Time since diagnosis ranged from 2 to 25 years. There was a commonly held belief that TIAs are 'short-lived events' associated with full recovery, whereas strokes always lead to permanent 'disability'. Only those who believed their TIAs to be 'serious' undertook activities to prevent further recurrence. Concordance with medication was the most popular prevention activity. The traditional medical definition of TIA and stroke do not reflect the views of patients who have had TIAs. One's perception of the severity of the initial TIA event and the risk of future stroke episodes may influence the uptake of secondary stroke prevention activities. Post TIA stroke prevention interventions should include tailored discussions focussing on the importance of the acute event and its implications for long-term health and future stroke risk.

Role of Renin-Angiotensin System Inhibitors in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Patients treated with quinapril had a 77% reduction in ischemic events (death, revasculariza-tion, myocardial infarction, recurrence of angina pectoris, ischemic stroke, or transient ischemic attack stroke; 15% vs 4%; P=0.04). Quinapril was well tolerated and was not asso-ciated with any untoward perioperative hemodynamic events. In a propensity-score-based analysis of 481 patients under-going isolated on-pump CABG,

Impact of Diabetes Mellitus (DM) on the Health-Care Utilization and Clinical Outcomes of Patients with Stroke in Singapore

This study aims to assess the impact of diabetes mellitus (DM) on the health-care utilization and clinical outcomes of patients with acute stroke. This is a retrospective cohort study. All patients who were admitted for the first time to one of the three public hospitals in the National Healthcare Group in Singapore from January 2005 to June 2007 with a primary diagnosis of acute stroke were included and were followed up for 1 year after the index hospitalization. The study population was divided into two groups: with DM and without DM. Both univariate and multivariate analyses were applied to compare the hospital length of stay (LOS), hospitalization costs, mortality, as well as the 1-year hospital readmissions between the DM and non-DM groups. There were 9766 study patients, and 38.5% of them had DM. DM patients with ischemic stroke (IS) and transient ischemic attack (TIA) stayed 1-day and 0.6-day longer, and incurred 10% and 26% higher hospital cost during index admission, respectively, compared with their counterparts in the non-DM group. They also had more hospital readmission within 1 year. The mortality rate in IS patients with diabetes was 24% higher. After risk adjustment, subarachnoid hemorrhage patients with diabetes had more hospitalizations. Intracerebral hemorrhage (ICH) and IS patients in the DM group had all worse outcomes but the 1-year stroke recurrence; TIA patients with DM incurred longer LOS and hospital costs. DM predicts worse clinical outcomes and higher health-care expenditures in the 1-year poststroke especially for the IS, ICH, and TIA stroke subtypes.

Carotid Stenting in the Elderly

Elderly patients are at higher risk of procedural complications. Surgical revascularization has been performed successfully in selected octogenarians.1,2 Nevertheless, it is widely believed that percutaneous approaches are safer in the elderly. Indeed, percutaneous coronary intervention is now successfully being performed even in selected nonagenarians.3 Thus, it is tempting to presume that carotid revascularization in the elderly might be safer if done via endovascular means (Figure).4 Figure. Angiography before (A) and after (B) a right carotid artery stent in an 81-year-old man with amaurosis fugax. Article see p 2343 The data to date, however, have been conflicting, with several reports demonstrating very high rates of stroke or death with carotid stenting in octogenarians. Furthermore, although carotid stenting with embolic protection has been shown to be noninferior to carotid endarterectomy in patients at high surgical risk, whether carotid stenting is equivalent to carotid endarterectomy remains an open question in patients at low surgical risk.5–7 Additionally, especially for asymptomatic patients, the question arises whether a patient will live long enough to derive potential benefit from any procedure. This question becomes more pressing as the elderly population expands and the definition of elderly creeps upward, and also as clinical trials continue to underenroll the elderly. The cut point where appropriate clinical caution turns instead into preconceived notions and age-related bias is difficult to define. In this issue of Circulation , Chiam et al report on 142 consecutive patients aged 80 years or older who underwent carotid stenting.8 This series of patients has previously been reported, with the current article adding observations related to intermediate-term …

Clinical Summaries

Clinical Summaries

Polymorphism in the human C-reactive protein (CRP) gene, serum concentrations of CRP, and the difference between intracranial and extracranial atherosclerosis

BackgroundC-reactive protein, a proinflammatory factor, is involved in the development of atherosclerosis. The CRP 1059G>C polymorphism appeared to be a susceptive marker for atherosclerosis. We investigated the relationship of the distribution of cerebral atherosclerosis with triggered serum CRP concentrations following acute ischemic stroke/transient ischemic attack (IS/TIA) and CRP 1059G>C polymorphism. MethodsWe recruited 222 IS/TIA patients (122 with only intracranial atherosclerotic lesions and 100 with isolated extracranial atherosclerotic lesions) and 227 controls. Intra- and extracranial atherosclerotic lesions were determined by digital subtraction angiography. Serum CRP concentrations were measured by particle-enhanced immunonephelometry assay. CRP 1059G>C genotypes were obtained through PCR amplification and restriction enzyme digestion. ResultsCRP concentrations were significantly higher in intra- and extracranial groups than in controls. No significant difference was found in CRP concentrations between intra- and extracranial groups. The CRP 1059G>C single-nucleotide polymorphism did not influence CRP serum concentrations. CRP genotype and allele frequencies did not differ significantly between patients and controls. However, the frequencies of GC genotype and C allele were significantly higher in extracranial group than that in intracranial group. The GC individuals showed a higher risk of extracranial atherosclerosis compared with GG individuals (OR 3.41; 95%CI, 1.124–10.347; P=0.030). ConclusionsSerum CRP is associated with cerebral atherosclerotic disease. CRP 1059G>C polymorphism is one possible genetic determinant for the difference between intra- and extracranial atherosclerosis.

Combined Effects of Systolic Blood Pressure and Total Cholesterol on Cardiovascular Disease Risk

Half of all adult deaths (and much severe disability) are caused by cardiovascular diseases, and most of these deaths involve ischemic heart disease or stroke. The Asia-Pacific region accounts for about half of the global burden of cardiovascular disease and the proportion is likely to increase during the next few decades.1,2 Smoking and elevated levels of systolic blood pressure (SBP) and total blood cholesterol are major causes of cardiovascular disease,3 yet much of our knowledge about the associations between these risk factors and cardiovascular diseases comes from studies carried out in North American and western European countries. In most Asian countries, however, the mean levels of total cholesterol are lower than those found in Western countries and the incidence of coronary heart disease (CHD) is also lower, whereas the incidence of stroke, particularly hemorrhagic stroke, is higher. Article p 3384 The Asia Pacific Cohort Studies Collaboration report in this issue of Circulation investigates the combined effects of SBP and total cholesterol on risk of cardiovascular disease in a meta-analysis of 36 cohort studies (29 conducted in Asia and 7 from Australia and New Zealand) involving 380 000 individuals.4 This meta-analysis differs from previous studies in several ways: It is the largest study from this region, involving >3000 CHD events and 4000 stroke events; individual records were available for each of the participants in each study, with cause and age of death (if applicable); and information on several thousand repeat measurements of blood pressure and cholesterol made during prolonged follow-up allowed correction for “regression dilution.” These features …

Strokes attributable to underuse of warfarin and antiplatelets

Despite their proven efficacy in stroke prevention, warfarin and antiplatelets remain underused. We determined the frequency of ischemic strokes attributable to underuse of warfarin and antiplatelets for stroke prevention in a Danish community. We included all patients with ischemic stroke in a Copenhagen community with 302,000 inhabitants admitted to the hospital between September 1999 and May 2000 (n = 426). Patients who did not receive warfarin or antiplatelet medication even though they were at known risk for cardiovascular disease before the incident stroke were identified; they had known atrial fibrillation, prior myocardial infarction, angina, or prior stroke transient ischemic attack (TIA). Sufficient information on cardiovascular risk factors before stroke was available in 404 patients. A total of 54 patients had atrial fibrillation known before the stroke. Of these, 16 had not received warfarin or antiplatelets on admission, 27 had not received warfarin but had received antiplatelets, and 11 had received warfarin. Assuming that warfarin and antiplatelets reduces the risk of stroke by 66% and 25%, respectively, it was calculated that between 6 and 12 of these strokes with atrial fibrillation could have been prevented if warfarin or antiplatelets had been given before stroke. A total of 147 patients had known stroke/TIA and/or myocardial infarction/angina before stroke (41 patients had not received antiplatelets on admission). If antiplatelet therapy had been given before stroke, 10 of these strokes could have been prevented. Our findings indicate that underuse of warfarin and antiplatelets is still of considerable magnitude and attributable to 4% to 5% (16 to 22 out of 404) of the ischemic strokes in a Danish urban community.

Effective Prophylaxis for Deep Vein Thrombosis After Stroke

Approximately 5% of hospitalized stroke patients have a clinically apparent deep vein thrombosis (DVT) and ≈2% will have a pulmonary embolus (PE) confirmed.1 However, prospective studies that systematically screen for DVT with, for example compression Doppler ultrasound or magnetic resonance imaging, identified DVT in up to 50% of patients.2 Some patients who are breathless because of aspiration pneumonia, chest infection, or heart failure may actually have had an undiagnosed pulmonary embolus. Autopsies often identify clinically unrecognized PEs that probably contributed to the patient’s death. Therefore, it seems sensible to offer patients prophylaxis against venous thromboembolism. However, a brief discussion with colleagues is likely to reveal wide variation in the approaches taken to prophylaxis. In our unit, we aim to treat all patients with ischemic stroke with aspirin within 48 hours, because this has been shown to improve long-term outcomes and probably also reduces the risk of venous thromboembolism to some extent.3 In addition, we …

The emergency department transient ischemic attack accelerated diagnostic protocol (TIA ADP) study

Study objectives: It is important to determine whether an accelerated diagnostic protocol (ADP) for transient ischemic attack (TIA) is economically or clinically beneficial. This is a preliminary report of a prospective study of a TIA ADP. The primary objective of this study is to determine whether emergency department (ED) TIA patients who are treated using an ADP will demonstrate a decrease in their index visit length of stay and cost, with comparable diagnostic and 90-day clinical outcomes relative to TIA patients randomized to traditional inpatient care. Methods: This prospective randomized study was conducted in the ED and ED observation unit of a high-volume university-affiliated suburban teaching hospital with an annual census of 113,105. Initial ED screening included a medical history, physical examination, ECG, and head computed tomographic imaging. Patients were then randomized to either an inpatient bed or ED observation unit for carotid imaging, cardiac monitoring, 2-dimensional echocardiogram, and serial neurologic examinations. Patients were discharged home if testing results were negative or when clinically stable. Hospital length of stay and total direct cost were compared, and clinical outcomes were compared initially and at 90 days. Results: During 8 months, 64 patients were randomized. There were small differences between inpatient and ED observation unit groups in terms of age (68.6 versus 71.1 years, respectively), percentage of male patients (52% versus 49%), the number of TIA stroke risk factors (2.82 versus 2.45), and TIA cardiac risk factors (1.04 versus 1.21). However, there were larger differences between groups in length of stay (2.61 versus 2.27 days) and total direct cost ($1,562 versus $1,103). Of ED observation unit patients, 74.4% had negative ADP results and were discharged in less time (0.91 days) and at lower costs ($955). Each group had 3 patients who were found to have had a stroke. One patient in the ED observation unit group received a carotid endarterectomy. Conclusion: These preliminary results suggest that an ADP for TIA may decrease length of stay and costs for selected patients.

The incidence and aetiology of stroke in the Caerphilly and Speedwell Collaborative Studies I: methods and incidence of events

Stroke mortality and morbidity remain high despite downward trends in incidence and case fatality. Population-based longitudinal studies which include collection of risk factor data are required for a better understanding of stroke aetiology. From a representative cohort of men from South Wales and South-west England, followed up for a median of 17 y, details of possible cerebrovascular events were collected from questionnaires, hospital admission data, general practitioner records, death certificates, radiology records and post-mortem reports. Radiology records, and strokes and transient ischaemic attacks were independently validated. There were 433 strokes and 163 transient ischaemic attacks identified during follow-up. Of these, 333 were the first ever in a lifetime strokes of which 139 were definite ischaemic, 20 were haemorrhagic and 168 were probable ischaemic strokes. The crude incidence rate for stroke was 445 (95% confidence interval 398–493) per 100 000 person years. The age-standardised rates for 10 y age-bands were: 45–54 y 91 (10–172); 55–64 y 351 (269–432) and 65–74 y 855 (669–1040). The 30 d case-fatality rate was 21.0% (70/333) for all strokes and 19.2% (60/312) for ischaemic strokes. For transient ischaemic attacks the age-standardised incidence rates for the same 10 y age bands were 92 (4–179), 111 (64–157), and 273 (167–80), respectively. These rates for stroke transient ischaemic attack are likely to be accurate given the high ascertainment of events in this representative population of middle-aged men. Such studies, reporting reliable measures of cerebrovascular events, are important for measuring burden of disease, and for analysis of risk factor associations to help improve understanding of stroke aetiology and inform preventive efforts. Public Health (2001) 115, 4–11