Long-term Incidence Of Stroke Research Articles

The value of revascularisation of atherosclerotic lesions of the innominate artery at the asymptomatic stage of the disease

To analyze the natural course of asymptomatic atherosclerotic lesions of the innominate artery and to study the long-term results of surgical interventions performed at the asymptomatic stage and to compare them with similar results at the symptomatic stage of the disease. The analysis of the natural course of the disease was performed in 74 asymptomatic patients who were divided into 3 groups depending on the initial degree of severity of the stenosis of the innominate artery: insignificant stenoses (less than 50%), moderate stenoses (50-69%) and haemodynamically significant lesions (70% and more). The analysis of the long-term results of surgical treatment was performed in 62 patients, in 29 of whom intrathoracic reconstructions were performed at the asymptomatic stage of the disease, in 33 - at the symptomatic stage. Cumulative freedom from stroke by the 10th year of follow-up was significantly higher in patients with insignificant stenoses and amounted to 100% in the groups of moderate stenoses and hemodynamically significant lesions - 25% and 0, respectively (log-rank p=0.000). Neurological fatality in patients with hemodynamically significant (initial or developed) lesions was 26.3%, while in patients with hemodynamically insignificant lesions it was 0 (log-rank p=0.004), which is confirmed by cumulative indices (log-rank p=0.008). Asymptomatic innominate artery reconstructions were associated with a lower incidence of stroke: the long-term incidence of stroke in such patients was 3.4%, while in initially symptomatic patients it was 18.2% (p=0.038). Initial degree II or IV cerebrovascular insufficiency was a predictor of stroke in the long-term period (OR=1.71; p=0.000). The cumulative freedom from stroke in asymptomatic patients by the 20th year of follow-up was 95% compared with 74% in symptomatic patients (log-rank p=0.032). Surgical interventions in asymptomatic hemodynamically significant lesions of the innominate artery should be performed to prevent primary cerebral circulatory disorders.

Systemic immune-inflammation index as a predictor of prognosis after carotid artery stenting compared with C-reactive protein.

Immune-inflammatory processes are highly associated with the progression of atherosclerosis. The systemic immune-inflammation index (SII) is a potential predictor for clinical outcomes in patients with stroke and ischemic heart disease. Therefore, this study aimed to investigate whether SII can accurately predict the short- and long-term prognoses in patients who underwent carotid artery stenting (CAS) compared to that with C-reactive protein (CRP). This study was a single-center retrospective investigation. Overall, 129 patients who underwent CAS were categorized into tertiles based on their SII levels. We primarily investigated the long-term major adverse cardiac and cerebrovascular events (MACCE) and secondarily the in-hospital and long-term stroke incidence, as well as all-cause death. The in-hospital stroke rate tended to increase with a rise in SII (P = 0.13). Over the 5-year follow-up period, the Kaplan-Meier overall incidence of MACCE was 9.3%, 16.3%, and 39.5% in the lowest to highest tertiles, respectively (log-rank trend test, P<0.001). The rates of stroke and MACCE during the long-term follow-up were significantly higher with increasing SII. Cox regression analysis showed that the highest tertile of SII (>647) was a predictor of the incidence of long-term stroke (hazard ratio (HR), 21.3; 95% confidence interval (CI), 2.41-188; P = 0.006) and MACCE (HR, 3.98; 95% CI, 1.80-8.81; P<0.001). However, after adjusting for both SII and CRP, only SII remained a significant independent predictor, whereas CRP became less relevant. The receiver operating characteristic curve analysis of long-term MACCE showed that the area under the curve (AUC) for SII (AUC, 0.72; 95% CI, 0.60-0.84; P<0.001) was greater than that of CRP (AUC, 0.64; 95% CI, 0.51-0.77; P = 0.040). SII was shown to be an independent predictor of long-term prognosis in patients who underwent CAS and was suggested to be superior to CRP as an inflammatory prognosis predictor.

Long-Term Incidence of Stroke and Dementia in ASCOT.

Management of stroke risk factors might reduce later dementia. In ASCOT (Anglo-Scandinavian Outcome Trial), we determined whether dementia or stroke were associated with different blood pressure (BP)–lowering regimens; atorvastatin or placebo; and mean BP, BP variability, and mean cholesterol levels. Participants with hypertension and ≥3 cardiovascular disease risk factors were randomly allocated to amlodipine- or atenolol-based BP-lowering regimen targeting BP <140/90 mm Hg for 5.5 years. Participants with total cholesterol ≤6.5 mmol/L were also randomly allocated to atorvastatin 10 mg or placebo for 3.3 years. Mean and LDL (low-density lipoprotein) cholesterol, BP, and SD of BP were calculated from 6 months to end of trial. UK participants were linked to electronic health records to ascertain deaths and hospitalization in general and mental health hospitals. Dementia and stroke were ascertained by validated code lists and within-trial ascertainment. Of 8580 UK participants, 7300 were followed up to 21 years from randomization. Atorvastatin for 3.3 years had no measurable effect on stroke (264 versus 272; adjusted hazard ratio [HR], 0.92 [95% CI, 0.78–1.09]; P=0.341) or dementia (238 versus 227; adjusted HR, 0.98 [95% CI, 0.82–1.18]; P=0.837) compared with placebo. Mean total cholesterol was not associated with later stroke or dementia. An amlodipine-based compared with an atenolol-based regimen for 5.5 years reduced stroke (443 versus 522; adjusted HR, 0.82 [95% CI, 0.72–0.93]; P=0.003) but not dementia (450 versus 465; adjusted HR, 0.94 [95% CI, 0.82–1.07]; P=0.334) over follow-up. BP variability (SD mean BP) was associated with a higher risk of dementia (per 5 mm Hg HR, 1.14 [95% CI, 1.06–1.24]; P<0.001) and stroke (HR, 1.21 [95% CI, 1.12–1.32]; P<0.001) adjusted for mean BP. An amlodipine-based BP regimen reduced the long-term incidence of stroke compared with an atenolol-based regimen but had no measurable effect on dementia. Atorvastatin had no effect on either stroke or dementia. Higher BP variability was associated with a higher incidence of later dementia and stroke.

Abstract WP213: Association Between Thoracic Aorta Surgery and Long Term Risk of Stroke in Adults

Introduction: Thoracic aorta surgery carries a risk of perioperative stroke, but the long-term incidence of stroke after the perioperative period in these patients remains unclear. We therefore assessed the long-term risk of stroke in patients who underwent thoracic aorta repair. Methods: We performed a retrospective cohort study using 2008-2015 claims data from a nationally representative 5% sample of Medicare beneficiaries. Our exposure of interest was thoracic aorta surgery, defined using ICD-9-CM hospital procedure codes for endovascular graft implantation (39.73) or surgical resection and replacement (38.45). Our primary outcome was ischemic stroke, defined using previously validated ICD-9-CM diagnosis codes. Patients with stroke during the index surgical hospitalization were excluded, since our focus was on long-term stroke risk after the perioperative period . Cox proportional hazards analysis was used to examine the association between thoracic aorta surgery and stroke risk after adjustment for demographics and vascular risk factors. Given a clear violation of the proportional hazards assumption, we calculated period-specific risk estimates. Results: Among 1,751,719 beneficiaries (mean age 73 ±8 years), 1,402 underwent thoracic aorta repair. During 4.6 ±2.2 years of follow-up, 62,702 patients were diagnosed with ischemic stroke. The incidence of stroke was 1.24% (95% CI, 0.93-1.66%) per year after thoracic aorta repair compared to 0.77% (95% CI, 0.76-0.78%) per year in patients without thoracic aorta surgery. In adjusted models, there was an increased risk of stroke in the first 120 days after discharge from thoracic aorta surgery (HR, 2.1; 95% CI, 1.2-3.7), but no heightened risk was seen beyond 120 days after discharge from surgery (HR, 0.7; 95% CI, 0.5-1.0). Conclusions: In a large sample of Medicare beneficiaries, thoracic aorta surgery was associated with an increased risk of ischemic stroke in the first 120 days after hospital discharge, but there was no excess risk beyond that time point.

An analysis of the long-term stroke morbidity and mortality in the regions of the Russian Federation included in the Federal patient assistance reorganization program

OBJECTIVE To analyze the average long-term incidence of stroke and mortality in the regions of Russia in the territories included in the Federal program for the reorganization of care for stroke patients from 2009 to 2016. MATERIAL AND METHODS The study is based on data from the territorial population register for an eight-year period for seven territories in the regions of Russia included in the Federal program for the reorganization of care for stroke patients. The study included the following territories: Stavropol krai, the Republic of Bashkortostan, Sverdlovsk region, Irkutsk region, Sakhalin region, and the Republic of Tatarstan. The total number of stroke cases in the study areas was 29 779. RESULTS The highest average incidence was shown in the Republic of Tatarstan, which had significant differences with all regions (p<0.001). The level of mean annual mortality was identified in Stavropol krai, which had significant differences with all regions (p=0.008-p<0.001). Significant differences in the average long-term stroke incidence were typical for nine pairs of territories out of 21 of the territories, and the average long-term stroke mortality was typical for six pairs of territories. CONCLUSION The incidence of stroke does not depend on the geographical location of the region, its economic development and ethnic composition of the population. The quality and effectiveness of primary prevention of cardiovascular diseases comes to the fore. In regions where it is not carried out at the proper level, the incidence of stroke is the highest. Only high-quality implementation of appropriate preventive measures will significantly reduce these indicators. Stroke mortality rates depend primarily on the quality of diagnosis and specialized medical care provided to stroke patients. The decrease in the mortality rate of these patients is possible only with the mandatory implementation of the approved clinical guidelines and protocols for treatment.

3047Long-term changes after carotid stenting assessed by intravascular ultrasound and near-infrared spectroscopy

Abstract Background/Introduction Long-term effect of carotid stenting (CAS) on the stabilization of the plaque is not well described. The interaction among the late stent expansion, neointimal hyperplasia, and lipid core might explain stabilization of the plaque and low long-term incidence of stroke after CAS. Purpose To assess long-term change in the lipid signal, stent, and luminal dimensions and restenosis after CAS with the multimodality intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS) imaging. Methods We performed follow-up NIRS-IVUS imaging in patients who underwent CAS at our institution. Of the 112 patients (120 carotid arteries) who had NIRS-IVUS during CAS, 96 were alive at the time of the study, and 52 (58 carotid arteries) agreed to participate on the study. The lipid signal of the stented segment was calculated from the NIRS-derived chemogram (a spectroscopic map) as the lipid core burden index (LCBI, a dimensionless number from 0 to 1000). Volumetric calculations were performed using dedicated software with the automated lumen and stent detection and manual corrections. Median time from CAS to the follow-up examination was 31 months (range 5–56). Results The mean (± SD) LCBI significantly decreased from 32±56 to 17±27 (p=0,002). The mean stent volume significantly increased from 717±302 mm3 to 1019±429 mm3 (p&lt;0,001) with mean stent expansion 43±24%. The mean luminal volume increased from 717±302 mm3 to 760±359 mm3 (p=0,025) due to the mean in-stent restenosis (ISR) 26±15% of the stent volume. Significant increase in the mean minimal stent area (MSA) (from 11,1±3,0 mm2 to 15,0±3,5 mm2, p&lt;0,001) was not observed in the minimal luminal area (MLA) (from 11,1±3,0 mm2 to 11,4±4,4 mm2, p=0,098) due to the ISR. Significant restenosis (reduction of MLA ≥50% from baseline) was present in 7 stents. Conclusions During nearly three years of the follow-up after CAS the lipid signal decreased suggesting stabilization of the plaque. Significant late stent expansion was balanced with substantial neointimal hyperplasia therefore the late luminal gain was only modest in volume and nonsignificant at the site of MLA. There was a major variability in the rate of the late stent expansion and restenosis.

Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation.

Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA2DS2-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA2DS2-VASc score was calculated for 615 patients, of which 82.2% had a CHA2DS2-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA2DS2-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.

Long-term stroke incidence in proximal thoracic aorta aneurysm survivors.

Aneurysm of proximal thoracic aorta (pTAA) is an often indolent, yet fatal disease. Although advancements in aneurysmal repair techniques have increased long-term survival rates, studies have proven that there are increases in perioperative risk for stroke incidence after pTAA surgery. Conversely, there is little evidence regarding the long-term stroke incidence in pTAA individuals, which strongly influences the morbidity, mortality, and usage of antithrombotic agents. Using the Taiwan National Health Insurance Research Database, a nationwide population-based cohort, we recruited 3013 pTAA survivors hospitalized from 1 January 2000 to 31 December 2012. To ensure study cohort quality, only patients aged 20 years and above who underwent aneurysmal repair surgery are included. The control cohort is identified by matching background features (comorbidities, age, gender) at a 1:4 ratio through the use of frequency matching. The primary outcomes include incidence of ischemic stroke and intracranial hemorrhage one month after aneurysmal repair surgery. The mortality of pTAA survivors is nearly twice of the matched controls despite aneurysmal repair (28.5 % vs. 15.2%, p < 0.001). Long-term follow-up of participants indicated that pTAA survivors had a higher risk for hemorrhage stroke (adjusted hazard ratio (aHR): 1.93; 95% confidence interval (CI): 1.47-2.53), but no significant increase in risk for ischemic stroke (aHR: 1.07; 95% CI: 0.92-1.25). Hemorrhagic stroke occurrence was found to be associated with age and diabetes mellitus. Comparison on hemorrhagic stroke subtypes between study and matched cohorts showed no statistical differences in intracerebral hemorrhage and subarachnoid hemorrhage. Despite the advancement of aneurysmal repair surgery, this study suggests that pTAA patients may still face an increased risk of hemorrhage stroke. Further investigation is warranted to provide better long-term care for the pTAA population.

Incidence and predictors of stroke in patients discharged with the diagnosis of acute coronary syndrome

BackgroundStroke is one the most feared cardiovascular disease due to its high risk of disability and its incidence after an acute coronary syndrome (ACS) is not uncommon. MethodsRetrospective study of all consecutive patients admitted for an ACS in two hospitals. Competing risk regression, taking all-cause mortality as a competing event, was used for the assessment of stroke incidence. ResultsWe included 8771 patients, AF prevalence 12.4%. AF patients were older and presented higher prevalence of cardiovascular risk factors, previous cardiovascular disease, and lower glomerular filtration rate. Less than half of AF patients were receiving oral anticoagulation before admission. In-hospital mortality was 5.1% and it was more than two-fold higher in AF patients (10.2% vs. 4.4%; p < 0.01). Relevant differences on medical treatments were observed at discharge and oral anticoagulation was roughly <50% in AF patients. During a median follow-up was 58.7 months, 313 patients experienced at least one stroke (incidence 3.8%, 95% CI 3.4–4.2,) and it was 2-fold higher in patients with AF: 7.8% vs. 3.3% (p < 0.01). Median time to first stroke was 33.0 (30.1) months and it was shorter for AF patients compared to non-AF patients (28.2 ± 22.3 vs. 34.6 ± 31.1; p < 0.01). The adjusted competing risk regression identified AF, previous stroke and CHA2DS2-VASc score = 2 or ≥3 as independent predictors of stroke; CHA2DS2-VASc score = 2 was associated to higher risk of stroke only in AF patients. ConclusionsThe long-term incidence of stroke after an ACS was 3.8%, 7.8% in AF-patients and 3.3% in patients without any diagnosis of AF.

Cost Saving Potential of an Early Detection of Atrial Fibrillation in Patients after ICD Implantation.

Atrial fibrillation (AF) is a relevant comorbidity in recipients of implantable cardioverter-defibrillators (ICD). Latest generation single-chamber ICD allow the additional sensing of atrial tachyarrhythmias and, therefore, contribute to the early detection and treatment of AF, potentially preventing AF-related stroke. The present study aimed to measure the impact on patient-related costs of this new ICD compared to conventional ICD. A Markov model was developed to simulate the long-term incidence of stroke in patients treated with a single-chamber ICD with or without atrial sensing capabilities. The median annual cost per patient and its difference, the number of strokes avoided, and the cost per stroke avoided were estimated. During a 9-year horizon, the costs for the ICD and stroke treatment were €570 per patient-year for an ICD with atrial sensing capabilities and €491 per patient-year for a conventional ICD. Per 1,000 patients, 4.6 strokes per year are assumed to be avoided by the new device. Higher CHA2DS2-VASc scores are associated with higher numbers of avoided strokes and larger potential for cost savings. Apart from clinical advantages, the use of ICD with atrial sensing capabilities may reduce the incidence of stroke and, in high-risk patients, may also contribute to reduce overall health care costs.

Occurrence and Classification of Cerebrovascular Events after Isolated Bioprosthetic Surgical Aortic Valve Replacement: A Competing Risk Analysis of the CAREAVR Study

ABSTRACTBackground: The long-term incidence of stroke and the proportion of cardioembolic events after bioprosthetic surgical aortic valve replacement (SAVR) remain largely unknown.Methods: The CAREAVR study sought to assess the rate of stroke and transient ischemic attack (TIA) in patients who underwent isolated surgical aortic valve replacement with a bioprosthesis at four Finnish university hospitals between 2002 and 2014. Data was collected retrospectively and included 721 patients. Median follow-up time was 4.8 [3.0–7.0] years.Results: At 5 years, freedom from stroke was 89.0%, from TIA 94.1%, and from stroke and TIA 83.7%. The median time between index procedure and stroke or TIA was 1.7 years [29 days–3.9 years]. Stroke was of cardioembolic origin in 44.4% of patients. In multivariable competing risk analysis, increased age (HR 1.03, 95%CI 1.00–1.06, p = 0.022), previous stroke or TIA (HR 1.75, 95%CI 1.14–2.70, p = 0.010), New York Heart Association (NYHA) class III or more (HR 1.51, 95%CI 1.01–2.24, p = 0.044) and insulin treatment at discharge (HR 1.20, 95%CI 1.09–3.64, p = 0.024) were independent predictors of stroke or TIA. Cerebrovascular events occurred in 47.2% of patients with ongoing anticoagulation therapy.Conclusion: In this study, the incidence of stroke in the early postoperative period after bioprosthetic SAVR was higher than previously documented. Almost half of strokes were of cardioembolic etiology. These findings highlight the need for the better prevention strategies for cardioembolic events after bioprosthetic SAVR.

Long-Term Anti-Hypertensive Therapy and Stroke Prevention: A Meta-Analysis.

Stroke causes approximately 6.7million deaths worldwide per year and is the second leading cause of death. Pharmacotherapy for hypertension, an independent risk factor for stroke, significantly reduces the incidence of stroke. Although prior meta-analyses demonstrate various antihypertensive classes are superior to placebo in reducing stroke risk, which class is most effective is unclear. We conducted a systematic MEDLINE search including only randomized controlled trials (RCT) of antihypertensive medications published between 1999 and 2014 in adults with stroke as a primary or secondary outcome. Five classes compared against all others were angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-adrenoceptor antagonists (β-blockers), calcium channel blockers (CCBs), and thiazide or thiazide-like diuretics (T-TLDs). Among 17 RCTs with 31 comparative arms, risk ratio was used to assess effect size, and a fixed- and random-effect model was used to calculate summary effect size, utilizing comprehensive meta-analysis statistical software version 2.0. The 251,853 subjects (46±11.4% female; mean age 67.2±6.8years), were grouped as follows: ACEI 52,887; ARB 7278; ACEI/ARB 60,165; β-blocker 24,099; CCB 98,950; and T-TLD 68,639. The mean follow-up was 42.9±15months. A random-effect model was used to assess for summary effect size in ACEI, ACEI/ARB, ARB, and T-TLD groups. The summary risk ratio for stroke occurrence in the different antihypertensive drug classes were as follows: ACEIs 1.01 (95% confidence interval [CI] 0.81-1.27; p=0.92); ACEIs/ARBs 0.94 (95% CI 0.78-1.13; p=0.51); T-TLDs 0.90 (95% CI 0.75-1.08; p=0.25); ARBs 0.83 (95% CI 0.59-1.18; p=0.30); β-blockers 1.42 (95% CI 1.26-1.61; p<0.01); and CCBs 0.83 (95% CI 0.79-0.89; p<0.01). Among the antihypertensive classes, CCBs were most effective in reducing the long-term incidence of stroke, whereas β-blockers were associated with significantly increased risk.

Outcomes After Cardioversion and Atrial Fibrillation Ablation in Patients Treated With Rivaroxaban and Warfarin in the ROCKET AF Trial

This study sought to investigate the outcomes following cardioversion or catheter ablation in patients with atrial fibrillation (AF) treated with warfarin or rivaroxaban. There are limited data on outcomes following cardioversion or catheter ablation in AF patients treated with factor Xa inhibitors. We compared the incidence of electrical cardioversion (ECV), pharmacologic cardioversion (PCV), or AF ablation and subsequent outcomes in patients in a post hoc analysis of the ROCKET AF (Efficacy and Safety Study of Rivaroxaban With Warfarin for the Prevention of Stroke and Non-Central Nervous System Systemic Embolism in Patients With Non-Valvular Atrial Fibrillation) trial. Over a median follow-up of 2.1 years, 143 patients underwent ECV, 142 underwent PCV, and 79 underwent catheter ablation. The overall incidence of ECV, PCV, or AF ablation was 1.45 per 100 patient-years (n = 321; 1.44 [n = 161] in the warfarin arm, 1.46 [n = 160] in the rivaroxaban arm). The crude rates of stroke and death increased in the first 30 days after cardioversion or ablation. After adjustment for baseline differences, the long-term incidence of stroke or systemic embolism (hazard ratio [HR]: 1.38; 95% confidence interval [CI]: 0.61 to 3.11), cardiovascular death (HR: 1.57; 95% CI: 0.69 to 3.55), and death from all causes (HR: 1.75; 95% CI: 0.90 to 3.42) were not different before and after cardioversion or AF ablation. Hospitalization increased after cardioversion or AF ablation (HR: 2.01; 95% CI: 1.51 to 2.68), but there was no evidence of a differential effect by randomized treatment (p value for interaction = 0.58). The incidence of stroke or systemic embolism (1.88% vs. 1.86%) and death (1.88% vs. 3.73%) were similar in the rivaroxaban-treated and warfarin-treated groups. Despite an increase in hospitalization, there were no differences in long-term stroke rates or survival following cardioversion or AF ablation. Outcomes were similar in patients treated with rivaroxaban or warfarin. (An Efficacy and Safety Study of Rivaroxaban With Warfarin for the Prevention of Stroke and Non-Central Nervous System Systemic Embolism in Patients With Non-Valvular Atrial Fibrillation [ROCKET AF]; NCT00403767).

Poor Neighborhood Socioeconomic Status and Risk of Ischemic Stroke After Myocardial Infarction

Data linking neighborhood socioeconomic status (SES) to stroke risk are scarce. We examined long-term stroke incidence according to neighborhood SES in a population-based cohort of patients hospitalized with first myocardial infarction (MI). Consecutive patients aged 65 years or less, discharged from 8 hospitals in central Israel after incident MI in 1992-1993, were followed for stroke through 2005. Individual demographic, socioeconomic, and clinical data were obtained at study entry. We estimated neighborhood SES through a composite census-derived index developed by the Israel Central Bureau of Statistics. During a median follow-up of 13 years, 196 incident ischemic strokes occurred in 1410 patients. Accounting for death as a competing risk, patients residing in disadvantaged neighborhoods had higher rates of ischemic stroke (cumulative survival estimates: 81%, 88%, and 89% in increasing tertiles of neighborhood SES). Upon multivariable adjustment for individual SES measures (including income, education, and employment), cardiovascular risk factors, MI characteristics and severity indices, and acute management, the overall hazard ratio for stroke in the lower versus upper tertile of neighborhood SES was 1.5 (95% confidence interval [CI] = 1.0-2.3); after 13 years, the adjusted absolute risk difference was 7.9 incident stroke cases per 100 participants with MI (95% CI = 1.7-14.1). Poor neighborhood SES is associated with increased risk of ischemic stroke post-MI. The association is only partly attributable to individual SES and other baseline characteristics. The potential mechanisms for this association require further study.

Four Blood Pressure Indexes and the Risk of Stroke and Myocardial Infarction in Japanese Men and Women

Information has been sparse on the comparison of 4 blood pressure (BP) indexes (systolic BP [SBP], diastolic BP, pulse pressure, and mean BP [MBP]) in relation to long-term incidence of stroke and myocardial infarction, particularly in middle-aged and older Asians. The Japan Arteriosclerosis Longitudinal Study Group conducted a meta-analysis of 16 cohort studies in Japan. A total of 48,224 men and women 40 to 89 years of age participated at baseline, and 1231 stroke events and 220 myocardial infarction events occurred during an average 8.4-year follow-up. Multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index were determined by Poisson regression. Analyses were also done in 4 age-sex groups. All 4 BP indexes were significantly related to all stroke risk. Stroke risk was most strongly related to MBP and SBP in both sexes and most weakly related to pulse pressure. Both stroke subtypes, ischemic and hemorrhagic, were most strongly related to MBP and SBP in both sexes. In addition, in men and women 70 to 89 years of age, MBP or SBP showed the strongest relation to all stroke risk. Myocardial infarction risk was most strongly related to SBP or MBP in both sexes. For any end points in any age-sex groups, pulse pressure was not the strongest predictor. The long-term incident risk of stroke and myocardial infarction associated with high BP in East Asian populations should be assessed mainly on the basis of SBP. MBP also may be an important predictor, but pulse pressure is a less important predictor for cardiovascular disease risk.

Effect of Neurology Consults on Outcomes for Patients Suffering Transient Ischemic Attacks After Coronary Artery Bypass Grafting

Stroke patients appear to have lower morbidity and mortality rates and better outcomes when neurologists serve as the primary admitting physician. The effect of neurological consultations on coronary artery bypass graft (CABG) patients who have suffered a postoperative transient ischemic attack (TIA) has not yet been determined. The authors evaluated whether neurology consultations improved outcomes. A retrospective analysis was conducted of CABG patients from a high-volume tertiary care center. Primary end points included 30-day mortality, discharge disposition, length of stay, and 1-year incidence of stroke. Post-CABG TIA patients receiving a neurological consult (N = 127) were compared with propensity-matched controls. Thirty-day mortality was identical (3.1%), with nonsignificant difference in long-term incidence of stroke. There were no differences in home discharges or length of stay. Including a neurologist in the treating team for patients suffering TIAs after CABG appears not to reduce post-operative incidence of morbidity and mortality, reduce length of stay, or improve patient disposition at discharge.

Ambulatory Blood Pressure for Cardiovascular Risk Stratification

Ambulatory blood pressure (ABP) monitoring is increasingly recognized as a valuable tool to refine prediction of cardiovascular risk related to blood pressure (BP).1 After the first landmark study published by Perloff and colleagues 24 years ago,2 several longitudinal event-based studies provided unequivocal evidence of an independent association between ABP and risk of cardiovascular disease. Although experimental procedures and statistical analyses varied from study to study, ABP generally improved cardiovascular risk stratification over and beyond traditional risk factors, including clinic BP.3 The Table, obtained through an electronic search of literature using the terms “ambulatory blood pressure” and “prognosis,” shows a list of longitudinal event-based studies performed by independent groups. It is worth noting that the list of available studies is longer because each group generally published other analyses of their database. Only the first-appearing or main contribution from each group has been included in the Table. View this table: Longitudinal Event-Based Studies From Independent Groups That Addressed the Prognostic Value of ABP Article p 2145 Three aspects of available investigations deserve special mention. First, the prognostic value of ABP has been examined not only in subjects with clinical diagnosis of hypertension but also in the general population and in a variety of settings, including diabetes mellitus, renal failure, and cerebrovascular disease. Second, subjects could be untreated or treated at the time of ABP monitoring. This point may raise concerns, because drug treatment could exert unpredictable effects on 24-hour ABP profile and, consequently, interpretation and applicability of results. Third, although a continuous relation emerged in most studies between ABP and cardiovascular risk, several investigators tried to define clinical categories based on arbitrary thresholds of ABP. Although such categories are potentially useful to make diagnostic and therapeutic decisions in clinical practice, their prognostic role requires confirmation from large and independent cohort …

Effective Ambulatory Blood Pressure Control in Medical Practice

A large number of studies has addressed the question of how effective is blood pressure (BP) control in the hypertensive population,1–3 with a consistent and unequivocal answer. That is, BP control is disappointingly low, because only a small fraction of patients diagnosed as having a BP elevation show on-treatment BPs <140 mm Hg systolic and 90 mm Hg diastolic, which are the target values for treatment recommended by international guidelines.4,5 This is the case regardless of whether patients are followed by general practitioners or specialists6,7 and have a low or high cardiovascular risk profile,8–10 the latter condition making the need of BP control even more compelling given the imminent risk of a cardiovascular event. Reality is obviously even worse when the lower BP targets that have been shown to be additionally protective in high-risk hypertensive patients, that is, <130/80 mm Hg, are considered.4,5 In a recent study performed in Italy, for example, we have shown that in diabetic (and, thus, high risk) hypertensive patients followed by general practitioners, an on-treatment BP <130/80 mm Hg was achieved in only 3% of the sample,7 the conclusion being that …

Short- and Long-Term Incidence of Stroke in White-Coat Hypertension

White-coat hypertension (WCH) has been associated with a low risk for stroke, but long-term data are scanty. We analyzed individual data from 4 prospective cohort studies from the United States, Italy, and Japan that used comparable methodology for 24-hour noninvasive ambulatory blood pressure monitoring (ABPM). Overall, 4406 subjects with essential hypertension and 1549 healthy normotensive controls who were untreated at the time of initial ABPM were followed for a median of 5.4 years up to censoring or occurrence of a first stroke. At entry, mean age of subjects was 56 years (range 18 to 97). Prevalence of WCH was 9%. During follow-up, there were 213 new cases of stroke. Stroke rate (x100 person years) was 0.35 in the normotensive group, 0.59 in the WCH group, and 0.65 in the group with ambulatory hypertension. In a multivariate analysis, the adjusted hazard ratio for stroke was 1.15 (95% confidence interval [CI], 0.61 to 2.16) in the WCH group (P=0.66) and 2.01 (95% CI, 1.31 to 3.08) in the ambulatory hypertension group (P=0.001) compared with the normotensive group. After the sixth year of follow-up, the incidence of stroke tended to increase in the WCH group, and the corresponding hazard curve crossed that of the ambulatory hypertension group by the ninth year of follow-up. In conclusion, WCH was not associated with a definitely increased risk of stroke during the total follow-up period. However, WCH might not be a benign condition for stroke in the long term.

White-Coat Hypertension and Risk of Stroke

The term “white-coat hypertension” (WCH; also commonly referred to as isolated office hypertension) describes the transient increase in blood pressure (BP), resulting from an alerting reaction and pressor response, observed in certain individuals when attending a clinic or doctors’ office.1 The diagnosis of WCH is usually ascribed when clinic BPs exceed 135/85 mmHg and average daytime BPs do not. WCH could be dismissed as a risk factor for stroke and other cardiovascular events, because the increase in BP is transient and may be idiosyncratic to the clinic setting.2 However, WCH may be a marker of stress reactivity per se, because surges in BP that occur in the doctor’s office are indicative of BP surges in other stressful scenarios.3 The article by Verdecchia et al featured in this edition of Hypertension 4 reports data from 6000 Italian, Japanese, and American adults. The purpose of the study was to explore the relationship between classically defined WCH and incident stroke during a median follow-up of 5.4 years. When compared with normotensive controls, a tendency for increased stroke incidence was observed in patients with WCH (unadjusted hazard ratio, 1.15). However, because the variance around the estimates of effect is large (95% confidence interval, 0.61 to 2.16), this association is not statistically significant, despite this study being the largest of its kind to date. By contrast, a statistically significantly association between ambulatory hypertension and stroke was observed (unadjusted hazard ratio, 2.01; 95% confidence interval, 1.31 to 3.08). The hypothesis that Verdecchia et al test is important because vessels in the brain may be particularly susceptible to transient elevations in BP. Furthermore, because WCH is highly prevalent,5 even a relatively small increase in stroke risk on an individual level could convey a high population-attributable risk. Although Verdecchia et al have demonstrated using …